Prediction of contralateral slipped capital femoral epiphysis using the modified Oxford bone age score.

BACKGROUND: The purpose of the present study was to determine whether the modified Oxford bone score can be used as a predictor for the risk of developing contralateral slipped capital femoral epiphysis (SCFE) in children who present with a unilateral slip. METHODS: We identified 260 patients treated for unilateral SCFE between 1980 and 2002 and followed them up to skeletal maturity or until development of contralateral slip. Exclusion criteria included patients with endocrine or metabolic disorder, Down syndrome, and those with radiographs inadequate to determine the modified Oxford bone score. The initial radiographs were given a score ranging from 16 to 26. Statistical analysis was used to determine whether the modified Oxford bone score was predictive of future development of contralateral slip. A linear regression model was used to estimate the probability of future development of a contralateral slip as related to the modified Oxford bone score. RESULTS: Of the 260 patients, 64 (24%) developed a contralateral slip, at an average of 10 months after initial presentation. Race, sex, age, and weight at initial presentation were not predictive of the development of contralateral slip. The modified Oxford score and a triradiate score of 1 were found to be significant (P<0.0001) predictors, with the modified Oxford score a better overall predictor. CONCLUSIONS: The modified Oxford bone age score is the best predictor of the risk of development of a contralateral SCFE in patients presenting with a unilateral slip. Controversy exists regarding prophylactic pinning of a normal hip in patients presenting with unilateral SCFE. The benefits of prophylactic pinning must outweigh risk. This study provides probability data for predicting a contralateral slip based on the modified Oxford bone maturity score that can be shared with families and allows physicians to decide their threshold for prophylactically pinning the contralateral hip in patients presenting with a unilateral slip. LEVEL OF EVIDENCE: Therapeutic level IV, Case series.

Revised modified Oxford bone score: a simpler system for prediction of contralateral involvement in slipped capital femoral epiphysis.

BACKGROUND: The decision to prophylactically treat the uninvolved hip in slipped capital femoral epiphysis (SCFE) remains controversial. The modified Oxford bone score (mOBS) is predictive of future contralateral involvement in slipped capital femoral epiphysis. The scoring method for this system is challenging to remember because out-of-context irrational number sequences and total score range (16 to 26) are used. This study was performed to evaluate intraobserver and interobserver reliability of the mOBS and to determine whether revising the scoring sequence to 0 to 2 for all 5 categories (total score range: 0 to 10) would be easier for orthopedic surgeons to remember. METHODS: Six orthopedic surgeons scored 30 normal pelvis radiographs using the mOBS (original or revised scoring system) on 2 separate occasions, at least 2 weeks apart, with the aid of reference diagrams and an explanatory key. At a later date, the observers were asked to complete blank reference diagrams from memory for both scoring systems (16 to 26 and 0 to 10). RESULTS: Intraobserver reliability was analyzed for each parameter independently and as a total score. Overall, intraobserver reliability was excellent, with total scores being within 1 and 2 points of each other 80.5% and 94.9% of the time, respectively. Interobserver reliability was very good, with total scores within 1 and 2 points of each other 69.6% and 87% of the time, respectively. None of the 6 observers were able to complete the blank mOBS key correctly from memory, despite being reminded of the 16 to 26-point range. Five of the 6 were able to correctly complete the revised key using the 0 to 10 point range system. CONCLUSIONS: The mOBS is a useful method to estimate risk of contralateral slip, with excellent intraobserver and very good interobserver reliability. Difficulty in remembering the original scoring scheme because of its illogic sequences in the modified method limits its clinical applicability. Revision of the mOBS to a consistent 0 to 2 (range: 0 to 10) system greatly enhanced the observers ability to recall the scoring system. LEVEL OF EVIDENCE: Level II - development of diagnostic criteria with reference to "gold" standard.

Nerve palsy after hamstring lengthening in patients with cerebral palsy.

BACKGROUND: The purpose of this study was to assess the incidence of, risk factors for, and treatment of nerve palsy after hamstring lengthening in children with cerebral palsy. METHODS: A medical record review of patients with cerebral palsy who had hamstring lengthening between 1994 and 2005 was performed. Data included the preoperative popliteal angle, the presence of a knee flexion contracture, postoperative pain management, and type of immobilization. The presence of postoperative nerve palsy was established based on the recording of numbness, loss of motor function in the foot, or hypersensitivity of the foot in the inpatient record or the postoperative clinic notes. The need for medical management and time to resolution of symptoms were noted. RESULTS: A total of 292 children underwent 329 hamstring lengthening surgeries. The mean age at surgery was 9.5 years (range, 2.5-18 years). Twenty-eight patients (9.6%) experienced postoperative nerve palsy. Time to recognition of the palsy ranged from 4 hours to 72 days. Patients diagnosed within 24 hours had loss of motor function and/or lack of sensation of the toes. Patients diagnosed from 8 to 72 days postoperatively had dysesthesias of the feet. Treatment of early palsies consisted of the removal of immobilization, bivalving of casts, or wedging casts into flexion. Fourteen of 28 patients were treated with Neurontin. Twenty-two of 25 patients with adequate follow-up recovered nerve function. Older children, noncommunicative patients, nonambulatory patients, and those who had epidural pain management were at statistically significant higher risk for postoperative palsy. The trend for palsies in spastic quadriplegic patients and after repeat lengthening procedures did not reach significance. There was no significant relationship between popliteal angle or the presence of a knee flexion contracture and development of nerve palsy. CONCLUSIONS: Nerve palsy occurred in 9.6% of patients undergoing hamstring lengthening. Although the greatest risk was in noncommunicative adolescents who were nonambulatory, a small number of younger ambulatory patients developed palsies as well, so that all patients must be considered at risk. Vigilance in patients with epidural pain control to avoid excessive hip flexion and/or knee extension is warranted. Treatment is immediate knee flexion. Resolution of symptoms occurred in 82.1% of patients.

Initial laxity does not correlate with subsequent laxity after ACL reconstruction in humans: a prospective evaluation.

Fifty-seven patients without other ligament injury underwent anterior cruciate ligament reconstruction (50 B-L-B, 7 hamstring). KT-1000 assessments were made preoperatively in clinic under anesthesia before and immediately after fixation and at 6-month follow-up. Preoperative manual maximum (ManMax) side-to-side difference (ManMaxdelta) under anesthesia (9.2 +/- 3.5 mm) was significantly larger than in clinic (6.1 +/- 1.8 mm), P < .0001. This difference is important when arthrometer thresholds are used for decision making. ManMaxdelta increased significantly from -0.7 +/- 2.5 mm immediately after surgery to 2.1 +/- 2.3 mm at 6 months (P < .0001). There was no significant correlation between immediate postoperative and 6-month ManMaxdelta (r = .125).