Hip Pain in Children

Background: Atraumatic hip pain in children is one of the most common symptoms with which pediatricians, orthopedists, and general practitioners are confronted, with an incidence of 148 cases per 100 000 persons per year. Methods: This article is based on publications up to April 2019 that were retrieved by a selective search in the PubMed database, including case reports and reviews. Results: Infants with fever often have purulent coxitis, which can be diagnosed by blood tests and ultrasonography. Toddlers and older children may suffer from painful restriction of motion of the hip joint, associated with limping (antalgic gait) or even the inability to walk. The main elements of the differential diagnosis in children aged 2-10 are coxitis fugax and idiopathic necrosis of the femoral head (Perthes disease). In children aged 10 and up, and in adolescents, slipped capital femoral epiphysis (SCFE) is typical. Bone tumors and rheumatic diseases must always be considered as well. The initial diagnostic steps on presentation of a child with restricted hip movement should be plain x-rays and joint ultrasonography for the detection of an effusion. Suspicion of a tumor is the main indication for tomographic imaging (computed tomography or magnetic resonance imaging). Conclusion: The underlying cause of hip pain in children should be diagnosed early to avoid adverse sequelae

Joint-Preserving Therapy for Osteogenesis Imperfecta

Background Osteogenesis imperfecta (OI) is a skeletal disease with a frequency of about 1:20,000, which paediatricians and orthopaedic surgeons are rarely confronted with. Method Selective literature search in the PubMed database including case studies and reviews up to August 2022. Results Interdisciplinary cooperation between paediatricians and orthopaedic surgeons is essential for an optimal therapeutic decision for or against surgical treatment of OI. While titanium elastic nails (TENs) are still frequently used for the surgical treatment of the forearm in small children, telescopic nails are primarily used for the joint-preserving treatment of OI as soon as the diameter of the bone permits. The most commonly used telescopic nail is the Fassier-Duval (FD) nail. In adult adolescents and adults, so-called custom made implants are necessary due to the small medullary canal diameters. In the absence of postoperative primary load stability, immobilisation is indicated, which leads to further deterioration of the already atrophic muscle in the OI patient. Conclusion Despite optimisation and the development of special implants, the joint-retaining treatment of OI continues to be a challenge for both patient and doctor

Periprosthetic infections: How do we diagnose and treat? Results of an online survey and comparison with international recommendations

Objective Endoprosthetic replacement surgery of hip and knee joints is widely performed, but always carries the risk of developing periprosthetic infection (PPI). Treatment of PPI is lengthy and demanding for the patient, often involving multiple surgeries as well as lengthy drug therapies. Remediation is not always successful despite extensive therapy. Methods An online survey was used to investigate whether the therapeutic measures implemented in German hospitals are based on international treatment recommendations. For this purpose, German physicians who regularly treat periprosthetic infections in their clinics were asked to complete an online questionnaire. The questionnaire asked about internal hospital procedures. These were then compared with international recommendations. Results With a response rate of 10.9%, the questionnaire shows agreement with the international recommendations in large parts of the operative and medicinal procedures. In preoperative imaging for example, two-plane radiographs are the standard. Similarly, the participants' approach to preoperative specimen collection, incubation time, and operative management (regarding one- or two-stage approach to septic joint) reflects the recommendations. Deviations were particularly evident in the area of laboratory diagnostics, where the erythrocyte sedimentation rate (ESR) is determined in only 17.1%, contrary to the recommendations. Whereas procalcitonin (PCT) and blood culture sampling takes place regularly. Clear differences emerges in the use of drains, which, contrary to the recommendations, are used very regularly (almost 70%). In this survey, the time intervals between the onset of infection symptoms and the start of therapy (prosthesis-preserving therapy) is shown to be longer than recommended internationally. Conclusion In summary, however, the recommended approaches of the international groups in most respects are followed, a high willingness of respondents to collaborate with local infectious disease specialists demonstrates the complexity of the disease

Impact of a pediatric infectious disease consultation service on timely step-down to oral antibiotic treatment for bone and joint infections

