Bimalleolar Axis Research Articles

Increased external rotation of the osteoarthritic knee joint according to the genu varum deformity.

To evaluate the rotational profile of the lower extremity using computed tomography (CT) in accordance with the degree of varus deformity in medial condyle-affected knee joint osteoarthritis (OA). This retrospective study included 1036 patients (872 lower extremities) with end-stage knee OA. The coronal alignment of the lower extremity was measured using standing anteroposterior radiography. The CT parameters of femoral anteversion and tibial torsion were assessed in relation to the knee joint. The axes were the femoral neck axis; the distal femoral axis, which was composed of the anterior trochlear axis, the clinical transepicondylar axis, and the posterior condylar axis; the axis of the proximal tibial condyles; and the bimalleolar axis. There was a tendency for increased external rotation of the knee joint parameters in relation to the hip and ankle joints as varus deformity of the lower extremity increased. The relative external rotational deformity of the knee joint in relation to the hip joint had a positive value with a good correlation. The relative external rotational deformity of the knee joint in relation to the ankle joint also demonstrated a positive value with a good correlation. The distal femur and proximal tibia (knee joint) tended to rotate externally in relation to the hip and ankle joint, respectively, as the degree of varus deformity increased. This study identified the relationship between lower extremity varus deformity and rotational deformity of knee joints with OA. III.

Lower extremity characteristics in recurrent clubfoot: Clinical and gait analysis findings that may influence decisions for additional surgery

BackgroundPatients with recurrent clubfoot may seek intervention to address impairments that impact gait function. An understanding of these impairments and associated gait issues will provide valuable information about ongoing treatment requirements. Research QuestionThe purpose of this study was to describe the prevalence of impairments and associated gait deviations in children with recurrent clubfoot and to evaluate whether these findings differ depending on unilateral or bilateral presentation. MethodsEighty-four affected feet (42 unilateral, 21 bilateral) were retrospectively reviewed. History, clinical exam, and gait data were collected. Statistical analysis included evaluations of associations between clinical exam and gait parameters and differences among patients with unilateral versus bilateral clubfoot and a database of healthy controls. ResultsThe average age was 7.5 ± 3.3 years for unilateral and 7.0 ± 2.8 years for bilateral patients. Patients presented with limited passive ankle dorsiflexion (unilateral/bilateral:67%/57%), limited ankle plantar flexion strength (unilateral/bilateral:53%/55%), metatarsus adductus (unilateral/bilateral:86%/83%) and internal foot-thigh angles (unilateral/bilateral:83%/82%), while only a subset presented with internal bi-malleolar axis angles (unilateral/bilateral:36%/45%). The most common gait deviations were internal foot progression (unilateral/bilateral:76%/73%), external hip rotation (unilateral/bilateral:66%/69%), reduced peak ankle plantar flexion moments (unilateral/bilateral:84%/83%), and reduced peak ankle power generation (unilateral/bilateral:67%/74%). Passive dorsiflexion was significantly correlated with peak dorsiflexion during stance and swing in both groups. Patients with unilateral compared to bilateral clubfoot showed decreased peak dorsiflexion and an associated knee flexor moment. SignificancePatients with recurrent clubfoot show gait deviations at the ankle that can be explained by joint level impairment and compensations at the knee, hip and pelvis. Patients with unilateral clubfoot typically show decreased dorsiflexion range of motion and associated greater gait impacts and compensations than bilateral clubfoot. Understanding the relationships between impairments and gait function and the implications of unilateral versus bilateral clubfoot will help improve prognostic ability and optimize future treatment outcomes.

Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture.

