Preoperative positioning and the incision Psoas tenotomy, capsular exposure and the capsulotomy Facilitation of the Gigli saw osteotomy Sizing and procurement of the graft Displacement and fixation of the osteotomy Application of the hip spica Some questions are worthy of debate:- Can the osteotomy be safely combined with open reduction of the high dislocation? Should the osteotomy be fixed before reducing the femoral head? Are there alternatives to autogenous bone graft and K-wire fixation? Is minimally invasive surgery an option? Are the contraindications and alternatives to the Salter osteotomy fully appreciated?
Purpose of study: The aim of this study was twofold. Firstly, to compare a subjective clinical with an objective biomechanical assessment of operated clubfeet, using the optical Dynamic Pedobarograph foot pressure system. Secondly, to develop the latter into a classification system for future prospective studies and to complement clinical evaluation of patients, especially those with relapse. Methods and results: Sixteen patients (21 feet) were randomly selected from a pool of patients that had undergone clubfoot surgery. The operations were carried out by a single surgeon and consisted of a lateral-posteromedial peritalar release utilising the Cincinnati incision. Post-operatively, all feet were independently classified using a modified functional outcome scoring system. After completion of treatment, patients were referred to the Foot Pressure Analysis Clinic in Dundee where a novel method has been developed for the evaluation of clubfeet, using a static and dynamic foot pressure analysis system which provide both a graphical and analytical model for comparison. A three point grading scale was developed. The correlation between clinical and biomechanical outcomes in the 21 feet was calculated using Kendall’s tau rank test for non-parametric data. The t value was 0.3524, which was significant (p <
0.05). Conclusion: There is a significant correlation between the above mentioned subjective and objective outcome measurements. Biomechanical assessment can complement, support or change the line of management after clubfoot surgery. This technique has not only proven to be objective but also clinically valuable and cost effective. A prospective study to refine this biomechanical classification into a reliable predictor of relapse in surgically corrected clubfeet is currently being considered
The term “skeletal skew” recognises the oblique positioning or slanting of two similar halves of the body. It is preferred to asymmetry which describes a disproportion between two quantities with no common measure. In 1982 69 babies with skeletal skew were described in relation to the abduction contracture which affects the hip and leg on which the body lies in persistent sidelying. The skeletal skew was evident at birth in 24 cases, but only became obvious at 4–6 months of age in the remaining 45 cases. The adducted, uppermost hip looks spuriously dysplastic but the proximal femoral ossification centre is usually equal to the opposite side and the ultrasound scan is within normal limits. Associated skewing affects the skull (plagiocephaly) the neck (torticollis), thorax, pelvis and feet in a proportion of these squint babies. When the pelvic radiograph is assessed confusion is avoided if the ischial lower border is set horizontally; this corrects the apparent, increased acetabular inclination (angle) on the adducted side. The concomitant rotational artefact can be appreciated by reviewing differences in the widths of the iliac wings and obturator foramina, sacral-symphysial alignment and femoropelvic overlap. Of the 45 cases with pronounced skeletal skew manifesting at 3–4 months of age, the oblique positioning corrected during early walking age, as shown by calculating the difference between the abduction arcs of the two hips. The plagiocephaly, with flattening of the brow on the upper side, may persist until skeletal maturity. Follow up at 18 years was achieved in 41 of the 45 cases. There was one case of mild bilateral hip dysplasia and one case of a leg length discrepancy of 1.5 cm. In 40 cases the hips were normal clinically and radiographically although 5 had persistence of increased femoral anteversion. No splintage or stretching of the adducted hip had been undertaken during infancy and hence the great majority of cases with skeletal skew correct. Ultrasound assessment is advised in borderline cases for this relatively common condition which results in a referral rate of 5.3 per 1000 live births, compared to the Edinburgh neonatal splintage rate for hip instability of 3.8 per 1000 live births.
