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Background: The sphericity of the femoral head is a metric used to evaluate hip pathologies and is associated with the development of osteoarthritis and femoral-acetabular impingement., Aim: To analyze the three-dimensional asphericity of the femoral head of asymptomatic pediatric hips. We hypothesized that femoral head asphericity will vary significantly between male and female pediatric hips and increase with age in both sexes., Methods: Computed tomography scans were obtained on 158 children and adolescents from a single institution in the United States (8-18 years; 50% male) without hip pain. Proximal femoral measurements including the femoral head diameter, femoral head volume, residual volume, asphericity index, and local diameter difference were used to evaluate femoral head sphericity., Results: In both sexes, the residual volume increased by age ( P < 0.05). Despite significantly smaller femoral head size in older ages (> 13 years) in females, there were no sex-differences in residual volume and aspherity index. There were no age-related changes in mean diameter difference in both sexes ( P = 0.07) with no significant sex-differences across different age groups ( P = 0.06). In contrast, there were significant increases in local aspherity (maximum diameter difference) across whole surface of the femoral head and all quadrants except the inferior regions in males ( P = 0.03). There were no sex-differences in maximum diameter difference at any regions and age group ( P > 0.05). Increased alpha angle was only correlated to increased mean diameter difference across overall surface of the femoral head ( P = 0.024)., Conclusion: There is a substantial localized asphericity in asymptomatic hips which increases with age in. While 2D measured alpha angle can capture overall asphericity of the femoral head, it may not be sensitive enough to represent regional asphericity patterns., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective: To compare the clinical outcomes between patients with moderate and severe slipped capital femoral epiphysis (SCFE) treated with osteotomy at the base of neck and osteoplasty and with healthy individuals., Methods: Comparative cohort with 12 patients (14 hips) with moderate and severe SCFE who underwent osteotomy at the base of neck and osteoplasty between 2007 and 2014. The mean age at surgery was 13.3 ± 2.5 years and the mean follow-up was 3.8 ± 2.2 years. We assessed the level of hip pain by the visual analog scale (VAS) and anterior impingement test (AIT); the level of function using the Harris Hip Score (HHS) and 12-Item Short Form Health Survey (SF-12), the range of motion (ROM) by goniometry and Drehmann sign, and the hip muscular strength by isokinetic and Trendelenburg sign., Results: The level of pain was slightly higher in the SCFE cohort compared with healthy hips (VAS, 0.8 ± 1.4 vs 0 ± 0, 0.007; AIT, 14% vs 0%, p = 0.06; respectively). No differences were observed between the SCFE and control cohort for the functional scores (HHS, 94 ± 7 vs 100 ± 1, p = 0.135); except for ROM, with increased internal rotation (37.3º ± 9.4º vs 28.7º ± 8.2º, p < 0.001), and strength, with decreased abduction torque (75.5 ± 36.9 Nm/Kg vs 88.5 ± 27.6 Nm/Kg, p = 0.045) in the SCFE cohort., Conclusion: The osteotomy at the base of neck and the osteoplasty restored the hip motion and muscle strength, except for the abductor strength, to near normal levels, representing a viable option for the treatment of moderate and severe SCFE. Level of Evidence III, Ambidirectional Cohort Study., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: To perform a systematic review and meta-analysis to compare clinical and surgical outcomes of posterior versus anterior approach to primary total hip arthroplasty (THA)., Methods: This study followed the standard methodology established by the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched for randomized controlled trials comparing posterior an anterior approach to primary THA with at least one quantifiable functional outcome published in the PubMed, Cochrane, and Virtual Health Library databases., Results: The analysis included ten randomized controlled trials conducted with 774 patients. The posterior approach was associated with shorter operative time (mean of 15.98 minutes shorter, 95% CI 11.21 to 20.76, p < 0.00001) while the anterior approach was associated with shorter length of hospital stay (0.31 days or about eight hours shorter, 95% CI 0.12 to 0.51, p = 0.002) and greater earlier improvement in functional outcomes up to six months from the procedure (mean Harris Hip Score of 4.06 points greater, 95% CI 2.23 to 5.88, p < 0.0001)., Conclusion: Whereas the posterior approach to primary THA is associated with a shorter operative time, the anterior approach has the potential to decrease the length of stay and provide greater short-term functional restoration. Level of evidence I, Systematic Review and Meta-Analysis. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: The plantar pressure distribution can be assessed quantitatively by computerized baropodometry such as carpet or insole. An insole-type system with wireless transmission was developed and plantar pressure results were previously validated by force platform. However, the reproducibility of the system had not been determined. Our objective was to evaluate the reliability of the results in different gait cycles, clinical characteristics and in different plantar anatomical sites., Methods: 41 healthy adults (age, 34 ± 13 years; body mass index, 25 ± 5 kg/m 2 ; 26 [63%], male, 26 [63%] practicing physical activity) were evaluated. Baropodometer evaluations were performed in 3 walking cycles with 100 m each, and the reliability between the cycles was examined. Pressure points on the heel, first metatarsal, fifth metatarsal and total plantar pressure were analyzed and compared., Results: Moderate agreement was identified between the second and third cycles (ICC, 0.66; 95% CI, 0.14-0.83). Physical activity practitioners showed higher total plantar pressure (70.8 vs 68.2 Kpa; p = 0.04) and higher pressure in the heel (70.7 vs 68.1 Kpa; p = 0.036) in relation to sedentary ones., Conclusion: The insole was able to assess plant pressure with moderate reliability from the adaptation period. Level of Evidence III, Case control study - Investigating a diagnostic test. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: The epiphyseal tubercle, the corresponding metaphyseal fossa, and peripheral cupping are key stabilizers of the femoral head-neck junction. Abnormal development of these features in the setting of supraphysiologic physeal stress under high forces (for example, forces that occur during sports activity) may result in a cam morphology. Although most previous studies on cam-type femoroacetabular impingement (FAI) have mainly focused on overgrowth of the peripheral cupping, little is known about detailed morphologic changes of the epiphyseal and metaphyseal bony surfaces in patients with cam morphology., Questions/purposes: (1) Does the CT-based bony morphology of the peripheral epiphyseal cupping differ between patients with a cam-type morphology and asymptomatic controls (individuals who did not have hip pain)? (2) Does the CT-based bony morphology of the epiphyseal tubercle differ between patients with a cam-type morphology and asymptomatic controls? (3) Does the CT-based bony morphology of the metaphyseal fossa differ between patients with a cam-type morphology and asymptomatic controls?, Methods: After obtaining institutional review board approval for this study, we retrospectively searched our institutional database for patients aged 8 to 15 years with a diagnosis of an idiopathic cam morphology who underwent a preoperative CT evaluation of the affected hip between 2005 and 2018 (n = 152). We excluded 96 patients with unavailable CT scans and 40 patients with prior joint diseases other than cam-type FAI. Our search resulted in 16 patients, including nine males. Six of 16 patients had a diagnosis of bilateral FAI, for whom we randomly selected one side for the analysis. Three-dimensional (3-D) models of the proximal femur were generated to quantify the size of the peripheral cupping (peripheral growth of the epiphysis around the metaphysis), epiphyseal tubercle (a beak-like prominence in the posterosuperior aspect of the epiphysis), and metaphyseal fossa (a groove on the metaphyseal surface corresponding to the epiphyseal tubercle). A general linear model was used to compare the quantified anatomic features between the FAI cohort and 80 asymptomatic hips (aged 8 to 15 years; 50% male) after adjusting for age and sex. A secondary analysis using the Wilcoxon matched-pairs signed rank test was performed to assess side-to-side differences in quantified morphological features in 10 patients with unilateral FAI., Results: After adjusting for age and sex, we found that patients with FAI had larger peripheral cupping in the anterior, posterior, superior, and inferior regions than control patients who did not have hip symptoms or radiographic signs of FAI (by 1.3- to 1.7-fold; p < 0.01 for all comparisons). The epiphyseal tubercle height and length were smaller in patients with FAI than in controls (by 0.3- to 0.6-fold; p < 0.02 for all comparisons). There was no difference in tubercle width between the groups. Metaphyseal fossa depth, width, and length were larger in patients with FAI than in controls (by 1.8- to 2.3-fold; p < 0.001 for all comparisons). For patients with unilateral FAI, we saw similar peripheral cupping but smaller epiphyseal tubercle (height and length) along with larger metaphyseal fossa (depth) in the FAI side compared with the uninvolved contralateral side., Conclusion: Consistent with prior studies, we observed more peripheral cupping in patients with cam-type FAI than control patients without hip symptoms or radiographic signs of FAI. Interestingly, the epiphyseal tubercle height and length were smaller and the metaphyseal fossa was larger in hips with cam-type FAI, suggesting varying inner bone surface morphology of the growth plate. The docking mechanism between the epiphyseal tubercle and the metaphyseal fossa is important for epiphyseal stability, particularly at early ages when the peripheral cupping is not fully developed. An underdeveloped tubercle and a large fossa could be associated with a reduction in stability, while excessive peripheral cupping growth would be a factor related to improved physeal stability. This is further supported by observed side-to-side differences in tubercle and fossa morphology in patients with unilateral FAI. Further longitudinal studies would be worthwhile to study the causality and compensatory mechanisms related to epiphyseal and metaphyseal bony morphology in pathogenesis cam-type FAI. Such information will lay the foundation for developing imaging biomarkers to predict the risk of FAI or to monitor its progress, which are critical in clinical care planning., Level of Evidence: Level III, prognostic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Each author certifies that neither he nor she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

