Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept.

BACKGROUND: A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones. DESCRIPTION: The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa. PURPOSE: This paper is a review article of this concept and of its physiopathological applications.

[Protective limp]. / Boiterie.

Limping in a child is a frequent reason for consultation, sometimes as an emergency. A distinction should be made between a protective limp, to avoid painful weight bearing, and an equilibration limp, which corresponds to an adaptation to a disturbance of muscular activity with a neuromuscular or osteoarticular origin. Etiological analysis of a protective limp is essentially based on the history and examination. Further radiological or biochemical investigations contribute to the diagnostic process and are essential in limps of recent onset. Broadly speaking, in children aged between one and two years, the main etiological hypothesis, in terms of frequency and potential seriousness, is osteoarticular infection, although fractures are also common. In children aged between three and eight years, osteoarticular infection should be sought as a priority. The diagnosis of acute transient synovitis (irritable hip) should only be made after excluding other conditions including benign bone tumours (such as ostioid osteoma), malignant tumours, inflammatory monoarthritis, primary osteochondritis of the hip, trauma with or without fracture, apophysitis, leukemia, etc. The diagnosis of acute transient synovitis should be questioned if the condition persists for more than seven days. After the age of nine years, the diagnosis that is important not to miss is proximal femoral epiphysiolysis, because this condition can have serious implications for the future function of the hip. The other diagnoses already cited remain possibilities. Finally, a psychogenic aetiology, tendinitis, or sprain should not be considered in children, and they risk delaying the diagnosis of a potentially serious condition. The aetiology of an equilibration limp is based on a precise clinical examination, aimed at detecting orthopedic or neurological pathology, which will direct further investigations.

[Congenital dislocation of the hip: current concepts as a preliminary for diagnosis and treatment]. / La luxation congénitale de hanche. Les faits, les signes, les mots. Etat de l'art.

Congenital hip dislocation has been regularly reviewed, in the wake of important progress made over the last thirty years, and more precisely in the field of clinical and ultrasonographic screening, as well as in early treatment. The search of a consensus on the best screening methods (who? how?) should start from one initial point: a thorough knowledge of anatomical, clinical, pathological and therapeutic definitions and concepts underlying this far-reaching question. This is the purpose of the present review of current ideas (from a historical perspective). The two authors, members of French Society for Paediatric Orthopaedics (SOFOP), have extensively researched this subject and contributed to the implementation of national "good practice".

Closed reduction in late-detected developmental dysplasia of the hip: indications, results and complications.

PURPOSE: The aim of the study was a review of the literature in order to evaluate the results and complications of closed reduction in late-detected developmental dysplasia of the hip (DDH). METHODS: This study consisted of an analysis of the literature relative to late-detected DDH treatment options considering hip congruency, rates of re-dislocation and of avascular necrosis. RESULTS: Gradual closed reduction (Petit-Morel method) appears to be an effective method concerning joint congruency restitution. Dislocation relapse and avascular necrosis are more efficiently prevented with closed versus open reduction. The tendency for spontaneous correction of acetabular dysplasia decreases if closed reduction is performed after 18 months of age. Patient age at the beginning of traction should be considered for the prognosis, with a lower rate of satisfactory results showing after the age of 3 years. CONCLUSION: In our opinion, the Petit-Morel method is a suitable treatment option for children aged between six months and three years with idiopathic DDH.

[Resection of navicular bone for severe midfoot deformity in children]. / Résection de l'os naviculaire pour déformation sévère du médio-pied de l'enfant.

PURPOSE OF THE STUDY: The navicular bone lies at the apex of the deformity in severe talipes planovalgus with forefoot abductus, in the residual cavus of congenital talipes equinovarus, in certain cases of congenital convexity, and in certain types of neurological equinovarus. Resection of the navicular bone can be proposed to correct certain deformities. MATERIAL AND METHODS: This series included 15 feet operated on in 13 children from 1980 to 2003. The deformity to be corrected was a residual cavus after surgery for congenital talipes equinovarus (five feet), plantar and medial dislocation of the navicular bone on an acquired equinovarus in non-walking children (three feet), planovalgus with major forefoot abductus in non-walking children (four feet). Among the 13 children in this series, five did not walk (seven feet) and underwent surgery because of skin wounds caused by protrusion of the head of the talus and serious mechanical problems (shoes, ortheses). Mean age at operation was 8.5 years (range 2-16 years). The surgical procedure was part of an overall strategy combining use of ortheses, physiotherapy, and medical management. For congenital equinovarus with residual cavus, naviculectomy was performed after the usual technique for equinovarus when the navicular bone was dislocated above the medial tarsal and prevented reduction of the cavus. After extraperiosteal release, resection of the navicular bone enabled correction of the cavus. The lateral column had to be shortened in order to avoid adductus subsequent to medial-lateral length discrepancy. The same surgical technique was used for acquired equinovarus except that the navicular bone was displaced medially and above the talus. The lateral column had to be shortened. Standard procedures were applied for congenital convex feet before naviculectomy when there was major forefoot abductus after medial tarsal release and tendon lengthenings. The lateral column was not shortened since it was already too short. For planovalgus with forefoot abductus, naviculectomy was combined with release of the calcaneocuboid joint. Fibular tendons were lengthened. RESULTS: Mean follow-up was two years five months (range 5 months-12 years 6 months). For the talipes equinovarus feet, the Méary Toméno angle was 24.4 degrees on average preoperatively and 5 degrees at last follow-up, giving a mean gain of 19.4 degrees . For congenital convex feet, the M5-lateral calcaneal border angle was 29.7 degrees on average preoperatively and 11.7 degrees at last follow-up for a mean gain of 18 degrees . For the planovalgus feet with forefoot abductus, the M5-lateral calcaneal border angle was 32.7 degrees on average preoperatively and 12.2 degrees at last follow-up, for a gain of 20.5 degrees on average; the mean Méary Toméno angle was -30 degrees preoperatively and -3 degrees at last follow-up, for a mean gain of 27 degrees . CONCLUSION: For carefully selected patients, naviculectomy performed in combination with other procedures can provide appropriate correction of severe midfoot deformities in children.

Congenital dislocation of the knee at birth - Part I: Clinical signs and classification.

INTRODUCTION: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period. HYPOTHESIS: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria. MATERIAL AND METHODS: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III. CONCLUSION: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors.

INTRODUCTION: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis. MATERIAL AND METHODS: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees. CONCLUSION: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Is non-operative management of childhood neurologic cavovarus foot effective?

INTRODUCTION: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE: IV.

Coexisting left congenital diaphragmatic hernia and esophageal atresia with tracheoesophageal fistula: successful management in a premature neonate.

The combination of left congenital diaphragmatic hernia (CDH) with esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) is extremely rare and is considered highly lethal. The authors describe a premature neonate with this association, who is alive at 6 1/2 years of age. Temporary banding of the gastroesophageal junction and gastrostomy was performed concurrently with hernia repair and prosthetic abdominoplasty to enlarge the abdominal cavity. A right thoracotomy for ligation of the fistula, using extracorporeal membrane oxygenation (ECMO), was performed 13 days later. Complete repair of the esophageal atresia was accomplished 7 weeks after birth. The methods that have been suggested in the literature are discussed. The institution of ECMO at birth could allow a primary complete surgical repair of EA and CDH. Nevertheless, surgical management with staged repair, as described herein, can be useful.

[Treatment of infectious osteoarthritis in children]. / Traitement des ostéoarthrites infectieuses de l'enfant.

Treatment of septic arthritis is an emergency; therefore antibiotherapy must be started rapidly following the bacteriological sampling. The risk for the articles justifies that treatment be started with two antibiotics given intravenously, the choice of the antibiotics being dependent upon the clinical history. If the bacteria is isolated, an adopted monotherapy is then maintained. A drainage of the joint can be performed by needle aspiration or by a percutaneous catheter, and in case of difficulty to control the sepsis, by surgical debridment. Intravenous antibiotherapy is maintained for 7 to 15 days. Whenever a good response is observed the treatment is continued orally for a total duration of 4 to 6 weeks.

