Pelvic Tilt Changes After Hamstring Lengthening in Children With Cerebral Palsy.

BACKGROUND: Flexion deformity of the knee is a common presentation in children with cerebral palsy with hamstring surgery as an option for addressing this. However, concerns with regard to increased pelvic tilt have been raised. The purpose of this study was to compare preoperative and postoperative pelvic tilt after isolated hamstring lengthening versus combined hamstring lengthening and the influence of Gross Motor Function Classification System (GMFCS) levels on pelvic tilt. METHODS: This retrospective study included 46 ambulatory children with cerebral palsy who had had open medial hamstring lengthening (mean age at surgery, 11 y 11 mo; SD, 2 y 11 mo; GMFCS I, 16; GMFCS II 20; GMFCS III 10). Twelve children underwent isolated surgery and 34 children underwent combined surgery. The isolated hamstring procedures could be combined with foot and/or ankle-level surgery, as only the hamstring procedure would affect the pelvic tilt. Combined surgery was defined as hamstring lengthening with other procedures performed at the knee or more proximally. The preoperative and postoperative 3-dimensional gait analysis data were evaluated in this study. RESULTS: Both the isolated and combined hamstring lengthening groups showed no significant change in pelvic tilt ([INCREMENT]1.28, P=0.203; [INCREMENT]1.47, P=0.113, respectively). A significant change in pelvic tilt was seen in children functioning at GMFCS III ([INCREMENT]4.66, P=0.009) but not GMFCS I and II ([INCREMENT]0.37, P=0.718; [INCREMENT]0.48, P=0.697). Significant postoperative decreases in the knee flexion angle at initial contact were seen for both isolated ([INCREMENT]5.72, P=0.010) and combined hamstring lengthening ([INCREMENT]10.95, P<0.001). CONCLUSIONS: Hamstring lengthening, for the majority of patients, did not lead to a clinically significant change in mean pelvic tilt and improved knee flexion angle at initial contact. Children who functioned at GMFCS level III had an increase in anterior pelvic tilt and caution should be exercised in this group. STUDY DESIGN: Level IV evidence-case series.

Anterior Guided Growth of the Distal Femur for Knee Flexion Contracture: Clinical, Radiographic, and Motion Analysis Results.

BACKGROUND: Fixed knee flexion deformity is common in children with neuromuscular disorders. Anterior guided growth (AGG) of the distal femur can achieve gradual correction in patients who are skeletally immature. Little outcome data are available on this procedure. METHODS: This is a retrospective matched cohort study. Forty-two knees (26 patients) underwent AGG surgery at our institution between 2007 and 2017. All patients underwent instrumented 3-dimensional gait analysis (3DGA). A nonsurgical control group of 49 knees (43 patients) was selected that matched for age, severity of preoperative knee contracture, and 3DGA parameters. Clinical, radiographic, and 3DGA outcomes were assessed and compared. RESULTS: Average preoperative knee flexion deformity in AGG group was 13±8 degrees. Following AGG, deformity improved by 8±7 degrees (P<0.001) as measured radiographically and by 7±7 degrees (P<0.001) as measured on physical examination. Average rate of correction was 0.7±0.6 degrees per month or 8±8 degrees per year. The 3DGA parameters such as minimum stance phase knee flexion and knee flexion at initial contact were also significantly improved following AGG. In contrast, flexion deformity as measured radiographically worsened by 3±3 degrees (P=0.002) in the control group. Twelve knees (29%) had failure of correction. Predictors of failure included older age, lower level of function, and greater severity of preoperative deformity. The age at time of surgery and the anteroposterior position of plate fixation relative to the distal femoral physis were associated with rate of correction. CONCLUSIONS: In children with neuromuscular disorders, AGG of the distal femur is effective in improving degree of fixed knee flexion deformity as well as objective gait parameters. A significant portion of knees experience inadequate correction. Addressing factors associated with correction failure (ie, age and plate placement) may improve the procedure's success. LEVEL OF EVIDENCE: Level III-case control study.

Three-Dimensional Printing and Surgical Simulation for Preoperative Planning of Deformity Correction in Foot and Ankle Surgery.

