Summary: The Ponseti technique with an initial percutaneous Achilles tenotomy fully corrected 19 arthrogrypotic clubfeet. At 30 months follow-up, 74% were plantigrade, all were braceable, none had surgery.

Introduction: Surgical releases for arthrogrypotic clubfeet have high recurrence rates, requiring further surgery, resulting in short, stiff, painful feet. Hypothesis: a modified Ponseti technique could achieve plantigrade, braceable feet, without surgery during infancy or early childhood.

Methods: Ten patients with 19 arthrogrypotic clubfeet, mean age 16.2 months (range, 3–40), underwent an initial percutaneous Achilles tenotomy (PAT), followed by weekly Ponseti style castings. A second PAT was performed prior to the last 3 week cast, except if the ankle dorsiflexed at least 20°. Correction was maintained by continuous ankle-foot orthoses (AFOs) bracing.

Results: Mean follow-up was 30.6 months (range, 5–60), age 47 months (range, 11–86.5). Mean number of casts was 7.3 (range, 4–13), 10 feet required a second PAT. Initial Dimeglio/Bensahel (D/B) score was 16 (range, 12–18), and 5 (range, 2–9) at follow-up. Similarly, Catterall/Pirani (C/P) scores improved from 4.8 (range, 1.6–6.0) to 0.9 (range, 0–2.0). Mean ankle dorsiflexion improved from −45° (range, −30° to −75°) to 5° (range, −20° to 35°) at follow-up. Five feet (26%) developed an average equinus of 13° (range, 5° to 20°). All feet were braceable, none had surgery, and no patient’s ambulatory ability was compromised by foot shape. Five patients (10 feet) had more than 2 years follow-up (range, 39–59.5, average 49.7 months), with an average dorsiflexion of 6.5°, average D/B and C/P scores were 4.8 and 0.8, respectively.

Discussion and Conclusion: Arthrogrypotic clubfeet were corrected without extensive surgery during infancy or early childhood. The initial PAT was crucial for unlocking the calcaneus from the posterior tibia, allowing for correction with Ponseti casting. Correction was maintained with AFOs at the final follow-up of 30 months. Although limited surgery may be required as the children age, plantigrade, braceable feet were achieved effectively in these patients with arthrogryposis, creating a stable platform for weightbearing.

Purpose: The purpose of the study was to identify those characteristics of congenital tibial dysplasia (CTD) that portend the worst prognosis, including the probable failure of all surgical attempts to achieve union. Clear identification/ classification of this select population of cases could add earlier consideration of relevant treatment options.

Method: While several classification systems for CTD exist, the Crawford classification was used to review the literature and our hospital cases (6) to examine the relationship between case characteristics, treatment, and outcome.

Results: An atypical variation of Crawford’s type IIC was identified, herein referred to as type IID, that was characterized by early onset, frank pseudoarthrosis, and deformity of the distal-one third of the tibia and fibula. As well, these patients underwent failed multiple surgeries and numerous type treatments over time without good functional outcome and with prolonged physical difficulties.

Conclusion: The cases that fall into this newly defined category (IID) of the Crawford classification for CTD are best treated with early amputation rather than repeated attempts to gain union.

Significance: Amputation for patients with congenital tibial dysplasia (congenital pseudoarthrosis of the tibia) that are identified as type IID cases and carry the characteristics for a bad prognosis, provides better functional results than repeated surgeries, even when union is achieved. The family should be warned from the beginning that a stable union is unlikely in these cases. Amputation should be offered as a primary or an early option to the family with full disclosure of the long-term advantages and disadvantages of all therapeutic paths.

To evaluate the correction of complex congenital deformities of the lower limb by six axes deformity analyses and computer assisted correction using the Taylor TM Spatial Frame (TSF), from 1998 to 2000, the authors performed corrections of multiple congenital deformities in 24 lower limbs in 18 patients. There were 9 males and 9 females. There were a total of 29 bone segments, (8 femurs, 21 tibiae) in the 24 lower limbs that were corrected with application of the TSF. Our series included the following diagnoses and deformities: unknown skeletal dysplasia (2), achondroplasia (3), pseudoa-chondroplasia (1), multiple epiphyseal dysplasia (2), spondyloepiphyseal dysplasia (2), fibular hemimelia (3) tibia hemimelia (1), hypophosphatemic rickets (3), and posteromedial bowed tibia (1).

The mean age of the patients was 15.4 years (range 0.5 to 35 years). The mean frame time until correction was 20.1 weeks (range 9 to 49 weeks). The mean follow up was 2.4 years (range 2 to 3.4 years). The apex of the deformity was directed posteromedial in 7, anterolateral in 6, medial in 5 and anteromedial in 5 patients. The mean coronal and sagittal plane deformities were 14.60 (range −230 to 400) and 70 (range, −400 to 280), respectively. The average magnitude of the deformity was 21.70 (range 90 to 470), and the plane of the deformity to the coronal plane was −23.30 (range −800 to 400). Eight patients had a mean lower extremity shortening of 12.3 mm (range 5 to 50 mm). One patient had 15° of internal rotation. With application of the TSF and the principles of distraction osteogenesis, we were able to reduce the coronal and sagittal plane deformities to 3.10 and 1.40 respectively. The overall mean magnitude of the deformity was decreased to 3.40. Shortening was corrected to an average of 3 mm. We experienced only 4 complications in the 24 limbs (16.7%). Complications in this patient group included one female patient with hypophosphatemic rickets who had residual deformity with significant lateral mechanical axis deviation due to inadequate translation. In addition, there were two superficial pin tract infections and one delayed union.

Computer-assisted six axes deformity planning and TaylorTM Spatial Frame application effectively and safely correct complex congenital and developmental limb deformities and offer significant advantages over the well-established Ilizarov technique.

The role of femoral and acetabular version in correction of dysplasia of the hip has been undereported. Between June 1995 and September 2000, a Bernese periacetabu-lar osteotomy (BPO) was performed in 25 patients (26 hips) by the senior author with an average follow-up of 3.7 years (range 2-5 years). The mean age of the patients (24 female, 1 male) at the time of surgery was 29.4 years (range, 11.5 to 45 years). Only patients with a primary diagnosis of acetabular dysplasia were included in this series.

The average Harris hip score increased from 55.1 (range 34–75) preoperatively to 92.9 (range 72–100) at the latest follow up (p< 0.0001). The mean pre-operative Merle d’Aubign score increased from 13.5 (range 10–15) to 17 (range 15–18) at the latest follow up. The mean lateral centre edge angle of Wiberg increased from 13.10 (range 00–200) pre-operatively to 52.60 (range 200-740) at latest follow-up (p< 0.0001). The anterior centre edge angle averaged 10.90 (range 4-170) pre-operatively and improved to 490 (range 210–760) at latest follow-up (p< 0.0001). The Mckibbin instability index is the sum of femoral and acetabular version (normal range 200–500). There were 6 hips with low instability index and 11 hips with high instability index pre-operatively. At the latest follow-up there were only 2 hips with low instability index and there were no patients with a high instability index. Our clinical results showed fi fteen patients with excellent results, eight good results and one fair and one poor results. Thus, overall good to excellent results were obtained in 92% of our patients. It is therefore possible that we had higher success rate in our series than that reported in other series because of the correction of version of the hip in addition to the coronal and sagittal defi ciency of the hip.

The aim of our study was to assess the efficacy and complications of treatment of limb deformities using six axes deformity analysis and the Taylor TM Spatial Frame [TSF]

Between January 1997 and March 2000, we treated 75 lower limbs in 66 patients with deformities. Patients were divided into four groups. The groups were Blount’s disease, congenital deformities, traumatic deformities, and a miscellaneous group. The data was prospectively collected. This was a consecutive series of the first 66 patients treated at our institution with the TSF. Deformity correction using the TSF is done with the aid of computer software.

The mean age of the 66 patients was 18.7 years (range 0.5 to 72 years). The average frame time was 18.6 weeks (range 9 to 49 weeks). There was shortening present in 31 limbs with a mean of 18.6 mm (range 5 to 50 mm). Deformity correction with distraction osteogenesis was begun 7 days after the osteotomy. The mean length of time until correction was 6.7 weeks (range 3 to 13 weeks). There were a total of 10 complications (13.3%) in the series.

