Introduction: Tibialis anterior tendon transfer (TATT) is a common procedure for recurrence in clubfeet treated with the Ponseti method. Fixation usually includes passing the tendon through a drill hole in the lateral cuneiform using sutures brought out through the plantar aspect of the foot. Drilling of the tunnel and passing the sutures holds potential for neurovascular damage. We performed a cadaver study to evaluate plantar nerve structures at risk during TATT.

Method: TATT was performed to the lateral cuneiform in fresh frozen adult cadaver limbs. In 3 feet, the drill hole was made perpendicular to the surface of the lateral cuneiform (group A), in 3 feet, the drill hole was perpendicular to the weight bearing surface of the foot (group B), in 3 feet, the drill was directed at 15 degrees in the frontal and sagital planes (group C) and in another 3 feet the drill was aimed at the middle of the foot (group D). The tendon sutures were pulled through the plantar aspect using two Keith needles aimed in the same direction as the drill hole. A layered dissection was performed. The distance from the drill hole to the nearest nerve or nerve branch was measured. Keith needles were passed 20 times per foot. With each pass, damage to nerve structures was noted.

Results: In group A, the drill was in proximity to the medial plantar nerve at a mean distance of 1.7mm (1–3mm). The bifurcation of the nerve trunk was found more proximally at a mean distance of 5mm (2–9mm). In group B, the drill was found to be close to the lateral plantar nerve branches at a mean distance of 0.3mm (0–1mm) with a mean distance to the bifurcation of 25.3mm (16–37mm). The drill hole in group C was at a mean distance of 1.7mm (0–3mm) to the lateral plantar nerve bifurcation and at a distance of 1mm to the lateral nerve branch in one case. In group D, the drill exited in the middle of the plantar aspect at a mean distance of 7.7mm (5–11mm) from the medial nerve branch and 13mm (10–18mm) from the bifurcation of the medial nerve and at a mean distance of 4.3mm (3–6mm) from the lateral nerve branch and 14.7mm (11–19mm) from the lateral nerve bifurcation.

Passing the Keith needles resulted in hitting a nerve structure 12 times in group A, 20 times in group B, 6 times in group C and once in group D.

Conclusion: In TATT, the drill hole should be aimed at the middle of the foot in the transverse and longitudinal planes. This results in a maximum distance to both the lateral and medial nerve. A blunt Keith needle might allow a safer passing of the sutures to avoid damage to nerves and vessels.

Introduction: Congenital clubfeet have increasingly been detected in routine prenatal ultrasound. However, many clubfeet are still missed and surprise the mothers at birth. The complex deformity and different treatment options available seem to make prenatal counseling desirable. Despite published studies on prenatal clubfoot diagnosis by ultrasound, it is unknown if mothers would indeed prefer to know about their child’s clubfoot before birth or not.

Methods: This survey included patients born between 2000 and 2007 who were treated for congenital clubfoot at one of the two participating institutions (center one: East coast USA; center two: Austria). Exclusion criteria were defined as underlying syndrome, genetic abnormality or pregnancy with multiple fetuses. A brief survey about the opinion of mothers towards ultrasound diagnosis of clubfoot consisting of three questions was sent out. A computer database was created for data collection and a statistic analysis was performed.

Results: Surveys were sent out to 401 mothers of patients meeting inclusion criteria. A total of 220 surveys were received back with 105 surveys from center one and 115 surveys from center two. In 97 cases the clubfoot was unilateral and in 123 cases bilateral. Routine ultrasound showed a clubfoot in 91 cases (41%) and failed to show the deformity in 128 cases (59%). The detection rate in center one was 60% compared to 25% in center two. Bilateral clubfeet had a detection rate of 53% whereas unilateral clubfeet had a detection rate of 29%. Between 2000 and the end of 2003 the overall detection rate was 31% versus 50% between 2004 and the end of 2007.

