Is posterior vertebral arthrodesis at the end of the electromagnetic rod lengthening program necessary for all patients? Comparative analysis of sixty six patients who underwent definitive spinal arthrodesis and twenty four patients with in situ lengthening rods.

PURPOSE: Magnetically controlled growing rods (MCGR) should be removed or changed at most two years after their implantation in the treatment of patients with early-onset scoliosis (EOS) (Safety notice July 2021). However, in the face of patients at high risk of intraoperative complications and relying on the principle of auto-fusion of the spine, some surgeons would prefer a more wait-and-see attitude. The aim of this study was to report on patients who did not undergo final fusion at the end of the lengthening program with MCGR and to compare them with those who did. METHODS: This was a multicenter study with ten centres. We collected all graduate patients with EOS who had received MCGR between 2011 and 2022. RESULTS: A total of 66 patients had final fusion at the end of the lengthening program and 24 patients kept MCGRs in situ. The mean total follow-up time was 66 months (range, 25.3-109), and the mean follow-up time after final lengthening was 24.9 months (range, 3-67.7). Regarding the main curve and thoracic height, there was no significant difference in the percentage of correction over the whole follow-up between the two groups (p = 0.099, p = 0.176) although there was a significant difference between the end of lengthening and the last follow-up (p < 0.001). After completion of the lengthening program, 18 patients who had final fusion developed 24 of the 26 recorded complications (92.3%). CONCLUSION: Contrary to the manufacturer's published safety notice, not all patients systematically benefited from the removal of the MCGRs. Although arthrodesis significantly improved the scoliotic deformity, no significant difference was found in terms of radiographic outcome between patients who underwent spinal fusion and those who kept the MCGRs in situ.

Clinical and radiographic evolution of graduate patients treated with magnetically controlled growing rods: results of a French multicentre study of 90 patients.

PURPOSE: The purpose of this study was to investigate patients with early-onset scoliosis (EOS) who completed their electromagnetic lengthening rod program to assess the demographics of this population and to analyze the evolution of clinical and radiological parameters and the occurrence of complications. METHODS: This was a multicenter study with 10 French centers. We collected all patients with EOS who had undergone electromagnetic lengthening between 2011 and 2022. They had to have reached the end of the procedure (graduate). RESULTS: A total of 90 graduate patients were included. The mean follow-up time over the entire period was 66 months (25.3-109). Of these, only 66 patients (73.3%) underwent definitive spinal arthrodesis at the end of the lengthening phase, whereas 24 patients (26.7%) kept their hardware in situ with a mean follow-up time from the last lengthening of 25 months (3-68). Patients had an average of 2.6 surgeries (1-5) over the entire follow-up. Patients had an average of 7.9 lengthenings for a mean total lengthening of 26.9 mm (4-75). Analysis of the radiological parameters showed a percentage reduction in the main curve of 12 to 40%, depending on the etiology, with an average reduction of 73-44°, and an average thoracic height of 210 mm (171-214) for an average improvement of 31 mm (23-43). There was no significant difference in the sagittal parameters. During the lengthening phase, there were a total of 56 complications in 43 patients (43.9%; n = 56/98), of which 39 in 28 patients (28.6%) resulted in unplanned surgery. In the graduate patients, there were a total of 26 complications in 20 patients (22.2%), all of which resulted in unscheduled surgery. CONCLUSION: MCGR, allow to decrease the number of surgeries, to progressively improve the scoliotic deformity and to reach a satisfactory thoracic height at the price of an important complication rate linked in particular to the complexity of the management of patients with an EOS.

Incidence of child abuse with subdural hemorrhage during the first year of the COVID-19 pandemic: a nationwide study in France.

