Safety of anti-TNF agents in patients with compensated cirrhosis: a case-control study.

BACKGROUND: There is limited data on the use of anti-TNF agents in patients with concomitant cirrhosis. The aim of this study is to assess the safety of anti-TNF agents in patients with compensated cirrhosis who used these medications for the treatment of an underlying rheumatologic condition or IBD. METHODS: Multicenter, retrospective, matched, case-control study. A one to three case-control match was performed. Adults who received anti-TNF therapy were matched to three adults with cirrhosis who did not receive anti-TNF therapy. Patients were matched for etiology of cirrhosis, MELD-Na and age. Primary outcome was the development of hepatic decompensation. Secondary outcomes included development of infectious complications, hepatocellular carcinoma (HCC), extra-hepatic malignancy, and mortality. RESULTS: Eighty patients with cirrhosis who received anti-TNF agents were matched with 240 controls. Median age was 57.2 years. Median MELD-Na for the anti-TNF cohort was seven and median MELD-Na for the controls was eight. The most common etiology of cirrhosis was NAFLD. Anti-TNF therapy did not increase risk of decompensation (HR: 0.91, 95% CI: 0.64-1.30, p = 0.61) nor influence the time to development of a decompensating event. Anti-TNF therapy did not increase the risk of hepatic mortality or need for liver transplantation (HR: 1.18, 95% CI: 0.55-2.53, p = 0.67). Anti-TNF therapy was not associated with an increased risk of serious infection (HR: 1.21, 95% CI: 0.68-2.17, p = 0.52), HCC (OR: 0.45, 95% CI: 0.13-1.57, p = 0.21), or extra-hepatic malignancy (OR: 0.82, 95% CI: 0.29-2.30, p = 0.71). CONCLUSIONS: Anti-TNF agents in patients with compensated cirrhosis does not influence the risk of decompensation, serious infections, transplant free survival, or malignancy.

Individual and community factors contributing to anemia among women in rural Baja California, Mexico.

INTRODUCTION: Anemia is a public health concern among women in rural Baja California, Mexico. The purpose of this study was to identify the individual and community factors contributing to the disproportionately high prevalence of anemia among women in this region. METHODS: A cross-sectional study of 118 women (15-49 years) was performed in a rural colonia (small settlement) in Baja California, Mexico in 2012. Participants completed a survey comprised of demographic, socioeconomic, health, and dietary questions and provided a capillary blood sample. A portable HemoCue was used to measure hemoglobin and diagnose anemia. Anemic participants provided a venous blood sample for laboratory testing to elucidate the etiology of anemia. Anemic participants received vitamin supplements and nutritional counseling. Assessments of six local tiendas (community grocery stores) were performed to ascertain the types of food available for purchase within the community. RESULTS: Prevalence of anemia was 22% among women; laboratory tests revealed iron deficiency was the primary etiology in 80.8% of anemia cases. Other causes of anemia in women included vitamin B-12 deficiency (11.5%) and combined iron and vitamin B-12 deficiency (7.7%). Women from low SES households and women enrolled in the government assistance program Prospera were significantly more likely to be anemic (OR = 3.48, 95% CI 1.35-8.98 and OR = 2.49, 95% CI 1.02-6.09, respectively). Vitamin supplementation was significantly more common among non-anemic women (OR = 0.12, 95% CI 0.02-0.94). Dietary assessments showed limited consumption of iron absorption enhancing foods such as fruits and vegetables. Assessments of local tiendas revealed at least one type of meat and citrus fruit available for purchase at each store; however, leafy green vegetables were only available for purchase at one store. CONCLUSION: All cases of anemia were due to nutritional deficiencies. While vitamin supplementation is a temporary solution, improved individual nutrition knowledge and community access to iron absorption enhancing foods, particularly produce, is needed. Promoting government assistance programs like Prospera and implementing additional programs designed to improve nutrition and health literacy, in conjunction with ensuring access to nutritious foods, might reduce the high prevalence nutritional anemia within the community.

Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty.

BACKGROUND: Alternative techniques have been developed to address pain after shoulder arthroplasty and are well documented. We evaluated the effect of adding intraoperative liposomal bupivacaine and intravenous dexamethasone during shoulder arthroplasty. METHODS: We retrospectively reviewed 2 consecutive cohorts undergoing elective shoulder arthroplasty. The 24 patients in cohort 1 and the 31 patients in cohort 2 received perioperative multimodal management with preoperative and postoperative intravenous and oral narcotics, gabapentin, nonsteroidal anti-inflammatory drugs, acetaminophen, and single-injection interscalene block. Cohort 2 also received 8 to 10 mg of intravenous dexamethasone intraoperatively after the skin incision and liposomal bupivacaine injected at surgery. Patients who did and did not use preoperative narcotics were analyzed together and separately. We evaluated hospitalization length of stay, narcotic use, and visual analog scale pain before and after the change in the perioperative protocol. RESULTS: Cohort 1 was hospitalized longer (2 vs. 1 day; P < .001), required more narcotics on postoperative day 1 (21.0 vs. 10.0 mg; P < .001) and days 0 and 1 cumulatively (30.5 vs. 17.5 mg; P = .001), and had more pain on postoperative days 0 (6.5 vs. 3.5; P < .001) and 1 (7.5 vs. 3.5; P < .001) than cohort 2. In patients using preoperative narcotics, cohort 2 had less pain on postoperative day 1 (3.5 vs. 7.0; P = .006), less cumulative narcotic use (20 vs. 58.5 mg; P = .03), and shorter hospitalization (1 vs. 2 days; P = .052) than cohort 1. CONCLUSION: These changes to the perioperative shoulder arthroplasty protocol decreased hospitalization length of stay, narcotic requirement, and pain.

Reverse shoulder prosthesis in the treatment of locked anterior shoulders: a comparison with classic reverse shoulder indications.

BACKGROUND: Locked anterior shoulder (LAS) with static instability and anterior glenoid bone loss is challenging in the elderly population. Reverse shoulder arthroplasty (RSA) has been employed in treating these patients. No study has compared RSA for LAS with classically indicated RSA. METHODS: A retrospective case-control study of patients treated with RSA for LAS with glenoid bone loss and static instability was performed using matched controls treated with primary RSA for classic indications. Twenty-four cases and 48 controls were evaluated. Average follow-up was 25.5 months, and median age was 76 years. Motion, outcome assessments, and postoperative radiographs were compared. RESULTS: Preoperatively, LAS had significantly less rotation and lower baseline outcome scores. Glenoid bone grafting was more common (P = .05) in the control group (26%) than in the LAS group (6.3%). Larger glenospheres were used more often (P = .001) in the LAS group (75%) than in the control group (29%). Both groups demonstrated significant improvements in pain, function, and outcome scores. Postoperatively, the control group had significantly better elevation and functional outcome scores. With the exception of flexion and Simple Shoulder Test score, effectiveness of treatment was similar between groups. Postoperative acromion stress fractures were seen in 21% of LAS patients and 9% of controls (P = .023) with a predominance of type 3 fractures in LAS. Two LAS patients remained dislocated. CONCLUSION: Patients with LAS treated with RSA can anticipate improvements in pain and function by use of larger glenospheres, often without the need for glenoid bone grafting. Worse postoperative motion and function and a higher incidence of acromion stress fracture may be expected.

Decreased Anemia Prevalence Among Women and Children in Rural Baja California, Mexico: A 6-Year Comparative Study.

Anemia is a public health problem in Mexico. This study sought to determine the prevalence and correlates of anemia among women and children residing in a rural farming region of Baja California, Mexico. An existing partnership between universities, non-governmental organizations, and an underserved Mexican community was utilized to perform cross-sectional data collection in 2004-2005 (Wave 1) and in 2011-2012 (Wave 2) among women (15-49 years) and their children (6-59 months). All participants completed a survey and underwent anemia testing. Blood smears were obtained to identify etiology. Nutrition education interventions and clinical health evaluations were offered between waves. Participants included 201 women and 99 children in Wave 1, and 146 women and 77 children in Wave 2. Prevalence of anemia significantly decreased from 42.3 to 23.3 % between Waves 1 and 2 in women (p < 0.001), from 46.5 to 30.2 % in children 24-59 months (p = 0.066), and from 71.4 to 45.8 % in children 6-23 months (p = 0.061). Among women in Wave 1, consumption of iron absorption enhancing foods (green vegetables and fruits high in vitamin C) was protective against anemia (p = 0.043). Women in Wave 2 who ate ≥4 servings of green, leafy vegetables per week were less likely to be anemic (p = 0.034). Microscopic examination of blood smears revealed microcytic, hypochromic red blood cells in 90 % of anemic children and 68.8 % of anemic women, consistent with iron deficiency anemia.

Anatomic and Reverse Total Shoulder Arthroplasty in Patients Older Than 80 Years.

Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) are routinely performed in patients older than 80 years. Often unaware of the differences between the 2 procedures, patients may expect similar outcomes from these procedures. This article reports the outcomes of primary TSA and RSA in patients older than 80 years, with attention directed toward differences in outcomes between the procedures. The authors evaluated a consecutive series of patients who were at least 80 years old and were treated with primary shoulder arthroplasty and had a minimum follow-up of 2 years. Of these patients, 18 underwent primary TSA for osteoarthritis and 33 underwent primary RSA for rotator cuff tear arthropathy. Pain scores, function scores, and range of motion were evaluated preoperatively and at final follow-up. Perioperative and postoperative complications, transfusion rates, length of stay, and subjective satisfaction with the outcome were reported. In these patients, TSA and RSA were similarly effective in improving pain scores, functional scores, and range of motion measurements. Patients who had TSA reported significantly greater satisfaction with surgery and had superior American Shoulder and Elbow Society total and function scores, forward elevation, and external rotation, but similar net improvement from preoperative levels. Although no significant differences were shown in complications, length of stay, or requirement for transfusion, patients treated with RSA had higher rates of transfusion and postoperative complications. Both procedures were similarly effective treatments for patients older than 80 years and showed similar improvements in pain, function, and motion. Patients undergoing RSA were less likely to have good to excellent results, with higher complication and transfusion rates.

Cerebral desaturation events in the beach chair position: correlation of noninvasive blood pressure and estimated temporal mean arterial pressure.

BACKGROUND: Cerebral oximetry (rSO2) has emerged as an important tool for monitoring of cerebral perfusion during surgery. High rates of cerebral desaturation events (CDEs) have been reported during surgery in the beach chair position. However, correlations have not been made with blood pressure measured at the cerebral level. The purpose of this study was to examine the correlations between brachial noninvasive blood pressure (NIBP) and estimated temporal mean arterial pressure (eTMAP) during CDEs in the beach chair position. METHODS: Fifty-seven patients underwent elective shoulder surgery in the beach chair position. Values for eTMAP, NIBP, and rSO2 were recorded supine (0°) after induction and when a CDE occurred in the 70° beach chair position. Twenty-six patients experienced 45 CDEs, defined as a 20% drop in rSO2 from baseline. RESULTS: Median reduction in NIBP, eTMAP, and rSO2 from baseline to the CDE were 48.2%, 75.5%, and 33.3%, respectively. At baseline, there was a significant weak negative correlation between rSO2 and NIBP (rs = -0.300; P = .045) and no significant association between rSO2 and eTMAP (rs = -0.202; P = .183). During CDEs, there were no significant correlations between rSO2 and NIBP (rs = -0.240; P = .112) or between rSO2 and eTMAP (rs = -0.190; P = .212). No significant correlation between the decrease in rSO2 and NIBP (rs = 0.064; P = .675) or between rSO2 and eTMAP (rs = 0.121; P = .430) from baseline to CDE was found. CONCLUSION: NIBP and eTMAP are unreliable methods for identifying a CDE in the beach chair position. Cerebral oximetry provides additional information to the values obtained from NIBP and eTMAP, and all should be considered independently and collectively.

Functional internal rotation after shoulder arthroplasty: a comparison of anatomic and reverse shoulder arthroplasty.

BACKGROUND: Recovery of functional internal rotation after primary shoulder arthroplasty is essential to perform many important activities of daily living. Functional internal rotation is typically reported as it relates to clinical examination findings of motion (posterior reach) and lift-off or belly-press tests. A more detailed evaluation of functional recovery of internal rotation after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) is needed. METHODS: A retrospective review of patients treated with primary TSA (n = 132) and RSA (n = 91) with a minimum 2-year follow-up was performed. Subanalysis of revision RSA (n = 24) and primary RSA was performed. Active range of motion, subjective internal rotation motion, manual internal rotation strength, and specific questions related to internal rotation function isolated from the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) functional questionnaires were reviewed. RESULTS: Compared with RSA, TSA patients could more likely reach the small of the back (SST) and wash the back/fasten bra (ASES). Active internal rotation motion, SST score, ASES score, and subjective internal rotation were greater after TSA. No significant difference was observed with respect to managing toileting between cohorts. Revision RSA patients were less likely to be able to wash the back/fasten bra (ASES) and easily manage toileting (ASES) compared with primary RSA patients. CONCLUSION: Primary anatomic shoulder arthroplasty yields greater functional internal rotation than does primary RSA, with either procedure being effective at managing toileting. Patient education regarding activities of daily living related to internal rotation can be predicted.

Association between temporal mean arterial pressure and brachial noninvasive blood pressure during shoulder surgery in the beach chair position during general anesthesia.

BACKGROUND: Estimation of cerebral perfusion pressure during elective shoulder surgery in the beach chair position is regularly performed by noninvasive brachial blood pressure (NIBP) measurements. The relationship between brachial mean arterial pressure and estimated temporal mean arterial pressure (eTMAP) is not well established and may vary with patient positioning. Establishing a ratio between eTMAP and NIBP at varying positions may provide a more accurate estimation of cerebral perfusion using noninvasive measurements. METHODS: This prospective study included 57 patients undergoing elective shoulder surgery in the beach chair position. All patients received an interscalene block and general anesthesia. After the induction of general anesthesia, values for eTMAP and NIBP were recorded at 0°, 30°, and 70° of incline. RESULTS: A statistically significant, strong, and direct correlation between NIBP and eTMAP was found at 0° (r = 0.909, P ≤ .001), 30° (r = 0.874, P < .001), and 70° (r = 0.819, P < .001) of incline. The mean ratios of eTMAP to NIBP at 0°, 30°, and 70° of incline were 0.939 (95% confidence interval [CI], 0.915-0.964), 0.738 (95% CI, 0.704-0.771), and 0.629 (95% CI, 0.584-0.673), respectively. There was a statistically significant decrease in the eTMAP/NIBP ratio as patient incline increased from 0° to 30° (P < .001) and from 30° to 70° (P < .001). CONCLUSION: The eTMAP-to-NIBP ratio decreases as an anesthetized patient is placed into the beach chair position. Awareness of this phenomenon is important to ensure adequate cerebral perfusion and prevent hypoxic-related injuries.

Improving diagnostic efficiency: analysis of pelvic MRI versus emergency hip aspiration for suspected hip sepsis.

BACKGROUND: Accurately diagnosing and treating childhood hip sepsis is challenging. Adjacent bone and soft-tissue infections are common and can lead to delayed and inappropriate treatment. This study evaluated the effect of early advanced imaging (bone scan, magnetic resonance imaging) in the management of suspected hip sepsis. METHODS: A retrospective review of pediatric patients admitted between 2003 and 2009 with suspected hip sepsis was performed. Patients were classified into 2 categories: group I-immediate hip aspiration or group II-advanced imaging performed before intervention. RESULTS: In total, 130 patients (53 in group I and 77 in group II) were included. No significant differences were found between the groups with regard to laboratory values, temperature, number of anesthetics, and length of hospital stay. However, patients in group I were younger than in group II (5.4 vs. 7.3 y, P=0.02) and more patients in group I were unable to bear weight on the affected limb compared with group II (83% vs. 61%, P=0.009). In group I, 36 patients (68%) had a septic hip compared with 35 patients (45%) in group II. In group I, 16 patients (30%) required reoperation versus 13 (17%) patients in group II. Results from the multivariate analysis demonstrated that reoperation was required 2.8 times (95% confidence interval, 1.12-6.78) more often in group I as compared with group II (P=0.03). CONCLUSIONS: Advanced imaging performed before hip aspiration improves diagnostic efficacy and may decrease the need for reoperation. LEVEL OF EVIDENCE: III.

Salter-Harris II fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure?

