Introduction: Therapeutic bone marrow transplantation has increased survival in Hurler syndrome, but the effects on musculoskeletal development remain unclear. Long term reports on mobility are poor, with many patients gradually losing walking ability in later childhood secondary to hip subluxation and joint contractures. As previous cohorts are small, data is limited.

Methods: We detail the follow up of twenty patients over a mean of 94 months (range 1 – 17.4 years). Radiographs were assessed for hip dysplasia using acetabular angle of Sharp, centre edge angle of Wiberg and tibiofemoral shaft angle. Clinical examination was performed at an annual multidisciplinary assessment by one clinician and compared against age matched controls. 3D gait analysis was performed on eight older children, and deviance in kinematic variables was plotted against controls with Mann-Whitney U test for statistical analysis.

Results: All patients demonstrated characteristic ace-tabular dysplasia. Fourteen patients have undergone containment surgery at a mean of 4.4 years. Innominate osteotomy is an essential part of this. Mean preoperative acetabular angle was reduced from 34 ± 4° to 22 ± 3°. Femoral head containment is maintained, with mean centre edge angle in older patients 39 ± 7°. Genu valgum is observed early, and five patients underwent medial epiphyseal stapling at a mean of 7.8 years, decreasing tibiofemoral angle by a mean of 8.0°. All patients are currently independently mobile, with restriction of internal hip rotation being the only significant clinical finding (P< 0.001). Joint contractures were not noted. Walking speed and stride length were comparable to controls, but endurance is reduced by about one quarter. Gait analysis demonstrates a characteristic pattern, with anterior pelvic tilt secondary to thoracolumbar gibbus, relative hip flexion throughout the gait cycle, valgus knees and compensatory pronated feet; all measured deviations were significant (P< 0.001).

Conclusions This large group maintained successful hip containment and good mobility throughout childhood. Innominate osteotomy alone has been used recently. Despite plain film appearance, genu valgum is a functional problem in gait, and we would anticipate greater use of corrective stapling in the future. This is the first report of gait analysis in Hurler syndrome, and features specific to the condition are described.

Introduction: There is little epidemiological data on childhood injury in Ireland, despite large numbers of referrals to fracture clinics particularly in the summer months. Information is difficult to obtain retrospectively, and our aim was to quantify paediatric injury referrals to our clinics and analyse trends in injury patterns.

Methods: A prospective injury surveillance system was initiated in our department. Parents were asked to record demographic information and a brief description of the injury at fracture clinics or admission to the ward. Diagnosis and treatment was completed by the attending doctor. Details were transferred to a customised database for analysis.

Results: Overall compliance was excellent. Of 397 recorded referrals, 66% had confirmed fractures, and 20% of these were admitted for operative management. There was an equal sex distribution, and mean age at presentation was 9.1 years. The peak hour of injury was 7 – 8 pm, with fairly even distribution throughout the week. 62% of injuries were due to falls. 39% of injuries occured in or about the home, including 61% of all falls greater than 1 metre, most often from walls and slides. Other common locations for injury were school (16%) and sportsfields (14%). Gaelic football and soccer were the predominant sports causing injury. Fractures occuring during unsupervised sport were more likely to need surgery. Road traffic accidents were an uncommon cause of injury. Home ‘bouncy castles’ and trampolines were a notable cause of injury, causing 6% of all fractures, particularly of the upper limb. Predictably, 41% of all fractures involved the radius. Fractures of the distal humerus, diaphyses of radius, ulna and tibia were most likely to need operative management.

Discussion Analysis yielded a timely insight into the local epidemiology of childhood injuries. In comparison with other studies, sports related injuries were frequent and road accidents were unusually few in our group. Many injuries occurring late in the evening needed early reduction, with almost two thirds of surgical procedures performed out of hours with significant implications on theatre and radiology staffing. A large proportion of higher energy trauma occured in or about the home, representing a potential area for injury prevention stratgies.

