Comparison of cast materials for the treatment of congenital idiopathic clubfoot using the Ponseti method: a prospective randomized controlled trial.

BACKGROUND: The Ponseti method of congenital idiopathic clubfoot correction has traditionally specified plaster of Paris (POP) as the cast material of choice; however, there are negative aspects to using POP. We sought to determine the influence of cast material (POP v. semirigid fibreglass [SRF]) on clubfoot correction using the Ponseti method. METHODS: Patients were randomized to POP or SRF before undergoing the Ponseti method. The primary outcome measure was the number of casts required for clubfoot correction. Secondary outcome measures included the number of casts by severity, ease of cast removal, need for Achilles tenotomy, brace compliance, deformity relapse, need for repeat casting and need for ancillary surgical procedures. RESULTS: We enrolled 30 patients: 12 randomized to POP and 18 to SRF. There was no difference in the number of casts required for clubfoot correction between the groups (p = 0.13). According to parents, removal of POP was more difficult (p < 0.001), more time consuming (p < 0.001) and required more than 1 method (p < 0.001). At a final follow-up of 30.8 months, the mean times to deformity relapse requiring repeat casting, surgery or both were 18.7 and 16.4 months for the SRF and POP groups, respectively. CONCLUSION: There was no significant difference in the number of casts required for correction of clubfoot between the 2 materials, but SRF resulted in a more favourable parental experience, which cannot be ignored as it may have a positive impact on psychological well-being despite the increased cost associated.

CONTEXTE: La méthode de Ponseti pour la correction du pied bot congénital idiopathique a de tout temps spécifié l'utilisation du plâtre de Paris comme matériau de choix; il y a toutefois certains inconvénients associés au plâtre de Paris. Nous avons voulu déterminer l'influence du matériau utilisé (plâtre de Paris c. fibre de verre semi-rigide) sur la correction du pied bot selon la méthode de Ponseti. MÉTHODES: Les patients ont été assignés aléatoirement soit au plâtre de Paris soit à la fibre de verre semi-rigide en vue de l'intervention de Ponseti. Le principal paramètre mesuré était le nombre de plâtres requis pour corriger le pied bot. Les paramètres secondaires incluaient le nombre de plâtres en fonction de la gravité, la facilité de retrait du plâtre, la nécessité de sectionner le tendon d'Achille, le port assidu de l'attelle, le retour de la difformité, la nécessité d'autres plâtres et interventions chirurgicales auxiliaires. RÉSULTATS: Nous avons inscrit 30 patients : 12 ont été assignés au plâtre de Paris et 18 à la fibre de verre. On n'a noté aucune différence entre les groupes quant au nombre de plâtres requis pour la correction du pied bot (p = 0,13). Selon les parents, le retrait du plâtre de Paris était plus difficile p < 0,001), prenait plus de temps (p < 0,001) et nécessitait le recours à plus d'une méthode (p < 0,001). Au moment du dernier suivi à 30,8 mois, les intervalles moyens avant un retour de la difformité nécessitant la pose d'un autre plâtre et/ou une chirurgie ont été de 18,7 et 16,4 mois dans les groupes traités au moyen de la fibre de verre semi-rigide et du plâtre de Paris, respectivement.. CONCLUSION: On n'a noté aucune différence significative entre les 2 matériaux quant au nombre de plâtres requis pour corriger le pied bot, mais la fibre de verre a donné lieu à une expérience plus agréable pour les parents, ce qui ne peut être ignoré en raison de l'impact potentiellement positif sur le bien-être psychologique, et ce, malgré un coût plus élevé.

Reliability of MRI Interpretation of Discoid Lateral Meniscus: A Multicenter Study.

Background: Discoid lateral meniscus (DLM) has a varied and complex morphology that can be challenging to assess and treat. Preoperative magnetic resonance imaging (MRI) is frequently used for diagnosis and surgical planning; however, it is not known whether surgeons are reliable and accurate in their interpretation of MRI findings when defining the pathomorphology of DLM. Hypothesis: Surgeons experienced in treating DLM are able to reliably interpret DLM pathology using MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Knee MRI scans from 44 patients (45 knees) were selected from a pool of surgically treated patients with DLM. Five reviewers (fellowship-trained pediatric sports medicine surgeons) performed independent review of each MRI scan using the PRiSM Discoid Meniscus Classification. Inter- and intraobserver reliability of the rating factors-primary (width, height, presence of peripheral instability or tear) and secondary (location of instability or tear, tear type)-was assessed using the Fleiss κ coefficient, designed for multiple readers with nominal variables (fair reliability, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). Reliability is reported as κ (95% CI). Results: Interobserver reliability in assessing most primary and secondary characteristics ranged from substantial (meniscal width) to moderate (peripheral instability, anterior instability, posterior instability, and posterior tear). Intraobserver reliability for most characteristics ranged from substantial (peripheral instability, presence of tear, anterior instability, posterior instability, and posterior tear) to moderate (meniscal width, anterior tear, and tear type). Notable exceptions were presence of tear, anterior tear, and tear type-all with fair interobserver reliability. Height had poor interobserver reliability and fair intraobserver reliability. Conclusion: Orthopaedic surgeons reliably interpret MRI scans using the PRiSM Discoid Meniscus Classification for the majority of DLM characteristics but vary in their assessment of height and presence and type of tear. MRI evaluation may be helpful to diagnose discoid by width and identify the presence of instability: 2 major factors in the decision to proceed with surgery. Arthroscopic evaluation should be used in conjunction with MRI findings for complete DLM diagnosis.

Discoid Meniscus.

Discoid meniscus is the most common congenital variant of the meniscus. Its variability in pathology leads to a spectrum of clinical presentations in patients. Treatment must be tailored to the specific pathology of the discoid meniscus. Imaging studies such as radiographs and magnetic resonance imaging can be useful in confirming the diagnosis, but may be the most accurate in determining specific pathology. Thorough intraoperative evaluation of the discoid is critical to appropriate surgical management. Rim preservation and repair is preferred to prevent degenerative changes in the knee.

Femoral fractures in children younger than three years: the role of nonaccidental injury.

BACKGROUND: Nonaccidental injury (NAI) in children is a major cause of morbidity and mortality, with fractures being the second most common presentation. The presence of a femur fracture has been reported to be suggestive of nonaccidental trauma in 30% to 60% of young children. The purpose of this study was to determine the percentage of NAI in children younger than 3 years presenting with a femur fracture to a single institution within a western Canadian population. METHODS: A retrospective cohort study was performed for children younger than 3 years who presented to the Alberta Children's Hospital during the years 1994 to 2005. The primary outcome variable was the percentage of NAI associated with femur fracture. Secondary outcome variables included patient demographics, injury characteristics, radiological and other workup, and suspicion of NAI. RESULTS: The overall percentage of NAI was 11% (14/127 patients) and 17% (10/60 patients) in children younger than 12 months. Age younger than 12 months (P = 0.04), nonambulatory status (P = 0.004), delayed presentation (P = 0.002), mechanism of injury unwitnessed or inconsistent (P = 0.008), and other associated injuries (P = 0.006) were significant risk factors for NAI. CONCLUSIONS: Children younger than 3 years who present with femoral fracture are at risk for associated NAI, although perhaps this risk is not as high as previously thought. Regardless, a high index of suspicion is mandatory when these children are encountered, and careful screening with a thorough history, physical examination, and other investigations, where indicated, is warranted to rule out associated NAI. LEVEL OF EVIDENCE: Retrospective cohort study, level IV.