Can Rigid Femoral Nailing Be Used for Pediatric Femoral Shaft Fracture in Children 8 to 10 Years? Use of RIN in Patients With Femoral Shaft Fracture.

BACKGROUND: The treatment modalities for pediatric femoral shaft fractures are determined by their age, weight, and fracture pattern. Rigid intramedullary nailing (RIN) is usually recommended for patients >11 years of age, and elastic intramedullary nailing (EIN) has been used for patients under 10 years. However, little is known about the use of RIN in patients aged 8 to 10 years. We examined the differences in patients with femoral shaft fractures who were treated with EIN or RIN in terms of (1) fracture healing; (2) changes of anatomic parameters; and (3) related complications. METHODS: We retrospectively reviewed 54 patients between 8 and 10 years of age, with femoral shaft fractures, who were treated with either EIN or RIN between 2011 and 2020. Lateral trochanteric entry was used for RIN procedure. The mean follow-up period was 26.4 months (range, 6 to 113 mo). There were 17 patients in the EIN group and 37 patients in the RIN group. The mean age at the time of surgery was 1 year younger in the EIN group ( P <0.01). The mean weight of the patient was significantly heavier in the RIN group compared with the EIN group. RESULTS: Complete union of the fracture was achieved slightly faster in the RIN group at 3.4 months compared with 3.7 months in the EIN group ( P =0.04). There were no clinically significant changes of the anatomic parameters in either group, including neck shaft angle and articulotrochanteric distance. There was no evidence of avascular necrosis at the time of final follow-up for either group. There were no significant differences in postoperative complications between the groups. CONCLUSION: RIN using lateral trochanteric entry is a feasible surgical option for femoral shaft fractures in patients 8 to 10 years of age that are heavier than 40 kg or with unstable fracture patterns. LEVEL OF EVIDENCE: Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Membrane-Inducing "Masquelet" Technique for Massive Traumatic Diaphyseal Femur Bone Loss in a Pediatric Patient: A Case Report.

CASE: A 14-year-old boy sustained 22 cm of femur bone loss after a motor vehicle accident. The patient underwent treatment with the membrane-inducing "Masquelet" technique for management of the injury. The grafts incorporated to form new bone and fill-in the void. CONCLUSION: Although the Masquelet technique is thoroughly described in adult orthopaedic trauma and oncology literature, there are minimal reports to support its use in pediatric patients. Five-year follow-up data on this patient concluded that utilization of this technique for significant bone defects proves to be a safe and effective alternative for the management of pediatric trauma patients.

Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort.

BACKGROUND: Closed reduction (CR) is a common treatment for infantile developmental dysplasia of the hip. The purpose of this observational, prospective, multicenter study was to determine the early outcomes following CR. METHODS: Prospectively collected data from an international multicenter study group was analyzed for patients treated from 2010 to 2014. Baseline demographics, clinical exam, radiographic/ultrasonographic data, and history of previous orthotic treatment were assessed. At minimum 1-year follow-up, failure was defined as an IHDI grade 3 or 4 hip and/or need for open reduction. The incidence of avascular necrosis (AVN), residual dysplasia, and need for further surgery was assessed. RESULTS: A total of 78 patients undergoing CR for 87 hips were evaluated with a median age at initial reduction of 8 months (range, 1 to 20 mo). Of these, 8 hips (9%) were unable to be closed reduced initially. At most recent follow-up (median 22 mo; range, 12 to 36 mo), 72/79 initially successful CRs (91%) remained stable. The likelihood of failure was unaffected by initial clinical reducibility of the hip (P=0.434), age at initial CR (P=0.897), or previous treatment in brace (P=0.222). Excluding those hips that failed initial CR, 18/72 hips (25%) developed AVN, and the risk of osteonecrosis was unaffected by prereduction reducibility of the hip (P=0.586), age at CR (P=0.745), presence of an ossific nucleus (P=0.496), or previous treatment in brace (P=0.662). Mean acetabular index on most recent radiographs was 25 degrees (±6 degrees), and was also unaffected by any of the above variables. During the follow-up period, 8/72 successfully closed reduced hips (11%) underwent acetabular and/or femoral osteotomy for residual dysplasia. CONCLUSIONS: Following an initially successful CR, 9% of hips failed reduction and 25% developed radiographic AVN at early-term follow-up. History of femoral head reducibility, previous orthotic bracing, and age at CR did not correlate with success or chances of developing AVN. Further follow-up of this prospective, multicenter cohort will be necessary to establish definitive success and complication rates following CR for infantile developmental dysplasia of the hip. LEVEL OF EVIDENCE: Level II-prospective observational cohort.

Management of Irreducible Hip Dislocations in Infants With Developmental Dysplasia of the Hip Diagnosed Below 6 Months of Age.

BACKGROUND: Infants with dislocated irreducible (D/I) hips can be substantially harder to treat than infants with dislocated but reducible hips. The purpose of this study was to compare treatment methods and outcomes for infants with D/I hips in order to optimize management of this difficult patient cohort. METHODS: A multicenter prospective hip dysplasia study database was analyzed from 2010 to 2016. Infants aged below 6 months with clinically and radiologically confirmed D/I hips were included in the study. Teratological hips (syndromic/neuromuscular) were excluded. RESULTS: In total, 59 hips in 52 patients were included. All hips were clinically Ortolani negative and radiologically dislocated but irreducible on presentation and had at least 20 months of follow-up. Mean age at diagnosis was 1.9 months (range, 0.1 to 5.9 mo). There were 33 left hips, 12 right hips, and 14 bilateral hips (7 patients). In total, 48 of 59 hips were treated in Pavlik harness. The remainder were treated by alternative braces or primary closed or open reductions. Pavlik treatment was successful in 27 of 48 hips. Pavlik treatment was abandoned in 21 D/I hips, 3 due to femoral nerve palsy and the remainder due to failure to achieve reduction. There was no statistical correlation between Pavlik success and age at diagnosis (P=0.22), patient sex (P=0.61), or bilateral compared with unilateral D/I hips (P=0.07). Left hips were more likely to be successfully reduced in Pavlik harness than right hips (P=0.01). Five complications occurred: 3 patients developed femoral nerve palsy in Pavlik harness, while 2 patients developed avascular necrosis, both after failed Pavlik treatment and subsequent surgery. CONCLUSIONS: Pavlik harness treatment has been demonstrated to be a safe and sensible first-line treatment for infants with D/I hips. Left hips were more likely to be successfully reduced in Pavlik harness than right hips, but age, sex, and bilaterality were not correlated. The outcomes demonstrated from this multicentre prospective database inform management of this complex patient cohort. LEVEL OF EVIDENCE: Level II-prognostic study: less-quality prospective study.

Results of the Scoliosis Research Society Morbidity and Mortality Database 2009-2012: A Report From the Morbidity and Mortality Committee.

INTRODUCTION: Members of the Scoliosis Research Society are required to annually submit complication data regarding deaths, visual acuity loss, neurological deficit and infection (2012-1st year for this measure) for all deformity operations performed. The purpose of this study is to report the 2012 results and the differences in these complications from the years 2009-2012. METHODS: The SRS M&M database is a self-reported complications registry of deformity operations performed by the members. The data from 2009-2012, inclusive, was tabulated and analyzed. Differences in frequency distribution between years were analyzed with Fisher's exact test. Significance was set at α = 0.05. RESULTS: The total number of cases reported increased from 34,332 in 2009 to 47,755 in 2012. Overall mortality ranged from 0.07% in 2011 to 0.12% in 2009. The neuromuscular scoliosis group had the highest mortality rate (0.44%) in 2010. The combined groups' neurological deficit rate increased from 0.44% in 2009 to 0.79% in 2012. Neurological deficits were significantly lower in 2009 compared to 2012 for idiopathic scoliosis >18 years, other scoliosis, degenerative and isthmic spondylolisthesis and other groups. The groups with the highest neurological deficit rates were dysplastic spondylolisthesis and congenital kyphosis. There were no differences in vision loss rates between years. The overall 2012 infection rate was 1.14% with neuromuscular scoliosis having the highest group rate at 2.97%. CONCLUSION: Neuromuscular scoliosis has the highest complication rates of mortality and infection. The neurological deficit rates of all groups combined have slightly increased from 2009 to 2012 with the highest rates consistently being in the dysplastic spondylolisthesis and congenital kyphosis groups. This could be due to a number of factors, including more rigorous reporting.

Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure.

