Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This?

BACKGROUND: In recent decades, nonoperative Ponseti casting has become the standard of care in the treatment of idiopathic clubfoot. However, the rate of recurrence, even after successful Ponseti treatment is not insignificant. The purpose of this study was to determine the future rate, timing, and type of surgery needed in patients whose idiopathic clubfeet treated by Ponseti casting were considered successful at the age of 2 years. METHODS: Inclusion criteria for this retrospective study were patients under 3 months with idiopathic clubfoot treated exclusively by Ponseti casting, who had successful outcomes at 2 years of age without surgery, and who had at least 5 years of follow-up. The total number of surgical interventions in the age range 2 to 5 and above 5 years, the number and type of procedures performed, and the timing of surgery were reviewed. RESULTS: Three hundred thirty-six patients with a total of 504 clubfeet fulfilled the inclusion criteria. One hundred twenty-two of these 336 patients (36.3%) eventually underwent surgical intervention. Between 2 and 5 years of age, 79 patients (23.5%) with 104 feet (20.6%) underwent surgery. The most common procedures performed between 2 and 5 years were limited (a la carte) in scope: tibialis anterior tendon transfer, posterior release, plantar fascia release, and repeat tendo-Achilles lengthening. At age above 5 years, 53 patients (20.1%) with 65 feet (16.9%) underwent surgery. Ten of these 53 patients had already undergone surgery between 2 and 5 years of age. The procedures most commonly performed were similar. CONCLUSIONS: In patients with idiopathic clubfoot who reached 2 years of age with successful outcomes from Ponseti cast treatment, ∼35% eventually underwent surgical intervention, mostly limited (a la carte), to regain or maintain a plantigrade foot. The most commonly performed procedures include tibialis anterior tendon transfer, posterior capsular release, plantar fascia release and repeat tendo-Achilles lengthening, either in isolation or in combination. However, before considering surgery, the need for these procedures can, and should, be minimized by recasting recurrent deformities using Ponseti method. LEVEL OF EVIDENCE: Level III.

How Many Patients Who Have a Clubfoot Treated Using the Ponseti Method are Likely to Undergo a Tendon Transfer?

BACKGROUND: The Ponseti method has become the standard of care for the treatment of idiopathic clubfoot. A commonly reported problem encountered with this technique is a relapsed deformity that is sometimes treated in patients older than 2.5 years by an anterior tibial tendon transfer (ATTT) to the third cuneiform. Presently, there is insufficient information to properly counsel families whose infants are beginning Ponseti treatment on the probability of needing later tendon transfer surgery. METHODS: All idiopathic clubfoot patients seen at the authors' institution during the study period who met the inclusion criteria and who were followed for >2.5 years were included (N=137 patients). Kaplan-Meier Survival analysis was used to determine the probability of survival without the need for ATTT surgery. In addition, the influence of patient characteristics, socioeconomic variables, and treatment variables on need for surgery was calculated. RESULTS: On the basis of the survivorship analysis, the probability of undergoing an ATTT remained below 5% for all patients at 3 years of age, but exceeded 15% by 4 years of age, increasing steadily afterwards such that by 6 years of age, the probability of undergoing an ATTT reached 29% of all patients. Overall, controlling for all other variables in the analysis, parent-reported adherence with bracing reduced the odds of undergoing surgery by 6.88 times, compared with parent-reported nonadherence (P<0.01). CONCLUSIONS: This is the first study to report the probability of undergoing ATTT surgery as a function of age using survivorship analysis following Ponseti clubfoot treatment. Although the overall probability reached 29% at 6 years, this was significantly reduced by compliance with bracing. This information may be useful to the clinician when counseling families at the start of treatment. LEVEL OF EVIDENCE: Level III-theraputic.

Botulinum Toxin Injection for Internal Rotation Contractures in Brachial Plexus Birth Palsy. A Minimum 5-Year Prospective Observational Study.

BACKGROUND: Brachial plexus birth palsy is frequently associated with internal rotation contractures of the shoulder as a result of muscle imbalance. The purpose of this study is to assess the effect of botulinum toxin A (BTX-A) injection in the subscapular (SC) muscle on external rotation and the need for tendon transfer for external rotation of the shoulder. METHODS: A prospective comparative study was performed including 15 consecutive patients treated with BTX-A and a historic control group of 67 patients with mean age 30 months (SD 10). The BTX-A injection (2 IU/kg body weight) was performed immediately following MRI under general anesthesia in the SC muscle. Passive external rotation, the need for tendon transfer surgery, glenohumeral deformity, and muscle degeneration were evaluated. The hazard ratio for no relapse of internal rotation contracture after BTX-A injection compared with no BTX-A injection was calculated. RESULTS: In the BTX-A group, the passive external rotation in adduction increased from -1 degree (95% CI, -10 to 8) to 32 degrees (95% CI, 17-46) at 3 months and 6 patients were indicated for surgery compared with a decline from -2 degrees (95% CI, -7 to 3) to -11 degrees (95% CI, -17 to -6) in the control group with 66 indications for surgery. At 5 years of follow-up, 10 patients in the BTX-A group were indicated for surgery with a hazard ratio of 4.0 (95% CI, 1.9 to 8.4). CONCLUSIONS: BTX-A injection in the SC muscle of brachial plexus birth palsy patients can reduce internal rotation contractures and subsequently the need for tendon transfer surgery. At 5 years of follow-up a relapse was seen in 67% of the patients treated with BTX-A. Because at MRI less SC degeneration was found in the good responders on BTX-A treatment, this group seems to be the best target group. Further research is needed on patient selection for BTX-A injection including glenohumeral deformity, SC degeneration, as well as doses of BTX-A to be used. LEVEL OF EVIDENCE: Level II-prospective comparative study.

[Transosseous refixation of the common extensor muscle tendons in chronic lateral epicondylitis with and without additional reconstruction of the LUCL--a retrospective evaluation of 101 patients]. / Die transossäre Refixation der Extensoren bei chronischer radialer Epikondylopathie mit und ohne Rekonstruktion des LUCL-Komplexes--eine retrospektive Analyse von 101 Patienten.

INTRODUCTION: The chronic lateral epicondylitis (EHR) as a common pathology of the elbow is often associated with posterolateral rotatory instability of the elbow (PLRI). After evaluation of intra-articular pathology by prior diagnostic arthroscopy, we aimed to build patient groups regarding the stability of the elbow joint. In patients with a stable elbow joint, open surgery with a debridement to the origin of the common extensor tendon and transosseous refixation was performed. Patients with relevant posterolateral rotatory instability, however, underwent an additional LUCL complex stabilisation using triceps tendon graft besides debridement as mentioned above. The purpose of this study was to evaluate and compare the clinical functional outcome between these groups. MATERIAL AND METHODS: 101 patients were included in our study. Arthroscopies were first performed on all patients to identify intra-articular pathological changes. In 26 patients with stable elbows, open surgery with debridement to the origin of the common extensor tendon and transosseous refixation was performed. For the other 75 patients who were found presenting a relevant posterolateral rotatory instability, a stabilisation of the LUCL in addition to the open procedure mentioned above was performed. Examinations and questionnaires were used for retrospective evaluation at follow-up. RESULTS: Both groups of patients revealed significant improvement in pain relief and elbow function. We observed no significant difference between the two methods concerning clinical and functional outcome. CONCLUSION: We recommend diagnostic arthroscopy with assessment of stability prior to the open performance to offer a more reliable evidence for surgical technique selection and therefore to achieve a better clinical outcome.

A systematic review of conflicting meta-analyses in orthopaedic surgery.

Meta-analyses are important evaluations in orthopaedic surgery, not only to create clinical guidelines, but also because their findings are included in public health and health policy decision making. However, with increasing numbers of meta-analyses, discordant and frankly conflicting conclusions have been reported. We searched for conflicting meta-analyses, ie, those arriving at different conclusions despite following the same research question, identified potential reasons for these differences, and assessed the statistical significance and clinical importance of differences. We identified conflicting meta-analyses on graft choice in ACL reconstruction and the use of hyaluronic acid. We found significant differences in individual results only for meta-analyses on hyaluronic acid, but the 95% confidence intervals of the magnitude of differences included values as much as 40% for ACL meta-analyses. However, our findings suggest most conflicts derive from differences in the interpretation of pooled results rather than in the actual results. Thus conclusions and interpretations from meta-analyses should be scrutinized as critically as those from any other type of study and subjected to reassessment if deemed necessary.

Acceptable benefits and risks associated with surgically improving arm function in individuals living with cervical spinal cord injury.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: To determine how quadriplegics in the US view tendon transfer surgeries (TTS) and what activities of daily living (ADL) involving arm/hand function are important in improving quality of life (QoL). SETTING: World wide web. METHODS: Individuals >or=18 years of age living with a cervical spinal cord injury (SCI). Participants obtained a pass code to enter a secure website and answered survey questions. A total of 137 participants completed the survey. RESULTS: Two-thirds of participants had injury levels between C4/5 and C5/6. Over 90% felt that improving their arm/hand function would improve their QoL. ADL that were ranked most important to regain were dressing, feeding, transferring in/out of bed, and handwriting. Less than half of the participants had never been told about TTS and only 9% had ever had TTS. Nearly 80% reported that they would be willing to spend 2-3 months being less independent, while recovering from surgery, to ultimately become more independent. Over 75% reported that the ideal time preferred to have TTS, if chosen, would be within 5 years post-injury. CONCLUSION: Regaining arm and hand function is of primary importance to individuals with cervical SCI, in particular, to increase independence in multiple ADL. There is a critical need in the US to improve awareness of TTS as a viable option for improving arm/hand function in some people. This information needs to be provided early after injury so that informed choices can be made within the first 5 years.

Protection of the deltoid to triceps tendon transfer repair sites.