Background: In adolescents at or near skeletal maturity, correction of severe scoliosis may be facilitated by first mobilising the spine anteriorly before the definitive posterior fusion and instrumentation. There is no dispute that this is effective, but it is significantly more invasive, and carries greater risks. The benefits have been measured in greater reduction in the Cobb angle, but the patient’s real concern is with cosmesis. Surface topography can measure this aspect.

Methods: Retrospective comparison of topographic parameters (before surgery and at 7 days, 6 months, and 2 years after, and at latest review, if more than two years) after one-stage (Group 5, N=10) and two stage (Group 3, N=39) with normal adolescents (Group 1, N=63). Patients operated for adolescent idiopathic scoliosis by one surgeon (FED) were compared with girls referred and then judged normal from the screening programme. Topographic parameters (spinal angle, saggittal profile, asymmetry and trunk balance) and Cobb angles were compared by t-test.

Results: Prior to surgery, both treatment groups differed significantly from the index group on all parameters except saggittal profile; from each other, they differed only in mean Cobb (Group 3: 73.6°, Group 5: 59°) and spinal angles and Suzuki hump sum. After surgery, both groups showed significant mean reduction in most parameters and in final Cobb angle (Group 3: 32.7° (−40.9°), Group 5: 29° (−30°) postoperatively) excepting rib hump, and were not statistically distinguishable. Over two years, there was continued improvement in trunk balance and re-establishment of lumbar lordosis in both groups. Group 5 (single stage) showed a slight recurrence of some asymmetry parameters that was statistically (but perhaps not clinically) significant. All patients had a solid fusion post-operatively.

Conclusion: Ideally, this study would be done prospectively, on a controlled, double-blind, randomised basis, but the numbers required and time involved make this impractical. These two surgical groups were pre-selected on the basis of curve severity, and these results may show that the anterior procedure is necessary to bring Group 3 to the same end-point as Group 5. Alternatively, while the anterior procedure improves the reduction of the Cobb angle, it might be the posterior fusion that rearranges the shape of the back and hence brings about the cosmetic improvement. In conclusion reducing the Cobb angle has been the standard of surgical assessment, but the cosmetic result does not necessarily correlate with this. The possibility that less invasive surgery may give as good a cosmetic outcome is worth discussing, as the savings in time, money and risk would be enormous.

We compared the long-term clinical outcome scores of the Stanmore total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA, n=26 subjects) versus osteoarthritis (OA, n=35 subjects) at a mean of 12 years after THA. Patients with RA were a mean of 11 years younger at review (66 years, P< 0.001) than those with OA. A greater proportion of RA patients had bilateral THA (19/26 versus 12/35, p=0.03), and were of Charnley grade C (23/26 versus 2/35, p< 0.001). The proportion of male versus female subjects and body mass index were similar between groups (p> 0.05 all comparisons). The overall SF-12 score and SF-12 physical component score were 8% and 15% poorer, respectively, in subjects with RA versus those with OA (P< 0.05). The hip-specific Oxford and Harris hip scores, however, were similar between groups (p> 0.05). Within the individual domains of the Harris hip score, patients with RA had poorer scores for walking distance, stair climbing, putting on of socks/shoes, and ability to enter public transport (p< 0.05 all comparisons). The other domains of pain, limp, use of walking aids, sitting, deformity and range of movement were similar between groups (p> 0.05). The observed differences in outcome scores between RA and OA groups were independent of age and whether the patient had bilateral THA (ANOVA, p> 0.05). Clinical outcome scores in the long term after THA are poorer in RA subjects versus OA. The principal differences occur in the ability to walk long distances, and the use of stairs and public transport.

Background: Scoliosis occurring during the growing years of childhood, while less common, has a greater potential for severe deformity than that with adolescent onset. Treatment is therefore more urgent, and the untreated natural history more difficult to determine. Orthotic treatment and the more recently improved surgical techniques may halt or even reverse the natural history, but the length of time needed for adequate follow-up makes this hard to verify. This report examines the outcome for a historical group of these patients, treated and not, to establish a bench-mark against which results can be measured.

