Purpose of the study

To evaluate the outcome of the Modified French osteotomy for the correction of cubitus varus resulting from a supracondylar distal humerus fracture in children.

Aim

To determine the preferable treatment for congenital pseudarthrosis of the tibia, we retrospectively reviewed 19 patients (20 limbs) treated consecutively over a 22 year period (1988–2007). Fifteen were followed up to maturity. The patients were assessed for union, leg length discrepancy (LLD), ankle valgus, range of ankle movement and distal tibial physeal injury.

Purpose of the Study:

Spontaneous intraarticular haemorrhages are the most frequent bleeding episodes encountered in the haemophiliac population, causing pain, joint deformity and arthropathy. Chronic haemophiliac arthropathy is characterised by persistent joint swelling, proliferative synovitis, and damage to or loss of articular cartilage. Elimination of the synovitis is the key to prevention of recurrent intraarticular haemorrhages and joint damage. The purpose of the study was to investigate the indications for, and outcome of, radioactive synoviorthesis for haemophiliac arthropathy.

Purpose of study

Serial manipulations and casting for the treatment of congenital clubfoot has long been the practice internationally. There are, however, a great variety of manipulative techniques being practiced with differing results. We aim to determine how the rate of major surgery, ie. a full posteromedial-release (PMR), as initial surgical intervention has changed since introducing the Ponseti method of plastering at our centre in 2002. We also aim to determine whether pre-operative radiographs have any bearing on the type of surgery performed.

Purpose

The outcome of idiopathic chondrolysis in South Africa has been reported as a progressive downhill course resulting in a painful, stiff hip (Jones 1971, Sparks&Dall 1982). The cause of the disease remains unknown. Theories suggested are mechanical (decreased movement with loss of synovial nutrition; increased joint pressure) and an auto-immune response in genetically predisposed individuals. Our experience with continuous passive motion (CPM) and anti-inflammatory treatment has been disappointing.

Single screw fixation for the management of slipped upper femoral epiphysis (SUFE) was introduced in 1984 and has been reported to have less chondrolysis and avascular necrosis (AVN) than previous methods using multiple pin fixation or osteotomy (Ward 1992). Two groups of patients were investigated. The first group of 55 hips (44 patients) were treated over a 27 year period (1963–1989). Forty four hips were treated with multiple pins and 11 hips with primary intra- or extracapsular osteotomy. These patients were followed up for an average of 8 years (3–27yrs). The second group of 88 hips (69 patients) were treated over a 6 year period (1999–2004). All were treated with single screw fixation and followed up for at least one year.

The duration and severity of slip were found to be similar for both groups. In the second group 16 hips (20%) were unstable (unable to walk even with crutches). Instability had not been coined as a term in the first group. All serial radiographs were retrospectively reviewed for AVN and chondrolysis and correlated with clinical findings. In the first group AVN occurred in 8 hips (14.5%). Five (9%) were due to osteotomies, two (3.5%) due to manipulation and one (2%) due to pinning in the superior quadrant. Chondrolysis occurred in 14 hips (25%); eight (14%) at presentation and six (11%) due to persistent pin penetration. In the second group AVN occurred in two hips (2%). Both were unstable. Two of 16 unstable hips (12.5%) developed AVN. Chondrolysis occurred in 6 hips (7%); four (4.5%) at presentation and 2 (2.5%) due to persistent pin penetration.

The authors conclude that single screw fixation is a safer technique than multiple pin fixation or osteotomy. AVN only occurred in unstable slips. Chondrolysis due to pin penetration is significantly reduced.

Forearm lengthening in children is controversial. Paley (1990) and Peterson (1994) advocate aggressive treatment of the deformity for cosmetic and functional reasons. Scoenecker (1997) has shown that mature patients are comfortable with their appearance and functional deficit.

We reviewed 8 forearm lengthenings performed in 8 children in the 14 year period from 1991 to 2004. Five patients had ulnar shortening (osteochondromata = 4, growth arrest due to trauma = 1). Of the three patients with radial shortening, one was due to a congenital short radius and two following growth arrest (post trauma and meningococcal septicemia). The shortening resulted in a cosmetically unacceptable ulnar or radial tilt with absent radial or ulnar deviation of the wrist and decreased supination and/or pronation. One patient with a proximal ulnar osteochondroma had a dislocation of the radial head with cubitus varus.

