Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities?

BACKGROUND: Idiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function. METHODS: Patients 8-17 years with flexible flatfeet (FFF, n=217) recurrent clubfeet (RCF n=38) and overcorrected clubfeet (OCCF, n=71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n=48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures. RESULTS: The variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation. CONCLUSIONS: The static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice.

Long-term Results of Conservative Therapy of Adolescent Idiopathic Scoliosis Using the Cheneau Brace.

Adolescent idiopathic scoliosis is a disease of the growing skeleton. The goal in therapy is to decelerate or to prevent progression of the spinal curve. As part of a retrospective study the patient group of the scoliosis surgery from 1995-2016 was analysed according to the inclusion criteria of the Scoliosis research Society (SRS). 159 of 643 of the patients fullfilled the specific criteria. The assessment of effectiveness was based on the progression of the angle of curvature. If it was ≤5° it was judged positively. The therapy in accordance to Cheneau is a full-time bracing orthosis. Data from 159 patients - 136 fem. (85.5%), 23 male (14.5%) was analysed. The average age at the beginning of treatment was 13.3±1.7 years. The average duration was 3.47±1.2 years. The average Cobb-angle before treatment was 28.39°±9.44°. At the completion is was 27.7°±12.34°. Stabilisation of scoliosis (≤5°) was achieved for 136 of the patients (85.5%). The final follow-up showed a progression of the Cobb angel>5° in 23 cases, of which 19 had to undergo secondary surgery. The length of therapy had a positive influence (p=0.057) on the result. Brace treatment constitutes an effective method of therapy at curvatures between 20-40°. Short duration of therapy correlates with a expressively increased risk towards progression (p=0.057). The Cheneau brace treatment constitutes an effective treatment at curvature angles between 20-40°. The risk of progression can be reduced by a timely and correct identification.

Perioperative complications of scoliosis surgery in patients with Duchenne muscular dystrophy and spinal muscular atrophy, focussing on wound healing disorders.

PURPOSE: Patients with Duchenne muscular dystrophy (DMD) or spinal muscular atrophy (SMA), both neuromuscular diseases, sustain spinal scoliosis in the course of their disease. To reduce the concomitant major morbidity and to improve their quality of life, patients require surgical spine stabilization. This can lead to complications like respiratory, cardiac or neurological complications or wound healing disorders (WHD). To find out the different complexities and risk factors increasing the chance to develop a WHD, the inpatient database was analyzed. METHODS: We performed a retrospective statistical study. Therefore, we analyzed the inpatient database of 180 patients (142 DMD and 38 SMA patients). The focus was on WHD. To figure out the risk factors leading to WHD, we conducted a logistic regression. RESULTS: Cardiac complications occurred most frequently, followed by pulmonary complications and neurological lesions. Fifty-seven out of 180 patients developed a WHD. In 23 cases the WHD was aseptic, in the other 34 cases dermal organisms, Pseudomonas species and intestinal organisms were responsible. By means of the logistic regression, we were able to identify two more risk factors, in addition to diagnosis and gender, for developing a WHD in our patients: the year of surgery and the direction of pelvic tilt. CONCLUSIONS: Most common complications following scoliosis surgery are respiratory and cardiac complications. WHD is a severe complication that implies a prolonged therapy. Some risk factors for developing WHD could be identified in this analysis. Specifically, these were the date of surgery and the direction of pelvic tilt.

Orthopedic management of patients with Pompe disease: a retrospective case series of 8 patients.

INTRODUCTION: Pompe disease (PD), a lysosomal storage disease as well as a neuromuscular disorder, is a rare disease marked by progressive muscle weakness. Enzyme replacement therapy (ERT) in recent years allowed longer survival but brought new problems to the treatment of PD with increasing affection of the musculoskeletal system, particularly with a significantly higher prevalence of scoliosis. The present paper deals with the orthopedic problems in patients with PD and is the first to describe surgical treatment of scoliosis in PD patients. PATIENTS AND METHODS: The orthopedic problems and treatment of eight patients with PD from orthopedic consultation for neuromuscular disorders are retrospectively presented. We analyzed the problems of scoliosis, hip dysplasia, feet deformities, and contractures and presented the orthopedic treatment options. RESULTS: Six of our eight PD patients had scoliosis and two young patients were treated by operative spine stabilization with benefits for posture and sitting ability. Hip joint surgery, operative contracture release, and feet deformity correction were performed with benefits for independent activity. CONCLUSION: Orthopedic management gains importance due to extended survival and musculoskeletal involvement under ERT. Surgical treatment is indicated in distinct cases. Further investigation is required to evidence the effect of surgical spine stabilization in PD.

Orthopaedic Disorders in Myotonic Dystrophy Type 1: descriptive clinical study of 21 patients.

BACKGROUND: Myotonic Dystrophy Type 1 (DM1) is the most common form of hereditary myopathy presenting in adults. This autosomal-dominant systemic disorder is caused by a CTG repeat, demonstrating various symptoms. A mild, classic and congenital form can be distinguished. Often the quality of life is reduced by orthopaedic problems, such as muscle weakness, contractures, foot or spinal deformities, which limit patients' mobility.The aim of our study was to gather information about the orthopaedic impairments in patients with DM1 in order to improve the medical care of patients, affected by this rare disease. METHODS: A retrospective clinical study was carried out including 21 patients (11 male and 10 female), all diagnosed with DM1 by genetic testing. All patients were seen during our special consultations for neuromuscular diseases, during which patients were interviewed and examined. We also reviewed surgery reports of our hospitalized patients. RESULTS: We observed several orthopaedic impairments: spinal deformities (scoliosis, hyperkyphosis, rigid spine), contractures (of the upper extremities and the lower extremities), foot deformities (equinus deformity, club foot, pes cavus, pes planovalgus, pes cavovarus, claw toes) and fractures.Five patients were affected by pulmonary diseases (obstructive airway diseases, restrictive lung dysfunctions). Twelve patients were affected by cardiac disorders (congenital heart defects, valvular heart defects, conduction disturbances, pulmonary hypertension, cardiomyopathy).Our patients received conservative therapy (physiotherapy, logopaedic therapy, ergotherapy) and we prescribed orthopaedic technical devices (orthopaedic custom-made shoes, insoles, lower and upper leg orthoses, wheelchair, Rehab Buggy). We performed surgery for spinal and foot deformities: the scoliosis of one patient was stabilized and seven patients underwent surgery for correction of foot deformities. CONCLUSIONS: An orthopaedic involvement in DM1 patients should not be underestimated. The most common orthopaedic impairments are contractures, foot deformities and spinal deformities. Contractures are typically located distally in the lower extremities, but can also occur in the hip or shoulder joints. Foot deformities could be treated with orthopaedic custom-made shoes, orthoses or insoles. Surgery is indicated for severe foot deformities or contractures.

Natural course of scoliosis in proximal spinal muscular atrophy type II and IIIa: descriptive clinical study with retrospective data collection of 126 patients.

BACKGROUND: Progressive scoliosis, pelvic obliquity and increasing reduction of pulmonary function are among the most significant problems for patients with SMA type II and SMA type III once they have lost the ability to walk. The aim of this study was to examine and document the development and natural course of scoliosis in patients with spinal muscular atrophy type II and IIIa. METHODS: For the purposes of a descriptive clinical study, we observed 126 patients, 99 with SMA II and 27 with SMA IIIa and the data of scoliosis, pelvic obliquity and relative age-dependent inspiratory vital capacity were evaluated. RESULTS: Scoliosis and pelvic obliquity were regularly observed already in children under 4 years old in the group with SMA II. The severity and progression of both conditions were much more pronounced in the SMA II group than in the IIIa group. There was already a distinct reduction in relative vital capacity in the group of 4- to 6-year-olds with SMA II. CONCLUSIONS: The differences between the two SMA types II and IIIa described in this study should be taken into consideration when developing new treatments and in management of scoliosis in the childhood years of these patients.

Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients.

BACKGROUND: According to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HYPOTHESIS: The aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. PATIENTS AND METHODS: A cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. RESULTS: 46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%). CONCLUSION: In geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests-consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test-are well suited for further reproducible, objective studies with a larger patient collective. LEVEL OF EVIDENCE: IV.

Characteristic 3D foot motion patterns during gait of patients with Charcot-Marie-Tooth identified by cluster analysis.

BACKGROUND: CMT is a clinically and genetically heterogenous disease with varying degrees of progression. Different foot deformities, gait and movement patterns are observed. In order to achieve an improved, targeted treatment strategy, the participants are divided into characteristic groups using a mathematical cluster analysis based on the data from the three-dimensional foot kinematics during walking. METHODS: Outpatients from age 5-64 years (N = 33 participants, 62 feet) with a proven CMT type 1 (N = 16, 31 feet) or CMT without any further type assignment (N = 17, 31 feet) were retrospectively analyzed. After a standard clinical examination, participants underwent 3D gait analysis using the Oxford Foot Model. To classify the movement patterns, a k-means cluster analysis was calculated based on the principal component analysis (PCA) of the foot kinematics data. Gait parameters, clinical parameters and X-ray data were statistically tested. RESULTS: The cluster analysis divided the gait data of the participants into two groups. Cluster 1 (N = 21 participants, 34 feet) showed increased dorsiflexion of the hindfoot and increased plantarflexion of the forefoot with cavus position in the sagittal plane, a hindfoot inversion and forefoot pronation with hindfoot varus in the frontal plane and in the transversal plane a forefoot adduction. Cluster 2 (N = 17 participants, 28 feet) deviated significantly from the norm mainly in the frontal plane and were characterized by a strong eversion of the hindfoot with a supination in the forefoot. DISCUSSION: Based on the findings, the resultant clusters can be interpreted as cavovarus feet (cluster 1) and pes valgus (cluster 2). The most reliable variables in the 3D gait analysis to classify CMT feet with regard to significance are the ones in the frontal plane. This subdivision of participants goes hand in hand with the various necessary guidelines for orthopedic treatment.

Long-term results of total knee arthroplasty following high tibial osteotomy according to Wagner.

PURPOSE: There is relatively little information available about the long-term results of total knee arthroplasty (TKA) following high tibial osteotomy. The aim of our study was to share our experiences and long-term results of TKA after a previous closing wedge high tibial osteotomy according to Wagner. METHODS: In a retrospective study we identified 48 consecutive patients who had undergone TKA after a previous closing wedge high tibial osteotomy according to Wagner with a follow-up of over ten years. The average duration of follow-up after the TKA was 13.3 years (min 10.0, max 15.5). X-rays were taken in two planes before TKA, one week after TKA and at the latest follow-up. Tibio-femoral alignment was measured on weightbearing long-leg anteroposterior radiographs. Radiolucent lines at the latest follow-up were documented. Functional evaluations were performed preoperatively and postoperatively (at the time of latest follow-up). RESULTS: The mean Knee Society function score increased from 63.1 points preoperatively to 90.0 points postoperatively. The mean overall Knee Society score increased from 93.2 points preoperatively to 160.8 points postoperatively. The mean average femoro-tibial angle was corrected from varus 0.8° (varus 14°-valgus 8.0°) preoperatively to valgus 7.6° (valgus 2-9°) at the last follow-up. CONCLUSIONS: The closing wedge high tibial osteotomy according to Wagner does not compromise subsequent total knee replacement and leads to good clinical and radiological results.

Operative treatment of scoliosis in proximal spinal muscular atrophy: results of 41 patients.

INTRODUCTION: The early development of progressive scoliosis with pelvic obliquity is the most significant orthopaedic problem for non-ambulatory children with spinal muscular atrophy (SMA). PATIENTS: 24 SMA patients were operated on for scoliosis using the ISOLA(®) system and 17 patients using a telescopic rod. The average age at spinal surgery was 12.3 years (6.5-22.7) in the ISOLA(®) group and 6.7 years (4.8-10.9) in the telescopic rod group. RESULTS: The Cobb angle was corrected on average from pre-operative 83°(54°-120°) to post-operative 39°(5°-70°) in the ISOLA(®) group and, respectively, from 62°(28°-86°) to 18°(0°-34°) in the telescopic rod group. Mean loss of correction at mean follow-up of 6 years (3-10) was 6°(0°-33°) in the ISOLA(®) group and at mean follow-up of 8.6 years (3-12) 13°(0°-49°) in the telescopic rod group excluding the patients with rod failure. The vital capacity is not worsened by these operations in comparison to the natural course. After telescopic rods were implanted, there were some unsatisfactory results due to crankshaft phenomenon and an increase of pelvic obliquity. CONCLUSION: Our recommendation for non-ambulatory SMA patients is to have definitive stabilisation using multisegmental instrumentation, starting from the age of 10 to 12 years.

Treatment of spastic varus/ equinovarus foot with split-tendon transfers in cerebral palsy: How does it affect the hindfoot motion?

INTRODUCTION: The flexible spastic varus foot in cerebral palsy is commonly corrected by split-tendon transfer of tibialis anterior or tibialis posterior. These tendon transfers are said to preserve hindfoot motion, which is until now not been proven. Therefore, the aim of the study was to show the hindfoot motion following split-tendon transfer in comparison to a midtarsal arthrodesis. MATERIALS AND METHODS: A retrospective study was done on patients with flexible spastic varus foot in cerebral palsy who underwent a combined split-tendon transfer of tibialis anterior and posterior. Patients with a rigid foot deformity underwent a midfoot arthrodesis. These children and normal children served as controls. An instrumented gait analysis was done in all patients before and at follow-up. A statistical analysis was done using 2-factor ANOVA with repeated measures on time. RESULTS: Thirteen children underwent a combined split-tendon transfers of tibialis anterior and posterior muscles and 14 children midtarsal arthrodesis. The mean follow-up was 2.4 (SD=0.8) years for flexible varus foot and 1.9 (SD=0.7) years for rigid foot deformity. The preoperative hindfoot range of motion in eversion-inversion was 54% and 49% of TD controls in flexible varus foot and rigid foot deformity respectively. At follow-up, it reduced further to 45% and 42% of TD controls in the respective groups. CONCLUSION: Both flexible and rigid hindfoot deformity reduced the hindfoot motion. However following surgery, the hindfoot motion reduced further and was identical in both groups independent of the type of surgery. This indicates a tenodesis-effect of split-tendon transfers on the hindfoot.

Is shortening of Tibialis Anterior in addition to calf muscle lengthening required to improve the active dorsal extension of the ankle joint in patients with Cerebral Palsy?

INTRODUCTION: Shortening of the tibialis anterior tendon (TATS) has been shown to improve the ankle dorsiflexion in swing following the calf muscle lengthening procedure (CMLP) in patients with cerebral palsy (CP). Others have reported the similar improvements following CMLP but without TATS. However there are no studies comparing both procedures. Therefore the purpose of the study was to compare the ankle dorsiflexion in swing and foot position in the sagittal plane during gait following TATS and CMLP to that of CMLP alone. MATERIALS AND METHODS: A retrospective study was carried out in CP patients who presented with fixed equinus deformity. They were grouped into unilateral CP and bilateral CP. Depending on the procedures, each group was again subdivided into subgroup CMLP only and subgroup CMLP and TATS (CMLPTATS). All patients were subjected to pre and postoperative clinical and gait analysis. RESULTS: 44 feet in 44 patients were included in the study. Of these, 24 feet (24 patients) belonged to unilateral and 20 feet (20 patients) to bilateral CP group. The mean age of the patients at surgery was 11.5 years (6.0 - 29.0) in the unilateral CP group and 10.5 years (5.0-34.0) in the bilateral CP group. In the unilateral CP group, 12 feet belonged to subgroup CMLP and 12 to subgroup CMLPTATS with a mean equinus contracture of 7.5° in both subgroups. In bilateral CP group, 11 feet belonged to subgroup CMLP with a mean equinus contracture of 5° and 9 to subgroup CMLPTATS, with a mean equinus contracture of 10°. The subgroups did not vary significantly in the demographics, anthropometry, kinematics and kinetics of ankle joint preoperatively. The mean follow up time was 19.7 months. The surgery produced significant changes in both groups and subgroups. However, none of the relevant gait parameters were significantly different between groups and subgroups. SIGNIFICANCE: Adding TATS to CMLP, compared to CMLP alone did not improve ankle dorsiflexion in swing and the foot position more than CMLP alone.

Navigated percutaneous screw fixation of a periprosthetic acetabular fracture.

Periprosthetic fractures are severe complications of total hip arthroplasty with increasing incidence. Most fractures are localized around the femoral component of prosthesis, whereas periacetabular fractures are rare and their management is difficult. In most cases, an operative procedure with revision and exchange of the acetabular cup is necessary. The approaches are demanding and an increased risk of complications is reported. We present the case of a female patient with a cementless total hip arthroplasty due to severe arthritis, suffering of an infratectal transverse periprosthetic fracture. After an initial conservative treatment attempt, we performed a minimally invasive screw fixation using navigated 2-dimensional fluoroscopic guidance. In this report, the literature for treatment recommendations is reviewed and the chosen navigation technique discussed.

Fractures in proximal spinal muscular atrophy.

INTRODUCTION: Fractures are a common problem for patients with spinal muscular atrophy (SMA). PATIENTS: A total of 131 patients with proximal SMA with an average age of 13.2 +/- 9.2 years (0.7-65.6) were evaluated retrospectively. In 60 patients 94 different fractures were observed. The group consisted of 11 patients with type Ib, 81 with type II, 33 with type IIIa, 4 with IIIb and 2 with type IV. 38 of 81 SMA II patients and 17 of 33 SMA IIIa patients had suffered fractures at an average age of 8.3 +/- 5.3 years (0.0-25.1) (SMA II) and 9.3 +/- 6.0 years (0.0-22.1) (SMA IIIa). RESULTS: The most frequent fractures were of the femur (50), usually distal, of the lower leg and ankle (15), and upper arm (9). The distribution of fractures was different in SMA II and SMA IIIa. Most of the fractures could be treated conservatively. Only two femoral shaft fractures, one upper arm and a lower arm fracture were treated surgically by osteosynthesis. CONCLUSION: Competent fracture treatment is an important part of the orthopaedic care of SMA patients.

Does an overcorrected clubfoot caused by surgery or by the Ponseti method behave differently?

BACKGROUND: Overcorrection is a recognized problem following surgical treatment of congenital clubfoot. Recently this complication has also been mentioned following Ponseti treatment. RESEARCH QUESTION: Do overcorrected clubfeet (OCCF) caused by surgery behave differently from those caused by Ponseti treatment in terms of segmental motion of the feet and show differences in the severity of deformity on X-rays? METHODS: Children between 7 and 12 years with OCCF were included in this study. Depending on the aetiology causing them, the feet were divided into 2 groups (Ponseti and peritalar release surgery). 25 typically developing children served as controls. All subjects were subjected to clinical and radiological examination and 3-Dimensional gait analysis using the Oxford Foot Model. RESULTS: Thirty-two children with OCCF, of these 18 feet in the surgical and 14 feet in the Ponseti group, were included in the study. No radiological differences were seen in the flatfoot parameters between OCCF groups except in the calcaneal inclination angle that was more pathological in the Ponseti group. The clinical ankle plantar flexion was significantly reduced in the surgical group. During walking the range motion of the hindfoot in the frontal plane was significantly reduced in surgically treated feet compared to the Ponseti group. The other parameters did not show any significant difference between groups. SIGNIFICANCE: The overcorrected clubfeet following surgery and Ponseti showed similar appearance and showed no significant differences in 11/12 radiological parameters. The segmental motion of the feet showed no significant differences between groups except the in the range of motion of the subtalar eversion. A considerable subtalar joint motion was present even in the surgical group. These findings might help plan the treatment of these feet.

Orthotic Care Based on the Ferrari Concept for Children and Adults with Meningomyelocele. / Orthesenversorgung in Anlehnung an das Ferrari-Konzept bei Kindern und Erwachsenen mit Meningomyelozele.

BACKGROUND: Even today, myelomeningocele (MMC) is still encountered in clinical medicine and its incidence has not decreased over the last 20 years despite a known reduction in risk due to the use of folic acid supplements. The spectrum of clinical symptoms is extremely broad and, depending on the level of the defect, varies from mild to severe. Subject to the degree of paralysis, patients are reliant on the use of orthopaedic aids and orthoses for the treatment of primary contractures and deformities and the prevention of secondary ones. This forms the basis for attaining or maintaining mobility in many patients. The objective of the study was to determine the practical application of the proposed Ferrari concept for the provision of orthoses for children and adults. PATIENTS AND MATERIAL: The retrospective study comprised medical records of 180 patients (97 m) with an average age of 19.44 years (3 - 52 years, SD 9.3) at the time of investigation. The average duration of treatment was 15.34 years (1 - 38 years, SD 8.96). Data relating to deformities of the vertebral column and lower limbs, provision of hydrocephalus shunts and orthoses, and patient mobility was evaluated. RESULTS: Most patients were given systematic treatment with orthoses at an early stage. In 58,9% of cases, it was possible to implement the proposed concept for providing patients with dynamic orthoses, whereby the treatment concept was more difficult to implement with high lumbar lesions than with lower lesions. Moreover, a decrease in the patients' mobility with increasing age was noticeable. Some 42.3% of adult patients were able to walk with marked variations in mobility in relation to the different levels of lesions. CONCLUSION: Taking into consideration the complexity of both the clinical picture and therefore the provision of orthopaedic devices, the result of the implementation of the proposed orthotic concept can be considered positive. Similarly, early commencement of provision of orthoses and hence the possibility of achieving a positive influence on later mobility can be considered a success. The need for individual concepts and further development in order to increase mobility particularly in the case of patients with thoracic or high lumbar lesions is evident. A more comprehensive provision of information to patients regarding orthotic treatment options and their consequences for prophylaxis and quality of life should be an important component of interdisciplinary long-term patient care.

Cluster analysis to identify foot motion patterns in children with flexible flatfeet using gait analysis-A statistical approach to detect decompensated pathology?

INTRODUCTION: The paediatric flexible flatfoot constitutes the major cause of clinic visits for orthopaedic foot problems. It shows variations of deformities in different planes and locations of the foot and its indication for treatment have been extensively discussed. Despite its high prevalence there exists no classification of flatfeet during walking as a prerequisite for treatment decision. Therefore, the aim of this study is to classify flexible flatfeet based on 3D foot kinematics during walking. METHODS: Patients age 7-17 years with flexible flatfeet (N = 129, 255 feet) of non-neurogenic or syndromic origin, were retrospectively included. Patients underwent gait analysis using the Oxford Foot Model after standard clinical examination. A k-means cluster analysis was performed on 3 scores derived from the principal component analysis of the foot kinematic waveforms over the gait cycle. Gait and clinical parameters were then statistically tested between clusters. RESULTS: Cluster analysis revealed two groups of flexible flatfeet that were discriminated best by the inversion at push-off during walking. Cluster 2, including 110 feet, showed an average eversion instead of an inversion at push-off and a lower number of heel rises in the clinical test. Both was significantly different between clusters (p < 0.001). DISCUSSION: Based on the findings, the resultant clusters can be interpreted as describing compensated and decompensated feet, with the latter presenting a group that may require surgical interventions, even if they are not yet present with pain. The hindfoot inversion capability at push-off is the most important variable in the 3D gait analysis to classify flexible flat feet.

Outcome after Achilles tendon lengthening with a posterior capsulolysis according to Imhäuser in idiopathic congenital clubfoot.

