Ponseti method of treating clubfoot - Is there difference if treatment is started before or after one month of age?

INTRODUCTION: Most of the authors currently agree that congenital talipes equinovarus (CTEV) or idiopathic clubfoot can be effectively treated with the Ponseti method instead of extensive soft tissue surgery. This study was conducted to investigate whether there is a difference in the outcome between starting treatment before one month of age or after that age. METHODS: This is a retrospective study on babies with CTEV treated in University Malaya Medical Centre from 2013 to 2017. The 54 babies (35 boys and 19 girls) were divided into two cohorts, Group 1 that had treatment before the age of one month, and Group 2 that had treatment after one month old. The number of cast changes, rate of full correction, and rate of relapse after treatment were compared between the two groups. RESULTS: Of the 54 babies, with 77 CTEV treated during the period, our outcome showed that the mean number of cast change was 5.9 for Group 1 and 5.7 for Group 2. The difference was not statistically significant. All the affected feet (100%) achieved full correction. One foot in the Group 1 relapsed, while three feet in Group 2 relapsed, but the difference was also not statistically significant. All of the relapsed feet were successfully treated with repeated Ponseti method. CONCLUSIONS: Treating CTEV using Ponseti method starting after one month was not associated with more casting change of higher rate of relapse.

Artificial Intelligence: Impact and Challenges to Authors, Journals and Medical Publishing.

Artificial intelligence (AI)-assisted technologies are here to stay and cannot be ignored. These tools are able to generate highly-realistic human-like text and perform a wide range of useful language tasks with a wide range of applications. They have the potential to expedite innovation in health care and can aid in promoting equity and diversity in research by overcoming language barriers. When using these AI tools, authors must take responsibility for the output and originality of their work, as publishers expect all content to be generated by human authors unless there is a declaration to the contrary. Authors must disclose how AI tools have been used, and ensure appropriate attribution of all the text, images, and audio-visual material. The responsible use of AI language models and transparent reporting of how these tools were used in the creation of information and publication are vital to promote and protect the credibility and integrity of medical research, and trust in medical knowledge. Educating postgraduate and undergraduate students, researchers and authors on the applications and best usage of AI-assisted technologies, together with the importance of critical thinking, integrity and strict adherence to ethical principles, are key steps that need to be undertaken.

Antimicrobial gauze as a dressing reduces pin site infection: a randomized controlled trial.

BACKGROUND: Pin site infection is a common problem in external fixation. Plain gauze wetted with normal saline is commonly used for a pin site dressing owing to the simplicity and low cost. Evidence to support adding an antimicrobial agent in the dressing material is lacking. QUESTIONS/PURPOSES: We compared the rate of pin tract infection using plain gauze and gauze impregnated with polyhexamethylene biguanide in patients undergoing limb lengthening procedures. PATIENTS AND METHODS: We included 38 patients (40 limbs) undergoing limb lengthening or deformity correction using an external fixator between July 2009 and June 2010. There were 23 male patients and 15 female patients, with a mean age of 26.3 years (range, 5-68 years). The patients were randomized into two groups: a polyhexamethylene biguanide group (22 limbs) and a control group (18 limbs). The metal-skin interfaces were assessed by a researcher blinded to the type of gauze at 2, 4, 8, and 12 weeks after surgery for the pin site infection based on a predetermined grading system. There were a total of 483 metal-skin interfaces, with 1932 total observations. Infection rates were compared using the chi square test and relative risk with 95% confidence interval. RESULTS: The infection rate was lower (χ(2) [1, n = 1932] = 23.00) and the risk for infection was lower (relative risk, 0.228; 95% confidence interval, 0.118, 0.443) for the polyhexamethylene biguanide group (n = 1068; 1.0%) than for the control group (n = 864; 4.5%). CONCLUSIONS: Use of polyhexamethylene biguanide-impregnated gauze can reduce the risk of pin tract infection in external fixation. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Pattern of distal radius fracture in malaysian children.

INTRODUCTION: The distal radius is the most common fracture site in children, but local information on the fracture pattern, mechanism of injury and socio-demographic characteristics of the fracture is lacking. MATERIAL METHODS: We interviewed 126 children and their family members who were under follow up for this fracture in a single institution over a period of 2 years. Radiological images were reviewed to ensure that only those with fracture in the distal one third of the forearm were included. RESULTS: The overall incidence of this fracture increased with age, and male dominance was noted starting from schooling age. Most fractures occurred at home (38.8%), and 52.3% of all fractures were due to low energy falls. Sports injuries were mainly due to playing football, and road accidents due to riding bicycles. There were 49 (38.8%) children with incomplete fractures, and 19 (15.0%) with physeal plate fractures. CONCLUSION: Male dominance for distal radius fracture occurred at a comparatively younger age in our population. Preventive measures should focus on home environment since this is the most common place for fracture to occur. Special attention should be paid to boys after the school going age.

Foot Arch Changes after Endoscopic Plantar Fascia Release for Recalcitrant Plantar Fasciitis.

Introduction: Endoscopic plantar fascia release (EPFR) is a minimally invasive surgical intervention for recalcitrant plantar fasciitis. Its efficacy has been convincing but the in vivo effect on medial longitudinal foot arch and footprint has not been studied. Our objective is to evaluate the changes of foot posture using radiographs and footprints following endoscopic plantar fascia release in recalcitrant plantar fasciitis. Materials and methods: This prospective cohort involved patients with recalcitrant plantar fasciitis who failed six months of conservative treatment. Two-portal endoscopic release of not more than 50% of plantar fascia width was performed. Footprint and standard weight-bearing anteroposterior and lateral radiographs of the foot were taken pre-operatively and at 12 months post-surgery. Arch index, normalised navicular height truncated, calcaneal inclination angle, calcano-1st metatarsal angle, talonavicular coverage angle and talus-2nd metatarsal angle were measured. Results: Sixteen patients (18 feet) were reported. Patients' follow-up ranged from 14 to 31 months after surgery (mean±SD: 23.44±5.76). The increase of arch index, calcano-1st metatarsal angle and reduction of calcaneal inclination angle were found statistically significant (p<0.05). Two normal arch patients progressed to asymptomatic flat arch feet. Three complications were noted between three to nine months post-surgery, one with medial column and two with lateral column symptoms. Conclusion: There is evidence of reduction in medial longitudinal arch of the foot after EPFR. Although the reduction remains asymptomatic, post-operative complications related to changes in biomechanics of the foot can occur between three to nine months. Patients should be monitored at least for 12 months and longer for those who are symptomatic.

Suppression of near-Fermi level electronic states at the interface in a LaNiO3/SrTiO3 superlattice.

Standing-wave-excited photoemission is used to study a SrTiO3/LaNiO3 superlattice. Rocking curves of core-level and valence band spectra are used to derive layer-resolved spectral functions, revealing a suppression of electronic states near the Fermi level in the multilayer as compared to bulk LaNiO3. Further analysis shows that the suppression of these states is not homogeneously distributed over the LaNiO3 layers but is more pronounced near the interfaces. Possible origins of this effect and its relationship to a previously observed metal-insulator-transition in ultrathin LaNiO3 films are discussed.

Pre-operative Halo-Pelvic Traction for Neurofibromatosis Patients with Severe Proximal Thoracic Spinal Deformity: Indications and Early Treatment Outcome.

