Stop Maligning the Asymptomatic Child’s Flatfoot

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

Authors: Benjamin Joseph [1]

[1] Aster Medcity, Kochi, Kerala, India.

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

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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10-Year Radiological Follow-Up of Multifocal Recurrent Eosinophilic Granuloma With Vertebra Plana: A Case Report and Review of Literature

Volume 4 | Issue 2 | July-December 2018 | Page: 32-36 | Amit Kumar, Shivam Sinha, Shyam Kumar Saraf, Vineeta Gupta, Deepa Rani, Jyoti Kumari

DOI- 10.13107/ijpo.2018.v04i02.016

Authors: Amit Kumar, Shivam Sinha, Shyam Kumar Saraf, Vineeta Gupta [1], Deepa Rani [2], Jyoti Kumari [3]

 

Departments of Orthopedics, [1] Pediatrics and, [2] Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, [3] Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

Address of Correspondence
Dr. Amit Kumar,
Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi − 221 005, Uttar Pradesh, India.
E-mail: amit2k03@gmail.com

Abstract

Eosinophilic granuloma (EG) is the benign localized form of histiocytosis. Owing to the relative rarity of the condition, diagnosis is often delayed or missed, and many questions remain unanswered, ranging from cause and pathogenesis to therapy. Observation and immobilization are adequate for improvement of the condition in most patients. However, treatment other than simple observation is recommended in patients with symptomatic EG. This article presents a 10-year follow-up study of a 15-year-old girl with a symptomatic multifocal EG treated effectively by monitored chemotherapy and orthosis.
Keywords: Eosinophilic granuloma, langerhans cell histiocytosis, osteochondritis, osteogenesis imperfecta, tuberculosis, vertebra plana

References 

1. Willman CL, Busque L, Griffith BB, Favara BE, McClain KL, Duncan MH, et al. Langerhans histiocytosis (histiocytosis X): A clonal proliferative disease. New Engl J Med 1994;331:154-60.
2. Lichtenstein L. Histiocytosis X (eosinophilic granuloma of bone ‘Letterer-Siwe disease and Schuller-Christian disease’): Further observations of pathological and clinical importance. J Bone Joint Surg Am 1964;46:76-90.
3. Ladish S, Jaffe ES. The histiocytocis. In: Pizzo PA, Poplack DG, editors. Principles and Practices of Pediatric Oncology. Philadelphia: J. B. Lippincott Company; 1989. p. 491-504.
4. Huvos AG. Bone tumors. Diagnosis, Treatment and Prognosis. 2nd ed. Philadelphia: WB Saunders; 1990.
5. Sweasey TA, Dauser RC. Eosinophilic granuloma of the cervicothoracic junction. J Neurosurg 1989;71:942-4.
6. Nesbit ME Jr. Bone tumours in infants and children. Paediatrician 1972 /73;1:273-87.
7. Tanaka N, Fujimoto Y, Okuda T, Nakanishi K, Sumida T, Manabe H, et al. Langerhans cell histiocytosis of the atlas. A report of three cases. J Bone Joint Surg Am 2005;87:2313-7.
8. Dickinson LD, Farhat SM. Eosinophilic granuloma of the cervical spine. A case report and review of the literature. Surg Neurol 1991;35: 57-63.
9. Bertram C, Madert J, Eggers C. Eosinophilic granuloma of the cervical spine. Spine (Phila Pa 1976) 2002;27:1408-13.
10. Capanna R, Springfield DS, Ruggieri P, Biagini R, Picci P, Bacci G, et al. Direct cortisone injection in eosinophilic granuloma of bone: A preliminary report on 11 patients. J Pediatr Orthop 1985;5:339-42.
11. Garg S, Mehta S, Dormans JP. Langerhans cell histiocytosis of the spine in children long-term follow-up. J Bone Joint Surg Am 2004;86: 1740-50.
12. Bechan GI, Egeler RM, Arceci RJ. Biology of Langerhans cells and Langerhans cell histiocytosis. Int Rev Cytol 2006;254:1-43.
13. Egeler RM, Favara BE, van Meurs M, Laman JD, Claassen E. Differential in situ cytokine profiles of Langerhans-like cells and T cells in Langerhans cell histiocytosis: Abundant expression of cytokines relevant to disease and treatment. Blood 1999;94:4195-201.
14. Seimon LP. Eosinophil granuloma of the spine. J Pediatr Orthop 1981;1:371-6.
15. Brown CW, Jarvis JG, Letts M, Carpenter B. Treatment and outcome of vertebral Langerhans cell histiocytosis at the Children’s Hospital of Eastern Ontario. Can J Surg 2005;48:230-6.
16. Greenlee JD, Fenoy AJ, Donovan KA, Menezes AH. Eosinophilic granuloma in the pediatric spine. Pediatr Neurosurg 2007;43: 285-92.
17. Yeom JS, Lee CK, Shin HY, Lee CS, Han CS, Chang H. Langerhans’ cell histiocytosis of the spine. Analysis of twenty-three cases. Spine 1999;24:1740-9.
18. Plasschaert F, Craig C, Bell R, Cole WG, Wunder JS, Alman BA. Eosinophilic granuloma. A different behaviour in children than in adults. J Bone Joint Surg Br 2002;84:870-2.
19. Levy EI, Scarrow A, Hamilton RC, Wollman MR, Fitz C, Pollack IF. Medical management of eosinophilic granuloma of the cervical spine. Pediatr Neurosurg 1999;31:159-62.
20. Fernández-Latorre F, Menor-Serrano F, Alonso-Charterina S, Arenas- Jiménez J. Langerhans’ cell histiocytosis of the temporal bone in pediatric patients. AJR Am J Roentgenol 2000;174:217-21.
21. Kamimura M, Kinoshita T, Itoh H, Yuzawa Y, Takahashi J, Ohtsuka K. Eosinophilic granuloma of the spine: Early spontaneous disappearance of tumor detected on magnetic resonance imaging. J Neurosurg 2000;93(2 Suppl):312-6.
22. O’Donnell J, Brown L, Herkowitz H. Vertebra plana-like lesions in children: Case report with special emphasis on the differential diagnosis and indications for biopsy. J Spinal Disord 1991;4: 480-5.
23. Egeler RM, Thompson RC Jr, Voûte PA, Nesbit ME Jr. Intralesional infiltration of corticosteroids in localized Langerhans cell histiocytosis. J Pediatr Orthop 1992;12:811-4.
24. Grois N, Pötschger U, Prosch H, Minkov M, Arico M, Braier J, et al. Risk factors for diabetes insipidus in Langerhans cell histiocytosis. Pediatr Blood Cancer 2006;46:228-33.
25. Munn SE, Olliver L, Broadbent V, Pritchard J. Use of indomethacin in Langerhans cell histiocytosis. Med Pediatr Oncol 1999;32:247-9.
26. da Costa CE, Annels NE, Faaij CM, Forsyth RG, Hogendoorn PC, Egeler RM. Presence of osteoclast-like multinucleated giant cells in the bone and nonostotic lesions of Langerhans cell histiocytosis. J Exp Med 2005;201:687-93.
27. Raab P, Hohmann F, Kuhl J, Krauspe R. Vertebral remodelling in eosinophilic granuloma of the spine: A long-term follow-up. Spine 1998;23:1351-4.
28. KasteSC,Rodriguez-GalindoC,McCarvilleME,ShulkinBL.PET-CTin pediatric Langerhans cell histiocytosis. Pediatr Radiol 2007;37:615-22.
29. Lau LM, Stuurman K, Weitzman S. Skeletal Langerhans cell histiocytosis in children: Permanent consequences and health-related quality of life in long term survivors. Pediatr Blood Cancer 2008;50: 607-12. Kumar, et al.: Multifocal recurrent eosinophilic granuloma with vertebra plana : A case report 76

How to Cite this Article:  Kumar A, Sinha S, Saraf SK, Gupta V, Rani D, Kumari J | Year Radiological Follow-Up of Multifocal Recurrent Eosinophilic Granuloma With Vertebra Plana: A Case Report and Review of Literature | July-December 2018; 4(2): 32-36.
 

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The Role of Imaging in Diagnosis and Management of Congenital High Scapula (Sprengel’s Deformity): Case Report and Review

Volume 4 | Issue 2 | July-December 2018 | Page: 27-31 | Nada Garrouche, Saida Jerbi, Nedra Chouchane, Wassia Kessomtini, Hssine Hamza

DOI- 10.13107/ijpo.2018.v04i02.015

Authors: Nada Garrouche, Saida Jerbi, Nedra Chouchane, Wassia Kessomtini [1], Hssine Hamza

Departments of Radiology and, [1] Physical Medicine Rehabilitation, Taher Sfar University Hospital, Mahdia- Tunisia

Address of Correspondence
Dr. Nada Garrouche,
Rue Habib Zine el Abidine n°200 (7) Sahloul 2 Sousse 4054-Tunisia.
E-mail: nadagarrouche@yahoo.fr

Abstract

Sprengel’s deformity is the congenital failure of descent of the scapula. The diagnosis is based on a clinical examination and radiological procedures. Volume rendering three-dimensional computed tomography reconstructions analyze the precise topography and spatial proportions of examined bone structures. It enables an optional rotation of visualized bone structures to clarify the anatomical abnormalities. Ultrasound and magnetic resonance are useful in prenatal management and for the diagnosis of concomitant abnormalities. In this paper, we report our imaging experience from one child with Sprengel’s deformity and discuss the importance of imaging techniques with a particular focus on the role of three-dimensional reconstructions.
Keywords: Congenital high scapula, CT, MRI, Sprengel’s deformity, ultrasound, volume rendering 3D-CT

References 

1. Cho TJ, Choi IH, Chung CY, Hwang JK. The Sprengel deformity. Morphometric analysis using 3D-CT and its clinical relevance. J Bone Joint Surg Br 2000;82:711-8.
2. Dilli A, Ayaz UY, Damar C, Ersan O, Hekimoglu B. Sprengel deformity: Magnetic resonance imaging findings in two pediatric cases. J Clin Imaging Sci 2011;1:13.
3. Horwitz AE. Congenital elevation of the scapula–Sprengel’s deformity. Am J Orthop Surg 1908;s2-6:260-311.
4. Grogan DP, Stanley EA, Bobechko WP. The congenital undescended scapula. Surgical correction by the Woodward procedure. Bone Joint J 1983;65:598-605.
5. Gonen E, Simsek U, Solak S, Bektaser B, Ates Y, Aydin E. Long-ter results of modified Green method in Sprengel’s deformity. J Chil Orthop 2010;4:309-14.
6. Bindoudi A, Kariki EP, Vasiliadis K, Tsitouridis I. The rare Sprengel deformity: Our experience with three cases. J Clin Imaging Sci 2014;4:55.
7. Siu KK, Ko JY, Huang CC, Wang FS, Chen JM, Wong T. Woodwar procedure improves shoulder function in Sprengel deformity. Chang Gung Med J 2011;34:403-9.
8. Nakamura N, Inaba Y, Machida J, Saito T. Use of glenoid inclination angle for the assessment of unilateral congenital high scapula. J Pediatr Orthop B 2016;25:54-61.
9. Stein-Wexler R. The Shoulder: Congenital and Developmental Conditions. Pediatric Orthopedic Imaging. Berlin Heidelberg: Springer; 2015. p. 129-39.
10. Greitemann B, Rondhuis JJ, Karbowski A. Treatment of congenital elevation of the scapula: 10 (2–18) year follow-up of 37 cases of Sprengel’s deformity. Acta Orthop Scand 1993;64:365-8.
11. Füllbier L, Tanner P, Henkes H, Hopf NJ. Omovertebral bone associated with Sprengel deformity and Klippel-Feil syndrome leading to cervical myelopathy. J Neurosurg Spine 2010;13:224-8.
12. Chinn DH. Prenatal ultrasonographic diagnosis of Sprengel’s deformity. J Ultrasound Med 2001;20:693-7.
13. Cavendish ME. Congenital elevation of the scapula. J Bone Joint Surg Br 1972;54:395-408.
14. Rockwood CA. Rockwood and Matsen’s the shoulder. Elsevier; 2017.
15. van der Molen AJ, Prokop M, Galanski M, Schaefer-Prokop CM. Spiral and Multislice Computed Tomography of the Body. Stuttgart, New York: Georg Thieme Verlag; 2003.
16. Yuksel M, Karabiber H, Yuksel KZ, Parmaksiz G. Diagnostic importance of 3D CT images in Klippel-Feil syndrome with multiple skeletal anomalies: A case report. Korean J Radiol 2005;6:278-81.
17. Rasul ME, Reddy AV. The sprengel deformity. Int J Res Med Sci 2015;3:3869-71.
18. Rockwood CA. The shoulder. Vol. 1, Ch. 3, Elsevier Health Sciences;2009. p. 120-4.
19. Andrin J, Macaron C, Pottecher P, Martz P, Baulot E, Trouilloud P, et al. Determination of a new computed tomography method for measuring the glenoid version and comparing with a reference method. Radio-anatomical and retrospective study. Int Orthop 2016;40:525-9.
20. Friedman RJ, Hawthorne KB, Genez BM. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg Am 1992;74:1032-7.
21. Nyffeler RW, Jost B, Pfirrmann CW, Gerber C. Measurement of glenoid version: conventional radiographs versus computed tomography scans. J Shoulder Elbow Surg 2003;12:493-6.
22. Hamner DL, Hall JE. Sprengel’s deformity associated witmultidirectional shoulder instability. J Pediatr Orthop 1995;15: 641-3.
23. Guillaume R, Nectoux E, Bigot J, Vandenbussche L, Fron D, Mézel A, et al. Congenital high scapula (Sprengel’s deformity): Four cases. Diagn Interv Imaging 2012;93:878-83.
24. Wada A, Nakamura T, Fujii T, Takamura K, Yanagida H, Yamaguchi T, et al. Sprengel deformity: Morphometric assessment and surgical treatment by the modified green procedure. J Pediatr Orthop 2014;34:55-62.
25. Woodward JW. Congenital elevation of the scapula. J Bone Joint Surg Am 1961;43:219-28.

How to Cite this Article:  Garrouche N, Jerbi S, Chouchane N, Kessomtini W, Hamza H The Role of Imaging in Diagnosis and Management of Congenital High Scapula (Sprengel’s Deformity): Case Report and Review | July-December 2018; 4(2): 27-31.

 

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Amputation Following Meningococcal Septicaemia in Children: the Surgical Management of the Residual Limb

Volume 4 | Issue 2 | July-December 2018 | Page: 20-26 | Brigid M. Aherne, Fergal P. Monsell

DOI- 10.13107/ijpo.2018.v04i02.014

Authors: Brigid M. Aherne, Fergal P. Monsell [1]

 

Medical Student, University of Bristol, [1] Consultant Orthopaedic Surgeon, Bristol Royal Hospital for Children, Bristol, England, United Kingdom.

Address of Correspondence
Mr. Fergal P. Monsell,
Bristol Royal Hospital for Children, Upper Maudlin St, Bristol BS2 8BJ, England, United Kingdom.
E-mail: Fergal.Monsell@UHBristol.nhs.uk

Abstract

Background: Meningococcal septicaemia is a potentially life-threatening disease and remains the most common infective cause of mortality in the UK. Improvements in healthcare have led to early recognition and treatment, and a decrease in mortality. As more children now survive the initial acute illness, the long-term musculoskeletal consequences have become more prevalent. These include growth plate injury, tissue loss and amputation. Patients with limb loss present specific difficulties due to the effect of remaining longitudinal growth on the function of the residual limb, and often require surgical treatment that continues throughout childhood.
Patients and Methods: This case series reviews the histories of 13 children who underwent amputation as a complication of meningococcal septicaemia. All patients attend a specialist clinic and our experience in the management of the residual limb is described.
Results: Thirteen patients, with a mean age of 16 months at the onset of meningococcal septicaemia, required amputation in the management of the skeletal consequences of the infection. Revision surgery was necessary for all 13 patients and involved management of bone overgrowth, growth arrest, scar and soft tissue contracture, neuroma development, and infection. The details of our approach to each of these complications is described.
Conclusion: Due to improvements in diagnosis and initial management, a significant proportion of patients are surviving infantile meningococcal septicaemia. Many develop musculoskeletal consequences including amputation, and this case series serves to increase knowledge in the complex managements of the residual limb in these patients.
Keywords: Amputation, meningococcal septicaemia, residual limb

References 

1. Paize F, Playfor SD. Improvements in the outcome of children with meningococcal disease. Crit Care 2007;11:172.
2. Maat M, Buysse CM, Emonts M, Spanjaard L, Joosten KF, De Groot R, et al. Improved survival of children with sepsis and purpura: Effects of age, gender, and era. Crit Care 2007;11:R112.
3. Nectoux E, Mezel A, Raux S, Fron D, Maillet M, Herbaux B. Meningococcal purpura fulminans in children: I. Initial orthopedic management. J Child Orthop 2010;4:401-7.
4. de Kleijn ED, Hazelzet JA, Kornelisse RF, de Groot R. Pathophysiology of meningococcal sepsis in children. Eur J Pediatr 1998;157:869-80.
5. Davies MS, Nadel S, Habibi P, Levin M, Hunt DM. The orthopaedic management of peripheral ischaemia in meningococcal septicaemia in children. J Bone Joint Surg Br 2000;82:383-6.
6. Belthur MV, Bradish CE, Gibbons PJ. Late orthopaedic sequelae following meningococcal septicaemia. J Bone Joint Surg Br 2005;87:236-40.
7. Booy R, Habibi P, Nadel S, de Munter C, Britto J, Morrison A, et al. Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery. Arch Dis Child 2001;85:386-90.
8. Monsell FP, McBride AR, Barnes JR, Kirubanandan R. Angular deformity of the ankle with sparing of the distal fibula following meningococcal septicaemia: A case series involving 14 ankles in ten children. J Bone Joint Surg Br 2011;93:1131-3.
9. Monsell F. The skeletal consequences of meningococcal septicaemia. Arch Dis Child 2012;97:539-44.
10. Nectoux E, Mezel A, Raux S, Fron D, Klein C, Herbaux B. Meningococcal purpura fulminans in children. II: Late orthopedic sequelae management. J Child Orthop 2010;4:409-16.
11. Park DH, Bradish CF. The management of the orthopaedic sequelae of meningococcal septicaemia: Patients treated to skeletal maturity. J Bone Joint Surg Br 2011;93:984-9.
12. Buysse CM, Oranje AP, Zuidema E, Hazelzet JA, Hop WC, Diepstraten AF, et al. Long-term skin scarring and orthopaedic sequelae in survivors of meningococcal septic shock. Arch Dis Child 2009;94:381-6.
13. Nogi J. Physeal arrest in purpura fulminans − A report of 3 cases. J Bone Joint Surg Am 1989;71:929-31.
14. Wheeler JS, Anderson BJ, De Chalain TM. Surgical interventionsin children with meningococcal purpura fulminans − A review of 117 procedures in 21 children. J Pediatr Surg 2003;38: 597-603.
15. Grogan DP, Love SM, Ogden JA, Millar EA, Johnson LO. Chondro-osseous growth abnormalities after meningococcemia − A clinical and histopathological study. J Bone Joint Surg Am 1989;71:920-8.

How to Cite this Article:  Aherne BM, Monsell FP | Amputation Following Meningococcal Septicaemia in Children: the Surgical Management of the Residual Limb | July-December 2018; 4(2): 20-26.
 

