Management of congenital talipes equinovarus using the Ponseti method: a systematic review.

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.

Correction of neglected idiopathic club foot by the Ponseti method.

The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0). A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity. We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.

Effect of high-intensity running in rectus femoris muscle fiber in rats.

The effect of a 12-week high-intensity intermittent exercise program on fiber type composition and the oxidative capacity of rectus femoris skeletal muscle from 20 male Wistar rats (Trained, n = 10; Sedentary, n = 10) was histochemically determined. The training exercise program was developed in a motorized treadmill. It consisted of four running bouts of 2 min duration at 48 m/min, alternated with recovery intervals of 4 min. Training increased relative cross-sectional area of oxidative fibers (I, IIA, IIX) and decreased the same parameter in type IIB non-oxidative fibers (P < 0.001). Our results suggest that this type of strength exercise program is enough to induce changes in muscle fiber composition. This opens a possibility to use this kind of exercise in preventing and treating muscle atrophy.

Effect of endurance running on cardiac and skeletal muscle in rats.

We studied the effect of resistance running on left cardiac ventricle size and rectus femoris muscle fiber composition. Ten male Wistar rats were trained on a treadmill 6 days per week for 12 weeks. Ten rats remained sedentary and served as controls. A higher endurance time (40%) and cardiac hypertrophy in the trained animals were indicators of training efficiency. Morphometric analysis of the left ventricle cross-sectional area, left ventricular wall, and left ventricular cavity were evaluated. The endurance-running group demonstrated a hypertrophy of the ventricular wall (22%) and an increase in the ventricular cavity (25%); (p<0.0001). Semi-quantitative analysis of rectus femoris fiber-type composition and of the oxidative and glycolytic capacity was histochemically performed. Endurance running demonstrated a significant (p<0.01) increase in the relative frequency of Type I (24%), Type IIA (8%) and Type IIX (16%) oxidative fibers, and a decrease in Type IIB (20%) glycolytic fibers. There was a hypertrophy of both oxidative and glycolytic fiber types. The relative cross-sectional area analysis demonstrated an increase in oxidative fibers and a decrease in glycolytic fibers (p<0.0001). Changes were especially evident for Type IIX oxidative-glycolytic fibers. The results of this study indicate that the left ventricle adapts to endurance running by increasing wall thickness and enlargement of the ventricular cavity. Skeletal muscle adapts to training by increasing oxidative fiber Type. This increase may be related to fiber transformation from Type IIB glycolytic to Type IIX oxidative fibers. These results open the possibility for the use of this type of exercise to prevent muscular atrophy associated with age or post-immobilization.

Acetabular development in developmental dysplasia of the hip complicated by lateral growth disturbance of the capital femoral epiphysis.

BACKGROUND: Lateral growth disturbance of the capital femoral epiphysis is the most common type of physeal arrest complicating the treatment of developmental hip dysplasia. Although this type of physeal damage has been assumed to result in poor acetabular development, the natural history of dysplastic hips affected by this pattern of growth disturbance is still unclear. To investigate this issue, we evaluated acetabular development in a retrospective study of fifty-eight hips in forty-eight patients who had lateral physeal arrest after management of developmental hip dysplasia. METHODS: Of the fifty-eight hips, thirty-six were reduced closed and twenty-two were reduced open. The average age of the patients was twenty-two months (range, three to ninety-seven months) at the time of the reduction and twenty-one years (range, ten to fifty-five years) at the time of the latest follow-up evaluation. Hips rated as Severin class I (an excellent result) or II (a good result) were defined as having a satisfactory result, and those rated as Severin class III (a fair result) or IV (a poor result) were considered to have an unsatisfactory result. Specific femoral head changes were sought in the complete radiographic files on all hips. Various radiographic parameters of hip integrity, including the degree of lateral tilt of the capital femoral epiphysis, were measured over time, and comparisons were made between hips classified as satisfactory and those classified as unsatisfactory at four time-points: before the reduction, at two years after the reduction, at six to eight years of age, and at the time of the final follow-up. RESULTS: Lateral growth disturbance of the capital femoral epiphysis was first evident by an average of ten years of age (range, four to fourteen years of age). There was no consistent early pattern of changes in the epiphysis, physis, or metaphysis related to later development of valgus tilt of the epiphysis. Thirty-four hips (59 percent) were rated as satisfactory and twenty-four were rated as unsatisfactory at the latest follow-up evaluation. Hips classified as unsatisfactory exhibited poor acetabular development by an average age of seven years. The inclination of the epiphyseal plate became progressively more horizontal or even reversed over time; however, serial measurements of inclination were not significant predictors of Severin classification. CONCLUSIONS: Lateral growth disturbance of the capital femoral epiphysis is not necessarily associated with poor acetabular development, as when dysplasia does occur it is generally evident prior to the identification of the physeal arrest. It is important to monitor acetabular development after reduction rather than search for radiographic changes of physeal arrest, which are difficult to detect in young children.

