Knee osteoarthritis (OA) is a serious health concern, requiring novel therapeutic options. Walking mechanics has long been identified as an important factor in the OA process. Specially, a larger peak knee adduction moment during the first half of stance (KAM) has been associated with the progression of medial knee OA. Consequently, various gait interventions have been designed to reduce the KAM, including walking with a decreased foot progression angle (FPA). Other gait variables have recently been associated with medial knee OA progression, particularly a larger peak knee flexion moment during stance (KFM) and a larger knee flexion angle at heel-strike (KFA). Currently, there is a paucity of data regarding the effect of reducing the FPA on the KFM and KFA. This study aimed to test for correlations between the FPA and the KAM, KFM and KFA. It was hypothesized that reducing the FPA is beneficial with respect to these three OA-related gait variables. Seven healthy subjects participated in this study after providing informed consent (4 male; 24 ± 5 years old; 21.9 ± 1.5 kg/m^2). Their walking mechanics was determined using a validated procedure based on a camera-based system (Vicon) and floor-mounted forceplates (Kistler). Participants were first asked to walk without instructions and these initial trials were used to determine their normal footstep characteristics. Then, footsteps with the same characteristics as during the normal trials, except for the FPA, were displayed on the floor and participants were requested to walk following these footsteps. Nine trials with visual instructions were collected for each participant, corresponding to FPA modifications in the range ± 20° compared to the normal FPA, with 5° increment. For each participant, the associations between FPA and knee biomechanics (KAM, KFM and KFA) were assessed using Pearson correlations based on the data from the 9 trials with FPA variations. Significant level was set a priori to 5%. Significant correlations were noted between FPA and KAM for 5 out of the 7 participants, with R comprised between 0.75 and 0.96. Four participants also reported significant correlations between FPA and KFA (−0.88<R<−0.69). Significant correlations between FPA and KFM were observed in 2 participants, with inconsistent R (−0.68 and 0.78). There was no significant correlation between FPA and walking speed for none of the participants. While the results confirmed that decreasing the FPA (toeing in) is often associated with a KAM reduction, they also showed relationships between decreased FPA and increased KFA. Therefore, this study suggests that reducing the FPA should be done in consideration of the possible negative changes in KFA. Similarly, although only one participant increased the KFM when decreasing the FPA, it seems important monitoring the effects FPA modifications could have on the KFM. The large variations observed among participants further suggest individualized gait modifications. This study should be extended to medial knee OA patients and longitudinal research is necessary to better understand the effects of decreasing the FPA

Purpose: To test the null hypotheses that no significant differences in the net external knee adduction moment waveform captured during gait exist between neutral, toe in and toe out foot progression angle (FPA) modifications and between those with mild to moderate knee OA and asymptomatic control subjects. Method: Ten patients with mild to moderate knee OA (age 45±7 years) and 16 asymptomatic control subjects (age 54±8 years) participated. Informed consent was obtained for all participants. Three-dimensional (3D) motion and ground reaction force data were recorded during gait. Five trials of each condition,. Self-selected walking (Neutral),. Toe out walking (10o> self-selected, velocity +/− 0.1 m/s of self-selected) and. Toe in walking (10o. Results: There was a significant condition effect for FPA (Neutral=7o, Toe out=24o and Toe in=−9o) and a significant group effect for walking velocity (Asymptomatic=1.46m/s, Knee OA=1.27m/s). In both groups, a toe out FPA produced. a reduction in the overall knee adduction moment (captured by PC1),. a reduction in the late stance magnitude of the knee adduction moment magnitude (captured by PC2 and PC3) and. an increase in the early stance knee adduction moment magnitude (captured by PC2) (p< 0.05). Conclusion: The knee adduction moment is considered an indicator of medial tibio-femoral compressive loading. In this study, a toe out FPA modification during gait altered the characteristics of the knee adduction moment. A reduction in the overall magnitude, more specifically during late stance was found with the toe out gait modification. An increased initial stance peak magnitude was also found during toe out gait. This finding is novel, indicating that a greater peak medial compartment load is produced

