Postoperative Immobilization Period for Pediatric Supracondylar Fractures: The Shorter the Better?

BACKGROUND: There are now recognized standards of care published by the British and American Orthopaedic Associations which detail key areas of evidence-based recommendations for the treatment of children with displaced supracondylar humerus fractures. Although many aspects of treatment are covered in these recommendations, both the American and British Orthopaedic Associations do not recommend the exact duration of immobilization postoperatively. METHODS: This study retrospectively compared outcomes of operatively managed supracondylar fractures immobilized postoperatively for short immobilization (SI) defined as 28 days or less, with long immobilization (LI) defined as more than 28 days. The outcomes measured were clinical (deformity, range of motion, and pin site infection) and radiologic (loss of position after the removal of K-wires, Baumann's angle, anterior humeral line, refracture, and signs of osteomyelitis). Demographic data were recorded to evaluate and ensure satisfactory matching of the 2 groups for analysis. RESULTS: The study included 193 pediatric supracondylar fractures over a 4-year period which were treated with manipulation under anesthetic and K-wire fixation. The difference in average time in plaster between the 2 groups was statistically significant (SI: n=27.5 d, SD 1.23; LI: n=43.9 d, SD 15.29, P =0.0001). Data for operative techniques-closed or open reduction (SI: n=66, LI: n=78, P =0.59), and crossed wires (SI: n=37, LI: n=50, P =0.57) between the two groups showed no statistical significance. There was no statistical difference between the groups for the average number of days postoperatively at which wires were taken out (SI: n=28.9 d, SD 5.95, LI: n=30.1 d, SD 5.57, P =0.15), number of pin site infections requiring antibiotic treatment (SI: n=3, LI: n=5, P =0.70), or children from each group who were recorded to have regained full range of motion symmetrical to their contralateral arm (SI: n=79, LI: n=99, P =0.74). CONCLUSIONS: Our study therefore suggests that shorter immobilization of these patients (SI group) does not yield a higher rate of complications including refracture and malunion.

A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018.

BACKGROUND: Necrotising fasciitis is a rapidly progressing soft-tissue infection with a low incidence that carries a relevant risk of morbidity and mortality. Although necrotising fasciitis is often fatal in adults, its case fatality rate seems to be lower in children. A highly variable clinical presentation makes the diagnosis challenging, which often results in misdiagnosis and time-delay to therapy. METHODS: We conducted a protocol-based systematic review to identify specific features of necrotising fasciitis in children aged one month to 17 years. We searched 'PubMed', 'Web of Science' and 'SCOPUS' for relevant literature. Primary outcomes were incidence and case fatality rates in population-based studies, and skin symptoms on presentation. We also assessed signs of systemic illness, causative organisms, predisposing factors, and reconstructive procedures as secondary outcomes. RESULTS: We included five studies reporting incidence and case fatality rates, two case-control studies, and 298 cases from 195 reports. Incidence rates varied between 0.022 and 0.843 per 100,000 children per year with a case-fatality rate ranging from 0% to 14.3%. The most frequent skin symptoms were erythema (58.7%; 175/298) and swelling (48%; 143/298), whereas all other symptoms occurred in less than 50% of cases. The majority of cases had fever (76.7%; 188/245), but other signs of systemic illness were present in less than half of the cohort. Group-A streptococci accounted for 44.8% (132/298) followed by Gram-negative rods in 29.8% (88/295), while polymicrobial infections occurred in 17.3% (51/295). Extremities were affected in 45.6% (136/298), of which 73.5% (100/136) occurred in the lower extremities. Skin grafts were necessary in 51.6% (84/162) of the pooled cases, while flaps were seldom used (10.5%; 17/162). The vast majority of included reports originate from developed countries. CONCLUSIONS: Clinical suspicion remains the key to diagnose necrotising fasciitis. A combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotising fasciitis. Incidence and case-fatality rates in children are much smaller than in adults, although there seems to be a relevant risk of morbidity indicated by the high percentage of skin grafts. Systematic multi-institutional research efforts are necessary to improve early diagnosis on necrotising fasciits.

Correction to: A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018.

After publication of the original article [1], we were notified that two of the author names were incorrectly displayed in the pdf version of the paper, while one other name was incorrectly tagged in the XML version.

Prognostication in Developmental Dysplasia of the Hip Using the Ossific Nucleus Center Edge Angle.

BACKGROUND: The aim of this paper was to determine the prognostic potential of the ossific nucleus center edge angle (ONCEA) in patients below 5 years of age treated for developmental dysplasia of the hip (DDH) to predict final outcome and the need for a secondary procedure. METHODS: The interobserver and intraobserver reliability was calculated using the intraclass correlation coefficient for measurement of the ONCEA. The ONCEA was divided a priori into 3 groups: group A≥10 degrees, group B -9 to 9 degrees, and group C ≤-10 degrees. Final outcome was measured using the McKay score and Severin classification. The presence of osteonecrosis was recorded at final follow-up. RESULTS: One hundred one patients with 133 dislocated hips underwent closed or open reduction for DDH. Mean age at presentation was 19 months with a mean age at final follow-up of 12.4 years. A significant difference was shown in a comparison of the 3 ONCEA groups using the McKay score, Severin classification, and need for a secondary procedure. Eighty seven of the 101 patients underwent ONCEA reliability measurements. The ONCEA was shown to have a mean intrarater reliability of 0.89, and a mean interrater reliability of 0.77. CONCLUSIONS: The ONCEA is a reliable measurement in predicting medium-term outcome of the hip post reduction in children under the age of 5 years with DDH and might be useful as a predictor for a secondary procedure before the age of 5 years. LEVEL OF EVIDENCE: Level III-prognostic case control study. CLINICAL RELEVANCE: This case control study shows the importance of measuring the ONCEA within 6 months of removing the final cast after reduction of a dislocated hip and its implications for further management and outcome.

Vitamin D Status in Blount Disease.

INTRODUCTION: Blount disease can be defined as idiopathic proximal tibial vara. Several etiologies including the mechanical theory have been described. Obesity is the only causative factor proven to be associated with Blount disease. The aim of this study is to assess if there is an association of vitamin D deficiency and Blount disease. METHODS: This a retrospective study of preoperative and postoperative patients with Blount disease who were screened for vitamin D deficiency. Patients with genu varum due to confirmed vitamin D deficiency and rickets were excluded. The study patients had the following blood tests done: calcium, phosphate, alkaline phosphatase, parathyroid, and 25-hydroxyvitamin D (25(OH)D) hormones. RESULTS: We recruited 50 patients. The mean age of these patients was 10.4 years (SD±3.88) with average body mass index of 28.7 kg/m (±10.2). Thirty (60%) patients were diagnosed with infantile, 4 (8%) juvenile, and 16 (32%) adolescent Blount disease. Eight (16%) patients were found to be vitamin D deplete (25(OH)D levels <50 nmol/L). Of these, 8 patients, 6 were insufficient (25(OH)D levels between 30 and 50 nmol/L) and the other 2 were deficient (25(OH)D levels <30 nmol/L). CONCLUSIONS: This study showed that the prevalence of vitamin D deficiency in children with Blount disease was similar to that of healthy children living in Johannesburg. There is no evidence that vitamin D deficiency is a factor in causing Blount disease. LEVEL OF EVIDENCE: Level III-retrospective study.

Common normal variants of pediatric vertebral development that mimic fractures: a pictorial review from a national longitudinal bone health study.

Children with glucocorticoid-treated illnesses are at risk for osteoporotic vertebral fractures, and growing awareness of this has led to increased monitoring for these fractures. However scant literature describes developmental changes in vertebral morphology that can mimic fractures. The goal of this paper is to aid in distinguishing between normal variants and fractures. We illustrate differences using lateral spine radiographs obtained annually from children recruited to the Canada-wide STeroid-Associated Osteoporosis in the Pediatric Population (STOPP) observational study, in which 400 children with glucocorticoid-treated leukemia, rheumatic disorders, and nephrotic syndrome were enrolled near glucocorticoid initiation and followed prospectively for 6 years. Normal variants mimicking fractures exist in all regions of the spine and fall into two groups. The first group comprises variants mimicking pathological vertebral height loss, including not-yet-ossified vertebral apophyses superiorly and inferiorly, which can lead to a vertebral shape easily over-interpreted as anterior wedge fracture, physiological beaking, or spondylolisthesis associated with shortened posterior vertebral height. The second group includes variants mimicking other radiologic signs of fractures: anterior vertebral artery groove resembling an anterior buckle fracture, Cupid's bow balloon disk morphology, Schmorl nodes mimicking concave endplate fractures, and parallax artifact resembling endplate interruption or biconcavity. If an unexpected vertebral body contour is detected, careful attention to its location, detailed morphology, and (if available) serial changes over time may clarify whether it is a fracture requiring change in management or simply a normal variant. Awareness of the variants described in this paper can improve accuracy in the diagnosis of pediatric vertebral fractures.

