Are All Hardware Removals Equal?

The objective of this study is to report operative time and associated complications of six types of implants and to determine if surgeons are adequately compensated. Hardware removals were analyzed from 2014-2019. Implants were flexible nails, intramedullary rigid nails, long plates, screw(s), single guided-growth plates, and multiple guided-growth plates. Patient demographics, operative time, blood loss, complications, and relative value units (RVU)/min were collected. RVU/min was used to maximize rate. In total, 392 patients were analyzed. Long plate removals took significantly longer than screw removal, therefore RVU/min was significantly lower (p < 0.001). Long plate removals also took significantly longer, and RVU/min was significantly lower compared to guided-growth plate removal (p < 0.001). Intramedullary nails took significantly longer compared to flexible nails, nearly double the RVU/min (p = 0.02). The results from this study indicate that the RVU/ minute for these six different types of implant removals are not equal. Surgeons can use this data to set up their schedule to ensure maximum utilization. (Journal of Surgical Orthopaedic Advances 30(1):020-023, 2021).

Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room: A Multicenter Perspective.

BACKGROUND: The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management). METHODS: A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded. RESULTS: In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P<0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P<0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group. CONCLUSIONS: There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures. LEVEL OF EVIDENCE: Level III.

Incidence, Risk Factors, and Definition for Nonunion in Pediatric Lateral Condyle Fractures.

INTRODUCTION: Lateral condyle fractures are a common pediatric elbow injury. Nonunion is a known complication of this injury but its incidence and causative risk factors are unknown. Further, a clear and consistent definition of nonunion for pediatric lateral condyle fractures does not exist. The purpose of this study is to determine the rate of nonunion, the risk factors associated with it and to provide a clear definition. METHODS: A retrospective chart review of all pediatric lateral condyle fractures treated at an urban, tertiary pediatric care center between 2001 and 2014. Data collected included demographics, Weiss classification, type of treatment, follow-up, time from injury to surgery and complications. For patients with nonunions, additional treatments and final range of motion were also recorded. A nonunion was defined as lack of callus with fragment migration by 8 weeks after initiation of treatment. RESULTS: A total of 530 patients were identified of which 500 were available for review. There were 7/500 (1.4%) nonunions in the cohort. Nonunion occurred in 1.4% (2/140) of type I fractures, 0% (0 /178) of type II fractures, and 3% (5/168) of type III fractures. The only significant risk factor for nonunion was the presence of a type III fracture (P=0.05). Five patients with nonunion underwent revision surgery with a partially threaded cannulated cancellous screw. All of these patients went on to union. Four of the 5 patients had their screws removed after union. CONCLUSION: Nonunion after pediatric lateral condyle fracture is rare and is defined by lack of any callus with fragment migration at 8 weeks. The only significant risk factor for nonunion development was the presence of a type III fracture. Revision surgery with a partially threaded screw achieved union in all cases. LEVEL OF EVIDENCE: Level IV-retrospective case review.

Sacral Alar Iliac (SAI) Screws Fail 75% Less Frequently Than Iliac Screws in Neuromuscular Scoliosis.

BACKGROUND: Despite recent popularity of sacral alar iliac (SAI) screws for fusion to the pelvis for neuromuscular scoliosis, there are little data regarding the failure rate of this technique compared with traditional modes of iliac fixation. Theoretical advantages of the SAI screws are obviating the need for a rod to iliac screw connector and a lower implant profile. The purpose of this study is to determine whether SAI screws have fewer failures than iliac screws in neuromuscular scoliosis. METHODS: Review of neuromuscular patients treated with posterior spinal fusion with pelvic fixation from 2004 to 2012 with minimum 2-year follow-up was conducted. Medical records and imaging studies were reviewed. Patients were divided into 2 groups based on the type of pelvic fixation (SAI or iliac screws), and implant failures were compared between the groups. RESULTS: A total of 101 patients were reviewed, including 55 patients with iliac screws and 46 patients with SAI screws. Implant failures included: disengagement of the rod to iliac screw connector (10%, 10/101), separation of screw head from screw shaft (4%, 4/101), and set screw disengagement (2%, 2/101). The SAI group had a lower implant failure rate (7%, 3/46) compared with the iliac screw group (24%, 13/55) (P=0.031). Rod to iliac screw connectors failed in 18% (10/55) of patients. There were significantly less surgical revisions in the SAI group (2%, 1/46) for pelvic screw prominence compared with the iliac screw group (11%, 6/55) (P=0.027). CONCLUSIONS: SAI screws had a lower rate of implant failure and revision surgery compared with iliac screws. If rod to screw connector failures are excluded, the failure rate of SAI screws of 6.5% (3/46) is similar to that of iliac screws 5.5% (3/55); therefore, the most important advantage of the SAI technique may be obviating the need for a screw to rod connector. LEVEL OF EVIDENCE: Level III.

Muscle strength and knee range of motion after femoral lengthening.

Background and purpose - Femoral lengthening may result in decrease in knee range of motion (ROM) and quadriceps and hamstring muscle weakness. We evaluated preoperative and postoperative knee ROM, hamstring muscle strength, and quadriceps muscle strength in a diverse group of patients undergoing femoral lengthening. We hypothesized that lengthening would not result in a significant change in knee ROM or muscle strength. Patients and methods - This prospective study of 48 patients (mean age 27 (9-60) years) compared ROM and muscle strength before and after femoral lengthening. Patient age, amount of lengthening, percent lengthening, level of osteotomy, fixation time, and method of lengthening were also evaluated regarding knee ROM and strength. The average length of follow-up was 2.9 (2.0-4.7) years. Results - Mean amount of lengthening was 5.2 (2.4-11.0) cm. The difference between preoperative and final knee flexion ROM was 2° for the overall group. Congenital shortening cases lost an average of 5% or 6° of terminal knee flexion, developmental cases lost an average of 3% or 4°, and posttraumatic cases regained all motion. The difference in quadriceps strength at 45° preoperatively and after lengthening was not statistically or clinically significant (2.7 Nm; p = 0.06). Age, amount of lengthening, percent lengthening, osteotomy level, fixation time, and lengthening method had no statistically significant influence on knee ROM or quadriceps strength at final follow-up. Interpretation - Most variables had no effect on ROM or strength, and higher age did not appear to be a limiting factor for femoral lengthening. Patients with congenital causes were most affected in terms of knee flexion.

Percutaneous Reduction of Displaced Radial Neck Fractures Achieves Better Results Compared With Fractures Treated by Open Reduction.

There is uniform agreement in the literature that radial neck fracture with <30 degrees of angulation and minimal translation in younger children can be managed by casting alone, without the need for closed reduction. For more severe fractures, closed manipulation techniques followed by percutaneous reduction technique (in case closed reduction fails) should be performed before switching to an open reduction technique. Debate still exists regarding the best treatment protocol for severely displaced fractures. Although some surgeons favor open reduction with the argument that repeat manipulations may cause iatrogenic injuries, and stiffness, others believe that open reduction is one of the most contributing factors for poor outcome. On the basis of this paradigm, we present our treatment algorithm based on the data demonstrating that percutaneous reduction of displaced radial neck fractures achieve better results than open reduction.

Patient Satisfaction After Limb Lengthening With Internal and External Devices.

External fixation has long been used for limb lengthening but can result in many complications, such as tethering of the soft tissues, pain, decreased joint motion, scarring, and nerve injury. Recently, a controllable, telescopic, internal lengthening nail was developed to address many of these issues and hopefully improve the overall experience for the patient. The satisfaction rates of internal and external fixation for limb lengthening were compared in 16 patients, all of whom have experienced both methods. Thirteen out of 16 patients responded to a limb-lengthening questionnaire, developed by the authors for this patient population. Patients preferred the internal device with respect to overall satisfaction, reduced pain, ease of physical therapy, and better cosmetic appearance. When asked which device they would prefer if another surgery was required, all patients chose the internal device. From the patients' perspective, the internal lengthening device is an improvement over the traditional external fixator.

Internal lengthening device for congenital femoral deficiency and fibular hemimelia.