INTRODUCTION: To report the indications and early treatment outcomes of pre-operative halo-pelvic traction in patients with neurofibromatosis associated with severe proximal thoracic (PT) spinal deformity. MATERIALS AND METHODS: We reviewed four patients with neurofibromatosis with severe PT spinal deformity. Case 1, a 16-year-old male presented with severe PT kyphoscoliosis (scoliosis: 89°, kyphosis: 124°) and thoracic myelopathy. Case 2 was a 14-year-old, skeletally immature male who presented with a PT lordoscoliosis (scoliosis: 85°). Case 3, a 13-year-old male, presented with severe PT kyphoscoliosis (scoliosis: 100°, kyphosis: 95°). Case 4, a 35-year-old gentleman, presented with severe PT kyphoscoliosis (scoliosis: 113°, kyphosis: 103°) and thoracic myelopathy. All patients underwent pre-operative halo-pelvic traction. After a period of traction, all patients underwent posterior spinal fusion (PSF) with autologous bone grafts (local and fibula bone grafts) and recombinant human bone morphogenetic protein-2 (rhBMP-2). RESULTS: Both patients with thoracic myelopathy regained near normal neurological status after halo-pelvic traction. Following traction, the scoliosis correction rate (CR) ranged from 18.0% to 38.9%, while the kyphosis CR ranged from 14.6% to 37.1%. Following PSF, the scoliosis CR ranged from 24.0% to 58.8%, while the kyphosis CR ranged from 29.1% to 47.4%. The total distraction ranged from 50-70mm. Duration of distraction ranged from 26-95 days. The most common complication encountered during halo-pelvic traction was pin-related e.g. pin tract infection, pin loosening and migration, osteomyelitis, and halo-pelvic strut breakage. No patients had cranial nerve palsies or neurological worsening. CONCLUSION: Pre-operative correction of severe PT spinal deformities could be performed safely and effectively with the halo-pelvic device prior to definitive surgery.

The Perils of Predatory Journals and Conferences.

Predatory journals and conferences have little or no peer review. Their raison d'être is for making money through the article processing charges and the conference registration fees. Without a critical evaluation, predatory journals publishing flawed results and conclusions would cloud the existing scientific literature. Predatory conferences are the offshoots of predatory publishing. The conferences are not organised by learned societies, but by profit-making event organisers. There is a need for awareness among researchers and clinicians regarding predatory publishing. The scourge of predatory publishing and conferencing should be more often highlighted during scientific meetings and publication courses.

COVID-19 in Singapore and Malaysia: Rising to the Challenges of Orthopaedic Practice in an Evolving Pandemic.

With the increasing number of COVID-19 cases and related deaths worldwide, we decided to share the development of this condition in Singapore and Malaysia. First few cases were diagnosed in the two countries at the end of January 2020, and the numbers have surged to thousands by end of March 2020. We will focus on strategies adopted by the government and also the Orthopaedic community of the two countries up till the beginning of April 2020. We hope that by sharing of relevant information and knowledge on how we are managing the COVID-19 condition, we can help other communities, and health care workers to more effectively overcome this pandemic.

Diluted povidone-iodine versus saline for dressing metal-skin interfaces in external fixation.

PURPOSE: To compare infection rates associated with 2 dressing solutions for metal-skin interfaces. METHODS: 60 patients who underwent distraction osteogenesis with external fixators were equally randomised into 2 dressing solution groups (diluted povidone-iodine vs. saline). Fixations were attained using either rigid stainless steel 5-mm diameter half pins or smooth stainless steel 1.8-mm diameter wires. Half-pin fixation had one metal-skin interface, whereas wire fixation had 2 interfaces. Patients were followed up every 2 weeks for 6 months. RESULTS: Of all 788 metal-skin interfaces, 143 (18%) were infected: 72 (19%) of 371 in the diluted povidone-iodine group and 71 (17%) of 417 in the saline group. Dressing solution and patient age did not significantly affect infection rates. Half-pin fixation was more likely to become infected than wire fixation (25% vs 15%). CONCLUSION: Saline is as effective as diluted povidone-iodine as a dressing solution for metal-skin interfaces of external fixators. Saline is recommended in view of its easy availability and lower costs.

A New Approach to Body Donation for Medical Education: The Silent Mentor Programme.

Cadaveric dissection is an integral component of medical education. There had been concerns about negative impact on medical students exposed to deceased donors before their clinical years, but most studies reported overall positive outcome following this form of teaching. Due to reducing number of body donations in most parts of the world, many institutions are adopting alternative models especially for the teaching of gross anatomy. A new body donation programme that incorporate humanistic values in the procurement process was initiated by Tsu Chi University of Taiwan in 1996. Early observations following teaching with the so-called "silent mentors" noted less negative emotional impact on the students. With increasing number of body donation following the initiation of the silent mentor programme as reported in some regions, we will be able to continue the time-honoured cadaveric dissection for anatomy teaching, at the same time promoting humanistic values on junior doctors.

