We reviewed 22 children with cubitus varus who had been treated by a reverse V osteotomy and fixation by cross-pinning and wiring. The mean pre-operative humeral-elbow-wrist angle was −16.9° (−25° to +9°) and at the latest follow-up it was +7.3° (−2° to +14°). No child had a lateral prominence greater than 5 mm after correction. An excellent result was achieved in 20 children and a good result in two. We believe that this osteotomy has the advantages of better inherent stability, the avoidance of a prominent lateral condyle after correction and firm fixation allowing early movement.

We reviewed the management of 100 cases of slipped upper femoral epiphysis treated over a period of 26 years. A total of 14 slips was identified as unstable on admission. These underwent reduction and stabilisation within 24 hours of the onset of severe symptoms. Of the 86 stable slips four progressed to avascular necrosis (AVN), which was not seen in the unstable slips. The literature on slipped upper femoral epiphysis suggests that the acute unstable slip is at higher risk of developing AVN. We recommend reduction and stabilisation of unstable slips within 24 hours of the onset of symptoms in order to reduce the risk of AVN.

Relapsed congenital talipes equinovarus is difficult to assess and treat. Pedobarography provides dynamic measurement of the pressures under the foot, and may be used in the assessment of these patients both before and after operation.

Our findings showed a statistically significant difference in the distribution of pressure across the foot after treatment by the Ilizarov technique.

Seven children with a post-traumatic cubitus varus deformity were treated using the Ilizarov technique of distraction osteogenesis. The outcome was rated as excellent in each case and all were satisfied with the cosmetic appearance. No complications had been encountered by the latest follow-up at a mean of 66.7 months. This technique seems reliable for the treatment of such deformities, provided that it achieves full correction by gradual distraction. Nerve palsy and unsightly scars are avoided, and the range of movement of adjacent joints is preserved.

The conventional osteotomies used to treat infantile tibia vara (Blount’s disease) may require internal fixation and its subsequent removal. These techniques, which carry the risk of traction injury, and potential problems of stability and consolidation, do not always succeed in correcting the rotational deformity which accompanies the angular deformity.

We have used a new surgical approach, the serrated W/M osteotomy of the proximal tibia, to correct infantile tibia vara in 15 knees of 11 patients. We present the results in 13 knees of nine patients who have been followed up for a mean of eight years. The mean angular correction achieved after operation was 18 ± 5.8°. The mean femorotibial shaft angle was corrected from 14.2 ± 3.7° of varus to 4.6 ± 4.4° of valgus. At the last follow-up, the mean angular correction had reduced to 1.3 ± 4.9° of valgus without compromising the rotational correction and the overall good clinical results. All the patients and parents were satisfied, rating the result as excellent or good. There were no major postoperative complications and no reoperations. Eight patients were free from pain and able to perform physical activities suitable for their age. One complained of occasional pain. This procedure has the advantage of allowing both angular and rotational correction with a high degree of success without the need for internal fixation.

Cleidocranial dysplasia (CCD) is inherited as an autosomal dominant disorder characterised by failure of membranous ossification. The condition is due to a mutation of the cbfa1 gene on chromosome 6 which has a role in the development of osteoblasts from the mesenchymal cells. In their growing years, these patients have an unusual shape of the femoral head reminiscent of a ‘chef’s hat’. In order to confirm the consistency of this sign, we have reviewed the radiographs of 28 patients with CCD. All except three had this appearance. The sign was also seen in patients with coxa vara associated with a variety of other conditions. The chef’s hat sign may occur secondary to the particular mechanical environment created by coxa vara as well as abnormal cellular function in patients with CCD. Although coxa vara has some influence on the shape of the femoral head, it is not entirely responsible for its morphology since it was present in only six of the 28 patients with CCD.

Scoliosis seen in the chicken after pinealectomy resembles adolescent idiopathic scoliosis in man. It has been suggested that in both species, deficiency of the pineal hormone, melatonin, is responsible for this phenomenon.

In nine patients with adolescent idiopathic scoliosis and in ten age- and gender-matched controls, the circadian levels of serum melatonin and the excretion of urinary 6-hydroxy-melatonin-sulphate, the principal metabolite of melatonin, were determined. There were no statistically significant differences in the secretion of serum melatonin or the excretion of urinary 6-hydroxy-melatonin-sulphate between the patients and the control group. The hypothesis of melatonin deficiency as a causative factor in the aetiology of adolescent idiopathic scoliosis cannot be supported by our data.

We present the results of the management of 17 relapsed club feet in 12 children using the Ilizarov method with gradual distraction and realignment of the joint. Review at a mean of three years after surgery showed maintenance of correction with excellent or good results in 13 feet. Five mobile feet which had been treated by a split transfer of the tibialis anterior tendon two weeks after removal of the frame had an excellent result.

We performed superselective angiography in 28 hips in 25 patients with Perthes’ disease in order to study the blood supply of the lateral epiphyseal arteries (LEAs). Interruption of the LEAs at their origin was observed in 19 hips (68%). Revascularisation in the form of numerous small arteries was seen in ten out of 11 hips in the initial stage of Perthes’ disease, in seven of eight in the fragmentation stage and in five of nine in the healing stage. Penetration of mature arteries into the depths of the epiphysis was seen in four of nine hips in the healing stage. Vascular penetration was absent in the weight-bearing portion of the femoral head below the acetabular roof. Interruption of the posterior column artery was seen where it passed through the capsule in seven hips when they lay either in internal rotation or in abduction with internal rotation.

We suggest that in Perthes’ disease the blood supply of the LEAs is impaired at their origin and that revascularisation occurs from this site by ingrowth of small vessels into the femoral epiphysis. This process may be the result of recurrent ischaemic episodes.

Between March 1993 and February 1999, 14 children aged from eight months to 14.75 years were admitted to the paediatric intensive-care unit with meningococcal septicaemia in association with severe peripheral ischaemia. Of these, 13 were operated upon, eight of whom had early fasciotomies. Five children died. Of the nine survivors, one had no amputations while in the other eight 14 limb segments were amputated. We review the case histories and propose a protocol for the early management of these children.

We performed intraoperative arthrography of the knee in 12 children with congenital short femur, Blount’s disease or Ollier’s disease in whom the Ilizarov technique was used for correction of deformity, leg lengthening or both.

In each case, arthrography revealed a joint surface considerably different from that assumed from plain radiographs, and resulted in a change in the placement of our reference wires before application of the frame. This gave significant improvement in the mechanical axis obtained at the time of removal of the frame. The technique is safe, cheap and easy to perform. It is a useful adjunct to the application of the Ilizarov frame when used for complex lengthening and correction of deformity in the leg.

We treated 120 children between the ages of 12 and 31 months with 137 developmental dislocations of the hip and reviewed them at a mean follow-up of 14 years.

We had used two-directional arthrography of all hips before reduction to evaluate the anterior, superior, and posterior portions of the limbus. Of the 137 hips, 64 had no interposed limbus in the AP view of the arthrogram, but 45 of these had an interposed anterior or posterior portion of the limbus. The hips with good stability and no interposed limbus in either AP or lateral arthrograms had excellent results by closed methods; in the other cases the results were less satisfactory.

Our findings suggest that hips suitable for management by closed reduction can be identified by two-directional arthrography. Hips shown to have an interposed limbus are best managed by open reduction.

We report the six-year results of a prospective, controlled demographic trial of developmental dysplasia of the hip (DDH) treated in the Pavlik harness using ultrasound supervision. Our aim was to assess the value of ultrasound and its role in monitoring reduction in the harness, in terms of progression or failure of reduction at an early state.

From 1988 to 1994, a total of 221 patients with 370 ultrasonographically abnormal hips was treated in the Pavlik harness. This represents a treatment rate for the Southampton district of 5.1 per 1000 live births. Sixteen hips in 12 patients were not reduced in the harness and required surgical treatment; 95.7% were successfully reduced. One case of mild avascular necrosis (0.3%) was identified in those treated by harness alone. Of the 221 patients 87.8% remain under radiological review, with 3.2% of affected hips showing continued, mild acetabular dysplasia.

We conclude that ultrasound monitoring has led to an acceptably low level of intervention, a high reduction rate and minimal iatrogenic complications. The trial is continuing.

We performed MRI on 13 infants after operative reduction for developmental dysplasia of the hip (DDH). Using an axial gradient-echo sequence, MRI accurately depicted the acetabular anatomy and confirmed adequate reduction in 12 patients. The one patient with redislocation after surgery was correctly identified. MRI can be carried out quickly, inexpensively and without risk of radiation and is the investigation of choice to confirm adequate reduction in DDH.

We reviewed 32 children after the treatment of simple bone cysts by intralesional injections of methyl-prednisolone acetate. The age of the child and the activity and size of the cyst did not significantly affect the radiological outcome. The earliest time at which the radiological response could be reliably determined was three months. After a median period of review of five years, four (13%) cysts had healed, 20 (62%) cysts were partially visible but sclerotic, four (12.5%) were still visible but opaque and four (12.5%) were clearly visible. The healed and partially visible but sclerotic cysts were classified as having satisfactory radiological healing. This was observed in 13 of 32 cysts (41%) after the first injection, in eight of 21 (38%) after the second injection, but in relatively few of the remaining cysts after subsequent injections.

A satisfactory symptomatic outcome was achieved in all of the 18 children with humeral cysts and in the one child with a fibular cyst irrespective of the radiological outcome, but only in nine (67%) of the 13 children with femoral or tibial lesions, in whom the cysts were healed or sclerotic. The remaining four children had exertional bone pain and repeated fractures of their femoral or tibial cysts which were incompletely healed with sclerosis in one and opacities in three.

We conclude that the healing response to intralesional corticosteroids is unpredictable and usually incomplete even after multiple injections. The failure rate in weight-bearing bones is too high.