318 Patients were allowed immediate weight-bearing and rehabilitation similar to patients undergoing TKA.

Results: One elderly patient died in the immediate perioperative period of respiratory failure and one was lost to follow-up after placement in a nursing home. Average follow-up on 25 evaluable patients was 47 months (7122). Reoperations were for recurrent infection (six) and tibial component loosening (three). Five of the six with infection were treated with synovectomy, antibiotic beads and suppressive oral antibiotics, and all ve devices are still in place at an average of 54 months (range, 25100). One severely diabetic patient had had multiple episodes of sepsis unrelated to the prosthesis which eventually seeded the distal femur and required a hip disarticulation. MSTS functional scores at last follow-up averaged 49% (1380%) and HSS knee scores averaged 71% (3790%). Conclusion: DFR is a useful salvage procedure in low demand patients. Initially, six patients were scheduled for transfemoral amputation and three were conned to wheelchairs. Patients other than the hip disarticulation were at minimum household ambulators at last followup. In spite of problems with infection, most patients improved in overall function. At least one of the authors is receiving or has received material benets or support from a commercial source.

COMBINED ORTHOPAEDIC ASSOCIATIONS if a hip is pinned prophylactically it will not slip. The benets of prophylactic pinning are therefore determined by identifying the percentage of contralateral hips that will subsequently slip and then develop early osteoarthritis requiring total hip arthroplasty at a young age. In our cost analysis model, the cost of diagnosis, treatment, and follow-up was developed for the two treatment modes using actual hospital costs and standardised medicare reimbursement schedules for professional fees. Results: If a hip is not pinned prophylactically, there is a 7% risk of requiring a total hip arthroplasty in the contralateral hip at an early age due to osteoarthritis. This 7% is a combination of patients whose contralateral femoral epiphysis slipped moderately or severely and was pinned in a non-anatomic position (1.5% of the initial population) and patients whose substantial slip was not detected (5.5%). The risk of prophylactic pinning appears to be associated with a 0.3% chance of developing avascular necrosis. Other risks would include chances of infection or chondrolysis, although these have not been reported to date. If every patient is managed by the prophylactic pinning protocol, the total cost per patient, not including lost time at work or school, for pinning a slipped capital femoral epiphysis, prophylactically pinning the contra lateral side, and post-operative follow-up is $6266. Conversely, the total cost per patient for the second mode, pinning a slipped capital femoral epiphysis, post-operative followup and pinning of subsequent contralateral slips that are detected is $6864. Costs of later hip arthroplasty were not included. This analysis suggests that costs to a national health care system for treatment of SCFE would not increase by prophylactic contralateral pinning. Conclusions: Prophylactic pinning of the contralateral side is merited on the basis of both risk/benet and cost-effectiveness analyses. Ultimately, the decision must incorporate the physicians assessment of patient risk factors including: age, weight, co-morbidities, sports activities, the likelihood and feasibility of regular follow-up, and the patients and parents acceptance of prophylactic surgery. At least one of the authors is receiving or has received material benets or support from a commercial source.

PRIMARY SUBACUTE HAEMATOGENOUS OSTEOMYELITIS IN CHILDREN M.N. Rasool South African Orthopaedic Association, Durban, South Africa
Introduction and Aims: This disease has an insidious onset and develops as a result of increased host resistance and decreased bacterial virulence. The aim of this paper is to describe the spectrum of primary subacute forms of haematogenous osteomyelitis and highlight the difculties in diagnosis and the importance of histology. Method: Twenty-ve children aged two to 12 years were reviewed between 1990 and 2002. Symptoms and signs were mild. Complaints were present for two to eight weeks; laboratory tests were non-contributory. Bone scans were done in all patients. All patients had biopsy with curettage of cavitating lesions. Microscopy, culture and histology were done in all patients. Four patients had MRI scans. Results: There were 28 osseous lesions in 24 children. The anatomical sites were: the tibia, 24 lesions, femur three and ulna one. One child had multifocal involvement involving both tibiae and the ulna. The lesions were classied using the system of Roberts et al. Two lesions were in the epiphysis, six in the metaphysis and 20 in the diaphysis. Radiologically, the lesions resembled several benign and malignant conditions such as tuberculosis and fungal infections, Ewings sarcoma, leukaemia, osteosarcoma, chondroblastoma and osteoid osteoma. Bone scan was positive in all cases. Histology of bone showed features of subacute osteomyelitis inammatory cells, plasma cells and polymorphonuclear leukocytes. Staphylococcus aureus was cultured in eight patients. All children were treated with Cloxacillin for six weeks. Follow-up ranged from six months to ve years. All diaphyseal and epiphyseal lesions healed completely. Residual sclerosis was seen in metaphyseal lesions. No growth disturbance or articular changes were seen in this study. Conclusion: Primary subacute haematogenous osteomyelitis is uncommon. Metaphyseal and epiphyseal forms are more commonly reported in the literature. The diaphyseal form was the predominant type in this study. Bone lesions mimic benign and malignant conditions. Biopsy is mandatory. The diagnosis is made on histology. Staphylococus aureus is the usual causative organism, but difcult to culture. At least one of the authors is receiving or has received material benets or support from a commercial source.

PROXIMAL TENSOR FASCIA LATA (TFL) RELEASE IN PAEDIATRIC AND ADOLESCENT SNAPPING HIPS R. Vadivelu, C.N. Esler and C.J. Kershaw University Hospitals of Leicester NHS Trust, Leicester, UK
Introduction and Aims: External snapping hip, secondary to a tight thickened portion of the iliotibial band snapping over the greater trochanter is usually treated by Z-plasty. We report experience of managing painful paediatric snapping hips by a novel alternative, proximal TFL release. Method: Patients referred between 19892002 with painful snapping hips to the paediatric orthopaedic unit were retrospectively reviewed. Diagnosis was made on the basis of history and physical examination. All the patients had a plain radiograph of the hip and other causes of an audible snap were excluded. Most cases had failed to improve with physiotherapy pre-operatively. Fifteen patients (21 hips) had proximal tensor fascia lata release. All the patients had regular follow-up and were assessed for recurrence and complications. Results: There were two boys and thirteen girls. The mean age at the time of operation was 15 years and minimum post-operative follow-up was six months. Two hips required revision surgery. Eighty-one percent had a pain-free non-snapping hip at the time of discharge. The remainder were pain-free, with a reduced frequency of snapping. Conclusion: For painful snapping hips when conservative methods have failed, proximal release can offer good results with low morbidity in a paediatric population. At least one of the authors is receiving or has received material benets or support from a commercial source.

THE CHIARI OSTEOTOMY IN THE OLDER CHILD WITH EARLY PERTHES DISEASE A. Schepers and A.F. Robertson University of the Witwatersrand, Johannesburg, South Africa
Introduction and Aims: In a radiological study we evaluated the outcome of the Chiari osteotomy as a primary method of femoral head containment in patients with Perthes disease presenting at the age of eight years or older. Even when Salters prerequisites are met, the results of a Salter osteotomy is known to be poor in this group. Method: Thirteen patients underwent a Chiari osteotomy at a mean age of nine years and four months. The osteotomy was performed before femoral head deformity had occurred. The hip was considered to be at risk because of the late onset of the disease. Measurements were made on the pre-operative x-ray, the pre-operative arthrogram and the latest follow-up x-rays. Patients have been followed up for an average of ve years and four months. On the pre-operative arthrogram there was no femoral head deformity or hinging on abduction. At the time of surgery it was too early in the disease process to assign a hip reliably to a particular classication. During the follow-up period, 12 hips manifested as a Catterall group IV. Eleven hips became Herring type B and two Herring type C. Results: At latest follow-up all hips could be reliably graded according to the Stulberg classication. Currently, eight hips were a Stulberg type II and ve a Stulberg type III, but this might change as skeletal maturity is reached. It is clear that none of the hips will be a Stulberg type IV or V, which is seen in a signicant number of untreated hips at this age. Conclusion: The Chiari osteotomy achieves a congruent hip in this specic group of patients where a poor outcome would otherwise be anticipated. At least one of the authors is receiving or has received material benets or support from a commercial source.

THE TREATMENT OF BONE DEFECTS FOLLOWING CHRONIC PYOGENIC OSTEOMYELITIS IN CHILDREN M.N. Rasool South African Orthopaedic Association, Durban, South Africa
Introduction and Aims: Chronic pyogenic osteomyelitis, with pathological fractures, sequestra and subsequent bone defects, is still a major problem in developing countries. The treatment is challenging. Unhealthy skin with discharging sinuses make routine grafting procedures difcult. The aim of this paper is to describe the methods used to treat resulting defects. Method: Thirty-four children, aged one to 12 years, treated between 1991 and 2002, were reviewed. The tibia was involved in 24 children, femur (ve), radius (four), and ulna (one). Twenty-nine children had sequestrectomy and debridement. Five children presented with established bone defects. Bone defects measured 1 20cm. Four methods of grafting were used. Autogenous onlay grafts were used in defects <2cm in seven children. The Papineau technique was used in cavitating defects in two, bicortical segmented iliac crest grafts (1cm x 1.5cm) threaded over a Kirschner wire were used in 15 defects (<10cm) and bone transfer was performed in six children proximal bula to tibia (ve) and radius to ulna (one). Results: Three children required repeat grafting, one for fracture and three for non-union. All the remaining grafts incorporated by three to six months. Distal procedures including tibio bular fusion and bular epiphysiodesis were performed in six children. An above knee caliper was used in 11 cases till graft hypertrophy and consolidation occurred. All patients are ambulant presJ BONE JOINT SURG [BR] 2005; 87-B:SUPP III

A DECISION AND COST-EFFECTIVENESS ANALYSIS FOR PROPHYLACTIC PINNING OF SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) T. Renshaw Yale University, New Haven, CT, USA
Introduction and Aims: Practice standards vary considerably for prophylactic pinning the contralateral hip opposite a scfe. This work provides a data-driven framework with which to analyse the risks, benets, and costs of two modes of treatment: prophylactic pinning the normal side contralateral to a scfe versus observation; and pinning of subsequent slips. Method: A decision analysis model was constructed using the English language literature to estimate SCFE incidence and severity. The model framework assumes that