Excision of the osteochondroma was done 6 months prior to lengthening. Lengthening was accomplished with two Ilizarov rings and a distal corticotomy for radial and proximal for ulnar shortening. Reduction of the dislocated radial head was achieved with an olive wire. Associated procedures were: hemiepiphyseal stapling of the distal radius for an increased radial articular angle in 3 patients with osteochondroma, and corrective osteotomy of the distal radius in 1 patient with growth arrest. The average lengthening obtained was 23 mm (range 13–40 mm) with an average lengthening index of 1.45 months per cm.

At an average follow-up of six years (range 2–15 years; 7 to maturity) all patients were satisfied with the cosmetic improvement and had full radial and ulnar deviation. Except for two patients the supination/pronation was improved. We concluded the forearm lengthening is warranted for cosmetic and functional reasons.

Physeal bar resection for partial growth plate arrest was first described by Langenskjold in 1967. The initial enthusiasm by Peterson (1989) who found that 83% of patients resumed physeal growth was tempered by Birch (1992) who only had 33% success. Poor results were due to failure to resume growth or premature growth arrest.

We retrospectively reviewed 21 physeal bar resections performed in 19 children from 1987 to 2003. The average age at surgery was 8.2 years (range 3–12 years). The aetiology of the physeal arrest was : growth plate fracture (8), meningococcal septicaemia (5), osteitis (3; 2 neonatal), dysplasia (3), gunshot (1) and idiopathic (1). The commonest site was the distal femur (12; 5 due to growth plate fracture), followed by the proximal tibia (5; 3 due to meningococcal septicaemia), and the distal tibia (4; 2 due to growth plate fractures). Assessment of the size and location of the bar was with biplanar tomography in 7, MRI in 5 and both in 7. We found equal accuracy with both modalities, but currently prefer MRI. The bar was plotted on an anterior-posterior and lateral map of the growth plate. The average size of the bar was 25% (range 15 to 50%) of the area of the growth plate. Only 3 bars were larger than 30%. Fifteen of the bars were peripheral, 5 linear and 1 central.

Results were classified poor if there was no resumption of growth or if premature growth plate arrest occurred, good if there was resumption of growth which continued to maturity or to follow-up, and excellent if the growth exceeded the expected growth. There were 5 (24%) poor results; all failed to resume growth. Three bars exceeded 30% and 2 were due to meningococcal septicaemia. The remaining 16 bars were followed up for a range of 2 to 12 years; 10 to maturity. Four (19%) had an excellent and 12 (57%) had a good result.

The authors conclude that physeal bar resection is a worthwhile procedure if the size of the bar is equal to or less than 30% of the area of the growth plate. In growth arrest due to meningococcal septicaemia we only had a 60% success rate.

Tarsal coalition has been well recognized as the commonest cause of peroneal spastic flat feet in children and adolescents (Mosier and Asher 1984). Other rare causes are tuberculosis and rheumatoid arthritis. If no etiology can be found the term idiopathic peroneal spastic flat foot has been coined by Schoenecker (2000).

We prospectively assessed all children and adolescents with peroneal spastic flat feet seen at our clinic in the period 2002 to 2004. Twelve patients (17 feet) were assessed. The average age was 11,9 years (range10 to15years). Seventy five percent of the patients were above the 95th percentile weight for age. Screening for tuberculosis (ESR, Mantoux and chest radiograph) was negative in all patients. Rheumatoid factor was positive in one patient with juvenile idiopathic arthritis (JIA). Radiology was standardized. Plain radiographs were standing lateral and 45 degree oblique views. CT and MRI:

axial: parallel to plantar surface;

This latter view best illustrates a talocalcaneal coalition (Newman 2000).

Two patients (four feet) had a calcaneonavicular coalition on the 45 degree oblique plane radiographs. This was also shown on the axial CT and MRI views. No talocalcaneal coalition was visualized on the coronal oblique CT and MRI views. In order to find a diagnosis and to confirm the accuracy of the MRI and CT, the middle facet of the talocalcaneal joint was explored in eight feet and a synovial biopsy done. No talocalcaneal coalition was found. JIA was histologically confirmed in one patient.

The authors concluded that the idiopathic type is by far the commonest peroneal spastic flat foot seen in our clinic. The 45 degree oblique plain radiograph is as accurate as axial CT and MRI to diagnose calcaneonavicular coalition. The coronal oblique CT and MRI views are equally accurate to exclude a talocalcaneal coalition.