Methods: Retrospective analysis of records derived from the scoliosis database. Subjects were patients presenting with non-congenital scoliosis before the age of ten years and who were at least ten years old when last reviewed. Outcome measures were treatment protocols, the age and incidence of surgery, and the radiological and cosmetic outcome.

Results: 243 children were included, being 38 infantile idiopathic scoliosis (IIS: 20 male, 18 female); 86 juvenile idiopathic scoliosis (JIS: 19 male, 67 female); 119 symdromic scoliosis (Syn:46 male, 71 female) Depending on age, perceived progression potential and individual factors, treatment was either jacket and brace, or observation unless surgery was deemed advisable. In all, 81 children were braced and 162 were not; 129 have had surgery (25 IIS, 48 JIS; 56 Syn.). The individual groups showed no statistical advantage to non-operative treatment in preventing surgery, but in the whole group it appears that a significantly greater proportion (Z=2.7269, p< 0.01) of those braced were subsequently operated. Mean age at surgery was 7.3 years for IIS, 12.97 for JIS and 8.3 for Syn. Recurrence of deformity post-operatively was always observed in those operated before puberty, regardless of the surgical technique.

Conclusion: Ten years of age was taken as the minimum for inclusion, although it is significantly earlier than skeletal maturity, because it has been practice to offer surgery well before this age, and some short term effects may already be apparent by the tenth birthday. This was not a trial of treatment between similar groups, so the appearance of increased surgery in the braced children suggests that, while the clinicians were well able to identify those with a worse prognosis, orthotic treatment was not effective in altering this prognosis. A recently published study¹ demonstrated the failure of past surgical techniques to prevent progressive deformity and respiratory compromise in infantile-onset scoliosis. Here it was found that the older the patient at corrective surgery, the better the result, that methods supposed to prevent post-operative recurrence in skeletally immature children failed to do so, and, while non-operative treatment may be effective at least in postponing surgery, even preventing it in some cases, this was not demonstrated statistically. Treatment of spinal deformity in pre-adolescent children warrants debate as a separate subject, and is a more serious problem than that occurring in adolescence.

There is little data regarding the epidemiology of childhood injury in Ireland. This is difficult to obtain retrospectively. The aim of this study was to prospectively evaluate paediatric trauma referrals to our department, describe their epidemiology, and identify potentially preventable injuries in children. Our unit at the National Childrens Hospital is located in a growing suburban area in South Dublin. Injury surveillance was conducted on orthopaedic referrals by distributing a form to parents of children attending fracture clinics or admitted acutely for surgery. Parents were asked for demographic information, and a brief description of the injury in terms of location, mechanism and circumstance of injury. Diagnosis was completed by the attending doctor and data was transferred to a computerised database. We analyzed data from the 397 referrals in the first month of this study. The mean age of injury was 9.1 years and the male: female ratio was 1.3:1. The peak hour of injury was 7 – 8 pm. Only 33% of injuries occured during the weekend. 62% of injuries were due to falls, usually form the standing position. The most common location for injury was in or about the home (39%), and other notable locations were school (16%) and sportsfield (14%). 61% of falls greater than 1 metre occurred at home, mostly from walls and childrens slides. 20% of injuries occurred while participating in organized sport, including Gaelic football, soccer and hurling. Injuries occuring during unsupervised sport were more likely to need surgery. Domestic ‘bouncing castles’ and trampolines, increasingly popular in our area, were a notable cause of significant trauma to the upper limb. 7% of injuries occurred by falling from a bicycle, but vehicular road traffic accident was an uncommon cause of injury. 263 children had confirmed fractures, other injuries consisting largely of sprains to the ankle, elbow and wrist. Predictably, the bones most commonly fractured were the radius (41%), phalanges (15%) and humerus (11%). 20% of fractures needed operative management, mostly forearm manipulation under anaesthesia. 63% of operative cases were performed outside of normal working hours. Several countries utilise injury surveillance as a means of development and evaluation of injury prevention strategies. In our initial study, basic surveillance has outlined local characteristics of chilhood trauma, and some trends were noted. In particular, we suggest home injuries need further attention in out catchment area.

