RESUMO
BACKGROUND: Systemic inflammatory response syndrome (SIRS) is a well-recognized phenomenon in adult trauma populations. The "initial hit" of the traumatic event is often coupled with a systemic immune response characterized by changes in vital signs and laboratory indicators. A "second hit" from surgery during this time frame often results in acute lung injury, along with deterioration of the patient's clinical condition. We hypothesized that children and adolescents would experience SIRS physiology, but would not experience adult respiratory distress syndrome (ARDS) or "second hit" related death to the extent seen in the adult populations. METHODS: We queried the trauma database of our level 1 pediatric trauma center from January 2005 to December 2015 for patients with injury severity scores of >16. We used the electronic medical record to track SIRS criteria in patients days 1 to 4 posttrauma. Trends were examined in patients with an orthopaedic injury (OI) and with no orthopaedic injury. Patients were further subcategorized and analyzed by age group based on the convention for definition of pediatric SIRS. Patients in the orthopaedic cohort were further examined for pulmonary complications and death. Logistic regression was used to identify risk factors for SIRS physiology in the first 4 days of hospitalization. RESULTS: 81.4% (OI) and 69.1% no orthopaedic injury reached the threshold for SIRS within their first 4 days of hospitalization. Nine patients died in the hospital. Only 3 OI patients developed the criteria for ARDS, and only 3 patients with orthopaedic injuries died, 2 died within 24 hours of presentation and 1 within 48 hours, all had severe brain trauma. Increasing age groups showed increasing proportion of patients with SIRS. Increasing injury severity score and increasing age were independent predictors of SIRS during days 1 to 4. DISCUSSION: SIRS seems to be as common in children as the reported rates for adults, and the proportion of SIRS in children increases with increasing age and injury severity. The high mortality rate and rate of ARDS observed in adults was not observed in our cohort. The presence or absence of major orthopaedic injuries was not a significant predictor. The SIRS response in polytraumatized children is poorly understood. The clinical phenomenon of acute lung injury/ARDS is observed less often in children, but the exact mechanism by which this occurs is unknown. LEVEL OF EVIDENCE: Level III-case control.
Assuntos
Osso e Ossos/lesões , Traumatismo Múltiplo/fisiopatologia , Traumatismo Múltiplo/cirurgia , Sistema Musculoesquelético/lesões , Síndrome do Desconforto Respiratório/etiologia , Síndrome de Resposta Inflamatória Sistêmica/fisiopatologia , Adolescente , Fatores Etários , Estudos de Casos e Controles , Criança , Pré-Escolar , Registros Eletrônicos de Saúde , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Traumatismo Múltiplo/complicações , Estudos Retrospectivos , Síndrome de Resposta Inflamatória Sistêmica/etiologiaRESUMO
BACKGROUND: The management of septic arthritis of the hip in children can be complicated by the presence of additional coexisting periarticular infections (PAIs). Criteria predicting the presence of PAI have recently been proposed by Rosenfeld and colleagues with the goal of using magnetic resonance imaging (MRI) efficiently in the workup of septic arthritis. The purpose of this study was to determine the applicability of recently published predictive criteria for PAI (developed in the Southwestern United States using a variety of joints) to septic arthritis of the hip treated at a large Northeastern tertiary care center. METHODS: We studied patients treated for septic arthritis of the hip with irrigation and debridement in a large Northeastern tertiary care center over a 10-year period. Laboratory and clinical variables related to presentation, treatment, and outcome were collected. Subjects with and without a perioperative MRI were compared with published criteria by Rosenfeld and colleagues. RESULTS: Fifty-one subjects (53 hips) were identified with a mean age of 7.0 years (range, 1.2 to 19.3 y) and mean follow-up was 16 months (range, 2 to 85 mo). MRIs were obtained in 20 subjects (43%). Coexisting osteomyelitis was revealed in 7/20 of these studies (35% of MRIs); 4 of which showed coexisting intramuscular abscesses. Within our MRI cohort, the Rosenfeld criteria were found to have a sensitivity of 86%, a specificity of 54%, and a false-positive rate of 50% for the hip (compared with originally reported sensitivity of 90%, specificity of 67%, and false-positive rate of 33%). Overall, advanced imaging changed management in 5/51 patients (9%) by influencing the need for further treatment, whereas the remainder underwent isolated treatment of the septic hip joint with no adverse outcomes. One patient in the MRI cohort (without PAI) developed osteonecrosis of the femoral head. CONCLUSIONS: We found lower sensitivity and specificity and higher false-positive rates for the Rosenfeld criteria in the hip for our geographically distinct population. Using the Rosenfeld criteria, MRIs would have been ordered unnecessarily in half of our series. Because of potential differences in regional microbiology and anatomic-specific factors, general predictive criteria for coexisting PAI based a single geographic region may be less generalizable to cases of hip sepsis in other geographic areas such as the Northeastern United States. LEVEL OF EVIDENCE: Level 4-retrospective cohort study.
Assuntos
Artrite Infecciosa/complicações , Articulação do Quadril , Artropatias/diagnóstico , Adolescente , Adulto , Artrite Infecciosa/terapia , Criança , Pré-Escolar , Comorbidade , Desbridamento/métodos , Feminino , Articulação do Quadril/microbiologia , Articulação do Quadril/cirurgia , Humanos , Lactente , Imageamento por Ressonância Magnética/normas , Masculino , Osteomielite/complicações , Osteonecrose/etiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Irrigação Terapêutica , Adulto JovemRESUMO
Pediatric distal humerus fractures are common, and numerous variations can occur depending on patient's age, position of the extremity at the time of injury, and energy of impact. Classic injury patterns include the flexion/extension supracondylar humerus, medial epicondyle, lateral condyle, and the transphyseal distal humerus. We describe our treatment philosophy for pediatric elbow fractures and how these principles were applied to some unusual fractures that presented to our institution.
Assuntos
Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/terapia , Criança , Pré-Escolar , Feminino , Fixação de Fratura/métodos , Humanos , Imageamento por Ressonância Magnética , Masculino , Procedimentos Ortopédicos/métodos , Intensificação de Imagem RadiográficaRESUMO
BACKGROUND: Although many studies have separately investigated the treatment of developmental dysplasia of the hip and spastic hip disease, little data exist regarding the treatment of infants with dislocated hips and underlying spasticity. The purpose of this study was to review our results after the surgical treatment of these infants. METHODS: We retrospectively reviewed all children below 3 years of age who underwent hip reconstruction for dislocated hips in the setting of cerebral palsy or other spastic/high-tone neuromuscular disease. Medical records were reviewed for clinical data including treatment course, complications, and need for further surgery. Preoperative and postoperative radiographs were used to determine International Hip Dysplasia Institute (IHDI) grade of dislocation, acetabular index, migration percentage, and presence of avascular necrosis according to the Salter criteria. RESULTS: Eleven patients with 15 hips met our inclusion criteria with a mean age of 20±8 (range, 6 to 34) months. Preoperatively, 12 of 15 hips (80%) were IHDI grade 4 and 3 of 15 (20%) were IHDI grade 3. Mean acetabular index was 29±8 (range, 19 to 46) degrees. Patients underwent open reduction (15 hips), adductor tenotomy (14 hips), femoral osteotomy (10 hips), and pelvic osteotomy (12 hips). At a mean follow-up of 40±16 (range, 13 to 71) months, 13 of 15 hips were IHDI grade 1 (86.7%), 1 was IHDI grade 2 (6.7%), and 1 hip was IHDI grade 3 (6.7%). The mean postoperative migration index was 7%±24% (range, -30% to 46%); the mean acetabular index was 22±8 (range, 9 to 38) degrees. No patients developed radiographically significant osteonecrosis. Complications included 2 femur fractures (13.3%) and 1 symptomatic implant that required early removal. One patient underwent further reconstructive hip surgery. CONCLUSIONS: In this series of infants with hip dislocations and underlying spasticity, open reduction±pelvic osteotomy and/or femoral osteotomy has a nearly 90% success rate in achieving and maintaining adequate hip reduction at intermediate-term follow-up. In the unique population of infants with dislocated hips and underlying spasticity, comprehensive hip reconstruction is largely successful with an acceptable rate of complications. LEVEL OF EVIDENCE: Level IV-retrospective.
Assuntos
Luxação do Quadril/cirurgia , Redução Aberta/estatística & dados numéricos , Osteotomia/estatística & dados numéricos , Paralisia Cerebral/complicações , Pré-Escolar , Feminino , Luxação do Quadril/complicações , Luxação do Quadril/diagnóstico por imagem , Humanos , Lactente , Masculino , Espasticidade Muscular/complicações , Radiografia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Use of the minimally invasive Ponseti method has been increasing in low and middle-income countries, where most of the world's children with clubfoot are born. This method requires a system of service delivery involving screening, serial casting with or without a tenotomy to achieve correction, and long-term use of an orthosis to maintain correction. The goal of this systematic review is to evaluate the barriers to service delivery and the solutions that have been proposed or implemented to address these barriers. METHODS: A literature search of Medline, Embase, and SCOPUS produced 3251 results. Twenty-four papers were selected for final review. Barriers and their attempted solutions were organized into a previously described health barrier model. We reported on high-impact, sustainable solutions that are feasible for organizations to implement, as opposed to solutions that require major policy or country-wide infrastructure changes. RESULTS: Common barriers found to have the most impact on patient care included financial constraints, transportation, difficulties with brace and cast care, self-perceived health status, lack of physical resources, and provider's lack of knowledge and skill. The most common solutions detailed were education of the provider or patient and financial assistance for patients. CONCLUSIONS: Recognizing that contextually relevant solutions to the challenges of setting up a system for clubfoot service delivery are required, several common barriers have emerged within this systematic review of papers from multiple countries, including spatial accessibility, affordability, and availability. Programs can best prepare for challenges by placing clinics close to population centers and/or allocating funds to subsidize transportation, ensuring that an adequate supply of materials are available for the casting and tenotomy, and enhancing the education of families and health providers. Strengthening communication and establishing partnerships between individuals and organizations promoting the Ponseti method will improve systems for service delivery. LEVEL OF EVIDENCE: Level IV-prognostic study.
Assuntos
Pé Torto Equinovaro/terapia , Países em Desenvolvimento , Acessibilidade aos Serviços de Saúde , Braquetes , Moldes Cirúrgicos , Competência Clínica , Pé Torto Equinovaro/economia , Atenção à Saúde/organização & administração , Custos de Cuidados de Saúde , Nível de Saúde , Humanos , Autocuidado , Meios de TransporteRESUMO
BACKGROUND: The emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has altered the management of pediatric musculoskeletal infections. Yet, institution-to-institution differences in MRSA virulence may exist, suggesting a need to carefully examine local epidemiological characteristics. The purpose of this study was to compare MRSA and methicillin-sensitive S. aureus (MSSA) musculoskeletal infections with respect to prevalence and complexity of clinical care over the past decade at a single children's hospital. METHODS: We retrospectively reviewed a series of patients presenting to The Children's Hospital of Philadelphia with a diagnosis of osteomyelitis, septic arthritis, or both over a 10-year period. Inclusion criteria were S. aureus (SA) infections proven by positive culture of blood, bone, or joint aspirate. Exclusion criteria were non-SA infectious etiologies. Hospital-acquired infections were also not included to exclusively evaluate acute, community-acquired cases. Data related to hospital course, laboratory values, and number of surgical interventions were collected and compared between MRSA and MSSA cohorts. RESULTS: In our series of pediatric patients, we identified 148 cases of acute, community-acquired musculoskeletal SA infections (MRSA, n=37 and MSSA, n=111). The prevalence of MRSA musculoskeletal infections increased from 11.8% in 2001 to 2002 to 34.8% in 2009 to 2010. Compared with MSSA, MRSA infections resulted in higher presenting C-reactive protein levels (10.4 vs. 7.8 mg/L, P=0.04), longer inpatient stays (10 vs. 5 d, P<0.01), multiple surgical procedures (n>1) (38% vs. 14%, P<0.01), increased sequelae (27% vs. 6%, P<0.01), and more frequent admissions to the intensive care unit (16% vs. 3%, P<0.01). CONCLUSIONS: At our institution over the past decade, we found an approximate 3-fold rise in community-acquired pediatric MRSA musculoskeletal infections accompanied by an elevated risk for complications during inpatient management. Awareness of the epidemiological trends of MRSA within the local community may guide parental counseling and facilitate timely and accurate clinical diagnosis and treatment. LEVEL OF EVIDENCE: Level II-prognostic retrospective study.
Assuntos
Artrite Infecciosa/microbiologia , Hospitais Pediátricos , Staphylococcus aureus Resistente à Meticilina , Osteomielite/microbiologia , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/microbiologia , Doença Aguda , Adolescente , Artrite Infecciosa/cirurgia , Proteína C-Reativa/metabolismo , Criança , Pré-Escolar , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/cirurgia , Feminino , Humanos , Lactente , Tempo de Internação , Masculino , Osteomielite/cirurgia , Philadelphia/epidemiologia , Prevalência , Estudos Retrospectivos , Infecções Estafilocócicas/cirurgiaRESUMO
BACKGROUND: No preferred procedure exists for the chronically painful, unreconstructable subluxated or dislocated hip in cerebral palsy. The purpose of this study was to compare pain relief and complication rates of salvage procedures in cerebral palsy for ambulatory and nonambulatory populations. METHODS: We searched Medline, Embase, and Cochrane databases using the search terms "cerebral palsy" and "hip dislocation." Inclusion and exclusion criteria were established to maintain data quality for analysis. A systematic review yielded 28 studies. Relevant information for postoperative pain and complications were extracted from each study and described. Our initial search identified 721 articles. Two hundred twenty duplications were excluded. Five hundred one were screened by title and abstract. One hundred articles underwent further full text and reference evaluation, yielding 25 studies. An additional 3 studies were then identified from the list of 25, yielding a total of 28 studies, which met our inclusion criteria. RESULTS: Among nonambulators, femoral head resection (FHR), valgus osteotomy (VO), and total hip arthroplasty (THA) were found to relieve pain better than arthrodesis [odds ratio (OR) 7.3, 95% confidence interval (CI), 2.2-24.8; OR 5.9, 95% CI, 1.6-22.8; OR 11.7, 95% CI, 1.1-297.5, respectively]. Arthrodesis had a significantly higher complication rate than FHR, VO, THA, and shoulder prosthetic interposition. No significant differences in complication rate were found between FHR and VO. Pain relief rates among nonambulators for FHR, VO, THA, shoulder prosthetic interposition, and arthrodesis were 90.4%, 88.4%, 93.8%, 90.9%, and 56.3%, respectively. Complication rates among nonambulators were 24.0%, 33.3%, 35.3%, 28.6%, and 106.3%, respectively. Comparison of pain relief and complication rates among ambulatory cerebral palsy patients in all procedures except THA was not possible because the populations could not be separated from nonambulators in numbers sufficient to perform statistical analysis. Data were available for 32 confirmed cases of THA in ambulators and was associated with a 93.3% pain relief rate and a 38.2% complication rate. CONCLUSIONS: Among nonambulators, the available literature suggests that FHR, VO, and THA may be superior at relieving pain than arthrodesis. FHR had the lowest absolute percentage of complications; however, no significant differences in complication rate or pain relief were found in nonambulators undergoing FHR or VO. Most of the complications for VO were implant related, and potentially amenable to hardware removal versus complications in FHR, which were related to the procedure itself such as proximal migration and heterotopic bone formation. THA in nonambulators was associated with complications such as dislocation and revision. Arthrodesis in nonambulators was associated with >100% complication rate and inferior pain relief compared with other procedures. Ambulatory patients had excellent pain relief with THA; however, the complication rate is higher than can be expected with non-neurological populations. Insufficient data exist to support use of other salvage procedures in ambulators. These conclusions should be interpreted with caution as all studies involved level IV evidence. LEVEL OF EVIDENCE: IV (systematic review of level IV studies).
Assuntos
Artroplastia de Quadril , Paralisia Cerebral/complicações , Luxação do Quadril , Osteotomia , Dor Pós-Operatória , Terapia de Salvação/métodos , Artrodese/efeitos adversos , Artrodese/métodos , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Pesquisa Comparativa da Efetividade , Cabeça do Fêmur/cirurgia , Luxação do Quadril/etiologia , Luxação do Quadril/fisiopatologia , Humanos , Osteotomia/efeitos adversos , Osteotomia/métodos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapiaRESUMO
Road traffic crash-related death, injury, and chronic disability continue to be a major worldwide burden to drivers, pedestrians, and users of mass transit, especially in low- and middle-income countries (LMIC). Projections predict worsening of this burden, and while motorization of LMIC increases exponentially, a corresponding improvement in prehospital and acute in-hospital trauma care has not been seen. The WHO now has 2 programs that address different elements of this challenge, namely, the Violence and Injury Prevention department (prevention) and the Emergency and Essential Surgical Care project (treatment). Activities of Violence and Injury Prevention have included developing guidelines for prehospital and essential trauma care, whereas activities of the Emergency and Essential Surgical Care have included developing the Integrated Management of Emergency and Essential Surgical Care toolkit and a textbook, "Surgical Care at the District Hospital." Organized surgical institutions in high-income countries-trauma associations, university departments, surgical nongovernmental organizations, etc.-can benefit from the infrastructure and tools the WHO has developed to better address the deficits in surgical services to improve the equitable distribution of surgical care services and resources to LMIC.
Assuntos
Acidentes de Trânsito/prevenção & controle , Sistema Musculoesquelético/lesões , Ortopedia/organização & administração , Organização Mundial da Saúde/organização & administração , Ferimentos e Lesões/prevenção & controle , Acidentes de Trânsito/estatística & dados numéricos , África Subsaariana/epidemiologia , Efeitos Psicossociais da Doença , Atenção à Saúde/organização & administração , Países em Desenvolvimento/estatística & dados numéricos , Pessoas com Deficiência/estatística & dados numéricos , Humanos , Internacionalidade , Ferimentos e Lesões/terapiaRESUMO
STUDY DESIGN: This is a retrospective review of 265 consecutive patients with scoliosis treated by posterior spinal fusion (PSF) and 2990 postoperative radiographs at a single institution. OBJECTIVE: To document implant-related complications on postoperative radiographs within the first 2 years after PSF and determine if these led to additional surgical procedures. SUMMARY OF BACKGROUND DATA: To date, there is an absence of studies investing the utility of radiographs after pediatric PSF surgery. METHODS: The patient's average age was 14.9 years (8.2-21.8 yr). Positive radiographical findings included implant loosening, fracture, migration, or loss of fixation. We also noted which patients' required additional surgery for a radiographical finding and/or clinical finding (neurological deficit, intractable back pain, fever, and elevated erythrocyte sedimentation rate, c-reactive protein, or while blood cell count). RESULTS: At an average follow-up of 16.3 months (12-24), only 18 (0.60%) radiographs demonstrated a positive finding. Of these, only 5 (0.17%) radiographs (along with clinical presentation) prompted revision. No patient returned to the operating room purely from a radiographical finding. The remaining 13 (0.37%) abnormal plain images were not associated with a clinical abnormality and were managed nonoperatively. The timing of the second operation was in the range from 1 day to 23 months (average, 11 mo). Postoperative plain radiographs had a sensitivity of 26.5%, a specificity of 99.5%, and a positive predictive value of 25%. CONCLUSION: Only 0.60% of postoperative images (18/2990) demonstrated an implant-related complication, and in the absence of clinical indications, none of these patients required surgical intervention. Isolated postoperative radiographs did not lead to any change in management, and consideration should be given to reviewing current protocols for plain radiographs as a monitoring tool after PSF.
Assuntos
Vértebras Lombares/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Escoliose/diagnóstico por imagem , Fusão Vertebral , Adolescente , Criança , Seguimentos , Humanos , Vértebras Lombares/cirurgia , Complicações Pós-Operatórias/cirurgia , Radiografia , Estudos Retrospectivos , Escoliose/cirurgia , Fusão Vertebral/métodos , Resultado do Tratamento , Adulto JovemRESUMO
STUDY DESIGN: Therapeutic level II cohort study. OBJECTIVE: To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg. SUMMARY OF BACKGROUND DATA: Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported. METHODS: We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2-8 mo) were recorded. RESULTS: Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was -0.03 and between the preoperative and postoperative day 4 draw was -0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection. CONCLUSION: In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP. LEVEL OF EVIDENCE: 2.