Localization of dominantly inherited isolated triphalangeal thumb to chromosomal region 7q36.

Triphalangeal thumb is an autosomal dominantly inherited form of abnormal preaxial skeletal development. In most families, however, the triphalangeal thumb phenotype coexists with a spectrum of limb deformities, including polydactyly and syndactyly. We describe two Iowa kindreds with triphalangeal thumb. In one family, with nine affected members, triphalangeal thumb was the only manifestation of limb deformity. We performed linkage analysis on both pedigrees, demonstrating a maximum LOD score of 6.23 with marker D7S559 on chromosome 7q36. This corresponds to a previous study of a candidate region of 450 kb in which data from several families with preaxial polydactyly were employed. Further analysis of the unique family with isolated triphalangeal thumb in the current study may demonstrate allelic variability of the gene involved in these disorders.

Treatment of idiopathic clubfoot: an historical review.

Idiopathic clubfoot, one of the most common problems in pediatric orthopaedics, is characterized by a complex three-dimensional deformity of the foot. The treatment of clubfoot is controversial and continues to be one of the biggest challenges in pediatric orthopaedics. This controversy is due in part to the difficulty in measuring and evaluating the effectiveness of different treatment methods. We believe the heart of the debate is a lack of understanding of the functional anatomy of the deformity, the biological response of young connective tissue to injury and repair, and their combined effect on the long-term treatment outcomes. The aim of this review is not only to assess the different methods of clubfoot treatment used over the years in light of an evolving understanding of the pathoanatomy of the deformity, but to also clarify factors that allow a safe, logical approach to clubfoot management. Further research will be needed to fully understand the pathogenesis of clubfoot, as well as the long-term results and quality of life for the treated foot.

Diabetic muscle infarction.

Diabetic muscle infarction is a rare complication of diabetes mellitus that is not clearly defined in the orthopaedic literature. This study is a descriptive case series of 7 new cases of diabetic muscle infarction and 55 previously reported cases in the literature. In the majority of patients, diabetic muscle infarction presents as a localized, exquisitely painful swelling and limited range of motion of the lower extremity. No cases affecting the muscles of the upper extremity have been observed. The onset is usually acute, persists for several weeks, and resolves spontaneously over several weeks to months without the need for intervention. Diabetic muscle infarction is a condition that should be considered in the differential diagnosis of any diabetic patient with lower extremity pain and swelling without systemic signs of infection. Magnetic resonance imaging is sensitive and specific enough to make the diagnosis. Muscle biopsy and surgical irrigation and debridement are not recommended since they are associated with complications. Pain management and activity restriction in the acute phase followed by gentle physical therapy is the treatment of choice. Recurrences in the same or opposite limb are common. Although the short-term prognosis is very good and the majority of cases resolve spontaneously, the long-term survival is uncertain in this patient population.

Stress fracture of the hip and pubic rami after fusion to the sacrum in an adult with scoliosis: a case report.

Correction of adult scoliosis frequently involves long segmental fusions, but controversy still exists whether these fusions should include the sacrum. It has been suggested that forces associated with activities of daily living transfer the stresses to the remaining levels of the spine and to the pelvis. The case described here was a 43-year-old woman with scoliosis and chronic back pain refractory to non-surgical modalities. Radiographically, the patient had a 110 degree lumbar curve. An anterior and posterior fusion with Luque-Galveston instrumentation was performed. Six months postoperatively the patient returned with a 2-week history of right hip pain with no history of trauma. There was radiographic evidence of a displaced femoral neck fracture and pubic rami fractures. The femoral neck fracture was treated with a total hip replacement. Further surgeries were required to correct a lumbar pseudoarthrosis and hardware failure. We believe that this case provides evidence that fusion into the lumbosacral junction may distribute forces through the pelvic bones and hip resulting in stress and potential hardware complications, especially in patients at risk due to osteopenic conditions.

Is bone a target-tissue for the nervous system? New advances on the understanding of their interactions.

Bone cells respond in specific ways to various hormones and growth factors, but the biology of skeletal innervation and its physiologic significance in bone metabolism is poorly understood. With the introduction of immunohistochemical staining techniques and new molecular biology tools, the knowledge in this field has significantly improved. In this review, we update current understanding of the effects of neuropeptides on bone metabolism, specifically vasoactive intestinal peptide (VIP) and calcitonin-gene related peptide (CGRP). In addition, new information concerning the role of growth factors, such as neurotrophins, is also discussed. There is strong evidence to suggest that bone can be a target of the nervous system. Further investigations in this field will allow us to answer questions related to pre-natal development, bone growth, fracture healing, osteoporosis, osteoarthritis or neoplasias of mesoderm origin.