Thirty four patients underwent 34 single entry percutaneous physiodesis (SEPP) of both distal femur and proximal tibia between July 1996 and June 2004. Twenty six patients had attained maturity and the rest continue to be followed up. There were 10 females and 16 males. The mean ages were12.8yrs (range11–14yrs) and 13.8yrs (range11–15) respectively.

All patients underwent at least three assessments of limb length discrepancy(lld) using CT Scannograms. The Mosely’s straight line graph was then used to predict lld and timing of correction. The procedure was performed under image intensifier control using a 6.5mm drill passed through a small incision. The drill was passed in three directions through a single entry . The physis was curetted.

The mean lld at SEPP was 3.36cm(range1.5–5.9cm). The prediction of lld at maturity after SEPP was a mean of 1.4cm(range0.2–2.5cm) and final lld was a mean of 1.38cm (range0.3–2.5cm). The accuracy of prediction was found to have a mean of 0.44cm (range0–0.7cm). One patient (6%) complained of knee pain for about 2 weeks that settled.

The rest had no complications. We feel that this technique is minimally invasive with a cosmetic scar, has a shorter hospital stay, low complications and is reliable for phuseal ablation. This technique aided by the CT scannogram and a Mosely’s straight line graph provides a reliable and effective method in the management of small amounts of lld.

Back pain screening clinics are established to clinically screen patients with back pain for organic lumbar pathology. The aim of this study is to assess the relationship between clinical signs of organic pathology and the level of disability as measured by functional outcome scores. Methods: Notes from 581 consecutive patients who were seen in the back screening clinic was analyzed. Sixty-nine patients who were found to have clinical signs of organic pathology and 69 age and sex-matched patients from 512 patients who were found to have no signs of organic pathology in the same time period in the back pain screening clinic were selected. The Oswestry disability, Short form-36 and visual analogue (pain) scores between the two groups were statistically analyzed.

The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed. Results: Although there was a signiþcant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). We also found a strong relationship between psychological disability and the duration of back symptoms. Conclusions: High level of disability is associated with organic pathology. Acute back pain should be treated promptly to reduce it impact on the psychological disability.

Objective: To assess the treatment outcome at a minimum age of 15 years in patients who had presented with idiopathic scoliosis in infancy.

Design: Patients were recalled for full pulmonary function testing (spirometry, lung volumes and gas diffusion) and surface topography. Results were correlated with history and clinical radiographs.

Subjects: The records showed 32 patients, of whom 23 could be contacted and agreed to take part in the study. Thirteen had no other abnormality, and 9 had a variety of additional problems not thought to directly precipitate their spinal deformity. There were 13 female and 9 male and age at testing ranged from 15.2 to 30.2 years.

Outcome measures: Spirometry (forced vital capacity (FVC), forced expiratory volume in one minute (FEV₁)), lung volumes ( total lung capacity (TLC), residual volume (RV)) and gas diffusion (carbon monoxide diffusion (DLCO), and alveolar volume (VA)) were correlated with the most recent Cobb angle, surface topography and age at surgery where applicable.

Results: Those who were successfully managed without recourse to surgery (N=6) had normal cosmesis and pulmonary function (mean FEV₁ = 98.7%, mean FVC = 96.6%). When surgery had been postponed until after age 10 (N=6, mean age at surgery 12.9 years) pulmonary function showed some restriction (mean FEV₁ = 79%, mean FVC = 68.3%). Those who underwent corrective surgery before age 10 years (N=11, mean age at surgery 4.1 years) had significant recurrence of deformity and diminished respiratory function (mean FEV₁= 41%, range 14 – 72%, mean FVC = 40.8%, range 12 – 67%). There was statistically significant correlation (p< 0.01 or less) between respiratory measures on the one hand and age at surgery (where applicable), surface topography measures and latest Cobb angle.

