The aetiology of rickets-like lower limb deformities in Malawian children.

UNLABELLED: Debilitating rickets-like lower limb deformities are common in children throughout the world, particularly in Malawi, Africa where the causes are unknown. We have identified that Blount disease and calcium deficiency rickets are the likely causes of these deformities and propose calcium supplementation as a potential treatment of Malawian rickets. INTRODUCTION: Surgical correction of rickets-like lower limb deformities is the most common paediatric operation performed at Beit Cure Orthopaedic Hospital, Malawi. The aim of this study was to investigate the aetiology of these deformities. METHODS: Children with a tibio-femoral angle of deformity >20° were enrolled (n = 42, 3.0-15.0 years). Anthropometric and early life and well-being data were collected. Early morning serum and urine samples were collected on the morning of the operation for markers of calcium and phosphate homeostasis. Knee radiographs were obtained, and the children were diagnosed with either Blount (BD, n = 22) or evidence of rickets disease (RD, n = 20). As BD is a mechanical rather than metabolic disease, BD were assumed to be biochemically representative of the local population and thus used as a local reference for RD. RESULTS: There were no differences in anthropometry or early life experiences between BD and RD. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, total alkaline phosphatase and urinary phosphate were significantly higher and serum phosphate, 25-hydroxyvitamin D (25OHD) and tubular maximal reabsorption of phosphate significantly lower in RD than BD. There was no difference in serum calcium, fibroblast growth factor 23 or markers of iron status between groups. All children had 25OHD > 25 nmol/L. CONCLUSIONS: Vitamin D deficiency is not implicated in the aetiology of RD or BD in Malawian children. The cause of RD in Malawi is likely to be dietary calcium deficiency leading to elevated PTH resulting in increased losses of phosphate from the bone and glomerular filtrate. The causes of BD remain unclear; there was no evidence in support of previously suggested risk factors such as being overweight or starting to walk early. Prior to surgical intervention, supplementation with calcium should be considered for children with RD.

Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2-10.

The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2-10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2-10, comprising 100 clubfeet (64 patients). Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1-20, 21-45 and > 45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2-4, 5-7 and 8-10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau = 0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.

Club foot treatment in Malawi - a public health approach.

UNLABELLED: PURPOSE. Malawi is a very poor country with a current population of 12 million people and very few orthopaedic surgeons or physiotherapists. An estimated 1125 babies are born per year with club foot. If these feet are not corrected early, then severe deformity can develop, requiring complex surgery. A task force was established to address this problem using locally available resources. METHODS: A nationwide early manipulation programme was set up using the Ponseti technique, and a club foot clinic established in each of Malawi's 25 health districts. One year later the clinics were reviewed. RESULTS: Twenty out of the 25 clinics originally established were still active, and over one year had seen a total of 342 patients. Adequate records existed for 307 patients, of whom 193 were male and 114 female (ratio 1.7:1). A total of 175 patients had bilateral club foot and 132 were unilateral (ratio 1.3:1) giving a total of 482 club feet; 327 of the 482 feet were corrected to a plantigrade position. Most clinics had problems with supply of materials. Many patients failed to attend the full course of treatment. CONCLUSIONS: Overall the establishment of a nationwide club foot treatment programme was of benefit to a large number of children with club feet and their families. In a poor country with many demands on health funding many challenges remain. The supply of plaster of Paris and splints was inadequate, clinic staff felt isolated, and patient compliance was limited by many factors which need further research.

For how long should antibiotics be given in acute paediatric septic arthritis? A prospective audit of 96 cases.

Ninety-six cases of uncomplicated acute septic arthritis in children aged 12 years and under were treated by arthrotomy under general anaesthesia, saline washout and antibiotics for six weeks. They were prospectively studied for 24 weeks to assess clinical, haematological and radiological changes. Clinical improvement was most marked in the first two weeks and did not change significantly after six weeks. Haematological indices (haemoglobin concentration, serum white cell count and erythrocyte sedimentation rate) all improved from the start of treatment and continued to improve throughout the study, even after antibiotics were finished. Radiological changes in the bone adjacent to the infected joint were noted to be present in 21 cases by two weeks after presentation, and in a further 10 cases by six weeks after presentation, suggesting some continued infective activity in the bone adjacent to the septic joint even after two weeks of antibiotics. No new radiological changes were noted after six weeks. It is therefore suggested that antibiotics in septic arthritis should be continued for six weeks.

Children's surgery cancelled due to malaria and anaemia.

At our hospital 461 children were admitted for elective orthopaedic and reconstructivesurgery between January and December 2003; 90 of these (19.5%) were positive for malaria, and 37 (8%) had haemoglobin levels below 8 g/dL. The mean delay between admission and operation was five days for patients without anaemia or malaria, 7.17 days for patients with malaria,11.05 days for patients with anaemia and 13 days for patients with both anaemia and malaria.

Correlation of clinical and ultrasonographic findings after Achilles tenotomy in idiopathic club foot.

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity.

Does long-term chloramphenicol cause anaemia in Malawi?

Common clinical practice in many tropical paediatric departments is that chloramphenicol courses are limited to 2 weeks due to concerns about anaemia. However, this approach is not supported by current research and animal models. We used chloramphenicol for 6 weeks in 146 children with septic arthritis. All the children improved clinically. Most children were anaemic on presentation (mean haemoglobin [Hb] 8.43 SD 1.9), but the anaemia improved rapidly with clinical resolution of the infection and was maintained at 6 months after presentation (mean Hb 10.57 SD 1.86).

Clinical features and microbiology in 204 cases of septic arthritis in Malawian children.

We examined 204 children (137 boys and 67 girls) aged 12 years and under with septic arthritis. Their mean age was 31.1 months (1 to 144; SD 41.6). The most common joints affected were the knees and shoulders. Joints in the upper limb were affected more often in younger children and in the lower limb in those who were older. The mean age for an infection was 12 months in the shoulder and 73 months in the hip. The most common organisms cultured were species of Salmonella.

Septic arthritis of the shoulder in children in Malawi. A randomised, prospective study of aspiration versus arthrotomy and washout.

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up.

Wound healing after implant surgery in HIV-positive patients.

We performed a prospective, blind, controlled study on wound infection after implant surgery involving 41 procedures in patients infected with the human immunodeficiency virus (HIV) and 141 in HIV-negative patients. The patients were staged clinically and the CD4 cell count determined. Wound infection was assessed using the asepsis wound score. A risk category was allocated to account for presurgical contamination. In HIV-positive patients, with no preoperative contamination, the incidence of wound infection (3.5%) was comparable with that of the HIV-negative group (5%; p = 0.396). The CD4 cell count did not affect the incidence of infection (r = 0.16). When there was preoperative contamination, the incidence of infection in HIV-positive patients increased markedly (42%) compared with that in HIV-negative patients (11%; p = 0.084). Our results show that when no contamination has occurred implant surgery may be undertaken safely in HIV-positive patients.

Delay in skeletal maturity in Malawian children.

The atlas of Greulich and Pyle for skeletal maturity and epiphyseal closure is widely used in many countries to assess skeletal age and to plan orthopaedic surgery. The data used to compile the atlas were collected from institutionalised American children in the 1950s. In order to determine whether the atlas was relevant to subSaharan Africa, we compared skeletal age, according to the atlas, with chronological age in 139 skeletally immature Malawian children and young adults with an age range from 1 year 11 months to 28 years 5 months. The height and weight of each patient were also measured in order to calculate the body mass index. The skeletal age of 119 patients (85.6%) was lower than the chronological age. The mean difference was 20.0+/-24.1 months (t-test, p = 0.0049), and the greatest difference 100 months. The atlas is thus inaccurate for this group of children. The body mass index in 131 patients was below the normal range of 20 to 25 kg/m2. The reasons for the low skeletal age in this group of children are discussed. Poor nutrition and chronic diseases such as malaria and diarrhoea which are endemic in Malawi are likely to be contributing factors. We did not find any correlation between the reduction in body mass index in our patients and the degree of retardation of skeletal age.

Geometric measurements of the acetabulum in adult Malawians: radiographic study.

OBJECTIVES: To determine the acetabular depth as well as acetabular and centre edge angles; to assess the influence of sex, if any, in these geometric measurements; and to determine the prevalence of hip dysplasia in adult Malawians. DESIGN: A retrospective study. SETTING: Queen Elizabeth Central Hospital (QECH) and Blantyre Adventist Hospital (BAH). MAIN OUTCOME MEASURES: The acetabular and centre edge angles, acetabular depth and the prevalence of hip dysplasia were determined. MATERIALS AND METHODS: Two hundred and fifty three bilateral radiographs of the hip from adults, 133 men and 129 women, were used to measure the acetabular depth, angle and centre edge angle using a calliper and goniometer. The radiographs were taken from patients with no underlying bone disease between January 1997 and February 2001 at QECH and BAH. RESULTS: The prevalence of hip dysplasia was 11.54% for men and 13.16% for women with respect to centre edge angles but this difference by sex was not significant (P>0.1). However, the prevalence of hip dysplasia with respect to centre edge angle showed significantly more dysplasia in Malawian men than Nigerian and Chinese men (P<0.001 and P<0.05, respectively). Centre edge angles also showed a wider range in Malawian men (19-51 degrees right, and 15-52 degrees left) than women (18-45 degrees right, 20-46 degrees left). In both hips, the acetabular angles were more obtuse in men (35.52 degrees right, 34.21 degrees left) than women (29.43 degrees right, 29.29 degrees left), and this difference was significant (P<0.001). The ranges of acetabular angles were wider in women (11-38 degrees right, 8-40 degrees left) than men (24-49 degrees right, 20-40 degrees left). Acetabular depth was also greater in men than in women (P<0.01 right hip, P<0.02 left hip). CONCLUSION: Sex influences geometrical measurements of the acetabulum. The prevalence of hip dysplasia with respect to centre edge angle was significantly higher in women than men and the prevalence for men with respect to centre edge angle was significantly different when compared with Nigerian and Chinese men. This information will assist clinicians in the region and Malawi in particular to interpret hip X-rays of African patients.

The effects of introducing artemether-lumefantrine malaria treatment and insecticide-impregnated bed nets to an elective surgical hospital.

Malaria and anaemia in patients admitted for elective orthopaedic operations commonly cause delays to surgery. Our hospital has introduced artemether-lumefantrine as the standard treatment for malaria in accordance with the national policy, replacing sulphadoxine-pyrimethamine. Insecticide-impregnated bed nets were also introduced throughout our wards. A retrospective audit of all new elective surgical admissions over a 12-month period was performed in order to assess the effect of these changes. The study was designed to follow an identical audit performed before their introduction. Of the 435 patients admitted, 75 (17.2%) had malaria parasites present on blood film. In these patients, surgery was significantly delayed, by a mean of 9.9 days more than the group without malaria (P < 0.001). Before the changes to malaria treatment, the mean delay was 2.2 days (P < 0.05). Six patients (1.7%) developed malaria during admission, significantly fewer than the 16 (4.3%) before the introduction of bed nets (P = 0.036). The average haemoglobin level on admission in patients with malaria parasites was 11.8 g/dL (95% confidence interval [CI] 11.4-12.2) and in those without 13.1 g/dL (95% CI: 12.9-13.3). Seventeen patients (3.9%) were admitted with a haemoglobin concentration of <10 g/dL and two (0.5%) of <8 g/dL. There were no significant delays to surgery in these patients compared to those without anaemia. The adoption of artemether-lumefantrine by our hospital significantly increased delays to surgery. The introduction of insecticide-impregnated bed nets significantly reduced the number of patients developing malaria during their hospital stay.