BACKGROUND: The use of a brace has been shown to be an effective treatment for hip dislocation in infants; however, previous studies of such treatment have been single-center or retrospective. The purpose of the current study was to evaluate the success rate for brace use in the treatment of infant hip dislocation in an international, multicenter, prospective cohort, and to identify the variables associated with brace failure. METHODS: All dislocations were verified with use of ultrasound or radiography prior to the initiation of treatment, and patients were followed prospectively for a minimum of 18 months. Successful treatment was defined as the use of a brace that resulted in a clinically and radiographically reduced hip, without surgical intervention. The Mann-Whitney test, chi-square analysis, and Fisher exact test were used to identify risk factors for brace failure. A multivariate logistic regression model was used to determine the probability of brace failure according to the risk factors identified. RESULTS: Brace treatment was successful in 162 (79%) of the 204 dislocated hips in this series. Six variables were found to be significant risk factors for failure: developing femoral nerve palsy during brace treatment (p = 0.001), treatment with a static brace (p < 0.001), an initially irreducible hip (p < 0.001), treatment initiated after the age of 7 weeks (p = 0.005), a right hip dislocation (p = 0.006), and a Graf-IV hip (p = 0.02). Hips with no risk factors had a 3% probability of failure, whereas hips with 4 or 5 risk factors had a 100% probability of failure. CONCLUSIONS: These data provide valuable information for patient families and their providers regarding the important variables that influence successful brace treatment for dislocated hips in infants. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

What Is the Impact of Center Variability in a Multicenter International Prospective Observational Study on Developmental Dysplasia of the Hip?

BACKGROUND: Little information exists concerning the variability of presentation and differences in treatment methods for developmental dysplasia of the hip (DDH) in children < 18 months. The inherent advantages of prospective multicenter studies are well documented, but data from different centers may differ in terms of important variables such as patient demographics, diagnoses, and treatment or management decisions. The purpose of this study was to determine whether there is a difference in baseline data among the nine centers in five countries affiliated with the International Hip Dysplasia Institute to establish the need to consider the center as a key variable in multicenter studies. QUESTIONS/PURPOSES: (1) How do patient demographics differ across participating centers at presentation? (2) How do patient diagnoses (severity and laterality) differ across centers? (3) How do initial treatment approaches differ across participating centers? METHODS: A multicenter prospective hip dysplasia study database was analyzed from 2010 to April 2015. Patients younger than 6 months of age at diagnosis were included if at least one hip was completely dislocated, whereas patients between 6 and 18 months of age at diagnosis were included with any form of DDH. Participating centers (academic, urban, tertiary care hospitals) span five countries across three continents. Baseline data (patient demographics, diagnosis, swaddling history, baseline International Hip Dysplasia Institute classification, and initial treatment) were compared among all nine centers. A total of 496 patients were enrolled with site enrolment ranging from 10 to 117. The proportion of eligible patients who were enrolled and followed at the nine participating centers was 98%. Patient enrollment rates were similar across all sites, and data collection/completeness for relevant variables at initial presentation was comparable. RESULTS: In total, 83% of all patients were female (410 of 496), and the median age at presentation was 2.2 months (range, 0-18 months). Breech presentation occurred more often in younger (< 6 months) than in older (6-18 months at diagnosis) patients (30% [96 of 318] versus 9% [15 of 161]; odds ratio [OR], 4.2; 95% confidence interval [CI], 2.3-7.5; p < 0.001). The Australia site was underrepresented in breech presentation in comparison to the other centers (8% [five of 66] versus 23% [111 of 479]; OR, 0.3, 95% CI, 0.1-0.7; p = 0.034). The largest diagnostic category was < 6 months, dislocated reducible (51% [253 of 496 patients]); however, the Australia and Boston sites had more irreducible dislocations compared with the other sites (ORs, 2.1 and 1.9; 95% CIs, 1.2-3.6 and 1.1-3.4; p = 0.02 and 0.015, respectively). Bilaterality was seen less often in older compared with younger patients (8% [seven of 93] versus 26% [85 of 328]; p < 0.001). The most common diagnostic group was Grade 3 (by International Hip Dysplasia Institute classification), which included 58% (51 of 88) of all classified dislocated hips. Splintage was the primary initial treatment of choice at 80% (395 of 496), but was far more likely in younger compared with older patients (94% [309 of 328] versus 18% [17 of 93]; p < 0.001). CONCLUSIONS: With the lack of strong prognostic indicators for DDH identified to date, the center is an important variable to include as a potential predictor of treatment success or failure.

The management of pediatric subtrochanteric femur fractures with a statically locked intramedullary nail.

OBJECTIVES: To evaluate locked intramedullary (IM) fixation as an alternative treatment method for children with subtrochanteric fractures. DESIGN: Retrospective review. SETTING: Level 1 trauma center in a Children's Hospital. PATIENTS/PARTICIPANTS: Pediatric patients with subtrochanteric femur fractures with open growth plates. INTERVENTION: All patients were treated with a lateral entry IM locking nail. OUTCOME MEASUREMENTS: Patients were followed until full fracture consolidation or until implant removal. Data on time to full weight bearing, return to full activity, residual pain, any form of gait abnormality, and any other complication from follow-up visits were collected. RESULTS: There were 9 males and 1 female patient with an average age of 12 years and average follow-up of 22 months. Most of the fractures occurred secondary to high-energy trauma. Partial weight bearing was started at 24 days and full at 66 days. Implants were removed on average at 11 months after implantation. There were neither intraoperative complications nor major complications in the postoperative period recorded after removal. Two patients presented with a longer limb on the affected side, both 8 mm, and 2 presented with asymptomatic grade I heterotopic ossification. CONCLUSIONS: The use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children is a safe and efficacious method of treatment with few complications and risks and satisfactory outcomes in children over the age of 8 years. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can we alter the natural history of osteoarthritis after SCFE with early realignment?

In situ fixation has been the gold standard for the treatment of slipped capital femoral epiphysis for some time. This technique has been popular despite obligate residual proximal femoral deformity due to the increased risk for catastrophic avascular necrosis of the femoral head with closed manipulation and historical open reduction techniques. As the body of evidence regarding long-term outcome has grown, it has become evident that early osteoarthritis is common after in situ or conservative treatment because of femoroacetabular impingement of the deformed femoral neck on the acetabular rim. New techniques have been developed that show promise in preventing the early onset of osteoarthritis while minimizing the risk of avascular necrosis with early realignment of the proximal femoral anatomy and elimination of femoroacetabular impingement.

Outcomes after salvage procedures for the painful dislocated hip in cerebral palsy.

BACKGROUND: The painful dislocated hip in the setting of cerebral palsy is a challenging problem. Many surgical procedures have been reported to treat this condition with varying success rates. The purpose of this study is to retrospectively evaluate and compare the outcomes of 3 different surgical procedures performed at our institution for pain relief in patients with spastic quadriplegic cerebral palsy and painful dislocated hips. METHODS: A retrospective chart review of the surgical procedures performed by 5 surgeons for spastic, painful dislocated hips from 1997 to 2010 was performed. The procedures identified were (1) proximal femoral resection arthroplasty (PFRA); (2) subtrochanteric valgus osteotomy (SVO) with femoral head resection; and (3) proximal femur prosthetic interposition arthroplasty (PFIA) using a humeral prosthesis. Outcomes based on pain and range of motion were determined to be excellent, good, fair, or poor by predetermined criteria. RESULTS: Forty-four index surgeries and 14 revision surgeries in 33 patients with an average follow-up of 49 months met the inclusion criteria. Of the index surgeries, 12 hips were treated with a PFRA, 21 with a SVO, and 11 with a PFIA. An excellent or good result was noted in 67% of PFRAs, 67% of SVOs, and 73% of PFIAs. No statistical significance between these procedures was achieved. The 14 revisions were performed because of a poor result from previous surgery, demonstrating a 24% reoperation rate overall. No patients classified as having a fair result underwent revision surgery. All patients receiving revision surgery were eventually classified as having an excellent or good result. CONCLUSIONS: Surgical treatment for the painful, dislocated hip in the setting of spastic quadriplegic cerebral palsy remains unsettled. There continue to be a large percentage of failures despite the variety of surgical techniques designed to treat this problem. These failures can be managed, however, and eventually resulted in a good outcome. We demonstrated a trend toward better outcomes with a PFIA, but further study should be conducted to prove statistical significance. LEVEL OF EVIDENCE: III.

The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective.

