We analysed static footprints of 2300 children between the ages of four and 13 years to establish the influence of footwear on the prevalence of flat foot. The incidence among children who used footwear was 8.6% compared with 2.8% in those who did not (p < 0.001). Significant differences between the predominance in shod and unshed children were noted in all age groups, most marked in those with generalised ligament laxity. Flat foot was most common in children who wore closed-toe shoes, less common in those who wore sandals or slippers, and least in the unshod. Our findings suggest that shoe-wearing in early childhood is detrimental to the development of a normal longitudinal arch.

No abstract

We analysed the static footprints of 1846 skeletally mature individuals to establish the influence of the age at which shoe-wearing began on the prevalence of flat foot. The incidence was 3.24% among those who started to wear shoes before the age of six years, 3.27% in those who began between the ages of 6 and 15 and 1.75% in those who first wore shoes at the age of 16 (p < 0.001). Flat foot was highest in those who, as children, wore footwear for over eight hours each day. Obese individuals and those with ligament laxity had a higher prevalence of flat foot (p < 0.01 and p < 0.0001, respectively). Even after adjusting for these two variables, significantly higher rates of prevalence were noted among those who began to wear shoes before the age of six years. Our findings suggest an association between the wearing of shoes in early childhood and flat foot.

Records and 2,634 pairs of radiographs (anteroposterior and lateral) of 610 patients with Perthes disease were reviewed. The evolution of the disease was divided into seven stages (stages Ia, Ib, IIa, IIb, IIIa, IIIb, and IV) based on plain radiographic appearances. Intraobserver and interobserver reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stages at which epiphyseal extrusion and widening of the metaphysis occurred and the stages at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth, and the radius of the acetabulum were assessed in hips that had healed. The new classification system of the evolution of Perthes disease was reproducible and helped to identify when crucial events occur during the course of the disease. The median duration of each stage varied between 95 and 335 days. Epiphyseal extrusion and metaphyseal widening was modest in stages Ia, Ib, and IIa but increased dramatically after stage IIb. More than 20% extrusion occurred in 70% of the hips by stage IIIa. Metaphyseal changes were most frequently encountered in stage IIb, while acetabular changes were most prevalent in stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads. The timing of epiphyseal extrusion, metaphyseal widening, and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

To study how a femoral osteotomy alters the natural evolution of Perthes' disease, records and radiographs of 640 patients with Perthes' disease were analyzed. The data of 314 patients who underwent femoral osteotomy were compared with those of non-operated patients. A new modification of classification of the stages of evolution of the disease was used to identify the timing of surgery and to monitor the progress of the disease following surgery. The duration of each stage of the disease, the extent of epiphyseal extrusion, the extent of widening of the femoral metaphysis and the dimensions of the acetabulum were noted on sequential radiographs. The changes in the femoral epiphysis and metaphysis and changes in the acetabulum were also noted. It was observed that a varus osteotomy clearly alters the natural evolution of Perthes' disease. Of patients who were operated in the stage of avascular necrosis, 34% bypassed the stage of fragmentation. The duration of the disease was shorter in these patients. The duration of the stage of fragmentation was reduced in operated children who passed through the stage of fragmentation. The extent of femoral head extrusion was minimized at the stage when it was most vulnerable for deformation. Metaphyseal widening and subsequent femoral head enlargement were also minimized in children who underwent a femoral osteotomy. The chances of retaining the sphericity of the femoral head were much higher in those children who had a femoral osteotomy. These beneficial effects of a varus osteotomy, were most evident when the operation was performed either in the stage of avascular necrosis or in the early stage of fragmentation.

We studied case records and radiographs of 20 children with congenital posteromedial bowing of the tibia (CPMBT) retrospectively to determine the pattern of correction of the bowing, the associated growth abnormalities of the tibia and fibula, and the role of surgical intervention in CPMBT. The magnitude of diaphyseal bowing in two planes and the physeal inclination were measured. Abnormalities of ossification of the distal tibial epiphysis and inclination of the distal articular surface if present were noted and shortening of the tibia was recorded. The rate of resolution of deformity was noted from sequential radiographs and expressed as percentage reduction per month of follow-up. At initial presentation the magnitude of deformity varied; the most severe posterior diaphyseal bow was 70 degrees whereas the most severe medial diaphyseal bow was 64 degrees. Two distinct mechanisms seem to be responsible for resolution of the deformity in CPMBT; one involves physeal realignment and the other involves diaphyseal remodeling. In the first year of life, rapid resolution of angulation was noted; the rate of resolution reduced significantly thereafter. In a proportion of children with CPMBT residual deformity may persist till over 4 years of age. Physeal realignment occurred at a faster rate than diaphyseal remodeling. The degree of shortening was related to the severity of bowing and shortening as great as 40% was noted in a patient. Wedging of the distal tibial epiphysis and fibular hypoplasia with valgus inclination of the distal tibial articular surface occur in some children with CPMBT. Eccentric ossification of the distal tibial epiphysis in early childhood may be a predictor of wedging of the distal tibial epiphysis later on. We recommend all the children with CPMBT to be followed up periodically till skeletal maturity, to identify cases with residual bowing, ankle deformity, muscle weakness, and limb length inequality as active surgical intervention may be needed to correct these problems.

Level IV.

Radiographs of 155 Indian children were examined to identify the acetabular changes which occur in Perthes' disease. These changes included osteoporosis of the acetabular roof, irregularity of contour, premature fusion of the triradiate cartilage, hypertrophy of articular cartilage and changes in dimensions. These changes tended to be more marked in older children and when more than half of the femoral epiphysis was involved. Comparison with 25 cases of Perthes' disease from Liverpool showed the same picture. Several of the acetabular changes noted during the active stages were also seen in a series of 24 adult hips after Perthes' disease. Radio-isotope scans of the hips of 27 children with Perthes' disease showed a consistently increased uptake in the acetabulum on the affected side, indicative of a local increase in vascularity and metabolic activity. It was possible to postulate a working model for the pathogenesis of all the acetabular changes. A number of statistical correlations suggest that most of the changes have a bearing on the final outcome.