Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Characteristics of Pyogenic Musculoskeletal Infections in Older Children and Adolescents.

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.].

Blood Loss Trends and Financial Implications in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The primary goal was to evaluate risk factors related to increased blood loss in adolescent idiopathic surgery (AIS) surgery with the secondary goal being to evaluate the financial implications around the use of intraoperative cell salvage (ICS) and the routine preallocation of autogenous blood products. SUMMARY OF BACKGROUND DATA: Deformity correction for AIS is a complex procedure and can be associated with significant blood loss. METHODS: A retrospective cohort study was conducted on consecutive patients between the ages of 10 and 18 years who underwent posterior spinal fusion of 7-12 levels over a 3-year period between January 2013 and December 2015. Demographic information and surgical characteristics were recorded. All patients had a preoperative type and cross of 2 units and ICS was used in all cases. Charges for preoperative type and cross and ICS were also measured. Univariate and multivariable analyses were performed to identify pertinent variables affecting blood loss. RESULTS: In total, 134 patients met inclusion criteria. ICS was used in all cases. In total, 51 patients were transfused cell saver blood intraoperatively/postoperatively at the discretion of the surgeon. On average 133 mL were returned to the patient. No complications related to ICS were observed. Multivariable analysis identified male sex, lower body mass index and higher surgical time to be associated with increased blood loss (P<0.05). All 134 patients had a preoperative type and cross, with an average charge to patient of $311. Patients were charged $1037 for intraoperative use of ICS and $242 for centrifugation. Patients who had allogeneic transfusion were charged $1047. CONCLUSIONS: Several blood conservation strategies, including use of ICS, exist to minimize the consequences of blood loss. Routine use of preoperative type and cross may be avoided except in cases where significant blood loss is anticipated-that is adolescent male individuals, those with a lower body mass index and in whom a longer surgical time is anticipated.

Orthopaedic Manifestations of Sickle Cell Disease.

Sickle cell disease (SCD) is an autosomal recessive disorder that results in hemolytic anemia related to abnormal hemoglobin and erythrocyte levels. SCD is characterized by vascular occlusive episodes, visceral sequestration, and aplastic or hemolytic crises. These crises most commonly occur in bone. The orthopaedic manifestations of SCD comprise much of the morbidity associated with this disorder. Osteonecrosis and osteomyelitis are among the most disabling and serious musculoskeletal complications in patients with SCD. Effective management of the bone and joint sequelae requires an accurate diagnosis, an understanding of the pathophysiology of the disease, and knowledge of available medical and surgical treatment alternatives. The major orthopaedic manifestations of SCD are osteonecrosis, osteomyelitis, septic arthritis, and bone infarction. Patients with SCD require close monitoring in the perioperative period because of the risk for vasoocclusive crisis.

Adolescent Distal Humerus Fractures: ORIF Versus CRPP.

BACKGROUND: Although supracondylar humerus fractures are common in young children, the incidence in adolescents is much lower. As a result, there is a paucity of literature to guide treatment. The purpose of this study was to review the treatment and outcomes for a consecutive series of distal humerus fractures in adolescents and to compare outcomes between patients treated with percutaneous skeletal fixation and those treated with open reduction and fixation. METHODS: A retrospective review of patients 10 to 17 years of age who underwent surgical treatment for a distal humerus fracture from 2005 to 2014 was performed. Patients with medial epicondyle fractures and those with insufficient follow-up to document union or return of motion were excluded. Medical records were reviewed to collect demographic data as well as operative approach and method of fixation. Clinical outcomes included range of motion, time to maximum motion, and complications [nerve dysfunction, heterotopic ossification (HO), need for secondary surgery]. Radiographs were reviewed to determine time to union as well as coronal and sagittal alignment. RESULTS: One hundred eighteen adolescents with displaced distal humerus fractures were identified. Eighty-one met inclusion criteria. Forty-four of these were classified as extra-articular [Orthopaedic Trauma Association (OTA) 13-A], and 37 were intra-articular fractures (10 OTA 13-B and 27 OTA 13-C).Although not statistically significant, closed treatment with percutaneous fixation of extra-articular fractures resulted in greater flexion-extension arc of motion at final follow-up (128 vs. 119 degrees, P=0.17) and demonstrated more rapid return of motion (2.8 vs. 3.9 mo, P=0.05) when compared with open treatment despite a longer duration of immobilization and less formal physical therapy. Complications such as HO (P=0.05), nerve dysfunction (P=0.02), and secondary surgery (P=0.001) were more common in the open treatment group.Closed treatment with percutaneous fixation of intra-articular fractures was performed in younger patients of similar size (12.8 vs. 14.4 y, P<0.01; 154 vs. 142 lbs, P=0.5). There were no significant differences between groups in regard to outcomes or complications. There were trends toward increased frequency of HO, nerve dysfunction, and secondary surgery in the open treatment group.Patients with intra-articular fractures were older (14.2 vs. 11.5 y, P<0.001) and heavier (144 vs. 94 lbs, P<0.001) than patients with extra-articular fractures and were more likely to be treated open (74% vs. 11%, P<0.001). Extra-articular fractures demonstrated a greater total arc of motion (126 vs. 118 degrees, P=0.04) at final follow-up despite longer duration of immobilization (23 vs. 15 d, P=0.002), and less physical therapy (27% vs. 73%, P<0.001). Radiographic carrying angle (16.6 vs. 22.3 degrees, P=0.08) and anterior humeral line (95% vs. 81%, P=0.07) trended toward more anatomic alignment in the extra-articular group. Secondary surgery was more common after intra-articular fracture (24% vs. 7%, P=0.03). CONCLUSIONS: Closed reduction and pinning of extra-articular distal humerus fractures in adolescents resulted in predictable clinical and radiographic outcomes and allowed for earlier return of motion and fewer complications when compared with open treatment. Intra-articular distal humerus fractures occur more frequently in older adolescents and are more likely to require open reduction and internal fixation to obtain joint congruity. Patients with intra-articular injuries should be cautioned that regaining full elbow motion may be more difficult, and there is an increased risk for complications and need for additional surgery. Closed reduction and percutaneous fixation of intra-articular injuries appears to be a reasonable option in select patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Weightbearing Versus Nonweightbearing After Meniscus Repair.

CONTEXT: Optimal rehabilitation after meniscal repair remains controversial. OBJECTIVE: To review the current literature on weightbearing status after meniscal repairs and to provide evidence-based recommendations for postoperative rehabilitation. DATA SOURCES: MEDLINE (January 1, 1993 to July 1, 2014) and Embase (January 1, 1993 to July 1, 2014) were queried with use of the terms meniscus OR/AND repair AND rehabilitation. STUDY SELECTION: Included studies were those with levels of evidence 1 through 4, with minimum 2 years follow-up and in an English publication. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Demographics and clinical and radiographic outcomes of meniscus repair at a minimum of 2 years follow-up were extracted. RESULTS: Successful clinical outcomes ranged from 70% to 94% with conservative rehabilitation. More recent studies using an accelerated rehabilitation protocol with full weightbearing and early range of motion reported 64% to 96% good results. CONCLUSION: Outcomes after both conservative (restricted weightbearing) protocols and accelerated rehabilitation (immediate weightbearing) yielded similar good to excellent results; however, lack of similar objective criteria and consistency among surgical techniques and existing studies makes direct comparison difficult.

Applications of musculoskeletal ultrasonography in pediatric patients.

Ultrasonography is an excellent adjunct to other musculoskeletal imaging tools utilized in the pediatric population and in some instances offers advantages over CT and MRI. It permits dynamic examination of anatomic structures and assists in guiding minimally invasive procedures. In the lower extremity, ultrasonography assists in screening for such disorders as developmental dysplasia of the hip and in detecting slipped capital femoral epiphysis and femoral acetabular impingement. In the neonatal spine, ultrasonography can identify unossified vertebral arches. Among other applications in the upper extremity, ultrasonography may be used in the evaluation and examination of peripheral nerve injuries and is a preferred modality for imaging the shoulder in infants with neonatal brachial plexus palsy. It is also considered an optimal adjunct for administration of botulinum toxin-A in children with cerebral palsy. The portability, relative low cost, lack of radiation, and absence of known contraindications enhances the utility of ultrasonography in pediatric orthopaedics.

Outcomes following removal of instrumentation after posterior spinal fusion.

BACKGROUND: Although there is good evidence to support the removal of instrumentation for infection following posterior spine fusion, there are few studies that report outcomes following removal for late operative site pain. The purpose of this study was 3-fold: (1) to determine whether removal of instrumentation following posterior spinal fusion resolves preoperative pain, (2) to determine whether indolent infection not detected before removal of instrumentation is related to late operative site pain, and (3) to determine whether curve progression differs when spinal hardware is removed for infection versus late operative site pain. METHODS: A retrospective study of consecutive patients aged 10 to 21 years, who underwent removal of instrumentation after posterior spinal fusion over a 10-year-period was conducted. Patient demographics, preoperative and postoperative imaging results, laboratory studies, and operative findings were reviewed. All patients had a minimum 2-year follow-up. Statistical analysis was performed using 2-sample t test, bivariate analysis, and multivariate logistic regression models. RESULTS: Seventy-five patients were included. Indications for removal of spinal instrumentation were pain (57%), infection (28%), hardware failure (8%), and prominent hardware (7%). The mean time from index procedure to hardware removal was 2.8 years. The average loss of curve correction following complete hardware removal was 23.1 degrees. Patients who underwent removal of hardware because of infection had bigger changes in their curves than those without infection (mean, 33.8 degrees vs. 18.8 degrees). Of the 43 patients with pain, only 40% reported relief of their symptoms following removal of hardware. Sixteen of the 43 patients were found to have indolent infection confirmed by positive intraoperative culture results. CONCLUSIONS: Patients should be cautioned that hardware removal after posterior spinal fusion may not provide complete pain relief. Furthermore, there is risk for curve progression following removal of instrumentation, particularly in the setting of infection. Back pain may be an indicator of infection, and intraoperative cultures should be taken at the time of implant removal. LEVEL OF EVIDENCE: Level IV; retrospective case series.

Obesity and its effects on pediatric supracondylar humeral fractures.

BACKGROUND: This study evaluates the effects of childhood obesity on fracture complexity and associated injuries in pediatric supracondylar humeral fractures. METHODS: A billing query identified all patients who were two to eleven years of age and had undergone operative treatment for extension-type supracondylar humeral fractures over a 12.5-year period. Records were reviewed for demographic data, body mass index percentile, and injury data. Complex fractures were defined as type-3 supracondylar humeral fractures, supracondylar humeral fractures with intercondylar extension, or supracondylar humeral fractures with ipsilateral upper-extremity fractures. Logistic regression analyses were used to test relationships among body mass index subgroups, fracture complexity, elbow motion, preoperative and postoperative neurovascular status, and complications. RESULTS: Three hundred and fifty-four patients met our inclusion criteria. Forty-one children were underweight (BMI in the <5th percentile), 182 were normal weight (BMI in the 5th to 85th percentile), sixty-three were overweight (BMI in the >85th to 95th percentile), and sixty-eight were obese (BMI in the >95th percentile). There were 149 patients, eleven of whom were obese, with isolated type-2 fractures and 205 patients, fifty-seven of whom were obese, with complex fractures. Thirty-two patients had preoperative nerve palsies and twenty-eight patients had postoperative nerve palsies. Using logistic regression, obesity was associated with complex fractures (odds ratio, 9.19 [95% confidence interval, 4.25 to 19.92]; p < 0.001), preoperative nerve palsies (odds ratio, 2.69 [95% confidence interval, 1.15 to 6.29]; p = 0.02), postoperative nerve palsies (odds ratio, 7.69 [95% confidence interval, 2.66 to 22.31]; p < 0.001), and postoperative complications (odds ratio, 4.03 [95% confidence interval, 1.72 to 9.46]; p < 0.001). Additionally, obese patients were more likely to sustain complex fractures from a fall on an outstretched hand than normal-weight patients (odds ratio, 13.00 [95% confidence interval, 3.44 to 49.19]; p < 0.001). CONCLUSIONS: Obesity is associated with more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. To our knowledge, this study is the first to assess the implications of obesity on supracondylar humeral fracture complexity and associated injuries and it validates public health efforts in combating childhood obesity.

Postoperative spine and VEPTR infections in children: a case-control study.

BACKGROUND: Surgical site infection (SSI) after pediatric scoliosis surgery is a major cause of morbidity. We compared the odds ratios of various potential risk factors for infection among patients who developed a deep SSI following spinal deformity surgery and those who remained infection free. METHODS: This was a case-control study, not a matched study. More noninfection cases (50) than infection cases (20) were selected because more were available. Twenty children with a deep SSI after scoliosis surgery were compared with 50 similar children who did not develop a deep SSI. Fourteen perioperative factors were examined in both the groups. RESULTS: Of the 20 patients who had a deep SSI, 14 had neuromuscular scoliosis. In the infected group, 6 patients had undergone vertical expandable prosthetic titanium rib placement, 2 had undergone growing rod insertion, and 12 had undergone posterior spinal fusion. Eighteen patients developed a SSI within 1 year of the operation and 2 patients presented with a SSI >1 year after surgery. Sixteen patients had positive cultures. Majority were skin flora: coagulase-negative Staphylococcus (8) and Propionibacterium acnes (4). Both patients with tracheostomies had Enterococcus faecalis infections. When comparing the 20 patients with deep SSI to the 50 controls, increased preoperative Cobb angle (P=0.011), increased postoperative Cobb angle (P=0.0043), nonambulatory status (P=0.0002), and increased length of stay (P=0.015) were associated with significantly increased odds of infection. CONCLUSIONS: Our study shows that patients with neuromuscular scoliosis are at higher risk of developing a deep SSI after spinal deformity surgery. Skin flora is a common cause of deep SSI. We have now instituted a standard skin preparation protocol to include alcohol and chlorhexidine washes the night before and the morning of surgery. We have altered our prophylactic antibiotic regimen to cover skin flora in all patients and gastrointestinal flora in patients with a tracheostomy. We have counseled the families of nonambulatory children with large neuromuscular curves regarding the significantly increased odds of postoperative deep SSI. LEVEL OF EVIDENCE: Level III.

Distal femoral physeal fixation: are smooth pins really safe?

BACKGROUND: Distal femoral physeal fractures have a high incidence of physeal arrest. Several factors have been postulated to contribute to this high incidence, including fracture type, displacement, the undulating nature of the physis, and fracture reduction/fixation. The purpose of this study was to determine whether the position of percutaneous smooth pins across the physis contributes to physeal bar formation. METHODS: The previously validated New Zealand white rabbit model was used. Power analysis determined that 30 animals were required. All animals had a constant 0.045 smooth Kirschner (K) wire placed under fluoroscopic guidance from the distal lateral femur across the physis centrally. A second 0.045 K-wire was placed in a cross-pin configuration from the medial side in one of 2 positions: zone 1--crossing the physis centrally or zone 2--crossing the physis peripherally. Pins were removed after 4 weeks and micro computed tomography was performed at 8 weeks to assess for physeal bar formation. Histologic analysis was performed to confirm bar formation. RESULTS: Two physeal bars (7%) were seen after removal of the constant (lateral pin). The peripheral pin resulted in bar formation in 2 animals (13%) and the central pin in 1 animal (7%). A χ² test was performed; there was no statistically significant difference between zones in terms of bar formation (P=0.5428). CONCLUSIONS: Injury to the growth plate after distal femoral fracture may be unavoidable. Treatment is aimed to minimize further injury to the physis. Cross-pinning with smooth K-wires results in a low rate of physeal injury. Pins that cross the physis both centrally and peripherally appear to have the same risk for physeal bar formation. CLINICAL RELEVANCE: This study reveals that physeal bar formation can be seen with smaller than previously reported cross-sectional damage to the distal femoral physis. This study highlights the need to carefully select and perform fixation of the distal femoral physis with as little additional trauma to the physis as possible.

Evaluation of a Novel Method for Determining Transverse Plane Pelvic Obliquity.

STUDY DESIGN: This was a retrospective review of neuromuscular scoliosis radiographs evaluating interobserver and intra-observer error for a novel method of transverse plane pelvic obliquity. OBJECTIVES: To evaluate the utility of a previously described method by Lucas et al. of determining transverse plane pelvic obliquity using standard radiographs in patients with cerebral palsy and neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA: Evaluation of pelvic obliquity in the transverse plane has not been thoroughly studied. The pelvis has been noted to function as intercalary vertebra in neuromuscular scoliosis, resulting in marked obliquity in all 3 planes. METHODS: Forty radiographs were chosen from 10 patients with cerebral palsy and neuromuscular scoliosis who had had a posterior spine arthrodesis and Galveston spino-pelvic fixation. Four observers independently examined the radiographs at different levels of training on 2 dates 1 week apart. Measurements recorded by each observer were described by Lucas et al.: E (the distance measured on lateral radiographs between the ilium at the inferior part of the sacro-iliac joint and the lateral edge of the anterior superior iliac spine), FR and FL (the coronal plane linear distance between the same 2 landmarks, measured from a posteroanterior radiograph, where F was measured for both the left (FL) and right (FR) sides of the pelvis, respectively), and ß (the transverse plane rotation of the pelvis). Reproducibility of the measurements were analyzed using the concordance correlation coefficient (CCC). A CCC of 0.80 or higher was considered excellent agreement. RESULTS: The CCC between the first and second sets of measurements was lowest for E and highest for the calculated ß, although none of the CCC calculations was statistically significant, demonstrating poor agreement. CONCLUSIONS: The ability to reliably measure and calculate the degree of transverse plane rotation by radiographs in cerebral palsy patients with spino-pelvic deformity by the method described by Lucas et al. is poor, likely because of difficulty in consistently identify pelvic landmarks.

Flexible cavovarus foot in children and adolescents.

Flexible cavovarus feet in children and adolescents can be challenging. A careful history and physical examination are paramount for determining the best treatment strategy and a multitude of options are available. Specific treatment strategies should be individualized and any bony correction must be in conjunction with a muscle balancing procedure. Well-timed soft tissue and occasionally bony procedures can delay the progression of deformity. These patients are monitored long term because further treatment may be required.

Osteochondral injury after acute patellar dislocation in children and adolescents.

BACKGROUND: Acute patellar dislocation (APD) is a common injury in the pediatric patient population and may be associated with a spectrum of soft tissue and osteochondral injuries. This study describes the incidence of osteochondral fracture and associated injury patterns in a pediatric population after first-time APD and assesses functional outcomes after treatment. METHODS: One hundred twenty-two patients, aged 11 to 18 years, who were evaluated after first-time APD over a 10-year period were identified, 46 of whom had confirmed osteochondral injury on magnetic resonance imaging (MRI). Demographic data, including knee affected, mechanism of injury, recurrent dislocation, operations performed, and condition at last follow-up, were retrieved from the medical record. Operative reports and MRI were used to characterize the location of osteochondral injury. The functional outcome of each patient with an osteochondral fracture was assessed using the Pedi-IKDC questionnaire. RESULTS: Forty-six patients, mean age 14.6 years (range, 11 to 18 y), were included. Osteochondral fracture occurred at the patella in 35 patients (76%), the lateral femoral condyle in 11 patients (24%), and at both locations in 3 patients (6.5%). In 21 patients (44%), MRI confirmed osteochondral injury despite the plain radiograph interpretation as negative for fracture. Twenty-six patients (68%) subsequently underwent surgery after injury. Injury to the medial patellofemoral ligament was identified on MRI in 97.8% of patients (45/46). Fifteen patients (32.6%) underwent a concomitant medial repair at the time of surgery. Osteochondral injury to the distal femur on average had a lower International Knee Documentation Committee score than patellar injuries (72.3±18 vs. 91.1±10.2, P<0.003). Femoral osteochondral injury involving the weight-bearing surface (75.27±18.19) scored lower than non-weight-bearing surface injuries (93.22±7.47; P<0.001). CONCLUSIONS: The incidence of osteochondral injury associated with APD is high. Osteochondral fractures may initially go unrecognized on plain radiographs. Patients with weight-bearing lateral femoral condyle injuries had lower short-term functional scores, suggesting that outcomes depend on location of injury. LEVEL OF EVIDENCE: Level IV, diagnostic and therapeutic study.

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.

Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures.

BACKGROUND: Studies have demonstrated a higher risk of complications when children with fractures in the proximal third of the femur and length-unstable fractures are treated with titanium elastic nails. Alternative treatment methods include open plating and submuscular plating. We are not aware of any published studies that directly compare titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. The purpose of the present study was to retrospectively compare the outcomes and complications of titanium elastic nail and plate fixation of subtrochanteric femur fractures in children and young adolescents. METHODS: A total of 54 children aged 5 to 12 years with subtrochanteric femur fractures treated with titanium elastic nails or plating at 2 institutions between 2003 and 2010 were identified. We retrospectively compared 25 children treated with titanium elastic nails to 29 children treated with either open plating or submuscular plating. Similar to previous studies, a fracture that was located within 10% of the total femur length below the lesser trochanter was classified as subtrochanteric. Outcomes were classified as excellent, satisfactory, or poor. A major complication was defined as any complication that led to unplanned surgery. Minor complications were defined as complications that resolved with nonoperative treatment or did not require any treatment. RESULTS: Outcome scores were significantly better in the plating group (P=0.03), but both groups demonstrated high rates of excellent and satisfactory results. The overall complication rate was significantly higher in the titanium elastic nails group (48%; 12 of 25) when compared with the plating group (14%; 4 of 29) (P=0.008). Patients in the titanium elastic nails group were advanced to full weightbearing significantly earlier (6.6 vs. 9.9 wk) (P=0.005). The major complication rate, length of hospitalization, and time to radiographic union were similar for the 2 groups. CONCLUSIONS: Our results indicate that plate fixation of pediatric subtrochanteric femur fractures is associated with better outcome scores and a lower overall complication rate when compared with titanium elastic nails. LEVEL OF EVIDENCE: Therapeutic Level III.

Reliability of measurements of clavicle shaft fracture shortening in adolescents.

BACKGROUND: A relative indication for surgical treatment of midshaft clavicle fractures is shortening ≥2.0 cm. A standard method for determining shortening with routine clavicle radiographs has not been established. This study evaluated the interobserver and intraobserver reliability when measuring shortening of midshaft clavicle fractures in adolescents. METHODS: We identified all clavicle radiographs of simple midshaft clavicle fractures in adolescents from 2006 to 2010. Thirty-two radiographs were chosen following a power analysis for 7 observers. Each film was measured twice by each evaluator using 2 separate methods. Method 1 was the evaluator's method of choice to determine shortening on the digital radiographs. Method 2 was standardized. Intraclass correlation coefficient and confidence intervals (CI) were calculated to determine interrater reliability, and average differences between the 2 time points with 95% CI were calculated to determine intrarater reliability. RESULTS: Interrater reliability for method 1 was 0.771 (95% CI, 0.655-0.865) and 0.743 (95% CI, 0.604-0.851) at the 2 time points for fair agreement. Interrater reliability for method 2 was 0.741 (95% CI, 0.629-0.842) and 0.685 (95% CI, 0.554-0.805) at the 2 time points, for fair and poor agreement, respectively. Neither method was statistically superior to the other. For method 1, the SD for the measurements averaged 3.1 mm. For method 2, the average SD was 3.0 mm. Intrarater reliability for method 1 was 2.62 mm average difference between the 2 time points (95% CI, 2.24-3.00), and for method 2 it was 3.34 mm average (95% CI, 2.88-3.80). Method 2 had a significantly greater difference at the 2 time points than method 1 (P=0.027). CONCLUSIONS: There is only fair agreement among observers when measuring the shortening of clavicle fractures in adolescents on digital clavicle radiographs by either method described. However, as the average difference among measurers was only 3 mm, this is unlikely to influence clinical decision making. A lack of standardization of measurement in previous studies on clavicle fracture treatment may not represent a significant problem. LEVEL OF EVIDENCE: Level III diagnostic study.