Background Lower limb deformities include conditions such as leg length discrepancy, lower limb deficiency and associated angular and rotational deformities of the hips, knees, ankles and feet. Children with lower limb deformities often have physical limitations due to gait irregularities and pain. The differences in the appearance and function of their lower limbs can discourage participation in social, recreational and leisure activities, which may result in behavioural, emotional, psychological and social adjustment problems. The health-related quality of life (HRQL) of these children is often impacted due to the factors discussed above, as well as by the complex surgical procedures. Surgical treatment options for limb deformities in children vary from limb lengthening and reconstruction to amputation. The lack of evidence demonstrating superiority of either treatment options and their effect on HRQL limits the ability of healthcare providers to counsel families on the best evidence-based treatment option for them. This manuscript describes the international qualitative study which guided the development of a new patient-reported outcome measure (PROM). Individual semi-structured face-to-face interviews with children with lower limb deformities and their parents were conducted at five sites: Canada (2 sites), Ethiopia, India and the USA. Results Seventy-nine interviews were conducted at five international sites. Five main themes emerged from the qualitative interviews and formed the basis of the conceptual framework. These themes were: 1) appearance, 2) physical health, 3) psychological health 4) school and 5) social health. Conclusions Lower limb deformities have a substantial impact on the HRQL of children. The concepts of interest identified in our study were similar across children from all countries. The conceptual framework guided the development of outcome scales specific to these patients. The information about the impact of various treatment options on the HRQL of children with lower limb deformities, collected using this new PROM, could be used to inform parents and children about outcomes (physical, social, psychological) associated with specific treatment options. This information could supplement other objective outcome information (e.g., complication rates, how the leg will look, etc.) to help families to come to a more informed decision on a child’s course of treatment.

Level IV, retrospective case series.

Introduction: Trimalleolar fracture of the ankle joint is a significant injury causing long-term disability. We reviewed consecutive trimalleolar ankle fractures operated at our hospital to know the union rate, complication rate and morbidity associated with these fractures.Methods and materials: We retrospective reviewed 37 consecutive patients with trimalleolar fractures operated over two year period between 2007 and 2009. There were 14 men and 23 women with an average age of 52 (19-88) years. Missing a step either over kerb or stairs was the most common mechanism of injury (47%). 76% of patients had fracture dislocation of the ankle joint, out of which 3% were open. 85% of the patients required reduction as emergency procedure to obtain stable mortise either in A&E or Theatre. 50% were operated within 3 days after injury. Posterior malleolus was fixed if it was >1/3rd of articular size or if there was step in the articular surface after the medial and lateral malleolus were fixed. All patients were followed at 2 weeks, 6 weeks and 3 months in the fracture clinic, until fracture union.Results: 35% of the patients required more than two attempts to reduce the ankle mortise. 18.9% patients required posterior malleolar fixation. 16.2% required syndesmotic screw to maintain the mortise reduced. All patients had union of fracture by 3 months. 3% patients had wound problems. 6% of patients had either DVT/nonfatal PE post operatively. 32% patients required reoperation either to remove syndesmotic screw or implant removal. 25% had longterm pain even after the fracture union and rehabilitation.Conclusion: Trimalleolar fractures are highly unstable. There is significant thromboembolism rate in these patients and require close attention and prophylaxis. There is high reoperation rate. Trimalleolar fractures are associated with long-term morbidity in terms of pain, stiffness and arthritis. There is need for specialist care for these patients. Long-term followup studies are required to know the outcome of trimalleolar fracture of ankle joint.

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