The Effectiveness of Serial Casting in the Treatment of Recurrent Equinovarus in Children With Arthrogryposis.

BACKGROUND: Arthrogryposis multiplex congenita (AMC) is characterized by joint contractures in 2 or more body areas, often resulting in clubfoot deformities that are typically stiffer than those seen in idiopathic clubfoot deformities. While surgery is routinely used to treat clubfoot in AMC, it has a high rate of recurrence and complications. Current literature suggests serial casting (SC) could be useful in treating clubfoot in AMC, though evidence of its effectiveness is limited. METHODS: Passive range of motion (PROM), dynamic foot pressure, parent-reported Pediatric Outcomes Data Collection Instrument, brace tolerance, and the need for post-casting surgery were evaluated retrospectively in children with AMC treated with SC to address clubfoot deformities. Analysis of variance or paired t tests were used as appropriate on pre-casting, short-term (within 6 mo after SC) and/or longer-term (6 to 18 mo after SC) parameters to determine the effectiveness of SC. Brace tolerance before and after SC was analyzed using the Global Test for Symmetry, and medical records were reviewed to determine the need for surgery post-SC. RESULTS: Forty-six children (6.1±3.1 y old) were cast an average of 2.5±1.9 times, resulting in 206 SC episodes. PROM showed improvement in ankle dorsiflexion and forefoot abduction in the short term (P<0.05), returning to baseline measurements in the long term (P=0.09). Brace tolerance improved after casting (P<0.05). Only 15% of feet required surgery at follow-up at 10.3±5.5 years. There were no significant changes in dynamic foot pressure or Pediatric Outcomes Data Collection Instrument results after SC, except for an increase in the pain subtest (P<0.05). CONCLUSIONS: Serial casting in children with AMC can be effective in temporarily improving PROM and improving brace tolerance, but it does not impact dynamic barefoot position. Positive impact of conservative management in children with AMC can potentially delay or reduce the need for invasive surgical intervention by improving PROM and brace tolerance. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Lower Limb Deformity Correction: Analysis and Preoperative Planning.

Lower limb deformities have a wide range of presentations and require significant preparation and planning from the surgeon to correct. It is important to provide a clear and systematic approach to preoperative planning for these cases and to detail three well-established correction techniques: external fixation, plate fixation, and intramedullary nail fixation. In using a simple mnemonic that lays out the systematic analysis of various axis lines and joint angles from proximal to distal in the lower extremity, deformities can be readily identified, and correction strategies can be effectively used to produce a successful deformity correction that restores colinear alignment to the lower limb. Additional pearls and pitfalls for these techniques are also provided to assist with some of the nuances that exist in the field.

Has the Threshold for Epiphysiodesis Versus Lengthening Changed in the Era of Magnetically Controlled Nails?

INTRODUCTION: Limb length discrepancy (LLD) is common in both the pediatric and adult population. Length inequalities can be due to a multitude of etiologies including congenital, developmental, and acquired causes. There has been little consensus on the morbidity of LLD and, as a result, the threshold necessary for treatment of LLD to prevent morbidity. Advances in magnetically controlled lengthening devices achieve greater accuracy and patient satisfaction and create an opportunity to lower the threshold for limb lengthening. DISCUSSION: Asymptomatic LLD is relatively common in both pediatric and adult populations. Only ~10% of the population has equal leg length. LLD of <5 cm may lead to long-term morbidities such as scoliosis, lower back pain, gait abnormalities, stress on hip or knee joint, and lower extremity symptomatic versus asymptomatic osteoarthritis. The teaching in most orthopaedic textbooks is to adjust the shoe if symptomatic for discrepancies up to 2 cm; consider an orthotic, epiphysiodesis, or skeletal shortening for 2.5 to 5 cm; and possible limb reconstruction for >5 cm. The assumption is that there are no long-term consequences of mild LLD. However, data in recent literature show that small discrepancies may contribute to pathologic changes such as pain, gait abnormalities, and osteoarthritis. Major advances have been made in limb lengthening over the past 40 years. The increased accuracy and superior patient satisfaction of the magnetically controlled lengthening nail versus external fixation methods argue for including lengthening for LLD of <5 cm. CONCLUSION: If mild LLD can cause long-term pathology, it is important to counsel families on the full range of options for limb equalization no matter the size of the discrepancy. The evolution in technology and understanding of limb lengthening has provided additional safe surgical options. Therefore, the historic treatment protocol for addressing limb differences may need to include lengthening for smaller discrepancies even <2 cm.

Orthopedic Manifestations of Bruck Syndrome: A Case Series with Intermediate to Long-term Follow-Up.

The aim of this study was to evaluate the association of contractures, fractures, and deformities in four patients with Bruck syndrome treated in our facility. Data were collected from medical records, radiographs, dual-energy X-ray absorptiometry (DEXA) scans, genetic tests, and gait analysis. All had contractures at birth and genotypic findings including mutations in PLOD2 or FPKB10. Three cases were treated with bisphosphonates with improvement in bone density verified by DEXA. In Bruck syndrome, orthopedic deformities include the following sequential aspects: contractures, characterized by upper and lower extremity contractures such as clubfeet; fractures, characterized by multiple diaphyseal fractures in the long bones of the extremities; and deformities, characterized by malalignment of extremities and the spine. Physical therapy and bracing proved helpful for the contractures to try to stop progression. Bone fragility needs to be considered when deciding to attempt cast correction. Surgeries in the soft tissues can be performed to retain joint movement. In fractures with angulation, intramedullary nail fixation was useful, and in cases without deformity, casting alone was successful. We suggest monitoring the bone density with DEXA, nutrition support with vitamin D and calcium, and treatment with bisphosphonates. Spine deformities were successfully treated by spinal fusion and instrumentation.