This article describes in some detail the technique of crossed pin placement for 46 supracondylar fractures (74% Gartland type III and 26% Gartland type II). Four patients had neuropraxia of the ulnar nerve and in two patients cubitus varus developed despite fixation. The authors claim that the technique they describe is safe and reproducible.

The technique described has merit. However, is crossed pin fixation really superior to fixation with two lateral pins in the clinical situation? Evidence based on experiments on cadavers in the laboratory suggests that the former technique is superior biomechanically. No clinical study has compared the frequency of the loss of fixation with these two methods in patients. Till such time that evidence from a well designed randomised trial shows that crossed pin fixation is clearly superior, should we subject children to the potential 8% risk of an iatrogenic ulnar nerve injury?

20 culture proven cases of community-acquired septic arthritis of the hip were treated by urgent arthrotomy and parenteral antibiotics. All the children had Gram-positive infections. The parenteral antibiotics were stopped and oral antibiotics substituted once clinical improvement (no fever, decreased pain, increased joint motion) was documented. On an average the duration of parenteral antibiotic therapy was 8.2 days. At follow-up (mean 26 months) the range of motion and gait were normal in all 20 patients. Final radiographs of 11 hips were normal, while the others showed minor changes in the size of the epiphysis. The authors conclude that community-acquired acute Gram-positive septic arthritis require only a short course of parenteral antibiotics following surgical drainage.

The two aspects of this paper that warrant attention are that the infection was community-acquired and that early arthrotomy was performed in all the cases. If arthrotomy is delayed the outcome will never be as good as that reported by the authors. The vital aspect of management, therefore, is early diagnosis and early drainage. It also needs to be emphasised that if the infection is hospital acquired, there is a much higher chance of the infection being caused by Gram-negative organisms. In such cases parenteral antibiotics would be needed for longer periods.

The authors reviewed records of 282 children with acutely irritable hips for which differential diagnoses of transient synovitis and septic arthritis were considered. Using univariate and multiple regression analysis, a probability algorithm for differentiation between septic arthritis and transient synovitis was constructed. Four clinical predictors of septic arthritis were identified. They were: fever, inability to bear weight on the limb, ESR > 40mm, WBC count > 12,000/cu.mm. The predicted probability of septic arthritis was 0.2% if none of these predictors was present, 3.0% if one predictor was present, 40.0% if two were present, 93.1% if three were present and 99.6% if all four predictors were present.

This study is extremely relevant in our situation. All four predictors of septic arthritis can be identified in any hospital in India as no sophisticated investigations are involved. The authors have used sophisticated statistical methods to give simple guide lines for the diagnosis of septic arthritis. Any child with an irritable hip with three of these predictors should be treated as a case of septic arthritis and the hip must be drained. One hopes that surgeons would use these valuable clinical signs and intervene sufficiently early in suspected cases of septic arthritis snd prevent the horrendous sequelae of delayed treatment.

At the time of open reduction of 95 hips with DDH the position of maximum stability of the hip was assessed. A hip that was stable in flexion and abduction had an innominate osteotomy in addition to open reduction. For hips that were stable in abduction and internal rotation, a femoral varus derotation osteotomy was performed. For a double diameter acetabulum, a Pemberton osteotomy was performed. Hips that were stable in the neutral position, did not have any additional operation. After a mean follow-up of 15 years, 86% of hips treated on the basis of the position of stability had satisfactory results (Severin groups I & II). 7% of the patients required additional surgery for persistent hip dysplasia. 7% of hips developed avascular necrosis.

Even after concentric reduction is achieved in DDH, the hip can subluxate on account of acetabular dysplasia, femoral anteversion or acetabular anteversion. It may be difficult to decide whether additional surgery is needed to ensure stability of reduction. This article clearly states the indications for performing femoral or acetabular procedures in conjunction with open reduction in DDH. The particular value of the article is that the decision making is not based on fancy investigations which are out of reach of the orthopaedic surgeon in India. A decision can be made on the operating table and the reliability of this pattern of decision making appears to be quite satisfactory as the need for further surgery for subluxation was only 7%.

