Epidemiology and outcome of septic arthritis in childhood: a 16-year experience and review of literature.

INTRODUCTION: Septic arthritis (SA) is a devastating infection with a high rate of sequelae. The aim of this retrospective study was to determine the epidemiology, clinically significant sequelae and risk factors for developing these sequelae in children admitted to our hospital with SA. METHODS: Patients with bacteriologically and/or radiologically confirmed SA from January 1999 to December 2014 were identified from discharge and laboratory records. Data was collected through a retrospective review of the case notes. RESULTS: A total of 75 patients (62.7% male) met the inclusion criteria. The median age at presentation was six years (range two weeks to 15 years), and six patients were neonates. Microbiologic aetiology was determined in 40 (53.3%) patients, with Staphylococcus aureus being the most common organism. 68.0% of the patients underwent arthrotomy, and the average hospital stay was 15.3 days. Sequelae of SA were observed in nine patients on follow-up. Univariate and multivariate statistical analyses showed that young age, pyogenic bacterial isolation and concomitant osteomyelitis were significant risk factors for developing sequelae. CONCLUSION: Our study demonstrated that young age, pyogenic bacterial isolation and concomitant osteomyelitis are associated with a high risk of sequelae. Timely microbiologic diagnosis by novel polymerase chain reaction methods and the use of magnetic resonance imaging in high-risk children to identify adjacent infection could possibly prevent lifelong disabling sequelae in SA.

Posterior sloping angle of the capital femoral physis in slipped capital femoral epiphysis has poor clinical utility and should not guide treatment on prophylactic fixation.

BACKGROUND: Prophylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial as it balances increased surgical risks against the possibility of protecting a normal hip from initial slip and deformity. A posterior sloping angle (PSA) of greater than 12-14.5° has been proposed by various authors as a treatment threshold to predict for contralateral hip progression and prophylactic pinning. METHODS: A retrospective review of a 10-year series of patients with the diagnosis of SCFE and follow-up of 18 months was conducted. Patients were divided into two groups, those with Isolated Unilateral Slips and those who subsequently underwent Subsequent Contralateral Progression. PSA measurements were performed by two clinicians and assessed for inter-observer reliability. Data collected included age, sex, ethnicity, Loder class, endocrinopathy, renal impairment, radiation exposure, and PSA. RESULTS: There were no significant differences between the distribution of gender, site of slip, age of onset, Loder class, and presence of medical comorbidities between the Isolated Unilateral Slip and Subsequent Contralateral Progression groups (p > 0.05). The mean PSA value was not significantly higher in the Subsequent Contralateral Progression group (17.9 ± 4.32 (10.5-23.5)) compared to the Isolated Unilateral Slip group (15.8 ± 5.31 (6-26)) (p = 0.32). The receiver operator coefficient-derived ideal treatment threshold of 16.5° gave a sensitivity of 0.71, specificity of 0.64, and number needed to treat of 3. CONCLUSION: PSA differences between the Subsequent Contralateral Progression and Isolated Unilateral Slip groups were not statistically significant in this series. All proposed treatment thresholds had poor specificity. Prophylactic pinning should not be based on isolated PSA values. LEVEL OF EVIDENCE: III.

Alpha Angle as a Predictor of Impending Contralateral Slipped Capital Femoral Epiphysis in an Asian Population.

BACKGROUND: Prophylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial. The alpha angle, a measurement of femoral head-neck aspherity, was proposed as a predictor of progression of contralateral SCFE with a treatment threshold of greater than 50.5°. The aim of this study was to evaluate its validity in our cohort of patients. METHODS: A retrospective review of a 10-year series of patients who presented with unilateral SCFE was conducted. Minimum follow-up duration to identify contralateral progression was 18 months. Age, sex, ethnicity, and endocrinopathies were noted. Alpha angle measurements of the unaffected hip were performed by two independent observers. The average values of measurements were used for analysis. Univariate and multivariate logistic regression analyses were performed to identify predictors of contralateral progression. A receiver operating characteristic (ROC) curve was generated. RESULTS: There were 43 patients with unilateral SCFE. Seven patients (16.3%) developed contralateral SCFE. There were 31 males (72.1%) and 12 females (27.9%). The mean duration from index surgery to contralateral fixation was 43.9 weeks (range, 16.2 to 77 weeks). The mean alpha angle was significantly higher in the patients with contralateral progression (mean, 50.7°; standard deviation [SD], 5.4°; range, 43.8° to 58.5°) than in the patients without progression (mean, 43.0°; SD, 4.2°; range, 33.0° to 52.5°; p < 0.001). The alpha angle was also identified as a statistically significant predictor of contralateral progression on multivariate analysis (p = 0.02). The intraclass correlation coefficient for interobserver reliability was moderately strong at 0.76 (95% confidence interval, 0.55 to 0.87). The area under the ROC curve was 0.88. The treatment threshold of 50.5° had a sensitivity of 0.43, specificity of 0.94, and number needed to treat (NNT) of 2.7. The ideal treatment threshold derived from the ROC curve was 49.0°, which had a sensitivity of 0.71, specificity of 0.89, and an NNT of 1.7. CONCLUSIONS: Alpha angle is a potential predictor of contralateral hip involvement in children with SCFE who may benefit from prophylactic hip fixation. Results from our series suggest a treatment threshold be 49.0°. However, given the limited sample size and moderately strong interobserver reliability, larger studies are needed to validate our findings.