Over the five years 1997 and 2001 we evaluated five children (age range 10 to 14 years) with pathological femoral fractures due to rickets. All had quadriplegic cerebral palsy, and all were at home rather than in institutions. Four had been on long-term anticonvulsant therapy (ACT).

Radiographs showed typical features of rickets, with osteopoenia, cupping of metaphyses and widened growth plates. Biochemical analysis showed mean serum calcium of 1.87 mmol/l (1.71 to 2.2 – the normal range is 2.05 to 2.64), mean serum phosphate of 0.6 mmol/l (0.3 to 0.98 – the normal range is 1.0 to 1.85), and mean alkaline phosphatase of 1272 IU/l (414 to 2135 – normally less than 360).

The fractures were treated with Thomas splint traction or spica immobilisation. The rickets was treated with daily vitamin D (4000 IU) and calcium (1000 mg) for 3 months. The rickets healed radiologically at 2 months and the fractures united at 3 months.

For long-term prophylaxis a multifactorial therapeutic approach was adopted, entailing increasing exposure to sunlight, increasing dairy product intake, and changing the ACT to sodium valproate, which is less enzyme-inducing. No vitamin D supplementation was given.

At a mean follow-up of 3 years (2 to 8) no further fractures had occurred, and radiology and biochemistry were normal.

We assessed three children who had limb salvage surgery for sarcomata of the proximal fibula. Their ages ranged from 6 to 13 years. MRI showed involvement of the anterior, lateral and deep posterior compartments. Incisional biopsy showed two osteoblastic osteosarcomata and one Ewing’s sarcoma. Preoperative angiogram confirmed that the tibialis posterior artery was the main blood supply to the foot.

The surgical technique was as described by Malawer (1984): via an anterolateral incision, the anterior, lateral and deep posterior compartments were excised en bloc with the proximal fibula. The peroneal artery was sacrificed in all three patients, and the common peroneal nerve and tibialis anterior artery in two. In the patient with Ewing’s sarcoma, the tibialis anterior muscle, artery and nerve did not require excision. What remained were the tibialis posterior nerve and artery, gastrocnemius, flexor digitorum longus and most of soleus. The lateral gastrocnemius was rotated forward to fill the defect. The collateral ligament of the knee was reconstructed by suturing the lateral collateral ligament and biceps femoris to the proximal tibia.

All three patients had neo-adjuvant chemotherapy. Tumour necrosis ranged from 90% to 100%.

At follow-up at 2, 4 and 9 years, there was no recurrence. The Musculoskeletal Tumour Society evaluation was used and all patients scored more than 80% and were happy with the cosmetic result. Although two of the three patients required an orthotic because of weak dorsiflexion, the functional result was good.

We reviewed 600 children with 640 sites of acute haematogenous osteomyelitis treated between 1983 and 2002. Neonates and patients with septicaemia were excluded.

The mean age of the children was 7 years (3 months to 13 years). The male to female ratio was 2.3:1.

The diagnosis was made clinically and with the help of special investigations. The while cell count was elevated in 75% and the ESR in 98%. Blood cultures were positive in 79%. Radiographs showed metaphyseal rarefaction and/or periosteal reaction in 19% and isotope scan was positive in 43%. No aspiration was done to establish the diagnosis. In nine sites (1.5% of operated sites) the diagnosis was regarded as incorrect (no growth or subsequent bony changes on radiographs).

The distal femur was the most common site (25%), followed by the distal tibia (20%), proximal tibia (19%), proximal femur (7%), proximal humerus (5%), forearm (5%), distal fibula (4%), pelvis (4%), calcaneum (3%) and other (8%). Staphylococcus aureus was cultured in 89% of sites.

Treatment was with intravenous cloxacillin, followed by oral flucloxacillin for 6 weeks. Surgery was performed at 94.5% of sites. The 5.5% sites that were not operated upon were in the pelvis or were early limb sites with no swelling. At surgery, 21% of sites were found to have intra-osseous pus. In the remaining 79%, there was subperiosteal pus at 41% of sites and extraperiosteal pus at 38%. Patients were followed up until adequate bone stock was present on radiographs and no sinus or sequestrum was present. Poor results (sequestrum and/ or pathological fracture) occurred in 8.3% (53 sites). Poor results were not site-specific, but 99% occurred in patients with subperiosteal or extraperiosteal pus.

We reviewed 821 children with 869 sites of septic arthritis treated from 1983 to 2002. Neonates and patients with septicaemia and penetrating injuries were excluded.

There were two age groups: 46% of the children were two years or younger (mean 1.1 years) and 54% were between 3 and 12 years (mean 6.8 years). The male to female ratio was 1.7:1.

The diagnosis was made clinically and with the help of special investigations. The white cell count was elevated in 67% and the ESR in 96%. Blood culture was positive in 28%. Radiographs demonstrated widening of joint spaces in 19% and isotope bone scan was positive in 11% of sites, mainly in the hip. No diagnostic joint aspiration was done. In 42 sites (4.6%) the diagnosis was regarded as incorrect because there was no growth or white cells.

The most common site of septic arthritis was the knee (37%), followed by the hip (30%), ankle (14%), elbow (10%), shoulder (5%), wrist (3%) and subtalar joint (1%).

Treatment was with open arthrotomy and antibiotics (cloxacillin and/or ampicillin). Bacteriologically the most common finding was no growth (50% in each age group). In the younger group the most common finding was Haemophilus influenzae (24.5%). Staphylococcus aureus was found in 37% of the older group. From 2000 the incidence of H. influenzae declined, probably owing to the introduction of vaccine in 1998.

Results at 30 sites (3.5%) were poor. There was avascular necrosis in 18 hips, chondrolysis in five hips and three ankles, and stiffness in two knees, an ankle and a subtalar joint.

Further analysis showed that poor results were more likely to occur in older patients with S. aureus and where there was a delay in treatment. Where good results were achieved, the mean delay was 3.5 days. It was 9.3 days where results were poor.

We retrospectively reviewed 45 children treated between 1987 and 2002. Their mean age was 9 years (3 to 13). Fifteen patients had subacute osteitis. Only patients with Bledhill and Roberts type II, III and IV were included. Biopsy provided histological proof of subacute osteitis in nine patients, and six were successfully treated non-surgically with flucloxacillin. Six patients had Ewing’s sarcoma, 24 had osteosarcoma, 23 Enneking stage-IIB (extracompartmental) and one Enneking stage-IIA (intracompartmental).

The preoperative clinical signs, radiographs and MRI studies were reviewed. On plain radiographs, cortical destruction and periosteal reaction were assessed. On MRI the extent and nature of bone marrow involvement and the size of the soft tissue mass/oedema was analysed and correlated clinically. On plain radiographs, cortical destruction was present in all patients with Ewing’s sarcoma and stage-IIB osteosarcoma and in 50% of patients with subacute osteitis. An ill-defined zone of transition was found in all patients with Ewing’s sarcoma and osteosarcoma and in 50% of those with subacute osteitis. These findings therefore did not help to differentiate between the two groups.

The periosteal reaction was well-defined in subacute osteitis and lucencies between laminations were thin. In the malignant group the periosteal reaction was always ill-defined, with or without a Codman’s triangle, sunray spicules and hair-on-end. Lucencies between laminations were broad and broken. This was useful in differentiating between the two groups.

On MRI, patients with subacute osteitis had no soft tissue mass, with an infiltrative type of bone marrow involvement. In the malignant group, the soft tissue mass was large and the bone marrow involvement well demarcated.

We concluded that where there was a well-defined periosteal reaction on plain radiographs, and no soft tissue mass with infiltrative bone marrow involvement on MRI, patients could initially be treated as subacute osteitis without biopsy.

This is an ongoing retrospective study of 35 children treated from 1986 to 2001 for chronic osteomyelitis following acute haematogenous osteomyelitis. The purpose was to validate the use of a modified Cierny classification to predict behaviour, to assess the timing of sequestrectomy in relation to involucrum formation, and to evaluate the results of dealing with the resultant defect by conventional methods of bone grafting.

The mean age of the patients was 7 years (1 to 12). All except 18, who were treated within five days of acute onset, were delayed presentations or transfers. In 14 children the tibia was involved, in 13 the femur, in five the humerus and in three the fibula. Monthly radiographs were taken and the size and location of the sequestrum and involucrum was documented.

Our classification represents the size and location of the sequestrum. We divided the patients into cortical (one), medullary (three), corticomedullary (12) and structural (19) types. Fractures occurred in all the structural types, as well as in five of the 12 corticomedullary types. A sequestrum was apparent at a mean of 2.4 months (1 to 3). The mean length of the sequestrum at diagnosis was 8.5 cm and at surgery 5.8 cm, suggesting partial resorption. Involucrum formed in 69% of patients at a mean of 1.9 months (1 to 3) after sequestrum. In 31% of patients no involucrum formed from 4 to 12 months after surgery. This suggests that involucrum formation depends on viable periosteum and not on the sequestrum, and in the absence of involucrum early rather than late sequestrectomy is warranted.

The resultant incomplete bone defects in the corticomedullary type ranged from 1 cm to 15 cm, but had an intact cortical bed on one or more sides. These and complete defects of less than 6 cm in the structural type united after autogenous cancellous bone grafting, with or without an exoskeleton. Four structural defects greater than 6 cm united after fibular strut grafting (humerus) or bone grafting from fibula to tibia via a posterolateral approach (tibia).

Patients were followed up both clinically and radiologically for a mean of 2.9 years. Twenty patients (57%) had an excellent result and 15 (43%) a good result.

In a prospective study we assessed the accuracy of 3D-CT in defining the acetabular deficiency in developmental dysplasia of the hip (DDH), comparing pre-operative 3D-CT with plain radiographs, intraoperative stability testing and intraoperative acetabular morphology.

Twenty children (25 hips) with DDH who had open reduction and/or pelvic osteotomy from 1999 to 2001 were studied. On 3C-CT the morphology of the deficiency was described as normal, anterolateral deficient (overlapping shadows), lateral (increased acetabular index only) and global (double acetabulum). At open reduction, the position in which the hip was most stable with axial loading was assessed (Zadeh and Caterall, 2001). The surgeon’s assessment of the acetabular morphology intraoperatively was the standard against which the other modalities were tested. One hip was normal, five had a global and 19 an anterolateral deficiency.

3D-CT correlated well with the acetabular morphology (84%). Plain radiography correlated poorly, especially with the global type (60%). Mid-superior appearance on 3D-CT and lateral appearance on plain radiograph equated with an anterolateral deficiency morphologically. In the global type the hip was unstable in all positions, while the anterolateral type, while in the anterolateral type the hip was always stable in flexion and abduction and in only 31% of hips stable also in abduction and internal rotation.

The mean age at surgery was 3 years (1 to 7). The one hip with a normal acetabulum required open reduction only, the five global types an acetabuloplasty (Tonnis), and the 19 hips with anterolateral deficiency a redirectional (Salter) osteotomy.

3D-CT is helpful in appropriate osteotomy for a specific type of acetabular deficiency in DDH.

The results of 34 knees with stage IV to VI Blount’s disease were reviewed. 24 patients were treated over the seven-year period from 1994 to 2000.

The surgical technique addressed the medial joint line depression with an elevating osteotomy maintained with a tricortical wedge from the iliac crest. The tibial varus and intorsion was corrected with an osteotomy proximal to the apophysis. In the more recent patients a proximal lateral tibial and fibular epiphyseodesis was done concomitantly. The average preoperative mechanical varus angle of 30.6°(range 14° to 60°) was corrected to 0–4° mechanical valgus in 29 knees. In five knees an undercorrection of 2–4° mechanical varus occurred. At follow-up a further 8 knees developed residual varus due to a delayed epiphyseodesis. The tibial varus angle (ie. angle subtended by the mechanical axis of the tibia with the lateral tibial joint line) increased at an average of 1°/ month due to the inevitable medial growth plate fusion.

The average pre operative joint depression angle of 49° (range 40° to 60°) was corrected to an average of 26°(mean 20°–30°). There was no significant preoperative frontal plane f emoral deformity to warrant a femoral correction. At long term follow up of 3.5 years (range 2 to 5 years) all knees had a full range of movement without any varus instability. However in eight cases a delay of more than six months occurred before a lateral epiphysiodesis was performed, and in these patient’s mechanical axis varus recurred although the joint line correction was maintained. Neutral or valgus mechanical axis was maintained in all patients who underwent an epiphysiodesis within six months.

We concluded that although the joint elevation correction was maintained in our series, mechanical axis varus recurs if lateral epiphysiodesis is not performed early.

After tuberculosis of the spine, hip and knee, tuberculosis of the foot and ankle is the most common occurring area of skeletal tuberculosis seen in our unit. We retrospectively reviewed 14 patients (14 feet and/or ankles) seen over the 16-year period 1982 to 1997.

