Alexandre Arkader

Changing patterns of acute hematogenous osteomyelitis and septic arthritis: Emergence of community-associated methicillin-resistant Staphylococcus aureus

Introduction: An increase in the incidence and severity of acute osteoarticular infections in children was perceived after the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) in our community. This study was performed to describe changes in the epidemiology and clinical features of acute osteoarticular infections. Methods: The records of patients discharged from Le Bonheur Childrens Medical Center with a diagnosis of acute osteoarticular infection between 2000 and 2004 were reviewed. Data regarding signs and symptoms, diagnostic testing, therapeutics, surgery, and hospital course were collected. Results: There were 158 cases of acute osteoarticular infection. The incidence increased from 2.6 to 6.0 per 1000 admissions between 2000 and 2004. The proportion of infections caused by methicillin-susceptible S. aureus (MSSA) remained constant (10%-13%) and that caused by MRSA rose from 4% to 40%. There was no difference between MRSA and MSSA patients in the duration of fever or pain before diagnosis. Seventy-one percent of patients with MRSA had subperiosteal abscesses compared with 38% with MSSA (P = 0.02). Ninety-one percent of MRSA patients required a surgical procedure compared with 62% of MSSA patients (P < 0.001). Median hospital stay was 7 days for MSSA patients and 10 days for MRSA patients (P = 0.0001). Three patients developed chronic osteomyelitis, 2 with MRSA. There was no association between a delay in institution of appropriate antibiotic therapy and presence of subperiosteal abscess (P = 0.8). Conclusions: There has been an increase in the incidence and severity of acute osteoarticular infections in Memphis. Patients with community-associated MRSA infections are at higher risk of subperiosteal abscess requiring surgical intervention.

Clinical outcomes of radiation therapy in the management of Langerhans cell histiocytosis.

Objectives:Langerhans cell histiocytosis (LCH) is a rare disease with variable clinical presentation. In the present study, we report on the effectiveness and clinical complications of radiation therapy in children with LCH. Materials and Methods:We retrospectively reviewed all patients with LCH treated with radiation therapy over a 6-decade period at a single institution. Radiotherapy data, clinical features, radiographic data, and vital status were analyzed. Results:The mean age at diagnosis for 69 patients was 5.3 years (3 mo to 37 y) and the median duration of follow-up was 6 years (7 d to 32 y). Radiation therapy was performed for 169 sites, primarily bone lesions. The median radiotherapy dose was 10 Gy (2.5 to 45 Gy). Radiographic follow-up data were available for 139 of the sites treated and clinical follow-up was available for 156 of sites treated. The radiographic local control was 91.4%, and 13% of lesions showed complete sclerosis or reconstitution of bone. A total of 90.4% of patients reported stabilization or improvement in lesion-related symptoms, most often pain. Twelve patients had diabetes insipidus at diagnosis or during follow-up. Eight of these patients received radiation treatment to the pituitary and none experienced a reduction in desmopressin dosage posttreatment. Radiation complications were few, including femoral neck fracture in 1 patient and facial asymmetry in 3 patients. No secondary malignancies were observed. Conclusions:Radiotherapy for LCH has high rates of local control and symptomatic improvement. Importantly, however, there is evidence of short-term and long-term morbidity when children are treated with low-dose irradiation.

Chondroblastoma and Chondromyxoid Fibroma

Chondroblastoma and chondromyxoid fibroma are benign but locally aggressive bone tumors. Chondroblastoma, a destructive lesion with a thin radiodense border, is usually seen in the epiphysis of long bones. Chondromyxoid fibroma presents as a bigger, lucent, loculated lesion with a sharp sclerotic margin in the metaphysis of long bones. Although uncommon, these tumors can be challenging to manage. They share similarities in pathology that could be related to their histogenic similarity. Very rarely, chondroblastoma may lead to lung metastases; however, the mechanism is not well understood.

Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?

Background: Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury. Methods: A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study. Results: Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100). Conclusions: In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations. Level of Evidence: Level I prognostic study.

Treatment of Femur Fractures in Young Children: A Multicenter Comparison of Flexible Intramedullary Nails to Spica Casting in Young Children Aged 2 to 6 Years

Background: Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting. Methods: This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups. Results: Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P<0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P<0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023). Conclusions: TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN. Level of Evidence: Level III, this was a retrospective comparative study.

