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Talectomy is recommended as a primary or salvage procedure for management of rigid or recurrent equinovarus deformity in arthrogryposis. Twenty-one feet (11 children) that had undergone talectomy were reviewed at a mean follow-up of 11.1 years (range, 2-24). Fourteen (73.7%) feet were satisfactory at final review, whereas five (26.3%) had an unsatisfactory result. Attention to technical details and accurate positioning of calcaneus in the ankle mortise are the two important prerequisites to guarantee a satisfactory long-term result. Fusion of the tibiocalcaneal articulation in optimal position, either spontaneous or induced, is a favorable sign, as it ensures lasting correction of the deformity. The role of a tight and fibrotic tibialis anterior in causing recurrence of severe forefoot adduction and supination is discussed.

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A 42-month-old girl presented with a history of sudden onset swelling of the left shoulder of 4-5 days duration with no preceding history of significant trauma or fall. The child was irritable and mildly febrile on examination. A tense globular swelling measuring 6 x 5 x 5 cm was present in the left shoulder region which was tender and fluctuant on palpation (figure 1). There was an increase in the local temperature and the skin overlying the swelling was stretched and glossy. Shoulder movements were painful and restricted. There was no regional lymphadenopathy nor any distal neurovascular compromise. Other joints were normal and no abnormality was detected in other systems. The child had chronic non-pitting oedema of both legs and was reluctant to walk. There was no history of a bleeding disorder nor was any such family history elicitable. An X-ray of the left shoulder revealed a complete separation of the proximal humeral epiphysis with osteopenia and surrounding soft tissue swelling (figure 2).Haemogram revealed anaemia (haemoglobin 5.3 g/dl) but a normal leucocyte count of 7.2 x 109/l (polymorphs 44%, lymphocytes 48%, and eosinophils 8%). Reticulocyte count was 1%, platelet count was adequate, and the erythrocyte sedimentation rate was 10 mm at one hour. Bleeding time, clotting time and other tests for bleeding profile were within normal limits. Serum calcium and phosphorus levels were normal but alkaline phosphatase level was elevated to 306 IU/l (normal range 80-180 IU/l).Needle biopsy of the swelling resulted in the evacuation of approximately 20 ml of altered blood and a few soft tissue and bony fragments which on microscopic examination revealed the presence of proliferating fibroblasts, spicules of necrotic bone and abundant vascular proliferation. A single X-ray of the knee (figure 3), however, showed typical changes which aided in the diagnosis of this condition.

A 14-week-old girl was brought in with a history of painful swelling of both legs since the age of one month. The onset was insidious and was not associated with trauma or fall. There was no history of fever or associated constitutional symptoms. The birth history was normal and the infant was apparently asymptomatic until the age of one month. Examination revealed a healthy and alert infant. Both legs were bowed anteriorly and a uniform bony thickening of both tibiae was palpable throughout their lengths (figure 1). Both legs were extremely tender and the infant would withdraw both lower limbs and cry incessantly if any attempt was made to touch them. There was no increase in local temperature nor redness of the overlying skin. Knees and ankle joints were normal and demonstrated a full range of motion. Regional lymph nodes were not enlarged and other bones and joints were normal on examination. X-Rays of both legs revealed peri-osteitis of both tibiae with extensive subperiosteal new bone formation involving the entire diaphysis (figure 2).Questions

Skin necrosis and wound problems complicate surgical release of severe neglected clubfoot. This is primarily the result of excessive tension on the skin edges and a poor understanding of the abnormal vascular anatomy in clubfoot. We report a technique of primary skin closure by using a local-rotation fasciocutaneous flap. Posteromedial skin incision is taken. Posterior tibial artery perforators supplying the medial flap and saphenous vein are preserved. After soft-tissue release and correction of deformity, a defect appears in the posteromedial part of wound. Horizontal backcut is taken at proximal part of the incision and entire medial fasciocutaneous flap is rotated inferiorly to cover the defect. Triangular defect appearing proximally is sutured primarily or covered with skin graft. Primary uncomplicated wound healing was achieved within 2 weeks in all 20 rigid and neglected clubfeet (1-7 years) operated on with this technique. This flap is scientifically logical, technically easy, and ensures primary wound healing.

We report the results of circumferential periosteal sleeve resection of lower-limb bones for mild degrees of limb-length discrepancy (mean, 3.5 cm) secondary to postpolio residual paralysis in 23 patients. Results were expressed by calculating percentage of length discrepancy of the operated-on limb with respect to the normal limb and gain in length in centimeters of the operated-on limb over the normal limb. All patients had a uniform trend of gain in length with response in the femur lasting for approximately 1 year, whereas that in the tibia persisted >2 years. Circumferential periosteal sleeve resection is a safe and reliable method of longitudinal bone-growth stimulation, providing consistent results, especially for mild to moderate discrepancies.