Publications by authors named "Yan Lefevre"

26 Publications

  • Page 1 of 1

Functional and radiological outcome after forearm plating in children and adolescent fracture.

Acta Orthop Belg 2021 Mar;87(1):143-149

The literature on forearm overgrowth after plating in traumatic conditions is relatively poor though this technique can be useful when intra-medullary nailing is not sufficient in pediatric cases. The goal of this study was to assess a potential overgrowth after plating and identify impact on function. We conducted a retrospective study of all pediatric patients who underwent open surgery of the radius and/or ulna diaphysis with internal fixation by plating, in our institution, between October 2013 and July 2019. At last follow-up, functional and radiological outcomes were compared between the operated and uninjured forearm. Range of motion (ROM) of the wrist and elbow, clinical scores, radial and ulnar length were measured. A positive bone length discrepancy of more than 2mm was considered as an overgrowth. Were also studied the radio-ulnar index, radial inclination and radiocarpal angle. Thirteen patients were included. The mean age was 12.1 years old (±3.0 years), they were plated on the radius (10 cases) or on the ulna (3 cases). Mean follow- up was 4.4 years (± 1.8). In two cases, the plated bone (radius) was significantly longer than the uninjured one. There was no significant difference regarding radio-ulnar index, radial inclination and radiocarpal angle. The only statistically significant difference between the operated and uninjured forearm was the pronation/supination range, which was greater in the uninjured forearm (mean 160 ±48° versus 175 ±49°, p=0.01). This study confirms the good functional and radiological outcomes after plating even in a skeletally immature forearm. Level of evidence : IV.
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March 2021

Medium-term evaluation of leg lengthening by ISKD® intramedullary nail in 28 patients: Should we still use this lengthening system?

Orthop Traumatol Surg Res 2020 Nov 18;106(7):1433-1440. Epub 2020 Oct 18.

CHU Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France.

Introduction: Lower-limb lengthening presently uses intramedullary nailing. There are motorized systems and mechanical systems, each with their specific complications. The aim of the present study was to assess the efficacy of ISKD® mechanical nails (Orthofix Inc., Texas, USA) on 3D EOS® imaging, and also complications and functional impact.

Hypothesis: The study hypothesis was that nail lengthening is effective but should no longer use the ISKD® system, due to the high rate of specific complications.

Material And Methods: A single-center retrospective study included 28 patients (14 female, 14 male) undergoing limb-lengthening by ISKD® nail between 2005 and 2018. Mean age was 29 years. Twenty-four procedures were femoral and 4 tibial. Lengthening and consolidation parameters and residual discrepancy were measured on 3D EOS® imaging. Complications and functional scores were collated.

Results: Twenty-eight ISKD® nails were implanted in 28 patients. Mean follow-up was 75 months. Planned lengthening was achieved in 78.5% of cases, for a mean lengthening of 34.5mm. Mean lengthening and consolidation indices were respectively 0.94mm/day and 105 days/cm. Length discrepancy showed significant correction, with improvement in functional scores (p<0.01). The overall complications rate was 67.9%, 76% of which were specific to the ISKD® nail.

Discussion: The present study confirmed that nail lengthening is an indication of choice in lower-limb length discrepancy, but that the ISKD® system should no longer be used, due to an excessive rate of specific complications. Complications are due to deficient control of lengthening rate, not found with new-generation motorized nails, which show much fewer complications.

Level Of Evidence: IV, retrospective study without control group.
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http://dx.doi.org/10.1016/j.otsr.2020.06.007DOI Listing
November 2020

Epidemiology of spinal fractures in children: Cross-sectional study.

Orthop Traumatol Surg Res 2020 Nov 12;106(7):1245-1249. Epub 2020 Oct 12.

Société française de chirurgie rachidienne (SFCR), Société française d'orthopedie pédiatrique (SOFOP), 56, rue Boissonade, 75014 Paris, France.

Introduction: Epidemiological studies of fractures of the spine in children are all old, mostly single-centre, with series spanning periods of 5 to 20 years.

Hypothesis: As lifestyle is constantly changing, notably with an increase in sports activities and improvements in the prevention of road and household accidents, epidemiology has likely changed.

Objective: To update the description of spinal trauma in children and adolescents compared to the existing literature.

Material And Method: A multicentre cross-sectional study of spinal fracture, dislocation and spinal cord injury without radiological abnormality (SCIWORA) in children was carried out in 15 French university hospital centres, for a period of one year (2016).

Results: One hundred and sixty-five children were identified: 85 girls, 80 boys; mean age 11 years (range, 10 months-17 years); median, 12 years 6 months. One hundred and fifty-two children (92%) had fracture, 8 (5%) dislocation (including 7 C1-C2 rotary dislocations), and 5 (3%) SCIWORA. Fractures were multiple in 80 cases (49%), contiguous in 73 cases (91%) and non-contiguous in 7 (9%). Locations were cervical in 25 cases (15%), thoracic in 85 (52%), lumbar in 75 and sacral in 4 (2%). Fracture types comprised 234 vertebral compactions (78%), 25 burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures, and 33 other lesions. Causes comprised fall in 77 cases (47%), sports accidents in 56 (34%), road accidents in 29 (18%), and others in 3. In 52 cases (32%), there was ≥1 associated lesion: appendicular in 35 cases (67%), thoracic or abdominal in 31 (60%), and head in 16 (31%). Twenty-one cases had multiple lesions (40%). Eighteen cases showed neurological involvement (11%) including 5 SCIWORAs. Neurological complications were more frequent before 9 years of age.

