Introduction. This is a report of the outcome of management of congenital pseudoarthrosis of the tibia (CPT) at skeletal maturity. Materials and Methods. Retrospective study. Inclusion criteria:. CPT Crawford IV. Skeletally maturity. Availability of radiographs and medical records. Outcome: union rate, healing time, residual deformities, ablation and refracture. Results. 23 patients who reached maturity were analysed. Time to union was 7.6 months. Union rate 70%. External fixation group: 7 patients, age 6.1 years, all united, 1 needed Bone graft. Average union time 8.2 months, no residual mal-alignment, no amputations, 2/7 needed corrective osteotomies and residual LLD in 2/7 < 1 cm. Numbers of surgery was 3. Vascularized fibular graft was done in 3 cases; all had failed previous attempts. Union time was 7 months. 2/3 united, 1 had amputation due to extensive disease. All patients had residual mal-alignment. Rodding group included 13 patients, age 3.2 years, union rate 61%, union time 8.3 months. Average LLD 1 cm with 1 patient LLD > 2 cm. Residual knee mal-alignment in 2/13, 4 had procurvatum and 55% of patients had ankle valgus. Fibula pseudoarthrosis. Refracture was reported in 53% of the rodding group. The causes of refracture were mal-alignment in 3, traumatic in 2 and idiopathic in 2. Total surgeries no 5. 2 patients had amputations after an unsuccessful 1. st. attempt. Our current trend of treatment was applied on 8 patients. They are not skeletally mature yet. the treatment combined excision of hamartoma, tibial rodding, wrapped periosteal graft with/out neutralization frame, and fibular fixation. Average age 3.8 years, union time was 10 months, Union rate 80%, no residual deformities. Conclusions. Our study shows the evolution of the treatment of CPT with increasing union rate, fewer residual deformities, and numbers of surgeries with more recent techniques

It is generally accepted that children treated for congenital pseudarthrosis of the tibia (CPT) should be followed-up until skeletal maturity, before drawing conclusions about the efficacy of treatment. We undertook this study in order to evaluate the long-term results of treatment of CPT by excision of the pseudarthrosis, intramedullary rodding and onlay cortical bone grafting. Among a total of 46 children with CPT treated by a single surgeon during a 20-year period, 38 had been treated by this technique and 11 of these children have reached skeletal maturity. These eleven cases (nine boys and two girls) formed the basis for this study. The mean age at presentation was 3.1 years (range 0.4–7 years); the mean age at index surgery was 3.2 years (range 0.7–7 years). The mean age at follow-up was 18.4 years (range 16–21.6 years) with a mean interval between surgery and final follow-up of 15.2 years (range 12.8–17.4 years). In all 11 children bone graft was harvested from the contralateral tibial diaphysis. Rods passed from the heel were used in nine children and in two Sheffield telescopic rods were passed from the ankle into the tibia. The fibula was divided in three children to ensure that the tibial fragments were in good contact before placing the graft astride them; the fibula was not touched in the remaining eight instances. To ensure that the intramedullary rod supported the pseudarthrosis site till skeletal maturity, revision rodding was performed as needed when the tip of the rod receded into the distal third. A thermoplastic clamshell orthosis was used till skeletal maturity. At final follow-up the union at the pseudarthrosis site was deemed to be ‘sound’ only if two independent observers concurred that there was definite bony continuity of the cortices on both the anteroposterior and lateral radiographs. Deformities of the tibia and ankle and ranges of motion of the knee, ankle and subtalar joints were noted. The limb lengths were measured with scanograms. The morbidity at the bone graft donor site was recorded. The function of the ankle was assessed by applying the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Score. Primary union of the tibial pseudarthrosis was achieved in nine of 11 cases with a mean time to union of 6.1 months. Secondary union was achieved in the remaining two cases following further intervention. At final follow-up sound union of the tibial pseudarthrosis was noted in all eleven patients but persistent pseudarthrosis of the fibula was present in 10 of 11 cases. The lateral malleolus was proximally situated in six cases. Ten of eleven children underwent a total of 21 secondary operations on an average of 2.6 years (range 0.5–5.1 years) after initial union was achieved. Six re-fractures were encountered in five patients at a mean of 6.1 years after index surgery. All the re-fractures united following the single episode of intervention. The overall mean shortening at final follow-up was 2.6 cm. At final follow-up, five patients had ankle valgus greater than 10 degrees. All the 11 patients walked without pain. Only two patients had significant motion at the ankle. Despite the ankle stiffness in the remaining children the AOFAS ankle-hindfoot scores ranged between 70 and 98 (mean 83.3). Our long-term results are comparable to the results of other studies in terms of the rate of union, the re-fracture rate, limb length discrepancy, residual deformity and the frequency of surgery

