The promotion and practice of evidence-based medicine necessitates a critical evaluation of medical literature including the “gold standard” of randomised clinical trials. Recent studies have examined the quality of randomised clinical trials in various surgical specialties, but no study has focused on pediatric orthopedics. The purpose of this study was to assess and describe the quality of randomised clinical trials published in the last ten years in journals with high clinical impact in pediatric orthopaedics.

All of the randomised clinical trials in pediatric orthopedics published in five well-recognised journals between 1995–2005 were reviewed using the Detsky Quality Assessment Scale.

The mean percentage score on the Detsky Scale was 53% (95% CI: 46%–60%). Only seven (19%) of the articles satisfied the threshold for a satisfactory level of methodologic quality (Detsky > 75%).

The majority of randomised clinical trials in pediatric orthopedics that are published in well-recognised, peer-reviewed journals demonstrate substantial deficiencies in methodologic quality. Particular areas of weakness include inadequate rigor and reporting of randomization methods, use of inappropriate or poorly-described outcome measures, inadequate description of inclusion and exclusion criteria and inappropriate statistical analysis. Further efforts are necessary to improve the conduct and reporting of clinical trials in this field in order to avoid inadvertent misinformation of the clinical community.

Avascular necrosis (AVN) of the femoral head is a devastating complication of slipped capital femoral epiphysis (SCFE). The reported prevalence of AVN following unstable SCFE has ranged between fifteen and forty-seven per cent in the literature. The explanation for this discrepancy is not clear. The inter-observer and intra-observer agreement between Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE has not been reported. It is the objective of this study to estimate these parameters between two experienced pediatric Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE.

A retrospective review of all one hundred and three cases of SCFE treated at a Canadian pediatric referral center between 1995 and 2005 was performed. Of these, eight were diagnosed, by the treating surgeon, with AVN. Each of these eight children and a random sample of fifteen of the remaining children, who were not diagnosed with AVN, were included in this study. The most recent anteroposterior and lateral radiographs were digitised and presented to two experienced pediatric orthopaedic surgeons in a blinded, random order. Each surgeon reviewed the radiographs independently and recorded which radiographs they believed to be consistent with AVN. The surgeons were told that each patient had SCFE and that some developed AVN, however neither the classification of the slip, nor the proportion who developed AVN were divulged. Each observer repeated this process two weeks after the initial review in order to determine intra-observer agreement. The kappa value was determined to assess inter-observer and intra-observer agreement.

The first observer recorded eight cases of AVN at the initial and seven cases at the second observation time. The intra-observer agreement was 0.9. The second observer recorded six cases of AVN at the initial and five cases at the second observation time. The intra-observer agreement was 0.88. The inter-observer agreement was determined at the first observation time and was 0.79.

On the basis of the results of this study, both the inter-observer and intra-observer agreement for the radiographic diagnosis of AVN following SCFE, amongst experienced pediatric Orthopaedic surgeons, was very high. It is unlikely that the reported discrepancy in prevalence of AVN following SCFE is due to a lack of inter-observer agreement, on the basis of the findings of this study. The inter-observer agreement between less experienced observers requires further study to determine if this may be the source of the variability in the reported prevalence of AVN following SCFE.

Introduction and Aims: Rotationplasty is a functional alternative to above knee amputation in very young patients with a lot of growth remaining and patients with large tumors necessitating excision of the thigh musculature. The development of gait following rotationplasty surgery was studied with serial gait and clinical analysis.

Method: Five patients have been reviewed using three dimensional gait analysis incorporating temporal and spatial measures. A gait analysis was performed after the initial prosthetic fitting, six and 12 months postoperatively. The gait analysis included velocity, temporal/spatial measurements (velocity, cadence, step/stride length, pedobarographs), optical tracking and electromyography.

Results: The kinematic and kinetic data revealed the rapid incorporation of knee flexion/extension (ankle dorsi/plantar flexion) into the gait cycle. Electromyography also showed the gastrocnemius to be simulating the quadriceps and the tibialis anterior to mimic the hamstrings in terms of firing time in the stance and swing phase of the rotated limb. Propulsive forces on the kinetic analysis suggest further gait maturation can occur for several years following this procedure.

Conclusion: Children adapt very well to the altered anatomy following rotationplasty and using gait analysis confirms the new role of the altered muscles. Weakness about the hip remains a major concern that needs to be addressed with physiotherapy for several years postoperatively.

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated.

Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old).

Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients)

Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents.