Slipped Upper Femoral Epiphysis in Adolescents: Evolving Information on Its Mode of Presentation and Management.

Background and objective Slipped upper femoral epiphysis (SUFE) is one of the most common hip pathologies in adolescents and pre-adolescents, the diagnosis of which is often missed due to delayed presentations. In this study, we aimed to conduct a retrospective analysis of SUFE cases treated in the hospital during the 15-year period from 2003 to 2018 and examine its bilateral presentation and the need for prophylactic pinning on the unaffected side. Methods This retrospective cohort study involved cases that were treated from 2003 to 2018. The case details were retrieved from the medical records department. Records older than 15 years were excluded owing to their inaccuracy, and 26 cases of SUFE were included in the final analysis. Each case was subjected to physical and radiological examinations of the symptomatic and asymptomatic hips. IBM SPSS Statistics v23 (IBM Corp., Armonk, NY) was used for data analysis. Results In this study, six of the 26 patients had bilateral SUFE and required subsequent surgical pinning. The duration of surgical interventions ranged from two to 22 months, while the mean intervention duration was 10.3 months. Among the cases, 61.5% (p<0.05) were idiopathic in nature upon documentation. However, 19% (p<0.05) of the cases were shown to be associated with an underlying condition or prior symptoms of the condition, whereas 7.6% (p<0.05) had an increased basal metabolic index; 11% (p<0.05) of the cases had an inherited family history of SUFE. A comparison between males and females showed a slightly higher frequency of complications in males (n=14) than in females (n=12) (p=0.556). The age of the patients at the presentation ranged between and 10-15 years, with an average age of 12.5 years. Conclusion Based on our findings, males were affected more than females and most of the cases were idiopathic. There is no significant evidence to support the need for prophylactic pinning of the unaffected hip. We recommend prospective studies with a larger sample of patients to gain more insight into the topic.

Proposal of a novel predictive radiological method to assess the possibility of closed reduction in late presenting developmental dysplasia of the hip: the femoro-acetabular zones.

Late presentation of developmental dysplasia of the hip (DDH) remains a major orthopedic problem. However, existing management is not standardized and is highly surgeon dependent. The theory behind femoro-acetabular zones (FAZ) system is to find a relationship between acetabular maturity and severity of dislocation in one hand, and the outcome of closed reduction, on the other hand in late presenting cases. A retrospective study was performed on children with untreated DDH that underwent closed treatment. Our series consisted of 65 hips; mean patient age was 24 months (range: 9-30 months) with a minimum follow-up of 3 years. FAZ classification was applied to the pre-reduction pelvic radiograph, while the results were evaluated according to Severin's scoring system. Overall, 37 of 65 hips (57%) achieved a satisfactory outcome (Severin I and II), while 22 hips (33%) were found to be unsatisfactory (Severin III). Six hips (10%) needed an open reduction. FAZ expressed a simple and reliable classification in predicting the success of closed reduction. This novel X-ray-based classification system can easily predict patients with DDH in whom a closed reduction is likely to succeed and defer patients with higher grades to surgical intervention. Yet, its validity has to be verified in larger cohort studies and directly compared to the established International Hip Dysplasia Institute classification.

The Pediatric Hip: A Rare Case of Acetabular Labral Tear and Paralabral Cyst: A Case Report.

CASE: We report the case of an active 8-year-old patient with a 2-year history of groin and thigh pain. Magnetic resonance imaging of the hip demonstrated a paralabral cyst arising from a superior labral tear. Arthroscopic labral repair and decompression of the cyst were performed, and the patient remains asymptomatic at 2-year follow-up. CONCLUSIONS: Acetabular labral tears with concomitant paralabral cysts have been described in the literature in the adult population and successfully treated arthroscopically. We propose that surgeons should be aware of this as a cause for undiagnosed groin and thigh pain in the pediatric population and that arthroscopic management is successful.

Reliability and predictability of the centre-edge angle in the assessment of pincer femoroacetabular impingement.

PURPOSE: The aim of the study was to assess the use of the centre-edge (CE) angle in the assessment of pincer femoro-acetabular impingement (FAI) for reliability and predictability in the diagnosis. METHODS: Between 2004 and 2008, 55 patients underwent surgical treatment for FAI. A control group of 30 was identified among patients attending the emergency department with normal radiographs. Radiographs were assessed by two independent observers both before and after the operation. Nine patients with trauma were excluded. The magnetic resonance arthrogram reports of the remaining 46 patients were assessed for pincer FAI. Nineteen patients were identified and underwent repeat radiographic assessment. All underwent surgical dislocation of hip (SDH), acetabular, with/without femoral osteochondroplasty. Acetabular depth and version were also assessed. The intraclass correlation (ICC) was used to assess reliability of the CE angle. The paired t test and independent groups t test were used to assess the difference between the pincer FAI group, both pre-op and post-op and against controls. RESULTS: The control and pincer groups were similar in demographics (p=0.1769). Coxa profunda was present in 14 patients with eight also having retroverted acetabuli. Of the rest two had retroverted acetabuli and one protrusio. The mean CE angle in the control group was 31.4°, in the pre-op pincer group 46.2° and in the post-op pincer group 38.3°. The ICC for intra-observer correlation was 0.977 and 0.992 pre-op and 0.986 and 0.974 post-op. The ICC for inter-observer correlation was 0.960 and 0.957 pre-op and 0.979 and 0.967 post-op.The p value was <0.001 between the controls, the pre-op and post-op pincer groups. The test characteristics using the CE angle ≥ 40 is a reasonably good predictor of FAI, with a sensitivity of 84.2% and a specificity of 100%. CONCLUSIONS: The pincer FAI can be reliably assessed with the CE angle and can be predicted in patients presenting with FAI.

Intermetatarsal angle after first metatarsophalangeal joint arthrodesis for hallux valgus.

BACKGROUND: First metatarsophalangeal (MTP) joint arthrodesis is commonly done for hallux valgus with an arthritic joint. In patients with a wide preoperative first intermetatarsal (IM) angle an important question is whether the metatarsus varus will be corrected by the first MTP joint fusion alone or whether an additional basal osteotomy is necessary. METHODS: The charts and radiographs of 20 patients who had arthrodesis of the first MTP joint were retrospectively reviewed. All 20 patients were female with a mean age of 54.2 (range 42 to 78) years. Either a Hallu-S plate (Integra Life Sciences, Nudeal, France) or two crossed screws were used to stabilize the arthrodesis. The IM angles were measured independently by two individuals on weightbearing preoperative, 6-week postoperative, and final followup films. The final followup radiographs were taken at an average of 13.7 (range 6 to 30) months after surgery. A Student t-test was used to evaluate the changes in the IM angle and interobserver variations. RESULTS: The mean preoperative IM angle was 16.65 (range 12 to 26) degrees. The mean postoperative IM angle was 10.35 (range 6 to 15) degrees. The mean IM angle at final followup was 8.67 (range 5 to 12) degrees. The mean change between preoperative IM angle and IM angle at final followup was 8.22 (range 4 to 14) degrees. This change of the IM angle was statistically significant (p < 0.0001). CONCLUSIONS: These results indicate that in patients with severe hallux valgus and first MTP joint degeneration arthrodesis can significantly correct the IM angle without the addition of a basal osteotomy.

The effect of traction on compartment pressures during intramedullary nailing of tibial-shaft fractures. A prospective randomised trial.

Our aim was to study the effect of traction on the compartment pressures during intramedullary nailing of closed tibial-shaft fractures. Thirty consecutive patients with Tscherne C1 fractures were randomised into two groups. Sixteen patients underwent intramedullary nailing of the tibia with traction and 14 patients without traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure. The data collected was analysed using Student's t test. There was no statistically significant difference (p>0.05) in the pre-operative mean compartment pressures for both groups. The mean post-operative measurements were higher in all four compartments in the traction group (p<0.05). None of the pressures reached the critical level. These results show that traction as an aid unnecessarily increases compartment pressures.

Long-term functional outcome assessment of plate fixation and autogenous bone grafting for clavicular non-union.

INTRODUCTION: The aim of our study was to assess the long-term functional and radiological outcome of clavicular non-union in patients treated with open reduction and bone grafting. A total of 24 non-unions treated between 1994 and 2001 were analysed using chart and radiological review and assessed with the American Academy of Orthopaedic Surgeons (AAOS) DASH questionnaire. RESULTS: There were 13 males and 10 females with a mean age of 37.95 (range 21-65) years. One patient had bilateral injuries. The average time from injury to operation was 10.3 (range 4-29) months and the average follow-up post-operatively was 42.1 (range 6-75) months. All patients were treated using a dynamic compression or reconstruction plate with autogenous bone grafting. Twenty-two of the 24 non-unions eventually healed. DASH assessment indicated a higher level of disability in the treated group than found in the normal population. This only proved significant in the sub-population of patients with associated co-morbidities. CONCLUSION: We conclude that the long-term outcome results of this procedure indicate it to be a well-tolerated and successful operation in treating the disability and pain associated with clavicular non-union. Most patients return to a daily level of function close to the general population. Patients with associated co-morbidities should have these treated pre-operatively for best results.