Varicella-related musculoskeletal complications in children

Eight children with post-varicella musculoskeletal complications were treated between 2001 and 2009. The complications that were observed were cellulitis (three children), pyomyositis (three children), osteomyelitis (two children) and gangrene (one child). On average, 8.8 days elapsed between primary varicella infection and complication. The most common presentation was pain. Before we started treating them, all children received antibiotics during interhospital transfers (average: 2.4). Interventions included drainage (eight), fasciatomy (one), arthrotomy (one), bone drilling (one), and amputation (one). Blood cultures were negative in all children. Two children had positive pus cultures for Staphylococcus aureus, one of them had a methicillin-resistant S. aureus infection. One of the four children who developed coagulopathy ended with significant morbidity. Varicella-related methicillin-resistant S. aureus osteomyelitis suggests a widening spectrum of these infections.     

Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections

BACKGROUND: Staphylococcus aureus remains the most common etiologic agent of acute osteomyelitis in children. Recently, methicillin-resistant S. aureus (MRSA) has emerged as a major pathogen. METHODS: Records of all children admitted with acute osteomyelitis from January 1999 to December 2003 were reviewed. For the comparative analysis, the study population was evenly distributed in 2 periods: period A, January 1999 to June 2001; n = 113; and period B, July 2001 to December 2003; n = 177. In addition, clinical findings of MRSA osteomyelitis were compared with non-MRSA osteomyelitis, including methicillin-sensitive S. aureus infections. RESULTS: Two hundred ninety children (60% male subjects) with acute osteomyelitis were identified. Median (25th-75th percentile) age at diagnosis was 6 years (range, 2-11 years). Significant clinical findings included the following: localized pain (84%), fever (67%), and swelling (62%). Affected bones included the following: foot (23%), femur (20%), tibia (16%), and pelvis (7%). Thirty-seven percent of blood cultures were positive, and a bacterial isolate was obtained in 55% of cases. Bacteria most frequently isolated included the following: methicillin-sensitive S. aureus (45%) (57% in period Avs 40% in period B), MRSA (23%) (6% in A vs 31% in B; P < 0.001), Streptococcus pyogenes (6%), and Pseudomonas aeruginosa (5%). Children with MRSA compared with those with non-MRSA osteomyelitis had significantly greater erythrocyte sedimentation rate and C-reactive protein values on admission and increased length of hospital stay, antibiotic therapy, and overall rate of complications. We observed significant changes in antibiotic therapy related to increased use of agents with activity against MRSA. CONCLUSIONS: Methicillin-resistant S. aureus was isolated more frequently in the second study period and was associated with worse clinical outcomes.     

The changing epidemiology of acute and subacute haematogenous osteomyelitis in children

We have reviewed the incidence of bacteriologically or radiologically confirmed acute haematogenous osteomyelitis in children under 13 years of age resident in the area of the Greater Glasgow Health Board between 1990 and 1997. In this period there was a fall of 44% in the incidence of both acute and subacute osteomyelitis, mainly involving the acute form (p = 0.005). This mirrors the decline of just over 50% previously reported in the same population between 1970 and 1990. Using multiple regression analysis a decline in incidence of 0.185 cases per 100,000 population per year was calculated for the 28-year period (p < 0.001). Staphylococcus was the most commonly isolated pathogen (70%). Only 20% of patients required surgery and there was a low rate of complications (10%). In general, patients with a subacute presentation followed a benign course and there were no complications or long-term sequelae in this group. Haematogenous osteomyelitis in children in this area is becoming a rare disease with an annual incidence of 2.9 new cases per 100,000 population per year.     

A protocol for the treatment of severe infections of the hand

A protocol for the treatment of hand infections was used for 69 patients in a university teaching hospital. The protocol prescribes incision and drainage under optimal conditions (in the operating room) when the patient is first seen and intravenous antibacterial therapy effective against anaerobic and aerobic bacteria initiated immediately after obtaining aerobic and anaerobic cultures. Results of bacteria studies confirmed the significant frequency (nearly 30%) of mixed aerobic and anaerobic infection. Use of the protocol resulted in a shorter hospital stay, faster healing, and fewer complications (recrudescence of infection, reoperation, stiffness, arthritis, and osteomyelitis) when compared with 107 patients who were treated before institution of the protocol.     