Overall 74% of mothers wanted to know about their baby’s clubfoot before birth and 24% after birth. Of the 91 mothers who had a positive ultrasound 96% wanted to know before birth. Of the 128 patients who had a negative ultrasound 59% would have wanted to know while 38% did not want to know about the clubfoot prenatally. In center one 89% of mothers wanted to know before birth versus only 60 % in center two. Comments on the survey form showed that mothers who had or wanted to have the prenatal diagnosis appreciated the time to prepare and to find out more about the condition and different treatment options. Many wished for more information at the time of prenatal diagnosis. Mothers that would prefer to find out about the clubfoot postnatally feared that the diagnosis would have affected the experience of the pregnancy.

Discussion: Although the detection rate increased over time there are still cases of clubfeet missed in the routine ultrasound, especially in center two where the rate of detection was low. Mothers in the US are more reluctant to know before birth than mothers in Austria which is most likely related to the differences in the two health care systems. Detailed information about the nature and treatment of clubfeet should be given at prenatal diagnosis.

Introduction: Achondroplasia is a form of rhizomelic dwarfism. Even if patients can compensate for their short arms through the mobility in their spine during the childhood, the flexibility in their spine becomes less with aging. Because of that, as they get older they experience problems in maintaining personal hygiene especially in reaching the back. In addition putting on socks and tying their own shoes might become difficult.

Methods: Inclusion criteria included any patient with a history of achondroplasia who had undergone humeral lengthening in the proximal part of the humerus (just distal to deltoid muscle insertion). Patients who had distal humeral (supracondylar) osteotomy and/or who received other than monolateral external fixator were excluded from the study. 50 humeri of 25 patients with achondroplasia were lengthened using Orthofix mono-lateral external fixator utilizing proximal humeral osteotomy. Sixteen patients were female and nine were male. Mean age was 15.4 months (range, 9.6 – 21.8). Lengthening was started at 7th day. Patients were lengthened at 1/4 turn four times a day reaching 1 mm/day. Physical therapy was performed 3 times a week. Goal of lengthening was around 10 cm or whatever length the patient could tolerate. Patients wore Sarmiento type fracture brace 4–6 weeks after the fixator was removed.

Results: Mean follow-up time from surgery was 51.5 months (range, 6 – 143 months). Mean follow-up time from removal of external fixator was 44.7 months (range, 0 – 135 months). Average external fixation time was 7.3 months. In 20 humeri it was noted that the average duration of lengthening was 4.2 months (range, 3 – 5.8 months). A mean lengthening of 9.3 cm was obtained (range, 4.3 – 12.8 cm). At latest follow-up range of motion was not compromised due to lengthening. All patients had similar ROM before and after the surgery. Complications included radial nerve palsy in 8, pin tract infection in 7, fracture through regenerate in 3, premature consolidation in 1, nonunion in 1, delayed healing in 1. Radial nerve palsy recovered without intervention in one case. In others it recovered uneventfully after successful decompression. No complications at all occurred in 30 cases.

Discussion: Fifty humeri of 25 patients with achondroplasia received successful humerus lengthening as part of extensive limb lengthening offered in our center. None of the patients had long term sequela, and all radial nerve palsies recovered. Patients were satisfied with the lengthening and found it easier to undergo through humerus lengthening compared to lower limb lengthening. After a mean follow-up time of almost 4 years, these patients returned back to their normal lives with optimum upper limb function with no hindrance in maintaining personal hygiene, putting on socks or tying their own shoes.

Purpose: Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external fixator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external fixator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation first and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a final phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method.

Methods: During a five-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, five had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with fibular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program.

Results: All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superficial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the first metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases.

Conclusions: We believe that the Ponseti sequence of correction can be applied to older children with residual club-foot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed.

Significance: The Ponseti-inspired method of residual club-foot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures.

Introduction and Aims: We propose a new, simple, and universal method to predict adult height: the Height Multiplier Method. Our aim was to calculate height multipliers from various databases and validate their use for height prediction.

Method: Standard growth charts, based on a diverse population, were published by the Centres for Disease Control and Prevention (CDC) in 2000. Height multipliers (M) for boys and girls were calculated by dividing the height at skeletal maturity (Htm) by the present height (Ht) (M = Htm/Ht) for each age, gender, and height percentile using CDC data. These multipliers were compared with multipliers derived from various height databases of 28 boys and 24 girls. The accuracy of the multipliers was tested on individual longitudinal data sets from 52 normal children.

