Treatment of Septic Arthritis of the Hip Joint Using Repeated Aspirations: When Should We Operate?

Background: The well-accepted treatment of septic arthritis of the hip joint (SAHJ) is surgical drainage of the joint, but repeated aspirations of the hip joint under sonography, have been used for over twenty years with significant success in some centers, including ours. In recent years, we identified some children who did not respond to aspirations and had to undergo arthrotomies. We were concerned that some children may have reached the operating room after a longer than ideal time. Objective: Identification of the characteristics of patients who did not respond to repeated aspirations and development of a treatment algorithm that expedites decision-making regarding the necessity of surgery. Methods: This is a single-center retrospective cohort analysis. All the patients diagnosed with SAHJ between 2007 and 2019 were identified. Patients who responded to repeated aspirations were compared to those who did not improve and required surgery. Demographic and clinical data and laboratory results were obtained from the patients' electronic medical records. Results: Forty-eight children (88.9%) were treated successfully with repeated aspirations and six children (11.1%) did not improve after aspirations and underwent hip arthrotomies. Five out of 48 children from the aspiration group (10.4%) and 4 out of 6 from the arthrotomy group (66.7%) had chronic comorbidities (p = 0.0051). The mean duration of fever over 38.5 degrees centigrade and the length of stay were higher in the arthrotomy group (p = 0.0040, p = 0.0301, respectively). When we examined the change in C-reactive protein (CRP) levels before and after the first aspiration (Delta CRP), we found a decrease in the aspiration group and an increase in the arthrotomy group (p = 0.0044). Conclusion: The new algorithm which we present allows an expeditious assessment of the patient's response to the repeated aspiration method and thus prevents unnecessary surgeries for the treatment of SAHJ. Patients with chronic comorbidities, prolonged fever, and an increase in CRP level following the first aspiration, are at risk of treatment failure and should be treated with an arthrotomy. Level of evidence for clinical articles: Level 4-cohort study.

Correction: Barak, S. et al. "Long-Term Outcomes of Early Enzyme Replacement Therapy for Mucopolysaccharidosis IV: Clinical Case Studies of Two Siblings". Diagnostics 2020, 10, 108.

The authors wish to make the following correction to this paper [...].

Long-Term Outcomes of Early Enzyme Replacement Therapy for Mucopolysaccharidosis IV: Clinical Case Studies of Two Siblings.

Enzyme replacement therapy (ERT) is one of the available therapies for mucopolysaccharidosis (MPS). This study presents a follow-up of two siblings with MPS IVA (Morquio A disease) that received ERT. Both siblings received weekly intravenous infusions of elosulfase alfa for 4.5 years. One sibling (patient 1, P1; male) started therapy at 54 months of age, and the other sibling (patient 2, P2; female) started at 11 months of age. ERT was well-tolerated. In comparison to P1, P2's growth curves deviated less from the norm. The orthopedic deformities of P1 were more severe than those of P2 and required several surgical corrections. P1's sleep test at 48 months revealed obstructive sleep apnea, while by the age of 102 months, parameters were normal. P2 never had sleep apnea. Only P1 demonstrated ear, nose, and throat clinical illnesses. In comparison to P1, P2's physical function was better maintained. In conclusion, ERT was safe in both patients during a 4.5-year follow-up. Although the typical characteristics of this disease were similar in both patients, P1 had a complex clinical course in comparison to P2, which influenced function and quality of life. Therefore, in order to make the most of ERT, it may be more beneficial when initiated at a relatively young age.

Is a radiograph needed one week after internal fixation of a supracondylar humeral fracture?

Displaced supracondylar fractures of the humerus (SCFH) require surgical treatment, most commonly closed reduction with pin fixation. Postoperative displacement following pin fixation is uncommon. Routinely, an early follow-up visit with a radiograph was recommended after fixation of SCFH. The aim of this study was to examine the rate of displacement of SCHF treated with pin fixation using objective radiologic measurements and to determine the need for the early follow-up radiographs. We retrospectively reviewed 161 patients with displaced SFCH treated surgically. The primary outcome measure was loss of reduction (LOR). We examined patient and fracture characteristics and postoperative complications. LOR was defined as a change of 5° or more in measurement of Bauman's angle or the lateral capitellohumeral angle. After applying exclusion criteria, the study group consisted of 131 patients; 87 (66.4%) were male; the left limb was involved in 76 patients (58%); 98 were classified as Gartland type 3 (74.8%); 118 patients had extension type fractures (90%); complications included nerve injury in 32 patients (24.4%), mostly involving the ulnar nerve (17, 13%). Pin-tract infection occurred in four patients (3%). LOR was found in five patients (3.8%). In all these patients, there was evidence of inadequate fixation in the intraoperative radiographs. When adequate fixation is obtained intraoperatively, the next follow-up radiograph is recommended after 3 weeks, at the time of pin removal.

