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   Table of Contents - Current issue
Coverpage
July-December 2017
Volume 3 | Issue 2
Page Nos. 41-76

Online since Monday, July 16, 2018

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EDITORIAL  

Stop Maligning the Asymptomatic Child’s Flatfoot p. 41
Benjamin Joseph
DOI:10.4103/pors.pors_10_17  
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ORIGINAL ARTICLES Top

Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified? p. 43
Petnikota Harish
DOI:10.4103/pors.pors_5_17  
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.
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Predicting the Need for Tenotomy in the Management of Idiopathic Clubfoot by the Ponseti Method p. 51
Ranjit V Deshmukh, Aditi A Kulkarni
DOI:10.4103/pors.pors_4_17  
Purpose: The aim of this study was to determine the role of Pirani scoring system for predicting the treatment of idiopathic clubfoot with the Ponseti technique. Materials and Methods: A retrospective study was conducted. The records of 132 idiopathic clubfeet of patients treated by the Ponseti method and scored by the Pirani system between May 2007 and September 2015 were analyzed. Result: Of the 132 feet, 101 (76.5%) feet of the patients required tenotomy. The mean number of casts required was significantly higher (P = 0.033) for the group that required tenotomy (5.53 ± 1.6 casts) than the group that did not require tenotomy (4.87 ± 0.9 casts). Conclusion: The initial Pirani score is predictive of the number of casts that may be required and the need for a tenotomy of the Achilles tendon.
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The Role of Pirani Scoring in Predicting the Frequency of Casting and the Need for Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot Using the Ponseti Method p. 55
Chukwuemeka O Anisi, Joseph E Asuquo, Innocent E Abang, Michael E Eyong, Onyebuchi G Osakwe, Ngim E Ngim
DOI:10.4103/pors.pors_8_17  
Background: The Pirani scoring system is a simple tool widely used for grading the severity of clubfoot. This study was designed to objectively assess its value in predicting the total number of casts required, and the need for percutaneous Achilles tenotomy to achieve correction of the idiopathic clubfoot treated by the Ponseti method. Patients and Methods: All patients with idiopathic clubfoot, who attended our clubfoot clinic between January, 2013 and December, 2015, were prospectively studied. Each clubfoot was scored at presentation and at each visit by the first and second authors, using the Pirani scoring system. All patients were treated by the first and second authors by weekly stretching and cast application following the Ponseti treatment protocol until correction was achieved (with or without percutaneous Achilles tenotomy). Chi-square tests were applied to establish any existing relationship between the Pirani scores and the need for percutaneous tenotomy as well as the number of casts required to achieve correction. Results: A total of 69 patients with 108 idiopathic clubfeet were recruited into the study. In that, 14 patients defaulted, leaving the study with 81 clubfeet belonging to 55 patients. The median total Pirani score (TPS), midfoot contracture score and hindfoot contracture score at presentation were 4.0, 2.0 and 2.0, respectively. A total of 57 (70.4%) feet required percutaneous Achilles tenotomy to achieve correction. The average number of casts (including casts after tenotomy) required to achieve correction was 4.9 (2–10). The average number of casts required to achieve correction was 4.1 (2–10) for the no tenotomy group and 5.4 (3–10) for the tenotomy group. Statistically significant relationship was established between the TPS and number of casts required to achieve correction for both the tenotomy group (P = 0.039) and no tenotomy group (P = 0.05). Conclusion: High Pirani scores were associated with increased number of casts and percutaneous Achilles tenotomy for the correction of idiopathic clubfoot using the Ponseti method.
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Amputation Following Meningococcal Septicaemia in Children: the Surgical Management of the Residual Limb p. 60
Brigid M Aherne, Fergal P Monsell
DOI:10.4103/pors.pors_9_17  
Background: Meningococcal septicaemia is a potentially life-threatening disease and remains the most common infective cause of mortality in the UK. Improvements in healthcare have led to early recognition and treatment, and a decrease in mortality. As more children now survive the initial acute illness, the long-term musculoskeletal consequences have become more prevalent. These include growth plate injury, tissue loss and amputation. Patients with limb loss present specific difficulties due to the effect of remaining longitudinal growth on the function of the residual limb, and often require surgical treatment that continues throughout childhood. Patients and Methods: This case series reviews the histories of 13 children who underwent amputation as a complication of meningococcal septicaemia. All patients attend a specialist clinic and our experience in the management of the residual limb is described. Results: Thirteen patients, with a mean age of 16 months at the onset of meningococcal septicaemia, required amputation in the management of the skeletal consequences of the infection. Revision surgery was necessary for all 13 patients and involved management of bone overgrowth, growth arrest, scar and soft tissue contracture, neuroma development, and infection. The details of our approach to each of these complications is described. Conclusion: Due to improvements in diagnosis and initial management, a significant proportion of patients are surviving infantile meningococcal septicaemia. Many develop musculoskeletal consequences including amputation, and this case series serves to increase knowledge in the complex managements of the residual limb in these patients.
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CASE REPORTS Top

The Role of Imaging in Diagnosis and Management of Congenital High Scapula (Sprengel’s Deformity): Case Report and Review p. 67
Nada Garrouche, Saida Jerbi, Nedra Chouchane, Wassia Kessomtini, Hssine Hamza
DOI:10.4103/pors.pors_11_16  
Sprengel’s deformity is the congenital failure of descent of the scapula. The diagnosis is based on a clinical examination and radiological procedures. Volume rendering three-dimensional computed tomography reconstructions analyze the precise topography and spatial proportions of examined bone structures. It enables an optional rotation of visualized bone structures to clarify the anatomical abnormalities. Ultrasound and magnetic resonance are useful in prenatal management and for the diagnosis of concomitant abnormalities. In this paper, we report our imaging experience from one child with Sprengel’s deformity and discuss the importance of imaging techniques with a particular focus on the role of three-dimensional reconstructions.
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10-Year Radiological Follow-Up of Multifocal Recurrent Eosinophilic Granuloma With Vertebra Plana: A Case Report and Review of Literature p. 72
Amit Kumar, Shivam Sinha, Shyam Kumar Saraf, Vineeta Gupta, Deepa Rani, Jyoti Kumari
DOI:10.4103/pors.pors_10_16  
Eosinophilic granuloma (EG) is the benign localized form of histiocytosis. Owing to the relative rarity of the condition, diagnosis is often delayed or missed, and many questions remain unanswered, ranging from cause and pathogenesis to therapy. Observation and immobilization are adequate for improvement of the condition in most patients. However, treatment other than simple observation is recommended in patients with symptomatic EG. This article presents a 10-year follow-up study of a 15-year-old girl with a symptomatic multifocal EG treated effectively by monitored chemotherapy and orthosis.
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