Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

This study addresses a crucial gap in the knowledge of normative spinal growth in children. The objective of this study is to provide detailed and accurate 3D reference values for global and segmental spinal dimensions in healthy children under the age of 11. Radiographic spine examinations of healthy children conducted to rule out scoliosis were reviewed in four scoliosis referral centers in North America. All consecutive children aged three to eleven years old with EOS biplanar good quality x-rays, but without diagnosed growth-affecting pathologies, were included. Postero-Anterior and Lateral calibrated x-rays were used for spine 3D reconstruction and computation of vertebral body height and spine length. Median and interquartile range were calculated from cross-sectional data. Smooth centiles growth curves for 3D True Spinal Length (3DTSL) between T1 and S1, as well as for mid-vertebral heights of T5, T12 and L3, where fit and calibrated from data using the Lambda-Mu-Sigma method (GAMLSS package for R). This method automatically selects the best performing distribution from a familly of choices. Tables of centiles were then predicted from the computed models for selected ages. A total of 638 full spine examinations from asymptomatic patients were reconstructed in 3D, 397 in girls and 241 in boys. Medians and interquartile ranges were calculated for 3DTSL (T1-S1): 285 (24) mm, 314 (26) mm and 349 (31) mm, and for selected vertebral heights T5: 10 (1) mm, 11 (1) mm and 12 (1) mm, T12: 13 (2) mm, 14 (1) mm and 16 (2) mm, and L3: 14 (1) mm, 16 (2) mm and 18 (2) mm, respectively for the 3–6, 6–8 and 8–11 age groups. Centile curves ready for clinical use of the 3DTSL (T1-S1) and of the vertebral heights of T5, T12 and L3 as a function of age were derived for the 5, 10, 25, 50, 75, 90 and 95th centiles. In general, boys presented linear relationships between spinal dimensions and age, and girls presented more diverging trends with increased variance for older ages. Accordingly curves for boys follow the Normal distribution whereas those for girls follow the original Box-Cox-Cole-Green distribution. Model diagnostic tests (normally distributed residuals, adequate wormplots and |Z statistics| < 2) confirmed adequacy of the models and the absence of significant misfit. Accurate reference values were derived for spinal dimensions in healthy children. Spinal dimension charts showed that the spinal lengths and vertebral heights changed relatively constantly across the age groups closely resembling WHO total body height charts. The reference values will help physicians better assess their patients' growth potential. It could also be used to predict expected spinal dimensions at maturity or changes in pathologic conditions as well as to assess the impact of growth friendly interventions in the correction of spinal deformities

Introduction. Hip dysplasia is the most common congenital deformity of the musculoskeletal system. This is a pathology that brings the hip joint from subluxation to dislocation. Frequency of hip dysplasia − 16 children per 1000 newborns. Materials and Methods. Diagnostic methods of research are X-ray inspection which is necessarily carried out at internal rotation (rotation) of an extremity as lateral rotation of a hip on the radiograph always increases an angle of a valgus deviation of a neck. Surgical treatment is performed in the subclavian area of the femur. An external fixation device is applied and a corrective corticotomy is performed, and valgus deformity and anteversion are eliminated. The duration of treatment is 2.5–3 months. Results. Frequency of hip dysplasia − 16 children per 1000 newborns. We perform about 30 operations a year, including 60% girls and 40% boys. In addition, valgus deformity can be traced -. - in cerebral palsy. - after polio. - at progressing muscular dystrophies. - tumor in the area of the epiphyseal cartilage. At insufficient stability in a hip joint at insufficiently expressed roof of an acetabulum of rotational deformation of a neck of a hip, for prevention of a coxarthrosis and normalization of a ratio of articular ends operation detorsion-varying subvertebral corticotomy of a femur is shown. Conclusions. The operation is minimally invasive, with accesses of 5–6 mm, anatomical and topographical features are taken into account, which will eliminate damage to tissues, nerve trunks and the circulatory system

