The Ponseti method is a proven treatment for idiopathic clubfoot, yielding excellent outcomes with minimal pain or disability. However, as many as 40% of patients fail to respond to initial treatment or develop recurrent deformities.
On Wednesday, January 25, 2017 at 8:00 PM EST, The Journal of Bone & Joint Surgery will host a complimentary webinar that delves into two recent JBJS studies investigating how to predict which patients are most likely to get subpar results from the Ponseti method, and how best to manage clubfoot relapses if they occur.
- Matthew Dobbs, MD, describes in detail various soft-tissue abnormalities present in patients with treatment-resistant clubfoot that are not present in treatment-responsive patients. These parameters could be used to predict which clubfoot patients are at greater risk of relapse.
- Jose Morcuende, MD, will spotlight findings from a study that followed treated clubfoot patients for 50 years to determine whether relapses managed with repeat casting and tibialis tendon transfer during early childhood prevented future relapses.
This webinar is moderated by James Kasser, MD, surgeon-in-chief at Boston Children’s hospital and a member of the JBJS Board of Trustees. The webinar will offer additional perspectives on the authors’ presentations from two clubfoot-management experts—Steven Frick, MD and Gregory Mencio, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.
Seats are limited, so register now!
In the November 16, 2016 edition of The Journal of Bone & Joint Surgery, Kim et al. improve our understanding of how blood flow is restored to the necrotic femoral head in Legg-Calve-Perthes disease. Using a series of perfusion MRI scans, the authors evaluated 30 hips with Stage-1 or -2 disease; 15 of the hips were treated conservatively, and 15 underwent one of three operative interventions.
Revascularization rates varied widely (averaging 4.9% ± 2.3% per month), but the revascularization pattern was similar, converging in a horseshoe-shaped pattern toward the anterocentral region of the femoral epiphysis from the posterior, lateral, and medial aspects of the epiphysis. The MRIs yielded no evidence of regression or fluctuation of perfusion of femoral heads, which casts some doubt on the proposed repeated-infarction theory of pathogenesis for this disease.
In a related commentary, Pablo Castaneda emphasizes that the study was not designed to evaluate the effects of different treatments, but he says knowing about an MRI pattern that is predictive of final outcomes in Legg-Calve-Perthes disease “has potential for improving our prognostic abilities.” Still, neither the commentator nor the authors suggest routinely obtaining serial MRIs in this patient population.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
Having passed the half-century mark with continued relevance, this classic JBJS article by T.G. Barlow, published in the British volume in 1962, rewards the reader with pearls and insights that can still help us make good decisions about treatment of infants with hip dysplasia. Exploring new approaches always pays rich dividends, and this report details Barlow’s observations from a five-year study (1957-1962) in which he examined all newborns at his hospital and followed them up at one year of age. This effort was undertaken at a time before the emerging field of pediatric orthopaedics had many full-time adherents.
Barlow studied nearly 10,000 newborns at the Hope Hospital in Manchester, England. He conducted the first examinations during the first week of life, in an era when newborns in the UK stayed in the hospital for at least one week. He carefully recorded his findings and made observations on incidence of hip dislocation, natural history, and treatment.
His first contribution, for which he is still remembered, was to show that in newborns, with their low resting muscle and tissue tension, the Ortolani test is often subtle, and a dislocated hip may escape notice. The Ortolani test was often impressive in older babies, but less so in newborns. Therefore, Barlow devised his eponymous test, which increases the proprioceptive feedback by applying axial pressure and provoking subluxation or dislocation. Simply put, it is often easier to feel the hip displacing with pressure than to feel it slip back in. The number of babies who have benefited from this method of early detection is too numerous to count!
Barlow’s other observations are equally relevant and useful. He observed that many babies with dislocatable but non-dislocated hips will stabilize naturally. He showed that only one-eighth of unstable hips will have a persistent dislocation, which is why we now only treat dislocated hips immediately upon detection. Recent articles1 have added further insights in this regard.
Barlow also showed that with a program of screening and treatment, no patient in his experience presented at a year of age with a hip dislocation. We still debate the proper method of early detection, but he properly targeted the neonatal period as the time that instability usually begins. Barlow also demonstrated a simple abduction splint made of aluminum and leather that holds the hips in flexion and abduction. Although the Pavlik harness has become more popular as an initial treatment, experts have recently come to realize that a fixed-angle brace can benefit some children who do not stabilize in a Pavlik.2
This classic article was fun to re-read and remains useful to general and pediatric orthopaedic surgeons. Barlow’s disciplined undertaking has shaped our understanding of this important disorder. The man and his insights are remembered for good reason.
Paul D. Sponseller, MD
JBJS Deputy Editor
- Upasani VV, Bomar JD, Matheney TH, Sankar WN, Mulpuri K, Price CT, Moseley CF, Kelley SP, Narayanan U, Clarke NM, Wedge JH, Castañeda P, Kasser JR, Foster BK, Herrera-Soto JA, Cundy PJ, Williams N, Mubarak SJ. Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure. J Bone Joint Surg Am. 2016 Jul 20;98(14):1215-21
- Sankar WN, Nduaguba A, Flynn JM. Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip. J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7.
Despite the remarkable success of modern treatments for congenital clubfoot, including the Ponseti method, some kids still end up with a rigid residual deformity after walking age. In the October 19. 2016 edition of JBJS, Dragoni et al. investigated the Ponseti treatment in 44 patients (68 feet; mean age of 4.8 years) who had been previously treated with various surgical and conservative protocols but whose outcomes were fair or poor, according to International Clubfoot Study Group scores.
The authors performed Ponseti manipulation and cast application with the patients under conscious sedation. Depending on the clinical situation, some patients also received percutaneous heel-cord surgery or percutaneous fasciotomy, and all those over 3 years old (88% of the feet) received tibialis anterior tendon transfer (TATT).
At a mean follow-up of just under 5 years, 84% of the feet had achieved excellent or good results. No feet showed a lack of plantar flexion or were not plantigrade. Despite the mobility problems that a series of long leg Ponseti casts posed for kids of walking age, the authors reported that “families enthusiastically agreed to continue the Ponseti treatment as soon as they looked at the improved shape of their child’s foot after removal of the first plaster cast.”
Relapse of clubfoot deformity has been attributed to non-adherence to post-corrective bracing recommendations. The October 5, 2016 issue of The Journal of Bone & Joint Surgery contains a study by Sangiorgio, et al. in which wireless sensors measured the actual brace use in 44 patients aged 6 months to 4 years who were supposed to use a post-corrective foot abduction orthosis for an average of 12.6 hours per day. The authors compared the mean number of hours of daily brace use as measured by the sensors with the physician-recommended hours and with parent-reported hours of brace use.
Here’s what Sangiorgio et al. found:
–Median brace use recorded by the sensors was 62% of that recommended by the physician and 77% of that reported by parents.
–18% of the patients experienced relapse. The mean number of daily hours of brace use for those patients (5 hours a day) was significantly lower than the 8 hours per day for those who didn’t experience relapse.
While this study suggests that 8 hours or more of daily brace use may be helpful to prevent relapse, studies with larger cohorts will be needed to determine more definitive bracing minimums. Still, the authors say that “routine brace monitoring has the potential to accurately identify patients who are receiving an inadequate number of hours of brace use and facilitate more effective counseling of these families.”
The 3-dimensional spinal deformities associated with scoliosis may affect other organ systems. In the October 5, 2016 issue of The Journal, Shen et al. correlated radiographic severity of thoracic curvature/kyphosis with pulmonary function at rest and exercise capacity measured with a bicycle ergometer. Forty subjects with idiopathic scoliosis were enrolled in the prospective study (mean age 15.5 years), 33 of them female.
The study found no correlation between coronal thoracic curvature and static pulmonary function tests in the female patients. Female patients with a thoracic curve of ≥ 60° had lower blood oxygen saturation at maximal exertion during the exercise test, but overall exercise tolerance did not appear to be correlated with the magnitude of the thoracic curve and kyphosis. According to the authors, taken together, the many specific cardiopulmonary findings in this study suggest that “the cardiovascular system may be less affected than the respiratory system in patients with idiopathic scoliosis.”
Not surprisingly, exercise capacity was better in patients who performed regular aerobic exercise. Although physical training may not be able to change pulmonary pathology in this population, the authors emphasized that physical activity is still recommended for patients with idiopathic scoliosis for maintaining cardiovascular and peripheral muscle conditioning.
Surgeons often prescribe more postoperative pain medication than their patients actually use. That’s partly because there is limited procedure-specific evidence-based data regarding optimal amounts and duration of postoperative narcotic use—and because every patient’s “relationship” with postoperative pain is unique. Nevertheless, physician prescribing plays a role in the current opioid-abuse epidemic, so any credible scientific information about postoperative narcotic usage will be helpful.
The Level I prognostic study by Grant et al. in the September 21, 2016 issue of The Journal of Bone & Joint Surgery identified factors associated with high opioid use among a prospective cohort of 72 patients (mean age 14.9 years) undergoing posterior spinal fusion for idiopathic scoliosis.
Higher weight and BMI, male sex, older age, and higher preoperative pain scores were associated with increased narcotic use after surgery. Somewhat surprisingly, the number of levels fused, number of osteotomies, in-hospital pain level, self-reported pain tolerance, and surgeon assessment of anticipated postoperative narcotic requirements were unreliable predictors of which patients would have higher postoperative narcotic use.
Because the authors found that pain scores returned to preoperative levels by postoperative week 4, they say, “further refills after this point should be considered with caution.” Additionally, after reviewing the cohort’s behavior around disposing of unused narcotic medication, the authors conclude, “We consider discussion of narcotic use and disposal to be an important component of the 1-month postoperative visit…This important educational opportunity could help decrease abuse of narcotics.”
Infection, whether acute, chronic, local, or systemic, is something that all surgeons respect and fear. To counter infection, tissue injury activates an acute-phase response mediated by the liver and promotes coagulation, immunity, and tissue regeneration. However, microorganisms are able to survive and disseminate throughout tissues because of virulence factors that they express. These virulence factors help to modulate and hijack the acute-phase response.
In this month’s Editor’s Choice article, An et al. discuss how an understanding of virulence strategies of musculoskeletal pathogens will help to guide clinical diagnosis and decision-making through monitoring of acute-phase markers such as C-reactive protein, the erythrocyte sedimentation rate, and fibrinogen. As pathogenic bacteria possess virulence factors that allow them to invade, persist, and disseminate within the human body, this review focuses on the pathophysiology of musculoskeletal infection and the virulence factors that enable pathogens to thrive within the context of tissue damage.
The authors demonstrate that tissue injury ruptures anatomic compartment boundaries, leading to the contamination of microenvironments that require complex physiological processes for proper temporary repair. Certain organisms, such as Staphylococcus aureus and Streptococcus pyogenes, have evolved mechanisms for evading and hijacking the hemostatic, tissue regenerative, and antimicrobial properties of the acute-phase response. Indeed, a better understanding of the virulence strategies used by pathogenic microorganisms should enhance our ability to treat infections and improve patient outcomes in the future.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
Michael McMaster, a widely respected and well-published orthopaedic surgeon from Edinburgh who treated a great number of pediatric spinal deformity patients over a 36-year career, published this classic JBJS article more than 30 years ago. His report continues to serve as the basis for what we as pediatric spinal deformity surgeons recommend for treatment in children with congenital scoliosis. The classification that he proposed allows us to know early in childhood which congenital scoliosis patients require early, aggressive treatment and who can be followed with little need for treatment.
By assessing 251 growing patients with congenital scoliosis in a longitudinal manner, Mr. McMaster determined the rate of progression with growth for 5 different primary curve types. The most progressive deformity is a unilateral vertebral bar (failure of segmentation) with a contralateral hemivertebra (failure of formation). Common congenital single hemivertebrae worsen most in the thoracolumbar and lower thoracic areas, and all hemivertebrae progress at a faster rate after 10 years of age than prior to age 10.
Knowing the natural history of any deformity in pediatric orthopaedics is the major factor in determining the need for treatment. Mr. McMaster here provided the pediatric spinal deformity surgeon with essential information that still guides our treatment of congenital scoliosis on a daily basis today.
Vernon T. Tolo, MD
JBJS Editor Emeritus
Orthopaedic surgery is generally a discipline where functional restoration and pain relief take precedence over esthetics. However, all practicing surgeons know that how incisions appear is important to many patients and their families. This is especially true in pediatric orthopaedics, where parents feel a responsibility to limit any adverse experiences their child may have.
In the August 17, 2016 edition of The Journal, Davids et al. provide our community with an important contribution regarding some basic principles of scar management in children—in this case, kids with cerebral palsy who had a second surgery to remove an implant. The take-home message is that scars that are acceptably thin with minimal discoloration are safe to treat and do well cosmetically with a repeat incision through the original scar. Scars that are broad and/or discolored basically end up with the same appearance when the implant is removed through excision (a second incision about the margins of the first incision) and layer closure.
This field is ripe for further investigation, and careful attention to methodology will be very important. Interventions that deserve additional study include topical and intralesional treatments for healing incisions, the impact of immobilization on the quality of scars below the knee, and the effects on scars of limited weight bearing, to name a few. Similar investigations in select groups of adults with scars about the shoulder, knee, and ankle will also be welcome additions to this objective evaluation of surgical-incision outcomes by Davids et al.
Marc Swiontkowski, MD