Purpose In recent years an earlier step down to oral antibiotic therapy has been advocated for numerous infections. Trained infectious disease specialists regularly consulting their colleagues may speed up the implementation of such recommendations into clinical practice and thus may improve treatment. Methods We retrospectively analyzed bone and joint infections in children admitted to the University Hospital of Cologne between 2010 and 2021. We assessed clinical, imaging, and microbiological findings and treatment modalities. Additionally, we assessed both the impact of a newly implemented pediatric infectious diseases consultation service and publications on revised treatment recommendations by comparing antibiotic therapy in two periods (2010-2016 versus 2017 to 2021). Results In total, 29 children presented with osteomyelitis, 16 with bacterial arthritis and 7 with discitis. In period 2 (2017-2021) we observed shorter duration of intravenous treatment (p = 0.009) and a higher percentage of oral antibiotic treatment in relation to the total duration of antibiotics (25% versus 59%, p = 0.007) compared to period 1 (2010-2016). Yet, no differences were identified for the total length of antibiotic treatment. Additionally, biopsies or synovial fluid samples were retrieved and cultured in more children in period 2 (p = 0.077). The main pathogen identified in osteomyelitis and bacterial arthritis was Staphylococcus aureus (MSSA), diagnosis was confirmed predominantly with MRI. Conclusion Recent guidelines addressing the safety of an earlier step-down (to oral) antibiotic therapy have influenced clinical practice in the treatment of bone and joint infections in our hospital. A newly implemented pediatric infectious diseases consultation service might have accelerated this progress resulting in a faster step down to oral treatment

Periprosthetic Infection in Joint Replacement Diagnosis and Treatment

Background: The volume of joint replacement surgery has risen steadily in recent years, because the population is aging and increasingly wishes to preserve a high functional status onward into old age. Infection is among the more common complications of joint replacement surgery, arising in 0.2% to 2% of patients, or as many as 9% in special situations such as the implantation of megaprostheses. The associated morbidity and mortality are high. It is thus very important to minimize risk factors for infection and to optimize the relevant diagnostic and therapeutic strategies. Methods: This review is based on pertinent publications retrieved by a selective search in PubMed, including current guidelines and expert recommendations. Results: The crucial diagnostic step is joint biopsy for the identification of the pathogenic organism, which succeeds with over 90% sensitivity and specificity. If the prosthesis is firmly anchored in bone, the pathogen is of a type that responds well to treatment, and symptomatic infection has been present only for a short time, then rapidly initiated treatment can save the prosthesis in 35-90% of cases. The pillars of treatment are thorough surgical care (radical debridement) and targeted antibiotic therapy. On the other hand, if the prosthesis is loose or the pathogen is of a poorly treatable type, the infection can generally only be cured by a change of the prosthesis. This can be performed in either one or two procedures, always in conjunction with systemic antibiotic therapy tailored to the specific sensitivity and resistance pattern of the pathogen. Conclusion: The risk of infection of an artificial joint is low, but the overall prevalence of such infections is significant, as the number of implanted joints is steadily rising. Artificial joint infections should be treated by a standardized algorithm oriented toward the recommendations of current guidelines. Many of these recommendations, however, are based only on expert opinion, as informative studies providing high-grade evidence are lacking. Thus, for any particular clinical situation, there may now be multiple therapeutic approaches with apparently comparable efficacy. Randomized trials are urgently needed

Four decades of developmental dysplastic hip screening according to Graf: What have we learned?

PurposeSonographic hip examination according to Graf is widely accepted standard for diagnosing developmental dysplastic hips (DDH) but it is criticized for alleged intra- and interobserver variations. This review was conducted to evaluate whether objective quality criteria according to the Graf method are fulfilled within scientific literature. MethodsA systematic literature search on Pubmed was performed using the search string: [(DDH) OR (Hip dysplasia)] AND (Graf). Studies suitable by title, abstract, manuscript, containing an image of sonographic hip examination and online accessibility were included into analysis. Results131 studies were included into final analysis. Only 68 (51.9%) presented correct sonographic images according Graf's criteria. 98 (74.8%) studies plotted alpha-angles (angle between bony roof line and base line) but only 85 (64.8%) studies beta-angles (angle between cartilage roof line and base line). Studies were contributed from 25 countries. ConclusionAssumingly, skepticism regarding the Graf method is based on user errors and insufficient application of the Graf quality assessment algorithm resulting in high intra- and interobserver variations. When performed correctly, the Graf method is of high diagnostic value

Treatment Failure in Vertebral Osteomyelitis Is it All About Staphylococcus aureus?

Study Design. Retrospective cohort study. Objective. The aim was to compare the influence of 2 common vertebral osteomyelitis (VO) causing pathogens on treatment failure within the first year of diagnosis. Summary of Background Data. VO is mainly caused by Staphylococcus aureus (SA), while enterococci and streptococci (ENST) are also responsible for a significant proportion of VO, particularly in elderly patients. Data on VO caused by SA show a tendency for worse outcome, whereas data on VO caused by ENST are scarce. For this purpose, our study compares characteristics of patients with VO caused by SA or ENST in order to analyze risk factors for treatment failure. Methods. We conducted a retrospective monocentric study including VO patients from 2008 to 2020. Primary outcome was treatment failure defined as death or relapse within 1 year (T1). We compared patients diagnosed with VO caused by Staphylococcus aureus including MRSA to patients diagnosed with VO caused by Enterococcus and Streptococcus species, which were combined into one group. Polymicrobial infections were excluded. We employed multiple logistic regression analysis to adjust for confounding. To account for moderation, the model was repeated with an included interaction term. Results. Data of 130 VO patients (SA=95; ENST=35) were available at T1. Treatment failure occurred in 37% of SA patients and 23% of ENST patients. On multivariate analysis SA [odds ratio (OR): 3.12; 95% confidence interval (CI): 1.09-10.53; P=0.046], Charlson comorbidity index (OR: 1.31; 95% CI: 1.11-1.58; P=0.002) and infectious endocarditis (IE; OR: 4.29; 95% CI: 1.23-15.96; P=0.024) were identified as independent risk factors for treatment failure. Conclusion. In our cohort every third patient with VO caused by SA or ENST dies within 1 year. Our findings indicate that patients with VO caused by SA, concomitant IE and/or a high Charlson comorbidity index score may be at elevated risk for treatment failure. These findings can be used to individualize patient care and to direct clinical surveillance. This could include echocardiography evaluating for the presence of IE in patients with VO caused by gram-positive pathogens

Establishment of an interdisciplinary board for bone and joint infections

Purpose The incidence of bone and joint infections is increasing while their treatment remains a challenge. Although guidelines and recommendations exist, evidence is often lacking and treatment complicated by complex clinical presentations and therapeutic options. Interdisciplinary boards shown to improve management of other diseases, seem potentially helpful. We describe the establishment of an osteomyelitis board to show the existing demand for such a platform. Methods All patients discussed in the board for bone and joint infections between October 2014 and September 2020 were included in this retrospective study. Data were extracted from patient records and analyzed descriptively. Results A total of 851 requests related to 563 patients were discussed in the board during the study period. After a run-in period of 3 years, a stable number of cases (> 170/year) were discussed, submitted by nearly all hospital departments (22 of 25). Recommendations were mainly related to antibiotic treatment (43%) and to diagnostics (24%). Periprosthetic joint infections were the most frequent entity (33%), followed by native vertebral osteomyelitis and other osteomyelitis. In 3% of requests, suspected infection could be excluded, in 7% further diagnostics were recommended to confirm or rule out infection. Conclusions A multidisciplinary board for bone and joint infections was successfully established, potentially serving as a template for further boards. Recommendations were mainly related to antibiotic treatment and further diagnostics, highlighting the need for interdisciplinary discussion to individualize and optimize treatment plans based on guidelines. Further research in needed to evaluate impact on morbidity, mortality and costs