License
International Journal of Paediatric Orthopaedics is licensed under a
https://creativecommons.org/licenses/by-nc-sa/4.0/
Publisher
Official Journal of:
Paediatric Orthopaedic Society of India (POSI)
Publisher:
ResearchOne Publishing House,
An "Indian Orthopaedic Research Group (IORG) initiative.
IORG House,
A-203, Manthan Apts, Shreesh CHS, Hajuri Road,
Thane [West], Maharashtra, India.
Pin Code- 400604
Tel- 02225834545
Publisher Email: indian.ortho@gmail.com
Editor Email: editor.ijpo@gmail.com
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Lower Limb Deformity Management in Arthrogryposis – What to Correct and When
Volume 10 | Issue 2 | May-August 2024 | Page: 00-00 | Ishani P Shah, Sujika Ranmuthuge, Varun Parnami, Anastasios Chytas
DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.000
Submitted: 18/05/2024; Reviewed: 06/06/2024; Accepted: 16/07/2024; Published: 10/08/2024
Authors: Ishani P Shah DNB Ortho. FRCS (T & O) [1], Sujika Ranmuthuge MD, FRCS (T & O) [1], Varun Parnami DNB Ortho. [1], Anastasios Chytas MD, MSc [1]
[1] Department of Paediatric Orthopaedic Surgery, Royal Manchester Children’s Hospital, Oxford Road, M13 9WL
Address of Correspondence
Dr. Ishani P Shah,
Consultant Paediatric Orthopaedic Surgeon, Royal Manchester Children’s Hospital, Oxford Road, M13 9WL.
E-mail: ishanipshah@gmail.com
Abstract
Arthrogryposis is a descriptive term involving non – progressive joint contractures of two or more joints at birth. It is associated with more than 300 diseases. Lower limb involvement is seen in about 95% of the cases with variable affection of the foot, knee and hip. Management depends on the severity, affection of number of joints and co-morbidities. Multidisciplinary management is crucial with realistic expectations. Prognosis should be discussed with parents prior to undertaking surgical intervention, especially the risk of recurrence as age advances. Deformities include soft tissue contractures, fibrotic hypoplastic muscles and in older children, deformed articular congruity. Foot is most commonly affected and Ponseti casting is the gold standard first line of treatment. Failed correction or late presentations are treated with soft tissue/bony surgery and/or fixator. Knee contractures can be flexion or extension with or without joint subluxation and patella involvement. Options for management are serial casting, soft tissue release, growth modulation, bony surgery, gradual correction with fixator or a combination of these based on the severity and age at presentation. Pterygium management is difficult due to proximity of neurovascular structures to the skin web and higher risk of recurrence. Hip contractures and dislocation when unilateral should be treated surgically. Treatment of bilateral affection is controversial and should be individualised.
Keywords:
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(Article Text HTML) (Full Text PDF)
Blount’s Disease: Review Article
Volume 10 | Issue 2 | May-August 2024 | Page: 39-48 | Yashwant Singh Tanwar, Sirazul Haque Malik, Karolina Siwicka, Nando Ferreira, Pieter Herman Maré
DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.192
Submitted: 02/05/2024; Reviewed: 29/05/2024; Accepted: 21/06/2024; Published: 10/08/2024
Authors: Sudhanshu Yashwant Singh Tanwar MS Ortho., DNB, MRCS [1], Sirazul Haque Malik MS Ortho. [2], Karolina Siwicka MD, PhD (T & O) [3], Nando Ferreira FC Orth (SA), MMed (Orth), PhD [3], Pieter Herman Maré FC Orth (SA), PhD [4]
[1] Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
[2] Department of Orthopedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Jollygrant, Uttarakhand, India.
[3] Division of Orthopedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa.
[4] Paediatric Orthopaedics Unit, Grey’s Hospital, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
Address of Correspondence
Dr. Yashwant Singh Tanwar
Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
E-mail: tanwar_yashwant@yahoo.co.in
Abstract
Blount’s disease, or non-physiological idiopathic tibia vara, is a growth disturbance affecting the medial proximal tibial physis, leading to a progressive three-dimensional deformity characterized by varus, procurvatum, and internal rotation. While its precise etiology remains unclear, the condition has been closely linked to obesity, mechanical stress, and potential genetic predisposition. Infantile Blount’s typically presents between one and three years of age, often bilaterally, whereas late-onset forms occur in juveniles (4–10 years) or adolescents (>10 years) and are more commonly unilateral. Early differentiation from physiological bowing is essential, as untreated disease results in progressive deformity and joint instability.
Radiographic evaluation is critical in confirming the diagnosis and planning treatment. Key parameters, including the meta-diaphyseal (Drennan) angle, medial metaphyseal beak angle, and mechanical tibiofemoral axis deviation, provide objective measures to distinguish Blount’s disease from other causes of genu varum. Medial tibial plateau depression, best assessed using an arthrogram, is a key determinant in surgical planning, particularly in advanced cases.
Management strategies depend on the stage and severity of the disease. In early stages, guided growth using tension-band plating may modulate physeal development and prevent progression. However, in advanced or recurrent cases, surgical correction is required. Metaphyseal osteotomy, with or without internal fixation, remains the mainstay of treatment. In cases with significant medial plateau depression, a medial hemiplateau elevation osteotomy is indicated to restore joint congruency and knee stability. Severe or late-presenting cases may necessitate double osteotomy techniques, combining joint line realignment with metaphyseal correction. Acute correction methods, including oblique and dome osteotomies, are effective but carry risks of neurovascular compromise. In cases of complex multiplanar deformity, gradual correction using circular external fixation offers precise correction while minimizing complications.
Despite surgical intervention, recurrence remains a concern, particularly in cases with persistent medial physeal slope abnormalities. Strategies such as prophylactic lateral tibial and fibular epiphysiodesis, as well as controlled overcorrection, have been proposed to minimize recurrence risk. Perioperative considerations, including prophylactic fasciotomy and careful fibular osteotomy placement, play a role in preventing complications such as compartment syndrome and peroneal nerve palsy.
Blount’s disease is a progressive condition requiring early diagnosis and timely intervention to prevent long-term morbidity. A structured approach, incorporating clinical assessment, radiographic analysis, and stage-specific management, is essential to optimize outcomes. While current surgical techniques provide reliable correction, ongoing research into the pathophysiology and treatment of Blount’s disease remains essential to improving long-term prognosis.
Keywords: Blount’s disease, Infantile tibia vara, Adolescent tibia vara
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Understanding the Biomechanics of Lever Arm Disorders in Cerebral Palsy
Volume 10 | Issue 1 | January-April 2024 | Page: 09-13 | Jayanth Sampath, Taral Nagda
DOI- https://doi.org/10.13107/ijpo.2024.v10i01.172
Submitted: 01/02/2024; Reviewed: 14/02/2024; Accepted: 18/03/2024; Published: 10/04/2024
Authors: Jayanth Sampath MS Ortho [1], Taral Nagda MS Ortho [2]
[1] Department of Paediatric Orthopaedics, Rainbow Children’s Hospital, Bangalore, Karnataka, India.
[2] Department of Paediatric Orthopaedics, SRCC NH Children’s Hospital, Mumbai, Maharashtra, India
Address of Correspondence
Dr. Jayanth S. Sampath,
Rainbow Children’s Hospital, Bangalore, Karnataka, India.
E-mail: jayanthdoc@gmail.com
Abstract
Levers in the human body play an important role in facilitating efficient movement. Muscle forces act around the axis of movement of adjacent joints. The normal moment of a joint (M) is the product of the muscle force (F) and the length of lever arm (d). The primary neurological insult in cerebral palsy (CP) causes shortening of muscles, joint contractures, and torsional abnormalities in bones. The resulting ineffective lever arm leads to a failure to produce an appropriate torque and subsequent gait abnormalities. Therefore, the effects of lever arm dysfunction should be considered when gait improvement surgery is being offered to children with CP. This review will explain the role of levers in normal human biomechanics and the significance of lever arm dysfunction in the management of CP.
Keywords: Biomechanics, Lever arm, Disorder, Cerebral palsy
References
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Upper Limb in Cerebral Palsy
Volume 10 | Issue 1 | January-April 2024 | Page: 39-49 | Praveen Bhardwaj, Vigneswaran Varadharajan, Mukil Venthan S, S Raja Sabapathy
DOI- https://doi.org/10.13107/ijpo.2024.v10i01.177
Submitted: 28/01/2024; Reviewed: 16/02/2024; Accepted: 11/03/2022; Published: 10/04/2024
Authors: Praveen Bhardwaj MS Ortho [1], Vigneswaran Varadharajan MS Ortho [1], Mukil Venthan S MS Ortho [1], S Raja Sabapathy MS Ortho [2]
[1] Department of Hand & Reconstructive Microsurgery Ganga Hospital, Coimbatore, Tamil Nadu, India
[2] Department of Plastic, Hand & Reconstructive Microsurgery Ganga Hospital, Coimbatore, Tamil Nadu, India
Address of Correspondence
Dr. Praveen Bhardwaj,
Consultant- Hand & Reconstructive Microsurgery Ganga Hospital, 313- Mettupalayam Road Sai Baba Colony Coimbatore, Tamil Nadu, India
E-mail: drpb23@gmail.com
Abstract
Cerebral palsy (CP) is a complex neuromuscular disorder characterized by impaired movement and coordination, often resulting in significant gait abnormalities. The spectrum of motor function impairment varies greatly among individuals with CP, influenced by muscle control issues and specific types of cerebral palsy, including spasticity and ataxia. Gait analysis, comprising both observational and instrumented techniques, is essential for assessing gait patterns and identifying abnormalities. While observational gait analysis provides qualitative insights, instrumented gait analysis offers a detailed and objective assessment through motion capture technology, allowing for comprehensive evaluation of joint angles(Kinematics) and forces(Kinetics).
Understanding gait patterns is crucial for making informed clinical decisions regarding therapeutic interventions such as surgery and orthotic management. Literature has demonstrated that gait analysis significantly improves surgical recommendations and outcomes, highlighting the importance of incorporating detailed gait data into treatment planning. However, limitations such as variability in data accuracy, the complexity of methods, and hesitancy among some orthopaedic surgeons to adopt these techniques need to be addressed. The integration of gait analysis into clinical practice represents a paradigm shift in the management of cerebral palsy, transitioning treatment from an art to a science. It enables clinicians to tailor interventions based on individual biomechanical profiles, ultimately enhancing the functional ability and quality of life for patients. Continued research and standardized practices are essential to maximize the effectiveness of gait analysis in this population, ensuring that children withe cerebral palsy receive the most appropriate and effective care.
Keywords: Gait Analysis, Cerebral Palsy, Instrumented Gait Lab
References
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Role of Gait Analysis in Management of Cerebral Palsy
Volume 10 | Issue 1 | January-April 2024 | Page: 34-38 | Chasanal Rathod
DOI- https://doi.org/10.13107/ijpo.2024.v10i01.176
Submitted: 13/01/2024; Reviewed: 05/02/2024; Accepted: 21/03/2024; Published: 10/04/2024
Authors: Chasanal Rathod MS Ortho [1,2]
[1] Department of Paediatric Orthopaedic Surgery, SRCC Children’s Hospital, Mumbai, Maharashtra, India.
[2] Xavier’s Gait Lab, Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Chasanal Rathod,
Paediatric Orthopaedic Surgeon, SRCC Children’s Hospital, Mumbai, Maharashtra, India. Xavier’s Gait Lab Mumbai, Maharashtra, India.
E-mail: chasanal@gmail.com
Abstract
Cerebral palsy (CP) is a complex neuromuscular disorder characterized by impaired movement and coordination, often resulting in significant gait abnormalities. The spectrum of motor function impairment varies greatly among individuals with CP, influenced by muscle control issues and specific types of cerebral palsy, including spasticity and ataxia. Gait analysis, comprising both observational and instrumented techniques, is essential for assessing gait patterns and identifying abnormalities. While observational gait analysis provides qualitative insights, instrumented gait analysis offers a detailed and objective assessment through motion capture technology, allowing for comprehensive evaluation of joint angles(Kinematics) and forces(Kinetics).
Understanding gait patterns is crucial for making informed clinical decisions regarding therapeutic interventions such as surgery and orthotic management. Literature has demonstrated that gait analysis significantly improves surgical recommendations and outcomes, highlighting the importance of incorporating detailed gait data into treatment planning. However, limitations such as variability in data accuracy, the complexity of methods, and hesitancy among some orthopaedic surgeons to adopt these techniques need to be addressed. The integration of gait analysis into clinical practice represents a paradigm shift in the management of cerebral palsy, transitioning treatment from an art to a science. It enables clinicians to tailor interventions based on individual biomechanical profiles, ultimately enhancing the functional ability and quality of life for patients. Continued research and standardized practices are essential to maximize the effectiveness of gait analysis in this population, ensuring that children withe cerebral palsy receive the most appropriate and effective care.
Keywords: Gait Analysis, Cerebral Palsy, Instrumented Gait Lab
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Lever Arm Disorders of the Feet in Cerebral Palsy
Volume 10 | Issue 1 | January-April 2024 | Page: 26-33 | Atul Bhaskar
DOI- https://doi.org/10.13107/ijpo.2024.v10i01.175
Submitted: 11/02/2024; Reviewed: 26/02/2024; Accepted: 13/03/2024; Published: 10/04/2024
Authors: Atul Bhaskar MS Ortho, FRCS Ortho, MCH, DNB [1,2,3]
[1] Department of Orthopaedics, Apollo Hospital, Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, SRCC NH Hospital, Mumbai, Maharashtra, India.
[3] Department of Orthopaedics, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Atul Bhaskar,
Paediatric Orthopaedic Surgeon, Department of Orthopaedics, Apollo Hospital, SRCC NH Hospital, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India.
E-mail: arb_25@yahoo.com
Abstract
The key for optimum management for progressive musculoskeletal deformities in cerebral palsy patients is understanding the causative mechanisms. The impact of muscle shortening and contracture on the long bones and joints leads to lever arm problems in the foot and ankle and the associated deformities.
Management of each deformity is considered separately although many of these can occur concurrently and the severity my vary in an individual.
Keywords: Lever, Cerebral palsy, Foot & Ankle
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https://doi.org/10.13107/ijpo.2024.v10i01.175
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