Aims. Using 90% of final height as a benchmark, we sought to develop a quick, quantitative and reproducible method of estimating skeletal maturity based on topographical changes in the distal femoral physis. Patients and Methods. Serial radiographs of the distal femoral physis three years prior to, during, and two years following the chronological age associated with 90% of final height were analyzed in 81 healthy children. The distance from the tip of the central peak of the distal femoral physis to a line drawn across the physis was normalized to the physeal width. Results. A total of 389 radiographs of the distal femur with corresponding Greulich and Pyle bone ages and known chronological ages were measured. Children reached 90% of final height at a mean age of 11.3 years (. sd. 0.8) for girls and 13.2 years (. sd. 0.6) for boys. Linear regression analysis showed higher correlation coefficent in predicting the true age at 90% of final height using chronological age + gender + central peak value (R. 2 . = 0.900) than chronological age + gender (R. 2.  = 0.879) and Greulich and Pyle bone age + gender (R. 2.  = 0.878). Conclusion. Chronological age + gender + central peak value provides more accurate prediction of 90% of final height compared with chronological age + gender and Greulich and Pyle bone age + gender. Cite this article: Bone Joint J 2018;100-B:1106–11

Aims. The aim of this study was to establish the incidence of developmental dysplasia of the hip (DDH) diagnosed after one-year of age in England, stratified by age, gender, year, and region of diagnosis. Patients and Methods. A descriptive observational study was performed by linking primary and secondary care information from two independent national databases of routinely collected data: the United Kingdom Clinical Practice Research Datalink and Hospital Episode Statistics. The study examined all children from 1 January 1990 to 1 January 2016 who had a new first diagnostic code for DDH aged between one and eight years old. Results. The incidence of late-diagnosed DDH was 1.28 per 1000 live births. Within the study population, 754 children were identified with a diagnosis of DDH after one-year of age. Of all late diagnoses, 536 (71.1%) were detected between one to two years of age. There were 608 female patients (80.6%) and 146 male patients (19.4%), giving a female-to-male ratio of 4.2:1. Distribution was evenly spread throughout England. Conclusion. The incidence of late-diagnosed DDH has not been reduced from that reported 35 years ago, prior to the introduction of the national selective screening programme for DDH. Cite this article: Bone Joint J 2019;101-B:281–287

Aims. Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure. Materials and Methods. This retrospective study evaluated 30 children with a chronic Monteggia lesion. There were 18 boys and 12 girls with a mean age of 7.4 years (4 to 13) at the time of open reduction. The mean interval to surgery, after the initial fracture, was 23.4 months (6 to 120). Clinical grading used a Kim modified elbow score: radiological outcome was recorded. The effect of the patient’s age, gender, duration from initial injury, Bado classification, and annular ligament reconstruction were analyzed. The mean follow-up was 42.2 months (15 to 20). Results. The Kim elbow scores evaluated at the last clinic visit were excellent in 23 patients, good in three, fair in two, and poor in two. A majority of the patients were found to have significant improvement of elbow flexion (p < 0.001). Six met the criteria of a fair radiological outcome; four of these were operated on more than 24 months after the initial injury, and three had surgery after the age of 11. Univariate analysis failed to find any factor that was significantly associated with a fair or poor outcome. Conclusion. Good clinical and radiological outcomes can be expected in most patients. Osteoarthritic changes were associated with age > 11 years and/or a delay of treatment of > 24 months. However, no statistically significant factor could be identified which correlated with an unfavourable outcome. Cite this article: Bone Joint J 2018;100-B:1117–24

Aims. The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. Patients and Methods. National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. Results. A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). . Conclusion. This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109–18

