Tendon Lengthening Research Articles

Orthopedic Management in Hemophilia: A Spanish Outlook

Hematologists are of the opinion that orthopedic surgeons will eventually not be required in the clinical management of patients with hemophilia. Although such a belief is indicative of a strong desire to end the orthopedic complications associated with hemophilia, this has yet to become reality. Current knowledge and appropriate prophylactic treatment have the potential to reduce the level of orthopedic problems affecting hemophilia patients, but optimal therapy cannot be implemented globally. The Spanish Health System places no restrictions on the treatment of patients with hemophilia, and consequently children with this condition have better musculoskeletal status than their counterparts of 30 years ago. Unfortunately, older patients continue to present with severe articular deformities that require the intervention of an orthopedic surgeon. This article considers surgical techniques used to address orthopedic problems associated with hemophilia, and reviews procedures frequently performed in Spanish clinics. These include arthrocenteses, radioactive synoviortheses, arthroscopic synovectomies and articular debridements, tendon lengthening, alignment osteotomies, joint arthroplasties, opening of compartment syndromes, and removal of pseudotumors.

Correction of Anteversion in Skeletally Immature Patients

There has been reluctance by some surgeons to accept antegrade femoral nailing in children and adolescents due to concerns about producing iatrogenic osteonecrosis or growth disturbance of the femoral neck. Others believe that with the recent advent of pediatric transtrochanteric intramedullary nails, femoral fracture and osteotomy fixation may now safely be accomplished using these devices. Extrapolating from experience treating mature patients, the senior author (P.S.) has adopted the technique of percutaneous femoral osteotomy and transtrochanteric intramedullary fixation in skeletally immature patients as a standard approach for the correction of anteversion, combining this with concomitant surgery as indicated. With the institutional review board approval, we reviewed our experience using the Phillips intramedullary rod (EBI/Biomet, Inc, Warsaw, Ind), to secure femoral osteotomies in a series of 30 patients with 40 femoral osteotomies (10 bilateral). The etiologies of anteversion included idiopathic and neuromuscular. There were 10 boys and 20 girls, ranging in age from 8 to 16 years and in weight from 32 to 60 kg. Additional surgical bony and soft tissue procedures were combined as indicated. These included supramalleolar osteotomy, hindfoot stabilization, tendon lengthening or transfers, and hemiepiphysiodesis in select patients. Two of the femoral rotational corrections were combined with shortening. Despite early mobilization without casts, each osteotomy healed primarily in an average of 3 months, and the complication rate was exceedingly low. One patient had removal of a loose distal interlocking screw at 6 weeks postinsertion. By that time, he had formed good callus and had rotational stability; thus, the outcome was not compromised. Importantly, we have not observed osteonecrosis, growth disturbance of the femoral neck, or limb length discrepancy resulting from this treatment method. In the skeletally immature patient, femoral anteversion can safely be corrected using the Phillips/Biomet antegrade locked intramedullary rod, placed through a transtrochanteric approach; growth disturbance has not been encountered. This device is well tolerated, with a low complication rate. Compared with alternative techniques, recuperation is rapid and fixation problems seen with plates or crossed pins/spica are largely circumvented. The advantages include quadriceps sparing, minimal blood loss, and the use of a load-sharing, low-profile implant. IV (retrospective, clinical).

Innervation zone shift at different levels of isometric contraction in the biceps brachii muscle

Experiments were carried out to examine whether innervation zone (IZ) location remains stable at different levels of isometric contraction in the biceps brachii muscle (BB), and to determine how the proximity of the IZ affects common surface electromyography (sEMG) parameters. Twelve subjects performed maximal (MVC) and submaximal voluntary isometric contractions at 10%, 20%, 30%, 40%, 50% and 75% of MVC. sEMG signals were recorded with a 13 rows × 5 columns grid of electrodes from the short head of BB. The IZ shifted in the proximal direction by up to 2.4 cm, depending upon the subject and electrode column. The mean shift of all the columns was 0.6 ± 0.4 cm (10% vs. 100% MVC, P < 0.001). This shift biased the average values of mean frequency (+21.8 ± 9.9 Hz, P < 0.001), root mean square (−0.16 ± 0.15 mV, P < 0.05) and conduction velocity (−1.15 ± 0.93 m/s, P < 0.01) in the channels immediately proximal to the IZ. The shift in IZ could be explained by shortening of the muscle fibers, and thus lengthening of the (distal) tendon due to increasing force. These results underline the importance of individual investigation of IZ locations before the placement of sEMG electrodes, even in isometric contractions.

Correction of the pes equinus component in congenital clubfoot by freeing the triceps surae muscles and by tibiocalcaneal distraction

20 children, average age 9 months, were treated of 27 inborn deformed feet by a new method. It consists in a wide release of m. triceps surae and its tendon, posterior lateral and posterior medial release and lengthening of the muscle with the help of a personal distraction apparatus, leaving the tendon untouched. Control examinations from 9 months to 4.7 years after operation showed correction of the equinus component by an average of 49 degrees and correction of the profile of the talocalcaneal angle by an average of 34 degrees.

Effect of NKISK on tendon lengthening: An in vivo model for various clinically applicable dosing regimens

One proposed mechanism of tendon lengthening is the "sliding fibril" hypothesis, in which tendons lengthen through the sliding of discontinuous fibrils after release of decorin-fibronectin interfibrillar bonds. The pentapeptide NKISK has been reported to inhibit the binding of decorin, a proteoglycan on the surface of collagen fibrils, to fibronectin, a tissue adhesion molecule, which are thought to play a role in interfibrillar binding. Prior investigations have demonstrated that NKISK produces in vivo tendon lengthening. This study investigates the effect of potential clinically applicable NKISK injection regimens in an in vivo model. One hundred and thirteen male Sprague-Dawley rats were divided into 15 different treatment groups, each receiving percutaneous patellar tendon injections of NKISK, QKTSK (a "nonsense" pentapeptide), or PBS of varying volumes, concentrations, and injection schedules. Following sacrifice, the patellar tendon lengths were measured in all groups, and biomechanical testing was performed with comparisons made to the contralateral, untreated control limbs. Tendon lengthening was significantly greater (p < or = 0.05) in nearly all NKISK-treated tendons as compared to PBS- and QKTSK-treated tendons and was dose-dependent. Measured lengthening was less in rats whose sacrifice was delayed following the final injection of NKISK, which likely indicates recontraction of lengthened tendons, but they remained significantly longer than the controls. Biomechanical testing did not reveal significant differences in ultimate load, modulus, stiffness, or displacement. This study demonstrates that NKISK given in clinically plausible dosing regimens produces dose-dependent tendon lengthening in an in vivo setting with minimal effects on the mechanical properties of the treated tendons.

Ipsilateral teratologic high hip dislocation, femoral hypoplasia and below-knee hemimelia associated with contralateral fibular hemimelia: report of a case with functional result

In this case report, we present a patient with right teratologic high hip dislocation, femoral hypoplasia and below-knee hemimelia associated with left fibular hemimelia. Combined open reduction, proximal femoral osteotomy and a Dega acetabuloplasty were performed in the right hip. Closed tibial wedge osteotomy and centralization of the foot with lateral release and Achilles tendon lengthening were performed for the left side. The patient was able to walk with her prosthesis successfully within the first six postoperative months.

Management of the subscapularis contracture during shoulder arthroplasty for primary glenohumeral arthritis

To evaluate the safety and effectiveness of a particular subscapularis release in shoulder arthroplasty for primary glenohumeral arthritis. Twenty-eight patients (19F, 9M) underwent shoulder arthroplasty for primary glenohumeral arthritis. Preoperative average Constant Score (CS) was 31.2 points (range 14-52), active anterior elevation (AAE) 92 degrees (30-100 degrees ) and active external rotation (AER) 11 degrees (-40 to 20 degrees ). During arthroplasty for subscapularis contracture, patients underwent subscapularis release freeing the superior tubular tendon (STT) with a section of the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL) and a deep release consisting of a section of the middle glenohumeral ligament (MGHL), very close to the glenoid labrum, and the inferior glenohumeral ligament (IGHL). An anatomic study was performed on 13 cadavers, verifying the structure of subscapularis tendon and its relationship with the capsule, the surrounding ligaments and the axillary nerve. Moreover, after having placed traction sutures on the subscapularis tendon, its lengthening was measured after STT release alone and after STT and deep release. The complete absence of neurological and vascular lesions was also verified. Average follow-up: 2.9 years. Postoperative mean CS was 70.5 (p[Symbol: see text]0.005), with an absolute gain of 39.1. AAE increased from 92 degrees to 142 degrees (p=0.001) while AER increased from 8 degrees to 48 degrees (p=0.002). At the last follow-up, 19 patients (67.8%) were very satisfied, 5 patients (17.8%) were satisfied, 3 patients (10.7%) partially satisfied and 1 patient (3.5%) unsatisfied. In the anatomic control, the average lengthening of subscapularis tendon was 0.9 cm after STT release alone and 2.5 cm after STT and deep release. No vascular and neurological lesions were observed. The subscapularis release during shoulder arthroplasty is extremely important to obtain the proper balance between anterior and posterior soft tissues and to achieve an optimal range of motion and joint stability. An adequate anatomical dissection could give good tendon mobilisation and lengthening, necessary for a good repair, and lead to a recovery of the range of motion, particularly for external rotation.

The Relationship Between Passive Ankle Plantar Flexion Joint Torque and Gastrocnemius Muscle and Achilles Tendon Stiffness: Implications for Flexibility

Experimental laboratory study. We tested the hypothesis that the muscle fibers and the connective tendinous structures, combined in series, provide the resistance to passive joint movement at the ankle. We also determined the relative association between passive joint torque and each of these 2 elements. The reason for individual variation in joint flexibility or tightness is not clearly understood, but the influence of musculotendinous stiffness has been inferred. Each of the subjects (6 women and 6 men) was seated with the right knee extended and right ankle positioned at a 30 degrees , 20 degrees , 10 degrees , 0 degrees , -10 degrees , -20 degrees , and -30 degrees (0, neutral position, positive values reflecting plantar flexion) angle while passive plantar flexion torque was measured. The distal muscle-tendon junction of the medial gastrocnemius was visualized by ultrasonography, and its positional change was defined as muscle belly length change. The whole muscle-tendon unit length change was estimated from joint angle changes, from which Achilles tendon length change was estimated. Both the muscle belly and tendon were significantly elongated as the ankle was dorsiflexed (at 0 degrees the mean +/- SD muscle belly elongation was 10.3% +/- 1.8 %, and the tendon elongation was 2.8% +/- 1.2 %, of the initial length at 30 degrees of ankle plantar flexion), from which stiffness indices were determined both for muscle belly and tendon. The passive torque at 0 degrees , -10 degrees , -20 degrees , and -30 degrees was significantly correlated with the stiffness indices of the Achilles tendon (at 0 degrees , r2 = 0.70 and 0.62 for overall and specific stiffness, respectively; P<.05). A tendon stiffness index, separately obtained from tendon lengthening during maximal isometric contraction, was also correlated with passive ankle plantar flexion torque at 0 degrees , -10 degrees , -20 degrees , and -30 degrees (at 0 degrees , r2 = 0.76; P<.05). The specific stiffness index of the muscle belly was correlated (r2 = 0.47, P<.05) with the passive ankle plantar flexion torque at 0 degrees , but its overall stiffness index was not (r2 = 0.32, P>.05). Results suggest that extensibility of the muscle-tendon unit of the Achilles tendon for the most part is related to passive ankle plantar flexion joint torque.

Open Elbow Arthrolysis for Post-traumatic Elbow Contracture

Background: Post-traumatic contracture is a common complication after elbow trauma. If conservative therapy fails to restore adequate elbow motion, arthrolysis is indicated. The purposes of this study were to evaluate the clinical outcome of open arthrolysis for post-traumatic elbow contracture and to determine factors influencing the outcome.Methods: Twenty-seven patients with post-traumatic elbow contracture were followed-up after open arthrolysis for at least 12 months. Before surgery, the mean limitation in extension was 30 ° and the mean maximum flexion was 83 °. A posterior surgical approach was used in 18 patients, and a lateral approach was employed in nine patients. Using the posterior approach, the fibrotic posterior capsule was excised and the ulnar collateral ligament was split. Both the anterior and posterior capsules were released with a lateral approach.Results: The mean flexion increased from 83 ° to 121 °, but the mean extension improved little from –30 ° to –26 °. The mean flexion-extension arc increased from 53 ° to 95 °. According to the elbow evaluation score by the Japanese Orthopaedic Association, both pain and function scales improved significantly. By Hertel's subjective evaluation, the results were good in 13 patients, fair in ten patients, and poor in four patients. Twenty-three patients (85 percent) were satisfied with the results, but four were not satisfied because of residual contracture. These poor results were related to severe soft tissue trauma, residual displacement of intra-articular fragments, and recurrence of heterotopic bone formation.Conclusions: Tendon lengthening of stiff triceps, accurate reduction of intra-articular fragmens, and sharp epiperiosteal resection around the heterotopic bones are essential procedures of open arthrolysis to restore adequate motion in post-traumatic elbow contracture.

Balancing of the Transmetatarsal Amputation with Peroneus Brevis to Peroneus Longus Tendon Transfer

The transmetatarsal amputation (TMA) is a commonly used procedure in salvage of the diabetic foot. The goal of the procedure is to provide a plantigrade foot that can fit into a shoe with appropriate insole and allow the patient to continue ambulating with a low risk of ulceration. This goal can be achieved with appropriate tendon balancing to avoid development of or address existing equinovarus deformity, a commonly reported complication of the TMA (1–4). To prevent this deformity, several authors have recommended a combination of Achilles’ tendon lengthening or gastrocnemius recession along with tibialis anterior tendon transfer (2–6).

Die endoskopische Verlängerungsoperation des Musculus gastrocnemius zur Behandlung des Gastrocnemius equinus

Endoscopic gastrocnemius recession is a new technique to treat gastrocnemius equinus. Smaller incisions and the ability to perform the technique in a supine position are purported advantages. This study was designed to evaluate the results and possible complications of this new technique. 47 patients undergoing 54 endoscopic gastrocnemius recessions were followed in a prospective study. Pre-operative criteria were a lack of ankle dorsiflexion with the knee extended to create a 90 degrees relationship of the foot to the leg in symptomatic patients. Pre- and postoperative ankle dorsiflexion were assessed, as were complications such as infection, nerve injury, haematoma, over-lengthening and poor cosmesis. Mean age of the patients was 49.4 years. Post-operative follow-up from the index procedure was 27 months (range: 12 - 62 months). Pre-operative dorsiflexion was - 8 +/- 4 degrees; post-operative this improved significantly to 7 +/- 4 degrees (p = 0.00001). Most patients had additional reconstructive procedures. There were no infections; six limbs had lateral foot or leg dysaesthesia, one haematoma, one over-lengthened gastrocnemius while six limbs has an unacceptable cosmesis (due to tenting of the skin). Two diabetic patients required additional Achilles tendon lengthening in subsequent surgery. Patients with pre-operative dorsiflexion of - 10 degrees or more had an untoward result, but this was not statistically significant (p = 0.13). Lateral foot dysaesthesia was observed more often in patients having a combined procedure with calcaneal osteotomy (p = 0.03). The endoscopic gastrocnemius recession procedure can significantly increase ankle dorsiflexion, but has potential complications including lateral dysaesthesia (11 %), and unacceptable cosmesis (11 %) as the most common. Modifications to the technique may be needed. Overall, the endoscopic technique appears promising in decreasing gastrocnemius contracture.

Résection de l’os naviculaire pour déformation sévère du médio-pied de l’enfant

Purpose of the study The navicular bone lies at the apex of the deformity in severe talipes planovalgus with forefoot abductus, in the residual cavus of congenital talipes equinovarus, in certain cases of congenital convexity, and in certain types of neurological equinovarus. Resection of the navicular bone can be proposed to correct certain deformities. Material and methods This series included 15 feet operated on in 13 children from 1980 to 2003. The deformity to be corrected was a residual cavus after surgery for congenital talipes equinovarus (five feet), plantar and medial dislocation of the navicular bone on an acquired equinovarus in non-walking children (three feet), planovalgus with major forefoot abductus in non-walking children (four feet). Among the 13 children in this series, five did not walk (seven feet) and underwent surgery because of skin wounds caused by protrusion of the head of the talus and serious mechanical problems (shoes, ortheses). Mean age at operation was 8.5 years (range 2-16 years). The surgical procedure was part of an overall strategy combining use of ortheses, physiotherapy, and medical management. For congenital equinovarus with residual cavus, naviculectomy was performed after the usual technique for equinovarus when the navicular bone was dislocated above the medial tarsal and prevented reduction of the cavus. After extraperiosteal release, resection of the navicular bone enabled correction of the cavus. The lateral column had to be shortened in order to avoid adductus subsequent to medial-lateral length discrepancy. The same surgical technique was used for acquired equinovarus except that the navicular bone was displaced medially and above the talus. The lateral column had to be shortened. Standard procedures were applied for congenital convex feet before naviculectomy when there was major forefoot abductus after medial tarsal release and tendon lengthenings. The lateral column was not shortened since it was already too short. For planovalgus with forefoot abductus, naviculectomy was combined with release of the calcaneocuboid joint. Fibular tendons were lengthened. Results Mean follow-up was two years five months (range 5 months-12 years 6 months). For the talipes equinovarus feet, the Méary Toméno angle was 24.4° on average preoperatively and 5° at last follow-up, giving a mean gain of 19.4°. For congenital convex feet, the M5-lateral calcaneal border angle was 29.7° on average preoperatively and 11.7° at last follow-up for a mean gain of 18°. For the planovalgus feet with forefoot abductus, the M5-lateral calcaneal border angle was 32.7° on average preoperatively and 12.2° at last follow-up, for a gain of 20.5° on average; the mean Méary Toméno angle was -30° preoperatively and -3° at last follow-up, for a mean gain of 27°. Conclusion For carefully selected patients, naviculectomy performed in combination with other procedures can provide appropriate correction of severe midfoot deformities in children.

Neutral Ring Fixation for High-Risk Nonplantigrade Charcot Midfoot Deformity

Charcot foot arthropathy negatively impacts the health-related quality of life (HRQL) of affected individuals. The disease process often is responsible for the development of significant deformity and disability, often progressing to lower extremity amputation. Many patients are morbidly obese, immunocompromised, and have complex wounds with underlying bony infection or poor bone quality, making operative correction and internal fixation problematic. Using a prospective clinical algorithm, 26 consecutive diabetic adults with multiple diabetic co-morbidities, including morbid obesity, had operative correction of nonplantigrade Charcot midfoot deformity at the midfoot level. Correction was maintained with a neutrally applied three-level ring external fixator. Average body mass index was 38.31 +/- 12.51. Nineteen patients used insulin. Fourteen had open wounds with underlying osteomyelitis. The altered relationship between the forefoot and hindfoot was measured as 14.04 +/- 31.09 degrees in the anteroposterior axis, and 16.70 +/- 17.47 degrees in the lateral axis before surgery. Surgery included Achilles tendon lengthening, excision of infected bone, correction of the multiplanar deformity, and culture-specific parenteral antibiotic therapy. At a minimum 1-year followup, 24 of 26 patients were ulcer and infection free and able to ambulate with commercially-available depth-inlay shoes and custom accommodative foot orthoses. One patient died of unrelated causes, and one had transtibial amputation for persistent infection. Four developed recurrent plantar ulcers, which resolved with excision of underlying bony prominences. There were two stress fractures through olive wire pin sites, one requiring intramedullary nailing. The radiographic anteroposterior axis was corrected to 3.12 +/- 9.42 degrees, and lateral to 10.42 +/- 11.86 degrees after surgery. Morbidly obese diabetic individuals with multiple co-morbidities complicating severe Charcot foot deformity can achieve correction of midfoot deformity after operative correction of the deformity and maintenance of that correction with a neutrally applied ring external fixator.

Quantitative ultrasound (QUS) assessment of tissue properties for Achilles tendons

Quantitative ultrasound (QUS) techniques have recently been widely applied for the characterization of tissues. For example, they can be used for the quantification of Achilles tendon properties based on the broadband ultrasound attenuation (BUA) and the speed of sound (SOS) when the ultrasound wave passes through the tissues. This study is to develop an integrated system to investigate the properties of Achilles tendons using QUS images from UBIS 5000 (DMS, Montpellier, France) and B-mode ultrasound images from HDI 5000 (ATL, Ultramark, USA). Subjects including young (32 females and 17 males; mean age: 23.7 ± 2.0) and middle-aged groups (8 female and 8 males; mean age: 47.3 ± 8.5 s) were recruited and tested for this study. Only subjects who did not exercise regularly and had no record of tendon injury were studied. The results show that the BUA is significantly higher for the young group (45.2 ± 1.6 dB MHz−1) than the middle-age group (40.5 ± 1.9 dB MHz−1), while the SOS is significantly lower for the young (1601.9 ± 11.2 ms−1) compared to the middle-aged (1624.1 ± 8.7 m s−1). On the other hand, the thicknesses of Achilles tendons for both groups (young: 4.31 ± 0.23 mm; middle age: 4.24 ± 0.23 mm) are very similar. For one patient who had an Achilles tendon lengthening (ATL) surgery, the thickness of the Achilles tendon increased from 4 mm to 4.33 mm after the surgery. In addition, the BUA increased by about 7.2% while the SOS decreased by about 0.6%. In conclusion, noninvasive ultrasonic assessment of Achilles tendons is useful for assisting clinical diagnosis and for the evaluation of a therapeutic regimen.

A case of congenital kyphosis misdiagnosed as cerebral palsy

Congenital kyphosis is an uncommon spinal deformity that needs prompt recognition and early surgery due to its progressive nature, which can lead to neurological compromise. An 11-year-old boy presented with deteriorating ambulatory function after bilateral Achilles tendon lengthening and calcaneal osteotomies. He previously had a series of orthopedic surgeries of the lower extremities, having been diagnosed with spastic diplegic cerebral palsy based on clinical features and history of prematurity. His computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed compressive thoracic myelopathy due to the fusion of vertebral bodies from T2 to T5. He was treated with anterior decompression and anteroposterior fusion of the thoracic spine. Neurological impairment such as spastic paraplegia in children can lead to an erroneous diagnosis of cerebral palsy, resulting in unnecessary surgeries with their attendant potential complications. This report alerts clinicians to the presentation and progression of congenital vertebral anomalies and highlights the importance of a thorough neurological examination and radiological evaluation.

HS03 BOTULINUM TOXIN A IN THE UPPER LIMB IN CEREBRAL PALSY

Purpose To evaluate patients with cerebral palsy treated with botulinum toxin A injections to assist with the management of contracted muscles and joints as well as co‐contraction.Methods Since 1998, 40 limbs have been treated. The average age was 14 years (range 4 to 33 years) and the average dose given was 107 units (range 50 to 200 units). Digital flexors were injected in 26 limbs, elbow flexors in 18, wrist flexors in 17, thumb adductors in 13, pronator teres in 9, intrinsics in 3, shoulder abductors in 2 and ECU in one limb. All patients were injected under a general anaesthetic, allowing for an assessment of fixed contractures. Padded plaster casts were applied, putting the injected muscles on full stretch before the reversal of anaesthesia and were maintained for approximately 3 weeks. Thermoplastic splits were then wore 23 hrs per day for a further three weeks. Splints were serially modified to achieve progressively more extension as the flexion contractures were corrected. Simultaneous surgical procedures such as tendon lengthening and transfers were performed in 14 limbs.Results The results in the elbow flexors were disappointing. The finger, thumb and wrist flexors have responded extremely well, despite fixed flexion deformities being documented under anaesthesia in the majority of patients.Conclusion It is estimated that the muscle bellies have been elongated by 3 to 4 cm either by the lengthening of, or addition to the sarcomeres.The results in these patients are vastly superior to that which could be obtained surgically.

Patellar tendon lengthening for patella infera using the Ilizarov technique

Patella infera can cause knee pain and lead to patellofemoral osteoarthritis. Treatment is usually unsatisfactory. We describe a case of severe patella infera after operative treatment for fracture of the patella. We used Ilizarov external fixation and gradual lengthening of the patellar tendon. The patellar height was restored and the patient's symptoms were much improved.

Early Results of a New Method of Treatment for Idiopathic Congenital Vertical Talus

BACKGROUND: The treatment of idiopathic congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Ponseti for the treatment of clubfoot deformity, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles tendon in patients with idiopathic congenital vertical talus. METHODS: The cases of eleven consecutive patients who had a total of nineteen feet with an idiopathic congenital vertical talus deformity were retrospectively reviewed at a minimum of two years following treatment with serial manipulations and casts followed by limited surgery consisting of percutaneous Achilles tenotomy (all nineteen feet), fractional lengthening of the anterior tibial tendon (two) or the peroneal brevis tendon (one), and percutaneous pin fixation of the talonavicular joint (twelve). The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Patients were evaluated clinically and radiographically at the time of presentation, immediately postoperatively, and at the time of the latest follow-up. Radiographic measurements obtained at these times were compared. In addition, the radiographic data at the final evaluation were compared with normal values for an individual of the same age as the patient. RESULTS: Initial correction was obtained both clinically and radiographically in all nineteen feet. A mean of five casts was required for correction. No patient underwent extensive surgical releases. At the final evaluation, the mean ankle dorsiflexion was 25° and the mean plantar flexion was 33°. Dorsal subluxation of the navicular recurred in three patients, none of whom had had pin fixation of the talonavicular joint. At the time of the latest follow-up, there was a significant improvement (p < 0.0001) in all of the measured radiographic parameters compared with the pretreatment values, and all of the measured angles were within normal values for the patient's age. CONCLUSIONS: Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, foot function, and deformity correction as measured radiographically at a minimum two years, in patients with idiopathic congenital vertical talus.

High recurrence after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity

Both gastrocnemius recession and Achilles tendon lengthening lead to scarring in the calf and have high reported recurrence rates when performed under the age of 8 years. Triceps surae lengthening by external fixation seemed to be a valuable alternative. Twelve calf lengthenings have been performed with an Ilizarov device with a mean correction of 27 degrees. No calcaneal gait was observed, but there was a slow continuous loss of dorsiflexion over the observation period. The Ilizarov technique has a higher recurrence rate than most operative procedures for calf lengthening, but carries virtually no risk in producing calcaneus. The technique cannot be recommended for routine clinical use and may only be an alternative for selected cases.

Early Clubfoot Recurrence After Use of the Ponseti Method in a New Zealand Population

Background: Nonoperative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. The purpose of the current study was to examine the early rate of clubfoot recurrence following the use of the Ponseti treatment method in a New Zealand population and to analyze patient characteristics to identify factors predictive of recurrence. Methods: Fifty-one consecutive babies with a total of seventy-three clubfeet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any subsequent operative treatment, was analyzed with respect to the severity at presentation, the time of presentation, the number of casts needed to obtain the initial correction, any family history of clubfoot, ethnicity, and the compliance with postcorrection abduction bracing. Recurrence was classified as minor, defined as requiring a tendon transfer or an Achilles tendon lengthening, or major, defined as requiring a full posterior or posteromedial surgical release to achieve a corrected plantigrade foot. Results: Twenty-one (41%) of the fifty-one patients had a recurrence, which was major in twelve of them and minor in nine. The parents of twenty-six babies (51%) complied with the abduction bracing protocol, and only three of these children had a major recurrence. Compliance with abduction bracing was associated with the greatest risk reduction for recurrence (odds ratio, 0.2; p = 0.009). When the parents had not complied with the bracing protocol, the patient had a five times greater chance of having a recurrence. With the numbers studied, no significant relationships were found between recurrence and the severity at presentation, the time of presentation, the number of casts needed to obtain correction, ethnicity, or a family history of clubfoot. Conclusions: Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. When the parents comply with the bracing protocol, the Ponseti method is very effective at maintaining a correction, although minor recurrences are still common. When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.