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

Purpose: Parent worry about torsional or angular anomalies of the lower limbs of their children is widespread. The relationship between a child’s postural habits and torsional anomalies of the lower limbs is often mentioned in the literature despite the lack of a single study demonstrating solid evidence. Active treatment of such anomalies is exceptionally necessary. Postural education is undoubtedly provided by parents. The purpose of this study was not to establish a cause and effect relationship between postural habits and torsional anomalies but rather to determine whether children who exhibit a preferential nocturnal and diurnal posture have torsional anomalies of the lower limbs. Material and methods: This retrospective analysis included all patients consulting one paediatric orthopaedist for in-toeing during a period of six years. Patients with a neurological disorder, bone and joint disease, or a congenital malformation as well as those with a history of orthesis use for fracture or surgery of the lower limbs were excluded. The cohort was composed of 463 children aged 1.5 to 15 years. Five habitual postures were studied: sitting cross-legged, sitting on knees feet under the buttocks, laying on knees with buttocks upward and feet inward, laying on belly knees extended and feet inward, and indifferent sitting and reclining positions. Abnormal torsion was determined clinically. Internal hip rotation greater than 70 (Staheli) observed in the ventral decubitus position with knees flexed 90° was considered to indicate excessive femoral anteversion (EFAV). Internal tibial torsion (ITT) was considered to be present when the thigh-foot angle was 0 measured in the ventral decubitus position or sitting on the table legs hanging. We searched for correlations between habitual posture and abnormal torsion as well as the influence of gender and age using the chi-square test and 95% confidence intervals. Patients with both EFAV and ITT were stratified by group using the Woolf method associated with the Mantel-Haenszel test. Results: Abnormal torsion was found more often in children aged less than 4 years with no difference between boys and girls. Among the children in this study presenting in-toeing, 31% did not have a preferred sitting or reclining position and only 7% presented clearly abnormal torsion. There was a significant direct correlation between EFAV and sitting crosslegged and a significant inverse correlation between EFAV and the other habitual postures. Conversely, there was no significant correlation between ITT and the habitual postures studied. Discussion and conclusion: This study provided objective information concerning widely accepted but poorly documented notions. There were two limitations: 1) the lack of a control group not presenting in-toeing, 2) the absence of precise goniometric measurements, a problem encountered in most studies using clinical methods. Although the presence of abnormal torsion of the lower limb appears to significantly influence the gait pattern in children, it does not appear to affect habitual postures. A significant relationship was found only between habitual posture and EFAV, and not ITT. These results should be taken into consideration when planning treatment

Aim: To assess the effectiveness of a physiotherapist led normal variant clinic for children. Method: The study comprised all children presenting to the physiotherapy clinic at the Royal Liverpool Children’s hospital between January 2000 and January 2006. The clinic is run by two specialist physiotherapists alongside a consultant led Orthopaedic clinic, providing support as required. Physiotherapy staff are able to request and interpret radiographs and order blood tests independently. The numbers of patients, the range of conditions seen in the clinic, and the outcome of the consultations recorded in the practitioner case-notes were examined for the purpose of this study. Complete data was available for the full period under review except for the year 2003. Results: During the five year study period 1594 children were seen, a mean of 318 patients annually (range 267–387). The age distribution of patients was 33.1% (527) under the age of 2, 38.9% (620) 2–5 years, 19.3% (307) 5–10 years and 8.8% (140) 10–16 years. The most common conditions seen were genu valgum 28.7% (458), genu varum 18.4% (293), in-toeing 14.7% (234) and toe walking 6.0% (96). Most patients (94.7% n=1509) were managed independent of consultant supervision by the physiotherapist. A minority of patients required consultant review in the clinic (4.2% n=67). Fewer still were referred to another medical clinic (1.1% n=18). Conclusions: Children with a spectrum of orthopaedic conditions can be appropriately managed by a trained physiotherapist independent of consultant input

