Development of acetabular retroversion in LCPD hips-an observational radiographic study from early stage to healing.

BACKGROUND: Acetabular retroversion is observed frequently in healed Legg-Calvé-Perthes disease (LCPD). Currently, it is unknown at which stage and with what prevalence retroversion occurs because in non-ossified hips, retroversion cannot be measured with standard radiographic parameters. METHODS: In a retrospective, observational study; we examined pelvic radiographs in children with LCPD the time point of occurrence of acetabular retroversion and calculated predictive factors for retroversion. Between 2004 and 2017, we included 55 children with a mean age of 5.7 ± 2.4 years at diagnosis. The mean radiographic follow-up was 7.0 ± 4.4 years. We used two new radiographic parameters which allow assessment of acetabular version in non-ossified hips: the pelvic width index and the ilioischial angle. They are based on the fact that the pelvic morphology differs depending on the acetabular version. These parameters were compared among the four Waldenström stages and to the contralateral side. Logistic regression analysis was performed to determine predictive factors for acetabular retroversion. RESULTS: Both parameters differed significantly among the stages of Waldenström (p < 0.003 und 0.038, respectively). A more retroverted acetabulum was found in stage II and III (prevalence ranging from 54 to 56%) compared to stage I and IV (prevalence ranging from 23 to 39%). In hips of the contralateral side without LCPD, the prevalence of acetabular retroversion was 0% in all stages for both parameters. Predictive factors for retroversion were younger age at stage II and IV, collapse of the lateral pillar in stage II or a non-dysplastic hip. CONCLUSIONS: This is the first study evaluating acetabular version in children with LCPD from early stage to healing. In the developing hip, LCPD may result in acetabular retroversion and is most prevalent in the fragmentation (stage II) and early healing stage (stage III). Partial correction of acetabular retroversion can occur after healing. This has a potential clinical impact on the timing and type of surgical correction, especially in pelvic osteotomies for correction of acetabular version. LEVEL OF EVIDENCE: Level III, retrospective observational study.

Minimal Out-Toeing and Good Hip Scores of Severe SCFE Patients Treated With Modified Dunn Procedure and Contralateral Prophylactic Pinning at Minimal 5-year Follow up.

BACKGROUND: Slipped capital femoral epiphyses (SCFE) is associated with out-toeing of the foot and external rotation gait. But it is unknown if SCFE patients treated with the modified Dunn procedure have out-toeing at follow up.Therefore, we used instrumented gait analysis and questioned (1) do severe SCFE patients treated with a modified Dunn procedure have symmetrical foot progression angle (FPA) compared with contralateral side and compared with asymptomatic volunteers (2) what is the prevalence of out-toeing gait and what are the outcome socres at follow up. METHODS: Gait analysis of 22 patients (22 hips) treated with an unilateral modified Dunn procedure for severe SCFE (slip angle >60 degrees, 2002 to 2011) was retrospectively evaluated. Of 38 patients with minimal 5-year follow up, 2 hips (4%) had avascular necrosis of the femoral head and were excluded for gait analysis. Twenty-two patients were available for gait analysis at follow up (mean follow up of 9±2 y). Mean age at follow up was 22±3 years. Mean preoperative slip angle was 64±8 degrees (33% unstable slips) and decreased postoperatively (slip angle of 8±4 degrees). Gait analysis was performed with computer-based instrumented walkway system (GAITRite) to measure FPA with embedded pressure sensors. Patients were compared with control group of 18 healthy asymptomatic volunteers (36 feet, mean age 29±6 y). RESULTS: (1) Mean FPA of SCFE patients (3.6±6.4 degrees) at follow up was not significantly different compared with their contralateral side (5.6±5.5 degrees) and compared with FPA of controls (4.0±4.5 degrees). (2) Of the 22 SCFE patients, most of them (19 hips, 86%) had normal FPA (-5 to 15 degrees), 2 patients had in-toeing (FPA<-5 degrees) and 1 had out-toeing (FPA >15 degrees) and was not significantly different compared with control group. (3) Mean modified Harris hip score (mHHS) was 93±11 points, mean Hip Disability and Osteoarthritis Outcome Score (HOOS) score was 91±10 points. Three patients (14%) had mHHS <80 points and walked with normal FPA. The 2 patients with in-toeing and one patient with out-toeing had mHHS >95 points. CONCLUSIONS: Patients with severe SCFE treated with modified Dunn procedure had mostly symmetrical FPA and good hip scores at long term follow up. This is in contrast to previous studies. Although 1 patient had out-toeing and 2 patients had in-toeing at follow up, they had good hip scores. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

What Is the Prevalence of Cam Deformity After Prophylactic Pinning of the Contralateral Asymptomatic Hip in Unilateral Slipped Capital Femoral Epiphysis? A 10-year Minimum Followup Study.

BACKGROUND: Prophylactic pinning of the asymptomatic and normal-appearing contralateral hip in patients with unilateral slipped capital femoral epiphysis (SCFE) remains controversial. Understanding the minimal 10-year clinical, functional, and radiographic outcomes of the contralateral asymptomatic hip in unilateral SCFE may be helpful in the decision regarding whether the benefits associated with potentially preventing a SCFE are outweighed by the risk of additional surgery. QUESTIONS/PURPOSES: Among patients with SCFE treated with prophylactic pinning of the asymptomatic and contralateral hip, we sought (1) to determine the complications and reoperations; (2) to evaluate the development of cam deformities and the frequency and severity of osteoarthritis progression; and (3) to characterize hip pain and function as measured by the Harris hip score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) at minimal 10-year followup. METHODS: Between 1998 and 2005 all patients with SCFE seen at our institution were treated with the modified Dunn procedure and all were offered prophylactic pinning of the contralateral asymptomatic hip. Of the 41 patients who underwent the unilateral modified Dunn procedure and who had an asymptomatic contralateral hip, 37 patients (90%) underwent pinning of that contralateral hip. Of those, 33 patients (80%) were available for clinical and radiographic evaluation for this retrospective study at a minimum of 10 years (mean followup 12 ± 2 years) after surgery. Three patients of the 37 patients only had 10-year clinical followup, including questionnaires sent by mail and telephone, because they refused further radiographic followup and one patient was lost to followup. The group included 19 males and 17 females whose age at surgery was a mean of 13 ± 2 years. Medical charts were reviewed and patients were asked about complications and additional surgical procedures. Most recent postoperative radiographs were evaluated for measurement of the alpha angle, head-neck offset, epiphysis orientation, and osteoarthritis grading according to Tönnis classification and minimum joint space width. The presence of a cam deformity was defined by an alpha angle measurement > 60° on the AP radiograph and/or > 55° on the lateral radiograph. Hip function and pain were assessed by the HHS and HOOS outcome measures. RESULTS: No complications with prophylactic in situ pinning were recorded. Four of 36 (11%) patients underwent subsequent surgical treatment for cam-type femoroacetabular impingement (FAI), and hardware removal was performed in four hips (11%). The mean alpha angle was 53° ± 8° on the AP radiograph and 49° ± 8° on the lateral view at followup. In total, 10 of 33 hips (30%) had a cam morphology at the femoral head-neck junction and four (12%) were symptomatic and underwent FAI surgery. Six of 33 patients (18%) developed an asymptomatic cam morphology at the femoral head-neck junction; in three of 33 hips (9%), the cam deformity instead of lesion were visible only on the lateral projection, and 9% were visible on both the AP and lateral projections. The preoperative offset of the femoral head-neck junction was 10 ± 3 mm on the AP view and 11 ± 4 mm on the lateral view. At followup, the AP offset was 7 ± 3 mm and the lateral offset was 6 ± 3 mm, and on the lateral view, the offset was < 10 mm in eight hips (22%). No patient had radiographic signs of hip osteoarthritis (Tönnis Grade 0). The mean minimum joint space width was 4 ± 0.4 mm. The mean HHS for the 32 patients who did not undergo subsequent surgery was 97 ± 5 at latest followup. The mean postoperative HOOS was 94 ± 8 for the 32 patients at latest followup. CONCLUSIONS: At a minimum followup of 10 years after prophylactic pinning of a contralateral asymptomatic hip, most patients achieve excellent hip scores; however, a substantial proportion will develop a symptomatic cam deformity despite prophylactic pinning. No patient had signs of osteoarthritis at a minimum of 10 years, but almost one-third of the patients who underwent prophylactic pinning developed a cam deformity. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Health-related Quality of Life After Fractures of the Lateral Third of the Clavicle in Children and Adolescents.

INTRODUCTION: The health-related quality of life after pediatric fractures of the lateral third of the clavicle is unknown. Given the trend in the literature toward surgical management of clavicular fractures in adults, we frequently receive referrals for surgical management of lateral clavicular fractures in children.Therefore, we examined (1) the health-related quality of life of patients who sustained a fracture of the lateral third of the clavicle in childhood and who were treated at a large regional pediatric trauma center, (2) if the health-related quality of life was associated with the age at the time of the injury, and (3) whether fracture and displacement patterns were associated with health-related qualify of life. METHODS: This is a retrospective case series. We were able to identify 69 patients (21 girls and 48 boys) who sustained a fracture of the lateral third of the clavicle between the period spanning from January 2004 to June 2015. These patients were asked to fill in a questionnaire that included the Quick version of the Disability of Arm, Shoulder, and Hand (DASH) (primary outcome) and the Pediatric Quality of Life Inventory (Peds-QL). Until July 2017, we were able to get a response from 56 of these patients, resulting in a follow-up of 81%. RESULTS: Treatment was conservative in all cases but one. In these cases, after a mean follow-up of 6.5 years (range, 1 to 13.2 y), the mean Quick-DASH was 1.2 (SD, 4.4) at a scale of 0 to 100, with lower values representing better quality of life. The mean physical function score of the Peds-QL was 97.8 (SD, 4.4), and the mean psychosocial function score was 91.8 (SD, 10.8), both at a scale of 0 to 100, with higher values representing better quality of life.There was no statistically significant association of age at the time of injury on the primary outcome Quick-DASH.There were no statistically significant associations between fracture or displacement patterns with regard to health-related quality of life. CONCLUSIONS: Conservative treatment of lateral clavicular fractures in children and adolescents is associated with excellent health-related quality of life, as measured with the disease-specific Quick-DASH and the non-disease-specific Peds-QL at a mean follow-up of 6.5 years (range, 1 to 13.2 y). There was no effect of age at the time of injury, and we were unable to identify associations to commonly analyzed risk factors, such as displacement patterns.As the conservative treatment of this type of fracture in children and adolescents is associated with such a good health-related quality of life, it is unlikely that these results could be further improved by surgical interventions. LEVEL OF EVIDENCE: Level IV-case series.

Randomized Controlled Trials for Arthroscopy in Degenerative Knee Disease: Was Conservative Therapy Appropriately Tried Prior to Arthroscopy?

PURPOSE: We aimed to determine if the randomized controlled trials (RCTs) evaluated in the most recent meta-analysis on arthroscopic surgery for degenerative knee arthritis included documented trials of appropriate conservative treatment prior to randomization. METHODS: We selected all RCTs of the most recent meta-analysis by Brignardello-Petersen and recorded for each RCT, if physiotherapy prior to randomization was mandatory. We compared the treatment effect of arthroscopy in studies in which physiotherapy prior to randomization was mandatory versus studies in which it was not. This review was registered in the PROSPERO database (CRD42017070091). RESULTS: Of the 13 RCTs in the meta-analysis, there were 2 in which physiotherapy prior to randomization was mandatory. In 1 additional multicenter RCT, prior conservative treatment was mentioned as mandatory in the publication, but not in the protocol. The treatment effects attributed to arthroscopy in terms of short-term pain (P = .0037), short-term function (P = .0309), and long-term function (P = .0012) were larger in studies in which prior physiotherapy was mandatory. CONCLUSIONS: Although the most recent meta-analysis claims that it is based "on patients who do not respond to conservative treatment," physiotherapy was mandatory prior to randomization only in 2 of the 13 studies. As several orthopaedic guidelines recommend that the first line of treatment in patients with degenerative arthritis of the knee should be conservative, for instance with physiotherapy, and the question of performing arthroscopy arises once conservative treatment fails, 11 of the 13 RCTs failed to adhere to these accepted guidelines. Therefore, patient selection in these 11 studies may not represent the typical indications for arthroscopy, where patients have tried conservative management prior to being offered surgery. When comparing studies where prior physiotherapy was mandatory to studies in which it was not mandatory, there were statistically significant effects favoring arthroscopy in terms of pain in the short term, and for function both in the short and the long term. These findings suggest that the treatment effects attributed to arthroscopy were higher when prior physiotherapy was mandatory. Given these findings, the external validity of most of these RCTs, and the resulting "strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease," is called into question. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

High Survivorship and Little Osteoarthritis at 10-year Followup in SCFE Patients Treated With a Modified Dunn Procedure.

BACKGROUND: The modified Dunn procedure has the potential to restore the anatomy in hips with slipped capital femoral epiphyses (SCFE) while protecting the blood supply to the femoral head and minimizing secondary impingement deformities. However, there is controversy about the risks associated with the procedure and mid- to long-term data on clinical outcomes, reoperations, and complications are sparse. QUESTIONS/PURPOSES: Among patients treated with a modified Dunn procedure for SCFE, we report on (1) hip pain and function as measured by the Merle d'Aubigné and Postel score, Drehmann sign, anterior impingement test, limp, and ROM; (2) the cumulative survivorship at minimum 10-year followup with endpoints of osteoarthritis (OA) progression (at least one Tönnis grade), subsequent THA, or a Merle d'Aubigné and Postel score < 15; (3) radiographic anatomy of the proximal femur measured by slip angle, α angle, Klein line, and sphericity index; and (4) the risk of subsequent surgery and complications. METHODS: Between 1998 and 2005, all patients who presented to our institution with SCFE were treated with a modified Dunn procedure; this approach was applied regardless of whether the slips were mild or severe, acute or chronic, and all were considered potentially eligible here. Of the 43 patients (43 hips) thus treated during that time, 42 (98%) were available for a minimum 10-year followup (mean, 12 years; range, 10-17 years) and complete radiographic and clinical followup was available on 38 hips (88%). The mean age of the patients was 13 years (range, 9-18 years). Ten hips (23%) presented with a mild, 27 hips (63%) with a moderate, and six hips (14%) with a severe slip angle. Pain and function were measured using the Merle d'Aubigné and Postel score, limp, ROM, and the presence of a positive anterior impingement test or Drehmann sign. Cumulative survivorship was calculated according to the method of Kaplan-Meier with three defined endpoints: (1) progression by at least one grade of OA according to Tönnis; (2) subsequent THA; or (3) a Merle d'Aubigné and Postel score < 15. Radiographic anatomy was assessed with the slip angle, Klein line, α angle, and sphericity index. RESULTS: The Merle d'Aubigné and Postel score improved at the latest followup from 13 ± 2 (7-14) to 17 ± 1 (14-18; p < 0.001), the prevalence of limp decreased from 47% (18 of 38 hips) to 0% (none in 38 hips; p < 0.001), the prevalence of a positive Drehmann sign decreased from 50% (nine of 18 hips) to 0% (none in 38 hips; p < 0.001), and both flexion and internal rotation improved meaningfully. Cumulative survivorship was 93% at 10 years (95% confidence interval, 85%-100%). Radiographic anatomy improved, but secondary impingement deformities remained in some patients, and secondary surgical procedures included nine hips (21%) with screw removal and six hips (14%) undergoing open procedures for impingement deformities. Complications occurred in four hips (9%) and no hips demonstrated avascular necrosis on plain radiographs. CONCLUSIONS: In this series, the modified Dunn procedure largely corrected slip deformities with little apparent risk of progression to avascular necrosis or THA and high hip scores at 10 years. However, secondary impingement deformities persisted in some hips and of those some underwent further surgical corrections. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Computed tomography guided navigation assisted percutaneous ablation of osteoid osteoma in a 7-year-old patient: the low dose approach.

Osteoid osteoma (OO) is a benign tumour that can cause severe pain and functional limitation to children and young adults; the treatment of choice is image-guided ablation. Due to the very small size of the lesion, detection and accurate needle placement may be challenging. Computed tomography (CT) offers very detailed imaging of the skeleton and is the modality of choice for the detection of small OO and for ablation guidance. Nevertheless, CT-guided positioning of the ablation applicator is linked to significant radiation exposure, particularly for the paediatric population. This case describes the successful use of a novel CT-based navigation system that offers the possibility of accurate ablation with only minimal radiation exposure in a paediatric patient.

Displaced supracondylar humeral fractures: influence of delay of surgery on the incidence of open reduction, complications and outcome.

BACKGROUND: Closed reduction and pinning is the accepted treatment choice for dislocated supracondylar humeral fractures in children (SCHF). Rates of open reduction, complications and outcome are reported to be dependent on delay of surgery. We investigated whether delay of surgery had influence on the incidence of open reduction, complications and outcome of surgical treatment of SCHFs in the authors' institution. METHODS: Three hundred and forty-one children with 343 supracondylar humeral fractures (Gartland II: 144; Gartland III: 199) who underwent surgery between 2000 and 2009 were retrospectively analysed. The group consisted of 194 males and 149 females. The average age was 6.3 years. Mean follow-up was 6.2 months. Time interval between trauma and surgical intervention was determined using our institutional database. Clinical and radiographical data were collected for each group. Influence of delay of treatment on rates of open reduction, complications and outcome was calculated using logistic regression analysis. Furthermore, patients were grouped into 4 groups of delay (<6 h, n = 166; 6-12 h, n = 95; 12-24 h, n = 68; >24 h, n = 14) and the aforementioned variables were compared among these groups. RESULTS: The incidence of open procedures in 343 supracondylar humeral fractures was 2.6 %. Complication rates were similar to the literature (10.8 %) primarily consisting of transient neurological impairments (9.0 %) which all were fully reversible by conservative treatment. Poor outcome was seen in 1.7 % of the patients. Delay of surgical treatment had no influence on rates of open surgery (p = 0.662), complications (p = 0.365) or poor outcome (p = 0.942). CONCLUSIONS: In this retrospective study delay of treatment of SCHF did not have significant influence on the incidence of open reduction, complications, and outcome. Therefore, in SCHF with sufficient blood perfusion and nerve function, elective treatment is reasonable to avoid surgical interventions in the middle of the night which are stressful and wearing both for patients and for surgeons. LEVEL OF EVIDENCE: III (retrospective comparative study).

MR-based Bony 3D models enable radiation-free preoperative patient-specific analysis and 3D printing for SCFE patients.

Objectives: Slipped capital femoral epiphyses (SCFE) is a common pediatric hip disease with the risk of osteoarthritis and impingement deformities, and 3D models could be useful for patient-specific analysis. Therefore, magnetic resonance imaging (MRI) bone segmentation and feasibility of 3D printing and of 3D ROM simulation using MRI-based 3D models were investigated. Methods: A retrospective study involving 22 symptomatic patients (22 hips) with SCFE was performed. All patients underwent preoperative hip MR with pelvic coronal high-resolution images (T1 images). Slice thickness was 0.8-1.2 mm. Mean age was 12 ± 2 years (59% male patients). All patients underwent surgical treatment. Semi-automatic MRI-based bone segmentation with manual corrections and 3D printing of plastic 3D models was performed. Virtual 3D models were tested for computer-assisted 3D ROM simulation of patients with knee images and were compared to asymptomatic contralateral hips with unilateral SCFE (15 hips, control group). Results: MRI-based bone segmentation was feasible (all patients, 100%, in 4.5 h, mean 272 ± 52 min). Three-dimensional printing of plastic 3D models was feasible (all patients, 100%) and was considered helpful for deformity analysis by the treating surgeons for severe and moderate SCFE. Three-dimensional ROM simulation showed significantly (p < 0.001) decreased flexion (48 ± 40°) and IR in 90° of flexion (-14 ± 21°, IRF-90°) for severe SCFE patients with MRI compared to control group (122 ± 9° and 36 ± 11°). Slip angle improved significantly (p < 0.001) from preoperative 54 ± 15° to postoperative 4 ± 2°. Conclusion: MRI-based 3D models were feasible for SCFE patients. Three-dimensional models could be useful for severe SCFE patients for preoperative 3D printing and deformity analysis and for ROM simulation. This could aid for patient-specific diagnosis, treatment decisions, and preoperative planning. MRI-based 3D models are radiation-free and could be used instead of CT-based 3D models in the future.

