Surgical treatment of septic arthritis of the hip in children: arthrotomy compared with repeated aspiration-lavage.

PURPOSE: To review two cohorts of children treated by two different protocols (repeated needle aspiration-lavage vs. arthrotomy) for surgical treatment of septic arthritis of the hip (SAH). METHODS: In order to compare between the two methods, the following parameters were checked: (a) Scar cosmesis was assessed by the Patient and Observer Scar Assessment Scale (POSAS). We considered satisfactory results (no scar discomfort) when POSAS was within 10% of the ideal score; (b) 24-h post-operative pain was evaluated by visual analog scale (VAS); (c) Complication rates of incomplete drainage (re-arthrotomy/therapy modification from aspiration-lavage to arthrotomy). The results were evaluated by the Student t-test or by the chi-square test. RESULTS: Seventy-nine children (aged 2-14 years) admitted during 2009-2018 and available for at least two years of follow-up were enrolled. The POSAS score (range 12-120 points) at the latest follow-up was higher in the arthrotomy group compared with the aspiration-lavage group (18.10 ± 6.22 versus 12.27 ± 1.40, p < 0.001); 77.4% of patients treated by arthrotomy had no scar discomfort. The 24-h post-intervention VAS (range 1-10) was 5.06 ± 1.29 after arthrotomy and 4.03 ± 1.13 after aspiration-lavage, p < 0.04. Complications were three times more frequent in the aspiration-lavage group (8.8% in the arthrotomy group and 26.7% in the aspiration-lavage group, p = 0.045). CONCLUSIONS: We conclude that the lower complication rate observed in the arthrotomy group outweighs by far scar cosmesis and post-operative pain advantages in the aspiration-lavage group. Arthrotomy as a drainage method is safer than aspiration-lavage.

The Influence of Achilles Tenotomy and Compliance with Foot Abduction Orthosis on the Relapse Rate of Ponseti Treatment for Idiopathic Clubfoot: A Regional Study.

The Ponseti method for treating idiopathic clubfoot is based on gradual manipulations and corrective plaster castings followed by a years-long period of use of a foot orthosis. The role of surgery is limited. The factors that may affect outcome and their influence are subject of controversy. The aim of the study is to systematically and objectively evaluate the results of Ponseti treatment in our region of Southern Israel and focus on the role of the Achilles tenotomy and compliance to foot orthosis as factors that may influence outcome. The use of Ponseti method was retrospectively studied (level of evidence IV) by searching computerized medical files and clinical photos. The severity of deformity was evaluated by Dimeglio score (D-score) at baseline and at last examination. During 2006-2014, 57 children with idiopathic clubfoot (total 90 feet) were enrolled. An Achilles tenotomy was performed in 55/90 (61.1%) of the feet. If the D-score was 15 or higher there was a 20% increase in the incidence of Achilles tenotomy. The parental compliance had a weak protective effect against relapse. The treatment of idiopathic clubfoot by the Ponseti method was successful and reliable, proving efficiency and universality of the method. A dominant predictor for relapse was not seen. An incidental observation was that extended time in cast may buffer the adverse effects of low compliance rate. Although the initial severity, or compliance to braces are important, there may be other factors that affect the outcome such as, accuracy of the casting technique, time in the cast, access to a dedicated clubfoot clinic, cooperation with nurses and pediatricians, economic status that allows purchase of new generation of braces, cultural perception, and education level of the patient population are some examples.

Septic arthritis in children: Updated epidemiologic, microbiologic, clinical and therapeutic correlations.