Twenty children under six years of age with cerebral palsy (10 hemiplegic &10 diplegic) who had less than 10 degrees of fixed equinus deformity were treated by serial plaster casts. The mean passive dorsiflexion of the ankle with the knee in extension increased from 3o to 20o when the casts were removed. After a mean follow-up of 3 years the mean passive ankle dorsiflexion was 90.

This article reminds us that serial plaster casting is still a very useful method of dealing with spasticity of the triceps surae and that it can also effectively correct minor degrees of myostatic contracture of the muscle in cerebral palsy. There is no doubt that if surgical lengthening of the muscle tendon unit can be avoided it would be ideal, particularly in the younger child. Some surgeons are sceptical about the lasting value of serial casting and claim that the effect of casting is very short-lived. This article demonstrates that the effect of casting can last for 2 to 3 years. Even if surgery can be deferred for this period it is still very useful. This cost-effective method of treatment of spastic equinus is also to be recommended in situations where regular physiotherapy is not feasible.

Information on 340 patients with pseudarthrosis of the tibia from 13 countries were compiled during the course of the study. This is the largest cohort of patients with this condition ever analysed. Data gleaned from the records enabled the group to study the aetiology, epidemiology, classification, pathology, treatment and functional results at skeletal maturity.

The study confirmed that several of the older methods of treatment have a very high failure rate. Resection of the pseudarthrosis, bone grafting and compression at the resection site by the Ilizarov technique was successful in 75% of instances. The study group recommended this as the procedure of choice. The success rate with microvascular free fibular transfer was 61% and the study group recommended that this procedure be reserved for cases where the Ilizarov technique fails.

The evaluation of the functional outcome at skeletal maturity showed that 40% of the patients needed permanent bracing. Unlimited walking was possible in 67% of patients. The limbs were of equal length in 40% of the patients. What was particularly noteworthy was that only 29% of the patients had normal ankle function. Degenerative arthritis and severe ankle valgus were common.

The study group also recommended that in the pre-pseudarthrotic stage bracing should be preferred to surgery.

It would be worthwhile recollecting the recommendations made in the review on pseudarthrosis of the tibia that appeared in a previous issue of POSITIVE. The author had listed treatment recommendations that were virtually identical to those made by the EPOS group.

1. 1. In the pre-pseudarthrotic stage - brace the patient
2. 2. Reserve microvascular free fibular transfer for situations where other options have failed.
3. 3. The Ilizarov technique was recommended for skeletally mature individuals as the treatment of choice.

However, there was one important recommendation that was different from that of the EPOS study. The author had recommended intramedullary rodding and onlay bone grafting as a viable option for the skeletally immature patient. The procedure has yielded results comparable to the Ilizarov technique and is certainly simpler and more cost-effective for our country.

Sundaresh DC, Gopalakrishnan D, Shetty N. MS Ramaiah Medical Teaching Hospital, Bangalore. Journal of Bone and Joint Surgery (British) 2000; 82-B: 28-32.

Bhatia M, Joseph B. Kasturba Medical College, Manipal. Pediatric Radiology 2000; 30: 184-5.

Joseph B, Mulpuri K. Kasturba Medical College, Manipal. Journal of Pediatric Orthopaedics - B 2000; 9: 16-23.

Mulpuri K, Joseph B. Kasturba Medical College, Manipal. Journal of Pediatric Orthopaedics 2000; 20: 267-73.

Joseph B, Ajith K, Varghese RA. Kasturba Medical College, Manipal, Journal of Pediatric Orthopaedics 2000; 20: 524-8.

Aroojis A, Johari AN. Bai Jerbai Wadia Hospital for Children, Mumbai.Journal of Pediatric Orthopaedics 2000; 20: 544-9.

The authors would be pleased to send copies of their articles to any member who requests them.

Is there an abnormal torsion of the tibia in congenital clubfoot ?

Some authors state that internal tibial torsion is an associated deformity in congenital clubfoot1,2,3. Others state that internal tibial torsion does not occur in association with clubfoot 4, 5, while Swann, Lloyd-Roberts & Catterall 6 contend that there is external tibial torsion in congenital clubfoot.

The reasons for the divergent views on this issue are that:

1. the techniques of measuring tibial torsion have differed and,

2. the bony landmarks used for measuring torsion have also varied from report to report.