Determine the association between net external knee adduction moment (KAM) characteristics and foot progression angle (FPA) in asymptomatic individuals and those with moderate and severe osteoarthritis through discrete variable and principal component analysis (PCA). Fifty-nine asymptomatic (age 52 ± 10 years), fifty-five with moderate knee OA (age 60 ± 9 years) and sixty-one individuals with severe knee OA (age 67 ± 8 years, tested within one week of total knee replacement surgery) participated. Three-dimensional (3D) motion (Optotrak) and ground reaction force (AMTI) data were recorded during gait. Subjects walked at a self-selected velocity. The KAM, calculated using inverse dynamics was time normalised to one complete gait cycle. FPA was calculated using stance phase kinematic gait variables. The discrete variable, peak KAM, was extracted for the interval (30–60%) of the gait cycle. PCA was used to extract the predominant waveform features (Principal Components (PC)) of which PC-Scores were computed for each original waveform. Pearson Product Moment Correlations were calculated for the FPA and both the PC-scores and peak KAM. Alpha of 0.05 used to test significance. No significant correlations were noted for the groups between peak KAM and the FPA, or for the first PC-Scores (PC1) of which captured the original KAM waveforms overall magnitude and shape. The second PC (PC2) captured the shape and magnitude during the second interval of stance (30–60%) with respect to the first. Correlations of FPA to PC2 were significant for the asymptomatic group(r=−0.40, p=0.002) and the moderate OA group (r=−0.32, p=0.017) but not for the severe group(r=−0.13, p=0.316). No relationship between FPA and peak KAM was found across the groups using discrete variable analysis despite reports of associations in asymptomatic subjects. The PCA results suggest a toe out FPA was moderately correlated to a decreased KAM during 30–60% of the gait cycle for asymptomatic and moderate OA individuals only. These individuals respond to a toe out progression angle, altering the KAM which directly affects medial knee compartment loading, where those with severe OA do not

Aims. Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. Patients and Methods. A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. Results. We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. Conclusion. In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218–1229

Introduction. Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome. Materials & Methods. A systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone. Results. 1548 studies were screened by 2 independent reviewers. 8 studies were included with a total of 134 cases, with an age range of 14–71 years. Surgical management ranged from arthroscopic, open or ultrasound guided release of the ITB, as well as gluteal muscle releases. Common outcome measures showed statistically significant improvement pre- and post-operatively in visual analogue pain score (VAPS) and the Harris Hip Score (HHS). VAPS improved from an average of 6.77 to 0.3 (t-test p value <0.0001) and the HHS improved from an average of 62.6 to 89.4 (t-test p value <0.0001). Conclusions. Although good surgical outcomes have been reported, no study has reported on the effect of rotational profile of the lower limbs and snapping hip syndrome. We present the case of a 13-year-old female with snapping hip syndrome and trochanteric pain. Ultrasound confirmed external snapping hip with normal soft tissue morphology and radiographs confirmed no structural abnormalities. Following extensive physiotherapy and little improvement, she presented again aged 17 with concurrent anterior knee pain, patella mal-tracking and an asymmetrical out-toeing gait. CT rotational profile showed 2° of femoral neck retroversion and excessive external tibial torsion of 52°. Consequently, during her gait cycle, in order to correct her increased foot progression angle, the hip has to internally rotate approximately 35–40°, putting the greater trochanter in an anterolateral position in stance phase. This causes the ITB to snap over her abnormally positioned greater trochanter. Therefore, to correct rotational limb alignment, a proximal tibial de-rotation osteotomy was performed with 25° internal rotation correction. Post-operatively the patient recovered well, HHS score improved from 52.5 to 93.75 and her snapping hip has resolved. This study highlights the importance of relevant assessment and investigation of lower limb rotational profile when exploring causes of external snapping hip, especially where ultrasound and radiographs show no significant pathology

