The role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and epiphyseal growth arrest in the surgical treatment of distal tibial epiphysiolysis.

BACKGROUND: Distal tibial epiphyseal fractures damage to epiphyseal growth plate. Epiphyseal growth arrest (EGA), reflex sympathetic dystrophy and ankle joint stiffness may also occur after distal tibial epiphyseal injury. This study aims to evaluate the role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and EGA in the surgically treated distal tibial epiphyseal fractures. METHODS: Twenty seven patients who underwent surgery for distal tibial epiphyseal fracture between the 2011 and 2017 were evaluated retrospectively. The effects of trauma mechanism, fixation technique, preoperative duration, fracture patterns on the clinical results and EGA were examined. AOFAS (The American Orthopedic Foot and Ankle Score) and MOXFQ (The Manchester-Oxford Foot Questionaire) were used for clinical evaluation. RESULTS: Twenty seven patients (17 male and 10 female) were included in this study. The most important complication of epiphyseal injury was the growth pause in eight patients. No statistically significant difference was observed concerning clinical scores and complications according to trauma mechanism, fixation techniques and fracture patterns (p>0.05). CONCLUSION: Regardless of the trauma mechanism, fracture pattern and the fixation material, an anatomical reduction should be obtained in distal tibial epiphyseal fractures to reduce complications and prevent the EGA.

Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report.

CASE: We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation. CONCLUSION: Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

[Osteonecrosis of the femoral head complicating prophylactic screw fixation for upper femoral epiphyolysis: case report and literature review]. / Ostéonécrose de la tête fémorale compliquant un vissage préventif d'une épiphysiolyse fémorale supérieure: cas clinique et revue de la littérature.

The therapeutic approach for the treatment of children with radiologically "normal" hip presenting with epiphysiolysis of the contralateral upper femur is controversial. We here report the case of a 12-year-old boy with osteonecrosis of radiologically "normal" and asymptomatic left femoral head prophylactically fixed due to acute femoral epiphysiolysis of the contralateral hip. Eight months after first surgery, the patient developed symptoms of avascular osteonecrosis of the femoral head. Specific criteria to be used in evaluating the most effective treatment between preventive screw or simple close monitoring exist. Despite these criteria, the risk of osteonecrosis in the "healthy" hip is not zero.

The unstable slipped capital femoral epiphysis: does the rate of osteonecrosis really depend on the timing of surgery and surgical technique?

The aim of this study was to investigate whether the timing of surgery and surgical technique affect the rate of osteonecrosis in unstable slipped capital femoral epiphysis (SCFE). This is a retrospective review of all unstable slips that were treated at our institution over 8.5 years with a minimum follow-up period of 12 months. Patients with stable slips were excluded from this analysis. Demographic data, time to surgery, and surgical technique were analyzed. Twenty-three unstable slips were included for study after excluding 40 stable slips. There were 17 males and six females, with an average age of 11.9 years; 13 patients had right SCFEs. The average time from diagnosis to surgery was 57.7 h. Nine (39.1%) surgeries were performed within 24 h of admission, whereas 14 (60.9%) surgeries were performed after 24 h. Minimum follow-up was 23 months. Two patients developed osteonecrosis: one underwent surgery within 24 h of admission and the other after 24 h. Both underwent in-situ screw fixation. In the group that did not develop osteonecrosis, 76.2% underwent in-situ screw fixation and 23.8% underwent manipulative reduction. The rate of developing osteonecrosis following screw fixation in unstable SCFE was unrelated to whether surgery was performed before or after 24 h of admission (P = 1.0), or whether in-situ screw fixation or manipulative reduction pre-fixation was performed (P = 0.605). The results of this small series challenge the practice of stabilizing unstable SCFEs emergently and the belief that gentle manipulative reduction pre-fixation is not recommended because it may increase the rate of osteonecrosis. Level of Evidence: Level IV Evidence.

