We reviewed 19 patients (30 feet) with congenital vertical talus treated surgically between 1987 and 1999, 22 of them by the same surgeon.

The etiological diagnosis was idiopathic in seven patients. Six patients had associated congenital abnormalities (four arthrogryposis, two digitotalar dysmorphism) and six had associated neurological abnormalities (three microcephalic, three spinal dysraphism). Only two patients had surgery after the age of 18 months. The mean age at surgery was 14.7 months (6 to 51).

In 15 feet a two-stage procedure was performed. Lengthening of the extensor tendons, notably tibialis anterior, was followed six weeks later by posterior release. In 15 feet a one-stage procedure was done, with no lengthening of the extensors or transfer of tibialis anterior. The Kidner procedure was done in seven feet, but the tibialis posterior was never found to be subluxed and the procedure was abandoned. The calcaneocuboid joint was opened and pinned in eight feet. The peroneal tendons required lengthening in eight feet.

At a mean follow-up of 5.8 years (2 to 13.5), results were excellent in 17 feet (normal forefoot and hind-foot). Results were good in seven feet (normal radiographs, normal hindfoot, but pronated forefoot). In four feet the result was fair (valgus hindfoot with a plantarflexion angle of the talus more than 35(). In one patient, the results in both feet were poor (uncorrected).

All seven good results followed a two-stage procedure. We concluded that this was due to relative weakening of the lengthened tibialis anterior to the peroneus longus. Where necessary, plantarflexion of the talus should be corrected at operation, and this should be correlated with intra-operative fluoroscopy. Adequate reduction of the navicula inferomedially on the talar head obviates the need for tendon transfer.

We retrospectively reviewed 10 children treated for tuberculosis of the elbow over a 21-year period from 1979 to 1999.

The mean age at diagnosis was 5.5 years (1 to 11). The median duration of symptoms was 10 weeks (l week to 18 months). The patients presented mainly with swelling of the elbow joint due to synovitis. Radiological appearances of the elbow at presentation were assessed according to Kerri and Martini’s classification. One elbow was stage I (osteopoenia), eight were stage II (osteopoenia and erosions) and one stage III (joint space narrowing).

Open biopsy was performed on all patients. There was positive histology (caseating granuloma) and/or positive culture in eight patients. Of the two patients with non-specific histology and negative culture, one was found on chest radiograph to have tuberculosis involvement and the other healed on anti-tuberculosis therapy. All patients were treated with rifampicin, isoniazide and pyrazinamide for nine months. No synovectomy was done. Postoperatively all patients were immobilised in a backslab and then actively mobilised.

At a mean follow-up of three years (1 to 10), patients were assessed according to a modification of Kerri and Martini’s classification. Seven of the eight stage-I or stage-II patients had an excellent result (full range of movement) or good result (loss of less than 30% of range of movement). One stage-II patient had a fair result (loss of range of movement of 30% to 50%). The stage-III patient had a poor result (loss of more than 50% of range of movement).

We concluded that elbows with stage-I and stage-II disease (synovitis) have a good outcome. Anti-tuberculosis chemotherapy is effective in the treatment of stage-I and stage II disease. Synovectomy is unnecessary.

In order to assess the incidence of avascular necrosis (AVN) following septic arthritis of the hip in children, we retrospectively reviewed the outcome of 227 hips with septic arthritis treated over an 18-year period. The mean age at presentation of the 221 patients, six of who had bilateral conditions, was 5.6 years (5 months to 14 years).

All patients underwent open arthrotomy and pus was found at surgery. Patients were treated with cloxacillin and patients aged six months to two years also received ampicillin. Staphylococcus areus was cultured in 51% of hips, Haemophilus influenzae in 9%, Streptococcus pneumoniae in 4% and Streptococcus pyogenes in 6%. The remaining 30% had no growth. Septicaemia was present in 20 patients at presentation.

AVN developed in 24 hips (10.5%), and chondrolysis in five (2.2%). Of the hips with AVN, seven were septicaemic. The most important factor in the development of AVN was a delay of five or more days from onset of symptoms to surgery. The risk of AVN with five days’ delay was 50% and increased exponentially with a longer delay. Septicaemia did not constitute a risk per se, but did contribute to a delay in diagnosis of hip involvement. The total head was involved in 14 of the 24 hips with AVN, while 10 had partial head involvement, with a better long-term outcome.

To assess the role of pelvic osteotomy during the closure of bladder and cloacal exstrophy, we retrospectively reviewed 10 patients treated from 1990 to 1999.

Six patients had cloacal exstrophy and four had bladder exstrophy. Two patients had no primary osteotomy. Two had posterior, two anterior pubic and two midiliac oblique osteotomies. Osteotomies were performed at a median age of 5.3 weeks.

The mean follow-up time was five years (2 to 11). We assessed facilitation of closure, reconstitution of pelvic anatomy, maintenance of interpubic distance (IPD), urinary continence and gait.

All osteotomies facilitated soft tissue closure at the time of surgery. Subjectively, the best restoration of pelvic anatomy was with a midiliac oblique osteotomy. In all patients, IPD increased progressively with increasing age (mean pre-operatively 3.3 cm, postoperatively 1.9 cm and 5.0 cm at follow-up).

The results of soft tissue surgery to provide continence and maintain abdominal wall closure were poor. All procedures to address incontinence failed and there was a 100% dehiscence/sepsis rate. Although half the children had increased external rotation of the hip at review, only one child had an externally rotated joint. .

We retrospectively reviewed 52 children treated for tuberculosis of the knee in the 21-year period 1979 to 1999.

The mean age at which the condition was diagnosed was 5.3 years (8 months to 13 years). The median duration of symptoms was four weeks (1 month to 3 years). All patients presented with swelling, mainly owing to synovitis. Pain was a symptom in only two thirds of patients.

Using Kerri and Martini’s classification of radiological appearances, 33 knees were stage I (osteopoenia), 15 stage II (osteopoenia with erosions), two stage III (joint space narrowing) and two stage IV (joint space narrowing with anatomical disorganisation). All knees had either positive histology (caseating granuloma) and/or a positive culture for tuberculosis.

Treatment was with rifampicin, isoniazide and pyrazinamide for nine months. No synovectomy was done. Of the 48 knees with stage-I and stage-II disease, 22 were immobilised for at least three months and 26 actively mobilised.

At a mean follow-up of five years (2 to 16 years), the results were classified according to Wilkinson. All stage-I and stage-II knees had an excellent result (full range of motion) or good result (more than 90° of flexion). Stage-III and stage-IV knees had a fair result (less than 30°of flexion) or poor result (ankylosis). In stage-I and stage-II knees, immobilisation did not affect outcome.

In the same period, 25 knees with a non-specific histology and negative culture presented the problem of the differential diagnosis between tuberculosis and particular juvenile rheumatoid arthritis (JRA). Of these 17 were subsequently diagnosed as JRA. A histological study assessed the value of synovial lining (SLC) hyperplasia. The sensitivity of SLC hyperplasia for JRA was only 53%. Synovial biopsies from 10 joints with tuberculosis (positive histology or culture) were subjected to the polymerase chain reaction test. The sensitivity was only 40% for tuberculosis.