Lower-limb intramedullary nailing in patients with polyostotic fibrous dysplasia who had a previous unsuccessful treatment. A report of 48 cases.

BACKGROUND: Intramedullary nailing (IN) seems to be the best primary surgical treatment for patients with either polyostotic fibrous dysplasia or McCune-Albright syndrome (PFD/MAS) when the femur and tibia are totally affected by fibrous dysplasia (FD) and pain, fracture and deformity are likely to occur. However, other management protocols have been applied in these cases, often leading to disabling sequelae. This study sought to evaluate if IN could also have been effective as a salvage procedure to provide patients with satisfactory results, regardless of the poor results due to the improper treatment previously performed. MATERIALS AND METHODS: Twenty-four retrospectively registered PFD/MAS patients with 34 femurs and 14 tibias totally affected by fibrous dysplasia had received various treatments with unsatisfactory results in other institutions. Before the IN performed in our hospital, 3 patients were wheelchair bound; 4 were fractured; 17 limped; and many used an aid for walking. Salvage IN was performed in our hospital at a mean patient age of 23.66 ± 6.06 years (range, 15-37 years). The patients were evaluated before-except for the four fractured ones-and after IN using the validated Jung scoring system, and the data were statistically analyzed. RESULTS: The mean length of follow-up after IN was 9.12 ± 3.68 years (range, 4-17 years). The patients' mean Jung score significantly improved from 2.52 ± 1.74 points before IN to 6.78 ± 2.23 at follow-up (p < 0.05). Ambulation was improved in ambulatory patients and restored in wheelchair users. The complication rate was 21%. CONCLUSIONS: Regardless of the high rate of complications, IN may be considered a reliable surgical procedure to salvage a failed treatment in PFD/MAS, with long-lasting satisfactory results achieved in most patients. Trial registration statement: Not applicable. LEVEL OF EVIDENCE: IV.

COVID-19 lockdown and hip arthroplasty rehabilitation changes: mid-term clinical outcomes.

OBJECTIVE: Hip arthroplasty is one of the most performed surgeries in orthopedics. Rehabilitation process after surgery allows rapid recovery of joint functions in absence of pain in most patients. During COVID-19 pandemic, rehabilitation clinics have reduced the number of beds available. Thus, an increasing number of patients were forced to home rehabilitation programs. Our study aimed at determining any significant differences in clinical and functional outcomes between those patients who underwent a home rehabilitation program and those others who were granted a place in a Rehabilitation clinic during COVID-19 pandemic, at mid-term follow-up. PATIENTS AND METHODS: An observational retrospective single-center study was designed. The patients included were 63, divided into two groups: Group A (29 patients) for home rehabilitation, and Group B (34 patients) for clinic rehabilitation. Follow-up was performed at 1, 6 and 12 months after surgery. Clinical evaluation was assessed through Oxford Hip Score for hip function, Visual Analogue Scale (VAS) for pain and hip range of motion (ROM) to evaluate joint recovery. RESULTS: ROM was compared at follow-up with significant differences 12 months after surgery (107.93° group A vs. 104.7° group B; p=0.0168). Pain felt by patients according to the VAS scale showed no significant differences at follow-up (1 month 3.27 vs. 3.65 p=0.1489; 6 months 1.89 vs. 2.18 p=0.105; 12 months 0.58 vs. 0.68 p=0.6263). Regarding the Oxford Hip score, significant differences emerged at 1-month follow-up (38.75 group A vs. 37.94 group B; p=0.0498). CONCLUSIONS: At mid-term follow-up, little differences were found between patients who went through home rehabilitation and those who went to a rehabilitation clinic. Therefore, decreasing the number of beds available in rehab clinics during COVID-19 pandemic was not an obstacle for elective surgery for orthopedic surgeons.

Vancouver B2 and B3 periprosthetic femoral fractures treated by ORIF. Mid to long-term follow-up study in 28 patients.

OBJECTIVE: Periprosthetic femoral fractures (PFF) are a serious complication in patients who have undergone hip arthroplasty. Some authors consider revision arthroplasty as the gold standard in the surgical treatment of Vancouver type B2 and B3 PFF. Others, however, prefer treating PFF by open reduction and internal fixation (ORIF), without revising loose stems, especially in elderly patients. In the present retrospective study, we report mid/long-term results in a series of patients affected by B2 or B3 PFF surgically treated by ORIF, using a locking compression plate (LCP), thus avoiding the need of revision arthroplasty. MATERIALS AND METHODS: We reviewed 28 patients affected by B2 or B3 PFF surgically treated between 2010 and 2017 by ORIF using a LCP, after an average follow-up of 5.5 years. The average age of the patients at diagnosis was 78 years; in 17 patients, the femoral stem was uncemented while in 11, cemented. The mean interval time between hip arthroplasty and PFF was 6.7 years. Clinical results were assessed using Harris Hip Score (HHS), while radiographic results according to Beals and Tower criteria. RESULTS: At follow-up, HHS ranged from 72 to 96 points; 8 patients had an excellent result, 12 got a good result and 8 a fair result. According to Beals and Tower criteria, all the radiographic results were excellent (9 patients) or good (19 patients). The majority of our patients returned to their previous ambulatory levels. CONCLUSIONS: According to our results, in elderly patients affected by Vancouver type B2 or B3 PFF, surgical treatment by ORIF using a locking compression plate, without a stem revision, seems to be associated with satisfactory outcome.

Medial subtalar dislocation from a low-energy trauma. A case report and review of the literature.

INTRODUCTION: Subtalar dislocation is a rare injury characterized by a simultaneous dislocation of the talocalcaneal and talonavicular joints. The most common type is caused by high-energy trauma with medial dislocation of the foot. This injury is frequently associated with fractures, but isolated dislocations are also reported. CASE PRESENTATION: We report a rare case of medial subtalar dislocation secondary to low-energy injury in a 61-year-old woman. Following X-rays and CT scan, prompt closed reduction was performed under sedation and, after reduction, X-rays showed a good realignment of the foot. The CT scan revealed an occult non-displaced fracture of the posterior part of the talus. The patient was managed conservatively by a non-weight bearing cast for four weeks, followed by a rehabilitation program. At follow-up, six months later, we observed a good clinical and radiographic result. DISCUSSION: The reported case confirms that the mechanism of injury is an important factor in predicting the final result, since subtalar dislocations secondary to a high-energy trauma are often associated with significant complications. We believe, in agreement with other authors, that a low-energy trauma generally doesn't produce long-term morbidity. Prompt reduction is very important in order to minimize soft tissue and neurovascular complications, although a CT is recommended to identify occult fractures. CONCLUSION: Subtalar dislocations, caused by low energy trauma, if adequately reduced in the emergency room, generally heal with conservative treatment, reducing the risk of significant complications. However, since we report a single patient, further case analysis is needed to make solid conclusions.

Heterotopic ossification around the lesser trochanter of the femur simulating a malignant lesion. A case report with long-term follow-up and revision of literature.

We report the case of a 28-year-old female who complained of groin pain and restricted range of motion of the hip for the previous two months. A plain radiograph, CT scan and MRI of the pelvis showed a bone mass of uncertain origin around the lesser trochanter, simulating malignancy. An open biopsy was performed to obtain a correct diagnosis. The histological examination excluded a malignant lesion. Two months later, the mass was surgically excised and at follow-up, 9 years after surgery, the patient was completely asymptomatic, without any radiographic sign of recurrence. This is a rare case of heterotopic ossification of the proximal part of the femur, that appeared without any significant trauma or other predisposing risk factors; because the lesion led us to suspect a malignant disease, an open biopsy was needed to make the diagnosis. From an accurate review of the literature, heterotopic ossifications mimicking a malignant lesion that appeared without any predisposing factors are extremely rare.

Infection rate of intramedullary nailing for treatment of lower limb polyostotic fibrous dysplasia.

Polyostotic fibrous dysplasia (PFD) generally cause deformities and fractures of femur and tibia and surgery is often required. The current surgical treatment for deformities is based on single or multiple osteotomies followed by stabilization with intramedullary nails, which are commonly used also for fractures. One of the most common surgical complications of intramedullary nailing is represented by surgical site infection with possible extension to the whole skeletal segment. In the present study we evaluated the incidence of surgical site infections in 44 patients affected by PFD in which 91 femurs or tibiae underwent intramedullary nailing to treat deformities or fractures. We never observed any infection of the operated femurs or tibiae until the final follow-up. The only post surgical infection was present in a patient with monomelic involvement at the contralateral non affected limb, which was surgically treated for limb length inequality, by femur shortening osteotomy stabilized by an intramedullary nail. The most likely hypothesis to explain the complete absence of infections in these patients may be related to the high local concentration of prophylactic antibiotic in the highly vascularized fibrodysplastic bone.

Monitoring of C-reactive protein level (CRP) and Erythrocyte sedimentation rate (ESR) after total hip and knee arthroplasty.

C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) are the two most commonly serum biomarkers for the diagnosis of periprosthetic joint infections (PJI). We monitored CRP and ESR in 60 patients affected by osteoarthritis who underwent primary total hip or knee arthroplasty to verify their utility for an early diagnosis of periprosthetic hip and knee infections. In all but two patients, both CRP and ESR increased rapidly after surgery, reaching a peak value around the 3rd day postoperatively; CRP decreased rapidly in 20 days, reaching normal value one month after surgery, while ESR decreased slowly, reaching the normal value after three months. In two patients, CRP and ESR were still elevated six months after the surgical procedure and in both cases a diagnosis of PJI was made. Our study confirms that postoperative screening of CRP and ESR values are very useful in making an early diagnosis of this serious complication.

Orthopaedic aspects in seventy-two children affected by Marfan syndrome. Correlations between pathological features and fibrillin-1 gene mutations.

Marfan syndrome is an autosomal dominant disorder of the connective tissue caused by mutations of the fibrillin-1 gene (FBN1) that primarly involves the cardiovascular, skeletal and ocular systems. We investigated 72 children affected by Marfan syndrome in order to identify possible correlations between some musculoskeletal features and specific mutations of fibrillin-1 gene. The following FBN-1 gene mutations have been observed: a missense mutation in 21 children, a stop mutation in 9, a splice mutation in 15 and other mutations in the remaining 27 patients. We observed a statistical significant association between chest asymmetry and splice mutation (p=0.031) and between scoliosis >20° or thoracolumbar kyphosis and stop mutation (p=0.039). However, we did not find a true genotype-phenotype correlation between the fibrillin-1 gene mutations observed and the prognosis of the disease. Future studies are necessary to demonstrate further genotype-phenotype correlations in order to identify early prognostic markers of Marfan syndrome and to plan the most appropriate clinical management accordingly.

Induced membrane by silver-coated knee megaprosthesis: keep or toss?

In the orthopaedic field the foreign body reaction is well known for therapeutic purposes in the alleged Masquelet technique consisting of segmental bone loss two-stage reconstruction. The induced membrane creates advantageous local conditions that promote bone graft remodeling and osteointegration. The aim of our study was to describe the first two cases in Literature of induced membrane observed following silver-coated knee megaprosthesis reconstruction. In addition, it was our interest to evaluate their histological features.

Pubic osteolysis simulating a malignant lesion. A case report with long-term follow-up.

Pubic osteolysis is a rare pathology characterized by a painful radiographic destructive changes in the pubic rami, pubis or pubic symphysis that often follows a post-traumatic event. The etiology is unclear but it is a benign lesion, frequently misinterpreted as malignant. We report a case of a 54-year-old woman with pubic osteolysis mimicking a malignant lesion, diagnosed after open bone biopsy, conservatively treated without any sequelae and followed-up 10 years after the end of treatment. Although in the majority of the reported cases, a previous trauma has been commonly referred, in our case the patient did not refer to any cause before the onset of clinical symptoms. Knowledge of this entity is important to avoid invasive diagnostic procedures, costly investigations or overtreatment.

