Introduction: Ankle fractures accounts for 25% to 38% of all physeal fractures. An accurate diagnosis is the key to the appropriate management of these fractures. Traditionally the management decisions have been based on x-ray findings. We have used computed tomograpy (CT) scans in additon to x-rays in the management of these fractures.

Objective: To determine the usefulness of computed tomograpy (CT) scans in the management of ankle fractures in children.

Materials and Methods: Between 2001 to 2005, 53 patients with ankle fractures who were managed in our unit had CT scans in addition to plain radiographs. The mean age was 12.3 years (+/− 2.1). The radiographs were reviewed by senior paediatric orthopaedic surgeon who classified the fractures and formulated treatment plans (operative/non-operative). The CT scans were then reviewed by the respective surgeon and a similar exercise undertaken. A Radiologist confirmed that the fractures were classified accurately.

Results: In 47% (25 fractures) the x-ray diagnosis/classification tallied with the CT scans whilst in 53% (28 fractures) the CT scans showed the fractures were more extensive/serious than noticed on the x-rays. The management was changed in 34% after reviewing the CT scans, In 9 from operative to non-operative treatment and in the other 9 from non-operative to operative treatment.

Conclusion: We have found CT scans to be more useful than plain radiographs in making an accurate diagnosis of ankle fractures in children and thus planning appropriate management.

Purpose of study: To evaluate the clinical outcome of operative intervention for chronic patellar instability for patients treated by a single paediatric orthopaedic surgeon over a 74-month period

Method: There were 11 patients (16 knees) with a mean age at operation of 11.9 years (5 to 17 years). Patients were treated with combined proximal and distal patellar realignment. Mean follow-up was 44.6 months (11–86 months). All patients were assessed post-operatively with satisfaction scores, the Trillat grading system and the Activity Scale for Kids (ASK). They were also questioned specifically for patellofemoral symptoms and examined for signs of mal-tracking.

Results: Subjective patient rating of all procedures revealed 10 (62.5%) responses of excellent or very good, 4 (25%) good, 1 (6.25%) fair and 1 poor (6.25%). Formal Trillat grading revealed 9 (56.3%) excellent, 6 (37.5%) good, 1 (6.2%) fair and no poor outcomes. The mean ASK score was 82% (39–100%). All except one patient felt that they would choose to undergo the surgery again. There was one complication of a superficial wound infection.

Conclusions: These results show improvement in symptoms and function as judged by Trillat grading and a majority of patients satisfied with the results of the procedure. We feel that the advantage of appropriate surgical intervention at a young age is not only the improvement in symptoms, but also that successful realignment of patellar tracking may reduce subsequent degenerative problems associated with chronic instability and allow better rehabilitation of the dynamic stabilisers of the patellofemoral joint.

Introduction: Prophylactic pinning of an asymptomatic hip in SCFE is controversial. Bone age has been used as evidence of future contralateral slip risk and used as an indication for such intervention. The efficacy of bone age assessment at predicting contralateral slip was tested in this study.

Patients and Methods: 18 Caucasian children prospectively had bone age assessment using wrist and hand x-rays when presenting with a unilateral SCFE. Patients and parents were informed about the chance of con-tralateral slip and risks of prophylactic fixation, and advised to attend hospital immediately on development of symptoms in contralateral hip. After in-situ fixation of the affected side prospective monitoring in outpatient department was performed. Surgical intervention was undertaken if the contralateral hip was symptomatic.

Results: Three children (2 boys) went on to develop to a contralateral slip at a mean of 20 months from initial presentation. 6 children (5 boys) were deemed at risk of contralateral slip due to a bone age below 12.5 years for boys and 10.5 for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95). The sensitivity and specificity were 33% and 66% respectively. With positive predictive value of 15% and diagnostic efficiency of 61%.

Conclusion: Delayed bone age by itself is not a good predictor of future contralateral slip at initial presentation. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. Prospective long term longitudinal study is required.

Introduction: Prophylactic pinning of an asymptomatic hip in SCFE is controversial. Bone age has been used as evidence of future contralateral slip risk and used as an indication for such intervention. The efficacy of bone age assessment at predicting contralateral slip was tested in this study.

