Long-term Follow Up of Van Nes Rotationplasty for Proximal Focal Femoral Deficiency

Proximal focal femoral deficiency (PFFD) is a congenital anomaly that presents challenges for orthopaedic and prosthetic management. The Van Nes rotationplasty is one treatment in which the extremity is surgically rotated to utilize the ankle and foot as a functional knee joint in a prosthesis. The purpose of this study is to determine the long-term functional and quality of life (QOL) outcomes for individuals who have undergone rotationplasty surgery for congenital PFFD compared to age and gender matched controls

Long-term Follow up of Van Nes Rotationplasty for Congenital Proximal Focal Femoral Deficiency [Proceedings]

INTRODUCTIONProximal focal femoral deficiency (PFFD) is a congenital anomaly that presents challenges for orthopaedic and prosthetic management. The Van Nes rotationplasty is one treatment in which the extremity is surgically rotated to utilize the ankle and foot as a functional knee joint in a prosthesis. The purpose of this study is to determine the long-term functional and quality of life (QOL) outcomes for individuals who have undergone rotationplasty surgery for congenital PFFD compared to age and gender matched controls. METHODSThis prospective study had 12 prosthetic participants (PFFD Group: 8 M, 4F, age range 16-57 years) average 31.6±13.5 years and 12 control participants (Control Group: 8M, 4F) with an average age 32.6±14.1 years. Participants completed the following outcome questionnaires: SF-36, Revised-Faces Pain Scale, Harris Hip Score, Oswestry back pain score; and underwent lower extremity range of motion (ROM), hand held dynamometry, gait analysis, computerized dynamic posturography and Timed ‘Up& Go’ (TUG) testing. The PFFD Group also completed the Prosthetic Evaluation Questionnaire© (PEQ). The Wilcoxon Signed rank test was used to statistically compare each PFFD Group participant to the matched Control Group participant with values statistically significant at p\u3c 0.0123. RESULTSParticipants had rotationplasty performed at an average age of 6.5±3.9 years with follow up testing done 25.1±11.2 years later. All adult subjects were working full time in a variety of manual and office/desk jobs. No significant issues were seen for body image. Pain: The PFFD and Control Groups both reported similar low back pain with 6.8±9.7% and 7.0±13.0% disability respectively on the Oswestry back pain questionnaire. On the day of testing, only one PFFD participant reported mild low back pain on the Revised- Faces Pain Scale. The average Harris Hip Score for the PFFD Group was 92.7±9.2 out of 100, indicating excellent outcome. Two participants reported pain on their non-prosthetic hip. ROM: The PFFD Group showed significantly decreased hip flexion and ankle dorsiflexion, and increased ankle plantarflexion strength on the prosthetic side compared to the Control Group. The PFFD Group had significantly greater ankle abduction strength on their non-prosthetic side compared to the Control Group. Strength: The PFFD Group demonstrated significantly weaker hip flexion, hip abduction and ankle plantarflexion on the prosthetic side compared to the Control Group. TUG: The PFFD Group scored an average of 8.5±1.6 seconds on the TUG, demonstrating a low fall risk. The Control Group scored significantly lower with an average of 6.5 ±1.0 seconds. SF-36: There were no significant differences between the groups in overall health and well-being. PEQ©: The PFFD Group scored lower in areas of satisfaction, appearance, and sounds of the prosthesis. However, participants reported that others perceived them well and they did not see themselves as a social burden. Gait Analysis: Temporal-spatial gait parameters for the PFFD Group demonstrated significant decrease in cadence, stride time, opposite foot off, single support and walking speed compared to Control Group. Posturography: The PFFD Group showed significant decrease in symmetry in stance, as well as a decrease in end point and maximum excursion in limits of stability testing compared to the Control Group. DISCUSSION AND CONCLUSIONOverall, long-term follow up of teens and adults who underwent Van Nes rotationplasty showed that they maintained a high level of function, participation and QOL. They did present with significant differences in temporal spatial and posturography parameters compared to the Control Group

Segmental Kinematic Analysis of Planovalgus Feet during Walking in Children with Cerebral Palsy

Pes planovalgus (flatfoot) is a common deformity among children with cerebral palsy. The Milwaukee Foot Model (MFM), a multi-segmental kinematic foot model, which uses radiography to align the underlying bony anatomy with reflective surface markers, was used to evaluate 20 pediatric participants (30 feet) with planovalgus secondary to cerebral palsy prior to surgery. Three-dimensional kinematics of the tibia, hindfoot, forefoot, and hallux segments are reported and compared to an age-matched control set of typically-developing children. Most results were consistent with known characteristics of the deformity and showed decreased plantar flexion of the forefoot relative to hindfoot, increased forefoot abduction, and decreased ranges of motion during push-off in the planovalgus group. Interestingly, while forefoot characteristics were uniformly distributed in a common direction in the transverse plane, there was marked variability of forefoot and hindfoot coronal plane and hindfoot transverse plane positioning. The key finding of these data was the radiographic indexing of the MFM was able to show flat feet in cerebral palsy do not always demonstrate more hindfoot eversion than the typically-developing hindfoot. The coronal plane kinematics of the hindfoot show cases planovalgus feet with the hindfoot in inversion, eversion, and neutral. Along with other metrics, the MFM can be a valuable tool for monitoring kinematic deformity, facilitating clinical decision making, and providing a quantitative analysis of surgical effects on the planovalgus foot

Long-term Follow up of Van Nes Rotationplasty for Congenital Proximal Focal Femoral Deficiency

Van Nes rotationplasty may be used for patients with congenital proximal focal femoral deficiency (PFFD). The lower limb is rotated to use the ankle and foot as a functional knee joint within a prosthesis. A small series of cases was investigated to determine the long-term outcome. At a mean of 21.5 years (11 to 45) after their rotationplasty, a total of 12 prosthetic patients completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires, as did 12 age- and gender-matched normal control participants. A physical examination and gait analysis, computerised dynamic posturography (CDP), and timed ‘Up & Go’ testing was also completed. Wilcoxon Signed rank test was used to compare each PFFD patient with a matched control participant with false discovery rate of 5%. There were no differences between the groups in overall health and well-being on the SF-36. Significant differences were seen in gait parameters in the PFFD group. Using CDP, the PFFD group had reduced symmetry in stance, and reduced end point and maximum excursions. Patients who had undergone Van Nes rotationplasty had a high level of function and quality of life at long-term follow-up, but presented with significant differences in gait and posture compared with the control group

Kinematic foot types in youth with pes planovalgus secondary to cerebral palsy

Background Kinematic variability of the foot and ankle segments exists during ambulation among individuals with pes planovalgus (PPV) secondary to cerebral palsy (CP). Clinicians have previously recognized such variability through classification schemes to identify subgroups of individuals, but have been unable to identify kinematic foot types. Research question The purpose of this work was to identify kinematic foot types among children with PPV secondary to CP using 3-dimensional multi-segment foot and ankle kinematics during gait as inputs for principal component analysis (PCA) and K-means cluster analysis. Methods In a single assessment session, multi-segment foot and ankle kinematics using the Milwaukee Foot Model (MFM) were collected in 31 children/adolescents with pes planovalgus (49 feet) and 16 typically developing (TD) children/adolescents (31 feet). PCA was used as a data reduction technique on 34 kinematic variables. K-means cluster analysis was performed on the identified principal components (PCs) and one-way analyses of variance (ANOVA) was done to determine the effect of subgroup membership on PC scores. Results The PCA reduced the kinematic variables to seven PCs which accounted for 91% of the total variance. Six distinct kinematic foot types were identified by the cluster analysis. The foot types showed unique kinematic characteristics in both the hindfoot and forefoot. Significance This study provides further evidence of kinematic variability in the foot and ankle during ambulation associated with pes planovalgus secondary to CP. The specific contributions of the hindfoot and forefoot would not have been detected using a single segment foot model. The identification of kinematic foot types with unique foot and ankle characteristics has the potential to improve treatment since patients within a foot type are likely to benefit from similar intervention(s)

Evaluation of Cast Creep Occurring During Simulated Clubfoot Correction

The Ponseti method is a widely accepted and highly successful conservative treatment of pediatric clubfoot involving weekly manipulations and cast applications. Qualitative assessments have indicated the potential success of the technique with cast materials other than standard plaster of Paris. However, guidelines for clubfoot correction based on the mechanical response of these materials have yet to be investigated. The current study sought to characterize and compare the ability of three standard cast materials to maintain the Ponseti-corrected foot position by evaluating cast creep response. A dynamic cast testing device, built to model clubfoot correction, was wrapped in plaster of Paris, semi-rigid fiberglass, and rigid fiberglass. Three-dimensional motion responses to two joint stiffnesses were recorded. Rotational creep displacement and linearity of the limb-cast composite were analyzed. Minimal change in position over time was found for all materials. Among cast materials, the rotational creep displacement was significantly different (p \u3c 0.0001). The most creep displacement occurred in the plaster of Paris (2.0°), then the semi-rigid fiberglass (1.0°), and then the rigid fiberglass (0.4°). Torque magnitude did not affect creep displacement response. Analysis of normalized rotation showed quasi-linear viscoelastic behavior. This study provided a mechanical evaluation of cast material performance as used for clubfoot correction. Creep displacement dependence on cast material and insensitivity to torque were discovered. This information may provide a quantitative and mechanical basis for future innovations for clubfoot care

Limb lengthening in pediatric patients with ollier's disease

Background: Ollier's disease is a non-hereditary skeletal disorder. Orthopedic management of limb length discrepancy could be complex given the nature of bone pathology, the significant amount of length discrepancy and the difficulty to predict it. The goal of the study is to identify the outcomes and complications associated with surgical management of limb length discrepancy. Methods: This is an IRB approved, retrospective review of patients with Ollier's disease who had limb lengthening. The age at the time of surgery, amount of total length discrepancy and discrepancy for each individual bone, amount of lengthening and as a ratio to the length of the bone itself, type of fixator, duration of the fixator, complications are recorded. Unpaired T-tests evaluated the effect of simultaneous versus single-bone lengthening and tibia vs. femur being lengthened on the external fixator index. One-way ANOVA test was used to evaluate the effect of osteotomy location on mean External Fixator Index (EFI). Results: 14 patients with 40 segmental limb lengthening procedures are identified. The mean LLD was 7.1 cm and mean amount of length gained was 7.8 cm. Follow up was minimum 2 years and maximum 18 years 2 months. The average fixator duration was 178.6 days. The average percent of lengthening through each bone was 19.2. The average EFI was 36.5 days/cm. There was no difference between tibia vs. femur and between simultaneous vs. single bone on EFI. There was no difference among osteotomy type. There were 3 cases of nonunion, one delayed union, 5 cases of premature consolidation. One case had fixation failure. There were 7 cases of knee stiffness of which 3 cases required surgery. Conclusions: Our study shows that Enchondromal bone appears to respond to lengthening with a structurally proper regenerate. Premature consolidation needs to be always kept in mind and appropriate adjustment should be made in the rate of lengthening