Congenital knee dislocation. Therapeutic protocol and long-term functional results. / Luxación congénita de rodilla. Protocolo terapéutico y resultados funcionales a largo plazo.

BACKGROUND AND OBJECTIVE: Congenital knee dislocation is a very rare entity, characterised by deformity in knee recurvatum present at birth, and there is currently no consensus on the optimal treatment. The aim of the present study is to analyse the functional results and long-term complications after the application of a protocol of therapeutic action for the management of congenital knee dislocation (CKD) created in a reference centre for child orthopaedics. MATERIALS AND METHODS: Retrospective descriptive study of patients with congenital dislocation of the knee who followed CRPL between January 1997 and December 2010. Demographic variables, type of treatment, functional outcomes at the end of the follow-up, complications and relapses were studied. The conservative treatment consisted of serial casts, leaving the surgical treatment for cases in which passive flexion was not achieved above 30° or the conservative treatment failed. RESULTS: 9 patients (11 knees) met the inclusion criteria. The 66.7% were girls and the average follow-up was 15 years (9-22). In all cases, conservative treatment was initiated. Of the 11 knees treated, less than half (36%) required surgery. The average Lysholm questionnaire was 90.3 points, the WOMAC pain 0.4 (0-1), WOMAC stiffness 1.8 (0-6) and WOMAC function 3.8 (1-12). CONCLUSIONS: The existence and application of the PLCR protocol in a pathology as rare as congenital knee dislocation suggests good long-term functional results with few complications and no recurrences.

[Adequacy and effect of preventive antiepileptic treatment after a first epileptic seizure 30 days after discharge from hospital emergency departments: the ACESUR registry]. / Adecuacion y efecto del tratamiento antiepileptico preventivo tras una primera crisis epileptica a los 30 dias del alta de servicios de urgencias hospitalarios: registro ACESUR.

AIM: To evaluate the adequacy and effect of preventive antiepileptic treatment in adult patients with the first epileptic seizure in adverse outcomes at 30 days after discharge from the hospital emergency department (HED). PATIENTS AND METHODS: ACESUR was an observational registry of multipurpose, prospective and multicentric cohorts with a systematic sampling. Phone follow-up was done at 30 days. Clinical variables were collected in the index visit and the follow-up result. The main variable was «adequate preventive treatment according to indications¼ and the result of «some adverse outcome¼ (recurrence of epileptic seizure, revisits to HED, hospitalization or death) 30 days after discharge from HED. A logistic regression model was used to isolate the effect of adequate preventive treatment. RESULTS: 151 (22.7%) patients with a mean age of 55 years old were included with first epileptic seizure discharged from 18 HED with follow-up data. Preventive treatment was considered adequate in 128 (84.8%) patients. 41 (27.2%) patients presented some adverse outcome 30 days after discharge. After the logistic regression, the appropriate preventive treatment to the discharge of the HED exerts a protective effect on the variable «some adverse outcome to 30 days¼. CONCLUSIONS: In the ACESUR registry, preventive treatment was adequate for most patients and its effect was independent protective at 30 days. Therefore, adequate preventive treatment could improve the short-term results of adult patients discharged with the first epileptic seizure of the HED.