Background: Contemporary studies have described the rotational mechanism in patients with slipped capital femoral epiphysis (SCFE). However, there have been limited patient imaging data and information to quantify the rotation. Determining whether the epiphysis is rotated or translated and measuring the epiphyseal displacement in all planes may facilitate planning for surgical reorientation of the epiphysis., Questions/purposes: (1) How does epiphyseal rotation and translation differ among mild, moderate, and severe SCFE? (2) Is there a correlation between epiphyseal rotation and posterior or inferior translation in hips with SCFE? (3) Does epiphyseal rotation correlate with the size of the epiphyseal tubercle or the metaphyseal fossa or with epiphyseal cupping?, Methods: We identified 51 patients (55% boys [28 of 51]; mean age 13 ± 2 years) with stable SCFE who underwent preoperative CT of the pelvis before definitive treatment. Stable SCFE was selected because unstable SCFE would not allow for accurate assessment of rotation given the complete displacement of the femoral head in relation to the neck. The epiphysis and metaphysis were segmented and reconstructed in three-dimensions (3-D) for analysis in this retrospective study. One observer (a second-year orthopaedic resident) performed the image segmentation and measurements of epiphyseal rotation and translation relative to the metaphysis, epiphyseal tubercle, metaphyseal fossa, and the epiphysis extension onto the metaphysis defined as epiphyseal cupping. To assess the reliability of the measurements, a randomly selected subset of 15 hips was remeasured by the primary examiner and by the two experienced examiners independently. We used ANOVA to calculate the intraclass and interclass correlation coefficients (ICCs) for intraobserver and interobserver reliability of rotational and translational measurements. The ICC values for rotation were 0.91 (intraobserver) and 0.87 (interobserver) and the ICC values for translation were 0.92 (intraobserver) and 0.87 (intraobserver). After adjusting for age and sex, we compared the degree of rotation and translation among mild, moderate, and severe SCFE. Pearson correlation analysis was used to assess the associations between rotation and translation and between rotation and tubercle, fossa, and cupping measurements., Results: Hips with severe SCFE had greater epiphyseal rotation than hips with mild SCFE (adjusted mean difference 21° [95% CI 11° to 31°]; p < 0.001) and hips with moderate SCFE (adjusted mean difference 13° [95% CI 3° to 23°]; p = 0.007). Epiphyseal rotation was positively correlated with posterior translation (r = 0.33 [95% CI 0.06 to 0.55]; p = 0.02) but not with inferior translation (r = 0.16 [95% CI -0.12 to 0.41]; p = 0.27). There was a positive correlation between rotation and metaphyseal fossa depth (r = 0.35 [95% CI 0.08 to 0.57]; p = 0.01), width (r = 0.41 [95% CI 0.15 to 0.61]; p = 0.003), and length (r = 0.56 [95% CI 0.38 to 0.75]; p < 0.001)., Conclusion: This study supports a rotational mechanism for the pathogenesis of SCFE. Increased rotation is associated with more severe slips, posterior epiphyseal translation, and enlargement of the metaphyseal fossa. The rotational nature of the deformity, with the center of rotation at the epiphyseal tubercle, should be considered when planning in situ fixation and realignment surgery. Avoiding placing a screw through the epiphyseal tubercle-the pivot point of rotation- may increase the stability of the epiphysis. The realignment of the epiphysis through rotation rather than simple translation is recommended during the open subcapital realignment procedure. Enlargement of the metaphyseal fossa disrupts the interlocking mechanism with the tubercle and increases epiphyseal instability. Even in the setting of a stable SCFE, an increased fossa enlargement may indicate using two screws instead of one screw, given the severity of epiphyseal rotation and the risk of instability. Further biomechanical studies should investigate the number and position of in situ fixation screws in relation to the epiphyseal tubercle and metaphyseal fossa., Level of Evidence: Level III, prognostic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Each author certifies that neither he nor she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