To define the pathoanatomy of the posterior malleolus fracture associated with a spiral distal tibia fracture to guide clamp and implant placement when treating these common injuries. Retrospective cohort. Level I trauma center. One hundred twenty-two spiral infraisthmal tibia fractures identified from a cohort of 922 tibia fractures undergoing intramedullary nailing over a 7-year period. We collected instances of intra-articular extension seen on preoperative, intraoperative, or postoperative imaging. For patients with a posterior malleolus fracture and computed tomography imaging, we used an axial image 2-3 mm above the articular surface to create a fracture map. Intra-articular extension was present in 84 patients (68.9%), with posterior malleolus fractures occurring most commonly (n = 59, 48.4%). Other fractures included plafond fractures (n = 8), medial malleolus fractures (n = 7), anterior-inferior tibiofibular ligament avulsions (n = 5), and other anterior fractures (n = 5). Forty-one of 44 (93%) posterior malleolus fractures with cross-sectional imaging were Haraguchi type I (posterolateral-oblique type) with an average angle of 24 degrees off the bimalleolar axis. The remaining 3 were type II (transverse-medial extension type) fractures. Posterior malleolus fractures were visible 61% of the time on preoperative radiographs. Posterior malleolus fractures occur in approximately half of spiral distal tibia fractures and are consistently posterolateral in their morphology. This study can be used to enhance evaluation of the posterior malleolus intraoperatively (eg, ∼25 degrees external rotation view), and if the typical variant of posterior malleolus is identified, clamps and lag screws might be applied accordingly.

SYSTEMATIC REVIEW OF SURGICAL INDICATIONS FOR TIBIAL DEROTATIONAL OSTEOTOMY

Background: Tibial torsion is a lower extremity disorder of children and adolescents that may be idiopathic in nature. While spontaneous correction of the torsion occurs in the majority of patients during childhood, a small percentage of cases will persist into adulthood and can be associated with significant functional compromise due to patellofemoral instability, osteoarthritis, and anterior knee pain. Furthermore, late detection of tibial torsion may lead to compromise of other therapeutic efforts to alleviate symptoms. Idiopathic tibial torsion is best corrected by a tibial derotational osteotomy. However, determining which patients may benefit most from surgical correction is not well-understood, given the wide range of accepted values for normal tibial torsion depending on various measurement techniques. This review seeks to establish surgical indications for the procedure in a pediatric population with no underlying neurological, muscular, or osseous abnormalities. Methods: Systematic literature searches of 10 major databases and grey literature resources were conducted (Medline and Embase (via OVID), Cochrane Library, SPORTDiscus, Web of Science, Scopus, ClinicalTrials.gov, WHO ICTRP, and Global Index). Studies were screened by two independent reviewers based on previously established inclusion and exclusion criteria. Articles that focused on non-idiopathic torsion, such as torsion associated with neuromuscular causes, or that did not involve derotational osteotomy were excluded. Included studies were assessed for bias by two independent reviewers using GRADE and the Newcastle Ottawa Scale. Results: 911 articles were retrieved through the searches, 16 of which were ultimately included in the study. Due to the rarity of the condition, most authors studied a mixed population of skeletally mature and immature patients, except for one study. The most common surgical indications described were functional gait or cosmetic disability (70%), followed by patellofemoral instability and anterior knee pain (30%). Only a few articles cited numerical limits of abnormal torsion, and these depended on the method of measurement. Thigh-foot angle (TFA) was most often used (external torsion > 30°, internal torsion > 15°, and TFA > 2 or 3 standard deviations from the mean for the patient’s age). A bimalleolar axis with <20° external rotation was deemed excessively internally rotated. No numerical data was provided for defining abnormal foot-progression angle. Almost all authors recommended waiting until a patient was greater than 8 years old to allow for spontaneous correction of tibial torsion. Only two studies utilized computed tomography for pre- and post-operative assessment, given the cost of advanced imaging, and two other authors measured with gait analysis the effect of derotational tibial osteotomies on knee moments and ankle power. Conclusion/Significance: The diversity of measurement techniques and different anatomic references axes for describing tibial torsion has translated into a heterogenous set of surgical indications for tibial derotational osteotomies. At this time, the literature suggests that most correction procedures are decided by a patient’s functional and/or cosmetic disability. Further research is warranted to define clear standards and numerical values of tibial torsion that would benefit from surgical correction.

