Lior Shabtai

Worldwide spread of the Ponseti method for clubfoot

The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. This has been demonstrated by the increase in Ponseti related PubMed publications from many countries. We found evidence of Ponseti activity in 113 of 193 United Nations members. The contribution of many organizations which provide resources to healthcare practitioners in low and middle income countries, as well as Ponseti champions and modern communication technology, have helped to spread the Ponseti method around the world. Despite this, there are many countries where the Ponseti method is not being used, as well as many large countries in which the extent of activity is unknown. With its low rate of complication, low cost, and high effectiveness, this method has unlimited potential to treat clubfoot in both developed and undeveloped countries. Our listing of countries who have not yet shown presence of Ponseti activity will help non-governmental organizations to target those countries which still need the most help.

Limits of Growth Modulation Using Tension Band Plates in the Lower Extremities.

Growth modulation using tension band plates (TBP) has been shown to be a safe, effective, and popular method for correcting pediatric frontal plane angular deformity around the knee. Recently, TBPs have been used to achieve reversible epiphysiodesis to treat limb-length discrepancy. Many surgeons have expanded the indications to include diagnoses other than frontal plane angular deformities, anatomic sites other than the knee, and correction of sagittal and oblique plane deformities. Despite the rapid acceptance of TBPs, the limits of this option have not been explored. We undertook a systematic literature review and found that the success rate for idiopathic cases approaches 100% with a low complication rate. Pathologic cases have a slightly lower success rate and a higher complication rate. The potential to avoid osteotomy with growth modulation makes TBPs a reasonable option for all but the most extreme pediatric frontal and sagittal plane lower extremity deformities. Applications to hip deformities remain unproven.

Radiographic Indicators of Surgery and Functional Outcome in Ponseti-Treated Clubfeet

Background: Evaluation of the results of treatment for clubfoot by the Ponseti technique is based on clinical and functional parameters. There is a need to establish universally recognized quantitative measurements to compare, better understand, and more precisely evaluate therapeutic outcome. Methods: Nine angles were measured on standard radiographs of 145 children with idiopathic clubfeet treated between 2000 and 2010 with the Ponseti method. The average follow-up was 6.3 years. The need for additional surgery and the functional outcome was correlated to the radiologic measurements. Results: Three radiologic parameters were identified as having significant (P ≤ .001) predictive value. The lateral tibiocalcaneal angle with the ankle at maximal dorsiflexion measuring fixed equinus was larger in the preoperated group (77 ± 12 degrees) compared to the nonoperated group (67 ± 14 degrees). Functional outcome was better with smaller angles. The lateral talocalcaneal angle with the ankle at maximal dorsiflexion measuring hindfoot rigidity was smaller (29 ± 8 degrees) in the preoperated group compared to the nonoperated group (35 ± 9 degrees). Functional outcome was better with larger angles. The lateral talo-first metatarsal angle with the ankle at maximal plantarflexion measuring foot cavus was larger in the preoperated group (31 ± 10 degrees) compared to the nonoperated group (22 ± 11 degrees), whereas functional outcome did not correlate with this angle. Conclusions: The lateral view with the foot in maximal dorsiflexion was found to be the most significant and useful view to detect abnormality in Ponseti-treated clubfeet. In our practice now, we are using only this view in order to reduce the radiation exposure to the child. Level of Evidence: Level III, retrospective case series.

Custom Knee Device for Knee Contractures After Internal Femoral Lengthening.

The development of knee flexion contractures is among the most common problems and complications associated with lengthening the femur with an internal device or external fixator. Conservative treatment strategies include physical therapy, serial casting, and low-load prolonged stretching with commercially available splinting systems. The authors developed an individually molded, low-cost custom knee device with polyester synthetic conformable casting material to treat knee flexion contractures. The goal of this study was to evaluate the results of treatment with a custom knee device and specialized physical therapy in patients who had knee flexion contracture during femoral lengthening with an intramedullary lengthening femoral nail. This retrospective study included 23 patients (27 limbs) who underwent femoral lengthening with an internal device for the treatment of limb length discrepancy. All patients had a knee flexion contracture raging from 10° to 90° during the lengthening process and were treated with a custom knee device and specialized physical therapy. The average flexion contracture before treatment was 36°. The mean amount of lengthening was 5.4 cm. After an average of 3.8 weeks of use of the custom knee device, only 2 of 27 limbs (7.5%) had not achieved complete resolution of the flexion contracture. The average final extension was 1.4°. Only 7 of 27 limbs (26%) required additional soft tissue release. The custom knee device is an inexpensive and effective method for treating knee flexion contracture after lengthening with an internal device.

Muscle strength and knee range of motion after femoral lengthening.

Background and purpose — Femoral lengthening may result in decrease in knee range of motion (ROM) and quadriceps and hamstring muscle weakness. We evaluated preoperative and postoperative knee ROM, hamstring muscle strength, and quadriceps muscle strength in a diverse group of patients undergoing femoral lengthening. We hypothesized that lengthening would not result in a significant change in knee ROM or muscle strength. Patients and methods — This prospective study of 48 patients (mean age 27 (9–60) years) compared ROM and muscle strength before and after femoral lengthening. Patient age, amount of lengthening, percent lengthening, level of osteotomy, fixation time, and method of lengthening were also evaluated regarding knee ROM and strength. The average length of follow-up was 2.9 (2.0–4.7) years. Results — Mean amount of lengthening was 5.2 (2.4–11.0) cm. The difference between preoperative and final knee flexion ROM was 2° for the overall group. Congenital shortening cases lost an average of 5% or 6° of terminal knee flexion, developmental cases lost an average of 3% or 4°, and posttraumatic cases regained all motion. The difference in quadriceps strength at 45° preoperatively and after lengthening was not statistically or clinically significant (2.7 Nm; p = 0.06). Age, amount of lengthening, percent lengthening, osteotomy level, fixation time, and lengthening method had no statistically significant influence on knee ROM or quadriceps strength at final follow-up. Interpretation — Most variables had no effect on ROM or strength, and higher age did not appear to be a limiting factor for femoral lengthening. Patients with congenital causes were most affected in terms of knee flexion.

Fibular Hemimelia: Principles and Techniques of Management

Children with fibular hemimelia (FH) present with a short lower leg of varying degrees of severity, often accompanied by a wide range of associated anomalies of the ipsilateral foot, ankle, and knee. Mild cases need only appropriately timed contralateral epiphysiodesis. Moderate cases require tibial lengthening, with realignment of the ankle in selected cases. For severe cases, the choice comes down to amputation versus limb salvage. One of the biggest challenges in limb salvage is to obtain a plantigrade foot. For the stiff equinovalgus ankle (the most common severe manifestation of FH), special reconstruction techniques are recommended to achieve a plantigrade foot. The knee may require anterior or posterior cruciate ligament reconstruction. Knee valgus is often treated by growth modulation. Associated congenital femoral deficiency should be addressed, either with lengthening or with contralateral epiphysiodesis. In summary, treatment of FH must be individualized according to the needs and expectations of each family/child and the reconstructive options available regionally.

Congenital tibial pseudarthrosis, changes in treatment protocol.

Ten children with congenital pseudarthrosis of the tibia were treated with resection of pathologic bone, bone grafting, intramedullary rodding, compression with circular frame, simultaneous proximal tibia lengthening, and bone morphologic proteins. Thirteen operations were performed to achieve union. Four patients underwent simultaneous lengthening and four patients received recombinant human bone morphologic protein. Six children required complementary operations for residual ankle and knee valgus, and shortening. Union of the pseudarthrosis was achieved in all cases with lengthening up to 5 cm. This protocol is effective in achieving union of congenital pseudarthrosis of tibia; attention should be paid to the ankle joint to achieve functionality of the limb.