Transfer Validity of Pediatric Supracondylar Humeral Fracture Pin Placement Practice on In-Theater Performance by Orthopedic Trainees Using an Augmented Reality Simulator: Protocol for a Pilot Interventional Cohort Study With a Retrospective Comparator Cohort.

BACKGROUND: Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray-guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of "see one, do one, teach one" are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients. OBJECTIVE: This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees. METHODS: This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort's performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training. RESULTS: As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021). CONCLUSIONS: This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/38282.

An Update on Pediatric Acute Hematogenous Osteomyelitis in New Zealand - A Decade on.

INTRODUCTION: New Zealand (NZ) has high rates of pediatric acute hematogenous osteomyelitis (AHO) with males and children of Pasifika and Maori ethnicity overrepresented. AIMS: To update the incidence of Pediatric AHO over 10 years, identifying trends in presentation, organisms, treatment, and outcomes. METHODS: A 10-year retrospective review of children aged 6 weeks to 15 years admitted with Pediatric AHO across two centers from 2008 to 2017. Demographic data, features of presentation, investigations, management, and complications were collected. Incidence was calculated from census data. Data were compared with our osteomyelitis database from the previous decade. (1). RESULTS: 796 cases were identified. The incidence was 18 per 100,000 per annum. The average age was 7.7 years. Pasifika and Maori children are overrepresented (57%). 370 children (51%) came from low socioeconomic areas. Methicillin-sensitive Staphylococcus aureus was the most common pathogen (87%). Methicillin-resistant Staphylococcus aureus (MRSA) rates are low (4.4%). Forty-four (5.5%) children were admitted to the Pediatric Intensive Care Unit (PICU) with 9% mortality. The mean duration of antibiotics was 40 days. 325 children (41%) had surgery. Chronic infection has increased from 1.7% to 5.7%. CONCLUSIONS: NZ has high rates of AHO, however, the incidence has decreased from the previous decade. Males, those in low socioeconomic areas, Pasifika and Maori have high disease burden. The use of MRI as a diagnostic modality has increased. Future studies should focus on improving treatment via prospective analysis and reporting long-term morbidity to improve outcomes for children with severe disease and reduce rates of chronic infection.

A microbiology study on the wounds of pediatric patients undergoing spinal fusion for scoliosis.

PURPOSE: Surgical site infection is a significant complication in posterior spinal fusion for scoliosis in pediatric and adolescent patients. Current literature demonstrates a lack of consensus regarding best prophylactic systemic and topical antibiotic regimens for reducing infection rates. This study aims to identify which common microbes are present at particular locations in the spine, and whether these are covered by our current systemic and topical antibiotic prophylaxis regimens. METHODS: A prospective observational study at a National Children's Hospital was conducted on 21 consecutive patients who underwent elective surgery for spinal deformity. Swabs were taken from four layers of the spine, including the superficial skin surface at the start of the case (after surgical site preparation with povidone-iodine), the deep dermis, and the deep surgical bed at the end of exposure and again after the corrective maneuver prior to closure. At each layer, swabs were taken from the proximal, middle, and distal portion of the wound. Swabs were sent to the laboratory for culture and susceptibility testing. RESULTS: Thirteen (62%) of patients had positive microbial growth. Two microbes were identified, Staphylococcus epidermidis (9.5% of patients) and Cutibacterium acnes (Propionibacterium acnes) (52% of patients). 100% of these microbes were sensitive to cefazolin and vancomycin. 3% of patients had positive growth at the skin layer, 32% positive at the dermal layer, 17% positive after exposure, and 40% positive at the conclusion of the case (p = 0.006). No difference was observed in microbial presence in the upper thoracic, lower thoracic and lumbar spine. CONCLUSION: Despite adequate surgical site preparation and sterile procedure, microbial contamination remains abundant in the dermal layer and deeper in the spinal wound throughout the case.

A Prospective, Median 15-Year Comparison of Ponseti Casting and Surgical Treatment of Clubfoot.

BACKGROUND: In 2010, 2 authors of this current study reported the results of Ponseti treatment compared with primary posteromedial release (PMR) for congenital talipes equinovarus in a cohort of 51 prospective patients. This current study shows outcomes recorded at a median of 15 years after the original treatment. METHODS: Patient health records were available for all 51 patients at a median of 15 years (range, 13 to 17 years) following treatment of congenital talipes equinovarus with either the Ponseti method (25 patients [38 feet]) or PMR (26 patients [42 feet]). Thirty-eight of 51 patients could be contacted, and 33 patients (65%) participated in the clinical review, comprising patient-reported outcomes, clinical examination, 3-dimensional gait analysis, and plantar pressures. RESULTS: Sixteen (42%) of 38 Ponseti-treated feet and 20 (48%) of 42 PMR-treated feet had undergone a further surgical procedure. The PMR-treated feet were more likely to undergo osteotomies and intra-articular surgical procedures (15 feet) than the Ponseti-treated feet (5 feet) (p < 0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group, compared with the PMR group, demonstrated better Dimeglio scores (5.8 compared with 7.0 points; p < 0.05), Disease Specific Instrument (80.7 compared with 65.6 points; p < 0.05), Functional Disability Inventory (1.1 compared with 5.1; p < 0.05), and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire scores (52.2 compared with 46.6 points; p < 0.05), as well as improved total sagittal ankle range of motion in gait and ankle plantar flexion range at toe-off. The PMR group with clinical hindfoot varus displayed higher pressures in the lateral midfoot and the forefoot. CONCLUSIONS: Although the numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR-treated feet had greater numbers of osteotomies and intra-articular surgical procedures. Functional outcomes were improved at a median of 15 years for feet treated with the Ponseti method compared with feet treated with PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti method as the initial treatment of choice for idiopathic clubfeet. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

How Do Complications Within the First 30 days after Spinal Deformity Surgery in Children with Cerebral Palsy Affect Length of Stay?

BACKGROUND: Surgery for spinal deformity in patients with cerebral palsy is reported to have high perioperative complication rates. However, minor complications are not generally reported and the influence of the varied severity of complications on length of stay is not known. Understanding the risk factors for both minor and major perioperative complications and their effect on length of stay is important information for clinicians who seek to improve care for this group of children. QUESTIONS/PURPOSES: (1) What is the prevalence of postoperative complications in the first 30 days after surgery for spinal deformity in a New Zealand national cohort of children with cerebral palsy using the Clavien-Dindo classification? (2) What are the patient and operative predictive risk factors for minor and major perioperative complications? (3) What is the effect of year of operation on risk of minor and major perioperative complications? (4) What is the effect of perioperative complications on length of stay? METHODS: We conducted a retrospective cohort study, identifying all children in New Zealand with a confirmed diagnosis of cerebral palsy who had surgery for a spinal deformity from January 1997 to January 2018. Two hundred-three patients with cerebral palsy (102 boys) were surgically treated for a spinal deformity, at a mean age of 14 ± 3 years, at one of three centers in New Zealand. Six children had Gross Motor Function Classification System Level II or III, 66 had Gross Motor Function Classification System Level IV, and 131 had Gross Motor Function Classification System Level V. Thirty-day perioperative complications were extracted from the patients' health records and classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to identify patient and operative risk factors for complications, and the effect on length of stay. RESULTS: In all, 85% of patients experienced at least one perioperative complication. There were 300 Clavien-Dindo Grade I complications in 141 patients, 156 Clavien-Dindo Grade II complications in 102 patients, 25 Clavien-Dindo Grade III complications in 22 patients, 29 Clavien-Dindo Grade IV complications in 28 patients, and one Clavien-Dindo Grade V complication (death; 0.5%). Univariate analysis showed that multiple independent factors, Gross Motor Function Classification System Level V ability (odds ratio 2.13 [95% confidence interval 1.15 to 3.95]; p = 0.02), seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01), preoperative Cobb angle of greater than 70° (OR 2.40 [95% CI 1.20 to 4.78]; p < 0.01), and anterior approach to surgery (OR 3.29 [95% CI 1.21 to 8.90]; p = 0.02), were associated with Grade I complications but, of these factors, only the presence of a seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01) was associated with Grade I complications on multivariate analysis. Previous recurrent respiratory infections predicted an increased risk of Clavien-Dindo Grade II complications (OR 3.6 [95% CI 1.81 to 7.0]; p = 0.03). The presence of a feeding gastrostomy was associated with an increased risk of Clavien-Dindo Grade IV complications (OR 2.6 [95% CI 1.19 to 5.87]; p = 0.02). The year of operation did not influence the frequency of any grade of complication, but the presence of any complication led to an increased length of stay. CONCLUSION: Overall, 85% of patients with cerebral palsy had at least one complication after spinal deformity surgery and 25% had major complications (Grades III, IV, and V), with proportionate increases in the postoperative length of stay. Patient-specific factors aid in the identification of complication risk. LEVEL OF EVIDENCE: Level II, prognostic study.

