The Need for Standardizing Treatment of Clubfoot
Currently there is no universally accepted method of classification of the severity of the deformity in clubfoot. The approach to treatment and the evaluation of results are also extremely varied all over the world. There is no doubt that several of our members have tremendous experience in treating clubfoot and sharing of these experiences would be invaluable in establishing a rational protocol of management of clubfoot. It would then be possible for us to embark on a series of multicentre trials to answer questions that would arise regarding the problem areas in the treatment of what is probably the commonest congenital anomaly seen in paediatric orthopaedic practice.
It is with this aim in mind that a questionnaire on the management of clubfoot has been included in this issue of POSITIVE.
The numbers of clubfeet we treat in this country are phenominal; the surgical skills of the average Indian surgeon is superb; the treatment of clubfoot does not require sophisticated paraphernalia which is out of reach of any surgeon in the country and so there would be no justification for not establishing guidelines for treating clubfoot more effectively.
It is our hope that every member of POSI would spare some time to fill in the questionnaire and return it promptly. The responses would be analysed and it is hoped that we would be able to present the data to the members at the next POSI meeting in January 1999.
1. The effect of elbow position on the radial pulse measured by Doppler ultrasonography after surgical treatment of supracondylar elbow fractures in children.
Mapes RC, Hennrikus WL. Naval Hospital, San Diego, USA. Journal of Pediatric Orthopaedics, 1998; 18:441-4.
This study evaluated the effect of elbow flexion and forearm position on the blood flow in the limb after closed reduction and percutaneous K-wire fixation of extension supracondylar fractures in 20 children. The blood flow was measured by Doppler ultrasonography with the forearm in supination or pronation as the elbow was gradually flexed. The point at which the pulse disappeared was noted. The radial pulse disappeared with less elbow flexion in Gartland III fractures than in Gartland II fractures (mean 104o vs 128o, p < 0.001) when the forearm was in supination. With the forearm in pronation the radial pulse disappeared slightly earlier than when the elbow was in supination. The authors conclude that vascular safety is enhanced by extending the elbow and supinating the forearm.Editorial Comment
The paper addresses a very pertinent issue related to a common problem. This simple study suggests that the risk of Volkmann's ischaemia following a supracondylar fracture may be reduced by holding the elbow in extension and supination. However, this would not be possible without fixation of the fragments as the fracture is only stable in flexion and pronation. There is an urgent need to adopt recommendations such as these because regretfully we still continue to see Volkmann's contractures far too frequently.
2. Cosmetic results of supracondylar osteotomy for correction of cubitus varus.
Barrett IR, Bellemore MC, Kwon Y-M. Royal Alexandra Hospital for Children, Sydney, Australia. Journal of Pediatric Orthopaedics 1998; 18: 445-7.
The appearance of the elbow following French osteotomy for correction of cubitus varus was evaluated subjectively (based on opinion of the patients and parents) and objectively by clinical assessment in 17 children. Specifically, the authors were looking for a cosmetically unacceptable prominence of the lateral condylar region or an unsightly scar. In 12 patients (76%) excellent results were noted without any evidence of either of these unacceptable features. In 16 out of the 17 patients there was no discernible bulge in the lateral condylar region. The authors conclude that a simple lateral closing wedge osteotomy in skeletally immature children produces excellent cosmetic results.Editorial Comment
As the authors rightly point out, the indication for corrective osteotomy for cubitus varus is to improve cosmesis and not function. In the light of this, it is only appropriate that the cosmetic outcome be assessed. Though authors in the past have expressed dissatisfaction with the cosmetic results following the French osteotomy, the present paper refutes them. The results of this study are important since the French technique is probably the most widely used and it is one of the simplest methods of correcting the deformity.
3. Calcaneal fractures in children.
Inokuchi S, Usami N, Hirashi E, Hashomoto T. Keio University, Tokyo, Japan. Journal of Paediatric Orthopaedics, 1998; 18: 469-74.
The authors report 20 calcaneal fractures in 18 children between the ages of 1 year and 14 years seen over a period of ten years. Only two patients had surgery; one of whom had avulsion of the Achilles tendon insertion and the other who had an intra-articular fracture. The outcome in all the patients was satisfactory. The authors also noted that 44% of their cases were initially missed at the time of initial examination, probably because many were incomplete fractures without displacement.Editorial Comment
Calcaneal fractures are considered to be rare in children. Nevertheless, they are encountered in paediatric orthopaedic practice and hence it is useful to be aware of the prognosis in these fractures. The authors suggest that the prognosis is good in children.
*At the annual meeting of POSI at Madras in 1996, one of our members, Dr. R.S.Kulkarni from Kudal had presented his experiences with fractures of the calcaneum. He had seen 26 children with 28 fractures of the calcaneum, all of whom were treated non-operatively, and his message too was that the prognosis following calcaneal fractures is generally very good in children.
4. Sacral-level myelomeningocele: Long-term outcome in adults.
Selber P. Dias L. The Children's Memorial Hospital Chicago, Illinois, USA. Journal of Pediatric Orthopaedics 1998; 18: 423-7.
The long term outcome of 46 patients with sacral level myelomeningocele (mean age : 23 years) was studied. 30 patients had high sacral lesions (weak gluteus medius & maximus and triceps surae), and 16 had low sacral lesions (fair to normal glutei and triceps surae). 13 patients had a tethered cord and 39 patients underwent a total of 217 operations. 41 patients (89%) remained as community ambulators, of whom 32 required no external support for walking. Foot deformities which occurred frequently in these patents were treated by soft tissue and extra-articular procedures but arthrodesis was avoided. Deformities at the knee requiring surgery were more frequent with high level sacral lesions. Tethered cord syndrome occurred in 13 patients which was released. Scoliosis developed in some of the patients with a tethered cord.
5. Bilateral dislocation of the hip in spina bifida: A long-term follow-up study.
Heeg M, Broughton NS, Menelaus MB.. Royal Children's Hospital, Parkville, Victoria, Australia. Journal of Pediatric Orthopaedics 1998; 18: 434-6.
Nineteen patients with spina bifida with bilateral hip dislocations were followed up for 10 years. 10 patients had high lesions (thoracic to L3) and 9 had low lesions (L4 to sacral). In 2 patients the dislocations were not treated. Open reduction was performed in 10 hips, 9 of whom had iliopsoas transfer and in 3 hips an innominate osteotomy was also performed. In the remaining patients soft tissue release operations were done. At follow-up, of the 10 patients with high level lesions, only 2 were walkers but both had persistent bilateral hip dislocations. All 9 patients with low level lesions remained walkers but, 4 of them had bilateral dislocations at follow-up. The authors conclude that a level pelvis and a good range of movement of the hips are more important for ambulation than the reduction of bilateral hip dislocation.Editorial Comment
Both these articles bring to our attention some very important aspects of treatment of spina bifida. Selber & Dias rightly emphasise that the long-term function in patients with sacral level lesions is very good. However, foot deformities are common and surgery is frequently warranted for them. Their recommendation that arthrodesis should be avoided while correcting foot deformites is extremely important. The likelihood of neuropathic ulceration is distinctly less if the foot is plantigrade and SUPPLE rather than plantigrade and STIFF. This was clearly demonstrated in an earlier report by Maynard et al (J Pediatr Orthop.1992;12:786-8). Selber & Dias also point out that scoliosis is uncommon with sacral level lesions, and if it does occur it should make the surgeon suspect an underlying tethered cord. Heeg et al clearly demonstrate that bilateral hip dislocation in spina bifida may well be left alone as it does not seem to have any bearing on the ambulatory status of these children. Furthermore, redislocation occurs very often despite elaborate surgery. It would, therefore, seem reasonable to suggest that treatment should be directed to correction of deformities and appropriate bracing to facilitate ambulation.
6. Simple bone cysts treated with aspiration and a single bone marrow injection. A preliminary report.
Delloye Ch, Docquier PL, Cornu O et al. Cliniques Universtaires St-Luc, Brussels, Belgium. International Orthopaedics 1998; 22: 134-8.
A single percutaneous injection of autologous bone marrow was performed after aspiration of simple bone cysts in 8 patients. In all but one case regression of the cyst was noted. In one patient complete healing occurred while in six only a very small cystic area remained after a mean follow-up of 31 months.Editorial Comment
This report supports the findings of Lokiec et al (J Bone Joint Surg, 1996;78-B:934-7), who first reported this approach to the treatment of simple bone cysts. This method seems very simple and effective with negligible morbidity. (The Editor performed this procedure in one patient and the results have been extremely gratifying.)
7. Powered prosthetic hands in very young children.
Datta D, Ibbotson V. Northern General Hospital, Sheffield, England. Prosthetics and Orthotics International 1998; 22: 150-4.
Eleven children with congenital upper limb deficiencies were fitted with powered prosthetic hands at an average age of 20.6 months. 8 of these children adapted to the prosthesis and began using them successfully. The authors suggest that introduction of a powered prosthesis at a very early age is a more suitable alternative than provision of a body powered device while waiting for the child to reach an older age before a powered prosthesis is considered.Editorial Comment
The article describes an approach which differs from the traditional practice of giving a body powered device initally and then fitting a powered prosthesis only once the child is considered to be old enough to learn to use it. The report should be an eye-opener to several clinicians in India, as it is certainly not uncommon in our practice to enounter children with congenital upper limb deficiencies who are referred for prosthetic fitting very late (often after the child is old enough to go to school). It has been well established that the younger the child at which a prosthesis is fitted, the better the acceptance and use of the device. The present authors go even further to encourage the use of myoelectric prostheses in children under two years of age.
Articles Published by Members of Posi
Rotation fasciocutaneous flap for neglected clubfoot: A new technique.
D'Souza H, Aroojis A, Yagnik MG. Bai Jerbai Wadia Hospital for Children, Bombay. India. Journal of Pediatric Orthopaedics 1998; 18:319-22.Treatment of internal rotation gait due to gluteus medius and minimus overactivity in cerebral palsy: Anatomical rationale of a new surgical procedure and preliminary results in twelve hips.
Joseph B. Kasturba Medical College, Manipal, India. Clinical Anatomy 1998; 11:22-8.
The authors would be pleased to send copies of their articles to any member who requests them.
Spinal Deformity Following Spinal Tuberculosis in Children
The series of international multicentre trials on the management of spinal tuberculosis conducted by the Medical Research Council of Great Britain have shown quite clearly that chemotherapy is as good as radical surgery in achieving disease clearance. However, progressive spinal deformity (kyphosis) after disease clearance is a problem that occurs in some patients following non-operative treatment. If kyphosis is severe, it can lead to compromised pulmonary function and neurological deficit, including late onset paraplegia. The treatment of severe degrees of kyphosis is difficult and is associated with a very high complication rate. For these reasons it is imperative that prevention of kyphosis be one of the aims of treatment of spinal tuberculosis.Frequency of progressive kyphosis
In 30% of patients no progression of the kyphosis occurs after healing. When progression does occur, the average increase in the kyphosis is between 15 to 20 degrees. However, in around 20% of patients the deformity increases to more than 20 degrees, and children form a major part of this group. Children are at risk of developing gross spinal deformity when treated non-operatively.Pathology of deformity in spinal tuberculosis
95% of patients with spinal tuberculosis have anterior spinal disease which can lead to vertebral destruction anteriorly. Vertebral collapse tends to continue till healthy bone above and below the diseased area meets anteriorly. When two or more vertebral bodies are destroyed by disease, severe kyphosis occurs before such spontaneous anterior stabilisation occurs. The final gibbus angle, therefore, depends on the amount of vertebral destruction. In adults, about 30 to 35 degrees of kyphus develops following complete destruction of one vertebral body in the dorsal or dorso-lumbar regions. In patients who are skeletally mature at onset of the disease, 85% of the vertebral collapse occurs within 12 months of onset, and virtually no increase in the deformity occurs. In children, the average initial vertebral loss is greater than in adults. The extent of deformity that occurs is also greater in children than in adults for the same degree of vertebral destruction. In addition, in children, anterior spinal disease destroys the anterior parts of the vertebral growth plates. The posterior structures continue to grow while growth of the anterior structures have been arrested due to the disease. This differential growth of the spine, even after healing of the disease, leads to progressive kyphosis. The increase in spinal deformity continues till the spinal growth spurt is over.Patterns of progression of spinal deformity
Three patterns of progression of spinal deformity have been noted in children with spinal tuberculosis.Pattern 1: Children with > 40 degrees of kyphosis to begin with, extensive destruction of the vertebral bodies including the anterior growth plates.
Progressive increase in kyphosis occurs due to unbalanced growth of the spine. These children frequently end up with a deformity in excess of 70 degrees.Pattern 2: Children with < 30 degrees of kyphosis to begin with, minimal destruction of the vertebral bodies and sparing of the anterior growth plates.
- Phase one : Vertebral collapse with initial increase in the deformity occurs while the disease is active.
- Phase two : (Plateau phase) No progression of deformity occurs as consolidation and healing occurs.
- Phase three : Regeneration of the vertebral bodies commences after a period of two to three years with gradual decrease in the kyphosis. This phase extends over several years as growth continues.
- Phase one : Vertebral collapse with increase in kyphosis occurs over a period of 18 months.
- Phase two : (Latent plateau phase) No progression of the deformity occurs for several years.
- Phase three : Progression of kyphosis during the final growth spurt. The kyphosis may occasionally increase by 40 degrees. This sometimes occurs gradually without it being noticed by the patient till the deformity is very severe.
Pattern I: As in children who have > 40 degrees of kyphosis at the commencement of treatment, the spinal deformity generally progresses relentlessly, spinal fusion is indicated. In these patients, both anterior and posterior fusion are required.
Pattern II: As gradual partial resolution of the deformity occurs with growth, no surgery is required in these children.
Pattern III: This is the most vulnerable group for delay in treatment. In most countries where spinal tuberculosis is common, children tend to be discharged from follow-up once the disease is cured. The possibility of progression of the deformity several years later may not be appreciated and consequently the parents are not counselled about such an eventuality. As a result of this the patient may be seen again only once the deformity has progressed to an unacceptable degree. It is essential that children with cured spinal tuberculosis are followed-up till skeletal maturity. At the earliest sign of deformity progression a posterior spinal fusion must be performed.
Is the routine use of pre-reduction traction for DDH justified?
The routine use of traction before open or closed reduction of developmental dysplasia of the hip became popular after Salter1 published the results of his work in 1969. He suggested that the frequency of avascular necrosis of the femoral capital epiphysis can be minimised by :
- 1. maintaining the "human position" in plaster
- 2. performing an adductor myotomy and
- 3. using pre-reduction traction
It is presumed that preliminary traction stretches the contracted soft tissues, thereby facilitating reduction and preventing avascular necrosis in developmental dysplasia of the hip. These three principles of management advocated by Salter were widely adhered to for over a decade. However, subsequent reports that have appeared in the literature have suggested that traction may neither influence the frequency of avascular necrosis nor facilitate reduction.
Regretfully, there are no reports of randomised controlled trials which would help us to draw definite conclusions regarding the value and safety of pre-operative and pre-reduction traction. We are, therefore, forced to look for circumstantial evidence from published series based largely on retrospective analysis. In the literature, different authors have used quite different criteria for the diagnosis of avascular necrosis and hence the reported incidence of avascular necrosis has varied widely. This makes it even more difficult to interpret data related to the incidence of avascular necrosis.
What evidence is there that pre-reduction traction may be beneficial?
In a retrospective clinical study, Salter et al1 noted the frequency of avascular necrosis in three groups of patients treated in different ways as shown below:
Group Traction Adductor Myotomy Position Spica AVN I No No Lorenz (Frog position) 30% II Yes Yes Wide abduction 15% III Yes Yes Human position 5%
Buchanan et al, Gage & Winter, Weiner et al, Langenskiold & Paavilainen in different retrospective studies 2-5 noted a significant reduction in the frequency of avascular necrosis in children who had had pre-reduction traction. Their results suggested that not only did the overall frequency of avascular necrosis reduce but the frequency of severe avascular damage was clearly less when traction had been employed. However, there is no consensus among these authors on the optimal duration of traction, the position of the limb during traction or the choice of skin or skeletal traction. Several of the patients included in some of these reports had been treated in plasters in the Lorenz and Lange positions (as they were treated well before Salter's paper, emphasising the harmful effects of these positions for post-reduction immobilisation, had been published).What evidence is there that pre-reduction traction may NOT be beneficial?
Weinstein6, in 1987, reported a very low rate (5%) of avascular necrosis in pateients who underwent open reduction without preliminary traction. Subsequently Kahle et al7 presented excellent results of treatment of DDH without preliminary traction. Closed reduction under general anaesthesia was attempted in 47 hips without preliminary traction. 20 of the hips could not be reduced closed and required open reduction. Only 4% developed avascular necrosis.
A closer look at the study of Salter is needed in the light of the assertions of Kahle et al. As the latter authors rightly point out, the study analyses the effect of three variables on the incidence of avascular necrosis, viz. preliminary traction, adductor myotomy and the position of immobilisation. The inference from the study that one variable, i.e. preliminary skin traction, reduces the incidence of avascular necrosis does not take into account that the other two variables (adductor myotomy and the position of immobilisation) are possibly confounding variables. The position of immobilisation is, in all probability, the most important factor which determines the frequency of avascular necrosis as this has been well established by the experimental work of Salter. The position of immobilisation, thus, is a definite confounding variable. On account of this, the study of Salter does not adequately substantiate the claim that traction is even partly responsible for the decrease in the frequency of avascular necrosis.
Kahle et al go further to question the value of traction in facilitating reduction of the dislocated hip. They point out that during open reduction of the hip, the structures most frequently encountered as obstructions to reduction are, a thickened transverse acetabular ligament, hypertophied ligamentum teres and pulvinar, constricted inferior capsule and an inverted limbus. They emphasise that none of these structures can possibly be affected by traction. In the study of Kahle et al 43% of the hips could not be reduced by closed means and had to undergo open reduction. Interestingly, they report that in an earlier series in which the same authors had used preliminary traction, 42% of the hips could not be reduced by closed means. In their hands, the frequency of achieving closed reduction was identical whether preliminary traction was employed or not.Kahle et al in the conclusion of their paper published in 1990 wrote :
"We realise that our skepticism about the value of preliminary traction in the treatment of congenital dislocation of the hip challenges a philosophy of care that is deeply ingrained in the orthopaedic community. We hope that our findings will prompt others to take a fresh look at this issue"
They were absolutely correct about the fact that this philosphy is deeply ingrained in the minds of orthopaedic surgeons. In 1991 Fish et al8 reported a study conducted by the Pediatric Orthopaedic Society of North America. 87% of the 335 members of POSNA responded to a questionnaire prepared to define the practice in the use of preliminary traction for DDH. 95% of the respondents used pre-reduction traction and most of them believed that traction reduces the incidence of avascular necrosis and enables easier reduction.
From the available information in the literature, there is no scientifically substantiated proof that preliminary traction either minimises the frequency of avascular necrosis or facilitates easier reduction. There is also no sound evidence to prove that it is of no benefit at all. It is, therefore, imperative that we take cognizance of Kahle's exhortation "to take a fresh look at the issue". Only a well designed prospective randomised clincal trial will give us clearer answers.References:
- Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as a complication of treatment of congenital dislocation of the hip in young children: A clinical and experimental investigation. Canadian J Surg. 1969;12:44-62.
- Buchanan Jr, Greer RB, Cotler JM. Management strategy for prevention of avascular necrosis during treatment of congenital dislocation of the hip. J Bone Joint Surg (Am) 1981;63A:140-6.
- Gage JR, Winter RB, Avascular necrosis of the capital femoral epiphysis as a complication of closed reduction of congenital dislocation of the hip. J Bone Joint Surg (Am) 1972;54A:373-88.
- Weiner DS, Hoyt WA, O'Dell HW. Congenital dislocation of the hip: the relationship to premanipulation traction and age to avascular necrosis of the femoral head. J Bone Joint Surg (Am) 1977;59A:306-11.
- Langenskiold A, Paavilainen T. The effects of traction treatment on the results of closed or open reduction for congenital dislocation of the hip: A preliminary report. In Congenital dislocation of the hip, Ed.Tachdjian M.O.Churchhill Livingstone, New York 1982: pp365-71.
- Weinstein SL. Anteromedial approach to reduction for congenital hip dysplasia. Strategies Orthop Surg 1987;6:2.
- Kahle WK, Anderson MB, Stevens PM, Coleman SS. The value of preliminary traction in the treatment of congenital dislocation of the hip. J Bone Joint Surg (Am) 1990;72A:1043-7.
- Fish DN, Herzenberg JE, Hensinger RN. Current practice in use of prereduction traction for congenital dislocation of the hip. J Pediatr Orthop 1991;11:149-53.
I would urge members to note that the response rate for the questionnaire sent out by POSNA, mentioned above, was 87%. I am sure we in POSI can do better than that while responding to the questionnaire on clubfoot. Please send in your completed clubfoot questionnaire as soon as possible. Thank you!
The Editors thank Dr. S. Rajasekaran for his contribution on "Spinal deformity following spinal tuberculosis in children"
Dr. Rajasekaran is a Consultant Orthopaedic Surgeon at Ganga Medical Centre & Hospital, Coimbatore. He is a member of the Executive Committee of POSI and his special interests are Paediatric Orthopaedics and Spinal Surgery. He has published some excellent articles related to spinal tuberculosis in the Journal of Bone & Joint Surgery.
The Editors also thank Dr. Maneesh Bhatia for his contributions for this issue. He prepared the questionnaire on clubfoot and the Debate on the role of traction in DDH. Dr.Bhatia is currently working as the Paediatric Orthopaedic Fellow at Kasturba Medical College. He was awarded the first Fellowship position which was created last year in the Paediatric Orthopaedic Unit at Kasturba Medical College.Correspondence from Members
Dr. Jagdish Patwa from Ahmedabad responded to the Editorial Comment in a previous issue of POSITIVE pertaining to fibular hemimelia which is reproduced below.
Dr. Patwa asks " What is wrong with wearing an orthosis after correction rather than wearing a prosthesis after amputation". He went on to give details of his experience with successful management of a 15 year-old patient with fibular hemimelia who had previously undergone an attempt at limb lengthening which failed. He opted to correct the foot deformity first and then proceeded to lengthen the tibia by 17 cms.
We thank Dr. Patwa for his response and congratulate him on his success. We agree that if function can be well preserved by any reconstructive procedure, it is certainly superior to amputation. If, however, the function of the limb is severely compromised after surgery, amputation may be more acceptable.Next Posi Conference
The next POSI Conference is being held in Bangalore on 9 & 10 January 1999. In case you have not received information regarding the meeting please contact Dr. D.C. Sundaresh at PO Box 5425, MSRIT Post, Bangalore 560 054, Fax 80 3345493, E-mail: email@example.comFellowship in Paediatric Orthopaedics
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 last date for submitting applications is May 15, 1999.Errata
In the last issue of POSITIVE, in line 7 of the Debate "Is arthrodesis of the shoulder justifiable in children"Dr.Benjamin Joseph,
... 2. The femoral head should read as: ....2. The humeral head. The error is regretted - Editor.
(Note: The Editor of the Indian Journal of Orthopaedics took pains to point out this mistake to us.)
Published for and on behalf of the Paediatric Orthopaedic Society of India by
Department of Orthopaedics
Kasturba Medical College & Hospital
MANIPAL 576 119 , Karnataka State