The Overcorrected Clubfoot in Children.

Clubfoot overcorrection can develop gradually over years and is characterized in school age by hindfoot valgus position due to excessive rigid peritalar eversion, sometimes accompanied by supramalleolar valgus malalignment. Surgical treatment is recommended in severe cases and consists of bony realignment at the peritalar complex by osteotomy or fusion, correction of the supramalleolar valgus deformity in younger children by hemiepiphyseodesis, or osteotomy in adolescents. In addition, dorsal bunion requires stabilization of the medial tarsometatarsal ray and transfer of the tendons of Mm. tibialis anterior and flexor hallucis longus.

Radiological tarsal bone morphology in adolescent age of congenital clubfeet treated with the Ponseti method.

BACKGROUND: Major abnormalities of tarsal bone shape after surgical clubfoot treatment are well known from the literature. The Ponseti method has gained widespread acceptance in primary treatment of congenital clubfeet. Despite the longtime experience, data regarding the development of tarsal bones after this treatment are still rare. The aim of the study was therefore to evaluate radiographic parameters describing tarsal bone shape of clubfeet after Ponseti treatment and compare them to age-matched healthy feet. METHODS: Twenty two consecutive severe clubfeet in 14 patients were investigated by repeated diagnostic ultrasound during the corrective process. Extent and temporal course of correction were documented with standardized X-rays after a mean follow-up of 12 years (between the ages of 10-14 years) and compared to a group of age-matched normal feet. RESULTS: Reliability testing for all X-ray parameters showed good to excellent results. In comparison to the control group, all parameters except the radius of the trochlea (RT) were significantly altered in clubfeet with highest differences shown for the anterior talar motion segment (ATM), talonavicular coverage (TNC) and the talometatarsal index (TMT-Index). Differentiation between minor and major deformities showed significant differences only for the front tarsal index (FTI). CONCLUSIONS: Tarsal bone shape of clubfeet treated by the Ponseti method differs significantly from normal feet. One of the most pronounced and clinically relevant difference of the clubfoot talus compared to the normal talus is the markedly reduced anterior talar motion segment.

Heat stress and cow factors affect bacteria shedding pattern from naturally infected mammary gland quarters in dairy cattle.

Mastitis-causing pathogens are shed from infected mammary gland quarters and thus contribute to an increased risk of new intramammary infections. The objective of the current study was to investigate the shedding characteristics of various mastitis-causing pathogens and associated animal-specific (somatic cell score and parity) and environmental (heat stress) factors. In a longitudinal study, infected udder quarters were sampled consecutively on 5 dairy farms in Germany. To capture climatic factors, temperature-humidity index (THI) was calculated. In the laboratory analysis, the pathogens and their counts in the milk samples were determined. A generalized linear mixed model with gamma link was used to evaluate the factors influencing pathogen-shedding characteristics. The variables somatic cell count, pathogen, parity, and THI had significant influence on pathogen shedding. Staphylococci were shed in lower values than streptococci. The pathogen shedding from mammary gland quarters with intramammary infections was higher in the first and second lactation than in higher lactations. Exceeding the THI threshold 60 resulted in higher pathogen counts on the same day. This was only caused by the pathogens yeasts and Streptococcus uberis. Possible mechanisms causing differences in pathogen shedding are changes in the counts due to influenced milk quantities, better growth conditions at higher temperatures, or altered immunological reactions. The mechanisms often remain speculative and require further investigation. The study underlines the contribution of cows with high somatic cell counts regarding the transmission of mastitis pathogens within a herd. Furthermore, it becomes clear that heat stress in Germany influences udder health and that prevention measures are useful.

Is it possible to define reference values for radiographic parameters evaluating juvenile flatfoot deformity? A case-control study.

BACKGROUND: Numerous radiographic parameters are described to evaluate juvenile flexible flatfeet. Reference values for these measurements are based on few studies. The purpose of this study was to determine boundary values among the most widely used radiographic measurements to evaluate juvenile flatfeet. METHODS: Twenty-two patients with normal hind-, midfoot configuration (group A: control group; 22 ft, mean age: 12,1 years) and 19 patients with flatfoot deformity (group B: study group; 22 ft, mean age: 12,4 years) were retrospectively analyzed. Nine radiographic parameters were measured (Talocalcaneal-angles, Calcaneal-pitch-angle, Costa-Bartani-angle, Talo-metatarsal-I-angles, Talo-first-metatarsal-base-angle, Talo-navicular-coverage, Calcaneus-fifth-metatarsal-angle). ROC curve analysis was used to calculate optimal differentiating thresholds of each parameter. RESULTS: Four out of nine parameters (TC-dp, TC-lat, Calc-MTV, Calc-P) were not statistically different between the groups and their ability to distinct between normal foot and flatfoot was low (AUC values = 0,660 - 0,819). Calculation of reference values for these parameters was not performed due to threshold ranges between the groups of > 10°. Reference values could be defined only for three parameters: TMTInd >(-)31°, TMTIB >(-)7,5°, TMT-lat > (-)13,5°. The TMTInd was shown to be a very reliable and valid combination of two measurements (TMTIB and TMT-lat) in the differentiation of normal feet and flatfeet (AUC = 0,998). CONCLUSION: The calculation of reference values for established radiographic parameters used to evaluate juvenile flatfeet is difficult for most parameters. The TMTInd as a combination of TMTIB and TMT-lat has been shown to be reliable and valuable to distinct normal feet from flatfeet.