Patients and Methods: 18 Caucasian children prospectively had bone age assessment using wrist and hand x-rays when presenting with a unilateral SCFE. Patients and parents were informed about the chance of con-tralateral slip and risks of prophylactic fixation, and advised to attend hospital immediately on development of symptoms in contralateral hip. After in-situ fixation of the affected side prospective monitoring in outpatient department was performed. Surgical intervention was undertaken if the contralateral hip was symptomatic.

Results: Three children (2 boys) went on to develop to a contralateral slip at a mean of 20 months from initial presentation. 6 children (5 boys) were deemed at risk of contralateral slip due to a bone age below 12.5 years for boys and 10.5 for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95). The sensitivity and specificity were 33% and 66% respectively. With positive predictive value of 15% and diagnostic efficiency of 61%.

Conclusion: Delayed bone age by itself is not a good predictor of future contralateral slip at initial presentation. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. Prospective long term longitudinal study is required.

CTEV is a difficult condition to treat with chances of recurrence, re-operation rate and over correction. Recent literature based on evidence is favourable with the Ponseti management. The aim of the study was to review our surgical results over a 5-year period using the Cincinnati approach.

Children with failure of conservative serial stretching and casting for 6 months underwent open release. The records and radiographs were reviewed retrospectively from 1997–2002. 60 patients were identified with 92 feet undergoing primary sub radical releases using the Cincinnati approach in 40 male and 20 female children. The mean age at surgery was 10 months. 55 patients were idiopathic with 3 syndromal and 2 teratological.

Consultants performed > 75% of operations, with k-wire stabilisation done in 46 patients and primary wound closure in 25; the majority of wounds were left open. The timing of plaster change varied, with the majority at 2 weeks. Wound problems occurred in 4 patients (significant in 2). All patients but one wore splints for an average length of 13 months. Complication rate was 20% comprising infection, over- correction and recurrence. Re-operation rate for early recurrence was 12%. Further surgery in the form of tibialis anterior transfer and derotation osteotomy was performed on 15% and 10% of feet respectively. 6 feet in 4 patients showed signs of significant over correction.

Wound healing by secondary intention of the Cin-cinnati approach is safe. Results and complications are comparable to other series, but not to the Ponseti non-operative management. Practice is now changed to the latter based on evidence.

Acute total knee dislocations are uncommon injuries for which some surgeons use artificial ligaments as their choice of graft for reconstruction. The goal of this study is to evaluate on a short and long term basis the stability and function of the LARS reconstructed knee. Flexion ROM was the only parameter which showed significant difference (p< 0.05) between subgroups. Therefore this treatment option for dislocated knee reconstruction seems to give good and lasting results even though patient’s quality of life may suffer.

Although a variety of options have been proposed for the treatment of knee dislocations, the optimal one remains controversial. Allografts and autografts have both been used for reconstruction of the cruciate ligaments. The purpose of this study is to evaluate acute reconstruction of both cruciate ligaments using Ligament Advanced Reinforced System (LARS) artificial ligaments.

We reviewed treatment of forty-eight acute knee dislocations. All patients had reconstruction of both cruciate ligaments with LARS ligaments. Patients were assed using SF-36, Lysholm and IKDC questionnaires as well as a physical exam. Stability of the reconstructed knee was evaluated radiologically using TELOS instrumentation. The controlateral knee was used as reference.

The forty-eight patients were subdivided into four groups of post-operative intervals ranging from six months to seven years. The average ROM was 120°of flexion and −1.4° of extension. The differential average TELOS for LCA, LCP at 30° and LCP at 90° were respectively 2.9 mm, 2.8 mm, 6.9 mm. and their average Lysholm, SF-36 and IKDC scores were 72.0, 72.5, 53.5. Statistical results showed no significant difference (p> 0.05) between subgroups in terms function, laxity and extension but did in flexion.

Our data show that patients treated by this method can regain a functional knee in terms of motion, stability and functional status and does not seem to deteriorate with time.

Knee reconstruction with artificial ligaments shows promising results at short and longer term even though it seems to affect quality of life in this population.

Financing: This study was partially financed by JK Orthomedic Inc.

Thirty-four patients were studied through the whole of the Perthes’ disease in Alder Hey Children’s Hospital, Liverpool. The acetabular changes included osteopaenia of the roof, irregularity of its contour, and decrease in the depth. These changes were proportional to the femoral head involvement. The purpose of the study was to know the effect of the morphological changes of the femoral head on the acetabulum and its outcome.

Radioisotope scans of the hip were examined in fourteen children with unilateral Perthes’ disease and comparison was made with the contralateral hip. These scans showed increased uptake on the lateral part of the acetabulum and no uptake over the avascular part of the femoral head. Average follow-up was ten years and on an average children were followed up from six years to fifteen years of age. Six readings of the measurements of various dimensions of the acetabulum and the femoral head were done. CT scan also showed irregularity in the acetabulum. Statistical tests lead to the conclusion that the decrease in the depth of the acetabulum was secondary to the femoral head involvement and the extent of its dimensional changes affected the final congruity between the femoral head and the acetabulum. Also the remodelling potential of acetabulum decreases as the child grows older. Therefore containment procedures could be done by femoral osteotomy in younger children and acetabular osteotomy may benefit older children.

To review the results of limb lengthening and deformity correction in fibular hemimelia, fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achter-man and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had sig-nificant femoral deficiency. Lengthening of tibia and in significant cases femur was done using De Bastiani or Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique.

The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis.

Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb.

We demonstrated for the first time that HNE, a lipid peroxidation end product, plays a role in osteoarthritic (OA) cartilage degradation. The level of HNE/protein adducts increased in synovial fluids from OA patients and in cellular extracts of OA chondrocytes treated with free radicals donors (H2O2 or SIN). We have found that HNE induces MMP-13 synthesis and activity but in contrast inhibits type II collagen and TIMP-1 synthesis. By immunoprecipitation approach, we demonstrated the formation of HNE/type II collagen adducts in OA cartilage and their increased level in the presence of H2O2 or SIN.

To investigate the role of peroxidation end product, 4-hydroxynonenal (HNE), in osteoarthritic (OA) cartilage degradation.

Total HNE/protein adducts were quantified in synovial fluids or in cellular extracts of chondrocytes using a house Elisa. The formation of HNE/type II collagen adducts was analysed by immunoprecipitation. Type II collagen synthesis was analysed by Western blotting. MMP-13 activity and synthesis as well as TIMP-1 synthesis were measured by commercial kits.

Our data show that the level of HNE/protein adducts markedly increased in OA synovial fluids compared to normal subjects and in cellular extracts of OA chondrocytes treated with free radicals donors (H2O2 or SIN) compared to untreated cells. Using an immunoprecipitation approach, we demonstrated the formation of HNE/type II collagen adducts in OA cartilage and their increased level in the presence of H2O2 or SIN. Furthermore, we find that HNE induces MMP-13 synthesis and activity in a dose-dependent manner, but in contrast, inhibits type II collagen and TIMP-1 synthesis. Interestingly, HNE was proved to exert a dual effect in vitro, activating proMMP-13 at low molar ratio (MR~100:1) and inhibiting active MMP-13 at high molar ratio (MR > 1000:1).

The data generated in this study support the hypothesis that HNE plays a dual role in OA cartilage degradation. At posttranslational level, HNE promotes modification of type II collagen and MMP-13 by adducts formation. At transcriptional level, HNE inhibits type II collagen and TIMP-1 synthesis and induces MMP-13 synthesis and activity.

Support: This work was supported by FRSQ

To review the results of reconstruction of pseudoar-throsis and/or significant varus with retroversion of proximal femur in congenital longitudinal lower limb deficiencies, twenty-three of ninety-five patients with lower limb deficiencies underwent proximal femoral reconstruction at the Sheffield Children’s Hospital. All twenty-three underwent valgus derotation osteotomies to correct coxa vara and retroversion of femur. Seven patients also had pseudoarthrosis of the neck of femur. Three of these were treated with valgus derotation osteotomy and cancellous bone grafting, two with fibular strut grafts, one King’s procedure and one with excision of fibrous tissue and valgus derotation osteotomy. A variety of internal fixation devices and external fixator were used.

Seventeen of the twenty-three patients had valgus osteotomies repeated more than once (average 2.3) for recurrence of varus deformity. Average initial neck-shaft angle was 72 degrees, which improved to an average of 115 degrees after reconstruction.

All seven patients with pseudoarthroses underwent multiple procedures (average 3.3) to achieve union. Cancellous bone grafting was repeated twice in two patients to achieve union but all three with cancellous bone grafting underwent repeat osteotomies to correct residual varus. Two patients achieved union after fibu-lar strut grafting. One patient, who underwent excision of pseudoarthrosis, achieved union but had to undergo further valgus osteotomy. No particular advantage of any one-fixation device over the others was noted in achieving correction.

Early axis correction using valgus derotation oste-otomy is important in limb reconstruction when there is significant coxa vara and retroversion, although recurrence may require repeated osteotomies. Pseudoarthro-ses needed more aggressive surgery to achieve union.

Aim: To report our experience and early results with the Ilizarov pelvic support realignment lengthening osteotomy for complex hip pathology in children.

Material & Methods: Between 1997 & 2004, seven children were treated with this technique and five have completed treatment. The treatment was undertaken for sequelae of DDH in 4 patients and septic arthritis in 1 patient. The median age of the patients was 13(10–17). There were 3 boys and 2 girls. The outcome assessment was performed using the Harris hip score, clinical and radiological parameters.

Results: 4 patients presented with hip instability, shortening of the lower limb, pain and restricted motion. The remaining patient presented with a nonfunctional ankylosis with shortening. The median time between the onset of symptoms and the operation was 3 years (2–5). The median preoperative leg-length discrepancy was 3 cm (2–4.5). The median fixator time was 5 months (3–6). The median follow-up was 24 months (9–72).

Patients had improvement of pain, posture, hip instability, walking ability and limb length discrepancy. The median lengthening of the femur was 3 cm (2–5). The mechanical axis was realigned in all patients. All patients were satisfied with the outcome. Planned secondary contra lateral epiphyseodesis was required to equalise leg length in 2 patients. Complications included a stiff knee (1) that required a Judet quadricepsplasty, premature consolidation (1) that required reosteotomy and knee subluxation (1) that required cross knee stabilisation.

Conclusion: This is a safe and reliable alternative option to joint replacement, Colonna arthroplasty and arthrodesis for the reconstruction of multiply operated complex hip pathology in children.

Purpose: The aim of this part retrospective and part prospective study was to establish the incidence of pinsite infections and assess evolution of changes in practice

Methods: Data was collected retrospectively and prospectively for pin site infections from the inception of limb reconstruction service viz. 1985 to January 2002. There were 812 patients, 1042 limb segments, and 9935 pins. The various external fixators used were limb reconstruction system (LRS) 549; Ilizarov 397; Sheffield ring fixator (SRF); Dynamic axial fixator (DAF) 35; LRS/Sequoia 8; LRS/Garche 7; and Pennig 5.

Results: The pin site infections were graded from 0 to 6 ( Saleh & Scott). There were no infections in 206 segments. The infection grade is shown below:

We changed our pin tract care practice from 1996. We had a significant decrease in pin tract infections since then (p< 0.0001). We also found that using Ilizarov wires had significantly less infections than with half pins used with monolateral fixators (p< 0.0001; linear trend, p= 0.0338). There were 48 patients that required hospital admissions for IV antibiotics. and of these 10 patients required debridement. There were no residual long lasting infections or chronic osteomyelitis.

Conclusion: Attention to detail in insertion of wires and half pins is crucial to avoid pin site infections. This audit supports the fact that external fixation is a safe method from the point of view of infection contrary to general belief.

Aim: To report our experience and early results with flexible nailing for unstable or irreducible displaced proximal humeral fractures in children.

Material & methods: Between 1997 & 2004, 15 children with unstable or irreducible displaced fractures of the proximal humerus were treated with closed/open reduction and flexible IM nailing. There were 10 boys and 5 girls. The median age of the patients was 12.5 years (9–15). Thirteen children had a Salter – Harris II, Neer grade III/IV fracture and 2 children had metaphyseal fractures. The outcome assessment was performed using the shoulder score, clinical and radiological parameters.

Results: All fractures united. None of the patients had a clinically significant malunion/shortening. Three patients had irritation at the nail insertion site. One patient had a transient radial nerve neurapraxia. There were no other operative or postoperative complications. The flexible nails were removed at a median time of 6 months (1.5–10) in 12 patients and 3 patients are awaiting removal. At a median follow-up of 30 months (4–66) all patients had a normal or near normal glenohumeral motion, full strength and all reported regaining full pre-injury functional use of the involved extremity.