Purpose: To compare the 3D morphology of the metaphyseal fossa among mild, moderate and severe stable slipped capital femoral epiphysis (SCFE) and normal hips., Methods: We identified pelvic CT of 51 patients (55% male; mean 12.7 years (sd 1.9; 8-15)) with stable SCFE. In all, 16 of 51 hips (31%) had mild, 14 (27%) moderate and 21 (41%) severe SCFE. A total of 80 patients (50% male; mean age 11.5 years (sd 2.3; 8 to 15)) with normal hips who underwent pelvic CT due to abdominal pain made up the control cohort. CT scans were segmented, and the femur was reformatted using 3D software. We measured the metaphyseal fossa depth, width, length and surface area after the epiphysis was subtracted from the metaphysis in the 3D model., Results: The metaphyseal fossa width was significantly larger in severe (adjusted difference: 6.9%; 95% confidence interval (CI) 2.1 to 11.8; p = 0.001), moderate (6.5%; 95% CI 0.8 to 12.2; p = 0.02) and mild SCFE (6.2%; 95% CI 0.8 to 11.6; p = 0.01), in comparison with normal hips. Severe SCFE showed larger fossa length compared with mild SCFE (6.8%; 95% CI 0.6 to 13.0; p = 0.02) and normal hips (6.0%; 95% CI 1.4 to 10.6; p = 0.004). The fossa surface area was larger in severe (3.5%; 95% CI 1.3 to 5.7; p < 0.001) and moderate SCFE (2.7%; 95% CI 0.1 to 5.2; p = 0.03) when compared with normal hips. There were no differences in fossa depth between SCFE and normal hips., Conclusion: The metaphyseal fossa is wider and more extensive but not deeper in hips with moderate and severe SCFE in comparison with normal hips. Although hips with severe SCFE had larger length and surface area than mild SCFE hips, further research is needed to clarify whether enlargement of the metaphyseal fossa is a consequence of slip progression., Level of Evidence: III., (Copyright © 2020, The author(s).)

