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1.  Author's reply 
doi:10.4103/0019-5413.139898
PMCID: PMC4175877  PMID: 25298570
2.  Classification of relapse pattern in clubfoot treated with Ponseti technique 
Indian Journal of Orthopaedics  2013;47(4):370-376.
Background:
Relapse of clubfoot deformity following correction by Ponseti technique is not uncommon. The relapsed feet progress from flexible to rigid if left untreated and can become as severe as the initial deformity. No definitive classification exists to assess a relapsed clubfoot. Some authors have used the Pirani score to rate the relapse while others have used descriptive terms. The purpose of this study is to analyze the relapse pattern in clubfeet that have undergone treatment with the Ponseti method and propose a simple classification for relapsed clubfeet.
Materials and Methods:
Ninety-one children (164 feet) with idiopathic clubfeet who underwent treatment with Ponseti technique presented with relapse of the deformity. There were 68 boys and 23 girls. Mean age at presentation for casting was 10.71 days (range 7-22 days). Seventy three children (146 feet, 80%) had bilateral involvement and 18 (20%) had unilateral clubfeet. The mean Pirani Score was 5.6 and 5.5 in bilateral and unilateral groups respectively. Percutaneous heel cord tenotomy was done in 65 children (130 feet, 89%) in the bilateral group and in 12 children (66%) with unilateral clubfoot.
Results:
Five relapse patterns were identified at a mean followup of 4.5 years (range 3-5 years) which forms the basis of this study. These relapse patterns were classified as: Grade IA: decrease in ankle dorsiflexion from15 degrees to neutral, Grade IB: dynamic forefoot adduction or supination, Grade IIA – rigid equinus, Grade IIB – rigid adduction of forefoot/midfoot complex and Grade III: combination of two or more deformities: Fixed equinus, varus and forefoot adduction.
In the bilateral group, 21 children (38 feet, 28%) had Grade IA relapse. Twenty four children (46 feet, 34%) had dynamic intoeing (Grade IB) on walking. Thirteen children (22 feet, 16%) had true ankle equinus of varying degress (Grade IIA); eight children (13 feet, 9.7%) had fixed adduction deformity of the forefoot (Grade IIB) and seven children (14 feet, 10.7%) had two or more fixed deformities. In the unilateral group seven cases (38%) had reduced dorsiflexion (Grade IA), six (33%) had dynamic adduction (Grade IB), two (11%) had fixed equinus and adduction respectively (Grade IIA and IIB) and one (5%) child had fixed equinus and adduction deformity (Grade III). The relapses were treated by full time splint application, re-casting, tibialis anterior transfer, posterior release, corrective lateral closing wedge osteotomy and a comprehensive subtalar release. Splint compliance was compromised in both groups.
Conclusion:
Relapse pattern in clubfeet can be broadly classified into three distinct subsets. Early identification of relapses and early intervention will prevent major soft tissue surgery. A universal language of relapse pattern will allow comparison of results of intervention.
doi:10.4103/0019-5413.114921
PMCID: PMC3745691  PMID: 23960281
Classification; clubfoot; Ponseti technique; relapse
4.  Utility of combined hip abduction angle for hip surveillance in children with cerebral palsy 
Indian Journal of Orthopaedics  2011;45(6):548-552.
Background:
Spontaneous hip lateralization complicates the management of non-ambulatory children with cerebral palsy (CP). It can be diagnosed early using radiographs, but it involves standardization of positioning and exposure to radiation. Hence, the aim of this study was to assess the utility of Combined hip abduction angle (CHAA) in the clinical setting to identify those children with CP who were at greater risk to develop spontaneous progressive hip lateralization.
Materials and Methods:
One hundred and three children (206 hips) with CP formed our study population. There were 48 boys and 55 girls aged 2–11 years (mean 5.03 years). 61 children were Gross Motor Function Classification System (GMFCS) level 5, while 42 were GMFCS level 4. Clinical measurements of CHAA were statistically correlated with radiographic measurements of Reimer's migration percentage (MP) for bivariate associations using χ2 and t tests.
Results:
CHAA is evaluated against MP which is considered as a reliable measure of hip subluxation. Thus, for CHAA, sensitivity was 74.07% and specificity was 67.35%. False-positive rate was 32.65% and false-negative rate was 25.93%.
Conclusions:
Our study shows that correlation exists between CHAA and MP, which has been proved to be useful for hip screening in CP children at risk of hip dislocation. CHAA is an easy, rapid, cost-effective clinical test which can be performed by paraclinical health practitioners (physiotherapists) and orthopedic surgeons.
doi:10.4103/0019-5413.87129
PMCID: PMC3227360  PMID: 22144749
Cerebral palsy; combined hip abduction angle; hip subluxation; reimer's migration percentage
6.  RETRACTED ARTICLE: Missed Monteggia fracture in children: is annular ligament reconstruction always required? 
Background
Missed radio-capitellar joint dislocation is one of the feared complications of Monteggia fractures, especially when associated with subtle fractures of the ulna bone. Many treatment strategies have been described to manage the chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. This study is an attempt to address the issue of annular ligament reconstruction in the surgical management of missed Monteggia fracture.
Materials and methods
A retrospective study was performed in 12 patients who presented with missed Monteggia fracture. All children underwent open reduction of the radio-capitellar joint. Five children (Group A) were treated with ulna angulation–distraction osteotomy and annular ligament reconstruction, and six cases required only an ulna angulation–distraction osteotomy without ligament reconstruction. The duration of missed dislocation was from 3 to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III, respectively.
Results
The mean follow up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15° in Group A and 10° in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. In one case (Group A), there was 3 mm of radiographic subluxation of the radial head, but this child was clinically asymptomatic. The elbow score was excellent in ten cases and good in two cases.
Conclusion
Distraction–angulation osteotomy of the ulna suffices in most cases of missed Monteggia fracture and the need for annular ligament reconstruction is based on the intra-operative findings of radial head instability.
doi:10.1007/s11832-009-0202-9
PMCID: PMC2758182  PMID: 19768479
Missed Monteggia; Annular ligament reconstruction; Ulna osteotomy
7.  Missed Monteggia fracture in children: Is annular ligament reconstruction always required? 
Indian Journal of Orthopaedics  2009;43(4):389-395.
Background:
Chronic (neglected) radiocapitellar joint dislocation is one of the feared complications of Monteggia fractures especially when associated with subtle fracture of the ulna bone. Many treatment strategies have been described to manage chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. The purpose of this study is to highlight the management of missed Monteggia fracture with particular emphasis on utility of annular ligament reconstruction by comparing the two groups of patients.
Materials and Methods:
In a prospective study 12 patients with mean age of 7.4 years, who presented with neglected Monteggia fractures, were studied. All children underwent open reduction of the radiocapitellar joint. Five children (Group A) were treated with angulation-distraction osteotomy of ulna and annular ligament reconstruction and six cases (Group B) required only angulation-distraction osteotomy of ulna without ligament reconstruction. In one case an open reduction of the radiocapitellar joint was sufficient to reduce the radial head and this was included in Group B. The gap between injury and presentation was from 3 months to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III respectively. We used the Kim's criteria to score our results.
Result:
The mean follow-up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15 degree in Group A and 10 degree in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. The elbow score was excellent in 10 cases, and good in two cases.
Conclusion:
Distraction-angulation osteotomy of the ulna suffices in most cases of missed monteggia fracture and the need for annular ligament reconstruction is based on intraoperative findings of radial head instability.
doi:10.4103/0019-5413.55978
PMCID: PMC2762552  PMID: 19838391
Missed Monteggia fracture; annular ligament reconstruction; ulna osteotomy
8.  Congenital vertical talus: Treatment by reverse ponseti technique 
Indian Journal of Orthopaedics  2008;42(3):347-350.
Background:
The surgery for idiopathic congenital vertical talus (CVT) can lead to stiffness, wound complications and under or over correction. There are sporadic literature on costing with mixed results. We describe our early experience of reverse ponseti technique.
Materials and methods:
Four cases (four feet) of idiopathic congenital vertical talus (CVT) which presented one month after birth were treated by serial manipulation and casting, tendoachilles tenotomy and percutaneous pinning of talonavicular joint. An average of 5.2 (range - four to six) plaster cast applications were required to correct the forefoot deformity. Once the talus and navicular were aligned based on the radiographic talus-first metatarsal axis, percutaneous fixation of the talo-navicular joint with a Kirschner wire, and percutaneous tendoachilles tenotomy under anesthesia was performed following which a cast was applied with the foot in slight dorsiflexion.
Results:
The mean follow-up period for the four cases was 8.5 months (6-12 months). At the end of the treatment all feet were supple and plantigrade but still using ankle foot orthosis (AFO). The mean talocalcaneal angle was 70 degrees before treatment and this reduced to 31 degrees after casting. The mean talar axis first metatasal base angle (TAMBA) angle was 60° before casting and this improved to 10.5°.
Conclusion:
Although our follow-up period is small, we would recommend early casting for idiopathic CVT along the same lines as the Ponseti technique for clubfoot except that the forces applied are in reverse direction. This early casting method can prevent extensive surgery in the future, however, a close vigil is required to detect any early relapse.
doi:10.4103/0019-5413.41860
PMCID: PMC2739479  PMID: 19753164
Casting; congenital vertical talus; conservative treatment

Results 1-8 (8)