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Background: Previous reports have indicated high complication rates associated with non-fusion surgery in patients with early-onset scoliosis. This study was performed to evaluate the clinical and radiographic complications associated with growing-rod treatment., Methods: Data from the multicenter Growing Spine Study Group database were evaluated. Inclusion criteria were growing-rod treatment for early-onset scoliosis and a minimum of two years of follow-up. Patients were divided into treatment groups according to rod type (single or dual) and rod location (subcutaneous or submuscular). Complications were categorized as wound, implant, alignment, and general (surgical or medical). Surgical procedures were classified as planned and unplanned., Results: Between 1987 and 2005, 140 patients met the inclusion criteria and underwent a total of 897 growing-rod procedures. The mean age at the initial surgery was six years, and the mean duration of follow-up was five years. Eighty-one (58%) of the 140 patients had a minimum of one complication. Nineteen (27%) of the seventy-one patients with a single rod had unplanned procedures because of implant complications, compared with seven (10%) of the sixty-nine patients with dual rods (p ≤ 0.05). Thirteen (26%) of the fifty-one patients with subcutaneous rod placement had wound complications compared with nine of the eighty-eight patients (10%) with submuscular rod placement (p ≤ 0.05). The patients with subcutaneous dual rods had more wound complications, more prominent implants, and more unplanned surgical procedures than did those with submuscular dual rods (p ≤ 0.05). The risk of complications occurring during the treatment period decreased by 13% for each year of increased patient age at the initiation of treatment. The complication risk increased by 24% for each additional surgical procedure performed., Conclusions: Regardless of treatment modality, the management of early-onset scoliosis is prolonged; therefore, complications are frequent and should be expected. Complications can be reduced by delaying initial implantation of the growing rods if possible, using dual rods, and limiting the number of lengthening procedures. Submuscular placement reduces wound and implant-prominence complications and reduces the number of unplanned operations.

Background: There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that would help to direct quality assurance efforts., Methods: Surveys were sent to 5540 Academy fellows, and 917 were returned (a response rate of 16.6%), with 53% (483) reporting an observed medical error in the previous six months., Results: A general classification of errors showed equipment (29%) and communication (24.7%) errors with the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, and both involved narcotic administration errors. By location, 78% of errors occurred in the hospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involved in 60% of the errors; a nurse, in 37%; another orthopaedic surgeon, in 19%; other physicians, in 16%; and house staff, in 13%. Wrong-site surgeries involved the wrong side (59%); another wrong site, e.g., the wrong digit on the correct side (23%); the wrong procedure (14%); or the wrong patient (5% of the time). The most frequent anatomic locations were the knee and the fingers and/or hand (35% for each), the foot and/or ankle (15%), followed by the distal end of the femur (10%) and the spine (5%)., Conclusions: Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed toward areas with higher error occurrence (equipment and communication) and high risk (medication and wrong-site surgery).

In a retrospective study of thirty-one ankles in twenty-nine patients with osteochondral lesions, we found that lateral lesions were associated with inversion or inversion-dorsiflexion trauma, were morphologically shallow, and were more likely to become displaced in the joint and to have persistent symptoms. Medial lesions were both traumatic and atraumatic in origin, morphologically deep, and less symptomatic. Using the classification system of Berndt and Harty, it appeared that Stage-I and Stage-II lesions should be treated non-operatively, regardless of location. Stage-III medial lesions should be treated non-operatively initially but if symptoms persist surgical excision and curettage are indicated. Stage-III lateral lesions and all Stage-IV lesions should be treated by early operation. Long-term results indicated that few lesions unite when treated non-operatively. Degenerative changes in the ankle joint, whether symptomatic or not, were common (50 per cent of the ankles) regardless of the type of treatment.

Eighty hips with unilateral Legg-Calvé-Perthes disease were evaluated at an average follow-up of 22.4 years to determine the long-term results of treatment by a weight-relieving sling or harness. Results were good in sixty-four patients, fair in nine, and poor in seven. The patients with fair results had no clinical symptoms despite unacceptable roentgenograms. The hips that were most likely to have unsatisfactory results were those with Catterall Group-III or IV involvement and with onset at the age of six years or later, but of fifty-eight patients with Catterall Group-III or IV grades (eighteen of whom were six years old or older), forty-two had good results. Catterall's classification could not be accurately applied for an average of 8.1 months after the onset of disease. Identification of so-called head-at-risk signs, while it was important, appeared to add little to the Catterall grading as a prognostic index or therapeutic guide. Thirty-nine hips were identified as being at risk, including six of the seven with poor results and all of the nine hips with fair results.