Natural history of AIS >30° in skeletally mature patients is poorly defined. Studies reporting rates and risk factors for progression are predominantly of large curves in immature patients. Our aim was to determine the rate of curve progression in AIS following skeletal maturity, any associated changes in SRS-22 scores, and identify any potential predictors of curve progression. Patients enrolled in a prospective, longitudinal, multicentre non-surgical AIS database were evaluated. All patients had minimum 2 year follow-up, idiopathic scoliosis >30°, and were skeletally mature. SRS-22 functional outcome scores and radiographic data were compared at baseline and 2-year follow-up. Patients were divided into 3 groups based on curve size: A=30°-39°, B=40°-49°, C= >50°. Curve progression was defined as any change in curve magnitude. There were 80 patients, majority females (93.8%) with a mean age of 16.5+/−0.16. Mean BMI was 21+/−0.31 with 15.1% overweight. Mean major cobb at baseline was 38.3°+/−0.88°. At 2 year follow-up 46.3% of curves had progressed an average 3.4°+/−0.38°. Of curves that progressed, patients in group A had the largest mean rate of progression followed by group B. SRS-22 scores on average declined significantly over 2 years in this cohort (4.23 to 4.08; p=0.002). Patients who progressed had on average a more significant decline in SRS outcome scores compared to those that did not (p=0.018, p=0.041 respectively), with the most significant change noted in the Self-Image domain (p=0.03). There was no significant difference in the change in SRS scores over 2 years based on curve size. Univariate analysis did not identify any factors predictive of curve progression in this cohort. Skeletally mature patients with AIS >30°may continue to have a risk of progression at a mean rate of 1.7°/yr and significant decline in SRS-22 outcome scores, in particular Pain and Self-Image, over time

Introduction. Legg-Calvé-Perthes disease (LCPD) often results in femoral head deformity and leg length discrepancy (LLD). Objective of this study was to analyse femoral morphology in LCPD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalisation on proximal and subtrochanteric femoral lengths. Materials and Methods. All patients treated for LCPD in our institution between January 2013 and June 2020 were retrospectively reviewed. Patients with unilateral LCPD, LLD of ≥5mm and long leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD) and subtrochanteric femoral length were compared between LCPD side and unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis. Results. 79 patients were included, 21/79 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort the average LLD was 1.8cm (95% CI 1.5 – 2.0), average ATD difference was 1.8cm (95% CI −2.1 – −1.9) and average subtrochanteric difference was −0.2cm (95% CI −0.4 – 0.1). In the epiphysiodesis group the average LLD before epiphysiodesis was 2.7 (1.3 – 3.4) cm and 1.3 (−0.5 – 3.8) cm at skeletal maturity. In the non-epiphysiodesis group the average LLD was 2.0 (0.5 – 5.1), p=0.016. The subtrochanteric region on the LCPD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the non-epiphysiodesis group: −1.0 (−2.4 – 0.6) versus 0.1 (−1.0 – 2.1), p<0.001. Conclusions. This study concludes that LLD after LCPD originates from the proximal segment only. In patients who had had a contralateral epiphysiodesis, the subtrochanteric femoral region was significantly longer on the LCPD side. These anatomical changes need to be considered by paediatric surgeons when advising leg length equalisation procedures, and by arthroplasty surgeons when LCPD patients present for hip arthroplasty

Introduction. Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Materials & Methods. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). Results. The median initial LLD was 39.0 mm (35.0–45.0). 21 patients (84%) presented valgus and 4 (16%) showed varus malalignment. Leg length equalization was achieved in 13 patients at skeletal maturity (62%). The median LLD of patients with a residual LLD > 10 mm was 15.5 mm (12.8–21.8). Limb realignment was obtained in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Conclusions. The combination of antegrade femoral lengthening and tHED can efficiently correct LLD and coronal limb malalignment in skeletally immature patients. Nevertheless, achieving limb length equalization and realignment may render difficult in cases of severe LLD and angular deformity. Furthermore, the reported techniques ought to be thoroughly planned and executed and require regular clinical and radiological examinations until skeletal maturity to avoid - or timely detect and manage - adverse events such as overcorrection and rebound of deformity

Introduction. Leg length discrepancy (LLD) in patients with unilateral developmental dysplasia of the hip (DDH) can be problematic for both patients and surgeons. Patients can acquire gait asymmetry, back pain, and arthritis. Surgical considerations include timing of correction and arthroplasty planning. This study audits standing long leg films performed at skeletal maturity in our patients. The aim of this study is to identify if surgical procedure or AVN type could predict the odds of needing an LLD Intervention (LLDI) and influence our surveillance. Materials and Methods. Hospital database was searched for all patients diagnosed with DDH. Inclusion criteria were patients with appropriately performed long leg films at skeletal maturity. Exclusion criteria were patients with non DDH pathology, skeletally immature and inadequate radiographs. All data was tabulated in excel and SPSS was used for analysis. Traumacad was used for measurements and AVN and radiologic outcome grades were independently classified in duplicate. Results. 110 patients were identified. The mean age of follow-up was 15 years with final average LLD of 1mm(±5mm). The DDH leg tended to be longer and length primarily in the femur. 31(28.2%) patients required an LLDI. 19 Patients had a final LLD >1.5cm. There was no statistical significant difference in the odds of needing an LLDI by type of surgical procedure or AVN. AVN type 4 was associated with greatest odds of intervention. The DDH leg was more likely to require ipsilateral epiphysiodesis or contralateral lengthening in Type 1 and 2 AVN. Conclusions. The DDH leg tends to be longer, leg lengths should be monitored, and leg length interventions are frequently required irrespective of previous DDH surgical procedure or the presence of AVN

Purpose. The incidence of hip displacement in children with cerebral palsy is approximately 30% in large population based studies. The purpose of this study was to report the long-term effect of hip surgery on the incidence of hip displacement using a newly validated Cerebral Palsy (CP) hip classification. Method. Retrospectively, a sub-group of 100 children who underwent surgery for hip displacement were identified from a large-population based cohort of children born with CP between January 1990 and December 1992. These children were followed to skeletal maturity and closure of their tri-radiate cartilage. All patients returned at maturity for clinical and radiographic examination, while caregivers completed the disease specific quality of life assessments. Patients were grouped according to motor disorder, topographical distribution and GMFCS. Radiographs were independently graded according to CP hip classification scheme to ensure reliability. Surgical Failures were defined as CP Grade > IV. Results. Ninety-seven children and 194 hips were available for final review. According to GMFCS, greater than half the children were GMFCS IV and V (67/94, 67%), 12 were II and 18 were III. Fifteen hips were dislocated or had salvage surgery for dislocation (15/194, 7.7%) at time of skeletal maturity. The majority of hips were graded Grade II and III (149/194, 76.8%). A total of 39 (39/194, 20%) hips were classified as surgical failure with 95% (37/39) hips occurring in GMFCS IV and V children. Conclusion. Using the CP hip classification scheme, the natural history and outcome of 100 children with CP at skeletal maturity have been described. Despite hip surveillance and surgical intervention GMFCS IV and V children are at the greatest risk for surgical failure at skeletal maturity. In this study, the majority of failures were associated with either no hip surveillance and/or index surgery at a non-specialist centre. In contrast, hip surveillance and index surgery at a specialist tertiary centre was associated with a very high probability of a successful outcome. This is the first population based cohort study of children with cerebral palsy followed from index surgery to skeletal maturity for hip displacement. Surgical success rates for the treatment of hip displacement in children with cerebral palsy have not previously been reported. This information will aid surgeons in the treatment of hip displacement in children with cerebral palsy

