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.

Congenital pseudarthrosis of the tibia (CPT) is a rare but well recognised condition. Obtaining union of the pseudarthrosis in these children is often difficult and may require several surgical procedures. The treatment has changed significantly since the review by Hardinge in 1972, but controversies continue as to the best form of surgical treatment. This paper reviews these controversies.

Cite this article: Bone Joint J 2013;95-B:1027–34.

Untill recently, major reduction defects of the tibia were treated by amputation and prosthetic fitting. However, Wada et al (1) and Weber (2) recently reported impressive results of limb reconstruction in children with tibial aplasia. If an attempt is being made to reconstruct the leg and foot, a clear understanding of the nature of anomalies is necessary.

A retrospective study of case records and radiographs of children with congenital anomalies of the tibia seen at our centre was undertaken to determine the patterns of associated anomalies in the leg and foot. In addition, five amputated specimens of the leg and foot from children with complete tibial aplasia were dissected.

A wide spectrum of congenital anomalies of the tibia was seen and this included complete aplasia, partial aplasia, hypoplasia, dyplastic trapezoidal tibia and congenital bowing.

Complete and partial aplasia was seen either with or without duplication of the formed skeletal elements. The patterns of duplication that were seen included fibular dimelia, pre-axial mirror polydactyly, duplication of the calcaneum, cuboid and lateral cuneiforms. Trapezoidal dysplastic tibia was associated with duplication of the talus and pre-axial mirror polydactyly.

Dissection of the amputated specimens of complete tibial aplasia revealed aplasia of some muscles, aberratant tendinous structures, abnormal insertion of muscles and absence of the plantar arterial arch.

An understanding the nature of these associated anomalies in children with tibial aplasia and dyplasia will help the surgeon to decide the strategies for reconstruction of the limb if that is the desired option.

At the other end of the spectrum of congenital anomalies of the tibia is posteromedial bowing which was considered an innocuous condition that required little or no treatment. A review of 20 cases of posteromedial bowing demonstrated that there are number of problems related to the leg, ankle and foot that may require surgical intervention.

The foot and ankle are very commonly affected in various paralytic conditions. Paralysis of different muscles acting on the foot results in characteristic gait aberrations. The gait abnormalities are a result of one or more of the consequences of paralysis including: loss of function, muscle imbalance, deformity and instability of joints.

The aims of treatment of the paralysed foot and ankle are to: make the foot plantigrade, restore active dorsiflexion during the swing phase of gait (if this is not possible then prevent the foot from ‘dropping’ into plantar flexion during swing), ensure that the ankle and subtalar joints are stable throughout the stance phase of gait, facilitate a powerful push-off at the terminal part of the stance phase (if this is not possible, at least prevent a calcaneal hitch in terminal stance).

The specific aims of treatment in each patient depend on the pattern and the severity of paralysis that is present and hence the aims are likely to vary. In order to determine what treatment options are available in a particular patient, it is imperative that a careful clinical assessment of the foot is done. Based on the clinical assessment, these questions need to be answered before planning treatment: What are the muscles that are paralysed What is the power of each muscle that is functioning? Is there muscle imbalance at the ankle, subtalar or midtarsal joints that has either already produced a deformity or has the potential to produce a deformity in future? Are there any muscles of grade V power that can be spared for a tendon transfer without producing a fresh imbalance or instability

To facilitate responses to these questions, the muscle power of each muscle can be charted on a template that facilitates graphic representation of the muscle balance around the axes of the ankle and subtalar joints. This assessment clarifies whether a tendon transfer is a feasible option. If a tendon transfer is considered feasible, then the following questions also need to be answered: Is there a fixed, static deformity that needs to be corrected prior to a tendon transfer? If a tendon transfer was performed, would the child be capable of comprehending and cooperating with the post-operative muscle re-education programme?

The decision-making process will be outlined and the use of the template in choosing the tendon transfer and deciding the site of anchorage of the transferred tendon will be explained. With suitable examples the choice of tendon transfers in different patterns of paralysis would be illustrated.

