Kingella kingae septic arthritis.

AIMS: The aim of this study was to determine the extent to which patient demographics, clinical presentation, and blood parameters vary in Kingella kingae septic arthritis when compared with those of other organisms, and whether this difference needs to be considered when assessing children in whom a diagnosis of septic arthritis is suspected. METHODS: A prospective case series was undertaken at a single UK paediatric institution between October 2012 and November 2018 of all patients referred with suspected septic arthritis. We recorded the clinical, biochemical, and microbiological findings in all patients. RESULTS: A total of 160 patients underwent arthrotomy for a presumed septic arthritis. Of these, no organism was identified in 61 and only 25 of these were both culture- and polymerase chain reaction (PCR)-negative. A total of 36 patients did not undergo PCR analysis. Of the remaining 99 culture- and PCR-positive patients, K. kingae was the most commonly isolated organism (42%, n = 42). The knee (n = 21), shoulder (n = 9), and hip (n = 5) were the three most commonly affected joints. A total of 28 cases (66%) of K. kingae infection were detected only on PCR. The mean age of K. kingae-positive cases (16.1 months) was significantly lower than that of those whose septic arthitis was due to other organisms (49.4 months; p < 0.001). The mean CRP was significantly lower in the K. kingae group than in the other organism group (p < 0.001). The mean ESR/CRP ratio was significantly higher in K. kingae (2.84) than in other infections (1.55; p < 0.008). The mean ESR and ESR/CRP were not significantly different from those in the 'no organism identified' group. CONCLUSION: K. kingae was the most commonly isolated organism from paediatric culture- and/or PCR-positive confirmed septic arthritis, with only one third of cases detected on routine cultures. It is important to develop and maintain a clinical suspicion for K. kingae infection in young patients presenting atypically. Routine PCR testing is recommended in these patients. Cite this article: Bone Joint J 2021;103-B(3):584-588.

A Population Survey of Dietary Attitudes towards Gluten.

It is unclear how the prevalence of people who believe the gluten-free diet (GFD) to be generally healthy ("Lifestylers") is impacting the overall rates of self-reported gluten sensitivity (GS). We repeated a population survey from 2012 in order to examine how attitudes towards GS have changed over time. Our survey (N = 1004) was administered in Sheffield (UK) in 2015, replicating the 2012 experiment. The questionnaire included a food frequency survey and assessed self-reported GS as well as associated variables (prevalence, current diet, pre-existing conditions, etc.). The overall rates of key variables and chi-squared analysis in comparison to the previous survey were as follows: self-reported GS was 32.8% (previously 12.9%, p < 0.001), pre-existing coeliac disease (CD) was 1.2% (previously 0.8%, p = 0.370), following a GFD was 3.7% (previously 3.7%, p = 0.997). Self-reported GS was positively associated with some pre-existing conditions, including anxiety, depression, chronic fatigue, headaches, and other food allergies/intolerances (including irritable bowel syndrome (IBS); chi-squared analyses, all p < 0.001). Over a 3-year period, the fraction of people who self-reported GS increased by over 250%. Despite this, arguably more meaningful indications of underlying physiological GS remained comparable. This research suggests that the public perception of gluten is causing a marked increase in the number of people who erroneously believe they are sensitive to it.

Intramedullary devices in the management of Judet III and IV paediatric radial neck fractures.

PURPOSE: The aim of this study is to discuss the results of different intramedullary devices used in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique. METHODS: Thirty patients with isolated Judet III and IV fractures were included in this prospective study. Judet I and II fractures and radial neck fractures associated with other injuries were excluded. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow Score. RESULTS: The functional result was good to excellent in 24 of 30 cases (80%). The mean Oxford Elbow Score was 44.32. The mean follow-up was 40.11 months. The complications seen were radiocapitellar joint penetration - 6 cases at mean 4.87 weeks, redisplacement - 6, radial epiphyseal sclerosis - 5, and heterotopic ossification - 1 case. CONCLUSION: Intramedullary K wires may result in radiocapitellar joint penetration. Titanium Elastic Nail System should not be used as purely fixation devices as they may not prevent redisplacement. Regular follow-up until at least 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be given a guarded prognosis. The paper highlights the pitfalls of the technique and makes recommendations regarding the type of implant, follow-up and patient counselling in Judet IV fractures.

Pelvic pyomyositis in children: changing trends in occurrence and management.

AIMS: We present the largest series of paediatric pelvic pyomyositis from a temperate country, analyse the factors influencing long term prognosis and suggest a diagnostic protocol. MATERIALS AND METHOD: We included 41 patients diagnosed with primary paediatric pelvic pyomyositis between 1998 and 2016, in this study with a mean age of 7.5 years. Demographic, clinical, radiological and follow-up data were reviewed. Statistical analysis was performed to analyse the influence of early diagnosis and treatment on the final outcome. RESULTS: There was an increased occurrence of primary pelvic pyomyositis in the last two years. Of cases identified, 85% fulfilled Kocher's criteria for hip septic arthritis. The mean time to diagnosis was 2.8 ± 0.8 days. The most common muscle affected was obturator internus (65.85%) and multifocal involvement was common (46.34%). Early diagnosis and antibiotic treatment within seven days from the time of onset of symptoms was the only factor that influenced final outcome (p < 0.001). DISCUSSION AND CONCLUSION: Pyomyositis is no longer restricted to tropical countries. The time from onset of symptoms to start of antibiotic treatment influences the final outcome. Clinical examination and inflammatory markers have low specificity in distinguishing between pyomyositis, septic arthritis, osteomyelitis or other infections. MRI is more sensitive and can diagnose pyomyositis in its early stages. Every suspected case of septic arthritis of the hip should undergo an ultrasound. MRI scan may be performed if the ultrasound shows inconclusive evidence of an effusion. Early identification will facilitate early antibiotic treatment which will improve the final outcome. CLINICAL RELEVANCE: There is an increasing occurrence of this tropical disease in temperate countries. Early diagnosis with an MRI scan and early antibiotic use results in good outcomes.

Wrist Arthroscopy in Children and Adolescent With Chronic Wrist Pain: Arthroscopic Findings Compared With MRI.

BACKGROUND: Wrist arthroscopy is a dynamic diagnostic procedure and its indications are growing as a treatment modality in the adult population. The aim of the study was to retrospectively report our series of pediatric and adolescence with chronic wrist pain, with or without wrist instability who underwent wrist arthroscopy after failing at least 4 months of conservative management. Our secondary aim was to report the sensitivity and specificity of clinical examination and magnetic resonance imaging evaluation for various injury subgroups against the gold standard of the arthroscopic findings. Technical challenges, complications, and outcomes are also discussed. METHODS: A retrospective review of the medical records of 32 pediatric and adolescent patients who underwent wrist arthroscopy was conducted. Preoperative clinical diagnosis, radiographic, and intraoperative findings including classifications of triangular fibrocartilage complex (TFCC) and interosseous ligaments were obtained. Patients were followed up to 1 year postoperatively and were discharged if symptom free. RESULTS: Thirty-three wrist arthroscopies in 32 patients were performed from 1996 to 2004. There were 2 male and 30 female patients. At arthroscopy 16 wrists were found to have TFCC injuries, 11 wrists had scapholunate injuries, and 8 had lunotriquetral (LT) injuries. Clinical examination for diagnosis of TFCC injury was too sensitive and nonspecific; however, clinical diagnosis of scapholunate injury was sensitive and specific. LT injury was under diagnosed clinically. Magnetic resonance imaging was found to have a low sensitivity for diagnosis of LT injury but diagnosis of TFCC was sensitive and specific. CONCLUSIONS: The sex ratio of 2 males:30 females was startling. Nevertheless, this therapeutic level 3 study supports a thorough search for pathology in any patient with persistent wrist symptoms because pathology was identified in 32 of the 33 wrists at arthroscopy. LEVEL OF EVIDENCE: Level III-Therapeutic.

Transverse divergent dislocation of elbow in a child: a case report and review of current literature.

We present a case report on transverse divergent dislocation of the elbow, highlighting the spatial relation among the proximal radius, ulna, and distal humerus in this rare pediatric elbow injury and reasons leading to misinterpretation of radiographs. Elbow dislocation is a rare injury in children. It comprises only 6% of pediatric elbow injuries. Most pure dislocations are posterior, but they can occur in any direction. Divergent dislocation of the elbow is a subgroup of posterior dislocation, which is extremely rare. It is important that the pediatric emergency physician is aware, able to identify, and manage this injury. It is defined as a specific elbow dislocation in which the distal humerus is forced between the proximal radius and ulna, resulting in the divergence of the proximal forearm bones. Joint laxity is said to be a predisposing cause in pediatric age group. Atraumatic divergent dislocation of the elbow has been reported in the adults with rheumatoid arthritis. Imaging is challenging because there is no defined specific radiological views, therefore making the diagnosis difficult. This often leads to misdiagnosis or inappropriate treatment. A thorough understanding of mechanism of injury and basis for atypical radiological findings will help in identifying the injury early, and the simple Thompson technique to relocate the elbow will give an excellent functional outcome.

Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique?

The use of foot abduction orthosis [Denis Browne boot (DBB)] is vital for maintaining correction after the Ponseti technique for treating idiopathic clubfoot. Lack of adherence to DBB regimen is reported to be a potent cause for recurrence. Adherence to the boots and bars programme is difficult and patients sometimes resist their use. The evaluation of alternatives that may facilitate adherence is therefore necessary and reasonable. There are less data published regarding the outcome after the use of alternative splints. In patients who showed poor adherence to DBB, we introduced a novel unilateral foot abduction orthosis (UFAO) as an alternative. The aim of this study was to determine whether the recurrence rates were increased by exchanging DBB with UFAO in nonadherent patients and to find out whether UFAO was more acceptable to families who had refused to use DBB. We reviewed 27 children with 35 idiopathic clubfeet. Twenty-three patients used the boots and bars programme for the first 3 months after completion of serial casting, before UFAO was introduced into the treatment plan for resistance to DBB usage. In four cases, UFAO was commenced immediately after the serial casting. The mean follow-up was 25 months (16-36 months). Most families reported that UFAO was easier for their child to use and facilitated adherence was observed. Recurrence (the need for further casting or operation) was observed in 11 feet. Six of these 11 recurrences responded favourably to a further period of serial casting with or without repeated tendoachilles tenotomy. Three of these 11 patients responded favourably to tibialis anterior transfer and two required a traditional posteromedial release. The recurrence rates in patients using UFAO were higher compared with those reported by others using DBB after Ponseti serial casting. Our results indicated that although a unilateral orthosis is preferred and accepted by families who do not adhere to a DBB regimen, recurrence with UFAO use is higher. This study therefore questions the effectiveness of UFAO as an alternative to DBB. The importance of following the original method described by Ponseti should be stressed.

Congenital clavicular pseudarthrosis: comparison of two treatment methods.

BACKGROUND: Congenital pseudarthrosis of the clavicle is rare and popular surgical options include excision of the non-union, iliac crest bone grafting and stabilisation with either a fully threaded pin or stabilisation with a reconstruction plate. METHODS: Between 1995 and 2009, ten patients with congenital pseudarthrosis of the clavicle were retrospectively reviewed for outcome of two different forms of surgical management. Five patients had excision of the non-union, iliac crest bone grafting and stabilisation with a fully threaded pin (group A) and the other five patients had excision of the non-union, iliac crest bone grafting and stabilisation with a reconstruction plate (group B). One patient in the second group had bilateral pseudarthrosis. RESULTS: In group A, three patients achieved radiological union at a median of 6 months. Two patients failed to unite at the pseudarthrosis and one of them had further surgery with a reconstruction plate in order to achieve union. In group B, all five patients (six clavicles) achieved radiological union at a median of 3 months. All patients had painless full range of shoulder movement and were engaging in unrestricted activities. CONCLUSION: Excision of the pseudarthrosis, autogenous iliac bone grafting and stabilisation with plate achieves union quicker and with lower incidence of complications compared to excision of the pseudarthrosis, autogenous iliac bone grafting and stabilisation with fully threaded pins.

Tropical primary pyomyositis in children of the UK: an emerging medical challenge.

Pyomyositis is a commonly encountered condition in the tropics. It was not described in the UK until 1998. The reason for the increasing incidence is not understood. We sought to identify the experience gained of this condition within a UK paediatric tertiary referral unit. Retrospective review of cases of pyomyositis from our institution since 1998 was undertaken to identify demographics, presentation, diagnosis and management. Thirteen cases were identified. The obturator internus was most commonly affected (62%). Staphylococcus aureus was cultured in nine cases (69%). One diagnostic retroperitoneal exploration was performed and all cases were identified by computed tomography or magnetic resonance imaging. To our knowledge, this is the first UK series of pyomyositis, reflecting its increasing Western incidence. Early diagnosis and treatment with antibiotics is all that is needed in the majority of cases. A greater awareness of this emerging condition is necessary to prevent misdiagnosis and unnecessary surgical intervention by all surgeons.

Lipoblastoma--an unfamiliar but important diagnosis. A case series and literature review.

Lipoblastoma and its infiltrative variant lipoblastomatosis are rare adipose tissue tumours seen in infants and children. Many surgeons are unfamiliar with these uncommon lesions and hence they are suboptimally treated. We report a case series of six patients in our tertiary paediatric hospital. Cases were reviewed retrospectively with reference to demographics, investigations, diagnosis and their management. Lipoblastomas are easily misdiagnosed and excision before proper investigations may result in incomplete resection, recurrence and further potentially mutilating surgery.

Long-term follow-up of Ethibloc injection in aneurysmal bone cysts.

The aim of this study is to assess the long-term results of Ethibloc injection in aneurysmal bone cysts (ABC). Thirty-three patients with ABC were treated with computed tomography-guided percutaneous injection of Ethibloc into the cyst cavity. Twenty-two patients had Ethibloc injection as primary treatment and 11 patients had presented to us with recurrence after previous procedures including steroid injection, bone marrow injection, curettage bone grafting and various other surgical procedures. The mean follow-up was 54 (22-90) months. Symptoms were relieved in all patients. Two patients were lost to follow-up. Eighteen (58%) of the 31 patients followed, had complete resolution of the lesion, 11 (35.5%) patients had partial healing (asymptomatic residual nonprogressive lytic areas). Two (6.5%) patients showed recurrence in the proximal humerus during the follow-up. They are under follow-up but asymptomatic and another two patients encountered more significant complications after the procedure. Ethibloc injection is a relatively simple, minimally invasive alternative procedure for the treatment of ABC, and makes open operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of ABC's excluding spinal lesions as shown by our largest and longest follow-up study.

Epidemiology of acute haematogenous osteomyelitis in children--a single unit's experience over three different time-periods.

The epidemiology of paediatric osteomyelitis in a single health district in England from 2000 to 2005 was compared to that from two prior timeframes. Fifty-three children were diagnosed with acute haematological osteomyelitis (AHO) and were compared to 36 and 49 patients from 1982 to 1986 and 1947 to 1951 respectively. The annual incidence of AHO in the most recent period was 0.4 patients per 100 000 of the total population. The mean age of presentation was 40 months (ranging between 0.5 and 179). This was statistically significantly less than the two earlier timeframes. Staphylococcus species was the commonest isolated organism. Plain radiography had a pickup rate of 32.7%. Second line investigation of nuclear medicine and magnetic resonance imaging had greater sensitivities of 78.8% and 75% respectively. The rate of surgical intervention was halved comparing 2000-05 to 1947-51. We were unable to unequivocally demonstrate a decreased incidence AHO in our region. However the review does confirm that the clinical approach to diagnosing and treating AHO had changed over the years.