Acetabular "Fleck" Sign: Outcomes of Surgical Repair.

BACKGROUND: Traumatic, posterior hip dislocations in the pediatric population are typically managed by closed reduction to achieve a concentric hip joint. The presence of an acetabular "fleck" sign, despite concentric reduction, has been shown to signify significant hip pathology. The purpose of this study was to evaluate the outcomes of open labral repair through a surgical hip dislocation (SHD) in a consecutive series of patients with an acetabular "fleck" sign associated with a traumatic hip dislocation/subluxation. METHODS: A retrospective review of patients between 2008 and 2022 who presented to a single, level 1 pediatric trauma center with a traumatic posterior hip dislocation/subluxation was performed. Patients were included if they had an acetabular "fleck" sign on advanced imaging and underwent open labral repair through SHD. Medical records were reviewed for sex, age, laterality, mechanism of injury (MOI), and associated orthopaedic injuries. The modified Harris hip score (mHHS) was utilized as the primary clinical outcomes measure. Patients were assessed for the presence of heterotopic ossification (HO) and complications, including implant issues, infection, avascular necrosis (AVN), and post-traumatic dysplasia. RESULTS: Twenty-nine patients (23 male, average age: 13.0±2.7 y; range: 5.2 to 17.3) were identified. Eighteen injuries were sports related, 9 caused by motor vehicle accidents, and 1 pedestrian struck. All patients were found to have an acetabular "fleck" sign on CT (26 patients) or MRI (5 patients). Associated injuries included: femoral head fracture (n=6), pelvic ring injury (n=3), ipsilateral femur fracture (n=2), and ipsilateral PCL avulsion (n=1). At the latest follow-up (2.2±1.4 y), all patients had returned to preinjury activity/sport. Three patients developed asymptomatic, grade 1 HO in the greater trochanter region. There was no incidence of AVN. One patient developed post-traumatic acetabular dysplasia due to early triradiate closure. mHHS scores showed excellent outcomes (n=21, 94.9±7.4, range: 81 to 100.1). CONCLUSIONS: The acetabular "fleck" sign indicates a consistent pattern of osteochondral avulsion of the posterior/superior labrum. Restoring native hip anatomy and stability is likely to improve outcomes. SHD with open labral repair in these patients produces excellent clinical outcomes, with no reported cases of AVN. LEVEL OF EVIDENCE: Level IV-therapeutic.

Ankle Mortise Instability in Multiple Hereditary Exostoses.

Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.

Outcomes of MPFL Reconstruction Utilizing a Quadriceps Turndown Technique in the Adolescent/Pediatric Population.

PURPOSE: Recurrent instability following a lateral patellar dislocation is a common indication for surgical intervention. Several surgical procedures are described in the literature to address recurrent patellar instability. Medial patellofemoral ligament (MPFL) reconstruction utilizing the quadriceps turndown technique attempts to restore medial stability. Results of the quadriceps turndown technique have previously only been reported in adult populations. The purpose of this study was to assess the safety, efficacy, and patient-reported outcomes following a quadriceps turndown MPFL reconstruction in the pediatric and adolescent population. METHODS: Records of all patients who underwent MPFL reconstruction using a quadriceps turndown technique between 2011 and 2018 were reviewed for demographics, risk factors, complications, mechanism of injury, and concomitant procedures. Return to activities of daily living (ADLs), return to presurgery level of sport, length of bracing, and recurrent instability were assessed with the administration of the Kujala Anterior Knee Pain Score. All analyses were completed using IBM SPSS Statistics 26. RESULTS: Thirty-six knees [14 female (39%), 22 male (61%)] from 34 patients met inclusion/exclusion criteria. The average follow-up length was 35.9±15.2 months. The average age was 16.3±1.8 years at the time of surgery. The average time for resumption of ADLs was 8.1±6.0 weeks after surgery. Ninety-four percent of patients returned to preinjury level of sport at an average of 23.6±12.0 weeks after surgery. Mean Kujala Anterior Knee Pain Score was 90.7±10.3. Female patients (P<0.001) reported significantly lower Kujala scores. Three patients (8%) experienced recurrent instability during ADLs and an additional 4 (11%) reported subjective feelings of instability only during sport or elevated activity. One knee required a return to the operating room for irrigation and debridement due to infection. CONCLUSION: This study demonstrates that the quadriceps turndown technique for MPFL reconstruction is a safe and effective procedure for the management of recurrent patellar instability in pediatric and adolescent patients. LEVEL OF EVIDENCE: Level III-therapeutic.