Conclusion: The epidemiology of spine fractures in children has slightly changed. There are now fewer cervical lesions. Causes are less often road accidents and more often sports accidents. Multi-level lesions remain frequent and the rate of neurological complications is around 10%. Compaction fracture is the most common type.
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http://dx.doi.org/10.1016/j.otsr.2020.06.015DOI Listing
November 2020

Surgical management of burst fractures in children and adolescents: A Multicentre Retrospective Study.

Orthop Traumatol Surg Res 2020 Feb 20;106(1):173-178. Epub 2019 Nov 20.

Service de chirurgie orthopédique pédiatrique, hôpital Purpan, 31300 Toulouse, France.

Background: Spinal fractures are rare in children, in whom they contribute only 2% to 5% of all traumatic spinal injuries. The management of burst fractures is well standardised in adults but remains controversial in paediatric patients, due to specific growth-related considerations. The objective of this study was to assess the clinical and radiographic outcomes of surgical management in a multicentre cohort of paediatric patients with burst fractures, in order to devise an optimal therapeutic strategy.

Hypothesis: A therapeutic strategy for burst fractures in children and adolescents can be devised based on data from a patient cohort and on previously published information.

Material And Methods: Patients younger than 18 years who were managed surgically for one or more burst fractures (Magerl A3) were included in this retrospective multicentre study. Clinical, radiographic, and surgical data were collected before surgery, within 3 months after surgery, and 2 years after surgery. The primary surgical approach was posterior in all patients. Computed tomography (CT) was performed post-operatively to assess the extent of anterior bone loss in order to determine whether anterior fusion was required. The 26 included patients had a mean age of 15±1 years. The thoraco-lumbar spine was involved in 15 (57%) patients. Surgery consisted in correction by instrumentation and posterior fusion only in 14 patients and in posterior correction with anterior fusion in 12 patients. In 10 (38%) patients, the instrumentation extended one vertebra above and one vertebra below the fractured vertebra.

Results: Significant correction of the vertebral kyphosis was achieved (17°±11° before vs. 4°±2° after surgery, p=0.001). Anterior and posterior vertebral heights were significantly increased (15±3mm vs. 20±3mm, p=0.01 and 23±4mm vs. 26±4mm, p=0.04, respectively).

Discussion: The decision to perform surgery rests on the degree of kyphosis and presence of instability. Anterior bone grafting can be added if the instrumentation is short or a bone defect persists after posterior correction. Correction of the local kyphosis is important to prevent sagittal malalignment with its adverse functional consequences in adulthood. Neural decompression must be performed in patients with neurological deficits.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.otsr.2019.08.021DOI Listing
February 2020

Divergent Intramedullary Nailing (DIN): A Modified Intramedullary Nailing Technique to Treat Paediatric Distal Tibial Fractures.

J Pediatr Orthop 2019 Nov/Dec;39(10):e773-e776

Department of Pediatric Orthopaedics, University Hospital of Bordeaux, France.

Introduction: Elastic stable intramedullary nailing (ESIN) allows for efficient reduction and stabilization of fractures of the tibial shaft in children and adolescents. However, for fractures of the distal third of the tibia, traditional ESIN could be inappropriate, thus compromising the stability and the healing of the fracture. The aim of this study was to present and to assess a new technique of modified ESIN to treat fracture of the distal third of the tibia, called divergent intramedullary nailing (DIN).

Methods: We performed a retrospective monocentric study. All patients less than 16 years old, managed in our pediatric orthopaedics department, and operated upon according to the DIN technique for a displaced and/or unstable fracture of the distal third of the tibia were included. Demographic and surgical data were collected. X-rays were performed preoperatively, postoperatively, at 6 weeks, and every 6 months. The surgical technique starts as does the classic ESIN. However, nails are not curved, so that they cross only once at the proximal part of the tibia; they are divergent and supported by the medial and lateral distal part of the tibial shaft. This allows for reduction and stabilization of the fracture.

Results: A total of 13 patients were included, with a mean age of 10 years and a mean follow-up of 32 months. The size of the nail varied between 2.5 and 4 mm. The mean surgical time was 54 minutes. The DIN technique provided a satisfying reduction (coronal and sagittal angulation <3 degrees) for the 13 fractures. In addition, there was no secondary displacement at 6 weeks. All patients were healed at 6 months, with no clinical torsion or axis malalignment.

Conclusions: The current study confirms the feasibility and the efficiency of the DIN method to treat fracture of the distal third of the tibia.
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http://dx.doi.org/10.1097/BPO.0000000000001366DOI Listing
January 2020

Efficacy, pain, and overall patient satisfaction with pediatric upper arm fracture reduction in the emergency department.

Orthop Traumatol Surg Res 2019 05 6;105(3):513-515. Epub 2019 Mar 6.

Department of Pediatric Surgery, Hopital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France.

Introduction: Immediate closed reduction and cast immobilization performed under sedation in the emergency room is the mainstay management for most isolated displaced or angulated upper limb fractures in children. We aimed to determine if this approach is safe, effective and if patients, parents and staff are satisfied with this approach.Our working hypothesis was this management provides a high satisfaction rate.

Patients And Methods: Between January 2017 and October 2017 we included 118 children presenting with upper arm fractures amenable to closed reduction under our institutional analgesia protocol. Children received 0.4mg/kg of Oramorph oral solution, they were then evaluated 40minutes later, and if their Face Legs Activity Cry Consolability (for children under 16 years-old) and/or Visual Analog Scale (for children over 6 years-old) were under 4, they underwent closed reduction by an orthopaedic resident under Nitrous oxide. If their pain assessment scale was above 4, they received an extra 0.4mg/kg of Oramorph oral solution and underwent closed reduction 40minutes later under nitrous oxide. These children were managed without hospitalization, as outpatients. Children>6, families and nursing staff were also given a visual satisfaction scale (using a 1-10 score) just before being discharged from the ER in order to evaluate their experience.

