Assessing the reliability of the modified Gartland classification system for extension-type supracondylar humerus fractures.

PURPOSE: The Gartland extension-type supracondylar humerus (SCH) fracture is the most common paediatric elbow fracture. Treatment options range from nonoperative treatment (taping or casting) to operative treatments (closed reduction and percutaneous pinning or open reduction). Classification variability between surgeons is a potential contributing factor to existing controversy over treatment options for type II SCH fractures. This study investigated levels of agreement in extension-type SCH fracture classification using the modified Gartland classification system. METHODS: A retrospective review was conducted on 60 patients aged between two and 12 years who had sustained an extension-type SCH fracture and received operative or nonoperative treatment at a tertiary children's hospital. Baseline radiographs were provided, and surgeons were asked to classify the fractures as type I, IIA, IIB or III according to the modified Gartland classification. Respondents were then asked to complete a second round of classifications using reshuffled radiographs. Weighted kappa values were calculated to assess interobserver and intraobserver levels of agreement. RESULTS: In all, 21 paediatric orthopaedic surgeons responded to the survey and 15 completed a second round of ratings. Interobserver agreement for classification based on the Gartland criteria between surgeons was substantial with a kappa of 0.679 (95% confidence interval (CI) 0.501 to 0.873). Intraobserver agreement was substantial with a kappa of 0.796, (95% CI 0.628 to 0.864). CONCLUSION: Radiographic classification of extension-type SCH fractures demonstrated substantial agreement both between and within surgeon raters. Therefore, classification variability may not be a major contributing factor to the treatment controversy for type II SCH fractures and treatment variability may be due to differences in surgeon preferences. LEVEL OF EVIDENCE: III.

Arthroscopic treatment of femoroacetabular impingement following slipped capital femoral epiphysis.

UNLABELLED: Slipped capital femoral epiphysis (SCFE) may lead to symptomatic femoroacetabular impingement (FAI). We report our experience of arthroscopic treatment, including osteochondroplasty, for the sequelae of SCFE. Data were prospectively collected on patients undergoing arthroscopy of the hip for the sequelae of SCFE between March 2007 and February 2013, including demographic data, radiological assessment of the deformity and other factors that may influence outcome, such as the presence of established avascular necrosis. Patients completed the modified Harris hip score (mHHS) and the non-arthritic hip score (NAHS) before and after surgery. In total, 18 patients with a mean age of 19 years (13 to 42), were included in the study. All patients presented with pain in the hip and mechanical symptoms, and had evidence of FAI (cam or mixed impingement) on plain radiographs. The patients underwent arthroscopic osteoplasty of the femoral neck. The mean follow-up was 29 months (23 to 56). The mean mHHS and NAHS scores improved from 56.2 (27.5 to 100.1) and 52.1 (12.5 to 97.5) pre-operatively to 75.1 (33.8 to 96.8, p = 0.01) and 73.6 (18.8 to 100, p = 0.02) at final follow-up, respectively. Linear regression analysis demonstrated a significant association between poorer outcome scores and increased time to surgery following SCFE (p < 0.05 for all parameters except baseline MHHS). Symptomatic FAI following (SCFE) may be addressed using arthroscopic techniques, and should be treated promptly to minimise progressive functional impairment and chondrolabral degeneration. TAKE HOME MESSAGE: Arthroscopy of the hip can be used to treat femoroacetabular impingement successfully following SCFE. However, this should be performed promptly after presentation in order to prevent irreversible progression and poorer clinical outcomes.

The treatment of severe slipped capital femoral epiphysis via the Ganz surgical dislocation and anatomical reduction: a prospective study.

We present our experience of the modified Dunn procedure in combination with a Ganz surgical dislocation of the hip to treat patients with severe slipped capital femoral epiphysis (SCFE). The aim was to prospectively investigate whether this technique is safe and reproducible. We assessed the degree of reduction, functional outcome, rate of complications, radiological changes and range of movement in the hip. There were 28 patients with a mean follow-up of 38.6 months (24 to 84). The lateral slip angle was corrected by a mean of 50.9° (95% confidence interval 44.3 to 57.5). The mean modified Harris hip score at the final follow-up was 89.1 (sd 9.0) and the mean Non-Arthritic Hip score was 91.3 (sd 9.0). Two patients had proven pre-existing avascular necrosis and two developed the condition post-operatively. There were no cases of nonunion, implant failure, infection, deep-vein thrombosis or heterotopic ossification. The range of movement at final follow-up was nearly normal. This study adds to the evidence that the technique of surgical dislocation and anatomical reduction is safe and reliable in patients with SCFE.