The average age of the children was 5.2 years (range 1.5 to 11 years). The duration of symptoms ranged from 1 week to 1 year. The most common presentation was swelling and pain of the involved joint, but three patients each presented with a chronic discharging sinus after being drained elsewhere as an acute abscess. Radiographs revealed osteo-penia with or without lytic areas, joint margin destruction or joint space narrowing. The average sedimentation rate (ESR) was 52.3 mm/hour (range 9 to 120). The Mantoux test was positive in 13 out of the 14 patients. Chest x-rays demonstrated latent or active tuberculosis in 50% of patients. Open biopsy was performed in all patients. Hypertrophic synovium was found in all cases except one, where atrophic tuberculosis with joint space narrowing was present. A positive diagnosis of tuberculosis was made in all cases, either by demonstrating caseating granulomatous tissue on histology, or by growing a positive culture for mycobacterium tuberculosis or both. Histology was positive in 86%, acid-fast bacteria were seen in 28.5% and a positive culture was obtained in 82% of the patients.

At an average follow up of 7.4 years (range 1 to 17 years) all patients were assessed both clinically and radiologically. Patients with lytic lesions and destruction of joint margins reconstituted well radiologically, had a good clinical outcome with a good range of movement of the affected joint, however the one patient with atrophic tuberculosis remained with a narrowed joint space, stiffness and a poor clinical result compared to the rest.

We reviewed 16 metaphyseal-diaphyseal junction (MDJ) fractures treated over the four-year period 1997 to 2000. MDJ fractures occur in the area proximal to the supracondylar fossae and distal to the intersection of the metaphyseal flange and diaphysis of the humerus.

MDJ fractures are far less common than displaced classic supracondylar (SC) fractures: on average we see four MDJ and 80 SC fractures a year. The mean age of patients with MDJ fractures is 4.8 years, while the mean age of patients with SC fractures is 6.3 years. MDJ fractures are more often the result of a violent force: 56% occurred in falls and 38% in pedestrian traffic accidents, while 100% of SC fractures were due to falls. Only 1% of SC fractures were compound, while 13.5% of MDJ fractures were. MDJ fractures were of the extension type in 63% and of the flexion type in 37%. Only 3.7% of SC fractures were of the flexion type.

We treated four of the 16 MDJ fractures conservatively in a U-slab and 12 with percutaneous pinning (three with cross pinning, nine with one or both pins up the intramedullary shaft).

At a mean follow-up of two years (1 to 4) there were 11 satisfactory and five poor results. Three of the four patients managed conservatively had a poor result with varus malunion. The other two poor results were in percutaneously pinned fractures. One was pinned in varus and one refractured after the pins were removed at three weeks.

We conclude that MDJ fractures are distinct from SC fractures, and that percutaneous pinning is the best form of treatment. Because the fractures are more diaphyseal, immobilisation for four weeks rather than three is advised to prevent refracture.

We reviewed the results in 24 children (34 knees) following double-elevating osteotomy for late presenting infantile Blount’s disease.

The mean age of our seven male and 17 female patients was 9.1 years (7 to 13.5). Obesity was noted in 15 (above the 95th percentile). Previous valgus osteotomy had been performed on nine knees.

Ten knees were Langenskîld stages IV, six stage V and 18 stage VI. The surgical technique addressed the medial joint line depression with an elevating osteotomy, which was maintained by insertion of a tricortical wedge from the iliac crest and the excised fibula. The tibial varus and internal torsion was corrected with an osteotomy proximal to the apophysis. In the more recent patients, a proximal lateral tibial and fibular epiphysiodesis was done concomitantly.

The mean preoperative mechanical varus of 30.6( (14( to 60() was corrected to 0( to 4( mechanical valgus in 29 knees. In five knees there was under-correction to 2( to 4( mechanical varus. At follow-up a further eight knees developed varus owing to late epiphysiodesis. The tibial varus angle (the angle subtended by the mechanical axis of the tibia and a line along the lateral tibial joint line) increased at a mean of 1( a month due to inevitable medial growth plate fusion.

The mean preoperative joint depression angle of 49( (40( to 60() was corrected to 26( (20( to 30(), which was maintained at follow-up. There was no noteworthy femoral valgus or varus present preoperatively to warrant femoral osteotomy.