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Background The insidious nature of BCG-osteomyelitis makes it challenging for clinicians to detect it early on. Methods This 12-year retrospective analysis was conducted at a single tertiary hospital in central Taiwan. Electronic medical records of pediatric patients treated for BCG-osteomyelitis were reviewed. Demographics, clinical features, and laboratory findings were compared with patients diagnosed with culture-proven pyogenic osteomyelitis. Results In total, eight patients fulfilled our inclusion criteria. Their median age was 16 months, and no obvious gender prevalence was found. Six of the eight patients had lesions involving the lower extremities. When compared with the pyogenic osteomyelitis group, age of disease onset was found to be significantly younger in the BCG osteomyelitis group (p=0.038). Absence of fever and pain in the BCG osteomyelitis group was found to be statistically significant when compared with the pyogenic group (p=0.002 and p=0.026 respectively). CRP and ESR were found to be significantly higher in the pyogenic osteomyelitis group (p=0.000 and p=0.004 respectively). Conclusion BCG-related osteomyelitis must be considered when evaluating an afebrile child presenting with an unexplainable swelling or limp, and especially when the lesion is located on a lower limb. Laboratory studies may reveal normal WBC and CRP, with a normal to modest elevation of ESR. Imaging studies, including plain radiographs, magnetic resonance imaging (MRI), or computed tomography (CT) should be employed to rule out BCG-related osteomyelitis. Early diagnosis help minimize inappropriate antibiotics use, and may lead to a better outcome.

Maffucci syndrome is a rare congenital, non-hereditary condition characterised by presence of multiple enchondromas and haemangiomas. Enchondromatous lesions affecting epiphysial growth plates can lead to angular deformities and leg-length discrepancy in the lower limb. We describe a 12-year-old girl with monomelic Maffucci syndrome affecting her left lower limb. She presented with progressive genu valgus deformity of her left knee. This caused her to limp during her gait and was a cosmetic dissatisfaction. The deformity affected her quality of life. She underwent a supracondylar distal femoral corrective osteotomy with a successful clinical outcome and restoration of her gait and cosmetic deformity.

Bohan Zhang,1,2,&ast; Jingyang Sun,1,2,&ast; Yinqiao Du,2,3 Junmin Shen,2,4 Tiejian Li,1,2 Yonggang Zhou1– 3 1Medical School of Chinese PLA, Beijing, 100853, People’s Republic of China; 2Department of Orthopedics, The First Medical Center of PLA General Hospital, Beijing, 100853, People’s Republic of China; 3Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, People’s Republic of China; 4Medical School of Nankai University, Tianjin, 300071, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Yonggang ZhouDepartment of Orthopedics, The First Medical Center, Chinese People’s Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, People’s Republic of ChinaTel +8613801287599Email ygzhou301@163.comObjective: We aimed to demonstrate the methods of treatment for coxa vara with modular total hip arthroplasty (THA) and evaluate clinical and radiographic outcomes, and further survivorship at the midterm follow-up.Methods: We retrospectively reviewed 33 patients (42 hips) who underwent modular THA for coxa vara deformity from May 2008 to December 2019. The clinical and radiographic results, including Harris Hip Score (HHS), leg length discrepancy (LLD), greater trochanteric height, femoral offset, abductor lever arm, stem alignment and limp, and complications, were evaluated.Results: The follow-up time was mean 69.9± 43.7 months. Clinically, the HHS improved significantly (p< 0.001) on average from 42.90± 14.44 points to 89.54± 4.75 points. The mean LLD decreased from 33.3± 19.4 mm to 5.0± 5.8 mm (p< 0.001), and 27 patients (82%) thought that total equality of the lower limbs was obtained. Patients demonstrated diminished or no limping in 88% (29/33) of hips and a significant improvement of biomechanics. At the final follow-up, all stems of hips were in clinical neutral alignment and the prostheses survivorship rates for all-causes revisions was 97.6%.Conclusion: Modular THA is a valuable alternative to render favorable outcomes for treatment of osteoarthritis secondary to severe coxa vara.Keywords: osteoarthritis, coxa vara, modular, total hip arthroplasty

Introduction In approximately one-third to half of patients of ankylosing spondylitis (AS), involvement of the hips may occur with 50–90% of these presenting with bilateral hip involvement. Total hip arthroplasty (THA) in these patients provide mobile hip, which significantly improves their functional capability and lifestyle. Aim of our study was to assess the clinical outcome of unilateral THA in AS patients with bilaterally ankylosed hips in terms of pain, hip mobility, ability to perform functional activities like sitting and walking and radiological evaluation in terms of position of acetabular cup, heterotrophic ossification (HO) and any sign of osteolysis. Methods Eight male patients (8 hips), between 25 and 40 years with ankylosed hips and spine in which only unilateral cemented THA was done due to financial constraints, were studied with average follow-up of 18.25 months (Range- 12–30 months). Results were assessed by walking ability, Harris Hip Score (HHS) and radiological findings. Results Mean pre-op HHS was 31.3. All these patients were more or less dependent on others for daily activities. None of the patient was able to sit on chair and all were able to walk indoor only. Mean HHS at final follow-up was 76.4. At final follow-up, all the patients could sit comfortably on a chair for more than 1 hour and were walking independently, although with a limp. Radiologically, acetabular cup inclination and anteversion was within Lewinnek’s safe zone in all the patients. Conclusion Unilateral cemented THA is a potential option in rehabilitation of patients of AS with bilaterally ankylosed hips, who cannot afford bilateral THA. But these young patients with rigid spine, who are very much dependent upon hip mobility, must be kept under observation to discover complications like loosening and for maintaining hip mobility.

Background Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs. Objectives We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion. Methods This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds. Results We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0–5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4–10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82). Conclusions We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.

Surgical stress response, fluid and nutritional balance, and pain management are among the key factors influencing on the postoperative period. These areas are reflected in the Enhanced Recovery After Surgery (ERAS) concept, which is based on a set of measures aimed at minimizing the surgical stress response. The lack of ERAS recommendations for the pediatric population of surgical patients prompts to search for a solution of adaptation and implementation of the ERAS programs in children. The aim of the study. To determine the effectiveness of the complex application of the enhanced recovery after surgery by studying its influence on the factors of the surgical stress response in pediatric patients undergoing limp surgery. Materials and methods. The prospective randomized study included 47 patients aged 1 to 17 years. In the study group (n = 22), the ERAS program was used, which consisted of 14 components of preoperative, intraoperative and postoperative measures. In the control group (n = 25), the complex of all ERAS components was not purposefully applied. We compared glycaemic stress index (GSI) and length of hospital stay after surgery (LOS) as a primary outcome; secondary outcomes were fasting time after drinking fluids before induction of anesthesia, estimated fluid deficiency just before induction of anesthesia, hemodynamic parameters, the need for opioids during and after surgery, blood glucose and beta-hydroxybutyrate in the beginning and in the end of the surgery and next day morning after surgery, postoperative nausea and vomiting. Results. GSI was significantly less in the study group (1,62 ± 0,78 vs 2,12 ± 0,93, р=0,046). LOS in the study group was 37.5% less than in the control group (p = 0.002). The period of preoperative fasting and fluid deficit in the patients of the study group were shorter. The needs of fentanyl intraoperatively in the study group was 47% less (p

Background: Significant articular depression, separation of both condyles, diaphyseal comminution and dissociation, and loss of soft-tissue envelope integrity are all associated with high-energy proximal tibia fractures (Schatzker VI). Over the past 50 years, there has been a lot of research on plating problems in these complicated fractures. For the care of these complex injuries, Ilizarov devised a new method (ring fixator). Aim of the Study: To examine the outcomes of patients who received a ring fixator for the treatment of high-energy proximal tibia fractures (Schatzker VI). Materials and Methods: Fourteen patients (mean age 36) were treated with the Ilizarov fixator and transfixion wires for high-energy fractures of the proximal tibia (Schatzker VI). Nine of the patients had open fractures, and five of them had significant soft tissue damage. They were all tracked for an average of 19.4 months. The result was analyzed using the criteria set by Honkonen & Jarvinen (1992). Results: Thirteen fractures healed in an average of 14.6 weeks, with one taking six months. Twelve patients recovered complete extension, while eight others regained more than 110 degrees of flexion. All of the patients knees were stable, except one who had a minor varus deformity. Nine patients walked normally, while four had a little limp. Except for one, all of the knees exhibited an articular step-off of less than 4 mm and normal axial alignment. Six knees were found to be outstanding, five to be decent, and three to be fair. There were no instances of postoperative skin infection or septic arthritis, however, three patients did have a pin tract infection that was effectively managed. Conclusion: The technique is suitable for the treatment of complex proximal tibia fractures when there is substantial comminution at the fracture site as well as soft tissue damage (Schatzker VI).

1. Susamita Kesh, MD* 2. Jacob S. Ward, DO* 3. Ashley M. Cooper, MD† 1. *Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO 2. †Department of Pediatrics, Division of Rheumatology, Children’s Mercy Hospital, Kansas City, MO A previously healthy 5-year-old white girl presents to her pediatrician’s office with a 2-day history of limp. She has no preceding trauma, fever, viral, or constitutional symptoms. At the primary care office, she walks with an antalgic gait, appearing to favor her left leg but has no localizable source of pain, visible swelling, or joint limitation. Radiographs of the pelvis and lower extremities are obtained and demonstrate a lucency of the left proximal tibial metaphysis. Magnetic resonance imaging (MRI) with intravenous contrast reveals hyperintense metaphyseal lesions of the bilateral proximal tibiae and right distal tibia concerning for infection (Fig 1). Figure 1. Magnetic resonance imaging of the lower extremities with contrast. Bilateral proximal tibial and right distal tibial lesions with associated marrow edema (arrows) and right subtalar joint effusion (arrowheads). She is admitted to the hospital for additional evaluation. During the initial evaluation and treatment, she develops a nonpainful, nonpruritic rash on her palms and soles. Physical examination reveals erythematous plaques of 3 to 5 cm in diameter with overlying scale and few central pustules (Fig 2). Figure 2. Erythematous plaques with overlying scale and rare pustules on the palms and soles. Complete blood cell count is normal with the exception of a mildly elevated platelet count of 456 × 103/mcL. Erythrocyte sedimentation rate is 44 mm/h, C-reactive protein less than 0.5 mg/dL. Bone biopsies from the tibial lesions reveal focal marrow fibrosis and no evidence of malignancy or inflammation. Aerobic, anaerobic, and fungal cultures sent from bone biopsy are negative. Echocardiogram shows no vegetations. Additional infectious studies, including testing for Blastomyces, tuberculosis, and Bartonella, are negative. Whole-body MRI strongly supports the presumed diagnosis. The patient’s limp improves after starting scheduled naproxen. The care team’s initial differential included infectious osteomyelitis, malignancy, Langerhans cell histiocytosis, and chronic recurrent multifocal osteomyelitis (CRMO). …

Background Joint-sparing resections (JSR) of the proximal femur allow for preservation of the proximal femoral growth plate and native hip joint, but whether this offers fewer complications or better function and longevity of the reconstruction remains unknown. In this study, we compared the functional outcomes of pediatric patients with bone sarcomas undergoing JSR of the proximal femur with intercalary allograft (ICA) reconstruction to those undergoing proximal femoral resections (PFR) with allograft-prosthetic composite (APC) reconstructions. Methods We retrospectively reviewed all patients undergoing JSR with ICA reconstruction and PFR with APC reconstructions between 1995 and 2013 at a tertiary pediatric referral center. Primary outcomes included major and minor complications and secondary outcomes included the need for a secondary procedure, presence of local or distant relapse, survival status, and the presence of pain and ambulatory status (limp, assistive device, highest level of function). We assessed differences in outcomes using the Fisher exact and Wilcoxon rank-sum tests. Results Eight patients underwent a JSR and ICA reconstruction, while 7 patients underwent a PFR with APC reconstruction. Median patient follow-up was 60.4 months (interquartile range: 36.8 to 112.9) Patients undergoing JSR and ICA reconstruction were younger than patients undergoing PFR with APC reconstruction (7.7 vs. 11.7 y, P=0.043); however, we found no other statistically significant differences in patient demographics. There were no statistically significant differences in primary or secondary outcomes between the study groups; however, patients who underwent JSR with ICA had more major complications (62.5% vs. 42.9%, P=0.29) and a lower rate of minor complications (25% vs. 28.6%, P=0.22). Conclusion Treatment of proximal femoral bone sarcomas in pediatric and adolescent patients remains a challenging enterprise. JSR with ICA reconstruction in the proximal femur, when feasible, may provide a similar function and risk of intermediate-term major and minor complications when compared with PFR with APC reconstruction. Further long-term studies are required to determine the impact of the native femoral head retention with respect to revision rates. Level of evidence Level III, retrospective comparative study.

Bone tumours are uncommon diagnoses and there is often a delay from first presentation to a healthcare professional (HCP) to definitive diagnosis and management. Patients may present to secondary care in a number of ways. Patients may present acutely with pathological (or impending) fractures, patients may present as urgent 2-week referral from primary care or patients may present with incidental findings on radiological investigations. A thorough history and examination is essential, followed by radiological investigations. Common clinical findings include pain, which is usually the main reason for patient presentation to an HCP. Other reasons include limp or loss of function of limb, swelling or lump, or pathological fracture. As part of the work-up, it is important to ask about constitutional symptoms, past history of malignancy and family history of known syndromes. Plain radiographs are vital for diagnosis. The patient's age is important for the differential diagnosis. The location, morphology and how the tumour is affecting the bone, periosteum and soft tissues are key to the diagnosis. For patients presenting with bone lesions, it is essential to follow the bone sarcoma referral guidelines so that patients are promptly diagnosed and treated.

Congenital coxa vara is a rare condition which is also referred to as infantile coxa vara, but may be better called as developmental femoral neck dysplasia. It is due to a primary defect of the cartilaginous femoral neck and not a growth disturbance of capital physis. We aim to highlight that this condition produces a three-dimensional deformity in coronal, sagittal and axial planes which progresses till skeletal maturity as no treatment will address the primary pathology and surgery will correct only the resultant deformities. Coronal plane deformities were observed commonly and valgus osteotomies were done to correct them. Subsequent persistence of limp was attributed for a long time to recurrence of the deformity before realising the importance of correction of deformities in other planes. A straight plate used by us with Borden osteotomy has given a maximum coronal plane correction. Correction of a multiplanar deformity with a single surgery is being advocated to avoid multiple operations. But that may result in sub-optimal correction of all the components and difficulty in stabilising the osteotomy due to small bones in the child. This is associated with higher chances of re-operations and further growth inhibition of abnormal femoral neck cartilage which may exacerbate coxa brevis. We believe that, in a non-highly specialised centre, it is safe to correct the varus in the first instance. The necessity for correction of retroversion and trochanteric overgrowth should be decided on the follow- up. One has to keep in mind the potential need for a total hip replacement in the adulthood if the anatomy of the proximal femur gets grossly distorted with a complex multiplanar corrective osteotomy.

BACKGROUND: Percutaneous sacroiliac screw fixation is the standard treatment for sacroiliac joint (SIJ) dislocation. In most hospitals, the procedure is guided by a C-arm X-ray fluoroscopy system, which must be repeatedly repositioned during surgery. In this study, we investigated the feasibility of using 2 fluoroscopes simultaneously. METHODS: A total of 28 consecutive patients with SIJ dislocation were included in this study. The patients were randomly allocated to groups and underwent percutaneous sacroiliac screw fixation using either 1 or 2 fluoroscopes. Total radiation exposure frequency, radiation dose, and operation time were recorded and compared. Dislocation reduction quality was assessed using the Tornetta and Matta standard, and the Majeed functional score was used to evaluate clinical, imaging, and social function following pelvic injury. Complications were also recorded. RESULTS: The results showed that the radiation exposure frequency was significantly less with 2 fluoroscopes than with a single fluoroscope (21.5±8.6 and 42.6±18.3 times, respectively; P0.05) between the 2 groups was not significantly different. The total operation time was also significantly shorter with 2 fluoroscopic devices than with a single device (35.8±12.9 and 65.5±19.7 minutes, respectively; P0.05) did not differ significantly between the 2 groups at the final follow-up. Complications, such as pain, superficial infection, restricted squatting, limp, and screw failure, were rarely recorded in either group. CONCLUSIONS: The simultaneous application of 2 fluoroscopes is highly appropriate during percutaneous sacroiliac screw fixation to treat SIJ dislocation, and can significantly reduce radiation exposure frequency and operation time.

Introduction: The management of infected nonunion of the tibia is challenging, particularly with segmental bone loss, multiple draining sinuses, poor soft tissue cover, osteopenia, adjacent joint stiffness, limb deformity, or multidrug-resistant polymicrobial infection. The Ilizarov method permits early rehabilitation and addresses all the problems such as non-union, infection, shortening, soft tissue loss and deformity simultaneously at single stage. Ilizarov ring fixation technique has its own advantages as well as associated complications. Methods: The present study was a prospective randomized open study in which aim was to evaluate Complications with Ilizarov ring fixator in open tibial fracture. The study was conducted in 30 skeletally mature patients in Department of Orthopaedics, SGRD University of health sciences, Amritsar from July 2017 to May 2019. The patients were assessed clinically based on history and physical examination. Radiological evaluation using plain antero-posterior and true lateral radiographs of the involved leg was done and evaluated by complications.Results: Mean age was 37.7 years. Out of 30 cases 24(80%) were male and 6(20%) were female. Right tibia was involved in 24 cases out of 30 cases. 29 cases had history of road side accident and 1 had history of fall from height. In present study following complications were noted, limp in 12 cases(40%), ankle stiffness in 7 cases(23.33%), pin site infection in 9 cases(30%), limb oedema in 7 cases(23.33%), knee stiffness in 3 cases(10%), loosening of pins in 2 cases(6.67%), deformity in 2 cases(6.67%) and refracture in 1 case(3.33%). There was no complication of neurovascular injury, malunion, breakage of wires, axial deviation or limb length discrepancyConclusion: Limp and Pin tract infection were the most common complications. Most complications can be prevented by diligent post-operative care. Complications if diagnosed early can be managed effectively. As such advantages of Ilizarov ring fixator outweigh the associated complications.

A 21-year-old female presented with a huge painful aneurysmal bone cyst (ABC) involving the left ilium, acetabulum, and ischium, resulting in a limp and activity limitation. After serial selective arterial embolization, intravenous bisphosphonates, and surgical curettage with bone grafting and cementing, she could achieve painless, nearly full range of motion at 2-year and 3-month follow-up with no recurrence. Her quality of life using the RAND 36-item Health Survey (version 1.0), the Musculoskeletal Tumor Society Scoring System (MSTS), and the Toronto Extremity Salvage Score indicated a good outcome. The aim of reporting this case was to show that it is safe to surgically approach a large pelvic ABC after devascularization with scleroembolic procedures augmented with intravenous bisphosphonates.

A 3-hour-old full-term female neonate presents with white pupils noted at the time of NICU admission. ### Prenatal and Birth Histories The infant was limp and cyanotic at delivery and required positive pressure ventilation for 5 minutes. No risk factors for sepsis were noted and there was no evidence of placental abruption. In addition, the fetal heart rate tracing was normal before delivery. The reasons for the perinatal depression at birth were unclear. Subsequently, the infant started breathing spontaneously and was transitioned to room air. Neurologic examination findings obtained at the outside facility were significant for wide-eyed appearance with staring and generalized low muscle tone. ### Presentation The infant was transferred to the NICU at 3 hours of age for therapeutic hypothermia evaluation. Initial physical examination findings were remarkable for the presence of leukocoria bilaterally. This was visualized easily with both ambient lighting in the patient room as well as direct examination with an ophthalmoscope (Fig 1). Red reflex was absent bilaterally. Figure 1. Bilateral leukocoria. The infant’s neurologic assessment findings at admission were consistent with moderate hypoxic-ischemic encephalopathy. Therapeutic whole-body cooling was initiated. An umbilical venous catheter was placed and continuous electroencephalogram obtained. The infant also received ampicillin and ceftazidime, intravenous fluids, and continuous fentanyl infusion. ### Vital Signs (3 Hours of Age)

The limping child is a common presentation to the emergency department. When confronted with a crying child who cannot walk or explain why, a structured approach based on an appreciation of the underlying physiology can help identify those children with (sometimes subtle) red flags, avoid unnecessary interventions and hospital stays. Here we discuss the differential diagnosis of an acute atraumatic limp, and suggest an approach to examination and investigation, including some key pitfalls and signs to look out for.

A previously healthy 27-year-old gravida 1, para 0 woman is admitted with preterm labor and loss of fluids at 28 weeks’ gestation. She receives antenatal steroids and obstetric ultrasonography shows bilateral cerebral ventriculomegaly and an absent stomach bubble. Before admission, her pregnancy had been uneventful and findings on early anomaly screening ultrasonography at 19 weeks’ gestation are normal. Serologic tests for maternal group B Streptococcus , cytomegalovirus, toxoplasma, and Treponema all have negative findings. The fetal tracing becomes non-reassuring and the neonate is born via emergency cesarean delivery. The neonate has apnea, hypotonia, and bradycardia at birth and does not respond to face mask ventilation. He undergoes intubation by 5 minutes after birth, with improvement in his heart rate, but he remains limp without any spontaneous breathing. His Apgar scores are 1, 2, and 3 at 1, 5, and 10 minutes after birth, respectively. Arterial and venous cord blood gases are 7.29 pH and 7.36 pH. Initial examination shows a preterm infant with appropriate weight, length, and head circumference for age, decorticate posturing, hypotonia of the lower extremities, …

Slipped Capital Femoral Epiphysis is the leading cause of limp in the adolescent population. This study aimed to discuss that intertrochanteric Imhauser osteotomy led to an improved functional outcome, and discussing indications, contraindications and surgical technique of Imhauser osteotomy.In moderate and severe slips, residual growth and remodeling after in situ stabilization are unable to compensate for the remaining femoral neck deformity. In these slips, a modified Dunn procedure might be more effective in order to reduce the risk of early onset hip osteoarthritis but carries high risk for avascular necrosis.Subtrochentric Imhauser osteotomy provides excellent option for correction of the residual deformities in chronic or healed SCFE.The Imhauser osteotomy is Subtrochentric valgus, flexion and internal rotation so correct the deformities in the chronic cases of SCFE. In consideration of our 23-year follow-up and in regard to other studies, we still consider the Imhauser ¨user osteotomy to be indicated for SCFE with angles of displacement >40°.

Background: Children with Legg-Calve-Perthes disease (LCPD) are classically described as small, thin, high-energy children presenting with a painless limp. Epidemiologic studies have historically been retrospective and regional in nature. The purpose of this study was to determine the demographic and clinical features of children presenting in the early stages of LCPD in an international, multicenter cohort. Methods: Children (6 to 10 years) in the early stages of LCPD (modified Waldenstrom stage I to IIa) were enrolled in a prospective, multicenter study. Demographic and clinical data at presentation were analyzed. Body mass index percentiles were determined using country-specific growth charts for children in the United States and India, two countries with largest enrollment. Statistical analyses included t-tests and chi-square. Results: A total of 209 children (86% males; mean age 7.9 ± 1.2 years) from 25 centers (six countries) were included. Eight-four percent of children presented with pain with or without a limp. Average pain score at presentation was 3 ± 2 (range 0 to 9), and 63% of children (n = 105) used pain medications. Of these children 65% required medication more than once per week. Thirty percent of children missed school due to pain in the past month, and of those, 74% missed at least 1 day per week. Twenty-nine percent of children from the United States and 20% of children from India were overweight or obese. Nineteen percent reported household smoking. Discussion: This prospective study provides a new international multicenter representation of early LCPD. The frequency of pain and missed school highlights the substantial morbidity and potential social cost and burden for children and families. The prevalence of being overweight/obese in our LCPD cohort was comparable to rates within the pediatric cohort as a whole, and fewer children have a history of smoke exposure than in previous reports. Level of Evidence: Level II, prospective comparative study.

1. Talin Nora Arslanian, MD* 2. Myriam Almeida-Jones, MD† 3. Sarah Myrlee Gustafson, MD*,‡ 1. *Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA 2. †Department of Pediatric Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 3. ‡Department of Pediatrics, Harbor UCLA Medical Center, Torrance, CA 1. Address correspondence to: Talin N. Arslanian, MD, Department of Pediatrics, David Geffen School of Medicine at the University of California, Los Angeles, 757 Westwood Plaza Box 951752, Los Angeles, CA 90095-1752. Email: tarslanian{at}mednet.ucla.edu A 26-day-old girl who was born at 39 weeks and 4 days’ gestational age via normal spontaneous vaginal delivery is brought in by ambulance for an episode of limpness and pallor. Her mother reports that she had been doing well until the morning of presentation when she became irritable during a diaper change, then became pale and limp. The episode was brief and had resolved by the time of paramedic arrival. This has not happened before. There are no other symptoms, no changes in feeding patterns, and review of systems is unremarkable. Prenatal, perinatal, postnatal courses are reviewed and noted to be uncomplicated, though there is no record of a prenatal anatomy ultrasound. Her temperature is 97.9oF (36.6oC), respirations are 36 breaths/min, heart rate is 160 beats/min, blood pressure is 88/63 mmHg, and oxygen saturation is 100% on room air. Physical exam reveals normal facies, regular rate and rhythm, a 2/6 holosystolic murmur at the left sternal border, and 2+ femoral pulses without brachio-femoral delay. There are also 5 well-circumscribed hypopigmented patches of varying sizes located on the chest, arm, abdomen, leg, and buttocks; the largest patch measures 2 cm by 1 cm. Labs show a white blood cell count of 8.7×103/mcL (8.7×109/L), hemoglobin of 15.2 g/dL, and platelets of 396 ×103/mcL (396×109/L). A chemistry panel reveals no electrolyte abnormalities; glucose is 103 g/dL, and total bilirubin …

Introduction Typical consequences of Legg-Calve-Perthes disease (LCPD) in its severe stage are pathological changes in the anatomy of the hip joint which lead to functional disorders of the musculoskeletal system, clinically manifested by limp. Objective To study biomechanical characteristics of walking in children with unilateral Legg-Calve-Perthes disease to determine the functional state of the musculoskeletal system after surgical treatment with the use of various methods. Material and methods Temporal and dynamic parameters of gait were studied in 31 patients with unilateral Legg-Calve-Perthes disease aged from 8 to 13 years old. They were examined two to five years after surgical treatment. In the control group of patients (15 children), varus osteotomy (VO) was performed. In the main group (16 children), triple pelvic osteotomy (TPO) was used. All children were operated in the disease stages II–IV corresponding to the classifications of S.A. Reinberg (1964) and to groups III–IV according to the classification of Catterall (1971). To objectify the study, 18 healthy children of the same age without signs of orthopaedic pathology were examined. Gait biomechanics were studied using the STEDIS complex (Neurosoft LLC, Ivanovo) that includes a set of platformless inert sensors "Neurosens" that record the data on accelerations in three mutually perpendicular planes. The temporal characteristics of the gait cycle and shock loads during walking were recorded. Results After surgical treatment, the biometrics of the support and shock load phases in both groups of children with LCPD did not reach the level of healthy individuals. It indicates preservation of deviations in walking parameters. The least significant asymmetry between the affected and unaffected limb were detected in patients after TPO, compared with patients after VO in whom the asymmetry of temporal parameters in the phase of the forefoot rocker and asymmetry of shock loads in the phases of rocking over the heel and ankle joint were preserved. Conclusion After ТPO operations in patients with LCPD, the gait was closer to the physiological one in comparison with patients after VO who retained a non-optimal motor stereotype. The reasons for such differences in motor activity between the groups of patients lies in the gluteal muscle dysfunction due to high position of the greater trochanter after corrective (varus) femur osteotomy and iatrogenic shortening of the affected limb. Triple pelvic osteotomy lacks these negative effects.

During COVID-19 pandemic, the world scientific community is seeking for efficient and high-quality means to battle the virus itself and its complications. Unfortunately, so far there is no specific methods to treat COVID-19. The main therapeutic strategies include supporting and controlling approaches. So prevention is the best way to eliminate the viral contagion. In the view of this, the scientists paid their attention to pentoxofylline which has been well-known in medicinal practice for a long time. Pentoxifylline is methylxanthine-derived which has been used for the last three decades to treat remittent limp. When used in clinical doses (max. daily dose — 1200 mg), it improves rheological blood values: it reduces plasma viscosity mostly due to decrease fibrinogen level; it leads to increase of erythrocyte elasticity and decrease of thrombocyte aggregation; it provides the increase of blood filtration due to inhibition of neutrophil activation. Viral infections are usually related to the constant formation of the oxidized products and COVID-19 is not an exception as well. Post-mortem analysis of the people affected with SARS-CoV showed the massive formation of the oxidized phospholipids (OxPL) during acute lung injury (ALI). By showing its anti-oxidant and anti-inflammatory properties, pentoxifylline renews glutathione level, supports mitochondrial viability, inhibits TNF-α production, saves the functions of vascular endothelium which in its turn reduces the length of stay at the hospital and ICU, frequency of multi-organ dysfunctions, mechanical ventilation time and mortality rate. Academic works show that pentoxifylline has anti-inflammatory, anti-oxidant, immune-modulating, anti-viral properties; it also has positive effect on respiratory symptoms alleviation which supports the idea that it can used as the adjuvant therapy for COVID-19 patients. Moreover, it can be also used to treat thrombotic complications at the severe COVID-19.

Limping in children is not an uncommon presentation in general practice. Although trauma is a major cause, and the aetiology usually obvious, the presentation of a child with atraumatic limp can cause significant concern in parents and carers. This paper will discuss atraumatic limp, concentrating on diagnoses which are common, serious or both.

Objective: It has been demonstrated that performing percutaneous coronary intervention (PCI) in the absence of mechanical circulation support (MCS) for patients with complex high-risk coronary artery disease bears a high risk. Alternatively, to figure out the procedure effectiveness and the mid-term prognosis of PCI for complex high-risk coronary artery disease, we accomplished the whole process by the assistance of extracorporeal membrane oxygenation (ECMO). Methods: Between July 2016 and October 2017, 6 consecutive complex and high-risk coronary disease patients underwent routine ECMO-supported PCI. Results: The average age of the patients was 70.5±11.98, and half of them (50%) were male. The mean creatinine (Cr) was 188.67±151.68 µmol/L. The average scores for SYNTAX, SYNTAX II, and LVEF pre the procedure was 41.33±12.14, 47.87±9.45 / 31.55±8.82, and 44.40±12.58%, respectively. The mean supporting duration of ECMO was 10.50±7.79 h. Regarding the postoperative complication, one case observed lower limp venous thrombosis and another reported infection at the access site. Two patients (33.3%) died for refractory heart failure during the follow-up course of 17.00±9.51 months, and the average net improvement index (NII) was 28.30±25.11% for this period. Conclusion: With the support of ECMO, the prognosis of complex high-risk coronary disease has shown to be improved by intervention in our study.

The objective is to describe an atypical case ofBernhardt-Roth syndrome, manifested without paresthesia and hypesthesia in the zone of innervation of the lateral femoral cutaneous nerve and accompanied by an intermittent limp and to demonstrate the effectiveness of surgical treatment of an atypical variant of this tunnel syndrome. Materials and methods. A pain intensity (on a visual analog scale), neurological status, walking ability, lower extremity function (on a Lower Extremity Functional Scale), and quality of life (using a NeuroQoL questionnaire), as well as the results of electroneuromiography, ultrasound examination of the nerves of the lower extremities, and magnetic resonance imaging of the hip joint were assessed before and after surgery in patient with Bernhardt-Roth syndrome. Results. A patient with an atypical variant of Bernhardt-Roth syndrome underwent neurolysis of the lateral femoral cutaneous nerve. The positive effect of surgical treatment (improving the quality of life and restoring the functional status of the lower limb) was revealed. Conclusion. Neurolysis of the lateral femoral cutaneous nerve is effective in the atypical version ofBernhardt—Roth syndrome.

There are limited reports on segment movement and their coordination pattern during gait in patients with hip osteoarthritis. To avoid the excessive stress toward the hip and relevant joints, it is important to investigate the coordination pattern between these segment movements, focusing on the time series data. This study aimed to quantify the coordination pattern of lumbar, pelvic, and thigh movements during gait in patients with hip osteoarthritis and in a control group. An inertial measurement unit was used to measure the lumbar, pelvic, and thigh angular velocities during gait of 11 patients with hip osteoarthritis and 11 controls. The vector coding technique was applied, and the coupling angle and the appearance rate of coordination pattern in each direction were calculated and compared with the control group. Compared with the control group, with respect to the lumbar/pelvic segment movements, the patients with hip osteoarthritis spent more rates in anti-phase and lower rates in in-phase lateral tilt movement. With respect to the pelvic/thigh segment movements, the patients with hip osteoarthritis spent more rates within the proximal- and in-phases for lateral tilt movement. Furthermore, patients with osteoarthritis spent lower rates in the distal-phase for anterior/posterior tilt and rotational movement. Patients with hip osteoarthritis could not move their pelvic and thigh segments separately, which indicates the stiffness of the hip joint. The rotational movement and lateral tilt movements, especially, were limited, which is known as Duchenne limp. To maintain the gait ability, it seems important to pay attention to these directional movements.

A 23-year old male with bilateral hip dislocations and associated femur head fractures (Pipkin type-II) presented with pain and flexion deformity of both hips after 9 days. After imaging, closed reduction was attempted but failed. Open reduction through Kocher-Langenbeck approach was performed and the femoral head fracture was accessed through Ganz's safe surgical dislocation. The fracture was reduced anatomically and fixed with headless Herbert screws. After two years, the patient was walking without pain or limp and there was no evidence of osteonecrosis. Simultaneous sequential Ganz's safe surgical dislocation can be performed in bilateral Pipkin's fracture dislocation with excellent short term outcome.

Role of surgical containment in late onset and healed Perthes is still controversial and ill defined. Untreated and partially treated Perthes disease can progress to osteoarthritis by the fourth decade. The main complication is femoral head deformation. Two important factors contributing to complication: 1. Extruded femoral head2. Deformed head leads to early onset of osteoarthritisThis study evaluates the clinical and radiological outcome of varus derotation osteotomy (VDRO) in late onset and early healed Perthes with extruded femoral head with remaining growth potential.Materials and Methods: 30 children (19 males and 11 females) falling in the group of 10-16 years, belonging to modified Elizabethtown classification Stage 4–healed stage / Waldenstrom’s stage 4- residual stage, radiologically – reossified, extruded, deformed femoral head are treated with open wedge VDRO, between 2009 and 2017 were included in this study. 21(70%) are between 10-14yrs, rest are 14 – 16yrs, mean age of osteotomy is 12.37yrs. All patients had limitation of abduction and internal rotation. 14 patients (46.67%) had pain at the hip and 26 patients (86.7%) had limp. Mean time between diagnosis and corrective surgery was 3 weeks.Results: The evaluation was done using caput index (CI) and epiphyseal quotient (EQ) radiologically, range of motion and Harris Hip Score for clinical outcome.Our minimum follow up was 3yrs and maximum follow up of 10years. We studied Radiological and clinical parameters on 3rd year follow up. All measurement was done on pre-op, post op x-rays at 3rd year follow up and also compared with the contralateral hip. We noted improvement in the clinical outcome and radiologically femoral head attained more spherical contour after containment. In our studies 21 children (70%) had good result with Spherical head and fully contained by acetabulum, 6 children (21%) had fair result with congruent head and acetabulum covering>4/5th of femoral head. Rest 3 children had poor result with clinically symptomatic and extruded deformed head. There was a significant change (P = 0.000) in CI among all the patients after surgery. The final EQ after 3 years of VDRO was 0.685 and was significant (P = 0.0000).Conclusion: In Healed perthes with extruded and deformed femoral head, containing with VDRO helps to achieve a spherical femoral head, thereby delaying the onset of osteoarthritis. Mould for a spherical femoral head is the acetabulum. Containg the head resumes its growth until achieving skeletal maturity. The remaining growth potential is utilized to mould the head into sphericity.

Pyometra in dogs is a condition of the accumulation of purulent material in the uterus of female dogs caused by hormonal imbalances resulting in bacterial infections and excess fluid production in the uterus. A female Golden Retriever named Merry, age 4 years old, having her address at Jln. Raya Dharmasaba Denpasar with complaints of a limp dog, anorexia, issued a thick reddish-colored discharge from the genitals and smelly. Based on the results of systematic clinical examination and the results obtained that the temperature of the dog is 38.1 ℃ (normal), pulsus frequency 120x/minute and the frequency of breathing 40x/ minute. At the time of inspection and palpation of the large abdomen, the nipple comes out. In a complete blood test conducted at Anom Animal Clinic showing the results of Leucosytosis (an increase in white blood cells) which indicates the incidence of bacterial infection, the dog is diagnosed with pyometra after being supported also by X-ray examination results showing radiopaque on the abdomen and ultrasound results showing the uterus anechoic. Dogs treated by surgery to remove the ovary and uterus (ovaryohysterectomy) and continued administration of antibiotics and analgesics. On the 9thday after surgery the incision wound had dried, the skin fused well, and was no longer removing the discharge from the genitals.

Recountings of the Washington, DC punk rock scene’s history often start with the founding of Dischord Records in 1980 and focus on the subsequent ascent of Dischord co-owner Ian MacKaye’s bands like Minor Threat and Fugazi. As seminal as Dischord remains in the narrative of DC punk ‐ a community still thriving today ‐ the years just prior to the label’s founding generated the scene’s true incunabula. Beginning with the self-released debut EP from the Slickee Boys in 1976, this first wave of DC bands ‐ also including Razz, Nurses, White Boy and others ‐ combined elements of art rock, surf, proto-punk, pub rock and power pop together to craft a protean version of punk that embraced eccentricity and humour, serving as the city’s own defiant rebuke of the staid state of 1970s rock music. No record label was more central to the nascent punk scene in DC than Limp Records. Operated by Skip Groff, Limp provided the punk community with its first proper record label. Rather than a label that centred around the efforts of a single band ‐ as most other new DC punk labels did ‐ Limp issued singles for several groups, collaborating with the fledgling Dacoit and O’Rourke labels to co-release defining singles for the Slickee Boys and Razz. DC punk would not have taken shape the way it did without Groff’s efforts, particularly considering his connections with bands like Bad Brains and the Slickee Boys and his musical and entrepreneurial influence on local teenage punks like MacKaye, Jeff Nelson and Henry Rollins. This article is a history of DC punk record labels from 1976 to 1980 and seeks to establish this overshadowed era of the scene as one of the most critical in the community’s 43-year existence. Considering the outsize influence the DC scene ultimately had on punk culture ‐ whether through the eponymous clean living philosophy inspired by the Minor Threat song ‘Straight Edge’, the unwaveringly independent business model of Dischord or the pacesetting music reliably turned out each decade by participants in the scene ‐ the impact of Groff and his first wave DC punk peers must be acknowledged.

Objectives The purpose of this study is to discuss the natural history and management of primary epiphyseal osteomyelitis (PEO), to differentiate clinico-radiologic features of PEO caused by Mycobacterium and other organisms, and to discuss their intermediate-term outcomes. Methods Between 2006 and 2017, 18 patients of PEO were managed at our center. Blood investigations, x-rays, and magnetic resonance imaging of affected part were carried out. Surgical drainage of lesions was done to retrieve infective fluid and tissue for examination. Antibiotics were administered for 1 year in Mycobacterial PEO and for 6 weeks in bacterial PEO. Average follow-up of patients was 5.5 years (range, 2 to 11 y). Results Boys were more commonly affected (11/18). Distal femur was the most common site involved (12/18). Eleven patients had Mycobacterium tuberculosis as the causative organism, 6 were positive for Staphylococcus aureus, and 1 for Brucella. Swelling and limp were predominant in patients with Tubercular PEO, whereas pain was more common in bacterial PEO. Nine of 11 patients with Tubercular PEO had penetration into the joint, whereas none in bacterial PEO. All patients recovered completely without residual movement restriction or growth alteration. On follow-up magnetic resonance imaging, 4 patients with Tubercular PEO had thinning of articular cartilage. Conclusion High index of suspicion is required for early diagnosis of PEO. It is important to differentiate Tubercular from other bacterial PEO as it has more subtle symptoms and poor prognosis if left untreated. Aggressive surgical treatment followed by antibiotic therapy of appropriate duration is required to avoid complications related to joint destruction. To our knowledge, this is the largest reported series with longest follow-up.

Background: The of the iliopsoas abscess is a rare entity with a variable etiology. Its location and nonspecific clinical features makes it becomes a diagnostic and therapeutic challenge for the general surgeon. The opportunity to treat a series of cases in a relatively short period of time motivates this communication.Objective: From a consecutive case series, we analyze etiology, clinical features , as well as diagnostic and therapeutic approaches, with special emphasis on percutaneous drainage, as well as a brief review of recent literature.Material and methods: Retrospective analysis of a consecutive series of six patients diagnosed with an ilipsoas abscess in a tertiary care center.Results: The series consists of 6 cases, 5 of primary type and 1 of secondary type. Pain, Limp and leu- cocitosis were the more prevalent signs; computed tomography of the abdomen was the diagnostic method of choice. Percutaneous drainage was the therapeutic option in 5 cases (83.3%), while in the remaining, antibiotic therapy and the drainage of an adjacent collection were indicated. The evolution of all cases was favorable with no mortality nor morbidity.Conclusion: The iliac psoas abscess is a pathology that needs a high level of suspicion given its nons- pecific presentation. For diagnosis, together with the clinic, computed tomography is the method of choice. Percutaneous drainage of collection under tomographic control is a safe and effective option for the treatment of this entity

Background Neglected traumatic hip dislocation in children is uncommon and there is no consensus on appropriate management. Previous studies report varied operative management with high rates of avascular necrosis and postoperative subluxation/dislocation. We report a series of 7 consecutive cases who underwent operative reduction after neglected hip dislocation and describe our technique for treatment. Methods All 7 children sustained posterior dislocations and had no treatment before presentation at our institution. An associated marginal acetabular fracture was present in 2 cases. One additional patient was excluded from the study due to complete loss of articular cartilage that precluded open reduction. The mean time before surgical intervention was 13.1 months (4 to 36 mo) with a mean age of 7 years (5.3 to 10.8 y). All children underwent preoperative skeletal traction for 10 to 14 days. A postero-lateral approach was used in all cases. The acetabulum was cleared of scar tissue and a femoral shortening performed as required (5 cases). Minor erosion of the articular cartilage of the posterior aspect of the femoral head was noted in 3/6 cases. After reduction, a posterior capsulorrhaphy was performed and the patient immobilized in a hip spica for 6 to 12 weeks. Results The mean follow-up was 44 months (33 to 56 mo). The majority of children (86%) could walk and run without a limp, could squat, and had no pain. One child had mild pain and a limp. Mean Harris Hip Score was 98.9. No hip subluxed or dislocated postoperatively. The radiographs at latest follow-up showed no evidence of growth disturbance in 29% of cases, coxa magna in 57%, and partial femoral head collapse in 1 case (14%). Of note, those patients managed within 8 months of injury had none or minimal evidence of growth disturbance. Conclusions At medium-term follow-up, open reduction with a postero-lateral approach, posterior capsulorrhaphy, and femoral shortening (as required) produces a satisfactory outcome with a stable, congruent reduction. Good clinical function can be expected with a low incidence of avascular necrosis. Level of evidence Level IV.

A limp is a common presentation to pediatricians, emergency centers, and orthopedists. A directed history and physical examination, and the development of a differential diagnosis based on limp type, patient's age, and the anatomic site that is most likely affected, provides a selective approach to diagnostic testing. Laboratory tests are indicated when infection, inflammatory arthritis, or a malignancy is considered. Imaging usually begins with plain radiography. Ultrasonography is valuable in assessing irritable hips. Advanced imaging is done in select cases. Prompt referral to an orthopedist is essential, especially if septic joint, vascular or compartment issues, or open fractures are suspected.

The success of assembly process automation is strongly influenced by the part design. To support process automation, already in the 1960s and 70s part design rules were developed. These rules exist almost exclusively for rigid parts, however, in reality many products like for example automotive wire harnesses consist of a considerable amount of limp components. In this paper, we derive design rules to support assembly automation for parts containing limp components. The derived design rules are based on our approach for limp component classification. Therefore, we extend this approach with an attribute ranking system and a characteristic classification.

Ankle and foot injuries present a persistent problem for athletic populations,[1][1] and this is reflected in military populations where these injuries are one of the most common musculoskeletal presentations[2][2] causing impact on the deployability of service personnel. For example, 16 Air Assault

Background: Primary meningococcal arthritis (PMA) is defined as the presence of acute septic arthritis with the identification of Neisseria meningitidis in synovial fluid or blood cultures but no clinical evidence of sepsis or meningitis. This report aimed to describe a clinical case of PMA caused by serogroup W, an uncommon etiology of this disease in Uruguay, and review the available literature. Case report: We report the case of a 5-year-old female, with no past medical history, admitted to the emergency department with a 12-hour history of fever of 39 °C and a limp. The patient was hemodynamically stable and had no clinical evidence of meningitis. Hip ultrasound showed an increase in synovial fluid. Arthrocentesis showed purulent exudate and synovial fluid culture showed no growth after five days. The blood culture showed isolates of N. meningitidis, serogroup W. The patient received treatment with ceftriaxone, and drainage of the affected joint was performed with excellent clinical response. Conclusions: Primary meningococcal arthritis is a rare presentation of meningococcal disease. Systematic arthrocentesis and the adequacy of antibiotic therapy when septic arthritis is clinically suspected are essential for confirming the diagnosis and decompressive drainage of the involved joint. This report is the first of PMA caused by serogroup W in Uruguay. Although the most common serogroup involved in meningococcal arthritis is serogroup B in Uruguay, an increase in serogroup W-related diseases has been reported in Chile and Argentina, emphasizing the need for epidemiological surveillance.

Introduction: Abductor deficiency can be a debilitating problem following hip arthroplasty surgery and causes severe pain, limp and instability. Description of Technique: The authors had experienced abductor deficiency secondary to hemiarthroplasy following which a revision hemiarthroplasty was done and abductor reconstruction was performed using the anterior fibres of gluteus maximus. This flap served as a substitute for gluteus medius and minimus. Ultimately, both limp and pain showed prominent reduction. Keywords: Abductor reconstruction with gluteus maximus, Revision hemiarthroplasty.

OBJECTIVES Low health literacy is both pervasive in the United States and a substantial barrier to satisfactory patient care and the appropriate utilization of healthcare resources. This prospective study aims to evaluate the factors that contribute to limited musculoskeletal literacy in patients who undergo shoulder arthroplasty. METHODS Ninety patients undergoing shoulder replacement surgery completed demographics and Literacy in Musculoskeletal Problems (LiMP) surveys. Scores of less than six were considered indicative of limited musculoskeletal literacy. RESULTS The overall percentage of participants with limited musculoskeletal literacy was 38.8%. Multivariable logistic regression analysis with multiple imputation modeling demonstrated a significant positive relationship between patient income and adequate LiMP scores (p = 0.009) with an odds ratio of 1.15 (CI: 1.04; 1.28) while level of education (p = 0.173) and patient ethnicity (p = 0.830) among other patient characteristics did not have a significant relationship with LiMP scores. CONCLUSION In patients undergoing shoulder replacement surgery, low income was the only variable found to be predictive of limited musculoskeletal health literacy scores. Therefore, when discussing the risks and benefits of shoulder arthroplasty, orthopaedic surgeons should be cognizant of the possibility that any given patient may not meet the threshold of adequate musculoskeletal literacy.

Background Tropical pyomyositis has had a recent increase in the United States, Europe, and other nontropical areas. The purpose of this study was to provide an accurate description of the demographics, presenting features, sites of involvement, microbiology, imaging modalities, medical and surgical management, complications, and predictors of clinical course. Methods We searched PubMed, Cochrane, Web of Science Collection, Scopus, and Embase databases yielding 156 studies. Of these, 23 articles were selected for statistical analysis. Results The average age at presentation was 8.4±1.9 years with males more commonly affected. Fever, painful limp, and localized pain were the most common presenting symptoms. Pelvis, lower extremity, trunk and spine, in descending order, were the most commonly affected locations. Iliopsoas, obturator musculature, and gluteus musculature were the most commonly affected muscle groups. The mean time to diagnosis was 6.6±3.05 days. Staphylococcus aureus was the most common offending organism. The mean length of hospital stay was 12.0±4.6 days. Medical management alone was successful in 40% of cases (143/361) with an average duration of 9.5±4.0 and 22.7±7.2 days of intravenous and oral antibiotics, respectively. Surgical management consisted of open drainage in 91.3% (199/218) or percutaneous drainage in 8.7% (19/218) of cases. Painful limp, fever, and larger values of white cell count and erythrocyte sedimentation rate were associated with an increased need for surgery. Obturator and calf muscle involvement were strongly associated with multifocal involvement. There were 42 complications in 41 patients (11.3%). Methicillin-resistant S. aureus was associated with an increased risk of complications. The most common complications were osteomyelitis, septicemia, and septic arthritis. Conclusions Primary pyomyositis should be considered in cases suggesting pediatric infection. Magnetic resonance imaging is the most commonly used imaging modality; however, ultrasound is useful given its accessibility and low cost. Medical management alone can be successful, but surgical treatment is often needed. The prognosis is favorable. Early diagnosis, appropriate medical management, and potential surgical drainage are required for effective treatment. Level of evidence Level IV-systematic review.

Background: There are controversies regarding the diagnosis of lupus nephritis. Also, its clinical manifestations and severity are different from one patient to another. Objectives: The current study aimed to interpret clinical and laboratory features of lupus nephritis according to the results of the biopsy. Methods: Following a retrospective design, 30 patients with lupus, who were candidates for renal biopsy and undergoing kidney biopsy, were studied. Clinical findings (blood pressure and limb edema) and laboratory findings (Cr, ESR, CRP, BUN, C3, C4, CH50, Anti-ds DNA, and hematuria) were gathered. Finally, the diagnostic value of clinical and laboratory findings was interpreted according to the biopsies and the staging of samples in the pathology. Data were analyzed using SPSS. Quantitative variables are displayed using mean and quartiles. Fisher’s exact test was used to compare study groups. Also, independent samples t-test and Levene’s test were used to evaluate variances of quantitative variables. Results: Of 30 cases, 5 had a biopsy of 3 and FSGN. Also, 8 cases were on stages 3 and 4, 9 had a stage of 4 biopsy, and 8 cases were on stage 4 - 5, 5, and 5 - 6. The association between age, Limp edema, ESR, and biopsy was statistically significant (P < 0.05). Conclusions: This study demonstrated the usefulness of clinical and laboratory findings to determine the severity of the disease in the shortest time, mainly due to its easy, non-invasive access and early preparation of the results, which will facilitate the initiation of treatment.

Objectives Legg-Calve-Perthes disease (LCPD) and Blount's disease share a similar presenting age in addition to similar symptoms such as limp or knee pain. A little overlap is mentioned about both diseases. We sought to present cases of children having both conditions to discuss the implications of this co-occurrence on diagnosis and management. Methods After institutional review board approval, we retrospectively reviewed records of four children who developed both Blount's disease and LCPD. Patient details and outcomes were analyzed. Radiographs were evaluated for the lateral pillar classification, Stulberg classification, tibial metaphyseal-diaphyseal angle and tibiofemoral angle. Results Two of the cases were initially diagnosed with Blount's disease and subsequently developed Perthes, one case presented initially with both disorders and the final case had Perthes followed by Blount's. Three children were obese and one was overweight. The common symptom to all patients was an abnormal gait, which was painless in two children and painful in two. Blount's disease required surgery in three children. Radiographs showed Lateral Pillar B, B/C border and C hips, and the final Stulberg was stage II (n = 2) or stage IV (n = 2). Conclusion Obesity is associated with Blount's disease and LCPD, so obese children can be at an increased risk of developing both disorders. Therefore, a child with Blount's disease who has persistent, recurrent or worsening symptoms such as gait disturbance or thigh or knee pain might benefit from a careful physical exam of the hips to prevent a delayed or even missed LCPD diagnosis.

1. Sarah Gustafson, MD*,† 2. Darien Nguyen, MD* 3. Michael Bolaris, MD*,† 1. *Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA 2. †David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA A previously healthy 10-year-old boy presents with 12 days of headache, 8 days of fever, and 3 days of generalized weakness. His headaches are associated with photophobia and localize to the right retro-orbital region. The headaches and daily fevers (102o–104oF [38.9o–40oC]) are unresponsive to medications. On the day of hospital admission he has developed worsening fatigue, weakness, intermittent pain in his posterior thighs and calves, and a limp favoring his left side, and he has started dropping objects. His eyes also appeared red 1 day before admission. His mother notes a 2-lb weight loss during the past week. There is no congestion, rhinorrhea, sore throat, chest pain, abdominal pain, emesis, hematuria, dysuria, diarrhea, rash, easy bruising, or easy bleeding. He lives in a suburban home with 4 dogs and 1 cat. Other animal exposures include multiple rats in the backyard but no known direct contact with the patient. He has not traveled recently and denies new food exposures or sick contacts. He is fully immunized. His temperature is 103.1oF (39.5oC), heart rate is 146 beats/min, blood pressure is 115/64 mm Hg, respirations are 22 breaths/min, and oxygen saturation is 100% on room air. On physical examination he is tired but well-appearing, with no pallor or jaundice. No conjunctivitis is noted. There is pain on passive neck flexion. A 1-cm left anterior cervical lymph node is palpated. Mucous membranes are dry, lips are cracked, and he is tachycardic with a 2/6 systolic murmur at the left sternal border. Neurologic and musculoskeletal examination findings are normal except for an antalgic gait favoring the left side. Laboratory evaluation is significant for the following values: white blood cell count …

BACKGROUND Pediatric limp is a common presenting complaint to emergency departments. Despite this, diagnosis can be difficult in young patients with no history of trauma. Ultrasound can be used to identify a hip effusion, which may be the etiology of limp in pediatric patients. Brief educational training sessions have successfully been used to introduce novice ultrasound users to point-of-care (POC) ultrasound; however, the education of POC hip ultrasound is underexplored, and the efficacy of educational training sessions in this domain remains unknown. OBJECTIVE To evaluate the feasibility and efficacy of using a brief educational training session to teach novice ultrasound users to identify hip anatomy and effusions. METHODS Medical and physician assistant students were enrolled during an ultrasound education conference. A pretest evaluated prior knowledge, experience, and confidence level regarding POC hip ultrasound. Students attended a brief didactic session and then completed an objective structured assessment of technical skill as well as a posttest. RESULTS Twenty-eight students naive to hip ultrasound participated in this study. Levels of training included medical and physician assistant students. Mean test scores increased from the pretest (4.8 of 9, SD = 1.6) to the posttest (7.9 of 9, SD = 0.72) (P < 0.001). Average objective structured assessment of technical skill was 4.6 of 5 (SD, 0.75; 95% confidence interval, 4.3-4.9). After the sessions, confidence levels in identifying landmarks, joint space, and a joint effusion significantly increased (P < 0.001). CONCLUSIONS Pediatric hip ultrasound knowledge, performance, skills, and confidence improved as demonstrated by novice ultrasound users after a brief educational training session. Our study shows that a brief, targeted educational intervention was a feasible and effective method of introducing pediatric POC hip ultrasound to novices.

We aimed to report outcome of a limb salvage of 3 weeks open infected tibia fibula fracture treated by Ilizarov external fixator (IEF). A male 42-year-old male, had sustained a motorcycle accident leading to a midshaft open type IIIB comminuted tibia fibula fracture. In face of poor prognosis, after 10 days, due to inadequate wound care, the orthopedic team made a decision to amputate the leg. In the context of lack of means, the patient has been transferred to a community hospital at Kpalime, town located at 120km from Togo’s capital in other to be managed by a team of trip missionary. After three procedures and intensives wound care associated to appropriate antibiotic, the consolidation was achieved at 6 months. A year follow up showed healing without infection. Patient walked with a limp and no cane. A combination of a stronger immune system, proper external fixation with adequate compression and thorough wound care treatments allowed this patient to keep his leg and perform daily activities.