Extensive Soft Tissue Release Research Articles

Extensive Posteromedial Soft Tissue Release for Skeletally Mature Patients With Rigid Pes Cavus Deformity

Introduction: Adult-onset cavovarus foot deformity is a highly disabling condition that can seriously interfere with daily activities. Charcot-Marie-Tooth is the most common etiology associated with cavus foot. Patients and Methods: We reviewed 30 feet in skeletally mature patients with rigid cavovarus deformities who were treated with extensive posteromedial soft tissue release without performing osteotomies or internal fixation. Clinical evaluation was done using the Foot Function Index for the pain, disability, and limitation of movement. The radiologic assessment was done by measurement of the lateral talo-first metatarsal angle, the lateral calcaneal-first metatarsal angle, and the lateral tibio-calcaneal angle in standing lateral foot radiographs. All patients were followed up for a mean of 36 months postoperatively. Results: Throughout the course of the study, the Foot Function Index for pain, disability, and limitation improved from an average of 51.46 points, 47.06 points, and 22.6 points preoperatively to postoperative averages of 23.65 points, 21.88 points, and 10.2 points, respectively. Radiologically, the talo-first metatarsal angle, the calcaneo-first metatarsal angle, and the tibio-calcaneal angles had preoperative values of 28.9 degrees, 132.4 degrees, and 62.35 degrees which improved postoperatively to 7.55 degrees, 117.65 degrees and 50.35 degrees, respectively. Conclusion: The outcomes of this study shed light on the use of pure soft tissue release without associated osteotomies as a simple, safe, and effective technique in treating rigid cavovarus deformities in skeletally mature patients. This could carry some advantages regarding preserving foot function as it preserves the integrity of foot joints. Level of Evidence: Level IV.

Results of treatment of congenital vertical talus by the Dobbs method

Congenital vertical talus is a rare foot deformity. The hindfoot is valgus and equinus, the midfoot is dorsiflexed and forefoot is abducted due to a fixed dorsal dislocation of the navicular on the head of the talus and the cuboid on the anterior part of the calcaneus. The epidemiology and etiology of vertical talus is unknown. Dobbs et al. (J Bone Joint Surg Am 88(6):1192–200, 2006) described a minimally invasive alternative which allowed to avoid the need for extensive soft tissue release procedures in treatment of congenital vertical talus. Eleven congenital vertical talus feet (group 5 according to Hamanishi) in eight children (four boys and four girls) constituted the study material. Upon the diagnosis, the patients’ age ranged from 5 to 26 months old (the mean – 14.6). The treatment involved serial manipulation and casting according to the reverse Ponseti method (from 4 to 7 casts) followed by a minimally invasive approach consisting in temporary stabilization of the talonavicular joint with the use of K-wire and Achilles tenotomy according to the Dobbs technique. Then patients continued the shoe and bar program for 2 years. The X-ray measurements on lateral radiographic included the talocalcaneal angle, tibiotalar angle and talar axis—first metatarsal base angle whereas AP radiographic images—the talocalcaneal angle and talar axis—first metatarsal angle. The Wilcoxon test was used to compare dependent variables. The final clinical assessment made during the last follow-up (the mean: 35.8 months, the range: 25–52) revealed that neutral position of the foot and normal range of motion were observed in ten cases and recurrence of foot deformity in one case. The last X-ray examination showed normalization all of radiological parameters, except for one case, and examined parameters were statistically significant. The minimally invasive technique described by Dobbs should be the first option in treatment of congenital vertical talus. It allows to reduce the talonavicular joint, brings good results and preserves foot mobility. The attention should be put on early diagnosis.