Temporoparietal Fascial Flap for Soft Tissue Reconstruction of Pediatric and Young Adult Foot Defects: A Case Series.

Soft tissue defects of the foot due to trauma, infection, or malignancy are common and present a reconstructive challenge, as the foot requires specialized tissue that is thin, supple, yet durable enough to support the high demand of its function. The temporoparietal fascial flap, based on the superficial temporal artery and vein, is a reliable and versatile flap that possesses all these advantages. We present a case series detailing our experience with this flap for reconstruction of post-traumatic soft tissue defects of the foot in 4 patients (3 children and 1 young adult) with 5-year follow-up data. All patients were able to use the foot normally again to full capacity and wear normal footwear. They were also satisfied with the aesthetic outcome of the reconstruction and well-concealed donor site. This series highlights the success of this flap in providing excellent functional and aesthetic coverage for soft tissue foot defects in children and young adults, with minimal donor site morbidity.

Pediatric Tibial Osteomyelitis.

BACKGROUND: Osteomyelitis shows a strong predilection for the tibia in the pediatric population and is a significant source of complications. The purpose of this article is to retrospectively review a large series of pediatric patients with tibial osteomyelitis. We compare our experience with that in the literature to determine any factors that may aid diagnosis and/or improve treatment outcomes. METHODS: A 10-year retrospective review was performed of clinical records of all cases of pediatric tibial osteomyelitis managed at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007, at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kids First Hospital. RESULTS: One hundred ninety-one patients fulfilled the inclusion criteria, and had a review of clinical notes and relevant investigations. The average duration of symptoms before presentation to hospital was 5.7 days. Less than 40% of patients had a recent episode of trauma. Almost 60% of patients could not bear weight on admission. Over 40% of patients had a temperature above 38°C. Erythrocyte sedimentation rate was elevated in 78% and the C-reactive protein was elevated in 90% of patients. In total, 42% of blood cultures and almost 75% of tissue cultures were positive, with Staphylococcus aureus being the most commonly cultured organism. X-rays, bone scans, and magnetic resonance imaging were all used to aid the diagnosis. About 43% of patients had surgery. Treatment length was an average of 2 weeks 6 days of intravenous antibiotics followed by 3 weeks 2 days of oral treatment. Six postsurgical complications and 46 readmissions were noted: 25 for relapse, with the remainder due to social and antibiotic-associated complications. CONCLUSIONS: Although generally diagnosed on presentation, pediatric tibial osteomyelitis can require more sophisticated investigations and prolonged management. Treatment with intravenous and oral antibiotics and surgical debridement where indicated can lead to a good clinical outcome, although complications are often noted. LEVEL OF EVIDENCE: Level IV-Prognostic study.

Mutations Preventing Regulated Exon Skipping in MET Cause Osteofibrous Dysplasia.

The periosteum contributes to bone repair and maintenance of cortical bone mass. In contrast to the understanding of bone development within the epiphyseal growth plate, factors that regulate periosteal osteogenesis have not been studied as intensively. Osteofibrous dysplasia (OFD) is a congenital disorder of osteogenesis and is typically sporadic and characterized by radiolucent lesions affecting the cortical bone immediately under the periosteum of the tibia and fibula. We identified germline mutations in MET, encoding a receptor tyrosine kinase, that segregate with an autosomal-dominant form of OFD in three families and a mutation in a fourth affected subject from a simplex family and with bilateral disease. Mutations identified in all families with dominant inheritance and in the one simplex subject with bilateral disease abolished the splice inclusion of exon 14 in MET transcripts, which resulted in a MET receptor (MET(Δ14)) lacking a cytoplasmic juxtamembrane domain. Splice exclusion of this domain occurs during normal embryonic development, and forced induction of this exon-exclusion event retarded osteoblastic differentiation in vitro and inhibited bone-matrix mineralization. In an additional subject with unilateral OFD, we identified a somatic MET mutation, also affecting exon 14, that substituted a tyrosine residue critical for MET receptor turnover and, as in the case of the MET(Δ14) mutations, had a stabilizing effect on the mature protein. Taken together, these data show that aberrant MET regulation via the juxtamembrane domain subverts core MET receptor functions that regulate osteogenesis within cortical diaphyseal bone.

Rigid fixation improves outcomes of spinal fusion for C1-C2 instability in children with skeletal dysplasias.

BACKGROUND: Upper cervical instability is common in many skeletal dysplasias, and surgical treatment can be difficult because of small, fragile osseous elements. In this study of children with skeletal dysplasia and upper cervical instability, we compared fusion rates and complications between (1) patients treated with no instrumentation or with wiring techniques and (2) those who underwent rigid cervical spine instrumentation. We also sought to characterize the presentation and common parameters of upper cervical instability in this population. METHODS: A multicenter study identified twenty-eight children with skeletal dysplasia who underwent surgery from 2000 through 2011 for C1-C2 instability and were followed for a minimum of two years. Fourteen children were treated with no instrumentation or with instrumentation with wires or cables (nonrigid-fixation group) and fourteen were treated with screws (or hooks) and rods (rigid-fixation group). All patients received autograft, and twenty (twelve in the nonrigid group and eight in the rigid group) were treated with a halo-body jacket. RESULTS: Fourteen children had C1-C2 fusion, and fourteen had occipitocervical fusion. Eleven (39%) underwent spinal cord decompression. The nonunion rate was significantly higher in the nonrigid-fixation group (six of fourteen) than in the rigid-fixation group (zero of fourteen; p = 0.0057). Complications, including nonunion, occurred in nine patients in the nonrigid group and one patient in the rigid group. However, two of the complications in the nonrigid-fixation group were vertebral artery bleeding episodes that actually occurred during an attempt at rigid fixation (the fixation was subsequently done with wiring). No new neurologic deficits were observed. Five of the seven children with a preoperative neurologic deficit showed at least partial recovery, with significant improvement in the Japanese Orthopaedic Association upper-extremity score (p = 0.047). CONCLUSIONS: The nonunion rate is relatively high after patients undergo spinal fusion for C1-C2 instability with nonrigid instrumentation, even if a halo-body jacket is applied. Rigid fixation with screws and rods improves fusion rates.

Pediatric Acute Hematogenous Osteomyelitis.