Non-S. aureus staphylococci (NAS) in milk samples: Infection or contamination?

Non-S. aureus staphylococci (NAS) are the most frequently isolated pathogens from bovine milk and can cause intramammary infections (IMI). They can also be found in teat canals, on bovine skin and in cows' environment, which may lead to unnoticed contamination of milk samples. The aim of this study was to investigate the role of NAS species as mastitis-causing pathogens or contaminants, and to identify possible differences between NAS species. A longitudinal study was conducted with consecutive milk sampling in five German dairy herds. Species identification was performed using matrix-assisted laser desorption ionization-time of flight mass spectrometry. Infections were distinguished from contaminations using two different definitions based on the repeated detection of an NAS species. Of 15 NAS species found, eight and ten, respectively, were associated with an IMI. Staphylococcus simulans and S. chromogenes were associated with IMI in more than 90 % of the findings. S. warneri, S. xylosus, S. microti, S. haemolyticus, and S. succinus seem to be frequent causes of IMI as well as contaminants. If a species-differentiation is available after cultivating NAS, the findings should be interpreted in consideration of the observations made in this study, whether it is more likely a question of a contaminant or a cause of intramammary infection. The bacteria shedding intensity of the NAS species with a more substantially adverse effect on udder health seems to be higher than that of the less important NAS pathogens.

Early results after tibialis anterior tendon transfer for severe varus in total ankle replacement.

BACKGROUND: Treatment of severe ankle arthritis with varus malalignment remains controversial. METHODS: In 14 consecutive total ankle replacements (TAR) with tibiotalar varus malalignment of above 15 (range, 16 to 41) degrees, a complete transfer of the tibialis anterior tendon together with other soft-tissue and bony realignment measures was added to the primary procedure. RESULTS: After mean followup time of 33.4 (range, 21 to 49) months, only one case showed minor tibiotalar tilt in the frontal plane. The overall clinical results were good to excellent in all but two cases with an average AOFAS-score of 86.4 (range, 70 to 98) points. However, three cases of tibial nerve neuropathy due to entrapment or overtensioning were observed; one of these cases developed clinical problems with incomplete recovery. CONCLUSION: Tibialis anterior tendon transfer can be recommended in conjunction with TAR in cases of varus malalignment with severe muscular or ligamentous imbalance with neuropathy of the tibial nerve being the main complication.

[Resection of talocalcaneal coalition in children and adolescents without and with osteotomy of the calcaneus]. / Die Resektion der talokalkanearen Coalitio im Kindesund Adoleszentenalter ohne und mit Stellungskorrektur.

OBJECTIVE: Resection of the painful medial talocalcaneal fibrocartilaginous or bony bridge, thereby restoration of mobility of the peritalar joint complex; in case of flatfoot deformity realignment of the hindfoot and midfoot by medial sliding calcaneal osteotomy and in some cases correction of equinus contracture by intramuscular lengthening of the gastrocnemius muscle. INDICATIONS: Before growth arrest: --Bony or fibrocartilaginous bridge at the medial or dorsomedial talocalcaneal region with or without pain. --Rigid flatfoot deformity caused by talocalcaneal coalition. After growth arrest: --Resection is indicated only in case of local pain or hindfoot deformity. CONTRAINDICATIONS: Resection is not indicated in cases without local pain or deformity after growth arrest or in cases with marked osteoarthritis of the talonavicular or talocalcaneal joint. If the cross section of the bony bridge exceeds 20 x 30 mm, resection is not recommended. SURGICAL TECHNIQUE: Longitudinal incision at the medial facet of the subtalar joint. Exposure of the bony bridge. Subsequent resection until the talocalcaneal joint line is clearly visible. Gentle mobilization of the contracted subtalar joint to regain inversion. After resection of the coalition the distance between the corresponding bone areas should measure at least 10 mm. Bone wax is used to prevent bleeding and the gap is filled with fatty tissue. Additionally, in some cases an intramuscular lengthening of the contracted gastrocnemius muscle is necessary. In case of flatfoot deformity alignment should be restored by calcaneal lengthening and/or medializing sliding calcaneal osteotomy. POSTOPERATIVE MANAGEMENT: The lower leg is immobilized in a cast for at least 2 weeks postoperatively; additional procedures require an extended period of immobilization. Afterwards, range of motion exercises are useful to regain motion of the peritalar joint complex. RESULTS: 24 resections of a talocalcaneal coalition in 22 pediatric or adolescent patients were carried out. The coalition was located at the medial joint facet in 18 cases and in the dorsomedial talocalcaneal region in seven cases (in one patient combination of both). Three patients presented with an additional calcaneonavicular coalition. A talocalcaneal bone bridge of the entire joint was found in five cases. In seven patients an intramuscular lengthening of the gastrocnemius muscle was necessary. In nine patients a calcaneal lengthening procedure, and in five patients a calcaneal sliding osteotomy were added. A lengthening in the region of a calcaneocuboid synostosis was untertaken in one case. After a mean follow-up of 21.2 months 17 patients are completely or nearly pain-free. Five patients still complain of pain, but are improved. Two patients were lost to follow-up.