Dysplasia epiphysealis hemimelica of the left proximal femur was diagnosed in an eight-month-old girl. At the age of 18 months, radiographs of the hip and MRI showed overgrowth and loss of containment of the femoral head. She underwent resection of the superior portion of the head and neck of the femur at the age of 2.5 years. Six months later further radiographs and an MR scan show that the mass has increased in size and that hip containment has been lost. Further plain radiographs have shown that the left knee, ankle and spine were involved. To the authors’ knowledge, this is the first report of dysplasia epiphysealis hemimelica involving both the lower limb and the spine. A review of the literature is presented

Stature and its components were examined in 143 girls aged 11 to 15 years with adolescent idiopathic scoliosis. Correction was made for loss of height due to the lateral spinal curvature, and the findings were compared with those from 202 healthy girls of similar age. Using three components of stature (suprapelvic, pelvic and subischial heights) we were able to show that the relatively greater stature of girls with adolescent idiopathic scoliosis was due to changes in the pelvis and lower limbs but not significantly in the spine. Suprapelvic height was reduced relative to subischial height; this probably represents the growth pattern of predominantly ectomorphic individuals, reflecting the physique of many of these girls. Pelvic height was disproportionately increased, and this is considered to be a true rather than an apparent difference. Cephalocaudal disproportion involving two segments suggests a common mechanism of causation which is unlikely to be secondary to the scoliosis. These physical features may in some way be associated with a predisposition to progression of the scoliosis

We report a case of fatal pulmonary embolism following a simple ankle fracture in a 17-year-old girl. The diagnosis was confirmed at post-mortem. The risk factors for deep venous thrombosis and pulmonary embolism and their significance in orthopaedic fracture management are discussed

Lumbar disc herniation (LDH) is uncommon in youth and few cases are treated surgically. Very few outcome studies exist for LDH surgery in this age group. Our aim was to explore differences in gender in pre-operative level of disability and outcome of surgery for LDH in patients aged ≤ 20 years using prospectively collected data.

From the national Swedish SweSpine register we identified 180 patients with one-year and 108 with two-year follow-up data ≤ 20 years of age, who between the years 2000 and 2010 had a primary operation for LDH.

Both male and female patients reported pronounced impairment before the operation in all patient reported outcome measures, with female patients experiencing significantly greater back pain, having greater analgesic requirements and reporting significantly inferior scores in EuroQol (EQ-5D-index), EQ-visual analogue scale, most aspects of Short Form-36 and Oswestry Disabilities Index, when compared with male patients. Surgery conferred a statistically significant improvement in all registered parameters, with few gender discrepancies. Quality of life at one year following surgery normalised in both males and females and only eight patients (4.5%) were dissatisfied with the outcome. Virtually all parameters were stable between the one- and two-year follow-up examination.

LDH surgery leads to normal health and a favourable outcome in both male and female patients aged 20 years or younger, who failed to recover after non-operative management.

Cite this article: Bone Joint J 2015;97-B:1675–82.

Aims. Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room. Methods. A randomized controlled trial was conducted. A total of 255 patients were included, aged five to 17 years, who needed plaster treatment for a fracture of the upper or lower limb. Randomization was stratified for age (five to 11 and 12 to 17 years). The intervention group was distracted with VR goggles and headphones during the plaster treatment, whereas the control group received standard care. As the primary outcome, the post-procedural level of anxiety was measured with the Child Fear Scale (CFS). Secondary outcomes included the children’s anxiety reduction (difference between CFS after and CFS before plaster procedure), numerical rating scale (NRS) pain, NRS satisfaction of the children and accompanying parents/guardians, and the children’s heart rates during the procedure. An independent-samples t-test and Mann-Whitney U test (depending on the data distribution) were used to analyze the data. Results. The post-procedural CFS was significantly lower (p < 0.001) in the intervention group (proportion of children with no anxiety = 78.6%) than in the control group (56.8%). The anxiety reduction, NRS pain and satisfaction scores, and heart rates showed no significant differences between the control group and the intervention group. Subanalyses showed an increased effect of VR on anxiety levels in young patients, females, upper limb fractures, and those who had had previous plaster treatment. Conclusion. VR effectively reduces the anxiety levels of children in the plaster room, especially in young girls. No statistically significant effects were seen regarding pain, heart rate, or satisfaction scores. Cite this article: Bone Joint J 2024;106-B(7):728–734

There is a need for non-radiographic, objective outcome measures for children with Adolescent Idiopathic Scoliosis (AIS). Standing balance and stability is altered in children with AIS. The Margin of Stability (MoS) has been used to compare gait stability in clinical populations. Our objective was to compare the MoS in anterior-posterior (MoS. AP. ) and mediolateral (MoS. ML. ) directions in girls with AIS to Controls. Girls with AIS and healthy girls walked at three speeds on an instrumented treadmill wearing retroreflective markers, surrounded by motion capture cameras. The MoS. AP/ML. was calculated at left and right heel strike. Data was processed in Visual 3D. A two-way ANOVA was used to compare MoS. AP/ML. between group, speed and the interaction between group and speed. Pearson's correlation coefficient was used to compare the MoS to Cobb angle. Statistical significance was accepted when p > 0.05. A priori power analysis suggested 12 participants per group. Three Cases and four Controls were recruited. Girls with AIS all had right-sided main thoracic curves (Lenke type 1a, 61.3° ± 10.0°). MoS. AP. was significantly bigger for Cases compared to Controls on the left (p=0.038) and right foot (p=0.041). There was no significant difference between Cases and Controls for MoS. ML. , but there was a visual trend for a smaller MoS. ML. in Cases. There was no significant difference for speed or the interaction between group and speed for MoS. AP. or MoS. ML. In Cases, MoS. AP. increased with increasing Cobb angle on the left (r. 2. =0.687, p=0.054) and right (r. 2. =0.634, p=0.067) and MoS. ML. decreased with increasing Cobb angle on the left (r. 2. =-0.912, p=0.002). Further subjects are being recruited. Girls with Lenke type 1a AIS are more stable in the AP direction and less stable in the ML direction than Controls during treadmill walking. AP stability increases and ML stability decreases with increasing Cobb angle. This research suggests that the MoS could be used as an outcome measure for children with AIS. Continued work is required to increase the power of this study. Further work could consider these changes during walking overground, measuring an MoS or MoS-like measure using a wearable device, and in different curve types

Objectives. The development of tibiofemoral angle in children has shown ethnic variations. However this data is unavailable for our population. Methods. We measured the tibiofemoral angle (TFA) and intercondylar and intermalleolar distances in 360 children aged between two and 18 years, dividing them into six interrupted age group intervals: two to three years; five to six years; eight to nine years; 11 to 12 years; 14 to 15Â years; and 17 to 18 years. Each age group comprised 30 boys and 30 girls. Other variables recorded included standing height, sitting height, weight, thigh length, leg length and length of the lower limb. Results. Children aged two to three years had a valgus angulation with a mean TFA of 1.8° (. sd. 0.65) in boys and 2.45° (. sd. 0.87) in girls. Peak valgus was seen in the five- to six-year age group, with mean TFAs of 6.7° (. sd. 1.3) and 7.25° (. sd. 0.64) for boys and girls, respectively. From this age the values gradually declined to a mean of 3.18° (. sd. 1.74) and 4.43° (. sd. 0.68) for boys and girls, respectively, at 17 to 18 years. Girls showed a higher valgus angulation than boys at all age groups. Conclusion. This study defines the normal range of the TFA in south Indian boys and girls using an easy and reliable technique of measurement with a standardised custom-made goniometer. Cite this article: Bone Joint Res 2013;2:155–61

Background. Surgical treatment of AIS includes several purposes such as arrest deformity progression through a solid fusion, obtain a permanent correction of the deformity and others. Objectives. To evaluate the improvement of sagittal spinopelvic parameters and clinical outcomes in patients with adolescent idiopathic scoliosis 2 years after corrective surgery. Methods. Radiological and clinical data of 134 consecutive scoliosis patients including 11 boys and 124 girls with the average age of 15.37 years, with AIS Lenke 1, 2, 3, 4, 5 or 6 were included in this retrospective study with 2-year follow-up. Whole spine anterior/posterior and lateral Xray, CT scan and MRI were taken preoperatively, immediately after surgery, at 3 months and 2 years after corrective surgery. Radiological parameters were evaluated and compared pre and post operatively. Result. In coronal plan, significant reduction was observed in main curve, proximal curve and distal curve P<0.001, 2 years after corrective surgery. Meanwhile, the translation of apex vertebra decreased p<0.001. But sagittal profile of the patients did not show obvious changes such as LL, TK. The pelvic parameters indicated that PI was 50.6 degrees, PT was 13.8, SS was 37.0 and TPA was 47.5 degrees preoperatively. Vertebral body height increased dramatically just after surgery and showed further in the last follow up. Conclusion. The changes in coronal plan was significant 2 years after correction surgery for AIS patients and were not correlated with restoration of sagittal profile. Conflict of interest. None. Sources of funding. None

To analyze the dynamics of the thoracic spine during deep breathing in AIS patients and in healthy matched controls. Case-control cross-sectional study. 20 AIS patients (18 girls, Cobb angle, 54.7±7.9°; Risser 1.35±1.2) and 15 healthy volunteers (11 girls) matched in age (12.5 versus 15.8 yr. mean age) were included. In AIS curves, the apex was located in T8 (14) and T9 (6). Conventional sagittal radiographs of the whole spine were performed at maximal inspiration and expiration. The ROM of each spinal thoracic functional segment (T1-T7, T7-T10, T10-T12), the global T1–T12 ROM were measured. Respiratory function was assess by forced vital capacity (FVC), expiratory volume (FEV1), FEV1/FVC, inspiratory vital capacity (IVC) and peak expiratory flow (PEF). In healthy subjects, the mean T1–T12 ROM during forced breathing was 16.7±3.8. AIS patients showed a T1-T12 ROM of 1.1±1.5 (p<0.05) indicating a sagittal stiffness of thoracic spine. A wide T7–T10 ROM (15.3±3.0) was found in healthy controls (91.6% of the T1–T12 ROM). AIS patients showed only 0.4±1.4 ROM at T7-T10 (36.4% of the T1–T12 ROM) (p<0.001). There was a significant correlation between T7-T10 ROM and IVC. Lenke 1A AIS patients show a restriction of the thoracic spine motion with an almost complete abolition of T7-T10 ROM, a crucial segment participating in the deep breathing. T7-T10 stiffness could explain the ventilatory limitations found in AIS patients

In healthy subjects, respiratory maximal volumes are highly dependent on the sagittal range of motion of the T7-T10 segment. In AIS, the abolition of T7-T10 dynamics related to the stiffness induced by the apex region in Lenke IA curves could harm ventilation during maximal breathing. The aim of this study was to analyze the dynamics of the thoracic spine during deep breathing in AIS patients and in healthy matched controls. This is a cross-sectional, case-control study. 20 AIS patients (18 girls, Cobb angle, 54.7±7.9°; Risser 1.35±1.2) and 15 healthy volunteers (11 girls) matched in age (12.5 versus 15.8 yr. mean age) were included. In AIS curves, the apex was located at T8 (14) and T9 (6). Conventional sagittal radiographs of the whole spine were performed at maximal inspiration and exhalation. The ROM of each spinal thoracic functional segment (T1-T7, T7-T10, T10-T12) and the global T1-T12 ROM were measured. In healthy subjects, the mean T1-T12 ROM during forced breathing was 16.7±3.8. AIS patients showed a T1-T12 ROM of 1.1±1.5 (p<0.05), indicating a sagittal stiffness of the thoracic spine. A wide T7-T10 ROM (15.3±3.0) was found in healthy controls (91.6% of the T1–T12 ROM). AIS patients showed only 0.4±1.4 ROM at T7-T10 (36.4% of the T1-T12 ROM) (p<0.001). There was a significant positive correlation between the magnitude of T7-T10 kyphosis in maximal exhalation and both FVC (% of predicted FVC) and FEV1. In conclusion, Lenke 1A AIS patients show a restriction of the thoracic spine motion with an almost complete abolition of T7-T10 ROM, a crucial segment for deep breathing. T7-T10 stiffness could explain the ventilatory limitations found in AIS patients

Background. The advent of EOS imaging has offered clinicians the opportunity to image the whole skeleton in the anatomical standing position with a smaller radiation dose than standard spine roentgenograms. It is known as the fifth modality of imaging. Current NICE guidelines do not recommend EOS scans over x-rays citing: “The evidence indicated insufficient patient benefit in terms of radiation dose reduction and increased throughput to justify its cost”. Methods. We retrospectively reviewed 103 adult and 103 paediatric EOS scans of standing whole spines including shoulders and pelvis for those undergoing investigation for spinal deformity in a tertiary spinal centre in the UK. We matched this against a retrospective control group of 103 adults and 103 children who underwent traditional roentgenograms whole spine imaging at the same centre during the same timeframe. We aimed to compare the average radiation dose of AP and lateral images between the two modalities. We utilised a validated lifetime risk of cancer calculator (. www.xrayrisk.com. ) to estimate the additional mean risk per study. Results. In the Adult EOS Group (AEG) the mean estimated effective dose of AP was 0.08 mSv (0.04–0.15) and Lateral 0.06 mSv (0.03–0.14). Conversely in the Adult Roentgenograms Group (ARG) the mean AP was 0.49 mSv (0.15–1.88) and Lateral was 0.29 mSv (0.07–1.20). In the Paediatric EOS Group (PEG): the mean dose of AP was 0.07 mSv (0.02–0.21) and Lateral 0.04 mSv (0.02–0.11). Conversely Paediatric Roentgenograms Group (PRG) had a mean dose in AP of 0.37 mSv (0.03–5.92) and in lateral of 0.17 mSv (0.03–0.44). The percentage differences were: ARG:AES AP 613%, ARG:AES Lat 483%, PPG:PEG AP 529%, PRG:PEG Lat 425%. Mean difference 513%. The additional lifetime cancer risk for AEG was 1 in 176056 for males and 1 in 138696 for females, compared to ARG 1 in 31596 for males and 1 in 24894 for females. In PEG that was 1 in 58207 for boys and 1 in 33367 for girls, compared to PRG 1 in 11860 for boys and 1 in 6797 in girls. Differences in additional lifetime risk of cancer per scan: ARG:AES Male 557%, Female 557%, PRG:PEG Male 491%, Females 491%. Conclusion. Standard plain film imaging of the whole spine requires approximately five-times higher doses of radiation compared to dual planar EOS scans. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in both children and adults. There is approximately 5-fold increase in risk of cancer for all groups with roentgenograms over EOS. We directly challenge the NICE guidance and recommend EOS dual planar imaging in favour of plane roentgenograms for investigation of spinal deformity

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. 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

Purpose. Ultrasound of the neonatal and infantile hip is a useful tool in diagnosis and treatment of the developmental dysplasia of the hip (DDH), especially given the fact that numerous cases of DDH do not present any findings in the clinical examination. Methods. Between January 2014 and May 2020, 10536 (5273 neonates and infants, 53% girls, 47% boys) consecutive neonatal and infantile hip joints were studied using the Graf Hip Ultrasound method. Results. 607 hips were diagnosed as abnormal. 523 (5%) hip joints were type IIA, 18 (0.17%) were type ΙΙΒ, 19 (0.18%) were type ΙΙC, 33 (0.31%) were type ΙΙΙ and 14 (0.13%) were type IV. 72% of patients were girls, 55% of patients were firstborns, 35,7% presented breech, 8,2% had a positive family history of DDH, 6% were part of a multiple pregnancy, while 27,2% had no predisposing factor for the disease. Type ΙΙΑ hips were treated with follow- up only and had all matured (turned to normal- type I hips) within a trimester. Type ΙΙΒ και ΙΙC hips were treated using an abductor harness and were normal (type I) within three months. 35.7% of type ΙΙΙ were treated with an abductor harness and 64.3% with hip spica. All type IV hips were treated with hip spica. The duration of therapy for type III and type IV hips was 3 months. Conclusion. The early use of a hip ultrasound provides us with the ability to diagnose and treat DDH efficiently, resulting in a normal hip joint within the first months of life

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

Aims. The goal of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) is to achieve and maintain concentricity of the femoral head in the acetabulum. However, concentric reduction is not immediately attainable in all hips and it remains controversial to what degree a non-concentric reduction is acceptable. This prospective study is aimed at investigating the dynamic evolution of the hip joint space after CR in DDH using MRI. Methods. A consecutive series of patients with DDH who underwent CR since March 2014 were studied. Once the safety and stability were deemed adequate intraoperatively, reduction was accepted regardless of concentricity. Concentricity was defined when the superior joint space (SJS) and medial joint space (MJS) were both less than 2 mm, based on MRI. A total of 30 children, six boys and 24 girls, involving 35 hips, were recruited for the study. The mean age at CR was 13.7 months (3.5 to 27.6) and the mean follow-up was 49.5 months (approximately four years) (37 to 60). The joint space was evaluated along with the interval between the inverted and everted limbus. Results. Only three hips (8.6%) were fully concentric immediately after CR. During follow-up, 24 hips (68.6%) and 27 hips (77.1%) became concentric at six months and one year, respectively. Immediate SJS after CR decreased from 3.51 mm to 0.79 mm at six months follow-up (p = 0.001). SJS in the inverted group decreased from 3.75 mm to 0.97 mm at six months follow-up. SJS or MJS in the everted group were less than those in the inverted group at each time of follow-up (p = 0.008, p = 0.002). Conclusion. A stable, safe but non-concentric reduction achieved before the age of two years appears to improve over time with nearly 80% of hips becoming fully concentric by one year. Cite this article: Bone Joint J 2020;102-B(5):618–626

Aims. We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP). Methods. We were able to follow-up on 775 patients (395 girls, 380 boys) who sustained a SCHF from 2004 to 2017. Patients completed questionnaires including the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH; primary outcome), and the Pediatric Quality of Life Inventory (PedsQL). Results. An AO type I SCHF was most frequent (327 children; type II: 143; type III: 150; type IV: 155 children). All children with type I fractures were treated nonoperatively. Two children with a type II fracture, 136 with a type III fracture, and 141 children with a type IV fracture underwent CRPP. In the remaining 27 children with type III or IV fractures, a lateral external fixator was necessary for closed reduction. There were no open reductions. After a mean follow-up of 6.3 years (SD 3.7), patients with a type I fracture had a mean QuickDASH of 2.0 (SD 5.2), at a scale of 0 to 100, with lower values representing better HRQoL (type II: 2.8 (SD 10.7); type III: 3.3 (SD 8.0); type IV: 1.8 (SD 4.6)). The mean function score of the PedsQL ranged from 97.4 (SD 8.0) for type I to 96.1 (SD 9.1) for type III fractures, at a scale of 0 to 100, with higher values representing better HRQoL. Conclusion. In this cohort of 775 patients in whom nonoperative treatment was chosen for AO type I and II fractures and CRPP or a lateral external fixator was used in AO type III and IV fractures, there was equally excellent mid- and long-term HRQoL when assessed by the QuickDASH and PedsQL. These results indicate that the treatment protocol followed in this study is unambiguous, avoids open reductions, and is associated with excellent treatment outcomes. Cite this article: Bone Joint J 2020;102-B(6):755–765

Objectives. The aim of the current study was to assess whether calcaneal broadband ultrasound attenuation (BUA) can predict whole body and regional dual-energy x-ray absorptiometry (DXA)-derived bone mass in healthy, Australian children and adolescents at different stages of maturity. Methods. A total of 389 boys and girls across a wide age range (four to 18 years) volunteered to participate. The estimated age of peak height velocity (APHV) was used to classify children into pre-, peri-, and post-APHV groups. BUA was measured at the non-dominant heel with quantitative ultrasonometry (QUS) (Lunar Achilles Insight, GE), while bone mineral density (BMD) and bone mineral content (BMC) were examined at the femoral neck, lumbar spine and whole body (DXA, XR-800, Norland). Associations between BUA and DXA-derived measures were examined with Pearson correlations and linear regression. Participants were additionally ranked in quartiles for QUS and DXA measures in order to determine agreement in rankings. Results. For the whole sample, BUA predicted 29% of the study population variance in whole body BMC and BMD, 23% to 24% of the study population variance in lumbar spine BMC and BMD, and 21% to 24% of the variance in femoral neck BMC and BMD (p < 0.001). BUA predictions were strongest for the most mature participants (pre-APHV R. 2. = 0.03 to 0.19; peri-APHV R. 2. = 0.05 to 0.17; post-APHV R. 2. = 0.18 to 0.28) and marginally stronger for girls (R. 2. = 0.25-0.32, p < 0.001) than for boys (R. 2. = 0.21-0.27, p < 0.001). Agreement in quartile rankings between QUS and DXA measures of bone mass was generally poor (27.3% to 38.2%). Conclusion. Calcaneal BUA has a weak to moderate relationship with DXA measurements of bone mass in children, and has a tendency to misclassify children on the basis of quartile rankings. Cite this article: B. K. Weeks, R. Hirsch, R. C. Nogueira, B. R. Beck. Is calcaneal broadband ultrasound attenuation a valid index of dual-energy x-ray absorptiometry-derived bone mass in children? Bone Joint Res 2016;5:538–543. DOI: 10.1302/2046-3758.511.BJR-2016-0116.R1

Introduction. Despite extensive research, the cause of adolescent idiopathic scoliosis (AIS) is still largely unclear. Girls with AIS tend to be taller and leaner, and have a lower body-mass index (BMI) and lower bone mass, than do healthy girls. Recent MRI studies have shown the presence of relative anterior spinal overgrowth in girls with AIS. The lower bone mineral status and BMI could be related to dysfunctional central regulation pathway of growth, bodyweight, and bone metabolism. Following several interesting reports on the role of leptin in regulation of the above pathway in animals and human beings, our recent study has shown a low leptin concentration in girls with AIS girls compared with healthy adolescents. This finding leads to our new hypothesis that abnormal leptin bioavailability could be associated with the lower bodyweight, lower bone mineral density, and relatively disproportional endochondral skeletal growth in AIS. This study aimed to investigate the leptin bioavailability in girls with AIS. Methods. 53 girls with AIS and 27 healthy girls (aged 11–16 years) were recruited in this preliminary study. Clinical and anthropometric data were obtained. Blood samples were obtained for ELISA of leptin and soluble leptin receptor (sOB-R). Independent Student's t test and multivariate regression were used in group comparison. Results. The AIS group had significantly lower BMI and longer arm span than did controls. Additionally, girls with AIS had significantly higher soluble leptin receptor concentrations (22·1 ng/mL [□}6·9] vs 17·8 ng/mL [4·4]; p<0·01). However, the leptin concentration (7·6 ng/mL [□}5·3] vs 8·7 ng/mL [□}6·0]) and the leptin/sOB-R ratio (0·38 [□}0·28] vs 0·56 [□}0·47]) were similar to that of the controls. In girls with AIS, the leptin, sOB-R, and the leptin/sOB-R ratio correlated well with bodyweight and BMI. After adjustment for BMI, sOB-R in girls with AIS was significantly higher than in controls (r=0·37, p=0·042). Conclusions. This preliminary report showed that the soluble leptin receptor could be abnormal in girls with AIS. Leptin and sOB-R are related to bodyweight. sOB-R is a major modulator of leptin concentration in circulation, the abnormality of which may lead to the retention of leptin in the circulation and thus abnormal regulatory effect. In this study, girls with AIS had lower BMI and longer arm span, which may reflect the possible change resulting from abnormal leptin bioavailability. Further longitudinal study with larger sample size would be useful to help to understand the long-term effect of the low leptin and high sOB-R in girls with AIS on their bodyweight and skeletal development. It is also noteworthy to study the mechanism of increased sOB-R in AIS

Aims. Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018. Methods. Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed. Results. Data were extracted from the clinical records of 32 children diagnosed with Perthes’ disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period. Conclusion. The results of this case review demonstrate a variation of care provided to children in the UK with Perthes’ disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes’ disease. Cite this article: Bone Joint Open 2020;1-11:691–695

Aims. The purpose of this study was to report the long-term results of extendable endoprostheses of the humerus in children after the resection of a bone sarcoma. Methods. A total of 35 consecutive patients treated with extendable endoprosthetic replacement of the humerus in children were included. There were 17 boys and 18 girls in the series with a median age at the time of initial surgery of nine years (interquartile range (IQR) 7 to 11). Results. The median follow-up time was 10.6 years (IQR 3.9 to 20.4). The overall implant survival at ten years was 75%. Complications occurred in 13 patients (37%). Subluxation at the proximal humerus occurred in 19 patients (54%) but only six (17%) were symptomatic. Subluxation was seen more commonly in children under the age of nine years (86%) than in those aged nine years or more (33%) (p = 0.002). Implant failure occurred in nine patients (26%): the most common cause was aseptic loosening (four patients, 11%). Lengthening of the implant was carried out in 23 patients (66%). At final follow up, three patients had a limb that was shortened by 5 cm or more. The mean Musculoskeletal Tumor Society (MSTS) functional score was 79% (73% to 90%). Conclusion. Extendable endoprosthetic replacement is a reliable method of reconstructing humerus after excision of a bone sarcoma. Children who are less than nine years old have a high risk of subluxation. Cite this article: Bone Joint J 2020;102-B(1):64–71

Background. The pattern of appearance of secondary ossification centers in the elbow has been based on historical studies and is popularly referred to with the mnemonic CRITOL. However the six secondary ossification centers can be variable in their presentation and pose a challenge in assessment of children with elbow injuries. Furthermore limited studies available in the current literature have reported an aberration to the sequence of appearance especially with the ossification centers of trochlea and olecranon. Aims. The aim of the study was to evaluate the relative sequence of appearance of secondary ossification centers for the trochlea and olecranon. Methods. Children between 8 and 10 years of age who had radiographs of elbow following trivial trauma between July 2013 and Feb 2015 were identified using the hospital PACS database. Cases with radiographic markers of significant trauma ie. fat pad sign, displaced fracture were excluded. Anteroposterior and lateral views of elbow were reviewed for the presence of the six ossification centers. Results. A total of 114 radiographs were reviewed of which 51 were boys and 63 were girls with a mean age of 9.03 years (±0.59). 60 radiographs were of right elbow and 54 were of the left elbow. The capitulum, radial head and medial epicondyle ossification centers were present in all patients. Both trochlea and olecranon ossification centers were noted in 51/114 (44.7%) children. 12/114 (10.5%) of the children were noted to have trochlea ossification center with no olecranon ossification center. Of these 12 children 7 were boys and 5 were girls. On the other hand 19/114 (16.7%) of the children had an olecranon ossification center but without a trochlea ossification center. Amongst these 7 were boys and 12 were girls. Discussion and Conclusions. The results of this limited cross sectional study demonstrate that the CRITOL sequence may not followed in 16.7% of cases and more so in girls. Historical studies were based on conventional radiographs. However the current digital radiographs with image enhancement tools help in accurate identification of relatively small ossification centers which may not be apparent on conventional radiographs. The current study has helped to quantify the violators to CRITOL sequence. Level of Evidence. Level III (Cross-sectional study among non-consecutive patients)

Assessment of skeletal age is important in children’s orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods. Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods. The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience. The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified. Cite this article: Bone Joint J 2014;3:1556–60

Aims. To explore the of age of onset distribution for Perthes’ disease of the hip, with particular reference to gender, laterality and conformity to the lognormal distribution. Patients and Methods. A total of 1082 patients were identified from the Liverpool Perthes’ Disease Register between 1976 and 2010, of which 992 had the date of diagnosis recorded. In total, 682 patients came from the geographical area exclusively served by Alder Hey Hospital, of which 673 had a date of diagnosis. Age of onset curves were analysed, with respect to the predefined subgroups. Results. The age of onset demonstrated a positive skew with a median of 5.8 years (interquartile range 4.6 to 7.5). Disease onset was a mean five months earlier in girls (p = 0.01) and one year earlier in those who went on to develop bilateral disease (p < 0.001). There was no difference in the age of onset between geographical districts with differing incidence rates. The entire dataset (n = 992) conformed to a lognormal distribution graphically and with the chi-squared test of normality (p = 0.10), but not using the Shapiro-Wilk test (p = 0.01). The distribution for the predefined geographical subgroup (n = 673) conformed well to a lognormal distribution (chi-squared p = 0.16, Shapiro-Wilk p = 0.08). Given the observed lognormal distribution it was assumed that Perthes’ disease followed on incubation period consistent with a point-source disease exposure. The incubation period was further examined using Hirayama’s method, which suggested that the disease exposure may act in the prenatal period. Conclusion. The age of onset in Perthes’ disease conforms to a lognormal distribution, which allows comparisons with infectious disease epidemiology. Earlier onset in girls and those who develop bilateral disease may offer clues to understanding the aetiological determinants of the disease. The analysis suggests that an antenatal aetiological determinant may be responsible for disease. Take home message: Perthes’ disease age of onset conforms to a lognormal model, which is most typical of infectious diseases. The shape of the distribution suggests that an aetiological trigger in the pre-natal period may be an important determinant of disease. Cite this article: Bone Joint J 2016;98-B:710–14

Aims. Using 90% of final height as a benchmark, we sought to develop a quick, quantitative and reproducible method of estimating skeletal maturity based on topographical changes in the distal femoral physis. Patients and Methods. Serial radiographs of the distal femoral physis three years prior to, during, and two years following the chronological age associated with 90% of final height were analyzed in 81 healthy children. The distance from the tip of the central peak of the distal femoral physis to a line drawn across the physis was normalized to the physeal width. Results. A total of 389 radiographs of the distal femur with corresponding Greulich and Pyle bone ages and known chronological ages were measured. Children reached 90% of final height at a mean age of 11.3 years (. sd. 0.8) for girls and 13.2 years (. sd. 0.6) for boys. Linear regression analysis showed higher correlation coefficent in predicting the true age at 90% of final height using chronological age + gender + central peak value (R. 2 . = 0.900) than chronological age + gender (R. 2.  = 0.879) and Greulich and Pyle bone age + gender (R. 2.  = 0.878). Conclusion. Chronological age + gender + central peak value provides more accurate prediction of 90% of final height compared with chronological age + gender and Greulich and Pyle bone age + gender. Cite this article: Bone Joint J 2018;100-B:1106–11

Background:. Paley et al has developed the multiplier method for predicting leg length. It is a tool that is used clinically to predict leg length discrepancy. The method is also a way of comparing different populations, to identify differences in growth trajectory. This has been done by identifying the differing multipliers for girls and boys. However it has not been used to identify trends in populations separated by time. Tanner showed that in the first half of the twentieth century girls went from an average age of menarche of 15 in 1900, to 13 in 1970, how this has affected growth trajectory over the last 50 years has not been studied. Purpose:. The multiplier method is based on data collected in the 1950's by Anderson and Green, we aim to assess whether there has been a change in growth trajectory between this historical cohort and a contemporary European based cohort. Methods:. The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a longitudinal cohort study of children recruited antenatally, and followed prospectively. Assessment of sub ischial leg length was made on clinical measurements. There were up to 8 measurements per patient, 2311 girls with a final age at assessment of greater than 15 years and 123 males with a final age of assessment of greater than 16 years were assessed. We used the multiplier method to assess the predicted final leg length and compared this with the actual leg length. Result:. There was no difference between the multiplier in girls, in the contemporary cohort and the historical cohort. The average age of menarche in the contemporary group was 12.7. In boys the data is limited, due to later growth and it is not possible to draw comparisons from this group. Conclusion:. This data provides good evidence that there has not been a significant change in growth trajectory in girls over the last 50 years. Significance:. Implications on the confidence with which we can use the multiplier method in this population

Aims. The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining. Methods. A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. Results. Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. Conclusion. Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902–907

Purpose. Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in children 9–15 years old. The epidemiology for SCFE in the total population of Sweden has not yet been described. Methods. In a prospective cohort study, we analysed pre- and postoperative radiographs and medical records for all children treated for SCFE in Sweden 2007–2013, and noted demographic data, severity of slip, and surgical procedures performed. Results. We identified 379 Swedish children with primary SCFE 2007–2013; 162 girls, median age 12 (7–15) years, and 217 boys, median age 13 (4–17) years. The cumulative incidence was 45.8/100 000 for girls and 58.2/100 000 for boys. As an initial symptom, 66% of the children had hip/groin pain and 12% knee pain. At first presentation, 7% of the children had bilateral SCFE. Prophylactic fixation was performed in 43% . Of the remaining children, 21% later developed a contralateral slip. Fixation with implants permitting further growth of the femoral neck was used in 90% of the children. Femoral neck osteotomy was performed for 11 hips. Of 34 treating hospitals, only three treated > 3 children with SCFE annually. Conclusions. The cumulative incidence 2007–2013 in the total population in Sweden showed a mild increase for girls. The male-to-female ratio was lower than previously described for Sweden. Prophylactic fixation was performed in 43% of the children. Fixation with an implant that allows further growth was used for 90% of the children. Most hospitals in Sweden treat < 2 children annually

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 patients with adolescent idiopathic scoliosis (AIS), anomalous extra-spinal left-right skeletal length asymmetries in upper limbs, periapical ribs, and ilia beg the question as to whether these bilateral asymmetries are connected in some way with pathogenesis. The upper arm and iliac length asymmetries correlate significantly with adjacent spinal curve severity respectively in thoracic and lower (thoracolumbar and lumbar) spine. In lower limbs, skeletal length asymmetries and proximo-distal disproportion are unrelated to spinal curve severity. Overall, these observations raise questions about mechanisms that determine skeletal bilateral symmetry of vertebrates in health and disorder, and whether such mechanisms are involved in the cause of this disease. We investigated upper arm length (UAL) asymmetries in two groups of right-handed girls aged 11–18 years, with right thoracic adolescent idiopathic scoliosis (RT-AIS, n=98) from preoperative and screening referrals (mean Cobb angle 45°) and healthy controls (n=240). Methods. Right and left UAL were measured with a Harpenden anthropometer of the Holtain equipment, by one of four observers (RGB, AAC, RKP, FJP). UAL asymmetry was calculated as UAL difference, right minus left, in mm. Repeatability of the measurements was assessed by technical error of the measurement (TEM) and coefficient of reliability (R). Results. In girls with RT-AIS, UAL asymmetry was greater than it was in healthy girls (mean 5·9 mm vs 2·5 mm, ANOVA p<0·001, correcting for age), regressed negatively with age (p<0·001, r= –0·374), and correlated significantly with Cobb angle (r=0·342, p=0·001) and apical vertebral rotation (Perdriolle, r=0·291, p=0·004). In healthy girls, UAL asymmetry was unrelated to age. Plotted against years after estimated menarcheal age, right UAL overgrowth reduced significantly for girls with RT-AIS (r= –0·312, p=0·006, n=76) but not for healthy girls (r=0·000, p=0·985, n=121), which was a significant finding (p=0·052, ANOVA). Conclusions. The abnormal overgrowth of right upper arm length may be secondary, or pathogenetically associated with the RT-AIS trunk deformity. The negative regression of UAL asymmetry may result from (1) older girls having less residual growth and/or (2) a transient, or resolving, asymmetry process common to arm and trunk. We hypothesise that the pathogenetic process of RT-AIS may include two components: a transient bilateral asymmetry process and growth velocity, both of which affect trunk and arm growth. In the spine, these rarely lead to scoliosis resolution because biomechanical, postural, melatonin-signalling, and other factors sustain and aggravate the curve. Four pathomechanisms may induce the asymmetry process in trunk and arms involving (1) neuromuscular function, (2) motor cortex, (3) sympathetic nervous system, and (4) intrinsic time-tallies in growth plates, some of which suggest therapeutic possibilities

Introduction: Previous studies have reported controversial associations between exercise and neck or shoulder pains in adolescents. In this study we evaluated the relationships between physical activity or sedentary activities and neck or occipital pain (NOP) or shoulder pain (SP) in a representative sample of adolescents. Methods: The study population consisted of adolescents belonging to the Northern Finland Birth Cohort 1986 (n=5993). Associations of physical activity level, total sitting time, and different kinds of sedentary activities with NOP and SP were analyzed at 15–16 years of age using logistic regression. “Reporting NOP and SP” (not seeking medical help) and “Consultation for NOP and SP” were assessed separately in girls, but were combined in boys because of low prevalence of “Consultations”. Results: Almost half of the girls and one third of the boys reported NOP or SP, and 5% of girls and 2% of boys reported “Consultation for NOP or SP” during the past six months. High level of physical activity associated with increased prevalence of both “Consultation for NOP” and “Consultation for SP” in girls, but not in boys. Prolonged sitting was associated with high prevalence of NOP and SP in girls, and NOP in boys. Of various sedentary activities, TV watching and reading books associated with NOP in girls, whereas playing or working with a computer associated with NOP in boys. In girls, TV watching also associated with “Reporting SP”. Discussion: Both prolonged sitting and high level of physical activity seem to be related to NOP and SP among adolescents

Low bone mass and osteopenia have been described in the axial and peripheral skeleton of patients with adolescent idiopathic scoliosis (AIS). Recently, many studies have shown that gene polymorphism is related to osteoporosis. However, no studies have linked the association between IL6 gene polymorphism and bone mass in AIS. This study examined the association between bone mass and IL6 gene polymorphism in 198 girls with AIS. The polymorphisms of IL6-597 G→A, IL6-572 G→C and IL6-174 G→A and the bone mineral density in the lumbar spine and femoral neck were analysed and compared with their levels in healthy controls. The mean bone mineral density at both sites in patients with AIS was decreased compared with controls (p = 0.0022 and p = 0.0013, respectively). Comparison of genotype frequencies between AIS and healthy controls revealed a statistically significant difference in IL6-572 G→C polymorphism (p = 0.0305). There was a significant association between the IL6-572 G→C polymorphism and bone mineral density in the lumbar spine, with the CC genotype significantly higher with the GC (p = 0.0124) or GG (p = 0.0066) genotypes. These results suggest that the IL6-572 G→C polymorphism is associated with bone mineral density in the lumbar spine in Korean girls with AIS

Background: Slipped capital femoral epiphysis (SCFE) is an important orthopaedic problem which emerges in early adolescence. Not clearly identified factors in the growth zone of proximal femur produce slip in which the femoral head remains in the acetabulum and femoral shaft rotates outwards and backwards. This occurs usually in one but occasionally in both hips. As we assumed that in Department of orthopaedic surgery in Ljubljana half of Slovenian adolescent population with SCFE was treated, we could calculate epidemiological data for SCFE for whole Slovenian population. Patients and Methods: In retrospectively study we analysed patients treated operatively at Department of orthopaedic surgery in Ljubljana between 1.1.1970 and 31.12.2006. The data about sex, age and side of the slips were collected. We calculated average age at occurance, ratio boys to girls, and predominance of left or right side. For determination of SCFE incidence in Slovenia, we used the attack rate method which is the sum of annual incidences of SCFE in age interval when the slips occur calculated for each one-year group. Results: There were 224 patients, 126 boys and 98 girls presenting with SCFE between 1970 and 2006 treated in Department of orthopaedic surgery in Ljubljana. The average age of boys was 12.9 and the age of girls 11.6 years (range: 8–16 years). On the average the age was 11.3 years. Slipped capital femoral epiphysis appeared more frequently on the left side (58%) than on the right side (31%). In 11% of cases the slips were bilateral. Incidence per 1000 adolescents extrapolated to Slovenian population (attack rate method) was 0,796 ‰ for boys, 0,667 ‰ for girls and 0,734 ‰ for entire endangered population. Yearly incidence of SCFE was thus 0,089 ‰ for boys and 0,073 ‰ for girls. Discussion: Epidemiological data for SCFE in Slovenia are comparable to those found in Sweden and is difficult to compare with other countries, where different statistical methods were used. Risk of getting SCFE in critical period for boys is 1:1265 and for girls: 1:1499. Risk for whole critical population is 1:1362. It is interesting that our study showed marked increase in the number of boys with SCFE in recent years. Boys to girls ratio has changed from 1:1 in years 1970 to 1994 (Zupanc in sod. 2002) to 1,29:1 in our study

Aims. The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH). Patients and Methods. Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a “one stop” clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated. Results. A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%. Conclusion. Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675–9

Aims. The Ponseti method is an effective evidence-based treatment for clubfoot. It uses gentle manipulation to adjust the position of the foot in serial treatments towards a more physiological position. Casting is used to hold the newly achieved position. At first, the foot resists the new position imposed by the plaster cast, pressing against the cast, but over time the tissues are expected to adapt to the new position and the force decreases. The aim of this study was to test this hypothesis by measuring the forces between a clubfoot and the cast during treatment with the Ponseti method. Patients and Methods. Force measurements were made during the treatment of ten idiopathic clubfeet. The mean age of the patients was seven days (2 to 30); there were nine boys and one girl. Force data were collected for several weeks at the location of the first metatarsal and the talar neck to determine the adaptation rate of the clubfoot. Results. In all measurements, the force decreased over time. The median (interquartile range) half-life time was determined to be at 26 minutes (20 to 53) for the first metatarsal and 22 minutes (9 to 56) for the talar neck, suggesting that the tissues of the clubfoot adapt to the new position within several hours. Conclusion. This is the first study to provide objective force data that support the hypothesis of adaptation of the idiopathic clubfoot to the new position imposed by the cast. We showed that the expected decrease in corrective force over time does indeed exist and adaptation occurs after a relatively short period of time. The rapid reduction in the forces acting on the foot during treatment with the Ponseti method may allow significant reductions in the interval between treatments compared with the generally accepted period of one week

Aims. The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of early onset scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction. Patients and Methods. We undertook an observational prospective cohort study of children with early onset scoliosis, who were recruited over a one-year period and followed up for a minimum of two years. Magnetically controlled rods were introduced in a standardized manner with distractions performed three-monthly thereafter. Adverse events which were both related and unrelated to the device were recorded. Ten children, for whom relevant key data points (such as demographic information, growth parameters, Cobb angles, and functional outcomes) were available, were recruited and followed up over the period of the study. There were five boys and five girls. Their mean age was 6.2 years (2.5 to 10). Results. The mean coronal Cobb angle improved from 57.6° (40° to 81°) preoperatively, 32.8° (28° to 46°) postoperatively, and 41° (19° to 57°) at two years. Five children had an adverse event, with four requiring return to theatre, but none were related to the device. There were no neurological complications or infections. No devices failed. One child developed a proximal junctional kyphosis. The mean gain in spinal column height from T1 to S1 was 45.4 mm (24 to 81) over the period of the study. Conclusion. Magnetically controlled growth rods provide an alternative solution to traditional growing rods in the surgical management of children with early onset scoliosis, supporting growth of the spine while controlling curve progression. Their use has clear psychosocial and economic benefits, with the reduction of the need for repeat surgery as required with traditional growing rods. Cite this article: Bone Joint J 2018;100-B:507–15

This prospective study of 136 children with progressive infantile scoliosis treated under the age of four years, and followed up for nine years, shows that the scoliosis can be reversed by harnessing the vigorous growth of the infant to early treatment by serial corrective plaster jackets. In 94 children (group 1), who were referred and treated in the early stages of progression, at a mean age of one year seven months (6 to 48 months) and with a mean Cobb angle of 32° (11° to 65°), the scoliosis resolved by a mean age of three years and six months. They needed no further treatment and went on to lead a normal life. At the last follow-up, their mean age was 11 years and two months (1 year 10 months to 25 years 2 months), 23 (24.5%) were at Risser stages 4 and 5 and 13 girls were post-menarchal. In 42 children (group 2), who were referred late at a mean age of two years and six months (11 to 48 months) and with a mean Cobb angle of 52° (23° to 92°), treatment could only reduce but not reverse the deformity. At the last follow-up, at a mean age of ten years and four months (1 year 9 months to 22 years 1 month), eight children (19%) were at Risser stages 4 and 5 and five girls were post-menarchal. Fifteen children (35.7%) had undergone spinal fusion, as may all the rest eventually

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

Aims. We report the use of the distal radius and ulna (DRU) classification for the prediction of peak growth (PG) and growth cessation (GC) in 777 patients with idiopathic scoliosis. We compare this classification with other commonly used parameters of maturity. Patients and Methods. The following data were extracted from the patients’ records and radiographs: chronological age, body height (BH), arm span (AS), date of menarche, Risser sign, DRU grade and status of the phalangeal and metacarpal physes. The mean rates of growth were recorded according to each parameter of maturity. PG was defined as the summit of the curve and GC as the plateau in deceleration of growth. The rates of growth at PG and GC were used for analysis using receiver operating characteristic (ROC) curves to determine the strength and cutoff values of the parameters of growth. Results. The most specific grades for PG using the DRU classification were radial grade 6 and ulnar grade 5, and for GC were radial grade 9 and ulnar grade 7. The DRU classification spanned both PG and GC, enabling better prediction of these clinically relevant stages than other methods. The rate of PG (≥ 0.7 cm/month) and GC (≤ 0.15 cm/month) was the same for girls and boys, in BH and AS measurements. Conclusion. This is the first study to note that the DRU classification can predict both PG and GC, providing evidence that it may aid the management of patients with idiopathic scoliosis. Cite this article: Bone Joint J 2016;98-B:1689–96

The intra-epiphyseal growth of the proximal femur has been focus of studies because of the potential relationship with the development of slipped capital femoral epiphysis and cam deformity in femoroacetabular impingement. We aimed to evaluate the developmental pattern of the epiphyseal tubercle and extension in normal boys and girls from eight to fifteen years, without hip conditions. We performed three-dimensional (3D) analysis of pelvic computed tomographic scans of 80 subjects with suspect of appendicitis, consisting of five boys and five girls for each age, from eight to 15 years old. Images were segmented slice by slice at the level of the growth plate using biplanar orientation. The 3D-segmented epiphyses were used to measure the location and height of the tubercle, the height of the epiphyseal extension, and the epiphyseal diameter. We found that the epiphyseal tubercle was eccentrically located at the posterolateral quadrant of the physeal surface. The absolute height of the epiphyseal tubercle did not vary between ages (R. 2. =0.04; p=0.101). The epiphyseal diameter increased with age (R. 2. =0.74; p<0.001), making the tubercle height proportionally smaller with the epiphyseal growth (9% reduction in tubercle height normalised by the epiphyseal diameter). The normalised epiphyseal extension height significantly increased by 160% from 8 to 15 years of age. Our observation validates the hypothesis of the cupping mechanism provided by the peripheral growth of the epiphyseal extension, while the epiphyseal tubercle relatively decreases in size during the skeletal growth. Further research will be important to determine the role of these structures in the epiphyseal stability

Aims. The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. Patients and Methods. National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. Results. A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). . Conclusion. This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109–18

Nachemson (1996), drawing upon the theses of Sahlstrand (1977) and Lidström (1988), articulated the view there are more girls than boys with progressive AIS for the following reason. The maturation of postural mechanisms in the nervous system is complete about the same time in boys and girls. Girls enter their skeletal adolescent growth spurt with immature postural mechanisms – so that if they have a predisposition to develop a scoliosis curve, the spine deforms. In contrast boys enter their adolescent growth spurt with mature postural mechanisms so that they are protected from developing a scoliosis curve. There is evidence that postural sway improves with age in boys and girls until about 10 years of age after which it is similar between the sexes (Hirashawa 1973, Odenrick and Sandstedt 1984) findings which need further evaluation. We term Nachemson’s concept the neuro-ossesous timing of maturation (NOTOM) hypothesis. It may have an evolutionary basis through natural selection towards sexual and skeletal development during adolescence being earlier in girls and later in boys. The NOTOM hypothesis suggests a treatment to prevent progression of late-juvenile idiopathic scoliosis, early-AIS, and some secondary scolioses based on delaying the onset of puberty used therapeutically in girls with idiopathic precocious puberty (IPP, Grumbach and Styne 1998). The proposal is to administer a gonadorelin analogue which in the pituitary down-regulates the receptors to hypothalamic gonadotropin-releasing hormone (GnRH) causing a fall in both luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which in turn causes a fall in oestrogens and androgens, and thereby delays or stops menarche and slows bone growth – as in girls and boys with IPP (Galluzzi et al 1998). Expert scrutiny of this therapeutic proposal is currently in progress

Introduction: Both physical activity and inactivity have been suggested as risk factors for LBP, but the current evidence is conflicting. In this study we evaluated how the level of leisure time physical activity and amount of sitting are associated with LBP in a general population of adolescents. Methods: The study population consisted of 5999 boy and girl members of the Northern Finland 1986 Birth Cohort who responded to mailed questions at the age of 15–16 years. LBP during the past six months was classified as “No LBP”, “Reporting LBP” (not seeking medical help), or “Consultation for LBP”. Odds ratios and 95% confidence intervals obtained by multinomial logistic regression were adjusted for smoking and BMI. Results: Being physically very active (more than six hours of brisk physical activity per week) was associated with increased prevalence of “Consultation for LBP” in both genders, and with “Reporting LBP” in girls, compared to being moderately active (2–3 hours of brisk physical activity per week). High amount of sitting associated with “Consultation for LBP” and “Reporting LBP” in girls, but not in boys. Discussion: Very active participation in physical activities in both genders and high amount of sitting in girls, irrespective of the level of physical activity, were associated with reported LBP. Perhaps encouraging adolescents to physically moderately active lifestyle could diminish LBP. In addition, avoiding excessive sitting-based activities such as television watching and playing video games may be recommendable among girls

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

Introduction:. Paley et al has developed a multiplier method for calculating both leg length and total height. In the development of this algorithm, they evaluated the effect of factors including bone age and sex. They established that sex had a significant impact, but adjusting for bone age did not improve accuracy. Bone age and menarche have been shown to improve other height prediction models. Purpose:. We used a large prospective cohort to evaluate if the multiplier is independent of physiological age using menarche as a proxy. Methods:. Using the ALSPAC dataset we determined the accuracy of the Paley multiplier for predicting total height and leg length, and assed weather if the date of first menses increased the accuracy of the multiplier. Female patients over the age of 8, with documented final height and final sub-ishial leg length over the age of 15 and a date of first menses were evaluated. Predicted final height was compared with actual final height at all data points. Results:. There were 28332 data points in 3062 girls prior to skeletal maturity in the total height cohort and 8395 data points in 2300 girls in the leg length cohort. When age was corrected using the difference in age at onset of menarche from average, the accuracy of multiplier decreased for both measurements. When a correction of 50% was used, there was an improvement in the accuracy of multiplier predictions, reducing the average error by up to 24%. Conclusions:. Previous studies have failed to demonstrate that the accuracy of the multiplier is improved when adjusted for bone age. We have used the date of first menses as a proxy for bone age and established that making a 50% correction for physiological age improves the accuracy of this method. Significance:. This will potentially allow more accurate prediction of leg length discrepancy, and total height in girls with early menarche

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

Background: Low bone mass in patients with adolescent idiopathic-scoliosis has been well reported in cross-sectional studies. No large-scale longitudinal-study has been conducted to track bone-mineral-density (BMD) trajectory in peripubertal AIS with varying scoliosis-severity. Aim: We evaluated the BMD trajectory and factors determining BMD accretion in AIS during peripubertal period. Method: One hundred and ninety-six newly diagnosed AIS girls with Cobb-angle > 100 and 122 healthy girls, aged 12–15 years were followed-up for two years. Weight, height, leg length, menarche and Cobb-angle were determined. Areal lumbar-spinal BMD (LSBMD) and femoral-neck BMD (FNBMD), and volumetric distal-tibial BMD (TiBMD) were evaluated by dual-energy-x-ray-absorptiometry and peripheral QCT respectively. BMD growth-models were fitted by multilevel modelling (mixed longitudinal design). Results: At baseline, 93% participants were pre-menarchial or within three years of menarche. Average Cobb-angles at baseline and subsequent follow-ups were 260, 230 and 260 respectively. TiBMD of AIS (moderate- and severe-severity) was significantly lower than the controls from 13–16 years (ANOVA, P< 0.05). Posthoc-test showed that TiBMD of severe-AIS was lower than moderate-AIS at 15–16 years (P< 0.05). LSBMD accrual was significantly lower among AIS (moderate- and severe-severity) than the controls from age 13–17 years (ANOVA, P< 0.05). FNBMD of AIS (moderate- and severe-severity) was lower than the controls at 15 years (ANOVA, P< 0.05). BMD trajectories of individuals differed inter-personally and intra-personally over time and that BMD growth followed a curvilinear pattern. The rates of BMD accretion reduced with retarded growth across peripubertal-period. Weight and height were significant time-varying predictors on BMD growth. BMD of AIS was persistently lower than the healthy girls throughout the study (P< 0.05). Conclusions: This large-scale longitudinal study in AIS girls with moderate to severe-curve-severity showed for the first time that both the volumetric and areal BMD were persistently lower when compared to the age-matched healthy girls throughout 12–17 years. AIS with more severe curve-severity were found to have much lower BMD throughout the peripubertal period. Promotion of a higher bone-mass is important for AIS to modify scoliosis-progression and to achieve peak bone mass in order to reduce the risk of osteoporosis later in life

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

Nachemson [2] drawing upon the theses of Sahlstrand [3] and Lidström [4] articulated the view there are more girls than boys with progressive AIS for the following reason. The maturation of postural mechanisms in the nervous system is complete about the same time in boys and girls. Girls enter their skeletal adolescent growth spurt with immature postural mechanisms – so if they have a predisposition to develop a scoliosis curve, the spine deforms. In contrast, boys enter their adolescent growth spurt with mature postural mechanisms so they are protected from developing a scoliosis curve. We term Nachemson’s concept the neuro-osseous timing of maturation (NOTOM) hypothesis [1,5] The earlier sexual and skeletal maturation of girls may have an evolutionary basis through natural selection. Curve progression in AIS is associated with acceleration of the adolescent growth spurt [6]. Postural sway involves proprioceptive, vestibular and visual input to the central nervous system. In normal children there is a significant reduction in postural sway amplitude between six to nine years and 10–14 years [7,8]. In 1071 normal children aged 6–14 years postural sway is more stable in girls from 6–9 years and over 10 years there is no sex effect [9]; all these findings fit the Nachemson concept. But in view of a subsequent report on 64 normal children aged 3–17 years showing the change with age is limited to boys [10] the age and sex effect of postural sway in healthy children needs further evaluation. In AIS children stabilometry findings are conflicting and observed greater postural sway may be secondary to the curve. In the siblings of scoliotics Lidström et al [11] concluded that postural aberration is a factor in the aetiology of AIS. Conclusion: The NOTOM hypothesis suggests a treatment to prevent progression of late-juvenile idiopathic scoliosis, early-AIS, and some secondary scolioses. It is based on delaying the onset of the adolescent growth spurt and puberty as used therapeutically in children with idiopathic precocious puberty (IPP)[12]. The proposal is to administer a gonadorelin analogue which in the pituitary down-regulates receptors to hypothalamic gonadotropin-releasing hormone (GnRH) causing a fall in both luteinizing hormone (LH) and follicle-stimulating stimulating hormone (FSH); in turn this causes a fall in oestrogens and androgens and thereby delays or stops menarche and slows bone growth – as in girls and boys with IPP [13]. Expert paediatric opinion is supportive. King [14] has suggested the use of a gonadorelin analogue (Lupron) to delay the onset of the adolescent growth spurt in progressive AIS

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

Aims. Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure. Materials and Methods. This retrospective study evaluated 30 children with a chronic Monteggia lesion. There were 18 boys and 12 girls with a mean age of 7.4 years (4 to 13) at the time of open reduction. The mean interval to surgery, after the initial fracture, was 23.4 months (6 to 120). Clinical grading used a Kim modified elbow score: radiological outcome was recorded. The effect of the patient’s age, gender, duration from initial injury, Bado classification, and annular ligament reconstruction were analyzed. The mean follow-up was 42.2 months (15 to 20). Results. The Kim elbow scores evaluated at the last clinic visit were excellent in 23 patients, good in three, fair in two, and poor in two. A majority of the patients were found to have significant improvement of elbow flexion (p < 0.001). Six met the criteria of a fair radiological outcome; four of these were operated on more than 24 months after the initial injury, and three had surgery after the age of 11. Univariate analysis failed to find any factor that was significantly associated with a fair or poor outcome. Conclusion. Good clinical and radiological outcomes can be expected in most patients. Osteoarthritic changes were associated with age > 11 years and/or a delay of treatment of > 24 months. However, no statistically significant factor could be identified which correlated with an unfavourable outcome. Cite this article: Bone Joint J 2018;100-B:1117–24

In subjects with lumbar, thoracolumbar or pelvic tilt scoliosis no pattern of structural leg length inequality has been reported [1]. Forty-seven girls of 108 consecutive adolescent patients referred from routine scoliosis school screening during 1996–1999 had lower spinal scoliosis – lumbar (LS) 17, or thoracolumbar (TLS) 30 (mean Cobb angle 16 degrees, range 4–38 degrees, mean age 14.8 years, left curves 25). The controls were 280 normal girls (11–18 years, mean age 13.4 years). Anthropometric measurements were made of total leg lengths (LL), tibiae (TL) and feet (FL) by one observer (RGB) and asymmetries calculated for LL, TL and FL, as absolutes and percentage asymmetries of right/left lengths. There are no detectable changes of absolute asymmetries with age for LL, TL or FL in scoliotic or normal girls. Asymmetries are found in scoliotic girls compared with normals with relative lengthening on the right for each of LL (0.95%) and TL (0.99%) (each p< 0.001), but not FL (0.38%). Conclusion: The relative lengthenings in the right leg are unrelated statistically to the severity or side of the lower spinal scoliosis; the cause is unknown and may be related to posture – free standing on the right leg [2] – to neuromuscular mechanisms, or to primary skeletal changes in growth plates of femur(s) and tibia(e)

1. General joint laxity affecting more than three joints was found in 7 per cent of normal schoolchildren. Similar laxity was found in fourteen of a random series of forty-eight girls, and in nineteen of twenty-six boys, with non-familial congenital dislocation of the hip. Such laxity was also found in four of seven girls and five of seven boys with familial (first degree relative affected) congenital dislocation of the hip. 2. It is concluded that persistent generalised joint laxity, which is often familial, is an important predisposing factor to congenital dislocation of the hip in boys. It is less important in girls, except perhaps in familial cases, as in girls there is an alternative temporary hormonal cause of joint laxity

Introduction: The values of Q angle in a child’s knee cover a wide range. Frequently its extreme values are responsible for complaints or the appearance of some pathological conditions( e.g. chondromalacia, recurrent dislocation of patella etc). Material and Methods: The Q angle has been measured in both lower limbs of 1955 children aged 7–12 (1017 boys and 938 girls). Cases of children with a history of previous fractures on lower limbs or major orthopedic or neurological disorders have been excluded. Eighty one per cent of children have had the right foot as their prominent one, the 14.8% of children have had the left foot as their prominent one, and the 4.2% of children have had no difference between their limbs. Results: For the children aged 7–8, the values of Q angle have been measured to range from 11.30±7.4 degrees in left limb to 11.52±7.4 degrees in right limb in boys, while in girls they ranged from 11.05±7.2 to 11.20±6.9 respectively. For the ages 9–10, the values ranged from 11.30±7.8 degrees in left limb to 11.38±7.2 degrees in right limb in boys, while in girls they ranged from 11.02±7.7 to 11.51±7.1 respectively. For the ages 11–12, the values of Q angle ranged from 11.72±8.8 degrees in left limb to 11.56±8.3 degrees in right limb in boys, while in girls they range from 11.87±8.3 to 12.06±8.4 respectively. There has been no difference between the right and left lower limbs in all ages and both sexes. There has been no difference between the boys and girls in both lower limbs in all ages. As girls are growing up the Q angle is increasing in both lower limbs ( P< 0.01), whereas boys have no difference in their limbs while they are growing up. Children with their prominent right limb have performed increased Q angle in both lower limbs( P< 0.05). Regarding boys, the more Bone Mass Index (BMI) has been increased, the more the Q angle has been decreased ( P< 0.001). Conclusion: We conclude that in children aged 7–12, the Q angle 1) frequently appears increased values, 2) performs no difference between both lower limbs, and 3) has negative correlation with BMI in boys

Routine examination for spinal deformity as part of a school health screening programme was introduced in Singapore in 1981. The three different ethnic groups included in the study provided figures for the prevalence of idiopathic scoliosis in an Asian population. A three-tier system of examination was used and a total of 110744 children in three age groups were studied. In those aged 6 to 7 years the prevalence was 0.12%. The prevalence in those aged 11 to 12 years was 1.7% for girls and 0.4% for boys, a ratio of 3.2 to 1. In girls aged 16 to 17 years the prevalence was 3.1%. In the latter two age groups there was a significantly higher prevalence in Chinese girls as compared with Malay and Indian girls. The optimal age for school screening seemed to be 11 to 12 years, but repeated examinations may be worthwhile

Aim: During periods of rapid growth hip diseases can deteriorate unexpectedly. This retrospective evaluation should determine standard values that might allow earlier determination of such growth disturbances and a better classification of almost normal findings. Methods: 520 standardized made and normal pelvis x-rays of children aged 4–16 years were examined under respect to the development of the hip and pelvis itself (20 x-ray pictures per age-group and gender). Among others these parameters were assessed: acetabular index (AC) and ACM-angle, acetabular width, depth and length, width and altitude of the epiphysis, transverse pelvic diameter and pelvic altitude. Results: At the age 6–14 years boys have a higher ace-tabular index and ACM-angle than girls. The acetabular index decreases up to the age of 15 to 10 in average, the ACM-angle up to the age of 9 years to 47 in boys and 45 in girls to be subsequently constant. The bony acetabulum grows concentrically and spherically in form and slower than the femoral head. The acetabulum of girls is deeper, smaller and stops growing at the age of 14. The pelvic growth proceeds with the exception of iliac width in girls up to the age of 16. Conclusion: Due to an age depending mechanical load of the femoral head on the acetabulum a mild DDH can develop to severe pathology in times of rapid growth. With the found normal values and its variations it is easier to assess the development of hip joints especially in such cases

The Acetabular Index and the Physeal Angle of the proximal femur are a radiographic assessment of the morphology of the acetabulum and the proximal physis, respectively. Their values to decrease with age and it remains unknown whether any correlation exists between them or if weightbearing has any influence. X-rays belonging to 30 infants (60 hips), 4 boys and 26 girls, were studied between 2003 and 2006, measuring the Acetabular Index (AI) and the Femoral Proximal Physeal Angle (PPA). Measurements were taken using a goniometer (error ± 1°). All the cases had ultrasound scans at 4 months of age, with alpha angles smaller than 50° (Graf type IIa) and cephalic coverage between 33% and 50%. Anteroposterior hip X-rays were taken at 3 months (pre-weightbearing) and 4–10 months (post-weightbearing). Statistics: t-Test and correlation. The AI was 21.5° (19.5° boys, 21.8° girls) pre-weightbearing and 20.9° (20.8° boys, 21° girls) post- weightbearing. The PPA was 76.5° (75.9° boys, 76.6° girls) pre-weightbearing and 74.9° (75.5° boys, 74.8° girls) post-weightbearing. AI and PPA decreased pre- and post- weightbearing, 2′8% and 2′1% respectively. The decrease was considered significant in the PPA (p = 0.02), especially in girls (p = 0.009), and not significant in the IA. Differences were found between sexes: the AI increased in boys (+6.3%) and decreased in girls (−8.3%), and the PPA decreased in both boys (−0.5%) and girls (−2.3%). The side had no influence. No relevant correlation was found between AI and PPA, both pre- (r = − 0.15, p = 0.27) and post- weightbearing (r = − 0.24, p = 0.07). We did not find any relevant correlation between IA and PPA values, neither previous to weightbearing, nor in the months after weightbearing occurs. The measured angles suffered a decrease after weightbearing but the only significant decrease was in the PPA

Aims

Perthes’ disease (PD) is a childhood hip disorder that can affect the quality of life in adulthood due to femoral head deformity and osteoarthritis. There is very little data on how PD patients function as adults, especially from the patients’ perspective. The purpose of this study was to collect treatment history, demographic details, the University of California, Los Angeles activity score (UCLA), the 36-Item Short Form survey (SF-36) score, and the Hip disability and Osteoarthritis Outcome score (HOOS) of adults who had PD using a web-based survey method and to compare their outcomes to the outcomes from an age- and sex-matched normative population.

Objective: Determination of the height at maturity of patients with congenital vertebral anomalies and analysis of the effect of spinal surgery. Design: Review of clinical measurements collected prospectively. Subjects: Patients with congenital vertebral anomaly who had passed their sixteenth birthdays. Outcome measures: Stature compared to normal centiles for age and gender, with consideration of the type of abnormality, age at surgery and co-existing abnormalities. Results: Thirty-eight boys, mean age 16.41 years, SD 0.31, and 79 girls, mean age 16.76 yrs, SD 1.3 were identified. Growth rate over two years after age16 years was slow (boys: 1.0 cm, SD 3.05; girls: 0.33 cms, SD 1.98). At maturity, mean height for boys was just above the third centile while girls were on theirs. Height was significantly lower for patients with prior spinal surgery and with a diagnosis of VACTERL association. In boys, there was no correlation between age at surgery and final height, but in girls final height correlated significantly with age at diagnosis and at surgery and negatively with age at menarche. Conclusion: Stature at maturity is reduced and this is exacerbated by associated abnormalities and by spinal surgery. However, those with more severe abnormalities are more likely to have had surgery, and these two effects were not differentiated in this study

Aims

The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

Purpose of the study: Idiopathic scoliosis is a tridimensional deformation of the spine. For an overall description of the deformation, it is important to determine the exact deformation in each dimension to identify the topography and amplitude of the curvatures as well as the sagittal balance and vertebral rotation. Scoliosis is actually a deformation of the thoracic cage, which could be considered as its fourth dimension. The purpose of this study was to measure thoracic parameters, particularly thoracic volume, as a function of spinal curvature and growth in children. The goal was to better describe the deformation and difference in comparison with the normal population. Material and methods: In this prospective study, The Orten (Lyon) optical acquisition system was used to fashion a corset for 130 patients (110 girls, 20 boys, aged 4–16 years) with idiopathic scoliosis. The volume, circumference, anteroposterior and frontal diameters as well as the lengths T1–T12 and sternum were noted. These data were confronted with the clinical growth parameters: age, height in the upright and sitting position, body length, body weight, body mass index. Thoracic curvatures were measured using the Cobb system (15–45°). The vertebral rotation component was noted. In order to compare these pathological data with those observed in a normal population, the same optical acquisition protocol was performed in a control group of 65 girls and 61 boys free of thoracic deformation. Results: There was no significant difference in thoracic volume relative to the different growth parameters between the control group and the scoliosis group (Wilcoxon test: p=0.056). There was a correlation between thoracic volume (3–17 dm3) and age: boys r=0.75 and girls r=0.74. At about 4 years, thoracic volume was on average 33% of volume attained at puberty and at 10 years, 55%. These reference points were true for girls and for boys in the scoliosis and the control groups. The following relationships between thoracic measurements and sitting height were found to remain unchanged during growth: frontal diameter is about 30% of sitting height; anteroposterior diameter is equal to the length of the sternum and is about 20% of sitting height. Discussion and conclusion: The Orton optical acquisition system can be used to describe quantitatively the deformation of the thoracic cage caused by scoliosis. There was however no significant difference in thoracic volume between the normal controls and the scoliosis children with a curvature < 45°. Major scoliosis leads to deformation of the vertebral bodies and thus the thorax. This fourth dimension of the deformation should be taken into consideration when establishing the treatment by corset or surgery. This study described the thoracic parameters observed during growth in children with mild to moderate scoliosis. A later study on more severe forms will complete these data and enable an objective assessment of the thoracic deformation

We investigated the incidence and risk factors for the development of avascular necrosis (AVN) of the femoral head in the course of treatment of children with cerebral palsy (CP) and dislocation of the hip. All underwent open reduction, proximal femoral and Dega pelvic osteotomy. The inclusion criteria were: a predominantly spastic form of CP, dislocation of the hip (migration percentage, MP > 80%), Gross Motor Function Classification System, (GMFCS) grade IV to V, a primary surgical procedure and follow-up of > one year. There were 81 consecutive children (40 girls and 41 boys) in the study. Their mean age was nine years (3.5 to 13.8) and mean follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included measurement of the MP, the acetabular index (AI), the epiphyseal shaft angle (ESA) and the pelvic femoral angle (PFA). The presence and grade of AVN were assessed radiologically according to the Kruczynski classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and Dega osteotomy is an effective form of treatment for children with CP and dislocation of the hip, there were signs of avascular necrosis in about two-thirds of the children. There was a strong correlation between post-operative pain and the severity of the grade of AVN. Cite this article: Bone Joint J 2015;97-B:270–6

Aims. The aim of this study was to evaluate the efficacy of the surgical dislocation approach and modified trapdoor procedure for the treatment of chondroblastoma of the femoral head. Patients and Methods. A total of 17 patients (ten boys, seven girls; mean age 16.4 years (11 to 26)) diagnosed with chondroblastoma of the femoral head who underwent surgical dislocation of the hip joint, modified trapdoor procedure, curettage, and bone grafting were enrolled in this study and were followed-up for a mean of 35.9 months (12 to 76). Healing and any local recurrence were assessed via clinical and radiological tests. Functional outcome was evaluated using the Musculoskeletal Tumour Society scoring system (MSTS). Patterns of bone destruction were evaluated using the Lodwick classification. Secondary osteoarthritis was classified via radiological analysis following the Kellgren–Lawrence grading system. Steinberg classification was used to evaluate osteonecrosis of the femoral head. Results. The epiphyseal plate was open, closing, and closed in five, five, and seven patients, respectively. In total, eight, six, and three patients were classified as having Lodwick classification IA, IB, and IC, respectively. Allogeneic and autogenous bone grafting was used in 13 and four patients, respectively. All patients had good bone healing and no local recurrence was observed. One patient developed osteonecrosis of the femoral head (Steinberg IA) and one developed secondary osteoarthritis of the hip joint (Kellgren–Lawrence Grade II). The mean postoperative MSTS functional score was 27.7 (24 to 30). Conclusion. Surgical dislocation and modified trapdoor procedures are safe and effective techniques for treating chondroblastoma in the femoral head. Cite this article: Bone Joint J 2019;101-B:732–738

The February 2024 Research Roundup³⁶⁰ looks at: If you use a surgical helmet, you should seal your gown-glove interface; The use of iodophor-impregnated drapes in patients with iodine-related allergies: a case series and review of the literature; Location of the ovaries in children and efficacy of gonadal shielding in hip and pelvis radiography; Prehospital tranexamic acid administration does not improve outcomes in severe trauma patients; Silver-coated distal femur megaprosthesis in chronic infections with severe bone loss: a multicentre case series.

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

Aims. Magnetically controlled growing rods (MCGRs) allow non-invasive correction of the spinal deformity in the treatment of early-onset scoliosis. Conventional growing rod systems (CGRS) need repeated surgical distractions: these are associated with the effect of the ‘law of diminishing returns’. The primary aim of this study was to quantify this effect in MCGRs over sequential distractions. . Patients and Methods. A total of 35 patients with a maximum follow-up of 57 months were included in the study. There were 17 boys and 18 girls with a mean age of 7.4 years (2 to 14). True Distraction (TD) was determined by measuring the expansion gap on fluoroscopy. This was compared with Intended Distraction (ID) and expressed as the ‘T/I’ ratio. The T/I ratio and the Cobb angle were calculated at several time points during follow-up. Results. The mean follow-up was 30 months (6 to 57). There was a significant decrease in the mean T/I ratio over time (convex rod at 3 months 0.81, . sd. 0.58 vs 51 months 0.17, . sd . 0.16, p = 0.0001; concave rod at 3 months 0.93, . sd. 0.67 vs 51 months 0.18, . sd. 0.15, p = 0.0001). A linear decline of the mean T/I ratios was noted for both convex rods (r. 2. = 0.90, p = 0.004) and concave rods (r. 2. = 0.81, p = 0.015) over 51 months. At the 24-month follow-up stage, there was a significant negative correlation between the mean T/I ratio of the concave rod with weight (r = -0.59, p = 0.01), age (r = -0.59, p = 0.01), and BMI of the child (r = -0.54, p = 0.01). Conclusions. The ‘law of diminishing returns’ is also seen after serial distraction using MCGR. Compared to previously published data for CGRS, there is a gradual linear decline rather than a rapid initial decline in lengthening. In older, heavier children a reduced distraction ratio in the concave rod of the MCGR device is noted over time. Cite this article: Bone Joint J 2017;99-B:1658–64

Aims

Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition.

We have measured the increase in height and width of the vertebral bodies and expressed them as percentages of the total growth in children aged 10 to 17 years. The first group, 10 boys and 10 girls, each had a single thoracic adolescent idiopathic scoliosis while the second group, 10 girls, each had a single lumbar adolescent idiopathic scoliosis. No significant differences were found between the growth increments and spinal dimensions of the vertebral bodies involved in the scoliotic curve and those vertebrae outside the curve in the same patient. The vertebrae were more slender in girls than in boys

Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS).

Objective: It is frequently said that the natural history of adolescent idiopathic scoliosis (AIS) is not understood. This study examines clinical data collected over some years and shows that the information is available and needs only to be generalised and applied. Design: Retrospective analysis of data, relating basic clinical information (age, Cobb angle, pubertal status, growth) to outcome in the practical terms that are relevant to clinical practice and patient management, Subjects: Two groups of female patients identified from the database: Group 1, girls diagnosed at least one year before the onset of menses and last reviewed at least one year afterwards; Group 2, girls diagnosed at least one day after menarche, followed for at least one year and not having surgery as a first option i.e. within six months. Outcome measures: Within and between group comparisons as regards age, height and Cobb angle at presentation and at last review and age at menarche. Change in height and Cobb angle of 10°, and the incidence of non-operative treatment and corrective surgery were considered. Statistical analysis was by student’s t test and Fisher’s exact. Results: Group 1 (N=58) presented at a mean age of 11.6 years SD 1.02, range 10 – 13.9 and reached menarche a mean of 2.1 years later, SD 0.86, range 1.0 – 4.5. Mean Cobb angle was 16.79 SD 8.58. Progression of more than 10° was observed in 24 girls, 11 of whom underwent surgery. Those who progressed had a higher initial Cobb angle (p=0.01) and were taller at discharge (p=0.041), but all other parameters were the same. Group 2 (N=92) presented at a mean age of 13.7 years SD 0.92 with a mean Cobb angle of 23.77° SD 14.52. Progression of 10° or more was observed, one of whom had surgery, her Cobb angle having increased from 48° to 64°. 6 had surgery for cosmetic reasons without further increase in Cobb angle. There was no statistically significant difference between the stable and progressive groups on any parameter other than final Cobb angle. Comparing Groups 1 & 2, girls in Group 1 were younger and smaller at diagnosis with lower Cobb angles. They were older at menarche, but this was inevitable from the selection criteria, and more likely to progress (p< 0.001), to receive a brace (p=0.047) and to undergo surgery (p=0.043). Age, final Cobb angle and height at discharge were not significantly different. Conclusions: 1.Girls diagnosed with AIS before puberty are at increased risk of progression but this is not usually clinically significant and does not usually lead to corrective surgery. 2.Girls diagnosed after menarche progress rarely and less. In practice, their deformity can be taken as stable at presentation. 3. In most cases, the course is benign and non-operative treatment had no discernible effect on outcome. As the percentage progressing significantly or requiring treatment at any stage is small, a less interventionist approach is indicated

Aims. The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children. Patients and Methods. A total of 35 children were studied. There were 19 girls and 16 boys. Their mean age was 11.9 years (2 to 18) at the time of surgery. Details of the radiological examinations were recorded during gradual correction using a Taylor Spatial Frame. The dose area product for each radiograph was obtained from the Computerised Radiology Information System database. The effective dose in millisieverts (mSv) was calculated using conversion coefficients for the anatomical area. The lifetime risk of developing cancer was calculated using government-approved Health Protection Agency reports, accounting for the age and gender of the child. Results. Correction was undertaken in five femurs, 18 tibiae, and 12 feet. The median duration of treatment was 45 months (11 to 118). The mean effective dose was 0.31 mSv (0.05 to 0.64) for the femur, 0.29 mSv (0.01 to 0.97) for the tibia, and 0.027 mSv (0.001 to 0.161) for the foot. The cumulative exposure gave ‘negligible’ risk in 26 children and ‘minimal’ risk in nine children, according to Public Health England categories. These results are below the mean annual background radiation in the United Kingdom. Conclusion. The lifetime attributable risk of developing cancer from repeated exposure to radiation was negligible or minimal in all children. This is the first study to quantify the exposure to radiation from serial radiographs in children with limb deformities who are treated surgically using circular external fixation, linking this to the risk of developing cancer. Cite this article: Bone Joint J 2019;101-B:241–245

Left-right skeletal length asymmetries in upper limbs related to curve side have been detected with adolescent thoracic idiopathic scoliosis (AIS). In school screening referrals with thoracic scoliosis we find apical vertebral rotation (AVR, Perdriolle) is associated significantly with upper arm length asymmetry. Sixty-nine of 218 consecutive adolescent patients referred routinely during 1988–1999 had idiopathic thoracic scoliosis of whom 61 had left and right upper arm lengths measured with a Holtain anthropometer (right curves 49, left curves 12, mean age 14.9 years, girls 38 postmenarcheal 34, boys 23). The controls are 278 normal girls and 281 boys (11–18 years, mean age 13.5 years). The mean value for Cobb angle is 18 degrees (range 4–42 degrees), AVR 13 (range 0–34 degrees), Cobb angle (CA) and AVR are each positively associated with upper arm length asymmetry (p=0.001 & p< 0.0001 respectively) and after correcting for each of Cobb side, apical level, sex and handedness, AVR and upper arm length asymmetry are still significantly associated (p=0.004 ANOVA). Partial correlation analysis shows AVR is associated with upper arm length asymmetry after controlling for CA (p=0.033); but not CA and upper arm length asymmetry after controlling for AVR (p=0.595). The reason why a larger AVR to the right is associated with a relatively longer right upper arm is unknown. Possibilities include neuromuscular and skeletal mechanisms, the latter relative concave overgrowth of neurocentral synchondrosis and/or of periapical ribs. We suggest consideration be given to combining convex vertebral body stapling (Betz) with concave periapical rib resection (Sevastik and Xiong) for right thoracic AIS in girls

A self-control ratio, the spine-pelvis index (SPI), was proposed for the assessment of patients with adolescent idiopathic scoliosis (AIS) in this study. The aim was to evaluate the disproportionate growth between the spine and pelvis in these patients using SPI. A total of 64 female patients with thoracic AIS were randomly enrolled between December 2010 and October 2012 (mean age 13 years, standard deviation (. sd. ) 2.17; 9 to 18) and a further 73 healthy female patients with a mean age of 12.4 years (mean age 12.4 years, . sd. 2.24; 9 to 18), were randomly selected from a normal control database at our centre. The radiographic parameters measured included length of spine (LOS), height of spine (HOS), length of thoracic vertebrae (LOT), height of thoracic vertebrae (HOT), width of pelvis (WOP), height of pelvis (HOP) and width of thorax (WOT). SPI was defined as the ratio LOS/HOP. The SPI and LOT/HOP in patients with AIS showed a significant increase when compared with normal girls (p < 0.001 and p < 0.001 respectively), implying an abnormal pattern of growth of the spine relative to the pelvis in patients with AIS. . No significant difference in SPI was found in different age groups in the control group, making the SPI an age-independent parameter with a mean value of 2.219 (2.164 to 2.239). We also found that the SPI was not related to maturity in the control group. . This study, for the first time, used a self-control ratio to confirm the disproportionate patterns of growth of the spine and pelvis in patients with thoracic AIS, highlighting that the SPI is not affected by age or maturity. Cite this article: Bone Joint J 2015;97-B:1668–74

1. Thirty-three patients who had had stapling of the lower femoral and upper tibial epiphysis to correct inequality of the leg lengths were reviewed after maturity. The staples were inserted so that correction of the disparity would coincide with termination of growth. 2. The predicted corrections were found to be inaccurate. The error was 47 per cent in girls operated on between ten and twelve and 51 per cent in boys between ten and thirteen. In older children the prediction was more accurate. 3. Despite the inaccuracy of prediction only four patients were left with shortening of more than 3·5 centimetres. 4. Complications of the operation were deformity, ligamentous laxity, subjective symptoms and necessity for further operation. 5. Only one girl had a serious deformity–genu recurvatum of 25 degrees. Half the patients had minor degrees of hyperextension. 6. The causes of the complications are discussed and suggestions made how their incidence might be reduced. 7. It is concluded that the operation of stapling the epiphyses around the knee of the long leg has a small but useful part to play in the correction of inequality of leg lengths. It should be confined to tall boys over thirteen and girls over twelve

Background: To compare height-adjusted fat and fat-free mass components of body composition in girls with adolescent idiopathic scoliosis to young adolescents with eating disorders. Adolescent idiopathic scoliosis (AIS) has been linked with low bone densities. Animal and human studies have shown that bone densities are influenced by a wide variety of inter-related factors that includes body fat, oestrogen levels, nutritional status and energy balance. Anthropometric studies have reported girls with AIS as being taller and more slender than their age-matched peers and that they also exhibit complex patterns of body asymmetry, particularly in the upper limb. There are also some studies report eating disorders in this population. Methods: Height-adjusted fat and fat-free mass components of body composition were examined. Fat mass index (FMI) and fat-free mass index (FFMI) were calculated and normalised for height and were superimposed onto UK 1990 growth reference data. The data for left and right limb length was also compared. A sample of 325 girls with AIS referred to the specialist spinal unit in Liverpool during the period 1970–1990. Results: The fat mass index and fat-free mass index were reduced in this sample of AIS subjects compared with normal reference children, but were similar to those diagnosed with eating disorders (anorexia nervosa). The cohort also exhibited significant upper limb asymmetry. Conclusion: The findings suggest that this population has significantly low fat mass compared to normal, healthy reference values. Since fat mass reflects energy balance, nutritional status (possibly eating disorders) and is closely linked to endocrine function, the implications of reduced fat mass on growth, bone mass accretion and the aetiology of AIS merit further investigation

Postdysplastic ischaemic necrosis of the proximal femoral epiphysis has its origin in the vascular crisis during conservative or operative treatment of DDH and in the majority of cases has an iatrogenic origin. The severity of the symptoms and functional disability is dependent on the anatomic changes of the proximal femur and the whole hip joint respectively, which were caused by previous conservative or operative treatment, including repeated surgery. The symptoms such as limping from leg length discrepancy and abductor insufficiency, pain and restricted ROM are less apparent in small children, but become more conspicuous with the approach of the end of growth. For the classification of the patterns of ischemic necrosis of the femoral head, the classification according to Bucholz and Ogden was used. Four principal types of this deformity are recognised. There are three main problems which are to be solved by surgical treatment. 1. The acetabular dysplasia with a pelvic osteotomy 2. Improving the bio-mechanics by distalisation of the greater trochanter and by the lengthening of the femoral neck with or without valgisation 3. Lengthening of the shorter extremity. The decision on the type of surgery to be performed depends on the age of the patient and the severity of the anatomic deformity, as well as the functional disability. A very useful method for treatment was found to be a double intertrochanteric osteotomy with a trochanteric advancement, and almost invariably in combination with a triple or Salter pelvic osteotomy. The lengthening osteotomy of the femoral neck follows the principles of Müller and Wagner. A similar technique was also proposed later by Morscher. My own contribution has been to modify the operation by an oblique execution of the osteotomy, and a method of fixation of the greater trochanter by means of an angle plate – providing a lengthening of the limb by up to 3 cm. In the case of acetabular dysplasia, a pelvic osteotomy should be performed as a first procedure in order to obtain better stability of the hip joint. A femoral osteotomy can follow at a minimal interval of three months. If the femoral osteotomy is performed as a first step without enlargement of the actabulum, there is the risk of further deterioration of the covering of the femoral head, even in a dislocation. This philosophy of treatment of sequel of postdysplastic necrosis has been used since 1979. Up to 1984, we operated on 48 hip joints in 46 patients, 39 girls and 7 boys aged 4 to 21, with a follow- up of at least 15 years. In 12 cases, 10 girls and 2 boys aged 4 to 8, a Salter and valgus osteotomy was performed. Thirty-four patients (29 girls and 5 boys) had a triple pelvic osteotomy, with 2 girls being operated bilaterally. In 22 hips, a lengthening osteotomy of the femoral neck was added as a second stage procedure. Five parameters were used for clinical evaluation: pain, limping, range of motion, Trendelenburg sign, and leg length discrepancy. For radiological assessment, we used an AP X-ray of the entire pelvis taken before and after osteotomy, and also during follow-up. CE angle, Sharp’s angle, ACM angle, and lateralisation were recorded. Hip score was measured on all hips, but we found that CE, Sharp and lateralisation were of greater value. In a group of 12 cases operated on up to the age of 8 by combining Salter and valgus osteotomy, a cementless THR was necessary for a young woman of 25. The remaining 11 patients are up to the present time without any major problems. In a group of 14 patients operated for sequel of postdysplastic necrosis Type II deformity (all with triple pelvic osteotomies and five in combination with femoral neck lengthening osteotomy), all have a normal quality of life, including having natural childbirths. From 22 Type III hip joints in 20 patients operated for sequel of postdysplastic necrosis, a cementless THR was implanted in three cases 14, 17 and 18 years after original surgery. Fourteen patients (15 hip joints − 67%) can be considered as good results without needing to have any therapy. Three patients (4 hips) suffer from degenerative arthritis and are candidates for THR

I still remember as a green 16-year-old being completely seduced by Newman's portrait of a university – the ideal of a liberal education. I was completely charmed not only by Newman's seductive prose – but by the humanising ideals of the effects of an excellent education. The picture was compelling and inspirational to the daughter of a small farmer whose parents were forced to leave school at 12 years of age to go and earn a living. I was sitting in the “lap of luxury” in a boarding school for girls, whose excellent principal generated a huge respect for, and absolute belief in, the right to and the ability to gain from a rigorous and serious education – which for me at that time in the 1970s extended at least to the end of secondary schooling – a luxury no one in my family had access to in the previous generation. What are universities for? Many authors have considered this issue since Newman's time – in recent times for example Boyd (1979), Graham (2005), Collini (2012). They all, in different ways suggests the need not only to respond to societal / economic needs, but also the need for a more balanced, holistic conception of university activity. Leaders of universities in the 21. st. century must try to articulate this, seek greater understanding of it. We must lobby government for greater recognition, understanding and support for the university's role not only for the present but also for the future. Contingency, vulnerability, adaptability, recognising the provisional nature of knowledge (and control); the caring versus the careless – all of this implies the need for diversity of disciplines, gender and experiences among university leadership in both the national and the international arena

Introduction and Aims: We propose a new, simple, and universal method to predict adult height: the Height Multiplier Method. Our aim was to calculate height multipliers from various databases and validate their use for height prediction. Method: Standard growth charts, based on a diverse population, were published by the Centres for Disease Control and Prevention (CDC) in 2000. Height multipliers (M) for boys and girls were calculated by dividing the height at skeletal maturity (Htm) by the present height (Ht) (M = Htm/Ht) for each age, gender, and height percentile using CDC data. These multipliers were compared with multipliers derived from various height databases of 28 boys and 24 girls. The accuracy of the multipliers was tested on individual longitudinal data sets from 52 normal children. Results: The average CDC-derived multipliers were significantly different at each age for boys and girls, but within gender, different percentiles at each age were very similar. These multipliers were very similar to multipliers derived from each of the databases. For predictions based on individual data sets from 52 children, the median, 90%, and standard deviation of absolute error prediction (AEP) were calculated. Boys’ median AEP ranged from 1.4–4.3cm; 90% AEP ranged from 1.8–8.3cm. Girls’ median AEP ranged from 0.68–4.38cm; 90% AEP ranged from 1.5–10.6cm. Conclusion: The Height Multiplier Method of stature prediction is as accurate as CDC growth charts when based on single-height measurements and is similar in accuracy to other methods. The Height Multiplier Method has the advantage of percentile, race, nationality, and generation independence. Growth charts have the advantage of showing trends over time

Avascular necrosis (AVN) is a serious complication of high-dose chemotherapy for haematological malignancy in childhood. In order to describe its incidence and main risk factors and to evaluate the current treatment options, we reviewed 105 children with a mean age of 8.25 years (1 to 17.8) who had acute lymphoblastic or acute myeloid leukaemia, or a non-Hodgkin’s lymphoma. Overall, eight children (7.6%) developed AVN after a mean of 16.8 months (8 to 49). There were four boys and four girls with a mean age of 14.4 years (9.8 to 16.8) and a total of 18 involved sites, 12 of which were in the femoral head. All these children were aged > nine years (p < 0.001). All had received steroid treatment with a mean cumulative dose of prednisone of 5967 mg (4425 to 9599) compared with a mean of 3943 mg (0 to 18 585) for patients without AVN (p = 0.005). No difference existed between genders and no thrombophilic disorders were identified. Their initial treatment included 11 core decompressions and two bipolar hip replacements. Later, two salvage osteotomies were done and three patients (four hips) eventually needed a total joint replacement. We conclude that AVN mostly affects the weight-bearing epiphyses. Its risk increases with age and higher steroid doses. These high-risk patients may benefit from early screening for AVN. Cite this article: Bone Joint J 2013;95-B:1708–13

We undertook a randomised clinical trial to compare treatment times and failure rates between above- and below-knee Ponseti casting groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below- or above-knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. A total of 26 children (33 feet) were entered into the trial. The above-knee group comprised 17 feet in 13 children (ten boys and three girls, median age 13 days (1 to 40)) and the below-knee group comprised 16 feet in 13 children (ten boys and three girls, median age 13 days (5 to 20)). Because of six failures (37.5%) in the below-knee group, the trial was stopped early for ethical reasons. The rate of failure was significantly higher in the below-knee group (p = 0.039). The median treatment times of six weeks in the below-knee and four weeks in the above-knee group differed significantly (p = 0.01). This study demonstrates that the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. Therefore, this technique is not recommended. Cite this article: Bone Joint J 2013;95-B:1570–4

In schoolchildren screened for scoliosis about 40% have minor, non-progressive, lumbar scolioses secondary to pelvic tilt with leg-length and/or sacral inequality [1] not reported with preoperative thoracic curves [2]. Forty-nine of 108 consecutive adolescent patients referred from routine scoliosis school screening during 1996–1999 had lower spinal scoliosis with measurable radiological sacral alar and hip tilt angles – lumbar scoliosis 18, thoracolumbar scoliosis 31 (girls 41, boys 8, mean Cobb angle 16 degrees, range 4–38 degrees). In standing full spine antero-posterior radiographs measurements were made of Cobb angle and pelvic asymmetries as sacral alar and iliac heights (left minus right). From anthropometric measurements derivatives were calculated as ilio-femoral length (total leg length minus tibial length) and several length asymmetries, namely: ilio-femoral length asymmetry, total leg length inequality and tibial length asymmetry (all left minus right). Ilio-femoral length asymmetry correlates significantly with sacral alar height asymmetry (girls negatively r= − 0.456, p=0.002, boys positively r=0.726 p=0.041) but not iliac height asymmetry (girls p=0.201) from which three types are identified. Total leg length inequality but not tibial length asymmetry in the girls is associated with sacral alar height asymmetry (r= − 0.367 p=0.017 & r=0.039 p=0.807 respectively). Interpretation is complicated by total leg lengths each including some ilium in which there is asymmetry [3]. But lack of association between ilio-femoral length asymmetry and iliac height asymmetry suggests that the femoral component is more important than iliac component in determining the associations between sacral alar height asymmetry and each of ilio-femoral length asymmetry and total leg length inequality. Conclusions:. Sacral alar height asymmetry and leg length asymmetries. The evidence suggests that sacral alar height asymmetry is not secondary to the leg length inequalities at least in most girls (negative correlations) and is more likely to result from primary skeletal changes in femur(s) and sacrum. Sacral alar height asymmetry and Cobb angle. Scoliosis progression and iliac height asymmetry [3] appear to need factors additional to those that determine ilio-femoral length asymmetry – for in the girls Cobb angle is associated with both sacral alar height asymmetry and iliac height asymmetry (each p< 0.001) but not with either ilio-femoral length asymmetry (p=0.249) or total leg length inequality (p=0.650). The additional factors may be biomechanical [4], and/or biological in the trunk [5] and central nervous system [6]

This paper reports a new method for expressing numerically asymmetry of the contour of the back in a forward-bending position. Information is given at three spinal levels (T8, T12 and L3) for 636 schoolchildren aged 8 to 15 years. Rib-hump and lumbar-hump scores were standardised to create trunk asymmetry scores (TASs) making comparison possible between children of different age, size and sex. Two groups of children were defined: those with clinically straight spines (585 children); and those with clinical evidence of lateral spinal curves (51 children). In the children with clinically straight spines the main findings were: about 1:4 had objectively detectable rib and lumbar humps; female-to-male ratios were 1.2:1 for the thoracic region and 1.4:1 for the lumbar region; right humps were about 10 times more common than left; TASs in the boys and girls at each spinal level had normal distributions about means to the right of zero (where zero represents perfect symmetry); at T8 and T12, a wider scatter of TASs in girls than in boys; at L3, larger TASs in girls than in boys; a relation between shortening of one lower limb and a contralateral hump on the back; and no relation to age (except at L3), stature (corrected for age) or handedness. The findings are discussed in relation to possible causes of back contour asymmetry, early diagnosis of scoliosis by screening, sexual dimorphism and significance for the pathogenesis of idiopathic scoliosis. Ten children with clinically straight spines and larger TASs, and 42 out of 51 children with clinical evidence of lateral spinal curves in the forward-bending position attended for radiographic examination. Twelve children had "scoliosis curves" of 11 degrees or more as defined by the Scoliosis Research Society. The results are reported in relation to TASs, spinal curve angle (Cobb) and vertebral rotation

In this case report a four-year-old girl with ulnar dimelia is described. She had six digits without mirror symmetry in her right hand. The first pre-axial digit was excised and true pollicisation performed for the second pre-axial digit. The arterial anatomy was abnormal but there was not symmetrical development of the arterial tree

1. Introduction. A significant correlation between handedness and laterality of the curve in scoliotic children is reported in the literature. This correlation is implicating cortical function as an aetiologic factor for scoliosis, (Goldberg and Dowling 1990). The truncal asymmetry expressed as a hump, is the sign at the presence of which there is a suspicion of a scoliotic curve. The above issue stimulated the search of existence of a possible correlation between handedness and the increasing truncal asymmetry, the existence of which represents a risk factor for development of scoliosis. Thus the aim of this study is the appraisal of the correlation of the existence of a truncal asymmetry as it is checked by the use of a scoliometer during the forward bending test and the handedness in schoolmates who were screened at school for scoliosis. 2. Material and Method. 2.1 The examined children. 4345 students (2183 girls and 2158 boys), 6 – 18 years of age were examined during the school-screening program for scoliosis. 2.2 The measurements. A protocol with a checklist is filled for each student in which handedness and truncal asymmetry is included. The probability of existence of scoliosis in the child and the recommendation for further clinical and radiological assessment at hospital is based on the amount of the recorded truncal asymmetry. The sitting and standing forward bending test is performed using the Pruijs scoliometer, on which reading ≥7° is a threshold for recommendation for reexamination. Truncal asymmetry was recorded for thoracic, thoracolumbar and lumbar region. 2.3 The statistical analysis. The techniques used for the study of the sample of children included cross tabulation and ÷2. 3. Results. The statistical analysis revealed that there is no statistical difference for handedness between boys and girls therefore the correlation between handedness and truncal asymmetry was performed for both sexes together. 91% children were right-handed (1932 boys and 1996 girls), while 9% left-handed (218 boys and 169 girls) respectively. A significant statistical correlation of truncal asymmetry and handedness was found both in boys and girls at thoracic (p < 0.022) and thoracolumbar (p< 0.027), but not at the lumbar region. 4. Discussion. These findings show that there is significant correlation of truncal asymmetry and the dominant brain hemisphere in terms of handedness, in children who are entitled at risk to develop scoliosis. Thus, the correlation of the handedness and the truncal asymmetry (the scoliosis convex) is present not only at scoliotic children but and at those being at risk that is before the development of the disease. These findings correlate cortical function and the truncal asymmetry, probably as a prodrome state of scoliosis and it is of aetiologic importance

Purpose of Study. A description of a procedure to stabilize symptomatic complete discoid menisci with medium term results. Methods and Results. Children with mechanical symptoms of lateral meniscal instability were assessed by MRI scan. In those with a lateral discoid meniscus an arthroscopic examination was performed to identify the presence of tears and confirm the radiological diagnosis. No incomplete or Wrisberg variant types were encountered. An antero-lateral arthrotomy was performed. The anterior horn of the meniscus was mobilized and traction sutures inserted. Flexion and extension of the knee whilst traction was applied led to delivery of the anterior horn into the wound. After confirmation of position with image intensifier a groove was fashioned in the anterior aspect of the cartilaginous portion of the proximal tibial epiphysis. Typically three titanium bone anchors with non absorbable sutures were placed in the base of the groove. The anterior horn of the meniscus was drawn into the groove and anchored with sutures. Active range of motion exercises were encouraged but a canvas knee immobilizer was employed whilst walking for the first six weeks. Four boys and three girls underwent meniscopexy performed at a mean age of 9.4 years (range 5.7 to 12.4 years). Follow up was at a mean of 4.9 years. At last follow up no patient reported symptoms of locking or pain. No patient has required revision surgery but one girl had a subsequent meniscopexy procedure on the opposite knee. Five of the children have had Lysholm scores performed at last follow up averaging 93.5 (80 to 100 points). Conclusion. Complete lateral discoid menisci in children can be rendered asymptomatic in the medium term by re-tensioning the anterior horn

This paper evaluates severe normal trunk asymmetry (TA) by higher and lower body mass index (BMI) values in 5953 adolescents age 11–17 years (boys 2939, girls 3014) whilst standing forward bending (FB) and sitting FB during screening for scoliosis. TA was measured as angle of trunk inclinations (ATIs) across the back (thoracic, thoracolumbar and lumbar) with abnormality defined as 2 standard deviations or more. The findings for sitting FB position are reported because the readings express TA free from any leg-length inequality. Relatively lower BMIs are associated statistically with. excess of abnormal TAs, and. later menarche. BMI is known to be linked to puberty timing and energy balance but not to TAs in healthy students. Similar to girls with adolescent idiopathic scoliosis, we suggest that severe TA is caused by a genetically-determined selectively increased hypothalamic sensitivity to leptin with asymmetry as an adverse hormetic response, exacerbated by presumed lower circulating leptin levels associated with relatively lower BMIs. The asymmetry is expressed bilaterally via the sympathetic nervous system to produce left-right asymmetry in ribs and/or vertebrae leading to severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk

In 11 paediatric patients (seven girls and four boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation and ligamentous laxity vastus medialis advancement, lateral release, partial patellar ligament transposition and Galeazzi semitendinosus tenodesis was undertaken to stabilise the patella. The diagnostic criterion for ligamentous laxity was based on the Beighton scale. Outcomes were evaluated radiologically and functionally by measurement of the range of knee movement and isokinetic testing. The evaluation also included the Lysholm knee scale. Follow-up studies took place at a mean of 8.1 years (5 to 15) post-operatively. Normal patellar tracking without any recurrence of dislocation was obtained in ten out of 11 patients. Pain related to vigorous activity was reported by nine patients. Compared with the opposite normal side, the isokinetic tests revealed a statistically significant decrease in the maximal torque values for the affected quadriceps muscle (p = 0.003 and p = 0.004), but no difference between the knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858 and p = 0.79). The applied surgical technique generally prevents the recurrence of the disorder in children with habitual patellar dislocation and ligamentous laxity. Quadriceps muscle weakness can be expected to occur post-operatively,. Cite this article: Bone Joint J 2015;96-B:129–33

We report the case of an eight-month-old girl who presented with a poliomyelitis-like paralysis in her left upper limb caused by enterovirus 71 infection. She recovered useful function after nerve transfers performed six months after the onset of paralysis. Early neurotisation can be used successfully in the treatment of poliomyelitis-like paralysis in children

Lumbar spondylolysis is a stress fracture of the pars interarticularis. We have evaluated the site of origin of the fracture clinically and biomechanically. Ten adolescents with incomplete stress fractures of the pars (four bilateral) were included in our study. There were seven boys and three girls aged between 11 and 17 years. The site of the fracture was confirmed by axial and sagittal reconstructed CT. The maximum principal tensile stresses and their locations in the L5 pars during lumbar movement were calculated using a three-dimensional finite-element model of the L3-S1 segment. In all ten patients the fracture line was seen only at the caudal-ventral aspect of the pars and did not spread completely to the craniodorsal aspect. According to the finite-element analysis, the higher stresses were found at the caudal-ventral aspect in all loading modes. In extension, the stress was twofold higher in the ventral than in the dorsal aspect. Our radiological and biomechanical results were in agreement with our clinical observations

Total hip replacement (THR) in children and very young teenagers is experimental since we do not know long-term results in these. We investigated the clinical and radiographic outcomes of THR performed in children and teenage patients identified in the Norwegian Arthroplasty Register. We included 111 patients (132 hips) who underwent THR before 20 years of age., together with information on the primary diagnosis, types of implants, and any revisions that required implant change. Radiographs and Harris hip score (HHS) were evaluated for patients that attended clinical follow-up. The mean age at primary THR was 17 (11–19) years, 60% were girls. Mean follow-up time was 14 (3–26) years. The 10-year survival rate after primary THR (with endpoint any revision) was 70%. Survival was better for the patients operated after 1996 (10 y 50% vs 90%). 39 patients had at least 1 revision and 16 patients had 2 or more revisions. In the latest radiographs, osteolysis and atrophy were observed in 19% and 27% of the acetabulae and 21% and 62% of the femurs, respectively. The mean HHS at the final follow-up was 83 (15–100). EQ-5DVAS was 74 (82 in normal population). The clinical scores after THR in these young patients were acceptable, but many revisions had been performed. The bone stock in many patients was poor, which could complicate future revisions

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome. We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027). This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes. Cite this article: Bone Joint J 2015;97-B:134–40

We present a case of late dislocation of the hip in a 30-month-old girl. Her hip was clinically stable at birth and an ultrasound scan at six weeks was normal. She had no additional risk factors for developmental dysplasia. She underwent anterior open reduction with a femoral osteotomy

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

Department of Epidemiology, ASL RM/E, Rome, Italy. School of Health and Social Care, University of Teesside, Middlesbrough, UK. Faculty of Health, Staffordshire University, Stoke on Trent, UK. Orthopaedic and Trauma Department, “Tzanio” General Hospital of Piraeus, Greece. University of Medical Sciences, Poznan, Poland. Department of Orthopaedic Surgery, Saitama Medical University, Kawagoe, Japan. Thriasio General Hospital, Athens, Greece. To evaluate the efficacy of bracing in adolescent patients with AIS. Cochrane systematic review. The following databases were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINHAL and reference lists of articles. Extensive hand searching of grey literature was also conducted. RCT's and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces were included. Two review authors independently assessed trial quality and extracted data. Two studies were included. There was very low quality evidence from one prospective cohort study including 286 girls. 1. indicating that braces curbed curve progression, at the end of growth, (success rate 74%), better than observation, (34%) and electrical stimulation (33%). Another low quality evidence from one RCT with 43 girls indicated that a rigid brace is more successful than an elastic one (SpineCor) at limiting curve progression when measured in Cobb degrees. 2. No significant differences between the two groups in the subjective perception of daily difficulties associated with brace wearing were found. There is very low quality evidence in favour of using braces, making generalization very difficult. The results from future studies may differ from these results. In the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes as well as measures such as Cobb angles. RCTs and prospective cohort studies should follow both the SRS and the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies

The incidence of congenital dislocation of the hip in 156 children with infantile idiopathic scoliosis was 6.4 per cent, approximately 10 times its frequency in the general population. In both of these deformities there was a predominance of girls (eight girls: two boys). In unilateral dislocation of the hip the convexity of the thoracic scoliosis was on the same side as the dislocation. Eight out of the 10 children with both deformities also had plagiocephaly