Pentti E. Kallio

Acute Patellar Dislocation in Children: Incidence and Associated Osteochondral Fractures

In a prospective two-year study on urban (city of Helsinki) Finnish children, 72 acute patellar dislocations were observed. The calculated annual incidence rate was 43/100,000 in children under 16 years. A total of 28 knees (39%) had associated osteochondral fractures. These fractures comprised 15 capsular avulsions of the medial patellar margin and 15 loose intra-articular fragments detached from the patella and/or lateral femoral condyle. The intra-articular fragments were found only after spontaneous relocation of the patella. The femoral fracture constantly involved the edge of the articular surface in the middle third of the condylar arc.

Acute Patellar Dislocation in Children and Adolescents: A Randomized Clinical Trial

BACKGROUND The treatment of acute patellar dislocation in children is controversial. Some investigators have advocated early repair of the medial structures, whereas others have treated this injury nonoperatively. The present report describes the long-term subjective and functional results of a randomized controlled trial of nonoperative and operative treatment of primary acute patellar dislocation in children less than sixteen years of age. METHODS The data were gathered prospectively on a cohort of seventy-four acute patellar dislocations in seventy-one patients (fifty-one girls and twenty boys) younger than sixteen years of age. Sixty-two patients (sixty-four knees) without large (>15 mm) intra-articular fragments were randomized to nonoperative treatment (twenty-eight knees) or operative treatment (thirty-six knees). Operative treatment consisted of direct repair of the damaged medial structures if the patella was dislocatable with the patient under anesthesia (twenty-nine knees) or lateral release alone if the patella was not dislocatable with the patient under anesthesia (seven knees). All but four patients who underwent operative treatment had a concomitant lateral release. The rehabilitation protocol was the same for both groups. The patients were seen at two years, and a telephone interview was conducted at a mean of six years and again at a mean of fourteen years. Fifty-eight patients (sixty-four knees; 94%) were reviewed at the time of the most recent follow-up. RESULTS At the time of the most recent follow-up, the subjective result was either good or excellent for 75% (twenty-one) of twenty-eight nonoperatively treated knees and 66% (twenty-one) of thirty-two operatively treated knees. The rates of recurrent dislocation in the two treatment groups were 71% (twenty of twenty-eight) and 67% (twenty-four of thirty-six), respectively. The first redislocation occurred within two years after the primary injury in twenty-three (52%) of the forty-four knees with recurrent dislocation. Instability of the contralateral patella was noted in thirty (48%) of the sixty-two patients. The only significant predictor for recurrence was a positive family history of patellar instability. The mode of treatment and the existence of osteochondral fractures had no clinical or significant influence on the subjective outcome, recurrent patellofemoral instability, function, or activity scores. CONCLUSIONS The long-term subjective and functional results after acute patellar dislocation are satisfactory in most patients. Initial operative repair of the medial structures combined with lateral release did not improve the long-term outcome, despite the very high rate of recurrent instability. A positive family history is a risk factor for recurrence and for contralateral patellofemoral instability. Routine repair of the torn medial stabilizing soft tissues is not advocated for the treatment of acute patellar dislocation in children and adolescents.

Operative treatment of primary patellar dislocation does not improve medium-term outcome : A 7-year follow-up report and risk analysis of 127 randomized patients

Background The best treatment for primary patellar dislocation has been the subject of debate. Surgery has been recommended for all patients or for special subgroups to improve outcome. We have previously reported similar 2-year results after closed or open treatment. This report concerns 127 patients who were re-evaluated by questionnaire at least 5 years after the primary onset. Patients and methods At baseline, the patients were randomized regarding closed treatment (57) or individually adjusted proximal realignment operation (70). All patients were re-evaluated after a mean follow-up of 7 (6-9) years. Results The outcomes were similar: the patients own overall opinion was excellent or good after closed treatment in 81% of cases and after operative treatment in 67%. Mean Kujala and Hughston VAS knee scores were 90 and 94, respectively, after closed treatment and 88 and 89 after operative treatment. The proportions of stable patellae were 30% and 36% for closed treatment and operative treatment, respectively. In a multivariate risk analysis, there was a correlation between a Kujala score of less than 90 and female sex (OR: 3.5; 95% CI: 1.4-9.0), loose bodies on radiographs (4.1; 1.2-15), and also an initial history of contralateral patellar instability (3.6; 0.9-15). There were 2 risk factors for recurrent instability: initial contralateral instability (4.9; 0.9-28) and young age (0.9; 0.8-1.0/year). Girls with open tibial apophysis had the worst prognosis for instability (88%; 95% CI: 77-98). Interpretation We do not recommend proximal realignment surgery for treatment of primary dislocation of the patella.

