Search

Purpose: The purpose of this prospective study was to assess and compare clinical outcomes for patients with bilateral tarsal coalitions who had at least one coalition treated with surgical excision. Method: Patients were identified prospectively and agreed to participate. Data was collected prior to surgery, and again after surgery for up to 2 years. Comparisons of patients with unilateral disease to bilateral disease as well as unilateral excision to bilateral staggered and bilateral concomitant excision was done. Results: Initial cohort included 55 patients with 70 feet containing a tarsal coalition. 30 patients with 45 feet had bilateral tarsal coalition excision during the study period. Post-operative outcomes were considerably improved from preoperative outcomes. Five bilateral patients had concomitant excision, and ten had staggered surgery. There was no difference in outcome from patients with unilateral disease when compared to bilateral disease. There was no difference in patients with bilateral disease who had only one side excised compared to those that had both sides excised, and there was no difference in outcome for patients with staggered surgery compared to those with concomitant surgery. Conclusions: Patients with bilateral tarsal coalition show improvement in their outcomes in a similar fashion to those with unilateral disease. Concomitant surgical outcomes are comparable to staggered outcomes in this group, although the series is small.

Background Adult literature has demonstrated chlorhexidine (CH) superiority at preventing surgical-site infections when compared with povidone-iodine (P-I). The purpose of this study is to compare the rate of postoperative infections after preoperative skin cleansing with either CH or P-I in pediatric orthopaedic surgery in an effort to identify superiority. Methods We retrospectively identified all patients (18 y and below) that underwent orthopaedic surgery at our institution in 2015, when P-I was the preoperative skin antisepsis of choice, and in 2018, when a change in protocol resulted in more frequent use of CH. Open fractures, infections, neuromuscular, and tumor surgeries were excluded. Orthopaedic surgeries were classified according to their subspecialty (sports-related/upper extremity, hip and lower extremity, trauma-related, or spine procedure). A 1:1 propensity score matching was conducted within each procedure group on the basis of age, sex, and year using nearest-neighbor matching. Spine procedures could not be matched and were subsequently excluded from analyses. Results Propensity score matching matched 1416 CH cases with 1416 P-I controls. The infection rate for CH was 19 infections per 1000 cases (27/1416; 1.9%) compared with an infection rate of 11 infections per 1000 cases (16/1416; 1.1%) for P-I subjects. No difference was detected in infection rate across preoperative skin antisepsis groups (P=0.12). Moreover, it was found that CH and P-I resulted in significantly equivalent infection rates to within ±1.5% (P=0.004). When stratified by procedure type, CH used in sports/upper extremity procedures resulted in 29 more infections per 1000 cases compared with P-I use (16/450; 3/450; P=0.005). No difference was detected in infection rate across CH and P-I skin antisepsis groups in lower extremity procedures (9/792; 8/792; P=1.00) or in trauma-related procedures (3/174; 4/174; P=1.00). Conclusions CH and P-I are both protective against postoperative infections after sports/upper extremity, lower extremity, and trauma-related pediatric orthopaedic procedures. P-I may provide improved protection over CH as a preoperative skin antisepsis in upper extremity and sports-related procedures. Level of evidence Level III-comparative cohort.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Background Excision of pediatric tarsal coalition has been successful in most patients. However, some patients have ongoing pain after coalition excision. This study prospectively assessed patient-based clinical outcomes before and after surgical excision of tarsal coalition, with particular emphasis on comparison to radiologic imaging. Methods We prospectively studied 55 patients who had symptomatic coalition excision for 2 years postoperatively. Patients filled out the modified American Orthopaedic Foot and Ankle Society score, the University of California Los Angeles activity score, and the simple question "does foot pain limit your activity" at 4 different time points: preoperative, 6 months postoperative, 12 months postoperative, and 24 months postoperative. Comparisons were done utilizing patient demographics, imaging parameters, and patient-reported outcomes. Results Compared with preoperative levels, patients showed improvements in all outcome parameters. Patients with calcaneonavicular coalitions showed initial rapid improvement with later slight decline, while patients with talocalcaneal coalitions showed more steady improvement; both were similar at 2 years postoperatively. Conclusions This prospective study demonstrated remarkable clinical improvements after tarsal coalition excision regardless coalition type, though postoperative courses differed between calcaneonavicular and talocalcaneal types. Finally, a subset of patients has ongoing activity limiting foot pain after coalition excision which could not be explained by the data in this study. Level of evidence Level II-prospective cohort study.

Purpose The presence of a clubfoot is often found prenatally and some families seek counselling with a specialist. The purpose of this study was to compare the parental anxiety levels in families that: a) knew prenatally and had prenatal counselling; b) knew prenatally but did not seek prenatal counselling; and c) did not know until after delivery. Methods This prospective cohort study evaluated the anxiety of parents as they presented to the paediatric orthopaedic clinic with their newborn with a foot disorder (prior to the diagnostic confirmation of clubfoot). Each family filled out the ‘Pre-visit orthopaedic surgeon questionnaire’ and then after the initial visit with the orthopaedic surgeon (confirming the clubfoot diagnosis) the family filled out the ‘Immediately post-visit orthopaedic surgeon questionnaire’. Through these questionnaires, anxiety level was assessed prior to meeting postnatally with the paediatric orthopaedic specialist, as well as after the meeting and compared across groups. Results A total of 121 parents completed questionnaires: 71% (86/121) confirmed clubfoot; 69% of families (59/86) received prenatal counselling (Group A); 16% (14/86) knew prenatally but had no counselling (Group B); and 15% (13/86) found out at birth (Group C). There was no difference in anxiety levels across groups before (p = 0.78) or after (p = 0.57) meeting with the paediatric orthopaedic surgeon; however, overall anxiety reduced significantly (p < 0.001). Conclusion We found no difference in the anxiety levels of across the three groups. Prenatal counselling for parents of children with likely clubfoot may not decrease parental anxiety, but nonetheless is very appreciated by the families who receive it. Level of Evidence Prognostic Level II

BACKGROUND Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature. METHODS Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery. RESULTS The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P