Purpose: To investigate whether body mass index (BMI) percentile impacts the morphology of the capital femoral epiphysis in children and adolescents without hip disorders., Methods: We assessed 68 subjects with healthy hips who underwent a pelvic CT for evaluation of appendicitis. There were 32 male patients (47%) and the mean age was 11.6 years (sd 2.3). The BMI (k/m 2 ) was calculated for sex- and age-related percentiles according to the Centers for Disease Control and Prevention growth charts. CT images were segmented, and the epiphysis and metaphysis were reformatted using 3D software. We measured the epiphyseal tubercle (height, width and length), the metaphyseal fossa (depth, width and length) and the peripheral cupping of the epiphysis. All measurements were normalized to the diameter of the epiphysis. Pearson's correlation analysis was used to assess the correlations between the variables measured and BMI percentile adjusted for age., Results: Following adjustment to age, increased BMI correlated to decreased tubercle height (r =-0.34; 95% confidence interval (CI) -0.53 to -0.11; p = 0.005), decreased tubercle length (r = -0.32; 95%CI -0.52 to -0.09; p = 0.008) and decreased tubercle width (r = -0.3; 95% CI -0.5 to -0.07; p = 0.01). There was no correlation between BMI and metaphyseal fossa and epiphyseal cupping measurements., Conclusion: The association between increased BMI percentile and decreased epiphyseal tubercle size, without changes of the metaphyseal fossa and peripheral cupping suggests another morphological change of the femur that may be associated with decreased growth plate resistance to shear stress. Further study is necessary to investigate whether the epiphyseal tubercle size plays a role in the pathogenesis of slipped capital femoral epiphysis in obese children and adolescents., Level of Evidence: Level IV., (Copyright © 2020, The author(s).)

Background: The diagnosis of slipped capital femoral epiphysis (SCFE) often is delayed. Although lack of clinical suspicion is the main cause of delayed diagnosis, typical radiographic changes may not be present during the initial phases of SCFE. The peritubercle lucency sign for follow-up of the contralateral hip in patients with unilateral SCFE may be beneficial in assisting the early diagnosis. However, the accuracy and reliability of this sign in patients with SCFE is unknown., Questions/purposes: (1) What is the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the peritubercle lucency sign on radiographs for the early diagnosis of SCFE compared with MRI as the gold standard? (2) What are the interobserver and intraobserver reliabilities of the peritubercle lucency sign on radiographs?, Methods: Between 2000 and 2017, 71 patients underwent MRI for an evaluation of pre-slip or a minimally displaced SCFE. Sixty percent of hips (43 of 71) had confirmed SCFE or pre-slip based on the presence of hip pain and MRI changes, and these patients underwent in situ pinning. Three independent experienced observers reviewed MR images of the 71 hips and agreed on the presence of a juxtaphyseal bright-fluid signal suggesting bone marrow edema in these 43 hips with SCFE, and absence MRI changes in the remaining 28 hips. The same three experienced observers and two inexperienced observers, including a general radiologist and an orthopaedic surgery resident, blindly assessed the radiographs for the presence or absence of the peritubercle lucency sign, without information about the diagnosis. Diagnostic accuracy measures including sensitivity, specificity, PPV, and NPV were evaluated. Intraobserver and interobserver agreements were calculated using kappa statistics., Results: The overall accuracy of the peritubercle lucency sign on radiographs was 94% (95% CI 91 to 96), sensitivity was 97% (95% CI 95 to 99), specificity was 89% (95% CI 90 to 96), PPV was 93% (95% CI 90 to 96), and NPV was 95% (95% CI 92 to 99). All accuracy parameters were greater than 85% for the five observers, regardless of experience level. Intraobserver agreement was perfect (kappa 1.0), and interobserver agreement was excellent for the peritubercle lucency sign on radiographs across the five observers (kappa 0.81 [95% CI 0.73 to 0.88]). The reliability was excellent for experienced observers (kappa 0.88 [95% CI 0.74 to 1.00]) and substantial for inexperienced observers (kappa 0.70 [95% CI 0.46 to 0.93]), although no difference was found with the numbers available (p = 0.18)., Conclusions: The peritubercle lucency sign on radiographs is accurate and reliable for the early diagnosis of SCFE compared with MRI as the gold standard. Improving the early diagnosis of SCFE may be possible with increased awareness, high clinical suspicion, and a scrutinized evaluation of radiographs including an assessment of the peritubercle lucency sign., Level of Evidence: Level III, diagnostic study.

Objective: To quantify pelvic retroversion during clinical evaluation of hip flexion with accelerometers and to verify the reliability of these sensors to measure hip flexion., Methods: An accelerometer was positioned laterally in the pelvis to measure pelvic retroversion. Another accelerometer was positioned anteriorly on the thigh to evaluate hip flexion amplitude. The evaluations were performed with volunteers in supine position by three raters. For evaluation of pelvic retroversion, the mean ± SD (minimum-maximum) was calculated. Reliability of the accelerometer between raters was determined by intraclass correlation coefficients (ICC). The linear correlation coefficient between hip flexion was determined by using goniometer and accelerometer., Results: The mean pelvic retroversion was 7.3° ± 0.93° (6°-11°) in the clinical limit of the hip range of motion, which was 106.25° ± 10.46° (93°-130°). The ICC between two raters were 0.60, 0.71 and 0.74 (goniometer) and 0.46, 0.71 and 0.83 (accelerometer). The linear correlation between hip flexion measurements with goniometer and accelerometer was 0.87., Conclusion: During clinical evaluation of the final range of hip flexion, there was an associated pelvic movement of approximately 7.3º. Accelerometers have proven to be reliable for measurement of hip flexion. Level of Evidence III, Study of nonconsecutive patients with no gold reference standard applied uniformly., Competing Interests: All authors declare no potential conflict of interest related to this article.

To evaluate the acetabular morphology in healed Legg-Calvé-Perthes disease after skeletal maturity using computed tomography (CT) scan and to compare with matched controls. We identified 33 (37 hips) patients with healed Legg-Calvé-Perthes disease and closed triradiate cartilage who underwent pelvic CT scan. Each patient was matched based on sex, age and side to a subject with no history of hip disease who had undergone pelvic CT evaluation because of abdominal pain. Both cohorts had 23 (70%) males and mean age of 16.4-16.5 ± 3.6 years. Two independent readers assessed lateral center-edge angle (LCEA), acetabular inclination angle (IA), acetabular depth-width ratio (ADR), acetabular version 10 mm below the dome (cranial) and at the acetabular center and anterior (AASA) and posterior acetabular sector angles (PASA). All measurements had good to excellent interobserver agreement (intraclass coefficients ≥ 0.87). The hips in the Legg-Calvé-Perthes disease cohort had a smaller mean ± standard deviation (SD) superior, anterior and posterior acetabular coverage as assessed by LCEA (13.2° ± 10.7° versus 28.2° ± 3.4°; P  < 0.0001), IA (11.6° ± 6.7° versus 3.5° ± 2.8°; P  < 0.0001), AASA (52.4° ± 9.5° versus 59.3° ± 5.0°; P  = 0.001) and PASA (79.3° ± 5.9° versus 92.3° ± 5.5°; P  < 0.0001) compared with controls. The acetabulum was shallower (ADR 287 ± 45 versus 323 ± 28; P  = 0.0002) and the acetabular version was decreased cranially (0.4°±9.2° versus 8.2°±6.8°; P  = 0.0002) and at the acetabular center (13.7°±5.1° versus 17.2° ±3.8°; P  = 0.004) in Legg-Calvé-Perthes disease hips. After skeletal maturity, hips with healed Legg-Calvé-Perthes disease have shallower and more cranially retroverted acetabula, with globally reduced coverage of the femoral head compared with age-, sex- and side-matched control hips., (© The Author(s) 2020. Published by Oxford University Press.)

Objective: Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years., Results: Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance., Conclusion: The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age. Level of Evidence: IV ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2020.)

Recent studies have suggested that the epiphyseal tubercle serves as a fulcrum for rotation in slipped capital femoral epiphysis (SCFE). However, radiographic evidence of the rotational mechanism is limited. In this study, we describe a novel radiographic staging system for SCFE based on the anatomic relationship between the epiphyseal tubercle and the metaphyseal socket., Methods: We reviewed the cases of 469 patients with SCFE who were treated at our institution between 2000 and 2017. SCFE was classified according to our proposed staging system using the preoperative lateral radiograph. Normal hips were considered to be Stage 0. In Stage 1, the tubercle is concentric within its metaphyseal socket, which is enlarged and may present peritubercle radiolucency. In Stage 2, there is evidence of eccentricity of the tubercle, which remains in contact with the posterior wall of the socket. In Stage 3, the tubercle and metaphyseal lucency reach the posterior cortex of the femoral neck. A complete dislodgment of the tubercle from the metaphysis is present in Stage 4. Intra- and interobserver agreement, and correlations between the staging system and the traditional classifications of severity, stability, and chronicity, were estimated., Results: The distribution by stage was as follows: 2% of the hips were classified as Stage 0, 19% were Stage 1, 48% were Stage 2, 15% were Stage 3, and 16% were Stage 4. The staging system had excellent intraobserver (κ = 0.89 [95% confidence interval (CI) = 0.83 to 0.96]) and interobserver agreement (κ = 0.87 [95% CI = 0.72 to 1.00]). There was a high correlation between the staging system and SCFE severity as assessed by the Southwick angle (r = 0.77 [95% CI = 0.73 to 0.82]; p < 0.001). There was a moderate correlation between the staging system and the Loder classification of stability (r = 0.55 [95% CI = 0.48 to 0.62]; p < 0.001) and a negligible correlation with the classification of chronicity (r = 0.19 [95% CI = 0.10 to 0.28]; p < 0.001)., Conclusions: The proposed staging system for SCFE is highly reliable and correlates well with the severity of SCFE based on the degree of displacement, with moderate correlation shown for stability. This new staging system helps in understanding the rotational mechanism of SCFE, warranting further investigation to determine its clinical application., Clinical Relevance: The novel classification has the potential for the identification of hips that demonstrate subtle SCFE or are at pre-slip stage, or those at risk for osteonecrosis of the femoral head, failure of fixation, or slip progression., (Copyright © 2019 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Objective: Hemipelvectomy is a complex surgery with a high complication rate. Here, we aimed to identify factors related to the onset of complications and calculate their impacts on hospital costs., Methods: We evaluated 31 consecutive patients who underwent hemipelvectomy between 1999 and 2015. We assessed the clinical and radiographic data to determine the patients' demographic factors, tumor and surgical characteristics, and complications. The individual hospital stays and financial balances were assessed up to 6 months following the index surgery., Results: The overall complication rate was 61% (19/31). Infection was the most prevalent complication (36%). Immediate postoperative death occurred in 5/31 patients (16%); another 5 (16%) died after hospital discharge due to disease progression. Histological grade, previous surgery, and previous radiotherapy were not associated with complications or infection. Acetabular resections, bone reconstruction, and longer operative times were associated with infection, whereas older age, pelvic organ involvement, and comorbidities were associated with immediate postoperative death. Complications and infection were associated with 4.8- and 5.9-fold increases in hospital costs, respectively., Conclusions: Acetabular resection and bone reconstruction are important factors that increase short-term complication rates, infection rates, and hospital costs. Mortality was associated with older age and adjacent pelvic tumor progression. Level of Evidence: IV, case series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Purpose: To investigate changes in acetabular morphology during the follow-up of slipped capital femoral epiphysis (SCFE) and search for factors associated with acetabular dysplasia at skeletal maturity., Methods: We evaluated 108 patients with unilateral SCFE (mean age at slip, 12.3 years sd 1.7) to skeletal maturity, with a minimum follow-up of two years (median 4.5 years; interquartile range 3.2 to 6.2). Acetabular parameters obtained from initial and most recent radiographs included the lateral centre-edge angle (LCEA), Tönnis angle (TA) and acetabular depth-width ratio (ADR). Acetabular dysplasia was considered for LCEA < 20° or TA > 10°. Femoral parameters consisted of the most recent head diameter, neck-shaft angle, neck length, articulotrochanteric distance and alpha angle., Results: At SCFE onset, the affected hip showed a slightly lower LCEA (26.4° sd 6.1° versus 27.3° sd 5.7°; p = 0.01) and ADR (330 sd 30 versus 340 sd 30; p < 0.001) compared with the uninvolved hip. At final follow-up, the affected hip showed lower LCEA (24.5° sd 7.6° versus 28.8°sd 6.6°; p < 0.001) and ADR (330 sd 40 versus 350 sd 40; p < 0.001), and TA was larger (5.5° sd 5.4° versus 2.3° sd 4.2°; p < 0.001) compared with the uninvolved hip. Acetabular dysplasia was observed in 27 (25%) of 108 hips with SCFE. Femoral head overgrowth, age at slip and SCFE severity were independent factors associated with acetabular dysplasia (p < 0.05)., Conclusion: Acetabular coverage and depth are not increased in SCFE, and the acetabular coverage tends to decrease up to skeletal maturity. A potential disturbance in the acetabular growth and remodelling exists mainly for young children with severe SCFE, and a potential for acetabular insufficiency may be observed at the diagnosis and follow-up of SCFE., Level of Evidence: Prognostic Level IV.

Background: Understanding the development of the capital femoral epiphysis is essential to identify pathologic variations that may lead to cam morphology., Purpose/hypothesis: The purpose of this study was to investigate the development of the capital femoral epiphysis during childhood and adolescence, with specific morphologic analysis of the peripheral growth and the metaphyseal surface of the growth plate. We hypothesized that age- and sex-dependent morphologic variations of the peripheral growth (cupping) and surface anatomy (epiphyseal tubercle) of the epiphysis would be evident with increasing age., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Pelvic computed tomography scans of 80 children and adolescents (range, 8-15 years; n = 10 per age group; 50% male), imaged because of suspected appendicitis, were used to reformat the proximal femur. All patients had asymptomatic hips with no signs or history of hip disorder. We measured the peripheral cupping of the epiphysis and the epiphyseal tubercle dimensions from 3-dimensional models. All measurements were normalized to the epiphyseal diameter. The effect of age on these parameters was evaluated by use of linear regression analysis. A 2-way analysis of variance (ANOVA) was used to compare these parameters between males and females., Results: The mean epiphyseal cupping increased with increasing age ( R 2 = 0.54; P < .001). The mean normalized epiphyseal cupping was consistently higher in the anterior and posterior directions compared with the inferior and superior locations. Male patients aged 10 and 11 years had lower ( P = .002) mean epiphyseal cupping compared with female patients of the same age. We observed no difference between male and female participants after 12 years of age ( P > .3). The normalized epiphyseal tubercle height ( R 2 = 0.08; P = .009), width ( R 2 = 0.13; P = .001), and length ( R 2 = 0.45; P < .001) decreased with increasing age, with no differences between male and female patients. On average, a 2.6-fold increase was found in epiphyseal cupping from 8 to 15 years of age, whereas normalized tubercle height decreased by 0.4-fold., Conclusion: Peripheral cupping of the epiphysis over the metaphysis increases with age, while the relative epiphyseal tubercle dimensions decrease. Females have an earlier onset of rapid increase in the peripheral cupping compared with males; however, no differences in epiphyseal tubercle dimensions were found between male and female patients. These findings may guide future studies investigating the development of cam morphology, which should consider the surface morphologic characteristics of the capital femoral epiphysis, the growth plate, and the differences in morphologic characteristics according to age and sex., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by a grant from the National Institutes of Health (grant R01 AR065462 to A.K.). E.N.N. has received educational support from Arthrex. D.A.M. has received a grant for postdoctoral fellowship from the Sao Paulo Research Foundation (FAPESP grant No. 2016/04376-3).

