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Mansoor Kassim

FRCS Trauma and Orthopaedics Exam: A guide to clinicals and vivas

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    is more than 20-30%.
    -failed reconstructions.
    -Performed at about one year of age.
    -Trimming of the condyles is not necessary in children.
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    cm.
    -nonfunctional foot
    -severe cosmetic problems
    -a patient who may not tolerate multiple surgeries over an extended period.
    -Supramalleolar osteotomy to correct valgus or
    -Gruca procedure: a lateral malleolus is created byperforming an oblique sliding distal tibial osteotomy.
    -Resection of talar coalitions or fusion.
    -Lengthening (up to maximum of 7 cm lengthening during each lengthening process).
    B) Syme amputation
    -Relative indications:
    -if there is an unstable non/poorly-functional.
    -if the limb-length discrepancy
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    lateral translation; c) combined ankle and subtalar deformities; d) malorientation of subtalar joint.
    Type 4: Fixed equino-varus ankle (clubfoot type).
    Management:
    The goal is to enable the child to gain maximal function by achieving adequate lower extremity alignment, length and stability. Amputation was the treatment of choice in the past but advances in limb reconstruction techniques have made reconstructions more common and allows to reconstruct more complex deformities.
    A) Limb reconstruction with lengthening.
    -If there is a good functional foot and ankle.
    -Relative contraindications:
    -maximum discrepancy 7.5-15
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    or miniature fibula;III=complete absence of the fibula.
    Tibiotalar joint and distal tibial epiphyseal morphology:H=horizontal; V=valgus (triangular distal tibial epiphysis; S=spherical (ball and socket).
    Presence of a tarsal coalition = “c”.
    Number of foot rays: 1-5
    Stanitski DF, Stanitski CL. Fibular hemimelia: a new classification system. J Pediatr Orthop 2003;23(1):30-4.
    Paley classification:
    Type 1: Stable normal ankle.
    Type 2: Dynamic valgus ankle.
    Type 3: Fixed equino-valgus ankle. a) ankle type: ankle in procurvatum (apex anterior) and valgus; b) subtalar type: malunited subtalar coalition in equino-valgus with lat
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    external rotation
    4. ACL and PCL deficiency
    5. Patella subluxation
    6. Genu valgus
    7. Short and/or bowed tibia (anteromedial bow)
    8. Ankle valgus
    9. Absent lateral rays
    10. Ball and socket ankle joint
    11. Tarsal coalitions
    12. Coxa vara
    13. Absent foot rays
    Classification:
    Achterman and Kalamchi:
    Type I: part of fibula present.
    Type II: fibula is absent.
    Achterman C, Kalamchi A. Congenital deficiency of the fibula. J Bone Joint Surg-Br 1979;61(2):133-7.
    Stanitski:
    Fibula:
    I=nearly normal fibula; II=small
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    The term postaxial hypoplasia has been suggested.
    -Minimal shortening to complete absence of the fibula.
    -Most common congenital longitudinal lower limb deficiency.
    -1 in 40000 live births.
    Associations:
    1. Proximal Femoral Focal Ddeficiency
    2. Hypoplastic lateral femoral condyle
    3. Femoral hypoplasia with ex
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    pes valgus (congenital vertical talus). The condition and its treatment: a review of the literature. Acta Orthop Belg 2007;73(3):366-72.
    Chalayon O, Adams A, Dobbs MB. Minimally invasive approach for the treatment of non-isolated congenital vertical talus. J Bone Joint Surg Am 2012;94(!!):e731-7.
    Dobbs MB, Purcell DB, Nunley R, Morcuende JA. Early results of a new method of treatment for idiopathic congenital vertical talus. J Bone Joint Surg Am 2006;88(6):1192-200.
    12. Fibular hemimelia
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    Three patients who did not have pin fixation had recurrent dorsal subluxation of the navicular at follow-up.
    Chalayan/Dobbs et al reported on 15 patients with 25 rigid vertical Talus deformities associated with syndromes. The treatment consisted of serial manipulation and casting followed by percutaneous Achilles tenotomy and either pin fixation of the talonavicular joint through a small medial incision to assure joint reduction and pin placement in five feet or capsulotomies of the talonavicular joint and anterior aspect of the subtalar joint in twenty feet. The results at a minimum of 2 years follow-up were excellent with a recurrence in 5 feet.
    Bosker BH, Goosen JH, Castelein RM, Mostert AK. Congenital convex
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    -application of above knee plaster. Removal of wires at 6 weeks followed by walking plaster for another 4 to 6 weeks.
    -More recently, a minimally invasive surgical approach has been described using early serial manipulation and casting (“reversed Ponseti”) after birth. Dobbs et al reported excellent short term (minimum of 2 years follow-up) correction of idiopathic congenital vertical talus deformities in 11 patients with 19 affected feet with serial manipulation and casting and percutaneous Achilles tendon tenotomy. Additional surgery involved fractional lengthening of the anterior tibial tendon in two feet, lengthening of the peroneal brevis tendon in one and percutaneous pin fixation of the talonavicular joint in 12 feet.
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    and peroneal tendons if contracted,
    -reduction of the navicular onto the talus and pin fixation,
    -reefing of the talonavicular joint capsule,
    -the plantar calcaneonavicular ligament is sutured under tension to the base of the 1st metatarsal,
    -the posterior tibial tendon is tightened and sutured to the inferior surface of the first cuneiform,
    -the tibial anterior tendon may be transferred completely or split and sutured to the undersurface of the head of the talus and navicular,
    -a second wire can be passed transverse through the calcaneum and incorporated into the cast or longitudinally into the calcaneum and talus,
    -reconstruction of the spring ligament.
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    ligament, division of the capsule of the calcaneocuboid joint and bifurcated ligament,
    -release of the posterior tibial tendon from its insertion into the navicular and the tibionavicular and talonavicular ligament and capsule,
    -the plantar calcaneonavicular ligament is divided from its attachment to the sustentaculum tali,
    -T-shaped incision of talonavicular joint capsule (transverse limb over tibionavicular ligament and dorsal and medial portion of talonavicular ligament, longitudinal limb over head and neck of the talus),
    -calcaneocuboid and talocalcaneal interosseous ligament need to be divided if necessary,
    -Z-lengthening of extensor hallucis, extensor digitorum longus
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    some authors recommend operative treatment at 3-6 months, some prefer to wait until about 12 months.
    -In Tachdjian’s Pediatric Orthopaedics, 4th edition 2008, the preferred technique is described as follows:
    -single stage release at about 1 year of age,
    -modified Cincinnati incision with extension across the dorsum of the foot as necessary to lengthen the toe extensors and peroneal tendons,
    -Z-lengthening of the Achilles tendon (the distal end is released on the lateral side of the calcaneum,
    -release of the posterior capsule of the ankle and subtalar joint if necessary,
    -release of calcaneofibular liga
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    Vertical talus:
    -50% idiopathic, 50% associated with syndromes (arthrogryposis, myelomeningocele, spinal dysraphism)
    -the calcaneum is in equinus, the metatarsals are dorsiflexed
    -50% bilateral
    -female = male
    Management
    -Bosker et al performed a review of the literature in 2007.
    In their opinion the technique of choice in a child under the age of 2 years was extensive soft tissue release with tendon lengthening and fixation of the talonavicular joint. The technique of choice in children over the age of 2 years was extensive soft tissue release with tendon transfer and fixation of the talonavicular joint.
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    A tomogram and ultrasound are also useful investigations to assess complex foot abnormalities.
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    the normal talocalcaneal angle on an anteroposterior radiograph measures 20-40 and on a lateral radiograph 35-50.
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    stretching and the heel can be dorsiflexed.
    Radiographs:
    -forced plantar flexion and forced dorsiflexion lateral radiographs are necessary to confirm the diagnosis. The flexion lateral radiograph in a vertical talus shows persistent malalignment of the long axis of the talus and the first metatarsal while the dorsiflexion lateral radiograph shows a persistently decreased tibiocalcaneal angle.
    -on a normal lateral foot radiograph a line drawn along the long axis of the talus cuts through the lower part of the cuboid. A line drawn through the long axis of the calcaneum cuts through the upper part of the cuboid. In vertical talus both lines miss the cuboid.
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    What do you see?
    A foot with a rocker bottom shape. The hindfoot is in equinus (and also valgus), the fore- and midfoot are in extension.
    What is the differential diagnosis?
    -congenital vertical talus (rigid flatfoot)
    -incorrect treatment of clubfoot deformity
    -calcaneo-valgus foot (flexible flatfoot)
    -the foot is in extreme hyperextension
    How do you differentiate congenital vertical talus from calcaneo-valgus foot?
    -The vertical talus foot is rigid with a rigid dorsal dislocation of the navicular bone. The calcaneovalgus foot is flexible, responds well to
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    children >3 years of age
    -stages 5 and 6
    -failed bracing
    -the distal segment must be fixed in valgus (10-15°), external rotation and lateral translation.
    -in stages 5 and 6 a physeal bar resection is necessary if it ispresent. If the bar is >50%, a hemiepiphysiodesis needs to be considered.
    -an anterior compartment decompression is recommended to reduce the risk of compartment syndrome.
    Sabharwal S. Blount Disease. J Bone Joint Surg Am 2009;91:1758-1776.
    Tachdijan’s Pediatric Orthopaedics. 4th edition 2008. John Anthony Herring. Elsevier.
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    plate.
    Types
    -infantile tibia vara (early onset). <4 years of age.
    -adolescent tibia vara (late onset): from 4 years of age. The adolescent type was originally described as occurring after 6 years of age and some references describe it as occurring after 10 years of age.
    How will you manage blounts disease?
    Non-operative with KneeAnkleFootOrthosis:
    -in children <3 years of age with stages 1 to 4.
    Operative:
    -proximal tibial/fibular valgus osteotomy (acute correction and fixation; gradual correction with an external fixator).
    -Indications:
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    the articular cartilage, separating the bony epiphysis into two portions and giving the appearance of a partially double epiphyseal plate. The medial articular surface of the upper end of the tibia is deformed, sloping medially and distally from the intercondylar area.
    VI (10 to 13 years): The branches of the double medial part of the epiphyseal plate ossify, whereas growth continues in its normal lateral part.
    Adolescent Type:
    The radiographic findings differ considerably from those in the infantile type. The middle part of the medial half of the epiphyseal plate is narrowed, with increased bone density on its other side. The bony epiphyses are normal in shape, and there is no step in the epiphyseal
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