Aims. To explore the of age of onset distribution for Perthes’ disease of the hip, with particular reference to gender, laterality and conformity to the lognormal distribution. Patients and Methods. A total of 1082 patients were identified from the Liverpool Perthes’ Disease Register between 1976 and 2010, of which 992 had the date of diagnosis recorded. In total, 682 patients came from the geographical area exclusively served by Alder Hey Hospital, of which 673 had a date of diagnosis. Age of onset curves were analysed, with respect to the predefined subgroups. Results. The age of onset demonstrated a positive skew with a median of 5.8 years (interquartile range 4.6 to 7.5). Disease onset was a mean five months earlier in girls (p = 0.01) and one year earlier in those who went on to develop bilateral disease (p < 0.001). There was no difference in the age of onset between geographical districts with differing incidence rates. The entire dataset (n = 992) conformed to a lognormal distribution graphically and with the chi-squared test of normality (p = 0.10), but not using the Shapiro-Wilk test (p = 0.01). The distribution for the predefined geographical subgroup (n = 673) conformed well to a lognormal distribution (chi-squared p = 0.16, Shapiro-Wilk p = 0.08). Given the observed lognormal distribution it was assumed that Perthes’ disease followed on incubation period consistent with a point-source disease exposure. The incubation period was further examined using Hirayama’s method, which suggested that the disease exposure may act in the prenatal period. Conclusion. The age of onset in Perthes’ disease conforms to a lognormal distribution, which allows comparisons with infectious disease epidemiology. Earlier onset in girls and those who develop bilateral disease may offer clues to understanding the aetiological determinants of the disease. The analysis suggests that an antenatal aetiological determinant may be responsible for disease. Take home message: Perthes’ disease age of onset conforms to a lognormal model, which is most typical of infectious diseases. The shape of the distribution suggests that an aetiological trigger in the pre-natal period may be an important determinant of disease. Cite this article: Bone Joint J 2016;98-B:710–14

We present the long-term results of open surgery for internal shoulder rotational deformity in brachial plexus birth palsy (BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean age 6.2 (0.6 to 34)) were operated on with subscapularis elongation and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder joints were relocated. The early results of these patients has been reported previously. We analysed 118 (64 females, 54 males, mean age 15.1 (7.6 to 34)) of the original patient cohort at a mean of 10.4 years (7.0 to 15.1) post-operatively. A third of patients with relocated joints had undergone secondary internal rotational osteotomy of the humerus. A mixed effects models approach was used to evaluate the effects of surgery on shoulder rotation, abduction, and the Mallet score. Independent factors were time (pre-and post-surgery), gender, age, joint category (congruent, relocated, relocated plus osteotomy) and whether or not a transfer had been performed. Data from a previously published short-term evaluation were reworked in order to obtain pre-operative values. The mean improvement in external rotation from pre-surgery to the long-term follow-up was 66.5° (95% confidence interval (CI) 61.5 to 71.6). The internal rotation had decreased by a mean of 22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95% CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves good long-term results for patients with BPBP and an internal rotation contracture, providing lasting joint congruency and resolution of the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article: Bone Joint J 2014;96-B:1411–18

Supracondylar humeral fractures are common in children, but there are no classification systems or radiological parameters that predict the likelihood of having to perform an open reduction. In a retrospective case–control study we evaluated the use of the medial spike angle and fracture tip–skin distance to predict the mode of reduction (closed or open) and the operating time in fractures with posterolateral displacement. A total of 21 patients (4.35%) with a small medial spike angle (< 45°) were identified from a total of 494 patients, and 42 patients with a medial spike angle of > 45° were randomly selected as controls. The medial spike group had significantly smaller fracture tip–skin distances (p < 0.001), longer operating times (p = 0.004) and more complications (p = 0.033) than the control group. There was no significant difference in the mode of reduction and a composite outcome measure. After adjustments for age and gender, only fracture tip–skin distance remained significantly associated with the operating time (β = -0.724, p = 0.042) and composite outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold for open reduction when treating patients with a small medial spike angle and a small fracture tip–skin distance. . Cite this article: Bone Joint J 2013;95-B:1290–4

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone. Cite this article: Bone Joint J 2013;95-B:1432–8

Two types of fracture, early and late, have been reported following limb lengthening in patients with achondroplasia (ACH) and hypochondroplasia (HCH). . We reviewed 25 patients with these conditions who underwent 72 segmental limb lengthening procedures involving the femur and/or tibia, between 2003 and 2011. Gender, age at surgery, lengthened segment, body mass index, the shape of the callus, the amount and percentage of lengthening and the healing index were evaluated to determine predictive factors for the occurrence of early (within three weeks after removal of the fixation pins) and late fracture (> three weeks after removal of the pins). The Mann‑Whitney U test and Pearson’s chi-squared test for univariate analysis and stepwise regression model for multivariate analysis were used to identify the predictive factor for each fracture. Only one patient (two tibiae) was excluded from the analysis due to excessively slow formation of the regenerate, which required supplementary measures. A total of 24 patients with 70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of the callus (lateral or central callus) was the only statistical variable related to the occurrence of early fracture in univariate and multivariate analyses. Late fracture was observed in six limbs and the mean time between removal of the fixation pins and fracture was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing index, and lateral or central callus were related to the occurrence of a late fracture in univariate analysis. A multivariate analysis demonstrated that the shape of the callus was the strongest predictor for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91 to 128). Lateral or central callus had a significantly larger risk of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction is important to prevent early and late fracture of lengthened limbs in patients with ACH or HCH. In patients with thin callus formation, some measures to stimulate bone formation should be considered as early as possible. Cite this article: Bone Joint J 2014;96-B:1269–73

We tested the hypothesis that children who sustain a supracondylar fracture have a greater range of elbow hyperextension than those with a fracture of the distal radius. Three observers made 358 measurements in 183 children (114 boys and 69 girls). There were 119 fractures of the distal radius and 64 supracondylar fractures. Initially, the group with a supracondylar fracture appeared to have extension 1.7° greater than that of the group with fracture of the distal radius. On average, there was a maximum variation of 3° between observers. After allowing for age, gender and observer, there was no significant difference between the groups. Our study had greater than 80% power to detect a difference in hyperextension of 2° at the 5% level with the above observer variability. When age and gender are taken into account, any variation in the amount of hyperextension at the elbow is not sufficient to explain the occurrence of a supracondylar fracture

This study was designed to provide normal reference values for the centre-edge angle of Wiberg in the Chinese population by measuring 1494 radiographs according to the criteria of Tönnis. The mean angle was 23.1° (4.7° to 46.4°) in childhood (four to nine years), increasing to 28.9° (6° to 48°) in adolescence (10 to 18 years) and reaching 32.8° (13.7° to 58.8°) in adults. The angle was positively correlated with age, increasing by a mean of 0.78° annually before adulthood and by 0.070° annually in adults. A relative upward tendency after middle age might contribute to degenerative changes. No gender difference was discovered. The change in the angle with age was similar to that observed in other ethnic groups, showing moderate differences in the average of individual age groups, but the ethnic differences are not sufficient to explain the variation of incidence of developmental dysplasia of the hip in different races

We assessed the medium-term outcome of three methods of isolated calf lengthening in cerebral palsy by clinical examination, observational gait analysis and, where appropriate, instrumented gait analysis. The procedures used were percutaneous lengthening of tendo Achillis, open Z-lengthening of tendo Achillis and lengthening of the gastrosoleus aponeurosis (Baker’s procedure). We reviewed 195 procedures in 134 children; 45 had hemiplegia, 65 diplegia and 24 quadriplegia. We established the incidence of calcaneus and recurrent equinus and identified ‘at-risk’ groups for each. At follow-up, 42% had satisfactory calf length, 22% had recurrent equinus and 36% calcaneus. The incidence of calcaneus in girls at follow-up was significantly higher (p = 0.002) while boys had an increased rate of recurrent equinus (p = 0.012). Children with diplegia who had surgery when aged eight years or younger had a 44% risk of calcaneus, while those over eight years had a 19% risk (p = 0.046). Percutaneous lengthening of tendo Achillis in diplegia was the least predictable, only 38% having a satisfactory outcome compared with 50% in the other procedures. The incidence of recurrent equinus in hemiplegic patients was 38%. Only 4% developed calcaneus. The type of surgery did not influence the outcome in patients with hemiplegia or quadriplegia. Severity of involvement, female gender, age at operation of less than eight years and percutaneous lengthening of tendo Achillis were ‘risk factors’ for calcaneus. Hemiplegia, male gender, and an aponeurosis muscle lengthening increased the risk of recurrent equinus

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis

We examined differences in the rate of open reduction, operating time, length of hospital stay and outcome between two groups of children with displaced supracondylar fractures of the humerus who underwent surgery either within 12 hours of the injury or later. There were 77 children with type-3 supracondylar fractures. Of these, in 43 the fracture was reduced and pinned within 12 hours and in 34 more than 12 hours after injury. Both groups were similar in regard to gender, age and length of follow-up. Bivariate and logistical regression analysis showed no statistical difference between the groups. The number of peri-operative complications was low and did not affect the outcome regardless of the timing of treatment. Our study confirmed that the treatment of uncomplicated displaced supracondylar fractures of the humerus can be early or delayed. In these circumstances operations at night can be avoided

Aims

The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL.

We performed a paired study of mature patients with Perthes’ disease to compare the radiological results after treatment between conservatively- and surgically-treated groups. One patient was selected from each group to create the pairs for this study. Each pair was strictly matched for gender, body mass index, age at onset, stage at the first visit, necrotic area and radiological at-risk signs and each was assessed by comparing the values of six radiological measurements. Eighteen pairs (36 hips) fitted the criteria. The radiological measurements which showed a statistically better result in the surgical groups were Mose’s method, the acetabular-head index and leg-length discrepancy. There were no statistical differences in the slope of the acetabular roof and the articulotrochanteric distance. Four hips in the conservative group were in Stulberg class II, five in class III and nine in class IV. In the surgical group, 13 were in Stulberg class II, four in class III and one in class IV. We conclude that surgical treatment improved the sphericity of the femoral head and provided greater acetabular cover, but did not reform the acetabular roof. It was noteworthy that a greater leg-length discrepancy and a smaller articulotrochanteric distance were not seen in the surgical group. Our study suggests that surgical treatment is preferable in patients with severe Perthes’ disease

Slipped capital femoral epiphysis may be associated with hypothyroidism and other endocrinopathies. Routine screening for such abnormalities is unlikely to be cost-effective since the overall incidence of these disorders, in association with slipped capital femoral epiphysis, is low. The identification of a presenting characteristic which would predict the chance of an associated endocrinopathy would allow only selected children to be screened. Our aim was to determine if certain characteristics were useful as a screen for patients with an underlying endocrinopathy who presented with slipped capital femoral epiphysis. Between January 1988 and December 1996 we recorded gender, age, height, unilateral or bilateral involvement and an associated diagnosis of endocrinopathy for all patients who were treated for slipped capital femoral epiphysis. Of 166 such patients 13 (7.8%) had an endocrinopathy. Height was the only useful screening characteristic, although bilateral involvement was more likely in those with an endocrinopathy. Most (90.9%) of this latter group were below the tenth percentile for height compared with only 5.4% in those who did not have an endocrinopathy (p < 0.005). The sensitivity and negative predictive value of detecting an underlying endocrinopathy in a patient presenting with a slipped capital femoral epiphysis and short stature (tenth percentile or less) were 90.2% and 98.6%, respectively. Patients who are on or below the tenth percentile for height at the time of presentation should be screened for a possible endocrine abnormality using measurement of thyroid-stimulating hormone and free thyroxine as a preliminary screening test. These hormones are most likely to be abnormal in the presence of endocrine dysfunction

Aims

The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) in situ epiphysiodesis for mild SCFE, 2) contralateral unaffected hips, and 3) hips from healthy individuals.

Aims

The Ponseti method is an effective evidence-based treatment for clubfoot. It uses gentle manipulation to adjust the position of the foot in serial treatments towards a more physiological position. Casting is used to hold the newly achieved position. At first, the foot resists the new position imposed by the plaster cast, pressing against the cast, but over time the tissues are expected to adapt to the new position and the force decreases. The aim of this study was to test this hypothesis by measuring the forces between a clubfoot and the cast during treatment with the Ponseti method.

Aims

Displaced fractures of the lateral condyle of the humerus are frequently managed surgically with the aim of avoiding nonunion, malunion, disturbances of growth and later arthritis. The ideal method of fixation is however not known, and treatment varies between surgeons and hospitals. The aim of this study was to compare the outcome of two well-established forms of surgical treatment, Kirschner wire (K-wire) and screw fixation.

Aims

The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

Aims

The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic.

Aims

Open reduction is required following failed conservative treatment of developmental dysplasia of the hip (DDH). The Ludloff medial approach is commonly used, but poor results have been reported, with rates of the development of avascular necrosis (AVN) varying between 8% and 54%. This retrospective cohort study evaluates the long-term radiographic and clinical outcome of dislocated hips treated using this approach.

