Treatment of Hip Instability in Children With Down Syndrome: Keys to Managing a Challenging Problem.

INTRODUCTION: Management of hip instability in children with Down syndrome is a challenging task to undertake for even the most experienced surgeons. As life expectancy of these patients increases, the importance of preserving functional mobility and hip joint stability in order to minimize late hip degeneration and pain has become a priority. The aim of this study is to evaluate the clinical and radiographic outcomes of children with Down syndrome and hip instability who underwent surgical reconstruction with femoral and/or acetabular procedures. METHODS: We performed a retrospective review of all children with Down syndrome age 18 years and younger, who underwent surgical intervention to address hip instability between 2003 and 2017. Data was recorded detailing the patient's demographics, preoperative and postoperative functional status and surgical details. Preoperative and postoperative radiographic analysis was performed as well as 3-dimensional computed tomography scan evaluation, when available. All major and minor complications were recorded and classified using the Severin radiographic classification and the Clavien-Dindo-Sink clinical classification. RESULTS: We studied 28 hips in 19 children that were followed for an average of 4.4 years postsurgical intervention for hip instability. The majority of patients improved in all radiographic parameters. A total of 14 hips (50%) had complications and 9 hips (32%) required a secondary surgery. Of those complications, 2 hips (7%) developed avascular necrosis and 4 hips (14%) developed recurrent instability after the index procedure. Two of these hips had a subsequent anteverting periacetabular osteotomy that produced a stable hip at final follow up. DISCUSSION: Surgical management of hip instability in children with Down syndrome remains challenging. The treating surgeon must have a thorough understanding of the pathoanatomy and design the surgical treatment to meet all of the underlying sources of instability. Combined femoral and acetabular osteotomies plus capsulorrhaphy are often required along with postoperative hip spica immobilization. Although complication and revision surgery rates are high, hip stability and good functional outcomes can be achieved.

Comparison of Surgical Outcomes Between a Triplane Proximal Femoral Osteotomy and the Modified Dunn Procedure for Stable, Moderate to Severe Slipped Capital Femoral Epiphysis.

BACKGROUND: Recent studies have demonstrated the intra-articular cartilage and labral damage that can occur from the proximal femoral cam-like deformity of a moderate to severe slipped capital femoral epiphysis (SCFE). The approach to treating this deformity in a symptomatic Loder stable hip is controversial. The purpose of this study was to compare radiographic outcomes, complication rates, and revision rates between Imhauser type triplane proximal femoral osteotomy (TPFO) and the modified Dunn procedure (MDP). METHODS: Twenty-six subjects with minimum 1-year follow-up were included (12 treated with a TPFO, and 14 treated with the MDP). A chart review was performed to capture data related to complications, revision procedures, surgical time, and body mass index. Radiographs were measured preoperatively and at final follow-up to evaluate epiphyseal-slip angle, neck-shaft angle, articular surface to trochanter distance, and medial proximal femoral angle. RESULTS: Surgical time was shorter for the TPFO group (150.0±57.4 min) compared with the MDP group (203.8±30 min) (P=0.005). All preoperative and postoperative radiographic measures were similar between the 2 groups except postoperative neck-shaft angle, which was significantly less in the TPFO group (129.7±8.6 vs. 140.9±9.4 degrees) (P=0.005). There were no cases of femoral head avascular necrosis (AVN) in the TPFO group. The modified Dunn group had a 29% AVN rate (P=0.1). The overall complication rate was similar between the TPFO (33%) and modified Dunn (36%) groups (P=1.0) and the reoperation rate was slightly greater in the TPFO group (33%) as compared with the modified Dunn group (21%) (P=0.67). CONCLUSIONS: The complex 3-dimensional proximal femoral deformity of a moderate to severe SCFE can be difficult to treat with relatively high complication/reoperation rates observed in both TPFO and MDP groups. All 4 instances of AVN in this study of stable slips, however, were in the MDP group. As this can be a devastating complication leading to early total hip arthroplasty, we advise against the MDP in stable SCFE patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Analysis of Acetabular Ossification From the Triradiate Cartilage and Secondary Centers.

BACKGROUND: Acetabular development is a complex process that involves both endochondral growth from the triradiate cartilage (TRC) and intramembranous growth from the primary and secondary ossification centers of the innominate bones. Ponseti and others have described these centers including their contribution toward the development of normal acetabular shape. Prior studies have not utilized advanced imaging to study the appearance and closure of these secondary centers. The purpose of this study was to determine the chronological age at which the secondary ossification centers of the acetabulum appear and close and where there are any sex differences. METHODS: Patients who underwent abdominal and pelvic computed tomography (CT) scans between January 2009 and December 2014 at a pediatric hospital were retrospectively reviewed. Patients between age 6 and 16 years with adequate imaging of acetabulum were included. CT scans were assessed for the appearance and closure of the 3 acetabular secondary ossification centers [anterior (os pubis), superior (os ilium), and posterior (os ischium)] and closure of the TRC. RESULTS: A total of 159 CT scans met inclusion criteria (66 males and 93 females). The median age of appearance of the secondary ossification centers was: posterior (10.1 females, 12.8 males), anterior (10.7 females, 13.4 males), and superior (11.1 females, 13.6 males). The median age of closure of the secondary ossification centers was: posterior (12.8 females, 13.6 males), anterior (12.8 females, 13.9 males), superior (14.5 females, 13.9 males), and TRC (14.5 females, 14.3 males). Most ossification centers in females appeared and closed approximately 2 to 3 years before males. CONCLUSIONS: Secondary ossification centers in the acetabulum appear sequentially (first posterior, then anterior, then superior), with almost all centers closing just before TRC. Closure occurs earlier in females than males. Knowledge of these centers and their closure patterns allows better radiologic readings (especially CT studies) and understanding of acetabular growth, allowing more informed management of childhood hip conditions including dysplasia, trauma, and over-use sports injuries. LEVEL OF EVIDENCE: Level III-Diagnostic.

Electronic Medical Record Adoption: The Effect on Efficiency, Completeness, and Accuracy in an Academic Orthopaedic Practice.

INTRODUCTION: The electronic medical record (EMR) is the new platform for documenting health information. The purpose of this study is to evaluate the impact of the EMR on efficiency, completeness, accuracy, and surgeon attitude in the orthopaedic program of a training hospital. METHODS: Sixty paper charts were compared with 60 EMRs. Pre-EMR and post-EMR billing data was used to determine outpatient clinic volume and the number of providers seeing patients per month. Completeness was evaluated by noting the presence of items from a predetermined list of clinical information pertinent to each diagnosis. Age and side of injury was used to evaluate note accuracy. A survey was used to evaluate surgeon's attitudes regarding the EMR. RESULTS: There was no difference in monthly volume pre-EMR and post-EMR. There was an increase in the number of providers needed to see patients, equating to a 19% reduction in the number of patient visits per provider. The EMR was 1.3 times more likely to include pertinent clinical information. Both paper charts and the EMR were highly accurate. The surgeon attitude survey revealed concerns regarding clinic efficiency, increased "off-hours" record keeping, and decreased clinic teaching. DISCUSSION: EMR is an important and essential component of medical care delivery. Record completion and accuracy were similar across medical record types. The use of EMR led to a 19% reduction in patients per provider. Creating the record in the clinic setting appears to detract from patient interaction, and resident/fellow education time. A more focused, specialty designed, EMR may be more efficient for an orthopaedic practice. Future EMR technology should allow a focused EMR designed for specialties that is efficient to create but that can be electronically converted into a "master record" that meets the needs of an associated larger organization. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Advanced Containment With Triple Innominate Osteotomy in Legg-Calve-Perthes Disease: A Viable Option Even in Severe Cases.

