Despite advances in understanding and management, paediatric osteoarticular infections continue to pose diagnostic difficulties for clinicians. Delays in diagnosis can lead to potentially devastating morbidity.
No single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively paediatric bone and joint infection. Diagnosis should be based on a combination of clinical signs, imaging and laboratory investigations. Algorithms should supplement, and not replace, clinical decision making in all cases.
The roles of aspiration, arthrotomy and arthroscopy in the treatment of septic arthritis are not clearly defined. There is a very limited role for surgery in the management of acute haematogenous osteomyelitis.
The ideal duration and mode of administration of antibiotic therapy for osteoarticular paediatric infection is not yet fully defined but there is increasing evidence that shorter courses (three weeks) and early conversion (day four) to oral administration is safe and effective in appropriate cases. Clear and concise antibiotic guidelines should be available based on local population characteristics, pathogens and their sensitivities.
Kingella kingae is increasingly identified through polymerase chain reaction and is now recognised as the commonest pathogen in children aged under four years. Methicillin-resistant Staphylococcus aureus and Panton-Valentine leukocidin-producing strains of Staph. aureus are being increasingly reported.
A multidisciplinary integrated evidence-based approach is required to optimise outcomes.
Further large-scale, multicentre studies are needed to delineate the optimal management of paediatric osteoarticular infection.
Cite this article: EFORT Open Rev 2017;1:7-12. DOI: 10.1302/2058-5241.2.160027.
Cerebral palsy (CP) children present complex and heterogeneous motor disorders that cause gait deviations.
Clinical gait analysis (CGA) is needed to identify, understand and support the management of gait deviations in CP. CGA assesses a large amount of quantitative data concerning patients’ gait characteristics, such as video, kinematics, kinetics, electromyography and plantar pressure data.
Common gait deviations in CP can be grouped into the gait patterns of spastic hemiplegia (drop foot, equinus with different knee positions) and spastic diplegia (true equinus, jump, apparent equinus and crouch) to facilitate communication. However, gait deviations in CP tend to be a continuum of deviations rather than well delineated groups. To interpret CGA, it is necessary to link gait deviations to clinical impairments and to distinguish primary gait deviations from compensatory strategies.
CGA does not tell us how to treat a CP patient, but can provide objective identification of gait deviations and further the understanding of gait deviations. Numerous treatment options are available to manage gait deviations in CP. Generally, treatments strive to limit secondary deformations, re-establish the lever arm function and preserve muscle strength.
Additional roles of CGA are to better understand the effects of treatments on gait deviations.
Cite this article: Armand S, Decoulon G, Bonnefoy-Mazure A. Gait analysis in children with cerebral palsy. EFORT Open Rev 2016;1:448-460. DOI: 10.1302/2058-5241.1.000052.
Patellar instabilities are the most common knee pathologies during growth. Congenital dislocations are rare. Extensive, early soft tissue releases relocate the extensor mechanism and may enable normal development of the femoro-patellar anatomy.
Conservative management is the preferred strategy after a ‘first-time’ traumatic dislocation. In cases with concomitant anatomical predisposing factors such as trochlear dysplasia, malalignment, malrotation or ligamentous laxity, surgical reconstruction must be considered. The same applies to recurrent dislocations with pain, a sense of instability or re-dislocations which may also lead to functional compensatory mechanisms (quadriceps-avoiding gait in knee extension) or cartilaginous lesions with subsequent patello-femoral osteoarthritis. The decision-making process guiding surgical re-alignment includes analysis with standard radiographs and MRI of the trochlear groove, joint cartilage and medial patello-femoral ligament (MPFL). Careful evaluation of dynamic and static stabilisers is essential: the medial patello-femoral ligament provides stability during the first 20° of flexion, and the trochlear groove thereafter.
Excessive femoral anteversion, general ligamentous laxity with increased femoro-tibial rotation, patella alta and increased distance between the tibial tuberosity and the trochlear groove must also be taken into account and surgically corrected.
In cases with ongoing dislocations during skeletal immaturity, soft tissue procedures must suffice: reconstruction of the medial patello-femoral ligament as a standalone procedure or in conjuction with more complex distal realignment of the quadriceps mechanism may lead to a permanent stable result, or at least buys time until a definitive bony procedure is performed.
Cite this article: Hasler CC, Studer D. Patella instability in children and adolescents. EFORT Open Rev 2016;1:160-166. DOI: 10.1302/2058-5241.1.000018.
Computer-assisted orthopaedic surgery was born in the 1990s. Nowadays, computer-assisted orthopaedic surgery is used for transpedicular screw fixation and for total knee arthroplasty.
Patient-specific instrumentation is one type of computer-assisted surgery based on volumetric images, such as computed tomography or magnetic resonance imaging.
In this article, possible applications of patient-specific instruments in paediatric orthopaedics are described. The use of patient-specific instrumentation for the correction of cubitus varus is given as an example with complex osteotomy. Another application for tarsal coalition resection is shown.
A last example of using patient-specific instrumentation for both tumour resection and allograft reconstruction is illustrated.
Patient-specific instruments based on computed tomography of the bone can increase peri-operative accuracy and decrease operative time. They are very helpful for the surgeon. Other applications are possible and will be probably developed in the future.
Cite this article: Docquier PL, Paul L, TranDuy V. Surgical navigation in paediatric orthopaedics. EFORT Open Rev 2016;1:152-159. DOI: 10.1302/2058-5241.1.000009.