The posterior deltoid muscle was used to replace lost elbow extension in 11 patients with C5 or C6 level tetraplegia. During surgery stainless steel sutures were inserted into the donor muscle, graft, and tendon insertion sites. Over the succeeding time periods (1 month to 2 years) the distances between the various markers were measured. Significant tendon elongation of 23.1 +/- 4.8 mm (mean +/- SEM; n = 6) was observed in patients receiving traditional postoperative care. To reduce the tendon elongation observed, a specially designed armrest was developed and applied the first postoperative day. The armrest was designed to maintain the elbow in 20 degrees flexion and to prevent shoulder adduction. The addition of this armrest to the traditional postoperative protocol resulted in a dramatic decrease of tendon elongation to only 8.4 +/- 3.0 mm (n = 5). Elongation occurred within the first 6 postoperative weeks in the armrest group; in the nonprotected group, elongation continued for several additional months. The majority of the elongation in both groups occurred in the proximal portion of the tendon-graft-tendon unit. Although this study did not explicitly measure strength, we conclude that preventing excessive muscle length change is required to protect repair sites in posterior deltoid to triceps transfer. (J Hand Surg 2000; 25A:144-149.

[Synovial healing in reconstructed cruciate ligaments. Our personal experience compared in single interventions and combined reconstructions]. / La maturazione sinoviale dei legamenti crociati ricostruiti. Esperienza personale a confronto negli interventi isolati e nelle ricostruzioni combinate.

INTRODUCTION: The healing process of tendon grafts used in cruciate ligament reconstruction is called ligamentization. The tendon structural architecture changes progressively into the histological appearance of normal ligament. Amiel and Clancy have demonstrated that this process is time-dependent in anterior cruciate ligament (ACL) reconstruction, the tendon graft taking one year to become similar to a normal cruciate ligament. Three different maturation phases of anterior cruciate graft ligamentization can be seen at MRI: periligamentous proliferation, intraligamentous proliferation and definitive healing. We report our MR findings in the reconstruction of single ACL, posterior cruciate ligament (PCL), and of both ACL and PCL. MATERIAL AND METHODS: January 1995 to January 1999 we selected 60 patients submitted to arthroscopic cruciate ligament reconstruction. The ACL was reconstructed with the patellar tendon in 22 cases and the PCL in 23; fifteen patients underwent double reconstruction of ACL, with hamstring tendons, and PCL, with patellar tendons. Fifty-five patients were followed-up with MRI: 45 with a dedicated permanent magnet (Artroscan, Esaote Biomedica, Genoa, Italy) and 10 with a permanent low-field unit (AIRIS, Hitachi, Japan); the same technical parameters were used in all cases. Forty of 55 patients were examined at 1, 3, 6, 9 and 12 postoperative months, while 15 were followed-up longer (12 to 36 months postoperatively). At the first follow-up MR examination, 5 patients (2 ACL and 3 PCL) were excluded for incorrect tunnel position (1 case), hypertrophic scarring (2 cases) and new trauma (2 cases). MR findings were compared with clinical data of joint stability. RESULTS: MRI showed the different stages of the healing process in 20 ACL patients: proliferating soft tissue around the graft with the low signal intensity typical of tendons (stage I, 1-3 months postoperatively), the graft becomes progressively hyperintense (stage II, 3-9 months postoperatively), and finally the low signal intensity indicating completed ligamentization (stage III, 12 months postoperatively). As for PCL reconstructions, MR findings were similar but the process took longer, even 24 months. Finally, in the 15 cases of double reconstruction, both grafts were difficult to distinguish on T1-weighted images for a very long time (24-36 months postoperatively). DISCUSSION AND CONCLUSIONS: Relative to the ACL, ligamentization takes longer for PCL and combined ACL and PCL reconstructions, probably because the morphological changes in PCL and double grafts may be impaired by many factors, such as gravity, long bone tunnels, hemarthrosis, hyperplastic synovial reaction in the intercondylar notch; also, rehabilitation protocols differ in ACL from PCL patients. No signs of instability were found at physical or arthrometric examinations. MRI demonstrates the different stages of ligamentization and thus proves a useful tool for postoperative follow-up in cruciate ligament reconstructions. Contrast-enhanced (Gd) studies are reserved to the cases of graft impingement or if other abnormalities are suspected.

[Primary and secondary augmentation reconstruction of the anterior cruciate ligament with the gracilis tendon]. / Primäre und sekundäre Augmentationsplastik des vorderen Kreuzbandes mit der Grazilissehne.

In both immediate and secondary surgical treatment for teared anterior cruciate ligament an additional augmentation procedure protecting the reinserted original ligament structures seems to be consequent. Main indications for augmentation are the gravity of destruction, an intermediate type of rupture, fibre displacement and atrophy. Respecting the quite good long term results of 40 isolated Lindemann-procedures (1975-1982) 6 to 14 years after treatment, and the results of 43 primary and 77 secondary augmentation procedures performed in a 4 year's period (1984-1988) the Lindemann dynamic transfer technique can be recommended for replacement and augmentation as well.