Ulnar Osteotomy with 2-Pin Unilateral Gradual Distraction for Treatment of Chronic Monteggia Fracture: A Case Report.

Missed Monteggia fracture leading to chronic radial head dislocation is a known complication. The surgical treatment options remain challenging. The aim of treatment is to reduce the radial head and to maintain the stability of the elbow in all ranges of motion. A few surgical techniques have been described with complications. We report the case of a 13 years old boy with chronic radial head dislocation as a result of an unrecognised Monteggia fracture-dislocation for eight years. We successfully reduced the radial head and corrected the cubital valgus from 45 degrees to 10 degrees with a proximal ulna osteotomy and gradual distraction with 2-pin Monotube external fixator. The correction was uneventful with good functional outcome.

A simple practical protocol for care of metal-skin interface of external fixation.

Patients treated with external fixation for limb reconsturciton or fracture stabilization equire regular and prolongedperiod of pin-tract care involving frequent visits to clinic and dressing traditionally carried out by trained nurses or medical assistants. A simple method of do-it-yourself dressing was introduced in our institution and this study was undertaken to evaluate the effectiveness of the protocol. Sixty patients (40 trauma-related problems and 20 congenital or developmental disorders) were enrolled into the study. Following application of external fixation, the patients and/or their caretakers were taught on how to do pin-site dressing using normal saline or drinking water as cleansing solution on daily basis. Patients were discharged on the second or third post-operative day and were followed-up every two weeks for an average 182 days (range 66 to 379 days) with special attention on identifying pin-tract infection. A simple grading system for pin-tract infections was proposed. Of 40 patients with trauma-related problems. 65% were post-traumatic infections. There were 788 metal-skin interfaces (239 half-pin fixations and 549 tensioned wire fixations. A total 143 metal-skin interface infections (18.1%) involving half-pin sites (41.3%) and tensioned wire sites (58.7%) was noted. Majority were grade I infections (79.7%), 18.8% grade II and only 1.4% grade III. Most infections (81%)were caused by Staphylococcus aureus. Grade I infections were successfully treated with frequent dressing, grade II by adjunctive oral antibiotic but grade III infections required removal of fixator. All eventually healed. Do yourself non-sterile dressing of metal-skin interfaces is a cost-effective method of pin-site care with a low infection rate. The infections were sucessfully treated using guidelines according to the proposed classification of pin-tract infections.

Total knee replacement subsequent to severe necrotising fasciitis of the lower limb.

The incidence of wound related complication following total knee arthroplasty is as high as 10%-20%. To perform total knee arthroplasty in a knee with extensive scarring around the knee can be a challenging task. We report a case of 55-year-old diabetic woman, who had total knee arthroplasty, performed two years after she had recovered from necrotizing fasciitis around the right knee. Understanding the vascular anatomy around the knee is of paramount importance in the planning of skin incision to ensure fewer wound related complications.

Size of interlocking nails used in the treatment of diaphyseal femoral fractures.

Fracture of the femur is most commonly treated with interlocking nailing. We conducted this study to describe and analyze the size of femoral interlocking nails used in our local population. This is a retrospective study on reamed intramedullary interlocking nailing procedures performed between 1st July 1998 and 30th June 2003. Demographic data, the diameter and length of femoral nails used were obtained from patient's medical record. A total of 267 procedures were included. The most common diameter used was 10 mm (56.9%), followed by 11 mm (27.0%) and 12 mm (13.1%). Only 2.6% of the nails were less than 10 mm in diameter. The most common nail length was 38 cm (31.1%), followed by 36 cm (24.9%) and 40 cm (19.5%). The longest nail used was 46 cm while the shortest 32 cm. The most commonly used femoral nails were of 10 mm diameter with the length ranging from 36 to 40 cm, which is smaller than those reported in the English literature. Nails with diameter smaller than 10 mm were required in 2.6% of patients.

Necrotizing fasciitis of the lower limb: an outcome study of surgical treatment.

Necrotizing fasciitis is a limb- and life-threatening rapidly spreading infection affecting the deep fascia with secondary necrosis of the subcutaneous tissue. It requires immediate medical attention and emergency surgery to prevent morbidity and death. This study was undertaken to determine its co-morbidity and risk factors affecting the outcome of its surgical treatment. This is a retrospective review of 36 cases of necrotizing fasciitis of the lower limb treated in our center between 1998 and 2002. Only 19% of the cases were correctly diagnosed upon admission and 48.6% were initially diagnosed as 'cellulitis'. Diabetes mellitus was the most common co-morbid. Pseudomonas, Staphylococcus, Streptococcus and Enterobactericae were the common pathogens isolated. Ten patients (27.8%) had major amputation as part of radical debridement. The overall mortality rate was 36% with laboratory parameters: high serum urea and creatinine, and low haemoglobin levels were predictors for higher mortality. Poor white cell response which is common in diabetic patients and a delay in surgical debridement were. notable attributes to a higher mortality. Necrotizing fasciitis is a serious infection associated with significant morbidity and mortality. A poor white blood cell response, high serum urea and creatinine, and low haemoglobin level were the predictors for mortality. Early diagnosis and prompt treatment are of paramount importance in the treatment of this infection.

Pattern of Presentation and Outcome of Short-term Treatment for Idiopathic Clubfoot / CTEV with Ponseti Method.

Introduction: Congenital Talipes Equinovarus (CTEV) is a common congenital foot deformity that is associated with long term disability. Treatment with Ponseti method has been successful especially for children who present early. We conducted this study to investigate the age of presentation of children and report the early outcome. Materials: This is a retrospective study from a single institution. We included 31 patients with 45 idiopathic clubfeet and investigated problems and success rate at the end of serial casting. Results: Mean age at presentation was 4.9 months. The mean number of casting was 6 and mean duration of casting was 2.7 months. The initial success rate of 91.1%, with four feet (8.8%) diagnosed as resistant clubfoot and eventually required soft tissue surgery. With mean follow up of 14.1 months, four other feet (8.8%) developed relapse but were treated with repeat Ponseti method. Conclusion: Many CTEV patients present late for treatment. However, the Ponseti method remained effective with high initial success rate of 91.1%. Relapsed CTEV can still be treated successfully with repeat casting using the Ponseti method.

Physical and Clinical Evaluation of Hip Spica Cast applied with Three-slab Technique using Fibreglass Material.

Introduction: Hip spica casting is an important component of treatment for developmental dysplasia of the hip (DDH) and popular treatment method for femur fractures in children. Breakage at the hip region is a relatively common problem of this cast. We have developed a three-slab technique of hip spica application using fibreglass as the cast material. The purpose of this review was to evaluate the physical durability of the spica cast and skin complications with its use. Methodology: A retrospective review of children with various conditions requiring hip spica immobilisation which was applied using our method. Study duration was from 1st of January 2014 until 31st December 2015. Our main outcomes were cast breakage and skin complications. For children with hip instability, the first cast would be changed after one month, and the second cast about two months later. Results: Twenty-one children were included, with an average age of 2.2 years. The most common indication for spica immobilisation was developmental dysplasia of the hip. One child had skin irritation after spica application. No spica breakage was noted. Conclusion: This study showed that the three-slab method of hip spica cast application using fibreglass material was durable and safe with low risk of skin complications.

Extracorporeal shock wave therapy for musculoskeletal pathology--a literature review.

For more than two decades extracorporeal shock wave lithotripsy has emerged as the standard therapy for calculi in the kidney and urinary tract, and biliary system. Application of extracorporeal shock waves in orthopaedics involves treatment of recalcitrant chronic pain of plantar fasciitis, tennis elbow and calcifying tendonitis of the shoulder. This review explores current evidence-based issues related to its potential use as a treatment option for some musculoskeletal conditions.