Ponseti Idiopathic and Nonidiopathic Clubfoot Correction With Secondary Surgeries.

The Ponseti method has revolutionized clubfoot treatment for not only idiopathic clubfoot but also non-idiopathic clubfoot. This study aimed to validate the existing literature with respect to the Ponseti method serving as first line treatment for clubfoot. The purpose of this study was to compare clubfoot type and recurrence with secondary surgical procedures following Ponseti method. Kaiser Permanente Northern California database was queried to identify clubfoot children under 3 years old with a consecutive 3-year membership. Associated comorbidities and operative procedure codes were identified. Chart review was performed on all surgical clubfoot patients who completed Ponseti method. Patients' average age at time of surgery, frequency of surgeries, and types of procedures performed were recorded. A logistic regression analysis assessed the adjusted association between surgery status and clubfoot type. Clubfoot incidence was about 1 in 1000 live births. Of the 375 clubfoot children, 334 (89%) were idiopathic and 41 (11%) were non-idiopathic. In the total study population, 82% (n = 309) patients maintained Ponseti correction without a secondary surgery; 66 patients (18%) underwent subsequent secondary surgeries. The non-idiopathic clubfoot underwent surgery more frequently compared to idiopathic clubfoot patients (41.5% vs 14.7%, respectively, p = .0001). Non-idiopathic clubfoot children underwent surgery at a younger age. This study validates the Ponseti method is the first line treatment for clubfoot correction despite etiology. However, patients with recurrent clubfoot may require secondary surgery following Ponseti method. Clubfoot recurrence surveillance is key for identifying early symptomatic recurrence in order to minimize foot rigidity and the need for osseous procedures.

Anatomic Determinants of Sacral Dysmorphism and Implications for Safe Iliosacral Screw Placement.

BACKGROUND: Upper sacral segment dysplasia increases the risk of cortical perforation during iliosacral screw insertion. Dysmorphic sacra have narrow and angled upper osseous corridors. However, there is no validated definition of this anatomic variation. We hypothesized that pelves could be quantitatively grouped by anatomic measurements. METHODS: One hundred and four computed tomography (CT) scans and virtual outlet views of uninjured pelves were analyzed for the presence of the five qualitative characteristics of upper sacral segment dysplasia. CT scans were reformatted to measure the cross-sectional area, angulation, and length of the osseous corridor. Principal components analysis was used to identify multivariable explanations of anatomic variability, and discriminant analysis was used to assess how well such combinations can classify dysmorphic pelves. RESULTS: The prevalences of the five radiographic qualitative characteristics of upper sacral segment dysplasia, as determined by two reviewers, ranged from 28% to 53% in the cohort. The rates of agreement between the two reviewers ranged from 70% to 81%, and kappa coefficients ranged from 0.26 to 0.59. Cluster analysis revealed three pelvic phenotypes based on the maximal length of the osseous corridor in the upper two sacral segments. Forty-one percent of the pelves fell into the dysmorphic cluster. The five radiographic qualitative characteristics of dysmorphism were significantly more frequent (p < 0.007) in this cluster. A combination of upper sacral coronal and axial angulation effectively explained the variance in the data, and an inverse linear relationship between these angles and a long upper sacral segment corridor was identified. A sacral dysmorphism score was derived with the equation: (first sacral coronal angle) + 2(first sacral axial angle). An increase in the sacral dysmorphism score correlated with a lower likelihood of a safe transsacral first sacral corridor. No subjects with a sacral dysmorphism score >70 had a safe transsacral first sacral corridor. CONCLUSIONS: Sacral dysmorphism was found in 41% of the pelves. The major determinants of sacral dysmorphism are upper sacral segment coronal and axial angulation. The sacral dysmorphism score quantifies dysmorphism and can be used in preoperative planning of iliosacral screw placement.

An observational cohort study of the adoption of elastic stable intramedullary nailing for the treatment of pediatric femur fractures in Kumasi, Ghana.

BACKGROUND: In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5-11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique. METHODS: An observational cohort study that included 84 pediatric patients ages 3-14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups. RESULTS: Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6-54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants. CONCLUSIONS: The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.

Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United States.

BACKGROUND: Musculoskeletal disease is a growing burden in low- and middle-income countries (LMICs), yet little research exists to describe the problem. The purposes of this study were to characterize orthopedic surgery in an LMIC and compare the findings to those from a developed country. METHODS: The study location was the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic surgeon, resident, and postgraduate training program numbers were compared to analogous data from a developed nation, the United States. Annual surgical volumes were compared to those at a level I trauma center in the United States, the San Francisco General Hospital (SFGH). RESULTS: There were 24 surgeons in Ghana compared to 23,956 in the United States. There were 7 orthopedic residents and 1 residency program in Ghana versus 3,371 residents and 155 residencies in the United States. Annual case volume was 2,161 at KATH and 2,132 at SFGH. Trauma accounted for 95 % of operations at KATH compared to 65 % at SFGH. The proportion of surgeries devoted to severe fractures was 29 % at KATH compared to 12 % at SFGH. Infections comprised 15 % of procedures at KATH and 5 % at SFGH. CONCLUSIONS: Annual case volume at a referral hospital in an LMIC is equivalent to that of a level I trauma center in an industrialized country. Total case volume is similar, but the LMIC institution manages a disproportionately large number of trauma cases, severe fractures, and infections. There is a large burden of orthopedic disease in the developing nation, and there are too few providers and training programs to address these conditions.

High-risk pediatric orthopedic pitfalls.

Pediatric patients often present to the emergency department with orthopedic pathology that can challenge the emergency department physician. This article focuses on key diagnoses that are frequently mismanaged. These diagnoses require specific knowledge to execute appropriate treatment. Pediatric fractures, compartmental syndrome, bone and joint infection, limp and non-accidental trauma are reviewed. Approach to the workup of these patients and treatment algorithms are discussed.

Atrial fibrillation propagates through gaps in ablation lines: implications for ablative treatment of atrial fibrillation.

BACKGROUND: It has been hypothesized that atrial lesions must be transmural to successfully cure atrial fibrillation (AF). However, ablation lines often do not extend completely across the atrial wall. OBJECTIVE: The purpose of this study was to determine the effect of residual gaps on conduction properties of atrial tissue. METHODS: Canine right atria (n = 13) were isolated, perfused, and mounted on a 250-lead electrode plaque. The atria were divided with a bipolar radiofrequency ablation clamp, leaving a gap that was progressively narrowed. Conduction velocities at varying pacing rates and AF frequencies were measured before and after ablations. AF was induced with an extra stimulus and acetylcholine. RESULTS: Gap widths from 11.2 to 1.1 mm were examined. Conduction velocities through gaps were dependent cycle length (P = .002) and gap size (P <.001). Overall, 253 (97%) of a total of 260 gaps allowed paced propagation; 51 (91%) of 56 gaps 1-3 mm in width permitted paced propagation, as did 202 (99%) of 204 gaps >or=3.0 mm. Similarly, 253 (97%) of a total of 260 gaps allowed propagation of AF. For AF, 51 (93%) of 55 gaps 1-3 mm allowed AF to pass through, as did 202 (99%) of 205 gaps >or=3.0 mm. Gaps as small as 1.1 mm conducted paced and AF impulses. CONCLUSIONS: Conduction velocities were slowed through residual gaps. However, propagation of wave fronts during pacing and AF occurred through the majority of residual gaps, down to sizes as small as 1.1 mm. Leaving viable tissue in ablation lines for the treatment of AF could account for failures.

Aortic valve replacement in octogenarians: risk factors for early and late mortality.

BACKGROUND: Excellent outcomes after aortic valve replacement (AVR) in elderly patients can be achieved, yet some practitioners are reticent to refer elderly patients for surgery. This study analyzed risk factors for mortality in patients aged 80 years and older undergoing AVR with or without concomitant coronary artery bypass grafting (CABG). METHODS: A retrospective review was performed of 245 patients (129 women) with a mean age of 83.6 +/- 2.9 years who had AVR with (n = 140) or without CABG (n = 105) at a single institution from 1993 to 2005. Data were analyzed with a multivariate logistic regression for predictors of operative mortality, Kaplan-Meier estimates of survival, and a Cox multivariate proportional analysis of factors influencing long-term survival. RESULTS: Mean preoperative New York Heart Association (NYHA) classification was 3.1 +/- 0.9, and 78% (192/245) of patients were classified as NYHA class III or IV. Operative (30-day) mortality was 9% (22/245). Independent risk factors for operative mortality included postoperative renal failure (odds ratio [OR], 20.9; 95% confidence interval [CI], 6.5 to 67.6; p < 0.001), postoperative permanent stroke (OR, 11.3; 95% CI, 1.7 to 75.1; p = 0.019), or intraoperative/postoperative intraaortic balloon pump (IABP) placement (OR, 14.9; 95% CI 2.9 to 75.8; p = 0.002). Survival after surgery was 82% (n = 183) at 1 year and 56% (n = 88) at 5 years. Prognostic factors for decreased long-term survival were regurgitant valve pathology (hazard ratio [HR], 6.0; 95% CI, 2.5 to 14.2; p = 0.002), intraoperative/postoperative IABP (HR, 2.9; 95% CI, 1.4 to 6.0; p = 0.010), postoperative renal failure (HR, 3.5, 95% CI, 2.2 to 5.7; p < 0.001), and postoperative stroke (HR, 7.0, 95% CI, 3.2 to 15.9; p < 0.001). Performing concomitant CABG was protective in terms of operative mortality (OR, 0.3; 95% CI, 0.09 to 0.83; p = 0.017) and improved long-term survival (HR, 0.7, 95% CI, 0.47 to 0.96; p = 0.020). Preoperative NYHA classification did not affect operative or long-term survival. CONCLUSIONS: Patients aged 80 years and older who undergo AVR have acceptable short-term and long-term survival regardless of NYHA status. Concomitant CABG improved operative and long-term survival in this population. Despite their increased age, aggressive surgical treatment is warranted for most patients.

Long-term outcomes in valve replacement surgery for infective endocarditis.

BACKGROUND: Infective endocarditis is associated with a high rate of long-term mortality. Patients with a history of intravenous drug use (IVDU) are at increased risk for infective endocarditis. However, few studies have reported results of surgical treatment on this population. We present 19.5 years of experience with surgically treated patients with infective endocarditis. METHODS: A retrospective study of all cardiac surgeries with a diagnosis of infective endocarditis at a single institution from 1986 to 2005 was performed. Logistic stepwise regression with an end point of operative mortality was done. Variables were age, gender, race, history of drug use, previous valve surgery, and previous valve replacement. Perioperative and outcome variables were compared between IVDU and non-IVDU populations. RESULTS: The IVDU population required surgery at a younger age (39 +/- 9 years versus 54 +/- 15 years; p < 0.001). Overall operative mortality was 12% (41/346). The perioperative complication rate was similar for both groups. When adjusted for age, the two groups had similar long-term survival (p = 0.78). Kaplan-Meier estimator showed that survival at 10 and 15 years was 66% and 54% for IVDU and 56% and 42% for non-IVDU (number at risk, 19, 11, and 61, 28, respectively; p = 0.137). Reoperation for recurrent infective endocarditis was necessary in 9 (17%) of 52 of the IVDU group versus 14 (5%) of 270 of the non-IVDU group (p = 0.03). CONCLUSIONS: Patients with a history of IVDU required reoperation for recurrent infective endocarditis at a significantly higher rate than the non-IVDU patients. Long-term survival was similar between the younger IVDU population and the older non-IVDU population. Anticipated life span is one of many factors when considering prosthetic valve choice in this population.

Epicardial microwave ablation on the beating heart for atrial fibrillation: the dependency of lesion depth on cardiac output.

BACKGROUND: Microwave energy is commonly used on the beating heart to create lesions for the surgical treatment of atrial fibrillation. However, lesion transmurality is likely to depend on several factors including tissue thickness and blood flow. This study was designed to determine the effect of cavitary blood flow on transmurality of acute atrial lesions with the FLEX 10 (Guidant Corporation, Santa Clara, Calif) microwave device. METHODS: Six pigs underwent median sternotomy and were placed on cardiopulmonary bypass. Microwave lesions on the atrium were performed for 60 seconds at 65 Watts at 4 different levels of cardiac output by varying cardiopulmonary bypass flow rates. Cardiac output was measured with a pulmonary artery flow probe. Four additional lesions on 2 animals were done for 120 seconds at 65 Watts with 0.0 to 0.5 L/min cardiac output. The animals were sacrificed, and tissue was stained with 2,3,5-triphenyltetrazolium chloride and sectioned at 5-mm intervals. Lesion depth and width were determined from photomicrographs. RESULTS: Sixty-second lesions were transmural in 90%, 65%, 54%, and 46% of atrial sections at cardiac output of 0.0 to 0.5 L/min, 0.6 to 1.9 L/min, 2.0 to 3.9 L/min, and 4.0 L/min or greater, respectively (P < .001). When ablations were performed for 120 seconds with a cardiac output of 0.0 to 0.5 L/min, 100% of lesions were transmural. Lesion width was also related to cardiac output, with the widest lesions produced when cardiac output was 0.0 to 0.5 L/min. CONCLUSIONS: Acute microwave ablation lesion depth and width are strongly dependent on the magnitude of cardiac output. Transmural lesions can be reliably produced on the porcine heart only while on cardiopulmonary bypass.