Introduction: Hip arthroscopy (HA) for adolescents is uncommonly performed and therefore evidence concerning outcomes are confined to small series. This study aimed to use registry data to describe procedures performed and outcomes in this group.

Methods: Patients aged 12-18 years who underwent HA between 1/01/2012 and 31/10/2020 were extracted from the UK Non-Arthroplasty Hip Registry along with patient characteristics and information about the femoral and acetabular procedure(s) performed and PROMS scores - iHOT-12 and EQ-5D.

Results: 259 HA were identified (62% female) with patient age ranging between 13.7 and 17.98 years (median 17.1 (IQR 1.1)). Cam excision was the most common femoral procedure performed (77 male(78%), 92 female(58%)) followed by labral repair (36 male(36%), 74 female46%)) and labral debridement (26 male(26%), 46 female(29%)). Chondral procedures were performed in approximately 20% of cases.

Compared to males, females’ iHOT-12 scores were significantly poorer pre-operative [mean 31.4 vs 40.9] and 12 months post-operatively [54.4 vs 75.2] with a similar trend observed for EQ-5D Index; female pre-op 0.48 vs male 0.57, female 6-month 0.63 vs male 0.74, female 12-month 0.70 vs male 0.83. Pre- and 12-month post-operative scores were available for 50 (19%) of the cohort with 71% of achieving the minimum clinically important difference for iHOT-12 and 57% significant clinical benefit at 12 months with no significant difference between sexes.

Conclusions: Compliance with follow-up was poor, however the majority of adolescent respondents benefited from HA with significantly improved outcomes maintained at 12 months.

Patients with residual erbs palsy, who lack adequate shoulder function, usually have shoulder subluxation or dislocation. This causes trumpeting which looks bad. Such children can be offered humeral derotation osteotomy. We wanted to analyse results after 4 years in cases we had done at least 4 years back. We studied 12 kids who underwent this procedure at least 4 years back. Before surgery 6 of them had dislocation, 3 had > 50 degree subluxation and 3 had less than 50 degree subluxation with internal rotation contracture. After the operation active external rotation improved 58 degrees and passive 62 degrees. This was maintained to active ER of 38 degres and passive of 48 degrees after 4 years. After a follow up of 4 years, all patients improvement of shoulder function of 4 points according to Mallet classification was maintained. Active internal rotation decreased from 6 to 4 points and passive internal rotation deteriorated from 6 to 5 points. There was no change in flexion and abduction movements and elbow movements. The trumpet sign was absent in none of our patients. Our results confirms that external derotational osteotomy is a safe and effective method to improve shoulder function in residual erbs palsy. It is a good alternative to extensive soft tissue release which may lead to poor midline function.

Introduction: The aim of our research group is to study the expression of various proteins in the contracted side tissue of relapsed clubfoot. We have already analysed the expression of over 70 proteins. Methods: Tissue samples were obtained during surgical procedures from patients with idiopathic clubfoot relapses after unsuccessful casting therapy. The methods of immunohistochemistry and image analysis, Real-time PCR and Mass Spectrometry were used in analyses to evaluate the differences in protein composition and gene expression. Results: We found a significant increase in the levels of 30 proteins that were overexpressed in the contracted medial side of the relapsed clubfoot. Conclusions: Until now, there have been only a small number of studies focusing on the possible etiology of clubfoot relapses. In his work, Professor Ponseti outlined an increase in collagen synthesis as a common pathological factor in relapses after Clubfoot therapy. We decided to pursue this topic in greater depth. The protein overexpression and the histological changes that have been detected by our team in the contracted side of the relapsed clubfoot can be discussed in terms of three pathways: fibroproliferation, tissue hypoxia and angioproliferation. These mechanisms are connected, and can possibly result in a relapse. Current therapeutical strategy worldwide is mostly based on repeated casting. Our results may shine a new light on studies of the etiology and pathogenesis of relapses in clubfoot therapy, and may contribute to the development of new therapeutical strategies for clubfoot therapy in the future.

Background: Acetabular morphology and orientation differs from ethnic group to another. Thus, investigating the natural history of the parameters that are used to assess both was a matter of essence. Nevertheless, clarification the picture of normal value in our society was the main aim of this study. However, Acetabular head index (AHI) and center edge angle (CEA) were the most sensitive indicative parameters for acetabular dysplasia. Hence, they were the main variables used in evaluation of acetabular development.
Methods: A cross-sectional retrospective study that had been done in a tertiary center where Computed tomography abdomen scouts’ radiographs of non-orthopedics patients were included. They had no history of pelvic or hips’ related symptoms or fractures in femur or pelvis.
Results: A total of 81 patients was included with 51% of them were males. The mean of age was 10.38± 3.96. Wiberg CEA was used, means of CEA were 33.71±6.53 and 36.50±7.39 for males and females, respectively. Nonetheless, AHI means were 83.81±6.10 and 84.66±4.17 for males and females, respectively. On the other hand, CEA was increasing by a factor 0.26 for each year (3-18, range). In addition, positive significant correlation was detected between CEA and age as found by linear regression r 2 0.460 (f(df1,79) =21.232, P ≤0.0001). Also, Body mass index (BMI) was positively correlated with CEA r 0.410, P 0.004).
Conclusion: This study shows that obesity and aging are linked to increased CEA. Each ethnic group has its own normal values that must be studied to avoid premature diagnosis.

Background:Ideal management of cerebral palsy remains a challenge for paediatric orthopaedicians.Indian scenario is further complicated by late presentation, social indifference, loss to follow-up and lack of resources.Methods:A retrospective study was conducted at our tertiary referral centre among cerebral palsy children who had undergone a gait analysis before surgery betweenJune 2018-February 2020.Instrumented Gait analysis was performed at state-of-the-art Gait Lab with 8 force plates,12 Infra-Red cameras and 2 video cameras (BTS, Italy) using Helen Hayes protocol.All children examined by 2 independent paediatric orthopaedicians- one Senior and another junior.Results:54 patients with mean-age of 12.2 years including 37-males and 17-females were included in the study.Commonest pattern was Diplegia followed by Hemiplegia.On the GMFCS scale, 40 were graded Level 2, while rest were either Level 3 or Level 1.Eight patients had underwent a previous surgical procedure at the time of Gait analysis while three had Botox injection.On clinical examination, Crouch gait was most common gait pattern followed by Jump gait, Toe walking and Intoeing gait.On comparing with clinical examination,Gait Analysis was found to be maximally useful in differentiating true equinus from apparent equinus;diagnosing functional Psoas/ Rectus tightness, as evidenced by absent femoro-pelvic dissociation; reducing the amount/ avoid release of Hamstrings in around 10 percent of cases.Conclusion:Our study suggested that Instrumented Gait Analysis objectively identifies gait deviations whenever there is subjective difference in assessment.It supplements clinical decision making especially in reducing the amount of releases compared to a static assessment.In few cases, it had picked up Psoas/ Rectus tightness which was not apparent to clinically. 

Introduction: In cases of neglected DDH with malformed hip joint The aim of the treatment is increasing femoral head coverage specially anterolateral side and establishing normal weight bearing across hip joint,If not addressed properly it can lead to development of the arthritis in the hip joint at early age and will need replacement.Innominate bone Osteotomy can be Redirectional , Reshape or Salvage osteotomy depending of the age of the patient and extent of the femoral head coverage needed.case report:A 14 year old female presented with mild pain and difficulty in walking.on x ray PBH there was subluxation and partial deformation of the left femoral head showing under coverage.shentons line was disrupted, acetabular index was 38 degrees s/o dysplasia hip.Neck shaft angle on CT scan was 150 degrees.head anteversion was more then 20 degrees.central edge angle was 17 degrees.3D Model was printed to plan the osteotomy intraoperatively.
2 stage surgery 4 weeks apart was planned and executed ,firstly salters osteotomy to increase the anterolateral femoral head coverage using Smith Peterson approach with bikini incision[ cosmetically better] and then proximal femoral varus derotation osteotomy and fixation using paediatric 95degree angle blade plate.Indomethacin was started to prevent heterotrophic ossification.There was improvement in the head coverage on x ray PBH and restoration of the shentons line and other parameters were within normal limits.Head was adequately covered without subluxation.At 3 year post op. There are no signs of arthritis in hip joint and patient is able to walk and do squatting.

The term single event multilevel surgery (SEMLS) describes surgical procedures to address muscle imbalance, contractures and musculoskeletal deformities secondary to spasticity. These include intramuscular or tendon lengthenings, tendon transfers and rotational osteotomies. The advantages include a shorter duration of hospitalization, decreased dependency and prevention of secondary contractures, thereby avoiding the ‘birthday syndrome’. Methods: 8 children with gait abnormalities (functionally, GMFCS levels 2 and 3) due to spastic cerebral palsy were included. All individuals underwent an individualized SEMLS, which included adductor and iliopsoas tenotomies, fractional lengthening of hamstrings, gastro-soleus recession, patellar tendon plication and supracondylar femoral extension osteotomies as deemed necessary. A short period of cast immobilization followed by an early return to physiotherapy and gait training was ensured. Ambulatory aids and orthoses were prescribed according the pattern of muscle involvement. Visual gait assessment using a slow-motion video analyzing software was done at 0, 6 and 12 months post-op. The range of motion, GMFCS and FMS were re-assessed at 12 months post-op.
Results: Maximum improvement of 5−25° was noted in knee flexion during the stance phase. Mobility on FMS deteriorated in the first 6 months post-SEMLS, followed by an improvement at 12 months. Although the gait improved, the impact of the interventions on the quality of life was debatable.
Conclusion: Although SEMLS did not improve the GMFCS level in any of the cases, it had tremendous bearing on the gait, with operated individuals demonstrating more efficient, energy-saving gait patterns and requiring lesser dependence on wheelchairs or cumbersome walking aids.

Children’s over one year of age with relapsed congenital clubfoot rigid clubfoot or unsuccessful treatment, or over pull of muscle tibialis anterior, It’s difficult to correct and tension tibilis anterior cause recurrence, so external hinge \ Salamehfi 2\modified. In relapsed cases of congenital clubfoot over one year until 11 years of age , we applied the external hinge distraction system Salamehfix 2 in order to make gradual reduction of all components of foot and a slight distraction of ankle joint in order to prevent its damage and a slight overcorrection of forefoot in order to wait a slight relapse .In Cases of relapsed congenital clubfoot over three years first we applied the external fixation and gradual foot reduction carried out , after 6 weeks we removed the external fixation and made split muscle transfer of tibialis anterior to the cuboid bone and external fixation system was removed and cast bellow knee was applied for another 6 weeks .we had control group of children which treated only with external fixation .Results From 1998 to 2016, 140 cases with relapsed congenital was treated ,first group 30 cases age from 1 to 3 years , from 3 to 11 years old 110 cases , second group 85 with combined external fixation and split muscle transfer and third group 25 cases with only external , in first group 7 cases relapsed , in second 3 cases relapse , in third 17 cases relapse and then they went again with repeated split muscle transfer.

In 10 % cases of CTEV management by Ponsetti’s technique, 15-20 times manipulation with plaster of paris is done by few Surgeons to achieve success. With modification, if Pirani’s score is > 3/6 , at fifth manipulation other procedures undertaken : i) limited soft tissue release with percutaneous method followed by POP cast; ii) Joshi’s External skeletal system (JESS) application in selected syndromic cases. Aim of the study was to assess efficacy and predictability . Out of 700 cases treated at CTEV 40 cases were treated with release percutaneously and 20 cases with JESS particularly in older age group. Result is satisfactory in 90 % cases. In difficult cases additional procedures result in better compliance and earlier correction.

OBJECTIVE:To determine the number of casts required to achieve satisfactory outcome inIdiopathic Clubfoot in children under 2 years age.
METHOD:This prospective study was conducted at Clubfoot Clinic,PonsetiResearch Training Centre at , JPMC Karachi, from January 2016 to December 2017.The patient with Idiopathic Clubfoot deformity under the age of 2 year with follow upduration of minimum one year were included.The patient with Postsurgical,Teretogenic,Paralytic Clubfoot deformities were excluded.
RESULTS:Out of 103 Children registered during Two year January 2016 to December 2017 the 25 (24.27%) were female and 78 (75.73%) male,The average age of the patients was 30.32±36.08 weeks. The satisfactoryresult found in 92:2,3.However thenumber of castvarieswith different age groups.The number of casts significantly increases as age exceeds in weeks after 3 months. This significantly increase parentsanxiety due to time & financial to travel to the clinic. The late presenting patient’s feet were quite resistant, requiring more than six cast before percutenous Tenotomy to achieve last correction ofEquinous component. Beside increasing age that needed more cast the other factors were: A. loosening plaster cast at toes & heel in Crawling age patient’s, by frequentkicking to bed in. To resolve this issue, soft fiber cast was used over Gypsona.
CONCLUSION:-Clubfoot deformity Ponseti method has been found very effective to achieveexcellent results withcomparable to published literature from westernworld. The method is simple, effective, inexpensive and ideally can be performed at outpatient departmentincluding Percutenous Tenotomy under local anaesthesia
Key Words: Clubfoot, Congenital,,Idiopathic, Pirani Score,Ponseti,Talipes Equino Varus.

