Nonossifying Fibromas: A Computed Tomography-based Criteria to Predict Fracture Risk.

BACKGROUND: Nonossifying fibroma (NOF) is the most common benign osseous lesion in children; however, our understanding of which lesions progress to a fracture remains unclear. In this study, we seek to formulate a classification system for NOFs to assess for fracture risk and determine what this classification system tells us regarding fracture risk of the distal tibia and distal femur NOFs. METHODS: Charts were retrospectively reviewed for patients with NOFs. A 4-point criteria was created and used to calculate fracture risk for distal tibia and distal femur NOFs. The analysis included incidence, specificity, and sensitivity. RESULTS: One point was given for each of the following findings on computed tomography (CT) scan: (1) >50% width on coronal view; (2) >50% width on sagittal view; (3) any cortical breach; (4) lack of a neocortex. In total, 34 patients with NOFs of the distal tibia had CT scans, of which 14 fractured. Zero with a 0- or 1-point score fractured, 2 with a 2-point score fractured (20%), 4 with a 3-point score fractured (44%), and 8 with a 4-point score fractured (100%). Sensitivities of 1-, 2-, 3-, and 4-point scores were 100%, 100%, 85.7%, and 57.1%, respectively, and specificities were 71.4%, 71.4%, 80%, and 100%, respectively. A total of 41 patients with NOFs of the distal femur had CT scans, of which 5 fractured. Zero with a 0-point score fractured, 1 with a 1-point score fractured (4%), 0 with a 2-point score fractured, 1 with a 3-point score fractured (20%), and 3 with a 4-point score fractured (100%). Sensitivities of 1-, 2-, 3-, and 4-point scores were 100%, 80%, 80%, and 60%, respectively; and specificities were 60%, 87.8%, 90%, and 100%, respectively. CONCLUSIONS: Our 4-point CT criteria is easy to apply and identifies patients at high risk of fracture, helping surgeons make decisions regarding treatment. LEVEL OF EVIDENCE: Level IV-prognostic study.

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.

Femoral Neck Aspiration Aids in the Diagnosis of Osteomyelitis In Children With Septic Hip.

BACKGROUND: The role of femoral aspiration (FA) in the treatment of septic arthritis of the hip is controversial. The purpose of this study was to determine if FA conducted concomitantly with irrigation and debridement (I&D) of the septic hip aids in microorganism and osteomyelitis identification and alters the treatment plan, or if the risks of the procedure outweigh its potential benefit. We also compare preoperative magnetic resonance imaging (MRI) with FA for diagnosis of osteomyelitis cooccurring with septic arthritis. METHODS: Retrospective review was performed of all patients treated at a single institution between January 2003 and June 2014 for suspected septic hip arthritis. Eighty-three patients were identified with suspected or confirmed septic arthritis and 28 patients (33%) had cooccurring osteomyelitis. Demographic and clinical data were recorded for each patient. The sensitivity and specificity of FA and MRI for diagnosing osteomyelitis were determined. RESULTS: Among the 83 patients with confirmed or suspected septic arthritis, 31 patients (37%) had a FA performed at the time of the hip I&D, resulting in positive cultures in 17 patients. All of these patients had other positive cultures (blood and/or joint fluid) that grew the same organism. 54 patients (65%) had a preoperative MRI. The MRI was falsely negative in 10 patients, 6 of whom had a positive FA resulting in appropriate management of osteomyelitis. Missed or delayed diagnosis of osteomyelitis resulted in significant morbidity in 3 patients (avascular necrosis and femoral neck fracture, extensive lower extremity osteomyelitis, and subtrochanteric fracture with malunion). No complications associated with FA were identified. FA and MRI were found to have sensitivity/specificity for osteomyelitis of 100%/100% and 38%/95%, respectively. CONCLUSIONS: Although FA did not improve microorganism identification, it did aid in the diagnosis of cooccurring osteomyelitis when treating children with septic arthritis, especially in patients with false negative MRI findings for osteomyelitis. We recommend FA at the time of septic hip I&D as its benefits appear to far outweigh its risks. LEVEL OF EVIDENCE: Level III-diagnostic study.

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

BACKGROUND: The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period. METHODS: This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated. RESULTS: There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%). CONCLUSIONS: Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates. LEVEL OF EVIDENCE: Level IV-therapeutic.

