The Kocher-Caird Criteria for Pediatric Septic Arthritis of the Hip: Time for a Change in the Kingella Era?

Pediatric septic arthritis of the hip (SAH) in children is a severe pathology, requiring prompt diagnosis and treatment to avoid destructive sequelae of the joint. Its diagnosis can be challenging, however, due to its spectrum of manifestations and differential diagnosis. Last century, multiple research teams studied the curves of systemic inflammation markers to aid the differential diagnosis. Kocher showed that a history of fever >38.5 °C, non-weight bearing, an erythrocyte sedimentation rate >40 mm/h, and serum white blood cells >12,000/mm3 were highly suggestive of SAH, with a predicted probability of 99.6% when all these predictors manifested in pediatric patients. Caird validated these criteria, also adding a C-reactive protein >20 mg/L, reaching a 98% probability of SAH when these five criteria were present. The Kocher and the Caird criteria were then applied in multiple settings, but were never clearly validated. Moreover, they were studied and validated in the years when Kingella kingae was just emerging, and this was probably responsible for false-negative cases in multiple centers. For this reason, the Kocher and the Caird criteria are still at the center of a debate on the diagnostic tools for pediatric SAH. We provide a historical overview of the development of clinical and laboratory test algorithms for pediatric SAH. Further, new perspectives for future research on the prediction rules of pediatric SAH are here proposed.

High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry.

BACKGROUND: Pelvic ring injuries are potentially lethal lesions associated with polytrauma patients and need an efficient trauma team for their management. The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients in a single level I trauma center during the 2020 pseudo-lockdown period related to the Coronavirus pandemic, and to compare it with corresponding periods in 2014-2019 in order to better understand the need of organized and dedicated personnel and infrastructures. METHODS: This retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients' Registry. Data were obtained for each year period (January 1st to December 31st) and corresponding pseudo-lockdown period (March 16th to June 19th). High-energy blunt pelvic ring injuries inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) pelvic ring injury presence. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution's catchment area; and (5) any document attesting the patient's will to not participate in any study. Polytrauma patients inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) Injury Severity Score ≥ 16. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient's will to not participate in any study. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors' level I trauma center, no inferential statistics were computed. RESULTS: The incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients remained within range of previous years despite pseudo-lockdown measures. CONCLUSIONS: These observations bring better knowledge about pseudo-lockdown's impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I trauma centers in terms of personnel and infrastructures.

High-energy blunt pelvic ring injury: dataset of patients and injury characteristics from a severely injured patients' registry.

Since mid-2013, data on high-energy trauma patients admitted to the Emergency Department of the University Hospitals of Geneva, Switzerland, are prospectively recorded in a dedicated registry. This includes data on patients with high-energy blunt pelvic ring injuries (PRI), defined as closed fracture of the pelvic ring following falls from a height >1 m, road traffic accidents, sport, crush, farm and industrial injuries. The registry was screened for patients aged ≥16 years with high-energy blunt PRI admitted to the aforementioned academic level I trauma center between 2014.01.01 et 2019.12.31, to assess the outcome of the institutional PRI management protocol. Data on 195 patients were collected and analyzed for this purpose [1]. The dataset "patients' demographic and injury characteristics" provides the raw demographics and Abbreviated Injury Scale (AIS) of these 195 patients. These data can contribute to the knowledge of patients' demographics and injury characteristics of high-energy blunt PRI patients.

Management of high-energy blunt pelvic ring injuries: A retrospective cohort study evaluating an institutional protocol.

INTRODUCTION: High-energy blunt pelvic ring injuries with hemodynamic instability are complicated by a high mortality rate (up to 32%). There is no consensus on the best management strategy for these injuries. The aim of this study was to evaluate the high-energy blunt pelvic ring injury management protocol implemented in the authors' institution. PATIENTS AND METHODS: This retrospective cohort study was performed in an academic level I trauma center. The institutional protocol incorporates urgent pelvic mechanical stabilization of hemodynamically unstable patients not responding to a pelvic belt, fluids, and transfusions. If hemodynamic instability persists, angiography ± embolization is performed. Adult patients sustaining a high-energy blunt pelvic ring injury between 2014.01.01 and 2019.12.31 were included in the study. The primary outcome was mortality at 1, 2, 30 and 60 days. The secondary outcomes were the number of packed red blood cell units transfused during the first 24 h, intensive care unit stay, and total hospitalization length of stay. RESULTS: 192 high-energy blunt pelvic ring injury patients were analyzed. Of these, 71 (37%) were hemodynamically unstable, and 121 (63%) were stable. The overall in-hospital mortality of the hemodynamically unstable and stable groups was 20/71 (28.2%) and 4/121 (3.3%) respectively (p<0.001). Cumulative mortality rates for hemodynamically unstable patients were 15.5% at day 1, 16.9% at day 2, 26.8% at day 30 and 28.2% at day 60, and for hemodynamically stable patients, rates were 0% at day 1 and 2, 2.5% at day 30 and 3.3% at day 60. Unstable patients required a higher number of packed red blood cell units than stable patients during the first 24 h (5.1 vs. 0.1; p<0.001). Intensive care unit length of stay and total hospitalization duration was 11.25 and 37.4 days for unstable patients and 1.9 and 20.9 days for stable patients (p<0.001). CONCLUSIONS: For both hemodynamically unstable and stable patients, the institutional protocol showed favorable mortality rates when compared to available literature. Comparative studies are needed to determine the management strategies with the best clinical outcome and survival.

[Management of ankle osteoarthritis in the young adult]. / Arthrose de la cheville : pourquoi si jeune, et quelle option thérapeutique ?

Ankle osteoarthritis often presents in patients with a history of lower leg trauma. Hence, they are young with sportive demands and in the active labor phase, treatment must be adapted. Non-surgical treatment is based on corrective orthotics, supportive shoes, and intraarticular hyaluronic acid injections. Joint preserving surgery (JPS) represents a valid alternative to the traditional ankle fusion. JPS may restore normal biomechanics of the ankle joint, resulting in substantial postoperative pain relief, functional improvement, and slowing of the degeneration process. Overall, JPS defers the need for secondary surgeries in most of these young patients, making these patients suitable candidates for joint motion-preserving surgery, as is the case of ankle arthroplasty.

L'arthrose de la cheville survient souvent chez les patients avec des antécédents de traumatisme de cheville. Parce que ces patients sont jeunes avec une haute demande fonctionnelle, le traitement doit être adapté. Le traitement conservateur est basé sur des orthèses correctrices, des chaussures de soutien et des infiltrations d'acide hyaluronique. La chirurgie conservatrice de la cheville représente une alternative au traitement traditionnellement proposé, soit l'arthrodèse de cheville. Elle peut améliorer la biomécanique articulaire, ralentir la dégénérescence et soulager substantiellement les douleurs. Elle permet également de retarder le besoin de chirurgies secondaires, et préserve la possiblité de bénéficier d'une chirurgie conservant la mobilité de la cheville ou d'une arthroplastie totale de cheville.

The Intraseptal Course of the Superficial Peroneal Nerve: An Anatomic Study.

BACKGROUND: Anatomic and clinical studies show many variants of the superficial peroneal nerve (SPN) course and branching within the compartments and at the suprafascial layer. The anatomy of the transition zone from the compartment to the subcutaneous layer has been occasionally described in the literature, mainly in studies reporting the intraseptal SPN variant in 6.6% to 13.6% of patients affected by the SPN entrapment syndrome. Despite the little evidence available, the knowledge of the transition zone is relevant to avoid iatrogenic lesions to the SPN during fasciotomy, open approaches to the leg and ankle, and SPN decompression. Our anatomic study aimed to describe the SPN transition site and to evaluate the occurrence of a peroneal tunnel and of an intraseptal SPN variant. METHODS: According to the institutional ethics committee requirements, 15 fresh-frozen lower limbs were dissected to study the SPN course and its branching, focusing on the transition site to the suprafascial layer. RESULTS: The SPN was located in the anterior compartment in 2 cases and in the lateral in 13. An intraseptal tunnel was present in 10 legs (66%), at a mean distance of 10.67 cm from the lateral malleolus. Its mean length was 2.63 cm. The tunnel allowed the passage of the main SPN in 8 cases and of its branches in two. In the remaining 5 legs (33%), the SPN pierced a crural fascia window. CONCLUSION: In our sample a higher rate than expected of intraseptal SPN variants was found. CLINICAL RELEVANCE: The knowledge of the anatomy of the SPN course and intraseptal variant is relevant to avoid iatrogenic lesions during operative dissection. Further studies are needed to evaluate the effective prevalence of an intraseptal tunnel, independently from the SPN entrapment syndrome, and how to avoid associated iatrogenic complications.

Is vitamin D deficiency a risk factor for osteonecrosis of the jaw in patients with cancer? A matched case-control study.

PURPOSE: A previous case-control histomorphometric study showed higher odds of osteomalacia in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ). Vitamin D deficiency causes osteomalacia and may therefore be involved in the pathogenesis of BRONJ. The present case-control study aimed at testing such hypothesis. MATERIALS AND METHODS: BRONJ+ and BRONJ- patients treated with bisphosphonates were matched by sex (same) and age (within 5 years). Serum 25-hydroxy-vitamin D (25-OH-D), parathyroid hormone, bone alkaline phosphatase, total procollagen type 1 amino-terminal propeptide, carboxy-terminal collagen crosslinks, Dickkopf WNT signaling pathway inhibitor 1 and sclerostin were measured. RESULTS: The main outcome was vitamin D deficiency defined as 25-OH-D < 50 nmol/l. A total of 51 BRONJ+ and 73 BRONJ- patients were studied. The frequency (95% CI) of vitamin D deficiency was 59% (45%-72%) in BRONJ+ and 62% (48%-75%) in BRONJ- patients. This amounts to a difference of -3% (-22%-16%, p = 0.77) for BRONJ+ patients. Serum 25-hydroxy-vitamin D and parathyroid hormone were similar in BRONJ+ and BRONJ- patients. Among the bone metabolism markers, only sclerostin differed between the two groups, being higher in BRONJ+ patients. CONCLUSION: The present matched case-control study suggests that vitamin D deficiency is not a risk factor for BRONJ.

Osteochondral flap fracture of the coronoid in pediatric elbow dislocation: a case report and literature review.

Osteochondral flap fractures of the coronoid are rare occult fractures, often diagnosed in delay, in pediatric patients who underwent elbow dislocations. Only 11 pediatric cases of osteochondral flap fractures of the coronoid are described in the literature. We describe a pediatric case treated in our institution for an elbow dislocation accompanied by a triad of elbow fractures, including the osteochondral flap fracture of the coronoid, and review available literature on the osteochondral flap fracture of the coronoid in pediatric patients.

Treatment of paediatric unstable displaced distal radius fractures using Kapandji technique: a case series.

BACKGROUND: The technique of intra-focal pinning described by Kapandji is seldom used in paediatric patients. We present our series of paediatric patients treated with Kapandji technique for unstable displaced distal radius fractures. METHODS: We retrospectively reviewed medical records and radiographs of a consecutive series of 56 paediatric patients who underwent closed reduction and fixation with Kapandji technique for unstable displaced metaphyseal and Salter Harris 2 distal radius fractures, from 2008 to March 2018. One or two percutaneous K-wires were inserted intra-focally without crossing the physis to lever out, reduce and stabilize the distal fragment. The arm was immobilized with an above-elbow cast, and radiographic controls were scheduled at 1, 4, 8 weeks, at least. RESULTS: The mean age at the time of the trauma was 10.5 years. The K-wires were removed at a mean of 6.4 post-operative weeks. An above-elbow cast was used for the first 4 weeks, afterwards a below-elbow cast for 2 weeks and a short-arm brace until the full recovery of motion. The mean follow-up was 18 months (range 1.5-108 months). No pin-related complications were found. All fractures showed good healing, and the full function of the wrist was achieved in every case. CONCLUSION: Kapandji pinning is a reliable technique in paediatric patients with unstable displaced distal radius fractures. It shows a lower complication rate compared to other techniques. For these reasons, we suggest implementing its use in clinical practice.

Treatment of Morton's neuroma: A systematic review.

BACKGROUND: The treatment of Morton's neuroma (MN) can be operative, conservative and infiltrative. Our aim was the evaluation of evidence on outcomes with different types of conservative, infiltrative and surgical treatment in patients affected by primary MN. METHODS: The bibliographic search was conducted in MEDLINE, Cochrane Library, DARE. Only studies in English were collected. The last search was in August 2015. Case series and randomized controlled trials (RCTs) assessing patients' satisfaction or pain improvement at an average follow-up of at least 6 months after treatment of primary MN were included. Two reviewers selected the studies, evaluated their methodological quality, and retrieved data independently. RESULTS: Of 283 titles found, only 29 met the inclusion criteria. Data showed better outcomes with operative treatment. CONCLUSIONS: The evaluated case series and few RCTs showed better results with invasive treatment. More and better RCTs which evaluate risk-benefit ratio are required to confirm these results.

Zancolli Technique for Delayed Repair of Tibialis Anterior Tendon Rupture: A Case Report and Literature Review.

BACKGROUND: Several techniques for repair of tibialis anterior tendon ruptures (TATRs) are reported, although it is a rare lesion. We describe a case of TATR, discuss our treatment, and review the criteria for the choice of treatment. METHODS: In November 2015, a 61-year-old woman presented to our department 13 days after an injury to her left ankle, with avulsion of TAT. Because of the stump retraction, we performed a Zancolli-like plasty, anchoring the tendon to the navicular bone. Evidence about the timing and type of surgery has been reviewed. RESULTS: The patient was followed up for 16 months before being discharged. The American Orthopaedic Foot and Ankle Society score improved from an initial value of 32 to a final score of 90. CONCLUSIONS: The choice of treatment depends on several factors. Patients' physical demands and the type of rupture guide the choice of surgical technique. LEVELS OF EVIDENCE: Therapeutic, Level IV: Retrospective.