Are Gait Indices Sensitive Enough to Reflect the Effect of Ankle Foot Orthosis on Gait Impairment in Cerebral Palsy Diplegic Patients?

BACKGROUND: Neuromuscular impairments may compromise gait function in patients with cerebral palsy (CP). As such, ambulatory children with CP often use ankle foot orthosis (AFO) to facilitate and optimize their ability to walk.The aim of this study was to evaluate whether the different gait indices, the Gillette Gait Index (GGI), the Gait Deviation Index (GDI), and the Gait Profile Score (GPS), reflect the improved gait that was previously shown using AFO. METHODS: A retrospective analysis of 53 studies on children with spastic diplegic CP. All had undergone a comprehensive gait study and were analyzed while walking, both barefoot and with their braces, in the same session.Kinematic and temporal spatial data were determined and summarized by 3 methods: GPS, GDI, and GGI. RESULTS: Significant differences were found between the barefoot condition and the AFO conditions for temporal and kinematic parameters: changes in GGI, GDI, and GPS were not statistically significant, with an improvement of 9.33% in GGI (P=0.448) and no change in GDI and GPS. CONCLUSIONS: The use of AFO in diplegic CP children caused a statistically significant improvement in temporal and kinematic parameters. Interestingly, it was found that this improvement was not reflected by GGI, GDI, or GPS.These findings might suggest that gait indices, as outcome measures, may sometimes not reflect all the effects of specific interventions. LEVEL OF EVIDENCE: Level III-retrospective study.

Influence of orthosis on the foot progression angle in children with spastic cerebral palsy.

We retrospectively assessed the effect of ankle-foot orthosis (AFO) on the foot progression angle (FPA) of 97 children with spastic cerebral palsy (CP) who had undergone comprehensive computer-based gait analysis both barefoot and with their orthosis, during the same session. The physical examination results and the gait study temporal and kinematic parameters comprise the study data. We focused on the peak FPA reached during stance and swing phases and at mid-stance and mid-swing, and also measured the transverse rotations of the pelvis, the femur and the tibia. AFOs improved gait, as reflected by improved temporal parameters, but they also increased internal rotation of the feet in diplegic CP children by 4.29 degrees for mid-stance, and by 3.72 degrees for mid-swing. The correlation between components of the rotational profile and FPA was significant for the diplegic group. AFOs did not produce any noteworthy differences between walking barefoot and walking with the brace in the hemiplegic group in what concerns FPA. Children with diplegic CP who use AFOs walk with increased internal FPAs in their orthoses. These findings might be explained by anatomical attributes as well as dynamic features during gait.

A functional electrical stimulation system improves knee control in crouch gait.

BACKGROUND: Crouch gait is a major sagittal plane deviation in children diagnosed with cerebral palsy (CP). It is defined as a combination of excessive ankle dorsiflexion and knee and hip flexion throughout the stance phase. To the best of our knowledge, functional electrical stimulation (FES) has not been used to decrease the severity of crouch gait in CP subjects and assist in achieving lower limb extension. PURPOSE: To evaluate the short- and long-term effects of FES to the quadriceps muscles in preventing crouch gait and achieving ankle plantar flexion, knee and hip extension at the stance phase. METHODS: An 18-year-old boy diagnosed with CP diplegia [Gross Motor Function Classification System (GMFCS) level II] was evaluated. The NESS L300(®) Plus neuroprosthesis system provided electrical stimulation of the quadriceps muscle. A three-dimensional gait analysis was performed using an eight-camera system measuring gait kinematics and spatiotemporal parameters while the subject walked shod only, with ground reaction ankle foot orthotics (GRAFOs) and using an FES device. RESULTS: Walking with the FES device showed an increase in the patient's knee extension at midstance and increased knee maximal extension at the stance phase. In addition, the patient was able to ascend and descend stairs with a "step-through" pattern immediately after adjusting the FES device. CONCLUSIONS: This report suggests that FES to the quadriceps muscles may affect knee extension at stance and decrease crouch gait, depending on the adequate passive range of motion of the hip, knee extension, and plantar flexion. Further studies are needed in order to validate these results.

The efficacy of neuroprosthesis in young hemiplegic patients, measured by three different gait indices: early results.

