The Role of Pirani Scoring in Predicting the Frequency of Casting and the Need for Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot Using the Ponseti Method

Volume 4 | Issue 2 | July-December 2018 | Page: 15-19 | Chukwuemeka O. Anisi, Joseph E. Asuquo, Innocent E. Abang, Michael E. Eyong, Onyebuchi G. Osakwe, Ngim E. Ngim

DOI- 10.13107/ijpo.2018.v04i02.013

Authors: Chukwuemeka O. Anisi, Joseph E. Asuquo, Innocent E. Abang, Michael E. Eyong [1], Onyebuchi G. Osakwe, Ngim E. Ngim

Departments of Orthopaedics and Traumatology, University of Calabar, Cross River State, Nigeria. [1] Departments of Paediatrics, University of Calabar, Cross River State, Nigeria.

Address of Correspondence
Dr. Chukwuemeka Okechukwu Anisi,
Department of Orthopaedics and Traumatology, University of Calabar Teaching Hospital, PMB 1278-Calabar, Cross River State, Nigeria.
E-mail: iall4him@yahoo.co.uk

Abstract

Background: The Pirani scoring system is a simple tool widely used for grading the severity of clubfoot. This study was designed to objectively assess its value in predicting the total number of casts required, and the need for percutaneous Achilles tenotomy to achieve correction of the idiopathic clubfoot treated by the Ponseti method. Patients and Methods: All patients with idiopathic clubfoot, who attended our clubfoot clinic between January, 2013 and December, 2015, were prospectively studied. Each clubfoot was scored at presentation and at each visit by the first and second authors, using the Pirani scoring system. All patients were treated by the first and second authors by weekly stretching and cast application following the Ponseti treatment protocol until correction was achieved (with or without percutaneous Achilles tenotomy). Chi-square tests were applied to establish any existing relationship between the Pirani scores and the need for percutaneous tenotomy as well as the number of casts required to achieve correction.
Results: A total of 69 patients with 108 idiopathic clubfeet wer recruited into the study. In that, 14 patients defaulted, leaving the study with 81 clubfeet belonging to 55 patients. The median total Pirani score (TPS), midfoot contracture score and hindfoot contracture score at presentation were 4.0, 2.0 and 2.0, respectively. A total of 57 (70.4%) feet required percutaneous Achilles tenotomy to achieve correction. The average number of casts (including casts after tenotomy) required to achieve correction was 4.9 (2–10). The average number of casts required to achieve correction was 4.1 (2–10) for the no tenotomy group and 5.4 (3–10) for the tenotomy group. Statistically significant relationship was established between the TPS and number of casts required to achieve correction for both the tenotomy group (P=0.039) and no tenotomy group (P=0.05).
Conclusion: High Pirani scores were associated with increased number of casts and percutaneous Achilles tenotomy for the correction of idiopathic clubfoot using the Ponseti method.
Keywords: Achilles tenotomy, clubfoot, idiopathic, Pirani scoring system, Ponseti method

References 

1. Solomon L,Warwick D, Selvadurai N.Appley’s Systemof Orthopaedics and Fractures. 9th ed. London: Hodder Arnold; 2010. p. 591-5.
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3. Ngim NE, Okokon E, Ikpeme IA, Udosen MA, Iya J. Profile of congenital limb anomalies in Calabar. Asian J Med Sci 2013;4:58-61.
4. Adewole AO, Giwa SO, Kayode MO, Shoga MO, Balogun RA. Congenital clubfoot in a teaching hospital in Lagos, Nigeria. Afr J Med Sci 2009;38:203-6.
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6. Adewole AO, Williams OM, Kayode MO, Shoga MO, Giwa SO. Early experience with Ponseti clubfoot management in Lagos, Nigeria. East Cent Afr J Surg 2014;19:72-7.
7. Ponseti IV. Current concept review. Treatment of congenital clubfoot. J Bone Joint Surg 1992; 74:448-54.
8. Sud A, Tiwari A, Sharma D, Kapoor S. Ponseti’s vs Kite’s methods in the treatment of clubfoot − A prospective randomized study. Int Orthop 2008;32:409-13.
9. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
10. Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005; 25:623-6.
11. Adegbehingbe OO, Oginni LM, Ogundele OJ, Ariyibi AL, Abiola PO, Ojo OD. Ponseti clubfoot management: Changing surgical trends in Nigeria. Iowa Orthop J 2010;30:7-14.
12. Ponseti IV. Current concept review. Treatment of congenital clubfoot. J Bone Joint Surg 1992;74:448-54.
13. Pirani S, Outerbridge H, Moran M. Method of evaluating the virgin clubfoot with substantial interobserver reliability. Presented at the annual meeting of the Pediatric Orthopaedic Society of North America, Miami, FL, 1995.
14. Dimeglio A, Bensahel H, Souschet P. Classification of clubfoot. J Pediatr Orthop 1995;3:129.
15. Adegbehingbe OO, Asuquo JE, Mejabi OJ, Alzahrani M, Morcuende JA. The heel pad in congenital idiopathic clubfoot: Implications for empty heel for clinical severity assessment. Iowa Orthop J 2015; 35:169-74.
16. Haft GF, Walter CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am 2007;89:487-93.
17. Boehm S, Limpaphayom N, Alaee F, Sinclair MF, Dobbs MB. Early result of the Ponseti treatment of clubfoot in distal athrogryposis. J Bone Joint Surg Am 2008;90:1501-7.
18. Janicki JA, Narayanan UG, Harvey BJ, Roy A, Weir S, Wright JG. Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot. J Bone Joint Surg Am 2009;91:1101-8.
19. Porecha MM, Parmar DS, Charda HR. Midterm results of Ponseti method for the treatment of congenital idiopathic clubfoot. J Ortho Surg Res 2011;6:3.
20. Rijal R, Shrestha BP, Singh GK, Singh M, Nepal P, Khanal GP, et al. Comparison of Ponseti’s and Kite’s methods of treatment of idiopathic clubfoot. Indian J Orthop 2010;44:202-7.
21. Morcuende JA, Dobbs MB, Frick SL. Results of the Ponseti method in patients with clubfoot associated with athrogryposis. Iowa Orthop J 2008;28:22-6.
22. Scher DM. The Ponseti method of treatment of clubfoot. Curr Opin Pediatr 2006;18:22-8.
23. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfoot. J Bone Joint Surg Am 2004;86:22-7.
24. Flynn JM, Donohoe M, McKenzie WG. An independent assessment of two clubfoot classification systems. J Pediatr Orthop 1998;18:223.
25. Scher DM, Feldman DS, van Bosse HJ. Predicting the need for tenotomy in the Ponseti method for correction of clubfoot. J Pediatr Orthop 2004;24:349.
26. Dyer PJ, Davis N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone J Surg Br 2006;88:1082-4.
27. BorN,Coplan JA,Herzenberg JE.Ponseti treatment for idiopathic clubfoot: Minimum 5-year follow up. Clin Orthop Relat Res 2009;467:1263-70.

How to Cite this Article:  Anisi CO, Asuquo JE, Abang IE, Eyong EM, Osakwe OG, Ngim E | The Role of Pirani Scoring in Predicting the Frequency of Casting and the Need for Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot Using the Ponseti Method | July-December 2018; 4(2): 15-19.

 

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Predicting the Need for Tenotomy in the Management of Idiopathic Clubfoot by the Ponseti Method

Volume 4 | Issue 2 | July-December 2018 | Page: 11-14 | Ranjit V. Deshmukh, Aditi A. Kulkarni

DOI- 10.13107/ijpo.2018.v04i02.012

Authors: Ranjit V. Deshmukh, Aditi A. Kulkarni [1]

 

Departments of Orthopedics, [1] Research, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India.

Address of Correspondence
Dr. Ranjit V. Deshmukh,
Department of Orthopedics, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune − 411 004, Maharashtra, India.
E-mail: drranjitdeshmukh@gmail.com

Abstract

Purpose: The aim of this study was to determine the role of Pirani scoring system for predicting the treatment of idiopathic clubfoot with the Ponseti technique.
Materials and Methods: A retrospective study was conducted. The records of 132 idiopathic clubfeet of patients treated by the Ponseti method and scored by the Pirani system between May 2007 and September 2015 were analyzed.
Result: Of the 132 feet, 101 (76.5%) feet of the patients required tenotomy. The mean number of casts required was significantly higher (P=0.033) for the group that required tenotomy (5.53 ± 1.6 casts) than the group that did not require tenotomy (4.87 ± 0.9 casts).
Conclusion: The initial Pirani score is predictive of the number of casts that may be required and the need for a tenotomy of the Achilles tendon.
Keywords: Casting, Clubfoot, Congenital talipes equinovarus, Pirani scoring, Ponseti, Tenotomy

References 

1. Chotel F, Parot R, Durand JM, Garnier E, Hodgkinson I, Berard J. Initial management of congenital varus equinus clubfoot by Ponseti’s method. Rev Chir Orthop Reparatrice Appar Mot 2002;88:710-7.
2. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am 2004;86:22-7.
3. ColburnM,Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg 2003;42:259-67.
4. Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop 2002;22:517-21.
5. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
6. Ponseti IV, Smoley EN. The classic: Congenital club foot: The results of treatment. 1963. Clin Orthop Relat Res 2009;467:1133-45.
7. Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am 1992;74:448-54.
8. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am 1995;77:1477-89.
9. Pirani S, Outbridge HK, Sawatzky B, Stothers K. A reliable & valid method of assessing the amount of deformity in the virgin congenital clubfoot deformity. 21st SICOT Congress, 1999.
10. Wainwright AM, Auld T, Benson MK, Theologis TN. The classification of congenital talipes equinovarus. J Bone Joint Surg Br 2002;84:1020-4.
11. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am 1980;62:23-31.
12. Radler C. The Ponseti method for the treatment of congenital club foot: Review of the current literature and treatment recommendations. Int Orthop 2013;37:1747-53.
13. Dyer PJ, Davis N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone Joint Surg Br 2006;88:1082-4.
14. Scher DM, Feldman DS, van Bosse HJ, Sala DA, Lehman WB. Predicting the need for tenotomy in the Ponseti method for correction of clubfeet. J Pediatr Orthop 2004;24:349-52.
15. Porecha M, Parmar D. The predictive value of Pirani scoring system in the management of idiopathic club foot by Ponseti method. Int J Orthop Surg 2008;11:1-4.
16. Goriainov V, Judd J, Uglow M. Does the Pirani score predict relapse in clubfoot? J Child Orthop 2010;4:439-44.
17. Bhaskar A, Patni P. Classification of relapse pattern in clubfoot treated with Ponseti technique. Indian J Orthop 2013;47:370-6.
18. Chandrakanth U, Sudesh P, Gopinathan N, Prakash M, Goni VG. Tarsal bone dysplasia in clubfoot as measured by ultrasonography: Can it be used as a prognostic indicator in congenital idiopathic clubfoot? A prospective observational study. J Pediatr Orthop 2016;36: 725-9.
19. Chu A, Labar AS, Sala DA, van Bosse HJ, Lehman WB. Clubfoot classification: Correlation with Ponseti cast treatment. J Pediatr Orthop 2010;30:695-9.
20. Agarwal A, Gupta N. Does initial Pirani score and age influence number of Ponseti casts in children? Int Orthop 2014;38:569-72.

How to Cite this Article:  Deshmukh RV, Kulkarni AA | Predicting the Need for Tenotomy in the Management of Idiopathic Clubfoot by the Ponseti Method | July-December 2018; 4(2): 11-14.

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Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?

Volume 4 | Issue 2 | July-December 2018 | Page: 03-10 | Petnikota Harish

DOI- 10.13107/ijpo.2018.v04i02.011

Authors: Petnikota Harish

Vasudev Children’s Orthopaedics Centre, Bellary, Karnataka, India

Address of Correspondence
Dr. Petnikota Harish,
‘Vasudev’, Opp. Shanti Sishu Vihar School, Talur Road, Bellary – 583 103, Karnataka, India.
E-mail: harishportho@gmail.com