Background: Although, various corrective osteotomy techniques have been described for correcting Paediatric cubitus varus, still, we are in search of the perfect technique that gives maximum possible deformity correction and cosmetic appearance that satisfies parents with minimal complications. We compared the outcomes of two technically sound osteotomy techniques having minimal post-operative lateral condyle prominence described in the literature.
Methods: Twenty children with unilateral cubitus varus resulting from malunited supracondylar humerus fractures were included. Randomization was done by computer-generated random slips. Ten cases each were operated by Modified Reverse step-cut osteotomy (MRSO) and Reverse V osteotomy (RVO) techniques, respectively. Clinical, radiological, and cosmetic appearance assessments were done at the final 2-year follow-up and compared between the two groups.
Results: The mean age of children in the MRSO and RVO groups is 9.9 years and 8.6 years, respectively. The mean pre-operative carrying angle in the deformed elbow of MRSO and RVO group was -20.5° and -19.5°, respectively, and the mean post-operative carrying angle in the corrected elbow of MRSO and RVO group was + 6.8° and + 6.5°, respectively. The lateral prominence index improved postoperatively in both groups, but was not statistically significant when compared between groups. There was no statistically significant difference (p > 0.05) when the clinical, radiological, and cosmetic outcomes were compared between the groups at final follow-up.
Conclusion: The surgeon can choose either one of these techniques based on their expertise since the results of both the techniques are comparable in terms of clinical, radiological, and cosmetic outcomes.

Introduction Cerebral Palsy (CP) is a non-progressive upper motor neuron disease due to injury to the immature brain and is one of the commonest neuromuscular disorders seen in children. As age advances, this disorder can lead to loss of muscular balance with a mixture of spasticity and contracture of affected joints. Materials and methods This is a study of 177 CP patients treated by us from January 2004 to December 2020 in GMFCS 1-4. There were 105 male and 72 female. Their age ranged from 2 to 24 years. The common presentation was spastic gait. Scissoring and equinus are common deformities in lower limb and pronation and wrist flexion deformity in the upper limb. Lower limbs were operated in 141 patients and upper limb in 39. Surgical procedures included soft tissue release, tendon transfer, corrective osteotomy and arthrodesis. 42 patients who presented with rigid deformities were treated with Ilizarov external fixator. Results 21 patients were lost in follow up. All patients improved significantly. Discussion CP is quite common in developing countries like India due to poor socio-economic conditions. Surgical treatment indicated when deformities and/or contracture interfere with activities of daily living. In early stages, most of the deformities and contracture can be corrected with soft tissue release to tendon transfer. At a later stage when deformities are rigid, they can be safely corrected with Ilizarov Fixator. Results were better in younger patients and patients in GMFCS 1-2. It is concluded what surgery can achieve in hours, physiotherapy cannot in years.

Chronic (neglected) Monteggia fractures though very rare are still not unusual in developing nations. Many treatment strategies have been described to manage chronic Monteggia fractures showing the complexities in its management. The purpose of this study is to highlight the management of missed or late presenting Monteggia fractures. We had 9 patients who presented with neglected Monteggia fractures with a mean age of 8.2 years. All children underwent open reduction of the radio-capitellar joint and angulation distraction osteotomy of ulna. An isolated angulation-distraction osteotomy of ulna with open reduction of joint was done in seven cases and in the remaining two cases additional annular ligament reconstruction was needed. We used a radio-capitellar pin in three of our cases where stability was of concern. The time gap between injury and presentation was from 7 months to 3.5 years. The mean follow-up period was 12 months. All ulna osteotomies healed uneventfully. Angulation-Distarction osteotomy of the ulna suffices in most cases of late presenting Monteggia fractures and the need for annular ligament reconstruction is based on intraoperative stability of radial head.