The total plasma alkaline phosphatase level has long been recognised as an indicator of osteoblastic activity, but lack of specificity makes it an insensitive index of the progress of disease and the response to treatment. Selective precipitation by wheatgerm lectin allows measurement of the plasma bone-specific alkaline phosphatase. We measured the plasma levels of this isoenzyme in 170 normal Chinese adolescents and adults, in 49 adults with fractures of a long bone, in 15 patients with osteosarcoma and in 38 patients with osteolytic metastases. The enzyme activity was also determined in 39 patients with liver disease. Of the patients with fractures, 94% had increased plasma activity during the healing process. The level was also increased in those with osteosarcoma but not in those with osteolytic bone metastases. There was no significant increase in activity in the patients with liver disease. We conclude that the plasma bone-specific alkaline phosphatase activity is a sensitive and reliable measure of osteoblastic activity

The late results of treatment of calcaneal fractures in 17 children (19 fractures) were reviewed at a mean of 16.8 years after injury. With the exception of one patient, all fractures had been treated conservatively. At follow-up there were few complaints. All but two patients had full or slightly reduced mobility of the subtalar joint and unrestricted foot function, including the ability to walk comfortably on uneven surfaces. Minor radiological abnormalities of the hindfoot were common; there were two cases of post-traumatic osteoarthritis. Clinical scoring of the ankle and hindfoot using the American Orthopaedic Foot and Ankle Society rating system averaged 96.2 points. The results suggest that up to 16.8 years after injury almost all children achieve excellent long-term functional results with conservative treatment of fractures of the os calcis. Open management may only be appropriate for adolescents with severe displacements

Introduction

There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery.

Of 290 Ugandan children and adolescents with proven Burkitt's lymphoma 11 had lesions in the long bones or the pelvis. These started in the medulla as small osteolytic foci which coalesced and penetrated the cortex causing subperiosteal new bone formation in layers or spicules, and giving rise to large soft-tissue masses. Common sites were the femoral and tibial diaphyses and the metaphyses around the knee. Five were in the epiphyses. Other sites were the pelvis, humerus and ulna. One patient had a lymphomatous synovial effusion of the knee. In the lower limbs the lesions were often bilateral and symmetrical. Five patients had pathological fractures. Radiologically the lesions mimicked Ewing's sarcoma, osteosarcoma, osteomyelitis, acute leukaemia, syphilis and yaws, but clinically they were relatively painless, an important differential diagnostic feature. In the five patients with sustained remissions after chemotherapy the lesions and fractures healed well and the growth plates were undamaged

1. During the past twenty-five years there have been admitted to this orthopaedic service twelve children or adolescents having a close relative who previously or subsequently developed slipped upper femoral epiphysis. This represents an incidence of approximately 7 per cent. 2. There is some evidence that the incidence is considerably higher. 3. In addition to those with close relations also with slipped epiphysis, two patients had parents with osteoarthritis of the hip. 4. I believe, therefore, that in slipped upper femoral epiphysis there is evidence of a genetic defect. This is probably due to a recessive gene of low penetrance. The frequency in this region is high because the north-east of Scotland has very definite geographical boundaries and the rural, agricultural population, from which the majority of these cases were drawn, has formed until recently a stable community likely to show a greater than average incidence

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.

The results of a study of the use of autograft versus allograft bone in the surgery of idiopathic adolescent scoliosis are presented. Two groups of patients, matched for age, sex, level and angle of curve, received bone grafts, 20 patients having autogenous bone from the iliac crest and the other 20 having donor bone from a bone bank. Both groups had otherwise identical posterior fusions and Harrington instrumentation. There was no difference between the two groups in a blind, radiographic assessment of bone graft mass at six months, nor in maintenance of the curve correction over the same period. No major operative complications nor failures of instrumentation were encountered. There was, however, a marked reduction in operative time and blood loss in the patients receiving donor bone and also a much lower incidence of late symptoms relating to the operative sites. We conclude that, even in the presence of adequate iliac crest, the use of bank bone is superior for grafting in idiopathic scoliosis surgery

Experience with thirty-eight Asian children and adolescents who presented with either stiffness of the knee, genu recurvatum, habitual dislocation of the patella or congenital lateral dislocation of the patella showed that all those disorders were manifestations of contracture of the extensor mechanism, which fell into two groups according to the components involved. In Group I the main components affected were in the midline of the limb, namely rectus femoris and vastus intermedius; these patients presented with varying degrees of stiffness of the knee, or worse, with genu recurvatum. In Group II the main components involved were lateral to the midline of the limb, namely vastus lateralis and the ilio-tibial band; these patients presented with habitual dislocation of the patella, or worse, congenital lateral dislocation of the patella. In both groups untreated patients developed secondary adaptive changes such as subluxation of the tibia or marked genu valgum which made operative procedures more formidable and less effective. Release of the contracture should therefore be performed as early as possible

1. The results of viscosity measurements on a number of normal, traumatic and osteoarthritic synovial fluids from human knee joints are described and discussed. 2. A decrease of the viscosity of normal synovial fluid with age has been found. 3. The decrease of the viscosity with age and in the pathological groups is analysed and its relation to the viscous anomaly is considered (Fig. 6). 4. The question whether dilution or depolymerisation is the important factor in decrease of viscosity in these groups, and the value of viscosity measurements as a whole, are discussed. 5. Measurements of pH have been made on the same groups of synovial fluids and on the blood of patients in these groups. 6. The mean values for blood and synovial fluid differ significantly, and the pH of the synovial fluid of adolescents is significantly higher than at other ages. 7. There is no significant difference between the traumatic and osteoarthritic groups, but both are significantly less than the normal. 8. In both fluids the peak frequency in all three groups is the same, that for blood being 7·3 to 7·5 and that for synovial fluid being 7·5 to 7·7 (Fig. 7)

Seat-belt fractures of the lumbar spine in adolescents and adults are well recognised but there are few reports of these injuries in young children. We reviewed all seat-belt injuries in skeletally immature patients (Risser 0), seen at a tertiary referral centre between 1974 and 1991. There were ten cases, eight girls and two boys, with an average age of 7.5 years (3 to 13). Four distinct patterns of injury were observed, most commonly at the L2 to L4 level. Paraplegia, which is thought to be uncommon, occurred in three of our ten cases. Four children had intra-abdominal injuries requiring laparotomy. There was a delay in diagnosis either of the spinal or of the intra-abdominal injury in five cases, although all had contusion of the abdominal wall, the 'seat-belt sign'. Treatment of the fractures was conservative, by bed rest and then hyperextension casts. The incidence of this potentially devastating injury can be reduced by the optimal use of restraints, but there is often a delay in diagnosis. Our classification system may aid in the early detection and evaluation of this injury

We have evaluated two methods of surgical treatment of adolescent idiopathic double major scoliosis in 59 patients. In group 1, 31 patients were treated by fusion of the upper curve only. In group 2, 28 patients had lumbar fusions also including most of the lower curve. The magnitude of the lower curve and the correction obtained in traction were good indicators of the correction achieved postoperatively. Forty-four patients were reviewed at a minimum of 10 years after operation. Those in group 1 showed sustained improvement of the lower curve with minimal stiffness and pain. Group 2 patients had lumbar curves of similar severity at review, but had significantly more low back pain and stiffness. The number of lumbar segments which remained mobile appeared to be a critical factor in determining the outcome. Selective fusion of the upper curve in double major scoliosis produces satisfactory results if the lumbar curve is less than 50 degrees. It may also be appropriate for flexible lumbar curves of larger angle

1. In a previous investigation, approximately 40 per cent of so-called "primary" degenerative disease or osteoarthritis of the hip appeared to have been the result of an abnormal joint mechanism caused by minimal epiphysiolysis in adolescence. Males were affected much more commonly than females. The residual abnormality of this disturbance, recognised radiologically, was termed the "tilt deformity" of the femoral head. 2. Three groups of young adult males, with different athletic backgrounds, have now been examined to assess the incidence of this abnormality and its relationship to athletic regimes. The condition was found to be more common in subjects who had been engaged in more active regimes and was also related statistically to a history of "growing pains". The deformity is compared with the gross disturbance of adolescent epiphysiolysis or slipped epiphysis, which is believed basically to be caused by chronic stress. 3. Degenerative disease of the hip of this type has a geographical and racial distribution corresponding to the degree of interest in and encouragement of competitive athletic activities. Many cases are therefore postulated to be the direct result of a minor and usually asymptomatic disturbance of this type, attributable to excess activity during adolescence