Conclusions: It has been reported that only in early-onset scoliosis is the growth of lung tissue and the multiplication of alveoli impeded[1,2] and treatment is directed at preserving both pulmonary function and cosmesis. Early surgery is recommended on the assumption that the Cobb angle can be controlled and normal pulmonary development enabled in those whose scoliosis did not respond to conservative methods. Methods have changed since the earlier cases in this series were treated, and it is hoped that later results will be different. However, caution requires that, in monitoring these patients, cosmesis and, more importantly, respiratory function be considered before a conclusion is drawn.

Langerhans-cell histiocytosis (LCH) is a reactive proliferative disease characterized by the accumulation of abnormal histiocytes. The disease is broadly divided into two groups, unisystem and multisystem disease. The aetiology of LCH is unknown; the disease is currently accepted to be a reactive process rather than a malignancy. Localized LCH of bone is a benign tumour-like condition, which is characterized by a clonal proliferation of Langerhan’s-type histocytes, which infiltrate bone and cause osteolytic lesions. The common bones involved include – skull, pelvis, and diaphysis of long bones.

We wanted to determine whether patient demographics at the time of presentation could help determine the clinical course and eventual outcome of the disease. We prospectively reviewed 68 patients with a primary diagnosis of LCH.

Forty-six patients had unisystem disease, 22 had multisystem disease. There was a statistically significant difference in the age of presentation between the two groups. There were 6 deaths, all had multisystem disease. Of the 46 patients with unisystem disease, 31 (67.3%) underwent orthopaedic surgical intervention, 26 open biopsies and 5 curettage and bone grafting of lesions of the humeras (2), skin, clavicle and skull (1 each). There was a statistically significant difference in the average length of follow-up, between the 2 groups.

We recommend closed and prolonged multidisciplinary follow-up of patient initially presenting with multisystem disease. Patients with unisystem disease can safely be discharged after a short follow-up period.

Objective: It is frequently said that the natural history of adolescent idiopathic scoliosis (AIS) is not understood. This study examines clinical data collected over some years and shows that the information is available and needs only to be generalised and applied.

Design: Retrospective analysis of data, relating basic clinical information (age, Cobb angle, pubertal status, growth) to outcome in the practical terms that are relevant to clinical practice and patient management, Subjects: Two groups of female patients identified from the database: Group 1, girls diagnosed at least one year before the onset of menses and last reviewed at least one year afterwards; Group 2, girls diagnosed at least one day after menarche, followed for at least one year and not having surgery as a first option i.e. within six months.

Outcome measures: Within and between group comparisons as regards age, height and Cobb angle at presentation and at last review and age at menarche. Change in height and Cobb angle of 10°, and the incidence of non-operative treatment and corrective surgery were considered. Statistical analysis was by student’s t test and Fisher’s exact.

Results: Group 1 (N=58) presented at a mean age of 11.6 years SD 1.02, range 10 – 13.9 and reached menarche a mean of 2.1 years later, SD 0.86, range 1.0 – 4.5. Mean Cobb angle was 16.79 SD 8.58. Progression of more than 10° was observed in 24 girls, 11 of whom underwent surgery. Those who progressed had a higher initial Cobb angle (p=0.01) and were taller at discharge (p=0.041), but all other parameters were the same. Group 2 (N=92) presented at a mean age of 13.7 years SD 0.92 with a mean Cobb angle of 23.77° SD 14.52. Progression of 10° or more was observed, one of whom had surgery, her Cobb angle having increased from 48° to 64°. 6 had surgery for cosmetic reasons without further increase in Cobb angle. There was no statistically significant difference between the stable and progressive groups on any parameter other than final Cobb angle.

Comparing Groups 1 & 2, girls in Group 1 were younger and smaller at diagnosis with lower Cobb angles. They were older at menarche, but this was inevitable from the selection criteria, and more likely to progress (p< 0.001), to receive a brace (p=0.047) and to undergo surgery (p=0.043). Age, final Cobb angle and height at discharge were not significantly different.

Conclusions: 1.Girls diagnosed with AIS before puberty are at increased risk of progression but this is not usually clinically significant and does not usually lead to corrective surgery. 2.Girls diagnosed after menarche progress rarely and less. In practice, their deformity can be taken as stable at presentation. 3. In most cases, the course is benign and non-operative treatment had no discernible effect on outcome. As the percentage progressing significantly or requiring treatment at any stage is small, a less interventionist approach is indicated.

The management of long bone infected non-unions; posttraumatic chronic osteomyelitis and primary segmental bone defects constitute some of the most difficult reconstructive challenges encountered by orthopaedic surgeons. Measures employed to treat these conditions are tantamount to limb salvage with amputation a likely outcome if reconstructive endeavors prove unsuccessful. The Ilizarov method of distraction osteogenesis and bone transport, following radical debridement in the case of infection, is one potential management option in such cases.

Aim: To assess outcome in a cohort of patients with long bone defects treated with this technique.

Methods: Clinical review coupled with retrospective chart study and radiographic assessment.

Results: 24 patients (20 adults, 4 children) underwent treatment over a 6-year period. 21 had defects of a primary traumatic aetiology (18 tibial and 3 femoral fractures). The mean interval between injury and commencing bone transport was 41.6 months. The mean defect dimension requiring transport was 9cm (range 4.5 to 28cm). The mean external fixation time was 14.6 months. Union occurred in 21 cases. Autologous bone grafting of the docking site was performed in 6 cases in order to stimulate union. Following removal, frames were reapplied in 4 cases due to refracture or development of angular deformity. Two patients proceeded to below knee amputations. According to ASAMI* criteria, the bone result was excellent in 12 patients, good in 5 patients, fair in one patient and poor in 6 patients. Functional outcome was excellent in 7 patients, good in 12, fair in 2 and poor in 3.

Conclusion: The Ilizarov method of bone transport is a reliable procedure providing consistent results in complex cases when frequently alternative treatment options have been exhausted. Outcome compares favorably with other treatment modalities such as vascularised free tissue transfer or Papineau type grafting procedures. The treatment period is lengthy and both major and minor complications are common but limb salvage is successful in the main part. More aggressive treatment and appropriate fracture management in the early stages may have a role to play in improving the prognosis of these patients.

*Association for the Study and Application of the Methods of Ilizarov

Introduction: The arguments for and against school screening for scoliosis are long since over, and centres have continued or ceased as they thought best and as funding allowed. However, the programmes did amass considerable volumes of observations that, being part of the over-all epidemiological picture, could advance our understanding of adolescent idiopathic scoliosis and of minor asymmetries of back shape.

Methods and Results: A retrospective examination of the records from the school screening programme at this centre concentrated on subjects with minor asymmetry, those who at first review did not qualify as ‘scoliosis’ yet were noted to have failed the forward bend test. There were 91,811 examinations on 55,484 girls: 2170 were classified as ‘non-scoliosis asymmetry’. Of these, 1574 were noted but not referred; 360 were reviewed in clinic without radiograph,; 107 had straight spines on radiograph and 221 had Cobb angles < 10°. Eleven are known to have progressed to 10° or more, three passed 25°, two passed 40° and one underwent surgery. This gives an incidence in this subgroup of 0.51% for defined scoliosis. For scoliosis => 25°, it was 0.14%; for scoliosis => 40°, 0.092%; and 0.046% for surgery, none of which shows a significant difference from the equivalent rates for the population as a whole. (0.6% Cobb angle => 10°, 0.2% Cobb angle => 25°, 0.08% Cobb angle => 40°, 0.045% surgery. (Goldberg CJ et al. (1995). Spine. 20(12):1368–1374).

Conclusion: These findings are in accordance with previous reports on school screening, and it is not proposed to re-open the discussion. Their relevance is their relationship to significant scoliosis: since these children are not at increased risk of developing deformity, they cannot be, as has been proposed (Nissinen et al (2000) Spine. 25:570–574) instances of mild or early scoliosis, and they do not need intensive investigation, follow-up or treatment. Non-scoliosis asymmetry is closer to the increased fluctuating asymmetry displayed by this age group (Wilson and Manning. (1996) Journal of Human Evolution. 30:529–537) and begs a more biological approach to spinal deformity, asymmetry and back shape.

Introduction: Historically, the spinal curvature of adolescent idiopathic scoliosis was considered a life-threatening occurrence, which would result in early death from cardio-respiratory compromise. Consequently, corrective surgery had the primary intention of preventing this unacceptable outcome: cosmetic improvement was considered to be certainly important, but not the prime objective of the treatment. More recent work (e.g. Branthwaite MA. (1986) Br.J.Dis.Chest. 80:360–369) has shown that, while significant deformity presenting in early childhood does carry this outlook, those with an adolescent onset should not be significantly affected in this way. Consequently, any surgery recommended is primarily cosmetic, to improve the deformity when it is unacceptable to the patient and her parents. This, of necessity, changes the criteria by which treatment outcome should be assessed. Scoliosis surgery has generally been judged by the correction in Cobb angle and, more recently, the derotation of vertebrae. However, it is well known that neither factor accurately expresses cosmesis, the criterion by which the patient will judge the operation. Surface topography attempts to quantify the external appearance of a patient and so the cosmetic effect of surgery. Since 1995, when a surface topographic system (Quantec) was acquired by this department, 61 patients were operated for adolescent idiopathic scoliosis, of whom 35 underwent anterior release and posterior fusion for rigid thoracic curves.

Methods and Results: Pre- and post-operative radiographs were compared with topographic results from the same periods and with the latest scan at last review. The mean pre-operative Cobb angle was 74.5° and, postoperatively was 40.7°, a mean correction of 45.4% and was statistically significant (p< .001). This was accompanied by statistically significant reductions in upper and middle topographic spinal angles (p=0.001), an increase in thoracic kyphosis (p< 0.05), a decrease in lumbar lordosis (p=0.001), lower rib hump (p< 0.05), Suzuki hump sum (a measure of back asymmetry, p=0.001) and posterior trunk asymmetry score (POTSI, a measure of trunk balance, p=0.003). At final follow-up a mean of 2.2 years later, topographic spinal angles and POTSI maintained their improvement, still being statistically significantly less than their pre-operative values. Thoracic kyphosis, lumbar lordosis, rib hump and Suzuki hump sum had returned towards pre-operative levels and no longer showed statistically significant differences.

Conclusions:This confirms previous reports of the recurrence of the rib-hump. In conclusion, after two-stage spinal fusion for adolescent idiopathic scoliosis, significant improvement in cosmetic appearance can be achieved. However, over time certain aspects of the original deformity, particularly distortion of the back surface (rib hump or asymmetry) recurs.

Assessment and referral of spinal disease in a primary care setting is a challenge for the general practitioner. This has led to establishment of spinal assessment clinic to insure prompt access to the patient who requires treatment by a spinal surgeon. These clinics are run by a trained physiotherapist who liaises with a member of the spinal team and decides the need for referral to the spinal clinic on the bases of the patient’s history and clinical examination. In our clinic each patient is also assessed with Oswestry disability index, Short form-36, visual analogue score and hospital anxiety score (HADS), although these scores do not contribute to the clinical decision-making. The aim of this study is to assess the screening value of Oswestry disability score, Short form-36 scores in diagnosing acute spinal pathology.

Sixty-nine patients who were referred to the spine clinic from the assessment clinic between March and December 2001 were recruited. Sixty-nine age and sex-matched patients were randomly chosen from five hundred and twelve patients who were seen in the spinal assessment clinic and did not need referral to the specialised spine clinic. The Oswestry disability score, Short form-36 scores and pain visual analogue scores between the two groups were statistically compared. The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed.

Although there was a significant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). The variation in the scores makes the scoring system unspecific for use as a screening tool. We also found strong relationship between psychological disability and length of symptoms indicating the need for prompt treatment for back pain.

Neonatal septic arthritis is a true orthopaedic emergency posing significant threat to life and limb.