Slipped capital femoral epiphysis: relevant pathophysiological findings with open surgery.

BACKGROUND: Traditionally arthrotomy has rarely been performed during surgery for slipped capital femoral epiphysis (SCFE). As a result, most pathophysiological information about the articular surfaces was derived clinically and radiographically. Novel insights regarding deformity-induced damage and epiphyseal perfusion became available with surgical hip dislocation. QUESTIONS/PURPOSES: We (1) determined the influence of chronicity of prodromal symptoms and severity of SCFE deformity on severity of cartilage damage. (2) In surgically confirmed disconnected epiphyses, we determined the influence of injury and time to surgery on epiphyseal perfusion; and (3) the frequency of new bone at the posterior neck potentially reducing perfusion during epimetaphyseal reduction. METHODS: We reviewed 116 patients with 119 SCFE and available records treated between 1996 and 2011. Acetabular cartilage damage was graded as +/++/+++ in 109 of the 119 hips. Epiphyseal perfusion was determined with laser-Doppler flowmetry at capsulotomy and after reduction. Information about bone at the posterior neck was retrieved from operative reports. RESULTS: Ninety-seven of 109 hips (89%) had documented cartilage damage; severity was not associated with higher slip angle or chronicity; disconnected epiphyses had less damage. Temporary or definitive cessation of perfusion in disconnected epiphyses increased with time to surgery; posterior bone resection improved the perfusion. In one necrosis, the retinaculum was ruptured; two were in the group with the longest time interval. Posterior bone formation is frequent in disconnected epiphyses, even without prodromal periods. CONCLUSIONS: Addressing the cause of cartilage damage (cam impingement) should become an integral part of SCFE surgery. Early surgery for disconnected epiphyses appears to reduce the risk of necrosis. Slip reduction without resection of posterior bone apposition may jeopardize epiphyseal perfusion. LEVEL OF EVIDENCE: Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

Partial Remodeling after Conservative Treatment of Trampoline Fractures in Children.

(1) Background: Trampoline fractures (proximal tibia fracture with positive anterior tilt) are increasing. This study represents the first attempt to determine the extent of remodeling in these fractures after conservative treatment (2) Methods: This Swiss prospective multicenter study included children aged 2 to 5 years with a trampoline fracture who were radiologically examined on the day of the accident and after one year. In addition, the anterior tilt angle was compared between the injured and unaffected tibia. Remodeling was defined as complete (final anterior tilt angle ≤ 0°), incomplete (smaller but still >0°), or no remodeling. (3) Results: The mean extent of remodeling was -3.5° (95% CI: -4.29°, -2.66°, p < 0.001). Among the 89 children included in the study, 26 (29.2%) showed complete, 63 (70.8%) incomplete, and 17 patients (19.1%) no remodeling. Comparison of the anterior tilt angles between the fractured and healthy tibia showed that the anterior tilt angle on the fractured leg was, on average larger by 2.82° (95% CI: 2.01°, 3.63°; p < 0.001). (4) Conclusions: Although the anterior tilt angle decreased during the study period, the majority of patients showed incomplete remodeling. In contrast, children with radiological examinations >1 year after the trauma showed advanced remodeling, suggesting that one year is too short to observe complete remodeling.

Assessment of femoral retroversion on preoperative hip magnetic resonance imaging in patients with slipped capital femoral epiphysis: Theoretical implications for hip impingement risk estimation.

Purpose: Slipped capital femoral epiphysis is a common pediatric hip disease and was associated with femoral retroversion, but femoral version was rarely measured. Therefore, mean femoral version, mean femoral neck version, and prevalence of femoral retroversion were analyzed for slipped capital femoral epiphysis patients. Methods: A retrospective observational study evaluating preoperative hip magnetic resonance imaging of 27 patients (49 hips) was performed. Twenty-seven untreated slipped capital femoral epiphysis patients (28 slipped capital femoral epiphysis hips and 21 contralateral hips, age 10-16 years) were evaluated (79% stable slipped capital femoral epiphysis, 22 patients; 43% severe slipped capital femoral epiphysis, 12 patients). Femoral version was measured using Murphy method on magnetic resonance imaging (January 2014-December 2021, rapid bilateral 3-dimensional T1 water-only Dixon-based images of pelvis and knee). All slipped capital femoral epiphysis patients underwent surgery after magnetic resonance imaging. Results: Mean femoral version of slipped capital femoral epiphysis patients (-1° ± 15°) was significantly (p < 0.001) lower compared to contralateral side (15° ± 14°). Femoral version of slipped capital femoral epiphysis patients had significantly (p < 0.001) wider range from -42° to 35° (range 77°) compared to contralateral side (-5° to 44°, range 49°). Mean femoral neck version of slipped capital femoral epiphysis patients (6° ± 15°) was lower compared to contralateral side (11° ± 12°). Fifteen slipped capital femoral epiphysis patients (54%) had absolute femoral retroversion (femoral version < 0°). Six of the 12 hips (50%) with severe slips and 4 of the 8 hips (50%) with mild slips had absolute femoral retroversion (femoral version < 0°). Ten slipped capital femoral epiphysis patients (40%) had absolute femoral neck retroversion (femoral neck version < 0°). Conclusion: Although slipped capital femoral epiphysis patients showed asymmetrically lower femoral version compared to contralateral side, there was a wide range of femoral version, underlining the importance of patient-specific femoral version analysis on preoperative magnetic resonance imaging. Absolute femoral retroversion was prevalent in half of slipped capital femoral epiphysis patients, in half of severe slipped capital femoral epiphysis patients, and in half of mild slipped capital femoral epiphysis patients. This has implications for anterior hip impingement and for surgical treatment with in situ pinning or femoral osteotomy (e.g. proximal femoral derotation osteotomy) or other hip preservation surgery.

Clinical stability of slipped capital femoral epiphysis does not correlate with intraoperative stability.

BACKGROUND: The most important objective of clinical classifications of slipped capital femoral epiphysis (SCFE) is to identify hips associated with a high risk of avascular necrosis (AVN)--so-called unstable or acute slips; however, closed surgery makes confirmation of physeal stability difficult. Performing the capital realignment procedure in SCFE treatment we observed that clinical estimation of physeal stability did not always correlate with intraoperative findings at open surgery. This motivated us to perform a systematic comparison of the clinical classification systems with the intraoperative observations. QUESTIONS/PURPOSES: We asked: (1) Is the classification of an acute versus chronic slip based on the duration of symptoms sensitive and specific in detecting intraoperative disrupted physes in patients with SCFE? (2) Is the stable/unstable classification system based on clinical symptoms sensitive and specific in detecting intraoperative disrupted physes in patients with SCFE? METHODS: We retrospectively reviewed 82 patients with SCFE treated by open surgery between 1996 and 2009. We classified the clinical stability of all hips using the classifications based on onset of symptoms and on function. We classified intraoperative stability as intact or disrupted. We determined the sensitivity and specificity of two classification systems to determine intraoperative stability. RESULTS: Complete physeal disruption at open surgery was seen in 28 of the 82 hips (34%). With classification as acute, acute-on-chronic, and chronic, the sensitivity for disrupted physes was 82% and the specificity was 44%. With the classification of Loder et al., the values were 39% and 76%, respectively. CONCLUSION: Current clinical classification systems are limited in accurately diagnosing the physeal stability in SCFE. LEVEL OF EVIDENCE: Level III, retrospective diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Triple innominate osteotomy for Legg-Calvé-Perthes disease in children: does the lateral coverage change with time?

BACKGROUND: Triple innominate osteotomy (TIO) is one of the modalities of surgical containment in Legg-Calvé-Perthes disease (LCPD). However, overcoverage with TIO can lead to pincer impingement. QUESTIONS/PURPOSES: We therefore asked (1) whether TIO contained the femoral head in Catterall Stages III and IV of LCPD; (2) whether the center-edge (CE) angle, acetabular roof arc angle (ARA), and Sharp's angle changed during the growing years; and (3) what percentage of patients had radiographic evidence of pincer impingement beyond a minimum followup of 3 years. METHODS: We identified 19 children who had 20 TIOs performed for Catterall Stages III and IV LCPD. Two blinded observers assessed sequential radiographs. Each observer made two sets of readings more than 2 weeks apart. Femoral head extrusion index, CE angle of Wiberg, ARA, and Sharp's angle were measured. Minimum followup was 3 years to document continued acetabular growth (mean, 3.8 years; range, 3-7 years). RESULTS: All patients exhibited femoral head containment at last followup. Eleven of 20 hips demonstrated no radiographic evidence of pincer morphology beyond a minimum followup of 3 years (mean, 3.8 years). Patients with CE angle corrected to 44° or less and an ARA of greater than -6° after TIO did not demonstrate a pincer morphology at last followup. CONCLUSIONS: TIO resulted in femoral head containment in all cases. Lateral acetabular coverage changed during the growing years in all patients. Surgical correction beyond 44° of CE angle and -6° of ARA should be avoided to prevent pincer morphology later.

The Locking Compression Paediatric Hip Plate: technical guide and critical analysis.

PURPOSE: Osteotomies of the proximal femur and stable fixation of displaced femoral neck fractures are demanding operations. An LCP Paediatric Hip Plate was developed to make these operations safer and less demanding. The article focuses on the surgical technique and critically analyses the device. METHODS: Between 2006 and 2008, 30 hips in 22 patients underwent surgery. Patients' demographics, perioperative details, postoperative outcome and complications were retrospectively collected and analysed. RESULTS: Patients' diagnoses included persistent congenital hip dysplasia (n = 4), neuropathic hip dysplasia (n = 9), idiopathic ante/retroversion (n = 8), femoral neck fracture (n = 3), Perthes' disease (n = 2), deformity after slipped capital femoral epiphysis (SCFE), congenital femoral neck pseudarthrosis, deformity after pelvic tumour resection and malunion following proximal femoral fracture (one each). In 21 of 22 patients, the postoperative radiographs showed corrections as planned. Two cases had to be revised for screw loosening. Intraoperative handling using the plate was excellent in all cases. CONCLUSIONS: In our case series of 30 hip operations, the LCP Paediatric Hip Plate was shown to be safe and applicable in the clinical setting with excellent results and a low complication rate. We consider that the LCP Paediatric Hip Plate is a valuable device for correction of pathological conditions of the proximal femur and for fixation of displaced femoral neck fractures in children. Larger studies should be carried out to better quantify the risk of clinically relevant complications.

