Ten cold clubfeet.

Background and purpose - Idiopathic clubfeet are commonly treated with serial manipulation and casting, known as the Ponseti method. The use of Plaster of Paris as casting material causes both exothermic and endothermic reactions. The resulting temperature changes can create discomfort for patients. Patients and methods - In 10 patients, we used a digital thermometer with a data logger to measure below-cast temperatures to create a thermal profile of the treatment process. Results - After the anticipated temperature peak, a surprisingly large dip was observed (Tmin = 26 °C) that lasted 12 hours. Interpretation - Evaporation of excess water from a cast might be a cause for discomfort for clubfoot patients and subsequently, their caregivers.

Long-term outcomes of slipped capital femoral epiphysis treated with in situ pinning.

PURPOSE: Slipped capital femoral epiphysis (SCFE) is the commonest hip disorder in adolescents. In situ pinning is commonly performed, yet lately there has been an increase in procedures with open reduction and internal fixation. These procedures, however, are technically demanding with relatively high complication rates and unknown long-term outcomes. Nevertheless, reports on long-term results of in situ fixation are not equivocal. This study evaluates the possible higher risk of worse outcome after in situ pinning of SCFE. METHODS: All patients treated for SCFE with in situ fixation between 1980 and 2002 in four different hospitals were asked to participate. Patients were divided into three groups, based on severity of the slip. Patients were invited to the outpatient clinic for physical examination and X-rays, and to fill out the questionnaires HOOS, EQ5D, and SF36. ANOVA and chi-squared tests were used to analyze differences between groups. RESULTS: Sixty-one patients with 78 slips filled out the questionnaires. Patients with severe slips had worse scores on HOOS, EQ5D, and SF36. 75 % of patients with severe slips had severe osteoarthritis, compared to 2 % of mild and 11 % of moderate slips. CONCLUSION: Hips with mild and moderate SCFE generally had good functional and radiological outcome at a mean follow-up of 18 years, and for these hips there seems to be no indication for open procedures. However, severe slips have a significantly worse outcome, and open reduction and internal fixation could therefore be considered.

Conservative treatment of a pathological fracture in a 3-year-old boy with primary hyperoxaluria type I.

Primary hyperoxaluria type I is a rare inherited disease that presents a disturbed metabolism of glyoxylate. Consequently, patients suffer from hyperoxaluria, leading to renal failure and subsequent skeletal calcium oxalate deposition. Areas with high concentrations of calcium oxalate, so-called dense metaphyseal bands, are at risk for pathological fracturing. The primary disease is treated by combined liver-kidney transplantation, although pathological fracturing also occurs in the posttransplant period. In the current case, we present a 3-year-old boy with a pathological fracture of his right femur, 2 years after liver-kidney transplantation. We opted for a conservative regime, leading to good fracture healing. As there are limited data in the literature regarding treatment of fractures in these patients, it is important to notify the outcome of conservative treatment of pathological fractures in patients with primary hyperoxaluria type I.

Long-term results of the posteromedial release in the treatment of idiopathic clubfoot.

BACKGROUND: Short-term follow-up studies show good results in foot function, after surgical treatment of idiopathic clubfeet. Long-term follow-up studies are rare and probably represent a mixture of experience of different treating orthopedic surgeons. The purpose of this study is to present the long-term results of the posteromedial release (PMR) in congenital clubfoot treatment of 1 treating surgeon. MATERIALS AND METHODS: Thirty-eight patients with 58 clubfeet had an a la carte PMRe, performed by 1 experienced pediatric orthopedic surgeon before the age of 2 years. This group had a mean follow-up of 16 years (range 13 to 24 years). All patients were interviewed and examined. Thereafter, the standing anteroposterior and lateral radiographs of the feet were taken. The results of the treatment were graded according to the system of Laaveg and Ponseti, and with the radiographs the grade of osteoarthritis was determined. The results were compared with the controlateral normal feet. RESULTS: In 53 feet, the mean rating was 80.6 points (range 43 to 97), according to the system of Laaveg and Ponseti. There were 15 excellent, 17 good, 13 fair, and 8 poor results. The majority of patients had the limitation of foot function with a significant decrease in dorsiflexion of 31% and a significant decrease of pronation-suppination of 24%. The grade of osteoarthritis was consistently higher in the clubfeet than in the controlateral normal feet. Five feet (9%) needed an additional bony procedure because of pain and overcorrection of the clubfeet. This was considered to be a failure of the surgical treatment. CONCLUSION: In our study population, PMR will lead to stiff, and therefore to clinical not fully functional, feet after a follow-up of 16 years. LEVEL OF EVIDENCE: Therapeutic level III.