TITLE: Adecuacion y efecto del tratamiento antiepileptico preventivo tras una primera crisis epileptica a los 30 dias del alta de servicios de urgencias hospitalarios: registro ACESUR.Objetivo. Evaluar la adecuacion y el efecto del tratamiento antiepileptico preventivo en pacientes adultos con una primera crisis epileptica en cuanto a resultados adversos a los 30 dias del alta del servicio de urgencias hospitalario (SUH). Pacientes y metodos. ACESUR fue un registro observacional de cohortes multiproposito, prospectivo y multicentrico con un muestreo sistematico. Se realizo seguimiento telefonico a los 30 dias. Se recogieron variables clinicas en la visita indice y de resultado en seguimiento. La variable principal fue «tratamiento preventivo adecuado segun indicaciones¼, y la de resultado, «algun resultado adverso¼ (recurrencia de crisis epileptica, revisita a SUH, hospitalizacion o muerte) a los 30 dias del alta de urgencias. Se realizo un modelo de regresion logistica para aislar el efecto del tratamiento preventivo adecuado. Resultados. Se incluyo a 151 (22,7%) pacientes con una media de 55 años con primera crisis epileptica, dados de alta de 18 SUH con datos de seguimiento. El tratamiento preventivo se considero adecuado en 128 (84,8%) pacientes. Cuarenta y un (27,2%) pacientes presentaron algun resultado adverso a los 30 dias del alta. Tras la regresion logistica, el tratamiento preventivo adecuado al alta del SUH ejerce un efecto protector sobre la variable «algun resultado adverso a 30 dias¼. Conclusiones. En el registro ACESUR, el tratamiento preventivo fue adecuado en la mayoria de los pacientes y su efecto resulto, de forma independiente, protector a los 30 dias. Por tanto, el tratamiento preventivo adecuado podria mejorar los resultados a corto plazo de pacientes adultos dados de alta con una primera crisis epileptica del SUH.

Outcome of childhood leukaemia survivors and necrosis of the femoral head treated with autologous mesenchymal stem cells

Purpose. Corticoid-induced osteonecrosis (ON) of femoral head can lead to severe hip joint impairment and hip replacement, with negative impact in young survivors of acute lymphoblastic leukaemia (ALL) with long life expectancy. We aim to improve quality of life in these patients with a novel approach. Methods/patients. Based on the regenerative capacities of mesenchymal stem cells (MSCs), we performed locally implanted autologous cell therapy in two adolescents suffering of bilateral femoral ON. This required a simple, minimally invasive surgical procedure. Results. Both patients experienced significant pain relief and restoration of gait kinematic values. Radiographic evaluation showed cessation of hip collapse. No toxicities/complications were observed after a 4-year follow-up. Conclusions. Our preliminary results suggest that autologous MSCs can be considered as a novel treatment for children and young adults with ON after overcoming ALL. It may avoid hip replacement and improve quality of life of leukaemia survivors

No disponible

Spinal infections in children: a multicentre retrospective study.

Aims: This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series. Patients and Methods: The medical records of children with such an infection, treated at four tertiary institutions between 2004 and 2014, were analyzed retrospectively. Epidemiological, clinical, paraclinical, radiological, and microbiological data were evaluated. There were 103 children, of whom 79 (76.7%) were aged between six months and four years. Results: We confirmed a significant male predominance in the incidence of primary pyogenic spinal infections in children (65%). The lumbar spine was the most commonly affected region, and 27 infections (26.2%) occurred at L4/5. The white blood cell count was normal in 61 children (59%), and the CRP level was normal in 43 (42%). Blood cultures were performed in 95 children, and were positive in eight (8%). A total of 20 children underwent culture of biopsy or aspiration material, which was positive in eight (40%). Methicillin-sensitive Staphylococcus aureus (MSSA) and Kingella ( K.) kingae were the most frequently isolated pathogens. Conclusion: MSSA remains the most frequently isolated pathogen in children with primary pyogenic infection of the spine, but K. kingae should be considered as an important pathogen in children aged between six months and four years. Therefore, an empirical protocol for antibiotic treatment should be used, with consideration being made for the triphasic age distribution and specific bacteriological aetiology. In the near future, the results of polymerase chain reaction assay on throat swabs may allow the indirect identification of K. kingae spondylodiscitis in young children and thus aid early treatment. However, these preliminary results require validation by other prospective multicentre studies. Cite this article: Bone Joint J 2018;100-B:542-8.

Outcome of childhood leukaemia survivors and necrosis of the femoral head treated with autologous mesenchymal stem cells.

