Dennis R. Wenger

We performedaprospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment withaHelfet heel-cup; or Group IV, treatment withacustom-molded plastic insert. All of the patients in Groups II, III, and IV hadaminimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstratedasignificant improvement in all groups (p 0.01), including the controls, and no significant difference between the controls and the treated patients (p 0.4). We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.

Background: We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis. Methods: We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed. Results: We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon. Conclusions: We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.

Childhood hip dysplasia is best treated in infancy or early childhood with hopes that the acetabulum will be completely normalized by nonoperative treatment methods, which may include Pavlik and brace treatment as well as formal closed reduction and hip spica casting. In many cases, this ideal result cannot be achieved and the child is left with residual dysplasia, which is often not symptomatic. Other patients may present late with hip dysplasia that is not identified in early childhood. Some develop hip pain with no prior known hip problem. Other children have asymptomatic dysplasia that is picked up on an incidental radiograph. The orthopaedic literature is clear regarding the need for corrective hip osteotomies in symptomatic children. Surgery to correct asymptomatic hip dysplasia remains controversial. Children who have no symptoms yet have abnormal radiographs present a puzzling circumstance. In these cases, surgeons need to use quoted radiographic normal values for acetabular coverage of the femoral head as well as long-term natural history studies to decide whether to proceed with a corrective acetabular osteotomy. Long-term follow-up studies confirm that even patients with borderline dysplasia are likely to have significant hip symptoms and arthritis by middle age. Many children and adolescents with asymptomatic residual hip dysplasia should have corrective acetabular procedures performed. Surgery is more easily performed with more predictable results when the child is younger than 8 years. It is impossible to state with certainty which children with residual radiographic hip dysplasia, but without symptoms, should have a corrective acetabular osteotomy. Review of the literature confirms that many patients have been undertreated in the past, with a high percentage of children with borderline hip dysplasia developing premature arthritis in early to mid-adult life. Current data suggest that surgery should be performed in borderline cases. Skill of the surgeon in performing acetabular osteotomies and/or ease of referral to a treatment center may temper the timing of such decisions.

Background: Advances in statistical science and the development of computers (a result of the digital revolution) have allowed many disciplines, including medicine, to develop a more objective analysis of data as applied to decision making. The concept of evidence-based medicine (EBM) includes that scientific study of disease and treatment efficacy will allow high-quality, cost-effective treatment. The concept of EBM is well established in medical specialties, particularly for cardiovascular disease and cancer, but less developed in the surgical specialties. Multiple factors make evidence-based surgical (EBS) studies more problematic. Entering children into prospective surgical treatment trials remains difficult for the parents and patients who are asked to allow a choice of procedures for a surgical intervention that will take just an hour or two but whose results could change the child’s entire life. Comparative effectiveness research, a subset of EBM, is of special interest to surgeons, who often need to decide on an expensive new implant versus a reliable, less expensive, established one. Factors that make the scientific analysis of surgical treatment efficacy more difficult include issues as practical as surgical skill. Prescribing an antihypertensive medication or a lipid-lowering drug has little variability in its delivery. Performance of a complex surgical procedure can vary immensely, allowing a procedure to be very effective in one surgeon’s hands but far less applicable by another surgeon (eg, arthroscopic vs. open shoulder surgery). Thus, large patient series with careful follow-up are required to clarify outcome differences. Scientific study of surgical treatment outcomes in childhood orthopaedic conditions remains in its infancy. Because of minimal funding available for such research, most available studies are poorly designed with an inadequate study sample size. As for the near future, neither the government nor industry sources seem to have a strong incentive to study outcomes in childhood surgical diseases that have a low prevalence. Because current research provides little evidence to guide parents and their surgeon (when a choice exists), consumers generally seek what they believe to be the best available “expert opinion.” Conclusions: Properly funded, the digital revolution will allow radical advances in establishing EBS decision making. However, the same digital revolution has produced an educated populace, greatly increasing their capacity for critical analysis of available data. Currently, both sophisticated parents and their surgeons remain hesitant to accept results from poorly designed studies when deciding on surgery for their child. As a result, expert opinion remains central to surgical decision making in children’s orthopaedics. Knowledgeable surgeons look forward to future quantum improvements in research quality that will allow secure EBS-based decisions for their surgical patients.

The goal of intervention in Legg-Calvé-Perthes disease has been to prevent femoral head deformation by containing the head within the acetabulum, using it as a mold for guiding femoral head development. With appropriate proximal femoral morphology, premature arthritis can hopefully be avoided. Both nonsurgical and surgical methods of treatment have evolved over time, from abduction casts and braces to advanced surgical containment methods, which are now the mainstay of treatment. The purpose of this study is to briefly review the evolution of surgical treatment of Legg-Calvé-Perthes disease, and to concentrate on 2 advanced surgical containment methods: combined Salter innominate osteotomy with femoral varus osteotomy and triple pelvic osteotomy.

Legg-Calvé-Perthes (LCP) disease has an extensive history that has provided an ongoing intellectual challenge for the orthopaedic community. Debate around etiology and treatment of LCP disease continues even after its initial description in the early 1900 s. In order for modern day clinicians to have a full understanding of the condition, one must be a scholar of its development. The purpose of our review will be to discuss the scientific communities' understanding of presentation, etiology, and treatment of LCP disease over time.

### Developmental Dysplasia of the Hip A prospective randomized trial evaluating immediate treatment compared with active sonographic surveillance for infants with dysplastic, nondislocatable hips demonstrated that surveillance halved the need for treatment without having an effect on the radiographic appearance of the hip at the age of one year1. In a study in which twenty-nine patients with bilateral dislocation of the hip were compared with thirty-eight patients with unilateral dislocation, there was no significant difference between the two groups with regard to the failure of Pavlik treatment2. Two studies analyzed factors associated with unsuccessful Pavlik harness treatment of dislocated hips3,4. In one series of 221 hips, successful reduction was obtained in 81.9% of the hips, with development of osteonecrosis in 8.8%3. Adduction contracture and decreased distance from the proximal medial femoral metaphysis (indicated by the “a” line) were identified as risk factors that were predictive of failure. Another study of eighty-five patients demonstrated a rate of Pavlik harness failure of 37%4. Sonographic findings associated with unsuccessful Pavlik harness treatment included an increased beta angle, superior femoral head migration relative to the labrum, and total femoral head displacement less than −30°4. In a retrospective review of late-presenting patients (age range, six to twenty-four months) who were managed with Pavlik harness reduction, 60% of Graf type-3 hips were reduced with no associated osteonecrosis, whereas no Graf type-4 hips were reduced5. A single-institution review of operative reduction of dislocated hips in late-presenting children demonstrated that femoral shortening osteotomy was more common in children with an age of more than thirty-six months or with femoral displacement of >30% of the pelvic height, with an overall prevalence of 35%6. In the study by Spence et al., open reduction combined with varus derotational proximal …

Background Although surgical containment has become a mainstay for the treatment of Legg-Calvé-Perthes (LCP) disease; traditional operations (varus osteotomy of femur, Salter osteotomy) have certain limitations, sometimes resulting in a prolonged limp or inadequate containment. This paper presents the surgical method and results of triple pelvic osteotomy for containment treatment of LCP disease. Methods This retrospective review of 39 children (40 hips; age 5 to 13 y) with LCP disease treated with triple pelvic osteotomy (1995 to 2005) included preoperative lateral pillar assessment and other measurements. Final follow-up films (minimum 3 y, range 3 to 9 y) were assessed using the modified Stulberg classification. Clinical follow-up evaluation assessed limp, limb-length inequality, range of motion, and activity level. Results Twenty-one (53%) hips were graded as lateral pillar B and 19 (48%) were lateral pillar C. Four patients required further treatment before the final follow-up. At final follow-up, 42% had a good outcome (Stulberg I/II), 47% had a fair outcome (Stulberg III), and 11% had a poor outcome. Thus, 89% of patients had satisfactory (good or fair) results. There was a significant difference in outcome based on the preoperative lateral pillar, with B hips more likely to have a good outcome (65%) compared with lateral pillar C hips (12.5%) (P=0.002). There were no lateral pillar B patients with a poor outcome. Seventeen percent of the lateral pillar C patients more than or equal to age 8 had a poor outcome compared with 50% being more than age 8 with a poor outcome. Four patients (3 lateral pillar C, 1 lateral pillar B) required further surgery. Conclusions Triple pelvic osteotomy resulted in maintenance of head shape in lateral pillar B patients of all ages and in younger lateral pillar C patients. Lateral pillar C patients over age 8 were more difficult to treat, however, we still advise containment for these cases because methods are now available to deal with containment failure. Triple pelvic osteotomy is an effective treatment method for LCP patients with lateral pillar B disease and younger patients with lateral pillar C disease. This method provides effective containment, which allows prolonged remodeling while avoiding the limitations of femoral varus osteotomy (limp, short limb) and Salter osteotomy (incomplete containment). Level of Evidence Level IV.