The study compared the long-term results of posterior release (n=30) and comprehensive release (n=29). The posterior release consisted of Achilles tendon lengthening and ankle and subtalar joint releases. The comprehensive release was as described by Carroll and entailed lengthening of the Achilles tendon and the tendons of the tibialis posterior, flexor hallucis longus and flexor digitorum longus. In addition, release of the capsules of the talonavicular, calcaneocuboid, posterior ankle and subtalar joints were performed.The patients were evaluated after a mean period of 28 years following the posterior release and 16 years following the comprehensive release. At the time of final review, the feet were assessed using the Ponseti's 100 point scoring system and with anteroposterior and lateral radiographs. Although the results in the two groups were not statistically different based on the Ponseti scale, the comprehensive release group had fewer secondary operations, more complete correction of the hindfoot varus and better subtalar motion. The final status of 28 unilateral clubfeet were also compared with the opposite normal foot. The calf circumference, foot size, range of ankle motion and the talocalcaneal angles were all less in the affected feet as compared to the nomal side.

The long-term results of surgery for clubfoot suggest that the more comprehensive the initial correction, the less likely the need for repeat surgery for relapse and residual deformity. The observation that the mobility of the hindfoot is more in those who underwent a more elaborate capsular release is an important one. This refutes the impression some surgeons hold that capsular releases predispose to joint stiffness. The observation that the operated clubfeet did not match the contralateral normal feet emphasises the sobering fact that we can, at best, only achieve a near-normal foot by surgery.

Fourteen patients treated by the Ilizarov technique for correction of severe foot deformities developed cysts in the bones of the foot. The location of the cysts did not correspond to the sites of penetration of the wires. These cysts did not resolve after a mean follow-up of 3.4 years. Histological examination of one such cyst resected at the time of triple arthrodesis demonstrated an empty lacuna without a cell lining; similar to the microscopic appearance of sub-chondral cysts seen in osteoarthrosis.

This report draws attention to a possible complication of the Ilizarov technique when used for correcting deformities of the foot. The long term implications of these cysts remain uncertain and hence surgeons employing the Ilizarov technique or similar techniques like the Joshi's technique need to monitor feet for several years. Only then will we know the frequency of occurrence of such cysts and whether they are innocuous.

Currently available data do not support the use of shoe modifications or shoe inserts for correcting paediatric foot problems like flatfoot and in-toeing. Studies show that children who have never worn shoes have greater flexibility of their feet and a lower incidence of static deformities and flatfoot compared to those who did wear shoes in childhood. Shoe modifications should be reserved for children who have rigid foot deformities or limb length discrepancy. The design of normal shoes should be on the barefoot model which promotes healthy foot development and adequate space for normal toe position.

This brief review emphasises that there is no scientifically proven evidence to indicate that shoe modifications cure flatfoot. The evidence cited in the review also indicates that the chances of developing flatfoot are higher among those who wear shoes in early childhood. In the light of this, we should refrain from prescribing special shoes for children with flatfoot but encourage them to play barefoot. This is particularly relevant in India where socio-economic considerations and the climatic conditions cannot justify the practice of prescribing special shoes for children with these deformities.

The results of surgical treatment of 63 clubfeet in spina bifida are presented. All the patients were initially treated by serial manipulation and plaster casting, followed by the use of an ankle-foot orthosis till the date of surgery. In all cases a radical postero-medial-lateral soft tissue release (PMLR) was performed through the Cincinnati incision. The contracted tendons (including the tibialis anterior) were excised . A K-wire passed into the talus was used to derotate the talus in the ankle mortise in 21 feet. The average age at the time of surgery was 14 months and the minimum follow-up was 2 years. 76% had good results, 14% fair results and 10% poor results. The patients with thoracic or high lumbar levels of paralysis had a higher percentage of poor results as compared to children with low lumbar and sacral level lesions. The tendon excision leading to a flail foot corrects any residual muscle imbalance.

The paper emphasises the need to radically excise (not just lengthen) contracted tendons in clubfeet in spina bifida. The concept of excising even the tibialis anterior in order to render the ankle and foot totally flail is worth considering. A supple flail foot which can be adequately supported in an orthosis is far less likely to develop a neuropathic ulcer than a stiff deformed foot. Despite this radical approach, it is disconcerting that 10% had poor results, and the number of poor results is almost certain to increase as these children are followed up for a longer period of time. It seems baffling as to why these deformities should recur once the muscle imbalance is decisively corrected. Another aspect worth noting in this paper is the fact that the authors routinely manipulated the feet. Though they caution the readers that adequate care should be taken to avoid pressure ulceration, one wonders whether the results of radical surgery would have been any worse if these feet had not been subjected to this potentially risky practice.

In a retrospective review of 288 children with torticollis seen at a single centre it was noted that 18.4% of the cases had a nonmuscular cause for the torticollis. Among the children with nonmuscular causes, 30% had a Klippel-Feil anomaly, 22% had ocular abnormalities, 17% had obstetric palsies and 11% had a central nervous system lesion. The authors conclude that nonmuscular causes of torticollis is not rare. They suggest an algorithm to investigate cases of torticollis. In children without a demonstrable contracture of the sternomastoid muscle they start with radiographs of the cervical spine. If these are normal, an ophthalmic examination is done. If this is normal, a detailed neurological evaluation is undertaken. If all these investigations do not reveal any abnormality, the child can be safely observed.

Fifteen children with torticollis without true contracture of the sternomastoid muscle underwent an ophthalmic examination. Five of these children were found to have ocular causes for the torticollis. There has weakness of the extra-ocular muscles in four and nystagms in one. In three children extra-ocular muscle surgery corrected the torticollis. The authors recommend that all patients with torticollis and no clear orthopaedic cause be referred for ophthalmic evaluation.

These two papers draw our attention to the fact that in a small but significant proportion of children with torticollis there may be an underlying ocular or neurological abnormality which needs urgent attention. The neurological lesions include intracranial tumours; while the ocular causes include paralytic squint and nystagmus. If there is no demonstrable contracture of the sternomastoid it is imperative that a more detailed ophthalmic and neurological examination be undertaken in children with torticollis.

Till recently authors reported dismal results with very low union rates following a variety of procedures for treating congenital pseudarthrosis of the tibia1,2,3. Nevertheless, some of these discouraging reviews gave valuable insight into the behaviour of this recalcitrant “fracture”. Careful analysis of accumulated reports showed clearly which procedures were least effective but they also did show the procedures that had a semblance of promise. However, the number of cases in most individual series were small and hence no specfic procedure could be recommended with any degree of confidence. As a consequence, newer modalities of treatment were tried; including electrical stimulation, microvascular free fibular transfer, and the Ilizarov technique.

Early reports of the use of free vascularised fibular transfers 4 and Ilizarov methods 5 in small series of patients suggested that these methods were very successful in obtaining union in this condition. However, equally good union rates were reported following intramedullary nailing and bone grafting 6,7. The prospect that options which are less labour intensive and technically less demanding than microvascular surgery or the Ilizarov technique could yield satisfactory results is reassuring particularly in the context of the Indian patient who may not always have access to this sophisticated technology. This brief review attempts to present the current status of the options available for dealing with this condition.

The three main problems of treatment of congenital pseudarthrosis of the tibia are :

• a) obtaining union,
• b) preventing a refracture and
• c) managing the shortening of the limb.

Any protocol of treatment must address these three problems

A critical review of the literature reveals that it is possible to address these three problems of management.

The most difficult aspect of the treatment of congenital pseudarthrosis of the tibia has been that of achieving union. Among the various procedures that have been described for treating congenital pseudarthrosis of the tibia, only four have had success rates of over 70%. The overall success rates shown in the Table are based on cumulative data gleaned from all the references available to the author. Though the data included clearly does not take into account every single report published in the literature, the numbers are large enough and the trends clear enough to make some valid observations. A closer look at some of the reports claiming impressive results following specific procedures shows that these results were often obtained following additional or secondary operations. For example, while the final union rate following microvascular free fibular transfer is 92%, the primary union rate is only 65%. It was for this reason that a distinction needs to be drawn between “primary” and “secondary” union.

Reports in the literature suggest that there is a very good chance of achieving union by a combination of excision of the pseudarthrosis with dual onlay bone grafting and intramedullary fixation. The overall primary union rate with this technique, based on data from different series is 88%. A closer look at the possible reasons for this degree of success is necessary. The type of graft used and the method of internal fixation are likely to have contributed to the encouraging results.

The use of autogenous cortical grafts appears to improve the union rate in this condition. Sofield 1 had emphasised that autogenous grafts have the best chance of facilitating union of the pseudarthrosis. Hardinge 2 in his review had documented abysmally poor results following Phemister grafting. Boyd 8, McFarland 9 and Baw 10 in their respective techniques had used cortical strut grafts with some measure of success. However, the results of their techniques do not compare with the results of series where a combination of onlay bone grafting and intramedullary fixation were used. This suggests that the use of the intramedullary rod greatly enhances the chances of union. This view was expressed by Anderson et al11 and Baker et al12

Paley et al13 reviewed the reports of this procedure for pseudarthrosis of the tibia and noted that in the originators hands, union was achieved in 91% of cases. Reports of this technique in the English literature are limited and they have been recorded in the Table. Plawecki et al5 emphasise that the pseudarthrosis site need not be exposed and that excision of the pseudarthrosis site is unnecessary, while Paley et al13 state that the pseudarthrosis site may need to be resected in previously operated cases. They also note that a review from Russian literature by Adrianov concludes that the most successful method combined the Ilizarov circular frame with open reduction of the pseudarthrosis and onlay bone grafting.

The procedure entails a preoperative angiographic evaluation of the vasculature of both the donor and recipient legs. Often two teams of surgeons are involved: one to remove the donor fibula and the other to prepare the recipient site. Most surgeons prefer to use the contralateral fibula as the donor graft but Uchida et al15 reported success with the use of the ipsilateral fibula. When the contralateral fibula is used the vascular anastomosis is usually between the peroneal vessels of the donor graft and either the anterior tibial or posterior tibial vesels of the recipient leg.

Several reports 4,14,15,16,20,21,22 testify to the efficacy of this procedure in obtaining union at the pseudarthrosis site. Simonis et al14 point out that the vascularity of the graft and the stability of fixation appear to be the factors that influence union. A striking feature of the fibular grafts after their incorporation is their hypertrophy to the size of the recipient tibiae. While the union rate following this procedure is 92%, in a significant proportion of patients additional operations were needed to obtain union at the host-graft junction. Simonis et al 14 noted that failures were more commonly seen in patients who had undergone previous surgery. In one instance the contralateral fibula had been excised during a previous operation and the ipsilateral peroneal vessels had been damaged, thereby precluding a successful vascular anastomosis.

Note : The numbers of cases shown are the total number of cases collated from all the eferences indicated against each technique in parenthesis.

Primary union implies successful union without any additional surgical procedures

Secondary union implies that one or more surgical procedures were employed in addition to the primary procedure in order to obtain union.

Invasive and non-invasive techniques of electromagnetic stimulation have been used in conjunction with bone grafting procedures to facilitate union of the pseudarthrosis 12,17,18,19. An analysis of all the reported cases show a union rate of 73%. However, it is emphasised that the technique of bone grafting and the type of fixation used varied considerably in each of the series. Paterson and Simonis17 used the invasive technique and implanted the cathode of the stimulator at the site of the pseudarthrosis. They routinely used cancellous bone graft and a transarticular intramedullary nail as the fixation device in addition to electrical stimulation. The union rate following this combined approach was 74%. Sutcliffe and Goldberg 18 and Bassett et al19 used the non-invasive pulsed electromagnetic fields and reported union rates of 70%.

Refractures following union of congenital pseudarthrosis of the tibia occur frequently enough to be a cause for concern. Andersen11 encountered refractures in as many as five out of nine patients after initial consolidation. Refractures occur irrespective of the procedure adopted to obtain initial union 11,13,16. The propensity for refractures appears to diminish after skeletal maturity.

One way of minimising this troublesome complication is to ensure that the child wears an external support in the form of an appropriate orthosis, whenever ambulant, till the child is skeletally mature 7,11,12. If an intramedullary nail is used for internal fixation, it is advisable to retain the fixation device till skeletal maturity even if sound union of the pseudarthrosis has occurred7,11,17,20. Refractures may occur with the rod in situ, but they can be managed by addtional bone grafting without disturbing the rod11. Fern et al7 and

Baker et al12 recommend the use of an orthosis in addition to retaining the intramedullary rod till skeletal maturity.

Hardinge2 had suggested that if the shortening of a pseudarthrotic limb was 9cm or more, amputation was justified. However, with the advent of newer methods of limb lengthening it has become possible to lengthen the short tibia to this extent. Yet, there has been some reservation to lengthen the tibia in this condition because it is assumed that the disease process affects the entire bone. Bitan et al6 state "in spite of a number of reassuring examples of tibial lengthening we have done in other patients, we remain distrustful of lengthening a segment of bone which is pathological". They proceeded to lengthen the femur in order to equalise the limb lengths. The advocates of the Ilizarov technique have demonstrated that lengthening of the tibia itself, either in the proximal metaphyseal region or through the physis, has been possible without undue problems 5,13.

It would seem reasonable to recommend an operation which has a high primary union rate and also which minimises the risk of the potentially troublesome complication of a refracture as the procedure of choice in the first instance. Dual onlay bone grafting and intramedullary fixation fulfills both these criteria.Yet another reason for advocating bone grafting and nailing is the relative ease of performing the operation; it is certainly simpler than both the Ilizarov technique and microvascular procedure. There is no doubt that it is also a cost-effective option which requires only minimal equipment and less time than other alternatives. The centres which can perform microvascular surgery would be few in several of the developing countries and even in some of the more affluent nations. Baw 10 had emphasised the socio-economic problems faced in developing nations and hence it is important to evolve methods of treatment that would yield satisfactory results even in such situations. In centres where there are adequate facilities and technical expertise, it maybe justified in opting for the Ilizarov technique or microvascular free fibular transfer. However, the risk of a refracture and the need for subsequent surgery must be borne in mind. Whatever method is chosen, it is important to not jeopardise subsequent attempts at achieving union, should the primary procedure fail. Thus it is important to avoid damaging the blood vessels in the calf and the contralateral fibula must be preserved for the possible eventuality of a free fibular transfer as a last resort. Finally, the role of electrical stimulation needs to be defined. The union rate of pseudarthrosis tibia following electrical stimulation is 73%, while the results of dual onlay grafting and intramedullary fixation is 88% suggesting that the value of electrical stimulation is questionable and hence we would refrain from this additional expenditure.

• 1. Sofield HA. Congenital pseudarthrosis of the tibia. Clin Orthop 1971; 76:33-42.
• 2. Hardinge K. Congenital anterior bowing of the tibia. The significance of different types in relation to pseudarthrosis. Ann R Coll Surg Eng 1972; 51:17-30.
• 3. Andersen KS. Congenital pseudarthrosis of the leg. Late results. J Bone Joint Surg (Am) 1976; 58-A : 657-62.
• 4. Pho RWH, Levack B, Satku K, Patradul A. Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg (Br) 1985; 67-B:64-70.
• 5. Plawecki S, Carpentier E, Lascombes P, Prevot J, Robb JE. Treatment of congenital pseudarthrosis of the tibia by the Ilizarov method. J Pediatr Orthop 1990;10:786-90.
• 6. Bitan F, Rigault P, Padovani, Touzet Ph. Congenital pseudarthrosis of the tibia in childhood. Results of treatment by nailing and bone graft in 18 cases. Fr J Orthop Surg 1987;1:331-9.
• 7. Fern ED, Stockley I, Bell MJ. Extending intramedullary rods in congenital pseudarthrosis of the tibia. J Bone Joint Surg (Br) 1990;72-B:1073.
• 8. Boyd HB. Congenital pseudarthrosis. Treatment by dual bone grafts. J Bone Joint Surg 1941; 23:497-515.
• 9. McFarland B. Pseudarthrosis of the tibia in childhood. J Bone Joint Surg (Br) 1951; 33-B: 36-46.
• 10. Baw S. The transarticular graft for infantile pseudarthrosis of the tibia. A new technique. J Bone Joint Surg (Br) 1975; 57-B:63-8.
• 11. Anderson DJ, Schoenecker PL, Sheridan JJ, Rich MM. Use of an intramedullary rod for the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg (Am) 1992; 74-A: 161-8.
• 12. Baker JK, Cain TE, Tullos HS. Intramedullary fixation for congenital pseudarthrosis of the tibia. J Bone Joint Surg (Am) 1992; 74-A: 169-78.
• 13. Paley D, Catagni M, Argnani F, Prevot J, Bell D, Armstrong P. Treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique. Clin Orthop 1992; 280: 81-93.
• 14. Simonis RB, Shirali HR, Mayou B. Free vascularised fibular grafts for congenital pseudarthrosis of the tibia. J Bone Joint Surg (Br) 1991; 73-B: 211-5.
• 15. Uchida Y, Kojima T, Sugioka Y. Vascularised fibular graft for congenital pseudarthrosis of the tibia. Long term results. J Bone Joint Surg (Br) 1991; 73-B: 846-50.
• 16. Gilbert A, Brockman R. Congenital pseudarthrosis of the tibia. Long-term followup of 29 cases treated by microvascular bone transfer. Clin Orthop 1995; 314: 37-44.
• 17. Paterson DS, Simonis RB. Electrical stimulation in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg (Br) 1985; 67-B: 454-62.
• 18. Sutcliffe ML, Goldberg AAJ. The treatment of congenital pseudarthrosis of the tibia with pulsing electromagnetic fields. A survey of 52 cases. Clin Orthop 1982; 166: 45-57.
• 19. Bassett CAL, Caulo N, Kort J.Congenital “pseudarthroses” of the tibia. Treatment with pulsing electromagnetic fields. Clin Orthop 1981; 154: 136-49.
• 20. Weiland AJ, Weiss A-PC, Moore JR, Tolo VT. Vascularised fibular grafts in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg (Am) 1990; 72-A: 654-62.
• 21. Dormans JP, Krajbich JI, Zuker R, Demuynk. Congenital pseudarthrosis of the tibia: Treatment with free vascularised fibular grafts. J Paediatr Orthop 1990; 10: 623-8.
• 22. de Boer HH, Verbout AJ, Nielsen HKL, van der Eijken JW. Free vascularized fibular graft for tibial pseudarthrosis in neurofibromatosis. Acta Orthop Scand 1988; 59: 425-9.
• 23. Vail TP, Urbaniak JR. Donor site morbidity with the use of vascularised autogenous fibular grafts. J Bone Joint Surg (Am) 1996; 78-A:204-11.

A review of the Japanese experience

The CDH Prevention Society of Japan has for some years been inviting Orthopaedic Surgeons from different parts of the world to spend time in Japan to study the methods that have been employed to reduce the incidence of CDH in the country. In 1996 it was decided to invite two Orthopaedic Surgeons from India and Dr.Ashok Johari and Dr.Benjamin Joseph were awarded this Fellowship.The brief review presented here is based on the information gathered during this visit and from published literature.

Katsumasa Ishida1 observed that the traditional Japanese way of clothing new born infants was to wrap the baby in such a way that the hips were held in extension. The experimental studies of Sijbrandji2 and Salter3 had demonstrated that splinting of the young animal's hind limbs in extension consistently resulted in subluxation or dislocation of the hips. Ishida assumed that this experimental evidence may have a bearing on the causation of hip dislocation in infancy. He noted that normal new born infant tended to hold the lower limbs in flexion for some time before gradually extending them over some weeks in the postnatal period. He surmised that the traditional Japanese custom of wrapping the babies with the hips in extension may have an adverse effect on the stability of the hip joint.

In 1966 he embarked on a study to test his hypothesis. Of over 5000 babies included in the study, 1967 children were clothed in the traditional manner with the hips in extension immediately after birth, while the remaining 3224 were clothed in diapers which permitted the babies to keep their hips naturally flexed. He then performed the Barlow's test on all these children within the first 24 hours after birth. The results are shown in the Table below.

It is to be noted that the babies nursed with the hips in extension were those born in the first two years of the study, while those nursed with the hips in flexion were those born in the next two years.

Since the results of this initial study appeared to support Ishida's hypothesis, he went on to a more elaborate community based study. Between 1971 and 1973, in a ward of Kyoto city, all the babies were clothed from birth in the traditional Japanese way with the hips in full extension. In 1973 a comprehensive health education programme was launched, where midwives, obstetricians, health nurses and expectant mothers were taught to ensure that the hips of the new-born babies were kept naturally flexed in the neonatal period. Illustrated manuals were distributed and lectures were delivered at every maternity hospital. The incidence of acetabular dysplasia, subluxation and complete dislocation of the hip in infancy reduced dramatically (see Box). This novel approach to reducing the incidence of hip dislocation caught the attention of several workers in Japan and similar community based programmes were conducted in different parts of the country. The results of these efforts were reviewed in 1993 by Ando4. All the surgeons noted an appreciable decline in the incidence of established dislocation of the hip in infancy. The general impression was that the health education measures had yielded dividends. However, Ando noted that even before the preventive measures had been instituted, some decline in the incidence of hip dislocation had been observed in Japan by Imada5. It, therefore, suggests that the dramatic fall in the incidence of hip dislocation in Japan is in part due to concerted efforts to prevent a postnatal environmental factor (the extended posture of the hips) and in part due to a spontaneous decline in the incidence due to unexplained reasons.

Present day epidemiologists may criticise the design of the studies employed by Ishida. In both the initial study and the subsequent one, the group of babies in whom the hips were permitted free flexion were those born in the second half of the study. In the light if the observations of Imada that a spontaneous reduction in the incidence of CDH had begun to become evident by the time these studies were conducted, it may be argued that the reduction in the incidence seen in the latter half of each study was due to the spontaneous decline in the occurrence of CDH rather than the effect of altered child-rearing practices. These results would undoubtedly have been more convincing if two randomly selected groups of infants were clothed in the two different ways concurrently, and the difference in the incidence of CDH in each group compared. Nevertheless, the magnitude of reduction in the incidence of CDH observed in the studies does support the claims of Ishida. The fact, that currently accepted epidemiological techniques were not employed with appropriate statistical validation of the results, does not in any way diminish the value of these observations. A disease which is clearly multifactorial in aetiology is less likely to occur if environmental factors conducive to the occurrence of the disease are avoided, and Ishida's work is an example of how one such factor can be avoided. The success of these efforts remind us that as surgeons we need to be equally concerned about epidemiological aspects of a disease as the surgical nuances of the condition. How much more cost-effective it is to prevent CDH than to surgically cure it! The Japanese CDH Prevention Society must be congratulated for propagating this message within Japan by on-going health education, and world-wide through their Fellowships.

• 1.Ishida K. Prevention of the development of the typical dislocation of the hip. Clin Orthop 1977;126:167-9.
• 2.Sijbrandji S. Dislocation of the hip in young rats produced experimentally by prolonged extension. J Bone Joint Surg (Br) 1965;47-B:792.
• 3.Salter RB.Etiology, pathology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J 1968;98:993.
• 4.Ando M. Prevention of congenital dislocation of the hip in infants. Excercise and results in Japan. Ando,Ed. Yamada Co.Ltd Asahikawa 1993.
• 5. Imada H. The incidence of congenital dislocation of the hip is decreasing. J Jpn Orthop Assoc 1973;14:1218-20.

The Department of Orthopaedics at Kasturba Medical College invites applications for a one year Fellowship in Paediatric Orthopaedics. The Fellowship offers an exposure to a broad range of Paediatric Orthopaedic diseases. The fellow will receive a monthly stipend and a certificate from the Manipal Academy of Higher Education ( A Deemed University ) on completion of the Fellowship. For further information contact : Dr.Benjamin Joseph, Paediatric Orthopaedic Service, Department of Orthopaedics, Kasturba Hospital, Manipal 576 119, Karnataka

The Editors would welcome copies of papers published by members of POSI for inclusion in the abstract section of POSITIVE. It would be a good way to keep fellow members informed about our contributions in the field of Paediatric Orthopaedics.

It is proposed to form working groups to share information and plan multicentre studies on common problems we see in our paediatric orthopaedic practice. The modalities of the functioning of these working groups would be discussed in the 1998 meeting of POSI. To begin with, study groups on clubfoot, developmental dysplasia of the hip and Perthes' disease are planned. Those interested in joining these groups kindly send in your names to Dr. Ashok Johari and please do attend the 1998 POSI meeting.