PURPOSE: Corticoid-induced osteonecrosis (ON) of femoral head can lead to severe hip joint impairment and hip replacement, with negative impact in young survivors of acute lymphoblastic leukaemia (ALL) with long life expectancy. We aim to improve quality of life in these patients with a novel approach. METHODS/PATIENTS: Based on the regenerative capacities of mesenchymal stem cells (MSCs), we performed locally implanted autologous cell therapy in two adolescents suffering of bilateral femoral ON. This required a simple, minimally invasive surgical procedure. RESULTS: Both patients experienced significant pain relief and restoration of gait kinematic values. Radiographic evaluation showed cessation of hip collapse. No toxicities/complications were observed after a 4-year follow-up. CONCLUSIONS: Our preliminary results suggest that autologous MSCs can be considered as a novel treatment for children and young adults with ON after overcoming ALL. It may avoid hip replacement and improve quality of life of leukaemia survivors.

Peromelia - congenital transverse deficiency of the upper limb: a literature review and current prosthetic treatment.

Peromelia or congenital transverse deficiency describes a truncation of the upper limb below various limb levels. Recommendations regarding treatment vary and are mainly based on expert opinions. This paper summarizes the current literature regarding the aetiology, pathogenesis and specifically treatment algorithms for children with peromelia. We performed a non-systematic review of the current literature from MEDLINE/PubMed to obtain comprehensive up-to-date information about peromelia, focusing on current recommendations for the treatment of peromelia (e.g. prosthetic fitting, external stump lengthening). The current literature lacks clear evidence as to whether prosthetic treatment is superior to prosthetic non-usage. However, based on the available studies, children with transradial or transhumeral peromelia should preferably be fitted with passive/cosmetic prostheses at the age between six and 24 months, followed by active/myoelectric devices at the age of 2.5 to four years. It remains controversial whether early myoelectric prosthetic fitting can reduce prosthesis rejection times; however, cognitive readiness and the ability to absolve a guided training programme are seen as important prerequisites for myoelectric fitting. Children with very short stumps may benefit from stump lengthening using external fixators and prosthetic modification. The treatment of children with peromelia generally requires a guided, multidisciplinary team approach. A training programme is essential to optimize individuals' performance in the execution of activities of daily living and decrease rejection risks whenever a myoelectric device is prescribed. Myoelectric fitting should preferably be commenced at no later than four years of age. However, long-term reports on the benefits of prosthetic treatment are still pending.

Resección de radios de la mano en pacientes pediátricos / Ray resection in paediatric population

Objetivo. Valoración de los resultados clínicos y funcionales de la resección completa de los radios de la mano en población pediátrica y descripción de los aspectos técnicos más relevantes de la cirugía. Material y método. Estudio retrospectivo observacional de pacientes intervenidos en el periodo comprendido entre 2010-2015. Criterios de inclusión: resección de uno o más radios de la mano y seguimiento mínimo de un año. Evaluación de las características clínicas, resultados funcionales y estéticos, complicaciones, necesidad de apoyo psicológico y grado de satisfacción. Resultados. Cuatro pacientes cumplieron criterios de inclusión. La edad media fue de 5 años (rango 1-14 años). Las causas fueron: hamartoma lipofibromatoso, amputación traumática, deficiencia radial y sindactilia compleja. El segundo radio fue resecado en tres pacientes y el tercer y cuarto radio en un paciente. No se realizó transferencia de radios adyacentes. No existieron complicaciones postoperatorias ni durante el seguimiento. Ningún paciente precisó ayuda psicológica. Todos presentaron excelentes resultados estéticos, funcionales y con un alto grado de satisfacción. Discusión. La resección completa de uno o más radios de la mano se utiliza como técnica de rescate en pacientes con lesiones vasculares, tumores, traumatismos, infecciones o malformaciones congénitas. Las publicaciones existentes son pequeñas series en pacientes adultos o casos clínicos aislados, no existiendo apenas referencias en población pediátrica. Conclusión. La resección de radios de la mano es una técnica útil y segura en la población pediátrica que proporciona excelentes resultados estéticos y funcionales en aquellos casos en los que es imposible la preservación de uno o varios dedos (AU)

Aim. Evaluation of clinical and functional outcome of ray resection in paediatric population and description of key aspects of surgical technique. Material and methods. We performed a retrospective review of all patients undergoing surgery between 2010-2015. Inclusion criteria: one or more ray resections of the hand and a minimum of one year follow-up. Evaluation of clinical characteristics, functional and cosmetic results, complications, need for psychological support and patient or family satisfaction. Results. Four patients met the inclusion criteria. The mean age at surgery was 5 years (range, 1-14 years). Aetiology was: fibrolipomatous hamartoma, traumatic amputation, radial deficiency and complex syndactyly. Second ray was resected in three patients and third and fourth ray in one. No finger transfer was performed. No immediate post-operative complications were found at the final evaluation. None of them needed psychological support. All the patients showed excellent clinical and functional results with a high grade of satisfaction. Discussion. Ray resection of the hand has been used as salvage procedure in patients with vascular lesions, tumours, trauma, infections or congenital malformations. There are only a few published studies including small samples in adults or case reports, with no references in the paediatric population. Conclusion. Ray resection of the hand is a useful and safe technique in paediatric population, obtaining excellent cosmetic and functional results in those cases in which it is impossible to preserve one or more fingers (AU)

Ray resection in paediatric population. / Resección de radios de la mano en pacientes pediátricos.

AIM: Evaluation of clinical and functional outcome of ray resection in paediatric population and description of key aspects of surgical technique. MATERIAL AND METHODS: We performed a retrospective review of all patients undergoing surgery between 2010-2015. INCLUSION CRITERIA: one or more ray resections of the hand and a minimum of one year follow-up. Evaluation of clinical characteristics, functional and cosmetic results, complications, need for psychological support and patient or family satisfaction. RESULTS: Four patients met the inclusion criteria. The mean age at surgery was 5 years (range, 1-14 years). Aetiology was: fibrolipomatous hamartoma, traumatic amputation, radial deficiency and complex syndactyly. Second ray was resected in three patients and third and fourth ray in one. No finger transfer was performed. No immediate post-operative complications were found at the final evaluation. None of them needed psychological support. All the patients showed excellent clinical and functional results with a high grade of satisfaction. DISCUSSION: Ray resection of the hand has been used as salvage procedure in patients with vascular lesions, tumours, trauma, infections or congenital malformations. There are only a few published studies including small samples in adults or case reports, with no references in the paediatric population. CONCLUSION: Ray resection of the hand is a useful and safe technique in paediatric population, obtaining excellent cosmetic and functional results in those cases in which it is impossible to preserve one or more fingers.

Inducción experimental de la enfermedad de Perthes en corderos / Experimental induction of Perthes disease in lambs

Objetivo: Establecer un modelo experimental sencillo, reproducible y seguro para conocer el desarrollo de la necrosis vascular isquémica de la cadera en el cordero. Material y metodología: Utilizamos 15 corderos (10 machos y 5 hembras) de 4 semanas de edad, divididos en un grupo control (7 animales) y otro grupo experimental (8 animales), a los que se provocó la isquemia de la extremidad proximal del fémur. Se efectuaron radiografía convencional y resonancia nuclear magnética. Tras el sacrificio de los animales, a la 4.a, 8.a y 12.a semanas poscirugía, extrajimos y medimos la cabeza femoral. Una vez fijada la pieza obtuvimos cortes histológicos de diferentes zonas que se tiñeron con hematoxilina-eosina. Resultados: Radiográficamente disminuyó la altura y aumentó la anchura de la cabeza femoral, más evidente a partir de la 4.a semana. No objetivamos cambios en la altura del pilar lateral ni en la distancia artículo-trocantérea. El grupo experimental macroscópicamente demostró hipertrofia y aplanamiento progresivo de la cabeza. A las 4 semanas de la cirugía aparecieron zonas de necrosis en el cartílago articular, una médula ósea más densa y menor altura de la fisis. Los vasos estaban engrosados por proliferación de la capa media y de la adventicia. A las 8 semanas encontramos una fibrosis subcondral, con un cartílago articular irregular, adelgazado y desvitalizado, y áreas de angiogénesis con grasa en el hueso subcondral. A las 12 semanas apreciamos el cierre de la fisis, áreas condrales en las trabéculas óseas y células adiposas en la médula diafisaria. Conclusión: Aunque los cambios histológicos son compatibles con necrosis de la cabeza femoral, las pruebas de imagen obtenidas no se asemejan a la enfermedad de Perthes, por lo que desaconsejamos este modelo experimental para el estudio de esta entidad (AU)

