The functional method: experience from the Robert Debré Hospital.

BACKGROUND: In the 1970s a conservative treatment for clubfoot (CF) deformity based on daily physiotherapy combining specific sequences was developed: the French functional method (FFM). Over time, the FFM technique has improved and additional measures have been introduced. The aim of this study was to report mid-term and long-term results of clubfeet treated conservatively by the FFM at birth. METHODS: All patients consecutively treated for clubfoot by the FFM between 1993 and 2010 were prospectively included. Initial severity was assessed by the Dimeglio classification. All patients were followed up by the same treating surgeon until skeletal maturity. Final assessment was performed using the International Clubfoot Study Group evaluation system (ICFSG). RESULTS: A total of 779 feet were included. Surgery was required in 41% of cases (mean age 2.0±0.1 years). The incidence of surgery significantly decreased after the introduction of percutaneous Achilles tenotomy (PAT) in 2000 (63.4% vs. 29.6%). At latest evaluation (mean follow-up 12±0.2 years), 86% of patients had excellent or good outcomes (mean ICFSG was 1.83±0.1). Mean ankle dorsiflexion was 10° in non-idiopathic CF and 12.1° in idiopathic CF. Eleven percent of the idiopathic clubfeet exhibited decreased ankle function (0-10°). There were no cases of overcorrection into excess ankle dorsiflexion or rocker bottom foot deformities. CONCLUSIONS: Current team was the funding institution of the FFM and several modifications were proposed over times to improve outcomes. Eighty-six percent of feet had excellent to good outcomes according to the ICFSG score, with minimal residual deformities (ankle dorsiflexion between 0° and 10°, calcaneal-thigh angle between 10° and 20°) or insufficient radiological correction (defined by talo-calcaneal angle between 10° and 20°) at latest follow-up.

Guided growth vs.Tibial osteotomy at early stage of Blount disease in squelletically immature patients.

BACKGROUND: There are no comparative study between guided growth and tibial osteotomy in early stage of Blount disease (BD) to our knowledge. The aim of this work was to compare the results of patients treated by these two techniques. METHOD: This was a retrospective, descriptive, and analytical study over a period of 5 years in including 17 children (24 Knees) with an early stage of infantile BD in two centers. Patient were classified in two groups: group 1(treated by guided growth), group 2 (treated by Tibial Osteotomy).Preoperative alignment analysis using the tibial femoral angle (HKA) and the proximal medial tibial mechanical angle (mMPTA) were compared with three measurements taken postoperatively in each of the groups. The mean variations of the angles were compared between the two groups. RESULTS: Socio-demographic characteristics were similar for the two groups. Median age at surgery was 6.5 ± 2.5 [3-9 years] in group 1 and 6.8 ± 2.9 years [3-9 years]. At a follow-up of 24 ± 3.5 months, the limb alignment was significantly corrected (1,03°/month) in group 1 (median HKA 144°-171°; p = 0,001; median MMPTA 78°-87°, p = 0,018), and in group 2 we observed at a follow-up of 23 ± 15 months a progressive loss (0,52°/month) of the correction obtained immediately postoperatively (median HKA 160°-176°(immediate post operative) to 165,5°; p = 0,31; median MMPTA = 78°-86° (immediate post operative) to 80,5°; p = 0,37).There was a statistically significant difference between the mean variation in HKA between the two groups (group 1 = 22,5; group 2 = 4,5, p = 0.00), as well as for MMPTA; (group 1 = 7; group 2 = 2,5, p = 0,023).The rate of correction was 78% in group 1 with no rebound at a median follow-up after removal of the material of 10 ± 2.4 months. Within group 2, the rate of correction was 10% with a recurrence rate of 60%. CONCLUSION: Guided growth appears to be the best treatment for early stage of BD in squelletically immature patients.

Medial to posterior release procedure after failure of functional treatment in clubfoot: a prospective study.

PURPOSE: Two conservative techniques for clubfoot treatment are still being debated and depend upon the institution's expertise. For >40 years, the current institution has been a pioneer in the development of the physiotherapy method; however, some severe deformities remain resistant to this method which causes pain, sprains, and difficulties wearing shoes. Therefore, a surgical approach was developed simultaneously for the treatment of these residual or recurring clubfeet. The procedure reproduces the same chronological steps by performing forefoot derotation before correcting hindfoot equinus. The aim of the current study was to assess the results of this surgical technique. METHODS: All clubfeet undergoing surgery between October 1995 and February 2009 were prospectively included. Initial severity was based on Dimeglio's classification and final outcomes on the International Clubfoot Study Group (ICFSG) outcome evaluation system. Last follow-up results were assessed by physical examination and radiographs. RESULTS: A total of 137 patients with severe clubfeet (mean Dimeglio score 12.0) underwent surgery. At the mean follow-up of 10.8 years, mean ICFSG score was 4.3 (range 0-23), and 12 % required revision surgery. The rate of undercorrection and overcorrection was low (17 pes-plano-valgus ft and 11 ft with undercorrection). Eight feet had a fixed deformity. CONCLUSIONS: Severe deformities are more resistant to conservative techniques even for institutions with large experience. These deformities require further treatment, including surgery if necessary. The medial to posterior soft-tissue release is a valuable technique with stable results. LEVEL OF EVIDENCE: Level IV.

Poor Efficiency of Eight-Plates in the Treatment of Lower Limb Discrepancy.

BACKGROUND: Among the numerous existing epiphysiodesis procedures, the eight-plate-guided growth technique, initially described for angular deformities correction, has progressively gained popularity among pediatric orthopaedic surgeons to treat lower limb discrepancy (LLD). The goal of this study was to assess the efficacy of eight-plates in LLD. METHODS: All children treated for LLD with eight-plates were prospectively included and followed until skeletal maturity. Efficacy of the epiphysiodesis was calculated 6 and 18 months postoperatively and at latest follow-up, according to a method previously validated for percutaneous epiphysiodesis using transphyseal screws (PETS). Radiologic measurements were performed using 3-dimensional low-dose stereoradiography. Intraoperative and postoperative complications were reported. RESULTS: Thirty-two patients were included (average age at surgery, 12.5 y). For femoral epiphysiodesis, efficacy was only 23% at 6 months and 68% at latest follow-up. The procedure was even less efficient on the proximal tibia, with only 42% of the expected growth arrest at latest examination. Eight patients (20%) experienced plate-related pain during follow-up, and 5 physes (12.5%) required unplanned revision surgery. CONCLUSIONS: Results of the current series show that the eight-plate technique procedure was associated with few perioperative complications, but the growth arrest observed at follow-up was unpredictable and lower than that achieved with PETS in previous reports. Eight-plate procedures cannot be considered as an efficient epiphysiodesis technique in comparison with standard technique. LEVEL OF EVIDENCE: Level IV.

Shoulder external rotator selective neurotomy in cerebral palsy: anatomical study and preliminary clinical results.

Shoulder external rotation posturing in patients with cerebral palsy can severely impair bimanual activities and lead to painful shoulder instability. We performed an anatomical study to describe the surgical approach to the shoulder external rotators nerves. Using this technique, we performed a selective neurotomy in five shoulders with external rotator shoulder spasticity. Ashworth scale dropped from 2 or 3 to 0 and active internal rotation increased from 0-10 to 60-70 degrees . This is a short series but preliminary results are encouraging and allow us to extend the study to a greater number of patients.

Claw toes after tibial fracture in children.

PURPOSE: The development of claw toe deformity following fracture of the tibia in children has not been described in our review of the literature. We report on the management of the acquired claw toe deformity after tibia fracture in five children. METHODS: We report on five patients, between 5 and 15 years of age, who developed clawing of the hallux following a fracture of the tibia. In two patients, the lesser toes were involved. On examination, when the ankle was passively plantar flexed, a flexion contracture of the interphalangeal joint of the hallux became fully flexible. When the ankle was dorsiflexed, the clawing became more obvious and fixed. A magnetic resonance imaging (MRI) study in two cases demonstrated fibrosis under or just proximal to the tarsal tunnel. RESULTS: The contractures were relieved by performing a tenolysis proximal to the medial malleolus. The operative findings demonstrated that the etiology could be possibly associated with a localized subclinical compartment syndrome. CONCLUSIONS: We described five patients with a claw toe deformity following a tibia fracture associated with adhesions of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles to the surrounding structures under or just proximal to the flexor retinaculum. It is the authors' opinion that this condition may be related to a subclinical compartment syndrome localized in the distal part of the deep posterior compartment. Soft-tissue release without tendon lengthening allowed recovery in all patients.

How to determine the upper level of instrumentation in Lenke types 1 and 2 adolescent idiopathic scoliosis: a prospective study of 132 patients.

BACKGROUND: The selection of fusion levels continues to be controversial in adolescent idiopathic scoliosis (AIS). The classifications of King and Lenke remain the most widely used, but recent studies have demonstrated their shortcomings, including poor interobserver reproducibility. We propose a method of preoperative planning that is independent of anatomical classifications, based on the anticipated effect of curve reduction. The objectives of this preoperative strategy are (1) to achieve satisfactory T1 tilt and shoulder balance and (2) to restore balance in the coronal and sagittal planes. The purpose of the present study was to evaluate the results of our strategy of deciding the proximal level of arthrodesis in Lenke types 1 and 2 AIS. METHODS: We included 132 adolescents operated on for thoracic AIS by posterior instrumentation. The choice of the proximal fusion level was based on preoperative analysis of the rigidity of the proximal curvature, T1 tilt, and shoulder balance. The preoperative, postoperative, and last follow-up radiographs were digitized then analyzed using computer software. Radiological parameters were compared using paired t tests. RESULTS: Average age at the time of surgery was 15.2 years (SD, 1.7 years). Mean follow-up was 30.2 months. The clavicle angle and T1 tilt were significantly improved in both Lenke types 1 and 2 curves. No correlation was found between T1 tilt and shoulder balance. At last follow-up, 89% of the patients satisfied all criteria for balance. CONCLUSIONS: The results of the present preoperative strategy, to which we adhered in 97% of cases, are encouraging and show that the systematic instrumentation of the entire proximal curvature is not justified in Lenke type 2 curves. However, long-term consequences of the residual T1 tilt need to be studied further.

Bioactive glass as a bone substitute for spinal fusion in adolescent idiopathic scoliosis: a comparative study with iliac crest autograft.

BACKGROUND: Iliac crest autograft is currently the gold standard material for spinal fusion. However, its use is limited by additional operative time, increased blood loss, and morbidity. Recently, a synthetic osteoconductive bone graft material composed of bioactive glass has been described, with high effectiveness in animal models. Its ability to achieve spinal fusion in human has never been reported. The aim of this study was to compare bioactive glass and iliac crest autograft as bone substitutes in the treatment thoracic adolescent idiopathic scoliosis (AIS). METHODS: Eighty-eight consecutive patients underwent posterior spinal fusion for progressive thoracic AIS. There were 2 study groups based on the type of bone graft used: iliac crest autograft (n = 40) or bioglass (n = 48). A minimum 2-year follow-up was required. Medical data and radiographs were retrospectively analyzed and compared using unpaired t test and Mann-Whitney U test. RESULTS: Mean follow-up was 40 months in the autograft group and 38 months in the bioglass group. In the autograft group, there were 2 infections (5%) and 3 mechanical failures (7.5%). One infection (2%) and 1 early mechanical failure (2%) occurred in the bioglass group. Loss of correction of the main thoracic curve between immediate postoperative and latest follow-up averaged 15.5% for autograft group and 11% for the bioglass group (P = 0.025). The mean (+/-SD) gain of frontal balance between immediate postoperative latest follow-up was 0.8 (+/-9.3) mm in the autograft group and 8.1 (+/-12) mm for the bioglass group (P = 0.005). CONCLUSIONS: Results of this retrospective study suggest that bioglass is as effective as iliac crest graft to achieve fusion and maintain correction in AIS. Less complications were seen in the bioactive glass group, but the difference did not reach statistical significance. Bioactive glass can be proposed in the treatment of AIS, avoiding the morbidity of iliac crest harvesting. However, clinical and radiological outcomes need to be confirmed at long-term follow-up. LEVEL OF EVIDENCE: Level III.

Calcaneal derotation osteotomy for clubfoot revision surgery.

To describe a derotation calcaneal osteotomy technique and assess its efficacy in the correction of relapsed clubfoot. Twenty-one osteotomies were performed in 20 children with recurrent clubfoot. Nineteen children had been previously treated operatively. The derotation osteotomy was the first procedure performed in one case. The procedure combined medial and plantar releases, followed by a curvilinear osteotomy of the calcaneus. Patients were evaluated clinically and with standing dorsoplantar and lateral radiographs preoperatively, postoperatively and at follow-up. The talocalcaneal angle was considered as the most important criteria to evaluate the deformity correction. The clubfoot was idiopathic in 16 cases and neurological in five cases. Mean age at surgery was 7 years old (range 3.4-12 years). Total number of procedures per foot averaged 2.4 (range 4-1). The mean postoperative follow-up period was 2.8 years (range 2-6 years). The talocalcaneal angle increased significantly after the procedure (P<0.001), and no significant loss of correction was seen at latest follow-up (P=0.17). Two scarring complications occurred. Only one foot underwent further surgery after the calcaneal osteotomy for residual forefoot adduction, associated to a cavus and severe fibrosis. The calcaneal curvilinear osteotomy, in which the calcaneoforefoot unit derotation is performed around the talus but within the calcaneus, is a safe and efficient technique that can be proposed for clubfoot revision surgery.