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This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series.

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The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method.

Aims

It is well established that there is a strong association between Perthes’ disease and worsening socioeconomic deprivation. It has been suggested that the primary determinant driving this association is exposure to tobacco smoke. This study aimed to examine this hypothesis.

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Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening.

Aims

After the initial correction of congenital talipes equinovarus (CTEV) using the Ponseti method, a subsequent dynamic deformity is often managed by transfer of the tendon of tibialis anterior (TATT) to the lateral cuneiform. Many surgeons believe the lateral cuneiform should be ossified before surgery is undertaken. This study quantifies the ossification process of the lateral cuneiform in children with CTEV between one and three years of age.

Aims

We present the clinical and radiographic outcome of 81 children with Gartland type I to III supracondylar humeral fractures at a minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following injury.

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To assess the long-term effect of distal trochanteric transfer (DTT) on the clinical and radiographic outcomes of patients with Legg-Calvé-Perthes’ disease (LCPD) following a varus derotational osteotomy (VDRO).

Aims

There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture.

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Our aim was to investigate the predictive factors for the development of a rebound phenomenon after temporary hemiepiphysiodesis in children with genu valgum.

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Extendible endoprostheses have been available for more than 30 years and have become more sophisticated with time. The latest generation is ‘non-invasive’ and can be lengthened with an external magnetic force. Early results have shown a worryingly high rate of complications such as infection. This study investigates the incidence of complications and the need for further surgery in a cohort of patients with a non-invasive growing endoprosthesis.

Aims

To determine the normal values and usefulness of the C1/4 space available for spinal cord (SAC) ratio and C1 inclination angle, which are new radiological parameters for assessing atlantoaxial instability in children with Down syndrome.

Aims

We report the use of the distal radius and ulna (DRU) classification for the prediction of peak growth (PG) and growth cessation (GC) in 777 patients with idiopathic scoliosis. We compare this classification with other commonly used parameters of maturity.

The aim of this prospective study was to investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). The hips of 221 infants (88 female, 133 male, mean age 31.11 weeks; standard deviation (sd) 2.51) who were born in the 34th week of gestation or earlier, and those of 246 infants (118 female, 128 male, mean age 40.22 weeks; sd 0.36) who were born in the 40th week of gestation, none of whom had risk factors for DDH, were compared using physical examination and ultrasound according to the technique of Graf, within one week, after the correction of gestational age to the 40th week after birth or one week since birth, respectively. Both hips of all infants were included in the study. Ortolani’s and Barlow’s tests and restricted abduction were accepted as positive findings on examination. There was a statistically significant difference between pre- and full-term infants, according to the incidence of mature and immature hips (p < 0.001). The difference in the proportion of infants with an α angle < 60° between the two groups was statistically significant (p < 0.001). The incidence of pathological dysplasia (α angle < 50 º) was not significantly different in the two groups (p = 1.000). The Barlow sign was present in two (0.5%) pre-term infants and in 14 (2.8%) full-term infants.

These results suggests that prematurity is not a predisposing factor for DDH.

Cite this article: Bone Joint J 2015; 97-B:716–20

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

The recognition of hips at risk of displacement in children with cerebral palsy (CP) is a difficult problem for the orthopaedic surgeon. The Gross Motor Function Classification System (GMFCS) and head–shaft angle (HSA) are prognostic factors for hip displacement. However, reference values for HSA are lacking. This study describes and compares the development of HSA in normal hips and children with CP.

We selected 33 children from a retrospective cohort with unilateral developmental dysplasia of the hip (DDH) (five boys, 28 girls) and 50 children (35 boys, 15 girls) with CP with GMFCS levels II to V. HSA of normal developing hips was measured at the contralateral hip of unilateral DDH children (33 hips) and HSA of CP children was measured in both hips (100 hips). Measurements were taken from the radiographs of the children at age two, four and seven years. The normal hip HSA decreased by 2° per year (p < 0.001). In children with CP with GMFCS levels II and III HSA decreased by 0.6° (p = 0.046) and 0.9° (p = 0.049) per year, respectively. The HSA did not alter significantly in GMFCS levels IV and V.

Between the ages of two and eight years, the HSA decreases in normal hips and CP children with GMFCS level, II to III but does not change in GMFCS levels IV to V. As HSA has a prognostic value for hip displacement, these reference values may help the orthopaedic surgeon to predict future hip displacement in children with CP.

Cite this article: Bone Joint J 2015;97-B:1291–5.

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104).

The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies.

Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure.

Cite this article: Bone Joint J 2015;97-B:1577–81.

A small proportion of children with Gartland type III supracondylar humeral fracture (SCHF) experience troubling limited or delayed recovery after operative treatment. We hypothesised that the fracture level relative to the isthmus of the humerus would affect the outcome.

We retrospectively reviewed 230 children who underwent closed reduction and percutaneous pinning (CRPP) for their Gartland type III SCHFs between March 2003 and December 2012. There were 144 boys and 86 girls, with the mean age of six years (1.1 to 15.2). The clinico-radiological characteristics and surgical outcomes (recovery of the elbow range of movement, post-operative angulation, and the final Flynn grade) were recorded. Multivariate analysis was employed to identify prognostic factors that influenced outcome, including fracture level. Multivariate analysis revealed that a fracture below the humeral isthmus was significantly associated with poor prognosis in terms of the range of elbow movement (p < 0.001), angulation (p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also a poor prognostic factor for recovery of the range of elbow movement (p = 0.027).

This is the first study demonstrating a subclassification system of Gartland III fractures with prognostic significance. This will guide surgeons in peri-operative planning and counselling as well as directing future research aimed at improving outcomes.

Cite this article: Bone Joint J 2015;97-B:134–40.

Aims

Although atlantoaxial rotatory fixation (AARF) is a common cause of torticollis in children, the diagnosis may be delayed. The condition is characterised by a lack of rotation at the atlantoaxial joint which becomes fixed in a rotated and subluxed position. The management of children with a delayed presentation of this condition is controversial. This is a retrospective study of a group of such children.

Aims

The aims of this study were to describe the course of non-operatively managed, bilateral Perthes’ disease, and to determine specific prognostic factors for the radiographic and clinical outcome.

Assessment of skeletal age is important in children’s orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods.

Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods.

The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience.

The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified.

Cite this article: Bone Joint J 2014;3:1556–60

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy.

Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head–shaft slip angle from 53.8^o (standard deviation (sd) 3.2) pre-operatively to 9.1^o (sd 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, sd 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention.

This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre.

Cite this article: Bone Joint J 2015;97-B:1718–25.

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening.

We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification.

Cite this article: Bone Joint J 2015;97-B:1726–31.

Developmental dysplasia of the hip (DDH) should be diagnosed as early as possible to optimise treatment. The current United Kingdom recommendations for the selective screening of DDH include a clinical examination at birth and at six weeks. In Northern Ireland babies continue to have an assessment by a health visitor at four months of age. As we continue to see late presentations of DDH, beyond one year of age, we hypothesised that a proportion had missed an opportunity for earlier diagnosis. We expect those who presented to our service with Tonnis grade III or IV hips and decreased abduction would have had clinical signs at their earlier assessments.

We performed a retrospective review of all patients born in Northern Ireland between 2008 and 2010 who were diagnosed with DDH after their first birthday. There were 75 856 live births during the study period of whom 645 children were treated for DDH (8.5 per 1000). The minimum follow-up of our cohort from birth, to detect late presentation, was four years and six months. Of these, 32 children (33 hips) were diagnosed after their first birthday (0.42 per 1000).

With optimum application of our selective screening programme 21 (65.6%) of these children had the potential for an earlier diagnosis, which would have reduced the incidence of late diagnosis to 0.14 per 1000. As we saw a peak in diagnosis between three and five months our findings support the continuation of the four month health visitor check. Our study adds further information to the debate regarding selective versus universal screening.

Cite this article: Bone Joint J 2015;97-B:1572–6.

The accurate assessment of skeletal maturity is essential in the management of orthopaedic conditions in the growing child. In order to identify the time of peak height velocity (PHV) in adolescents, two systems for assessing skeletal maturity have been described recently; the calcaneal apophyseal ossification method and the Sanders hand scores.

The purpose of this study was to compare these methods in assessing skeletal maturity relative to PHV. We studied the radiographs of a historical group of 94 healthy children (49 females and 45 males), who had been followed longitudinally between the ages of three and 18 years with serial radiographs and physical examination. Radiographs of the foot and hand were undertaken in these children at least annually between the ages of ten and 15 years. We reviewed 738 radiographs of the foot and 694 radiographs of the hand. PHV was calculated from measurements of height taken at the time of the radiographs.

Prior to PHV we observed four of six stages of calcaneal apophyseal ossification and two of eight Sanders stages. Calcaneal stage 3 and Sanders stage 2 was seen to occur about 0.9 years before PHV, while calcaneal stage 4 and Sanders stage 3 occurred approximately 0.5 years after PHV.

The stages of the calcaneal and Sanders systems can be used in combination, offering better assessment of skeletal maturity with respect to PHV than either system alone.

Cite this article: Bone Joint J 2015;97-B:1710–17.

This retrospective study was designed to evaluate the outcomes of re-dislocation of the radial head after corrective osteotomy for chronic dislocation. A total of 12 children with a mean age of 11 years (5 to 16), with further dislocation of the radial head after corrective osteotomy of the forearm, were followed for a mean of five years (2 to 10). Re-operations were performed for radial head re-dislocation in six children, while the other six did not undergo re-operation (‘non-re-operation group’). The active range of movement (ROM) of their elbows was evaluated before and after the first operation, and at the most recent follow-up.

In the re-operation group, there were significant decreases in extension, pronation, and supination when comparing the ROM following the corrective osteotomy and following re-operation (p < 0.05).

The children who had not undergone re-operation achieved a better ROM than those who had undergone re-operation.

There was a significant difference in mean pronation (76° vs 0°) between the non- re-operation and the re-operation group (p = 0.002), and a trend towards increases in mean flexion (133° vs 111°), extension (0° vs 23°), and supination (62° vs 29°). We did not find a clear benefit for re-operation in children with a re-dislocation following corrective osteotomy for chronic dislocation of the radial head.

Cite this article: Bone Joint J 2015;97-B:1582–7.

Over a 15-year prospective period, 201 infants with a clinically unstable hip at neonatal screening were subsequently reviewed in a ‘one stop’ clinic where they were assessed clinically and sonographically. Their mean age was 1.62 weeks (95% confidence interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value (PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic sonography for Graf type IV dysplastic hips had a 15-year sensitivity of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean, 99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI 41.6 to 68.5). There were 36 infants with an irreducible dislocation of the hip (0.57 per 1000 live births), including six that failed to resolve with neonatal splintage.

Most clinically unstable hips referred to a specialist clinic are female and stabilise spontaneously. Most irreducible dislocations are not identified from this neonatal instability group. There may be a small subgroup of females with instability of the hip which may be at risk of progression to irreducibility despite early treatment in a Pavlik harness.

A controlled study is required to assess the value of neonatal clinical screening programmes.

Cite this article: Bone Joint J 2015;97-B:265-9.

Controversy remains whether the contralateral hip should be fixed in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). This retrospective study compares the outcomes and cost of those patients who had prophylactic fixation with those who did not.

Between January 2000 and December 2010 a total of 50 patients underwent unilateral fixation and 36 had prophylactic fixation of the contralateral hip. There were 54 males and 32 females with a mean age of 12.3 years (9 to 16). The rate of a subsequent slip without prophylactic fixation was 46%. The risk of complications was greater, the generic health measures (Short Form-12 physical (p < 0.001) and mental (p = 0.004) summary scores) were worse. Radiographic cam lesions in patients presenting with unilateral SCFE were only seen in patients who did not have prophylactic fixation. Furthermore, prophylactic fixation of the contralateral hip was found to be a cost-effective procedure, with a cost per quality adjusted life year gained of £1431 at the time of last follow-up.

Prophylactic fixation of the contralateral hip is a cost-effective operation that limits the morbidity from the complications of a further slip, and the diminished functional outcome associated with unilateral fixation.

Cite this article: Bone Joint J 2015;97-B:1428–34.