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Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared., (Copyright © 2024. Published by Elsevier Inc.)

Aim: To investigate sex-based differences in the occurrence of intra-operative and post-operative complications and associated visual outcomes following cataract surgery., Methods: This was a retrospective study of patients who had phacoemulsification cataract surgery at the University of Colorado School of Medicine. Data collected included the patient's health history, ocular comorbidities, operative and post-operative complications, and the post-operative best corrected visual acuity (BCVA). The data were analyzed using univariate and multivariable logistic regression with generalized estimating equations to account for the correlation of some patients having two eyes included in the study., Results: A total of 11 977 eyes from 7253 patients were included in the study. Ocular comorbidities differed by sex, with males having significantly higher percentages of traumatic cataracts (males 0.7% vs females 0.1%), prior ocular surgery (6.7% vs 5.5%), and mature cataracts (2.8% vs 1.9%). Conversely, females had significantly higher rates of pseudoexfoliation (2.0% vs 3.2%). In unadjusted analysis, males had higher rates of posterior capsular rupture (0.8% vs 0.4%) and vitreous loss (1.0% vs 0.6%), but this difference was not significant after adjustment for confounders. Males had a significantly increased risk of post-operative retinal detachment, but in multivariable analysis this was no longer significant. Males were significantly less likely to undergo post-operative neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy for posterior capsule opacification (OR=0.8, 95%CI=0.7-0.9, P =0.0005). The BCVA was slightly worse for males pre-operatively; but post-operatively, both sexes exhibited similar visual acuity of Snellen equivalent 20/25., Conclusion: The study finds that in a cohort of patients presenting for cataract surgery, sex differences exist in pre-operative comorbidities and surgical characteristics that contribute to higher rates of some complications for males. However, observed surgical complication rates exhibit almost no difference by sex after adjusting for pre-operative differences and post-operative BCVA is similar between sexes., (International Journal of Ophthalmology Press.)

Purpose: The aim of this study was to compare endothelial cell loss for DMEK (Descemet membrane endothelial keratoplasty) tissue preparation techniques using the modified Jones tube and the DMEK EndoGlide with and without viscoelastic material to protect the endothelium., Methods: This ex vivo study included 10 DMEK grafts prepared using each of the 3 abovementioned techniques. After tissue preparation, transport conditions were simulated for a minimum of 45 hours before deployment of the DMEK tissue and quantification of endothelial cell loss. Comparisons between preparation technique groups were made using the Wilcoxon rank-sum test., Results: The Jones tube group had a mean endothelial cell loss of 11.0 ± 4.8% compared with the EndoGlide group with 12.9 ± 6.7% and the EndoGlide with viscoelastic group with 25.7 ± 15.0%. The differences between the EndoGlide with viscoelastic group and the other 2 were statistically significant both before (P < 0.01 and P = 0.01) and after (P = 0.01 and P = 0.02) adjusting for baseline characteristics. The difference between the EndoGlide and Jones tube groups was not significant (P = 0.73 and P = 0.53 after adjustment). Microscopy revealed endothelial cell loss in the area of viscoelastic use for the EndoGlide with viscoelastic group., Conclusions: Both the Jones tube and DMEK EndoGlide resulted in similar low rates of endothelial cell loss after tissue preparation, transport, and deployment. However, use of viscoelastic material to protect the endothelium using the DMEK technique actually resulted in increased cell loss in the area of its application resulting in overall higher rates of cell loss across the DMEK tissue., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The implementation of OpenNotes and corresponding increase in patient access to medical records requires thorough assessment of the risks and benefits of note-sharing. Ophthalmology notes are unique among medical records in that they extensively utilize non-standardized abbreviations and drawings; they are often indecipherable even to highly-educated clinicians outside of ophthalmology. No studies to date have assessed ophthalmologist perceptions of OpenNotes., Methods: A cross-sectional study was conducted from 4/28 to 5/12/2016. A survey was distributed to 30 clinicians (25 ophthalmologists, three optometrists, two nurses) in the University of Colorado's Department of Ophthalmology to evaluate provider attitudes towards granting patients access to online medical records., Results: Many clinicians felt patients would have difficulty understanding their records and may be unnecessarily alarmed or offended by them. Some clinicians worried their workload would increase and feared having to change the way they document. Perceived benefits of OpenNotes included improving patient understanding of their medical conditions, strengthening patient-physician trust, and enhancing patient care. Many perceived risks and benefits of note-sharing were associated with conceptions of the ideal clinician-patient relationship., Conclusions: Clinicians in ophthalmology perceived both benefits and consequences of increasing patient access to ophthalmic records, and there were significant correlations between these perceptions and their conceptions of the clinician-patient relationship. This is the first study to assess potential ophthalmology provider attitudes toward sharing ophthalmic records. Although limited in sample size and power, this study demonstrates some ways patient-accessible ophthalmic records can affect the clinical practice of ophthalmology and emphasizes the unique challenges of OpenNotes in ophthalmology., (© 2021. The Author(s).)

Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

Background Pediatric patients often present with vague complaints involving the anterolateral foot and ankle, the medial knee, the lower back, and the hip. In our experience, closer examination of these patients reveals a constellation of symptoms that involve pathology in the ankle, knee, back, and hip. This study aimed to detail the identification and treatment of patients with the triad of flexible flat feet, tight Achilles complex, and altered gait, and their clinical course over time. Methods All patients of age 18 years or younger who presented to our urban academic center outpatient clinic with foot, ankle, patellar, low back, or hip pain or pathology were included. Patients with identified tarsal coalitions, accessory naviculars, malalignment syndrome, bone cysts or tumors, soft tissue tumors, arthropathy, neuropathy, infection, limb length inequality, patellar subluxation or dislocation, or spinal pathology were excluded. For each patient, demographic information, symptom description, treatment, and clinical course, including the Foot and Ankle Outcome Score (FAOS) was recorded. Results A total of 62 patients were included in our study. Patients mostly presented with low back pain (n=24, 38.7%), medial patellar pain (n=36, 58.1%), anterolateral ankle pain (n=35, 56.5%), and vague foot pain (n=13, 21.0%). Overall, 53.8% of patients with back pain at the initial visit, 35.0% of patients with knee pain, 44.4% of patients with ankle pain and 80.0% of patients with foot pain improved at final follow up. While patient-reported sports and recreation subscale scores demonstrated a significant improvement at the final follow-up compared to baseline scores (p=0.02), all other scores did not significantly differ compared to baseline scores. At final follow-up, 12 of 26 (46.2%) patients reported being able to return to play in their desired sport. Conclusion Complaints of back, hip, knee, ankle, or foot pain in the pediatric population can be early markers for a constellation of conditions that include low back pain, flexible flat feet, Achilles contracture, and altered gait due to increased lateral subluxation of the patella and hip flexion., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Malige et al.)

Background Supracondylar humerus fractures (SCH) are common upper extremity fractures in children and are usually treated by closed reduction and percutaneous pinning. Post-operative management may cause complications, but the difference between cast and splint has not been closely investigated. Purpose Our objective was to compare casting and splinting of SCH fractures with respect to post-operative complications. Patients and methods We reviewed 1,146 pediatric SCH fractures that were reduced, percutaneously pinned, and immobilized by cast or splint. Open fractures, openly reduced fractures, and pre-operative neurological injuries were excluded. Over the course of immobilization, we noted if the initial cast or splint was maintained and if the patient returned due to complications. Results Post-operative casting was performed on 1,091 (95.2%) fractures and 55 (4.8%) were splinted. Age was a significant factor, increasing the likelihood of splinting by 12% with each year of age (p = 0.023). A total of 28 patients (2.4%) returned for unscheduled visits due to immobilization complaints, infection, and pain, but the rate difference between cast and splint was negligible. Reoperation was required for five patients (0.4%), and more likely for splinted fractures (p = 0.021). After controlling for age, splinting was still associated with reoperation (OR: 15.1, p = 0.004). Conclusions Although complications inevitably exist, both casting and splinting are effective immobilization methods. Both resulted in few complications such as post-operative discomfort, pain, infection, loss of reduction, or damage. It was difficult to evaluate significance with few splinted cases, but considering no major differences between splinted and casted fractures, clinicians should consider splinting to reduce the cost associated with casting., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2021, Lee et al.)

Aim: To quantify intraoperative and postoperative complications in complex phacoemulsification cataract extraction (phacoemulsification) with iris manipulation compared to non-complex and complex phacoemulsification without iris manipulation., Methods: All phacoemulsification cases at the University of Colorado between January 1, 2014, and June 30, 2017 were included. Exclusion criteria for the primary outcome of intraoperative complications were planned combination surgery and eyes with less than 28d follow-up. Exclusion criteria for the secondary outcomes of postoperative complications were unplanned additional surgery, and chronic steroid eye drop use prior to surgery. Data including sex, race/ethnicity, surgery length, visual acuity, intraoperative and postoperative complications, and intraocular pressures (IOP) were collected and analyzed utilizing general linear and Logistic regression modeling., Results: The medical records of 5772 eyes were reviewed (500 complex without iris manipulation, 367 with iris manipulation). The number of any intraoperative complication in the complex with iris manipulation and complex without iris manipulation groups was 15 (4.1%) and 26 (5.2%), respectively, compared to 41 (0.8%) in the non-complex group. Postoperative inflammation was found in 135 (2.8%) non-complex cases, 20 (4.1%) complex cases without iris manipulation, and 20 (5.6%) complex cases with iris manipulation. The adjusted odds ratio of postoperative inflammation in phacoemulsification with iris manipulation compared to non-complex was 2.3 (95%CI: 1.3-4.0, P =0.005). The rate of IOP spikes >10 mm Hg was significantly greater in cases with iris manipulation ( P =0.001)., Conclusion: Complex cases have more intraoperative complications. However, only complex cases with iris manipulation led to increase rates of postoperative inflammation and IOP spikes >10 mm Hg., (International Journal of Ophthalmology Press.)

Case: A 15-year-old boy with a right femur length discrepancy secondary to infection underwent hardware removal 1-year status-post right femur osteotomy with placement of an antegrade intramedullary magnetic lengthening nail after successful lengthening of 4.2 cm. During hardware removal, dissociation between the proximal (outer) and distal (inner) components of the device was observed. The distal component was removed using an endoscopic pituitary rongeur after considering multiple possible techniques., Conclusions: In the event of nail disconnection during removal of an intramedullary implant, we recommend use of a long pituitary rongeur to retrieve the distal nail component., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B384)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: To assess the accuracy of intraoperative aberrometry, the Barrett True-K No History (Barrett TKNH), Barrett TKNH with posterior corneal measurements (Barrett TKNH with PC), Shammas-PL, and Haigis-L formulas in patients with cataract who had prior myopic refractive surgery., Methods: This was a retrospective consecutive case series of patients with prior myopic refractive surgery undergoing cataract extraction. Mean absolute error (MAE) and median absolute error (MedAE) of refraction prediction were compared for each formula. Interactions of each biometry measurement were modeled for each formula to evaluate those with the most significant impact on refraction prediction., Results: One hundred sixteen eyes of 79 patients were analyzed. MAE was 0.40 ± 0.33 diopters (D) for intraoperative aberrometry and 0.42 ± 0.31 D for the Barrett TKNH, 0.38 ± 0.30 D for the Barrett TKNH with PC, 0.47 ± 0.38 D for the Shammas-PL, and 0.56 ± 0.39 D for the Haigis-L formulas. Comparisons between formulas were significant for Barrett TKNH versus Barrett TKNH with PC formulas (P = .046), Barrett TKNH with PC versus Shammas-PL formulas (P = .023), and for all comparisons with the Haigis-L formula (P < .001), and not significant for all other comparisons (P > .05). Eyes were within ±0.50 D of prediction 73%, 72%, 69%, 62%, and 52% of the time for intraoperative aberrometry, the Barrett TKNH with PC, Barrett TKNH, Shammas-PL, and Haigis-L formulas, respectively. Corneal asphericity (Q value) was significantly associated with prediction error for all five methods. Changes in anterior chamber depth had a significant impact on Shammas-PL prediction errors., Conclusions: Newer technology using information from the posterior cornea modestly improved outcomes when compared to established methods for intraocular lens selection in eyes that had previous laser refractive surgery for myopia. [J Refract Surg. 2021;37(1):60-68.]., (Copyright 2021, SLACK Incorporated.)

Background and Objective: To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification., Patients and Methods: Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries., Results: Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR., Conclusion: Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.]., (Copyright 2020, SLACK Incorporated.)

Estimating the appropriate tendon length and associated skin incision needed to achieve a plantigrade foot without compromising function are essential steps in open Achilles tendon lengthening. Here we describe a technique using basic surgical instruments referencing anatomic landmarks without the need for radiographs. The center of ankle rotation in the sagittal plane is found referencing the tip of the medial malleolus. This point is translated to the plantar surface of the foot, and a straight instrument in line with the foot is used to make a mark at the posterior calcaneal fat pad. The straight instrument is then rotated (representing the plantar surface of the foot) as if dorsiflexing the ankle along the axis of the transposed tibiotalar joint from a plantar-flexed position to the desired final position and a second mark is made at the posterior heel. The distance between the marks is measured, representing the amount of Achilles lengthening required. The skin incision and tendon limb lengths area a sum of the operative correction and the amount of desired tendon overlap, typically 2 cm of tendon overlap is optimal to allow for suture fixation, ensure tendon healing, and maintain the integrity of the repair. A Z-type lengthening is then performed using this tendon limb length. This technique allows an accurate and simple approach to lengthening the Achilles tendon. In this way the ideal tendon limb length is selected to optimize function while minimizing incision length, associated wound complications, inadequate lengthening, and overlengthening. Level of evidence: Technical note, Level V.

Purpose: To compare visual outcomes of eyes with and without previous laser refractive surgery that received an extended depth of focus intraocular lens during cataract surgery., Methods: This was a retrospective review of all eyes implanted with an extended depth of focus intraocular lens by two surgeons. Preoperative demographic and eye examination information were collected, as well as postoperative refraction, uncorrected distance visual acuity, and Visual Function Index (VF-14) questionnaire responses. Medical records were reviewed postoperatively to collect the number of patients who required a refractive touch-up or lens exchange., Results: Most patient eyes (187 of 215, 87%) had no prior refractive surgery, and there was no significant difference in preoperative characteristics between this group and the 28 eyes that did have previous laser refractive surgery. Postoperatively, most patients had a refractive error within ±0.50 diopters (D) (79% without vs 77% with previous laser refractive surgery, P = .40). Although more patients in the group without previous laser refractive surgery achieved 20/20 uncorrected distance visual acuity (UDVA) (56.8% versus 28.6%, P = .01), the majority in both groups achieved 20/25 or better UDVA (79.5% versus 85.7% for without versus with previous laser refractive surgery, P = .42). Postoperative subjective visual function score was also similar between the two groups as measured by the VF-14 questionnaire (86.9 vs 79.4, P = .15). Few patients required refractive surgery enhancement in either group (9 of 187 (4.8%) versus 1 of 28 (3.6%) for without versus with previous laser refractive surgery, P = .77)., Conclusions: The data suggest that extended depth of focus lens implantation can have successful results for patients with prior laser refractive surgery. [J Refract Surg. 2020;36(1):28-33.]., (Copyright 2020, SLACK Incorporated.)

Unlabelled: Presbyopia is the most common refractive disorder for people older than 40 years. It is characterized by a gradual and progressive decrease in accommodative amplitude. Many surgical procedures for the correction of presbyopia exist, with additional procedures on the horizon. This review describes the prevalent theories of presbyopia and discusses the available surgical options for correction., Financial Disclosure: Proprietary or commercial disclosures are listed after the references., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet., Methods: The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up., Results: A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion (p = 0.333) or recurrence rate (p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet., Conclusion: In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting.