Objective: To establish a simple, reproducible and safe experimental model, for the development of ischemic vascular necrosis of the hip in the lamb. Material and methods: We used 15 lambs (10 males and 5 females) aged four weeks, divided into a control group (7 animals) and an experimental group (8 animals) producing ischemia in the proximal femur. Standard radiography and MRI were performed. The animals were euthanised at the 4th, 8th and 12th weeks after surgery. The femoral heads were extracted and measured and a histological analysis was performed with hematoxylin-eosin staining. Results: Decreased height and increased width of the femoral head was observed in the X -rays, particularly after the 4th week. We did not observe any changes in the height of the lateral pillar or trochanteric distance. The experimental group showed macroscopical hypertrophy and progressive flattening of the head. At 4 weeks necrotic areas in articular cartilage were observed, bone marrow was dense and the growth cartilage height was lower. The vessels were thickened by proliferation of the medial and adventitia layers. At 8 weeks, we found fibrosis in the subchondral bone with thinned and devitalized angiogenesis fat areas. The articular cartilage showed irregularities. At 12 weeks the closure of the physis was noted, as well as chondral areas in the trabecular bone and fat cells in the methaphysis. Conclusion: Although the histological changes are consistent with necrosis of the femoral head, the images obtained did not resemble Perthes disease, so we do not advise this experimental model for the study of this disease (AU)

[Experimental induction of Perthes disease in lambs]. / Inducción experimental de la enfermedad de Perthes en corderos.

OBJECTIVE: To establish a simple, reproducible and safe experimental model, for the development of ischemic vascular necrosis of the hip in the lamb. MATERIAL AND METHODS: We used 15 lambs (10 males and 5 females) aged four weeks, divided into a control group (7 animals) and an experimental group (8 animals) producing ischemia in the proximal femur. Standard radiography and MRI were performed. The animals were euthanised at the 4th, 8th and 12th weeks after surgery. The femoral heads were extracted and measured and a histological analysis was performed with hematoxylin-eosin staining. RESULTS: Decreased height and increased width of the femoral head was observed in the X-Rays, particularly after the 4th week. We did not observe any changes in the height of the lateral pillar or trochanteric distance. The experimental group showed macroscopical hypertrophy and progressive flattening of the head. At 4 weeks necrotic areas in articular cartilage were observed, bone marrow was dense and the growth cartilage height was lower. The vessels were thickened by proliferation of the medial and adventitia layers. At 8 weeks, we found fibrosis in the subchondral bone with thinned and devitalized angiogenesis fat areas. The articular cartilage showed irregularities. At 12 weeks the closure of the physis was noted, as well as chondral areas in the trabecular bone and fat cells in the methaphysis. CONCLUSION: Although the histological changes are consistent with necrosis of the femoral head, the images obtained did not resemble Perthes disease, so we do not advise this experimental model for the study of this disease.

Epifisiolisis de la cabeza femoral / Slipped capital femoral epiphysis

La epifisiolisis de la cabeza femoral (ECF) se describe como el desplazamiento de la epífisis (cabeza femoral) respecto a la metáfisis (cuello) a través de la fisis. El término es confuso ya que es la metáfisis la que se desplaza en dirección anterosuperior mientras que la epífisis no se mueve y mantiene su posición respecto al acetábulo. La ECF se considera estable cuando el paciente es capaz de caminar e inestable cuando no puede hacerlo ni siquiera con ayuda de bastones. Los pacientes con ECF son adolescentes que presentan dolor en la región inguinal y/o en la rodilla asociado a cojera. El tratamiento de elección en las estables es la fijación in situ con un tornillo (AU)