The value of hip aspiration in pediatric transient synovitis.

INTRODUCTION: Hip transient synovitis (TS) is a common pediatric orthopaedic problem. Although a self-limiting illness, it often makes the patient temporarily disabled and poses a diagnostic difficulty because of its similarity to septic arthritis in clinical manifestations. The aim of this study was to evaluate the use of a single ultrasound-guided hip aspiration as a treatment modality for TS. METHODS: Between the years 1984 and 1989, 112 children with TS were treated through bed rest and using nonsteroidal anti-inflammatory drugs (group 1). Between the years 1990 and 1999, 119 children diagnosed with TS were treated using hip aspiration, bed rest, and nonsteroidal anti-inflammatory drugs (group 2). Recovery parameters were compared between these patient groups. RESULTS: Twenty-four hours after admission, limping was noted in 92% and 10% of the patients in groups 1 and 2, respectively, (P < 0.001). Refusal to bear weight was observed in 14% and 1% in groups 1 and 2, respectively, (P < 0.001), and hip joint pain was reported in 81% and 6% in groups 1 and 2, respectively, (P < 0.001). Larger joint effusions were found to be the reason behind the inability to bear weight. CONCLUSIONS: Pain due to TS may be because of capsule stretching owing to the accumulation of joint effusion. Ultrasound-guided hip aspiration relieves pain and limitation in movement and provides rapid differential diagnosis from septic arthritis of the hip joint.

[Spasmodic left waist pain in a six years old child--cat scratch disease].

Cat scratch disease is caused by Bartonella henselae, a bacterium transmitted to humans from cats through a scratch or by fleas. In 90% of cases, the clinical presentation is that of classical cat scratch disease where an adjacent lymph node is infected. Atypical manifestations include prolonged fever, liver and spleen abscesses, infective endocarditis, central nervous system involvement etc. We present a 6 years old girl who suffered from L2 vertebral osteomyelitis and epidural abscess, initially presenting as colic left waist pain, with no back pain or high fevers. During the process of diagnosis, she recovered without surgical intervention or antibiotic treatment. A review of the literature indicates that among the wide spectrum of clinical manifestations of cat scratch disease, skeletal involvement is rare. However, in cases of osteomyelitis, vertebrae are a common site as well as formation of a contiguous phlegmon. Although no studies have investigated the efficacy of different treatment regimens, all patients presented were treated with antimicrobial combinations and recovery rates were high. In view of the patient presented here, it is questioned whether the high recovery rates are a result of efficient antibiotic treatment or due to a benign natural course of the disease.

Fractures of the humerus in the neonatal period.

BACKGROUND: Fractures of the humerus in neonates can pose a diagnostic challenge, especially when the fracture occurs in the proximal or distal epiphysis. OBJECTIVES: To review our experience in the diagnosis and treatment of birth-related humeral fractures. METHODS: Between the years 2001 and 2009, seven newborn patients and two patients treated in the neonatal intensive care unit sustained a fracture of the humerus. Four of the fractures occurred in the humeral shaft, three in the proximal epiphysis and two in the distal epiphysis. In all the newborn patients the diagnosis was made on the first day of life using radiography and ultrasonography. The fractures of the shaft and of the distal epiphysis were treated by gentle manipulation and casting, and the fractures of the proximal epiphysis were treated by swaddling. RESULTS: All of the patients demonstrated fracture union within 2 weeks, and radiographs at the age of 6 months demonstrated complete remodeling of the fracture. CONCLUSIONS: Ultrasonography is a simple, readily available and inexpensive modality for the diagnosis of birth-related fractures of the humerus, especially in the yet unossified epiphyses.

Treatment of femoral fractures in neonates.

BACKGROUND: Fractures of the femur in neonates are relatively uncommon. The infants feel pain and discomfort, causing parental distress, and the hospital stay is longer. Treatment of this specific fracture is problematic because of the small size of the baby. OBJECTIVES: To review the results of the treatment of neonatal femoral fractures. METHODS: We retrospectively reviewed all neonatal fractures of the femur during a 12 year period. Thirteen fractures of the femur in 11 babies were treated with improvised Bryant skin traction of both legs. All the patients were reexamined after a mean follow-up period of 5.2 years. RESULTS: All fractures healed satisfactorily clinically and radiographically, with no residual deformity, leg length discrepancy or functional impairment. CONCLUSIONS: Bryant's traction for 2-3 weeks in hospital is a safe method for the treatment of femoral fractures in neonates, and the outcome is good.