Posttraumatic Tibiofibular Synostosis After Treatment of Distal Tibiofibular Fractures in Children.

INTRODUCTION: Posttraumatic pediatric distal tibiofibular synostosis is a rare complication following fracture. This is a retrospective, multicenter case series of synostosis of distal tibiofibular fractures in children. The purpose was to evaluate the incidence and pattern of posttraumatic distal tibiofibular synostosis in children. METHODS: Of the 604 pediatric distal tibiofibular fractures, 20 patients (3.3%) with synostosis after treatment of distal tibiofibular fractures were identified at 3 tertiary referral centers. There were 12 boys and 8 girls, with a mean age of 8.4±2.0 years (range, 3.7 to 11.5 y) at the time of injury. Medical records were reviewed, and serial radiographs were analyzed to determine fracture configuration, pattern of synostosis, and changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle. RESULTS: The time from the occurrence of fracture until the recognition of the synostosis ranged from 2 to 6 months (mean, 2.8 mo). The most common fracture configuration was oblique tibial fracture combined with comminuted fibular fracture. There were 12 focal types and 8 extensive types. The proximal tibiofibular distance was decreased in 13 patients. Proximal migration of the distal fibular physis developed in all cases. Five patients exhibited ankle valgus of 10 degrees or greater with moderate or severe distal fibular shortening. Eight patients were symptomatic after synostosis and 12 patients were asymptomatic. CONCLUSIONS: We identified 2 patterns of synostosis after the treatment of pediatric distal tibiofibular fracture: focal and extensive. The focal type was more prevalent than the extensive type, which was more likely to occur due to high-energy injury. When a tibiofibular cross-union develops, it creates growth abnormalities that warrant observation and potential treatment, as it may lead to progressive deformity or ankle pain. LEVEL OF EVIDENCE: Level IV.

What Risk Factors and Characteristics Are Associated With Late-presenting Dislocations of the Hip in Infants?

BACKGROUND: Most infants with developmental dysplasia of the hip (DDH) are diagnosed within the first 3 months of life. However, late-presenting DDH (defined as a diagnosis after 3 months of age) does occur and often results in more complex treatment and increased long-term complications. Specific risk factors involved in late-presenting DDH are poorly understood, and clearly defining an associated set of factors will aid in screening, detection, and prevention of this condition. QUESTIONS/PURPOSES: Using a multicenter database of patients with DDH, we sought to determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation. METHODS: A retrospective review of prospectively collected data from a multicenter database of patients with dislocated hips was conducted from 2010 to 2014. Baseline demographics for fetal presentation (cephalic/breech), birth presentation (vaginal/cesarean), birth weight, maternal age, maternal parity, gestational age, family history, and swaddling history of patients were compared among nine different sites for patients who were enrolled at age younger than 3 months and those enrolled between 3 and 18 months of age. A total of 392 patients were enrolled at baseline between 0 and 18 months of age with at least one dislocated hip. Of that group, 259 patients were younger than 3 months of age and 133 were 3 to 18 months of age. The proportion of patients with DDH who were enrolled and followed at the nine participating centers was 98%. RESULTS: A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002). CONCLUSIONS: Those presenting with DDH after 3 months of age have fewer of the traditional risk factors for DDH (such as breech birth), which may explain the reason for a missed diagnosis at a younger age. In addition, swaddling history was more common in late-presenting infants. A high index of suspicion for DDH should be maintained for all infants, not just those with traditional risk factors for DDH. Further investigation is required to determine if swaddling is a risk factor for the development of hip dislocations in older infants. More rigorous examination into traditional screening methods should also be performed to determine whether current screening is sufficient and whether late-presenting dislocations are present early and missed or whether they develop over time. LEVEL OF EVIDENCE: Level III, retrospective study.

In search of Ortolani: the man and the method.

Dr Marino Ortolani was an Italian pediatrician who developed a test for hip instability in the infant (1936) and then promoted early diagnosis of this condition to the medical community. He studied the pathoanatomy of hip instability in the 1940s. He wrote his textbook in 1948 and in 1952 he produced a movie about the examination and treatment of hip dysplasia which was translated into many languages to promote early diagnosis and treatment of developmental dysplasia of the hip (DDH). In his career, he wrote a monograph and 31 articles on the subject of hip dysplasia and besides his classic test he developed various braces to treat the infants with hip instability. A remarkable achievement for this early clinician-scientist.

Preliminary radiographic outcomes of surgical correction in juvenile hallux valgus: single proximal, single distal versus double osteotomies.

BACKGROUND: Surgical correction of juvenile hallux valgus has a high risk of recurrence and complications. This short-term follow-up study evaluates the radiographic differences between 3 osteotomy types: distal first metatarsal osteotomy, proximal first metatarsal osteotomy, and double first metatarsal osteotomy with regard to ability to achieve correction and the risk of hallux varus. METHODS: A total of 106 feet were evaluated. Percent correction of hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) was recorded, as well as complication and reoperation rates. Radiographs were evaluated at the initial visit, intraoperatively, and at final follow-up. RESULTS: The single distal osteotomy achieved: IMA within normal limits 21% of the time with no cases of overcorrection; HVA within normal limits 42% of the time with 13% overcorrected; and DMAA within normal limits 46% of the time with 4% overcorrected.The single proximal osteotomy achieved: IMA within normal limits 36% of the time with no cases of overcorrection; HVA within normal limits 36% of the time with no cases of overcorrection; and DMAA within normal limits 36% of the time with 7% overcorrected.The double osteotomy achieved: IMA within normal limits 54% of the time with no cases of overcorrection; HVA within normal limits 40% of the time with 7% overcorrected; and DMAA within normal limits 56% of the time with 22% overcorrected.The rate of HVA overcorrection was not found to be correlated with osteotomy type (P=0.37). The double osteotomy was found to have a higher DMAA overcorrection rate than either single osteotomy (P<0.001). CONCLUSIONS: The single distal osteotomy for juvenile hallux valgus seems to have the most consistent outcomes, with improved radiographic parameters and low risk of complication compared with the other surgical cohorts. However, the double osteotomy can have the best correction of all 3 radiographic parameters at once, but the highest risk for overcorrection of the DMAA. LEVEL OF EVIDENCE: Level III-retrospective case control study.

Fundamental concepts of developmental dysplasia of the hip.

To provide the best possible care to patients with developmental dysplasia of the hip, it is helpful to understand the normal growth and development of the hip joint; the pathoanatomy, epidemiology, and diagnosis of the condition; and the natural history of a missed diagnosis of dislocation, subluxation, and dysplasia.

C sign: talocalcaneal coalition or flatfoot deformity?

BACKGROUND: C sign is used to alert the physician of the possible presence of talocalcaneal coalition (TCC), so that advanced imaging can be ordered. The purpose of this study was to know the prevalence of the C sign among patients with TCC and its relationship to the presence of a TCC or to hindfoot alignment. METHODS: Retrospective reviews of the presence of C sign in radiographs of 88 feet with TCC (proved by computed tomography scan or surgical findings) and 260 flexible flatfeet were conducted. C sign was classified as complete and interrupted (types A, B, and C). The interobserver variability of the C sign was studied. Seven radiographic parameters were measured to analyze the relationship of these measurements with the presence or absence of the C sign. RESULTS: C sign was present in 68 feet (77%) with TCC: 14.5% complete and 62.5% interrupted (26% type A, 19.5% type B, and 17% type C). C sign was present in 116 flatfeet (45%), all of them interrupted (0.4% type A, 5.5% type B, and 39% type C). The talo-first metatarsal angle, the talohorizontal angle, the calcaneal pitch, the calcaneo-fifth metatarsal angle, and the naviculocuboid overlap presented a more pathologic value when a C sign was present. The κ-value for the presence of a C sign was 0.663. CONCLUSIONS: The so-called true C sign (complete or interrupted type A) indicates the presence of a TCC and it is not related to flatfoot deformity. However, it is only present in 41% of the cases. The interrupted C sign is much more likely to be related to flatfoot deformity than to the presence of a TCC, specifically when a type C is found. LEVEL OF EVIDENCE: Diagnostic Study level I.

The use of a portable CT scanner for the intraoperative assessment of talocalcaneal coalition resections.