Slipped capital femoral epiphysis (SCFE) is characterized by displacement of the capital femoral epiphysis from the metaphysis through the physis. The term is confusing, because the metaphysis moves upward and outward while the epiphysis remains in the acetabulum. The SCFE is considered stable when the child is able to walk with or without crutches, and it is considered unstable when the child cannot walk with or without crutches. Patients with SCFE present with pain in the groin, knee and limp. The current treatment of stable SCFE is in situ stabilization with a single screw (AU)

[Slipped capital femoral epiphysis]. / Epifisiolisis de la cabeza femoral.

Slipped capital femoral epiphysis (SCFE) is characterized by displacement of the capital femoral epiphysis from the metaphysis through the physis. The term is confusing, because the metaphysis moves upward and outward while the epiphysis remains in the acetabulum. The SCFE is considered stable when the child is able to walk with or without crutches, and it is considered unstable when the child cannot walk with or without crutches. Patients with SCFE present with pain in the groin, knee and limp. The current treatment of stable SCFE is in situ stabilization with a single screw.

Necrosis avascular de la cabeza femoral: estudio experimental en corderos / Avascular necrosis of the femoral head: experimental study in lambs

Objetivo: Establecer un modelo experimental reproducible, en el cordero, para provocar una necrosis avascular de la cabeza del fémur. Material y metodología: Utilizamos 21 corderos, con edades comprendidas entre los 6 y 22 semanas. En el primer grupo (13 corderos) se seccionó la musculatura ilio-inguinal, inyectando una sustancia esclerosante y ligando los vasos pericapsulares en el cuello femoral, mediante cerclaje de alambre. En el segundo grupo (9 corderos) se ligó el cuello femoral mediante brida de plástico y sección del ligamento redondo. No se utilizó ningún tipo de inmovilización. El sacrificio de los animales se realizó, según el grupo, entre las 15 y 34 semanas. Efectuamos estudios radiográficos, macroscópicos e histológicos. Resultados: Las cabezas femorales mostraron un centro secundario de osificación y un adelgazamiento del cartílago fisario, más intenso en los animales con evolución superior a 7 semanas tras el insulto vascular. Se observó un aumento de la densidad ósea de la cabeza femoral, con aplanamiento cefálico, disposición irregular de la fisis e hipercrecimiento del trocánter mayor. Hallamos necrosis del cartílago articular sin apreciar una invasión vascular de la zona hipertrófica del cartílago de crecimiento. En la metáfisis hallamos áreas fibróticas. Conclusión: La lesión vascular experimental en la cadera de corderos inmaduros produce cambios apreciables en el cartílago articular, el centro secundario de osificación, la fisis de crecimiento y la metafisis (AU)

Objective: To establish a reproducible experimental model in lambs to cause avascular necrosis of the femoral head. Material and Methods: We used 21 lambs, aged between 6 and 22 weeks. In the first group (13 lambs), the ilioinguinal musculature was sectioned, injecting a sclerosing substance and ligating the pericapsular vessels in the femoral neck by wire cerclage. In the second group (9 lambs), the femoral neck was ligated using a plastic loop and sectioning of the round ligament. No type of immobilization was used. The animals were sacrificed, depending on the group, between 15 and 34 weeks. We conducted radiographic, gross, and histological studies. Results: The femoral heads showed a secondary site of ossification and thinning of growth plate cartilage, more severe in the animals with course longer than 7 weeks after vascular injury. Increased bone density in the femoral head, with cephalic flattening, irregular arrangement of the physis and hypergrowth of the greater trochanter was observed. We found necrosis of joint cartilage without evidence of vascular invasion. of the hypertrophic area of cartilage growth. We found fibrotic areas in the metaphysis. Conclusion: Experimental vascular injury in the hip of immature lambs causes substantial changes in joint cartilage, the secondary site of ossification, the growth physis and metaphysis (AU)