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Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Volume 4 | Issue 2 | July-December 2018 | Page: 03-10 | Petnikota Harish DOI- 10.13107/ijpo.2018.v04i02.011 Authors: Petnikota Harish Vasudev Children’s Orthopaedics Centre, Bellary, Karnataka, India Address of Correspondence Dr. Petnikota Harish, ‘Vasudev’, Opp. Shanti Sishu Vihar School, Talur Road, Bellary – 583 103, Karnataka, India. E-mail: harishportho@gmail.com Abstract Context: Early surgical intervention is the […]

Stop Maligning the Asymptomatic Child’s Flatfoot

Volume 4 | Issue 2 | July-December 2018 | Page: 01-02 | Benjamin Joseph DOI- 10.13107/ijpo.2018.v04i02.010 Authors: Benjamin Joseph Aster Medcity, Kochi, Kerala, India Address of Correspondence Prof. Benjamin Joseph, 18 H.I.G. Colony, Manipal − 576 104, Karnataka, India E-mail: bjosephortho@yahoo.co.in Recently, a lady met me and gave me some very colourful pamphlets about a […]

Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Stop Maligning the Asymptomatic Child’s Flatfoot

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Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Volume 4 | Issue 2 | July-December 2018 | Page: 03-10 | Petnikota Harish

DOI- 10.13107/ijpo.2018.v04i02.011

Authors: Petnikota Harish

Vasudev Children’s Orthopaedics Centre, Bellary, Karnataka, India

Address of Correspondence
Dr. Petnikota Harish,
‘Vasudev’, Opp. Shanti Sishu Vihar School, Talur Road, Bellary – 583 103, Karnataka, India.
E-mail: harishportho@gmail.com

Abstract

Context: Early surgical intervention is the key for good outcome in children with acute haematogenous osteomyelitis (AHO) or septic arthritis. Often there is an impasse to observe or intervene early when the diagnosis is inconclusive due to blunted clinical findings and equivocal investigations. Aim: This study is aimed at justifying early surgical intervention in these doubtful/suspected cases. Settings and
Design: This study was a retrospective review of AHO/septic arthritis treated by the author between August 2010 and January 2015. A new scoring system, haematogenous osteomyelitis and septic arthritis (HOMSA) score was developed to aid in classifying and decision-making. With a maximum score of 8, a score >6 in the absence of infection elsewhere or a score <6 with radiological evidence makes the diagnosis of AHO/septic arthritis definite. A score 6 without radiological evidence makes the diagnosis suspected/doubtful. Outcome was measured by a new discrete criterion for the upper and lower limbs.
Materials and Methods: The protocol was early surgical intervention in both the groups. In septic arthritis, open arthrotomy along with joint lavage and debridement was performed. In AHO, bone decompression with abscess drainage was performed. Initial parenteral administration of antibiotics was followed by oral antibiotic administration. Necessary adjuvant treatment was given.
Results: Thirty-four children with 40 sites of infection were identified. Among them, 50% were neonates. Only 4/40 children were treated conservatively. Following surgery, outcome was excellent-to-good in 92.8% of the children with doubtful/suspected diagnosis and 96.6% with definite infection. One child in each group who were treated surgically, and two children in the group with definite infection treated non-operatively had fair-to-poor outcomes. Conclusion: Early surgical intervention is justified even in children with a doubtful/suspected diagnosis of AHO or Septic Arthritis. The new scoring system, HOMSA Score, is a better tool to diagnose Acute septic arthritis or osteomyelitis, even with limited resources.
Keywords: Acute haematogenous osteomyelitis, Early surgery, Infants and children, Neonates, New outcome, Measure, New scoring system, Septic arthritis

References

1. Kuong EE, To M, Yuen MH, Choi AK, Fong CM, Chow W. Pitfalls in diagnosing septic arthritis in Hong Kong children: Ten years experience. Hong Kong Med J 2012;18:482-7.
2. Stans AA. Musculoskeletal infection. In: Weinstein SL, Flynn JM, editors. Lovell and Winter’s Paediatric Orthopaedics. 7th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer 2014. p. 369–425.
3. Herring JA, editor. Infections of the musculoskeletal system. Tachdjian’s Paediatric Orthopaedics. 4th ed. Philadelphia: Saunders Elsevier 2008. p. 2089-155.
4. Bennet OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop Relat Res 1992; 281: 123-32.
5. Chen CE, Ko JY, Li CC, Wang CJ. Acute septic arthritis of the hip in children. Arch Orthop Trauma Surg 2001;121:521.
6. Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, et al. A clinical practice guideline for treatment of septic arthritis in children. J Bone Joint Surg Am 2003;85:994-9.
7. Lyon RM, Evanich JD. Culture-negative septic arthritis in children. J Pediatr Orthop 1999;19:655.
8. Morrey BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in children. Orthop Clin N Am 1975;6:923-34.
9. Cole WG, Dalziel RE, Leitl S. Treatment of acute osteomyelitis in childhood. Bone Joint J 1982;64:218-23.
10. Wang CL, Wang SM, Yand YJ, Tsai CH, Liu CC. Septic arthritis in children: Relationship of causative pathogens, complications and outcomes. J Microbial Immunol Infect 2003;36:41-6.
11. Scoor RJ, Christofersen MR, Roberson WW Jr, Davidson RS, Rankin L, Drummond DS. Acute osteomyelitis in children: A review of 116 cases. J Pediatr Orthop 1990;10:649-52.
12. Klein DM, Barbera C, Gray ST, Spero CR, Perrier G, Teicher JL. Sensitivity of objective parameters in the diagnosis of paediatric septic hips. Clin Orthop Relat Res 1997;338:153-9.
13. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: An evidencebased clinical prediction algorithm. J Bone Joint Surg Am 1999;81: 1662-70.
14. Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg 2004;86:956-62.
15. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg 2004;86:1629-35.
16. Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. J Bone Joint Surg Am 2006;88:1251-7.
17. Bonheffer J, Haeberle B, Schaad UB, Heininger U. Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children’s Hospital Basel. Swiss MedWkly 2001;131:575-81.
18. Peltola H, Vahvanen V, Aalto K. Fever, C-reactive protein, and erythrocyte sedimentation rate in monitoring recovery from septic arthritis: A preliminary study. J Pediatr Orthop 1984;4:170-4.
19. Morrey BF, Peterson HS. Hematrogenous pyogenic osteomyelitis in children. Orthop Clin North Am 1976;6:935-51.
20. Segbefia M, Howard A. Acute Septic Arthritis and Osteomyelitis in Children − An African Perspective; 2013. Available from:
http:// ptolemy.library.utoronto.ca/sites/default/files/review/2010/February- Acuteseptic Arthritis and Osteomyelitis.pdf. [Last accessed on 2015 Apr].
21. Smith RL, Schurman DJ, Kajiyama G, Mell M, Gilkerson E. The effect of antibiotics on the destruction of cartilage in experimental infectious arthritis. J Bone Joint Surg Am 1987;69:1063-8.
22. Nunn TR, Cheung WY, Rollinson PD. A prospective study of pyogenic sepsis of the hip in childhood. J Bone Joint Surg Br 2007;89:100-6.
23. Welcon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: A review of 95 cases. Pediatr Infect Dis 1986;5: 669-76.

How to Cite this Article: Harish P Early Surgical Intervention | in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified? | July-December 2018; 4(2): 03-10.

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Stop Maligning the Asymptomatic Child’s Flatfoot

Volume 4 | Issue 2 | July-December 2018 | Page: 01-02 | Benjamin Joseph

DOI- 10.13107/ijpo.2018.v04i02.010

Authors: Benjamin Joseph

Aster Medcity, Kochi, Kerala, India

Address of Correspondence
Prof. Benjamin Joseph,
18 H.I.G. Colony, Manipal − 576 104, Karnataka, India
E-mail: bjosephortho@yahoo.co.in

Recently, a lady met me and gave me some very colourful pamphlets about a range of fancy foot wear and shoe inserts for toddlers and young children designed to ’correct’ flatfeet. I asked her why asymptomatic flatfeet need to be treated. I patiently listened to her as she listed several ‘harmful effects of flatfeet’ including a predilection for foot injury, back ache and so on, which, according to her could be avoided by using the shoes and shoe inserts she was promoting. Needless to say, there were no scientific data to support these claims. After she left, I reflected about what the scientific literature had to say about flatfoot and also recollected my personal experience of dealing with flatfeet in young children in my practice.
There has been a long-held notion that flatfeet are bad and that they may interfere with strenuous physical activity. On the basis of this, young men with flatfeet were rejected from recruitment into the armed forces. However, Cowan et al.[1] did a study on army recruits in the USA and could not demonstrate a higher frequency of injuries in those with flatfeet. Esterman and Pilotto[2] did a similar study in Australia and concluded that ’foot shape has little impact on pain, injury and function’. Tudor et al.[3] studied athletic performance in school children with flatfoot and normal arches and documented no difference in performance in 17 different tasks. So it is high time we dispel the erroneous notion that the flatfoot is in some way inferior to feet with a well-formed arch.
Stemming from the belief that flatfoot is undesirable, concerted efforts have been made to ‘treat’ young children with shoe modifications and various types of shoe inserts that elevate the medial longitudinal arch or control the hindfoot valgus. Despite the fact that Wenger et al.,[4] in as early as 1989, demonstrated clearly that shoes and shoe inserts in no way alter the natural history of flatfoot, orthopaedic surgeons continue to prescribe them. This wasteful and meaningless practice needs to stop.
The natural history of asymptomatic flexible flatfoot is that of resolution in the vast majority of children because the arch develops by the age of 6–7 years. This is very evident as at 1 year of age, 95% of children have flatfeet and by the age of 10, the prevalence is as low as 5%. The increase in the tone of muscles that support the arch and spontaneous reduction in joint laxity as the child grows facilitate the arch to develop. Barefoot activity in early childhood also facilitates the arch to develop while shoe-wearing appears to be detrimental to the development of the arch. This was demonstrated in two large cross-sectional surveys, which showed that the prevalence of flatfoot was highest among children who wore closed-toe shoes below the age of 6 years and lowest in the unshod.[5,6] The frequency of flatfoot in children who wore sandals and slippers fell between these two. With this evidence, it seems hardly logical to prescribe shoes for a young child with flatfoot. Instead, we need to spread the message to encourage children to play barefoot outdoors on sand and gravel. We could also encourage school authorities to have sandals rather than shoes as the regulation footwear. These suggestions are perfectly appropriate in the warm climate in India.
In my practice, I have never had parents from the lower socio-economic strata bring a child for the treatment of flatfoot. Every single child brought to me with the complaints of flatfoot has been from an affluent family. Often it has been a paediatrician, or family physician, who referred the child with flatfoot to me. For a long time, I wondered why there was this socio-economic difference in my flatfoot practice. It then dawned on me; the poor child is unshod and in early childhood has played barefoot, and the poor child consequently is unlikely to have flatfoot. Even if the poor child has flatfeet, they cause no pain and the feet function perfectly well. The child’s parents have no access to the internet, so they have never heard anyone maligning their child’s feet. No wonder, I never saw a poor child with flatfoot in my clinic.

Benjamin Joseph
Aster Medcity, Kochi, Kerala, India

References

1. Cowan DN, Jones BH, Robinson JR. Foot morphologic characteristics and risk of exercise-related injury. Arch Fam Med 1993;2: 773-7.
2. Esterman A, Pilotto L. Foot shape and its effect on functioning in Royal Australian Air Force recruits. Part 1: Prospective cohort study. Mil Med 2005;170:623-8.
3. Tudor A, Ruzic L, Sestan B, Sirola L, Prpic T. Flat-footedness is not a disadvantage for athletic performance in children aged 11 to 15 years. Pediatrics 2009;123:e386-92.
4. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am 1989;71:800-10.
5. Rao UB, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br 1992;74:525-7.
6. Sachithanandam V, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 1846 skeletally mature persons. J Bone Joint Surg Br 1995;77:254-7.

How to Cite this Article: Joseph B Stop Maligning the | Asymptomatic Child’s Flatfoot | July- December 2018; 4(2): 01-02.

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Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Stop Maligning the Asymptomatic Child’s Flatfoot

Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Stop Maligning the Asymptomatic Child’s Flatfoot

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Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Authors: Petnikota Harish

Abstract

References

(Article Text HTML) (Download PDF)

Stop Maligning the Asymptomatic Child’s Flatfoot

Authors: Benjamin Joseph

References

(Article Text HTML) (Download PDF)

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