Introduction. Fibula contributes to weight bearing and serves as a lateral buttress to the talus. Fibular shortening leads to ankle valgus, distal tibial epiphyseal wedging and ankle instability. Trauma, infection and skeletal dyplasias are the common causes of fibular shortening in children. Aim was to review this cohort who underwent fibular lengthening and ankle reconstruction. Materials and Methods. Retrospective review from a prospective database of clinical and radiographic data of all children who underwent fibular lengthening for correction of ankle valgus. Distraction osteogenesis with external fixator was performed for all cases. Results. Eight children with 10 fibulae (average age: 10 years) were followed up for an average of 75.6 months. In older children, corrective tibial osteotomy was performed in addition to fibular lengthening. TSF frame mounted with mini-rail fixator was used in seven children who required adjuvant tibial correction and mini-rail was used for bilateral fibular lengthening in one. Remodelling of the wedged distal tibial epiphysis was noted in 75%. Talar tilt and mLDTA improved in 66.7% and fibular station in 85.7% limbs. Seven year old girl required re-lengthening. Two children developed fibular non-union. Proximal fibular migration was observed in one child, in whom the tibial wire did not engage the fibula. Conclusions. Restoration of tibial mechanical axis and lateral talar buttress is necessary to correct ankle valgus. Stabilisation of fibula to the tibia is prudent during distraction. Younger children may require re-lengthening. Remodelling of the triangular tibial epiphysis can be achieved when done early

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

Introduction. Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. Materials and Methods. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed. Results. The mean age at surgery was 13 years (range, 9–14). The mean body weight was 43.3 kg (range, 30–66). There were five mid-shaft fractures, one proximal third and one distal third. There were Four type A fractures, two type B and one type C. Four patients had road traffic accidents while three had direct trauma. The mean preoperative haemoglobin concentration 12.5 g/dl (range 11.3–13 g/dl). No blood transfusion was needed intraoperatively or postoperatively. The operative time averaged 122 minutes, and the mean hospital stay was one (range 1–4 days). The patients reported no pain at a mean of 1.5 weeks (range, one-three weeks). All fractures united at a mean of 8.7 weeks (range 6–12 weeks). No wound healing problems nor deep infections happened. The knee joint range of motion was full in all patients at six weeks postoperatively. There was no mechanical irritation from the inserted plate. At the final follow-up, all fractures united without malalignment nor length discrepancy. Conclusions. External fixator-assisted internal fixation of pediatric femoral fractures would facilitate the accuracy and control of fracture reduction and allow minimally invasive percutaneous osteosynthesis. Our study has shown a decrease in operative time, and an accompanying reduction in length of inpatient stay, prolonged need for analgesia and post-operative rehabilitation

Introduction. In situ pinning for classic slipped capital femoral epiphysis(SLIP) is evolving to a more direct and anatomic realignment of proximal femoral epiphysis; but in no study the result of such a treatment in Valgus Slip, an uncommon type of slipped capital femoral epiphysis, has been reported. Material and methods. Three hips in three patients (one male, two female) with valgus SCFE were treated by sub-capital realignment (two hips) or femoral neck osteotomy (one hip) for anatomic realignment of proximal femoral epiphysis. Extended retinacular flap technique performed through surgical hip dislocation in all hips. They followed clinically by Merle d'Aubigne Scale and visual analog scale for pain and radiographically for AVN, recurrence of SLIP, chondrolysis and osteoarthritis. Result. The age of the patients was 10,11 and 18 years. In all hips the neck-shaft angle was increased.18 years old male had bilateral chronic valgus SLIP with severe retro tilt of the head over the neck and bilateral acetabular dysplasia.11 years old girl with an acute valgus SLIP also had bilateral acetabular dysplasia and in 10 years old girl only one hip presented with acute on chronic valgus SLIP. All had severe displacement. The mean preoperative epiphyseal shaft angle (ESA) of 107.5° (range 85–125°) was reduced to 60° (range 55–70°) postoperatively. mean Merle d'Aubigne Scale was 16 and radiographically complete union and good alignment achieved without any complication. Conclusion. Anatomical realignment of proximal femoral epiphysis in this small series of patient with valgus type SCFE had good to excellent results

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur. We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury. 74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94). Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery

This study aimed to evaluate the clinical outcomes of paediatric patients who underwent a retrograde drilling treatment for their osteochondritis dissecans (OCD) of the talus. The secondary purpose was to identify factors that are predictive of a failure of the treatment. A retrospective study was done. All patients treated for talar OCD between 2014 and 2017 were reviewed to extract clinical and demographic information (age, sex, BMI, OCD size and stability, number of drilling, etc). Inclusion criteria were: (1) talar OCD treated with retrograde drilling, (2) less than 18 years, (3) at least one available follow up (4) stable lesion. Exclusion criteria was another type of treatment for a the talar OCD. Additionally, all pre-operative and post-operative medical imaging was reviewed. Outcome was classified based on the last follow-up appointment in two ways, first a score was attributed following the Berndt and Harty treatment outcome grading and second according to the necessity of a second surgery which was the failure group. Chi-square and Mann-Whitney tests were used to compared the success and failure group. Seventeen patients (16 girls and 1 boy, average age: 14.8±2.1 years) were included in our study group. The mean follow up duration was 11.5 (±12) months. Among this population, 4/17 (24%) had a failure of the treatment because they required a second surgery. The treatment result grading according to Berndt and Harty outcome scale identified good results in 8/17 (47%) patients, fair results in 4/17(24%) patients and poor results in 5/17 (29%) patients. The comparisons for various patient variables taken from the medical charts between patients who had a success of the treatment and those who failed did not find any significant differences. At a mean follow-up duration of 11.5 months, 76% of patients in this study had a successful outcome after talar OCD retrograde drilling. No statistically significant difference was identified between the success and failure group. Talar OCD in a paediatric population is uncommon, and this study reviewed the outcome of retrograde drilling with the largest sample size of the literature. Retrograde drilling achieved a successful outcome in 76% of the cases and represents a good option for the treatment of stable talar OCD

Osteomyelitis and septic arthritis are common pathologies in young children. Because of their skeletal immaturity, children are particularly vulnerable to orthopaedic complications, including limb-length discrepancies, angular deformities, chondrolysis, etc. The primary objective of this study was to review the clinical follow up and outcomes of paediatric patients diagnosed with osteoarticular infections. The secondary purpose was to look for significant differences in the clinical characteristics between the one with and without complications. Patients' medical charts, hospitalised between 2010 and 2016, were retrospectively reviewed. The inclusion criteria were: patients (1) aged of less than 10 years old (2) treated and followed for osteomyelitis of long bones of upper and lower extremities and/or septic arthritis (3) with at least one year of radiological follow up. The exclusion criterion was: (1) any concomitant chronic diseases. The information collected included demographic and clinical data. A late sequela was defined as a limb-length discrepancy superior to 5 mm or an abnormal articular angulation of more than 5°, or a symptomatic chondropathy. Patients were separated in two groups: with and without complications. Chi-square tests were used for categorical variables and Mann-Whitney U tests for continuous data in order to establish significant differences between both groups. Of the 401 patients with osteomyelitis and/or septic arthritis treated in our tertiary paediatric hospital over 7 years, 50 met the inclusion criteria. There were 24 girls and 26 boys. The etiological agent was identified in 56% of the cases. Staphylococcus aureus was the predominant causal pathogen (50%), followed by Kingella kingae (19.2%). The mean follow up was 780 days. Six out of 50 (12%) patients had physeal or chondrolytic complications at the latest follow-up. The only significant difference between the 2 groups was the delay between onset of symptoms and initiation of antibiotic therapy (P = 0.039). Only 12.5% of the patients were followed up at least one year. In the population of 50 skeletally immature patients without comorbidities, 12% had a sequela. The delay in initiating antibiotic treatment was significantly longer in the group with the presence of sequelae. The results of this study reveal that there were low rates of outpatient follow-up reaching more than a year after an osteoarticular infection, thus raising the question about the importance of a follow up after such a diagnosis. Twelve percent of the patients had a growth or chondrolysis complication and this might be related to the delay before initiating antibiotic treatment

