The Creation and Validation of an Ankle Bone Age Atlas and Data Predicting Remaining Ankle Growth.

BACKGROUND: The purpose of the current study was 2-fold: (1) to create and validate an ankle bone age atlas spanning the pediatric and adolescent years and (2) to utilize this atlas in conjunction with distal tibia/fibular growth data as measured on serial radiographs to develop a predictive growth model for the lower extremity. METHODS: Radiographs were surveyed to identify distinguishable, reproducible, radiographic features. Radiographic features of the tibia, fibula, hindfoot, and midfoot from 270 patients were identified and a "standard" for each age/sex was selected to create an atlas. A separate cohort of 90 ankle radiographs was selected to validate the atlas. A subcohort of 41 patients with left-hand radiographs within 3 months of ankle imaging was used to compare the 2 bone age approaches. Harris growth lines were evaluated in 304 serial images of the distal tibia to determine the remaining growth. RESULTS: The distal tib/fib ossification centers provided the best age assessment for early childhood (male age: 1 to 8 y; female age: 1 to 4 y). The ossification/fusion of the calcaneal apophysis provided the best age assessment in the preadolescent stage (male age: 6 to 14 y; female age: 5 to 12 y). The closure of the distal tib/fib physes best determined skeletal maturity (male age: 14 to 16 y; female age: 12 to 14 y). The ankle atlas had excellent interobserver and intraobserver reliability (intraclass correlation coefficient=0.993, P <0.001 and 0.998, P <0.001), respectively. We found an excellent correlation between the patient's chronologic age and ankle bone age ( r =0.984; P <0.001). Ankle bone age assessment and Greulich and Pyle were correlated ( rs =0.822, P <0.001). We found that males with a bone age of ≥15 years and females with a bone age of ≥13 years had ≤2 mm of residual growth of the distal tibia/fibula physes. CONCLUSIONS: bone age can be determined using ankle films ordered to assess/treat ankle injuries. This tool, along with our growth remaining table, may have important clinical implications when managing patients with ankle trauma with premature physeal closure. LEVEL OF EVIDENCE: IV.

Traditional Versus Water-resistant Short Leg Casting: A Randomized Controlled Pilot Study.

INTRODUCTION: We conducted a randomized controlled trial comparing fiberglass short leg casts with traditional cast padding to similar casts with water-resistant cast padding and recorded the opinion of the patient/caregiver and Orthopaedic Technicians (Ortho Techs) that applied and removed the casts. METHODS: Subjects with an injury that would be treated with a short leg cast were enrolled and randomized into a traditional cast or a water-resistant cast. Following cast application, the Ortho Tech that applied the cast completed a questionnaire asking their opinion on ease of application, moldability, padding level, and time taken for application. Following the removal of the study cast, the Ortho Tech that removed the cast completed a questionnaire that included an assessment of skin condition and evidence of the patient poking items inside the cast, as well as their opinion of ease of padding removal, padding durability and longevity, and an overall quality assessment of the cast padding. Following cast removal, the patient (or caregiver) also completed a questionnaire asking for their assessment of comfort, the weight of the cast, itchiness, heat/sweat, smell, and satisfaction. Patients who were treated with an expanded polytetrafluoroethylene cast were also asked about their happiness with the cast's water resistance and asked how long the cast took to dry. RESULTS: Sixty patients were included in this study, thirty in each group. The water-resistant casts took longer to apply than the traditional casts (12.4±4.0 vs. 8.2±3.2 min, P <0.001). The Ortho Techs favored the traditional cast when it came to ease of application ( P <0.001), moldability ( P =0.003), ease of padding removal ( P <0.001), padding durability ( P =0.006), padding longevity ( P =0.005), and their overall impression ( P =0.014). The patients/caregivers responded similarly among the 2 groups for each survey question. CONCLUSIONS: Patients randomized into each cast type tolerated their cast similarly; however, the Ortho Techs involved in this study preferred the traditional cast.

The Anterior Modified San Diego Acetabuloplasty Does Not Increase Superior-Anterior Coverage in Patient-Specific 3D-Printed Models.

