S Dix-Peek

Tuberculosis of the elbow in children

Ten children with tuberculosis of the elbow treated over a 21-year period from 1979 to 1999 were reviewed retrospectively. At presentation, they had pain and swelling of the joint mainly due to synovitis, and the median symptom duration was 10 weeks. All had a decreased range of movement. All were treated with 9 months of antituberculous chemotherapy without synovectomy. The radiologic stage at presentation, rather than duration of symptoms, predicted outcome. Of the 9 patients with stage 1 or 2 disease (synovitis), 8 had an excellent or good outcome. One stage 2 patient had a posterior dislocation of the radial head and had a fair outcome. The one stage 3 (arthritic) patient had a poor outcome.

Diagnostic Accuracy of the Xpert MTB/RIF Assay for Extrapulmonary Tuberculosis in Children With Musculoskeletal Infections.

Background: Xpert MTB/RIF (Xpert) is useful for the diagnosis of extrapulmonary tuberculosis (TB) in adults, but there is limited evidence on its usefulness in children. We aimed to investigate the accuracy of Xpert for the diagnosis of extrapulmonary TB in children with musculoskeletal infections. Methods: The diagnostic accuracy of Xpert was compared with a reference standard of culture or histopathology in children hospitalized with suspected osteoarticular TB in Cape Town, South Africa from June 2013 to May 2015. Results: One hundred and nine samples of 102 patients (60 male; 58.8%) with a median age of 5.6 years (interquartile range: 2.2–8.7) were included. There were 23 samples with confirmed TB by culture or histology (21.1%); histology was positive in all of these, while culture was positive in 14 samples (12.8%). Xpert was positive in 17 samples (15.6%), providing a sensitivity of 73.9% (95% confidence interval: 51.6–89.8) and specificity of 100% (95% confidence interval: 95.7–100). Xpert was positive at a mean of 0.8 days (0.46–1.4) compared with 21 days (19–30) for culture, P < 0.001. Multidrug-resistant TB was detected on culture in a single sample that was negative on Xpert testing. Conclusions: Xpert confirmed extrapulmonary TB of bone and joints more accurately and faster than culture and should be used as a first-line test. Histology remains a useful test for musculoskeletal TB in children.

Epidemiology of Musculoskeletal Tuberculosis in an Area with High Disease Prevalence

Study Design Retrospective observational study. Purpose The aim of this study was to assess the distribution of age and site of infection in patients with musculoskeletal tuberculosis (TB) and determine the number of TB/human immunodeficiency virus (HIV) coinfections as well as the incidence of multidrugresistant (MDR) TB. Overview of Literature Of all TB cases, 1%–3% show skeletal system involvement and 30% are HIV coinfected. Although the reported distribution of skeletal TB is majorly in the spine, followed by the hip, knee, and foot/ankle, the epidemiology of extrapulmonary TB and especially musculoskeletal TB remains largely unknown, particularly in areas with a high prevalence of the disease. Methods This is a retrospective study of a consecutive series of patients admitted to a tertiary care facility in an area with the highest prevalence of TB worldwide. TB was confirmed on tissue biopsy with polymerase chain reaction testing (Xpert for Mycobacterium tuberculosis and rifampicin resistance), culturing, or histological analysis. Data were analyzed regarding demographic information, location of the disease, HIV coinfections, and drug resistance. Results In all, 125 patients (44 children; 35%) with a mean age of 27 years (range, 1–78 years) were included. Age peaks were observed at 5, 25, and 65 years. Spinal disease was evident in 98 patients (78%). There were 66 HIV-negative (53%) and 29 (23%) HIVpositive patients, and in 30 (24%), the HIV status was unknown. Five patients (4%) showed MDR TB. Conclusions The age distribution was trimodal, spinal disease was predominant, MDR TB rate in our cohort was high, and a large portion of TB patients in our hospital were HIV coinfected. Hence, spinal services with sufficient access to operating facilities are required for tertiary care facilities in areas with a high TB prevalence.

Spina bifida: a multidisciplinary perspective on a many-faceted condition.

Open spina bifida or myelomeningocele (SBM) is the most common birth defect involving the central nervous system, second only in incidence to congenital cardiac disease. Outcomes in this disorder were poor until the mid-20th century, when modern neurosurgical techniques (closing the lesion and treating hydrocephalus) and treatment for the neuropathic bladder addressed the major causes of mortality, although SBM may still be poorly treated in the developing world. Initial management - or mismanagement - has a profound impact on survival and long-term quality of life.

Pre-peritoneal pelvic packing in a paediatric unstable pelvic fracture: An undescribed complication of lower limb compartment syndrome

Pre-peritoneal pelvic packing for haemodynamic instability following unstable pelvic fracture has recently been added to the trauma surgeon’s armamentarium, as a means of controlling venous and bone haemorrhage. We present a child who underwent this procedure as a lifesaving measure in a level 2 hospital prior to transfer to a tertiary setting. We review the background of the technique and highlight potential complications and poor outcomes in the paediatric patient if incorrect technique is used.

French Osteotomy for Cubitus Varus in Children: A Long-term Study Over 27 Years.

Background: Cubitus varus is a cosmetically unacceptable complication of supracondylar fractures of the elbow in children. We have performed the lateral closing wedge (French) osteotomy to correct the varus for 27 years. More complex osteotomies have been described to correct the associated hyperextension and internal rotation deformities and to prevent a prominent lateral condyle. Methods: We retrospectively reviewed 90 consecutive patients (1986 to 2012). The mean age of the patients at surgery was 8.2 years (3 to14 y). The varus angle (mean, 21.4 degrees; range, 8 to 40 degrees) was assessed preoperatively with the humero-elbow-wrist angle. The postoperative carrying angle (mean, 10.4 degrees) and the preoperative and postoperative range of movement were assessed clinically. The lateral condylar prominence index (LCPI) was retrospectively measured at union. Results: Eighty-four (93.3%) of the patients had a good or excellent result. Six (6.7%) had a poor result (residual varus, loss of >20 degrees of preoperative range of flexion or extension or a complication necessitating resurgery). There were no neurovascular complications. The mean LCPI was +0.14. Conclusions: The results of the French osteotomy are comparable with the more technically demanding dome, step-cut translation, and multiplanar osteotomies, with a lower complication rate. The literature reports adequate remodeling of the hyperextension deformity (⩽10 y) and the LCPI (⩽12 y), and that the internal rotation deformity is well tolerated by the patient. Level of Evidence: Level IV—case series.

The orthopaedic management of myelomeningocele

Despite improvement in antenatal care and screening, myelomeningocele remains the most common congenital birth defect, with a reported incidence of 1 - 2.5/1000 patients in the Western Cape, South Africa. The multidisciplinary team involved in the Spinal Defects Clinic at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa consists of neurosurgeons, urologists, orthopaedic surgeons, stomatherapists and orthotists. Orthopaedic surgeons have a protean involvement in the management of myelomeningocele.