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Does Recent advances mean Hi-Tech Himanagement ?

A perspective from the management of deformities in orthopaedics

BY Dr.Landge D.K Coordinator Dr. Panse sir

WHAT IS RECENT Practiced in US ? COSTLY ? Market driven ???? That which is debatable in Conferences ??? Which fills up pages in journals?? Topics that makes the difference , the way we

practice

FIVE ANGLES OF INTEREST CLINICAL ACADEMIC INDUSTRIAL SOCIAL RESEARCH

DISCLAIMERThe speaker did not receive any outside/inside funding or grants in support of this presentation.

Every attempt has been done to make statements in this presentation with reference to standard internationally / nationally accepted journals and textbooks, audience requested to exercise their discrimination at individual level for best practices in the interest of profession.

INTRODUCTION published the first book on orthopedic surgery, in 1741=L orthopdie two Greek Words, Orthos= signifies straight free from Deformity and Pais = a Child. Out of these two Words ,I have compounded that of Orthopaedia, to express in one Term the Design I propose, which is to teach the different Methods of preventing and correction the Deformities of Children

Nicolas ANDRY 1658 1742

Andry :

That Tendon which goes from the Calf of the leg to the Heel, is sometimes so short, that the Person is obliged to walk upon the fore part of his Foot, without being able to set the Heel to the Ground . . . Children are sometimes born with this Defect, and sometimes they come by it afterwards. In either Case it may be cured, provided this Shortness does not proceed from any violent Cause, which has absolutely maimed the Tendon, such as a Burning after Birth, for example, or any other Accident that is capable of rendering this Shortness incurable.

When a new gadget/product comes in the market a hype is created and the gadgets are used to treat a wide variety of clinical situations. People are excited about new technology. Later on the excitement weans off . Should not we be using technology conceptually with rationale indication instead of subjecting the populations for surgery due to excitement of new technology Ref. IJO 2007 ; Editorial

WHY DEFORMITY AS RECENT Why not ACI Why not Newer Common Can be Prevented Rewarding Surgical

approaches(MIS) Why not BMP s Why not Gene therapy Why not transplant Why not fMRI

results Tender age (Pediatric)

DEFORMITIES IN CHILDRENCOMMON CHILDHOOD FOOT CONDITIONS =CTEV, ROTATIONAL PROBLEMS, FLAT FEETCVT / TARSAL COALITION COMMON CHILDHOOD KNEE DE. = Genu vara / valgus HIP SPINE = COXA VARA, COXA PLANA = Idiopathic scoliosis

Cerebral palsy PPRP LLD

CONGENITAL LL DEFORMITIES (Prevalence wise)ROTATIONAL FLAT FEET CTEV MET.ADDUCTUS CPT / ANGULAR CVT FIBULAR HEMIMELIA TIBIAL HEMIMELIA PFFD LLD

CONGENITAL VERTICAL TALUS

X-RAYS IN CVT

CLUB FOOT CHILD ON Rx

REVIEW OF LITERATURE

Shortcut to J Bone Joint Surg Am. 1905;s2-2288-302.lnk

ARE OP S REQUIRED IN CTEV 1905=MACKENZIE

Dr. Ponsetti

says

About Development of the technique In the mid 1940s, I examined 22 patients with clubfoot that had been surgically treated in the 1920s by Arthur Steindler, a good surgeon. The feet had become rigid, weak, and painful. About Delayed acceptance of the technique It was disappointing that my first article on congenital clubfoot, published in the The Journal of Bone and Joint Surgery in March 1963, was disregarded. It was not carefully read and, therefore, not understood. My article on congenital metatarsus adductus, published in the same journal in June 1966, was easily understood, perhaps because the deformity occurs in one plane. The approach was immediately accepted, and the illustrations were copied in most textbooks. A few orthopaedic surgeons studied my technique and began to apply it only after the publication of our long-term follow-up article in 1995, the publication of my book a year later, and the posting of Internet support group web sites by parents of babies whose clubfoot I had treated. I have been reprimanded for not pushing the method more forcefully from the beginning .

KITE S ERRORKite s method of manipulation Kite believed that the heel varus would correct simply by everting the calcaneus. He did not realize that the calcaneus can evert only when it is abducted (i.e., laterally rotated), under the talus.

Thou shall not pronate

ORIGINAL LANDMARK ARTICLE Manipulation as described by

Ponseti. The thumb is positioned over the lateral aspect of the head of the talus, and the index finger is positioned behind the lateral malleolus. No counterpressure should be applied at the calcaneocuboid joint. The cavus and the adduction are corrected by slight supination and abduction of the forefoot. The forefoot is never pronated

Shortcut to PONSETTI IN J. PAEDIATRICS.lnk

Shortcut to Current Concepts Review=PONSETI=1992.lnk

Pirani Severity Scoring

Clinical ( not radiological) . Scores six clinical signs 0 normal 0.5 moderately abnormal 1 severely abnormal Midfoot score Three signs comprise the Midfoot Score (MS), grading the amount of midfoot deformity between 0 and 3. Curved lateral border [A] Medial crease [B] Talar head coverage [C] Hindfoot score Three signs comprise the Hindfoot Score (HS), grading the amount of hindfood deformity between between 0 and 3. Posterior crease [D] Rigid equinus [E] Empty heel [F]

AFTER

CORRECTION

SURGICAL SCAR

LATE PRESENTATION CTEV

JESS

PRINCIPLE OF JESS

Residual Clubfoot Problems

supination hindfoot varus cavus forefoot adductus

LLD

PFFD FIBULAR HEMIMELIA TIBIAL HEMIMELIA CP -HIP DISLOCATION

CONGENITAL DEFICIENCIES OF THE LONG BONES(Swanson classification =only taxonomical advantage)

CONGENITAL DEFICIENCIES OF THE LONG BONES

Prognosis in Fibular hemimelia

Severity LLD FOOT DEFORMITY No. of rays ( less than two=poor prognosis0

Ankle fusion =Plantigrade foot Syme s amputation= In severe deformities gives more functional results than deformity corrections

CONGENITAL PSEUDARTHROSIS OF THE TIBIA

RADIAL CLUB HAND

ILLIZARROV

FOR CLUB HAND

CPPRE-OP POST-OP

General Principles of managing patients

Communication Counseling Likely outcome of Sx of relatives in case of severe deformities like arthogryposis/ muscular dystrophy Club hand Scoliosis CPT

Correction of deformitiesClub foot Coxa vara Genu Valgus

Joint reconstructionTime buy osteotomies PAO, HTO // Joint Replacements

TITANS Ignacio Ponseti

Dror Paley =living legends John E. Herzenberg

Gavriil Ilizarov Langenskiold Grice - Green

PRINCIPLES OF DEFORMITY CORRECTION

Measure quantity of deformity Find plane of deformity Calculate wedge open/close Decide fixation IF

Staples/plates/IMN EXFIX---ILLIZAROV/ORTHOFIX/TSF/JESS

ORTHO RADIOGRAM

DISTRACTION OSTEOGENESIS

PRINCIPLES OF DESIGNS Illizarov=Distraction osteogenesis JESS=Differential distraction TSF = Projective Geometry - similar to that used in Aircraft Simulators (Dr. J. Charles Taylor 1990) Angulation +rotation+translation= HEXAPOD=SIX AXIS correction A MIND THAT KNOWS THE PRINCIPLES WILL DEVICE HIS OWN METHODS

Illizarrov Important innovation in

Taylor Spatial Computer based

deformity correction Foot strategies: ligament distraction up to 8 years old, osteotomies in older children. Disadvantages: long learning curve; difficulty in rotational correction

technology Six-axis deformity correction Most accurate external fixator available

Ponseti-inspired Clubfoot Sequence Abduct foot while holding

counter pressure on neck of talus

When heel varus and internal

rotation are corrected, reprogram for dorsiflexion

Talar neck wire initially attached

to tibial ring, then moved to foot ring

If needed, cut foot ring at end

and modify to correct adductus/cavus

SELF

LENGTHENING

NAILS

Problems with Closed corticotomy More of a fancy than comfort

Fully implantable computer controlled intramedullary Lengthening device FITBONE ..Germany No reference

LENGTHENING OVER NAIL.. High complication Rates All series Bost;J Bone Joint Surg Am.1956;38:567-584 Paley,Herzenberg ; JBJS 1997 Milind Choudhary; IJO 2008

RECENT ? = LOOKING INTO FUTUREHow do we prepare for the future? How do we adequately prepare to seize the Internet explosion and use it to our advantage? How do we continue to attract, train, and keep the best and the brightest young students who prefer medicine but are increasingly entering the business world because of opportunity costs? How do we engage current notions on a host of topical issues whether they be ethical, political, economic, social, or cultural to make us wise and more informed about the people who come to us and about the forces driving their lives? Reference JBJS 2004 (Am) India specific problems in medical education. Lack Infrastructure in Public sector/ Lack of commitments to medical education in private sector Reference . IJO 2004 Sept

As medicine becomes more about profit than about health, and as physicians are given even more powerful incentives to withhold care, the interests of the doctor and the patient are being pushed out of alignment. We find ourselves operating within a healthcare system that is almost perfectly designed, however inadvertently, to undermine the essential bond between patient and doctor. Residents being used as Workforces JBJS 2005(Am)

Competition to maintain the integrity and valu

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