Fibular hemimelia is the most common congenital long-bone deficiency. It is usually unilateral and results in a limb-length discrepancy. The literature generally subscribes to the concept of constant inhibition, a process by which limb-length ratios between the shorter and longer extremity remain constant throughout growth, but scientific data supporting this concept are sparse. Additionally, recent literature suggests that these children have abnormal skeletal maturation. To elucidate the lower-extremity long-bone growth patterns and skeletal maturation of children with unilateral fibular hemimelia. We reviewed medical records of children with unilateral fibular hemimelia seen at a large pediatric hospital over a 17-year period. Inclusion criteria were: at least two scanograms prior to any shortening/lengthening procedure, and no other congenital or acquired disorders. We collected the study cohort’s femoral and tibial lengths (scanogram reports), plotted them against patient chronological ages and compared them to published growth standards. When these children’s bone ages (Greulich and Pyle) were available, we plotted them against the children’s chronological ages. Twenty-three children were included (total=115 scanograms). At least 1 bone-age assessment was performed in 19 children (total=84 bone ages). All bone growth curves were within normal growth standards for the femur and tibia. Length ratios between shorter and longer limbs remained constant. Skeletal maturation was within two standard deviations of normal in 90% of bone ages. Lower-extremity long bones of children with unilateral fibular hemimelia have relatively normal growth curves, supporting and confirming the concept of constant inhibition. Most children show normal skeletal maturation.

Limb-length discrepancy (LLD) in children with congenital lower extremity shortening is constant in proportion from birth to skeletal maturity (known as constant inhibition), but its developmental pattern in utero is unknown. The popular prenatal multiplier method to predict LLD at birth assumes constant inhibition in utero to be true. Verifying the in utero developmental pattern of LLD, and thus confirming the validity of the prenatal multiplier method, is crucial for meaningful prenatal parental counseling.To elucidate the in utero developmental pattern of LLD in fetuses with congenital lower extremity shortening.Clinical indications for 3,605 lower extremity radiographs performed on infants (1 year old) at a large tertiary hospital over a 17-year period were reviewed. Inclusion criteria were (1) diagnosis of congenital lower extremity shortening, (2) bilateral lower limb postnatal radiographs documenting LLD and (3) fetal ultrasound (US) documenting LLD. Available measurements of femoral, tibial and fibular lengths on fetal US and postnatal radiographs were collected. Prenatal and postnatal length ratios of shorter-to-longer bones were calculated and compared.Eighteen infants met inclusion criteria. Diagnoses were proximal focal femoral deficiency=4, congenital short femur=2, tibial hemimelia=3, posteromedial tibial bowing=6 and fibular hemimelia=3. The correlations between postnatal and prenatal length ratios were high for the femur, tibia and fibula (R0.98, P0.0001). The relative differences in the postnatal and prenatal length ratios of these bones were small (|average|0.026, standard deviation0.068).Our data indicate that the postnatal and prenatal length ratios were equivalent, supporting the constant inhibition pattern of LLD in utero, thus validating the prenatal multiplier method for predicting LLD.

Purpose To compare two common surgical techniques of epiphysiodesis: drill/curettage epiphysiodesis (PDED) versus cross screw epiphysiodesis (PETS). The hypothesis is that the two techniques have similar efficacy but demonstrate differences in length of hospital stay (LOS), time to return to activity and complication rates. Methods A retrospective review of growing children and adolescents less than 18 years old who required an epiphysiodesis with leg-length discrepancy (LLD) of 2 cm to 6 cm with minimum two years of follow-up was conducted. Characteristics including age at surgery, gender, epiphysiodesis location, side, operative time, LOS and hardware removal were compared across treatment groups. LLD, expected growth remaining (EGR) and bone age were determined preoperatively and at most-recent visit. The correction ratio (change in EGR) was calculated along with a 95% confidence interval (CI) to assess if correction in leg length was achieved. Results A total of 115 patients underwent epiphysiodesis in the femur (53%), tibia (24%) or a combination (24%). The cohort was 47% male, with a mean age of 12.6 years (7.7 to 17.7) at surgery. Median follow-up was 3.7 years (2.0 to 12.7). In all, 23 patients underwent PETS and 92 patients had PDED. Both treatment groups achieved expected LLD correction. There was no significant difference in median operative time, complication rates or LOS. PETS patients returned to activity at a mean 1.4 months (interquartile range (IQR) 0.7 to 2.1) while PDED patients returned at a mean 2.4 months (IQR 1.7 to 3) (p < 0.001). Conclusion Effectiveness in achieving expected correction, LOS and operative time are similar between screw and drill/curettage epiphysiodesis. Patients undergoing PETS demonstrated a faster return to baseline activity than patients with PDED. Level of Evidence III

Purpose Treatment of idiopathic clubfoot with the Ponseti method is now standard, but predicting relapse can be difficult. Most experts recommend bracing to the age of four years, but this can be challenging for families, and may not be necessary in all patients. The purpose of this study is to compare patterns of bracing and age of relapse to help determine if predictable patterns exist. Methods The 70 patients with idiopathic clubfoot treated initially with the Ponseti technique who had relapse of their clubfoot were identified. Relapse was defined as a return to casting or surgery due to recurrent deformity. Data collected included demographics, treatment and brace adherence. Patients who sustained initial relapse before the age of two years were compared with those who sustained initial relapse after the age of two years. Results In total 56% (39/70) had their initial relapse prior to age two years while 44% (31/70) were after age two years. Of the patients who relapsed prior to the age of two years, 28% (11/39) were adherent with bracing while 72% were non-­adherent. For patients who initially relapsed after age two, 74% (23/31) were adherent with bracing while 26% were non-adherent (p < 0.001). Of those who had initial ­relapse ­prior to age two, a subsequent relapse was seen in 69% (27/39). Conclusion Patients with idiopathic clubfoot who experienced recurrence prior to age two years are significantly more likely to be non-adherent with bracing than those who sustain recurrence after age two. After initial relapse prior to age two, bracing adherence does not affect likelihood of subsequent recurrence.

Posteromedial subtalar (PMST) coalitions are a recently described anatomic subtype of tarsal coalitions. We compared with clinical patient-based outcomes of patients with PMST and standard middle facet (MF) coalitions who had undergone surgical excision of their coalition. The included patients had undergone surgical excision of a subtalar tarsal coalition, preoperative computed tomography (CT), and patient-based outcomes measures after surgery (including the American Orthopaedic Foot and Ankle Society [AOFAS] scale and University of California, Los Angeles [UCLA], activity score). Blinded analysis of the preoperative CT scan findings determined the presence of a standard MF versus a PMST coalition. The perioperative factors and postoperative outcomes between the MF and PMST coalitions were compared. A total of 51 feet (36 patients) were included. The mean follow-up duration was 2.6 years after surgery. Of the 51 feet, 15 (29.4%) had a PMST coalition and 36 (70.6%) had an MF coalition. No difference was found in the UCLA activity score; however, the mean AOFAS scale score was higher for patients with PMST (95.7) than for those with MF (86.5; p = .018). Of the patients with a PMST, none had foot pain limiting their activities at the final clinical follow-up visit. However, in the group with an MF subtalar coalition, 10 (27.8%) had ongoing foot pain limiting activity at the final follow-up visit (p = .024). Compared with MF subtalar tarsal coalitions, patients with PMST coalitions showed significantly improved clinical outcomes after excision. Preoperative identification of the facet morphology can improve patient counseling and expectations after surgery.

