Search

Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures.A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making.Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (β=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making.There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes.Level V.

Background Distal radius fractures are the most common injury in the pediatric population. The purpose of this study was to determine the variation among pediatric orthopaedic surgeons when diagnosing and treating distal radius fractures. Methods Nine pediatric orthopaedic surgeons reviewed 100 sets of wrist radiographs and were asked to describe the fracture, prescribe the type of treatment and length of immobilization, and determine the next follow-up visit. κ statistics were performed to assess the agreement with the chance agreement removed. Results Only fair agreement was present when diagnosing and classifying the distal radius fractures (κ=0.379). There was poor agreement regarding the type of treatment that would be recommended (κ=0.059). There was no agreement regarding the length of immobilization (κ=-0.004).Poor agreement was also present regarding when the first follow-up visit should occur (κ=0.088), whether or not new radiographs should be obtained at the first follow-up visit (κ=0.133), and if radiographs were necessary at the final follow-up visit (κ=0.163). Surgeons had fair agreement regarding stability of the fracture (κ=0.320).A subgroup analysis comparing various traits of the treatment immobilization showed providers only had a slight level of agreement on whether splint or cast immobilization should be used (κ=0.072). There was poor agreement regarding whether long-arm or short-arm immobilization should be prescribed (κ=-0.067).Twenty-three of the 100 radiographs were diagnosed as a torus/buckle fracture by all 9 surgeons. κ analysis performed on all the treatment and management questions showed that each query had poor agreement. Conclusions The interobserver reliability of diagnosing pediatric distal radius fractures showed only fair agreement. This study demonstrates that there is no standardization regarding how to treat these fractures and the length of immobilization required for proper fracture healing. Better classification systems of distal radius fractures are needed that standardize the treatment of these injuries. Level of evidence Level II.

Purpose The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. Methods A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the products was created. Results Trampoline-related fractures rose 14% yearly from 1991 to 1999, reached a plateau from 1999 to 2003, corresponding with a 1999 AAP statement. Injury rates dropped 4.3% from 2006 to 2010 after 2005 and 2006 statements, and reached another plateau thereafter, as 2010 and 2012 statements were published. ATV-related fractures rose 14% yearly between 1997 and 2002, then dropped 15% from 2007 to 2010 following yearly AAP or AAOS statements from 2004 to 2007. From 2010 to 2014, the injury rate held constant during which time 2010, 2013, and 2014 statements were published. Lawnmower injury rates did not fall despite statements in 1998 and 2001 and a poster campaign in 2001. A 25% drop from 2007 to 2008 coincided with an AAOS statement in 2008. Fracture rates further dropped 31% from 2009 to 2011 and 21% from 2012 to 2014, amidst 2012 and 2014 statements. For ATV-related and lawnmower-related injuries, more male individuals were affected than female individuals, and for ATVs alone, injury rates increased with age. Conclusions Although AAOS/AAP statements did not universally coincide with dropping fracture rates, statements often were associated with substantial decreases in following years. This is likely because injury prevention messages are dispersed from providers to the public over time and outcomes depend on highly variable patient behaviors. Level of evidence Level V-systematic review of descriptive data.

Background The orthopaedic treatment of the patient with cerebral palsy (CP) is complex and must take into account the heterogeneity and natural history of the condition. Although the goals of management are for the most part universal, the specific interventions and outcome measures used to reach these goals are wide ranging. This update serves to summarize some of the recent publications in the field of pediatric orthopaedics that have made important contributions to our understanding and care of the patient with CP. Methods We searched the PubMed database using the following terms: "cerebral palsy" AND "orthopedic." The results were then filtered to include only review papers or clinical trials published in English from 2010 to 2014. The obtained list of references was then reviewed for publications in the fields of lower extremity muscle imbalance, foot and ankle deformities, hip and acetabular dysplasia, and advances in orthopaedic-related technology. Results Updates in the field of pediatric orthopaedics are constant and the current level of evidence for the effectiveness of specific treatment modalities in patients with CP was reviewed. The search method yielded 153 publications, of which 31 papers were identified as having contributed important new findings. Conclusions Our understanding of orthopaedic treatments for children with CP continues to grow and expand. The studies reviewed illustrate just some of the strides we have taken in utilizing evidence-based surgical decision making in practice. Nevertheless, there remains a paucity of randomized controlled trials and higher evidence research, which may contribute to the variability in current practices among providers. By elucidating these gaps we can more purposefully delegate our time and resources into targeted areas of research. Level of evidence Level 4-literature review.