[Diagnostic difficulties of isolated symptomatic unilamellar periosteal appositions. Uncommon form of fatigue fracture in children]. / Difficultés diagnostiques des appositions périostées unilamellaires symptomatiques isolées. Forme inhabituelle des fractures de fatigue de l'enfant.

We describe five cases of painful periosteal reaction occurring in children. The initial radiographic appearance of stress fracture may be troublesome since the new bone formation may be confused with malignant bone lesion. Because of the importance of making a correct diagnosis multiple imaging techniques will often be employed. We discuss the radiographic signs and their usefulness in the differential diagnostic of periosteal reaction.

[Clinical examination of the hips in newborn infants]. / L'examen clinique des hanches en maternité.

The author describes the criteria for screening a hip at risk in the newborn. The following criteria are important: evaluation of abduction, fetal position of the lower limbs and instability. After examination, the hips are classified as normal, irreducible and questionable. A good clinical examination can clarify most of these diagnoses.

[Congenital equinovarus clubfoot]. / Pied bot varus équin congénital.

A congenital clubfoot is often associated with a neuromuscular disease, a chromosomal anomaly, or a syndrome. The present review will only study the idiopathic clubfoot seen in an otherwise normal child. It is considered nowadays that a clubfoot is secondary to a defect in the spontaneous "rotation-elevation" mechanism which should occur between the 9th and 10th week of fetal development. Several possible factors influence the embryonic development: genetic, neurologic, muscular, environmental, and toxic factors. Modern notions of anatomy and physiology of the foot allow a better understanding of the deformations seen in a clubfoot: calcaneo-forefoot block, talonavicular joint double "belonging", notion of "relative" hindfoot supination. The osteo-articular deformations involve mainly the talus, the calcaneus, the navicular. They are associated to articular stiffness secondary to soft tissue retractions like the posterolateral, anteromedial, and the anterolateral fibrous knots. Prenatal diagnosis can be made using the ultrasound which is usually performed at 20 weeks of gestation. Nevertheless, only the clinical exam at birth will evaluate the degree of severity of the clubfoot based upon its reducibility, the presence of skin creases, and the importance of muscular atrophy. Imaging techniques (especially standard x-ray) are useless diagnostic tools. They will be necessary for the follow-up, the evaluation of residual defects, and for the possible surgical indications. Conservative treatment is used first, and in the hands of experienced teams will give a sufficient correction in 70 to 80% of the patients. The surgical treatment is used to complete the correction obtained by conservative means. Surgical treatment will free the retracted soft tissues. Postoperatively the foot will be immobilized in the appropriate position for 2 to 3 months. Clubfoot treatments are associated with complications which have to be known to avoid them if possible and/or to be able to take the appropriate therapeutic actions when necessary. The results of clubfoot treatment are satisfactory in the majority of patients despite the treatment difficulties and the possible relapses during growth. Follow-up is mandatory until the end of growth.

[Traumatic scapulo-humeral dislocation in children and adolescents. Apropos of 9 patients]. / Luxation scapulo-humérale traumatique chez l'enfant et l'adolescent. A propos de 9 patients.

From 1974 to 1989, 9 children or adolescents, with an average age of 12 years and 4 months were seen for traumatic dislocation of the shoulder. All patients were followed for a minimal period of 2 years following the primary dislocation. Six patients were treated with closed reduction and immobilization for 3 weeks followed by a rehabilitation program. The recurrence rate was 71%. The authors insist on the fact that traumatic glenohumeral dislocation is a rare pathology in pediatric traumatology. The recurrence rate following the initial episode is higher however than for the adult population. These patients should be followed until consolidation of their lesions.

[Idiopathic congenital club foot: results of functional treatment (269 feet)]. / Pied bot varus équin congénital idiopathique: résultats du traitement "fonctionnel" (269 pieds).

The manipulative treatment consisted of manipulations, muscular stimulations and fixation of the foot on a sole with non elastic strapping. This "functional" method used since the neonatal period was studied in 183 infants (269 clubfeet) with an average follow-up of 6 years and 2 months. A surgical release completed the correction in 139 feet. The initial examination permitted to distinguish 3 different grades of clubfeet, according to the clinical stiffness. The physiotherapist who treated the patients were separated in "specialized" and "unspecialized". During the evolution, 5 different categories were defined according to the clinical and radiological aspects. The criteria adopted for evaluating the results were scored with a screen of 100 points. The results obtained from 157 feet with a minimal follow-up of 4 years, were excellent and good in 86.6 per cent cases, fair in 10.2 per cent and poor in 3.2 per cent. The global results of the "functional" method, taking the insufficient follow-up into account, are for the whole series: success in 38.7 per cent, intermediary results in 15.6 per cent and failure in 45.7 per cent. The main factors which have a pejorative influence on the results are the irreducibility (according to the initial classification), the "unspecialized" physiotherapists, the socio-familial problems.

[Comparison of evaluation methods of the results of congenital clubfoot treatment]. / Comparison des methodes d'evaluation des resultats du traitement du pied bot varus equin congenital.

INTRODUCTION: An ideal method for the assessment of the results of treatment in congenital clubfoot should take into account the morphology of the foot and its function, the personal satisfaction of the patient of his parents, interexaminer variability, and be applied for any type of treatment. MATERIAL AND METHODS: We evaluated at- end of growth the results of treatment of 35 patients with unilateral clubfoot, and analyzed them according to 13 different rating scores already published in the literature. The material was divided in 3 groups; 15 feet having undergone multiple surgeries, 10 feet having had only one posteromedial release procedure, and 10 feet having been treated nonoperatively. RESULTS: None of the 13 reviewed rating methods seems to be ideal. The results of treatment, for one taken foot, were often different from one method to the other. DISCUSSION: The high number of rating scores published in literature, is the direct evidence that there is no concensus in the evaluation of the results of treatment in congenital clubfoot. A unanimous new method should be created and should fill all the prerequisites of the ideal method, described above. Some criteria are very important to consider: A iatrogenic deformity or disability, i.e. severe lateral translation of the foot, acquired convex foot, or calcaneus foot, should be severely penalized; hopping on one foot should be the test used to evaluate the strength of triceps surae muscle in children above 5 years of age ; Radiological evidence of talonavicular dislocation is a very important long term prognostic element. CONCLUSION: A new unanimous method for the assessment of the results of clubfoot treatment is necessary. It should be simple, easy to teach, and easy to use.

[Hip dysplasia in adolescence]. / Dysplasie de hanche à l'adolescence.

INTRODUCTION: Hip growth continues on till adolescence with the fusion of the different ossification centers. Does this growth exist in hip dysplasia? What is the role of surgery at adolescence? Is an additional varus osteotomy indicated with a pelvic osteotomy? MATERIAL AND METHODS: Clinical and radiological criteria of adolescent hip dysplasia were studied in a series of 18 patients (mean age 12 years). The 28 hips were divided into 4 groups depending on the treatment: non operated hips (group 1, N = 8), hips operated on only by pelvic osteotomy (group 2, N = 8), hips operated on by combined pelvic and femoral osteotomies (group 3, N = 9), and hips operated on only by femoral osteotomy (group 4, N = 3). Tonnis's clinical criteria were used. The acetabular index of the weight bearing zone, the center-edge angle of Wiberg, the acetabular angle of Idelberger and Frank, the neck-shaft angle, the head coverage index were measured and compared between the 4 groups (average follow-up was 46 months). RESULTS: We noted continuation of growth of the acetabulum at adolescence with a correction of moderate hip dysplasia when the head was covered (group 1), the acetabular index of the weight-bearing zone decreased from 20.1 degrees to 11.1 degrees; the center-edge angle of Wiberg increased from 15.25 degrees to 23 degrees. The comparison of groups 2 and 3 showed that an additional femoral osteotomy does not change significantly the radiologic results. DISCUSSION: Does surgery benefit at adolescence from the growth which exists during this period? The clinical results and the evolution of arthrosis following a Chiari pelvic osteotomy are better when the operation is performed early. CONCLUSION: A pelvic osteotomy is indicated in symptomatic hips, when the congruity is abnormal, with deficient head coverage, as well as moderate dysplasia when the evolution of the acetabular parameters are not satisfactory. A femoral osteotomy in addition to a pelvic osteotomy does not seem justified.

[Growth disorders of the upper end of the femur following treatment of congenital hip luxation]. / Les troubles de développement de l'extrémité supérieure du fémur après traitement de la luxation congénitale de hanche.

From approximately 2,500 cases of treated congenital dislocation of the hip, the authors have selected 82 cases with 100 hips showing disturbance of the superior epiphysis and metaphysis of the femur. These have been observed after several types of treatment - napkins in abduction, abduction harnesses, abduction splintage, closed reduction by Lorenz technique, progressive reduction by Somerville technique or open reduction. The risk factors have been analysed in 22 hips treated by progressive reduction. It is concluded that changes in the metaphysis and in the growth plate are the main cause of late abnormality. A classification of these abnormalities is proposed to aid diagnosis and for the institution of earlier treatment. In severe cases, combined pelvic and femoral osteotomy give the most satisfactory results.

[Congenital dysplasia and dislocation of the hip. Pathological anatomy in the newborn and infant (author's transl)]. / Dysplasie et luxation congénitale de la hanche. Anatomie pathologique chez le nouveau-né et le nourrisson.

The authors have had the opportunity of making a complete and precise dissection of newborns with congenital dislocation of the hip. They have also made a dynamic study of the hip joints in the specimens. The findings have been compared with other studies published in the literature. It is concluded that the dislocation is posterior or postero-superior and that acetabular dysplasia is consistent in unstable hips in the newborn. The acetabular plasia is secondary to the dislocation and lies postero-superiorly. It cannot be detected radiologically. The existence of primary acetabular dysplasia is doubtful. The main responsibility for congenital dislocation of the hip is a faulty position of the foetus in utero. The disease therefore cannot be prevented. It is of importance to diagnose the disease as soon as possible.

[Open reduction after failure of conservative treatment for congenital dislocation of the hip initiated before the age of six months]. / Réduction chirurgicale pour échec du traitement orthopédique de la luxation congénitale de hanche entrepris avant l'âge de 6 mois.

PURPOSE OF THE STUDY: The aim of this study was to present the indications, technique and results of open reduction for congenital hip dislocation performed after failure of conservative treatment. MATERIAL AND METHODS: Criteria of inclusion in the series were: congenital dislocation of the hip treated conservatively before the age of six months requiring open reduction for failure of initial treatment between 1978 and 1998. During this period, 3000 hips sustained conservative treatment. The series counted 33 hips in 29 children. Mean number of different conservative methods used for one hip was 2.6. One-third of the hips had had previous surgery. Avascular necrosis was noticed in 17 cases (51.5%). Mean age at open reduction was 2 years. Pelvic (61%) and/or femoral (79%) osteotomies were combined with open reduction. RESULTS: Mean follow-up was 9.5 years. Among the complications, minor avascular necrosis was noticed in five hips without preoperative lesions. Hip joint congruency was excellent or good in 80.7% of the cases. There were no recurrent dislocations. Ten hips (32.3%) were free of avascular necrosis but 4 presented severe avascular necrosis (13%). DISCUSSION: Indications for open reduction are exceptional, attesting to the efficacy of conservative treatment. This salvage procedure achieves good results in the hands of experienced surgeons. The quality of the reduction depends not only on the intra- and extra-articular excision, but also on the stability achieved with peri-articular osteotomies. The main factor of prognosis is avascular necrosis induced by previous treatment.