BACKGROUND: Patients with congenital limb shortening can present with joint instability, soft tissue contractures, and significant leg length discrepancy. Classically, lengthening is done with external fixation, which can result in scarring, pin site infection, loss of motion, and pain. We therefore developed an alternative to this approach, a new, controllable, internal lengthening device for patients with congenital limb shortening. QUESTIONS/PURPOSES: We evaluated this device in terms of (1) healing index, (2) complications, (3) accuracy of the device's external controller, and (4) adjacent-joint ROM. METHODS: Between January 2012 and May 2013, we treated 66 patients for congenital limb shortening, of whom 21 were treated using this device. During this period, general indications for using the device were patients with leg length discrepancies of 2 cm or more, with intramedullary canals able to withstand rods of at least 12.5-mm diameter and 230-mm length, without active infection in the affected bone, able to comply with the need for frequent lengthening, and without metal allergies or an implanted pacemaker. We included only those patients who had completed their course of treatment and were currently fully weightbearing, leaving 18 patients (21 bone segments) available for followup at a minimum of 6 months after limb lengthening (mean, 14 months; range, 6-22 months). Mean age was 19 years (range, 9-49 years). Sixteen femurs and five tibias were lengthened a mean of 4.4 cm (range, 2.1-6.5 cm). Mean distraction index was 1.0 mm/day (range, 0.5-1.8 mm/day). Healing index, complications, device accuracy, and ROM were recorded. To date, 10 of the 21 devices have been removed. This was typically done 12-24 months after insertion when the bone was solidly healed on all four cortices. RESULTS: Mean healing index was 0.91 months/cm (range, 0.2-2.0 months/cm). There were seven complications requiring an additional unplanned surgery, including one hip flexion contracture, three femurs with delayed healing, one tibia with delayed healing, one hip subluxation/dislocation, and one knee subluxation. The external controller was accurate as programmed and actual lengthening amounts were consistent. ROMs of the hip, knee, and ankle were essentially maintained. CONCLUSIONS: This device is completely internal, allowing for satisfactory joint motion during treatment in most patients. Lengthening was achieved in an accurate, controlled manner, and all patients reached their goal length. Complications remain a concern, as is the case with all approaches to this complex patient population. Both future comparative studies and longer-term followup are needed. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

[Biphosphonate in the treatment of avascular necrosis of the femoral head].

Avascular necrosis (AVN) is a multifactorial, heterogeneous group of disorders that lead to a final common pathway of mechanical failure of the bone joint dysfunction. Pain in avascular necrosis is the result of resorption of necrotic bone during revascularization, before new bone has formed or consolidated enough for load-bearing. Biphosphonate can reduce bone resorption, thus prolonging the bone formation phase available, so that structural failure may be avoided. The aim of this study was to make a systematic review of the use of bisphosphonate in the treatment of AVN.

Post-retrieval functionality testing of PRECICE lengthening nails: The "Sleeper" nail concept.

INTRODUCTION: PRECICE intramedullary magnetic lengthening nails, introduced in 2011, have changed the landscape of long bone limb lengthening. The implants have a stroke ranging from 5 to 8 cm, but it may be desirable to perform part of the lengthening at one treatment, allow bone healing, leave the implant in place, dormant, and then return one or more years later to re-lengthen with the same implant. We call this the "sleeper" nail concept. This strategy may be gentler for the joints and soft tissues. Would the nail mechanism still be functional one or more years later? METHODS: We tested 102 intact, consecutively explanted nails. Using a "fast magnet," the male part was lengthened to 5 mm short of its maximum stroke capacity and retracted back to 35 mm (all nails start with the male part exposed 30 mm). The nails passed the test if the male part succeeded in lengthening to 5 mm short of the maximum stroke capacity and back to 35 mm (or only retract in case fully deployed at testing). During our testing, the nails were prevented from reaching their full capacity of lengthening/retraction to avoid jamming the gears. Failure was defined as the inability or partial ability to complete the process. RESULTS: Eighty-six nails (84.3%) performed successfully according to our testing standard. When comparing successful and failed nails in terms of nail type, generation, diameter, length and in vivo interval, there was no statistical significance. Comparing both groups in terms of status at testing (fully deployed or not) showed statistical significance with 9 of the 16 failed nails fully deployed at testing (p < 0.001). CONCLUSION: Dormant PRECICE nails can be reactivated for further lengthening. The results imply that full deployment may damage the mechanism, making future re-use by retracting and then re-lengthening unsuccessful. The candidate nails for this purpose should not have any signs of clear damage (bending or breakage) and should not have been fully deployed. However, surgeons and patients should be aware of the need for possible nail exchange if the "sleeper" nail fails to wake up. LEVEL OF EVIDENCE: Level IV case series analysis of retrieved surgical implants.

