Faculty Bibliography

One hundred and thirty-seven idiopathic clubfeet were treated by the Ponseti technique and followed for at least 2 years. Nine feet (7%) were not corrected with initial casting and required early surgery. Recurrence after correction was related to compliance with bracing. At latest follow-up, two-thirds of those noncompliant with brace had recurrences with one-third of these recurrences requiring more extensive surgery than Achilles tenotomy and anterior tibial tendon transfer while only 14% of those compliant with brace had recurrences with none requiring more than Achilles tenotomy and anterior tibial tendon transfer. Early failures and recurrences constituted about 20% of our 137 feet by 2 years of follow-up. When the Ponseti method was fully followed, including initial casting, compliance with brace and treatment of recurrences by recasting, Achilles tenotomy and/or anterior tibial tendon transfer, our success rate was 93%

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

Plain radiographs are commonly used to evaluate the degree of bone healing after an osteotomy and the application of an external fixator. The purpose of the study was to assess intraobserver and interobserver reliability in determining bone healing, defined as bridging callus across three of four cortices, of osteotomy sites on radiographs. Substantial intraobserver reliability and a high intraobserver percentage agreement were found. Interobserver reliability was moderate and interobserver percentage agreement was less than half for agreement between all involved orthopaedic surgeons. The lower reliability across surgeons suggests that the determination of the extent of the bone healing is subjective

A 17-month-old boy with a toed-out left lower extremity was presented for evaluation. Before coming to the doctor, the mother had applied a zinc oxide lotion to treat a simple diaper rash in the groin. The radiologist did not remove the boy's diaper for the radiographic examination and so did not notice the lotion. The first radiograph showed what looked like multiple soft-tissue calcifications in the groin, but the radiopacities had been produced by the zinc oxide. This case serves as a reminder to be aware that metal-containing substances both on and in the body can produce radiopacities

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 group's 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

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 > or = 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 > or = 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

A relatively simple triple pelvic osteotomy using two cosmetically small skin incisions can provide excellent coverage of the femoral head. An adductor approach and a bikini approach are used to do the osteotomy. The 'almost' percutaneous pelvic osteotomy successfully increases femoral head coverage in a concentric hip joint. The VCA angle of Lequesne and the center-edge angle of Wiberg both show significant improvement in the coverage of the femoral head. Three-dimensional computed tomography scanograms may provide a more graphic representation before and after surgery. Preoperatively, this is especially useful in evaluating posterior acetabular coverage of the femoral head. The almost percutaneous pelvic osteotomy is another possible triple pelvic osteotomy for procedures for hip dysplasia. It has a relatively low learning curve in comparison with other triple pelvic osteotomies for hip dysplasia in children aged 6-14 years. With careful patient selection, femoral head coverage can be improved with small incisions that are cosmetically acceptable

Medical records and radiographs of 17 known cases of slipped capital femoral epiphysis, treated with in-situ pin fixation and complicated by chondrolysis were reviewed. Fourteen of these 17 hips that developed chondrolysis had definite evidence of pin penetration of the femoral head. One hip had intra-articular pin penetration of the femoral neck. In the remaining two hips, the pins were placed within the anterolateral quadrant of the femoral head and within 2 mm of the articular surface. Overall, this is an 88% incidence of definite intra-articular pin penetration on postoperative radiographs, and a 100% rate if the two probable cases are included. This suggests a correlation between pin penetration and the development of chondrolysis following slipped capital femoral epiphysis.