IFPOS Combined Meeting EPOS - 26th Annual Meeting

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J Child Orthop (2007) 1:S13–S132 DOI 10.1007/s11832-007-0015-7

ABSTRACTS

EPOS/IFPOS Combined Meeting EPOS - 26th Annual Meeting Sorrento, 11–14 April 2007

Oral Presentations Session 2: Tumors of the musculoskeletal system

Signiﬁcance: This work represents an entirely new approach to take biopsies from the bone that can only identiﬁed by MRI. Further the method avoids any radiation and is therefore perfectly applicable in children.

1 2 MRI guided biopsy and treatment of osseous lesions in children Author: Thomas Wirth (Germany) Co-Authors: Micha Langendo¨rfer (Germany), Peter Winkler (Germany) Purpose: MRI has evolved to a dominant diagnostic tool for evaluating pain and detecting skeletal lesions in children. Often MRI identiﬁes non-speciﬁc signal enhancements which need to be clariﬁed histologically for precise diagnosis. We have developed a precise MRI guided biopsy method to precisely ﬁnd and diagnose such lesions. Methods: Under MRI control the area for biopsy is identiﬁed and a titanium wire is placed in the center of the lesion using the navigation potential of the system. The correct position of the wire is veriﬁed. For biopsy purposes the sample is then taken with the wire as a guide by use of a biopsy needle. A representative bone cylinder is sent for histology. For treatment, e. g. drilling of a bony lesion, a titanium drill system suitable for MRI is used. Results: Up to date 12 MRI guided biopsies and 6 MRI guided therapeutic interventions have been performed in 16 patients. There were ﬁve girls and eleven boys. The diagnoses were osteoidosteoma (n = 6), osteomyelitis (3) Ewing sarcoma (2), metastatic disease, eosinophilc granuloma and synovial sarcoma in one case each. In four patients recurrence of a tumour was to be ruled out. The samples were taken from the femoral neck in ﬁve patients, iliac wing (4) sacrum (3), lumbar spine (2), tibia (2), humerus (1) and talus (1). There was no complication. In two cases the biopsy had to be repeated due to recurrence of the disease. In particular in cases with drilling of bony lesions such as osteoidosteomas a signiﬁcant learning curve is experienced. Conclusions: The harvest of bone biopsies under MRI control is an entirely new method which is particularly suitable in children since it does avoid any radiation. The method is extremely precise as it is the only way of exactly hit bony lesions which are mainly identiﬁed on MRI images. The method is also very efﬁcient in the treatment of bony lesions like osteoidosteoma by minimal invasive approaches.

Whole body MR imaging in malignant bone tumor in children : preliminary results. Author: Olivier Lousteau (France) Co-Authors: Jerome Sales de Gauzy (France), Christiane Baunin (France), Guillaume Moscovitch (France), Franc¸ois De Maupeou (France), Herve´ Rubie (France), Eric Ouhayoun (France), Jean Railhac (France) Purpose: The purpose of this study is to evaluate the accuracy of Whole body MR imaging, WBMRI, for the detection of bone metastases in children with malignant bone tumor, MBT. Methods: This is a prospective study that was leaded between October 2004 and September 2006. The patient population included 10 children who ranged in age from 7 to 17 years. Primary bone tumor comprised 5 osteosarcoma and 5 Ewing’s sarcoma. All these children had 3 whole body imaging modalities: WBMRI, skeletal scintigraphy and 18-FDG positron emission tomography (PET). WBMRI consisted of coronal STIR sequences acquired in 3 or 4 overlapping stations. The results of these exams where compared with surgical and histologic results. Results: In 2 cases, WBMRI showed bone metastases that where not seen by other modalities and induced therapeutic changes. In one case, WBMRI and PET showed bone metastases that where not seen by scintigraphy. This induced therapeutic changes. In one case WBMRI showed benign lesion but this induced no therapeutic changes. In one case WBMRI showed signal anomalies related to bone hyperostosis. In four cases both WBMRI and PET showed enlarged inguinal lymph node. Biopsy found no malignant cells. In one case all modalities not showed bones metastases. Conclusions: These preliminary results suggest that WBMRI could be more sensitive than skeletal scintigraphy and PET for screening children with MBT. Further evaluation is necessary to precise sensibility and speciﬁcity of WBMRI before to use it in routine. Signiﬁcance: WBMRI would be useful in the future for screening of MBT.

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S14 3 Scintigraphic evaluation of osteoblast activity after implantation of bas-0 bioactive glass-ceramics into long bone defects Author: Pavel Sˇponer (Czech Republic) Co-Authors: Karel Urban (Czech Republic), Karel Karpasˇ (Czech Republic), Elen Urbanova´ (Czech Republic) Purpose: The purpose of the study was to evaluate a radionuclide uptake at the site of defects in long bones ﬁlled with the nonresorbable bioactive glass-ceramic material BAS-0 by three-phase bone scintigraphy at a long follow-up. Methods: 14 men and 6 women operated on between 1990 and 2000 for benign bone tumors or tumor-like lesions localized in the femur, tibia or humerus were comprised in the study. Their average age at the time of surgery was 14 years (range 8 to 24 years). The metaphysis was affected in 8 and the diaphysis in 12 patients. Clinical, radiological and scintigraphic examinations were carried out at 2 to 12 years (7 years on average) after surgery. Osteointegration of glass-ceramics was investigated on radiographs. Radionuclide uptake was considered normal when the index value was equal to 1.0, mildly increased at an index value up to 1.2, moderately increased at 1.2–1.5 and markedly increased at an index value higher than 1.5. Results: The clinical evaluation showed that 6 patients had no subjective complaints and 2 reported transient pain in the group of patients with implants in metaphyses. In the patients with nonresorbable glass-ceramics in diaphyses, pain was recorded in 9 and no complaints were in 3 patients. No restriction in weightbearing of the limb treated was reported by any of the patients. On radiography 18 patients were free from any disease residue or recurrence. Two patients had a residual defect. The bioactive glassceramic material BAS-0 was completely incorporated in all patients. On three-phase bone scans radionuclide distribution on the ﬂow and soft tissue phases was symmetrical in the both limbs of all patients. For the metaphyseal location of implants, the delayed images demonstrated physiological radionuclide distribution in 1 patient, mildly increased distribution in 4, moderately increased uptake in 2 patients, and markedly increased uptake in 1 patient. For the diaphyseal location of implants, the delayed scans demostrated mildly increased radionuclide distribution in 2, moderately increased in 2 and markedly increased uptake in 8 patients. Conclusions: This paper presents problems associated with implantation of the non-resorbable bioactive glass-ceramic material BAS-0 in the treatment of diaphyseal defects of long bones. The results show that, for ﬁlling of the defects described herein, non resorbable glass-ceramic materials are not suitable. Signiﬁcance: The tissue during incorporation of a non-resorbable synthetic material is inﬂuenced by stress-shielding. This changes local mechanical signals, which has a negative effect on the adjacent bone tissue. Stress accumulating at the interface of a rigid implant and bone tissue may result in pain, and is detected by scintigraphy as an increased nucleotide uptake, particularly in diaphyseal implants. 4 Preservation of the Native Knee in Patients with Malignant Bone Tumors in the Metaphyseal Area of the Distal Femur and Proximal Tibia, Using Massive Allografts. Author: J. Ivan Krajbich (United States) Co-Authors: Kelly Alexander (United States) Purpose: Demonstrate the feasibility of preservation of the patient’s native knee in malignant bone tumors about the knee as

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Oral presentations: Abstracts 1–123/J Child Orthop long as the epiphysis of the distal femur or proximal tibia respectively is free of tumor and can be preserved. Methods: Fourteen patients who met the criteria of having malignant sarcoma in either distal femoral or proximal tibia metaphysis with no invasion into the epiphysis and underwent knee saving procedure using massive metaphyseal allograft were reviewed. There were four distal femur lesions and ten proximal tibial lesions with eight females and six males. All patients had at least a two-year follow-up. Final outcome and complications were reviewed in all patients. Results: Patients were alive and well at the time of the review. There were three infections necessitating allograft removal and local recurrence. There were allograft fractures which healed with ﬁxation revision and bone graft. All patients with retained allograft regained at least 90 of the knee range of motion. There were no signiﬁcant long term complications, although several patients use a knee brace for sports activity. Conclusions: Our study demonstrates good long-term results of metaphyseal allograft replacement and knee preservation in pediatric age group treated for malignant bone tumors. Careful selection of patients to avoid local tumor recurrence is mandatory. Complication rates are about the same as for any other limb salvage group other than the fact that long-term results are considerably better than the literature reported data for endoprosthetic replacement patients. Signiﬁcance: Attractive alternative to endoprosthetic replacement in the pediatric age group in a carefully selected group of patients. 5 Complications of Osteochondral Tibial Allografts in Pediatric Osteosarcoma Reconstruction: Review of 12 cases Author: Mihir Thacker (United States) Co-Authors: H. Thomas Temple (United States), J. David Pitcher, Jr. (United States), Sean Scully (United States) Purpose: Reconstruction after resection of tumors of the proximal tibia is challenging due to its unique anatomic features. Various reconstructive options are available, with the bias being towards a more biologic reconstruction in younger patients. The aim of this study was to review our experience with the use of tibial osteochondral allografts in pediatric patients with osteosarcoma. Methods: This was a retrospective review of 12 pediatric patients (< 18 years) with Stage IIB tibial osteosarcomas treated with resection and reconstruction with osteochondral allografts. The demographic features, techniques of reconstruction, use of ﬂaps and their effect on functional and oncologic outcomes were studied. Results: There were ﬁve boys and eight girls with a median age of 13.5 years (10–17). All patients received chemotherapy and none had radiation. Gastrocnemius ﬂaps were used in 10/12 patients as part of the index procedure. The mean follow-up was 54.5 months (14–198). There were 20 complications in 12 patients. These included allograft fractures (6) at an average of 37.5 months, deep infection (5), non-unions (2), nerve injury (2), arthrosis (1). The event-free survival was 23 months (2–65). Three patients needed revision to allo-prosthetic composites, two to metallic endoprostheses and one underwent an amputation. There were two local recurrences and three patients died of metastatic disease. The predicted ﬁve year survival was 41%. Conclusions: Deep infections and allograft fractures were the most common causes of return to the operating room. Osteochondral

Oral presentations: Abstracts 1–123/J Child Orthop allograft reconstruction for tibial osteosarcoma is associated with a high complication rate. Signiﬁcance: Osteochondral allografts used for reconstruction in pediatric patients with osteosarcoma have a high complication rate and better alternatives should be sought. 6 Case series on ‘lipoblastoma’, a rare tumour in children Author: Harvey Lappakkaran George (United Kingdom) Co-Authors: Yogesh Joshi (United Kingdom), Leroy James (United Kingdom), Neraj Garg (United Kingdom), Colin Bruce (United Kingdom) Purpose: To discuss on Clinical presentations, Investigations, Histopathology, Differential diagnosis and Treatment options based on a series of six Lipoblastomas that we encountered in our paediatric orthopaedic practice. Methods: This series consists of six children with lipoblastoma who attended Alder Hey Hospital between 2000 and 2006. Mean age 17 months. Mean follow up was 26 months. The youngest was a six month old infant with a swelling on his right instep. The second patient was a three year old girl who presented with a limp and swelling in her foot, the third patient was an 18 month old boy with a swelling on the dorsum of his left forearm, fourth patient had a swelling of his left thigh and two patients had swellings in their back. They were investigated appropriately with MRI, CT or USG and surgical excision planned accordingly. Results: Male to female ratio was 5:1. Age groups; 2 patients were of less than 12 months of age, another two of them was between 12 to 24 months and the last two were under 36 months at the time of diagnosis. Anatomically three patients had swellings in the lower limb, 2 had swellings over dorsum of their trunk one patient had a forearm swelling. Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up. Conclusions: All patients were originally thought to have simple lipomas or soft tissue swellings. This is primarily because lipoblastoma is a rare tumour and is rarely encountered in orthopaedic training. It is important that we orthopaedic surgeons be aware that lipoblastoma is in fact the most likely diagnosis of a fatty lump in a child of less than two years of age. Lipoblastomas needs through imaging and if possible cytogenetic evaluation for accurate diagnosis before surgery because complete surgical resection is mandatory to prevent a likely local recurrence. Signiﬁcance: Lipoblastomas are uncommon, benign tumour of embryonal mesenchymal cells. It is a rare tumour but occurs mostly during infancy and early childhood. It most often presents on the extremities, back, head and neck. Histology: cellular neoplasm composed of lipoblasts in different stages of maturation and ﬁne vascular network, with well deﬁned septa. Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading. These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported. Differential diagnosis includes myxoid liposarcoma, well-diffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.

S15 7 Step Activity Assessment in Limb Salvage Children Author: Melissa Sheiko (United States) Co-Authors: Kristie Bjornson (United States), Kit Song (United States), Ernest ‘‘Chappie’’ Conrad (United States) Purpose: The goal of a limb salvage procedure is to retain a functional extremity. However, the measurement of that function is challenging. We compared the physical and emotional health and orthopedic functional evaluation to the activity levels of children after limb salvage. Methods: The children of this study were age and gender matched to typically developing youth (TDY) controls. To qualify for the limb salvage group, children had to be between 10 and 20 years of age, diagnosed with a malignant bone tumor of the lower limb and at least one year post-op from their initial limb salvage. The 21 recruited patients (12 females and 9 males) had an average age of 15 years. Patients’ activity was measured with a Stepwatch activity monitor for 1 week, which counted the number of steps the patient took every minute. In addition, patients and control subjects completed the Youth Quality of Life questionnaire, Child Health Questionnaire, the Activities Scale for Kids questionnaire, and the Musculoskeletal functional questionnaire. Results: The initial analysis of 13 limb salvage children and 13 typically developing youth showed limb salvage children walked an average of 5730 [3881–7580] steps per day, as compared to 7601 [6235–8968] steps per day for the normals. Limb salvage children spent 45.33% [37.61–53.06] of their time being active, whereas TDY spent 50.83% [45.02–56.64] of their time being active. Subdividing the active time into levels of high, medium, and low activity rate reveals limb salvage children spent 64.42% [56.63–72.20] of their time at a low activity level, while the normals spent 54.33% [49.16–59.51] of their time at low. Limb salvage children walked at a medium level for 28.33% [22.67–33.99] of their time, and normals were 33.92% [30.42–37.41]. Finally, limb salvage children moved at a high activity rate for 7.25% [3.84–10.66] of their time in contrast to 11.92% [8.50–15.34] for normals. Also of interest, the BMI of the limb salvage group measured 20.53 [16.66–24.39] versus 16.93 [14.80–19.07] for normals. In the Activities Scale for Kids- performance version, limb salvage children reported an activity level of 88.3 [83.9–93.7], and normal children reported a level of 93.6 [88.6–99.5]. Conclusions: Initial analysis showed some statistical signiﬁcance, but the calculations were swayed by one limb salvage subject who exhibited a much higher activity level than any other child in the study (12,056 steps per day). Signiﬁcance: We hope to increase the statistical signiﬁcance of our results with a longer study cohort. Further analysis comparing age differences, site of the tumor, allograft vs. implant, and activity levels versus reported physical and emotional health will be performed, which will include 21 limb salvage children compared to 21 matched normals. 8 Perceived Quality of Life in Children with Primary Bone Sarcoma Author: Jenny Margareta Frances (United States) Co-Authors: Carol Morris (United States), Zarko Nikolic (United States), Edward Athanasian (United States), Patrick Boland (United States), Alexandre Arkader (United States), John Healey (United States)

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S16 Purpose: To evaluate perceived quality of life in children with pediatric sarcoma to identify predictors of quality of life and evaluate our treatment strategies. Methods: Quality of life data, using the Pediatric Outcomes Data Collection Instrument (PODCI), was collected annually after index procedure in 43 children age 6–16, with primary Ewings sarcoma, osteosarcoma or chondrosarcoma. A retrospective chart review was done to collect clinical data. Statistical analysis was done to evaluate change of quality of life (QOL) over time and to identify potential predictors of quality of life. Results: Children with primary bone sarcoma reported low scores in the Sports domain, good scores in the Pain, Happiness and Global function domains, and high scores in Upper Extremity and Transfer, in an average followup of 3 years. Scores were lowest the ﬁrst 12 months after surgery, with signiﬁcant improvement seen at 24 months after surgery. Tumor size larger than 8 cm was a negative predictor for Sports and Physical Function. Girls reported lower scores in Sports, Pain and Global Function than boys. Although there was no difference in scores between patients who underwent limb sparing surgery of the lower extremity (n = 31) or not (n = 7), a larger study group would be needed to verify the accuracy of this observation. Conclusions: The PODCI gives discriminatory detailed textured evaluation of the outcome of children treated for skeletal malignancy. Signiﬁcance: The PODCI is a good tool in evaluating QOL in children with bone sarcoma. Further development of QOL measures is needed to make the PODCI helpful enough to guide treatment.

9 Non Rhabdomyosarcoma Soft Tissue Sarcomas in children –Management and outcome Author: Franck Chotel (France) Co-Authors: R Grimer (United Kingdom), Lee Jeys (United Kingdom), A Abudu (United Kingdom), R Tillman (United Kingdom), S Carter (United Kingdom) Purpose: To establish whether our current regime for management children with non rhabdo, STS is successful and to establish prognostic factors for survival and local control. Methods: We reviewed the patient, tumour, treatment and outcome data for 85 children with non rhabdo STS under the age of 21 at diagnosis who had deﬁnitive treatment at our centre from a prospectively compiled tumour database. All patients had >2 yrs follow up. Management was based on a combination of surgery, chemotherapy and radiotherapy. Chemotherapy was used in large tumours and in patients with metastases whilst radiotherapy was used postoperatively in cases with uncertain excision margins. Results: We identiﬁed 85 children (56 boys) with non rhabdo STS over a time period of 22 yrs. The most common diagnosis was synovial sarcoma (n = 30) followed by peripheral nerve sheath tumour (n = 8) and leiomyosarcoma (n = 6). Whilst the mean age was 14,5 yrs, the most common age was 19. 37% of the tumours were high grade and 33% intermediate and 30% low grade. The mean diagnosis delay was 21 months for intermediate and low grade and 10 months for high grade. Seven patients have metastasis at diagnosis. The median size was 7 cms. 60 were deep and 28 superﬁcial. Chemotherapy was used in initial management in 23 patients, and radiotherapy in 15. Overall survival was 75% at 5 yrs and 65% at 10 yrs. Local recurrence arose in 19%. The only factor related to LR was an inadequate pathological margin, whilst factors affecting overall survival were increasing size and high grade. Neither age at diagnosis or depth of the tumour

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Oral presentations: Abstracts 1–123/J Child Orthop was signiﬁcant. Because chemotherapy was often used for patients thought to have a poor prognosis, it proved impossible to show that chemotherapy beneﬁted survival, but in this series all but 2 of the patients who received chemotherapy subsequently died. Conclusions: Children with non rhabdo STS have the best chance of cure if the tumour is diagnosed early and treated by surgery obtaining clear margins. Signiﬁcance: Chemotherapy and radiotherapy should be used in selected cases as part of an international trial.

10 Simple bone cyst of the proximal humerus - Factors predictive of recurrence and healing Author: Kar Hao Teoh (United Kingdom) Co-Authors: Adam Watts (United Kingdom), Robin Reid (United Kingdom), Daniel Porter (United Kingdom) Purpose: The proximal humerus is the most common site for the simple bone cysts. Cyst recurrence in the proximal humerus occurs more frequently than other sites in the body. The purpose of this study was to examine the characteristics of pathological fractures caused by simple bone cysts in the proximal humerus and evaluate factors predictive of fracture and of healing following surgical curettage. Methods: From a cohort of patients held on a national database the factors predictive of recurrence following surgical curettage in patients with a simple bone cyst of the proximal humerus were examined. Thirty two cases were identiﬁed. The mean age was 11.4 years and 90% were male. Results: Most patients presented with a pathological fracture (97%) following a history of trauma (78%). Ten patients (31%) had recurrence of the lesion or re-fracture following curettage. The time to recurrence/resolution of the cyst was 12.4 months in our series (range: 2–49 months). None of the patients in whom the fracture occurred after skeletal maturity had a recurrence (p = 0.014). Simple bone cyst in the right proximal humerus were more likely to recur than the left (p = 0.01). Obliteration of the cyst occurred more frequently in those with impacted fractures (p = 0.04) and appeared multilocular (p = 0.004) on pre-operative radiographs. A higher cyst index at presentation also increased the likelihood of recurrence (p = 0.039). Conclusions: Factors predictive of recurrence following curettage were young age, right limb laterality, large size of cyst, multilocular cysts and fractures without impaction on initial radiographs. Patients with these features should be followed up until obliteration of the lesion or skeletal maturity. Signiﬁcance: Based on the largest reported series of biopsy proven SBC in the proximal humerus, factors have been identiﬁed that should alert clinicians to the risk of recurrence or refracture when treating patients.

11 Outcome at 45 years of open reduction and innominate osteotomy for late presenting developmental hip dislocation. Author: Simon Robert Thomas (United Kingdom) Co-Authors: John Wedge (Canada), Robert Salter (Canada) Purpose: A consecutive series of 76 patients (101 hips) underwent primary open reduction, capsulorrhaphy and innominate

Oral presentations: Abstracts 1–123/J Child Orthop osteotomy for late presenting developmental hip dislocation. They were aged 1.5 to 5 years at the time of surgery between 1958 and 1965. This study was designed to review their outcome into middle age. Methods: We located and reviewed 60 patients (80 hips) using a public records search. This represents a 79% rate of follow-up at 40–48 years postoperatively. 19 patients (24 hips) had undergone total hip replacement and 3 had died of unrelated causes. The remaining 38 patients (53 surviving hips) were assessed by the WOMAC and Oxford hip outcome questionnaires, physical examination and standing pelvic radiograph. The radiographs were analysed for minimum joint space width and the Kellgren and Lawrence score. Accepted indices of hip dysplasia were measured. Results: Kaplan-Meier survival analysis is presented using the end point of total hip replacement. Survival rates at 30, 40 and 45 years post-reduction are 99% (95% CI +/–2.4), 86% (+/– 6.9) and 54% (+/–16.4) respectively. Average Oxford and WOMAC scores for surviving hips were 16.8 (range 0–82) and 16.7 (range 0–71) respectively. Of 51 surviving hip radiographs, 38 had a minimum joint space width in excess of 2.0 mm, 13 had deﬁnite osteoarthritis (OA) on this criterion. 29 were Kellgren and Lawrence grade 0/1(no or doubtful signs of OA), 7 grade 2 (mild OA), 15 grade 3 or 4 (moderate or severe OA). The average centre-edge and acetabular angles were 40 (range 0–61) and 32 (20–43) respectively. There was no signiﬁcant association between outcome and the modiﬁable risk factors of body mass or age at surgery. Bilaterally treated hips were at signiﬁcantly greater risk of failure. Conclusions: This method of treatment achieves a 54% rate of hip survival at 45 years. Two thirds of surviving hips have an excellent prognosis at this stage. Signiﬁcance: This study is unique in following so large a group of patients with this condition into middle age. This is very important data to inform clinicians as to expected outcomes following surgery of this kind. 12 Does Salter Innominate Osteotomy with transiliac lengthening effect triradiate cartilage or cause posterior coverage insufﬁciency? Author: Hasan Hilmi Muratli (Turkey) Co-Authors: Tugrul Gunal (Turkey), Halil Yalcin Yuksel (Turkey), Ertugrul Aksahin (Turkey), Levent Celebi (Turkey), Serap Gulcek (Turkey), Ali Bicimoglu (Turkey) Purpose: In the treatment of DDH, we performed Salter innominate osteotomy with a modiﬁcation of transiliac lengthening described by Klisic et al. By this method we believed that we can obtain better anterior and lateral coverage. However this method may have several disadvantages including increased posterior coverage deﬁciency and triradiate cartilage injury due to increased periosteal stripping in order to obtain much more tilt. That is why in this study we aimed to investigate if this modiﬁed Salter Osteotomy and increasing amount of tilt cause posterior coverage problem and triradiate cartilage defects. Methods: 45 patients with unilateral DDH treated by open reduction and femoral shorthening and modiﬁed Salter innominate osteotomy were included in this study. Mean age was 38.44 ± 19.79 (mean ± S.D) months at the operation. Mean follow up was 49.84 ± 27.73 months. We measured amount of the tilt of iliac bone (difference of acetabuler index values between the preoperative and postoperative X-rays obtained as soon as after the operation). And we divided the hips in two groups according to tilt amount with the cut off value as 20 degrees. There

S17 was 29 hips in group 1 (deviation amount is under 20 degrees) and 16 hips in group 2 (deviation amount is 20 degrees or higher). At the latest follow-up pelvic –X ray examination and axial plane computed tomographic analysis were performed in all patients. We measured medial wall thickness, tear drop width and hemi pelvis heights in order to evaluate triradiate cartilage intactness indirectly. And posterior center edge angle which reﬂects posterior coverage of the hip in the CT scans was also measured. Then comparison between the groups were performed by covariant analysis (age was accepted as a dependent variable) and MannWhitney u-Wilcoxon Rank sum W tests. Results: There was no difference between groups regarding all measured parameters (p > 0.05). Conclusions: As long as deﬁnite intraoperative stability tests are performed and intraoperative stability is obtained, modiﬁed Salter osteotomy with trans iliac lengthening can be performed safely and better coverage can be obtained in frontal and axial plane without damage of triradiate cartilage. Signiﬁcance: As long as deﬁnite intraoperative stability tests are performed and intraoperative stability is obtained, modiﬁed Salter osteotomy with trans iliac lengthening can be performed safely and better coverage can be obtained in frontal and axial plane without damage of triradiate cartilage. 13 Changes of acetabular orientation and hip muscle lengths by Salter innominate osteotomy Author: Thomas Pressel (Germany) Co-Authors: Stefan Max (Germany), Henning Windhagen (Germany), Christof Hurschler (Germany) Purpose: Despite early sonographic screening for dysplasia of the hip, some children are still diagnosed late or conservative treatment fails. Early operative correction of severe dysplasia is indicated to prevent degenerative osteoarthritis. Salter innominate pelvic osteotomy is an established procedure for improving the coverage of the femoral head in children. While the operative technique is well deﬁned, the effects of variations like height of the osteotomy or the insertion angle of the bone wedge on the acetabular position are not known exactly. In this study the effect of osteotomy height and wedge insertion angle on lengths of three hip muscles and acetabular correction was investigated with a computer model. Methods: The bony structures of left hemipelvis and proximal femur of an eight year old girl with severe dysplasia of both hips were segmented from computed tomography (CT) image data and imported into the multibody analysis software MSC.ADAMS. Patient-speciﬁc joint centers and segment masses were imported from an anthropometric database. Origin and insertion points of muscles were determined based on the anatomical literature. A standard virtual bone wedge was inserted between two contact planes from different angles which were combined with osteotomy heights from baseline to 20 mm cranially. Acetabulum edge positions, muscle insertion points and hip center location were calculated for each step before and after the operation. Results: An insertion angle of the bone wedge of 40 relative to the frontal plane led to a maximal inferior displacement of the lateral and ventral acetabular edge at baseline osteotomy height. While generally glutaeal muscles were lengthened in comparison to the preoperative situation, extreme anterior insertion angles over 65 even shortened these muscles. An osteotomy higher than 15 mm above baseline shortened glutaeal muscles in comparison to the preoperative situation; piriformis was shortened when small insertion angles relative to the frontal plane were investigated.

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S18 Conclusions: Pelvic geometry and particularly acetabular orientation is variable so that the results of this study which were based on individual imaging data might be different in other patients. The symphysis and sacroiliac joint were represented by simpliﬁed ideal joints; the postoperative pelvic geometry might also be inﬂuenced by soft tissue forces which were not accounted for in this model. Not only geometrical changes inﬂuence the surgical outcome, but also biomechanical consequences of the procedure have to be considered and have to be investigated in future studies. Signiﬁcance: Multibody computer simulation is a valuable tool for geometrical and biomechanical analysis and optimization of Salter innominate osteotomy. The method can only suggest improvements of the surgical technique. 14 Is still the labrum an obstacle to reduction of congenital dislocation of the hip? Author: Maurizio Pietro De Pellegrin (Italy) Co-Authors: De´sire´e Moharamzadeh (Italy) Purpose: The ﬁbrocartilaginous labrum acetabulare enlarges the acetabular socket and contributes to the stability of the femoral head. In DDH the labrum is everted and pushed upwards by the femoral head. In the dislocated hip the labrum is often inverted into the acetabular cavity and obstructs anatomic reduction. In the past, excision of the labrum was performed to allow the reduction of the femoral head. The aim of the study was to evaluate the position of the labrum in early detected decentered hips and its role in the early treatment of DDH. Methods: During the eleven-year period from 1992–2002, 21 709 neonates (43 418 hips) were examined both by ultrasound and by Ortolani’s test to establish the diagnosis of DDH. Results: According to Graf’s classiﬁcation the following hips were present: 298 type D hips, 252 type IIIa hips, 4 type IIIb and 20 type IV. Therefore 431 of the patients (356 F 75 M), showed 574 sonographically unstable hips affected by DDH (1.32%). Due to its echogenic structure, the ﬁbrocartilaginous labrum is clearly visible by ultrasound. In type D, type IIIa, and type IIIb it was always located cranially to the femoral head; in type IV it was located medially to the femoral head. The average age of the children at the time of the diagnosis was 42 plus/minus 33 days. Ortolani’s test was positive in 61 hips (10.63%) and negative in the remainder of the hips (89.37%). 21.5% of the cases were diagnosed within the second week of life, 52.9% between the third and the eighth week, and 25.5% after the eighth week. The labrum was not inverted in any of these cases, nor was an open reduction necessary in order to remove it as an obstacle to the closed reduction. Conclusions: In conclusion, early US-diagnosis (by the 8th week of age) was possible in 74.5% of the cases; in no case was the labrum inverted; the labrum did not represent an obstacle to closed reduction. Signiﬁcance: When an early diagnosis of DDH is made the labrum is not inverted and a closed reduction is always possible. 15 Axial STIR and axial proton density MRI images, a fast and accurate method of conﬁrming femoral head reduction in Developmental Hip Dysplasia. Author: Eimear Conroy (Ireland) Co-Authors: James Harty (Ireland), Marcus Timlin (Ireland), Frank McManus (Ireland) Purpose: Non-concentric reduction of the femoral head within the acetabulum is detrimental to its delicate cartilaginous structure

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Oral presentations: Abstracts 1–123/J Child Orthop and may result in a growth disturbance. Successful relocation of the dislocated femoral head depends on subtle clinical ﬁndings and radiography. The combination of a dislocated femoral head and a severely dysplastic acetabulum can result in a clinical exam that is unhelpful in conﬁrming reduction under anaesthesia. In cases where uncertainty existed regarding head reduction in a spica cast we performed axial STIR and axial proton density MRI scans. We retrospectively reviewed the efﬁciency and accuracy of MRI in conﬁrming femoral head location after closed reduction and spica application in eight children. Methods: 153 cases of developmental dysplasia were treated with examination under anaesthesia, and spica application in our unit over a three-year period. Eight cases where MRI scan was performed were identiﬁed. These children were galeazzi positive and had limited abduction necessitating a percutaneous adductor tenotomy. Before application of the spica cast we used radiographic screening to assess the stability of the reduction. Absence of the ossiﬁc nucleus within the femoral head made conﬁrmation of location with the image intensiﬁer unreliable. To conﬁrm concentric femoral head location after closed reduction and spica application we performed an MRI scan in the immediate post operative period. Results: All scans were performed within 30 minutes of application of the spica, the average time for each scan was 5 minutes. All eight children who had MRI post application of spica had concentric reduction of the femoral head. MRI allowed threedimensional appreciation of the acetabulum and femoral head. Use of the axial STIR images allows accurate assessment of the cartilaginous ossiﬁc nucleus. All patients were discharged the same afternoon, and followed up at outpatients. No patient in our group required contrast arthrography. Conclusions: While not indicated in all cases of femoral head dislocation MRI is useful to conﬁrm concentric reduction of the femoral head in a dysplastic acetabulum when examination under anaesthesia and radiographic screening have been uncertain. In our series 1 in 20 cases needed MRI. Signiﬁcance: This is a reliable, non-invasive method conﬁrming deﬁnite reduction of the femoral head prior to discharge in all our patients. 16 Long-term results after closed reduction of late-detected hip dislocation Author: Terje Terjesen (Norway) Co-Authors: Purpose: This retrospective study was undertaken because there is limited knowledge about the long-term results in late-detected hip dislocation. The aims were to evaluate the outcome after skeletal maturity and to ﬁnd predictive factors for good and poor results. Methods: The material included 60 patients (78 hips, 53 girls) treated during the period 1958–62. The primary treatment was skin traction for 36 (16–76) days. Closed reduction was performed in all the hips except 4 that needed open reduction. The mean age at reduction was 20 (4–65) months. Hip spica plaster was worn for 9 (6–20) months. Within 3 years from the start of treatment, derotation femoral osteotomy was performed because of increased femoral anteversion in 35 patients. Later, 28 patients underwent additional surgery on the femur or acetabulum to improve femoral head coverage. Radiographs at the time of diagnosis and during follow-up to skeletal maturity were assessed. The average age of the patients at the most recent follow-up was 26 (15–42) years. Results: The femoral head coverage normalized during the primary treatment and decreased thereafter somewhat during the

Oral presentations: Abstracts 1–123/J Child Orthop remaining growth period. The dysplasia of the acetabulum improved markedly during the ﬁrst year after reduction and continued to improve, but to a much lesser degree, until 8–10 years of age. A satisfactory radiographic outcome at skeletal maturity (Severin grades I and II) was obtained in 63% of the hips. Avascular necrosis of the femoral head occurred in 14% of the hips. Risk factors for unsatisfactory outcome at skeletal maturity were high initial dislocation, steep acetabulum 1 year after reduction, reduced femoral head coverage at age 8–10 years, and avascular necrosis. Osteoarthrosis had occurred in 7 of the 26 hips (27%) with follow-up longer than 30 years. Conclusions: The present treatment regime with long traction time, closed reduction, and relatively long time in hip spica plaster, gave good radiographic results at skeletal maturity in nearly two thirds of the patients. Early derotation osteotomy of the femur did not improve the outcome. Signiﬁcance: The treatment concepts have changed considerably since these patients were treated more than 40 years ago. Nevertheless, the speciﬁc risk factors and the long-term results would be valuable for comparison with outcome studies after more modern treatment regimes.

17 The Weinstein antero-medial approach for the treatment of DDH. Results after a minimal follow-up of 5 years. Author: Edilson Forlin (Brazil) Co-Authors: Dulce Grimm (Brazil), Luiz Munhoz Cunha (Brazil), Luis Munhoz Rocha (Brazil), Michelle Zanferari (Brazil) Purpose: Open reduction of DDH in younger children is indicated for no reducible or unstable hip for conservative treatment. The antero-medial (Weinstein) or medial approach is no widely used because the believe of major risk for avascular necrosis. The goal is to review the results and complication of the anteromedial approach as described by Weinstein in patients with DDH. Methods: We reviewed 36 patients with 47 hips treated. Thirty-one were girls and ﬁve boys. The mean age was 8, 4 months (range, 2 to 21 months). The hips treated were left in 16, right in 9 and bilateral in 11. Twenty-four hips in 19 patients had previous treatment: Pavlik harness in 13, closed reduction in four patients and a combination of Pavlik harness and closed reduction in two. The results were evaluated clinically by McKay criteria and radiographic ally classiﬁed by Severin proposal. The mean followup was 8 years (5 to 11 years). The technique of open reduction was that described by Weinstein. The length of casting ranged from 10 to 16 weeks. A abduction brace was used in all patients for a mean length of 8 months. Results: The mean age at last visit was 9, 2 years (range from 5, 2 to 13 years). Clinically 41 hips were considered satisfactory and 2 unsatisfactory (because a Trendelenburg sign). For Severin classiﬁcation there were 28 hips class IA, 2 IB, 10 as IIA, one as IIB, and two as III. There were no immediate complications. Two hips had signiﬁcantly avascular necrosis. Seventeen hips needed a secondary acetabular procedure for persistent or progressive dysplasia, in others two the surgery was indicated. Overall results presented 83% as satisfactory and 17 % as unsatisfactory. Secondary acetabular correction indication was 44%. Conclusions: The Weinstein antero-medial approach showed to be effective, safe and a with a low incidence of avascular necrosis for reduction of DDH in younger children. The indication for acetabular correction is high. Signiﬁcance: A safe and reliable treatment for unstable DDH in young children.

S19 18 Complications, Radiological Outcome and Patient Satisfaction After Periacetabular Pelvic Osteotomy Author: Rainer Biedermann (Austria) Co-Authors: Leo Donnan (Australia), Andreas Gabriel (Austria), Roland Wachter (Austria), Martin Krismer (Austria), Hannes Behensky (Austria) Purpose: Periacetabular osteotomy (PAO) is a well established method to treat hip dysplasia in the adult. There are, however, a number of complications associated with this procedure that can inﬂuence the long term result. It is essential that patients are fully informed as to the effectiveness of PAO, the likelihood of complications and their inﬂuence on the subjective outcome prior to giving consent for surgery. Generic outcome measures offer the opportunity to determine treatment efﬁcacy and the inﬂuence on the outcome by complications. Methods: 60 PAOs on 50 patients were investigated retrospectively after a mean follow up of 7.4 years. The patients’ self reported assessment of health and function was evaluated by the SF-36 and the WOMAC questionnaires at last follow-up. 40 healthy persons served as a control group. Results: The centre-edge angle improved from a mean of 8.7 to 31.5. The weight bearing surface improved from a mean lateral opening of 8.7 to 4.2. The degree of osteoarthritis improved in one case, remained unchanged in 20 and deteriorated in 17. There was a tendency of higher CE-angles towards a higher rate of deterioration, indicating that overcorrection may increase osteoarthritic degeneration. 13 of the 60 interventions had no complications. Minor complications occurred in 25 (41%) interventions and in 22 (37%) at least one major complication occurred. SF-36 summary measure was 76.4 for PAO patients and 90.3 for the control group. Mean WOMAC score was 25.1. The severity of ectopic bone formation, incidence of postoperative peroneal nerve dysfunction and delayed wound closure did not inﬂuence the subjective result. Patients with major complications had a similar subjective outcome as patients with minor or no complications, but persistent dysesthesia due to lateral femoral cutaneous nerve dysfunction led to a worse subjective function as assessed with the WOMAC score. Conclusions: There was a tendency of higher CE-angles towards a higher rate of deterioration, suggesting that overcorrection is a reason for increased osteoarthritic degeneration. Patients with major complications have a comparable subjective outcome after more than seven years as do patients with minor or no complications. Nevertheless, the outcome as measured with SF-36 and WOMAC are reduced when compared with a healthy control group, but comparable with patients after THR according to literature. Lateral femoral cutaneous nerve dysfunction with persistent dysesthesias appears to reduce the patients’ subjective function in the mid term and a surgeon should be aware that this ostensibly minor complication is important. Signiﬁcance: The PAO is demanding procedure with a high initial rate of complications and a steep learning curve. Unless 20 to 50 operations are performed in one centre, all operations should be carried out by a single surgeon.

19 Application of arthroscopic surgery for Developmental displasia of the hip Author: Hajime Sugiyama (Japan) Co-Authors: Yoshiki Hamada (Japan), Tadahiro Horiuchi (Japan), Kenyuu Kimori (Japan), Takatoshi Ide (Japan)

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S20 Purpose: We report the usefulness of an arthroscopic surgery for reduction of developmental displasia of the hip (DDH). Methods: The patients were ﬁve female and two male children, average age was 2 years old (range 1 to 4 year old) . The arthrogram of the hip joint revealed ﬁlling defects, which were due to hypertrophy of the acetabular pulvinar and the inverted labrum. The operation was done under arthroscopic observation using three portals as in adult cases. After hypertrophic acetabular pulvinar was resected using electric cauterization scalpel, inverted labrum was reversed by placing incisions at 2 to 3 sites in a radiating form using a clow formed probe. Results: After operation, the femoral heads were reduced into noramal acetablum position, with signiﬁcant improvement in CE angle. The ﬁlling defect observed preoperatively due to inverted labrum and hypertrophy of the acetabular pulvinar disappeared on the postoperative arthrographic ﬁndings. All caces have a exellent reduction after surgery, and good CE angles were continued except one elder case. Conclusions: Open reduction of DDH is a considerable invasive technique, and excessive growth of the femoral head after operation poses a problem. In 7 cases of DDH reported in this paper, reduction was successfully conducted with less insult by resection of the tissue impairing reduction and reduction under arthroscopic observation. In general, in cases where reduction is difﬁcult with conservative therapy, causes that open reduction are considered to lie within the joint. Therefore arthroscopic surgery is the useful method for the treatment of DDH. Signiﬁcance: Arthroscopic suregery is less invasive and the risk of femoral head defomity is less. Arthroscopic surgery is considered to be one of the methods useful for the treatment of DDH. 20 Symptomatic developmental dysplasia of the hip (DDH) -arthroscopic ﬁndings Author: Yasuharu Nakashima (Japan) Co-Authors: Masanori Fujii (Japan), Yasuo Noguchi (Japan), Seiya Jingushi (Japan), Takuaki Yamamoto (Japan), Taro Mawatari (Japan), Eiji Suenaga (Japan), Toshio Fujii (Japan), Yukihide Iwamoto (Japan) Purpose: The purpose of this study was to clarify the intra-articular pathology of the symptomatic DDH in patients who were less than 20 years old. Methods: We conducted the hip arthroscopy during the operation of corrective osteotomy in 21 hips in 20 patients. All the patients were female and the average age at operation was 16.0 years old. Seventeen hips were in prearthritic stage (acetabular dysplasia without apparent radiological change) and 4 hips were in early stage (sclerosis, joint space narrowing). Fifteen hips in 15 patients had the history of the treatment for DDH. The degeneration of the cartilage was classiﬁed into 4 grades, Grade 0: no degeneration, 1: cartilage softening, ﬁne irregularity, 2: ﬁbrillation, erosion, 3: subchondral bone exposure. The presence and location of the labrum tears were also recorded. Results: Fourteen hips (82%) in prearthritic stage had cartilage degeneration of grade 1 or more. Cartilage lesions were more frequent in acetabulum than in femoral head (70.6% versus 17.6%). Sixty-ﬁve percent of the acetabular lesions were located at the antero-superior area. The labrum tears were observed in 76.5% of hips in prearthritic stage and located at the antero-superior (64.7%), superior (47%) and posterior area. Isolated cartilage degeneration was seen in only 23.5% and the isolated labrum lesions were seen in 17.6%. Many of hips had the both ﬁndings. The degree of cartilage degeneration and labrum lesions in early stage was more severe, but the pattern of the lesions was basically the same.

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Oral presentations: Abstracts 1–123/J Child Orthop Conclusions: The incidence of the intra-articular lesions such as cartilage degeneration and labrum tears of DDH was high even in the prearthritic stage. These lesions originated in the anterosuperior area of the acetabulum and were generally progressive. Signiﬁcance: This study focused on the intra-articular lesions of the symptomatic DDH in the patients who were leass than 20 years old. The incidence of the intra-articular lesions such as cartilage degeneration and labrum tears of DDH was high even in the prearthritic stage. These lesions originated in the anterosuperior area of the acetabulum and were generally progressive.

Session 4: Infection 21 Pediatric bone and joint infections due to Panton Valentine leukocidin-positive Staphylococcus aureus. Setting the surgical treatment. Author: Bruno Dohin (France) Co-Authors: Jerome Etienne (France), Daniel Floret (France), Remi Kohler (France) Purpose: Panton-Valentine Leukocidine (PVL) secreted by Staphylococcus aureus is a necrotizing toxin. Deep-seated infections associated with PVL-positive S. aureus strains are frequently characterized by their severity and those of osteomyelitis and arthritis is not well deﬁne. Methods: The demographics, selected clinical features, biological and microbiological data, and imaging ﬁndings were collected for 14 cases of PVL-positive S. aureus osteomyelitis and arthritis that occurred in children between 2001 and 2005. Factors affecting outcome (antibiotic treatment, surgical procedures) were studied. Results: Severity of PVL-positive S. aureus bone and joint infections (BJI) was conﬁrmed by clinical features of severe sepsis, 6 of the 14 patients presented a septic shock. At admission, median value of leukocyte count was 9.7 G/L (2.8–17.6) and CRP median rate was 185 mg/L (58.7–415). Eleven patients presented local extension of infection observed by magnetic resonance imaging and 7 patients presented severe deep-seated infectious complications observed by computed tomography (CTS). The median time of hospitalization was 45 days (10–90). The median duration of intra venous antibiotic treatment was 48 days (10–112). A mean of 3 surgical procedures were needed in 10 patients (1–5). Mean patient follow-up was 25 months and only 2 cases recovered without complication. No active chronic osteomyelitis was noted at ﬁnal follow-up. Conclusions: PVL-positive S. aureus BJI must be treated with appropriate antibiotics. In case of failure, local complications have to be detected by MRI and treated by surgical drainages without unnecessary antibiotic treatment modiﬁcation. Surgical treatment appears to be an important part of the treatment of PVL-positive S. aureus BJI. Signiﬁcance: PVL-positive S. aureus BJI as other deep-seated infections associated with PVL-positive S. aureus strains are frequently characterized by their severity. The present study emphasizes that either surgical drainage than antibiotherapy, appear to be as important parts in the treatment in such BJI. 22 CRMO – Do we need a new diagnostic algorithm? Author: Micha Langendoerfer (Germany) Co-Authors: Toni Hospach (Germany), Guenther Dannecker (Germany), Peter Winkler (Germany), Thomas Wirth (Germany)

Oral presentations: Abstracts 1–123/J Child Orthop Purpose: Chronic non-bacterial osteomyelitis is an aseptic form of osteomyelitis with manifestations in children, adolescents and adults. There are several synonyma such as CRMO (chronic recurrent multifocal osteomyelitis) and SAPHO-Syndrom (‘‘synovitis, acne, pustulosis, hyperostosis, osteitis’’) describing an inﬂammatory disorder of unspeciﬁed origin. Clinical appearance and symptomatic therapy modalities suggest the association to rheumatoid diseases. The aim of the study is to develop an efﬁcient way to correctly separate nonbacterial from bacterial chronic osteomyelitis cases at an early stage. Methods: Over the period from 1997 to 2004 in the orthopaedic and paediatric department of the Olgahospital Stuttgart 338 children were treated due to manifestations of non-speciﬁed osteomyelitis. The cases were retrospectively evaluated, 238 cases could be classiﬁed as chronic osteomyelitis. Since 2005 full-body MRI was used instead of skeletal scintiscan. Results: In 48 cases (e.g. 20 % of chronic osteomyelitis) the diagnosis of a non-bacterial osteomyelitis, e.g. CRMO, could be met following the strict criteria under exclusion of bacterial infection or other tumorous lesions. In 31 % of these cases further extraosseous manifestations were associated, some of which could only be detected by the use of a full-body MRI-scan. In 8 cases arthritis (in 3 cases chronic affection), in 5 cases pulmonary inﬁltration, in 4 cases skin manifestations (acne), in 3 cases splenomegaly, in 3 cases kidney lesions (haematuria, nephrocalcinosis), in 2 cases intestinal manifestations (M. Crohn), in 1 case unspeciﬁed ascites were found. Conclusions: The initial differentiation of a possible bacterial origin or the exclusion of a possible tumor may cause ﬁrst diagnostic and then therapeutic problems. The variety of possible associated lesions is wide and may be misleading in ﬁnding a correct diagnosis. For detecting all possible osseous and extraosseous lesions full-body MRI is most helpful, since it is minimally invasive and also reproducible, it can be used for follow-ups and control of therapeutic efﬁciency. The strategy in diagnosing and treating chronic osteomyelitis should include biopsy with histological and microbiological examination and, in case of signs of nonbacterial origin, a full-body MRI-scan to detect lesions which may be not (yet) symptomatic. Full-body-MRI is superior to scintiscan in detecting the osseous lesions, it is radiation-free and reduces the need for further screening methods. Signiﬁcance: Since every 5th case (48 of 238 cases) in our collective is according to strict criteria classiﬁed as nonbacterial osteomyelitis, the arising problems in false or prolonged treatment are signiﬁcant. The early detection of extraosseous or multiple ‘‘silent’’ osseous lesions is an important factor in establishing a correct diagnosis and thus may avoid prolonged and maybe unnecessary antibiotical treatment and/or further surgical interventions. 23 Neonatal skeletal infection caused by group B streptococci agalacticae Author: Karin Schara (Slovenia) Co-Authors: Natasˇ a Berden (Slovenia), Arabella Leet (United States) Purpose: Group B streptococcal osteomyelitis in the neonate presents with few inﬂammatory signs, a mild clinical picture and extensive bony destruction. In the last ten years we treated three neonate surgically because of acute bone or joint infection caused by group B Streptococci agalacticae (SA).Causes of infection, clinical symptoms, diagnostic methods, and outcome of treatment were evaluated.

S21 Methods: 45 children were treated for bone and joint infections in our dept. during the last ten years (1995–2005). We report on three neonate (2 boys and 1 girl) 3 weeks of age that were treated surgically in our department. One hip, one knee and one shoulder joint were involved. Laboratory blood tests, ultrasound, x-rays and MRI were performed in order to conﬁrm the diagnosis. Blood cultures and aspirates were examined. Surgical incision, drainage and antibiotic treatment followed. Intraoperative cultures were analyzed. Clinical examination and x ray were performed one year after the event. Results: Recognition of the disease was difﬁcult, clinical symptoms were vague, and the babies had no fever. No risk factors like prematurity or respiratory distress syndrome were present. Two mothers were treated for mastitis a week after delivery. The ﬁrst identiﬁed sign was lack of limb movement and later moderate swelling of the involved joint. White cell counts and sedimentation rate were normal. In one baby we isolated SA from the blood cultures and in two babies the same organism was aspirated from the joint. Ultrasound showed periosteal reaction in the distal femur in one baby. X ray of the shoulder joint showed distension of the joint space while the studies of the knee and hip joints were normal and MRI was necessary to make the diagnosis. The delay between the onset of symptoms and diagnosis was from 2 to 4 days. The treatment consisted of surgical incision and drainage. From intraoperative cultures SA was isolated in all three babies. The same bacteria serotype was isolated from the milk of two mothers. Babies and mothers received antibiotic therapy with penicillin. Breastfeeding was temporarily suspended. On clinical examination full range of motion of the involved joint was observed. X rays one year later showed no changes when comparing to the uninvolved side. Conclusions: The diagnosis of osteomyelitis or septic arthritis in the neonate is difﬁcult. Loss of limb movement presents an important early sign. In order to isolate the causative agent blood cultures and aspirates may be required. Mastitis and intrauterine infection should arouse suspicion. With early diagnosis and treatment we can avoid destruction of bone or joint that can result in severe deformities. Signiﬁcance: In neonatal period Streptococcus B infection can be transmitted from mother to the child. The outcome depends on early recognition as well as on surgical and antibiotic treatment. 24 Pyogenic Sacroiliitis in the Infance. Review of 6 Years. Author: Schaufele P. (Chile) Co-Authors: Cerna C. (Chile); Ibieta A. (Chile), Pineda D. (Chile) Introduction: Pyogenic sacroiliitis (PS) is one of the less frequent localizations among joint infections, near the 1,5% . It is habitually presented between the 7 and 14 years, usually unilateral. A late diagnosis generally exists. Material and method: A retrospective study of 20 records was carried out, 17 with diagnosis of entrance of PS and 3 with diagnosis of another pathology that turned out to be a PS, among the years 1999 and 2005 in our unit. Results: 11 only fulﬁlled the requirements to be classiﬁed as PS (Clinic features of infection and sacroiliac localization, laboratory exams and Tc-99 bone scintigraphy alterations). 7 males and 4 females (64% males), 55% left sacroiliac joint, 4 had clinically predisposing conditions (trauma), aged between 3 and 14 years (average 10.2 years). The half time of clinical evolution foresaw to diagnosis it was of 6,5 days (range between 5 and 10 days). The main symptom that motivates the consultation was fever (100%)

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S22 accompanied by FABER test positive (82%) and by limping, negative to walk and buttock pain (36% each one). Laboratory exams : WBC count was normal in 5 cases and elevated in 5 cases too and only in 1 case with left deviation (PMNs elevated); CRP higher than 55 mg/dl in all patients, ERS with value average of 62 mmHg/hour (27–111). Blood cultures were positive in 75% and the Staphylococcus aureus was the only bacteria founded (100%). No radiological alterations were found initially. The Tc-99 bone scintigraphy showed in all the cases pathological accumulation of radiofa´rmaco in one of the sacroiliac joints. All patients had a 7 to 12 days course of intravenous antibiotics (oxacillin + amikacina) and then completed 6 weeks with oral oxacillin. All patients recovered without sequel. Conclusions: Blood cultures may be obtained prior the administration of antibiotics. The Staphylococcus aureus is for far the most frequent germ involved in this process, and may guide the empiric antibiotic therapy. The precocious antibiotic treatment solves the case without sequels. The PS is an uncommon pathology in children that makes that it’s often not recognized initially. Wrong diagnosis such as appendicitis, transient synovitis of the hip, discitis, etc. can be avoided if PS is sought in a systematic way.

25 Puncture wounds in children’s foot complicated with osteomyelitis Author: George Tagaris (Greece) Co-Authors: George Christodoulou (Greece), George Sdougkos (Greece), George Protopapadakis (Greece), Sotirios Koukos (Greece) Purpose: This study determines the clinical picture and laboratory ﬁndings of osteomyelitis of the foot following puncture wounds and evaluates the results of the applied treatment. Methods: We studied 14 children with osteomyelitis of the foot following puncture wounds during a period of 15 years. Involved bones were calcaneum in 6 cases, metatarsal bones in 2 cases, phalanges in 2 cases, navicular bone in 1 case, cuboid bone in 1case. The mean age of patients was 10 years. The average observation period was 9 years. 13 of the children were treated surgically and 1 conservatively. In 11 cases the wound was caused by a metallic object (usually nail), whereas in 3 cases by a wooden one. All patients had previously received oral antibiotics. The presentation and diagnosis was delayed for an average of 14 days (4 days - 2 months). Results: Three of the patients were presented with fever >38 o. The local symptoms were mild, involving pain, redness and swelling. ESR was elevated in all cases while CRP in 50%, and WBC in 28% of cases. Pus cultures were positive in 80%, demonstrating Pseudomonas aeruginosa as the main causative organism. At follow-up, all but one were asymptomatic apart from residual radiographic lesions in 3 cases of calcaneous osteomyelitis (widening, shortening, early closure of the physis), 1 case of metatarsal bone synosteosis and 1 case of spontaneous arthrodesis of the metatarsophalangeal joint. These ﬁndings were more common among younger children and those who received delayed treatment (more than 15 days post-traumatically). Conclusions: In studied cases of osteomyelitis following puncture wounds of the foot the symptoms were mild, leading to delayed diagnosis and treatment. The preferred treatment is extensive surgical debridement and appropriate antibiotic therapy. Signiﬁcance: In all cases of puncture wounds of the foot, close follow up with a warning to the family about the danger of osteomyelitis is required.

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Oral presentations: Abstracts 1–123/J Child Orthop 26 One-step treatment of chronic bone infection by continuous intraosseous lavage-drainage system Author: Gheorghe Burnei (Romania) Co-Authors: Dana Vasilescu (Romania), Costel Vlad (Romania), Dan Cosma (Romania), Ileana Georgescu (Romania), Stefan Gavriliu (Romania), Daniela Dan (Romania) Purpose: Infection of bone is one of the most serious complications in the ﬁeld of orthopedic and trauma orthopedic surgery. It can result from a variety of etiologies but most often is a consequence of trauma to a long bone. In children the most common cause of chronic osteomyelitis is the incorrect treated acute osteomyelitis. This paper presents the results of one-step treatment of chronic bone infection using the continuous intraosseous lavagedrainage system. Methods: Our series included 287 patients with 325 foci of chronic bone infection treated in our departments during 1988–2005. Excepting the cases with ﬁstulisation our treatment protocol started with broad-spectrum antibiotics after cultures were taken at operation and were changed to organism-speciﬁc therapy when culture results were available. Parenteral antibiotics were continued for a mean of ﬁve weeks. We proposed a one-step surgical treatment including ﬁstulectomy, sequestrectomy, opening of the proximal and distal intramedullary canal and placement of the continuous intraosseous lavage-drainage system with antiseptic ﬂuids. When large bone defects or fracture risk resulted after sequestrectomy the external ﬁxation devices were used. The evolution during the treatment was monitored by inﬂammatory parameters, C-reactive protein and ﬂuid cultures. When ﬂuid cultures were sterile the system was removed. Results: In our series of 287 patients we noted the following forms: 161 monofocals, 53 mono-osseous multifocals, 44 chronic with acutization, 21 with ﬁstulae and 8 with soft tissue loss. In postoperative follow-up evaluation, none of the patients have had evidence for recurrent osteomyelitis or osteitis. Conclusions: Our results indicate that this challenging disease can be solved by a one-step procedure that provide sterilization of the septic foci and provide second-healing of the skin defects excluding bony and soft-tissue reconstruction. Signiﬁcance: 3b. 27 Septic Arthritis in Children: a One Centre-based experience of 40 years Author: Cosimo Gigante (Italy) Co-Authors: Giorgia Martini (Italy), Cristian Berton (Italy), Cristina Vallongo (Italy), Sisto Turra (Italy), Francesco Zulian (Italy) Purpose: Retrospective overview of 40 years experience concerning the treatment of septic arthritis in children. Methods: The study includes the overall period between 1965 and 2005. The patients were divided in 3 groups on the basis of the different clinical and therapeutic approach. Group A (1965–1978) includes 62 children (26 new-borns) with 72 joints (knee 50%; hip 19%); the treatment was mostly conservative (72%). In Group B (1979–1998) there are 25 children (4 new-borns) with 32 joints (knee 38%; hip 38%); the treatment was mostly surgical (84%). In Group C (1999–2005) are collected the most recent patients treated by a dedicated team of a paediatric orthopaedics and rheumatologist. On admission x-ray, ultrasound and joint

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aspiration were performed. All patients were treated emergently with i.v. oxacillin/cefotaxime with the addition of gentamicin for high risk neonates. In Group C there are 21 children (4 newborns) affected by septic arthritis (knee 43%; hip 24%); the treatment was mostly conservative (71%). Surgical drainage was performed in all but one septic arthritis of the hip and in two osteoarthritis of the knee. Staphylococcus aureus was the main pathogen in both Group A and B but the causative organism remained undiagnosed in 64% of Group A and in 63% of Group B. Also in Group C only 7/21 joint aspirates (33%) had positive cultures (Streptococcus pneumoniae was the main pathogen). In a previous report the patients of Group A and B were respectively reviewed at an average follow-up of 3,2 years (range 1–6 yrs) and 9,7 years (range 6 mo–20 yrs). The patient of Group C were reviewed at an average follow-up 4,5 years (range 9 mo–7 yrs). The results were classiﬁed as good, fair or poor according to the functional and radiological Rigault classiﬁcation. Results: In Group A the outcome was good in 73%, fair in 7%, poor in 20% of the joints. In Group B the outcome was good in 90%, fair in 3% and poor in 7% of joints. In Group C the outcome was good in 90%, fair in 5% and poor in 5% of joints. Conclusions: In the two oldest series of patients, the outcome of Group B (mostly surgical patients) was signiﬁcantly better than in Group A (mostly conservative patients). In the most recent series (Group C) the same good outcome observed in Group B was obtained with a more conservative treatment performed by a dedicated team of specialists on the basis of a new established algorithm. Signiﬁcance: An appropriate algorithm for the prompt diagnosis and medical treatment of septic arthritis can lower the need for surgery and guarantee the same good functional outcome of extensive surgery. Surgical joint drainage remains the ﬁrst choice in the septic arthritis of the hip and in all the resistant osteoarthritis.

femur in a weight bearing position. Trochanteric arthroplasty helps out for a limited time. Signiﬁcance: This small and heterogenic series does not allow to state signiﬁcance.

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30

Treatment of sequelae of infantile septic arthritis of the hip

The Graft has Fallen to the Floor!!!

Author: Klaus Parsch (Germany)

Author: Federico Fernandez-Palazzi (Venezuela)

Co-Authors: Jana Schiering (Germany)

Co-Authors: Manuel Guzman (Venezuela)

Purpose: Sequelae of infantile septic arthritis can cause lifelong major handicaps. Early reconstruction of the subluxed or dislocated hip and correction of the femoral neck malposition are recommended, leading to satisfactory results in the majority of cases. Methods: Retrospective evaluation of surgical reconstructions in 18 children with 19 involved hips with type II, III, and IV deformities following Choi’s (1990) classiﬁcation. Results: In 8 children with type II A and B surgical leg length equalization in prepuberty helped to overcome LLD. In 5 children with type III A and B: Valgusosteotomy with anterotation was effective. Additional leg length equalization was necessary in all cases 4 children had unilateral Type IV A or B destruction, 1 child had bilateral type IV B deformity. In 3 children open reduction of the residuum of the femoral head was done within the ﬁrst 12 months, followed by valgus osteotomy at a later stage. All children needed later an epiphyseodesis to overcome LLD. 1 child had trochanteric arthroplasty with a satisfactory result over more then 10 years. Later THR is facilitated by the preservation of the acetabulum. Conclusions: All 5 type III sequelae were treated by valgus and anterotation osteotomy with satisfactory results. 3 out of 4 type IV sequelae proﬁted from reconstructive surgery. The procedure is advised as early as with 12 months. The residual head is placed inside the joint. In two hips secondary valgus ostetomy aligned the

Purpose: To demonstrate the effectivenes of different antiseptics on a possible infected graft. Methods: In 17 samples taken from patients subjected to different surgical procedures such as fractures, hip degeneration or herniated discs, bone fragments were taken to be exposed to contaminating suspension of E. Coli, Staphylococcus coagulasa positive and to ﬂoor dust, and later to the effect of antiseptics 3 different antiseptics Benzalconium Clorhide, Iodopolivinilpirrolidona and laurildimetilbencil-amonio for 15 min. and, then they were analyzed from the laboratory point of view. Results: Except in 2 samples treated with iodopolivinilpirrolidona, in all the rest the bacterial growth persisted. The bacterial growth in the exposed bone fragments to antiseptics allows to evaluate the little effectiveness of these. The sterilization markers (0-1-2-3) demonstrated the different degrees of effectiveness of the antiseptic used. Data was statistical signiﬁcant. Conclusions: None of the antiseptics used was effective, neither did they cover the sterilization expectation to decontaminate the bone implant that had fallen to the ﬂoor. In one of the controls sample of the antiseptic there was bacterial growth, even in different lots. Signiﬁcance: Has just the immediate rinse with sterile water the same effect as the use of antiseptics when a graft falls to the ﬂoor?

29 Harmon Reconstruction for Severe Sequelae of Infantile Septic Arhtritis of the Hip Author: Magdy El-Batouty (Egypt) Co-Authors: Purpose: This paper describes our experience with an old technique described by Harmon (1942) for reconstruction of the hip in children in whom the femoral head and neck had been destroyed by septic arthritis. Methods: This operation was carried out in eight children aged 14 – 53 months (average 25 months) with severe late sequelae of infantile septic arthritis of the hip. Two hips were classiﬁed as Choi Type IIIB, four as Type IVA, and two as Type IVB. All of them had problems of hip instability and leg length discrepancy. Results: When reviewed at an average of 17.8 months (range 15 – 22 months), radiographs showed that the upper end of the femur had reshaped into a rounded medial shadow contained in the acetabulum that looked like a femoral head, and a lateral shadow that looked like a greater trochanter. Conclusions: All children had a stable hip, a satisfactory range of painless movement. All could walk and run for long distances with only a slight abductor lurch. Signiﬁcance: Early reconstruction is recommended to stabilize the hip joint and restore the anatomy of the hip to as near to normal as possible.

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Session 6: Foot & Ankle 31 Comparison of two different surgical techniques in severe ﬂexible pes planovalgus: calcaneal lengthening and Dennyson-Fulford subtalar extra-articular arthrodesis. Author: ahmet dogan (Turkey) Co-Authors: Yunus Akman (Turkey), Ismail Mumcuoglu (Turkey), Gazi Zorer (Turkey) Purpose: To compare the results in realigning the foot after calcaneal lengthening and Dennyson-Fulford subtalar extra-articular arthrodesis performed in patients with severe ﬂexible pes planovalgus (PPV) deformity due to a variety of etiologies. Methods: Two patient groups with similar spectrums of etiologic distribution who had randomly underwent calcaneal lengthening (Group I) or Dennyson-Fulford extra-articular arthrodesis (Group II) were constituted. In Group I, 25 feet of 13 patients (mean age 130 months; mean follow-up period 23 months, range 13–75 ), in Group II 27 feet of 15 patients (mean age 115 months; mean follow-up period 41.8 months, range 17–82) were included in the study. Clinical and radiographic evaluations were done. Mann-Whitney U test and repeated measurments from general linear models were used to evaluate statistical results. Results: Clinical results were excellent in 19 feet (76%), good in 3 (12%), moderate in 2 (8%), and poor in 1 (4%) in Group I and excellent in 19 feet (70%), good in 5 (19%), moderate in 2 (7%) and poor 1 (4%) in Group II. Radiological results were excellent in 6 feet (24%), good in 14 (56%) and moderate in 5 (19%) in Group I patients, and good in 7 feet (26%), moderate in 18 (67%), and poor in 2 (7%) in Group II patients. Pre-operative values of AP talocalcaneal and AP talonavicular angles were worse (p < 0.05) in Group II when compared with Group I. All other parameters were alike between the two groups preoperatively (p > 0.05). Post-operative values of lateral talocalcaneal, AP and lateral talonavicular angles in Group I were worse than that of Group II (p < 0.05) and calcaneal pitch angle in Group II was worse (p < 0.05) than that of Group I. All parameters, except for AP naviculometatarsal angle in Group I (p > 0.05), showed signiﬁcant correction within each group postoperatively when compared with preoperative values. By using repeated measures from linear models, a better correction was obtained (p < 0.05) in AP and lateral talocalcaneal, medial longitudinal arch, lateral talonavicular and AP naviculometatarsal angles in Group II. Conclusions: Although signiﬁcant (p < 0.05) correction of the deformity was obtained with both techniques, Dennyson-Fulford extra-articular arthrodesis technique showed signiﬁcant (p < 0.05) superiority over calcaneal lengthening on reduction of the talo-calcaneo-navicular joint complex, correction of the forefoot supination in relation to the hindfoot, and reconstruction of the medial longitudinal arch. Signiﬁcance: Although both Dennyson-Fulford and calcaneal lengthening techniques are efﬁcient in obtaining satisfactory correction, the former technique is superior than the latter technique in the surgical correction of ﬂexible PPV. 32 Calcaneal lengthening osteotomy for talocalcaneal tarsal coalition Author: Vincent S. Mosca (United States) Co-Authors: Wesley Bevan (New Zealand) Purpose: Surgical resection of the persistently painful talocalcaneal tarsal coalition has not been shown to reliably relieve

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Oral presentations: Abstracts 1–123/J Child Orthop symptoms in patients with coalitions that are large (33–50% of the area of the subtalar joint) and have associated hindfoot valgus and subtalar arthrosis. It has been recommended that these patients undergo triple arthrodesis, a procedure that has been shown to lead to premature arthrosis of the ankle joint. To avoid additional stress on this important joint, treatment of this group of patients using the calcaneal lengthening osteotomy (CLO), with or without resection of the coalition, has been performed at our institution over the last 16 years. Methods: A retrospective review of all patients with talocalcaneal coalitions who had undergone CLO was performed. Clinical and radiographic records were reviewed. Demographic data, preoperative and postoperative pain and function were recorded. Pre and postoperative radiographs and CT scans were reviewed and measurements performed. Computed tomography was used to calculate the degree of hindfoot valgus and the size of the coalition. Patients were recalled for interview, clinical examination, and radiographs. Results: Sixteen feet in eleven patients with foot pain related to talocalcaneal coalitions underwent CLO. Follow-up averaged 6.9 years, with a range from 1 year to 16 years. Seven patients with 11 feet underwent CLO without resection of the coalition to correct deformity associated with a large middle facet coalition, with or without arthrosis, but with severe hindfoot valgus deformity. All patients report improved comfort and function. One patient reported improved comfort and function following bilateral simultaneous resections and CLOs. Two of three patients had improvement in comfort and function in a foot that had residual pain and deformity after a prior talocalcaneal resection. The appearance of the feet was improved in all. All patients required a concurrent Achilles or gastrocnemius lengthening for contracture. Conclusions: CLO, usually accompanied by a heel cord lengthening, is a useful operation both in the failed middle facet resection where there is persistent pain and deformity, and also in the very large talocalcaneal tarsal coalition with associated valgus deformity and/or arthrosis that is not appropriate for resection. It corrects the foot deformity, improves comfort and function, maintains motion in Chopart’s joints and, unlike triple arthrodesis, avoids creating additional stresses in the ankle joint. Signiﬁcance: Calcaneal lengthening osteotomy appears to solve the problem of the unresectable, painful middle facet talocalcaneal tarsal coalition. 33 The Severe Flexible Flatfoot : A Combined Reconstructive Procedure with Rerouting Of The Tibialis Anterior Tendon Author: Hazem Mossad El Tayeby (Egypt) Co-Authors: Purpose: To present a new reconstructive procedure for the severe ﬂexible ﬂatfoot adressing all the components at fault. Methods: A combined procedure starting by an Evan’s Calcaneal Distraction wedge osteotomy to lenghten the lateral column will correct the heel valgus and forefoot abduction + A Cuneiform wedge resection osteotomy (Based medial and plantar) will shorten and reshape the collapsed medial arch. This is augmented by reconstruction and plication of the lengthened plantar ligaments. Besides, shifting the tibialis anterior pull proximally by rerouting its tendon to attain an L course, the vertical limb of which will act as a sling to the talar head, while its horizontal limb will augment the supporting plantar ligaments. Z-Plasty of the concealed tight tendo-Achillis is always needed. Results: 29 feet in 15 patients were the subject of this study. The age ranged from 12–16 years (average 13.9 years). The period of

Oral presentations: Abstracts 1–123/J Child Orthop the follow up ranged from 6–8 years. The results were assessed according to the relief of foot strain and calf pains, improvement in shoe ware, general activity and foot shape. The children and parents were satisﬁed with the ﬁnal results in 26 feet (13 patients). Improvement of the radiological measurements was evident and was statistically signiﬁcant. Conclusions: The described procedure proved to be an excellent reconstruction for the severe ﬂexible ﬂatfoot. Signiﬁcance: An easy procedure that can be applied for the severe disabling ﬂexible ﬂatfoot. 34 Minimal invasive ‘calcaneo – stop’ method in cases of pes planovalgus in childhood with ‘‘Bone Star’’ implant Author: Sandor Roth (Croatia) Co-Authors: Purpose: To improve better results in Calcaneo-Stop Method with spongious screw, we managed to construct a new canulated titanium implant for per cutem implatation. Methods: We have operated on 218 cases from 1997 to 2005 with the Calcaneo-Stop Method using the spongious screw. We have a minimum of ﬁve year follow-up period in 94 cases. In 92% of the cases we had excellent and good results. Complications showed : breakage of screws (8), wrong positioning of the screws (7). In 8 % we did not achieve correction postoperatively, therefore we constructed a new type of a screw, which would bring better results. We reinforced the screw’s dimensions and shape, and changed the material (titanium alloy) to make it more ﬂexible and resistant to breakage. Further on, we canulated it to make the placement easier by means of Kirschner wire. We placed the apex-thread and the conical smooth body with spongious coil. We need to place the implant the Kirschner –wire, ﬂuorograph control, canulated Imbus key, the titanium screw (‘‘bone star’’), scalpel, scissors and two stiches. Results: From July 1995 till September 2006, we operated on 42 cases of patiens with planovalgus gradus III/IV, and up to now we did not have neither wrongly positioned screw nor breakages of the screw. There was no surgical complications whatsoever. We think that we have improved the Calcaneo-Stop Method with this implant. Conclusions: Despite of short follow up we have proven minimal invasive effect of the new screw as well as security and higher effeciency. Signiﬁcance: childhood, surgical treatment of ﬂat foot, arthroereisis, canulated titan implant.

S25 compares the results of the PT directed Ponseti casting with that of surgeons’ casting (MD) in order to evaluate the success of the PT clubfoot clinic. Methods: A retrospective review from 2002 until 2005 was completed. Patients were excluded for a diagnosis other than idiopathic clubfoot, if treated by surgeons without Ponseti training, or had < 1 yr follow up. 2 Ponseti trained surgeons treated 30 children with 42 clubfeet prior to the establishment of the PT Clubfoot Clinic. 149 patients with 220 clubfeet were treated by the PT from 2003–2005. Outcomes evaluated included the number of casts, the % of patients requiring TAT, % of recurrences and secondary procedures. Results: The mean age at presentation was 9.3 (0–68) weeks in the PT group & 22 (0–130) weeks in the MD group (p < 0.01). The mean follow up was 28 months (12–46) in the PT group and 46 months(23–60) in the MD group. Number of initial casts was 4.8 casts (2–11) in the PT group and 4.5 casts (2–7) in the MD group (p = NS). Percutaneous TAT was necessary in 142/220 (65%) feet in the PT group and in 33/42 in the MD group (85%)(p < 0.05). Recurrence during maintenance phase requiring additional treatment occurred in 17/220 (8%) in the PT group and in 9/42 (21%) in the MD group (p < 0.05). In addition to repeat serial casting, additional procedures included second percutaneous TAT (5 PT & 3 MD), limited posterior/posterior medial release (5 PT, 6 MD) totaling 10/220 (4.5%) in the PT group and 9/42 (21%) in the MD group (p < 0.01). Conclusions: Although the children in the PT group were younger and have been not been followed for as long as the MD group, the early results show that the PT directed Ponseti management is at least as effective as the treatment by Surgeons alone. There were fewer TATs, recurrences and additional procedures in the PT group. Signiﬁcance: One of the advantages of the Ponseti method is its simplicity, allowing physician extenders such as physiotherapists both learn and implement this technique. Our institution is a large tertiary children’s hospital that services a large volume of patients. The introduction of a PT run Clubfoot clinic has been a very efﬁcient model of effective delivery of quality care. The physiotherapist has more time to educate families and to monitor post correction maintenance protocol with abduction orthoses. This model can run without compromising, but possibly contributing to improved, outcomes. 36 Aplication of ponseti method for relapses after posteromedial release in clubfoot Author: Anna Maria Ey Batlle (Spain)

35 A comparison of physician and physiotherapist run clubfoot clinics using the ponseti method Author: Joseph A. Janicki (Canada) Co-Authors: Unni Narayanan (Canada), Anvesh Roy (Canada), Barbara Harvey (Canada), James Wright (Canada) Purpose: The Ponseti method of the treatment of idiopathic clubfeet was introduced at The Hospital for Sick Children, Toronto in 2002. In 2003, a physiotherapist (PT) trained in the Ponseti method was appointed to run the serial casting program and post-tenotomy/abduction bracing protocol for all children with idiopathic clubfeet. Surgeons completed the initial assessment, performed the percutaneous tendoachilles tenotomy (TAT), and were available for patient review as needed. This study

Co-Authors: Jose´ Illobre Yebra (Spain), Laia Sabate´ Cequier (Spain), Marta Vallverdu´ Pujol (Spain), Diego Gutie´rrez de la Iglesia (Spain) Purpose: We want to show the utility of Ponseti’s method for relapsed cases after PMR. Methods: We include in the study all the patients received in the hospital from September 2001 to June 2006,with clubfoot relapse after PMR. (we have excluded isolated posterior release cases and neurologic deformities). We apply the same management as Ponseti’s method for relapses : # < 2 years old : correction casts+ abduction brace +/– percutaneous Achilles tenotomy and fasciectomy. # 2–3 years old: Depending on the case # > 3 years old : Correction casts to get at least 40 abduction + anterior tibial tendon transfer( using a titanium anchor) +/– percutaneous Achilles tenotomy and fasciectomy

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Oral presentations: Abstracts 1–123/J Child Orthop

Results: Patients :

•

N: 43 feet in 29 patients / Age : from 16 m-14a (average 5,3) / Male18-Female11

Previous surgery:

•

1 Surgery: 27feet / > 1 Surgery: 16 feet (12f -2S / 3f-3S /1f-4S)

Treatment aplicated :

• • •

Casts+Brace: 14cases . (in 3 cases Achilles tenotomy was necessary) Anterior tibial transfer 29 cases.(Achilles-22 cases, Fasciectomy29cases,Other procedure-1 case) Number of casts: 0–3 feet;1–20 feet; 2–10 feet; 3–8 feet; 4–2 feet

Treatment results : We have evaluated previous and post treatment the following parameters : Cavus .- PRE: 43 POST:10 Heel Varus.- PRE: 43 POST:12 Equinus.-PRE: 33POST: 8 AdductusPRE: 43POST: 5 SupinationPRE: 43POST: 3 Skin ThickeningPRE: 43POST: 1 PainPRE: 18POST: 0 Special shoesPRE: 38POST: 2The ﬁrst 5 parameters have been valorated using 3 degrees, and the last 3 parameters using presence-absence.

All the residual deformities after the treatment are mild and doesn’t affect the normal function of the feet. Improvement of scars have been observed in young patients. But all of them are rigid at the beginning we have observed an improvement after the casts. None of the patients has developed recurrence of the previous deformity. Complications: 1 Pseudoaneurism of plantar artery, 1 Intolerance to anchor suture. Conclusions

– We can conﬁrm that Ponseti’s management for recurrences is also an effective treatment for PMR relapse of clubfoot.

– The anterior tibial tendon transfer corrects the foot balance and avoids the possibility of relapse.

Purpose: The treatment of patients with Talipes Equinovarus, commonly known as clubfoot, has been controversial due to the difﬁculty of assessing their long-term outcomes. The purpose of this study is to compare patient-based measures of long term outcomes in two cohorts of patients, one treated with Ponseti method, and the other treated with the open surgical method. Methods: The study population consisted of 24 patients who underwent open surgical repair and 16 patients who were treated with Ponseti method for their idiopathic clubfoot deformity. The patients with the open surgical method were treated at the Division of Pediatric Orthopaedics at Morgan Stanley Children’s Hospital of New York-Presbyterian. The patients with Ponseti method were treated at the Department of Orthopaedics at University of Iowa. The Child version of the Child Health Questionnaire (CHQ CF-87) 17 was utilized in this study. The means of all domains of the CHQ in the two patient cohorts were compared using independent samples t tests. Results: There were no signiﬁcant differences between two groups in gender, race and age at treatment; however, there was signiﬁcant difference in age at follow up (p < 0.001). Mean age for the surgical patients were 16.4 ± 1.5 years old while Ponseti patients were 26.6 ± 5.1 years old in average. The patients treated with the Ponseti method patients had signiﬁcantly higher pain than the patients with open surgical method (p = 0.036). The patients treated with the Ponseti method also scored signiﬁcantly higher in General Health and Family Cohesion domains (ps = 0.027) and signiﬁcantly lower in Mental Health domain (p = 0.047) on the CHQ than the patients treated with the open surgical method. Conclusions: Surprisingly, the patients who were treated with Ponseti method reported higher pain than the patients who had open surgery. This difference may be due to the fact that the patients with Ponseti method had the follow-up 10 years longer on average than the patients with open surgical method. Psychosocial outcomes might attribute to environmental factors rather than the treatment methods. Signiﬁcance: The patients treated with the Ponseti method patients had signiﬁcantly higher pain than the patients with open surgical method. The patients treated with the Ponseti method also scored signiﬁcantly higher in General Health and Family Cohesion domains and signiﬁcantly lower in Mental Health domain) on the CHQ than the patients treated with the open surgical method.

– We improve foot support and appearance using Ponseti’s management without using extensive corrective surgeries.

– The obtained results should make reconsider orthopaedic surgeons the approach to PMR relapse

Signiﬁcance: Relapse after PMR (posteromedial release) has been usually treatted using extensive joint and ligaments operations, sometimes associated to tendon transfers or bone surgeries. Ponseti’s management has been described as an elective technique for congenital clubfoot ; the accepted patients to use this method are: untreated, recurrent, resistant and atypical clubfeet. The use of this technique for PMR relapses has never been reported. 37 Comparison of patient-based outcomes in clubfoot treatment: a long term follow-up study Author: Joshua Ethan Hyman (United States) Co-Authors: Hiroko Matsumoto (United States), Samuel Dellenbaugh (United States), Jose Morcuende (United States), Michael Vitale (United States)

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38 Long-term results of posteromedial release in congenital clubfoot treatment Author: Harjanneke Van Gelder (Netherlands) Co-Authors: Jan (Netherlands)

Visser

(Netherlands),

Patrick

Maathuis

Purpose: Short-term follow-up studies show good results in foot function, after surgical treatment of idiopathic clubfoot. Longterm follow-up studies are rare and probably represent a mixture of experience of the different treating orthopaedic surgeons. It is the aim of this study to present the long-term results of the Postero-Medial-Release (PMR) in congenital clubfoot treatment of one treating surgeon. Methods: Thirty-eight patients with ﬁfty-eight clubfeet had a PMR, a la carte, performed by one experienced pediatric orthopaedic surgeon before the age of two. This group had a mean follow-up of sixteen years (range thirteen to twenty-four years). All patients were interviewed and examined and standing

Oral presentations: Abstracts 1–123/J Child Orthop anteroposterior and lateral radiographs of the feet were made. The results of treatment were graded according to the system of Laaveg and Ponseti. With the radiographs the grade of osteoarthritis was determined and those results were compared with the contralateral normal feet, in case of unilateral clubfoot. Results: In ﬁfty-three feet, the mean rating was 80.6 points (range 43 to 97), according to the system of Laaveg and Ponseti. There were ﬁfteen excellent, seventeen good, thirteen fair and eight poor results. The majority of patients had limitation of foot function with a signiﬁcant decrease in dorsiﬂexion of 31% and a signiﬁcant decrease of pronation-supination of 24%. The grade of osteoarthritis was consistently higher in the clubfeet than in the contralateral normal feet. Five feet (9%) needed an additional bony procedure because of pain and overcorrection of the clubfeet. This was considered to be a failure of the surgical treatment. Conclusions: We conclude that in our hands, PMR has a high chance of leading to stiff and therefore not fully functional feet after a follow-up of sixteen years. We expect our results to deteriorate in the next ﬁfteen years as is suggested in literature. We recommend to classify all clubfoot before and after treatment to an accepted classiﬁcation system, like the DiMeglio- or Piraniscore. Signiﬁcance: The long term functional outcome of this group of operative treatment of clubfoot can serve as a control group. Against this historical background, it will be possible to compare the inﬂuence on long term outcome of new techniques in future research concerning the treatment of clubfeet. Standard classiﬁcation is a prerequisite for reliable and objective comparison. 39 Iatrogenic Rocker Bottom Deformity in Congenital Idiopathic Clubfoot. A report of 36 cases with 15 years follow-up. Author: Georgios Koureas (France) Co-Authors: Philippe Wicart (France), Alice Fassier (France), Rapha¨el Seringe (France) Purpose: The purpose of this study is to analyze the evolution of Rocker Bottom Deformity (RBD), ﬁnd out the age of its manifestation, localize the articulation where the apex of the deformity occurs, and evaluate the ﬁnal outcome. Methods: Inclusion criteria: Patients hospitalized from 1975 to 1996, full term gestation, Clubfoot (CF) treated as early as one month of age, plantar convexity demonstrated radiologically. 1120 CF, 36 feet in 23 patients were identiﬁed presenting RBD. All feet were initially treated by manipulations, muscular stimulations, and ﬁxation of the foot on a sole with non elastic strapping followed by an above knee plaster splint immobilization. 33 feet out of 36 with RBD were operated. A postero medial release associated to anterior tibialis lenghtening ± calcaneocuboid lateral release was performed. The v2 test, the Student t-test and the Pearson’s correlation coefﬁcient (r) were applied for the statistical analysis. Results: Follow-up was 15.4 ± 3.7 years. RBD was apparent radiologically at 3–6 month period (p = 0.028). The age of surgery was 12 ± 6.8 months. RBD increases the risk for surgical treatment 2.76 times. Two third of the feet presenting RBD were belonging to either Dimeglio D or C group. In 34 feet the convexity was located in the Chopart joint. The calcaneo-cuboidal subluxation improved signiﬁcantly post-op (p < 0.001). Hindfoot equinus also improved signiﬁcantly post-op (p = 0.035). There were not observed any immediate post-operative complications. The ﬁnal functional result according to Ghanem & Seringe classiﬁcation was excellent or good in 70% of surgically or conservatively treated feet while fair or poor in 30%.

S27 Conclusions: The Chopart joint locates the apex of this sagittal deformity early after birth. A convex talo-metatarsal I angle and an increase of the clinical measured dorsal foot ﬂexion with a resistance of hind-foot equinus are early diagnostic factors of RBD. RBD represents a risk factor for surgical treatment. Tibialis anterior lengthening is very important in the correction of the plantar convexity. Roentgenographic control before six months of age should be carried out for early diagnosis. Signiﬁcance: This study clariﬁes the evolution of RBD and demonstrated the exact location of the deformity which is very important for the surgical procedure. 40 Scarf Osteotomy in Adolescent Hallux Valgus Author: Leroy Anthony James (United Kingdom) Co-Authors: Harvey George (United Kingdom), Deepak Shivarathre (United Kingdom), Alﬁe Bass (United Kingdom), Colin Bruce (United Kingdom) Purpose: To determine whether Scarf osteotomy is a safe and effective treatment option in adolescent patients with symptomatic Hallux Valgus deformity. Methods: Data was collected retrospectively from a tertiary referral children hospital between April 2001 and June 2006. The pre and post operative intermetatarsal angle (IMA), hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA) were determined. In addition, any complications were recorded and the hallux metatarsophalangeal interphalangeal scale developed by the American Orthopaedic Foot and ankle society (AOFAS) score calculated. Results: 23 scarf osteotomies were perfomed in 16 patients with a mean age of 14.3 years (12–18). The mean pre operative IMA of 14.4 degrees was improved to a post operative value of 9.3 degrees, p < 0.0001. The mean HVA angle was improved from 34.7 to 16.5 degrees, p < 0.0001. The DMAA was improved from 13.1 to 8 degrees, p < 0.0001. There were 2 cases of superﬁcial wound infections successfully treated with oral antibiotics. One patient developed a complex regional pain syndrome that resolved with physio and analgesia. One patient complained of a prominent suture in the wound. The AOFAS score averaged 91.4 at six weeks and improved to 100 at ﬁnal follow up. Conclusions: In the adolescent age group, the Scarf osteotomy has consistently achieved a signiﬁcant improvement in the intermetatarsal angle, hallux valgus angle and distal metatarsal articular angle with few complications and good patient satisfaction. Signiﬁcance: Scarf osteotomy is a safe and effective treatment option in adolescents with symptomatic bunions. 41 The paradoxic effect of alendronate on osteoblasts in osteogenesis imperfecta Author: Arabella Iris Leet (United States) Co-Authors: Tamara Kazarian (United States), Edward McCarthy (United States), Jain Alka (United States), Jay Shapiro (United States), Neal Fedarko (United States) Purpose: Bisphosphonates, used to treat children with osteogenesis imperfecta (OI), have not been shown to have an effect on normal osteoblasts (1). However, there have been recent clinical reports that raise suspicion for an osteoblastic effect of this drug class: some children with OI have gone on to non-union after surgical osteotomy and bisphosphonate treatment (2). Our research examines the possibility of an osteoblastic effect of alendronate (ALD) on normal and OI osteoblasts.

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S28 Methods: Proliferation assay: 48 wells were seeded with cells from a normal patient as well as 4 different OI patients with different ages and phenotypes. 8,000 cells per well were allowed to attach for 24 hours than media was changed exposing half of the plate to growth media, the other half of the plate to 2 · 10–5 M alendronate. Cells were ﬁxed with glutaraldehyde at day 0 and at 3 day intervals thereafter for 3 weeks. Crystal violet staining as described by Fedarko (3) allowed quantiﬁcation of cell growth. In vivo transplantation: An ossicle system as described by Mankani (4) was utilized to study bone formation. Over 2 millions cells were combined with 1 cc of HA-TCP and allowed to attach via centrifugation and incubation. The pellet was placed into the subcutaneous tissue of nude mice for 12 weeks. Normal osteoblasts as well as two OI cell lines were compared. Results: Normal osteoblasts exposed continuously to drug demonstrated a favorable response to alendronate with an increase in maximal cell growth at conﬂuence (1.4 v 1.8, p < .008); however, the OI cell lines were adversely effected by the same drug conditions: in one sample of the 12 year old with type 3 OI the maximal cell growth declined (1.37 v. 1.02, p = .001); the remaining cell lines exhibited not only a decline in proliferation, but eventual loss in cell number compared with the original number of cells seeded. The in vitro results were seen in vivo. In the normal osteoblasts bone formation was promoted by drug from a bone score of 0 to 4. While the opposite effect was seen in the type 3 OI cells where drug exposure prior to formation of the implants caused a decrease in the bone score from 2 to 1. Conclusions: We report a direct osteoblastic effect of a bisphosphonate and ﬁnd that the presence of a gene defect in COLIAI changes the response of the osteoblasts to drug. While normal osteoblasts appear to have improved proliferation and bone formation under drug effect, OI cells show the opposite response. Signiﬁcance: Our study supports further in vivo studies of the role of bisphosphonates and fracture healing in children with OI. 42 WITHDRAWN

43 Signiﬁcance of fever post multilevel surgery in neuro-orthopaedic patients Author: Eduardo Daniel Segal (Argentina) Co-Authors: Juan Couto (Argentina), Eduardo Samara (Argentina) Purpose: Fever following orthopaedic operation in children is a common event. The presences of fever usually generates consternation and worry by patient’s parents, physicians and nursing staff Our purpose: Identify risk factors, complications. To suggest a guide to follow. Methods: Fifty consecutives paediatrics orthopedic surgeries with multiple procedure at the same stage were analyzed, 35 include bone proceedings and conform Group A. 15 involved only soft tissue procedures, Group B. Duration of surgery, anesthesia, approaches, transfusions, temperature records, supplementary studies and complications were analized. Fever was deﬁned as a temperature > 38C. Results: Considering both groups 42% (21/50) of patients had postoperative fever. Group A. 51% (18/35) and Group B 20% had fever (3/15). Patients with myelomeningocele presented higher fever incidence 71% (10/14) Only 3 from 21 patients with fever

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Oral presentations: Abstracts 1–123/J Child Orthop had any complication, a pressure heel sore, one otitis and one atelectasia. This complications were diagnosed as a result of the examination of the patients. Conclusions: Our results suggest that a meticulous general physical examination should be the appropriate response to fever at postoperative. Signiﬁcance: Routine septic work-up should not be undertaken merely on the basis of fever, and fever should not necessarily delay hospital discharge.

Session 7: Trauma 44 Interventions for treating wrist fractures in children – a Cochrane Systematic Review Authors: Alwyn Abraham (United Kingdom) and Tahir Khan Co-Authors: Purpose: Background: The epidemiology of fracture in children has been reported in detail by other authors. The most common mechanism in their study was a fall in or around the house onto an outstretched hand causing a fracture of the distal radius and ulna. These injuries accounted for 35.8% of all fractures in this age group and the annual incidence was estimated to be 16 per 1000 children in the UK. The controversial issues in the management of distal radius fracture involve what constitutes a degree of fracture displacement and angulation likely to be compensated by remodelling with growth over time, indications for fracture stabilisation with wires or other invasive methods compared with plaster casting alone, details of the position of the arm during immobilisation in a cast, and whether the cast should immobilise the wrist alone or both, the wrist and the elbow. The management of buckle fractures of the distal radius is relatively uncontroversial, involving splintage for symptomatic relief from pain. Some authors have advocated removable wrist supports, with discontinuation of splintage at the parents’ discretion. We performed a systematic review of all areas of the management of distal radius metaphyseal fractures in children. Growth plate injuries were not included for analysis. Methods: Any randomised or quasi-randomised controlled trials which compared types of immobilisation and the use of wire ﬁxation for distal radius fractures in children were included. Types of outcome measures

• • • • • • • • •

Radiological deformity Effect of cast index Complications of k-wiring Remanipulation rates Compliance with splintage Cost of various forms of splintage Effect of intact ulna Upper limb function while immobilised Wrist and elbow ROM

10 studies complied with the inclusion criteria and were analysed using Review Manager software provided by the Cochrane Collaboration.

Results: Regarding displaced metaphyseal fractures:

• •

K wire ﬁxation reduces redisplacement There is no proven increase in complications with k wires

Oral presentations: Abstracts 1–123/J Child Orthop

• • • • •

Intact ulna favours redisplacement Long casts do not reduce displacement Short casts allow better early function Regarding stable compression fractures Removable splints are not associated with displacement Patients prefer removable splints for buckle fractures

Conclusions: Distal Radius metaphyseal fractures should be stabilised with k-wires if the ulna is intact. A below elbow cast will provide sufﬁcient stability for such fractures treated non operatively. Soft removable splintage is the most convenient form of splintage for stable compression fractures. Signiﬁcance: K-wires or short forearm casts are recommended for metaphyseal fractures and removable splintage for buckle fractures. 45 Cast index following closed manipulation of distal forearm fractures in children Author: Sreejib Das (United Kingdom) Co-Authors: Ujjwal Kanti (United Kingdom), Rachit Shah (United Kingdom), Abhijit Ranjan (United Kingdom) Purpose: To assess the relevance of cast index as a predictor of re displacement. Methods: 174 consecutive paediatric patients (124M : 50F), with a mean age of 9.8 years (range 2–15 years), presenting with forearm fractures were analysed radiologically. 156 patients were included in the study who had manipulation for either distal radius alone or combined distal radius and ulna fracture. All patients were manipulated in OR and a moulded above elbow cast was applied. Patients were followed up with radiographs in the ﬁrst and third weeks. The cast index was measured on immediate post manipulation radiographs. Results: Displacement of the fracture within the original plaster cast occurred in 32/174 patients (18.4%), 24/124 males (19.4%); 8/ 50 females (16%). The cast index in the 32 patients requiring a second procedure (mean 0.92, sd .081) was signiﬁcantly more than the cast index (mean 0.78, sd .08) in the others (p < .001). Conclusions: Cast index is a valuable tool to assess the quality of moulding of the cast following closed manipulation of distal radius fractures in children. A high cast index in post manipulation radiographs indicates increased risk of re-displacement of the fracture and these patients should be kept under close review. Signiﬁcance: Higher cast index in the post-manipulative X-rays following distal radius fractures in children should raise the suspicion of redisplacement. The patients in the ages below ﬁve and above ten should be carefully monitored. All children undergoing manipulation for angulated distal radial fractures should be treated with a well moulded cast and cast index should be measured in the post manipulation X-rays. 46 Stiffness in displaced pediatric both-bone forearm fractures Author: Charles T. Mehlman (United States) Co-Authors: Mike Greiwe (United States), Eric Wall (United States), Alvin H (United States) Purpose: Both-bone forearm fractures are common pediatric injuries. Displaced forearm fractures are notoriously difﬁcult to manage because of their inherent instability. Two philosophies

S29 exist regarding the management of these fractures: casting and intramedullary (IM) ﬁxation. Unforunately, the two techniques have not been researched in head-to-head prospective, randomized controlled trials. The purpose of this paper was to compare range of motion and complication data in IM and closed reduction using a meta-analysis. Methods: A literature search was employed for IM ﬁxation and closed treatment techniques. Studies were limited to the modern English literature (1970-present). Papers were excluded if they had less than 20 patients, poor range of motion or complication reporting, other fracture sites included in the data, if they ﬁxed only one bone, or if they compared ORIF to IM ﬁxation. Nine papers concerning IM treatment and six papers regarding closed treatment were identiﬁed. Range of motion and complications were tabulated for each group. Pronation and supination loss was divided into mild (15–35), moderate (36–59) and severe loss (> 60). Complications were separated into minor and major categories. Data analysis was performed by the chi-squared test. Results: Mild (40/219 vs. 14/278) and moderate (9/219 vs. 0/278) range of motion loss was present in the closed treatment group with more frequency (p < 0.05). Although there was a trend, severe (5/219 vs.1/278) range of motion loss was not statistically signiﬁcant between the groups. In addition, IM ﬁxation had more minor complications (21.15% vs 6.4%) (p < 0.05), but major complications were similar IM 2.9% vs. closed 2.3%. Conclusions: Our meta-analysis identiﬁed that pronation and supination losses are more prevalent using a closed reduction technique. IM ﬁxation is associated with more minor complications, but major complications were similar. Signiﬁcance: IM ﬁxation is a viable treatment option for bothbone forearm fractures.

47 Associated Ipsilateral Elbow Fractures in Paediatric Elbow Dislocations Author: Bulent Daglar (Turkey) Co-Authors: Onder Delialioglu (Turkey), Ertugrul Gungor (Turkey), Bulent Tasbas (Turkey), Kenan Bayrakci (Turkey), Ugur Gunel (Turkey) Purpose: Elbow is a frequent site of injury in paediatric age group. However, elbow dislocations are not seen that often during childhood. Because of the weak link between metaphysis and epiphysis, dislocations frequently associated with fractures around the elbow in children. Aim of this study is to determine the incidence of fractures associated with paediatric elbow dislocations in our hospital and to evaluate functional results after these injuries. Methods: We retrospectively reviewed our database and looked for diagnosis of elbow dislocation, elbow epicondylar, condylar, radial head and olecranon fractures, Monteggia and equivalent fracture dislocations in patients with ages lower than 18 years. During 5 years period, between January 2000 and December 2005, 482 patients were identiﬁed. Within these 32 elbow dislocations and associated injuries were detected. Patients’ demographic and trauma data besides treatment and follow-up results were noted. Elbows were evaluated by using QuickDASH and Mayo scores. Results: 23/32 patients were males. Dominant elbow injury was detected in 26/32. Most common injury mechanism was sports injuries (12 of 32) followed by playground accidents (6 of 32). All but one elbow dislocations were associated with fractures around elbow. 23 medial epicondyle, 4 lateral condyle, 3 radial head and 1 olecranon fractures were concomitant injuries

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S30 detected ipsilaterally. Medial ulnar collateral ligament injury was detected associated with medial epicondyle fracture dislocation in a 17 years old girl, who is an elite level Olympic weight lifter. All associated fractures except 9 medial epiconylar, were treated surgically. All but 3 patients were symptom free at sixth month after injury. Mean Mayo elbow score was 90 points in this series. Patients treated conservatively with closed manipulation and posterior splint had slightly higher Mayo scores (93 versus 88, p = 0,025). Conclusions: Elbow dislocations were infrequent injuries in children. When occurred, one must be very careful not to overlook associated ipsilateral bony injuries around the elbow since dislocations are rarely seen as isolated injuries at this age group. Depending on the mechanism of injury open reduction and soft tissue repair might be indicated also in paediatric patients. Signiﬁcance: Elbow dislocations in children frequently associated with fractures around the ipsilateral elbow. These associated injuries might change the treatment strategy and should be looked for at initial presentation of the paediatric patients. 48 Avascular Necrosis of the Trochlea of the Humerus Revisited – Long Term Follow-up Author: Kaye Wilkins (United States) Co-Authors: Erik V. Nott (United States), K. Sri Ram (India) Purpose: To review fracture patterns associated with avascular necrosis (AVN) of the trochlea of the humerus as well as determine if any long term complications exist. Methods: We retrospectively reviewed the x-rays of thirty four patients who were thought to have AVN of the trochlea. These cases and ﬁlms had been collected over a thirty year period. Many of these cases had been included in a previous report on Avascular Necrosis of the Trochlea presented at the EPOS meeting in Prague, Czech Republic in 1986. The initial fracture patterns involving the distal humerus were analysed on most of the ﬁlms collected. In addition, the patterns of AVN were characterized using on the current classiﬁcation system into two types. The Type A patterns presented with dissolution of the lateral crista of the trochlea producing the typical ‘‘ﬁshtail’’ deformity. The Type B patterns were manifest as dissolution of the entire trochlea. The patient record information was reviewed prior to contacting the patients for follow-up interval history, physical exam and radiographs. Results: AVN of the trochlea was observed to occur with every type of distal humerus fracture/elbow fracture to include: supracondylar humerus fractures, lateral condyle fractures, distal humeral physeal separations, medial condyle fractures, and osteomyelitis. We were able to characterize the fracture patterns in 27 patients. There were 17 with Type A and 10 with Type B. Follow-up was achieved in ﬁve patients from the senior author’s case series, as well as two cases provided to the senior author while visiting India. Average time of follow-up was 16 years (range 10–22 yrs). All patients had cubitus varus. 3/5 patients had pain with prolonged use, especially with heavy lifting. All patients were functional with activities of daily living and work, but none were heavy laborers. 4/5 patients were unable to fully extend their elbows. The average ﬂexion was 131 deg (range 100– 150), average extension was 17 deg (range –25–40), average supination was 92 deg (range 90–100), average pronation was 77 deg (range 60–90), average arc of ﬂexion/extension was 113 deg (range 60–175). No cases of delayed motor or sensory deﬁcits were found.

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Oral presentations: Abstracts 1–123/J Child Orthop Conclusions: Type A AVN of the trochlea can result in minimal radiographic changes and minimal functional changes.Type B AVN of the trochlea can result in drastic radiographic changes with collapse of the medial joint and sometimes subluxation of the elbow joint. There is often signiﬁcant loss of function of the elbow joint with this pattern of necrosis. Signiﬁcance: In a review of the literature to date, this appears to be the only report describing the long term functional and radiographic results in patients with AVN of the trochlea. the disability acquired depends upon the pattern of necrosis that develops. 49 Fracture neck of radius in children – factors affecting outcomes and complications. Author: Arjandas Mahadev (Singapore) Co-Authors: B Lim (Singapore), E Lee (Singapore) Purpose: The aims of this study are to determine the local incidence and demography and identify the factors that affect outcomes of the treatment of radial neck fractures. Based on these, we aim to suggest a possible algorithm for treatment of these fractures. Methods: A retrospective case note and Xray review of 108 consecutive radial neck fractures treated at the KK Women’s and Children’s Hospital Singapore from 1997 to 2001 was carried. The treatment was classiﬁed as cast immobilisation without any further manipulation (CI), closed manual manipulation and reduction (MR), percutaneous K-wire assisted manipulation and reduction (PKWR) and open reduction (OR). All patients included in the study were then requested to return for a clinical evaluation to ascertain treatment outcome. Xrays were independently assessed. The angular displacement was measured as the angle made by the perpendicular of the axis of the displaced radial epiphysis and the axis of the radial shaft. Results: Of the 108 patients, 54% were boys with an average age of 8.7 years, ranging from 2 years to 14 years. 86 patients were treated by CI alone. 8 had MR, 7 had PKWR and 7 were had OR. They were followed up for an average of 2.7 years. 86% patients had excellent clinical outcome, 4% had fair and none had poor outcome. One patient had heterotropic calciﬁcation and another had proximal radio ulnar synostosis. The factors associated with a poorer outcome and increased rates of complications include age, degree of angulation, associated fractures and, interestingly, open surgery. Conclusions: Although relatively less common, radial neck fractures can produce signiﬁcant poor outcomes and complications which are dependent on age, degree of angulation, associated fractures and interestingly open surgery. We propose a step-wise approach to surgical reduction of radial neck fractures with angulation more than 30 degrees. Closed reduction should be attempted in all radial neck fractures with unacceptable angulation. Failing which, percutaneous reduction should be attempted followed by open reduction if an acceptable reduction of less than 30 degrees angulation cannot be achieved. Signiﬁcance: The above study has one of the larger series of radial neck fractures treated. Treatment protocols proposed so far can be confusing and as such, the above study proposes a treatment plan stressing on a stepwise approach with open surgery as a last resort as it has been shown to be an independent factor for poor outcome.

Oral presentations: Abstracts 1–123/J Child Orthop 50 Do proximal femoral fractures result from high energy trauma? analysis of causes and severity of injury in 1299 cases of pediatric proximal femoral fractures Author: Brian Grottkau (United States) Co-Authors: Gleeson Rebello (India), Wouter Willems (Netherlands) Purpose: Proximal femoral fractures (PFF) make up less than 1 % of all pediatric fractures. The severity of injury causing these fractures in children is not accurately documented in the literature. The aim of our study was to recognize the mechanisms of injury and to measure the severity of trauma resulting in the injury. Methods: Injured children bearing ICD-9 codes 820.0–820.9, registered in the National Pediaric Trauma Registry (NPTR) between 1988 and 2001, were included in the study. 1299 patients were stratiﬁed into age groups < 1 yr, 1–4 yrs, 5–9 yrs, 10–14 yrs and 15–19 yrs. External Cause of Injury Codes were used to obtain mechanisms of injury, grouped into nine functionally descriptive categories. The location of the injury and additional injuries were also noted. The Injury Severity Score (ISS) was used to determine the severity of trauma. Bonferroni’s multiple comparisons tests were used to determine differences among subgroups of patients. Results: Falls (33%), MVA (30%), pedestrian versus motor vehicle crashes (16%), bicycle accidents (7%), struck by an object (6%), intentional abuse (2%) and ﬁrearm injuries (1.6 %) were the leading causes of injury. The leading cause of injury in those < 1 year was abuse (35%) while children 1–4 yrs (37%) and 10– 14 yrs of age (40%) most frequently suffered falls. 5–9 yr olds (30%) and 15–19 yr olds(54%) were most frequently injured in motor vehicle accidents. 47% of the injuries occured on the road and 26% at home. Major additional injury occured in 23% of the children. ISS scores were < 9 in 57%, 10–18 in 28% and 19–75 in 14% of the injured children. Children < 1 yr, 1–4 yrs and 10– 14 yrs had a median ISS of 9. Children 5–9 yrs and 15–19 yrs of age had a median ISS of 10. Conclusions: Overall, falls (33%) were the leading cause of PFF in children. The median ISS in all age groups were 9 or 10. Severely injured children made up 14 % (ISS > 18) of the study population. We conclude that proximal femoral fractures are not as frequently associated with severe high-energy trauma as has been previously reported. Signiﬁcance: Proximal femoral fractures in children are not necessarily the result of high energy trauma with 86% of our study population suffering low to moderate energy trauma as measured by the ISS. 51 Complete Distal Femoral Metaphyseal Fractures: A Harbinger of Child Abuse Author: Lawrence Wells (United States) Co-Authors: Jared Friedman (United States), Alexandre Arkader (United States), William Warner (United States) Purpose: We contend that metaphyseal femur fractures are also a potential indicator of child abuse in children less than one year old. Methods: This retrospective study was performed at two level-1 United States pediatric trauma centers. Query of a trauma database revealed a complete distal femur fracture from 1995–2005 in 117 pediatric patients; 29 (24.8%) sustained metaphyseal fractures

S31 with 20 (69%) one-year-old or younger. The average age for the 14 males and 6 females was 6 months, 10 days. All radiographs, mechanisms of injury and associated injuries were evaluated by the respective Suspected Child Abuse or Neglect (SCAN) protocols at each institution. Results: Ten cases (50%) were conﬁrmed to have a history of abuse, whereas another ﬁve cases (25%) were suspected of abuse. In all, 15 (75%) cases of complete distal femoral metaphyseal fractures indicated child abuse after a SCAN team evaluation at each hospital. Conclusions: With 50% of our cases conﬁrmed to be caused by child abuse and another quarter suspected, complete distal femoral metaphyseal fractures occurring in children before walking age should prompt further inquiry for possible etiology of child abuse. Signiﬁcance: Health care workers are advised that in addition to epiphyseal corner fractures, complete metaphyseal fractures of the femur are highly associated with child abuse in children before walking age. 52 Acute Patellar Dislocation in Children and Adolescents Author: Sauli Palmu (Finland) Co-Authors: Pentti Kallio (Finland), Aarno Nietosvaara (Finland) Purpose: The aims of this prospective population based study were to evaluate the natural history of acute patellar dislocation (APD) in the pediatric patient population, to compare the outcome of primary surgical repair to conservative treatment and to assess the prognosis in patients with intra-articular osteochondral fractures (OCF). Methods: 74 consecutive primary patellar dislocations in 51 girls and 20 boys (< 16 years old) were treated in Aurora Hospital, Helsinki during 1991–92. Arthroscopy revealed damage of the joint surfaces in 41 % of the knees (chondral lesions 16 and OCF 14). Knees without OCF larger than 15 mm in diameter were treated randomly either by immobilization (29) or by surgery (35). All patients were followed up at 2 years and at mean 6 years. The last follow-up (68 patients, 92 % of the knees) was conducted by an independent observer at mean 14 years (11–15) after the injury. Recurrent instability (redislocations and subluxations), reoperations, subjective and functional results (Kujala score, Hugston VAS and Tegner activity level) were recorded. Results: The subjective result at the ﬁnal follow-up was either good or excellent in 75% of the patients with conservative treatment, 66% in operatively treated patients and in 54% of the patients with OCF. Recurrent patellar dislocation (RPD) occurred in 69% and recurrent patellar instability in 90% of all patients with insigniﬁcant differences between the different study groups. Two-thirds of RPD occurred within 3 years of the primary injury. Half of the patients experienced contralateral patellar instability. The mean Kujala score was 84 after conservative treatment, 83 after operative treatment and in patients with OCF. Hugston VAS scores were 91, 84 and 85 respectively. The median Tegner activity score of all patients was 5 before the injury and at the last followup. Positive family history was a risk factor for RPD and contralateral patellar instability. Girls had signiﬁcantly lower functional scores and activity level than boys. Conclusions: The majority of pediatric patients with APD are satisﬁed with their knees in young adulthood despite the very high recurrent instability rate. Primary repair of the torn medial retinacular structures is not advocated. OCF in association with APD is a risk factor for poor subjective result.

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S32 Signiﬁcance: The knowledge of the prognosis of APD in the pediatric patient population concerning the subjective result, recurrent instabilityand function is very useful for patient information and treatment decisions. 53 Excision Of Partial Physeal Arrest Followed To Skeletal Maturity; A Report of 100 Lower Extremity Cases Author: Anthony Stans (United States) Co-Authors: Rudolph Klassen (United States), William Shaughnessy (United States), Hamlet Peterson (United States) Purpose: The purpose is to determine the outcome of partial physeal arrest excision and insertion of polymethylmethacrylate interposition material in lower extremity long bones of 100 patients followed to skeletal maturity. Methods: A prospective study of 100 patients followed to skeletal maturity following partial physeal arrest resection was performed. Partial arrest occurred in the distal femur in 45 patients, proximal tibia in 18, and distal tibia in 37 patients. Surgical excision and interposition of polymethylmethacrylate (Cranioplast) were performed in all cases. Sex, age, etiology, limb length, angular deformity, growth, and percent physeal involvement were recorded. Results: Compared to the normal contralateral limb, average physeal growth following physeal arrest resection was 78 percent in the femur, 88 percent in the proximal tibia, and 93 percent in the distal tibia. Area of physeal arrest was greater than 45 percent in 16 patients, greater than 30 percent in 17, and less than 30 percent in 65 patients. Additional operations included epiphyseodesis in 40, osteotomies in 37, lengthening in 13 and physeal arrest recurrence excision in 16 patients, for an average of 1.1 additional surgeries per patient. Two patients fractured through resection sites. Conclusions: Following partial physeal arrest resection, the affected physis grows at a slower rate and matures earlier than the normal physis. Virtually all patients will require additional surgery to correct length and alignment. Signiﬁcance: Patients and families should be counseled regarding the inevitable need for additional surgery following partial physeal arrest resection, and appropriate treatment and follow-up plans made to provide optimal care.

Session 8: Legg-Calve-Perthes Disease 54 Legg-Calve-Perthes Disease with Onset before Age Six; a retrospective review Author: John Anthony Herring (United States) Co-Authors: Scott Rosenfeld (United States) Purpose: To evaluate the outcome of Legg Perthes disease relative to the Lateral Pillar classiﬁcation in untreated hips with onset before age six. Methods: We retrospecetively reviewed 190 hips in 173 patients who had the onset of Legg Perthes disease before age six. All patients were seen at Texas Scottish Rite Hospital for children between 1949 and 1998 and had not had speciﬁc treatment. Classiﬁcations were conﬁrmed by two observers. Results: In the entire group there were 7 lateral pillar A, 101 lateral pillar B, 27 B/C border, and 29 C hips. There were 131

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Oral presentations: Abstracts 1–123/J Child Orthop Stulberg I-II, 14 III, and 19 Stulberg IV results. The group B hips had Stulberg I-II outcome in 95 of 101 hips while only 14 of 29 group C hips had a Stulberg I-II result and 10 of 29 had a Stulberg IV outcome (p < 0.0001). In a logistic regression with the B hips compared to the B/C border and C hips, both age and lateral pillar classiﬁcation were signiﬁcant predictors of outcome. We found a unique group of 12 patients who had simultaneous onset of bilateral Perthes-like radiographic changes and symmetric evolution through the stages of fragmentation and reossiﬁcation. Radiographs of other joints and spine revealed no evidence of epiphyseal dysplasia. There were 7 lateral pillar B, 4 B/C border, and 13 lateral pillar C hips. At ﬁnal followup there were 21 Stulberg I-II and 3 Stulberg III results, and only one patient had different results between the two hips. Conclusions: Children who have the onset of Legg-Calve-Perthes disease prior to age 6 have a high probability (80%) of a good result without treatment. Lateral pillar classiﬁcation is predictive of outcome, but the infrequent group C hips will have a Stulberg IV outcome about 1/3 of the time. Bilateral simultaneous onset disease may represent a variant of Legg Perthes, with some characteristics of Meyer’s dysplasia, or may represent some other unknown abnormality. Signiﬁcance: This work which reviews a large number of untreated hips reinforces the concept that children with Legg Perthes with onset before age six should not routinely have major treatment or activity restrictions. Treatment programs should focus on group C hips, but the efﬁcacy of treatment for these children remains to be demonstrated. 55 Comprehensive Range of Motion Treatment of Perthes Disease Author: Perry Lee Schoenecker, MD (United States) Co-Authors: Margaret Rich, MD (United States) Purpose: The goal of containment treatment of Perthes disease is to minimize permanent deformation of the femoral head. In most centers this method of treatment includes femoral and/or pelvic osteotomy (ies) or acetabuloplasty. A femoral varus extension osteotomy decreases hip abduction and ﬂexion. Innominate osteotomy potentiates acetabular retroversion which may exacerbate femoral-acetabular impingement. Combined proximal femoral and acetabular osteotomy produces an additive loss of motion. The optimal treatment of Perthes disease, which is a biological process more than a problem of instability, should be functional containment of the deformable femoral head as the healing process evolves. This requires dynamic not static containment, which is designed to and promotes optimal physiologic range of both femoral head and acetabular remolding and congruence. Methods: From 1985 through 2001, 316 patients have been treated for Perthes disease solely with a comprehensive range of motion approach. Protocol treatment for these patients included an examination under anesthesia, adductor release as needed, application of an abduction cast, and subsequent dynamic containment, using an A-frame orthosis and progressive weight-bearing. Results: This preliminary report presents the outcome of 251 patients (291 hips) whose age at presentation was 6 years (range 2–12). Herring classiﬁcation of 12 hips were A, 121 B and 158 C. Coxa magna was noted, but with less proximal femoral deformity (coxa breva). Two hundred three hips were mature enough for Stulberg classiﬁcation. Average age at Stulberg classiﬁcation was 12.1 years; 73 hips were class I, 78 class II, 43 class III, 9 class IV and no class V. Conclusions: An analysis of our experience to date with this treatment approach strongly suggests that a satisfactory radio-

Oral presentations: Abstracts 1–123/J Child Orthop graphic outcome will occur and is superior to the results of the Perthes study group. Assessment of passive hip motion (abduction) is used as the determinant factor for treatment in stages of this disease. The need for soft tissue release, additional abduction casting and progressive weight-bearing are based on the adequacy of hip abduction which is necessary for physiologic containment. Signiﬁcance: This method of dynamic containment which focuses on hip range of motion acts to minimize deformity of the recovering femoral head, encourages acetabular remodeling and femoral/acetabular congruence which is critical. The outcome of dynamic containment is as good as and often better than with osteotomy and avoids secondary problems associated with osteotomy.

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S33 Signiﬁcance: Given a chronic disproportion between the size of the femoral head and the acetabulum therapy should aim at: A. B.

Retardation of the (cartilaginous) enlargement of the femoral head Promotion of widening or growth of the acetabulum.

We believe that current conservative modes of treatment are effective through rationale A and B. Operative modalities, in particular pelvic osteotomies and /or intertrochanteric varus osteotomy, seem to be mainly effective through rationale B. By reorientation of the acetabulum and/or the proximal femur they should favour a better distribution of forces through the hip joint allowing for a gradual widening of the acetabulum. In addition, the operative trauma in the vicinity of the triradiate cartilage should have a stimulating effect on acetabular growth.

MR-Based Volumetric Analysis of the Femoral Head and the Acetabulum in Perthes’ Disease Author: Ludwig Meiss (Germany) Co-Authors: Sintje Singerhoff (Germany), Christian Habermann (Germany) Purpose: Coxa magna is well known in Perthes’ disease but a quantitative evaluation of the early, in particular cartilaginous, enlargement of the femoral head and the necessary adaptive changes of the acetabulum (widening and/or growth) does not exist. We would like to present MR-based volumetric data. Methods: We measured the volume of the femoral head and the acetabulum in MRI by means of a software established for the sizing of tumours before therapy and the determination of liver lobe volume prior to transplantation. We evaluated MRI exams in 47 children with Perthes’ disease and 72 normal children from 4 to 9 years and present data of the affected hip in comparison to the unaffected hip and to normal hips. Results: Femoral head: 1. 2.

On the average the affected head had a volume that was 47% (range 42–57%) larger than on the unaffected side and 44 % (range 13–59%) larger than in hips of healthy children. Cases with serial exams showed that the volume of the affected head increased in the course of time.

Acetabulum: 1. 2.

3.

On the average the acetabular volume was 21% (range 13 to 30%) larger on the affected side than on the unaffected side and 20% (range 10 to 29%) larger than in healthy children. In patients who underwent surgery (pelvic osteotomy, alone or together with intertrochanteric varus osteotomy) the acetabular volume was 24% larger (range 9–33%) on the affected side than on the unaffected side. In patients without surgery the acetabular volume was 16% larger (range 10 to 33%) on the affected side. In cases with serial exams there was a deﬁnite increase of the acetabular volume after surgery.

Conclusions: 1. 2. 3.

We found that Perthes’ disease is associated with an average increase of femoral head volume of 47% in comparison to the unaffected side and of 44% in comparison to healthy children. There was an average increase of the acetabular volume of 21% in comparison to the unaffected side and of 20% in comparison to healthy children. These data may allow a better understanding of the disease and a reappraisal of current forms of treatment.

57 Legg-Calve´-Perthes-Disease –The Role of the Acetabulum Author: Andreas Schreiner (Switzerland) Co-Authors: Purpose: Stulberg pointed out the signiﬁcance of the acetabular morphology for the prognosis in Legg-Calve´-Perthes disease. Since then some studies have delt with the effect of acetabular pathology in the different stages of the disease on the outcome. And yet, there are contradictory observations and many remaining questions as to the role of the acetabulum within the Perthes process. Methods: Longstanding X-ray evolutions of patients in two major paediatric orthopaedic centres in Austria and Switzerland were studied. There were 45 hips fulﬁlling the criteria of a completed disease process. The observation protocol included the sphericity of the femoral head as a matter of course, but also the inclination of the acetabular roof, the reasons for salvage operations and the nature of these operations. Results: In 22 of those 45 hips an operation was done for sequelae of the disease. 12 of those operations consisted in a pelvic osteotomy in order to correct an increased inclination of the acetabular roof in cases of Stulberg III, which means that the femoral head was not spherical, but not ﬂat. In 2 hips different operations were used for the same reason and end. For 4 operations an extreme shortening of the femoral neck was the indication. Only in 4 cases the lost sphericity of the femoral head was the essential pathology. Furthermore there are observations suggesting independent acetabular phenomena within the disease process. Conclusions: In the majority of outcomes requiring an operation it was not the loss of cephalic sphericity to give rise to the intervention, but the increased inclination of the acetabular roof. This is astonishing, because according to Stulberg’s ﬁndings those hips have a very good prognosis. And yet, it can be shown, that in these cases the operation was reasonable and achieved for the most its goal to save the hip from major osteoarthritis. The generally speaking good prognosis in these cases is not really understandable anyway before the background of Pauwels’ insight in the adverse biomechanical effect of an increased inclination of the acetabulum. So, there is a lot of confusion about the role of the acetabulum in Legg-Calve´-Perthes disease. This confusion can be dissolved by the point of view that the acetabulum is a site of pathology in its own right, which plays an innate part in the evolution of a Perthes hip.

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S34 Signiﬁcance: This study adds genuine new aspects to the understanding of the pathogenesis of Legg-Calve-Perthes disease.

58 Hinge Abduction in Perthes’ disease: Pathomechanism of Out-toeing and In-toeing Author: In Ho Choi (Korea, Republic of) Co-Authors: Won Joon Yoo (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Tae-Joon Cho (Korea, Republic of), Ki Seok Lee (Korea, Republic of), Dong Yeon Lee (Korea, Republic of) Purpose: The purpose of this study was to investigate the relationship between the femoral head deformity and the abnormal gait pattern in the transverse plane, i.e. out-toeing (n = 4) and intoeing (n = 4). Methods: Three-dimensional computed tomography (3D-CT) scans and three dimensional (3D)-gait analysis were performed in 8 patients with late-presenting unilateral Perthes’ disease. Spatial features, i.e. location, size and shape, of the ‘hump’ on the femoral head were determined using 3D-CT. Gait parameters included foot progression angle, hip rotation, and pelvis rotation in the transverse plane; hip ﬂexion and extension in the sagittal plane; hip adduction and abduction in the coronal plane. Results: In out-toeing patients, all hips were externally rotated in the CT gantry as compared to the contralateral normal side. And the most protruded ‘hump’, when seen from above, faced the anterolateral aspect of hip joint, implying that the ‘hump’ was located relatively anteriorly. On the other hand, all hips were internally rotated in in-toeing patients, and the most protruded ‘hump’ faced the anterolateral aspect of hip joint, implying that the hump was located at relatively laterally. Gait laboratory data conﬁrmed abnormal foot progression angle, decreased hip ﬂexion in all out-toeing patients and increased downward pelvic obliquity in all in-toeing patients. Conclusions: Three-dimensional CT and instrumented gait analysis were helpful to delineate the pathomechanism of abnormal gait patterns in the transverse plane in late-presenting Perthes’ disease with hinge abduction. Out-toeing and in-toeing gaits are apparently caused by compensatory rotation of proximal femur in an attempt to avoid impingement by placing the ‘hump’ to the relatively deﬁcient anterolateral aspect of hip joint. Signiﬁcance: The results of this study support our opinion that hinge abduction is a complex manifestation of the hinge movement which occurs in the continuum between lateral impingement and anterior impingement. 59 Gait characteristics in perthes disease during the ﬂorid stage Author: Bettina Westhoff (Germany) Co-Authors: Andrea Petermann (Germany), Marcus Ja¨ger (Germany), Ru¨diger Krauspe (Germany) Purpose: The ﬁnal outcome of Perthes disease is dependant on the deformity of the femoral head and the congruity of the hip joint. Parameters inﬂuencing the severity of head-involvement and the ﬁnal outcome are poorly understood. Follow-up-evaluations are analyzing only subjective results, clinical parameters and radiological changes. No studies are evaluating the functional impairments during gait. Methods: 21 children (16 #, 5 $, average age 6,9 ys.) were included. Inclusion criteria were: 1. unilateral hip involvement in initial or

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Oral presentations: Abstracts 1–123/J Child Orthop fragmentation stage 2. age > 6 ys. 3. no previous surgical treatment at the hips 4. no other disorder leading to gait deviations. All children were investigated clinically and radiographically. 3D-gait-analysis was performed with a VICON 512 system. Spatiotemporal, kinematic and kinetic parameters were evaluated and compared to a group of normal children (n = 30, 14 #, 16 $, average age 8,1 ys.). A modiﬁed ‘‘hip ﬂexor index’’ (HFI) according to Schwartz after repeating principal component analysis with the data of our normal population was applied to our study group for quantifying hip ﬂexor function during gait. The gait patterns in frontal plane were categorized according to Westhoff et al.. Statistical analysis was performed by the Wilcoxon-test, a p-value of less than 0,05 was considered to indicate statistical signiﬁcance. Results: Spatiotemporal parameters: Stance phase on the sound side was signiﬁcantly prolonged, on the affected side single stance phase was shortened, the step length was reduced on both sides; gait velocity was not signiﬁcantly altered. Kinematics: Major deviations in sagittal plane kinematics were found at the pelvis (increased anterior tilt and ROM) and at the level of the hip (elevated minimum ﬂexion, reduced ROM). In frontal plane only 8 (38%) children showed a normal gait pattern, 42,8% showed a type 2 pattern (similar to Duchenne gait), 14,3% a type 1 pattern (Trendelenburg). Kinetics The hip abductor moment as a parameter of hip loading was signiﬁcantly reduced during single stance on the affected side (0.32 + 0.13 Nm/kg, control 0.40 + 0.08 Nm/kg, p = 0.008). Power generation was reduced as well. The modiﬁed HFI was signiﬁcantly increased (4.36 + 2.99, control 0.00 + 1.17, p < 0.001). Conclusions: There are signiﬁcant changes of the spatiotemporal parameters and of the gait pattern in the sagittal and frontal plane. These deviations are mainly part of an unloading mechanism. The changes at the pelvis can be interpreted as compensation mechanisms of altered hip joint kinematics. Signiﬁcance: Further studies will show in which way these deviations will alter the ﬁnal outcome in Perthes disease. 60 Gait Changes after Greater Trochanter Transfer in Patients with Unilateral Legg-Perthes Disease Author: Sun Young Joo (Korea, Republic of) Co-Authors: Hui Wan Park (Korea, Republic of), Hyun Woo Kim (Korea, Republic of) Purpose: To examine the results of distal and lateral transfer of the greater trochanter in patients with unilateral Legg-Perthes disease complicated by relative overgrowth of the greater trochanter. Methods: 9 hips in 9 patients were included in the study. Clinical, radiological examinations and three dimensional gait analysis were performed to examine the postoperative gait changes. Results: Fatigue pain on walking and limping gait were improved and Trendelenberg sign was disappeared in all cases. Radiologic parameters such as articulotrochanteric distance were also improved. In coronal plane, pelvic obliquity was decreased postoperatively, and there was no change in the hip abduction angle. However, the abduction moment decreased in affected hips after the operation especially in patients with decreased center-edge angle and limb length discrepancy more than 1 cm preoperatively and patients classiﬁed as Stulberg III or IV at the latest follow up. Conclusions: Distal and lateral transfer of greater trochanter improved limping gait and fatigue pain in patients with unilateral Legg-Perthes disease complicated by relative overgrowth of the greater trochanter. However, the abductor moment was not increased in patients with dysplastic and/or subluxated hip and limb length discrepancy.

Oral presentations: Abstracts 1–123/J Child Orthop Signiﬁcance: Distal and lateral transfer of greater trochanter improves clinical and radiological parameters, however the abductor moment does not increase in patients with dysplastic and/or subluxated hip and limb length discrepancy more than 1 cm. 61 The outcome of patients with hinge abduction in severe Perthes’ disease treated by shelf acetabuloplasty Author: Robert Freeman (United Kingdom) Co-Authors: Yasser Kandil (Egypt), Andrew Wainwright (United Kingdom), Tim Theologis (United Kingdom), Michael Benson (United Kingdom) Purpose: To assess the value of shelf acetabuloplasty in children with hinge abduction in severe Perthes’ disease. Methods: Twenty seven consecutive patients with severe Perthes’ and arthrographically proven hinge abduction treated with shelf acetabuloplasty were reviewed radiographically and clinically. The severity of the disease was assessed according to Catterall’s, Salter-Thompson’s, and Herring’s lateral pillar classiﬁcation. Radiological measurements included head size, sphericity, and head coverage. Measurements were made at presentation, preoperatively and at serial follow up, with ﬁnal grading by the Stulberg classiﬁcation. Results: The mean post-operative follow-up was 57 months (26– 125 months). No patients were lost to follow up. All patients were Catterall grade III or IV, lateral pillar grade B or C and had arthrographically proven hinge abduction at the time of operation. At ﬁnal follow-up 15 patients (56%) were graded Stulberg 1 or 2; nine hips Stulberg 3; two hips Stulberg 4 and one hip Stulberg 5. The percentage acetabular cover increased from 82% preoperatively to 98% postoperatively. A striking ﬁnding was the swift relief in pain together with the improved range of movement early postoperatively. At ﬁnal follow up twenty three patients were pain free, but four patients felt mild occasional pain. Conclusions: For children with severe Perthes’ disease who demonstrate progressive subluxation with hinge abduction the anterolateral shelf acetabulaplasty may improve outcome. The procedure is relatively simple, pain relief follows swiftly and at mean follow-up of 57 months the outcomes appear better than in historical reports. Signiﬁcance: The role of surgery in the management of children with severe Perthes’ and uncontainable hips with hinge abduction has been questioned. This paper supports the use of shelf acetabuloplasty in this group of patients. 62 Treatment of Severe Late Onset Perthes’ Disease with Soft Tissue Release and Articulated Hip Distraction Author: Eitan Natan Segev (Israel) Co-Authors: Michael Fishkin (Israel), Moshe Yaniv (Israel), Yoram Hemo (Israel), Eli Ezra (Israel), Shlomo Wientroub (Israel) Purpose: To evaluate the clinical and radiographic results of soft tissue release and hip joint distraction for severe late onset Perthes’ disease. Methods: Nineteen patients, 10 of whom at skeletal maturity, who had undergone soft tissue release and articulated hip distraction for late onset Perthes’ disease were included in the study.

S35 Distraction was discontinued when Shenton line was corrected (4– 5 months). All patients completed the Oxford hip questionnaire for pain and function. In patients at skeletal maturity, we assessed the Harris hip score for pain, function, daily activities, as well as the hip range of motion, and limb length discrepancy. Results: Surgery was performed at an average age of 12.5 years (range 9.4–16.0). At the last follow-up, the average pain score on an analog scale dropped from a preoperative 7.0 to 1.6 and Shenton line breakage improved from 7.6 mm to 2.1 mm. An improved hip range of motion was found in all patients. Epiphyseal index improved from 0.69 to 0.8. In the skeletally mature group, the mean age at surgery was 12.3 years (range 9.4–15.1 years) and the mean duration of follow-up was 5.7 years (range 4.3–7.8). The mean age at last follow up was 18.0 years (range 15.2–22.8). The average Harris hip score was 86.7/100 (range 48.5–96). Average Oxford hip score was 17.2/60 (range 12–31). Some limitation of hip abduction and internal rotation compared to the normal side was present. Three patients had short leg limp and one had positive Trendelenburg sign. Three patients had no limb length discrepancy, while 4 had 1 cm. Two patients with 3.5 cm of shortening and one with 4 cm of shortening used shoe lifts. X-rays of the hip joint at last follow up showed that most femoral heads were coxa magna and of spherical shape with good congruency to the acetabulum. Conclusions: Soft tissue release and hip joint distraction for severe late onset Perthes’ disease resulted in clinical and radiographic improvement for the hip joint. The positive effect was continuous and became signiﬁcant at skeletal maturity. Signiﬁcance: The above techniques can be regarded as a salvage procedure for this severe hip pathology, without eliminating future interventions such as osteotomies and total joint replacement.

63 Exact indications of femoral varus osteotomies for severely involved Perthes’ disease Author: Makoto Kamegaya (Japan) Co-Authors: Takashi Saisu (Japan), Junnichi Nakamura (Japan), Hideshige Moriya (Japan), Tomonori Kenmoku (Japan), Chikato Mannoji (Japan) Purpose: To conﬁrm the efﬁcacy of our surgical strategy for severely involved Perthes’ disease. Based on our analysis of the surgical outcomes, we tried to identify the exact indications for a femoral varus osteotomy (FVO). Methods: The number of patients who underwent FVOs due to their severity was 38 (39 hips) out of a total 113 Perthes’ patients from 1990 to 1999. The operation rate was 33.6%, which coincides with the generally accepted rate of poor outcomes treated conservatively in Perthes’ disease. Thirty-three were male and 5 were female. Thirty-one patients were unilaterally affected and 7 were bilaterally affected. One of the 7 patients underwent FVOs in both sides. The remaining 6 had FVO in one side. The average age at operation and followup were 8.4 and 17.0 years respectively. Our surgical indication was decided on the following conditions before the healing stage: the age of 8 years or more at the onset with Herring’s class B (Catterall’s III) with more than two risk signs and/or persistent limitation of the range of hip motion, or all ages with Herring’s C (Catterall’s IV). Retrospectively, pre-operative arthrography was investigated to ﬁnd exact indicators for obtaining good surgical outcome of FVOs. All arthrography was performed under general anesthesia. The Caput Index, Subluxation Indices in both neutral and maximum abduction deﬁned as the ratio of

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tear drop distance to acetabular depth, and Epiphyseal Slip-in Index (ESI) deﬁned as the ratio of the distance from the acetabular rim to the tip of the epiphysis slipped into the acetabulum in maximum abduction to acetabular depth were measured in the arthrography. Final outcome was radiologically evaluated with the modiﬁed Stulberg’s classiﬁcation, Slope of Acetabular Roof (SAR) and Acetabular Head Index (AHI). Results: An acceptable result was shown in 23 hips (59%). According to the stepwise multiple regression analysis, the ESI was the most reliable arthrographic indicator for acceptable outcomes of FVOs (p < 0.0001). Based on this fact, 20% or more ESI was at least required to have better sphericity of the femoral head, better acetabular cover and better acetabular conﬁguration. Conclusions: Our surgical outcomes were not satisfactory in resolving 41% of the hips. However, this study has clariﬁed exact indications for obtaining good surgical outcomes of FVOs, based on the ﬁndings of pre-operative arthrography. Signiﬁcance: The surgical indication for Perthes’ disease which had been given poor prognosis has been shown in many works of literature. However, it has not been indicated which surgical method would be the most effective for which patient. Therefore, we propose certain indications for FVOs, while, at the same time, we suggest the necessity of a new procedure for patients whose outcomes would be predicted as unacceptable even with FVOs.

AC: 0.68 cm2) (p > 0.05). At the end of 6 months the average canal diameter was signiﬁcantly lower in the arthrodesis and instrumentation groups when compared to the control group (AA: 1.20 cm2, AI:1.24 cm2 vs AC:1.41 cm2) (p < 0.001). There was no difference between the average canal diameters of the arthrodesis and instrumentation groups (AA: 1.20 cm2 vs AI: 1.24 cm2) (p > 0.05). The average percent increase in the canal area in the arthrodesis segment and the instrumented segments were signiﬁcantly lower than the control levels (AA: 72.6%, AI: 77.1% vs AC: 110.1%) (p < 0.001). There was no difference in the percent increase in the canal area between the arthodesis segment and instrumented segment (AA: 72.6% vs AI: 77.1%) (p > 0.05). Conclusions: This study demonstrated that anterior spinal arthrodesis or instrumentation in the immature spine may result in iatrogenic spinal stenosis. The growth of the neurocentral cartilage might be either disturbed by the tethering effect of the arthodesis or secondary to direct destruction by the anterior screws. Destruction of NCC or blocking of posterior movement of NCC might result in iatrogenic spinal stenosis. Signiﬁcance: Early anterior instrumentation and fusion in children may cause iatrogenic spinal stenosis leter in life.

Session 10a: Spine I

Author: Federico Canavese (Italy)

64 The effect of early anterior spinal fusion on spinal canal size in an immature porcine model Author: G Yilmaz (Turkey) Co-Authors: M Pekmezc_ı (Turkey), K Daglioglu (Turkey), A Alanay (Turkey), ER Acaroglu (Turkey), CF Oner, M Yazici (Turkey) Purpose: Neurocentral cartilage (NCC) is located at the posterior 2/3 of vertebrae and responsible for the growth of the pedicles and posterior vertebral body. NCC moves posteriorly during the growth of spinal column. Injury to the NCC or disruption of posterior movement of NCC can result in spinal stenosis. The aim of this study is to evaluate the effect of anterior spinal instrumentation and fusion on the development of vertebral body in a porcine model. Methods: Twelve 8 week-old domestic pigs had CT scans preoperatively and underwent anterior circumferential discectomy of the L3-L4 and L4-L5 discs . Anterior spinal instrumentation was performed between L3 and L5 (L4 skipped). When they reach skeletal maturity, their vertebrae were evaluated with CT scan for the presence of anterior fusion and the size of the vertebral canal. The canal area was calculated by using the sections passing through pedicle level. The average area of vertebral segments adjacent to the proximal and distal instrumented segments was used as control level area (AC), average area of L3 and L5 was used as the area change in the instrumented levels (AI), and the area of L4 was used as the area change at the arthrodesis level (AA). The percent increases in the canal area, as well as total canal area were compared among groups. Results: One subject was lost during the immediate postoperative period. All subjects had documented anterior fusion. There was no difference in the average canal diameters of the three groups in the preoperative period (AA: 0.70 cm2; AI: 0.70 cm2 and

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65 Posterior or dorsal arthrodesis of the thoracic spine in pre pubertal rabbits and effects on thoracic cavity growth

Co-Authors: Alain Dimeglio (France), Fabiano Cavalli (Italy), Francois Bonnel (France), Donatella Volpatti (Italy), J-P Daures (France), Marco Stebel (Italy), Eugenio Pittioni (Italy), Bartolomeo Canavese (Italy) Purpose: Can a posterior (or dorsal) arthrodesis inﬂuence the thoracic growth pattern,the length of the sternum and the thoracic cavity volume in pre pubertal rabbits? Methods: 12 pre pubertal female W NZ rabbits (r.) were subjected to surgery for posterior arthrodesis of the upper thoracic spine.Two ‘‘C’’-shaped titanium bars,measuring 10 cm in length,were placed with metal wire beside the spinous processes of the ﬁrst 6 thoracic vertebrae that were immobilized.Three CT scans were performed under general anesthesia 10(T1),55(T2) and 139(T3) days after surgery.All the CT scans were analyzed by an expert in radiology to avoid inter-observer errors.The dorsalventral (DV) and lateral-lateral (LL) thoracic diameters at the fused levels,the length of the sternum (SL) as well as the lung volumes (LV) were measured by means of the Myran Pro program.The dorsal and ventral length and diam. of all thoracic vertebral bodies (D1-D12) were measured with the same computer program. Results: 3 groups (G.) of r. were identiﬁed - G.1: 6 r.,complete fusion;G.2: 3 r.,incomplete fusion;G.3: 3 sham-operated r. as control group.The average DV/LL thoracic diam. ratio at fused levels was 0.953 at T1, 0.931 at T2 and 0.894 at T3 in G.1, and 1.026 at T1, 1.031 at T2 and 1.048 at T3 in G.3 (p < 0.005).The average growth of the sternum between T1 and T3 in G.1 was 19.75 mm (SL at T1:75.37 mm–SL at T3:95.12 mm) and 26.70 mm in G.3 (SL at T1:81.87 mm–SL at T3:107.57 mm) (p < 0.005).The LV grow less in G.1 compared to G.3:+1.83 cm3 vs +8.33 cm3 on average.D1-D6 length was smaller in G.1 compared to G.3 (48.69 mm vs. 54.40 mm) whereas no differences were observed between the two groups in the D7-D12 segment (79.81 mm and 81.30 mm respectively). Conclusions: Posterior arthrodesis in prepubertal rabbits changes thoracic growth patterns.In operated rabbits the DV thoracic

Oral presentations: Abstracts 1–123/J Child Orthop diam. grows more slowly than the LL thoracic diam. and leads to an asymmetrical growth of the thorax which becomes almost elliptical and thinner.The sternum and the lung volume grow less.These changes reduce sternum growth and lung development.The crankshaft phenomenon is evident at the fused vertebral levels where there is a reduction of the thoracic kyphosis due to anterior vertebral growth.Posterior surgery directly inﬂuences the growth pattern of the ribs which are connected posteriorly to the fused vertebral bodies (D2-D6) and to the sternum in front (sternal ribs).However,lower ribs,which are connected neither to the sternum nor to fused vertebral bodies (non-sternal ribs), also grow less under the inﬂuence of the reduced growth of the upper sternal ribs.The thorax as a whole grows,and a substantial modiﬁcation of the upper part has effect on the lower part.Posterior surgery can directly inﬂuence the growth of sternal ribs and indirectly of non-sternal ribs,but has no inﬂuence on the growth of underlying vertebral bodies. Signiﬁcance: experimental study.

Basic Science 66 Intervertebral Disc Adaptation to Wedging Deformation in Scoliosis Author: David D Aronsson (United States) Co-Authors: Ian Stokes (United States), Katherine Clark (United States), Maria Roemhildt (United States) Purpose: The scoliosis deformity includes vertebral and disc wedging. Although wedging of vertebrae is reported to be caused by asymmetric growth, little is known about the discs, and whether disc wedging is caused by mechanical inﬂuences on growth and/or remodeling. Methods: Percutaneous pins inserted into vertebrae were attached to an Ilizarov-type external ﬁxator that applied compression and 15 degrees angulation to each of two adjacent immature rat caudal intervetebral discs for 5 weeks (4 animals), or 10 weeks (4 animals). Micro-CT scans were performed each week to document the in vivo wedging of the discs. After euthanasia, the vertebral segments were excised and the disc ﬂexibility was measured over a range of lateral bending. The angle of maximum ﬂexibility was recorded. The discs were then ﬁxed in situ, with the external ﬁxator in place, and sectioned for polarized light microscopy. Results: Disc wedging averaged 15 degrees initially, 20 degrees after 5 weeks, and then reduced to 10 degrees after 10 weeks. The decreased disc wedging after 5 weeks was interpreted as being secondary to steadily increasing vertebral wedging. The lateral bending ﬂexibility showed a distinct maximum at an average of 1.1 degrees from the in vivo position in the 5-week animals, indicating structural remodeling of the discs almost to the deformed geometry. The 10-week animals had a maximum ﬂexibility of 1.4 degrees from the in vivo position. There was no signiﬁcant difference between the 5 and 10-week animals. The collagen crimp angles were not signiﬁcantly different between the convex and concave sides, indicating that remodeling had occurred. Conclusions: A mechanically induced scoliosis deformity in a skeletally immature rat model caused intervertebral disc wedging that demonstrated remodeling within 5 weeks. Signiﬁcance: This indicates that this animal model is suitable for studying adaptive wedging changes in human scoliosis.

S37 67 Lung Function Asymmetry in children with congenital and infantile scoliosis Author: Kit M Song (United States) Co-Authors: Greg Redding (United States), Steven Inscore (United States), Eric Effman (United States), Robert Campbell (United States) Purpose: We evaluated right and left lung function in chiildren with progressive infantile scoliosis. We aimed to see if progressive increases in Cobb angle would correlate with increasing lung function asymmetry. Methods: 39 children ages 20–186 months and diagnosed with infantile or congenital scoliosis without chest wall abnormality and being considered for VEPTR placement had preoperative V/ Q or Q scans with Tc99M-radiolabeled albumin microaggregates and Tc99M-labeled DTPA, and spine radiographs. Normal distribution is 55% right and 45% left. Asymmetry in lung function was correlated with Cobb angles using non-parametric Pearson correlation coefﬁcient. P < 0.05 was considered signiﬁcant. Results: Two-thirds of the 25 children with congenital scoliosis had fused ribs; 13 children had infantile scoliosis. Cobb angles ranged from 30–112 degrees in the group (median value = 71 degrees) with the concave lung being the left lung in 61% of cases. Lung function relations between the right and left lung were abnormal (>+/–5% from the normal 55%right/45%left) in 21 (54%) of patients. Rightleft contributions to lung perfusion ranged from 86%R-/14% L to 26%R-74%L among the 39 children. Lung function in the concave lung was reduced below the normal proportion in 20 children (51%), and increased above predicted proportion of function in 17 children (44%). Lung function asymmetry, measured as the deviation from the normal contributions of the right and left lungs, did not correlate with Cobb angle values. (r = .12, p > 1.0) Ventilation asymmetry and perfusion asymmetry were concordant and correlated closely (r = .79, p < .001). Conclusions: Asymmetric ventilation and perfusion between the right and left lungs occurs in more than half of children with severe congenital and infantile thoracic scoliosis. However, the severity of lung function asymmetry does not relate to Cobb angle measurements. Signiﬁcance: Asymmetry in lung function is an important physiologic impairment. It is inﬂuenced by deformity of the chest wall in multiple dimensions, and cannot be ascertained by chest radiographs alone. 68 The effect of early thoracic fusion on pulmonary function in non-neuromuscular scoliosis Author: Kiril Mladenov (Germany) Co-Authors: Lori Karol (United States), Charles Johnston (United States) Purpose: To determine the effect of early thoracic fusion on pulmonary function at intermediate follow-up. Methods: Patients who had thoracic spine fusions before age 8 yrs with minimum 5 yrs follow-up underwent pulmonary function testing (PFT). Patients with neuro-muscular disease, skeletal dysplasias, or preexisting pulmonary disease were excluded, while those with rib malformations were included. Results: No patient died of pulmonary insufﬁciency. Twenty-eight patients reported for PFT. Twenty of them had congenital scoli-

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S38 osis, three had neuroﬁbromatosis, three idiopathic scoliosis, one syndromic scoliosis and one congenital kyphosis. Twenty six patients underwent anterior and posterior surgery as their primary initial surgery, one had isolated posterior surgery and one isolated anterior surgery. Eleven of the 28 patients underwent revision spinal surgery. Age at surgery averaged 3.3 yrs (range 4 mo to 8.4 yrs), age at follow up averaged 14.6 yrs (range 7.3 to 22.8 yrs), the lenght of follow-up averaged 11.2 yrs (range 6.4 to 20.5 yrs). PFT results: The forced vital capacity (FVC) averaged 57.8% (range 27% to 99%)of age matched normal values. FVC was less than 50% of normal in 12 of 28 patients implying signiﬁcant lung disease in 42.9% of the study group. The average FEV 1 was 54.7% of age matched normal values (range 23% to 91 %). FEV 1 was less than 50% in 12 of the 28 patients. Obstructive lung disease (FVC /FEV 1 less than 85%) was noted in 35.7% of the patients. Age at fusion and PFT were not signiﬁcantly related(r = 0.28, p = 0.15). The % FVC did strongly correlate with the per cent of the thoracic spine fused at the index procedure (r = –0.46, p = 0.01). There was a highly statistically signiﬁcant correlation between the proximal level of the thoracic spine fused and %FVC (r = 0.62, p = 0.0004). Proximal fusions deteriorated PFT’s most, since 8 from 12 patients (66.7%)with fusion beginning at T1 or T2 had FVC less than 50%, while only 4 out of 16 (25%) with fusions beginning below T3 had FVC less than 50%. None of the 7 patients with fusions below T6 had FVC less than 50%. There was no correlation between revision surgery and % PFT (p = 0.15). Conclusions: Signiﬁcant restrictive lung disease (FVC and FEV 1 less than 50%) was present in 43 % of the patients. Poor pulmonary function correlated with extensive thoracic fusion and with fusions beginning proximally at T1 or T2. Obstructive lung disease was diagnosedin 35.7% of the patients. Young children who require extensive fusions of the thoracic spine are most at risk for thoracic insufﬁciency syndrome, and alternative treatments should be considered in this group of patients. Signiﬁcance: Retrospective study. 69 Correlation of plain radiographic measurements and CT lung volumes in early onset scoliosis Author: Charles E Johnston (United States) Co-Authors: Salah Fallatah (Canada) Purpose: To correlate chest, spine and pelvic dimensions on radiographs with CT lung volumes in patients with early onset scoliosis (EOS). Methods: Spine radiographs and chest CT of 21 patients with EOS were reviewed. Age range: 9 mo - 8 + 9 yr at time of CT, with no patient having had surgery. T1- T12 length, coronal chest width at T6 and pelvic width were measured from the PA radiograph. Sagittal chest depth T6- sternum was measured on the lateral. These measurements were correlated with CT lung volumes of the right, left and both lungs. Results: There were 7 congenital, 4 idiopathic, 3 congenital MD, and 7 syndromic/miscellaneous deformities. Main curve Cobb angles averaged 53o (range 24–108). Coronal chest width at T6 (13.4 cm, range 10.2–18.4) had a signiﬁcant correlation(r = 0.72, p = 0.0008) with each of the three CT lung volumes. Pelvic width (mean 7.4 cm, range 5.5–9.1) had a modest correlation (r = 0.5, p = 0.03) with the three CT volumes. T1-12 length and T6-sternum sagittal depth did not correlate with CT volumes. Multiple linear regression indicated that chest width at T6 and to lesser extent pelvic width were predictors of CT lung volume measurements.

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Oral presentations: Abstracts 1–123/J Child Orthop Conclusions: T6 chest width and to a lesser extent pelvic width are predictors of CT lung volumes (right, left and combined) and may be used to assess lung development in EOS patients at risk for TIS, possibly providing an objective indication for commencing prophylactic treatment. Signiﬁcance: Patients with EOS are at risk to develop chest wall deformity with pulmonary hypoplasia. Current treatment strategies (expansion thoracoplasty, growing rods, etc) focus on the prevention of thoracic insufﬁciency syndrome (TIS). However, objective criteria deﬁning TIS and indications for treatment are incomplete. A method to predict lung volumes and by implication risk for TIS from standard chest and pelvic measurements would be invaluable to establish objective indications for prophylactic treatment. This study conﬁrms the value of the pelvic width data from Emans et al (SRS 2004).

70 A Retrospective Cohort Study of Pulmonary Function, Radiographic Measures and Quality of Life in Children with Congenital Scoliosis: An Evaluation of Patient Outcomes after Traditional Spine Surgery. Author: Michael Guy Vitale (United States) Co-Authors: Hiroko Matsumoto (United States), Michael Bye (United States), Joshua Hyman (United States), Jaime Gomez (United States), Whitney Booker (United States), David Roye (United States) Purpose: Children with congenital scoliosis are at an increased risk for severe progression of their spinal curvature, which will eventually impact their pulmonary function. Recently, new surgical options have become available to treat these conditions by expansion of the thoracic cavity without early fusion. It is important to evaluate the outcomes of children who were treated with traditional methods before any comparative studies can be conducted. The purpose of this study is to evaluate pulmonary function (PFT) and quality of life (QOL) of children who were treated with growing rods and/or fusion for progressive congenital scoliosis and to compare them to healthy children. The relationships between radiographic measures, PFT and QOL will also be examined. Methods: Twenty seven patients (13.7 ± 4.9 years old) with a primary diagnosis of congenital scoliosis who were treated with growing rod/fusion and subsequent fusion were evaluated using radiographs, (PFT) and QOL surveys using Child Health Questionnaire Parent Form (CHQ). They were, on average, 6.8 years post deﬁnitive fusion. Average age at initial surgery was 6.7 years. Results: Forced vital capacity (FVC) (p < 0.001), forced expiratory volume in one second (FEV1) (p < 0.0001), total lung capacity (p = 0.001), and vital capacity (p < 0.001) were signiﬁcantly lower than those in healthy children. The CHQ scores in our study patients were signiﬁcantly lower than healthy children in physical function (p = 0.001), general health (p = 0.001), and physical summary (p < 0.001) and signiﬁcantly higher in bodily pain (p < 0.001) and impact on parent time (p = 0.036). Patients with larger thoracic curves had lower FVC (r = –0.467, p = 0.04) and FEV1 (r = –0.466, p = 0.04). Patients with larger cervicothoracic curves were likely to present lower FEV1 (r = –0.435, p = 0.03). Patients with larger kyphotic angels had lower self esteem (r = –0.462, p = 0.02) and patients with larger thoracolumbar curves had higher impact on parental time (r =–0.511, p = 0.01). Patients who had lower FEV1 obtained higher scores on parental impact on time (r = –0.408, p = 0.04). Conclusions: Compared with healthy peers, patients with congenital scoliosis treated with a growing rod technique and/or

Oral presentations: Abstracts 1–123/J Child Orthop subsequent fusion have signiﬁcantly worse pulmonary function and quality of life scores when assessed at an average of 6.8 years following initial surgery. Children with larger curves present lower PFT and CHQ results and show higher burden of care. Signiﬁcance: PFT scores were signiﬁcantly lower than those in healthy children. Quality of life physical scores are signiﬁcantly lower but psychological scores are similar to those found in healthy peers. Children with larger curves present lower PFT and CHQ results, they also show higher burden of care. 71 Surgical Treatment of High-Grade Spondylolisthesis in Children and Adolescents- Results of One-Stage Posterior Surgical Reduction Author: Monica Elena Ursei (France) Co-Authors: Jerome Sales de Gauzy (France), Aziz Abid (France), Jorge Knorr (France), Jean-Philippe Cahuzac (France) Purpose: The main purpose of this study was to analyze the results of this reduction technique in patients with high-grade spondylolisthesis, presenting sagittal spinopelvic imbalance, gait abnormalities and neurological signs. Methods: 15 patients with high-grade spondylolisthesis (Meyerding III, IV and spondyloptosis) were retrospectively evaluated with an average follow-up of 52 months(range, 25–129). Mean age at surgery was 12 years (range, 9 to 16). Indication for surgery consisted in low-back pain, radicular pain and progression of the slippage. Surgical technique consisted in posterior decompression, reduction by pedicle instrumentation and circumferential fusion by a single-stage posterior approach. During surgery evoked potentials were routinely used. Postoperative all patients were immobilized in a lumbar cast prolonged over one thigh for 3 months, followed by a lumbar brace for another 3 months. Clinical and radiographic evaluation were performed. Results: Clinical evaluation showed complete pain relief and no activity limitation in 14 patients. One patient accused intermittent pain. Radiographic analysis: L5–S1 slippage averaged 71% preoperatively (52–100) and 35% postoperatively (8–95). Slip angle measured preoperatively averaged –14 degrees( range, –30 to –5). Postoperatively it had a mean positive value of 3 degrees (range, –30 to +20). In 14 patients the slip angle improved after surgery and in one it remained the same. Pelvic incidence: mean preoperative value of 85 degrees (65–100) and 74 postoperatively ( 50–92). We report 9 postoperative complications: one wound infection, 6 cases of broken or pullout screws, 2 cases of progression of the slippage. No neurological deﬁcit was noted. Conclusions: Surgical treatment of high-grade spondylolisthesis using this one-stage posterior reduction technique provides good clinical and radiographic results. The major indication of this procedure is high-grade spondylolisthesis, with trunk imbalance and gait abnormalities. Signiﬁcance: Reduction of spondylolisthesis using pedicle screw sistem represents a technically challenging method, that requires spinal surgical experience and exposes to neurological risks, like other reduction techniques. It provides sufﬁcient spinal stability and restores spinopelvic alignment. 72 Single Stage Posterior Vertebral Resection Osteotomy for Correction of Paediatric Spinal Deformities Author: Nanjundappa Somasekhar Harshavardhana (United Kingdom)

S39 Co-Authors: Mihir Bapat (India), Vinod Laheri (India), Satyajit Marawar (India), Prashanth Deshmane (India), Harish Patni (India), Siddarth Badve (India) Purpose: To deﬁne the role and analyse the results of Single Stage Posterior Vertebral Resection Osteotomy in the management of Pediatric Kyphotic / Kypho-scoliotic deformities. Methods: 42 children (35 primary and 7 revision cases) aged 5 to 16 yrs with severe post-tuberculous spinal deformities operated between 1999 to 2004 formed the study group. The kyphosis (Ko) angle ranged from 66o to 128o (av 76o). The deformities were grouped as cervico-dorsal (2), upper dorsal (5), dorsal (17) and dorso-lumbar (18). 11 patients had pre-operative neurological deﬁcits [2 ambulatory and 9 non-ambulatory]. Positive sagittal imbalance ranged form + 7 to + 32 mm. The number of vertebrae at the apex varied from 2 to 6 (av 2.7). The apex was grouped as soft (wet) in 12 and rigid (dry) in 30 based on the nature of tuberculous lesion on MRI. 9 had signiﬁcant coronal plane deformity (i.e Scoliosis) ranging from 97o to 134o with coronal imbalance of 10 to 55 mm. 4 patients had Anaconda Spine (i.e the apex of kyphosis being cranial to the most distal vertebra in the compensatory curve). In this small group of patients, a pre-operative traction was employed to asses the correction / ﬂexibility of the curve. In 7 patients, a previous surgery had failed to achieve desired correction / fusion. Results: A single stage posterior vertebral resection osteotomy was performed in all patients. The average follow-up was 2 years. The average correction achieved was 64.77% with an average improvement in sagittal balance of 15 mm. 1 had post-operative transient neurological deﬁcit. All patients with neurodeﬁcit attained independent ambulation. There were 4 deep and 2 superﬁcial infections. Implant failure and loss of kyphosis correction occurred in 4 cases warranting a revision surgery of which 1 had dural injury during the revision procedure. 1 patient was detected to have multi-drug resistant tuberculosis (MDR-TB). 1 died due to pulmonary complications 2 mo after the surgery and 2 others required ventilatory support for post-op pneumonia. The average correction achieved in revision procedure was 60.86% as compared to primary procedures. In kyphoscoliotic deformity, kyphotic correction was 57.88% while scoliotic correction averaged 42.10%. 1 patient required 2 revision procedures to achieve fusion. Conclusions: A prospective analysis of correction of severe kyphosis / kypho-scoliosis in children is sparse in literature. A single stage posterior vertebral resection osteotomy provides excellent correction with column shortening. Application of this technique to the paediatric spine is challenging & difﬁcult owing to weak bony elements that impedes application of corrective forces to the spine. Signiﬁcance: The single stage posterior vertebral resection osteotomy is a safe & excellent mode of restoring the sagittal / coronal balance in axial immature skeleton but has a steep learning curve.

73 Spondylo-costal dysostosis treated by costal distraction without thoracostomy. Author: Yan Alfred Lefe`vre (France) Co-Authors: Franck Launay (France), Elke Viehweger (France), Jean Luc Jouve (France), Ge´rard Bollini (France) Purpose: The spondylo-costal dysplasia (SCD) consists of unilateral and asymmetric costal and spinal malformations combining costal anomalies, with different vertebral anomalies leading to

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S40 spinal curvature. We studied a series of patients who presented with SCD with spinal curvature without major rib fusions but major rib deﬁciency, proposing an expandable device to maintain distraction on the concave side of the curve in order to limit its progression. The purpose of this preliminary study was to investigate the efﬁciency and complications of the treatment of SCD with partial rib-cage aplasia (PRCA) by mainly using rib distraction. Methods: We studied six cases of patients SCD with PRCA without major extended rib fusion treated by rib distraction alone. Surgery was indicated after an increase of the curvature greater than seven degrees in six months. The side of distraction was decided according to the limits of the thoracic curvature and the position of the aplasia in relation to the side of the concavity. Clinical examination and radiographs were performed every six months according to the case evolution. Surgery to increase distraction was performed according to the deformity progression if the Cobb angle increased more than 7 degrees. Results: Six patients were treated, four girls and two boys. Mean age at the initial operation was 15,3 months (1 month to 31 months). None of them presented with a neurologic deﬁciency. Mean follow up was 36,2 months (24 to 49 months). The mean number of surgeries (including initial placement of the device) and its expansion to increase the distraction was three (one to six). The mean Cobb angle of thoracic curves before surgery was 33,3, and mean Cobb angle of thoracic curves at the last follow up was 33,8. In 18 operations, there were three complications, two fractures of an upper rib, and an infection of the operative site. Conclusions: The distraction concave device was effective in so far as there was no progression greater than 3,5 per year after the onset of treatment with new distraction necessitated by any curve progression. Our complication rate was similar to others methods using costal or vertebral distraction. We feel that those cases with mainly rib aplasia with curve progression are indications for rib distraction without thoracostomy. On the other hand, we agree that SCD with signiﬁcant rib fusions need opening wedge thoracostomy to allow a rib distraction. In conclusion, preliminary results of rib distraction treatment to control scoliosis associated with a form of spondylo-costal dysostosis in which rib aplasia is a predominant feature, demonstrated satisfactory outcomes with an acceptable complication rate. The use of this method for the SCD form with predominant aplastic ribs must be differentiated from cases of SCD with spinal anomalies and major rib fusions which require thoracostomy as well. Signiﬁcance: Retrospective study.

Session 11a: Spine II 74 Surgical treatment of scoliosis associated with myelomeningocele Author: Stella Gilberto (Italy) Co-Authors: Marco Carbone (Italy), Mariabeatrice Michelis (Italy) Purpose: A longer life expectancy for patients with myelomeningocele increases a number of patients with progressive spinal deformities. Deformity may present at 2 to 3 years of age, becoming severe before 10 years of age. A main factor that needs to be considered in the surgical treatment of these patients is the high infection rate and pseudoarthrosis. Methods: Twenty-seven patient(13 male, 14 female; mean age 13,3 years) with severe(average 100, angle range 80–160 Cobb)

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Oral presentations: Abstracts 1–123/J Child Orthop thoraco-lumbar and lumbar scoliosis due to myelomeningocele were treated by spinal fusion.1 by posterior arthrodesis with instrumentation, 1 by anterior arthrodesis with instrumentation, 25 by combined anterior and posterior fusion extended to the sacrum and with double instrumentation. Number of surgical procedures: 52. The anterior fusion and instrumentation should be done ﬁrst. The most utilized instrumentation in posterior approach was CDH. In anterior approach the instrumentation was mainly TSRH and Colorado2. For pelvic ﬁxation we prefer Dunn-McCarthy technique. This kind of pelvic ﬁxation with new vertebral implant allows a deep contact of the instrumentation to the spine. This allows suitable muscle-skin coverage and allows a very good laminar decortication of the lumbo-sacral junction; it efﬁcently opposes the torsional and bending forces of the trunk. An excellent alternative is ileo-sacral screw of Dubousset. Results: Mean period of follow-up was three years and eight months. The ﬁnal average curve correction was 60%. Correction of pelvis obliquity was 65% at follow-up. Complications: 5 infection( 3 superﬁcial, 2 deep infection) after posterior instrumentation; 1 stress ulcer; 1 sore due to sacral rod requiring partial rod removal; 1 lumbo-sacral pseudoarthrosis; 1 instrumentation loosening in posterior approach; 1 screw pull-out in anterior approach (no operative reinsertion was necessary). Conclusions: Only thoracolumbar and lumbar curves under 70–80 with normal spine in sagittal plane and without or moderate pelvic obliquity need only anterior fusion and instrumentation with standard thoracolumbar approach. Almost every patients requiring surgery needs both anterior and posterior fusion and instrumentation. In these children the combined anterior and posterior instrumentation and fusion gave the best correction of the deformity and reduced the rate of pseudoarthrosis. Infection after posterior approach was the most serious problem. Signiﬁcance: A longer life expectancy for patients with myelomeningocele increases a number of patients with progressive spinal deformities that needs surgical treatement. 75 The surgical treatment of scoliosis in Duchenne Muscular Dystrophy Author: Francesco Turturro (Italy) Co-Authors: Antonello Montanaro (Italy), Luca Labianca (Italy), Marco Spoletini (Italy), Fortunato Mangiola (Italy), Federico Sciarra (Italy), Sonia Messina (Italy), Andrea Ferretti (Italy) Purpose: Scoliosis is observed in approximately 90% of patients with Duchenne Muscular Dystrophy (DMD), after stop walking. The main consequences of the progression of scoliosis are: 1) the impossibility of remaining in a comfortable sitting position; 2) back pain; 3) pressure sores; 4) difﬁculties in nursing care; 5) worsening of the respiratory deﬁciency. Several data indicate that conservative treatment with braces or spinal supports is unable to control the progression of the scoliosis, while surgical treatment appears to be the only effective way of treating such a pronounced and rapidly-evolving deformity. The goal of our study was to evaluate the results of surgical treatment of scoliosis in DMD patients. Methods: We retrospectively reviewed the records of 33 DMD patients who underwent spinal surgery between 1991 and 2006. A spinal fusion from T2 or T3 as far as the sacrum and trans-iliac pelvic ﬁxation was always performed. The surgical instrumentations used were: Luque in 25 patients and Plus in 8 patients. Postoperative support with a plaster cast or brace was not used in any patient. The patients underwent the ﬁrst clinical and instru-

Oral presentations: Abstracts 1–123/J Child Orthop mental re-examinations (spirometry and echocardiography) 3 months after the operation and then every 6 months; an X-ray of the spine in toto in a sitting position was done 3 months, 1 year and 2 years after the operation. As control group to evaluate pulmonary function, we analysed 20 age-matched DMD patients who refused surgical treatment. Results: At the time of surgery, the mean age was 13.1 yrs (range 12–17) and the mean Cobb angle was 45 (range 20–95). The mean postoperative angle was 16 (range 0–32). The mean loss of correction at follow up was 10 (range 0–15). We observed 3 major complications: 3 deep infections requiring the removal of the hardware 2 months after its insertion. All patients achieved the sitting position within 7–10 days after surgery. Discomfort in sitting position or prolonged back pain were observed in 3 out of 33 (10%) patients. No signiﬁcant differences in the respiratory function were observed between surgically-treated and control patients. When asked, the majority of patients and their parents (80%) would give again the consent to surgery. Conclusions: Surgery successfully corrected the curve and the pelvic imbalance of DMD patients with scoliosis. This also caused a more comfortable sitting position, an easier application of respiratory aids and a simpler nursing care. All these aspects signiﬁcantly ameliorated the quality of life for these patients, as also acknowledged by patients and their parents. However, respiratory function was not affected by surgical correction. Signiﬁcance: We describe the outcomes of spinal surgery in patients with Duchenne Muscular Dystrophy and scoliosis, adding new evidences on the efﬁcacy of the surgical strategy, especially on the quality of life of these patients. 76 Upper cervical fusion in children with Morquio’s disease: long-term results Author: William Mackenzie (United States) Co-Authors: Mihir Thacker (United States), Aaron Littleton (United States), Mohan Belthur (United States) Purpose: Children with Morquio’s syndrome have a high incidence of upper cervical instability, which can lead to compression of the spinal cord resulting in progressive neurological deterioration, quadriplegia and death. Upper cervical fusion has been advocated to arrest this instability and prevent neurological deterioration. However, long term results of this procedure in this select population have not been reported. The purpose of this study is to evaluate the long-term clinical and radiological outcome of upper cervical fusion in children with Morquio’s disease. Methods: The charts and radiographs of 13 patients with Morquio’s type A disease who had undergone upper cervical fusion to arrest upper cervical instability were reviewed for evidence of bony fusion, instability of the subaxial spine, sagittal alignment of the cervical spine, neurological improvement and complications. Results: The average follow up was 105 months (range 44–148). All 13 patients achieved solid fusion at ﬁnal follow up. 12 (92%) achieved fusion by 6 months after the index procedure. The remaining patient developed a symptomatic pseudarthrosis, which had to be revised. Four patients had minor complications including halo pin site infections and a pressure sore under the halo body jacket. Three patients (23%) developed symptomatic subaxial instability below a successful fusion and had to have the fusion extended. The average time to revision surgery was 64 months (range 43–113) Of 5 patients with preoperative neurological involvement, 4 (80%) experienced improvement. The sagittal alignment of the cervical spine was lordotic in 8 (69%), neutral in 3 (23%) and kyphotic in 1 patient respectively.

S41 Conclusions: Upper cervical arthrodesis is a safe and effective procedure in children with Morquio’s disease to arrest upper cervical instability and neurological deterioration. Long-term follow up is recommended for early detection and management of late subaxial instability after successful upper cervical fusion in this patient population. Signiﬁcance: Upper cervical arthrodesis is a safe and effective procedure in children with Morquio’s disease, and patients should be followed long-term for subaxial instability after successful upper cervical fusion. 77 Limited Atlantooccipital and Cervical Range of Motion in Patients with Familial Dysautonomia Author: David Feldman (United States) Co-Authors: Eric Henderson (United States), Mark Schweitzer (United States), Felicia Axelrod (United States) Purpose: Familial Dysautonomia (FD) is a neurological disease seen in Ashkenazic Jews. Severe kyphoscoliosis occurs in 85–90% of FD patients. Surgical scoliosis correction is often followed by proximal junctional kyphosis; proximal end screw pullout is not uncommon. These patients appear to have limited cervical ﬂexion, which may facilitate their junctional kyphosis. A retrospective radiographic study of cervical spine ﬂexion-extension in FD patients was undertaken to verify this clinical ﬁnding and investigate a causal relationship between deﬁcient ﬂexion and instrumentation failure. Methods: Active cervical ﬂexion and extension lateral radiographs of ﬁfteen pediatric FD patients were measured. Intervertebral ﬂexion-extension was measured. Measurements of the FD population were compared to normal values available in the literature. Results: Flexion-extension in the FD patients was signiﬁcantly lower than the control population at all intervertebral levels except C1–C2. Atlantooccipital motion was reduced more than at other interspaces. Similar motion was seen in the FD and control populations at the remaining interspaces, however, motion in the FD patients at all levels was considerably less than in published, age-matched normal values. Conclusions: Decreased cervical ﬂexion, particularly at occiput-C1, is a common ﬁnding in patients with FD. Proximal junctional thoracic kyphosis following scoliosis surgery may be compensation for ﬁxed upward gaze secondary to deﬁcient ﬂexion of the cervical spine. Bone quality is often low in FD patients and risk of proximal instrumentation failure is increased if the thoracic spine is corrected beyond a point of possible compensation. These ﬁndings warrant consideration in planning scoliosis surgery for FD patients. Signiﬁcance: The signiﬁcantly decreased cervical ﬂexion that was found in patients with Familial Dysautonomia may contribute to the development of proximal junctional thoracic kyphosis after scoliosis surgery. 78 The Role of Amicar in Same-Day Anterior and Posterior Spinal Fusion in Idiopathic Scoliosis Author: George H. Thompson (United States) Co-Authors: Ivan Florentino-Pineda (United States), Connie PoeKochert (United States), Douglas A Armstrong (United States) Purpose: A retrospective study of the effectiveness of Amicar in decreasing perioperative blood loss and the need for transfusion in

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same-day anterior (ASF) and posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) in idiopathic scoliosis. Methods: Amicar is administered at 100 mg/kg over 15 minutes not to exceed 5 grams at induction of anesthesia. Maintenance is 10 mg/kg until wound closure. There were three study groups: Group 1, (n = 15), no Amicar; Group 2, (n = 27), Amicar for PSF only; and Group 3, (n = 16), Amicar for both ASF and PSF. Results: The total perioperative blood loss (estimated intraoperative blood loss for the ASF and PSF, measured suction and chest tube drainage) and the transfusion requirements (autologous and bank blood) were: Group 1, 3807 +/– 105 ml and 3.1 +/–1.5 units; Group 2, 2080 +/–659 ml and 1.9 +/– 0.9 units; and Group 3, 2183 +/– 851 ml and 1.0 +/– 0.8 units. Conclusions: Amicar is effective in decreasing perioperative blood loss and transfusion in same-day ASF, PSF with SSI in idiopathic scolosis. It is most effective in decreasing intraoperative PSF blood loss and chest tube drainage. It had little effect on ASF blood loss since it was relatively low in all three groups. Signiﬁcance: The use of Amicar results in less preoperative autologous blood donation, blood transfusions, lowers costs, and reduces the potential for transfusion related complications. 79 What is the role of the autonomic nerve system in etiology of idiopathic scoliosis? – A prospective electronmicroscopic and morphometric study. Author: Martin Repko (Czech Republic) Co-Authors: Drahomı´ r Horky´ (Czech Republic), Martin Krbec (Czech Republic), Richard Chaloupka (Czech Republic), Irena Lauschova´ (Czech Republic) Purpose: Prevalent scoliotic deformities have been classiﬁed as an idiopathic one. The real etiology is still unknown. Trunk and rib cage developmental asymmetry seems like one of possible etiology of the adolescent idiopathic scoliosis (AIS). This deformities can be induce by asymmetrical intercostal vascular nutrition due to changes in autonomic nerve system (ANS). The changes in sympathetic ANS seems like one of the possible cause of AIS. Some studies have shown that the left breast of girls with right convex thoracic AIS is signiﬁcantly more vascular than the right one. This expression can produce an asymmetry of the breast and consequently it can leads the origin of the spinal deformity. The main purpose of this study is to search the possible causation of AIS in development changes of the ANS. In our prospective study we have been followed up the changes in autonomic nerve structure, as well as discrepances between concavity and convexity of the scoliotic curve. Methods: We evaluated 9 patients with diagnosis idiopathic scoliotic deformities and control set of 3 patients without scoliotic deformity between period March-November 2005. We took the samples of peripherial autonomic nerves from convexity and concavity of the scoliotic deformity during the surgical correction of them using the transthoracal approach. We examined the samples by using the electronmicroscopic method. Then we used the morphometric statistical evaluation in comparison with control samples which has been taken during the surgical tretament of non-scoliotic patients. Results: 1. 2.

scoliotic convexity: 23,71% of myelinised nerve ﬁbres (MNF), 12,21% of unmyelinised nerve ﬁbres (UNF) and 5,0% of Schwanns´ cells (SC) by morphometric measurements. scoliotic concavity: 17,36% of MNF, 5,82% of UNF and 5,27% of SC.

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There were the main morphological abnormalities expressed as degenerated nerve ﬁbres with massive lesion and separation of the myelin vagina. Also the vacualization of the Schwanns´ cells cytoplasma and condensation of the cytoblast are abnormal. 3.

control non-scoliotic samples: 29,9% of MNF, 19,9% of UNF and 16,7% of SC.

Conclusions: There were statistically signiﬁcant diferences between both sides of scoliotic deformity (convexity and concavity), as well as discrepancies between scoliotic samples and non-scoliotic control samples. Signiﬁcant morphologic changes were in all scoliotic samples mostly in myelin vaginas with abnormalities and compression of the axon ﬁbre. All these changes had been not found in control set of patients without scoliotic deformities. Signiﬁcance: This ﬁndings can help us in search of the scoliotic etiology. The abnormalities in the myelinated ﬁbers may be origin by the primary genetic lesion and in this way they can inﬂuence the development of scoliosis.

80 Pedicle Screw Versus Hook Versus Hybrid Instrumentation in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis – a Minimum 2 Year Follow Up Comparative Study Author: Battugs Borkhuu (United States) Co-Authors: Aaron Littleton (United States), Mohan Belthur (United States), Dan Mason (United States), Peter Gabos (United States), Suken Shah (United States) Purpose: The purpose of this study was to comprehensively compare the 2-year postoperative results of posterior correction and fusion with segmental pedicle screw instrumentation versus those with hook and hybrid constructs in adolescent idiopathic scoliosis (AIS) treated at a single institution. Methods: A total of 105 patients with AIS at a single institution who underwent a posterior spinal fusion with segmental pedicle screw (35), hook (35) or hybrid (35) instrumentation were sorted and matched according to the following criteria: similar age at surgery, identical Lenke curve types, curve magnitude and Risser grade. Patients were evaluated before, immediately after, and at 2years post surgery for radiographic parameters, complications, and outcome. Results: The preoperative Cobb angle of the major curve in the screw (58.1%), hybrid (55.4%), and hook (55.6%) groups were comparable (F = 1.49, p = 0.23). The groups also showed no statistical difference in age (F = 0.54, p = 0.58) or number of levels fused (F = 0.58, p = 0.56). The correction rate of the major curve was signiﬁcantly better in the screw (78.5) and hybrid (70.0) groups as compared to the hook group (56.8) (F = 16.9, p = 0.00). Repeated measures ANOVA showed that technique had a signiﬁcant effect on Cobb angle over time (F = 8.27, p = 0.00). There was no loss of sagittal plane alignment or kyphosis in either the thoracic spine over time in any of the groups. Lumbar lordosis was well preserved. All screw constructs provided signiﬁcantly more correction of the compensatory curve compared to the hook group (F = 3.99, p = 0.022). Better apical vertebral translation was achieved in the screw group as compared to the hook group (p = 0.00). Better horizontalization of the last instrumented vertebra was achieved in the screw group as compared to the hybrid and hook groups (F = 8.42, p = 0.00). There were no neurologic or visceral complications in any group. Hook dislodgement was seen in 2 patients in the hook group by 2-year follow up; both patients had loss of correction, needing revision surgery. SRS-22 outcomes scores were similar for all groups.

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Conclusions: Pedicle screw instrumentation for AIS offers signiﬁcantly better major and compensatory curve correction, apical vertebral translation and horizontalization of the lowest instrumented vertebra without an increased complication rate over hook and/or hybrid spinal instrumentation. SRS-22 outcomes were similar for all groups. Signiﬁcance: Pedicle screw instrumentation for AIS offers signiﬁcantly better major and compensatory curve correction, AVT and horizontalization of the LIV over hook and/or hybrid spinal instrumentation.

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Co-Authors: Michael Fishkin (Israel), Orna Filo (Israel), Adi Shechtman (Israel), Shlomo Wientroub (Israel)

Use of the vertical expandable prosthetic rib for management of spinal deformity in non-ambulator spina biﬁda patients Author: John M. Flynn (Puerto Rico) Co-Authors: Norman Ramirez-LLuch (Puerto Rico), Robert Campbell (United States), John Smith (United States), Randal Betz (United States) Purpose: The purpose of this report is to evaluate the patients with myelodysplasia and spinal deformity treated with the Vertical Expandable Prosthetic Titanium Rib (VEPTR) and included in the FDA Request For Approval Of Humanitarian Device Exemption For the Synthes Vertical Expandable Prosthetic Titanium Rib Indicated For The Treatment Of Thoracic Insufﬁciency In Children. Methods: The FDA report includes 247 patients with surgeries performed at 8 centers. Twenty patients were myelodysplastic none ambulatory. Six patients had less than 4 months follow up and were excluded from this report. Data from the remaining 14 patients was extracted from the FDA report and analyzed. Results: The average age at the time of the ﬁrst surgery was 5 years (range 1 – 14 yrs). The average time of follow up was 47.3 months (range 5.0 to 106.4 mo). The main indication for surgery was a hypoplastic thorax in three children, rib fusion in 7 patients, progressive scoliosis in 5 patients and ﬂail chest in 1 patient. In nine patients the Cobb angle was decreased an average of 14.4 degrees; in ﬁve patients the Cobb angle increased an average of 12.6 degrees. Thoracic spinal height was increased in twelve patients an average of 3.2 cm. and there was a loss spinal height in two patients an average of 0.8 cm. Twelve patients improved in ventilator function. Two patients did not improve ventilatory function: one went from supplemental oxygen preop to part time use of ventilator and the other went from room air to night time use of ventilator. Implant lengthening was done on the average of every sixth months and device exchange every 30 months. Complications in ﬁve patients were due to the severity of the decreased pulmonary capacity and not directly related to the surgery. Implant failure and skin breakdown occurred in six patients. During the study period two patients died from cardiopulmonary problems at 20 and 65 months post the initial surgery. Conclusions: The rate of complications reported in this group of patients lies within the range reported for spinal fusion using the posterior or combined anterior and posterior approaches. The number of surgical procedures increases due to the need for expanding the implants as the child grows. Signiﬁcance: The advantages of the VEPTR are: surgical incisions are away from the midline avoiding the scarred tissue from previous myelomeningocoele closure and avoiding a spine fusion allowing growth of the spinal column with improved space available for the lung.

WITHDRAWN

83 SpineScan-aided school screening signiﬁcantly improves positive predictive value in detecting idiopathic scoliosis Author: Dror Ovadia (Israel)

Purpose: School screening for scoliosis aims to prevent the need for surgery by detecting curve changes in children at an early stage, at which bracing may be effective in halting the progression of the deformity. American Academy of Orthopaedic Surgeons (AAOS) and Scoliosis Research Society (SRS) continue to support school screening, even though the effectiveness of the current techniques has not been established yet and a low positive predictive value (PPV) have been reported (Wong HK et al. Spine 2005;30:118–96, 40%;Karachalios T et al. Spine 1999;24:2318–24, 17%). The major criticism focuses on the cost-ineffectiveness of the process, as too many students are unjustiﬁably referred to specialists for radiographs/treatment. Moreover, examiner’s skills and experience are important factors in screening outcome. An ongoing, large-scale study of school screening is conducted to assess the reliability of a new, hand-held computerized device (SpineScan) that was designed to measure the ‘‘angle of trunk inclination’’ (ATI), and is less dependent on examiner’s level of medical training. Methods: In a ﬁrst phase of the study, 375 children (195 boys,180 girls) aged 12 to 14 years were screened. Each child underwent ‘‘blinded’’ examinations by two examiners with different skills (a pediatric orthopaedic surgeon and a physiotherapist), each of whom using a different tool (a scoliometer and SpineScan, respectively). Screening was performed in examination positions speciﬁc for true scoliosis (standing and sitting forward bending) and ATI measurements were compared. Children with an ATI = /> 7 measured with either tool at both positions were referred to undergo a standard full spine X-ray in standing position, on which an experienced pediatric orthopaedic surgeon measured the Cobb angles. Curves =/>10 were considered true positive ﬁndings for scoliosis. Statistical analysis included speciﬁcity, sensitivity and predictive value estimates of both methods. Comparison of proportions of false positives and false negatives between the methods was carried out using the Exact Binomial test. Results: Referral rate for scoliometer was 3.7% and for SpineScan 3.5%. We assumed that all the children who were not referred to radiological evaluation were true negatives. Although the speciﬁcity values of both methods were almost similar (99.2% with 95% CI [98.2–99.9%] and 99.7% with 95% CI [97.4–99.8%], respectively), SpineScan achieved a signiﬁcantly higher PPV (91%), compared to that of the scoliometer (73%). Conclusions: The high PPV and speciﬁcity value achieved using SpineScan in the preliminary phase of the study show that the new device can be considered a reliable tool. Over-referral and low PPV, which have been reported in the available screening protocols, were absent. Signiﬁcance: The new method can signiﬁcantly improve positive predictive value of results of school screening for idiopathic scoliosis.

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Session 12a: Limb reconstruction 84 Morphological changes in dorsal root ganglia and spinal cord after limb-lengthening Author: Gyorgy Szoke (Hungary) Co-Authors: Sandor Kiss (Hungary), Zita Puskar (Hungary), Tamas Shisha (Hungary), Karoly Pap (Hungary) Purpose: Nerve injury is one of the most serious complications of the limb lengthening. As a result, pain, sensory loss and motor weakness are the most frequent symptoms in patients who had this type of operation. Despite of the fact that this is a common practice, the precise etiology of nerve injury is still unknown. In this study, we examined the morphological and neurochemical changes in the dorsal root ganglia and spinal cord segments associated with the limb lengthening in rabbits. Methods: Three groups of rabbits were operated and different lengthening protocols were used. In group A (5 rabbits) the surgery was followed by 7 days compression. 1 mm distraction once a day was applied for 20 days, to achieve 120% length in comparison of the contralateral leg. In group B (5 rabbits) the lengthening was started after 7 days compression (three times 1 mm per day for 10 days, to achieve 130% length in comparison of the contralateral leg). Group C was the control containing only untreated animals. Using immunohistochemistry and confocal image analysis, the portion of the Substance P (SP) immunreactive neurons was determined in dorsal root ganglia (DRG) and the changes in SP immunoreactivity were detected in the spinal cord. The Datas was analysed with the help of logistical regression analysis. Results: In group A and B, huge vacuoles appeared in large ganglion cells in the ipsilateral side of the operation. The morphological appearance of the vacuoles was very similar to those existing after nerve transsection in rats. However, the number of the SP immunoreactive cells in the DRGs decreased (by 10%), while the total number of DRG neurons was not changed. SP, CGRP and IB4 immunoreactivity also decreased in the operated side of the spinal cord. Conclusions: Our results suggest that vacuolisation and changes in peptide expression in DRGs and in the spinal cord could result in different pain symptoms in patients during limb lengthening. Signiﬁcance: This animal model could be an important step to understand the pain, sensory loss and motor weakness during limb lengthening. 85 Unexpected Absence of Effect of rh-BMP-7 (OP-1) on Distraction Osteogenesis Author: Frederic Sailhan (France) Co-Authors: Franck Chotel (France), Roger Parrot (France), Eric Viguier (France), Aygulph Chousta (French Guiana), Jerome Berard (France) Purpose: We asked whether locally applied rh-BMP-7 with a Type I collagen carrier could enhance the consolidation phase in distraction osteogenesis. Methods: We performed unilateral transverse osteotomy of the tibia in 28 immature male rabbits. In 1/2 of the animals (14 rabbits), 70 lg of rh-BMP-7 (28.5 mg of rh-BMP-7/CC, OP-1) was locally applied on the day of osteotomy; the control group (14

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Oral presentations: Abstracts 1–123/J Child Orthop rabbits) had no local application. After 7 days, 3-weeks of distraction was begun at a rate of 0.5 mm/12 hours. Starting Week 2 of distraction, we assessed radiographic, ultrasonographic, and densitometric parameters once per week. Animals were sacriﬁced after 3 weeks of distraction, and after 1, 2, and 3 weeks of further consolidation. Histologic analysis was performed after sacriﬁce of the animal and harvensting of the callus. Results: Radiographic evaluation revealed a tendency for increased bony union and bone differentiation in the control group compared with the rh-BMP-7/CC group. The bone mineral content was higher in the control group at each time point. Ultrasonographic evaluation revealed the development of a cyst within the regenerate in 92% of the animals in the rh-BMP-7/CC group versus 0% in the control group. Ultrasonography and histomorphometry showed delayed regenerate development in the rhBMP-7/CC group. Conclusions: Rh-BMP-7 with collagen carrier did not enhance consolidation in this rabbit model of tibia lengthening. We suggest the poor results related to the relatively large bulk of the solid carrier of the OP-1 that might have acted as a mechanical obstacle. Signiﬁcance: A single local application of 70 lg (30 lg/kg) solid rhBMP-7/CC (OP-1) before distraction delayed the consolidation of the callus. We suggest the cyst developed in the regenerates of the treated animals because of the solid consistency of the BMP. Solid BMPs should probably not be used as interposition material in a distraction osteogenesis procedure. 86 Effect of Local Growth Factors on Muscle Regeneration in Distraction Osteogenesis Author: Hyun Dae Shin (Korea, Republic of) Co-Authors: Kwang-Jin Rhee (Korea, Republic of), Ho-Seop Song (Korea, Republic of) Purpose: Our aim was to assess the distraction rate-related effect of the growth factor on muscle regeneration after bone distraction. Methods: We measured the effects of distraction on the tibialis anterior and soleus of rats. We used IGF-•, PDGF, and bFGF development for markers. 6 month-old Sprague-Dawley rats were used. The right tibia was distracted, contralateral limbs were control. We divided two group into six 0.35 mm/24 h(2 times) and six 0.7 mm/24 h(2 times) distraction rate. Results: In tibalis anterior, IGF-• expression at lengthening site compared with nonlengthening site signiﬁcantly increased (p < 0.001), at group that lengthening rate was 0.7 mm/day compared 0.35 mm/day group signiﬁcant decreased (p < 0.01), but in soleus muscle, there was no signiﬁcant change (p > 0.05). PDGF expression in tibialis anterior although in lengthening 0.7 mm/day group compared 0.35 mm/day group increased but not statistically change (p = 0.145). In soleus, lengthening 0.7 mm/day group compared 0.35 mm/day group decreased, but not signiﬁcant change (p > 0.05). Conclusions: Bone distraction promotes growth factor release, but the growth factor release in mature muscle is decreased dependent on distraction rate. The bFGF is not related myoblast cell proliferation and differentiation and The faster distraction of the muscle growth dose not adapt to muscle lengthening. Signiﬁcance: The growth factor release in mature muscle is decreased dependent on distraction rate. So We can reduce the complication during distraction osteogenesis with local growth factor.

Oral presentations: Abstracts 1–123/J Child Orthop 87 Staged lenghtening in preventing deformities and correcting achondroplasic children. 25 years experience Author: Giovanni Peretti (Italy) Co-Authors: Antonio Memeo (Italy), Fabio Verdoni (Italy), Omar De Bartolomeo (Italy), Walter Albisetti (Italy) Purpose: The Authors review their 25 years long experience in correcting the achondroplasic dwarves. We already presented in 1994 our preliminary report of staged lengthening in the prevention of dwarﬁsm in achondroplasic children. The aim of the operation is not only to increase the height of the patients, but also to correct limb deviations, to ameliorate their function and to transform a disharmonic in an harmonic individual. Our method consists in performing the lengthening in different stages (two operations on the tibiae and two operations on the femurs; up to 1996 we lengthen also humeruses. Methods: With our method we treated 97 patients, 53 males and 44 females, lengthening a total of 572 segments. The operation by means of metaphyseal corticotomy and, in few cases, by means of epiphyseal distraction and applying a circular ﬁxation for tibia and an axial one for femur and humerus; only in 4 femurs we used the intramedullary lengthening nail. The distraction was carried out at a rate of 0.5 mm every 12 hours, after an average waiting period of 4 days. Results: Among our patients 19 of have completed the staged program obtaining an average lengthening of 31,5 cm (range 28 to 36) and 13 underwent also the lengthening of upper limbs. Complications are very frequent during and at the end of lengthening and have been examined in this paper; the patient and his family implication is very important, but all patient are satisﬁed of the result and are glad to have spent a so long time to obtain a result. Conclusions: The lengthening in dwarﬁsm has become a standardised procedure with good prognosis, however there is a certain risk and many complications. Signiﬁcance: With new lengthening devices we believe now to can reduce complication and to make easer the operations.

88 Bone lengthening in symmetric pathological short stature: long term follow up. Author: German Garcia-Llaver (Argentina) Co-Authors: Eduardo Stefano (Argentina), Gabriela Martinez (Argentina), Nestor Vallejos-Meana (Argentina) Purpose: The purpose of this study is to perform a therapeutic protocol of lengthening for patients with symmetric pathological short stature. Methods: We review the long term functional and cosmetic results of 260 bone lengthenings in symmetric short stature between 1987 and 2003. There were 81 patients included in the study with a mean of 3.2 lengthening per patient. The etiology of the deformity included 35 achondroplasias, 19 hypocondroplasias, 8 rickets, 7 Turner syndrome, 5 pseudoachondroplasias, 3 multiple epiphyseal dysplasia and 4 non-classiﬁed dysplasias. Results: The operated on bone include 116 femurs, 132 tibias and 12 humerus. The average age at the time of frame application was 10.2 years old. The mean follow up was 10.8 years. The functional and cosmetic results were analyzed using a satisfaction scale, a radiographic assessment and a clinical test one year and 3 years

S45 after frame removal. We found that 100% of the patients fell better after the lengthening, the average length gained per segment was 8.2 cm, and the bone healing index was in average 32. 2 days/ cm. There also was a proof improvement in the activities of daily life. Conclusions: In developing countries severe short stature is not only a cosmetic problem, these patients have multiples impediments to perform regular activities of the daily life that’s why we recommend to lengthen patients with ﬁnal predicted height of 130 centimeters or less. Signiﬁcance: After more than 250 lengthening in patients with pathological short stature we perform a therapeutic protocol of lengthening depending on the ﬁnal predicted height that consist in 1 or 2 bilateral tibia and successive bilateral femur lengthening, and sometimes 1 bilateral humerus lengthening at the end of the lower limbs lengthening.

89 Development of Genu Varum in Achondroplasia: Its relation to Fibular overgrowth Author: Hae-Ryong Song (Korea, Democratic People’s Republic of) Co-Authors: Seok-Hyun Lee, Jae-Hyuk Yang, Sameer Desai, Gautam Shetty, Harry Matta Purpose: Development of genu varum in achondroplasia has very complex and multifactorial origin with little mention in literature about the role of ﬁbular over growth. The purpose was to observe the contribution of ﬁbular length to tibial length (F:T) ratio, a measure of ﬁbular overgrowth, to the development of genu varum. Methods: Standing full length AP radiographs of 53 patients of achondroplasia were analyzed. 30 patients were skeletally immature and 23 were skeletally mature. Fibular length, and tibial length was measured and their ratio (F:T ratio) was used as measure of ﬁbular overgrowth. Regression analysis was done to ﬁnd out the causal relation between the ﬁbular overgrowth on the various indices of lower extremity alignment. Results: Analysis showed that FT ratio had signiﬁcant effect on medial proximal tibial angle and mechanical axial deviation in skeletally immature group. Conclusions: We thus conclude that, ﬁbular overgrowth is significantly related to the development of genu varum in achondroplasia in the skeletally immature age group. Signiﬁcance: Fibula Overgrown contributes signiﬁcantly to development of gunu varum in achondroplasia and hence early prevention of overgrowth of ﬁbula will probably prevent the development of deformity.

90 Massive bone lengthening in short stature patients Author: Dalia Sepu´lveda (Chile) Co-author: Juan Carlos Herna´ndez Bueno (Chile); Sepu´lveda Matı´ as (Chile) A retrospective study was performed in 21 patients undergoing massive long bones lengthening, between January 1994 to December 2006 at the Reconstruction Surgery Unit of the Roberto del Rio Hospital and University of Chile in Santiago, Chile.

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S46 The series is conformed by 21 patients; 2 of whom were not available for study, 8 out of 21 are female (42%) and 11 are males (58%), mean age at the ﬁrst surgery was 10 years and 8 months old, (range 7 to 16), the initial mean height was 105 cm (range 85 to 125 cm) and the mean projected height at maturity before lengthening was 127 cm. Mean follow up 63,3 months. The achondroplasia group, representing the biggest one, is composed by 11 patients (57, 9%); 3 other patients had constitutional short stature (15, 8%) and 3 had other skeletal dysplasias; 1 has a Turner Syndrome (5, 25%) and 1 had an unclassiﬁed etiology. 72 bone segments wee lengthened : 12 femur (17%), 44 tibias (61%), and 16 humerous (22%).;16 patients undergone conventional bone lengthening technique with unilateral external ﬁxators, (54 segments, 75% of the surgeries).; 5 patients, 14 bone segments (20%) were converted to a blocked endomedulary nail once the lengthening was ﬁnished; only in 2 patients, 4 bone segments (6%) the bone lengthening technique was done over an endomedulary nail since the beginning of the procedure. All the devices were monolateral external ﬁxators. Evaluation in this study includes statistical demographic results in extensor but overall we emphasize: bone segments lengthened, time in frame and consolidation index to meet the goal, complications during lengthening and the patients and doctors’ satisfaction.

91 Functional outcome after 8 years follow up following the treatment of Congenital Pseudarthrosis of the Tibia By Ilizarov Technique Author: Hani Mohamed Elmowaﬁ (Egypt) Co-Authors: Barakat Elalfy (Egypt), Mohamed Refai (Afghanistan) Purpose: Congenital pseudarthrosis of the tibia remains one of the most controversial pediatric entities in treatment and prognosis. In this study, we reported our results in the treatment of congenital pseudarthrosis of the tibia by Ilizarov technique. Methods: Twenty legs in 20 patients (15 boys and 5 girls) with CPT were treated in the Orthopaedic Department, Mansoura University Hospital, Mansoura, Egypt from 1997 to 2005 (Table I). The average age at time of Ilizarov application was 6.8 years old (range 4 to 15 years). Patients were classiﬁed as Crawford’s classiﬁcation into 9 patients type II and 11 patients type IV. 15 patients underwent excision of the affected part of the tibia. Excision of the affected part of both tibia and ﬁbula was achieved in 5 patients (3 type IV and 2 Type II). Type IV patients as Crawford’s classiﬁcation was treated with excision of affected part of the tibia and acute shorting with insertion of the distal part of the tibia into the proximal part of the tibia by the mouth ﬁsh technique. Out of 11 patients type IV 3 cases treated with mouth ﬁsh technique and periosteum graft and 2 cases treated with the same technique with excision the affected part of the ﬁbula. 9 cases with type II treated with excision of the affected part of the tibia, 2 of them treated with excision of the affected part of both tibia and ﬁbula. If the defect after excision was less than 4 cm, acute shortening was followed by bone lengthening (5 patients). In 4 patients the gap was more than 4 cm (6 cm and 10 cm), and bone transport was preferred. Results: The mean duration of follow up period was 4.2 years. Bony union at pseudarthrosis site of the tibia was achieved in all patients. Leg length discrepancy was occurred in 3 patients, refracture in 2 patients. Genu valgus deformity and foot valgus deformity was occurred in 14 patients. The deformity was developed with patients treated with excision of the affected

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Oral presentations: Abstracts 1–123/J Child Orthop part of the tibia only. All patients with deformity underwent correction. Conclusions: The Ilizarov method has been shown to be effective in achieving union at pseudarthrosis site, correcting any associated angular deformity and lengthing of the tibia if the affected part of both tibia and ﬁbula is excised. Signiﬁcance: The Ilizarov method has been shown to be effective in achieving union at pseudarthrosis site, correcting any associated angular deformity and lengthing of the tibia if the affected part of both tibia and ﬁbula is excised. 92 Lengthening Reconstruction Surgery for Treatment of Fibular Hemimelia Author: Dror Paley (United States) Co-Authors: Said Saghieh (Lebanon), Baek Song (Korea, Republic of), M Young (United States), John Herzenberg (United States) Purpose: Fibular hemimelia presents a problem with limb length discrepancy and equinovalgus foot deformity. Our protocol simultaneously treats both problems, with the goals of equalizing limb length and achieving a plantigrade, painless, functional foot. Methods: Seventy-eight patients with ﬁbular hemimelia underwent 92 lengthenings and foot deformity correction. Equinovalgus foot deformity was corrected by four different methods in 67 cases: distraction, soft tissue release, release plus supramalleolar and/or subtalar osteotomy, and ﬁbular transport. Results: Goals of lengthening and foot deformity correction were achieved in all cases. Foot deformity recurred in 19 patients and was retreated. Foot deformity recurrence occurred in nine (56%) of 16 distraction cases, four (22%) of 18 soft tissue release cases, two (7%) of 28 release plus osteotomy cases, and four (80%) of ﬁve ﬁbular transport cases. Genu valgum developed in many cases with no or partial anlage resection. Genu valgum did not develop in any cases with complete anlage resection. Final results based on functional and radiographic evaluation: 46 excellent, 28 good, and 18 fair. Final result did not correlate with number of rays in foot. Conclusions: Limb length discrepancy and foot deformity can be successfully treated by simultaneous lengthening and foot deformity correction. Soft tissue release plus osteotomy and complete anlage resection yielded best results. Signiﬁcance: Lengthening reconstruction surgery is an excellent alternative to ablative surgery and prosthetic ﬁtting for patients with all severities of ﬁbular hemimelia. 93 The Metaphyseal Arc System to Correct Epiphyseal, Physeal and Metaphyseal Deformities– 5 year Experience. Author: Alfred D Grant (United States) Co-Authors: Purpose: The Metaphyseal Arc System has been in use for approximately 5 years to treat deformities in the proximal tibia, the distal femur and the distal tibia/ﬁbula. There have been 56 cases at our hospital of which all have been reviewed through to the end of correction. Of these 47 were proximal tibia varus corrections, 7 were ankle valgus deformities and two were distal femoral recurvatum deformities (sagital plane deformities). There were 43 cases of proximal tibial deformity properly corrected. The failures were due to not ﬁnding the plane of deformity (3 cases), over correction (1 case) and under correction because of improper

Oral presentations: Abstracts 1–123/J Child Orthop mounting of the device (1 case). One of the ankle cases was under corrected, leaving the ankle in 10 degrees of valgus. Both distal femoral deformities, recurvatum were corrected. Problem of pin tract infections have been managed with frequent and/or long term use of antibiotics. One ﬁbula prematurely consolidated requiring re-osteotomy and separate correction with a small rail device. Mounting maneuvers have allowed one stage correction of procurvatum/recurvatum and rotation (which can also be corrected gradually with use of an attachable rotation arc).Additional cases have been able to beneﬁt from the miniaturization of the device such that it can be used for the younger and/or small dysplasia child. Recently the Multiaxial Correction system (M.A.C.) has been used for diaphyseal corrections. Methods: (Please refer to purpose ﬁeld) Results: (Please refer to purpose ﬁeld) Conclusions: (Please refer to purpose ﬁeld) Signiﬁcance: (Please refer to purpose ﬁeld)

Session 10b: Hip/Lower Extremity I 94 Current practice acute/unstable SUFE in the United Kingdom and the Netherlands Author: Melinda Witbreuk (Netherlands) Co-Authors: P Besselaar (Netherlands), Deborah Eastwood (United Kingdom) Purpose: Traditionally, a slip of the upper femoral epiphysis (SUFE) is classiﬁed into preslip, acute, acute-on-chronic and chronic phases. More recently a stable/ unstable classiﬁcation relating to weight-bearing ability has become more prognostic. The management of acute unstable SUFEs remains controversial as noted in a recent questionnaire sent to POSNA (Pediatric Orthopaedic Surgeons of North America) members. Agreement existed on method of patient evaluation, but discrepancies remained in classiﬁcation and ﬁxation methods. Our goal was to compare management strategies in two European countries with those identiﬁed by the POSNA survey. Methods: A questionnaire similar to the POSNA survey was sent to all members of the British Society of Children’s Orthopaedic Surgery (BSCOS) and the Werkgroep Kinder Orthopaedie (WKO). Only 33.1% (263 of 794) of POSNA members responded whereas our overall response rate was 65% (142 of 220). Results: Amongst responders, the mean duration of consultant practice was 12.9 years. 63% had >50% paediatric workload. Overall, 68 % use both acute/chronic and unstable/stable classiﬁcation methods but the use of both systems is signiﬁcantly more common in surgeons with a higher paediatric workload. All use Xrays in two planes; 30 % also use dynamic ﬂuoroscopy, CT, MRI and bone scans. 88% operated < 24 hours. 69% use a traction table. 88% perform percutaneous ﬁxation; 79% using a single screw. 66% never reposition the slip. Others reposition gently or accept an ‘accidental’ reposition prior ﬁxation. Only 29% decompress the capsule and 26% routinely pin the contralateral side. 33% always remove metal work. Conclusions: In all three countries, agreement exists on evaluation. The UK has signiﬁcantly better agreement on classiﬁcation and preoperative positioning. Interestingly, those with < 15 years experience tend to use percutaneous single screw ﬁxation techniques. The survey engendered discussion regarding the gentle repositioning of unstable slips and within what time this should occur. Signiﬁcance: Level 5?

S47 95 Analysis of the hip at risk in the slipped capital femoral epyphisis Author: Gilberto Waisberg (Brazil) Co-Authors: Claudio Santili (Brazil), Miguel Akkari (Brazil), Susana Braga (Brazil), Marcelo almeida (Brazil) Purpose: To investigate the patients with EEPF that were attended at the Department of Orthopedics of Santa Casa of Sa˜o Paulo and determine which were at risk for slip of the contralateral hip. Methods: From November 71 to January 98 the clinical charts of 736 patients with the diagnosis of Slipped Capital Femoral Epiphysis (S.C.F.E.) were analyzed. Due to the lack of clinical data 177 charts were excluded, leaving us with 559 charts, divided into four groups: Group A: 253 patients with unilateral disease, not presenting any signs or symptoms of the disease on the contralateral hip until the onset of skeletal maturity; Group B: 43 patients with unilateral disease that presented contralateral hip involvement during follow-up; Group C: 136 patients with bilateral disease at the time of diagnosis; Group D: 127 patients whose healthy proximal femurs were prophylactic pinned. A comparative analysis was performed between groups A (unilateral slip) and B (contralateral slip during follow up), in which various factors were analyzed: gender, side of disease, race, back ground, age at the time of diagnosis, age of contralateral slip, classiﬁcation of slip (acute, chronic and acute-on-chronic) and concomitant diseases. Results: We observed that factors such as age and gender were directly related to the development of bilateral disease. The other factors studied were not related to the late slip on the contralateral hip. Conclusions: The study suggests that younger patients (age bellow 14 for boys and 12 for girls) at the time of diagnosis are at higher risk, and could be beneﬁted from bilateral pinning. Signiﬁcance: level III. 96 New Trans-trochanteric corrective osteotomy for SCFE based on 3DCT Author: Toshio Kitano (Japan) Co-Authors: Keisuke Nakagawa (Japan), Yuuki Imai (Japan), Kosuke Sasaki (Japan), Takaaki Kuroda (Japan), Mitsuaki Morita (Japan), Kunio Takaoka (Japan) Purpose: To perform the precise and safe correction of the deformed femoral head after Slipped Capital Femoral Epiphysis (SCFE), we introduced new osteotomy based on three-dimensional (3-D) computerized tomography (CT). Our new osteotomy is the trans-trochanteric oblique rotational osteotomy (TORO) on the axis of capital slip. Methods: The procedure of TORO consists of 3 steps. First of them is pre-operative planning. We introduced 3-D imaging software (Mimics9.11, Materialise, Leuven, Belgium) to ﬁnd the true axis of capital slip. Using the software, the axis of capital slip could be drawn on the 3-D proximal femoral images constructed from the CT data. We describe the circle which center is the axis of capital slip on the lateral image using the software. Second step is the transtrochanteric oblique rotational osteotomy on the axis of correction. Osteotomy was performed at the site of trochanter through the circumferential line which center is the axis of capital slip previously drawn on the lateral 3-D image using the apparatus specially made. Final step is ﬁxation using a plate specially made for this osteotomy or external ﬁxator. Slip angle (posterior slip angle) was measured on

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S48 the roentgenograph before and after the osteotomy. Post-operative complications were checked out on medical records. Results: Ten children with 11 affected hips were treated using our new osteotomy. The average age at surgery was 13.4 years (range, 11.0 to 16.5). The average slip angle before the osteotomy was 58.3°, and the average slip angle after the osteotomy was 26.1°. There were no complications after this operation. Conclusions: TORO could make the precise and safe correction for the deformed head after SCFE. Signiﬁcance: Our new femoral osteotomy on the axis of capital slip based on 3-D image could make the precise and safe correction for SCFE. 97 Avascular necrosis in acute and acute-on-chronic slipped capital femoral epiphysis. Author: Aamer Nisar (United Kingdom) Co-Authors: Amir Salama (United Kingdom), A G Davies (United Kingdom) Purpose: This study was carried out to assess various factors responsible for the development of avascular necrosis and the effect of treatment on clinical outcome. Methods: We studied the clinical notes and radiographs of patients presenting with SCFE during the period between 1994 and 2003. Results: Seventy three patients (n = 73) with ninety two (n = 92) hips were included in the study. There were 16 acute, 43 acute-onchronic, 29 chronic and 4 preslips. Seventy Seven (n = 77) slips were classiﬁed as stable and 15 as unstable slips. Fifty three slips (57.6%) were mild, 34 (37%) were moderate and ﬁve (5.4%) were severe slips. Despite no deliberate attempts to reduce the slip at the time of surgery eighteen hips (n = 18) showed a median decrease in slip angle of 8 degrees (range 2—36) in acute and acuteon-chronic slips. The mean preoperative slip angle was 32 degrees (range 9–76) compared to postoperative slip angle of 29.9 degrees (range 10–75) (p = 0.004). Four patients developed avascular necrosis (AVN). Intraoperative reduction of the slip was signiﬁcantly related to development of AVN (p < 0.001). According to the criteria of Heyman and Herndon eight patients had functional deﬁcit at the time of ﬁnal follow up and clinical outcome was fair, poor or failure. All of these patients had a reduction in the angle of slip at the postoperative radiographs compared to their preoperative radiographs. Conclusions: Reduction of slipped capital femoral epiphysis is responsible for poor outcome and also related to the development of avascular necrosis. We recommend single in situ pinning for these cases regardless of severity of slip. Signiﬁcance: Avascular necrosis is one of the most devastating consequences of slipped capital femoral epiphysis. In situ pinning of these patients prevents development of avascular necrosis and poor clinical outcome. 98 Preliminary Results of Cementless Total Hip Arthroplasty in Adolescents Author: Renata Suda (Austria) Co-Authors: Martin Pospischill (Austria), Christof Radler (Austria), Karl Knahr (Austria), Franz Grill (Austria) Purpose: Joint replacement for treatment of sequelae of pediatric hip disorders is a controversial subject due to the reported survival rates of total hip arthroplasty (THA) sytems and the expected

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Oral presentations: Abstracts 1–123/J Child Orthop revisions. The purpose of this study was to assess clinical and radiographic results of young patients who had undergone cementless THA. Methods: Between 1998 and 2005 28 primary cementless total hip arthroplasties in 26 patients with osteoarthritis secondary to childhood hip disorders were performed at our clinic. In all cases cementless THA systems (Alloclassic, Variall, Bicon) were used. Mean age of patients at operation was 19.7 (range 13–27). A retrospective review of the preoperative radiographs and the records was performed. Mean follow-up was 3.2 years (range 0.5–6.5). Clinical outcomes were evaluated using the Harris Hip Score (HHS) and the SF-36 questionnaire. Postoperative radiographs were analysed according to DeLee and Charnley for the cup. On the femoral side the zones described by Gruen et al. were used. Results: Mean HHS at last follow-up was 95.7 (100). Pain score was 43.1(46), function score was 52.6 (56). No early loosening and no implant fracture were found in these series. In one case (3.6 %) the reason for revision was progressive polyethylene wear. Cup exchange due to post-traumatic aseptic loosening was carried out in one hip (3.6 %). One patient (3.6 %) needed revision surgery because of a late deep infection. All of the 28 cups were considered stable, radiolucent lines around the cup were observed in 5 patients (17.9%). Conclusions: Cementless ﬁxation in THA is a reasonable technique in total hip replacement in adolescents. Especially in this group of active young patients progressive polyethylene wear is still a major problem. Improvement of quality of life can be achieved in most patients. Signiﬁcance: These early results may expect good long-term outcomes and suggest that cementless THA is a sufﬁcient solution in the treatment of osteoarthritis secondary to pediatric hip disorders.

99 Patient-reported outcomes ten years after hip arthrodesis Author: Andreas Roposch (United Kingdom) Co-Authors: John Wedge (Canada) Purpose: To determine the health-related quality of life of young adults who underwent hip arthrodesis in their teenage years. Speciﬁcally, we were interested in physical function and ipsilateral knee status. Methods: 10 patients (8 female) who underwent a hip arthrodesis (1987–2001) at a median age of 15 years (SD 2.98) were studied after a median follow-up of 10 years (SD 4.71). The SF-36 was used to determine health-related quality of life (higher scores represent better status). Scores were compared to normative population data (signed rank test). The WOMAC is a diseasespeciﬁc measure and was used to assess ipsilateral knee function. Its 3 subscales (possible scores) are: pain (0–20), stiffness (0–8), physical function (0–68), whereas lower scores represent better status. One-on-one interviews were performed using a standardized questionnaire to explore patient satisfaction. Results: Patient scored lower in all SF-36 subscales compared to normative data. Signiﬁcant differences were found in physical function (P = .001) and vitality (P = .0493) subscales with mean differences (95% CI) of –35.9 (–50.53, –21.26) and –12.9 (–24.55, –1.24), respectively. Mean differences (95% CI) in role functioning (P = .175) and pain (P = .132) subscales were –14.6 (–34.76, 5.6) and –13.2 (–29.51, 3.11), respectively. Mean WOMAC scores were 7.44 (pain); 2.11 (stiffness); 24.11 (physical function). For all patients, the most dissatisfying aspect of the procedure was physical limitation but 8 rated the limited

Oral presentations: Abstracts 1–123/J Child Orthop function as acceptable and would have the same procedure done again. 7 felt their quality of life improved since the operation. Conclusions: The results suggest that arthrodesis affects physical function but not role functioning. For patients who are willing to accept improvement of pain at the expanse of their daily physical activities, arthrodesis seems to be a good and predictable treatment option in end stage hip disease. Patients for whom physical functioning beyond role activities is important should not consider arthrodesis but explore alternative options. Signiﬁcance: Patients are coping well ten years after hip arthrodesis but at the expense of their activities.

100 Quadruple and periacetabular pelvic osteotomy using single approach. Technique and results in hip dysplasia and Perthes disease. Author: Roger Jawish (Lebanon) Co-Authors: Jacques Ghorayeb (Lebanon), Rami Khalife (Lebanon), Antoine Kahwaji (Lebanon) Purpose: We performed with a single anterior approach the periarticular pelvic osteotomy which is traditionally achieved with two different approaches. Our population included a group of young children with severe dysplasia, necessitating a high degree of reorientation where Salter’s osteotomy is classically indicated. In elder children a quadruple osteotomy of the ischium, pubis, ilium and ischial spine was performed to release the sacrospinal ligament and important displacement of the acetabulum was achieved. Methods: 30 osteotomies have been carried out on 26 patients. The mean age was 6.7 years, 10 patients were younger than ﬁve, with 6 years of follow up [range 2 to 13 years].The indications included acetabular dysplasia (15 cases) those aged under 5 years had important acetabular deﬁciency with lateral subluxation or dislocation after treated DDH, Perthes disease (14 cases) and one caput valgum. Results: Compared to preoperative clinical exam, the postoperative ﬂexion was decreased by 14, extension increased by 7, external rotation increased by 5, internal rotation decreased by 5. Radiographic assessment demonstrated an average angle of correction 20 for the acetabular angle of Sharp, 32 for the CEA, and 18 for the slope of sourcil. Conclusions: We concluded that lateral coverage must be achieved in a frontal plan, avoiding the ﬁgure-of-four maneuvers and displacement in a transverse plan. Despite the signiﬁcant reorientation of the acetabulum, we didn’t observe excessive external rotation. The quadruple osteotomy allowed important acetabular displacement in elder patients. The single approach avoided prone position and permitted a simpler postoperative management. Signiﬁcance: We performed the triple osteotomy in children under 5 years old, with severe dysplasia and important acetabular deﬁciency. We described a new technique of periacetabular osteotomy which has been performed in elder children necessitating important displacement of the acetabulum. 101 Pelvic osteotomy techniques and comparative effects on biomechanics of the hip Author: Rajan Maheshwari (United Kingdom) Co-Authors: Sanjeev Madan (United Kingdom)

S49 Purpose: Dysplasia of the hip in children, characterised by a shallow acetabulum and a deﬁcient coverage of the femoral head, generally causes altered biomechanics of the hip joint. A kinematic analysis on the individual and comparative spatial movement of the acetabulum with some of the pelvic osteotomy techniques is performed. The osteotomy providing greater correction in most of the parameters potentially leading to greater reduction in loading is the choice of the surgeon. Methods: Adult saw bone hip models have been used. Points of reference have been carefully chosen and data has been obtained using the Polhemus Electromagnetic measuring system before and after the osteotomy. Five techniques (Chiari, Salter, Steel, Tonnis and Ganz) have been performed, parameters like the Centre-edge angle, Sharp’s angle, Acetabular Head index (Femoral head cover), translation and rotation in 3 planes have been analysed. Results: Results show an improvement in most of the parameters when the above pelvic osteotomies are performed. CentreEdge angle improved by a mean (in degrees) of 7.4(Chiari), 9.6(Salter), 16.9(steel), 28.4(Tonnis) and 31.0(Ganz). There has been marked increase in Femoral head cover with mean 24% with Tonnis and Ganz. Signiﬁcant changes in rotational parameters in all 3 planes were achieved, particularly with Ganz and Tonnis techniques. Conclusions: Traditionally acetabular dysplasia correction has been assessed in one or two dimensions by plain radiographs and true three dimensional movement of the acetabulum is difﬁcult to assess with simple techniques. This study describes a simple and reproducible method to compare the various pelvic osteotomies and comparative effects these can produce on the kinematics of the hip joint. Signiﬁcance: It is intended to extend this study to include kinetics to compare the forces and stress distribution changes caused by performing the above techniques and a larger study is recommended, based on this technique and the initial trend of results shown.

102 Minimally invasive, iliac crest-sparing approach (ICSA) for pelvic osteotomies in children. Author: Ismat Ghanem (Lebanon) Co-Authors: Fernand Dagher (Lebanon), Khalil Kharrat (Lebanon) Purpose: to describe a new surgical approach to the sciatic notch, which allows enough exposure to perform common iliac osteotomies in children, while fulﬁlling the criteria of MI surgery. Methods: The ICSA was used for 65 hips in 54 patients who underwent a pelvic osteotomy (with or without open reduction of the femoral head) for various reasons. Age at surgery ranged from 1,7 to 8 years. Surgical technique: The distal part of a modiﬁed SP incision is used. The inter-spinal notch (between the anterior superior iliac spine and the anterior inferior iliac spine) is exposed subperiosteally, between tensor fascia lata and sartorius. The psoas tendon is divided. The sciatic notch is approached medially and laterally using a periosteal elevator, without splitting the iliac crest cartilage. Length of skin incision, difﬁculties encountered during exposure, bleeding, easiness and amount of distal fragment displacement following pelvic osteotomy, hazards of internal ﬁxation, duration of surgery, and severity of postoperative pain, were recorded for each patient. Acetabular index was measured preoperatively, immediately after surgery, and at a follow-up ranging from 6 to 40 months.

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S50 Results: Skin incision ranged from 3 to 5,5 cm. The two main difﬁculties encountered during surgery were: 1/ Limited view during exposure of the medial aspect of the sciatic notch, the surgical ﬁeld being obliterated by the surgeon’s hand. 2/ Passage of the Gigli saw from one side of the sciatic notch to the other. Exposure was easier in younger children. Bleeding did not exceed 50 ml except for one case (the second case of the series) of persistent bleeding from a perforating artery in the sciatic notch, which required shifting to a conventional SP approach. In all cases, displacement of distal fragment was easy and without tension. Duration of surgery varied from 50 minutes in the beginning of our experience to 20 to 25 minutes for the last cases of the series (in cases not including open reduction). Pain was difﬁcult to assess. Acetabular index improved from an average 41 preoperatively to 15 postoperatively and 16 at last followup. Conclusions: The ICS approach fulﬁlls the criteria of MI surgery. When compared to conventional SP, it includes smaller skin incisions, uses anatomical bloodless pathways, avoids injury to the iliac crest growth plate, and decreases surgical duration and morbidity, while insuring an optimal coverage of the femoral head. Some hints at every step of the procedure have been gained with experience. New instruments intended to further facilitate the procedure are designed and currently under fabrication. Signiﬁcance: It is possible to optimally perform common iliac osteotomies without splitting the iliac crest growth cartilage.

103 The spectrum of intra-articular ﬁndings of the symptomatic hip with MED/SED Author: Dennis Robert Roy (United States) Co-Authors: Purpose: The purpose of this study is to review the intra-articular ﬁndings of patients with either multiple epiphyseal (MED) or spondyloepiphyseal dysplasia (SED) who presented with a change in their baseline hip pain. Methods: The medical records, radiographic studies and operative reports were retrospectively reviewed of patients with MED/SED who presented with either a sudden onset of hip pain or a change in their baseline symptoms. The patients had impingement signs on physical exam. The intra-articular ﬁndings were identiﬁed at either open arthrotomy or by hip arthroscopy. Results: Five patients presented for evaluation of their pain. Three presented with sudden onset during daily activities, while two presented with progressive pain. One patient, age 4, underwent arthrotomy, while the remaining patients were treated arthroscopically. Two patients were found to have large chondral fractures and rupture of the ligamentum teres; one patient had a chondral ﬂap with a loose body, one patient had overly ballotable cartilage, and the ﬁnal patient had considerable thinning of femoral head and acetabulum cartilage associated with a large labral tear. Conclusions: Signiﬁcant intra-articular pathology can occur in patients with MED/SED during normal daily activities. Sudden onset of pain or a change in pain status should prompt rapid evaluation and treatment. Signiﬁcance: The pathological development of the chondralosseous junction of the hip in patients with skeletal dysplasias may lead to signiﬁcant intra-articular events which will contribute to the early deterioration of the joint.

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Session 11b: Hip/Lower extremity II 104 Eight-Plate for Temporary Hemiepiphysiodesis to Correct Angular Deformities Author: John Eric Herzenberg (United States) Co-Authors: Rolf Burghardt (Germany), Dror Paley (United States), Shawn Standard (United States) Purpose: The eight-Plate Guided Growth System allows surgeons to perform temporary hemiepiphysiodesis to correct malalignment. It is an alternative to the Blount staple and has potential improvements: less compression of the growth plate, decreased risk of breakage and extrusion, and a more precise implantation technique. The senior authors have implanted 50 eight-Plates to correct angular deformities of the lower extremities in 40 children from August 2004 to December 2005. We are reporting our results in the ﬁrst group of patients who have completed treatment. Methods: Eleven patients (17 eight-Plates) underwent treatment for angular deformities that were caused by a variety of conditions. Average age at hemiepiphysiodesis was 10 years 2 months (age range, 4 years 11 months–13 years 8 months). The device was inserted in the lateral distal femur (two cases), the medial distal femur (eight cases), the lateral proximal tibia (two cases), the medial proximal tibia (four cases), and the medial distal tibia (one case). Average time between insertion and removal of the eight-Plate was 10.2 months (range, 5–13 months). Results: Joint orientation angles and the mechanical axis satisfactorily improved in all patients except one who had a resected osteosarcoma and little potential growth remaining after resection. Mechanical lateral distal femoral angle changed an average of 9.1 degrees (range, 5–11 degrees), medial proximal tibial angle changed an average of 6 degrees (range, 0–10 degrees), and lateral distal tibial angle changed an average of 10 degrees. Mechanical axis improved an average of 29.8 mm (range, 0–55 mm). No hardware failures or other complications were observed. Conclusions: Performing hemiepiphysiodesis by using the eightPlate is a safe and effective treatment for improving angular deformities, even in children as young as 5 years. Signiﬁcance: The eight-Plate has the potential to extend the indication for hemiepiphyseal stapling to a younger age group. 105 Ceformity around the knee joint using hemiepiphyseal stapling in children with multiple epiphyseal dysplasia Author: Tae-Joon Cho (Korea, Republic of) Co-Authors: In Ho Choi (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Won Joon Yoo (Korea, Republic of), Kee Jung Bae (Korea, Republic of) Purpose: Multiple epiphyseal dysplasia (MED) is a genetic disease caused by mutations in cartilage matrix proteins such as type IX collagen, cartilage oligomeric matrix protein, and matrilin-3. Genu valgum or genu varum deformities are not uncommon in MED patients, and may contribute to development of precocious osteoarthritis as well as cause cosmetic and functional disturbance. Hemiepiphyseal stapling has been well established as a safe and effective method for angular deformity correction in growing children. The authors present clinical outcome of this method in MED patients. Methods: Nine children with multiple epiphyseal dysplasia, who underwent hemiepiphyseal stapling for angular deformity

Oral presentations: Abstracts 1–123/J Child Orthop correction around the knee joint from January 2000 to May 2006 and had staples removed after completion of angular deformity correction, were included in this study. They were ﬁve boys and 4 girls. Among the sixteen knee joints operated upon, thirteen knee joints had valgus deformity and three varus deformity. Hemiepiphyseal stapling was applied to twenty two physes - ﬁfteen distal femoral physes and seven proximal tibial physes. The mean age at the time of stapling was 11.5 years (range, 8 to 14). Two staples were inserted in 13 of 15 distal femoral physes and 4 of 7 proximal tibial physes. One staple was inserted in the rest of the physes. The patients were regularly followed after operation with standing teleradiograph of the lower limb. Angular deformity correction was monitored by measuring the anatomical lateral distal femoral angle (aLDFA), medial proximal tibial angle (MPTA), and the mechanical axis deviation (MAD). MAD was determined by the deviation of the mechanical axis from the center of the knee joint divided by half of the knee joint width, and described as %. Results: We didn’t encounter any staple-related complications. The mean duration up to removal of staples was 15.9 months and the mean follow-up after removal was 15.0 months. Mean aLDFA improved by 14.7 degrees, and mean MPTA by 8.4 degrees. The mean correction rate was 0.85 degree/ month at the distal femur, and was 0.67 degree/month at the proximal tibia. The MAD improved from preoperative 105.5% to 40.2% at the time of removal, and to 26.2% at the time of the latest follow-up. Thirteen of sixteen knee joints had mechanical axis deviation less than 50% at the time of last follow-up. Conclusions: Hemiepiphyseal stapling efﬁciently corrected the angular deformity at the knee joint in children with MED with minimal morbidity. Long term consequence until skeletal maturity needs to be investigated. Signiﬁcance: Hemiepiphyseal stapling is safe & effective for correction of the angular deformity at the knee joint in children with multiple epiphyseal dysplasia. 106 Lower Extremity Deformities in Morquio Syndrome: Natural History and Results of Surgical Correction Author: Mihir Thacker (United States) Co-Authors: Mohan Belthur (United States), Aaron Littleton (United States), Freeman Miller (United States), William Mackenzie (United States) Purpose: We undertook this study to deﬁne lower extremity deformities in Morquio syndrome and evaluate the their natural history as well as results of surgical treatment. Methods: This was a retrospective clinical and radiographic review of 16 patients with Morquio syndrome. Patient demographics were recorded. Lower extremity deformities were analyzed using standard radiographs and deformity parameters. Gait analysis was available for 8/16 patients. The details of surgical procedures were recorded and the clinical and radiographic outcomes determined. Results: There were 8 male and 8 female patients. The average age at presentation was 5 years and 9 months and at last follow up was 14 years and 4 months. Gait analysis demonstrated hip ﬂexion deformities as well as increased femoral anteversion with external tibial torsion. Natural History: All patients had valgus alignment of the lower extremities. There was progressive proximal and lateral migration of the hips with ﬂattening and eventual disappearance of the capital femoral epiphysis. Progressive genu valgum was seen with predominant proximal tibial valgus and joint laxity. Ankle valgus and forefoot adduction were common.

S51 Results of Surgery: There were a total of 41 surgical procedures in 16 patients. The average age at ﬁrst surgery was 8 + 10 for the hip and 10 years for the knee. Six patients underwent VDRO’s, 4 had a shelf acetabuloplasty and 1 had a Dega osteotomy. Recurrent hip subluxation was seen in all patients treated with proximal femoral realignment alone. The mean CE angle improved from –14.1 to 6.5 degrees at ﬁnal follow-up. The mean MPTA and tibio-femoral angles improved from 97 to 92 and 22 to 12 degrees respectively following realignment osteotomies or hemi-epiphyseal stapling in 12 patients. Ankle valgus correction was performed in 6 patients with 2 recurrences. One patient with a symptomatic planovalgus foot did well with a lateral column lenghtening. Conclusions: Lower extremity valgus in patients with Morquio Syndrome is multifocal. Pre-operative gait analysis was helpful in assessing the sagittal plane and rotational deformities. Early progressive hip subluxation needs to be addressed with both femoral as well as acetabular procedures. Recurrent hip and knee deformities were common and needed revision surgery. Foot deformities though common, are rarely symptomatic. Signiﬁcance: Early progressive hip subluxation was common. Genu valgum primarily resulted from proximal tibial valgus and joint laxity. Recurrent hip and knee deformities were common and needed revision surgery. 107 The ‘‘Four-in-One’’ Procedure for Habitual Patellar Dislocation in Children with Aplasia of the Femoral Trochlea and Generalized Ligamentous Laxity Author: Hyun Woo Kim (Korea, Republic of) Co-Authors: Sun Young Joo (Korea, Republic of), Hui Wan Park (Korea, Republic of) Purpose: To examine the clinical results of the ‘‘Four-in-One’’ procedure for habitual dislocation of the patella in children with generalized ligamentous laxity and aplasia of the femoral trochlea. Methods: 6 knees in ﬁve patients were included in the study. Down syndrome and William’s syndrome were the underlying disease in three patients, and all the patients had generalized ligamentous laxity(Beighton score greater than 7) and aplasia of the femoral trochlea. All the patients had the following procedure; lateral retinacular release, medial placation, semitendinosus tenodesis, and patellar tendon transfer. The average age of the patients at the time of operation was 5.5 years and the subjects were followed up to the average of 40 months postoperatively. Clinical results were evaluated using the criteria of Kujala’s scoring system as well as the physical examination and radiological ﬁndings. Results: During the follow-up period, there were no recurrent dislocations, knee joint pain, limitation of motion or gait disturbances in all cases. The mean Kujala score was 93.8. Two cases had complications related to wound healing, but they healed eventually. Conclusions: The ‘‘Four-in-One’’ procedure was effective in the prevention of recurrent patellar dislocation in patients with generalized ligamentous laxity and aplasia of th femoral trochlea. Signiﬁcance: The ‘‘Four-in-One’’ procedure is useful for habitual dislocation of the patella in children with generalized ligament laxity and formation failure of femoral trochlea. 108 Immediate treatment of congenital knee dislocation in neonates: personal experience in 32 cases Author: Nikolay Jurievich Rumyantsev (Russian Federation) Co-Authors:

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S52 Purpose: The purpose of the study is to show a different types of treatment programmes for neonates with congenital knee dislocation. Methods: Prenatal sonographic video-evaluation and X-rays at the birth were used. Treatment methods included permanent gentle manual manipulations (traction & ﬂexion), von Rosen splinting and cast correction. Results: The mean follow-up is 6 years (range from 1 to 17 years) We use ﬁve clinical and radiological criteria to evaluate the results. All results were good or excellent, and no surgical rocedures were necessary. Conclusions: The treatment of congenital knee dislocation should be started in the ﬁrst hours of life.We believe, that this condition could be a primarily reversible, but the possibility of correction diminishes drastically with every day of patient’s life. Signiﬁcance: The analysis of prenatal sonographic data shows, that this condition is formed between 12-th and 24-th weeks of gestation. 109 Correlation of gait analysis with computed tomography in rotational gait abnormality Author: Christof Radler (Austria) Co-Authors: Andreas Kranzl (Austria), Hans Manner (Switzerland), Michaela Hoeglinger (Austria), Rudolf Ganger (Austria), Franz Grill (Austria) Purpose: It has been proposed that rotational gait abnormalities in the normal child are usually reﬂections of the anatomic deformity. However, compensatory factors may inﬂuence the resulting dynamic rotational proﬁle during gait. We compared rotational computed tomography (CT) data with gait analysis data to evaluate their correlation and to elucidate the inﬂuence of possible compensatory mechanisms. Methods: Between 2001 and 2005 rotational computed tomography (CT) and gait analysis for assessment of rotational malalignment have been performed in 79 patients. CT scans were available for review in 23 patients (46 lower limb segments). Three dimensional gait analysis (Motion Analysis Corporation, Santa Rosa, USA) was performed using the Cleveland clinical marker set. Lower limb segments showing more than 15 degrees of frontal plane varus-valgus movement in the knee joint were excluded to increase quality of data. The femoral and tibial torsion as found in the rotational CT was statistically correlated with the data from gait analysis for hip rotation and knee rotation at several events during the gait cycle. The relationship between parameters was evaluated by determination of Pearson’s correlation coefﬁcient. Results: The study included 6 female and 15 male patients with a mean age at the time of gait analysis of 17 years (9–61 years). All patients presented for correction of rotational malalignment due to idiopathic, posttraumatic or congenital rotational deformity. Forty lower limb segments (20 left and 20 right segments) in 21 patients were analyzed. The mean antetorsion in the femur was 29 degrees (range: 2 degrees of retrotorsion to 56 degrees of antetorsion) and the mean external torsion of the tibia was 29 degrees (range: 1–57 degrees). Evaluations of Pearson’s correlation coefﬁcient revealed correlation between femoral torsion and mean hip rotation during the stance phase (r = 0,408, p < 0,05) and at the end of the ﬁrst double support phase (r = 0,344, p < 0,05). A strong linear correlation was found between the tibial torsion and the mean knee rotation over the whole stance phase (r = 0,764, p < 0,001), the knee rotation at initial contact (r = 0,753, p < 0,001) and

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Oral presentations: Abstracts 1–123/J Child Orthop knee rotation at the end of the ﬁrst double support phase (r = 0,753, p < 0,001). Conclusions: The rotation of the hip as found in the gait analysis showed only weak correlation with rotational CT data. This is not surprising as the hip segment offers many possibilities for compensation and muscular inﬂuences. The torsion of the tibia was found to correlate very strongly with the gait analysis. Signiﬁcance: When assessing femoral torsion an effort should be made to integrate data from rotational CT, gait analysis and clinical evaluation. The evaluation of tibial tosional deformities can accurately be performed with rotational CT.

110 Dynamic femoral anteversion in an abled-body paediatric population. Author: Samuel Jacopin (France) Co-Authors: Elke Viehweger (France), Michel Jacquemier (France), Vincent Pomero (France), Sandrine Scorsone-Pagny (France), Franck Launay (France), Jean-Luc Jouve (France), Ge´rard Bollini (France) Purpose: Clinical consequences of excessive femoral anteversion during walking motivates numerous consultations in paediatric orthopaedics during childhood. To explain variable rotational gait behaviour of the lower limb it’s necessary to investigate the ‘‘dynamic’’ femoral neck orientation. Existing literature data are based on virtual mathematical modelling and not on data acquisition in children. Our purpose was to measure the so-called ‘‘Relative Femoral Anteversion’’ (RFA), the position of the femoral neck relative to a reference transversal axis, perpendicular to walking direction, along the gait cycle in a healthy pediatric population. Methods: 27 volunteer healthy children were included (20 boys, 7 girls, mean age 9,3 ± 3 years). Anatomic femoral anteversion (AFA), tibial torsion, and hip range of motion was assessed clinically. Instrumented 3D-gait analysis was performed for each child. Gillette Gait Index (GGI) was used to select reference gait trials. Joint centre coordinates and anatomical segments orientation were calculated and we developed a speciﬁc computation model to calculate the rotation of the femur in relation to the frontal plane. Therefore RFA was calculated along the whole gait cycle. Results: RFA expressed a low amplitude (12,2) during gait cycle. Its mean value (29) was very close to the mean AFA value (27,8). The curve aspect of the RFA during the gait cycle was homogeneous for stance phase and for terminal swing phase. During the loading response phase, the RFA decreased, then the RFA increased during the single limb support. Curve aspect along swing phase was heterogeneous. Conclusions: Our results demonstrate low RFA amplitude during the gait cycle. We described a typical curve pattern which varies with gait velocity. Our results based on real time dynamic analysis in children differ widely from the mathematical based literature results. Further prospective RFA studies may lead to ‘‘RFA’’ patterns correlated to hip pathologies. Signiﬁcance: Different RFA patterns due to variable AFA related to acetabular torsion may help to explain physiopathology of a part of paediatric orthopaedic pathologies including slipped capital epiphysis, Legg-Perthes-Calve´ disease or progressive neurological hip dysplasia or consequently development of hip arthritis in adult.

Oral presentations: Abstracts 1–123/J Child Orthop 111 3D Time-resolved Magnetic Resonance Angiography of the abnormal limbs in children Author: Pierre Journeau (France) Co-Authors: Laurence Mainard (France), Damien Mandry (France), Thierry Haumont (France), Pierre Lascombes (France), Michel Claudon (France) Purpose: To evaluate the interest of magnetic resonance angiography with Time-Resolved Imaging of the Contrast Kinetics (TRICKS) in children limbs diseases. Methods: TRICKS is a contrast-enhanced MR angiographic technique allowing the acquisition of multiple 3D dynamic volumes (temporal resolution 10 sec). 113 children (mean age 10.3 years) were evaluated, including osteochondritis (17), bony or joint infections (9), epiphysiodesis (8), juvenile chronic arthritis (20), arterio-venous malformations (AVM)(14), benign (32) and malignant tumors (n = 3, with post-chemotherapy follow-up in 10). TRICKS data were correlated with T2 and T1 weighted images, 99Tc bone scintigraphy, surgery and pathology ﬁndings. Results: In osteochondritis and osteomyelitis, enhancement delineated sequestrae. In epiphysiodesis, 3D acquisitions allowed a precise localization and size of bony bridges within the enhanced growth plate. Early and massive enhancement was observed in active hypertrophic pannus. AVM kinetics depended on the presence of shunts. In benign tumors, enhancement correlated with scintigraphy uptake. In malignant tumors, decreased enhancement under chemotherapy correlated with the degree of necrosis at pathology. Conclusions: TRICKS provides high-quality images and kinetics data on abnormal growth plate vascularization, inﬂammatory changes and tumor viability in children limbs diseases. Signiﬁcance: The TRICKS imaging is non invasive imaging technic allowing to evaluate the quality, and also the quantity of bone or growth plate vascularization. It is possible to compare the abnormal quantity of vascularization with the adjacent normal bone, needed special software. 112 Fibrous hamartoma at atrophic congenital pseudoarthrosis of the tibia is not osteogenic but osteoclastogenic Author: Tae-Joon Cho (Korea, Republic of) Co-Authors: Joong Bae Seo (Korea, Republic of), Dong Yeon Lee (Korea, Republic of), Won Joon Yoo (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Jin A Kim (Korea, Republic of), In Ho Choi (Korea, Republic of) Purpose: CPT remains as one of the most challenging orthopaedic problems. Main pathology of the pseudarthrosis is ﬁbrous hamartoma (FH) that is continuous with abnormally thickened periosteum in the adjacent bone segments. Understanding the biologic behavior of this pathologic tissue should be a key to development of optimal treatment method. In this study, the authors compared the FH cells with normal periosteal cells with reference to mRNA expression of cytokines involved in osteoclastogenesis and osteogenesis, and responses to exogenous bone morphogenetic protein (BMP) treatment. Methods: After approval from the IRB, ﬁbrous hamartoma (FH) surgically excised during osteosynthesis for atrophic type CPT and distal tibial periosteum (TP) obtained as a normal control during tibial derotational osteotomy in cerebral palsy patients were used.

S53 Fibroblast-like cells were enzymatically dissociated, and grown in DMEM with 10% FBS. FH cell from 5 patients and TP cells from 2 patients were used in this study. Total RNA was extracted, and BMP-2, BMP-4, and NF1 mRNA expression was tested using RT-PCR. RANKL and OPG mRNA expression level was quantiﬁed using real time RT-PCR and standardized by that of GAPDH. Both FH cells and TP cell were treated with rhBMP-2 (R&D System, Mineapolis, MN)(0 or 100 ng/ml) for 2 weeks. Cellular alkaline phosphatase (ALP) activity was determined and mRNA expressions of the transcription factors involved in osteoblastic differentiation, such as Dlx5, Msx2 and Runx2, were measured using real-time RT-PCR. Results: Both FH and TP cells were spindle-shaped and indiscernible morphologically. They expressed BMP-2, BMP-4, and GRD1 and GRD2 types of NF1 mRNAs. RANKL mRNA expressions in the FH cells were higher than in the TP cells, whereas OPG mRNA expression were lower. BMP treatment increased ALP staining and activity in TP cells, while decreased in FH cells. The mRNA expression of Dlx5 was up-regulated and that of Msx-2 was down-regulated by BMP treatment in both FH cells and TP cell. Runx2 mRNA expression increased in TP cells, but resulted in divergent changes in FH cells. Conclusions: FH cells seem to maintain some of osteogenic phenotype, but suppressed osteogenic phenotype by BMP treatment contrary to TP cells. This suggests that main defect of the ﬁbrous hamartoma lies in the response to BMP signals. This study also showed that the FH cells are more osteoclastogenic than TP cells. Signiﬁcance: These ﬁndings suggest that meticulous excision of the ﬁbrous hamartoma tissue is mandatory in the treatment of CPT as it would not respond to either endogenous or exogenous BMP’s. Enhanced osteoclastogenicity of this tissue seems to contribute to development of CPT. 113 The performance of an Extensible Intramedulary Nail anchorad by hooks (HIMEX) in Osteogenesis Imperfecta Author: William Dias Belangero (Brasil) Children with osteogenesis imperfecta often need surgical treatment for correction of deformities and for avoiding new fractures. The use of extensible nails, is accepted, but the great number of pos-surgical complications requires many reoperations. The objective of the study was to evaluate the performance of an extensible intramedulary nail named HIMEX, anchored in epiphysis by hoocks, for children with osteogenesis imperfecta. The performance was measured by the effect of the nail for reducing the number of fractures, improving the motor development, decreasing the migration of the nail and for increasing the nail survival. A retrospective transversal study was done, with all patients treated from 1990 to 2004 with the HIMEX. The casuistic included 14 patients aged from two to eighteen years old; eight females; seven patients type III, six type IV and one type I, according SILLENCE (1981). The average age at the ﬁrst fracture was nearly ﬁve months (148,21 days), with average fractures/patient of 42,6. Forty six bones in the lower limb were treated (28 femur, 18 tibia), with 39 primary insertion (25 femur, 14 tibia) and seven revision procedures (3 femur, 4 tibia). The average follow-up was 50,35 months, statistically longer for femoral procedures (60,14 months) than for tibia procedures (35,11 months). The average age at the insertion of the ﬁrst rod in femur was signiﬁcantly higher than in tibia (7,64 years X 11,56). After of surgical treatment there was a statistically signiﬁcant decrease of the number of fractures from 42,6 to 0,78 fractures/patient. Although

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there has been improvement in the motor development, the results were not statistically signiﬁcant (HOFFER e BULLOCK, 1981). The percentage of reoperations was 18%. The migration of the nail occurred in 5/39 surgeries (12%). By survivorship analysis patients had a higher risk of requiring reoperation when the procedure was made in tibia. The type of osteogenesis imperfecta, the age of the patients at the surgery and the period when the surgery was made were not statistically signiﬁcant for requiring reoperation. It was concluded that the use of HIMEX signiﬁcantly reduced the number of fractures and the incidence of migration besides to increase the nail survival, regarding literature basis.

Session 12b: Cerebral Palsy

Rates of utilization of gait analysis for surgical decision making for ambulatory cerebral palsy in North America Author: Unni G Narayanan (Canada) Co-Authors: Shannon Weir (Canada), Alan Morris (Canada), Sue Redekop (Canada) Purpose:

2. 3.

4.

115 Power generation in children with spastic hemiplegic cerebral palsy

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ment(PODCI) and the Gross Motor Function Measure(GMFM-66). Conclusions: There is wide area variation in the rates of utilization of clinical gait analysis in Canada and the US. Despite wide variation in their beliefs about the clinical value of gait analysis, surgeons have little uncertainty about their beliefs. Signiﬁcance: Ambulatory children with CP are either being deprived of a valuable assessment in many centres or being subjected to an unnecessary & expensive evaluation in others. The survey results should provide the impetus for a much needed multi-centre RCT to address this controversy.

Measure the rates (and determinants) of utilization of gait analysis for surgical decision-making in ambulatory CP; Estimate surgeons’ beliefs about the clinical value of gait analysis for decision making & their conﬁdence/certainty of their beliefs; Gauge the support for a multicentre randomized trial to address whether the addition of gait analysis to surgical decisionmaking improves the functional outcomes of orthopaedic surgery; Identify the primary outcome/s of choice for such a trial.

Methods: A survey of 732 members of POSNA was conducted over 6 months. After pilot testing, members were invited to complete a self-administered web-based online questionnaire, also available in paper form for return by fax/mail. Results: Responses were received from 413/732(56.4% total response rate), of which 354(48.4%) were fully completed surveys: 323/680(47.5%) for US & 31/52(60%) for Canadian surgeons, from140 different cities in 43/50 US States and 11 cities in 7/10 Canadian provinces. 90% reported CP management including multilevel surgery was part of their practice. 59%(209/ 354) reported some training in gait analysis. 38% of respondents did not have access to a gait laboratory. 8% had access for research only. For those with access, 44% relied on private health insurance but 20% did not have any funding for clinical gait analysis. 59% of respondents believe that gait analysis is indicated at least sometimes for decision making prior to multilevel surgery. Only 41% of the respondents actually use gait analysis for this purpose. The main reasons for this difference included lack of access to a gait lab, lack of funding, or poor experience with interpretation. The overall rates of actual utilization of gait analysis for clinical decision making among surgeons who treat children with CP was 42.6%(US) and 25.8%(Canada). There was wide variation in surgeons’ beliefs about the value of clinical gait analysis and the indications for decision making prior to multilevel surgery. 47% of the respondents were certain/very certain about their beliefs, 36% somewhat certain & only 7% uncertain. 69.8% indicated their willingness to participate in a multi-centre trial to resolve the controversy. The outcome measures of choice for such a trial were the Pediatric Outcomes Data Collection Instru-

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Author: Jacques Riad (Sweden) Co-Authors: Freeman Miller (United States) Purpose: Spastic hemiplegic cerebral palsy is a challenging disorder where often relatively high functional and cognitive level makes the children good candidates for physiotherapy programs with coordination and muscle strengthening exercises. The goal of this study was to investigate the power generation on both the hemiplegic and non-involved side, from the hips and ankles in children with spastic hemiplegic cerebral palsy, who had no previous surgery. Methods: Ninty-nine patients with spastic hemiplegic CP with a mean age of 8.4 years (range 4.0–19.8) were included. Medical records and three dimensional gait analysis data were reviewed. Patients were classiﬁed using Winter’s criteria and classiﬁed into either group 1,2,3 or 4. Twenty-two patients (22%) of the total 99 could not be classiﬁed in any group and we call this group 0, since they had the smallest deviations from normal. The ground reaction force vectors were collected and together with kinematic data moments and power generation/absorption could be calculated. The power generation was calculated as the area under the curve on the hip and ankle graphs. The A1 power generation in the hip represents mainly the extensor muscles of the hip, the gluteus muscles. The A2, the power absorption and the A3 the iliopsoas muscle power generation. In the ankle the A1 curve represents power absorption, the A2 ankle power generation in the early part of stance phase that is not present in the normal population. The A3 in the ankle in late stance phase represents the normally existing gastro-soleus muscle power generation. Results: The hip extensor power generation, A1, was higher on both the hemiplegic and the non-involved side in all classiﬁcation groups compared to age matched normals. The power generation from the iliopsoas, A3, was very close to normal in all groups on both sides. The normally not existing power generation in the early part of stance phase was present in all groups on both the hemiplegic and non-involved side. The power generation from the ankle regarding the gastro-soleus muscle A3 in all groups, had less ankle power generation on both the hemiplegic and non-involved side compared to normals. Conclusions: We found a major power generation shift from the ankle to the hips in children with spastic hemiplegic cerebral palsy both on the hemiplegic and the non-involved side. This could be interpreted as if symmetry in power generation is a way of compensating for decreased ankle power generation on the hemiplegic side. This may also mean that power loss, such as after tendon achilles lengthening, at the ankle may be of less importance in the hemiplegic cerebral palsy child.

Oral presentations: Abstracts 1–123/J Child Orthop Signiﬁcance: The results could support that muscles strengthening physiotherapy should be directed toward the hip power generators mainly and coordination exercises should be focused distally to the knee and ankle. Consideration of the power shift might also inﬂuence surgical treatment plans.

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Author: Chin Youb Chung (Korea, Republic of)

20 degrees (50 preoperatively) and mean centre-edge angle of 29 degrees (–5 preoperatively) No statistical difference was noted between the three year and ten year follow-up results demonstrating sustained improvement in clinical and radiological outcome. Conclusions: Bilateral simultaneous combined hip reconstruction in whole body cerebral palsy provides painless, mobile and anatomically competent hips in the longer term. Signiﬁcance: The majority of the available literature considers the short term outcome of surgical reconstruction of the hips in this condition. This paper demonstrates that the initial improvements in structure and function are maintained in the longer term.

Co-Authors: In Ho Choi (Korea, Republic of), Tae-Joon Cho (Korea, Republic of), Won Joon Yoo (Korea, Republic of), Moon Seok Park (Korea, Republic of)

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116 Morphometric Changes Of The Acetabulum After Dega Osteotomy In Cerebral Palsy

Purpose: To analyze the effect of Dega osteotomy on acetabulum in cerebral palsy using 3 dimensional computed tomography. Methods: Fourteen hips of 9 cerebral palsied patients with hip instability were evaluated, and the contralateral hips of 10 unilateral LCP patients were used as a control. There were 7 males and 2 females with the mean age of 7.8 years. Dega osteotomy and femoral varization derotation osteotomy was performed in all affected hips, and 3D CT was taken pre- and postoperatively. For the assessments, 3 directional acetabular indices (anterosuperior, superolateral and posterosuperior) were designed and measured using multiplanar reformation. Acetabular volume was also calculated. Results: All hips were concentrically reduced without complications. Anterosuperior and superolateral indices were signiﬁcantly improved toward the value of control group (p = 0.001), and posterosuperior index was even smaller than that of control group postoperatively (p = 0.007). The volume of acetablum increased by 67% and showed a statistical signiﬁcance (p = 0.001). Conclusion: We conclude that not only posterosuperior but also anterosuperior coverage is improved after Dega osteotomy. Furthermore, Dega osteotomy actually increases acetabular volume.

117 Ten-year follow -up of bilateral hip reconstruction in severe whole body cerebral palsy. Author: Fergal Monsell (United Kingdom) Co-Authors: Mohannad Barakat (United Kingdom), Tom While (United Kingdom), Martin Gargan (United Kingdom), Jane Pyman (United Kingdom) Purpose: The results of a functional, clinical and radiological study of 30 children (60 hips) with whole body cerebral palsy are presented with a mean follow-up of ten years. Methods: Bilateral simultaneous combined soft-tissue and bony surgery was performed at a mean age of 7.7 years (3.1–12.2). Evaluation at ten years involved interviews with patient/carers and clinical examination. Plain radiographs of the pelvis assessed migration percentage and centre-edge angle. Results: Twenty two patients were recalled. Five had died of unrelated causes and three were lost to follow-up. Pain was uncommon, present in 1 patient (4.5%). Improved handling was reported in 18 of 22 patients (82%). Carer handling problems were attributed to growth of the patients. All patients/carers considered the procedure worthwhile. The range of hip movements improved, with a mean windsweep index of 36 (50 pre-operatively) Radiological containment improved, with mean migration percentage of

Proximal femoral resection arthroplasty for patients with Cerebral Palsy and dislocated hips Author: Andreas Knaus (Norway) Co-Authors: Terje Terjesen (Norway) Purpose: Hip dislocation of several years duration in cerebral palsy(CP), especially in the most severe mentally retarded and non-ambulatory individuals with quadriplegia, can lead to many problems including pain as the most annoying. During the last years we have performed proximal femoral resection in these cases. The aim of the current study was to evaluate the clinical outcome of this operation, especially to what degree pain was reduced and whether sitting balance and perineal care improved. Methods: During the period 1998 to 2005 we operated 22 patients with chronic hip dislocation. They were 20 non-ambulatory patients with quadriplegic CP, 1 patient with Down syndrome and 1 patient with Arthrogryposis(13 with unilateral dislocation and 9 with bilateral). The average age at operation was 15(3–27) years. The criteriae to select patients for operation were hip dislocation which had lasted for 2 years plus severe clinical problems like pain(13 patients), problems with perineal care(13), and difﬁculties with seating(3 patients), or a combination of these symptoms(10 patients). The operative technique used was the proximal femoral resection-interposition arthroplasty as described by Mc Carthy et al. in 1988. 16 patients underwent bilateral resection(9 with bilateral dislocation and 7 with unilateral), 6 patients unilateral resection (5 with dislocation and 1 with subluxation). Postoperative treatment was skin traction for 2–5 weeks for most of the patients. After 35(3–72) months follow-up time a telephone questionnaire was designed to ask patients or caretakers about pain, mobility, function and about their rate of overall satisfaction with the surgery. Radiographs taken immediately after surgery were compared to those taken at the most recent clinic visit to assess proximal femoral migration and the presence of heterotopic ossiﬁcation. Clinical charts were reviewed for details of the surgical procedure, postoperative care and complications after surgery. Results: 15 patients were satisﬁed(9 very satisﬁed) with the surgery, 4 were unsatisﬁed and 2 were unsure. 5 patients were dead. Complications after surgery included prolonged pain up to 6 months, 1 deep vein thrombosis and 1 patient developed oedema, lost appetite and needed gastrostomia. 1 patient was reoperated because of heterotopic ossiﬁcation. Pain rated on a scale from 1–10 was in average 7(1–10) before surgery and reduced to 2(1–7) at follow-up. All operated hips had an improved range of motion. All 10 patients without sitting ability before surgery were able to sit afterwards. Conclusions: Pain and function, especially sitting ability, improved postoperatively and the majority of patients and caretakers were satisﬁed with the surgery.

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S56 Signiﬁcance: Patients with CP and severe pain or other major problems because of long-standing hip dislocations seem to beneﬁt from proximal femoral resection. 119 The triceps surae muscle ﬂexes and internally rotates the hip under load Author: Reinald Brunner (Switzerland) Co-Authors: Carlo Frigo (Italy), Thomas Dreher (Germany) Purpose: Internal rotation gait in patients with spastic cerebral palsy is a common problem. Correction by bony or soft tissue surgery at the hip level is often disappointing. Other factors hence need to be responsible for internal rotation as well. Methods: A biomechanical model of the body is created and animated. Soleus and gastrocnemii activity is simulated without and with ﬂoor resistance (inﬂuence of gravity). The results from the model study are veriﬁed in a review of 47 consecutive patients with spastic hemiplegia and 49 with diplegia respectively (mean age 12 y, no Botulinum toxin therapy for at least 6 month or any surgery before). All these patients underwent full instrumented gait analysis (VICON 360 6 cameras, 2 Kistler force plates, dynamic EMG). 3D hip and pelvic kinematics was correlated with ankle kinematics. A paired t-test was used to compare the 2 groups (signiﬁcance set at p = < 0.05). Results: Simulation of soleus activation without gravity shows plantarﬂexion as expected. With ﬂoor resistance the hip is internally rotated and ﬂexed with extension of the knee, together with retrotorsion and elevation of the ipsilateral pelvis. Similar happens with gastrocnemii but the knee is ﬂexed. Knee ﬂexion before activation of the tested muscles erases the effect on hip and pelvis at least partially. For hemiplegia correlation of ankle ﬂexion and hip rotation was r = 0.5, p = 0.001, for pelvic rotation r = o.4, p = 0.007. For diplegia, r = o.1, p = 0.262 and r = 0.1, p = 0.366 respectively. Diplegic patients showed signiﬁcantly more knee and hip ﬂexion than hemiplegic patients in stance phase while ankle ﬂexion did not differ. Conclusions: Plantarﬂexion under load produces hip internal rotation and pelvic retroversion as a direct effect which is of importance in patients walking with little or no knee ﬂexion such as hemiplegic patients. This effect, however, is not proven in diplegic patients who walk with bent knees. Signiﬁcance: Triceps overactivity and shortening need to be corrected as well in patients with hip inernal rotation deformities. 120 The functional outcome of soft tissue procedures for the treatment of spastic pronation in children and adolescents. Author: Konstantinos Malizos (Greece) Co-Authors: Nikolaos Rigopoulos (Greece), Athanasios Liantsis (Greece) Purpose: The spastic pronation (SP) is considered as the most prevailing segment of spastic upper extremity pattern. We are presenting the overall outcome in upper extremity function of soft tissue procedures for the treatment of SP. Methods: In a 5-yrs period: (2000–2005), 18 children/adolescents: (11 boys, 7 girls), mean age: 7.6, suffering from hemiplegia (13) or quadriplegia (5) were treated surgically for SP. IQ was normal and family support adequate in all cases. At least one of the following soft tissue procedures were performed in each patient: ﬂexor

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Oral presentations: Abstracts 1–123/J Child Orthop tendon lengthening (8), pronator teres rerouting (13), biceps branch lengthening (5), transfer of ﬂexor carpi ulnaris to the extensor radialis brevis (13). Patients were classiﬁed (Gerschwind & Tonkin) as type I-IV according to pre- and post-operative range of pronation/supination. Final ranges of motion of wrist/elbow/ shoulder were recorded and gross/ﬁne motor skills as well. Results: Follow-up period ranged from 1–5.5 yrs. The majority of patients were 6–8 yrs. Although all of them had undergone lower extremity procedures, no one had been operated in upper extremity before. Tendon transfers represented almost 54% of soft tissue procedures and pronator teres rerouting was 43% of them. The best improvement in ﬁnal ROM was in type III patients and represented 34% of favourable results. Conclusions: A signiﬁcant improvement was recorded not only in gross/ﬁne hand function but also in elbow and shoulder ﬁnal active range of motion, indicating the biomechanical importance of spastic pronation treatment (especially soft tissue procedures) in the overall upper extremity function. Signiﬁcance: A signiﬁcant improvement was recorded not only in gross/ﬁne hand function but also in elbow and shoulder ﬁnal active range of motion, indicating the biomechanical importance of spastic pronation treatment (especially soft tissue procedures) in the overall upper extremity function. 121 Utility of Bone Scan in Non-Communicative Children with Pain Author: Gela Bajelidze (United States) Co-Authors: Mohan Belthur (United States), Freeman Miller (United States), Kirk Dabney (United States) Purpose: Pain in non-communicative children is difﬁcult to localize and diagnose. The purpose of this study is to report our experience using a three-phase whole body Technetium bone scan as a screening tool in identifying the source of persistent pain in profoundly handicapped children who can not communicate. Methods: We reviewed the medical and imaging records of 45 patients who met the inclusion criteria of the study, which included a diagnosis of spastic quadriplegic cerebral palsy with severe motor and cognitive impairment, persistent pain of more than one week in duration with no recognizable source, and a three-phase bone scan as part of the pain workup. Results: The study group included 26 females and 19 males with an average age at presentation of 13.5 years (range 3–20 years). A positive bone scan (tracer uptake) was seen in 24 patients (53.3%). A diagnosis and the source of pain was identiﬁed in all 24 patients with a positive bone scan, with the bone scan being instrumental in establishing a diagnosis or localization in 22 patients. A diagnosis was never established in the 21 patients with a negative bone scan. Based on the bone scan results additional imaging was obtained at the position indicated. Bone scan was used to establish a diagnosis of fracture in 10 of 24 patients and a variety of other diagnoses. Other diagnoses included three patients with painful internal hardware, two with sinusitis, two with infections, and one with obstructed kidneys, among others. Conclusions: Based on the results of this study we feel that the bone scan can be a useful tool in identifying the source of persistent pain in the profoundly handicapped, non-communicative child. Signiﬁcance: Bone scan is a viable imaging option to identify the source of persistent pain in the profoundly handicapped non-

Oral presentations: Abstracts 1–123/J Child Orthop communicative child. Bone scan can assist in localizing the source of pain and direct the location for further imaging as needed.

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Femoral derotation osteotomy as part of single-stage multi-level surgery in diplegic cerebral palsy children using Intramedullary Stable Elastic Nail ﬁxation (ISEN)

Scoliosis in Quadriplegic Cerebral Palsy: Risk factors for progression

Author: Tim Theologis (United Kingdom)

Author: Hakan Senaran (United States)

Co-Authors: Julie Stebbins (United Kingdom), Andrew Wainwright (United Kingdom), Nicky Thompson (United Kingdom)

Co-Authors: Suken Shah (United States), Kirk Dabney (United States), Joseph Glutting (United States), Freeman Miller (United States) Purpose: The natural history of scoliosis and risk factors for progressive scoliosis in children with spastic quadriplegic cerebral palsy (CP) await clariﬁcation. The effect of adolescent growth spurt on the progression of scoliosis in CP has not been clearly deﬁned. To deﬁne the natural history of scoliosis, risk factors for progressive scoliosis, and the effect of adolescent growth spurt on the progression of scoliosis in children with spastic quadriplegic cerebral palsy. Methods: A retrospective review of the medical records and radiographs of 135 cerebral palsy patients followed at the same institution who had adequate radiographs of the spine at initial and follow up presentation and who had at least 25 degrees of scoliosis at follow up was performed. The effects of curve type, adolescent growth spurt, functional capacity of the patient and surgically treated previous hip subluxation were evaluated on the rate of curve progression and pelvic obliquity. Results: The mean rate of curve progression was found to be 13.9 degrees/year in spastic quadriplegic children. Scoliosis was diagnosed and treated at an earlier age in wheelchair bound patients compared to ambulatory patients. The rate of curve progression increased proportionately to the worsening functional capacity of the patient. Using analysis of covariance, juvenile patients( < 10 years at last follow up) had signiﬁcantly higher rate of curve progression than the adolescent patients(>10 years old at initial presentation). Surgically treated previous hip subluxation signiﬁcantly increased the magnitude of pelvic obliquity. Curve type and gender have no effect on rate of curve progression. Lumbar curves were the most common. Conclusions: The adolescent growth spurt has no effect on the rate of curve progression, but most curves increased with growth. The spasitic quadriplegic patients who had previous hip subluxation should be followed closely for pelvic obliquity, to protect them from the potential complications of pelvic obliquity such as sitting inbalance, pressure ulcers and hip pain. Gender and curve type has no signiﬁcant effect on rate of curve progression. Spastic quadriplegic cerebral palsy patients who developed curves at less than 10 years of age and who are nonambulatory with previous or co-existing spastic hip disease should be monitored at frequent intervals and their caretakers counseled on the natural history of progressive scoliosis since they have highest risk of curve progression. Signiﬁcance: Spastic quadriplegic cerebral palsy patients who developed curves at less than 10 years of age and who are nonambulatory with previous or co-existing spastic hip disease should be monitored at frequent intervals and their caretakers counseled on the natural history of progressive scoliosis since they have highest risk of curve progression.

Purpose: Femoral derotation osteotomy (FDRO) is often part of single-stage multi-level (SSML) surgery in children with spastic diplegic cerebral palsy (CP). Failure of the ﬁxation following early weight bearing, non-union, infection and incomplete correction are potential problems. Periosteal stripping is undesirable while muscle dissection to gain adequate bone exposure may further compromise pre-existing problems of weakness.Muscle weakness is now a recognised problem in CP. We have shown that lower limb muscles remain weaker than pre-operatively at 1 year after SSML, although gait parameters are signiﬁcantly improved. We are therefore in the process of combining new ‘‘strength preserving’’ surgical techniques, allowing earlier mobilisation, with resistance strength training. As part of this programme, we perform the FDRO using closed corticotomy and ﬁxation with ISEN. The aim of this study was to compare the early results of strength preserving surgery to conventional SSML, with particular focus on the results of the femoral osteotomy. Methods: Seven patients who underwent 13 FDROs as part of SSML were compared with an equal number of patients matched for age and function (GMFCS) who underwent conventional SSML. Clinical examination and gait analysis were performed preoperatively and at 6 months post-op. Routine radiographs were taken at 6–8 weeks post-op. The surgical technique included distal insertion of both nails, advancement to the isthmus of the femur, closed corticotomy at this level, derotation and ﬁnal advancement. A k-wire centrally placed in the femoral neck was used to assess the correction of anteversion. The clinical and gait parameters in the two groups were compared using t-test (p < 0.05). Results: All osteotomies healed without complications within 6–8 weeks post-operatively. The ISEN group showed signiﬁcantly less blood loss (average 109 ml vs 255 ml, p < 0.0002) and time to mobilise (average 8.5 days vs 45 days p < 0.00004). Operative time was shorter in the ISEN group (191 min vs 245 min but p = 0.22). Comparison of the groups at 6 months showed no signiﬁcant difference in the correction of femoral anteversion, the Gillette Gait Index and the gait parameters relating to dynamic hip rotation. Hip rotation during gait corrected to normal limits at 6 months post-operatively in 11/13 legs in both groups. Conclusions: Performing FDRO in the context of multi-level surgery in CP can safely and effectively be achieved with corticotomy and ﬁxation with ISEN. The correction achieved, as measured clinically and with gait analysis at 6 months post surgery, is similar to conventional techniques. Moreover, our technique led to signiﬁcantly less blood loss, faster mobilisation as well as shorter surgical time. Signiﬁcance: Our technique carries signiﬁcant advantages over conventional techniques.

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Poster Presentations Basic Science

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125 Zink in Non-mature Bone. Author: Bjarne Møller-Madsen (Denmark) Co-Authors: J Ovesen (Denmark), JS Thomsen (Denmark) Purpose: The aim of the present study was to visualize Zn ions in cartilage tissue and synovial membrane. Methods: Fortyﬁve male Wistar rats, aged four weeks were randomly divided into three groups. They received diet with different amounts of zink added. Group A received zink-free diet. Group B received normal diet. Group C received diet supplemented to 60 mg zink/kg. Rats were sacriﬁced 4 weeks later. Hind limbs were dissected from the body and ﬁxed in glutaraldehyde. Longitudinal sections were prepared according to the zink speciﬁc Neo-Timm method and examined microscopically. Controls were included. Results: Alimentary zink supply resulted in an increase in the height of the total growth plate in a dose-dependent manner. Zink were localised in chondrocytes of epiphyseal and articular cartilage and in the inner layer of the synovial membrane. Conclusions: Previously publiced data have suggested zink to be a regulator of the calciﬁcation. Nobody has previously visualised Zn ions in the chondrocytes of the articular cartilage. Signiﬁcance: The localisation may indicate a role in the calciﬁcation of cartilage and/or a role in the regulation of the formation of cartilage and thereby the longitudinal growth of long bones.

Neuromuscular disorders 126 Strategy to treat bilateral hip dislocations in arthrogryposis multiplex congenita -open reduction including circumferential capsulotomy and iliopsoas transfer using extensive anterolateral approachAuthor: Kiyoshi Aoki (Japan) Co-Authors: Hirofumi Akazawa (Japan), Takumi Nasu (Japan), Sachiko Goto (Japan), Hirosuke Endo (Japan), Shigeru Mitani (Japan), Ko Oda (Japan) Purpose: Arthrogryposis multiplex congenita (AMC) is a rare disease with multiple joint contractures. It was widely believed that bilaterally dislocated hips should not have been reduced since movement was satisfactory and results of open reduction were poor. Akazawa reported middle-term follow-up (the mean was 11.8 years) of the new open reduction method (J.B.J.S.(Br) 80 636–640 1998). The purpose of this presentation is to report long-term follow-up (the mean was 20.2 years) and think about the role of our method for bilaterally dislocated hips in AMC.

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Poster presentations: Abstracts 124–322/J Child Orthop Methods: From 1954 to 1995, we have examined 48 arthrogrypotic children. Of these, there were 11 patients with 21 hip dislocations; 10 had bilateral and one unilateral dislocation. Since 1977 we have performed a new method of open reduction including circumferential capsulotomy and iliopsoas anterolateral transfer on ten bilaterally dislocated hips in ﬁve children with AMC. The mean age at surgery was 31.5 months (17 to 64) and the mean follow-up 20.2 years (15.4 to 29.6). Followup examination included assessment of the range of movement and walking and radiography. Motion in the joint was evaluated on the criteria of Gruel et al. Anteroposterior radiographs of each hip were graded according to the classiﬁcation of Severin. Results: At the ﬁnal follow-up, all patients walked without crutches or canes. Two managed independently, one required a long leg brace and two had short leg braces because of knee and/or foot problems. Walking ability was maintained in all patients. The clinical results were good in six hips, fair in two and poor in two. On the Severin classiﬁcation eight hips were rated as good (group I or II). Conclusions: We believe that our open reduction method including circumferential capsulotomy and iliopsoas transfer using extensive anterolateral approach could be one of the useful strategies to treat bilateral hip dislocations in AMC. Signiﬁcance: Long-term follow-up (the mean was 20.2 years) of the open reduction method including circumferential capsulotomy and iliopsoas transfer using extensive anterolateral approach for bilaterally dislocated hips in AMC is reported. 127 ‘Keep them walking!’: Functional results of tendon transfers in MMC Author: Arnold T. Besselaar (Netherlands) Co-Authors: Alexander Haverkamp (Netherlands), Ralph Sakkers (Netherlands), Rene´ Castelein (Netherlands), Hans Pruijs (Netherlands) Purpose: Many patients with myelomeningocele (MMC) have progressive deformities of the feet causing a decrease in ambulance level. These deformities can either be caused by structural abnormalities in the foot or can be secondary to muscle imbalance. A number of reports describe favourable results of tendon transfers in this last group but reports on long-term functional outcome after these procedures are scarce. In this retrospective study, children with MMC are followed after tendon transfers in the feet until after puberty. Methods: Seventy-one children with MMC with a motor level beneath L2 had tendon transfers in the feet in the Wilhelmina Children’s Hospital between 1985 en 2006. Because ambulance often decreases in puberty, follow-up was done until after puberty (minimal age of follow-up 13 years in girls and 14 years in boys). After the usage of this inclusion criterium 32 of the 71children were selected. The ambulance level according to Hoffer was scored pre-operatively and at last follow-up. (Hoffer 1: community walker, 2: household walker, 3: therapeutic walker and 4: wheelchair bound). The level of MMC and the presence or absence of hydrocephalus was recorded. Results: Mean age at operation was 8.4 years and mean age at follow-up was 19.3 years. Decrease of ambulance level was not stopped in the upper lumbar MMC’s, mean Hoffer increased from 2.8 to 3.2 for L2–L3 levels and from 1.6 to 1.9 in L3–L4 levels all with hydrocephalus. Ambulance was improved in the L5–S1 levels, Hoffer score decreased from 1.2 to 1.0 For S1 and lowerlevels Hoffer score remained stable at 1.The group L5–S1 levels with

Poster presentations: Abstracts 124–322/J Child Orthop hydrocephalus showed also a decrease in Hofferscore, from 1.6 to 1.1. MMC’s ambulance levels seem to improve after tendon transfers of functional muscles. Children without hydrocephalus seem to have a better outcome. Conclusions: Many reports are written about joint mobility results related to tendon transfer operations in MMC. However effects on ambulation, for example by using the Hoffer score, have not been published. This study shows the level of MMC and the presence/absence of hydrocephalus as main factors that inﬂuence the ﬁnal outcome. Tendon tranfers can preserve or improve ambulation levels in the long-term in children with lower lumbar and lumbar-sacral MMC. Signiﬁcance: level II, cohort study. 128 The Effect of Hamstrings Stretching on Hip Displacement in Cerebral Palsy Author: Chia Hsieh Chang (Taiwan) Co-Authors: Yu Chen (Taiwan), Zhon Lee (Taiwan) Purpose: Hamstring, a hip extensor, is seldom regarded as a factor for hip displacement in cerebral palsy. A common method to stretch hamstrings is passive knee extension when hip 90 ﬂexion. This study is to explore the changes of hip when hamstrings are stretched at 90-90 position. Methods: Twenty children with spastic cerebral palsy had pelvis computer tomography (CT) before operation for hip displacement. Patients were supine on a special ﬂame with one hip ﬂexion (study side) and one hip extension. Two sets of CT studies were done when resting in 90-90 position and when hamstrings stretching. The power holding the legs in stretching position was 7.0–8.5 lb measured by a hand-held dynamometer. Distance from triradiate cartilage to the lateral margin of femoral epiphysis was measured and compared between resting and stretching using paired-t test. Results: Twenty children had CT study at age of 5.8 (4.0–8.5) years. The migration percentage of the 40 hips was 47% (28–81) in average. Distance from triradiate cartilage to the lateral margin of femoral epiphysis was 42.1 mm at resting and 44.8 mm at hamstrings stretching, and the difference is statistically signiﬁcant. The lateral displacement (2.7 mm) was equal to 13% migration percentage when divided by the epiphysis diameter. This phenomenon was not noted in normal children. Conclusions: Spasticity induces muscle contraction and applies a posteriorly displacing force on the femur, when hamstrings are stretched at hip ﬂexion. We recommend stretching hamstrings for children with cerebral palsy by passive hip abduction at hip extension position instead of 90-90 position. Signiﬁcance: Further deterioration of hip displacement was demonstrated by stretching hamstrings at 90-90 position in the children with established hip displacement. 129 Botulinum toxin before orthopaedic surgery in cerebral palsy children, what are the beneﬁts? Author: Bruno Dohin (France) Co-Authors: Remi Kohler (France), Christophe Garin (France) Purpose: Spasticity could be aetiology of pain in cerebral palsy (CP) children. Orthopaedic surgery is often needed in such patient and post surgical pain could be increased by spasticity. Moreover, symptoms could be worse by abnormal movements, cast immobilization and patient’s anxiety. Treatment of spasticity is needed

S59 after orthopaedic surgery in CP children (Nolan J 2000). It has been previously reported in a randomized study (Barwood S 2000) a beneﬁt as regard of pain in using botulinum toxin (BT) before surgical tenotomy in CP children. The aim of this work was to assess the beneﬁts, as regards of pain and comfort, obtain by the use of BT before bone surgery in total body involved CP children. Methods: Two successive groups of 9 total body involved CP patients were compared in a retrospective study. All the patients underwent an orthopaedic surgery procedure for bone surgery or multilevel surgery. The second group was treated before surgery with multilevel injection of BT. The main studied criteria were: efﬁciency and adverse effects of BT, duration of hospitalization and pain symptoms, length of level III analgesic treatment (morphine), sleep quality and skin lesions under cast immobilization. Results: No signiﬁcant difference was noted in the characteristics of the both groups except the treatment with BT. Efﬁciency of BT was clinically conﬁrmed using Aschworth scale and no adverse effect was noted. The mean ages of the both groups were 8.7 y (ET 2.04) versus 10.9 y old (ET 4.37). The mean body weights were 20 Kg (ET 5.6) and 26 Kg (ET 7.7). Dose of BT in the BT group was a mean of 11.6 U BOTOX/kg (9.7 to 14.8). The mean delay for BT injection before surgery was 27 days (23 to 31). All the patients had cast immobilization after surgical procedure, except 2 (BT group, orthopaedic traction). The mean duration was 6 weeks in both groups. No signiﬁcant variation was noted in duration of hospitalization: 7.33 days (ET1.5) versus 7.88 d (ET1.7) and duration of level III analgesic treatment: 4.33 days (ET 1.9) versus 4.16 d (ET 2.5). However, the duration of pain symptoms decrease significantly from 6.87 d (ET2.9) to 2.22 d (ET 1.7) and sleep quality was improve from 7/9 patients to 1/9 patients with disturb sleep. Four under cast skin lesions were noted in the ﬁrst group but none in the BT group. Conclusions: We can not conﬁrm that BT used in bone surgery induces lesser consumption of analgesic. However, our results support the hypothesis that treatment of spasticity using BT before bone surgery decrease duration of postoperative pain and improve comfort of children. Moreover, the study suggest that postoperative under cast skin lesions could be prevent. Signiﬁcance: This work suggest that beneﬁts as regard of pain and comfort could be obtain when using BT as multilevel injection before orthopaedic surgery in spastic total body involved CP children.

130 Ambulatory activity, health and quality of life in youth with arthrogryposis Author: Kit M Song (United States) Co-Authors: Erin Dillon (United States), Ken Jaffe (United States), Kristie Bjornson (United States) Purpose: To compare physical activity between youth with amyoplasia or distal arthrogryposis and typically developing youth (TDY) and to explore the correlation between the ambulatory activity achieved by youth with arthrogryposis and selfreported health and quality of life. Methods: This is a cross-sectional comparision study. The daily frequency, duration and intensity of ambulatory activity were measured using the StepWatch? Activity Monitor (SAM). Twelve youth with amyoplasia or distal arthrogryposis and 11 age and gender matched TDY wore the monitor on their ankles

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S60 for 7 days. Subjects completed the Activities Scale for Kids, Performance (ASKp) and Capabilities (ASKc) questionnaires to compare self-reported activity levels with SAM measurements. The Child Health Questionnaire, Child Version (CHQ-CF 87) and Parent Version (CHQ-PF50) measured self-reported health status. Quality of life was measured with the Youth Quality of Life Research version (YQOL-R) completed by both parent and child. Results: The mean age of the arthrogryposis group was 10.9 while the mean age of the TDY group was 9.5. There were 8 males and 4 females in the arthrogryposis group and 6 males and 5 females in the TDY group. Youth with arthrogryposis took an average of 5425.25 +’- 1100.65 steps each day and spent 8.50 +/– 2.86 percent of their active minutes in high step rates. The age and gender matched TDY took an average of 7420.91 +/– 1557.97 steps each day and spent 11.91 +’- 5.07 percent of their active minutes in high step rates. The youth with arthrogryposis scored an average of 73.6108 +/– 10.8012 on the ASKp self-report follow up while the TDY scored an average of 91.4009 +/– 3.6042. There was a trend for children with amyoplasia to have more limitation than children with distal arthrogryposis. Conclusions: Youth with arthrogryposis took fewer total steps each day than TDY and spend a lower percentage of each day in high activity levels. The youth with arthrogryposis also scored lower on the ASKp activity scale than TDY. Signiﬁcance: This is the ﬁrst study to quantify functional differences for children with amyoplasia and distal arthrogryposis from typically developing children. Information regarding baseline functional disability is important to assess the impact of intervention.

Cerebral Palsy 131 Quantifying nerve traction injury during correction of knee ﬂexion deformities in children with cerebral palsy Author: Claudia Auner (United Kingdom) Co-Authors: Haur Tho (United Kingdom), Ramesh Nadarajah (United Kingdom), David Ingram (United Kingdom), Mark Paterson (United Kingdom) Purpose: Bilateral hamstring lengthening is used to correct ﬂexion deformity at the knee in children with cerebral palsy. To our knowledge, there has been no publication which reports the frequency of post-operative peripheral nerve complication in these patients. Damage to the nerve may occur at the time of operation after passive stretching or post-operatively when the limb is splinted in its new position. Methods: Seven children with cerebral palsy were treated with hamstring lengthening by the senior author. The amount of correction of the deformity was determined by the pre-and postoperative measurement of popliteal angles in each case. We used neurophysiological studies to evaluate the effects of hamstring lengthening on nerve function in these patients both pre-operatively and at pre-determined periods postoperatively. Results: Post-operative peripheral nerve complication is frequent in these patients and sub-clinical nerve damage does occur. Conclusions: A relationship exists between amount of corrective lengthening and the degree of neurophysiological abnormality.

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Poster presentations: Abstracts 124–322/J Child Orthop Signiﬁcance: Our results, combined with clinical judgement, help provide guidelines for safe corrective surgery. 132 Ambulatory Activity in Youth with Cerebral Palsy. Author: Kristie Fay Bjornson (United States) Co-Authors: Basia Belza (United States), Deborah Kartin (United States), Rebecca Logsdon (United States), John McLaughlin (United States) Purpose: To describe the day-to-day ambulatory activity of youth with Cerebral Palsy (CP) compared to typically developing youth (TDY). Methods: Within a cross-sectional comparison study design, the StepWatchTM, was calibrated to each youths walking pattern, was worn for 7 consecutive days during the school year. Five (24 hour) days of data (four school days and one weekend day) were analyzed. Average total steps per day, percentage of all time active, ratio of medium to low activity level and percentage of time at high activity levels were calculated. Low activity was deﬁned as < 14 step/min, medium 14–42 step/min and high activity. A convenience sample of 81 youth with CP, GMFCS Levels I-III, and 30 TDY recruited from three tertiary care children’s hospitals and a regional military hospital. Participant age averaged 11.8 (SD+ 1.2) years, half were male (52%), majority were Caucasian (79%), and one third of guardians (36%) attended some vocational school or college. Results: Average steps per day were 4,244 (CI 3739–4749) and 6,740 (CI 6123–7355) for youth with CP and TDY respectively (p < .001). Youth at GMFCS Level I averaged signiﬁcantly more steps per day than Levels II and III (p < .001). Percentage of total active time walking ranged from 10 to 67% for youth with CP with only the Level III youth signiﬁcantly different (p < .01) from TDY. Ratio of medium to low activity was ordered by functional level (TDY > CP) and ranged from .14 to .47. Percent of time in high activity level ranged from zero to 20%, and increased with higher functional level. Youth at Levels II & III differed from TDY for both variables (p < .003). Youth in Level 1 demonstrate variability of walking (% medium to low) and a level of high step activity (> 42 steps/minute) consistent with the TDY sample. Conclusions: Daily ambulatory activity (performance) increases as GMFCS level (capacity) increases . Youth with CP in level I appear as active as the TDY. Youth requiring assistive devices to walk have the greatest limitation in number of steps taken per day, overall active time, ability to use a variety of activity levels and/or attain and use high activity levels. Signiﬁcance: Treatments aimed at improving daily ambulatory activity have the most potential for change in youth at Levels II and III. These results provide preliminary normative data of walking activity in youth with CP using an objective measurement.

133 Long term outcome in cerebral palsy patients with unilateral hip dysplasia managed by proximal femoral osteotomy Author: Khaled Emara (United States) Co-Authors: khaled Emara (Egypt), Johnathan Sembrano (Philippines), Vector Bialik (Israel), Michael Aiona (United States), Michael Sussman (United States)

Poster presentations: Abstracts 124–322/J Child Orthop

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Purpose: review the long term outcome of intertrochnteric osteotomy for hip subluxation in GMFCS level 5 children, and the long term effect on the contralateral hip. Methods: This study presents a long term follow-up of 28 spastic cerebral palsy patients (GMFCS level V) who presented with unilateral hip subluxation. All patients were managed initially by unilateral soft tissue release and proximal femoral inter-trochanteric osteotomy with internal ﬁxation. All patients included in the study were followed until skeletal maturity. We reviewed clinical and operative notes, and radiographs from the time of presentation until age of 21. The data collected included the GMFCS level, demographic data, type of surgery, method of ﬁxation, type of implant, any other surgical procedures before, associated or followed the index procedure, migration percentage, acetabular inclination, and associated scoliosis. Results: There were 14 male & 13 female patients identiﬁed. Average age at the time of intertrochanteric osteotomy was 7 years and 2 months old. Out of the 28 patients 13 osteotomy for the contralateral hip during the follow up period. The average interval between the initial surgery & the contra lateral hip surgery was 6 years and 3 months. During follow-up 15 patients needed re-operation due to recurrent deformity for the operated hip. These revisions included revision of the inter-trochanteric varus osteotomy +/– soft tissue release, and pelvic osteotomy. Conclusions: Unilateral inter-trochanteric osteotomy in cerebral palsy patients with GMFCS level 5 is associated with high chance of resubluxation and the need for further intervention during the long term follow-up. There is also a high chance for the contralateral hip subluxation in this group of patients (46.4%). Therefore patients undergoing surgical treatment for unilateral hip subluxation must continue to be monitored for repeat or contralateral subluxation until skeletal maturity. Signiﬁcance: this study show the long term effect of intertrochanteric varus osteotomy for hip containment on the treated hip & the contralateral hip.

subgroup receiving two BTX-A treatments (N = 6). For each group, the median and interquartile range (IQR) for the 4 parameters were calculated at different evaluation times. A Wilcoxon signed rank test was performed determining statistical signiﬁcant differences between pre and post BTX-A conditions. The critical P-value was deﬁned as 0.05. All statistical procedures were performed with the SAS system. Results: A signiﬁcant improvement (p < 0,01) of Reimers’ index was noticed after the ﬁrst botox inﬁltration. The index decreased from 42% to 35% and also the interquartile range narrowed. Post botox X ray’s were taken at a median of 5,68 months. From eleven of our patients a second X-ray was available taken at a median of 11, 2 months after the botox inﬁltration. The Reimers’ index again increased to a median of 40% wich meant a signiﬁcant worsening compared to the ﬁrst post botox value (p < 0,05). Six patients received a second botox inﬁltration, between 9 and 34 months after their ﬁrst treatment (at a median age of 6 years and 11 months). This group is too small to draw statistical conclusions. But a decrease with a narrow interquartile range could be achieved. The median Reimers’ index decreased from 42% to 36% after the second inﬁltration without any excessive value above 40% . So these patients could have been stabilized conservatively during 2 years. Conclusions: The use of BTX-A decreases the subluxation percentage of the hips in CP patients. A repeat treatment should be considered. Signiﬁcance: This study showed us how an early varisation-derotation osteotomy can be delayed in CP patients with subluxating hips.

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Purpose: The treatment of spastic plano-valgus feet is challenging especially in adolescents and young adults, due to severe and rigid deformities. The purpose of this study is to present the preliminary results of the surgical treatment of this deformity by arthrodesis of the foot medial column and internal ﬁxation with a small fragment DCP plate. Methods : Between March 2003 and September 2006, 13 patients (22 feet) with spastic Cerebral Palsy and plano-valgus feet were treated with arthrodesis of the foot medial column and internal ﬁxation with a small fragment DCP plate. The mean age was 17 + 2 (min. 13 + 2, max. 29 + 9), 7 male and 6 female patients. 5 patients non-walkers, 5 household-walkers and 3 community walker. 5 diplegic and 8 tetraplegic. The right side was operated in 9 feet and 13 on the left side. The surgical indications : severe deformity, gait dysfunction and pain. The arthrodesis on the medial column addressed the talonavicular, navicular-medial cuneiform and medial cuneiform-1st metatarsal joints, being all cases internally ﬁxed with a molded small fragment DCP plate, to restore the medial longitudinal arch. In 3 feet was associated the arthrodesis of the calcaneo-cuboid joint and in 3 feet tendon Achilles lengthening. All patients were in short leg cast for a mean time of 8 weeks. After this period physiotherapy was initiated. All radiographic measurements were done on the lateral view of the foot : - angle of the inclination of the calcaneus: min. –26, max. 16, mean –2,3.- talocalcaneal angle : min. 22, max. 55, mean 38,6. The mean follow-up period was 1 year and 6 months (ranging from 0 + 6 to 3 + 6). Results: All patients are being followed and presenting with improvement of the foot deformity, no pain or shoe wear dif-

The use of Botulinum toxin A in the treatment of hip subluxation in spastic cerebral palsy Author: Kristof Fabry (Belgium) Co-Authors: Kaat Desloovere (Belgium), Anja Vancampenhout (Belgium), Guy Molenaers (Belgium) Purpose: The purpose of this study is to evaluate the effect of Botulinum toxin A (BTX-A) on the subluxation of the hips in patients with spastic CP. Methods: We report on 12 cerebral palsy patients with 15 treated hips. Ten patients were quadriplegic and two were diplegic. The initial radiographic evaluation was taken at an age between 5 years and 7 years and 3 months (median: 5 y and 6 months). Reimer’s migration percentage was determinded on a standard a.p. X-ray one to fourteen (median 2.63) months before and two to nine months (median 5,68) after botox inﬁltration. The dose of therapeutic Botox per muscle was selected based on muscle size and the desired treatment effect Post botox abduction was given by an abduction brace or long leg casts with an abduction bar. Intensive stretchings of adductor and psoas musculature was started. The orthosis was worn during 23 hours a day during 6 weeks. After this period continuous abduction was built in wheelchair and nightorthosis. To exclude the effect of outliners in a limited test group, non-parametric statistical analyses were performed. The data analysis of the study were split up into three parts: 1. analysis of the total group (N = 15), 2. analysis of the subgroup with two follow-up times (N = 11), 3. analysis of the

135 Medial column arthrodesis in spastic plano-valgus foot. Author: Patrı´ cia Moraes de Barros Fucs (Brazil) Co-Authors: Celso Svartman (Brazil), Rodrigo Assumpc¸a˜o (Brazil), Simone Simis (Brazil)

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ﬁculties. No change in function status of the patients occurred. Radiographically post-operatively: angle of the inclination of the calcaneus improved to a mean of 10, min. 5, max. 18; talocalcaneal angle with mean 35,4, min. 23, max. 48. There were two hardware failures due to pseudoarthrosis at the navicular-medial cuneiform joint. This complications were managed by changing the hardware and bone grafting, healing uneventfully. Conclusions: In conclusion the stabilization of the foot medial column could be an option in the treatment of the severe and rigid spastic plano-valgus feet in adolescent and young adults. Signiﬁcance : Case series study, Level 4.

mo one stage improvement at least and a mean 16% inrease of their gmfm score at 6 months and 24% increase at 24 months accordingly. Conclusions: According to this study function improvement can be anticipated in children with cerebral palsy through a minimally invasive technique where muscle length is achieved through percutaneously performed myofascial cuts. Signiﬁcance: Soft tissue surgery in cerebral palsy patients has traditionally been open with a period of hospitalization and post operative immobilization. The method discussed offers favourable results having the merits of requiring no hospitalization and no immobilization with profound beneﬁts to patient’s emotional and functional status.

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External ﬁxation of hip osteotomies in patients with neuromuscular conditions

Neurogenic foot deformities – Optimal treatment for individual foot deformities

Author: Anastasios D. Kanellopoulos (Greece)

Author: Alexander Krebs (Austria)

Co-Authors: Leonidas Badras (Greece), Dimitrios Lamprou (Greece)

Co-Authors: Walter Strobl (Austria), Robert Csepan (Austria)

Purpose: To assess the efﬁcacy of external ﬁxation in securing upper femoral osteotomies in patients with cerebral palsy. Methods: 12 patients,5 females and 7 males with mean age 9 yrs (range 5–16) with hip dislocation secondary to cerebral palsy underwent varus derotational osteotomies that were ﬁxed with external ﬁxation. One patient had bilateral dislocations. Results: Mean follow up was 25 mo(range 14–37 mo). Neck shaft angle correction was at an average of 43 degrees (range 35–54). All osteotomies healed with no loss of the initially achieved correction. No patient required blood transfusion. All devices were removed at the ofﬁce. Conclusions: External ﬁxation is efﬁcassious in stabilizing upper femoral osteotomies in patients with cerebral palsy. Signiﬁcance: External ﬁxation can be an alternative to plate and screw ﬁxation of upper femoral osteotomies, since it can be performed through a smaller surgical approach, it is adjustable even after surgery and does not require a second operation for removal. 137 Change of functional status in children with cerebral palsy after percutaneous myofascial lengthenings Author: Anastasios Kanellopoulos (Greece) Co-Authors: Stamatios Vrettos (Afghanistan), Hristos Giannakopoulos (Afghanistan), Leonidas Badras (Afghanistan) Purpose: To assess the effect of a minimally invasive technique that requires no hospitalization and no post-operative immobilization on the functional status of children with cerebral palsy. Methods: The study includes 74 patients that were preoperatively classiﬁed to the 5 stages slassiﬁcation according to their gmfcs that was also assessed. The score and the stage was re-determined at 6 months,12 and 24 months post-operatively. All such measurements were performed by a certiﬁed pediatric physiotherapist specialized in cerebral palsy,blinded to the method. Mean age of the patients were 8 years (3.5–16). Results: No patient lost pre-operative functional status. None required hospitalization. All demonstrated at ﬁnal follow up at 24

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Purpose: Patients with cerebral palsy and neurogenic diseases often suffer from foot deformities limiting mobility and quality of life. We analysed the results of surgical correction and determined the optimal treatment for the main deformities. Methods: We analysed retrospectively the results of surgical correction of foot deformities. 87 Patients were treated between 1995 and 2003. We have actual data from 51 Patients (59%) with 68 feet treated. Mean follow up time is 4,25 years. We had 23 Patients with neurogenic clubfoot, 16 with ﬂatfood, 25 with pes equinus, 2 pes cavus and 2 hallux valgus. Of these patients 73% were able to walk before surgery. Results: Measuring quality of life we evaluated pain, walking disorders and problems by skin lesions with a Visual Analogue Scale (0–10). Pain decreased from 4,01 to 1,58 (p < 0.001), walking problems improved from 6,87 to 3,31 (p < 0.001), problems by skin lesions improved from 3,79 to 1,35 (p < 0.001). Maximum walking time increased from a mean of 17 minutes to 52 minutes (p < 0.001). The level of mobility was increased in 34%. These results were the basis for the analysis of the best treatment for each deformity. For each group (neurogenic clubfoot, ﬂatfoot and equinus) the best and poorest outcomes were selected and analysed. We evaluated diagnosis, indication for surgery, mobility and expectations of the patient before surgery in comparison to the outcome, postoperative physiotherapy and the use of orthoses. Conclusions: Surgical reconstruction of neurogenic foot deformities showed excellent results. Essential is a muscular balancing to achieve long lasting results. Regular physiotherapy and night orthoses can improve the outcome. In conclusion we like to present our algorithm for the surgical and conservative treatment of neurogenic foot deformities. Signiﬁcance: Therapeutic Study, Level III. 139 Intrathecal Baclofen Therapy for Children with spastic cerebral palsy and total body involvement. Author: Alexander Krebs (Austria) Co-Authors: Walter Strobl (Austria), Radomir Cumlivski (Austria) Purpose: Management of functional disturbing or painful spasticity in patients with spastic cerebral palsy and total body involvement is

Poster presentations: Abstracts 124–322/J Child Orthop crucial. Oral medication with anti spastic medicaments is often limited by the side effects and local treatment with botulinum toxine type A would exceed the maximum dose in certain patients with total body involvement. In these special cases we use intrathecal baclofen since 1999. Our aim of this study is to evaluate quality of life after implantation of a baclofen pump. Methods: An intrathecal baclofen pump was implanted in 15 patients since 1999. 10 patients had spastic cerebral palsy, 5 patients head injuries. We analysed spasticity according to the modiﬁed Ashworth scale and maximum sitting time. Sitting comfort, pain, nursing and positioning were analysed using a visual analogue scale. Results: The mean Ashworth scale decreased highly signiﬁcant from 4.38 to 3 (p < 0.001). Other parameters also showed signiﬁcant (p < 0.1) improvement. Patients and care takers were very satisﬁed with the results. Quality of life increased by improving the sitting abilities and reducing pain. Conclusions: Intrathecal baclofen therapy is an efﬁcient and safe therapy for patients with severe total body involvement. Quality of life may be increased. Excellent cooperation and compliance by patients and/or their care takers are essential because regular checks and reﬁllings are necessary every 3 to 6 month. To achieve good postoperative results an individual test period with an external pump is necessary for these patients. Signiﬁcance: Therapeutic Study, Level IV. 140 Management of spasmodic torticollis and abnormal trunk posture with botulinum toxin type A in children with spastic type cerebral palsy Author: Hideaki Kubota (Japan) Co-Authors: Suyun Ryu (Japan), Yutaka Oketani (Japan), Aiji Matsuura (Japan), Yumi Ito (Japan), Hiromichi Hara (Japan) Purpose: The porpose of this study was to examine the effects of botulinum toxin type A (BTx-A) injection for improving spasmodic torticollis and reducing trunk spasticity in children with spastic type cerebral palsy. Methods: 14 children with cerebral palsy (median age when ﬁrst receving medicaiton was 7.1 years) were injected with BTx-A. The evaluation was carried out before and each month after an injeciton. The assessment included the modiﬁed Tsui scale, the Ashworth scale, the aid difﬁculty scale and Cobb’s ange. Results: All children had spastic quadriplegia classiﬁed at the GMFCS level V. No major side effects appeared during treatment and the follow-up period. We found a signiﬁcant improvement in the Ashworth scale and the aid difﬁculty scale. Conclusions: BTx-A is a safely and useful medication for improving spastic muscles imbalance nad secondary dynamic deformity in the neck and trunk muscles as well as extremities spasticity of children with cerebral palsy. Signiﬁcance: There are a few papers with regard to examining the effects of BTx-A injection for improving spasmodic torticollis and reducing trunk spasticity.

141 Analysis of scoliosis progression in patients with cerebral palsy treated by Baclofen pump implant Author: Guido La Rosa (Italy) Co-Authors: Francesco Costici (Italy), Osvaldo Mazza (Italy)

S63 Purpose: The Authors analyze a group of 15 patients with cerebral palsy, treated by Baclofen pump implant, to verify if the treatment with muscular relaxing drugs could beneﬁt the progression of a pre-existing scoliosis or the development of a new scoliosis. Methods: Literature review shows a general worsening in pre-existing implant scoliosis, even if different authors have contrasting opinions.15 patients was analyzed for scoliosis progression,monitorized via x-rays pre and post-treatment.Followup ranged from two to twentyfour months. Results: This work analyzes scoliosis evolution curves considering follow-up and scoliosis severity classiﬁcation at the time of implant. In patients with developing scoliosis, we have considered the relationship between King type of curve and the drug dose released by the pump, in order to make the possible connection between critical curve angle, drug dose and King type of deformity.A signiﬁcant curve progression was recorded at followup,irrespective of Baclofen administration,mainly depending on curve severity at the moment of implant. Conclusions: Neurological scoliosis natural evolution is so remarkable that it’s difﬁcult to evaluate if the real inﬂuence of the Baclofen pump implant on a scoliosis development is effectively worse than a deformity natural progression. Signiﬁcance: Evidence of scoliosis progression in patients who have scoliosis exceding 60 prior to implant must be kept in mind,in order to treat spinal deformity simultaneously with a Baclofen Pump implant,or in a sequential way of procedure.

142 Reliability of Popliteal Angle Measurement: A study in Cerebral Palsy Patients and Healthy Controls Author: Patrick Maathuis (Netherlands) Co-Authors: Sabine ten Berge (Netherlands), Jan Halbertsma (Netherlands), Nienke Verheij (Netherlands), Karel Maathuis (Netherlands) Purpose: The popliteal angle is a widely used clinical measure for hamstring contracture in cerebral palsy (CP) patients, as well as in healthy individuals. Reliability of popliteal angle measurement is being questioned. The aim of this study is to determine the reliability of popliteal angle measurement by means of visual and goniometric assessment. Methods: Three different observers, measured the popliteal angle in 15 CP patients and 15 healthy volunteers. In each subject popliteal angles were visually estimated and measured with a blinded goniometer twice by all observers with approximately one hour between measurements. Results: The intra-class correlation coefﬁcient (ICC) was lower in the CP group compared to healthy controls. The ICC for intraobserver differences was higher than 0.75 for both groups. The ICC for inter-observer reliability of visual estimates and goniometric measurements was low for both groups. Intermethod ICC was higher than 0.75 for both groups. Conclusions: Measurements in the CP group appeared to be less reliable than measurements in the control group. Intra-observer reliability is reasonable for both groups, but lower in CP patients than in controls. Inter-observer reliability of both visual estimates and inter-observer reliability of goniometrical measurements is low. No signiﬁcant differences in reliability have been found between visual estimation or goniometric measurement.

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S64 Signiﬁcance: Because of low inter observer reliability of popliteal angle measurement his should not be the only parameter in clinical decision making in CP patients. 143 Changes in dynamic pedobarography and 3-dimensional gait analysis after subtalar arthrodesis for pes planovalgus in patients with cerebral palsy

Poster presentations: Abstracts 124–322/J Child Orthop Conclusions: The normalization of the relative impulses of 1,2,3,4th metatarsal heads of group I means that the plantarﬂexion is more improved in group I. The increase of lateral column length in group I is the cause of improvement of plantarﬂexion and we think this may be the results of the increase of working length of peroneus longus. Signiﬁcance: The increase of lateral column length after calcaneal neck lengthening osteotomy is the cause of better improvement of foot-pressure distribution and we think this may be the results of the increase of working length of peroneus longus.

Author: KyungSoo Oh (Korea, Republic of) Co-Authors: HuiWan Park (Korea, Republic of), HyunWoo Kim (Korea, Republic of), KunBo Park (Korea, Republic of) Purpose: To analyze the results of subtalar arthrodesis for pes planovalgus deformity in children with cerebral palsy using dynamic pedobarography and gait analysis. Methods: 28 patients(48 feet) who recieved subtalar arthrodesis between 2003 and 2004 were included in this study. 21 patients are boys and 7 patients are girls. The mean age at the time of operation was 9 years 2 months and the mean follow up duration was 12 months. Three-dimensional gait analysis and dynamic footpressure measurement were performed to analyze the results of index operation. Results: The pressure of medial midfoot was decreased and the pressure distribution of forefoot was improved. But, the pressure of 1st metatarsal head was decreased below normal range. The sagittal angle of pelvic anterior tilt was increased. The moment and power of plantarﬂexion of ankle were not improved. But, peak knee extension was increased because of increased ankle dorsiﬂexion. So, knee extension-ankle plantar ﬂexion coupling was improved. Conclusions: The proper lengthening of plantar ﬂexor for concerning about ankle dorsiﬂexion and power of ankle plantarﬂexor is an important factor for the gait improvement after subtalar arthrodesis. Signiﬁcance: This study is the analysis the result of extraarticular subtalar arthrodesis by 3-D gait analysis and dynamic pedobarography. 144 Dynamic pedobarographic analysis of calcaneal lengthening osteotomy and extraarticular subtalar arthrodesis in patients with cerebral palsy Author: KunBo Park (Korea, Republic of) Co-Authors: HuiWan Park (Korea, Republic of), KyungSoo Oh (Korea, Republic of), HyunWoo Kim (Korea, Republic of) Purpose: The purpose of this study is to analyze the diffferences between extraarticular subtalar arthrodesis and clacaneal neck lengthening osteotomy using dynamic pedobarogrdphy. Methods: The patients with other foot deformity, recurred deformity during follow up period and overcorrection of foot deformity were excluded. 26 patients(40 feet) were selected. Group I (20 feet) were received calcaneal neck lengthening osteotomy and group II (20 feet) were received extraarticular subtalar arthrodesis. The follow up periods are not different between two groups. Results: The relative impulses of hallux, 1st metatarsal head, medial midfoot were decreased and the relative impulses of lateral midfoot, medial and lateral calcaneus were increased in all gropus. The relative impulses of 1,2,3,4th metatarsal heads were more decreased in group II and those were below normal range. But, in group I, there are no differences to normal value in the relative impulses of 1,2,3,4th metatarsal heads.

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145 Results of triple arthrodesis for equinovarus foot deformity in cerebral palsy children and adolescents Author: Szymon Pietrzak (Poland) Co-Authors: Bartlomiej Grabowski (Poland), Jaroslaw Czubak (Poland) Purpose: The aim of the study was to assess the results of triple arthrodesis performed in cerebral palsy (CP) patients with equinovarus feet treated in our department between 1995 and 2004. Methods: The material consists of 109 CP children with foot deformities. Among numerous operative techniques triple arthrodesis was performed in 23 equinovarus feet and data of these 20 patients were assessed in further analysis. The age at surgery was from 6 to 18 years (mean 12 years). The follow-up was from 1 to 10 years (mean 5.3 years). Clinical assessment included data about pain, function and orthoses if they were applied, as well as information about other surgical procedures. The positioning of hind- and forefoot was assessed, as well as range of motion and presence of other deformities. The radiographic evaluation was based on X-rays taken in a-p and lateral views. The GMFCS was applied for the functional assessment. Results: None of the patients reported pain before the surgery, 3 of them reported pain after long walking in the follow-up. Overcorrection was observed in 3 feet, arthrosis – in 11 feet after the surgery. The patients did not improve functionally after during the follow-up, (the mean pre-op GMFCS score was 2.7 vs 2.6 post-op). Conclusions: Surgery did not signiﬁcantly improve patients’ functional status. There was no correlation between the functional status and the presence of arthrosis, although all these patients who reported about pain in the follow-up had evident arthrosis on the X-rays. Signiﬁcance: Equinovarus deformity of the feet in CP children, caused by the primary muscular imbalance, signiﬁcantly impairs their motor function. The triple arthrodesis of the foot enables correction of more severe and rigid deformities.

146 Intraoperative Measurement Of Muscle Properties Reveal A Relationship Between Muscle Remodeling And Contracture Formation Author: Eva Magdalena Ponte´n (Sweden) Co-Authors: Richard Lieber (United States), Stefan Gantelius (Sweden) Purpose: The development of muscle contractures represents a serious surgical and therapeutic challenge. Unfortunately, structural and functional changes that occur in muscles that cause the

Poster presentations: Abstracts 124–322/J Child Orthop contracture are poorly understood. We developed a tool to measure muscle sarcomere length (Ls) in children with cerebral palsy and then measured ﬂexor carpi ulnaris (FCU) sarcomere length prior to tendon transfer surgery (n = 17 children). Measurements from the FCUs of radial nerve injury patients were used as ‘‘control’’ values to represent normally-innervated muscle. Methods: Prior to surgery, the degree of contracture was assessed by measuring the extent of passive wrist motion. Then, during surgery, the FCU muscle belly was exposed and small ﬁber bundles isolated by blunt dissection. Laser diffraction was performed and sarcomere length was measured by using the ±1st order spacing distance. Results: Intraoperative Ls were extremely long in spastic FCU muscles compared to normal FCUs from radial nerve injury patients (4.6 ± 0.3 lm vs. 2.9 ± 0.2 lm). Importantly, there was a highly signiﬁcant correlation between the degree of contracture and the intraoperative sarcomere length (r = 0.70, p < 0.005). Speciﬁcally, the greater the contracture, the longer the measured Ls. The relationship between degree of contracture (in degrees) and intraoperative Ls was: y () = 15.5¢ Ls (/lm) + 130. Conclusions: There is a progressive remodeling of the muscle-tendon unit during contracture formation. These data suggest that the increase in sarcomere length may be due to progressive loss of serial sarcomeres during contracture formation. This would have the functional effect of pulling the wrist into ﬂexion as sarcomeres are lost. The underlying mechanism for the muscular changes that occur secondary to upper motorneuron lesion is not known. Signiﬁcance: These results on the relation between sarcomere length and contracture in the upper limb in cerebral palsy give new information on the molecular changes during contracture formation. 147 Mini-invasive subtalar stabilisation of pronated feet in CP patients. Author: Jan Poul (Czech Republic) Co-Authors: Purpose: To introduce mini-invasive subtalar stabilisation of pronated feet in CP patients,the method which can replace open surgery. Methods: Totally 13 feet in 7 patients were operated. Principles of operation: Harvesting the cancellous bone graft from iliac wing by using the set for mosaic plasty. Denudation of sinus tarsi from lateral mini-incision was done by using an arthroscopic shaver (blades and burrs).Then after the foot was manipulated into the correction a guiding wire was introduced from mini-incision over the talar neck slightly caudally and dorsally through the neck of talus and both cortices of calcaneus under the control of x-ray image intesiﬁer. Insertion of cannulated screw followed. Harvested bone grafts were transferred into denudated sinus tarsi by delivery tamp. All three mini-incisions were closed each with one single suture. POP cast for 6 weeks, then AFO orthosis for 3 months. All operated feet were severely everted. Age 6–8 years. Male-4, female-3. Operation time 1 hour per one foot. Results: Short follow-up 6–12 months. In all but 3 feet full correction of the deformity was achieved. In all only discrete scars were apparent. Complications: Breakage of the shaft of the cannulated screw in 3 out from 13 feet. In two retrograde-migration of the screw developed needing reﬁxation. On x-ray apparent talocalcaneal fusion was achived in 8 out from 13 feet.

S65 Conclusions: Results are preliminary, patients are uder follow-up. It seems, it could be a good method of subtalar stabilisation for near future. Signiﬁcance: Comparison of presented results (partial failure in 3 out from 13 cases, 23%)with classical open surgery (DennysonFulford) does not show substantial difference. 148 Classiﬁcation of spastic hemiplegic cerebral palsy in children Author: Jacques Riad (Sweden) Co-Authors: Freeman Miller (United States) Purpose: The Winter classiﬁcation of spastic hemiplegic cerebral palsy (CP) is based on sagittal kinematic data from three-dimensional gait analysis used in preoperative decision making and postoperative evaluation. Our goal was to investigate how well children with spastic hemiplegic CP can be classiﬁed using Winter’s criteria. Secondly, we assessed if patients move between groups over time and/or with surgical intervention. Methods: One hundred and twelve patients with spastic hemiplegic CP with a mean age of 8.1 years (range 3.6–19.8 years) and no surgery before the ﬁrst gait analysis were included. Medical records and gait analysis data were reviewed and patients were classiﬁed using Winter’s criteria. Forty-six patients had two gait analysis and were reclassiﬁed. Results: Thirty-one patients (28%) with no ankle dorsiﬂexion above neutral during swing phase were classiﬁed as group 1. Twenty-two patients (20%) who had no ankle dorsiﬂexion above neutral during the whole gait cycle were classiﬁed as group 2. Nineteen patients (17%) had total knee range of motion less than 45 degrees and were considered group 3. Fourteen patients (12%) with less than 35 degrees range of motion at the hip were classiﬁed as group 4. We found 26 patients (23%) that could not be classiﬁed according to Winter’s criteria. We deﬁned these patients as group 0, since they showed the least deviation from normal values. Each of the ﬁve groups in our study showed a higher mean velocity of gait and the patients were younger than in any of the groups from the Winter study. In regards to rotational alignment, kinetic variables, and to a certain extent muscle tone, group 0 showed the least deviations. When reclassifying patients after a mean of 3 years, 8 of 15 had deteriorated in the non-surgical group, moving to a higher numbered group. No patient in the non-surgical group had improved meaning moved to a lower numbered group and 7 remained in the same group. In the surgical group 19 of 31 treated patients had improved and moved to a lower numbered group. Four patients had deteriorated and moved to a higher group while 8 remained in the same group. Conclusions: The Winter classiﬁcation failed to classify 23 % (26/ 112) of our spastic hemiplegic cerebral palsy children. We suggest that the classiﬁcation be complemented with the less involved group 0. In this way all patients can be classiﬁed and thus treatment plans can be established for all patients. The classiﬁcation can be divided into ankle, knee and hip joint involvement. The ankle-involvement can be further divided into three separate groups. Treating physicians should be aware of the possibility that patients may move into another classiﬁcation group over time. Signiﬁcance: This complement of the Winter classiﬁcation, including all patients makes the system a useful tool in making not only treatment plans but can also help in follow-up studies and in research.

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shoe ﬁtting problems together with skin ulcerations. The aims of this study are to present an intraarticular technique of subtalar fusion using allograft and internal ﬁxation to achieve stabilization and to report the results and clinical outcome of a series of intraarticular subtalar arthrodesis performed in children with cerebral palsy. Methods: We performed a retrospective review of radiographs and medical records of 145 children with cerebral palsy who underwent intraarticular subtalar fusion from January of 1994 to December of 2004. The subtalar joint was ﬁxed through the anterior facet with a cannulated screw while the anterior aspect of the calcaneus was parallel to the anterior aspect of the head of the talus. Tricortical iliac crest allograft was placed into the sinus tarsi and the denuded posterior facet area. Results are grouped as good, satisfactory and poor according to the radiographic and clinical outcome. Results: Good results were obtained in 242 feet (96%). Satisfactory results were obtained in 6 feet (2%) which were painless pseudoarthrosis of subtalar joint in 2 feet and screw removal was required in 4 feet because of pain. Non union of the subtalar joint together with recurrence of deformity was observed in 5 feet (2%) which is accepted as poor result and required revision surgery. No deep infections, implant failure, or allograft failure were observed after a mean of 4.8 years follow up. Conclusions: In conclusion, our described technique of intraarticular subtalar joint fusion is safe and effective in children with CP, and produces a high rate of satisfactory results. Signiﬁcance: Pes planovalgus deformity in children with cerebral palsy can be corrected effectively with the described subtalar fusion technique using corticocancelleus allograft.

Cartilage defects associated with knee pain in adolescents with cerebral palsy Author: Karin Petra Schara (Slovenia) Co-Authors: Arabella Leet (United States) Purpose: The aim of our retrospective reiew study was to report a case series of four young adults with cerebral palsy and cartilage defects in the knee joint as the etiology of knee pain. Most children and adolescents with knee pain are thought to have knee pain secondary to contractures, patella alta, or malalignment syndrome (femoral anteversion with compensatory external tibial torsion). Although early degenerative changes have been reported in the hip joint, no description of loss of articular cartilage in the knee as the etiology for knee pain has been previously described. Methods: We report four cases from two centers one in Ljubljana, Slovenia and the other Baltimore, USA treated in our institutions during last three years. Three male patients were ambulatory spastic diplegic and one female non-ambulatory spastic quadriplegic, age 14 to 16 years. They all presented with severe knee pain and effusion. Knee ﬂexion contractures were present in all cases and progressed over time. In three patients moderate trauma preceded the onset of clinical signs. Plain radiographs showed patella alta and knee ﬂexion but did not have evidence of subchondral bone changes. MRI or diagnostic arthroscopy were performed in two patients; the remaining patients had an arthrotomy for patellar stabilization. Results: Cartilage loss in the distal femoral condyle of the knee was seen during arthroscopy or patella stabilization in the study population. The range of denuded area varied from a minimum of 1 cm2 to a maximum of 4 cm2. One patient had a medial meniscal tear and partial meniscetomy was performed. Another patient underwent chondroplasty in order to ﬁll in a 4 cm2 lesion on the medial femoral condyle in combination with hamstringlenghtening. In two patients, a patella stabilization procedure was performed and the cartilage deformity were drilled with a small caliber drill into the subchondral bone, followed by hamstring lengthening. All four patients improved clinically following surgery. Conclusions: Loss of the cartilage surface in the knee can cause severe knee pain with loss of ambulatory function in patients with cerebral palsy, but the pain may be attributed to other etiologies instead. The prevalence and the cause of cartilage defects in the knee in adolescents and young adults with cerebral palsy is unknown, but should be considered in the differential diagnosis of knee pain in patients with cerebral palsy. Signiﬁcance: Adolescents may have cartilage defects in the knee causing pain and loss of function. Surgical intervention is of beneﬁt to return patients to a better functional level. We are not sure if this is a rare pathology, or is simply missed with knee pain being contributed to other etiologies. 150 Subtalar Fusion in Cerebral Palsy Patients. Results of a new technique using corticocancellous allograft Author: Hakan Senaran (Turkey) Co-Authors: Mary Nagai (Canada), Kirk Dabney (United States), freeman miller (United States) Purpose: Valgus deformity of the hindfoot in cerebral palsy patients is common and causes functional deterioration and

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151 Intramedullary ﬁxation following diaphyseal derotational osteotomy in children – A preliminary report Author: Deepak G Shivarathre (United Kingdom) Co-Authors: Raheel Shariff (United Kingdom), Jay Sampath (United Kingdom), Alﬁe Bass (United Kingdom) Purpose: Various methods of ﬁxation following femoral derotational osteotomy for correction of excessive femoral anteversion in children have been reported with no one procedure proven to be superior. The key to the success of the surgery lies in achieving correction and early mobilisation. There are deﬁnite beneﬁts to early mobilisation and rehabilitaion of children undergoing multi-level surgery. We report the clinical and radiological outcome of intramedullary ﬁxation following corrective femoral diaphyseal derotation in children. The study also reviews the safety and beneﬁts of the procedure in multilevel lower limb surgery in children with spastic diplegia. Methods: We conducted a retrospective study of all femoral diaphyseal derotational osteotomies with Trigen antegrade intramedullary ﬁxation (TAN system, Smith & Nephew) from April 2005 to June 2006 in 9 consecutive patients with 14 affected limbs. 8 out of the 9 children had spastic diplegia and 5 children underwent the osteotomy as part of multilevel surgery. Difﬁculty in walking with frequent tripping and falls was the most common complaint in most of the children. Results: The mean age at surgery was 13.7 years (Range 11.2 – 17.3 years). The mean preoperative femoral anteversion was 43.6 degrees (Range 30 – 50 degrees) with the mean internal & external rotation being 61.6 (Range 50 – 70) & 8.3 (Range 0 – 20) degrees respectively. The average follow-up period was 9.5 months (Range 1.5 – 15 months). All patients mobilised with crutches in an average of 5 days (Range 3–12 days) and full weight bearing was achieved by 65 days (Range 45 – 150 days). Marked

Poster presentations: Abstracts 124–322/J Child Orthop improvement in gait was noted in all children with postoperative mean internal & external rotation being 42.9 & 52.6 degrees respectively. There were no post-operative complications and we have not encountered any instances of avascular necrosis to date. Correction was maintained at the ﬁnal follow up in all children with good bony union by 8 – 12 weeks. Conclusions: Intramedullary ﬁxation following diaphyseal derotational osteotomy in children is a safe, effective, cosmetic and reliable procedure with rapid bony union attributable to biological ﬁxation and early mobilisation. Signiﬁcance: Good early results have been obtained in children with cerebral palsy undergoing this procedure as a part of the multilevel corrective surgery. 152 Comparison of Hinged and Rigid Ankle-Foot-Orthoses on CP Diplegic Ambulation Using Gait Analysis Author: Sheldon Simon (United States) Co-Authors: Deborah Wilson (United States), Thomas Santner (United States) Purpose: Ankle-foot orthosis (AFO) are prescribed for children with CP diplegia to prevent dynamic equinous. It is also hoped that the use of such orthosis - rigid or hinged – will improve their walking ability. But as walking ability varies widely, we sought to determine whether any barefoot gait parameter can help to prescribe which brace type optimizes walking improvement. Methods: We examined 43 consecutive CP diplegia children with spastic equinous who were referred for clinical gait evaluation within 3 months after being prescribed a new AFO by their treating physician and made by the child’s orthotist. Those in the two brace groups were compared with respect to age; leg length; velocity, stride length, cadence; sagittal hip, knee, and ankle jointangles; and ambulatory function (household, limited, full community). Results: There were no differences between groups with respect to demographics. With either brace, age-related stride-length and velocity increased, whereas age-related cadence remained unchanged or decreased slightly. For rigid AFO users, the difference in age-related velocity between barefoot and braced walks increased independent of barefoot velocity. For hinged AFO users, the difference depended on barefoot velocity and the gait-cycle time when maximum knee extension and maximum dorsiﬂexion occurred. As age-related barefoot velocity increased, the difference in velocity decreased, exceeding that found for those with rigid braces only at low speeds. In only a few children did wearing either brace alter their functional ambulation status. Conclusions: Barefoot gait parameters can predict the improvement in walking speed when a hinged brace, while the change made by a rigid brace seems independent of such parameters. Signiﬁcance: Prescribing brace type based on barefoot walking function may be important only at speeds that change the child’s functional ambulatory level. At other speeds, the cost of each brace type and the braces effect on other functions, seem as important. 153 Characterizing Muscle Strength Deﬁcits in Patients with Spastic Diplegia: The Impact of Selective Dorsal Rhizotomy (SDR) Author: Michael D. Sussman (United States)

S67 Co-Authors: Cathleen Buckon (United States), Susan Sienko Thomas (United States), Michael Aiona (United States), Barry Russman (United States) Purpose: To determine if muscle strength differs based on location, joint position and type of muscle activity in patients with spastic diplegia with and without dorsal rhizotomy. Methods: Study Design: Prospective cohort: Sixteen patients with spastic diplegia (GMFCS Level 1&2), eight patients >5 years following SDR and eight age-matched patients with spastic diplegia and eight peers were studied. Muscle strength at the elbow, knee and ankle were assessed using a Biodex System 3 Pro isokinetic dynamometer. Results: Elbow: No signiﬁcant differences were found in upper extremity strength. Knee: Isometric extensor strength was decreased in both patient groups compared to peers at 30 and 60, but not 90. Isometric ﬂexor strength was decreased in only the SD group compared to peers in all testing positions Concentric extensor and ﬂexor strength were decreased in the SD group compared to peers at all speeds and compared to the SDR group at the faster speeds during ﬂexion. Concentric extensor strength in the SDR group was decreased at only the slowest speed while concentric ﬂexor strength was decreased at all speeds compared to peers. Eccentric extensor strength was decreased in the SDR group compared to peers while no differences were seen in eccentric ﬂexor strength. Ankle: Isometric and concentric plantarﬂexor and dorsiﬂexor strength were decreased in both patient groups compared to peers for all testing positions and speeds, with concentric dorsiﬂexion more impaired in the SD group than SDR group at the faster speed Eccentric plantarﬂexor strength was decreased in the SDR group compared to the SD and peer groups, while no differences were seen in eccentric dorsiﬂexor strength. Conclusions: Muscle strength deﬁcits are greater distally than proximally in patients with spastic diplegia. Isometric muscle strength was affected by joint position in both patient groups with greater impairment when muscles were in a shortened position. The difference between patients with and without a history of SDR suggests that decreased spasticity improves concentric strength at faster speeds of movement; however, the reduction in eccentric extension strength in patients with a history of SDR indicates the need for further investigation. Signiﬁcance: Children with spastic diplegia have muscle weakness which may be improved by a muscle strengthening program. Those children who underwent dorsal rhizotomy may have greater concentric strength at faster speeds due to elimination of antagonist spasticity. Muscle strengthening may provide functional improvement.

154 Orthopaedic Treatment of the Neglected Child and Adolescent with CP Author: Selim Yalcin (Turkey) Co-Authors: (Turkey)

Cengiz

Cabukoglu

(Turkey),

Nadire

Berker

Purpose: Some children with CP cannot receive proper medical care because of reasons related to the family, the society and to the health care system they live in. Neglected children are unable to reach their full potential and become a burden for their caregivers in the long run. Most neglected children need orthopaedic surgery for better function. The decision to per-

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form surgery is risky because the prognosis may be poorer than expected. This is a descriptive study of the consequences of orthopaedic treatment of neglected children and adolescents with CP. Methods: A total of 23 children and adolescents with CP who had major orthopaedic deformities limiting function due to neglect were included. The age range was from 12 to 22 years and the minimum follow-up period was 2 years. All the patients were either mild total body involved (9 cases) or severe diplegics (14 cases) who had ambulation potential but were unable to due to major deformities of the lower extremities. The deformities consisted of severe knee ﬂexion, ankle plantar ﬂexion, ankle dorsiﬂexion and valgus, and femoral anteversion. Results: All patients underwent surgical release of the knee ﬂexion contracture, 9 required distal femur knee extension osteotomy, 1 required talectomy and 4 had derotational osteotomies. Main problems encountered in the postoperative period were pain in all cases, fractures of the distal femur in 2 cases, and poor compliance with the exercise program in 9 cases. Skin problems occurred in 19 cases even though casts were not used in any of the patients and all used plastic KAFOs. The rehabilitation program lasted for an average of 15 days as an inpatient in the hospital, average of 30 days as an outpatient in the rehabilitation unit and a home program with community based physical therapy for a year. All patients were standing in plastic KAFOs in parallel bars at the time of discharge from the hospital and all were able to walk in paralel bars at the time of discharge from the outpatient rehabilitation unit. Follow-up at a year post-op showed that 60% were ambulatory at home, 20 % had only therapeutic ambulation and 20% were wheelchair-bound. Conclusions: The neglected patients needed bone surgery as well as muscle tendon lengthenings to correct the deformities to stand in an erect posture. Muscle weakness, pain and skin problems were much more pronounced compared to the young child who received adequate therapy. Patients who had not had primary mobility before surgery, had little motivation and no social life remained at the therapeutic ambulation level after surgery in spite of aggressive rehabilitation. Signiﬁcance: It is difﬁcult to gain ambulation in a child who has been in a wheelchair for a couple of years. In spite of all, children who have good intelligence and strong motivation should be given the chance of ambulation through orthopaedic surgery and aggressive rehabilitation.

achieved. Surgical technique. Under ﬂuoroscopic guidance a 2mm K-wire was drilled through a 5-mm skin incision, advanced through the centre of the cyst cavity and ﬁxed to the opposite cortex. It was left in place throughout the procedure to serve as a guiding device. Using cannulated instrumentation the proximal cortex was perforated with a 3.5 / 2.2-mm cannulated drill, and a 4.5 / 2.6-mm screw was inserted over the K-wire. In order to achieve optimal ﬂuid drainage, the appropriate length of the screw was determined by positioning its tip in the centre of the cavity. The cyst was aspirated through the screw, and a cystogram was performed using 50% Iohexol (Omnipaque) solution to determine if there were separate cavities. If separate cavities were present, a new screw was placed in each cavity, following the same procedure. Once the cyst had healed, the screws were removed percutaneously. Results: To evaluate new treatment we studied 69 children with unicameral bone cysts treated either by 1) open curettage and bone grafting, 2) steroid injection, or 3) cannulated screw insertion. During a mean follow-up of 69 months (range, 12–58), the cysts were evaluated by radiological criteria. The treatment was considered to be a failure if a subsequent procedure was undertaken or indicated (grade 3 or 4). Cysts rated as radiologically healed or healed with defect (grade 1 or 2) were regarded as having been successfully treated. The healing rate after the ﬁrst treatment in group 1) was 25% in group 2) 12% and in group 3) 29%. After the second treatment the healing rate was 50% in group 1), 19% in group 2) and 65% in group 3). Conclusions: The study has demonstrated the advantages of the decompression technique for unicameral bone cysts over open surgery and steroid injections treatment. This result also stresses the deﬁnite role of mechanical disruption of the cyst in its resolution. Signiﬁcance: We propose a new, simple and successful method for the treatment of unicameral bone cyst which is also safe and could be performed as a day case.

12 - Tumors and metabolic disorders

Author: Riad Dakwar (Israel)

156 WITHDRAWN

157 Nancy Nail Fixation of Femoral Fractures in Children With Osteogenesis Imperfecta.

Co-Authors: Gershon Volpin (Israel), Haim Shtarker (Israel) 155 Continuous decompression of unicameral bone cyst with percutaneous application of cannulated screws: new treatment option Author: Janez Brecelj (Slovenia) Co-Authors: Lovro Sohodolcˇan (Slovenia) Purpose: We present decompression treatment of the solitary bone cyst with special canulated screws and determine its role in the resolution of unicameral bone cyst by comparison to surgical and steroid treatment. Methods: Titanium cannulated screw was designed and ﬁrst used by the ﬁrst author in 1995. Its shape permits the use of a special targeting system for screw insertion (Heli Pro ) and its removal once the goal of decompression therapy has been

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Purpose: Stable minimal invasive ﬁxation of femoral fractures in patients with Osteogenesis Imperfecta. We report our experience during the past 3 years with ﬁxation of femoral fractures using Nancy Nails, in 9 children with Osteogenesis Imperfecta. Methods: The average age of patients was 5.2 (2–9) years. Eight were diagnosed as Osteogenesis Imperfecta Type I, and one as Type III. All patients had an anamnesis of at least 6 previous pathologic fractures of limbs; in two of them pathologic vertebral fractures were also found. In two patients who had normal alignment of the femur before the fracture and without narrowing of the medullar canal, closed reduction and percutaneous nailing were performed through short incisions above the distal femoral physis on both sides. In the remaining seven patients, who had severe malalignment or obstruction of the canal by a former callus, open reduction of fracture with re-canalization of the medullary canal was performed. In two patients multiple osteotomies

Poster presentations: Abstracts 124–322/J Child Orthop of femur were performed in order to correct severe deformity. In two cases spica cast was applied after the surgery, in all other cases knee immobilizer (Johns bandage or Zimmer Splint) was applied. Weight bearing was allowed after appearance of callus on control X-Ray (6–9 weeks after surgery, depending on age and weight of the child). Results: Fracture healing was achieved in all cases. All patients were free of pain. No cases of infection were observed, and no cases of postoperative contracture of knee joint were observed. No growth arrest of femoral bone was observed after surgery. Normal alignment was restored in all cases with previous malalignment of femur. In three of the patients an exchange with a longer nail was performed one and half years after the ﬁrst surgery, through a short incision in the distal femur. Four patients had prophylactic nailing of contra lateral side. 8 patients with OI Type-I were able to walk without pain and limping. The patient with OI Type III had never walked before surgery. He is 2.5 years old and does not yet walk. One patient with OI type I developed severe bilateral genu varum. Two patients had additional fractures of femur after Nancy nail ﬁxation, but fractures were undisplaced. The nail prevented displacement and no additional surgery was performed. Conclusions: This method has been proven useful for ﬁxation of pathologic fractures in Osteogenesis Imperfecta. There were no complications in our series. Signiﬁcance: Easy and stable method of ﬁxation of brittle bone.

158 Skeletal features of primary hyperoxaluria type 1 Author: Samer El Hage (Lebanon) Co-Authors: Ismat Ghanem (Lebanon), Andre´ Baradhi (Lebanon), Chebl Mourani (Lebanon), Samir Mallat (Lebanon), Fernand Dagher (Lebanon), Khalil Kharrat (Lebanon) Purpose: Hyperoxalurias are rare metabolic disorders, which can be lethal if not adequately treated. The purpose of this study is to describe the skeletal manifestations of primary hyperoxaluria type 1 (PH1), the most common of the primary hyperoxalurias. Methods: We clinically and radiographically reviewed 12 consecutive patients diagnosed with PH1 aged between 2 and 17 years. Current and past medical histories were taken and each patient was subjected to a complete skeletal survey including spine, pelvis, upper limb, lower limb, and kidney-ureter-bladder X-rays. X-rays were interpreted by two independent pediatric osteo-articular radiologists. Results: All patients had evidence of some degree of renal involvement, 4 of whom were at the end stage renal disease (ESRD) and were under dialysis. The main symptom was skeletal pain and was present only in the 4 severely involved patients and appeared during the ﬁrst two years after initiation of dialysis. The two most severely involved patients had evidence of pathologic fractures two of which necessitated internal ﬁxation. Patients with less severe renal impairment did not have any musculoskeletal symptoms. Radiological signs were present in patients with or without symptoms and consisted mainly of characteristic dense and radiolucent metaphyseal bands and distinctive vertebral osteocondensations, which were found mainly in the severely involved individuals, and other less speciﬁc such as osteopenia, subperiosteal erosions, distal phalangeal osteolysis and periosteal appositions which were also found in less severely involved patients. Interestingly, our study revealed the presence of spondylolysis in 25% of cases, one of which was associated with a grade 1 spondylolisthesis. Conclusions: Skeletal involvement in PH1 is only seen in the advanced renal failure stages and may or not be symptomatic. It

S69 comprises radiographic signs which are almost speciﬁc of oxalosis such as dense and lucent metaphyseal bands, as well as the vertebral osteocondensations, and other less speciﬁc signs probably related to the secondary hyperparathyroidism and renal osteodystrophy. Pathologic fractures occur in severely involved individuals and should be aggressively managed. To our knowledge, this is the ﬁrst study describing cases of spondylolysis in conjunction with hyperoxaluria. Signiﬁcance: Primary hyperoxaluria has typical skeletal features independently from any associated renal failure. This is the largest series reporting on such manifestations and the ﬁrst to our knowledge to report on spondylolysis as a possible and not exceptional manifestation of primary hyperoxaluria. 159 Autogenic ﬁbula bone graft in treatment humeral cyst lesion. Long term follow-up. Author: Andrzej Grzegorzewski (Poland) Co-Authors: Marek Synder (Poland), Ewa Pogonowicz (Poland) Purpose: Benign bone tumors usually do not give problems during treatment course. Simply surgical excision is the best option. Some benign bone cyst (aneurismal bone cyst, bone cyst, ﬁbrous dysplasia) could lead to bone destruction, pathologic bone fracture and become clinically malignant tumors. The aim of the study is long term follow-up of the autogenic ﬁbula bone graft in treatment of humeral cyst lesion. Methods: The study population consisted of 20 patients, mean age at the time of surgery was 11.8 years (range, 3 – 28 years) and mean follow-up was 19 years (range, 2 – 24 years). All patients underwent the same surgical procedure. Local destruction (both layers: trabecular and spongy bone) of the humeral bone caused the need of bone graft. The bone graft from ﬁbula (length range: 8–18 cm) was taken the ﬁrst, than the humeral tumor was whole excised with trabecular layer and the ﬁbula bone graft was inserted intramedullary between ends of the humeral bone without any ﬁxation. Cast immobilization was applied immediately after operation for 6 – 12 weeks and than patients underwent physical therapy for 1 – 4 months. We did not observe any bone graft fracture, bone graft loosening or nerve paresis. Histological examination revealed bone cyst (10 cases), aneurismal bone cyst (4), ﬁbrous dysplasia (2) and ossifying ﬁbroma (2). Results: Final clinical examination after growth end revealed full range of motion of the humeroscapular joint in all cases and the humeral bone shortening in 3 patients (range, 3 – 7 cm, mean 4.5 cm). The reason of the humeral shortening was bone tumor localization directly to proximal humeral epiphyseal growth plate, which was destroyed either by tumor or during operation. We observed full restoration of the ﬁbula in 6 patients. We did not see any cyst recurrence during follow-up. Patients did not complain for tibia or foot pain. Conclusions: Autogenic ﬁbula bone graft in treatment humeral cyst lesion gives clinically and radiologically very good results and it is a save procedure. Signiﬁcance: Recommended method of treatment humeral cyst lesion with bone destruction. 160 Management Of Deformities in Thalassemia Patients Author: Gamal Ahmed Hosny (Egypt) Co-Authors: Mohamed Fadel (Egypt)

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S70 Purpose: Beta-thalassemia is a common cause of chronic hemolytic anaemia and it represents a major genetic disease and a public health problem. It contributes to marked osteopenia, frequent fractures and skeletal deformities. Hypertransfusion therapy in the last 20 years has prolonged life expectancy [Vinchinsky, 1998]. High incidence of deformities in thalassemia had been reported before[Exarchou, 1984] which would increase the morbidity in these cases. However, the risk of infection, osteoporosis and immune problems may preclude operative correction. We report our experience in operative correction of deformities in thalassemics using external ﬁxator. Methods: From 1999 till 2004, 5 cases with thalassemia major with skeletal deformities were referred to our institution. Age of patients ranged from 11 y to 21y with an average of 14.5y. There were 3 female and 2 males. The right side was affected in 2 cases. The site of the deformity was tibial in 2 cases, femoral in 2 cases and humeral in one case.Shortening ranged from 5.5 to 7 cm.Evaluation parameters included: pain,limb length discrepancy, mechanical axis deviation, ROM, functional activities and satisfaction of the patients. Results: Follow up period ranged from 1y to 4y. There were 2 excellent and 3 good results. The average healing index was 48 days/cm. The time in the ﬁxator ranged from 5 to 9.5 m. Complications included: pin tract infetion in all cases and fracture after ﬁxator removal in 2 cases. Conclusions: Up to the best of our knowledge management of skeletal deformities in thalassemia patients using external ﬁxation has not been previously reported. Bone lengthening and correction of deformities has been successful using external ﬁxator with longer time for regenerate formation. Signiﬁcance: Recently,the prognosis of thalassemia has much improved, with many people surviving to the ﬁfth decade of life. Therefore, it is feasible to reduce the morbidity due to skeletal deformities with the application of external ﬁxators.

161 Percutaneous injection of bone marrow and demineralizing bone matrix of bone cysts stabilized with intamedullary ﬁxation Author: Anastasios Kanellopoulos (Greece) Co-Authors: Hristos Giannakopoulos (Greece), Leonidas Badras (Greece) Purpose: Bone cysts in children are of ambigous aetiology.both mechanical (as medullary canal occlussion) and biological (increased bone resorption) causes are considered. This study assess the efﬁcacy of a combined approach that addresses both factors. Methods: 17 skeletally immature patients with active bone cysts were studied. All had MRI, CT, and biopsies performed. Closed elastic ﬂexible nailing was performed in all but one patients, that a cortical strut was used. After stabilization of the bony segment and at the same surgical session a mixture of autologous bone marrow and demineralized bone matrix was injected percutaneously into the cyst. All cysts had length more than 2.5 times the normal bone diameter. 4 were located in the femur and 13 at the humerus. Mean age was 8 yrs(6–13). 6 patients were females and 11 males. Results: All cysts went into involution according to the Neer classiﬁcation. No refracrure occurred. All patients returned to sports with no restrictions. Conclusions: The combination of mechanical stabilization of active bone cysts in children with biological stimulation with

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Poster presentations: Abstracts 124–322/J Child Orthop demineralized bone matrix and bone marrow mixture was proven successful in the management of these lesion. Signiﬁcance: This study reinforces the recently represented in the literature trend that mechanical stabilization of active bone cysts in children leads to their involution especially if it is combined with biological stimulation.

162 Direct percutaneous Ethibloc injection in the treatment of Aneurysmal Bone Cysts: long term follow-up Author: Guido La Rosa (Italy) Co-Authors: Piergiorgio Falappa (Italy), Fausto Fassari (Italy), Antonio Di Lazzaro (Italy), Rita Devito (Italy), Elisabetta Genovese (Italy) Purpose: Objective: To evaluate long term efﬁcacy of Aneurysmal Bone Cysts (ABC) treatment with Ethibloc percutaneous injection. Study Design: Prospective observational non-randomized study Methods: Matherials and Methods: Fortyone patients affected by ABC were treated by means of percutaneous Ethibloc injection, delivered under ﬂuoroscopic imaging or CT. Filling of the cysts was incomplete, to avoid retrograde leakage and intracystic overpressure. The whole treatment was monitorized by magnetic resonance imaging to detect relapse or monitor ossiﬁcation of the cavitary lesion. Follow-up lasted from 2 to 98 months. Results: Thirty nine patients showed remarkable shrinkage of the cystic lesions with cortex thickening. The reduction of the lesion was not satisfactory for only two patients who has been successively operated on by means of courettage and grafting of the cyst. Pain disappeared in35 patients, persisted in two and occurred occasionally in four. No severe complications were observed: three patients had a local leakage of Ethibloc through the injection site, self resolving without complications. One had a mild allergic reaction. Conclusions: In our experience direct percutaneous Ethibloc injection is effective in the treatment, after a mandatory histologic diagnosis; furthermore scleroembolization does not preclude any subsequent surgical approach. MRI must be considered in all the phases of therapeutic treatment,including follow-up. Signiﬁcance: Usefulness of a percutaneous,mininvasive terapeuthic method to treat pediatric ABC.

163 Percutaneous radiofrequency ablation of the osteoid osteoma: our experience. Author: Maria Gabriella Lettera (Italy) Co-Authors: Fabrizio Cigala (Italy), Venanzio Iacono (Italy), Francesco Sadile (Italy), Antonio Lambiase (Italy), Luca Maddaluno (Italy), Vittorio Iaccarino (Italy), F Fiore (Italy), Flavio Fazioli (Italy) Purpose: The purpose of this paper is to evaluate CT-guided radiofrequency (RF) ablation as a minimally invasive therapy for osteoid osteoma with regard to our clinical success and immediate and delayed complications. Methods: From November 2004 to June 2006, in the Departement of Orthopaedic Surgery of University ‘‘FedericoII’’ and in the

Poster presentations: Abstracts 124–322/J Child Orthop Departement of Orthopaedic Surgery of National Institute of Tumours ‘‘G.Pascale’’, we observed 30 patients with osteoid osteoma; all patients clinically suspected of having an osteoid osteoma (they complained nocturnal pain that was not related to physical activity and that was typically allieviated by ingestion of salicylates) were screened according to a protocol that included the performance of radiography in two orthogonal directions, CT scanning with reconstructed section thickness of 1–3 mm and triple-phase bone scintigraphy. 30 patients underwent percutaneous radiofrequency ablation for an osteoid osteoma: 22 male and 8 female (male-female ratio = 2,75), with an average age of 17 years (age range min 3, max 47). Two of these patients underwent surgery before they were treated with thermocoagulation. The procedure of thermocoagulation was performed in regional or general anesthesia; after localization of the nidus with 1 mm CT sections, osseous access was estabilished with an 11-gauge Jamshidi needle. RF ablation was performed at 90C for a period of 4–5 minutes with use of a rigid RF electrode with a diameter of 1 mm.The mean duration of the entire procedure was 60 minutes. In all cases, the procedure was effected in Day-surgery: discharge was scheduled for the next morning to control the pain and the occurrence of immediate complications. Results: Clinical success was achived in 96% of patients; in all of them the nocturnal pain caused by osteoma disappeared within one day. 1 of 30 patients (3%) had residual pain, without impaired function, after ﬁrst thermocoagulation session. Complications were observed in two patients: one patient had neurophaty of sciatic nerve, another one had myalgia after the treatment, both resolved in around six months. Conclusions: CT-guided percutaneus RF ablation is a simple, minimally invasive, safe and highly effective tecnique for treatment of osteoid osteoma in alternative to the traditional open surgical treatment. This procedure is particularly indicated in osteoid osteoma deeply located, requiring an aggressive and risky surgical approach. Signiﬁcance:

164 The Natural History of Lower Limb Deformities Seen in Hurler’s Syndrome Following Bone Marrow Transplantation Author: Randeep Mohil (United Kingdom)

S71 no consensus as to the best management of the lower limb problems in this disorder. Signiﬁcance: Well conducted long-term follow up is essential. 165 The Histopathological Features of Proteus Syndrome Author: Fergal Monsell (United Kingdom) Co-Authors: Deborah Eastwood (United Kingdom), Susannah Hoey (United Kingdom), Loshan Kangesu (United Kingdom), John Harper (United Kingdom), Neil Sebire (United Kingdom) Purpose: To describe the histopathological features encountered in a series of patients with Proteus syndrome from a single centre. Methods: Patients with Proteus syndrome who had undergone therapeutic surgical resection or biopsy were identiﬁed from a database and the histopathological ﬁndings were reviewed, with particular reference to descriptive features of the underlying tissue abnormality. Results: There were 18 surgical specimens from nine patients, median age 4 (range 1–9) years, including four main categories; soft tissue swellings (lipomatous lesions), vascular anomalies (vascular malformation and haemangioma), macrodactyly (hamartomatous overgrowth) and others (sebaceous naevus and non-speciﬁc features). In all cases the clinical features of overgrowth were due to increased amounts of disorganised tissue, indicating a hamartomatous-type defect in which normal tissue constituents were present but with an abnormal distribution and architecture. Vascular malformations represented a prominent category of lesions, accounting for 50% of the specimens, predominantly comprising lymphatic and lymphovascular malformations. No malignancy or cytological atypia was identiﬁed in any case. Conclusions: The histopathological features of lesions resected from children with Proteus syndrome predominantly include hamartomatous mixed connective tissue lesions, benign neoplasms such as lipomata and lymphatic-rich vascular malformations. Signiﬁcance: Proteus Syndrome is a rare, sporadic overgrowth disorder for which the underlying genetic defect remains unknown. Although the clinical course is well-described, this is the ﬁrst systematic histopathological description of the lesional pathology. 166

Co-Authors: Philip Hopgood (United Kingdom), John Grainger (United Kingdom), Robert Wynn (United Kingdom), Ed Wraith (United Kingdom), Tim Meadows (United Kingdom)

Minimally Invasive Treatment Of Aggressive Unicameral Cyst: Intramedullary Fixation With Metaizeau Elastical Rods And Arthroscopic Curettage.

Purpose: To determine the natural history of lower limb deformities in Hurler’s after bone marrow transplantation. Methods: Between 1990 and 2005, 24 patients have been successfully engrafted and have been followed up for a mean of 6.8 years (range 18 months to 15 years) at Royal Manchester Children’s Hospital. We describe the lower limb problems and their management in these patients. We report on their skeletal development following successful transplant. Radiographic analysis was done using the following measurements where possible – acetabular index, centre-edge angle, migration percentage, femoral neck-shaft angle and tibio-femoral shaft angle. Results: Of the 24 patients, one has had bilateral staged shelf acetabuloplasty and bilateral staged medial epiphyseal stapling (MES). of theuppertibia.ThesecondpatienthashadbilateraluppertibialMES. Conclusions: There is very little in the literature on the long-term natural history of the orthopaedic manifestations of Hurler’s Syndrome after bone marrow transplantation. Presently there is

Author: Antonio Pascarella (Italy) Co-Authors: Pasquale Guida (Italy), Nando de Sanctis (Italy), Narco Rizzo (Afghanistan), Pier Luigi Di Giacomo (Italy), Rocco Cavallo (Italy), Mariano Di Salvatore (Italy) Purpose: Many surgical techniques have been described for the treatment of pathological fractures due to aggressive unicameral bone cysts in order to varying rates of success and incomplete healing or recurrence. Many Authors suggested curettage and bone grafting as effective treatment in case of active lesion in children 8 – 12 years old, adjacent to the physis with width of the lesion exceeds that of the adjacent physis and recurrence or persistence. Due to invasive nature of operation this method non is preferred by several Authors :we preferred minimally invasive treatment consisting closed reduction and ﬂexible with titanium rod (Nancy)intramedullary ﬁxation for low operative morbidity whether for the fracture or for the cyst; in case of recurrence of the

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S72 cyst the closed curettage of the cyst with arthroscopic technique can be applied successful. Methods: Between 2002–2004 40 aggressive unicameral cysts were observed as pathologic fractures in patients between 5–15 years old in these cases there was a signiﬁcant loss of bone stock. The site of involvement was in 33 patients the metadiaphysis of humerus, in 7 the femur; radiograms reveal expanding lesion in metaphysealdiaphyseal site with cortex tinned from its inner surface and erosion with infraction with displacement. The parents were informed about contextual presence of two lesions: the fracture and cyst. The proposed internal ﬁxation with Nancy titanium rods heals the ﬁrst and might heal the second lesion ; in case of failure this method do not exclude another possibility of treatment as arthroscopic curettage. The Nancy ﬂexible intramedullary ﬁxation was performed with retrograde access 3 0 4 mm. diameter. Two nails with ‘‘ Eiffel Tower’’ construction were inserted by two miniportals 1 centimetres far from the physis. Follow up of treated lesion was made with periodic x rays performed every 45 days. Results: In 36 patients after a 2-year period of observation the cyst has completely or incompletely healed but with a sufﬁcient bone stock in the remainder four cases the arthroscopic procedure was performed. Curettage of cystic wall by trimmer blade and multiple miniportals 4,5 millimetres is the best way to treat all the cyst. In all the cases we used the standard optical cannula 30. Conclusions: In conclusion minimally invasive treatment by Nancy rods and artrhoscopy can be effective because assure high incidence of favourable results by decompression-scaffolding of the lesions. Signiﬁcance: the patient quickly recover natural life and school attendance.

167 Elastic Stable Intramedullary Nailing for the Treatment of Fractures of the Femur and Humerus in Osteogenesis Imperfecta Author: David Rowland (United Kingdom) Co-Authors: Andrew Morgan (United Kingdom), James Fernandes (United Kingdom), Michael Bell (United Kingdom) Purpose: Treatment of acute fractures in Osteogenesis Imperfecta presents a signiﬁcant challenge. Plaster immobilisation and nonweightbearing cause loss of bone density. Plates are undesirable because of the risks of stress shielding, osteopaenia and periprosthetic fracture. Straight rods rods provide adquate stabilisation of the length of a bone but are technically difﬁcult to insert, particularly in the presence of deformities from previous fractures. Spica treatment for femoral fractures may be uncomfortable and carries a risk of malunion, which may predispose to further fractures. Traction requires long inpatient stays. Non operative treatment of humeral fractures is difﬁcult and has a signiﬁcant risk of non-union or malunion, often related to the shape of the chest against which the arm rests. We present the results of treatment of femoral and humeral fractures with elastic intramedullary nails. Methods: A retrospective review of notes and patients provided 8 cases (3 female and 5 male). The mean age was 12 years. We treated 6 femoral fractures and 2 humeral fractures. The femoral fractures were acute. The humeral fractures had been treated nonoperatively with no success. Standard techniques for the insertion of elastic nails were used. Care was taken to ensure that the nails did not breach the cortex of the bone as they were advanced. Results: All fractures progressed to union. Two of the patients required further surgery to adjust the position of the nails after the implants backed out, causing discomfort. There were no infections.

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Poster presentations: Abstracts 124–322/J Child Orthop Conclusions: Elastic stable intramedullary nailing in osteogenesis imperfecta is a satisfactory method for treating fractures of the long bones, even in the presence of preexisting deformity where other methods may be difﬁcult. There is a small risk of minor complications, namely backing out of the implants but this can be avoided if the nails are buried or if soft tissues are formally closed over the ends of the implants. Signiﬁcance: We demonstrate that a recognised technique for the management of fractures may be applied to patients with osteogenesis imperfecta, a group in whom such treatment has not previously been described.

168 Fifteen years survival and extensive, unexpected functional regeneration of the knee joint following the resection of the medial femoral condyle. Author: Ka´lma´n Szepesi (Hungary) Co-Authors: Ga´bor Kova´cs (Hungary), (Hungary), Gabriella Szu¨cs (Hungary)

Istva´n

Mo´rocz

Purpose: To present a case in which the medial condyle of the femur was resected due to osteosarcoma at the age of 8. The patient is currently alive after 15 postoperative years. Tumor recurrence or metastasis was never observed. Without further reconstructive surgery, the knee joint of the patient showed extensive functional regeneration to such an extent, that at the age of 23, the joint is fully stable in extension, and the patient is able to walk without any aiding device. Methods: The patient was admitted to our department in 1991 due to uncertain left knee symptoms that have been persisting for the two previous months. In addition, one week preceeding his admission, the knee swell and pain was experienced also at night. The X-ray, CT and angiographic examinations showed a lytic tumor in the medial condyle of the femur, that elevated but did not penetrate the periosteum and partially destroyed the physis. During surgery, it was possible to resect the tumor within the normal tissues, thus the medial condyle was removed together with the medial collateral and the cruciate ligaments and the medial part of the joint capsule. The histological diagnosis was osteosarcoma. Subsequently the patient received postoperative chemotherapy according to the COSS-86 protocol. According to the protocol, at the timepoint of the deﬁnitive operation, the resection surface of the femur was surgically exposed but the area was tumor-free as proved by histology. Following the application of a plaster cast, the child began to walk by using a caliper that stabilized the operated knee. Fifteen months after the operation, the child fell and the femur broke immediately proximal to the resection site. The dislocation-free fracture heeled in a plaster cast without any complication and the patient subsequently walked without any problem with the help of a caliper. Unexpectedly, four years after the operation the child was able to use the affected joint securely without any aiding device and was walking with an only slightly noticeable limp. Results: The follow-up X-ray showed the thickening of the femur, and the regular CT and scintigraphy controls did not indicate either metastasis or tumor recurrence. At present, at the age of 23, the patient lives a normal life, works as a professional driver without the use of any aiding device. His affected knee joint is fully stable in extended position, and 80o of ﬂexion is possible. He is satisﬁed with his condition and does not request either reconstructive surgery or an orthopaedic shoe to alleviate the 6 cm shortening of the limb.

Poster presentations: Abstracts 124–322/J Child Orthop Conclusions: Unexpected good result was observed after partial resection of the knee joint due to osteosarcoma, and treatment according to protocol COSS 86. Signiﬁcance: In special cases even of highly malignant tumors very good results can be achieved with adequate treatment.

169 Eosinophilic granuloma in children and adults – the scottish experience Author: Kar Teoh (United Kingdom) Co-Authors: Jim Huntley (United Kingdom), Kishan Sokhi (United Kingdom), Robin Reid (United Kingdom), Daniel Porter (United Kingdom) Purpose: Langerhans cell histiocytosis (LCH) is a tumour-like condition that runs a variable clinical course. Recent series have suggested that skeletally immature patients with a solitary bony focus (eosinophilic granuloma) have an especially good prognosis. We aim to compare recurrence/progression rates for Scottish patients with solitary eosinophilic granulomas, according to skeletal maturity. Methods: A retrospective case note review of patients with eosinophilic granuloma were identiﬁed from the Scottish Bone Tumour Registry. Results: We identiﬁed 70 cases of biopsy-proven non-spinal eosinophilic granuloma of bone. Of these, 39 were skeletally immature (< 16 years) and 31 were skeletally mature (>16 years). Followup (mean 8.25 years) was either continuing or to discharge/death. On the basis of initial screening (skeletal survey/bone scan), 9 cases (13 %; 4 and 5 patients, from the paediatric and adult groups respectively) were found to have multi-focal disease. Considering those with unifocal disease: (i) in the immature group, 6 patients (ex 35; 17%) developed a further manifestation of the condition (2 had recurrences at same site; 2 developed a distinct focus in bone; 1 developed a distinct soft tissue lesion causing spinal cord compression; 1 developed diabetes insipidus), (ii) in the mature group, 3 patients (ex 26; 12%) developed a distinct focus in bone but there was no other recurrence/progression. Conclusions: For this population, these data show that the prognosis for paediatric patients with isolated eosinophilic granuloma of bone must be more guarded than that suggested by other series. Signiﬁcance: Based on our study, the clinical course for paediatric patients with isolated eosinophillic granuloma might not be as good as stated in other series and would require more aggressive treatment to prevent recurrence.

S73 metatarsal. The purpose of this study is to present the postoperative outcome in six children (eight metacarpals) with congenital brachymetatarsia who underwent metatarsal lengthening by callus distraction. Methods: Between July 2001 and March 2006 eight congenital short metatarsals in six children (ﬁve girls and one boy) with ages ranging from 10 to 14 years were lengthened by callus distraction technique (Callotasis) using the Orthoﬁx M101 Standard MiniRail Lengthener. The follow up time ranged from 6 months to 48 months. One patient had bilateral congenital short 1st metatarsal, and another one had bilateral short 4th metatarsal. The third patient had short 3rd metatarsal (right foot), the fourth patient had short 5th metatarsal (left foot), and the last two patients had short 4th metatarsal (one right and one left foot). Lengthening was initiated on the day 7 after application of external ﬁxator and metatarsal diaphyseal osteotomy at a distraction rate of 0,5 mm per day. Weight bearing was allowed 1 day post op. The regenerate was monitored with standard x-rays and the ﬁxator was removed after sufﬁcient callus consolidation had been achieved. Results: The median lengthening obtained was 15 mm (range 9 – 25 mm) which was 35% (range 20–63%) of the original metatarsal length. The median bone healing index (BHI) was 66,1 days/cm (range 38,0–87,8). In all metatarsals the target length was achieved. All patients tolerated the procedure well and were satisﬁed with the functional and cosmetic results. No bone grafting was done. No neurovascular compromise, malunion or angulation deformities were noted. In 4 of the 8 cases joint stiffness and narrowing of metatarsophalangeal joint space were observed during distraction but these were gradually resolved after the removal of the external ﬁxator. Superﬁcial pin tract infections in 5 patients were treated with per os administration of antibiotics. Conclusions: Metatarsal lengthening by callus distraction in childhood congenital brachymetatarsia it is simple and safe procedure without serious complications. Signiﬁcance: Although requires longer treatment period, callus distraction gives sufﬁcient lengthening for the treatment of congenital brachymetatarsia. It overcomes the disadvantages of one-stage lengthening which include a small gain in length, no capability of early weight bearing, and neurovascular damage. This method could be recommended as the procedure of choice. 171 It is possible to propose an early planned series of moderate lengthenings for complete congenital ﬁbular deﬁciency Author: Olivier Franc¸ois Badelon (France) Co-Authors:

Limb reconstruction

170 Metatarsal Bone Lengthening By Callus Distraction In Childhood Congenital Brachymetatarsia Author: John Anastasopoulos (Greece) Co-Authors: Aikaterini Aretaki (Greece), Stylianos Kolovos (Greece), George Matsinos (Greece), Elias Karanikas (Greece) Purpose: Congenital brachymetatarsia is a rare deformity of the foot that may lead to functional (irritation, metatarsalgia, calluses, stress fractures) and cosmetic problems. The aim of the surgical correction is the restoring of the normal length of the

Purpose: Fifteen years ago the recommendation was an early Syme amputation in complete absence of the ﬁbula if the limb length discrepancy was 4 cm or greater at one year of age. In the practice of the author, parents had refused this indication. On the other hand in 1985–86, he had an initial experience with the technique of Ilizarov in young children, which showed that it was possible to expand the indication of lengthening when the hip was stable with a functional foot. Methods: Five patients with unilateral involvement have been treated since 1989. The femorotibial inequality was 54.8 mm (35–80) at one year of age, with a discrepancy of 19.4 % (13–30). The calculated shortening at skeletal maturity was 15.6 cm (10–24), not including the foot. A posterolateral release of the foot was performed before walking age in 3 cases, with an osteotomy of the distal tibia in 2 patients and an arthrodesis of the ankle in one patient. The lengthenings were begun at 2 years of age

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S74 (1.6–2.8) for the tibia with a lateral release of the leg, and at 4 years of age (3.5–4.4) for the femur. They had 5.6 lengthenings (3–7) per child, 21 of the tibia and 7 of the femur, with an angular correction of 10 to 40 degrees without bone resection. The callotasis technique was used (1 mm per day) with an external ﬁxator of Ilizarov in 2 procedures and an Orthoﬁx in 26, without weightbearing during the lengthening period. Lengthening per bone segment ranged from 15 to 40 mm (12 to 20 %). The interval between each lengthening was 9 to 23 months. Results: Complications occurred only in the lengthened bone with 7 bowings, 5 fractures and one chronic infection in the hole of a pin. No articular disturbances were observed. A genu valgum of 20 was treated by a simple osteotomy of the upper tibia in one At the last follow-up, all the children had ﬁnished their lengthening program with an epiphysiodesis of the contralateral knee by 12 years of age (10 to 13). They were 15.7 years of age (15–17.6). The femorotibial inequality was 3 mm (+5/–10) with a limb discrepancy of 38 mm (–15/–45) because of the foot. They had a genu valgum of 9 degrees (5/12). The foot was in a lateral position in 3 but functional in all. All of them had normal shoes with a compensation of 12 mm (8/20) and a medical sole in only one. They had a normal lifestyle without any effect on schooling. Conclusions: This step by step lengthening program should be considered before 3 years of age if the predicted femorotibial inequality at skeletal maturity is less than 25 cm and if the foot is or will be functional after surgical release. Signiﬁcance: This proposition should be considered in young children with other diseases. It is safer and simpler than the attempted greater lengthenings in older children and adolescents, with the possibility of prosthesis avoidance during the school years. 172 Factors affecting distraction osteogenesis at the proximal tibial metaphysis in congenital pseudoarthrosis of the tibia patients Author: Tae-Joon Cho (Korea, Republic of) Co-Authors: In Ho Choi (Korea, Republic of), Ki Seok Lee (Korea, Republic of), Won Joon Yoo (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Sang Min Lee (Korea, Republic of) Purpose: Tibial shortening is the most frequently encountered problem remaining after osteosynthesis in congenital pseudoarthrosis of the tibia (CPT). Ilizarov method enables comprehensive approach by concomitant limb lengthening. Previous reports on Ilizarov method focused mainly on achievement of bony union at the pseudarthrosis site. The purposes of the current study were to investigate the outcome of distraction osteogenesis at the proximal metaphysis using Ilizarov method in CPT patients, and to ﬁnd out the risk factors for poor or delayed bone formation. Methods: Twenty-seven cases of distraction osteogenesis (DO) in 22 patients with CPT were divided into two groups. Group I was those in which the target length was achieved with healing index (HI) of 70 day/cm (median value) or less, and Group II those in which HI was over 70 day/cm or additional procedures were required. Clinical and radiological characteristics were compared between these two groups. They included age at the time of surgery, type of Ilizarov construct, association with neuroﬁbromatosis type I, length gain, overall distraction rate, proximal tibial dysplasia, presence of intramedullary rod, and repeated lengthening. HI was again compared among another subgroups divided according to the signiﬁcant risk factors. Statistical analysis was performed using Mann-Whitney U test, Fisher’s exact test, and Kruskal-Wallis test.

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Poster presentations: Abstracts 124–322/J Child Orthop Results: Ten cases belonged to Group I, of which HI averaged 39.3 day/cm. Seventeen cases belonged to Group II with a mean HI of 117.4 day/cm. In Group II 12 autogenous bone grafts and 4 bone marrow injections were performed additionally. Length gain and distraction rate were larger in the Group I reﬂecting their favorable conditions for distraction osteogenesis. All the cases with proximal tibial dysplasia (11 cases) or repeated lengthening (6cases) belonged to Group II, which were statistically signiﬁcant. The other parameters were not signiﬁcantly different between the two groups. When the 27 cases were divided into four groups according to the two risk factors, signiﬁcant difference in HI was observed among the four groups. Those who did not have any of these two factors showed the largest length gain and distraction rate, and the shortest HI. Conclusions: Proximal tibial lengthening and repeated lengthening are two signiﬁcant risk factors for poor bone formation in distraction osteogenesis at the proximal metaphysis of CPT. Signiﬁcance: Distraction osteogenesis at the proximal tibial metaphysis can be safely performed in CPT patients without these risk factors. Delayed bone formation or nonunion is expected with any of these risk factors. Physeal distraction may be an alternative option in these cases. 173 The role of CT-angiography in diagnosis and treatment strategy of proximal femoral focal deﬁciency (PFFD) Pappas II and III Author: J Chomiak (Czech Republic) Co-Authors: M. Horak (Czech Republic), M. Masek (Czech Republic), M. Frydrychova (Czech Republic), P. Dungl (Czech Republic), O. Adamec (Czech Republic), M. Ostadal (Czech Republic) Purpose: To evaluate the role of CT-angiography and 3D-CT reconstruction of PFFD Pappas II and III for diagnosis and treatment strategy. Methods: 7 patients (6 boys, 1 girl, age 2 to 11 years) with PFFD Pappas II and III underwent CT examinations with visualisation of vessels between July 2005 and August 2006. Iomeron 400 (doses acc. to weight) and Siemens Somatom Sensation 16 were used for the examination. There were 6 patients with Type III and 1 patient with Type II according to Pappas, respectively. In all but one, the right side was involved. The feet were normal in 6 patients and severe hypoplasia of tibia and ﬁbula and 2-rays foot were present in 1 patient. Results: CT examination revealed proximal femoral epiphysis in dysplastic acetabulum in 6 cases, which was connected through the soft tissue with remnants of diaphysis (Type III), whereas the femoral epiphysis was not seen in 3 patients on plain radiograph. In one case (Type II) proximal epiphysis failed in dysplastic acetabulum, and remnant of femur was highly proximally dislocated. Angiography reconstruction had shown the normal anatomical vascular pattern of the extremity in 5 cases, where the extremity and pseudoarthrosis were supplied through the femoral artery as the branch of the external iliac artery. In 2 cases, both types of Pappas III, the pseudoarthrosis was supplied from the femoral artery (external iliac artery) as the terminal branch, but the remnant of the extremity was supplied from the internal iliac artery, which enters the thigh dorsally from the hip joint and continues to the popliteal artery. The concomitant veins follow the arteries in 6 cases. There were no signiﬁcant anastomoses between the femoral and popliteal arteries in this vascular pattern. This vascular pattern was not connected with any external body exceptions. The children were treated according to the age and type of deﬁciency. Namely, there were 2 pseudoarthroses reconstructions and lengthening of the

Poster presentations: Abstracts 124–322/J Child Orthop femur, 1 knee-for-hip procedure, 1 pelvi-femoral distraction and 3 patients younger than 3 years used the ortho-prosthesis. Conclusions: 3D-CT reconstruction helps to identify the proximal femoral epiphysis and the spatial conﬁguration of the pseudoarthrosis. The CT-angiography reconstructions show either a normal or atypical pattern of the vascular supply of pseudoarthrosis and the extremity. Both methods in combination were used for the decision of the type of surgical approach and surgical method in order to save the blood supply of pseudoarthrosis and extremity. Signiﬁcance: We have not found literature reports concerning a systemic study of the vascular pattern of the PFFD type Pappas II-III. CT reconstructions and angiography help the surgeon decide the treatment strategy. These methods can introduce a new concept of the current classiﬁcations and improve the treatment strategy of PFFD. 174 Correction of deformities in children using the Taylor spatial frame Author: Mark Eidelman (Israel) Co-Authors: Viktor Bialik (Israel), Alexander Katzman (Israel) Purpose: Taylor Spatial Frame (TSF) is a unique external ﬁxator. Using computer software, the TSF can correct the most difﬁcult deformities and simultaneously correct six-axis deformities. The purpose of this study was to determine the effectiveness of the TSF for treatment of various conditions in pediatric patients. Methods: We reviewed treatment of 40 patients (51 frames) who where operated on from January 2003 until December 2005. Mean age of patients at the time of surgery was 12.5 years (range 3.5– 16 years). Eleven patients had complicated fractures, six Blount’s disease, ﬁve malunions with subsequent growth arrest, two had congenital short femurs and tibiae, four knee ﬂexion contractures, four clubfeet, and eight had various deformities of the lower limbs. Results: All frames were removed after a mean time of 12.6 years(range, 8–20 weeks).All but one patient were anatomically corrected, and all contractures were corrected. Complications included superﬁcial tract infection in 20 patients, three children had fractures of femora through regenerate, and two had complications related to half-pin insertions (transient peroneal nerve palsy and genicular artery bleeding). Conclusions: We believe that TSF is excellent tool for the correction of multiple plane deformities in children and adolescents and signiﬁcantly expands our ability to correct precisely the most difﬁcult deformities. Signiﬁcance: Combination of a stable external ﬁxator and the accuracy of computer based technology makes the TSF the treatment of choice in the precise correction of limb deformities. 175 Distraction osteogenesis lengthening with and without deformity correction using Orthoﬁx and Ilizarov ﬁxators. Author: German Garcia-Llaver (Argentina) Co-Authors: Eduardo Stefano (Argentina), Gabriela Martinez (Argentina), Nestor Vallejos-Meana (Argentina) Purpose: The goal of this study was compare the result and complications of distraction osteogenesis lengthenings in 2 different Orthopaedic Hospitals.

S75 Methods: Between 1993 and 2003 the authors review the result and complications of 248 bone lengthenings. We divided the cases in 2 groups: Group I Axial Bone Lengthening 161 segments (128 in HNRG and 33 in DKCH) Group II Bone Lengthening + Deformity Correction 87 segments (70 at HNRG and 17 at DKCH) Results: The average age at the time of frame application was 10.8 years old in HNRG and 16.7 years old in DKCH. We performed an statistical analysis taking in consideration the time in frame, percentage of the initial bone length lengthened, length achieved, angular correction, bone healing index and complications rate to determine the effect of the type of frame and simultaneous deformity correction on these parameters. Conclusions: The type of frame used and the simultaneous deformity correction in addition to the lengthening procedure were not determinants factors in terms of complications rates and bone healing indices (p < 0.05). Patients who were 14 years old or more were associated with higher rates of complications. We believe that BHI is a controversial parameter to evaluate the ﬁnal result of a bone lengthening because depends on the amount of length gained and subjective criteria to frame’s removal and could not be used to predict an increase in the complications because of poor bone formation. Signiﬁcance: Distraction osteogenesis is a useful and effective method of bone lengthening but we suggest lengthen no more that 20 % of the initial bone length or no more that 6 centimeters in patients with LLD and no more that 8 to 10 centimeters in those with short stature due to skeletal dysplasia, because beyond this limit the risk of complications and additional anesthesia increase dramatically. 176 Treatment of limb length discrepancy using the Ilizarov method Author: Vicky Vassiliki Gereis (Greece) Co-Authors: Nikolaos Papandreou (Greece), Dimitris Pasparakis (Greece), Nikolaos Agorastidis (Greece), Georgios Pistevos (Greece). Purpose: To study the results and complications of the Ilizarov method for the treatment of leg length discrepancy. Methods: During the period from 1986 to 2002 we treated 142 children with leg length discrepancy of various aetiologies. The mean age was 12.7 years (range 4–20). All children were treated with the Ilizarov external ﬁxator. Outcome measures used, were total length gained, number and severity of complications, correction of residual deformities, leg length equalisation and patient satisfaction. Alterations in limb function (improvement or deterioration) were also noted. Follow up ranged from 3 to 13 years. Results: The total length gained ranged from 6–13 centimetres, with an average of 9.6 cm. Using limb length equalisation and axis correction as an outcome measure, the results were rated as very good. The functional and aesthetic results were also very good, in relation of course to the severity of the initial disorder that caused the discrepancy. The majority of complications were minor; most were observed in children with leg length inequality of congenital aetiology and did not alter the ﬁnal result. The complication rate decreases with increasing experience of the medical team, owing to the learning curve of the method. Conclusions: The Ilizarov method is a reliable method for the treatment of large leg length discrepancy. In addition to length-

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S76 ening, residual deformities can also be corrected, resulting in restoration of the mechanical axis and improvement of function. The complication rate is high, but most are minor and do not affect the ﬁnal result. Signiﬁcance: This is a long term follow up study of a large series that adresses the results and complications of the Ilizarov method.

177 Humeral lengthening in achondroplastic patients using the Ilizarov system and a peripheral supracondylar osteotomy Author: Vicky Vassiliki Gereis (Greece) Co-Authors: Dimitrios Pasparakis (Greece), Nikolaos Papandreou (Greece), Nikolaos Agorastidis (Greece), Georgios Pistevos (Greece) Purpose: To evaluate the results of humeral lenthening in achondroplastic patients, using the Ilizarov method. Methods: From 1996–2002 52 humeral lengthenings were performed in 26 achondroplastic patients using the Ilizarov apparatus and a peripheral supracondylar osteotomy. There were 16 boys and 10 girls with a mean age of 14 years 8 months (range 10–18). The total length gained in each segment ranged from 6,5–10 cm (mean 7.57 cm). The average treatment time was 6.2 months with a mean healing index of 26 days/centimetre of length. The average follow-up time was 6 years. Results: Functional and aesthetic results were graded as excellent or very good with high patient satisfaction. Most complications were of mild severity and did not alter the ﬁnal result. There were six superﬁcial pin tract infections that responded well to oral antibiotics. There were no cases of deep infection or osteomyelitis. There was one case of delayed union and one fracture following removal of the apparatus that was treated with a plaster cast and healed uneventfully. There were 2 neurapraxias of the radial nerve during lengthening that resolved by slowing down the rate of lengthening for a few days. Conclusions: Humeral lengthening using the Ilizarov technique and a peripheral osteotomy, is safe and reliable with an acceptable complication rate. The length gained aided in greater autonomy and patient conﬁdence as well as in better body proportions. Signiﬁcance: This is a large series of humeral lengthening using the Ilizarov external ﬁxator and a supracondylar osteotomy. The study demonstrates the results as well as the advantages and disadvantages of this method. 178 Results After Limb Reconstruction using the Taylor-Spatial Frame to Treat Congenital & Acquired Paediatric Problems Author: Gordon Andrew Higgins (United Kingdom) Co-Authors: Christopher Bradish (United Kingdom) Purpose: To assess the use and versitility of the Taylor-Spatial Frame for correction of paediatric deformities. Including Blounts disease, ﬁbular hemimelia,Olliers disease,Congenital Pseudoarthrosis of the tibia, growth arrest due to idiopathic growth arrest and growth arrest after meningiococcal septicaemia. Methods: We identiﬁed all consecutive patients, under the age of 18, who have had treatment with a Taylor-Spatial frame at the

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Poster presentations: Abstracts 124–322/J Child Orthop Royal Orthopaedic Hospital. All frames were applied by the senior author. We recorded the diagnosis, initial deformity parameters, number of days taken for correction to be achieved,satisfaction of correction according to normal values, amount of time frame worn and complications; including joint contractures, subluxation,dislocation, neuropraxia and deep infection. Results: 17 Taylor-Spatial frames were applied. 13 patients were treated and 4 patients had bilateral treatment.The average age was 9.4(2–17) years. The average time taken to achieve correction was 29 (12–80) days. The average valgus deformity was 10.2 (5–15) degrees and the average varus deformity was 16.1 (14–23) degrees. Rotational deformity ranged from 10–20 degrees and leg lengthening ranged from 0–50 mm. There were no deep infections, neuropraxias, joint subluxation or contractures noted. 38% of patients had staph aureus pin site infections conﬁrmed by microbiology. These were all treated with antibiotics and erradicated. All patients achieved full correction. Conclusions: We found the Taylor-Spatial frame to be very versatile and effective at treating complex limb deformities and achieving sound bony union in children. Children, with parents, can understand and operate the frames. Signiﬁcance: There is little published data with the use of TaylorSpatial frames in children. Treatment of complex limb deformities with the ilizarov frame is complicated and difﬁcult. The TaylorSpatial frame, and computer generated correction data, is a powerful tool that can be simply adjusted by children and their parents to correct deformities reliably and successfully.

179 Forces during limb lengthening with different distraction rhythms in a child with constitutional shortness Author: Joachim Horn (Norway) Co-Authors: Harald Steen (Norway), Gudrun Aarnes (Norway), Per Ludvigsen (Norway), Leif Kristiansen (Norway) Purpose: Tensile forces are believed to be an indicator of soft tissue adaptation during limb lengthening, and thereby to play an important role in the pathogenesis of complications associated with distraction osteogenesis. Based on previous results, the purpose of our investigation was to see if a distraction rhythm which includes one day without lengthening every 4th day would reduce tensile forces in the treated limb compared to continuous lengthening and to see how tensile forces inﬂuence lengthening index and pain. Methods: An 18 year old female with constitutional shortness underwent bilateral bifocal lengthening using an Ilizarov external ﬁxator. Tensile forces were regularly measured by force transducers mounted in series across the proximal lengthening zone. Lengthening was performed with an average distraction rate of 0.75 mm/day and a distraction rhythm of 3 · 0.25 mm/day on the left tibia and 4 · 0.25 mm/day with one day ‘‘off’’ every 4th day on the right tibia. Distal lengthening zone was distracted 0.75 mm/day on both sides. Results: The total achieved lengthening for each side was 70 mm, 35 mm at each lengthening zone. Force values were lower in the limb which followed the distraction rhythm with one day without lengthening every 4th day. Maximum tensile force in this limb was 250 N compared to 300 N in the other limb. These differences were signiﬁcant according to Kleinbaums test of slope and force difference (p < 0.001). The side with continuous lengthening showed higher force values, but better healing and less pain (Paired t-test: p < 0.001) for the patient.

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Conclusions: Pre-planned regular rest periods in distraction resulted in: reduced tensile forces across the callotasis zone, increased lengthening index and increased pain. Signiﬁcance: Upper and lower limits of tensile forces may exist for optimal bone healing, and in the present study tensile forces of about 300 N were probably closer to the optimal value for stimulation of osteogenesis.

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Purpose: Congenital pseudarthrosis of the tibia is a rare and difﬁcult condition to treat, and in the past a large number of patients have undergone amputation. With the advent of Ilizarov technique and microsurgical bone transfer radically changed the management of this condition. Comparison of our experience with both the techniques is presented. Methods: Nine cases of congenital pseudarthrosis of tibia were treated in our hospital. Of these Five patients were treated by Ilizarov technique. Two patients who went into non-union using Ilizarov technique and an additional four children were treated by microsurgical free ﬁbular transfer. Age of the patient’s ranged from 1.5 yrs to 5 yrs. The longest followup with Ilizarov group was 9 yrs and in free ﬁbula was 5 yrs. Results: We achieved bone union in all patients of free ﬁbula transfer group and three patients in Ilizarov group. In Ilizarov group average surgical procedures were six (includes frame realignment, bone grafting and change in to free ﬁbular group) In free ﬁbular graft group, only one surgical procedure was done in all patients, which excluding the removal of ‘K’ wire and external ﬁxator. In Ilizarov group two patients required bone grafting procedure at docking site at average of 17 months (14 months and 20 months) due persistent nonunion and union achieved in both the cases at average of 24 weeks (27 weeks and 26 weeks). Two patients in this group changed to free ﬁbular graft procedure due to unsatisfactory bone growth and recurrence of deformity after an average of 8.5 months (8 months and 9 months) duration of presence of ﬁxator in the patient was varying from 8 months to 10 months (mean 9 months) Six patients were treated in free ﬁbular graft procedure, which includes the two patients whom changed from Ilizarov group. Bone union was achieved from 10 weeks to 14 weeks (mean 12 weeks) in all patients. Conclusions: Microvascular free ﬁbular transfer is now our preferred technique for the management of congenital pseudarthrosis. It provides a reliable bone union compared with Ilizarov technique. Patient compliance is also better. Inability to simultaneously correct leg length and additional deformities of the foot are limitations. Signiﬁcance: The sample is too small to calculate the statistical signiﬁcance.

Distraction Osteogenesis in Lower Limb Author: Mahzad Javid (Iran, Islamic Republic of) Co-Authors: Gholam Shahcheraghi (Iran, Islamic Republic of), Fatemeh Hadavi (Iran, Islamic Republic of) Purpose: Report the variability of Ilizarov leg lengthening results in a mixed practice set-up,where the majority of patients come from villages far away from the main hospital, and go back,after a week, to their homes where there is no easy access to health facilities. Methods: 61 lower limb segments in 56 patients with leg length discrepancy who had undergone lengthening with Ilizarov technique and principals were evaluated with an average of 6.1 years follow-up. Besides full joint, limb and gait evaluation, detailed functional outcome assessment was performed by several evaluation tools including Short Musculoskeletal Function Assessment, WOMAC, MACTAR, and SF36. The parents’ and patients’ satisfaction questionnaires were also completed by all the cases. Results: Among the 17 cases of congenital bone deﬁciencies, 11 post paralytic,11 post traumatic, 8 post infection,and 9 miscellaneous cases,like congenital tibial pseudarthrosis and osteogenesis imperfecta a mean length of 7.6 centimeters from a single bone was obtained. The healing index was 30.5 days per centimeter for unifocal and 19.2 for bifocal lengthening. The group of congenital deﬁciencies which included 7 bifocals had the lowest and the paralytic ones the highest indices. The goal of one stage lengthening was achieved in 82% and was not reached in 8 cases who had an estimated discrepancy of 8–19 centimeters-either due to parents’ intolerance to the lengthy procedure or due to major complications.Side-effects were observed with a rate of 0.4 per femoral and 0.8 per tibial lengthening. The femurs-mainly congenital deﬁciencies-encountered more major side-effects, often requiring additional surgeries. Bifocal lengthening faced 0.9 per segment side-effect, in comparison with 0.4 in unifocals. The younger than 8 year old patients, those requiring simultaneous deformity correction and congenital cases undergoing more than 8 centimeters of lengthening were affected by more side-effects. In terms of function, improved walking, jumping, stair navigation and sporting activities was seen in 80% and remained unchanged in 20%. WOMAC score was excellent or good in71.4% and fair in 28.6%. 52 patients were satisﬁed, with congenital cases being the happiest. The 4 unsatisﬁed cases had not achieved the full expected length and would require additional lengthening. The amount of gained length or the category of disease had no meaningful relation with encountered side-effects. Conclusions: Ilizarov technique can be safely used for major length gain. Despite its high rate of side-effects, it is associated with high satisfaction rate, and signiﬁcant functional improvement. Signiﬁcance: One does not need a sophisticated limb lengthening center for lengthening,and the technique can be easily and safely used for villagers leaving far away from major treatment centers.

Comparison of free ﬁbula transfer and Ilizarov method for reconstruction of Congenital Pseudarthrosis of tibia Author: Durga N Kowtharapu (India) Co-Authors: Rajasekaran S (India), Dheenadhayalan J (India), Raja S (India), Hari Venkatramani (India)

182 Combination of Transphyseal Elevating Osteotomy, Epiphyseodesis, Meta-diaphyseal Osteotomy with Axial Correction and Lengthening in Blount´s Disease Author: Joachim Lauen (Germany) Co-Authors: Kathrin Hochmuth (Germany), Jens Eckhoff (Germany) Purpose: Blount´s disease (tibia vara) is characterized by a growth disorder of the medial part of the tibial physis, metaphysis and epiphysis. Methods: A transphyseal osteotomy with elevation of the medial tibia plateau and simultaneous epiphyseodesis in combination with a second closed wedge valgization-derotation corticotomy meta-diaphyseal and lengthening was performed using a mono-

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S78 lateral ﬁxator. With transphyseal opening wedge osteotomy proximal to the MCL insertion the ligamentous laxity was retensioned by acute distraction. The permanent growth arrest by epiphyseodesis stopped the deformity progression. The callus distraction corrected the length deﬁciency. Results: Five cases were treated with this method, the follow up two to ﬁve years. Uncomplicated surgeries could be reported, lengthening progress and consolidation time were within regular healing indices. Conclusions: The clinical and radiographic results showed the complex options of this combined double osteotomy procedure. Deﬁnitively a reconstruction of tibial plateau with a better realignment of knee joint, an axial and derotational correcture and a length gain could be achieved in all cases. Signiﬁcance: The surgical method reconstructs the multi-level deformity, stops the growth disorder, regains length deﬁciency and retensiones ligament laxity.

183 Combined correction and lengthening of forearm deformities with external ﬁxator Author: Joachim Lauen (Germany) Co-Authors: Kathrin Hochmuth (Germany), Jens Eckhoff (Germany), Rainer Gradinger (Germany) Purpose: Congenital forearm deformities are rare, the growth disorders relatively complex. Surgical reconstructions are difﬁcult, because of severe growth disorders with associated joint anomalies. Most methods refer to acute reconstructions using closed or open wedge osteotomies with limited length gain. Combined correction and lengthening techniques with monolateral ﬁxators were less reported. Methods: 22 patients were included in this study, ages 10 to 25. Indications were Madelung´s deformity (5 cases), complex deformities by congenital multiple exostosis (14 cases), and post-traumatic physeal growth disorders with axial deformity and length deﬁciency (3 cases). The surgical technique included a strictly radial and ulnar pin application from an open approach, acute deformity correction, lengthening by callusdistraction. The systems used, were standard monolateral ﬁxators, for special lengthening demands a new long rail module constructed with a higher axial stability. Results: Malformations and length deﬁciencies, stability and function were improved in all treated cases. No contractions or vascular complications were seen, a temporary paraesthesia for a few days remitted ad integrum. The infection rate was restricted to pin tract infections grade 1, no higher grades occurred. System related the double ball joint proofed instable for lengthening demands. Conclusions: The surgical technique with mono- or bilateral application of ﬁxators without compromising muscles or tendons reduces the complications of contractures. Signiﬁcance: The deﬁned sites of pin application allow a functional control of the lengthening extent.

184 The results of the modiﬁed Van Nes rotationplasty for proximal femoral focal deﬁciency. Author: Tadeusz Lejman (Poland) Co-Authors: Bartholomew Kowalczyk (Poland)

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Poster presentations: Abstracts 124–322/J Child Orthop Purpose: To present the results of our own modiﬁcation of this surgical technique. Methods: Between 1988–2004, we operated on 6 children with unilateral PFFD type II according to the clinical Gillespie and Torode classiﬁcation. There were 4 boys and 2 girls in the average age at the surgery 7.5 year (range: from 3 to 16 years). Three children had type C and another 3 had type D according to the radiological Aitken classiﬁcation. The mean follow up period was 8 years (range: from 3 to 10 years) and the average age of the patients at follow up was 15.5 years (range: from 6 to 26 years). At the surgery, in all except one patient, the femoral artery and the peroneal nerve were not exposed. The anterior, medial and lateral aspect of the knee capsule was exposed by a sharp dissection. The posterior aspect was separated bluntly from the popliteal fossa and its structures were protected with Hohmann elevators. The biceps tendon was not transsected in all the cases. After the resection of the knee articular surfaces and external rotation of the calf in all but one child, an additional rotational osteotomy of the midtibia was neccesary to achieve 180 degrees of rotation. In all the patients, an intramedullar Rush rod stabilization was used. All the patients were clinically and radiographicaly evaluated at follow up. Five teenage or adult patients completed the quality of life questionnaire. Results: There were no neurological or vascular complications. A solid fusion was achieved in all the patients. On follow up, all the patients walked efﬁciently without crutches using a prosthesis. In four children, the foot derotated and two of them required repeated midtibial osteotomy. All children had full extension of the ‘‘knee’’ and its mean active ﬂexion was 80 degrees (range: from 45–120). Three children had an average ﬂexion contracture of the hip of 13.3 degrees. The mean active movements of the hip were: ﬂexion – 67.8 degrees, abduction – 38 degrees, adduction – 11 degrees, internal rotation – 45.8 degrees, external rotation – 11.6 degrees. The appearance of the operated extremity was fully accepted by all the patients, their families and the society. All the patients reported an improvement in their physical and social abilities. None of them was bothered with the operated leg; none felt less attractive than before operation. Four of them would deﬁnitely choose the same operation again and one would probably choose the procedure. Conclusions: The presented surgical technique is easier than the Torode and Gillespie modiﬁcation and it is safe. The clinical results and the quality of life in all patients are satisfactory. Signiﬁcance: There are few papers presenting results of rotationalplasy procedures for PFFD. No reports are given on the quality of life after this treatment. 185 Treatment for slipped capital femoral epiphysis using pins (Wagner Method) Author: Horacio Fernando Miscione (Argentina) Co-Authors: Horacio Fernando (Argentina) Purpose: The purpose of the present study is to introduce a modiﬁcation to the technique described by Wagner to treat slipped capital femoral epiphysis and show the development of those patients who have undergone this procedure. Methods: Between July 1997 and July 2003, 15 patients (6 female and 9 male) were treated with this procedure at the Hospital Garrahan. All patients had clinical and radiographically acute-on-chronic slip. Out of 21 hips, 6 had a bilateral disease (Type I and II). The mean age of the patients was

Poster presentations: Abstracts 124–322/J Child Orthop 10.8 years. Technical modiﬁcations consisted of performing a lateral femoral approach under the great trochanter, exposing the lateral femur and placing three 3 mm pins ﬁxing the femoral head in situ. The pins were cut and bended on the femoral surface through the same approach using a simple twist, cutter and bender system. The distal end of the pins was ﬁxed using a small plate placed perpendicular to the diaphyseal axis with only one pin of 3.5 mm. Results: Patients were diagnosed as primary hyperparathyroidism (1), renal osteodystrophy (5), hypothyroidism (1) and idiopathics (8). Excellent results were obtained in 13 hips and good results in 8 (according to Heyman and Herndon Classiﬁcation). The main complication presented by this technique was that pins had to be replaced in 6 patients because as patients grew they became short. The mean follow up was 3 years. Conclusions: This technique proves to be successful when treating patients with this pathology. We obtained excellent results in short patients or with delay of epiphyseal closure. The advantages offered by this technique are that it allows residual growth of the proximal femur, a minimal approach and the removal of the pins without complications. The disadvantage is the need to replace pins as patients grow. Signiﬁcance: This procedure demands the use of non complex devices to treat small bones and non expensive materials, such as mechanical cutter and pins, that can be easily found in the market.

186 Percutaneous plating after distraction osteogenesis: A new Wagner method Author: Chang-Wug Oh (Korea, Republic of) Co-Authors: Hae-Ryong Song (Korea, Republic of), Hyun-Dae Shin (Korea, Republic of), Byung-Chul Park (Korea, Republic of) Purpose: Although limb length discrepancy or large bone defect has been successfully treated by distraction osteogenesis, many complications arise from the long duration of external ﬁxation and even after its removal. We tried a novel method of percutaneous plating over the distraction callus, to remove external ﬁxators earlier or to correct deformity after its removal. Methods: In eleven children of limb lengthening (6 cases) or bone transport (5 cases) by distraction osteogenesis, there were 7 of growth arrest, 2 of congenital pseudoarthrosis of tibia, and 2 of ﬁbula hemimelia. In the purpose of plating, 8 were treated to remove external ﬁxator earlier after achieving of the target length, and 3 were treated as a salvage operation of deformities after removal. Using the locking compression plate, submuscular plating was done over the distraction callus percutaneously. Results: Mean age of index procedure was 11 years-old (range, 5 to 14 years-old), and mean amount of distraction was 5.4 cm (range, 4.3–7 cm). In all patients, the distraction callus healed with maintaining its length or correcting into the original alignment. The external ﬁxation index was 34.3 days/cm in average and healing index was 52.6 days/cm in average. In 8 patients with the early removal of external ﬁxator, the external ﬁxation index was 26.9 days/cm in average, which is nearly a half of healing index (51.7 days/cm). No one developed deep infection or implant failures. All patients recovered the preoperative joint motion and satisﬁed their function. Conclusions: Since external ﬁxator can be removed earlier than the traditional method, percutaneous plating over the distraction

S79 callus may be a successful method with fewer complications and makes patients to return to daily life earlier. Signiﬁcance: Different from classic Wagner technique, percutaneous plating after distraction osteogenesis don’t need bone graft and has less complications. 187 Femoral Lengthening with an Intramedullary Telescopic Nail: Does Lengthening Along the Anatomic Axis Create Malalignment? Author: Dror Paley (United States) Co-Authors: Rolf Burghardt (Germany), Stacy Specht (United States), John Herzenberg (United States), Ashish Ranade (United States) Purpose: The purpose of the study was to see whether lengthening over the anatomic axis of the femur induces malalignment of the lower extremity. The development of new intramedullary lengthening devices makes this an important question to consider. Methods: Twenty-four patients (27 femora) underwent isolated femoral lengthening with the intramedullary skeletal kinetic distractor (ISKD). The age of the patients ranged from 16 to 57 years, and three patients underwent bilateral lengthenings. We excluded patients who underwent simultaneous realignment procedures of the tibia/femur. The amount lengthened ranged from 1.5 to 8.0 cm (average, 4.4 cm). Preoperative, immediate postoperative, and 6-month postoperative radiographs were used to measure the alignment of the lower extremity. We measured the mechanical axis deviation (MAD), the anatomic-mechanical angle (AMA), and the amount of length obtained. Results: Femoral ISKDs were inserted through the piriform fossa in 21 femora, and tibial ISKDs were inserted through the greater trochanter in six femora. On average, the level of the osteotomy was 5.5 cm distal to the lesser trochanter (range, 3.3 to 8.9 cm). Ten limbs experienced no change of the MAD (no change was deﬁned as an overall change of less than 2 mm). Sixteen limbs experienced a lateral shift of the MAD (average change, 1.6 mm/ cm of lengthening; range, 0.5–2.8 mm/cm of lengthening). The one remaining limb experienced a medial shift of the MAD (1.4 mm/cm of lengthening). Conclusions: Lengthening with an intramedullary telescopic nail along the anatomic axis can result in signiﬁcant changes to the MAD. Lateral shift of the mechanical axis occurs when the mechanical and anatomic axes are convergent distally before lengthening. Medial shift of the mechanical axis occurs when the mechanical and anatomic axes are divergent distally before lengthening. Signiﬁcance: The potential for the MAD to change should be taken into account when planning femoral lengthening of a substantial amount, especially for cases in which lateral MAD is already present. 188 Management of lower limbs dismetries secondary to malignant long bone tumors Author: Marı´ a Carmen Pe´rez (Spain) Co-Authors: Rosendo Ullot (Spain), Santiago Cepero (Spain), Ramon Huguet (Spain), Alicia Gargantilla (Spain) Purpose: Treatment of lower limbs malignant long bone tumors entails great resections and reconstructions with bank bone

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S80 allografts. These resections often ablate the epi and metaphyseal bone (including the physeal plates). Allografts can not grow up as the contralateral limb does. Therefore, these children suffer great dismetries upon completion of growth. Once the patients are free of illness, thay complain of problems caused by these secondary dismetries. We describe the results of 4 bones lengthening by distraction osteogenesis using a tibial external ﬁxator to correct secondary dismetries, in four femur sarcomas. Methods: Four patients who were diagnosed since 1999 to 2000 as having a malignant long bone tumor were treated. Three of them had a femur Osteosarcoma, and one of them had an Ewing’s Sarcoma. Distal femur was involved in three cases, and proximal femur was involved in one of them. The male/female rate was 3:1, and the mean patients age at the time of tumor diagnose was 11 years and 9 months old. In all of them, chemotherapy preceded the subsequent wide resection of the involved bone and the reconstruction using a bank bone allograft. In one case a knee arthrodesis was necessary. After the total physeal closure they had a lower limbs dismetry of 8.8 cm, 10 cm, 10.5 cm and 12.5 cm, respectively. The lengthening was performed after total physeal closure in three of the four cases, and the mean age at the time of lengthening was 15 years old. In all cases, tibial lenghtening by distraction osteogenesis was performed by using a unilateral external ﬁxator (Orthoﬁx). All of them were healed from the tumor when we enhanced the lenghtening. Results: In three cases we achieved total lenghtening and bone union. The fourth patient had a ﬁnal dismetry of 2.5 cm. We did not length the femur in any case. All cases subsequently received an Aquiles tenotomy. The healing index mean was 32.5 d/cm (range, 28–35.6). Three of them developed a superﬁcial pin site infection. We did not have any important complication. Conclusions: Malignant lower limbs tumor treatment often generates great dismetries in children because of the physeal plates sacriﬁce. In attempt to prevent non-union, lengthening must never be done in the tumoral bone. Signiﬁcance: We think that bone lengthening to correct lower limbs dismetries after treatment of a malignant long bone tumor is an innovating practice. Therefore, there are not many reports about such interesting challenge. 189 Bifocal Tibial Corrective Osteotomy With Lengthening in Achondroplasia. An Analysis of Results and Complications Author: Hae-Ryong Song (Korea, Democratic People’s Republic of) Co-Authors: Jae-Hyuk Yang, Sandeep Vaidya, Sameer Desai, Gautam Shetty Purpose: To study the results and complications of Bifocal Tibail Osteotomy. Methods: Retrospective review of 47 tibiae in 24 achondroplastic patients. Comparison was made between the parameters of angular and torsional deformities of the tibia preoperatively, at ﬁxator removal, and at last follow-up. Results: statistically signiﬁcant change was seen postoperatively in the values of medial proximal tibial angle, lateral distal tibial angle, mechanical axis deviation, and tibial torsion, which changed from 78.8 ± 7.05 degrees, 103.2 ± 11.8 degrees, 25.1 ± 14.6 mm (medial), and 22.7 ± 10 degrees (internal) preoperatively to 87.3 ± 6.3 degrees, 90.9 ± 5.4 degrees, 5.3 ± 10 cm (medial), and 15.8 ± 4.2 degrees (external), respectively. at the time of ﬁxator removal; and this correction was

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Poster presentations: Abstracts 124–322/J Child Orthop maintained during the follow-up period. Mean total tibial lengthening was 6.84 ± 1.3 cm. Average healing index was 26.06 d/cm. Complications observed were 15 pin tract infections, 1 residual varus, 1 overcorrection into valgus, 2 recurrence of varus, 22 equinus contractures, 2 premature consolidations, and 3 ﬁbula malalignments. Recurrence of varus was observed in limbs with a residual abnormal medial mechanical axis deviation due to femoral deformity. A hundred percent incidence of equinus was observed in limbs with tibial lengthening of more than 40%, with distal tibial lengthening of more than 15%. Conclusions: This procedure is safe and efﬁcacious if performed with strict adherence to prescribed technique. Fibula malalignment was not observed after double ﬁbula osteotomy. Signiﬁcance: To minimize the risk for occurrence of equinus, we recommend restriction of distal tibial lengthening in achondroplasia to less than 15%, although total tibial lengthening may exceed 40%.

190 Deformity Correction with External Fixator in Pseudoachondroplasia Author: Hae-Ryong Song (Korea, Democratic People’s Republic of) Co-Authors: Seok-Hyun Lee, Sameer Desai, Gautam Shetty, Harry Matta, R Mahajan Purpose: Patients with pseudoachondroplasia have complex, difﬁcult to correct deformities including angular deformity, rotational deformity, and ligament laxity. Methods: We retrospectively reviewed seven patients (two children, ﬁve adults) with 26 segmental deformities (12 femora, 14 tibiae). We performed bilateral femoral and tibial osteotomies in six patients and bilateral tibial osteotomies in one patient. Distraction osteogenesis was used in 20 segments and acute deformity correction was done in six segments. Results: Of 26 segments, there were ﬁve good, 12 fair, and nine poor radiographic results with nine major and 12 minor complications. Recurrent deformity in children and refracture in adults were related to poor results. Of 14 limbs, there were four good, ﬁve fair, and ﬁve poor clinical results with ﬁve major and 14 minor complications. Knee stiffness was the most common complication related to poor results in our series, and occurred particularly in patients with simultaneous correction of the ipsilateral tibial and femoral deformities. Conclusions: two-stage surgery including bilateral tibial osteotomies ﬁrst and then bilateral femoral osteotomies is recommended instead of simultaneous correction of the ipsilateral tibial and femoral deformities to avoid knee stiffness. Signiﬁcance: Risk of recurrence of deformity needs to be explained to patient and staged lengthening is recommended.

191 Relative ability of young and adult muscle to respond to limb lengthening Author: Gyo¨rgy Szo¨ke (Hungary) Co-Authors: Tamas Shisha (Hungary), Sandor Kiss (Hungary), Karoly Pap (Hungary), Hamish Simpson (United Kingdom) Purpose: The response of the muscle during limb lengthening is critical in determining the functional outcome. We hypothesised

Poster presentations: Abstracts 124–322/J Child Orthop that the response of muscles would vary with age and that there would be signiﬁcant differences in the proliferative response of the muscle belly and the myotendinous junction region. Methods: The response of the muscles was studied during tibial lengthening in both young (n = 10) and mature (n = 10) rabbits. A bromodeoxyuridine technique (indirect immunohistochemistry) was used to identify the dividing cells both in the muscle belly and the myotendinous junction of each muscle. Results: The young animals demonstrated a signiﬁcantly greater proliferative response to the distraction stimulus than the mature animals. This was particularly pronounced at the myotendinous junction but also evident within the muscle belly. However, during the distraction stimulus, though the proliferative response in the myotendinous junction remained greater than in the muscle belly, the ratio between the two decreased signiﬁcantly. This change was the result of an increased contribution of the muscle belly to proliferation. Conclusions: The results demonstrate that younger muscle adapts better to lengthening. This suggests that, for patients in whom a large degree of muscle lengthening is required, it may be beneﬁcial to carry out the lengthening when they are young in order to achieve the optimal functional result. Signiﬁcance: No previous study compared the proliferative response of muscle cells in both the muscle belly and the myotendinous junction in young and adult animals as well. These experiments help us understand the different mechanisms of adaptation of young and adult muscle to distraction.

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Sport injuries 193 Heely Injuries: A new epidemic warranting a government health warning! Author: Sinead Boran (Ireland) Co-Authors: Brian Lenehan (Ireland), Orla Callender (Ireland), David Moore (Ireland), Esmond Fogarty (Ireland), Frank Dowling (Ireland) Purpose: To review all patients presenting to Trauma Orthopaedic Services at our institutions with injuries sustained while wearing Heelys were included in this study. Methods: From April to June 2006, all patients presenting to Trauma Orthopaedic Services at our institutions with injuries sustained while wearing Heelys were included in this study. Results: 39 patients are included in this study. The mean age was 9.1 years(range 7–13, median 9 years. Of the 39 patients referred to the Orthopaedic Service 8 required admission to hospital. One patient admitted following a head injury required craniotomy and evacuation of extradural haematoma. Conclusions: The public perception of safety is incorrect and manufacturers rightly recommend strongly the use of safety gear. Signiﬁcance: The signiﬁcance of the injuries encountered demonstrates the potentially devastating results from the use of heelys. 194

192 Great trochanter distal transfer and femoral lenghtening in patients with DDH. Author: Fabio Verdoni (Italy) Co-Authors: Antonio Memeo (Italy), Gabriele Anelati (Italy), Emilio Regondi (Italy), Giovanni Peretti (Italy) Purpose: Several abnormalities of the femoral neck and great trochanter have been described after treatment for developmental dysplasia of the hip (DDH). Cases of the DDH occur after walking age because of late or missed diagnosis and failed conservative or operative treatment. Deformities of the great trochanter result in clinical symptoms: hip instability, limping gait, shortening of the extremity involved and limitation of range of motion. All of these symptoms derive from weakening of the hip abductor. Correction of gluteal insufﬁciency due to the short femoral neck that usually has a marked varus angulation, is achieved by distal transfer of the greater trochanter. Methods: We have treat 12 patients performing a distal transfer of the greater trochanter and a positioning a external axial ﬁxator to correct the lengthening of the femur after diaphysal osteotomy. Results: We obtained the correction of the dismetry of the extremity and no signs of instability of the abductor muscles. No palsy of femoral or ischiatic nerve was registered. These complications took place: fractures of the great trochanter in 1 case, superﬁcial infections in 3 cases, lumbar hyperlordosis in 9 cases. Conclusions: We believe that this procedure is characterized by a simple surgical technique with good results due to the fact that external ﬁxation allow to achieve the correct length of the extriminity involved without having severe nerve complications. Signiﬁcance:

Optimizing athletic performance and minimizing injury in adolescent females: performance and training effects of an ACL prevention program Author: Theodore Ganley (United States) Co-Authors: Jeffrey Albaugh (United States) Purpose: Participation in pre-practice knee injury prevention programs have reported signiﬁcant reduction in ACL injuries, however, strength and performance gains associated with this type of prevention program have not been investigated. The purpose of our investigation was to determine the effectiveness of a preventative, warm-up program to increase strength and performance in female high school soccer players. Methods: Subjects consisted of 45 female high school athletes from two high schools participating on their school soccer team. One school participated in a preventative, warm-up program (N = 33), while the other served as a control (N = 12). Prior to each soccer practice, the preventative, warm-up group participated in a 15-minute dynamic stretching, strengthening and plyometric program. The control performed their traditional warm-up which consisted of a light jog and static stretching. All subjects underwent pre- and post-testing after an eight week period. Testing included Biodex assessment, vertical jump and triple hop testing as well as a subjective drop-jump screen. Results: For all nine measures of performance and strength, the warm-up group showed signiﬁcant improvement. The control group demonstrated signiﬁcant gains for only two measures – peak quadriceps torque at 300o/sec and peak hamstring torque at 180o/sec on the Biodex. Actual difference in training effect between the preventative, warm-up and control group was not signiﬁcant. Subjective assessment of the drop-jump screen revealed a higher percentage improved their lower extremity alignment for the preventative, warm-up group. Conclusions: A 15 minute on-ﬁeld, warm-up prevention program performed prior to practice provides similar strength and

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S82 performance results as more time consuming traditional off-ﬁeld programs. Signiﬁcance: Increasing lower extremity strength is one of the factors leading to improved neuromuscular control at the knee and lower extremity, which is the main biomechanical goal of these prevention programs. Though injury prevention is the objective, application by coaches as well as athlete compliance and motivation may improve if ancillary strength and performance gains are noted. 195 Nerve Block vs. Intra-Articular Anesthetics in Pediatric Patients Undergoing Arthroscopic ACL Reconstruction: Efﬁcacy, Cost and Operative Time Author: Theodore John Ganley (United States) Co-Authors: Kristofer Jones (United States), Lawrence Wells (United States), Giovanni Cucchiaro (United States), John Flynn (United States) Purpose: Post-operative pain management following ACL reconstruction may be achieved through femoral sciatic nerve block (FSNB) or intra-articular injection (IA) of combinations of local anesthetics or opioids. In this postoperative randomized study, we investigated the hypothesis that FSNB offers better postoperative analgesia than IA in patients undergoing ACL reconstruction. The overall cost and operative time for the two procedures was also evaluated. Methods: 36 patients undergoing ACL reconstruction with a single incision technique using either Achilles tendon allograft or hamstring autograft were randomized into two groups of 18 FSNB patients and 18 IA patients. Age, sex, and weight were similar for both groups. Standard anesthesia protocols were followed for administering FSNB and IA. Patients received standardized morphine PCA and rescue morphine boluses postoperatively. Opioid requirement and VAS pain scores amongst the two groups were compared along with the time spent administering the anesthetic and the relative cost of the two procedures. Results: Patients treated with FSNB required less intraoperative opioids. The mean pain score after FSNB was lower on PACU arrival and during the ﬁrst 24 hours postoperatively. FSNB rescue opioid use in the ﬁrst 24 hours postoperatively was signiﬁcantly lower and the FSNB group when longer without initiating use of the PCA pump. Both OR time and the overall cost of the procedure were higher in the FSNB group in comparison to IA. All of these results were statistically signiﬁcant. Conclusions: Combined femoral-sciatic nerve block provides greater postoperative analgesia than the intra-articular injection of combined anesthetics and opioids, with signiﬁcantly lower intraoperative and postoperative requirement of opioids. Increased experience administering FSNB may lead to potential improvements in cost and operative time for the overall surgical procedure. Signiﬁcance: Improvements in postoperative analgesia with nerve blocks was noted which can improve overall patient experience. 196 Rising Trend in Paediatric Trampoline-related Injuries. Author: Cyrus Jensen (United Kingdom) Co-Authors: S Sandhu (United Kingdom), Robert Jarman (United Kingdom) Purpose: Recently there have been several reports published in the media and medical journals suggesting an increase in the number

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Poster presentations: Abstracts 124–322/J Child Orthop of trampolining injuries. The aim of this study is to identify and quantify the trend in paediatric trampoline-related injuries in the UK. Methods: A retrospective case note review of all children (under 16 years) attending the Accident & Emergency Department in an urban district general hospital in the UK, during the same 5 week period (May to June) in 2004 and 2005 was carried out. Patients were included if their injuries were identiﬁed as being related to trampolining. Data collected from notes included patient demographics and mechanism, site and severity of injury. Data on weather conditions during these two time periods were collected from the UK Meteo Ofﬁce. Results: There was no statistical difference in the populations (age, sex, numbers) or weather conditions during the two time periods studied. A statistically signiﬁcant 500% (95% CI 221.6% - 1126.1%) increase in paediatric trampoline-related injuries was noted from 2004 to 2005 (p < 0.0001.) In the 2005 group of injured patients 64% were injured whilst on the trampoline, 76% sustained injuries to extremities and 33% sustained fractures. Conclusions: The exponential rise in trampoline-related injuries seen in the USA following the popularisation of recreational trampolining in the 1990’s is now being repeated in the UK. Our results show a statistically signiﬁcant ﬁve-fold rise in paediatric trampoline-related injuries from 2004 to 2005. In addition, several patients would not have been injured had they followed the Royal Society of the Prevention of Accidents (RoSPA) guidelines regarding safe use of trampolines - including age restrictions (over 6 years old), trampolining ‘one at the time’ rule and avoiding unsupervised trampolining. Signiﬁcance: The authors suggest that there is a need for increased public awareness of both the dangers associated with trampolining and the guidelines issued by the RoSPA regarding responsible use of domestic trampolines. 197 Soccer Ball Velocity in Young Soccer Players Author: Kevin G. Shea (United States) Co-Authors: Kurt Nilsson (United States), Alex Homaechevarria (United States), Anthony Paris (United States), Derek McCool (United States), Jennifer Belzer (United States), Dennis Phelps (United Kingdom) Purpose: Recent studies have suggested that subtle cognitive deficits and degenerative cervical spine changes in soccer players may be related to the cumulative affects of repetitive trauma from head-ball contact events. Some have suggested that the rules of soccer should be changed, to reduce the risk of head-ball contact, or to introduce protective head gear. Younger athletes may be more vulnerable to head/neck injury at lower impact forces. Comprehensive ball velocity studies have not been conducted in young athletes. The purpose of this study was to determine soccer ball velocity generated by youth soccer players. Methods: IRB approval and consent was obtained. Using soccer athletes from an elite, 11 state tournament, ball velocities were measured for ages 12 through 19 years of age. 20 athletes from each age group, and sex were evaluated. Demographic information for age, sex, weight, height, and years of experience were collected. Each athlete was given 5 attempts at kicking a ball into a goal. Using a radar speed gun, the ball velocity was calculated for each group. The average and maximal velocity was calculated for each group. Results: For male athletes, the lowest average velocity was 66 kph in the 12 year old age group – this age group demonstrated a peak value of 83 kph. The 16 year old group demonstrated the highest

Poster presentations: Abstracts 124–322/J Child Orthop average value at 98 kph, and the highest peak velocity of 120 mph. For female athletes, the lowest average velocity was 59 kph in the 12 year old age group – this age group demonstrated a peak value of 75 kph. The 17 year old group demonstrated the highest average value at 77 kph, and the highest peak velocity of 86 kph. Conclusions: Recent studies have suggested that soccer ball head impacts may produce measurable neuro-cognitive function deﬁcits and cervical spine degeneration. Additional studies will be necessary to conﬁrm these ﬁndings. This study describes soccer ball velocity in young athletes, and demonstrated that young athletes can generate very high peak velocities. Signiﬁcance: Recent studies have suggested the the immature nervous system is more vulnerable to injury. This information may be used for future modeling studies of head-ball impact in pediatric and adolescent athletes.

198 Physeal injury of the proximal tibia during ACL reconstruction in pediatric patients Author: Kevin G. Shea (United States) Co-Authors: Nick Hutt (United States), Peter Apel (United States), Ron Pfeiffer (United States), Kurt Knilsson (United States) Purpose: ACL reconstruction in pediatric patients has a risk of producing physeal arrest. Studies on physeal volume damage have suggested that physeal injury below a certain threshold may have a small risk of producing a physeal arrest. This study used three dimensional computer generated models of the proximal tibia to determine the location and magnitude of physeal arrest of the proximal tibia during ACL reconstruction. Methods: MRIs of 10 skeletally immature knees were reviewed. (Average age = 8.1 years, range 5–10). The image ﬁles were imported into MimicsTM. MimicsTM, a specialized imaging software capable of constructing a 3D virtual surface model from MRI or CT image data. The sagittal sections were digitized, and converted into images with separate designations for the metaphyseal, physeal, and epiphyseal regions. These images were converted into three- The SolidworksTM software was used to place drill holes in these models, simulating tunnels used for ACL reconstruction. These tunnels were positioned to avoid injury to the apophyseal region of the physis, and to pass through the central portion of the tibial physis. Drill hole diameters were 6, 7, 8 and 9 mm. The software was used to calculate total physeal volume and volume of physis removed by the tunnel. Excel was used to analyze these variables, and determine the ratio of physis volume removed/total physis volume. Results: The average physeal volume for this series 7085 mm3 (range 3087 to 11126 mm3). For 6, 7, 8, and 9 mm diameter drill holes, the average physis volume removed/total physis volume was 1.6, 2.2, 2,9, 3.8 % respectively. For all subjects, the volume removed was less than 7.% for all subjects using an 6–9 mm drill holes. Conclusions: Drill hole placement during ACL reconstruction produces a zone of injury to the proximal tibial physis. With careful drill hole placement, the region of injury is central, and the total volume of injury can be less than 5 % of the total volume of the tibial physis. Both of these factors (non-peripheral location and volume of injury less than 5%) suggest that the risks of producing a clinically signiﬁcant physeal arrest is small, although further clinical study will be necessary to conﬁrm this.. Larger diameter drill holes, and more peripheral drill hole injury to the physis may increase the chance of producing a physeal arrest. The

S83 starting point of the drill hole should avoid the apophyseal region to reduce the volume of damage to the physeal/apophyseal regions of the physis. Signiﬁcance: A better understanding of the relationship between the ACL and physis may guide the placement of tibial drill holes which have a lower risk of producing physeal arrest. 199 Heelys – a potential hazard for the ‘walk and roll’ generation Author: Mihai Vioreanu (Ireland) Co-Authors: Eoin Sheehan (Ireland), Aaron Glynn (Ireland), Noelle Cassidy (Ireland), Michael Stephens (Ireland), Damian McCormack (Ireland) Purpose: Heelys are the only shoes with a removable wheel in the heel. Concerns have been raised by the media regarding the safety of children wearing Heelys. We highlight an increasing trend in orthopaedic injuries in children as a result of ‘heeling’. We report the incidence and costs of ‘heeling’ injuries during summer holiday in inner-city population requiring orthopaedic treatment. Methods: We prospectively recorded the data of all ‘heeling’ injuries referred to the orthopaedic department in our hospital during the summer school holiday. Using a Data Collection Sheet we recorded demographical data (sex, age), type of injury, mechanism and place of injury, ‘heeling’ experience, using of safety equipment, methods of treatment and the children intention to continue ‘heeling’ after recovery from their injury. Results: From 1st of July to 15th of September this year, 67 children with orthopaedic injuries resulted from ‘heeling’ were referred to our service for treatment. There were 56 girls and 11 boys with a mean age of 9.6 years of age (from 6.2 to 14.9 years). Upper limb were by far the most common type of injury, resulting from either forward (22) or backward falls (36). Forearm fractures were the most prevalent (49 fractures in 48 children) followed by supracondylar fractures (5), elbow dislocations (2) and hand fractures (2). There were 5 ankle fractures, 2 tibial fractures and 2 knee injuries. The majority (76%) of children suffered the injury while ‘heeling’ outdoors and 16 injuries happened indoors, either in the house (7) or in shopping centres (9). Interestingly 20% of the injuries happened while trying Heelys for the ﬁrst time and 36% of the injuries while learning (using 1–5 times) how to ‘heel’. None of the children used any sort of protection gear at the time of the injury and only 12% (8) were familiar with the instructions to use. From all injuries 38% required emergency admission to hospital and manipulation under anaesthetic in the operating theatre. The cost of these injuries was estimated around 1.500e per injury. The estimated cost for management of the remaining injuries (52, 62%) was around 300e. The majority (58%) of the injured children (38) expressed their intention of continuing ‘heeling’ after complete recovery of their injury. Conclusions: Our study shows that the majority of children with injuries from ‘heeling’ are girls. Most children suffered injuries whilst using Heelys for the ﬁrst time or while learning to use them. We recommend close supervision of children using Heelys during the steep learning curve and usage of protective gear at all times whilst ‘heeling’. ‘Heeling’ injuries have a serious impact on children health and constitute a burden for the paediatric orthopaedic service. Signiﬁcance: We report the single largest epidemiological study of orthopaedic injuries in children during the summer holiday resulted from the increasingly popular new craze: ‘heeling’.

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adults. The increased soft tissue elasticity and anatomic differences in children younger than 8 years make upper cervical spine injuries more likely. Methods: We have collected 3 cases of C1-C2 injuries in our department, all of them following a car crash. 2 female and 1 male. The patients had respectively 2, 2,5 and 3 years old at the admission in the hospital. 2 lesions were classiﬁed as unstable and treated with posterior sublaminar wiring ﬁxation and arthrodesis C1-C2 and external immobilization, 1 patient classiﬁed as stable lesion and treated with halo-vest. 2 lesions were neurological intact, 1 patient was classiﬁed as Frankel B. Results: All the patients had full neurological recovery. The 2 patients treated with posterior surgical synthesis healed with a solid fusion. The minimum follow-up is 1 year. Conclusions: The child who has sustained a considerable trauma must be very carefully investigated, immobilized on a spinal board and studied with standard radiographs, MRI and CT evaluations. In the lateral x-ray view rupture of the transverse atlantal ligament allows more than 4 mm of anterior displacement of the atlas. The alar ligaments prevent further displacement, but when there is 10 to 12 mm of displacement, these ligaments are ruptured and cord compression can result. MRI is useful for delineate bone and soft tissue injury and permits predictive classiﬁcation of spinal cord injuries. The majority of these injuries can heal with external immobilization with halovest. Close reduction must be done with general anesthesia, neurologic monitoring (SSEP, MMEP) after halo placement with ﬂuoroscopic control. In case of unstable lesions, surgery is mandatory. A posterior approach to C1-C2 and the reduction using a reabsorble wire is, in our opinion, one of the best choice for treat these very young patients. Fusion must be always performed with autologous grafts to prevent pseudoarthrosis. External immobilization after posterior open reduction permits to reach a solid arthrodesis. Signiﬁcance: The signiﬁcance of this paper is to explain the deﬁne the modalities of these particular kind of injuries in very young children where the upper cervical spine is more involved than the lower and to update the modalities of modern treatment.

Management of symptomatic discoid lateral meniscus in children Author: Moshe Yaniv (Israel) Co-Authors: Michael Fishkin (Israel), Eli Ezra (Israel), Shlomo Wientroub (Israel) Purpose: Symptomatic discoid lateral meniscus in children is a common condition requiring surgical intervention and use of arthroscopic technique. Findings in the arthroscopic evaluation mandates different surgical solutions. Avoidance of complete menisectomy is recommended, while repair of the detached attachment with saucerization of the discoid morphology is the practice of choice. The study is an overview of our experience with the clinical presentation, arthroscopic treatment ﬁndings and results of symptomatic discoid lateral meniscus in pediatric patients. Methods: We retrospectively analyzed the charts and surgical ﬁndings of 38 pediatric patients with discoid lateral meniscus who presented consecutively since 1999 and were treated arthroscopically. Evaluation of the clinical presentation, arthroscopic ﬁndings and procedures, and evaluation of the ability to return to full functional and sport activity. Mean age at surgery was 11.8 years (5–17), mean postoperative follow-up period was 3.4 years (6 m-7y). Results: Nine children (24%) had complete discoid lateral menisci, and 29 (76%) incomplete. Instability of the meniscus was found in 7 knees (18%). An associated tear was found in 21 knees (55%). Partial menisectomy and meniscal reshaping was done to all knees. Two knees with a deformed and unstable meniscal tissue underwent subtotal menisectomy leaving a small rim of the meniscus. Repair of the unstable peripheral rim attachment was performed in 6 knees. Associated lateral femoral condyle osteochondral lesions were found in 3 knees and were treated by reshaping of the discoid meniscus without addressing directly the osteochonral lesions, all of which showing complete clinical and radiologic resolution. 33 patients reported no symptoms and return to full functional and sport level, 4 patients had minor symptoms like click sensation with no pain or limited activity. One patient developed a symptomatic osteochondral lateral femoral condyle lesion. Two patients needed a second arthroscopic procedure due to symptoms recurrence (12 and 6 months after the ﬁrst procedure, respectively). Conclusions: Management of symptomatic discoid lateral meniscus is dictated by the arthroscopic ﬁndings. The importance of meniscal tissue preservation and the variability of the discoid lateral meniscus arthroscopic ﬁndings compel the surgeon to consider different surgical techniques and solutions. Associated conditions such as osteochondral lesion of the femoral condyle or meniscal instability should be diagnosed prior to and intraoperatively and addressed with an adequate procedure. Signiﬁcance: The importance of surgeon’s awareness and skills to address the various expressions of this complicated pathology is highlighted.

Spine 201 Treatment of C1-C2 injuries in very young children Author: Massimo Balsano (Italy) Co-Authors: Antonio Villaminar (Italy), Marta Comisso (Italy) Purpose: Cervical spinal injuries in the very young child are relatively uncommon compared with older children, adolescents, and

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202 Shoulder height after surgical correction of thoracic adolescent idiopathic scoliosis. Author: Sinead Boran (Ireland) Co-Authors: Brian Lenehan (Ireland), Caroline Goldberg (Ireland), David Moore (Ireland), Esmond Fogarty (Ireland), Frank Dowling (Ireland) Purpose: To determine the incidence and extent of shoulderimbalance before posterior spinal surgery and to ascertain its outcome, using radiographic and topographic measures. Methods: Patients with right thoracic adolescent idiopathic scoliosis who had undergone corrective posterior spinal fusion by one surgeon were identiﬁed. Pre- and all postoperative spinal radiographs and surface topography were evaluated and correlated. Any effect from concomitant anterior release procedures was sought. The Quantec System consists of a desktop computer, a video camera and a slide projector that throws a specially designed pattern on the child’s back. The subject stands free in a customised frame, with feet separated by a standard wooden blocks, arms by sides and looking straight ahead. The dimples of Venus, Spinous process of T1 are marked with paper stickers, The image is captured. The axillary

Poster presentations: Abstracts 124–322/J Child Orthop skin crease is mapped. The computer analyzes the image and map 3 further points. ½ way between T1 and the axilla, 1/3 way between axilla and dimples of venus ½ way to midline and 2/3 way between axilla and dimples of venus. The image is then analyzes by customised software according to several parameters. Results: Sixty six patients were identiﬁed, 56 girls and 10 boys. Their mean age was 15.14 yrs ± 1.72 Their pre-operative major Cobb angle was 73 ± 14.0 and the mean correction was 38.8 ± 12.333 (56%). Their pre-operative minor Cobb angle was 36.35 ± 13.83 and mean correction was 22.0 ± 2.72(62%). Before surgery, surface topography showed the mid-point of the right shoulder to be at a mean of 18.57 mm. ± 11.24 higher than the equivalent left point; 1 week later, the difference was –6.0 mm. ± 9.91, a mean change of 24.57 mm ± 11.8. At six months, it was –4.52 ± 8.02, statistically unchanged. At two years, it was –2.55 ± 7.2(p = 0.051) and at three years, 1.76 ± 6.53 and indistinguishable from zero or perfect balance. The difference between pre-operative and ﬁnal shoulder level difference was 19.54 mm. ± 9.09. The Cobb angle of the compensatory upper thoracic curve was not signiﬁcantly changed throughout. There was no statistically signiﬁcant difference in shoulder height between patients undergoing single or two-stage surgery, either before or at any stage after. Conclusions: Correction of post-operative shoulder imbalance does occur spontaneously. Signiﬁcance: Correction of post-operative shoulder imbalance is a function of spinal accommodation to the new anatomy. 203 Sagittal Spine Characteristics as a Predictor of Proximal Junctional Kyphosis Author: David Feldman (United States) Co-Authors: Eric Henderson (United States) Purpose: Familial Dysautonomia (FD) is a neurological disease seen in Ashkenazic Jews. Severe kyphoscoliosis is common in FD patients who have a high incidence of excessive proximal junctional kyphosis (PJK) following surgical correction. Proximal end screw pullout is not uncommon. A retrospective radiographic study of the sagittal spine in FD patients was undertaken to investigate a causal relationship with PJK. Methods: Preoperative, postoperative, and most recent follow-up lateral radiographs of eighteen pediatric FD patients were measured for kyphosis, lordosis, sagittal balance, and proximal junctional alignment. The scoliotic curve was also measured. Measurements of patients found to have PJK (‡20) were compared to those who had normal junctional measurements. Results: Nine of the eighteen patients developed PJK. Three patients required revision surgery for proximal hardware pullout following onset of PJK. Seven of nine patients who developed PJK were in positive sagittal balance preoperatively while seven of nine patients who did not develop PJK were in negative sagittal balance preoperatively; this was statistically signiﬁcant (p = 0.025). No statistically signiﬁcant difference in the patients’ preoperative scoliosis, kyphosis, or lordosis was found. Seven of the nine patients who developed PJK did so within two months of surgery. Conclusions: Positive sagittal balance is a signiﬁcant risk factor for development of PJK in patients with FD and should be considered when planning corrective surgery for scoliosis. The resulting PJK increases cantilever bending forces on the proximal hardware and can lead to failure. These ﬁndings may provide clues as to the cause of PJK in patients with idiopathic adolescent scoliosis.

S85 Signiﬁcance: Positive sagittal balance is a signiﬁcant risk factor for development of proximal junctional kyphosis in patients with Familial Dysautonomia and should be considered when planning scoliosis surgery. 204 Multiplier Method for the Prediction of Sitting Height and Spinal Height Author: John Eric Herzenberg (United States) Co-Authors: Mordchai Shualy (United States), Maya Goldberg (United States), Dror Paley (United States), Amanda Gelman (United States) Purpose: The purpose of this study is to develop multipliers for the spine and for sitting height that predict spinal height and sitting height at maturity. Methods: Using cross-sectional and longitudinal clinical databases, we divided the total sitting height, cervical length, thoracic length, and lumbar length at skeletal maturity by the sitting height, cervical length, thoracic length, and lumbar length at each age for each percentile given. These multipliers were then compared with each other, compared between percentiles, and compared between different racial, national, and ethnic groups. Results: The multipliers calculated for sitting height had little variability and correlated with those calculated for the thoracic and lumbar spinal heights. The cervical spinal multipliers were nearly identical to the multipliers for the upper extremity. The multipliers of different racial, national, and ethnic groups were also the same. Conclusions: The multiplier method has been proven to be independent of percentile, generation, ethnicity, and race. It is a simple and effective method of predicting spinal height and sitting height. The multiplier for sitting height can be used to predict sitting height at maturity, the heights of the cervical, thoracic, and lumbar spine, and the height lost as a result of spinal fusion. Signiﬁcance: The sitting height multiplier will determine a child’s sitting height at maturity. Additionally, the total height lost as a result of spinal fusion can easily be determined by using both the spinal and sitting height multipliers.

205 Analysis of preexistent vertebral rotation in the normal spine - MRI study in humans with situs inversus totalis (SIT) Author: Jan-Willem M Kouwenhoven (Netherlands) Co-Authors: Lambertus Bartels (Netherlands), Koen Vincken (Netherlands), Max Viergever (Netherlands), Abraham Verbout (Netherlands), Tammo Delhaas (Netherlands), Rene Castelein (Netherlands) Purpose: An important component of idiopathic scoliosis is vertebral rotation – thoracic curves rotating to the right side predominate. Recently, the authors demonstrated that a similar pattern of vertebral rotation is also an anatomical feature in the normal spine – in humans, as well as in quadrupeds. Since the thoracic organs in humans and in quadrupeds are asymmetrically situated, we postulate that this asymmetrical anatomy could play an important role in the development of this preexistent rotation. The purpose of this study was to investigate vertebral rotation in humans with a complete mirror image

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S86 reversal of the internal body organs – called situs inversus totalis (SIT). Methods: Twenty males and 17 females, mean age 32.1 years, underwent MRI examination of the thoracic and lumbar spine. There was no clinical or radiological evidence of scoliosis or other spinal pathology. Vertebral rotation was analysed from level T2 to L5 by using the same measurement method as used in our previous studies.1;2 The longitudinal axis of the vertebrae was deﬁned as the line through the Centre Of Mass (COM) of the vertebral canal and the COM of the anterior half of the vertebral body. The reference line was deﬁned as the line through the COM of the vertebral canal and the COM of the sternum at level T5. The reference line was deﬁned as zero degrees rotation; rotation to the right was deﬁned as a positive angle, rotation to the left as a negative angle. Results: A predominant rotation to the left side was found of the mid and lower thoracic vertebrae – the observed frequencies of right and left vertebral rotation differed signiﬁcantly from an equal right-left distribution (P < 0.05). Measurement of the vertebral rotation angles showed a signiﬁcant mean rotation angle to the left side at levels T5 to T11, with a maximum rotation of 2.7˚ at level T7 (P < 0.001). Conclusions: Our study shows a predominant rotation to the left side of the mid and lower thoracic vertebrae in the normal, nonscoliotic spine of persons with SIT. This rotational pattern is opposite to what was found in humans and quadrupeds with normal organ anatomy. Based upon these results, it seems likely that the asymmetrical position of the thoracic organs is an important causative factor in the development of this preexistent rotational tendency. Signiﬁcance: Despite years of extended research the etiology of idiopathic scoliosis has still not been resolved. The results of our studies show the existence of a pre-existent pattern of vertebral rotation in the normal nonscoliotic spine. We assume that this rotational tendency determines the direction of curvature once scoliosis starts to develop. 206 Cervicothoracic Myelopathy In Children With Morquio Disease Author: William Mackenzie (United States) Co-Authors: Mihir Thacker (United States), Leslie Grissom (United States), Mohan Belthur (United States) Purpose: Previously reported causes of myelopathy in Morquio disease (MD) include atlanto-axial instability and / or soft-tissue hypertrophy, as well as thoraco-lumbar cord compression. To the best of our knowledge, there are no reports of cervicothoracic stenosis (CTS) in these patients reported in literature. The purpose of this study was to report the presence of cervico-thoracic compression as a cause of myelopathy in children with Morquio disease and evaluate the outcome of surgical decompression in these cases. Methods: This was a retrospective, IRB approved clinical and radiolographic review of four patients with MD with CTS who had undergone decompression and fusion, at our center between 1990–2005. Results: All patients had previously undergone occipito-cervical fusion for atlantoaxial instability. There were 3 girls and 1 boy with an average age of 76 months (54–112) at presentation for neurological symptoms. All had upper motor neuron signs in lower and / or upper limbs. MRI demonstrated CTS with anterior vertebral wedging, platyspondyly and posterior disc bulges at the levels of cord compression in all 4 patients. Three patients

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Poster presentations: Abstracts 124–322/J Child Orthop underwent posterior decompression and fusion. The fourth underwent an anterior corpectomy with an anterior and posterior fusion. All patients had neurologic improvement post-operatively. Two of 4 patients required subsequent surgery for compression distal to the cervicothoracic junction. Conclusions: Cervicothoracic stenosis can be a cause of neurological deterioration in patients with Morquio syndrome. MR Imaging of the entire spine is essential to identify the site of cord compression and to plan appropriate surgical management. Signiﬁcance: Cervicothoracic stenosis can be a cause of neurological deterioration in patients with Morquio disease; MRI of the entire spine is essential to identify the site of cord compression and to plan surgical management. 207 The Safety of Pedicle Screw Fixation in the Thoracic Spine Author: Heather McCann (United States) Co-Authors: Richard Gross (United States) Purpose: The objective of this study was to report the safety of thoracic pedicle screw ﬁxation using the anatomic method for spinal deformity surgery. Methods: The authors retrospectively reviewed medical records for patients with pediatric spinal deformity surgery from January 2002 to May 2006 for one pediatric orthopaedic surgeon at one institution. Following a one day tutorial, the senior author (RHG) used pedicle screw ﬁxation placed by the anatomic method described by Lenke for spinal deformity surgery. Instead of CT scan documentation of pedicle anatomy and screw ﬁxation, a true AP radiograph of the most rotated segment of the curve was made to assess pedicle shape and size. Multiple ﬂuoroscopy images were made intraoperatively prior to rod placement, obtaining a true AP view at all instrumented levels. Results: Pedicle screw ﬁxation was used in 75 cases of pediatric spinal deformity correction. A total of 1714 screws, 1275 thoracic screws and 439 lumbar screws, were placed without complication. Conclusions: Thoracic pedicle screws can be successfully inserted even when preoperative radiography indicated the pedicle size was inadequate. The tutorial is an effective method of instruction for learning the technique of thoracic pedicle screw insertion. Signiﬁcance: Thoracic pedicle scres can be successfully placed without complication with adequate preoperative planning. 208 Classiﬁcation of Chance fracture in children using MRI Author: Je´roˆme Sales de Gauzy (France) Co-Authors: Jean Jouve (France), Philippe Violas (France), Jean Guillaume (France), Anne Coutie´ (France), Franck Accadbled (France), Franck Launay (France), Ge´rard Bollini (France), Jean Cahuzac (France) Purpose: Flexion distraction fracture of the spine (Chance fracture) are rare in children. Several classiﬁcations were described in adult, but they might be inappropriate in children because of the presence of a growth plate. Rumball and Jarvis identiﬁed 4 distinct patterns of injury based on a radiographic study in a series of 10 paediatric cases. Nevertheless, standard X-rays do not enable disc or growth plate lesions of the spine to be investigated. We performed a retrospective study based on MRI examinations in

Poster presentations: Abstracts 124–322/J Child Orthop order to deﬁne the different lesions which can occur in paediatric ﬂexion distraction fractures of the spine. Methods: From 1995 to 2005, the data of 31 ﬂexion distraction fractures from 3 centres were collected. Among these patients, 18 (12 male, 6 female) were evaluated with an MRI before any treatment. Mean age at injury was 7.5 years (3–17). 17 had car accidents and 1 a motor-bike accident. Associated intra-abdominal injuries were noted in 11 cases. None of the 18 patients presented peripheral neurological complications. The initial X rays and MRI of each patients were analysed. Results: The level of injury was located between T12 and L4. On X-rays, a bony fracture passing through the pedicle and the vertebral body was noted in 6 patients. A wide inter vertebral disc space and kyphotic deformation was observed in 12 patients. On MRI, in all cases, no abnormal signs were noted on the vertebral disc either on T1 or T2 sequences. As on X-rays 6 real Chance fractures were diagnosed. In the other 12 cases, we noted a physeal injury on the superior end plate (8 cases) or the inferior end plate (4 cases). In these 12 cases the posterior lesions were always located either above or below the pedicle and damaged the soft tissue and/or the articular facet (superior or inferior). Consequently 3 fracture patterns were identiﬁed according to the location of the lesion in relation to the pedicle. Type I (8 cases): physeal injury of the superior growth plate associated with posterior lesion above the pedicle (soft tissue or superior facet). Type II (6 cases): osseous type. Fracture through the vertebral body, pedicle, lamina and spinous process. Type III (4 cases): physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue or inferior facet)There was no correlation between fracture type and age, gender, level of injury or associated complications. Conclusions: Adult classiﬁcations are not available for children since they described disc lesions without physeal injuries. Our ﬁndings based on MRI examination are different from the paediatric classiﬁcation reported by Rumball and Jarvis based on X rays. MRI is useful in the diagnosis of paediatric ﬂexion-distraction injuries of the spine. Signiﬁcance: MRI allows physeal injury to be clearly identiﬁed from disc injury. A proper diagnosis using MRI can be useful to treat these patients.

S87 14.2 years). All surgeries were performed by the same surgeon using the respective recommended techniques. Arthrodesis was achieved using bone substitute in all cases. Neurologic complications did not occur. For each patient, we measured cobb angle of the instrumented curve, the upper non instrumented curve and the lower non instrumented curve. Measurements were performed preoperatively on frontal X rays and on bending, and postoperatively at a minimum follow-up of 2 years. Sagittal X rays were also analysed preoperatively and post-operatively. Results: Measurements of the instrumented curves as well as the non instrumented curves showed no signiﬁcant difference between the groups either preoperatively or at follow-up. In the three groups an improvement in the instrumented curves as well as in the non instrumented curve was achieved. Instrumented curve : Preop: I 53.5 ± 10.5, II 53.8 ± 14.8, III 52.7 ± 10.1. P = 0.91 Bending: I 25.9 ± 11.6, II 27.7 ± 19.2, III 25.8 ± 12.9. P = 0.95 Follow-up : I 21.8 ± 11.9, II 24.4 ± 13.2, III 23.4 ± 10.2. P = 042

Upper non instrumented curve Preop: I 22.4 ± 12.6, II 21.2 ± 13.6, III 22.2 ± 13.2. P = 0.95 Bending: I 11.5 ± 10.5, II 13.9 ± 12.6, III 11.9 ± 11.1. P = 0.79 Follow-up: I 11.8 ± 10.3, II 14.1 ± 9.1, III 13.9 ± 10.5. P = 0.75

Lower non instrumented curve Preop: I 31.5 ± 6.7, II 27.1 ± 9.4, III 26.5 ± 15.8. P = 0.76 Bending : I 1.75 ± 3.3, II 4.15 ± 4.84, III 3.1 ± 5.4. P = 0.43 Follow-up: I 14.1 ± 9.0, II 9.4 ± 7.2, III 11.5 ± 9.0. P = 0.39

In contrast, the sagittal proﬁle of the vertebral column was not improved by the operation. T5T12 preop: I 19.2 ± 9.8, II 18.7 ± 9.2, III 21.9 ± 8.8. P = 0.49 T5T12 follow-up: I 20.6 ± 8.1, II 23.2 ± 8.0, III 22.2 ± 9.9. P = 0.61 L1L5 preop : I 46.4 ± 10.9, II 42.1 ± 9.4, III 44.5 ± 11.2. P = 0.39 L1L5 follow-up : I 41.6 ± 12.1, II 43.0 ± 8.9, III 39.6 ± 10.2. P = 0.56

Conclusions: Derotation, translation and in situ contouring achieve a similar correction of the scoliotic deformities in frontal and sagittal plane. Signiﬁcance: The use of either a rod rotation, a translation manoeuvre or an in situ contouring method does not result in any measurable difference both in instrumented and non instrumented curves.

209 Adolescent idiopathic scoliosis surgery. Rod rotation versus translation versus in situ contouring. Author: Je´roˆme Sales de Gauzy (France) Co-Authors: Franck Accadbled (France), Nicolas Lapie (France), Maxime Cournot (France), Jean Cahuzac (France) Purpose: Since the introduction of Cotrel-Dubousset instrumentation, several types of instrumentation and correction manoeuvres have been used for the surgical treatment of adolescent idiopathic scoliosis (AIS). By now correction may be achieved using three main strategies: derotation, translation or in situ contouring. The goal of the present study is to investigate whether one of these 3 operative procedures leads to a better correction of AIS than the other. Methods: 60 AIS operated on using one of the three strategies were analysed: group I rod rotation (20 cases), group II translation (20 cases), group III in situ contouring (20 cases). Mean age at surgery was similar in each group (14.9, 15.5,

210 Cervical Spine in Pseudochondroplasia:Characteristics and Rationale of Management Author: Hae-Ryong Song (Korea, Democratic People’s Republic of) Co-Authors: Gautam Shetty, Jae-Hyuk Yang, Seung-Woo Suh Purpose: Little has been mentioned in literature regarding the characteristics of cervical spine in Pseudochondroplasia,a rare autosomal dominant skeletal dysplasia.The purpose of this study was to analyse the relation between the incidence of upper cervical instability and the os odontoideum and to deﬁne the characteristics of upper cervical spine instability in patients with Pseudochondroplasia. Methods: Fifteen patients of Pseuochondroplasia were evaluated for upper cervical spine instability having mean age of 23.7 yrs (range 3–44 yrs). Evaluation of neurological status was done by

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S88 Nurick’s Grading System and evaluation of myelopathy by JOA Scoring. Group1(n = 9) with os odontoideum and Group2(n = 6) without os odontideum. InstabilityIndex, RotationalInstability, AtlantodensInterval(ADI), Space available for cord(SAC) were measured by computed tomographic (CT)studiesThe followup period was 1–5 years (mean 2 yrs). Results: There was signiﬁcant difference when the 2 groups were compared on the basis of Space available for cord(SAC). Rotational Instability and JOA (Japanese Orthopaedic Association) scoring. Incidence of Os odontoideum was 66% in our study population. The presence of Os odontoideum led to increase in the incidence of upper cervical spine instability and the incidence of instability increased with age of the patient. Only 3 patients in Group 2 had features of cervical myelopathy with no deterioration of their neurological status and no patient required surgical stabilization. Conclusions: Cervical instability in the presence of os odontoideum has a linear relationship with age and myelopathy. Prognosis for patients with instability depends on early diagnosis and these patients should undergo clinicoradiological evaluation of their upper cervical cervical spine at regular intervals. Signiﬁcance: (—)

211 Transcranial Motor Evoked Potential Monitoring for Pediatric Spine Surgery Author: Kit M Song (United States) Co-Authors: Dan Emerson (United States), Mark Balvin (United States), James Chen (United States), Adam Bergeson (United States), Nathalia Jiminez (United States), Jefferson Slimp (United States), Klane White (United States) Purpose: Review our early experience and learning curve in the implementation of TcMEP monitoring at our center using total intravenous anesthesia (TIVA) with propofol infusion. To identify factors related to positive changes, identify strategies for dealing with positive strategies, and to determine the sensitivity of TcMEP to SSEP for true positive changes. Methods: With IRB approval, we reviewed our ﬁrst 3 years experience in 137 consecutive spinal surgery cases using TcMEP. We speciﬁcally reviewed anesthetic agents given, rate of propofol infusion, ﬂuctuations in blood pressure at 15 minute intervals, spinal manipulations being performed, neurologic outcome after surgery, age of child being studied, other diagnoses and co-morbidities present, and number of positive TcMEP changes over time with no neurologic deﬁcit. Results: 80 pateints were neurologically normal preop and normal postop. 52 patients were neurologically abnormal preop and had no change postop. 5 patients were abnormal preop and were more abnormal postop. TcMEP was 100% predictive of a persistent deﬁcit postoperatively. The rate of positive TcMEP without deﬁcit postop was 20% in the ﬁrst year, but decreased to less than 5% after 3 years of experience. Of those with intraoperative TcMEP changes where there was full recovery by the end of the case, only 12% has associated SSEP changes. 3/5 subjects with true neurologic change had TcMEP change, but no SSEP change. The use of inhalational agents, high propofol infusion rates, younger age, and hypotension led to TcMEP changes. Reversal of the above in most cases led to normalization of the TcMEP. Conclusions: TcMEP is safe and reliable for the detection of changes in the spinal motor pathways. With experience over time and close collaboration between surgeon, monitoring team,

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Poster presentations: Abstracts 124–322/J Child Orthop and anesthetic staff, the stability of the technique can be greatly increased. The use of inhalational agents, very high levels of propofol infusion, excessive hypotension, and very young age of patient are associated with reversible positive changes in TcMEP. Signiﬁcance: TcMEP is physiologically more accurate that NMEP and SSEP for detection of evolving motor deﬁcits in children undergoing spinal surgery. With experience, it should become the standard for electorphysiologic monitoring in spinal surgery. 212 Fusion Rates Following Thoracoscopic Release And Bone Graft Substitutes In Idiopathic Scoliosis Author: George Harman Thompson (United States) Co-Authors: Jochen Son-Hing (United States), Brett Weinzapfel (United States), Douglas Armstrong (United States), Laurel Blakemore (United States), Connie Poe-Kochert (United States) Purpose: To compare fusion rates between allograft bone and Grafton DBM Flex in thoracoscopic anterior spine surgery. Methods: Between 1998 and 2004, thoracoscopic anterior discectomy and fusion followed by instrumented posterior spinal fusion was performed in 47 patients with idiopathic scoliosis. Forty patients have been followed more than one year. Twelve patients had morselized allograft bone (allograft group) while 28 patients had Grafton DBM Flex contoured and folded into ‘‘tacos’’ to ﬁll the disc spaces (DBM group). Patients were evaluated at one month, one year, and at last follow-up. Major curves were measured using the Cobb method and interbody fusion was assessed using the grading scale as reported by Newton et al. for standard radiographs (1–100% fusion, II - greater than 50% fusion, III -less than 50% fusion, IV - no fusion). Results: The mean follow-up was 4.3+/–1.8 years in the allograft group and 2.6+/–1.1 years in the DBM group. There were no signiﬁcant differences in age at surgery, number of vertebrae fused, or estimated anterior blood loss. There were no signiﬁcant differences in preoperative major curve, initial correction, or correction at last follow-up. There was minimal postoperative loss of correction. No patient had crankshaft, pseudarthrosis or hardware failure. At most recent assessment, 160 of 182 disc spaces (88%) were rated grade I or II and there were no signiﬁcant differences between the two groups. Conclusions: Grafton DBM ﬂex ‘‘tacos’’ are an effective bone graft substitute in thoracoscopic surgery for idiopathic scoliosis. Signiﬁcance: Autograft harvest is traditionally associated with increased operative time, blood loss and pain. Grafton DBM Flex ‘‘tacos’’ avoid these issues and are easy to insert, more ﬂexible, expand when hydrated with blood, and are less likely to dislodge or block correction. 213 The efﬁcacy of preoperative erythropoietin administration in pediatric neurogenic scoliosis patients Author: Michael Guy Vitale (United States) Co-Authors: Hiroko Matsumoto (United States), David Privitera (United States), Joshua Hyman (United States), Linda Waters (United States), David Roye (United States) Purpose: The preoperative use of recombinant human erythropoietin (rhEPO) has been shown to decrease perioperative

Poster presentations: Abstracts 124–322/J Child Orthop transfusion requirements in many adult and pediatric patients. A recent study at our institution demonstrated the efﬁcacy of rhEPO in pediatric idiopathic scoliosis patients, but suggested the possibility of an ‘‘erythropoietin resistance’’ in the pediatric neurogenic scoliosis population. The purpose of this study is to investigate this ﬁnding further by analyzing the effect of rhEPO on hematocrit (Hct) and transfusion rates in patients with neurogenic scoliosis. Methods: This is a retrospective cohort study examining 61 patients with neurogenic scoliosis who underwent anterior and/or posterior spinal instrumentation at the age of 18 years and younger. The decision to use rhEPO was on the preference of the treating surgeon, though there was a trend toward increased use over time. Thirty ﬁve children received preoperative rhEPO and iron, while 26 patients did not receive the treatment with rhEPO in this study. We found no signiﬁcant difference in comorbidities, numbers of level fused, Cobb angle or rates of pelvic ﬁxation in two groups. Results: Neurogenic scoliosis patients who received RhEPO had a signiﬁcantly higher preoperative Hct level (p = 0.01) and postoperative Hct level (p = 0.02) than their non-RhEPO counterparts. Patients treated with rhEPO had a 57.1% rate of transfusion while those without rhEPO had a 50.0% rate although there was no signiﬁcant difference (p = 0.613). Conclusions: The administration of rhEPO had no signiﬁcant effect on reducing the likelihood of transfusion in neurogenic patients in this study. While we acknowledge that selection and time bias, these data stand in stark contrast to previous work examining the efﬁcacy of rhEPO in averting transfusion in idiopathic populations. We hypothesize that anemia of chronic disease, rhEPO resistance, preexisting coagulopathies, and the nature of surgery in these children all play a role in obscuring the relationship between preoperative Hct and transfusion rates. Signiﬁcance: Neurogenic scoliosis patients who received RhEPO had a signiﬁcantly higher preoperative Hct level and postoperative Hct level than their non-RhEPO counterparts. However, the administration of rhEPO had no signiﬁcant effect on reducing the likelihood of transfusion in neurogenic patients in this study.

214 Health Related Quality of Life in Children with Thoracic Insufﬁciency Syndrome Author: Michael Guy Vitale (United States) Co-Authors: David Roye (United States), Hiroko Matsumoto (United States), Betz Randal (United States), Emans John (United States), David Skaggs (United States), John Smith (United States), Kit Song (United States), Robert Campbell (United States) Purpose: The traditional surgical or non-surgical techniques to treat Thoracic Insufﬁciency Syndrome (TIS) are not able to stabilize or improve chest wall size or pulmonary function while allowing spine growth. To this end, Vertical Expandable Prothestic Titanium Rib (VEPTR) was speciﬁcally designed to treat TIS by allowing growth of the thoracic cavity and control/correction of spine deformity. The purpose of this study was to compare quality of life (QOL) of children with TIS and impact on their parents prior to and after implantation of the VEPTR. We also compared the QOL of children with TIS and the parental impact prior to implantation of the VEPTR with previously published QOL of healthy children. Methods: As part of the original multi-center evaluation of the VEPTR, Child Health Questionnaire (CHQ) was collected

S89 preoperatively on forty ﬁve patients who were subsequently treated with expansion thoracoplasty using the VEPTR. The average age was 8.2 ± 2.6 and parent form of the CHQ was ﬁlled out by the primary caretaker. Patients were divided in to three broad diagnostic categories; Rib Fusion (RF, N = 15), Hypoplastic Thorax Syndromes (HT, N = 17) and Progressive Spinal Deformity (PS, N = 13). Results: There were signiﬁcant differences between the study patients and healthy children in physical domains. Compared with parents of healthy children, parents of children with TIS experienced more limitations on their time and emotional lives due to their children’s health problems. In addition, they had poor expectations for their children’s health. There were no signiﬁcant differences in CHQ scores in these children before and after the surgery except for a signiﬁcant decrease in the Self-Esteem score among patients with HT. None of the domains in the CHQ had moderate or large degree of responsiveness across the all three diagnostic categories. Conclusions: The children with TIS had lower physical domain scores and higher caregiver burden scores than healthy children. However, the scores in psychosocial domains were similar to those in healthy children. Since responsiveness of the CHQ was small, it can be concluded that our study demonstrates the lack of ability in the questionnaire to reﬂect clinically important minimal changes in response to the VEPTR instrumentation in this population. Therefore, a Disease Speciﬁc Instrument (DSI) may be needed in order to detect the minimal changes in this population. Current efforts are underway to better understand the clinical features that have the most profound effects on the life of these children and to develop a DSI for this population. Signiﬁcance: The children with TIS had lower physical domain scores and higher caregiver burden scores than healthy children. None of the domains in the CHQ had moderate or large degree of responsiveness. A DSI may be needed in order to detect the minimal changes in this population. 215 Development of the thoracic kyphosis and lumbar lordosis in normal children and adolescents. Author: Jose Batista Volpon (Brazil) Co-Authors: Carlos Giglio (Bulgaria) Purpose: To establish the limits of the angular variation of thoracic and lumbar curves in normal children and adolescents of both genders. Methods: A pantograph was developed to measure the dorsal spinal curves. In short, it consisted of a tripod and a vertical bar that held a mobile arm. This arm was placed on the spinous process of C7 and ran down to L5 while moving forward or backward, according to the spinal curves. A laser bean system was used to get the proper positioning of both the pantograph and the subjects. Such movements were captioned and processed by computer software so that the spinal contour was drawn on screen, thus allowing the measurement of the kyphotic and lordotic angles. Before performing the population study, the performance of the pantograph was assessed in 20 normal individuals by comparing data obtained with the pantograph with data obtained from sagittal X-rays for the thoracic and lumbar curves and no statistical signiﬁcance was found (p < 0.005). For the population survey, 718 normal subjects of any race and with normal weight and stature were selected. Furthermore, individuals with past history of spinal problems or presenting either generalized laxity, or muscular

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S90 shortening were not included. The data were analyzed for age range and gender. Proper statistical study was performed and regression analysis was obtained. Results: The comparison between genders showed no statistical difference. The kyphotic curve steadily increased from 26 at 05 years of age to 36 in 20 year-old individuals (kyphotic angle = 25.14 + 0.58 x age). The lordotic curve increased from 22 at 05 years of age to 32 in 20 year-old individuals (lordotic angle = 24.22 + 0.51 x age). The best statistical model that represented the progression for both curves was the linear regression. Conclusions: The pantograph developed for this research accomplished its ﬁnalities and both the kyphotic land lordotic curves in the normal population showed a clear tendency to increase with age with no difference between genders. Signiﬁcance: The sagittal proﬁle of the lordotic and kyphotic spinal curves was established and it is possible to determinate the normal range of variation for different age groups. These data can be used to identify normal and abnormal spinal curvatures in the sagittal plane and can contribute to evaluate posture.

16 - Musculoskeletal infections 216 Surgical treatment for the sequelae of meningococcal sepsis Author: Lucas Pen˜a (Spain) Co-Authors: JL. Barroso (Spain), JL. Monasterio (Spain), JL. Beguiristain (Spain) Purpose: Introduction: Meningococcal sepsis is responsible for physeal plates disturbances at multiple sites affecting axial and longitudinal limb growth and therefore requiring correction with different surgical techniques. Methods: We carried out a retrospective study of 14 patients suffering sequealae of meningococcal sepsis (8 excluded due to failure to attend follow up). 6 patients were treated, 2 girls and 4 boys with an average time of 12 months before the diagnosis of sepsis was established (8–20 m) and 4 years before the ﬁrst visit to the clinic (2–10 years). We reviewed the symptoms, radiological ﬁndings, types of treatments realized, complications and clinical situation at the last follow up. The average follow up was 12 years (5–17 years). Results: The most common reason for attending the clinic was varus deformity of the knees (10), ankles(2) and hips (1), followed by lower limb length discrepancy (2). The most frequent surgical techniques were valgus osteotomies of the tibia (18) and femur (3) leg lengthening with correction of tibial (4) and femoral (3) axis, physeal distractions (2) and 2 epiphysiodesis (distal femoral and proximal tibial). For the ttreatment of complications we carried out 1 calcaneo-stop procedure for a valgus foot and a KrogiusLecene procedure for a recurrent patella dislocation. Amongst the sequelae found at last follow up were 2 patients with minimal leg length discrepancy (1,6 cm), a valgus knee, a varus knee and a varus ankle deformity all of them being followed up at that time. Conclusions: Conclusions: We want to remark the importance of appropriate follow up of these patients until skeletal maturity in order to avoid the high number of musculoskeletal disturbances that they can present and their tendency to recur and therefore reduce the number of surgical procedures required. Signiﬁcance: *

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Poster presentations: Abstracts 124–322/J Child Orthop 217 Primary sternal osteomyelitis in a 40 days old infant. Case report presentation Author: Nikolaos Pettas (Greece) Co-Authors: Maria Fragaki (Greece), Alexandros Apostolopoulos (Greece), Georgios Skarpas (Greece), Nikolaos Voutsas (Greece), Helen Kyrikou (Greece) Purpose: Primary sternal osteomyelitis is extremely rare in children and only very few cases have been reported in the international literature. The purpose of our abstarct is to present a case report of a 40 days old infant where its diagnosis and management are discussed. Methods: A 40 days old infant was referred to our clinic with a 4 days history of fever and malaise, accompanying a painful swelling of 4 days duration involving the lower end of the sternum. Examination revealed a 2 cm swelling which was ﬁxed to the underlying bone. A full blood count, ESR, CRP were measured and X-Rays (Anterior and Lateral views) and Ultrasound was performed. Blood cultures were also taken. The patient was commenced empirically to Vancomycin and Cefotaxime iv. The values of WBC (16,720), ESR (132 mm) and CRP (108 mg/dl) were elevated, the X-rays showed bone destruction and dislocation of the 3rd sternal nuclei and in the U/S performed appeared a soft tissue mass measuring 2.37 cm/1.02 cm related to the periosteum. Surgical debridement was then performed and swab cultures were taken intraoperatively. The infant grew Streptococcus Pneumoniae and Enterococcus Spp. The later microorganisms have never been reported before to cause primary sternal osteomyelitis in children. Results: The infant was discharged after 25 days from the hospital. She gradually improved over a period of 2 months, became pain free and repeated X-Rays showed signiﬁcant bone resolution. The infant was examined 3 years after her discharge from the hospital in the outpatient’s department is pain free and in the X-Rays performed, there was a total bone resolution. Conclusions: Diagnosing sternal osteomyelitis can be difﬁcult, but failure to clinically recognize this type of infection in its early stages can lead to serious sequelae. The diagnosis should be suspected in a young patient presenting with acute inﬂammatory swelling over the sternum. Primary osteomyelitis in infants is a very rare condition that usually resolves with antibiotic therapy and surgical debridement. Signiﬁcance: There are only very few cases of primary sternal ostemyelitis in infants reported in the international literature. 218 Osteomyelitis of head of humerus presenting as Erb palsy: 2 case reports. Author: Manuel Resende Sousa (Portugal) Co-Authors: Filipe Silva (Portugal), Delﬁn Tavares (Portugal), Francisco sant’Anna (Portugal), Manuel Cassiano Neves (Portugal) Purpose: Osteomyelitis occurring during the neonatal period is uncommon. Hematogenous dissemination is responsible for most of these cases. Brachial plexus pseudopalsy is a well recognized complication of shoulder osteomyelitis / septic arthritis. Our aim is to report 2 cases of brachial plexus palsy in the neonate. Methods: Two neonates with previous normal neurologic examination presented with reduced movement and pain of the upper

Poster presentations: Abstracts 124–322/J Child Orthop

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extremity. There was no history of fever or signs of constitutional illness. Shoulder osteomyelitis was diagnosed from clinical, haematological and radiological ﬁndings. Pus culture grew staphylococcus aureus. Results: Following surgical drainage and intravenous antibiotics, resolution of the symptoms was progressive and complete. Conclusions: Neonatal osteomyelitis affecting the humerus can present as Erb palsy. It results from hematogenous spread and skin/umbilical sepsis are a predisposing factor. Diagnosis is often difﬁcult and delayed. We suggest that such infection should be considered in every neonate with acute paralysis of the arm beyond the perinatal period. Signiﬁcance: Diagnosis is often difﬁcult and delayed. We suggest that such infection should be considered in every neonate with acute paralysis of the arm beyond the perinatal period.

Signiﬁcance: The interest in that case consists of the difﬁculty in the differential diagnosis at the ﬁrst evaluation (the newborn underwent 3 non orthopaedic surgical procedures before correct localization of the disease was established), in the orthopaedic misdiagnosis based on the lack of a complete preoperative imaging where a MR was not performed (a septic arthritis was supposed at the time of orthopaedic evaluation), and ﬁnally in the long term excellent result after a prompt surgical treatment.

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Co-Authors: Hee Pyo Jang (Korea, Republic of), Eun Jin Sul (Korea, Republic of)

Septic Physeal Separation of Proximal Femur in a Newborn Author: Roberto Schiavon (Italy) Co-Authors: Andrea Borgo (Italy), Andrea Micaglio (Italy), Naldo Chiaramonte (Italy) Purpose: Physeal separations in newborns are a problem in diagnosis and treatment. In developed countries, septic osteomyelitis and septic arthritis in newborns are unusual and represent a problem in differential diagnosis among several diseases, often far away from the orthopaedics and frequently needing all diagnostic resources to obtain the correct diagnosis. This in order to get the best knowledge of the actual condition and to avoid an unsuitable treatment or to avoid an unexpected anatomical situation in case of surgical exposition. Therapy needs to be carried out as soon as possible in order to prevent the possible negative anatomical and functional consequences. Association between septic event and physeal separation is really rare. Methods: We report a 28-days female, admitted for persisting elevated temperature, shudder, irritability and abdominal symptoms with abdominal levels on the abdominal X-ray. At the time of admission, when ﬁrst evaluated by the paediatric surgeon, and inguinal hernia was reduced. For the persistence of clinical conditions, in the following days she underwent to two surgical explorative laparoscopy with no regression. Four days later become visible, at the left groin plica, a swelling extending to the posterior proximal thigh; a needle drainage performed by the paediatric surgeon evidenced pus presence. At this time she underwent to orthopaedic surgeon evaluation and after a correct exposition of the pelvis to direct X-ray (that evidenced a lateralization of the femoral shaft) and an ultrasonography of the left hip (that showed an indeﬁnable morphology of the hip, the presence periarticular and proximal parostal femoral shaft liquid collection) a diagnosis of septic arthritis with consequent hip dislocation was formulated and surgical open drainage was indicated. Actually, only at the time of surgery was possible to observe the presence of a separation between the connected epiphysio-great trochanteric nuclei and the femoral shaft, with unexpected close and clear hip joint. After drainage a reduction between the epiphysio-trochanteric complex and the femoral shaft was obtained and a stabilization with Kirschner wires was performed. Results: When 4-years last reviewed, the two hip joints were symmetric on X-ray image and in range of motion. Conclusions: Association of musculo-skeletal septic event and physeal separation is rare, difﬁcult to diagnose, and need a prompt surgical treatment.

220 Acute pyogenic arthritis in neonate: prognostic factors and outcome Author: Jong Sup Shim (Korea, Republic of)

Purpose: The aim of this study were to investigate relationship of the multiple prognostic factors and outcome of acute pyogenic arthritis in neonate. Methods: Thirty neonates (13 females and 17 males) underwent operative procedure under diagnosis of an acute pyogenic arthritis and survived until ﬁnal follow-up were included in this study. Ages ranged from 10 days to 2 months (mean 43 days). The most common sites of involvement were hip (21 patients). Twenty-three patients (77%) had deﬁnite intraoperative pus drainage. Ten (33%) had an underlying disease. Thirteen (43%) had a concomitant septicemia. The symptom duration before treatment ranged from 1 day to 30 days (mean 5.7 days). Twenty-ﬁve children (83%) were febrile. Nine patients (30%) had a radiographic change on preoperative plain X-ray. WBC count was elevated in twenty-three patients (77%). The ESR increased in ﬁfteen patients (50%) and CRP increased in twenty-six patients (87%). Fourteen cases (47%) had positive culture from joint ﬂuid. The predominant causative organism was Staphylococcus aureus (11/14), six of which were methicillin-resistant. We rated ﬁnal result as good, fair, and poor according to the range of motion of the joint and radiographic ﬁndings (Good: full range of motion and no radiographic deformity, fair: mild limitation of motion or mild radiographic deformity, bad: limitation of motion and deformity required correction). The average follow up period was 5 years 2 months (2–9 years). Seven cases were good, seventeen were fair and six were bad. Possible prognostic factors including gender, age, prematurity, birth weight, fever, symptom duration and laboratory ﬁndings, site, pus, sepsis, radiographic ﬁnding, culture, underlying disease and pathogens were evaluated. Statistical analysis was evaluated by Krusskal-Wallis test and v2 test. Results: Our results showed that the prognosis is worse in the case of who showed preoperative radiographic change in plain X-ray, premature, low birth weight and who had underlying disease. Outcome did not depends on other factors, including gender, age, fever, symptom duration, laboratory ﬁndings, site, pus, sepsis, culture and pathogens. Conclusions: Unhealthy neonates with low birth weight, premature or comorbidity have the poor general condition that necessitated several invasive procedures such as catheterization and monitoring, which made them more susceptible to invasion of the microorganism. Also, radiographic change means that the diagnosis is delayed. These factors may predispose to the development of infection sequelae and poor end result. Signiﬁcance: The progressive joint destruction in the neonate with septic arthritis do not correlated with the severity of the perioperative clinical manifestations.

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Purpose: Most work in our speciality is not admitted to hospital. Because of this, much is not captured by the ICD coding system. As a result it is difﬁcult to use such methods to adequately reﬂect what we do and to recall patients for research purposes. Methods: We have developed, and used for some 13 years, a simple method of coding all the patients we see. The coding system has been designed speciﬁcally for children’s orthopaedic surgery. Results: We now have some 53,000 patients coded by this simple system. Sampling has revealed it to be 97.5% accurate. Conclusions: By augmenting the more usual methods of coding by a system speciﬁcally designed fro our speciality, we have produced a method of recall fro all patients seen in the department. Signiﬁcance: Such method of recall is vital both for audit of what we do and as a research tool. It enables easy recall of all patients seen and thus allows easy retrospective study both of workload and of speciﬁc conditions. We would recommend the development of a standardised coding system for our speciaity and suggest that this is something which EPOS might undertake.

The use of polymerase chain reaction (PCR) for the detection and speciation of bacterial bone and joint infections in children Author: Kit M Song (United States) Co-Authors: Karl Boatright (United States), William Nilsson (United States), Jeff Drassler (United States), Mark Strom (United States), Jane Burns (United States), Wesley Bevan (New Zealand) Purpose: To develoop and test an accurate, rapid, and easily applied PCR/RFLP techique for detecting and differentiating bacterial species causing osteomyelitis and septic arthritis in children. To compare the ability of PCR/RFLP to standard bacterial cultures in detecting and identifying bacterial pathogens in bone and joint infections in children. Methods: We prospectively enrolled 36 consecutive patients with open physes who met our inclusion criteria for probable infection. Blood and body ﬂuid/joint aspirate specimens were collected sterilely with half the specimen undergoing routine processing for bacterial cultures and the other half frozen for later PCR/RFLP analysis. Extracted genomic material was ampliﬁed using a ﬂuorescent labeled universal primer for the small subunit 16S gene. The resultant amplicons were puriﬁed and were then digested with selected restriction endonucleases to yield characteristic fragments which were then compared to a library of common organisms for pediatric bone and joint infections that had undergone the same PCR ampliﬁcation and endonuclease digestion. Positive controls used blood and synovial specimens from control patients known to be free of infection. Negative controls were from patients undergoing routine arthroscopy, elective osteotomy with sterile marrow aspirates, and blood draws from patients undergoing elective surgical procedures. Results: Of 36 enrolled patients, 3 had contaminated specimens and were excluded from analysis. Five were found to have diagnoses other than a bacterial bone or joint infection. Of the remaining 28 patients, site-speciﬁc bacterial cultures were positive in 15/28 patients (53.5%). Nine of 15 were PCR positive for the same organism and one of these had a polymicrobial infection based upon PCR. Of 6 patients who were culture positive and PCR negative, 4 were Staph Aureus and 2 were Kingella Kingae. Five of 13 culture negative patients had a positive PCR and one of these was polymicrobial. 27 of 28 had blood cultures and 7 of these were culture positive. Four of these were PCR positive for the same organism. No culture negative blood cultures were PCR positive. Conclusions: The use of PCR/RFLP with a universal primer was not found to be more sensitive than standard bacterial cultures, but was found to be complementary with culture negative specimens being PCR positive and polymicrobial infections being detected that were not detectable by standard culture techniques. Signiﬁcance: The use of PCR/RFLP methods may be of use in situations in unknown or polymicrobial infections where organism speciﬁc probes or direct sequencing of ampliﬁed genomic material may not be feasible to use.

Other 222

223 Williams syndrome in childhood: the role of the orthopaedic surgeon. Author: Enrica Cristini (Italy) Co-Authors: Chiara Comelli (Italy), Antonio Memeo (Italy), Angelo Silicorni (Italy), Alessia Fraponi (Italy), Giovanni Peretti (Italy) Purpose: Williams syndrome (WS) is a rare genetic condition which causes medical and developmental problems. It is present at birth, and affects males and females equally. The prevalence of WS is about 1/7500. The clinical presentation is variable, with different degrees of severity. It is characterized by: mental retardation and/or learning difﬁculties, developmental problems, cardiovascular disease, a distinctive facial appearance and, sometime, hypercalcemia. WS is due to a random genetic mutation (deletion of a small piece of chromosome 7).The main orthopaedic problems include: scoliosis, ﬂat foot, genu valgum, kyphsis, ligamentous laxity and muscular hypotonia. Methods: We reviewed 115 patients with WS that were treat in De Marchi Syndromologic Centre of Milan University. Results: Scoliosis with variable degrees of severity occurred in 14 patients, ﬂat foot in 15, valgus knees in 28, kyposis in 11, toe walking in 1, cavus foot in 1, permanent patellar dislocation in 1, hallux valgus in 4, clinodactylia of the ﬁfth ﬁnger in 4 cases, minor orthopaedic problems in 11 and no musculoskeletal involvement in 14 patients. Conclusions: All the child presented a generalized muscular hypotonia and a retardation in physical development and generally a low stature. Surgical treatment was reserved only to really severe scoliosis and to permanent patellar dislocation. All patients underwent a rehabilitation program to improve tone and muscular control. Signiﬁcance: We can conclude that orthopaedic surgeons play an important role in carefully monitoring children with WS. 224 Pediatric trauma related to motor-vehicle accident

A Method of Coding Children’s Orthopaedics

Author: Mahzad Javid (Iran, Islamic Republic of)

Author: George Bennet (United Kingdom)

Co-Authors: Gholam Shahcheraghi (Iran, Islamic Republic of)

Co-Authors: Alistair Murray (United Kingdom), Neil Wilson (United Kingdom)

Purpose: To ﬁnd the patterns and common mechanisms of motor –vehicle related pediatric trauma in a metropolitan city

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Poster presentations: Abstracts 124–322/J Child Orthop (Tehran-Iran), to guide the health planners of the city in proper planning and resource application and distribution. Methods: A pilot study was started in three major pediatric – trauma referral centers in Tehran by the Iranian Orthopaedic Association. All the cases below age 14 who visited the emergency department of those three hospitals, with body trauma resulting from a vehicle-related accident were studied. Cases were collected on a 24-hour basis in 1 month of each four seasons of the last year. The data collection was done by contracted physicians with the use of a detailed questionnaire. Results: A total of 318 cases (74.2% male, 25.8% female) with the mean age of 8.32 years (4 months to 14 years) had the seasonal distribution of: 22.1 % spring, 30% summer, 20.9% fall, and 27% winter. 12.6% of the accidents happened on roads, 71.1% on city streets, and 16.4% on alleys. 56.9% happened at night and 43.1% during the day. Motorcycle hitting pedestrian accounted for 33%, car-pedestrian accident for32.1%, and car-motorcycle for 11.6%. The rest were combinations of car to car, car to bike, motorcycle to bike, etc. The injury types consisted of 86 (65.2%) lower, 38 (28.8 %) upper, and 8 (6%) combined upper and lower extremity fractures. 106 (33.8%) of cases had multiple trauma, 183(57.5%) had head injury (22 unconscious, 5 confused), 5.7% pelvic, 4.7 spinal, 5% abdominal, 1.6% chest and 0.6% vessel injury. In the lower extremity, tibia /ﬁbula fractures were the most common (64.5%), followed by femur (26.6%). In the upper limb radius/ulna fracture with incidence 39.1% was the followed by and humerus and clavicle (23.9% and 15.2%). 24.8% of the cases had been brought in by ambulance and 75.2% by friends, family or by standers. The recommended safety support was not in use at the time of accident in 83%. 12.3% of children were holding parents’ or guardian hands when the accident happened. 68.6% of children were crossing the width of the road, alley, or highway when they were hit. Conclusions: Vehicle related fractures happen more in male children, more in summer after school closing. Crossing the streets, especially at night is dangerous for children. Motorcycles and cars hitting the walking or running kids are common etiologies for fractures. (either due to lack of respect for trafﬁc rules by the drivers or from children not obeying pedestrian trafﬁc rules). Signiﬁcance: Children become disabled far too frequently in the city, from lack of proper training, proper enforcement of trafﬁc rules by the children and the drivers. Appropriate measures of safety in the crowded metropolitan city of Tehran are essential, and this report can be a guide for the other major cities of the third world. 225 Time cost of digital imaging (CD) in orthopaedic clinics Author: Stephanie Juenemann (Switzerland) Co-Authors: Carol Hasler (Switzerland), Reinald Brunner (Switzerland) Purpose: X-Rays are presented on CD‘s in a digital format with increasing frequency. The impression is that this technique requires more time to present a given x-ray compared to conventional pictures. Methods: Time was measured for 6 orthopaedic residents presenting the most recent ap-view out of a given set. Ten sets of 6 xrays for each case were saved in the conventional and digital format each. The order was randomised. As a precondition the computer was on and the same viewer software was used for all digital sets. The results were compared using a non linked student‘s t-test (signiﬁcance level p = 0,05).

S93 Results: Presentation of conventional x-rays required 21 sec (+-7,46), of digital x-rays 90 sec (+- 27,56) respectively (p < 0,001). Conclusions: In spite of ideal conditions digital x-rays on CD need signiﬁcant more time in the orthopaedic clinic. In major centres patients present with different software and software in other languages which increase the required time even furhter. This latter problem will be assessed in another study. Signiﬁcance: This increase of preparation time used by a highly qualiﬁed staff member has implications on economics and logistics.

226 Characteristics of the fractures in children who were presented to the emergency department of the hospital Author: O¨nder Kalenderer (Turkey) Co-Authors: Tanzer Gurcu (Afghanistan), (Afghanistan), Haluk Agus (Afghanistan)

Ali

Reisoglu

Purpose: This study concerns the breakdown and frequency of fractures in children by recording the children who were diagnosed with and treated for fractures at Tepecik Eg˘itim ve Aras tırma (Education and Research) Hospital and time of fracture, age, sex, mechanism of fracture, fracture time and type. Methods: Children, who age between 0–14 and were presented to emergency department with fracture diagnoses on even numbered days were included in this prospective, random study. Forms including information about characteristics of the fractures were ﬁlled in for each case. For 3 years, age, sex, date and time of fractures, how they occurred, fracture place and type have been recorded for the cases and child fracture case frequency and breakdown were determined. Results: Total number of cases was 1706 (992 boys and 714 girls). The most frequent age for fractures were 7 and 3 (9 % and 8 %) for the boys, whereas it was 4 and 5 (9 % and 8.5 %) for the girls. Most frequent cause of fracture was domestic accidents. School (22 %), trafﬁc (17 %) and sport (8 %) accidents follow in order. Fractures took place most frequently in summer months (35 %) especially in July and then in order in autumn (24 %), spring (20 %) and in winter (21 %). Fractures were brought to the emergency department most frequently between 16:00 – 20:00 (32 %) and secondly 20:00 – 24:00 hours (25 %). Most frequent cases were observed around distal radius. In order, elbow, forearm, clavicula, tibia, femur, hand and foot small bone fractures follow. Conclusions: In our area, child fractures generally take place during summer and spring months and at play hours as a result of a fall. Generally conservative methods are applied for the treatment. Distal radius fractures are observed most frequently and these fractures are observed at younger ages despite the current literature data. Signiﬁcance: Child fractures generally take place during summer and at play hours. 227 The aetiology and short-term morbidity of fasciotomy for acute or impending compartment syndrome in children. Author: Kevin Lim (Singapore) Co-Authors: Tero Laine (Finland), Unni Narayanan (Canada) Purpose: To study the aetiology of acute or impending compartment syndrome (AICS) in children, and to describe the early morbidity associated with fasciotomy for AICS.

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S94 Methods: The surgical database of a large tertiary children’s hospital was used to identify all patients who underwent fasciotomy for acute or impending compartment syndrome from April 1992 to March 2005. The medical records were reviewed to determine the aetiology and reasons for fasciotomies, the location, the timing, number of subsequent operations, method of wound closure, length of hospital stay and short term complications. Results: 112 faciotomies were performed in 104 children for AICS. Mean age was 10.2 years (SD:4.6). 70% were male. The aetiology for AICS was trauma in 93 cases (89%), elective osteotomies in 4 (4%); and vascular/hematological or infection related in 7 (7%). Fasciotomies were performed in 53 lower legs (47%), 43 forearms (38%), 12 feet (11%), 2 thighs and 2 hands. Eight children (7.7%) had fasciotomies at two different sites. In 63 (60%) cases, fasciotomy was performed at, or as, the index operation, while 41 (40%) underwent fasciotomy as a secondary procedure. Compartment pressures were recorded only in 51 cases (49.0%). Median number of additional operations (for wound closure) was 2, with 16 requiring 4 or more procedures. 33 (32%) needed a skin graft, including 4 requiring ﬂap coverage. Mean inpatient stay was 15.7 days (SD 11.7). 7 patients (6.7%) developed fasciotomy wound infections, and 8 patients (7.7%) required blood transfusion following fasciotomies. Conclusions: Fasciotomy for AICS is associated with signiﬁcant early morbidity including multiple operations for delayed wound closure and prolonged hospital stays. Signiﬁcance: Fasciotomies are the only effective way to prevent irreversible ischemic necrosis associated with untreated or missed AICS. The decision to intervene is inﬂuenced by some combination of clinical signs and symptoms, measurement of compartment pressures and/or clinical judgment. However, fasciotomies are associated with signiﬁcant morbidity and utilization of health care resources that have not previously been quantiﬁed. Development of reliable, sensitive and highly predictive diagnostic tests might reduce the number of unnecessary fasciotomies. More efﬁcient methods of wound closure might also reduce morbidity, hospital stay and complications. 228 The Gonad Shield in Pelvic X-Rays - Covering a Multitude of Sins? Author: Aaron Hugh McManus (United Kingdom) Co-Authors: Naomi Davis (Consultant in Paediatric Orthopaedic Surgery, Booth Hall Children’s Hospital, Central Manchester and Manchester Children’s University Hospital NHS Trust) (United Kingdom) Purpose: To determine the value of the gonad shield in paediatric pelvic x-rays by considering the effectiveness of their placement. Methods: A retrospective study of paediatric pelvic and hip radiographs Manchester Children’s Hospitals (MCH). The focus was on gonadal shield use in paediatric patients, with speciﬁc reference to areas of bone obscured by the shields and whether the gonads were effectively shielded. Each X-ray was examined for shield presence and (when present,) correct placement. If bone was covered, this was recorded using a numerical system for bony areas of the pelvis. In total, 1720 radiographs were reviewed (508 hip, 1212 pelvic); 53.3% (n = 917) were female and 46.7% (n = 803) male. Results: The National Radiation Board (NRPB), European Commission and MCH request gonadal shield use in 100% of paediatric pelvic radiographs, except for the ﬁrst radiograph in emergency/ trauma cases for fear that any important bony abnormality is

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Poster presentations: Abstracts 124–322/J Child Orthop obscured by the radiopaque gonadal shield. All of the studies mentioned here have used these guidelines and aim for 100% shield usage in eligible cases. 79.0% of radiographs had a shield present. 81.5% were female, and 76.2% male. 65.4% of radiographs were considered to have unprotected gonads. This compares well with Doolan et al (2004), Sikand et al (2003) and Kenny and Hill’s (1992) results, which showed presence of a shield in 2%, 33% and 60% of radiographs respectively, When a shield was present, only 43.8% were considered fully protected. 29.01% of females were protected adequately. For males, only 40.97% were satisfactorily shielded. Female patients were signiﬁcantly more likely to have a shield present than males (p < 0.05). When a shield was used, females were signiﬁcantly less protected than male patients (p < 0.05), a result echoed by Kenny and Hill (boys v girls; 64 v 45; p < 0.012). 51.4% had an area of bony pelvis covered when a shield was used. Male patients were signiﬁcantly less likely to have bones covered than female patients (p < 0.05). Conclusions: Standard protocols for gonadal shield usage in pelvic and hip x-rays in children appear to fall below a reasonable standard. Recommendations for improvement have been made. Signiﬁcance: The form of gonadal shields widely available and the guidelines involved in their usage are resulting in a higher than necessary radiation dose in children. This is the largest study of its kind to date and highlights the need for new designs and techniques that are required to reduce gonadal radiation dose and subsequent side-effects in children. 229 Paediatric trauma in an tertiary referral centre. Author: Patrick O’Toole (Ireland) Co-Authors: Orla Callender (Ireland), Brendan O’Hare (Ireland), Sean Walsh (Ireland), Esmond Fogarty (Ireland) Purpose: To assess the epidemiology of major paediatric trauma attending a paediatric tertiary referral unit in Ireland. Methods: We prospectively collected data on 153 major trauma patients admitted to our tertiary level paediatric facility, over a seven year period. 112 patients were secondary referrals from other hospitals, with 41 patients primarily presenting to the Emergency Department in our hospital. 153 children were included. There were 14 deaths (9%). Results: There were 99 males and 54 females. RTA’s (road trafﬁc accidents) were consistently the commonest cause of admission (39%) followed by thermal injuries (32%), and falls (12%). Others included bicycle injuries (6%), non accidental injuries (3%) and miscellaneous (8%). Of the occupants 68% were either unrestrained or incorrectly restrained. 9 cyclists were involved in road trafﬁc accidents. Only one cyclist was wearing a helmet. 19 thermal injuries were due to scalds, with the remaining 30 cases being as a result of injuries sustained due to ﬁre and ﬂames. Scald injuries peaked between 1 and 5 years of age, while injuries caused by ﬂammable materials were seen mainly in the older age groups. The majority of falls were from a height < 20 ft representing 80% with the remaining 20% falling from a greater height. The majority of the children who sustained a fall were in the 1–5 year age group (65%). There were 5 admissions with a diagnosis of non-accidental or intentional injury.The average length of stay in the intensive care unit was 4.1 days with a range of 1 to 36 days. The majority of patients were discharged home (83%). 14 patients (9%) died. The overall mean ISS (Injury Severity Score) in this study was 27.6. The average age of the fatalities was 5.2 years. Conclusions: This study captured all seriously ill children referred from multiple centres around the country and also in our own

Poster presentations: Abstracts 124–322/J Child Orthop catchment area. However our unit is not the only tertiary referral hospital for paediatric trauma in the country. 68% of the occupants of vehicles involved in an accident in this study were either unrestrained or incorrectly restrained.Despite the effectiveness of bicycle helmets, rates of helmet wearing in this study were low at just 11%. Signiﬁcance: Improving trauma care should lead to better outcomes which will have major social consequences and reduce avoidable death and unnecessary morbidity. Preventative strategies are needed as well as enforcement of current legislation. 230 Is major paediatric trauma decreased by the introduction of a penalty point demerit system for speeding? Author: Patrick O’Toole (Ireland) Co-Authors: Orla Callender (Ireland), Brendan O’Hare (Ireland), Sean Walsh (Ireland), Esmond Fogarty (Ireland) Purpose: The aim of this study was to evaluate the impact of the penalty points system on the number and severity of major paediatric trauma caused by road trafﬁc accidents. Methods: We prospectively collected data on 64 patients who suffered major trauma, as a result of a road trafﬁc accident, over a seven year period (1999–2005 inclusive). We collected data on a number of different variables including patient age, type, site and mechanism of accident, transport to hospital, complete evaluation of patient history and examination ﬁndings, management, and outcome. We speciﬁcally looked at the patients in two groups, those who were injured pre penalty points and those injured post the points system respectively. We used Fischer’s Exact Test when comparing the different variables pre and post introduction of penalty points. We compared the two groups using the ChiSquared Test. Results: There were a total of 64 patients in total admitted to the Paediatric Intensive Care Unit (PICU) over the 7 year time period. 42 patients were admitted before October 2002, while the remaining 22 were admitted after this time. There was no difference in the two groups, mean age pre 6.4 yrs, post 6.41 yrs (p = 0.99), number of males pre 29, post 11 (p = 0.18), number of females pre 13, post 11 (p = 0.18). The percentage of the total admissions to the PICU that each group represented for their given time period was 48.8% and 34.9% pre and post points respectively. This was not signiﬁcant, (p value 0.1). There was no statistical difference in the pre and post groups in relation to whether those injured were cyclists, pedestrians or vehicle occupants. There was no signiﬁcant difference in the number of injuries sustained in the two groups respectively. Conclusions: Despite previous studies showing a decrease in the number of injuries sustained with the introduction of a penalty points system for speeding, we have shown no difference in the number of major paediatric trauma cases post introduction of the system. Signiﬁcance: We have shown that there is no difference in the number and seerity of paediatric trauma with the introduction of a penalty points system for speeding.

S95 Purpose: Hypomelanosis of Ito (HI) (OMIM # 300337) is a rare neurocutaneous disorder characterized by hypopigmented skin lesions arranged in whorls and/or streaks along the lines of Blaschko (a non-random developmental system of cutaneous markings characterizing the distribution of various linear and segmental skin disorders). Even though Ito’s original report in 1952 described a purely cutaneous disease, subsequent case reports and case series have recorded a signiﬁcant association with multiple extra-cutaneous manifestations. Cytogenetic studies have revealed a wide variety of mosaic chromosomal abnormalities in about half cases: thus, it has been suggested that this group of conditions is rather a non-speciﬁc manifestation (i.e., a phenotype) reﬂecting genetic mosaicism which likely disrupt expression or function of pigmentary genes. Musculoskeletal anomalies are considered the second most frequent extra-cutaneous alterations, after nervous system involvement, in HI. However, rather non-speciﬁc limb and skeletal defects and miscellaneous radiographic ﬁndings are usually associated to HI, whilst there is no systematic study on skeletal involvement in HI. The aim of study was to deﬁne the frequency and the degree of musculoskeletal involvement in children and adults with HI. Methods: Ninety-eight white Italian subjects (46 M, 52 F), aged 16 months to 34 years, with the typical clinical features of HI were examined at the University Departments of Paediatrics and Orthopaedics in Catania, Italy over a sixteen-year longitudinal follow-up which included clinical, laboratory and imaging examination (CT and/or MRI of the head and spine and skeletal radiographs). Results: We recorded macrocephaly (n = 11) or microcephaly (n = 2); asymmetry of length or size of limbs and body parts along with joint contractures particularly talipes (n = 22); height at or below the 3rd percentile (n = 19); delayed skeletal maturation (n = 18); dystrophic (n = 5) or idiopathic (n = 18) kyphoscoliosis or scoliosis; pectus excavatum (n = 23) or carinatum (n = 12); small hands and feet (n = 2); pes valgus (n = 4) or varus (n = 5), genu valgus (n = 3) or congenital hip dislocation (n = 3); polydactyly (n = 2); ectrodactyly (n = 1); or syndactyly (n = 5). Conclusions: All these defects are likely related to the age dependant effect of the genetic mosaic abnormality. Notably, the bone abnormalities were usually seen on the same side/area as the hypomelanotic skin and the most severe cases were associated to chromosomal mosaicism. Signiﬁcance: This is the ﬁrst systematic study, which estimates the extent of musculoskeletal involvement in a large HI series followed for a long period of time in the same geographical area. All the recorded abnormalities were congenital and only mildly progressive.

232 Validation of the AO paediatric Comprehensive Classiﬁcation of long - bone Fractures: a web-based multicenter agreement study Author: Theddy Slongo (Switzerland)

231 Musculoskeletal Involvement in Patients with Hypopigmentation Along the Lines of Blaschko (Hypomelanosis of Ito) Author: Vito Pavone (Italy) Co-Authors: Martino Ruggieri (Italy)

Co-Authors: Laurent Audige´ (Switzerland), Jean-Michel Clavert (France), Nicolas Lutz (Switzerland), Steve Frick (United States), James Hunter (United Kingdom) Purpose: The ﬁrst AO comprehensive paediatric long bone fracture classiﬁcation system has been proposed following a structured path of development and validation with experienced pediatric surgeons. This study was conducted to assess the

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S96 reliability and accuracy of this classiﬁcation among a wide range of surgeons with various level of experience. Methods: A web-based multi-centre agreement study was conducted between 2004 and 2005 involving 70 surgeons in 15 clinics and 5 countries. Training was provided on each clinic prior to the session. Using the internet, participants classiﬁed at their own pace 275 supracondylar, radius and tibia fractures based on standard pre-treatment radiographs. Results: Kappa coefﬁcients for the single-surgeon diagnosis of fracture type E (epiphyseal), M (metaphyseal) or D (diaphyseal) were 0.66, 0.80 and 0.91, respectively. Median accuracy estimates for each bone and type were all above 80%. Pediatric training and at least 2 years experience were associated with signiﬁcant improvement in reliability and accuracy. Using simulation, classifying fractures by consensus among surgeons within each clinics improved reliability with kappa above 0.80. Kappa coefﬁcients for diagnosis of speciﬁc child patterns were 0.51, 0.63 and 0.48 for E, M and D fractures, respectively. Results supported the coding of fracture severity in just two categories (simple vs complex), and the need to conduct additional pilot agreement studies for the evaluation of exception codes for supracondylar fractures (von Laer) and fractures of the radial head. Conclusions: This classiﬁcation system received wide acceptance and support among involved surgeons. As long as appropriate training could be performed, the system classiﬁcation was reliable, especially among surgeon with a minimum of 2 years clinical experience, and when a consensus among all surgeons within clinics was considered. Signiﬁcance: We encourage a wide consultation among surgeons’ international Societies, and the use of this classiﬁcation system in the context of clinical practice as well as prospective for clinical studies. 233 PHEX Gene Mutations and Genotype–Phenotype Analyses of Korean Patients with Hypophosphatemic Rickets Author: Hae-Ryong Song (Portugal) Co-Authors: Sung-Chul Jung (Afghanistan), Joo-Won Park (Afghanistan), Dae-Yeon Cho (Afghanistan), Jae Hyuk Yang (Afghanistan), Hye-Ran Yoon (Afghanistan), Gautam Shetty (Afghanistan), Sameer Desai (Afghanistan) Purpose: X-linked hypophosphatemic rickets (XLH) results from mutations in the PHEX gene. Methods: Mutational analysis of the PHEX gene in 15 unrelated Korean patients with hypophosphatemic rickets. Results: The study revealed eight mutations, including ﬁve novel mutations, in nine patients: two nonsense mutations, two missense mutations, one insertion, and three splicing acceptor/donor site mutations. Of these, c.Ala22Ser, c.Arg567X, c.466_467insAC, IVS10-1G>A, and IVS17 + 5G>A are novel mutations. To analyze the correlation between genotype and phenotype, phenotypes were compared between groups with and without a mutation, in terms of mutation location, mutation type, and sex. Skeletal disease tended to be more severe in the group with a mutation in the C-terminal half of the PHEX gene, but no genotype–phenotype correlation was detected in other comparisons. Conclusions: Further extensive studies of the PHEX gene mutations and analyses of the genotype–phenotype relationships are required to understand PHEX function and the pathogenesis of XLH. Signiﬁcance: Skeletal disease tended to be more severe in the group with a mutation in the C-terminal half of the PHEX gene.

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Upper extremity 234 WITHDRAWN

235 Modiﬁed green’s procedure for sprengel deformity; Resection of anterior curvature of the supraspinous portion is important Author: Toshio Fujii (Japan) Co-Authors: Akifusa Wada (Japan), Kazuyuki Takamura (Japan), Haruhisa Yanagida (Japan), Noriko Urano (Japan) Purpose: To evaluate the surgical results for Sprengel deformity who were treated by the modiﬁed Green’s procedure. Methods: We reviewed 32 patients with Sprengel deformity who were treated by the modiﬁed Green’s procedure in which we dissected ﬁbrous bands in serratus anterior muscle radically. The age of the patients at surgery ranged from two to six years. We sutured the inferior angle of scapula to the spinous processes of thoracic spine in stead of wire traction. Twenty nine patients had omovertebral bones and Klippel-Feil syndrome. Results: Postoperatively, shoulder abduction improved well. The cosmetic results were also good in all the patients except two who had severe Klippel-Feil syndrome. We found marked anterior curvature of the supraspinous portion which was clearly shown on 3DCT. The resection of this portion is essential to obtain good results in descending scapula procedure. Conclusions: We found that radical release of strong ﬁbrous bands, which connected scapula to chest wall, and resection of anterior curvature of the supraspinous portion are important to obtain good results and it could be easier to look at those directly by Green’s approach. Signiﬁcance: Green’s approach gives us a good advatage to obtain good surgical results for Sprengel deformity patients.

236 Congenital pseudarthrosis of the clavicle Author: Alicia Gargantilla (Spain) Co-Authors: Marı´ a Pe´rez (Spain), Rosendo Ullot (Spain), Santiago Cepero (Spain), Ramon Huguet (Spain) Purpose: Congenital pseudarthrosis of the clavicle (CPC) is a rare malformation of the scapular waist, of unknown etiology very little frequents of wich 220 cases published at the present time have been reported. The lesion is usually right-sided and unilateral. Due to his etiopatogenia, probably the congenital pseudarthrosis of the clavicle undergoes a lack of fusion of the both centers of ossiﬁcation embryonic stages, due to posicion of the right artery subclavia and/or malformations vasculares. The thurd means appear in form of tumoracion to clavicle. The diagnosis is conﬁrmed by plain radiology. Differential diagnosis includes postraumatic pseudarthrosis, cleidocranial dysostosis and neuroﬁbromatosis. Surgical treatment is indicated in symptomatic patients or major deformity. Methods: Retrospective review of clinical chart of the 17 patients with 18 CPC followed in our hospital from 1986 to the 2005.

Poster presentations: Abstracts 124–322/J Child Orthop Results: Of the 17 patients who presented PCC 9 they were girls and 8 boys with unilateral right CPC side in all the cases, except in a patient who was bilateral and brother of another patient affection of PSC. Seven patients they referred pain, without functional impairment and in other seven alterations estetics. They present one clavicular assymetry in x-ray ranged from 0.5 to 1 cm, without accompanying pathologic ﬁndings. Surgical treatment has been performed in 11 cases, with resection of ﬁbrous pseudarthrosis, internal ﬁxation and iliac bone graft. In 10 patients callus response was achieved in 2 months; the remaining one required withdrawal of orthopaedic material 2 months later because of its protrusion through the skin, no further surgical treatment having been necessary so far. Conclusions: The indications of the surgery treatment are as much the deformities estetics that usually they present these patients, like functional impairment The ideal age to carry out this surgery to the 4–5 age. The treatment with actual surgery techniques with internal ﬁxation and iliac bone graft obtains good results to solve this malformation. Signiﬁcance: CPC is a rare disease, therefore, reports on objective results or surgical techniques and problems are limited. We describe 17 cases over the 200 cases reported.

237 Current concept for treatment of obstetrical brachial plexus lesions Author: Werner Girsch (Austria) Purpose: For a long time the treatment of obstetrical brachial plexus lesions (OBPL) consisted of conservative treatment mainly. Surgery was indicated only in severe cases suffering from persistant complete ﬂail arm. Gilbert introduced a much more aggressive concept with surgical intervention whenever the biceps is not working at three months of life, a strategy which caused discussions permanently. As a result of this discussion and with respect to Clarkes work the concept was modiﬁed in the last years again. Methods: The diagnosis of an OBPL has to be followed by monthly clinical examinations. Testing for muscle regeneration is not only focussed on biceps muscle but also on time and topographic course of regeneration. Lack of shoulder and biceps activity at three months of life or negative ‘‘handkerchief-test’’ at six months represent indications for immediate surgical revision of the brachial plexus (primary early nerve surgery). In cases showing ongoing regeneration the conservative treatment is maintained. Relevant deﬁciencies in motor function (less than 50% of ROM or power in correlation with the unaffected side) at twelfe months of life represent an indication for brachial plexus surgery again (primary late nerve surgery). Further nerve procedures, usually isolated nerve transfers (secondary late nerve surgery), can be performed in selected cases up to two years of life. After that time musle transfers and osteotomies (secondary procedures) are perfomed to achieve further increase in function. Results: In brachial plexus surgery new concepts of ‘‘extraplexual neurotisation’’ and ‘‘end-to-side neurorraphy’’ have increased the possibilities of reconstruction by increasing the amount of nerve sources. Secondary procedures, including free functional muscle transplantation, have become an integrative part of the overall treatment strategy. Conclusions: Although obstetrical techniques have improved in the industrialized countries, there still exists an incidience of 1–2 OBPL per 1000 newborns, last but not least with regard to an increasing number of babies weighing more than 4500 g. It is known that 8 of

S97 10 OBPL recover spontaneously. New investigations have revealed relevant deﬁciencies in 4 out of 10 of these children at an age of 15 years. Actually the number of children requiring surgery is small. Signiﬁcance: But for these children it is important to make the right decisions in time to minimise deﬁciencies and achieve optimal results. 238 Muscular Pathology in Brachial Plexus Birth Injury with Elbow Flexion Contracture Author: Tiina Po¨yhia¨ (Finland) Co-Authors: Antti Lamminen (Finland), Jari Peltonen (Finland), Aarno Nietosvaara (Finland) Purpose: To determine whether limited range of motion of the elbow and the forearm in patients with permanent brachial plexus birth injury (BPBI) is correlated with speciﬁc patterns of muscular pathology. Methods: For 15 BPBI patients with a mean extension deﬁcit of 31˚ (10˚–90˚) of the elbow joint, total active motion (TAM) of the elbow (extension–ﬂexion) and the forearm (pronation–supination) were clinically measured. MR imaging of both elbow joints and musculature of the arms and forearms allowed assessment of congruency of the elbow, grading of fatty inﬁltration and size reduction of the muscles. Statistical analysis was performed with the Wilcoxon Signed-Rank Test and Spearman’s two-tailed correlation test. Results: The mean TAM of the elbow was 113˚ (50˚–140˚) and that of the forearm 91˚ (10˚–165˚). The higher the age and the greater the size reduction of the brachioradial muscle, the more diminished was TAM of the elbow. The more extensive the BPBI and muscle pathology of the pronator teres, the more limited was the TAM of the forearm. Muscle pathology of the supinator and brachial muscles appeared in every patient. Conclusions: Extensive permanent BPBI may result in marked limitation of TAM, especially when both the agonist and antagonist muscles are affected. Elbow ﬂexion contracture seems to be caused mainly by brachial muscle pathology. Rotation of the forearm is better preserved when the pronator teres is not severely affected. Signiﬁcance: Elbow ﬂexion and forearm rotation contractures in BPBI are secondary to the primary nerve injury. The most profound permanent changes affect the most distal target muscles of the injured roots. 239 Remodeling of the lateral condylar prominence after supracondylar lateral closing wedge osteotomy in children with cubitus varus Author: Jong Sup Shim (Korea, Republic of) Co-Authors: Eunjin Sul (Korea, Republic of) Purpose: We tried to evaluate the effectiveness of the supracondylar lateral closing wedge osteotomy, and the remodeling of the lateral condylar prominence. Methods: Supracondylar lateral closing wedge osteotomy for cubitus varus deformity was performed in 48 children. The average age of patients was 8.7 (5~14) years. The operation was performed through a lateral approach. A wedge of bone was removed as much as assessed preoperatively and intraoperatively with ﬂuoroscopy. In all cases, the medial

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S98 cortex of wedge was kept intact and acted as a lever. Medial translation for decreasing lateral prominence or transposition of ulnar nerve was not performed. Fixation was done by an average 3.2 Steinmann pins with long-arm cast immobilization. After follow-up (av. 29 months; 12– 74 months), Humero-Ulnar(HU) angle, Shaft-Condylar (SC) angle, lateral prominence index, and lateral prominence amount were measured on radiographs and the range of motion was measured by physical examination. The results were analyzed with SPSS version 12.0.1(created by SPSS inc.) through Wilcox on, Spearman, Pearson, Mann-Whitney, and Rascal-Wallis test. Results: No major complication such as bone infection, malunion, nonunion or loss of correction occurred. Range of motion of the elbow improved from an average 136.9 degrees to 139.2 degrees(p = 0.050). HU angle improved from an average –17.4 degrees to 10.3 degrees (p = 0.000). SC angle improved from an average 25.8 degrees to 36.0 degrees (p = 0.000). The lateral prominence index and the lateral prominence amount signiﬁcantly improved from 2.27 (range 1.65~3.87) and 34.2 percent (range 20.4~50.7 percent) to 1.17 (range 0.89~1.83) and 8.7 percent (range 0.4~24.1 percent), respectively (p = 0.000, p = 0.000). These were correlated to preoperative HU angle (p = 0.000, p = 0.000). Remodeling of the lateral prominence index was correlated with preoperative HU angle, SC angle, and the length of follow-up (p = 0.000, p = 0.000, p = 0.023, respectively). Also remodeling of the lateral prominence amount was correlated with preoperative HU angle, SC angle, age, and the length of follow-up (p = 0.000, p = 0.000, p = 0.000, p = 0.000, respectively). Conclusions: Supracondylar lateral closing wedge osteotomy of the humerus is a safe and effective operative method for correction of cubitus varus in children. Also, good results on the cosmetic aspects can be expected with excellent remodeling of lateral condylar prominence of the humerus in most of the patients. Signiﬁcance: Considering the remodeling capacity of the children, extensive operative procedures to eliminate the lateral condylar prominence are usually unnecessary. 240 Operative treatment for congenital radial head dislocation Author: Kwang Soon Song (Korea, Republic of) Co-Authors: Chul-Hyung Kang (Korea, Republic of), ByungWoo Min (Korea, Republic of), Ki-Chul Bae (Korea, Republic of), Chul-Hyun Cho (Korea, Republic of) Purpose: Congenital radial head dislocation (CRHD) is considered that a deﬁnite diagnosis followed by observation is most appropriate. There have been only a small number of published cases of open reduction of CRHD. The purpose of this study is to investigate an effectiveness of early operative treatment for CRHD. Methods: We retrospectively analyzed charts and radiographs of 35 elbows in 25 patients with CRHD. 7 cases were performed surgical treatment including open reduction, ulnar osteotomy, annular ligament reconstruction, or ulnar lengthening or corrective ostetomy of distal humerus for excessive valgus deformity of elbow. 10 patients were involved bilaterally and 14 patients were combined with other congenital anomalies including congenital radial deﬁciency(3 cases), congenital radioulnar synostosis(3 cases), osteochondroma(2 cases), Rett’s syndrom, Poland syndrom, congenial below elbow amupation, multiple pterysium syndrome, clindactyly,microdactyly, and idiopathic brachialplexus injury (1 case in each disease). The radial head displaced

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Poster presentations: Abstracts 124–322/J Child Orthop anteriorly in 15 cases, posteriorly in 12 cases, anterolaterally in 4 cases, laterally in 3 and posterolaterally in one case. Results: 4 elbows treated with open reduction, ulnar osteotomy and annular ligament reconstruction were reduced and maintained for more than 3 years. One case with severe valgus deformity was corrected with distal humeral open wedge osteotomy. One case was failed in open reduction due to deformed head and shortening of the ulna. One case treated with ulnar lengthening was failed due to fracture of the ulna (too small to insert the pins). Conclusions: We considered that early operative treatments (including the open reduction, ulanar osteototmy and reconstruction of annular ligament) may be justiﬁed for treatment of simple CRHD without combined anomaly around the elbow. However, this is a little limited cases due to rarity of disease, further study is needed to obtain more deﬁnite conclusion. Signiﬁcance: Early operative tretment for congenital radial head dislocation is suitable treatment option in selected cases which have no combined anoamly in same elbow.

241 Polydactyly of the thumb with symphalangism Author: Ruiko Takagi (Japan) Co-Authors: Hidehiko Kawabata (Japan), Mayuko Wada (Japan), Daisuke Tamura (Japan) Purpose: Polydactyly of the thumb is one of the most common abnormalities of the hand. Most classiﬁcations including Wassel’s are based on the bifurcation level of two thumbs. We reviewed our 200 patients with polydactyly of the thumb and found four cases in which the radial thumb was complicated with symphalangism. These four cases are difﬁcult to categorize by traditional classiﬁcations for polydactyly of the thumb. In this study we illustrate such cases and discuss about those speciﬁc features. Methods: There were one female and three male patients. All the cases were unilateral and right side was involved in three cases and left in one case. Age at operation ranged from 8 months to 3 years 6 months. Follow-up period was 10 years on average. Results: In all four patients symphalangism was appeared in the radial thumb, which was more hypoplastic. Symphalangism took place at the interphalangeal joint level in three cases and at the metacarpophalangeal joint level in one case. Intraoperative ﬁnding revealed both the extensor and ﬂexor tendon hypoplasty in one case and abnormal insertion of the ﬂexor tendon in another case. Long term follow-up showed partial growth plate premature closure in one case and triphalangeal thumb in another, both of which required secondary surgery. The range of motion of the interphalangeal joint was limited in the other two cases. Conclusions: Polydactyly of the thumb complicated with symphalangism is rare anomaly and surgical results were not so good as typical polydactyly because of its unique anatomy. Signiﬁcance: Only four cases have been reported in the literature so far. We added other four cases in this presentation.

242 Soft Tissue Reconstruction for Type IV-D Duplicated Thumb Author: Yin-Chun Tien (Taiwan) Co-Authors: Yin-Chih Fu (Afghanistan), Peng-Ju Huang (Afghanistan), Tai-Lung Wang (Afghanistan)

Poster presentations: Abstracts 124–322/J Child Orthop Purpose: Type IV-D duplicated thumb has the most complex anomalies and difﬁculties for treatment among polydatyly. Double osteotomy is usually recommended to gain the best cosmetic and functional outcome. However, four cases of type IV-D duplicated thumb were treated only by soft tissue procedure in this study. Methods: At operation, a conjoined A2 Pulley was routinely identiﬁed and the FPL was found bifurcated distal to the conjoined pulley in every of these cases. Instead of double osteotomy, a soft tissue procedure which included centralization of FPL and A2 pulley reconstruction were pursued to correct these special anomalies. Results: The overall clinical results were evaluated by a modiﬁcation of Tada’s scoring system based on the range of motion, joint stability, alignment of the remaining thumb, and subjective opinion regarding the reconstructed thumb after an average follow-up of 3.3(2.5–4.7) years. According to the scoring system, the results were rated as good in three cases and fair in one case. Conclusions: The results demonstrated that a careful soft tissue balance procedure can correct the type IV-D duplicated thumb successfully and the postoperative alignments are maintained well after the deforming pathoanatomy is corrected. Signiﬁcance: When double osteotomy is used to correct this special deformity, the surgery usually should be postpone until bone getting mature enough for purchasing pins to ﬁx the osteotomy. We presented an alternative soft tissue method to allow correcting the deformity in younger age.

Hip/Lower extremity 243 Management of complete absence of the femur with iliac acetabuloplasty and rotationplasty at the walking-age. Author: Olivier Franc¸ois Badelon (France) Purpose: Complete absence of the femur without acetabulum is extremely rare. The classic management is prosthetic with or without above-knee amputation. The goal was to obtain ﬁrstly a growing roof of the acetabulum using the growth cartilage of the iliac crest to give a stable hip with a functional range of motion to walk and to sit ; secondly a well balance and stable position of the leg to use the ankle as a knee into the prosthesis. Methods: Two cases of unilateral total deﬁciency of the femur (class I of Pappas or type D of Aitken) with a normal foot were treated in 1988 and 1992. An original Iliac Acetabuloplasty was performed at 14 and 18 months of age with a periacetabular incision of the capsule and a resection of the transverse acetabular ligament, reduction of the femorotibial epiphysis in front of the paleoacetabulum, then reconstruction of the acetabular roof with an enlarge shelf procedure using the lateral part of the iliac crest growth cartilage and of the ilium extending the decortication inferiorly to the superior margin of the acetabulum. Borggreve rotational osteotomy was performed 3 and 6 months later with shortening of the tibia, and repeated 3 and 1 year later. A second shelf procedure was performed in one case at 10 years of age with the contralateral iliac crest. Results: At the last follow-up, they have 18 and 15 years old with complete radiologic data and a walking analysis. They have a well balanced walk with a below knee prosthesis and a simple ischial ring support. In both cases, the hip-knee joint is stable for the weightbearing with a ﬂexion authorizing the sitting position (80&60). They have a heel at the same level that of the normal knee with a complete extension of the knee-ankle joint which is stiff in this position in the ﬁrst case with a full range of motion in the second. X-rays shows a a very good acetabulum in the both case.

S99 Conclusions: The results shows that it is possible to obtain a growing hip which is stable at adolescenthood. It is recommended to use all the lateral part of the anterior iliac crest with the growth plate for the acetabuloplasty. Signiﬁcance: This early surgical procedure before the age of two years is an alternative to the classic prosthesis management. 244 Radiological evaluation of acute and acute-on-chronic slipped capital femoral epiphysis treated by a single cannulated HDB screw (proximal threading) Author: J Be´rard (France) Co-Authors: F Sailhan (France), O Brunet (France), R Parot (France), V Cunin (France), F Chotel (France) Purpose: The treatment of slipped capital femoral epiphysis (SCFE) is still controversial with regard to the implants used for stabilization of the epiphysis. The objective of this study was to determine whether stabilization of the epiphysis with the HDB screw (with proximal partial threading) would allow further growth of the femoral neck in the affected and unaffected side (after prophylactic transﬁxation of the epiphysis). Methods: We retrospectively reviewed the charts of 23 patients with acute or acute-on-chronic SCFE treated in our unit with internal ﬁxation of the epiphysis using a single cannulated HDB screw with a proximal 30 mm threading. Both the affected and unaffected side were always operated. The child’s sex, age, body mass index, symptom duration, and slip severity were recorded. Radiographic parameters were analysed on both hips of each patient at admission and at last follow-up: CCD angle, length of the femoral neck, width of the femoral neck, and the distance from the tip of the greater trochanter to the tip of the epiphysis (GTTE). The width (in cm) of the epiphysis situated over the Klein line was also recorded for all hips. Statistical analysis (T test of Student) was performed to compare results between the SCFE and unaffected side. Results: The charts of 8 girls (mean age 10.25 years) and 14 boys (mean age 12.6 years) were analysed for a total of 23 affected and 23 unaffected hips. The SCFE was diagnosed in the left side in 59% of the cases. After a mean follow-up of 30 months we found a statistically signiﬁcant increase in the length of the femoral neck in both the affected and unaffected sides (4.66 and 7.90 mm respectively). This growth in length was signiﬁcantly higher in the unaffected side (p = 0.03). On the affected side the CCD angle remained stable with time (134.2 to 133.9). Evolution of the width of epiphysis over the klein line and of the distance GTTE between both sides showed the affected side presented important remodelling. We did not encounter any cases of avascular necrosis or chondrolysis. All screws were removed without complications as removal is facilitated by the proximal theading. Conclusions: Results are discussed and compared to other main series of the literature. Signiﬁcance: The HDB screw seems to be effective in stabilizing the epiphysis in the SCFE. It allows growth of the femoral neck and effective remodelling of the epiphysis as the threaded part of the screw is proximal. 245 The Hip in Patients Lengthened for Proximal Focal Femoral Deﬁciency. Author: Silvio Boero (Italy) Co-Authors: Maria Beatrice Michelis (Italy), Marco Stella (Italy), Francesca Vittoria (Italy)

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S100 Purpose: Patients with severe congenital proximal focal femoral deﬁciency have a higher risk of dislocation or subluxation of the hip joint during lengthening, which increases the longitudinal forces from the muscles that act on the hip. Acetabular dysplasia results in reduction of the anterior and lateral support to the femoral head, and can be associated with other malformations, such as coxa vara with or without pseudarthrosis of the femoral neck, or proximal diaphyseal varus, which increase the likelihood of dislocation or subluxation of the hip during lengthening. Methods: The authors have reviewed the clinical records and x-ray results of 48 patients with congenital proximal focal femoral deﬁciency. The patients have been grouped according to Pappas’ classiﬁcation. The acetabular index and the pre- and post-operative CE angles have been recorded with the procedures required to prevent articular complications. Results: This study has shown that deﬁciencies graded IV and VII in Pappas’ classiﬁcation increase the risk of hip subluxation during lengthening, due to the diminished CE angle and an increased acetabular index. Conclusions: In Patients with severe congenital proximal focal femoral deﬁciency it’s important to evalue the acetabular index and the CE angle to avoid dislocation or subluxation of the hip during the treatment. Signiﬁcance: The authors suggest adequate prevention measures to avoid dislocation or subluxation of the hip when the CE angle is close to 20 degrees and the acetabular index close to 34 degrees. 246 The Utility of Computer Tomography to Assess Acetabular Morphology in Morquio - Brailsford Syndrome Author: Andrzej Borowski (United States) Co-Authors: Aaron Littleton (United States), Mihir Thacker (United States), William Mackenzie (United States), Leslie Grissom (United States) Purpose: Morquio - Brailsford syndrome (MS) is an inherited metabolic lysosomal storage disorder, one of the large groups of mucopolysaccharidosis (MPS). Alterations in connective tissue lead to abnormal formation and growth of the skeletal system. Major treatable concerns in patients with MS involve C1-C2 instability, genu valgum and hip subluxation. Untreated hip subluxation has been shown to be a predisposing factor leading to early onset of arthrosis of the hip. Early appropriate pelvic osteotomies may restore (improve) load transmission and retard the onset of osteoarthritis (OA). Computed tomographic measurements of acetabular morphology in Morquio – Brailsford syndrome have not been reported in the literature, although ultrasonographic evaluation of hip in osteochondrodysplasias has been described. The purpose of this study was to evaluate morphology (shape) of the acetabulum in Morquio – Brailsford syndrome using two-dimensional CT scans. Methods: In order to assess the acetabular roof, the acetabular index was measured on AP radiographs of the pelvis. Various CT measures were used to assess the acetabular anatomy in the axial plane. Results: The average acetabular index on the antero-posterior radiographs of the pelvis was 32.1 (average age-matched difference from normal = 11.6). 2-D computer tomography (axial cuts) showed the average acetabular anteversion angle was close to normal, measuring 11.5. The average anterior acetabular index was 60.3 (average age-matched difference from normal = 11.4) and posterior acetabular index was 53.8 (average age-matched difference from normal = 3.2). Calculated axial acetabular index ranged from 90 to 133 (mean 114.1, 14.6 average difference from normal). Conclusions: 2-D computer tomography of the hip in patients with MS demonstrated a severe dysplasia of the anterior

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Poster presentations: Abstracts 124–322/J Child Orthop acetabular wall as well as the roof of the acetabulum. The acetabular version, though was normal. Treatment of hip dysplasia in Morquio – Brailsford syndrome should focus on increasing the overall depth of the acetabulum to better contain the femoral head. 2-D computer tomography is recommended prior to bony acetabular procedures in order to assess the degree of acetabular deﬁciencies. Signiﬁcance: 2-D computer tomography of the acetabulum helps in preoperative decision making and planning prior to an acetabular procedure in patients with Morquio- Brailsford syndrome. 247 Surgical treatment of dislocating patella in children Author: Morris Duhaime (Canada) Co-Authors: Benoit Benoit (Canada), Yves Laﬂamme (Canada), Dominique Rouleau (Canada), Benoit Morin (Canada), Guy Grimard (Canada) Purpose: Patella alta is a major cause favouring patellar dislocation, either recurrent, or habitual. Because of open growth plates, the choice of treatment of such a condition is always a challenge in the growing child. A controlled study using a speciﬁc technique is presented. Methods: The ﬁrst case regarding this technique was done some thirty-ﬁve years ago. Follow-up was sparce for these long standing cases. This eventually led to a controlled study of twelve (12) knees in eight (8) patients, having had correction of patella alta, a major predisposing factor causing patellar dislocation. The technique used was the following: complete detachment of patellar tendon, with adjusted lowering and re-insertion at proper height and with proper tension. Lateral release and VMO advancement is added. Patellar height was assessed using the Koshimoto and Caton Deschamps index. Mean age at surgery: 10.9 yrs. Mean follow-up: 60 months. Results: At follow-up, one patella had re-dislocated. Patient had a second surgery and patella is now stable. At last follow-up, all knees were stable without any evidence of pain. Radiological assessment shows that the patellar height is improved. Minimal complications are reported. Conclusions: The treatment of recurrent dislocation of the patella in subjects with open growth plate can be treated efﬁciently and safely with a lateral release, a detachment of the patellar tendon and a VMO advancement. Signiﬁcance: The technique presents a reasonable alternative, and this short study validates its use in the treatment of patellar dislocation, with patella alta, in the immature child. 248 Adolescent Blount’s disease: Is ﬁbular osteotomy necessary? Author: Mark Eidelman (Israel) Co-Authors: Alexander Katzman (Israel), Viktor Bialik (Israel) Purpose: The standard treatment of adolescent Blount’s disease includes proximal tibial valgus osteotomy and osteotomy of the ﬁbula. Some believe that the ﬁbula should also be ﬁxed to prevent migration and subluxation. We performed correction of deformities in eight patients (10 tibiae) with adolescent Blount’s disease using the Taylor Spatial Frame (TSF). In all patients, the origin (virtual hinge) was placed at the level of the proximal tibial ﬁbular joint. The purpose of this study was to review treatment outcome of proximal tibial osteotomy without osteotomy of the ﬁbula in patients with adolescent Blount disease.

Poster presentations: Abstracts 124–322/J Child Orthop Methods: Eight patients (ten tibiae) were treated by proximal tibial osteotomies and gradual correction by TSF without ﬁbular osteotomy over a period of three years. All patients were males with a mean age of 14.6 years (range, 14–17 years). All patients had severe proximal tibial varus, four had signiﬁcant proximal tibial procurvatum, and six had internal tibial torsion. The ﬁbula was not ﬁxed in ﬁve patients, and ﬁxed distally in three. Results: Frames were removed at an average of 12.8 weeks (range, 12–15 weeks). The mean preoperative proximal tibial varus was 16.2 (range, 12–19), corrected to normal values in all patients. The mean preoperative MPTA was 71.4 (range, 67–77) and corrected to a mean MPTA 87.1 (range, 85–89). In four patients (5 tibiae) with proximal tibial procurvatum, the PPTA was corrected to normal range. Mean correction of internal tibial torsion was 10 (range, 5– 15), performed in six patients (8 tibias). Preoperative MAD was 55.8 mm medial to center of the knee (range, 44–77 mm), corrected to a mean MAD of 4.9 mm medial to center of the knee (range, 2– 11 mm). Complications included superﬁcial pin tract infections in seven patients. No complications related to the ﬁbula were observed during/after correction. Conclusions: Based on our initial experience, we believe that most patients with adolescent Blount disease could have successful and predictable correction of tibial deformities without a need for osteotomy and ﬁxation of the ﬁbula. Signiﬁcance: In most cases of late -onset tibia vara tibial deformities can be corrected without ﬁbular osteotomy and thus eliminate potentional morbidity of this procedure. 249 Joint Arthropathy as a Study of Neuropathic Joints in Hereditary Sensory and Autonomic Neuropathy Types III and IV Author: David Feldman (United States) Co-Authors: David Ruchelsman (United States), Daniel Spencer (United States), Joseph Straight (United States), Mark Schweitzer (United States), Felicia Axelrod (United States) Purpose: To determine the etiology of the joint arthropathy seen in children with Hereditary Sensory and Autonomic Neuropathy (HSAN) Types III and IV and to differentiate osteonecrosis and Charcot arthropathy as seen in these groups of patients, both of whom suffer from decreased pain perception. Methods: From a database of 547 patients with HSAN Type III and thirty-two patients with HSAN Type IV, we performed a retrospective chart review and radiographic analysis of all patients who presented with joint swelling and deformity. Underlying joint pathology was classiﬁed as either osteonecrosis or Charcot arthropathy. Results: In the HSAN Type III population, forty-four (twenty-two males, twenty-two females) of the 547 patients (8%) had clinical evidence of arthropathy. In forty-two patients, forty-eight joints demonstrated radiographic evidence osteonecrosis; forty-ﬁve of the forty-eight joints (94%) with osteonecrosis occurred in the lower extremity. In each case of osteonecrosis of the knee (n = 19), isolated involvement of the lateral distal femoral condyle was seen consisting of varying sizes of posterolateral osteochondral fragmentation. In the thirty-two patients comprising the HSAN Type IV population, eighteen (56%) were found to have radiographic ﬁndings consistent with Charcot arthropathy in a total of thirty affected joints. One patient demonstrated Charcot arthropathy of the spine and subsequent progressive spondylolisthesis. Nine patients (twelve joints) also demonstrated osteomyelitis. Conclusions: In patients with HSAN Type III, osteonecrosis is the initial lesion preceding destructive arthropathy. Osteonecrosis and

S101 osteochondral fragmentation were always isolated at the lateral distal femoral condyle in the knee. This pathology may be amendable to surgical reconstruction of the joint to stabilize the knee in severe cases. HSAN Type IV was most commonly associated with Charcot arthropathy or joint subluxation and dislocation. Late secondary changes at the articular surface may make radiographic distinction difﬁcult. Charcot arthropathy affected both sides of the involved joint with evidence of collapse and fragmentation. With osteonecrosis, the articular process was found to be disproportionately mild. Signiﬁcance: There are two types of ‘‘neuropathic joints’’ seen in these disease states. One is primarily osteonecrosis and the other is classical Charcot arthropathy with joint subluxation. The differentiation of these types is critical for evaluation and treatment. 250 The Effect of Pelvic Positioning on Acetabular Measurements, a CT Study Author: David Feldman (United States) Co-Authors: Eric Henderson (United States), Debra Sala (United States), Zehava Rosenberg (United States), Harold van Bosse (Afghanistan) Purpose: To investigate the effect of patient positioning on measured acetabular parameters of CT scans of the pelvis. Methods: A radioopaque model of a human pelvis with articulated hips was attached to a plexiglass sheet, and suspended by four adjustable struts. Positioning of pelvis in coronal, sagittal, and transverse planes allowed for changes in pelvic obliquity, tilt, and rotation, respectively. CT images of pelvis were taken at 3 mm increments. Acetabular anteversion (AA), as well as anterior, posterior, and horizontal sector angles (AASA, PASA and HASA) were measured. Effects of single and multi planar deviations on these parameters were determined by multiple regression. Results: For every 5 of increased pelvic obliquity, the measured AA would decrease by 2.2, and the AASA, PASA and HASA would increase by 9.7, 5.0 and 14, respectively. Obliquity to other side would have opposite effect. Every 5 of anterior pelvic tilt would decrease the measured AA by 3.8 and the PASA by 2.6; it would increase the AASA and HASA by 5.4 and 2.6, respectively. Posterior pelvic tilt would have the opposite effect. All ﬁndings were signiﬁcant, p < 0.0005. Pelvic rotation caused no measurement error. Conclusions: Redirectional acetabular procedures require accurate knowledge of pre-operative acetabular parameters. Signiﬁcant measurement error may result from relatively small changes in patient positioning during a pelvis C.T. study, leading to incorrect interpretation of acetabular anteversion and coverage. Strict attention must be paid to anatomical pelvic alignment in CT scanner. Alternatively, post-scan reorientation of a 3D pelvic model can be performed. Signiﬁcance: Changes in pelvic alignment in the CT scanner were found to create signiﬁcant error in acetabular measurements. 251 The hip in femoral proximal focal defect: Stabilize or not stabilized? When? How? Author: Federico Fernandez-Palazzi (Venezuela) Co-Authors: Purpose: To evaluate our experience in 22 patients treated from 1981 to 1990. Plus, 3 years early results, in 2 cases - 1 bilateral-

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Poster presentations: Abstracts 124–322/J Child Orthop

with a technique developed by us (Funnel-cone) for Fixen LLoyd Roberts III cases Methods: We use Fixen and Lloyd Roberts classiﬁcation due to its easiness of interpretation and prognostic value. We compared the results obtained in Fixens and our grouping in A. tip of foot was above the knee.5 patients treated by hip stabilization and orthesis. Group B tip of foot at upper tibia level . 14 patients treated by hip stabilization and leg lengthening and group C with tip of foot at lower tibial level. 3 patients. Hip was stable and were treated by orthesis or raise in boot. A new technique of hip stabilization developed by us by means of a femoro-iliac arthrodesis (Funnel – cone) used on 2 cases, one bilateral, of Fixen-Lloyd A with unstables hips is presented and its 3 years early results exposed. Results: Group A (5) F.and LL. R. I (stables) 2 (40%) II 2 (40 %) III 1 (20%)

Group B (14)

Group C (3)

7 (50 %) 5 (35.7 %) 2 (14.3%)

0 (0%) 0 (0%) 3 (100%)

and 82 for MRI. Negative predictive value was 87 for clinical examination and 95 for MRI and speciﬁcity was 68 for both. For osteochondral defects based on arthroscopy ﬁndings positive predictive value for clinical examination were 64 and of MRI were 68, were as speciﬁcity was 78 for clinical examination and 81 for MRI. Negative predictive value was 93 and sensitivity 87 for MRI. Conclusions: The clinical diagnosis and arthroscopic ﬁndings were same in half of the patients, but this was almost same as the number of patients who had same MRI diagnosis and arthroscopy ﬁndings. For detecting anterior cruciate ligament injuries clinical examination is still the gold standard and MRI should be used only as an adjunct. The efﬁciency of MRI in detecting meniscal and osteochondral injuries is slightly better than clinical examination, but the risks of surgery need to be considered. Signiﬁcance: To show the importance of clinical examination in the diagnosis of paediatric knee problem.

253 Lower limbs rotational proﬁle in bladder exstrophy

Conclusions: FPFD patients should be evaluated very early in order to stabilize the hip, should this be required and plan the future or futures procedures that will be required to convert his or her limb in a functional one. Signiﬁcance: The aim of treatment is to obtain a ‘‘functional Limb’’ in FPFD, even in cases of unstable hips - thus the technique proposed by us- and not an amputated limb child.

252 Importance of clinical examination in diagnosing paediatric knee problem, a comparison with MRI and arthroscopy Author: Harvey Lappakkaran George (United Kingdom) Co-Authors: Ravi Pydisetty (United Kingdom), Jabeen Jalaludhin (United Kingdom), Jay Sampath (Afghanistan) Purpose: The aim of this study is to determine the accuracy of clinical diagnosis and MRI based on arthroscopic ﬁndings in detecting paediatric knee pathologies. Methods: 95 patients admitted in our institute between 1997 and 2004 were analysed. We retrospectively looked at case notes, operative notes and radiology reports. Correlation between Clinical Vs Arthroscopic ﬁnding and MRI Vs Arthroscopic ﬁndings were evaluated using positive predictive value, negative predictive value, sensitivity and speciﬁcity. Results: The clinical and MRI diagnosis were same in 69.47 % of patients, partially same in 6.31% of patients and different in 24.21 % of patients, were as MRI and arthroscopic ﬁndings were same in 49.47% of patients partially same in 4.21% and different in 46.31%. Correlation between clinical and arthroscopic ﬁndings was same in 47.36 %of patients, partially same in 6.31% of patients and different in46.31% of patients. For ACL injuries based on arthroscopy ﬁndings positive predictive value for clinical examination were 40 and of MRI were 50, were as speciﬁcity was 97 for clinical examination and 98 for MRI. Negative predictive value and sensitivity was 100 for both. For meniscal injuries based on arthroscopy ﬁndings positive predictive value for clinical examination were 27 and of MRI were 37, were as sensitivity was 53 for clinical examination

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Author: Cosimo Gigante (Italy) Co-Authors: Giorgio Perrone (Italy), Walfro Rigamonti (Italy), Sisto Turra (Italy) Purpose: To investigate the rotational proﬁle of lower limbs in bladder extrophy. Methods: We studied 19 bladder and 1 cloacal extrophies (aged from 2 to 49 years at the follow-up). Direct closure of the bladder and abdominal wall was obtained in 10 newborns; 6 posterior vertical iliac osteotomies (O’Phelan’s technique), 3 ischio-pubic osteotomies (Frey’s technique) and 3 anterior and horizontal osteotomies (Gibbon’s technique) were associated in the oldest patients. The rotational proﬁle of the lower limbs was assessed both clinically and radiologically; pubic diastasis, CE and CA angles were measured by direct x-rays. Iliac wing angle, acetabular version, femoral anteversion, tibial torsion and patellofemoral congruency were measured by CT in 14/20 patients. Results: Out-toeing was seen in 13/20 patients. The average footprogression angle was 9 (min. 0, max. 45). The average value of pubic diastasis was 37.8 mm. in immature patients and 100.8 mm. in adults. The average iliac wing angle was 42.9 in immature patients and 53.5 in adults. Discrepancy > 10 in the right /left iliac wing angle was observed in 1 patient with evident pelvic asymmetry. The average acetabular version was –17 in immature patients (min. –4; max. –31) and –14 in adulthoods (min. +2; max. –25). No hip dysplasia was seen. In adulthoods the average CE angle was 36 and the average CA angle was 51. The TC rotational proﬁle showed that the average femoral anteversion was 27 in immature patients (min. 16 in a 14 years aged adolescent ; max. 44 in an 8 years aged child) and 24 in adulthoods (min. 8; max. 41). The average external tibial torsion was 42 (min. 35; max. 47) in children younger than 10 years, 41 in adolescents (min. 29; max 53) and 40 (min. 27; max. 51) in adulthoods. The patellofemoral congruency was abnormal in 4/14 TC views showing lateral subluxation of the patella in 7/8 knees of 4 adult patients (2 of them complained anterior knee pain). In these patients the average femoral anteversion was 30 (20 in patients with normal patellofemoral congruence) and the average external tibial torsion was 43 (37 in patients with normal patellofemoral congruence. Conclusions: Despite pubic diastasis the waddling gait is mild in most patients. The increased iliac wing angle and acetabular retroversion are partially compensated by increased femoral anteversion and tibial

Poster presentations: Abstracts 124–322/J Child Orthop torsion. This altered rotational proﬁle of the lower limbs may lead to patellofemoral instability and knee pain in adult patients. No signiﬁcant secondary dysplastic or degenerative alteration of the hip was observed both in young and mature patients. Signiﬁcance: The compensatory rotational proﬁle of the lower limbs minimizes the effects of the persistent pubic diastasis in bladder extrophy but a serious patellofemoral instability and knee pain may occur in the adult patients with the most evident alteration of femoral anteversion and tibial torsion. 254 Parametric study of geometrical factors related to slipped capital femoral epiphysis Author: MªJose´ Go´mez-Benito (Spain) Co-Authors: Oscar Paseta (Spain), Jose´ Garcı´ a-Aznar (Spain), Carlos Barrios (Spain), Jose´ Gasco´ (Spain), Manuel Doblare´ (Spain) Purpose: Different anatomical and mechanical factors inducing growth plate overloading have been implicated in the etiology of Slipped Capital Femoral Epiphysis (SCFE). So far, loads at the epiphyseal growth plate of the femoral head has been poorly investigated. In this work, we analyse SCFE from a biomechanical point of view. The main objective of this research is to determine the inﬂuence of the proximal femur geometry on the femoral slippage by means of Finite Element Analysis (FEA). Methods: A parametric femur was created by a 3D Cad software (Catia) based on a set of CT scans from a child affected by pre-SCFE in his left hip. In this parametric model of the proximal femur all geometrical parameters could be modiﬁed. The model was validated comparing the results with these obtained from the real geometries of the pre-SCFE hip and the healthy one of the child. Next, an adolescent standard femur was modelled based on the values of the mean geometrical parameters collected in literature. Several geometrical parameters, as the Physis Sloping Angle (PSA), the Posterior Sloping Angle of the Physis (L), the Neck Diaphysis Angle (NDA) or the Growth Plate Area, were varied with respect the standard femur. In each model the same loads corresponding to walking, stairs climbing and sitting were applied. Results: The computed results showed a strong dependence of the growth plate failure on the geometry of proximal femur. Higher values of the Physis Sloping Angle (PSA) and the Posterior Sloping Angle and lower values of the growth plate area are related to higher growth plate stresses and therefore more probability of slippage. The highest stress level was always found in the posteromedial region of the physis that is the site where usually growth plate begins to fail. Conclusions: Based on these results we could conclude that geometrical factors have a strong inﬂuence on growth plate failure. Signiﬁcance: This study contributes to a better understanding of mechanical factors implicated in the etiopathogenesis of the SCFE. 255 Prediction of Change in Effective Leg Length Discrepancy after Angular Deformity Correction by Hemiepiphyseal Stapling Author: Ho-Joong Jung (Korea, Republic of) Co-Authors: Tae-Joon Cho (Korea, Republic of), In Ho Choi (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Won Joon Yoo (Korea, Republic of) Purpose: The purpose of this study was to predict effective leg length change in angular deformity correction of lower extremities by hemiepiphyseal stapling.

S103 Methods: Inhibition of longitudinal growth in the operated limb segment and change in the effective leg length by angular correction were analyzed. From this analysis, a trigonometric formula was derived to predict effective leg length change (DELLD) by hemiepiphyseal stapling. This formula was veriﬁed in seven cases in which a unilateral angular deformity of lower extremity was corrected by hemiepiphyseal stapling. Results: Contributing parameters on DELLD were magnitude of angular deformity to be corrected (h), width of the operated physis (d), lower limb length distal to the operated physis. DELLD = (1-cosh) x L - (d x tanh) / 2. Among the cases tested, angular correction by unilateral hemiepiphyseal stapling predicted to increase effective leg length of the affected limb in four cases and to decrease in three cases. This prediction was in good accord with the clinical outcome. As L/d ratio was in narrow range in most cases, h practically determined whether effective leg length increased or decreased. Conclusions: Angular correction by hemiepiphyseal stapling may increase effective leg length in a certain condition. In practice, the more severe angular deformity is corrected, the more likely is effective leg length gained. Signiﬁcance: This study shows that hemiepiphyseal stapling can either increase or decrease effective leg length depending upon the amount of correction and anatomical parameters of the operated limb. This phenomenon needs to be taken into consideration when deciding upon the surgical options for angular deformity correction in growing children. 256 The relationship between the physeal line and joint surface in the skeletally immature lower extremity: An MRI study Author: William Mackenzie (United States) Co-Authors: Muharrem Inan (Turkey), Mary Nagai (United States), Leslie Grissom (United States) Purpose: Accurate measurement of an angular deformity of the lower extremity is crucial to achieve satisfactory correction. In the pediatric population it is difﬁcult to determine the orientation of the joint line of the distal femur, and the proximal and distal tibia prior to complete ossiﬁcation of the epiphysis because much of the condyle is cartilaginous. The purpose of this study was to evaluate the relationship between the physeal line and its respective articular surface in the lower extremity in children 10 years of age and younger. Methods: Magnetic resonance imaging (MRI) studies of 15 ankles and 42 knees indicated to investigate septic arthritis or a tumor but found to be normal were reviewed. The average age of the patients was 7.5 years (range, 2 months to 10 years). The relationship between the physeal line and the articular surface was determined in both the coronal and sagittal plane MRIs. Results: The distal femoral articular surface was found to be in 5.0 + 2.4 degrees of valgus relative to the orientation of the distal femoral physis. The proximal and distal tibial physeal lines were parallel to the joint surface in the coronal and sagittal planes. Statistical analysis showed excellent consistency between observers for the orientation of the proximal tibia in the coronal plane (0.940), proximal tibia in the sagittal plane (0.981), and distal femur in the coronal plane (0.890). Conclusions: This study illustrates that the proximal and distal tibial physeal lines and the joint surfaces are parallel to one another and hence are interchangeable for measurement purposes. The distal femoral physis and its respective articular line are not interchangeable because the distal femoral articular surface is in 5.0 degrees of valgus relative to the orientation of the physeal line. The physeal lines of the distal femur and proximal and distal tibia

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S104 can be used to analyze a lower extremity deformity and aid in the preoperative planning in children before ossiﬁcation of the epiphysis. Signiﬁcance: The physeal lines of the distal femur and proximal and distal tibia can be used to analyze a lower extremity deformity and aid in the preoperative planning in children before ossiﬁcation of the epiphysis.

Poster presentations: Abstracts 124–322/J Child Orthop Signiﬁcance: We conclude that removal of compression hip screws in children is safe enough to recommend it as routine procedure. This will avoid making a later arthroplasty more difﬁcult than it needs to be.

259

257

Hip arthrodesis in the XXI st century. Still Valuable? Still up to date?

Imaging of tibial hemimelia

Author: Manuel Resende Sousa (Portugal)

Author: Andreas H. Mahnken (Germany)

Co-Authors: Delﬁn Tavares (Portugal), Francisco Sant’Anna (Portugal), Manuel Cassiano Neves (Portugal)

Co-Authors: Purpose: Tibial hemimelia is associated with a broad spectrum of the osteochondral and extrasosseous abnormalities. Methods: Radiology has to provide detailed information on the abnormalities in the osteocartilaginous and the extraosseous structures, i.e. articular or periarticular components such as ligaments, tendons, menisci and muscles as well as the arteries. Results: As either form of lower limb hemimelia is typically associated with abnormalities of the adjacent joints, muscular variations and vascular abnormalities, conventional radiography alone is not sufﬁcient for assessing the extent of disease. Conclusions: MR imaging is the only imaging modality that provides detailed information on the hemimelia itself as well as concurrent pathology. Therefore, the combination of conventional radiography and MR imaging including contrast enhanced studies and lower limb MR angiography has to be considered the standard of reference at the point of diagnosis. While conventional radiography is sufﬁcient for routine follow-up, MR imaging also provides valuable 3-dimensional information on the position and the perfusion of the osteocartilaginous and muscular structures after surgery. 258 Complications of hip screw removal following proximal femoral osteotomies in children. Author: Richard John Montgomery (United Kingdom) Co-Authors: James Webb (United Kingdom), Mohammed Almaiyah (United Kingdom) Purpose: Proximal femoral osteotomies in children are usually ﬁxed internally. Arthroplasty may follow childhood hip disease, and retained metalware can cause technical problems. It happens often enough for routine removal of metalwork to be high on the ‘wish list’ of arthroplasty surgeons. However, removal of metalwork can be associated with signiﬁcant complications, such as 1% fracture with devices such as the ﬁxed angle blade plate. There are no reports in the literature of the extent of complications associated with the removal of compression hip screws. Methods: We retrospectively reviewed the records following removal of 75 compression hip screws in a paediatric population.There was a minimum 2 year follow-up post-operatively. Results: There were two superﬁcial wound infections which resolved with antibiotics. In another the metalware could not be removed.In one case a haematoma was surgically evacuated. Conclusions: This gives a overall complication rate of approximately 5% including a reoperation rate of 1%. There were no fractures, and no long-term harmful effects.

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Purpose: The last 35 years have been rich in the development of new techniques and improved implants for hip replacement surgery. For some, hip fusion has become neglected and even obsolet. Nevertheless, hip prosthesis have a variable lifetime and young patients will be submitted to several revision arthroplasties. Our goal is to review the short-term outcome of 6 adolescents with hip arthrodesis. Methods: Six patients aging between 13 and 16, with DDH or septic arthritis sequelae, were submitted to hip arthrodesis. In 2 of them the fusion was accomplished with 2 cannulated screws, in other 2 with the cobra plate and the last 2 with external ﬁxation. The exposure was through a Watson-Jones approach preserving the pelvi-trocanteric muscles, thinking of a future conversion in a hip arthroplasty. The minimum follow-up between surgery and the clinical review was 14 months (one patient had 12 years posop). Every patient had pre-op x-ray of the pelvis and hip, and blood tests to rule out infection. The follow-up was at 2, 4, 6 and 12 months and then after annually. Results: Hip fusion was succeed in every patient between the 14th and the 26th week except for one patient with septic arthritis sequela. This patient was initially treated with DHS then an external ﬁxator and 16 weeks after convertion to a cobra plate, the arthrodesis was successful. All patients were satisﬁed with the ﬁnal outcome and one kept performing as an actress. Conclusions: Hip arthrodesis allows a good functional result if correctly performed and in selected cases, such as young patients with septic arthrtis sequelae or large asseptic necrosis of the femural head. Signiﬁcance: Hip arthrodesis is still up to date because it delays the need for a hip prosthesis for as much as 30 years.

260 Does Hip Arthroscopy Play a Role in Reconstructive Surgery of the Hip in Adolescents and Young Adults? Author: Dennis Robert Roy (United States) Co-Authors: Khaled Emara (Egypt) Purpose: To evaluate the role of hip arthroscopy in planning reconstructive surgery in adolescents and young adults. Methods: A provisional reconstructive procedure was planned in 51 adolescent and young adult patients based on physical exam and imaging studies. All patients had mechanical symptoms and/or signs and had residual deformity or dysplasia from a childhood or adolescent hip disorder. All patients underwent arthroscopy of the hip, after which, a deﬁnitive surgical plan was made. The inﬂuence of the arthroscopic ﬁndings on the subsequent reconstructive surgery was then assessed.

Poster presentations: Abstracts 124–322/J Child Orthop Results: The provisional surgical plan was compared to the deﬁnitive plan with the inﬂuence of hip arthroscopy being no change in plan; minor modiﬁcation of plan (change in amount of angulation or rotation); or major modiﬁcation (change in osteotomy, salvage procedure or cancel plans for reconstruction). In 22 of the 51 patients (47%) there was no change to the provisional plan. In the 22 patients with hip dysplasia, there were 11 changes; 6 minor and 5 major. In the 18 patients with Legg-Calve-Perthes disease, there were 13 changes; 9 minor and 4 major. Conclusions: In addition to treating the intra-articular pathology, hip arthroscopy provides a safe way to effectively assess the pattern of joint damage to assist in planning reconstructive surgery of the hip. Signiﬁcance: For proper planning of treatment in patients with adolescent and young adult hip disorders. 261 Correction of proximal tibial deformity with the Orthoﬁx T-Garches external ﬁxator

S105 distance. Radiographic evaluation included measurement of the distal femoral angle, the anatomic femoral tibial angle and the mechanical axis before stapling and at the time of staples removal. The time of staples removal was calculated using the Paley’s multiplier method. Average age at the time of surgery was 12.9 years and the mean follow-up period was 4.6 years. Results: Correction rarely took more than one year (mean period 11 months). After stapling we noted improvement in gait, clinical symptoms and all radiographic parameters. At skeletal maturity the median intermalleolar separation was 3 cm for boys and 2 cm for girls. The median frontal angle before operation was 14 degrees for boys and 6 degrees at follow-up, the corresponding ﬁgures for girls being 14 degrees and 4 degrees. Conclusions: The timing of epiphysiodesis remains a difﬁcult problem and the physician should be very cautious in determining the good time for surgery. At least one year of knee growth is required to achieve correction and care is needed to avoid over correction. Hemiphyseal stapling addresses the anatomic malalignment, alleviating symptoms while offering a high degree of patient satisfaction. It has proved to be a safe, effective and predictable operation for genu valgum in children. Signiﬁcance: 3b.

Author: Noriko Urano (Japan) Co-Authors: Toshio Fujii (Japan), Akifusa Wada (Japan), Hideaki Kubota (Japan), Kazuyuki Takamura (Japan), Haruhisa Yanagida (Japan)

263

Purpose: Developmental angular and rotational deformities show very rapid change with growth. We reviewed our experience using the T-Garches ﬁxator for correction of 11 proximal tibial deformities in 11 patients. Methods: The mean age of the patients at the time of the osteotomy was 11.3 years, and the mean duration of follow-up was 1.8 years. Etiology of the deformities was Blount disease in four, bone dysplasia in three, osteomyelitis in two, and exostosis and vitamin D-resistant rickets in one patient each. Results: Results: Bone consolidation was completed in all cases. Neurovascular complications were observed in one patient. Callus distraction lengthening was followed by the correction of the deformity in seven patients. The corrections ranged from 10 to 35 degrees in angulation and from 10 to 20 degrees in rotation, and the lengthening ranged from 10 to 40 mm. Conclusions: Early mechanical axis correction has great possibilities for preventing further deformity with growth. Signiﬁcance: The use of the T-Garches ﬁxator was safe and effective for correction of proximal tibial deformity.

Author: Akifusa Wada (Japan)

262 Our experience in treating children’s genu valgum by temporary medial hemiepiphysiodesis

Open reduction of teratologic hip dislocation

Co-Authors: Toshio Fujii (Japan), Noriko Urano (Japan), Kazuyuki Takamura (Japan), Haruhisa Yanagida (Japan) Purpose: Teratologic dislocations of the hip joint show advanced changes in the hip joint at the time of birth and are much more rigid than the vast majority of typical dislocations of developmental dysplasia of the hip. We reviewed our experience of open reduction for this condition. Methods: Open reduction was performed in 20 patients with 3hip dislocations. The age at surgery ranged from one to three years. There was an association with other severe malformations such as arthrogryposis multiplex congenita, Larsen syndrome, metatrophic dysplasia, cat-crying syndrome, chromosomal abnormalities, and other rare syndromes. Results: Follow-up duration ranged from one to 16 years. Femoral derotation varus and/or pelvic osteotomies were combined with open reduction according to the severity of the femoral anteversion and acetabular dysplasia. Conclusions: Although the reduced hips had some limitation of motion, all the patients acquired stabilized hip joints. Signiﬁcance: It remains controversial as to whether bilateral teratologic hip dislocations should be reduced, but successful results of open reduction were obtained in this study.

Author: Dana Vasilescu (Romania) Co-Authors: Dan Cosma (Romania), Dan Vasilescu (Romania) Purpose: Children’s idiopathic genu valgum may cause anterior knee pain, patellofemoral instability, circumduction gait and difﬁculty running. If the deformity persists or increases it can cause a long-term cosmetic or functional problem. The purpose of this study was to evaluate and discuss the treatment of children’s genu valgum using medial stapling of the growth plates around the knees. Methods: We reviewed 20 patients (29 legs) who underwent temporary stapling of the medial femoral and/or tibial physes, between 1998–2005. Clinical evaluation included assessment of gait, limb length, alignment, patellofemoral stability and intermalleolar

DDH 264 Measurement errors in acetabular index and center-edge angle according to pelvis position - 3-D image analysis Author: Tae-Joon Cho (Korea, Republic of) Co-Authors: Hwan Seong Cho (Korea, Republic of), In Ho Choi (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Won Joon Yoo (Korea, Republic of)

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S106 Purpose: Acetabular index and center-edge (CE) angle are the most important parameters in evaluating pediatric hip dysplasia. Measurement errors can arise from intra- or interobserver variability, irregularity in ossiﬁcation, and non-standardized pelvic positioning. We investigated the change in measurements of acetabular index and CE angle according to pelvic rotation and tilting, using 3-D CT images. Methods: 3D-CT images of the pelvis of 21 LCP patients were used in this study. Age at the time 3D-CT study averaged 7.5 years (range, 4 ~ 11). 3-D Maximum Intensity Projection image was placed in the anatomical position. Then, it was rotated around the superoinferior axis in 3 increments to 15 of both sides, and tilted around the mediolateral axis in 3 increment to 9 of both directions. Acetabular index, CE angle, foramen obturator index (FOI) and pelvic tilt index (PTI) were measured in each positions, and compared with those measured in the anatomical position. Results: FOI correlated well with the amount of pelvic rotation, whereas PTI did not. Acetabular index and CE angle were underestimated when externally rotated, while overestimated when internally rotated. Forwardly tilted pelvis produced underestimation of these parameters in most range rotation, but more overestimated in maximal internal rotation than backwardly tilted pelvis. Rotation of the pelvis within 6 (FOI:0.66~1.43) produced measurement error of the acetabular index less than 2. Change of acetabular index measurement according to the rotation was exaggerated when forwardly tilted, while it remains relatively consistent when backwardly tilted. Signiﬁcance: Measurement error of these parameters according to the pelvis position should be taken into consideration when evaluating hip dysplasia. Frog-leg lateral projection of the hip joints may provide more accurate measurement of the acetabular index.

265 Neglected D.D.H.: Treatment with a one stage surgical procedure. What we have learned after long term observations. Author: Rozalia I Dimitriou (Greece) Co-Authors: John Dimitriou (Greece) Purpose: The purpose of this study is to analyze the long term outcome at ten to thirty eight years postoperatively, after a one stage procedure for the treatment of neglected D.D.H. in children over three years of age. Methods: From 1963 to 1990, 112 cases of neglected D.D.H. in children over three years old at presentation were treated in our institution, with the majority (85%) being from 4 to 9 years old. In all cases, a one stage surgical procedure was performed, consisting of open reduction, subtrochanteric femoral shortening with simultaneous correction of neck-shaft angle, anteversion and acetabular reconstruction by means of Salter’s pelvic osteotomy, if needed. From all cases, 45 (39 girls and 6 boys) for which full records are available and with a minimum follow-up of 10 years (range: 10 to 38 years) are reviewed. Results: We consider the femoral shortening as the fundamental step of the procedure, as it makes reduction easier, avoiding thus the catastrophic pressure on the femoral head. The clinical and radiological results seem to be more than satisfactory in the majority of cases. We also noticed that the results obtained at 5 years postoperatively, had hardly altered at the later follow-up examination.

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Poster presentations: Abstracts 124–322/J Child Orthop Conclusions: Following up our cases for such a long period of time, we support the view that the described method of treatment of these cases is the treatment of choice. Certainly, we expect a number of patients to develop eventually osteoarthritic changes at a later age, but according to our observations, all patients can live a normal or satisfactory life for years in their adolescent and early adult life. Signiﬁcance: Given that modern techniques of diagnosis and early treatment of D.D.H. offer the possibility of a much more effective control of the disease, the neglected cases will certainly be extremely rare. Even so, missed cases still appear and probably will continue to do so. Thus, it is worthwhile for physicians interested in treating D.D.H. to also be familiar with the described method.

266 Inﬂuence of caeserean section on the incidence of ddh in breech infants Author: Martin Murphy (Ireland) Co-Authors: Damian McCormack (Ireland), Frank McManus (Ireland) Purpose: Breech presentation is an established important risk factor for developmental dysplasia of the hip (DDH). It was the senior author’s personal observation that there appeared to be a reduced rate of DDH in the Caesarean section breech group as compared to the Vaginal delivery breech group. We wished to establish whether delivery by Caesarean section inﬂuenced the incidence of developmental dysplasia of the hip in breech infants. Methods: All infants with the risk factor of breech presentation are routinely referred to our dedicated weekly DDH clinic at Children’s University Hospital, Temple Street. We prospectively followed all Breech infants referred to our clinic. All had ABIR radiographs performed at age 4/12. We used the Chi-squared test to compare the Normal vs DDH numbers in both the Caesarean Section and Vaginal Delivery Groups. The null hypothesis was that mode of delivery has no inﬂuence on the incidence of DDH in breech presentation. Results: We prospectively followed 192 singleton term breech (>= 37 weeks gestation) infants born in our region over one year. 177 were born by caesarean section while 15 were delivered vaginally. Of the infants delivered by caesarean section DDH was diagnosed on radiographs at 4/12 of age in 37 of the infants (21%). While the remaining 140 infants were passed normal on radiographs at 4/12 of age (79%). Of the 37 DDH cases 7 were dislocations while the other 30 were cases of acetabular dysplasia. Of the vaginally delivered group (15 infants) 7 were normal (47%) at 4/12 radiograph while 8 (53%) demonstrated acetabular dysplasia at 4/12 radiograph. Using the Chi-squared test (see table) we were able to demonstrate a statistically signiﬁcant difference between the normal and DDH numbers in the Caesarean section breech group p < 0.001, rejecting the null hypothesis. However there was no statistically signiﬁcant difference in the Vaginal delivery breech group. Conclusions: Our ﬁndings indicate that the mode of delivery inﬂuences the incidence of DDH in infants with breech presentation. However this study is limited by the ever decreasing numbers of breech infants delivered vaginally. We suggest that the force of labour on the fetal hip contributes to DDH. The resting intrauterine pressure is 4 to 5 mmHg but during the active phase of labour this can increase to as much as 100 mmHg.

Poster presentations: Abstracts 124–322/J Child Orthop Signiﬁcance: Conclusion Thus it would appear that caesarian section for breech infants has a protective inﬂuence for the development of DDH.

S107 268 Operative Treatment in Congenital Dislocation of the Hip in the Older Child Author: Guillermo Oscar Herna´ndez Tierno (Brazil)

267 Salter innominate osteotomy for avascular necrosis following treatment of developmental dysplasia of the hip Author: Shinichi Satsuma (Japan) Co-Authors: Daisuke Kobayashi (Japan) Purpose: To assess the efﬁciency of Salter innominate osteotomy for avascular necrosis following treatment of developmental dysplasia of the hip, we analysed the radiographic outcomes of twenty-nine patients. Methods: There were 27 women and 2 men. The right hip was involved in 12 patients and the left in 17. The mean age at follow-up was nineteen years old (range, 14 to 24). We divided patients into three groups according to treatment and location of the insult when ischemic change was radiographically detected. Group A included 17 patients. In this group, insult occurred only in the proximal femoral epiphysis and Salter innominate osteotomy was performed. In group B, there were 4 patients and in this group the insult occurred only in the proximal femoral epiphysis and Salter innominate osteotomy was not performed. Group C included 8 patients. There the insult occurred both in the proximal femoral epiphysis and metaphysis, and Salter inominate osteontomy was performed. At the ﬁnal follow-up, we measured the center-edge angle, Sharp?s acetabular angle, acetabular-head index, and articulo-trochanteric distance. We also used Kalamchi?s and Severin?s criteria. And we performed a Statistical analysis with one-way analysis of variance to compare values among the three groups and between the affected and the unaffected side. Results: Differences in CE angle, Sharp’s angle, and AHI between the affected and the unaffected side in each group were not statistically signiﬁcant. However the ATD between the affected and the unaffected side in all groups did have a signiﬁcant difference. In each radiological measurement among the three groups, the CE of the affected side between group A and C showed a signiﬁcant difference. And the ATD of the affected side also showed signiﬁcant difference between groups A and B and groups A and C. In group A, twelve hips (70.6%) were classiﬁed as Kalamchi’s group I. In group B, only one hip (25%) was classiﬁed as Kalamchi’s group I, and three hips (75%) as group III. In group C, seven hips (87.5%) were classiﬁed as Kalamchi’s group IV, only one (12.5%) as Kalamchi’s group III. The rate of Severin’s group I or II was 88.2%, 75%, and 50% in group A, B and C respectively. Conclusions: In group A, all indexes except ATD were good. In group B, the coverage of the acetabulum was good. However the growth of proximal femoral physis tended to be poor and the femoral head couldn’t be molded spherically. And although there were no statistical differences among indexes in group C, the growth of acetabulum and the proximal femoral physis tended to be poor and the femoral head also tended to be aspherical. Signiﬁcance: We concluded that when ischemic insult is limited to the proximal femoral epiphysis, Salter innominate osteotomy should mold the femoral head spherically and form a good acetabulum.

Co-Authors: Milena Cruz (Brazil), Jose´ Pedreira (Brazil) Purpose: The most important thing is to know that an early diagnosis, made during the neonatal stage or the ﬁrst months of life can prevent more uncomfortable and difﬁcult treatments than the simple Pavlik’s harness. But when we have a late diagnostic always will be a challenge for the orthopaedist. Difﬁculties posed in managing developmental dysplasia of the hip diagnosed late include a high-placed femoral head, contracted soft tissues and a dysplastic acetabulum. A combination of open reduction with femoral shortening of untreated congenital dislocations is a well-established practice. Femoral shortening prevents excessive pressure on the located femoral head which can cause avascular necrosis. Instability due to a coexisting dysplastic shallow acetabulum is common, and so a pelvic osteotomy is performed to achieve a stable and concentric hip reduction. Methods: We retrospectively reviewed 20 patients presenting with developmental dysplasia of the hip aged four years and above who were treated by a one-stage combined procedure performed by the senior author. The mean age at operation was ﬁve years and tree months (5 years to 7 years). The mean follow-up was six years .All patients were followed up clinically and radiologically in accordance with Ponseti criteria and the modiﬁed Severin classiﬁcation. Results: According to the Ponseti criteria, every hips were assintomatics. The Severin classiﬁcation demonstrated 12 hips of grade I, 6 of grade II, and 2 of grade III. Two patients haved avascular necrosis and one required revision. Conclusions: One-stage correction of congenital dislocation of the hip in an older child is a safe and effective treatment with good results in the short to medium term. Signiﬁcance: test t-student. 269 One stage surgical treatment of the developmental dysplasia of the hip after the walking age. Author: Jose Batista Volpon (Brazil) Co-Authors: Luis Mandarano Filho (Brazil), Manoel Chagas Jr (Brazil) Purpose: To evaluate the results of the surgical treatment of the developmental dysplasia of the hip in the walking age. Methods: Twenty-four children (32 hips) with developmental dysplasia of the hip in the walking age were treated between 1986 and 2003 with a standard surgical procedure which basically consisted of open reduction, acetabular cleaning, psoas lengthening, femoral shortening and correction of excessive rotation, pelvic osteotomy and capsuloplasty. The surgical procedure was carried out through one anterior approach to the hip and one lateral proximal femoral approach. Reduction was maintained with a Kirschner wire and a hip spica cast. No previous traction was used. The results were assessed on x-ray plain ﬁlms before, just after the operation and at the latest evaluation. The following parameters were obtained: Wiberg angle and Shenton line. The results were evaluated by criteria of Severin and clinical

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S108 complications were recorded. Proper statistical analysis was done (Spearmann, Wilcoxon, Mann-Whitney). Results: The mean age at the operation was three years and seven months and the mean follow-up was six years and two months. Seventy two per cent of the hips showed excellent or good results. The Salter pelvic osteotomy was performed in 15 hips (46.9%), the lateral To¨nnis osteotomy in 14 hips (43.8%) and the Pemberton type in 2 hips (6.2%). Statistical analysis showed no difference in the results for the osteotomy type. The mean surgical femoral shortening was 1.6 cm and the mean derotation was 20 degrees. The acetabular index changed from 40 to 20 after the treatment. No avascular necrosis of the femoral head ossiﬁc nucleus occurred. Complications occurred in four hips: 3 reductions were lost and one superﬁcial infection occurred. All of these cases were reoperated but one of them ended in poor result. Conclusions: The one stage surgical treatment of developmental dysplasia of the hip in the walking age could correct the main pathological alterations and gave good overall results. Signiﬁcance: One stage surgical treatment of DDH after the walking age can approach all the main pathological changes and can shorten the period of treatment as previous traction is not necessary.

Legg-Calve Perthes disease 270 Prognostic factors of perthes’ disease: implication of lateral subluxation index Author: In Ho Choi (Korea, Republic of) Co-Authors: Dong Yeon Lee (Korea, Republic of), Chin Youb Chung (Korea, Republic of), Tae-Joon Cho (Korea, Republic of), Won Joon Yoo (Korea, Republic of) Purpose: The purpose of this study was to determine the implications of the LSI (combination of epiphyseal extrusion ratio, type of acetabular margin, medial joint space widening, and calciﬁcation lateral to epiphysis) as a prognostic factor in the management of Perthes’ disease. Methods: In a case series of 527 unilateral Perthes’ patients, demographic features and radiographic ﬁndings including Waldenstro¨m stage at initial presentation, the severity of involvement and lateral pillar collapse, epiphyseal extrusion ratio, type of acetabular margin, medial joint space widening (difference), calciﬁcation lateral to epiphysis were evaluated retrospectively. Four latter indices were considered reﬂecting subluxation of femoral head. All four indices had complementary weak points. So we combined four indices with a scoring system (LSI, total scores 1~9). Final outcomes at healing were classiﬁed radiographically according to the modiﬁed Stulberg classiﬁcation. Results: All four indices reﬂecting subluxation were closely correlated with the severity of lateral pillar collapse and radiographic outcomes at the latest followup. When four subluxation factors were considered as an independent factor, stepwise regression analysis revealed that lateral pillar collapse was the highest predictor followed by age at symptom onset, medial joint space widening in order. But, when subluxation factors were combined and depicted as LSI, LSI was the highest predictor followed by lateral pillar collapse, age at symptom onset in order. The scores of LSI strongly correlated with ﬁnal outcomes in the non-surgical treatment group. In the hips with higher LSI (‡6), only less than 20% were classiﬁed as spherical femoral head (Stulberg I or II); when LSI

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Poster presentations: Abstracts 124–322/J Child Orthop was lower (£4), more than 90% of hips healed in spherical femoral heads at healing. Conservative containment treatment including Atlanta brace and hip abduction cast had limited role in terms of preventing progression of subluxation. But, surgical containment appeared to increase the chance to obtain spherical head at healing in hips with higher LSI (‡6) (p < 0.05). Conclusions: LSI is considered to be a better measurement of the extent of subluxation and a strong predictor of outcome. Signiﬁcance: LSI may be used for guidance for decision-making of surgical containment. 271 Radiographic and MRI dissociation in Legg-Calve´-Perthes disease. Author: J C Di Sicco (Brazil) Co-Authors: E Dobashi (Brazil), P Yamane (Brazil), A Ishida (Brazil), C Milani (Brazil) Purpose: The purpose of this paper is to demonstrate the results of the acetabulum-femoral-head index in 60 hips of 60 children with LCP disease using plain x-rays and MRI. Then compare the obtained results to demonstrate if there is correlation or not of the calculated index between these two different methods as we called dissociation. Methods: Our material is constituted by 60 patients (60 hips) with Legg-Calve´-Perthes disease with 46(76,67%) male and 14 (23,33%) female with the mean age of 6 y10 m (2 y6 m to 12 y10 m), 46 white patients and 14 non-white. Regarding to the affected side 34 (56,67%) were on the right side and 26 (43,33%) on the left. We applied the classiﬁcation proposed by WALDENSTRO¨M (1922) and modiﬁed by JONSA¨TER (1953). This way, 34(56,67%) hips were considered in necrotic phase, 13 (21,67%) in fragmentation, 9 (15%) in reossiﬁcation and 4 (6,67%) in the ﬁnal stage of the disease. To measure de femoral head coverage index we applied the knowledge of HEYMAN & HERDON (1950) using a computed program software developed for this purpose in x-ray and in MRI images. Results: We observed that in 23 hips (38,33%) there are disagreement in the information concerned to the femoral head coverage because there were considered sufﬁcient according to plain x-ray but insufﬁcient when MRI images were analysed. Conclusions: Many orthopedic services use to apply plain x-ray for diagnosis even for treatment and follow-up. But the information regarding this method does not provide the real state of the femoral head concerning the femoral head cartilage and labrum coverage. Then, the results obtained for us suggest that MRI provides trustworthy information to conduct the treatment of LCP disease, independent of the chosen method. Signiﬁcance: (empty). 272 Staheli’s shelf acetabuloplasty in the treatment of Legg-Calve´-Perthes disease: Indications and mid-term results Author: Elias Haddad (Lebanon) Co-Authors: Ismat Ghanem (Lebanon), Suha Haddad-Zebouni (Lebanon), Noe¨l Aoun (Lebanon), Fernand Dagher (Lebanon), Khalil Kharrat (Lebanon) Purpose: to evaluate the efﬁcacy and safety of Staheli’s shelf acetabuloplasty in those LCP hips classically associated with poor prognosis.

Poster presentations: Abstracts 124–322/J Child Orthop Methods: A retrospective study was conducted on 20 consecutive patients (15 boys and 5 girls) with an average age of 6.65 years, presenting with a severe and progressive form of LCP disease (Catterall 3 and 4, Herring B and C) with ‘‘head at risk’’ signs and treated by Staheli’s acetabuloplasty, with or without femoral varus osteotomy between november 1997 and June 2004. The shelf was done on hips presenting an aspherical uncongruency with ﬂatenning, extrusion and lack of femoral head coverage, as demonstrated on pre-operative radiographs and/or arthrography. All patients were reexamined at an average follow-up of 51 months (18–96). A clinical (pain, limp, motion, leg length discrepancy), radiological (femoral head extrusion, femoral head size, Sharp angle, Reimers index, Wiberg angle) and CT scan evaluation (with 2D and 3D reconstruction, 3D congruency, shelf migration, offset, size of the shelf) was undertaken. Stulberg and Mose classiﬁcations were applied as radiological indicators of prognosis. Statistical analysis was performed using Pearson correlation test and variance analysis for repetitive measures; all tests were bilateral; a p value < 0.05 was considered signiﬁcant. The SPSSV13 software was used for analysis. Results: At last follow-up, all patients are pain free and have normal (17) or almost normal (3) hip motion. Eleven (55%) walk normally, 7 (35%) with mild limp and 2 (10%) with pronounced limp. LLD is found in 9 cases ranging from 1 to 3.5 cm. Three hips (15%) are classiﬁed Stulberg 1, 9 (45%) Stulberg 2, 6 (30%) Stulberg 3 and 2 (10%) Stulberg 4. The average neck-shaft angle is 127 (107–145). A statistically signiﬁcant improvement of femoral head extrusion (p = 0.05), of Sharp angle (p = 0.000), of Reimers index (p = 0.000) and of Wiberg angle (p = 0.000) was found. The scannographic study found no offset nor migration of the shelves in any case. On CT, The femoral head was regular in 14 patients (70%), ﬂattened in 6 (30%). Despite 2 cases of Stulberg 4 found on radiographs, the 3D congruency was good in all cases. The average coronal length of the shelf was 8 mm and the axial one 16 mm. A positive correlation was found between Wiberg angle improvement and the young age at the time of surgery (p = 0.050), which goes against the concept that Staheli’s shelf acetabuloplasty may interfere with growth of the acetabular roof. Conclusions: Staheli’s shelf acetabuloplasty improves outcome of hips with severe LCP. It insures a better and lasting coverage and remodeling of the femoral head, while preserving acetabular roof growth. Signiﬁcance: Staheli’s shelf acetabuloplasty improves outcome of hips with severe LCP. It insures a better and lasting coverage and remodeling of the femoral head, while preserving acetabular roof growth. 273 LCPD - The hunt for genetic associations Author: Shlomo Hayek (Israel) Co-Authors: Eli Ezra (Israel), Shlomo Wientroub (Israel), David Steinberg (Israel), Nurit Rosenberg (Israel), Dalia Waldman (Israel), Gili Kenet (Israel) Purpose: The etiology of Legg-Calve Perthes disease (LCPD) is still an unsolved enigma. The role of heritable thrombophilic risk factors in the pathogenesis of this multifactorial disease is controversial. Since clinical and radiological ﬁndings of avascular hip necrosis due to LCPD may be indistinguishable from Gaucher disease, we previously studied the commonest Jewish N370S Gaucher mutation among LCPD patients and found a threefold increase of its prevalence. Familial osteonecrosis of femoral head has recently been found to be associated with variant mutations of collagen type II. Our aim was to study the potential role of all those above mentioned genetic factors in a cohort of LCPD patients.

S109 Methods: Genomic DNA of 119 radiologically conﬁrmed LCPD patients (diagnosed 1986–2004) was analysed for the following thrombophilic polymorphisms: FVL, 677T-MTHFR and FIIG20210A. Results were compared with 276 pediatric controls referred for elective surgery. DNA was also analysed for the following Gaucher mutations: N370S, G insertion (84GG), L444P, Intron 2(IVS2 + 1G>A) and R496H. Enzyme assays were performed for conﬁrmation of Gaucher disease status. Collagen (COL2A1) mutations of 12q13 gene were analyzed as previously described (Liu et al, NEJM, 2005). Statistical analysis was performed using the chi-squared test with Yates’ correction. Results: The prevalence of thrombophilic markers was similar among cohort patients and controls. Gaucher mutations prevalence was consistent with the Israeli population carriership data and did not conﬁrm the association with LCPD found in a smaller previous study. All our patients were negative for COLA21 mutations studied. Conclusions: Our study did not conﬁrm genetic association of LCPD to Gaucher disease or collagen (COLA21) mutations. Thrombophilia was not increased among our patients as compared to controls although a transient hyper-coagulability state during the early phases of the disease cannot be ruled out. Further studies are warranted in order to shed more light upon the genetic background of LCPD. Signiﬁcance: Thrombophilia, Gaucher mutations have no etiological role in LCPD. 274 Intertrochanteric Varus Open Wedge Osteotomy in Legg-Calve-Perthes Disease Patients Older than 9 Years Old. Author: In-Young Ok (Korea, Republic of) Co-Authors: Seok-Jung Kim (Korea, Republic of) Purpose: To evaluate the outcome of intertrochanteric varus open wedge osteotomy in LCP for the patients above 9 years old. Methods: Thirty three patients older than 9 years diagnosed as LCP were treated by intertrochanteric varus open wedge osteotomy from August, 1989 to August, 2002. The mean age of the patients was 10.2 years (range 9–14), a mean duration of follow up was 7.7 years (range 3.2–14.1 years). According to Harring classiﬁcation system, group A patients were 3, B were 21,and C were 11. Thirty was male and the others were female. There are 2 cases of both sides involvement of LCP in female patients. Radiographic outcome was assessed utilizing Stulberg’s classiﬁcation to grade residual deformity. Results: Stulberg class I and II(spherically congruent) were 10, III and IV)(aspherically congruent) were 15,and V(aspherically incongruent) were 10. Less involvement of the disease and early stage treatment produced better outcome. Conclusions: Intertrochanteric varus open wedge osteotomy is a reliable treatment in LCP after the age of 9, if the disease is evaluated individually according to the extent of involvement and stage of it. Signiﬁcance: Remodelling after containment treatment could be expected in advanced age group. 275 The Results of Hip Abduction Brace (Nishio) Treatment for Legg-Carve-Perthes’ Disease Author: Yutaka Oketani (Japan) Co-Authors: Toshio Fujii (Japan), Kazuyuki Takamura (Japan), Haruhisa Yanagida (Japan), Akifusa Wada (Japan), Hideaki Kubota (Japan), Suin Ryu (Japan), Aiji Matsuura (Japan)

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S110 Purpose: To report the results of the non-weight bearing hip abduction brace (Nishios Brace) for unilateral Legg-Calve-Perthes disease. Methods: We studied 97 hips that were treated by Nishio’s brace that contains the femoral head in the acetabulum at 30 degrees hip abduction and has a pole beneath the sciatic tubercle for the nonweight bearing of the hip. Average age at the time of ﬁrst visit is 6.5 years, and at the last visit was 13.0 years. We evaluated hips with Catterall classiﬁcation, lateral pillar classiﬁcation and Stulberg classiﬁcation. Results: The Catterall classiﬁcation judged when the period ended dividing (passage of nine months on the average from the ﬁrst medical examination) showed in two hips type 1, 37 in type2, 39 in type 3, and 19 in type 4. The lateral pillar classiﬁcations showed eight hips in group A, 54 in group B, 22 in group B/C, and 13 in group C. The Stulberg classiﬁcation when the ﬁnal passage was observed showed 26 hips in type1, 40 in type2, and 20 in type3, nine in type4, and two in type5. Namely, 68.0% (66/97 hips) showed satisfactory results. Conclusions: Nishios brace is satisfactorily effective for the treatment of unilateral LCPD. Signiﬁcance: Nishios brace is satisfactorily effective for the treatment of unilateral LCPD.

276 Bone age delay patterns in Legg-Calve-Perthes disease - an analysis using the TW3 method Author: Hae-Rong Song (Korea, Republic of) Co-Authors: Seok-Hyun Lee, Jae-Hyuk Yang, Sandeep Vaidya, Sameer Desai, Gautam Shetty Purpose: To study the bone age delay patterns in different stages of Perthes’ disease. Methods: 140 hand and corresponding hip radiographs in 83 patients were assessed. In the hand radiographs, the RUS (radius, ulna, metacarpals and phalanges) and carpal bone ages were calculated using the Tanner and Whitehouse 3 (TW3) method and the Greulich and Pyle (G&P) bone age was assessed using the Greulich and Pyle atlas. From corresponding hip radiographs, the modiﬁed Elizabethtown stage was assessed. Results: RUS and carpal bone age as well as G&P bone age were found to lag behind the chronological age. The 95% conﬁdence interval for difference between RUS and G&P bone ages was 0.19 to 0.43 years and between carpal and G&P bone ages was –0.516 to –0.14 years indicating a close agreement between the TW3 and G&P methods. RUS bone age delay was maximum in stage Ia (2.00 ± 1.08 years) while carpal delay was maximum in stage IIa (2.15 ± 1.28 years). Bone maturation acceleration was observed in later stages of the disease as bone age tried to catch up with chronological age. Carpal delay was signiﬁcantly greater than RUS delay from stage Ib to IIIb (p < 0.05) but no signiﬁcant difference was observed between carpal and RUS delays in stage IV (p = 0.21) implying that bone maturation acceleration occurs in the radius, ulna, metacarpals and phalanges (RUS) in the earlier stages and carpal bone age tends to catch up with RUS bone age in the healed stage of the disease. RUS and carpal bone age delays in stage I were signiﬁcantly greater in severe (Catterall’s groups 3 and 4) disease than in mild (Catterall’s groups 1 and 2) disease. Conclusions: All patients in whom RUS or carpal bone age delay in stage I was greater than 2 years subsequently developed severe dis-

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Poster presentations: Abstracts 124–322/J Child Orthop ease indicating a positive correlation between bone age delay in stage I and subsequent extent of involvement of capital femoral epiphysis. Signiﬁcance: Regular followup is required in patients showing a bone age delay with Perthes disease. 277 Salter Osteotomy in Legg - Calve- Perthes disease (LCPD) Followed Until Skeletal Maturity. Author: George H. Thompson (United States) Co-Authors: Susan Scherl (United States) Purpose: A prospective study to evaluate the clinical and radiographic results at skeletal maturity of patients with LCPD treated with a Salter osteotomy. Standardized criteria were used to make the results comparable to previous and future studies on LCPD. Methods: Between 1979 and 1996, a Salter osteotomy was performed on 52 patients (53 hips) with a clinical age of onset between 6 and 10 years of age (5 to 10 years in females) with more than onehalf of the capital femoral epiphysis (CFE) involved ( Catterall groups III and IV, Salter-Thompson Group B, and lateral pillar Groups B and C). They were followed until skeketal maturity and then evaluated clinically and classiﬁed radiographically using the Stulberg, et al and Mose circle criteria. Results: Forty-nine patients and 49 hips (92%) met the criteria for evauation. There were 39 males and 10 females with a mean age at onset of 7.5 years (5.9–10.8 years). Their mean follow-up was 9.8 years (5.0–19.1 years). Preoperatively, 44 hips were Catterall III and 5 Catterall IV; all were Salter-Thompson Group B; and 13 hips were Lateral pillar Group B and 36 Group C. At maturity, the clinical results were uniformily good and only 6 patients had sports related symptoms. Radiographically, 32 hips were Stulberg, et al class II (65%), 14 class III (29%), and 3 class IV (6%). Thus, 46 hips(94%) had satisfactory results. The Mose criteria was more restrictive as there 20 hips (41%) rated good, 14 (28%) fair and 15 (31%) poor. Conclusions: Salter osteotomy is an effective method of surgical containment for patients with LCPD who have a poor prognosis. It alters the natural history. It effects are permanent and appears to enhance remodeling of the CFE. Signiﬁcance: Salter osteotomy is an execellent procedure when surgical treatment is necessary for LCPD. It requires experience to perform correctly but does not require postoperative immobilization. It has numerous advantages (secondary) over a proximal femoral osteotomy.

6 - Foot and ankle 278 Single Stage Surgical Correction of Congenital Vertical Talus by Complete Subtalar Release Using Three Incisions. Author: Mostafa El-Sherbini (Egypt) Co-Authors: Purpose: To evaluate the effect of Complete Subtalar Release bySingle Stage Surgical Correction in the treatment of Congenital Vertical Talus through three incisions. Methods: 10 feet of 6 patients with congenital vertical talus which were treated by single stage surgical correction by complete sub-

Poster presentations: Abstracts 124–322/J Child Orthop talar release and peritalar reduction using 3 incisions,posteromedial,lateral and anterior midleg incision for dorsiﬂexors lengthening.There were 3 male and 3 female.There ages ranged between 9 months and 3 years with average 14.5 months .The follow up ranged between 18 months and 51 months with average 31.1 months. Results: There were 8 good and 2 fair results.There was one case of avascular necrosis of the talus .Radiologically,there was a significant improvement in the anteroposterior and lateral talocalcaneal angles, and at follow up,the group averages for each of these angles were within the normal ranges. Conclusions: In the treatment of congenital vertical talus,good clinical and radiological outcomes can obtained with a low incidence of complications,using this single-stage surgical correction with three incisions. Signiﬁcance: To acheve pritalar reduction with low incidence of complicatiuons. 279 Shortness Of The Fourth Toe Author: Gamal Ahmed Hosny (Egypt) Co-Authors: Purpose: Shortness of the fourth toe is a rare problem.It does not usually produce a functional problem.However,it may produce a signiﬁcant cosmetic problem specially in girls.The aim of this study is to evaluate the validity of gradual distraction of the fourth metatarsal to tackle this problem. Methods: From 1993 till 2005,8 cases of congenital shortening of the fourth toe were referred to our center.6 cases were bilateral[total 14 feet].All cases were females.Age of patients ranged from 13 to 20 years[average: 15.5 y].Shortening ranged from 10 to 70% of the original length.There were no functional problems preoperatively.Lengthening was performed using miniﬁxator[Pennig External ﬁxator} with 2 proximal & 2distal2 mm self tapping screws.After the application of the srews,the frame was temporarely removed and osteotomy was performed in the middle through 1 cm incision.Then the frame was reapplied.After a waiting period of 12 days,distraction started at a rate of 0.75 mm per day.Then the rate was modiﬁed according to regenerate formation and the degree of developing stiffness in the the metatarsophalangeal joint.Evaluation depended upon the achievement of the target length,angulation,pain & satisfaction of the patient. Results: There were 10 excellent & 4 good results after an average follow up of of 3 y[range 6 months to 6.5 years]The average healing index was 45 days/cm.Complications included mild pin tract infection in 11 cases which responded to antibiotics.Subluxation of the metatarsophalangeal joint developed in 2 cases who resolved spontaneousely.Delayed regenerate formation in 2 cases who were treared by repeated compression & distraction. Conclusions: We recommend cosmetic gradual lengthening of the fourth metatarsal as the treatment of choice for shortness of the fourth toe.We do not recommend soft tissue release or ﬁxation of the metatarsophalangeal joint to guard against displacement. Signiﬁcance: Cosmetic lengthening is justiﬁed in these cases. 280 Mc’Hale’s procedure (open wedge osteotomy of the ﬁrst cuneiform and close wedge osteotomy of the cuboid) for club foot revision surgery. Author: Raytcho Ivanov Kehayov (Bulgaria)

S111 Co-Authors: Evgenii Mednikarov (Bulgaria), Hristo Georgiev (Bulgaria), Stefan Stefanov (Bulgaria), Borislav Vladimirov (Bulgaria) Purpose: The authors report 24 cases of revision in recurrent club foot deformity. They assessed Mc’Hale’s procedure for treatment of the residual forefoot adduction. This procedure was generally associated with postero-medial, plantar release, and split tibialis anterior tendon transfer. Methods: 16 children (24 feet), aged 5 to 15 years, underwent medial open wedge osteotomy of the ﬁrst cuneiform for correction of 16 feet, closed wedge osteotomy of the cuboid has been added to correct the varus deformity of the fore foot, it allowed lateral swing of the forefoot : the bone excised from cuboid is used to stabilized medial osteotomy. This procedure is carried out when varus of the tarso metatarsal joint is superior to 20 degree, it is reduced to its normal value, between 5 and 10 degree. Results: Results have been studied with follow up ranginq between 18 months and 5 years. The revision chart comprised 12 clinical and radiological items. 9 feet were considered as excellent, 10 as good, 3 as fair, and 2 as poor. Conclusions: Treatment of the adduction component with Mc’Hale’s procedure is focused on the midfoot, and on the calcaneo-navicular block by postero medial release. This operation is riskless for foot growth, and needs two approaches which can be useful for simultaneous procedures as split lateral transfer of tibialis anterior tendon. Signiﬁcance: Mc’Hale’s procedure associated with soft tissues release and split anterior tibial transfer, seems to be effective in surgical treatment of relapsed clubfeet, but the debate concerning the location of the adduction component of the deformity remains still open. 281 Distraction lengthening of the long bones of the foot in children Author: Alexander Kirienko (Italy) Co-Authors: Luigi Spreaﬁco (Italy), Massimo de Donato (Italy), Valerio Sansone (Italy) Purpose: This study investigated metatarsal and phalanx lengthening by distraction osteogenesis for congenital or post-traumatic shortening in 23 metatarsals and 3 phalanx of the hallux, in a group of 17 patients. Methods: There were 7 males and 10 female patients, mean age 13 years (range from 8 to 17 years). We treated 2 patients with Turner syndrome with bilateral shortening of third and fourth metatarsal, brachymetatarsia of fourth metatarsal in 9 (three bilateral) and post-traumatic and congenital defect of ﬁrst metatarsal in 3 of them. Three patients had stump of the proximal phalanx of the hallux. We performed lengthening using semicircular and Ilizarov’s mini-ﬁxator for ﬁngers. We ﬁxed bones to the external ﬁxators by wires crossed in the transversal plane, performed percutaneous osteotomy and then we started distraction ﬁve days after the operation. Early weight bearing was allowed in all cases. The initial rate of lengthening was of 0,75 mm per day. After 2 weeks this rate was slowed to 0,5 mm per day. Results: The average in length was 17,3 mm (range 12–25 mm), with an equivalent increase of 36% (range 25–46%) and a mean healing index of 61 days/cm. The American Orthopedic Foot and Ankle Society (AOFAS) average score for lesser toes was 85,3 (range 53–100) and 73 (range 51–93) for hallux. The most common complication was stiffness of metatarsophalangeal

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S112 joint (6), subluxation of this joint (2), angular deviation of the lengthened bone (5), pin track infection in 4 cases, one retard of consolidation after lengthening that needed to proceed with distraction bone transport. We did not need to use bone grafting in all cases, no neurovascular complications were encountered. Conclusions: This technique of gradual distraction gives a sufﬁcient precision lengthening for forming physiological arch of metatarsals heads. It also permits a contemporarily correction of deformities without bone grafting and soft tissue modiﬁcations. Subluxation of metatarsophalangeal joint may be prevented by pitting of the toe with longitudinal K-wire. Excellent clinical and functional results were obtained with both semicircular and Ilizarov’s mini-ﬁxators. Signiﬁcance: This method could be recommended as the way of choice for solving the problem of metatarsal and phalanx shortening. Bone lengthening is effective in patients not only for aesthetics, but also to relieve pain and callosities on the plantar surface on the second and third metatarsal heads and prevent secondary deformities of toes nearby. 282 Highly constrained frame in correction of deformed feet Author: Hatem Ahmed Kotb (Egypt) Co-Authors: Purpose: Ilizarov Method in the correction of complex feet has proved efﬁciency. Highly constrained and non constrained distraction has been described. The aim of this study is to evaluate out come after Ilizarov highly constrained frame feet correction, and to determine the adequate number of tibial rings needed for correction. Methods: Forty-three feet were operated using a highly constrained Ilizarov frame from 1996 till 2005. The tibial ﬁxation was two rings in ﬁve cases and one tibial ring in thirty-seven. Two cases were treated by distraction osteotomies and forty-one by soft tissue distraction. Nine cases had additional surgical procedure. The average age at operation was 10.7 years (range 3– 25 years). Average follow up was 5.2 years (range nine years to nine months). The indication for correction were neglected or relapsed idiopathic congenital talipes equino varus in 22 cases. Eight paralytic feet and six rocker bottom feet. 5 talipes equino varus feet associated with syndromes. 31 feet had previous operation average 1.8 opration (range 1–4 operations). 6 had previous Ilizarov operations. Clinical, functional and radiographic evaluation was performed. Results: the average ﬁxation time was 2.7 months (range from 1–5 months). All feet were corrected except one. At ﬁnal follow up 31 had good results, 7 had satisfactory results and 5 had unsatisfactory results. There has been a marked average increase in the function and ankle and subtalar range of motion. There has been 43 minor complication, 3 serious complications and no serious complications were related to single tibial ring ﬁxation. Conclusions: Ilizarov ﬁxator is an effective tool for correction of deformed feet, one tibial ring ﬁxation is adequate to achieve correction. An increase in function and range of motion can be expected. Signiﬁcance: one tibial ring ﬁxation is adequate to achieve correction. An increase in function and range of motion can be expected.

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Poster presentations: Abstracts 124–322/J Child Orthop 283 New Modiﬁcation of John’s Technique to Restore Dorsiﬂexion of the Ankle Joint and Normal Development of the Hallux Author: Nagy Ahmed Sabet (Egypt) Purpose: John’s operation is a popular procedure to restore dorsiﬂexion of the ankle joint in cases of drop foot due to paralysis of the tibialis anterior. The original procedure is composed of transfer of the extensor hallucis longus to the neck of the ﬁrst metatarsal bone and arthrodesis of the interphalyngeal joint of the big toe. The previous procedure cannot be done in skeletally immature patients because it will stop the development of the hallux and lead to deformity and shortening of it. Modiﬁcation of this technique was tried by doing tenodesis of the interphalyngeal joint using the stump of the extensor hallucis longus muscle to prevent ﬂexion deformity of the joint, but this procedure will fail after few years due to progressive development of the phalanx and necessitate revision of the tenodesis or arthrodesis of the interphalyngeal joint. We tried a new modiﬁcation by suturing the stump of the extensor hallucis longus to the tendon of the extensor hallucis brevis. This procedure preserves active dorsiﬂexion and normal development of the hallux. Methods: The present procedure was performed to 42 limbs from January 2000 to December 2004, 2 cases were bilateral.Regarding the surgical procedure; Tendo-achillis lengthening was performed routinely to all patients in this study, The extensor halluces longus tendon was transferred to the neck of the ﬁrst metatarsal in (20 cases) where there was no varus deformity associated with the equinus, The tendon was transferred laterally to the middle cuniform bone if there was varus deformity (22 cases), and Suturing of the stump of the extensor halluces longus to the extensor halluces brevis was performed in 40 cases out of 42 included in this study due to normal congenital variant in which the extensor hallucis brevis muscle is congenitally absent. Post operative care; Above knee cast was applied to all cases for one month followed by below knee cast for 2 weeks. Physiotherapy & walking exercises were performed after removal of the cast. Results: Follow up was ranged from one & half year to six years & 6 months. Active dorsiﬂexion of the ankle was achieved in all cases. Active dorsiﬂexion of the hallux was also achieved in all cases with different degrees. Conclusions: Some complications were experienced, 3 cases showed superﬁcial wound infection and were treated by antibiotics. Failure of the tendon suture due to direct trauma to the hallux occurred in one case and necessitated revision of the operation. Congenital absence of the extensor halluces brevis was found in three cases and was excluded from the study. Signiﬁcance: We concluded that suturing of the stump of the extensor hallucis longus to the extensor hallucis brevis in John’s procedure is a valuable method to restore dorsiﬂexion of the hallux and allow normal development of the phalanx.

284 Arthroscopic treatment for osteochondritis dissecans of the talus in adolescents. a review of 18 cases. Author: Vidal Imma Vilalta (Spain) Co-Authors: Font Ullot (Spain), Eva Planes (Spain), Campa` Cepero (Spain)

Poster presentations: Abstracts 124–322/J Child Orthop Purpose: It’s not frequent that de pathology of the ankle could be treated with arthroscopy in children and adolescent. This technique is used in our service since 1996, being the osteochondritis dissecans of the talus the most frequent pathology with 18 cases. The ﬁrst description of the arthroscopic treatment of this injury was made in 1982. Methods: We reviewed 18 patients, since 1996 to 2006, ages from 10–17 years, who had been treated for an osteochondral defect of the talus by arthroscopic drilling. The indication for surgical treatment was persistent symptoms after leaving physical activity for at least six months. There were 9 boys and 9 girls. The lesion involved the right ankle in 13 and the left in 5 cases. 70% of the cases were associated with a previous trauma. Arthroscopic drilling was performed and the mean follow-up was 7–10 years. Results: The results were evaluated at least of 1 year by clinical ﬁndings, X-ray and CT-scan. The outcome was excellent and the participation in sport was possible after 9 moths. Conclusions: We emphasize the role of the arthroscopic of the ankle, for surgical processing of the osteochondritis dissecans of the talus. The arthroscopic, allow an adequate viewing of the entire joint and avoids the complications of the open surgery. Signiﬁcance: The aim of this communication is to conﬁrm that we have to treat the osteochondritis dissecans of the talus by arthroscopic drilling because of minimally invasive technique with excellent results and avoids the complication of the open surgery.

Clubfoot 285 Residual forefoot adduction in clubfoot - comparison of two methods of treatment Author: Ondrej Adamec (Czech Republic) Co-Authors: Pavel Dungl (Czech Republic), Jiri Chomiak (Czech Republic), Monika Frydrychova (Czech Republic) Purpose: To compare outcomes of temporary transfer tibialis anterior tendon and metatarseal osteotomy to corection of residual adduction deformity of the forefoot after the extensive subtalar release. Methods: Two surgical methods were used. Compared to original method described by Garceau (1967) in proper technique tibialis anterior tendon pass through subcutaneus tunnel. Result of the pass beneath annular ligament of ankle is mostly loss of function, because of concretion. Metatarseal dome shaped osteotomies we made from three lenghtwise incisions and ﬁxed every metatarseal bone by one wire. From the group of 460 feet (348 patients) operatet in years 1984 to 2002 by extensive subtalar release was transfer of tibial anterior tendon used in 78 feet (62 patients) and metatarseal osteotomy in 56 feet (43 patients). Age of patiens ranged between 32 months and 13,5 years. In every cases, deformity demonstrated adduction and supination of forefoot. For functional evaluation was used modiﬁed scoring system according to Mc Kay, forefoot rigidity was evaluated according to Black. X-ray assessment was made by use of talo-I.metatarsal and calcaneo-V.metatarsal angle changes in dorsoplantar weightbearing wiew. Results: In subjective evaluation whith average follow-up 4,5 years (2 to 8) was effect of operation percieved at 49 (72 %) feet as excelent, at 15(22 %) as good and et 4 (6 %) as a minimal change. Deformity became extinct clinicaly and radiologicaly in 53 % of cases. Persistance of adductional position of forefoot clinicaly and radiologicaly we recorded in 26 % feets in tibialis

S113 anterior transfer group at 6 years of age and more, when the effect of method was smaller or transient because of presence forefoot rigidity. In metatarseal osteotomy group we noted 5 non-unions represents 1.8% of 280 osteotomized metatarseal bones. Conclusions: Temporary transfer of tibial anterior tendon by proper modiﬁed technique passing tendon in subcutaneous tunnel is safe and reliable method to affect residual forefoot deformity in patients between 3 to 6 years of age. In patients older than 8 years of age and for every rigid deformities (Black II and III) we recommended metatarseal osteotomy as a method of treatment. Signiﬁcance: Mean comparisons following analysis of variance showed signiﬁcant differences (all p < 0.0001) between used methods and patients age in time of surgery. A signiﬁcant difference (p = 0.0216) was also noted between the rigid and non rigid forefoot deformity.

286 Congenital clubfoot. An epidemiological investigation: 1980–2005 Author: Alain Dimeglio (France) Co-Authors: Federico Canavese (Italy), Frederique Bonnet (France), Tayeb Bentahar (France) Purpose: This epidemiological investigation was performed to analyse data on 901 children with clubfoot born in a region of about 2.100.000 residents with 25.000 births/years on average. Methods: 754.532 live births were recorded in the period january 1980 - august 2005: 826 children had idiopatic clubfoot (91.7%) and 75 non-idiopatic clubfoot (8.3%). All data were statistically analysed. Results: The birth prevalence of isolated idiopatic clubfoot (no other birth defects present) was 1/1000 total births and of associated idiopatic clubfoot (other birth defect present) was 0.12/1000 total births. 7.7% of children with idiopatic clubfoot had other associated congenital abnormalities: the most common one was DDH in 2.7% of cases followed by metatarsus adductus (1.6%). Others malformations such as upper limb malformations (0.5%), patella dislocation (0.4%), cardiac malformations (0.4%) were uncommon. Since 1990 ultrasounds are regularly performed to diagnose DDH. Left metatarsus adductus was frequently associated to right unilateral idiopatic clubfoot (p < 0.001). Non-idiopatic clubfeet were frequently related to arthrogryposis. Male gender (67.02%) is more likely to have an increased risk of idiopatic clubfoot but there is no signiﬁcant association between gender and severity of deformity (p>0.05) and gender and side affected (p > 0.05). Unilateral forms make up 55% (31.83% right and 23.17% left) and bilateral forms are 45%. Prognosis is not inﬂuenced by the sex (p > 0.1). The mean age of fathers was 31.56 years (17.21–68) and of mothers was 28.92 years (14.09–44.04). Family history was positive in 14.14% of cases. 3.2% of infants were born preterm and 59.87% had birthweight over 3000 gr. (mean birthweight: 3200 gr.; range: 800–4645 gr.). Analysis failed to identify a monthly or seasonal variation in this population. According to a scale from 0 to 20 5.9% of feet were benign and completely reductible (score 1–5), 24.56% moderate (score 6–10), 58.55% severe (score 11–15) and 10.99% very severe (score 16–20). After 1997 the lengthening of triceps (Vulpius technique) was included in the protocol. Conclusions: Results are correlated to the Scoring System ; classiﬁcation is helpful to evaluate the impact of treatment; a significant follow up is necessary to evaluate the effect of treatment; after 1997 the lengthening of triceps (Vulpius technique) was in-

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S114 cluded in the protocol: this mini surgical procedure his helpful to improve the effects of the conservative treatment. Signiﬁcance: Retrospective Study. 287 Treatment of Residual Clubfoot Deformities with the Taylor Spatial Frame Using a Ponseti Sequence Author: Mark Eidelman (Israel) Co-Authors: Alexander Katzman (Israel), Noam Bor (Israel), Bradley Lamm (United States), John Herzenberg (United States) Purpose: Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external ﬁxator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external ﬁxator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation ﬁrst and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a ﬁnal phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method. Methods: During a ﬁve-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, ﬁve had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with ﬁbular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75– 15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program. Results: All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superﬁcial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the ﬁrst metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases. Conclusions: We believe that the Ponseti sequence of correction can be applied to older children with residual clubfoot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed. Signiﬁcance: The Ponseti-inspired method of residual clubfoot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures. 288 The Ponseti method for treatment of clubfoot. Review of a 12 years experience Author: Edilson Forlin (Brazil)

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Poster presentations: Abstracts 124–322/J Child Orthop Co-Authors: Dulce Grimm (Brazil), Luiz Munhoz da Cunha (Brazil), Luis Munhoz da Rocha (Brazil) Purpose: The Ponseti method for treatment of clubfoot has became widely used in the world. Except those from Iowa, most of the studies presented has a short follow-up. We start to use the method in our hospital in 1993. Since then more than 200 patients were treated. The goal of this study is to present the results, prognosis, problems and difﬁculties of the ﬁrst years of the use of the method. Methods: Criteria to be included in this study was idiopathic clubfoot treated from 1993 to 1999, age at the initial casting from 0 to three months and a minimal follow-up of 3 years. Eight-one feet in 49 patients were included. Thirty-one male and 18 female. Thirty-two patients had bilateral involvement. Achilles tenotomy was performed in 79 feet at mean of 10 weeks of casting. Casting post tenotomy average 8 weeks. Ortosis used was Denis-Brown for 19 patients, KAFO for 26 patients and none in four patients. Results were classiﬁed as: satisfactory (a plantigrade foot, neutral or external rotation alignment at gait, calcaneal aligment in neutral or valgus and a dorsal ﬂexion of at least 15 degrees), unsatisfactory when the foot had residual deformity and failure when a PML release was performed. Results: The mean follow-up was 48,2 months (36 to 135 months). Final results showed 60 feet as satisfactory, from this group 8 needed a limited release (seven transposition of tibialis anterior and one posterior release), 10 as unsatisfactory and 11 as failure. Unsatisfactory result was related with bilateralism, under correction at the time of the end of casting and with lower degree of external rotation. Length of time using orthosis or its no use was not related with unsatisfactory result. Conclusions: Our results on these initial series were inferior those reported from Iowa. We believe that some changes of the method were related with the result. The position at the end of casting may be the more important prognostic factor. At that time we had some difﬁcult to accept some concepts as the tenotomy, limited casting (6 to 10 weeks) and observance to the external rotation. A more recent series, following Ponseti´s recommendation more restrict, has been studied and presented better outcome. Signiﬁcance: As far as we know, our experience with the Ponseti method is one of the longest outside Iowa. The patients of this series were treated when the Ponseti´s method was not so well known and accepted widely. This study demonstrated the prognostic importance of the position of the foot at the end of casting. To follow with attention the principle of the PonsetiAˆ´s method is crucial for high quality of results. 289 Ultrasound examination of clubfoot in the Ponseti method Author: Cosimo Gigante (Italy) Co-Authors: Enrico Talenti (Italy), Sisto Turra (Italy) Purpose: Critical decision in the Ponseti method is the selection of the clubfeet which needs Achilles tenotomy. Purpose of this study was to determine if ultrasound assessment of clubfoot may be helpful in making surgical decision. Methods: 98 newborns with 122 congenital clubfeet were treated by the Ponseti casting technique from mid-2000 to June 2006. According to Manes classiﬁcation, there were 20 mild, 47 moderate and 55 severe clubfeet. After 3 to 8 weeks of casting, clubfeet candidate to surgery underwent sonographic assessment according to the original technique previously published by the authors. On the sagittal posterior plane the R.O.M. of the ankle and subtalar joints was stated both in neutral position

Poster presentations: Abstracts 124–322/J Child Orthop and under manipulation. No surgery was performed in clubfeet with normal sonographic dorsiﬂexion, percutaneous tenotomy was done in clubfeet with mild limited sonographic dorsiﬂexion and more extensive posterior release (tendon Z-lengthening and posterior cut of ankle and subtalar joint) was performed in clubfeet with most evident sonographic persistent equinus and anterior dislodgment of the talus in the ankle mortise. The R.O.M. was checked again by ultrasound at the end of treatment. According to Ponseti method a Denis Browne bar, with clubfoot 60 externally rotated, was worn full time until the walking age. Results: 35 /122 clubfeet (28,6%) were treated conservatively (all the 20 mild and 15 / 47 of moderate deformities), 87 / 122 (71,4%) surgically (32/47 of moderate deformities and all the 55 severe deformities) . On the basis of the dynamic ultrasound evaluation 38 clubfeet underwent simple tenotomy and 49 ones underwent extensive posterior release. At the end of the casting normal dorsiﬂexion was documented by ultrasound in 72 (82,7%) of the operated feet. Conclusions: The need of surgery in the Ponseti casting technique shows a great variability in Literature. These controversial data are probably due to the different criteria used in evaluating the correction obtained by casting. Ultrasound assessment of the deformity gives objective qualitative and quantitative information about the restoration of the physiological dorsiﬂexion and articular biomechanics. On the basis of this simple, non invasive and widely available procedure the surgeon can evaluate the effectiveness of the serial casting and may be able to establish and graduate the need of corrective surgery. Signiﬁcance: To operate or not to operate the clubfoot at the end of the conservative treatment may be controversial. The ﬁnal decision is sometime subjective and related to the personal experience and opinion of the paediatric orthopaedist. Ultrasound dynamic examination allows to check the physiological biomechanics of dorsiﬂexion and it was helpful in the selection of the feet which need surgery to optimise the corrective treatment. 290 Does the percutaneous Achilles tenotomy in clubfoot treatment objectively modify the equinus immediately after the procedure ? Author: Guy Grimard (Canada) Co-Authors: Benoit Morin (Canada), MA Cantin (Canada), Morris Duhaime (Canada) Purpose: Achilles tenotomy is generally required in the treatment course of idiopathic clubfeet according to Ponseti technique. The tenotomy is usually performed around the ﬁfth week after the beginning of treatment. However, no study has assessed its immediate effect on the tibio-calcaneal angle or the equinus. The purpose of this study was to determine the immediate effect of Achilles tenotomy on the tibio-calcaneal (TC) tibio-foot (TF) angles. Methods: This prospective study was carried out at Ste-Justine Hospital at the clubfoot clinic between July 2005 and August 2006. All patients with a diagnosis of idiopathic clubfoot were potential candidates. After a minimum of four weeks of manipulation and serial casting, patients with a residual equinus or a lack of ankle dorsal ﬂexion that was ﬁlled to restrain the improvement of correction received a percutaneous Achilles tenotomy under local anesthesia. Before and immediately after the tenotomy, a lateral X-ray of the foot with maximal dorsal ﬂexion of the ankle was obtained using a mini C-arm ﬂuoroscope. Afterwards, the foot was placed in a long leg cast for 2 weeks. All

S115 the X-ray images were stored on the PACS and measured by two observers. Two measures were assessed, the tibio-calcaneal and the tibio-foot angles, respectively. A paired-t test was used to compare the measures pre- and post-tenotomy. Results: Thirty-four clubfeet (23 patients) were enrolled in the study. There were 17 males and 6 females. The right foot was involved 17 cases. The mean age at the tenotomy was 50.7 ± 16.6 days. The mean pre- and post-tenotomy TC angle was 83 ± 10 degrees and 66 ± 9 degrees, respectively (p < 0.001). The mean pre-tenotomy and post-tenotomy TF angle was 77 ± 10 degrees and 60 ± 6 degrees, respectively (p < 0.001). No complications were associated with the tenotomy. Conclusions: In conclusion, percutaneous Achilles tenotomy performed in the initial stage of the treatment of clubfeet immediately improves the residual equinus in idiopathic clubfeet. Signiﬁcance: This study conﬁrms objectively the positive effect of the percutaneous Achilles tenotomy early in the course of treatment of clubfeet and reinforces the necessity to perform it when indicated.

291 Idiopathic Congenital Talipes Equino Varus: Predictors of Outcome when using Ponseti Method Author: Hatem Ahmed Kotb (Egypt) Co-Authors: Purpose: Identifying risk factors for poor outcome in the management of idiopathic congenital talipes equino varus foot deformity using Ponsetti Method. Methods: 198 feet of idiopathic congenital talipes equino varus foot deformity in 126 children, were treated using the Ponseti technique. They were followed up for a maximum of 36 months. Patient prenatal, natal and family history were documented. Pre and post intervention morphologic measures were recorded. All cases had thorough clinical examination to exclude cases other than idiopathic congenital talipes equino varus, identiﬁed syndromes were excluded. Serial weekly plaster casting to correct cavus adducts and varus, followed by heel cord tenotomy if needed. Then foot abduction brace was used. Results were graded as fully plantigrade(good), not fully plantigrade (fair) and relapsed (poor). Results: The mean follow up was 19.9 + 5 months, 14 children 22 (11.1%) feet failed to show up at last follow up. Mean age at presentation was 56 + 143.6 days (1 day to 4 years). 112 children with 176 feet showed up at last follow up. 84 (75%)were males and 28 were females 12.5% had a similar condition in the family, positive consanguinity was in 35.7%. 31.2% were delivered by Caesarian section. The average number of casts was 8.2 for each foot, 14 (7.9%) had no tenotomy, all feet were corrected. 22 (12.5%) relapsed and recasted, 11 (6.2%) feet had retenotomies. In 18 (10.2%) feet (13 children) the parents refused the Ponseti management and under went open surgical releases else were. 21.4% of parents were compliant with abduction splint. In the surgical group 3 feet (16.6%) had a good result, 11 (61.1%) fair and 4 feet (22.2%) poor, 1 (5.5%) foot had residual metatarsus adducts. In the Ponseti managed group of (158 feet), 95 feet (60.1%) were good, 54 feet (34.2%) were fair and 9 feet (5.7%) poor, 21 (13.3%) feet had residual metatarsus adducts. Caesarian section (p = 0.71), consanguinity (p = 0.864), positive family history (p = 0.12), sidedness (p = 0.12) and age at presentation (p = 0.52) had no bearing on results. Equinus angle of 50 or more carries 20 % relapse angel more than 60 bears a 66.6% chance of relapse. The predictive ability of these cut points have a sensitivity of 84.7 and speciﬁcity of 100%.

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S116 Conclusions: Parents’ compliance and devotion is a key factor for the successes of the technique. Signiﬁcant bad prognostic factors were found to be; non compliance of parents (p = 0.000), open surgical release (p = 0.001), maternal illiteracy (p = 0.028), male gender (p = 0.031). Signiﬁcance: Signiﬁcant bad prognostic factors were found to be; non compliance of parents (p = 0.000), open surgical release (p = 0.001), maternal illiteracy (p = 0.028), male gender (p = 0.031). 292 A Prospective study of surgical management of club foot – Comparision between suturing vs non-suturing of ‘Z’ plasty tendons Author: Durga N Kowtharapu (India) Co-Authors: Rajasekaran S (India), Ajoy P (India) Purpose: Recurrence is one of the common problems after clubfoot surgery. It is mainly due to contracture and tethering of tendons that may be due to suturing tendons tightly at the time of surgery. We report here a prospective comparative study to verify the outcome of two groups, one in which the tendons were sutured and in other tendons were not sutured after ‘Z’ plasty lengthening. Methods: 42 children with 65 clubfeet with an average age of 6.2 months (range3–10 months) were treated by Modiﬁed Turco Posteromedial soft tissue release & Steindler’s procedure. They were divided into Group A (right sided clubfeet n = 37) and Group B (left sided clubfeet n = 28) and evaluated at an average of 20 months(range 8–30 months).In Group A tendons were aligned side by side after ‘Z’ plasty, but not sutured. Where as in Group B they were sutured at appropriate length. Results: Results in both groups were evaluated preoperatively and postoperatively by DIMEGLIO 20 point scoring system. Preoperatively equines (score 2.77,2.79), was the severe deformity followed by adduction (score 2.26,2.25),varus (score2.07,2.08) and calcaneoforefoot rotation (score1.68,1.67) in Group A&B respectively. Average preoperative scores in Group A&B were 10.72 and 10.70. Postoperative scores were 3.8&3.7 respectively. Postoperatively equinus (Score0.57&0.55) had the best outcome followed by adduction (1.05&1.08), varus (Score1.09&1.11) and calcaneoforefoot rotation (0.91&0.92).There is no signiﬁcant difference in outcome between the two groups. Conclusions: This study showed at the end of 20 months there is no signiﬁcant difference in functional and cosmetic outcome by either suturing or not suturing the tendons. However, long term follow up is necessary to identify any difference in the recurrence rate. Signiﬁcance: There is no signiﬁcant difference in outcome between the two groups (P < 0.05). 293 Outcome of the Treatment of Relapsed Talipes Equinovarus Using the Ilizarov External Fixator Author: Fergal Monsell (United Kingdom) Co-Authors: Sally Pollock (United Kingdom), Anthony Caterrall (United Kingdom), Fulvio Franceschi (Italy), Deborah Eastwood (United Kingdom) Purpose: The Ilizarov external ﬁxator has theoretical advantages over conventional revision surgery for the treatment of recurrent clubfoot deformity where scarred tissue planes, abnormal anatomy and impairment of local blood supply are common. This

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Poster presentations: Abstracts 124–322/J Child Orthop paper assesses the outcome of treatment of recurrent club-foot deformity using this device. Methods: The study evaluated Ilizarov external ﬁxator correction of 40 feet in 31 patients. Deformity was idiopathic in 29 patients, associated with constriction bands in 6 patients and was syndromic or associated with a deﬁned neuromuscular disorder in 6 patients. Patients were reviewed clinically and completed questionnaires documenting pain, function and satisfaction before and after treatment at a mean follow-up of 44 months (range 14–131). All patient’s notes and radiographs were examined. Results: Pain and function scores after treatment improved in 67% and 72% of cases respectively. A subjective increase in stiffness was noted in 46%. Patient satisfaction with outcome was 61%, correlating with improved pain and function scores. Pain and function scores were not signiﬁcantly different in stiff versus non-stiff feet. The overall recurrence rate was 44%, and was highest in the idiopathic group (59%) compared with the constriction band group (17%) and the neuromuscular/syndromic group (0%). Feet with recurrent deformity had been treated with the Ilizarov ﬁxator at a younger mean age (7.8 years) than those feet which did not recur (mean age 12.6 years). 71% of recurrences experienced signiﬁcant pain post treatment, compared with only 36% of those feet where deformity did not recur. Functional ability was, however, similar in the two groups. Further surgical treatment has been necessary in 6 patients, including 4 further Ilizarov frames. Complications included almost universal minor pin-site infections, ﬂexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle ﬂap. Conclusions: Treatment of relapsed clubfoot with the Ilizarov ﬁxator can improve the appearance of the foot, correlating with improvement in pain, function and patient satisfaction. This must be balanced however against a high recurrence rate, particularly in young idiopathic feet, an increase in stiffness of the ankle, which has implications for future surgery, and the risk of complications inherent in the technique. Signiﬁcance: This paper demonstrates that the Ilizarov device can be used successfully in the management of severe recurrent talipes equinovarus. There is however a signiﬁcant rate of recurrence particularly if treatment is necessary under ten years of age. 294 Percutaneous section of the calcaneal tendon with a needle for correction of the residual equinus of clubfoot. Assessment of the technique and reparative process with ultrasound. Author: Jose Batista Volpon (Brazil) Co-Authors: Daniel Leal (Brazil), Frederico Gatti (Brazil), Daniel Maranho (Brazil) Purpose: To evaluate the technique of division of the calcaneal tendon with a needle inserted percutaneously for the treatment of residual equinus of clubfoot. Methods: Sixteen tenotomies were prospectively analyzed in 13 patients with clubfoot treated by the Ponseti technique. The tenotomy was performed percutaneously, under local anesthetic, with a 16 gauge needle and ultrasonographic image was obtained immediately to assure that a complete section was achieved and to measure the gap between the two tendon stumps. The following repairing process was followed up with ultrasound examinations performed at three weeks and six months after the tenotomy. Results: The ultrasonography showed that the tenotomy was complete in all but two cases which were completed soon afterwards under ultrasound visualization. One case showed bleeding that was controlled with local pressure. The mean stump gap

Poster presentations: Abstracts 124–322/J Child Orthop shortly after the tenotomy was 5.2 mm (3.0 – 9.09 mm). Three weeks later, the gap was ﬁlled with hypoecoic tissue and mechanical continuity was observed with muscular movements transmitted from the calf to the heel. At six months in all but one case, the ultra-sound appearance of the lengthened part was similar to the neighbor normal tendon. Conclusions: The percutaneous section of the Achilles tendon with a needle proved to be an effective method, with no major complications, but ultrasound examination was important to assure that the tenotomy was really completed. There was a complete repair of the lengthened tendon with normal tissue within six months. Signiﬁcance: Percutaneous tenotomy with a needle, theoretically, decreases morbidity and ultrasound examination assures that a complete division has been achieved.

295 Use of the longitudinal osteotomy of the talus in treating the recurrent clubfoot in a developing country. Author: Kaye Evan Wilkins (United States) Co-Authors: Idgie Garnier-Kenol (Haiti) Purpose: In many developing nations clubfeet are still managed primarily surgically with variations of the standard posterior medial release. Unfortunately, for a variety of reasons there is a high rate of recurrence. In countries with limited medical resources repeat soft tissue releases can be difﬁcult because of the scar formation from the old surgery. In the past 20 years the senior author has modiﬁed the Veribeli-Ogston procedure to create a horizontal lateral based closing wedge osteotomy of the talus to obtain a correction of the equinovarus thus avoiding operating through the old medial scar. The purpose of this review is to demonstrate that the longitudinal osteotomy of the talus can be good alternative to correct hind foot varus in children that are older than 3 years of age in neglected or recurrent clubfoot in countries with limited surgical resources. Methods: In the past ﬁve years 20 patients over 3 years of age who had this procedure in a nation in the Caribbean were reviewed. Nine had undergone prior soft tissue releases. Eleven had the longitudinal osteotomy of the talus as their primary procedure bypassing the usual soft tissue release. Of those with the primary osteotomy, two had a concurrent soft tissue release. To correct the forefoot adduction,18 underwent had a concurrent anterior calcaneal osteotomy (Litchblau or Evans). In three patients, a distal tibial osteotomy was needed to complete the correction. Results: There were 10 males and 10 females. All the cases except one who failed to return were seen in follow-up. At follow-up all the patients had a plantigrade foot. In some of the cases the primary longitudinal osteotomy provided an incomplete correction. In these cases an adequate correction was achieved with either a repeat longitudinal osteotomy or decancellation of the talus. An anterior closing wedge osteotomy of the distal tibial metaphysis was needed in three cases to correct the residual equinus. Conclusions: Talus longitudinal osteotomy does correct the varus of a hind foot and is a good alternative for clubfoot children older than 3 years old that can’t have a triple arthrodesis. Signiﬁcance: 1. 2.

The longitudinal osteotomy talus is good procedure to obtain a functional plantigrade foot following a failed primary soft tissue release. In there is a recurrence, the osteotomy of the talus can be repeated,

S117 3.

To prevent any recurrences, it is important that al the muscle forces be balanced.

296 An alternative orthosis to prevent relapse of the Clubfoot Deformity after correction with the Ponseti Method Author: Timur Yildirim (Turkey) Co-Authors: Aysegul Bursali (Turkey), Sukru Gursu (Turkey), Bahattin Aydin (Turkey), Semih Ayanoglu (Turkey) Purpose: It’s essential to use an abduction orthosis after clubfoot correction with the Ponseti method. The Dennis-Brown bar is the most commonly used device for this purpose. However in some cases it’s not possible to use this bar. In this study we aimed to present an alternative device to be used in cases where DennisBrown bar is not suitable. Methods: Among our 167 patients with clubfoot deformity, all of whom were treated with the Ponseti method, 14 (8.3%) were not suitable candidates for using the Dennis-Brown device because of non-compliance. 12 of these patients were male, 2 were female with a mean age of 4,5 months at presentation (between 11 days and 14 months). 6 of these patients had bilateral clubfeet and 8 had unilateral (20 clubfeet). Mean period of follow up was 17 months (6–47 months). 8 patients had previous history of treatments other then the Ponseti method. The number of the casts used for the correction of the deformity was in average 5.3. 10 of the patients underwent percutaneus achilles tenotomy under local anesthesia. The device we used is originally designed for correcting metatarsus adductus deformity. It’s made up of 2 pieces and has a calcaneal support, which is our modiﬁcation, attached to it. It provides external rotation of the knees and the feet are kept in abduction. Results: The device is used for 14 patients. 10 patients were given this device because they couldn’t tolerate using the Dennis-Brown bar. 2 had very fat feet so that they could not wear shoes. 1 of them was very small (11 days old at presentation) and ﬁtting shoes could not be made for his feet. The last child to use this device had a rudimentary left leg and a right clubfoot. Non of the families reported non-compliance with this device. Complications such as contractures, decrease in the range of motion in any joints depending on the device were not seen. No patient has recurrent deformity up to date. Conclusions: Bracing after correction of clubfoot deformity with the Ponseti method is a necessity. But as explained in some cases this might be a problem because of the non-compliance with the DennisBrown bar. In such cases this device could be used successfuly. Signiﬁcance: Clinical Study.

Trauma - Upper limb 297 The advantages of posterior approach for paediatric supracondylar humerus fractures: easy reduction, short operation time Author: Ismail Demirkale (Turkey) Co-Authors: Mahmut Ugurlu (Turkey), Osman Tecimel (Turkey), Metin Dogan (Turkey), Tughan Kalkan (Turkey), Murat Bozkurt (Turkey), Nihat Tosun (Turkey)

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S118 Purpose: Nearly 60% of all elbow fractures at the paediatric age is supracondylar humerus fractures. Susceptibility to the trauma increases because of the decreasing thickness of osseous structure at the anterior-posterior plane between 5–8 years of age. In this study we discussed the importance of posterior approach fort the reduction and ﬁxation of the fractures. Methods: We assessed the comparison of lateral and posterior approaches that were established to 32 extension type Gartland type 3 supracondylar humerus fractures between November 2005 – August 2006. Posterior and lateral approaches were applied to 16 patients per group. After removal of the pins, elbow range of motion at the ﬁrst and second months and the extension strength at the posterior approach group were examined. Results: No difference was found between the posterior and lateral group for the extension strength and elbow range of motion at the end of second month. Also we evaluated the usage of posterior approach and the operation times. Mean operation time was shorter and reduction was easier in the posterior group. Conclusions: Posterior approach towards the lateral one used for the treatment of paediatric age supracondylar humerus fractures doesn’t cause secondary loss of neither ROM nor extension strength. However this exposure has an advantage of easy reduction and shorter operation time. Signiﬁcance: The reduction is easier and more visible by posterior approach at paediatric supracondylar humerus fractures.

298 Post-traumatic wrist epiphysiodesis Author: Alain Dimeglio (France) Co-Authors: Djamel Louahem (France), Joseph Habanbo (Lebanon) Purpose: Distal radial growth arrest is related to many factors, including the severity of trauma, degree of displacement, repeated and delayed manipulation, and repeated drilling.With radial physeal closure and ulnar overgrowth, a wrist deformity may appear. The purpose of this study was to evaluate the consequence of wrist physeal fractures and the results of correction osteotomies. Methods: this is s retrospective study on 10700 fractures between the years 1994 and 2005.the average age was 12.6 years. 610 patients had physeal fractures of the distal radius. Eight cases were complicated by epiphysiodesis (6 closed radial Salter II fractures, 1 closed Salter III fracture and 1 open Salter I fracture). Four patients were treated with open-wedge osteotomy of the distal radius associated with ulnar shortening, two patients had ulnar shortening, one patient had ulnar shortening with epiphysiodesis of the distal end of the ulna, and one epiphysiodesis of the of the distal end of the ulna.The mean follow-up was 3.2 years. Results: Growth arrest of the distal radius occurred only in 1.31% of cases. Diagnosis was made about 1.7 years after injury. The average radio-ulnar index was +10 mm. 50% of results were good, 37% were excellent and 13% unsatisfactory. The average R.O.M (palmar ﬂexion and dorsiﬂexion) was 116. All of our patients had a good cosmetic appearance of the wrist after the surgical treatment. Conclusions: Post-traumatic disorders of growth plates can affect the biomechanics of the wrist. However, the risk of epiphysiodesis is not high, it was 1.31% in our experience. Children with physeal fractures of the wrist should be radiographed every 3–6 months

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Poster presentations: Abstracts 124–322/J Child Orthop for signs of a bony bridge. CT scan and MRI are helpful to describe the site and the extent of the lesion. Treatment of a growth arrest of the distal radius may require an epiphyseodesis of the distal ulna if signiﬁcant malalignement of the distal radial joint surface has occurred, ulnar shortening may be added if the remaining growth is important. Signiﬁcance: this is a retrospective study conducted at our institution. 299 A Novel Innovative Technique of pin passage and construct in the treatment of Gartland’s extension type 3 Supracondylar Fracture Humerus in Children Author: Nanjundappa Somasekhar Harshavardhana (United Kingdom) Co-Authors: Samir Pilankar (India), Anil Karkhanis (India), Nilesh Patil (India), Vaibhav Bagaria (India), Vikram Sapre (India), Manish Lambat (India), Ravi Bharadwaj (India), Ajay Sahu (India) Purpose: Elimination of Iatrogenic Ulnar N palsy by our new innovative method. Methods: We conducted a prospective study (19 cases) of Gartland’s extension type 3 supracondylar humerus fractures. Good reduction was achieved with closed reduction in 16 while open reduction was required in 3 cases. Our new technique involved passing two 1.6 mm smooth Kirschner wires superiorly from the lateral condyle at an angle of 30 degrees to the humeral axis across the fracture site to obtain purchase in the medial cortex. A 3rd K wire was passed from the lateral supracondylar pillar proximal to the fracture site in a downward direction to gain purchase in the subchondral bone of the medial condyle under image intensiﬁer. Care was taken not to breach the subchondral bone so as to avoid ulnar nerve injury. Reduction and position of the wires was once again conﬁrmed and stability was checked by rotation in real time imaging. Average age of study population was 7.1 years. On an average surgery was undertaken within 25 hours of sustaining fracture. The timing of K wire removal was 3 weeks post operatively in closed pinning and 5 weeks following open reduction. All the patients were operated under GA in supine. Lateral approach was employed by the same pin construct in cases which required open reduction. We favor lateral approach as it is through intermuscular planes, avoid postoperative stiffness and need to change the patient position. Above elbow plaster splint was applied for a period of 3 weeks, at the end of which active assisted mobilization was started. Post-operatively these patients were examined on 5th day, 3rd & 6th weeks and at 3 months for assessment of nerve injury, stiffness, deformity, elbow range of motion. Wires were removed on the appearance of callus radiologically (3 weeks for closed pinning and 5 weeks for open pinning). Results: Patients were assessed on the basis of Flynn’s stringent criteria. Flynn’s criteria takes into consideration both the factors i.e. loss of carrying angle and range of motion. 16 cases had excellent results while 3 patients had good results. None of the cases had fair or poor outcome. Patients were followed for a mean of 11 weeks. None of them had any post-operative nerve palsy, pin tract infection or loss of reduction, cubitus varus or hyperextension deformity. Conclusions: Various studies state the risk of ulnar neuropraxia to be 3% to 5% by medial percutaneous pin passage. To avoid this iatrogenic ulnar nerve palsy, lateral pin constructs have been used at the cost of compromising fracture stability. Our new innovative

Poster presentations: Abstracts 124–322/J Child Orthop technique represents a good option providing the biomechanical advantages of cross wiring and eliminating the risk of iatrogenic ulnar nerve paresis. Signiﬁcance: We recommend our new innovative technique as a sound & safe option for the treatment of type 3 displaced supracondylar humeral fractures. 300 Fracture Dislocation of the Distal Humeral Physis in the Newborn Sustained at Delivery Author: F. Stig Jacobsen (United States) Co-Authors: Goran Hansson (Sweden), Johan Nathorst-Westfelt (Sweden), Mats Jonsson (Sweden) Purpose: Fracture dislocation of the distal humeral physis is a rare fracture usually seen after birth trauma or child abuse. The fracture is often over-looked. Its treatment is controversial going from closed reduction to open reduction and pinning and can cause varus deformity in up to one-third of the cases. The purpose of this study is to deﬁne the complication and treatment in the fracture sustained after birth injury. Methods: Six patients presented with severely displaced distal humeral fractures after difﬁcult deliveries, which is the largest series published. Only three out of six were referred with the correct diagnosis. Further, MRI, ultrasound and arthrogram were done in ﬁve of the six patients. Three patients presented late and were casted in ﬂexion and pronation while the other three had closed reduction and casting without pinning. Results: At followup (1–10 years) all patients had a normal range of motion and ﬁve of the six had a normal carrying angle. One patient with only one year followup had 10 degrees of varus deformity. Conclusions: Closed reduction and casting seem to be sufﬁcient treatment, even in fractures with signiﬁcant displacement after reduction. Signiﬁcance: Guidelines for the treatment of displaced distal humeral physis fracture in the newborn vary in the literature. We did not ﬁnd any indication for open treatment or pinning of this fracture. 301 Iatrogenic ulnar nerve injuries after supracondylar humeral fractures treated with closed reduction and percutaneous pinning Author: O¨nder Kalenderer (Turkey) Co-Authors: Levent Surer (Turkey), Ali Reisoglu (Turkey), Haluk Agus (Turkey) Purpose: The purpose of this study was to assess the iatrogenic ulnar nerve injuries after supracondylar humeral fractures treated with closed reduction and percutaneous pinning in the largest series published. Methods: The series consisted of 473 children with supracondylar humeral fractures. There were 371 patients at Gartland type III fractures, the remaining 102 had type II. All patients were treated closed reduction and percutaneous pinning. Neurological examination performed immediately after the operation revealed 25 ulnar nerve injuries (5.2%) in patients who had completely normal neurological ﬁndings in the preoperative period. Electromyographic examinations were performed at 6 and 12 weeks postoperatively in patient with ulnar nerve lesions. Presence of ulnar nerve palsy did not affect the postoperative regimen at the pins

S119 were removed when the solid union was observed in plain radiograms, that was 4–6 weeks as in patients without nerve lesions. Results: All but three of the 25 were followed up. The mean age was 6 years (4–8). The mean hospitalization time was 2 days and the mean follow-up time was 30.8 months (17–63). All patients with electromyogram showed partial denervation and conduction blocks at the elbow in 6 weeks. Regenerative electromyogram ﬁndings were determined in 12 weeks. Sensorial function of all patients had return average 2 months (1–4) while motor function had return average 5.4 months (1–7). All patients had complete return of nerve function and full motion in their elbows. Conclusions: We observed ulnar nerve paralysis in 25 of 473 cases, that means a 5.2 % rate of injury and that is comparable with most of the series in the literature. Ulnar nerve injury following percutaneous ﬁxation of supracondylar humeral fractures seems to be the major complication. But all iatrogenic ulnar nerve injuries were resolved spontaneously by time and closed reduction and percutaneous ﬁxation is a safe and reliable methods in these fractures. Signiﬁcance: Iatrogenic ulnar nerve injuries is the most important complication in supracondylar humerus fractures treated with closed reduction and percutaneous pinning and this problem was resolved spontaneously.

302 Metacarpophalangeal joint dislocation of the thumb in children Author: Rajan Maheshwari (United Kingdom) Co-Authors: Himanshu Sharma (United Kingdom), Roderick Duncan (United Kingdom) Purpose: The thumb metacarpophalangeal (MCP) joint dislocations in children are uncommon injuries and scarcely reported in the English literature. The aim of this study was to report the demographics, clinical course and outcome of a large series of traumatic dislocations of the thumb MCP joints in children and to correlate the radiological pattern with the type of dislocation. Methods: We retrospectively reviewed a cohort of 37 children treated during a ﬁfteen year period. Details were obtained from departmental database, case notes and radiographs. The mean follow up was 6 weeks. Results: The mean age at injury was 7.3 years. 33 out of 37 underwent closed reduction (a third under a GA ). 4 patients needed open reduction. All patients undergoing open reduction had 1 to 4 unsuccessful closed reduction attempts. 2 of the 4 open reductions revealed soft tissue interposition. All gained a good result. There was no infection, recurrent dislocation or gross stiffness. Conclusions: Thumb MCP dislocations in children are mostly dorsal (97.2%) and majority of them are managed non operatively, with excellent outcome. Irreducible dislocations may need open reduction due to volar plate and other soft tissue interposition. The so called ‘simple complete’ dislocations may present with the classical radiological ﬁnding of the joint at 90 degrees dorsal angulation but may require open reduction and may actually be ‘complex complete’ injuries. Signiﬁcance: The signiﬁcance of this study, which is to report the largest series, to our knowledge, of the metacarpophalangeal joint dislocation of the thumb in children is to understand that the radiological presentation of these injuries does not always follow the traditional classiﬁcation system and the surgeon must bear that in mind while reducing these dislocations by closed or open techniques.

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S120 303 Lateral humeral condyle fractures in children: a comparative cohort study of screws versus k-wires Author: Rajan Maheshwari (United Kingdom) Co-Authors: Himanshu Sharma (United Kingdom), Neil Wilson (United Kingdom) Purpose: There remains little evidence in literature to discern whether K-wires or screws have different outcomes in the management of lateral condylar mass (LCM) fractures in children. We present a large series of 77 displaced (Jacob types II and III) fractures of the lateral humeral condyle in 77 children in order to infer the relative beneﬁt of one mode of ﬁxation over another. Methods: Between 1990 and 2005, we identiﬁed 77 children with Lateral Condyle fractures in the departmental database who underwent operative management. Information was collected from theatre-charts, casenotes and radiographs. We analysed demographic data, fracture features, treatment modalities, complications, and clinical and radiographic results. We excluded all complex LCM associated with elbow dislocations, olecranon fractures and bi-condylar fractures. The mean follow-up was 5.3 months (range, 6 weeks to 3 years). Results: We reviewed the results of screw osteosynthesis (n = 44) versus K-wire (incl.cross wires or 2 lateral wires, n = 33) at an average age of 5.3 years (range, 8 months to 10.9 years). There were 49 boys and 28 girls. The average interval between the injury and the operation was 1.6 days (injury-surgery interval). The mean duration of implant removal was 3.6 weeks for K-wires (removed without anaesthesia) and 20.7 weeks for screws (removed under general anaesthesia). There was no non-union in this series. Superﬁcial wound infection (all K-wires) was found in three patients, which completely settled with oral antibiotic therapy. No infection was found with screw ﬁxation. There was one delayed union in each group. One patient had cubitus varus(mild degree) in each group and an additional cubitus valgus in one(screw), which required a corrective osteotomy. Loss of range of motion of 10–50 (mean 22 degrees.) degrees was found in 6 cases (3 in each group). Conclusions: Based on our observations, we believe that K-wire ﬁxation has comparatively similar ﬁnal outcome to screw ﬁxation. Screw necessitates a second procedure for removal under General anaesthetic, while K-wires are removed in the pin clinic but K-wires have increased risk of superﬁcial infection. Signiﬁcance: In our study we have found no signiﬁcant difference in the ﬁnal outcome of the screw versus K-wire technique of ﬁxation of lateral condyle fractures in children. 304 Neonatal brachial plexus palsy - incidence and risk factor analysis from United States national databases Author: Charles Mehlman (United States) Co-Authors: Susan Foad (United States), Jun Ying (United States), Linda Michaud (United States) Purpose: The purpose of this study was to analyze a large national pediatric database regarding the incidence of neonatal brachial plexus palsy (NBPP) as well as its potential risk factors. Methods: The 1997, 2000, and 2003 Health Care Utilization Project (HCUP) databases were analyzed relative to NBPP (ICD9 767.6). Weighted estimates and multivariate logistic regression models were used to assess incidence and risk factor relationships. Data were derived and reported via combining all three databases, accounting for discharge data on over 2 ¼ million children.

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Poster presentations: Abstracts 124–322/J Child Orthop Results: An overall incidence of 1.5 cases (1.51 +/– 0.02) per 1,000 live births was noted. Multivariate analysis revealed that several demographic factors to be signiﬁcantly (p < 0.001) associated with an increased risk of NBPP including race / ethnicity of AfricanAmerican or Hispanic, delivery at a teaching hospital, and female sex. Asian race/ethnicity was found to be signiﬁcantly (p < 0.001) associated with a lower risk of NBPP. Clinical factors signiﬁcantly (p < 0.001) associated with an increased risk of NBPP included assisted delivery (e.g. forceps), shoulder dystocia, macrosomia (> 4.5 g), and neonates with major complications. Conclusions: T7he incidence of NBPP in the United States is 1.5 per 1,000 and reliable pre-delivery predictors of NBPP need to be developed. Signiﬁcance: The incidence on NBPP has remained remarkably stable over many decades. Our study reconﬁrms several well known clinical risk factors and introduces some new demographic ones (race, sex, hospital type). None of the clinical risk factors can be reliably identiﬁed prior to delivery. 305 Active mobilization programme after ﬂexor tendon repair in children and adolescents Author: Aarno Nietosvaara (Finland) Co-Authors: Nina Lindfors (Finland), (Finland), Sanna Rautakorpi (Finland)

Nadja

Ristaniemi

Purpose Hypothesis: active motion programme after multistrand ﬂexor tendon repair in children results in good ﬁnal outcome. Methods: 25 ﬂexor tendon lacerations involving 17 ﬁngers in 10 consecutive children (7–14 years of age) were repaired. Repair was performed with pull-out sutures in two zone 1 injuries. In eight zone 2, two zone 3 and eleven zone 5 tendon injuries a four- or sixstrand core suture was used. A thermoplastic splint was applied 1– 3 days post-operatively for 6 weeks. Active exercises were performed four times a day without the splint. An ergo therapist followed up all patients at 1, 3, 5 and 7 weeks. Range of motion (ROM) of the wrist and ﬁnger joints as well as grip strength were recorded at a mean 38 months (12–53) after the injury. Results: There were no infections nor failures of the tendon repairs. Mean ROM of the DIP-joint (60, range 40–90) after zone 2 injuries was lower compared to injuries outside zone 2 (82, range 65–90). ROM of PIP-, MP- and wrist joints were restored to normal. Functional outcome was good or excellent in all ﬁngers using ASSH (5/17 excellent), Buck-Gramcko (13/17 excellent), and revised Strickland (16/17 excellent) evaluation systems. Mean grip strength ratio of the injured vs. uninjured hand was 1 (0.9–1.2). Conclusions: Active mobilization programme is an effective, simple, patient- and therapist friendly technique for mobilization after multistrand ﬂexor tendon repair at all levels in children over 6 years of age. Signiﬁcance: Flexor tendon injuries in school age children can be reliably treated with a simple active mobilization programme with good functional outcome. 306 Forearm Fascial Strip for Repair of the Annular Ligament for Late Diagnosis and Failed Closed Reduction of Monteggia Fractures in Children Author: Curtis Alexander Robb (United Kingdom) Co-Authors: Chris Bradish (United Kingdom), Xiao-Dong Wang (China)

Poster presentations: Abstracts 124–322/J Child Orthop Purpose: To report the use of forearm fascial strip for repairing the annular ligament in the treatment of late diagnosed and irreducible Monteggia fracture. Methods: Nineteen patients with Monteggia fractures of Bado Type I and Type II were treated with a technique using forearm fascia. 1 Approach; we adopted the Boyd’s approach to expose the proximal forearm fascia. 2 The width of the fascial strip is 1.5 cm and length of 6–7 cm, determined precisely following opening the lateral capsule of the joint. 3 The proximal fascia retains its attachment to the ulna. 4 The radial head is dislocated and then the strip is wound around the neck of the radius and the radial head reduced. Forearm rotation is checked to determine there is no tissue blocking the radioulnar joint. The strip is sutured to the residual annular ligament in the proximal ulna after correction of any ulna deformity. Once the ulna is stabilized, the stability of the radial head is assessed using intra-operative ﬂuoroscopy 5. Management of the deformity of the ulna: (not normally required with a fresh fracture) with late diagnosis, ulna lengthening of approximately 0.5 cm and stabilization with 4 or 5 hole semitubular AO plate. 6 Six weeks in a posterior long arm splint with the elbow immobilized in 90 of ﬂexion and full supination for Types I, Type II are splinted in the same manner in 70 ﬂexion to prevent radial head subluxation. Results: Stability of the radial head was achieved in all cases. According to the Anderson classiﬁcation the ﬁnal outcome was Excellent (less than 10 loss of elbow and wrist ﬂexion/extension) in ten cases (fresh fractures: six; late diagnosis: four); Satisfactory (less than 20 loss of elbow or wrist ﬂexion/extension, less than 50% loss of forearm rotation) in eight cases (fresh fractures: two; late diagnosis: six); Unsatisfactory (more than 30 loss of elbow or wrist ﬂexion/extension, greater than 50% loss of forearm rotation) in one late diagnosed patient associated radioulnar synostosis after recovery of compartment syndrome. There were no failures. Two radiocapitellar K-wires broke while in plaster in the initial period using this technique, subsequently the use of a K wire was abandoned. Conclusions: The length of the incision is less than that required for the Bell Tawse (triceps tendon) technique and permits a tourniquet on the upper arm. It is crucial to use an image intensiﬁer to verify anatomic fracture reduction and reduction of the radiohumeroulnar joint. Poorer results were achieved with delay in diagnosis beyond 6 months. From our clinical experience however it is still worthwhile reducing the radial head to prevent future problems with growth. Signiﬁcance: We have found this technique to be reliable for stabilizing the proximal radioulnar joint but patients must be warned of potential reduction of forearm rotation. 307 The use of nerve stimulation during percutaneous pinning of supracondylar fractures in children. Author: Haim Shtarker (Israel) Co-Authors: Gershon Volpin (Israel), Oleg Popov (Israel), Riad Dakwar (Israel) Purpose: Injury to the ulnar nerve from the medial pin is the major concern during percutaneous pinning for supracondylar fractures. The incidence is estimated to be 2% to 3%. Fixation of supracondylar fractures by 2 lateral pins doesn’t provide enough stability and sometime may not prevent secondary displacement of the fracture fragments especially rotation. Soft tissue edema or excessive mobility of ulnar nerve may be predisposing factors for iatrogenic ulnar nerve injury.

S121 Methods: During last three years 81 children with supracondylar fractures were operated in our department. Before use of nerve stimulator, we avoided applying medial pins especially in cases with swelling around the elbow. In all cases we used nerve stimulator permanently connected to pin during all time of wire insertion. In order to produce permanent monitoring of ulnar nerve during ﬁxation, changes in setting of stimulator were made. There were 67 children with extension type of supracondylar fracture and 14 with ﬂexion type. Average age of the patients was 5.3 years (range 3–9 years). Four of 81 fractures were open supracondylar fractures. Closed reduction and percutaneous KW ﬁxation by 2 or 3 pins were performed. The pin mounting was: 1 medial and 1 lateral pins or 1 medial and 2 lateral pins. In 77 cases of irritation of ulnar nerve, clear muscular contractions were observed and place of pin insertion was carefully established. I two children irritation of nerve was not found and exploration was necessary. One child had radial nerve neuropraxy in addition to ulnar palsy. In this case closed reduction with KW ﬁxationwas performed and during 4 months the neuropraxy recovered without additional interventions. In one case brachial artery was disrupted. The child underwent open reduction, vascular repair and nerve exploration. Results: In all cases anatomic reduction was achieved. No cases of nerve or vascular injury were observed in cases with clear nerve irritation (77/81). No cases of secondary fracture displacement were noted. All fractures healed in desirable position. In 4 cases malalignment due to partial growth arrest was observed in follow up. Conclusions: Changes in original setting of standard anesthesiology nerve stimulator may be performed easy in each hospital. Use of this device is very simple, even in cases of emergency. Signiﬁcance: The monitoring of ulnar nerve by nerve stimulator is reliable and makes insertion of wires secure. 308 Comparison of intramedullary nailing to plating for forearm fractures in children ages 10–16 years. Author: Roger Fanklin Widmann (United States) Co-Authors: Daniel Green, MD (United States), Keith Reinhardt, BS (United States), David Feldman, MD (United States), David Scher, MD (United States) Purpose: To compare radiographic and functional outcomes of intramedullary nailing versus plating of forearm fractures in children between 10 and 16 years of age. Methods: 31 patients who underwent operative ﬁxation of midshaft radius and ulna fractures were divided into nailing and plating groups, and compared retrospectively according to perioperative data and outcome measures (union at 3 and 6 months, loss of forearm rotation, restoration of radial bow magnitude and location, and complications). Results: The nailing group had 19 patients, mean age 12.5 years (range 10–14.6), and the plating group had 12, mean age 14.5 years (range 11.9–16). Groups were similar for gender, arm injured, fracture location, AO/OTA classiﬁcation, and number of open fractures. Duration of surgery and tourniquet use were signiﬁcantly shorter in the nailing group. No differences were found between the groups for union at 3 or 6 months. At latest follow-up, radial bow magnitude was similar for the two groups and restored to normal in both. Radial bow location in the nailing group was signiﬁcantly different than reported normal values (p = 0.007). Despite this, there was no difference in forearm rotation between groups. Complication rates were also similar between groups.

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S122 Conclusions: There were no signiﬁcant differences between groups for healing or magnitude of radial bow. There was a difference in location of maximal radial bow, with no effect on forearm rotation. Based on similar functional and radiographic outcomes with nailing and plating, the operative technique in children 10 to 16 years old can be chosen based upon fracture characteristics and surgeon preference. Signiﬁcance: This study suggests that there is no objective evidence supporting either operative method, when comparing nailing to plating. Decisions regarding operative ﬁxation can be made based on surgeon preference.

Trauma - Lower limb 309 Shortening after elastic intramedullary nailing of femoral fractures. Clinical study of a locking system with end caps. Author: Jean-Michel Clavert (France) Co-Authors: Theddy Slongo (Switzerland), James Hunter (United Kingdom), Richard Reynolds (United States), Wolfgang Schlickewei (Germany) Purpose: Shortening after elastic intramedullary nailing of femoral fractures is a rare but recognised complication when treating unstable fractures. Shortening can be of several centimetres and needs a change in the technique of osteosynthesis (external ﬁxation). Several methods of locking the elastic nails were biomechanically studied and ﬁnally it was the use of a threaded cap over the end of the nail that gave a sufﬁcient mechanical stability and the most convenient implantation technique. End caps avoid also the usual conﬂict between the rough cut nail and the skin. Methods: After a standard elastic nailing of a femoral shaft fracture, nails are implanted as high as possible to have a good cortical contact . Nails are cut and the bevelled hollow tamp is used, such that 8 to 10 mm protrude to ﬁt the internal dimensions of the end cap. The diameter of the holes in the distal metaphysis of the femur is not crucial because the nails make ﬁrm contact with the distal part of the hole and the locking effect is obtained mostly by the thread of the end cap on this part of the hole. The threaded end cap is implanted over each nail end using a custom driver. The purposes of the locking system are to maintain femoral length during healing, to protect the soft tissues, but not to allow immediate total weight bearing. An international multicentre study of the locking system is in progess and we are reporting the ﬁrst twenty ﬁve cases. Results: 25 femoral shaft fractures were treated by elastic intramedullary nailing and end caps.The stable cases were studied for ease of implantation, skin tolerance, healing index, and retrieval and the instable cases also for shortening. All fractures healed in a standard time. The locking end caps prevent compression at the fracture site, but did not lead to a pseudarthrosis or a delayed callus. We had no shortening and no end cap migration. An adolescent did not follow the partial bearing recommendations and walked without crutches from the fourth day without telescoping an unstable complex fracture. We recorded no skin problems. No problem was noticed during implant removal. Conclusions: The ﬁrst twenty ﬁve clinical cases of using a locking system by end caps for elastic intramedullary nailing of femoral shaft fractures showed no problems with fracture healing, shortening of unstable fractures and no skin problems. Signiﬁcance: End caps for elastic nailing may avoiding shortening of unstable fractures and skin problems related to the cut ends.

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Poster presentations: Abstracts 124–322/J Child Orthop 310 Initial Results of the Treatment of Femoral Shaft Fractures in Children Using the Trigen Trochanteric Antegrade Nail Author: Susan Haralabatos (United States) Co-Authors: Zhanna Sikorski (United States) Purpose: The Trigen trochanteric antegrade femoral nail has been designed for the treatment of femoral shaft fractures in the pediatric population. The purpose of this study to to report initial results of the treatment of pediatric femoral shaft fractures using this device. Methods: Results of twenty femur fractures in nineteen patients treated with the Trigen trochanteric antegrade nail treated over a six year period were reviewed. All patients had ﬁxation of the femoral fracture using a locked 8.5 mm Trigen TAN nail. All patients were followed clinically and radiographically. The femoral nail has been removed in ten of the patients. Length of follow-up was from one month to four years 2 months. Results: Seventeen of the nineteen patients were boys. One patient had bilateral fractures. The average age at the time of injury was 13 years 10 months (9 years 10 months - 17 years 6 months). Mechanism of injury was sports related in six, automobile passenger eight, and ﬁve patients who collided with a motor vehicle. Nine of the patients sustained other injuries, predominantly fractures and head injuries. Four of the fractures required open reduction. Patients who went home were discharged an average of 3.5 days after surgery (2–6 days). Two patients with other signiﬁcant head injury were lost to follow-up after transfer to rehabilitation centers, and three patients (four fractures) were excluded from analysis as their follow-up was less than six months. Patients demonstrated full range of motion of the hip and knee four to six weeks post-operatively, and were able to fully bear weight by eight weeks depending on the fracture pattern and other injuries. Patients were allowed to return to all activities within four months of surgery. Ten patients have had removal of the femoral nail an average of twelve months after injury (6–22 months). Average length of follow up is twenty-two months since injury (5 months – 4 years 2 months). Complications included hypertrophic scar in three patients and painful distal interlocking screw that required removal in one patient. No patient demonstrated clinically signiﬁcant limb length inequality, rotational malalignment, or avascular necrosis of the femoral head. Conclusions: Static, locked intramedullary nailing using the Trigen trochanteric antegrade nail can be performed in the pre-teens as well as teenagers. Preliminary results show that this technique is effective in allowing healing and early return of function with minimal morbidity. Signiﬁcance: Early results with the Trigen TAN nail are promising. Continued experience and long-term follow-up will determine if intramedullary ﬁxation of femur fractures becomes the treatment of choice in the pediatric age group.

311 Fractures of the base of the ﬁfth metatarsal in children Author: Jose A Herrera-Soto (United States) Co-Authors: Michael Scherb (United States), Michael Duffy (United States), Jay Albright (United States) Purpose: Fractures of the ﬁfth metatarsal are the most common metatarsal fractures in children. Their treatment is based on adult

Poster presentations: Abstracts 124–322/J Child Orthop literature. The purpose of our study was to identify the different types of ﬁfth metatarsal fractures, determine the mean time to healing and to examine whether current adult recommendations can be extrapolated to children and adolescents. Methods: 90 fractures of the 5th metatarsal were identiﬁed in 88 patients (45 males and 43 females), mean age of 12.7 years. Results: All 30 apophyseal injuries did well with 3–6 weeks of short-leg walking cast. Thirty-three patients presented with nondisplaced intraarticular fractures, most treated with a walking cast. The healing time for the non-displaced group was 37 days. The average length of treatment for 12 displaced fractures was 58 days. This difference in healing time was statistically signiﬁcant (p = 0.009). Treatment for 15 ‘‘Jones fracture’’ was walking cast for four weeks in eight patients, non-weight bearing cast for six weeks in ﬁve, immediate intramedullary ﬁxation in two. The average length of treatment from the day of injury to the day of fracture healing was 12.1 weeks. Three patients of the NWB group presented with refractures within 3–10 weeks of cast removal. All refractures underwent intramedullary ﬁxation with a cannulated lagged screw. Conclusions: Fractures of the 5th metatarsal in the pediatric population do well clinically after a course of casting, unless the fracture occurs in a speciﬁc anatomic area, necessitating nonweight bearing casting or surgery. Displaced intraarticular fractures respond better to non-weight bearing casting. ‘‘Jones fractures’’ may warrant intramedullary ﬁxation to get patients back quickly to regular activities, avoid delays in healing and prevent refracture. Signiﬁcance: Most of the pediatric injuries to the 5th metatarsal fractures behave similarly to those found in adults. Internal ﬁxation in ‘‘Jones fractures’’ may be warranted. 312 Biomechanical investigations into improving the stability of elastic nails with screw-in end caps Author: James Bowman Hunter (United Kingdom) Co-Authors: Theddy Slongo (Switzerland), Karsten Schwieger (Switzerland), M Windolf (Switzerland), Peter Steiger (Switzerland), Romano Matthys (Switzerland), B Linke (Switzerland), Jean-Michel Clavert (France), Richard Reynolds (United States) Purpose: Recent presentations and publications have highlighted the problem of the stability of elastic nails in unstable fractures and in older, heavier children and adolescents. Additionally the problem of skin irritation at insertion sites is well known. We present the results of our biomechanical studies of a design of endcap designed to address these difﬁculties. Methods: Experiment 1. Two sets of paired human femora were tested. Elastic nails were inserted in a retrograde fashion, cut as usual and end caps screwed over the nail end. The proximal portions were mounted in acrylic cement to prevent proximal migration of the elastic nails. A 45 degree, 1.5 cm segment was removed from the mid diaphysis of the femora to simulate an unstable fracture. The prepared femora were mounted in a mechanical testing apparatus that recorded force and displacement as a steady load, and acquired data on displacement at 10 Hz. Paired T-test was used for statistical analysis. Experiment 2. 15 plastic models of a paediatric femur were similarly tested to see if the angle of end cap insertion altered the push-out force required to dislodge them. End caps were inserted at 45, 55 and 65 degrees to the long axis of the femur, and the construct submitted to the same loading. The Kruskal-Wallis test was used to test for difference between angulations. Results: Push out force was increased up to six-fold by the addition of end caps to the cadaveric femora. The force at failure was

S123 between 0 and 250 Newton without end caps, and between 580 and 1200 Newton with end caps.(p = 0.007) Push out force was not affected by the angle of end cap insertion in model paediatric femora. The maximum force to failure was between 1500 and 2000 Newton for all three angles (p = 0.613). Conclusions: End caps signiﬁcantly increase the load to failure of elastic nails in cadaveric femora. The angle of insertion of the end caps does not affect the load to failure in the model paediatric femur. Signiﬁcance: The biomechanical data suggest that end caps can signiﬁcantly enhance the stability of elastic nails. A clinical study has been started to conﬁrm that these results translate into practice. 313 Paediatric Femoral Shaft Fractures: A Conservative Asian Perspective. Author: Arjandas Mahadev (Singapore) Co-Authors: Y Lee (Singapore), B Lim (Singapore), E Lee (Singapore) Purpose: This study sets out to ascertain the clinic outcome and cost effectiveness of the treatment of pediatric femoral shaft fractures in a largely Asian population like ours. It also sets out to determine if there is a need to follow the shift towards more surgical methods in order to shorten the hospital inpatient stay and cost as well as to avoid the discomfort of wearing the hip spica. Increased complications of the more conservative hip spica, especially in older Caucasian adolescents, is another reason cited for this shift. Methods: We retrospectively reviewed case notes and Xrays to determine the outcomes of femoral shaft fractures managed conservatively at our Children’s hospital over a ﬁfty-month period between September 1997 and December 2001 inclusive. Our series comprised of 63 children between the ages of 1 month and 15 years (mean 5.3 years), admitted with closed fractures of the femoral shaft that were treated with skin traction and subsequent hip spica. Results: We found that in our hands, there were no cases of malunion, non-union, rotational deformities and signiﬁcant limb length discrepancy on follow-up. When patients matched for age and hospital bed costs were compared, we found that treatment with ﬂexible intramedullary nailing incurred a cost more than one and a half times that of conservative treatment with traction and hip spica. This increased cost is largely due to implant costs, operating room costs and surgeon’s fees. Conclusions: In view of the fact that complications still do occur with surgical treatment and, in our case, can cost more, we advocate that skin traction followed by a hip spica in the treatment of closed femoral shaft fractures in our children, even in their adolescence, is safe, cost-effective and associated with a low complication rate. Signiﬁcance: In our largely Asian population, conservative management remains the most cost effective way to treat paediatric fractures even in adolescents with no signiﬁcant complications. This further conﬁrms the lag in bony and cartilage maturity in Asian children previously studied. 314 Knee articular fractures in teenagers (revision of 45 cases) Author: Antonia Matamalas Adrover (Spain) Co-Authors: Rosendo Ullot (Spain), L Gonza´lez-Can˜as (Spain), Santiago Cepero (Spain), A A´vila (Spain) Purpose: Studies dealing with articular knee fractures in adolescent are absent in the literature and their magnitude remains

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S124 unknown. Through a longitudinal descriptive study, their incidence in a children’s hospital will be unveiled. Methods: All 3,670 medical histories from people with fractures admitted in our centre between 1999 and 2005 were reviewed. Joint knee fractures were identiﬁed and sex, age, type of fracture, associated injuries and treatment was gathered in each case. Results: Forty-ﬁve articular knee fractures (1.2%) were identiﬁed, of them 29 were men (70.3%) and the average age was 14.8 years. The most frequent place of fracture was the proximal tibia (55.5%), followed by patella (28.8%) and distal femur (15.5%). Among the ones occurring in the proximal tibia, tibial plateau was the most frequent location (13), 7 followed by tibial spine (7), type III epiphysiolisis of the tibial tuberosity (4) and opened complex fracture (1). In the patella: 6 cross-sectional fractures, 1 longitudinal, 4 conminutes and 2 osteochondral. In the femur: 1 type III epiphysiolisis, 2 type IV epiphysiolisis, 1 fracture of condyle and 3 opened complex fractures. In 13 (31,7%) patients fractures healed with nonoperative treatment and 28 (68.3%) were ﬁxed intraoperatively. The time average of immobilization of the knee in nonoperative treatment was 6.3 weeks. 22 associated injuries were detected : 11 intra-articular (1 external meniscus injury and 9 ligamentous injuries: 6 disruptions of the anterior cruciate, 1 of the posterior cruciate, 2 of the lateral external ligament and 1 of the lateral internal one); and 11 extra-articular (6 diaphyseal femur, 3 ﬁbula and 1 tibial diaphysis fractures). In 15 (33,3%) some type of complication appeared: 11 knee stiffness (7 recovered completely with rehabilitation, 3 needed surgery and 1 mobilization under anesthesia and rehabilitation). 2 patients had a dismetry without clinical repercussion. Growth was not affected in any case. Paresis with complete recovery was found in 1 case. Formation of medial tibial exostosis appeared in 1 case. Conclusions: The knee intra-articular fractures in teenagers were unfrequent and were more frequent in men. The main mechanism was through trafﬁc accidents. More than a half required surgical treatment and the most common region was proximal tibia. The most frequent associated articular injury was disruption of anterior cruciate ligament and articular stiffness was the principal complication. Signiﬁcance: Our study provided the ﬁrst incidence of articular knee fractures in children. The rate, as well as the most common gender and mechanism were the spected ones. 315 Treatment of femoral shaft fractures in children: Comparison between intramedullary ﬂexible nails and traction followed by spica cast. Author: Fabiano Prata Nascimento (Brazil) Co-Authors: Claudio Santili (Brazil), Miguel Akkari (Brazil), Gilberto Waisberg (Brazil), Susana Braga (Brazil) Purpose: This study compares the results of the use of intramedullary nails to traction followed by spica cast. Methods: 57 children were evaluated with ages varying between ﬁve and thirteen years old, 29 treated with traction followed by spica cast and 28 with titanium ﬂexible intramedullary nails. Results: The time of hospitalization was an average of nine days for nail group and twenty for the spica group. The average time for healing was 7.6 weeks for the patients treated with the nails and 9.3 weeks for the ones treated with cast. A proportion of overgrowth with the use of nails was 64.3% e 13.8% for the cast group. Partial weight bearing was tolerated with 3.4 weeks for the nail s group and 9.6 weeks for the spica cast group. The proportion of new hospitalization for the spica group was 64.3% for the

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Poster presentations: Abstracts 124–322/J Child Orthop group that used nails and 17.2% for the group treated with cast. The period of traction and hospitalization were less in the nail group. Conclusions: The patients treated with cast presented a higher number of complications related to loss of reduction and asymmetry. The method of intramedulary nail had good results, especially about alignament and early rehabilitation. Signiﬁcance: Level III.

316 Complications, problems and femoral length after intramedullary stabilisation of femoral shaft fractures Author: Klaus Dieter Parsch (Germany) Co-Authors: Martin Schilz (Germany) Purpose: Controversial publications about problems, the rate of complications, as well as femoral overgrowth after intramedullary fracture stabilisation. Methods: Retrospective evaluation of 110 femoral shaft fractures treated from 1990 to 1998 by intramedullary ﬁxation. Problems or complications were judged from clinical notes and radiographic ﬁles. 64 children were seen in a follow-up clinic, and average of 61,5 months after surgery. Clinical and radiological outcome of the treatment and possible leg length discrepancy was evaluated. Results: Initially thick K-wires, later Nancy titanium nails of the ﬁrst and ﬁnally of the second generation were used. Mid-shaft and proximal fractures were treated by retrograde insertion of 2 elastic nails, distal fractures by 2 antegrade nails. Additional spica casts were applied during the ﬁrst 2 years. Hard-ware removal was done an average of 7,5 months after insertion. Major complication like osteomyelitis, AVN or malposition were not seen in this series. 9,1 % showed nail migration, mostly in combination with soft tissue irritation around the knee, mainly in cases with unicameral bone cysts or ﬁbrous dysplasia. An average plus of 0,50 cm was measured in femurs after intramedullary ﬁxation of the fracture . Several children with a persistent plus of more then 1 cm underwent epiphyseodesis during prepuberty. The problem of a super-obese child with > 100 kg was not encountered. Conclusions: Intramedullary titanium nails for femoral shaft fractures in children showed no serious complication in this oneunit series. There was a learning curve to avoid problems concerning soft tissue irritations around the knee joint, correct nail diameter, retrograde or antegrade pinning and the use of an additional spica cast. Signiﬁcance: No signiﬁcant relationship between age of child when sustaining a fracture, type of fracture and posttraumatic femoral length was seen. 317 Intraepiphyseal malleolar fracture of the ﬁbula or tibia Ogden type 7A or an accessory ossiﬁcation centre? The ultrasound diagnosis. Author: Tomas Pesl (Czech Republic) Co-Authors: Hana Melinova (Czech Republic), Petr Havranek (Czech Republic), Karel Cermak (Czech Republic) Purpose: Diferentiation between the distal ﬁbular or tibial epiphyseal fracture Ogden type 7A and the os subﬁbulare or subtibiale (subﬁbular or subtibial ossiﬁcation centre) in case of acute injury is necessary because of the consecutive way of

Poster presentations: Abstracts 124–322/J Child Orthop treatment. The authors try to use the ultrasound (USG) to solve this problem. Methods: Two hundred and thirty-six children with an acute injury of the ankle joint were treated in our department during the one-year period (2005). In all the plain radiographs in two standard planes were performed. In twenty-two of them the apical lesion of the distal ﬁbular or tibial epiphysis was diagnosed. The USG was performed to diferentiate the acute skeletal injury and the accessory ossiﬁcation. Results: In eight of the twenty-two injured children was veriﬁed by means of USG, that the continuity of the distal ﬁbular or tibial epiphysis was not interrupted. It indicated the diagnosis of an accessory osiﬁcation and a plain ankle joint sprain. In the rest fourteen cases the continuity of the ﬁbular or tibial malleoli was broken off. It indicated the diagnosis of the intraepiphyseal malleolar apex fracture Ogden type 7A of the tibia or ﬁbula. These ﬁngings were veriﬁed by follow up radiographs. Conclusions: The USG is safe, effective and useful method for diagnosis of the acute skeletal injury of the distal ﬁbular or tibial epiphyseal apex and/or for veriﬁing the os subﬁbulare or subtibiale. Signiﬁcance: Diferential diagnosis of the accessory ossiﬁcation versus the intraepiphyseal malleolar apex fracture Odgen type 7A of the tibia or ﬁbula represents an important clinical problem because of the dicrepancy of the plaster cast immobilisation in case of ankle joint sprain and the intraepiphyseal malleolar fracture Ogden type 7A. In children the ankle joint sprain requires only a short time plaster cast imobilisation of the ankle joint, if any because the ligaments are not affect. On the contrary the intraepiphyseal apical fracture of the distal ﬁbula or tibia Ogden type 7A should be immobilised for four to ﬁve weeks. 318 Fixation of Femoral Shaft Fractures in Children with a New Flexible Interlocking Intramedullary Nail Author: Jonathan Huw Phillips (United States) Co-Authors: Lubica Jencikova-Celerin (Canada), Werk Lloyd (United States), Stacey Wiltrout (United States) Purpose: This study examined whether ﬁxation of femoral shaft fractures in children with a new ﬂexible interlocking intramedullary nail (FIIN) would result in fewer complications, faster weight bearing, and quicker healing than standard surgical techniques (SST). Methods: Hospital, outpatient medical records and radiographs were reviewed in a retrospective cohort study among children 7 to 18 years old with femoral shaft fracture requiring open treatment. One hundred thirty-seven children met selection criteria including 59 subjects enrolled in the FIIN group and 78 among those in the SST group. There was no difference among groups based on age, gender, and fracture characteristics. Results: The most common fracture patterns recorded were transverse and comminuted with a location commonly in the second or third quarter of the femoral shaft. Average age was 11.5 years. Complications were found in 20.3 percent subjects in the FIIN group and 30.8 percent in the SST group. Trochanteric heterotopic ossiﬁcation was the most common complication 13.6 percent in the FIIN group and superﬁcial infection 12.8 percent in the SST group. Major complications including avascular necrosis, malunion, deep infection, and refracture were found in 1.7 percent of the FIIN and 11.5 percent of SST patients (p equals 0.043). Patients in the FIIN group achieved full weight bearing 34 days

S125 sooner (p equals 0.001) and healed radiographically 37.4 days sooner (p equals 0.043) than those in SST group. Conclusions: Patients treated with a ﬂexible interlocking intramedullary nail demonstrated better treatment outcomes than standard surgical techniques. Signiﬁcance: This new implant shows early promise in treatment of children’s femoral fractures. 319 Isolated Femur Fractures in Adolescents: Comparison of 4 Operative Methods Author: Leonhard Erich Ramseier (Switzerland) Co-Authors: Unni Narayanan (Canada) Purpose: To compare the results and complications of four methods of ﬁxation of isolated femur fractures in adolescents. Methods: This is a retrospective cohort study of isolated traumatic diaphyseal femur fractures in children, 11 to 18 yrs, treated from 1995–2005 at a level 1 paediatric trauma centre. Patients were characterized by age, weight, mechanism and energy of injury, fracture level, pattern, % comminution, and method of ﬁxation: elastic stable intramedullary nail(78), external ﬁxator(17), rigid IM nail(25) and plate osteosynthesis(12). We compared length of hospital stay, time to union and full range of motion, and complication rates: loss of reduction requiring reoperation, malunion (‡10 coronal &/or ‡20 sagittal), nonunion, refracture, infections, need for reoperation other than routine. Results: Mean age was 13.25 yrs(11–17.6). IM nail group was slightly older(14.5 yr). Mean weight was 48.5 kg(25 –80), similar across groups. ESIN group were mostly tranverse/oblique fractures of the middle & proximal femur with < 25% comminution; ExFix were comminuted spiral fractures of the proximal & middle femur; IM nails were proximal & mid femoral high energy fractures in older children; plates mostly distal fractures with < 25% comminution. Mean length of stay was 5 days for all groups. Mean follow-up was 12.7 months. All fractures healed, with radiographic union occurring at 9.5(ESIN), 12(ExFix), 9(IM), and 11(Plate) weeks respectively. Functional knee range of motion was recorded by 11 weeks in all groups but 24 weeks for ExFix group. Loss of reduction requiring a reoperation occurred in 2/78 ESIN and 4/17 ExFix. At ﬁnal follow-up minor malunion was noted in 4/75(ESIN), 2/ 16(ExFix), 1/25(IM) respectively, none of which were treated. 1 patient in the IM group had 2.5 cm shortening. 6 patients underwent reoperation in the ESIN group(1 non-union at 8 months, 1 late refracture due to reinjury, 2 prominent nails needing trimming/advancement, and 2 for reduction loss). 5 ExFix patients required 7 reoperations(5 for loss of reduction, 1 for replacement of an infected pin, and 1 debridement for deep infection). 1 prominent distal interlocking screw was removed. 23/75 ESIN were removed(21/23 for symptoms at nail insertion site), 3 rigid IM nails, and 2 plates(for pain) were removed. Conclusions: Treatment choice is inﬂuenced by age, fracture level, pattern and comminution. Adjusting for baseline differences, all 4 treatments had satisfactory outcomes, but are associated with speciﬁc complications. ESIN performs at least as well as other methods and most of tits complications are preventable. Signiﬁcance: No single technique is universally applicable to all adolescent femur fractures. Until evidence to the contrary is available, surgeons should be familiar with multiple techniques, the choice of which is likely to be inﬂuenced by patient and fracture characteristics and patient/family preferences.

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S126 320 Surgical treatment of nineteen anterior tibial tuberosity fracture in children. Author: Francisco Soldado Carrera (Spain) Co-Authors: Oscar Ares-Rodriguez (Spain), Roberto Seijas (Spain), Pedro Alvarez (Spain), Cesar Garcia Fontecha (Spain), Gilbert Steinbacher (Spain), Marius Aguirre Canyadell (Spain), Ramon Cugat (Spain) Purpose: The anterior tibial tuberosity is a very few frequent fracture (1 each 4 years). This fracture represents the 3% of the tibial fractures and 1% of the physeal fractures. It affects a athletics boys whose are between 14 and 17 years old. We show our experience in this kind of fractures. We use a technique with parallel screws to the proximal tibial physis. Methods: Retrospective study of the anterior tibial tuberosity avulsion-fractures in the last 10 years in Vall d’Hebron Hospital and the last 3 years in a football clinic. When the patient need surgery, we use screws or K-wire situated parallel to the tibial physis to avoid the fusion at this point. Results: You collect nineteen fractures, all of them male with mean age of 14,72 years (10–18). In 14 patients (73.7%) was affected the left side. All the fractures were closed ones. The distribution of the fractures according as Ogden classiﬁcation is: 2 IA; 2 IB, 2 IIA, 1 IIB; 6 IIIA, 6 IIIB. Three patient were treated with cast immobilization and 16 received surgery. We used screws in 80% of the patients and K-wires in 20 % of the cases. We use a cast immobilization for ﬁve weeks. Only in one case we practiced a fasciotomy. Only two patients didn’t need rehabilitation program. The ROM was full in all the cases. They began daily activities including sports after a mean of 13.71 weeks We have no compliations as infection or compartmental syndrome. During the follow-up, we did not have any case with early physeal closure and no case with genu recurvatum. 50 % of the patients need a second surgery to remove the internal ﬁxation. Conclusions: The surgery treatment is safe. The treatment has to achive four objectives, as an anatomical reduction of the articular fracture, no alteration of the physeal development, keeping the patella height and stable osteosynthesis. Our technique with parallel osteosynthesis give us an anatomical reduction, non epiﬁsiodesis full ROM. It is not necessary to remeove the material in all the cases. Signiﬁcance: III. 321 Complications in fractures of the proximal tibial metaphysis in children Author: George Tagaris (Greece) Co-Authors: George Christodoulou (Greece), George Sdougkos (Greece), Apostolos Vlachos (Greece), Alexander Vris (Greece) Purpose: This study examines the proximal tibial metaphyseal fractures in children and speciﬁcally the valgus deformity and leg overgrowth of the tibia. Methods: We examined 27 children with proximal tibial metaphyseal fractures. Among them, 11 presented with greenstick fractures, 6 with complete, 5 with hairline, 3 with torus and 2 with stress fractures. The mean age was 7 years old (1–14). The average follow up period was 9.5 years. Fifteen children were below the age of 7 while 12 were between 8–14 years old. Twenty ﬁve patients were treated conservatively and 2 surgically.

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Poster presentations: Abstracts 124–322/J Child Orthop Results: Valgus deformity occurred during the follow up period in 73% of the children aged below 7 y.o. and 17% of the older children. The higher values of valgus deformity ranged between 8–18 degrees and were observed at 10–18 months post-traumatically, especially in younger ages and after inadequate reductions. At the time of the ﬁnal follow up examination, satisfactory spontaneous correction of the deformity, inversely proportional to age was observed in all cases. The degree of ﬁnal valgus deformity ranged between 1–9 degrees. Overgrowth of the affected extremity was observed in 74% of the cases and ranged between 0, 4 and 1, 5 cm. Tibial overgrowth is not dependent to skeletal age. None of torus and stress fractures developed valgus deformity or longitudinal overgrowth. Compartment syndrome occurred in one case. Conclusions: A high tendency to valgus deformity, especially in younger ages, was observed in proximal tibial metaphyseal fractures, even among undisplaced or surgically treated ones. Approximately two years post-traumatically, the beginning of a progressive spontaneous satisfactory correction of the deformity – inversely proportional to age – was noticed. It is worth mentioning that valgus deformity up to 10 degrees and tibial overgrowth up to 1, 5 cm cause no functional or cosmetic problems. Signiﬁcance: The above observations prevent us from unnecessary surgical correction. Conservative treatment is preferred for the proximal tibial metaphyseal fractures. Operative treatment is indicated after inadequate reduction, especially in older children and after open fractures. 322 Long term results of the surgically treated displaced supracondylar humerus fractures Author: Mehmet Can U¨nlu¨ (Turkey) Co-Authors: Tuncay Centel (Turkey), Hayrettin Kesmezacar (Turkey), Egemen Ayhan (Turkey) Purpose: The primary purpose of this retrospective study was to evaluate long-term results of the completely displaced supracondylar humerus fractures that had been treated by open reduction and wire ﬁxation. Our secondary purpose was to assess the relation between the early postoperative reduction of the fracture and the radiological outcome at follow-up. Methods: The study included 49 children with displaced extension-type supracondylar fractures of humerus, all having unilateral extension-type Gartland type III fractures. Open reduction and crosswire ﬁxation with K-wires were performed in all patients. Two separate incisions (medial and lateral) were used for all the cases. Mean follow up was 18 years and 3.3 months. They were assessed using the criteria of Flynn. Baumann’s, humeroulnar and lateral angles were measured on the x-rays. Humeroulnar and lateral angles were also recorded on the radiographs made at follow-up. The lateral angle was determined by measuring the arc between the long axis of the distal humeral shaft and epicondylar ridges. Humeroulnar angle was found by measuring the angle between the lines of distal humerus and proximal ulna that intersect at the center of throchlear joint line. For statistical analysis, comparison of the radiological angles measured at early postoperative period and at the time of healing of the fracture was performed to determine any early loss of correction. Furthermore humeroulnar and lateral angles that were found soon after the surgery and at follow-up was compared if any change occurred during time. Finally radiological and clinical criteria of the injured elbows were evaluated in reference to the contralateral side.

Poster presentations: Abstracts 124–322/J Child Orthop Results: Measurement of the Baumann’s, humeroulnar and lateral angles at the time of fracture healing showed that there was no signiﬁcant loss of reduction comparing soon after the surgery. Follow-up examination revealed good or excellent functional results in 35 cases (71,4%). The humeroulnar angle measured after reduction was found to correlate well with the ﬁnal carrying angle. The Baumann’s angle was not found to correlate well with the ﬁnal carrying angle. In all of the fractures that were primarily reduced in ﬂexion in the sagittal plane, spontaneous correction occurred. Spontaneous correction could not be shown in reduction in extension. Growth distur-

S127 bance was discovered in 36,7% of the patients in the frontal plane. No growth disturbance was demonstrated in the sagittal plane. Spontaneous correction in the frontal plane could not be shown. Conclusions: Open reduction and crosswire ﬁxation with K-wires is a safe and efﬁcient treatment for displaced humerus surpracondylar fractures in children. The humeroulnar angle after reduction can be reliably used to predict accurately the ﬁnal carrying angle. Signiﬁcance: Deﬁning the humeroulnar angle as the indicator of the ﬁnal carrying angle contributes also to ﬁnal outcome.

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Author Index The numbers refer to the abstract(s) numbers(s) Aarnes G 179 Abid A 71 Abraham A 44 Abudu A 9 Acaroglu E 64 Accadbled F 208, 209 Adamec O 173, 285 Agorastidis N 176, 177 Agus H 226, 301 Ahmet A 64 Aiona M 133, 153 Ajoy P 292 Akazawa H 126 Akkari M 95, 315 Akman Y 31 Aksahin E 12 Albaugh J 194 Albisetti W 87 Albright J 311 Alexander K 4 Alka J 41 Almaiyah M 258 Almeida M 95 Alvarez P 320 Alvin H 46 Anastasopoulos J 170 Anelati G 192 Aoki K 126 Aoun N 272 Apel P 198 Apostolopoulos A 217 Ares-Rodriguez O 320 Aretaki A 170 Arkader A 8, 51 Armstrong D 212 Armstrong DA 78 Aronsson D 66 Assumpc¸a˜o R 135 Athanasian E 8 Audige´ L 232 Auner C 131 A´vila A 314 Axelrod F 77, 249 Ayanoglu S 296 Aydin B 296 Ayhan E 322 Badelon O 171, 243 Badras L 136, 137, 161 Badve S 72 Bae KJ 105 Bae K-C 240 Bagaria V 299 Bajelidze G 121 Balsano M 201 Balvin M 211 Bapat M 72 Baradhi A 158 Barakat M 117 Barrios C 254 Barroso JL 216

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Bartels L 205 Bass A 40, 151 Baunin C 2 Bayrakci K 47 Beguiristain JL 216 Behensky H 18 Belangero W 113 Bell M 167 Belthur M 76, 80, 106, 121, 206 Belza B 132 Belzer J 197 Bennet G 222 Benoit B 247 Benson M 61 Bentahar T 286 Be´rard J 85, 244 Berden N 23 Bergeson A 211 Berker N 154 Berton C 27 Besselaar A 127 Besselaar P 94 Betz R 81, 214 Bevan W 32, 221 Bharadwaj R 299 Bialik V 133, 174, 248 Bicimoglu A 12 Biedermann R 18 Bjornson K 7, 130, 132 Blakemore L 212 Boatright K 221 Boero S 245 Boland P 8 Bollini G 73, 110, 208 Bonnel F 65 Bonnet F 286 Booker W 70 Bor N 287 Boran S 193, 202 Borgo A 219 Borkhuu B 80 Borowski A 246 Bozkurt M 297 Bradish C 178, 306 Braga L 234 Braga S 95, 315 Brecelj J 155 Bruce C 6, 40 Brunet O 244 Brunner R 119, 225 Buckon C 153 Bueno J 90 Burghardt R 104, 187 Burnei G 26 Burns J 221 Bursali A 296 Bye M 70 Cabukoglu C 154 Cequier SL 36

Cahuzac J 71, 208, 209 Callender O 193, 229, 230 Campbell R 67, 81, 214 Canavese B 65 Canavese F 65, 286 Cantin MA 290 Canyadell AM 320 Carbone M 74 Carrera SF 320 Carter S 9 Cassidy N 199 Castelein R 127, 205 Caterrall A 293 Cavalli F 65 Celebi L 12 Centel T 322 Cepero C 284 Cepero S 188, 236, 314 Cequier SL 36 Cermak K 317 Cerna C 24 Chagas Jr M 269 Chaloupka R 79 Chang C 128 Chen J 211 Chen Y 128 Chiaramonte N 219 Cho C-H 240 Cho D-Y 233 Cho HS 264 Cho T-J 58, 105, 112, 116, 172, 255, 264, 270 Choi IH 58, 105, 112, 116, 172, 255, 264, 270 Chomiak J 173, 285 Chotel F 9, 85, 244 Chousta A 85 Christodoulou G 25, 321 Chung CY 58, 105, 112, 116, 172, 255, 264, 270 Cigala F 163 Clark K 66 Claudon M 111 Clavert J-M 232, 309, 312 Cole W 156 Comelli C 223 Comisso M 201 Conrad EC 7 Conroy E 15 Cosma D 26, 262 Costici F 141 Cournot M 209 Coutie´ A 208 Couto J 43 Cristini E 223 Cruz M 268 Csepan R 138 Cucchiaro G 195 Cugat R 320 Cumlivski R 139 Cunin V 244

Cunha ML 17 Czubak J 145 Dabney K 121, 122, 150 da Cunha ML 288 Dagher F 102, 158, 272 Daglar B 47 Daglioglu K 64 Dakwar R 157, 307 Dan D 26 Danielsson A 82 Dannecker G 22 da Paz Jr CA 234 da Rocha ML 288 Das S 45 Daures J-P 65 Davies AG 97 Davis N 228 De Bartolomeo O 87 de Donato M 281 de Gauzy SJ 2, 71, 208, 209 de la Iglesia GD 36 De Maupeou F 2 De Pellegrin M 14 de Sanctis N 166 Delhaas T 205 Delialioglu O 47 Dellenbaugh S 37 Demirkale I 297 Desai S 89, 189, 190, 233, 276 Deshmane P 72 Desloovere K 134 Devito R 162 Dheenadhayalan J 181 Di Lazzaro A 152 Di Sicco J 271 Dias L 42 Dillon E 130 Dimeglio A 65, 286, 298 Dimitriou J 265 Dimitriou R 265 Dobashi E 271 Doblare´ M 254 Dogan A 31 Dogan M 297 Dohin B 21, 129 Donnan L 18 Dowling F 193, 202 Drassler J 221 Dreher T 119 Duffy M 311 Duhaime M 247, 290 Duncan R 302 Dungl P 173, 285 Eastwood D 94, 165, 293 Eckhoff J 182, 183 Effman E 67 Eidelman M 174, 248, 287 El Hage S 158

S129 El Tayeby H 33 Elalfy B 91 El-Batouty M 29 Elmowaﬁ H 91 El-Sherbini M 278 Emara K 133 Emerson D 211 Endo H 126 Etienne J 21 Ey Batlle A 36 Ezra E 62, 200, 273 Fabry K 134 Fadel M 160 Falappa P 162 Fallatah S 69 Fassari F 162 Fassier A 39 Fazioli F 163 Fedarko N 41 Feldman D 77, 203, 249, 250, 308 Fernandes J 167 Fernandez-Palazzi F 30, 251 Fernando H 185 Ferretti A 75 Filo O 83 Fiore F 163 Fishkin M 62, 83, 200 Florentino-Pineda I 78 Floret D 21 Flynn J 195 Foad S 304 Fogarty E 193, 202, 229, 230 Fontecha GC 320 Forlin E 17, 288 Fragaki M 217 Frances J 8 Franceschi F 293 Fraponi A 223 Freeman R 61 Frick S 232 Friedman J 51 Frigo C 119 Frydrychova M 173, 285 Fu Y-C 242 Fucs P 135 Fujii M 20 Fujii T 20, 235, 261, 263, 275 Gabos P 80 Gabriel A 18 Ganger R 109 Ganley T 194, 195 Gantelius S 146 Garcı´ a-Aznar J 254 Garcia-Llaver G 88, 175 Garg N 6 Gargan M 117 Gargantilla A 188, 236 Garin C 129 Garnier-Kenol I 295 Gasco´ J 254 Gatti F 294 Gavriliu S 26

Gelman A 204 Genovese E 162 George H 40 Georgescu I 26 Georgiev H 280 Gereis V 176, 177 Ghanem I 102, 158 Ghorayeb J 100 Giannakopoulos H 137, 161 Gigante C 27, 253, 289 Giglio C 215 Gilberto S 74 Girsch W 237 Glutting J 122 Glynn A 199 Goldberg C 202 Goldberg M 204 Gomez J 70 Go´mez-Benito MJ 254 Gonza´lez-Can˜as L 314 Goto S 126 Grabowski B 145 Gradinger R 183 Grainger J 164 Grant A 93 Green D 308 Greiwe M 46 Grill F 98, 109 Grimard G 247, 290 Grimer R 9 Grimm D 17, 288 Grissom L 206, 246, 256 Gross R 207 Grottkau B 50 Gryfakis N 42 Grzegorzewski A 159 Guida P 166 Guillaume J 208 Gulcek S 12 Gunal T 12 Gunel U 47 Gungor E 47 Gurcu T 226 Gursu S 296 Guzman M 30 Habanbo J 298 Habermann C 56 Hadavi F 180 Haddad E 272 Haddad-Zebouni S 272 Halbertsma J 142 Hamada Y 19 Hansson G 300 Hara H 140 Haralabatos S 310 Harper J 165 Harshavardhana N 72, 299 Harty J 15 Harvey B 35 Hasler C 225 Hasserius R 82 Haumont T 111 Haverkamp A 127 Havranek P 317

Hayek S 273 Healey J 8 Heimkes B 124 Hemo Y 62 Henderson E 77, 203, 250 Herrera-Soto J 311 Herring J 54 Herzenberg J 92, 104, 187, 204, 287 Higgins G 178 Hochmuth K 182, 183 Hoeglinger M 109 Hoey S 165 Homaechevarria A 197 Hopgood P 164 Horak M 173 Horiuchi T 19 Horky´ D 79 Horn J 179 Hosny G 160, 279 Hospach T 22 Huang P-J 242 Huguet R 188, 236 Hunter J 232, 309 Huntley J 169 Hurschler C 13 Hutt N 198 Hyman J 70, 213 Hyun S 190 Iaccarino V 163 Iacono V 163 Ibieta A 24 Ide T 19 Imai Y 96 Inan M 256 Ingram D 131 Inscore S 67 Ishida A 271 Ito Y 140 Iwamoto Y 20 Jacobsen F 300 Jacopin S 110 Jacquemier M 110 Jae Y 89, 189, 210, 276 Jaffe K 130 Ja¨ger M 59 Jalaludhin J 252 James L 6 Jang HP 220 Janicki J 35 Jarman R 196 Javid M 180, 224 Jawish R 100 Jencikova-Celerin L 318 Jensen C 196 Jeys L 9 Jiminez N 211 Jingushi S 20 John E 214 Johnston C 68 Jones K 195 Jonsson M 300 Joo SY 60, 107

Joshi Y 6 Journeau P 111 Jouve J 208 Jouve J-L 73, 110 Juenemann S 225 Jung H-J 255 Jung S-C 233 Kahwaji A 100 Kalenderer O¨ 226, 301 Kalkan T 297 Kallio P 52 Kamegaya M 63 Kandil Y 61 Kanellopoulos A 136, 137, 161 Kang C-H 240 Kangesu L 165 Kanti U 45 Karanikas E 170 Karkhanis A 299 Karol L 68 Karpasˇ K 3 Kartin D 132 Katzman A 174, 248, 287 Kawabata H 241 Kazarian T 41 Kehayov R 280 Kenet G 273 Kenmoku T 63 Kesmezacar H 322 Khalife R 100 Khan T 44 Kharrat K 102, 158, 272 Kim HW 60, 107, 143, 144 Kim JA 112 Kim S-J 274 Kimori K 19 Kirienko A 281 Kiss S 84, 191 Kitano T 96 Klassen R 53 Knahr K 98 Knaus A 118 Knilsson K 198 Knorr J 71 Kobayashi D 267 Kohler R 21, 129 Kolovos S 170 Kotb H 282, 291 Koukos S 25 Koureas G 39 Kouwenhoven J-W 205 Kova´cs G 168 Kowalczyk B 184 Kowtharapu D 181, 292 Krajbich JI 4 Kranzl A 109 Krauspe R 59 Krbec M 79 Krebs A 138, 139 Krismer M 18 Kristiansen L 179 Kubota H 140, 261, 275 Kuroda T 96 Kyrikou H 217

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S130 La Rosa G 141, 162 Labianca L 75 Laﬂamme Y 247 Laheri V 72 Laine T 227 Lambat M 299 Lambiase A 163 Lamm B 287 Lamminen A 238 Lamprou D 136 Langendoerfer M 22 Langendo¨rfer M 1 Lapie N 209 Lascombes P 111 Lauen J 182, 183 Launay F 73, 110, 208 Lauschova´ I 79 Leal D 294 Lee DY 58, 112, 270 Lee E 49, 313 Lee KS 58, 172 Lee SM 172 Lee S 89, 276 Lee Y 313 Lee Z 128 Leet A 23, 149 Lefe`vre Y 73 Lejman T 184 Lenehan B 193, 202 Lettera M 163 Liantsis A 120 Lieber R 146 Lim B 49, 313 Lim K 227 Lindfors N 305 Linke B 312 Littleton A 76, 80, 106, 246 Lloyd W 318 Logsdon R 132 Louahem D 298 Lousteau O 2 Ludvigsen P 179 Lutz N 232 Maathuis K 142 Maathuis P 38, 142 Mackenzie W 76, 106, 206, 246, 256 Macri R 124 Madan S 101 Maddaluno L 163 Mahadev A 49, 313 Mahajan R 190 Maheshwari R 101, 302, 303 Mahnken A 257 Mainard L 111 Malizos K 120 Mallat S 158 Mandarano FL 269 Mandry D 111 Mangiola F 75 Manner H 109 Mannoji C 63 Maranho D 294 Marawar S 72

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Martinez G 88, 175 Martini G 27 Masek M 173 Mason D 80 Matamalas AA 314 Matı´ as S 90 Matsinos G 170 Matsumoto H 37, 70, 213, 214 Matsuura A 140, 275 Matta H 89, 190 Matthys R 312 Mawatari T 20 Max S 13 Mazza O 141 McCann H 207 McCarthy E 41 McCool D 197 McCormack D 199, 266 McLaughlin J 132 McManus A 228 McManus F 15, 266 Meadows T 164 Mednikarov E 280 Mehlman C 46, 304 Meiss L 56 Melinova H 317 Memeo A 87, 192, 223 Messina S 75 Micaglio A 219 Michaud L 304 Michelis MB 245 Michelis M 74 Milani C 271 Miller F 106, 115, 121, 122, 148, 150 Min B-W 240 Miscione H 185 Mitani S 126 Mladenov K 68 Moen T 42 Moharamzadeh D 14 Mohil R 164 Molenaers G 134 Møller-Madsen B 125 Monasterio JL 216 Monsell F 117, 165, 293 Montanaro A 75 Montgomery R 258 Moore D 193, 202 Morcuende J 37 Morgan A 167 Morin B 247, 290 Morita M 96 Moriya H 63 Mo´rocz I 168 Morris A 114 Morris C 8 Mosca V 32 Moscovitch G 2 Mourani C 158 Mumcuoglu I 31 Muratli H 12 Murphy M 266 Murray A 222

Nachemson A 82 Nadarajah R 131 Nagai M 150, 256 Nakagawa K 96 Nakamura J 63 Nakashima Y 20 Narayanan U 35, 114, 227, 319 Nascimento F 315 Nasu T 126 Nathorst-Westfelt J 300 Neves CM 218, 259 Nietosvaara A 52, 238, 305 Nikolic Z 8 Nilsson K 197 Nilsson W 221 Nisar A 97 Noguchi Y 20 Nott EV 48 Oda K 126 Oh C-W 186 Oh KS 143, 144 O’Hare B 229, 230 Ohlin A 82 Ok I-Y 274 Oketani Y 140, 275 Oner C 64 Ostadal M 173 O’Toole P 229, 230 Ouhayoun E 2 Ovadia D 83 Ovesen J 125 Paley D 92, 104, 187, 204 Palmu S 52 Pap K 84, 191 Papandreou N 176, 177 Paris A 197 Park B-C 186 Park HW 60, 107, 143, 144 Park J-W 233 Park KB 143, 144 Park M 116 Parot R 244 Parrot R 85 Parsch K 28, 316 Pascarella A 166 Paseta O 254 Pasparakis D 176 Pasparakis D 177 Paterson M 131 Patil N 299 Patni H 72 Pavone V 231 Pedreira J 268 Pekmezc_ı M 64 Peltonen J 238 Peluso C Pen˜a L 216 Peretti G 87, 192, 223 Pe´rez M 236 Pe´rez MC 188 Perrone G 188, 236 Pesl T 317

Petermann A 59 Peterson H 53 Pettas N 217 Pfeiffer R 198 Phelps D 197 Phillips J 318 Pietrzak S 145 Pilankar S 299 Pineda D 24 Pistevos G 176, 177 Pitcher Jr JD 5 Pittioni E 65 Planes E 284 Plitz W 124 Poe-Kochert C 78, 212 Pogonowicz E 159 Pollock S 293 Pomero V 110 Ponte´n E 146 Popov O 307 Porter D 10, 169 Pospischill M 98 Poul J 147 Po¨yhia¨ T 238 Pressel T 13 Privitera D 213 Protopapadakis G 25 Pruijs H 127 Puskar Z 84 Pydisetty R 252 Pyman J 117 Radler C 98, 109 Railhac J 2 Raja S 181, 292 Rajasekaran S 181 Ram SK 48 Ramirez-Lluch N 81 Ramseier L 319 Ranade A 187 Randal B 81, 214 Ranjan A 45 Rautakorpi S 305 Rebello G 50 Redding G 67 Redekop S 114 Refai M 91 Regondi E 192 Reid R 10, 169 Reinhardt BSK 308 Reisoglu A 226, 301 Repko M 79 Reynolds R 309, 312 Rhee K-J 86 Riad J 115, 148 Rich M 55 Rigamonti W 253 Rigopoulos N 120 Ristaniemi N 305 Rizzo N 166 Robb C 306 Rocha ML 17 Roemhildt M 66 Roposch A 99 Rosenberg N 273

S131 Rosenberg Z 250 Rosenfeld S 54 Roth S 34 Rouleau D 247 Rowland D 167 Roy A 35 Roy D 103, 260 Roye D 70, 213, 214 Rubie H 2 Ruchelsman D 249 Ruggieri M 231 Rumyantsev N 108 Russman B 153 Ryu S 140, 275 Sabet N 283 Sadile F 163 Saghieh S 92 Sahu A 299 Sailhan F 85, 244 Saisu T 63 Sakkers R 127 Sala D 250 Salama A 97 Salter R 11 Samara E 43 Sampath J 151, 252 Sandhu S 196 Sansone V 281 Sant’Anna F 218, 259 Santili C 95, 315 Santner T 152 Sapre V 299 Sasaki K 96 Satsuma S 267 Schara K 23, 149 Schaufele P 24 Scher D 308 Scherb M 311 Scherl S 277 Schiavon R 219 Schiering J 28 Schilz M 316 Schlickewei W 309 Schoenecker P 55 Schreiner A 57 Schweitzer M 77, 249 Schwieger K 312 Sciarra F 75 Scorsone-Pagny S 110 Scully S 5 Sdougkos G 25, 321 Sebire N 165 Segal E 43 Segev E 62 Seijas R 320 Sembrano J 133 Senaran H 122, 150 Seo JB 112 Sepu´lveda D 90 Seringe R 39 Shah R 45 Shah S 80, 122 Shahcheraghi G 180, 224 Shapiro J 41

Shariff R 151 Sharma H 302, 303 Shaughnessy W 53 Shea K 197, 198 Shechtman A 83 Sheehan E 199 Sheiko M 7 Shetty G 89, 189, 190, 210, 233, 276 Shim JS 220, 239 Shin HD 86 Shin H-D 186 Shisha T 84, 191 Shivarathre D 40, 151 Shtarker H 157, 307 Shualy M 204 Sienko TS 153 Sikorski Z 310 Silicorni A 223 Silva F 218 Simis S 135 Simon S 152 Simpson H 191 Singerhoff S 56 Skaggs D 214 Skarpas G 217 Slimp J 211 Slongo T 232, 309, 312 Smith J 81, 214 Sohodolcˇan L 155 Sokhi K 169 Song B 92 Song H 89 Song H-R 186, 189, 190, 210, 233, 276 Song H-S 86 Song K 7, 67, 130, 211, 214, 221 Song K 240 Son-Hing J 212 Sousa RM 218, 259 Specht S 187 Spencer D 249 Spoletini M 75 Sˇponer P 3 Spreaﬁco L 281 Standard S 104 Stans A 53 Stebbins J 123 Stebel M 65 Steen H 179 Stefano E 88, 175 Stefanov S 280 Steiger P 312 Steinbacher G 320 Steinberg D 273 Stella M 245 Stephens M 199 Stokes I 66 Straight J 249 Strobl W 138, 139 Strom M 221 Suda R 98 Suenaga E 20 Sugiyama H 19

Sul EJ 220 Sul E 239 Surer L 301 Sussman M 133, 153 Svartman C 135 Synder M 159 Szepesi K 168 Szoke G 84 Szo¨ke G 191 Szu¨cs G 168 Tagaris G 25, 321 Takagi R 241 Takamura K 235, 261, 263, 275 Takaoka K 96 Talenti E 289 Tamura D 241 Tasbas B 47 Tavares D 218, 259 Tecimel O 297 Temple HT 5 Ten Berge S 142 Teoh K 10, 169 Terjesen T 16, 118 Thacker M 5, 76, 106, 206, 246 Theologis T 61, 123 Tho H 131 Thomas S 11 Thompson G 78, 212, 277 Thompson N 123 Thomsen JS 125 Tien Y-C 242 Tierno G 268 Tillman R 9 Timlin M 15 Tosun N 297 Turra S 27, 253, 289 Turturro F 75 Ugurlu M 297 Ullot F 284 Ullot R 188, 236, 314 U¨nlu¨ M 322 Urano N 235, 261, 263 Urban K 3 Urbanova´ E 3 Ursei M 71 Vaidya S 189, 276 Vallejos-meana N 88, 175 Vallongo C 27 Vallverdu´ PM 36 van Bosse H 250 Van Gelder H 38 Vancampenhout A 134 Vasilescu D 262 Vasilescu D 26, 262 Venkatramani H 181 Verbout A 205 Verdoni F 87, 192 Verheij N 142 Viehweger E 72, 110 Viergever M 205

Viguier E 85 Vilalta V 284 Villaminar A 201 Vincken K 205 Violas P 208 Vioreanu M 199 Visser J 38 Vitale M 37, 70, 213, 214 Vittoria F 245 Vlachos A 321 Vlad C 26 Vladimirov B 280 Volpatti D 65 Volpin G 157, 307 Volpon J 215, 269, 294 von Liebe A 124 Voutsas N 217 Vrettos S 137 Vris A 321 Wachter R 18 Wada A 235, 261, 263, 275 Wada M 241 Wainwright A 61, 123 Waisberg G 95, 315 Waldman D 273 Wall E 46 Walsh S 229, 230 Wang T-L 242 Wang X-D 306 Warner W 51 Waters L 213 Watts A 10 Webb J 258 Wedge J 11, 99 Weinzapfel B 212 Weir S 114 Wells L 51, 195 Westhoff B 59 While T 117 White K 211 Wicart P 39 Widmann R 308 Wientroub S 62, 83, 200, 273 Wilkins K 48, 295 Willems W 50 Wilson D 152 Wilson N 222, 303 Wiltrout S 318 Windhagen H 13 Windolf M 312 Winkler P 1, 22 Wirth T 1, 22 Witbreuk M 94 Woo S 210 Wraith ED 164 Wright J 35 Wynn R 164 Yalcin S 154 Yamamoto T 20 Yamane P 271

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S132 Yanagida H 235, 261, 263, 275 Yang J 89, 189, 210, 276 Yang JH 233 Yaniv M 62, 200

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Yazici M 64 Yebra IJ 36 Yildirim T 296 Yilmaz G 64 Ying J 304

Yoo WJ 58, 105, 112, 116, 172, 255, 264, 270 Yoon H-R 233 Young M 92 Yuksel HY 12

Zanferari M 17 Zorer G 31 Zulian F 27

IFPOS Combined Meeting EPOS - 26th Annual Meeting

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