Controversies in the Management of Unstable Slipped Capital Femoral Epiphysis.

Slipped capital femoral epiphysis (SCFE) involves anterior-superior displacement of the proximal metaphysis relative to the epiphysis of the proximal femur. It is the most common hip disorder affecting the pediatric population. SCFE has a higher incidence in adolescent males in addition to racial and regional predilections. Despite being described over 500 years ago, there remains controversy surrounding the topic. This article examines current concepts in SCFE, with a spotlight on treatment. An evidence-based discussion of treatment controversies regarding reduction method, fixation construct, supplemental procedures and surgical timing is included.

Intramedullary Bone Graft Harvest Using Reamer-Irrigator-Aspirator System: A Case Series.

Autogenous iliac crest bone grating has been the gold standard. Recently, intramedullary bone graft harvest using a reamer-irrigator-aspirator (RIA) had been gaining more interest among orthopedic surgeons. Twenty-four RIA bone graft harvesting procedures in 23 consecutive patients with nonunions were included. The mean age was 37.8 years. Rates of perioperative complications, secondary surgical procedures, and union were assessed for all patients. At mean 10.1 months follow-up, three donor site complications occurred (12.5%), including two fractures (8.3%). Eighteen patients (78%) progressed to radiographic union, three (13%) were lost for follow-up, and two (9%) failed to achieve union. Mean reamer size was 13.7 mm (mode, 14.0 mm), producing an average volume of 39.4 mL (range, 15-90 mL) bone graft. While RIA bone grafting results in predictably high rates of union, patients should be counseled extensively about fracture risk. Tibial RIA may be less optimal as a primary source of bone grafting. (Journal of Surgical Orthopaedic Advances 26(4):233-238, 2017).

Ilio-Sacral (IS) Screw Fixation for Sacral and Sacroiliac Joint (SIJ) Injuries in Children.

BACKGROUND: Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger. METHODS: This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function). RESULTS: In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion. CONCLUSIONS: IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws.

Patient-Based and Surgical Risk Factors for 30-Day Postoperative Complications and Mortality After Ankle Fracture Fixation.

OBJECTIVE: The purpose was to calculate the incidence rates and determine risk factors for 30-day postoperative mortality and morbidity after ankle fracture open reduction and internal fixation (ORIF). METHODS: The NSQIP database was queried to identify patients undergoing ankle fracture ORIF from 2006 to 2011, with extraction patient-based or surgical variables and a 30-day clinical course. Multivariable logistic regression analysis identified significant predictors on outcome measures. RESULTS: Mean age was 50.3 (±18.2) years while diabetes mellitus (12.8%) and body mass index ≥40 kg/m(2) (9.2%) were documented from a total of 3328 patients identified. The 30-day mortality rate was 0.30%, and complications occurred in 5.1%. Chronic obstructive pulmonary disease [odds ratio (OR): 4.23, 95% confidence interval (CI): 1.19-15.06] and a nonindependent functional status before surgery (OR: 2.25, 95% CI: 1.13-4.51) were the sole independent predictors of mortality and major local complications, respectively. Major local complications occurred in 2.2% of patients, and significant predictors were peripheral vascular disease (OR: 6.14; 95% CI: 1.95-19.35), open wound (OR: 5.04; 95% CI: 2.25-11.27), nonclean wound classification (OR: 3.02; 95% CI: 1.31-6.93), and smoking (OR: 2.85; 95% CI: 1.42-5.70). Independent predictors of hospital stay >3 days were cardiac disease, age 70 years or older, open wound, partially/totally dependent functional status, American Society of Anesthesiologists (ASA) classification ≥3, body mass index ≥40 kg/m(2), bimalleolar or trimalleolar ankle fracture pattern, female sex, and diabetes. CONCLUSIONS: Chronic obstructive pulmonary disease increased the risk of mortality after ankle fracture ORIF. Risk factors for postoperative complications included peripheral vascular disease, open wound, nonclean wound classification, age 70 years or older, and ASA classification ≥3. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program.

BACKGROUND: This investigation sought to evaluate risk factors for morbidity and mortality from a large series of below-knee amputees prospectively entered in a national database. STUDY DESIGN: All patients undergoing below-knee amputations in the years 2005-2008 were identified in the database of the National Surgical Quality Improvement Program (NSQIP). Demographic data, medical comorbidities, and medical history were obtained. Mortality and postoperative complications within 30 days of the below-knee amputation were also documented. Chi-square test, univariate, and multivariate logistic regression analyses were used to assess the effect of specific risk factors on mortality, as well as the likelihood of developing major, minor, or any complications developing. RESULTS: Below-knee amputations were performed in 2,911 patients registered in the NSQIP database between 2005 and 2008. The average age of patients was 65.8 years old and 64.3% were male. There was a 7.0% 30-day mortality rate and 1,627 complications occurred in 1,013 patients (34.4%). Multivariate logistic regression analysis identified renal insufficiency, cardiac issues, history of sepsis, steroid use, COPD, and increased patient age as independent predictors of mortality. The most common major complications were return to the operating room (15.6%), wound infection (9.3%), and postoperative sepsis (9.3%). History of sepsis, alcohol use, steroid use, cardiac issues, renal insufficiency, and contaminated/infected wounds were independent predictors of one or more complications developing. CONCLUSIONS: Renal disease, cardiac issues, history of sepsis, steroid use, COPD, and increased patient age were identified as predictors of mortality after below-knee amputation. Renal disease, cardiac issues, history of sepsis, steroid use, contaminated/infected wounds, and alcohol use were also found to be predictors of postoperative complications.

The epidemiology of ankle sprains in the United States.

BACKGROUND: Ankle sprain has been studied in athletic cohorts, but little is known of its epidemiology in the general population. A longitudinal, prospective epidemiological database was used to determine the incidence and demographic risk factors for ankle sprains presenting to emergency departments in the United States. It was our hypothesis that ankle sprain is influenced by sex, race, age, and involvement in athletics. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for all ankle sprain injuries presenting to emergency departments between 2002 and 2006. Incidence rate ratios were then calculated with respect to age, sex, and race. RESULTS: During the study period, an estimated 3,140,132 ankle sprains occurred among an at-risk population of 1,461,379,599 person-years for an incidence rate of 2.15 per 1000 person-years in the United States. The peak incidence of ankle sprain occurred between fifteen and nineteen years of age (7.2 per 1000 person-years). Males, compared with females, did not demonstrate an overall increased incidence rate ratio for ankle sprain (incidence rate ratio, 1.04; 95% confidence interval, 1.00 to 1.09). However, males between fifteen and twenty-four years old had a substantially higher incidence of ankle sprain than their female counterparts (incidence rate ratio, 1.53; 95% confidence interval, 1.41 to 1.66), whereas females over thirty years old had a higher incidence compared with their male counterparts (incidence rate ratio, 2.03; 95% confidence interval, 1.65 to 2.65). Compared with the Hispanic race, the black and white races were associated with substantially higher rates of ankle sprain (incidence rate ratio, 3.55 [95% confidence interval, 1.01 to 6.09] and 2.49 [95% confidence interval, 1.01 to 3.97], respectively). Nearly half of all ankle sprains (49.3%) occurred during athletic activity, with basketball (41.1%), football (9.3%), and soccer (7.9%) being associated with the highest percentage of ankle sprains during athletics. CONCLUSIONS: An age of ten to nineteen years old is associated with higher rates of ankle sprain. Males between fifteen and twenty-four years old have higher rates of ankle sprain than their female counterparts, whereas females over thirty years old have higher rates than their male counterparts. Half of all ankle sprains occur during athletic activity.