Michael G. Uglow

The management of slipped capital femoral epiphysis

Sir, We read with interest the article by Uglow and Clarke[1][1] in the July 2004 issue entitled ‘The management of slipped capital femoral epiphysis’. While we found most of the article to be an excellent review and discussion, we must take exception to the recommended management of the

The functional outcome of staged surgery for the correction of talipes equinovarus.

Between 1988 and 1995, 110 idiopathic clubfeet from a cohort of 120 recalcitrant feet in 86 patients requiring surgical treatment were studied. There were 61 male and 25 female patients. The mean age at surgery was 9.5 months. In 91 feet, the surgery consisted of an initial plantarmedial release, followed 2 weeks later by a posterolateral release. Nineteen feet required only a posterolateral release. Feet were categorised preoperatively and prospectively according to a system suggested by Dimeglio into four groups, and the rates of relapse and wound healing data were previously reported. This paper reports the functional outcome of this cohort of idiopathic clubfeet and the results are related to the preoperative grade, the patients gender, the age at which the child first walked, and whether the deformity is unilateral or bilateral. The interim functional outcome is good in the majority of cases despite a high rate of relapse in the more severe deformities.

Residual Clubfoot in Children

The deformities encountered in any patient who has residual clubfoot comprise various degrees of equinus, varus, adduction, supination, cavus, and toe deformity. Joint flexibility or stiffness, tarsal dysmorphism, articular incongruence, and progressive degrees of degeneration may be present. Add to this the scars of previous attempts at correction and various etiologic factors, and surgeons can find that treatment solutions are far from straightforward. A philosophy of careful history, examination, investigation, and surgery à la carte will provide a safe foundation for treating patients who have these often complex and difficult problems. A surgical strategy progressing from proximal to distal, performing soft tissue surgery before fixed deformity occurs, extra-articular osteotomies to correct bony deformity, and augmentation with rebalancing of soft tissue-deforming forces will help improve pain and function for many patients. Joint fusions should be reserved as a last salvage option to avoid future degeneration of adjacent joints.

Distal radio-ulnar joint subluxation following intramedullary nailing of the radius in a child.

We describe a patient with fractures of both bones of the forearm in whom flexible intramedullary nail fixation of the radius alone led to ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Wound problems in surgery for talipes equinovarus.

The traditional treatment for talipes equinovarus (TEV) has been open surgery inmany units around the world. The complication rates for primary corrective surgery are relatively small but may affect outcome significantly. The complications of surgery in relapsed TEV are more frequent than for primary surgery, and problems relating to wound healing present difficult challenges to the treating surgeon. An overview of the approaches to management of this still challenging condition are presented, and the factors involved in wound healing problems and strategies for their prevention and treatment are presented. In particular, the belated but rapid spread worldwide of the Ponseti nonoperative approach to treating talipes is the most important factor in reducing the rates of surgery and therefore the complications that may ensue.

Percutaneous Pediatric Foot and Ankle Surgery

The techniques for performing percutaneous osteotomies in treating deformities of the foot in children are presented along with a detailed description of the operative details. The authors use of minimal-access surgery for tibial, os calcis, and midfoot osteotomies is described using a cooled side-cutting burr that has not previously been described for use in the childs foot. The cancellous nature of the bones in the child are easily cut with the burr and the adjacent soft tissues are not damaged. The early experience of the healing times are not impaired and the complications associated with percutaneous scars seem to be negligible.

CONGENITAL DISLOCATION OF THE HIP IN EXTRAUTERINE PREGNANCY

Only two cases have been reported of congenital dislocation of the hip in infants born after extrauterine pregnancies. We report a further two and discuss the management and the variable outcome. These cases seem to confirm that congenital dislocation of the hip is associated with moulding forces rather than being a teratological abnormality.