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

Predictions of lower limb growth are based upon historical data, collected from patients who had coexistent poliomyelitis. By utilising standardised longitudinal prospective European data, our objective was to generate superior estimates for the age and rate at which lower limb skeletal maturity is reached; thus improving the timing of epiphysiodesis, for the management of leg length discrepancy. The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a longitudinal cohort study of children recruited antenatally 2. Using a previously validated Multiplier Method, a sequence of leg length multipliers were calculated for each child. 15,458 individuals were recruited to the ALSPAC study; and of those whose growth was measured, 52% were boys and 48% girls, each with an average of eight recording episodes. 25,828 leg length multiplier (LLM) values were calculated with final recordings taken at a mean age of 15.5 years. From this data, the age at which girls reach skeletal maturity (LLM=1) is 11 months later than previously calculated and for boys nearly 9 months earlier. With nearly 4000 more children recruited in this cohort than preceding studies, this study brings increased power to future leg length calculations

This study is a mid-term follow up of an original series of 51 babies treated with a modified Ponseti technique for idiopathic congenital talipes equinovarus using below-knee Softcast (easier to remove and hygienic). 1. to determine whether this method is as effective as traditional above-knee plastering. Methods. 51 consecutive babies were treated (April 2003-May 2007) and serial Pirani scores were recorded. Dennis Browne Boots (DBB) were applied when correction was achieved and an Achilles tenotomy was performed if necessary to complete the correction. DBB were worn fulltime for 3 months and at night for 3.5 years. Results. Of the original 51, 3 were lost to follow up and 3 were diagnosed with a neuromuscular condition and excluded. 45 patients, 34 boys and 11 girls were followed up for a mean of 55.3 months (range 36–85 months). Mean age at presentation was 16 days with a median Pirani score of 6.0 (5.5, 60). 75.7% required an Achilles tenotomy before DBB. Median Pirani score at tenotomy was 2.5 (2.0, 2.5). Time to boots (weeks) was mean 5.0 (4.2, 6.0) in the non-tenotomy group and 10.7 (9.8, 11.8) in the tenotomy group. 2 patients had residual deformity after plastering requiring surgery and there were 6 recurrences requiring surgery (4 tibialis anterior tendon transfers and 2 open releases). There appears to be a greater risk of operative intervention for girls and non-compliance with DBB. The estimate of 5-year (60 month) survival without surgery was 85% (96% CI; 70,99%). Conclusion. Below knee Softcast allows correction of CTEV with comparable results to traditional above knee techniques. Consistent with current literature, our series found that compliance with DBB is one of the strongest predictors of success. Brewster MB, Gupta M, Pattison GT, Dunn-van der Ploeg ID. Ponseti casting: a new soft option. JBJS(Br) 2008 Nov; 90(11): 1512–1515

Ankle sprains are common athletic injuries, with a peak lifetime incidence between the ages of 15 and 19 years, especially in young males. However, an unclear history, an imprecise physical exam, and unhelpful radiographies lead to frequent misdiagnosis of paediatric ankle traumas, and subsequently, inappropriate treatment. Improper management may lead to residual pain, instability, slower return to physical activity, and long-term degenerative changes. The purpose of this study was to evaluate the initial management and treatment of acute paediatric ankle sprains at our center, a tertiary care paediatric hospital. Our hypothesis was that the initial diagnosis is often incorrect, and treatment varies considerably amongst orthopaedic surgeons. We conducted a retrospective study of all cases of ankle sprains and Salter-Harris one (SH1) fractures referred to our orthopaedic surgery service between May and August 2014. Exclusion criteria included ankle fractures other than SH1 types, and cases where treatment was initially undertaken elsewhere before referral to our service. Patients were evaluated on a clinical and radiographic basis. Primary outcome was the difference between initial and final diagnosis. Secondary outcome was variation in immobilisation duration for each diagnosis. The main variables we considered were age, sex, mechanism of trauma, referral delay, patient symptoms, physical exam findings, radiographic findings, type and duration of immobilisation, prescription of any medication, and referral to physical therapy. A total of 3047 patients were reviewed and 31 cases matched our inclusion criteria, comprised of 17 girls and 14 boys, with a mean age of 10.4 years. Patients were seen at a mean of 10.3 days after injury. Initial diagnosis was SH1 fracture in 20 cases, acute ankle sprain in 8 cases, and uncertain in 3 cases. Final diagnosis was SH1 fracture in 11 cases, acute ankle sprain in 13 cases, uncertain in 5 cases, and other in 3 cases. During follow up, 48.5% of cases saw a change in diagnosis. Forty five percent (9/20) of cases initially diagnosed as SH1 fractures proved to be incorrect, with 55.5% (5/9) of these being ultimately diagnosed as acute ankle sprains. Amongst cases initially diagnosed as acute ankle sprains, 37.5% (3/8) received a different final diagnosis. Duration of immobilisation was significantly different between acute ankle sprain and SH1 fracture groups, with an average of 17.3 days and 26.1 days, respectively. Physical therapy was prescribed to 33.3% of acute ankle sprains and 9.1% of SH1 fractures. Initial distinction between acute ankle sprains and SH1 fractures can be difficult in paediatric ankle trauma. Case management and specific treatments vary considerably, as there is neither an evaluation algorithm nor consensus on treatment of these paediatric pathologies. This study reinforces the need to develop a systematic diagnostic and treatment protocol for paediatric ankle sprains

Our aim was to use CT Scanogram to evaluate fibular growth, and thus calculate normal growth velocity, which may aid in determining the timing of epiphysiodesis. Current understanding of normal lower limb growth and growth prediction originates in the work of Anderson et al published in the 1960s. There now exist several clinical and mathematical methods to aid in the treatment of leg length discrepancy, including the timing of epiphysiodesis. Early research in this area provided limited information on the growth of the fibula. It is now well recognized that abnormal growth of paired long bones may evolve into deformity of clinical significance. Existing work examining fibular growth used plain film radiography only. Computed Tomography (CT) scanogram is now the preferred method for evaluating leg length discrepancy in the paediatric population. We calculated fibular growth for 28 children (n = 28, 16 girls and 12 boys) presenting with leg length discrepancy to our unit. Mean age at presentation was 111.1 months (range 33 – 155 months). For inclusion, each child had to have at least five CT scanograms performed, at six monthly intervals. Fibular length was calculated digitally as the distance from the proximal edge of the proximal epiphysis to the most distal edge of the distal epiphysis. For calculation purposes, mean fibular length was determined from two measurements taken of the fibula. A graph for annual fibular growth was plotted and fibular growth velocity calculated. CT Scanogram may be used to calculate normal fibular growth in children presenting with leg length discrepancy

Aim:. To review the use of traction x-rays under anaesthesia in Late Onset Scoliosis to correlate traction x-ray flexibility and postoperative correction using posterior nonsegmental all pedicle screw constructs. Methods:. Prospective study. Preoperative anteroposterior, lateral and side bending x-rays were done and Cobb angles were measured. Intraoperatively, traction anteroposterior x-rays were taken under anaesthesia and Cobb angles were measured. All patients underwent nonsegmental posterior all pedicle screw construct correction using Biomet implants. Cobb angles greater than 60 degees were included in the study. Calculations were done including correction rate, traction flexibility and traction correction index. Results were entered onto an excel spreadsheet and analyzed using Statistica software. Results:. 16 patients were studied, 3 boys and 13 girls, average age 14, ranging from 8 to 17 years. Preoperative Cobb angles were mean 82 (60 to 105) degrees. Traction x-rays mean Cobb angle was 42 degrees with mean traction flexibility rate 49%. Mean correction rate was 65% and mean traction correction index 106. Preoperative Cobb angles correlated with traction flexibility with a p value of 0.01. Traction x-rays Cobb angle correlated with the traction correction index (p = 0.003), postoperative x-rays (p = 0.000) and also with correction rate (p = 0.024). There was no correlation between preoperative Cobb angle and correction rate. Conclusion:. Traction x-rays under anaesthesia in late onset scoliosis are a good predictor of postoperative correction with posterior nonsegmental all pedicle screw constructs in curves greater than 60 degrees

