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IntroductionIdiopathic congenital talipes equinovarus (CTEV) is the most common congenital limb deformity. Non-operative intervention using the Ponseti method has shown to be superior to soft tissue release and has become the gold standard for first-line treatment. However, numerous deviations from the Ponseti protocol are still reported following incomplete correction or deformity relapse. Significant variation in treatment protocols and management is evident in the literature. Reducing geographical treatment variation has been identified as one of The James Lind Alliance priorities in children’s orthopaedics. For this reason, the British Society of Children’s Orthopaedic Surgery (BSCOS) commissioned a consensus document to form a benchmark for practitioners and ensure consistent high quality care for children with CTEV.Methods and analysisThe consensus will follow an established Delphi approach aiming at gaining an agreement on the items to be included in the consensus statement for the management of primary idiopathic CTEV up to walking age. The process will include the following steps: (1) establishing a steering group, (2) steering group meetings, (3) a two-round Delphi survey aimed at BSCOS members, (4) final consensus meeting and (5) dissemination of the consensus statement. Degree of agreement for each item will be predetermined. Descriptive statistics will be used for analysis of the Delphi survey results.Ethics and disseminationNo patient involvement is required for this project. Informed consent will be assumed from participants taking part in the Delphi survey. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the consensus statement.

Objectives Selective dorsal rhizotomy (SDR) is used to improve spasticity, gait, and pain in children with spastic diplegia. There is growing evidence supporting its long-term benefits in terms of functional outcomes, independence, and quality of life. There is, however, little contemporary work describing the surgical morbidity of this irreversible procedure. The purpose of this study is to evaluate the surgical outcomes and complications of SDR at a single United Kingdom center. Methods Demographics, surgical, postoperative, and follow-up data for all patients undergoing SDR between 2011 and 2016 were collected from medical records. Results Preoperative Gross Motor Function Classification System levels in 150 consecutive patients were II (35%), III (65%), and IV (1%). Median age was 6 years and 58% were male patients. There were no deaths, cerebrospinal fluid leaks, returns to theater, or readmissions within 30 days. There were no new motor or sphincter deficits. Postoperative neuropathic pain was reported by 5.3% and sensory symptoms by 8.7%. Other complications included: postoperative nausea and vomiting (19.3%), superficial wound infection (3.3%), urinary retention (1.3%), headache (6.7%), and urine or chest infection (4.7%). Follow-up data were available for all patients (93% to 12 months, 72% to 24 months). Persistent neuropathic symptoms were reported in 6.5% at 24 months. Conclusions SDR using a single-level approach is a safe procedure with low surgical morbidity. This study complements the growing evidence base in support of SDR for spastic diplegia and should help inform decisions when considering treatment options.

Achondroplasia is a common cause of short stature. The condition is often encountered on the Trauma and Orthopaedic FRCS examination. This review covers the aetiology, clinical and radiographic features. Current general and orthopaedic treatments are discussed including potential medical developments with natriuretic peptide.

Stott NS, Atherton WG, Mackey AH, Galley IJ, Nicol RO, Walsh SJ. The reliability and validity of assessment of sagittal plane deviations in children who have spastic diplegia. Objective To assess the reliability and validity of a newly described classification of sagittal plane alignment in spastic diplegic gait. Design Twenty split-screen videos of children with spastic diplegia, Gross Motor Function Classification System levels I to III, were viewed on 2 occasions, 6 weeks apart, by 5 raters. The sagittal plane alignments of the right and left lower limbs in gait were classified separately as true equinus, jump knee, apparent equinus, or crouch, based on the published classification. A fifth category, nonclassifiable, was used if classification was not possible. We then used sagittal plane kinematic data to confirm the classification for each subject and these were compared with rater classification scores, which used the video information only. Setting Tertiary-level children's hospital. Participants Three pediatric orthopedic surgeons and 2 pediatric orthopedic residents. Interventions Not applicable. Main Outcome Measures Gait classification scores derived from visual observation were compared among and within raters. The gait classification scores derived from visual observation were compared with the scores derived from sagittal plane kinematic data to assess validity. Results A moderate correlation was found among the 5 raters within each session, with an interrater weighted κ score of .45 in session 1 and .49 in session 2. The intrarater, weighted κ scores showed a moderate to substantial level of agreement between sessions, ranging from .50 to .68. The classification scores of individual raters had moderate validity when compared with classifications derived from the sagittal plane kinematic data. However, there was a substantial level of agreement between the consensus opinion and the classification obtained using the kinematic data as well as the video recordings (weighted κ=0.8). Conclusions This classification has only moderate reliability and validity when a single experienced rater views the 2-dimensional gait videos. However, the consensus opinion derived from the scores of 5 raters considerably improves the validity of the assessment.

Pyomyositis of the obturator externus muscle is a rare cause of limp and hip pain in children. The exact etiology of the condition remains poorly understood, although a mechanism of transient bacteremia in association with increased muscle susceptibility has been proposed. This case describes the course of a rather than 1 child from presentation to diagnosis and demonstrates the requirement for magnetic resonance imaging in establishing a diagnosis.

The head-at-risk signs are used as prognostic indicators in Legg-Calvé-Perthes disease. These signs have been assessed only once regarding inter-observer reliability, however. Intra-observer reliability seems not to have been studied to date.76 anteroposterior pelvic radiographs of unilateral Legg-Calvé-Perthes disease were assessed by 5 observers on 2 occasions, in order to assess the inter- and intra-observer reliability in identifying head-at-risk signs. The observers included 1 consultant pediatric orthopaedic surgeon, 1 consultant radiologist, 2 specialist registrars and 1 senior house officer. Inter- and intra-observer reliabilities were assessed using the kappa coefficient.The intra-observer reliability was good for lateral subluxation and metaphyseal cystic changes, moderate for lateral calcification, and fair for Gage's sign and horizontal growth plate. The inter-observer reliability was moderate for lateral subluxation, fair for lateral calcification and metaphyseal cystic changes, and slight for Gage's sign and horizontal growth plate.There was considerable variation in the diagnosis of the head-at-risk signs between observers. This makes the classification difficult to use in clinical practice.