1. The term "observation hip" refers to a form of hip disease affecting children and adolescents, the most significant features being the transient nature of the symptoms and the absence of a bony or cartilaginous lesion on radiographic examination. 2. With a view to determining the possible sequelae of the disorder, twenty-three patients aged between two and fifteen years at the onset of the condition were studied fifteen to thirty years later. 3. Varying degrees of coxa magna, osteoarthritis or simple broadening of the femoral neck in the "observed" hip joint were found in the radiographs of twelve of the twenty-three patients studied. 4. This analysis suggests that the " observation hip" syndrome is the result ofan inflammatory process ofthejoint due to varied etiology, whether from injury or infection. The developmental and degenerative changes which may occur are a consequence of hypervascularisation of the bone. Thus changes may develop without necessarily producing the epiphysial necrosis characteristic of the first stage of ischaemia in Legg-Calvé-Perthes' disease. 5. The persistence of this stage of hypervascularity, and therefore the possible outcome of the transient synovitis, may be conditioned by the age at onset of the pathological process, the severity of the condition, and the duration of the symptoms and signs

1. Clinically, hallux rigidus is a painful condition of the joints of the great toe associated with loss of dorsiflexion of the first phalanx. 2. Pathologically, the morbid changes are those of a traumatic synovitis followed by an early development of osteoarthritis, the initial lesions of which are erosions of the cartilage at the centre and near the dorsal margin of the base of the proximal phalanx. There is no fundamental pathological difference between the adult and adolescent varieties of hallux ngidus. Both represent stages in the developmental cycle of osteoarthritis in the proximal joint of the great toe. 3. The radiographic density and apparent fragmentation of the phalangeal epiphysis do not represent an abnormality of the bone and have no significance in the etiology of hallux rigidus. 4. The cause of hallux rigidus is an abnormal gait developed either to protect an injured or inflamed metatarso-phalangeal joint from the pressure of weight-bearing, or to stabilise a hypermobile first metatarsal. The effects of this gait are to transfer most of the pressure from the flexor brevis tendon and the two sesamoids to the base of the first phalanx. Excessive pressure on this joint predisposes to osteoarthritis. 5. Evidence of this abnormal gait is found in the peculiarities of wear seen in old shoes. 6. There is a high correlation between unilateral hallux rigidus and the patient's footedness

Both osteochondritis dissecans and coxa plana are diseases with identical pathological changes, namely avascular necrosis. Although the etiology is not known in either case, it seems likely that when the etiological factors are fully determined they will prove to be applicable to either condition. The relative importance of each etiological factor in the multiple pathogenesis of these two conditions is almost certainly different in each disease process, and probably in each individual case. Present day concepts suggest that there is an underlying constitutional disturbance, which is associated with other factors (of which trauma is almost universally accepted as being one; perhaps the only one), to predispose the individual to these conditions. It is hoped that further studies along these lines will not only help to provide a better understanding of the two conditions mentioned above, but will also be of value in the appreciation of the pathogenesis and etiology of a large number of disturbances including such varied conditions as dysplasia epiphysialis multiplex congenita, cretinoid dysgenesis of the capital femoral epiphysis, adolescent coxa vara, transient synovitis of the hip, and the recently discussed (Merle d'Aubigné 1964) idiopathic avascular necrosis of the femoral head in adults. That there is an etiological relationship between osteochondritis dissecans and coxa plana seems clear, but much more work is required before we will have at hand the patho-physiological evidence that will permit an accurate correlation of these two conditions

The discrepancy between successful experimental studies of cartilage repair and the clinical results is unexplained. We have evaluated the effect of metabolic alterations in joint homeostasis owing to an articular defect on the outcome of cartilage repair using tissue engineering methods. We used 21 adolescent Dutch goats divided into three groups. The control knees were left untreated while the contralateral knee was randomised to receive either no treatment (N), early treatment (E) or late treatment (L). The metabolism of proteoglycans in the surrounding joint surface was determined and correlated with the O’Driscoll score used to quantify the histological aspect of the repair of the defect. Synthesis of proteoglycan (PG) was increased in all groups. The release of glucosaminoglycan (GAG) was significantly higher in the untreated but not after early transplantation (1.3 v 1.8 NS). The cartilage repair scores in the early treatment group were not as good as those of the normal control group, but were significantly better when compared with both the untreated defects and the late treated defects. Defects which had been treated late showed a significantly decreased score when compared with those which had had early treatment or the normal control group and did not differ (p = 0.12) from those with no treatment. The histological and biochemical scores closely resembled the macroscopic and functional parameters which showed a significant deterioration for the late treated group and those without treatment compared with animals treated early. Thus, tissue-engineered cartilage repair is negatively influenced by altered matrix metabolism. Early treatment showed significantly better results for repair of cartilage than late or no treatment, with a concurrent decrease in the detrimental disturbance of cartilage metabolism which constituted a protective effect on the articulation