This study is a mid-term follow up of an original series of 51 babies treated with a modified Ponseti technique for idiopathic congenital talipes equinovarus using below-knee Softcast (easier to remove and hygienic)1 to determine whether this method is as effective as traditional above-knee plastering. 51 consecutive babies were treated (April 2003-May 2007) and serial Pirani scores were recorded. Dennis Browne Boots (DBB) were applied when correction was achieved and an Achilles tenotomy was performed if necessary to complete the correction. DBB were worn fulltime for 3 months and at night for 3.5 years. Of the original 51, 3 were lost to follow up and 3 were diagnosed with a neuromuscular condition and excluded. 45 patients, 34 boys and 11 girls were followed up for a mean of 55.3 months (range 36–85 months). Mean age at presentation was 16 days with a median Pirani score of 6.0 (5.5, 60). 75.7% required an Achilles tenotomy before DBB. Median Pirani score at tenotomy was 2.5 (2.0, 2.5). Time to boots (weeks) was mean 5.0 (4.2, 6.0) in the non-tenotomy group and 10.7 (9.8, 11.8) in the tenotomy group. 2 patients had residual deformity after plastering requiring surgery and there were 6 recurrences requiring surgery (4 tibialis anterior tendon transfers and 2 open releases). There appears to be a greater risk of operative intervention for girls and non-compliance with DBB. The estimate of 5-year (60 month) survival without surgery was 85% (96% CI; 70,99%).Methods
Results
Indications for Total Knee Arthroplasty (TKA) include pain and disability. Correction of instability is essential to post operative outcome as instability is often a component of pre-operative functional disability, particularly in patients with valgus deformity. Soft tissue balancing is essential to the success of TKA. Anecdotally, patients with valgus deformity seemed to complain more of instability than pain. The aim of this study was to identify the role and significance of instability and determine whether patients with instability benefit more from TKA as it is useful to determine which patient characteristics will predict success in TKA. Five hundred and two patients aged 45–90 years underwent 522 Kinemax TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Soft tissue releases were recorded and objective soft tissue balance recorded using a ‘balancer’ device. Independent observers assessed patients using 3 outcome measures including the American Knee Society Score (AKSS) for a minimum of 12 months. Pre-operative alignment was divided into 6 groups according to the degree of varus or valgus deformity (mild, moderate, severe varus or valgus). Specific components of the AKSS including pain scores, knee scores and medio-lateral stability scores were specifically analyzed. There is a significant difference in the improvement of the knee scores between the severely valgus knees and all varus knees (ANOVA p=0.000). Significant differences were found between pre-operative pain scores, knee scores and medio-lateral stability between severely varus and severely valgus knees (ANOVA p=0.029, p=0.000 &
p=0.000 respectively). Knees with severe valgus deformities have significantly worse pre operative scores and show greater improvement with equivocal post-operative outcome, when compared to those with severe varus deformity. We believe that this significant improvement is due to the fact that both key issues in the severely deformed valgus knee, namely pain and instability, have been addressed.
Soft tissue balance is known to be an important factor for the success of Total Knee Arthroplasty (TKA). This is of particular relevance in the surgical management of a valgus knee which has both bony and soft tissue abnormalities which need addressing. The correction of instability, particularly in severely valgus knees is essential to post operative outcome as instability is often a component of pre-operative functional disability. Traditional surgical techniques involve soft tissue releases and bony cuts to achieve the correct balance. Evaluation of balance is currently based on subjective intra-operative clinical assessment, or the feel of the knee. More recently, an instrument to objectively measure soft tissue balance following bony cuts has been developed. Soft tissue releases using this instrument may be extensive. 502 patients aged 45–90 years underwent 522 Kine-max TKAs, performed by seven surgeons in five centres between October 1999 and December 2002. Soft tissue releases were recorded and objective soft tissue balance recorded using a balancer device. Independent observers assessed patients using 3 outcome measures for a minimum of 12 months. Pre-operative alignment was divided into 6 groups according to the degree of varus or valgus deformity (mild, moderate, severe varus or valgus). There is a significant difference in the improvement of the knee scores between the severely valgus knees and all varus knees (ANOVA p=0.000). Significant differences were found between pre-operative pain scores, knee scores and medio-lateral stability between severely varus and severely valgus knees (ANOVA p=0.029, p=0.000 &
p=0.000 respectively). Knees with severe valgus deformities have significantly worse pre operative scores and show greater improvement with equivocal post-operative outcome, when compared to those with severe varus deformity. In addition to pain relief, is the correction of instability the key to this improvement in this group of patients?
In order to determine the potential for an internervous safe zone, 20 hips from human cadavers were dissected to map out the precise pattern of innervation of the hip capsule. The results were illustrated in the form of a clock face. The reference point for measurement was the inferior acetabular notch, representing six o’clock. Capsular branches from between five and seven nerves contributed to each hip joint, and were found to innervate the capsule in a relatively constant pattern. An internervous safe zone was identified anterosuperiorly in an arc of 45° between the positions of one o’clock and half past two. Our study shows that there is an internervous zone that could be safely used in a capsule-retaining anterior, anterolateral or lateral approach to the hip, or during portal placement in hip arthroscopy.
