Benjamin Joseph

Management of severe crouch gait in children and adolescents with cerebral palsy.

Background Crouch gait in cerebral palsy is associated with spasticity and contracture of the hamstrings and weakness of the extensors of the hip and knee and ankle plantar flexors. Different treatment options have been described in the literature to deal with this difficult problem. We devised a different protocol of treatment aimed at correction of the flexion deformity of the knee, weakening of the hamstrings, and augmenting the power of the knee and hip extension, which we used on 17 children with severe crouch. Methods This surgery, performed in 2 stages, entailed shortening of the femur, plication of the patellar tendon, transfer of the semitendinous to the back of the femur, and fractional lengthening of the other hamstrings. The degree of fixed deformity, the popliteal angle, quadriceps power, range of knee motion, ambulatory status and the efficiency of gait, and the position of the patella were evaluated before surgery and again after a minimum 2-year follow-up. Results The gait improved and the power of the quadriceps and the range of knee motion increased. The flexion deformity and popliteal angle decreased significantly. Patella alta was corrected and all fragmentation of the tibial tuberosity and fractures of the patella healed. The Functional Mobility Scores and the ambulatory capacity increased in all the children. There was no evidence of damage to the sciatic nerve in any patient. Conclusions The method of treatment of severe crouch gait outlined in this study seems to be an effective and safe method of dealing with this difficult problem. Study Design Level of evidence: IV.

The choice of intramedullary devices for the femur and the tibia in osteogenesis imperfecta.

The results of intramedullary rodding of 50 femoral and 25 tibial segments were analyzed retrospectively. The techniques of femoral rodding included single Rush rodding, dual Rush rodding and Sheffield telescoping rodding. Single Rush rods or Sheffield rods were used in the tibia. The frequencies of fractures following rodding and implant-related complications and the interval between initial rodding and rod revision were analyzed. The longevity of the rods was evaluated by survival analysis. In the femur, dual Rush rods and Sheffield rods were equally effective and both were superior to a single Rush rod with reference to each of the outcome variables. The technique of dual Rush rodding was more demanding than telescoping rodding. In the tibia, a single Rush rod was as effective as a Sheffield telescoping rod. Based on our results, a single Rush rod would be the preferred implant in the tibia while in the femur, dual Rush rods or a Sheffield telescoping rod may be preferred.

Evaluation of outcome of treatment of congenital clubfoot.

Abstract: The study was undertaken to determine whether existing systems of outcome evaluation of clubfoot are comparable; to determine the relationship between the shape of the foot, its function, and radiological tarsal relationships; and to identify which objective variables used in the assessment of clubfeet are reproducible. Fifty treated idiopathic clubfeet were assessed by the scoring systems of Laaveg and Ponseti, McKay, Magone, and Ghanem and Seringe. Although there was a good correlation between the scores, there was very poor agreement between the grading of feet by these different systems. The feet were also evaluated using a new scoring system that has 3 domains of evaluation, viz, morphological, functional, and radiological. Comparison of the scores in each of these domains showed that there was a correlation between morphology, function, and radiological measurements of tarsal alignment. Several of the criteria used in this new scoring system were reproducible.

Evaluation of the hemi-Cincinnati incision for posteromedial soft-tissue release in clubfoot

Posteromedial soft-tissue release operations were performed on 42 idiopathic clubfeet in children younger than 2 years of age through the medial half of the Cincinnati incision (the hemi-Cincinnati incision). This incision gave adequate exposure to all structures to be released. Wound closure was possible in all 42 feet without having to hold the foot in plantarflexion or inversion. Wound healing was satisfactory in the majority of instances and 81% of the scars, assessed 9 months after the operation, were graded as excellent or good. The scar is located in an area of the foot that can be concealed easily and should a more radical soft-tissue operation be needed later, the same incision can be extended easily. The authors recommend this incision as the incision of choice for performing posteromedial soft-tissue release operations on clubfeet in children younger than 2 years of age.

Congenital aplasia of the patella and the distal third of the quadriceps mechanism.

Congenital absence of the patella and aplasia of the muscles are very rare anomalies. We describe a 4-year-old boy with bilateral congenital aplasia of the patella and agenesis of the distal third of the quadriceps muscle who was unable to walk owing to the lack of active knee extension. The features of this child differed from all other conditions associated with patellar aplasia. The continuity of the quadriceps mechanism was restored and he began walking normally. This appears to be the first report of the combination of aplasia of the patella and the distal third of the quadriceps that was successfully treated.

The use of a working model for teaching functional and applied surgical anatomy of the subtalar joint.

Background: Some aspects of functional and applied anatomy may be difficult to conceptualize if taught by conventional methods. In such situations, alternative methods of teaching may need to be adopted. This study was undertaken to evaluate whether a working model can facilitate understanding of the functional and applied surgical anatomy of the subtalar joint. Methods: A working model of the articulated talus and calcaneus was constructed and used to explain the mechanics of motion of the subtalar joint, the rationale of release of structures to correct hindfoot deformity in clubfoot, principles of tendon transfers, and the rationale of extra-articular subtalar joint arthrodesis. Twenty-four orthopedic residents were divided into two groups (A and B). Group A was taught these specific concepts of functional and applied anatomy with the help of the model, while Group B was taught the same concepts with a written text and diagrams. The level of knowledge of both groups was evaluated by a test with multiple-choice questions. A week later, Group A was given the text while Group B was shown the model. Both groups then answered a questionnaire assessing the value of the model in enhancing their understanding of the subject. Results: In the test, the performance of students in Group A was better than those in Group B. Students of both groups felt that the model gave them a much clearer understanding of the functional anatomy of the subtalar joint. Conclusions: We conclude that this simple, inexpensive model is a valuable teaching aid that helps students to understand the surgical anatomy of the subtalar joint. Clinical relevance: Surgeons can use this model to effectively teach trainees in this field about the mechanics and anatomy of the subtalar joint and other relevant applications.

Does proximal femoral varus osteotomy in Legg–Calvé–Perthes disease predispose to angular mal-alignment of the knee? A clinical and radiographic study at skeletal maturity

BackgroundThough there is an impression that proximal femoral varus osteotomy (FVO) can result in a valgus deformity at the knee there is no agreement on this issue. This study was undertaken to ascertain whether a FVO predisposes to the development of genu valgum in children with Legg–Calvé–Perthes disease (LCPD).MethodsOne hundred and one children with unilateral LCPD who underwent a FVO during the active stage of the disease and 32 children who were treated non-operatively were followed till skeletal maturity. The FVO was performed with a 20° varus angulation in all the patients and weight-bearing was not permitted till the stage of reconstitution. The alignment of the knee was assessed clinically at skeletal maturity. A subset of 33 operated children also had full length standing radiographs of the limbs. The mechanical axis deviation, femur-tibial angle, lateral distal femoral angle and the medial proximal tibial angle of both limbs were measured on these radiographs.ResultsThe frequency of clinically appreciable mal-alignment of the knee was not greater on the affected side in patients who had undergone FVO when compared to the unaffected limb and also when compared to the affected limb in non-operated patients. The mechanical axis of the lower limb of operated children was relatively in more valgus than that of normal limbs but they fell within the normal range.ConclusionThis study does not support the impression that a proximal femoral osteotomy for LCPD predisposes to clinically discernable degrees of genu valgum in children who have had 20° of varus angulation at the osteotomy site and who have avoided weight-bearing for a prolonged period following surgery. Further studies are needed to clarify if genu valgum would develop if early post-operative weight-bearing is permitted.Level of evidenceIII.

The fate of the joint space in Legg-Calvé-Perthes' disease

ObjectiveThis study was undertaken to identify variations in the hip joint space in patients with healed Legg–Calvé–Perthes’ disease (LCPD) and to correlate these changes with the radiological outcome of treatment.MethodsThe width of the joint space was measured on radiographs of 121 skeletally mature individuals with healed LCPD. The joint space width at the stage of healing in 79 patients was compared with the joint space at skeletal maturity. The hips were graded by the Stulberg classification and the femoral head radius was measured. Associations between the joint space width, the Stulberg class and the femoral head radius were tested. The reproducibility of measurement was tested by measuring 30 radiographs twice and computing the intra-class correlation coefficient (ICC). The joint space width was measured on radiographs of 25 patients taken both while recumbent and standing, to determine if the joint space alters on weight-bearing.ResultsThe reproducibility of measurements was satisfactory; no difference was noted in the joint space in recumbent and weight-bearing films. Increased joint space was noted both at healing of the disease and at skeletal maturity; the width was minimally increased in Stulberg Class I hips and considerably increased in Class III, IV and V hips. There was a significant correlation between the increase in joint space and enlargement of the femoral head.ConclusionsAn increase in joint space width occurs quite frequently following LCPD; the increase is most evident in hips with a poor outcome. The implications of this observation need to be elucidated.

Management of a Flail Foot in Cauda Equina Syndrome by Neoligament Tenodesis : A Case Report

Paralysis of all the muscles around the ankle and foot with loss of sensation on the sole after traumatic cauda equina syndrome results in three distinct problems. First, during the swing phase of gait, the foot drop necessitates a high-stepping gait which is both unsightly and energy inefficient. Second, the hindfoot is unstable because of paralysis of both the invertors and the evertors. Third, there is a risk of neuropathic ulcers developing under the metatarsal heads because of uncontrolled toe contact at the initiation of the stance phase of gait. To overcome these problems, the ideal procedure would prevent the foot drop, retain passive dorsiflexion of the ankle, stabilize the subtalar joint, and not stiffen the joints of the foot. Currently available options include the use of an orthosis or operative stabilization. The operative options include a Lambrinudi type of triple arthrodesis, a pantalar arthrodesis, or a triple arthrodesis combined with a posterior bone block operation.2 None of these procedures fulfill all the criteria listed; this report describes a procedure that does.