We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia

Introduction. The most challenging aspect in rotational deformity correction is translating the pre-operative plan to an accurate intra-operative correction. Landmarks away from the osteotomy site are typically employed at pre-operative planning and this can render inadequate correction. Our proposed technique of pre-operative planning using CT scan and leg length radiographs can translate to accurate intra-operative correction. Materials and Methods. A circle was superimposed at osteotomy site with its centre serving as the centre of correction of rotation. Medio-lateral distance at osteotomy site measured and used as diameter of the circle. Circumference of the circle was calculated by multiplying diameter with Pi and used in the below formula to obtain accurate de-rotation distance;. Derotation distance = (Circumference/360) × correction value for desired ante-version. The exact site of osteotomy was measured in theatre under C-arm and exposed. Derotation distance was marked on the surface of bone as point A and point B with a flexible ruler. Osteotomy performed with saw and derotation was done till point A and point B were co-linear. Derotation distance obtained using this technique is specific for the site of chosen osteotomy and implies a specific degree of correction for every millimeter derotated. Distal femur was the chosen site of osteotomy if there was associated patellar instability and proximal femur if there was no patellar instability. Results. We have used the above technique to successfully correct rotational malalignment of femur and tibia in three patients thus far. The foot progression angle improved in all patients following surgery. One patient had post-operative CT scan of the hips which showed accurate reduction of ante-version. Conclusions. Our new technique of rotational deformity correction is simple and reproducible using commonly available tools as CT scan and leg length radiographs. This technique effectively translates the pre-operative plan to accurate intra-operative correction of rotational deformity

Torsional deformities of the tibia are common in children, but in the majority both the torsion and the associated disturbance of gait resolve without intervention. There are, however, a significant number of children and adults with neuromuscular disease who present with pathological tibial torsion, which may require surgical correction. We conducted a prospective study in two centres, to investigate the outcome of supramalleolar derotation osteotomy of the tibia, using internal fixation with the AO-ASIF T plate. A range of outcome variables was collected, prospectively, for 57 patients (91 osteotomies), including thigh foot angle, foot progression angle, post-operative complications and serial radiographs. Correction of thigh foot angle and foot progression angle was satisfactory in all patients. Three major complications were recorded; one aseptic nonunion, one fracture through the osteotomy site after removal of the plate and one distal tibial growth arrest. We found that supramalleolar derotation osteotomy of the tibia, with AO-ASIF T plate fixation is an effective method for the correction of torsional deformities of the tibia and the associated disturbances of gait in children and adults with neuromuscular disease, with a 5.3% risk of major complications

Purpose: The aim of this research was to characterize the correlation of magnetic resonance image (MRI) measurements of femoral anteversion and tibial torsion with transverse plane kinematics from the gait analysis of ten healthy and nine cerebral palsy (CP) children. Methods: The bone morphologies of nine spastic diplegic CP and ten healthy children were obtained by analysis of 3D MRIs. Location of anatomical landmarks along the femur and tibia were detected using medical imaging software. Each point was then defined with respect to bone-embedded femoral and tibial Cartesian coordinates, allowing 3D reorientation of the bone independent of the patient position within the scanner. Femoral anteversion was defined as the angle between the femoral neck and the transcondylar plane. Tibial torsion was defined as the angle between the transcondylar axis of the proximal tibia and the bi-malleolar axis. Three-dimensional motion of the lower limbs was measured using gait analysis. Transverse plane kinematics, including hip rotation and foot progression angles were recorded. Results: A moderate correlation was found between femoral anteversion, and maximum and average hip rotation in CP children (0.64 and 0.65). A high correlation was also seen between tibial torsion and maximum and average values of hip rotation for CP children (0.71 and 0.74). In healthy children, the only correlation observed was between femoral anteversion and average foot progression in stance (0.75). Discussion: In healthy children, femoral anteversion appears to influence foot progression angle, implying that this can lead to an internally rotated gait. In CP children, the correlation between femoral anteversion and hip rotation is only moderate. The interaction between different joints is more complex and the rotation of joints is determined by multiple factors. This study showed that tibial torsion also plays a role in determining hip rotation during gait

