We utilized a dry-bone model of the pelvis and proximal femur, set upon transparent Lucite plates with four mounting screws and adjustable struts, allowing measurable and reproducible pelvic tilt and rotation. Our protocol for osteotome placement at each of the osteotomy sites strictly followed the technique described by Ganz. A 30°, 15 mm bifid osteotome was used for imaging at the initial ischial osteotomy at the infracotyloid groove. A 30°, 2 cm straightedge osteotome was placed 4 cm below the pelvic brim to image the retroacetabular osteotomy on the quadrilateral plate. Various osteotome placements were imaged with the C-arm image intensifier to better define the risks of inferior and posterosuperior intraarticular osteotomies at each of these sites, respectively. A 600 osteotome oriented at 500 to the quadrilateral plate was also utilized. In addition, violation of the inferior quadrant of the joint as well as posterolateral slipping of the osteotome blade along the posterior column, were appreciated on all images of pelvic flexion and rotation. The false-profile view always confirmed the perpendicular orientation of the osteotome blade. The false-profile view allowed for accurate evaluation of the positioning of the 30°, 2-cm straightedge osteotome along the retro-acetabular osteotomy site. In the views obtained, the blade could be seen aligned parallel to the posterior surface of the acetabulum, while respecting the posterosuperior joint space with optimal step-off from the posterior column. False-profile and posterior judet views provided optimal visualization of the 60° osteotome on the quadrilateral plate. In addition, pelvic flexion and rotation did not impact the ability to visualize the inferior margin of the acetabulum in evaluating the potential for creating an inferior intraarticular osteotomy. The results of our study indicate that awareness of the appearance of ideal osteotome placements at each osteotomy site on AP and false profile C-arm image intensification will decrease the incidence of iatrogenic osseous and therefore neurovascular complications reported in the literature and reduce post-operative patient morbidity.
To evaluate the correction of complex congenital deformities of the lower limb by six axes deformity analyses and computer assisted correction using the Taylor TM Spatial Frame (TSF), from 1998 to 2000, the authors performed corrections of multiple congenital deformities in 24 lower limbs in 18 patients. There were 9 males and 9 females. There were a total of 29 bone segments, (8 femurs, 21 tibiae) in the 24 lower limbs that were corrected with application of the TSF. Our series included the following diagnoses and deformities: unknown skeletal dysplasia (2), achondroplasia (3), pseudoa-chondroplasia (1), multiple epiphyseal dysplasia (2), spondyloepiphyseal dysplasia (2), fibular hemimelia (3) tibia hemimelia (1), hypophosphatemic rickets (3), and posteromedial bowed tibia (1). The mean age of the patients was 15.4 years (range 0.5 to 35 years). The mean frame time until correction was 20.1 weeks (range 9 to 49 weeks). The mean follow up was 2.4 years (range 2 to 3.4 years). The apex of the deformity was directed posteromedial in 7, anterolateral in 6, medial in 5 and anteromedial in 5 patients. The mean coronal and sagittal plane deformities were 14.60 (range −230 to 400) and 70 (range, −400 to 280), respectively. The average magnitude of the deformity was 21.70 (range 90 to 470), and the plane of the deformity to the coronal plane was −23.30 (range −800 to 400). Eight patients had a mean lower extremity shortening of 12.3 mm (range 5 to 50 mm). One patient had 15° of internal rotation. With application of the TSF and the principles of distraction osteogenesis, we were able to reduce the coronal and sagittal plane deformities to 3.10 and 1.40 respectively. The overall mean magnitude of the deformity was decreased to 3.40. Shortening was corrected to an average of 3 mm. We experienced only 4 complications in the 24 limbs (16.7%). Complications in this patient group included one female patient with hypophosphatemic rickets who had residual deformity with significant lateral mechanical axis deviation due to inadequate translation. In addition, there were two superficial pin tract infections and one delayed union. Computer-assisted six axes deformity planning and TaylorTM Spatial Frame application effectively and safely correct complex congenital and developmental limb deformities and offer significant advantages over the well-established Ilizarov technique.
The role of femoral and acetabular version in correction of dysplasia of the hip has been undereported. Between June 1995 and September 2000, a Bernese periacetabu-lar osteotomy (BPO) was performed in 25 patients (26 hips) by the senior author with an average follow-up of 3.7 years (range 2-5 years). The mean age of the patients (24 female, 1 male) at the time of surgery was 29.4 years (range, 11.5 to 45 years). Only patients with a primary diagnosis of acetabular dysplasia were included in this series. The average Harris hip score increased from 55.1 (range 34–75) preoperatively to 92.9 (range 72–100) at the latest follow up (p<
0.0001). The mean pre-operative
The aim of our study was to assess the efficacy and complications of treatment of limb deformities using six axes deformity analysis and the Taylor TM Spatial Frame [TSF] Between January 1997 and March 2000, we treated 75 lower limbs in 66 patients with deformities. Patients were divided into four groups. The groups were Blount’s disease, congenital deformities, traumatic deformities, and a miscellaneous group. The data was prospectively collected. This was a consecutive series of the first 66 patients treated at our institution with the TSF. Deformity correction using the TSF is done with the aid of computer software. The mean age of the 66 patients was 18.7 years (range 0.5 to 72 years). The average frame time was 18.6 weeks (range 9 to 49 weeks). There was shortening present in 31 limbs with a mean of 18.6 mm (range 5 to 50 mm). Deformity correction with distraction osteogenesis was begun 7 days after the osteotomy. The mean length of time until correction was 6.7 weeks (range 3 to 13 weeks). There were a total of 10 complications (13.3%) in the series. 27 tibiae in 23 patients underwent correction with the TSF for Blount’s disease. There were 11 infantile and 16 adolescent forms. Correction of congenital deformity was performed in 20 tibiae and 8 femurs in 18 patients. There were 9 males and 9 females. There were 13 male and 8 female patients with traumatic lower limb injuries. There were 11 malunions and 10 nonunions (including 2 infected nonunions) that were corrected with the TSF. The TaylorTM Spatial Frame is an effective technique in treating deformity. Angulation, translation, shortening and rotation can be corrected simultaneously. Based on our results, we conclude that the TSF allows safe, gradual correction that is accurate and well tolerated.
To determine the effectiveness of six-axis analysis deformity correction using the Taylor Spatial Frame for the treatment of post-traumatic tibial malunions and non-unions, the study design was a retrospectively reviewed, consecutive series. Mean duration of follow-up: 3.2 years (range 2–4.2 years). All patients had been referred to a tertiary referral centre for deformity correction. Eighteen patients were included in the study (11 mal-unions and 7 nonunions). All deformities were post-traumatic in nature. The mean number of operations prior to the application of the spatial frame was 2.6 (range 1–6 operations). All patients completed the study. Six-axis analysis deformity correction using the Taylor Spatial Frame (Smith &
Nephew, Memphis, TN) was used for correction of post-traumatic tibial malunion or nonunion. Nine patients had bone grafting at the time of frame application. One patient with a tibial plafond fracture simultaneously had deformity correction and an ankle fusion for a mobile atrophic nonunion. Two patients had infected tibial nonunions that were treated with multiple debridements, antibiotic beads, and bone grafting at the time of spatial frame application. A rotational gastrocnemius flap was used to cover a proximal third tibial defect in one patient. The average length of time the spatial frame was worn, time to healing, was 18.5 weeks (range 12–32 weeks). The main outcome measurements involved assessment of deformity correction in six axes, knee and ankle range of motion, incidence of infection, and return to preinjury activities.
A percutaneous Achilles tenotomy was performed if the foot could not be dorsiflexed to 15 prior to application of the final cast. Tenotomies were performed as an office procedure under local anesthesia in 36 to 50 feet (72%).
This paper evaluates the ability to predict the need for a tenotomy prior to beginning the Ponseti method. The purpose of this study was to determine how one might predict the need for tenotomy at the initiation of the Ponseti treatment for clubfeet. Fifty clubfeet in thirty-five patients were treated with serial casting. The feet were prospectively rated according to two different scoring systems (Pirani, et. al. and Dimeglio, et. al.). The decision to perform a tenotomy was made when the foot could not be easily dorsiflexed 15 degrees prior to application of the final cast. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required a significantly greater number of casts (p<
0.05). Of 27 feet with an initial Pirani score 5.0, 85.2% required a tenotomy and 14.8% did not. 94.7% of the Dimeglio Type III feet required tenotomies. At the time of the initial evaluation there was a significant difference between those that did and did not require a tenotomy for multiple components of the Pirani hind-foot score. Following removal of the last cast there was no significant difference between those that did and did not have a tenotomy. In conclusion, children with clubfeet who have an initial score of 5.0 by the Pirani system or are rated as Type III feet by the Dimeglio system are very likely to need a tenotomy. Those that needed a tenotomy were more severely deformed with regard to all components of the hindfoot deformity, not just equinus. At the end of treatment feet were equally well corrected whether or not they needed a tenotomy.
A retrospective review of records, radiographs, Computerized Tomography (CT) scans, and Magnetic Resonance Imaging (MRI) scans was done from January 1994 to January 2002. Of the 35 patients in this study, 15 were females and 20 males. The mean age of the patients was 12.8 years (range, 9 to 19 years). There were 14 feet with bilateral coalition, 8 were right and 13 were left. There were 28 talo-calcaneal (all middle facets) coalitions of which 9 were bilateral. There were 20 calcaneo-navicular coalitions of which 5 were bilateral. One patient had a naviculo-cuboid coalition. The mean followup was 6.4 months (range, 1.2 to 36 months). Twenty six patients were treated conservatively with satisfactory outcome. Of the 23 patients operated 16 patients had good outcome, 5 had fair outcome, and 2 had poor outcome. Totally there were 10 out of 329 patients that had multiple tarsal coalition when we reviewed our cases and the literature. This gave an incidence of 3 percent of all the symptomatic tarsal coalition i.e. in other words the true incidence of multiple coalition is around 0.03%. This is the only study that establishes the incidence of multiple coalition.
To evaluate the effectiveness of a casting method for the early treatment of clubfoot deformity, a scoring system utilizing the French [DiMeglio], English [Pirani], and our functional rating system before and after each casting session was used to determine the final assessment and results of the Iowa [Ponseti] clubfoot technique. Between Jan 2000 to June 2001, 49 clubfeet in 33 patients were assessed before and after the Ponseti casting at a minimum of 1 year follow up using the Dimeglio/ Bensahel, Hospital for Joint Diseases functional rating, and Catterall/Pirani scoring system. Mean age of presentation was 7 weeks [range 0.5 to 28 weeks]. Patients had casting +/− percutaneous TAL. At latest follow up patients who were compliant for Foot Abduction Orthosis [n=32 feet] had good results without any deterioration in their scores. Of the noncompliant patients 8 patients remained good. Of the nine feet that had poor results, 5 improved with recasting, 2 required percutaneous TAL and 2 required open TAL and posterior release. Early treatment of the idiopathic clubfoot with serial [Ponseti] casting will be effective in over 90% of cases and patients will require no other treatment except for percutaneous tenotomy of the Achilles tendon. Early use of the Iowa [Ponseti] technique [before the age of one year] will significantly reduce the current number of extensive surgical procedures performed for the treatment of clubfoot. Moreover, it will produce more flexible and supple feet and avoid the problem of stiff, recurrent post-surgical clubfoot.
To assess the efficacy of software assisted correction using six axes analyses for Blounts deformity. Between 1998 and 2000, 22 tibiae in 19 patients underwent correction of Tibia Vara with the TSF. There were six females and thirteen males. There were 8 infantile and 14 adolescent forms. The mean patient age was 9.9 years (3–16 years). Shortening was present in 18 patients, averaging 11 mm (range: 3–30 mm). The mean follow up was 2.8 years (range: 2–4.1 years). The mean preoperative varus deformity was 16.5 degrees (range, 8 to 50 degrees) which improved to 0 degree (−2 to 2 degrees), and mean procurvatum deformity was 12.2 degrees (2 to 21 degrees) which improved to 0.1 degree (−2 to 3 degrees). The plane of the deformity was an average of 31 degrees (0 to 62 degrees) from the coronal plane and the mean magnitude of the deformity was 20.5 degrees (11.3 to 3.8 degrees) Taylor spatial frame uses the six axes software assisted analysis to correct complex deformities such as Blounts disease. It is very effective in correcting the Blounts deformity and has minimal complications.