Minimally displaced paediatric proximal humerus fractures (PHFs) can be reliably managed non-operatively, however there is considerable debate regarding the appropriate management of severely displaced PHFs, particularly in older children and adolescents with limited remodelling potential. The purpose of this study was to perform a systematic review to answer the questions: “What are the functional and quality-of-life outcomes of paediatric PHFs?” and “What factors have been associated with a poorer outcome?”. A review of Medline and EMBASE was performed on 4. th. July 2021 using search terms relevant to PHFs, surgery, non-operative management, paediatrics and outcomes. Studies including ≥10 paediatric patients with PHFs, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes. Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favourable outcome scores were found for patients with minimally displaced fractures, and for children aged less than ten years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score. An excellent functional outcome can be expected following non-operative management for minimally displaced paediatric PHFs. Prospective trials are required to establish a guideline for the management of severely displaced PHFs in children and adolescents according to fracture displacement and the degree of skeletal maturity

Proximal femoral focal deficiency is a congenital disorder of malformation of the proximal femur and/or the acetabulum. Patients present with limb length discrepancy and clinical features along a spectrum of severity. As these patients progress through to skeletal maturity and on to adulthood, altered biomechanical demands lead to progression of arthropathy in any joint within the lower limb. Abnormal anatomy presents a challenge to surgeons and conventional approaches and implants may not necessarily be applicable. We present a case of a 62-year-old lady with unilateral proximal femoral focal deficiency (suspected Aitken Class A) who ambulated with an equinus prosthesis for her entire life. She presented with ipsilateral knee pain and instability due to knee arthritis but could not tolerate a total knee arthroplasty due to poor quadriceps control. A custom osteointegration prosthesis was inserted with a view to converting to the proximal segment to a total hip replacement if required. The patient went on to develop ipsilateral symptomatic hip arthritis but altered acetabular anatomy required a custom tri-flange component (Ossis, Christchurch, New Zealand) and a custom proximal femoral component to link with the existing osseointegration component (Osseointegration Group of Australia, Sydney, Australia) were designed and implanted. The 18 month follow up of the custom hip components showed that the patient had Oxford hip scores that were markedly improved from pre-operatively. Knee joint heights were successfully restored to equal when the patient's prosthesis was attached. The patient describes feeling like “a normal person”, walks unaided for short distances and can ambulate longer distances with crutches. Advances in design and manufacture of implants have empowered surgeons to offer life improving treatments to patients with challenging anatomy. Using a custom acetabular tri-flange and osseointegration components is one possible solution to address symptomatic ipsilateral hip and knee arthropathy in the context of PFFD in adulthood

