Background In situ pinning is the conventional treatment for a stable slipped capital femoral epiphysis (SCFE). However, with a severe stable SCFE the residual deformity may lead to femoroacetabular impingement and articular cartilage damage. A modified Dunn subcapital realignment procedure has been developed to allow for correction at the level of the deformity while preserving the blood supply to the femoral head. Questions/purposes We compared children with severe stable SCFE treated with the modified Dunn procedure or in situ pinning in terms of (1) proximal femoral radiographic deformity; (2) Heyman and Herndon clinical outcome; (3) complication rate; and (4) number of reoperations performed after the initial procedure. Methods In this nonmatched retrospective study, 15 patients treated with the modified Dunn procedure (between 2007 and 2012) and 15 treated with in situ pinning (between 2001 and 2009) for severe but stable SCFE were followed for a mean of 2.5 years (range, 1-6 years). During the period in question, the decision regarding which procedure to use was based on the on-call surgeon's discretion; six surgeons performed in situ pinning and three surgeons performed the modified Dunn procedure. A total of 15 other patients were treated for the same diagnosis during the study period but were lost to followup before 1 year; of those, 12 were in the in situ pinning group. Radiographs were reviewed to measure the AP and lateral alpha angles, femoral head-neck offset, and Southwick angle preoperatively and at the latest clinical visit. The Heyman and Herndon clinical outcome, complications, and subsequent hip surgeries were recorded. Results At latest followup, the median AP alpha angle (52°, range 41°-59°versus 76°, interquartile range [IQR]: 68°-

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Background Osteonecrosis of the femoral head is a major complication that negatively impacts the clinical and radiographic long-term outcome after treatment of developmental hip dysplasia (DDH). There are conflicting results in the literature whether age at the time of closed or open reduction and a specific surgical approach are associated with osteonecrosis. Better understanding of the impact of age at reduction and surgical approach is important to reduce the risk of osteonecrosis in patients with DDH. Questions/purposes We aimed to evaluate the association between occurrence of osteonecrosis and (1) age at closed reduction; (2) age at open reduction; and (3) medial versus anterior operative approaches.Methods A systematic review identified studies reporting osteonecrosis occurrence after treatment of DDH and at least 2 years of followup. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Methodologic quality was assessed using the methodologic index for nonrandomized studies. Generalized logistic models were used to estimate pooled odds ratios (ORs) in the meta-analysis. Sixty-six studies were included in the systematic review and 24 in the meta-analysis. Data on 481 hips treated by closed reduction and 584 hips treated by open reduction were available to evaluate the association between osteonecrosis and age. The association between osteonecrosis and operative approach was assessed using data on 364 hips treated by medial open reduction and 220 hips treated by anterior open reduction. Results Age at reduction ([ 12 months versus B 12 months) was not associated with osteonecrosis after closed reduction (OR, 1.1; 95% confidence interval [CI], 0.4-3.2; p = 0.9) or open reduction (OR, 1.1; 95% CI, 0.7-1.9; p = 0.66). The overall, adjusted incidence of osteonecrosis (C Grade II) was 8.0% (95% CI, 2.8%-20.6%) among patients treated with closed reduction at or before 12 months of age and 8.4% (95% CI, 3.0%-21.

Pediatric femoral neck fractures are rare injuries that are associated with a high risk of osteonecrosis of the femoral head. This study compared pediatric patients with fully displaced femoral neck fractures treated with either open reduction and internal fixation (ORIF) or closed reduction and internal fixation (CRIF). After institutional review board approval was obtained, the authors identified 53 patients who were treated for femoral neck fracture between 2003 and 2012. Inclusion criteria were as follows: (1) diagnosis of a fully displaced femoral neck fracture with no anatomic cortical contact; (2) age of at least 4 years; and (3) clinical/radiographic follow-up of at least 1 year. Medical records and radiographs were retrospectively reviewed. Excluded from the study were 16 patients who had fractures that were not fully displaced, 4 who were outside of the eligible age range, 1 who had insufficient radiographs, and 10 who had insufficient follow-up. Of the 22 patients included, 6 were treated with ORIF and 16 were treated with CRIF. Treatment groups were compared with Fisher's exact test for categorical outcome data and the Wilcoxon rank-sum test for continuous variables. There was a significantly (P=.051) greater occurrence of osteonecrosis after CRIF (50%) than after ORIF (0%). Further, patients who underwent ORIF had a higher (P=.009) quality of reduction, a higher (P=.046) rate of anatomic union, and fewer (P=.009) complications than those who underwent CRIF. Major complications occurred in significantly fewer (P=.015) hips after ORIF than after CRIF. No significant difference (P=.477) was seen between groups, according to the Ratliff assessment of final results. Fully displaced pediatric femoral neck fractures treated with ORIF had a significantly higher quality of reduction, with fewer complications, including osteonecrosis, than those treated with CRIF.

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A significantly higher mean alpha angle from the superior to the anterior-superior regions of the femoral head-neck junction and lower acetabular version were found in adolescents who sustained low-energy, sports-related posterior hip dislocations.

Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

The cerebral structure and function of a group of ten men admitted to a special (high~security) hospital in the south of England were assessed using a range of methods. All had committed at least one act of very serious violence, or similarly dangerous acts (e.g. arson). Six of the group had schizophrenia and four a primary personality disorder. The men were all regarded as still posing a sufficiently high risk to others that they would not have been allowed to leave the hospital without a multi~ ple nurse escort. Previous reports suggest that magnetic resonance imaging (MRI) is better than computed tomography (CT) in detecting structural cerebral lesions in people with a mental disorder. The main purpose of this study, therefore, was to test the feasibility of using an MRI scanner which could be taken into the hospital to eval~ uate the men, and then undertake a preliminary review of the relative roles of the dif ferent approaches to cerebral investigation. All the men tolerated the MRI without incident. Results from neuropsychological testing and MRI were similar insofar as both indicated definite cerebral pathology in nine of the ten cases, while the CT scan suggested damage in just half of the cases and the EEG in only six men. In six cases MRI demonstrated atrophy of mesial temporal structures that had not been detected with CT. In only one case did the CT scan provide evidence of localised disturbance, and the EEG was only slightly better in this regard. There were discrepancies in localisation of damage between the neuropsychological testing and the MRI results. A full~scale, systematic study of mentally disordered serious offenders using a broad~ based approach seems important. Thus far this is the largest such series.