Introduction and Aims: The authors present their results following treatment of 15 patients with complex hip deformities by this new combination of operations. Method: Fifteen patients aged 14 to 36 years (one male) were treated by contemporaneous metal-on-metal hip resurfacing and rotation osteotomy of the femur to nor-malise anteversion over a five-year period (1996–2001). The resufacing was performed in the usual way; anteversion was corrected at the end of the operation where limited internal or external rotation (< 20deg) was felt likely to interfere with the foot progression angle. The plate was removed about one year later. Results: There were no peri-operative complications. Weightbearing was restricted until bone healing was complete (8–13 weeks). Thereafter patients mobilised normally. One patient had her plate removed at six months, as there was sleep disturbance due to local tenderness. At review, all patients were pleased with the outcome. Pre-operative HHS was 65–72: at review it was 89–96. There were no complications in the medium term. All patients had an abnormal foot progression angle pre-operatively (14 had fixed internal rotation, one external rotation). At review, in extension all fell within the physiological range IR50/ER50. Conclusion: This new combination of established operations facilitates the bone conserving benefits of the metal-on-metal resurfacing with corrective rotational osteotomy in patients with complex hip deformity. We have avoided the use of expensive custom protheses and have allowed patients the benefits of a prosthesis minimising bone resection and retaining the physiological modulus of elasticity

Aim: This study was designed to investigate the association between clinical assessment International Clubfoot Study Group (ICFSG) and quantitative gait data of the children. Methods: Nineteen patients with 30 surgically treated clubfoot were included in this study. Bilateral involvement was present in 11. Average age was 9 years (range 6–14 years) at the time of last follow-up. Patients were treated with different surgical techniques at early childhood period. At the final follow-up they were evaluated according to ICFSG clinical scale. This rating system is based on three main subgroups of evaluation as morphologic evaluation, functional evaluation and radiological evaluation. The maximum score is 12 in morphologic evaluation, 36 in functional evaluation and 12 in radiological evaluation. The total score is from 0 for a perfect result to 60 for the worst result. Further, a total score of 0–5 is rated as excellent, 6–15 as good, 16–30 as fair and over 30 as poor. Quantitative gait data was collected with the Vicon 370 (Oxford Metrics, Oxford, UK). Two force plates (Bertec, Colombus, Ohio, USA) were used for kinetic analysis. All time-distance (walking velocity, cadence, step time, step length, double support time), kinematic (joint rotation angles of pelvis, hip, knee and ankle in sagittal, coronal and transverse planes) and kinetic (ground reaction forces, moments and powers of hip, knee and ankle) data were processed using Vicon Clinical Manager software package. Spearman correlation analysis was used to evaluate if there is a correlation between total clinical score and gait parameters. Results: Average ICSG score was 8.63 (range 1–29). Outcome was excellent in 16, good in 8 and fair in 6 patients according to ICSG. There was a significant correlation between total ICSG score and walking velocity (rs=−0.195, p=0.004), step length (rs=−0.476, p=0.019), pelvic excursion in sagittal plane (rs=−0.429, p=0.026), hip excursion in sagittal plane (rs=−0.511, p=0.006), knee excursion in sagittal plane (rs=−0.486, p=0.019), Ankle excursion in sagital plane (rs=−0.413, p=0.040), peak ankle plantar flexion moment (rs=−0.600, p=0.039), peak ankle plantar flexion power (rs=−0.487, p=0.025). When we compare the gait parameters between groups only foot progression angle showed a significant difference (p=0.031). Conclusion: ICFSG score is a successful method to follow outcome in patients with surgically treated clubfoot. ICFSG score is correlated with many kinematic and kinetic gait data however foot progression angle is the only parameter predicting outcome in children with surgically treated idiopathic clubfoot. Quantitative gait analysis may help to define the liable factors of the functional deficits, and to prescribe novel rehabilitation techniques to enable better outcome for children with clubfeet

