Abstracts
PAEDIATRIC ORTHOPAEDIC SOCIETY OF INDIA
President: Prof. Verghese Chacko
"Illampallil", Tiruvalla – 689 111 (Kerala), India
Tel: Resi.: 0473-630439
The Paediatric Society of India was very happy indeed when Madurai came forward to host the ‘Seventh Annual Conference’. Besides, being the cultural capital of South India, Madurai attracts conferences. With the excellent organizational ability of Prof. Devadoss and his team, giving special attention to every detail, one can look forward to a very enjoyable time.
Paediatric Orthopaedics is gaining greater interest among the young orthopaedic surgeons of this country. Surgeons in general are inundated with trauma work. The general impression that conditions like DDH and Slipped Capital Femoral Epiphysis and Congenital anomalies are rare, is changing. While, incidences of polio and its rehabilitative work is getting less in some parts of the country, we still have many crippled children from polio, cerebral palsy and other neurological disabilities to deal with. I’m sure that this conference with outstanding faculty both form within and outside this country would enlighten us on various aspects of Paediatric Orthopaedic Problems.
We look forward to an exciting period at the ‘Seventh Annual Conference’.
February 7, 2001
Seventh Annual Conference of the Paediatric Orthopaedic Society of India Madurai, India
Prof. A. Devadoss
(Organizing Chairman)
INSTITUTE OF ORTHOPAEDIC RESEARCH & ACCIDENT SURGERY
No. 484-B, K.K. Nagar, Madurai – 625 020 India
Phone:91-452-650811/12
Fax:91-452-650810
E-mail:ioras@md3.vsnl.net.in
Message from the Organizing Chairman
I have great pleasure to send this message for Souvenir of the 7th Annual Conference of POSI 2001. It was at Bangalore conference that it was decided that Madurai will host the 7th POSI Conference in 2001. Although Madurai is a historical city to conduct a scientific conference of this magnitude is quite difficult. However we have made all the efforts to have a good scientific feast.
The foreign faculty are all expert in Paediatric Orthopaedics, whose experience will help all the Indian delegates in updating their knowledge in Paediatric Orthopaedics. I welcome all the delegates for the scientific meeting and also to enjoy the hospitality of this temple city. I wish the Conference all Success.
USE OF SHEFFIELD EXTENSILE INTRA-MEDULLARY RODDING IN OSTEOGENESIS IMPERFECTA
Dr. NV Girish Kumar, Dr.AJ McGuinness
University Hospital, Cork, Ireland
Management & prevention of multiple fractures of long bones in severe OI is a therapeutic challenge. Walking potential is significantly impaired by the recurrent fractures & consequent deformities in the long bones. Sheffield Extensile Intra-Medullary Rods are a good way of treatment in this difficult scenario. We are outlining the clinical success of this nail on our series of 8 nails in 5 consecutive patients. The success rate is very high and the complication rate is very low. The earlier Bailey-Dubow rods had a high complication rate. Improvements in surgical technique and design of the nail are vital components for a good outcome. The nails extend the whole length of the diaphysis, are anchored in the epiphysis, lengthen along with longitudinal bone growth. Hence recurrence of fractures & deformities due to longitudinal growth of the bone beyond the nail is prevented which is a major problem with other treatment methods.
SURGICAL STRATEGY IN CONGENITAL SCOLIOSIS
Dr. J. Dheenadhayalan
Dr. S. Rajasekaran
Ganga Hospital
Swarnambika Layout
Coimbatore 641 009
Congenital scoliosis often presents a challenge in the management because of its varied presentations, complex pathology, associated birth defects and a high rate of complications with surgical correction. We present here the surgical strategy adopted by us in the management of 20 cases of congenital scoliosis.
Material and Methods:Between 1993 and 2000, 42 patients with congenital scoliosis were seen of whom 20 were found to have progressive deformity and underwent surgical treatment. There were 11 males and 9 females. The age of presentation ranged from 15 months to 17 years. The involved area was dorsal in 9 patients, dorsolumbar in 6 patients and lumbar in 5 patients. Formation defects accounted for 11 patients whereas the remaining 9 and combination of formation and segmentation defects, 4 patients had intradural anomalies with split cord syndrome and diastametamalia of whom 2 had cord tethered cord syndrome also. 2 Patients had parapersis and one had paraplegic with bladder involvement at the time of presentation.
