Chronic Recurrent Multifocal Osteomyelitis Mimicking Scurvy in a Child: A Case Report.

Scurvy is a rare clinical syndrome resulting from prolonged vitamin C deficiency and is uncommon in the Gulf area. It can present with non-specific symptoms, making diagnosis and treatment challenging. In pediatric patients, symptoms may include weight loss, lethargy, low-grade fever, anemia of varying degrees, easy bruising or bleeding, joint and muscle pain, and poor wound healing. Despite advances in healthcare in many Gulf countries, nutritional deficiencies can still occur in certain populations. Therefore, it is important for pediatricians, orthopedists, rheumatologists, and radiologists to consider scurvy in the evaluation of children with low-grade, multisystemic involvement. We report a case of a six-year-old boy who presented to the emergency department (ED) multiple times with progressive right (RT) leg pain. The clinical picture and imaging findings suggested chronic recurrent multifocal osteomyelitis (CRMO). Despite symptom progression, scurvy was ultimately diagnosed and treatment with vitamin C led to rapid resolution of his symptoms. This case highlights the importance of considering scurvy in the differential diagnosis of children with multisystemic involvement, especially in regions where nutritional deficiencies may be more prevalent.

The influence of the site of rupture and gap distance in acute Achilles tendon rupture treated with functional rehabilitation.

AIM: To determine the influence of gap distance and its location on clinical and radiological outcomes in patients with acute rupture of Tendo-Achilles (TA) treated non-operatively with functional rehabilitation. METHODS: Twenty-six patients with acute complete TA rupture underwent ultrasound (US) scanning within a week of their injury. The measurements taken included the distance of the rupture from the enthesis and the gap distance between the tendon edges in varying degrees of ankle and knee positions. All patients were managed non-operatively in functional weight-bearing orthoses. Nineteen patients were then followed up at a mean of 6.1 years (range 5.8-6.5) to assess their clinical and radiological outcomes. The outcomes included ultrasound assessment of tendon healing, Achilles Tendon Rupture Score (ATRS) and modified Leppilahti Score (mLS). RESULTS: In the initial ultrasound, the mean distance of the rupture from the enthesis was 52 mm (range: 40-76). The mean gap distance with the foot plantigrade was 11.4 mm, which reduced to 4.8 mm with the foot in equinus. At final follow up, no re-ruptures had occurred. The mean ATRS and mLS were 86 and 71 respectively. There was a significant correlation between the distance of the rupture from the enthesis with the MLS total score (p = 0.02), mLS Fatigue domain score (p = 0.03), and the ATRS domains of strength (p = 0.04) and fatigue (p = 0.02). There was no significant correlation between the measured gap distance with respect to the mLS, ATRS or individual ATRS domain scores. Also, there was no significant difference in ATRS and mLS outcomes when comparing tendons with respect to healed tissue appearance and fibre orientation on ultrasound. CONCLUSION: The initial gap distance had no relationship with any of the measured clinical outcomes at the final follow up. The distance of the gap from the enthesis, however, may carry a greater prognostic value following non-operative treatment of Achilles tendon injuries.

Pediatric distal humeral supracondylar fracture - achievement of optimal pinning configuration.

Pediatric supracondylar humeral fracture is com- monly managed using closed reduction and per- cutaneous Kirschner wires pinning. However, there is no consensus on optimal pinning configuration in the literature. Our study aims to review the pinning configuration in our department, correlate our results with the available literature, and suggest the optimal configuration using basic biomechanics principles. We performed a retrospective review on children that were treated with K-wire pinning for supracondylar fracture at our institution between August 2017 and August 2019. Intra-operative antero-posterior view fluoroscopic images were used to measure the pin separation ratio (PSR), pin crossing angle (PCA), medial inclination angle (MIA) and lateral inclination angle (LIA). Pearson Correlation was used to identify the relationship between the variables. Ninety-one patients were included for analysis (39 male: 52 female), with a mean age of 6. Average PCA in the crossed pin and lateral-entry only technique CA was 75° and 12°, respectively. Mean crossed pin and lateral-entry only technique PSR is 0.54 and 0.17, respectively. There was a significant difference in both mean PSR and PCA between the configurations (p <0.01). In subgroup analysis, optimal PSR > 0.33 and PCA >90° were best achieved in crossed pinning using 1 medial and 2 lateral pins. Assessing the biomechanical characteristics of the different fixation techniques, we have found that 2 lateral divergent pins and 1 medial pin using the crossed pin technique optimized both the PSR and PCA. We would recommend this configuration to optimize the stability of the fixation construct.

