Paediatric anterior cruciate ligament tears: management and growth disturbances. A survey of EPOS and POSNA membership.

PURPOSE: The therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR). METHODS: An email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied. RESULTS: In all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR. CONCLUSION: Current practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome. LEVEL OF EVIDENCE: II.

A comparison of screw versus drill and curettage epiphysiodesis to correct leg-length discrepancy.

PURPOSE: To compare two common surgical techniques of epiphysiodesis: drill/curettage epiphysiodesis (PDED) versus cross screw epiphysiodesis (PETS). The hypothesis is that the two techniques have similar efficacy but demonstrate differences in length of hospital stay (LOS), time to return to activity and complication rates. METHODS: A retrospective review of growing children and adolescents less than 18 years old who required an epiphysiodesis with leg-length discrepancy (LLD) of 2 cm to 6 cm with minimum two years of follow-up was conducted. Characteristics including age at surgery, gender, epiphysiodesis location, side, operative time, LOS and hardware removal were compared across treatment groups. LLD, expected growth remaining (EGR) and bone age were determined preoperatively and at most-recent visit. The correction ratio (change in EGR) was calculated along with a 95% confidence interval (CI) to assess if correction in leg length was achieved. RESULTS: A total of 115 patients underwent epiphysiodesis in the femur (53%), tibia (24%) or a combination (24%). The cohort was 47% male, with a mean age of 12.6 years (7.7 to 17.7) at surgery. Median follow-up was 3.7 years (2.0 to 12.7). In all, 23 patients underwent PETS and 92 patients had PDED. Both treatment groups achieved expected LLD correction. There was no significant difference in median operative time, complication rates or LOS. PETS patients returned to activity at a mean 1.4 months (interquartile range (IQR) 0.7 to 2.1) while PDED patients returned at a mean 2.4 months (IQR 1.7 to 3) (p < 0.001). CONCLUSION: Effectiveness in achieving expected correction, LOS and operative time are similar between screw and drill/curettage epiphysiodesis. Patients undergoing PETS demonstrated a faster return to baseline activity than patients with PDED. LEVEL OF EVIDENCE: III.

Immunoglobulin-containing cells in jejunal mucosa of children with protein-energy malnutrition and gastroenteritis.

Jejunal biopsies from 20 well nourished children (average age 12.8 months) with gastroenteritis, and 20 children (average age 20 months) with protein-energy malnutrition were examined by immunofluorescent technique for immunoglobulins A, G, M, E, and D, and for epithelial glycoprotein secretory component. Compared with previous studies on normal infants, the children with gastroenteritis showed a moderate increase in IgA-containing cells, a large increase in IgM-containing cells, and no change in IgG-containing cells. These findings are similar to previously recorded findings on adults with gastroenteritis. In contrast there was a pronounced and highly significant decrease in IgA-containing cells in the jejunal mucosa of the children with protein-energy malnutrition. No significant differences were noted between the populations of IgG-, IgM-, IgE-, and IgD-containing cells in the two groups. It is suggested that this selective deficiency in mucosal IgA results from a delay in maturation of the secretory IgA system, and the mechanisms of such a deficiency are discussed.

Effects of autologous plasma on lymphocyte transformation in malaria and in acute protein-energy malnutrition. Comparison of purified lymphocyte and whole blood cultures.

Phytohaemagglutinin (PHA) induced lymphocyte transformation in whole blood and in purified lymphocyte cultures was investigated in Gambian children with acute Plasmodium falciparum malaria or with acute protein-energy malnutrition (PEM). Responses of purified lymphocytes cultured in the absence of autologous plasma were normal, with one exception. Autologous plasma depressed the response of purified lymphocytes to a low dose of PHA in several malaria and PEM patients. In whole blood cultures of 1 day and of 3 day duration, responses of several children with malaria or PEM were less than those of control children. Responses were not related to absolute lymphocyte counts. In 3 day, but not 1 day, cultures from control and malarious children, responses were inversely proportional to neutrophil counts. Cultures of whole blood and of purified lymphocytes in autologous plasma gave comparable results in 58 of 70 patients.

Neonatal vaccination with 'universal strength' BCG vaccine.