BACKGROUND: The Ponseti method has radically reduced the need for extensive surgical treatment in idiopathic clubfoot. At present there are no universally accepted criteria for the use of the various surgical techniques. MATERIAL AND METHODS: 77 patients with idiopathic congenital clubfoot (111 affected feet) were treated according to Imhäuser. The operative release included z-shaped Achilles tendon lengthening and a posterior capsulolysis of the talocrural and talocalcaneal joint. In case of relapse in infancy and school age, a transfer of the tendon of the anterior tibial muscle (n=26) and a release of the alonavicular, navicular cuneiform I and cuneiform metatarsal I joints (n=15) were carried out. 49 patients with 70 clubfeet were followed up at a mean age of 9.8 years (+/- 7 years) and the length of follow-up averaged 8.6 years (+/- 6.2 years). RESULTS: In 71.4% (50 feet) a "very good" or "good" correction of shape and in 64.2% (45 feet) "very good" or "good" function was achieved. A statistically significant correlation was found between delayed onset of walking and the risk of revision surgery due to a relapse of the deformity. CONCLUSIONS: Important problems in the treatment of clubfoot according to Imhäuser in our study were residual partial forefoot adduction and restriction of mobility in the upper ankle joint. Our analysis of radiographs showed that despite unsatisfactory X-ray findings, clinical correction and mobility were good. Rigid congenital clubfeet, however, require peritalar releases.

Management of Severe Equinovalgus in Patients With Cerebral Palsy by Naviculectomy in Combination With Midfoot Arthrodesis.

BACKGROUND: Equinovalgus deformity is the second most common deformity in cerebral palsy and may be flexible or rigid. Several operative methods from joint sparing to arthrodesis have been described with varying success rates. The aim of this study was to investigate the effectiveness of naviculectomy in combination with midfoot arthrodesis (talo-cuneiform and calcaneocuboid arthrodesis) in the correction of a rigid equinovalgus foot deformity in cerebral palsy. METHODS: Forty-eight rigid equinovalgus feet were operated upon in 30 patients from 2008 to 2013. Of these, 44 feet in 26 patients with cerebral palsy (Gross Motor Function Classification System III, IV, or V) with follow-up of more than 2 years were included in the study. The mean age at surgery was 18.1 years. The outcomes were measured objectively using radiographic angles and subjectively using 5 questions to be answered by the caregiver. The feet were then graded into excellent, good, fair, and poor. The mean follow-up was 5.0 ± 1.7 years. RESULTS: Excellent to good results were obtained in 81% of the feet. Both objective and subjective outcomes improved significantly postoperatively ( P < .001). Three feet in 2 patients were graded as poor and underwent a revision operation for pain and recurrence. CONCLUSIONS: Naviculectomy in combination with midfoot arthrodesis enabled a good 3-dimensional correction of the forefoot. However, the procedure did not necessarily correct the fixed subtalar joint deformity. Several additional bony and soft-tissue procedures were necessary to achieve a complete correction in these difficult feet. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Treatment of scoliosis in intermediate spinal muscular atrophy (SMA type II) in childhood.

Summary. Progressive scoliosis with increasing pelvic obliquity in early childhood of patients with SMA type II is a common feature in this disease. Spinal surgery in muscle disorders should be carried out as soon as a progressive curve of more then 20 Celsius Cobb and a preserved FVC of 20-30% is proved. In later stages or severe forms of SMA II spinal stabilization becomes often impossible due to the respiratory insufficiency, the poor general condition and the severity of the scoliosis with marked pelvic obliquity. A special telescope rod was developed in order to enable a lengthening of this instrumentation during growth for children treated in early childhood. In 15 of 20 patients with SMA II in early childhood not satisfactory results after telescope rod implantation were observed. In spite of the telescope technique crankshaft phenomenon appeared and curve progression were observed. So then we stopped telescope rod implantation. This instrumentation could be in principle a good therapeutical tool for this indication, but its technical manufacturing has firstly to be improved decisively. For SMA II patients younger than 10 years with progressive scoliosis our therapeutic recommendation is nowadays a corset until the age of 10-12 years followed by definitive surgical correction using other multisegmental instrumentation like the Isola(R) system.