Long-term effects of neonatal bone and joint infection on adjacent growth plates

An update on recent progress of the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis: a review

Acute septic arthritis is on the rise among all patients. Acute septic arthritis must be extensively assessed, identified, and treated to prevent fatal consequences. Antimicrobial therapy administered intravenously has long been considered the gold standard for treating acute osteoarticular infections. According to clinical research, parenteral antibiotics for a few days, followed by oral antibiotics, are safe and effective for treating infections without complications. This article focuses on bringing physicians up-to-date on the most recent findings and discussions about the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis. In recent years, the emergence of antibiotic-resistant, particularly aggressive bacterial species has highlighted the need for more research to enhance treatment approaches and develop innovative diagnosis methods and drugs that might combat better in all patients. This article aims to furnish radiologists, orthopaedic surgeons, and other medical practitioners with contemporary insights on the subject matter and foster collaborative efforts to improve patient outcomes. This review represents the initial comprehensive update encompassing patients across all age groups.

A systematic review of the optimal drainage technique for septic hip arthritis in children

INTRODUCTION

The hip is one of the most commonly affected joints in paediatric septic arthritis. Drainage can be performed using arthrocentesis (articular needle aspiration), arthroscopy or arthrotomy. The objective of this systematic review was to identify the most effective drainage technique for septic hip arthritis in the paediatric population.

MATERIALS AND METHODS

The electronic MEDLINE, EMBASE and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the paediatric hip. Outcome parameters were additional drainage procedures, clinical outcomes and radiological sequelae. The quality of each of the included studies was assessed with the Methodological Index for Non-randomized Studies (MINORS) score.

RESULTS

Out of 2428 articles, 19 studies with a total of 406 hip joints were included in the systematic review. Additional arthroscopy or arthrotomy was performed in 15% of the hips treated with arthrocentesis, in 14% after arthroscopy and in 3% after arthrotomy. Inferior clinical outcomes and more radiological sequelae were seen in patients treated with an arthrotomy. A meta-analysis could not be performed due to the diversity and low quality of the studies (MINORS median 4 [range 2-15]).

CONCLUSIONS

This systematic review gives a comprehensive overview of the available literature on treatment for septic hip arthritis in children. Arthrocentesis and arthroscopic procedures may have a higher risk of additional drainage procedures in comparison with arthrotomy. However, arthrotomy might be associated with inferior outcomes in the longer term. The included studies are diverse and the scientific quality is generally low.

Benefits of diffusion-weighted imaging in pediatric acute osteoarticular infections

BACKGROUND

Contrast-enhanced magnetic resonance imaging (MRI) is recommended for the diagnosis of acute osteoarticular infections in children. Diffusion-weighted imaging (DWI) may be an alternative to the injection of gadolinium.

OBJECTIVE

To evaluate unenhanced MRI with DWI in comparison to contrast-enhanced MRI for the diagnostic work-up of acute osteoarticular infections in children.

MATERIALS AND METHODS

This retrospective study included 36 children (age range: 7 months-12 years) with extra-spinal osteoarticular infections and MRI performed within 24 h of admission. MRI protocol included short tau inversion recovery (STIR), water-only T2 Dixon, T1, DWI, and gadolinium-enhanced T1 sequences. Two readers reviewed three sets of images: 1) unenhanced sequences, 2) unenhanced sequences with DWI and 3) unenhanced followed by contrast-enhanced sequences (reference standard). Sensitivity and specificity of sets 1 and 2 were compared to set 3 and assessed to identify osteoarticular infections: osteomyelitis (long bones, metaphyseal equivalents), septic arthritis and abscess (soft tissues, bone).

RESULTS

All 14 cases of osteomyelitis in the metaphyses and diaphyses of long bones and all 27 cases of septic arthritis were identified by unenhanced sequences, but 4/16 abscesses were missed. For the diagnosis of abscess, DWI increased sensitivity to 100%. Among the 18 osteomyelitis in metaphyseal equivalents, 4 femoral head chondroepiphyses were identified by contrast-enhanced sequences only.

CONCLUSION

MRI for suspected pediatric acute osteoarticular infections is the best diagnostic modality to guide patient management. An unenhanced protocol with DWI may be an alternative to a contrast-based protocol, even in the presence of an abscess. However, gadolinium remains necessary to assess for chondroepiphyseal involvement of the femoral head.

The recent bacterial etiology of childhood osteoarticular infections focusing on the vaccine initiation for Streptococcus pneumoniae and Haemophilus influenzae: A single-center retrospective analysis in Japan

Background

Pediatric acute osteomyelitis and septic arthritis can destroy growth plate cartilage and joint cartilage, causing permanent deformities and growth disorders. Preventing the contraction of osteoarticular infections is important. Various types of bacteria cause osteoarticular infections in children. Since 2013, when routine vaccination against Streptococcus pneumoniae and Haemophilus influenzae was initiated in Japan, diseases caused by these bacteria (other than osteoarticular infection) are reported to decrease. In this study, we aimed to re-confirm the actual situation including the presence of pathogenic bacteria of pediatric bone and joint infections.

Methods

The subjects were patients of 15 years old or younger who had been diagnosed with acute osteomyelitis or septic arthritis and received initial treatment in our hospital from April 1995 to March 2019. We obtained information from the medical records and analyzed them statistically.