BACKGROUND: The modified Dunn procedure has rapidly gained popularity as a treatment for unstable slipped capital femoral epiphysis (SCFE), but limited data exist regarding its safety and efficacy. The purpose of this study was to present results and complications following this procedure in a large multicenter series. METHODS: We reviewed the outcomes of all patients who had been treated with the modified Dunn procedure by five surgeons from separate tertiary-care institutions. All slipped capital femoral epiphyses were defined as unstable according to the Loder criteria. Patients with less than one year of follow-up and those with an underlying endocrinopathy or syndrome were excluded. All surgical procedures were performed by pediatric orthopaedic surgeons who had specific training in the modified Dunn procedure. Operative reports, outpatient records, and follow-up radiographs were used to determine the demographic information, type of fixation, final slip angle, presence of osteonecrosis, and any additional complications. Standardized surveys were administered to determine the pain level (0 to 10 scale), satisfaction (0 to 100 scale), function (modified Harris hip score, 0 to 91 scale), and activity level (UCLA [University of California Los Angeles] activity score, 0 to 10 scale) at time of the most recent follow-up. RESULTS: Twenty-seven patients (twenty-seven hips) with a mean of 22.3 months (range, twelve to forty-eight months) of follow-up met the inclusion criteria. Four patients (15%) had broken implants at three to eighteen weeks after surgery and required revision fixation. Seven patients (26%) developed osteonecrosis at a mean of 21.4 weeks (range, ten to thirty-nine weeks), with each surgeon having at least one case of osteonecrosis. The mean slip angle at the time of the most recent follow-up was 6° (95% confidence interval, 2° to 11°). Patients who did not develop osteonecrosis had significantly better clinical results compared with those who developed osteonecrosis, as demonstrated by a lower mean pain score (0.3 compared with 3.1, p = 0.002), higher level of satisfaction (97.1 compared with 65.8, p = 0.001), higher modified Harris hip score (88.0 compared with 60.0, p = 0.001), and higher UCLA activity score (9.3 compared with 5.9, p = 0.031). CONCLUSIONS: This largest reported series of unstable slipped capital femoral epiphyses treated with the modified Dunn procedure demonstrated that the procedure is capable of restoring anatomy and preserving function after a slip but that implant complications and osteonecrosis can and do occur postoperatively.

Arthrogram-assisted fixation of slipped capital femoral epiphysis: a CT and radiographic study.

BACKGROUND: Intraoperative fluoroscopy does not always provide the operating surgeon with optimal visualization of a slipped capital femoral epiphysis (SCFE). Arthrography can be used to enhance fluoroscopic images of these patients. This study retrospectively compared the screw placement between patients who received conventional versus arthrographic-assisted in situ screw fixation for SCFE. METHODS: We reviewed the charts and radiographs of all patients diagnosed with a SCFE at our institution from 2005 to 2010. We isolated those who received postoperative computed tomography (CT) scans to confirm screw placement, and subdivided the patients into 2 groups: those who received arthrograms to facilitate screw placement and those who did not. The screw-tip-to-articular-surface distance was then measured on intraoperative fluoroscopic images and postoperative CT scans. RESULTS: Seventy-eight patients met inclusion criteria and 24 received an intraoperative arthrogram. Screw placement determined by intraoperative fluoroscopic images did not differ between the 2 groups. When measured on postoperative CT scans the screw-tip-to-articular-surface distance was significantly smaller in the arthrogram-assisted cohort (2.8 vs. 5.2 mm), and the difference between intraoperative and postoperative measurements was significantly greater in the arthrogram-assisted cohort (4.9 vs. 1.6 mm). No cases of intra-articular screw placement were found in either cohort, nor were there any cases demonstrating loss of fixation. CONCLUSIONS: Arthrogram-assisted fixation of SCFE is a safe and effective tool in patients whose body habitus makes diagnostic fluoroscopic images difficult to obtain. It is, however, not without technical challenges. After the dye is injected it becomes more difficult to visualize the subchondral bone on fluoroscopic images. Our screws were, on average, 4.9 mm closer to the joint space on CT scans than seen intraoperatively. The operating surgeon must be aware of this fact to avoid joint penetration. LEVEL OF EVIDENCE: Level III.

Treatment of delayed and nonunited fractures and osteotomies with pulsed electromagnetic field in children and adolescents.

Nonunion of fractures or osteotomies in the pediatric population is rare. The gold standard for the treatment of nonunions involves harvesting autologous iliac crest bone graft and sometimes internal fixation, which are invasive procedures. The purpose of this study was to evaluate the effectiveness of pulsed electromagnetic field on a non-united fracture or osteotomy in the pediatric population. A retrospective study was performed on all patients at the authors' institution who used pulsed electromagnetic field as part of their treatment for nonunion or delayed union. Success of the initial nonunion treatment was defined as complete union of the fracture or osteotomy site. Two types of treatment were administered once delayed bone healing was identified: pulsed electromagnetic field alone or pulsed electromagnetic field plus an adjunct treatment. Twenty-one patients were included; 8 osteotomies and 14 fractures developed a nonunion. Average patient age was 11.7 years. Average age for patients who healed with the initial treatment was 10.7 years, whereas nonhealers had an average age of 14 years. Eighty-nine percent of osteotomy nonunions healed with their first management. Fifty-seven percent of fracture nonunions healed at the first attempt. The use of pulsed electromagnetic field is a good option for the initial treatment of pediatric nonunions, especially for patients who develop nonunions secondary to osteotomies. Adding bone marrow aspiration improves the outcomes and is minimally invasive compared with autologous iliac crest bone graft, with no complications.

Radius crossover sign: an indication of malreduced radius shaft greenstick fractures.

BACKGROUND: Radius shaft greenstick fractures in children can be a challenging injury to treat because angulation and rotational alignment are difficult to assess. METHODS: In this report, we describe a simple method for analyzing the deformity and identifying rotational and angular malalignment. This technique involves analyzing the forearm radiographs as 2 segments, proximal and distal, and assuring that the rotational position of each matches the other. RESULTS: We present 3 cases of proximal radius greenstick fractures in malalignment to demonstrate the radius crossover sign. CONCLUSIONS: Identifying the radius crossover sign, and proceeding with further closed reduction may prevent deformity that could otherwise result in a significant loss of forearm motion. LEVEL OF EVIDENCE: Level V.

Core decompression for juvenile osteonecrosis.

Core decompression may be used as adjunct for treatment in some cases of Legg-Calvé-Perthes disease (LCPD). The primary application is for patients with onset at 12 years of age or older. We recommend classifying these older patients as idiopathic juvenile osteonecrosis and treating them similarly to adults with avascular necrosis. Juvenile osteonecrosis may benefit from core decompression combined with shelf acetabuloplasty during the early stages of necrosis. Younger children with LCPD may benefit from decompression by fenestration of the femoral head. Experience in adult-onset osteonecrosis and our early experience suggest that some patients may benefit from these adjunctive treatments.

Bilateral unstable slipped capital femoral epiphysis: a look at risk factors.

Unstable slipped capital femoral epiphysis can have disastrous complications including osteonecrosis and chondrolysis. It has been shown that 20% to 80% of patients may develop a contralateral slip ≤18 months after diagnosis. The purpose of this article is to report and characterize patients who developed bilateral unstable slips. After Institutional Review Board approval, the patients included were only those with bilateral unstable slipped capital femoral epiphyses. A minimum 2-year follow-up was required. Seven patients, all female, were included in the study, with an average age of 11.4 years at the time of their first slips. The interval between slips averaged 127 days (range, 0-245 days). All but 1 patient presented with a severe slip. The second slip was also severe in 3 patients and less severe in 4 patients. The triradiate cartilage was open in 3 patients. Two patients required corrective osteotomies. Chondrolysis developed in 2 patients with no osteonecrosis reported. The incidence of bilateral unstable slips ranged from 4% to 20% of all unstable slipped capital femoral epiphyses based on our findings. Skeletal immaturity was not a risk factor. The surgeon must be vigilant for the possibility of bilateral slips. The family must be instructed on precautions patients must take while recuperating from unstable slipped capital femoral epiphyses. Contralateral fixation of the unaffected side may be warranted in patients with initial severe unstable slipped capital femoral epiphyses to prevent this condition.

Infantile kyphosis secondary to lumbar hypoplasia: six cases with excessive upright sleeping as a possible cause.

Abnormal thoracolumbar kyphosis in infants may be due to lumbar hypoplasia that resolves with development of upright posture. The cause of this deformity has not been previously identified. The goal of this study was to find whether excessive time in an upright posture while sleeping and sitting may play a role in the etiology of infantile thoracolumbar kyphosis. We retrospectively reviewed infants with the diagnosis of kyphosis from 2001 to 2005. Inclusion criteria were patients diagnosed prior to age 3 years without syndromic, neuromuscular, or congenital kyphosis and minimum 2-year follow-up. Serial radiographic evaluation was used to assess change in kyphotic deformity. Six infants with an average age of 7 months at the time of diagnosis were identified. All had marked thoracolumbar kyphosis with vertebral wedging and scalloping. Some had pseudosubluxation at the T12-L1 level. The initial average Cobb angle was 30° (normal, 0°-5°). Careful history revealed that all patients slept in an upright posture in addition to sitting while awake. All of the patients were observed following parental instruction in proper sleeping and sitting habits. At last follow-up, all patients had normal sagittal alignment with an average Cobb angle of 1.3°. Proper sleeping and sitting habits with good spine support is recommended for infantile thoracolumbar kyphosis with lumbar hypoplasia. Allowing "tummy time" during waking hours may help the paraspinal muscles gain strength to provide support to the spine. Radiographic evidence of vertebral body height restoration may be delayed for several years.

Steel syndrome: dislocated hips and radial heads, carpal coalition, scoliosis, short stature, and characteristic facial features.

BACKGROUND: A syndrome of children with short stature, bilateral hip dislocations, radial head dislocations, carpal coalitions, scoliosis, and cavus feet in Puerto Rican children, was reported by Steel et al in 1993. The syndrome was described as a unique entity with dismal results after conventional treatment of dislocated hips. The purpose of this study is to reevaluate this patient population with a longer follow-up and delineate the clinical and radiologic features, treatment outcomes, and the genetic characteristics. METHODS: This is a retrospective cohort study of 32 patients in whom we evaluated the clinical, imaging data, and genetic characteristics. We compare the findings and quality of life in patients with this syndrome who have had attempts at reduction of the hips versus those who did not have the treatment. RESULTS: Congenital hip dislocations were present in 100% of the patients. There was no attempt at reduction in 39% (25/64) of the hips. In the remaining 61% (39/64), the hips were treated with a variety of modalities fraught with complications. Of those treated, 85% (33/39) remain dislocated, the rest of the hips continue subluxated with acetabular dysplasia and pain. The group of hips that were not treated reported fewer complaints and limitation in daily activities compared with the hips that had attempts at reduction. CONCLUSIONS: Steel syndrome is a distinct clinical entity characterized by short stature, bilateral hip and radial head dislocation, carpal coalition, scoliosis, cavus feet, and characteristic facial features with dismal results for attempts at reduction of the hips. LEVEL OF EVIDENCE: Prognostic Study Level II.

Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents.

BACKGROUND: Tibial eminence fractures are rare injuries in children and adolescents. Displaced fractures require reduction and fixation. Operative stabilization can be accomplished with either open or arthroscopic reduction and fixation. Whereas loss of extension has been reported, there are no reports in the literature that quantify loss of motion or provide guidance for treatment. PURPOSE: To report a series of patients who developed knee stiffness after operative treatment for displaced tibial eminence fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Review of medical records and imaging studies of pediatric patients with displaced tibial eminence fractures who developed arthrofibrosis after surgical intervention. RESULTS: Thirty-two patients were identified. Twenty-four required reoperation for loss of flexion (n = 9), loss of extension (n = 4), or both (n = 11). Manipulation under anesthesia resulted in distal femoral fractures and subsequent growth arrest in 3 patients. Twenty-nine patients were able to achieve near full knee motion at final follow-up. CONCLUSIONS: Children with tibial spine fractures are at risk for arthrofibrosis. Stabilization of the fracture is important to allow early postoperative rehabilitation. Should stiffness occur, manipulation of the knee should be performed only in conjunction with lysis of adhesions.

Traumatic hip dislocations in children and adolescents: pitfalls and complications.

Traumatic hip dislocation is an uncommon injury in children. Lack of familiarity with management of the treating physician may lead to complications. Hip dislocation in young children can occur with minor trauma; in adolescents, greater force is required to produce a traumatic complete hip dislocation. Transient hip dislocation with spontaneous but incomplete reduction is a diagnostic pitfall that can occur in adolescents. Any asymmetric widening of the hip joint warrants additional investigation. Most dislocations in children can be reduced with gentle manipulation. Urgent reduction of the hip within 6 hours of injury reduces the risk of osteonecrosis. However, closed reduction in adolescents should be performed with caution because of the risk of displacement of the femoral head during manipulation. Open reduction is indicated when closed reduction fails or when there is interposition of bone or soft tissue following attempted closed reduction. Late complications include osteonecrosis, coxa magna, and osteoarthritis.