Flatfoot in children and adolescents. Analysis of imaging findings and therapeutic implications

SummaryIntroductionPes planovalgus (PPV) is a complex three-dimensional deformity of which routine radiographs provide only a two-dimensional analysis.HypothesisAngles and other radiographic parameters of the foot in children and adolescents, when studied on both the dorsoplantar and the lateral view, can be used to establish a radiographic classification system for PPV that provides useful therapeutic guidance in clinical practice.Materials and methodsA retrospective single-centre study was conducted on 65 feet in 35 patients aged 7 to 18 years and having adequate ossification. All patients had a clinical diagnosis of idiopathic or neurologic PPV and available weight-bearing dorsoplantar and strict lateral radiographs. We excluded pes planus due to tarsal coalition, congenital bone deformities, or overcorrection of talipes equinovarus (n=25). All possible axes were drawn and angles measured after an evaluation of interindividual agreement.ResultsWe identified four patterns of PPV: subtalar pes planus (n=16) with marked subtalar valgus and longitudinal sag predominating at the talonavicular joint, midtarsal pes planus (n=12) without subtalar valgus but with marked midtarsal abduction and sag predominating at the cuneonavicular joint, mixed pes planus (n=28) with subtalar valgus, midtarsal abduction, and sag at both the talonavicular and cuneonavicular joints, and pes planocavus (n=9) with sag of the medial arch and cavus deformity of the lateral arch.ConclusionThis original classification system provides therapeutic guidance by helping to match the surgical procedure to the nature and location of the deformities.Level of evidenceLevel IV

Can procalcitonin measurement help the diagnosis of osteomyelitis and septic arthritis? A prospective trial

<p>Abstract</p> <p>Objectives</p> <p>Procalcitonin (PCT) is an accurate marker for differentiating bacterial infection from non-infective causes of inflammation or viral infection. However, there is only one study in children which tested procalcitonin as a diagnostic aid in skeletal infections. With this study we sought to evaluate the sensitivity, specificity and predictive values of procalcitonin for identifying bone and joint infection in children evaluated in the emergency department for non traumatic decreased active motion of a skeletal segment.</p> <p>Methods</p> <p>Patients aged 1 month to 14 years were prospectively included in the emergency department when suspected for osteomyelitis or septic arthritis. Procalcitonin levels, C reactiv protein, white blood cell count were measured and bacteriological samples were collected before initiation of antibiotic treatment. Patients were assigned to 3 groups according to the degree of suspected infection: group 1 confirmed infection, group 2 presumed infection and group 3 non infected patients.</p> <p>Results</p> <p>Three hundred thirty nine patients were included (118 girls and 221 boys). Group 1 comprised 8 patients (2 had PCT levels > 0.5 ng/ml). Two had osteomyelitis and 6 septic arthritis. Forty children were incuded in group 2 (4 had PCT levels > 0.5 ng/ml). Eighteen had presumed osteomyelitis and 22 presumed septic arthritis. Group 3 comprised 291 children (9 PCT levels > 0.5 ng/ml) who recovered without antibiotic treatment. The specificity of the PCT as a marker of bacterial infection (comparing Group 1 and Group 3) was 96.9% [95% CI, 94.2-98.6], the sensitivity 25% [95% CI, 3.2-65.1], the positive predictive value (PPV) 18.2% [95% CI, 2.3-51.8] and the negative predictive value (NPV) 97.9% [95% CI, 95.5-99.2].</p> <p>Conclusion</p> <p>PCT is not a good screening test for identifying skeletal infection in children. Larger studies are needed to evaluate still more the place of PCT measurements in the diagnosis of osteomyelitis and septic arthritis.</p

Biomechanical cadaver study of proximal fixation in a minimally invasive bipolar construct

Study design Biomechanical human cadaver study. Objective To determine the three-dimensional intervertebral ranges of motion (ROMs) of intact and hook-instrumented tho- racic spine specimens subjected to physiological loads, using an in vitro experimental protocol with EOS biplane radiography. Summary of background data Pedicle screws are commonly used in thoracic instrumentation constructs, and their biome- chanical properties have been widely studied. Promising clinical results have been reported using a T1–T5 thoracic hook–claw construct for proximal rod anchoring. Instrumentation stability is a crucial factor in minimizing mechanical complications rates but had not been assessed for this construct in a biomechanical study. Methods Six fresh-frozen human cadaver C6–T7 thoracic spines were studied. The first thoracic vertebrae were instrumented using two claws of supra-laminar and pedicle hooks, each fixed on two adjacent vertebrae, on either side of a single free vertebra. Quasi-static pure-moment loads up to 5 Nm were applied to each specimen before and after instrumentation, in flexion–extension, right and left bending, and axial rotation. Five steel beads impacted in each vertebra allowed 3D tracking of vertebral movements on EOS biplanar radiographs acquired after each loading step. The relative ranges of motion (ROMs) of each pair of vertebras were computed. Results Mean ROMs with the intact specimens were 17° in flexion–extension, 27.9° in lateral bending, and 29.5° in axial rotation. Corresponding values with the instrumented specimens were 0.9°, 2.6°, and 7.3°, respectively. Instrumentation sig- nificantly (P < 0.05) decreased flexion–extension (by 92–98%), lateral bending (by 87–96%), and axial rotation (by 68–84%). Conclusion This study establishes the biomechanical stability of a double claw–hook construct in the upper thoracic spine, which may well explain the low mechanical complication rate in previous clinical studies. Level of evidence Not applicable, experimental cadaver study

Mortality Associated with Neurofibromatosis 1: A Cohort Study of 1895 Patients in 1980-2006 in France

<p>Abstract</p> <p>Background</p> <p>Neurofibromatosis 1 (NF1), a common autosomal dominant disorder, was shown in one study to be associated with a 15-year decrease in life expectancy. However, data on mortality in NF1 are limited. Our aim was to evaluate mortality in a large retrospective cohort of NF1 patients seen in France between 1980 and 2006.</p> <p>Methods</p> <p>Consecutive NF1 patients referred to the National French Referral Center for Neurofibromatoses were included. The standardized mortality ratio (SMR) with its 95% confidence interval (CI) was calculated as the ratio of observed over expected numbers of deaths. We studied factors associated with death and causes of death.</p> <p>Results</p> <p>Between 1980 and 2006, 1895 NF1 patients were seen. Median follow-up was 6.8 years (range, 0.4-20.6). Vital status was available for 1226 (65%) patients, of whom 1159 (94.5%) survived and 67 (5.5%) died. Overall mortality was significantly increased in the NF1 cohort (SMR, 2.02; CI, 1.6-2.6; <it>P </it>< 10^-4). The excess mortality occurred among patients aged 10 to 20 years (SMR, 5.2; CI, 2.6-9.3; <it>P </it>< 10^-4) and 20 to 40 years (SMR, 4.1; 2.8-5.8; <it>P </it>< 10^-4). Significant excess mortality was found in both males and females. In the 10-20 year age group, females had a significant increase in mortality compared to males (SMR, 12.6; CI, 5.7-23.9; and SMR, 1.8; CI, 0.2-6.4; respectively). The cause of death was available for 58 (86.6%) patients; malignant nerve sheath tumor was the main cause of death (60%).</p> <p>Conclusions</p> <p>We found significantly increased SMRs indicating excess mortality in NF1 patients compared to the general population. The definitive diagnosis of NF1 in all patients is a strength of our study, and the high rate of death related to malignant transformation is consistent with previous work. The retrospective design and hospital-based recruitment are limitations of our study. Mortality was significantly increased in NF1 patients aged 10 to 40 years and tended to be higher in females than in males.</p

Expansion of Regulatory T Cells in Patients with Langerhans Cell Histiocytosis

Frederic Geissmann and colleagues find that Langerhans cell accumulation in Langerhans cell histiocytosis results from survival rather than uncontrolled proliferation, and is associated with the expansion of regulatory T cells

Donor/recipient origin of lung cancer after lung transplantation by DNA short tandem repeat analysis

BackgroundLung cancer is more common in posttransplant recipients than in the general population. The objective of this study was to examine the chimerism donor/recipient cell origin of graft cancer in recipients of lung transplant.MethodsA retrospective chart review was conducted at Foch Hospital for all lung transplantations from 1989 to 2020. Short tandem repeat PCR (STR-PCR) analysis, the gold standard technique for chimerism quantification, was used to determine the donor/recipient cell origin of lung cancers in transplant patients.ResultsFourteen (1.4%) of the 1,026 patients were found to have graft lung cancer after lung transplantation, and one developed two different lung tumors in the same lobe. Among the 15 lung tumors, 10 (67%) presented with adenocarcinoma, four (27%) with squamous cell carcinoma and one with small cell lung cancer. STR analysis showed that the origin of the cancer was the donor in 10 patients (71%), the recipient in three patients (21%), and was undetermined in one patient. Median time to diagnosis was 62 months.ConclusionThe prevalence of lung cancer in lung transplant recipients is very low. However, the results of our study showed heterogeneity of genetic alterations, with 21% being of recipient origin. Our results highlight the importance of donor selection and medical supervision after lung transplantation

Herpes-Virus Infection in Patients with Langerhans Cell Histiocytosis: A Case-Controlled Sero-Epidemiological Study, and In Situ Analysis

BACKGROUND: Langerhans cell histiocytosis (LCH) is a rare disease that affects mainly young children, and which features granulomas containing Langerhans-type dendritic cells. The role of several human herpesviruses (HHV) in the pathogenesis of LCH was suggested by numerous reports but remains debated. Epstein-barr virus (EBV, HHV-4), & Cytomegalovirus (CMV, HHV-5) can infect Langerhans cells, and EBV, CMV and HHV-6 have been proposed to be associated with LCH based on the detection of these viruses in clinical samples. METHODOLOGY: We have investigated the prevalence of EBV, CMV and HHV-6 infection, the characters of antibody response and the plasma viral load in a cohort of 83 patients and 236 age-matched controls, and the presence and cellular localization of the viruses in LCH tissue samples from 19 patients. PRINCIPAL FINDINGS: The results show that prevalence, serological titers, and viral load for EBV, CMV and HHV-6 did not differ between patients and controls. EBV was found by PCR in tumoral sample from 3/19 patients, however, EBV small RNAs EBERs -when positive-, were detected by in situ double staining in bystander B CD20+ CD79a+ lymphocytes and not in CD1a+ LC. HHV-6 genome was detected in the biopsies of 5/19 patients with low copy number and viral Ag could not be detected in biopsies. CMV was not detected by PCR in this series. CONCLUSIONS/SIGNIFICANCE: Therefore, our findings do not support the hypothesis of a role of EBV, CMV, or HHV-6 in the pathogenesis of LCH, and indicate that the frequent detection of Epstein-barr virus (EBV) in Langerhans cell histiocytosis is accounted for by the infection of bystander B lymphocytes in LCH granuloma. The latter observation can be attributed to the immunosuppressive micro environment found in LCH granuloma

Mortalité néonatale et organisation des soins (hôpital principal de Dakar, Sénégal, 2007-2008)

L'importance de la mortalité néonatale constitue un véritable fardeau pour les pays en développement. Les infections et les cas de souffrance asphyxique sont les principaux pourvoyeurs de ces quatre millions de décès annuels. L'application étendue d'interventions simples pourrait cependant diminuer considérablement ce chiffre. Nous avons étudié l'épidémiologie du service de néonatologie de l'hôpital principal de Dakar au cours d'une année calendaire avant de mener une étude prospective visant à proposer une optimisation rationnelle des soins. L'organisation de la prise en charge du risque infectieux peut être modifiée tant au niveau de la détermination des motifs d'hospitalisation que de la mise en route d'une antibiothérapie précoce. L'important volume d'admission est responsable d'une surmortalité nosocomiale évitable. L'utilisation systématique des critères anamnestiques décrits par l'ANAES permet une meilleure prédiction du risque infectieux. Enfin, dans le contexte que nous décrivons, un tableau de souffrance fœtale aigue doit aussi évoquer une infection materno-fœtale. Cette approche rationnelle de l'organisation des soins est adaptée au fonctionnement de ce service et vise à promouvoir une amélioration de la mortalité néonatale.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF