Use of PROMIS in Assessment of Children With Ponseti-treated Idiopathic Clubfoot: Better Scores With Greater Than 3 Years of Brace Use.

BACKGROUND: Patient-Reported Outcomes Measurement Information System (PROMIS) is a well-validated tool used to measure health-related quality of life for children and adolescents with chronic medical conditions. The current study evaluates PROMIS scores in 3 domains for children with Ponseti-treated idiopathic clubfoot. METHODS: This is a retrospective cohort study of 77 children, ages 5 to 16 years, treated by Ponseti protocol for idiopathic clubfoot. Three pediatric PROMIS domains (Mobility, Pain Interference, and Peer Relationships) were administered between April 2017 and June 2018. One-way analysis of variance with Bonferroni post hoc and independent sample t tests were performed to explore differences across PROMIS domain scores by sex, age, initial Dimeglio score, laterality, bracing duration, and whether the child underwent tibialis anterior transfer. RESULTS: In the self-reported group (ages 8 to 16), mean T-scores for all 3 domains in both unilaterally and bilaterally affected groups were within the normal range, with respect to the general reference pediatric population. However, children with unilateral clubfoot had a significantly higher mean Mobility T-score (54.77) than children with bilateral clubfoot (47.81, P=0.005). Children with unilateral clubfoot also had significantly lower mean pain scores (39.16) than their bilateral counterparts (46.56, P=0.005). Children who had braced >36 months had a significantly higher mean Mobility T-score (53.68) than children who braced ≤36 months (46.28, P=0.004).In the proxy group (ages 5 to 7), mean T-scores for all 3 domains in both laterality groups were within the normal range, with respect to the reference population. Children who had braced >36 months had a significantly higher mean Mobility T-score (52.75 vs. 49.15, P=0.014) and lower Pain Interference score (43.04 vs. 49.15, P=0.020) than children who braced ≤36 months. CONCLUSIONS: Children treated by Ponseti protocol for idiopathic clubfoot yielded PROMIS scores for Mobility, Pain Interference, and Peer Relationships domains similar to the reference population. Bracing duration >36 months and unilaterality were associated with less mobility impairment than their counterparts. These findings may help guide parent recommendations. LEVEL OF EVIDENCE: Level III.

Neurodevelopmental difficulties in children with idiopathic clubfoot.

AIM: To evaluate neurodevelopmental difficulties in children with idiopathic clubfoot. METHOD: A cross-sectional study of 106 children (29 females, 77 males; aged 8-10y) with idiopathic clubfoot and 109 age-, sex-, and residential area-parallelized children from the general population. Neurodevelopmental difficulties were assessed using the parent-report Five to Fifteen (FTF) questionnaire. Group differences were analysed for FTF domains, subdomains, and items. The 90th centile cut-off of the general population on FTF and the parent-based disease-specific instrument (DSI) were used to evaluate clinical relevance of neurodevelopmental symptoms in idiopathic clubfoot. RESULTS: Modest group differences were found for several FTF domains (motor skills, perception, and language) and subdomains (gross and fine motor skills, relation in space, comprehensive and expressive language skills). Thirty-one per cent of the children with idiopathic clubfoot scored in the clinically significant range on 2 or more FTF domains. DSI scores were lower in this subgroup. INTERPRETATION: Findings indicate a moderate and selective increase of neurodevelopmental difficulties in children with idiopathic clubfoot as a whole, especially in the areas of motor skills, perception, and language. Idiopathic clubfoot with marked neurodevelopmental symptoms are associated with less satisfaction of the clubfoot treatment. Our results recommend awareness of neurodevelopmental difficulties in the assessment and treatment of idiopathic clubfoot. WHAT THIS PAPER ADDS: A substantial minority of children with idiopathic clubfoot show neurodevelopmental difficulties. Children with idiopathic clubfoot might present additional difficulties in motor skills, perception, and language. Children with idiopathic clubfoot and marked neurodevelopmental symptoms show poorer parent-reported clubfoot treatment satisfaction. Neurodevelopmental difficulties should be considered in clinical practice of idiopathic clubfoot.

Neurodevelopmental difficulties negatively affect health-related quality of life in children with idiopathic clubfoot.

AIM: To study health-related quality of life (HRQoL) in children with idiopathic clubfoot (IC) and the influence of sex, clubfoot laterality and neurodevelopmental difficulties (NDD) on HRQoL. METHODS: A cross-sectional questionnaire-based study in Stockholm and Skåne Counties, Sweden, of 106 children with IC born 2004-2007 (mean 9.4 ± 0.6 years) and a general population sample of 109 schoolchildren (mean 9.5 ± 0.6 years). The children and their caregivers answered the EQ-5D-Y (Youth) and Five to Fifteen questionnaires to operationalise HRQoL and NDD, respectively. RESULTS: No reduced HRQoL on the EQ-5D-Y dimensions were reported by 51% of the children with IC, and 71% in the general population sample, with significant more problems in the IC sample regarding 'mobility', 'doing usual activities' and 'having pain or discomfort', despite similar overall health status. Neither sex nor clubfoot laterality affected HRQoL. Children with IC and NDD combined reported more problems in three out of five dimensions and lower overall health status compared with children with IC alone. CONCLUSION: Despite similar overall health status, children with IC had more HRQoL problems compared with the general population, being associated with coexisting NDD but not sex or clubfoot laterality.

The Validity of Patient-reported Outcome Measurement Information System (PROMIS) Parent Proxy Instruments to Assess Function in Children With Talipes Equinovarus.

BACKGROUND: Idiopathic talipes equinovarus (ITEV) is a prevalent structural deformity of the foot and ankle in children. The disease-specific instrument (DSI) has commonly been used as an outcomes metric in these patients. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to examine the quality of life across various medical conditions. PROMIS has been validated for multiple conditions; however, no studies have evaluated the use of the PROMIS in children with ITEV. METHODS: A prospective analysis was performed whereby the 2 questionnaires were mailed out to the parents of 91 patients, aged 5 to 17 years, with ITEV. Construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of Mobility, Fatigue, Pain Interference, and Pain Intensity to the DSI Function domain and PROMIS domains of Anxiety, Depressive Symptoms, Peer Relationships, and Pain Intensity to DSI Satisfaction domain. RESULTS: Thirty-one complete responses (34% response rate) were returned. The patients' current mean age was 8.8 years, 7 were female individuals, and 12 had unilateral ITEV. Bivariate correlation analysis, using Spearman correlation coefficients, demonstrated a moderate positive correlation between the DSI Function domain and the PROMIS Mobility domain (rs=0.52) and a moderate negative correlation between the DSI Function domain and the PROMIS Pain Interference domain (rs=-0.56), as well as the PROMIS Pain Intensity domain (rs=-0.75). A fair negative correlation (rs=-0.38) with PROMIS Fatigue domain was found. Correlations between the DSI Satisfaction domain and the PROMIS domains were fair or had little relationship. CONCLUSIONS: These results provide support for the validity of the PROMIS Mobility, Pain Interference, and Pain Intensity domains in this population, however there are no items in PROMIS that can assess overall satisfaction, as with the DSI. LEVEL OF EVIDENCE: Level II-prospective comparative study.

[Disease Experience after Many Years of Orthopedic Therapy in Childhood]. / Krankheitserleben nach langjähriger orthopädischer Therapie in der Kindheit.

The orthopedic medical history of the now 56-year-old Mr. Z began immediately after his birth with an inpatient clubfoot therapy. With the onset of adolescence, multilocular pain began. The long-standing patient career was characterized by disappointment about the early onset and recurrent need for treatment. The disappointment motive is closely related to the relationship between the patient and his mother. The biography illustrates the intertwining of early (orthopedic) treatment, primary bonding and disease experiences. A multimodal pain therapy was able to target Mr. Z, create positive body experiences and finally reduce the pain.

[Hungarian validation of the Clubfoot Disease-Specific Instrument]. / Dongaláb-specifikus életminoség-kérdoív magyar adaptációja.