Abstract. Aims. Growth disturbances after transphyseal paediatric ACL reconstruction have led to the development of physeal-sparing techniques. However, evidence in their favour remains weak. This study reviews the literature to identify factors associated with growth disturbances in paediatric ACL reconstructions. Materials and Methods. Web of Science, Scopus and Pubmed were searched for case series studying paediatric ACL reconstructions. Titles, abstracts, text, results and references were examined for documentation of growth disturbances. Incidences of graft failures were also studied in these selected studies. Results. 78 studies with 2693 paediatric ACL reconstructions had 70 growth disturbances (2.6%). Of these 17 were varus, 26 valgus, 13 shortening, 14 lengthening and 5 patients had reduced tibial slope. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest respectively. Extraphyseal technique were least likely to have growth disturbances. 62 studies documented 166 graft failures in 2120 patients (7.83%). Conclusion. Growth disturbances resulting from transphyseal ACL reconstruction can be minimised by keeping drill size small, drilling steep and away from the physeal periphery. Insertion of bone plug, hardware or synthetic material through the drilled physis should be avoided. The evidence to accurately quantify such growth disturbances till skeletal maturity remains weak. Robust long term studies such as national ligament registries may standardise preoperative and postoperative outcome assessment to further characterise the risk of growth disturbance and re-ruptures

Abstract. Aims. Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis allowing correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. Methods. A retrospective analysis of 20 patients (M:F=19:1 – 9–17 years) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). Results. There were ten patients in each group with a total of 23 curves operated upon. VBT-GM mean age −12.5 years (9 to 14), mean Risser of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) and mean Risser of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40°–58°) compared to VBT-ASC 56.5° (40°–79°). Postoperative VBT-GM Cobb was 20.3° and VBT-ASC was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. Latest Cobb angle at mean five years' follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Overall, 5% of patients required fusion. Conclusion. We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for scoliosis correction in the skeletally immature patient. This is the first report at five years showing two possible options of VBT depending on the skeletal maturity of the patient: GM and ASC

In 2010, we published results of Ponseti versus primary posteromedial release (PMR) for congenital talipes equinovarus (CTEV) in 51 prospective patients. This study reports outcomes at a median of 15 years from original treatment. We followed 51 patients at a median of 15 years (range 13–17 years) following treatment of CTEV with either Ponseti method (25 patients; 38 feet) or PMR (26 patients; 42 feet). Thirty-eight patientsd were contacted and 33 participated in clinical review (65%), comprising patient reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. Sixteen of 38 Ponseti treated feet (42%) and 20 of 42 PMR treated feet (48%) had undergone further surgery. The PMR treated feet were more likely to have osteotomies and intra- articular surgeries (16 vs 5 feet, p<0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group demonstrated better scores on the Dimeglio (5.8 vs 7.0, p<0.05), the Disease Specific Instrument (80 vs 65.6, p<0.05), the Functional Disability Inventory (1.1 vs 5.0, p<0.05) and the AAOS Foot & Ankle Questionnaire (52.2 vs. 46.6, p < 0.05), as well as improved total sagittal ankle range of motion in gait, ankle plantarflexion range at toe off and calf power generation. The primary PMR group displayed higher lateral midfoot and forefoot pressures. Whilst numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR treated feet had greater numbers of osteotomies and intra-articular surgeries. Outcomes were improved at a median of 15 years for functional data for the Ponseti method versus PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti Method as the initial treatment of choice for idiopathic clubfeet

Sixty-two children with unilateral Perthes disease who underwent trochanteric epiphyseodesis combined with varus osteotomy of the femur during the active stage of the disease, (mean age at surgery: 8.4 years) and twenty controls were followed up untill skeletal maturity. The following measurements were taken on radiographs taken at skeletal maturity: the articulo-trochanteric distance (ATD), the center-trochanteric distance (CTD), the length of the abductor lever arm, the neck-shaft angle, the radius of the femoral head and the Reimer's migration index of normal and affected hips. The shape of the femoral head was assessed according to the criteria of Mose. The range of hip motion, the strength of hip abduction and limb lengths were measured and the Trendelenburg sign was elicited. The mean values of ATD and CTD were greater and the frequency of a positive Trendelenburg sign was less in children who had undergone trochanteric epiphyseodesis in 60% of operated children. The procedure was not effective in 30% and there was over-correction in in 10% of children. Logistic regression analysis showed that the size of the femoral head and the age at surgery were variables that significantly influenced the effectiveness of trochanteric growth arrest. At skeletal maturity, the mean shortening of the affected limb in operated children was 0.44 cm (SD 0.68 cm), while that of non-operated children was 0.86 cm (SD 0.78 cm) (p: 0.023). The range of motion of the hip was excellent and there were no significant differences in the range of motion between children with optimal correction, under-correction and over-correction. A probability curve plotted on the basis of the of a logistic regression model suggests that effective trochanteric arrest may be achieved in a high proportion of children operated at, or before, 8.5 years of age, and in half the children operated between the age of 8.5 years and 10 years

Introduction. Angular deformity in the lower extremities can result in pain, gait disturbance, deformity and joint degeneration. Guided growth modulation uses the tension band principle with the goal of treatment being to normalise the mechanical axis. To assess the success of this procedure we reviewed our results in an attempt to identify patients who may not benefit from this simple and elegant procedure. Materials and Methods. We reviewed the surgical records and imaging in our tertiary children's hospital to identify all patients who had guided growth surgery since 2007. We noted the patient demographics, diagnosis, peri-operative experience and outcome. All patients were followed until skeletal maturity or until metalwork was removed. Results. 173 patients with 192 legs were assessed for eligibility. Six were excluded due to inadequate follow-up or loss of records. Of the 186 treated legs meeting criteria for final assessment 19.8% were unsuccessful, the other 80.2% were deemed successful at final follow up. Complications included infection and metal-work failure. Those with a pre-treatment diagnosis of idiopathic genu valgum/ varum had a success rate of 83.6%. Conclusions. In our hands, guided growth had an 80-percent success rate when all diagnosis were considered. Those procedures that were unlikely to be successful included growth disturbances due to mucopolysaccharide storage disease, Blounts disease and achondroplasia. Excluding those three diagnoses, success rate was 85.4%. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity

Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. To be a valid predictor of disease and management, radiographic evaluation should include frontal and lateral views of the spine and a complete view of the pelvis, leading to accurate Cobb angle measurements and Risser staging. The study objectives were to determine 1) the adequacy of index images to inform treatment decisions at initial consultation by generating a score and 2) the utility of index radiology reports for appropriate triage decisions, by comparing reports to corresponding images. We conducted a retrospective chart and radiographic review including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1-April 30, 2021. A score was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity (view of full spine, coronal=two, lateral=one, pelvis=one, ribcage=one). Index images were considered inadequate if repeat imaging was necessary. Comparisons were made between index radiology report, associated imaging, and new imaging if obtained at initial consultation. Major discrepancies were defined by inter-reader difference >15°, discordant Risser staging, or inaccuracies that led to inappropriate triage decisions. Location of index imaging, hospital versus community-based private clinic, was evaluated as a risk factor for inadequate or discrepant imaging. There were 94 patients reviewed with 79% (n=74) requiring repeat imaging at initial consultation, of which 74% (n=55) were due to insufficient quality and/or visualization of the sagittal profile, pelvis or ribcage. Of index images available for review at initial consult (n=80), 41.2% scored five out of five and 32.5% scored two or below. New imaging showed that 50.0% of those patients had not been triaged appropriately, compared to 18.2% of patients with a full score. Comparing index radiology reports to initial visit evaluation with <60 days between imaging (n=49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients, with 18.4% (95% CI 10.0, 31.4) categorized as major discrepancies. Risser stage was reported in only 14% of index radiology reports. In 13.8% (n=13) of the total cohort, surgical or brace treatment was recommended when not predicted based on index radiology report. Repeat radiograph (p=0.001, OR=8.38) and discrepancies (p=0.02, OR=7.96) were increased when index imaging was obtained at community-based private clinic compared to at a hospital. Re-evaluation of available index imaging demonstrated that 24.6% (95% CI 15.2, 37.1) of Cobb angles were mis-reported by six to 21 degrees. Most pre-referral paediatric spine radiographs are inadequate for idiopathic scoliosis evaluation. Standardization of spine imaging and reporting should improve measurement accuracy, facilitate triage and decrease unnecessary radiation exposure

Introduction. Historically, amputation or rotationplasty were the treatment of choice in skeletally immature patients. The introduction of expandable endoprostheses in the late 1980s offered the advantages of limb-salvage and limb length equality at skeletal maturity and a promising alternative with improved cosmetic results and immediate weight bearing. Objective. to describe the Rizzoli experience in reconstruction with three different types of expandable prostheses in growing children with malignant bone tumors of the femur, assess the outcome of limb salvage in these patients, analyze survival and complications related to these prostheses used over time. Materials and Methods. Between 1996 and 2010, 39 expandable implants were used in 32 children (16 boys and 16 girls; mean age, 9 years at initial surgery) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The most common diagnosis was osteoblastic osteosarcoma; all children were classified as having a stage IIB lesion and had preoperative and postoperative chemotherapy. The minimally invasive Kotz Growing prosthesis was used in 17 cases (10 primary implant and 7 revision after failure of non-invasive Repiphysis®), the non-invasive Repiphysis® in 15 cases and Stanmore® expandable prostheses in 7 cases. The mean follow-up was 48 months. Functional evaluation and survival analysis of the children and implants were performed. Results. The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection and breakage. The mean total lengthening was 26 mm (4 to 165 mm) achieved by 78 procedures (2.4 procedures/patient). Three of the nine children who reached skeletal maturity had limb length equality and six discrepancy of 15–30 mm. The survival of the children was 94% and 76% at 24 and 72 months. The survival of the primary prostheses was 90% and 70% at 24 and 72 months. Survival was significantly higher only for the Kotz compared to the Repiphysis® prostheses (p= 0.026). The mean MSTS score was excellent (79%) without a significant difference between the type of prostheses (p= 0.934). Conclusions. In the growing children expandable prostheses are viable reconstruction options with good and excellent oncological and functional outcome, and limb-length equality at skeletal maturity. Mechanical failures including aseptic loosening and breakage, dysfunction of the expansion mechanism, contractures especially around the knee, dislocation and infection were the most common; some designs have been associated with an unacceptably high inherent risk of complications. However, the non-invasive systems are associated with high complications and failure rates. Early experience is promising, but further study is warranted to determine long-term structural integrity of these newer designs

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

With observed success and increased popularity of growth modulation techniques, there has been a trend towards use in progressively younger patients. Younger age at growth modulation increases the likelihood of complete deformity correction and need for implant removal prior to skeletal maturity introducing the risk of rebound deformity. The purpose of this study was to quantify magnitude and identify risk factors for rebound deformity after growth modulation. We performed a retrospective review of all patients undergoing growth modulation with a tension band plate for coronal plane deformity about the knee with subsequent implant removal. Exclusion criteria included completion epiphysiodesis or osteotomy at implant removal, ongoing growth modulation, and less than one year radiographic follow-up without rebound deformity. Mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), hip-knee-ankle angle (HKA), and mechanical axis station were measured prior to growth modulation, prior to implant removal, and at final follow-up. Sixty-seven limbs in 45 patients met the inclusion criteria. Mean age at growth modulation was 9.8 years (range 3.4–15.4 years) and mean age at implant removal was 11.4 years (range 5.3–16.4 years). Mean change in HKA after implant removal was 6.9O (range 0O–23 O). Fifty-two percent of patients had greater than 5O rebound and 30% had greater than 10O rebound in HKA after implant removal. Females less than ten years and males less than 12 years at time of growth modulation had greater mean change in HKA after implant removal compared to older patients (8.4O vs 4.7O, p=0.012). Patients with initial deformity greater than 20O degrees had an increased frequency of rebound greater than 10O compared to patients with less severe initial deformity (78% vs 22%, p=0.002). Rebound deformity after growth modulation is common. Growth modulation at a young age and large initial deformity increases risk of rebound. However, rebound does not occur in all at risk patients, therefore, we caution against routine overcorrection. Patients and their families should be informed about the risk of rebound deformity after growth modulation and the potential for multiple surgical interventions prior to skeletal maturity