Surgical Versus Ponseti Approach for the Management of CTEV

Results from a comparative study of Ponseti versus surgical management for congenital talipes equino varus (CTEV), using historically managed patients, are presented. No bias existed in terms of management choice or participants recruited. Twenty-three surgically treated children (31 club feet; mean age 9.1 y) and 29 treated by the Ponseti technique (42 club feet; mean age 6.5 y) agreed to participate in the study. Twenty-six typically developing children (mean age 7.9 y) were also recruited as a control group. A physical examination and 3-dimensional gait analyses were carried out on all participants, and each child and his/her parent also, independently, completed the Oxford Ankle Foot Questionnaire (OxAFQ). The Ponseti group underwent fewer joint-invasive procedures than the surgical group. Passive range of dorsiflexion and plantarflexion were significantly less in the CTEV groups when compared with the control group (P<0.001), and plantarflexion was also significantly less in the surgical than in the Ponseti group (P<0.05). The bimalleolar axis was found to be significantly less in the CTEV groups than in the control group (P<0.001) and also significantly less in the surgical than in the Ponseti group (P<0.05). The gait deviation index, a gait score based on kinematics, showed a more normal gait pattern in the Ponseti group compared with the surgical group (P<0.001). The CTEV groups did not differ significantly from each other in terms of ankle sagittal and transverse plane kinematics or kinetics, but foot progression angle for the Ponseti group was external, whereas that for the surgical group was internal. The Ponseti group also scored higher than the surgical group in terms of patient satisfaction, with significantly better parent-rated OxAFQ scores in the "emotional" and "school and play" domains. The adoption of the Ponseti technique has resulted in fewer and less-invasive operations for our CTEV population, with accompanying improvement in the overall gait pattern (gait deviation index) and parent satisfaction (OxAFQ). Level III.

Tibiofibular torsion in congenital clubfoot

Tibiofibular torsion was measured by computed tomography in three series of patients affected by congenital clubfoot who were treated with different protocols. The normal leg of unilateral deformities served as the control. For the bilateral cases, only the right side was included in the study. The angle between the bicondylar axis of the tibia and the bimalleolar axis was the index of tibiofibular torsion. There were 34 clubfeet in the first series, treated with a posteromedial release, and 40 clubfeet in the second series, treated with a modified Ponseti method, whereas the third series included 16 clubfeet, treated with the original Ponseti method. All 90 clubfeet were graded at birth as group 3 according to the Manes classification. No patient had previous treatment. The patients of the first and the second series were followed up to maturity, whereas the patients of the third series were followed up to a maximum of 11 years of age. In the congenital clubfoot, the tibia and the fibula were externally rotated, in comparison with the normal leg; in fact, the average value of the angle of tibiofibular torsion was 32.2° in the first series, 23.9° in the second series, and 21.1° in the third series. In the normal tibiae, the average value of the angle of tibiofibular torsion was 21.4°. The difference between the first series and the normal controls was statistically significant, as was the difference between the first one and the other two series. The value of the tibiofibular torsion angle seems to be related to the manipulation technique used to treat clubfoot: when the manipulation does not allow a progressive eversion of the talus underneath the calcaneus, the external tibial torsion increases. At follow-up, an intoeing gait was present in seven treated clubfeet of the first series. In all of them except one, the highest value of the external tibial torsion angle was observed, with a low value of the Kite's angle and/or residual forefoot adduction. In the treated congenital clubfoot, persistent intoeing is not related to the angle of tibial torsion but rather to the amount of correction of calcaneal inversion and residual forefoot adduction.

Reliability of the assessment of lower limb torsion using computed tomography: analysis of five different techniques

Various methods have been described to define the femoral neck and distal tibial axes based on a single CT image. The most popular are the Hernandez and Weiner methods for defining the femoral neck axis and the Jend, Ulm, and bimalleolar methods for defining the distal tibial axis. The purpose of this study was to calculate the intra- and interobserver reliability of the above methods and to determine intermethod differences. Three physicians separately measured the rotational profile of 44 patients using CT examinations on two different occasions. The average age of patients was 36.3 ± 14.4 years, and there were 25 male and 19 female patients. After completing the first two sessions of measurements, one observer chose certain cuts at the levels of the femoral neck, femoral condylar area, tibial plateau, and distal tibia. The three physicians then repeated all measurements using these CT cuts. The greatest interclass correlation coefficients were achieved with the Hernandez (0.99 intra- and 0.93 interobserver correlations) and bimalleolar methods (0.99 intra- and 0.92 interobserver correlations) for measuring the femoral neck and distal tibia axes, respectively. A statistically significant decrease in the interobserver median absolute differences could be achieved through the use of predefined CT scans only for measurements of the femoral condylar axis and the distal tibial axis using the Ulm method. The bimalleolar axis method underestimated the tibial torsion angle by an average of 4.8° and 13° compared to the Ulm and Jend techniques, respectively. The methods with the greatest inter- and intraobserver reliabilities were the Hernandez and bimalleolar methods for measuring femoral anteversion and tibial torsion, respectively. The high intermethod differences make it difficult to compare measurements made with different methods.

The Availability of Radiological Measurement of Tibial Torsion: Three-Dimensional Computed Tomography Reconstruction

ObjectiveTo assess the intra-rater and inter-rater reliability for measuring tibial torsion measurements by a radiographic method using three-dimensional computed tomography reconstruction (3D-CT) and to compare the physical measures to those of 3D-CT.MethodThe study included 33 children who presented with intoeing gait. Tibial torsion was measured by 3D-CT. Distal reference point was the bimalleolar axis. Proximal reference points were the transtibial axis and posterior condylar axis. Physical measurements included thigh-foot angle (TFA) and bimalleolar angle (BMA). 3D-CT measurement and physical measurement were performed twice at both lower extremities by each rater. The intra-rater and inter-rater reliability were calculated by intraclass correlation coefficiency (ICC). The relationship between radiological and physical examination was calculated by Spearman correlation coefficient.ResultsThe 3D-CT measures for tibial torsion were reliable within individual raters and between different raters. However, physical measures for tibial torsion were reliable within an individual rater but not reliable between raters. The 3D-CT measures by any proximal reference axis were more reliable within a rater and between raters than physical measurements. There was no significant impact introduced by the selection of the proximal reference axis. The correlation coefficiency between 3D-CT and physical measurement methods was low.ConclusionBecause the 3D-CT measurements for tibial torsion are more reliable than physical measurements, we recommend that accurate diagnosis of internal tibial torsion should be detected by using 3D-CT measurements. Also, considering the disadvantages of radiological measurements, physical measurement may be used for short term follow-up by same raters, as intra-rater reliability is relatively good.

The neck–malleolar angle: an alternative method for measuring total lower limb torsion that considers the knee joint rotation angle

A greater understanding of the lower limb geometry is necessary for the correction of lower limb torsional deformities. The purpose of our study was to measure the normal values of knee torsion using CT and to introduce the neck-malleolar angle as an alternative for measuring lower limb torsion. We studied 77 consecutive CT studies performed from 2007 to 2009 in our clinic. In 67 cases, there was evidence of old trauma or surgical intervention to one limb, whereas the contralateral limb was healthy. The remaining 10 patients had no history of trauma or surgical intervention and were available for paired analysis in order to find the normal intraindividual variability. The whole limb, femoral and tibial torsion were measured according to the "Ulm method". Finally, the knee joint rotational angle and the neck-malleolar angle (the angle between the femoral neck axis and the bimalleolar axis) were measured. The average knee joint rotation angle was 2.4 ± 6.4° while the neck-malleolar angle was 13.2 ± 10.2°. Right to left side differences in healthy paired limbs for total limb rotation, knee joint rotation and the neck-malleolar angle were 6.1 ± 4.1°, 3.9 ± 2.8° and 7.5 ± 4.3° respectively. The mean absolute rotational differences between injured and healthy limbs was 14.5 ± 10.1°, whereas the mean absolute neck-malleolar differences amounted to 12.5 ± 9.9° (p = 0.013) indicating that the knee compensates for torsional asymmetries. The neck-malleolar angle takes into consideration the buffering effects of the knee joint in the transverse plane and contributes valuable additional information. Further studies including the long-term results of patients with torsional errors are important.

Treatment of posterior malleolar fractures by fixation with minimally invaslve percutaneous cannulated screws

Objective To discuss clinical results and techniques of treatment of posterior malleolar fractures by fixation with minimally invasive percutaneous cannulated screws. Methods A total of 18posterior malleolar fractures were treated with percutaneous cannulated screws (4.0 ram) between March 2004 and September 2006. According to Lauge-Hansen system, 14 were diagnosed as supination external rotation stage Ⅳ, and 4 as pronation external rotation stage Ⅳ. In all cases, the size of fragment exceeded 25% of the articular surface with displacement of more than 2 mm on the lateral radiograph. We studied the preoperative CT to determine the size of the posterior fragment, displacement and the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. After ORIF of outer and medial malleoli, the posterior malleolus was treated by minimally invasive osteosynthesis. Results Follow-ups of 16.5 (range, 6-35) months on average revealed that all cases healed. According to the Ankle Hindfoot Clinical Rating System of the American Orthopaedic Foot & Ankle Society (AOFAS), the results were rated as excellent in 11 cases, good in 5 cases,moderate in 1 case, and poor in 1 case, with the good-excellent rate being 88.9%. Conclusions Fixation with minimally invasive percutaneous cannulated screws is a good method with advantages of mini-invasion and rigid fixation. Careful preoperative plan according to CT scan is a prerequisite for good results. Key words: Posterior malleolar; Fracture; Fracture fixation,internal

Tibial torsion in non-arthritic Indian adults: A computer tomography study of 100 limbs

Background:Knowledge of normal tibial torsion is mandatory during total knee replacement (TKR), deformity correction and fracture management of tibia. Different values of tibial torsion have been found in different races due to biological and mechanical factors. Value of normal tibial torsion in Indian limbs is not known, hence this study to determine the norm of tibial torsional value in normal Indian population.Materials and Methods:Computer tomography (CT) scans were performed in 100 non-arthritic limbs of 50 Indian adults (42 males, eight females; age 26-40 years). Value of tibial torsion was measured using dorsal tangent to tibial condyles proximally and bimalleolar axis distally.Results:Normal tibial torsion was found to be 21.6 ± 7.6 (range 4.8 to 39.5) with none of the values in internal rotation. Right tibia was externally rotated by 2 degrees as compared to the left side (P 0.029). No significant difference was found in male and female subjects. Value of tibial torsion was less than in Caucasian limbs, but was comparable to Japanese limbs when studies using similar measurement technique were compared.Conclusions:Indian limbs have less tibial torsion than Caucasian limbs but the value of tibial torsion is comparable to Japanese limbs.

PATHOANATOMY OF POSTERIOR MALLEOLAR FRACTURES OF THE ANKLE

Background: The functional outcome following ankle fractures that involve a posterior malleolar fragment is often not satisfactory, and treatment of this type of fracture remains controversial. Thorough knowledge of the pathologic anatomy of the posterior malleolar fracture is essential for planning appropriate treatment. Thus, we conducted a computed tomographic study to clarify the pathologic anatomy of the posterior malleolar fracture. Methods: Between 1999 and 2003, fifty-seven consecutive patients with a unilateral ankle fracture with one or more posterior fragments were managed at our hospital. We reviewed the patients' preoperative computed tomographic scans to determine (1) the ratio of the posterior fragment area to the total cross-sectional area of the tibial plafond and (2) the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. Each fracture was categorized according to the location of the major fracture line on the computed tomographic image at the level of the tibial plafond. Results: The fifty-seven fractures were categorized into three types: (1) the posterolateral-oblique type (thirty-eight fractures; 67%), (2) the medial-extension type (eleven fractures; 19%), and (3) the small-shell type (eight fractures; 14%). Two of the eleven medial-extension fractures extended to the anterior part of the medial malleolus, and the other nine actually consisted of two fragments. The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. In the cases of seven of the nine fractures that comprised >25% of the tibial plafond, the fracture line extended to the medial malleolus. The angles between the bimalleolar axis and the major fracture line of the posterior malleolus varied. Conclusions: The fracture lines associated with posterior malleolar fractures appear to be highly variable. A large fragment extending to the medial malleolus existed in almost 20% of the posterior malleolar fractures in the current study, and some fragments involved almost the entire medial malleolus. Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. The information obtained from this study will be helpful for conducting basic research of this condition and for determining appropriate surgical approaches.

Pathoanatomy of Posterior Malleolar Fractures of the Ankle

The functional outcome following ankle fractures that involve a posterior malleolar fragment is often not satisfactory, and treatment of this type of fracture remains controversial. Thorough knowledge of the pathologic anatomy of the posterior malleolar fracture is essential for planning appropriate treatment. Thus, we conducted a computed tomographic study to clarify the pathologic anatomy of the posterior malleolar fracture. Between 1999 and 2003, fifty-seven consecutive patients with a unilateral ankle fracture with one or more posterior fragments were managed at our hospital. We reviewed the patients' preoperative computed tomographic scans to determine (1) the ratio of the posterior fragment area to the total cross-sectional area of the tibial plafond and (2) the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. Each fracture was categorized according to the location of the major fracture line on the computed tomographic image at the level of the tibial plafond. The fifty-seven fractures were categorized into three types: (1) the posterolateral-oblique type (thirty-eight fractures; 67%), (2) the medial-extension type (eleven fractures; 19%), and (3) the small-shell type (eight fractures; 14%). Two of the eleven medial-extension fractures extended to the anterior part of the medial malleolus. A total of nine of the eleven medial-extension fractures actually consisted of two fragments [corrected] The conditions are not exclusive of one another; for example, in the case of one of the fractures exhibiting two fragments, the fracture also extended to the anterior part of the medial malleolus [corrected] The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. In the cases of seven of the nine fractures that comprised >25% of the tibial plafond, the fracture line extended to the medial malleolus. The angles between the bimalleolar axis and the major fracture line of the posterior malleolus varied. The fracture lines associated with posterior malleolar fractures appear to be highly variable. A large fragment extending to the medial malleolus existed in almost 20% of the posterior malleolar fractures in the current study, and some fragments involved almost the entire medial malleolus. Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. The information obtained from this study will be helpful for conducting basic research of this condition and for determining appropriate surgical approaches.

Clubfoot Analysis With Three-Dimensional Foot Models

The purpose of this study was to develop a method of defining, in mathematical terms, the interpositional relationships of the bones of the hindfoot complex in the idiopathic clubfoot and the neurogenic clubfoot. The neurogenic clubfoot and contralateral normal-appearing foot of a stillborn infant with myelomeningocele, and the normal foot of a 10-year-old were sectioned with a cryomicrotome. Magnetic resonance images (MRIs) of the clubfoot and the normal foot of a 3-month-old boy were obtained. Using a computer program, three-dimensional foot models were generated from the digitized cryomicrotome sections and from the MRIs. The central principal axes were determined for the talus and calcaneus. The long central principal axes of the talus and calcaneus were neutrally rotated with reference to the bimalleolar axis in the idiopathic clubfoot while in the neurogenic clubfoot the long central principal axis of the talus was medially rotated 52 degrees and that of the calcaneus 10 degrees. The talocalcaneal angles defined by the long central principal axes in the superior and medial views were 0 degree and 10 degrees, respectively, in the idiopathic clubfoot, and 42 degrees and 56 degrees, respectively, in the neurogenic clubfoot.

Assessment of hindfoot deformity by three-dimensional MRI in infant club foot

In 12 infants aged under 16 months with unilateral club foot we used MRI in association with multiplanar reconstruction to calculate the volume and principal axes of inertia of the bone and cartilaginous structures of the hindfoot. The volume of these structures in the club foot is about 20% smaller than that in the normal foot. The reduction in volume of the ossification centre of the talus (40%) is greater than that of the calcaneus (20%). The long axes of both the ossification centre and the cartilaginous anlage of the calcaneus are identical in normal and club feet. The long axis of the osseous nucleus of the talus of normal and club feet is medially rotated relative to the cartilaginous anlage, but the angle is greater in club feet (10° v 14°). The cartilaginous structure of the calcaneus is significantly medially rotated in club feet (15°) relative to the bimalleolar axis. The cartilaginous anlage of the talus is medially rotated in both normal and club feet, but with a smaller angle for club feet (28° v 38°). This objective technique of measurement of the deformity may be of value preoperatively.

Assessment of hindfoot deformity by three-dimensional MRI in infant club foot.

In 12 infants aged under 16 months with unilateral club foot we used MRI in association with multiplanar reconstruction to calculate the volume and principal axes of inertia of the bone and cartilaginous structures of the hindfoot. The volume of these structures in the club foot is about 20% smaller than that in the normal foot. The reduction in volume of the ossification centre of the talus (40%) is greater than that of the calcaneus (20%). The long axes of both the ossification centre and the cartilaginous anlage of the calcaneus are identical in normal and club feet. The long axis of the osseous nucleus of the talus of normal and club feet is medially rotated relative to the cartilaginous anlage, but the angle is greater in club feet (10 degrees v 14 degrees). The cartilaginous structure of the calcaneus is significantly medially rotated in club feet (15 degrees) relative to the bimalleolar axis. The cartilaginous anlage of the talus is medially rotated in both normal and club feet, but with a smaller angle for club feet (28 degrees v 38 degrees). This objective technique of measurement of the deformity may be of value preoperatively.

Results of serial casting and additional posterior release in congenital talipes equinovarus

Lengthening of the achilles tendon and release of the posterior aspect of the ankle and subtalar joint after serial cast correction of midfoot and forefoot deformities has been recommended for residual equinus in congenital clubfeet. Published results depend on different treatment modalities and type of post-operative rating systems for evaluation. The aim of this study was to investigate the results of serial casting and a standardized posterior release using several functional and radiographic evaluation systems. This review includes 43 patients (62 feet). Treatment began in all patients soon after birth with manipulation and serial casting until a posterior release was performed at a mean age of 4.2 months (range 3–8). The mean follow-up after surgery was 42.3 months (range 12–93). Different rating systems were used which combined a subjective and objective clinical assessment and radiographic criteria. On standard anteroposterior and lateral radiographs the talo- and tibiocalcaneal angle, talar-first metatarsal angle, first-ray angle, and navicular position were measured. Hindfoot varus could be corrected in most feet. Radiographically, there was a mean improvement of the AP talocalcaneal angle of 12.9° (from a mean value of 21.7° pre-operatively to 34.6° post-operatively) and of the lateral talocalcaneal angle of 17.9° (from 14.0° to 31.9°), while clinically, a mild varus deformity persisted in 23 feet (37.1%). In 35 feet (56.6%) there was a residual forefoot adduction of >5°, but the talar-first metatarsal angle improved from a mean value of −22.5° pre-operatively to −1.6° post-operatively. The navicular position was considered central or satisfactorily improved in most patients after the operation (average grade +0.1, range −2 to +2). According to the functional rating system of Lehman et al. 1990 82% of the results were good and excellent, 14.5% fair and 3.2% poor. With the assessment of Magone et al. 1989 59.7% of the patients still showed good and excellent results, but due to a high rating of normal ankle motion and bimalleolar axis, the evaluation by the functional score of McKay 1983 was significantly worse. Neben einer Verlängerung der Achillessehne und der dorsalen Kapsulotomie des oberen und unteren Sprunggelenkes nach initial redressierender Gipsbehandlung werden in der Literatur viele andere Therapieverfahren und Operationstechniken zur Behandlung des angeborenen Klumpfußes angegeben. Publizierte Ergebnisse sind jedoch nicht immer eindeutig vergleichbar, da eine von allen Autoren einheitlich angewendete Erfolgsbeurteilung anhand standardisierter und reproduzierbarer Kriterien häufig unterbleibt. Ziel unserer Studie war deshalb eine retrospektive Analyse der Behandlungsergebnisse initialer Gipsbehandlung mit anschließend durchgeführtem dorsalem Release, wobei die Evaluation klinisher und röntgenologischer Parameter anhand unterschiedlicher funktioneller Scores aus der Literatur erfolgte. Damit soll sowohl ein Vergleich zu den Behandlungsergebnissen anderer Autoren erleichtert wie auch der Einfluß unterschiedlicher Evaluationssysteme auf das Resultat gezeigt werden. Bei insgesamt 43 Kindern (62 Füsse) wurde wegen eines angeborenen Klumpfußes im Durchschnittsalter von 4.2 Monaten (3–8 Monate) nach initial redressierender Gipsbehandlung die Achillessehnenverlängerung und Kapsulotomie des oberen und unteren Sprunggelenkes über einen dorsalen Zugang vorgenommen. Nach einer durchschnittlichen Beobachtungszeit von 42,3 Monaten (12–93 Monate) erfolgte bei allen Patienten die klinische Nachuntersuchung anhand der von McKay 1983, Magone et al. 1989 und Lehman et al. 1990 in den jeweiligen Funktionsscores angegebenen Kriterien. Die radiologische Auswertung von Talo- bzw. Tibiocalcanearwinkel, Talus-MT-I-Winkel, Metatarsalreihen-Winkel und Lage des Os naviculare wurde auf standardisierten seitlichen und anteroposterioren Aufnahmen der Füsse in der Technik nach Simons [1983] vorgenommen. Obwohl postoperativ eine leichte Varuskomponente des Rückfußes bei 23 Patienten (37,1%) verblieb, zeigte die radiologische Ausmessung des Talocalcanearwinkels in der AP-Aufnahme eine Verbesserung um durchschnittlich 12.9° (von präoperativ 21,7° auf postoperativ 34,6°) und in der seitlichen Ebene um 17,9° (von 14,0° auf 31,9°). Bei genauer Vermessung wiesen 35 Füsse (56,6%) klinisch noch eine Adduktion von mehr als 5° auf, was sich röntgenologisch in einem durchschnittlichen Talus-MT-I-Winkel von −1,6° (präoperativ −22,5°) bestätigte. Die Naviculare-Position normalisierte sich jedoch bei den meisten Patienten (post-operative Graduierung von −2 bis +2 mit einem Mittelwert von +0,1). Die Ermittlung des Gesamtergebnisses anhand des von Lehman et al. 1990 angegebenen Scores zeigte 82% gute und exzellente sowie 14,5% mäßige und 3, 2% schlechte Resultate. Während die Beurteilung nach den von Magone et al. 1989 publizierten Kriterien noch 59,7% gute und sehr gute Behandlungsergebnisse aufwies, lag der McKay-Score 1983 deutlich darunter, was auf eine übergproportionale Bewertung von normaler OSG-Beweglichkeit und bimalleolärer Achse zurückzuführen ist.

Management of the resistant idiopathic clubfoot: The Kaiser experience from 1980–1990

Sixty-three congenital idiopathic clubfeet were clinically and radiographically evaluated following a single Turco-type complete posteromedial soft tissue release with internal fixation. Average age at the time of surgery: 12.4 months; average postoperative follow-up: 67.2 months. A new rating system that weighs dynamic functional results more heavily was used to compare our findings. The results were rated as excellent in 29 feet (46%), good in 15 feet (24%), fair in 8 feet (13%), and poor/failures in 11 feet (17%). Ninety-five percent of the parents were satisfied with the current results, although 59% felt that their child would have physical limitations in the future. Clinical complications included the following residual deformities: hindfoot varus (3.2% or two feet), equinus (3.2% or two feet), cavus (22.2% or 14 feet), and forefoot adductus (41.3% or 26 feet). The bimalleolar axis in the 63 clubfeet averaged 74.9 degrees. No calcaneus gaits were present. Radiographic complications included both over-correction (1.6% or one foot) and under-correction (4.8% or three feet) of the talonavicular joint articulation, avascular necrosis of the navicular, (14.3% or nine feet), talus (4.8% or three feet), and calcaneus (1.6% or one foot). Thirty-three feet (52.4%) revealed some degree of abnormal talar dome flattening, 22 feet (34.9%) revealed navicular dorsal subluxation or "wedging." Only 37 (58.7%) exhibited normal talonavicular joint congruity.

Clubfoot analysis with three-dimensional computer modeling.

Which way are the bones rotated in a clubfoot? This question has long been debated by clubfoot surgeons. Opinions have been based on observations from surgery, radiographs, and autopsies. These methods all have pitfalls and are subject to misinterpretation. We used three-dimensional computer modeling to analyze histologic sections of a newborn clubfoot and a newborn normal foot. Relative to the bimalleolar axis in the axial plane, the normal talus demonstrated 5 degrees of internal rotation of its body and 25 degrees internal rotation of its neck. The clubfoot talus showed 14 degrees of external rotation of its body and 45 degrees of internal rotation of its neck. The calcaneus was externally rotated 5 degrees in the normal foot and internally rotated 22 degrees in the clubfoot.

Measurement of tibial torsion by ultrasound.

A method of measuring tibial torsion with ultrasound, using reference lines on the tibia, was developed and tested on dry adult tibiae. This technique was used for evaluation of a group of children with apparently normal tibiae and another group of children with spina bifida, cerebral palsy, or clubfoot. The study showed that it is possible to measure true tibial torsion (rather than tibiofibular torsion) with ultrasound. The technique was found to be reliable and accurate enough for routine clinical use and had advantages over clinical methods and other radiographic imaging techniques. Values obtained by this technique are higher than those obtained by methods using the bimalleolar axis as the distal reference line.