Reliability of popliteal angle measurement: a study in cerebral palsy patients and healthy controls.

UNLABELLED: The popliteal angle is a widely used clinical measure for hamstring contracture in cerebral palsy (CP) patients and in healthy individuals. The reliability of popliteal angle measurement is being questioned. The aim of this study is to determine the reliability of popliteal angle measurement by means of visual and goniometric assessment. METHODS: Three different observers measured the popliteal angle in 15 CP patients and 15 healthy volunteers. In each subject, popliteal angles were visually estimated and measured with a blinded goniometer twice by all observers with approximately 1 hour between measurement sessions. RESULTS: All intraclass correlation coefficients (ICCs) were lower in the CP group compared with healthy controls. The ICC for intraobserver differences was higher than 0.75 for both groups. The ICC for interobserver reliability of visual estimates and goniometric measurements was low for both groups. Intermethod ICC was higher than 0.75 for both groups. CONCLUSIONS: Measurements in the CP group seemed to be less reliable than measurements in the control group. Intraobserver reliability is reasonable for both groups, but lower in CP patients than in controls. Interobserver reliability of both visual estimates and goniometrical measurements is poor. No significant differences in reliability have been found between visual estimation and goniometric measurement. Because of poor interobserver reliability of popliteal angle measurement, this should not be the only variable in clinical decision making in CP patients.

Prevention of pin tract infection in external stainless steel fixator frames using electric current in a goat model.

Pin tract infections of external fixators used in orthopaedic reconstructive bone surgery are serious complications that can eventually lead to periostitis and osteomyelitis. In vitro experiments have demonstrated that bacteria adhering to stainless steel in a biofilm mode of growth detach under the influence of small electric currents, while remaining bacteria become less viable upon current application. Therefore, we have investigated whether a 100microA electric current can prevent signs of clinical infection around percutaneous pins, implanted in the tibia of goats. Three pins were inserted into the lateral right tibia of nine goats, of which one served for additional frame support. Two pins were infected with a Staphylococcus epidermidis strain of which one pin was subjected to electric current, while the other pin was used as control. Pin sites were examined daily. The wound electrical resistance decreased with worsening of the infection from a dry condition to a purulent stage. After 21 days, animals were sacrificed and the pins taken out. Infection developed in 89% of the control pin sites, whereas only 11% of the pin sites in the current group showed infection. These results show that infection of percutaneous pin sites of external fixators in reconstructive bone surgery can be prevented by the application of a small DC electric current.

Perioperative contamination in primary total hip arthroplasty.

UNLABELLED: All surgical procedures have the risk of microbial contamination. However, procedures in which prosthetic materials are involved have a high risk for future infectious problems because of the protection offered by the biofilm mode of growth. Studies of perioperative contamination have been done on involved surgical instruments, but whether these instruments transmit contamination to the prosthesis or future site of the prosthesis is not known. The aim of this study was to detect possible bacterial contamination in total hip arthroplasty through instruments that are used at the direct site of implantation during the primary procedure. Samples of the broaches used for preparing the acetabulum and femur, and samples of the reamed acetabular and femoral bone, were collected during 67 consecutive primary total hip arthroplasties in 67 patients. Broach samples were taken at the start and end of every reaming procedure. Four hundred two samples were taken, of which 26 were found to be positive for microorganisms. In 20 patients, at least one of these positive samples had been in direct contact with the actual prosthesis site, indicating that at least 30% of the involved patients had a possible bacterial contamination when leaving the operating theater. LEVEL OF EVIDENCE: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients--with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.