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ABSTRACT: BACKGROUND: The durability and risks associated with total hip arthroplasty (THA) for patients with a history of Legg-Calvé-Perthes disease (LCPD) are not well known. QUESTIONS/PURPOSE: We sought to (1) determine the survivorship of THAs performed for LCPD; (2) assess hip scores and complications associated with THA in this patient population; and (3) compare results between patients who had undergone surgery in childhood with patients who had conservative treatment. METHODS: We reviewed 99 primary THAs performed in 95 patients with a history of LCPD with minimum 2-year followup (mean ± SD, 8 ± 5 years). Mean age at THA was 48 ± 15 years. RESULTS: A total of 10 revisions were performed. Using revision for any reason as the end point, the 8-year survival rate was 90% (95% confidence interval [CI], 76%-96%) for cementless implants compared with 86% (95% CI, 57%-96%) for hybrid implants. The mean Harris hip score improved by 31 ± 16 (n = 76). Complications occurred in 16% of hips. The most common major complication was intraoperative fracture (eight femoral, one acetabular). Three patients developed sciatic nerve palsy after a mean lengthening of 2.2 ± 1 cm compared with a mean of 1.4 ± 1 cm in patients with intact sciatic nerve (p = 0.3). CONCLUSIONS: Cementless THAs for the sequelae of LCPD demonstrate 90% survival from any revision at 8 years followup. THAs for the sequelae of LCPD can be complicated and technically difficult. Intraoperative fractures and nerve injuries are common. Care should be taken to avoid excessive limb lengthening. LEVEL OF EVIDENCE: Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 04/2013; · 2.53 Impact Factor
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ABSTRACT: BACKGROUND: The indications for prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis (SCFE) remain controversial in part because the natural history of the contralateral hip is unclear. QUESTIONS/PURPOSES: We therefore determined (1) the incidence of contralateral slips in patients with unilateral SCFE, (2) the rate of subsequent corrective surgery, and (3) the Harris hip score (HHS) and VAS pain score for hips that sustained a contralateral slip after unilateral pinning. METHODS: We retrospectively reviewed 226 patients with unilateral SCFE at initial presentation between 1965 and 2005; of these, 133 met our inclusion criteria and were followed at least 2 years. Latest followup included examination and radiographs for 52 patients and HHS (without radiographs) and VAS pain score for 81 hips. Minimum followup was 2 years (median, 13 years; range, 2-43 years). RESULTS: Of the 133 patients at risk for a subsequent slip, 20 patients developed a contralateral slip (15%). One patient developed avascular necrosis requiring arthroplasty, and another patient had a mild contralateral slip with disabling pain. For the 15 patients with contralateral slips and scores available, the mean HHS was 90 (range, 49-100) and the mean VAS pain score was 20 of 100. Six found the contralateral hip painful. CONCLUSIONS: The contralateral slip sustained by the majority of patients was for the most part mild. However, nearly 1/3 of the contralateral slipped hips were painful. One patient has severe pain, and a second required THA for avascular necrosis after an unstable slip. These may have been preventable by prophylactic pinning. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 01/2013; · 2.53 Impact Factor
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ABSTRACT: Previous long-term studies have shown good outcomes for most patients after in situ pinning of slipped capital femoral epiphyses (SCFE). However, concern is growing about the effects of leaving the epiphysis in a nonanatomic position. We undertook a retrospective study to carefully document patient-reported outcomes and need for additional surgery after in situ pinning of SCFE. Further, we sought to determine the risk factors for persistent pain and dysfunction after in situ pinning.
Between 1965 and 2005, 146 patients (176 hips) with SCFE underwent in situ pinning at a tertiary referral center. Medical records and radiographs were reviewed for slip characteristics and need for subsequent surgery. Patient-reported outcome measures were collected by mailed survey. Mean follow-up was 16 years (range, 2 to 43 y).
Twenty-one hips (12%) underwent reconstructive surgery for persistent symptoms, including femoral osteotomy (11), surgical hip dislocation (2), and total hip arthroplasty (8). Mild slips, as well as moderate and severe slips, were treated with reconstructive surgery, including total hip arthroplasty. Of the remaining hips, 33% were painful with a mean overall visual analog score of 2.4 (range, 0 to 10). Mean outcome scores were as follows: Harris Hip Score 90 (max. 100); Hip Dysfunction Osteoarthritis Outcome score 411 (max. 500); UCLA Activity Score 8 (max. 10); and Marx Activity Score 5 (max. 16).
Reconstructive surgery was performed in 12% of hips. Patients with mild, moderate, and severe slips underwent arthroplasty for degenerative changes. Persistent mild pain was common in one third of patients treated with in situ pinning.
Level IV, therapeutic study, case series.
Journal of pediatric orthopedics 03/2012; 32(2):125-30. · 1.23 Impact Factor
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ABSTRACT: Acetabular retroversion has been identified in mature patients with sequelae of Legg-Calvé-Perthes (LCP) disease. Whether this is a contributing etiologic factor that leads to the disease process or result of the head deformity is not known. The prominence of the ischial spine (PRIS) sign, which reflects retroversion, can be observed before ossification of the anterior and posterior walls in a skeletally immature patient and could help determine whether the retroverted acetabulum is present before or after head involvement in patients with LCP disease.
We therefore determined (1) the prevalence of the PRIS sign in patients with LCP disease compared with healthy control subjects, (2) whether the PRIS sign is seen at the time of head involvement in patients with LCP disease, and (3) the prevalence of bilaterality of the PRIS sign in patients with LCP disease and control subjects.
Of 295 patients with LCP disease, 47 (49 hips) met our inclusion criteria. Of these, 39 (41 hips) had open triradiate cartilage and comprised the study group. Twenty-five pediatric patients with polytrauma (50 hips) with standardized radiographs comprised the control group.
A positive PRIS sign was noted in 37 of the 41 skeletally immature hips compared with only 16 of the 50 control hips. We observed a positive PRIS sign early in the LCP disease process with eight of nine patients in the fragmentation phase having a positive PRIS sign. The PRIS sign was seen bilaterally in 25 of 39 patients with unilateral LCP disease and in only five of 25 control patients.
Acetabular retroversion, as evidenced by a positive PRIS, was present in nine of 10 children with LCP disease. It is uncertain if retroversion is a cause or a sequela of the disease, but it was seen early in the disease process at the time of head involvement in the majority of patients.
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 01/2011; 469(7):2012-8. · 2.53 Impact Factor
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ABSTRACT: Motocross is a nationally organized sport that is growing in popularity. The distribution and severity of motocross injuries in the pediatric population is not known. We hypothesize a high rate of musculoskeletal injuries requiring hospitalization and/or surgical intervention.
All patients 17 years of age or younger with injuries sustained while using off-road 2-wheeled motorcycles were identified through surgical, diagnostic, and trauma registries at a level 1 regional trauma center. Type, severity, and mechanism of injury were assessed, as well as charges billed for medical care. Both recreational and competitive motocross activities were included.
From 2000 to 2007, 299 cases were noted in 249 unique patients. In 141 instances, hospital admission was required, for a total of 412 inpatient days. Twenty patients required ICU admission. Surgery was performed in 91 cases (81 orthopaedic, 6 general, 1 urology, and 4 facial reconstructions). Orthopaedic surgical procedures included treatment of 29 femur fractures, 8 forearm, 6 ankle, 5 tibial shaft, 6 proximal tibia, 5 spine, 6 proximal humerus, 4 hand, 4 foot, 3 elbow fractures, and 5 other. Orthopaedic interventions also included 8 reductions under general anesthesia and 31 conscious sedations. Mean age at injury was 14.1 years (range: 5.4 to 17.9). Ninety-four percent of patients were male and 85% were White. The majority of patients were wearing helmets/safety equipment. One hundred and eighty-four injuries occurred on a track, with 150 during competition. The mean charge billed per injury was $14,947 (range: $105 to $217,780), with a total cost of $4.5 million.
Nearly half of motocross patients treated at a regional level 1 trauma center required hospitalization, and nearly one-third required surgery. The vast majority of surgical procedures (89%) were orthopaedic. Despite a high usage rate of helmets and protective gear, severe injuries were still sustained, including femur fracture (29), hemiparesis/spinal cord injury (2), and head injury (43). The majority of injuries occurred during organized race or practice. Families should be counseled with regard to the use of safety equipment and the severity of injuries sustained during competitive motocross activity.
Level IV, case series.
Journal of pediatric orthopedics 12/2009; 29(8):847-50. · 1.23 Impact Factor
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ABSTRACT: There is little data evaluating the risk factors, demographics, and prognoses for nonunions in children. Previous literature has reviewed time periods when contemporary techniques of internal fixation and management of open injuries had not been available. The purpose of this retrospective study was to evaluate a large consecutive series of pediatric nonunions treated at a level I trauma center. Between 1985 and 2000, 43 nonunions in 42 pediatric patients with a mean age of 9 years and 9 months (range, 3-14 years) were identified at our level I trauma center. Eleven of the original 43 fractures were open and 5 presented with active infection. Patients were observed until union or a minimum of 1 year with a mean follow-up of 50 months. Twenty of 43 nonunions (47%) were located around the elbow. Seventeen of 43 nonunions (39%) were diaphyseal. The operative fractures required a mean of 3.6 surgeries (range, 1-19 surgeries) to achieve bony union. All secondary attempts to achieve union were successful at last follow-up. Although nonunions in the pediatric population are rare, these data underscore the importance of careful evaluation and treatment of these fractures at risk for nonunion.
Orthopedics 07/2009; 32(6):410. · 2.66 Impact Factor
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ABSTRACT: To describe our experience with surgical intervention for symptomatic intraarticular vascular malformations of the knee in patients with peripheral vascular malformations including Klippel-Trénaunay syndrome (KTS).
Eleven patients underwent surgical intervention for symptomatic intraarticular vascular malformations of the knee between 1987 and 2008. Seven patients had KTS, and 4 patients had venous malformations. Surgical indications, imaging studies, clinical course, surgical procedures, complications, and follow-up visits were reviewed and recorded.
A total of 11 patients (8 males; 3 females; mean age, 11.7 years; range, 2.5-23 years) underwent 12 surgical procedures. Five patients had an amputation, and 6 patients had knee synovectomies. One patient had bilateral knee synovectomies. Surgical indications included pain, swelling, limited mobility, and/or loss of knee motion. The average time of follow-up was 54 months (range, 7-109 months). Patient-reported pain scores decreased significantly from a mean of 2.9 +/- 1.4 preoperatively to 1.3 +/- 0.9 postoperatively (P = 0.01).
When necessary, surgical intervention for intraarticular vascular malformations of the knee (amputation or synovectomy) may be effective in decreasing pain and improving mobility in patients with peripheral vascular malformations. It is possible that early synovectomy may slow or prevent the rapid destructive arthritis that occurs in these knees. Surgeons and patients should anticipate complications related to bleeding from vascular malformations. We recommend a multidisciplinary approach to the patient with KTS, particularly when surgical intervention is indicated.
Journal of pediatric orthopedics 07/2009; 29(4):380-4. · 1.23 Impact Factor
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ABSTRACT: Femoral neck fractures in children are severe injuries associated with the potentially disastrous complication of femoral head osseous necrosis. Our primary goal was to identify what factors contribute to the occurrence of femoral head osteonecrosis in skeletally immature patients with femoral neck fractures. We evaluated a large consecutive series of pediatric patients with femoral neck fractures. Between 1970 and 2000, 20 patients with a mean age of 11 years (range, 4-15 years) with femoral neck fractures were identified. All traumatic epiphyseal, transcervical, and basicervical (Types I, II, and III) fractures were included. There were 14 male patients and six female patients. The mean followup was 7 years (range, 1-28 years). Timing of surgery, type of fixation, and quality of reduction were analyzed with respect to the primary outcome measure-radiographic evidence of femoral head osteonecrosis. Eighteen of 20 hip fractures healed without complication; all had good or excellent reductions. Two patients had osteonecrosis develop; both had fair or poor reductions. Five patients were treated more than 48 hours after injury, including the two patients who had osteonecrosis develop. The mean time to fixation for the remaining patients was 12 hours. There was no relationship between capsular decompression and osteonecrosis development. Quality of reduction and timing of reduction influenced the risk of osteonecrosis.
Clinical Orthopaedics and Related Research 02/2007; 454:169-73. · 2.53 Impact Factor
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Orthopedics 04/2003; 26(3):329-30. · 2.66 Impact Factor
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ABSTRACT: Elbow contracture is a recognized sequela of traumatic and developmental elbow disorders, but little information is available regarding the surgical treatment of elbow stiffness in the pediatric population.
Thirty-seven patients who had had open surgical release of an elbow contracture at a mean age of sixteen years (range, ten to twenty years) were retrospectively studied after a mean duration of follow-up of fifteen months (range, six to forty-four months). The elbow contracture was posttraumatic in twenty-eight patients. The operation consisted of a capsular release with removal of osseous impediments to motion as necessary. No patient had muscle or tendon-lengthening.
The total arc of motion improved from a mean of 66 preoperatively to a mean of 94 postoperatively; however, only twenty-eight patients (76%) had an improvement of 10 and only seventeen (46%) achieved a functional arc of motion of 100 (from 30 to 130 ). Two patients lost motion after surgery. These results are less favorable than the results of previous studies of both pediatric and adult patients. Patients in whom the contracture had been caused by a simple dislocation of the elbow or an extra-articular fracture tended to have better results than those in whom the contracture was due to other causes.
The results of surgical treatment of elbow stiffness in pediatric patients are less favorable and less predictable than those in adult patients.
The Journal of Bone and Joint Surgery 04/2002; 84-A(3):382-7. · 3.27 Impact Factor
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ABSTRACT: There is no one large study on pediatric shoulder instability. The purposes of this study were to characterize patients with shoulder subluxation or dislocation, the treatments provided, outcomes, and the predictors of good outcomes. Seventy shoulders in 66 patients were retrospectively reviewed, all with follow-up >2 years. The authors defined characteristics, treatment, outcomes, and associations between patient and treatment variables and outcome measures. Instability was associated with boys, adolescents, and trauma. Forty-two shoulders received physical therapy, and 28 required surgery. At follow-up, 54 of 70 described their shoulders as "better" or "much better," and 90% were performing at the same or higher levels of sports and work. Surgically treated patients were less likely to have recurrent instability or to report limitations. The current study is a large study of pediatric shoulder instability. Surgery improved stability, but overall, stability improved over time, with few patients having limitations at moderate- to long-term follow-up.
Journal of Pediatric Orthopaedics 22(1):52-61. · 1.16 Impact Factor
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ABSTRACT: The children with congenital heart disease (CHD) have an increased risk of developing scoliosis. Many children with CHD may benefit from surgical intervention for scoliosis. However, there is uncertainty about the safety of spinal fusion in children with heart disease. The purpose of this study is to assess whether spinal fusion is safe and effective for children who have CHD.
We reviewed all the cases of children with CHD undergoing first-time spinal fusion for spinal deformity at Mayo Clinic between August 1976 and June 2008. Data were abstracted regarding cardiac history, major Cobb angle, type of spinal fusion (anterior, posterior, or both), intraoperative and postoperative complications, mortality, and follow-up.
Sixty-four children under the age of 18 (64% female patients; mean age=11.5 y) were included in the study. The most common types of CHD were pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Sixty-three percent of all patients had had prior cardiac surgery; 22% were cyanotic at the time of spinal fusion. Nine patients had single-ventricle physiology; 5 of whom had had Fontan palliation. Nine patients had pulmonary hypertension. Posterior fusion alone was carried out for 69% of the patients. Spinal instrumentation was used in 70% of cases. Average anesthesia time was 7.3 hours. Mean hospital stay was 9 days. Eighteen children (30%) required prolonged intubation of 1 day or longer. Prolonged intubation was more common in patients with a larger Cobb angle and in patients with pulmonary hypertension. Postoperative complications occurred in 27% of all patients and were more common in the patients with pulmonary hypertension. One child died postoperatively from a hemorrhage because of an arterial-esophageal fistula unrelated to her spinal fusion.
Spinal fusion in children with CHD is generally safe and effective. Children with pulmonary hypertension are at higher risk for complications from spinal fusion.
Level IV--Case Series.
Journal of pediatric orthopedics 30(7):670-5. · 1.23 Impact Factor
