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Purpose of the Study: The purpose of this study was to evaluate a diagnostic and management protocol for osteoarticular infection in children which was developed at the Rouen University Hospital in 1993. We studied the technical aspects of the protocol allowing improved certain diagnosis and bacteriological documentation as well as the reduction in intravenous treatments and hospital stay., Material and Methods: Two successive series were compared. The first constituted from May 1984 to February 1992 was a retrospective series of 106 children with osteoarticular infections. The second series was prospective an included 104 children with osteoarticular infection treated after institution of the protocol (January 1995 to December 1998). All children were treated in the same unit. Files were reviewed at a minimum follow-up of 18 months following the end of treatment. We analyzed: clinical, biological, and radiological data at admission; elements of the bacteriological study and their contribution to identification of the causal agent; duration of intravenous antibiotic therapy; total duration of antibiotic therapy, and hospital stay; complications and sequelae., Results: After institution of the protocol, we observed significant progress: certain diagnosis of acute osteomyelitis improved from 67% to 85% after institution of a more comprehensive diagnostic program; bacteriological identification improved from 37.5% to 72.2% for acute osteomyelitis and from 41.6% to 59.5% for septic arthritis, with a growing number of recognized cases of Kingella kingae infections causing acute osteomyelitis (n=2) or septic arthritis (n=4) due to technical progress in sampling and culturing. Mean duration of intravenous antibiotic therapy (15 days versus 9.95 days), mean duration of total antibiotic therapy (47.3 versus 33.8 d) as well as length of hospital stay (17.5 d versus 12.5 d) were significantly improved. The shorter antibiotic therapy did not led to any supplementary morbidity., Conclusions: A systematic bacteriological diagnostic protocol has enabled an improvement in treatment and hospitalization. The protocol has been further updated and simplified in light of these findings and observations of insufficiencies, taking into account recent data in the literature and epidemiological features of osteoarticular infection in children.

Unlabelled: Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent., Methods and Results: We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful., Discussion: Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection., Conclusion: This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.

Ambulatory surgery appears to minimize lasting psychological upset in children. Patients must be properly selected. It is essential that the children and their parents should have a visit with an anaesthetist prior to the patient's admission. Laboratory investigations should be prescribed at that time after questioning and examining the patient. Caudal anaesthesia is a useful regional technique for postoperative pain relief in children. Sacral canal puncture is carried out after the induction of general anaesthesia. Only a light state of general anaesthesia is required. The local anaesthetic mixture is made of equal volumes of 1% lidocaine and 0.5% bupivacaine without adrenaline. Rapid awakening, early feeding and pain relief increase reliability and comfort.

Ambulatory pediatric anaesthesia is done within a well-organized medical and surgical structure. The anaesthesia consultation confirms the surgical indications, taking into account certain medical pathologies. 27% of elective surgery is done in day-hospital. The anaesthetic techniques described have been done in children from three weeks to sixteen years of age. Intubation was not an exclusion criterion. The major causes for transfer to the general hospital (2.9%) are given. Anaesthetic complications represent 0.1% of such transfers. Scrupulous respect of the selection criteria, competence of anaesthesiologists and of pediatric surgeons are prerequisites for good results.