Confirmation of arterial deficiencies in a limb with necrosis following clubfoot surgery.

This study describes postoperative necrosis of the hallux and first ray in a child with clubfoot. Arteriography performed on this child's lower limbs demonstrated, in the operated leg, hypoplasia of both the anterior and posterior tibial arteries and failure of the dorsalis pedis artery to traverse the tarsus and complete the deep plantar arch. Previously, congenital vascular deficiency was suggested to predispose such operated limbs to necrosis. These findings confirm the association between vascular deficiency and necrosis. In this present study, the metabolic demands of wound healing were sufficient in a limb with vascular deficiency to cause localized distal hypoperfusion leading to cyanosis and necrosis of the hallux and medial foot.

Arterial abnormalities in talipes equinovarus as assessed by angiography and the Doppler technique.

Preoperative angiography in 30 uncorrected clubfeet demonstrated abnormal vascular patterns in all but two limbs with hypoplasia or premature termination of the anterior tibial and medial plantar arteries in the remainder. Postoperative Doppler studies in nine of the limbs with abnormal vessels indicated that these arteries were present. We suggest that the continuous-wave Doppler technique is less useful for identifying major arteries than either dissection or angiography. Furthermore, arterial dysgenesis may play a role in the etiology of clubfoot. Since the posterior tibial artery usually provides the sole arterial supply to the foot, this vessel must be preserved at surgery and during subsequent ankle dorsiflexion.

Anterolateral approach for moderate to severe slipped capital femoral epiphysis.

The efficacy of the anterolateral pinning of moderate and severe slipped capital femoral epiphysis (SCFE) was studied both mechanically and clinically. The mechanical stability of anterolateral pinning was equivalent to that of conventional lateral pinning as shown by study in 16 immature porcine hips. The clinical results in the group pinned from the anterolateral approach were superior in that fewer complications occurred as compared with the traditional lateral approach. The group with anterolateral pinning had 2 complications in 13 hips, whereas lateral pinnings resulted in 8 complications in 28 hips. We recommend the anterolateral approach rather than the conventional lateral approach in pinning of moderate and severe SCFE.

Gage's sign--revisited!

This article describes the use of the eponym "Gage's sign," one of the "at-risk" signs in Legg-Calvé-Perthes disease, described by Catterall in 1971. Catterall's description of this radiographic finding differs from the radiographic finding described by Gage in 1933. Thus, what we have come to call Gage's sign would be more appropriately called "Catterall's sign."

Accurate correction in rotational osteotomies.

A method for controlling the degree of rotational correction in rotational osteotomies of long bones is presented. The formula L = 0.017QR has been derived, where Q is the desired angle of correction in degrees, R is the radius of the bone as measured on standard roentgenograms, and L is the distance between marks on the two rotated segments of the surgical specimen. The method is easy, accurate, and reproducible and has been experimentally confirmed on both an acrylic pipe and cadaveric femurs. This technique is useful for controlling rotational correction in osteotomies of all long bones.

Congenital arterial malformations associated with clubfoot. A report of two cases.

Arteriograms were examined in three limbs of two patients who had talipes equinovarus. An abnormal arterial pattern characterized by severe diminution in the size of the anterior tibial artery and diminution or absence of the dorsalis pedis artery was evident. Inasmuch as one of these patients was preambulatory, the arterial malformation is congenital and would not have been acquired in walking. The relationship between the abnormal arterial and bony pattern in talipes equinovarus is comparable to that previously described for congenital absence of the fibula. A possible etiologic relationship between TEV and embryonic arterial accidents is suggested.

Determination of the Catterall classification in Legg-Calvé-Perthes disease.

Fifty hips in forty-four children with Legg-Calvé-Perthes disease, treated at the Shriners Hospital for Crippled Children, San Francisco, were evaluated with a simplified method of Catterall's classification. Our data indicate that the Catterall rating changed in 40 per cent of the hips when they were classified before they had reached the fragmentation stage of Waldenström compared with only 6 per cent when they were classified after fragmentation had occurred.

An analysis of residual deformity in club feet submitted to early operation.

The contributions made by metatarsus primus varus, medial subluxation of the navicular, and angulation of the neck of the talus to the residual deformity in treated club feet were assessed from radiographs. Their relation to the appearance of the feet, to the age of the patient, to the results of operations, and to the age at the time of the first operation were investigated. Lateral rotation of the ankle and flattening of the talus were also studied. Medial subluxation of the navicular was found to be the most important factor influencing both the appearance of the feet and the lateral rotation of the ankle. Relocation of the talonavicular joint correlated with the success of operative treatment; and the timing of the primary operation determined the degree of relocation which could be achieved. Metatarsus primus varus and angulation of the talus were of little importance. Increased emphasis is given to the need for early relocation of the talonavicular joint.

The results of early operation in talipes quino-varus. A preliminary report.

The results of operation performed within the first six months of life upon seventy-seven resistant club feet are presented. The indications for and the rationale of early operation are discussed. Particular attention has been paid to the relationship between the age at operation and the outcome more than four years later; the results were greatly superior when operation was undertaken early. Two surgical techniques are compared, the postero-medial release proving better than a simple posterior release. The relationship between clinical and radiological assessment is discussed, and also the influence of the results reported upon future practice.