BACKGROUND: Legg-Calve-Perthes disease (LCPD), in its severe form, remains a challenge. More recent classifications, particularly the modified Elizabethtown classification, have highlighted the chronologic stage of LCPD and its effect on surgical outcome. Hip severity and age of disease onset have also been shown to be powerful determinants of outcome. This study was performed to determine whether disease stage, disease severity, or patient age, are absolute indicators of whether a patient can benefit from surgical containment with triple innominate osteotomy (TIO). METHODS: All patients with LCPD treated with TIO between 1995 and 2011 were collected. Only those patients with a minimum of 2-year radiographic follow-up and no previous or concomitant femoral realignment surgery were included. Fifty-four patients (56 hips) met our inclusion criteria. The modified Elizabethtown classification was used to classify disease stage as early (

Sex Differences in Cartilage Topography and Orientation of the Developing Acetabulum: Implications for Hip Preservation Surgery.

BACKGROUND: Increased attention is being placed on hip preservation surgery in the early adolescent. An understanding of three-dimensional (3-D) acetabular development as children approach maturity is essential. Changes in acetabular orientation and cartilage topography have not previously been quantified as the adolescent acetabulum completes development. QUESTIONS/PURPOSES: We used a novel 3-D CT analysis of acetabular development in children and adolescents to determine (1) if there were sex-specific differences in the growth rate or surface area of the acetabular articular cartilage; (2) if there were sex-specific differences in acetabular version or tilt; and (3) whether the amount of version and tilt present correlated with acetabular coverage. METHODS: We assessed acetabular morphology in 157 patients (314 hips); 71 patients were male and 86 were female. Patient ages ranged from 8 years to 17 years. A 3-D surface reconstruction of each pelvis was created from CT data using MIMICs software. Custom MATLAB software was used to obtain data from the 3-D reconstructions. We calculated articular surface area, acetabular version, and acetabular tilt as well as novel measurements of acetabular morphology, which we termed "coverage angles." These were measured in a radial fashion in all regions of the acetabulum. Data were organized into three age groups: 8 to 10 years old, 10 to 13 years old, and 13 to 17 years old. RESULTS: Male patients had less acetabular anteversion in all three age groups, including at maturity (7° versus 13°, p<0.001; 10° versus 17°, p<0.001; 14° versus 20°, p<0.001). Males had less acetabular tilt in all three age groups (32° versus 34°, p=0.03; 34° versus 38°, p<0.001; 39° versus 41°, p=0.023). Increases in anteversion correlated with increased posterior coverage angles (r=0.805; p<0.001). Increases in tilt were correlated with increases in superior coverage angles (r=0.797; p<0.001). The posterosuperior regions of the acetabulum were the last to develop and this process occurred earlier in females compared with males. Articular surface area increased from 18 (8-10 years) to 24 cm(2) (13-17 years) in males and from 17 (8-10 years) to 21 cm(2) (13-17 years) in females. [corrected]. Articular surface area was higher in males beginning in the 10- to 13-year-old age group (p=0.001). CONCLUSIONS: Using a novel technique to analyze acetabular morphology, we found that acetabular development occurs earlier in females than males. The posterosuperior region of the acetabulum is the final region to develop. The articular cartilage surface area and articular cartilage coverage of the femoral head are increasing in addition to total coverage of the femoral head during the final stages of acetabular development. LEVEL OF EVIDENCE: Level III, prognostic study.

Surgical treatment of developmental dysplasia of the hip.

Ideally, developmental dysplasia of the hip is treated early in childhood by nonsurgical methods. If these methods are ineffective, surgical reduction in a nonambulating child is required. A young child (age 6 to 18 months) who requires surgical reduction can be treated by formal anterior open reduction or by the medial Ludloff approach to the hip. Additional bony procedures are usually not required in these young patients. Delayed diagnosis is still common, requiring surgical reduction for children of walking age. These older children usually require formal open reduction (anterior approach) plus an associated bony osteotomy (acetabular, proximal femoral, or, in some cases, both types of osteotomies) to better stabilize the hip. The addition of a proximal femoral derotational shortening osteotomy for open reduction in older children was first used in children older than 3 years, but now it is commonly used in children as young as 2 years. This osteotomy decreases the forces on the reduced hip and minimizes the chances for redislocation and osteonecrosis. In all surgical procedures for developmental dysplasia of the hip, the surgeon must avoid too great a focus on bony osteotomies because the management of soft-tissue abnormalities is critical in achieving a stable reduction.