Conclusion: Flexible nailing can be used safely to maintain reduction in unstable or irreducible displaced fractures of the proximal humerus and allows early return to normal activities and function with minimal complications. This treatment is also useful in older children who have minimal remodelling potential.

Introduction: Planovalgus is a clinical deformity on weightbearing. Extra-articular calcaneal lengthening osteotomy, is a recognised surgical treatment for symptomatic flat feet. The aim of this study was to assess the difference in pedal pressures and radiographic parameters in the assessment of patients undergoing lateral column lengthening for planovalgus deformity.

Methods: Operative records of one surgeon were reviewed over a 5 year period to identify those who had undergone a lateral column lengthening procedure. 10 patients, 14 feet were identified. Patients were recalled for post-operative pedobarography and pre- and post-operative X-rays were identified. Peak plantar pressures were measured at 8 sites and a line plotted to show maximum deviation of pressure progression from the anatomical axis of the foot. 5 angles on X-rays were measured by 2 observers on 2 occasions.

Results: Difference in pressure under the 3^rd metatarsal head (p=0.0004), hallux (p=0.02) and medial midfoot (0.001) suggested a highly significant change. Results for the first (p=0.41) and second (p=0.91) metatarsal heads showed no change. The centre of pressure maximum deviation, plotted using a line drawn between the second toe and the rear of the heel was found to be highly significant postoperatively (p=0.00051) indicating that load bearing shifted from medial to lateral. Changes in X-ray angles of the lateral talo-1^st metatarsal angle(p=0.006), calcaneal pitch(p=0.002), AP talocalcaneal angle(0.0001) and talonavicular coverage(p=0.003) were all highly significant.

Discussion: Lateral lengthening in adolescent feet changes the pedal pressures in an advantageous way.

Introduction and Aims: To review the existing classifications in characterising the pathologic morphology of congenital lower limb deficiencies (CLLLD) and their usefulness in planning limb reconstruction.

Method: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken, Amstutz, Hamanishi, Gillespie and Torode, Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems.

Results: All patients with predominant deficiency of one segment (femoral or fibular) also had associated shortening of the other segment in the same limb. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterise the morphology of the involved limb using the following method:

Acetabulum: Dysplastic/Non-dysplastic

Conclusion: Existing classifications do not represent the complete morphology of the entire involved lower limb in CLLLD and therefore a systematic method of characterising the morphology of the lower limb is more useful in planning limb reconstruction.

Aim: To evaluate our results of articulated hip distraction in children with a painful, stiff hip.

Materials & Methods: Between 1988 & 2003, 10 children underwent hip distraction and 7 have completed treatment. The diagnoses were varied, though the presentations were those of pain & stiffness of the hip, poor posture and gait. The Orthofix articulated hip device was used in all patients. The outcome assessment was performed by clinical and radiological review.

Results: The mean age of the patients was 13.7 years (Range 12–17 years). The primary diagnosis was SUFE- 3, Perthes-4, trauma-1, septic arthritis -1, chemotherapy induced -1. The mean fixator time was 12 weeks (range 10–14 weeks). The follow-up period ranged from 4–183 months. Soft tissue releases and joint debridement were done in 6 and 2 patients respectively. Results were good in one, fair in five and poor in one patient. Patients with non-functional ankylosis gained functional position with some increase in range of motion. Grade 2 pin tract infections were noted in 4 patients.

Conclusion: Early results with hip distraction in this difficult, complicated group of patients are promising clinically and radiologically.

Introduction We have reviewed the clinical outcome and complications of Monofocal and Bifocal Callotasis for lower limb lengthening in children with Achondroplasia.

Methods Between August 1986 and January 1999, 57 children with Achondroplasia had lower limb lengthening. Monofocal callotasis had been carried out in 147 Segments of 44 children and bifocal callotasis in 38 segments of 17 children. Complications were noted and final outcomes recorded.

Results The 29 children who completed the programme gained an average of 20 cms in height. For all patients, the mean length gained per segment was roughly nine centimetres. Average Bone Healing Index in the mono-focal lengthening group was 39.9 days/cm and in the bifocal lengthening group 33.6 days/cm. Complications were staged and graded and the average was 2.8 complications per lengthened segment. Most were pin-site related and occurred during stage of distraction. Twenty percent of the segments required further axis corrections. Most patients regained their pre-operative range of motion. Serious irreversible complications were seen in only two patients and included a physeal bar and psychological disturbances. Functional outcome analyses are planned.

Conclusions Limb lengthening for short stature due to Achondroplasia can be confidently undertaken with favourable results in most cases. Bifocal lengthening is an alternative technique with quicker consolidation time.

Aims: To review the results of reconstruction of pseudoarthrosis and/or significant varus with retroversion of proximal femur in congenital longitudinal lower limb deficiencies. Methods: 23 of 95 patients had proximal femoral reconstruction. 7 had pseudoarthrosis of the neck of femur and the remaining had significant coxa vara with retroversion of femur. 3 patients with pseudoarthroses were treated with valgus derotation osteotomy and cancellous bone grafting, 2 with fibular strut grafts, 1 King’s procedure and 1 with excision of fibrous tissue and valgus derotation osteotomy. Remaining patients underwent valgus derotation osteotomies. A variety of internal fixation devices and external fixators were used. Results: All patients with pseudoarthroses underwent multiple procedures to achieve union. 3 with cancellous bone grafting underwent repeat osteotomies to correct residual varus and 2 had grafting repeated twice. 2 patients achieved union after fibular strut grafting. One patient, who underwent excision of pseudoarthrosis, achieved union but had to undergo further valgus osteotomy. The remaining 17 patients with coxa vara and retroversion of femur also had valgus osteotomies repeated more than once (average 2.3) for recurrence of varus deformity. There were significant numbers of implant failures. Average initial neck-shaft angle of 72 degrees improved to 115 degrees after reconstruction. Conclusion: Achieving union of pseudoarthrosis and early axis correction using valgus derotation osteotomy with a view to later lengthening is important in limb reconstruction. Recurrence may require repeated osteotomies and pseudoarthrosis may need more aggressive surgery to achieve union. Muscle slides and soft tissue releases decrease the stress on implant and maintain correction.

Aims: To review the results of limb lengthening and deformity correction in fibular hemimelia. Methods: Fifty-five patients with fibular hemimelia underwent limb reconstruction at Sheffield Children’s Hospital. According to Achterman and Kalamchi classification, twenty-six were classified as Type IA, six as Type IB and twenty-three as Type II fibular hemimelia. All patients had at least some shortening of ipsilateral femur but forty-nine had significant femoral deficiency. Lengthening of tibia and in significant cases femur was done using either De Bastiani, Vilarrubias or Ilizarov methods. Ankle valgus and heel valgus were corrected through osteotomies either in the supramalleolar region or heel. Equinus was corrected by lengthening of tendoachelis with posterior soft tissue release and in severe cases using Ilizarov technique. Results: The average length gained was 4.2 cm (range 1 to 8) and the mean percentage of length increase was 15.82 (range 4.2 to 32.4). Mean bone healing index was 54.23 days/cm. Significant complications included knee subluxation, transient common paroneal nerve palsy, and recurrence of equinus and valgus deformity of foot. Overall alignment and ambulation improved in all patients. Knee stiffness due to cruciate deficient subluxations needed prolonged rehabilitation. Presence of 3-ray foot gives a better functional result and cosmetic acceptance by patients. The Ilizarov frame has the advantage to cross joints and lengthen at the metaphysis. Conclusion: Limb reconstruction in fibular hemimelia using limb lengthening and deformity correction techniques improve functional status of involved lower limb.

Aims: To test the hypothesis that there is a trend to over correction in patients who demonstrate signs of generalised joint laxity.

Patients and methods: 41 patients with an average age of 6.5yrs (3–15) were examined for generalised joint laxity using the Biro score. This gave 52 feet (11 bilateral) for clinical assessment using the podoscope and graded based on Tachdijans flat foot score.

Results: The results were assessed and the patients divided into 2 groups depending on whether or not they had joint laxity. This left 15 patients with 18 feet in the non-lax group and 26 patients with 34 feet in the lax group. The 2 groups were then compared to see if there was a difference in flat foot grade. In the non-lax group 2 patients showed evidence of over-correction whereas in the lax group 25 patients were over corrected to some extent. Using the fisher’s exact test there was a significant difference between the 2 groups with a trend towards over correction in those with generalised joint laxity (p = 0.002).

Conclusion: Based on the findings of this study there is a correlation between generalised joint laxity and over correction in congenital talipes equino-varus.