Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up

PURPOSE

In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee.

TYPE OF STUDY

A case series of patients with 7 to 17 years' follow-up.

METHODS

Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively.

RESULTS

The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement.

CONCLUSIONS

Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.

Osteopetrosis

Osteopetrosis is a rare skeletal condition characterized by skeletal sclerosis caused by aberrant osteoclast-mediated bone resorption. Three clinically distinct forms of osteopetrosis are recognized--the infantile malignant autosomal recessive form, the intermediate autosomal recessive form, and the adult benign autosomal dominant form. The disease represents a spectrum of clinical variants because of the heterogeneity of genetic defects resulting in osteoclast dysfunction. The pathogenic defects may be intrinsic to either the osteoclast-monocyte lineage or the mesenchymal cells that constitute the microenvironment that supports osteoclast ontogeny and activation. Implicated factors include specific proto-oncogenes, growth factors, and immune regulators. A subset of patients with the intermediate autosomal recessive form has been characterized with carbonic anhydrase II isoenzyme deficiency. Management of patients with osteopetrosis requires a comprehensive approach to characteristic clinical problems including hematologic and metabolic abnormalities, fractures, deformity, back pain, bone pain, osteomyelitis, and neurologic sequelae. Medical treatment of osteopetrosis is based on efforts to stimulate host osteoclasts or provide an alternative source of osteoclasts. Stimulation of host osteoclasts has been attempted with calcium restriction, calcitrol, steroids, parathyroid hormone, and interferon. Bone marrow transplant has been used with cure for infantile malignant osteopetrosis. As osteopetrosis likely represents a spectrum of underlying etiologies resulting in osteoclast dysfunction, effective therapies most likely need to be individualized.

Tibial eminence fractures in children: prevalence of meniscal entrapment

BACKGROUND

Meniscal entrapment under a displaced tibial eminence fragment may be a rationale for arthroscopic or open reduction in type 2 and 3 tibial eminence fractures.

PURPOSE

To determine the prevalence of meniscal entrapment in children with type 2 and 3 tibial eminence fractures.

STUDY DESIGN

Case series.

METHODS

Records of a consecutive series of 80 skeletally immature patients (mean age, 11.6 years; range, 5 to 16) who underwent arthroscopic (71), open (5), or combined arthroscopic and open (4) reduction and internal fixation of type 3 tibial eminence fractures (57) or type 2 fractures that did not reduce in extension (23) from 1993 to 2001 were reviewed.

RESULTS

Entrapment of the anterior horn of the medial meniscus (36), intermeniscal ligament (6), or anterior horn of the lateral meniscus (1) was seen in 26% (6 of 23) of type 2 fractures and 65% (37 of 57) of type 3 fractures. An associated meniscal tear was seen in 3.8% of patients (3 of 80).

CONCLUSIONS

Meniscal entrapment is common in patients with type 2 and 3 tibial eminence fractures. Arthroscopic or open reduction should be considered for type 3 fractures and for type 2 fractures that do not reduce in extension to remove the incarcerated meniscus, allowing for anatomic reduction.

Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up

PURPOSE

In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee.

TYPE OF STUDY

A case series of patients with 7 to 17 years' follow-up.

METHODS

Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively.

RESULTS

The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement.

CONCLUSIONS

Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.

Little league elbow: valgus overload injury in the paediatric athlete

This article describes a variety of elbow injuries often seen in young, throwing athletes. Understandings of normal skeletal development, as well as the biomechanics of throwing, provide a basis on which to evaluate, diagnose and manage "little league elbow". With emphasis on an anatomically-based differential diagnosis, the pathologic forces placed upon the young thrower's elbow, and the subsequent injury patterns, are reviewed. Medial side injuries are the most common and relate to chronic forces of valgus overload produced during the early and late cocking phases of throwing. The majority of this force is placed on the medial epicondyle and produces age-dependent injury patterns, such as apophysitis in childhood and epicondylar avulsion fractures in the more mature athlete. With repetitive valgus overload, lateral side injuries such as Panner's disease and osteochondritis dissecans of the capitellum and radial head become more apparent. These injuries relate to the compressive forces produced by the late cocking and early acceleration phases of throwing. Finally, posterior injury patterns consistent with olecranon apophysitis and posteromedial impingement, as well as flexion and capsular contracture, can be seen. The key in the treatment of "little league elbow" is prevention and this responsibility lies not only with the evaluating or team physician, but also with the coach, trainer, parents and officials. Proper throwing mechanics must be emphasised at an early age, and the determinants of elbow injury among young pitchers better understood. Early recognition and proper treatment of such injuries will then prevent later sequelae or functional disability.

Effect of functional bracing on subsequent knee injury in ACL-deficient professional skiers

The effect of functional bracing on subsequent knee injury in anterior cruciate ligament (ACL) deficient professional skiers was evaluated. A cohort of 180 ACL-deficient skiers was identified from a knee screening of 9410 professional skiers from 1991-1997. An ACL-deficient knee was defined by an abnormal examination (Lachman or pivot-shift) and a > or = 5-mm KT-1000 manual maximum difference. The dependent variable was subsequent knee injury, which occurred in 12 knees. A significantly higher proportion of injuries occurred in nonbraced skiers compared with braced skiers (P = .005). The risk ratio for subsequent knee injury comparing nonbraced with braced skiers was 6.4 (13% and 2%, respectively). Univariate analysis revealed no significant effects of the other covariates. Logistic regression identified bracing status (P < .01; odds ratio = 8) and KT-1000 manual maximum difference (P = .02; odds ratio = 1.3) as significant multivariate risk factors for subsequent knee injury, controlling for covariates.

The prevalence of glenohumeral osteoarthrosis in unstable shoulders

BACKGROUND

Glenohumeral osteoarthritis has been a well-described complication of open procedures to correct shoulder instability. What remains unknown is whether chondral injuries sustained during instability episodes contribute to osteoarthritis or whether the cause is primarily the stabilization procedure itself.

PURPOSE

To determine the prevalence of osteoarthrosis in a large database of patients with acute and chronic shoulder instability before primary stabilization surgery.

STUDY DESIGN

Retrospective review of prospectively collected data.

METHODS

Surgical and demographic data were collected on 422 patients with a diagnosis of shoulder instability who underwent arthroscopic examination and shoulder stabilization.

RESULTS

There was a significant association between the grade of osteoarthrosis and the presence of osteoarthritis (grade III or IV chondral damage) with time from injury to surgery. Patients with osteoarthritis were significantly older than those without (34.9 versus 29.6 years). Multivariate analysis identified older age and time from injury to surgery as independent predictors of osteoarthritis. We found no association between direction of instability and the presence of osteoarthritis.

CONCLUSION

The overall prevalence of glenohumeral osteoarthrosis was low. Predictors of osteoarthritis included time from injury to surgery and age.

Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis

BACKGROUND

The optimal management strategy for acute Achilles tendon rupture is controversial.

PURPOSE

To determine the optimal management by using expected-value decision analysis.

STUDY DESIGN

Cross-sectional study.

METHODS

Outcome probabilities were determined from a systematic literature review, and patient-derived utility values were obtained from a visual analog scale questionnaire. A decision tree was constructed, and fold-back analysis was used to determine optimal treatment. Sensitivity analyses were used to determine the effect of varying outcome probabilities and utilities on decision-making.

RESULTS

Outcome probabilities (expressed as operative; nonoperative) were as follows: well (0.762; 0.846), rerupture (0.022; 0.121), major complication (0.030; 0.025), moderate complication (0.075; 0.003), and mild complication (0.111; 0.005). Outcome utility values were well operative (7.9), well nonoperative (7.0), rerupture (2.6), major complication (1.0), moderate complication (3.5), and mild complication (4.7). Fold-back analysis revealed operative treatment as the optimal management strategy (6.89 versus 6.30). Threshold values were determined for the probability of a moderate complication from operative treatment (0.21) and the utility of rerupture (6.8).

CONCLUSIONS

Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.

Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction

BACKGROUND

The purpose of this study was to identify the determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament.

METHODS

A cohort of 201 patients undergoing primary reconstruction of the anterior cruciate ligament was studied prospectively. All patients were followed for a minimum of two years (mean, 35.9 months). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Nonparametric univariate analysis and multivariable modeling were performed to identify determinants of satisfaction.

RESULTS

The demographic variables were not found to have a significant association (p > 0.05) with patient satisfaction. The variables at surgery demonstrated a significant association (p < 0.05) with patient satisfaction only with respect to the status of the lateral meniscus, the presence of osteophytes, and concurrent plica excision. The objective variables at follow-up revealed that patients were significantly less satisfied (p < 0.05) if they had a flexion contracture, increased laxity of the involved leg on the manual maximum test as measured on a KT-1000 device, an abnormal result on the pivot-shift examination, effusion, or tenderness at the medial joint line or patella. With regard to the subjective symptoms at follow-up, patients were found to be significantly (p < 0.05) less satisfied with the outcome if they had symptoms of pain, swelling, partial giving-way, full giving-way, locking, noise, stiffness, or a limp. Analysis of the subjective function at follow-up demonstrated that patients were significantly less satisfied (p < 0.05) with the outcome if they had a lower level of activity, sports activity, strenuous work, activities of daily living, overall knee function, sports participation, or symptom-free activity; if they were unemployed; or if they had difficulty with walking, squatting, ascending or descending stairs, running, jumping, cutting, or twisting. Patient satisfaction was significantly associated (p < 0.05) with the Lysholm knee score, overall International Knee Documentation Committee (IKDC) knee score, IKDC subjective subscore, IKDC symptoms subscore, and IKDC range-of-motion subscore. The seven independent multivariate determinants (adjusted R (2) = 0.83, p < 0.001) of patient satisfaction included the Lysholm score, overall subjective knee function, IKDC range-of-motion subscale, patellar tenderness, full giving-way, flexion contracture, and swelling.

CONCLUSIONS

Univariate and multivariate determinants of patient satisfaction with the outcome after reconstruction of the anterior cruciate ligament were established. Although some specific surgical and objective variables were important, subjective variables of symptoms and function had the most robust associations with patient satisfaction. In assessing the outcome of reconstruction from the perspective of patient satisfaction with the outcome, we should emphasize patient-derived subjective assessment of symptoms and function, particularly those involving issues of stiffness, giving-way, swelling, and patellofemoral symptoms.

Partial tears of the anterior cruciate ligament in children and adolescents

BACKGROUND

The functional outcome after partial anterior cruciate ligament tears in children and adolescents treated without reconstruction has not been established.

HYPOTHESIS

Nonreconstructive management of partial anterior cruciate ligament tears can be effective in certain pediatric patients.

STUDY DESIGN

Prospective cohort study.

METHODS

We studied 45 skeletally mature and immature patients 17 years of age or less who had an acute hemarthrosis, magnetic resonance imaging signal changes, grade A or B Lachman and pivot shift result, and an arthroscopically documented partial anterior cruciate ligament tears. All patients were treated without reconstruction, underwent a structured rehabilitation program, and were followed up for a minimum of 2 years.

RESULTS

Fourteen patients (31%) underwent subsequent reconstruction. Significant associations with subsequent reconstruction included tears that were greater than 50%, predominantly posterolateral tears, a grade B pivot shift test result, and older chronologic and skeletal age. Among patients who did not require reconstruction, those with tears that were greater than 50% or predominantly posterolateral had significantly lower Lysholm, satisfaction, and Cincinnati Knee Scale scores.

CONCLUSIONS

Nonreconstructive management is recommended for partial anterior cruciate ligament tears in children and adolescents 14 years of skeletal age or younger with normal or near-normal Lachman and pivot shift results. Reconstruction is recommended in older athletes or in those with greater than 50% or predominantly posterolateral tears.

Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group

Expert opinion regarding experience with the management and complications of pediatric anterior cruciate ligament (ACL) injuries was studied by surveying members of The Herodicus Society and The ACL Study Group. There was large practice variation in initial management and ACL reconstruction technique. There were 15 reported cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg length discrepancy. Associated factors included fixation hardware across the lateral distal femoral physis in 3 cases, bone plugs of a patellar tendon graft across the distal femoral physis in 3 cases, large (12 mm) tunnels in 2 cases, fixation hardware across the tibial tubercle apophysis in 3 cases, lateral extra-articular tenodesis in 2 cases, and over-the-top femoral position in 1 case. Based on this experience, we recommend a guarded approach to ACL reconstruction in the skeletally immature patient with careful attention to technique and follow-up.

The relative importance of acromial morphology and age with respect to rotator cuff pathology

The purpose of this study was to examine the relationship between patient age, acromial morphology, and rotator cuff pathology. Data on 523 patients who had arthroscopic and/or open shoulder surgery were reviewed. Acromial morphology was classified by the system of Bigliani. All patients were categorized by postoperative diagnosis as having tendinitis of the rotator cuff, partial rotator cuff tear, complete rotator cuff tear, and non-rotator cuff-related pathology. Univariate analysis results for acromial morphology (P <.001), age (P <.001), and gender (P =.019) showed a significant association with rotator cuff pathology. Fifty percent of patients with rotator cuff tendinitis had type I acromions, and 58% of patients with full-thickness rotator cuff tears had type III acromions. Stratified univariate analysis revealed no significant association between acromial morphology and rotator cuff pathology in patients who were over 50 years old. Patients with full-thickness rotator cuff tears were significantly older than those with partial-thickness tears or tendinitis. A larger proportion of male patients than female patients had full-thickness rotator cuff tears. Multivariable logistic regression analysis identified acromial morphology, age, and gender as independent multivariate predictors of rotator cuff pathology. Age, acromial morphology, and gender all have an independent association with rotator cuff pathology.

Ghost surgery: the ethical and legal implications of who does the operation

Case 1: A patient who is rehospitalized for complications after shoulder arthroscopy discovers that his surgeon's partner performed the operation. The orthopaedists contend that they practice as a "team," deciding who does the specific case just prior to the operation(1). Case 2: Arthroscopic partial meniscectomy is performed by a resident. The attending orthopaedist scrubs briefly and then leaves to perform a simultaneous procedure in another room. The patient has a postoperative complication(2). Case 3: Carpal tunnel release is performed by a resident, under the supervision of an attending orthopaedist who has been present for the entire case and who has introduced the resident as his assistant in the informed-consent process. The median nerve is injured by the resident(3).

Functional and radiographic outcome of juvenile osteochondritis dissecans of the knee treated with transarticular arthroscopic drilling

Management of juvenile osteochondritis dissecans is controversial. The purpose of this study was to evaluate the functional and radiographic outcomes of transarticular arthroscopic drilling for isolated stable, juvenile osteochondritis dissecans lesions of the medial femoral condyle with an intact articular surface after 6 months of nonoperative management had failed. We reviewed 30 affected knees in 23 skeletally immature patients (mean age, 12.3 years; range, 8.5 to 16.1) at an average follow-up of 3.9 years (range, 2.0 to 7.2). Functional outcome was determined using the Lysholm score and radiographic outcome was determined using lesion size, and the radiographic score of Rodegerdts and Gleissner. There was significant improvement in the mean Lysholm score (from 58 to 93). There was significant improvement in the mean lesion size on anteroposterior (4.5 +/- 5.8 mm decrease) and lateral (8.4 +/- 8.1 mm decrease) radiographs. There was also significant improvement in the mean radiographic score (from 3.0 to 1.9). Radiographic healing was achieved in all patients at an average of 4.4 months after drilling (range, 1 to 11 months). Linear regression analysis revealed that younger age was an independent, multivariate predictor of Lysholm score improvement. There were no apparent surgical complications.

Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents

To determine the diagnostic performances of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents we compared them with arthroscopic findings in a consecutive series of pediatric patients (< or = 16 years old). Stratification effects by patient age and magnetic resonance imaging center were examined. There were 139 lesions diagnosed clinically, 128 diagnosed by magnetic resonance imaging, and 135 diagnosed arthroscopically. There was no significant difference between clinical examination and magnetic resonance imaging with respect to agreement with arthroscopic findings (clinical examination, 70.3%; magnetic resonance imaging, 73.7%), overall sensitivity (clinical examination, 71.2%; magnetic resonance imaging, 72.0%), and overall specificity (clinical examination, 91.5%; magnetic resonance imaging, 93.5%). Stratified analysis by diagnosis revealed significant differences only for sensitivity of lateral discoid meniscus (clinical examination, 88.9%; magnetic resonance imaging, 38.9%) and specificity of medial meniscal tears (clinical examination, 80.7%; magnetic resonance imaging, 92.0%). For magnetic resonance imaging, children younger than 12 years old had significantly lower overall sensitivity (61.7% versus 78.2%) and lower specificity (90.2% versus 95.5%) compared with children 12 to 16 years old. There was no significant effect of magnetic resonance imaging center. In conclusion, selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously in cases where the clinical diagnosis is uncertain and magnetic resonance imaging input will alter the treatment plan.

Ultrasonographic screening for developmental dysplasia of the hip: an epidemiologic analysis (Part I)

Ultrasonography offers distinct advantages in the imaging of the neonatal hip and has proved useful in the diagnosis and management of developmental dysplasia of the hip (DDH). However, its role as a screening tool for DDH remains controversial. The purpose of this article is to critically assess ultrasonographic screening of DDH from an epidemiologic viewpoint, considering aspects of the disease to be screened and characteristics of the screening tool, while evaluating screening efficacy and feasibility.

Cost and effectiveness of routine pathological examination of operative specimens obtained during primary total hip and knee replacement in patients with osteoarthritis

BACKGROUND

The challenge of cost-efficiency is maintaining the quality of medical care while reducing costs and eliminating unnecessary practices. The purpose of this investigation was to evaluate the cost and effectiveness of routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement for the treatment of osteoarthritis.

METHODS

Effectiveness was assessed by comparing clinical and pathological diagnoses associated with 1,234 consecutive primary total joint replacements (471 hip and 763 knee replacements) performed between 1992 and 1995 in one hospital in patients with the clinical diagnosis of osteoarthritis. Clinical and pathological diagnoses were considered concordant if they agreed, discrepant if they differed without a resultant change in patient management, and discordant if they differed with a resultant change in patient management. Cost identification was performed by determining charges, reimbursement, and costs in 1998-adjusted American dollars for both total hip and total knee replacement. The cost per health-effect was determined by calculating the cost per discrepant and discordant diagnosis.

RESULTS

The prevalence of concordant diagnoses was 97.6 percent (1,205 of 1,234) (95 percent confidence interval, 96.6 to 98.4 percent), the prevalence of discrepant diagnoses was 2.3 percent (twenty-eight of 1,234) (95 percent confidence interval, 1.4 to 3.1 percent), and the prevalence of discordant diagnoses was 0.1 percent (one of 1,234) (95 percent confidence interval, 0.1 to 0.3 percent). The cost per discrepant diagnosis was $4,383, and the cost per discordant diagnosis was $122,728.

CONCLUSIONS

Routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement because of the clinical diagnosis of osteoarthritis had limited cost-effectiveness at our hospital due to the low prevalence of findings that altered patient management.

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Surgical management of spinal involvement in children and adolescents with Gaucher's disease

Gaucher's disease is an uncommon hereditary glycolipid storage disorder characterized by the accumulation of glucocerebroside in the lysosomes of macrophages of the reticuloendothelial system. Skeletal manifestations are variable in severity and typically involve the long bones. Vertebral involvement is less well characterized, particularly in children and adolescents. We report on the surgical management of spinal involvement in four children and adolescents with Gaucher's disease; two for kyphotic deformity and two for kyphotic deformity associated with neurologic compromise. We recommend anterior spinal release with fusion and posterior spinal fusion with segmental instrumentation in cases of kyphotic deformity. In cases of spinal cord compromise at the apex of the kyphotic deformity with retropulsion of involved bone, anterior decompression also should be performed. Routine surveillance for spinal deformity in patients with Gaucher's disease is necessary to allow early intervention before the development of severe deformity and neurologic compromise.

Orthopaedic aspects of child abuse

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.

Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm

BACKGROUND

A child who has an acutely irritable hip can pose a diagnostic challenge. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation.

METHODS

We retrospectively reviewed the cases of children who were evaluated at a major tertiary-care children's hospital between 1979 and 1996 because of an acutely irritable hip. Diagnoses of true septic arthritis, presumed septic arthritis, and transient synovitis were explicitly defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression analysis were used to compare groups. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested.

RESULTS

Patients who had septic arthritis differed significantly (p < 0.05) from those who had transient synovitis with regard to the erythrocyte sedimentation rate, serum white blood-cell count and differential, weight-bearing status, history of fever, temperature, evidence of effusion on radiographs, history of chills, history of recent antibiotic use, hematocrit, and gender. Patients who had true septic arthritis differed significantly (p < 0.05) from those who had presumed septic arthritis with regard to history of recent antibiotic use, history of chills, temperature, erythrocyte sedimentation rate, history of fever, gender, and serum white blood-cell differential. Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, erythrocyte sedimentation rate of at least forty millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter). The predicted probability of septic arthritis was determined for all sixteen combinations of these four predictors and is summarized as less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. The chi-square test for trend and the area under the receiver operating characteristic curve indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis.

CONCLUSIONS

Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.