Open reduction and internal fixation of displaced clavicle fractures in adolescents

The literature available on patient oriented outcomes of operative management for clavicle fractures in adolescents is fairly limited. The purpose of this study was to analyze the potential of open reduction and internal fixation for displaced mid-shaft clavicle fractures in adolescent patients. We reviewed our series of surgical cases performed in 19 adolescents (mean age: 14.6 years) with displaced unilateral clavicle fractures. Baseline data acquisition included demographic and radiographic variables. A Synthes® LCP clavicular plate was utilized for fixation in all cases. Follow-up data included functional outcome assessment using the Quick Disability of Arm, Shoulder, and Hand Questionnaire (DASH), the simple shoulder test (SST) and additional binary questions. At a mean follow-up of 16 months, quick DASH scores were 4.0 (range: 0–35.5) and mean number of positive yes responses on the SST for all operative patients was 11 (range: 9–12). All cases proved complete radiological union at the 3-month follow-up. All patients returned to full athletics at a mean time of 14 weeks (range: 12–17 weeks). Two patients had minimal hypertrophic scars while no patient was noted with keloid formation or neurovascular deficit. One patient complained of implant prominence and occasional symptoms of discomfort at the 15 month follow-up and opted for implant removal. This was successfully performed with uneventful full recovery. All patients were fully satisfied with their choice for surgical intervention. Anatomical reduction with internal fixation and early mobilization of adolescent displaced clavicle fractures remains a viable treatment option with predictable results and no major complications in reliable hands

Hip arthrodesis in the pediatric population: where do we stand?

Reconstructive and salvage procedures have continued to evolve in orthopedic surgery with changing functional demands of the population as well as advances in implants and surgical techniques. What used to be popular or traditional care at some point may eventually become a thing of the past, and this is true as far as many orthopedic surgical procedures are concerned. Understanding the etiology, pathogenesis, and managing and postponing the destructive pathway of osteoarthritis (OA) has been the goal of orthopedists since the specialty began in the early part of 18th century. Options of treating the severe sequelae of an arthritic joint have varied in different treatment eras. Management options have changed from a spectrum of non-treatment and slow suffering to muscle and soft-tissue releases, interposition arthroplasty and eventual extreme options like joint fusion or arthrodesis. The concept and advent of joint replacement surgery started a new era in the management of OA and was a dream come true in many ways. Mobility and stability are achieved together during the arthroplasty (joint replacement) that allowes the patient to maintain a good level of function. Arthroplasty certainly has its pros and cons as we have discovered in the past six decades. Pushing the envelope to younger population has its limitation in terms of longevity of the prosthesis, early loosening, need for repeated revisions that at some point may not be technically possible and risk of infection and disastrous consequences like PE and death associated with the gravity of the procedure. As infrequent as it is in today's clinical practice, arthrodesis of the hip joint has a role and remains a solid option for a well selected case

Narrative Review of Complications Following DDH Treatment.

BackgroundThe purpose of this narrative review was to survey the literature for common complications following treatment of DDH in children less than 4 years old.MethodsThe Pubmed database was queried. Search result titles were reviewed to identify papers that were pertinent to the topic. Abstracts for these papers were obtained and read, and a subset of these were selected for review of the complete manuscript.Results92 manuscripts were reviewed. Residual dysplasia, redislocation, and osteonecrosis are the primary complications of treatment in this age group. In the long term, hips without complications related to DDH treatment tend to do well, although a significant percentage of them will inevitably require joint replacement surgery.ConclusionAlthough there is excellent potential for a good outcome when DDH is diagnosed and treated under age 4 years, osteonecrosis continues to be a concern with all treatment methods. A subset of patients from this young cohort will continue to have residual dysplasia or recurrent dislocation requiring return to the operating room

Extra-articular, Intraepiphyseal Drilling for Osteochondritis Dissecans of the Knee

Symptomatic osteochondritis dissecans lesions of the knee frequently occur in skeletally immature patients. When conservative treatment fails, retro-articular drilling, also known as intraepiphyseal extra-articular drilling, becomes a viable treatment option. The purpose of this article is to describe our surgical technique and postoperative management of patients with stable osteochondritis dissecans lesions involving the femoral condyles. This technique is reproducible, uses readily available equipment, and has yielded good clinical outcomes with high healing rates and relatively early return to sports

Assessment of three-dimensional acetabular coverage angles.