PURPOSE: To evaluate functional electrical stimulation (FES) neuroprothesis as a method to improve gait in hemiplegic patients, using three different gait scoring methods as measures. METHODS: Five hemiplegic patients (four with cerebral palsy at GMFCS I, one with diffuse pontine glioma) with a mean age of 16.5 years were given a FES neuroprosthesis (NESS(®) L300™) that was applied and calibrated individually. After an adaptation period during which the participants increased their daily use of the neuroprosthesis, gait was assessed with the stimulation off and with the FES on. Kinematic, kinetic, and temporal spatial data were determined using motion analysis and summarized by three scoring methods: Gait Profile Score (GPS), Gait Deviation Index (GDI), and Gillette Gait Index (GGI). Indices were calculated using the Gaitabase program available online. Patients were followed for a minimum of 1 year. RESULTS: When comparing gait with and without stimulation, all scoring methods showed improvement. GPS and GDI of the affected leg were significantly improved: 12.23-10.23° (p = 0.017) and 72.36-78.08 (p = 0.002), respectively. By applying the movement analysis profile, the decomposed GPS score, we found that only the ankle dorsiflexion and the foot progression angle were significantly changed. GGI of the affected leg showed improvement, but without statistical significance: 168.88-131.64 (p = 0.221). Total GPS of legs and the GPS, GDI, and GGI of the nonaffected leg showed improvement without statistical significance. At the 1-year follow-up, all patients expressed high satisfaction and continued to use the device. CONCLUSIONS: Dorsiflexion functional electrical stimulation improves gait in hemiplegic patients, as reflected by GPS, GDI, and GGI.

The influence of brace type on the success rate of the Ponseti treatment protocol for idiopathic clubfoot.

PURPOSE: The success of the Ponseti method for treating idiopathic clubfoot deformity is dependent on the casting techniques and the adherence of the patient to the foot abduction brace protocol. Newly developed brace designs claim to be more comfortable, to be easier to use and to prevent dislodgement of the foot from the brace, making them more efficient and improving patient compliance. They are, however, more costly, and, therefore, accessible to fewer patients. We compared the compliance and treatment outcome using two brace designs, the traditional simple brace of pre-walking shoes attached to a Dennis Browne (DB) bar and the new sophisticated Mitchell brace. METHODS: We compared the functional outcome and compliance with the post-corrective bracing protocol of 38 children with idiopathic clubfoot treated in our institution using two brace designs. Twenty-one chose the DB brace and 17 chose the Mitchell brace. RESULTS: There was no difference in the compliance rate or in the final clinical and radiological outcomes of the two groups after a minimum of 2 years of follow-up. A positive correlation was found between the Pirani score at the beginning of treatment and the final functional score for both groups. Both groups were satisfied with the selected brace. Both groups were equally compliant with the brace protocol. CONCLUSION: We conclude that new and more expensive brace designs do not necessarily provide better clinical results. Fully corrected foot and a strong family-treating team partnership are crucial to adherence with the brace protocol.

Intra- and interobserver reliability analysis of digital radiographic measurements for pediatric orthopedic parameters using a novel PACS integrated computer software program.

BACKGROUND: The between-observer reliability of repeated anatomic assessments in pediatric orthopedics relies on the precise definition of bony landmarks for measuring angles, indexes, and lengths of joints, limbs, and spine. We have analyzed intra- and interobserver reliability with a new digital measurement system (TraumaCad Wizard™). METHODS: Five pediatric orthopedic surgeons measured 50 digital radiographs on three separate days using the TraumaCad system. There were 10 anterior-posterior (AP) pelvic views from developmental dysplasia of the hip (DDH) patients, 10 AP pelvic views from cerebral palsy (CP) patients, 10 AP standing view of the lower limb radiographs from leg length discrepancy (LLD) patients, and 10 AP and 10 lateral spine X-rays from scoliosis patients. All standing view of the lower limb radiographs were calibrated by the software to allow for accurate length measurements, using as reference a 1-inch metal ball placed at the level of the bone. Each observer performed 540 measurements (totaling 2,700). We estimated intra- and interobserver standard deviations for measurements in all categories by specialists and nonspecialists. The intraclass correlation coefficient (ICC) summarized the overall accuracy and precision of the measurement process relative to subject variation. We examined whether the relative accuracy of a measurement is adversely affected by the number of bony landmarks required for making the measurement. RESULTS: The overall ICC was >0.74 for 13 out of 18 measurements. Accuracy of the acetabular index for DDH was greater than for CP and relatively low for the center-edge angle in CP. Accuracy for bone length was better than for joint angulations in LLD and for the Cobb angle in AP views compared to lateral views for scoliosis. There were no clinically important biases, and most of the differences between specialists and nonspecialists were nonsignificant. The correlation between the results according to the number of bony landmarks that needed to be identified was also nonsignificant. CONCLUSIONS: Digital measurements with the TraumaCad system are reliable in terms of intra- and interobserver variability, making it a useful method for the analysis of pathology on radiographs in pediatric orthopedics.