Background: The use of a brace has been shown to be an effective treatment for hip dislocation in infants; however, previous studies of such treatment have been single-center or retrospective. The purpose of the current study was to evaluate the success rate for brace use in the treatment of infant hip dislocation in an international, multicenter, prospective cohort, and to identify the variables associated with brace failure. Methods: All dislocations were verified with use of ultrasound or radiography prior to the initiation of treatment, and patients were followed prospectively for a minimum of 18 months. Successful treatment was defined as the use of a brace that resulted in a clinically and radiographically reduced hip, without surgical intervention. The Mann-Whitney test, chi-square analysis, and Fisher exact test were used to identify risk factors for brace failure. A multivariate logistic regression model was used to determine the probability of brace failure according to the risk factors identified. Results: Brace treatment was successful in 162 (79%) of the 204 dislocated hips in this series. Six variables were found to be significant risk factors for failure: developing femoral nerve palsy during brace treatment (p = 0.001), treatment with a static brace (p < 0.001), an initially irreducible hip (p < 0.001), treatment initiated after the age of 7 weeks (p = 0.005), a right hip dislocation (p = 0.006), and a Graf-IV hip (p = 0.02). Hips with no risk factors had a 3% probability of failure, whereas hips with 4 or 5 risk factors had a 100% probability of failure. Conclusions: These data provide valuable information for patient families and their providers regarding the important variables that influence successful brace treatment for dislocated hips in infants. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Supracondylar humeral fractures are the most common elbow fractures in children requiring operative intervention. They are classified according to the Gartland system as nondisplaced (type I), displaced with hinging and the posterior cortex intact (type II), and completely displaced (type III). The standard treatment for type-II and III fractures is closed reduction and percutaneous pinning. The timing of surgery depends on the severity of the fracture and the presence of any neurovascular injury. Preoperative assessment of the neurologic and vascular status is imperative, and can be challenging in a young child. The steps of the surgical procedure consist of the following.Position the patient supine with the affected extremity on a fluoroscopy detector or hand-table.Perform closed reduction.Apply longitudinal traction with the elbow in 30° of flexion.Correct medial or lateral translational displacement.Correct varus or valgus malalignment.Maintain traction and flex the elbow, placing pressure over the olecranon process to correct extension at the fracture site.Assess reduction using anteroposterior, oblique, and lateral fluoroscopic views.Place divergent pins from the lateral side, using 2 pins for type-II and 3 pins for type-III fractures.Assess stability by moving the elbow through a range of motion under live fluoroscopy in the lateral projection. If the fracture is determined to be unstable with lateral-only pins, proceed with medial pin placement through a mini-open approach.Cut the pins and bend them outside the skin. Then apply a long-arm bivalved cast. The pins are removed between 3 and 4 weeks postoperatively, depending on patient age, and range of motion is initiated. Elbow stiffness is common for 4 to 6 weeks, but a return to a nearly full range of motion can be expected. Resumption of normal activities should be delayed until the fracture is fully healed and the range of motion is nearly normal.

BACKGROUND Fractures of the fifth metatarsal bone are common and surgery is uncommon. The "Jones" fracture is known to be in a watershed region that often leads to compromised healing, however, a "true Jones" fracture can be difficult to determine, and its impact on healing in pediatric patients is not well described. The purpose of this study was to retrospectively assess patterns of fifth metatarsal fracture that led to surgical fixation in an attempt to predict the likelihood for surgery in these injuries. METHODS A retrospective review was performed on patients aged 18 and under who were treated for an isolated fifth metatarsal fracture from 2003 through 2010 at our pediatric hospital. Patient demographics, treatment, and complications were noted. Radiographs were reviewed for location of fracture and fracture displacement. Patients and fracture characteristics were then compared. RESULTS A total of 238 fractures were included and 15 were treated surgically. Most surgical indications were failure to heal in a timely manner or refracture and all patients underwent a trial of nonoperative treatment. Jones criteria for fracture location were predictive of needing surgery (P

Purpose: Detection of congenital lower limb deformities often occurs at the time of routine prenatal ultrasound. Counseling referred patients on the basis of these abnormal ultrasound findings presents a challenge for orthopedic surgeons, given limited reports on the accuracy of ultrasound findings in these conditions. In this study, we aimed to determine the accuracy of prenatal ultrasound in the diagnosis of lower extremity congenital disorders. Additionally, …

Purpose: To compare two common surgical techniques of epiphysiodesis: drill/curettage epiphysiodesis versus cross screw epiphysiodesis. The study hypothesis is that these two techniques have similar efficacy, but demonstrate differences in hospital stay and complication rates. Methods: Between 2004 and 2012 a retrospective review of patients 0- 18 years of age who required an epiphysiodesis to correct a leg length discrepancy (LLD) of 2-6 cm with minimum 2 year follow up were identified. Only cases with screw (S) or drill/curettage (D) epiphysiodesis technique …

The difference between medial (MAOR) and anterior (AAOR) approaches for open reduction of developmental hip dysplasia in terms of risk for avascular necrosis (AVN) and need for further corrective surgery (FCS, femoral and/or acetabular osteotomy) is unclear. This study compared age-matched cohorts undergoing either MAOR or AAOR in terms of these 2 primary outcomes. Prognostic impact of presence of ossific nucleus at time of open reduction was also investigated.Institutional review board approval was obtained. Nineteen hips (14 patients) managed by MAOR were matched with 19 hips (18 patients) managed by AAOR based on age at operation (mean 6.0; range, 1.4 to 14.9 mo). Patients with neuromuscular conditions and known connective tissue disorders were excluded. Primary outcomes assessed at minimum 2 years' follow-up included radiographic evidence of AVN (Kalamchi and MacEwen) or requiring FCS.MAOR and AAOR cohorts were similar regarding age at open reduction, sex, laterality, and follow-up duration. One hip in each group had AVN before open reduction thus were excluded from AVN analysis. At minimum 2 years postoperatively (mean 6.2; range, 1.8 to 11.7 y), 4/18 (22%) MAOR and 5/18 (28%) AAOR met the same criteria for AVN (P=1.0). No predictors of AVN could be identified by regression analysis. Presence of an ossific nucleus preoperatively was not a protective factor from AVN (P=0.27). FCS was required in 4/19 (21%) MAOR and 7/19 (37%) AAOR hips (P=0.48). However, 7/12 (54%) hips failing closed reduction required FCS compared with 4/26 (16%) hips without prior failed closed reduction (P=0.024). Cox regression analysis showed that patients who failed closed reduction had an annual risk of requiring FCS approximately 6 times that of patients without a history of failed closed reduction (hazard ratio=6.1; 95% CI, 1.5-24.4; P=0.009), independent of surgical approach (P=0.55) or length of follow-up (P=0.78).In this study of age-matched patients undergoing either MAOR or AAOR, we found no association between surgical approach and risk of AVN or FCS. In addition, we identified no protective benefit of a preoperative ossific nucleus in terms of development of AVN. However, failing closed reduction was associated with a 6-fold increased annual risk of requiring FCS.To the best of our knowledge, this is the first study comparing these 2 surgical techniques in an age-matched manner. It further corroborates previous studies stating that there may be no difference in risk of AVN based on surgical approach or presence of ossific nucleus preoperatively.Level III-retrospective comparative study.

Background Clubfoot is associated with maternal cigarette smoking in several studies, but it is not clear if this association is confined to women who smoke throughout the at-risk period. Maternal alcohol and coffee drinking have not been well studied in relation to clubfoot. Methods The present study used data from a population-based case–control study of clubfoot conducted in Massachusetts, New York, and North Carolina from 2007 to 2011. Mothers of 646 isolated clubfoot cases and 2037 controls were interviewed about pregnancy events and exposures, including the timing and frequency of cigarette smoking, alcohol intake, and coffee drinking. Results More mothers of cases than controls reported smoking during early pregnancy (28.9% vs. 19.1%). Of women who smoked when they became pregnant, those who quit in the month after a first missed period had a 40% increase in clubfoot risk and those who continued to smoke during the next 3 months had more than a doubling in risk, after controlling for demographic factors, parity, obesity, and specific medication exposures. Adjusted odds ratios for women who drank >3 servings of alcohol or coffee per day throughout early pregnancy were 2.38 and 1.77, respectively, but the numbers of exposed women were small and odds ratios were unstable. Conclusions Clubfoot risk appears to be increased for offspring of women who smoke cigarettes, particularly those who continue smoking after pregnancy is recognisable, regardless of amount. For alcohol and coffee drinkers, suggested increased risks were only observed in higher levels of intake.

Modified Dunn osteotomy has gained popularity over the past decade in the treatment of moderate to severe adolescent slipped capital femoral epiphysis. The purpose of this study was to retrospectively evaluate a consecutive series of adolescent slipped capital femoral epiphysis patients treated with the modified Dunn procedure at a single institution. We analyze the indications for the procedure as well as the complications after surgical treatment.Forty-three adolescent patients (18 boys and 25 girls) were treated with the modified Dunn procedure at our institution between September 2001 and August 2012. The average follow-up for this cohort was 2.6 years (range, 1 to 8 y). Complications were graded according to the modified Dindo-Clavien classification.Twenty-six patients (60%) had an unstable injury with an inability to ambulate with our without crutches. Seventeen patients (40%) had an acute injury with duration of symptoms3 weeks. Thirty-seven patients (86%) had a severe slip based on a Southwick slip angle of50 degrees. Twenty-two complications occurred in 16 patients (37%) in this cohort. Fifteen revision procedures were performed for femoral head avascular necrosis, fixation failure with deformity progression, or postoperative hip dislocation. Two patients developed end-stage degenerative joint disease and severe femoral head avascular necrosis and were referred for a total hip arthroplasty.The complication rate in this series is higher than most previous reports. This may be in part because of the fact that as a tertiary referral center our patient population was more complex. However, we identified a clear inverse relationship between surgeon-volume and patient-outcomes. On the basis of our results we have modified our practice. A high-volume surgeon must be present during each modified Dunn procedure, and only patients that have sustained an acute severe (50 degrees) epiphyseal displacement with mild chronic remodeling of the metaphysis that can be addressed within 24 hours of the slip may be treated with the modified Dunn technique.Level IV-therapeutic study.

Clubfoot, a common major structural malformation, develops early in gestation. Epidemiologic studies have identified higher risks among boys, first-born children, and babies with a family history of clubfoot, but studies of risks associated with maternal exposures are lacking. We conducted the first large-scale, population-based, case-control study of clubfoot with detailed information on maternal medication use in pregnancy. Study subjects were ascertained from birth defect registries in Massachusetts, New York, and North Carolina during 2007-2011. Cases were 646 mothers of children with clubfoot without other major structural malformations (i.e., isolated clubfoot); controls were mothers of 2,037 children born without major malformations. Mothers were interviewed within 12 months of delivery about medication use, including product, timing, and frequency. Odds ratios were estimated for exposure to 27 medications in pregnancy months 2-4 after adjustment for study site, infant sex, first-born status, body mass index (weight (kg)/height (m)(2)), and smoking. Odds ratios were less than 1.20 for 14 of the medications; of the remainder, most odds ratios were only slightly elevated (range, 1.21-1.66), with wide confidence intervals. The use of antiviral drugs was more common in clubfoot cases than in controls (odds ratio = 4.22, 95% confidence interval: 1.52, 11.73). Most of these results are new findings and require confirmation in other studies.

Objective Routine prenatal ultrasound has often resulted in the early detection of musculoskeletal disorders. The purpose of this study was to determine which socioeconomic factors are associated with prenatal detection of clubfoot.

The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb.The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed.Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue-encircled nerves.The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications.Level III.

BACKGROUND Hypoplasia or congenital absence of the anterior cruciate ligament (ACL) is a rare disorder occurring in ∼1 in every 6000 births. Although some patients with hypoplasia or agenesis of the ACL may not complain of instability, others desire to participate in more demanding activities that require the stability of a competent ACL. There are limited reports of surgical treatment of this patient population. The purpose of this study was to report ACL reconstruction in a case series of patients with symptomatic congenital ACL deficiency. METHODS A retrospective medical record review of the surgical treatment of 14 knees (13 patients) with congenital absence of the ACL at a tertiary care institution from 1995 to 2012 was performed. Patients with a minimum of 1 year of clinical follow-up were eligible for inclusion. RESULTS The mean age at time of surgery was 12.6 (range, 3 to 22), including 6 patients

UNLABELLED Fractures of multiple metatarsals in the pediatric population are uncommon; however, indications for surgical treatment have not been delineated. The aim of this study was to review multiple metatarsal fractures to help refine surgical indications. A total of 98 patients had multiple metatarsal fractures; displacement greater than 10% shaft width (displaced) was encountered in 33 (34.0%) patients. Fifteen patients had displacement of more than 75% shaft width of one metatarsal. Patients older than 14 years of age were more likely to have surgery for their injury (52.6%) than those younger than 14 years of age (3.7%) (P

To develop and evaluate an intervention to reduce breakdowns in communication during inpatient surgical care.Communication breakdowns are the second most common cause of avoidable surgical adverse events after technical errors.In a pre- and postintervention study, a random selection of patients on the surgical services of 4 teaching hospitals were observed according to 3 measures: (1) resident-attending communication of critical patient events (eg, transfer into the intensive care unit, unplanned intubation, cardiac arrest); (2) resident-attending notification regarding routine weekend patient status; and (3) frequency of weekend patient visits by an attending. All departments then developed and adopted a set of policy and education initiatives designed to increase prompt and consistent resident-attending communication (especially in critical events) and to improve regular attending visits with surgical patients. Specific reinforcement of the policies included a pocket information card for residents, as well as periodic reminders. Repeat audits of the surgical services were then conducted.We reviewed information for 211 critical events and 1360 patients for the nature of resident and attending communication practices. After the intervention, the proportion of critical events not conveyed to an attending decreased from 33% (26/80) to 2% (1/47), and gaps in the frequency of attending notification of patient status on weekends were virtually eliminated (P0.0001); the proportion of weekend patients not visited by an attending for greater than 24 hours decreased by half (from 61% to 33%; P = 0.0002). Contact resulted in attending-led changes in patient management in one-third of cases.An intervention to improve surgical communication practices at 4 teaching hospitals led to significant reductions in potentially harmful communication breakdowns during inpatient care; significant alterations in patient management were noted in one-third of cases in which there was an adherence to recommended communication practices.

Background Pediatric talus fractures are rare with variable rates of posttraumatic complications reported in the literature. The purpose of this retrospective study was to evaluate posttraumatic complications in children after talus fracture and report injury characteristics. Methods This study included 29 children with talus fractures sustained between 1999 and 2008 at an average age of 13.5 years (range, 1.2-17.8). Patient records and radiographs were reviewed to determine the mechanism of injury, fracture type, associated injuries, and treatment. Posttraumatic complications assessed were avascular necrosis, arthrosis, nonunion or delayed union, neurapraxia, infection or wound-healing problems, and the need for further unanticipated surgery. Clinical follow-up averaged 24 months (range, 6 mo-5 y). Results Twenty-nine children sustained a major fracture of the talar body, neck, or head. Avascular necrosis occurred in 2 patients (7%), arthrosis in 5 (17%), delayed union in 1 (3%), neurapraxia in 2 (7%), infection in 0, and the need for further surgery in 3 (10%). Both high-energy mechanism and fracture displacement corresponded to a greater number of posttraumatic complications. The number and severity of talus fractures increased in older children. Conclusions In this case series, posttraumatic complications after pediatric talus fractures occurred more frequently after a high-energy mechanism of injury or a displaced fracture. Talus fractures occurred more commonly and with more severity in older children. Level of evidence Level IV. Retrospective case series.

To measure and compare the dimensions of the sustentaculum tali (ST) in pediatric patients with unilateral subtalar coalition to determine if the contralateral side has altered morphology.The institutional review board approved this study, which was HIPAA compliant. Informed consent was waived. Radiology records were reviewed to identify 35 patients with unilateral subtalar coalition undergoing computed tomography (CT) (21 male, 14 female; mean age, 14.54 years) and 33 control patients with triplane fracture (21 male, 12 female; mean age, 13.48 years). CT images were reviewed, and reformatted images through the subtalar joint (on the side opposite the coalition) were created. Anteroposterior measurements of the middle facet (MF) and the ST were recorded by two observers with electronic calipers. The MF/ST ratio and the ST length extending posterior to the MF were calculated. Measurements between groups were compared by using Wald tests based on linear regressions. Inter- and intraobserver variabilities were determined by means of a component of variance model.The lengths of the MF and ST for the study and control groups were 12.86 and 16.82 mm (P.001) and 23.83 and 22.06 mm (P = .053), respectively. Intra- and interobserver correlations for both measurements were 0.94 and 0.92 and 0.86 and 0.77, respectively. MF/ST ratio was 0.54 versus 0.76 (P.001), and ST length extending posterior to the MF was 10.97 versus 5.24 mm (P.001).The MF is smaller and the ST extends further beyond the MF in patients with a contralateral subtalar coalition than in control patients. The morphology of the ST may provide insight into the origins and development of coalitions.

Rationale: The sciatic nerve runs a predictable course combining L4-S3 nerve roots through the true pelvis and under the greater sciatic notch. There are reports of bony protuberances from the sacrum and ilium in cases of spinal dysraphism; however advanced imaging, treatment, or outcomes are not described. There are no cases with associated fibular hemimelia in the current literature. Patient concerns: This is a 4-year-old girl with tethered cord, acetabular dysplasia with hip subluxation, congenital short femur, anterior cruciate ligament (ACL) deficiency, and fibular hemimelia with her sciatic nerve coursing through the ilium. Diagnosis: Aberrant course of the sciatic nerve through the ilium in the setting of spinal dysraphism. Outcomes: The hip subluxation was treated with a femoral varus derotation osteotomy and Salter osteotomy with transposition of the sciatic nerve into the greater sciatic notch resulting in a stable hip with no sciatic nerve symptoms at last follow-up. Lessons: The combination of spinal dysraphism with acetabular dysplasia should be a warning for anomalous sciatic nerveanatomy, possibly through the ilium. Preoperative imaging (MRI, CT scan) may be obtained and carefully reviewed for the course of the sciatic nerve prior to pelvic or femoral osteotomy. Decompressing the sciatic nerve from the aberrant foramen may be considered as part of the procedure.

A small subset of serious injuries to the pediatric elbow, deemed "TRASH" lesions, are easily missed on radiograph because of their benign appearance. These lesions however, represent a group of osteochondral injuries, which if treated insufficiently result in chronic long-term consequences. Epiphyseal separations, a displaced intra-articular medial condyles before ossification of the secondary center, capitellar shear fractures, radial head fractures with radiocapitellar subluxation and osteochondral fractures of the olecranon, radial head or distal humerus with joint incongruity comprise the group of "TRASH lesions". These injuries are usually seen in children less than 10 years of age who sustain high-energy trauma. The challenge is a prompt diagnosis requiring a high level of suspicion and early additional imaging. Many of these injuries are displaced and unstable requiring anatomic reduction, internal fixation with or without soft tissue repair for further stability. These injuries when diagnosed late, missed completely or treated improperly without aggressive surgical care can result in long-term complications. Surgical reconstruction of the late presenting malunion is difficult.

Background: Use of ultrasound in the prenatal period is increasing and musculoskeletal anomalies are often found. Parents-to-be are often confronted with the reality of a potentially imperfect child part-way into the pregnancy. Prenatal counseling with a pediatric orthopaedic surgeon may be of some benefit to alleviate concerns. Methods: Musculoskeletal anomalies found on prenatal ultrasound are reviewed, including those in the upper extremeity, spine, syndromes, and lower extremity. Incidence and associated anomalies are discussed. Results: Many different musculoskeletal anomalies across a broad spectrum of potential severity may be found on prenatal ultrasound. In most cases, isolated musculoskeletal diagnoses have the potential for excellent long-term function. Prenatal counseling with the parents-to-be may properly inform them of the issues and treatment expectations for their unborn child, and relieve their concerns and fears. Conclusions: Prenatal counseling with a pediatric orthopaedic surgeon for musculoskeletal diagnoses found on ultrasound may alleviate fears of the parents and better inform them of the treatment expectations for their unborn child.

Lipofibromatosis is a slow-growing, childhood soft-tissue neoplasm that is often confused with other conditions. We report a patient with lipofibromatosis causing extremity enlargement at birth. The lesion initially was thought to be a vascular anomaly or lipedema on clinical and MRI examination. When involving the lower extremity, diffuse lipofibromatosis must be differentiated from more common causes of lower limb enlargement in children: lymphatic malformation, lymphedema, or lipedema. Compared with these more frequent conditions, lipofibromatosis usually causes less morbidity. Management of the tumor includes observation or excision. Because complete extirpation of the lesion is difficult, the recurrence rate is high.

INTRODUCTION Avascular necrosis (AVN) of the femoral head remains a major complication in the treatment of developmental dysplasia of the hip (DDH) in infants. We performed a retrospective analysis to look at the predictive ability of postclosed reduction contrast-enhanced magnetic resonance imaging (MRI) for AVN after closed reduction in DDH. METHODS Twenty-eight hips in 27 infants (aged 1-11 months) with idiopathic hip dislocations who had failed brace treatment underwent closed reduction +/- adductor tenotomy and spica cast application under general anesthesia. Magnetic resonance imaging of the hips after intravenous gadolinium contrast injection for evaluation of epiphyseal perfusion was obtained immediately after cast application. Patients were followed with serial radiographs for a minimum of 1 year after closed reduction. Presence of AVN was determined by the presence of any one of the 5 Salter criteria by 2 readers. Magnetic resonance imaging was graded as normal, asymmetric enhancement, focal decreased enhancement, or global decreased enhancement by 2 radiologists. RESULTS Six (21%) of 28 hips showed evidence of clinically significant AVN on follow-up radiographs. Fifty percent of the hips with AVN, but only 2 of 22 hips without AVN, showed a global decreased MRI enhancement (P < 0.05, Fisher exact test). Multivariate logistic regression indicated that a global decreased enhancement was associated with a significantly higher risk of developing AVN (P < 0.01), independently of age at reduction (P = 0.02) and abduction angle. CONCLUSIONS In addition to accurate anatomical assessment of a closed reduction in DDH, gadolinium-enhanced MRI provides information about femoral head perfusion that may be predictive for future AVN. At present, it is premature to use the perfusion information for routine clinical use. However, it opens the door to studies looking at repositioning or alternative reduction methods that may reduce the risk of AVN in this higher risk group.

Complications associated with pediatric femur fractures vary according to the location of the fracture. Proximal femoral fractures of the head and neck account for less than 1 % of all pediatric fractures, and the most common complications are often severe, including femoral head osteonecrosis, premature physeal closure (and subsequent growth disturbance), fracture nonunion, coxa vara, infection, and chondrolysis. The most common femoral shaft fracture complications are malunion, leg-length discrepancy, and muscle weakness, with much rarer reporting of compartment syndrome, neurovascular injury, infection, and nonunion. The most frequent complications associated with distal femoral fractures are stiffness and growth disturbance, which may lead to angular deformity or leg-length discrepancy. Other reported complications are ligamentous injuries and neurovascular injuries. This chapter explores the evaluation and management of this array of complications, most of which can arise even with appropriate management of primary fractures.

Background Polydactyly of the foot is a relatively common condition. Approximately 15% of cases are preaxial, with one third of these cases involving duplication of the metatarsal [metatarsal type preaxial polydactyly (MTPP)].Surgical reconstruction of polydactyly is indicated to improve shoe tolerance. Reconstruction of MTPP has traditionally involved resection of the hypoplastic lateral ray in addition to soft tissue reconstruction to correct hallux varus. Poor postoperative results have frequently been reported, primarily due to residual hallux varus. We present a novel surgical technique for the treatment of children with MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy that permits retention of the stable medial metatarsotarsal joint while avoiding the complication of residual hallux varus. Methods This was a retrospective case series describing the surgical technique of an amalgamating osteotomy in the treatment of patients with MTPP and a cosmetic lateral hallux. The surgical technique involves corresponding metatarsal osteotomies of the medial and lateral halluces, with amalgamation of the metatarsals and ablation of the residual medial hallux, without the need for extensive soft tissue reconstruction. Clinical and radiologic outcomes were evaluated at a minimum of 2 years postoperatively in 2 patients who underwent this technique. Results Two children, 1 female and 1 male, underwent an amalgamating osteotomy at the age of 31 and 18 months, respectively. At latest follow-up, 7.3 and 2.8 years after osteotomy, respectively, both patients displayed an excellent functional result according to the Phelps and Grogan clinical outcome scale. Plain radiographs in both cases demonstrated a well-aligned first ray with no growth abnormality and no hallux varus. Conclusions We have presented a novel surgical technique for the reconstruction of MTPP presenting with a cosmetic lateral hallux, involving an amalgamating osteotomy without extensive soft tissue reconstruction. This simple technique maintains the stable medial metatarsotarsal joint, permits ongoing longitudinal metatarsal growth, and avoids the complication of hallux varus. Level of evidence Level IV-case series.

Traumatic hip dislocation is an uncommon injury in children. The urgency of closed reduction to prevent possible osteonecrosis may present some pitfalls. Adolescents with open proximal femoral physis may have sustained trauma to the physis at the time of dislocation that can lead to displacement of the epiphysis during the reduction maneuver. The purpose of this study is to report 5 cases with this complication and discuss potential etiology and management. All of the 5 patients were between 12 and 16 years old and underwent closed reduction under conscious sedation. Epiphysiolysis of the femoral head was diagnosed after reduction in all 5 patients. Every patient underwent emergent open reduction and internal fixation of the femur and open hip reduction. Avascular necrosis was identified in all 5 patients within 3 to 15 months postinjury. If there is any suspicion of associated physeal injury or if there is any physeal instability noted under fluoroscopy, an open reduction is recommended in the operating room under radiograph guidance to prevent displacement.

We performed a retrospective, nonrandomized cohort study of unilateral, chronic, severe, stable slipped capital femoral epiphysis comparing five girls and five boys who underwent in-situ screw fixation alone with five girls and five boys who underwent in-situ screw fixation combined with staged flexion intertrochanteric femoral osteotomy to restore proximal femoral alignment. Functional outcome was measured by the Harris hip score, with 20% selected as a goal for improvement in functional outcome after corrective osteotomy. While flexion intertrochanteric femoral osteotomy improved hip range of motion, we found no significant difference in functional outcome between the two groups at early follow-up. This is a level 3 evidence study.

Hip arthroscopy has become an established procedure for certain indications in adults, but experience in children and adolescents has been more limited. The purpose of this study is to report the early-term results of hip arthroscopy in children and adolescents. A consecutive case series of 54 hip arthroscopies in 42 patients 18 years old and younger over a 3-year period at a tertiary-care children's hospital with a minimum of 1 year of follow-up was reviewed. Patients were assessed with the modified Harris hip score (HHS) before and after surgery. Overall results and results by common diagnoses were analyzed. Indications for surgery included isolated labral tear (n = 30), Perthes disease (n = 8), hip dysplasia with labral tear after prior periacetabular osteotomy (n = 8), inflammatory arthritis (n = 3), spondyloepiphyseal dysplasia (n = 2), avascular necrosis (n = 1), slipped capital femoral epiphysis (n = 1), and osteochondral fracture (n = 1). Overall, there was a significant improvement in HHS from 53.1 to 82.9 (P < 0.001), with 83% of patients improved. By diagnosis, significant improvement in HHS was seen for patients with isolated labral tears undergoing labral debridement (before surgery 57.6; after surgery 89.2; P < 0.001), for patients with Perthes disease undergoing chondroplasty and loose body excision (before surgery 49.5; after surgery 80.1; P < 0.001), and for patients with hip dysplasia after prior periacetabular osteotomy undergoing labral debridement (before surgery 51.8; after surgery 79.8; P < 0.001). Complications included transient pudendal nerve palsy (n = 3), instrument breakage (n = 1), and recurrent labral tear (n = 3). Hip arthroscopy in children and adolescents appears to be safe and efficacious for certain indications in the short term.

A change in the locations where children are treated for supracondylar fractures of the humerus has occurred during the past 13 years. Pediatric orthopaedic surgeons at specialist centers are seeing an increased number of such fractures. In New England, the number of supracondylar fractures of the humerus treated by closed reduction and percutaneous pinning has remained relatively constant between 1991 and 1999 with a range of 276 to 346 fractures per year, averaging 320 per year. In 1991, 63% of patients were treated by general orthopaedic surgeons in a nonspecialist setting. By 1999, 68% of the fractures were treated at centers with pediatric orthopaedic specialists available whereas only 32% were treated in a general orthopaedic setting. Associated with this change is a decreased length of stay from 2.2 (+/- 0.6) days in nonspecialist centers to 1.4 (+/- 0.4) days average in specialist centers.

This study was designed to determine the efficacy of waterproof cast-lining materials in children with short-arm, long-arm, and short-leg casts. Eligible patients had healing fractures 2 weeks after reduction, stable fractures requiring no reduction, or sprains. A total of 165 waterproof-lined casts were applied and 124 children and parents completed a survey (76.9%) upon cast removal. Results revealed 79% very satisfied, 21% satisfied, and 0% dissatisfied. There were 16 (12.9%) minor skin integrity issues. Waterproof casts in stable fractures and sprains allow acceptable immobilization with no significant associated unusual risk and allow children to resume their usual recreational water activities and hygiene regimen without risk of adverse results.

Background: The management of the contralateral hip after unilateral slipped capital femoral epiphysis is controversial. The purpose of this study was to determine, with use of expected-value decision analysis, the optimal management strategy—prophylactic in situ pinning versus observation—for the contralateral hip. Methods: Outcome probabilities were determined from a systematic review of the literature. Utility values were obtained from a questionnaire on patient preferences completed with use of a visual analog scale by twenty-five adolescent male patients without slipped capital femoral epiphysis. A decision tree was constructed, fold-back analysis was performed to determine the optimal treatment, and one and two-way sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. Results: Observation was the optimal management strategy for the contralateral hip given the outcome probabilities and utilities that we studied (the expected value was 9.5 for observation and 9.2 for prophylactic in situ pinning, with a marginal value of 0.3). Increased rates of a late second slip favored prophylactic in situ pinning (the threshold probability was 27%). Risk-taking patients with a high utility for uncomplicated prophylactic in situ pinning favored prophylaxis (the threshold utility was 9.8). Conclusions: The iatrogenic risks of treating a healthy patient or an uninvolved body part rarely outweigh the potential benefits unless the probability of the adverse event is likely and the consequences of the adverse event are very severe. In this decision analysis, the optimal decision was observation. In cases where the probability of contralateral slipped capital femoral epiphysis exceeds 27% or in cases where reliable follow-up is not feasible, pinning of the contralateral hip is favored. For a given individual patient, the optimal strategy depends not only on probabilities of the various outcomes but also on personal preference. Thus, we advocate a model of doctor-patient shared decision-making in which both the outcome probabilities and the patient preferences are considered in order to optimize the decision-making process. Level of Evidence: Economic and decision analysis, Level III-1 (limited alternatives and costs; poor estimates). See Instructions to Authors for a complete description of levels of evidence.

Background: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children. Methods: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups. Results: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion. Conclusions: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

This is a retrospective review of four patients in whom a pattern of coxa vara with proximal femoral growth arrest and metaphyseal irregularities developed. These patients were all treated with neonatal extracorporeal membrane oxygenation and presented with a progressive gait disturbance and pain, leg-length discrepancy, and limited abduction. Imaging revealed coxa vara with proximal femoral growth arrest. Two patients (three hips) underwent proximal femoral valgus osteotomy, one patient underwent fixation of a femoral neck fracture with subsequent greater trochanter transfer, and one patient is being observed. This case series suggests an association between neonatal extracorporeal membrane oxygenation and this unusual pattern of coxa vara with proximal femoral growth arrest.

There are little patient-reported data on functional outcomes of tarsal coalition resection in children and adolescents. The purpose of this study is to evaluate the medium-term (2 y) outcomes in patients who have had surgical excision of their symptomatic tarsal coalition and to compare patient-based outcomes in patients who have calcaneonavicular (CN) coalitions to those with talocalcaneal (TC) coalitions.A billing query was conducted to identify patients who had surgical excision of their tarsal coalition between 2003 and 2008. Eligible patients were mailed questionnaires consisting of a modified American Orthopaedic Foot and Ankle Society (AOFAS) score and the University of California at Los Angeles (UCLA) activity scale. Patients were also specifically asked if their activity level was limited by their foot pain. Only patients who returned questionnaires were included. Demographics and diagnostic images were reviewed. A nonresponder analysis was completed. Complications such as infection and reoperation were reported.Sixty-three patients (22 females, 41 males) who returned questionnaires were included in the analysis. Twenty-four patients had bilateral surgery. TC coalitions were present in 20 patients (32%); CN coalitions were present in 43 patients (68%).Overall, mean modified AOFAS score was 88.3 and mean UCLA activity score was 8.33 at an average of 4.62 years after surgery. Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those with CN coalitions (88.0 and 8.3, both not significant).Of the 73% (46/63) patients who reported that their activity levels were not limited by their foot pain, the mean AOFAS score was 93.9 and the mean UCLA activity score was 8.9; 32 of these were CN and 14 were TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by their foot pain, the mean AOFAS score was 72.9 and the mean UCLA activity score was 6.9; 11 of these were CN and 6 were TC coalitions. There was a statistically significant difference in these groups both in modified AOFAS score (P0.0001) and UCLA activity score (P=0.006). There was no difference in outcomes between those who were treated for a TC and CN coalition.Patient-reported outcomes after surgical excision of tarsal coalition reveal that70% of patients' activities are not limited by pain and their functional outcome is terrific. A few patients continue to have problems with ongoing foot pain and activity limitations. The type of coalition does not seem to be an indicative factor in determining outcome.

Arthrogryposis is characterized by multiple, nonprogressive joint contractures which may be caused by maternal disorders such as oligohydramnios as well as fetal akinesia resulting from primary disorders of muscle, connective tissue, or neurologic tissue. Its prevalence is about 1 : 3000. Distal arthrogryposis (DA) is a heterogenous group of genetic disorders with a characteristic flexion of the joints of the hands and feet divided into different types with additional features. Sheldon-Hall Syndrome (SHS), also known as distal arthrogryposis type 2A (DA2A), has some nonorthopedic features of specific importance to anesthetic care.

INTRODUCTION Treatment of idiopathic clubfoot has shifted towards Ponseti technique, but previously surgical management was standard. Outcomes of surgery have varied, with many authors reporting discouraging results. Our purpose was to evaluate a single surgeon's series of children with idiopathic clubfoot treated with a la carte posteromedial and lateral releases using the Pediatric Outcomes Data Collection Instrument (PODCI) with a minimum of 2-year follow-up. METHODS A total of 148 patients with idiopathic clubfoot treated surgically by a single surgeon over 15 years were identified, and mailed PODCI questionnaires. Fifty percent of the patients were located and responded, resulting in 74 complete questionnaires. Median age at surgery was 10 months (range, 5.3 to 84.7 mo), male sex 53/74 (71.6%), bilateral surgery 31/74 (41.9%), and average follow-up of 9.7 years. PODCI responses were compared with previously published normal healthy controls using t test for each separate category. Included in the methods is the individual surgeon's operative technique. RESULTS In PODCIs where a parent reports for their child or adolescent, there was no difference between our data and the healthy controls in any of the 5 categories. In PODCI where an adolescent self-reports, there was no difference in 4 of 5 categories; significant difference was only found between our data (mean = 95.2; SD = 7.427) and normal controls (mean = 86.3; SD = 12.5) in Happiness Scale (P = 0.0031). DISCUSSION In this group of idiopathic clubfoot patients, treated with judicious posteromedial release by a single surgeon, primarily when surgery was treatment of choice for clubfoot, patient-based outcomes are not different from their normal healthy peers through childhood and adolescence. While Ponseti treatment has since become the treatment of choice for clubfoot, surgical treatment, in some hands, has led to satisfactory results. LEVEL OF EVIDENCE Level III.

A retrospective review of 16 patients with floating elbow injuries over a 9-year period at a tertiary care children's hospital confirms that these injuries are associated with substantial swelling and the potential to develop compartment syndrome, particularly when circumferential cast immobilization is used. Among 10 patients in whom the forearm was treated with closed reduction and plaster immobilization, a compartment syndrome developed in 2, and 4 patients had incipient compartment syndrome that responded to splitting of the cast; 3 of these subsequently required remanipulation of the distal radius. One patient with compartment syndrome had Volkmann ischemic contracture. Six patients underwent stabilization of both the distal humeral and forearm fractures with percutaneously inserted Kirschner wires, thereby allowing postreduction immobilization in a split cast. None of these patients had problems with excessive swelling or compartment syndrome. Percutaneous Kirschner wire fixation of both the humeral and forearm fractures in pediatric floating elbow injuries allows noncircumferential immobilization, thereby reducing the risk of compartment syndrome.