27 tibiae in 23 patients underwent correction with the TSF for Blount’s disease. There were 11 infantile and 16 adolescent forms. Correction of congenital deformity was performed in 20 tibiae and 8 femurs in 18 patients. There were 9 males and 9 females. There were 13 male and 8 female patients with traumatic lower limb injuries. There were 11 malunions and 10 nonunions (including 2 infected nonunions) that were corrected with the TSF.

The TaylorTM Spatial Frame is an effective technique in treating deformity. Angulation, translation, shortening and rotation can be corrected simultaneously.

Based on our results, we conclude that the TSF allows safe, gradual correction that is accurate and well tolerated.

Purpose: A retrospective study to determine the causes of failure of the Ponseti technique and treatment for those failed feet.

Materials and Methods: Eighty-nine patients with 136 clubfeet were treated by the Ponseti technique and evaluated on the Dimeglio/Bensahel and Catterall/ Pirani scoring systems. Six patients with 9 clubfeet were not corrected and therefore did not enter the dynamic ankle-foot orthosis stage. These 6 patients started treatment after the age of 8 months, except for one patient who was 9 weeks old at the start of treatment. Of these 9 feet, 8 underwent open Achilles tendon releases combined with posterior releases. Three of these feet had percutaneous Achilles tenotomies prior to their failure and 1 foot underwent complete soft tissue clubfoot releases. Eighty-three patients (127 clubfeet) completed the Ponseti technique. Eighteen patients with 28 club-feet were lost to 2-year follow-up (Group A), and 65 patients with 99 clubfeet (78.3%) had a greater than 2-year follow-up (Group B).

Results: Nine out of a total of 136 clubfeet failed the Ponseti technique. At 2-year follow-up, one-third (29/99) required additional procedure(s). At application of the dynamic ankle-foot orthosis in Group B, patients’ rating scores were similar. However, after 2-year follow-up, the noncompliant group’s scores (no orthosis) changed significantly for the worse when compared to the compliant group’s scores who used the orthosis for 2 years. After 2-year follow-up, Group B patients in the orthosis-compliant group had better scores than the 2-year failures (29 feet) who underwent further surgery and the initial 9 feet who failed the Pon-seti technique.

Purpose: The purpose of this paper was to determine how to predict the need for a percutaneous tenotomy at the initiation of the Ponseti method for treatment of a clubfoot.

Methods: Fifty clubfeet in 35 patients were treated with serial casting performed at weekly intervals and were rated according to the Pirani and Dimeglio clubfoot scoring systems. Scores for each foot were obtained at each visit, prior to cast application and following removal of the final cast. The final cast was applied with the foot in 15 degrees of dorsiflextion.

A percutaneous Achilles tenotomy was performed if the foot could not be dorsiflexed to 15 prior to application of the final cast. Tenotomies were performed as an office procedure under local anesthesia in 36 to 50 feet (72%).

Results: The patients that underwent tenotomy required significantly more casts. Of 27 feet with initial Pirani scores of ≥5.0, 85.2% required a tenotomy and 14.8% did not; and 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and those that did not have a tenotomy.

Conclusion: Children with clubfeet who have an initial score of ≥5.0 by the Pirani system or who are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

A retrospective review of records, radiographs, Computerized Tomography (CT) scans, and Magnetic Resonance Imaging (MRI) scans was done from January 1994 to January 2002. Of the 35 patients in this study, 15 were females and 20 males. The mean age of the patients was 12.8 years (range, 9 to 19 years). There were 14 feet with bilateral coalition, 8 were right and 13 were left. There were 28 talo-calcaneal (all middle facets) coalitions of which 9 were bilateral. There were 20 calcaneo-navicular coalitions of which 5 were bilateral. One patient had a naviculo-cuboid coalition. The mean followup was 6.4 months (range, 1.2 to 36 months). Twenty six patients were treated conservatively with satisfactory outcome. Of the 23 patients operated 16 patients had good outcome, 5 had fair outcome, and 2 had poor outcome. Totally there were 10 out of 329 patients that had multiple tarsal coalition when we reviewed our cases and the literature. This gave an incidence of 3 percent of all the symptomatic tarsal coalition i.e. in other words the true incidence of multiple coalition is around 0.03%. This is the only study that establishes the incidence of multiple coalition.

To evaluate the effectiveness of a casting method for the early treatment of clubfoot deformity, a scoring system utilizing the French [DiMeglio], English [Pirani], and our functional rating system before and after each casting session was used to determine the final assessment and results of the Iowa [Ponseti] clubfoot technique.

Between Jan 2000 to June 2001, 49 clubfeet in 33 patients were assessed before and after the Ponseti casting at a minimum of 1 year follow up using the Dimeglio/ Bensahel, Hospital for Joint Diseases functional rating, and Catterall/Pirani scoring system. Mean age of presentation was 7 weeks [range 0.5 to 28 weeks]. Patients had casting +/− percutaneous TAL. At latest follow up patients who were compliant for Foot Abduction Orthosis [n=32 feet] had good results without any deterioration in their scores. Of the noncompliant patients 8 patients remained good. Of the nine feet that had poor results, 5 improved with recasting, 2 required percutaneous TAL and 2 required open TAL and posterior release.

Early treatment of the idiopathic clubfoot with serial [Ponseti] casting will be effective in over 90% of cases and patients will require no other treatment except for percutaneous tenotomy of the Achilles tendon.

Early use of the Iowa [Ponseti] technique [before the age of one year] will significantly reduce the current number of extensive surgical procedures performed for the treatment of clubfoot. Moreover, it will produce more flexible and supple feet and avoid the problem of stiff, recurrent post-surgical clubfoot.

To assess the efficacy of software assisted correction using six axes analyses for Blounts deformity.

Between 1998 and 2000, 22 tibiae in 19 patients underwent correction of Tibia Vara with the TSF. There were six females and thirteen males. There were 8 infantile and 14 adolescent forms. The mean patient age was 9.9 years (3–16 years). Shortening was present in 18 patients, averaging 11 mm (range: 3–30 mm). The mean follow up was 2.8 years (range: 2–4.1 years).

The mean preoperative varus deformity was 16.5 degrees (range, 8 to 50 degrees) which improved to 0 degree (−2 to 2 degrees), and mean procurvatum deformity was 12.2 degrees (2 to 21 degrees) which improved to 0.1 degree (−2 to 3 degrees). The plane of the deformity was an average of 31 degrees (0 to 62 degrees) from the coronal plane and the mean magnitude of the deformity was 20.5 degrees (11.3 to 3.8 degrees)

Taylor spatial frame uses the six axes software assisted analysis to correct complex deformities such as Blounts disease. It is very effective in correcting the Blounts deformity and has minimal complications.

Purpose: To describe a simple method for performing pelvic osteotomies in children that will obtain appropriate femoral head coverage.

Method: The necessary femoral head coverage was preoperatively predicted by assessing the acetabular, Wiberg, and Lequesne angles, and by 3-D CAT scan evaluations of each hip. Postoperative results were evaluated in a similar manner and compared with the preoperative findings. An “almost” percutaneous triple pelvic osteotomy was performed using an adductor incision and a transverse incision.

Results: In spite of the theoretical restrictions in this age group to acetabular movement, i.e. rigid triradiate cartilage, stiff symphysis pubis and rigid sacrospinous and sacrotuberous ligaments, adequate coverage of the femoral head was attained with the described technique.

Conclusion: If a pelvic osteotomy is being considered to better stabilize a child’s hip due to a condition such as Legg-Calve-Perthes disease, hip dysplasia, a deformed femoral neck secondary to slipped capital femoral epiphysis or femoral head necrosis, the “almost” percutaneous triple osteotomy has a decided advantage over other well described pelvic osteotomies since it is simpler to perform and sufficiently covers the femoral head.

Primary skin closure after the surgical correction of severe club-foot may be difficult. We describe the use of a tissue expander to provide sufficient skin, and review some aspects of the use of the method.