Aims. To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus
Aims. To assess if congenital
Aims. To assess if older symptomatic children with club
Purpose: Severe trauma in the mid-foot induces various
Background. Weightbearing computed tomography scans allow for better understanding of foot alignment in patients with Progressive Collapsing
Progressive collapsing
Aims. Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and
At our institution surgical correction of symptomatic
flat
The equinovarus hind
The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the
Introduction. Congenital deficiency of the fibula frequently presents as spectrum of musculoskeletal anomalies involving the ipsilateral hip, femur, knee, tibia/fibula, ankle and foot. Until recently the treatment of choice for sever type-II fibular hemimelia has been Syme’s or Boyd’s amputation. The present technique of limb lengthening with distraction osteogenesis have proved to be a valid alternative. The study shows that simultaneous treatment of tibial and
In a consecutive series of 124 children with spina bifida we found that 220 (89%) of the 248 feet were deformed: 70 had a calcaneus deformity; 126 were in equinus; 16 were in valgus; 3 were in varus; and 5 had convex pes valgus. Operations were performed on 171 (78%) of the deformed feet. Spasticity of the muscles controlling the foot was detected in 36 (51%) of the 70 calcaneus feet and in 22 (17%) of the 126 equinus feet. The deformities were symmetrical in 94 children. There is a high incidence of
Introduction Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavo-varus
Introduction. Corrective fusion for the unstable deformed hind foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams. Patients and methods. We present our results with a series of 42 hind foot deformity corrections in 40 patients from a tertiary level teaching hospital in the United Kingdom. The mean patient age was 59 (33–82). 16 patients had type1 diabetes mellitus, 20 had type 2 diabetes and 4 were non-diabetic. 18 patients had chronic ulceration. 17 patients were ASA 2 and 23 were ASA grade 3. All patients had acute single stage correction and Trigen hind foot nail fusion performed through a standard technique by the senior author and managed peri-operatively by the multidisciplinary team. Our outcome measures were limb salvage, deformity correction, ulcer healing, weight bearing in surgical shoes and return to activities of daily living (ADL). Results. At a mean follow up of 37 months (7–79) we achieved 100% limb salvage initially and 97% healing of arthrodesis. One patient with persisting non-union has been offered amputation. Deformity correction was achieved in 100% and ulcer healing in 89%. 72.5% patients are able to mobilize and manage independent ADL. There were 11 patients with one or more complications including metal failure, infection and ulcer reactivation. We performed nine repeat procedures including one revision fusion and one vascular procedure. Conclusion. Single stage corrective fusion for hind
Between January 1996 and December 2006, 130 patients were operated on for acquired varus equinus
We reviewed the outcome of 30 patients treated with an Ilizarov frame for resistant
This paper outlines a valid and reliable, clinical method of assessing the amount of deformity in the congenital clubfoot. Clinical &
MRI clubfoot scoring systems were developed to score the amount of deformity clinically &
to image &
score osteochondral pathology of the club-foot -MRI Total Score (MTS), MRI Hindfoot Contracture Score (MHCS), &
MRI Midfoot Contracture Score (MMCS), Clinical Total Score (CTS), Clinical Hindfoot Contracture Score (CHCS), Clinical Midfoot Contracture Score (CMCS). Three independent observers tested the Clinical scoring systems Inter-observer reliability (Kappa Statistic) over one hundred consecutive clubfeet. Kappa values were CTS-0.92, CMCS-0.91, and CHCS-0.86- (almost perfect inter-observer reliability). Nineteen clubfeet were scored clinically and by thirty-eight MRI evaluations during treatment. Validity was evaluated by correlating the MRI and clinical scores (Pearson Correlation). The Pearson Correlations between clinical &
MRI scores were CTS: MTS = 0.786 (P<
0.01), CHCS: MHCS = 0.712 (P<
0.01) &
CMCS: MMCS = 0.651 (P<
0.01). All correlations were highly significant confirming validity. There is neither reliability nor validity in current methods of clubfoot assessment. This paper outlines a method of assessing the amount of deformity in the congenital
In a prospective study over 11 years we assessed the relationship between neonatal deformities of the foot and the presence of ultrasonographic developmental dysplasia of the hip (DDH). Between 1 January 1996 and 31 December 2006, 614 infants with deformities of the foot were referred for clinical and ultrasonographic evaluation. There were 436 cases of postural talipes equinovarus deformity (TEV), 60 of fixed congenital talipes equinovarus (CTEV), 93 of congenital talipes calcaneovalgus (CTCV) and 25 of metatarsus adductus. The overall risk of ultrasonographic dysplasia or instability was 1:27 in postural TEV, 1:8.6 in CTEV, 1:5.2 in CTCV and 1:25 in metatarsus adductus. The risk of type-IV instability of the hip or irreducible dislocation was 1:436 (0.2%) in postural TEV, 1:15.4 (6.5%) in CTCV and 1:25 (4%) in metatarsus adductus. There were no cases of hip instability (type IV) or of irreducible dislocation in the CTEV group. Routine screening for DDH in cases of postural TEV and CTEV is no longer advocated. The former is poorly defined, leading to the over-diagnosis of a possibly spurious condition. Ultrasonographic imaging and surveillance of hips in infants with CTCV and possibly those with metatarsus adductus should continue.
Introduction and Aims: The role of tendon transfer in progressive hereditary motor sensory neuropathy (CMT) is controversial. This paper examines a large single surgeon cohort and reviews the surgical outcome of tendon transfers against a large group of CMT patients represented by the Australian CMT Health Survey 2001. Method: A retrospective review was carried out in 19 patients (36 feet) with CMT, managed surgically by a single author (GW). Functional outcomes were measured using standard tools such as SF36, American Orthopaedic Foot and Ankle Score (AOFAS) rating scale, and a clinical review including a specially designed questionnaire. Quality of life and functional outcome has been compared with the Australian CMT Health Survey 2001 in 324 patients. Results: Nineteen patients were managed with tendon transfers, typically by flexor to extensor transfer of toes, combined with peroneus longus release and transfer, and tibialis posterior transfer. The Levitt classification of the objective results of surgery rates 79% of patients as having good-excellent outcomes. Eighty-nine percent of patients report an improvement overall with surgery, specifically 53% report improvement in pain, 79% feel their gait has benefited, and 58% report an improvement in the appearance of their
We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of ≥5 predicted the need for tenotomy (p <
0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey. We believe that the Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme.
This study aimed to objectively define gait derangements and changes before and after Tibialis Anterior Tendon Transfer surgery in a group of patients treated using the Ponseti method. 21 feet in 13 patients with Ponseti treated clubfoot who showed supination in swing on clinical examination, underwent gait analysis before, and approximately 12 months after, Tibialis Anterior Tendon transfer. 3–4 weekly casts were applied prior to the surgery, which was performed by transfer of the complete TA tendon to the lateral cuneiform. A parental satisfaction questionnaire was also completed.Purpose
Methods
6 revisions (13%) were performed in Group A (5 of these related to instability – all preoperatively varus of >
20 degrees). 10 revisions (8%) were performed in Group B (2 related to instability). 6 ankles underwent intra-operative deltoid release and 6 had pre or post-operative calcaneal osteotomy. Only one of these required revision for instability. 4 ankles underwent post-operative lateral ligament reconstruction. These ankles all failed due to instability. The mean postoperative American Foot and Ankle Society score in Group A was 85, compared to 78 in Group B.
To analyze whether the addition of risk-based criteria to clinical examination-based selective ultrasound screening would increase the rates of early detected cases of developmental dysplasia of the hip (DDH) and decrease the rate of late detected cases. A systematic review with meta-analysis was performed. The initial search was performed in the PubMed, Scopus, and Web of Science databases in November 2021. The following search terms were used: (hip) AND (ultrasound) AND (luxation or dysplasia) AND (newborn or neonate or congenital).Aims
Methods
Residual club foot (CTEV) is a challenging deformity which may require transfer of the tibialis anterior tendon to a more lateral position. The senior author has developed a modified SPLATT for residual forefoot supination in CTEV. We describe the SPLATT procedure and evaluate clinical and radiological outcomes of 11 patients(14 feet) (mean follow up 6.6 years; range 5.5–8.9) (mean age 6.9 years; range 2.9–10.0). Two patients had cerebral palsy, 1 spina bifida and 1 juvenile rheumatoid arthritis, the remaining 7 patients were ideopathic. Outcome measures based on patient centred assessment of function and foot appearance, by using the patient applied assessments of Chesney, Utukuri and Laaveg &
Ponsetti (there is increasing recognition that doctor-centred or radiograph-based scoring systems do not tally well with patient satisfaction). Objective assessment of outcome was provided by measurement of certain radiological parameters on the immediate pre-operative and the follow up weight-bearing radiographs (1st ray angle, talar-1st metatarsal angle, talar-2nd metatarsal angle, talo-calcaneal angle). The calcaneal line passing through the medial 1/3 of the cuboid or medial to the fourth metatarsal was also noted. The Blecks grade was recorded (pre-op 100% moderate-severe; post-op 88% mild-moderate). Parents assessed outcome based upon ‘best level of activity’, functional limitation and willingness to recommend treatment to others. Mean Chesney score at the time of follow up was 12.3 (8 to 15); mean Utukuri score was 15.8 (10 to 24); Laaveg and Ponsetti score was 81.5 (67 to 95). The best activity level achievable was ‘unlimited’ in 4 patients, ‘football’ in 4 patients, ‘running’ in 1 and limited by an associated condition in 2 patients (1 juvenile rheumatoid arthritis; 1 cerebral palsy related spastic paraparesis). All patients/parents indicated that they would undergo the same procedure again. One patient had delayed wound healing treated successfully with dressings. The 1st ray angle pre-operatively was 61.2°(range 50–70°), post-operatively it was 62.1°(range 50–81°). The talar-1st metatarsal angle was 28.8°(range 15–44°) pre-operatively and 19.1°(range 4–34°) post-operatively. The pre and post–operative talar-2nd metatarsal angles were 22.5°(range 0–35°) and 12.3(range 0–29°) respectively, the talo-calcaneal angle was 17.5°(range 10–35°) and 13.7(range 5–20°) respectively. The pre and postoperative lateral talo-calcaneal angles were 34.5°(range 25–40°) and 30.6(range 13–45°). The recognition that patient orientated subjective assessment is gaining in acceptance, and confirm patient satisfaction with function, cosmesis and pain levels with the SPLATT procedure. More traditional radiological outcome measures also confirm that the modified SPLATT is a safe, effective and acceptable procedure.
Hind
The December 2022 Foot & Ankle Roundup. 360. looks at: Evans calcaneal osteotomy and multiplanar correction in flat
The December 2023 Children’s orthopaedics Roundup. 360. looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial tendon transfers in cerebral palsy equinovarus
Aims. In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot
Introduction. Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross
3D accurate measurements of the skeletal structures of the foot, in physiological and impaired subjects, are now possible using Cone-Beam CT (CBCT) under real-world loading conditions. In detail, this feature allows a more realistic representation of the relative bone-bone interactions of the foot as they occur under patient-specific body weight conditions. In this context, varus/valgus of the hindfoot under altered conditions or the thinning of plantar tissues that occurs with advancing age are among the most complex and interesting to represent, and numerous measurement proposals have been proposed. This study aims to analyze and compare these measurements from CBCT in weight-bearing scans in a clinical population. Sixteen feet of diabetic patients and ten feet with severe adult flatfoot acquired before/after corrective surgery underwent CBCT scans (Carestream, USA) while standing on the leg of interest. Corresponding 3D shapes of each bone of the shank and hindfoot were reconstructed (Materialise, Belgium). Six different techniques found in the literature were used to calculate the varus/valgus deformity, i.e., the inclination of the hindfoot in the frontal plane of the shank, and the distance between the ground and the metatarsal heads was calculated along with different solutions for the identification of possible calcifications. Starting with an accurate 3D reconstruction of the skeletal structures of the foot, a wide range of measurements representing the same angle of hindfoot alignment were found, some of them very different from each other. Interesting correlations were found between metatarsal height and subject age, significant in diabetic feet for the fourth and fifth metatarsal bones. Finally, CBCT allows 3D assessment of
Introduction. Pes cavovarus is a
Introduction. Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique. Methods. This is a prospective observational case series of all patients who underwent surgical reconstruction of Charcot
A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing
Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative
Introduction. Limb-length discrepancy (LLD) is a common postoperative complication after total hip arthroplasty (THA). This study focuses on the correlation between patients’ perception of LLD after THA and the anatomical and functional leg length, pelvic and knee alignments and foot height. Previous publications have explored this topic in patients without significant spinal pathology or previous spine or lower extremity surgery. The objective of this work is to verify if the results are the same in case of stiff or fused spine. Methods. 170 patients with stiff spine (less than 10° L1-S1 lordosis variation between standing and sitting) were evaluated minimum 1 year after unilateral primary THA implantation using EOS® images in standing position (46/170 had previous lumbar fusion). We excluded cases with previous lower limbs surgery or frontal and sagittal spinal imbalance. 3D measures were performed to evaluate femoral and tibial length, femoral offset, pelvic obliquity, hip-knee-ankle angle (HKA), knee flexion/hyperextension angle, tibial and femoral rotation. Axial pelvic rotation was measured as the angle between the line through the centers of the hips and the EOS x-ray beam source. The distance between middle of the tibial plafond and the ground was used to investigate the height of the foot. For data with normal distribution, paired Student's t-test and independent sample t-test were used for analysis. Univariate logistic regression was used to determine the correlation between the perception of limb length discrepancy and different variables. Multiple logistic regression was used to investigate the correlation between the patient perception of LLD and variables found significant in the univariate analysis. Significance level was set at 0.05. Results. Anatomical femoral length correlated with patients’ perception of LLD but other variables were significant (the height of the foot, sagittal and frontal knee alignment, pelvic obliquity and pelvic rotation more than 10°). Interestingly some factors induced an unexpected perception of LLD despite a non-significant femoral length discrepancy less than 1cm (pelvic rotation and obliquity, height of the foot). Conclusions. LLD is a multifactorial problem. This study showed that the anatomical femoral length as the factor that can be modified with THA technique or choice of prosthesis is not the only important factor. A comprehensive clinical and radiological evaluation is necessary preoperatively to investigate spinal stiffness, pelvic obliquity and rotation, sagittal and coronal knee alignment and
Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of
Introduction. Amputation or disarticulation is a reliable option for management of severe
The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic
Aims. The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet. Methods. In this randomized prospective trial, 23 idiopathic clubfeet were immobilized with plaster-of-Paris casts and 23 clubfeet were immobilized with a splint made of Woodcast that encircled only two-thirds the circumference of the limb. The number of casts or splints needed to obtain full correction, the frequency of cast or splint-related complications, and the time taken for application and removal of the casts and splints were compared. Results. The mean number of casts required to obtain full correction of the deformity (Pirani Score 0) was 4.35 (95% confidence interval (CI) 3.74 to 4.95) when plaster-of-Paris was used and 4.87 (95% CI 4.33 to 5.41) when the Woodcast splint was used (p = 0.190). The time required for application and removal of the Woodcast splint were significantly less than that required for application and removal of plaster-of-Paris casts (p < 0.001). Woodcast splint-related complications were not more frequent than plaster-of-Paris cast related complications. Conclusion. Though Woodcast splints covering two-thirds of the circumference of the lower limbs of infants were effective in maintaining the correction of
Progressive collapsing
Introduction. Patients undergoing total knee arthroplasty (TKA) with end-stage osteoarthritis of knee have secondary foot and ankle pathology. Some compensatory changes occur at ankle and subtalar joint secondary to malalignment and deformity at the knee joint. Purpose was to evaluate the changes in hindfoot malalignment and
A cavovarus
Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg
Of the 34 723 infants born between 1 June 1992 and 31 May 2002, the hips of 2578 with clinical instability or at-risk factors for developmental dysplasia of the hip were imaged by ultrasound. Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the ‘at-risk’ groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when
Background. The complex deformities in cavovarus feet may be difficult to assess and understand. Weight-bearing CT (WBCT) is increasingly used to evaluate complex deformities. However, the bone axes may be difficult to calculate in the setting of severe deformity. Computer-assisted 3D-axis calculation is a novel approach that may allow for more accurate assessment of
Introduction. Hind
Introduction and Aims: Fibular hemimelia presents a problem with leg length discrepancy and equinovalgus
Treatments of complex