Background: Hip osteoarthritis has been reported in the contralateral hip in patients who had been treated for unilateral slipped capital femoral epiphysis (SCFE) during adolescence. Although this might be related to the presence of a mild deformity, the morphologic features of the contralateral hip in unilateral SCFE remains poorly characterized., Questions/purposes: Do measurements of (1) femoral head-neck concavity (α angle and femoral head-neck offset), (2) epiphyseal extension into the metaphysis (epiphyseal extension ratio and epiphyseal angle), and (3) posterior tilt of the epiphysis (epiphyseal tilt angle) differ between the contralateral asymptomatic hips of patients treated for unilateral SCFE and hips of an age- and sex-matched control population without a history of hip disease?, Methods: From January 2005 to May 2015, 442 patients underwent surgical treatment for SCFE at our institution. Patients were included in this study if they had a pelvic CT scan and unilateral SCFE defined by pain or a limp in one hip without symptoms or obligatory external rotation with flexion in the contralateral hip and no evidence of SCFE findings on available radiographs. Seventy-two (16%) patients had a pelvic CT scan; however, 32 patients with bilateral involvement and one patient with CT imaging of inadequate quality for multiplanar reformatting were excluded. Thirty-nine control subjects were identified from a preexisting database of patients who underwent pelvic CT between January 2008 and January 2014 for assessment of abdominal pain in the setting of suspected appendicitis. Patients in the contralateral asymptomatic hip group then were matched to control subjects using a modified nearest-neighbor approach based on sex and age. Patients in the contralateral asymptomatic hip group were separated in males and females and control subjects were assigned to an appropriate sex category. Then subjects closest in age were matched with each patient. If more than one subject was available as a match for a given patient, the control subject with the closest BMI was selected. The contralateral asymptomatic hip and matched groups had 19 (49%) male patients and 20 (51%) female patients, with mean ages (± SD) of 16 (± 3) years and 16 (± 3) years, respectively (p = 0.16). Matched subjects had a mean BMI of 25 ± 4 kg/m and the mean BMI difference among groups was 5 ± 5 kg/m (p < 0.001). According to the Southwick radiographic criteria nine patients (23%) had a mild slip, 10 (26%) had a moderate slip, and 19 (49%) had severe SCFE. The α angle and femoral head-neck offset, epiphyseal extension ratio and epiphyseal angle, and epiphyseal tilt were assessed in the anterior, anterosuperior, and superior femoral planes on radially reformatted CT by one observer not involved in clinical care of the patients. Inter- and intrarater reliability were determined on 10 randomly selected hips assessed by the same observer and another observer and it was found to be excellent for all femoral measurements (intraclass correlation coefficients > 0.85). Paired t-tests were used to compare the contralateral asymptomatic hip of patients with SCFE and control hips., Results: The head-neck junction showed decreased concavity in the contralateral femur of patients with unilateral SCFE compared with control subjects as assessed by slightly higher mean α angle in the anterosuperior plane (51° ± 6° versus 48° ± 7°; mean difference, 2°, 95% CI, 0°-5°; p = 0.04) and slightly higher median α angle in the superior plane (45° [range 37°-72°] versus 42° [range, 36°-50°], median shift, 4° [range, 2°-5°], p < 0.001), and slightly lower head-neck offset (anterosuperior: 5 mm ± 2 mm versus 6 mm ± 2 mm, mean difference, -1mm [range, -1 mm to 0 mm], p = 0.009; superior: median, 6 mm [range, 1 mm-8 mm] versus 7 mm [range, 5 mm-9 mm]; median shift, -1 mm [range, -1 mm to 0 mm], p < 0.001). There was less epiphyseal extension in the anterosuperior plane as evidenced by lower epiphyseal extension ratio (72% ± 6% versus 75% ± 6%; p = 0.005) and higher epiphyseal angle (64° ± 7° versus 60° ± 7°; p = 0.003). The epiphysis was slightly more posteriorly tilted (anterior plane tilt: 8° ± 6° versus 5° ± 4°; p = 0.03) and more vertically oriented (superior plane tilt 11° ± 5° versus 14° ± 4°; p = 0.006) in the contralateral asymptomatic hip of patients with SCFE., Conclusions: The contralateral femur in patients treated for unilateral SCFE shows decreased concavity of the head-neck junction assessed by a higher α angle and reduced head-neck offset compared with age- and sex-matched control subjects. Because we noted lower epiphyseal extension but a more posteriorly tilted epiphysis, the reduced concavity resembles a mild slip deformity rather than an idiopathic cam morphologic feature., Clinical Relevance: Although we noted a difference in the morphologic features of the head-neck junction between the two groups, the clinical significance is unclear because most differences were rather small. However, our findings suggest that the uninvolved hip in patients with unilateral SCFE may have a subtle asymptomatic cam morphologic feature that may be identified only with advanced imaging (CT or MRI). Future studies should investigate whether these morphologic changes influence development of contralateral SCFE or symptomatic femoroacetabular impingement in the contralateral hip of patients with unilateral SCFE and establish thresholds for indication of prophylactic fixation to avoid further slip and worsening of the morphologic features of the cam-femoroacetabular impingement.

Purpose: To investigate the outcomes of an anteverting triple periacetabular osteotomy for the treatment of hip instability in skeletally immature patients with Down syndrome., Methods: We evaluated 16 patients (21 hips) with Down syndrome and hip instability who underwent an anteverting triple periacetabular osteotomy between 2007 and 2016. There were nine females and seven males with an average age of 7.4 years SD 2.0. We assessed the level of hip pain, gait ability and clinical stability at a minimum of one year after surgery. Radiographic evaluation included pre- and postoperative lateral centre-edge angle (LCEA), Tönnis acetabular angle and extrusion index., Result: After an average follow-up of 4.1 years SD 2.6, 20 of 21 hips (95%) remained clinically stable. In all, 12 of 16 (75%) patients had a full gait without a major limp, but three patients (19%) had a persistent limp. Of the 21 procedures, one hip (5%) was considered a failure due to persistent instability. There was a mean increase of 18.3º SD 15.3º of the LCEA (p < 0.001); a mean decrease of 15.2º SD 11.6º (p < 0.001) for the Tönnis angle and the extrusion index had a mean decrease of 0.27 SD 0.20 (p < 0.001). The most common complications were minor and included nonunion of the pubis or ischium (24%) and stress fractures of the pubis and ischium (14%). Only one patient required unplanned surgery for the treatment of an infection; which was considered a major complication., Conclusion: The anteverting triple periacetabular osteotomy provided global deformity correction and achieved hip stability in 95% of the hips after a mean follow-up of 4.1 years., Level of Evidence: Therapeutic level IV.