The purpose of this article is to report the inter- and intra-observer reliability of a computerized objective technique to quantify patient-specific acetabular morphology. We describe the use of and provide the software code for a technique to better define the location and magnitude of acetabular pathology. We have developed software code that allows the end user to obtain detailed measurements of the acetabulum using traditional computed tomography data. We provide the code and detailed instructions on how to use it in this article. The methodology was validated by having an unbiased observer (that was not involved in this project but has been trained in this software measurement methodology) to perform the entire acquisition, reconstruction and analysis procedure and compare their measurements to the measurements of one of the authors. The author then repeated the procedure 2 months later to determine intra-observer reliability. Inter- and intra-observer reliability for version, tilt, surface area and total acetabular coverage angles ranged from an intra-class correlation coefficient of 0.805 to 0.997. The method provided in this manuscript gives a reproducible objective assessment of three-dimensional (3D) acetabular morphology that can be used to assist in the diagnosis of hip pathology and to compare the morphological parameters of subjects with and without hip pathology. It allows a surgeon to understand the 3D shape of each individual's acetabulum, share these findings with patients and their parents to demonstrate the magnitude and location of the clinical abnormality and perform patient-specific surgical corrections to optimize the shape and coverage of the hip

A medial portal for hip arthroscopy in children with septic arthritis : a safety study

Prompt open arthrotomy is historically utilized to treat pediatric septic arthritis of the hip, but arthroscopy has been described as a valid alternative to prevent long-term sequelae. Standard hip arthroscopy in adolescents and adults utilizes lateral-based portals, but successful irrigation in infants may necessitate a medial portal due to the smaller joint size. The purpose of this study was to determine the safety of a medial hip portal in children based on its anatomic relation to neurovascular structures

Prospective evaluation of in situ screw fixation for stable slipped capital femoral epiphysis.

PurposeWe aimed to determine which variables were associated with persistent symptoms or need for further surgery in patients treated with in situ fixation for stable slipped capital femoral epiphysis. We hypothesized that patients with greater proximal femoral deformity would require revision surgical intervention.MethodsWe prospectively collected data on stable slipped capital femoral epiphysis patients who underwent in situ screw fixation at a single institution. Demographic and radiographic information, as well as patient-reported outcomes, were collected.ResultsForty-six patients (54 hips) with an average follow-up of 3.5 years (range: 2.0-8.5) and mean pre-op Southwick slip angle of 40.5° ± 19.4° were studied. We observed one complication following the index procedure (2%). Twelve hips (22%) went on to have a secondary procedure 2.7 ± 2.2 years after the index surgery. Severe slips were 14.8× more likely to undergo a secondary procedure than mild and moderate slips (p < 0.001). We found no correlation between slip severity and patient-reported outcomes (p > 0.6). Hips requiring a secondary procedure had significantly lower Hip disability and Osteoarthritis Outcome scores (76.8 ± 18.4) at final follow-up compared to hips that did not require additional surgery (86.8 ± 15.7) (p = 0.042).ConclusionWith minimum 2-year follow-up, 22% of patients required a secondary surgery. Patient-reported outcomes did not correlate with slip severity, but were found to be significantly higher in slipped capital femoral epiphysis patients that did not require a secondary procedure. Prophylactic treatment of all slip-related cam deformity was not found to be necessary in this prospective cohort. Patients with moderate-to-severe slips may require secondary surgery.Level of evidenceLevel II