Four-in-one Extensor Realignment for the Treatment of Obligatory or Fixed, Lateral Patellar Instability in Skeletally Immature Knee.

BACKGROUND: Congenital (fixed) and obligatory (habitual) patellar dislocations in children are a complex clinical and surgical challenge. Numerous individual surgical techniques have been described. This study aims to assess results, patient satisfaction, and complications after a combined Roux-Goldthwait procedure, vastus medialis obliquus advancement, Galeazzi procedure, and extensive, lateral release (4-in-1 extensor realignment) in the skeletally immature knee with obligatory, or fixed lateral patellar instability. METHODS: Records of children with congenital fixed or obligatory patellar instability, who underwent the 4-in-1 procedure at a single institution, were reviewed. Clinical results included ability and time for the return to activities of daily living (ADL) and sport, recurrent instability and/or dislocation, and necessity of long-term bracing. Continued pain was assessed by the Kujala Score. Complications including infection, recurrent instability, and the necessity for secondary procedures were recorded. RESULTS: A total of 34 patients (46 knees) mean age 10.3±2.4 years, underwent the 4-in-1 procedure with a mean postoperative follow-up of 51.6±31.5 (range, 12 to 146) months. Sixteen patients (22 knees) responded to a phone interview and questionnaire. All 16 patients returned to ADL in a mean time of 10.3±2.4 weeks. Ninety-one percent returned to sport in a mean time of 23.1±15.5 weeks. Long-term bracing was required for 6 knees after the surgery. The mean Kujala Score was 93.0±5.2 (range, 83 to 100). Complications included 6 of 34 patients (18%) with recurrent instability at the latest follow-up and 2 with superficial wound infection. CONCLUSIONS: Patients with obligatory or fixed lateral, patellar instability who undergo the 4-in-1 procedure have good short-term results with low complication rates. Return to ADL and sporting activity with minimal pain can be expected, usually without the need for long-term bracing. The 4-in-1 procedure is a viable option for skeletally immature patients with obligatory or fixed, lateral patellar instability. LEVEL OF EVIDENCE: Level IV-Therapeutic study.

Treatment of Unstable Versus Stable Slipped Capital Femoral Epiphysis Using the Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure (open subcapital realignment via a surgical dislocation approach) has been shown to be a safe and effective way of treating acute, unstable slipped capital femoral epiphysis (SCFE). There is a paucity of literature comparing the modified Dunn procedure in stable SCFE. The purpose of this study was to compare acute, unstable versus chronic, stable SCFE managed with the modified Dunn procedure. METHODS: A retrospective chart review was performed on 44 skeletally immature patients who underwent the modified Dunn procedure for SCFE. Patients were divided into stable or unstable based on clinical presentation and intraoperative findings. Demographics, radiographic measurements, and complications were recorded and compared. χ and t tests were used to compare variables. RESULTS: In total, 31 consecutive hips (29 patients) with acute, unstable slips, and 17 consecutive hips (15 patients) with chronic, stable slips were reviewed. Average age was 12.5 and 13.8 years for acute and chronic, respectively (P=0.05). Mean follow-up was 27.9 months (unstable) and 35.5 months (stable). Average postoperative Southwick angle was 14.2 degrees; (unstable) and 25.3 degrees (stable) (P=0.001). Greater trochanteric height averaged 6.2 mm below the center of the femoral head in the acute group and 6.2 mm above center in the chronic group (P<0.001). Average femoral neck length measured 34.1 mm (unstable) and 27.1 mm (stable) (P<0.001). Two patients (6%) developed avascular necrosis (AVN) in the unstable group, with 5 patients (29.4%) in the stable group (P=0.027). All patients with hip instability (N=3) developed AVN. CONCLUSIONS: Although both acute, unstable and chronic, stable SCFE can be successfully treated with the modified Dunn procedure, the complication rate is statistically higher in patients with stable SCFE, specifically both AVN rate and postoperative instability. In addition, it is more difficult to establish normal anatomic indexes with regard to greater trochanteric height and femoral neck length. This procedure has great utility in the correction of the anatomic deformity associated with SCFE, but should be used with caution in patients with chronic, stable SCFE. LEVEL OF EVIDENCE: Level III-retrospective review.

Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure has been shown to be safe and effective in treating unstable slipped capital femoral epiphysis (SCFE). We present a consecutive series of unstable SCFE managed by a single surgeon with a focus on timing of surgical intervention, postoperative complications, and radiographic results. METHODS: Thirty-one consecutive unstable SCFEs were treated. Demographics, presentation time to time of operation, surgical times, and complications were recorded. Bilateral hip radiographs at latest follow-up were utilized to record slip angle, α angle, greater trochanteric height, and femoral neck length. RESULTS: Thirty-one consecutive hips in 30 patients were reviewed: 15 males (50%) and 15 females (50%), average age 12.37 years (range, 8.75 to 14.8 y), 20 left hips (65%) and 11 right hips (35%). Mean follow-up was 27.9 months (range, 1 to 82 mo). Time from presentation to intervention averaged 13.9 hours (range, 2.17 to 23.4 h). Two patients (6%) developed avascular necrosis at average 19 weeks postoperative. Three patients (10%) developed mild heterotopic ossification requiring no treatment. Two patients (6%) required removal of symptomatic hardware. One patient had hardware failure and in no patients was nonunion, delayed union, or postoperative hip subluxation/dislocation seen. Three patients (10%) presented with bilateral, stable SCFE requiring contralateral in situ pinning. Five patients (16%) had sequential SCFE requiring treatment with 1 patient having an acute, unstable SCFE 10 months after the previous realignment. Mean postoperative slip angle measured 2.5 degrees (range, +19 to -9.4 degrees) (SD, 7.2), α angle 47.43 degrees (range, 34 to 64 degrees) (SD, 7.49), greater trochanteric height averaged 3.5 mm below the center of femoral head (-17.5 to +25 mm), and mean femoral neck length difference measured -7.75 mm (range, -1.8 to -18.6 mm). CONCLUSIONS: A single surgeon series of unstable SCFEs treated by a modified Dunn procedure showed a 6% incidence of avascular necrosis and low complication rates at latest follow-up. Radiographs showed restoration of the slip angle, α angle, femoral neck length, and greater trochanteric height. This series reveals the safety and effectiveness of the modified Dunn procedure for unstable SCFE. LEVEL OF EVIDENCE: Level III-retrospective review.

A Quality Improvement Initiative Reduces Cast Complications in a Pediatric Hospital.

BACKGROUND: Casts, while frequently used as routine treatment in pediatric orthopaedic practice, are not without complications. At our large tertiary care pediatric hospital, the baseline rate of all casting complications was 5.6 complications per 1000 casts applied (0.56%). We tested the hypothesis that we could use quality improvement (QI) methodology to decrease the overall cast complication rate and improve patient care. METHODS: We initiated a QI program implementing concepts derived from the Institute for Healthcare Improvement models, including Plan-Do-Study-Act cycles, to decrease our cast complication rate. A resident casting education program was developed with a competency "checklist" to ensure that casts are applied, bivalved, and removed in a safe and standardized manner to prevent patient harm. AquaCast Saw Stop Protective Strips were required to be applied with every cast application. A review of our facility's processes and procedures determined adequate measures were in place to effectively manage inventory and maintenance of cast-saw blades. RESULTS: With the multimodal QI intervention, our cast complication rate was reduced to 1.61 complications per 1000 applications, a >90% improvement. CONCLUSIONS: Implementation of QI concepts to perform a QI initiative resulted in a shift toward fewer cast complications, leading to overall improved patient care at a large tertiary pediatric hospital. LEVEL OF EVIDENCE: Level II-prospective cohort study.

Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis.

BACKGROUND: The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE. METHODS: Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis. RESULTS: A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup. CONCLUSIONS: Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Standardization of patellofemoral morphology in the pediatric knee.

