Foot and ankle compensation for anterior cruciate ligament deficiency during gait in children.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common in adults and cause knee instability, pain, and an increased risk of osteoarthritis. Previous studies demonstrated changed gait patterns in adult patients with ACL deficiency. In paediatric patients, ACL injuries were once thought to be rare but are being increasingly diagnosed due to greater involvement of children in contact sports and to the introduction of more effective diagnostic tools such as magnetic resonance imaging (MRI). However, little is known about gait adaptation in children with ACL deficiency. The objective of this study was to look for compensatory foot and ankle behaviours during gait in paediatric patients with symptomatic ACL deficiency. HYPOTHESIS: Compensation for ACL deficiency during gait occurs at the foot and ankle in children, because compensation at the hip and pelvis would require greater energy expenditure. MATERIAL AND METHODS: We included 47 patients, 33 males and 14 females, ranging in age from 9 to 17 years (mean, 14.1 years). The patients had a history of unilateral ACL injury documented by MRI and initially treated by immobilisation and physical therapy. They were allowed to walk with full weight-bearing on the affected limb and were not taking medications at the time of the study. All patients had pain, knee instability, or functional limitation. The physical examination showed joint laxity indicating surgical ACL reconstruction. None had neurological conditions, congenital musculoskeletal abnormalities, or a history of knee surgery. Gait analysis (GA) was performed using a Vicon 460 system. Kinematic data for the ankle and foot were compared to those in a control group of 37 healthy children. Ankle angular positions were calculated for each group at the following stance time points: initial contact (0% of gait cycle [GC]), mid-stance (25% GC), terminal stance (60% GC), and swing (83% GC). Foot progression data were recorded at mid-stance (25% GC) and swing (70% GC). Student's t test was applied to compare the results to reference values obtained at our laboratory and to data from the control group. RESULTS: Compared to the reference values, the ankle was in plantar flexion at initial contact in 41 patients, and ankle dorsiflexion during the stance phase was diminished in 39 patients. The external foot progression angle was increased in 23 patients during the stance phase and 38 patients during the swing phase. Compared to the control group (mean age, 9.1 years), the patients had plantar flexion of the ankle at initial contact (3.43°±3.5° vs. 0.74°±3.6°, p<0.05) and decreased dorsiflexion during the stance phase (3.43°±3.5° vs. 0.74°±3.6°, p<0.05). No significant differences were found for any of the other parameters. DISCUSSION: Children with ACL deficiency developed compensatory foot and ankle behaviours during gait that improved knee stability. Understanding these compensations may guide treatment optimisation. LEVEL OF EVIDENCE: III, retrospective comparative study.

Pediatric Psoas Abscess, Early Diagnosis of a Challenging Condition.

INTRODUCTION: Psoas abscess is a rare entity at the pediatric stage of life. The clinical presentation of psoas abscess is insidious and not specifi c, and this usually causes diagnostic delay. Early diagnosis is relevant to prevent devastating consequences of this condition. AIMS: This study aimed to describe the natural history of psoas abscess, present our experience in a children's hospital, determine warning signs and symptoms that may lead to early diagnosis, and describe differential diagnoses. We also discuss the devastating consequences of misdiagnosing psoas abscess. METHODS: This retrospective study was performed at Sant Joan de Déu Children's Hospital (Barcelona, Spain) from 2008 to 2016. All patients younger than 18 years old (n = 12) with psoas abscess who were diagnosed by imaging tests were included. RESULTS: The initial clinical presentation of the patients was variable. Painful hip mobility at extension (7 cases), limping (5 cases), and fever (4 cases) were the most frequent presentations. Laboratory parameters were abnormal in nine patients. The main responsible bacteria was Staphylococcus aureus (9 cases). The mean hospital stay was 28 days (range, 10-71 days). Percutaneous drainage under ultrasound control was applied in two patients. Surgical debridement was performed in seven patients, and repeated procedures were required in three of them. CONCLUSIONS: Because of the erratic presentation of psoas abscess, its suspected diagnosis is essential for an early diagnosis, which will minimize the risk of diagnostic delay. One or more signs and symptoms at the same time might be considered as initiation of psoas abscess. Physicians should be aware of risk factors, such as previous traumatism and a known disturbed immunological system or temporal circumstances, which might lead to psoas abscess. Laboratory parameters may provide more confi dence in diagnosis, and early imaging tests provide a defi nitive diagnosis.

Percutaneous Ethibloc injection in the treatment of primary aneurysmal bone cysts.

The effects of percutaneous Ethibloc (Ethicon/Johnson & Johnson, St-Stevens-Woluwe, Belgium) injection into primary aneurysmal bone cysts were analysed. Two patients with a venous drainage after injection of a medium contrast were excluded. Twelve patients underwent at least one percutaneous injection of Ethibloc. The average follow-up period was 5.1 years. At final follow-up, six patients had complete healing of the cyst, three had partial healing and three, who had no response, were treated by curettage and bone grafting. Complete healing was observed for all the aggressive lesions. No major complications were noted. Ethibloc injection may be performed as a primary treatment of aneurysmal bone cysts if the technique is followed with precision.