Simultaneous Bilateral Femoral and Tibial Lengthening in Achondroplasia.

Previous studies on lengthening for achondroplasia have reported bilateral extensive femoral lengthening followed by bilateral extensive tibial lengthening. To decrease trauma on soft tissues and joints, we propose bilateral simultaneous moderate femoral lengthening and moderate tibial lengthening followed by a similar repeat lengthening a few years later. Fifty patients with achondroplasia underwent 65 simultaneous bilateral femoral and tibial lengthening procedures. Segment lengthening amount and adverse events were obtained from medical records. Mean follow-up after bone healing was 35.6 months. Mean tibial lengthening was 52 mm; mean femoral lengthening was 72 mm. Average healing index was 1.4 months/cm for the tibia and 1 month/cm for the femur. Mean duration of treatment with external fixation was 6.7 months (range, 4.4-10.5 months). Thirty-eight (76%) of 50 patients experienced one or more adverse events during lengthening. We observed 78 adverse events, 35 (45%) of which required additional surgical procedures. All resolved by the end of treatment. Mechanical axis deviation improved from a mean of 15 mm medially to 8 mm medially. Simultaneous lengthening of four segments in patients with achondroplasia is a feasible strategy. Compared with isolated femoral or tibial lengthening, distributing the lengthening between the femur and tibia decreases total external fixator time.

Arthroscopic rotator interval closure in shoulder instability repair: a retrospective study.

BACKGROUND: Arthroscopic Bankart repair (ABR) is a standard treatment for recurrent anterior shoulder instability. Young age, hyperlaxity, loss of bone stock and multidirectional or voluntary type of instability are all associated with failure of this procedure. Rotator interval laxity is associated with shoulder instability, whereas rotator interval closure increases humeral head stability and reduces shoulder range of motion. METHODS: The records of patients with recurrent anterior shoulder dislocations who underwent ABR with or without arthroscopic rotator interval closure (ARIC) in our department between 1999 and 2007 were reviewed. Rates of recurrent dislocation or symptomatic subluxation as well as functional outcome were evaluated using Walch-Dupley score. RESULTS: Three (8.1%) of the 37 ABR+ARIC patients (age 19-44 years, 32 males) had re-dislocated their shoulder at 42±16 months following the procedure, all of which had systemic joint hyperlaxity. Six (13%) of the 46 ABR patients (age 19-39 years, 42 males) had re-dislocated their shoulder at 13±14 months, three of which had systemic joint hyperlaxity and dislocated their shoulder within 1 year following the operation. Systemic joint hyperlaxity (28% of ABR and 41% of ABR+ARIC patients) was significantly associated with recurrent dislocation and poor functional outcome. ABR+ARIC patients had slightly more limited range of motion with similar good and excellent functional results (75%) at final follow up time. CONCLUSIONS: Systemic joint hyperlaxity is a risk factor for failure of ABR. When ARIC is performed in combination with ABR, it may have an additive effect on shoulder stability.

Incidence, risk factors and outcomes of avascular necrosis occurring after humeral lateral condyle fractures.

