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.

Introduction: Achondroplasia is a form of rhizomelic dwarfism. Even if patients can compensate for their short arms through the mobility in their spine during the childhood, the flexibility in their spine becomes less with aging. Because of that, as they get older they experience problems in maintaining personal hygiene especially in reaching the back. In addition putting on socks and tying their own shoes might become difficult.

Methods: Inclusion criteria included any patient with a history of achondroplasia who had undergone humeral lengthening in the proximal part of the humerus (just distal to deltoid muscle insertion). Patients who had distal humeral (supracondylar) osteotomy and/or who received other than monolateral external fixator were excluded from the study. 50 humeri of 25 patients with achondroplasia were lengthened using Orthofix mono-lateral external fixator utilizing proximal humeral osteotomy. Sixteen patients were female and nine were male. Mean age was 15.4 months (range, 9.6 – 21.8). Lengthening was started at 7th day. Patients were lengthened at 1/4 turn four times a day reaching 1 mm/day. Physical therapy was performed 3 times a week. Goal of lengthening was around 10 cm or whatever length the patient could tolerate. Patients wore Sarmiento type fracture brace 4–6 weeks after the fixator was removed.

Results: Mean follow-up time from surgery was 51.5 months (range, 6 – 143 months). Mean follow-up time from removal of external fixator was 44.7 months (range, 0 – 135 months). Average external fixation time was 7.3 months. In 20 humeri it was noted that the average duration of lengthening was 4.2 months (range, 3 – 5.8 months). A mean lengthening of 9.3 cm was obtained (range, 4.3 – 12.8 cm). At latest follow-up range of motion was not compromised due to lengthening. All patients had similar ROM before and after the surgery. Complications included radial nerve palsy in 8, pin tract infection in 7, fracture through regenerate in 3, premature consolidation in 1, nonunion in 1, delayed healing in 1. Radial nerve palsy recovered without intervention in one case. In others it recovered uneventfully after successful decompression. No complications at all occurred in 30 cases.

Discussion: Fifty humeri of 25 patients with achondroplasia received successful humerus lengthening as part of extensive limb lengthening offered in our center. None of the patients had long term sequela, and all radial nerve palsies recovered. Patients were satisfied with the lengthening and found it easier to undergo through humerus lengthening compared to lower limb lengthening. After a mean follow-up time of almost 4 years, these patients returned back to their normal lives with optimum upper limb function with no hindrance in maintaining personal hygiene, putting on socks or tying their own shoes.

Purpose: Use of six-axis analysis and computer assisted deformity correction via a circular external fixator is a new method for deformity correction. We investigated its accuracy and safety in reconstruction of femoral deformity in children and young adults.

Method: We retrospectively reviewed all cases including the indications for use and the methodology of application of the computer assisted six-axis analysis and circular external fixator for reconstruction of 22 femora in 20 patients. Twelve patients were female, and 8 were male. The average age was 13.9 (range, 5.9–24.6). Etiology included traumatic (7), idiopathic (6), multiple enchondromatosis (2), rickets (2), congenital femoral deficiency (2), spondyloepiphyseal dysplasia (1), congenital pseudohypoparathyroidisim (1), and multifocal osteomyelitis (1). Clinical and radiographic data were analyzed.

Results: Average follow-up was 14.4 months (range, 4.5–32). Average time in frame was 6.2 months (range, 2.6–19). Bone lengthening of 3.9 cm (range, 1–8.5) was performed in 12 femora. In genu valgum patients, the mLDFA improved from a mean of 73.7° to a mean of 89°. In genu varum patients, the mLDFA improved from a mean of 99.8° to a mean of 89.5°. Complications included pin tract infection in 6, knee stiffness in 3, delayed union in 2, skin irritation in 1, posterior knee subluxation in 2, both of which had stable knees preoperatively. One patient was lost to follow-up and returned back with deformity. No complications occurred in 8 patients.

Conclusion: Computer assisted femoral deformity correction with six-axis analysis and application of circular external fixator is a useful technique with the advantage of managing multiplanar deformities in children and young adults. It has the potential complications of the use of any external fixator. Close follow-up is necessary to avoid subluxation of the knee joint even in patients with stable knees. Accurate and safe correction can be achieved in almost all patients.

Purpose: To describe the clinical outcomes of adolescent patients, treated with hip distraction arthroplasty for avascular necrosis (AVN) of the femoral head. Outcomes were examined in order to better understand the usefulness and indications of performing hip arthrodia-stasis in this patient population.

Method: Retrospective review was performed on thirty-one hips with femoral head AVN treated with hip distraction arthroplasty. Mean age at treatment was 14.2 years. Preoperative and follow-up pain, and physical limitations, as well as follow-up range of motion (ROM) were assessed.

Results: Follow up assessment was obtained at 18.3 years of age. Time of follow up was 55.3 months after distraction. The etiologies of AVN were: 11 Slipped Capital Femoral Epyphysis (SCFE); 5 Idiopathic AVN; 3 with hip dysplasia; and 12 others. There was a significant difference in pain preoperatively and postoperatively (p< .001), the majority of patients (79.5%, n=23) had less pain after the treatment. Multivariate regression model demonstrated that patients with SCFE were likely to have less improvement in pain than patients with other etiologies (odds ratio: 24.8; p=.035). All patients had activity limitations before the treatment; at the postoperative assessment more than half of our patients (n=15) reported no limitations in their activities. Nine patients had minor complications with the fixator. At follow up, 5 (16.1 %) patients converted to total hip replacement or arthrodesis.

Conclusion: Hip distraction arthroplasty in adolescent patients with symptomatic AVN reduces the amount of pain and limitation in daily activities, at a follow up of 4.6 years. Arthrodiastasis is not the final solution to AVN, with longer follow up patient’s symptomatology increases. Patients with AVN secondary to SCFE do not beneficiate of this procedure as much as other patients do. Hip distraction is a safe and appropriate procedure to perform in these patients. The procedure might be able to delay definitive surgical procedures at an early age, restoring function and improving the patient s quality of life.