Debra A. Sala

Postoperative Weight-bearing after a Fracture of the Femoral Neck or an Intertrochanteric Fracture*

Sixty patients who had had operative treatment of a fracture of the femoral neck or an intertrochanteric fracture were allowed to bear weight as tolerated on the injured limb. The average age was seventy-seven years. Computerized gait-testing was performed at one, two, three, six, and twelve weeks postoperatively to quantify weight-bearing. For the purpose of analysis, the patients were divided into three groups according to whether they had internal fixation of a stable fracture, internal fixation of an unstable fracture, or a primary hemiarthroplasty. Thirty-two patients completed the entire twelve-week study. The average amount of weight that these patients placed on the injured limb increased progressively with time. The average load supported by the injured limb was 51 per cent that of the uninjured limb at one week, and it gradually increased to 87 per cent at twelve weeks. During the first three weeks, the patients who had had internal fixation bore substantially less weight than those who had had a hemiarthroplasty. By six weeks, we could detect no significant differences, with the numbers available, among the groups with regard to weight-bearing or other measured gait parameters. We concluded that elderly patients who are allowed to bear weight as tolerated after operative treatment of a fracture of the femoral neck or an intertrochanteric fracture appear to voluntarily limit loading of the injured limb.

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet.

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores ≥5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of ≥5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

Use of the foot abduction orthosis following Ponseti casts: Is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant groups scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.

Developmental implications of idiopathic toe walking

OBJECTIVE To determine whether children with persistent toe walking, without suspected developmental problems, and with normal results after neurologic examination, who were seen in an orthopedic clinic demonstrate delays in language development, gross or fine motor skills, visuomotor development, sensory integration function, or evidence of behavioral problems through a comprehensive multidisciplinary evaluation. STUDY DESIGN A prospective, descriptive study of 13 children (mean age = 3.9 years) referred for idiopathic toe walking. Each child was evaluated by a pediatric neurologist, developmental pediatrician, speech/language pathologist, occupational therapist, and physical therapist. RESULTS On developmental screening, 7 of 13 children demonstrated delays and 3 were questionably delayed; all 10 had speech/language deficits. Speech/language evaluation showed that 10 of 13 (77%) had receptive or expressive language delays or both. Occupational and physical therapy evaluations found 4 of 12 (33%) had fine motor delays, 4 of 10 (40%) had visuomotor delays, and 3 of 11 (27%) had gross motor delays. CONCLUSIONS Idiopathic toe walking was most often associated with speech/language delays, but delays in other areas were also present. We suggest that idiopathic toe walking should be viewed as a marker for developmental problems and recommend that any child with this condition should be referred for a developmental assessment.

Subfascial Implantation of Intrathecal Baclofen Pumps in Children: Technical Note

OBJECTIVEIndwelling intrathecal drug delivery systems are becoming increasingly important as a method of neuromodulation within the nervous system. In particular, intrathecal baclofen therapy has shown efficacy and safety in the management of spasticity and dystonia in children. The most common complications leading to explantation of the pumps are skin breakdown and infection at the pump implantation site. The pediatric population poses particular challenges with regard to these complications because appropriate candidates for intrathecal baclofen therapy are often undernourished and thus have a dearth of soft tissue mass to cover a subcutaneously implanted baclofen pump. We report a technique of subfascial implantation that provides greater soft tissue coverage of the pump, thereby reducing the potential for skin breakdown and improving the cosmetic appearance of the implantation site. METHODSEighteen consecutively treated children (average age, 8 yr, 7 mo) with spasticity and/or dystonia underwent subfascial implantation of a baclofen pump. These children’s mean weight of 42.9 lb is less than the expected weight for a group of children in this age group, ranging from 4 years, 8 months, to 15 years, 7 months. In all patients, the pump was inserted into a pocket surgically constructed between the rectus abdominus and the external oblique muscles and the respective anterior fascial layers. RESULTSAt an average follow-up of 13.7 months, no infection or skin breakdown had occurred at the pump surgical site in any of the 18 patients. CONCLUSIONAt this early follow-up, the subfascial implantation technique was associated with a reduced rate of local wound and pump infections and provided optimal cosmetic results as compared with that observed in retrospective cases.

Accuracy of correction of tibia vara: acute versus gradual correction.

The purpose was to assess the accuracy of deformity correction achieved in patients with tibia vara using acute intraoperative correction compared with gradual postoperative correction. Acute correction (AC) group consisted of 14 patients (14 tibiae) with a mean age of 11.4 years and whose tibia vara was corrected acutely and held using an EBI external fixator. Gradual correction (GC) group consisted of 18 patients (18 tibiae) with a mean age of 10.2 years and whose tibia vara was corrected gradually using 6-axis deformity analysis and Taylor Spatial Frame. Deformity measurements were compared preoperatively, postoperatively, and at latest follow-up. At latest follow-up, medial proximal tibial angle deviation from normal was similar for the 2 groups; posterior proximal tibial angle was significantly greater in the AC group (5.6 degrees) than in the GC group (1.9 degrees). Mechanical axis deviation was significantly greater in the AC group (17.1 mm) than in the GC group (3.1 mm). Postoperatively, frequency of accurate translation corrections (achieved translation within 5 mm of preoperative required translation) was significantly greater in the GC group (18/18) than in the AC group (7/14). Frequency of accurate angulation corrections (medial proximal tibial angle within 3 degrees of normal and posterior proximal tibial angle within 5 degrees of normal) was significantly greater in the GC group (17/18) than in the AC group (7/14). For both groups, all tibiae with preoperative internal rotation deformity had accurate rotation correction. Correction of preoperative limb-length inequality was achieved in 5 of the 7 patients in the AC group and 11 of the 11 patients in the GC group. Gradual deformity correction is a more accurate treatment method of tibia vara than acute correction.

Effect of Articular Step-off and Meniscectomy on Joint Alignment and Contact Pressures for Fractures of the Lateral Tibial Plateau

Objectives To determine the effects of intraarticular step-off and lateral meniscectomy on the alignment of the articular axis, contact area, and pressures for lateral tibial plateau fractures. Design Biomechanical cadaver study. Intervention Six fresh cadaveric knees were used. A simulated split fracture of the lateral tibial plateau was reproducibly created by osteotomies, and articular step-offs of zero, one, two, four, and six millimeters were achieved by using support shims. The knee was loaded with 500 newtons in 0 degrees and 350 newtons in 30 degrees of flexion. A digital camera determined changes in the alignment of the articular axis, and F-Scan sensors were inserted into the medial and lateral joint compartments to determine the pressures and pressure distributions. Main Outcome Measurement Each specimen was tested at step-offs of zero, one, two, four, and six millimeters, with the presence or absence of the lateral meniscus. The changes in alignment of the articular axis, the contact area, and the average and maximum contact pressures for each condyle were obtained. Results Increased articular step-off heights progressively increased valgus angulation and average and maximum contact pressures and progressively decreased contact areas in lateral compartment. At a six-millimeter step-off with 0 degrees of flexion, the valgus angle increased an average of 7.6 degrees, and average contact pressures and maximum contact pressures increased an average of 208 percent and 97 percent, respectively, and contact area decreased an average of 33 percent (p < 0.05). Meniscectomy increased valgus angles by an average of 38 percent and contact pressures by an average of 45 percent and decreased contact areas by 26 percent in the lateral compartment at the same articular step-off heights (p < 0.05). Conclusion The results of this study show the importance of decreasing articular step-off heights in treating lateral tibial plateau split fractures, particularly if a meniscectomy is performed.

Idiopathic toe-walking: a review

Debra A Sala* MS PT, Research Physical Therapist, Center for Neuromuscular and Developmental Disorders, Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003; Lisa H Shulman MD, Assistant Clinical Professor of Pediatrics, Director of Infant/Toddler Services, Children’s Evaluation and Rehabilitation Center, Rose F Kennedy, Center University Affiliated Programs, Albert Einstein College of Medicine, Bronx; Alfred D Grant MD, Clinical Professor, New York University Department of Orthopedics; Mary Lynn Y Chu MD, Associate Director, Center for Neuromuscular and Developmental Disorders, Hospital for Joint Diseases, New York, NY 10003, USA.

Clubfoot classification: correlation with Ponseti cast treatment.

Background Many different clubfoot classification systems have been proposed, but no single one is universally accepted. Two frequently cited systems, developed by Dimeglio/Bensahel and Catterall/Pirani, are often used for evaluation purposes in the treatment of idiopathic clubfoot. Our hypothesis was that the initial scores would be positively correlated with the number of casts required for clubfoot correction, indicating to us that the more severe score would require more casts, and therefore truly show the accuracy and usefulness of the scoring system. Methods From May 2000 to April 2008, 123 patients (185 feet) with idiopathic clubfeet were treated. All patients were below 60 days of age (mean 15.3 d, range: 2 to 57 d) at the time of their initial evaluation, and had not received prior clubfoot treatment. All cast placements were under the supervision of the same pediatric orthopedic surgeon. Initial correction was achieved in all patients. Results The mean number of casts required for correction was 5.1 (range: 2 to 8). On the basis of number of casts required, no significant differences were found in final total scores (Dimeglio/Bensahel P=0.14 and Catterall/Pirani P=0.44), indicating a similar level of correction for all feet. The Dimeglio/Bensahel and Catterall/Pirani classification systems were both similarly, poorly correlated with the number of casts needed [Spearman rank correlation coefficients (rs)=0.34 vs. 0.33]. The 2 components with the highest correlations were equinus (rs=0.39) and forefoot adduction (rs=0.35) for the Dimeglio/Bensahel system and coverage of the lateral head of the talus (rs=0.40) and rigid equinus (rs=0.39) for the Catterall/Pirani system. Conclusions When using the initial scores, both the Dimeglio/Bensahel and Catterall/Pirani classification systems had a low correlation with the number of Ponseti casts required. Analysis of the individual components revealed variability in the coefficients, with some having low-to-moderate correlation and others having none. There was no difference between the Dimeglio/Bensahel and Catterall/Pirani classification systems when measuring their correlation with the number of Ponseti casts required for clubfoot correction. An improved classification system is needed to predict the length of treatment and, ultimately, the risk of recurrence. Level of Evidence Prognostic Level IV.

Correction of Arthrogrypotic Clubfoot With a Modified Ponseti Technique

Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3–40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4–12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12–18 and 2–9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5–6.0 and 0.0–2.0), and maximum passive dorsiflexion from −45° (range, −75° to −20°) to 10° (range, 0° to 40°). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13–70 months), the mean maximum dorsiflexion was 5° (range, –20° to 20°), two patients had posterior releases and no patient’s ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.