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes.

Purpose: Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails. Methods: A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias. Results: Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies. Conclusions: An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations. Level of evidence: III.

Tibialis anterior tendon transfer using bone anchor for dynamic supination in congenital talipes equinovarus.

Tibialis anterior tendon transfer (TATT) is a recognised procedure for the treatment of recurrent congenital talipes equinovarus. The most common technique in use requires three skin incisions and breaching of the plantar tissues, risking pressure areas and damage to neurovascular structures. There have been no studies showing the clinical results of the use of a bone anchor to secure the tendon without drilling through the lateral cuneiform. This study presents the largest series of outcomes for such a procedure. Retrospective case series. Electronic records for all children under 18 undergoing TATT with anchor fixation included. Outcomes recorded were a failure of the tendon transfer and complications. Seventy-seven feet were identified in 61 children with a male-to-female ratio of 2.5:1, the average age at surgery of 5.6 years, and an average follow-up of 4.4 years. There were no cases of pullout of the anchor. Seventy-six cases (98.7%) had no recurrence of dynamic supination on follow-up. No revision surgery was required. Consistently reliable, reproducible and safe fixation of the tibialis anterior tendon in TATT can be achieved using a bone anchor for the treatment of dynamic supination in children with clubfeet following correction using the Ponseti method and is a quick and straightforward alternative method to traditional techniques.

The impact of instrumented gait analysis on decision-making in the interprofessional management of cerebral palsy: A scoping review.

BACKGROUND: Management of gait-related problems in children and young people with Cerebral Palsy (CYPwCP) is complex and requires an interprofessional approach. Irrespective of underlying mechanisms, instrumented gait analysis (IGA) can provide quantification of gait to support clinical decision-making for CYPwCP when planning treatment interventions. AIM: This scoping review aimed to determine the impact of instrumented gait analysis (IGA) on treatment decision-making for CYPwCP, paying particular attention to interprofessional decision-making. METHOD: PubMed, EMBASE, Web of Science and Scopus databases were searched from inception to October 2019 for studies including CYPwCP age<25 years. The PRISMA ScR protocol was followed, and Quality was assessed with the Downs and Black (D&B) scale. Influences on decision-making were coded according to the International Classification of Functioning, Disability and Health for Children and Youth framework (ICF-CY). RESULTS: Seventeen studies (1144 patients, 2.8-23 years) of varying quality (mean D&B = 17.2, range = 11-26) were included. Studies considered IGA influence at three decision-making stages 'Clinical Planning', 'Treatment Performed' and 'Follow up'. Child and Family, and Clinician and Service-centred factors had a high impact on engagement with IGA recommendations. INTERPRETATION: IGA guided recommendations can differ from initial clinical plans, and often lead to modification of the treatment ultimately performed. The effect on individual patients' outcomes when treatment recommendations based on instrumented gait analysis are followed is not yet clear and warrants further research. The differences in clinicians' engagement with IGA recommendations occur due to an array of Child and Family, and Clinician and Service-centred factors. Overall, IGA leads to less surgical recommendations, and has the potential to influence conservative gait-related management in CYPwCP.

Stabilization of Recurrent Elbow Instability in the Presence of Hyperlaxity in Children Using a Nonanatomic Soft Tissue Reconstruction.

Despite growing concordance of opinion in the adult setting, pediatric elbow instability and its management are poorly represented in the literature due to its low prevalence and often unique circumstances. The authors present a case of posttraumatic recurrent posterior pediatric elbow instability in a patient with joint hypermobility. Our patient, a 9-year-old girl, sustained a right-sided supracondylar fracture of the humerus in April 2019. Having been managed operatively, the elbow remained unstable and dislocated posteriorly in extension. Definitive surgical management was designed to provide a stable functional elbow. The principle of the surgery was to create a checkrein of tissue, not changing in length in extension and flexion, and to prevent further posterior elbow instability. A 3 mm slip of the central triceps tendon was dissected, leaving its attachment to the olecranon tip. Gracilis allograft was sutured to the strip of the triceps tendon to increase the tensile properties of the native tendon graft using a braided nonabsorbable suture. The tendon construct was then passed through a window made in the olecranon fossa and a transosseous tunnel in the ulna from the coronoid tip to the dorsal cortex. The tendon was tensioned and secured to the radial-dorsal aspect of the ulna with a nonabsorbable suture anchor in 90 degrees of flexion. At one year follow-up, the patient has a stable and pain-free elbow joint with no functional limitations.

Acute musculoskeletal infection in children: assessment and management.

Musculoskeletal infection in children is challenging to treat, and includes septic arthritis, deep tissue infection, osteomyelitis, discitis and pyomyositis. Delays to diagnosis and management, and under-treatment can be life-threatening and result in chronic disability. The British Orthopaedic Association Standards for Trauma include critical steps in the timely diagnosis and management of acute musculoskeletal infection in children, the principles of acute clinical care and the service delivery requirements to appropriately manage this cohort of patients. Orthopaedic and paediatric services are likely to encounter cases of acute musculoskeletal infection in children and thus an awareness and thorough understanding of the British Orthopaedic Association Standards for Trauma guidelines is essential. This article reviews these guidelines and associated published evidence for the management of children with acute musculoskeletal infection.

Traumatic patellar dislocation: loose bodies and the MPFL.

Traumatic patellar dislocation is a common occurrence in adolescents. Treatment in the acute situation is controversial but should always address replacement or removal of osteochondral loose bodies. Reconstruction of the medial patellofemoral ligament in the acute and recurrent situation has provided excellent results in this select patient group.

Epidemiology of acute osteoarticular sepsis in a setting with a high prevalence of pediatric HIV infection.

BACKGROUND: There is limited information on osteoarticular infections in human immunodeficiency virus (HIV)-infected children. The purpose of this study was to determine the effect of HIV on the epidemiology of osteoarticular infections in a setting with a high prevalence of pediatric HIV infection. METHODS: A retrospective evaluation of children presenting with acute septic arthritis or osteomyelitis from June 2005 to July 2009 was undertaken. Standard departmental protocols for the management of osteoarticular infections, including testing for HIV, were practised. RESULTS: A total of 102 cases of acute septic arthritis or osteomyelitis were identified during the study period. These included 22 (21.6%) episodes in HIV-infected children, 66 (64.7%) in HIV-non-infected children, and 14 (13.7%) cases in whom the HIV status was unknown. The median age of children was 30.6 months (range, 9.2 to 82.9 mo) and did not differ by HIV status. Streptococcus pneumoniae was identified in 8 of 12 (66.7%) HIV-infected children compared with 3 (9.7%) of 31 HIV-non-infected children (P<0.001). Conversely, fewer episodes in HIV-infected children (4.8%) were associated with Staphylococcus aureus compared with HIV-non-infected children (24.6%; P=0.06). No patients died. Twelve cases required repeated surgical procedures. CONCLUSIONS: Empirical management of osteoarticular infections in settings with a high prevalence of HIV-infected children or children known to be HIV infected needs to be tailored based on a higher proportion of episodes being due to S. pneumoniae in HIV-infected children. CLINICAL RELEVANCE: Our results suggest that HIV-infected children with osteoarticular infections should be started on broader spectrum antibiotics before culture results are available. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Recurrence in infantile tibia vara (Blount disease) after high tibia and fibula osteotomy.

Infantile Tibia Vara (ITV or Blount disease) often recurs after surgical correction of the deformity. Vastly different recurrence rates have been reported in the literature. The main objective of this study was to identify any risk factors for the recurrence of ITV following high tibia and fibula valgus osteotomy. This was a retrospective cohort comparative study of 44 patients with ITV (16 with bilateral involvement) who underwent a total of 60 high tibia and fibula osteotomies. Demographics, family history, BMI, walking age and age at surgery were recorded. Pre-, post- and follow-up weight-bearing anatomic femorotibial angles, were measured from X-rays. The limbs were divided into Langenskiöld stages based on preoperative X-rays. The study found an overall recurrence rate of 63.3% for children who had a high tibia and fibula osteotomy for ITV. Surgery after the age of 4 years, advanced Langenskiöld stages (stages 3-5) and overcorrection of less than 15 degrees of valgus were identified as risk factors for recurrence. This study recommends performing a high tibia and fibula valgus osteotomy before the age of 4 years in ITV to avoid recurrence. Overcorrection of the high tibia and fibula osteotomy to 15 degrees of valgus should be considered in older patients with high Langenskiöld stages at time of presentation.

The effect of COVID-19 on children with congenital talipes equinovarus in a tertiary service in the United Kingdom.

During the coronavirus disease 2019 (COVID-19) pandemic, many aspects of healthcare have been hindered. The primary aim of this study was to identify what the impact of COVID-19 was on the delivery of outpatient care for children with congenital talipes equinovarus deformity (CTEV) at a large tertiary hospital in the UK. This study reviewed the patients who commenced their Ponseti treatment between March and September 2020, representing the cohort who received hands-on care during the first wave of the COVID-19 pandemic. Equivalent 6-month periods were searched in 2019 and 2018 as control cohorts. This study included a total of 45 children (72 affected feet) presenting for treatment of clubfoot. Twenty-three babies were seen with CTEV in 2020. For the same time period in 2018 and 2019, 11 babies were treated each year. The distance commuted to by families was higher in 2020 compared to 2019 and 2018, although the difference did not reach statistical significance (P = 0.301). Treatment with Ponseti casting was commenced at a mean age of 52 days, with no statistically significant differences between cohorts (P = 0.758). Using strict precautions, the Ponseti service at a large tertiary hospital in the UK grew in size and successfully provided treatment for children presenting with CTEV during the first wave of the COVID-19 pandemic. This study has shown that with careful protocols in place, children with CTEV can be treated successfully during times of pandemic, thereby reducing the post-pandemic burden of older children requiring treatment.

Health-related quality of life and functional outcome measures for pediatric multiple injury: A systematic review and narrative synthesis.

BACKGROUND: Pediatric multiple injury is a major cause of mortality and morbidity worldwide, with varied long-term sequelae. To improve care, a better understanding of the outcome tools used following multiple injury is needed. OBJECTIVES: This study aimed to (1) identify the outcome tools used to assess functional and health-related quality of life outcomes in pediatric multiple injury and to (2) describe the tool domains and validity. METHODS: Eligible studies were those that included pediatric participants aged 0 to 17 years who experienced multiple injury or severe trauma based on Injury Severity Score/Abbreviated Injury Scale score and a functional outcome tool was used to assess outcomes (e.g., physical, psychological, quality of life). Excluded study designs were editorials, narrative, and systematic reviews. RESULTS: Twenty-two papers were included encompassing 16,905 participants and 34 different outcome tools. Ten tools were validated in children of which 4 were multiple injury specific; 18 were validated in adults of which 8 were trauma specific, and 6 were previously unvalidated. The tools were a mixture of patient reported (7 of 10 validated in children and 13 of 18 validated in adults) and clinician reported (3 of 10 validated in children and 2 of 13 validated in adults). Pediatric tool domains assessed were function, mobility, activities of daily living, pain, school, cognition, emotional domains, mental health, behavior, and high-risk behaviors. Using adult-validated tools to assess children may not capture the children's true function and health-related quality of life. CONCLUSION: There was a lack of consistency in the outcome tools used following multiple injury in children. Adult-validated measures may not accurately capture pediatric outcomes after multiple injury. To fully understand the impact of pediatric multiple injury and make comparisons between studies, development of a core outcome set is required. LEVEL OF EVIDENCE: Quantitative observational studies, level III.

'Does compliance with BOAST guidelines matter for displaced supracondylar fractures in children?': the experience of a tertiary referral major trauma centre over a 3.5-year period.

Supracondylar fractures are the most frequently occurring paediatric fractures about the elbow and can be associated with neurovascular injury. For that reason, the British Orthopaedic Association has published the British Orthopaedic Association Standards for Trauma (BOAST) 11 guidelines, aiming to the best management of supracondylar fractures. The aim of this study was to assess adherence to the BOAST 11 guidelines for displaced supracondylar fractures at a Major Trauma Centre in London, UK between 2015 and 2018 and to see whether adherence to guidelines affected the outcomes. A retrospective review was carried out between January 2015 and August 2018 of all paediatric patients who underwent either closed reduction and percutaneous pinning or open reduction and fixation for a displaced supracondylar fracture of the humerus. One hundred nine patients between 1 and 16 years of age with isolated displaced extension type supracondylar fractures (Gartland II, III and IV) were included in the study. The current study did not manage to achieve complete compliance with the BOAST 11 guidelines. K-wire size, fixation technique and pre-, intra-, postoperative documentation were the most important points of lack of compliance. However, deviating from specific guidelines did not cause any adverse clinical outcomes. Lack of correct documentation either preoperatively or postoperatively could be detrimental to patient outcome, especially with respect to neurovascular status. Implementation of a clerking template for use in the electronic medical records for all children with displaced supracondylar fractures is of value in order to improve our documentation.

Hemiepiphysiodesis: when should it be considered a day-case procedure?

Hemiepiphysiodesis is usually planned as a day-case but patients may stay overnight for pain control. In this study, we assessed the required level of analgesia (LOA) and length of stay (LOS) in patients undergoing hemiepiphysiodesis about the knee joint. We conducted a retrospective cohort study of patients that underwent temporary hemiepiphysiodesis of the distal femur or proximal tibia using hemiepiphysiodesis plates (eight-plates) for coronal plane deformities between January 2012 and October 2019. Demographics, type of procedure, anatomical site, anaesthetic time, preoperative, intraoperative and postoperative analgesia, and time of surgery were collected. Anterior hemiepiphysiodesis and permanent drill epiphysiodesis procedures were excluded. In this series of 79 patients, those with increased American Society of Anesthesiologists Score >1 and patients that were operated on >2 sites required increased LOA, (P < 0.05) and prolonged LOS (P < 0.05). The timing of surgery (morning vs. afternoon list) did not influence LOS or LOA. Patient-controlled analgesia (PCA) was required in 8 of 14 (57%) patients with four growth plates operated on. All (n = 12) patients that received PCA remained in hospital for at least one night. The use of local infiltration intraoperatively played a significant role in early discharge of the patients and t lower the LOA postoperatively (P < 0.05). Parameters including the number of growth plates operated on, use of tourniquet and intraoperative local infiltration can independently influence LOS and LOA postoperatively and at discharge. These parameters should be taken into consideration when consulting with the patient and family and when planning the postoperative course.

Assessment of the reliability and reproducibility of the Langenskiöld classification in Blount's disease.

The Langenskiöld classification is the most commonly utilized classification system for the radiological features of Blount's disease. Although there is only a single study found on the interobserver variability and none found on the intraobserver variability, it is commonly used for prognostication and guiding management decisions. The aim of this study was to determine the reliability and reproducibility of the Langenskiöld classification. A retrospective review of radiographs was done of patients treated for infantile and juvenile Blount's disease at Chris Hani Baragwanath Academic Hospital from 2006 to 2016. There were 70 radiographs of acceptable quality, which were reviewed and staged on two occasions according to the Langenskiöld classification by three orthopaedic consultants and three orthopaedic surgery senior residents. Pearson correlation coefficients, percentage agreements, and κ statistics were used to evaluate both the reliability and reproducibility. Of the 70 images staged, only two (2.9%) were staged the same by all six observers, and 20 (28.6%) images differed by a single stage. The consultants had 17 (24.3%) images staged the same whereas the residents had 12 (17.1%) images staged the same. The overall κ for all six observers showed a fair agreement of 0.24. Again, the consultants had a higher κ-value compared to residents of 0.25 and 0.24, respectively. The reproducibility amongst all observers was fair with a κ-value of 0.38. The consultants had a higher mean score of 0.48 compared to 0.26 for the residents. There was only a fair overall reliability and reproducibility amongst the six observers. We recommend the Langenskiöld classification be used with caution when being used for prognostication and management planning as well as when interpreting any research relying on this classification. Level of evidence: Level III, diagnostic study.

The femoral deformity in Blount's disease: a comparative study of infantile, juvenile and adolescent Blount's disease.

An associated femoral deformity in patients with Blount's disease is not commonly described in the literature. The objective of this study is to establish the presence and magnitude of deformity in the coronal plane of the distal femur in children of all ages with Blount's disease and compare this to a matched cohort of children from the same population. This was a retrospective review of patients from an academic hospital. A control group was established by matching for age and gender from a group of unaffected patients with mid to proximal third femur fractures or controls at the same hospital. Study participants were categorized by age at onset of deformity as follows: infantile (<4 years), juvenile (4-10 years) and adolescent (>10 years). The measurements of the anatomic lateral distal femoral angle (aLDFA) were recorded and the Wilcoxon rank-sum test was used to determine statistically significant differences in the LFDA between children with Blount's disease and those without. Seventy-two Black African children were included in the study with 118 affected limbs (27 infantile, 55 juvenile and 36 adolescent). The overall average aLDFA for all patients with Blount's disease was 87° (range 73-100°). Overall, children with Blount's disease had a higher aLDFA than children without (87° vs. 82°). There was a significant association between LDFA in the control group and children with Blount's disease in each of the three groups. This study found distal femoral varus deformity to be present in all groups of children with Blount's disease. In this study population, it was most significant in the infantile and adolescent groups when compared to a control group from the same population. Although further studies are required, the surgeon must always assess the distal femoral component in treating children with Blount's disease.