Upper tibial coronal plane - oblique osteotomy for deformity correction in Blount's disease

Correction of tibia vara deformity entails correction of varus and internal rotation deformities. In small children, the use of internal fixation is not desirable to avoid physeal violation; also, external fixator may not be applicable. Then, the osteotomy should be inherently stable, corrects all elements of deformity and allows post-operative adjustments of position. Oblique osteotomy has been described to perform varus derotation of the proximal femur and to correct varus internal rotation of the tibia in Blount's disease. The present study included 16 children. In ten patients the deformity was bilateral and it was unilateral in the other six patients, with a total of 26 tibiae. The youngest child was three years old and the oldest was 12 years old. The procedure included coronal plane oblique osteotomy starting distal to the tibial tubercle and runs up to the posterior tibial metaphysis just distal to the epiphyseal plate. A single fixation screw was used for limited internal fixation in the sagittal plane to allow post-operative position correction by cast wedging. All osteotomies healed within 12 weeks. The deformities were corrected with ten degrees of over-correction of varus deformity. In two patients post-operative weakness of extensor hallucis longus occurred which resolved within one week. Upper tibial oblique osteotomy in the coronal plane has the advantages of correction of all deformity elements with minimal internal fixation, at the same time allows post-operative adjustments which are desirable in small children

Early surgical extended posterior soft tissue release operation for club feet [CTEV]

This paper report the result of treatment of 33 club feet by early manipulation and proper timed sequential extended posterolateral soft tissue release operation avoiding extensive release and late talar distorsion. Correction was maintained by serial retension casts. The result of this simpler operative technique for 29 feet was satisfactory [19 feet [66%] had excellent, 9 feet [31%] had good and one foot [3%] had poor end result]. The indication and rational of the posterolateral release operation was discussed. The relationship between the age at operation, the severity of the initial deformity, the degree of the extended release, the postoperative cast retension period, the degree of ankle motion, the length of the follow up period and the patient subjective assessment in relation to functional outcome was discussed. The foot was assessed functionally, roentgenographically and by foot printing study after 27.5 months average follow up period. The results were greatly superior when the operation was done during the first six months [11 feet had excellent result out of 12]. The earlier the operation was done [within 6 months] the least interference was needed for posterolateral release step after operation the feet had the maximum opportunity to establish normal architectural relationship. Retension cast for longer period [6 months at least] improved the functional outcome and prevented early recurrence [early tight tendoachillis]. The range of ankle movement was the major factor determining the functional outcome. Excellent result obtained mean increased range of 32 degrees and good result obtained 25 degrees dorsiflexion range. The functional rating was also related to the standing heel position, and squalling ability. All patient's relative were satisfied with both the appearance and function of the foot. The radiological assessment was discussed in relation to functional outcome. Improvement in the lateral talocalcaneal [T.C.] angle and T.C. index [above 40 degrees] were corresponding to satisfactory functional results and contributing to satisfaction. T.C. index below 40 degrees is an indication for careful supervision to prevent early recurrence. There was no special risk after early operation for the foot or the patients. In minor percentage [3%] the ankle and foot motion was limited and the talo-calcaneal index was undercorrected the functional end result after the operation was good enough to recommend the indicated posterolateral release step for all patients under the age of 12 months and for severer deformity to improve the end result. This should be followed by long period of careful supervision clinically, roentgenographically and foot printing study. It is hoped that this procedure will give rise to higher percentage of correction and satisfactory functional end result in the future to minimise the need for further bony operations