Ponseti Method After Walking Age - A Multi-Centric Study of 429 Feet: Results, Possible Treatment Modifications and Outcomes According to Age Groups.

Objective: Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years. Results: Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance. Conclusion: The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age.Level of Evidence: IV.

Synovectomy using Samarium-153 Hydroxyapatite in the Elbows and Ankles of Patients with Hemophilic Arthropathy.

This study aimed to evaluate synovectomy with samarium-153 hydroxyapatite (153Sm-HA) in synovitis of the elbows and ankles of hemophilic patients. The synovectomy was performed using 185 MBq of 153Sm-HA in 166 joints of 82 hemophilic patients, with a mean age of 24.4 years and follow-up of 12 and 42 months, comprising 63 ankles and 84 elbows. Arthropathy was characterized by recurrent joint bleeding. Episodes of hemarthrosis, use of clotting factors, and pain intensity were evaluated before and after treatment. Scintigraphic controls and adverse effects were also considered. Statistical analyses used P ≤ 0,005 as significant. The results pointed that (a) reduction in hemarthrosis was 78% and 68% in elbows and 82% and 72% in ankles; (b) use of clotting factors was 80% and 70% in elbows and 85% and 75% in ankles; (c) pain was 37% and 34% in elbows and 61% and 57% in ankles, after 12 and 42 months, respectively. Three cases of mild reactive synovitis were observed in ankles and four in elbows. There was no joint effusion in any of the cases. In conclusion, the use of 153Sm-HA in elbows and ankles was effective, very safe, minimally invasive and showed consistency over time, is another material to utilize in median hemophilic joints.

ORTHOPEDIC APPROACH TO PECTUS DEFORMITIES: 32 YEARS OF STUDIES.

The authors summarize a 32-year experience in the study and in the non-operative approach of pectus carinatum and pectus excavatum. Data of 4,012 patients with pectus deformities were collected from 1977 to January 2009, allowing evaluation on the etiology, pathogenesis and treatment of these deformities. Growth disturbances of anterior chest wall bones and cartilages were detected in imaging studies. Heredity, and biomechanical factors, like respiratory disturbances and scoliosis were noticed in more than 40% of the patients. The method of dynamic remodeling of the thorax - compressive orthoses simultaneously to exercises practice - was indicated in 2453 patients. Concomitant treatment with bending brace was provided in patients with 20° to 52° scoliosis. Of pectus patients with treatment indication, 1717 returned for re-evaluation: 1632 children and adolescents and 85 adults. Good results were seen in 60.6% of children and adolescents and in 27% of adults treated. No scoliosis patient presented curve worsening, and a case of 52° presented an improvement of 20° in the scoliosis with the treatment. Disturbances in the growth of the sternum and costal arches, as well as biomechanical factors related to the pathogenesis of pectus deformities, demonstrate how these deformities are correlated to orthopaedics. Appropriate evaluation of the anterior chest wall and concomitant treatment with bending brace are recommended in the presence of scoliosis. The dynamic remodeling method of the thorax requires a protocol of medical actions for a successful treatment.