Twelve children with lumbar-level myelodysplasia (average age, eight and three-quarter years) underwent twenty-one pelvic displacement osteotomies for subluxated or dislocated hips. Nineteen of the twenty-one hips remained reduced on three-year follow-up. Gains in gait pattern, ease of bracing, and reduced pelvic obliquity were noted. Active function about the hips was not improved, nor was there a decrease in the amount of bracing needed following the osteotomy. Pelvic displacement osteotomy can be utilized in selected cases as part of the over-all management of chronic hip dislocation in myelodysplasia.

Thirty-nine fractures of the tibia involving the proximal tibial epiphyseal cartilage were treated at the Campbell Clinic over a twenty-five-year period. Stress roentgenograms were essential in making the diagnosis in three patients. Two patients had disruption of the popliteal artery, and both had posterior displacement of the tibial shaft. The other immediate complications that we encountered were anterior compartment syndrome, peroneal-nerve palsy, and associated ligamentous and meniscal injuries. Of twenty-eight fractures (twenty seven patients) with an average follow-up of 7.1 years, there were satisfactory results in twenty-four. Unsatisfactory results (four fractures) were due to chronic neurovascular insufficiency, growth disturbance, or traumatic arthritis.

Fifty-seven patients with congenital muscular torticollis who were treated between 1941 and 1977 were evaluated after an average follow-up of 18.9 years. We found that if congenital muscular torticollis persisted beyond the age of one year, it did not resolve spontaneously. Children with torticollis who were treated during the first year of life had better results than those treated later, and an exercise program was more likely to be successful when the restriction of motion was less than 30 degrees and there was no facial asymmetry or the facial asymmetry was noted only by the examiner. Non-operative therapy after the age of one year was rarely successful. Regardless of the type of treatment, established facial asymmetry and limitation of motion of more than 30 degrees at the beginning of treatment usually precluded a good result. While these fifty-seven patients had little functional abnormality at follow-up (some of those with a persistent head tilt had mild, asymptomatic compensatory scoliosis), noticeable cosmetic deformity was present in approximately 31 per cent of the patients.

Little attention has been paid to the various causes preventing or blocking a concentric reduction following traumatic dislocation of the hip without apparent fracture. In a review of fifty-four dislocations, nine required open reduction after either a failed attempt at closed reduction or a non-concentric reduction. The factors preventing closed reduction included the femoral head buttonholed through the capsule and the piriformis muscle displaced across the acetabulum. A concentric anatomical reduction was prevented because of an inverted lumbus or an osteocartilaginous loose body in the acetabulum. Guidelines for diagnosis and treatment are discussed.

End-result evaluations after an average follow-up of seventeen years are reported in sixty-one cases (sixty patients). There were five Type-1 (transepiphyseal), twenty-seven Type-II (transcervical), twenty-two Type-III (cervicotrochanteric), and seven Type-IV (intertrochanteric) femoral fractures. The majority of Type-I, Type-II, and displaced Type-III fractures were treated with closed or open reduction and Knowles-pin fixation. The majority of undisplaced Type-III and Type-IV fractures were treated with abduction plaster spica casts. Fifty-five per cent were found to have good resultswhile 20% were fair and 25%, poor. The incidence of complications--avascular necrosis, coxa vara, premature epiphyseal closure, infection, and non-union--was compared with that in previously reported series. The use of Knowles-pin fixation appeared to reduce the complications of non-union and coxa vara. Avascular necrosis caused most of the poor results. However, younger children with avascular necrosis obtained better results than did older ones. Some children with results graded as poor roentgenographically were only mildly symptomatic.

The syndrome of purpura fulminans has frequently been reported in the surgical and pediatric literature, but rarely in the orthopaedic literature. The mortality rate has decreased dramatically from early reports of approximately 90 per cent to more recent reports of 18 per cent. Amputation of a portion of the involved extremities, however, is usually required in the patients who survive. Over a twelve-month period, we treated four patients who had purpura fulminans, with resultant vasospasm and secondary ischemic gangrene. In three of the patients the syndrome developed following a one to two-day febrile illness, and in one, following varicella. All four patients survived, but two required a bilateral lower-limb amputation; one, a Syme amputation and a partial hand amputation; and one, an amputation of the fore part of the foot. Autoamputation of multiple fingertips and toes occurred in two of the four patients.

Seventy-one fractures through the neck of the talus were clinically evaluated and classified on the basis of roentgenographic appearance. The follow-up interval averaged 12.7 years. Good or excellent results were achieved in 59 per cent of the fractures. Accurate anatomical reduction of displaced fractures, if necessary by open reduction and internal fixation, is recommended. Avascular necrosis of the talar body occurred in 52 per cent of the fractures (in two of thirteen non-displaced fractures, in half of the fractures with subluxation or dislocation of the subtalar joint, and in sixteen of nineteen fractures with complete dislocation of the body of the talus). Many patients with avascular necrosis treated conservatively had satisfactory results. The complications of avascular necrosis, malunion, subtalar arthritis, and infection required twenty-five secondary procedures. Triple arthrodesis, tibiocalcaneal fusion, and dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.