Delayed primary closure after sternal wound infection

Infected median sternotomy is a major complication of cardiac operations. Over a 30-month period, 25 sternal wound infections were treated at a single institution. Twenty-four (2.7%) followed 883 operations with cardiopulmonary bypass, and 1 followed median sternotomy for a noncardiac procedure. Twenty-one of the 25 patients survived to sternal closure. Eighteen patients were treated with delayed primary closure and 3 with pectoralis muscle flaps. Fifteen patients (83%) had an uneventful postoperative course after delayed primary closure. In 2 patients reoperation was required for sternal dehiscence, and in 1 patient a superficial wound infection developed, which was treated with local wound care. In all 18 patients the sternum eventually healed. Criteria for delayed primary closure included clean tissue surfaces without purulent debris, the absence of pockets of purulent drainage, and negative wound cultures obtained 24 hours before closure. The average time from operation to sternal incision and drainage was 11 days (range, five to 59 days). Delayed primary closure was performed nine days after incision and drainage (range, five to 27 days). The average hospital stay was 24 days after sternal incision and drainage (range, nine to 85 days). Cultures from specimens taken at the time of sternal incision and drainage were positive in all patients. Wound cultures were positive at the time of sternal closure in 5 patients. Wound complications developed in 2 of these 5 patients. Delayed primary closure has many of the advantages of classic methods, but fewer complications. Results are comparable, while allowing simpler wound care and less cosmetic deformity. Delayed primary closure is an acceptable alternative in the treatment of sternal wound infections.     

Operative management of pancreatic pseudocysts in infants and children: a review of 75 cases.

This report combines the findings and treatment in 15 infants and children with pancreatic pseudocysts with 60 additional cases from a literature review. The mean age at diagnosis was 7.5 years with pseudocyst being more common in boys (44:31). Sixty per cent were due to trauma, while in 32% the cause was unknown. Abdominal pain (68%), a mass (64%), and vomiting (52%) were the most frequent findings. The serum amylase was elevated and the upper gastrointestinal contrast study consistent with a mass in 88% of cases. Operative treatment included external drainage in 25 children (33%), cystgastrostomy or cyst-jejunostomy in 34 (45%), excision in 10 (13%) and miscellaneous procedures in 6 (8%). Complications were relatively few and there were no deaths recorded. Recurrence rate for cyst-gastrostomy was 4.7%, cyst-jejunostomy 7.6%, external drainage 8% and cyst-duodenostomy 50%. External drainage operations had prolonged cutaneous drainage. These observations suggest the appropriate operation is determined by the location and duration of pseudocyst. Internal drainage is preferred and avoids complications seen following resection and external drainage. Cyst-gastrostomy is effective when the pseudocyst is retrogastric and adherent to the stomach wall. Cyst-jejunostomy is most useful in instances in which the pseudocyst in not adherent to the stomach wall. Low recurrence rates and a zero mortality rate makes operative treatment highly acceptable therapy. Low recurrence rates are expected in childhood cases, (particularly related to trauma) due to an absence of underlying pancreatic disease and ductal obstruction.     

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical incision to extract specimen

BackgroundSurgical treatment is the most important and effective therapy for resectable esophageal cancer. Minimally invasive esophagectomy (MIE) can reduce surgical trauma. A neck incision can be performed for extraction of surgical specimen. This study was performed to investigate the safety and feasibility of neck incision to extract surgical specimen in thoracolaparoscopic esophagectomy for esophageal cancer.Materials and methodsThirty-four patients who experienced thoracolaparoscopic esophagectomy for esophageal cancer and a neck incision for extraction of surgical specimen were enrolled. The clinical, surgical and follow-up data were analyzed.ResultsThe procedure was successful in all patients (100%), with a neck incision to extract the surgical specimen. The median surgical time was 309 min, and the median blood loss was 186 ml, with the mean length of hospital stay of 11.5 days. Pulmonary complications occurred in 8 patients (23.5%). Anastomotic leakage occurred in 5 patients (14.7%), with one patient being treated conservatively to recover and four (11.8%) who received interventional drainage. One patient with interventional drainage died of severe infection, resulting in a 30-day surgical mortality of 2.9% (n = 1). Gastrointestinal complications happened in 5 patients (14.7%), including ileus in three patients and anastomotic stenosis in two patients. Follow-up was performed at a median time of 20 months (interquartile range, 14–32 months), with no death during this period. No recurrence was found in the first 12 months after radical resection.ConclusionThe cervical incision to extract surgical specimen is safe and feasible with improved cosmetic effect in thoracolaparoscopic esophagectomy for esophageal cancer.     

