We undertook a randomised clinical trial to compare treatment times and failure rates between above- and below-knee Ponseti casting groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below- or above-knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks.

A total of 26 children (33 feet) were entered into the trial. The above-knee group comprised 17 feet in 13 children (ten boys and three girls, median age 13 days (1 to 40)) and the below-knee group comprised 16 feet in 13 children (ten boys and three girls, median age 13 days (5 to 20)). Because of six failures (37.5%) in the below-knee group, the trial was stopped early for ethical reasons. The rate of failure was significantly higher in the below-knee group (p = 0.039). The median treatment times of six weeks in the below-knee and four weeks in the above-knee group differed significantly (p = 0.01).

This study demonstrates that the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. Therefore, this technique is not recommended.

Cite this article: Bone Joint J 2013;95-B:1570–4.

The purpose of this study was to investigate the effects of right leg restriction at the knee, ankle or both, on a driver’s braking times. Previous studies have not investigated the effects of knee restriction on braking performance. A total of 23 healthy drivers performed a series of emergency braking tests in a driving simulator in either an above-knee plaster cast, a below-knee cast, or in a knee brace with an increasing range of restriction. The study showed that total braking reaction time was significantly longer when wearing an above-knee plaster cast, a below-knee plaster cast or a knee brace fixed at 0°, compared with braking normally (p < 0.001). Increases in the time taken to move the foot from the accelerator to the brake accounted for some of the increase in the total braking reaction time. Unexpectedly, thinking time also increased with the level of restriction (p < 0.001). The increase in braking time with an above-knee plaster cast in this study would increase the stopping distance at 30 miles per hour by almost 3 m. These results suggest that all patients wearing any lower-limb plaster cast or knee brace are significantly impaired in their ability to perform an emergency stop. We suggest changes to the legislation to prevent patients from driving with lower-limb plaster casts or knee braces

Twenty complex tibial deformities due to anterior poliomyelitis in 18 patients were corrected by a modified O’Donoghue osteotomy. This technique allowed correction of the deformity in three planes. This was achieved by widening the rectangular window distally to correct both rotation and valgus and by trimming the anterior edges of the step cuts to correct flexion deformity. An above-knee cast was applied for eight to 13 weeks and the patients followed up for a mean of 3.2 years. One of the 18 patients developed delayed union because of fracture of the medial limb of the step cut. The results showed excellent correction of the three-plane deformity and there was no recurrence. This method of osteotomy is a safe and simple procedure which does not require internal fixation and allows correction of torsional and angular deformity

Statement of purpose:. A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups. Methods and Results:. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below knee or above knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. Twenty-six children (33 feet) were entered into the trial, with a mean age of 17 days (range 1–40) in the above knee and 11 days (range 5–20) in the below knee group. Because of six failures in the below knee group (38%), the trial was stopped early for ethical reasons. Failure rate was significantly higher in the below-knee group (P 0.039). The median treatment times of six weeks in the below knee and four weeks in the above knee group differed significantly (P 0.01). Statement of conclusion:. Below knee plaster of Paris casts in conjunction with the Ponseti method showed significantly higher rates of failure than above knee plaster casts, requiring conversion to above knee casts, and a significantly longer treatment time. This higher rate of failure of below knee casts forced an early end of the trial. This study shows that a well moulded above knee plaster cast is safe and superior to a below knee plaster cast in conjunction with the Ponseti method. We do not believe that modifying the original Ponseti method in this manner is beneficial. Level of evidence: I

Traditionally clubfoot in South Africa is treated by manipulation, serial casting and, at the age of 3 to 4 months, posteromedial release. Revision surgery, with its attendant problems, is often necessary. In November 2003 we started using the Ponseti technique. To date we have treated 61 feet, most of which are type-III according to the Harold and Walker classification. Serial castings are done according to Ponseti technique. Initially the forefoot is manipulated into supination to align it with the hindfoot. The talonavicular joint is gradually reduced until 75° of abduction is achieved. Then percutaneous tenotomy is done to correct hindfoot equinus. Manipulation is done weekly and an above-knee cast is applied. Following tenotomy, the cast remains in place for 3 weeks, after which a Denis Brown splint is worn continually (except at bath time) for 3 months and then at night for 3 years. Parent compliance has been good. We have had six failures to date. One foot was found to have tarsal coalition and another was an arthrogrypotic foot, which was successfully corrected. Our results suggest that most operations for clubfoot are avoidable. The Ponseti manipulation technique is simple and can easily be taught to the staff of peripheral hospitals, making it ideal for treatment of clubfoot in Africa

This paper reports the results of pes anserinus insertion as a dynamic transfer for habitual dislocation of the patella. From 1995 to 2001 five patients were seen, ranging in age from 5 to 13 years. Follow-up ranged from nine months to three years. Through a long lateral incision, the iliotibial band and abnormal superolateral insertion of the vastus lateralis were divided. The lateral capsule down to the lateral border of the patellar tendon was released. Finally the vastus intermedius tendon was divided. The rectus femoris was lengthened in one patient. Through a medial parapatellar incision, the pes anserinus insertion was detached with a sleeve of periosteum and sutured to the anteromedial aspect of the patella and patellar tendon to act as a dynamic check rein. The relaxed medial capsule was reefed before the transfer. The child was immobilised in an above-knee cast for four weeks after wound closure and later had physiotherapy. In all patients the results were good. Movement was from 0° to 130° and there were no complications or redislocations. Skyline views showed the patella located in the groove. Dynamic stabilisation of the patella in habitual dislocations yields more successful results. Preserving the vastus medialis helps prevent the extensor lag that usually occurs after these procedures. Abnormal insertion of the vastus lateralis and a tight iliotibial band were identified as the main causes of the dislocation. The failure of reconstructive procedures is perhaps due to the inadequate strength of the soft tissue used as a static medial stabiliser of the patella

This paper reviews the outcome of 13 children with congenital pseudarthrosis of the tibia after intramedullary rodding and autogenous bone grafting. The oldest patient was aged nine years at the time of surgery. The ages of the others ranged from 12 to 24 months. The oldest patient at follow-up was 18 years. All 13 had bone defect and angulation. Ten children had clinical features of neurofibromatosis. Ten had pseudarthrosis involving the distal third of the tibia, two the middle third and one the proximal third. Autogenous iliac crest chips were used following excision of fibrous tissue and dense and atrophic bone. Rodding was done across the ankle joint in 10 patients. Postoperatively an above-knee cast was applied for 6 to 12 months, after which an above-knee brace was used to protect the rodding. At follow-up, which ranged from 10 months to 16 years after surgery, all patients were fully weight-bearing and ambulant. Three patients were lost to follow-up after 2 to 4 years. Complications included refracture and rod breakage (two), rod migration (three), and growth retardation with shortening of up to 5 cm. Ten patients had ankle and subtalar joint stiffness and two had valgus deformities of the ankle. Three patients underwent repeat rodding and bone grafting. Radiological union was observed to be progressing in all patients. Intramedullary rodding of the tibia for congenital pseudarthrosis of the tibia is a simple procedure and can be repeated. It avoids prolonged hospital stay and permits early weight-bearing. Careful supervision is necessary, and until there are signs of good bony union, external support is mandatory

Aim: Experimentally forming a frayed Achilles tendon rupture model in rabbit and repairing the ruptured site with different methods; after the tendon healing, with the help of biomechanical and histopathological analyses, to find out which repair method is the most ideal. Material and Method: This study was carried out using 34 mature, female New Zealand type of rabbits with weights ranging 2200 to 2900 grams (2429,4 on average). The animals were divided into two groups named P and V, each with 17 rabbits. In each group, Achilles tendon on the right side was employed for the experiment (Pd and Vd) and the other side as a control (Pk and Vk). In the experiment groups, a frayed Achilles tendon rupture was performed. The control groups, however, received no procedures. After the primary repair, the Achilles tendons in the group Pd were augmented with the plantaris tendon. The Achilles tendons in the group Vd were primarily repaired after releasing gastrocnemius aponeurosis using “inverted-V” incision. In both groups, an above-knee cast was applied on the surgically procedured sides. After six weeks of observation, the repaired sites on tendons in the animals alive were analyzed biomechanically and histopathologically. 12 and 3 animals from each group were used respectively for the biomechanical and the histopathological analyses. Results: The elongation at tendon to rupture was 3,02±0,47 mm for Pd and 2,86±0,35 mm for Vd. The difference between two groups, however, was not statistically significant (p> 0,05). The maximum load at rupture for Pd was 105,88±38,14 N, and it was 71,95±17,44 N for Vd, thus the difference was statistically significant (p< 0,05). The energy needed to initiate a damage to the tendon was 0,1979±0,0902 J for Pd, and 0,1309±0,0368 J for Vd, the difference was also statistically significant (p< 0,05). The elongation, maximum load and energy values were lower in Pd group than in Pk, and in Vd group than in Vk, and the differences between each groups were statistically significant (p< 0,05). In histopathological sense, the tendon healing process in group Pd was faster than in group Vd. Conclusion: Although the repairs made with the augmentation of plantaris tendon yielded better results; the tendon, no matter which method is used, could not has its former strength. Results are bound to be better with stronger repair, and if the repair as much as supported by adjacent tendinous structures. Key Words: Achilles tendon, rupture, primary repair, m. plantaris, rabbit

Purpose: Congenital idiopathic clubfoot is the most common congenital deformity in children and can be a major cause of disability for the child as well as an emotional stress for the parents. The Ponseti method of club-foot correction, consisting of serial manipulations and casting, is now the gold standard of treatment. It has traditionally been described using plaster of Paris (POP) above-knee casts, which are affordable, stiff, and easily moldable. Recently, semi-rigid fiberglass softcast (FSC, 3M Scotchcast) has grown in popularity due to ease of removal, durability, lighter weight, better appearance, ease of cleaning, and water resistance. There are currently no randomized controlled trials to prove its efficacy with respect to POP. The purpose of this study was to determine the influence of choice of cast material on the correction of congenital idiopathic clubfeet using the Ponseti method. Method: A prospective, randomized controlled trial. Based on the results of a pilot study performed at our centre, a sample size of 30 patients was determined to be appropriate. Thirty consecutive patients presenting with congenital idiopathic clubfoot were randomized into POP and FSC groups prior to commencement of treatment with the Ponseti Method. Clubfeet secondary to non-idiopathic diagnoses were excluded. The Pirani classification was used to determine clubfoot severity (less severe, < =4; severe > 4), and for surveillance during casting. The primary outcome measure was the number of casts required to correct the clubfoot deformities to the point where the foot was ready for a percutaneous tendo-achilles tenotomy (TAL) or when the foot was completely corrected (Pirani=0). Secondary outcome measures include: number of casts by clubfoot severity, ease of cast removal, number of methods needed to remove casts, need for percutaneous tendo-achilles tenotomy. Results: Of the 30 patients enrolled, 13 (40%) were randomized to POP and 18 (60%) to FSC. No patients were lost to follow-up. In the POP and FSC groups, eight (67%) and 11 patients (61%) underwent a TAL, respectively. In general, there were no differences in the mean number of casts required for clubfoot correction between the two groups (p=0.13). When analyzed by clubfoot severity, the mean number of casts for each material in the less severe group was equal (3 casts). In the severe group, the mean number of casts in the FSC group (6.4 casts) was considerably higher than for the POP group (4.7 casts) but our study was underpowered to verify this result. According to parents, POP was harder to remove than FSC (p< 0.001). Conclusion: In general, FSC was found to be as efficacious as POP in the correction of idiopathic clubfeet by the Ponseti Method and was the preferred cast material by parents. For stiffer, more severe feet, POP seemed to show a faster correction time than FSC

We present the treatment protocol of congenital clubfoot in different age groups that has been widely used in Bulovka Orthopedic Clinic since 1984. Conservative treatment begins immediately after delivery and corrects all presented deformities on the principle of subtalar derotation of the calcaneus. The correction is applied and an above-knee cast is changed every 48 hours. After five corrections and changes of casts, the casting and correction is then repeated weekly. After achieving reduction of deformities, the cast is changed at intervals of two to three weeks. Cast immobilisation should be continued for two to three months for postural clubfoot, and six to seven months for congenital clubfoot. After retention in the cast, a polypropylene above-knee splint is applied up to the age of two to three years. In addition, passive stretching exercise and stimulation of the lateral part of the foot should be provided in order to achieve muscle balance between the evertors and invertors. Surgical treatment: When conservative treatment is unsatisfactory, the goal of operative treatment is to reduce all deformities in a one-step procedure. Posterior capsulotomy at the age of three to six months is indicated when the forefoot has been corrected by conservative treatment but the hindfoot remains fixed in the equinus and mild varus, or at the age of six to 12 months for residual hindfoot equinus. Complete subtalar release according to McKay is required at the age of over six months to three years. Post-operative treatment is the same as for the abovementioned conservative treatment. Treatment between the age of three and seven: The choice of surgical procedure must be individual according to the deformity, but surgical correction of severe deformity principally includes extensive subtalar release, and lateral column shortening by cuboid enucleation. Treatment between the age of seven and ten: Individual procedures (Ilizarov method; Dwyer osteotomy of the calcaneus, or osteotomy of the mid-tarsal bones) are chosen to treat deformities. These procedures are usually combined with soft tissue release, but not with complete subtalar release. Treatment after the age of ten (skeletal maturity of the foot): The same methods as in the previous group are used. When severe or unsatisfactory results after previous surgical treatment are obvious, a triple subtalar arthrodesis is the appropriate salvage method of correction. Treatment of residual deformities: For treatment of dynamic deformities due to muscle imbalance after the age of four, a temporary lateral transfer of the whole tendon of the anterior tibial muscle is performed. For the same age group, forefoot adduction and supination are corrected with a ball and socket osteotomy of the base of metatarsals I-V. This therapeutic concept was applied to 397 operated feet. 60% of the cases were primary surgical corrections, and 40% were repeated surgical corrections. 95% of primary surgical procedures and 75% of secondary surgical procedures were classified as satisfactory, indicating that the foot was sufficiently mobile, with plantigrade weight bearing

Aims

The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment

Aims

The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet.

We have modified the Ponseti casting technique by using a below-knee Softcast instead of an above-knee plaster of Paris cast. Treatment was initiated as soon as possible after birth and the Pirani score was recorded at each visit. Following the manipulation techniques of Ponseti, a below-knee Softcast was applied directly over a stockinette for a snug fit and particular attention was paid to creating a deep groove above the heel to prevent slippage. If necessary, a percutaneous Achilles tenotomy was performed and casting continued until the child was fitted with Denis Browne abduction boots.

Between April 2003 and May 2007 we treated 51 consecutive babies with 80 idiopathic club feet with a mean age at presentation of 4.5 weeks (4 days to 62 weeks). The initial mean Pirani score was 5.5 (3 to 6). It took a mean of 8.5 weeks (4 to 53) of weekly manipulation and casting to reach the stage of percutaneous Achilles tenotomy. A total of 20 feet (25%) did not require a tenotomy and for the 60 that did, the mean Pirani score at time of operation was 2.5 (0.5 to 3). Denis Browne boots were applied at a mean of 10 weeks (4 to 56) after presentation. The mean time from tenotomy to boots was 3.3 weeks (2 to 10). We experienced one case of cast-slippage during a period of non-attendance, which prolonged the casting process. One case of prolonged casting required repeated tenotomy, and three feet required repeated tenotomy and casting after relapsing while in Denis Browne boots.

We believe the use of a below-knee Softcast in conjunction with Ponseti manipulation techniques shows promising initial results which are comparable to those using above-knee plaster of Paris casts.

Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems. We describe early excision and the use of the Masquelet technique to reconstruct the bone defect in a child aged 14 months. Consolidation sufficient for complete weight-bearing was achieved by seven weeks. After two and a half years, the child was asymptomatic with a fully reconstructed tibia and no leg-length discrepancy.

The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the treatment of congenital pseudarthrosis of the tibia has been investigated in only one previous study, with promising results. The aim of this study was to determine whether rhBMP-2 might improve the outcome of this disorder. We reviewed the medical records of five patients with a mean age of 7.4 years (2.3 to 21) with congenital pseudarthrosis of the tibia who had been treated with rhBMP-2 and intramedullary rodding. Ilizarov external fixation was also used in four of these patients. Radiological union of the pseudarthrosis was evident in all of them at a mean of 3.5 months (3.2 to 4) post-operatively. The Ilizarov device was removed after a mean of 4.2 months (3.0 to 5.3). These results indicate that treatment of congenital pseudarthrosis of the tibia using rhBMP-2 in combination with intramedullary stabilisation and Ilizarov external fixation may improve the initial rate of union and reduce the time to union.

Further studies with more patients and longer follow-up are necessary to determine whether this surgial procedure may significantly enhance the outcome of congenital pseudarthrosis of the tibia, considering the refracture rate (two of five patients) in this small case series.

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot.

Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release.

Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release.

Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic.

This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity.

Cite this article: Bone Joint J 2014;96-B:1424–6