Avascular necrosis (AVN) of the distal humerus is a known complication of lateral condyle fractures yet the specific rate of occurrence is unknown. The purposes of this study are to analyze the incidence, outcomes, and risk factors for AVN following lateral condyle fractures. A retrospective chart review of children diagnosed with a lateral condyle fracture between 2001 and 2014 at level-1 tertiary pediatric center was completed. Demographic data, Weiss classification, time from injury to surgery, operative vs. nonoperative management, open vs. closed reduction, and type of fixation were studied. For patients with radiographs consistent with AVN at any point in their care, elbow range of motion (ROM), pain, and deformity were measured at last follow up. Of the 500 patients evaluated, the incidence of AVN was 1.4%. All cases of AVN were following open reduction and percutaneous fixation (P = 0.01) as initial treatment. Type III fractures were significantly associated with AVN (P = 0.041). After average follow up of 59 weeks (range: 24-150 weeks), all patients regain full ROM except one patient who lacked of 15° of extension and 10° of flexion. Five patients were asymptomatic while two patients had mild pain. There was no radiographic evidence of valgus or varus deformity at final follow up. AVN following lateral condyle fractures is rare with a rate of only 1.4%. Type III fractures and open reduction were significantly associated with AVN. Provided no residual deformity and reconstitution of avascular bone, good outcomes can be expected.

The efficacy of guided growth as an initial strategy for Blount disease treatment.

PURPOSE: The aim of this study was to evaluate the success of guided growth by temporal hemiepiphysiodesis of the lateral proximal tibia as a first line treatment option for Blount disease. METHODS: This was a retrospective multicentre study conducted in five centres, covering data on 55 limbs in 45 patients, with an average follow-up of 24.5 months following plate insertion. Preoperative alignment analysis was compared with three measurements taken postoperatively. The normalization of the mechanical medial proximal tibia angle (mMPTA) was defined as the primary outcome measure. RESULTS: Mean age at surgery was 9.5 years. Average preoperative mMPTA was 77°. On average, at 24.5 months post-surgery, mMPTA was 86.33°, while 43/55 limbs (78.18%) have achieved normalization (mMPTA 85° to 90°). Average rate of correction was 1° per month. When grouping the children as infantile (11 limbs), juvenile (12 limbs) and adolescent (32 limbs), operated on before the age of four years, between four and ten years and after the age of ten years, respectively, 63.63%, 66.67%, 87.5% have completed correction of deformity during the follow-up period. Interestingly, the femoral component of the deformity has achieved correction as well in 33/55 limbs (64%). CONCLUSION: Hemiepiphysiodesis is an effective first line treatment for Blount disease. Overall success rate is good but varies according to child's age. Adolescent Blount has the best chance of achieving full correction while same treatment is less effective in infantile Blount.Level of evidence: IV.

Percutaneous versus open reduction and fixation for Tillaux and triplane fractures: a multicenter cohort comparison study.

The goal of this study was to compare open reduction versus percutaneous fixation of adolescent ankle fractures with regards to the incidence of growth disturbance. We performed a retrospective cohort analysis of adolescent patients with triplane or Tillaux fractures. There was an even distribution of triplane fractures and mean initial displacement between cohorts. Analysis of follow-up radiographs revealed no instances of growth disturbance in the percutaneous fixation group and six in the open reduction group (P=0.29). Growth disturbance does not pose a significant concern when selecting a surgical approach. Owing to the rarity of these fractures this study was underpowered.

Limits of Growth Modulation Using Tension Band Plates in the Lower Extremities.

Growth modulation using tension band plates (TBP) has been shown to be a safe, effective, and popular method for correcting pediatric frontal plane angular deformity around the knee. Recently, TBPs have been used to achieve reversible epiphysiodesis to treat limb-length discrepancy. Many surgeons have expanded the indications to include diagnoses other than frontal plane angular deformities, anatomic sites other than the knee, and correction of sagittal and oblique plane deformities. Despite the rapid acceptance of TBPs, the limits of this option have not been explored. We undertook a systematic literature review and found that the success rate for idiopathic cases approaches 100% with a low complication rate. Pathologic cases have a slightly lower success rate and a higher complication rate. The potential to avoid osteotomy with growth modulation makes TBPs a reasonable option for all but the most extreme pediatric frontal and sagittal plane lower extremity deformities. Applications to hip deformities remain unproven.

Radiographic Indicators of Surgery and Functional Outcome in Ponseti-Treated Clubfeet.

