Introduction: In children younger than 4-year-old, septic arthritis of the hip is more frequent than transient synovitis. This study aims to report the clinical outcomes and the microbiological results in a large group of children with confirmed K. kingae septic arthritis of the hip. Moreover, its purpose is also to assess the reliability of Kocher/Caird criteria to predict septic arthritis of the hip caused by K. kingae.
Methods: The medical charts of 140 children younger than 4-year-old suffering from a confirmed K. kingae septic arthritis of the hip were collected through a multicenter hospital database. Gender, age, temperature at admission, weight-bearing status, WBC, platelets count, CRP value, ESR and platelets count were extracted for each patient. Our attention focused on the Kocher/Caird prediction criteria for hip septic arthritis (body temperature, refusal to bear weight, leukocytosis, erythrocyte sedimentation rate, and C-reactive protein level) to assess their efficiency.
Results: All patients included in the study had confirmed K. kingae SAH; most of them presented with mild symptoms and near-normal laboratory. CRP (76.2%) had the best sensitivity for Kocher/Caird criteria, followed by weight bearing status (73.8%) and WBC count (69.6%). Body temperature and ESR exceeded cutoffs values of the Kocher/Caird algorithm in less than 50% of cases. Among 77 patients with full available Kocher criteria, 63.5% showed less than 40% probability to suffer from SAH. About the 50 children with completely available Caird criteria, 40% of them presented a 62.4% probability of SAH.
Conclusions: K. kingae septic arthritis of the hip can mimic many other medical conditions. Our results showed that Kocher & Caird criteria are insufficient to diagnose a septic arthritis of the hip due to K. kingae in pre-school aged children.

Transphyseal hematogenous osteomyelitis is a much more common infectious condition of what is recognized in the literature. A large proportion of acute or subacute pediatric hematogenous osteomyelitis can diffuse through the growth cartilage and therefore may be potentially responsible for growth disorders, leading to limb length discrepancy or angular deformities. The literature does not address this issue, and it is currently difficult to determine the real prevalence of this type of complications.

The present study aimed to identify both the prevalence of complications caused by transphyseal osteomyelitis, and factors influencing their occurrence.

All patients treated for transphyseal hematogenous osteomyelitis over a 17-year period at the University Hospitals of Geneva and the Gesù Bambino Hospital in Rome were retrospectively analyzed. Clinical, biological and bacteriological data were analyzed. Magnetic resonance imaging was reviewed for all patients to assess the surface area of growth plate involvement.
Restart of growth of the affected physeal cartilage was subsequently monitored by iterative radiological examination.

89 patients with a transphyseal hematogenous osteomyelitis were identified among a cohort of 594 hematogenous osteomyelitis (15.0%). Median age was 84 months [1; 167 months] with a bimodal distribution and peaks at 30 and 150 months of age; 59.6% (53/89) of patients were male. The lower limbs were most often affected, with the distal tibia and fibula accounting for 47.2% of all cases. Methicillin-sensitive Staphylococcus aureus and Kingella kingae were the most frequently identified pathogens, accounting for 41.2% of the total. Virulence factors, such as Panton-Valentin Leucocidin (PVL), Toxic Shock Syndrome Toxin (TSST), Accessory Gene Regulator (Agr) were recorded in 12.4% of cases. Transphyseal lesions affected in median 7.57% [0.79; 58.2] of the physeal surface and was greater than 7% in over 54.1% of cases. Complications affecting further growth were noted in 13% of THO. We noted that the presence of thrombocytopenia, marked leukocytosis on admission, and the presence of virulence factors significantly influence the occurrence of complications.

The prevalence of complications after THO was lower than suspected and occurred only 13% of cases. Finally, the presence of deep thrombocythemia, major leukocytosis and virulence factors, such as Agr, TSST, PVL, seems to strongly influence the occurrence of such complications.

Background: We carried out a historical narrative review of the studies on clinical and laboratory test algorithms for pediatric septic arthritis of the hip (SAH), to contextualize the Kocher and Caird criteria in their and our epoque.
Materials and Methods: The original papers by Kocher and Caird were critically appraised and their bibliography retrieved and studied. An extensive search of the literature on both the epidemiology and the clinical and laboratory criteria for SAH before and after the publication of the Kocher and Caird criteria was carried out. These studies were compared with Kocher and Caird and a historical overview was drawn.
Results: We retrieved 51 publications, including Kocher and Caird reports. By critically appraising Kocher and Caird’s studies, it emerged that their predictive criteria for SAH were originally validated in studies comparing SAH and transient synovitis of the hip (TSH) in children with a wide age range, without distinction for age subgroups. Moreover, these criteria were individuated and validated in a-priori-determined classes of patients—true SAH, presumed SAH, and true TSH—based on a joint fluid arthrocentesis (JFA) white blood cell count threshold of 50,000/mm3 and the results of JFA and blood cultures. Due to methodological differences among studies, validating Kocher and Caird criteria in different settings was not feasible. Moreover, the slow emergence of Kingella kingae in the pediatric osteoarticular infection scenario and the slow implementation of new diagnostic technologies have very likely contributed to the lack of validation of the Kocher Caird criteria, since the culture-negative cases could have been misdiagnosed and misclassified.
Conclusion: The Kocher and Caird algorithms completely ignore that clinical and biological aspects of SAH are closely related to a child's age and, above all, the pathogen responsible. They were also established in a period when the importance of Kingella kingae contribution was completely unknown. Further studies are required to define the biological markers that can unquestionably distinguish pediatric SAH (especially when due to K. kingae) and its mimics. New perspectives should be investigated by future research on the prediction rules of septic arthritis of the hip in children considering specifically the recipients’ age et the incriminated pathogens.

Introduction: As analyzing pediatric radiographs are always a challenge due to the growth plate and ossification centers we wanted to compare the gaze pattern behaviors of orthopedists and pediatricians when interpreting pediatric foot and ankle radiographs and their diagnostic accuracy. Our second aim was to assess the diagnostic accuracy of orthopedists and pediatricians with different levels of experience and Artificial Intelligence (AI) when interpreting pediatric foot and ankle radiographs.
Methods : Participants had to analyze 23 pediatric foot and ankle radiographs and to assess if there was a fracture. We selected the radiographs from patients who consulted in the emergency room. There was 10 normal x-rays and 13 x-rays with fracture of the foot and ankle. Their gaze pattern behaviors were assessed through an eye-tracker Eyelink 1000 Plus and the data collected in EvdentIDE (Okazolab). We analyzed the following eye-tracking data: amplitude of saccades, fixation duration of saccades, and count of saccades per second. We evaluated the diagnostic accuracy via the sensitivity and the specificity. Our artificial intelligence program was Gleamer.
Results : We had 25 participants (17 resident in orthopedic et 8 resident in pediatric). The orthopedists had a mean amplitude of saccades of 3.88 and a mean duration of saccades of 32.92ms. The pediatricians had a mean amplitude of saccades of 3.14 and a mean duration of saccades of 28.62ms. The difference between the two groups were significant (p < 0.0001). The orthopedists had a number of 3.07 fixations per second while the pediatricians had a number of 2.38 fixations per second. The orthopedists mean diagnostic accuracy was 74.4% : sensitivity of 76.5% and specificity of 76.3% and the mean diagnostic accuracy of the pediatricians was 72.92% with a sensitivity of 72.1% and specificity of 73.75%. For the AI, the sensitivity was 92% and the specificity 80%, with a mean of 87%.
Conclusion & perspectives: There’s a difference in the way of analyzing radiographs between orthopedic surgeon and pediatric physician. In general larger amplitudes of saccades are associated with a higher diagnostic accuracy. The AI doesn’t have a diagnostic rate of 100%.

Background:

Detecting developmental dysplasia of the hip (DDH) in infants is crucial, and various screening strategies have been proposed, including clinical examination and ultrasound. However, controversy exists regarding which screening method is optimal. There is no agreement on whether hip ultrasound should be performed on all newborns (universal screening) or only in those with risk factors or clinical instability of the hip during clinical examination (selective screening). We assessed the sensitivity of clinical screening for DDH conducted by experienced pediatric orthopedic surgeons in newborns.

Methods:

In this retrospective study, we compared the records of the clinical exam to the hip ultrasound according to Graf in 122 newborns aged between 0 -3 months treated at our tertiary care center for primary DDH.
Statistical analysis was applied to calculate the sensitivity of the clinical examination.

Results:

Clinical screening showed a sensitivity of 66%. This indicates that 34% of DDH cases would have not been diagnosed through clinical examination alone. Furthermore the sensitivity of the exam for unstable patients (Graf D, III and IV) was 91% and as low as 50% for stable patients (Graf IIA, IIB and IIC). This difference in sensitivity was statistically significant (P < 0.05).

Conclusion:

Clinical screening, even when conducted by experienced pediatric orthopedic surgeons, exhibited limited sensitivity. Universal ultrasound screening at birth provides a more comprehensive evaluation and has the potential to reduce delayed diagnoses and their associated complications.

Understanding the implications of decreased femoral torsion (FT) on dynamic
components of children and adolescents might help orthopaedic surgeons to optimise treatment to
avoid long-term damage. To date, there is limited evidence regarding the kinematic gait deviations
between children with FR and typically developing children (TDC) as well as regarding the
implications of FR on the adaptation of walking to running gait. An explorative 3D motion analysis
study was conducted to measure gait deviations during running and walking in patients with
decreased FT (n=15) compared to TDC (n=11). A linear mixed model was used to establish
comparisons within and between the aforementioned groups and investigate the relation between
the clinical examination, spatial parameter and difference mean hip rotation from running to
walking. Patients walked with an external mean hip rotation compared to an internal mean hip
rotation in controls and had higher peaks for the hip external rotation, knee valgus and out-toeing
in terms of foot progression angle. The same kinematic gait pattern was observed during running
and was significant for the peak knee valgus. With regard to the differences from running to
walking, patients turned their external rotated hip 3.84° internally, where controls kept the same
internal hip rotation. Patients revealed similar kinematic gait deviations during running compared to
walking as controls. The passive hip range of motion, torsions and velocity had no notable
influence on the difference mean hip rotation from running to walking. Patients with decreased FT
showed deviation in 3D gait kinematics. This study underscores the potential of 3D gait kinematics
to elucidate the functional implications of decreased FT and hence contribute to clinical evaluation
and decision making.

Background: Lower-extremity torsional abnormalities are a group of structural abnormalities impacting the foot progression angle, leading to an in-toeing or out-toeing gait depending on the direction of tibial torsion. Several clinical and radiological measurement methods are used, of which the CT scan is considered as the most accurate. Assessment with a CT scan include the use of the tibial plateau axis and the bimalleolar axis. However, we consider that the bimalleolar axis gives an inaccurate information about the foot position during the gait. The main aim of this study was to compare different tibial torsion assessments, considering a new method for the orientation of the ankle: TA (talar axis).

Methods: 120 CT-scans carried were retrospectively reviewed in pediatric patients. Clinical datas were collected from records. 4 measurements were performed: PTTA (proximal transtibial axis), PMTPA (posterior margin tibial plateau axis), IMA (intermalleolar axis) and TA (talar axis).

Results: 100 CT scans (38 girls, 62 boys) were included. Mean age was 11 ± 4.4 years old. Mean value of thigh-foot angle and bimalleolar angle were 15.6° ± 16° and 16.3° ± 16.5°. Mean value was -7.1° ± 14.7 for PTTA and -7.6° ± 14.2 for PMTPA without statistically difference (p > 0.05). Mean IMA was 5.8° greater than TA: 23° ± 16.2 vs 17° ± 16.9 with a statistically significant difference (p < 0.05). Mean tibial torsion angle was 27.3° and the mean time required for these measurements was 6'44'', with 2'24'' for PTTA, 36'' for PMTPA, 2'14'' for IMA and 1'12'' for TA.

Conclusion: The tibial torsion value may differ at the ankle level. PMTPA and TA should be used since it is a faster technique, in particular if the medial malleolus is not yet ossified.

Introduction : The too-long anterior process of the calcaneus (TLAPC) is a morphological anomaly which is recognized to generate an impingement due to both its interposition between the head of the talus and the cuboid and to its support on the navicular, causing pain facing the sinus tarsi and responible of subtalar stiffness. Nowadays, the diagnosis of TLAPC is defined on a calcaneonavicular distance (CND) less than 5-10 mm, based mainly on CT scans and plain radiography with small series of subjects. However, there is not a clear definition of normative values of the calcaneonavicular distance in a larger population that could be used to define a threshold for TLAPC and the distance that should be aimed after a surgical resection.

Methods : We rewieved 363 MRIs of healthy controls and 129 MRIs of symptomatic foot with a diagnosis of TLAPC. The calcaneonavicular distance was measured as the distance between the anterior process of the calcaneus and the navicular bone in sagittal and axial view in both groups.

Results : The mean CND was statistically different (p < 0.05) for all the measures compared between the control and TLAPC group. Surprisingly, the mean CND in the control group ranged from 4.51 ± 1.62 to 5.68 ± 2.01 mm according to the view used, and 40 to 45% of the subjects of the control group had values considered as pathological. The mean values in the symptomatic group were much smaller, from 2.65 ± 0.98 to 3.66 ± 1.08 mm. In addition, age seemed to play a major role in males, in which CND values decrease with bone maturation.

Conclusion : The results with our study could be used to defined a threshold of the normal and pathologic CND based on a large scale population study, and thus help to identify better the patients with TLAPC and the distance that should be aimed after surgical resection