Abstract

Context: Early surgical intervention is the key for good outcome in children with acute haematogenous osteomyelitis (AHO) or septic arthritis. Often there is an impasse to observe or intervene early when the diagnosis is inconclusive due to blunted clinical findings and equivocal investigations. Aim: This study is aimed at justifying early surgical intervention in these doubtful/suspected cases. Settings and
Design: This study was a retrospective review of AHO/septic arthritis treated by the author between August 2010 and January 2015. A new scoring system, haematogenous osteomyelitis and septic arthritis (HOMSA) score was developed to aid in classifying and decision-making. With a maximum score of 8, a score >6 in the absence of infection elsewhere or a score <6 with radiological evidence makes the diagnosis of AHO/septic arthritis definite. A score 6 without radiological evidence makes the diagnosis suspected/doubtful. Outcome was measured by a new discrete criterion for the upper and lower limbs.
Materials and Methods: The protocol was early surgical intervention in both the groups. In septic arthritis, open arthrotomy along with joint lavage and debridement was performed. In AHO, bone decompression with abscess drainage was performed. Initial parenteral administration of antibiotics was followed by oral antibiotic administration. Necessary adjuvant treatment was given.
Results: Thirty-four children with 40 sites of infection were identified. Among them, 50% were neonates. Only 4/40 children were treated conservatively. Following surgery, outcome was excellent-to-good in 92.8% of the children with doubtful/suspected diagnosis and 96.6% with definite infection. One child in each group who were treated surgically, and two children in the group with definite infection treated non-operatively had fair-to-poor outcomes. Conclusion: Early surgical intervention is justified even in children with a doubtful/suspected diagnosis of AHO or Septic Arthritis. The new scoring system, HOMSA Score, is a better tool to diagnose Acute septic arthritis or osteomyelitis, even with limited resources.
Keywords: Acute haematogenous osteomyelitis, Early surgery, Infants and children, Neonates, New outcome, Measure, New scoring system, Septic arthritis

References 

1. Kuong EE, To M, Yuen MH, Choi AK, Fong CM, Chow W. Pitfalls in diagnosing septic arthritis in Hong Kong children: Ten years experience. Hong Kong Med J 2012;18:482-7.
2. Stans AA. Musculoskeletal infection. In: Weinstein SL, Flynn JM, editors. Lovell and Winter’s Paediatric Orthopaedics. 7th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters Kluwer 2014. p. 369–425.
3. Herring JA, editor. Infections of the musculoskeletal system. Tachdjian’s Paediatric Orthopaedics. 4th ed. Philadelphia: Saunders Elsevier 2008. p. 2089-155.
4. Bennet OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop Relat Res 1992; 281: 123-32.
5. Chen CE, Ko JY, Li CC, Wang CJ. Acute septic arthritis of the hip in children. Arch Orthop Trauma Surg 2001;121:521.
6. Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, et al. A clinical practice guideline for treatment of septic arthritis in children. J Bone Joint Surg Am 2003;85:994-9.
7. Lyon RM, Evanich JD. Culture-negative septic arthritis in children. J Pediatr Orthop 1999;19:655.
8. Morrey BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in children. Orthop Clin N Am 1975;6:923-34.
9. Cole WG, Dalziel RE, Leitl S. Treatment of acute osteomyelitis in childhood. Bone Joint J 1982;64:218-23.
10. Wang CL, Wang SM, Yand YJ, Tsai CH, Liu CC. Septic arthritis in children: Relationship of causative pathogens, complications and outcomes. J Microbial Immunol Infect 2003;36:41-6.
11. Scoor RJ, Christofersen MR, Roberson WW Jr, Davidson RS, Rankin L, Drummond DS. Acute osteomyelitis in children: A review of 116 cases. J Pediatr Orthop 1990;10:649-52.
12. Klein DM, Barbera C, Gray ST, Spero CR, Perrier G, Teicher JL. Sensitivity of objective parameters in the diagnosis of paediatric septic hips. Clin Orthop Relat Res 1997;338:153-9.
13. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: An evidencebased clinical prediction algorithm. J Bone Joint Surg Am 1999;81: 1662-70.
14. Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg 2004;86:956-62.
15. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg 2004;86:1629-35.
16. Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. J Bone Joint Surg Am 2006;88:1251-7.
17. Bonheffer J, Haeberle B, Schaad UB, Heininger U. Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children’s Hospital Basel. Swiss MedWkly 2001;131:575-81.
18. Peltola H, Vahvanen V, Aalto K. Fever, C-reactive protein, and erythrocyte sedimentation rate in monitoring recovery from septic arthritis: A preliminary study. J Pediatr Orthop 1984;4:170-4.
19. Morrey BF, Peterson HS. Hematrogenous pyogenic osteomyelitis in children. Orthop Clin North Am 1976;6:935-51.
20. Segbefia M, Howard A. Acute Septic Arthritis and Osteomyelitis in Children − An African Perspective; 2013. Available from:
http:// ptolemy.library.utoronto.ca/sites/default/files/review/2010/February- Acuteseptic Arthritis and Osteomyelitis.pdf. [Last accessed on 2015 Apr].
21. Smith RL, Schurman DJ, Kajiyama G, Mell M, Gilkerson E. The effect of antibiotics on the destruction of cartilage in experimental infectious arthritis. J Bone Joint Surg Am 1987;69:1063-8.
22. Nunn TR, Cheung WY, Rollinson PD. A prospective study of pyogenic sepsis of the hip in childhood. J Bone Joint Surg Br 2007;89:100-6.
23. Welcon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: A review of 95 cases. Pediatr Infect Dis 1986;5: 669-76.

How to Cite this Article:  Harish P Early Surgical Intervention | in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified? | July-December 2018; 4(2): 03-10.

 

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Stop Maligning the Asymptomatic Child’s Flatfoot

Volume 4 | Issue 2 | July-December 2018 | Page: 01-02 | Benjamin Joseph

DOI- 10.13107/ijpo.2018.v04i02.010

Authors: Benjamin Joseph

Aster Medcity, Kochi, Kerala, India

Address of Correspondence
Prof. Benjamin Joseph,
18 H.I.G. Colony, Manipal − 576 104, Karnataka, India
E-mail: bjosephortho@yahoo.co.in

Recently, a lady met me and gave me some very colourful pamphlets about a range of fancy foot wear and shoe inserts for toddlers and young children designed to ’correct’ flatfeet. I asked her why asymptomatic flatfeet need to be treated. I patiently listened to her as she listed several ‘harmful effects of flatfeet’ including a predilection for foot injury, back ache and so on, which, according to her could be avoided by using the shoes and shoe inserts she was promoting. Needless to say, there were no scientific data to support these claims. After she left, I reflected about what the scientific literature had to say about flatfoot and also recollected my personal experience of dealing with flatfeet in young children in my practice.
There has been a long-held notion that flatfeet are bad and that they may interfere with strenuous physical activity. On the basis of this, young men with flatfeet were rejected from recruitment into the armed forces. However, Cowan et al.[1] did a study on army recruits in the USA and could not demonstrate a higher frequency of injuries in those with flatfeet. Esterman and Pilotto[2] did a similar study in Australia and concluded that ’foot shape has little impact on pain, injury and function’. Tudor et al.[3] studied athletic performance in school children with flatfoot and normal arches and documented no difference in performance in 17 different tasks. So it is high time we dispel the erroneous notion that the flatfoot is in some way inferior to feet with a well-formed arch.
Stemming from the belief that flatfoot is undesirable, concerted efforts have been made to ‘treat’ young children with shoe modifications and various types of shoe inserts that elevate the medial longitudinal arch or control the hindfoot valgus. Despite the fact that Wenger et al.,[4] in as early as 1989, demonstrated clearly that shoes and shoe inserts in no way alter the natural history of flatfoot, orthopaedic surgeons continue to prescribe them. This wasteful and meaningless practice needs to stop.
The natural history of asymptomatic flexible flatfoot is that of resolution in the vast majority of children because the arch develops by the age of 6–7 years. This is very evident as at 1 year of age, 95% of children have flatfeet and by the age of 10, the prevalence is as low as 5%. The increase in the tone of muscles that support the arch and spontaneous reduction in joint laxity as the child grows facilitate the arch to develop. Barefoot activity in early childhood also facilitates the arch to develop while shoe-wearing appears to be detrimental to the development of the arch. This was demonstrated in two large cross-sectional surveys, which showed that the prevalence of flatfoot was highest among children who wore closed-toe shoes below the age of 6 years and lowest in the unshod.[5,6] The frequency of flatfoot in children who wore sandals and slippers fell between these two. With this evidence, it seems hardly logical to prescribe shoes for a young child with flatfoot. Instead, we need to spread the message to encourage children to play barefoot outdoors on sand and gravel. We could also encourage school authorities to have sandals rather than shoes as the regulation footwear. These suggestions are perfectly appropriate in the warm climate in India.
In my practice, I have never had parents from the lower socio-economic strata bring a child for the treatment of flatfoot. Every single child brought to me with the complaints of flatfoot has been from an affluent family. Often it has been a paediatrician, or family physician, who referred the child with flatfoot to me. For a long time, I wondered why there was this socio-economic difference in my flatfoot practice. It then dawned on me; the poor child is unshod and in early childhood has played barefoot, and the poor child consequently is unlikely to have flatfoot. Even if the poor child has flatfeet, they cause no pain and the feet function perfectly well. The child’s parents have no access to the internet, so they have never heard anyone maligning their child’s feet. No wonder, I never saw a poor child with flatfoot in my clinic.

Benjamin Joseph
Aster Medcity, Kochi, Kerala, India

References 

1. Cowan DN, Jones BH, Robinson JR. Foot morphologic characteristics and risk of exercise-related injury. Arch Fam Med 1993;2: 773-7.
2. Esterman A, Pilotto L. Foot shape and its effect on functioning in Royal Australian Air Force recruits. Part 1: Prospective cohort study. Mil Med 2005;170:623-8.
3. Tudor A, Ruzic L, Sestan B, Sirola L, Prpic T. Flat-footedness is not a disadvantage for athletic performance in children aged 11 to 15 years. Pediatrics 2009;123:e386-92.
4. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am 1989;71:800-10.
5. Rao UB, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br 1992;74:525-7.
6. Sachithanandam V, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 1846 skeletally mature persons. J Bone Joint Surg Br 1995;77:254-7.

How to Cite this Article:  Joseph B Stop Maligning the | Asymptomatic Child’s Flatfoot | July- December 2018; 4(2): 01-02.

 

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Paediatric orthopaedics and global initiative for children’s surgery

Volume 4 | Issue 1 | January-June 2018 | Page: 01-02 | Vrisha Madhuri

Authors: Vrisha Madhuri [1]

[1] Paediatric Orthopaedics Unit, Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu, India.

Address for correspondence:
Dr. Vrisha Madhuri,
Professor and Head, Paediatric Orthopaedics Unit, Department of Orthopaedics, Christian Medical College,
Vellore, Tamil Nadu, India
E-mail: madhuriwalter@cmcvellore.ac.in

Global burden of surgical disease and attendant morbidity and mortality has received much attention in the recent past from the World Health Organization and the Lancet Commission on Global Surgery.[1],[2],[3] This has led to several initiatives in the last 2 years by the global surgical community to address the relevant issues. Among them is a coalition of children’s surgery organizations, led by American Paediatric Surgery Association and British Association of Paediatric Surgeons, who are working to bring together the providers and the implementers of surgical services for children in low- and medium-income countries. The coalition consists of health, advocacy and policy experts from the western world. Two meetings of this Global Initiative for Children’s Surgery (GICS) have taken place with the aim of analysing the current state of the surgical care; develop priorities to improve its delivery and identify and bring together needed resources.[4] The dream of GICS is that every child in the world with a surgical need will have access to the resources necessary to optimise his or her individual care.[4]

India has the largest child population in the world. Similar to other developing countries, we have a very wide range of causes including acute, chronic and neglected problems, with many of them being amenable to surgical treatment. The few centres providing high-quality specialised paediatric surgical care are concentrated in the metropolises, and inadequately trained non-paediatric specialists are available to address these problems in the community. Despite the success of a few focussed programs, such as ‘Smile Train’ for cleft lip and palate and the collaborative program between CURE International, India and several state governments for clubfoot conservative treatment and bracing, much of the surgical needs of the children in the community remain unaddressed because of the lack of adequate infrastructure to support children’s surgery, service delivery systems and trained manpower. The supporting services such as paediatric anaesthesia, intensive care, nursing and orthotics also lack infrastructure and trained personnel. Adequate planning at national and regional levels requires paediatric-specific determination of burden of illnesses in different areas such as congenital, neuromuscular disorders, trauma and oncology.

Rashtriya Bal Swasthya Karyakram, a new initiative by the Government of India, envisages the screening of all children and adolescents for key medical and surgical conditions and their referral and treatment by the existing healthcare providers in public and private sectors. However, in the existing system, the lack of paediatric surgical specialists forms a crisis, wherein identified children are unable to access or obtain quality care, and those suffering from complex conditions do not receive comprehensive care. The lack of a triaging system burdens the tertiary care referral centres with routine surgical conditions, which are best handled at secondary levels, causing overcrowding.

The paediatric orthopaedic community is a major stakeholder in the development of surgical services in the country. Our help, along with other paediatric surgical specialists, is required in needs assessment in the area of infrastructure, service delivery and manpower. A specialist organization such as paediatric orthopaedic society can do these in addition to setting up appropriate standards of care for different conditions, triaging systems by level of hospital, standardizing training programs and identifying areas of research. They can also be great advocates for children’s surgery and attract funding and resources. The baseline demographic studies can be used to determine optimal resources such as the number of children’s hospitals required for the population served. The other important areas are the standardization of equipment to be made available for children’s need and integration of infrastructure needs into national children’s surgical plan. They can also promote preventive strategies such as improved prenatal diagnosis and health promotion and rehabilitation.

While GICS is setting up the needs assessment and standards for infrastructure, healthcare delivery and processes and personnel at all levels of care, we can join hands with them and other paediatric surgical colleagues to provide the appropriate inputs and help build up systems and best practices to provide safe affordable surgical care for children.

References 

1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA,
et al. Global Surgery 2030: Evidence and solutions for achieving health,
welfare, and economic development. Lancet 2015;386:569-624.
2. Available from: http://www.who.int/bulletin/volumes/86/8/07-050435/
en/. [Last accessed on 2017 Jan 23].
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How to Cite this Article:  Madhuri V | Paediatric orthopaedics and global initiative for children’s surger y| International Journal of Paediatric Orthopaedics | January-June 2018; 4(1): 01-02.

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Grievous injuries in children due to tractor-related accidents

Volume 4 | Issue 1 | January-June 2018 | Page: 34-37 | Kala Ebenezer, Rimi Manners, Sampath Karl [1], Vrisha Madhuri [2]

DOI- 10.13107/ijpo.2018.v04i01.008

Authors: Kala Ebenezer, Rimi Manners, Sampath Karl [1], Vrisha Madhuri [2]

Paediatric Intensive Care Unit, [2] Paediatric Orthopaedic Unit, [1] Department of Paediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Address of Correspondence
Dr. Kala Ebenezer,
Paediatric Intensive Care Unit (PICU), Christian Medical College, Vellore – 632 004, Tamil Nadu, India.
E-mail: picu@cmcvellore.ac.in

Abstract

Introduction: Tractor-related accidents are common among the agricultural injuries. Children are prone to such incidents as farmers live in the vicinity of the farmland.
Materials and Methods: From the Paediatric Intensive Care unit (PICU) database we extracted the details of children with unintentional injuries and poisonings during the period January 2008 to June 2009. Those with tractor-related injuries were further analyzed using outpatient and inpatient charts, computerized hospital records were accessed to obtain laboratory and radiological investigations details. The clinical characteristics, injuries, and outcome of these children are presented.
Results: In the 18 months period, there were 107 children with trauma, envenomations and poisoning constituting 6.5% of all PICU admissions. Of the 31 (29%) with polytrauma, four (12.9%) children, three of them boys had sustained tractor-related injuries. The injuries included three with multiple limb fractures, two each of head, chest, musculoskeletal and perineal injury and one each of abdominal and major vascular injury. All had reached the hospital in life-threatening shock and were resuscitated. Multidisciplinary surgical intervention including craniectomy, liver resection and femoral vessels anastomosis were required along with blood transfusions, ventilatory support and inotropes. Three of them survived the injuries after a mean PICU stay of 34 days.
Conclusion: Tractor-related incidents among rural children are associated with major injuries and fatalities in children. The findings call for interventions to prevent such injuries and education of the farming community involved with tractors and other agricultural machineries.
Keywords: Critically ill, Farming machinery, Tractor

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How to Cite this Article:  Ebenezer K, Manners R, Karl S, Madhuri V | Grievous injuries in children due to tractor-related accidents | January-June 2018; 4(1): 34-37.

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