A paucity of published data is available describing the methods for the integration of 3-dimensional (3D) printing technology and surgical simulation into orthopedic surgery. The cost of this technology has decreased and the ease of use has increased, making routine use of 3D printed models and surgical simulation for difficult orthopedic problems a realistic option. We report the use of 3D printed models and surgical simulation for preoperative planning and patient education in the case of deformity correction in foot and ankle surgery using open source, free software.

Predictors of Nonunion and Infectious Complications in Patients With Posttraumatic Subtalar Arthrodesis.

OBJECTIVE: The objective of the present study was (1) to identify predictors of both nonunion and postoperative wound infections (POWI) and (2) to assess the union and complication rate following posttraumatic subtalar arthrodesis (STA). DESIGN: Retrospective comparative cohort study. SETTING: Level 1 trauma center. PATIENTS: All consecutive adult patients with STA following traumatic injuries between 2000 and May 2015. INTERVENTION: STA for posttraumatic deformities. MAIN OUTCOME MEASUREMENTS: Union (described as a combination of radiographic signs of osseous bridging and a clinically fused joint) and POWI as classified by the Centers for Disease and Control. RESULTS: A total number of 93 (96 feet) patients met the inclusion criteria. Union was achieved in 89% of patients. For primary, secondary in situ, and secondary correction arthrodesis, these percentages were 94%, 84,% and 90%, respectively (NS). The union rate significantly increased over time (P = 0.02). In 17 patients (18%), a POWI occurred, of which 2 were classified as superficial and 15 as deep POWIs. The POWI rate did not differ between the groups. Alcohol, nicotine, and drug abuse were not significantly associated with the occurrence of POWIs. Patients with an open fracture or an infection following open reduction internal fixation had a greater risk of a POWI following STA (P = 0.03 and P = 0.04, respectively). CONCLUSIONS: We could not identify predictors for nonunion. In 18% of the patients, an infectious complication following surgery occurred. Patients with an open fracture or an infection after primary surgical treatment (ie, open reduction internal fixation) have a higher chance of POWIs following STA. The union rate following posttraumatic STA is 89%. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shelf acetabuloplasty for containment in the early stages of Legg-Calve-Perthes disease.

BACKGROUND: To evaluate the effectiveness of shelf acetabuloplasty in the containment of extruded hips without hinge abduction in early stages of Legg-Calve-Perthes disease, we present a retrospective series of 44 patients (45 hips) treated between August 1999 and February 2010, which included 34 boys and 10 girls with a mean age at diagnosis of 7.4 years (range, 3.9 to 15.3). METHODS: All patients presented with sclerosis or early fragmentation stages. The average time from diagnosis to surgery was 2.1 months (range, 0 to 8.2) and the mean time to heal was 40.4 months (range, 20 to 82.2). The Reimer migration and the deformity indices were measured on initial, preoperative, postoperative, and healed x-rays. The average deformity index at 3 of those 4 timepoints was significantly related to their final Stulberg classification. CE angles increased and Sharp angles decreased significantly as a result of treatment. RESULTS: At the healed stage and consistent with other published series, 84.4% of patients were Stulberg III or less, denying any pain, and with full range of movement, whereas 15.6% were classified as Stulberg IV. CONCLUSIONS: We defend that shelf acetabuloplasty should be performed early in the disease and, uniquely, we propose that the indication for treatment should be guided by the deformity and the Reimer migration indices. LEVEL OF EVIDENCE: IV.

Evaluation of outcome of surgical excision of the nidus of osteoid osteoma of long bone.

Osteoid osteoma is a benign bone tumour usually found in the lower extremities of children and young adults. This tiny bone tumour causes pain out of all proportion to its size and hinders the daily activities. This Quasi-experimental study conducted in the department of Orthopaedic surgery of BSMMU from January 2008 to December 2009. Twenty one patients were included in the study where purposive sampling technique was used on the basis of inclusion and exclusion criteria and all the ethical conditions were fulfilled. Diagnosis was almost obtained by taking history, clinical examination, and relevant investigations. Clinical variables were age, sex, site, pain, swelling, deformity and outcome variables were painless active life, removal of swelling, prevention of deformity, rate of recurrence. After localization of the tumour with the help of C arm, the nidus was excised in a small block of bone. The outcome is categorized by consensus, as clinically successful, only if the patient was free of pain and was taking no medication. The treatment was considered to have failed if a subsequent procedure had been performed to remove tumour. Among 21 cases, 14(66.7%) were male and 7(33.7%) were female. Maximum number of patients 15(71.4%) was between 10 years to 20 years. Most of the patients (76.2%) affected by osteoid osteoma were young students and most of the patients (95.2%) experienced moderate aching pain, usually aggravating at night which was typically relieved by aspirin or other NSAIDs (71.4%). Lower limbs (76.2%) particularly femur and tibia were commonly affected. Out of 21 patients, 19(90.5%) patients have got immediate pain relief or required no medication. In only 2 patients (9.5%), subsequent procedure has been performed to relief pain. So, successful outcome (in 19 out of 21) was significantly (p<0.001) higher in comparison to failed. Surgical excision of the nidus is a simple and easy procedure and does not require extensive resection of bone. If localization is done properly success rate is high and patients can return to normal daily activities.

Charcot's foot: newest findings on its pathophysiology, diagnosis and treatment.

Charcot neuro-osteoarthropathy (CNO) is one of the more devastating complications affecting diabetic patients with peripheral and/or autonomic neuropathy. The acute phase of the disease is often misdiagnosed, and can rapidly lead to deformity and amputation. The rapid progression towards foot deformation calls for early detection and intervention. Classical neurotraumatic and neurotrophic theories fail to explain all of the features of the condition, although recent advances that have clarified the mechanisms underlying the pathophysiology may make up for this lack. In particular, new data have emerged on the central role of the RANK/RANK-ligand (RANK-L)/osteoprotegerin (OPG) system in the pathogenesis of osteopenia. Also, it is now recognized that the acute phase of CNO can be triggered by any factor leading to local inflammation of the foot, especially in predisposed patients. As the cornerstone of treatment remains any method that avoids weight-bearing on the foot, the primary importance of the RANK/RANK-L/OPG signalling pathway is that it opens up the field to new treatment strategies for the future.

The paper grip test for screening on intrinsic muscle paralysis in the foot of leprosy patients.

Plantar intrinsic foot muscles provide structure to the foot during walking and thus regulate mechanical foot sole stresses. When paralyzed, for instance in leprosy patients with neuropathy of the distal part of the tibial nerve, there is a high prevalence of plantar ulceration and deformities, especially when muscle weakness goes together with loss of foot sole sensibility. These patients should get immediate care involving education, special footwear and reconstructive surgery before further foot impairment and deformity becomes manifest. Thus far, in leprosy patients little attention is paid to screening of plantar intrinsic muscles activity. This can be done with a new simple and non-invasive method, the Paper Grip Test (PGT). There are two variants for detecting intrinsic muscle weakness of the foot, PGT1 for the great toe and PGT2 for the combined lesser toes. In this study, 517 leprosy patients and 170 healthy volunteers were investigated with the PGT. Sensibility of the foot sole was tested by means of a 10 gram monofilament. Specificity to the PGT1 is found to be about 95.3% which is considered good for physical diagnostic tests. PGT2 is less specific than PGT1. Individual muscle power and understanding of the patient seems to influence the outcome of the test to a certain extent. Sensitivity can only be calculated when the diagnosis is confirmed by electromyography. Especially patients with anesthetic feet, females, older patients and patients with PN-, BB- or LL-types of leprosy appeared to have a higher prevalence of intrinsic foot muscle weakness. All results were analyzed by means of the bivariate Pearson correlation-analysis and proved to be statistically significant (p = < 0.05). It is concluded that the PGT1, more than the PGT2, is a useful screening test on the function of plantar intrinsic foot muscles in leprosy patients in hospitals and during fieldwork in developing countries.

Surgical prevention of foot deformity in patients with Duchenne muscular dystrophy.

The purpose of this study was to evaluate the results of a modification of the posterior tibial tendon transfer in Duchenne muscular dystrophy patients with regard to foot deformity and ambulation. The records of 57 patients with Duchenne muscular dystrophy were retrospectively reviewed. Three treatment groups were studied: group 1, those who had surgery to maintain ambulation; group 2, those who had surgery to correct and maintain foot position; and group 3, those who had no surgery. All surgical patients had posterior tibial tendon transfer and Achilles tendon lengthening as part of their procedure. Thirty-four patients returned for interviews and examinations to assess outcomes and foot position. The mean age at cessation of ambulation for those who had surgery was 11.2 years versus 10.3 years for those who did not have surgery. Of 48 feet in 24 patients who underwent lower extremity surgery to correct and maintain foot position, 94% were clinically satisfactory at a mean of 8.5 years after surgery. Regardless of the desire to continue ambulation, all patients should have posterior tibial tendon transfer, Achilles tendon lengthening, and toe flexor tenotomies to maintain plantigrade feet.

Iatrogenic deformities of the first ray.

Surgical correction of a hallux valgus deformity is common among podiatric and orthopedic surgeons. Complications following hallux valgus surgery are not uncommon. Although many of these complications can be avoided by a comprehensive understanding of the pathomechanics of a hallux valgus deformity and continual honing o surgical skills, some are inevitable. This article provides a comprehensive overview and insight into the diagnosis and treatment of the more common complications encountered with hallux valgus surgery.

Feet and systemic disease.

Diabetes mellitus and rheumatoid arthritis often affect the foot. Indeed in either of these, the foot is commonly the initial site of symptoms. Early diagnosis appropriate treatment can prevent or at least slow the progression of the disease in the foot. Extra depth shoes and moulded inserts are the keystone of non operative treatment. Surgery is indicated when the deformity is severe. Surgery does have good results in rheumatoid arthritis but in diabetes mellitus it is usually reserved as a salvage procedure.

[Relation of early wound treatment and late deformity in burned children].

This article discusses the relationship between early wound treatment and late deformity in burned children. The writer believes the main causes of late deformity are as follows: to treat deep second burn wound too conservatively; to use pinch skin graft on functional position and too large ratio of mesh graft; to take skin too thick from donor area; no proper pressure dressing and rehabilitation after grafting. The better results can be obtained, if the early burn wounds are treated with some plastic surgical points of view and the deformities are corrected within half year postburn although the scar is still unstable.

The role of podiatrists in occupational health.

The podiatrist's role in occupational health is variable and depends on the type of programs offered to workers, methods of financing and delivering services, and contractual arrangements with management or labor. A positive and necessary impact on occupation-related disorders of the foot may be provided by the podiatrist at three levels of care: primary, secondary, and tertiary prevention or care.

Prophylactic surgery in the diabetic foot.

Prophylactic surgery in the diabetic foot is often fraught with complications, according to a five-year retrospective study at the University of Chicago Hospitals and Clinics. The findings indicate that seven major areas need be addressed in order to properly evaluate the potential diabetic surgical patient. These include careful evaluation of preoperative nutritional status, vascular status, neurologic status, bacteriologic culture status, deformity status, radiologic status, and surgical predictive index.

Prevention of complications of partial foot amputations in American Indian diabetics.

Lower extremity complications of diabetes mellitus have become one of the leading causes of amputations in the American Indian population served at the Phoenix Indian Medical Center. The author describes operative techniques, biomechanical considerations, and treatment philosophy for prevention of these complications.

Dynamic post-surgical hallux varus after lateral sesamoidectomy: treatment and prevention.

Hallux varus and clawing are occasionally seen after a McBride procedure, due to the severance of the flexor hallucis brevis, when the lateral sesamoid is removed. The present study includes six patients, (involving ten feet), who developed hallux varus and great toe clawing after McBride procedures were performed by various orthopedic surgeons. Treatment utilized partial proximal phalangeal resection, with and without silicone single-stem implants, extensor hallucis longus tendon transfer to the great toe metatarsal, and interphalangeal joint arthrodesis, or tenodesis of the great toe to correct clawing. One patient eventually required a great toe metatarsophalangeal joint fusion. This reconstructive surgery is generally effective by correcting capsular malalignment, the "bowstringing" tendency of the extensor hallucis longus, and great toe clawing that develops simultaneously with hallux varus. Lateral sesamoidectomy is risky, and believed unnecessary as adductor hallucis tenotomy is effective in relieving hallux valgus. Although, it can occur with excessive excision of the medial emminence and distal advancement of the abductor hallucis. The author is unaware of hallux varus developing after adductor hallucis tenotomies.