Consequently the conclusions drawn in each of the studies have differed profoundly.

The techniques of measuring tibial torsion reported in the literature include, cadaveric measurement (anatomical specimens)7, clinical measurements 8,9, plain radiography 10, ultrasonography 1,11 and CT scans 5,12.

The bony land marks used by different authors include:

• Proximal landmarks:
  Posterior articular margin of the tibia 1,11
  Transverse tibial condylar axis 5,7
  Anterior articular surface
  Tibial tuberosity 8
• Distal landmarks:
  Posterior articular margin of the tibia 1,11
  Bi-malleolar axis 5,9,12
  Tibio-fibular axis 10

The "normal" values of tibial torsion reported have again varied considerably, with values ranging from 8o to 40o, on account of the different bony land marks used for measurement.

To add to the confusion, several earlier studies did not evaluate the reliability of measurement and so we have no idea of how reproducible the measurement techniques were. The more recent studies evaluating techniques of measuring tibial torsion have reported acceptable levels of reproducibility of measurement11,5,11,12. In order to determine whether there is any torsional deformity of the tibia in clubfoot, we may rely only on those techniques that have been found to be reproducible.

Only two studies specifically designed to assess tibial torsion in clubfoot have employed techniques that have been shown to be reproducible 1,5 and among them only one study included data on the reproducibility of measurement1. A closer look at the results of these two reports (see Table) show that the imaging techniques are different, the proximal and distal landmarks used for measuring tibial torsion are different and the normal values of torsion recorded in the two studies are different. On account of these differences the results obtained and the conclusions drawn are diametrically opposite.

The rationale of using the the bi-malleolar axis as the distal line of reference is questionable for various reasons. The lateral malleolus is inherently mobile; it moves during dorsiflexion and plantarflexion of the ankle. This itself can result in differing values of tibial torsion depending on the position of the ankle. It has also been noted that in patients with clubfoot the lateral malleolus is situated more posteriorly in the fibular notch than in normal feet. It has been suggested that the posterior displacement of the lateral malleolus may be aggravated by serial manipulations. The position of the lateral malleolus will influence the value of "tibial torsion" when the bi-malleolar axis is used.

It is, therefore, essential that tibial torsion be measured using both the proximal and distal reference lines on the tibia itself.

From the available literature it is clear that only the study of Krishna et al has used a technique which involves measurement of tibial torsion using both reference lines on the tibia itself for evaluating tibial torsion in clubfoot. Till such time that further studies are performed, evidence from this single report has to be accepted. The results of the study suggest that children with clubfeet have associated internal tibial torsion.

Clearly further studies are needed to verify this impression. Future studies also need to confirm whether the position of the lateral malleolus is, in fact, posteriorly displaced in clubfeet. The study of Krishna et al also showed that the apparently "normal" contralateral leg in patients with unilateral clubfoot have relative internal tibial torsion when compared to normal children. On account of this, future studies should use normal children as controls rather than use the contralateral leg as "normal" controls.

1. Krishna M, Evans R, Sprigg A, Taylor JF, Theis JC. Tibial torsion measured by ultrasound in children with talipes equinovarus. J Bone Joint Surg (Br) 1991; 73-B: 207-10.
2. Hutchins PM, Foster BK, Paterson DC, Cole EA. Long term results of early surgical release in clubfeet. J Bone Joint Surg (Br) 1985; 67-B: 791-9.
3. Loren G, Karpinski NC, Mubarak SJ. Clinical implications of clubfoot histopathology. J Pediatr Orthop 1998; 18:765-9.
4. Herold HZ, Markovich C. Tibial torsion in untreated congenital clubfoot. Acta Orthop Scand 1976; 47: 112-7.
5. Cuevas De Alba C, Guille JT, Bowen JR, Harcke HT. Computed tomography for femoral and tibial torsion in children with clubfoot. Clin Orthop 1998; 353: 203-9.
6. Swann M, Lloyd-Roberts GC, Catterall A. The anatomy of uncorrected clubfoot: A study of rotation deformity. J Bone Joint Surg (Br) 1969; 51-B:263-9.
7. Le Damany PG. Technique of tibial tropometry. Clin Orthop 1994; 304: 4-10.
8. Khermosh C, Lior G, Weissman SL. Tibial torsion in children. Clin Orthop 1971; 79: 25-31.
9. Stahel LT, Engel GM. Tibial torsion: A method of assessment and a survey of normal children. Clin Orthop 1972; 86: 183-6.
10. Rosen H, Sandick H. The measurement of tibiofibular torsion. J Bone Joint Surg (Am) 1955; 37-A: 847-55.
11. Joseph B, Carver RA, Bell MJ, Sharrard WJW, Levick RK, Aithal V, Chacko V, Murthy SV. Measurement of tibial torsion by ultrasound. J Pediatr Orthop 1987; 7: 317-23.
12. Eckhoff DG, Johnson KK. Three dimensional computed tomography reconstruction of tibial torsion. Clin Orthop 1994; 302:42-6.

Lower Limb Bracing in Polio
This is the second part of a two-part article which outlines the options available for bracing in polio.

Stabilisation of the knee

Quadriceps paralysis (sagittal plane instability)

Quadriceps paralysis is one of the most common problems encountered in polio that requires bracing. The paralysis leaves the knee unstable with a tendency to collapse into flexion. Complete paralysis of the muscle is not necessary to render the knee unstable. Patients with a quadriceps power of MRC Grade III may also experience instability of the knee especially while walking on a slope or on uneven ground. Such patients also may need bracing.

The orthosis must

• a. prevent the knee from flexing during the stance phase of gait
• b. permit flexion of the knee during the swing phase

Options

• 1. Above knee calipers with knee locks
• 2. Above knee calipers with off-set knee joints
• 3. Thermoplastic floor reaction orthosis

A conventional above knee caliper with a knee lock can provide adequate stability to the knee. However, it is possible to stabilise the knee without preventing flexion of the knee during the swing phase of gait by using a floor reaction orthosis.

The floor reaction orthosis (FRO) is a thermoplastic or a fibre-reinforced plastic orthosis, which holds the ankle in a few degrees of plantarflexion. This ensures that the initial contact with the ground is made by the forefoot rather than the heel. This causes the body-weight line to pass in front of the axis of the knee joint, thereby stabilising it. The same mechanism is involved when a mild equinus contracture stabilises a paralysed knee effectively without the patient having to resort to the hand-on-thigh gait. In addition to holding the foot in plantarflexion, the upper part of the orthosis exerts a backward pressure in front of the knee and the suprapatellar region, forcing it into extension. This design of orthosis (which is a modification of the Salteil brace and advocated by Professor Sethi) has been found to be extremely effective. The FRO is much lighter than a conventional KAFO and it has the advantage that the knee is not kept locked.

There are however, a few situations where the floor reaction orthosis cannot be used viz. :

• 1. In patients with a flexion deformity of the knee - the brace will not stabilise the knee if there is a flexion deformity
• 2. In patients with a severe degree of recurvatum - the orthosis tends to increase any pre-existing genu recurvatum
• 3. In patients with bilateral quadriceps paralysis - patients cannot cope with bilateral FROs and here at least one side would need a knee-ankle-foot orthosis.

In patients with a quadriceps power of Grade II or more on the MRC scale, the knee may be stabilised by providing an above knee caliper with an off-set knee joint. Here the orthotic joint is aligned with its axis posterior to the axis of the knee such that the weight-bearing line passes anterior to the orthotic knee joint. This will enable the orthosis to remain stable in extension when the patient stands. The joint is not locked and so the knee can flex during the swing phase of gait.

The brace should

• a. control genu recurvatum
• b. prevent the knee from flexing during the stance phase of gait

The options are

• 1. Above knee caliper
• 2. Lehneis modification of the floor-reaction orthosis
• 3. Swedish knee cage

The Lehneis modification of the FRO is an excellent orthosis for controlling recurvatum. Here the posterior trim line of the orthosis is raised up to the popliteal fossa so as to give good counter-pressure. The Lehneis FRO can control both recurvatum and the quadriceps paralysis and hence is one orthosis that can effectively deal with instability of the knee in two directions while retaining free knee flexion during the swing phase of gait.

Multidirectional instability
Occasionally, in addition to sagittal plane instability there may be varus or valgus instability of the knee on account of stretching of the collateral ligaments.The orthotic option here is to use a knee-ankle-foot orthosis. If, however, the knee has also become painful, arthrodesis may be the only option.Stabilisation of the hip

The hip may be unstable on account of paralysis of the abductors (either isolated abductor paralysis or a flail hip) or on account of dislocation of the hip.

The traditional approach has been to prescribe a hip-knee-ankle-foot orthosis by incorporating a pelvic band and a hip joint that is locked in extension. Patients who have to walk with the hip and knee locked either swivel the entire trunk forward or have to adopt a swing-to or swing-through gait pattern. Both these modes of ambulation are profoundly energy inefficient.

More recently, it has been shown that a quadrilateral, thermoplastic, ischial weight-bearing socket can overcome the need for extending the orthosis above the hip in most patients with a flail hip. While this type of orthosis functions like a conventional above knee caliper, it affords sufficient stability to the hip to avoid the need for a pelvic band.

Comparison of conventional calipers and thermoplastic orthoses
In a study at the author’s centre a comparison of conventional metal and leather calipers versus thermoplastic orthoses was undertaken. Thirty patients with post-polio residual paralysis who had been using conventional calipers were then fitted with thermoplastic orthoses. The study came up with the following results:

• 1. The thermoplastic orthoses were lighter, cheaper, more rapidly fabricated and more appealing cosmetically than the traditional calipers.
• 2. The extent of bracing needed with the thermoplastic braces was less than the conventional calipers in several instances. A hip-knee-ankle-foot orthosis was not required in any case when a     thermoplastic orthosis was used.
• 3. Material failure was not more frequent than in conventional calipers.

Over the last eight years we have been prescribing thermoplastic orthoses following the pattern of decision making as outlined in this brief report with very gratifying results. The newer thermoplastic orthoses come closer to achieving the aims of orthotic management in polio referred to at the beginning of this article in terms of:

• 1. Minimising the weight of the orthoses
• 2. Reducing the number of joints rendered immobile by the orthoses.

Attempts at improving the designs of orthoses further are constantly needed in order to mitigate the disability of patients with post-polio paralysis. Listed below are some centres where these newer thermoplastic orthoses are made. The names of the contact persons are also furnished..

Contact: Professor P.K.Sethi, Department of Orthopaedics, SDM Hospital, Bhawani Singh Road, Jaipur, Rajasthan

Contact: Dr. Suranjan Bhattacharji, Department of Physical Medicine & Rehabilitation Christian Medical College Hospital Vellore 632 004, Tamilnadu

Contact: Dr. Benjamin Joseph, Department of Orthopaedics, Kasturba Medical College Manipal 576 119, Karnataka

Contact: Mr. Chapal Khasnabis, Mobility India, APD Campus, Hennur Road, Lingarajapuram Bangalore 560 084, Karnataka

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 on completion of the Fellowship.

For further information contact :

Paediatric Orthopaedic Service, Department of Orthopaedics,
Kasturba Hospital, Manipal 576 119, Karnataka.
The last date for submitting applications is July 15, 2001.

Inland Training Fellowships in Paediatric Orthopaedics administered by the World Orthopaedic Concern are being offered at Manipal and Mumbai for periods of 6 to 8 weeks. The training would be under Dr. Benjamin Joseph at Manipal and Dr. Ashok Johari at Mumbai.

For futher information contact:

The next annual conference of POSI would be held in Madurai between March 2^nd and 4^th, 2001.

For further details contact :

Copies of the Call for Abstracts for the 2001 Pediatric Orthopaedic Society of North America Annual Meeting to be held in Cancun, Mexico between May 3 - 5, 2001 are now available. Any member who would like to receive a copy, please contact Dr. Benjamin Joseph.
The call for abstracts can also be downloaded from the POSNA web site (www.POSNA.org).

Members interested in joining study groups on Clubfoot and Perthes' disease please contact Dr. Benjamin Joseph.

The Editors thank Dr. Narasimha Rao KL for his contribution on tibial torsion in clubfoot. Dr. Narasimha Rao is currentl working as the Paediatric Orthopaedic Fellow in the Department of Orthopaedics, Kasturba Medical College, Manipal.