Christof Radler

Torsional profile versus gait analysis: Consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity.

Measurements of femoral and tibial torsion obtained from radiographs or computed tomographic scans have been used to describe rotational malalignment of the lower extremities and to clarify indications for surgery. A weak relationship between anatomic torsion deformity and the resulting transverse plane gait pattern in patients with cerebral palsy has been described, but the observations have not yet been tested in an able-bodied patient population. We conducted a prospective study to investigate the correlation of femoral torsion and tibial torsion as measured by using computed tomography with transverse plane gait data for patients with rotational malalignment. Twenty-six lower limbs from 26 patients selected for surgery based on gait analysis were evaluated. Calculation of Pearson correlations showed that increase of femoral anteversion resulted in increase of pelvic range of motion. A very weak correlation between femoral torsion and hip rotation (determination coefficient, R(2)=0.22) was found in a linear regression model, whereas tibial torsion and knee rotation showed a strong correlation (determination coefficient, R(2)=0.71). The correlation between the foot progression angle and tibial torsion was higher than between the foot progression angle and femoral torsion. We conclude that there is a considerable dynamic influence of mechanisms of compensation, especially in the hip, that should be considered when evaluating the torsional profile. We therefore recommend conducting three-dimensional instrumented gait analysis for patients undergoing surgical correction of rotational malalignment.

Radiographic Evaluation of Idiopathic Clubfeet Undergoing Ponseti Treatment

BACKGROUND The Ponseti method for treatment of idiopathic clubfeet involves the use of serial casts, percutaneous Achilles tenotomy in most cases, and bracing with an abduction orthosis to prevent relapse. Although Ponseti recommended evaluation of the infant clubfoot strictly by palpation, many orthopaedic surgeons still rely on radiographs for decision-making during treatment. The aim of this study was to document with radiographs the effect of percutaneous Achilles tenotomy as described by Ponseti. METHODS We conducted a study of idiopathic clubfeet treated, at two centers, with the Ponseti method, including percutaneous Achilles tenotomy. Cast treatment was started within three weeks after birth, and radiographs were made before and after the tenotomy. Lateral radiographs with the foot in maximal dorsiflexion at the ankle were made for all patients, and anteroposterior radiographs of the foot were made at one center. The lateral tibiocalcaneal angle, the anteroposterior talocalcaneal angle, and the lateral talocalcaneal angle were measured on the radiographs. Foot dorsiflexion at the ankle was evaluated clinically. The results from both centers were evaluated separately and in combination. RESULTS Lateral dorsiflexion radiographs that showed the foot and ankle were evaluated for eighty-seven clubfeet, and anteroposterior radiographs that showed the foot were evaluated for sixty-five clubfeet. The mean improvement in the lateral tibiocalcaneal angle after the tenotomy was 16.9 degrees . The mean change in the anteroposterior talocalcaneal angle was 2.1 degrees , and the mean change in the lateral talocalcaneal angle change was 1.4 degrees . The mean increase in clinically measured dorsiflexion after the tenotomy (in sixty-five feet) was 15.1 degrees . Only the lateral tibiocalcaneal angle and dorsiflexion as measured clinically changed significantly after the Achilles tenotomy (p < 0.05). When the results at each center were analyzed separately, they were found to be nearly identical. CONCLUSIONS The increase in the lateral tibiocalcaneal angle after Achilles tenotomy is essentially the same as the increase in ankle dorsiflexion seen on clinical examination. The anteroposterior and lateral talocalcaneal angles are not influenced significantly by the tenotomy. Radiographs confirmed that the additional dorsiflexion obtained from the percutaneous Achilles tenotomy is true dorsiflexion occurring in the ankle and hindfoot and not in the midfoot. LEVEL OF EVIDENCE Therapeutic Level IV.

External fixation in clubfoot treatment - a review of the literature

The treatment of neglected or relapsed clubfoot is still a challenge. Extensive open surgeries may lead to postoperative scarring and various complications.Gradual distraction using circular fixators for treatment of these cases was described by many researchers in the last decades. Different techniques were used with and without open surgeries. Recently the Taylor Spatial Frame was described for clubfoot correction using the principles of the Ponseti technique. Results of treatment using different techniques are described in this review. External fixation with soft tissue distraction even without open surgery is an effective treatment for neglected or relapsed clubfoot.

Results of Gait Analysis Including the Oxford Foot Model in Children with Clubfoot Treated with the Ponseti Method

BACKGROUND The aim of the study was to evaluate how clubfeet treated with the Ponseti method compare with control feet in gait analysis and whether additional information can be provided by the Oxford foot model. METHODS All patients with a minimum age of three years in our prospective database of clubfeet treated with the Ponseti method were considered for inclusion. Exclusion criteria were an associated syndrome or neurological disease, positional (slight) clubfoot, and presentation at an age of more than three months. Of the 125 patients with 199 clubfeet who satisfied the criteria, thirty-six (29%) agreed to participate in the study. Four of these were excluded because of insufficient gait analysis data, leaving thirty-two patients with fifty clubfeet for evaluation. Clinical examination and three-dimensional gait analysis including the Oxford foot model were performed, and a disease-specific questionnaire was administered. Kinetic and kinematic results were compared with those of an age-matched control group (n = 15). RESULTS The mean score on the disease-specific questionnaire was 83.5. Gait analysis showed significantly decreased range of motion, plantar flexion, and power of the ankle compared with controls. The mean external foot progression angle of 5.7° in the Ponseti group was slightly less than that in the controls. Slight intoeing occurred in 24%, and 12% did not achieve a neutral position during swing phase. Slight compensation was observed, including external rotation of the hip in 28%. The Oxford foot model revealed differences in foot motion between the groups. CONCLUSIONS Clubfoot treatment with the Ponseti method yielded good clinical results with high functional scores. Three-dimensional gait analysis demonstrated distinctive but slight deviations. Intoeing was less frequent and less severe compared with groups in the literature. We recommend the use of three-dimensional gait analysis, including a foot model, as an objective tool for evaluation of the results of clubfoot treatment. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Knee deformity in congenital longitudinal deficiencies of the lower extremity.

The knee has various pathologic appearances in patients with congenital longitudinal deformities of the lower extremities. Radiographs from 39 patients with unilateral longitudinal congenital deficiencies of the lower extremities were analyzed to describe epiphyseal and metaphyseal configurations and position of the epiphyseal plate. We defined 22 radiographic parameters of the femur and tibia, calculated the mean values, and compared the parameters of the affected knee with the unaffected knee for patients in different age groups. In the femur, we observed hypoplasia of the lateral condyle in width and height. In the tibia, the lateral condylar hypoplasia was manifest primarily by lateral horizontal deficiency. Age group comparisons showed no horizontal epiphyseal deficiencies in the older patients, but there was persistence of vertical epiphyseal deficiencies. Bony deformities in congenital longitudinal deficiencies mainly were attributable to dysplasia of the lateral epiphysis in the distal femur and proximal tibia, whereas positions of the epiphyseal plate had varying physiologic values. Level of Evidence: Diagnostic study, Level II. See the Guidelines for Authors for a complete description of levels of evidence.

Interobserver Reliability of Radiographic Measurements of Contralateral Feet of Pediatric Patients with Unilateral Clubfoot

BACKGROUND Radiographs have traditionally been used to describe and quantify foot deformities in infants and children. We hypothesized that the interobserver reliability of measurements obtained from radiographs of pediatric feet would be low, especially with regard to the infant foot, and that normal ranges and standard deviations would decrease in association with increasing patient age. METHODS We retrospectively reviewed 494 radiographs of 121 patients treated for unilateral clubfoot at our institution and studied the contralateral normal foot. All anteroposterior radiographs, lateral radiographs, and lateral radiographs made with the foot in maximum dorsiflexion were analyzed by three observers, and the values were recorded. The databases created by the three observers were statistically analyzed according to five predefined age groups (birth to less than three months, three months to less than twelve months, twelve months to less than three years, three years to less than seven years, and seven years to less than fourteen years). RESULTS The anteroposterior talocalcaneal angle was rated as having good interobserver reliability (i.e., an intraclass correlation coefficient of 0.61 to 0.80) for all patients in each age group. Other angles that were associated with good interobserver reliability were the anteroposterior calcaneus-fifth metatarsal angle in the twelve months to less than three-year age group, the three-year to less than seven-year age group, and the seven-year to less than fourteen-year age group; the lateral talocalcaneal angle in the three-year to less than seven-year age group; the lateral tibiotalar angle in the three-year to less than seven-year age group; and the lateral talus-first metatarsal angle in the seven-year to less than fourteen-year age group. All other angles were rated as having very good interobserver reliability (i.e., an intraclass correlation coefficient of 0.81 to 1). The mean difference and the maximum difference among the observers decreased for all angles in nearly all age groups. CONCLUSIONS Interobserver reliability with regard to the radiographic measurement of pediatric feet was higher than expected, although measurement discrepancies can be as great as 30° with the infant foot. Interobserver reliability tended to improve with increasing patient age. The standard deviation showed a trend toward a decrease as patient age increased, although the trend was less notable than expected.

Broad spectrum of skeletal malformation complex in patients with cleidocranial dysplasia syndrome: radiographic and tomographic study.

Purpose Cleidocranial dysplasia is an autosomal dominant disorder characterized by defective ossification of the intramembraneous ossification (primarily the clavicles, cranium, and pelvis), and it is caused by mutations in the RUNX2 gene that is responsible for osteoblast differentiation. Spine deformities were of progressive nature and considered to be the major orthopedic abnormalities encountered in our practice in patients with cleidocranial dysplasia. We aimed to further delineate the underlying spine pathology and its etiological understanding. Extraspinal deformities were dealt with respectively. Material and Methods In this paper, we describe 7 patients who were consistent with the phenotypic and the genotypic characterization of cleidocranial dysplasia. Reformatted computed tomography (CT) scans have been applied in several instances to further understand the underlying pathology of progressive spine tilting. Radiographs were sufficient to illustrate other skeletal malformations. Results Anatomical survey demonstrates that a broad spectrum of frequently unrecognized orthopedic aberrations were encountered. We believe that torticollis has evolved in connection with the persistence of synchondrosis of the skull base and the upper cervical spine and these are strongly correlated to the well-known pathology of posterior occipital synchondrosis. Similarly, scoliosis and kyphoscoliosis resulted from the pathologic aberration of the cartilaginous stage of disrupted embryological development. All our results are discussed for the first time. Coxa vara, patellar dysplasia, and genu valgum were observed as extraspinal deformities. Conclusion This paper includes for the first time the anatomical analysis of the malformation complex of the craniocervical and the entire spine in patients with cleidocranial dysplasia. Reformatted CT scan was the modality of choice. We were able to illustrate that the persistence of skull base and the cervical spine synchondrosis were correlated with the pathological mechanism of the posterior occipital synchondrosis. Therefore, injuries to the craniocervical region in these patients might lead to a wide range of dreadful complications, ranging from complete atlanto-occipital or atlanto-axial dislocation to nondisplaced occipital condyle avulsion fractures with the possibility of morbid and or mortal outcome. On the other hand, the persistence of a cartilaginous spine was the reason behind the progressive spine tilting. This pathological form can be considered as a notoriously unpredictable malformation complex. The value of presenting these patients is to demonsterate that the genotype is not a precise index to assess the severity and the natural history of the phenotype.

Nerve structures at risk in the plantar side of the foot during anterior tibial tendon transfer: a cadaver study.

BACKGROUND Anterior tibial tendon transfer is a common procedure for treatment of clubfoot recurrence. Fixation of the tendon usually includes passing the tendon through the lateral cuneiform. Drilling the bone and passing sutures through the plantar aspect of the foot may cause neurovascular damage. METHODS Anterior tibial tendon transfer was performed through the lateral cuneiform in twelve cadaveric limbs. Drill holes were made perpendicular to the lateral cuneiform surface (group A), made perpendicular to the weight-bearing surface (group B), inclined 15° in the frontal and sagittal planes (group C), or aimed at the middle of the plantar aspect of the foot (group D). Two unmodified Keith needles and two blunted Keith needles were each passed ten times per foot. A dissection was performed. The average distance from the drill hole to the nerve structures and the number of punctures of nerve structures were reported. RESULTS In group A, the drill hole was 1.7 mm from a medial plantar nerve branch and 5 mm from the nerve bifurcation. In group B, the hole was 0.3 mm from a branch of the lateral plantar nerve and 25.3 mm from the lateral plantar nerve bifurcation. The drill hole in group C was 1.7 mm from the lateral plantar nerve bifurcation. In group D, the drill direction resulted in an inclination of 22° in the frontal plane and 4° in the sagittal plane. The drill exited 7.7 mm from a medial plantar nerve branch and 4.3 mm from a lateral plantar nerve branch. The medial and lateral plantar nerve bifurcations were at a distance of 13 mm and 14.7 mm, respectively, from the drill hole in group D. Unmodified Keith needles punctured nerve structures twelve times in group A, twenty times in group B, six times in group C, and once in group D. Use of blunted Keith needles resulted in no nerve punctures. CONCLUSIONS When anchoring the transferred anterior tibial tendon in the lateral cuneiform for the treatment of clubfoot recurrence, the drill should be aimed at the middle of the plantar surface of the foot to minimize the risk of nerve damage. Passing the sutures with a blunt needle might prevent damage to nerves or vessels when anterior tibial tendon transfer to the lateral cuneiform is performed for the treatment of clubfoot recurrence.

Advanced ossification of the carpal bones, and monkey wrench appearance of the femora, features suggestive of a propable mild form of desbeqious dysplasia: a case report and review of the literature

IntoductionAdvanced bone maturation is a radiographic feature that might be encountered in a number of different forms of skeletal dysplasias such as Desbuquois dyspalsia, Larsen syndrome, the Reunion Island form of Larsen syndrome, diastrophic dysplasia, acrodysostosis, Catel-Manzke syndrome, a variant of metatropic dysplasia and Maroteaux-lamy syndrome.Case presentationWe report on a 2-year- old boy from Slovakia was born to non-consanguineous parents. Prenatal and postnatal growth parameters were normal. Clubfoot and genu valgum were the most prominent orthopaedic abnormalities. Radiographic documentation showed bone age of 4 years and 8 months associated with the appearance of accessory ossification centers. Monkey wrench appearance of the proximal femora was a characteristic finding associated with significant vertebral changes.ConclusionThe major skeletal changes in our patient include advanced carpal ossification, monkey wrench appearance of the proximal femora associated with significant vertebral changes. No joint dislocations, no hitchhiker thumbs and or dysmorphic facial features were present. The normality of his growth, facial features, intelligence, and palate as well as the characteristic radiographic features were to certain extent in favour of a mild form of Desbuquois dysplasia. Additional laboratory findings allowed us to exclude other disorders with abnormal metabolic parameters such as mucopolysaccharoidosis.

Treatment of Severe Recurrent Clubfoot

Understanding the pathoanatomy of severe recurrent clubfoot and its implication on treatment options is important for the successful treatment. A comprehensive clinical evaluation of the different components helps in selecting procedures. Individual needs and social and psychological factors influencing treatment and the impact of treatment on the child have to be considered. With increasing dissemination and improved understanding of the Ponseti method, a further decrease in the frequency of severe recurrent clubfoot can be hoped for and expected.