All patients had MRI and a thorough systemic evalution. Patients in the dorsal region had either an excision of the hemivertebra or a posterior fusion with instrumentation depending upon the age and the type of pathology. Patient above the age of 10 years usually had a staged or a single stage anterior and posterior fusion. 5 patients who had involvement below the L1 area had excision of the hemivertebra with acute correction of the deformity. Superficial wound healing problems in 5 patients and 2 patients had release of the tethered cord before corrective surgery. One child had intraperative burns due to dysfunction of the heating pad which was the only major complication. All the 3 patients with neurological problems showed remarkable improvement following decompression and fusion.
Conclusion:The surgical strategy of congenital scoliosis has to be tailored to each patient according to the age, pathology and site of lesion. We have found that with proper indications and good diagnosis surgical procedure for congenital scoliosis offers very good results.
IS HAEMARTHROSIS HARMFUL? AN EXPERIMENTAL STUDY
Dr. H.L. Nag
Dept., of Orthopaedics, A.I.I.M.S.
Haemarthrosis is a common condition. The management of this varies from conservative inactivity to aggressive removal of the blood from the joint. The wide variance in management could partly be the consequence of improper understanding of haemarthrosis. Therefore, the basic question – is haemarthrosis harmful? To get a better understanding to this effect, this study was undertaken.
Materials and Methods:An experimental study was conducted. A single episode of haemarthrosis was created by injecting blood of same individual in the right knee joints of 18 rabbits. The left knee served as the control. Animals were divided into three groups with six rabbits in each group At 1, 3 and 6 weeks of post haemarthrosis rabbits of each group were sacrificed. Representative articular samples were harvested and processed. The surface and the cellular change were studied using Scanning Electron Microscope (SEM) and Light Microscope (LM) respectively.
Results:At pme weel. the articular surface under SEM revealed unevenness compared to normal smooth surface. At three weeks, multiple pits ad fissures were observed. And at six weeks, rolled leaf like appearance and exposed dead chondrocytes were seen on the surface. LM study at one week showed decrease in cellularity and disturbance in cellular arrangements. Three weeks sample revealed dead chondrocytes in superficial layer. On sixth week, hypercellularity and attempted restoration of cellular pattern were noticed.
Discussion:A single episode of haemarthrosis has harmful effect on both the articular surface and cellular levels. These adverse effects of haemarthrosis were found to be reversible in this study.
CLUB FOOT-JESS
Author. Proj. A Devadoss
Presenter. Dr. J C Ganesan
IORAS, Madurai
The bipedal stance of man differentiates him from his ancestors. To achieve this he needs a plantigrade, pliable foot. Club foot deformity is commonly seen in our day to day practice (1-2/1000 live births). This complex deformity is complicated when it relapses or neglected for a long time. Nevertheless the problem being addressed by various surgical procedures not all of them give appreciable result, but results in scarred stiff and small foot.
The aim is to achieve a pliable, plantigrade pain free and cosmetically acceptable foot. By applying the principles of differential distraction technique on the basis of Law of Tension Stress using the JESS Apparatus deviced by Prof. B.B. Joshi of Mumbai, consistent commendable results are achieved. In IORAS following this principles 46 feet in 30 children were treated with JESS apparatus. The results were quite appreciable when compared to other modalities of management. The methodology of the procedure and the results were discussed in this paper.
The Role of Differential Fractional Histogenesis by application of JESS fixator in the management of Rigid, Relapsed, Resistant and Neglected cases of CTEV.
Dr. S.S. Gill Dr. Harinder Singh Bath
Additional Professor
Department of Orthopedics
PGIMER, Chandigarh
Extract Fixators with Differential Distraction are fast emerging as the alternative to extensive soft tissue releases and bony resections in the difficult cases of CTEV. This prospective study included seventeen feet of fourteen children who presented in the department of Orthopedics, PGIMER, Chandigarh from January 1999 to June 2000. The patients who underwent the surgery had a preperative diagnosis of Rigid, Relapsed, Resistant or Neglected cases of Congenital Talipes Quinovarus. The mean age of JESS fixator application was 48 months. The patients were reviewed postoperatively and a minimum follow up of six months was assured (mean 9 months). The cases were assessed in terms of deformity correction and function. We report 76% excellent to good results, 18% fair and 6% poor result.