Results: The average CDC-derived multipliers were significantly different at each age for boys and girls, but within gender, different percentiles at each age were very similar. These multipliers were very similar to multipliers derived from each of the databases. For predictions based on individual data sets from 52 children, the median, 90%, and standard deviation of absolute error prediction (AEP) were calculated. Boys’ median AEP ranged from 1.4–4.3cm; 90% AEP ranged from 1.8–8.3cm. Girls’ median AEP ranged from 0.68–4.38cm; 90% AEP ranged from 1.5–10.6cm.

Conclusion: The Height Multiplier Method of stature prediction is as accurate as CDC growth charts when based on single-height measurements and is similar in accuracy to other methods. The Height Multiplier Method has the advantage of percentile, race, nationality, and generation independence. Growth charts have the advantage of showing trends over time.

Introduction and Aims: We evaluated the incidence, cause, predisposing factors, and treatment outcomes of fractures associated with limb lengthening. Our aim was to improve the prevention and treatment of these fractures.

Method: We studied 70 patients with 80 fractures retrospectively identified from a database of all patients who had undergone limb lengthening at our institution between 1987 and 1999. Fractures were analysed according to bone fractured, classification of fracture, timing, diagnostic group, treatment, and residual deformity. Treatment of fractures was individualised for each patient according to the specifics of fracture occurrence. A residual deformity was defined as shortening > 1cm or angulation of clinical significance > six degrees.

Results: Eighty fractures occurred with 986 lengthenings in 650 patients, yielding an overall fracture rate of 8.1%. Seventy-four percent of fractures occurred in regenerate bone or at the host-regenerate junction. Eighty-one percent of fractures occurred out of frame. Four percent occurred at time of frame removal, 16% with the frame still in situ. Majority of fractures sustained out of frame (84%) were through regenerate bone; majority in frame (85%) were through non-regenerate regions, 69% of these through a pinhole. Patients with dysplasia and those undergoing lengthening because of congenital syndromes had a higher incidence of fracture (11% and 19%, respectively) and a higher incidence of residual deformity (RD) (47% and 45%, respectively) than did the rest of the patient population. Overall incidence of RD was 38%. Rate of RD was 23% for fractures occurring in frame, 67% at removal time, and 40% for those sustained after removal.

Conclusion: Majority of fractures occur out of frame through regenerate bone. Most non-regenerate fractures occur at pin site. Operatively and non-operatively treated fractures had similar rates and magnitudes of residual deformity. Congenital and dysplastic had higher rates than post-traumatic (possibly more ambitious surgical goals, smaller bone diameter, more limiting soft tissues).

Introduction and Aims: Distraction osteogenesis can be used to stimulate healing in hypertrophic non-unions (HNU). We evaluated the use of closed (without opening the non-union) Ilizarov distraction for HNU with associated angulation, malrotation, and shortening.

Method: Sixty-seven consecutive patients (mean age, 38.3 years) with 71 HNU were treated (1988–2001) using Ilizarov distraction. Patients had undergone an average of five previous operations. HNU classified as stiff (< 5 degrees mobility) were distracted, and those classified as partially mobile (5–20 degrees mobility) were first compressed and then distracted.

Results: Non-unions included: 59 tibiae, six femora, two radii, and five ankle arthrodeses. Mean limb length discrepancy, 3.5cm; mean deformity, 16°; history of osteomyelitis, six cases. Closed distraction alone was successful in achieving union in 61 cases (86%) (mean follow-up, six years; mean time to union, eight months). Union rate was 91.6% (55 of 60 cases) for stiff HNU and only 54% (six of 11 cases) for partially mobile HNU. Distraction treatment alone failed to achieve union in 10 cases. In seven, union was achieved after bone grafting. Two required resection of infected non-union with bone transport to achieve union. One had persistent non-union. There were numerous superficial pin infections and three deep infections. Two cases had deformity at proximal tibial lengthening osteotomy site.