Non-contrast cardiac CT-based quantitative evaluation of epicardial and intra-thoracic fat in healthy, recently menopausal women: Reproducibility data from the Kronos Early Estrogen Prevention Study.

BACKGROUND: Cardiac fat is emerging as an important parameter for cardiovascular risk stratification. Accurate and reproducible volumetric measurements can facilitate in the serial assessment of cardiac fat by computed tomography (CT). We assessed the intra- and inter-observer variability of cardiac fat volumetric measurements using a semi-automated CT software. METHODS: We used non-contrast coronary calcium CT scans to quantify epicardial and intra-thoracic fat volumes. Two expert readers analyzed baseline and follow up CT scans of 45 subjects by using a semi-automated CT software (QFAT 2.0, Cedars Sinai-Medical Center). Correlation and Bland-Altman analysis was performed for both intra- and inter-observer comparisons for each cardiac fat type. RESULTS: The intra-observer correlation coefficients ranged between 0.86 to 0.99 and 0.87 to 0.99 for epicardial (median fat per reader (cm3) 20.9 to 25.7) and intra-thoracic (median fat per reader (cm3) 27.1 to 31.6) fat volumes respectively, with no significant differences between individual data points (all p > 0.38). The inter-observer correlation coefficient was 0.99 (p < 0.0001 for correlation) for both epicardial and intra-thoracic fat. By Bland-Altman analysis for epicardial fat measurements, mean difference of intra-observer was 0.90 cm3 with 95% confidence intervals (0.22,1.7) and -1.8 cm3 for inter-observer, with 95% CI (-2.9, -0.69). Bland-Altman plots for intra-thoracic fat measurements were similarly impressive for both inter- and intra-observer reads. CONCLUSIONS: Our data showed that measuring epicardial and intra-thoracic fat volumes by CT using a semi-automated software has excellent intra-observer and inter-observer reliability. Cardiac fat volumes can be obtained easily and reproducibly from routine calcium scoring scans and may help in assessing cardiovascular risk. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00154180; Keywords: Epicardial fat volume; intra-thoracic fat volume; computed tomography; intra-observer; inter-observer.

Biomechanical investigation into the torsional failure of immature long bone.

Approximately 50% of infant and toddler long bone fractures are attributed to non-accidental trauma; however, differentiating from benign mechanisms is subjective, due to an absence of evidence-based diagnostic tools. Previous studies investigated small ranges of rotational velocities in animal long bone models, although did not report the variation in the spiral fracture angle. This study considered the fracture angle as a potential clinical measure, correlating this data with a wider range of rotational velocities. The spiral fracture angle was measured relative to the long axis, whilst noting the narrowest diaphysial diameter, location of the fracture, and the extent of comminution and periosteal disruption. Twenty-six bones failed in spiral fracture, with the potting material failing in the remaining tests. All spiral fractures centred on the narrowest diaphysial diameter. Slower rotational velocities caused fracture angles approaching 45°, whereas fractures at greater velocities caused fracture angles nearer 30°. A relatively strong trend (R (2) = 0.78) is reported when the normalised fracture angle (against the narrowest diaphysial dimension) was plotted against the rotational rate. A relationship has been identified between the angle of spiral fracture and the rotational velocity using the immature bovine metatarsal model. This trend forms a scientific foundation from which to explore developing a diagnostic, evidence-based tool that may ultimately serve to assist differentiating between accidental and non-accidental injury.

Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials.

PURPOSE: To investigate the effectiveness of surgical treatment for minimally displaced and undisplaced scaphoid waist fractures compared with nonsurgical intervention through pairwise and network meta-analyses of randomized controlled trials. METHODS: We searched several databases from 1990 to 2009 for randomized controlled trials that evaluated surgical and nonsurgical treatments of undisplaced or minimally displaced scaphoid waist fractures. We based the main pairwise meta-analysis comparison on the odds ratio of fracture union between patients undergoing surgical versus nonsurgical treatment. We also investigated other outcome measures including complications, range of motion, grip strength, and osteoarthritis of the scaphotrapeziotrapezoid and radiocarpal joints. We used a network meta-analysis to simultaneously synthesize trials making different intervention comparisons while modeling different surgical and nonsurgical treatments distinctly. RESULTS: Of the 67 articles identified, 6 studies were eligible for the primary pairwise meta-analysis, with a total of 363 patients. The pooled odds ratio of fracture union between the surgical and nonsurgical groups was in favor of surgery but not statistically significant. Surgical treatment was associated with a statistically significant elevated risk of complication. Range of motion, grip strength, and osteoarthritis of the scaphotrapeziotrapezoid and radiocarpal joints did not reach statistical significance in the pairwise meta-analyses. The mixed-treatment network meta-analysis showed that open (Herbert) screw fixation had a probability of 0.73 as being the best treatment method compared with percutaneous screw fixation, short arm cast, and short thumb spica cast. CONCLUSIONS: Although surgical treatment is favored in terms of fracture union in our pairwise meta-analysis, this did not reach statistical significance, but was associated with a significantly increased risk of complications. The cumulative evidence at present does not support routine surgical treatment, and aggressive conservative management should remain the mainstay for scaphoid waist fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Dynamic ultrasound assessment of the effects of knee and ankle position on Achilles tendon apposition following acute rupture.

BACKGROUND: Previous reports have suggested that knee flexion improves tendon edge apposition following acute rupture of the Achilles tendon. The aim of the present study was to determine, with use of ultrasonography, the effects of knee and ankle position on the Achilles tendon gap distance in patients with an acute rupture. METHODS: Twenty-six patients with a unilateral acute complete Achilles tendon rupture that had been confirmed with ultrasonography were recruited within a week after the injury. The mean age at the time of presentation was forty-one years. Ultrasound measurements included the location of the rupture and the gap distance between the superficial tendon edges with the ankle in neutral and the knee extended. The gap distance was sequentially measured with the foot in maximum equinus at the ankle and with 0°, 30°, 60°, and 90° of knee flexion. RESULTS: The mean distance of the rupture from the calcaneal enthesis was 52 mm (range, 40 to 76 mm). The mean gap distance with the ankle in neutral and the knee extended was 12 mm (95% confidence interval, 10 to 13 mm). This distance decreased to 5 mm (95% confidence interval, 4 to 7 mm) when the foot was placed in maximum ankle equinus with 0° of knee flexion and to 4 mm (95% confidence interval, 3 to 5 mm) with 30° of knee flexion, 3 mm (95% confidence interval, 2 to 4 mm) with 60° of knee flexion, and 2 mm (95% confidence interval, 1 to 2 mm) with 90° of knee flexion. Expressing the reduction in gap distance with each successive position as a percentage of the gap distance with the knee extended and the ankle in neutral revealed a mean reduction of 55.7%, 64.4%, 75.4%, and 84.8% with maximum ankle equinus and 0°, 30°, 60°, and 90° of knee flexion, respectively. The difference in gap distance between each of these positions was significant (p < 0.05). CONCLUSIONS: Maximum ankle equinus alone significantly reduces the gap distance after acute Achilles tendon rupture. Increasing knee flexion further reduces the gap distance by small increments that, although significant, may not be clinically important.

The accuracy of assessment of walking distance in the elective spinal outpatients setting.

Self reported walking distance is a clinically relevant measure of function. The aim of this study was to define patient accuracy and understand factors that might influence perceived walking distance in an elective spinal outpatients setting. A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and other measures. There are over-estimators and under-estimators. Overall, the accuracy to within 9.14 metres (m) (10 yards) was poor at only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 111 m; mean response 245 m (95% CI 176.3-314.7), Functional test 1 actual distance 29.2 m; mean response 71.7 m (95% CI 53.6-88.9) Functional test 2 actual distance 19.6 m; mean response 47.4 m (95% CI 35.02-59.95). Surprisingly patients over 60 years of age (n = 43) are twice as accurate with each test performed compared to those under 60 (n = 60) (average 70% overestimation compared to 140%; p = 0.06). Patients in social class I (n = 18) were more accurate than those in classes II-V (n = 85): There was a positive correlation between poor accuracy and increasing MZD (Pearson's correlation coefficient 0.250; p = 0.012). ODI, LBOS and other parameters measured showed no correlation. Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate but still poor.

Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome.

A prospective longitudinal inception cohort study of 33 patients undergoing surgery for cauda equina syndrome (CES) due to a herniated lumbar disc. To determine what factors influence spine and urinary outcome measures at 3 months and 1 year in CES specifically with regard to the timing of onset of symptoms and the timing of surgical decompression. CES consists of signs and symptoms caused by compression of lumbar and sacral nerve roots. Controversy exists regarding the relative importance of timing of surgery as a prognostic factor influencing outcome. Post-operative outcome was assessed at 3 months and 1 year using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores for leg and back pain and an incontinence questionnaire. Statistical analysis was used to determine the association between pre-operative variables and these post-operative outcomes with a specific emphasis on the timing of surgery. Surgery was performed on 12 (36%) patients within 48 h of the onset of symptoms including seven patients (21%) who underwent surgery within 24 h. Follow up was achieved in 27 (82%) and 25 (76%) patients at 3 and 12 months, respectively. There was no statistically significant difference in outcome between three groups of patients with respect to length of time from symptom onset to surgery- <24, 24-48 and >48 h. A significantly better outcome was found in patients who were continent of urine at presentation compared with those who were incontinent. The duration of symptoms prior to surgery does not appear to influence the outcome. This finding has significant implications for the medico-legal sequelae of this condition. The data suggests that the severity of bladder dysfunction at the time of surgery is the dominant factor in recovery of bladder function.

Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.

OBJECTIVE: To examine the early and late surgical outcomes of feminizing genitoplasty (FG) in adult transsexuals in a UK single surgeon practice over a 10-year period. PATIENTS AND METHODS: Computerized and manual databases were searched over the period 1994-2004 to identify patients who had undergone male to female FG. Case-notes were retrieved and analysed to identify epidemiological data, the number and type of perioperative problems, early results at outpatient review, late occurring problems and patient satisfaction. A telephone questionnaire was then conducted targeting all FG patients in our series. The questions were directed at identifying surgical complications, outcome and patient satisfaction. RESULTS: In all, 233 case-notes were identified and 222 (95%) were retrieved. All patients had penectomy, urethroplasty and labiaplasty, 207 (93%) had formation of a neoclitoris, and 202 (91%) had a skin-lined neovagina. The median (range) age was 41 (19-76) years. The median hospital stay was 10 (6-21) days. A record of the first outpatient visit was available in 197 (84.5%) cases. The median time to follow up was 56 (8-351) days. Over all, 82.2% had an adequate vaginal depth, with a median depth of 13 (5-15) cm and 6.1% had developed vaginal stenosis. Three (1.7%) patients had had a vaginal prolapse, two (1.1%) had a degree of vaginal skin flap necrosis and one (0.6%) was troubled with vaginal hair growth. In 86.3% of the patients the neoclitorizes were sensitive. There was urethral stenosis in 18.3% of the patients and 5.6% complained of spraying of urine. Minor corrective urethral surgery was undertaken in 36 patients including 42 urethral dilatations, and eight meatotomies were performed. At the first clinic visit 174 (88.3%) patients were 'happy', 13 (6.6%) were 'unhappy' and 10 (5.1%) made no comment. Of the 233 patients, we successfully contacted 70 (30%). All had had penectomy and labioplasty, 64 (91%) had a clitoroplasty and 62 (89%) a neovagina. The median age was 43 (19-76) years and the median follow up was 36 (9-96) months. Overall, 63 (98%) had a sensate neoclitoris, with 31 (48%) able to achieve orgasm; nine (14%) were hypersensitive. Vaginal depth was considered adequate by 38 (61%) and 14 (23%) had or were having regular intercourse. Vaginal hair growth troubled 18 (29%), four (6%) had a vaginal prolapse and two (3%) had vaginal necrosis. Urinary problems were reported by 19 (27%) patients, of these 18 (26%) required revision surgery, 14 (20%) complained of urinary spraying, 18 (26%) had an upward directed stream and 16 (23%) had urethral stenosis. The patients deemed the cosmetic result acceptable in 53 (76%) cases and 56 (80%) said the surgery met with their expectations. CONCLUSION: This is largest series of early results after male to female FG. Complications are common after this complex surgery and long-term follow-up is difficult, as patients tend to re-locate at the start of their 'new life' after FG. There were good overall cosmetic and functional results, with a sustained high patient satisfaction.