BACKGROUND There is a dearth of literature examining the causes of cam-type femoroacetabular impingement (FAI) and when such morphology appears. The purpose of the current study was to analyze how the ossific portion of the proximal femur develops over time with respect to standard cam-type FAI parameters. METHODS A collection of 193 femurs from cadavers aged 4 to 21 years were evaluated. The age, sex, ethnicity, and status of the proximal femoral physes (open or closed) of each were recorded. Each specimen was digitally photographed in standardized anteroposterior and modified axial positions. From these photographs, the anterior offset, anterior offset ratio (AOR), and α-angle were determined. A cam lesion was defined as an α-angle >55 degrees on the lateral view. RESULTS The mean age of the specimens was 17.5±4.2 years. The majority were male (69%) and African American (79%) with closed physes (78%). There were significant differences among discrete age groups with respect to α-angle (P=0.01), anterior offset (P

Background: Although a plethora of literature exists on the impact of body mass index (BMI) in orthopaedic surgery, few have examined its implications in the pediatric cerebral palsy (CP) population. The aim of this study is to evaluate the effect of BMI class on 30-day complications after orthopaedic surgery on children with CP. Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric participant use files from 2012 to 2013 was conducted. Patients with a diagnosis of CP undergoing any orthopaedic procedure were included and subclassified according to BMI classes: underweight, normal weight, overweight, and obese. Multivariate logistic regressions were performed to evaluate the independent effect of BMI class on total, surgical site, and medical complications as well as unplanned reoperations. Results: A total of 1746 patients were included in our study. These included 345 (19.8%) underweight, 952 (54.5%) normal weight, 209 (12.8%) overweight, and 240 (13.7%) obese children and adolescents. In hip and lower extremity osteotomies, underweight class was an independent risk factor for total complications (P = 0.037) and medical complications (P = 0.031). Similarly, underweight class was a risk factor for total complications (P = 0.022) and medical complications (P = 0.019) in spine procedures. Weight class was not independently associated with complications in tendon procedures. Overweight and obesity classes were not associated with any independent increased risk for complications. Conclusions: With respect to the pediatric CP population, underweight status was deemed an independent predictor of increased complications in osteotomies and spine surgery with no independent increased risk in the overweight or obese cohorts. This information can greatly aid providers with risk stratification, preoperative counseling, and postoperative monitoring as it relates to orthopaedic surgery. Level of Evidence: Prognostic level III.

Pediatric scoliosis often requires operative treatment, yet few studies have examined readmission rates in this patient population. The purpose of this study is to examine the incidence, reasons, and independent risk factors for 30-day unplanned readmissions following scoliosis surgery.A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric database from 2012 to 2013 was performed. Patients undergoing spinal arthrodesis for progressive infantile scoliosis, idiopathic scoliosis, or scoliosis due to other medical conditions were identified and divided between 2 groups: patients with unplanned 30-day readmissions (Readmitted) and patients with no unplanned readmissions (Non-Readmitted). Multivariate logistic regression models were created to determine independent risk factors for readmissions.A total of 3482 children were identified, of which 120 (3.4%) had an unplanned readmission. A majority of patients had a readmission due to a surgical site complication regardless of scoliosis etiology. Risk factors for readmission included obesity (P0.001) and posterior fusion of 13 or more vertebrae (P=0.029) for idiopathic scoliosis, impaired cognition (P=0.009) for progressive infantile scoliosis, and pelvic fixation (P=0.025) and American Society of Anesthesiologist ≥3 (P=0.048) for scoliosis due to other conditions.We present 30-day readmissions risk factors based on independent patient and procedural risk factors. This may be useful in the clinical management of patients following scoliosis surgery, specifically for the role of preoperative and predischarge risk stratification.

Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients ( 11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.

In a retrospective review of 74 tibial osteotomies performed for Blount disease, the patients were divided into three groups based on age and treatment. Group A (26 osteotomies), 4 years old or younger, and group B (34 osteotomies), older than 4 years, were treated the same with osteotomy and crossed pins. Group C (14 osteotomies), older than 4 years, was treated with osteotomy and external fixator. At 6 years of follow-up, the recurrence of varus deformity was 46%, 94%, and 72% in groups A, B, and C, respectively. There was no correlation between recurrence of varus deformity and preoperative deformity angle or degree of surgical correction. Fixation with crossed pins or external fixator was not a factor. Surgery at 4 years old or younger and correction of the postoperative deformity angle in valgus may obviate recurrence of varus deformity in Blount disease at long-term follow-up.

BACKGROUND Obese patients are highly prevalent in the pediatric orthopaedic surgeon's practice and obesity is an increasing issue in the United States. Increased body mass index (BMI) has been associated with increased complications in pediatric orthopaedic patients, but no study has looked specifically at external fixation. The purpose of this study was to determine whether obesity is a risk factor for increased complications in lower-extremity procedures requiring external fixation. METHODS A retrospective chart review was conducted of pediatric patients who underwent external fixation as definitive operative treatment for any condition at a tertiary care hospital over a 15-year period. Patients were grouped into normal weight, overweight, and obese based on Centers for Disease Control definitions. All orthopaedic complications were recorded. RESULTS A total of 208 patients with a mean age of 11.2 years were identified. Ninety-four children were obese at the 95th percentile BMI or higher, 22 were overweight and 93 were normal weight. External fixation was applied to the tibia in 82 cases, to the femur in 77 and to both in 49. Mean duration of fixation was 160 days (range, 31 to 570 d) and patients were followed for a mean of 3.9 years (range, 1.0 to 12.0 y). There was no statistically significant difference in the rate of complications between the 3 groups (P=0.61). In the obese group complications occurred in 68.1% versus 66.7% in the overweight group and 61.3% in normal weight. CONCLUSIONS In the setting of external fixator use for lower-extremity pathology in pediatric patients, there is no association between an increase in complications and obesity as defined by BMI. Complication rates are high when external fixation is utilized for the lower extremity, however, patients and families should not be counseled that increased BMI will add to the burden of orthopaedic complications in this situation. LEVEL OF EVIDENCE Level II-prognostic.

The purpose of this study was to compare the clinical and radiographic results of plate and screw fixation with intramedullary nailing for unstable fractures of the radius and ulna in children. We proposed that there was a statistically significant difference in the functional outcome and rate of complications between the two groups of patients. A retrospective analysis of 23 patients who were treated with plate-and-screw fixation and 18 who were treated with intramedullary nailing was performed. The average age was 10 years (range, 5-15). Indications for operative treatment included open fractures, irreducible fractures, and unstable fractures. Excellent results were obtained in 78% of patients in both groups at an average of 12 months after surgery. The functional results, rate of union, and rate of complications were statistically similar for the two groups. Intramedullary fixation allows short operative time, excellent cosmesis, minimal soft-tissue dissection, ease of hardware removal, and early motion after nail removal. Intramedullary fixation may provide a useful alternative for treatment of unstable fractures of the radius and ulna.