Computer Assisted Navigation Surgery Obviates the Need of Extensive Soft Tissue Release During Total Knee Arthroplasty for Varus Knees

Introduction: We aim to (a) evaluate the kinematic patterns of varus deformities in patients with osteoarthritic knees (b) compare our result with literature published in the past and identify a valid classification scheme for the kinematic patterns of varus deformity, and (c) validate the concept of need-based soft tissue release in TKA. Methods: The computer navigations data for all those patients who underwent TKA for varus deformity was extracted and was used to assess the change in coronal plane alignment throughout the range of motion. Clinically, patient satisfaction levels were assessed by using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and functional outcomes were assessed using the Knee Society Score (KSS). Results: 120 patients satisfied the inclusion criteria set for the study. The mean age of the patients was 62.5 ± 7.09 years. The mean preoperative varus deformity was 9.5º ± 4.99o, which was correctable to a mean of 2.88º ± 2.48o in full extension. It was found that 74 (61.7%) patients had correctable varus while 46 (38.3%) had non-correctable varus. Based on the deformity pattern, the soft tissue release required was different in each group of patients. There was a statistically significant improvement both the clinical parameters (p < 0.001). Conclusion: Computer Assisted Navigation System helps to identify the dynamic nature of knee deformity before bone resections and soft tissue release. The soft tissue release for balancing the knee in varus osteoarthritic knees can be tailored sequentially according to need-base for a given pattern of deformity.

Minimally Invasive Method in Treatment of Idiopathic Congenital Vertical Talus: Recurrence is Uncommon.

Historically, treatment for congenital vertical talus (CVT) has included open reduction of the talonavicular joint and extensive soft tissue release. In 2006, a new minimally invasive method consisting of serial manipulation and casting followed by percutaneous fixation of the talonavicular joint and percutaneous Achilles tenotomy was introduced. Although the early results of this new technique are promising, more research is needed to verify that the talonavicular correction is maintained with time. We conducted a retrospective chart review of all patients with idiopathic CVT who underwent minimally invasive correction by a single surgeon at a tertiary care institution. Radiographic evaluation of the preoperative, immediate postoperative, 1 year postoperative and latest follow-up appointments were performed. Complications and clinical outcomes were recorded. Radiographic recurrence of the deformity was defined as lateral talar axis-first metatarsal base angle >30 degrees. Statistical analysis was performed on the maintenance of radiographic correction and factors associated with recurrence. Forty seven feet in 35 patients were included in the study with average follow-up of 45 months. The average preoperative lateral talar axis-first metatarsal base angle was 74±18 compared with 12±8 after initial surgical intervention. In addition, radiographic correction of all other measured angles was achieved in every child following the initial surgery. Radiographic recurrence of talonavicular deformity was seen in 4 feet (9%). No cases of recurrence required a second corrective surgery during the follow-up period. There was a significant association between patient age at the time of treatment and recurrence of talonavicular deformity with patients older than 12 months being more likely to experience recurrence ( P =0.041). In this large series, we found that correction of talonavicular deformity can be achieved and maintained in a large majority of children with idiopathic CVT who undergo treatment with this minimally invasive technique and recurrences are uncommon. Treatment with this technique should be initiated as soon as a diagnosis of CVT is confirmed and the patient is medically stable to decrease the likelihood of experiencing recurrence of talonavicular deformity. Level III.

Narrative review of ring fixator management of recurrent club foot deformity.

Despite the widespread use of the Ponseti method for treatment of clubfeet, there continue to be a significant number of patients who present with a severe, stiff clubfoot as a result of extensive intra-articular soft tissue release or lack of access to care. In such patients, circular external fixators can be utilized for deformity correction with distraction across soft tissues, joints, and osteotomies. Ilizarov or hexapod circular fixators may be utilized according to surgeon preference. Indications for soft tissue release and osteotomies to aid in correction of clubfoot deformity with Ilizarov and hexapod fixators are not standardized and are guided by patient age, joint congruity, soft tissue suppleness, and osseous deformity. Correction time varies according to clubfoot deformity severity. Following deformity correction, external fixators are left in place for several weeks to stabilize the soft tissues and allow for osteotomy healing. Complications range from relatively minor pin tract infections that resolve with oral antibiotics to tarsal tunnel syndrome, osteomyelitis, or disabling arthritis requiring revision procedures. At Scottish Rite Hospital for Children, we prefer to correct severe residual clubfoot deformity with a hexapod external fixator. Acute correction and gradual correction via distraction are considered for each segmental deformity and utilized to efficiently correct deformity while minimizing soft tissue trauma. The purpose of this article is to summarize the relevant literature related to circular external fixator treatment of recurrent clubfoot deformity and outline our approach to the segmental deformities of the foot and ankle in this patient population.