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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.
2. Canale ST, Beaty JH. Congenital anomalies of the lower limb. Campbell’s Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier 2007. p. 937-55.
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.
5. Omololu B, Ogunlade SO, Alonge TO. Pattern of congenital orthopaedic malformations in an African Teaching Hospital. West Afr J Med 2005;24:92-5.
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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Step-cut Translation Osteotomy and Y-plate Fixation: A Novel Method for Correction of Cubitus Varus and Valgus Deformity

Volume 4 | Issue 1 | January-June 2018 | Page: 12-15 | Kumar Shashi Kant, Vikas Gupta

DOI- 10.13107/ijpo.2018.v04i01.004

Authors: Kumar Shashi Kant, Vikas Gupta [1]

Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalya, [1] Central Institute of Orthopaedics, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi, India

Address of Correspondence
Dr. Vikas Gupta,
Central Institute of Orthopaedics, Vardhaman Mahavir Medical College, Safdarjang Hospital, New Delhi – 110 029, India.
E-mail: drvikas@hotmail.com

Abstract

Introduction: Many types of osteotomy have been proposed for the treatment of cubitus varus and valgus deformity. All these osteotomies have their advantages and disadvantages; however, till date there is no uniform consensus as to which osteotomy is the best suited for correction of these deformities. Materials and Methods: We reviewed the results of step-cut translation osteotomy in the management of cubitus varus and cubitus valgus deformity. This study includes 27 cases of cubitus varus and five cases of cubitus valgus deformity that underwent supracondylar step-cut translation osteotomy with Y-plate fixation for correction of the deformity. Results: The results were evaluated according to the modified criteria of Oppenheim et al. There were 25 excellent, six good, and one poor result. Overall, complication rate in our series was 12.5% (4/32). There was no recurrence of deformity in the available follow-up. Conclusions: Step-cut translation osteotomy is a relatively simple procedure that corrects cubitus varus and valgus deformities without any prominence of the medial or lateral condyle. Moreover, a wide osteotomy surface and rigid fixation allows early mobilization of the joint with good clinical results.
Keywords: Cubitus valgus, Cubitus varus, Step-cut osteotomy

References 

1. Skaggs DL, Glassman D, Weiss JM, Kay RM. A new surgical technique for the treatment of supracondylar humerus fracture malunions in children. J Child Orthop 2011;5:305-12.
2. Siris IE. Supracondylar fracture of the humerus: Analysis of 330 cases. Surg Gynecol Obstet 1939;68:201-22.
3. French PR. Varus deformity of the elbow following supracondylar fractures of the humerus in children. Lancet 1959;2:439-41.
4. King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg Am 1951;33-A:572-6.
5. Myint S, Molitor PJ. Dome osteotomy with T-plate fixation for cubitus varus deformity in an adult patient. J R Coll Surg Edinb 1988;43:352-4.
6. Tien YC, Chen JC, Fu YC, Chih TT, Huang PJ, Wang GJ. Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. J Bone Joint Surg Am 2005;87:1456-63.
7. Derosa GP, Graziano GP. A new osteotomy for cubitus varus. Clin Orthop Relat Res 1988;236:160-5.
8. Kim HT, Lee JS, Yoo CI. Management of cubitus varus and valgus. J Bone Joint Surg Am 2005;87:771-80.
9. Yamamoto I, Ishii S, Usui M, Ogino T, Kaneda K. Cubitus varus deformity following supracondylar fracture of the humerus: A method for measuring rotational deformity. Clin Orthop Relat Res 1985;(201):179-85.
10. El-Adl W. The equal limbs lateral closing wedge osteotomy for correction of cubitus varus in children. Acta Orthop Belg 2007;73:580-7.
11. Oppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res 1984;(188):34-9.
12. Chung MS, Baek GH. Three-dimensional corrective osteotomy for cubitus varus in adults. J Shoulder Elbow Surg 2003;12:472-5.
13. Chess DG, Leahey JL, Hyndman JC. Cubitus varus: Significant factors. J Paediatr Orthop 1994;14:190-2.
14. Labelle H, Bunnell WP, Duhaime M, Poitras B. Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop 1982;2:539-46.
15. Davids JR, Maquire MF, Mubarak SJ, Wenger DR. Lateral condylar fracture of the humerus following posttraumatic cubitus varus. J Pediatr Orthop 1994;14:466-70.
16. Takahara M, Sasaki I, Kimura T, Kato H, Minami A, Oqino T. Second fracture of the distal humerus after varus malunion of a supracondylar fracture in children. J Bone Joint Surg Br 1998;80:791-7.
17. Abe M, Ishizu T, Morikawa J. Posterolateral rotatory instability of the elbow after posttraumatic cubitus varus. J Shoulder Elbow Surg 1997;6:405-9.
18. O’Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings H 2nd, Morrey BF et al. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001;83:1358-69.
19. Abe M, Ishizu T, Shirai H, Okamoto M, Onomura T. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg Am 1995;20:5-9.
20. Griffin PP. Supracondylar fractures of the humerus. Treatment and complications. Pediatr Clin North Am 1975;22:477-86.
21. Ippolito E, Moneta MR, D’Arrigo C. Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am 1990;72:757-65.
22. Wong HK, Lee EH, Balasubramaniam P. The lateral condylar prominence. A complication of supracondylar osteotomy for cubitus varus. J Bone Joint Surg Br 1990;72:859-61.
23. Song HR, Cho SH, Jeong ST, Park YJ, Koo KH. Supracondylar osteotomy with Ilizarov fixation for elbow deformities in adults. J Bone Joint Surg Br 1997;79:748-52.

How to Cite this Article:  Kant KS, Gupta V | Step-cut translation osteotomy and Y-plate fixation: A novel method for correction of cubitus varus and valgus deformity | January-June 2018; 4(1): 12-15.

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Comparison of Two Different Medial Reference Points for Measurements of the Acetabular Index

Volume 4 | Issue 1 | January-June 2018 | Page: 07-11 | Sandeep Vijayan, Dhiren Ganjwala, Hitesh Shah

DOI- 10.13107/ijpo.2018.v04i01.003

Authors: Sandeep Vijayan, Dhiren Ganjwala [1], Hitesh Shah

Department of Orthopaedics, Paediatric Orthopaedic Service, Kasturba Medical College, Manipal, Karnataka,
[1] Paediatric Orthopaedic Service, Ganjwala Orthopaedic Hospital, Ahmedabad, Gujarat, India.

Address of Correspondence
Dr. Hitesh Shah,
Department of Orthopaedics, Kasturba Medical College, Manipal – 576 104, Karnataka, India.
E-mail: hiteshshah12@gmail.com

Abstract

Introduction: Acetabular index (AI) is a commonly used quantitative measurement of acetabular inclination in plain radiographs. Repeated measurements of this index are used to determine dysplasia in children and for decision making about surgical management. Persistent acetabular dysplasia may be an indication for performing an acetabuloplasty. AI is commonly measured between the Hilgenreiner’s line (line that connects both triradiate cartilages) and the line joining lateral most ossified margin of the acetabulum and triradiate cartilage. Two different methods for measurement of AI with two different medial reference points at the triradiate cartilage have appeared in the literature. Aim: The specific aim of the study was to investigate the difference between AI measurements with two different methods and report on intraobserver and interobserver reliability of both the methods. Materials and Methods: Ninety-eight children with developmental dysplasia of the hip (DDH) (treated and untreated), younger than 9 years, were included in the study. Anteroposterior radiographs of the pelvis having acceptable pelvic rotation and pelvic tilt were included in the study. AI was measured using two different reference points for the affected and normal sides. AI was measured twice at 1-month interval by two investigators. The difference between the two measurement techniques was compared by the paired “t” test. Pearson’s correlation coefficient was calculated to test associations between the two measurement techniques. Results: The reproducibility of measurements of both the techniques was found satisfactory [intraclass correlation (ICC)-0.90 and 0.87]. Statistically significant difference (P value < 0.001) (5.7° for affected and 5.3° for normal side) between the indices measured by two techniques was noted. This difference was noted for all age groups. Significant positive correlations between both the techniques were noted in normal as well as dysplastic hips. Conclusion: Acetabular indices measured with two different medial points gave significantly different values. All subsequent assessment should be consistently carried out by the same method.
Keywords: Acetabular index, Acetabuloplasty, Developmental dysplasia of hip, Medial reference point

References 

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How to Cite this Article:  Vijayan S, Ganjwala D, Shah H | Comparison of two different medial reference points for measurements of the acetabular index| International Journal of Paediatric Orthopaedics | January-June 2018; 4(1): 07-11.

 

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