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Background: Blount’s original paper in 1937 described a case series of 28 patients with “Tibia Vara”. Since then various authors have attempted to describe in more detail the tibial and femoral deformities seen in this disease. It is still a poorly understood condition. This study describes the femoral rotational deformity that can occur in Blount’s disease. Methods: Over a 2 year period, all patients with Blount’s disease seen in the Orthopaedic department of a regional hospital in South Africa were entered into a database. They underwent a review of their notes, a clinical rotational profile of their lower limbs and a CT scan of the femoral head/neck and distal femur. From this database we performed a cross sectional study. We then compared our results both to previously published controls for hip rotation and anteversion angles and with respect to the rotational profile, to a small cohort of 32 “normal” local children. Results: A statistically significant increase in femoral anteversion in the affected legs was noted, with on average the femurs in Blount’s disease being 26 degrees more anteverted than previously published controls. A significant decrease in external rotation were also noted. Conclusions: Our results suggest that the marked intoeing seen in many cases of Blount’s disease may be caused by internal femoral version, in addition to the well recognized internal tibial version. This study highlights the following issues:. A rotational profile should be part of the routine clinical assessment of all Blount’s cases. A CT assessment of anteversion should be considered to quantify this accurately. Overcorrection of the tibial internal version (to correct the added femoral version/torsion) should be considered when doing tibial osteotomies in cases with marked femoral internal version. Some cases of Blount’s disease will require further correction of rotation, after corrective surgery around the knee, that included external rotation of the tibia. Persistent in-toeing may need a de-rotation osteotomy of the femur shaft

Purpose: To compare gait kinematics and kinetics in five-year old children treated initially with Ponseti casting versus French physical therapy. A third group, consisting of patients initially treated with these non-operative methods and then undergoing surgery consisting of more than a tendoachilles lengthening, was compared to those children treated entirely non-operatively. Method: Ninety patients (125 clubfeet) were tested at age five years. Thirty-four feet had undergone only Ponseti treatment, 40 the French program, and 51 had initial non-operative treatment with either the Ponseti or French protocols but later had surgery at an average age of 2+3 years. Kinematics and kinetics were compared to age-matched normal subjects. Results: Average stance-phase dorsiflexion did not differ between groups or from normal. Incidence of equinus: French 5%, Ponseti 0%; Increased stance-phase dorsiflexion: French 3%, Ponseti 24%, Surgical 18% (p < 0.05). A similar number of feet that were not operated upon at age five had in-toeing: 30% French, 32% Ponseti. Decreased ankle power generation at push-off: 53% French; 47% Ponseti; 67% Surgical. Average ankle power generation: 2.21 W/kg French, 2.36 W/kg Ponseti, 1.97 W/kg Surgical (2.83 W/kg in normal 5-year-old children). There was a difference in ankle power generation between normal feet and both the French and surgical groups (p< 0.001). Feet in the non-operative groups that had undergone Achilles tenotomy (n=28) had similar ankle power to those feet (n=42) that did not have tenotomies (p =0.223). Hip power generation was increased 33% in children who had undergone Ponseti treatment (1.38 W/kg), and 41% after French nonoperative treatment (1.47 W/kg), compared to normal (1.04 W/kg). This may be to compensate for poor ankle push-off. Conclusion: The gait characteristics of those feet that have not had surgery reveal that the majority had normal ankle kinematics, but reduced efficiency is demonstrated by reduced ankle push-off power, regardless of whether or not an Achilles tenotomy was performed. Decreased ankle power and persistant internal rotation are more frequently seen in feet that have undergone surgery despite initial nonoperative treatment, compared to those treated only by either the Ponseti protocol or the French physical therapy program

Aims

The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy.

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

The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT.

We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis tendon transfer, split posterior tibialis transfer or a combination of these for recurrent deformity.

We concluded that selective soft-tissue release can provide satisfactory early results after failure of initial treatment of clubfoot by the Ponseti method, but long-term follow-up to skeletal maturity will be necessary.