BACKGROUND: Patients with developmental dysplasia of the hip may require pelvic osteotomies to improve acetabular coverage. The purpose of this study was to compare the changes in acetabular version, tilt, and regional coverage angles following the San Diego acetabuloplasty (SDA), the modified San Diego acetabuloplasty (mSDA), and the Pemberton acetabuloplasty (PA). METHODS: Fourteen patients with developmental dysplasia of the hip and computed tomography (CT) imaging were identified. From CT images, 2 identical pelvises were 3-dimensional-printed for each patient. Bone was printed with rigid material, and cartilage with flexible material. For each model pair, the SDA was performed on one and the PA was performed on the other. CT scans were obtained before and after acetabuloplasties. Next, the bone graft in the SDA model was moved anteriorly, representing the mSDA, and the model was rescanned. Acetabular version, tilt, and coverage angles (posterior, superior-posterior, superior, superior-anterior, and anterior) were calculated. Preoperative to postoperative differences were compared (repeated measures analysis of variance or Wilcoxon signed rank test). The significance was set to P <0.05. RESULTS: The mean age at CT was 5.8±1.2 years (range: 3.9 to 7.5 y). All 3 procedures (SDA, mSDA, and PA) significantly increased acetabular tilt; P <0.045), with a similar change observed for all 3 ( P =0.868). PA was the only procedure to significantly decrease relative acetabular version (6.5±6.5 degrees, preoperative: 12.9±5.3 degrees; P =0.004). Both the SDA and mSDA procedures significantly increased coverage in the superior-posterior octant (SDA: 92.6±9.3 degrees, mSDA: 92.3±9.8 degrees, preoperative: 81.9±9.5 degrees; P <0.02), with a similar percent change among the 2 ( P =1.0). All 3 procedures significantly increased superior coverage ( P <0.04); the increase was similar among the 3 ( P =0.205). The PA was the only procedure to produce a significant increase in coverage in the superior-anterior octant (91.0±16.7 degrees, preoperative: 74.0±12.1 degrees; P =0.005) or the anterior octant (50.7±11.7 degrees, preoperative: 45.8±8.9 degrees; P =0.012). CONCLUSIONS: The SDA and mSDA procedures produced similar postoperative changes, primarily in the superior and superior-posterior acetabular octants. Placing the graft more anteriorly did not increase anterior coverage in the mSDA, and only the PA increased coverage in the superior and superior-anterior acetabular octants.

Defining the Incidence of Residual Acetabular Dysplasia After Successful Reduction With a Harness.

BACKGROUND: The purpose of this study was to evaluate the rate of residual acetabular dysplasia (RAD), defined as an acetabular index (AI) of >90th percentile of age and sex-matched controls, in a cohort of infants successfully treated with the Pavlik harness (PH). METHODS: We retrospectively studied typically developing infants at a single center, with at least 1 dislocated hip, that was successfully treated with a PH and had a minimum of 48 months follow-up. Hip dislocation was defined as <30% femoral head coverage at rest on pretreatment ultrasound or IHDI grade 3 or 4 on the pretreatment radiograph. RESULTS: Forty-six dislocated hips (41 infants) were studied (4 males and 37 females). Brace treatment was initiated at an average age of 1.8 months (range: 2 d to 9.3 mo) and was maintained for an average of 10.2 months (range: 2.3 to 24.9 mo). All hips achieved IHDI grade 1 reduction. Five of 46 hips (11%) had an AI >90th percentile at the conclusion of bracing. Average follow-up was 6.5 years (range: 4.0 to 15.2 y). We found a 30% incidence of RAD (14/46 hips) on final follow-up radiographs. Of these hips, 13/14 (93%) had AI <90th percentile at the end of brace treatment. Comparing children with and without RAD, there were no differences in age at the initial visit or brace initiation, total follow-up, femoral head coverage at the initial visit, alpha angle at the initial visit, or total time in the brace ( P > 0.09). CONCLUSION: In a single-center cohort of infants with dislocated hips treated successfully with a PH, we observed a 30% incidence of RAD at a minimum 4.0-year follow-up. Normal acetabular morphology at the end of brace treatment did not result in normal acetabular morphology at the final follow-up in 13/41 hips (32%). We recommend that surgeons should pay close attention to the year-over-year change in both the AI and AI percentile. LEVEL OF EVIDENCE: Level IV: case series.

Allograft Anterior Cruciate Ligament Reconstruction in Adolescent Patients May Result in Acceptable Graft Failure Rate in Nonpivoting Sports Athletes.

BACKGROUND: Studies have demonstrated that pediatric patients have an increased risk of failure with allograft anterior cruciate ligament reconstruction (ACLR); however, there is no study investigating whether allograft ACLR may be safe in older adolescent patients who are not returning to competitive pivoting sports (ie, low risk). The purpose of this study was to assess outcomes for low-risk older adolescents selected for allograft ACLR. METHODS: We performed a retrospective chart review of patients younger than 18 years who received a bone-patellar-tendon-bone allograft or autograft ACLR by a single orthopaedic surgeon from 2012 to 2020. Patients were offered allograft ACLR if they did not intend to return to pivoting sports for 1 year. The autograft cohort was matched 1:1 based on age, sex, and follow-up. Patients were excluded for skeletal immaturity, multiligamentous injury, prior ipsilateral ACLR, or concomitant realignment procedure. Patients were contacted to obtain patient-reported outcomes at ≥2 years follow-up, including single assessment numerical evaluation, surgery satisfaction, pain scores, Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Parametric and nonparametric tests were used as appropriate. RESULTS: Of the 68 allografts, 40 (59%) met inclusion and 28 (70%) were contacted. Among the 456 autografts, 40 (8.7%) were matched and 26 (65%) were contacted. Two allograft patients (2/40; 5%) failed at a median (interquartile range) follow-up of 36 (12, 60) months. There were 0/40 failures in the autograft cohort and 13/456 (2.9%) among the overall autografts; neither were significantly different from the allograft failure rate (both P > 0.05). Two (5.0%) patients in the autograft cohort required manipulation under anesthesia and arthroscopic lysis of adhesions. There were no significant differences between cohorts for single assessment numerical evaluation, Lysholm, Tegner, pain, and satisfaction scores (all P > 0.05). CONCLUSIONS: Although ACL allograft failure rates remain nearly two times higher than autograft failure rates in older adolescents, our study suggests that careful patient selection can potentially bring this failure rate down to an acceptable level. LEVEL OF EVIDENCE: Level III; retrospective matched cohort study.

