Haemish Crawford

Background: Septic arthritis of the hip in infants and prewalking children is a surgical emergency that can lead to rapid joint destruction and long-term sequelae. Despite its urgency, diagnostic and management practices vary considerably, and high-quality comparative evidence remains limited. This study aimed to develop expert consensus on the key principles of diagnosis and management using a modified Delphi methodology. Methods: A working group of 3 pediatric orthopaedic surgeons developed 20 statements addressing clinical diagnosis, imaging, medical and surgical management, postoperative care, and follow-up. Forty-five fellowship-trained pediatric orthopaedic surgeons from 12 countries, including 15 from high-resource and 30 from low-resource countries, were invited to participate. Thirty-five completed round 1, and 32 completed round 2. Consensus was defined a priori as ≥70% agreement. Statements that did not reach consensus were revised and redistributed in round 2. Results: Eight statements reached consensus in round 1, including universal laboratory testing, avoidance of antibiotic-only treatment, preference for anterior arthrotomy, and early surgical decompression. Twelve statements were revised for round 2, of which 7 subsequently achieved consensus. The final consensus emphasized: (1) pseudoparalysis with pain on passive movement as the most important clinical sign; (2) selective but important use of MRI in cases of diagnostic uncertainty or suspected osteomyelitis; (3) open anterior arthrotomy as the preferred surgical approach; (4) immobilization only for unstable hips; (5) an antibiotic duration of ≤4 weeks for isolated septic arthritis; and (6) a minimum follow-up of 2 years. Five statements did not reach consensus. Conclusion: This international Delphi study provides expert-derived recommendations for the diagnosis and management of septic arthritis of the hip in prewalking children. These consensus statements offer a practical framework for clinical decision-making and identify key areas requiring further research, including the role of routine ultrasound, synovial fluid analysis, and postoperative care. Level of Evidence: Level V (expert opinion/consensus statement).

Background: Pediatric acute hematogenous osteomyelitis (PAHO) is a bone infection usually caused by Staphylococcus aureus , where bacteria spread through the bloodstream and colonize bone tissue. In many countries, including New Zealand, most cases of PAHO are attributed to methicillin-susceptible S. aureus (MSSA). Although standard antibiotic therapy is effective in many cases (uncomplicated infections), some are difficult to resolve, leading to a poor clinical outcome (complicated infections). These patients often require intensive care admission, extended antibiotic treatment, and sometimes develop chronic infection. While antibiotic resistance and host factors are well-known contributors, bacterial genetic determinants remain relatively underexplored and likely play a critical role in disease severity and therapeutic response. Questions/purposes: (1) Are the MSSA isolates found in children who had complicated infections genetically distinct from those from uncomplicated infections? (2) Is a complicated clinical outcome in PAHO associated with MSSA displaying reduced phenotypic susceptibility to antibiotics or the carriage of known genetic determinants of antimicrobial resistance? (3) Which genes and, in particular, which virulence factors are associated with complicated infections? Methods: The study cohort comprised 85 MSSA isolates from 85 patients with PAHO collected at New Zealand’s largest children’s hospital. These isolates were split into two groups: complicated (n = 38, from patients with infections that required intensive care admission or were difficult to resolve with standard antibiotic treatment) and uncomplicated (n = 47, from patients with readily cleared infections). Phenotypic antimicrobial susceptibility testing was performed for all isolates. Whole-genome sequencing was performed for molecular typing, identification of antimicrobial resistance genes, and virulence factor genes. Isolate relatedness was identified using phylogenetic analysis. A genome-wide association study was conducted to identify genetic determinants associated with a complicated outcome. Results: MSSA infections in PAHO are caused by a genetically diverse group of isolates, with no clustering of strains between complicated and uncomplicated infections. No differences in the levels of phenotypic susceptibility and presence of beta-lactam resistance genes between complicated and uncomplicated isolates was observed. However, genome-wide association analysis identified several virulence factors associated with complicated outcomes, including Panton-Valentine leukocidin (PVL) genes lukS-PV and lukF-PV (OR 23; q < 0.001), von Willebrand factor-binding protein (vWbp) (OR 13; q = 0.015), and capsular polysaccharide type 8 genes cap8HIJK (OR 11; q = 0.038). The fosfomycin resistance–associated mutation glpT_L27F was also associated with complicated outcomes. Conclusion: Our findings suggest that complicated outcomes in MSSA infections in PAHO are associated with specific virulence gene carriage rather than classical antimicrobial resistance mechanisms. In a clinical setting, these findings have the potential to contribute to improved outcomes by molecular detection of high-risk virulence profiles, enabling targeted management in high-risk cases. Future studies could investigate whether biofilm formation and differential virulence factor gene expression contribute to variable clinical outcomes. Level of Evidence: Level II, therapeutic study.

Study Design: Retrospective case series.Purpose: To determine the prevalence of neural axis abnormalities (NAA) in patients with adolescent idiopathic scoliosis (AIS) undergoing deformity corrective surgery and evaluate factors that may predict the presence of underlying NAA in these patients.Overview of Literature: There is no clear consensus regarding the use of magnetic resonance imaging (MRI) to screen for potential NAA in patients with AIS. Various clinical and radiographic risk factors predicting underlying NAA have been suggested, but these remain controversial.Methods: This study included 282 patients with presumed AIS who underwent preoperative MRI to exclude NAA between 2010 and 2020 in multiple centers. Spinopelvic parameters, including Cobb angle, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence, were measured on preoperative and postoperative radiographs. Additional clinical data were gathered on curve characteristics, symptomatic back pain, and abnormal preoperative neurological examinations.Results: The median age was 14 years (range, 11–18 years). The cohort consisted of 49 males (17%), 217 patients (77%) of European ethnicity, 30 (10.6%) Māori, and 7 (2.5%) Pacific Islanders. Twenty-one patients (7.4%) had NAA, of which five required neurosurgical intervention. Among the NAA group, four were diagnosed with Chiari malformations, seven with syringomyelia, and four with both. The presence of NAA did not affect curve reduction with surgery. No significant association was found between NAA and any investigated variable.Conclusions: Routine preoperative MRI is justifiable, as 7.4% of the cohort had NAA, with five patients requiring neurosurgical intervention, thereby altering operative management.

Lactoferrin (Lf), we have previously shown, has therapeutic potential in the field of skeletal regenerative medicine demonstrating its potent stimulating effects on bone growth. Recently, we have identified bovine lactoferrin (bLf) as a factor that also enhances antibiotic killing of Staphylococcus aureus (S. aureus). Biofilms are associated with around 65% of all infections and 80% of chronic infections. One feature of biofilm infection is tolerance to antibiotics due to the survival of a subpopulation of biofilm bacteria, where laboratory tests on planktonic cells indicate susceptibility. Tolerance is seen in bone infections of osteomyelitis and prosthetic joints, where methicillin-susceptible S. aureus (MSSA) strains predominate, but where treatments with the frontline penicillinase-resistant antibiotic cefazolin (CEF) can be ineffective. In vitro-grown biofilms of MSSA are 1000-fold more tolerant to CEF but can be eradicated by CEF at 10x minimal inhibitory concentration in the presence of bLf. Bone infection can impede blood circulation within the bone, leading to bone death. Lf as a potent stimulator of bone growth adds to its appeal as a treatment for bone infections.

Objective: Advanced imaging in the management of childhood bone and joint infection (BJI) has the potential to improve disease outcomes. Knowledge about the optimal timing for magnetic resonance imaging (MRI) in relation to both surgically and nonsurgically managed BJI is limited. This study examines the impact of MRI timing on number of surgeries, length of stay (LOS), hospitalization cost, and disease recurrence in childhood BJI. Methods: This is a retrospective review of patients younger than 16 years with acute hematogenous osteomyelitis (AHO) or septic arthritis (SA) treated in the Auckland region from 2018 to 2023. Cases undergoing MRI as part of diagnostic workup were included. Treatment, hours between admission and MRI, LOS, hospitalization cost, and infection recurrence were assessed. Results: There were 563 cases of BJI, of which 390 met the inclusion criteria. Cases were primarily AHO (85%). The percentage of cases having MRI increased over time from 54% (2018) to 80% (2023). Locally disseminated infections such as subperiosteal abscess or adjacent septic arthritis occurred in 48%. Children with preoperative (n = 145) versus postoperative MRI (n = 60) had a lower reoperation rate (33% vs 77%, P = 0.001) and shorter LOS (14.1 vs 22.4 d, P = 0.002). Hospitalization costs appeared lower but did not differ statistically ($59,419 vs $159,353, P = 0.12). In nonoperative cases, LOS was shorter if an MRI occurred within 48 hours of admission (7.3 vs 10 d, P = 0.03). Disease recurrence was not associated with MRI timing. Conclusion: Overall, children with BJI who underwent MRI scans before surgery had lower reoperation rates. Children receiving MRIs within 48 hours of admission had shorter LOS.

Background: Childhood bone and joint infection (BJI) is a potentially severe disease with consequences for growth and development. Critically unwell children may require prolonged hospitalization and multiple surgeries. Acknowledging rising healthcare costs and the financial impact of illness on caregivers, increased efforts are required to optimize treatment. This systematic review aims to characterize existing costs of hospital care and summarize strategies, which reduce treatment expense. Methods: A systematic review of the literature was performed from January 1, 1980, to January 31, 2024. Data were extracted on hospitalization costs for pediatric BJI by decade and global region. Results have been converted to cost per day in US dollars with purchase parity for 2023. Studies reporting innovations in clinical care to reduce length of stay (LOS) and simplify treatment were identified. Studies trialing shorter antibiotic treatment were only included if they specifically reported changes in LOS. Results: Twenty-three studies met inclusion criteria; of these, a daily hospitalization cost could be derived from 7 publications. Overall hospitalization cost and inpatient charges rose steeply from the 1990s to the 2020s. By contrast, average LOS seems to have decreased. Cost per day was higher in the United States than in Europe and higher for cases with confirmed methicillin-resistant Staphylococcus aureus. Sixteen studies report innovations to optimize care. For studies where reduced LOS was achieved, early magnetic resonance imaging with immediate transfer to theater when necessary and discharge on oral antibiotics were consistent features. Conclusion: Rising costs of hospital care and economic consequences for families can be mitigated by simplifying treatment for childhood BJI. Hospitals that adopt protocols for early advanced imaging and oral antibiotic switch may provide satisfactory clinical outcomes at lower cost. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

LONG-TERM HEALTH OUTCOMES OF PAEDIATRIC MULTIFOCAL MUSCULOSKELETAL SEPSIS: A 15-YEAR REVIEW

ADOLESCENT IDIOPATHIC SCOLIOSIS WITH CONCOMITANT SPONDYLOLYSIS: CHOICE OF FUSION LEVELS EVALUATION OF THE OUTCOMES OBTAINED LEAVING THE LYTIC LEVEL NOT INSTRUMENTED

15 YEARS ON: A PROSPECTIVE COMPARISON OF PONSETI CASTING VERSUS SURGICAL TREATMENT OF CLUBFOOT

Background: Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray–guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of “see one, do one, teach one” are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients. Objective: This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees. Methods: This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort’s performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training. Results: As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021). Conclusions: This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb International Registered Report Identifier (IRRID): DERR1-10.2196/38282