Radial neck fractures in children: experience from two level-1 trauma centers

The aim of this study was to compare different treatment modalities for different severities of pediatric radial neck fractures in a large cohort of patients and determine prognostic factors. A retrospective, comparative study was conducted of all children treated for different severities of radial neck fractures at two level-1 pediatric trauma centers between 1990 and 2007. Pertinent data were collected, and the outcome was measured by the Tibone criteria. Several variables were compared to determine the prognostic value. Seventy-eight children were identified, 35 male and 43 female, at an average age of 7.8 years (range 3–15 years). Twenty-nine of the 78 (37%) children had associated injuries. Fracture patterns varied in their severity. Nineteen patients needed casting alone; 16 required closed reduction; of the children requiring surgery, 26 responded to percutaneous reduction and 17 were severe enough to need open reduction. Complications occurred in 28/78 (36%) children, 24 of which were related to stiffness. Seventeen of the 19 (89%) fractures that were amenable to casting alone had excellent or good outcomes, as did 11/16 (69%) in the closed reduction group. Among children treated operatively, 19/26 (73%) patients who underwent percutaneous reduction had an excellent or good outcome. Only 6/17 (35%) of the severe cases who underwent open reduction had an excellent or good outcome. The treatment method, essentially dictated by the severity of the cases, did correlate with the outcome (P=0.001). Compared with more severe fractures that required operative treatment, patients treated nonoperatively had a higher rate of excellent to good outcome (P=0.018). In particular, patients who underwent percutaneous reduction alone had improved outcomes versus open reduction (P=0.008). The outcome was not related to the presence of an associated injury (P=0.302). Initial fracture severity, as graded by the Judet classification, correlated with the outcome (P=0.004). Furthermore, age also expressed significance, as patients younger than 10 years of age tended to do better than those above 10 years of age (P=0.025). Children with less severe radial neck fractures amenable to nonoperative treatment fare well. Operative treatment of these fractures, particularly in severe cases when an open (not percutaneous) reduction is needed, is associated with a higher risk of poor outcome. Children over 10 years of age, especially those with more severe initial angulation, tend to fare worse. The presence of associated injuries does not appear to increase the risk of a poor outcome after treatment. There is a high rate of complications (36%), stiffness being the most common (24). This large bi-center retrospective study from two level-1 pediatric trauma centers emphasizes that in severe cases of radial neck fractures, open treatment does not necessarily decrease the risk of a poor outcome.

Vascular anomalies of the extremities

Vascular anomalies of the extremities are not uncommon and can significantly impede limb function. Currently, misdiagnosis is a frequent cause of delay in treatment or initiation of incorrect treatment that may detrimentally affect patients. With accurate diagnosis, the appropriate treatment can be implemented with good functional outcomes in most types of vascular anomalies. The goal of this paper is to review the classification, diagnosis, and treatment of vascular anomalies, with particular focus on recent innovations and multimodal management. By clarifying the classification system and developing an algorithmic approach, successful management of vascular anomalies can be achieved. The complexity of these disorders requires communication across multiple disciplines for coordination of care and timely interventions. A typical multidisciplinary team will include an orthopaedist, plastic surgeon, general surgeon, interventional radiologist, dermatologist, oncologist, and geneticist, among others.

Femoral neck fracture as an atypical presentation of child abuse

Femoral neck fractures account for 46% of the proximal femur fractures in children; however, the overall incidence of proximal femur fractures in children is <1%. Pathologic causes for proximal femur fractures include local or global causes of bone weakness, such as metabolic bone conditions or neoplastic causes. Nonpathologic causes of femur fractures are caused almost exclusively by high-energy trauma and are readily identified. Nonaccidental injury leading to femoral neck fracture is unusual and can be challenging to diagnose when the medical history is not forthcoming. Femoral neck fractures in children usually are a consequence of high-energy trauma or less frequently are associated with pathologic conditions. If neither condition is readily identified, the possibility of nonaccidental injury should be considered. This article presents a case of nonaccidental injury with an atypical presentation in a 3-year-old girl with a femoral neck fracture and discusses the diagnostic rationale for a diagnosis of nonaccidental injury. This case report highlights the magnitude of child abuse and its early recognition in the orthopedic community.

Predictors of conversion from conservative to operative treatment of pediatric forearm fractures.

Forearm fractures occur commonly in children; however, there is still uncertainty on what leads to conversion from conservative to operative management. Patients who initially underwent closed reduction and casting for diaphyseal forearm fractures were evaluated for predictors of conversion to operative management. We found that the 20 of 124 (16%) patients in whom there was conversion to operative management were significantly older (11.1 vs. 5.7 nonoperative), had less angulation in the anterior–posterior (or coronal) plane (20.2 vs. 12.8° for the radius, 17.5 vs. 7.8° for the ulna), had a more proximal ulnar fracture location, and had more translated or shortened radius fractures. Level of evidence: level 3, retrospective case–control.

Outcomes of children younger than 24 months with langerhans cell histiocytosis and bone involvement: a report from a single institution.

Background: Langerhans cell histiocytosis (LCH) is a rare disorder that ranges from single-system to disseminated multisystem disease. Patients younger than 24 months of age more commonly present with risk organ (liver, spleen, hematopoietic system, or lung) involvement at diagnosis and have a poor prognosis. Treatment approaches have changed over the last 25 years. Our goal was to describe the course and outcomes of patients younger than 24 months of age at diagnosis and identify the role of bone involvement in outcomes. Methods: We conducted a retrospective chart review of patients diagnosed with LCH at Children’s Hospital Los Angeles from 1984 to 2010, focusing on 71 patients younger than 24 months of age at diagnosis. Results: Ten patients had single bone lesions at diagnosis and did well irrespective of therapy. The majority of patients (40/71 or 56%) had multiple bone lesions. Of the 37 patients with multisystem disease, 27 children (73%) had risk organ involvement. Fourteen patients with risk organ involvement received ⩽6 months of initial chemotherapy with prednisone and vinblastine. Six of these patients had reactivation of the disease, and bone was the most frequent site of reactivation. Seven patients with risk organ involvement were treated with at least 12 months of chemotherapy. Only one of these patients had reactivation of the disease, and none died. The majority (7/10) of patients with risk organ involvement who progressed on therapy died despite multiple treatment regimens. Conclusions: Patients younger than 24 months of age at diagnosis are more likely to have multiple bone lesions than older patients, supporting that a radiographic skeletal survey at the time of LCH diagnosis is important to evaluate the extent of bone involvement. Bones were the most common site for reactivation for all patients. As expected, subjects with risk organ involvement had better outcomes when treated with systemic chemotherapy for at least 1 year. Level of Evidence: As a retrospective review of all cases at our institution over a 26-year period, this article represents level IV evidence.