416例次针形刀困难乳头括约肌切开的体会

目的探讨针形切开刀在困难乳头括约肌切开术中应用的技巧和价值。方法222例采用针形刀开窗术（needle—knife fenestration，NKF），158例直接用针形刀做乳头切开（needle—knife papillotomy，NKP），36例NKF失败后再行NKP。结果NKF组成功率75．2％（167／222），NKP组97．9％（190／194），总成功率85．8％（357／416）。术后发生胆道感染5例（1．2％），其中3例转外科手术胆道引流，2例重新经内镜置人引流管和用抗生素控制感染。术后并发胰腺炎24例（5．8％），其中1例急性重症胰腺炎经3处腹腔穿刺引流术治愈，余均经内科保守治疗。切口大量出血1例，内镜下注射硬化剂止血。结论应用针形刀可使极大多数标准EST或预切开失败者获得乳头切开成功。NKP成功率明显高于NKF，重新NKP可再提高成功率，而严重的并发症和死亡率并无增加，但对乳头过小和胆总管末端较细长者应尽量限制。     

Common bile duct exploration—Primary closure of the duct with retrograde transhepatic biliary drainage—

A new method of retrograde transhepatic biliary drainage (RTBD) using and RTBD tube with primary closure of the common duct was investigated with special reference to the usefulness and feasibility of this procedure. At operation, an atraumatic vinyl chloride tube was inserted from a choledochotomy incision and in most cases advancedvia the left hepatic duct to the liver surface, which was then penetrated. After the choledochotomy incision had been primarily sutured, the RTBD tube was fixed to the abdominal wall. This drainage method was applied to 71 patients as an alternative to the conventional T-tube drainage and its effect on bile drainage was prominent. The insertion of an RTBD tube did not influence liver function tests and an RTBD tube cholangiography revealed no severe deformity at the primary closure site of the bile duct. The most common complication was movement of the optimal site for stenting of the bile duct, however, no serious complications were encountered. On average, the RTBD tube was removed on the 16th postoperative day, the mean postoperative stay in hospital being 22 days. These findings suggest the need for a prospective randomized clinical trial to prove the usefulness and feasibility of primary bile duct closure using our drainage method.     

Common bile duct exploration--primary closure of the duct with retrograde transhepatic biliary drainage

A new method of retrograde transhepatic biliary drainage (RTBD) using an RTBD tube with primary closure of the common duct was investigated with special reference to the usefulness and feasibility of this procedure. At operation, an atraumatic vinyl chloride tube was inserted from a choledochotomy incision and in most cases advanced via the left hepatic duct to the liver surface, which was then penetrated. After the choledochotomy incision had been primarily sutured, the RTBD tube was fixed to the abdominal wall. This drainage method was applied to 71 patients as an alternative to the conventional T-tube drainage and its effect on bile drainage was prominent. The insertion of an RTBD tube did not influence liver function tests and an RTBD tube cholangiography revealed no severe deformity at the primary closure site of the bile duct. The most common complication was movement of the optimal site for stenting of the bile duct, however, no serious complications were encountered. On average, the RTBD tube was removed on the 16th postoperative day, the mean postoperative stay in hospital being 22 days. These findings suggest the need for a prospective randomized clinical trial to prove the usefulness and feasibility of primary bile duct closure using our drainage method.     

The outcome of therapy of osteomyelitis in children

Summary From 1987 to 1994, 28 children were admitted to our hospital with a haematogenous osteomyelitis. They were evaluated by chart review for history, clinical presentation, diagnostic work-up, treatment and outcome. The patients were considered to have an acute (n=12) or a chronic osteomyelitis (n=16). The mean age was 5.5 years and 5.9 years, respectively. Clinical symptoms such as local tenderness and swelling were present for 8 and 128 days, respectively. The mean temperature at admission was 38.4 and 37.3°C, respectively. The ESR, CRP and WBC were elevated in children with an acute osteomyelitis. In chronic osteomyelitis cases these findings were less elevated. On the X-rays in 6 and 16 children, respectively, abnormalities were visible. All children underwent a surgical procedure: a cortical window was made, pus was drained and necrotic tissue was excised. Positive cultures were obtained in 9 and 7 children, respectively. Subsequently, all patients were treated with i.v. and oral antibiotics. The mean duration of i.v. plus oral antimicrobial therapy was 20 plus 22 days for acute osteomyelitis and 20 Plus 25 days for chronic osteomyelitis. The mean duration of hospitalisation was 23 days in both groups. The mean follow-up was 3.7 years for patients with an acute osteomyelitis and 2.7 years for patients with a chronic osteomyelitis. After treatment, all but one patients were clinically well and the infection parameters had returned to normal values. Three patients had residual signs (ankylosis, decreased function). After surgical intervention it appears that six weeks of antibiotic therapy is sufficient to eradicate acute as well as chronic osteomyelitis in children.     

Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial

One hundred and thirty-seven consecutive acute superficial abscesses were randomly allocated to incision, curettage and primary suture without parenteral antibiotics (64 cases) or to conventional treatment with incision, drainage and dressings (73 cases). Wound healing was faster; 7.0 days: 25.1 days (P less than 0.01, Wilcoxon's rank sum test), the number of hospital visits was smaller; 3.8 visits: 11.1 visits (P less than 0.01) and the time off work was shorter; 4.0 days: 14.1 days (P less than 0.01) in the group treated by primary closure compared with those managed conventionally. In this study no complications attributable to the withholding of antibiotics occurred. Incision and primary closure of abscesses is safe and more economic than conventional drainage. Routine antibiotic cover is not necessary.     

Acute septic arthritis of the hip in children

Thirty-three cases of acute septic arthritis of the hip in children were treated at our hospital from 1986 to 1997. The average follow-up period was 6 years (range 2–¶11 years). In 17 cases the right hip was affected, and in 16 the left hip. The average duration of symptoms was 5 days (range 1–14 days). Microorganisms were isolated from the blood, joint aspirate, or surgical specimens in 25 cases (76%). Staphylococcus aureus was the most common bacteria found (44%). Those patients with S. aureus infection were older than 1 year of age. There was no significant difference in the final outcome between the younger and the older age groups. Twenty-six out of 33 patients (89%) had a satisfactory outcome. Satisfactory results can also be expected with arthrocentesis and medical treatment if the diagnosis is made early, and antibiotic treatment affords a good clinical response. Four out of 7 cases with an unsatisfactory result were associated with osteomyelitis of the proximal femur. The two most important factors associated with poor results included a delay of definite treatment lasting longer than 5 days and the presence of osteomyelitis of the proximal femur.     

Complications of K-wire fixation of fractures and dislocations in the hand and wrist

Kirschner wire (K-wire) fixation of fractures and dislocations of the hand and wrist is a common procedure. Of the 590 K-wire fixations performed on 236 patients, 36 (15.2%) experienced complications which included osteomyelitis, tendon rupture, nerve lesion, pin tract infection, pin loosening or migration. There were no deep soft-tissue pin infections or pyarthrosis. Technical failure, mainly when the procedure was performed by residents, and poor patient compliance were the major causes of complications. K-wire fixation is a simple but demanding procedure that cannot be left to an inexperienced resident. Elimination of technical failure, supervision in the operating room, close monitoring, prompt treatment upon discovery of a complication, and improvement of patient compliance can reduce the rate of complications. Received: 30 October 2000     

The role of pelvic magnetic resonance in evaluating nonhip sources of infection in children with acute nontraumatic hip pain

We retrospectively identified all children with acute hip pain who underwent pelvic magnetic resonance (MR). Children with septic hip or history of trauma were excluded; the remaining children with signs of infection (fever, >38 degrees C; leukocytosis, >12 x 10(9)/L; or elevated erythrocyte sedimentation rate [ESR], >30 mm/h) comprised the study group. Thirty-three children (9 girls; age, 0.8-15.8 years) were identified. On MR examination, 18 (55%) of 33 children had hip joint effusion, whereas 19 (58%) of 33 children had other abnormalities, including pyomyositis (n=15), osteomyelitis (n=12), and sacroiliitis (n=3). Staphylococcus aureus was cultured from 13 (68%) of these 19 children. Compared with MR, sensitivity for bone and soft tissue abnormalities was 30% for pelvic radiography (n=26) and 71% for bone scintigraphy (n=8). Elevated ESR (>30 mm/h) was the clinical finding that best predicted pelvic osteomyelitis or pyomyositis. Pelvic MR should be performed to rule out pelvic osteomyelitis or pyomyositis in children with acute hip pain, ESR of more than 30 mm/h, and no evidence of septic hip.     

腹腔镜与开腹手术治疗小儿急性阑尾炎的对比研究

目的：对比腹腔镜与开腹手术治疗小儿复杂急性阑尾炎的临床疗效。方法：2004年1月至2009年1月收治小儿复杂阑尾炎253例,分别行腹腔镜阑尾切除术（laparoscopic appendectomy,LA）123例,开腹阑尾切除术（open appendectomy,OA）130例,比较两组术中出血量、恢复进食时间、术后住院时间、抗生素使用时间及术后并发症。结果：LA组术中出血量、恢复进食时间、腹腔引流管拔除时间、术后住院时间、抗生素使用时间均明显少于OA组,LA组术后切口感染、肠梗阻、腹腔脓肿发生率低于OA组。结论：腹腔镜治疗小儿复杂急性阑尾炎的疗效明显优于开腹手术。     

骶前持续低负压冲洗引流在骶前囊肿切除术后促进骶前残腔及会阴切口恢复价值研究

目的 探讨骶前持续低负压冲洗引流在骶前囊肿切除术后促进骶前残腔及会阴切口恢复的临床效果及价值。方法 回顾性分析2014年1月至2021年1月郑州大学附属肿瘤医院收治的130例接受骶前囊肿切除术病人的临床资料,根据骶前引流方式不同,分为骶前持续低负压冲洗引流组（67例）和传统骶前引流组（63例）,比较两组病人术后骶前残腔、会阴部切口并发症及治疗效果,骶前残腔、会阴部切口感染的处理及效果等。结果 骶前持续低负压冲洗引流组会阴部切口感染、骶前积液并感染的发生率均显著低于传统骶前引流组［3例（4.5%）vs 10例（15.9%）,1例（1.5% ）vs 7例（11.9%）;P均＜0.05］;骶前持续低负压冲洗引流组骶前残腔恢复时间及会阴部切口愈合时间均短于传统骶前引流组［14（12,24）vs.16（14,40）d,12（10,28）vs. 14（12,48）d;P均＜0.05］。两组共21例术后骶前残腔及会阴部感染,骶前持续低负压冲洗引流组切口拆开引流处理低于传统骶前引流组［0 vs.10例（58.8%）,P＜0.05］;其骶前残腔及会阴部切口感染症状转归时间短于传统骶前引流组［（5.0±1.4）d vs.（7.2±2.6）d,P＜0.05］。结论 骶前持续负压冲洗引流可降低骶前积液及会阴部切口感染的发生率,加速骶前囊肿切除术后骶前残腔及会阴部切口恢复,促进病人快速康复。     

Acute hematogenous osteomyelitis in children

We reviewed the cases of 60 children with acute osteomyelitis with an average follow-up of 34 months. All patients were treated initially with high-dose intravenous (i.v.) antibiotics. Eight patients did not respond to this treatment within 48 h and had surgical drainage. The remaining 52 patients were divided into two subgroups: (a) 35 patients received i.v. antibiotics for an average of 21 days; (b) 17 patients received i.v. antibiotics for an average of 8 days followed by 4 weeks of oral therapy with monitoring of serum bactericidal levels. The incidence of chronic infection (12% for the operatively treated group and 4% for the nonoperatively treated group) depended more on the time interval between the presentation of symptoms and the onset of treatment than it did on the route of antibiotic administration.     

Die Saug-Spül-Behandlung bei der Behandlung der chronischen Osteomyelitis

The instillation drainage is a very important part in the treatment of chronic osteomyelitis (the débridement of necrotic bone and soft tissue cellulitis, the need of stability, the local antiinfectious treatment, and the plastic reconstruction of soft tissue and bone defects). In acute osteomyelitis under stabile conditions the instillation drainage helps spontaneous reossification, in most of these cases bone grafting is not necessary. For the local treatment of an intramedullary infection the closed technique of the instillation drainage is recommended. There must be an exact balance of Ringer's solution in the instillation and drainage system. In the open technique no retention of solution is possible.—Antibiotics can be added to Ringer's solution for the first few days, the more important effect of the instillation drainage is the mechanical cleansing of all infected spaces.     

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重症急性胰腺炎(SAP)的治疗经历了一个多世纪的艰苦探索,从最初积极手术到提倡保守治疗,再到选择性手术干预;从简单手术引流、早期胰腺包膜切开引流到胰腺切除,再到坏死组织清除。如今SAP的整体病死率已从当初的60%~80%下降至10%~20%。SAP的治疗涉及到早期液体复苏、器官功能的保护与替代治疗、腹腔间隔室综合征的处理,以及营养代谢调理、感染并发症的防治及坏死后病变的手术等。进一步加强对SAP多器官功能障碍及胰腺坏死后病变及感染并发症的综合防治,准确把握手术时机及选择正确的手术方式,有望实现SAP疗效的突破。