Results

There were 65 patients with 65 bones with acute osteomyelitis, and 120 patients with 124 joints with septic arthritis. The pathogenic bacteria were identified in 26 (40.0%) osteomyelitis patients and 59 (49.2%) septic arthritis patients. Staphylococcus aureus was the most common pathogenic bacterium, and S. pneumoniae and H. influenzae were identified in four and seven patients respectively, frequently in younger patients. After routine vaccination against S. pneumoniae and H. influenzae, these bacteria were no longer detected in patients under five years old.

Conclusions

The efficacy of the S. pneumoniae and H. influenzae vaccine against orthopedic infectious diseases in Japan was indicated.

Developments in diagnosis and treatment of paediatric septic arthritis

Acute septic arthritis in children is an orthopaedic emergency. A delay in diagnosis and inappropriate treatment can result in devastating damage to the joint with lifelong disability as a consequence. The clinical presentation can be a diagnostic challenge, especially in young children. A recent systematic review showed that joint tenderness and fever are important signals of septic arthritis. Ultrasound is helpful in detecting the presence of a joint effusion. Plain radiographs may show bone changes but magnetic resonance imaging is the most reliable imaging study for detecting concomitant osteomyelitis. The diagnosis of acute septic arthritis is highly suggestive when pus is aspirated from the joint, in case of a positive culture or a positive gram stain of the joint fluid, or if there is a white blood-cell count in the joint fluid of more than 50000/mm³. Staphylococcus aureus is the most commonly cultured organism. Recent systematic reviews have identified the most effective drainage techniques, including needle aspiration, arthroscopy and arthrotomy, depending on the affected joint. After the drainage procedure it is important to monitor the clinical and laboratory outcomes. Additional drainage procedures may be necessary in select cases.

The Deleterious Effects of Impaired Fibrinolysis on Skeletal Development Are Dependent on Fibrin(ogen), but Independent of Interlukin-6

Chronic diseases in growing children, such as autoimmune disorders, obesity, and cancer, are hallmarked by musculoskeletal growth disturbances and osteoporosis. Many of the skeletal changes in these children are thought to be secondary to chronic inflammation. Recent studies have likewise suggested that changes in coagulation and fibrinolysis may contribute to musculoskeletal growth disturbances. In prior work, we demonstrated that mice deficient in plasminogen, the principal protease of degrading and clearing fibrin matrices, suffer from inflammation-driven systemic osteoporosis and that elimination of fibrinogen resulted in normalization of IL-6 levels and complete rescue of the skeletal phenotype. Given the intimate link between coagulation, fibrinolysis, and inflammation, here we determined if persistent fibrin deposition, elevated IL-6, or both contribute to early skeletal aging and physeal disruption in chronic inflammatory conditions. Skeletal growth as well as bone quality, physeal development, and vascularity were analyzed in C57BL6/J mice with plasminogen deficiency with and without deficiencies of either fibrinogen or IL-6. Elimination of fibrinogen, but not IL-6, rescued the skeletal phenotype and growth disturbances in this model of chronic disease. Furthermore, the skeletal phenotypes directly correlated with both systemic and local vascular changes in the skeletal environment. In conclusion, these results suggest that fibrinolysis through plasmin is essential for skeletal growth and maintenance, and is multifactorial by limiting inflammation and preserving vasculature.

Arthrocentesis, arthroscopy or arthrotomy for septic knee arthritis in children: a systematic review

PURPOSE

Septic knee arthritis in children can be treated by arthrocentesis (articular needle aspiration) with or without irrigation, arthroscopy or arthrotomy followed by antibiotics. The objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the knee in children.

METHODS

The electronic PubMed, Embase and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the knee. The quality of all included studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria. This systematic review was performed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Out of 2428 articles, 11 studies with a total of 279 knees were included in the systematic review. The quality of evidence was low (MINORS median 4 (2 to 7)). A meta-analysis could not be performed because of the diversity and low quality of the studies. In septic knee arthritis, additional drainage procedures were needed in 54 of 156 (35%) knees after arthrocentesis, in four of 96 (4%) after arthroscopy and in two of 12 (17%) after arthrotomy.

CONCLUSION

Included studies on treatment strategies for septic arthritis of the knee in children are diverse and the scientific quality is generally low. Knee arthroscopy might have a lower risk of additional drainage procedures as compared with arthrocentesis and arthrotomy, with acceptable clinical outcomes and no radiological sequelae.

LEVEL OF EVIDENCE

IV.

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

Acute bone and joint infections (BJIs) in children may clinically occur as osteomyelitis (OM) or septic arthritis (SA). In clinical practice, one-third of cases present a combination of both conditions. BJIs are usually caused by the haematogenous dissemination of septic emboli carried to the terminal blood vessels of bone and joints from distant infectious processes during transient bacteraemia. Early diagnosis is the cornerstone for the successful management of BJI, but it is still a challenge for paediatricians, particularly due to its nonspecific clinical presentation and to the poor specificity of the laboratory and imaging first-line tests that are available in emergency departments. Moreover, microbiological diagnosis is often difficult to achieve with common blood cultures, and further investigations require invasive procedures. The aim of this narrative review is to provide the most recent evidence-based recommendations on appropriate antinfective therapy in BJI in children. We conducted a review of recent literature by examining the MEDLINE (Medical Literature Analysis and Retrieval System Online) database using the search engines PubMed and Google Scholar. The keywords used were “osteomyelitis”, OR “bone infection”, OR “septic arthritis”, AND “p(a)ediatric” OR “children”. When BJI diagnosis is clinically suspected or radiologically confirmed, empiric antibiotic therapy should be started as soon as possible. The choice of empiric antimicrobial therapy is based on the most likely causative pathogens according to patient age, immunisation status, underlying disease, and other clinical and epidemiological considerations, including the local prevalence of virulent pathogens, antibiotic bioavailability and bone penetration. Empiric antibiotic treatment consists of a short intravenous cycle based on anti-staphylococcal penicillin or a cephalosporin in children aged over 3 months with the addition of gentamicin in infants aged under 3 months. An oral regimen may be an option depending on the bioavailability of antibiotic chosen and clinical and laboratory data. Strict clinical and laboratory follow-up should be scheduled for the following 3–5 weeks. Further studies on the optimal therapeutic approach are needed in order to understand the best first-line regimen, the utility of biomarkers for the definition of therapy duration and treatment of complications.

Treatment of Post-traumatic Pediatric Ankle Varus Deformity with Physeal Bar Resection and Hemi-Epiphysiodesis

Children presenting with partial physeal arrest and significant remaining growth may benefit from physeal bar resection, although the operation is a technique demanding procedure. This study evaluates the treatment of post-traumatic pediatric ankle varus deformity using physeal bar resection and hemi-epiphysiodesis with the assistance of two operative methods. Forty-five patients presenting with a distal tibial medial physeal bridge as well as ankle varus deformity following traumatic ankle physeal injury between 2009 and 2017 were followed. These patients were treated with physeal bar resection and hemi-epiphysiodesis, with the assistance of either fluoroscopy (10 cases) or intraoperative three-dimensional navigation (35 cases). Of the 45 cases, the median age was 9.0 years (range: 3-14 years) with 28 male and 17 female patients. The median of pre-operation ankle varus angle was 20 degrees (IQR 15-25) and 5 degrees (IQR 0-20) at the time of final follow up, representing a statistically significant difference (P<0.05). No differences were observed with regards to age, gender, and surgical history between effective group and ineffective group (P>0.05). The median of pre-operative ankle varus angles of the navigation and fluoroscopy groups were both 20 degrees (P>0.05). The median correction angle of the navigation and fluoroscopy groups was 10 and 15 degrees, respectively (P>0.05). Our results indicate that physeal bar resection and hemiepiphysiodesis are effective treatments for correcting ankle varus deformity due to traumatic medial physeal arrest of the distal tibia. We observe no difference in outcome between fluoroscopy group and three-dimensional navigation group during the procedures.

Current Approach to the Evaluation and Management of Septic Arthritis

Septic arthritis is an emergent condition caused by bacterial infection of a joint space. The most common etiology is hematogenous spread from bacteremia, but it can also occur from direct inoculation from bites, injection injuries, cellulitis, abscesses, or local trauma. Septic arthritis occurs most frequently in the lower extremities, with the hips and knees serving as the most common locations. The most sensitive findings include pain with motion of the joint, limited range of motion, tenderness of the joint, new joint swelling, and new effusion. Laboratory testing and imaging can support the diagnosis, but the criterion standard is diagnostic arthrocentesis. Treatment involves intravenous antibiotics and joint decompression.

Severity Adjusted Risk of Long-term Adverse Sequelae Among Children With Osteomyelitis

BACKGROUND

The purpose of this investigation was to evaluate the risk for long-term, adverse outcomes among children with osteomyelitis.

METHODS

Children with osteomyelitis were prospectively enrolled from 2012 to 2014. Care was accomplished by a multidisciplinary team according to an institutional algorithm. Data were collected to define the severity of illness during the initial hospitalization and assess short, intermediate and long-term outcomes. Clinical examination, radiographic assessment and functional outcome survey administration were performed at a minimum of 2 year follow-up. A comparison cohort analysis was performed according to initial severity of illness score of mild (0-2), moderate (3-6) and severe (7-10).

RESULTS

Of 195 children enrolled, 139 (71.3%) returned for follow-up at an average of 2.4 years (range, 2.0-5.0 years). Children with severe illness were less likely to have normal radiographs (severe, 4.0%; moderate, 38.2%; mild, 53.2%, P < 0.0001), and more likely to have osteonecrosis, chondrolysis, or deformity (severe, 32.0%; moderate, 5.9%; mild, 1.3%, P < 0.0001). Functional outcome measures did not significantly differ between severity categories. By regression analysis severity of illness score, plus age less than 3 years and Methicillin-resistant Staphylococcus aureus predicted severe sequelae with an area under the curve of 0.8617 and an increasing odds ratio of 1.34 per point of increase in severity score.

CONCLUSION

Long-term severe adverse outcomes among children with osteomyelitis occurred in 11 of 139 (7.9%) children and were predicted by initial severity of illness. Other risks that diminished the likelihood of complete resolution or increased the risk of severe sequelae included Methicillin-resistant Staphylcoccus aureus etiology and young age. The majority of children with osteomyelitis do not require long-term follow-up beyond the initial treatment period.