Intra-articular benign osteoblastoma of the acetabulum: a case report.

The acetabulum is an unusual location for benign osteoblastoma, usually seen in adolescents and young adults. This article reports a case of an intra-articularly expanding benign osteoblastoma of the acetabulum in a 6-year-old boy. The diagnostic and surgical features of the disease in this unusual location at this young age are discussed. Excisional biopsy and curettage of the lesion followed by bone grafting resulted in healing of the acetabular lesion without acetabular dysplasia, but with a resultant coxa magna.

Long-term outcome after open reduction through an anteromedial approach for congenital dislocation of the hip.

We reviewed the long-term outcome of open reduction of ninety-three congenitally dislocated hips (in seventy-six children) through an anteromedial approach. The average age of the patients was fourteen months (range, two to fifty months) at the time of the reduction and eleven years (range, four to twenty-three years) at the time of the most recent follow-up evaluation. At the most recent follow-up evaluation, sixty-six hips (71 per cent) had an excellent or good result, twenty-four (26 per cent) had a fair result, and three (3 per cent) had a poor result, according to the Severin classification system. An inverted neolimbus at the time of the operation and postoperative growth disturbance of the femoral head were associated with a poor roentgenographic result. According to the classification of Bucholz and Ogden, twenty-two hips (24 per cent) had type-II avascular necrosis, thirteen hips (14 per cent) had type-III, three (3 per cent) had type-IV, two (2 per cent) had non-classifiable lesions, and fifty-three (57 per cent) did not have avascular necrosis. A high hip dislocation and an operation after the age of twenty-four months were associated with a higher rate of growth disturbances of the femoral head. With the numbers available for study, we did not find any association between short-term preoperative traction, ligation of the medial circumflex vessel, or the type of neolimbus and the prevalence of growth disturbances. Two hips redislocated postoperatively, and seven had transient stiffness. We consider the anteromedial approach to be useful in the management of patients with congenital dislocation of the hip who are twenty-four months old or less. The advantages of this approach include direct access to the obstacles to reduction, avoidance of damage of the iliac apophysis and the abductor muscles, minimum blood loss, the need for only a single operative session for treatment of both hips, and a cosmetically acceptable scar. The prevalence of type-II growth disturbances of the femoral head was higher than had been expected, emphasizing the need for additional investigation.

Congenital metatarsus adductus in early human fetal development: a histologic study.

Two feet with congenital metatarsus adductus from fetuses at early development (16 and 19 weeks of gestation) were studied by making serial histologic sections in the horizontal plane of the foot. It was observed that the shape of the medial cuneiform was altered and the first cuneometatarsal joint tilted toward the medial and dorsal directions. The first metatarsal appeared normal, whereas the other metatarsals were deformed in slight adduction at the metaphyseal level. Subluxation at the other cuneometatarsal joints and naviculocuneiform joint was not observed, and the navicular showed no signs of medial or lateral displacement in relation to the head of the talus. No histologic abnormalities of the joint capsules, ligaments, or tendons were observed. On the basis of these pathologic findings, the possibility of a developmental abnormality of the medial cuneiform as a pathogenic factor for the congenital metatarsus adductus deformity should be considered.

The teardrop in congenital dislocation of the hip diagnosed late. A quantitative study.

We retrospectively reviewed the radiographs of the pelvis and hips of forty-five patients who had unilateral congenital dislocation of the hip treated with closed reduction and application of a cast without subsequent operations. The radiographs were made at the time of the initial diagnosis, two years after the reduction, when the child was ten years old, and at skeletal maturity. The width, shape, and type of the teardrop; the thickness of the acetabular floor; the acetabular index; the center-edge angle; the articulotrochanteric distance; and the Severin class at maturity were measured in the dislocated and contralateral, normal hips. At the time of the initial diagnosis, a well defined teardrop was seen in thirty-six (80 per cent) of the normal hips and in seven (16 per cent) of the dislocated hips. There was no difference in the width of the teardrop in the seven dislocated hips compared with that in the normal hips, although the v-shaped and crossed types of teardrops were more frequent in the dislocated hips. The v shape was not observed in the normal hips but was seen in sixteen dislocated hips two years after the reduction and in twelve dislocated hips when the children were ten years old. The superior and inferior widths of the teardrop of the dislocated hips were significantly greater than those of the normal hips (p < 0.001 and p < 0.05, respectively) when the children were ten years old. The hips with residual acetabular dysplasia had a v-shaped teardrop, widening of the superior width of the teardrop, and thickening of the acetabular floor. These hips, which were usually Severin class IV at the time of skeletal maturity, had a poor prognosis in adult life.

Radiologic pelvic asymmetry in unilateral late-diagnosed developmental dysplasia of the hip.

Eighty-three cases of unilateral late-diagnosed (older than 4 months of age) developmental dysplasia of the hip (DDH) were studied to evaluate pelvic shape and innominate bone relationships in the initial anteroposterior radiograph. To be included, each initial radiograph had to have no lumbar pedicle rotation, lumbar scoliosis, gas shadows, or metallic protectors. Measurements were done using as reference a medial pelvic line, which divides the pelvis into two innominate bones. Lineal parameters were defined to assess pelvic radiologic shape; angular parameters defined the relationship between the ilium, ischium and pubis, and sacrum. Statistically significant differences were observed in most cases, and pelvis asymmetry was evident. The asymmetry was more obvious in cases in which the teardrop had a negative value and in low dislocations. Similar changes have been observed in experimental dislocation of the hip secondary to a triplane pelvic deformity. We suggest that similar alterations of pelvic shape occur in DDH, possibly secondary to growth disturbance in the triradiate cartilage.

Proliferative and phenotypic responses of bone-like cells to mechanical deformation.

Limited in vivo and in vitro experiments suggest that bone and bone-like cells respond to mechanical signals in a trigger-like rather than a dose-response fashion; i.e., they fail to respond until they have been stimulated with some given number of cycles of loading, and then once they respond, additional cycles produce little or no effect. To explore this notion, rat calvaria-derived osteoblast-like cells and the cell line MC3T3-E1 were plated at a high cell density (5,000 cells/mm2) on silicone membranes coated with type-I collagen and were allowed to attach for 24 hours. The membranes then were exposed to vacuum pressure (-1 kPa, 0.5 Hz) on a daily basis, and cultures were assayed every 2 days for 2 weeks. The proliferation of nontransformed cells increased 7-fold with as few as four daily cycles but not with one cycle per day. Furthermore, 1,800 cycles of vacuum did not result in a greater response than four cycles per day. We observed inverse phenotypic responses: the expression of osteocalcin was depressed compared with controls in the cultures of osteoblast-like cells that were strained with as few as four cycles per day. Alkaline phosphatase activity was depressed in the cultures of both the osteoblast-like cells and the MC3T3-E1 cells exposed to low vacuum pressures (-1 kPa) with four daily cycles of vacuum pressure. Increasing the vacuum magnitude did not affect the occurrence of a "trigger response" between one and four cycles of vacuum application.(ABSTRACT TRUNCATED AT 250 WORDS)

Femoral head avascular necrosis associated with metaphyseal aneurysmal bone cyst.

A 12-year-old girl had an aneurysmal bone cyst in the proximal femoral metaphysis simultaneously with an avascular necrosis of the femoral head, as seen on radiological examination. No extension of the lesion across the growth plate into the femoral epiphysis was observed. The expansive behavior of this lesion (ABC) could have compromised the posterosuperior vascular supply of the femoral epiphysis, since no radiographic signs of fractures could be found. Vascular anomalies within the lesion that increase venous pressure could be another factor responsible for the decrease in the blood supply of the femoral epiphysis and could cause necrosis, hence compromising the morphology of the hip joint at maturity.

Orthopedic aspects of skeletal dysplasia in children.

Significant advances in the management of skeletal dysplasia have occurred during the past year. A revision of the Paris classification of constitutional disorders of bone has been proposed. New mutations have been identified in several disorders that confirm genetic heterogeneity within similar phenotypes. New clinical data of growth, fracture rates, and incidence of major skeletal and extraskeletal changes as well as the natural history and treatment of spinal deformities in osteogenesis imperfecta have been reported. Pilot studies of short-term growth hormone therapy in patients with achondroplasia and hypochondroplasia and nasal-osteocalcin therapy in osteogenesis imperfecta patients has been described, but the long-term effectiveness of these treatments remains to be determined. Extensive limb lengthening continues to be an important part of the treatment of patients of short stature in Europe, but complication rates continue to be very high. Both the current and future roles for this type of therapy are highly controversial. The potential for enzyme replacement therapy and retrovirus-mediated gene transfer in a variety of mucopolysaccharidosis disorders has been given new meaning by studies with cultured fibroblasts, which suggest that active enzymes can enter into and be synthesized in abnormal cells resulting in normalization of substrate turnover.