It was concluded that JESS fixator is a good alternative to extensive soft tissue releases and bony resections. It’s a semi-invasive technique with the advantage of no scarring, achieving a supple foot and restoring the normal foot length.
Evaluating the Outcome of Treatment of Clubfoot - A need for better yardsticks
Renjit A. Varghese, Benjamin Joseph
(Additional Professor)
P.G.I.M.E.R.
5 cases of congenital muscular torticollis were treated by Bipolar release of sternocleidomastoid muscle in Dept of Orthopaedics, P.G.I.M.E.R. and were followed for one year.
The criteria for selection of cases was:
- Surgical correction in older children with severe deformity.
- Persistent deformity in previously failed surgery (bipolar tenotomy)
- Facial asymmetry
- Limitation of movement of more than 30 degree
- There should not be any scalenus contracture, vertis ab N., CNS disorder Bipolar tenotomy of SCM was performed using Frenkels technique as well as release of contracted fascia & muscles. Surgical correction was followed by period of exercise, head halter traction and cervical collar. The period of post-op follow up was 12 months.
All case showed better correction of deformity, improvement of neck motion, improvement in facial symmetry, no visual errors. All patients were satisfied with results and there were no complications.
CONCLUSION: Bipolar release of SCM is a good procedure for correction of torticollis in severe cases.
TREATMENT OF IDIOPATICH RELAPSED CLUBFOOT IN OLDER CHILDREN
A comparison of Ilizarov method with redo radical soft tissue release in relapsed idiopathic clubfoot
For consideration for presentation as prize paper
Dr. Rajkumar is applying for membership of POSI
C. Rajkumar Registrar (age- 28 years)
Vrisha Madhuri Professor
Dept of Orthopaedics
CMC Hospital, Vellore
33 children with relapsed clubfoot following surgery, the age group 3-13 years were treated by us by redo radical soft tissue release or Ilizarov method between 1990 and 1998, 24 patients with 33 feet could be followed up. Those with redo radical soft tissue relase (14 children with 20 affected feet) were in group I and those with Ilizrov correction (13 feet in 10 patients) were in Group 2. Those in group I were done prior to 1996 and had a mean follow up of 6.6 years. Those in group II were done after 1995 and had a mean follow up of 2.4 years. 3 children with 4 affected feet who had failed in group I had joined group II. Mean number of surgeries in group I were 1.4 and in group 2 were 1.9 Preoperatively all patients had grade 3 or grade 4 (Dimeglio) deformity.
Patients in group I were treated by radical soft tissue release in all cases. In addition in 2 patients calcaneocuboid fusion was carried out. Two patients also had Garceau’s procedure. In the Ilizarov group all were treated by differential distraction. No additional procedure was carried out.
Post operatively follow up was by personal examination. Magone’s criteria was used for assessment. In two patient’s only the last follow up was by questionnaire, x-rays, photographs and findings recorded by the local orthopaedic surgeons. Radiological studies were carried out in all patients. The mean post op score was 60 in group I and 83 in group 2. The difference was significant at p=0.04. There were 6/20 (30%) excellent and good results in group I, 3 fair and 11(55%) poor results. In group 2, 11/13(84.6%) had excellent and good results and 2 had fair results. There were no poor results. Equinous, varus and forefoot adduction deformities were significantly higher in Group I. Mean ankle dorsiflexion was significantly better in group II. Pain was present in 3 children in group I and none in group II. Group I had significant wound problems in 8 feet. Four feet in Group II had pin track infection requiring antibiotic therapy. Post operative radiological results showed statistically significant better results in AP talo-Ist metatarsal angle and lateral talocalcaneal angle.
In conclusion plantigrade feet with good function was obtained in all patients treated with Ilizarov method with results far superior to those of treatment by repeat soft tissue release. We recommend Ilizarov method as the treatment of choice in relapsed clubfoot in the age group of 3 to 13 years.
IS THE KITE’S INDEX OBSOLETE!! A VERIFICATION OF CLUBFOOT RADIOLOGICAL MEASUERMENT BY MRI
For consideration for presentation as prize paper
Dr. Thomas Palocaren has applied for membership of POSI
Thomas Palocaren* Registrar (age 32 years)
Reji Atyal Lecturer
Vrishna Madhuri* Professor
Dept of Orthopaedics* and Radiology
CMC Hospital
Vellore
Preoperative and 1 year post-operative radiology and MRI was done on 8 children undergoing clubfoot correction for 10 feet by Ilizarov method. Simon’s technique was used for positioning feet for radiology. Positioning for MRI was standardized by placing the feet in weight bearing plaster casts prior to placing in the gantry. Scanning was performed using a head coil. Scanning was performed on Philips 0.5 TESLA gyro scan power track MRI scanner. T1 & T2 weighted 3D-FFE scans were performed. Sections were taken with a 2mm thickness at 1mm intervals. For the analysis multiplanar reconstruction were performed from the volume stracks on 1 Siemen’s work station.
For the purpose of the study, following commonly used radiological angles were assessed – the AP and lateral talocalcaneal angle, the anterior talo-1st metatarsal angle, and the lateral calcaneo-1st metatarsal angle. The same angles were also assessed on the reconstructed sagittal and axial scans.
Thirty-two individual measurements of each radiological index done by MRI and radiographs were compared. Data obtained was analyzed using Intraclass correlation coefficient and Wilcoxon matched pair test.
The correlation of Lateral talo-calcaneal angle, anterior talo-first metatarsal angle, and the lateral calcaneo-first metatarsal angle was good. The talocalcaneal index and the anterior talo-calcaneal angle correlated poorly.
We suggest that the anterior talo-calcaneal angle and the tal-calcaneal index are unreliable indicators in the radiological assessment of clubfoot deformity.
Gait following Ilizarov correction in clubfoot deformity
Vrisha Madhuri* - Professor
Thomas Palocaren* - Registrar
Ganesh - Gait Analyst
Ashish Macaden - Lecturer
Suranjan Bhattacharji - Professor
Department of Orthopaedics* and Physical Medicine and Rehabilitation
Christian Medical College and Hospital
Vellore
The best was to assess the success of surgery in a lower limb deformity is to measure the improvement in gait. We have assessed the improvement in gait following clubfoot correction in 8 children after minimum of 1 year after correction of deformity.
The gait was assessed by video gait analysis sagittal kinematics, and EMG. Standard surface LEDs were placed using the SELSPOT system and sagittal kinematics were measured. Kinetics were obtained using a single force plate. EMG data was collected using surface electrodes on both limbs. Muscles monitored were tibialis anterior, gastrosoleus, medial hamstrings, rectus femoris, vastus lateralis, tensor fascia lata and gluteus maximus. For comparision normal rural children’s data from another study was used.
The gait analysis showed normal stride length, walking speed, stance /swing ratio, single limb support percentage and hip and knee ranges. Range of ankle dorsiflexion improved significantly post-operatively however it was less than the normal range. Kinetics showed significant reduction in the medical / lateral ground reaction forces and significant increase in the forward force in some cases. The video analysis revealed dynamic forefoot adduction in early stance phase which corrected in the late stance phase in two patients, initial contact with forefoot in one and one with significant hyperextension at the knee. EMG data showed a tendency to revert to normal however abnormalities still persisted especially in the tibialis anterior and gastrosoleus.
In conclusion the gait does not completely revert to normal in these children who are corrected late although the external appearance of the foot is satisfactory. One year is too short a period for complete reversion to occur.
EVALUATING THE OUTCOME OF TREATMENT OF CLUBFOOT - A need for better yardsticks
Renjit A. Varghese, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
Currently available scoring systems for evaluating the outcome of treatment of clubfoot described by Laaveg & Ponseti, Lehman, Mckay and Magone are not comparable. Weightage for different variables differ from system to system. Some subjective criteria are not relevant to the rural Indian context. The present study was undertaken to attempt to design and evaluate a method of assessment of clubfoot incorporating only objective criteria.
Methods:Assessment variables used in each of the existing scoring systems were listed under the following groups: 1) Subjective variables 2) Functional variables 3) Radiological variables 4) Deformity assessment variables.
The percentage weightage given for each group in each of the existing systems was calculated. A new system of assessment was designed with separate scores for a) Deformity b) Function (which includes gait, muscle power and range of movement) c) Radiological parameters. 25 treated clubfeet were evaluated by two independent observers using the following systems: a) Laaveng & Ponseti b) Lehman c) McKay d) Magone e) the new system. The reproducibility of each system and the degree of correlation between each system were evaluated.
Results:The different scoring systems were clearly not comparable. Several subjective criteria used in the older scoring systems were not applicable to young children or were not relevant to Indian children. The reproducibility of several variables used in all systems was unsatisfactory. The advantages of the new system were that structure, function and radiological parameters were assessed independently. These three groups of variables did not always tally.
Conclusions:While assessing the results of treatment of clubfoot care must be taken in interpreting results based on established scoring systems. More objective, standardized methods of assessment are needed in order to compare different series.
NON-FRAGMENTING TYPE OF PERTHES’ DISEASE IN OLDER CHILDREN - An effect of femoral osteotomy
P. Sivaramakrishnan, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
Though most reports of perthes diseases suggest that fragmentation of the epiphysis occurs during the evolution of the disease, Nevelos described a non-fragmenting type of Perthes” diseases in young children. This study was undertaken to see if non-fragmenting type of perthes” diseases occurs in older children from southwest India.
Methods:Sequential radiographs of 640 children with perthes” disease were reviewed. The stage of evaluation was noted on each radiograph using a modification of the Elizabethtown classification. 116 patients who presented initially in Stage Ia and Ib (stage of avascular necrosis) were identified. The stage of the disease was also identified on each subsequent radiograph. The date of each radiograph was noted to compute the time interval between sequential radiographs. 76 of these 116 children underwent proximal femoral osteotomy in stage I itself, while 40 were treated non-operatively.
Results:The stage of fragmentation (stage II) was by-passed in only one single patient who was not operated, while in 26 children who were operated in the stage of avascular necrosis (Stage I) the stage of fragmentation was by-passed (Chisquare 13.03, p (<)0.0001). The duration of the diseases was reduced in those who had by-passed the stage of fragmentation. Collapse of the lateral pillar did not occur in any hip which had by-passed the stage, of fragmentation. Among the children B who by passed the fragmentation stage, all who have reached the stage of healing have spherical heads.
Conclusions:Fragmentation appears to be an inevitable part of the natural evolution of perthes” in children in southwest India. However, proximal femoral osteotomy appears to alter the natural history of the disease such that fragmentation of the epiphysis and subsequent collapse and deformation are avoided.
BIPOLAR RELEASE IN CONGENTIAL MUSCULAR TORTICOLLIS
Dr. Gill S.S. Dr. Ravinder Puri
(Additional Professor)
P.G.I.M.E.R.
5 cases of congenital muscular torticollis were treated by Bipolar release of
sternocleidomastoid muscle in Dept of Orthopaedics, P.G.I.M.E.R. and were followed for one year.
The criteria for selection of cases was:
- Surgical correction in older children with severe deformity.
- Persistent deformity in previously failed surgery (bipolar tenotomy)
- Facial asymmetry
- Limitation of movement of more than 30 degree
- There should not be any scalenus contracture, vertis ab N., CNS disorder Bipolar tenotomy of SCM was performed using Frenkels technique as well as release of contracted fascia & muscles. Surgical correction was followed by period of exercises, head halter traction and cervical collar. The period of post-op follow up was 12 months.
All case showed better correction of deformity, improvement of neck motion, improvement in facial symmetry, no visual errors. All patients were satisfied with results and there were no complications.
CONCLUSION:Bipolar release of SCM is a good procedure for correction of torticollis in severe cases.
Management of Tibia Vara
V.V.J. Soma Raju, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
We undertook this retrospective study to evaluate the outcome of treatment of tibia vara.
Methods:Case records and radiographs of 17 patients with varus angular deformities of the tibia due to different aetiologies were reviewed. The underlying conditions included classical Blount’s disease, adolescent Blount’s disease, tibia vara associated with exaggerated physiological genuvarum, skeletal dysplasia and fibrocartilaginous defect of the proximal tibial metaphysis.
Corrective diaphyseal osteotomies of the tibia with or without minimal internal fixation were performed in children under the age of 13 years. All adolescents with unilateral tibia vara were treated by gradual correction of the tibial deformity and concomitant correction of the limb length by callotasis with the help of Garches Orthofix fixator. One adolescent with bilateral tibia vara had bilateral metaphyseal osteotomies. In patients with established lateral collateral ligament laxity, knee-ankle-foot orthoses were used following bony correction.
Results:Correction of deformity and maintenance of correction was noted in young children following the surgery. Minor degrees of ligament laxity appeared to correct with time. In older children, though the deformity correction was achieved, ligament laxity persisted. In one older child there was some recurrence of the deformity. The results of correction in the adolescent group have been uniformly good.
Conclusions:Disphyseal osteotomy without internal fixation in young children, diaphyseal osteotomy with minimal internal fixation in older children and metophyseal correction in adolescents are recommended for treating tibia vara. The need for early correction, to prevent recurrence and irreversible laxity of the collateral ligament, is emphasized.
Fractures in transfusion dependent beta thalassemia- An Indian study
Dr. Shivinde S Gill, MS, MNAMS
Additional Professor*
Dr. Ravinder Puri, MS
Senior Resident*
Dr. Shivinde S Gill, MS, MNAMS
Associate Professor*
Dr. Shivinde S Gill, MS
Senior Resident*
From: The Department of Orthopaedics
Post Graduate Institute of Medical Education and Research
Chandigarh, India
Aim of Study: To analyze the incidence of fractures in beta thalassemia patients and to identify causative factors.
Methods: We examined all cases of transfusion dependent beta thalassemia (TDBT) seen at out institute over a 2 year period. The transfusion records, incidence of fractures, cause of fracture and Hb levels were recorded. Radiograph of the involved part were taken in cases with fractures only.
Results and Conclusions: Amongst 105 cases TDBT assessed, 14 sustained a total of 28 fractures. Seven patients sustained more than one fracture. Two thirds of these fractures were caused by trivial trauma. All fractures, except one, were of the closed type. Radiologically, fractures frequently showed minimal or no displacement. All fractures were successfully treated by closed modalities of treatment. Majority of the fractures healed within normal union time for a given bone. Permanent deformities and gross limb length discrepancies were uncommon. On reviewing the literature, we noted that the incidence of fractures in our series and in the latest reports was lesser than previously reported. We postulate that this is a result of better and earlier control of hemoglobin status by improved transfusion techniques, and earlier of the disease. Difficulties arise due to inadequate blood transfusion facilities in under-developed countries.
MANAGEMENT OF INFANTAILE TIBIA VARA = TIBIAL OSTEOCLASIS
Dr. M. RAJEEV RAO, M.S. (ORTH)
Dr. EJAZKADER, M.S. (ORTH)
Dr. V.C. SUJITH, M.S. (ORTH)
Dr. VICENT THOMAS
Jubilee Mission Hospital, Thrissur, Kerela 680 005
Infantile tibia is a development condition producing progressive varus deformity of knee in young children. Early diagnosis of tibia vara clinically and radiologically is an important step in its management. Its treatment by simple method of tibial osteoclasis can prevent forth-coming complication of growth, deformity and Osteoarthritis of knee of at late age.
MATERIAL & METHOD:Since 1994 to 2000, 26 children of average age of 27 months (18-34 months) were diagnosed as tibia vara on clinical and radiological parameters. Ugly gait and growing deformity was the main complaints of parents for these children. The intercondylar distance average 7cm. (4-9 cm.), Tibio-femoral varus angle average 2. (100-320), Metaphyseal – diaphyseal angle average 120 (90 – 140) and Langenskiold radiological classification of grade 1 to 111 tibia vara were included in our study. (Nutritional cases of tibia vara were excluded). Under short general anesthesia tibial osteoclasis was performed and varus deformity was over corrected and maintained in above knee P.O.P. cast for 4 weeks, with calcium and Vitamin D supplementation. 4 weeks plaster cast was removed; child allowed all the activities without any brace shoe.
RESULT:The average follow up of 28 months (4 months – 56 months) no clinical and radiological deformity was there after treatment average valgus of 30 (00 – 50) at knee. All the children had full range of movement and activities without any deformity and complication.
CONCLUSION:Early detection of case of tibia vara on clinical suspicious and radiological assessment is important. The tibial osteoclasis is a simple, safe, economic, easy and sure method of treatment for infantile tibia vara with excellent result in short period of four weeks.
CONGENITAL PSEUDARTHROSIS OF FIBULA
Dr. Ramani Narasimhan
Consultant Pediatric Orthopaedic Surgeon
Indraprastha Apollo Hospital
New Delhi
Congenital Pseudarthrosis of Fibula is a rare condition with only 15 cases reported in literature so far. Dooley et al described 4 gradations in the severity of congenital pseudarthrosis of fibula namely; 1) fibular bowing without fibular pseudarthrosis; 2) fibular pseudarthrosis without ankle deformity; 3) fibular pseudarthrosis with ankle deformity but without late development of tibial pseudarthrosis; and 4) fibular pseudarthrosis with the late development of pseudarthrosis of the tibia. Ankle valgus is a common association and may present at an early or late age.
A case of Pseudarthrosis of fibula associated with an ipsilateral pre-pseudarthrotic condition of tibia is reported. The patient also has Neurofibromatosis type 1 without any family history. In a 16 year follow-up, the fibular pseudarthrosis persisted and the antero-lateral bowing of tibia straightened gradually with protected weight bearing using a total contact bivalved ankle-foot orthosis. A valgus deformity at the ankle appeared at the age of 10 and was surgically corrected after skeletal maturity at the age of 16 years. The distal tibial osteotomy united and the patient currently is weight bearing without further bracing and is asymptomatic.
Congenital pseudarthrosis of fibula is a relatively benign condition and needs to be listed as a distinct separate entity. Bracing of the limb at an early age and continuing the orthosis until skeletal maturity appears to delay the appearance of ankle valgus.
Fibrodysplasia Ossificans Progressiva – Case Study
By Dr. V.R. Ganesan, M.S. Ortho. D.N.B. Ortho
Dept. of Orthopaedic Surgery & Taumatology,
Govt. Rajaji Hospital, Madurai
FOP- One of the rare connective tissue disorders – of autosomal dominant inheritance – wherein ectopic ossification occurs in muscle, tendon, fascia and other connective tissue. Though incidence is quoted to be 1 in 20 lakhs, only upto 600-700 cases reported world wide.
3 of these rare cases are presented, one of the largest series in our country. All the 3 cases tried with different modes of treatment. One case treated with bisphosphonate therapy, one with conservative management and one with corrective osteotomy of femur, though surgery is a relative contraindication in these cases.
In all these 3 cases, we found that the paternal age average was more than 45 years at the time of childbirth. So we report that this may be one of the reasons for the chromosomal mutation in these cases.
Recent reports mentioned that the chromosomal deletion is in long arm of chromosome 4 and efforts are being made to find the cause of this deletion. We are working with the Dept. of Immunogenetics & Biology, Madurai Kamaraj University, to find about the chromosomal abnormality if any and to link them with increased paternal age.
Idiopathic Rectus Femoris Contracture
Dr. Taral Nagda*
* Department of Orthopedics KEM Hospital Parel, Mumbai
Dr. Ashok Johari**
** Department of Pediatric Orthopedics, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai
Introduction: Rectus Contracture can occur in patients with cerebral palsy. We report here five cases of idiopathic unilateral rectus femoris contracture. This condition has been sparsely reported in literature and little is known about it natural history.
Material and Methods: We have so far treated five patients with rectus femoris contracture. They presented with altered gait. All the patients walked with “stiff knee” gait. They had restriction of knee flexion with hip in extension. Knee flexion was possible on flexing the hip. Prone rectus test was positive in all cases. They had a palpable band of tight rectus femoris tendon. All the patients were initially subjected to physiotherapy to stretch the tight muscle. On non response to the conservative treatment all needed surgery in form of rectus release through anterior approach.
Results: None of the Patients responded to physiotherapy. All the patients had improvement in gait and an average 140 flexion of knee with hip extended at the last follow-up.
Conclusion: Although idiopathic rectus femoris contracture is uncommon, high index of suspicion is needed to diagnose this clinical entity. Conservative treatment has probably no role in its management. Surgical release of rectus femoris gives rise to excellent results in these cases.