Comparison of Intra-Articular versus Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Study

Background: Total Knee Arthroplasty (TKA) is widely used in clinical applications. Considerable postoperative blood loss, however, is an unavoidable occurrence due to the extensive soft-tissue release, and the large area of cancellous bone osteotomy associated with the procedure. Besides, knee flexion and extension activities those begin the day after the operation adds to the problem. Aim of the Work: To compare between the intra-articular and the intravenous application of Tranexamic Acid (TXA) in total knee arthroplasty. Patients and Methods: It is a prospective Double-blinded Randomized controlled trial. This prospective study was conducted at El-Hussein University Hospital &amp; El Agouza Hospital on 30 patients who undergo total knee arthroplasty and fulfill all inclusion and exclusion criteria. Results: The results were the average total blood loss in the drain after 48hrs. In the 1st group was 365±74.722 while average blood loss in the 2nd group was 575±88.976. This indicates a significant decrease in blood loss in the 1st group (intraarticular TXA group) than the 2nd group (intravenous TXA group) the P value &lt;0.001 which is highly significant. It was found that The decrease in Hb level is less in the 1st group than in the 2nd group which indicates less postoperative anemia in the blood count, the P-value &lt;0.05 considered significant.

Comparative evaluation and analysis of outcomes in non-idiopathic and idiopathic clubfeet with Ponseti method at a tertiary care centre of a developing country

BackgroundIdiopathic clubfoot (congenital talipes equinovarus, CTEV) is being managed worldwide by Ponseti method with high success rates, while for non-idiopathic clubfoot surgical interventions is being widely used with variable results. This study evaluated the effectiveness of Ponseti method in non-idiopathic clubfoot and compared the results with idiopathic clubfoot. MethodsThe paper evaluated the epidemiological incidence and demographic profile of non-idiopathic clubfoot in a tertiary centre of developing country. A total of 108 subjects with 85 having idiopathic (group I;125 feet) and 23 having non-idiopathic variety (group II;34 feet) were managed with Ponseti method and were followed for a mean duration of 38.33 (12–62) and 36.27 months (12–58) in group I and II respectively. The most common associations were meningomyelocele (MMC/spina bifida,5), arthrogryposis multiplex congenita (AMC,4), developmental dysplasia of hip (DDH,3) and Down’s syndrome and amniotic band syndrome (2 each). ResultsPrimary correction was achieved in both the groups in 98% and 87% in group I and II respectively, while recurrences of at least one deformity was observed in 11 (9%) and 12 (40%) feet in group I and II respectively. Favourable outcomes were noticed in 22 (65%) feet in non-idiopathic group and 12 feet (35%) underwent extensive soft tissue release as compared to 3 feet (2.4%) in idiopathic variety. ConclusionDeformities improved significantly in non-idiopathic clubfeet with Ponseti methods although complete correction was not possible. Extensive surgical interventions were reduced in up to 35% feet in non-idiopathic variety and hence, it is recommended as primary treatment for all variety of clubfeet, irrespective of their etiology.

What is the optimal treatment for equinus deformity in walking-age children with clubfoot? A systematic review.

Equinus contracture is the most common deformity at clubfoot relapse and causes pain and functional limitation. It presents a challenge to the orthopaedic surgeon throughout childhood.A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were: (i) original articles, (ii) investigating management of relapsed idiopathic clubfoot, (iii) with at least a partial study population of primarily equinus deformity, and (iv) a paediatric study population of independent walking age.Nine studies were included with a total of 163 patients (207 feet). Studies presented five management paradigms: gastrocnemius-soleus complex release, extensive posterior soft tissue and joint release, anterior distal tibial hemi-epiphysiodesis, distal tibial osteotomy, and circular frame distraction.All approaches reported success in at least one of our selected outcome domains: plantigrade status, range of motion, clinical outcome scores, functional status, radiographic outcomes, patient-reported outcomes, and complications. Younger children tend to be managed with soft tissue release while older children tend to require more extensive bone/joint procedures. Relapse in surgically treated feet is harder to treat.Comparison across treatment approaches is limited by the small size and low evidence level of the literature, as well as a lack of consistent outcome reporting. It is therefore not possible to recommend any one treatment option in any age group.This review highlights the need for a validated core outcome set to enable high-quality research into the management of equinus deformity.Cite this article: EFORT Open Rev 2021;6:354-363. DOI: 10.1302/2058-5241.6.200110

Late Effects of Clubfoot Deformity in Adolescent and Young Adult Patients Whose Initial Treatment Was an Extensive Soft-tissue Release: Topic Review and Clinical Case Series

Children with congenital clubfoot often have residual deformity, pain, and limited function in adolescence and young adulthood. These patients represent a heterogeneous group that often requires an individualized management strategy. This article reviews the available literature on this topic while proposing a descriptive classification system based on a review of patients at our institution who underwent surgery for problems related to previous clubfoot deformity during the period between January 1999 and January 2012. Seventy-two patients (93 feet) underwent surgical treatment for the late effects of clubfoot deformity at an average age of 13 years (range 9 to 19 years). All patients had been treated at a young age with serial casting, and most had at least one previous surgery on the affected foot or feet. Five common patterns of pathology identified were as follows: undercorrection, overcorrection, dorsal bunion, anterior ankle impingement, and lateral hindfoot impingement. Management pathways for each group of the presenting problems is described. To our knowledge, this topic review represents the largest report of adolescent and young adult patients with residual clubfoot deformity in the literature.

One-stage release by double surgical approach for neglected congenital vertical talus: results in a series of walking children in Tanzania.

Congenital vertical talus is an uncommon rigid flatfoot deformity present at birth, producing pain and disability if untreated. This study reports results and complications in a series of walking children affected by neglected congenital vertical talus treated by one-stage release through a double surgical approach in a hospital sited in the Tanzanian rural outback. Between 2009 and 2014, nine consecutive congenital vertical talus were observed in five patients (three males and two females) aged between 2 and 4 years. In two children, the deformity was idiopathic, in two it was associated to distal arthrogryposis and in one to Larsen syndrome. The surgical procedure was performed through a posteromedial and a lateral incision and included extensive soft tissue release and reduction of talo-navicular and subtalar joint, pinned with percutaneous Kirschner wires. The talar axis-first metatarsal base angle (TAMBA) was measured preoperatively and at follow-up. Results were summarized using the Adelaar score and the PODCI (Pediatric Outcomes Data Collection Instrument) questionnaire. The mean follow-up was 2.6 years (2-4). No major intraoperative complications were observed. The TAMBA passed from 74.4° (range 68-82°) to 20.2° (range 18-24°). No talar osteonecrosis was observed. The results were excellent in three cases, good in five cases and fair in one (Adelaar score). The mean postoperative PODCI score was 48 (range 38-60). None of the patients underwent further surgery. In case of neglected congenital vertical talus and limited health resources, this surgical technique has proved to be a viable option, providing satisfactory results, with low rate of surgical and postsurgical complications.

Distal Metaphyseal Osteotomy Allows for Greater Ulnar Shortening Compared to Diaphyseal Osteotomy for Ulnar Impaction Syndrome: A Biomechanical Study.

Purpose To compare the biomechanical characteristics between diaphyseal and metaphyseal ulnar-shortening osteotomy with respect to (1) maximal shortening achieved at each osteotomy site and (2) force required to achieve shortening at each site. Methods Nine fresh frozen cadaveric upper extremities were affixed through the proximal ulna to a wooden surgical board. A metaphyseal 20-mm bone wedge was resected from the distal ulna and sequential shortening was performed. A load cell was attached to a distal post that was clamped to the surgical board and used to measure the force required for each sequential 5-mm of shortening until maximal shortening was achieved. The resected bone was reinserted, and plate fixation was used to restore normal anatomy. A 20-mm diaphyseal osteotomy was performed, and force measurements were recorded in the same manner with (1) interosseous membrane intact, (2) central band released, and (3) extensive interosseous membrane and muscular attachments released. Results Metaphyseal osteotomy allowed greater maximal shortening than diaphyseal osteotomy with the interosseous membrane intact and with central band release but similar shortening when extensive interosseous membrane and muscle release was performed. Force at maximal shortening was similar between metaphyseal and diaphyseal osteotomy. Sequential soft tissue release at the diaphysis allowed for increased shortening with slightly decreased shortening force with sequential release. Conclusion Metaphyseal ulnar osteotomy allows greater maximal shortening but requires similar force compared with diaphyseal osteotomy. Sequential release of the interosseous membrane permits increased shortening at the diaphysis but requires extensive soft tissue release. Clinical Relevance Both sites of osteotomy can achieve sufficient shortening to decompress the ulnocarpal joint for most cases of ulnar impaction syndrome. The greater shortening from metaphyseal ulnar osteotomy may be reserved for severe cases of shortening, especially after distal radius malunion or in the setting of distal radius growth arrest in the pediatric population. Level of Evidence This is a Level V, basic science study.

Two-stage total hip arthroplasty following skeletal traction after extensive soft tissue release for severe limb-length discrepancy.

To maximise limb-length discrepancy (LLD) resolution during total hip arthroplasty (THA) for untreated developmental hip dysplasia or septic hip sequelae, THA following limb lengthening was introduced using different methods. We aimed to evaluate 2-stage THA results following limb lengthening via skeletal traction after extensive soft tissue release. In total, 24 hips with severe LLD in 10 men and 14 women (mean age, 49.6 ± 15.2 years) underwent 2-stage THA and were followed thereafter (mean 6.3 ± 3.7 years). The entire abductor muscle origin was subperiosteally released from the ilium, and the soft tissue around the hip joint, including the psoas tendon, short external rotator, joint capsule, and adductor tendon, was extensively released. 2-stage THA was performed after 2-week skeletal traction using proximal tibial pins. During the final THA, 7 hips necessitated subtrochanteric shortening osteotomy (STO) for hip joint reduction. We evaluated the clinical and radiological results and especially focused on LLD and neurological complications. The Harris Hip Score improved from 57.1 ± 9.6 to 88.3 ± 6.3 points. No patients showed worse abductor power. LLD improved from 5.0 ± 2.0 to 1.4 ± 1.0 cm. No permanent neurological complications occurred except for 1 transient peroneal nerve palsy during traction, which resolved fully after cessation of traction. There were 2 hips with STO nonunion treated with osteosynthesis and stem revision. 2-stage THA following skeletal traction after extensive soft tissue release showed favourable results in terms of neurologic complication prevention and LLD resolution. However, a large proportion of patients still necessitated shortening osteotomy with a risk for nonunion at the osteotomy site. Though surgical procedures might be complicated and necessitate longer hospital stays, 2-stage THA with extensive soft tissue release might be an alternative treatment option for patients with severe LLD willing to resolve their limb length discrepancy.

Comparison of Intra-articular versus Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Study