BACKGROUND: Osteomyelitis continues to be a significant problem among the New Zealand pediatric population. We present a large series of acute hematogenous osteomyelitis (AHO) cases, with the aim to identify any changing trends and guide successful management of the disease. METHODS: A 10-year retrospective review was performed of clinical records of children with AHO at the 2 children's orthopaedic departments in the Auckland region. Cases were identified from Starship Children's Hospital between 1997 and 2007 and Middlemore's Kidz First Hospital between 1998 and 2008. RESULTS: A total of 813 cases of pediatric AHO were identified. The incidence was 1:4000, which was decreasing over the 10-year period. There was a male predominance and New Zealand (NZ) Maori and Pacific Islanders were overrepresented. The diagnosis was made clinically in 27%, radiographically in 66%, and surgically in 7%. The most common pathogen was Staphylococcus aureus and the incidence of methicillin-resistant S. aureus was low (2%). The average length of antibiotic treatment was 44 days and 44% required surgery. This produced a recurrence rate of only 7% and a 15% treatment-related complication rate. CONCLUSIONS: In the New Zealand population, the incidence of AHO remains high with NZ Maori and Pacific Islanders overrepresented. The predominant pathogen remains S. aureus and our population has a very low incidence of methicillin-resistant S. aureus; flucloxacillin remains a good choice for empiric treatment in our population. Our rate of relapse and subsequent chronic osteomyelitis is low. This could be explained by traditionally longer antibiotic courses; however, this may also lead to increased treatment-related complications. Through prompt and accurate diagnosis with the aid of laboratory and radiologic tests and effective treatment with appropriate antibiotics (guided by local pathogen sensitivities) and surgical treatment when indicated, AHO can be well managed with minimal severe complications. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Pediatric Humeral Osteomyelitis.

BACKGROUND: Osteomyelitis is a common problem among the pediatric population. The humerus is the most commonly affected bone in the upper limb; however, there are relatively few series in the literature. This article retrospectively reviews a large number of cases of pediatric humeral osteomyelitis. We aim to further define the disease and its clinical course to aid in improved treatment. METHODS: A 10-year retrospective review was performed of clinical records of pediatric humeral osteomyelitis at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007 at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kidz First Hospital. RESULTS: Forty-nine patients were identified. Sixty-one percent were male with an average age of 4.2 years. Maori and Pacific Islanders were overrepresented. Seventy-eight percent were not using the limb, 70% complained of pain. Only 55% were febrile. White cell count, erythrocyte sedimentation rate, and C-reactive protein raised in 73%, 74%, and 79% of cases, respectively. X-ray, bone scintigraphy, and particularly magnetic resonance imaging were useful in radiologic diagnosis. Blood and tissue cultures revealed Staphylococcus aureus as the most common organism; there were 2 cases of community-acquired methicillin-resistant S. aureus. The distal humerus was more commonly affected. Fifty-three percent required surgery. Antibiotic therapy averaged 2.7 weeks intravenous and 2.6 weeks of oral therapy. There were 7 cases with adjacent septic arthritis, which had higher inflammatory markers. Major complications included 2 multiorgan failure and 1 growth disturbance. CONCLUSIONS: Humeral osteomyelitis can be diagnosed with an appropriate history, clinical examination, and investigations. One should be aware of concurrent septic arthritis and be prepared to treat this urgently. Those children with septic arthritis were not using the limb and had higher inflammatory markers. Treatment with intravenous and oral antibiotics and surgical debridement/washout if indicated can lead to good clinical outcomes with minimal complications. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Early results of total hip arthroplasty in patients with slipped upper femoral epiphysis compared with patients with osteoarthritis.

We have investigated the results of primary total hip arthroplasty (THA) performed in patients with slipped upper femoral epiphysis (SUFE). Through the New Zealand Joint Registry, we identified all patients with SUFE undergoing primary THA (n = 117) and all patients with primary osteoarthritis (OA) undergoing primary THA (n = 40 589) between January 1, 1999, and December 31, 2008. Baseline information, operative characteristics, and postoperative outcomes were analyzed and compared between the SUFE and the OA groups. There was no significant difference in postoperative Oxford Hip Score or revision rate between the 2 groups. Our results support THA as a successful surgical option in the management of degenerative arthritis in SUFE, with comparable functional outcomes and revision rates to THA performed for primary OA.

Early results of total hip arthroplasty in patients with developmental dysplasia of the hip compared with patients with osteoarthritis.

We have investigated the results of primary total hip arthroplasty (THA) performed in patients with developmental dysplasia of the hip (DDH). Through the New Zealand Joint Registry, we identified all patients with DDH undergoing primary THA (n = 1205) and all patients with primary osteoarthritis (OA) undergoing primary THA (n = 40 589) between January 1, 1999, and December 31, 2008. Postoperative outcomes, baseline information, and operative characteristics were analyzed and compared between the DDH and the OA groups. There was no significant difference in Oxford Hip Score or revision rate between the 2 groups. Our results support THA as a successful surgical option in the management of degenerative arthritis in DDH, with comparable functional outcomes and revision rates to THA performed for primary OA.

The paediatric Bohler's angle and crucial angle of Gissane: a case series.

BACKGROUND: Bohler's angle and the crucial angle of Gissane can be used to assess calcaneal fractures. While the normal adult values of these angles are widely known, the normal paediatric values have not yet been established. Our aim is to investigate Bohler's angle and the crucial angle of Gissane in a paediatric population and establish normal paediatric reference values. METHOD: We measured Bohler's angle and the crucial angle of Gissane using normal plain ankle radiographs of 763 patients from birth to 14 years of age completed over a five year period from July 2003 to June 2008. RESULTS: In our paediatric study group, the mean Bohler's angle was 35.2 degrees and the mean crucial angle of Gissane was 111.3 degrees. In an adult comparison group, the mean Bohler's angle was 39.2 degrees and the mean crucial angle of Gissane was 113.8 degrees. The differences in Bohler's angle and the crucial angle of Gissane between these two groups were statistically significant. CONCLUSION: We have presented the normal values of Bohler's angle and the crucial angle of Gissane in a paediatric population. These values may provide a useful comparison to assist with the management of the paediatric calcaneal fracture.

Pediatric calcaneal osteomyelitis.

BACKGROUND: Osteomyelitis continues to be a common problem amongst the pediatric population. Osteomyelitis of the calcaneus is an uncommon problem that still poses a problem to the treating physician. The purpose of this article is to retrospectively review a large series of pediatric patients with calcaneal osteomyelitis. We compare our experience with that in the literature to determine any factors that may aid earlier diagnosis and or improve treatment outcomes. METHODS: A 10-year retrospective review was performed of clinical records of all cases of pediatric calcaneal osteomyelitis managed at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007, at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kids First Hospital. RESULTS: Sixty patients fulfilled the inclusion criteria, and had a review of clinical notes and relevant investigations. The average duration of symptoms before presentation to hospital was 6.8 days. About 40% of patients had a recent episode of trauma. About 82% of patients could not bear weight on admission. Only 22% of patients had a temperature above 38°C. Erythrocyte sedimentation rate was elevated in 81% and the C-reactive protein was elevated in 77% of patients. About 27% of patients had positive blood cultures with Staphylococcus aureus being the most commonly cultured organism. X-rays, bone scans, and magnetic resonance imaging were all used to aid the diagnosis. About 20% of patients had surgery with an average of 1.3 surgeries for those who progressed to surgery. Treatment length was an average of 2 weeks 6 days of intravenous antibiotics followed by 3 weeks 2 days of oral treatment. There were no postsurgical complications and 10 readmissions: 3 for relapse, 3 for peripherally inserted central catheter line problems, and 4 for antibiotic-associated complications. CONCLUSIONS: Although sometimes more difficult to diagnose, calcaneal osteomyelitis can be diagnosed with an appropriate history, clinical examination, and investigations. Treatment with intravenous and oral antibiotics and surgical debridement if indicated can lead to a good clinical outcome with minimal complications.

Separating the chicken from the egg: an attempt to discern between clubfoot recurrences and incomplete corrections.

