The Choice Between Total Hip Arthroplasty and Arthrodesis in Adolescent Patients: A Survey of Orthopedic Surgeons.

For adolescent patients with end-stage hip disease, the choice between total hip arthroplasty (THA) and arthrodesis is complex; the clinical evidence is not definitive, and there are difficult trade-offs between clear short-term benefits from THA and uncertain long-term risks. We surveyed nearly 700 members of the Pediatric Orthopedic Society of North America and the American Association of Hip and Knee Surgeons. Respondents chose between a recommendation of THA or arthrodesis in four clinical vignettes. A clear majority of surgeons recommended THA in two of the vignettes, however opinion was somewhat divided in one vignette (overweight adolescent) and deeply divided in another (adolescent destined for manual labor job). Across all vignettes, recommendations varied systematically according to surgeons' age and their attitudes regarding tradeoffs between life stages.

Treatment of Clubfoot Using the Ponseti Method.

The Ponseti method consists of a specific technique of manipulation of the clubfoot deformity, followed by the application of a plaster cast with the foot in the corrected position. A percutaneous tenotomy of the Achilles tendon is done prior to the final cast to gain complete correction in most patients. Bracing with a foot abduction orthosis is necessary to minimize relapse of the deformity. The method begins with the Ponseti manipulation and consists of the following steps: (1) Identify the head of the talus by palpation. (2) Supinate the forefoot to eliminate the cavus deformity and create a normal-appearing arch. (3) Abduct the forefoot with the vector of force parallel to the sole of the foot while using the lateral head of the talus as the fulcrum and maintaining the reduction of the cavus deformity. (4) This manipulation is followed by the application of an above-the-knee cast with the foot in the corrected position. (5) The manipulation and casting steps are repeated every 5 to 7 days until the foot is abducted approximately 50° from the frontal plane of the tibia. (6) In most patients (60% to >90%), a percutaneous tenotomy of the Achilles tendon is necessary to correct the residual ankle equinus after gaining full abduction of the foot with the manipulations. (7) The final cast is applied and worn for three weeks. (8) After removal of the final cast, the patient is managed with bracing with a foot abduction orthosis for 23 hours per day for 3 months. Bracing at night and during nap time is recommended until the child is 4 to 5 years old. The cavus deformity is eliminated after the application of 2 or 3 casts by the simple positioning maneuver. Abduction of the forefoot in the plane of the sole of the foot while using the head of the talus as the fulcrum results in the correction of the midfoot adduction deformity simultaneously with the hindfoot varus and the subtalar component of the equinus deformity. After full abduction is obtained, the cavus, adduction, and subtalar varus and equinus deformities are all completely corrected. The only residual deformity is the ankle equinus. Most feet require a percutaneous tenotomy to fully correct the ankle component of the equinus. The tenotomy can be performed as an outpatient procedure under local anesthetic without the need for sedation. If the foot can be dorsiflexed to >15° (without midfoot breach), a tenotomy is unnecessary. This manipulation allows complete correction of almost all idiopathic clubfeet in 4 to 7 sessions. Long-term follow-up (mean, 34 years; range, 25 to 42 years) has shown that clubfeet treated with the Ponseti method function as well as normal feet with respect to pain and level of activity.

Outcomes of a Simple Treatment for Complex Regional Pain Syndrome Type I in Children.

BACKGROUND: Chronic Regional Pain Syndrome type I (CRPSI) in children is a disorder of unknown etiology. No standard diagnostic criteria or treatment exists. Published treatment protocols are often time and resource intensive. Nonetheless, CRPSI is not rare and can be disabling. This reports the results of a simple and inexpensive treatment protocol involving no medicines, nerve blockades, physical therapy resources or referrals to pain specialists. The patient is instructed in a self-administered massage and mobilization program. The diagnosis required allodynia (pain on light touch of the skin) and signs or the history of signs of autonomic dysfunction. METHODS: A chart review of patient coded for "reflex sympathetic dystrophy" or 'autonomic dysfunction" was performed yielding a cohort of eighty-three patients treated by a common protocol. Most patients were identified in the last 15 years. Most patients with this CRPSI were doubtless coded simply as "foot pain" or "knee pain", etc and were not identified in this search. Charts were reviewed for patient demographics and outcomes. A subset of patients filled out the Pediatric Outcomes Data Collection Instrument (PODCI) giving a validated pre-treatment disability measure. RESULTS: The cohort characteristics were similar to prior reports with respect to age, gender, location, and history of trauma. Of the 26 patients who completed the PODCI before treatment the Pain/Comfort Core Scale score mean was 20.81(0-63). The Global Functioning Scale score mean was 52.11(27-83.5). Eighty-nine percent of 51 patients who attended clinic until their outcome was definite had no or minimal residual pain. Treatment averaged 2.2 visits per patient, typically over a six-week period. CONCLUSIONS: A simple, inexpensive protocol can be effective in treating CRPSI in children. The protocol is risk free, inexpensive to families and conservative of physician and physical therapy resources. LEVEL OF EVIDENCE: Therapeutic Level IV.

The Bangladesh clubfoot project: audit of 2-year outcomes of Ponseti treatment in 400 children.

BACKGROUND: Congenital clubfoot deformity can cause significant disability, and if left untreated, may further impoverish those in developing countries, like Bangladesh. The Ponseti method has been strategically introduced in Bangladesh by a nongovernment organization, Walk For Life (WFL). WFL has provided free treatment for over 8000 Bangladeshi children with clubfeet, sustained by local ownership, and international support. This audit assesses the 2-year results in children for whom treatment began before the age of 3 years. METHODS: The 10 largest WFL clinics, of the 24 across Bangladesh, were pragmatically accessed in this audit availing 1442 subjects meeting the study criteria, from which 400 children were randomly selected and examined. A specific assessment tool was developed and validated. RESULTS: Results for 400 cases were returned: 269 males, 131 females. Typical clubfeet comprised 79% of cases, and 55% were bilateral. A tenotomy rate of 79%, and brace use after 2 years of 85%, were notable findings. Functionally, most children could walk independently (99.0%), run (95.5%), squat (93.3%), and manage steps unassisted (93.0%). The ability to squat was the most indicative outcome measure, correlating with: less corrective casts, good and continued brace use, nonvarus heel position, good ankle range of motion, good Bangla clubfoot scores, and the ability to walk. Relapsing deformity was suspected with heel varus (18.0% left; 21.5% right). Parental satisfaction was very high, but cost of 3000 Taka ($US 38.48) was deemed unaffordable by 59%. CONCLUSIONS: The outcomes in young children after 2 years of Ponseti treatment for clubfoot deformity showed that 99% were able to walk independently. The assessment tool developed for this study avails ongoing monitoring. Without the patronage of WFL, most of these children would not have had access to treatment, and be unable to walk. LEVEL OF EVIDENCE: Level II-lesser-quality prospective study.

What is the best evidence for the treatment of slipped capital femoral epiphysis?

BACKGROUND: There are many different treatment methods for slipped capital femoral epiphysis (SCFE). It was the purpose of this study to review the results from the literature for different methods of SCFE treatment and on the basis of level of evidence determine the current best evidence treatment. METHODS: A systematic review of the literature was undertaken. Treatment results were grouped into 2 categories. The first was all methods without surgical hip dislocation, and the second was all methods in which surgical dislocation was used. RESULTS: For stable SCFEs without surgical dislocation, the best recommended treatment (mostly level IV) recommends in situ single screw fixation over multiple pin fixation, epiphysiodesis, osteotomy, or spica cast. For the unstable SCFEs without surgical dislocation (all level IV), the best recommended treatment is urgent reduction with decompression and internal fixation. For both stable and unstable SCFEs, the short-term small series in the literature (all level IV) does not demonstrate an advantage or improvement in outcomes compared with in situ single screw fixation for stable SCFE and urgent reduction, decompression, and internal fixation in unstable SCFEs. CONCLUSIONS: A systematic review of the literature recommends on the basis of level of evidence that the best treatment for a stable SCFE is single screw in situ fixation and for unstable SCFEs urgent gentle reduction, decompression, and internal fixation. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.

Surgeon age as the major factor in recommendation of uni-compartmental knee replacement versus high tibial osteotomy: a case study in orthopaedic decision making.

This case report concerns surgical decision making. The subject is a 59 year old male orthopaedic surgeon with medial compartment knee arthritis. Both high tibial valgus osteotomy and uni-compartmental knee replacement would be appropriate with similar outcomes reported in the literature. Surprisingly, almost all young surgeons recommended a uni-compartmental knee replacement and almost all older surgeons recommended a high tibial osteotomy. We discuss the reasons that surgeon age, which is clearly irrelevant to the optimal decision, is the dominant determinant of surgical recommendation for this patient.

Bracing following correction of idiopathic clubfoot using the Ponseti method.

The Ponseti method for the management of idiopathic clubfoot has recently experienced a rise in popularity, with several centers reporting excellent outcomes. The challenge in achieving a successful outcome with this method lies not in correcting deformity but in preventing relapse. The most common cause of relapse is failure to adhere to the prescribed postcorrective bracing regimen. Socioeconomic status, cultural factors, and physician-parent communication may influence parental compliance with bracing. New, more user-friendly braces have been introduced in the hope of improving the rate of compliance. Strategies that may be helpful in promoting adherence include educating the family at the outset about the importance of bracing, encouraging calls and visits to discuss problems, providing clear written instructions, avoiding or promptly addressing skin problems, and refraining from criticism of the family when noncompliance is evident. A strong physician-family partnership and consideration of underlying cognitive, socioeconomic, and cultural issues may lead to improved adherence to postcorrective bracing protocols and better patient outcomes.

Evaluation of a disease-specific instrument for idiopathic clubfoot outcome.

UNLABELLED: In 2001, Roye et al. developed a disease-specific instrument (DSI) to measure outcomes of treatment for clubfoot. We assessed this instrument using a cohort of 62 patients, ages 5 through 12 years (mean, 8.6 years), with idiopathic clubfoot who were treated as infants by various methods. Treatment groups were defined by whether the patient received joint-invasive surgery (posterior or posteromedial release surgery) or joint-sparing treatment only (manipulation and casting with or without tendo-Achilles lengthening or anterior tibial tendon transfer). The DSI scales demonstrated internal consistency reliability of 0.74 to 0.85 using Cronbach's alpha. Higher (better) DSI scores were associated with "excellent" general health ratings and better health-related quality of life; lower DSI score were related to special healthcare needs. Patients treated using joint-sparing techniques only (eg, Ponseti technique) had higher DSI scores than those who had received joint-invasive surgery. DSI scores for patients who had received posterior or posterior medial release surgery were very similar to those reported by Roye et al. in New York for a comparable group of patients. Our findings suggest the DSI is sensitive to differences in treatment technique or underlying severity of disease. These data support the use of the Roye DSI as an outcome measure for idiopathic clubfoot in children. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Two novel point mutations in the long-range SHH enhancer in three families with triphalangeal thumb and preaxial polydactyly.

Spatio-temporal expression of sonic hedgehog (SHH) is driven by a regulatory element (ZRS) that lies 1 Mb upstream from SHH. Point mutations within the highly conserved ZRS have been described in the hemimelic extra toes mouse and in four families with preaxial polydactyly [Lettice et al., 2003]. Four North American Caucasian families were identified with autosomal dominant triphalangeal thumb. DNA from 20 affected and 36 unaffected family members was evaluated by sequence analysis of a 774-bp highly conserved ZRS contained within LMBR1 intron 5. Mutations within ZRS were identified in three of four families. In pedigree A and C, a novel A/G transition was identified near the 5' end of ZRS at bp 739 that segregated with disease or carrier status. Pedigree A, described previously [Dobbs et al., 2000], is a large family with 19 affected members who exhibit a milder phenotype, including predominantly triphalangeal thumbs and low penetrance (82%) relative to other families. Pedigree C is a small family with two affected family members with triphalangeal thumb, and one affected with both triphalangeal thumb and preaxial polydactyly. A novel C/G mutation at bp 621 was identified in pedigree B that segregated with the disease in all four affected individuals who manifested both preaxial polydactyly and triphalangeal thumb. Both mutations alter putative Cdx transcription factor binding sites. Mutations within ZRS appear to be a common cause of familial triphalangeal thumb and preaxial polydactyly. A genotype/phenotype correlate is suggested by pedigree A, whose mutation lies near the 5' end of ZRS; this family demonstrates a higher rate of nonpenetrance and milder phenotype. However, modifier genes may be contributing to the milder phenotype in this family.

Treatment of a recurrent clubfoot deformity after initial correction with the Ponseti technique.

Early recognition and appropriate treatment of recurrent deformity (relapse) is an important component of the Ponseti technique of clubfoot correction. After correction of a clubfoot deformity by the Ponseti technique, relapse usually involves equinus and varus of the hindfoot. Cavus and adductus rarely recur to a clinically significant degree. Clubfoot recurs most frequently and quickly while the foot is rapidly growing-during the first several years of life. Recurrence of deformity will almost always occur, even after complete correction with the Ponseti technique, if appropriate bracing is not used. Treatment of clubfoot relapse in infants and toddlers is identical to the original correction maneuver. In a patient approximately 2.5 years of age, a relapse can be treated with anterior tibial tendon transfer to the third cuneiform with or without Achilles tendon lengthening. The indication for anterior tibial tendon transfer is the presence of dynamic supination during gait. After tendon transfer, bracing is no longer required because the eversion force of the transferred tendon maintains the correction. In a long-term follow-up study of patients treated by the Ponseti technique, the necessity for anterior tibial tendon transfer did not compromise the outcome with respect to level of pain and functional limitations. Because anterior tibial tendon transfer is joint sparing, the foot retains maximal strength and suppleness. Good long-term results can be anticipated despite clubfoot relapse.

Medium-term follow-up of Achilles tendon lengthening in the treatment of ankle equinus in cerebral palsy.

INTRODUCTION: The optimal treatment for equinus of the ankle in ambulatory patients with cerebral palsy is not known. This study assessed the medium term follow-up results of treatment of spastic ankle equinus deformity in cerebral palsy using Hoke or coronal Z-lengthening of the Achilles tendon. It was hypothesized that the use of Achilles tendon lengthening (TAL) as a treatment for spastic ankle equinus during gait results in a high rate of over-weakening of the triceps surae resulting in crouch gait. We also investigated patient characteristics that could identify which patients are at risk for crouch gait due to triceps surae weakening from Achilles tendon lengthening. MATERIALS AND METHODS: Seventy-nine patients (114 procedures) who had undergone Achilles lengthening were retrospectively reviewed to determine how many patients developed crouch gait with dorsiflexion of the ankle throughout stance phase requiring anterior-floor-reaction bracing. The following patient characteristics were evaluated: age at surgery, geographic type of cerebral palsy, length of follow-up, need for anterior-floor-reaction bracing, length of time after surgery when brace was prescribed, age at time of need for bracing, side of surgery, technique used, additional procedures performed at time of TAL, previous or later procedures performed, and walking ability. RESULTS: The average age at the time of TAL was 7 years and 3 months, and the average follow-up was seven years. The geographic type of cerebral palsy greatly affected the outcome. None of the twenty-three hemiplegic patients required bracing. Fourteen of 34 (41%) patients with spastic diplegia and seven of fourteen (50%) patients with spastic quadriplegia required bracing. There was no significant difference in outcome between the Hoke and the Z-lengthening procedures. Patients who underwent more procedures and bilateral procedures were more likely to require anterior-floor-reaction bracing. CONCLUSIONS: Achilles tendon lengthening as practiced by the senior author results in a high rate of over weakening of the triceps surae as defined by the need for a floor reaction brace. Results are best in patients with hemiplegia and non-hemiplegic patients who require only single leg surgery, and who do not require concomitant or subsequent surgery. Alternative treatment, such as gastrocnemius fascial lengthening, or non-surgical treatment may be the optimal treatment of ambulatory patients with spastic diplegia and quadriplegia who have spastic ankle equinus during gait.

Slipped capital femoral epiphysis in down syndrome.

Slipped capital femoral epiphysis (SCFE) and Down syndrome are both uncommon in the population at large, and rarely are both conditions present in a single individual. Institutional records were searched for both Down syndrome and SCFE. At least 2 years of follow-up was required. Eight patients were identified. At presentation four patients could not walk due to pain and four could walk. Six of eight hips presented with grade III SCFE. Four hips were treated with internal fixation in situ and four were manipulatively reduced in the operating room at the time of fixation with percutaneous screws or pins. Three hips healed uneventfully. Five hips developed aseptic necrosis (three partial, two whole head). This small retrospective study suggests an extremely high rate of complications in adolescents with Down syndrome and SCFE.

Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot. METHODS: Consecutive case series were conducted from January 1991 through December 2001. A total of 157 patients (256 clubfeet) were evaluated. All patients were treated by serial manipulation and casting as described by Ponseti. Main outcome measures included initial correction of the deformity, extensive corrective surgery rate, and relapses. RESULTS: Clubfoot correction was obtained in all but 3 patients (98%). Ninety percent of patients required