Operative versus closed treatment of primary dislocation of the patella Similar 2-year results in 125 randomized patients

To assess whether initial surgery is beneficial for patients with primary dislocation of the patella, we carried out a prospective randomized study. Knee stability was examined under anesthesia, and associated injuries were excluded by diagnostic arthroscopy. 55 patients then had closed treatment and 70 patients were operated on with individually adjusted proximal realignment procedures. Surgery gave no benefit based on 2 years of follow-up. The subjective result was better in the non-operative group in respect of mean Houghston VAS knee score (closed 90, operative 87), but similar in terms of the patients own overall opinion and mean Lysholm II knee score. Recurrent instability episodes (redislocation or recurrent subluxation) occurred in 20 nonoperated and in 18 operated patients. Of these, 15 and 12, respectively, then suffered redislocations. Function was better after closed treatment. Serious complications occurred after surgery in 4 patients. In conclusion, the recurrence of patellar dislocation may be more frequent than reported, whatever the form of treatment. Routine operative management cannot be recommended for primary dislocation of the patella.

Short- versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive cases.

Background: Considerable uncertainty exists on the optimal duration of antimicrobials for acute hematogenous osteomyelitis (AHOM) in children. Often they are administered for 1 to 2 months, the first 1 to 2 weeks intravenously, and decompressive surgery is usually added. No prospective, randomized, sufficiently powered comparative trial has been available. Methods: Children aged 3 months to 15 years with culture-positive AHOM were randomly assigned to receive clindamycin or a first-generation cephalosporin for 20 or 30 days, including an intravenous phase for the first 2 to 4 days. Surgery was kept at minimum. Illness was monitored with preset criteria. Antimicrobial was discontinued once most signs had subsided and serum C-reactive protein decreased ≤20 mg/L. The primary end point was full recovery without need for further antimicrobial therapy because of an osteoarticular indication during the 12 months after the primary therapy. Results: Of the 131 cases, 18% also involved the adjacent joint. Staphylococcus aureus caused 89% of cases, and all strains were methicillin susceptible. The median duration of treatment was 20 days for 67 children, and 30 days for 64 children. Most children underwent only the diagnostic percutaneous aspiration or drilling, and 24% had no surgery. Except for 1 mild sequela in both treatment groups, all patients recovered entirely. Conclusions: Most cases of childhood AHOM can be treated for 20 days, including a short period intravenously, with large doses of a well-absorbed antimicrobial such as clindamycin or a first-generation cephalosporin, provided the clinical response is good and C-reactive protein normalizes within 7 to 10 days. Extensive surgery is rarely needed.

Prospective, Randomized Trial of 10 Days versus 30 Days of Antimicrobial Treatment, Including a Short-Term Course of Parenteral Therapy, for Childhood Septic Arthritis

BACKGROUND The standard treatment for septic arthritis in children is antimicrobials for several weeks (initially administered intravenously) and arthrotomy (at least for the hip and shoulder joints). No sufficiently powered study has examined the true need for these treatments. METHODS In a randomized, multicenter prospective trial in Finland, children aged 3 months to 15 years who had culture-positive septic arthritis were randomized to receive clindamycin or a first-generation cephalosporin for 10 days or 30 days (intravenously for the first 2-4 days). The number of surgical procedures was kept to a minimum. Illness was monitored with preset criteria. Antimicrobial therapy was discontinued when the clinical response was good and the C-reactive protein level decreased to 20 mg/L. The primary end point was full recovery without need for further administration of antimicrobial therapy because of an osteoarticular indication during the 12 months after therapy. RESULTS Of the total 130 cases, 88% were caused by Staphylococcus aureus, Haemophilus influenzae, or Streptococcus pyogenes; 63 patients were in the short-term treatment group, and 67 were in the long-term treatment group. The median durations of antimicrobial treatment were 10 days and 30 days, respectively. Surgical procedures that were more extensive than percutaneous joint aspiration were performed for 12% of patients, with no preponderance to hip or shoulder arthritis. Two late-onset infections occurred in 1 child in the long-term treatment group; however, all patients recovered without sequelae. CONCLUSIONS Large doses of well-absorbed antimicrobials for <2 weeks (initially administered intravenously) and only 1 joint aspiration are sufficient for treatment of most cases of childhood septic arthritis, regardless of the infecting pathogen or anatomical site, if the clinical response is good and the C-reactive protein level normalizes shortly after initiation of treatment.

Decreasing incidence and changing pattern of childhood fractures: A population-based study†

Fractures are common in children, and some studies suggest an increasing incidence. Data on population‐based long‐term trends are scarce. In order to establish fracture incidence and epidemiologic patterns, we carried out a population‐based study in Helsinki, Finland. All fractures in children aged 0 to 15 years were recorded from public health care institutions during a 12‐month period in 2005. Details regarding patient demographics, fracture site, and trauma mechanism were collected. All fractures were confirmed from radiographs. Similar data from 1967, 1978, and 1983 were used for comparison. In 2005, altogether 1396 fractures were recorded, 63% in boys. The overall fracture incidence was 163 per 10,000. Causative injuries consisted of mainly falls when running or walking or from heights less than 1.5 m. Fracture incidence peaked at 10 years in girls and 14 years in boys. An increase in fracture incidence was seen from 1967 to 1983 (24%, p < .0001), but a significant decrease (18%, p < .0001) was seen from 1983 to 2005. This reduction was largest in children between the ages of 10 and 13 years. Despite the overall decrease and marked decrease in hand (−39%, p < .0001) and foot (−48%, p < .0001) fractures, the incidence of forearm and upper arm fractures increased significantly by 31% (p < .0001) and 39% (p = .021), respectively. Based on these findings, the overall incidence of childhood fractures has decreased significantly during the last two decades. Concurrently, the incidence of forearm and upper arm fractures has increased by one‐third. The reasons for these epidemiologic changes remain to be elucidated in future studies.

Use of anesthesia induction rooms can increase the number of urgent orthopedic cases completed within 7 hours

Background:Mean turnover times and the time spent in the operating room (OR) can be reduced by concurrent induction of anesthesia. Previous studies of anesthesia induction outside the OR have concentrated either on anesthesia-controlled time or turnover time. The goal of this study was to investigate the impact of an induction room model on the whole surgical process, its phases and delays between the phases, and the number of cases performed during the 7-h working day. Methods:A prospective analysis of OR times was conducted for 5 weeks with the traditional induction-in-the-OR model followed by 4 weeks with a new model: A team of two nurses and one anesthesiologist was added to one OR to perform parallel anesthesia induction in a separate induction room. The durations of phases of surgical process, number of completed cases between 7:45 am and 3:00 pm, and daily raw utilization of the OR were assessed. Results were compared to those measured before the intervention. Results:The mean nonoperative time was reduced by 45.6%, whereas surgery time remained unchanged. The time savings contributed to the concurrent anesthesia induction and the cut down in delays between the phases. The new model allowed one additional case to be performed during the 7-h working day. Conclusions:Anesthesia induction outside the OR can increase the number of surgical cases performed during a regular workday.

Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood-a prospective quasi-randomized controlled trial

No sufficiently powered trial has examined two antimicrobials in acute osteoarticular infections of childhood. We conducted a prospective, multicentre, quasi-randomized trial in Finland, comparing clindamycin with first-generation cephalosporins. The age of patients ranged between 3 months and 15 years, and all cases were culture-positive. We assigned antibiotic treatment intravenously for the first 2-4 days, and continued oral treatment with clindamycin 40 mg/kg/24 h or first-generation cephalosporin 150 mg/kg/24 h in four doses. Surgery was kept to a minimum. Subsiding symptoms and signs and normalization of C-reactive protein (CRP) level were preconditions for the discontinuation of antimicrobials. The main outcome was full recovery without further antimicrobials because of an osteoarticular indication during 12 months after therapy. The intention-to-treat analysis comprised 252 children, 169 of whom were analysed per-protocol: 82 cases of osteomyelitis, 80 of septic arthritis, and seven of osteomyelitis-arthritis. Staphylococcus aureus strains (all methicillin-sensitive) caused 84% of the cases. Except for one non-serious sequela during convalescence in both groups, and two late infections caused by dissimilar agents in one child, all patients recovered. The entire courses (medians) of clindamycin and cephalosporin lasted for 23 and 24 days, respectively. CRP normalized in both groups in 9 days. The patients were discharged, on average, on day 10. Loose stools were reported less often (1%) in the clindamycin group than in the cephalosporin group (7%), but two clindamycin recipients developed rash. Clindamycin or a first-generation cephalosporin, administered mostly orally, perform equally well in childhood osteoarticular infections, provided that high doses and administration four times daily are used. As most methicillin-resistant staphylococci remain clindamycin-sensitive, clindamycin remains an option instead of costly alternatives.

Managing urgent surgery as a process: Case study of a trauma center

OBJECTIVES Industrial management principles could be used to improve the quality and efficiency of health care. In this study, we have evaluated the effects of a process management approach to trauma patient care. The major objective was to reduce the waiting times and increase the efficiency of the hospital. METHODS Urgent surgery care was analyzed as an overall process. The process development followed the Plan-Do-Check-Act (PDCA) cycle and was based on statistical analysis of certain performance metrics. Data were collected from hospital databases and by personnel interviews. To develop the process, the anesthesia induction was performed outside the operating room, better process guidance was developed, and patient flow was reorganized. The transition time for these changes was 1 year (2002 to 2003). RESULTS Waiting times decreased by 20.5 percent (p < .05), nonoperative times in the operating room were reduced by 23.1 percent (p < .001), and efficiency was increased by 9.7 percent (p < .001) after reengineering of the care process. Overtime hours decreased by 30.9 percent. CONCLUSIONS Managing urgent surgical care as a process can improve the productivity and quality of care without a need to increase personnel resources. The focus should be on reducing waiting times and waste times.