Percutaneous Pediatric Foot and Ankle Surgery.

The techniques for performing percutaneous osteotomies in treating deformities of the foot in children are presented along with a detailed description of the operative details. The author's use of minimal-access surgery for tibial, os calcis, and midfoot osteotomies is described using a cooled side-cutting burr that has not previously been described for use in the child's foot. The cancellous nature of the bones in the child are easily cut with the burr and the adjacent soft tissues are not damaged. The early experience of the healing times are not impaired and the complications associated with percutaneous scars seem to be negligible.

Comparison of Ponseti versus surgical treatment in congenital talipes equinovarus.

In the present study we compared the rate of relapse after conservative Ponseti treatment method with that of a historical cohort who underwent conventional operative treatment. From June 2002 to December 2004, 70 patients presented with 107 clubfeet and started Ponseti treatment. Of these 70 patients, 9 (15 feet) were excluded because of a teratologic deformity. Thus, 50 patients with 75 clubfeet were studied (41 [82%] boys and 9 [18%] girls). Data were compiled from the clinic assessment forms and patient notes. All cases resulting in recasting or additional operative procedures were regarded as failure of conservative treatment. The minimum follow-up period was 2 years or failure of the Ponseti method within this period. These data were then compared with the published data from the same center, regarding relapse after the 2-stage operative method. From 1988 to 1995, 86 patients had presented with 120 clubfeet and undergone operative treatment. Of the 86 patients, 68 (91 clubfeet; 48 boys and 20 girls) underwent the 2-stage operative procedure and were followed up to a mean age of 5.7 (range 2.2 to 9.6) years. The mean age at operative treatment was 8.9 months. The relapse rate of both treatment methods was compared for all feet in all Dimeglio grades. The relapse rate for Ponseti versus surgery was 18.2% versus 0% for grade 2, 36.2% versus 20.4% for grade 3, and 35.3% versus 65.4% for grade 4, respectively. No statistically significant difference was found. The Ponseti method is as valid as the 2-stage operative method for the treatment of clubfoot. The functional outcomes of the 2 treatment methods need to be compared.

Residual clubfoot in children.

The deformities encountered in any patient who has residual clubfoot comprise various degrees of equinus, varus, adduction, supination, cavus, and toe deformity. Joint flexibility or stiffness, tarsal dysmorphism, articular incongruence, and progressive degrees of degeneration may be present. Add to this the scars of previous attempts at correction and various etiologic factors, and surgeons can find that treatment solutions are far from straightforward. A philosophy of careful history, examination, investigation, and surgery à la carte will provide a safe foundation for treating patients who have these often complex and difficult problems. A surgical strategy progressing from proximal to distal, performing soft tissue surgery before fixed deformity occurs, extra-articular osteotomies to correct bony deformity, and augmentation with rebalancing of soft tissue-deforming forces will help improve pain and function for many patients. Joint fusions should be reserved as a last salvage option to avoid future degeneration of adjacent joints.

Relapse rates following staged surgery in the treatment of recalcitrant talipes equinovarus: 9- to 16-year outcome study.

PURPOSE: We aimed to identify the long-term rate of relapse of deformity in a cohort of children with talipes equinovarus and to correlate it with pre-operative grading. METHODS: Between 1988 and 1995, 120 club feet in 86 patients were surgically treated. A review at an average follow-up of 11.5 years (range 9-16 years) was performed. Of 59 of the children, 69 feet were assessed clinically and data for the remaining 20 children (30 feet) were obtained from the records. The patients were assessed using the method of Bensahel and Dimeglio but radiological analysis was omitted. Functional and morphological evaluation was recorded. RESULTS: Initial grades were grade 2 in 26 feet (26%), grade 3 in 48 feet (49%) and grade 4 in 25 feet (25%). Relapse occurred in one case in grade 2 (3.8%), 13 feet in grade 3 (27%) and in 19 in grade 4 (76%). Since an initial review in 1997, a further 12.5% of grade 3 and 25% of grade 4 feet have relapsed. Overall function did not correlate with severity of deformity. CONCLUSION: Relapse continues to occur after surgery during the first decade. There is a high rate of relapse (76%) in grade 4 feet.

Wound problems in surgery for talipes equinovarus.

The traditional treatment for talipes equinovarus (TEV) has been open surgery in many units around the world. The complication rates for primary corrective surgery are relatively small but may affect outcome significantly. The complications of surgery in relapsed TEV are more frequent than for primary surgery, and problems relating to wound healing present difficult challenges to the treating surgeon. An overview of the approaches to management of this still challenging condition are presented, and the factors involved in wound healing problems and strategies for their prevention and treatment are presented. In particular, the belated but rapid spread worldwide of the Ponseti nonoperative approach to treating talipes is the most important factor in reducing the rates of surgery and therefore the complications that may ensue.

Low-intensity ultrasound stimulation in distraction osteogenesis in rabbits.

Low-intensity pulsed ultrasound has been shown to accelerate fracture healing. This experiment investigated its possible role in distraction. Thirty-four New Zealand White rabbits had distraction osteogenesis, followed by low-intensity pulsed ultrasound therapy. Seventeen animals had the ultrasound transducer switched off (controls). Four and 6 weeks postoperatively, tibiae were analyzed using quantitative computed tomography and four-point mechanical testing. Two tibiae from each group had histologic analysis at 4 weeks. No significant differences were identified between regenerates of ultrasound-treated and control groups with respect to bone mineral content, cross-sectional area, and strength. No significant reductions in osteopenia proximal and distal to the regenerate were observed. Histologic observation showed no differences in bone volume fraction, but ultrasound-treated regenerates appeared to have fewer trabeculae of increased thickness, and fewer osteoclasts. The modulation by ultrasound may occur by accelerating endochondral ossification through action on chondrocytes, yet distraction osteogenesis is largely intramembranous. Although ultrasound is proven to be effective in unconstrained systems such as plaster, the current study does not support the role of low-intensity pulsed ultrasound as an adjunct for patients having distraction osteogenesis in a rigid fixator. Additional research is needed to definitively support the use of low-intensity pulsed ultrasound in such situations.

Clinical and functional outcome of relapse surgery in severe congenital talipes equinovarus.

From a cohort of 110 idiopathic clubfeet, 26 feet in 18 children requiring surgery for severe relapse have been studied. Surgery comprised a lateral column shortening procedure (Lichtblau) plus or minus a plantarmedial release. Surgery was staged to avoid wound complications. Preoperatively feet were prospectively categorized, according to a system reported by Dimeglio, into one of four grades. This grading system provides a clinical assessment. Children were reviewed on two subsequent occasions. At review feet were again graded and in addition appearance and functional outcome were analysed. This included an assessment of gait, activity and functional limitation. Three children were lost to follow-up leaving 22 feet in seven male and eight female patients available for review. The mean age at surgery was 43 months (23-82 months). The mean time from surgery to first and second reviews was 35 and 56 months respectively. There was a significant improvement in grading at first review compared with preoperative grading (Wilcoxon signed ranks test). Although there remained a significant improvement in grading at second review compared with the preoperative grading, there was a significant reduction in the number of feet in which grading had improved when compared with first review. There was no significant change in function between the two postoperative reviews, with the majority of children experiencing little functional limitation. There were no wound complications. We conclude that relapse surgery, involving a lateral column shortening procedure for severe clubfoot, results in a significant initial improvement when assessed using a grading system. This improvement in grading subsequently decreases over time. However, the functional outcome in such cases remains favourable.