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The purpose of this study was to investigate whether presence of an infolded limbus on hip arthrogram at index closed reduction was associated with increased residual dysplasia or secondary surgery.We retrospectively reviewed all patients who underwent closed reduction for dysplasia of the hip with a minimum 2-year follow-up between 1980 and 2016. Demographic data was obtained including the age at reduction and severity of dislocation based on the International Hip Dysplasia Institute (IHDI) classification. Arthrograms performed at time of closed reduction were separately reviewed by 3 fellowship-trained pediatric orthopaedic surgeons to evaluate for an infolded limbus. The primary radiographic outcome was acetabular indices at 2 and 4 years postreduction. We also assessed the presence of avascular necrosis and rate of secondary reconstructive surgery for residual dysplasia.A total of 182 hips in 165 patients underwent closed reduction at a mean age of 9.8±4.5 mo and were followed a mean of 9.0±4.9 y. An infolded limbus was identified in 20.3% (37/182) hips with substantial agreement among the 3 graders (Fleiss κ=0.75). The frequency of labral infolding increased with the severity of dislocation (8.8%% of IHDI II, 26.7% IHDI III, and 25.0% of IHDI IV hips; P=0.03). Hips with infolded limbus were older at reduction (12.4±5.3 vs. 9.2±5.8 mo, P=0.001). The mean acetabular index was higher in hips with infolded limbus than hips without at 2 years postreduction (34.8±4.8 vs. 32.6±5.8 degrees, respectively; P=0.04). However, multivariate analysis revealed that only the severity of dislocation predicted dysplasia at 2 years postreduction. No significant difference in acetabular index was seen at 4 years postreduction (27.2±7.4 vs. 25.4±6.5 degrees, P=0.24). There was no difference in avascular necrosis between groups (P=0.74). There was no difference in rate of secondary surgery between hips with labral infolding and those without (35% vs. 30%, respectively; P=0.52).An infolded limbus was more common in older patients with more severe dislocations. However, it is not associated with increased residual dysplasia or secondary surgery and may have limited utility in decision-making during closed reduction.Level II-prognostic study.

Introduction Physicians and surgeons in all specialties encounter and manage complications throughout their careers. Little attention has been given to a surgeon's emotional experience and reaction to the stresses of managing complications. Methods The author has reviewed relevant literature and added observations from 4 decades of experience with a pediatric orthopedic faculty. The author also reviewed the types of complications and principles of successful management of surgical complications. Results and discussion A small number of published articles dealing with the issues of physician and surgeon responses to stressful occurrences were found. Proper management of complications will markedly reduce the stress upon the surgeon. Analysis of the complications with colleagues is essential to the reduction of feelings of guilt, and are useful in preventing future events. Discussions of the accompanying stress between the surgeon and colleagues, family, and occasionally counselors are helpful in achieving resolution and emotional healing. Conclusions Greater attention to emotional stress issues affecting caregivers, and especially surgeons, is needed. This should happen at all levels of education from medical school through postgraduate training, and in the everyday practice of surgery. Research to clarify the effectiveness of various interventions is needed.

Two children with spastic quadriplegia who developed excessive lumbar lordosis after selective dorsal rhizotomy are described. The rhizotomy did not change the ambulatory status of either child (one nonambulator, one household ambulator). Preservation of unopposed hip flexion in the presence of multiple laminectomies may lead to the development of a lordotic deformity in children who sit most of the time. Excessive lumbar lordosis may cause pain and difficulty in sitting. Surgical correction of this deformity is complex because of the removal of posterior elements during the rhizotomy.

Summary: We studied 83 hips in 72 children being treated for developmental hip dislocation to assess the influence of home traction upon the incidence and severity of avascular necrosis (AVN). We compared two types of traction prior to closed or open reduction: inpatient Bryant's skin traction (40 hips), and outpatient (home) Bryant's skin traction (43 hips). No routine intraction radiographs were taken in either group. After traction, a stable closed reduction was achieved in 55 hips (66%). Open reduction was performed on 28 hips (34%). The rate of severe AVN involving growth disturbance and resultant deformity (Bucholz types II, III, and IV) was low in both traction groups (inpatient, three out of 40, outpatient, one out of 43). These results demonstrate that an outpatient traction program without attention to radiographic hip station is as safe as identically instituted inpatient programs, as well as those that emphasize achievement of a traction reduction or a predetermined hip station.

A retrospective review was performed of 192 newborn hips in 112 patients referred for hip evaluation. The average age at presentation was 12.7 days, with average radiographic follow-up of 15.9 months. Inclusion criteria for our study were a normal physical examination of the hip without evidence of instability and an ultrasound examination that was considered abnormal. Pavlik harness treatment was chosen at the discretion of the treating physician. At final follow-up, dysplasia was defined as greater than two standard deviations above the mean acetabular index (AI) for age. Group I consisted of 43 hips that had Pavlik treatment, and group II consisted of 149 hips that did not receive treatment. There was no difference in these two groups with respect to risk factors for dysplasia or the initial abnormalities seen on ultrasound evaluation, although patients in group I had less coverage of the femoral head during stress maneuvers. No hip in group I and two (1.3%) hips in group II were considered dysplastic (AI > 2 SD) at final radiographic follow-up (p > 0.10). There was no correlation between the severity of the ultrasound abnormality at birth and the subsequent presence of dysplasia (p > 0.10). The two hips considered dysplastic on radiograph were not being actively treated. When the hip examination of a newborn hip younger than 1 month is normal, a screening ultrasound does not appear to predict accurately subsequent hip dysplasia. In this specific setting, an initial screening ultrasound may be too sensitive and does not appear warranted.

Fourteen patients with classic Marfan syndrome and spinal deformity treated at Texas Scottish Rite Hospital for Crippled Children (Dallas, TX) after 1975 have been conservatively treated to maturity or are at least 2 years after spinal fusion. Brace treatment was successful in one of nine patients. Nine patients underwent fusion. Three had a solid fusion, two lost 20 degrees of correction, and four required revision for multiple pseudarthroses. These latter four all had or developed a kyphotic deformity. Although Marfan syndrome patients can achieve solid fusion, they require massive bone graft, secure segmental internal fixation, and careful observation for pseudarthrosis. Kyphotic deformities require anterior fusion.

Specific exercises designed to strengthen trunk muscles are an integral part of most Milwaukee brace treatment protocols. To assess the effectiveness of these exercises, we established a prospective study evaluating a closely monitored exercise program coordinated with the use of a Milwaukee brace. Between 1973 and 1979, 24 girls treated with a Milwaukee brace for documented progression of primary right thoracic idiopathic scoliosis were selected for the study. All patients were instructed to perform a standard set of exercises based on the program of Blount and Moe (The Milwaukee Brace [Williams and Wilkins, 1973]). Twelve patients who were regular exercisers constituted the exercise group; 12 patients noncompliant in performing regular exercises composed the control group. Both groups remained faithful brace wearers. No significant difference was found between the two groups regarding age at onset, initial curve degree, skeletal maturity, total time in brace, or general activity level. There was no statistically significant difference in curve improvement between the two groups (p = 0.95). This preliminary study suggests that the Milwaukee brace alone is as effective in halting curve progression as a Milwaukee brace plus standard prescribed exercises.

We reviewed 27 teratologic hip dislocations in 17 patients. Four hips underwent closed reduction, 10 hips had medial adductor open reduction, 9 hips had iliofemoral open reduction, and 4 hips had iliofemoral open reduction and femoral shortening. Avascular necrosis occurred in 48%, redislocation in 19%, and subluxation in 22% of the hips. Results were best in those hips treated by anterior open reduction and femoral shortening and worst in those having closed reduction. Poor results correlated with multiple other involved joints, hypotonia, developmental delay, and poor head control.

Slipped capital femoral epiphysis is a common malady which must be managed by virtually every orthopedic surgeon. While each of us has a "foolproof method" of managing the disease, we also have somewhere in our files a patient with a disastrous outcome. The next several instructional cases will focus on the trials and tribulations of this disorder. Each of the discussants has had to formulate his opinions regarding management at each step in the case presentation, without knowledge of the subsequent outcome. We hope through this process we all will learn from our own and others' mistakes.

One-third of the adolescent patients followed up in our prosthetic clinic have developed patellar dislocation. Four cases are described, and radiographs are evaluated for femoral-tibial alignment, patellar height, and tibial length. Patella alta was present in each patient. We propose that the forces associated with the patellar tendon-bearing prosthesis may produce elongation of the patellar tendon in young patients and predispose them to patellar instability.

Two patients with grade III spondylolisthesis of L5 on S1 underwent magnetic resonance imaging (MRI) as part of their preoperative evaluation. The nucleus pulposus of the involved intervertebral disc was noted to be divided into anterior and posterior halves. The signal intensity of the involved nucleus pulposus was decreased, a finding correlated to degenerative changes of the disc material. Moderate narrowing of the thecal sac was noted at the level of spondylolisthesis. Both patients underwent in situ posterolateral spinal fusion from L4 to S1 without decompression. We were not able to correlate the MRI findings to etiology of pain in spondylolisthesis.