Fundamental concepts of developmental dysplasia of the hip.

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

Acute, unstable, slipped capital femoral epiphysis: is there a role for in situ fixation?

BACKGROUND: Slipped capital femoral epiphysis, a common disorder in adolescents, may be increasing in incidence in North America because of the obesity epidemic. In most cases, the slip is mild and can be treated with in situ fixation. Even in more severe cases of a stable slip, in situ fixation remains a widely accepted choice. When the slip is acute and unstable, treatment remains controversial. We reviewed the orthopaedic literature and our personal experience in managing acute, unstable slipped capital femoral epiphysis. The reported range of avascular necrosis (AVN) is high and the literature shows no clear recommendations for the best treatment choice. Treatment choices include: in situ stabilization with possible later corrective osteotomy, formal manipulative closed reduction plus screw fixation, partial reduction through an open approach with the hip joint decompressed (Parsch method), and anatomic reduction by the modified Dunn method. Review of the literature and our experience suggests a high AVN rate in acute unstable slips no matter what treatment method is selected. Most North American reports suggest an AVN rate with in situ screw fixation ranging from 20% to 50%. The method described by Parsch, which includes an urgent, open capsulotomy, joint decompression, and gentle partial reduction, shows a low AVN rate as reported from his institution (<10%). The AVN rate reported for anatomic reduction (modified Dunn procedure) performed through an open surgical hip dislocation was initially quite low, but after being restudied in North American centers appears to be about 25%. CONCLUSIONS: Safe treatment of an acute unstable slip remains problematic. The literature suggests that these patients should be treated urgently; however, simple in situ stabilization results in a high AVN rate. A likely safer modification is to open the hip anteriorly to decompress the joint and to stabilize after partial reduction as described by Parsch. The modified Dunn method is becoming more widely used, but results in North American centers cite a significant AVN rate.

The role of capital realignment versus in situ stabilization for the treatment of slipped capital femoral epiphysis.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) can be treated by a variety of methods with the traditional method of in situ pin fixation being most commonly used. More recently, the Modified Dunn (Mod. Dunn) procedure consisting of capital realignment has been popularized as a treatment method for SCFE, particularly for more severe cases. Over the last 5 years, our institution has selectively used this method for more complex cases. The purpose of this article is to evaluate the differences between these 2 treatment methods in terms of avascular necrosis (AVN) rate, reoperation rate, and complication rate. METHODS: Eighty-eight hips that were surgically treated for SCFE between July 2004 and June 2012 met our inclusion criteria. The in situ fixation group included 71 hips, whereas 17 hips were anatomically reduced with the Mod. Dunn procedure. Loder classification, severity, acuity, complication rate, and reoperation rate were determined for the 2 cohorts. The χ analysis was performed to evaluate the relationship between the treatment method and outcome. RESULTS: As expected, stable slips did well with in situ pinning with no cases of AVN, even in more severe slips. Ten stable slips were treated with the Mod. Dunn approach and 2 (20%) developed AVN. Unstable slips were more difficult to treat with 3 of the 7 hips stabilized in situ developing AVN (43%). Two of the 7 unstable slips treated by the Mod. Dunn procedure developed AVN (29%). The other outcomes studied (reoperation rate and complication rate) were not significantly related to the surgical treatment method (P = 0.732 and 0.261, respectively). CONCLUSIONS: In situ pinning remains a safe and predictable method for treatment of stable SCFE with no AVN noted, even in severe slips. Attempts to anatomically reduce stable slips led to severe AVN in 20% of cases, thus this treatment approach should be considered with caution. Treatment of unstable slips remains problematic with high AVN rates noted whether treated by in situ fixation or capital realignment (Mod. Dunn). LEVEL OF EVIDENCE: Level III retrospective comparative study.

Improving diagnostic efficiency: analysis of pelvic MRI versus emergency hip aspiration for suspected hip sepsis.

BACKGROUND: Accurately diagnosing and treating childhood hip sepsis is challenging. Adjacent bone and soft-tissue infections are common and can lead to delayed and inappropriate treatment. This study evaluated the effect of early advanced imaging (bone scan, magnetic resonance imaging) in the management of suspected hip sepsis. METHODS: A retrospective review of pediatric patients admitted between 2003 and 2009 with suspected hip sepsis was performed. Patients were classified into 2 categories: group I-immediate hip aspiration or group II-advanced imaging performed before intervention. RESULTS: In total, 130 patients (53 in group I and 77 in group II) were included. No significant differences were found between the groups with regard to laboratory values, temperature, number of anesthetics, and length of hospital stay. However, patients in group I were younger than in group II (5.4 vs. 7.3 y, P=0.02) and more patients in group I were unable to bear weight on the affected limb compared with group II (83% vs. 61%, P=0.009). In group I, 36 patients (68%) had a septic hip compared with 35 patients (45%) in group II. In group I, 16 patients (30%) required reoperation versus 13 (17%) patients in group II. Results from the multivariate analysis demonstrated that reoperation was required 2.8 times (95% confidence interval, 1.12-6.78) more often in group I as compared with group II (P=0.03). CONCLUSIONS: Advanced imaging performed before hip aspiration improves diagnostic efficacy and may decrease the need for reoperation. LEVEL OF EVIDENCE: III.

Is there a role for acetabular dysplasia correction in an asymptomatic patient?

BACKGROUND: Childhood hip dysplasia is best treated in infancy or early childhood with hopes that the acetabulum will be completely normalized by nonoperative treatment methods, which may include Pavlik and brace treatment as well as formal closed reduction and hip spica casting. In many cases, this ideal result cannot be achieved and the child is left with residual dysplasia, which is often not symptomatic. Other patients may present late with hip dysplasia that is not identified in early childhood. Some develop hip pain with no prior known hip problem. Other children have asymptomatic dysplasia that is picked up on an incidental radiograph. The orthopaedic literature is clear regarding the need for corrective hip osteotomies in symptomatic children. Surgery to correct asymptomatic hip dysplasia remains controversial. METHODS: Children who have no symptoms yet have abnormal radiographs present a puzzling circumstance. In these cases, surgeons need to use quoted radiographic normal values for acetabular coverage of the femoral head as well as long-term natural history studies to decide whether to proceed with a corrective acetabular osteotomy. Long-term follow-up studies confirm that even patients with borderline dysplasia are likely to have significant hip symptoms and arthritis by middle age. RESULTS: Many children and adolescents with asymptomatic residual hip dysplasia should have corrective acetabular procedures performed. Surgery is more easily performed with more predictable results when the child is younger than 8 years. CONCLUSIONS: It is impossible to state with certainty which children with residual radiographic hip dysplasia, but without symptoms, should have a corrective acetabular osteotomy. Review of the literature confirms that many patients have been undertreated in the past, with a high percentage of children with borderline hip dysplasia developing premature arthritis in early to mid-adult life. Current data suggest that surgery should be performed in borderline cases. Skill of the surgeon in performing acetabular osteotomies and/or ease of referral to a treatment center may temper the timing of such decisions.

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.

Limitations of evidence-based medicine: the role of experience and expert opinion.