Ingrowing toenails in children and adolescents: is nail avulsion superior to nonoperative treatment?

INTRODUCTION: Ingrowing toenail (IGTN) or onychocryptosis is not uncommon in children and adolescents. However, there is a dearth of evidence in the literature on the management of IGTN in this age group. This study aimed to compare the results of nonoperative treatment for IGTN with that of operative treatment among children and adolescents. METHODS: All children and adolescents who were treated for IGTN at our institution between 2010 and 2014 were included for this retrospective study. Demographic data, treatment prescribed and outcome at six months after presentation were analysed. RESULTS: Overall, 199 patients were recruited. There were 123 (61.8%) boys and 76 (38.2%) girls. Median age was 14 years. Among 199 toes, 162 (81.4%) were treated nonoperatively, with nail care advice, topical antibiotics and daily cleansing. Only 37 (18.6%) toes were treated operatively. In the operative group, 23 (62.2%) patients underwent wedge resections, while the remaining 14 (37.8%) had total nail avulsions; for all patients, germinal matrices were preserved. At the six-month follow-up, there were 5 (3.1%) cases of recurrence in the nonoperative group when compared to 3 (8.1%) recurrences in the operative group. CONCLUSION: We recommend that IGTN in children and adolescents be treated in the first instance by nonoperative methods. Operative options can be considered for resistant cases or in case of recurrence of IGTN.

Developmental dysplasia of the hip: why are we still operating on them? A plea for institutional newborn clinical screening.

INTRODUCTION: Developmental dysplasia of the hip (DDH) is a common orthopaedic condition at birth. Non-surgical management with the Pavlik harness can effectively treat DDH in the newborn by providing an early clinical diagnosis, but open surgeries continue to be performed. We aimed to elucidate the reasons for this. METHODS: A retrospective review was performed of all open surgeries related to DDH from 2006 to 2016. Patients were either born at our institution (Group 1) or outside of it (Group 2). All Group 1 newborns were routinely screened for DDH at birth. RESULTS: 27 patients (Group 1: n = 5, Group 2: n = 22) presented at age 25 ± 19 months. Left-sided DDH (n = 21, 77.8%) and female infants (n = 22, 81.5%) were more common. The mean age at surgery was 40 ± 31 months. The most commonly performed procedure was soft tissue release open reduction with acetabuloplasty (n = 20, 74.1%). Gender, site, median age at presentation and at surgery, and prevalence of risk factors were similar for both groups. Both groups were mostly made up of late presenters (> 3 months; p = 0.34). A few patients had undergone prior treatment (p = 0.64). Newborn screening was the only significantly different variable between the groups (p < 0.01). CONCLUSION: Lack of institutionalised newborn clinical screening appears to be the root cause of late presentation of DDH leading to open surgery for its management. We recommend quality institutionalised newborn clinical screening to reduce the number of late presentations.

Pattern of fractures in non-accidental injuries in the pediatric population in Singapore.

BACKGROUND: Fractures as a result of non-accidental injuries (NAI) are not uncommon among children. The purpose of our study was to describe the incidence, demographic characteristics, and associated risk factors in patients with NAI in a multiethnic Asian cohort. METHODS: A retrospective record review of patients admitted to our hospital between September 2007 and 2009 with the diagnosis of NAI was conducted. RESULTS: A total of 978 children were reported with suspicion of NAI. Among them, 570 patients (58.28%) were diagnosed with NAI. Fractures were observed in 35 children (6.14%). NAI fractures were highest among female infants (73.3%). The biological father was the most common known perpetrator of NAI (n = 155, 29.0%). The most common perpetrator sadly remained unknown (n = 14, 40%). All NAI fractures were closed (n = 35, 6.14%), and the most commonly affected bone was the humeral shaft (n = 10, 28.57%) with an oblique configuration. Age < 1 year and parental divorce were significant risk factors associated with these fractures. CONCLUSIONS: The skeletal injury pattern and risk factors highlighted in our study will help treating physicians identify patients susceptible to NAI, as many of these patients are young and vulnerable. Protective measures can be initiated early by recognizing these injuries and preventing further physical and psychological harm to the child.

Radial head and neck injuries in children with elbow dislocations: a report of three cases.

In children, traumatic elbow dislocations usually occur after the epiphysis has closed and with associated radial head and neck fractures and osteochondral fragments. The fragments are also usually interposed in the joint restricting complete congruent joint motion. We report on 3 children with traumatic elbow fracture-dislocation with associated radial head and neck injuries treated with open reduction and stabilisation. All patients achieved good outcomes and returned to pre-injury level of activities.