BACKGROUND: Septic arthritis (SA) is an infection characterized by significant epidemiologic and microbiologic differences between developed and developing regions and between age groups. OBJECTIVES: To determine the epidemiologic, clinical, microbiologic and therapeutic aspects of pediatric SA in Southern Israel. METHODS: A retrospective case-series study based on the records of children <16 years of age admitted with SA at Soroka Medical Center, Beer-Sheva, during 2006-2013. RESULTS: 189 patients were enrolled. There were 119 (63%) Bedouin and 70 (37%) Jewish children. The knee (39.7%), hip (28%) and ankle (13.8%) were the most commonly involved joints. Blood and/or synovial fluid cultures were positive in 48 (25.4%) patients. Overall SA incidence among children <16 years and <5 years was 11.7 and 25.4/100,000, respectively, without changes throughout the study period. SA incidence among Bedouin children was higher than among Jewish children (15.4 vs. 8.3/100,000 cases). Staphylococcus aureus was the most commonly isolated pathogen (18, 19.5% of all patients), followed by Kingella kingae (10, 5.3%)-(37.5% and 20.8% among culture-positive patients, respectively). The number of children with culture-positive SA that required surgery was higher than those with culture-positive SA treated conservatively (P < 0.001). Hospitalization was longer in children treated surgically than in those treated conservatively (P < 0.001). CONCLUSION: This study is the largest single-center series on pediatric SA published in the last five years and provided an updated picture on incidence and the microbiologic, clinical and therapeutic aspects of pediatric SA in Southern Israel. The study supports a regional presentation pattern of SA and may guide its therapeutic management.

Current data on acute haematogenous osteomyelitis in children in Southern Israel: epidemiology, microbiology, clinics and therapeutic consequences.

BACKGROUND: Acute haematogenous osteomyelities (AHO) is the most common form of osteomyelitis, occurring when bone is infected secondary to transient bacteremia. The prevalence, aetiology and outcome of AHO may vary from region to region and period to period. The study objectives were to define the epidemiology, clinical, laboratory and imaging characteristics and treatment consequences of AHO in children in southern Israel. METHODS: This was a retrospective cohort study, enrolling all children <16 years of age hospitalized with AHO. Epidemiologic, clinical, laboratory and imaging data were recorded from medical charts. RESULTS: Ninety-one patients were diagnosed with AHO (52.7 % <4 years of age). Most children (80.24 %) did not receive antibiotic treatment prior to diagnosis. During 2005-2012 the AHO incidence was 5.6:100,000; the AHO incidence in the Bedouin and Jewish population was 7.3 and 4.1:100,000, respectively. Fifty-four (57.8 %) patients were afebrile at admission and 34 (37.4 %) showed leukocytosis >15,000/mm(3). The most involved bone was tibia (39.6 %), followed by femur (19.8 %), humerus (8.8 %) and pelvis (8.8 %). Positive cultures were reported in 26 (28.6 %) patients. The most common pathogen was methicillin-susceptible Staphylococcus aureus (MSSA, 18 patients, 19.8 %). There was only one case of MRSA. More positive cultures were recorded among children requiring surgery compared to children treated conservatively (P < 0.01). MSSA representation in cases requiring surgical intervention was higher than in cases treated conservatively (P = 0.01). There were nine bone biopsies and 33 bone aspirations (MSSA in 44.4 % and 24.2 %, respectively). The longest hospitalization was observed in patients with humerus-AHO (14.8 ± 12.2 days). There was no difference in the number of days of hospitalization between patients who received previous antibiotics compared with children who did not receive antibiotics before admission. CONCLUSIONS: Tibia was the most frequently involved bone, but humeral AHO required more surgical intervention and longer hospitalization. Negative cultures were frequent, MSSA was the most commonly involved pathogen and MRSA was rare. Culture positive AHO was associated with higher requirement for surgical intervention.

[Femoroacetabular impingement: a new direction in the diagnosis and treatment of the hip joint].

Femoroacetabular impingement is a relatively recently described condition in which an abnormally shaped proximal part of the femur or acetabular overcoverage causes interference between the femoral head-neck junction and the acetabular rim. These disorders are now recognized as common causes of prearthritic hip pain and secondary osteoarthritis. Two mechanisms have been described. Cam-type impingement is caused by insufficient concavity of the femoral head-neck junction. Pincer-type impingement is caused by overcoverage of the femoral head by the acetabulum. Abnormal femoroacetabular abutment predisposes affected patients to labral tears, articular cartilage damage, and premature osteoarthritis. Early diagnosis of hip disease and referral for specialized care may optimize clinical outcomes and alter the natural history of these disorders. This review aims to describe this syndrome and to review the contemporary concepts of the etiology and surgical treatment of the disorder.

Cesarean section and the risk of fractured femur.

BACKGROUND: The rate of cesarean section is increasing and in the United States recently exceeded 30% of all deliveries. Birth injuries during CS are relatively rare. Femur fractures have a very low incidence during both vaginal delivery and CS. OBJECTIVES: To assess our 10 year experience (2008-1997) in managing fractured femur during CS, including a typical case. METHODS: We reviewed the prevalence of femur fractures in two tertiary, academic, level one trauma center hospitals in Israel (Hadassah in Jerusalem and Soroka in Beer Sheva). RESULTS: During the study period 221,939 deliveries occurred in both hospitals. Of these, 17.6% were cesarean sections (38,990 CS). Of the total number of deliveries, the incidence of femur fracture was 0.077 per 1000 deliveries (17 fractures), and the incidence of femur fracture during CS was 0.308 per 1000 CS (12 fractures). CONCLUSIONS: Cesarean section increases the risk of femur fractures (P < 0.001) with an odds ratio of 11.26 (confidence interval 3.97-31.97).

[Arthroscopic treatment for osteoarthritic knee].

Osteoarthritis (OA) is the leading cause of knee morbidity. Age and overweight are the main risk factors for development of knee OA. The majority of patients respond to conservative treatment. For those who don't, surgical treatment is the only alternative. Arthroscopic surgery for the osteoarthritic knee is a well known procedure. Recently, numerous publications addressed the advantages of arthroscopic treatment for this indication. Some of the publications concluded that arthroscopic treatment for knee OA equals placebo. Others found temporary relief of symptoms. Among special subgroup of patients, in which acute pain exacerbation, mechanical block or early OA, utilizing arthroscopic techniques revealed satisfactory results. In this review, we discuss the indications and contraindications for arthroscopic treatment of the osteoarthritic knee according to the latest literature.

Nailing before vascular repair in tibial fracture with associated arterial injury.

The incidence of arterial injuries in extremity fractures is approximately 1% to 2%. In patients with combined vascular and orthopedic injury but without a mangled extremity, the decision whether to give priority to the fracture fixation or to the vascular repair is still somewhat controversial. We successfully used the unreamed tibial nail before the arterial repair when treating an open tibial shaft fracture associated with a torn anterior tibial artery and present it as an illustrative case for the method. Fracture alignment was achieved manually and an unreamed tibial nail was introduced. The nail was secured only proximally by two interlocking screws inserted through jig. The procedure provided good alignment and length for end-to-end reconstruction of the anterior tibial artery. The distal interlocking screws were inserted at the end of vascular reconstruction.

Salmonella diskitis in a 2-year old immunocompetent child.

Spine infections are uncommon in paediatrics and are generally caused by Staphylococcus aureus. Salmonella spp. are a rare cause of spine infections, usually affecting children with sickle-cell anaemia. We present a case of group C1 Salmonella diskitis in a previously healty 2-y-old child, and review the relevant literature.

Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects.

The lumbar spine was assessed by magnetic resonance imaging (MRI) in 14 children (mean age 12.4 years) with unspecific activity-related low back pain for more than 3 weeks presenting with normal plain radiographs. Impending spondylolysis was diagnosed when typical signal abnormalities were confined to the pars interarticularis without signs of thinning or fragmentation. After brace treatment for 3 months, follow-up MRI was performed 3 and 6 months after treatment. MRI signals returned to normal after 3 months in six patients and after 6 months in one patient. MRI showed promising results in detecting and monitoring the early onset of spondylolysis. Bracing and avoiding strenuous activities prevented the formation of pars defects in all our patients.