An update on tarsal coalitions

Tarsal coalitions are anomalous connections between two or more bones in the hindfoot or midfoot secondary to embryonic failure of segmentation and differentiation of the mesenchyme. Calcaneonavicular and talocalcaneal coalitions are the most common. Although it is a congenital deformity, presentation is usually in adolescence which coincides with ossification of the coalition. Patients typically present with diffuse foot pain, calf muscle pain, recurrent ankle ligament sprains and a rigid hindfoot valgus deformity. Initial management is non-operative and may involve activity reduction, a trial of immobilization in a walking boot or cast, physiotherapy, corticosteroid injections and regular analgesia. Close to a third of patients experience symptom relief but the remaining patients with persistent symptoms will require operative intervention. Patients without degenerative joint disease undergo resection of the coalition. It is now established that an associated severe hindfoot valgus foot should be addressed at this stage to prevent inevitable future joint degeneration. The indications for joint fusion remain unclear and the tendency is to postpone this when possible until a later age. In recent years, arthroscopic resection of talocalcaneal coalitions has gained popularity, despite being technically demanding. It gives good visualization of the coalition, better postoperative pain relief and quicker improvement of the hindfoot stiffness.     

Diagnosis and management of the acute hot diabetic foot

Diabetes is an increasing problem in the modern world. Along with the rise in prevalence of the disease the number of diabetic complications presenting is increasing and amongst these is diabetic foot issues. Foot infection and Charcot arthropathy are the two key pathologies that present acutely with a hot swollen foot. Both require timely diagnosis and management to prevent disastrous long-term sequelae.Acutely presenting foot infections are both limb and life threatening and require urgent intervention to improve the chance of limb salvage. The ability to recognize and acutely deal with a diabetic foot requiring urgent surgical drainage is relevant to all orthopaedic surgeons with an on-call commitment and not solely to the foot and ankle specialist.Charcot arthropathy results in foot deformity that increases the likelihood of future ulceration and infection. The differentiation and acute management of the two conditions will be discussed.     

Peri-operative management of major spinal surgery

Paediatric and adult patients requiring major spinal surgery often have significant pre-existing medical co-morbidities as well as their presenting condition, be it deformity, infection, neoplasia or trauma. These patients require preoperative optimization as well meticulous surgical technique and knowledge of the possible intraoperative and postoperative complications to minimize potential morbidity and mortality, which can occur during or after major spinal surgery.     

Understanding congenital vertical talus

Congenital vertical talus (CVT) is a rare foot deformity that presents with a rigid flat foot at birth. CVT can present as an isolated abnormality in the newborn, however in at least 50% of cases in association with other conditions. Full neuro-axial imaging is essential to detect any associated neurologic problems. Radiographs of the foot, including forced plantar and dorsiflexion laterals, are diagnostic. Gold standard modern treatment uses the Dobbs method of serial manipulation and casting with minimally-invasive stabilization of the talonavicular joint and Achilles tendon tenotomy.     

Total temporomandibular joint reconstruction with a Delrin titanium implant.

Numerous alloplastic materials have been used for partial or total reconstruction of the temporomandibular joint in patients with fibrous or bony ankylosis, severe degenerative joint disease, or traumatic deformity, and for reconstruction following tumor resection and corrective surgery following multiple arthroplasties. We have had initial success with the use of a polyoxymethylene (Delrin) condylar head affixed to a pure titanium mesh for these reconstructive procedures. This versatile prosthesis does not require use of a separate glenoid fossa prosthesis. The surgical technique, as well as a historical perspective on alloplastic total joint prostheses used to date, is described in several patients.     

Spinal injuries in the elderly population

The average age of the population is increasing and spinal traumatic injuries of the elderly are significantly more common. This frail population is prone to suffering serious injuries from minor or low-impact trauma when compared to younger patients. The reduced agility and ability to avoid falls in the elderly population may be the result of a combination of decreased stability due to altered sensory mechanisms, progressive spinal deformity, increased rigidity, osteoarthritis and neurological disorders, reduced cognitive function and hypotension, along with polypharmacy. Associated risk factors, including metabolic and autoimmune conditions may significantly increase the risk of morbidity and disability in this group. The most frequent injuries are odontoid fractures, vertebral compression fractures and traumatic central cord syndrome, all of which may be frequently associated with other lesions. Patient resilience and expectations will determine selection of consensual treatment aiming for a balance between maintaining function and achieving recovery. Conservative management is often the preferred method of treatment in the most common spinal injuries in the elderly as non-union or some degree of spinal deformity may be clinically well tolerated. Surgical treatment may provide benefit in the presence of persistent cord compression or spinal instability in patients that can tolerate the procedure. Ultimately, treatment should be tailored individually. Prevention of these injuries should be the focus in a world population with an ever-increasing proportion of elderly people.     

The role of less invasive surgery in the treatment of adolescent idiopathic scoliosis and adult spinal deformity

The overall impact of spinal deformity reconstructive surgery on short- and long-term quality of life and patients' perioperative experience has been widely studied in recent literature. With the advancement of modern less invasive (anterior/lateral/posterior percutaneous) spinal deformity techniques the ‘gold standard’ role of open traditional approaches has been questioned. Minimally invasive surgical (MIS) techniques are rapidly evolving and further research is required to determine whether a particular surgical treatment may be suitable for all patients or a patient-tailored individual treatment and surgical technique should be selected and could offer better results. Focus of the present article is to report the most recent research in ‘pure’ less invasive spinal deformity surgery (LIS) as applied both for adolescent idiopathic scoliosis (AIS) and adult spinal deformity (ASD) and describe a single centre's experience on such ‘treatment philosophy’ as adopted in the last 7 years.     

The diabetic foot and ankle

Diabetes mellitus is a common malady of our time with ever increasing numbers of patients presenting with diabetic foot and ankle pathology. Diabetes requires treatment by a multidisciplinary team and vascular disease requires management involving vascular surgeons. There is, however, an increasing burden on the orthopaedic surgeon with ulceration, foot deformity, osteomyelitis and Charcot osteo-arthropathy being direct complications of diabetes. Potential severe complications following fracture and elective surgery require an understanding of diabetes and its effects on soft tissue and bone. The key topics are: Pathophysiology - effects of hyperglycaemia on vascular, neuronal and immune systems, Assessment - examination of diabetic foot pathology and how to spot the ‘at risk foot’, Ulceration - management of foot and ankle ulceration and indications for intervention, Charcot osteo-arthropathy - brief overview of Charcot-type foot and ankle disease, and Management of ankle fractures - overview of current trends in options for conservative and surgical intervention.     

Management of temporomandibular joint arthritis in children and adolescents: An introduction for orthodontists

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatic disease of childhood. JIA can affect any joint and the temporomandibular joint (TMJ) is one of the joints most frequently involved. TMJ arthritis impacts mandibular growth and development and can result in skeletal deformity (convex profile and facial asymmetry), and malocclusion. Furthermore, when TMJs are affected, patients may present with pain at joint and masticatory muscles and dysfunction with crepitus and limited jaw movement. This review aims to describe the role of orthodontists in the management of patients with JIA and TMJ involvement. This article is an overview of evidence for the diagnosis and treatment of patients with JIA and TMJ involvement. Screening for the orofacial manifestation of JIA is important for orthodontists to identify TMJ involvement and related dentofacial deformity. The treatment protocol of JIA with TMJ involvement requires an interdisciplinary collaboration including orthopaedic/orthodontic treatment and surgical interventions for the management of growth disturbances. Orthodontists are also involved in the management of orofacial signs and symptoms; behavioural therapy, physiotherapy and occlusal splints are the suggested treatments. Patients with TMJ arthritis require specific expertise from an interdisciplinary team with members knowledgeable in JIA care. Since disorders of mandibular growth often appear during childhood, the orthodontist could be the first clinician to see the patient and can play a crucial role in the diagnosis and management of JIA patients with TMJ involvement.     

Assessing outcomes of surgical treatment in adult spinal deformity: a critical approach

Adult spinal deformity (ASD) comprises a range of aetiologies and pathologies affecting the lumbar, thoracic or thoracolumbar region during the ageing process. Management of ASD is an increasing health-care burden due to its prevalence in patients aged over 65 years and increasing age of populations in developed countries. Non-operative management of ASD has limited benefit, but may be appropriate for patients with a mild spinal deformity, who can cope with their level of symptoms, or those patients too frail for major spinal surgery. Surgical management of ASD is a major undertaking, associated with significant risks. Minimally invasive surgical (MIS) techniques are rapidly evolving and further research is required to determine the most suitable ASD patient profiles and clinical parameters for treatment by MIS, hybrid, or open techniques. Understanding the resources available for preoperative risk stratification, patient optimization and outcomes assessment following surgery can help to personalize risk-benefit discussions with patients and to develop pragmatic patient-specific surgical strategies for patients with ASD to obtain successful outcomes and reduce the risk of complications. This narrative review discusses patient assessment, treatment outcomes, and surgical strategies to manage patients with ASD.     

Correction of neurological deformity in the foot and ankle

Deformities of the foot and ankle in neuromuscular conditions are often complex and occur at multiple levels. Careful examination of the patient is key to identifying the deformity, and whether it is flexible or fixed. This will help to guide management options. This paper outlines treatment options for the common deformity patterns seen in clinical practice.     

The management of spastic equinus in cerebral palsy

Equinus of the foot is the most common deformity in children with spastic cerebral palsy. Patients with cerebral palsy who are able to walk may have different problems because of an equinus deformity. They may have a clumsy gait and often stumble, fall and suffer injuries. Secondary hip and knee deformities, forefoot callosities and pain, shoe fitting problems and excessive wear on shoes are common. The treatment of equinus is either nonoperative or operative. Nonoperative treatment is indicated in dynamic equinus, during the fast-growth phase of a child's development. The most favourable results can be expected with a combination of different forms of such treatment including repeated injections of Botulinum toxin type A together with orthotics and physical therapy. If there are simultaneous contractures in the hip and/or knee joints, multilevel surgery with nonoperative treatment of dynamic equinus may be the best solution. Operative treatment is indicated in patients with fixed equinus. In diplegia and quadriplegia the most favourable outcome can be expected with either a procedure on the gastrocnemius muscle or triceps surae muscle. In hemiplegia the best results may be expected with procedures on the triceps surae muscle. Multilevel surgery at the hip and knee joints is the rule in cases of contractures or deformity.     

Scleroderma: a case report of possible cause of restricted movement of the temporomandibular joint with effects on facial development

Scleroderma is a rare abnormality in which fibrosis of the skin, subcutaneous tissues and muscle may occur. All forms of scleroderma are rare in childhood: the most common form is localized scleroderma. Localized scleroderma is often benign, but may cause significant deformity, if it occurs on the face or extends across joint surfaces. Structural changes may occur in the osseous tissue and result in mandibular joint restriction (pseudoankylosis) and facial and occlusal disharmonies. This article describes a case of facial linear scleroderma in a nine-year-old child and the treatment performed to minimize consequences on occlusion and face development. Available clinical data will be illustrated.     

正颌手术对颞下颌关节影响的研究进展

正颌术术后的复发往往与颞下颌关节（TMJ）结构和位置异常有关，包括髁突移位、进行性髁突吸收和关节盘移位等。正颌外科作为一种创伤性的手术，对TMJ的结构和位置能产生一定的影响。由于牙颌面畸形患者往往术前即有TMJ的疾病，因此正颌手术本身对TMJ的影响是否导致了复发和产生颞下颌关节紊乱病（TMD）需要多项研究探索。有一些学者提出，正领手术同期行关节盘复位术可提高手术效果稳定性。对预防由于TMJ结构和位置异常引起的复发或TMD，目前临床尚无特定方法。鉴于此，本文将在正颌外科对TMJ结构的影响，与TMD的关系，以及预防术后复发和TMD的方法等三个方面进行综述。     

The role of simultaneous gap arthroplasty and distraction osteogenesis in the management of temporo-mandibular joint ankylosis with mandibular deformity in children.

INTRODUCTION: Temporo-mandibular joint ankylosis is a common cause of acquired deformity in children. PURPOSE: Surgical correction of the ankylosis only leaves the patient with an uncorrected mandibular deformity. This study was to evaluate the use of distraction osteogenesis for simultaneous correction of the mandibular deformity. MATERIAL: This study was done on six children with temporo-mandibular joint ankylosis and mandibular deformity. Uniaxial double pin distractors with Schanz pins were used in this study. METHODS: The patients underwent simultaneous gap arthroplasty and mandibular osteotomy (retromolar) with distractor insertion. Distraction was started on the fifth post-operative day. The patients were put on dynamic temporo-mandibular joint exercises on the first post-operative day. RESULTS: All patients had a satisfactory mouth opening on follow-up. Satisfactory cosmetic correction of the mandibular deformity was also achieved in all these patients. Some degree of malocclusion resulted from treatment due to which the patients were placed on orthodontic treatment.CONCLUSIONS: Distraction osteogenesis can be used simultaneously with gap arthroplasty in patients with temporo-mandibular ankylosis, for the correction of the mandibular deformity.     

Metatarsal fracture management

Metatarsal fractures represent a significant proportion of all foot injuries. Patients present with pain and difficulty with ambulation either after a traumatic insult or an increase in activity level. Diagnosis requires a foot X-ray series and tarsometatarsal injuries may need to be excluded with a CT. Management is determined by patient factors and fracture pattern. The aim of treatment is to preserve the longitudinal and transverse arches of the forefoot and restore the alignment of the metatarsals to achieve normal weight distribution. Open fractures, fractures with sagittal plane displacement more than 10° or with 3–4 mm displacement in any other plane may benefit from surgical intervention. The majority are minimally displaced and can be treated with a walking boot or hard-soled shoe with arch support or non-weight bearing in a short leg cast for 6–8 weeks. Any suggestion of instability or displacement for the first metatatarsal will require surgical treatment. Proximal fifth metatarsal fractures have differing treatments depending on the location of the fracture.     

Management of spinal osteomyelitis-associated deformity

Spinal osteomyelitis predominantly affects the anterior vertebral column. Pyogenic infection seldom results in significant deformity but rather the more insidious causes such as tuberculosis. The typical deformity is a single plane kyphosis, other than when the infection affects the more mobile and more loaded lumbar spine where facet subluxation may result in a three-dimensional torsional deformity. Management is dictated by whether the disease process is active versus healed disease, the skeletal maturity of the patient and whether there is ongoing spinal growth expected and associated neurological deficit. Surgical strategies may be anterior only, such as in the sub-axial cervical and thoracic active disease, combined anterior and posterior procedures at the cervico-thoracic and thoracic‐lumbar junctions, but the posterior circumferential vertebral column resection (VCR) is increasingly utilized for rigid healed disease, especially with late presenters and in those patients who have associated neurological impairment.     

正颌外科患者术前的颞下颌关节功能评价

目的　了解正颌患者颞下颌关节 (TMJ)的功能状况 ,探讨牙颌面畸形与颞下颌关节之间的关系。方法正颌外科发育性牙颌面畸形 12 3例患者 ,平均年龄 2 3.8岁 ,男性 45例 ,女性 78例。颞下颌关节功能的检查方法采取问诊与检查相结合 ,颞下颌关节功能记分采取 Helkim o指数记分方法。结果　 (1)牙颌面畸形患者颞下颌关节紊乱病 (TMD)各种症状发生率明显高于对照组人群。(2 )男性患者弹响症状发生率高于女性 ,而女性患者关节触诊疼发生率高。(3) 16～ 2 5岁患者张口受限发生率较高 ,但大多数为轻度张口受限。(4 )不对称畸形 (下颌前突偏斜 )者弹响症状发生率较高 ,而且相应偏斜侧最大侧向移动度小。而下颌后缩组开口度明显小于其他各组 ,提示其关节功能受损较严重。结论　牙颌面畸形患者的颞下颌关节功能不同于正常人 ,部分下颌偏斜与后缩患者关节功能受损     

Hand, foot, and mouth disease.

Hand, foot, and mouth disease, also known as vesicular stomatitis with exanthem, is a vesicular disorder affecting both skin and oral mucosa. The disease is usually caused by Coxsackie virus A-16 and affects mainly children. The oral lesions may require differential diagnosis from other conditions, such as herpetic gingivostomatitis, aphthous stomatitis, and herpangina. Hand, foot, and mouth disease should not be confused with foot-and-mouth disease of cattle, which is rare in human beings and is not caused by Coxsackie virus.     

Nasoalveolar Moulding for Children with Unilateral Cleft Lip and Palate

Introduction

Cleft lip and palate represents the most frequently occurring congenital deformity second only to club foot deformity in our country. Wide alveolar clefts if not preceded by pre surgical orthodontic adjuncts like nasoalveolar moulding, may affect the final outcome of the primary surgery. Presurgical nasoalveolar moulding is to align and approximate the alveolar cleft segments while at the same time achieving correction of the nasal cartilage and soft tissue deformity.

Materials and methods

The device we used is designed by Barry Grayson. It is simple to fabricate, causes less discomfort to the patient and optimum results are achieved in three months of time, compared to other complicated appliances like Latham’s which are more invasive. A child of 3 months presented with a complaint of unilateral cleft deformity on one side of the face.

Conclusion

After three months of nasoalveolar moulding considerable changes were observed. The widths of the cleft alveolus were reduced and the nasal contours of columella on the cleft side showed considerable improvement.