Utilization of the foot load monitor for evaluating deep plantar tissue stresses in patients with diabetes: proof-of-concept studies.

The purposes of the present study were to (1) determine the internal plantar mechanical stresses in diabetic and healthy subjects during everyday activities, and (2) identify stress parameters potentially capable of distinguishing between diabetic and healthy subjects. A self-designed, portable, real-time and subject-specific foot load monitor which employs the Hertz contact theory was utilized to determine the internal dynamic plantar tissue stresses in 10 diabetic patients and 6 healthy subjects during free walking and outdoors stair climbing. Internal stress parameters and average stress-doses were evaluated, and the results obtained from the two groups were compared. Internal plantar stresses and averaged stress-doses during free walking and outdoors stairs climbing in the diabetic group were 2.5-5.5-fold higher than in the healthy group (p<0.001; stair climbing comparisons incorporated data from five diabetic patients). The interfacial pressures measured during free walking were slightly higher ( approximately 1.5-fold) in the diabetic group (p<0.05), but there was no significant difference between the two groups during stairs climbing. We conclude that during walking and stair climbing, internal plantar tissue stresses are considerably higher than foot-shoe interface pressures, and in diabetic patients, internal stresses substantially exceed the levels in healthy. The proposed method can be used for rating performances or design of footwear for protecting sub-dermal plantar tissues in patients who are at risk for developing foot ulcers. It may also be helpful in providing biofeedback to neuropathic diabetic patients.

Long-term effect of repeated injections of botulinum toxin in children with cerebral palsy: a prospective study.

PURPOSE: To prospectively evaluate long-term effects of repeated botulinum toxin A (BTX-A) injections in children with cerebral palsy (CP). METHODS: Repeated injections of BTX-A were offered to children with CP, according to clinical indications, for a maximum of four injections within a period of two years. Injections were administered into lower extremity muscles of 26 consecutive children (age 3.7 +/- 1.2 years, 16 boys) with hemiplegic or diplegic CP. Clinical assessments before and one month following each injection included a gross motor function measure (GMFM), a modified Ashworth scale, and range-of-motion of knee extension and ankle dorsiflexion. RESULTS: Twelve children received two injections, six received three injections, five received one injection, and three received four injections. The most common reason for discontinuing treatment was the need for orthopedic surgery (n = 17). A long-term effect was demonstrated by a significant increase of the GMFM score before the first injection compared with the last injection for each patient (P < 0.0001). There was no comparable change in the muscle tone or range-of-motion. The mean rate of GMFM change during the study was significantly higher than literature norms for CP children (13.2 vs. 5.37 per year, respectively, P < 0.01). The increase of the GMFM score before and one-month after injection (short-term effect) was significantly higher after the first injection than after the last injection (P < 0.05). Similar results were found for the Ashworth scale and popliteal angle. CONCLUSIONS: Botulinum toxin A injections have a long-term effect on gross motor function in children with CP even though the effect on muscle tone is short-term. The effect apparently declines with repeated injections, with most children benefitting from 2 to 3 injections.

Effects of exercise training on quadriceps muscle gene expression in chronic obstructive pulmonary disease.

Exercise capacity and training response are limited in chronic obstructive pulmonary disease (COPD), but the extent to which this is related to altered skeletal muscle function is not fully understood. To test the hypothesis that muscle gene expression is altered in COPD, we performed needle biopsies from the vastus lateralis of six COPD patients and five sedentary age-matched healthy men, before and after 3 mo of exercise training. RNA was hybridized to Affymetrix U133A Genechip arrays. In addition, peak O(2) uptake and other functional parameters (e.g., 6-min walk) were measured before and after training. The 6-min walk test increased significantly following training in both groups (53.6 +/- 18.6 m in controls, P = 0.045; 37.1 +/- 6.7 m in COPD, P = 0.002), but peak O(2) uptake increased only in controls (19.4 +/- 4.5%, P = 0.011). Training significantly altered muscle gene expression in both groups, but the number of affected genes was lower in the COPD patients (231) compared with controls (573). Genes related to energy pathways had higher expression in trained controls. In contrast, oxidative stress, ubiquitin proteasome, and COX gene pathways had higher expression in trained COPD patients, and some genes (e.g., COX11, COX15, and MAPK-9) were upregulated by training only in COPD patients. We conclude that both COPD and control subjects demonstrated functional responses to training but with somewhat different patterns in muscle gene expression. The pathways that are uniquely induced by exercise in COPD (e.g., ubiquitin proteasome and COX) might indicate a greater degree of tissue stress (perhaps by altered O(2) and CO(2) dynamics) than in controls.

Treatment of severe late-onset Perthes' disease with soft tissue release and articulated hip distraction: revisited at skeletal maturity.

PURPOSE: Late-onset Perthes' disease is diagnosed after 9 years of age. Conservative treatment and conventional surgical techniques have limited ability to reduce the pressure in the joint or change the shape of the femoral head. We used a combination of soft tissue release and joint distraction with a hinged mono-lateral external fixator for these patients. Ten of our patients reached skeletal maturity and were evaluated. METHODS: Clinical assessment included: Harris hip score, hip range-of-motion (ROM), limb length discrepancy, and the Oxford hip questionnaire for pain and function. Radiographic assessment included: Sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre-Brook), at frame removal, and, at last follow-up, the epiphyseal quotient (of Sjovall) and the Stulberg classification. RESULTS: Our study included eight boys and two girls (mean age at surgery 12.3 years, range 9.4-15.1, mean age at last follow-up 18.1 years, range 15.2-22.8). The mean follow-up was 5.7 years (range 4.3-7.8). The mean Harris hip score was 86.3/100 (range 48.5-96); one patient had <85 points. The hip ROM was slightly limited in most patients, and seven patients had limb shortening between 1-4 cm. The mean Oxford hip questionnaire score was 17.4/60 (range 12-31). The mean Sharp transverse acetabular inclination of the affected side was 42 degrees (range 36-54) compared to 39 degrees for the unaffected side (P = 0.045). The mean uncoverage percentage was 37% (range 27-47) compared to 20% for the unaffected side (P = 0.017). The mean epiphyseal index was 0.71 (range 0.31-0.92) before surgery, 0.79 (range 0.50-0.93) at frame removal (P = 0.012), and 0.72 (range 0.51-0.89) at last follow-up (P = 0.646). The epiphyseal quotient for the eight unilateral cases was 0.72 (range 0.49-0.91), and the Stulberg classification was type III for three cases and type IV for seven. CONCLUSION: Patient satisfaction for function and pain following the combined procedure was good. Radiographic parameters did not change significantly. This should be regarded as a salvage procedure.

The effect of community-prescribed ankle-foot orthoses on gait parameters in children with spastic cerebral palsy.

PURPOSE: To evaluate the efficacy of ankle foot orthoses (AFOs) prescribed in the community for children with cerebral palsy (CP). METHODS: Fifty-six children (32 boys and 24 girls, mean age 8.9 years, range 4-17) who were diagnosed as having CP were enrolled. They were grouped according to the type of CP, diplegic (n = 38) and hemiplegic (n = 18). Three-dimensional gait analyses while patient were barefoot and with AFOs were obtained and analyzed. RESULTS: The spatio-temporal findings were the most significantly changed as a result of AFO use. In the hemiplegic group, stride length was 11.7% (p = 0.001) longer with AFOs in both affected (10.2%) and non-affected (12.4%) legs, and cadence was reduced by 9.7%; walking speed was not affected. In the diplegic group, stride length with AFOs was 17.4% longer compared to barefoot (p < 0.001) and walking velocity improved by 17.8% (p < 0.001); cadence was unchanged. AFOs also increased ankle dorsiflexion at initial contact in both groups. In the hemiplegic group, AFOs produced an average 9.4 degrees increase of dorsiflexion at initial contact (IC) on the affected side (p < 0.001) and 5.87 degrees on the unaffected side (p = 0.007), and an increase of 9.9 degrees (p < 0.001) dorsiflexion at swing, on the affected side. In the diplegic group, dorsiflexion at IC was increased by 13.4 degrees on the right side and 7.8 degrees on the left side (p = 0.05; p > 0.001, respectively) and an increase of 6 degrees (p = 0.005) at swing. In the hemiplegic group of patients, knee flexion at initial contact on the affected side was reduced by 8.5 degrees (p = 0.032) while in the diplegic group we found no influence. The number of patients that reached symmetry at initial double support tripled (from 5.6 to 16.7%) with the use of AFOs. CONCLUSIONS: Our results showed that the use of AFOs improves spatio-temporal gait parameters and gait stability in children with spastic cerebral palsy. It has a lesser effect on proximal joint kinematics. Children with spastic hemiplegia display greater improvement than those with spastic diplegia.

Asymptomatic or minimally symptomatic hyperCKemia: histopathologic correlates.

BACKGROUND: Persistent creatine kinase elevation is occasionally encountered in subjects without any clinical manifestation of a neuromuscular disorder or any condition known to be associated with increased serum CK levels. It is still unresolved whether extensive investigations and specifically a muscle biopsy should be performed in clinically normal individuals with elevated CK levels. OBJECTIVE: To study the muscle pathology of patients with asymptomatic or minimally symptomatic hyperCKemia. METHODS: The clinical and laboratory data of patients with persistent hyperCKemia and normal neurologic examination were reviewed and their muscle biopsies evaluated. RESULTS: The study group included 40 patients aged 7-67 years; the male to female ratio was 3:1. Nineteen patients were completely asymptomatic, 20 had mild non-specific myalgia, and 1 had muscle cramps. Electromyography was performed in 27 patients and showed myopathic changes in 7 (26%). Abnormal muscle biopsy findings (e.g., increased variation in fiber size, increased number of central nuclei, and occasional degenerating fibers) were detected in 22 of the 40 patients (55%). No fat or glycogen accumulation was detected. Immunohistochemistry demonstrated abnormal dystrophin staining in 3 patients (8%), resembling the pathologic changes of Becker muscular dystrophy. No abnormal findings were detected on immunohistochemical staining for merosin, dysferlin, caveolin 3, or alpha and gamma sarcoglycans. The EMG findings did not correlate with the pathologic findings. CONCLUSIONS: Abnormal muscle biopsies were found in 55% of patients with asymptomatic or minimally symptomatic hyperCKemia. Specific diagnosis of muscular dystrophy, however, was possible in only 8% of the patients.

Effects of aerobic training on gene expression in skeletal muscle of elderly men.

PURPOSE: To analyze the effect of 3 months of training on global gene expression in skeletal muscle of healthy elderly men in order to better characterize the pathways that differentiate the trained from the sedentary state. METHODS: Needle biopsies were obtained from the vastus lateralis of six healthy, sedentary, 68.0 +/- 2.7-yr-old males, before and after 3 months of training at 80% of maximal capacity, that improved peak O2 uptake by 17.8 +/- 4.0% (P = 0.009). RNA extracted from the samples was hybridized to Affymetrix U133A Genechip arrays. RESULTS: Overall, training modified the expression of 397 out of 14,500 genes tested. In the trained state, the expression of genes linked with energy metabolism, protein amino acid dephosphorylation, and heme biosynthesis increased, whereas those linked with ribosome and protein catabolism decreased. CONCLUSION: This set of 397 genes that includes the upregulated energy pathways and the downregulated protein catabolism genes represents the transcriptional response of the skeletal muscle in the trained state. It is highly likely that many of these genes are mediators of the beneficial effects of physical activity on health and fitness.

Early experience with the Ponseti method for the treatment of congenital idiopathic clubfoot.

BACKGROUND: The preferred conservative treatment for congenital idiopathic clubfoot deformity remains a controversial issue. OBJECTIVES: To compare the outcomes of two groups of CICF patients who underwent two different treatment protocols. METHODS: The study cohort included 72 infants treated in our hospital from August 1998 to December 2002. Group 1 comprised 40 infants (61 clubfeet) who were treated by a traditional method (a modification of the Kite and Lovell technique), and group 2 consisted of 32 infants (48 clubfeet) treated with the Ponseti technique. Both groups were similar in age, gender and severity of the deformity (Dimeglio scoring system). RESULTS: After an average follow-up of 54.9 months (range 44-68), 35 (57%) clubfeet in group 1 required surgical intervention and 27 (44%) clubfeet had a residual deformity at last follow-up. In the Ponseti group, 45 (94%) clubfeet were fully corrected at last follow-up (average 29.2 months, range 16-45) while 3 (6%) clubfeet had residual deformity and required surgery. Achilles tendon tenotomy was performed with no complications in 47 clubfeet (in group 2) at an average age of 2.4 months (range 2-4 months). CONCLUSIONS: Even after a relatively short follow-up period, our success rate with the Ponseti approach already appears to be significantly higher and to bear fewer complications than the traditional treatment, in agreement with the results published by other medical centers. We now endorse the Ponseti technique of conservative manipulative treatment for congenital idiopathic clubfoot in our department.

Adjustable bracing technique for the prevention of knee flexion contracture during tibial lengthening.

The authors present a simple thigh-knee brace that prevents flexion contracture during tibial lengthening. The brace is strapped to the thigh and connected to the Ilizarov frame via two simple hinges. While in the brace the knee can be mobilized for physiotherapy and locked in extension during rest.

Atypical mycobacterial granulomatous epiphyseal osteomyelitis in an immunocompetent child.

Osteomyelitis caused by atypical mycobacteria is rare in children. The majority of affected patients have had some kind of predisposing factor, namely a penetrating injury or surgery, or were immune-compromised. Our experience shows that this diagnosis should be considered in apparently healthy children as well. The use of polymerase chain reaction has now made it possible to identify the pathogen in cases that were previously diagnosed as granulomatous osteomyelitis. We present a case of atypical mycobacterial osteomyelitis affecting the distal femoral epiphysis in an immunocompetent 10-year-old child. The diagnosis in this case was made by the use of the polymerase chain reaction assay.

Epiphyseal involvement of simple bone cysts.

Epiphyseal involvement of a simple bone cyst (SBC) is uncommon. Eight patients are reported in whom an SBC was found to cross the growth plate, involving the epiphysis in seven patients and the apophysis in one. All patients had more than two pathologic fractures. In seven patients growth disturbance was found. Functional impairment did not develop in any patient. Radiographically, all lesions presented a characteristic involvement of the epiphysis and metaphysis in various proportions. Only one of four cysts treated with methylprednisolone acetate injections showed incomplete healing; the others failed to respond. After percutaneous grafting of autologous bone marrow, three of seven cysts healed and the others attained incomplete healing. Epiphyseal involvement of SBC should be considered a more aggressive form of an active lesion.

Parameters for predicting favorable responses to botulinum toxin in children with cerebral palsy.

We sought markers for predicting a favorable outcome of botulinum toxin A injected to the lower-extremity muscles of 26 children with hemiplegic or diplegic cerebral palsy. Clinical assessment preceding and 1 month following injection included gross motor function measure, a modified Ashworth scale, and evaluation of range of motion of knee extension and ankle dorsiflexion. Response to treatment was classified based on a parent questionnaire. The 19 children (73%) considered by their parents as being good responders were compared to the 7 (27%) considered as being poor responders. In the good responders, the preinjection Ashworth scale (spasticity) was significantly higher (P < .05) and gross motor function measure scores (function) were lower (P < .05). Sixty-eight percent of the good responders were nonindependent walkers compared to 14% of the poor responders (P < .05). There were no differences in age, type of cerebral palsy, and dose of injection. An Ashworth scale indicating increased muscle tone, lower gross motor function measure scores, and nonindependent ambulatory status were predictive for a favorable response to botulinum toxin A injections and can guide patient selection and expectations of treatment outcome.

Perthes-like changes in geleophysic dysplasia.

Geleophysic dysplasia is a rare skeletal dysplasia characterised by 'happy natured' facies, short stature with short limbs, brachydactyly, and joint contractures. This report describes a case of a patient with unilateral Legg-Calvé-Perthes-like changes associated with dysplastic proximal capital femoral epiphysis, typical to geleophysic dysplasia.

Primary subacute epiphyseal osteomyelitis: role of conservative treatment.

Primary subacute epiphyseal osteomyelitis is a rare disease. Owing to its insidious onset, mild symptoms, and inconsistent supportive laboratory data, diagnosis and treatment are usually delayed. The authors report a retrospective review of 16 patients with hematogenous osteomyelitis primarily affecting the epiphysis. In all of these patients an osteolytic lesion developed. In eight patients it was confined to the epiphysis or apophysis alone; in the other patients there was contiguous involvement of the adjacent metaphysis. Complete clinical and radiologic healing was observed in all patients after antibiotic therapy alone. Based on this experience, in view of the controversy in the literature, the authors recommend a conservative treatment policy in the management of both epiphyseal and epiphyseal-metaphyseal subacute osteomyelitis as the treatment of choice. Surgery should be reserved for persistent infection that does not respond to appropriate antibiotic therapy or when bone lesions cannot be distinguished from bone tumors by use of all available imaging modalities.