Treatment of Hip Instability in Children With Down Syndrome: Keys to Managing a Challenging Problem.

INTRODUCTION: Management of hip instability in children with Down syndrome is a challenging task to undertake for even the most experienced surgeons. As life expectancy of these patients increases, the importance of preserving functional mobility and hip joint stability in order to minimize late hip degeneration and pain has become a priority. The aim of this study is to evaluate the clinical and radiographic outcomes of children with Down syndrome and hip instability who underwent surgical reconstruction with femoral and/or acetabular procedures. METHODS: We performed a retrospective review of all children with Down syndrome age 18 years and younger, who underwent surgical intervention to address hip instability between 2003 and 2017. Data was recorded detailing the patient's demographics, preoperative and postoperative functional status and surgical details. Preoperative and postoperative radiographic analysis was performed as well as 3-dimensional computed tomography scan evaluation, when available. All major and minor complications were recorded and classified using the Severin radiographic classification and the Clavien-Dindo-Sink clinical classification. RESULTS: We studied 28 hips in 19 children that were followed for an average of 4.4 years postsurgical intervention for hip instability. The majority of patients improved in all radiographic parameters. A total of 14 hips (50%) had complications and 9 hips (32%) required a secondary surgery. Of those complications, 2 hips (7%) developed avascular necrosis and 4 hips (14%) developed recurrent instability after the index procedure. Two of these hips had a subsequent anteverting periacetabular osteotomy that produced a stable hip at final follow up. DISCUSSION: Surgical management of hip instability in children with Down syndrome remains challenging. The treating surgeon must have a thorough understanding of the pathoanatomy and design the surgical treatment to meet all of the underlying sources of instability. Combined femoral and acetabular osteotomies plus capsulorrhaphy are often required along with postoperative hip spica immobilization. Although complication and revision surgery rates are high, hip stability and good functional outcomes can be achieved.

Prolonged Brace Treatment Does Not Result in Improved Acetabular Indices in Infantile Dislocated Hips.

BACKGROUND: The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. However, significant variability exists in the duration of brace treatment after successful reduction of the dislocated hip. The purpose of this study was to evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database. METHODS: We retrospectively studied prospectively enrolled infants with at least 1 dislocated hip that were initially treated with a PH and had a recorded AI at 2-year follow-up. Subjects were treated at 1 of 2 institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured shorter brace treatment protocol. Hip dislocation was defined as <30% femoral head coverage at rest on the pretreatment ultrasound or International Hip Dysplasia Institute (IHDI) grade III or IV on the pretreatment radiograph. RESULTS: Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace ×3 longer than hips from institution 2 (adjusted mean 8.9±1.3 vs. 2.6±0.2 mo) (P<0.001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (P=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9 degrees) compared with Institution 2 (adjusted mean 23.5±0.8 degrees) (P=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age-matched and sex-matched AI normal data (P=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia (more than 2 SD from the mean), compared with a 22% (6/27) from Institution 2 (P=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (P=0.071). CONCLUSIONS: The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at 2-year follow-up. LEVEL OF EVIDENCE: Level III.

Plate Versus Lag Screw Only Fixation of Unstable Ankle Fractures Involving the Fibula in Adolescent Patients.

BACKGROUND: Plate fixation has been the traditional technique for fracture repair of unstable ankle injuries with an associated lateral malleolus fracture. Recently, biomechanical and clinical data have demonstrated lag screw only fixation to be an effective alternative to plate fixation in the adult population. This comparison has yet to be studied in the adolescent or pediatric population. The objective of this study was to compare lag screw only fixation with traditional plating for lateral malleolus fractures in adolescents. METHODS: A retrospective review was conducted of 83 adolescents with unstable oblique lateral malleolus fractures treated at a single pediatric level-1 trauma center between 2011 and 2019 with a minimum clinical follow-up until fracture union. Patients were divided into 2 surgical groups: (1) plate fixation (n=51) or (2) lag screw fixation (n=32). Radiographic and clinical outcomes and complications were measured in both groups. RESULTS: All patients in both groups achieved our primary outcome measure of fracture union without loss of reduction. The mean surgical time for subjects treated with a plate was 15 minutes longer (64 vs. 49 min) (P=0.001) and these patients were 3.8 times more likely to have symptomatic implants (P<0.044) than subjects treated with screws. Approximately 50% of the cohort was available by phone for patient-reported outcomes at a mean follow-up of 50 months. The mean Single Assessment Numerical Evaluation scores, Foot and Ankle Ability Measure Activities of Daily Living scores, Foot and Ankle Ability Measure sports scores, and return to sports rates were similar (92 vs. 93, 98.2 vs. 98.1, 93.2 vs. 94.0, 95% vs. 86%, respectively; P>0.05) between the 2 treatment methods. CONCLUSIONS: Lag screw only fixation is a safe and effective procedure for noncomminuted, oblique fibula fractures in the adolescent population as demonstrated by equivalent fracture healing rates without loss of reduction and similar outcome scores. Given these comparable results with the additional benefits of shorter surgical time and less symptomatic implants, lag screw only fixation should be considered as a viable treatment alternative to traditional lateral plating in the adolescent population. LEVEL OF EVIDENCE: Level III.