Introduction: When used for strict surgical indications, operative management of chronic symptomatic os subfibulare in children involving fragment excision and ligament repair can significantly improve visual analog scale pain scores and result in high Foot and Ankle Outcome Scores., Step 1 Indications and Preoperative Planning: Operative indications are chronic pain at the distal part of the fibula, symptoms of instability at the anterior talofibular ligament and/or calcaneofibular ligament, and a radiographic finding of an os fibulare., Step 2 Ossicle Excision: Perform an approach to the lateral malleolus and excise the fragment while preserving the anterior talofibular ligament and calcaneofibular ligament., Step 3 Ankle Examination: Examine the ankle for loose bodies or other associated damage., Step 4 Preparation for Ligament Repair: Repair the anterior talofibular ligament and calcaneofibular ligament to the debrided distal part of the fibula ., Step 5 Preparation for Modified Broström Procedure: Imbricate the lateral capsule to secondarily reconstruct and reinforce the ligaments, adding to the strength of the repair., Step 6 Repair Reconstruction and Closure: Reduce the ankle joint and tie down the sutures., Step 7 Casting: Patients wear a cast and remain non-weight-bearing for six weeks postoperatively., Step 8 Postoperative Protocol: Patients advance to full weight-bearing in a CAM boot and start physical therapy at six weeks., Results: We performed a retrospective case study of the first twenty-three patients treated with our procedure for symptomatic os subfibulare.IndicationsContraindicationsPitfalls & Challenges.

Background: Infantile Blount disease is a developmental condition characterized by disorganized endochondral ossification in the medial aspect of the proximal tibial physis., Objective: To describe the MR imaging abnormalities in the proximal tibia, distal femur, menisci and ligaments of children with infantile Blount disease., Materials and Methods: We retrospectively evaluated 11 children (18 total knee MR examinations) with infantile Blount disease and compared them with an age-matched control group with normal MR examinations. Morphological and morphometric measurements were performed., Results: The medial menisci were enlarged with increased T2 signal intensity in all MR examinations. The medial femoral epiphyseal cartilage showed abnormal foci of increased signal intensity in nine (50%). The mid-coronal thickness of the medial tibial epiphyseal cartilage was decreased with concomitant increase in the mid-coronal joint space distance. Angular measurements of the proximal tibia demonstrated posteromedial down-sloping configuration., Conclusions: Most severe abnormalities of infantile Blount disease occur in the medial compartment of the knee, especially at the medial tibial physis and epiphysis. However, other important structures of the knee and the lateral compartment are often affected. MR imaging helps to delineate the extent of multiple tibial and extra-tibial abnormalities, including meniscal abnormalities, perichondrial membrane changes and premature physeal closure.

Clubfoot is one of the most common congenital anomalies seen in newborns and children. Although the cause is unknown, strides have recently been made in uncovering the etiology causes of clubfoot. In the last decade, the treatment of clubfoot has undergone a significant change with a shift away from extensive operative intervention to a less invasive approach. Long-term residual deformity and pain from surgically corrected club feet still continues to occur and presents diagnostic and therapeutic challenges for the orthopedic surgeon., (Copyright 2010 Elsevier Inc. All rights reserved.)

Placement of the blade-plate chisel into the femoral neck can be challenging at times, due to patient positioning and imaging issues. We describe a technique of intraoperative visualization of the femoral neck and head for safer placement of the hardware.

This is a retrospective review of 25 tibial osteotomies (in 19 patients) performed with either acute or gradual correction to determine the outcome of treatment and incidence of neurovascular complications. Patients undergoing gradual correction had fewer neurovascular complications and greater correction than those undergoing acute correction (27 degrees vs. 18 degrees, respectively). It was concluded that gradual correction tends to be a safer technique for the treatment of tibial deformities and allows greater correction.

Objectives: We investigated the relationship between the grade and chronicity (acute-chronic) of the slip and the development of avascular necrosis (AVN) of the femoral head after surgery for slipped capital femoral epiphysis (SCFE)., Methods: The study included 424 hips of 269 patients (174 boys, 95 girls; mean age 12 years) who underwent surgery for SCFE and had a minimum follow-up period of one year. The patients were classified according to the severity and chronicity of the slipping using the Southwick classification. The relationship of the slip severity and chronicity with the development of AVN was statistically evaluated., Results: Involvement was unilateral in 114 patients, and bilateral in 155 patients. The mean follow-up period was 32.9 months. The hips were classified as grade I to II in 267 hips (63%), 120 hips (28.3%), and 37 hips (8.7%), respectively. The symptoms were acute in 130 hips (30.7%), and chronic in 294 hips (69.3%). The incidence of AVN was 4.5% (19 hips; 13 in unilateral cases, 6 in bilateral cases). In logistic regression analysis, a strong correlation was found between the grade of the slip and the development of AVN (odds ratio 10.27; p<0.0001). The acute nature of the slip was also correlated with the development of AVN, but this relation was weaker (odds ratio 0.20, p<0.01)., Conclusion: A strong correlation is present between the slipping grade and the development of AVN in SCFE, requiring a closer observation of patients having a high grade slipping in terms of AVN risk. The acute nature of the symptoms represents another risk factor for AVN.

We report a 13-year-old girl with Ewing's sarcoma of the tibia who was treated with multiagent chemotherapy, followed by local control tumor surgery consisting of wide resection of the tumor and bone transport with distraction osteogenesis for reconstruction. The bone defect created by resection was 13 cm long and was replaced by bone transport using a monolateral external fixator. Evaluation of the resected specimen revealed wide tumor-free margins with 100% chemonecrosis. A planned Harmon-type autogenous bone grafting between the middle and proximal segments of the tibia (docking site) was done primarily after docking occurred, and a solid union was obtained by 23 months after resection. The bone healing index (treatment index) was 54 days/1 cm distraction, which is indicative of slow healing. Clinical evaluation of the affected extremity using the Musculoskeletal Tumor Society rating system revealed 80% normal functional capability. Indications for bone transport in reconstruction of bone defects created by wide resection of bone sarcomas are discussed. In retrospect, we have concerns regarding the suitability of this technique in the setting of diaphyseal sarcoma reconstruction in patients with Ewing's sarcoma who require aggressive and intense multiagent chemotherapy.

The purpose of this study was to determine the effects of limb lengthening on the rate of growth of the lengthened limb. The rate of growth of the lengthened and control (contralateral) limb segment were determined radiographically pre- and postoperatively in 19 skeletally immature patients (20 limbs). There were 13 femoral and seven tibial lengthenings. The mean age at the time of lengthening was 9.4 years (range 4.2-12.3). The limbs were lengthened by a mean of 6.7 cm (24%). Mean follow-up was 3.6 years. No significant difference was found between the change in the rate of growth of the lengthened and control limb (P=0.59). This was true for both the femur and the tibia, when analyzed separately. This study indicates that the change in the rate of growth between the lengthened and control limbs did not vary significantly in our patient group.

Purpose: This article describes a case in which a patient presented with a previously undetected metallic foreign body in the anterior chamber angle., Methods and Results: A 42-year-old Hispanic man presented with a 5-day history of foreign-body sensation and redness in his left eye. He had been using a hand saw without safety glasses 2 days before the onset of his initial symptoms. Physical examination revealed a metallic foreign body embedded in the inferior angle of his left eye. Surgical removal of the foreign body was performed, and the patient remains well 1 year after surgery., Conclusions: All physicians should maintain a high degree of clinical suspicion for intraocular foreign bodies when presented with a patient who may have sustained ocular trauma. All eye-care providers need to emphasize the need for proper eye protection to patients who engage in high risk activities that may lead to penetrating ocular trauma.