Do teenagers return to normal physical activity levels after limb fractures? A longitudinal, accelerometry-based, activity monitoring study

PURPOSE

This study aimed to elucidate whether levels of physical activity (PA) return to normal after bone healing or whether long-term behavioural changes in PA are to be expected in children and teenagers who have sustained limb fractures.

METHODS

In all, 100 children and teenagers with a first episode of limb fracture and 100 sex- and age-matched healthy controls (CTRL) were recruited for a prospective study. PA in limb fracture patients was assessed at 18-month follow-up using accelerometer measurements, and values were compared with those of CTRL. Time spent in PA at different levels of intensity was determined for each participant and expressed in minutes and as a percentage of total validly measured time.

RESULTS

Mean levels of PA at different levels of intensity by previously injured children and teenagers were similar than CTRL (42 sets of paired data). However, time spent in moderate-to-vigorous PA (MVPA) was lower than 60 minutes among limb-fracture patients at 18-month follow-up.

CONCLUSION

The amount of skeletal loading in children and teenagers returns to normal values by 18 months after limb fracture. Even if time spent in MVPA is not significantly lower in children and teenagers with limb fractures, it no longer reached the international recommendations for school-aged children (MVPA > 60 minutes), which may be interpreted as a lifestyle modification or a behavioural change to avoid new trauma.

LEVEL OF EVIDENCE

II.

Spinal infections in children: a multicentre retrospective study

Aims

This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series.

Patients and Methods

The medical records of children with such an infection, treated at four tertiary institutions between 2004 and 2014, were analyzed retrospectively. Epidemiological, clinical, paraclinical, radiological, and microbiological data were evaluated. There were 103 children, of whom 79 (76.7%) were aged between six months and four years.

Results

We confirmed a significant male predominance in the incidence of primary pyogenic spinal infections in children (65%). The lumbar spine was the most commonly affected region, and 27 infections (26.2%) occurred at L4/5. The white blood cell count was normal in 61 children (59%), and the CRP level was normal in 43 (42%). Blood cultures were performed in 95 children, and were positive in eight (8%). A total of 20 children underwent culture of biopsy or aspiration material, which was positive in eight (40%). Methicillin-sensitive Staphylococcus aureus (MSSA) and Kingella ( K.) kingae were the most frequently isolated pathogens.

Conclusion

MSSA remains the most frequently isolated pathogen in children with primary pyogenic infection of the spine, but K. kingae should be considered as an important pathogen in children aged between six months and four years. Therefore, an empirical protocol for antibiotic treatment should be used, with consideration being made for the triphasic age distribution and specific bacteriological aetiology. In the near future, the results of polymerase chain reaction assay on throat swabs may allow the indirect identification of K. kingae spondylodiscitis in young children and thus aid early treatment. However, these preliminary results require validation by other prospective multicentre studies. Cite this article: Bone Joint J 2018;100-B:542-8.

Minimally invasive surgery for adolescent idiopathic scoliosis

Aims

The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications.

Patients and Methods

We prospectively collected the data of 70 consecutive patients with AIS treated with MIS using three incisions and a muscle-splitting approach by a single surgeon between June 2013 and February 2016 and these were retrospectively reviewed. There were eight male and 62 female patients with a mean age of 15 years (sd 4.5 ) with a mean body mass index of 19.8 kg/m2 (sd 5.4). The curves were classified according to Lenke; 40 curves were type 1, 15 were type 2, three were type 3, two were type 4, eight were type 5 and two were type 6.

Results

The mean primary Cobb angle was corrected from 58.9° (sd 12.6°) pre-operatively to 17.7° (sd 10.2°) post-operatively with a mean correction of 69% (sd 20%, p < 0.001). The mean kyphosis at T5 to T12 increased from 24.2° (sd 12.2°) pre-operatively to 30.1° (sd 9.6°, p < 0.001) post-operatively. Peri-operative (30 days) complications occurred in three patients(4.2%): one subcutaneous haematoma, one deep venous thrombosis and one pulmonary complication. Five additional complications occurred in five patients (7.1%): one superficial wound infection, one suture granuloma and three delayed deep surgical site infections. The mean ORT was 337.1 mins (sd 121.3); the mean EBL was 345.7 ml (sd 175.1) and the mean LOS was 4.6 days (sd 0.8).

Conclusion

The use of MIS for patients with AIS results in a significant correction of spinal deformity in both the frontal and sagittal planes, with a low EBL and a short LOS. The rate of peri-operative complications compares well with that following a routine open technique. The longer term safety and benefit of MIS in these patients needs to be evaluated with further follow-up of a larger cohort of patients. Cite this article: Bone Joint J 2017;99-B:1651–7.

Widespread intracranial calcifications in the follow-up of a patient with cartilage-hair hypoplasia--anauxetic dysplasia spectrum disorder: a coincidental finding?

BACKGROUND/PURPOSE

Intracranial calcifications have been identified in many neurological disorders. To our knowledge, however, such findings have not been described in cartilage-hair hypoplasia - anauxetic dysplasia spectrum disorders (CHH-AD), a group of conditions characterized by a wide spectrum of clinical manifestations.

METHODS/RESULTS

We report a 22-year old female patient, diagnosed with this disorder during her first year of life, and in whom bilateral intracranial calcifications (frontal lobes, basal ganglia, cerebellar dentate nuclei) were discovered by brain MRI at the age of 17 years.

CONCLUSION

The etiology of this finding remains unclear. Some causes of such deposits can be of a reversible nature, thus prompting early recognition although their consequences on clinical outcome remain mostly unknown.

Benign fibrous histiocytoma of bone in a paediatric population: a report of 6 cases

Case records and radiological investigations of six children with benign fibrous histiocytoma were studied retrospectively. BFH occurred in the femur (n = 2), tibia (n = 2) and fibula (n = 2). Clinically, patients reported pain from the lesion lasting several months (mean 6 months). The pain was not associated with pathological fracture in any patient. On X-rays, the lesions appeared as lytic and sharply demarcated with a sclerotic rim and fine trabeculations. The reported cases were located in the metaphysis and the diaphysis of the long bones. The tumour was restricted to bone, without periosteal or soft tissue reaction. Treatment consisted of careful intralesional curettage of the lesion; the defect was thereafter filled with bone bank graft or injectable phosphocalcic cement. The length of follow-up ranged from 24 months to 4.75 years (mean 35.2 months). One case presented with recurrence of the disease and required successful repeat intralesional curettage. Benign fibrous histiocytoma is probably underestimated among patients less than 20 years of age. This diagnosis should be considered in any child or teenager who presents with a non-ossifying fibroma accompanied by unexplainable pain or a rapid growing. Surgery restricted to the osteolytic lesion seems sufficient to achieve bone healing.

PTH improves titanium implant fixation more than pamidronate or renutrition in osteopenic rats chronically fed a low protein diet

SUMMARY

We evaluated the effects of parathyroid hormone (PTH), pamidronate, or renutrition on osseointegration of titanium implants in the proximal tibia of rats subject to prolonged low-protein diets. PTH improved mechanical fixation, microarchitecture, and increased pull-out strength. Pamidronate or renutrition had lesser effects. PTH can thus improve implant osseointegration in protein-malnourished rats.

INTRODUCTION

Protein malnutrition impairs implant osseointegration in rats. PTH and pamidronate prevent deleterious effects of protein restriction introduced just prior to implantation. Whether these treatments improve osseointegration after chronic protein deprivation, i.e., in osteopenic bone at time of implantation, is unknown. We evaluated effects of PTH, pamidronate, or renutrition on resistance to pull-out of titanium rods implanted into the rat tibiae following isocaloric low-protein intake.

METHODS

Forty-one adult female rats received normal or isocaloric low-protein diets. Six weeks later, implants were surgically inserted into proximal tibiae. Following implantation, rats on low-protein diets were treated with PTH (1-34), pamidronate, saline vehicle, or normal protein diets, for another 8 weeks. Tibiae were removed for micro-computerised tomographic morphometry and evaluation of pull-out strength.

RESULTS

Pull-out strength decreased in rats on isocaloric low-protein diets compared with normal protein group (-33.4%). PTH increased pull-out strength in low-protein group, even compared to controls from the normal protein group. PTH and pamidronate increased bone volume/tissue volume, bone-to-implant contact, and trabecular thickness, whilst trabecular separation was reduced, with a shift to more plate-like bone surrounding the implants.

CONCLUSIONS

PTH reversed the deleterious effects of long-term protein undernutrition on mechanical fixation and bone microarchitecture and improved implant osseointegration more than pamidronate or renutrition, likely through changes to structure model index.

[Dislocation of a total hip prosthesis: etiology and treatment]

Dislocation of a total hip prosthesis is a substantial burden in terms of morbidity and health care costs. The incidence of dislocation is highest during the first postoperative months but the risk persists throughout the entire life of the patient. The first dislocation is treated by an emergency closed reduction of the hip undergeneral anaesthesia, following which about three out of four patients will have a stable hip. In cases of recurrent dislocation the treatment is difficult, depending upon the time between surgery and dislocation, the identification of an etiologic factor, and the general status of the patient. Patients in which a specific cause can be identified have better results after surgical revision. When no causal factor is detected several surgical options are possible, but the results are less consistent.

Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.

The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.

We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.

[Acute bone and joint infections in children: how much attention should be paid to persistent fever during intravenous antibiotic therapy?]

PURPOSE OF THE STUDY

Bone and joint infections are challenging therapeutic situations requiring rapid antibiotic therapy as soon as bacteriology specimens have been obtained. Laboratory tests (C reactive protein, erythrocyte sedimentation rate, white cell count) and clinical findings are used to assess therapeutic efficacy. Most of the clinical signs however, particularly in children or after a surgical procedure, are not explicit enough to allow proper assessment of the clinical course under antibiotic therapy. Body temperature is the only parameter currently used in routine practice. But the measurement of body temperature is not always reliable and variations observed during treatment should not always be attributed to treatment failure. The purpose of this work was to assess the significance of changes in body temperature observed in children given effective intravenous antibiotic treatment for bone and joint infections.

MATERIAL AND METHODS

We reviewed retrospectively the files of 60 children treated in our unit for acute bone and joint infections. The patients had acute hematogeneous osteomyelitis (n=27), septic arthritis (n=25), and infectious osteoarthritis (n=8). A bacterial strain was identified on cultures of blood, joint fluid, or metaphysis puncture samples in all cases. Blood test results (C-reactive protein, erythrocyte sedimentation rate, white cell count) were recorded during treatment. Body temperature was recorded three times a day until normalization then daily until discharge. We searched for correlations between variations in the temperature curve observed during treatment and blood test results.

RESULTS

Ninety percent of the children had fever at admission (mean 39.1 degrees C). Among the six children without fever, the temperature rose in 5 during the first 48 hours of hospitalization. Even when the treatment was effective, apyrexia was achieved slowly, on the average after 8 days of antibiotic treatment. We also observed that the peak temperature occurred during the first 5 days of antibiotic treatment considered effective. C-reactive protein level normalized within a satisfactory time (10.5 days), reflecting the efficacy of the antibiotics.

DISCUSSION

The efficacy of antibiotic treatment must always be verified in patients with acute bone and joint infections. Generally, biological parameters are used to monitor efficacy. Currently, C-reactive protein appears to be the most reliable parameter to assess efficacy, its rapid decline reflecting clinical cure. Erythrocyte sedimentation rate and white cell counts are poor surveillance parameters. Finally, body temperature is not a specific surveillance parameter and persistent fever during treatment does not necessarily signify ineffective antibiotic treatment. In light of this fact, body temperature should always be compared with C-reactive protein level to draw any conclusion concerning therapeutic failure.