Results: Closed reduction in the ER was judged satisfactory from an orthopedic point-of-view in 115 cases (97.6%). Parents, children and the nursing team gave the experience in the ER an average satisfaction score of 9 out of 10.

Conclusion: ER reduction is not only safe and effective but is also associated with a high satisfaction rate amongst children, their families and the nursing staff.
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http://dx.doi.org/10.1016/j.otsr.2018.10.027DOI Listing
May 2019

Long-Term (>10 Years) Results After Endoscopic Injection Therapy for Vesicoureteral Reflux.

J Laparoendosc Adv Surg Tech A 2018 Nov 23;28(11):1408-1411. Epub 2018 Jul 23.

2 Department of Pediatric Surgery, Children's Hospital , CHU Toulouse, France .

Objective: Endoscopic injection is an accepted alternative for the treatment of vesicoureteral reflux (VUR) with the most commonly used agent being dextranomer/hyaluronic acid (Dx/HA). There are few reports on very long-term results after this treatment, although the biodegradable nature of the product could indicate that results might deteriorate on the long term. We, therefore, decided to evaluate the efficacy of Dx/HA copolymer endoscopic injection, in terms of recurrence of febrile urinary tract infections (fUTIs) in children, with a follow-up of at least 10 years.

Materials And Methods: We analyzed the medical data of all children who were diagnosed with VUR and underwent endoscopic injection with >10 years follow-up, in two University Hospitals. We reviewed their medical files and then contacted patients by phone.

Results: We found 68 patients who had undergone endoscopic treatment of VUR with a follow-up of minimum 10 years. We were able to contact 53 of these patients of whom 38 were girls, and 36 had bilateral VUR with a total of 89 ureteral units. Mean age at surgery was 86 months (26-136). Mean follow-up was 12.5 years (range: 10.5-15). No child presented postinjection obstruction. Thirteen patients presented with a recurrence of fUTI during the postoperative course of whom 8 presented persistent VUR. All recurrences of fUTI occurred within the first 5 years of follow-up. Four underwent a second injection and 4 underwent open reimplantation. Success rate per patient was 85%.

Conclusion: Results of endoscopic injection using Dx/HA remain stable over time (>10 years). In our series, recurrences of fUTI occur within the first 5 years of follow-up.
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http://dx.doi.org/10.1089/lap.2018.0035DOI Listing
November 2018

Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort.

Eur Spine J 2018 09 29;27(9):2241-2250. Epub 2018 Jun 29.

Pediatric Orthoapedic Department, Robert Debre University Hospital, Paris VII University, Paris, France.

Introduction: Proximal junctional kyphosis (PJK) is a frequent complication, up to 46%, in adolescent idiopathic scoliosis surgical treatment (AIS). Several risk factors have been evoked but remain controversial. The purpose of this study was to analyze the incidence of PJK in a multicenter cohort of AIS patient and to determine risk factor for PJK.

Materials And Methods: Lenke I and II AIS patients operated between 2011 and 2015 (minimum of 2-years follow-up) were included. On fullspine X-rays, coronal and sagittal radiographic parameters were measured preoperatively, postoperatively and at final follow-up. Occurrence of radiological PJK corresponding to a 10° increase in the sagittal Cobb angle, measured between the upper instrumented vertebra (UIV) and UIV + 2, between postoperative and 2-years follow-up X-rays, was reported.

Results: Among the 365 patients included, 15.6% (n = 57) developed a PJK and only 10 patients required a revision surgery. Preoperatively, PJK patients had significantly larger pelvic incidence (57° ± 13° vs. 51° ± 12°), larger lumbar lordosis (LL) (63° ± 12° vs. 57° ± 11°) and bigger C7 slope. Postoperatively (3 months), in the non-PJK group, thoracic kyphosis (TK) was increased and LL was not significantly different. However, postoperatively, in the PJK group, no significant change was observed in TK, whereas C7 slope decreased and LL significantly increased. There was also a postoperative change in inflection point which was located at a more proximal level in the PJK group. Between postoperative time and final follow-up, TK and LL significantly increased in the PJK group.

Conclusion: PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK. As demonstrated in ASD, one of the causes of PJK might be postoperative posterior imbalance that can be due to increased LL, insufficient TK or inflection point shift during surgery. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-018-5640-yDOI Listing
September 2018

Optimal postoperative immobilisation for supracondylar humeral fractures.

Orthop Traumatol Surg Res 2018 09 25;104(5):645-649. Epub 2018 May 25.

Service de chirurgie pédiatrique, CHU de Bordeaux, site Pellegrin, place Amélie Raba-Leon, 33076 Bordeaux, France.

Background: Supracondylar humeral fractures (SCHFs) are very common in paediatric patients. In France, percutaneous fixation with two lateral-entry pins is widely used after successful closed reduction. Postoperative immobilisation is typically with a long arm cast combined with a tubular-bandage sling that immobilises the shoulder and holds the arm in adduction and internal rotation to prevent external rotation of the shoulder, which might cause secondary displacement. The objective of this study was to compare this standard immobilisation technique to a posterior plaster splint with a simple sling.

Hypothesis: Secondary displacement is not more common with a posterior plaster splint and sling than with a long arm cast.