BACKGROUND: Advances in statistical science and the development of computers (a result of the digital revolution) have allowed many disciplines, including medicine, to develop a more objective analysis of data as applied to decision making. The concept of evidence-based medicine (EBM) includes that scientific study of disease and treatment efficacy will allow high-quality, cost-effective treatment. The concept of EBM is well established in medical specialties, particularly for cardiovascular disease and cancer, but less developed in the surgical specialties. Multiple factors make evidence-based surgical (EBS) studies more problematic. Entering children into prospective surgical treatment trials remains difficult for the parents and patients who are asked to allow a choice of procedures for a surgical intervention that will take just an hour or two but whose results could change the child's entire life. Comparative effectiveness research, a subset of EBM, is of special interest to surgeons, who often need to decide on an expensive new implant versus a reliable, less expensive, established one. Factors that make the scientific analysis of surgical treatment efficacy more difficult include issues as practical as surgical skill. Prescribing an antihypertensive medication or a lipid-lowering drug has little variability in its delivery. Performance of a complex surgical procedure can vary immensely, allowing a procedure to be very effective in one surgeon's hands but far less applicable by another surgeon (eg, arthroscopic vs. open shoulder surgery). Thus, large patient series with careful follow-up are required to clarify outcome differences. Scientific study of surgical treatment outcomes in childhood orthopaedic conditions remains in its infancy. Because of minimal funding available for such research, most available studies are poorly designed with an inadequate study sample size. As for the near future, neither the government nor industry sources seem to have a strong incentive to study outcomes in childhood surgical diseases that have a low prevalence. Because current research provides little evidence to guide parents and their surgeon (when a choice exists), consumers generally seek what they believe to be the best available "expert opinion." CONCLUSIONS: Properly funded, the digital revolution will allow radical advances in establishing EBS decision making. However, the same digital revolution has produced an educated populace, greatly increasing their capacity for critical analysis of available data. Currently, both sophisticated parents and their surgeons remain hesitant to accept results from poorly designed studies when deciding on surgery for their child. As a result, expert opinion remains central to surgical decision making in children's orthopaedics. Knowledgeable surgeons look forward to future quantum improvements in research quality that will allow secure EBS-based decisions for their surgical patients.

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

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

Treatment outcomes of hips in patients with epiphyseal dysplasia.

Hip containment surgeries in multiple epiphyseal and spondyloepiphyseal dysplasia (MED/SED) patients aim to improve the mechanical environment of the hip joint. The purpose of this study was to determine if surgical intervention to improve femoral head coverage improved radiographic and clinical outcomes. A retrospective study identified patients with MED/SED seen in clinic between May 2000 and September 2017, with a minimum of 2-year follow-up. Patient charts/radiographs were reviewed for radiographic hip measurements, pain, and gait. Sixty-nine hips in 35 patients were identified. Forty-four hips were treated nonoperatively and 25 were treated surgically. The mean age at diagnosis was 6.2 years. The mean follow-up was 7.7 years for the surgical group and 7.1 years for the nonsurgical group. The mean postoperative follow-up was 5.4 years. Acetabular index decreased from initial to final visit by 9.0° in the surgical group and 1.6° in the nonsurgical group. Tonnis angle decreased by 13.5° in the surgical group and 1.5° in the nonsurgical group. Center edge angle increased by 19.0° in the surgical group and 7.1° in the nonsurgical group. Hips in the surgical group were 6.1 times more likely to experience an improvement in pain compared with hips in the nonsurgical group. Gait at the final follow-up was similar among the two groups. In this study cohort, containment surgery provided increased femoral head coverage; however, there was equal femoral head deformation despite intervention. Hips treated surgically were more likely to experience an improvement in pain; however, gait alterations did not improve.

Surgical management of the problematic hip in adolescent and young adult patients.

Surgical management of the problematic hip in adolescent and young adult patients can be challenging. In many of these patients, hip arthrosis and pain occur secondary to hip dysplasia associated with chronic instability, whether the result of prior treatment or chronic unmanaged acetabular dysplasia. Surgical techniques such as the Bernese periacetabular osteotomy are performed to correct acetabular deficiency, restore hip joint stability, and eliminate pain. Patients with previous Legg-Calvé-Perthes disease or slipped capital femoral epiphysis frequently note onset of symptomatic hip arthrosis and pain in adolescence or young adulthood. Pain occurs secondary to pathologic impingement of the deformed proximal femur against the anterolateral acetabulum (ie, femoroacetabular impingement). The recent successful innovation of the transtrochanteric surgical hip dislocation approach provides complete access to the hip and offers the potential for comprehensive correction of both the often severe proximal femoral deformity and associated labral chondral disease secondary to Legg-Calvé-Perthes disease and slipped capital femoral epiphysis. Restoration of more normal proximal femoral morphology results in marked improvement in functional outcome. Effective orthopaedic management requires an understanding of the mechanisms of hip disease as well as surgical expertise.