Elbow stiffness poses a significant challenge for surgeons as well as physiotherapists during and after surgery. To date, there is no consensus regarding the subsequent rehabilitation after surgical release of the stiff elbow.

The aim is to evaluate the most important therapeutic strategies following open or arthroscopic release of the stiff elbow based on a comprehensive literature review, and to develop a consensus for or against specific therapeutic methods with the help of a survey among elbow experts of the D-A-CH Association for Shoulder and Elbow Surgery (DVSE).

Literature search was performed based on guidelines, the "health technology assessments", systematic reviews and clinical studies that examined rehabilitation after osteocapsular release of the stiff elbow. The databases of the "Guidelines International Network", various national guidelines, PubMed, the "Cochrane Central Register of Controlled Trials", the "Cochrane Database of Systematic Reviews", and the "Physiotherapy Evidence Database" were scanned, each for the period from January 1989 to December 2019. As part of an online survey, all active members of the DVSE were asked about their strategies in immediate aftercare and rehabilitation after elbow arthrolysis.

A total of 5 reviews and 55 articles could be identified from 107 articles since 1989, which served as the basis for the preparation of an evidence-based aftercare recommendation. By reviewing all the mentioned paper and evaluation of the survery of DVSE members, a basic concept could be finalized.

For pediatric osteomyelitis and septic arthritis, 10-24% of cases occur in the upper extremity (UE). Due to delays in presentation and diagnosis, UE infections are often more complex and severe than infections of the lower extremity (LE). This review evaluates the literature from the past 6 years related to pediatric osteomyelitis and septic arthritis of the UE and provides a guide for professionals managing these conditions in children.

The shoulder and elbow are the most commonly affected joints, and the humerus is the most commonly affected bone. As with the LE, diagnosis of UE osteoarticular infections is based on clinical evidence, laboratory data, and diagnostic imaging. While Staphylococcus aureus is the primary bacteria identified in UE infections, there is an underappreciation of the burden from Kingella kingae as a causative organism in culture-negative patients where PCR is not performed. Septic joints should be treated with irrigation and debridement urgently, with subsequent antibiotic therapy for a minimum of 2-4 weeks. For acute osteomyelitis without abscess or concomitant septic joints, antibiotic therapy is standard of care. Methicillin-resistant Staphylococcus aureus is associated with more severe infection requiring more surgeries. Various strategies exist for managing segmental bone loss in chronic osteoarticular infections. Osteomyelitis and septic arthritis tend to occur less frequently in the UE than the LE but have a devastating impact on the health and quality of life of children around the world. Complete resolution of disease can be achieved through an individualized approach to antibiotic and operative management. Further study is needed to assess the efficacy of aspiration as a primary treatment strategy in UE joints.

There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database.

Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected.

Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02).

UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare.

Level IV, prognostic.

Acute septic arthritis in children is an orthopaedic emergency. A delay in diagnosis and inappropriate treatment can result in devastating damage to the joint with lifelong disability as a consequence. The clinical presentation can be a diagnostic challenge, especially in young children. A recent systematic review showed that joint tenderness and fever are important signals of septic arthritis. Ultrasound is helpful in detecting the presence of a joint effusion. Plain radiographs may show bone changes but magnetic resonance imaging is the most reliable imaging study for detecting concomitant osteomyelitis. The diagnosis of acute septic arthritis is highly suggestive when pus is aspirated from the joint, in case of a positive culture or a positive gram stain of the joint fluid, or if there is a white blood-cell count in the joint fluid of more than 50000/mm3. Staphylococcus aureus is the most commonly cultured organism. Recent systematic reviews have identified the most effective drainage techniques, including needle aspiration, arthroscopy and arthrotomy, depending on the affected joint. After the drainage procedure it is important to monitor the clinical and laboratory outcomes. Additional drainage procedures may be necessary in select cases.

Upper extremity arthritis in children can be treated with joint aspiration, arthroscopy or arthrotomy, followed by antibiotics. The literature seems inconclusive with respect to the optimal drainage technique. Therefore, the objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the upper extremity in children.Two independent investigators systematically searched the electronic MEDLINE, EMBASE and Cochrane databases for original articles that reported outcomes of aspiration, arthroscopy or arthrotomy for septic arthritis of the paediatric shoulder or elbow. Outcome parameters were clinical improvement, need for repetitive surgery or drainage, and complications.Out of 2428 articles, seven studies with a total of 171 patients treated by aspiration or arthrotomy were included in the systematic review. Five studies reported on shoulder septic arthritis, one study on elbow septic arthritis, and one study on both joints. All studies were retrospective, except for one randomized prospective study. No difference was found between type of treatment and radiological or clinical outcomes. Aspiration of the shoulder or elbow joint required an additional procedure in 44% of patients, while arthrotomy required 12% additional procedures.Conclusion: Both aspiration and arthrotomy can achieve good clinical results in children with septic arthritis of the shoulder or elbow joint. However, the scientific quality of the included studies is low. It seems that the first procedure can be aspiration and washout and start of intravenous antibiotics, knowing that aspiration may have a higher risk of additional drainage procedures. Cite this article: EFORT Open Rev 2021;6:651-657. DOI: 10.1302/2058-5241.6.200122.

Acute osteoarticular infections (AOI) should be treated as top emergencies. The first few days following the inception of infection are ultra-critical to long-term prognosis.A comprehensive road map for management of childhood AOI is still lacking despite recent advances in microbiology and imaging (magnetic resonance imaging). The many faces of childhood AOI warrant a multidiscipline approach to management.Laboratory and imaging findings of are still debatable and should not overshadow or delay a management plan based on the experienced physician's clinical judgment.Ample evidence-based practice supports the use of a few days of intravenous antibiotic administration followed by oral therapy until correlative clinical and basic laboratory (acute phase reactants) results improve.The growing body of evidence on 'high-risk' children/neonates of AOI warrants continual clinical extra-vigilance in identifying these patient subsets.Open drainage and debridement remain the mainstay of treatment of septic hips, whereas for other joints the use of alternative surgical techniques should be individualized or on case-by-case basis.Because the consequences of misdiagnosis of AOI are usually grave and permanent, proactive treatment/overtreatment is justified in the event of unconfirmed but suspicious diagnosis. Cite this article: EFORT Open Rev 2021;6:584-592. DOI: 10.1302/2058-5241.6.200155.

Acute osteomyelitis of the distal fibula is a rare disease in children and is characterized by special features compared with other sites. The objective of this study was to report the functional outcome at long-term follow-up.

We reviewed retrospectively, between January 2000 and December 2010, all cases of acute osteomyelitis of the distal fibula. Epidemiological and bacteriological data as well as therapy and outcome factors were analyzed. At the last follow-up, functional outcome was studied based on ankle motion, growth disturbance, and radiological sequelae.

Seven cases of acute osteomyelitis of the distal fibula were found. The mean age was patients was 7.71 years and the sex ratio was 2.5. The portal of entry of the pathogen was a skin injury in 57% of cases. Staphylococcusaureus was identified in 71% of cases. The mean duration of antibiotic therapy was 33.2 days. At a mean of 12.85 years of follow-up, no growth disturbance was found. The mean plantar and dorsal flexion was 41° and 27.7°, respectively. The mean postoperative American Orthopedics Foot and Ankle score (AOFAS) was 96.71 points.

Acute osteomyelitis of the distal fibula in children is scarce and rarely reported in the literature. It occurs more often in boys at an average age of 7 years. Local symptoms are usually more obvious than general symptoms. Surgical debridement of the subperiosteal abscess without bone trepanation seems to lead to a satisfactory outcome.

Level IV - case series. IRB: Sahloul Hospital Human Research Ethics Committee.