Objective. To determine the incidence of delayed infections in idiopathic scoliosis treated with TSRH instrumentation, proper wound management after instrumentation removal, and whether the previously identified bacterial trend remains consistent. Methods. All patients with idiopathic scoliosis ≥2 years after surgery with posterior TSRH instrumentation were included. Those cases with delayed infections were retrospectively reviewed. Time of presentation (infection) from index operation, clinical picture, sedimentation rate, presence of pseudarthrosis, organisms grown on culture, type of wound closure, and duration of antibiotics were examined. Results. A total of 489 patients were identified ≥2 years postoperation; 23 had delayed infections (4.7%). Time of presentation averaged 27 months after initial surgery. Spontaneous drainage occurred in 15 patients, fluctuance in 6, and neither in the remaining 2 (pain and fever). Sedimentation rate averaged 48 mm/hr. All patients had instrumentation removed. Primary closure (1 stage) was performed in 14 patients, and delayed primary closure (≥2 stages) was performed in nine patients. All wounds healed uneventfully. Cultures at the time of instrumentation removal grew Propionibacterium acnes in 12 patients, Staphylococcus epidermidis (or Staphylococcus coagulase-negative) in 4, Micrococcus varians in 1, and Staphylococcus aureus in 1. Five patients had negative cultures. After removal, patients received parenteral antibiotics; in 21 of these patients this was followed by oral antibiotics. Conclusions. Low-virulent skin organisms are primarily responsible for delayed infections. Intraoperative seeding followed by subclinical quiescent periods appears to be the method by which infection occurs. The increased bulk and modularity of modern instrumentation systems can lead to inflammation and bursa formation, thus contributing significantly to the activation of these infections. Primary wound closure results in successful wound healing. Delayed closure after 48 hours is unnecessary. Short-term postoperative parenteral antibiotics (2–5 days) followed by short-term oral antibiotics (7–14 days) is recommended.

Purpose.: To report early results of conservative treatments (including modifications in activities of daily living) for mild femoroacetabular impingement. Methods.: 27 male and 10 female athletic patients aged 23 to 47 years presented with unilateral hip pain secondary to femoroacetabular impingement and an alpha angle of <60°. Patients were instructed to adapt to their safe range of movement and perform activities of daily living with minimal friction. The Harris Hip Score and non-arthritic hip score before and after treatment were compared. Open or arthroscopic hip surgery to remove the impinging bone was indicated when conservative treatment failed. Results.: Patients were followed up for 25 to 28 months. Of the 37 patients, 4 underwent surgical treatment after conservative management failed. For the remaining 33 patients, the mean Harris Hip Score improved significantly from 72 before treatment to 91 at the 24-month follow-up. The mean non-arthritic hip scores improved from 72 to 91, and the mean visual analogue scores for hip pain from 6 to 2. Six of the 33 patients had recurrent hip pain and discomfort but not severe enough for surgical treatment. Conclusion.: Conservative treatment did not improve the range of hip movement, despite improvement in function and symptoms. Yet it achieved good early results, as long as the patients could modify activities of daily living to adapt to their hip morphology.

Background: The purpose of the present study was to determine whether the modified Oxford bone score can be used as a predictor for the risk of developing contralateral slipped capital femoral epiphysis (SCFE) in children who present with a unilateral slip. Methods: We identified 260 patients treated for unilateral SCFE between 1980 and 2002 and followed them up to skeletal maturity or until development of contralateral slip. Exclusion criteria included patients with endocrine or metabolic disorder, Down syndrome, and those with radiographs inadequate to determine the modified Oxford bone score. The initial radiographs were given a score ranging from 16 to 26. Statistical analysis was used to determine whether the modified Oxford bone score was predictive of future development of contralateral slip. A linear regression model was used to estimate the probability of future development of a contralateral slip as related to the modified Oxford bone score. Results: Of the 260 patients, 64 (24%) developed a contralateral slip, at an average of 10 months after initial presentation. Race, sex, age, and weight at initial presentation were not predictive of the development of contralateral slip. The modified Oxford score and a triradiate score of 1 were found to be significant (P<0.0001) predictors, with the modified Oxford score a better overall predictor. Conclusions: The modified Oxford bone age score is the best predictor of the risk of development of a contralateral SCFE in patients presenting with a unilateral slip. Controversy exists regarding prophylactic pinning of a normal hip in patients presenting with unilateral SCFE. The benefits of prophylactic pinning must outweigh risk. This study provides probability data for predicting a contralateral slip based on the modified Oxford bone maturity score that can be shared with families and allows physicians to decide their threshold for prophylactically pinning the contralateral hip in patients presenting with a unilateral slip. Level of Evidence: Therapeutic level IV, Case series.

Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use.

Purpose Hip displacement is common in children with cerebral palsy (CP). The risk of hip displacement is related to gross motor function level as graded with the Gross Motor Function Classification System (GMFCS). Most clinicians agree that surgical treatment is indicated for progressive hip subluxation in patients with CP. However, it is unclear whether unilateral bony surgery and musculotenduous release is effective in cases in which the contralateral hip is well seated. The purpose of this study is to describe the fate of the original and the contralateral hip of severely involved patients with CP, GMFCS III to V, with unilateral hip subluxation or dislocation treated by unilateral femoral osteotomy with or without pelvic osteotomy along with unilateral or bilateral soft tissue release when the contralateral hip was well seated followed to skeletal maturity. Methods A continuous group of GMFCS III to V CP patients with unilateral hip subluxation or dislocation who underwent soft tissue release (adductor and iliopsoas) and unilateral intertrochanteric varus, rotation and shortening osteotomy with or without pelvic osteotomy are included. All patients were clinically and radiologically followed from the time of presentation until skeletal maturity. Results Twenty-seven children and adolescents with GMFCS level III, IV, and V met the inclusion criteria. Two patients (7.4%) were GMFCS III, 5 (18.5%) were GMFCS IV and 20 (74.1%) GMFCS V. The male:female ratio was almost 1 (13 boys and 14 girls). At the time of chart and radiograph review, the average age of this patient group was 20.4 years (range: 14 to 25 y). Twelve patients (44%) required subsequent bony surgical management of the contralateral hip for subluxation or dislocation after the index procedure. Initially, in all cases there was pelvic obliquity with the operative side higher, which reversed in cases in which the contralateral hip deteriorated, and did not reverse when the contralateral hip remained stable. Nine of them were treated with femoral varus osteotomy alone and 3 underwent a combination of femoral and pelvic osteotomy. Three of these 12 (25%) patients had revision of the first hip and bony correction of the contralateral hip. Age at surgery did not seem to have a significant effect on maintaining reduction or in preventing the contralateral hip to deteriorate. Conclusions The rates of recurrence of the original hip and contralateral hip subluxation and dislocation after unilateral bony surgery in GMFCS III to V spastic patients are higher than those of other earlier series. However, in this series patients were followed until skeletal maturity. It is prudent to warn families of the possibility of long-term subluxation or dislocation of the original hip and development of the hip dysplasia requiring surgery on the contralateral side. Consideration should be given to adductor and iliopsoas release and bony surgery on the contralateral side in a GMFCS level III to V child undergoing surgery for hip displacement, even when the hip seem radiologically normal. If unilateral bony surgery is carried out, close radiological follow-up of both hips is recommended. It also seems that unilateral hip surgery alters the forces maintaining pelvic alignment, which can lead to destabilization of the contralateral hip. Level of Evidence Case series. Level IV.

Ilizarov technique is useful in the management of infected nonunions of the tibia. Its main drawback is the long duration of external fixation (EF) with marked patient discomfort. Several techniques have been described for early removal of EF to avoid this problem. Between September 2000 and October 2001, a prospective study at a tertiary trauma center was performed. Thirty-three patients with infected nonunion of the tibial shaft were included. The eradication of infection was by debridement, followed by limb reconstruction using segment transport technique with Ilizarov EF system. When the transported segment reached the docking site, we offered the patients removal of EF, and replacement by intramedullary (I M) fixation with bone graft at the docking site. Advantages and risks were explained to all patients. Patients (N = 17) who accepted this technique were compared with patients (N = 16) who preferred to continue in EF till full bone union, with bone graft at the docking site used in both groups. Mean age of the patients was 29 years, and mean duration of nonunion was 12.6 (range, 6-22) months. Average duration of follow-up from the date of presentation was 36 (range, 22-48) months. Main outcome measurements were assessment of bone and functional outcome using the classification of the Association for the Study and Application of the Method of Ilizarov, EF index, radiographic consolidation index, healing time, duration of EF, and complications The average duration of EF in the first group was 3.1 month, meanwhile in the second group it was 8.5 months. The Association for the Study and Application of the Method of Ilizarov bony and functional outcome assessment score showed no statistically significant difference between the two techniques on follow-up. Early removal of EF and replacement by intramedullary nail can achieve complete healing for infected nonunion of the tibial shaft with shorter duration of EF; nearly one-third the usual duration of EF and give the same functional and bony outcome as the classic technique. It is a relatively safe technique but the risk of infection recurrence must be explained to the patient.