[Femoral head reduction osteotomy to improve femoroacetabular containment in Legg-Calve-Perthes disease]. / Femurkopfreduktionsosteotomie zur Verbesserung des femoroazetabulären Containments bei Morbus Perthes.

OBJECTIVE: Restoration of hip congruence and containment through central femoral head resection/reduction via an extended surgical hip dislocation, while maintaining/respecting the femoral head blood flow. Simultaneous or subsequent reorientation of the acetabulum by triple TPO (Pediatric Triple Osteotomy) or PAO (Peri-Acetabular Osteotomy) may be necessary. INDICATIONS: Surgical hip dislocation with femoral head reduction can be performed at any age in cases with hinge abduction and Stulberg class IV and V deformity. Procedure indicated for patients with active or healed disease. After the resection, a viable residual femoral head must remain, i.e. at least 50% of the expanded femoral head, which is best planned using "comparative" 3D reconstruction. CONTRAINDICATIONS: Completely destroyed cartilage or femoral head. SURGICAL TECHNIQUE: The same surgical procedure as described for classic surgical hip dislocation is followed. Preparation of retinacular flaps. With detailed knowledge of the vascular supply and precise execution of this technique, blood supply to the femoral head will be preserved; once safely surgically dislocated, the femoral head and neck can be split and the necrotic part of the femoral head removed. Reformation of the femoral head as spherical as possible is achieved by screw fixation of the femoral neck to align the two articular parts of the femoral head. Distalization and fixation of the great trochanter helps to restore offset (functional femoral neck length). Depending on the congruence and stability of the femoral head in the acetabulum, a primary TPO or PAO may also be necessary. POSTOPERATIVE MANAGEMENT: Intraoperative stability must be achieved to ensure functional posttreatment without a hip spica cast. Walking with crutches with toe contact only is advised. Active rotation is not allowed. Active and passive flexion up to 90° allowed. These measures have to be observed for 8-10 weeks. Then, active physiotherapy rehabilitation may commence, depending on healing, as assessed clinically and radiologically. RESULTS: Our published follow-up examinations (currently 21 years) show consistently good results with a technically correct operation and correct indication as well as adequate follow-up treatment. No necrosis of the reduced femoral head has been observed. All split femoral heads and femoral necks are primarily healed.

[Triple osteotomy for patients with Legg-Calve-Perthes disease]. / Tripleosteotomie bei Morbus Perthes.

OBJECTIVE: Osteotomy of iliac-pubic and ischial bone in order to cover the lateralized femoral head with the acetabulum. With the restoration of the containment of the hip joint, the acetabulum functions as a template for the femoral head, thus, allowing it to keep its sphericity during the vulnerable stages of Legg-Calve-Perthes disease. INDICATIONS: Lateralized femoral head in severe Legg-Calve-Perthes disease and visible head at risk signs on the radiographs. Prerequisite is possible concentric reduction of the femoral head (confirmed by preoperative abduction radiograph or arthrography). CONTRAINDICATIONS: Hinged abduction. Impossible concentric reduction of the femoral head. SURGICAL TECHNIQUE: Hip arthrography to confirm the indication of the triple pelvic osteotomy is recommended. Osteotomy of the ischial bone by a modified Ludloff approach. Osteotomy of pubic and iliac bone by anterior approach (Smith Peterson/bikini incision). Turning the acetabulum over the femoral head allows improvement of the containment of the hip. Fixation of the acetabulum with fully threaded Kirschner wires or 3.5 mm cortical screws. POSTOPERATIVE MANAGEMENT: Touch-down weight bearing with crutches (wheelchair in younger children) for 4-6 weeks depending on the age of the child. After radiologic evidence of consolidation, transition to full-weight bearing within 1-2 weeks. RESULTS: Promising results in our own practice. Good functional and radiological results in a to-date unpublished study of 30 patients with Legg-Calve-Perthes disease after an average 5­year follow-up.

Health-Related Quality of Life after Adolescent Fractures of the Femoral Shaft Stabilized by a Lateral Entry Femoral Nail.

(1) Background: In adolescents, fractures of the femoral shaft that are not suitable for elastic-stable-intramedullary-nailing (ESIN), are challenging. We aimed to evaluate the health-related quality of life (HRQoL) and complications in adolescents treated with intramedullary rodding using the adolescent lateral trochanteric entry femoral nail (ALFN), and to assess if HRQoL was associated with additional injuries. (2) Methods: We followed-up on 15 adolescents with a diaphyseal femoral fracture who were treated with an ALFN from 2004 to 2017. Patients were asked to fill in a questionnaire that includes the iHOT, Peds-QL, and the Pedi-IKDC. (3) Results: The ALFN was used as a primary method of fixation in 13 patients, and as a fixation for failed ESIN in two cases. All 15 fractures healed radiographically. One distal locking screw broke. After a mean follow-up of 2.8 years, the mean iHOT-12 was 14.0 (SD 15.4), PedsQL-function was 85.7 (SD 19.3), PedsQL-social-score was 86.2 (SD 12.5), and the mean Pedi-IKDC was 77.2 (SD 11.3). In patients where the femoral fracture was an isolated injury, the HRQoL-scores were consistently higher compared with patients who sustained additional injures. (4) Conclusions: Treating diaphyseal fractures in adolescents with an ALFN resulted in good radiographic outcomes in all our cases. HRQoL, as measured by the iHOT, PedsQL, and Pedi-IKDC, was good to excellent; but it was consistently inferior in patients with additional injuries. These results suggest that the ALFN is a good alternative when patients are not suitable for ESIN, and that the HRQoL of adolescents who were treated with an ALFN is mainly influenced by the presence of additional injures, and less by the fracture of the femur itself.

Most of patients with femoral derotation osteotomy for posterior extraarticular hip impingement and high femoral version would do surgery again.

AIMS: To assess (1) hip pain and function and ROM; (2) subsequent surgeries, complications; and (3) subjective satisfaction and PROMs in patients undergoing femoral derotation osteotomies. METHODS: Femoral derotation subtrochanteric osteotomies to treat symptomatic posterior extraarticular ischiofemoral hip impingement were performed in 23 patients (25 hips) between 2013 and 2017. The mean age was 26 ± 8 years (96% female) with a minimum 2-year follow-up (mean follow-up of 4 ± 1 years). Surgical indication was a positive posterior impingement test and limited external rotation (mean 16° ± 8°) in extension in patients with abnormal high femoral version (mean 46° ± 9, measured on CT scans with the Murphy method) and high McKibbin instability index (mean 67°). Femoral osteotomies were combined with a surgical hip dislocation in 96% for cam resection and labrum or cartilage treatment. Preoperative MRI and 3D-CT with dynamic impingement simulation were evaluated. RESULTS: (1) The posterior impingement test decreased significantly from preoperatively 100% to 4% (p < 0.001). External rotation in extension increased significantly (p < 0.001) from preoperative 16° ± 8 to 44° ± 16°. The MdA score increased significantly from 14 ± 1 to 16 ± 2 (p < 0.001) points.(2) At follow-up, all 25 hips were preserved. No conversion to THA and no revision osteosynthesis was performed. 64% underwent complete hardware removal.(3) 80% of the patients reported at follow-up that they would undergo surgery again. Subjective satisfaction (SHV) increased significantly (p < 0.001) from preoperatively 24% to 84% postoperatively. CONCLUSIONS: Femoral derotation subtrochanteric osteotomies for the treatment of posterior extraarticular ischiofemoral hip impingement are safe and improve posterior hip pain and function and external rotation in mostly female patients with high femoral version and a high McKibbin instability index.

Health-Related Quality of Life after Fractures of the Distal Forearm in Children and Adolescents-Results from a Center in Switzerland in 432 Patients.

(1) Background: We aimed to evaluate the health-related quality of life (HRQoL) in children with fractures of the distal forearm and to assess if HRQoL was associated with fracture classification; (2) Methods: We followed up on 432 patients (185 girls, 247 boys) who sustained a fracture of the distal radius or forearm from 1/2007 to 6/2007, 1/2014 to 6/2014, and 11/2016 to 10/2017. Patients filled in the Quick-DASH (primary outcome) and the Peds-QL; (3) Results: The radius was fractured in 429 and the ulna in 175 cases. The most frequent injury of the radius was a buckle fracture (51%, mean age 8.5 years), followed by a complete metaphyseal fracture (22%, 9.5 years), Salter-Harris-2 fracture (14%, 11.4 years), greenstick fracture (10%, 9.3 years), Salter-Harris-1 fracture (1%, 12.6 years), and other rare injuries. The most common treatment was closed reduction and an above-elbow cast in 138 cases (32%), followed by a cast without reduction (30%), splint (28%), and K-wire fixation and cast (9%). Definite treatment was performed initially in 95.8%, a new cast or cast wedging was performed in 1.6%, and revision surgery was performed in 2.5%. There were no open reductions and no plate fixations. After a mean follow-up of 4.2 years, patients with buckle fractures had a mean Quick-DASH of 3.3 (scale of 0-100) (complete fracture: 1.5; greenstick: 1.5; SH-1: 0.9; SH-2: 4.1; others: 0.9). The mean function score of the PedsQL ranged from 93.0 for SH-2 fractures to 97.9 for complete fractures; (4) Conclusions: In this cohort of 432 children with fractures of the distal forearm, there was equally good mean mid- and long-term HRQoL when assessed by the Quick-DASH and the PedsQL. There was a trend for children with complete metaphyseal fractures reporting better HRQoL than patients with buckle fractures or patients with Salter-Harris II fractures, however, these differences were not statistically significant nor clinically relevant.