1. Paralytic dislocation of the hip in spina bifida generally requires reduction and iliopsoas transfer. The muscle transfer ensures that the hip remains reduced, lessens the need for calipers and prevents progressive flexion deformity. In addition, varus and rotation osteotomy of the femur and innominate osteotomy are sometimes required. Varus and rotation osteotomy alone is indicated if the psoas is not strong enough for transfer. The age for reduction of dislocated hips and muscle transfer has been reduced to eight months as experience and confidence has been gained. 2. Flexion deformity is best prevented by early iliopsoas transfer. An anterior release operation is occasionally indicated when there is flexion deformity and a weak psoas muscle. This procedure, alone or supplemented by extension osteotomy, may be necessary to correct severe flexion deformity in children seen late. 3. Lateral rotation deformity of the hip may be caused by unbalanced iliopsoas action or the unbalanced action, or contracture, of the short lateral rotator muscles. If the deformity is sufficient to make the gait bizarre, or if it is difficult to fit a caliper, then soft-tissue operations as described are of value. 4. Abduction deformity can be corrected by division of the unopposed or contracted abductors

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°). . However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot. In its present form, we cannot recommend the routine use of this bolt. Cite this article: Bone Joint J 2015; 97-B:809–13

We evaluated scapular dysplasia and malposition in 15 patients with the Sprengel deformity using three-dimensional CT (3D-CT). The shape, height-to-width ratio, the areas of both scapulae, the anterior curvature of the supraspinous portion and glenoid version were assessed on scapular posterior, medial and inferior views. The degree of rotation and superior displacement were measured on the trunk posterior view. The omovertebral connection was also assessed and correlated with the operative findings. Most of the affected scapulae had a characteristic shape with a decrease in the height-to-width ratio and were larger than the contralateral scapulae. There was an inverse relationship between scapular rotation and superior displacement. The typical curve of the supraspinous portion of the scapula was seen in only three cases. There was no significant difference in glenoid version. The point of tethering of the omovertebral connection may determine the shape, rotation and superior displacement of the scapula. 3D-CT was helpful in delineating the deformity in detail, and in planning scapuloplasty

A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis

Valgus deformity of the hindfoot can occur at the subtalar joint, the ankle joint, or at both sites. In children suffering from spina bifida, the ankle is often the main site of deformity. Thirty-five ankles with valgus deformity of the hindfoot were studied in 23 children with spina bifida. A radiological triad was observed in all patients: shortening of the fibula, lateral wedging of the distal tibial epiphysis, and lateral tilt of the talus at the ankle mortise . There was a definite correlation between the severity of wedging and the degree of talar tilt, and a fair correlation between the severity of wedging and the extent of fibular shortening. The results of operation in 12 feet are presented. It is concluded that any operations performed below the ankle on these patients (subtalar fusion or triple arthrodesis) is unlikely to succeed; the deformity needs to be corrected above the ankle (by epiphysiodesis or supramalleolar osteotomy). Radiological assessment of the ankle by taking weight-bearing films in the anteroposterior plane is essential to determine the true extent of the deformity before undertaking any operation

1. A series of 106 central slip injuries has been reviewed. 2. Although the boutonnière deformity in many cases may be no more than a cosmetic defect, this survey has shown that in some instances it can constitute a slowly progressive lesion, with considerable disability and gross deformity of a digit. 3. Conservative treatment seems to be superior to operation, at least in those patients seen within six weeks of injury. Treatment by splintage alone yielded in this series a 75 per cent success rate, whereas operation showed only 50 per cent success. 4. When a sizeable fragment of bone has been avulsed from the middle phalanx, suture of the fragment in position is indicated and gives remarkably satisfactory results. 5. Injuries with soft-tissue loss over the proximal interphalangeal joint may yield successful results after suture or plastic repair of the tendon, and wound closure by split-skin grafts or local rotation flaps. 6. Poor results tend to occur in cases complicated by phalangeal fracture or by multiple hand injuries, and it may be advisable to defer the repair of the central slip until recovery from the other injuries has been completed. 7. With gross disruption of the proximal interphalangeal joint primary arthrodesis is probably indicated

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition

A 64-year-old man presented with a severe deformity of the tibia caused by Paget’s disease and osteoarthritis of the ipsilateral knee. Total knee replacement required preliminary correction of the tibial deformity. This was successfully achieved by tibial osteotomy followed by distraction osteogenesis using the Taylor spatial frame. The subsequent knee replacement was successful, with no recurrence of deformity

1 . A classification of Madelung's deformity on an etiological basis is suggested. 2. Seven patients with "idiopathic" Madelung's deformity and one occurring in association with Turner's syndrome are discussed. 3. Cytogenetic studies of five patients are recorded and their significance discussed. 4. Arthrodesis of the radio-carpal joint by the "wedge" technique is preferred for those patients whose symptoms warrant treatment

We report the treatment in 17 patients of 27 angular deformities of the long bones by progressive opening-wedge osteotomy. The technique consists of percutaneous osteotomy and progressive angular correction using a modified Wagner distractor. Ten patients (20 bone segments) had adolescent bilateral idiopathic tibia vara with a mean angular deformity of 12 degrees varus (10 to 16). Seven other adolescent patients had secondary angular deformities either at the distal femur or the distal tibia. One of the femoral deformities had an associated 5.5 cm of shortening which was treated simultaneously. The patients with idiopathic tibia vara achieved a final mean angular correction of 15 degrees (mechanical axis from 12 degrees varus to 3 degrees valgus). In patients with secondary angular deformities the mean angular correction was 17 degrees. The Wagner device was removed in an average period of 12 weeks (9 to 27), and no major complications were observed. Progressive opening-wedge osteotomy is an alternative to conventional osteotomies for the treatment of angular deformities of the long bones in adolescent patients, and has the advantage of requiring less invasive surgery, allowing progressive and adjustable correction with bone lengthening if needed

We reviewed 31 patients at a mean of five years after mallet deformity of the finger had been treated with a thermoplastic splint. Intra-articular fractures were present in 35% of patients. Osteoarthritic changes had developed in 48%, most in association with fracture, and 29% had a swan-neck deformity. There was a loss of extension greater than 10° in 35%; the average deficit at the interphalangeal joint was 8.3° and the average flexion arc was 48.5°. Despite these findings, patient satisfaction was generally high, with little evidence of functional impairment

Adults with deformities of the lower limb due to spasticity may be considerably improved by operation, but thorough pre-operative assessment as an inpatient is essential in order to pinpoint the disability. The commonest deformity is equinovarus which often responds to simple operative procedures. The results of seventy-seven operative procedures in fifty patients are recorded. Correction once achieved is stable and the deformity does not recur

A pronation deformity of the forearm following an obstetric brachial plexus injury causes functional and cosmetic disability. We evaluated the results of pronator teres transfer to correct their deformity in 14 children treated over a period of four years. The mean age at surgery was 7.6 years (5 to 15). The indication for surgery in each case was impairment of active supination in a forearm that could be passively supinated provided that there was no medial contracture of the shoulder and normal function of the hand. The median follow-up was 20.4 months (8 to 42). No patient was lost to follow-up. Qualitative results were also assessed. The median active supination improved from 5° (0° to 10°) to 75° (70° to 80°) with no loss of pronation. A passively correctible pronation contracture can be corrected safely and effectively by the transfer of pronator teres

Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly. Posterior spinal fusion alone in the rapidly progressing congenital deformity may not prevent further progression, particularly in those cases iwth unilateral bars. Anterior resection of the vertebral body with later posterior fusion with Harrington instrumentation is safe and effective

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion

We determined the frequency, rate and extent of development of scoliosis (coronal plane deformity) in wheelchair-dependent patients with Duchenne muscular dystrophy (DMD) who were not receiving steroid treatment. We also assessed kyphosis and lordosis (sagittal plane deformity). The extent of scoliosis was assessed on sitting anteroposterior (AP) spinal radiographs in 88 consecutive non-ambulatory patients with DMD. Radiographs were studied from the time the patients became wheelchair-dependent until the time of spinal fusion, or the latest assessment if surgery was not undertaken. Progression was estimated using a longitudinal mixed-model regression analysis to handle repeated measurements. Scoliosis ≥ 10° occurred in 85 of 88 patients (97%), ≥ 20° in 78 of 88 (89%) and ≥ 30° in 66 of 88 patients (75%). The fitted longitudinal model revealed that time in a wheelchair was a highly significant predictor of the magnitude of the curve, independent of the age of the patient (p <  0.001). Scoliosis developed in virtually all DMD patients not receiving steroids once they became wheelchair-dependent, and the degree of deformity deteriorated over time. In general, scoliosis increased at a constant rate, beginning at the time of wheelchair-dependency (p < 0.001). In some there was no scoliosis for as long as three years after dependency, but scoliosis then developed and increased at a constant rate. Some patients showed a rapid increase in the rate of progression of the curve after a few years – the clinical phenomenon of a rapidly collapsing curve over a few months. A sagittal plane kyphotic deformity was seen in 37 of 60 patients (62%) with appropriate radiographs, with 23 (38%) showing lumbar lordosis (16 (27%) abnormal and seven (11%) normal). This study provides a baseline to assess the effects of steroids and other forms of treatment on the natural history of scoliosis in patients with DMD, and an approach to assessing spinal deformity in the coronal and sagittal planes in wheelchair-dependent patients with other neuromuscular disorders. Cite this article: Bone Joint J 2014;96-B:100–5

Patients with acetabular dysplasia commonly undergo peri-acetabular osteotomy after skeletal maturity to reduce the risk of the late development of osteoarthritis. Several studies have suggested that deformity of the femoral head influences the long-term outcome. We radiologically examined 224 hips in 112 patients with acetabular dysplasia and early-stage osteoarthritis. There were 103 women and nine men with a mean age of 37.6 years (18 to 49). A total of 201 hips were placed in the acetabular dysplasia group and 23 in a normal group. The centre–edge angle and acetabular head index were significantly smaller (both p < 0.001), and the acetabular angle, acetabular roof angle and roundness index were significantly greater in the acetabular dysplasia group than those in the normal group (all p < 0.001). There were significant correlations between the roundness index and other parameters. Femoral head shape may be influenced by the severity of the acetabular dysplasia. Cite this article: Bone Joint J 2013;95-B:1192–6

We reviewed 36 cases of forearm deformity caused by multiple osteochondromas in 30 patients and classified them into three types: Type I showed a combination of ulnar shortening and bowing of the radius secondary to osteochondromas of the distal ulna (22 forearms). Type II showed dislocation of the radial head, either with osteochondromas of the proximal radius (Type IIa, two forearms) or secondary to more distal involvement (Type IIb, five forearms). Type III had relative radial shortening due to osteochrondromas at the distal radius (seven forearms). Operations were performed on 16 forearms in 13 patients, with 92% of satisfactory results. For Type I deformity, excision of osteochondromas, immediate ulnar lengthening and corrective osteotomy of the radius are recommended. For Type IIa, excision of the radial head is necessary, and for Type IIb, we advise gradual lengthening of the ulna using an external fixator. Excision of osteochondromas alone gave good results in Type III deformity. Our classification gives a reliable indication of the prognosis and is a guide to the choice of surgical treatment

We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis tendon transfer, split posterior tibialis transfer or a combination of these for recurrent deformity. We concluded that selective soft-tissue release can provide satisfactory early results after failure of initial treatment of clubfoot by the Ponseti method, but long-term follow-up to skeletal maturity will be necessary

We reviewed the results of anterior hip release for fixed flexion deformity in 57 hips in 38 children with spina bifida at an average follow-up of 8.9 years (2 to 22). The indication for this operation was a fixed flexion deformity of more than 30° which interfered with function. In 43 hips there was a good outcome in that the fixed flexion deformity remained less than 30° at follow-up. Four hips had a good initial result but deteriorated after an average of five years, and ten had a poor outcome with deformity of over 30°. Six hips required a repeated anterior hip release and two of these were successful. The success of anterior hip release could not be related to the neurological level or the age at operation. Successful surgery correlated with the walking ability of the child at the latest follow-up