Despite recent advances in the management of slipped capital femoral epiphysis (SCFE), controversy remains about the treatment of choice for unstable slips. Surgical dislocation and open reduction has the advantage of identifying and preserving the blood supply of femoral head thereby potentially reducing the risk of avascular necrosis, (AVN). There is large variation in the literature from several small series about reported AVN rates ranging from two to 66% for unstable SCFE treated with surgical dislocation. The aim of our study was to analyze our experience with acute open reduction and internal fixation of unstable acute and unstable acute on chronic slips using the technique of surgical dislocation described by Professor Reinhold Ganz.

A retrospective review of 11 patients (12 hips) treated by surgical dislocation, reduction and pinning as the primary procedure for unstable acute and unstable acute on chronic SCFE in a tertiary referral children's hospital was undertaken. This represents the entire series treated in this manner from September 2007 to January 2018. These procedures were performed by a team of Orthopaedic surgeons with significant experience performing surgical dislocation of the hip including patients with chronic SCFE, Perthes' disease, impingement and acetabular fractures. Demographic data, intraoperative records, postoperative notes and radiographs including details of subsequent surgery were reviewed.

There were seven boys and four girls with mean age of 13.4 years, range 11 to 15 years at the time of surgical dislocation. Out of 12 hips, two had acute unstable slip while the remaining 10 had acute on chronic unstable slip. Six patients had good or excellent results. The remaining six patients developed AVN of which three patients had total hip replacement at six months, 17 months and 18 months following primary procedure. Seven patients required more than one operation. Three patients lost their correction and required re fixation despite surgical dislocation, reduction and fixation being their primary procedure.

This series demonstrates a high percentage of AVN (50%) in severe unstable SCFE treated with surgical dislocation despite careful attention to retinacular flap development and intra operative doppler studies. This is in direct contrast to our experience with subcapital reorientation with surgical dislocation in stable slips where excellent results were achieved with a low rate of AVN. Pre-operative imaging with MRI and perfusion studies may identify where ischemia has occurred and might influence operative treatment. Based on our results, we do not recommend routine use of surgical dislocation in unstable SCFE. This technique requires further scrutiny to define the operative indications in unstable SCFE.

Purpose: Congenital idiopathic clubfoot is the most common congenital deformity in children and can be a major cause of disability for the child as well as an emotional stress for the parents. The Ponseti method of club-foot correction, consisting of serial manipulations and casting, is now the gold standard of treatment. It has traditionally been described using plaster of Paris (POP) above-knee casts, which are affordable, stiff, and easily moldable. Recently, semi-rigid fiberglass softcast (FSC, 3M Scotchcast) has grown in popularity due to ease of removal, durability, lighter weight, better appearance, ease of cleaning, and water resistance. There are currently no randomized controlled trials to prove its efficacy with respect to POP. The purpose of this study was to determine the influence of choice of cast material on the correction of congenital idiopathic clubfeet using the Ponseti method.

Method: A prospective, randomized controlled trial. Based on the results of a pilot study performed at our centre, a sample size of 30 patients was determined to be appropriate. Thirty consecutive patients presenting with congenital idiopathic clubfoot were randomized into POP and FSC groups prior to commencement of treatment with the Ponseti Method. Clubfeet secondary to non-idiopathic diagnoses were excluded. The Pirani classification was used to determine clubfoot severity (less severe, < =4; severe > 4), and for surveillance during casting. The primary outcome measure was the number of casts required to correct the clubfoot deformities to the point where the foot was ready for a percutaneous tendo-achilles tenotomy (TAL) or when the foot was completely corrected (Pirani=0). Secondary outcome measures include: number of casts by clubfoot severity, ease of cast removal, number of methods needed to remove casts, need for percutaneous tendo-achilles tenotomy.

Results: Of the 30 patients enrolled, 13 (40%) were randomized to POP and 18 (60%) to FSC. No patients were lost to follow-up. In the POP and FSC groups, eight (67%) and 11 patients (61%) underwent a TAL, respectively. In general, there were no differences in the mean number of casts required for clubfoot correction between the two groups (p=0.13). When analyzed by clubfoot severity, the mean number of casts for each material in the less severe group was equal (3 casts). In the severe group, the mean number of casts in the FSC group (6.4 casts) was considerably higher than for the POP group (4.7 casts) but our study was underpowered to verify this result. According to parents, POP was harder to remove than FSC (p< 0.001).

Conclusion: In general, FSC was found to be as efficacious as POP in the correction of idiopathic clubfeet by the Ponseti Method and was the preferred cast material by parents. For stiffer, more severe feet, POP seemed to show a faster correction time than FSC.