In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision.

A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings.

At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system.

We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful.

3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision.

Cite this article: Bone Joint J 2015; 97-B:899–904.

Aims: Pathologic studies in foetuses and stillborns with congenital clubfoot have shown atrophy of the musculature of the leg omolateral and incresased fibrous tissues within the muscles belly. Both the triceps surae and the tibialis posterior are mostly involved and their tendons thickened. Atrophy of the musculature of the leg has been described in various clinical studies on congenital clubfoot, but most of the authors believe that atrophy might be secondary to surgical treatment and prolonged immobilization in plaster cast and brace. In our study, we correlated the pathology of foetal leg muscle atrophy with leg muscle atrophy shown by patients with congenital clubfoot.

Methods: We investigated the MRI aspects of leg muscles in untreated babies and in children and adults who had been treated soon after birth for unilateral congenital clubfooft. The MRI aspects of the leg muscle in treated patients were compared to those of untreated babies, and to the histopathologic findings of the same muscles in foetuses with congenital clubfoot.

Results: The ratio between the muscles of the normal leg and the leg of the clubfoot side was almost the same as measured either on the histological sections of foetuses with congenital clubfoof or in patients before and after treatment, from birth to adulthood.

Conclusions: Our study shows that in congenital club-foot leg muscle atrophy is a primitive pathologic finding rather than secondary to treatment.

Five patients with isolated Madelung’s deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas average age at follow-up was 53 years. The deformity was bilateral in 4 patients and unilateral in 1.

At diagnosis deformity, pain and limitations of the range of motion were present in all the wrists except 2, which were painless but presented marked functional impairment. In all the patients the typical radial deviation of the hand, was observed, with dorsal prominence of the distal end of the ulna. The x-rays showed, in anteroposterior view, the V-shaped arrangement of the first carpal row, with the lunate at the apex of the V and the marked obliquity of the articular surface of the radius toward the ulnar side. In the lateral view, the articular surface of the radius was markedly angulated anteriorly, the ulna was subluxated posteriorly and carpal bones were translated anteriorly. In no patient did we observe growth disturbance of the other bones or deformities typical of osteochondrodysplasias. In some cases the deformity progressed rapidly, whereas in the others the progression was slow. Surgical correction was sought by both the family and the patients mainly for functional reasons, although cosmetic improvement was also expected.

The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At the operation all the patients had passed the adolescence growth spurt, although in 5 out of the 9 wrists growth plates were still open.

At follow- up, all the patients were satisfied with the results of the operations and the range of motion of the wrists was improved. Some residual radiographic abnormalities were present in 4 wrists, but all patients were mostly pleased with the absence of pain and improvement of wrist cosmesis. No radiographic osteoarthritis was present in any of the operated wrists, although 4 of the 5 patients were over 55 years of age.

Conclusions: An association of distal radial wedge-closing osteotomy and either distal ulnar hand resection or shortening distal ulnar osteotomy to correct Madelung’s deformity gave very good results in line with other reports. The limited number of our cases may be compensated by the very lengthy long-term follow-up of our series that showed how the results of these corrective operations do not deteriorate in time; moreover no radiographic osteoarthritis was present even almost 50 years after the operation.

The initial treatment of the congenital clubfoot is still a debated subject among different schools. We report our current experience with Ponseti method.

Materials and Methods: From April 1999 to May 2001 we have consecutively treated with this method 80 idiopathic clubfeet of 57 children put under treatment at neo-natal period. Progressive correction of the deformity has been obtained with 7 toe-to-groin plaster casts changed weekly. When complete derotation of the hind-foot and forefoot has been reached, subcutaneus tenotomy of the tendon Achilles has been performed. At the end of this first period, the feet have been adapted in Denis Browne splint, worn full time for four months and thereafter just at night. The feet have been evaluated clinically (score of Dimeglio and Bensahel), radiologically and some with MRI.

Results: Whole correction of the deformity at the end of treatment with plaster casts, has been achieved for 71 times. When the plaster casts are removed, the talocalcaneal divergence, on antero-posterior and lateral views and the tibial-calcaneal angle (x-ray in maximum dorsal flexion ), were respectively, as an average of 20; 30,7; 21,9 degrees. At an average of 20 months follow up, 54 feet of 80 had a score of 0 or 1 of 20, and 14 had a score of 2; on radiological aspect the talo-calcaneal divergence in antero-posterior and lateral views and the tibial-calcaneal angle were respectively as an average of 29; 24,5; 14 degrees. At this evaluation the percentage of relapses of the deformity was 20% (17 cases). All the relapses have been treated again in plaster casts with 40% of success. So far, only four medial release operations have been necessary. Six feet benefited by the transfer of the tibialis anterior tendon to the third cuneiform and slight medial release.

Discussion and Conclusion: The Ponseti’s method presents several advantages: high quality reduction of the clubfoot with the restoration of a “sub-normal” anatomy, low cost and small displeasing worry for the parents, with this method the functional re-education does not seem to improve the quality of results. The prevention of the relapse goes by good compliance to the splint.