Three-dimensional Analysis of Acetabular Morphology and Orientation in Patients With Slipped Capital Femoral Epiphysis.

BACKGROUND: Previous studies analyzing the acetabuli in patients with slipped capital femoral epiphysis (SCFE) have not definitively addressed the relationship between SCFE and acetabular shape. Femoral head overcoverage and acetabular version are thought to contribute to SCFE. The purpose of this study was to determine the acetabular morphology and orientation in hips with SCFE and compare them with normally developing children. METHODS: Pelvic computed tomography (CT) images of patients with SCFE were compared with pelvic CTs of patients without orthopedic abnormalities (normal controls). Three-dimensional (3-D) reconstructions were created from each CT examination. Custom software uniformly aligned the pelvis then determined acetabular measures from the reconstructions including acetabular version, acetabular tilt, articular surface area, and acetabular coverage angle measured in a radial manner dividing the acetabulum into octants. RESULTS: Two-hundred forty-four hips were included (53 SCFE, 31 unaffected contralateral hips in patients with SCFE, and 160 controls). The acetabular version was similar among SCFE hips, unaffected contralateral hips, and normal controls (P=0.48). Control hips had higher acetabular tilt than SCFE-affected hips (P=0.01) and unaffected contralateral hips (P=0.04). The acetabular surface area was higher in SCFE-affected hips compared with controls (P<0.05). SCFE-affected hips and the unaffected contralateral hips in patients with SCFE had increased acetabular coverage compared with controls in all 5 acetabular octants. CONCLUSIONS: Contrary to some previous studies, the authors did not find the acetabulum to be retroverted in patients with SCFE compared with controls. Both affected and unaffected hips of patients with SCFE have decreased acetabular tilt. Acetabular surface area is higher in hips with SCFE compared with normal controls, and both the SCFE-affected hips and unaffected hips had increased acetabular coverage compared with controls in all 5 octants of the acetabulum. The shared morphology of affected and unaffected hips in patients with SCFE suggests that their acetabular anatomy may predispose them to slip. LEVEL OF EVIDENCE: Level III.

Reliability of Low-dose Biplanar Radiography in Assessing Pediatric Torsional Pathology.

BACKGROUND: Low-dose biplanar radiographs (LDBRs) significantly reduce ionizing radiation exposure and may be of use in evaluating lower extremity torsion in children. In this study, we evaluated how well femoral and tibial torsional profiles obtained by LDBR correspond with 3-dimensional (3D) computed tomography (CT) and magnetic resonance axial imaging (MRI) in pediatric patients with suspected rotational abnormalities. METHODS: Patients who had both LDBR and CT/MRI studies performed for suspected lower extremity rotational deformities were included. Unlike previous publications, this study focused on patients with lower extremity torsional pathology, and bilateral lower extremities of 17 patients were included. CT/MRI torsion was measured using the Reikerås method, after conversion to 3D reconstructions. The LDBRs were deidentified and sent to the software division of EOS imaging, who created 3D reconstructions and evaluated each reconstruction for the torsional quantification of the femurs and tibiae. These imaging modalities were compared using correlation statistics and Bland-Altman analyses. RESULTS: The mean age of the cohort was 12.1±1.7 years old. Torsional values of the femur were significantly lower in LDBRs versus 3D CT/MRIs at 17.7±15.1 and 23.3±17.3, respectively (P=0.001). Torsional values of the tibia were similar in LDBRs versus 3D CT/MRIs at 23.6±10.6 and 25.3±11.2, respectively (P=0.503). There was a good intermodality agreement between LDBR and 3D CT/MRI torsional values in the femur (intraclass correlation coefficient=0.807) and tibia (intraclass correlation coefficient=0.768). Bland-Altman analyses showed a fixed bias with a mean difference of -5.6±8.8 degrees between femoral torsion measurements in LDBRs versus 3D CT/MRIs (P=0.001); 15% (5/34) of femurs had a clinically significant measurement discrepancy. Fixed bias for LDBR measurements compared with 3D CT/MRIs for the tibia was not observed (P=0.193), however, 12% (4/34) of tibias had a clinically significant measurement discrepancy. CONCLUSION: Although we found strong correlations between torsional values of the femur and tibia measured from LDBRs and 3D CT/MRIs, torsional values of the femur produced from LDBRs were significantly lower than values obtained from 3D CT/MRIs with some notable outliers. LEVEL OF EVIDENCE: Level III.

Functional Outcomes of Unstable Ankle Fractures in Adolescents.

BACKGROUND: The purpose of this study was to describe the functional outcomes and complications of unstable supination external rotation (SER) and pronation external rotation (PER) ankle fractures in adolescents. A secondary outcome was to compare functional outcomes of SER stage IV injuries that were treated definitively with closed reduction and cast application to a similar group of minimally displaced fractures treated with open reduction and internal fixation (ORIF). METHODS: A retrospective review of adolescents aged 10 to 18 years with unstable ankle fractures treated at a single institution between 2009 and 2017 was conducted. All patients had functional outcomes data from the Foot and Ankle Ability Measure obtained at a minimum of 1-year follow-up. RESULTS: In total, 67 adolescents (41 SER, 26 PER) were included (mean follow-up: 52.3±24.8 mo). A total of 56 were treated with ORIF and 11 were closed reduced and casted. No patients treated nonsurgically had a loss of reduction and none required subsequent surgical intervention. Preoperative radiographic predictors of syndesmotic injury (>6 mm of tibiofibular clear space or <2 mm of tibiofibular overlap) were not sensitive and only moderately specific predictors of intraoperative syndesmotic injury. There was no difference in functional outcome between the 11 SER stage IV fractures treated nonoperatively and a group of minimally displaced SER injuries treated with ORIF. Patients with open or partially open physes had better functional outcomes. Patients with syndesmotic injuries, medial malleolus fractures, or fracture-dislocations were not associated with lower functional outcome scores in our adolescent cohort. CONCLUSIONS: Unstable SER and PER injuries in adolescents have favorable functional outcomes at intermediate-term follow-up, though a minority continue to have impaired ankle function. Minimally displaced SER stage IV injuries with near anatomic alignment after closed reduction can be successfully treated with continued closed management, and have no difference in functional outcomes compared with similar injuries treated with ORIF. LEVEL OF EVIDENCE: Level III.

3D Knee Trochlear Morphology Assessment by Magnetic Resonance Imaging in Patients With Normal and Dysplastic Trochleae.

BACKGROUND: Trochlear dysplasia is recognized as a significant risk factor for patellar instability, but current imaging modalities fail to allow full visualization and classification of the complex 3-dimensional (3D) anatomy of the trochlea. The purpose of this study was to elucidate primary differences in trochlear morphology between patients with and without patellar instability by utilizing 3D magnetic resonance imaging (MRI) reconstructions of the trochlea. METHODS: An institutional review board-approved retrospective review included 24 patients with a diagnosis of patellar instability and an age-matched and sex-matched control population of 12 patients. 3D models of the femoral trochlea were created from MRI images and measurements were performed. 3D measurements were trochlear groove volume and surface area that were normalized to the femoral width. 2D measurements were performed throughout the length of the trochlea including the bony and cartilaginous sulcus angles as well as the bony and cartilaginous trochlear depths. Differences were also assessed between sex, skeletal maturity, and trochlear dysplasia severity. RESULTS: Surface topography of the trochlea varied significantly based on location with the trochlea becoming progressively more flat proximally away from the notch (P<0.05). Patients with patella instability had reduced trochlear volumes and trochlear depths compared with control patients (P<0.05). These differences were more pronounced with the cartilaginous measurements as well as more proximally within the trochlea. Patients with high-grade dysplasia had greater reductions in trochlear volumes and depth especially proximally in the trochlea (P<0.05). Once femoral size was standardized, minimal differences were observed based on sex or skeletal maturity (P>0.05). CONCLUSIONS: Novel 3D MRI reconstructions demonstrated that measurements of trochlear morphology varied significantly between patients with and without patellar instability. When trochlear dysplasia is present, it appears to affect the majority of the trochlear surface, but preferentially the proximal extent. Future trochlear dysplasia classification systems may benefit from assessment of articular cartilage surface measures rather than primarily osseous structure measurements. LEVEL OF EVIDENCE: Level III-case-control prognostic study.

Comparison of Staged Versus Same-day Bilateral Hip Surgery in Nonambulatory Children With Cerebral Palsy.

BACKGROUND: Bilateral hip reconstructions with osteotomies are commonly required in patients with severe cerebral palsy (CP) and dysplasia. These procedures can be performed by staging each hip surgery, separated by weeks to months, or by addressing both hips in a single-event surgery. The optimal timing of such surgery is yet to be determined. The purpose of this study was to retrospectively compare major complications between the staged and single-event approaches. METHODS: Medical records of patients who underwent bilateral hip osteotomies, with at least one side including a pelvic osteotomy, were retrospectively reviewed. Subjects were identified who had a diagnosis of nonambulatory CP (defined by Gross Motor and Functional Classification System level IV or V), and at least 1 year of clinical follow-up. All hips were treated by 1 of 7 surgeons: 2 surgeons who always performing single-event surgery and 5 who always perform staged surgeries. Complications were stratified by the Modified Clavien-Dindo Classification (grades 1 to 5). The primary outcome was major complications (grade ≥3), while minor complications, readmissions, reoperations, and resource utilization outcomes were investigated secondarily. RESULTS: Sixty-five patients met our inclusion criteria: 35 received single-event surgery and 30 received staged surgery. The staged group had a higher rate of major complications per patient (0.30 vs. 0; P=0.013). Unplanned readmissions and reoperations were likewise increased in the staged group. Minor complication rates were high in both groups, with no differences observed between staged and single-event approaches (3.27 per patient vs. 2.91; P=0.952). There were no complications causing permanent disability or death. The total length of stay (6.2 vs. 4.0 d; P<0.001) and mean nonsurgical operating room time (65.7 vs. 45.6 min; P<0.001) were increased in the staged group versus the single-event group. CONCLUSIONS: The staged approach to bilateral hip reconstructions in the nonambulatory CP population was associated with a higher rate of major complications compared with a single-event approach. Minor complications were similar for both approaches. Both approaches can have an acceptable safety profile with no observed grade 4 or 5 complications. LEVEL OF EVIDENCE: Level III.

Comparison of Surgical Outcomes Between a Triplane Proximal Femoral Osteotomy and the Modified Dunn Procedure for Stable, Moderate to Severe Slipped Capital Femoral Epiphysis.

BACKGROUND: Recent studies have demonstrated the intra-articular cartilage and labral damage that can occur from the proximal femoral cam-like deformity of a moderate to severe slipped capital femoral epiphysis (SCFE). The approach to treating this deformity in a symptomatic Loder stable hip is controversial. The purpose of this study was to compare radiographic outcomes, complication rates, and revision rates between Imhauser type triplane proximal femoral osteotomy (TPFO) and the modified Dunn procedure (MDP). METHODS: Twenty-six subjects with minimum 1-year follow-up were included (12 treated with a TPFO, and 14 treated with the MDP). A chart review was performed to capture data related to complications, revision procedures, surgical time, and body mass index. Radiographs were measured preoperatively and at final follow-up to evaluate epiphyseal-slip angle, neck-shaft angle, articular surface to trochanter distance, and medial proximal femoral angle. RESULTS: Surgical time was shorter for the TPFO group (150.0±57.4 min) compared with the MDP group (203.8±30 min) (P=0.005). All preoperative and postoperative radiographic measures were similar between the 2 groups except postoperative neck-shaft angle, which was significantly less in the TPFO group (129.7±8.6 vs. 140.9±9.4 degrees) (P=0.005). There were no cases of femoral head avascular necrosis (AVN) in the TPFO group. The modified Dunn group had a 29% AVN rate (P=0.1). The overall complication rate was similar between the TPFO (33%) and modified Dunn (36%) groups (P=1.0) and the reoperation rate was slightly greater in the TPFO group (33%) as compared with the modified Dunn group (21%) (P=0.67). CONCLUSIONS: The complex 3-dimensional proximal femoral deformity of a moderate to severe SCFE can be difficult to treat with relatively high complication/reoperation rates observed in both TPFO and MDP groups. All 4 instances of AVN in this study of stable slips, however, were in the MDP group. As this can be a devastating complication leading to early total hip arthroplasty, we advise against the MDP in stable SCFE patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Comparison of 3 Pediatric Pelvic Osteotomies for Acetabular Dysplasia Using Patient-specific 3D-printed Models.

BACKGROUND: Children with developmental dysplasia of the hip may require a pelvic osteotomy to treat acetabular dysplasia. Three osteotomies are commonly performed in these patients (Pemberton, Dega, and San Diego), though comparative studies of each are limited. The purpose of this study was to compare changes in acetabular morphology (acetabular version, volume, and octant coverage angles) created by these 3 osteotomies using matched patient-specific 3D-printed pelvic models. METHODS: Fourteen patients with developmental dysplasia of the hip and preoperative computed tomography (CT) imaging were retrospectively included. For each patient CT, bone and cartilage tissues were independently segmented, and 3 identical pelvises were 3D-printed using a dual material printer. Bone was printed with rigid material and cartilage with flexible material to simulate the flexibility of the triradiate cartilage and pubic symphysis. Pemberton, Dega, and San Diego acetabular osteotomies were performed on the triplicate set of 3D prints. Acetabular version, volume, and octant coverage angles (posterior, superior-posterior, superior, superior-anterior, and anterior) were determined before and after each mock surgery by morphologic assessment using preoperative and postoperative CT images. RESULTS: San Diego osteotomy yielded a small increase (+3.34±1.71 degrees) in version, compared with decreases with Pemberton (-5.47±1.54 degrees) and Dega (-8.57±1.21 degrees, P<0.05). Acetabular volume decreased similarly for Pemberton (-13.36%±2.88%), Dega (-19.21%±2.73%), and San Diego (-19.29%±2.44%; P=0.215) osteotomies. San Diego osteotomy tended to have a larger postoperative increase in the posterior regions, and the Dega and Pemberton osteotomies tended to have larger postoperative increases in the anterior coverage regions. CONCLUSIONS: Quantifiable differences were identified in acetabular octant coverage angles and version between the 3 pelvic osteotomies. San Diego osteotomy increased acetabular coverage posteriorly resulting in acetabular anteversion, whereas Pemberton and Dega had greater superior-anterior coverage resulting in relative acetabular retroversion. This study is the first known to utilize 3D-printed models for comparison of surgical approaches in pediatric pelvic osteotomies.

The "Double Medial Malleolus": A New Physical Finding in Talocalcaneal Coalition.

PURPOSE: It has been the observation of the senior author that there is a bony fullness or "double medial malleolus" over the middle facet as a consistent finding with most talocalcaneal coalitions (TCC). To document this observation, we reviewed records and radiographs in 3 patient groups. METHODS: Part 1: retrospective chart review was completed for 111 feet to determine the clinical presence of a palpable "double medial malleolus." Part 2: computed tomography (CT) scans for evaluation of tarsal coalition or symptomatic flatfoot between January 2006 and December 2014 were retrospectively reviewed for the same cohort. Soft tissue thickness was measured as the shortest distance between bone and skin surface at both the medial malleolus and the middle facet/coalition. The volume of the middle facet or coalition was measured at their midpoint. These findings were compared among feet with TCC (n=53), calcaneonavicular coalition (CNC) (n=20), and flatfoot (n=38). RESULTS: Part 1-clinical: from medical records, 38 feet (34%) had documented record of a palpable medial prominence. Of the feet reviewed with a "double medial malleolus," all had TCC (no false positives or false negatives). Clinical and CT prominence demonstrated significant correlation (rs=0.519, P=0.001). Part 2-radiographic: CT observation of "double medial malleolus" is significantly associated with TCC (P<0.001). CT observation of double medial malleolus is 81% sensitive and 79% specific as a predictive test for TCC. The middle facet-to-skin distance was significantly closer in those with TCC versus controls (P<0.001). The ratio was larger in patients with TCC versus CNC (P=0.006) or flatfeet (P<0.001). Volume was nearly twice the size in patients with TCC versus the controls (P<0.001). CONCLUSIONS: TCCs have a bony prominence below the medial malleolus on clinical exam and CT scan not present in flatfeet or CNCs. This abnormal middle facet is almost twice the size of the normal middle facet. Obesity or severe valgus may mask this finding. If a palpable bony prominence is noted just below the medial malleolus during examination of a painful foot with a decrease in subtalar motion, the likely diagnosis is TCC. With this added clinical finding, appropriate images can be ordered to confirm the diagnosis of the latter. We advise CT scans with 3D images for surgical planning. The primary finding for tarsal coalitions in textbooks is decreased subtalar motion. This new finding of a palpable enlarged medial prominence just below the medial malleolus is highly associated with TCCs. LEVEL OF EVIDENCE: Level III.

Secondary Ossification Center Appearance and Closure in the Pelvis and Proximal Femur.

INTRODUCTION: Variable ossification patterns of the pelvis in skeletally immature patients can make the interpretation of pelvic radiographs challenging. Inconsistencies among prior studies and lack of sex comparisons underscore the need for a more comprehensive characterization of the secondary ossification centers. This study evaluates the chronology and sex differences for appearance and closure of pelvic and proximal femoral secondary ossification centers using computed tomography (CT). METHODS: Patients who underwent abdominal and pelvic CT scans between January 2009 and December 2014 at 2 tertiary level 1 trauma centers were retrospectively reviewed. Patients between the ages of 2 and 32 years with adequate imaging of the pelvis and proximal femurs were included. Patients with a history of orthopaedic trauma or pathology affecting ossification were excluded. CT scans were assessed for the appearance and closure of the following secondary ossification centers: anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), femoral head (FH), greater trochanter (GT), iliac crest (IC), ischial tuberosity (IT), lesser trochanter (LT), posterior superior iliac spine (PSIS), symphysis pubis (SP), and triradiate cartilage (TRC). Basic descriptive statistics are reported. RESULTS: A total of 496 CT scans met inclusion criteria (240 males and 256 females). The order of appearance of the secondary ossification centers was: (male) GT, LT, AIIS, IT, ASIS, PSIS, IC, and SP; (female) GT, LT, IT, AIIS, PSIS, IC, ASIS, and SP. The order of closure was similar: (male) TRC, LT, FH, AIIS, GT, ASIS, PSIS, IT, IC, and SP; (female) LT, TRC, AIIS, FH, GT, ASIS, PSIS, IT, IC, and SP. Female ossification centers appeared ∼1 to 2 years before males in all locations. Female ossification centers closed ∼1 to 2 years before males in all locations except TRC, IC, and SP. CONCLUSIONS: The appearance and closure of the pelvis and proximal femur secondary ossification centers follow a predictable pattern of development, occurring slightly earlier in females than males. Knowledge of more precise ages of development and sex differences better characterize this complex skeletal development. Future studies may use secondary ossification centers to further evaluate skeletal maturity, assess pediatric pathology, and aid surgical management. LEVEL OF EVIDENCE: Level III.

A Medial Portal for Hip Arthroscopy in Children With Septic Arthritis: A Safety Study.

BACKGROUND: Prompt open arthrotomy is historically utilized to treat pediatric septic arthritis of the hip, but arthroscopy has been described as a valid alternative to prevent long-term sequelae. Standard hip arthroscopy in adolescents and adults utilizes lateral-based portals, but successful irrigation in infants may necessitate a medial portal due to the smaller joint size. The purpose of this study was to determine the safety of a medial hip portal in children based on its anatomic relation to neurovascular structures. METHODS: A retrospective review of children 6 years of age or below with septic hip arthritis who obtained a preoperative magnetic resonance imaging (MRI) between 2009 and 2015 was performed. Multiple measures were recorded from the MRI to create a 3D cone with the vertex just posterior to the adductor longus at the convergence of the gluteal and inguinal creases-a previously described posteromedial portal-with the cone base being a circle defined as the central joint diameter. The distance to the femoral vessels and nerve were then recorded. An adult cadaver was then utilized to replicate the proposed portal starting point and trajectory to confirm that it could be reproducible in a clinical setting. RESULTS: After applying criteria, 47 MRI were evaluated (21 boys, 26 girls) demonstrating a mean distance to femoral vessels and nerve: at insertion, 18.9 mm (minimum 10.5 mm) and at the hip joint, 11.1 mm (minimum 5.2 mm). Girls and boys did not differ significantly, but there was a significant correlation of both age (r=0.75) and body weight (r=0.84) to the measured distance (P<0.001). Imaging of the cadaver confirmed that the starting point could be replicated. CONCLUSIONS: There is a direct relation to size of the child and the distance from the neurovascular structures to the cannula trajectory, but even the smallest of children have at least 5.5 mm of adductor longus to protect the femoral structures. A medial-based portal that utilizes a medial needle for initial aspiration features a wide margin of safety for children requiring treatment for septic hip arthritis. LEVEL OF EVIDENCE: Level IV.

Analysis of Acetabular Ossification From the Triradiate Cartilage and Secondary Centers.

BACKGROUND: Acetabular development is a complex process that involves both endochondral growth from the triradiate cartilage (TRC) and intramembranous growth from the primary and secondary ossification centers of the innominate bones. Ponseti and others have described these centers including their contribution toward the development of normal acetabular shape. Prior studies have not utilized advanced imaging to study the appearance and closure of these secondary centers. The purpose of this study was to determine the chronological age at which the secondary ossification centers of the acetabulum appear and close and where there are any sex differences. METHODS: Patients who underwent abdominal and pelvic computed tomography (CT) scans between January 2009 and December 2014 at a pediatric hospital were retrospectively reviewed. Patients between age 6 and 16 years with adequate imaging of acetabulum were included. CT scans were assessed for the appearance and closure of the 3 acetabular secondary ossification centers [anterior (os pubis), superior (os ilium), and posterior (os ischium)] and closure of the TRC. RESULTS: A total of 159 CT scans met inclusion criteria (66 males and 93 females). The median age of appearance of the secondary ossification centers was: posterior (10.1 females, 12.8 males), anterior (10.7 females, 13.4 males), and superior (11.1 females, 13.6 males). The median age of closure of the secondary ossification centers was: posterior (12.8 females, 13.6 males), anterior (12.8 females, 13.9 males), superior (14.5 females, 13.9 males), and TRC (14.5 females, 14.3 males). Most ossification centers in females appeared and closed approximately 2 to 3 years before males. CONCLUSIONS: Secondary ossification centers in the acetabulum appear sequentially (first posterior, then anterior, then superior), with almost all centers closing just before TRC. Closure occurs earlier in females than males. Knowledge of these centers and their closure patterns allows better radiologic readings (especially CT studies) and understanding of acetabular growth, allowing more informed management of childhood hip conditions including dysplasia, trauma, and over-use sports injuries. LEVEL OF EVIDENCE: Level III-Diagnostic.

Electronic Medical Record Adoption: The Effect on Efficiency, Completeness, and Accuracy in an Academic Orthopaedic Practice.

INTRODUCTION: The electronic medical record (EMR) is the new platform for documenting health information. The purpose of this study is to evaluate the impact of the EMR on efficiency, completeness, accuracy, and surgeon attitude in the orthopaedic program of a training hospital. METHODS: Sixty paper charts were compared with 60 EMRs. Pre-EMR and post-EMR billing data was used to determine outpatient clinic volume and the number of providers seeing patients per month. Completeness was evaluated by noting the presence of items from a predetermined list of clinical information pertinent to each diagnosis. Age and side of injury was used to evaluate note accuracy. A survey was used to evaluate surgeon's attitudes regarding the EMR. RESULTS: There was no difference in monthly volume pre-EMR and post-EMR. There was an increase in the number of providers needed to see patients, equating to a 19% reduction in the number of patient visits per provider. The EMR was 1.3 times more likely to include pertinent clinical information. Both paper charts and the EMR were highly accurate. The surgeon attitude survey revealed concerns regarding clinic efficiency, increased "off-hours" record keeping, and decreased clinic teaching. DISCUSSION: EMR is an important and essential component of medical care delivery. Record completion and accuracy were similar across medical record types. The use of EMR led to a 19% reduction in patients per provider. Creating the record in the clinic setting appears to detract from patient interaction, and resident/fellow education time. A more focused, specialty designed, EMR may be more efficient for an orthopaedic practice. Future EMR technology should allow a focused EMR designed for specialties that is efficient to create but that can be electronically converted into a "master record" that meets the needs of an associated larger organization. LEVEL OF EVIDENCE: Level III-retrospective comparative study.