Ankle arthrodesis and replacement are the widely accepted options in managing end-stage ankle arthritis. Ankle replacement as an alternate treatment option for ankle arthritis is relatively new and this is in large part to the successes observed with hip and knee arthroplasty for arthritis. Relative benefits of ankle replacement and arthrodesis remains a contentious topic. We conducted a multicenter pilot randomized controlled trial, first of its kind, comparing the clinical outcomes of ankle arthrodesis and ankle replacement in managing ankle arthritis. We hypothesized that clinical outcomes would be similar for both. Patients recruited for this study were part of Canadian Orthopaedic Foot and Ankle Society (COFAS) Database. Canadian orthopaedic surgeons with fellowship training in foot and ankle surgery or extensive experience in the surgical treatment of end stage ankle arthritis determined whether the patient met the criteria for randomization, skeletal maturity, symptomatic ankle arthritis no longer amenable to non-operative management, and ability to give informed consent. Data was collected on patient demographics, follow-up time period, complication rates, and Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. Our analysis of clinical outcomes was divided into two parts: (1) comparison of pre and postoperative data for each cohort separately, and (2) comparison of outcome scores, and revision rates between both cohorts. We employed the Student's t-test and calculated effect sizes in assessing improvements in AOS and SF-36 scores from baseline to latest follow-up within and between the two groups. We also examined postoperative complication and reoperation rates in the study population using the standardized coding system for reoperations following ankle replacement and arthrodesis. Thirty-nine ankles were enrolled in the study with a mean follow-up of 5.1 ± 2.8 years. Ankle osteoarthritis scale scores improved significantly from baseline and last follow-up in both groups. The average baseline AOS total score for ankle replacement improved from 59.4 ±15.9 to 38 ±20 at last follow-up (p-value 19.7 to 31.8 ±16.5 at last follow-up (p-value 25.4 compared to ankle replacement's 20.3 ±23. Two major complications (10.5%) were observed in the ankle replacement cohort while the ankle arthrodesis cohort saw four major complications (20%). Clinical outcomes of ankle replacement and arthrodesis were comparable. The ankle arthrodesis cohort held a slight advantage over ankle replacement in improvement of AOS scores, though not statistically significant. Rates of major complications and reoperations were higher with ankle arthrodesis

Fractures through the physis account for 18–30% of all paediatric fractures, leading to growth arrest in 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients < 1 8 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators and radiographic data were collected at baseline, one and two years post-injury. A total of 167 patients had at least one year of follow-up. Average age at injury was 10.4 years, 95% CI [9.8,10.94]. Reduction was required in 51% of cases. Right-sided (52.5%) and distal (90.1%) fractures were most common. After initial reduction 52.5% of fractures had some form of residual angulation and/or displacement (38.5% had both). At one year follow-up, 34 patients (21.1%) had evidence of a bony bridge on plain radiograph, 10 (6.2%) had residual angulation (average 12.6°) and three had residual displacement. Initial angulation (average 22.4°) and displacement (average 5.8mm) were seen in 16/34 patients with bony bridge (48.5%), with 10 (30.3%) both angulated and displaced. Salter-Harris type II fractures were most common across all patients (70.4%) and in those with bony bridges (57.6%). At one year, 44 (27.3%) patients had evidence of closing/closed physes. At one year follow-up, there was evidence of a bony bridge across the physis in 21.1% of patients on plain film, and residual angulation and/or displacement in 8.1%. Initial angulation and/or displacement was present in 64.7% of patients showing possible evidence of growth arrest. The incidence of growth arrest in this patient population appears higher than past literature reports. However, plain film is an unreliable modality for assessing physeal bars and the true incidence may be lower. A number of patients were approaching skeletal maturity at time of injury and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine the true incidence and impact of growth arrest