Chondrolysis after slipped capital femoral epiphysis.

Chondrolysis, or acute cartilage necrosis, is a controversial and perplexing complication of slipped capital femoral epiphysis (SCFE) in adolescents. It usually leads to deformity, pain, limping, and limitation of motion in the affected extremity. Although several theories have been proposed, no agreement has been reached as to the etiology or the pathogenesis of chondrolysis. Furthermore, no treatment program has been completely successful, and the general prognosis and natural history of this condition are not clear. An overview of the latest knowledge of the matter is presented.

Subtrochanteric fracture after fixation of slipped capital femoral epiphysis: a complication of unused drill holes.

Subtrochanteric fracture of the femur has been infrequently reported after in situ fixation of slipped capital femoral epiphysis, and this occurred in only 1.4% of our patients over a 10-year period. As this technique is used more frequently, however, the incidence of this complication is likely to rise. All four subtrochanteric fractures occurred through unused drill holes, and avoiding extraneous screw holes seems to be the best way to prevent postoperative subtrochanteric fracture. Once subtrochanteric fracture occurs, immediate open reduction and internal fixation with a compression hip screw device is the recommended treatment.

Prediction of angular deformity and leg-length discrepancy after anterior cruciate ligament reconstruction in skeletally immature patients.

Injuries to the anterior cruciate ligament (ACL) in young children and adolescents are becoming more common as more youngsters participate in organized sports. The dilemma for the orthopaedic surgeon is that untreated ACL ruptures may result in meniscal damage and joint degeneration, whereas surgical treatment may result in physeal arrest, with shortening and angular deformity. To help determine the appropriate timing for ACL repair in skeletally immature patients, graphs have been developed to predict the amount of shortening and angular deformity to expect after repair.

Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: preliminary results and complications.

Thirty-one femoral-shaft fractures in 30 patients were treated with interlocking intramedullary nails. The 19 boys and 11 girls ranged in age from 10 to 15 years (average age 12 + 3 years) at the time of injury. All fractures united, and the average leg-length discrepancy (comparing the injured to the uninjured extremity) was 0.51 cm. Two patients had overgrowth of > 2.5 cm; none had angular or rotational malunions. One patient developed asymptomatic segmental avascular necrosis of the femoral head, which was not seen on radiographs until 15 months after injury. All nails were removed at an average of 14 months after injury; no refracture or femoral neck fracture has since occurred. Intramedullary nailing is a reasonable alternative for the treatment of isolated femoral-shaft fractures in older adolescents and in younger adolescents with multiple trauma.

Childhood survival of atlantooccipital dislocation: underdiagnosis, recognition, treatment, and review of the literature.

Traumatic childhood atlantooccipital dislocation (AOD) may be overlooked, especially in patients with concomitant closed head injury and multiple trauma. We diagnosed and treated 4 children with traumatic AOD seen in less than a 2-year period. We found published descriptions of only 15 other survivors of childhood traumatic AOD in the literature. Clinical histories, radiographic findings, treatment, outcome, and complications in these 15 children as well as our 4 patients were reviewed. The age distribution of childhood AOD survivors (average age 6.8 years) closely resembles that of pediatric multiple trauma patients. Early diagnosis of traumatic AOD hinges on precise interpretation of the lateral cervical radiograph. Longitudinal AOD was seen most often. Usually these children presented with cranial nerve palsies, major motor deficits, and depressed level of consciousness. Most underwent posterior atlantooccipital fusion. Outcome varied from normal neurological function to prolonged ventilator dependency and delayed demise. AOD must be diagnosed early to avoid attributing potentially reversible neurologic changes to irreversible injuries since closed head injury and high spinal cord dysfunction may be confused clinically and the outcome of a patient with AOD is unpredictable.

Comparison of two instrumentation techniques in treatment of lumbar kyphosis in myelodysplasia.

Thirty-three patients with myelodysplasia had kyphectomies for correction of spinal deformities. Harrington compression instrumentation was used for fixation in 21 patients, with postoperative immobilization in a spinal orthosis for 6 months. Twelve patients had Luque rod instrumentation, with fixation through the first sacral foramina with a modification of the Dunn technique and with no postoperative immobilization. Kyphosis recurred in eight patients with Harrington rod instrumentation and in none of those with Luque rod instrumentation. Nine patients with Harrington compression rods required 15 procedures for instrumentation problems. Only five of the 21 patients with Harrington compression rods had no significant complications, although ultimately 20 of 21 patients had solid fusions without further progression of the kyphosis. All 12 patients with Luque rods had solid fusions with no recurrences of the kyphotic deformity. One patient required operation for instrumentation problems.

Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis.

A retrospective review of 264 patients treated for slipped capital femoral epiphysis (SCFE) identified 36 who developed avascular necrosis (AVN). Twenty-two patients (24 hips) were evaluated at an average follow-up of 31 years. Nine have undergone reconstructive surgery: four during adolescence and five during adulthood. The remaining 13 patients (15 hips) have had no further operations, but all show degenerative changes on current roentgenograms. The natural history appears to be that of gradual degenerative changes for which reconstructive surgery most often can be delayed until adulthood.

A fluoroscopic technique for determining the incision site for percutaneous fixation of slipped capital femoral epiphysis.

A fluoroscopic technique, and its geometric basis, used to determine the incision site for percutaneous fixation of slipped capital femoral epiphysis (SCFE), is described.