Managing of musculoskeletal infections in children.

OBJECTIVE: Epidemiological features of musculoskeletal infections are in continuous evolution. The incidence of emerging causative pathogen is arising. Nevertheless, up to 50% of osteoarticular infections shows negative cultures. Septic arthritis, with or without concurrent osteomyelitis, are most common in newborn while osteomyelitis frequently affects older patients. We retrospectively analyzed all the children affected by musculoskeletal infections treated at the Children's Hospital Bambino Gesù in ten years, focusing on the results of an early diagnostic and therapeutic management. MATERIALS AND METHODS: The study population consists of 150 children with acute septic arthritis, osteomyelitis and discitis, treated from 2006 to 2016, excluding patients with less than 12 months of follow-up and previous treatment sustained in others hospitals. A wide spectrum of data has been extracted from clinical charts, laboratory studies and imaging. Patients were categorized into 3 groups on the base of their age. The diagnostic and therapeutic protocol consisted of intravenous empirical treatment while diagnosis was ongoing then switched to oral treatment, according to the pathogen and the systemic symptoms. RESULTS: Only 31% of pathogens were identified. The most common was Staphylococcus aureus methicillin-sensible (MSSA) but an increase of cases caused by Kingella Kingae and Staphylococcus aureus methicillin-resistant (MRSA) was observed. The mean antibiotic treatment was 6.8 weeks. It's important to underline a significant correlation between age and C-reactive protein serum levels. CONCLUSIONS: Among others frequent pathogens, MRSA shows a high rate of physis involvement. Musculoskeletal infections represent a challenge in skeletally immature patients because of their potential severe complications. Timing of diagnosis and consequent targeted treatment is fundamental to avoid complications and functional sequelae.

The familiarity of idiopathic scoliosis: statistical analysis and clinical considerations.

PURPOSE: The etiology of idiopathic scoliosis (IS) has been the subject of extensive research, and the current opinion is in favor of a multifactorial pathogenesis with an important genetic component. The aim of this study is to investigate the pattern of inheritance over generations of IS and its possible risk factors. METHODS: A total of 70 patients affected by IS was selected and studied up to the third generation for an overall cohort of 2,055 subjects. The genealogy was investigated and correlated for scoliosis. RESULTS: The outcomes showed that 73 % of the patients had an age between 12 and 15 years. The 60 % of the mothers had an age between 20 and 29 years and 57 % of the patients were "first born". The 5.8 % of the brothers and the 12.7 % of the sisters were affected by scoliosis. From the analysis of the total sample, it is clear that in 53 % of the families, there is at least another scoliotic besides the patient. CONCLUSION: The statistical analysis revealed three different types of transmission: autosomic dominant, autosomic recessive and multifactorial. When this last mode of inheritance is involved, female sex and firstborn resulted as risk factors of IS.

Osgood Schlatter lesion: histologic features of slipped anterior tibial tubercle.

No study reports the histological features of the various zone of the anterior tubercle of the tibia in the different stages of the Osgood-Schlatter (O-S) lesion. For this reason we carried on an histological study. Specimens were taken from 13 patients with O-S lesion prior to surgery. In 4 cases in the apophyseal stage lesions were present in an altered fibrocartilage anterior to the ossification centre. In 9 cases in the epiphyseal stage varying degrees of reparative tissues were observed in the bed of the fragment of the secondary ossification centre. In 3 of them a zone of lesion was observed within the fibrocartilage anterior to the ossification centre. These results suggest that the slippage of the patellar tendon insertion may be progressive and caused by pathological fibrocartilage.

Pridie's marrow stimulation technique combined with collagen matrix for cartilage repair. a study in a still growing sheep model.

The study assessed the spontaneous repair of large critical full-thickness defects (FTD) in not mature and still growing sheep model and compared repaired tissue after Pridie's technique to the same technique combined with type I collagen matrix. Thirty-six FTD were divided into group 1 (untreated), group 2 (treated according to Pridie's technique with 10.2 as value ratio of marrow stimulation), and group 3 (treated using Pridie's marrow stimulation technique, and covered by a type I collagen matrix) . The histological exam at 12 months showed fibrous repair of the untreated defects. In group 2 the reparative tissue showed a prevalence of fibrocartilaginous tissue. The mean ICRS visual assessment scale score was 8.9. In group 3 the reparative tissue was similar to the normal surrounding cartilage. The mean ICRS visual assessment scale score was 14.7. Subchondral drilling with defined ratio between the stimulated marrow area and the lesion area could improve the quality of FTD repair in articular cartilage in not mature and still growing stifle sheep model if combined with type I collagen matrix.

Segond fracture with anterior cruciate ligament tear in an adolescent.

The authors report a case of acute knee injury in a 14-year-old teenager. The X-ray showed a so-called Segond's fracture: a small avulsed bone fragment, elliptical in shape, lying immediately below the external tibial plateau, a few millimeters from the lateral tibial cortex. The fracture site was in the portion of the tibial condyle which is linked to the middle third of the lateral capsule by meniscal tibial fibers. Clinical examination under anesthesia and subsequent arthroscopy revealed a total intrasubstance ACL (anterior cruciate ligament) tear close to the proximal insertion. The authors confirm Segond's report of a possible association of this avulsion fracture with ACL injuries, even in adolescence.

Slipped capital femoral epiphysis in skeletally immature patients.

Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes premature physeal closure. The use of a modified, standard, single, cannulated screw designed to maintain epiphyseal fixation without causing premature closure of the physis was reviewed in ten patients. The nine boys and one girl aged between 10.6 and 12.6 years with unilateral slipped capital femoral epiphysis (SCFE), were markedly skeletally immature (Tanner stage I, bone age 10 to 12.6 years). Clinical and radiological review at a mean follow-up of 44.3 months (36 to 76) showed no difference in the time to physeal closure between the involved and uninvolved side. Measurement of epiphyseal and physeal development showed continued growth and remodelling in all patients. Use of this device provided epiphyseal stability and maintained the capacity for physeal recovery and growth following treatment for both unstable and stable slipped capital femoral epiphysis.

The effect of intra-articular ACL reconstruction on the growth plates of rabbits.

We performed intra-articular reconstruction of the anterior cruciate ligament (ACL) with the semitendinosus tendon placed in 2 mm diameter tunnels in 21 skeletally immature rabbits. The operation caused 11% damage to the physis of the femur on the frontal plane and 3% of its cross-sectional area but no alteration of growth or axial deviation of the bone resulted. In the tibia, the operation caused 12% damage to the physis in the frontal plane and 4% of the cross-sectional area. Two tibiae developed valgus deformities and one was shortened. Histological examination showed no areas of epiphysiodesis. There was no abnormality of growth-plate thickness in the two cases of tibia valga. Osseous metaplasia in the grafted tendons did not occur. The results suggest the need for careful evaluation of the percentage of damage to the growth plate before using intra-articular methods for reconstruction of the anterior cruciate ligament in adolescents.

Patellofemoral malalignment in adolescents. Computerized tomographic assessment with or without quadriceps contraction.

Twenty-seven adolescents with anterior knee pain with or without patellar instability were studied by computerized tomography to detect patellofemoral malalignment. The examination was performed with and without quadriceps contraction with the knee flexed to 15 degrees. Congruence angle, patellar tilt angle, sulcus angle, and trochlear depth were measured. This investigation showed the well-known types of patellofemoral malalignment with quadriceps relaxed (tilted, lateralized, lateralized, and titled patella) and, in 52% of cases, revealed changes in type and severity with quadriceps contraction (in 41%, lateralization and tilting were markedly more evident; in 11%, the type of malalignment changed). The results demonstrate that, in addition to assessment with quadriceps relaxed, computerized tomography with quadriceps contraction is a useful adjunct to diagnose and define the type of malalignment in particularly difficult circumstances.

Slipped capital femoral epiphysis: comparison of a roentgenographic method and computed tomography in determining slip severity.

Various conventional roentgenographic methods have been proposed to determine the severity of chronic slipped capital femoral epiphysis (SCFE) on the sagittal plane, with some maintaining that computed tomography (CT) is more accurate and reproduces better than roentgenography. We used a modified Dunlap's technique and angular measurement to determine slip severity. Three orthopaedists obtained data from roentgenograms and CT of 20 hips with chronic SCFE. Statistical analysis showed concordance between our method and the measurements and reproducibility produced with CT. The results suggest that our method is as effective as and less expensive than CT.

[The indications for and limits of "extensive" posterior lysis in the surgical treatment of congenital clubfoot (talipes equinovarus supinatus)]. / Indicazioni e limiti della lisi posteriore "allargata" nel trattamento chirurgico del piede torto congenito equino-varo-supinato.

The authors present the preliminary results (after 4-7 years) of 69 cases of congenital torsive equino-varus-supinated foot treated operatively from 1982 to 1985 (of a total of 25% cases treated from 1982 to 1989). Both the modalities and the stages of execution of the treatment are described. After the initial clinical evaluation and the first weeks of manipulation, the feet were immobilized in corrective plaster casts, which were carefully constructed to correct the varus and supination. After 4-8 months, thorough clinical and radiographic assessment enabled the authors to plan the surgical procedure for correction of the remaining deformity, customizing it for each individual patient. There is an in-depth discussion of the stages of the "widened" posterior release procedure. Using this procedure, the authors achieved satisfactory intraoperative correction in 85% of the patients, correction which was maintained over time in 76.5% of the cases. In this way the medial stage of the surgical procedure, associated "ab initio" to the posterior release, may be reserved to a fewer number of patients (15-20%) under one year of age.

[Metaphyseal and diaphyseal fractures of the femur resulting in growth inequality in children under 3 years of age]. / L'esito in dismetria delle fratture metafisarie e diafisarie del femore in bambini fino ai 3 anni di età.

The authors clinically and radiographically review 42 of 53 children between the ages of 5 months and 3 years treated by closed means from 1983 to 1987 for femoral fracture (average follow-up, 4 years). Evaluation of a large number of patients in this particular age group offers several advantages: a) it regards a phase of evolution in which the modalities of growth do not affect in any significant way the metabolic balance of the growth plate chondrocyte, as occurs in periods of rapid growth. This makes the sample group statistically homogeneous; b) it eliminates the age variable in the search for the factors which may contribute to limb-length discrepancy. The importance of the following factors was statistically analyzed: location, type, and initial displacement of the fracture, accuracy of reduction, and characteristics of the traumatic event. There was a significant correlation between a large degree of limb lengthening and further reduction or corrective procedures under general anesthesia. Overlapping reduction and limb shortening were also closely related. A highly significant correlation was also found between limb lengthening exceeding 15 mm. (range, 15-22 mm.) and the time of day at which the trauma occurred (9-10 pm). The results of treatment suggest the need for a reevaluation, using recently gained knowledge, of Lacroix's theory of the pathogenesis of this disorder as well as the need to examine more thoroughly, with further clinical and experimental studies, the hormonal changes following the trauma.

[Considerations on the role of echography in the study of hip dysplasia]. / Considerazioni sul ruolo dell'esame ecografico nello studio della displasia dell'anca.

The authors explain the general criteria in performing an ultrasound exam and the pathological finding of congenital dislocation of the hip. They based the study on the screening of 500 patients between the ages of ten days and eight months (2% of which resulted pathological) and on evaluation of 80 cases of dislocated hip not included in the original sample group. The ultrasound test in dislocated hip pathology proved to be superior to traditional x-ray tests for viewing the muscular and cartilaginous elements, obtaining a dynamic view of the anatomical structures and, in particular, studying the morphological aspect and the development of the acetabulum. Thus it is possible diagnose different types of CDH at very early stage. The authors, however, consider an easier classification more useful than the original one suggested by Graf and propose division of the abnormal hip into three pathological types based on clinical, radiological and ultrasound findings: primary sub-luxation or "non-dislocatable" hip; pre-dislocation or "dislocatable" hip; dislocation or "dislocated" hip. This is extremely important in order to better understand and evaluate each singular case and then set up adequate therapy.

[Surgical treatment of diaphyseal fractures of the forearm during pre-adolescent age]. / Il trattamento chirurgico delle fratture diafisarie dell'avambraccio in età evolutiva.

The results of treatment of 10 both-bone unstable diaphyseal fractures of the forearm in children by open-reduction and intramedullary fixation with Kirschner wiring of the radius are presented. All fractured healed in perfect alignment. No complications occurred. In a 3 year and 2 month follow-up all the patients had excellent results with full range of movement. The advantages of this method are: a) it is easy to carry out; b) it maintains anatomical reduction; c) a second operation to remove the internal fixation device is not required; d) fixation of the ulna is not necessary, because in all patients a realignment of the ulnar fragments occurred after radius reduction.

[Rare skeletal pathology: the diagnostic problems in the first year of life]. / Patologia rara dello scheletro: problemi diagnostici nel primo anno di vita.

The authors report a series of affections which determine diffused modifications of the skeleton during early childhood. More common pathological forms are dealt with, of relatively simple diagnosis, and having pathological pictures which based on frequency, means of occurrence, and clinical-radiographic aspects, are rarely observed, and difficult to diagnose. Based on several clinical cases, the authors report problems related to diagnosis, emphasising the meaning of various radiographic pictures and the value and choice of hematochemical tests aimed at selecting patients in whom biopsy is required.

[Torsional changes in the lower limbs in childhood]. / Le alterazioni della torsione degli arti inferiori in età pediatrica.

Based on their observation of approximately 1000 patients aged from 4 to 14 years and on a comparison of their experience with the data reported in the literature, the authors discuss the problem of modifications in torsion of the lower limbs during pediatric age. After a brief discussion of anatomy and the natural progression of the angle of femoral anteversion and tibial torsion, they stop to accurately describe the most frequently occurring defects in torsion, both isolated and combined. After affirming the contribution that axial vision has made to an understanding of the subject, they emphasise the current usefulness of the method in cases in which a clinical examination allows for doubts to persist and, in particular, if qualitative and quantitative diagnosis is required in relation to the therapeutic protocol. The authors conclude by suggesting that therapy be carried out during the growth age (much before 14 years of age) while they suggest waiting until skeletal maturity in order to make a general evaluation and to decide on treatment of combined defects.

[The Freeman-Sheldon syndrome]. / La sindrome di Freeman-Sheldon.

The authors report two cases of Freeman-Sheldon syndrome, characterised by recessive autosomic transmission, affecting a brother and a sister born of parents who were not blood relations. The syndrome, for which 50 cases are described in the literature, takes its name from the authors who were the first to describe it in 1938. The typical picture is based on congenital deformity involving the cranium, the face and the locomotor apparatus, with a particular aspect of the subject affected related to his or her expression, resembling that of someone whistling ("whistling face", Burian, 1963). In addition to the descriptive aspect of the syndrome and to the means of its transmission, the authors report orthopaedic aspects concerning the locomotor apparatus and problems related to the type of surgery performed.

[Congenital metatarsus varus]. / Il metatarso varo congenito.

The authors report on "congenital primitive metatarsus varus". After discussing the incidence, etiology, pathogenesis and classification, the clinical features and associated malformations are evaluated. Then they go into treatment details affirming, according to the literature, that this malformation is susceptible to complete regression if treated bloodlessly during the early months of life, and in any case, before the onset of loss of ambulation, by manipulations followed by a series of plaster casts and finally by corrective braces and shoes. If this treatment is fruitless or in cases seen at an advanced age and with a high degree of varus, there are several surgical operations that achieve satisfying results operating on tendons or on articular capsules.

[Congenital hallux valgus]. / Alluce varo congenito.

Congenital hallux varus is a rare deformity. The authors discuss 3 clinical cases observed and define the specific features of the anomaly. The clinical and radiographic pictures are described, emphasising essential aspects and possible variations, including the rare occurrence of congenital varus of a single interphalangeal joint. Differential diagnosis is discussed and surgical indications determined.

Primary osteoliposarcoma of bone. First observation in the pediatric age group.

An unusual case of primary bone neoplasm with histologic features of osteoliposarcoma is reported. No more than 5 cases with lesions of corresponding nature can be found in the world literature up to now; our report is the first dealing with a patient of pediatric age.