Acute leukemia (AL) in children can mimic several orthopedic pathologies at presentation, with a variable delay in the correct diagnosis. This is a major problem, which may result in fractures, loss of mobility, and deformity, with resultant adverse effects on quality of life. Here, we studied the clinical and radiological musculoskeletal manifestations in children with AL. We reviewed 328 children [208 boys (62%), median age 7.2 years] with acute lymphoblastic (279, 85%) or myeloid (49, 15%) leukemia, treated between January 1982 and December 2003 by the Paediatric Oncology Service, Second University of Naples. The group was further divided into two groups: group 1 included 255 patients (78%, 163 boys) without skeletal morbidity at diagnosis, and group 2 included 73 patients (22%, 41 boys) with musculoskeletal symptoms. This group was further subdivided into group 2A (56 patients), which included children with symptoms related to the appendicular skeleton, and group 2B (17 patients), which included children with symptoms related to the axial skeleton. Moreover, we also reported the long-term complications of therapy, such as osteonecrosis of the weight-bearing joints. In group 2A, 44 children presented only pain, seven septic arthritis-type symptoms, and five osteomyelitis-type symptoms. Joint compression was in the tibia-tarsus (21 patients), knee (16), coxofemoral (12), and elbow (seven). In group 2B, 11 patients presented with vertebral collapses. The remaining six patients complained of localized pain in the lumbar-sacral area, with limited flexor and extensor muscle capacity. Fifty-five (75.3%) patients showed radiographic abnormalities: osteoporosis in 22 patients (40%), pathological fractures in 11 (20%), osteolysis in 10 (18.1%), osteosclerosis in five (9%), periosteal reactions in four (7.2%), and metaphyseal bands in three (5.4%). Four (1.2%) patients in total showed avascular necrosis (4.3% when only high-risk patients were considered). At presentation, 22% of our children had at least one musculoskeletal manifestation and 75.3% showed one radiographic change. Our study highlights the importance of including AL in the differential diagnosis of musculoskeletal manifestations. Four cases of avascular necrosis confirm the need for regular check-ups, both orthopedic and nonorthopedic, particularly in adolescent girls, to prevent permanent disability.

SummarySubjects with chronic diseases are more likely to be nonpersistent to pharmacological treatment. Lack of persistence is common among subjects using oral anti-osteoporotic drugs, and leads to increased risk of fragility fracture. The aim of our retrospective study is to analyze the rates and reasons for discontinuation of anti-osteoporotic drugs in the Campania Region. Subjects aged over 40 years were included if they had received at least one prescription for any anti-osteoporotic drugs. Data were obtained from an administrative database of regional data on outpatient drug prescriptions reimbursed by the National Health Service. Patients were followed until the discontinuation of anti-osteoporotic therapy or until the end of the observation period. A total of 30,048 were incident users of anti-osteoporotic drugs: 28,317 (94.2%) females. The mean age of the cohort was 69.0±10.0 years. Weekly bisphosphonates (51.1%) were the most commonly prescribed drugs. In the overall population, persistence rates were 34.8% after 6 months and 13.4% at one year. A multivariate Cox proportional hazard analysis showed that daily regimen (HR 1.9) treatments remained at higher risk of early discontinuation compared to weekly regimen therapies.Our data showed that the persistence to osteoporosis therapy is significantly worse than reported in literature.

Paediatric valgus flexible flatfoot is a common childhood paramorphism. Its treatment options consist of rehabilitation, corrective footwear and, if necessary, surgical intervention. The aim of our study was to compare a group of children who followed a rehabilitative programme versus a historical group of children who had been treated with insoles and orthopaedic footwear. Over a 2 year period (1995-1997), 300 children (mean age was 3.4-184 male, 116 female) with bilateral flexible flatfoot (600 feet) were recruited and underwent a rehabilitative programme for a mean period of 2.75 years. The feet were classified according to Viladot's method: 386 feet presented a type III degree deformity and 214 feet presented a type II degree deformity. The rehabilitative programme consisted of simple therapeutic exercises, which could be easily learnt by both patients and their caregivers. These children were compared to a historical group of children (674 feet) who had been treated in our department for infantile flexible flatfoot with the use of orthosis. In these groups, 396 feet presented a type III degree deformity and 278 feet presented a type II degree deformity. In the group of children who underwent the rehabilitative protocol, during follow-up at the age of eight, 352 of the 386 type III degree feet could be classified as normal and 210 of the 214 type II degree cases became normal. In the historical cohort of children treated with orthosis, at the age of eight, 214 of the 396 type III degree feet could be classified as normal; and 248 of the 278 type II degree cases became normal. Our results show that comparing the percentage of success (changing from type III or II degree to type I or N) in the two groups (children treated with rehabilitation and children treated with orthosis), the rehabilitative approach seems to be more effective. Probably it has a marginal influence on the natural history of paediatric valgus flexible flatfoot even though it plays a role in maintaining good flexibility of the flatfoot thus limiting functional impairment.