Congenital dislocation of the knee at birth - Part I: Clinical signs and classification.

INTRODUCTION: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period. HYPOTHESIS: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria. MATERIAL AND METHODS: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III. CONCLUSION: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors.

INTRODUCTION: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis. MATERIAL AND METHODS: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees. CONCLUSION: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Recurrent club-foot deformity following previous soft-tissue release: mid-term outcome after revision surgery.

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds. The results were independent of the age at which revision was undertaken.