BACKGROUND: Evaluation of the results of treatment for clubfoot by the Ponseti technique is based on clinical and functional parameters. There is a need to establish universally recognized quantitative measurements to compare, better understand, and more precisely evaluate therapeutic outcome. METHODS: Nine angles were measured on standard radiographs of 145 children with idiopathic clubfeet treated between 2000 and 2010 with the Ponseti method. The average follow-up was 6.3 years. The need for additional surgery and the functional outcome was correlated to the radiologic measurements. RESULTS: Three radiologic parameters were identified as having significant (P ≤ .001) predictive value. The lateral tibiocalcaneal angle with the ankle at maximal dorsiflexion measuring fixed equinus was larger in the preoperated group (77 ± 12 degrees) compared to the nonoperated group (67 ± 14 degrees). Functional outcome was better with smaller angles. The lateral talocalcaneal angle with the ankle at maximal dorsiflexion measuring hindfoot rigidity was smaller (29 ± 8 degrees) in the preoperated group compared to the nonoperated group (35 ± 9 degrees). Functional outcome was better with larger angles. The lateral talo-first metatarsal angle with the ankle at maximal plantarflexion measuring foot cavus was larger in the preoperated group (31 ± 10 degrees) compared to the nonoperated group (22 ± 11 degrees), whereas functional outcome did not correlate with this angle. CONCLUSIONS: The lateral view with the foot in maximal dorsiflexion was found to be the most significant and useful view to detect abnormality in Ponseti-treated clubfeet. In our practice now, we are using only this view in order to reduce the radiation exposure to the child. LEVEL OF EVIDENCE: Level III, retrospective case series.

Congenital tibial pseudarthrosis, changes in treatment protocol.

Ten children with congenital pseudarthrosis of the tibia were treated with resection of pathologic bone, bone grafting, intramedullary rodding, compression with circular frame, simultaneous proximal tibia lengthening, and bone morphologic proteins. Thirteen operations were performed to achieve union. Four patients underwent simultaneous lengthening and four patients received recombinant human bone morphologic protein. Six children required complementary operations for residual ankle and knee valgus, and shortening. Union of the pseudarthrosis was achieved in all cases with lengthening up to 5 cm. This protocol is effective in achieving union of congenital pseudarthrosis of tibia; attention should be paid to the ankle joint to achieve functionality of the limb.

Custom Knee Device for Knee Contractures After Internal Femoral Lengthening.

The development of knee flexion contractures is among the most common problems and complications associated with lengthening the femur with an internal device or external fixator. Conservative treatment strategies include physical therapy, serial casting, and low-load prolonged stretching with commercially available splinting systems. The authors developed an individually molded, low-cost custom knee device with polyester synthetic conformable casting material to treat knee flexion contractures. The goal of this study was to evaluate the results of treatment with a custom knee device and specialized physical therapy in patients who had knee flexion contracture during femoral lengthening with an intramedullary lengthening femoral nail. This retrospective study included 23 patients (27 limbs) who underwent femoral lengthening with an internal device for the treatment of limb length discrepancy. All patients had a knee flexion contracture raging from 10° to 90° during the lengthening process and were treated with a custom knee device and specialized physical therapy. The average flexion contracture before treatment was 36°. The mean amount of lengthening was 5.4 cm. After an average of 3.8 weeks of use of the custom knee device, only 2 of 27 limbs (7.5%) had not achieved complete resolution of the flexion contracture. The average final extension was 1.4°. Only 7 of 27 limbs (26%) required additional soft tissue release. The custom knee device is an inexpensive and effective method for treating knee flexion contracture after lengthening with an internal device.

Worldwide spread of the Ponseti method for clubfoot.

The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. This has been demonstrated by the increase in Ponseti related PubMed publications from many countries. We found evidence of Ponseti activity in 113 of 193 United Nations members. The contribution of many organizations which provide resources to healthcare practitioners in low and middle income countries, as well as Ponseti champions and modern communication technology, have helped to spread the Ponseti method around the world. Despite this, there are many countries where the Ponseti method is not being used, as well as many large countries in which the extent of activity is unknown. With its low rate of complication, low cost, and high effectiveness, this method has unlimited potential to treat clubfoot in both developed and undeveloped countries. Our listing of countries who have not yet shown presence of Ponseti activity will help non-governmental organizations to target those countries which still need the most help.