'Universal strength' BCG vaccine was given to 219 neonates and 2 months later 159 infants were Mantoux-tested with 5 Tu PPD-S and their BCG scars measured. The results showed a satisfactory conversion rate of over 90%. Though 30% of the lesions discharged, this only lasted for a few days and the vaccine was well tolerated and acceptable for use in neonates.

Delayed hypersensitivity to PPD-S following BCG vaccination in African children--an 18-month field study.

BCG vaccine given to young Gambian children produced a conversion rate, measured by delayed hypersensitivity to PPD-S, which increased with improving nutritional status. Retesting when nutrition had improved showed a considerable loss of delayed hypersensitivity in all nutritional groups. This may be the result of enhanced macrophage microbicidal acitvity at the time the BCG was administered. BCG is not likely to be very effective if given to malnourished children or to those who are undergoing repeated antigenic stimulation.

Depression of lymphocyte response to phytohaemagglutinin in the presence of plasma from children with acute protein energy malnutrition.

Phytohaemagglutinin-induced lymphocyte transformation of four healthy adults and a child with kwashiorkor was performed in the presence of plasma from nineteen patients with protein energy malnutrition and a nutritionally normal child. Marked inhibition occurred in the presence of plasma from six patients who subsequently died, moderate inhibition occurred in six other patients in the acute stage and in two of these six in the convalescent stage, whilst in the remaining seven there was no effect. Reduction in response did not appear to be due to plasma cytotoxicity. Plasma factors in some cases of malnutrition, associated with certain infections appear to inhibit the lymphocyte response and this may have prognostic implications.

Anthrax in the Gambia: an epidemiological study.

Epidemiological data on 448 cases of human cutaneous anthrax from the Gambia showed that this particular strain of anthrax bacillus causes widespread morbidity and some mortality with, at the same time, subclinical infection. Analysis also showed that anthrax is not an occupationally related disease in the Gambia.The possibility of human-to-human spread, affecting all age groups and both sexes, by means of a communal toilet article was also shown. The fact that the strain is a good toxin producer but contains a weak antigen may have accounted for the repeated clinical infection and the fact that antibody titres were generally transient. Subclinical infection in animals was also found, particularly in sheep and goats, and also, with an unusually low mortality, in cows. Insect vectors were not excluded, but were unlikely. Vultures may spread the disease from village to village. Some possible public health and immunization procedures are discussed, with a view to containing this difficult problem in this part of west Africa.

Jejunal microflora in malnourished Gambian children.

Growth of bacteria greater than 10-5 organisms/ml was found in 22 children, of whom 17 gave a histroy of chronic diarrhoea. The other 8 children had either no diarrhoea or where having an acute attack lasting for a few days. In those with chronic diarrhoea, Esch. coli, bacteroides, and enterococci tended to occur more frequently, whereas streptococci occurred more frequently in those with acute diarrhoea. Bacilli, staphylococci, micrococci, klebsiellas, pseudomonads, and candidas often occurred in both groups and in large numbers in those with chronic diarrhoea. This confirms previous reports in other parts of the world that some children with malnutrition have considerable bacterial contamination of the jejunum, and that this may be of aetiological significance as a cause of much of the diarrhoea seen in malnourished children. It is possible too that this may be important in the pathogenesis of malnutrition. The presence of intestinal parasites in these malnourished children is also noted. A double-blind trial in the use of antibiotics in this condition is advocated to determine whether it is possible to break the diarrhoea-malabsorption-malnutrition cycle. At the same time the effect of simply removing the child to a more sanitary environment, together with an estimate of the natural clearance of bacteria from the upper intestine, should be evaluated.

A survey of infantile gastroenteritis.

In 1967 we admitted 339 cases of infantile gastroenteritis; one-third of these were dehydrated, and in this group the commonest biochemical abnormality found was hypernatraemia, sometimes with metabolic acidosis. A higher incidence of dehydration was found in the patients who had received oral glucose fluids before admission. EnteropathicEscherichia coliwere isolated from the faeces of 16% of the cases. Associated infections, especially of the respiratory tract, were common. Treatment was aimed at the restoration of fluid and electrolyte balance. Usually this was achieved with oral fluids, though intravenous fluids were used in the most severely dehydrated cases. Recovery was complete in 320 cases and a further 14 cases were discharged as carriers of enteropathicE. coli. There were five deaths (1.5%) in the series; three occurred immediately after admission.