INTRODUCTION: Congenital structural clubfoot is the most common congenital deformity of the foot. Despite successful treatment, the affected side may present signs of athrophy, differences in length, functional maldevelopment and in some cases it may also result in pain. Although several international studies have been investigating the quality of life of individuals with clubfoot, no research has been done in Hungary. Patient-based assessment is used for the evaluation of the effectiveness of treatment and for the comparison of the traditional versus the Ponseti method. AIM: To gain permission for the use of the internationally most well-known Clubfoot Disease-Specific Instrument (hereafter: 'Clubfoot Specific Questionnaire') consisting of 10 items and two subscales, and furthermore, to adapt its parent and child-version for Hungary and to carry out the internal and external validity testing of the measure. METHOD: The Questionnaire was completed by 75 individuals (44 boys, 28 girls) belonging to three age groups (under age 12, aged 12-17.99 years and those aged above 18); the mean age was 12.45 years (range: 2-44 years). The measures used: the Hungarian version of the 'Clubfoot Specific Questionnaire' (adapted versions for the given age groups), and the Hungarian version of EQ-5D-3L to measure the general quality of life. RESULTS: Both the parent- and the child-version of the 'Clubfoot Specific Questionnaire' showed adequate internal validity (parent-version: 0.872, child-version: 0.923); the individual items showed medium to strong correlations with the EQ-5D-3L dimensions besides the existing significant connections. CONCLUSION: The Hungarian adaptation of the measure proved to be successful. The validated questionnaire provides a further tool for the assessment of the quality of life of individuals with clubfoot and also for the evaluation of the success rate of therapies. Orv Hetil. 2018; 159(31): 1269-1277.

[Rehabilitation and psychological follow-up of a child with talipes equinovarus]. / Impact psychologique dans la rééducation de l'enfant atteint d'un pied bot varus équin.

In France, one child in every 800 is born with talipes equinovarus. This congenital deformity of the foot prevents the flexion and extension of the ankle. Follow-up by a psychologist is essential during the care of a child with this condition, in parallel with functional rehabilitation by the masseur-physiotherapist.

Influence of Back Pain on Patient Satisfaction Scores.

OBJECTIVES: Patient satisfaction scores are increasing in importance. Although the influence of selected patient and physician characteristics on satisfaction scores has been identified, the impact of different pediatric diagnoses is unknown. The purpose of this study was to compare patient satisfaction scores in visits for mechanical back pain with visits for clubfoot or scoliosis. METHODS: A retrospective analysis of patient satisfaction scores from pediatric visits for back pain, clubfoot, and scoliosis at three tertiary centers was performed. Satisfaction data were obtained from survey questions that used a 5-point scale ranging from very poor (1) to very good (5). Statistical analysis was performed using χ(2) and Fisher exact tests. RESULTS: Data from 565 visits for scoliosis, 81 for clubfoot, and 57 for mechanical back pain were used. The mean scores in back pain visits for the likelihood of recommending the care provider, confidence in the care provider, and explanation by the care provider were 4.87, 4.79, and 4.70, respectively. These scores were not lower than visits for scoliosis and clubfoot (P < 0.05). The mean score for likelihood to recommend the practice after back pain visits was 4.73, with more scores of 3 or higher than clubfoot or scoliosis (P < 0.05). CONCLUSIONS: Satisfaction scores in pediatric patients with back pain were not lower than visits for scoliosis or clubfoot. Future research can be directed toward identifying common goals in visits for pediatric mechanical back pain to further improve the patient experience.

Is tibialis anterior tendon transfer effective for recurrent clubfoot?

BACKGROUND: Tibialis anterior tendon transfer surgery forms a part of Ponseti management for children with congenital talipes equinovarus who, after initial correction, present with residual dynamic supination. Although retrospective studies support good outcomes, prospective longitudinal studies in this population are lacking. QUESTIONS/PURPOSES: We assessed strength, plantar loading, ROM, foot alignment, function, satisfaction, and quality of life in patients with clubfoot that recurred after Ponseti casting who met indications for tibialis anterior tendon transfer surgery, and compared them with a group of patients with clubfoot treated with casting but whose deformity did not recur (therefore who were not indicated for tibialis anterior tendon transfer surgery). METHODS: Twenty children with idiopathic congenital talipes equinovarus indicated for tibialis anterior tendon transfer surgery were recruited. Assessment at baseline (before surgery), and 3, 6, and 12 months (after surgery) included strength (hand-held dynamometry), plantar loading (capacitance transducer matrix platform), ROM (Dimeglio scale), foot alignment (Foot Posture Index(©)), function and satisfaction (disease-specific instrument for clubfoot), and quality of life (Infant Toddler Quality of Life Questionnaire™). Outcomes were compared with those of 12 age-matched children with congenital talipes equinovarus not indicated for tibialis anterior tendon transfer surgery. Followup was 100% in the control group and 95% (19 of 20) in the tibialis anterior transfer group. RESULTS: At baseline, the tibialis anterior tendon transfer group had a significantly worse eversion-to-inversion strength ratio, plantar loading, ROM, foot alignment, and function and satisfaction. At 3 months after surgery, eversion-to-inversion strength, plantar loading, and function and satisfaction were no longer different between groups. Improvements were maintained at 12 months after surgery (eversion-to-inversion strength mean difference, 8% body weight; 95% CI, -26% to 11%; p = 0.412; plantar loading, p > 0.251; function and satisfaction, p = 0.076). ROM remained less and foot alignment more supinated in the tibialis anterior tendon transfer group between baseline and followup (p < 0.001, p < 0.001). CONCLUSIONS: Tibialis anterior tendon transfer surgery was an effective procedure, which at 12-month followup restored the balance of eversion-to-inversion strength and resulted in plantar loading and function and satisfaction outcomes similar to those of age-matched children with congenital talipes equinovarus who after Ponseti casting were not indicated for tibialis anterior tendon transfer.

Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better?

BACKGROUND: Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child. QUESTIONS/PURPOSES: We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot. METHODS: This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics. RESULTS: Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01). CONCLUSIONS: Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function. LEVEL OF EVIDENCE: Level III, prognostic study.

Dr Karl Koenig: a brief survey of his extraordinary early years.

Over 70 years ago, an Austrian émigré doctor - Karl Koenig - came to Scotland where he established the Camphill Movement. Today that Movement embraces over 100 communities for children and adults with developmental disabilities in at least 24 countries. One aspect of Koenig's biography that has not been explored concerns his childhood: an extraordinary omission given its inspirational character. Without an appreciation of this critical period in his life, any understanding of his very considerable achievements not least his pioneering success in establishing the Camphill Movement must be incomplete.

Maternal attitudes towards prenatal diagnosis of idiopathic clubfoot.

OBJECTIVES: To examine maternal attitudes towards prenatal diagnosis of idiopathic clubfoot and to determine the incidence of false-negative ultrasound examinations. METHODS: Surveys were mailed to mothers of patients with clubfoot born between 2000 and 2007 who were treated at either Sinai Hospital of Baltimore or Orthopaedic Hospital Speising. Exclusion criteria were underlying syndrome, genetic abnormality and multiple pregnancy. The survey asked the mother whether she had had any ultrasound examinations before her child was born, whether any of these had shown clubfoot, and whether she would have preferred to find out about her child's clubfoot before birth or after birth. RESULTS: Mothers completed 220 (USA, 105 surveys; Austria, 115 surveys) of 401 mailed surveys. The prenatal detection rate was 60% in the USA compared with 25% in Austria (P = 0.001). Overall, 74% of mothers indicated a preference for prenatal diagnosis and 24% indicated a preference for postnatal diagnosis of the condition. Of 92 patients diagnosed prenatally, 96% of mothers indicated a preference for a prenatal diagnosis. Of 128 patients diagnosed postnatally, 58% of mothers indicated a preference for prenatal diagnosis, 38% for postnatal diagnosis and 4% were undecided. CONCLUSIONS: The diagnosis of clubfoot is still often missed during routine ultrasound examination. When a prenatal diagnosis is made, most mothers appreciate having this information. However, when prenatal diagnosis is missed, a significant proportion of mothers seem to accept the false-negative diagnosis retrospectively.

Outcome of prenatally diagnosed isolated clubfoot.

OBJECTIVES: To analyze the aneuploidy risk and treatment outcome of prenatally diagnosed isolated clubfoot, to determine the false-positive rate (FPR) of ultrasound diagnosis and to calculate the risk of diagnostic revision to complex clubfoot. METHODS: By chart review, 65 patients were retrospectively ascertained to have unilateral or bilateral clubfeet diagnosed prenatally. We calculated the rates of false positives, aneuploidy and diagnostic revision to complex clubfoot, and used an ad hoc scoring system to determine orthopedic outcome. Published rates of aneuploidy were pooled and evaluated. RESULTS: Prenatally diagnosed isolated clubfoot FPR (defined as 1 - positive predictive value) was 10.5% (95% CI, 5.8-18%) (calculated per foot). After a minimum of 1-year postnatal follow-up, 13% (95% CI, 6-26%) of patients had revised diagnoses of complex clubfoot. No patients had aneuploidy identified by cytogenetic analysis or clinical assessment. Of the 34 patients with 2-year postnatal follow-up, 76.5% were treated with serial casting with or without Botox. All children with isolated clubfoot were walking and had an average outcome score of 'very good' to 'excellent'. CONCLUSIONS: When counseling women regarding prenatally diagnosed isolated clubfoot, it is important to tell them that approximately 10% of individuals will have a normal foot or positional foot deformity requiring minimal treatment. Conversely, 10-13% of prenatally diagnosed cases of isolated clubfoot will have complex clubfoot postnatally, based on the finding of additional structural or neurodevelopmental abnormalities. Although this study did not identify an increased risk of fetal aneuploidy associated with isolated clubfoot, a review of the literature indicates a risk of 1.7-3.6% with predominance of sex chromosome aneuploidy.

Clubfoot treatment with Ponseti method-parental distress during plaster casting.

BACKGROUND: Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot. Therefore, we want to determinate first, how pronounced the parents' worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents' mental resilience in relation to the therapy of the child as a global distress parameter. METHODS: To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T0) and at the end (TE) of the treatment with plaster casting. RESULTS: High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T0) and mental resilience (T0) is 0.21, so the initial hypothesis had to be rejected. CONCLUSION: The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

Subjective and objective outcome in congenital clubfoot; a comparative study of 204 children.

BACKGROUND: Outcome following management of congenital talipes equinovarus (clubfoot) can be assessed in a number of ways. Bjonness stated simply that "the patient is the final judge of whether he has a good foot"; a purely subjective assessment. Others have employed objective measures. Combining subjective evaluation with a more objective assessment of movement and position of the foot, is likely to give a more comprehensive picture of the final result of clubfoot. The purpose of this study was to compare subjective and objective outcome following management of clubfoot, and evaluate sex differences in outcome. METHODS: We used a patient-administered subjective assessment of outcome following treatment of clubfoot and compared it with objective anthropometry and range of movement of the ankle to assess and compare subjective and objective outcome in clubfoot. Statistical analysis was performed using Pearson correlation coefficients. Significance was tested using Student's t-test test. RESULTS: Objective outcome can be assessed using length of the foot, calf circumference and range of movement at the ankle. These are easy to measure, reproducible, and correlate well with subjective outcome. Objective outcome is comparable for boys and girls. However, subjectively, female patients and their parents are less happy with the results of management of clubfoot. CONCLUSION: There is a correlation between the anthropometric measures and the subjective outcome and an objective grading can be designed using foot length, calf muscle bulk and range of movement at the ankle.

Psychiatric disorders after childhood stroke.

OBJECTIVES: To determine the rate, types, and correlates of psychiatric disorder (PD) following stroke and orthopedic disorders in children and adolescents. METHOD: Children aged 5 to 19 were assessed. The study used a cross-sectional design that compared 29 stroke subjects with 29 congenital clubfoot or scoliosis subjects. Assessments of psychiatric status; cognitive, adaptive, academic, and family functioning; family psychiatric history; neuroimaging; and neurological status were conducted. The main outcome measure was a current PD not present before the stroke or orthopedic disorder. RESULTS: Poststroke PD occurred significantly more often than postorthopedic diagnosis PD (17/29 [59%] versus 4/29 [14%], p < or =.001). Subjects with ongoing poststroke PD had significantly more impaired intellectual and adaptive functioning, higher intensity family psychiatric history scores, and tended toward higher neurological severity index scores, but they were not different regarding lesion volume or family functioning compared with stroke subjects without PD. Regression analyses showed that neurological severity and family psychiatric history independently contributed significantly to predicting PD. CONCLUSIONS: The data suggest that there are significant biopsychosocial correlates of PD in children with focal neurological lesions. These include a relatively abnormal neurological exam, lower IQ, and increased family psychopathology.

Psychogenic equinovarus: the importance of recognition and non-operative treatment.

Although the potential for musculoskeletal symptoms in hysteric conversion disorder was recognized by Sigmund Freud, reports of it in the orthopaedic literature have been limited to upper extremity manifestations. This study reports 3 cases which illustrate hysteric conversion presenting as primary foot and ankle complaints. Given its relative rarity, it is a diagnosis that is easy to miss. Clinical clues to its diagnosis and accepted methods of treatment are discussed. It is important to realize that this condition arises from an unconscious conflict and does not represent a voluntary falsification of symptoms. As such, confrontational treatment is not generally successful.

[Treatment of spastic equinovarus foot in the hemiplegic adult by retrograde fixation of the peroneus brevis tendon onto the anterior tibialis tendon]. / Traitement du pied varus équin spastique de l'adulte hémiplégique par amarrage rétrograde du tendon du court fibulaire sur le tibial antérieur. A propos d'une série de 41 cas.

PURPOSE OF THE STUDY: The purpose of the present study was to assess the Bardot procedure in the treatment of equinovarus deformities of the foot in spastic hemiplegia. This procedure associates the fixation of the peroneus brevis distal tendon onto the tibialis anterior, heel-cord lengthening, and tenotomies of the flexores digitorum. MATERIAL AND METHODS: Fifty-six patients underwent this procedure between 1989 and 1996. The indication for surgery was equinovarus deformity in adult spastic hemiplegia. Preoperatively all the patients had an instability and 80.5 per cent of them had to wear an ankle and foot orthesis. Postoperatively forty-one patients with a mean follow up of 3.5 years (range: one to 9 years), were available for examination including 24 females and 17 males with a mean age of 46 years at time of surgery (range: 27 to 76). RESULTS: All the patients were objectively improved. Seven of them had a discreet residual varus deformity, but none felt unstable. They all were able to walk barefooted, only one patient still required an adapted shoe. The gait and the quality of live were subjectively improved for 92.7 per cent of the patients. None of the patients has been worsened. DISCUSSION: When spastic equinovarus disturbs significantly quality of live, tendon re-balancement of the hemiplegic foot should be proposed. The fixation of the distal tendon of the peroneus brevis onto the tibialis anterior is effectively performed only if this latter is efficient in the swing phase of gait. If there is no fixed contracture, neurosurgery or chemotherapy are preferable. In case of irreducible articular deformities arthrodesis could be indicated. CONCLUSION: Tendon re-balancement in hemiplegic foot using a peroneus tendon fixation onto the tibialis anterior should be carried out after examination by a team of specialists (surgeon, neurosurgeon, rehabilitation team). In such conditions it offers constantly an improvement to the patients.

[Problems of development and care of children born with selected congenital malformations: Down's syndrome, cardiopathy, cleft lip and palate, clubfoot]. / Problemi dello sviluppo e dell'assistenza di nati con malformazioni congenite selezionate: sindrome di Down, cardiopatia, labiopalatoschisi, piede torto.

In connection with the surveillance programme of congenital malformations in Emilia Romagna led by I.M.E.R. Group since 1978 a crosswise survey has been performed on selected malformations: Down's syndrome, cardiac defects, unilateral or bilateral cleft lip and/or palate, unilateral or bilateral club foot. This survey has been useful as a pilot-study for another longitudinal survey which had a place in the programmes of the C.N.R. (National Research Council). By means of a multi-discipline approach we have collected information both of pediatric and of psycho-social character. A total of 187 children with the above named malformations were recorded at birth, 106 boys and 81 girls, aged from 9 months to 4 years. The neonatal diagnosis was confirmed in 84 out 86 cases under study. The rate of infant mortality was particularly high among children with heart defects (39.1%) and Down children (27.4%). The surgical centres where these children were operated upon, through with large variations in connection with the type of malformation, were in Emilia Romagna (49%), outside it (40%), and abroad (10.9%). As for the parental reaction to the birth of babies with congenital malformations, it was of initial rejection 5 cases of Down children, 3 cases of cardiopathy and 1 case of cleft lip and palate. Later the refusal was permanently confirmed only in 2 cases of Down children (who were subsequently adopted). The birth of a malformed baby has affected the relationship between husband and wife contributing to the separation in 3 cases of Down's syndrome and in 1 case of cardiopathy.