Material And Methods: One hundred patients with extension Gartland type III SCHFs managed by closed reduction and percutaneous fixation with two lateral-entry pins between December 2011 and December 2015 were assessed retrospectively. Postoperative immobilisation was with a posterior plaster splint and a simple sling worn for 4 weeks. Radiographs were obtained on days 1, 45, and 90.

Results: Secondary displacement occurred in 8% of patients. No patient required revision surgery.

Discussion: The secondary displacement rate was comparable to earlier reports. Of the 8 secondary displacements, 5 were ascribable to technical errors. The remaining 3 were not caused by rotation of the arm and would probably not have been prevented by using the tubular-bandage sling.

Conclusion: A posterior plaster splint combined with a simple sling is a simple and effective immobilisation method for SCHFs provided internal fixation is technically optimal.

Level Of Evidence: IV retrospective observational study.
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http://dx.doi.org/10.1016/j.otsr.2018.03.015DOI Listing
September 2018

Children with abnormal DMSA nuclear scan present a higher risk of recurrent febrile urinary tract infections.

World J Pediatr 2019 Apr 20;15(2):204-205. Epub 2018 Mar 20.

Methodological Support Unit, CHU de La Reunion, La Reunion, France.

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http://dx.doi.org/10.1007/s12519-018-0152-8DOI Listing
April 2019

Bladder Dysfunction in Children with Neurofibromatosis Type I: Report of Four Cases and Review of the Literature.

Urol Int 2018 7;100(3):339-345. Epub 2018 Mar 7.

University of Bordeaux, Bordeaux, France.

Aim: Neurofibromatosis type 1 (NF1) is a rare autosomal dominant disorder. Malignant transformation into malignant peripheral nerve sheath tumors (MPNST) can occur. However, urinary tract involvement is rare. We report 4 cases of NF1 with bladder dysfunction.

Methods: A retrospective single center analysis of 4 patients was conducted over a 17-year period, focusing on urinary tract involvement.

Results: NF1 was diagnosed at a median of 16.5 months (4-36) and urinary involvement occurred at a median of 5.25 years (4-9) after diagnosis. Bladder dysfunction was due to spinal cord compression in 2 cases, bladder invasion in 1 case, and cerebral lesions in 1 case. Malignant transformation of neurofibromas into MPNST occurred in 2 patients. Mechanisms of urinary involvement in NF1 are diverse and no pre-established protocol of management and follow-up exists.

Conclusion: Although rare, dysfunction of the bladder can arise in NF1 and innovative strategies then need to be considered. This is best achieved with the help of a multidisciplinary team and a national reference center when available.
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http://dx.doi.org/10.1159/000487193DOI Listing
December 2018

How can we decrease preoperative anxiety in parents of children undergoing surgery?

Arch Dis Child 2018 10 4;103(10):1001-1002. Epub 2018 Jan 4.

Department of Paediatric Surgery, Hopital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, Aquitaine, France.

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http://dx.doi.org/10.1136/archdischild-2017-314579DOI Listing
October 2018

Planning for Bone Excision in Ewing Sarcoma: Post-Chemotherapy MRI More Accurate Than Pre-Chemotherapy MRI Assessment.

J Bone Joint Surg Am 2018 Jan;100(1):13-20

Departments of Pediatric Orthopaedics (C.T.-L. and J.S.d.G.) and Radiology (L.D. and J.V.), Hôpital des Enfants, Toulouse-Purpan University Hospital, Toulouse, France.

Background: In determining the level of bone resection in Ewing sarcoma, the most suitable time at which to perform magnetic resonance imaging (MRI) remains controversial. Current guidelines recommend that surgical planning be based on MRI performed prior to neoadjuvant chemotherapy. The goal of this study was to determine whether pre-chemotherapy or post-chemotherapy MRI provides greater accuracy of tumor limits for planning bone excision in the management of Ewing sarcoma.

Methods: This was a single-center, retrospective study. MRI was performed using 3 sequences: T1-weighted, T1-weighted with contrast enhancement by gadolinium injection, and a fluid-sensitive sequence (STIR [short tau inversion recovery] or proton-density-weighted with fat saturation). The tumor extent as assessed on pre-chemotherapy and post-chemotherapy MRI was compared with histological measurement of the resected specimen.

Results: Twenty patients with Ewing sarcoma of a long bone were included. In 6 cases, the tumor was located on the femur, in 5, the tibia; in 5, the fibula; and in 4, the humerus. The median patient age at diagnosis was 9.7 years. We found greater accuracy of measurements from MRI scans acquired after chemotherapy than from those acquired before chemotherapy. For both pre-chemotherapy and post-chemotherapy MRI, the greatest accuracy was achieved with the nonenhanced T1 sequence. There was no benefit to gadolinium enhancement. The median difference between T1 MRI and histological measurements was 19.0 mm (interquartile range [IQR], 4.3 to 32.8 mm) before chemotherapy and 5.0 mm (IQR, 2.0 to 13.0 mm) after chemotherapy. Adding a minimum margin of 20 mm to the limit of the tumor on post-chemotherapy T1 MRI always led to safe histological margin.

Conclusions: Post-chemotherapy MRI provided a more accurate assessment of the limits of Ewing sarcoma. Surgical planning can therefore be based on post-chemotherapy MRI. Surgical cuts can be, at minimum, 20 mm from the limits as seen on MRI.
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http://dx.doi.org/10.2106/JBJS.16.01461DOI Listing
January 2018

Can quantity of amniotic fluid reliably predict postnatal renal function in boys with posterior urethral valves: a decision curve analysis.

Prenat Diagn 2017 Sep 6;37(9):931-934. Epub 2017 Aug 6.

Unité de Soutien Méthodologique, CHU de La Réunion, Saint-Denis, La Reunion, France.

Objective: Prenatal management of male fetuses with suspected posterior urethral valves depends on reliable markers for postnatal long-term renal function. Whether ultrasound parameters, including the presence or absence of oligohydramnios, are reliable remains the subject of debate. We decided to evaluate the reliability of quantity of amniotic fluid to predict postnatal renal function using decision curve analysis (DCA), a method for evaluating the clinical utility of a diagnostic test.

Methods: We analyzed retrospectively 51 male fetuses born with prenatally suspected posterior urethral valves between 2009 and 2012. We studied the relationship between quantity of amniotic fluid on prenatal ultrasound and the nadir creatinine during the first year of life as a proxy of postnatal renal function using DCA.

Results: Twelve fetuses presented with prenatal oligohydramnios. Thirty-one children had a normal nadir creatinine, of which one had prenatal oligohydramnios (3.2%). Thirteen had a nadir creatinine between 35 and 75 μmol/L, of which four had prenatal oligohydramnios (30.8%). Seven had a nadir creatinine >75 μmol/L, all of them had prenatal oligohydramnios.

Conclusion: In this retrospective study, DCA confirms the relationship between prenatal quantity of amniotic fluid volume and postnatal renal function. © 2017 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/pd.5120DOI Listing
September 2017

Critical Analysis of a Series of Early Inguinal Ureterostomies: Are They Useful and How Well Are They Tolerated?

Urol Int 2017 13;98(3):328-333. Epub 2016 Dec 13.

Department of Urology, Royal Children's Hospital, Parkville, Australia.

Introduction: The study aimed to evaluate the advantages of temporary inguinal ureterostomy in the management of neonates with uropathies and early or recurrent pyelonephritis.

Patients And Methods: We performed a retrospective analysis of all patients who underwent ureterostomies between 1989 and 2012, with specific regards to indications and outcomes. We also performed a survey of parents to evaluate their acceptance of diversion.

Results: We included 18 patients (12 primary high-grade vesicoureteral reflux [VUR] and 6 primary obstructive megaureters [MUs]). Indications were recurrent febrile urinary tract infections (UTIs) despite antibiotic prophylaxis, doubtful function of the overlying kidney for the oldest cases, when renal function was only assessed by intravenous urography, or both. Cutaneous diversion was performed between the ages of 2 weeks to 5 months (median: 1.8 months). Renal function was assessed prior to undiversion to choose between reimplantation and nephrectomy. The incidence of febrile UTIs significantly decreased during the period of diversion. Urinary diversion was judged socially acceptable by parents. Ureterostomy did not modify the overlying kidney function.

Conclusion: Temporary inguinal ureterostomy does not enable better evaluation of renal function by suppressing the pressure of an obstacle or refluxing urines. Its remaining indication seems to be the prevention of recurrent UTIs in neonates and infants with VUR or MU, pending reimplantation.
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http://dx.doi.org/10.1159/000452865DOI Listing
October 2017

Conservative treatment of pediatric thoracic and lumbar spinal fractures: outcomes in the sagittal plane.

J Pediatr Orthop B 2017 Jan;26(1):73-79

Departments of aPediatric Orthopaedics bAdult Orthopaedics, Pellegrin University Hospital, Bordeaux cDepartment of Pediatric Orthopaedics, Robert Debré Hospital, ap-hp, Paris dDepartment of Pediatric Orthopaedics, Purpan University Hospital, Toulouse, France.

To assess sagittal plane spinopelvic balance and functional outcomes in a pediatric cohort of patients with a thoracic and/or a lumbar fracture treated conservatively. A multicentric study retrospectively reviewed radiological and functional outcomes (mean follow-up 49 months) of 48 patients (mean age 12 years) with thoracic and/or lumbar spinal fractures that occurred between 1996 and 2014. Demographic data and radiological spinopelvic parameters were analyzed. Functional outcome was evaluated by a telephone interview. First, a comparison between the initial and the last follow-up full-spine radiographs was performed for the assessment of bone remodeling and sagittal plane balance. Then, patients were classified into two groups (group 1: Risser≤2 and group 2, Risser>2) to assess the influence of skeletal maturity on the restoration of a correct sagittal balance. A total of 62% of the patients were at skeletal maturity at the final follow-up (Risser 4 and 5). Patients with a Risser grade of 2 or less had a higher remodeling potential. The mean residual local kyphosis in thoracic and lumbar fractures was, respectively, 8.2° and 8.7°. The mean thoracic global kyphosis remains stable at the last follow-up, in contrast to lumbar lordosis, which increased significantly. Sagittal plane global measurements on the basis of the C7-plumbline remained unchanged at the last follow-up. There was no change in the pelvic parameters, except for the sacral slope in the group 1 for patients with a lumbar fracture. The current study confirms a greater correction in younger patients (Risser≤2) in spinal fractures and reported that thoracic fractures have a higher remodeling potential than lumbar fracture. A local kyphosis of almost 10° remained at the last follow-up. However, no deterioration in the sagittal plane balance was found. This suggests compensatory mechanisms in adjacent structures for children and adolescents and excludes the only hypothesis of bone remodeling.
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http://dx.doi.org/10.1097/BPB.0000000000000329DOI Listing
January 2017

Effects of glia metabolism inhibition on nociceptive behavioral testing in rats.

Data Brief 2016 Jun 26;7:372-5. Epub 2016 Feb 26.

Neurocentre Magendie, Inserm U1215, F-33000 Bordeaux, France; Univ. Bordeaux, F-33000 Bordeaux, France.

Fluoroacetate has been widely used to inhibit glia metabolism in vivo. It has yet to be shown what the effects of chronic intrathecal infusion of fluoroacetate on nociceptive behavioral testing are. The effects of chronic infusion of fluoroacetate (5 nmoles/h) for 2 weeks were examined in normal rats. Chronic intrathecal fluoroacetate did not alter mechanical threshold (von Frey filaments), responses to supra-threshold mechanical stimuli (von Frey filaments), responses to hot (hot plate) or cool (acetone test) stimuli and did not affect motor performance of the animals, which was tested with rotarod. This suggests that fluoroacetate at appropriate dose did not suppress neuronal activity in the spinal cord.
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http://dx.doi.org/10.1016/j.dib.2016.02.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781975PMC
June 2016

Neuropathic pain depends upon D-serine co-activation of spinal NMDA receptors in rats.

Neurosci Lett 2015 Aug 13;603:42-7. Epub 2015 Jul 13.

Neurocentre Magendie, Inserm U862, F-33000 Bordeaux, France; Univ. Bordeaux, F-33000 Bordeaux, France. Electronic address:

Activation of N-methyl-d-aspartate (NMDA) receptors is critical for hypersensitivity in chronic neuropathic pain. Since astroglia can regulate NMDA receptor activation by releasing the NMDA receptor co-agonist d-serine, we investigated the role of NMDA receptor and d-serine in neuropathic chronic pain. Male Wistar rats underwent right L5-L6 spinal nerve ligation or sham surgery and were tested for mechanical allodynia and hyperalgesia after 14 days. Acute intrathecal administration of the NMDA receptor antagonist d-AP5 as well as chronic administration of the glia metabolism inhibitor fluoroacetate significantly reduced mechanical allodynia in neuropathic rats. The effect of fluoroacetate was reversed by acutely administered intrathecal d-serine. Degrading d-serine using acute intrathecal administration of d-aminoacid oxidase also reduced pain symptoms. Immunocytochemistry showed that about 70% of serine racemase, the synthesizing enzyme of d-serine, was expressed in astrocyte processes in the superficial laminae of L5 dorsal horn. Serine racemase expression was upregulated in astrocyte processes in neuropathic rats compared to sham rats. These results show that neuropathic pain depends upon glial d-serine that co-activates spinal NMDA receptors.
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http://dx.doi.org/10.1016/j.neulet.2015.07.010DOI Listing
August 2015

Post-trauma scoliosis after conservative treatment of thoracolumbar spinal fracture in children and adolescents: results in 48 patients.

Eur Spine J 2016 Apr 9;25(4):1144-52. Epub 2015 Jan 9.

Department of Pediatric Orthopaedics, Pellegrin University Hospital, Place Amélie Raba-Léon, 33076, Bordeaux, France.

Purpose: Authors examined a case series of patients younger than 18 years old who had sustained a traumatic thoracolumbar spine fracture to evaluate radiological and clinical findings of coronal spinal balance, after conservative treatment.

Methods: From 1996 to 2014, a tricentric cohort of 48 patients with an average age of 12 years was radiographically reviewed at 50 months. Cobb angle of fractured vertebra and regional Cobb angle were measured both at baseline and follow-up. Analyses were done according to initial Risser grade, number of fractures and level of injury.

Results: There was a total of 11 scoliosis. In group with Risser grade 3 or above, with a single vertebral fracture and lumbar fracture, final regional Cobb angle was statistically higher than initial regional Cobb angle.

Conclusions: The prevalence of scoliosis in our population is higher than those of idiopathic scoliosis; Risser grade 3 or above, lumbar fracture and a single fracture seem to account for more severe coronal deformation.
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http://dx.doi.org/10.1007/s00586-014-3744-6DOI Listing
April 2016

Digital avulsion with compromised vascularization: study of 23 cases in children.

J Pediatr Orthop 2011 Apr-May;31(3):259-65

Department of Pediatric Orthopaedic, Robert Debré Hospital, AP-HP, Paris 7 University, Paris, France.

Background: Avulsion of a digit has not always been an indication for replantation because of extensive injuries. The advent of microsurgery changed this, permitting avulsed digit replantations with varying rates of success. The aim of this study was to analyze surgical management of finger avulsion injuries of an exclusively pediatric series.

Methods: A retrospective study of children with finger avulsion injuries and compromised arterial circulation degloving or amputation, treated primarily in our institution between 1997 and 2007. Factors that could affect the outcome included demographic and clinical data, description of the lesion using Urbaniak's and Tamai's classification, technical data related to surgery, and results of revascularization were collected.

Results: Twenty-three children with 23 digital injuries were identified as digital avulsions with compromised vascularization. The mean age was 11 years and 8 months (range, 2 to 15 y). Four cases involved devascularization classified as Urbaniak 2 and the other 19 cases involved amputation or complete degloving, classified as Urbaniak 3. In 7 cases, replantation was not performed because of the extent of the lesions (all were classified as Urbaniak 3). The complete survival rate when revascularization or replantation was attempted was 25%. One case required a new procedure 6 days after the first surgery with a trans-P2 amputation. Injuries classified as Urbaniak 2 had an overall survival rate of 75% and injuries classified Urbaniak 3 had an overall survival rate of 5.3%.

Conclusions: The global rate of survival after revascularization or replantation of avulsed fingers in children seemed to be poor. Urbaniak classification is an important prognostic factor with a good prognosis for lesions classified as Urbaniak 2 and a very poor prognosis for lesions classified as Urbaniak 3.
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http://dx.doi.org/10.1097/BPO.0b013e31820fc620DOI Listing
July 2011

Thoracoscopy in children less than 20 kg for the management of spinal disorders: efficacy at long-term follow-up.

J Pediatr Orthop 2011 Mar;31(2):170-9

Department of Pediatric Orthopaedic, Robert Debré Hospital, AP-HP, Paris 7 University, Paris, France.

Background: Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients.

Methods: This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required.

Results: Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases.

Conclusions: This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation.

Level Of Evidence: IV.
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http://dx.doi.org/10.1097/BPO.0b013e31820a91feDOI Listing
March 2011

Hybrid constructs for tridimensional correction of the thoracic spine in adolescent idiopathic scoliosis: a comparative analysis of universal clamps versus hooks.

Spine (Phila Pa 1976) 2010 Feb;35(3):306-14

Robert Debré Hospital, Paris, France.

Study Design: Retrospective study of prospectively collected data.

Objective: Compare Universal Clamps (UCs) and hooks for the thoracic correction of adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: In scoliosis surgery, sagittal correction is as important as frontal correction due to the risk of junctional kyphosis. Compared to all-screw constructs, hybrid constructs with lumbar pedicle screws and thoracic hooks or sublaminar wires have been shown to achieve similar coronal correction while providing superior postoperative thoracic kyphosis. The authors used a novel sublaminar thoracic implant, the UC with improvements over sublaminar wires. Hybrid constructs using thoracic UCs were compared to those with thoracic hooks.

Methods: This series involved 150 patients treated for AIS with hybrid constructs. A total of 75 consecutive patients operated from 2001 to 2003, who had thoracic hooks with in situ contouring, distraction, and compression (Group 1), were compared to 75 consecutive patients operated from 2004 to 2006, who had thoracic UCs with posteromedial translation (Group 2). All had intraoperative somatosensory/motor-evoked potential monitoring and at least 2-years follow-up.

Results: Except for follow-up (longer in Group 1), the 2 groups were similar before surgery. The UCs achieved better thoracic coronal correction (P < 0.001), Cincinnati index (P < 0.001), kyphosis (P = 0.02), and apical rotation (P < 0.001). In normokyphotic or hypokyphotic patients, the UC corrected thoracic kyphosis by 11.2 degrees (55%) versus 0.4 degrees (2%) achieved by hooks (P < 0.0001). These differences were stable at last follow-up. There were no intraoperative complications or changes in somatosensory/motor-evoked potentials. UC reduced operative time by 20% (60 minutes; P < 0.001) and blood loss by 23% (250 mL; P < 0.001).

Conclusion: Although both of these hybrid constructs efficaciously corrected the coronal and axial deformities in AIS, the results of the UC technique were superior to those achieved with hooks in all 3 planes, especially the sagittal plane. Moreover, the UC technique is straightforward and safe, reducing both operative duration and blood loss.
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http://dx.doi.org/10.1097/BRS.0b013e3181b7c7c4DOI Listing
February 2010

Efficacy and safety of posteromedial translation for correction of thoracic curves in adolescent idiopathic scoliosis using a new connection to the spine: the Universal Clamp.

Eur Spine J 2009 Feb 16;18(2):158-69. Epub 2008 Dec 16.

Department of Pediatric Orthopaedics, Robert Debré Hospital, AP-HP, Paris 7 University, Paris, France.

Correction of adolescent idiopathic scoliosis (AIS) has been reported with various systems. All-screw constructs are currently the most popular, but they have been associated with a significant decrease in thoracic kyphosis, with a potential risk of junctional kyphosis, not observed with hybrid constructs in the literature. In addition, it is important to weigh potential advantages of pedicle screw fixation against risks specific to its use. Because hybrid constructs are associated with a lower risk of complications and better sagittal correction than all-screw constructs, at present we use lumbar pedicle screws combined with a new sublaminar connection to the spine (Universal Clamps) at thoracic levels. The purpose of this study was to determine the efficacy and safety of the Universal Clamp (UC) posteromedial translation technique for correction of AIS. Seventy-five consecutive patients underwent posterior spinal fusion and hybrid instrumentation for progressive AIS. Correction was performed at the thoracic level using posteromedial translation. At the lumbar level, correction was performed using in situ contouring and compression/distractions maneuvers. A minimum 2-year follow-up was required. Medical data and radiographs were prospectively analyzed and compared using a paired t test. The average age at surgery was 15 years and 4 months (+/-19 months). The average number of levels fused was 12+/-1.6. The mean follow-up was 30+/-5 months. The average preoperative Cobb angle of the major curve was 60 degrees+/-20 degrees. The immediate postoperative major curve correction averaged 66+/-13%. The average loss of correction of the major curve between the early postoperative assessment and latest follow-up was 3.5 degrees+/-1.4 degrees . The mean Cincinnati correction index was 1.7+/-0.8 postoperatively, and 1.57+/-1 at last follow up. The mean rotation of the apical vertebra was corrected from 23.3 degrees+/-9 degrees preoperatively to 7.3 degrees+/-5 degrees at last follow up (69% improvement, P<0.0001). In the sagittal plane, the mean thoracic kyphosis improved from 23.8 degrees+/-14.2 degrees preoperatively to 32.3 degrees+/-7.3 degrees at last follow up. For the 68 patients who had a normokyphotic or a hypokyphotic sagittal modifier, thoracic kyphosis increased from 20.5 degrees+/-9.9 degrees to 31.8 degrees+/-7.4 degrees, corresponding to a mean kyphosis correction of 55% at last follow up. No intraoperative complication occurred and none of the patients developed proximal junctional kyphosis during the follow up. The principal limitation of the UC technique was the rate of proximal posterior prominence (14.6%), leading us to recommend the use of conventional claws at the upper extremity of the construct. The technique was safe, and reduced operative time, radiation exposure, and blood loss. While achieving correction of deformity in the coronal and axial planes equivalent to the best reported results of all-screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome in all three planes was maintained at 2 year follow up.
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http://dx.doi.org/10.1007/s00586-008-0839-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899338PMC
February 2009

Molecular diagnosis of Kingella kingae osteoarticular infections by specific real-time PCR assay.

J Med Microbiol 2009 Jan;58(Pt 1):65-68

Genomic Research Laboratory, Service of Infectious Diseases, University of Geneva Hospitals (HUG), CH-1211 Geneva 14, Switzerland.

Kingella kingae is an emerging pathogen that is recognized as a causative agent of septic arthritis and osteomyelitis, primarily in infants and children. The bacterium is best detected by rapid inoculation in blood culture systems or by real-time PCR assays. Pathogenesis of the agent was linked recently to the production of a potent cytotoxin, known as RTX, which is toxic to a variety of human cell types. The locus encoding the RTX toxin is thought to be a putative virulence factor, and is, apparently, essential for inducing cytotoxic effects on respiratory epithelial, synovial and macrophage-like cells. Herein, we describe a novel real-time PCR assay that targets the RTX toxin gene and illustrate its use in two clinical cases. The assay exhibited a sensitivity of 30 c.f.u., which is 10-fold more sensitive than a previously published semi-nested broad-range 16S rRNA gene PCR, and showed no cross-reactivity with several related species and common osteoarticular pathogens.
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http://dx.doi.org/10.1099/jmm.0.47707-0DOI Listing
January 2009

How to determine the upper level of instrumentation in Lenke types 1 and 2 adolescent idiopathic scoliosis: a prospective study of 132 patients.

J Pediatr Orthop 2008 Oct-Nov;28(7):733-9

Department of Pediatric Orthopaedic, Robert Debré Hospital, Paris 7 University, Paris, France.

Background: The selection of fusion levels continues to be controversial in adolescent idiopathic scoliosis (AIS). The classifications of King and Lenke remain the most widely used, but recent studies have demonstrated their shortcomings, including poor interobserver reproducibility. We propose a method of preoperative planning that is independent of anatomical classifications, based on the anticipated effect of curve reduction. The objectives of this preoperative strategy are (1) to achieve satisfactory T1 tilt and shoulder balance and (2) to restore balance in the coronal and sagittal planes. The purpose of the present study was to evaluate the results of our strategy of deciding the proximal level of arthrodesis in Lenke types 1 and 2 AIS.

Methods: We included 132 adolescents operated on for thoracic AIS by posterior instrumentation. The choice of the proximal fusion level was based on preoperative analysis of the rigidity of the proximal curvature, T1 tilt, and shoulder balance. The preoperative, postoperative, and last follow-up radiographs were digitized then analyzed using computer software. Radiological parameters were compared using paired t tests.

Results: Average age at the time of surgery was 15.2 years (SD, 1.7 years). Mean follow-up was 30.2 months. The clavicle angle and T1 tilt were significantly improved in both Lenke types 1 and 2 curves. No correlation was found between T1 tilt and shoulder balance. At last follow-up, 89% of the patients satisfied all criteria for balance.

Conclusions: The results of the present preoperative strategy, to which we adhered in 97% of cases, are encouraging and show that the systematic instrumentation of the entire proximal curvature is not justified in Lenke type 2 curves. However, long-term consequences of the residual T1 tilt need to be studied further.
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http://dx.doi.org/10.1097/BPO.0b013e318185a36bDOI Listing
December 2008

Surgical treatment of missed Monteggia lesions in children.

J Child Orthop 2007 Oct 29;1(4):237-42. Epub 2007 Aug 29.

Department of Pediatric Orthopaedics, Children's Hospital, University Hospital of Geneva, rue Willy-Donzé 6, 1205, Geneva, Switzerland,

Purpose: The treatment of an unrecognized Monteggia lesion continues to pose a therapeutic challenge, as evidenced by the variety of surgical techniques described. Moreover, there are high complication and redislocation rates following surgery. This report concerns a surgical technique to reduce a chronic dislocation of the radial head utilizing an ulnar osteotomy and internal fixation.

Methods: Six consecutive cases of missed Monteggia lesions were treated in our institution between August 2001 and September 2003. Patient mean age was 6.5 (range 4-8) years, and the mean interval between injury and surgical procedure was 17 (range 1-49) months. Surgery consisted of an ulnar osteotomy with angulation and lengthening, bone grafting at the osteotomy site, and internal fixation. Open reduction of the radial head, repair or reconstruction of the annular ligament or temporary fixation of the radial head with a transarticular wire was not undertaken. Cast immobilization with the forearm in neutral rotation was maintained for 2 weeks.

Results: There was one case of nonunion. At an average follow-up of 3 (range 1.5-4.4) years, all patients had regained painless function of the forearm, good range of elbow and forearm motion, and maintenance of the radial head reduction.

Conclusions: Both angulation and elongation of the ulna are required to allow for reduction of the radial head. We do not see any indication for procedures directed at the radio-capitellar joint.
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http://dx.doi.org/10.1007/s11832-007-0039-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656735PMC
October 2007