Operative treatment of paralytic hip dislocation in myelomeningocele by Dega transiliac osteotomy combined with iliopsoas transfer: technique and historical case series.

The technique of one stage procedure - open reduction, Dega transiliac with or without femoral subtrochanteric osteotomy combined with iliopsoas transfer according to Mustard - has been described for the treatment of paralytic dislocation of the hip in myelomeningocele patients. Historical series of 16 children (26 hips) operated on between 1987 and 2003 were analyzed retrospectively. There were nine boys and seven girls with upper and lower lumbar level lesions (15 with Sharrard groups 3 and 4 and one with Sharrard 2) and 20 dislocated and six subluxated hips. The mean age at operation was 5.1 years (3-12.3). Ten children were operated bilaterally. Follow-up ranged from 1 to 17 years (mean 10). Concentric reduction was achieved in 23 hips, subluxation in 1 and redislocation in 2. In one hip, acute avascular necrosis of the femoral head was visible early after operation. Immediately after the operation, most of the patients improved ambulation. After operation, 15 patients out of 16 became community ambulators. At the final follow-up, none of the patients worsened their ambulation due to operation. Open reduction and Dega transiliac osteotomy with or without subtrochanteric derotation/varus shortening osteotomy combined with iliopsoas transfer seem to be safe and valuable procedure for operative treatment of dislocated hip in myelomeningocele patients. Levels of evidence: level IV - case series.

The significance of the Dega osteotomy.

Wiktor Dega has significantly impacted contemporary pediatric orthopedics by developing transiliac osteotomy - Dega's pelvic osteotomy. The global implementation of the surgery technique gained dynamism in the 2000s after being published by Ward and Grudziak. Since then, derivative operative techniques called Dega, Dega-like or Dega family osteotomies have been developed. We analyzed the original articles published by Dega between 1929 and 1974 concerning transiliac osteotomy technique development and articles about its derivatives. The epidemiological significance of developmental hip dysplasia focused Wiktor Dega's attention in the 1920s. At that time, he treated patients according to König's idea of acetabular roof plastic surgery. The osteotomy depth gradually increased, which allowed deeper graft placement to perform what we nowadays call acetabuloplasty. In 1958, Dega coined the name 'supraacetabular semicircular osteotomy'. It differed from the final concept of the transiliac osteotomy by not assuming the cut of the inner cortex of the iliac bone. The hinge for the acetabular rotation was located at the inner cortex's whole length, disallowing the excessive redirection. The final concept of osteotomy allows for simultaneous acetabuloplasty and redirection to change the shape, location and acetabular volume. Dega derivatives are Mubarak (San Diego) and high Dega osteotomies. Dega osteotomy and its derivates are routinely implemented to treat developmental hip dysplasia and spastic hip disorders. It might be considered an option in Legg-Calve-Perthes disease, congenital deficiencies, and flaccid hip displacement in neurological conditions.

Ankle arthrodesis from lateral transfibular approach: analysis of treatment results of 23 feet treated by the modified Mann's technique.

BACKGROUND: The aim of the study was to analyze the results of treatment by ankle arthrodesis by modified Mann's technique. METHODS: The study included 23 patients, and a total of 23 feet were treated. Stabilization of arthrodesis was performed by two screws going from the sinus tarsi to the talus and tibia. Lateral part of the fibula was fixed with one or two screws to the talus and tibia. No additional medial approach to the ankle was performed. In 16 feet, arthrodesis was done due to secondary posttraumatic osteoarthritis, in five due to paralytic drop foot and in two due to osteoarthritis of unknown etiology. In 18 patients, the purpose of arthrodesis was also to correct the malalignment. The average age at operation was 46 (range 19-74) years. The average follow-up was 32 (range 12-69) months. RESULTS: At follow-up, the average AOFAS score was 76 points and subjective scale result 7.9 points. The correct alignment was not achieved in three feet. In one foot, fusion was not achieved and the patient needed repeated operation. CONCLUSIONS: The study has confirmed the effectiveness of the technique.

Surgical Treatment of Active Amniotic Band Syndrome (ABS) by Z-plasty and Radical Excision of the Overgrown Tissue: A Report of 2 Cases With Progressive Lymphedema Causing Vascular Insufficiency.

UNLABELLED: The study describes 2 children at risk of limb amputation due to lower extremity active amniotic band syndrome, in which the constriction bands were released surgically using the extensive approach. Both patients presented almost the same clinical appearance: a deep constriction band localized in one third of the distal part of the leg and a pseudoconstriction at the ankle joint level resulting from the tightening of the retinaculum of extensors. In both the cases, after birth amniotic band syndrome caused progressive enlargement of the distal part of the foot, which was associated with edema and vascular insufficiency. Case 1, at the age of 3 months, underwent a primary excision and Z-plasty of the proximal constriction band, and after 6 weeks a secondary excision was performed covering the soft tissue bulk from the dorsal part of the foot formed due to vascular insufficiency progression. In contrast, case 2 underwent a more radical 1-staged surgery at the age of 4 weeks, that is, an excision and Z-plasty of the proximal constriction and the same radical excision of the soft tissue bulk. In addition, in both patients decompression fasciotomy was performed. A follow-up after surgery, respectively, at the age of 20 and 5 years, revealed a fully functional foot and restoration of blood supply. Thus, the 1-staged radical excision of constrictions combined with removal of the overgrown skin and pathologic soft tissue can be recommended for similar cases. LEVELS OF EVIDENCE: Level IV-case series.

Joint preserving surgery versus arthrodesis in operative treatment of patients with neuromuscular polyneuropathy: questionnaire assessment.

The purpose of the paper was to present the results of surgical treatment of foot deformities in peripheral neuropathies using bone procedures: both joint preserving and with joint arthrodesis. The study included 26 patients, 14 males and 12 females (43 feet). The age of the patients at surgery ranged from 5 to 55 years (average 23 years). The follow-up ranged from 0.5 to 15 years (average 4.3 years). Seventeen patients presented Charcot-Marie-Tooth disease, three Friedreich's ataxia and six peripheral motor and sensory neuropathies of undetermined nature. Sixteen patients had bilateral procedures. Four patients had to be re-operated during the follow-up. The patients were divided into four groups depending on the age and the surgical technique applied. The groups I and II (9 children, 17 feet) included patients with growth plate still present in the foot just before surgery. In the groups III and IV (17 adults, 26 feet), bone growth was completed. The assessment of all patients based on a modified AOFAS scale ranged from 44 to 105 points (mean 83.7; SD 17.5). The assessment on the subjective scale ranged from 3 to 10 points (mean 7.4; SD 2.1). The assessment of quality of life on the WOMAC scale ranged from 0 to 41 points (mean 15.7; SD 13.2). All patients stated that they would decide to undergo the treatment again. For groups I and II, joint preserving surgeries gave better results; however, the results could not be statistically confirmed. The results for the groups III and IV were inconclusive as to which surgical techniques should be preferred, arthrodesis or joint preserving. The results show that none of the surgical techniques used for correction of foot deformities in motor-sensory polyneuropathies seems to be preferable.

Congenital posteromedial bowing of the tibia and fibula: treatment option by multilevel osteotomy.

Few papers have described patients treated surgically with single osteotomy for congenital posteromedial bowing of the tibia and fibula. Only one paper has described two-level osteotomy for deformity correction: the first for deformity correction and the second for bone lengthening. There are no publications describing the surgical correction of deformation only by the method of multilevel tibial and fibular osteotomy. Research material included four children aged between 3.1 and 5.1 years (average age: 3.7 years) who were operated upon for bowing of the tibia and fibula exceeding 35° in the coronal plane. In all cases, tibial osteotomy was carried out at three or two levels accompanied by fibular osteotomy, and with intramedullary stabilization using K-wires (three patients) or Rush pin (one patient). Follow-up ranged from 3 to 7.7 years. In all cases, axis correction and bone healing were achieved. In large congenital posteromedial bowing of the tibia and fibula, a multilevel tibial and fibular osteotomy may be a better solution than an orthosis or a long time waiting for a spontaneous correction of the deformation. Large circumferential periosteal release that accompanied the surgery influenced the stimulation of bone growth. It may induce the process of lower limbs' equalization not to require the application of intensive surgical procedures.

Knowledge of participants of the 5th Polish Foot and Ankle Society (PFAS) Congress about the diagnosis and treatment of plano-valgus feet secondary to posterior tibial tendon dysfunction (PTTD).

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) ranks among the most common causes of adult acquired flatfoot deformity. The deformity develops gradually through characteristic stages and its early manifestations are often ignored or mis-diagnosed. The aim of the study was to gain an insight into what the participants of the 5th Polish Foot and Ankle Society Congress knew about the diagnosis and treatment of flatfoot. MATERIAL AND METHODS: An anonymous survey described the clinical presentation of a hypothetical patient with fixed stage III (according to the Johnson and Strom classification) acquired flatfoot deformity in PTTD. A total of 65 questionnaires were distributed and 51 (78%) were completed and returned. The respondents included 40 orthopaedics consultants and 11 orthopaedics and traumatology resident doctors. The mean time of work experience of the specialists was 17.5 years and that of resident doctors, 3.5 years. RESULTS: The deformity was properly diagnosed by 36 respondents (71%), including 29 specialists (73%) and 7 resident doctors (63%). Proper operative treatment was selected by 28 respondents (52%): 24 specialists (60%) and 4 residents (36%). Overall, appropriate comprehensive diagnostic work-up and treatment was planned only by 19 respondents (35%), including 17 specialists (32%) and 2 residents (4%). Appropriate diagnostic work-up and treatment of acquired flatfoot deformity in PTTD was planned by less than half of the respondents and their work experience did not have any relation with the management they suggested. CONCLUSIONS: 1. There is a significant lack of knowledge about PTTD among residents. 2. The majority of PFAS members surveyed selected the correct method of diagnostic work-up and treatment, but the differences with respect to non-PFAS respondents were not statistically significant.

Methods of diagnosis and treatment of ankle fractures--the opinion of members and supporters of the Polish Foot and Ankle Society.

BACKGROUND: The present paper is based on a survey distributed among the participants of the 3rd Congress of the Polish Foot and Ankle Society in Jastarnia on April 22-24, 2010. MATERIAL AND METHODS: A clinical description and imaging data of a hypothetical patient with a typical ankle fracture were used to identify current methods of diagnosis and treatment of such injuries in Poland. The participants were orthopaedists. Eighty-five questionnaires were distributed and 54 (63%) were completed and returned. RESULTS AND CONCLUSIONS: Most respondents correctly recognized the fracture mechanism and identified the type of fracture. They preferred operative treatment, but were not able to apply the AO classification. The answers regarding post-operative radiological follow-up did not provide for long-term follow-up and the suggested methods of imaging to detect disruption of the tibiofibular syndesmosis were insufficient. The recommendations concerning the timing and staging of post-operative weight bearing as well as antithrombotic prophylaxis complied with current standards.

Triple arthrodesis of the foot after calcaneal fractures. Twelve patients treated using K wires stabilization.

The most frequent problem following intra-articular calcaneal fracture is pain from the subtalar joint. Subtalar arthrodesis is not considered to be an optimal solution because it can lead to degenerative changes in the ankle joint. The aim of this study was to evaluate patients with such fractures treated by triple arthrodesis. The treated group consisted of 12 patients (5 female, 7 male) with no bilateral fractures. The mean age at injury was 36 years (22-54). The patients had surgery 2 years on average after injury. In all cases the arthrodesis was stabilized with Kirschner wires. The follow-up ranged from 1 to 5 years (average 2.9 ± 1.4). In 2 feet the calcaneal fracture was associated with a fracture of the talus. At clinical evaluation the Ankle-Hindfoot Scale (AOFAS) was applied. From the 100 point scale the question concerning movement in the subtalar joint was removed which made the scale range from 0 to 94 points. Postoperative scoring ranged from 19 to 92 points (mean 57.3 ± 25.1). The patients also evaluated the result of treatment on a visual analogue scale from 0 to 10 points which gave a mean score of 7.7 ± 2.2. Early results of the treatment of calcaneal fractures by triple arthrodesis show that this is valuable method for the prevention of significant foot pain.

Corrective arthrodesis to treat sequelae of compartment syndrome and ischaemic syndromes of lower leg and foot.

BACKGROUND: There is a scarcity of studies concerning the treatment of foot and talocrural deformities secondary to a compartment syndrome or ischaemia. MATERIAL AND METHODS: Five patients (4 males and 1 female) were treated by talocrural arthrodesis (1 foot) and triple tarsal arthrodesis (4 feet) due to equinovarus foot deformity secondary to compartment syndrome or ischaemia. The age at surgery ranged 28 to 50 years (mean 39 years). The deformity was a sequela to compartment syndrome due to an injury in 3 patients, popliteal artery damage in one male patient, and an embolism in the femoral artery during hip arthroplasty in one female patient. The evaluation of the results was based on the AOFAS Ankle-Hindfoot Scale functional scoring system and a subjective assessment of treatment outcomes according to a 10-grade scale (from 0 [worst] to 10 [best], no visualization). RESULTS: A complete correction of the deformity was achieved in 4 patients. A superficial infection and a prolonged healing process of the post-operative wound after the surgery occurred only in one (female) patient. The same patient had a slight persistent varus deformity in the rigid talocrural joint. The mean post-operative AOFAS score was 66.4 (35-86) and 8.4 (5-10) in the subjective scale. CONCLUSIONS: Corrective arthrodesis is an effective method of correction of foot deformities secondary to compartment syndrome and ischaemic syndromes. No significant post-operative complications were noted.

[Arthrodesis of the lisfranc joint as salvage procedure after trauma injury]. / Artrodeza stawu Lisfranca w leczeniu pourazowych zmian zwyrodnieniowo-znieksztalcjacych.

Dislocations and fractures of the tarsometatarsal joints (Lisfranc joint) are rare, often non properly diagnosed and treated. Lack of proper diagnosis and postponed operative treatment causes painful deformity of the foot. There are presented results of operative treatment in 6 patients (6 feet) with fracture/dislocation of the Lisfranc joint. In all of them arthrodesis as salavage procedure was performed. Age at the fracture/dislocation ranged from 13 to 58 years. After trauma no one was treated operatively. Injury was overlooked in 2 patients. Indications for arthrodesis were pain causing limping as well flattening and abduction deformity fo the foot. Arthrodesis was performed from 1 to 39 years after trauma. It was closing wedge resection of the Lisfranc joint, stabilization with Kischner wires for 6 weeks and below knee plaster cast for 3 months. Follow-up ranged from 14 to 52 months. Functional results in AOFAS scale ranged from 6 do 90 points (mean 63 points) of 100. Subjective results ranged from 1 to 8 points (mean 5.6 points) of 10. Two females were not satisfied with the results of treament.

[Surgical treatment of hallux valgus in Poland---analysis based on opinion of Polish Foot and Ankle Society members]. / Techniki operacyjnego leczenia paluchów koslawych stosowane w Polsce--na podstawie opinii czlonków Polskiego Towarzystwa Stopy i Stawu Skokowo-Goleniowego.

The purpose of this study was to determine the current techniques of hallux valgus surgery by orthopaedic surgeons who have special interest in foot and ankle problems in their daily practice. The questionnaire survey was conducted during I-st Polish Foot and Ankle Society Congress which took place in Jastarnia on 2 to 4 of October 2008. The pictures of two hypothetical patients were created, with moderate and severe hallux valgus deformity. Participants were asked for a brief description of the prefferd surgical technique, performed on the individual forefoot segment in each of the cases. Of the 84 questionnaires distributed among participants authors received 52 (61%) answers about patients with moderate and 54 (64%) with severe hallux valgus. The most frequently proposed technique in patient with moderate hallux valgus was distal chevron osteotomy (50%). In the second patient respondents suggested a wide variety of surgical techniques like metatarsocuneiform joint arthrodesis (Lapidus procedure), scarf osteotomy and double level osteotomy of the Ist metatarsal. All orthopaedic surgeons, taking part in the survey, considered necessary to perform osteotomy of the Ist metetarsal bone, in cases of surgical treatment of moderate and severe form of hallux valgus. A change in stabilization method was noticed -- Kirschner wires are displaced by the screws and the plates.

[Triple arthrodesis of the foot after treated talar fracture--report of 3 cases]. / Potrójna artrodeza stepu po leczonym zlamaniu kosci skokowej--opis 3 przypadków.

Fracture of the talus, especially talar neck associated with talar dome necrosis, due to serious disorders of the ankle and subtalar joints. Disorders are so great that they often suggest to perform arthrodesis of the ankle joint. Disorders of subtalar joint are not so much visible on standard X-rays. Results of triple arthodesis performed in 3 patients (3 feet) because of talar fracture sequele were reported. In 1 femal talar fracture was combined with calcaneal fracture in the same foot. Age at trauma ranged from 22 do 31 years (mean 27). Indications for secondary operative treatment were mainly clinical criterias as subtalar pain and in 1 male additionaly varus deformity of the foot. Feet were stabilized by K wires going both through Chopart and ankle joints. Follow-up ranged from 35 to 50 months. Functional results in modyfied AOFAS scale ranged from 43 to 81 points (mean 65) of 94. Subjective results ranged from 7 to 10 points (mean 8) of 10. At follow-up examination no one reported restricted range of motion in the ankle joint in comparison to pre operation as well no any progression of osteoarthritis was visible on x-rays.

Intravertebral deformation in idiopathic scoliosis: a transverse plane computer tomographic study.

BACKGROUND: The scoliotic vertebrae are submitted to (1) the displacement in the 3-dimensional space and (2) the bone remodeling, which results in a 3-dimensional intrinsic vertebral deformation. Both phenomena are most expressed inside the apical zone of the curve and can be measured in a computer tomographic (CT) scan. A comparative study of CT thoracic scans in scoliotic and normal children was performed to provide a better description of the altered anatomy with respect to patomechanism of scoliosis. METHODS: Twenty-three scoliotic girls, aged 14.3 +/- 2.1 years, a case of a right thoracic curve with a Cobb angle of 60.6 +/- 19.3 degrees, and 24 controls, free of spinal deformity, sex- and age-matched, underwent CT examination of the thorax at the level of Th8 to Th9 vertebra. The rotation angle of the apical vertebra and the sagittal to coronal rib cage diameters ratio were measured. The intravertebral deformation was assessed by measuring the angles between the axis of the whole vertebra and the axes of the spinous or transverse processes. RESULTS: The ratio of sagittal to coronal chest diameter was reduced in scoliosis patients (P < 0.001) and correlated with the Cobb angle. The angle between the axis of vertebra and the spinous process increased (P = 0.008), and its value was positively correlated with the rotation angle of the vertebra (r = 0.78, P < 0.05); however, the rotation was oriented clockwise, whereas the spinous process deviation was counterclockwise. The angle between the spinous and the transverse process revealed greater values on the concave side (P < 0.001), whereas the transverse processes were not deviated from the axis of vertebra (P = 0.469). CONCLUSIONS: A constant pattern, previously not described, of the alteration of morphology of the apical vertebra due to the intravertebral bone remodeling was identified. The intravertebral deformation accompanied the displacement of the vertebra with a linear correlation; however, the 2 phenomena were developing in the opposite directions. CLINICAL RELEVANCE: Level III, cross-sectional study.

Transverse plane of apical vertebra of structural thoracic curve: vertebra displacement versus vertebral deformation.

CT transversal scans of the trunk provided at the level of Th8 or Th9 (apical vertebra) of 23 patients with structural thoracic scoliosis were reviewed. The following parameters were studied: 1) alpha angle formed by the axis of vertebra and the axis of spinous process, 2) beta concave and beta convex angle between the spinous process and the left and right transverse process respectively, 3) gamma concave and gamma convex angle between the axis of vertebra and the left and right transverse process respectively, 4) rotation angle to the sagittal plane according to Aaro and Dahlborn, 5) Cobb angle. Values of measured parameters demonstrated a common pattern of intravertebral deformity: counter clockwise deviation of the spinous process (alpha angle 15,0 +/-8,5 degrees), beta concave (69,8 +/-8,5 degrees) significantly greater than beta convex (38,8 +/-8,5 degrees), gamma concave (54,3 +/-7,8 degrees) not different from gamma convex (56,0 +/-8,0 degrees). Strong linear positive correlation between alpha angle and Aaro-Dahlborn angle was observed (r=0,78, p<0,05). Changes in morphology of apical vertebra due to intravertebral bone remodelling followed the vertebral spatial displacement and there existed a linear correlation in between. The two processes develop in opposite directions.

[Chronic exertional anterior compartment syndrome of the leg with fascial hernia--case report and review of the literature]. / Przewlekly, przeciazeniowy zespól ciasnoty przedzialów powieziowych goleni z przepuklina powieziowa--opis przypadku i omówienie pismiennictwa.

18-year-old female with chronic exertional anterior compartment syndrome was described. Pain was localized on the anterior part of the leg after long distance walking or another physical activity. Disorder was confirmed by electromyography and using Compartmental Pressure Monitor System (Stryker, USA). Intracompartmental pressure was measured three times--after rest, immediately after exercises and again after 30 min. rest. During measurement each compartment was injected by 0.2 ml 0.9% NaCl. The pressure value was noted 10 seconds later. The following values were noted: resting pressure--9 mmHg (normal 0-5 mm), immediately after exercises (active dorsal flexion of the foot)--99 mmHg (normal < 30 mm), after 30 minutes rest--29 mmHg. The patient was treated operatively by subcutaneous fasciotomy of the anterior and lateral compartment of the leg. This procedure was combined with neurolysis of the neural branches within a hernia. 6 months later at follow-up examination complete disappearing of the pain was confirmed. Chronic exertional anterior compartment syndrome should be consider in diagnostics of the lower extremity pain unknown origin in young adults (sportsmen).

The effect of the therapeutic approach on the course of Perthes' disease and its outcome: Conservative vs. surgical treatment.

Background. The aim of our study was to compare the outcome of Perthes' disease in children treated conservatively or surgically, and to attempt to answer the question as to whether surgery shortens the duration of the disease and its treatment. Material and methods. We reviewed the clinical records of 61 children with Perthes disease (68 hips) from the years 1990-1994 were reviewed. There were 11 girls and 50 boys, the mean age at the onset of the disease was 5.3 years (range from 1.6 to 12.7), and the mean follow-up was 7.8 years (from 4.2 to 10.3). 36 hips underwent surgery (Dega transiliac osteotomy combined with an interrtrochanteric osteotomy of the femur). The remaining 32 hips were treated conservatively with various methods. The Catterall and Herring classification schemes were applied for the radiological assessment of the involvement of the femoral head, and the outcomes were evaluated using Stulberg's classification. Results and Conclusions. The mean time from the onset of the disease to full weight bearing was 20 months (range from 5 to 56) in the operated hips, and 20 months (range from 5 to 51) in the non-operated hips. There was no statistically significant correlation between the end results of the conservative and operative treatment for each group assessed according to the Catterall or Herring classification schemes. However, it should be borne in mind that the operated hips were initially classified as more involved than the non-operated ones.

Double osteotomy in the surgical treatment of Perthes' disease: Dega's transiliac osteotomy and subtrochanteric osteotomy.

Background. The combination of Dega transililiac and femoral subtrochanteric is used in our department in the treatment of Legg-Calvé-Perthes' disease. Subtrochanteric osteotomy, initially performed as varus-derotation osteotomy, is now mainly extension osteotomy with shortening. Femoral shortening is crucial for joint decompression and makes room for pelvic redirection after pelvic osteotomy. Material and methods. 34 children (36 hips) were analyzed retrospectively. All children were operated using subtrochanteric osteotomy with shortening and Dega's transiliac osteotomy of the pelvis. There were several variants of subtrochanteric osteotomy: extension osteotomy only, varus-extension, extension-varus-derotation, extension-derotation, and varus-derotation. In one case only varus osteotomy was performed. Before surgery 18 hips were Catterall group IV, 14 group III and 4 group II; in the Herring classification, 24 hips were group B, 11 group C, and 1 group A. All patients were evaluated clinically and radiologically at follow-up using the Stulberg classification. The mean follow-up was 8 years. Results. In the Stulberg classification 4 hips were scored after surgery as group I, 23 as group II, 4 as group III, 4 as group IV and only 1 hip as group V. In 6 patients limping was observed, 2 patients had a positive Trendelenburg sign, and 11 a positive Duchenne sign. The mean shortening of the lower limb was 0.25 cm. Six patients complained of pain after physical activity. Conclusion. Subtrochanteric shortening osteotomy of the femur combined with Dega transiliac osteotomy is a safe and valuable procedure for surgical treatment of Perthes' disease.

Catterall and Herring classifications in assessing Perthes disease - inter- and intra-observer study.

Background. The purpose of this study was to compare the inter-observer validity and intra-observer reliability of the Catterall and Herring classification systems used in assessing pathological changes in Perthes' disease. Material and methods. The material consisted in x-rays from 58 patients (12 girls and 46 boys, 63 hips, average age 6) treated conservatively or surgically. The x-rays were assessed by a board-certified orthopedist with 19 years of experience, an orthopedist just taking board exams with 5 years of experience, and a resident. For statistical analysis we used the weighted kappa coefficient and the percentage of agreement. Results. The majority of the cases were qualified to groups II and III, and the younger observers evaluated more severely. The least inter-observer validity in both classification systems occurred between the resident and the senior physician. When the material was divided into two age groups (younger and older than 6), the validity of the Catterall scheme was similar in both groups, while in the Herring classification there was greater inter-observer validity for the older children. The Herring system shows greater intra-observer reliability overall; in the two age groups, the Catterall system shows greater reliability in the younger children, and the Herring system in the older. Conclusions. The Catterall classification system shows less validity and reliability than the Herring system, especially in reference to children older than 6. The greatest difficulties in classification decisions occur between Catterall groups II and III.

[Flexible flatfoot in children--a controversial subject]. / Stopa plaska statyczna dziecieca--kontrowersyjny temat.

In this review article authors present current opinion on flexible flatfeet in children. In young generation the incidence of flexible flatfeet is different according to investigator and evaluation method and ranges from 3 to 90 percent. The high percentage of appearance of flatfeet in healthy population is recognized mainly by investigators who are not orthopaedic surgeons. The flexible flat foot in children can be divided on developmental and static. The first one is visible in children immediately after starting walking and disappears spontaneously. The second one is associated with generalized but not pathologic soft tissue laxity. It is confirmed, that both do not need treatment. Nevertheless, the tendency for over-treatment of deformity by exercises, inserts and special shoes is observed. This kind of treatment results in costs and low effectiveness as well as psychological problems in patients. Persistent deformity does not cause worse quality of life in adulthood. Flexible flatfeet can be associated with shortening of the gastrocnemius muscle or even Achilles tendon. It results in valgus deformity of the hindfoot as compensation for the lack of dorsal flexion of the foot in the ankle joint. This deformity can be treated surgically.