Background: Total knee arthroplasty (TKA) is commonly performed for the advanced knee joint disease. Considerable postoperative blood loss, however, is an unavoidable occurrence because of extensive soft-tissue release, and the large area of cancellous bone osteotomy associated with the procedure. In addition, knee flexion and extension activities that begin the day after the operation adds to the problem. Aim of the Work: to compare between the intravenous the intraarticular tranexamic acid (TXA) administration in total knee arthroplasty surgery. Patients and Methods: It is a prospective double-blinded randomized controlled study. This prospective, two-arm, parallel-group study was conducted at El-Hussein University Hospital and El-Agouza Hospital on 20 patients who underwent total knee arthroplasty and fulfilled all assumed inclusion and exclusion criteria. Results: The average total blood loss amount in the drain after 48 hrs. in the 1st group was 365±74.722 while in the 2 nd group it was 575±88.976. This indicates a significant decrease in blood loss amount in the 1st group (intraarticular TXA group) than the 2 nd group (intravenous TXA group). Also, it was found that the decrease in hemoglobin (Hb) level is less in the 1st group than in the 2nd group which indicates less postoperative anemia. Conclusion: Concerning intraarticular administration of TXA seemed to be effective much more than intravenous injection in terms of blood loss amount and transfusion frequency.

Comparison of Intra-articular versus Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Study

Background: Total knee arthroplasty (TKA) is commonly performed for the advanced knee joint disease. Considerable postoperative blood loss, however, is an unavoidable occurrence because of extensive soft-tissue release, and the large area of cancellous bone osteotomy associated with the procedure. In addition, knee flexion and extension activities that begin the day after the operation adds to the problem. Aim of the Work: to compare between the intravenous the intraarticular tranexamic acid (TXA) administration in total knee arthroplasty surgery. Patients and Methods: It is a prospective double-blinded randomized controlled study. This prospective, two-arm, parallel-group study was conducted at El-Hussein University Hospital and El-Agouza Hospital on 20 patients who underwent total knee arthroplasty and fulfilled all assumed inclusion and exclusion criteria. Results: The average total blood loss amount in the drain after 48 hrs. in the 1st group was 365±74.722 while in the 2 nd group it was 575±88.976. This indicates a significant decrease in blood loss amount in the 1st group (intraarticular TXA group) than the 2 nd group (intravenous TXA group). Also, it was found that the decrease in hemoglobin (Hb) level is less in the 1st group than in the 2nd group which indicates less postoperative anemia. Conclusion: Concerning intraarticular administration of TXA seemed to be effective much more than intravenous injection in terms of blood loss amount and transfusion frequency.

Effect of Medial Soft Tissue Releases During Posterior-Stabilized Total Knee Arthroplasty on Contact Kinematics and Patient-Reported Outcomes

BackgroundMinimal to extensive medial soft tissue releases are part of the exposure and achieving adequate varus knee balance in total knee arthroplasty (TKA). However, the effect of these releases on knee kinematics and patient-reported outcomes is unclear. Our objective was to compare the postoperative in vivo tibiofemoral contact kinematics of a posterior-stabilized TKA between patients who received minimal medial soft tissue releases intraoperatively to those who received extensive releases. We also compared these groups using patient-reported outcomes. MethodsA prospective imaging study was performed in a single-center over a 14-month period. Patients with end-stage osteoarthritis and varus deformity undergoing primary TKA were included. Baseline data were collected 1 month before surgery. The radiostereometric analysis imaging took place at least 1 year postoperatively and composed of weight-bearing radiographic stereo examinations of knee flexion starting in full extension and in 20° increments of flexion to a maximum of 120°. Intraoperative medial soft tissue releases were recorded. Patient-reported outcomes used included Short-Form 12, Western Ontario and McMaster Osteoarthritis Index, and Knee Society Score. ResultsFifty-one patients were included in the statistical analysis. Demographic characteristics were similar between all. Patients were divided into 3 groups depending on the amount of releases they received. No statistically significant differences in tibiofemoral contact positions or excursions on the medial or lateral condyles were found throughout flexion from 0° to 120°. Postoperative patient-reported outcome scores were not different. ConclusionCorrecting severe varus deformities with extensive medial soft tissue release largely did not alter knee kinematics or clinical outcome scores compared to those with minimal soft tissue release.

Outcomes of the Ponseti Method for Untreated Clubfeet in Nepalese Patients Seen Between the Ages of One and Five Years and Followed for at Least 10 Years.

To our knowledge, there are no reports of the Ponseti method initiated after walking age and with >10 years of follow-up. Our goal was to report the clinical findings and patient-reported outcomes for children with a previously untreated idiopathic clubfoot who were seen when they were between 1 and 5 years old, were treated with the Ponseti method, and had a minimum follow-up of 10 years. A retrospective review of medical records was supplemented by a follow-up evaluation of physical findings (alignment and range of motion) and patient-reported outcomes using the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C). The initial treatment was graded as successful if a plantigrade foot was achieved without the need for an extensive soft-tissue release and/or osseous procedure. We located 145 (91%) of 159 patients (220 clubfeet). The average age at treatment was 3 years (range, 1 to 5 years), and the average duration of follow-up was 11 years (range, 10 to 12 years). The initial scores according to the systems of Pirani et al. and Diméglio et al. averaged 5 and 17, respectively, and an average of 8 casts were required. Surgical treatment, most commonly a percutaneous Achilles tendon release (197 feet; 90%), was required in 96% of the feet. A plantigrade foot was achieved in 95% of the feet. Complete relapse was rare (3%), although residual deformities were common. Patient-reported outcomes were favorable. A plantigrade foot was achieved in 95% of the feet initially and was maintained in most of the patients, although residual deformities were common. Patient-reported outcomes were satisfactory, and longer-term follow-up with age-appropriate outcome measures will be required to evaluate function in adulthood. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Midterm Results of the Ponseti Method for Treatment of Clubfoot in Patients With Spina Bifida.

Clubfoot occurs in 30% to 50% of patients with spina bifida. The Ponseti casting method has changed treatment of idiopathic clubfoot to a primarily nonoperative regimen. The Ponseti method is now widely applied to clubfoot in spina bifida, however, few studies report treatment outcomes. Most available studies include heterogeneous diagnoses or short-term results. The purpose of this study is to report midterm outcomes in patients with spina bifida and clubfoot treated with the Ponseti method. IRB-approved retrospective chart review of 17 consecutive patients (26 feet) below 1 year of age with spina bifida and clubfoot treated with Ponseti method. Charts reviewed for age at treatment initiation, number of casts, surgeries performed, recurrence of deformity, and further treatments. Primary outcome was recurrence of deformity requiring further treatment. Data were analyzed using t tests for means and χ tests for categorical data. Initial correction was achieved in 26 of 26 feet patients. A total of 23 of 26 feet patients underwent a surgical procedure for the tendo-Achilles at an average age of 105 days, 12 percutaneous tenotomies (percT) and 11 open tendonectomy (openT). At average follow-up of 5 (1.8 to 7.5) years, 11 feet (42.3%) in 8 patients were successfully treated with Ponseti method. Of the 15 feet (57.7%) with recurrence, 10 required posterior releases, 4 posterior-medial-lateral releases and 1 tendon transfers. Average age at further treatment was 1.5 years (0.9 to 3.1 y). Those with recurrence required more casts before tendon surgery (7.6 vs. 6.1, P=0.02). A total of 100% patients (12/12) with percT had recurrence of deformity, compared with 18% (2/11) of patients with openT (P<0.0005). Midterm evaluation of Ponseti method for clubfoot in spina bifida shows a successful outcome in 42.3%. Recurrence with openT was significantly lower than percT and also substantially lower than previously published recurrence rates in spina bifida (33.3% to 68%). In spina bifida, Ponseti method leads to reliable initial correction and is useful to decrease extensive soft tissue release. An open excision of the Achilles should be performed. Families should be counseled about high risk of recurrence and potential need for further treatment. Level III-retrospective comparative study.

Efficacy of Ponseti Technique in Virgin and Relapsed Clubfeet: A Comparative Study

Doubts still loom over the effectiveness of Ponseti casting in treating children with recurrent clubfeet. We have undertaken this study to confirm whether excellent results obtained in treating virgin clubfeet by Ponseti casting can be reproduced with equal success in relapsed clubfeet. The patients were divided into 2 groups; Group I was untreated children with congenital clubfeet younger than 1 year of age (21 feet) and Group II was children with relapsed congenital clubfeet younger than 2 years of age (21 feet). The Ponseti method was applied with equal success in both groups. Groups I (virgin) and II (recurrent) were similar in terms of number of casts, period of immobilization, and successful initial correction. We did not find statistically significant differences (p value = .75) when comparing the number of casts required for correcting deformity in virgin (mean 6.3) and relapsed group (mean 5.5). The Pirani score improved significantly after treatment from 4.3 to a post-treatment value of 0.4 (p < .001) in recurrent clubfeet and from 5.4 to 0.31 (p < .001) in virgin clubfeet. The results of our study suggest that excellent initial correction of deformity can be achieved without the need for an extensive soft tissue release in more than 95% of children with recurrent clubfeet.

Intravenous Tranexamic Acid Reduces Postoperative Blood Loss After High Tibial Osteotomy

Medial opening wedge high tibial osteotomy (HTO) entails extensive soft tissue release that may lead to substantial perioperative bleeding. Although tranexamic acid (TXA) is a well-established blood-conserving agent in total joint arthroplasty, its potential to reduce blood loss in patients undergoing HTO has not been studied extensively. (1) Does TXA reduce total estimated blood loss in HTO? (2) Does TXA use in HTO affect in-hospital endpoints as measured by visual analog scale (VAS) pain scores at rest the day after surgery, wound complications in the immediate postoperative period, blood transfusions, or symptomatic deep vein thrombosis? Between January 2015 and May 2017, a single surgeon performed 156 HTOs, all of which were done using the medial opening wedge technique. We began using intravenous TXA for all HTOs in June 2016. This left us with 89 patients who were treated during a time when no TXA was used and 67 patients who were treated when all patients received TXA. Two patients in the control group had simultaneous TKA in the contralateral leg and one patient in each group had missing data so these patients were excluded, leaving 86 (97%) patients in the control group and 66 (98.5%) in the TXA group available for analysis in this retrospective study. There were no demographic differences between the groups in terms of age, sex, body mass index, and baseline hemoglobin values. Total estimated blood loss was the primary outcome variable, which was calculated using total blood volume and decrease in hemoglobin values. Secondary outcome variables included pain VAS at rest the day after surgery, wound complications in the immediate postoperative period, allogeneic blood transfusions, and occurrence of symptomatic thromboembolic manifestations. The decision on when to transfuse was based on predetermined criteria. An orthopaedic surgeon not involved in patient care collected the patient data from electronic medical records and did chart review. The TXA group had less total blood loss (372 ± 36 mL versus 635 ± 53 mL, mean difference 263 mL [95% confidence interval, 248-278]; p < 0.001). Between groups, differences in VAS pain scores at rest the day after surgery favored the TXA group but were small and unlikely to be clinically important. There were two wound complications in the control group (one hematoma and one superficial wound infection) and none in the TXA group. No patients in either group received a blood transfusion, and no symptomatic thromboembolic events were detected in either group. This study demonstrates that the systemic administration of TXA reduces postoperative blood loss in medial opening wedge HTO; however, insofar as no transfusions were administered to patients even before the routine use of TXA in this series, and no clinically important differences in pain scores were identified, the clinical benefit of routine use of TXA in patients undergoing HTO is uncertain. Our study was too small to make safety-related claims on rare endpoints such as wound complications or thromboembolic events. Larger, and preferably randomized, trials are needed to help define whether it is important to use TXA in this setting. Our data can help inform sample size calculations for such studies. Level III, therapeutic study.

Does Generalized Hypermobility Increase the Risk of Relapse or Overcorrection in Idiopathic Clubfoot Treated with the Ponseti Method

Purpose: Previous studies have suggested a role for joint laxity in the etiology of clubfoot, however, the influence of joint laxity on the treatment and outcome idiopathic clubfoot has not been thoroughly investigated. An earlier study found that the presence of hypermobility lead to overcorrection of clubfoot in patients treated with extensive soft tissue release. The goal of this study was to determine if the presence of hypermobility influenced the treatment or short-term outcome of patients …