INTRODUCTION: Premature physeal closure (PPC) is a common complication resulting from the management of a displaced Salter-Harris II (SH II) fracture of the distal tibia. The purpose of this study was to evaluate our institution's treatment approach to assess PPC and complication rates of fractures treated both surgically and nonsurgically. METHODS: We performed a retrospective review of all patients presenting with a displaced SH II fracture between 2004 and 2010. Initial treatment was closed reduction in the emergency department. Further treatment and subsequent categorization was based on amount of residual displacement. Patients with <2 mm of postreduction displacement were treated with a non-weight-bearing long-leg cast (LLC; group 1), patients with residual displacement between 2 and 4 mm were treated with one of 2 approaches based on surgeon preference: either LLC (group 2) or open reduction and internal fixation (ORIF) with removal of any interposed tissue (group 3). Patients with >4 mm of residual displacement were treated with ORIF (group 4). Follow-up radiographs were performed for a minimum of 6 months. If there was clinical concern about PPC, computed tomography imaging was performed to assess for a bony bar. RESULTS: In total, 96 patients with a mean age of 12.6 years at presentation were included in the study. Among the 14 patients with <2 mm of postreduction displacement, 29% had a PPC and 7% had to undergo a subsequent procedure (epiphsyiodesis, osteotomy, etc.). Of the 33 patients with 2 to 4 mm of displacement who were treated with a LLC, 33% had a PPC and 15% had to undergo a subsequent procedure. Of the 11 patients with 2 to 4 mm of displacement treated with ORIF 46% had a PPC and 18% had a second procedure. Finally, 38 patients with >4 mm of displacement treated with ORIF had a PPC rate of 55% and 23% had a subsequent procedure. No statistical differences in PPC (P=0.19) or subsequent surgeries (P=0.57) were observed between groups. Among those with 2 to 4 mm of postreduction displacement, patient age (P=0.36), sex (P=0.39), mechanism of injury (P=0.13), time to fracture management (P=0.51), amount of initial displacement (P=0.34), number of reduction attempts (P=0.43), and operative treatment (P=0.47) did not significantly influence PPC. CONCLUSIONS: Patients with displaced SH II distal tibia fractures pose a challenging problem for the treating physician with a high rate of PPC (43% overall). Although surgical fixation with anatomic reduction and removal of interposed tissue may be necessary to improve joint alignment, it does not reduce the incidence of PPC and may increase the need for subsequent surgeries.

Partial rotator cuff tears in adolescents: factors affecting outcomes.

INTRODUCTION: In the adult population, rotator cuff tears are common and established treatment methods yield satisfactory results. In adolescents, however, these injuries are uncommon and few treatment methods and outcome reports exist. The purpose of this study was to examine a series of adolescent rotator cuff tears, identify associated pathology, and report treatment outcomes. METHODS: A retrospective comparative analysis of adolescent patients treated for rotator cuff tears diagnosed by magnetic resonance imaging (MRI) or arthroscopy between 2008 and 2010 was performed. Patients were divided by treatment rendered: nonoperative or operative. Demographic and diagnostic variables were compared between the 2 groups. After release to full activity, 3 patient outcome measures were obtained: QuickDASH (Disability of the Arm, Shoulder, and Hand), QuickDASH Sports module, and the Single Assessment Numerical Evaluation (SANE). RESULTS: Fifty-three adolescents (38 boys and 15 girls) with a mean age of 15.8 years (8.8 to 18.8 y) met the inclusion criteria. All rotator cuff tears were partial articular-sided tendon avulsions, and surgical treatment (when required) consisted of debridement to stable edges. All patients underwent a trial of at least 6 weeks of physical therapy, with 57% failing to improve and requiring subsequent surgery. In the patients that were treated nonoperatively, 39% were diagnosed with associated pathology based on MRI findings, whereas operative patients exhibited an associated pathology rate of 70%. Patients with MRI-diagnosed associated pathology were 1.8 times more likely (95% confidence interval, 1.02-3.13, P=0.025) to require surgery compared with those without MRI-identified associated pathology. Nineteen patients (13 operative, 6 nonoperative) completed the outcome questionnaires at a mean 16.9 months after treatment. QuickDASH, SANE, and QuickDASH Sports module scores were not statistically different between nonoperative and operative treatment groups (7.5 vs. 8.1, P=0.90; 85.3 vs. 80.6, P=0.47; and 5.2 vs. 19.5, P=0.39, respectively). All outcome measures exhibited significant correlations with one another, with the strongest correlation being a negative association between SANE and Sports module scores (r=-0.76, P=0.001). DISCUSSION: Isolated partial articular-sided tendon avulsion injuries may be successfully treated with physical therapy, with return to sports expected; however, if associated pathology was present then nonoperative treatment was less successful. Improvement in pain and activities of daily living can be achieved with surgery after failed conservative management for rotator cuff injuries; however, the adolescent athlete will often have residual shoulder complaints during sports participation. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Publication rates of abstracts presented at pediatric orthopaedic society of North America meetings between 2002 and 2006.

BACKGROUND: Earlier studies have indicated that across medical specialties, the overall publication rate of submitted manuscripts ranges from 36% to 66%. However, there have not been any recent studies conducted concerning the publication rates specifically for the Pediatric Orthopaedic Society of North America (POSNA). Consequently, the purpose of our study was to determine the overall publication rates of abstracts presented during the POSNA annual meetings, and whether there were differences in publication rates and time to publication according to type of presentation (podium vs. poster), journal, and orthopaedic subspecialty. METHODS: A comprehensive literature search using PubMed and Google Scholar for all abstracts (including podiums, posters, and e-posters) presented at the 2002 to 2006 POSNA annual meetings was performed. Abstracts were classified according to presentation type: podium, poster, or e-posters, and were subsequently categorized into a specific orthopaedic subspecialty: basic science, hip, lower extremities, spine, trauma, and upper extremity. RESULTS: A total of 762 abstracts were presented at POSNA meetings between the years of 2002 and 2006. Of these 762 abstracts, 386 (50.7%) were published in peer-reviewed literature. There was no significant variation in the yearly publication percentage rate between 2002 and 2006 (P=0.63). However, overall time between presentation at POSNA and publication in a peer-reviewed journal varied significantly by year (P=0.002), with the average time to publication being 29 months in 2002, compared with 18.8 months in 2006. Time to publication also varied significantly by journal (P=0.025). For the combined years of 2002 to 2006, podiums were 1.47 times (95% confidence interval, 1.10-1.98) more likely to be published compared with posters (P=0.009). When abstracts were stratified by subspecialty (trauma, spine, hip, basic science, lower extremity, and upper extremity), there was no difference in publication rate between each group (P=0.425) or in overall time to publication (P=0.354). CONCLUSIONS: Our study indicated that there was a significant decrease in mean publication time between 2002 and 2006, which may support the notion that the process of accepting papers for publication has become more efficient with time. Furthermore, we found that there was a quantifiable difference in the overall publication rates for podium and poster presentations. The data suggest that the quality of poster and podium presentations are not equivalent. In addition, our study indicated that publication rates among pediatric orthopaedic subspecialties (trauma, spine, hip, basic science, lower extremity, and upper extremity) did not differ. This indicates that publication representation across all areas of pediatric orthopaedic practice is generally uniform.

Intramedullary nailing of pediatric femoral shaft fracture.

Intramedullary nail fixation of pediatric long bone fracture, particularly femoral shaft fracture, has revolutionized the care and outcome of these complex injuries. Nailing is associated with a high rate of union and a low rate of complications. Improved understanding of proximal femoral vascularity has led to changes in nail insertion methodology. Multiple fixation devices are available; selection is based on fracture type, patient age, skeletal maturity, and body mass index. A thorough knowledge of anatomy and biomechanics is required to achieve optimal results without negatively affecting skeletal development.

Calcaneonavicular coalition: treatment by excision and fat graft.

BACKGROUND: Symptomatic calcaneonavicular coalitions treated with resection and interposition of the extensor digitorum brevis (EDB) muscle often have unpredictable improvement of symptoms. Concerns with regard to skin cosmesis from a bony prominence on the lateral aspect of the foot and inadequate filling of the resection gap potentially causing reossification have motivated us to use fat graft interposition instead. The purpose of this study was to describe our surgical technique and report our clinical and radiographic outcomes for fat graft interposition after resection of a calcaneonavicular coalition. METHODS: A retrospective review of all pediatric patients surgically treated with a calcaneonavicular coalition resection from January 1999 to December 2006, was performed. Presenting symptoms and examination findings were recorded. Postoperative examinations and imaging studies were evaluated to grade reossification, and functional outcomes were assessed for all patients with minimum 1-year postoperative follow-up. In addition, a cadaveric study was performed to compare the efficacy of EDB and fat graft interposition in terms of filling the postresection gap. RESULTS: Foot pain was the most common presenting complaint, though limitation of activities, stiffness, preoperative hindfoot malalignment, and associated injuries were also frequently observed. One year after resection, 87% of the patients returned to sport or their past activities, whereas 5% had symptomatic regrowth requiring repeat resection. Seventy-four percent had improvement of subtalar motion and 82% had improvement of plantarflexion; which was identified as an additional clinical sign of a calcaneonavicular bar. Preoperative pain averaged 7 of 10, whereas postoperative pain averaged less than 1 of 10 at rest, while walking, and with activities. The cadaveric study showed that the EDB was able to fill on average only 64% of the resected gap, leaving approximately 10 mm of the plantar gap unfilled. CONCLUSIONS: Reossification and reoperation rates with fat graft interposition in our series were lower than in most published reports of EDB interposition. Ankle and subtalar motion improved in a vast majority of the patients, and most patients returned to sport without requiring further surgery. Resection of a calcaneonavicular coalition with interposition of fat graft, when meticulously performed, is an effective way to relieve symptoms, restore subtalar motion, and return patients to activities, while preventing reossification.