Introduction. The posterior condylar axis of the knee is the most common reference for femoral anteversion. However, the posterior condyles, nor the transepicondylar axis, provide a functional description of femoral anteversion, and their appropriateness as the ideal reference has been questioned. In a natural standing positon, the femur can be internally or externally rotated, altering the functional anteversion of the native femoral neck or prosthetic stem. Uemura et al. found that the femur internally rotates by 0.4° as femoral anteversion increases every 1°. The aim of this study was to assess the relationship between femoral anteversion and the axial rotation of the femur before and after total hip replacement (THR). Method. Fifty-nine patients had a pre-operative CT scan as part of their routine planning for THR. The patients were asked to lie in a comfortable position in the CT scanner. The internal/external rotation of the femur, described as the angle between the posterior condyles and the CT coronal plane, was measured. The native femoral neck anteversion, relative to the posterior condyles, was also determined. Identical measurements were performed at one-week post-op using the same CT methodology. The relationship between femoral IR/ER and femoral anteversion was studied pre- and post-op. Additionally, the effect of changing anteversion on the axial rotation of the femur was investigated. Results. There was a strong correlation between axial rotation of the femur and femoral anteversion, both pre-and post-operatively. Pearson correlation coefficients of 0.64 and 0.66 respectively. This supported Uemura et al.'s findings that internal rotation of the femur increases with increasing anteversion. Additionally, there was a moderate correlation, r = 0.56, between the change in axial rotation of the femur and change in anteversion. This trend suggested that external rotation of the leg would increase, if stem anteversion was decreased from the native. Conclusions. Patients with high femoral anteversion may have a natural mechanism of “correction” with femoral internal rotation. Equally, patients with femoral retroversion tend to naturally externally rotate their leg. Decreasing stem anteversion from native, trended toward an increase in external rotation of the femur. This finding is supported by the clinical observation of patients with high anteversion and compensatory in-toe, who have normal foot progression angle post-operatively after having their anteversion decreased. These findings have implications when planning implant alignment in THR

In podiatric medicine, diagnosis of foot disorders is often merely based on tests of foot function in static conditions or on visual assessment of the patient's gait. There is a lack of tools for the analysis of foot type and for diagnosis of foot ailments. In fact, static footprints obtained via carbon paper imprint material have traditionally been used to determine the foot type or highlight foot regions presenting excessive plantar pressure, and the data currently available to podiatrists and orthotists on foot function during dynamic activities, such as walking or running, are scarce. The device presented in this paper aims to improve current foot diagnosis by providing an objective evaluation of foot function based on pedobarographic parameters recorded during walking. 23 healthy subjects (16 female, 7 males; age 35 ± 15 years; weight 65.3 ± 12.7; height 165 ± 7 cm) with different foot types volunteered in the study. Subjects' feet were visually inspected with a podoscope to assess the foot type. A tool, comprised of a 2304-sensor pressure plate (P-walk, BTS, Italy) and an ad-hoc software written in Matlab (The Mathworks, US), was used to estimate plantar foot morphology and functional parameters from plantar pressure data. Foot dimensions and arch-index, i.e. the ratio between midfoot and whole footprint area, were assessed against measurements obtained with a custom measurement rig and a laser-based foot scanner (iQube, Delcam, UK). The subjects were asked to walk along a 6m walkway instrumented with the pressure plate. In order to assess the tool capability to discriminate between the most typical walking patterns, each subject was asked to walk with the foot in forcibly pronated and supinated postures. Additionally, the pressure plate orientation was set to +15°, +30°, −15° and −30° with respect to the walkway main direction to assess the accuracy in measuring the foot progression angle (i.e. the angle between the foot axis and the direction of walk). At least 5 walking trials were recorded for each foot in each plate configuration and foot posture. The device allowed to estimate foot length with a maximum error of 5% and foot breadth with an error of 1%. As expected, the arch-index estimated by the device was the lowest in the cavus-feet group (0.12 ± 0.04) and the highest in the flat-feet group (0.29 ± 0.03). These values were between 4 – 10 % lower than the same measurements obtained with the foot scanner. The centre of pressure excursion index [1] was the lowest in the forcibly-pronated foot and the largest in the supinated foot. While the pressure plate used here has some limitations in terms of spatial resolution and sensor technology [2], the tool appears capable to provide information on foot morphology and foot function with satisfying accuracy. Patient's instrumental examination takes only few minutes and the data can be used by podiatrists to improve the diagnosis of foot ailments, and by orthotists to design or recommend the best orthotics to treat the foot condition

Most discussions of alignment after TKA focus on defining “malalignment”; the prefix mal- is derived from Latin and refers to bad, abnormal or defective and thus by definition malalignment is bad, abnormal or defective alignment. No one then wants a “malaligned” knee. The intellectually curious, however, might switch the focus to the other end of the spectrum and ask what does an ideally aligned knee look like in 2015? Is there really one simple target value for alignment in all patients undergoing TKA? Is that target broad (zero +/−3 degrees mechanical axis) or is it a narrow target in which a penalty, in regard to durability or function, is incurred as soon as you deviate even 1 degree? Is that ideal target the same if we are evaluating the functional performance of the TKA versus the durability of the TKA or could there be 2 different targets, one that maximises function and one that maximises durability? Is that target adequately described by a single 2-dimensional value (varus/valgus alignment in the frontal plane) as measured on a static radiograph? Is that value the same if the patient has a fixed pelvic obliquity, a varus thrust in the contralateral knee or an abnormal foot progression angle?. It is revealing to ask “do we understand TKA alignment better in 2015 than in 1979…?” Maybe not. We allowed ourselves over the past 2 decades to be intellectually complacent in regard to questions of ideal alignment after TKA. The constraints on accuracy imposed by our standard total knee instruments and the constraints on assessment imposed by 2-dimensional radiographs made broad, simple targets like a mechanical axis +/− 3 degrees reasonable starting points yet we have not further worked to verify if we can do better. It is naïve to think that the complex motion at the knee occurring in 6-dimensions over time can be reduced to a single static target value like a neutral mechanical axis and have strong predictive value in regard to the success or failure of an individual TKA. We assessed 399 knees of 3 different modern cemented designs at 15 years and found that factors other than alignment were more important than alignment in determining the 15-year survival. Until more precise alignment targets can be identified for individual patients or sub-groups of patients then a neutral mechanical axis remains a reasonable surgical goal. However, the traditional description of TKA alignment as a dichotomous variable (aligned versus malaligned) defined around the broad, generic target value of 0 +/− 3 degrees relative to the mechanical axis is of little practical value in predicting the durability or function of modern TKA

Early results of Ponseti treatment in 14 children (17 feet) aged between 2 and 10 years at the start of treatment are assessed. Method and Results 14 children aged between 2 and 10 years (mean 5.4) presented with relapsed or under- corrected club feet. All had previous treatment with strapping and bebax or pedro boots. 8 had subsequently undergone posterior release of the Achilles tendon, ankle and subtalar joint through a longitudinal posterior incision. All patients presented with absent heel strike, walking on the lateral border of the foot. 14 feet had a varus heel and 15 had an internal foot progression angle. Mean Pirani score was 2.14. Photographs and videos were taken. Ponseti casting was implemented. 15 feet required an Achilles tenotomy, and 15 feet had a tibialis anterior transfer to help maintain the correction. Pirani scores improved from a mean of 2.64 to 0.21 in the group that had had previous surgery, and 1.64 to 0.07 in those that had had previous conservative treatment. All patients achieved a heel strike and ceased to walk on the lateral border of the foot. Heel varus corrected in 11/14 and partially corrected in 3. Internal foot progression resolved in 12/15 and improved in 3. At latest follow up (16 months- 20 months), all transfers were working and all patients walked with heel strike and a plantargrade foot. 2 patients required further casting for relapse in forefoot adductus, and one for recurrent posterior tightness. Conclusions The Ponseti method has been successful in the under corrected or relapsed club foot in children aged between 2 and 10 years in this series, including those with previous surgical intervention

