Aims. Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs. Methods. A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters. Results. From 91 eligible studies, 27 individual outcomes were identified, including those related to clinical assessment (n = 12), mobility (n = 4), adverse events (n = 6), investigations (n = 4), and miscellaneous (n = 1). Ten outcome measurement tools were identified, of which Hoffer’s Functional Ambulation Scale was the most commonly used. Several studies used unvalidated measurement tools originally developed for other conditions, and 26 studies developed new measurement tools. On the OMERACT filter, most outcomes reported pathophysiology and/or the impact on life. There were only six patient- or parent-reported outcomes, and none assessed the quality of life. Conclusion. The outcomes that were reported were heterogenous, lack validation and failed to incorporate patient or family perceptions. Until outcomes can be reported unequivocally, research in this area will remain limited. Our findings should guide the development of a core outcome set, which will allow consistency in the reporting of outcomes for this condition. Cite this article: Bone Joint J 2024;106-B(3):277–285

This study aimed to determine the major diagnoses and needs of children in Rwanda with musculoskeletal conditions to enable the Rwandan government to begin to plan orthopaedic and rehabilitation services. BACKGROUND. When faced with developing orthopaedic services for children in Sub-Saharan Africa, there is little objective evidence-based data on the magnitude and type of services needed. Rwanda is a small country that is in the process of developing orthopaedic and rehabilitation services, and its Ministry of Health supported a survey that would provide information necessary for planning such services. METHODS. A national survey of musculoskeletal impairment (MSI) prevalence was undertaken. Of a population of 8.4 million, 8368 people were enumerated. Four thousand one hundred thirty-four were aged 16 years or less. Cases who failed a screening test for MSI were examined, allocated a diagnostic category, and assessed as to treatment needed. RESULTS. Of 4134 people aged 16 years or less who were enumerated, 3526 (85%) were screened and 91 had MSI, giving a prevalence of MSI among children of 2.58% (95% confidence interval; 2.06-3.10). Twenty-three percent of MSIs were a result of congenital deformity, 14% neurologic conditions, 12% trauma, 3% infection, and 46% other acquired pathology. Of the MSIs, 56.7% were mild, 37.8% moderate, and 5.6% severe. Extrapolated treatment needs suggest that 2% of Rwandan children (approximately 80,000) need orthopaedic physical therapy, 1.2% (50,000) need orthopaedic surgery, and approximately 10,000 need orthopaedic appliances. CONCLUSIONS. These results will be of use in planning future paediatric orthopaedic services in Rwanda, and for comparative studies in other low-income countries

Aims

The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip.

Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients. Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity

Aims

The aim of this study was to inform the epidemiology and treatment of slipped capital femoral epiphysis (SCFE).

Identification of the paediatric orthopaedic patient at high risk of venous thromboembolism (VTE) can allow a targeted approach to thromboprophylaxis. There is currently no national consensus on the correct method of risk assessment in this patient group. The Royal National Orthopaedic Hospital has developed a guideline using the evidence available to allow stratification of risk for the paediatric orthopaedic patient. A list of departments offering specialist paediatric orthopaedic surgery was obtained from the member list of the British Society of Paediatric Orthopaedic Surgeons (BSCOS). These hospitals were contacted via telephone interview to determine if they have a specific guideline or risk assessment proforma for paediatric VTE risk. A total of 74 hospitals were identified with a specialist paediatric orthopaedic practice in the United Kingdom. A response rate was gained from 100% of these hospitals. Only 3/74 of these hospitals had a guideline or protocol in place for the formal assessment of VTE risk in the paediatric patient (Royal National Orthopaedic Hospital, Stanmore; Sheffield Children's Hospital; Barts & the London NHS Trust). All three hospitals were able to provide details of their guideline. Both the RNOH and Barts & the London commented that their guideline was based on that of the Sheffield group, with adaptations for their own requirements. The majority of hospitals in the UK with a paediatric orthopaedic interest do not have guidance available for the management of VTE risk. Presented here is the outcome of using the limited evidence available, in combination with expert opinion, to develop a guideline suitable for the requirements of a paediatric unit in an orthopaedic hospital. This may be of benefit to other units producing their own guidelines, producing thought and discussion as to the specific requirements of paediatric patients undergoing orthopaedic procedures

The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery. A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation. This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications. The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females. The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken. The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery

Meningococcal septicaemia from meningococcal infection is a devastating illness affecting children. Advances in medical management have reduced the mortality rate to approximately 15 to 20% and children who survive can develop late orthopaedic sequelae from growth plate arrests with resultant complex deformities. Our aim in this study was to review and analyze the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author. We describe a treatment strategy to address the multiple deformities that may occur in these patients. Methods & Results Between 1990 and 2009, 12 patients were treated for late orthopaedic sequelae after meningococcal septicaemia by the senior author. There were 8 girls and 4 boys. All patients had lower limb involvement. 1 patient had involvement of the upper limb requiring treatment. Each patient had had a mean of 3 operations (range from 2 to 9). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. At final follow-up 9 of the 12 patients were skeletally mature. In 9 patients limb length discrepancy in the lower limb was corrected to within 1 cm, with normalization of the lower limb mechanical axis. Conclusion. Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests leads to limb length discrepancy, and partial growth plate arrests leads to an angular deformity. In addition, limb amputations may occur and there may be altered growth of the stump requiring further surgery. In cases of central growth arrest with limb shortening alone, limb equalisation is performed with limb lengthening procedures. In cases of partial growth arrests, angular correction is performed together with ablation of the affected growth plate. We recommend ablation of the affected growth plates at the initial surgery to prevent recurrence of angular deformity. Angular correction can be performed acutely, with a dome or transphyseal osteotomy; or gradually, with application of Ilizarov or Taylor Spatial frames. Severe deformities of the tibial plateau are treated by plateau elevation with bone graft augmentation. With the appropriate strategy deformities can be corrected and further lengthening procedures can be undertaken if necessary. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity

The aim of our survey was to study the current practice to manage DDH in UK by the members of the British Society for Children's Orthopaedic Surgery. An online questionnaire link to ask about the management of DDH was emailed to 204 members of the British Society for Children's Orthopaedic Surgery. The response rate was 39%. 73% respondents have a local screening programme, 19% screen only high risk children and 8% had no screening programme. Pavlik harness was used by 87% respondents for Graf Type 2, 96% for Graf type 3 and 90% for Graf type 4. 14% respondents will only observe for Graf Type 2. 36% respondents will follow up children every week, 45% every 2 weeks, 3% every 3 weeks, 9% every 4 weeks, 4% every 6 weeks and 3% will decide the follow up according to severity of DDH and treatment.1.3% respondents will follow up these patients for 6 months, 13% for 12 months, 10.5% each for 24 months, 36 months, 48 months and 50% until skeletal maturity. After the failure of initial splintage, 7% respondents will consider surgery immediately, 13.5% at 3 months, 36.5% at 6 months, 4% at 9 months, 28% at 12 months, 5.4% according to HIP-OP Trial and 5.6% according to the situation. There was no consensus about the treatment of DDH. 73% respondents have a local screening programme. The most common splintage method used was Pavlik harness. 45% respondents will follow up children every 2 weeks following the start of treatment. 50% respondents will follow up these patients until skeletal maturity. 36% respondents will consider surgery at 6 months following the failure of splintage. This survey highlights the fact that the management of DDH is an art based on the scientific evidence, parent's choice and personal expertise

Purpose. Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning. Method. A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under. Results. There were 800 interventions which should have been coded over 148 patient episodes. Of these 442 (55%) were not coded, 189 (24%) were coded inappropriately and 169 (21%) were coded correctly. The HRG3.5 group was coded 18% correctly, the HRG4 29% correctly. However, 70% of the HRG4 and 49% of the HRG 3.5 group were inaccurately grouped. The resulting deficit was a £54,352 (HRG4-£36,711, HRG3.5-£17,641) an average of £507 per patient stay. A conservative estimate of 150 ward admissions monthly means a projected loss of £912,600 per annum. The fractured radius and ulna group (one of the most common causes of admission) suffered greatest financial losses. Additional losses come from paediatric/orthopaedic top-ups (63% and 14% respectively) as only one can be applied to each HRG. Conclusion. The implementation of HRG4 means accuracy is crucial as smaller inaccuracies result in bigger costing discrepancies than with HRG 3.5. Financial losses are larger with paediatric orthopaedics from inadequate top-ups. This system of Payment by Estimates not Results is only acceptable if financial underestimates are balanced with financial overestimates. These results strongly suggest this is not happening

Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities

Aim. The use of intraoperative cell salvage as a tool for reducing allogenic transfusion has been demonstrated in pelvic osteotomies. The aims of this audit were to identify any problems or complications with cell salvage, reduction in allogenic transfusion and identify procedures that would benefit. Methods. The use of cell salvage and allogenic transfusions were prospectively recorded over a 27-month period for all those who had major non spinal surgery looking at whether cell-salvage reduced allogenic transfusions and where cell salvage was used it was matched to procedure, diagnosis and age with cases where it was not used over the same time period. Results. Cell salvage was used in 61 cases. For these, average blood loss was 624mls and re-transfused volume 176mls (range=0-888mls). There were no complications. 4 problems occurred, 2 where suction became desterilised and 2 with insufficient sample to process. Of those that were matched, 3/55 cases required allogenic transfusion versus 11/55 that did not have cell salvage (p=0.03). Sub group analysis according to procedure did not reach significance. Excluding those with osteogenesis imperfecta, no isolated femoral osteotomy required allogenic transfusion (total number=48). Conclusion. Overall its use has reduced the number of children receiving allogenic blood and negates the need to cross match preoperatively. Group and save sample is probably sufficient for most major paediatric orthopaedic surgery with cell salvage. The specific indications for cell salvage have not been identified by this study, though useful in OI

Aim. Assess the incidence of Vitamin D deficiency from a cohort of new referrals to a general Paediatric Orthopaedic outpatient clinic and evaluate the relationship between Vitamin D deficiency and the diagnosis of radiological or biochemical nutritional rickets. Methods. We performed a retrospective case note and biochemistry database review of all new patients seen in an elective Paediatric Orthopaedic clinic in the year 2010, who had Vitamin D levels measured. Radiographs were reviewed by the senior author to determine the presence or absence of radiological rickets. Biochemical rickets was diagnosed if there was deficient Vitamin D (< 20 mcg/ml) and raised PTH. Results. We identified 115 children with a mean age of 10.95 years (95% CI 10.24 to 11.68). There were 63 females, 52 males and 51 were of Asian ethnicity. The mean vitamin D level was 18.27mcg/ml (95% CI 16.13 to 20.41). One hundred and three patients (88%) were found to have sub-optimum vitamin D levels. Although, males and those of Asian origin were more likely to be deficient, this was not statistically significant. Winter/Springtime blood sampling was statistically more likely to show Vitamin D deficiency than in Summer/Autumn. Three Asian female children (2.61%) had radiological rickets. The association between low Vitamin D levels (< 20) and radiological or biochemical rickets had poor positive predictive values PPV. Conclusion. Suboptimal Vitamin D levels are common in children presenting with vague limb or back pain, suggesting ‘growing pains’ might reflect deficiency. Vitamin D levels cannot be used as a screening test for the diagnosis of radiological or biochemical ‘rickets’ due to its poor Positive Predictive Value. Further research into Vitamin D requirement is necessary, particularly in relation to growth and age, as growth is not linear and Vitamin D requirement is likely to vary accordingly

Purpose. To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact. Methods. We reviewed the medical records of 12 consecutive patients presenting to our unit. Radiographic analysis of deformity included assessment of mechanical axis and dysplasia at hip, knee and ankle measured by acetabular index (AI), Reimer's migration percentage (MP), neck-shaft angle, distal lateral femoral (aDFLA) and proximal (mMPTA) and distal tibial angles. The paediatric/adolescent PODCI questionnaires and the SF36 were used to assess quality of life issues. Results. 12 patients (9 female) were reviewed at median age 18yrs (range 12-43yrs). Most symptoms related to walking tolerance, joint discomfort and deformity: 9 patients had genu varum, 7 tibial torsion, 2 patella instability and 3 significant low back pain. All patients had hip dysplasia. 10 had medial displacement of the mechanical axis, with a mean mDFLA 105 deg (88 -128) and mMPTA 75deg (51-90). 2 patients have been treated only with growth hormone; 10 patients have undergone a total of 9 distal femoral, 19 proximal tibial and 2 supramalleolar osteotomies. 6 procedures were performed using an external fixator. 7 limb segments have been treated by guided growth and in all these cases alignment has improved. One patient has had bilateral hip arthroplasties (age 29), a second patient has had bilateral patellectomies. These 10 patients have undergone a mean 3.8 operative procedures on a mean 2.4 occasions. Patients scored less well than their peer groups in all domains of the PODCI assessment. All have maintained some independent mobility. Conclusions. PSACH is a severe skeletal dysplasia with deformity at all levels of the lower limb affecting patient satisfaction and quality of life. Knee deformities are those which most frequently require surgical intervention. Significance. The genetic defect in PSACH differs from that in achondroplasia, joint degeneration is more common and maintenance of limb alignment is essential

Introduction. Albania is one of the poorest countries in Western European with a GDP per capita standing at 26 percent of the EU average in 2010. Whilst there is government-funded universal free provision of healthcare, it is accepted that delivery is patchy, not accessible to all and lacking expertise for more complex paediatric orthopaedic conditions. With the sponsorship of a UK-based charity, we have set up and completed 5 visits to Albania (3 assessment and 2 operative) to provide additional expertise for paediatric orthopaedic disorders running parallel to and utilising currently available local services. We present the results of this treatment and training programme to date. Patients and methods. Between 2008 and 2011, we assessed 204 children and adolescents with paediatric orthopaedic disorders in Tirana and Durres on 3 separate visits. Of these, 28 were listed for surgical procedures whilst the rest were treated non-operatively. Of the listed patients, 14 patients underwent surgical intervention (total of 18 procedures). Results. The most common diagnoses were developmental dysplasia of the hip, club feet, cerebral palsy and scoliosis. Most patients were treated non-operatively with advice and/or reassurance. Of those listed for surgery, the reasons for cancellation included problems with access to the treating hospital and failure to establish patient contact on the day of admission. Of the operated patients, the procedures performed, the perioperative challenges and significant complications (2/18) will be discussed. Conclusion. Although it is viable to establish parallel service delivery of paediatric orthopaedic surgical services in countries such as Albania, the perioperative and social challenges must be considered

Purpose This was an observational study to determine the prevalence of 25-hydroxyvitamin D (25[OH]D deficiency in our paediatric orthopaedic patient population. Methods We have measured serum 25(OH)D levels in 44 paediatric patients who presented with bone pain. None of these patients had a pre-existing diagnosis of 25(OH)D deficiency. The age of patients ranged from 11 months to 16.5 years. There were 23 female and 21 male patients. The range of diagnoses included hip pain/irritable hip (4), Blount's disease (4), developmental hip dysplasia (7), genu valgum (3), Legg Calve Perthes’ disease (6), slipped capital femoral epiphysis (11), knee pain (3), other (6). Those found to be 25(OH)D deficient underwent further biochemical investigation and were referred for paediatric endocrinology review with a view to vitamin D supplementation. Results We found 9 patients (20%) with serum 25(OH)D levels of <20ng/mL indicating 25(OH)D deficiency. 17 patients (39%) had serum 25(OH)D levels in the range 20-30ng/mL indicating possible deficiency. The remaining 18 patients (41%) had a normal level of 25(OH)D. There was no association between low serum 25(OH)D level and any specific diagnosis, nor with gender or age of patient. There was, however, a statistically significant difference between the serum 25(OH)D level in those patients with unexplained joint pain (mean 22.5ng/mL) and those with other diagnoses (mean 30.7ng/ml) (P<0.05). Conclusion Our results are consistent with other recent prevalence studies showing a concerning level of 25(OH)D deficiency among the paediatric population, and may suggest an increasing burden of disease in the coming years arising from the problem

The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children's Orthopaedic Surgery (BSCOS). A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test. The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P<0.0001). 52.6% (58/110) of surveyed BSCOS members would offer surgery for an unstable SCFE between 1 and 7 days after onset of symptoms. Single screw fixation in situ was advocated by 96.4% (106/110) and 70.9% (78/110) while corrective osteotomy was preferred by 1.8% (2/110) and 26.4% (29/110) of respondents for the mild and the severe stable slips respectively (P<0.0001). Surgeons preferring osteotomy are more likely to perform an intracapsular technique. Prophylactic fixation of the contralateral normal hip was performed by 27.3% (30/110) of participants. There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached

Most children with spastic hemiplegia have high levels of function and independence but fixed deformities and gait abnormalities are common. The classification proposed by Winters et al is widely used to interpret hemiplegic gait patterns and plan intervention. However, this classification is based on sagittal kinematics and fails to consider important abnormalities in the transverse plane. Using three-dimensional gait analysis, we studied the incidence of transverse-plane deformity and gait abnormality in 17 children with group IV hemiplegia according to Winters et al before and after multilevel orthopaedic surgery. We found that internal rotation of the hip and pelvic retraction were consistent abnormalities of gait in group-IV hemiplegia. A programme of multilevel surgery resulted in predictable improvement in gait and posture, including pelvic retraction. In group IV hemiplegia pelvic retraction appeared in part to be a compensating mechanism to control foot progression in the presence of medial femoral torsion. Correction of this torsion can improve gait symmetry and function

Peripheral limb ischaemia is rare in children. We have treated only 12 infants and children with this condition in the past 15 years at the Royal Hospital for Sick Children in Glasgow. There were nine neonates and three older children. Most were suffering from life-threatening illnesses or severe infection. Two were born with ischaemic arms with no apparent cause. We have analysed the factors leading to ischaemia, the outcome of the initial treatment and the later orthopaedic problems. Two required amputation of both legs, one of an arm, two of feet and one of toes. Two had skin grafts. All surgery was performed after demarcation was well established and delayed closure was used after amputation. Five children developed limb-length discrepancy or an angular deformity. To date two have required additional corrective surgery

The aim was to determine reliability in treatment threshold based on USS angular measurements between observers involved in the DDH hip screening programme at the NOC and assess the effect of image orientation on the accuracy of these measurements.

3 independent observers measured alpha and beta angles on bilateral hips in 10 consecutive patients seen in the DDH hip screening clinic. All scans were performed by a single radiographer and observers used the same set of USS images for a given patient. Each observer measured alpha and beta angles a total of 4 times: conventional ultrasound image projection (with the ilium horizontal) (round 1), Graf's anatomical projection (round 2), and both techniques repeated 1 month later (round 3 and 4 respectively) to assess intra-observer reliability. To determine its effect on treatment threshold taking into account alpha and beta angles and patient's age, the consistency between observers' management recommendations was evaluated for each round. Possible outcomes were: 1) patient discharged, 2) no treatment needed yet, but follow-up required, 3) start treatment.

Intra-observer reliability for conventional projection was moderate (Kappa 0.58), and improved for anatomical projection (Kappa 0.65). Inter-observer reliability, as a surrogate measure of consistency in management recommendations between observers, ranged from fair to moderate across the 4 rounds (Kappa 0.30 – 0.50). However, contrary to previous recommendations, reliability was better with conventional projection (Kappa 0.41 (95% CI 0.11–0.72)) compared to anatomical projection (Kappa 0.36 (95% CI −0.01–0.73)). The overall agreement in management recommendations, pooling all results across 4 rounds, was 51.3% (Kappa 0.39 (95%CI 0.15–0.63)).

This audit supports the argument that anatomical image projection improves intra-observer consistency. However, as with all USS measurements, angular measurements were highly user dependent and treatment threshold based on USS may not be as consistent as anticipated.