BACKGROUND: Our understanding of osseous morphology and pathology of the patellofemoral joint continues to improve with the use of magnetic resonance imaging (MRI), but a paucity of data currently exists in the pediatric population. OBJECTIVE: We aim to formulate a reproducible means of quantitative assessment of patellofemoral morphology in children using MRI and to describe morphological changes based on sex and age. MATERIALS AND METHODS: We identified 414 children presenting between 2002 and 2014 who obtained a knee MRI to evaluate for knee pain or clinically suspected knee pathology. After application of inclusion criteria, 144 "normal" MRIs in 131 children (71 boys, 60 girls) were included in the analysis. The following MRI measurements were recorded: lateral trochlear inclination, trochlear facet asymmetry, trochlear depth, tibial tuberosity-trochlear groove distance, sulcus angle and patellar height ratio. To assess intraobserver reliability, measurements in 30 randomly selected children were repeated. Differences between patient age and sex were assessed using independent t-tests and adjusted regression analysis. RESULTS: All recorded measurements had strong to very strong inter- and intraobserver reliability: lateral trochlear inclination (0.91/0.82), trochlear facet asymmetry (0.81/0.83), trochlear depth (0.83/0.90), tibial tuberosity-trochlear groove distance (0.97/0.87), sulcus angle (0.84/0.78) and patellar height ratio (0.96/0.83). When age and sex were mutually adjusted, statistically significant differences between males and females were observed in trochlear depth (P = 0.0084) and patellar height ratio (P = 0.0035). However, statistically significant age differences were found on all measurements except for lateral trochlear inclination. As expected, mean measurement values approached adult norms throughout skeletal maturation suggestive of age-dependent patellofemoral maturation. CONCLUSION: Our data verify the development of patellofemoral morphology with advancing age. We found that six of the most commonly used patellofemoral measurements in adults can be accurately reproduced regardless of age.

Bridge Plating Length-Unstable Pediatric Femoral Shaft Fractures.

The treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.

Incidence of Hip Dysplasia Associated With Bladder Exstrophy.

BACKGROUND: Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients. METHODS: We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available. RESULTS: In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y). CONCLUSIONS: We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions. LEVEL OF EVIDENCE: Level III-retrospective study.

Traumatic, Posterior Pediatric Hip Dislocations With Associated Posterior Labrum Osteochondral Avulsion: Recognizing the Acetabular "Fleck" Sign.

BACKGROUND: Traumatic dislocation of the hip is uncommon in the pediatric population. Concentric reduction is usually achieved by closed means. Open reduction may be needed if there is femoral head fracture, incarcerated fragment, or incomplete reduction due to soft tissue entrapment. We present a series of 10 patients who sustained a posterior hip dislocation or subluxation with associated osteochondral avulsion of the posterior labrum. During surgery they were noted to have a labral injury pattern not previously recognized. Such treatment was dictated by postreduction advanced imaging, which revealed a consistent acetabular "fleck" sign indicative of this labral injury, which has not been previously described in literature. METHODS: We performed a retrospective case review of patients with traumatic posterior hip dislocation/subluxation, treated operatively for a suspected associated labral tear and fractures. RESULTS: Ten patients (2 girls and 8 boys) were identified. Average age was 12.7 years. Eight patients had postreduction computed tomography scans, which revealed a posterior acetabular wall "fleck" sign, suggestive of osteochondral injury. The small bony fragment was consistently displaced at least 2 to 3 mm in all patients with majority of the posterior wall remaining intact. Closed reduction was felt to be congruent in 7 of the 10 patients. All patients were treated operatively for exploration and stabilization of the suspected posterior labrum pathology and associated injuries using a surgical hip dislocation. A consistent pattern of labral pathology was seen in all patients, with disruption of the posterior labrum from the superior 12 o'clock attachment to detachment at the inferior 6 o'clock location. Reattachment of the osteochondral labral avulsion was performed with suture anchors along the posterior rim, and the associated femoral head fractures were also addressed with internal fixation. Two patients had inadequate follow-up and were excluded, the average follow-up for the remaining 8 patients was 9.8 months (range, 6 to 26 mo). There were no findings of avascular necrosis in any of the 8 patients. CONCLUSIONS: Posterior hip dislocation in children may produce an acetabular "fleck" sign on advanced imaging, which in a stable, concentrically reduced hip has been treated without surgery in the past. Acetabular fleck sign may represent a near-complete avulsion of the posterior labrum as seen in our series. We recommend a high suspicion for this type of labral pathology and surgical repair when acetabular "fleck" sign is identified with hip subluxation or dislocation. Traumatic, posterior hip dislocations in young patients may be associated with significant labral pathology. Acetabular "fleck" sign on advanced imaging may predict such pathology. LEVEL OF EVIDENCE: IV, retrospective study.

Prevalence of Bilateral JOCD of the Knee and Associated Risk Factors.

PURPOSE: Juvenile osteochondritis dissecans (JOCD) of the knee affects cartilage and subchondral bone surface. Multifocal JOCD is described as multiple lesions within the knee or presence of lesions in other joints. The true prevalence of bilaterality of JOCD is unknown. The purpose of this study is to determine the prevalence of bilateral JOCD and to identify potential risk factors for bilateral disease. METHODS: We evaluated 108 consecutive patients presenting for JOCD at a single pediatric hospital system. If an OCD lesion of the knee was found, contralateral knee x-rays were performed. Lesion location was documented according to Cahill and Berg, magnetic resonance imaging (MRI) grading documented according to Dipaola, and if surgical treatment was undertaken, intraoperative grading performed according to Guhl. Patients with unilateral JOCD were compared with those with bilateral disease. Statistical analysis of categorical data was performed utilizing likelihood ratio χ test or Fisher exact test and continuous data compared using nonparametric Wilcoxon 2-sample test. RESULTS: There were 85 male (79%) and 23 females (21%) with an average age of 12.3 years (range, 6 to 18 y). Sixty-three percent of lesions were located on the medial femoral condyle and 33% on the lateral femoral condyle. Ninety percent of all lesions were considered weight-bearing lesions. Eighty percent were considered stable on MRI evaluation. Of those lesions that underwent surgical intervention, 61% were either grade I or II lesions. Seventy-three of 108 patients (68%) underwent some form of surgical intervention. Thirty-one patients (29%) were found to have contralateral JOCD lesions. Thirty-nine percent of contralateral lesions found on contralateral radiographs were asymptomatic at presentation and nearly all of those evaluated with MRI (16 of 18) were stable. Sixty-nine percent of contralateral lesions were located on the medial femoral condyle, 27% on the lateral femoral condyle, and 94% were considered weight-bearing lesions. Twelve of 31 contralateral lesions (39%) underwent surgical intervention. Comparing patients with unilateral and bilateral disease, female patients (P<0.05) and younger age at presentation (P<0.009) were risk factors for bilateral JOCD. No statistical difference among other variables was seen with regard to location, MRI or operative stability of lesion, or presence of symptoms. CONCLUSIONS: In our consecutive series of 108 patients with JOCD, we found a 29% incidence of bilateral disease. Almost 40% of contralateral lesions were asymptomatic upon presentation. Female sex and younger age at presentation were significant risk factors for bilateral disease. Lesion location, stability, and pain were not statistically significant variables. The authors recommend bilateral radiographic knee evaluation for all patients found to have JOCD. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Multifocal juvenile osteochondritis dissecans of the knee: a case series.

BACKGROUND: This retrospective case series reports on a group of patients with multifocal juvenile osteochondritis dissecans (MJOCD) of the knee and discusses demographic data, lesion location, stage, and treatment results. METHODS: Records of patients identified with MJOCD of the knee at a single institution were retrospectively reviewed. Demographic, radiographic, and surgical results were recorded. Lesions were descriptively classified and lesions undergoing surgical treatment were staged. Results of operative and nonoperative treatment were recorded. RESULTS: Fifty-nine lesions were identified in 28 patients who met the inclusion criteria. There were 22 males (78%) and 6 females (21%). Average age was 11.8 years (males, 6 to 17; females, 10 to 14). Thirty-six (61%) lesions were on the medial femoral condyle (MFC), 19 (32%) on the lateral femoral condyle, 2 (3%) on the trochlea, 1 (2%) on the patella, and 1 (2%) on the anteromedial tibial plateau. Forty-four (74%) lesions required operative treatment. Of the 32 stable lesions managed surgically, 25 (78%) achieved healing with operative treatment. All 12 unstable lesions identified were managed surgically with 5 (41%) healed after the initial operation. Lesions located on the MFC had a significantly higher rate of healing (89%) compared with lateral femoral condyle lesions (37%) (P<0.0001). CONCLUSIONS: MJOCD of the knee defines a subset of patients with >1 identified lesion occurring in the same or the contralateral knee. Prevalence of MJOCD of the knee is unknown. A high percentage of these patients require surgical intervention with only one quarter of stable lesions healing with conservative treatment. Healing rates of stable lesions after surgery was nearly twice that of unstable lesions undergoing surgical intervention. Lesions located on the MFC healed at a statistically significant greater rate than other locations within the knee. Sex, age, and associated discoid menisci had no effect on healing prognosis. LEVEL OF EVIDENCE: Level IV-case series.

A retrospective review of femoral nerve block for postoperative analgesia after knee surgery in the pediatric population.

BACKGROUND: To investigate the outcomes of pediatric patients receiving a femoral nerve block (FNB) in addition to general anesthesia for arthroscopic knee surgery compared with those receiving general anesthesia alone. METHODS: This retrospective review included all patients undergoing arthroscopic knee surgery from January 2009 to January 2011 under general anesthesia both with and without a FNB. After the induction of general anesthesia, those patients selected for regional anesthesia received a FNB using real-time ultrasound or nerve stimulator guidance. For the FNB, 0.2 to 0.4 mL/kg of local anesthetic solution was injected around the femoral nerve at the level of the inguinal crease. Intra-articular injection of bupivacaine (0.25%, 10 mL) was administered by the surgeon for all patients not receiving a FNB. Additional analgesic medications, PACU length of stay, duration of hospitalization, hospital course, and any acute or nonacute complications were recorded and evaluated. RESULTS: There were no adverse effects related to the FNB. Using a 0 to 10 visual analogue scale (0=no pain), there was a statistically significant difference in both the high (4.0 ± 4.0 vs. 5.3 ± 3.1, P=0.0004) and low (1.5 ± 1.8 vs. 2.1 ± 2.0, P=0.002) pain scores in patients who received a FNB versus those who did not with the scores being lower in those who had received a FNB. There was a decreased need for the use of opioids postoperatively (61% vs. 71%, P=0.04) and a decreased duration of postoperative stay in patients who were admitted to the hospital (11.7 ± 8.1 vs. 15.8 ± 10 h, P=0.044) in individuals who had a FNB. There was a significantly lower admission rate in patients undergoing anterior cruciate ligament repair in the FNB group (72% vs. 95%, P=0.001). There was no difference in the incidence of postoperative nausea and vomiting between the groups. CONCLUSION: After arthroscopic knee surgery in pediatric patients, a FNB shortens hospital stay, reduces opioid requirements, and decreases postoperative pain scores. For anterior cruciate ligament repairs, FNB lowers postoperative admission rates. CLINICAL EVIDENCE: Level III.

Is there still a place for cast wedging in pediatric forearm fractures?

BACKGROUND: Forearm fractures are common skeletal injuries in childhood and can usually be treated nonoperatively with closed reduction and casting. Trends toward increasing operative treatment of these fractures have emerged. We aim to demonstrate the safety and efficacy of cast wedging for treatment of pediatric forearm fractures. METHODS: We performed a prospective chart review of patients with forearm fractures, including distal radius (DR) fractures, treated with cast wedging at a single large pediatric hospital from June 2011 to September 2012. Inclusion criteria specified open distal radial physis, closed injury, loss of acceptable reduction, and availability of clinical and radiographic data from injury to cast removal. Exclusion criteria included pathologic fractures, neurovascular injury, fracture dislocations, open fractures, and closed DR physis. Reductions were performed and patients followed according to standard protocol at our institution, including placement into long-arm casts, initial follow-up visit within 5 to 10 days postinjury, and weekly visits for 2 weeks thereafter. If alignment were deemed unacceptable within 3 weeks of injury, cast wedging was utilized. Radiographic measurements of alignment included both radius and ulna on the injury film, postreduction, prewedge, postwedge, and final films. Radiographic technique was standardized, with repeatability testing demonstrating a precision of ±2 degrees. RESULTS: Over 15 months, our hospital treated 2124 forearm or DR fractures with closed reduction and casting. There were 60 fractures treated either with percutaneous fixation (36) or open treatment (24). A total of 79 forearm or DR fractures were treated with cast wedging secondary to loss of reduction, of which 70 patients had complete clinical and radiographic data. Average age was 8.4 years (range, 3 to 14 y), with 25 females and 45 males. Significant improvement in angulation for both-bone forearm fracture from prewedge to final films was seen in 69 children, with no major complications. One patient failed wedging and required surgical reduction and fixation. CONCLUSIONS: Cast wedging is a simple, safe, noninvasive, and effective method for treatment of excessive angulation in pediatric forearm fractures. LEVEL OF EVIDENCE: Level IV.

Novel pelvic immobilization method following bladder exstrophy repair.

We introduce a novel method of pelvic immobilization following bladder exstrophy repair involving a custom-made brace that offers adequate pelvic immobilization with the added benefits of no added operative time, easy evaluation of surgical sites, simplified wound care including sponge bathing, and overall less cumbersome management for the family given its more streamlined size.

Septic arthritis of the neonatal hip: acute management and late reconstruction.

Septic arthritis of the hip in neonates is rare but can have devastating consequences. Presenting signs and symptoms may differ from those encountered in older children, which may result in diagnostic challenge or delay. Many risk factors predispose neonates to septic arthritis, including the presence of transphyseal vessels and invasive procedures. Bacterial infection of the joint occurs via hematogenous invasion, extension from an adjacent site, or direct inoculation. A strong correlation exists between younger age at presentation and severity of residual hip deformity. Diagnosis is based on clinical examination, laboratory markers, and ultrasound evaluation. Early management includes parenteral antibiotics and surgical drainage. Late-stage management options include femoral and pelvic osteotomies, trochanteric arthroplasty, arthrodesis, pelvic support procedures, and nonsurgical measures. Early diagnosis and management continues to be the most important prognostic factor for a favorable outcome in the neonate with septic arthritis.

Submuscular bridge plating for length-unstable, pediatric femur fractures.

BACKGROUND: Submuscular bridge plating has become an acceptable method of treatment for pediatric femur fractures. The purpose of our study was to describe a technique for submuscular bridge plating and review a series of consecutive, length-unstable, pediatric femur fractures treated at a single institution with this technique. METHODS: We performed a query of hospital records from January 4, 2006, to May 10, 2011, to identify length-unstable femur fractures treated with submuscular bridge plating by 5 pediatric surgeons. Included were patients treated with submuscular bridge plating for a femur fracture. Excluded were patients with incomplete medical records, inadequate radiographs, or follow-up <6 months duration. Fifty-one patients met diagnostic criteria; 19 patients were excluded due to incomplete medical records and/or radiographs. RESULTS: The study cohort included 32 patients with 33 femur fractures. There were 15 left femurs and 18 right femurs, including 1 bilateral fracture patient. Fracture pattern was composed of 13 comminuted, 5 spiral, 9 long oblique, and 6 short oblique. Mechanisms of injury included: fall from height (8), recreation (23), and MVA (2). Mean time for full weightbearing was 8.1 weeks (range, 3 to 17.6 wk). All patients were radiographically healed by their 12-week assessment. There were no intraoperative complications. Implant removal occurred in 26 patients. There were 2 cases of a broken screw discovered upon implant removal. The remnant screw was not removed in either case. The mean follow-up time for those with implant removal was 43.6 weeks (range, 27 to 83 wk). The 11 patients without implant removal had a mean follow-up time of 38.6 weeks (range, 31.6 to 50 wk). There were no cases of varus or valgus malalignment >10 degrees. One patient experienced implant irritation. There were no cases of wound infections. CONCLUSIONS: Our technique of surgical intervention has simplified both implantation and removal, and produced comparable and excellent healing rates, low complication rates, and early return to full weightbearing. LEVEL OF EVIDENCE: Level IV, case series.

Surgical Hip Dislocation in Pediatric and Adolescent Patients.

LEVEL OF EVIDENCE: V, Expert opinion.