COMOC 2016

The Paediatric Specialty Day is Tuesday 12 April at CTICC, Cape Town.
Invited Guests with attached abstracts include:

1. Dr Matthew Dobbs, St Louis, USA.

Dr Dobbs photo

Management of neglected as well as syndromic and neglected clubfoot

The Ponseti Method has been widely shown to be successful for treating infants and young children with isolated clubfoot deformity.  There is less data on the use of the Ponseti method to correct the rigid severe clubfeet associated with neuromuscular or genetic disorders.   I will illustrate the efficacy of the Ponseti method in this difficult group of patients as well as the successful correction of neglected clubfeet up to the age of 21 years.    I have expanded the use of the Ponseti method to patients that have undergone prior extensive soft-tissue releases and have developed relapse.  There are essentially no clubfeet for which the Ponseti method should not be utilized for it always allows at minimum partial correction leaving any surgical interventions to an “a la carte” approach.

Congenital vertical talus – Update and management

My treatment method for congenital vertical talus evolved from the Ponseti method for clubfoot management.  A key to my vertical talus minimally invasive technique lies in the ability to palpate the head of the talus just as it is clubfoot.  This can be challenging in the small infant foot.  The principle of manipulation relies on the fact that the talus is fixed in the ankle mortise but the rest of the foot including the subtalar joint complex can rotate around the head of the talus.  The method is gentle and serial casting is performed in the clinic on a weekly basis.  It takes an average of 5 casts to achieve correction.  Once correction achieved it is maintained with pin fixation of the talonavicular joint and a tendo Achilles tenotomy.  While clubfoot uses the head of the talus as a fulcrum to externally rotate the foot, my method for vertical talus correction uses the head of the talus as a fulcrum to reduce the talonavicular joint while bringing the foot into plantar flexion and adduction.  It is key to apply both a dorsal and lateral force on the talus to correct not only the lateral plane deformity, but also the coronal plane deformity.  The other keys to the technique are to cast gradually into maximal equinovarus deformity to reduce the talonavicular joint.  This is analogous to achieving 70˚ of external rotation in the final Ponseti cast for clubfoot correction.  The maximal equinovarus position is essential to overcorrect the deformity in order to adequately stretch the dorsal and lateral soft tissues.  If this is not done, there will either be lack of full correction or high relapse risk.  My method has been shown to be effective for both isolated vertical talus and vertical talus associated with neuromuscular and genetic disorders and results in better long-term outcomes than vertical talus treated with extensive soft-tissue release surgery.

2. Dr Deborah Eastwood, London, UK.

Dr D Eastwood
How to pick the winners from the losers:
Not all club feet are the same and the skill lies in identifying those that are truly idiopathic from those that are not. We have already identified the complex and atypical idiopathic feet but there are other clues in the history and examination and in the response to treatment that might warn you that care must be taken. The accelerated programme may work in some feet but not in others – why? The phenotype must be described so that we can work towards identifying the relevant genotypes too.
The stiffness of the foot – hind foot and forefoot, the neurological status and muscle power are factors mentioned in the Bensahel-Dimeglio classification but ones which perhaps deserve more consideration.
Poor evertor power and/or significant hindfoot stiffness and calf wasting can be identified clinicially. The question for the future might be: are there any investigations that might improve our understanding of the individual foot to allow us to define our treatment plan on a more individual basis: surely, in the future, not ALL idiopathic feet will have to be braced for such a long time?
We may not have all the answers but if you keep your eyes and ears open, it is possible to pick up some of the ‘winners’ and identify some of the ‘losers’ from an early stage.


3. Dr David Little, Sydney, Australia.

David Little Photo_1411125_10-12-14_DSC_3401_03
Update on pathophysiology of SCFE and AVN.
Slipped Capital Femoral Epiphysis is a mainly idiopathic condition, which seems to be increasing in incidence. As one major risk factor for SCFE is obesity, and obesity incidence is rising, this makes sense. While known hormonal risk factors for SCFE include growth hormone deficiency (and perhaps growth hormone treatment), as well as hypothyroidism and renal failure, it is unknown if subtle hormonal effects in obese patients also contribute.
Once retroversion commences, the force required to further retrovert the femoral head decreases. At some point the repetitive forces on the growth plate cause widening and disorganisation of the physis, also seen in other paediatric overuse syndromes. From around 15-20 degrees it is likely that the deformity will continue to progress. Some patients continue to slip slowly until the femoral head abuts the posterior neck, with resultant impingement, loss of motion and gait disturbance. Others acutely progress usually after minor trauma leading to an unstable slip and the risk of avascular necrosis.
Urgent treatment can save some but not all unstable slips from undergoing loss of blood supply and AVN. AVN will lead to collapse and destruction of the hip in the majority of cases. Current efforts at treating AVN involve a period of weight relief, anti-catabolic therapy (bisphosphonates, denosumab) and anabolic therapies of either bone grafting or BMP. Animal studies are showing some success but in clinical practice AVN remains a huge challenge.
4. Dr Manoj Ramachandran, London, UK.

Dr M Ramachandran photo

Unstable SCFE:

This talk will explore stable and unstable SCFE and the current approaches to treatment. For stable SCFEs, screw-related factors will be explored along with surgical techniques. For unstable SCFEs, surgical approaches such as anterior, anterolateral, surgical dislocation and arthroscopic approaches will be discussed.

Outcome in CTEV and CVT:

This talk will explore both clinician- and non-clinician factors in the outcomes of CTEV and CVT treatment. Variations in treatment technique and their effect on outcome will be explored. In addition, non-technical factors such as adherence, parental factors, psychological and socioeconomic issues will be discussed.

5. Dr Jonathan Schoenecker, Nashville, USA.

Jonathan Schoenecker, M.D., Ph.D. Orthopaedics Vanderbilt University Medical Center photo: Anne Rayner; VUMC

Management of Unstable SCFE: 

SCFE predominantly leads to an external rotation deformity of the femur and incongruence of the femoral head/neck junction. Together these abnormalities prohibit a functional range of motion of the hip without impingement. It is thought that these deformities significantly contribute to the often rapid deterioration and pain in the hip of these patients. In order to restore the functional range of motion of the hip in these patients an orthopedic surgeon must correct abnormalities without compromising the precarious vascularity of the proximal femoral epiphysis. The safest mode of reconstruction of the proximal femur is through osteotomies that do not put the epiphyseal vascularity at risk. This can be accomplished through combinations of an intertrochanteric osteotomy and osteochondroplasties. An alternative method of proximal femoral reconstruction is through an osteotomy of the epiphyseal metaphyseal junction, often referred to as a capital realignment. These osteotomies provide the most direct restoration of the anatomy but carry the greatest risk of iatrogenic avascular necrosis which can lead to devastating consequences. The objective of this lecture will be to discuss the most common deformities caused by SCFE and how to address these deformities without compromising epiphyseal vascularity.


6. Dr Baxter Willis, Ottawa, Canada.

Willis, Baxter Photo

Advanced Clubfoot and Vertical Talus Management. Overview and Historical Perspectives:

The evaluation and treatment of congenital clubfoot has undergone a momentous shift in the last 15-20 years. Robert Jones in 1923 stated ‘ he had never met with a case where treatment has been started in the first week where the deformity could not be completely rectified by manipulation and retention in 2 months”. Unfortunately, his results could not be duplicated in many centres resulting in various forms of treatment with far from perfect feet.

The modern era of conservative management of clubfeet was made popular by Hiram Kite of Atlanta, although he treated each component of the deformity separately and he failed to understand the concept of correction of the hindfoot varus by abduction before eversion could be obtained.

In the 1970’s, surgical correction as popularized by Vincent Turco ( posteromedial release ) and George Simons ( comprehensive subtalar release ) resulted in plantigrade feet but often with overcorrection, joint damage, stiffness and eventual arthrosis, muscle weakness and pain.

Slipped Capital Femoral Epiphysis. Overview and Historical Perspective:

The treatment of Slipped Capital Femoral Epiphysis ( SCFE ) had changed very little in the time from the 1940’s until the last 5-10 years when specifically the treatment of unstable slipped epiphysis has been altered by early work, originally by Ganz and Swiss surgeons and more recently by Sucato ( TSRH-Dallas ), Millis and Kim ( Boston) and Little ( Sydney ).

The classification of Loder is universally accepted and forms 2 distinct groups with quite different prognoses.

Stable slips are universally treated by in-situ stabilization ( smooth pins in Europe, screws in North America and Australasia ) and the complication rate is very low. Femoroacetabular impingement may occur in more severe stable slips leading to labral degeneration and eventual degenerative joint disease.

This has led to management of FAI by arthroscopic and open techniques + or – femoral neck realignment osteotomies or intertrochanteric osteotomies with encouraging results.

On the other hand, unstable slips with a high rate of avascular necrosis have continued to be problematic. Recent work which involves “ safe surgical hip dislocation “ , femoral neck trimming with realignment of the capital femoral epiphysis has demonstrated encouraging results in some centres with AVN rates of 10-20 %.

This begs the question whether this form of management should be undertaken in all centres or only in centers of special expertise.

The JJ Craig lecture is on Friday 15 April by Dr M Eltringham – A walk along the path of clubfoot management in South Africa.

For more information please go to the site www.comoc2016.org