Purpose: The lateral pillar classification for Perthes disease described by Herring in 1992 has gained wide acceptance as a method of predicting outcome and planning treatment. Our purpose was to determine the reproducibility of Herring’s lateral pillar classification using visual estimation and by direct measurement and determine if the Herring’s grading alters as the child passes through the stage of fragmentation in Perthes’ disease.

Method: One hundred AP and frog lateral radiographs of children with unilateral Perthes’ disease in the stage of fragmentation were classified according to the Herrings classification by two investigators utilizing a visual and measurement technique. The change in Herring’s grading with progression of disease was evaluated in 86 patients with sequential radiographs in the stage of fragmentation.

Results: The level of intra-observer agreement by the measurement technique was excellent for both AP and lateral radiographs (Kappa = 0.92 and 0.98) as compared to the visual method for which the agreement was moderate (Kappa = 0.65 and 0.5). The inter-observer reproducibility was moderate by the visual method for both AP and lateral radiographs (Kappa = 0.51 and 0.43). The level of agreement for the measurement method was good for the AP radiographs (Kappa = 0.66) and was only moderate for the frog lateral radiographs (Kappa = 0.53). Of the total 86 cases that had sequential radiographs in the stage of fragmentation, 33 showed change in Herring’s grading. Among these 33 cases, 25 showed a change in the extent of epiphyseal collapse in the AP radiographs alone whereas 8 cases showed a change in lateral radiographs. Upgrading of Herring’s grade from A to B was seen in 11 cases and from B to C in 14 cases as observed in the AP radiographs. The clinical variables and radiological variables did not show any association with progression of Herring’s grade.

Conclusion: The measurement technique of assessing Herring’s classification is much more reliable than the originally described visual method. However, the Herring’s grade changes with the evolution of the disease even during the process of fragmentation and must be used with caution when predicting prognosis.

Background: Current treatment for Perthes disease aims at preventing deformation of the femoral head during the active stage of the disease by obtaining containment of the femoral head. To effectively pre-empt femoral head deformation, one needs to know, when during the disease irreparable femoral head deformation occurs. This study was undertaken to attempt to clarify this.

Methods: Records and 2634 pairs of radiographs (AP and lateral) of 610 patients with Perthes’ disease were reviewed. The evolution of the disease was divided into seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) based on plain radiographic appearances. Intra-observer and inter-observer reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stage at which epiphyseal extrusion and widening of the metaphysis occurred and the stage at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth and the radius of the acetabulum were assessed in hips that had healed.

Results: The reproducibility of the new classification system of the evolution Of Perthes’ disease was good. The median duration of each stage varied between 95 and 326 days. Epiphyseal extrusion and metaphyseal widening was modest in Stages Ia, Ib and IIa but increased dramatically after Stage IIb. > 20% extrusion occurred in 70% of the hips by Stage IIIa. Metaphyseal changes were most frequently encountered in Stage IIb, while acetabular changes were most prevalent in Stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads.

Conclusions: The new classification of the stages of evolution of Perthes’ disease helps to identify when crucial events occur during the course of the disease. The timing of epiphyseal extrusion, metaphyseal widening and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by Stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

In reality, the diagnosis of idopathic clubfoot is never delayed, however, treatment is often delayed in developing countries on account of socio-economic factors. The experience gained from treating children who present late in these countries can be effectively used in more developed countries to treat relapsed clubfeet.

The author considers any treatment for clubfoot offered after a child has started walking as “late treatment”.

The treatment options vary depending on the age of the child and the extent of deformities. The aim of treatment is to obtain a plantigrade foot, retaining the mobility of as many of the tarsal joints as possible.

Accordingly, an outline of treatment is suggested. Soft tissue release operations are recommended for children between 1 and 3 years; soft tissue release operations with or without bony surgery for children between 3 and 5 years; soft tissue release combined with mid tarsal and calcaneal osteotomies and tendon transfers in children between 5 and 14 years. The role of external fixators and distraction techniques advocated by Ilizarov and Joshi, and finally, the role of salvage operations like triple fusion and talectomy are discussed.

We studied the natural history of Perthes’ disease in 62 children in whom the onset of symptoms was in adolescence.

Three patterns of disease were noted, namely, late-onset pattern, segmental collapse, or destructive with failure of revascularisation. In the late-onset pattern, the disease followed the sequence of healing seen in younger children, but adequate epiphyseal remodelling did not occur. Consequently, the femoral head was never spherical after revascularisation. With segmental collapse, early and irreversible collapse of part of the epiphysis occurred with gross deformation of the femoral head. The destructive pattern was characterised by a failure of revascularisation and repair of the avascular epiphysis.

The radiological outcome was poor in all three patterns. The poorest clinical results were found in the destructive type which was frequently associated with incapacitating pain requiring arthrodesis or excision arthroplasty within three years of onset of the disease.

We analysed the short-term outcome after varus osteotomy for Perthes’ disease in 48 older children from south-west India, comparing them with 30 historical controls.

The children were between 7 and 12 years of age at the onset of the disease. All had stage-I or stage-II disease, with half or more of the epiphysis involved. The operated children had an open-wedge subtrochanteric varus osteotomy with derotation or extension and a trochanteric epiphyseodesis. Weight-bearing was avoided until late stage III. The non-operated children had been treated symptomatically by conservative methods.

At the time of healing, 62.5% of the operated group had spherical femoral heads compared with 20% of those treated non-operatively (p < 0.001). Of the operated children with Catterall group-IV involvement, 48% had good results as against 24% of the non-operated group (p < 0.05). The percentage increase in the radius of the affected femoral head compared with the normal side was significantly lower in children who had operations (14.68 v 25.65; p < 0.001).

We have shown that the short-term results of early surgical containment in children over seven years of age are satisfactory.

We analysed the static footprints of 1846 skeletally mature individuals to establish the influence of the age at which shoe-wearing began on the prevalence of flat foot. The incidence was 3.24% among those who started to wear shoes before the age of six years, 3.27% in those who began between the ages of 6 and 15 and 1.75% in those who first wore shoes at the age of 16 (p < 0.001). Flat foot was highest in those who, as children, wore footwear for over eight hours each day. Obese individuals and those with ligament laxity had a higher prevalence of flat foot (p < 0.01 and p < 0.0001, respectively). Even after adjusting for these two variables, significantly higher rates of prevalence were noted among those who began to wear shoes before the age of six years. Our findings suggest an association between the wearing of shoes in early childhood and flat foot.

We analysed static footprints of 2300 children between the ages of four and 13 years to establish the influence of footwear on the prevalence of flat foot. The incidence among children who used footwear was 8.6% compared with 2.8% in those who did not (p less than 0.001). Significant differences between the predominance in shod and unshod children were noted in all age groups, most marked in those with generalised ligament laxity. Flat foot was most common in children who wore closed-toe shoes, less common in those who wore sandals or slippers, and least in the unshod. Our findings suggest that shoe-wearing in early childhood is detrimental to the development of a normal longitudinal arch.

Serum immunoglobulin concentrations in 41 children with Perthes' disease and 82 age and sex matched controls were measured by radial immunodiffusion. Significant increases in IgG and IgM were seen in children with Perthes' disease.

Radiographs of 155 Indian children were examined to identify the acetabular changes which occur in Perthes' disease. These changes included osteoporosis of the acetabular roof, irregularity of contour, premature fusion of the triradiate cartilage, hypertrophy of articular cartilage and changes in dimensions. These changes tended to be more marked in older children and when more than half of the femoral epiphysis was involved. Comparison with 25 cases of Perthes' disease from Liverpool showed the same picture. Several of the acetabular changes noted during the active stages were also seen in a series of 24 adult hips after Perthes' disease. Radio-isotope scans of the hips of 27 children with Perthes' disease showed a consistently increased uptake in the acetabulum on the affected side, indicative of a local increase in vascularity and metabolic activity. It was possible to postulate a working model for the pathogenesis of all the acetabular changes. A number of statistical correlations suggest that most of the changes have a bearing on the final outcome.