Conclusion: Closed distraction is safe and reliable for stimulating union in stiff HNU. It is especially effective in a scarred limb that has undergone previous operations. It allows for simultaneous correction of deformity and length. Main disadvantage is lengthy time spent in external fixator.

Introduction and Aims: Congenital femoral deficiency (CFD) can be managed by femoral lengthening using callotasis with external fixation. A common complication is fracture with angular deformation soon after fixator removal. We developed a novel technique to overcome this complication using intermedullary stabilisation. Special hand reamers are needed to re-establish medullary canal blocked by cortical plates around previous external fixator pin sites and not yet recanalised regenerate bone.

Method: Since 2000, we treated nine of these fractures in children with an average age of 5.4 years. The children had spent an average of 22 weeks in a fixator, gaining a mean of 7cm of length. Most fractures occurred as ‘spontaneous’ events at a mean of three weeks after fixator removal, resulting in a transverse fracture through the regenerate bone, host-regenerate interface, or proximal pin sites. All were stabilised with intermedullary nailing.

Results: Union was achieved satisfactorily in approximately six weeks. No serious complications, such as infection, avascular necrosis, or non-union, occurred. All bones were successfully realigned, and the mean loss of length was only 0.7cm.

Conclusion: Careful surgical technique, using specific operative steps described (including use of flexible hand reamers to create canal, small percutaneous osteotomies to allow proper reduction, and Rush pins for stabilisation) has achieved good results. We recommend this approach to surgeons involved in the management of fractures occurring after fixator removal.

Introduction and Aims: Fibular hemimelia presents a problem with leg length discrepancy and equinovalgus foot deformity. Our protocol is to simultaneously treat both problems, with the goals of equalising limb length and achieving a plantigrade painless functional foot.

Method: Seventy-eight patients with fibular hemimelia underwent 92 lengthenings and foot deformity correction. Equinovalgus foot deformity was corrected by four different methods in 67 cases: distraction, soft tissue release, release plus supramalleolar and/or subtalar osteotomy, and fibular transport.

Results: Goals of lengthening and foot deformity correction were achieved in all cases. Foot deformity recurred in 19 patients and was retreated: 9/16 (56%) distraction cases, 4/18 (22%) soft tissue release cases, 2/28 (7%) release plus osteotomy cases, and 4/5 (80%) fibular transport cases. Genu valgum developed in many cases with no or partial anlage resection. Genu valgum did not develop in any cases with complete anlage resection. Final results based on functional and radiographic evaluation: 46 excellent, 28 good, 18 fair. Final result did not correlate with number of rays in foot.

Conclusion: Limb length discrepancy and foot deformity can be successfully treated by simultaneous lengthening and foot deformity correction. Soft tissue release plus osteotomy and complete anlage resection yielded best results. Lengthening reconstruction surgery is an excellent alternative to ablative surgery and prosthetic fitting for patients with all severities of fibular hemimelia.

Introduction: The management of post-traumatic, tibial, segmental, skeletal defects is a difficult problem that often requires complex approaches for successful limb salvage. Bone transport and acute shortening with subsequent relengthening are two techniques that have been made possible using Ilizarov’s methods.

Aim: To determine whether either technique offers any intrinsic advantage relative to the other.

Methods: We carried out a retrospective review of charts and radiographs of 42 patients with post-traumatic tibial defects that had been managed using Ilizarov’s methods. The follow-up period averaged 26 months. We selected patients with defects between 3 cm and 10 cm to provide a suitable comparison. The patients were divided into two groups of 21 each, treated either by bone transport or acute shortening.

Results: The defects averaged 7.0 cm in the transport group and 5.8 cm in the acute shortening group. The transport group averaged 12.5 months in the fixator; the acute shortening group averaged 10.1 months. However, the external fixation index was virtually identical in the two groups (mean 1.8 months/cm in the transport group and 1.7 months/cm in the acute shortening group). The complication rate, radiographic results, and functional results were slightly better in the acute shortening group.

Conclusions: Both techniques demonstrated excellent results overall and the external fixation index was nearly identical for these related methods. The final results after treatment by acute shortening were found to be slightly better than the final results following bone transport. There may be a slight advantage to the use of this technique for smaller defects in properly selected patients.