Hip flexion contracture (HFC) in the ambulatory child with cerebral palsy (CP) may impair function and lead to deteriorations in health-related quality of life. Furthermore, increasing HFC may lead to increasing disability. However, the association between passive range of motion and the measures of function and well-being is unclear. This study was designed to determine whether increasing HFC is associated with functional outcome.A total of 181 children, with an average age of 14.0 ± 10.2 years, were evaluated as part of a multicenter prospective data collection of patients with ambulatory CP. Measurements of HFC were recorded, and patients were evaluated using walking score from Gillette Functional Assessment Questionnaire (FAQ), Gross Motor Function Measure (GMFM), and the Pediatric Outcome Data Collection Instrument (PODCI). Patients were grouped on the basis of severity of HFC: group A, 0 to 14 degrees; group B, 15 to 29 degrees; and group C ≥ 30 degrees. Associations were examined using the Spearman correlation.There was an inverse association between degree of HFC and FAQ walking score (P0.01, ρ=-0.25). Similarly, there was an inverse association between the degree of HFC and GMFM parts D (P0.001, ρ=-0.31) and E (P0.001, ρ=-0.32). Lastly, the PODCI domains of global function, mobility, and physical function also showed an inverse association with degree of HFC (P0.001, ρ=-0.24).As surgeons treating children with CP, we often rely on joint measurements as an indirect measure of function. This study of children with ambulatory CP suggests that increased HFC from the physician's perspective is associated with deterioration in function from a patient and a therapist's perspective.Level II, prospective study.

Poliomyelitis in children can cause paralysis of shoulder girdle muscles leading to a flail shoulder. Shoulder arthrodesis is indicated as a possible treatment for these children in order to stabilize the shoulder. This retrospective study reviewed all shoulder arthrodesis surgeries owing to complications of polio performed at a major medical institution between 1981 and 1996 to assess position of fusion, radiographic evidence of fusion, complications, and patient satisfaction.A review of medical records identified 11 patients undergoing 13 shoulder arthrodesis procedures, with a mean age of 14.7 years at the time of the procedure. Internal fixation was achieved with large cancellous screws in 8 patients and a Dynamic Compression Plate (DCP) plate in 5 procedures. Average follow-up period was 41 months. Eight patients were placed into a spica cast and 5 used a sling postoperatively.Shoulder arthrodesis surgery in this cohort resulted in an average position of fusion with 42.3 degrees of abduction, 23.8 degrees of flexion, and 26.2 degrees of internal rotation. Twelve of the 13 procedures assessed for radiographic union demonstrated fusion. The most common complications were malrotation and nonunion. Of the 13 procedures, 2 underwent humeral osteotomies for malrotation, and 1 with 6.5 mm cancellous screws required revision with a DCP plate owing to nonunion. Six patients underwent hardware removal, 3 of which were specifically owing to complaints of painful hardware. At final follow-up, no patient reported pain and all expressed satisfaction with their results and improved shoulder function after repair.This study is the largest series of shoulder arthrodesis surgeries for treatment of patients with a flail shoulder from polio to date, providing a more thorough analysis of its efficacy as an indicated treatment.Level III-Retrospective Comparative Study.

BACKGROUND Questionnaires translated into languages other than English are often not validated to the same extent as the English versions. This study examined the concurrent and discriminant validity of selected domains related to physical function from Spanish language versions of the Child Health Questionnaire (CHQ), Pediatric Outcomes Data Collection Instrument (PODCI), and Pediatric Evaluation and Disability Inventory (PEDI). METHODS Concurrent validity was examined in 93 children with cerebral palsy by correlating questionnaire domain scores with Gross Motor Function Measure and Gillette Functional Assessment Questionnaire walking scale scores. Discriminant validity with respect to Gross Motor Function Classification System (GMFCS) level was examined using analysis of variance and nonparametric discriminant analysis. RESULTS Concurrent validity was demonstrated for 3 domains from the PEDI (Mobility functional skills, tau = 0.62; Mobility caregiver assistance, tau = 0.46-0.55; and Self-care functional skills, tau = 0.30-0.36), 3 domains from the PODCI (Sports and physical function, tau = 0.48-0.51; Transfer and basic mobility, tau = 0.48-0.51; and Upper extremity physical function, tau = 0.28), and 1 domain from the CHQ (Physical function, tau = 0.31-0.36). Discriminant validity was demonstrated for the same domains based on significant decreases in domain scores with increasing GMFCS level. Discriminant validity was highest for the PODCI, which correctly classified 98% (91/93) of subjects into the correct GMFCS level when all 3 domains were considered. CONCLUSIONS For the first time, concurrent validity and discriminant validity have been demonstrated for the physical function domains of Spanish language versions of the PODCI, PEDI, and CHQ questionnaires. PODCI and PEDI had the highest concurrent validity, and PODCI had the best discriminant ability. CLINICAL RELEVANCE It is important to examine the validity of instruments when they have been translated from English into other languages. This importance will only increase as the population of non-English-speaking patients expands.

Background The Gillette Gait Index (GGI) is a summary measure incorporating 16 clinically important kinematic and temporal parameters. The purpose of this study was to compare GGI scores from computerized gait analysis versus qualitative visual assessments of overall gait to assess the validity of the GGI as a summary score for gait analysis. Methods The GGI was calculated for 25 children with cerebral palsy who underwent computerized gait analysis before and 1 year after lower extremity surgery to correct gait problems. Twelve observers reviewed video recordings from the gait analysis to assess the severity of each patient's gait impairment preoperatively and postoperatively and the amount of preoperative to postoperative change. Variability of the video ratings was assessed, and GGI scores were compared with the mean video ratings. Results The individual ratings showed some variability, with moderate intrarater agreement (weighted kappa = 0.49-0.56) and slight to fair interrater agreement (kappa = 0.11-0.25). However, the mean scores from all raters were much more consistent, as demonstrated by a highly significant relationship in preoperative to postoperative change viewing the videos separately versus together (r2 = 0.62; P = 0.0001). GGI scores were correlated with these mean scores preoperatively (r2 = 0.34; P = 0.003), postoperatively (r2 = 0.30; P= 0.005), and in preoperative to postoperative change (r2 = 0.30, P = 0.006 for absolute change; r2 = 0.22, P = 0.02 for percentage change). Conclusions These results support the validity of GGI as a gait analysis summary score and suggest that GGI may be a useful outcome measure in patients undergoing gait analysis. Clinical relevance Clinicians and researchers should consider using the GGI as a quantitative outcome measure for assessing overall gait.

Background: Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cerebral palsy (CP) usually focus on data from instrumented gait analysis and clinical examination without examining functional and health-related quality of life (HRQOL) outcomes. Recently, outcome measures for well-being in children with a variety of musculoskeletal disorders have also been validated specifically for CP. Therefore, this study aimed to investigate the impact of multilevel surgery on the function and HRQOL in a group of ambulatory children with CP. Methods: In a multicenter prospective trial, 57 ambulatory children with CP, mean age 9.5 years, underwent multilevel soft tissue surgery to correct sagittal imbalance. Validated clinical outcome measures for HRQOL were administered preoperatively and postoperatively with an average follow-up time of 15.2 months. The functional and psychosocial components of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Quality of Life Questionnaire (PedsQL), and the Functional Assessment Questionnaire Walking Score were used. Results: Significant improvements in outcome scores occurred postoperatively in the following: PedsQL parent-total (17.6%; P < 0.001) and parent-physical sections (25.0%; P < 0.001), the Functional Assessment Questionnaire Walking Score (15.3%; P < 0.001), and the PODCI sections for transfers and basic mobility (15.8%; P < 0.001), sports and physical function (23.9%; P = 0.012), and global (12.9%; P < 0.001). Improvements also occurred in the PedsQL child-total (8.4%; P = 0.104) and child-physical sections (8.6%; P = 0.189), but these were not statistically significant. There were no significant changes in the PODCI parent-derived pain (-3.2%; P = 0.504) and happiness sections (1.9%; P = 0.645). Conclusions: Multilevel surgery in ambulatory patients with CP improves function and HRQOL. However, improved functional well-being does not imply improved psychosocial well-being, and patients and their families should be counseled accordingly. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Introduction: Both advanced and delayed bone age relative to chronological age have been described in non ambulatory children with moderate to severe cerebral palsy (CP). The purpose of our study was to assess skeletal maturation in an ambulatory CP population and determine the affects of body mass index (BMI), type of CP, and Gross Motor Function Classification System (GMFCS) on skeletal maturity. Methods: A retrospective chart and radiograph review was performed on 51 patients with ambulatory CP. A control group of 50 patients was also analyzed. Age, sex, height, weight, type of CP, and GMFCS were recorded from the chart. The height and weight were used to calculate BMI. Bone age was determined using the Oxford method. Statistical analysis for the data included descriptive statistics with bivariate and multivariate regression analyses. Significance was determined as P < 0.05. Results: There were 26 boys and 25 girls. All CP patients were independent ambulators. The mean chronological age was 7.1 years for boys and 8.6 years for girls. The mean bone age was 9.9 years for boys and 10.6 years for girls. Overall, 48 (94%) of 51 patients had advanced bone age compared with chronological age. Bone age was significantly advanced compared with chronological age for boys (P = 0.033) and showed a trend toward significance in girls (P = 0.079). Bone age was advanced compared with our control population in both sexes. In multivariate analysis, quadriplegic CP type showed a trend toward significance (P = 0.066), and GMFCS III was significantly associated with advanced bone age in boys (P = 0.011). In girls, quadriplegic CP type and BMI of less than 15 were significantly associated with advanced bone age (P < 0.05 in both). Conclusion: Our results demonstrated that most of the ambulatory CP patients had advanced bone age compared with chronological age. Quadriplegic CP type in boys and girls contributed to advanced bone age. GMFCS III and a low BMI also contributed to advanced bone age in boys and girls, respectively. Understanding factors that lead to either delayed or advanced skeletal maturation is important in planning the appropriate timing for orthopaedic surgical intervention.

Purpose: Treatment protocols using the Turco and the Cincinnati incisions are widely used for the surgical correction of clubfoot deformity. However, it is unclear which surgical approach leads to fewer wound problems. We therefore sought to determine which treatment method led to a lower incidence of wound complications. Study Design: A retrospective chart review of 217 consecutive patients (308 feet) who underwent a primary posteromedial release for the treatment of idiopathic clubfoot under the age of 24 months via either the modified Turco or Cincinnati treatment methods was used to document the incidence of postoperative wound complications. The modified Turco protocol involved immediate postoperative casting in neutral, whereas the Cincinnati method involved staged casting with the foot initially in equinus, then to neutral with a cast change 7 days later. Results: A significantly lower incidence of wound complications was seen in the Cincinnati treatment group when compared with the modified Turco treatment method (6.9% vs 19.6%, respectively, P < 0.003). When patients were stratified based on immediate versus staged postoperative casting methods, there was a significantly lower incidence of wound complications (P < 0.05) in feet in the Cincinnati treatment group versus the modified Turco treatment method; however, the statistical populations were markedly unequal. Among all feet treated with the Cincinnati method, patients who underwent a staged cast change had significantly fewer wound problems when compared with those who underwent immediate casting with the foot in neutral (5.1% vs 16.7%, respectively, P < 0.04). Conclusions: In the surgical correction of idiopathic clubfoot, the incidence of wound complications is significantly decreased with the use of the Cincinnati treatment method rather than the modified Turco treatment protocol. Whether this effect is a result of the incision or the postoperative casting protocol is unclear.

The resistant clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Previous reviews have concluded that this method can provide satisfactory correction and outcome. This study presents a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, treated with Ilizarov external fixation and gradual distraction by 1 of 2 surgeons. Outcome measures were graded based on function and presence of residual deformity: (a) excellent (painless, plantigrade foot, with no functional limitations); (b) good (plantigrade foot in a patient able to ambulate long distances with mild pain; (c) fair (mild residual deformity, required bracing, and/or had some functional limitations but an active life); and (d) poor (significant residual deformity, pain, and activity limitations). Radiographic measures of the talocalcaneal and talo-first metatarsal angles were compared preoperatively and postoperatively. At an average follow-up of 6.64 years (range, 2.25-10.50 years), 9.5% (2) achieved an excellent result; 4.8% (1), good; 33.3% (7), fair; and 52.4% (11), poor. All 11 of the feet graded poor required revision surgery at an average of 5.63 years postoperatively (range, 2.67-10.2 years). Only the talo-first metatarsal angle displayed a clinically and statistically significant correction. We conclude that the Ilizarov method for treatment of resistant clubfoot deformities results in poor outcome associated with residual or recurrent deformity, often requiring revision surgery.

The purpose of this study was to determine whether there is a significant association between function and well-being in children with cerebral palsy. To determine this, the authors used validated measures of function (Gillette Functional Assessment Questionnaire, Gross Motor Function Classification System, Gross Motor Function Measure, and walking speed) and correlated them to health-related quality of life (HRQOL) measures (Pediatric Outcomes Data Collection Instrument, Pediatric Quality of Life instrument). In a cross-sectional study of ambulatory children with mild to moderate cerebral palsy aged 10.2 ± 3.2 years, mild to moderate decreases in function were found when compared with normative data. As the assessment of HRQOL comprises both functional well-being and psychosocial well-being, the authors decided to specify the aspect of well-being to which they were referring. It was found that the child's function was not correlated to psychosocial well-being. The children with mild cerebral palsy had greater effects on their psychosocial well-being than would be predicted by their functional disability. Functional measures were good at predicting the functional well-being but were weak at predicting the psychosocial arm of well-being.

Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients (11 years) and a group of more skeletally mature patients (11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.

In a retrospective review of 74 tibial osteotomies performed for Blount disease, the patients were divided into three groups based on age and treatment. Group A (26 osteotomies), 4 years old or younger, and group B (34 osteotomies), older than 4 years, were treated the same with osteotomy and crossed pins. Group C (14 osteotomies), older than 4 years, was treated with osteotomy and external fixator. At 6 years of follow-up, the recurrence of varus deformity was 46%, 94%, and 72% in groups A, B, and C, respectively. There was no correlation between recurrence of varus deformity and preoperative deformity angle or degree of surgical correction. Fixation with crossed pins or external fixator was not a factor. Surgery at 4 years old or younger and correction of the postoperative deformity angle in valgus may obviate recurrence of varus deformity in Blount disease at long-term follow-up.

Tibial osteotomies in children have been associated with a number of complications. A retrospective review of 116 children who had 129 tibial osteotomies was performed to assess these complications at our institution. Results showed that there were 35 cases of wound problems, 6 cases of recurrence/reoperation, 5 cases of delayed union, 2 cases with transient peroneal nerve palsy, 1 case of nonunion, and 1 case of mal-union. Patients having certain comorbidities had a higher frequency of complications. There were no significant differences between the location of the tibial osteotomy (proximal or distal) and the incidence of complication. External fixation was associated with a lower incidence of complications than the use of pins and casting. Although our results demonstrate an overall low complication rate, there is a significant association between complications and comorbid conditions. This highlights the need to recognize comorbidities preoperatively and the potential of increased postoperative complications.

We describe an extra-articular triplane fracture of the distal tibia in the skeletally immature patient. This variant of the triplane fracture has been largely ignored in the literature. The clinical significance of recognizing this fracture is that, although it constitutes an epiphyseal fracture, it remains extra-articular. Unlike the standard triplane fracture that exists through the tibiotalar joint, this variant can be treated acceptably with less than an anatomical reduction, therefore often avoiding the need for surgical management.