Clinical features and outcomes in children with bone and joint infections of the ankle or foot

BackgroundThe foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae.MethodsWe performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform–cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed.ResultsThe median (range) time to diagnosis was 3.18 days (0–10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcus aureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5–19). Sequelae (spontaneous tibia–talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess.ConclusionPhysicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.     

Septic elbow arthritis in children: Epidemiology and outcome

Introduction

Septic elbow arthritis is a rare disease, especially in children. The aim of this study was to report the functional outcome of our pediatric population with both demographic and microbiological features.

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

ObjectiveDespite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair.Materials and methodsA retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n = 408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery.ResultsForeskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2–120 months), and the median follow-up period was 11 months (1–100 months).ConclusionsA good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.     

Osteomielitis aguda: epidemiología,manifestaciones clínicas,diagnóstico y tratamiento

Background and aimsThe present study focuses on the epidemiology, clinical and laboratory data, and management of osteomyelitis in a pediatric third level hospital.MethodologyAll cases of children under 15 years-old admitted with osteomyelitis between 2000 and 2011 were retrospectively reviewed until July 2006, then prospectively from then until 2011.ResultsA total of 50 patients were identified (52% males) with median age at diagnosis of 2 years. Principal onset manifestations were pain (94%), functional impairment (90%) and fever (72%). The femur (32%), fibula (28%) and calcaneus (22%) were most affected bones.Leucocytosis > 12.000/μl was found in 56%, elevated ESR > 20 mm/h in 26%, and elevated CRP > 20 mg/L in 64%. Blood culture was positive in 20%, with group A streptococcus being the most frequently isolated bacteria (11%).All diagnoses were confirmed by a ⁹⁹Tc scintigraphy bone scan.Antibiotic therapy was initially intravenously (mean time of administration: 10 days ± 3 SD), followed by oral medication (mean time of administration: 18 days ± 6 SD). Surgery was necessary in 3 patients. Evolution of all cases was excellent, despite 3 exceptions that resolved over time.ConclusionsThe current short-term intravenous therapy led to shorter hospitalizations. There were no statistically significant differences between time from clinical onset or in CRP levels at discharge compared to long-term therapies prior to 2006.     

Urethral advancement in hypospadias with a distal division of the corpus spongiosum: Outcome in 158 cases

ObjectiveOutcome of urethral mobilization and advancement (Koff procedure) in hypospadias with a distal division of the corpus spongiosum and redo cases with distal urethral failure.Materials and methodsFrom January 1999 to November 2012, 158 children with a distal hypospadias (115 primary cases and 43 redo cases) underwent surgical repair using the Koff technique with a median age at surgery of 21 months (range, 12–217 months).ResultsMean follow-up was 19 months (median, 14 months). Thirty patients (19%) presented with a complication (13.9% in primary cases and 32.5% in redo surgery) mostly at the beginning of our experience. Meatal stenosis was the most common one (3.5% in primary case, 6% overall). Ventral curvature (>10°), which is considered as a possible long-term iatrogenic complication of the Koff procedure, was not found in patients with fully grown penis except in one redo patient who had, retrospectively, an inadequate indication for this type of repair. Of 158 patients, 33 reached the age of puberty (>14 years old) with a mean follow-up of 34 months, only one presented with a significant ventral curvature.ConclusionUrethral mobilization and advancement is a reasonable alternative for anterior hypospadias and distal fistula repair in selected cases. It has two major advantages compared to other techniques: it avoids any urethroplasty with non-urethral tissue and eliminates dysplastic tissues located beyond the division of the corpus spongiosum, which may not grow at the same pace as the rest of the penis. Significant iatrogenic curvature in fully grown penis is not supported by this series.     

Factors affecting outcome of tubularized incised plate (TIP) urethroplasty: Single-center experience with 500 cases

PurposeTo review our experience of tubularized incised plate (TIP) urethroplasty in children with hypospadias defects.MethodsOf 500 children (mean age 6 years) who received a TIP urethroplasty, 439 (87.8%) had primary hypospadias and 61 had one failed previous repair. The hypospadias defects were coronal in 110 (22%), distal penile in 261 (52.2%), midpenile in 78 (15.6%) and proximal in 51 (10.2%). Chordee was present in 98 (19.6%) patients. Presence of complications requiring re-operation and overall general appearance was recorded.ResultsThe mean (SD, range) follow-up was 34 (18, 7–77) months. Overall success rate was 81.4%. Re-operation was required in 93 patients (18.6%); for urethrocutaneous fistula in 47 (9.4%), complete disruption of the repair in 32 (6.4%) and meatal stenosis in 14 (2.8%). In univariate analysis, complications were significantly higher in stented repairs, posterior hypospadias, those with no neourethral coverage (spongioplasty), and repairs early in the study. The last three factors were the only significant independent risk factors in multivariate analysis.ConclusionsTIP is a reliable method for treating both distal and proximal hypospadias and is suitable for both primary and re-operative cases with a low rate of complications. A significantly better outcome is achieved with distal hypospadias, covering the neourethra with the mobilized corpus spongiosum (spongioplasty) or a flap, and experience. Stenting of the repair, patient age, or previous failed repair has no statistically significant impact on outcome.     

Long-Term Follow-Up of Distal Hypospadias Repair Using the Memo (Meatal Mobilization) Technique

PurposeMeatal mobilisation (MEMO) for distal hypospadias repair has proved to be an improved surgical technique for correction of most of distal hypospadias with a primary success rate of 97%. However major concerns using meatal mobilisation are the development of stenosis or penile deviation with time. Therefore long-time follow-up (> 5 years postop) was carried out in patients who had a primary hypospadias repair using the MEMO technique to define the incidence of meatal stenosis, penile deviation and fistula formation.Material and MethodsFrom May 1997 to June 2006, 218 patients with a mean age of 4,9 years had a repair of distal hypospadias, including coronal and subcoronal forms, using the MEMO technique. 104 patients had the operation 5 to 8 years (mean 6.3 years) ago. In 99 of these patients the long-time follow-up (> 5 years postop) was done using physical examination, urine sample, and uroflowmetry, residual urine by ultrasound and an objective symptom score (HOSE). 5 patients were lost of follow-up.ResultsAll patients voided with a good stream without residual urine. No additional stenosis or penile deviation occurred in the follow-up. Out of 99 patients, 93 patients reached the maximum of 16 points using the HOSE symptom score.ConclusionsThe MEMO technique with its primary success rate of 97% showed in long term follow-up no additional problems in regard to stenosis. In one patient a mild penile deviation was seen without need for surgical correction. The MEMO technique has proven to be a safe procedure for most distal hypospadias repairs postoperatively and in long term follow-up.     

Acute disseminated encephalomyelitis: A retrospective study of 20 children in a pediatrics department in Tunisia

BackgroundAcute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disorder of the central nervous system. Little information is available about the clinical and neuroradiological profile or the follow-up of this disease in Tunisian children.AimTo determine the clinical, laboratory, and radiological features and the outcome of ADEM in children admitted to the pediatrics department of a university hospital in Tunisia.MethodsAll children ≤ 18 years old presenting with ADEM and admitted to the tertiary referral center for pediatrics at Sahloul University Hospital from January 2000 to December 2020 were included in the study. The diagnosis of ADEM was confirmed according to the international pediatric multiple sclerosis study group criteria.ResultsA total of 20 patients (13 girls and 7 boys) fulfilled the diagnostic criteria for ADEM. The mean age at diagnosis was 5.6 years. The clinical presentation included polyfocal neurological signs such as cranial hypertension (45%), seizures (35%), and motor weaknesses (55%). Pyramidal tract signs and cranial nerve palsies were noted in 55% of cases. Brain magnetic resonance imaging showed particular features, namely, a relapsing tumor-like form in one case, and optic neuritis and demyelinating lesions of the white matter in the brain and the spinal cord with gadolinium cerebral ring-like enhancement in another case. The treatment consisted of intravenous immunoglobulin in 16 cases (80%) and corticosteroid in 19 cases (95%). Plasmapheresis was used for one patient. Complete recovery was observed in 12 patients (60%); 19 patients (95%) had a monophasic course of the disease while only one patient developed multiphasic ADEM.ConclusionsADEM remains a difficult diagnosis in children. Nevertheless, after prompt diagnosis and adequate treatment, most children with ADEM have a favorable outcome with restitutio ad integrum.     

Foreskin reconstruction does not increase urethroplasty or skin complications after distal TIP hypospadias repair

AimTo compare urethral and skin complications between consecutive patients undergoing distal TIP (tubularized incised plate) hypospadias repair with prepucioplasty versus circumcision.MethodsProspective case-cohort study comparing urethroplasty and skin complications between consecutive patients undergoing distal TIP with prepucioplasty versus circumcision. Those with <1 month follow-up or prior circumcision were excluded. Decision for prepucioplasty or circumcision was made exclusively by caregivers. Operative technique was the same except skin closure. Postoperative foreskin retraction was deferred ≥6 weeks after prepucioplasty.ResultsOf 343 circumcision and 85 prepucioplasty cases, median age and follow-up were 8 (3–420) and 7 (1.5–97.5) months, respectively. Urethroplasty complications occurred in 30 (8.7%) circumcision patients [16 fistulas, 13 glans dehiscences, 1 meatal stenosis due to balanitis xerotic obliterans (BXO) 5 years postoperatively], versus 7 (8.0%) after prepucioplasty [4 fistulas, 2 glans dehiscences, 1 urethral stricture], p = 1.0. Skin complications resulting in reoperation occurred in 7 (2.0%) circumcision patients and 2 (2.3%) prepucioplasty patients, including an unsightly dorsal whorl in 1 and BXO 66 months postoperatively in another, p = 1.0.ConclusionPrepucioplasty does not increase urethroplasty or skin complications after distal TIP hypospadias repair. We found no contraindication for prepucioplasty among consecutive patients, indicating hypospadiologists can manage the foreskin in distal repairs according to caregiver preference.     

Is it safe to solely use ventral penile tissues in hypospadias repair? Long-term outcomes of 578 Duplay urethroplasties performed in a single institution over a period of 14 years

ObjectivesUrethral plate tubulization (Thiersch-Duplay procedure) is a widespread procedure mostly used for distal hypospadias. Concerns of long-term outcome have led to this review of the results of a series of 578 cases.Patients and methodsA retrospective review was conducted of 578 patients treated in a single institution following the same procedure and with the same follow-up. Most patients had distal hypospadias (517/578) and were operated on between 12 and 24 months of age (343 patients). The mean follow-up was 25.6 months (6 months-17 years). Evaluation was focused on urethral complications related to inadequate healing of the reconstructed urethra (fistula, urethral dehiscence, urethral stenosis and clinical dysuria). Complications were arbitrarily categorized into early (when occurring less than one year after surgery) and late (after one year). All data were submitted to statistical analysis.ResultsOf the 578 patients, 153 (26.5%) had unsatisfactory outcomes, of which 118 (20.4%) had inadequate urethral healing. Of these, 97 appeared early (57%) and 73 appeared late (43%). Fistula and dehiscence were significantly more frequent in the first post-operative year (p < 0.0001), whereas stenosis of the reconstructed urethra was more frequent after one year. Follow-up and age at last consultation were significantly higher in patients with complications.Limits and flaws of this study focused on the absence of consensus on evaluation of hypospadias surgery. The paucity of literature on long-term outcomes of urethral plate tubulization was highlighted. A possible explanation of late stenosis of the reconstructed urethra was the poor growth capacity of the dysplastic tissues located beyond the division of the corpus spongiosum. Urethroplasties solely using ventral tissues may represent an additional risk of late failure, as they may not grow with the rest of the genital tubercle.ConclusionSignificant short and late complications occur with techniques tubularizing the urethral plate, mostly fistulae in the first post-operative year and urethral stenosis after 1 year following surgery. Urethroplasties using ventral tissues may not grow at the same pace as the rest of the genital tubercle and may explain late urethral dysfunction. This series confirms the necessity of long-term follow-up of hypospadias reconstructions.     

Distal hypospadias repair with or without foreskin reconstruction: A single-surgeon experience

ObjectiveDartos flap coverage is routinely used as a protective layer during tubularized incised plate urethroplasty (TIPU) except when an associated foreskin reconstruction (FSR) precludes its use. In this study we compare the outcome of distal hypospadias repair with and without foreskin reconstruction by the same surgeon.Materials and methodsBetween September 2002 and June 2007, 215 children with distal hypospadias underwent stented TIPU by a single surgeon. Of these, 25 (glanular 8, coronal 17) underwent a two-layer FSR without dartos flap coverage. An age- and time-matched group of 49 patients (glanular 10, coronal 39) who underwent TIPU with dartos flap coverage without foreskin reconstruction (NoFSR) were selected for comparison. Operative time and complications were recorded.ResultsThere was no significant difference in severity of hypospadias and follow-up duration (mean 17 vs 19 months, P = 0.57) between the two groups. Operative time ranged between 30 and 86 min (mean 57) in the FSR group and 35 and 113 min (mean 75) in the NoFSR group (P ≤ 0.01). Initial retraction of the foreskin by the surgeon at 6–8 weeks was successful in 15; five of the six who failed initial retraction responded to steroid cream. Four (16%) children underwent redo surgery in the FSR group (urethrocutaneous fistula in three, circumcision for recalcitrant phimosis in one). In the NoFSR group, six (12.2%) underwent redo surgery (urethrocutaneous fistula in four, removal of redundant skin in two). There was no significant difference in the need for redo surgery (P = 0.45) or incidence of fistula (P = 0.43) between the groups.ConclusionsThere was no statistical difference in outcome between the two techniques, particularly regarding fistula complication. The complication particular to FSR, namely initial failure of foreskin retraction, responds adequately to steroid cream application. Foreskin reconstruction is a surgical alternative in selected patients, particularly those with distal hypospadias and a personal preference of no circumcision. Larger prospective studies are needed to ascertain similarity in outcome between FSR urethroplasty and the conventional urethroplasty with dartos coverage.     

Long-term follow-up in children with benign convulsions associated with gastroenteritis

BackgroundThe outcome of benign convulsions associated with gastroenteritis (CwG) has generally been reported as being excellent. However, these data need to be confirmed in studies with longer follow-up evaluations.AimTo assess the long-term neurological outcome of a large sample of children presenting with CwG.MethodsWe reviewed clinical features of 81 subjects presenting with CwG (1994–2010) from three different Italian centers with a follow-up period of at least 3 years.ResultsFollow-up period ranged from 39 months to 15 years (mean 9.8 years). Neurological examination and cognitive level at the last evaluation were normal in all the patients. A mild attention deficit was detected in three cases (3.7%). Fourteen children (17.3%) received chronic anti-epileptic therapy. Interictal EEG abnormalities detected at onset in 20 patients (24.7%) reverted to normal. Transient EEG epileptiform abnormalities were detected in other three cases (3.7%), and a transient photosensitivity in one (1.2%). No recurrence of CwG was observed. Three patients (3.7%) presented with a febrile seizure and two (2.5%) with an unprovoked seizure, but none developed epilepsy.ConclusionsThe long-term evaluation of children with CwG confirms the excellent prognosis of this condition, with normal psychomotor development and low risk of relapse and of subsequent epilepsy.     

Isolated preputial reconstruction in distal hypospadias

ObjectiveThe aim of this single centre study was to determine: a) the outcome of isolated preputial reconstruction in distal hypospadias and b) overall parental satisfaction.MethodsA retrospective analysis of case notes was performed to determine outcome. Postal parent-satisfaction questionnaires were devised to quantify subjective assessment of care and outcome.ResultsA total of 33 cases of isolated preputial reconstruction were identified between 2006 and 2012. Three sets of notes were untraceable. The median age of the 30 remaining patients at surgery was 23 months (range 11–119). At follow-up, 28 (94%) patients had retractile foreskins that had healed well. One patient (3%) had a foreskin fistula and the parents chose to proceed with circumcision rather than fistula closure. A second patient (3%) developed late phimosis secondary to balanitis xerotica obliterans and also underwent circumcision. Twelve follow-up questionnaires were returned. The median overall success rating of the operation was 4.7/5.0 (94%). All respondents reported that they would recommend the procedure to another parent whose child has a similar diagnosis.ConclusionIsolated preputial reconstruction improves the cosmetic appearances in distal hypospadias, has a low complication rate and offers high parental satisfaction.     

Distal ureteral diameter measurement objectively predicts vesicoureteral reflux outcome

ObjectiveVesicoureteral reflux (VUR) grading may be difficult when discrepancies exist between the degree of dilation of the pyelocalyceal system and the ureter. Resolution may be more accurately predicted by the appearance of the distal ureter. We analyzed a novel, objective method of evaluating VUR based on the diameter of the distal ureter.MethodsSeventy-nine voiding cystourethrograms were reviewed (18 boys; 61 girls; aged 1 month to 7.5 years). The largest ureteral diameter within the false pelvis was measured and normalized by dividing by the distance from the L1-L3 vertebral body to give the distal ureteral diameter: L1-L3 ratio (UDR). Clinical outcome was defined as spontaneous resolution or surgical correction.ResultsA significant association between grade and UDR existed (p < 0.0001). Mean UDR was significantly greater in those who underwent surgical correction (0.34 ± 0.02 vs 0.18 ± 0.02; p < 0.0001). Logistic regression analysis demonstrated a significant association of UDR with outcome controlling for grade (p = 0.001). Grade effect on outcome when controlling for UDR was not significant (p = 0.76). Odds ratio for surgical correction corresponding to a 0.1 increase in UDR equaled 2.25 (95% CI: 1.39, 3.64).ConclusionUDR provides an objective measurement of VUR and appears more predictive of clinical outcome than grade in this series.     

Non-traumatic spinal cord ischaemia in childhood – Clinical manifestation,neuroimaging and outcome

BackgroundSpinal cord ischaemia is rare in childhood and information on clinical presentation and outcome is scarce.MethodsThis is a retrospective analysis of eight patients and 75 additional cases from the literature. Data search included: patient's age, primary manifestation, risk factors, neuroimaging and outcome.ResultsFive female and three male patients gave consent to participate. Mean age was 12.5 years (10–15 years). Six patients presented with paraplegia; this was preceded by pain in four. Brown Sequard syndrome and quadriparesis were the two others' presenting condition. Sensation levels were thoracolumbar in seven cases. Bladder dysfunction only or bladder and bowel dysfunction were reported in eight and five patients respectively. Time to maximal symptom manifestation was <12 h in 7/8. Risk factors included surgery, minor trauma, recent infection, and thrombophilia. Mean follow-up was 3.3 years (0.25–6.3 years). Three patients remained wheelchair-dependent and three patients were ambulatory without aid. Bladder function recovered fully in five children. Most affected aspects of quality of life were physical and mental well-being and self-perception.T2-weighted-MR images showed pencil-like hyperintensity (8/8) in sagittal and H-shaped or snake-eyes-like lesion (6/8) in axial views.Analyses of all 83 patients were in congruence with the above results of the study group.ConclusionSpinal cord ischaemia in childhood presenting with pain, paraplegia, and bladder dysfunction has high morbidity concerning motor problems and quality of life. Acute arterial ischaemic event in children seems similar to adult events with respect to clinical presentation and, surprisingly, also in outcome.     

小儿非骨化性纤维瘤的临床特点及诊治

目的：探讨小儿非骨化性纤维瘤的临床特点及治疗方法。方法：回顾性分析我院收治的小儿非骨化性纤维瘤20例。其中男12例，女8例，年龄1．5～14岁，平均8．5岁。病灶均在下肢长管状骨，其中股骨远端10例，股骨颈1例，胫骨近端7例，远端1例，腓骨1例。全部病例均经手术治疗，术式包括单纯病灶切除、病灶切除加自体髂骨或加异体骨移植术。结果：全部病例均经病理证实为非骨化性纤维瘤。术后随访1～5年，平均3．2年，无一例复发。结论：非骨化性纤维瘤的病因和发病机制不清。根据其临床特点，典型的X线片表现，诊断并不困难。但应与骨纤维异样增殖症、骨囊肿及骨巨细胞瘤相鉴别。因本病可引起疼痛及病理性骨折，确诊后应早期手术治疗。术式以病灶切除植骨术为主。     

Detrusorectomy reduces the need for augmentation and use of antimuscarinics in children with neuropathic bladders

ObjectiveTo assess bladder behaviour and long-term outcome after detrusorectomy in children.Material and methodsBetween 1990 and 2001, 49 detrusorectomies were performed (mean follow-up: 9.6 years) in children with neuropathic bladders (mean age at surgery: 9.8 years). Urodynamic study (UDS) was done before surgery (pre-UDS) and after surgery (UDS-1 and UDS-2). Bladder behaviour was assessed as good, fair or poor depending on the volume and intravesical pressure. In all patients, oxybutynin and clean intermittent catheterization were used preoperatively. In 24 patients, good bladder compliance and capacity were seen before detrusorectomy.ResultsGood and fair outcomes were observed in 35 (71%) patients at 1 year and in 39 (79%) patients 6 years after detrusorectomy. In 30 (60%) patients, there was hardly any difference between the first and second follow-up. In 9 (18%) patients, formal bowel bladder augmentation was necessary: in 6 (12%) because of poor compliance and in 3 because of small bladder volume and incontinence. Seven patients improved during follow-up, 5 of them after resuming oxybutynin. In 11 patients, oxybutynin could be stopped, and in 2 the dosage could be reduced to once daily.ConclusionsThe good short-term results of detrusorectomy generally remain unchanged at long-term follow-up. Detrusorectomy can reduce the need for antimuscarinics, and the need for formal bladder augmentation in selected cases.     

儿童腓骨移植对供腿功能影响的长期随访

目的:评价儿童腓骨切除后对小腿及踝关节功能的影响。方法:自1980年以来，对32例儿童作了腓骨移植术，其中对13例患儿作了长期随访，随访最长时间为14年，最短时间为5年，平均随访7年8个月。通过患儿小腿外观、功能活动及膝、踝关节X线片检查，观察外踝移位情况、关节间隙及胫腓两端骨骺结构变化。结果:随访结果显示，10例行走运动正常，但长时间大运动量后感小腿及踝关节乏力；2例踝关节外翻，内踝突出，供腿单足站立不稳；1例腓骨移植11年后，两小腿胫骨相差2．5cm。X线片结果显示：3例外踝上移或伴有后移，胫骨远端骨骺呈“楔形样变”，1例下胫腓关节分离；2例腓骨小头轻度下移外，膝关节外形活动正常，所有患儿未发生胫骨骨折和拇趾屈曲挛缩畸形。结论:儿童腓骨切除后对踝关节的结构有影响，腓骨切除位置愈低，影响愈大。     

Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients?

ObjectiveAlthough renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC.Materials and methodsBetween 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups.ResultsMean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m² in the AC group and 88.17 ± 28.20 ml/min/m² in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years).ConclusionsBladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.     

Acute tubulointerstitial nephritis in children and chronic kidney disease

BackgroundAcute tubulointerstitial nephritis (ATIN) is a rare condition in children. The etiology, treatment, and outcome of childhood ATIN remain poorly understood. The long-term prognosis seems to be favorable; however, chronic kidney disease has been reported. This article describes clinical outcomes in a series of children with biopsy-proven ATIN.MethodsAll medical records with biopsy-proven ATIN between January 2006 and 2016 were retrospectively analyzed. The incidence, clinical features, etiology, treatment, and outcome were recorded for each patient.ResultsOver 10 years, ATIN was diagnosed in 25 cases (8%) based on 306 renal needle biopsies. The most frequent clinical signs were abdominal pain, asthenia/weight loss, and fever. A median glomerular filtration rate estimated at 30.1 mL/min/1.73 m² (16.5; 45.5). Drug-induced toxicity was the main etiology (eight patients). Other causes were TINU syndrome (tubulointerstitial nephritis and uveitis) (seven patients), infection (two patients), and toxic agents other than medication (one patient). No etiology was found in seven patients (idiopathic cases). Eighteen patients (72%) were treated with steroids. At the end of follow-up, eight patients presented chronic kidney disease, three hypertension, and three tubular dysfunction. Overall, renal function was highest in the idiopathic ATIN group and in children treated without delay.ConclusionsIn a single-center 10-year series of biopsy-confirmed ATIN in children, drugs and TINU syndrome were the main etiologies of ATIN. This study suggests that children with idiopathic ATIN and prompt treatment have a better prognosis. In this series, occurrence of chronic kidney disease justified long-term follow-up.