Objective: To examine the clinical presentation, diagnosis, treatment and outcome of children presenting with septic arthritis in the neonatal period.

Design: Retrospective review of clinical notes and radiographs of children presenting over a 20 year period (1977–97).

Subjects: 34 patients with septic arthritis in a total of 36 joints.

Outcome measures: Clinical outcome was classified as satisfactory or unsatisfactory as per Morrey et al. Radiological outcome was graded I–IV as per Choi et al. Joint instability, destruction, limb length discrepancy and angular deformity were assessed.

Results: The hip joint was affected in 24 of the 34 cases. Pseudoparalysis was the most reliable clinical finding occurring in 29 out of 34 cases. Staph Aureus was isolated as the infecting pathogen in 22/34 patients. Sequelae occurred in 16 hips and 1 knee. Poor prognostic indicators were delayed diagnosis (p< 0.05) and the hip as site of infection (p< 0.01). Clinical outcome was unsatisfactory in 15 patients and satisfactory in 17 patients. Radiological outcome was Choi I or IIA (good) in 12 hips and Choi II to IV in 13 hips (poor). Multiple further reconstructive procedures were required in 15 cases.

Conclusions: Despite optimum treatment, neonatal septic arthritis results in significant long-term morbidity for a high proportion of cases.

Surgical correction of spinal deformity in patients with neural axis abnormalities has established risks of causing further neurological injury. It is necessary to identify individuals with a predisposition for such abnormalities before treatment is instituted.

Objective: Examination of the association between idiopathic scoliosis and underlying neural axis abnormalities in the infantile and juvenile age groups.

Design: Retrospective chart and radiographic review.

Subjects: Ninety-four (36 infantile, 58 juvenile) consecutive patients with non-congenital scoliosis under the age of eleven years.

Outcome measures: These consisted of the MRI findings, neurological examination, associated curve morphology and necessity for neurosurgical intervention or surgical curve correction.

Results: Approximately 25% of patients presenting as idiopathic juvenile scoliosis had underlying neural axis abnormalities. No patient with apparent infantile idiopathic scoliosis had an abnormal spinal MRI scan. Using the Z score for independent proportions, there was a statistically significant difference between infantile and juvenile scoliosis and the presence of an underlying neural axis abnormality (Z score of 2.089, equivalent to p< 0.02).

Conclusions: We advocate routine MR spinal imaging in all patients with juvenile idiopathic scoliosis. In infantile idiopathic scoliosis, to avoid unnecessary general anaesthetics, one should image the spinal canal only when clinically indicated

In 1993 a specialist limb length discrepancy and deformity clinic was established at Our Lady’s Hospital for Sick Children. Since then, the senior author has performed 193 lower limb lengthenings. Of these, there were 50 paediatric cases who had 74 segments lengthened using the Ilizarov method of distraction osteogenesis. A retrospective study of data and radiographic review of these children was performed. In particular, the grade of severity of deformity and complications encountered whilst lengthening were documented.

Complications were defined as any unwanted event and graded as minor or major with the major complications being further classed as serious or severe. Each patients deformity was classified using the Dahl Deformity Severity Scale which grades deformity according to percentage length discrepancy.

There were 26 females and 24 males in the study population, their average age being 13.1 years (range 2.8–18 years). 65% of the lengthenings had a congenital aetiology for the deformity. The mean hospital stay was 7 days and the average length achieved was 4.9cm. There were 79 minor complications and 48 major complications. The overall complication rate (total complications divided by the number of segments lengthened) was 1.74%.

This study shows how the Deformity Severity Scale may be used as a prognostic indicator to identify limb deformity at high risk of lengthening complication. It may also be used to determine the relative complication risk for each patient according to his or her percentage limb length discrepancy.

We reviewed 68 fractures of the distal radius in children, all treated by primary manipulation and plaster immobilisation. Complete displacement of the fracture and failure to achieve a perfect reduction were both associated with a significant increase in the chance of redisplacement. We recommend the use of percutaneous Kirschner wires to maintain a satisfactory position in all cases in which a perfect reduction cannot be achieved.