Objective: To evaluate the age in which the secondary ossification centers of the elbow appear and fuse in the Brazilian population., Methods: Nearly thirty radiographs were randomly selected for each age group from 0 to 18 years, with a total of 544 radiographs from 439 patients, between 2010 and 2015, without abnormalities secondary to trauma, metabolic or bone tumor diseases. Radiographs were retrospectively evaluated by two blind and independent observers, according to the presence or not of the ossification centers, and the fusion between them., Results: The age interval of appearance and fusion were, respectively: capitulum (0 to 1 year; 10 to 15 years), radius head (2 to 6 year; 12 to 16 years), medial epicondyle (2 to 8 years; 13 to 17 years), trochlea (5 to 11 years; 10 to 18 years), olecranon (6 to 11 years; 13 to 16 years), e lateral epicondyle (8 to 13 years; 12 to 16 years). Appearance and fusion were earlier in girls compared to boys (exception to capitulum and radius head)., Conclusion: The chronological order was similar to the literature. For girls, the radius head and medial epicondyle appeared simultaneously. There was a tendency of the olecranon center to appear before the trochlea for both sexes. Level of Evidence III, Diagnostic Study., Competing Interests: All authors declare no potential conflict of interest related to this article.

Hereditary motor and sensory neuropathies, especially Charcot-Marie-Tooth disease, are frequently expressed with an acquired cavusvarus foot which is characterized by a fixed increase of the plantar arch and hindfoot inversion. Diagnosis of the underlying condition achieved through careful patient assessment and local evaluations is the keystone for decision-making about the adequate treatment. The cavus may present as an isolated deformity of the forefoot, hindfoot or it may be a combination of both locations. Related deformities, mainly the varus and toe clawing require appropriate evaluation; clinical characteristics such as severity of the deformity, impairment of the muscular power, flexibility and patient's age are important characteristics in the treatment decision. Conservative treatment of the cavusvarus foot with physiotherapy, insoles and shoe modifications are reserved to young patients and mild deformities. However, there is a tendency of the deformity to become more severe over time because of the progressive feature of the underlying neurological condition. So, the surgical treatment by using classical techniques is performed in early stages. Most importantly is the identification of the primary and main components of each deformity to properly correct them, if possible. Muscular transfers are used to treat the dynamic unbalance, retracted structures should be either divided or lengthened and localized osteotomies should be preferred over arthrodeses, which are reserved for stiff and severely deformed feet in adults.

For proximal varus osteotomy of the femur in children, a stable fixation, is a concern regarding the safety and the protection of the surgery. The methods of fixation are mostly represented by plating systems; however, the tension band wiring is a simple and eligible option for fixation of proximal femur osteotomy. The purpose of this retrospective case series study is to evaluate outcomes and bone remodelation after using the tension band wiring technique to fixate proximal femoral varus osteotomies in children.The study enrolled 20 patients who underwent femoral varus osteotomy to treat Legg-Calvé-Perthes disease and other causes of necrosis of the femoral head. The mean patient age at the time of surgery was 7.4 ± 2.3 years (range, 4.3-13.8 y), and the follow-up period averaged 10 ± 4.3 years (range, 4.7-20.8 y). To assess the effects of the osteotomy at the neck-shaft angle and its evolution over time, radiographs obtained preoperatively and during the follow-up were analyzed. The neck-shaft angle was measured independently by 2 observers, and intraclass correlation coefficients (ICCs) were assessed for reliability.The ICC analysis showed good reliability. There was a significant reduction in the neck-shaft angle (P < 0.001) between the preoperative and the immediate postoperative periods, with an estimated difference of 14.3°. Between the immediate and the early postoperative periods, the estimated difference was 2.1°, which indicated a significant increase in the neck-shaft angle (P = 0.003). Between the early postoperative period and the final evaluation, there was a significant increase (P < 0.001), with an estimated difference of 7.0°. No implant failures or other complications were observed, but 1 case of peri-implant femoral fracture occurred >17 years postsurgery.The tension band wiring technique proved to be a simple and effective method for fixating proximal femoral varus osteotomy in children.The level IV is appropriated for our study (case series, retrospective).

To study the effects of mechanical loading on bones after SCI, we assessed macro- and microscopic anatomy in rats submitted to passive standing (PS) and electrical stimulation (ES). The study design was based on two main groups of juvenile male Wistar rats with SCI: one was followed for 33 days with therapies starting at day 3 and the other was followed for 63 days with therapies starting at day 33. Both groups were composed of four subgroups (n = 10/group): (1) Sham, (2) SCI, (3) SCI + PS, and (4) SCI + ES. Rehabilitation protocol consisted of a 20-minute session, 3x/wk for 30 days. The animals were sequentially weighed and euthanized. The femur and tibia were assessed macroscopically and microscopically by scanning electronic microscopy (SEM). The SCI rats gained less weight than Sham-operated animals. Significant reduction of bone mass and periosteal radii was observed in the SCI rats, whereas PS and ES efficiently improved the macroscopic parameters. The SEM images showed less and thin trabecular bone in SCI rats. PS and ES efficiently ameliorated the bone microarchitecture deterioration by thickening and increasing the trabeculae. Based on the detrimental changes in bone tissue following SCI, the mechanical loading through weight bearing and muscle contraction may decrease the bone loss and restore the macro- and microanatomy.