BACKGROUND: Intraoperative assessment of talocalcaneal (TC) coalition resection can be challenging, with no reliable plain radiographic view available for evaluation. Therefore, in March of 2011, we began using a CereTom portable CT scanner to assess TC coalition resections intraoperatively. This study evaluates the use of intraoperative CT during surgical resection of TC coalitions. METHODS: Patients who received CT scans before and after TC coalition resection, by a single surgeon, were included. Those treated without (control group, n=12 feet) and with (intraoperative CT group, n=14 feet) intraoperative CT scan were retrospectively compared. Two blinded pediatric orthopaedic surgeons assessed the quality of resection using a side-by-side comparison of preoperative and postoperative CT scans. Each resection was rated as "excellent," "fair," or "poor," and medical records were reviewed to evaluate clinical outcome. RESULTS: Substantial agreement was found between blinded reviewers (κ=0.71, 81% absolute agreement). Quality of resection was improved in the intraoperative CT group, with 57% of patients receiving an excellent rating compared with 25% in the control group. Patients in the intraoperative CT group were 4.0 times more likely to have a complete resection as compared with patients in the control group; however, this was not statistically significant (odds ratio, P>0.05; 95% confidence interval, 0.74-21.5). Intraoperative CT altered surgical decision making in 3 feet (21%) in the intraoperative CT group, leading to further resection and a subsequent excellent postoperative rating in 2 of these patients. There was 1 reoperation in the control group for continued pain and residual coalition identified on postoperative CT scan. In the intraoperative CT group there have been no reoperations for recurrent or residual qcoalition. CONCLUSIONS: This study illustrates that intraoperative CT can alter surgical decision making and may improve the ability to obtain a complete resection in TC coalition surgery. In these technically challenging cases, intraoperative scans give immediate imaging feedback to surgeons, allowing intervention if residual resection is identified. If intraoperative CT scan is available, it should be considered for surgical treatment of TC coalition resections. LEVEL OF EVIDENCE: Level III retrospective case-control study.

Salter-Harris II fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure?

INTRODUCTION: Premature physeal closure (PPC) is a common complication resulting from the management of a displaced Salter-Harris II (SH II) fracture of the distal tibia. The purpose of this study was to evaluate our institution's treatment approach to assess PPC and complication rates of fractures treated both surgically and nonsurgically. METHODS: We performed a retrospective review of all patients presenting with a displaced SH II fracture between 2004 and 2010. Initial treatment was closed reduction in the emergency department. Further treatment and subsequent categorization was based on amount of residual displacement. Patients with <2 mm of postreduction displacement were treated with a non-weight-bearing long-leg cast (LLC; group 1), patients with residual displacement between 2 and 4 mm were treated with one of 2 approaches based on surgeon preference: either LLC (group 2) or open reduction and internal fixation (ORIF) with removal of any interposed tissue (group 3). Patients with >4 mm of residual displacement were treated with ORIF (group 4). Follow-up radiographs were performed for a minimum of 6 months. If there was clinical concern about PPC, computed tomography imaging was performed to assess for a bony bar. RESULTS: In total, 96 patients with a mean age of 12.6 years at presentation were included in the study. Among the 14 patients with <2 mm of postreduction displacement, 29% had a PPC and 7% had to undergo a subsequent procedure (epiphsyiodesis, osteotomy, etc.). Of the 33 patients with 2 to 4 mm of displacement who were treated with a LLC, 33% had a PPC and 15% had to undergo a subsequent procedure. Of the 11 patients with 2 to 4 mm of displacement treated with ORIF 46% had a PPC and 18% had a second procedure. Finally, 38 patients with >4 mm of displacement treated with ORIF had a PPC rate of 55% and 23% had a subsequent procedure. No statistical differences in PPC (P=0.19) or subsequent surgeries (P=0.57) were observed between groups. Among those with 2 to 4 mm of postreduction displacement, patient age (P=0.36), sex (P=0.39), mechanism of injury (P=0.13), time to fracture management (P=0.51), amount of initial displacement (P=0.34), number of reduction attempts (P=0.43), and operative treatment (P=0.47) did not significantly influence PPC. CONCLUSIONS: Patients with displaced SH II distal tibia fractures pose a challenging problem for the treating physician with a high rate of PPC (43% overall). Although surgical fixation with anatomic reduction and removal of interposed tissue may be necessary to improve joint alignment, it does not reduce the incidence of PPC and may increase the need for subsequent surgeries.

Pathomechanics of Gowers' sign: a video analysis of a spectrum of Gowers' maneuvers.

BACKGROUND: Gowers' sign is a screening test for muscle weakness, typically seen in Duchenne muscular dystrophy but also seen in numerous other conditions. The mildest presentations and the variations of Gowers' sign are poorly described in the literature but are important to recognize to help with early diagnosis of a neuromuscular problem. QUESTIONS/PURPOSES: We therefore (1) defined the characteristics of the mildest forms and the compensatory mechanism used, (2) categorized the spectrum of this sign as seen in various neuromuscular diseases, and (3) provide educational videos for clinicians. METHODS: We videotaped 33 patients with Gowers' sign and three healthy children. Weakness was categorized as: mild = prolonged or rise using single-hand action; moderate = forming prone crawl position and using one or two hands on thigh; severe = more than two thigh maneuvers, rising with additional aid, or unable to rise. RESULTS: The earliest changes were exaggerated torso flexion, wide base, and equinus posturing, which reduce hip extension moment, keep forces anterior to the knee, and improve balance. Patients with moderate weakness have wide hip abduction, shifts in pelvic tilt, and lordosis, which reduce knee extension moment, improve hamstrings moment arm, and aide truncal extension. The classic Gowers' sign (severe) exaggerates all mechanisms. CONCLUSIONS: The classically described Gowers' sign is usually a late finding. However more subtle forms of Gowers' sign including mild hand pressure against the thigh and prone crawl position should be recognized by clinicians to initiate additional diagnostic tests.

Treatment of talocalcaneal coalitions.

BACKGROUND: The purpose of this study was to review outcomes of patients treated for symptomatic talocalcaneal coalition with resection and interposition of fat graft. METHODS: A retrospective review was performed on all patients who underwent surgical treatment for symptomatic talocalcaneal coalition over a 13-year period. Ninety-three feet were treated with excision and fat graft interposition by 6 surgeons. All patients underwent a chart review. Patient's outcome was assessed at the last follow-up using the American Orthopaedic Foot and Ankle Society Hindfoot scale. Postoperative computed tomography scans were available for 20 feet. RESULTS: Forty-nine feet had follow-up of at least 12 months and had a score obtained through the American Orthopaedic Foot and Ankle Society Hindfoot scale. At an average of 42.6 months of follow-up, the average score obtained was 90/100 (excellent). The postoperative computed tomography scans demonstrated 1 recurrence (3%), which was treated with repeat excision. An additional patient was reoperated for failure to excise the coalition completely. Eleven patients (34%) underwent a subsequent surgery to correct the alignment of the foot. To the best of our knowledge, none of the patients excluded because of short follow-up had repeat surgery or recurrence. CONCLUSIONS: A symptomatic talocalcaneal coalition can be treated with excision and fat graft interposition, and achieve good to excellent results in 85% of patients. Patients should be counseled that a subset may require further surgery to correct malalignment. LEVEL OF EVIDENCE: Level IV-case series.

Physeal fractures of the distal tibia and fibula (Salter-Harris Type I, II, III, and IV fractures).

Physeal fractures of the distal tibia and fibula are common and can be seen at any age, although most are seen in the adolescent. An understanding of the unique anatomy of the skeletally immature ankle in relation to the mechanism of injury will help one understand the injury patterns seen in this population. A thorough clinical exam is critical to the diagnosis and treatment of these injuries and the avoidance of potentially catastrophic complications. Nondisplaced physeal fractures of the distal tibia and fibula can be safely treated nonoperatively. Displaced fractures should undergo a gentle reduction with appropriate anesthesia while multiple reduction attempts should be avoided. Gapping of the physis >3 mm after reduction should raise the suspicion of entrapped periosteum that will increase the risk of premature physeal closure. Open reduction of displaced Salter-Harris type III and IV fractures is critical to maintain joint congruity and minimize the risk of physeal arrest.

Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique.

INTRODUCTION: Treatment of displaced Gartland type 3 supracondylar humerus fractures in children may include closed reduction and percutaneous pinning. The pin configuration may be all-lateral entry or cross-pin. Despite the improved stability possible with cross-pinning, there is an inherent iatrogenic risk to the ulnar nerve of about 6%. As medial fixation may be necessary for certain fracture patterns, this study was conducted to evaluate the risk of ulnar neuropathy using a technique here described and developed to minimize injury to this structure. METHODS: A retrospective review was performed on all children treated for a supracondylar humerus fracture at our institution between 2003 and 2010. All the type 3 displaced fractures were placed into 2 groups: lateral-entry pinning and cross-pinning. The 2 groups were then compared for risk of ulnar nerve injury, and a post hoc power analysis was performed. RESULTS: A total of 381 supracondylar humerus fractures met the inclusion criteria. Our cross-pinning technique was used in 187 (49%) of the children with a mean age of 5.8 years (range, 0.92 to 13.92 y). There were 4 ulnar nerve injuries in the entire cohort and 2 sustained as iatrogenic injuries in the cross-pinning group (1.1%). There was no significant difference between our 2 groups in regard to risk of ulnar nerve injury (P=0.24). There is a statistically significant lower risk of ulnar nerve injury in our cross-pinning technique than previously described techniques (P=0.0028), with a post hoc power analysis of 93%. CONCLUSIONS: Despite the inherent risk for iatrogenic nerve injury with cross-pinning completely displaced supracondylar humerus fractures, there is often a need to use this technique to improve fixation and stability of the fracture. Our method of cross-pinning is safe and reproducible for providing fracture stability with a significant decrease in the risk of iatrogenic ulnar nerve injury (1 in 94) when a medial pin is required. LEVEL OF EVIDENCE: Level III-therapeutic studies.

Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment.

BACKGROUND: Adolescent tibial tubercle fractures are uncommon, complex, high-energy injuries. The use of lateral radiographs in isolation to diagnose and treat these injuries is the standard of practice. However, with a single 2-dimensional (2D) view, there may be a risk that the degree of injury can be underestimated. This study was performed to report on the outcomes of tibial tubercle fractures operatively treated, determine the utility of a single lateral x-ray to accurately document injury severity and pattern, delineate the role of advanced imaging and intraoperative arthroscopy/arthrotomy in injury treatment, and propose a new classification system of tibial tubercle fractures that accounts for the complex 3D nature of proximal tibial physeal closure, and recognizes the importance of intra-articular extension, providing guidance for intervention. METHODS: A retrospective review of operatively treated tibial tubercle fractures at our institution from 2003 to 2010 was performed. Child age, weight, mechanism of injury, Ogden classification (x-ray), advanced imaging results [computed tomography (CT)/magnetic resonance imaging (MRI)] including intra-articular fracture patterns, surgical techniques, intraoperative articular findings, and postoperative complications were collected. In addition, we classified all of our patients into a new classification system (type A--tubercle youth, type B--physeal, type C--intra-articular, type D--tubercle teen) based on a combination of plain radiograph (anteroposterior and lateral), advanced imaging (CT/MRI), and intraoperative arthrotomy/arthroscopy findings. RESULTS: We found 41 tibial tubercle fractures in 40 children (all of whom were male) with a mean age of 15.0 ± 1.1 years, and mean weight of 80.3 ± 23.4 kg. Injuries mostly occurred during jumping activities. At initial presentation, compartment syndrome or vascular compromise was seen in nearly 10% of patients, all of whom had type B--physeal injuries under our new classification system. Fifty percent of injuries were underestimated and/or not appreciated by lateral x-ray alone. In patients with intra-articular involvement, consistent 3D fracture patterns were seen on CT including anterior fragments (sagittal plane), lateral fragments (coronal plane), and anterolateral fragments (axial plane). Our new 4 part classification system was able to classify all fractures: type A (2 patients, mean age, 12.7 ± 0.2 y), type B (13 patients, mean age, 14.8 ± 0.7 y), type C (22 patients, mean age, 15.3 ± 1.1 y), and type D (2 patients, mean age, 15.5 ± 0.1 y). All fractures achieved radiographic union with 2 patients (type A--tubercle youth and type B--physeal) requiring additional procedures due to premature physeal closure. CONCLUSIONS: Tibial tubercle fractures represent high-energy injuries with potentially devastating complications such as compartment syndrome and/or vascular compromise. Intra-articular involvement is often missed with the use of plain x-ray and drastically underestimates injury severity. The use of preoperative CT scan or MRI should be utilized as adjunct to plain lateral radiograph. If intra-articular involvement is recognized preoperatively, arthroscopy or open arthrotomy should be utilized at the time of surgery. Our new classification system is rooted in the development of the proximal tibia, accounts for intra-articular involvement, and provides guidance for treatment. LEVEL OF EVIDENCE: Level III--diagnostic study.

Comparison of the calcaneo-cuboid-cuneiform osteotomies and the calcaneal lengthening osteotomy in the surgical treatment of symptomatic flexible flatfoot.

BACKGROUND: Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot. METHODS: The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated. RESULTS: Average age at the time of surgery was similar (triple C: 11.2 ± 3 y, calcaneal lengthening: 11.6 ± 2.5 y, P = 0.51). Average follow-up was 2.7 ± 2.2 years in the triple C group and 5.3 ± 4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P = 0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3 ± 6.1, calcaneal lengthening: 44.7 ± 7.6, P = 0.52) and the ACFAS objective test (triple C: 28.6 ± 2, calcaneal lengthening: 25.9 ± 7, P = 0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5 ± 11.1, calcaneal lengthening: 7.4 ± 7.3, P = 0.001) and talonavicular coverage (triple C: 28 ± 14.7, calcaneal lengthening: 13.7 ± 12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group. CONCLUSIONS: Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Prevalence of painful peroneal tubercles in the pediatric population.

Pain isolated to the lateral aspect of the heel can be difficult to diagnose, particularly in the growing child. Peroneal tendinopathy or frank tears of the peroneal tendons secondary to an enlarged peroneal tubercle has been implicated as a potential source of pain in adults. Neither the prevalence of enlarged peroneal tubercles in the pediatric population nor the number of symptomatic tubercles in children has been elucidated. We conducted a review of children who presented to our institution with foot and/or ankle pain and who underwent 3-dimensional computed tomography. Initially, a radiographic review was undertaken of all computed tomography scans to determine the prevalence of peroneal tubercles in children. The peroneal tubercles were measured and then classified according to height. The children with tubercles 3 mm or greater in height (adult mean height) underwent a more detailed chart review to evaluate for the incidence of painful tubercles. During the study period, 2,689 children were seen for foot and ankle pain, and 367 underwent a computed tomography scan during their treatment course. Of these 367 patients, 57% had a measurable peroneal tubercle, and 162 (44%) met the criteria for chart review. Only 3 adolescents (1.9%) were found to have clinical symptoms and ultimately underwent surgical excision with successful relief of symptoms. Peroneal tubercle hypertrophy appears to exist in the pediatric population; however, in contrast to adults with associated peroneal tendinopathy and tears, the children in our series had isolated painful tubercles without significant tendinopathy. The clinical examination is important in the diagnosis, and treatment by excision appears to be successful. Although a relatively rare etiology of pain, it is important that treating physicians keep this pathologic process in the differential diagnosis, because conservative management might not reduce the pain in these children.

Navicular excision and cuboid closing wedge for severe cavovarus foot deformities: a salvage procedure.

BACKGROUND: The goals of cavus foot correction are to obtain a plantigrade foot with the heel in slight valgus position and to hopefully preserve joint motion in both the tarsal and metatarsal joints. The apex of many cavus deformities is near Chopart joint. We are reporting on a new technique involving navicular excision and cuboid osteotomy to correct severe stiff cavus feet. METHODS: A retrospective review of patients who underwent navicular excision and a cuboid dorsal closing wedge osteotomy to correct a rigid cavus foot deformity was performed. A total of 11 children and 16 feet were treated during the past 8 years at 2 centers. RESULTS: All feet had navicular excision and a cuboid dorsal closing wedge osteotomy to correct a rigid cavus foot deformity. The etiology of the deformity was as follows: multiply operated congenital clubfoot (5 feet), arthrogryposis (6 feet), and neurological deficits (5 feet). At a mean follow-up of 4.9 years, all had a plantigrade foot. CONCLUSIONS: This salvage procedure offers an alternative method to correct a severe stiff cavus deformity. The procedure is performed at the apex of the deformity and thus maximum correction can be obtained by this "wedge resection." The curved articular surfaces of the cuneiforms articulate with the head of the talus post navicular excision if no fusion is desired. Navicular excision has been used to correct children with vertical talus, but not previously reported as a method to handle severe cavus. It is a salvage procedure that should be considered to address severe rigid cavus. LEVEL OF EVIDENCE: Level IV.