Aims. The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care. Methods. An established Delphi approach with predetermined steps and degree of agreement based on a standardized protocol was used to determine consensus. The steering group members and Delphi survey participants included members from the British Society of Children’s Orthopaedic Surgery (BSCOS) and the Association of Paediatric Chartered Physiotherapists (APCP). The statements included definition, assessment, treatment indications, nonoperative and operative interventions, and outcomes. Descriptive statistics were used for analysis of the Delphi survey results. The AGREE checklist was followed for reporting the results. Results. A total of 227 participants (54% APCP and 46% BSCOS members) completed the first round, and 222 participants (98%) completed the second round. Out of 54 proposed statements included in the first round Delphi, 17 reached ‘consensus in’, no statements reached ‘consensus out’, and 37 reached ‘no consensus’. These 37 statements were then discussed, reworded, amalgamated, or deleted before the second round Delphi of 29 statements. A total of 12 statements reached ‘consensus in’, four ‘consensus out’, and 13 ‘no consensus’. In the final consensus meeting, 13 statements were voted upon. Five were accepted, resulting in a total of 31 approved statements. Conclusion. In the aspects of practice where sufficient evidence is not available, a consensus statement can provide a strong body of opinion that acts as a benchmark for excellence in clinical care. This statement can assist clinicians managing children with ITW to ensure consistent and reliable practice, and reduce geographical variability in practice and outcomes. It will enable those treating ITW to share the published consensus document with both carers and patient groups. Cite this article: Bone Joint J 2024;106-B(10):1190–1196

Idiopathic Toe-walking (ITW) is a condition where children persistently walk on their toes in the absence of neurological or orthopaedic structural abnormalities. ITW affects 2% of children at the age of 5.5yr. This may eventually result in fixed ankle equinus. There is a paucity of long-term natural history studies in untreated ITW however persisting equinus contractures are implicated in common adult foot conditions. The Aim of this study is to show if the percentage of contact pressure through the hindfoot during standing and walking improve following surgical tendoachilles lengthening one year after surgery in children with ITW when compared to a normative cohort. 23 patients (46 feet) diagnosed with ITW between 2017-2022; were treated with open zone III Achilles lengthening. We reported patient demographics, clinical resolution, or revision. Passive dorsiflexion range and hindfoot pressure percentage when standing and walking were measured on a baropodometric walkway and compared pre-operatively and at 12-18months postoperatively. We compared this to data from a previously studied normative cohort. 87% of children had compete resolution of toe-walking. 3 had recurrence with 1 patient having a revision surgery. Mean pre-operative static heel pressure percentage was 15.7%, this improved to 54.7% (p<0.001). This neared normative average of 70.6%. Mean pre-operative dynamic heel pressure percentage was 5.5%, this improved to 44.6% (p<0.001). This neared the normative mean of 52.0%. Mean Passive dorsiflexion in extension and 90˚ knee flexion was −5.8˚ and 0.5˚ respectively. This improved on average by 17.4˚ and 14.5˚ to a new mean of 11.6˚ and 15.0˚ (p<0.001). Open Zone III Achilles lengthening for ITW has high resolution rates. Hindfoot contact pressures and passive ankle dorsiflexion show improvement at 1 year post operatively

Purpose: The purpose of this study is to report on the outcomes of children with ITW who received Botulinum A Toxin (BTX-A) as an adjunct treatment to manipulations/casting and maintenance protocol. Method: ITW severity was classified using gait analysis and defined by the absence of 1. st. ankle rocker, early 3. rd. rocker and an early and increased first ankle moment. 1. Subjects who met the three severity criteria received a single BTX-A injection into both gastrocsoleus and placed immediately in below-knee casts. Casts were changed two weeks later for a total casting period of four weeks. Subjects then entered a maintenance protocol involving use of night splints or articulated ankle-foot-orthotics. Outcome measures collected at all follow-up visits were ankle dorsiflexion with knee in 90° flexion (DFF) and extension (DFE). Results: Thirteen subjects with severe bilateral ITW participated. Subjects were followed for an average of 48 weeks (range 7 – 168 weeks) post BTX-A injection. Given the variability in subject outcomes, analyses and reporting were stratified according to subjects’ right and left feet. At day of BTX-A, right foot DFF/DFE were 1.7° ± 14.4 and −1.5° ± 13.0 and mean left DFF/DFE were −1.5° ± 12.8 and −6.5° ± 12.1. Immediate improvement following BTX-A (2 weeks) were seen as right foot DFF/DFE were 14.1° ± 10.0 and 6.3° ± 7.7 and left DFF/DFE were 9.6° ± 14.1 and 3.9° ± 10.6. At 4 weeks, right DFF/DFE were 16.6° ± 9.5 and 11.7° ± 9.1 and left DFF/DFE were 13.1° ± 8.6 and 7.3° ± 8.3. At the half-life of BTX-A (12 weeks), right DFF/DFE were 15.2° ± 12.2 and 10.8° ± 10.5 and left DFF/DFE were 15.8° ± 12.4 and 13.0° ± 11.6. At follow-up visits, correction was maintained as right DFF/DFE were 15.6° ± 9.1 and 10.4° ± 10.3 and left DFF/DFE were 16.9° ± 11.2 and 9.8° ± 10.7. Conclusion: This is the first study to show early outcomes (improved DFF/DFE) following BTX-A injections in ITW and provides evidence for obtaining and maintaining the correction from a single BTX-A injection over a short-term follow-up period

The August 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Antibiotic prophylaxis and infection rates in paediatric supracondylar humerus fractures; Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK; Health-related quality of life in idiopathic toe walkers: a multicentre prospective cross-sectional study; Children with spinal dysraphism: a systematic review of reported outcomes; No delay in age of crawling, standing, or walking with Pavlik harness treatment: a prospective cohort study; No value found with routine early postoperative radiographs after implant removal in paediatric patients; What do we know about the natural history of spastic hip dysplasia and pain in total-involvement cerebral palsy?; Evaluating the efficacy and safety of preoperative gallows traction for hip open reduction in infants

Objective

Cement thickness of at least 2 mm is generally associated with more favorable results for the femoral component in cemented hip arthroplasty. However, French-designed stems have shown favorable outcomes even with thin cement mantle. The biomechanical behaviors of a French stem, Charnley-Marcel-Kerboull (CMK) and cement were researched in this study.

Objectives

Favourable results for collarless polished tapered stems have been reported, and cement creep due to taper slip may be a contributing factor. However, the ideal cement thickness around polished stems remains unknown. We investigated the influence of cement thickness on stem subsidence and cement creep.

Different calcaneal plates with locked screws were compared in an experimental model of a calcaneal fracture. Four plate models were tested, three with uniaxially-locked screws (Synthes, Newdeal, Darco), and one with polyaxially-locked screws (90° ± 15°) (Rimbus). Synthetic calcanei were osteotomised to create a fracture model and then fixed with the plates and screws. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1000 cycles at 800 N, 0.75 mm/s), and load to failure (0.75 mm/s).

During cyclic loading, the plate with polyaxially-locked screws (Rimbus) showed significantly lower displacement in the primary loading direction than the plates with uniaxially-locked screws (mean values of maximum displacement during cyclic loading: Rimbus, 3.13 mm (sd 0.68); Synthes, 3.46 mm (sd 1.25); Darco, 4.48 mm (sd 3.17); Newdeal, 5.02 mm (sd 3.79); one-way analysis of variance, p < 0.001).

The increased stability of a plate with polyaxially-locked screws demonstrated during cyclic loading compared with plates with uniaxially-locked screws may be beneficial for clinical use.