Eduardo N. Novais

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.

Periacetabular osteotomy after failed hip arthroscopy for labral tears in patients with acetabular dysplasia.

BACKGROUND Chronic mechanical overload of the acetabular rim may lead to acetabular labral disease in patients with hip dysplasia. Although arthroscopic debridement of the labrum may provide symptomatic relief, the underlying mechanical abnormality remains. There is little information regarding how the results of periacetabular osteotomy are affected by a prior primary treatment for labral disease in the presence of acetabular dysplasia. METHODS In a retrospective matched-cohort study, seventeen patients who had arthroscopic labral debridement prior to periacetabular osteotomy (the arthroscopy group) were compared with a control group of thirty-four patients who did not undergo arthroscopic labral debridement prior to periacetabular osteotomy (the non-arthroscopy group). Two control patients were randomly matched to each experimental patient from a pool of controls. Functional outcomes were assessed with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Failure of periacetabular osteotomy was defined as conversion to a total hip replacement. RESULTS Changes in the preoperative and postoperative WOMAC scores of arthroscopy and non-arthroscopy patients were comparable, and the differences between the two treatment groups were not significant. We were unable to show a significant difference between the seventeen arthroscopy and thirty-four non-arthroscopy patients with regard to the risk of having to undergo a total hip replacement. CONCLUSIONS When arthroscopic labral debridement fails to improve symptoms in patients with labral disease secondary to acetabular dysplasia, periacetabular osteotomy may still be considered as a joint-preserving procedure that can achieve good functional results.

Slipped Capital Femoral Epiphysis: Prevalence, Pathogenesis, and Natural History

BackgroundObesity is a risk factor for developing slipped capital femoral epiphysis (SCFE). The long-term outcome after SCFE treatment depends on the severity of residual hip deformity and the occurrence of complications, mainly avascular necrosis (AVN). Femoroacetabular impingement (FAI) is associated with SCFE-related deformity and dysfunction in both short and long term.Questions/PurposesWe examined obesity prevention, early diagnosis, reducing AVN and hip deformity as strategies to reduce SCFE prevalence, and the long-term outcomes after treatment.MethodsA search of the literature using the PubMed database for the key concepts SCFE and treatment, natural history, obesity, and prevalence identified 218, 15, 26, and 49 abstracts, respectively.Where Are We Now?A correlation between rising childhood obesity and increasing incidence of SCFE has been recently reported. Residual abnormal morphology of the proximal femur is currently believed to be the mechanical cause of FAI and early articular cartilage damage in SCFE.Where Do We Need to Go?Reducing the increasing prevalence rate of SCFE is important. Treatment of SCFE should aim to reduce AVN rates and residual deformities that lead to FAI to improve the long-term functional and clinical outcomes.How Do We Get There?Implementing public health policies to reduce childhood obesity should allow for SCFE prevalence to drop. Clinical trials will evaluate whether restoring the femoral head-neck offset to avoid FAI along with SCFE fixation allows for cartilage damage prevention and lower rates of osteoarthritis. The recently described surgical hip dislocation approach is a promising technique that allows anatomic reduction with potential lower AVN rates in the treatment of SCFE.

In situ fixation for slipped capital femoral epiphysis: perspectives in 2011.

Slipped capital femoral epiphysis is usually treated with in situ fixation to prevent progression of deformity. However, slipped capital femoral epiphysis always is associated with structural risk factors for hip dysfunction in addition to the risk of slip progression. Femoro-acetabular impingement causes some mechanical abnormality in every hip affected by slipped capital femoral epiphysis, even when the slip is mild. The severity of femoro-acetabular impingement caused by slipped capital femoral epiphysis depends on several factors. Cumulative injury to the articular cartilage can result from impingement, and it is better to prevent this type of injury than to treat it later. In situ fixation alone rarely relieves femoro-acetabular impingement in slipped capital femoral epiphysis. Skillful and precise in situ fixation allows careful analysis of hip function in the stabilized slip by eliminating the major risk of acute instability. The more subtle risk of long-term articular damage caused by femoro-acetabular impingement must be considered. The treatment of femoro-acetabular impingement in patients who have slipped capital femoral epiphysis is a separate issue from instability of the proximal femoral physis. Femoro-acetabular impingement must be assessed in every hip that is affected by slipped capital femoral epiphysis, even when the deformity is mild. Several treatment options exist for treating femoro-acetabular impingement associated with slipped capital femoral epiphysis.

Hypophosphatemic Rickets: The Role of Hemiepiphysiodesis

Abstract: Despite early medical intervention, children with hypophosphatemic rickets often have progressive deformities in the lower extremities. With the forces imparted by gravity and weight bearing, varus or valgus deformities that might otherwise have been physiological are likely to progress, causing gait disturbance and pain. Proper medical management is important and may theoretically slow or prevent the progression of varus or valgus, but is ineffective at correcting deformity once established. We have reviewed the literature and gathered a series of 10 patients, most of whom underwent hemiepiphysiodesis. We are presenting the rationale for, and the results of, that surgery, in an effort to define the role of this minimally invasive procedure.

Aneurysmal bone cyst of the cervical spine in children.

BACKGROUND Approximately 50% of patients with aneurysmal bone cyst of the spine are in the pediatric age group. Aneurysmal bone cyst is considered a locally aggressive benign tumor that may involve the posterior and anterior elements of the spine. Intralesional extended curettage and bone-grafting is the mainstay of treatment of aneurysmal bone cysts involving the long bones. However, the proximity to neurovascular structures and the potential remaining growth of the spine make its management in the spine more challenging. We evaluated the clinical presentation and the results of surgical treatment, following complete intralesional curettage along with spinal arthrodesis in pediatric patients with aneurysmal bone cysts of the cervical spine. METHODS We retrospectively reviewed the cases of seven children who were surgically treated for a primary aneurysmal bone cyst of the cervical spine between 1988 and 2008. There were four boys and three girls who had a mean age of 11.9 years (range, eight to 16.2 years) at the time of diagnosis. The mean duration of follow-up was 46.5 months (range, twenty-six to ninety-eight months). The mean age at the time of follow-up was sixteen years (range, 10.6 to 24.6 years). RESULTS Neck pain was the most common presenting symptom, and radiculopathy was the most common finding on physical examination. Radiographs, computed tomography, and magnetic resonance imaging were highly suggestive for the diagnosis that was confirmed histologically in all patients. The majority (four) of the patients required combined anterior and posterior approaches for complete removal of the tumor and arthrodesis of the spine. Two patients required additional procedures: one for a local recurrence and one for nonunion of the atlantooccipital junction. All patients were free of evidence of recurrent disease at the time of the last follow-up. With the exception of one patient who had permanent Horner syndrome, all patients were asymptomatic. CONCLUSIONS Preoperative arterial embolization, complete tumor excision by intralesional curettage and burring, followed by local spinal fusion, yield satisfactory results with a low rate of complications and low recurrence in children with an aneurysmal bone cyst of the cervical spine.

Diagnosis and treatment of femoroacetabular impingement in Legg-Calvé-Perthes disease.

Residual hip deformities secondary to Legg-Calvé-Perthes disease (LCPD) include growth disturbance of the proximal femoral physis with nonspherical femoral head, overriding greater trochanter with short femoral neck and secondary remodeling of the acetabulum. These deformities can change the mechanical function of the hip joint and contribute to femoroacetabular impingement. All these deformities need to be recognized and its contribution to the patients symptoms understood before a treatment strategy can be planned. Safe surgical dislocation of the hip allows for complete inspection of the hip joint and dynamic assessment of femoroacetabular contact during hip motion. The goals of this paper are to review the pathophysiology, clinical presentation, imaging findings, and the management of femoroacetabular impingement in patients with LCPD. We sought to present our treatment philosophy for patients who were diagnosed and treated for LCPD as a child and present with femoroacetabular impingement as adolescents and young adults.

Treatment of Gibbus deformity associated with myelomeningocele in the young child with use of the vertical expandable prosthetic titanium rib (VEPTR): a case report.

Approximately 8% to 21% of patients with myelomeningocele have an associated kyphotic deformity, most commonly in the upper lumbar or thoracolumbar area1-3. The natural history of congenital rigid kyphosis, or gibbus deformity, is rapid progression in early childhood1-6. The apex of the deformity is most frequently located in the middle and upper lumbar spine3,7 and is associated with vertebral anomalies, a sharp apical angulation, and the potential for skin breakdown over the deformity. It is the most common type of kyphosis associated with myelomeningocele4. A number of strategies have been used for the treatment of rigid kyphosis. For patients with myelomeningocele, conservative treatment with modified wheelchair seat cushions and bracing is relatively ineffective6,8-10. Bracing does not prevent progression of the deformity and may contribute to skin breakdown. Surgery has therefore been recommended as the treatment of choice. Since it was first described by Sharrard in 196811, osteotomy for the resection of the vertebral bodies (kyphectomy) and spinal fusion has been the standard surgical approach for the treatment of this kyphotic deformity3,4,7-9,12-22. Although the concept of vertebral resection is widely accepted, there are no consistent recommendations for the timing of surgery, the extent of the resection and fusion, and the ideal type of instrumentation used. Independent of the surgical technique, most authors agree that the rate of complications associated with correction of this deformity is high. Additionally, spinal instrumentation and fusion in an immature spine may lead to crankshaft changes in the spine17. In 2004, Campbell et al.23 described the use of the Vertical Expandable Prosthetic Titanium Rib (VEPTR; Synthes Spine, West Chester, Pennsylvania) for …

Treatment of the Symptomatic Healed Perthes Hip

Healed Legg-Calvé-Perthes disease may cause both intra-articular and extra-articular impingement, resulting in a symptomatic hip prior to the onset of osteoarthritis. Various impingement-relieving surgeries have been used in the past; however, the development of the safe surgical dislocation technique has allowed a better understanding of complex deformity that may be present in these hips and hence may improve treatment of these symptomatic prearthritic hips. This article outlines the range of deformities possible in a Perthes hip, and treatment strategies to surgically address these deformities. For Perthes disease good preoperative clinical and radiographic assessment is essential, and intraoperative assessment vital.

Obesity is a major risk factor for the development of complications after peri-acetabular osteotomy

Obesity is a risk factor for complications following many orthopaedic procedures. The purpose of this study was to investigate whether obesity was an independent risk factor increasing the rate of complications following periacetabular osteotomy (PAO) and to determine whether radiographic correction after PAO was affected by obesity. We retrospectively collected demographic, clinical and radiographic data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were followed for a mean of 48 months (12 to 60) after PAO. A total of 65 patients (23.2%) were obese (body mass index (BMI) > 30 kg/m(2)). Univariate and multivariate analysis demonstrated that BMI was an independent risk factor associated with the severity of the complications. The average probability of a patient developing a major complication was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient The odds of a patient developing a major complication were 11 times higher (95% CI 4.71 to 17.60, p < 0.0001) for an obese compared with a non-obese patient. Following PAO surgery, there was no difference in radiographic correction between obese and non-obese patients. PAO procedures in obese patients correct the deformity effectively but are associated with an increased rate of complications.