PURPOSE: To better delineate between incomplete clubfoot correction and true clubfoot recurrence based on the time at which the deformity reappears and the treatment necessary to correct the foot. METHODS: A chart review of all idiopathic clubfoot at a single institution treated by either the Ponseti method or short leg casting and surgery were reviewed for recurrent deformity involving the tibia, ankle, or foot. Comparisons of treatment required to correct deformities were made between those noticed within six months of initial treatment and those noticed after six months. Similar comparisons were made based on the initial treatment of the deformity. RESULTS: Forty-four of 51 patients showed some clinical deformities after their initial treatment. Over half of these deformities either resolved or did not require operative intervention at a minimum of two years follow-up, while 43% (19/44) were felt to require surgery. Eight patients had deformities re-appear within six months of initial treatment and eleven patients after six months. Six of the eight patients requiring surgery with deformities noticed less than six months after initial treatment required correction of structural deformities (osteotomies and posterior-medial releases), whereas 10/11 patients requiring surgery for deformities noticed after six months required correction for dynamic deformities. These differences were significant (p=0.01). No difference in terms of the number of deformities noticed (22/25 and 22/26) and number requiring surgery (11/22 in the Ponseti group and 8/22 in the surgical group) were found. However, deformities requiring further surgery in the surgical group re-appeared earlier 0.23±0.2 years than those in the Ponstei group 1.7±1 years (p=0.001). These earlier re-appearing deformities required more structural surgery (6/8) than those in the later appearing Ponseti group (1/11; p=0.01). CONCLUSIONS: Nearly half of all re-appearing deformities required surgery. The deformities noticed within six months of initial correction required more structural surgery to correct than those noticed after six months. We propose that the recurrent deformities noticed before six months of age represent incomplete corrections and those after six months true recurrences. Feet initially treated with surgery may be more prone to incomplete correction whereas those treated by the Ponseti method may be more prone to recurrence. SIGNIFICANCE: Not all re-appearing clubfoot deformities are the same. The initial treatment and time at which they first appear may have implications as to the surgery required to correct.

Ponseti method compared with surgical treatment of clubfoot: a prospective comparison.

BACKGROUND: Current trends in the treatment of idiopathic clubfoot have shifted from extensive surgical release to more conservative techniques. The purpose of the present study was to prospectively compare the results of the Ponseti method with those of surgical releases for the correction of clubfoot deformity. METHODS: We prospectively compared patients who had idiopathic clubfoot deformities that were treated at a single institution either with the Ponseti method or with below-the-knee casting followed by surgical release. The clinical records of the patients with a minimum duration of follow-up of two years were reviewed. All scheduled and completed operative interventions and associated complications were recorded. RESULTS: Fifty-five patients with eighty-six clubfeet were treated; forty feet were included in the group that was treated with the Ponseti method, and forty-six feet were included in the group that was treated with below-the-knee casts followed by surgery (with three of these feet requiring casting only). There was no difference between the groups in terms of sex, ethnicity, age at the time of first casting, pretreatment Pirani score (average, 5.2 in both groups), or family history. The average number of casts was six in the Ponseti group and thirteen in the surgical group. Of the feet that were treated with below-the-knee casts, forty-three underwent surgery, with forty-two undergoing major surgery (posterior release [eleven] or posteromedial release [thirty-one]). In the Ponseti group, fourteen feet required fifteen operative interventions for recurrences, with only one foot requiring revision surgery. Four of these fifteen were major (necessitating posterior [one] or posteromedial release [three]) while eleven were minor. Thirteen feet in the surgical group required fourteen surgical revisions. Two postoperative complications were seen in each group. CONCLUSIONS: While both cohorts had a relatively high recurrence rate, the Ponseti cohort was managed with significantly less operative intervention and required less revision surgery. The Ponseti method has now been adopted as the primary treatment for clubfoot at our institution.

Resource utilization in clubfoot management.

UNLABELLED: Both private and socialized healthcare systems require treatments to be not only effective, but also cost-efficient. Although the Ponseti method of clubfoot treatment is effective, its cost-effectiveness has not been demonstrated. We compared the difference in resource use between two prospective cohorts treated for clubfoot by either the Ponseti method or below-knee casting followed by primary surgical release in the socialized healthcare system of New Zealand. Using these cohorts and US billing data, costs of treating these cohorts in the US healthcare system were also calculated. Treatment of initial deformity, recurrences, and complications in both cohorts were included in the final assessment. Twenty-six patients (40 feet) were enrolled in the Ponseti cohort and 29 (46 feet) in the primary surgical cohort. For most patients, the Ponseti method was more cost-effective than the primary surgical treatment in both healthcare systems. The cost of treating both cohorts was lower in the socialized system than in the US healthcare system. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The outcomes of scoliosis surgery in patients with syringomyelia.

STUDY DESIGN: A retrospective review of a consecutive case series. OBJECTIVE: To describe patient demographics, syrinx morphology, and deformity characteristics, as well as postsurgical correction, progression, and complications. SUMMARY OF BACKGROUND DATA: Conflicting data are available on the natural and postsurgical history of patients with spinal deformity associated with syringomyelia. This is the largest series in the literature on the surgical outcomes of these patients. METHODS: All patients treated for spinal deformity at our institution with an associated syrinx were reviewed. Demographics, deformity morphology, treatment methods, and postoperative outcomes were measured and recorded. RESULTS: Thirteen patients met inclusion criteria. All were Lenke thoracic modifier normal or positive. Ten patients underwent neurosurgical decompression. All curves either progressed or remained unchanged following neurosurgical treatment. The average thoracic kyphosis measured 46 degrees (29 degrees-69 degrees). Thoracic kyphosis was significantly increased compared with a population of adolescent idiopathic patients (P = 0.00002). The average curve before scoliosis surgery was 71 degrees (31 degrees-119 degrees) in the coronal plane and 46 degrees (29 degrees-68 degrees) in the sagittal plane. The average correction from the initial scoliosis surgery was 48% (6%-83%). All patients had spinal cord monitoring or wake-up tests during surgery. There were no instances of spinal cord injury from surgery. Three patients progressed significantly following anterior fusion, 2 of whom required further corrective surgery. Following arthrodesis, 4 patients progressed >10 degrees during follow-up. CONCLUSION: The lack of thoracic hypokyphosis seen in idiopathic-like curves is a strong indicator of a possible underlying syrinx. Neurosurgical treatment of the syrinx did not improve the scoliosis. Caution should be exercised when choosing fusion levels, and arthrodesis should be planned with the underlying pathology in mind. Scoliosis surgery has proven to be safe in patients with treated syrinx when spinal cord monitoring or wake-up tests are used.

Early clubfoot recurrence after use of the Ponseti method in a New Zealand population.

BACKGROUND: Nonoperative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. The purpose of the current study was to examine the early rate of clubfoot recurrence following the use of the Ponseti treatment method in a New Zealand population and to analyze patient characteristics to identify factors predictive of recurrence. METHODS: Fifty-one consecutive babies with a total of seventy-three clubfeet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any subsequent operative treatment, was analyzed with respect to the severity at presentation, the time of presentation, the number of casts needed to obtain the initial correction, any family history of clubfoot, ethnicity, and the compliance with postcorrection abduction bracing. Recurrence was classified as minor, defined as requiring a tendon transfer or an Achilles tendon lengthening, or major, defined as requiring a full posterior or posteromedial surgical release to achieve a corrected plantigrade foot. RESULTS: Twenty-one (41%) of the fifty-one patients had a recurrence, which was major in twelve of them and minor in nine. The parents of twenty-six babies (51%) complied with the abduction bracing protocol, and only three of these children had a major recurrence. Compliance with abduction bracing was associated with the greatest risk reduction for recurrence (odds ratio, 0.2; p = 0.009). When the parents had not complied with the bracing protocol, the patient had a five times greater chance of having a recurrence. With the numbers studied, no significant relationships were found between recurrence and the severity at presentation, the time of presentation, the number of casts needed to obtain correction, ethnicity, or a family history of clubfoot. CONCLUSIONS: Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. When the parents comply with the bracing protocol, the Ponseti method is very effective at maintaining a correction, although minor recurrences are still common. When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected.