We describe a congenital deformity of the foot which is characterised by calcaneus at the ankle and valgus at the subtalar joint; spontaneous improvement does not occur and serial casting results in incomplete or impermanent correction of the deformities. Experience with five feet in four children indicates that release of the ligaments and tendons anterior and lateral to the ankle and lateral to the subtalar joint is the minimum surgery necessary; subtalar arthrodesis may be required in addition. The foot deformity described may occur as an isolated condition or in association with multiple congenital anomalies. The possibility of a neurological deficit should always be excluded.

Seven patients with Ewing's sarcoma of the pelvis were treated by chemotherapy followed by wide resection of the primary tumour. Although good function after operation is possible, survival in this series reflects the poor prognosis associated with the disease; two patients died, two are alive with local recurrence and metastases and three patients are alive with no evidence of disease.

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients.

We present three cases of a previously undescribed condition characterised by unilateral tibia vara associated with an area of focal fibrocartilaginous dysplasia in the medial aspect of the proximal tibia. The three children affected were aged 9, 15 and 27 months respectively. Two required tibial osteotomy, but in one the deformity resolved without treatment. The pathogenesis of the focal lesion remains conjectural; the most likely explanation is that the mesenchymal anlage of the tibial metaphysis has, for unknown reasons, developed abnormally at the insertion of the pes anserinus.

Six boys with fragmentation of the proximal pole of the patella are reported; the condition was bilateral in one. Four of the six presented with symptoms of Osgood-Schlatter's disease or Larsen-Johansson disease of the same or of the contralateral knee, but they had no symptoms or signs relating to the proximal pole of the patella; one also had features suggesting minimal chondromalacia patellae. Two boys had no objective abnormality in either knee. It is suggested that the fragmentation may be a further form of traction osteochondritis of the attachments of the quadriceps mechanism. Attention is drawn to its characteristic radiographic appearance, its association with other forms of juvenile traction osteochondritis (which are commonly symptomatic), and to its occurrence in boys aged 10 or 11 years.

Of 47 patients with spina bifida who had had transplantation of the iliopsoas more than 10 years previously, 32 (68%) were community walkers, 3 were household walkers and 12 were non-walkers. Comparison with other published reports showed that, at the very least, the patients reviewed had not had their walking ability jeopardized by the inevitable loss of hip flexor power. Furthermore, all but three of the community walkers were able to climb and descend stairs. There was a high proportion of non-walkers in those patients whose operation had been performed in the first year of life and such early surgery is no longer recommended. We also found that the pre-operative assessment of muscle power had, in some patients, been inaccurate. Finally, we found that, at review, the power of the transferred muscles was poor, suggesting that transplantation is beneficial because it achieves permanent and major reduction in hip flexor power; this usually prevents recurrent hip flexion deformity and dislocation.

Sixty-two children were reviewed between 3 and 14 years (average 9.8 years) after flexor tenotomy for curly toes or hammer toes. No patients were aware of loss of flexor power in the toes. In only 5% of 188 toes was the operation unsuccessful. When the cause of failure was identifiable it proved to be that the scar crossed one or more flexor creases. None of the operated toes had an abnormally extended posture; only one toe was stiff and this resulted from tethering by a scar. It is concluded that open flexor tenotomy is an effective method for correcting curly toes and hammer toes in childhood. Pre-operative assessment must demonstrate that the resting length of the flexor tendons is unduly short, and that this shortening is the only cause of the deformity.

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion.

The accuracy of a previously described calculation for the timing of epiphysiodesis, in the management of leg length discrepancy, has been improved modifications in the way in which the calculation has been applied. The value of the method is confirmed by a study of 94 patients who had reached maturity; 94.1 per cent of these then had discrepancies within three-quarters of an inch of that calculated and 85.1 per cent within half an inch. Over-retardation of growth was more common than insufficient retardation and was partially compensated by calculating for a discrepancy at maturity. A further 34 patients were not available for assessment at maturity but were included in analyses of the conditions for which epiphysiodesis was performed and of early complications from the operation. Both early and late complications were minor and infrequent.

Subcutaneous rupture of the tendon of tibialis anterior immediately proximal to its insertion affects patients over the age of 45 years and is most common in the seventh decade. The symptoms at the time of rupture are milder than is the case with rupture of the calcaneal tendon and the early disability is slight. Thus, affected patients commonly present several weeks or months after rupture and at a stage when reattachment of the tendon to its normal site of insertion (the most satisfactory surgical management) is impossible. Although the disability is slight if repair is not performed, there should be no disability after surgical repair and this should be offered to those patients who lead an active life and who present in the first three months after rupture. The relevant literature is reviewed and experience with four further patients is recounted.

Seventy children who had suffered from Perthes' disease were reviewed clinically and radiologically three to eight years from the onset of the condition in order to determine retrospectively the most satisfactory method of assessing the prognosis and the correlation between the clinical and radiological result. In younger children the femoral head was more likely to be spherical at the conclusion of the pathological process but not necessarily of normal proportions nor normally covered by the acetabulum. The prognosis was significantly poorer for girls than for boys. Clinical factors were not an aid to prognosis in the individual cases, but overall there was a close correlation between the clinical and the radiological end-results. The most reliable radiological factors indicating the prognosis were the extent of uncovering of the femoral head, the Catterall grouping, the presence of calcification lateral to the outer limit of the acetabulum and lateral displacement of the femoral head, as measured by comparing the head to tear-drop distances on each side.

An operative technique for correction of the severe kyphosis that may develop in cases of myelomeningocele is described. It includes excision of the apical vertebrae, correction of the full length of the kyphotic segment and of rigid compensatory curves, and extensive fusion aided by internal fixation with longitudinal threaded wires. The technique evolved during the management of eleven children. Of these, in the first two the internal fixation employed was inadequate; two others died; and in the remainder good correction was maintained up to the time of review one to six years later.

A method of triple arthrodesis is described which involves inlay of the subtalar and midtarsal joints. It is applicable to the undeformed and valgus foot as is encountered in poliomyelitis, spasmodic flat foot, cerebral palsy and spina bifida. The operation was successful in controlling deformity and pain. The only significant complication was failure of fusion of the midtarsal joint which occurred in three of eighty-five feet (3-5%).

The hip problems in 116 children with myelomeningocele are discussed. The management described stresses the importance of selection of the type of operation; major surgery is appropriate only for those children who benefit significantly, and this generally means only those with strong quadriceps muscles on both sides. Some children with acetabular dysplasia gain immediate stability if acetabuloplasty is combined with other hip operations. Children who lack strong quadriceps muscles are best served by simpler procedures, such as tendon excision, designed to rid them of fixed deformity and to prevent recurrent deformity. The operations described are performed whenever possible under one anaesthetic and are combined with any other limb operation that may be necessary. It is suggested that the aim in management is not the treatment of paralytic dislocation of the hip but the correction of fixed deformity so that the child can stand with a stable posture. Subluxation and dislocation are treated incidentally to procedures designed to prevent or correct fixed deformity.

Two children with radial club hand and absence of the biceps muscle were treated by centralisation of the ulna into the carpus and triceps transfer. The two operations were performed only a short time apart so that the period between the procedures could be used to stretch the triceps and to enable the children to adapt to an altered position of the wrist and to mobility of the elbow at one step and following a single period of plaster immobilisation. It is very likely that function is better than it would have been had the condition remained untreated. Before operation the children had only a crude hook function of the hand against the forearm and could not bring the hand to the mouth. Even if function is not much improved, the improvement in appearance is considerable and is by itself sufficient to justify the procedures.