Purpose: Currently, clubfoot is initially treated with non-operative methods including Ponseti casting and the French physical therapy program (PT). Our purpose was to evaluate the function of children treated with these techniques. Methods: Seventy-six idiopathic clubfoot patients were enrolled. Successful non-operative outcomes were achieved in 32 patients (44 feet) treated with casting and 44 patients (66 feet) treated by PT. Initial Dimeglio scores were 10–17. At average age 2.3 years (1.9–3.3yr), subjects’ gait was evaluated with a VICON 512 motion analysis system. Cadence and kinematic data was classified as abnormal if it fell outside of one standard deviation from normal. Results: No statistical differences for cadence parameters were found between the two groups. Two kinematic patterns were identified: Children treated with PT walked with knee hyperextension (41% of feet)*, equinus (17%)*, and foot-drop (28%)*; whereas zero casted patients walked in equinus and only one demonstrated foot-drop. In contrast, the casted group demonstrated increased stance dorsiflexion (47%)* and calcaneus (18%). More PT feet had increased internal foot progression angle (34% vs. 13%)* and increased shank-based foot rotation (56% vs. 33%)*. Both groups had equal rates of normal sagittal-plane ankle motion (59% PT vs. 55%). [*p< 0.05]. Conclusions: Half of the two year-old patients treated non-operatively for clubfoot had normal sagittal-plane ankle motion. Less than 20% in each group experienced calcaneus and equinus gaits, respectively. These differences may be the result of performing percutaneous tendo Achilles lengthening as part of the Ponseti casting technique, but not as part of the PT program

To evaluate the gait of five-year old children with club-feet initially treated non-operatively with the French functional technique and to compare these results to the data from this same cohort at the age of two years. Thirty-three patients (fifty-two idiopathic clubfeet) were initially treated with the French functional (physiotherapy) program. At the age of two years, no child underwent surgery for its clubfoot. Gait Analysis was performed with the VICON system (kinematics). At the age of five years, these patients were all re-evaluated in the gait laboratory. Of the thirty-three patients (fifty-two clubfeet) initially treated non-operatively and tested in the gait lab at two years of age, thirty-seven feet required subsequent surgery by the age of five years. This included posterior release (41%), posteromedial release (35%), tibial osteotomy (19%), and tendo Achilles lengthening (5%). The proportion of feet with the following gait parameters changed significantly (p< 0.05) between the ages of two and five years: Equinus (15% at 2 yrs vs. 2% at 5 yrs), Calcaneus (7% vs. 23%), Foot Drop (18% vs. 4%). The proportion of patients with internal foot progression angle did not change over this time (46% vs. 50%), nor did the proportion with normal sagittal plane ankle motion (61% vs. 54%). At age two years, the majority of patients treated with the French Functional non-operative treatment had normal sagittal plane ankle motion. Gait disturbances, when present at this age, were generally ankle equinus, foot drop and in-toeing. By the age of five years, 71% of these patients underwent surgery for their clubfeet. When re-tested in the gait laboratory at age five years, the proportion of feet with normal sagittal plane ankle motion did not change significantly, however, their resultant gait disturbances, when present, were predominantly calcaneus rather than equinus and foot drop. By treating patients with clubfeet with the French Functional technique exclusively, equinus gait may result in a small proportion. By subsequently treating these patients surgically after the age of two years, over-lengthening or over-release may occur and result in calcaneus gait. The French originators of this technique now incorporate an early gastrocsnemius fascial lengthening as part of their technique. This modification of their technique should improve the gait characteristics observed at two years of age and should decrease the necessity for late surgery that may have contributed to the gait characteristics observed at five years of age

Aims

Although CT is considered the benchmark to measure femoral version, 3D biplanar radiography (hipEOS) has recently emerged as a possible alternative with reduced exposure to ionizing radiation and shorter examination time. The aim of our study was to evaluate femoral stem version in postoperative total hip arthroplasty (THA) patients and compare the accuracy of hipEOS to CT. We hypothesize that there will be no significant difference in calculated femoral stem version measurements between the two imaging methods.

Aims

Traditionally, total hip arthroplasty (THA) templating has been performed on anteroposterior (AP) pelvis radiographs. Recently, additional AP hip radiographs have been recommended for accurate measurement of the femoral offset (FO). To verify this claim, this study aimed to establish quantitative data of the measurement error of the FO in relation to leg position and X-ray source position using a newly developed geometric model and clinical data.

Aims

Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD.