A quite accurate prediction of the number of casts and the need for tenotomy can be performed in most cases. The Dimeglio score showed slightly better accuracy in predicting both steps of Ponseti treatment.

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse). In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23. Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant. Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor.

Using Pirani score in guiding indication for tenotomy may imply different decisions in a portion of cases, which should be considered when comparing series.

Ninety-one children who had been treated for fractures of the proximal humerus (59 metaphyseal fractures; 32 epiphyseal fractures) from 1980 to 1992 at an average age of 10.7 years (range 3 to 14 years) were reviewed. In 82 cases a nonsurgical treatment (Desault bandage in 11 cases, hanging cast in nine cases, closed reduction and shoulder spica cast in 62 cases) was performed. At a mean time of 7.2 months (range 1 to 156 months), 96% of patients showed good/excellent clinical results. In 15 cases, radiographs were reviewed at a mean follow-up of 8 years (range 1 to 23.5 years): just a slight metaphyseal or meta-diaphyseal varus deformity was found in three cases. In nine cases surgery was required. Patients were reviewed by clinical examination at a mean time of 34.8 months (1-150 months), and in six cases radiographs were reviewed at a mean time of 5 years and 5 months (range 1 to 12.5 years) after surgery. In one case, a septic process occurred, that caused a severe deformity of the epiphysis and a noticeable functional deficit. Good/excellent clinical and radiographic results were achieved in the other patients. Conservative treatment of fractures of the proximal humerus in children is recommended. Surgery should be reserved for specific cases.

We report results of surgical treatment of ten knees affected by patellar dislocation in six children with Down syndrome. Four knees showed a dislocatable patella (grade III according to Dugdale), two a dislocated reducible patella (grade IV) and four a dislocated irreducible patella (grade V). Symptoms included frequent falls, limping and pain. In all the cases a Roux-GoldthwaitCampbell procedure was performed. Mean age at surgery was 10 years (range 6 years and 6 months to 13 years and 4 months). Patients were reviewed at an average follow-up of 8 years and 8 months (range 3 years and 6 months to 11 years and 5 months). None showed signs of recurrence of the dislocation. The median Lysholm score improved from 57.5 to 91/100. Statistical analysis showed a significant effectiveness of the procedure in improving function, and that surgery was significantly more effective in patients with more severe disability.

Arthrogryposis includes heterogeneous disorders, characterized by congenital contractures of multiple joints. Knee involvement is very common (38-90 % of patients with amyoplasia) ranging from soft-tissue contractures (in flexion or hyperextension) to subluxation and dislocation. Flexion contractures are more common and disabling and show significant resistance to treatment and rate of recurrence. Surgical procedures vary with severity of contracture and patient age and include soft-tissue release, femoral shortening-extension osteotomy, gradual correction with Ilizarov, and femoral anterior epiphysiodesis. The presence of pterygium greatly complicates treatment, given the high rate of complications reported. Hyperextension deformities (recurvatum, anterior subluxation, and dislocation) have better prognosis for walking ability. Surgical options include percutaneous (or mini-open) quadriceps tenotomy, open quadricepsplasty, and femoral shortening osteotomy with limited arthrotomy. Knee dislocations usually require surgery and should be reduced early.

This study confirmed that dynamics of correction in clinical setting correspond essentially to theoretical principles of Ponseti method. Muscle abnormalities are not uncommon in clubfeet and have great influence on the progression of correction. If abnormalities are recorded, their evolution along the treatment should be monitored. A more objective evaluation would be required.

One thousand nine hundred and eighty-four children who had received conservative treatment for shaft (diaphyseal and metadiaphyseal) fractures of lower limbs (1162 femoral, 822 tibial fractures) at an average age of 8.5 years (range 0-14 years) were reviewed by clinical and radiographic investigations at an average follow-up of 6.6 years (1-15 years). Particularly, two main features were evaluated: remodelling of (angular and rotational) deformities and post-traumatic overgrowth. Mechanisms underlying these processes are discussed, based on a review of the literature, and parameters conditioning their evolution are analysed. Finally, criteria for an acceptable reduction (and limits for residual deformities that may be tolerated) at the time of conservative treatment are proposed.