Periprosthetic hip and knee infections: comparison of etiology, perioperative management and costs.

OBJECTIVE: We compared two series of patients treated at our Hospital for periprosthetic hip and knee infections (PHI; PKI), in order to evaluate etiology, perioperative management (duration of spacer, antibiotic therapy, quality of life during the treatment), length of hospital stay, and costs. PATIENTS AND METHODS: We included in the study 32 patients with PHI and 30 patients with PKI. The average age of the patients was 74.8 in PHI and 71.2 in PKI. Treatment consisted of a two-stage revision associated with antibiotic therapy. All patients were followed up for at least two years after surgery. We analyzed the causative microorganism responsible for the infection, duration of the spacer and antibiotic therapy, quality of life during this time, length of hospital stay, and total hospital cost of treatment. RESULTS: The gram-negative microorganisms were more common in PHI, without any statistically significant difference compared to PKI. Duration of the spacer for PHI was 7.4 months and 5.5 months for PKI (p=0.005). Length of antibiotic therapy was 6.2 months for PHI and 4.1 months for PKI (p<0.001). Most patients in the two series had an acceptable quality of life during treatment. The mean length of hospitalization was 54 days in PHI and 26 days in PKI (p<0.001). The cost averaged 38,300 euros for PHI and 22,100 euros for PKI (p<0.001). CONCLUSIONS: Our study showed statistically significant differences between periprosthetic hip and knee infections as regards etiology, duration of treatment and global costs. Periprosthetic hip infections are caused by more virulent microorganisms that are harder to eradicate, require a longer length of treatment and have a greater economic impact on the healthcare system.

Lack of Response to HBHA in HIV-Infected Patients with Latent Tuberculosis Infection.

Heparin-binding haemagglutinin (HBHA) has been proposed as an immunological biomarker for discriminating active tuberculosis (TB) from latent TB infection (LTBI) and to identify those at higher risk of progressing to active disease. Few data are available in immune-compromised patients, which are those with increased risk of TB reactivation. The aim of this stusy was to evaluate the immune response to HBHA in HIV-infected subjects with LTBI (HIV-LTBI) or active TB (HIV-TB) in comparison with the immune response to additional Mycobacterium tuberculosis (Mtb) or HIV and CMV antigens. The responses are evaluated in relation to TB status and in the LTBI subjects with the progression to active TB within 2 years. Forty-one HIV-infected antiretroviral-naïve subjects were prospectively enrolled: 18 were HIV-TB and 23 HIV-LTBI. Whole blood was in vitro stimulated overnight with several antigens and mitogen. Interferon-γ response in the harvested plasma was evaluated by ELISA. Despite that CD4 cell count was significantly different between HIV-LTBI and HIV-TB, no differences were observed in response to Mtb- or HIV-specific antigens. Differently, low responses to HBHA were observed in both HIV-LTBI and HIV-TB subjects. Importantly, none of the six HIV-LTBI responding to HBHA developed TB, while two of 17 non-HBHA responders developed active disease. HIV-TB-coinfected subjects, regardless of their TB status, showed low responses to HBHA despite maintaining detectable responses to other antigens; moreover, among the HIV-LTBI, the lack of HBHA responses indicated an increased risk to develop active TB. These results, although preliminary, suggest that a positive response to HBHA in HIV-LTBI correlates with Mtb containment.

Optimized Use of the MALDI BioTyper System and the FilmArray BCID Panel for Direct Identification of Microbial Pathogens from Positive Blood Cultures.