This case series highlights the use of the Ganz approach (trochanteric slide approach) and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chondromatosis of the hip. The first patient was a 16-year-old girl, who presented with pain in her hip, having fallen whilst playing football. Investigations revealed a fibrous dysplasia, which was successfully excised returning her to an active lifestyle. The second patient was a 27-year-old lady, who presented having suffered left hip pain for four years. She was diagnosed with a pigmented villonodular synovitis, which was excised and the patient was able to return to the gym. The third patient was a 41-year-old lady, who presented after experiencing right hip pain both at night and at rest for a year, without any trauma. She was diagnosed with synovial chondromatosis and returned to all activities of daily living. The Ganz approach allows safe dislocation of the hip joint without the risk of osteonecrosis of the femoral head. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum to surgically treat these three tumours of the hip. The surgeon can thus be reassured that complete excision of the tumour has occurred. This series can recommend the Ganz approach with trochanteric slide and full surgical dislocation of the hip to excise pigmented villonodular synovitis, synovial chondromatosis and fibrous dysplasia of the hip

Purpose of Study. We report the outcome of five cases of chronic paediatric Monteggia lesion treated with a modified Bell-Tawse procedure. Methods. Five patients with a chronic Monteggia lesion were treated over an eight-year period (2004–2012) at our institution. All underwent a modified Bell-Tawse procedure. The patient medical records were retrospectively analysed. We report the outcome in five patients. Results. Four girls and one boy were treated for a chronic Monteggia lesion in the period studied. The mean age at time of surgery was 8 years old (range 4–14 years). The mechanism of injury was post-traumatic in four of the five cases, while in one case the mechanism was uncertain. All children underwent modified Bell-Tawse procedure. All children ultimately required ulnar osteotomy, while two also required radial osteotomy. At a mean follow-up of 22 months (range 16–38 months), four children had experienced complications. Symptomatic metalwork was removed in one case, two children re-dislocated the affected joint, and one child required revision Bell-Tawse procedure. No nerve palsies were noted on follow-up. Conclusion. Paediatric elbow trauma necessitates early, senior management. We report a series of five patients who underwent modified Bell-Tawse procedure for chronic Monteggia lesion. Four of the five children experienced complications. All required shortening osteotomies. The chronic Monteggia lesion is an unusual but troublesome presentation in the paediatric population. Further research in the area is necessary

Aims

To determine if the results of treatment of adolescents with coccydynia are similar to those found in adults. Adult patients with coccydynia may benefit from injection therapy or operative treatment. There is little data evaluating treatment results in adolescents. We have treated adolescent patients similarly to adults and compared the outcomes.

Purpose of study:. Congenital hallux varus is a rare condition presenting with medial deviation of the big toe. It consists of 2 variants: classical congenital hallux varus caused by an abnormal metatarsal-phalangeal articulation, and a more recently described variant due to a “bracket physis” of the first metatarsal. Our aim was to perform an audit of the spectrum of presentation of congenital hallux varus with its management and complications in our unit over a five year period. Description of methods:. A retrospective review of congenital hallux varus treated by a single surgeon was performed. Clinical notes, photographs and x-rays were reviewed. Two surgical methods of treatment were used as directed by clinical and radiological findings. Summary of results:. Four patients with congenital hallux varus were identified. Three had bilateral involvement, i.e. seven feet were treated. The ages of the patients ranged from 1 to 9 years, with 2 boys and 2 girls receiving treatment. In two patients (4 feet) the deformity was associated with pre-axial polydactyly. One patient had associated hand deformities. Only one of our four patients had a “bracket physis” and was treated with a metatarsal osteotomy. The other three patients (6 feet) were treated by soft tissue realignment using the Farmer procedure. One patient who had bilateral Farmer procedures subsequently developed a bunion over the 1st metatarso-phalangeal joint of one foot due to uncovering of the metatarsal head. No complications or recurrences were recorded in the other three patients on follow up visits. Conclusion:. Careful clinical and X-ray analysis is important to determine the type of congenital hallux varus and which method of surgical treatment is appropriate. Long term follow up is required to identify subsequent deformities