The global COVID-19 pandemic prompted governments to impose unprecedented sanitary measures, such as social distancing, curfews, and lockdowns. In France and other countries, the first COVID-19 lockdown raised concerns about an increased risk of child abuse. Abusive head trauma (AHT) is one of the most serious forms of child abuse in children aged 0-24 months and constitutes the leading cause of death in children under 2 years of age. Subdural hemorrhage (SDH) is present in 89% of cases of AHT and constitutes one of the most specific, objective clinical presentations in the diagnosis of child abuse. In a French nationwide study, we sought to evaluate the potential impact of the first year of the COVID-19 pandemic on the incidence of hospital admissions for child abuse with SDH, relative to the two previous years. We conducted a nationwide, retrospective study of data in the French national hospital discharge summary database by applying the International Classification of Diseases (10th Revision) codes for SDH and for child abuse. After including children aged up to 24 months with a diagnosis of child abuse and/or SDH following hospital admission anywhere in France between January 1, 2018, and December 31, 2020, we compared the incidence of child abuse, the incidence of SDH + child abuse, and the demographic data for 2020 with the corresponding values for 2018 and 2019. There were no significant differences in the number of hospital admissions due to child abuse or SDH + child abuse between 2020 and the 2018/2019 control years. The incidence of SDH + child abuse was higher among boys than among girls. There were significantly fewer hospital admissions in May 2020 (p = 0.01) and significantly more in December 2020 (p = 0.03), relative to the same months in the two preceding years. There was a nonsignificant trend toward a lower incidence of hospital admission for child abuse in 2020, relative to 2019 (decrease: 6.4%) and 2018 (decrease: 7.6%). CONCLUSION: When considering children under the age of 24 months in France, the incidence of hospital admission for SDH in the context of child abuse was not significantly higher in 2020 than in the two previous years. WHAT IS KNOWN: • The impact of COVID-19 lockdown on child abuse and more specifically on subdural hemorrhage remains unknown. WHAT IS NEW: • There was no increase in hospitalizations for child abuse and AHT. • We found that boys are more often victims of child abuse and subdural hemorrhage among children aged less than 12 months.

Treatment options for soft tissue defects in severe foot trauma in children.

OBJECTIVE: Severe foot trauma in children is a therapeutic challenge, with presence of devitalised and soiled distal tissues. Several reconstruction and covering procedures can be applied, including artificial dermis (AD), negative pressure wound therapy (NPWT), fasciocutaneous flaps and free flaps. Here, we have developed and evaluated an algorithm for treating severe foot injuries with skin defects in children. METHOD: Paediatric cases of severe foot injury treated over a 16-year period were retrospectively reviewed. Characteristics of the injuries, surgical procedures, complications and the modified Kitaoka score (clinical and functional rating score of the ankle and foot) were recorded. RESULTS: A total of 18 children were included. The mean age at the time of injury was four years and 10 months (range: 1-11 years). The mean follow-up period was 6.2 years. Of the children, 13 presented with an amputation (12 partial foot amputations and one whole ankle and foot). The skin defect was combined with tendon exposure in nine cases, and/or bone and cartilage in seven cases, and heel damage in two cases. A flap was implemented in eight cases, of which one failed. NPWT was used in 13 patients (for an average of 21 days) and was combined with AD in six patients. The mean modified Kitaoka score was 68 (range: 55-80). Additional surgery during the follow-up period was required in seven patients (dorsal skin retraction, a thick flap, osteoma, trophic ulcer or ankle deviation). CONCLUSION: Our algorithm suggests different therapeutic strategies for skin coverage and healing, depending on the size of the lesion and the exposed structures, and seems to offer good results. These procedures should be combined with NPWT to optimise these results (improved healing, reduced infections, decreased skin defects and enhanced granulation tissue) and so should be used more frequently.

Long-Term Outcomes of Atasoy Flap in Children With Distal Finger Trauma.

PURPOSE: Distal finger trauma is one of the most frequent emergencies in children and has the potential for functional and cosmetic damage to the hand. The Atasoy flap (AF) is a vascularized, subcutaneous pedicle V-Y advancement flap used to cover a loss of distal finger substance. Our hypothesis was that the AF is a safe, reliable flap that results in few complications and gives satisfactory functional and cosmetic results in children. METHODS: We retrospectively assessed children with distal finger trauma and AF pulp reconstruction in our pediatric orthopedic department between 2008 and 2017. The lesion zone was classified, and we also evaluated necrosis, infection, the shape of the pulp, pulp sensitivity (Weber test), hyponychial scarring, and the presence of a hook nail deformity. Lastly, we compared patients who developed a hook nail with those who did not. RESULTS: Thirty children were included (mean age at trauma, 6.4 years [range, 1.3-15.7 years]). In 21 cases, the finger damage was located in Ishikawa subzone II. No cases of necrosis or infection were reported. Epicritical tactile sensitivity was good in 20 patients (67%). A hook nail deformity was observed in 15 children (50%) and hyponychial scarring in 22 patients (73%). The pulp had a normal shape in 13 children (43%). The hook nail group displayed more hyponychial scarring, greater nail dystrophy, and lower pulp sensitivity. CONCLUSIONS: The AF yielded contrasting results. High reliability, good coverage, and minimal donor-site morbidity were compromised by suboptimal tip length/shape, nail appearance, and sensitivity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Middle Phalangectomy for the Correction of Toe Clinodactyly With Longitudinal Epiphyseal Bracket in Young Children.

Toe clinodactyly is often owed to the presence of a longitudinal epiphyseal bracket. We developed middle phalangectomy as a simple surgical solution for correction of toe clinodactyly because of longitudinal epiphyseal bracket in childhood. Ten children (ages 1-5 years) were operated on by the same surgeon between October 2007 and May 2012 (n = 15 feet). The same surgical technique was used in all the cases. A clinical evaluation included the appearance of the foot, the parents' level of satisfaction, and the presence or absence of bothersome symptoms (such as pain and discomfort when wearing footwear). A radiological evaluation under weight-bearing conditions enabled us to 1) rate the achievement of a natural-looking toe parabola and 2) detect the recurrence of clinodactyly (defined as an angle of >40° between 2 adjacent phalanges). The mean follow-up period was 5.4 (range 3.3 to 8.1) years. Nine sets of parents (90%) were satisfied with the results of the procedure. None had difficulties wearing boots, and only 1 child (10%) had residual pain during sports activities. Clinodactyly recurred in 3 feet in 3 patients (20% of feet, 30% of patients). Two (20%) of the latter patients underwent repeat surgery and achieved a lasting, satisfactory outcome. Middle phalangectomy is an appropriate procedure for the treatment of toe clinodactyly because of longitudinal epiphyseal bracket in young children. However, the patients' long-term outcomes (notably once bone growth has ended) must be assessed.

Minimally invasive, robot-assisted iliosacral screw insertion for fusionless fixation in children with neuromuscular scoliosis.

Fusionless surgery coupled with growing rod techniques is increasingly advocated for the treatment of early-onset scoliosis in general and neuromuscular scoliosis in particular. Iliosacral screws have excellent biomechanical characteristics but are hard to place safely. Here, the authors report on robot-assisted iliosacral screw positioning as part of growing rod surgery for the fusionless correction of early-onset scoliosis. The technique is based on a bilateral double sliding rod construct anchored to the pelvis proximally with 6 hooks or sublaminar bands and distally with iliosacral screws placed by the robot. The video can be found here: https://youtu.be/5HGH_DiD-ck .

Surgical Treatment of Subfibular Ossicle in Children: A Retrospective Study of 36 Patients with Functional Instability.

BACKGROUNDS: To evaluate the surgical management of a symptomatic subfibular ossicle after severe ankle sprain with functional instability and pain sequelae in children. METHODS: We analyzed 36 patients complaining of functional instability without laxity, 1 year after an ankle inversion trauma associated with the observation of a subfibular ossicle. We systematically suggested the open excision of the residual ossicles, followed by 6 weeks of immobilization and proprioceptive physiotherapy. Seventeen of them, constituting the "resection" group accepted this surgical approach. The remaining 19 patients, the "control" group, received only rehabilitative care. The American Orthopaedic Foot and Ankle Society ankle pain and function score was evaluated in both groups. RESULTS: The mean latest follow-up was 4 years and 4 months (range, 1 y 8 mo to 14 y 7 mo). A significant improvement of the American Orthopaedic Foot and Ankle Society score was observed and was significantly higher in the resection group with a mean gain of 31 points (SD=31.8), versus 7 points (SD=7) in the control group (P<0.001). CONCLUSIONS: We conclude that in the absence of objective laxity, excision of the os subfibulare appears as a simple and effective technique in the treatment of posttraumatic functional instability and ankle pain. LEVEL OF EVIDENCE: Level IV-retrospective case-control study.

Mitigating Risk of Ankle Valgus From Ankle Osteochondroma Resection Using a Transfibular Approach: A Retrospective Study With Six Years of Follow-Up.

To prevent worsening of ankle valgus and functional repercussions, a distal inter-tibiofibular osteochondroma can be removed using a transfibular approach. We evaluated the difference between the preoperative and postoperative tibiotalar tilt at the last follow-up examination and the clinical and radiologic outcomes. We included 10 consecutive ankles that had undergone removal of an osteochondroma using a transfibular approach. The mean patient age was 10.6 years. One ankle was lost to follow-up. The mean postoperative follow-up duration was 5.9 years. The mean preoperative and postoperative tibiotalar tilt was 7.2° and 7.1°, respectively, with no significant difference. The mean postoperative American Orthopaedic Foot and Ankle Society score was 92.4. Tibiofibular synostosis developed in 7 cases. Osteochondroma recurred in 1 case. The transfibular approach stabilizes ankle valgus and is associated with good functional outcomes. However, it is an extensive procedure associated with postoperative synostosis and, thus, should be considered primarily when surgical access for an anterior approach is limited.

Cartilaginous tibial eminence fractures in children: which recommendations for management of this new entity?

PURPOSE: Cartilaginous tibial eminence fracture (CTEF) is a new pattern of ACL rupture in children under the age of nine. MRI signs have been recently reported, but no series gave information about outcomes. It was hypothesized that primary treatment gave better results than delayed management due to frequent misdiagnosis. METHOD: This retrospective study focused on 15 patients, managed acutely (n = 7) or delayed (n = 8). The patients' median age at the time of initial injury was 6.5 years (range 5-9). Lysholm, IKDC 2000 subjective scores, and the measurement of the residual laxity by a side-to-side difference with a KT-1000 junior arthrometer were used at the time of revision. RESULTS: After a mean follow-up of 9.8 years (range 1-18.5), the mean Lysholm and IKDC subjective scores were, respectively, 97.7 ± 2.6 and 97 ± 3.4. The median residual laxity was 2 mm (range 0-4). Non-operative treatment lead to 2 failures: intermeniscal ligament entrapment and combined avulsion fracture at the femoral site. Suture fixation of the avulsed fragment allows regularly good results when performed acutely or even 4 years after the injury. The hypothesis that primary treatment gives better result than delayed treatment tends to be wrong as 2 failures were reported in each group. An ACL reconstruction was performed in 3 out of the 4 treatment failures. Progressive resorption of the avulsed fragment was noticed in 3 of the 4 failures suggesting an associated ACL resorption. CONCLUSION: CTEF has a good prognosis even after misdiagnosis and treatment at the time of non-union; this could be due to low-energy mechanism of injury and low rate of associated lesion. Orthopaedic treatment for acute minimally displaced fractures is only indicated under strict MRI control, and suture fixation is the recommended strategy in other situations. Conservative management of non-union could expose to ACL involution and cannot be recommended. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Tarsal Coalitions: Preliminary Results After Operative Excision and Silicone Sheet Interposition in Children.

Symptomatic tarsal coalitions that begin in early adolescence are usually treated by resection and interposition (fat, muscle, or bone wax) to prevent recurrence. The purpose of the present retrospective study was to describe our operative technique and report our clinical and radiologic outcomes with sterile silicone sheet interposition after resection of painful tarsal coalitions in 4 children (4 feet). The present series included 1 case of talocalcaneal synchondrosis and 3 of synostosis (2 talocalcaneal and 1 cuboid-navicular). Two validated functional scales were used to assess the patients' overall outcome and satisfaction with the procedure: the American Orthopaedic Foot and Ankle Society ankle-hindfoot score and the Foot Function Index. Conventional radiography, computed tomography with 3-dimensional reconstruction, and magnetic resonance imaging were performed at the final follow-up visit. The mean follow-up period was 40 (range 12 to 80) months. The mean age at surgery was 10.5 (range 8 to 13) years. All patients had achieved their desired activity level at 6 months postoperatively. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 93.5 (range 74 to 100), and the mean Foot Function Index was 3.25% (range 0% to 13%). No recurrence of the coalition on imaging at the final follow-up visit was observed in this patient series. Sterile silicone sheet interposition can be used to prevent recurrence of tarsal coalition in symptomatic tarsal coalitions after failure of conservative management.

Clinical experience and complications with limited pleural dissection combined with a novel, simplified technique for thoracic Redon-like drain in vertebral body tethering.

PURPOSE: To report on our experience with a simplified, suction-bottle-drain technique of thoracic drain (Redon-like) combined with fully thoracoscopic vertebral body tethering (VBT) and a limited pleural approach, with particular focus on the rate of pulmonary complications. METHODS: A retrospective study was performed on all consecutive patients who underwent VBT for adolescent idiopathic scoliosis. For all subjects, a 10G Redon drain, an active drain system consisting of a perforated tube and a suction bottle, was placed intrathoracically and tunneled under the skin. All drains were removed on the first postoperative day. Perioperative and postoperative data such as type of access, length of surgery, amount of fluid collection in the drain, and length of hospital stay were collected. The type and number of pulmonary complications occurring in the first 3 months after surgery, along with their symptoms and management, were recorded. RESULTS: One Hundred eighty-two patients were included in the analysis. The mean length of surgery was 97 min (75-120). The average fluid collection in the drain was 30 ml (5-50), the mean length of hospital stay was 3 days (2-4). During the observation period, pulmonary complications occurred in five patients (2%). Two patients presented an aseptic right pleural effusion; for two patients, a residual pneumothorax was diagnosed on the X-rays in the recovery room and one patient developed a chylothorax. All patients recovered without sequelae. CONCLUSION: The simplified, Redon-like drain combined with a fully thoracoscopic VBT and limited pleural approach seems a safe and effective alternative to the chest drain. This technique allows to remove the drain on the first postoperative day, thus simplifying the management of the patients and improving their comfort.

Antibiotic treatment of hand wounds in children: Contribution of a decision tree.

BACKGROUND: The need for prophylactic antibiotic treatment of hand wounds in children requiring emergency surgical exploration is still controversial. Our starting hypothesis was that the absence of prophylactic antibiotic treatment in this setting (as specified by a decision tree) does not increase the likelihood of surgical site infection. METHODS: A decision tree for antibiotic prescription was developed by a working group in compliance with the guidelines issued by the French High Authority for Health, as part of a clinical pathway. One injection of intravenous antibiotics was prescribed for bite injuries, open joint injuries, injuries left untreated for more than 24 h, and suspected contaminated wounds. All children admitted for surgical treatment of a hand wound between July 2018 and March 2023 were included. Demographic data, antibiotic prescription and onset of postoperative surgical site infection were recorded. RESULTS: The 238 children included had a mean age of 8 ± 4.8 years; 102 received antibiotics and 136 did not. Eleven children (4.6%) had superficial surgical site infection requiring no revision surgery or antibiotic therapy. 206 children (86.5%) were treated following the decision tree. Ten had superficial surgical site infection: 3 received antibiotics (3.7% of the 80 who were treated) and 7 did not (5.5% of the 126 not treated) (p = 0.74). Thirty-two patients (13.5%) were off-protocol, only 1 of whom received antibiotics for superficial surgical site infection. DISCUSSION: Applying the decision tree standardized the prescription of antibiotics in hand wounds, was not associated with a significantly greater rate of surgical site infection, and avoided exposure to antibiotics for 61.1% of the children, thus limiting potential adverse events. LEVEL OF EVIDENCE: III.

Effects of botulinum toxin injections in the upper limbs of children with cerebral palsy: A systematic review of the literature.

BACKGROUND: Spasticity is a common motor disorder in children with cerebral palsy (CP). Upper limb CP impairment has a significant negative impact on daily activities. Botulinum toxin (BTX-A) injections are widely used to reduce spasticity, but their effectiveness is not well-defined. We performed a systematic review of literature to answer questions about the effectiveness of BTX-A injections in the upper limb in children with CP. METHODS: A systematic review of literature was conducted according to PRISMA guidelines. Eligible studies were randomized controlled trials with a high level of evidence on BTX-A upper limb injections in children. The outcomes analyzed included the study population, spasticity, quality of movement, activity limitations, quality of life, pain, appearance and side effects. RESULTS: A total of 24 studies were included. The number of patients included was 1358 with a mean age between 3 and 11years. Improvement after BTX-A injection compared to the control group was observed for spasticity (n=10/19 studies), bimanual activities (Assisting Hand Assessment) (n=3/7), activity limitations (n=6/11), pain (n=2/2) and appearance (n=2/2). No study found an improvement in quality of life. Side effects were described in 16 studies and were moderate in all cases. CONCLUSION: This review of literature showed that BTX-A injections can improve spasticity and particularly activity limitations when reasonable objectives are established. LEVEL OF EVIDENCE: IV, systematic review.

Surgical Treatment of Juvenile Idiopathic Arthritis in the Era of Novel Drug Therapies.

Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily life. Over the last two decades, the introduction of new drug treatments (including disease-modifying antirheumatic drugs and biologics) has changed the course of this disease, thus reducing the indication for surgery. However, some patients fail to respond to drug therapy and thus require personalized surgical management, e.g., the local reduction of joint effusion or a synovial pannus (via intra-articular corticosteroid injections, synovectomy, or soft tissue release), and management of the sequelae of arthritis (such as growth disorders and joint degeneration). Here, we provide an overview of the surgical indications and outcomes of the following interventions: intra-articular corticosteroid injections, synovectomy, soft tissue release, surgery for growth disorders, and arthroplasty.

Bone health in children with severe cerebral palsy.

Aim: To describe bone health and associated factors in children with severe cerebral palsy. Method: In a retrospective, single-centre study, we performed a comprehensive bone evaluation (including clinical, densitometric and bone biomarker assessments) of children with severe cerebral palsy. Results: None of the 19 included children had a normal BMCTBLH Z score, and only one had a BMDTBLH Z score greater than -2. Six children had a BMDLS Z score greater than -2. The bone biomarker data were suggestive of excessive bone remodelling. Levels of bone remodelling markers factors and densitometric variables were not significantly related. Age, weight and pubertal stage were significantly related to bone mass. Discussion: Our results highlights the insufficient increase in bone mass with age (probably due to excessive bone remodelling) and confirms the high prevalence of low bone mineral density in children with severe cerebral palsy. Possible preventive measures might include calcium + vitamin D supplementation and the systematic management of underweight and delayed puberty. Bone remodelling markers might be of value for follow-up.

Knee laxity after anterior tibial eminence fracture in children: A 35-case series.

INTRODUCTION: Anterior tibial eminence (ATE) fractures are characterized by avulsion of the anterior cruciate ligament insertion. The aim of our study was to evaluate the long-term incidence of laxity and instability in the aftermath of these fractures. The secondary objective was to identify factors for instability. HYPOTHESIS: ATE fracture in children is responsible for laxity and instability in the medium and long term. MATERIAL AND METHODS: This retrospective, single-center study included 35 isolated fractures of the tibial intercondylar eminence during skeletal growth between January 2006 and January 2020. Analysis comprised demographics, laxity measured by GNRB™, range of motion and IKDC and Lysholm scores. Clinical reassessment was performed in 24 patients, the other 11 being interviewed by telephone. RESULTS: Mean laxity on GNRB™ was 1.46mm, and 3 patients had>3mm differential with respect to the healthy knee. Mean IKDC score was 92.2 and mean Lysholm score 93.1. Four patients showed instability, 2 of whom required surgical management. There was no significant difference in occurrence of laxity according to fracture type or reduction quality. Mean follow-up was 5.9years (range, 1.1-14.8). DISCUSSION: Our clinical and functional results were in accordance with the literature. The long-term clinical results were satisfactory. ATE fractures require long-term follow-up to screen for instability and laxity on GNRB™. LEVEL OF EVIDENCE: IV, retrospective study.