Despite the current reliance on blood cultures (BCs), the diagnosis of bloodstream infections (BSIs) can be sped up using new technologies performed directly on positive BC bottles. Two methods (the MALDI BioTyper system and FilmArray blood culture identification [BCID] panel) are potentially applicable. In this study, we performed a large-scale clinical evaluation (1,585 microorganisms from 1,394 BSI episodes) on the combined use of the MALDI BioTyper and FilmArray BCID panel compared to a reference (culture-based) method. As a result, the causative organisms of 97.7% (1,362/1,394) of the BSIs were correctly identified by our MALDI BioTyper and FilmArray BCID-based algorithm. Specifically, 65 (5.3%) out of 1,223 monomicrobial BCs that provided incorrect or invalid identifications with the MALDI BioTyper were accurately detected by the FilmArray BCID panel; additionally, 153 (89.5%) out of 171 polymicrobial BCs achieved complete identification with the FilmArray BCID panel. Conversely, full use of the MALDI BioTyper would have resulted in the identification of only 1 causative organism in 97/171 (56.7%) of the polymicrobial cultures. By applying our diagnostic algorithm, the median time to identification was shortened (19.5 h versus 41.7 h with the reference method; P < 0.001), and the minimized use of the FilmArray BCID panel led to a significant cost savings. Twenty-six out of 31 microorganisms that could not be identified were species/genera not designed to be detected with the FilmArray BCID panel, indicating that subculture was not dispensable for a few of our BSI episodes. In summary, the fast and effective testing of BC bottles is realistically adoptable in the clinical microbiology laboratory workflow, although the usefulness of this testing for the management of BSIs remains to be established.

The sociodemographic patterning of opposition to raising taxes on tobacco and restricting tobacco advertisements in Argentina.

BACKGROUND: Argentina has enacted important tobacco control initiatives in recent years. Yet little is known about the social patterning of attitudes toward tobacco control. Research is needed to explore what predicts opposition to tobacco control initiatives such as higher taxes on tobacco and the prohibition of tobacco advertising. STUDY DESIGN: Secondary analysis of Argentina's Global Adult Tobacco Survey (N = 6645). METHODS: Binary logistic regression analysis examining opposition to raising tobacco taxes and banning tobacco publicity. Models were stratified by smoking status. RESULTS: Respondents generally indicated very little opposition to either tobacco control measure, with only 15.6% of respondents opposed to increasing taxes on tobacco products and 9.6% opposed to banning tobacco advertisements. Smoking status is the most important predictor of opposition to increasing taxes (OR = 7.85, 95% CI = 6.60-9.34) and banning advertisements (OR = 1.72, 95% CI = 1.39-2.11). Opposition to these measures is most likely among young respondents (aged 15-24) and least likely among older age groups (55-64 and 65 or over), compared to the 25-34 age group. Stratified models suggest that the effect of age may be different for smokers and non-smokers. Low income is a significant predictor of opposition, but only in stratified models for smokers. CONCLUSION: There is general support for stronger tobacco control measures in Argentina. Opposition to raising taxes on tobacco products and banning tobacco advertisement appears to be concentrated among young smokers with low and medium levels of household income.

Sex-stratified and age-adjusted social gradients in tobacco in Argentina and Uruguay: evidence from the Global Adult Tobacco Survey (GATS).

OBJECTIVE: To examine social gradients in tobacco use in Argentina and Uruguay, using newly available directly comparable data sets. METHODS: Secondary analysis of Global Adult Tobacco Survey data from Argentina (N=6645) and Uruguay (N=5581). Social gradients in current tobacco use, exposure to secondhand smoke, and cessation attempt were examined with sex-stratified and age-adjusted logistic regression. RESULTS: Among men, there is evidence of higher odds of being a current smoker among respondents with lower levels of education, but the association is only statistically significant for respondents with less than primary education in Uruguay (OR=2.15, 95% CI 1.22 to 3.77). Similarly, women with lower levels of education have higher odds of being a current smoker in Uruguay. The association between education and exposure to secondhand smoke is broadly similar for both sexes in both countries, with generally higher odds among groups with low education, though the relationship is only statistically significant among men in Uruguay (OR=1.77, 95% CI 1.08 to 2.92). In both countries, respondents with lower levels of education in general have higher odds of having attempted to quit smoking in the past year, although these associations did not attain statistical significance. CONCLUSIONS: Social gradients in tobacco use, exposure to secondhand smoke and cessation attempts are broadly similar in both countries. Efforts to evaluate the long-term effects of tobacco control efforts in these countries should monitor how policies affect national averages, and the social gradients that are embedded in aggregate data.

Changes in the social gradients for Pap smears and mammograms in Argentina: evidence from the 2005 and 2009 National Risk Factor Surveys.

OBJECTIVES: To identify changes in the social gradients for Pap smears and mammograms in Argentina. STUDY DESIGN: Secondary analysis of the 2005 and 2009 Argentine National Risk Factor Surveys. METHODS: Logistic regression analysis was used to examine social gradients by income and education, adjusting for age and health insurance. RESULTS: The proportion of women who received a Pap smear in the previous 2 years increased from 51.6% in 2005 to 60.5% in 2009 (χ(2) = 344.8, P < 0.001). A significant increase was also seen in the receipt of a mammogram in the previous 2 years by women aged ≥50 years, with an increase from 39.6% in 2005 to 52.6% in 2009 (χ(2) = 279.6, P < 0.001). In 2005, low-income women were most likely not to have received a Pap test [odds ratio (OR) = 3.27, 95% confidence interval (CI) = 2.70-3.98], followed by medium-income women (OR = 1.73, 95% CI = 1.41-2.12), compared with high-income women. The gradient by education was of a similar magnitude, and both income and education gradients remained stable from 2005 to 2009. Restricting the analysis to eight provinces that have been deemed to be high priority due to their high levels of mortality from cervical cancer reveals an increasing income-based gradient in Pap smears. In contrast, inequalities in mammography diminished across the country, with a significant reduction in the social gradient measured either by income or education. In contrast to high-income women, low-income women experienced higher odds of not having a mammogram, but the gap diminished over time [OR = 4.14 (95% CI = 2.96-5.78) in 2005 vs OR = 2.37 (95% CI = 1.81-3.11) in 2009]. CONCLUSION: Social gradients in cancer screening are changing in Argentina. There are signs of a reduction in inequalities in mammograms, although this is attenuated by indications that inequalities in Pap smear utilization in priority provinces are growing. Surveillance of population indicators is needed to verify whether these short-term changes persist over time.

Fractures of the neck of the fifth metacarpal bone. Medium-term results in 28 cases treated by percutaneous transverse pinning.

The purpose of this study was to report the medium-term results in 28 patients affected by closed displaced fractures of the neck of the fifth metacarpal bone (boxer's fracture) with an associated severe swelling of the hand, who were treated with percutaneous transverse K-wire pinning, to verify the effectiveness of this surgical treatment. We opted for this treatment in all cases in which malrotation of the fifth finger and volar angulation of the metacarpal head greater than 30° were associated with a severe swelling of the hand. All the patients were reviewed clinically and radiologically at an average of 25 months after surgery. At the final follow-up, no patient reported residual pain. All patients had full extension of the fifth finger, except two in whom we observed a limitation of the extension of the fifth metacarpophalangeal (MP) joint of about 10°, without significant impairment of hand function. All patients had at least 90° flexion of the fifth MP joint and full range of motion of the interphalangeal (IP) joints. No patient had rotational deformity of the fifth finger with a deficit of grip strength. At the final follow-up, a residual palmar angulation of the head of the fifth metacarpal was found in three patients, with a mean of 7°. The disabilities of the arm, shoulder and hand (DASH) scale had a mean value of 5, and all patients considered their result as good or excellent. We recommend percutaneous transverse pinning in all boxer's fractures in which operative treatment is indicated, especially in patients with severe soft-tissue swelling. The surgical procedure is easy to perform, and surgical results are generally good.

Giant intra-articular extrasynovial osteochondroma of the knee: a report of two cases.

We report two cases of a giant extrasynovial osteochondroma of the knee located in the infrapatellar fat pad region, in two females who were 58 and 71 years old respectively. Both patients had noticed the mass many years before our first clinical observation. In both patients, at physical examination a solid, firm and hard mass was palpable in the anterior part of the knee in Hoffa's fat pad region, and the range of motion of the knee was severely restricted and painful. CT scan examination with 3D-reconstruction showed two large, calcified neoformations behind the patellar tendon, between the apex of the patella and the proximal third of the tibia. In both cases, the mass was completely resected surgically through an anterior longitudinal approach. At histological examination, the excised masses consisted of an outer layer of hyaline cartilage without significant chondrocyte atypia and an inner region of bone trabeculae formed by endochondral ossification. At follow-up, 8 and 4 years after the operation, both patients were pain-free, with complete recovery of the range of motion of the knee and without any clinical or radiographic evidence of recurrence. The authors believe that intra-articular extrasynovial osteochondroma of the knee is a primary metaplasia of Hoffa's fat pad. Usually, the tumor develops slowly and asymptomatically over many years. The treatment of choice is a marginal resection of the mass, although a biopsy should be considered in some cases. Recurrences are extremely rare.

Isolated paralysis of the adductor pollicis: a case report.

We report a case of isolated paralysis of the right adductor pollicis in a 30-year-old woman. Electromyographic study showed involvement of the deep motor branch of the ulnar nerve. A ganglion and an anomalous muscle were both ruled out clinically and by MRI as a possible cause of the paralysis. At surgical exploration, we found a fibrous band joining the pisiform and the hook of the hamate bone that compressed the deep motor branch of the ulnar nerve. The fibrous band was excised, and a neurolysis of the motor branch of the ulnar nerve was performed. At followup, eight months later, the patient had fully recovered strength of the adductor muscle.

Leg muscle atrophy in idiopathic congenital clubfoot: is it primitive or acquired?

PURPOSE: To investigate whether atrophy of the leg muscles present in congenital clubfoot (CCF) is primitive or secondary to treatment of the deformity. METHODS: Magnetic resonance imaging (MRI) of both legs was taken in three cohorts of patients with unilateral congenital clubfoot (UCCF): eight untreated newborns (age range 10 days to 2 weeks); eight children who had been treated with the Ponseti method (age range 2-4 years); eight adults whose deformity had been corrected by manipulation and casting according to Ponseti, followed by a limited posterior release performed at age 2-3 months (age range 19-23 years). All of the treated patients wore a brace until 3 years of age. Muscles were measured on transverse MRI scans of both legs taken midway between the articular surface of the knee and the articular surface of the ankle, using a computer program (AutoCAD 2002 LT). The same program was used to measure leg muscles in the histologic cross sections of the legs of two fetuses with UCCF, spontaneously aborted at 13 and 19 weeks of gestation, respectively. Measurements of the whole cross section of the leg (total leg volume: TLV), of the muscular tissue (muscular tissue volume: MTV), and of the adipose tissue (adipose tissue volume: ATV) of the tibia, fibula, and of the other soft tissues (tendons, nerves, and vessels) were taken by using an interactive image analyzer (IAS 2000, Delta System, Milan, Italy). RESULTS: Marked atrophy of the leg muscles on the clubfoot side was found in both fetuses and untreated newborns, with a percentage ratio of MTV between the normal and the affected leg of 1.3 and 1.5, respectively. Leg muscle atrophy increased with growth, and the percentage ratio of MTV between the normal and the affected leg was, respectively, 1.8 and 2 in treated children and adults. On the other hand, fatty tissue tended to increase relatively from birth to adulthood, but it could not compensate for the progressive muscular atrophy. As a result, the difference in TLV tended to increase from childhood to adulthood. CONCLUSIONS: Our study shows that leg muscular atrophy is a primitive pathological component of CCF which is already present in the early stages of fetal CCF development and in newborns before starting treatment. Muscular atrophy increases with the patient's age, suggesting a mechanism of muscle growth impairment as a possible pathogenic factor of CCF.