Imaging of Pediatric Growth Plate Disturbances

The growth plates, or physes, are visible on virtually all images obtained in skeletally immature children. The proper function of these growth plates depends on an intricate balance between chondrocyte proliferation, which requires nourishment from the epiphyseal vessels, and chondrocyte death, which requires the integrity of the metaphyseal vessels. Therefore, injury to the growth plate (ie, direct insult) or vascular compromise on either side of the growth plate (ie, indirect insult) can cause growth plate dysfunction. Direct growth plate insults occur most commonly with Salter-Harris fractures, and injuries that allow the transphyseal communication of vessels are at a higher risk for subsequent transphyseal bone bridge formation. Indirect insults lead to different sequelae that are based on whether the epiphyseal blood supply or metaphyseal blood supply is compromised. Epiphyseal osteonecrosis can result in slowed longitudinal bone growth, with possible growth plate closure, and is often accompanied by an abnormal secondary ossification center. In contrast, the disruption of metaphyseal blood supply alters endochondral ossification and allows the persistence of chondrocytes within the metaphysis, which appear as focal or diffuse growth plate widening. Imaging remains critical for detecting acute injuries and identifying subsequent growth disturbances. Depending on the imaging findings and patient factors, these growth disturbances may be amenable to conservative or surgical treatment. Therefore, an understanding of the anatomy and physiologic features of the normal growth plate and the associated pathophysiologic conditions can increase diagnostic accuracy, enable radiologists to anticipate future growth disturbances, and ensure optimal imaging, with the ultimate goal of timely and appropriate intervention. ^©RSNA, 2017.

In the setting of paediatric osteomyelitis do not be afraid to CAST an eye

The case commences with an innocuous right ankle injury (lateral malleolus), for which the patient, a 9-year-old boy, was placed in a temporary cast at his local hospital. Three days following this incident, the patient was diagnosed with new-onset type 1 diabetes mellitus. He was admitted to his local hospital with severe diabetic ketoacidosis appropriately treated and subsequently discharged c.1 week later clinically well. Approximately 1 week later, again he presented for a third time with a significant serosanguinous discharge from the site of the initial injury permeating through the temporary cast in place for c.2 weeks by that time. On removal of the cast, a severely invasive infection of bone and soft tissue was noted, and the patient was urgently transferred to our unit at the tertiary general hospital for further management. He underwent a series of orthopaedic and plastic surgery procedures with an eventual satisfactory outcome.

Acute Hematogenous Osteomyelitis in Children: Pathogenesis, Diagnosis, and Treatment

Acute hematogenous osteomyelitis (AHO) in children is an ideal condition to study due to its representation of a wide spectrum of disorders that comprise pediatric musculoskeletal infection. Proper care for children with AHO is multidisciplinary and collaborative. AHO continues to present a significant clinical challenge due to evolving epidemiology and complex pathogenesis. A guideline-driven, multidisciplinary approach has been introduced and shown to effectively reduce hospital stay, improve the timing and selection of empirical antibiotic administration, reduce delay to initial MRI, reduce the rate of readmission, and shorten antibiotic duration.

Arthroscopic Treatment of Septic Arthritis in Very Young Children

INTRODUCTION

Arthroscopic lavage is a well-established, minimally invasive treatment for septic arthritis (SA) in adults, but the use of arthroscopy in the pediatric population is typically restricted to sports injuries and deformity. Previous research on arthroscopic lavage of septic joints in the pediatric population has been limited to case reports and small case series of older children. As such, we aimed to evaluate the safety and efficacy of arthroscopic treatment of SA in various joints in very young children.

METHODS

Between 2011 and 2015, 24 children (aged 3 wk to 6 y) were treated for SA with arthroscopic lavage. A single portal was adequate for both inflow and outflow in most cases. A second portal was used in all knees and in other joints for synovectomy, when indicated. Drains were placed through the portal site and remained in place for 2 to 3 days. Antibiotics were managed by the infectious disease service.

RESULTS

Nine hips, 9 knees, 4 ankles, and 2 shoulders were included. Portal placement, visualization, and adequate lavage were straight forward in all joints. There was 1 transient femoral nerve palsy and no other arthroscopy-associated complications (iatrogenic damage, difficult drain placement, or conversion to open). Two patients required repeat arthroscopic lavage for disease eradication, one of which required a second admission. A third patient underwent open irrigation following arthroscopic lavage with a resultant 1.125 average procedures per subject. At final follow-up (2 to 49 mo, average 16 mo), no recurrence of infection or decreased range of motion was noted.

CONCLUSIONS

Arthroscopic lavage appears to be a safe, quick, and effective alternative to open arthrotomy for the treatment of SA in very young children. It is feasible in any large joint even in the infantile population, allowing for improved visualization and irrigation with little soft-tissue dissection and morbidity. Our relatively simple technique and positive results should encourage regular use of arthroscopic treatment of SA even in very young children.

LEVEL OF EVIDENCE

Level IV-case series.

Physeal separation and complete resorption of femoral head associated with chronic osteomyelitis of femoral diaphysis in a young child: rare case report

We report the case of a two and a half-year-old girl who presented with injury to the right thigh along with a discharging sinus in the midthigh region following a nonorthopaedic surgical procedure. Radiographs of the thigh indicated osteomyelitis of the femoral diaphysis with pathological fracture. During follow-up examination, shortening was observed in the affected limb, along with complete separation of the femoral epiphysis with partial resorption of the femoral head. A few cases of physeal separation of the femoral head following osteomyelitis of the femoral diaphysis have been reported in the published literature, but still it may go undiagnosed until late stages because of the lack of awareness among orthopaedicians about this entity. There was no history of any precipitating trauma to the hip. This case is of interest because of the difficulty in making differential diagnosis at the first evaluation; there was an orthopaedic misdiagnosis on the basis of the lack of complete preoperative imaging. Because of the devastating sequelae on immature skeleton including limb shortening, osteomyelitis, epiphyseal separation of proximal epiphysis and pathological fracture of shaft femur, the importance of early diagnosis, complete preoperative imaging and prompt treatment must be overemphasized.

Septic arthritis in children in resource limited and non-resource limited countries: an update on diagnosis and treatment

INTRODUCTION

Septic arthritis (SA) is an orthopedic emergency in childhood. It is uncommon in high resource settings. However, an incidence of 5-20 per 100,000 children has been reported in low-income countries. Area covered: The predictive value of serum markers is still under debate and the proposed diagnostic algorithms for SA are not sufficiently validated in children. Recent data suggest that short-course intravenous treatment, followed by oral therapy, is as effective as traditional long-term treatment. Results from three randomized controlled trials suggest that the addition of systemic steroids may accelerate clinical improvement. Minimally invasive surgical techniques have been proposed for treatment in recent years. Expert commentary: The causes and the epidemiology of septic arthritis will continue to mutate according to the changes in immunization practices, bacterial resistance patterns and the implementation of PCR techniques. Future research should focus on the assessment of appropriate antibiotic regimens and surgical procedures.

Bone and Joint Infections in Children: Septic Arthritis

The pathological invasion of a joint and subsequent inflammation is known as septic arthritis. The knee and hip are the most frequently involved joints. Staphylococcus aureus is the most common cause of septic arthritis in children. An acute onset of illness with an inflamed painful joint and restricted movements and inability to use joint (pseudoparalysis) clinically indicates septic arthritis. The diagnosis is difficult in a neonate or young child where refusal to feed, crying, discomfort during change of diaper (if hip is involved) or attempted joint movement may be the only findings. Fever and other systemic signs may also be absent in neonates. Septic arthritis is diagnosed clinically, supported by appropriate radiological and laboratory investigations. The peripheral blood white cell count is frequently raised with a predominance of polymorphonuclear cells. The acute phase reactants such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are often markedly raised. Ultrasonography and MRI are preferred investigations in pediatric septic arthritis. Determination of infecting organism in septic arthritis is the key to the correct antibiotic choice, treatment duration and overall management. Joint aspirate and/or blood culture should be obtained before starting antibiotic treatment. Several effective antibiotic regimes are available for managing septic arthritis in children. Presence of large collections, thick pus, joint loculations and pus evacuating into surrounding soft tissues are main indications for surgical drainage. Joint aspiration can be a practical alternative in case the lesion is diagnosed early, with uncomplicated presentations and superficial joints.

The normal and fractured physis: an anatomic and physiologic overview

The growth plate (physis) is responsible for enabling and regulating longitudinal growth of upper and lower limbs. This regulation occurs through interaction of the cells in the growth plate with systemic and locally produced factors. This complex interaction leads to precisely controlled changes in chondrocyte size, receptors, and matrix, which ultimately result in endochondral bone formation. With advances in cellular and molecular biology, our knowledge about these complex interactions has increased significantly over the past decade. Deficiency of any of the regulating factors or physeal injury during childhood can alter this well-orchestrated sequence of events and lead to abnormalities in growth. This review highlights the histology of the normal physis, including recent findings at the cellular and molecular levels, mechanics and mechanobiology of the growth plate, pathologies that can affect the physis, and treatment options, including interposition materials.

Total hip arthroplasty after treatment of pseudojoint infection in a patient with a highly dislocated hip

Infection at the pseudoacetabulum in a patient with a high hip dislocation has not been reported previously in the English literature. We report a case of total hip arthroplasty in a 28-year-old female who presented to us with hip pain following debridement of the infected pseudojoint in a case of neglected developmental dysplasia of the hip. The infection was treated with thorough debridement and drainage. However, even after achieving complete infection control, this patient complained of disabling right hip joint pain. Total hip arthroplasty with subtrochanteric osteotomy was performed to relieve the pain and improve gait. After surgery, the patient's symptoms were relieved. We consider that in this case of acute pseudojoint infection simple arthrotomy and debridement combined with irrigation and drainage provide effective treatment. But muscle weakness and more increased joint laxity can cause hip pain even after infection control. So total hip arthroplasty is likely to be necessary after the infection has been controlled in a patient with a highly dislocated hip.

Endoscopically aided physeal bar takedown and guided growth for the treatment of angular limb deformity

The treatment of physeal arrest after infection remains a challenge. This report describes localized endoscopic epiphysiolysis combined with guided growth in the treatment of partial physeal arrest and limb deformity in an infant after infection. Over a year's time, the valgus was corrected and the plate was removed. The patient returned to full activity. Physeal arrest may occur at anytime after physeal trauma, highlighting the importance of long-term follow-up. Endoscopic physeal bar takedown combined with guided growth of the distal femur can be an effective option for the treatment.

Congenital radial head dislocation with a progressive cubitus valgus: a case report

Congenital dislocation of the radial head is rare, although it is the most common congenital anomaly of the elbow. A concomitant progressive cubitus valgus of the elbow has not previously been described in literature. We describe a case of an 8-year-old girl with an unilateral congenital radial head dislocation with a progressive cubitus valgus of 35°, caused by a prematurely closing physis of the lateral humeral condyle. This might be caused by an increased pressure on the lateral physis by the anteriorly dislocated radial head. As no complaints or limitations were present, treatment was non-operative with clinical observation, with satisfactory results after a follow-up of 18 months. A concomitant progressive cubitus valgus can be present in patients with a congenital radial head dislocation. Non-operative treatment can provide satisfactory results.

Experimental assessment of nutrition and bone growth's velocity effects on Harris lines formation

Harris lines (HL) are radio-opaque transverse lines traditionally associated with stressors that halt or decelerate growth in humans. Harris lines' status as a stress marker is, however, questionable because their association to illness and deficient growth is low and they commonly form in the absence of stress during periods of accelerated growth. To assess Harris line's reliability as a stress marker, this study examined their association with nutritional status and bone growth velocity through an experimental study in rabbits. Forty-five New Zealand White rabbits were divided into: Control (normal laboratory conditions), Experimental-1 (moderately undernourished), and Experimental-2 (periodically fasted) groups during their growth. Variables analyzed included weight, forelimb length, humeral diaphyseal length, diaphyseal growth velocity, and number of Harris lines. Fewer lines were observed by the end of the study among Experimental-1 animals. More Harris lines formed during periods of rapid growth in the absence of nutritional stress. Accordingly, Harris lines are a poor marker of stress. Intrinsic limitations to paleopathological studies can be overcome, but even the most careful attentiveness to multiple stress markers and cultural context will go amiss if the markers used are unreliable.

The management of congenital and acquired problems of the distal radioulnar joint in children

Pain in the ulnar aspect of the pediatric wrist is an uncommon problem; however, when pain does occur it is usually the result of antecedent bony trauma or an underlying skeletal abnormality, which may lead to ulnar-sided wrist pain of varying etiology. The clinician must to be able to identify these entities within the pediatric wrist in order to make the appropriate diagnosis and plan for surgical intervention to prevent ongoing damage to the distal radioulnar joint (DRUJ). This article reviews the etiology, clinical presentation, and treatment strategies for the management of the unique problems that can affect the pediatric and adolescent DRUJ.

Pediatric musculoskeletal infection: trends and antibiotic recommendations

In the past decade, the incidence of methicillin-resistant Staphylococcus aureus infections in children has increased. This phenomenon has led to a rise in complex, deep infections involving the musculoskeletal system for which a comprehensive approach of evaluation and treatment has become necessary. Whenever possible, cultures should be obtained to guide specific antibiotic selection. The potential for infections involving multiple tissue locations within the same patient and the risk for complications such as deep vein thrombosis necessitate a thorough, often multidisciplinary, approach in the care of these children. MRI is valuable in defining the anatomic and spatial extent of infection as well as in guiding the decision and approach for surgery. Most patients have favorable outcomes with sequential parenteral to oral antibiotic therapy after adequate surgical débridement of the infection. Close outpatient follow-up is essential to ensure antibiotic compliance and to identify late consequences of the infection.

Septic physeal separation of proximal femur in a newborn

In newborns physeal separations and septic osteomyelitis or arthritis are unusual, representing a problem in diagnosis and treatment. Therapy needs to be carried out soon in order to prevent anatomical and functional consequences. Association between septic event and physeal separation is rare. We report a 28-day-old female, admitted for elevated temperature, who underwent three nonorthopaedic surgical procedures before, and orthopaedic evaluation 8 days after admission. After an X-ray and an ultrasonography a septic arthritis with consequent hip dislocation was supposed. Only at the time of surgery a separation between the epiphysio-trochanteric nuclei complex and the femoral shaft was observed, with clear hip joint. The interest in this case consists in the difficulty of the differential diagnosis at the first evaluation, the orthopaedic misdiagnosis based on the lack of complete preoperative imaging, and finally the long-term excellent result after a prompt surgical treatment.

Sequelae of septic arthritis of the hip in children: a new classification and a review of 41 hips

BACKGROUND

The sequelae of septic arthritis of the hip in children are diverse and represent a complex problem. A classification of the deformities is important to plan treatment and to give prognostic information. The radiographic main classification used provides detailed information of the deformities, but it is complicated and not feasible to apply in young children. The authors developed a simple and reliable method of classification and present the results of a large series of patients.

METHODS

The authors reviewed 37 children with 41 hips with sequelae of septic arthritis of the hip. Twenty-four were male subjects, and 13 were female subjects. Twenty-five had the acute infection at the neonatal period, and 16 were aged between 1 month and 3 years. None of them received adequate treatment at the acute process: 20 hips were not treated, and the other 21 had delayed drainage (at least 5 days after the onset of the infection). The hips were classified into 2 groups on the basis of radiographic appearance. Hips with sequelae grade 1 were reduced hips, with femoral head preserved (1A) or absent (1B); hips grade 2 were dislocated hips, with the femoral head preserved (2A) or absent (2B). There were 10 hips with grade 1A, 11 with grade 1B, 3 with grade 2A, and 17 were grade 2B. We compared our material and results with those presented by Choi et al and also compared the reliability of both classification. The criteria for satisfactory results were stability, range of motion of 50 degrees or more of flexion, a flexion contraction below 20 degrees, and a painless hip.

RESULTS

Our classification presented a greater concordance (25 of 41 hips against 7 in 41 for the Choi et al classification; P = 0.01). Thirty-seven hips were pain-free, and 4 had occasional pain. Thirty-seven hips had a satisfactory range of motion (90.2%). Stability was present in 29 hips (70.7%). Final results showed 24 hips classified as satisfactory and 17 as unsatisfactory. Our material and end results were comparable with those reported by Choi et al.Septic arthritis of the hip developed at the newborn period produced more severe sequelae. Hips with sequelae grade 1 have a good prognosis. Surgical procedures in these grades were necessary to correct acetabular dysplasia and improve congruency. Fifteen of 20 hips with sequelae grade 2 (unstable) underwent reconstruction. At a mean follow-up of 6.9 years (range, 2.7-11.3 years), satisfactory results were obtained in 8 of them.

CONCLUSIONS

The classification we proposed showed to be simpler and more reliable than the classification proposed by Choi et al. It may be useful to guide treatment and prognosis. Longer follow-up is needed to assess the real benefit of the reconstruction for unstable hips.

Experience of bone bridge resection and bone wax packing for partial growth arrest of distal tibia

Two patients with a partial growth arrest of the distal tibia were treated by bone bridge resection and bone wax packing technique. Their average age at the time of surgery was 7 years, both had been injured in an accident, and each had been treated with percutaneous pinning and a plaster cast. Unfortunately, partial growth arrest of the distal tibia occurred, and the ankle varus deformity gradually progressed. About 1 year after initial treatment, bone bridge resection and bone wax packing were performed. The average follow-up period was 80 months. There was no reformation of the bone bridge or recurrence of deformity, and gradual improvements in clinical and radiographic findings were observed. Although fat is typically used as an interpositional material after bone bridge resection, there are problems with its use, including a lack of hemostasis and the absence of intrinsic stability. Bone wax is readily available and commonly used in medical applications to control bleeding. It is considered a useful plug, it is inexpensive, and it is not associated with complications.

[Distraction osteogenesis for adjusting humeral length difference due to premature closure of the proximal growth plate in a simple bone cyst]

Complications after pathological fractures of simple bone cysts of the humerus are refracture, cyst recurrence, and in rare cases premature closure of the physeal plate with resulting shortening of the arm. Length discrepancies of the lower limbs beyond physiological limits need early compensation in children as well as adults to avoid interference with the pelvis and spine. However, surgical treatment of length differences of the humerus is usually cosmetic, because even considerable discrepancies do not lead to functional deficits. We report the long-term course of a complicated bone cyst of the proximal humerus and resolving a severe length difference of 7 cm by distraction osteogenesis in a young adult. The cause of the premature physeal closure and the primary therapeutical concept are discussed.

Septic arthritis in Western and sub-Saharan African children - a review

This article reviews what is known about the incidence, aetiology, presentation, bacteriology and management of septic arthritis in children. It compares where possible the different presentations and characteristics of this condition in the Western and sub-Saharan African regions.

Lateral growth disturbance of the proximal femur in premature infants who had neonatal sepsis

This is a retrospective review of four patients in whom a pattern of growth disturbance of the proximal femur with the bony bridge developed. They were born prematurely with low birth weight at birth and they had a suspicious sepsis, but they did not have any signs of localized infection. All presented with a progressive gait disturbance and a leg-length discrepancy. Radiographs showed an anterior tilting of the capital femoral epiphysis. Computed tomography and magnetic resonance imaging showed partial physeal closure with bony bridges. This case series suggests an association between neonatal sepsis of prematurity and growth disturbance of the proximal femur.

Implantation of perichondrium-derived chondrocytes in physeal defects of rabbit tibiae

BACKGROUND

Various cells and scaffolds have been used experimentally as interposition materials after physeal bar resection to treat partial physeal growth arrest. However, results of these cell therapies are unpredictable.

METHODS

We investigated the chondrogenic differentiation of rabbit perichondrial cells in vitro. We also investigated radiographic and histological changes after implantation of the perichondrium-derived chondrocytes, embedded in fibrin beads, into defects created in the medial aspect of the proximal tibial physis of 26 8-week-old New Zealand White rabbits. Physeal defects of the contralateral tibiae were left intact without any treatment, or were treated with fibrin beads not containing cells.

RESULTS

The perichondrial cells cultured in the alginate- fibrin beads were positive in immunohistochemical staining for S-100 protein and the extracellular area was stained with Safranin-O. RNase protection assay showed that the expression of type II collagen and aggrecan continued In the cell and bead-treated tibiae, varus deformity was reduced significantly and tibial length was maintained longer than that of the contralateral tibia. Histologically, cartilage clusters of varying size with intervening micro-bony trabeculae were found in the cell and bead-treated tibiae. The lateral, remaining physis in the untreated tibiae showed altered histology.

INTERPRETATION

Implantation of fibrin beads containing perichondrium-derived chondrocytes into the physeal defect helps to prevent angular deformation and shortening of long bone, but not completely. Physeal bony bar formation adversely affects the growth of the remaining physis from early stages onward.

Iliofemoral distraction and hip reconstruction for the sequelae of a septic dislocated hip with chronic femoral osteomyelitis

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.

Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations

Arthrotomy of the hip joint followed by a variable period of drainage or continuous irrigation and drainage is considered the accepted treatment of septic arthritis of the hip joint (SAHJ). The authors reviewed the results of a cohort of children with SAHJ with repeated aspirations of the hip joint. Thirty-four children diagnosed with SAHJ were treated with repeated aspirations of the hip joint. The aspirations were performed under ultrasound guidance and topical anesthesia or under sedation. After the aspiration the joint was irrigated using the same needle, and the procedure was repeated daily. Six of the patients were operated on and then treated with aspirations because of drain dislodgement or clogging. Twenty-eight of the patients were treated primarily with repeated aspirations. Four of those patients did not improve and underwent arthrotomies, and 24 were treated only by repeated aspirations and healed completely. The mean number of aspirations was 3.6 (range 3-5), and 75% of the patients resumed walking after 24 hours. The mean follow-up time was 7.4 years (range 3-18). No complications were seen. Repeated aspiration is a safe and efficacious method of treatment for SAHJ. This method of treatment is not associated with surgery and its complications and prevents scarring of the skin and the need for general anesthesia. Faster return to normal activity was noted in this series.

The use of early flap coverage in severe open physeal fractures: a report of two cases

Open physeal fractures associated with severe overlying soft tissue loss present significant challenges to the pediatric orthopaedic surgeon. In addition to providing adequate soft tissue coverage, preventing chronic infection, and achieving bony healing, surgical care should attempt to preserve the physis to maintain growth for the best long-term outcomes. Here we present two cases of open physeal disruptions with severe soft tissue loss. In each case, early use of vascularized flap coverage assisted in fracture healing and contributed to preservation of the physis and subsequent bony growth.

Osteomyelitis in the neonate

Osteomyelitis is defined as a bacterial infection of the musculoskeletal system. Osteomyelitis in the newborn is relatively rare, but if missed can have devastating, lifelong consequences for the growing infant. Those of us who care for neonates in intensive care units should have an understanding of this disease and be equipped to recognize it and begin treatment quickly to prevent long-term sequelae. This article reviews the pathophysiology of osteomyelitis and explains why the neonate is at an extraordinary risk for this disease. It reviews risk factors, clinical presentation, etiology and pathophysiology, diagnostic evaluation, treatment and monitoring of treatment, and long-term outcomes. A case study of a 27-week gestational age infant who presented with osteomyelitis and septic hip is presented, looking at the infant's hospital course and outcome.

Imaging of musculoskeletal infections

Imaging studies play a critical role in the diagnosis and management of musculoskeletal infections in children. Conventional radiography is usually the first imaging study performed with other imaging modalities as needed. Ultrasound is helpful in detecting joint effusions and fluid collections in the soft tissue and subperiosteal regions, and may guide localization for aspiration or drainage. CT can demonstrate osseous and soft tissue abnormalities and is ideal for detecting gas in soft tissues. Nuclear scintigraphy and MR imaging are valuable because of their high sensitivity. Scintigraphy is particularly useful in identifying multifocal involvement, which is an important consideration in neonatal osteomyelitis and CRMO. MR imaging provides accurate information on both the soft tissues and bones and is our imaging study of choice for evaluating the local extent of musculoskeletal infections.

Growth arrest lines and recurrent patellar dislocation: a new sign

The phenomenon of growth arrest lines has been widely described in the medical literature. They are usually found at the metaphysis of growing long bones and are the result of short periods of partial growth arrest. Recurrent dislocation of the patella is a well-recognised problem, particularly in adolescents. Several radiological features have been reported in association with patellar dislocation or instability. We have reported a hitherto undescribed radiological sign of patellar growth arrest lines on the skyline radiographs of two patients with this condition. The shape of the patella when symptoms were at their worst corresponded remarkably closely to the outline of the subsequent growth arrest line. We postulated that repeated dislocations adversely affect the process of normal maturation of the patella. With the resolution of symptoms, patella ossification resumes, leaving the telltale sign of previous injury in the form of a growth arrest line and an improvement in bone density once the patella has been stabilised and tracks normally.

Review article: Paediatric bone and joint infection

Paediatric musculoskeletal infection remains an important cause of morbidity. Methicillin sensitive Staphylococcus aureus is still the most common organism although the incidence of methicillin resistant S. aureus in the community is rising. Osteomyelitis and septic arthritis due to Haemophilus influenzae is decreasing in incidence secondary to immunisation and in some units has been replaced by infections with the gram negative bacillus, Kingella kingae. Recent prospective studies indicate that uncomplicated osteomyelitis can be treated by three to four weeks of antibiotics. However, there is still a small group of children who will have overwhelming disseminated infection. These children require aggressive surgical and medical intervention. Two recent reports have identified an increased incidence of septic arthritis in children who have hemophilia and are HIV positive.