Caso Clínico: Luxación Controlada de Cadera. Epifisiólisis de Cabeza Femoral / Case Report: Controlled Hip Dislocation. Slipped Capital Femoral Epiphysis

INTRODUCCIÓN: La epifisiólisis de la cabeza femoral es el desplazamiento de la epífisis con respecto a la metáfisis, en dirección anterosuperior; su etiología es desconocida, frecuente en adolescentes, periodo peripuberal, y con índice de masa corporal elevado, edad promedio entre 12 y 18 años. Su incidencia es variable, 0.2 (Japón) a 10 (Estados Unidos) por 100 000 habitantes. Se caracteriza por dolor progresivo en cadera, con irradiación a la ingle o rodilla, se asocia a cojera; con la detección precoz se puede instaurar un tratamiento adecuado, el más aceptado es la fijación in situ con tornillos centrales. CASO CLÍNICO: Paciente de sexo femenino 14 años de edad sin antecedentes patológicos, acudió al servicio de ortopedia infantil por presentar dolor lancinante crónico de cadera derecha de nueve meses de evolución que aumenta con la deambulación, diagnosticada por clínica y exámenes complementarios de imagen de epifisiólisis de cabeza femoral. Se realizó luxación quirúrgica de la cadera y reducción abierta anatómica con colocación de tornillos esponjosos. EVOLUCIÓN: Al tercer día de la cirugía, se decide alta hospitalaria; deambulación con muletas y sin apoyo durante un mes posquirúrgico. La osteosíntesis permaneció durante un año con controles mensuales y fisioterapia correspondiente; se ha evidenciado evolución favorable; arcos de movilidad de cadera conservados, deambulación normal, sin complicaciones. CONCLUSIÓN: El tratamiento inicial de un paciente con epifisiólisis de cabeza femoral estable depende del tiempo de evolución y se realiza fijando con tornillos o agujas mediante la luxación anatómica de la cadera y osteoplastia de remodelación del cuello femoral. La mayoría de los pacientes no desarrollan necrosis ni condrolisis y los resultados a largo plazo con la fijación in situ suelen ser excelentes, a diferencia de los pacientes con diagnóstico tardío.

BACKGROUND: The epiphysiolysis of the femoral head is the displacement of the epiphysis with respect to the metaphysis, in anterosuperior direction; it is etiology is unknown, frequent in adolescents, peripubertal period, and with high body mass index, average age between 12 and 18 years. It is incidence is variable, 0.2 (Japan) to 10 (United States) per 100 000 inhabitants. It is characterized by progressive pain in the hip, with irradiation to the groin or knee, is associated with lameness; with the early detection, an adequate treatment can be established, the most accepted one is the in situ fixation with central screws. CASE REPORT: A 14-year-old female patient with no pathological history attended the Children's Orthopedic Service due to the chronic lancinating pain of the right hip, which increases with walking, it is diagnosed by clinical examination and complementary exams of femoral head epiphysiolysis. Surgical dislocation of the hip and anatomical open reduction with placement of spongy screws was performed. EVOLUTION: On the third day of surgery, hospital discharge is decided; walking with crutches and without support during a postoperative month. The osteosynthesis remained for a year with monthly controls and corresponding physiotherapy; it has been evidenced favorable evolution; hip mobility arches preserved, normal ambulation, without complications CONCLUSIONS: The initial treatment of a patient with epiphysiolysis of stable femoral head depends on the evolution time and is done by fixing with screws or needles with of anatomical dislocation of the hip and osteoplasty of femoral neck remodeling. Most patients do not develop necrosis or chondro- lysis and long-term results with in situ fixation are usually excellent, unlike patients with late diagnosis.

Clinical and Radiographic Outcomes at 25-30 Years of a Hip Stem Fully Coated With Hydroxylapatite.

BACKGROUND: Little is known about the survival of total hip arthroplasty implants with bioactive coatings beyond the first 20 years. The authors aimed to report survival of a tapered hip stem fully coated with hydroxylapatite (HA) at follow-up of 25-30 years. METHODS: Of the original series of 320 patients (347 hips), 12 patients (12 hips) had stem and cup revisions, 54 patients (55 hips) had cup revisions, 17 patients (17 hips) had liner exchange. A total of 207 patients (225 hips) died with stems in place and 21 patients (24 hips) could not be reached. This left a cohort of 80 patients (86 hips) with their original stem for assessment. Survival was analyzed using the Kaplan-Meier (KM) method and cumulative incidence function (CIF). RESULTS: Considering stem revision as endpoint, the revision risk calculated using the KM method was 6.3%, whereas using the CIF it was 3.7%. Considering any reoperation as endpoint, the revision risk calculated using the KM method was 41.2%, whereas using the CIF it was 25.9%. The Harris Hip Score for 77 patients (18 hips) was 81.6 ± 15.2. Standard x-rays were available for 52 hips (49 patients), and 10 (19.2%) showed radiolucencies <2 mm thick. CONCLUSION: This study is the first to report outcomes of an HA-coated stem beyond 25 years. The survival of stem compares favorably with long-term survival of the Charnley cemented stem, and with shorter-term registry studies. The stem achieved its intended purpose of total osteointegration in the long-term, although the proximolateral region remains susceptible to radiolucencies.

Slipped Capital Femoral Epiphysis: Diagnosis and Management.

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents, occurring in 10.8 per 100,000 children. SCFE usually occurs in those eight to 15 years of age and is one of the most commonly missed diagnoses in children. SCFE is classified as stable or unstable based on the stability of the physis. It is associated with obesity, growth spurts, and (occasionally) endocrine abnormalities such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients with SCFE usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which should include anteroposterior and frog-leg views in patients with stable SCFE, and anteroposterior and cross-table lateral views in unstable SCFE. The goals of treatment are to prevent slip progression and avoid complications such as avascular necrosis, chondrolysis, and femoroacetabular impingement. Stable SCFE is usually treated using in situ screw fixation. Treatment of unstable SCFE also usually involves in situ fixation, but there is controversy about timing of surgery and the value of reduction. Postoperative rehabilitation of patients with SCFE may follow a five-phase protocol.

[Fractures of the upper limbs in childhood and adolescence]. / Frakturen der oberen Extremität im Kindes-/Wachstumsalter.

Fractures of the upper limbs are frequent and often need operative treatment in addition to a well-indicated conservative management. This depends on the maturity of the nearest growth plate and the local remodeling potential, which is dependent on age. Following conventional x­ray imaging an individual prognostic growth analysis leads to the therapeutic decision. Around the elbow and the shaft of the forearm, criteria are stricter than near the shoulder or wrist. Gilchrist or Desault bandages as well as braces are adequate for most subcapital and humeral shaft fractures. The short forearm cast is the method of choice at the wrist. In the case of osteosynthesis the elastic stable intramedullary nailing (ESIN) method is the first choice for subcapital humerus, radial neck and shaft fractures. Screw fixation is usually carried out for epicondylar and condylar fractures and for supracondylar and wrist fractures K­wires represent the standard procedure.

Coxa vara in postseptic arthritis of the hip in children.

The behavior and treatment of coxa vara and pseudarthrosis of the proximal femur secondary to sepsis is not well described. The aim of this study is to describe the pathoanatomy for coxa vara and pseudarthrosis in postseptic hips, evaluate progression of neck shaft angle (NSA), and discuss treatment. This is a retrospective case series of 20 patients (21 hips). There were 11 hips with predominant avascular necrosis of the capital femoral epiphysis without pseudarthrosis (type 1) and 10 with pseudarthrosis (type 2). The interobserver κ value was 0.79. There was a decrease in NSA from 110.3° to 99.3° during an average follow-up duration of 5.2 years (range: 2-14 years). The average change in NSA between the initial presentation and the final follow-up was 5.5° in type 1 and 17.1° in type 2. Nine patients underwent a surgical intervention. In cases where subtrochanteric valgus osteotomy was performed, the mean preoperative NSA was 94° and the mean NSA at the final follow-up was 128°; all operated pseudarthroses healed without bone grafting. Acetabuloplasty is not necessary in most cases.

[Slipped capital femoral epiphysis]. / Épiphysiolyse fémorale supérieure.

Slipped capital femoral epiphysis (SFCE) is a disorder of the hip, characterized by a displacement of the capital femoral epiphysis from the metaphysic through the femoral growth plate. The epiphysis slips posteriorly and inferiorly. SCFE occurs during puberty and metabolic and epidemiologic risk factors, such as obesity are frequently found. Most chronic slips are diagnosed late. Sagittal hip X-rays show epiphysis slip. In case of untreated SCFE, a slip progression arises with an acute slip risk. Treatment is indicated to prevent slip worsening. The clinical and radiological classification is useful to guide treatment and it is predictive of the prognosis. In situ fixation of stable and moderately displaced SCFE with cannulated screws gives excellent results. Major complications are chondrolysis and osteonecrosis and the major sequelae are femoroacetabular impingement and early arthritis.

Electrocautery technique for proximal tibial epiphysiodesis in Labrador retriever puppies: experimental study / Técnica de eletrocauterização para epifisiodese proximal da tíbia em cães filhotes da raça Labrador Retriever: estudo experimental

There are few studies about the treatment options for cranial cruciate ligament rupture in growing dogs, especially with epiphysiodesis techniques. The aim of this study was to evaluate the electrocautery technique for proximal tibial epiphysiodesis in Labrador retriever puppies. The novel electrocautery technique was compared with the screw technique regarding the efficacy for tibial plateau leveling in growing dogs. Six healthy Labrador retriever puppies were divided into two groups. The screw technique was used in one group and the electrocautery technique was used in the other group. Both proximal tibial epiphysiodesis techniques for tibial plateau leveling were effective in achieving reduced tibial plateau angle and did not cause significant joint changes. The screw technique was more invasive and caused slightly greater morbidity than the electrocautery technique. The electrocautery technique seems to be a good alternative for proximal tibial epiphysiodesis in young dogs.(AU)

São descritos poucos estudos sobre as opções de tratamento para a ruptura do ligamento cruzado cranial em cães na fase de crescimento, especialmente em relação às técnicas de epifisiodese. O objetivo deste estudo foi avaliar a técnica de eletrocauterização para epifisiodese proximal da tíbia em cães filhotes da raça Labrador Retriever. A nova técnica de eletrocauterização foi comparada com a do parafuso em relação à eficácia para nivelamento do platô tibial em cães na fase de crescimento. Seis filhotes saudáveis da raça Labrador foram selecionados e divididos aleatoriamente em dois grupos. A técnica do parafuso foi usada em um grupo, enquanto no outro foi usada a da eletrocauterização. Ambas as técnicas de epifisiodese proximal da tíbia para nivelamento do platô tibial foram eficazes na redução do ângulo do platô tibial e não causaram alterações articulares importantes. A técnica do parafuso foi considerada mais invasiva e causou morbidade um pouco mais acentuada do que a da eletrocauterização. Assim, a técnica da eletrocauterização parece ser uma boa alternativa para a epifisiodese proximal da tíbia em cães jovens.(AU)

Outcome of the unaffected contralateral hip in unilateral slipped capital femoral epiphysis: a report comparing prophylactic fixation with observation.

This was a retrospective review of 80 patients with unilateral slipped capital femoral epiphysis treated with either prophylactic fixation or observation. The unaffected hip of 44 patients (mean age 12.6 years) were subjected to simultaneous prophylactic fixation and 36 patients (mean age 13.4 years) were managed by observation. Fisher's exact test showed a significantly high incidence of sequential slip of unaffected hips in the observation group in comparison with prophylactic fixation (P=0.002). No cases had avascular necrosis or chondrolysis. Prophylactic fixation significantly reduces the incidence of sequential slip. It outweighs the minimal surgical risks compared with its benefit in the prevention of further sequential slip.

Is Assessment of Femoral Head Perfusion During Modified Dunn for Unstable Slipped Capital Femoral Epiphysis an Accurate Indicator of Osteonecrosis?

BACKGROUND: The modified Dunn procedure, which is an open subcapital realignment through a surgical dislocation approach, has gained popularity for the treatment of unstable slipped capital femoral epiphysis (SCFE). Intraoperative monitoring of the femoral head perfusion has been recommended as a method of predicting osteonecrosis; however, the accuracy of this assessment has not been well documented. QUESTIONS/PURPOSES: We asked (1) whether intraoperative assessment of femoral head perfusion would help identify hips at risk of developing osteonecrosis; (2) whether one of the four methods of assessment of femoral head perfusion is more accurate (highest area under the curve) at identifying hips at risk of osteonecrosis; and (3) whether specific clinical features would be associated with osteonecrosis occurrence after a modified Dunn procedure for unstable SCFE. METHODS: Between 2007 and 2014, we performed 29 modified Dunn procedures for unstable SCFE (16 boys, 11 girls; median age, 13 years; range, 8-17 years); two were lost to followup before 1 year. During this period, six patients with unstable SCFE were treated by other procedures. All patients undergoing modified Dunn underwent assessment of epiphyseal perfusion by the presence of active bleeding and/or by intracranial pressure (ICP) monitoring. In the initial five patients perfusion was recorded once, either before dissection of the retinacular flap or after fixation by one of the two methods. In the remaining 22 patients (81%), perfusion was systematically assessed before dissection of the retinacular flap and after fixation by both methods. Minimum followup was 1 year (median, 2.5 years; range, 1-8 years) because osteonecrosis typically develops within the first year after surgery. Patients were assessed for osteonecrosis by the presence of femoral head collapse at radiographs obtained every 3 months during the first year after surgery. Seven (26%) of the 27 patients developed osteonecrosis. Measures of diagnostic accuracy including sensitivity, specificity, and the area under the receiver operating curve (AUC) were estimated. Multiple variable logistic regression analyses were used to test whether the test options were better than random chance (AUC > 0.50) at differentiating between patients who did versus did not develop osteonecrosis. Nonparametric methods were used to test for a difference in AUC across the four methods. A secondary analysis was performed to identify risk factors associated with osteonecrosis. RESULTS: After adjusting for body mass index, which was found to be a confounding variable, assessment of femoral head perfusion with ICP monitoring before retinaculum dissection (adjusted AUC: 0.79; 95% confidence interval [CI], 0.58-0.99; p = 0.006), femoral head perfusion with ICP monitoring after definitive fixation (adjusted AUC: 0.82; 95% CI, 0.65-1.0; p < 0.001), bleeding before retinaculum dissection (adjusted AUC: 0.77; 95% CI, 0.58-0.96; p = 0.006), and bleeding after definitive fixation (adjusted AUC: 0.81; 95% CI, 0.63-0.99; p = 0.001) were found to be helpful at identifying osteonecrosis. We were not able to identify a specific test that had performed best because there was no difference (p = 0.8226) in AUC across the four methods. With the numbers available, we were unable to identify clinical factors predictive of osteonecrosis in our cohort. CONCLUSIONS: Assessments of femoral head blood perfusion by ICP monitoring or by the presence of active bleeding in combination with the patient's body mass index are effective at differentiating between patients who do versus do not develop osteonecrosis after a modified Dunn procedure for unstable SCFE. Additional research is needed to determine whether information gained from assessment of femoral head perfusion during surgery should be used to guide targeted treatment recommendations that may reduce the development of femoral head deformity secondary to osteonecrosis. LEVEL OF EVIDENCE: Level III, diagnostic study.

Physeal separation and complete resorption of femoral head associated with chronic osteomyelitis of femoral diaphysis in a young child: rare case report.

We report the case of a two and a half-year-old girl who presented with injury to the right thigh along with a discharging sinus in the midthigh region following a nonorthopaedic surgical procedure. Radiographs of the thigh indicated osteomyelitis of the femoral diaphysis with pathological fracture. During follow-up examination, shortening was observed in the affected limb, along with complete separation of the femoral epiphysis with partial resorption of the femoral head. A few cases of physeal separation of the femoral head following osteomyelitis of the femoral diaphysis have been reported in the published literature, but still it may go undiagnosed until late stages because of the lack of awareness among orthopaedicians about this entity. There was no history of any precipitating trauma to the hip. This case is of interest because of the difficulty in making differential diagnosis at the first evaluation; there was an orthopaedic misdiagnosis on the basis of the lack of complete preoperative imaging. Because of the devastating sequelae on immature skeleton including limb shortening, osteomyelitis, epiphyseal separation of proximal epiphysis and pathological fracture of shaft femur, the importance of early diagnosis, complete preoperative imaging and prompt treatment must be overemphasized.

Traumatic atlantoaxial rotatory dislocation and displaced ossiculum terminale epiphysiolysis treated with a halo device: a case report.

INTRODUCTION: The horizontal synchondroses of the infant axis are biomechanical weak regions in trauma. CASE: We report the case of a 6-year-old girl who presented with delayed atlantoaxial dislocation and displaced ossiculum terminale epiphysiolysis after a fall from a tree. TREATMENT: The patient was treated with halo traction for 3 days after which a CT scan showed normal position of the C1/C2 joint, and an acceptable position of the ossiculum terminale whereafter a halo brace was applied. Because of delayed union on CT scans, the treatment was prolonged to a total of 21 weeks. RESULT: At final follow-up 26 months after halo brace removal, the patient demonstrated normal range of movement of the neck on clinical examination and radiographs of the cervical spine including lateral flexion/extension radiographs showed no sign of instability of the atlantoaxial joint. DISCUSSION: Conservative treatment with a halo device versus surgical treatment is discussed.

Análise do risco do escorregamento epifisário femoral proximal contralateral pelo escore de Oxford modificado / Analysis on the risk of contralateral proximal femoral epiphyseal slippage using the modified Oxford score

Objetivo: Determinar a aplicacão do escore de Oxford modificado em pacientes com escorre gamento epifisário femoral proximal (EEFP) no auxílio da indicacão do tratamento cirúrgico profilático dos quadris contralaterais. Métodos: Análise retrospectiva dos prontuários dos pacientes atendidos na instituicão na qual os autores trabalham. Foram selecionados aqueles com um tempo de seguimento mínimo de dois anos, atendidos de 2008 até 2011, que apresentaram EEPF unilateral. Os cri térios de exclusão foram pacientes com doenca endócrina ou metabólica, síndrome de Down e aqueles com radiografias inadequadas para determinar a pontuacão no escore de Oxford modificado. As radiografias iniciais receberam uma pontuacão que varia de 16 a 26. A aná lise estatística foi usada para determinar se a pontuacão foi preditiva do desenvolvimento futuro de deslizamento contralateral. Resultados: Dos 15 pacientes selecionados com EEFP unilateral, cinco (33,3%) evoluíram para o escorregamento contralateral. Os pacientes foram divididos em dois grupos, qua tro pacientes foram considerados de risco e desses três desenvolveram o escorregamento contralateral. No grupo sem risco havia 11 pacientes, dois evoluíram para o escorregamento contralateral. Nota-se assim uma tendência de que pacientes do grupo que desenvolveu a doenca difiram do grupo que não desenvolveu em relacão à classificacão de risco. Conclusão: Apesar de na nossa amostra a aplicacão do escore de Oxford modificado não ter sido estatisticamente significativa, notamos uma tendência para o escorregamento contra lateral nos quadris com escore baixo.

OBJECTIVE: To determine the application of the modified Oxford score among patients with proximal femoral epiphyseal slippage (PFES) as an aid to indicating prophylactic surgical treatment on the contralateral hip. METHODS: Retrospective analysis on the medical files of patients attended at the institution where the authors work. From these, patients attended between 2008 and 2011 who presented unilateral PFES and were followed up for a minimum of two years were selected. Patients were excluded if they presented endocrine disease, metabolic disease, Down syndrome or radiographs that were inadequate for determining the modified Oxford score. The initial radiographs received scores ranging from 16 to 26. Statistical analysis was used to determine whether the scoring was predictive of future development of contralateral slippage. RESULTS: Among the 15 patients with unilateral PFES that were selected, five (33.3%) evolved with contralateral slippage. The patients were divided into two groups. Four patients were considered to present risk and three of them developed contralateral slippage. In the group that was considered not to present risk, there were 11 patients and two of these evolved with contralateral slippage. Thus, there was a tendency for the patients in the group that developed the disease to differ from the group that did not develop it, in relation to the risk classification. CONCLUSION: Although application of the modified Oxford score was not statistically significant in our sample, we noted a tendency toward contralateral slippage among hips with low scores.

Digital Chondrolysis and Epiphysiolysis Associated With Snakebite: A Report of 2 Cases.

BACKGROUND: Here, we present 2 cases of the unusual sequelae of a venomous bite to the finger in children resulting in chondrolysis and physeal loss. There have been few isolated case reports documenting this phenomenon. Currently, there is no preventative treatment, and patients should be warned of this possible complication of envenomation. METHODS: Two patients with chondrolysis and physeal loss have been seen in our practice. RESULTS: Chondrolysis and epiphysiolysis occurred in 2 patients. One patient was treated with proximal interphalangeal joint fusion and one is being managed conservatively. CONCLUSION: The toxic action of snake venom may cause loss of the growth plate and chondrolysis in the pediatric hand. LEVEL OF EVIDENCE: Level IV.

Myth busters: an AOA symposium: AOA critical issues.

One of the goals of the annual American Orthopaedic Association (AOA) meeting is to address controversy, both in leadership and clinical practice. A panel of experts in their respective fields presented the background and literature behind three "myths" in orthopaedic management and made conclusions as to their validity. First, Dr. Kocher took on the myth of prophylactic pinning on the contralateral "normal" side for a patient with a slipped capital femoral epiphysis. Second, Dr. Probe evaluated the myth that all intertrochanteric fractures are best treated with intramedullary devices. Last, Dr. Foster and Dr. Silvestri tackled the myth that autograft is always the best choice for anterior cruciate ligament (ACL) reconstruction. All three of these topics are subjects of current debate. The panel's careful examination of the available data along with their expertise in the management of these problems is presented in this thought-provoking JBJS Critical Issues article.

A modified Imhäuser osteotomy: an assessment of the addition of an open femoral neck osteoplasty.

The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered.