Need For Tenotomy Research Articles

Effect of Cultural Factors on Outcome of Ponseti Treatment of Clubfeet in Rural America

Nonoperative management of clubfoot with the Ponseti method has proven to be effective, and it is the accepted initial form of treatment. Although several studies have shown that problems with compliance with the brace protocol are principally responsible for recurrence, no distinction has been made with regard to whether the distance from the site of care affects the early recurrence rate. We compared early recurrence after Ponseti treatment between rural and urban ethnically diverse North American populations to analyze whether distance from the site of care affects compliance and whether certain patient demographic characteristics predict recurrence. One hundred consecutive infants with a total of 138 clubfeet treated with the Ponseti method were followed prospectively for at least two years from the beginning of treatment. Early recurrence, defined as the need for subsequent cast treatment or surgical treatment, and compliance, defined as strict adherence to the brace protocol described by Ponseti, were analyzed with respect to the distance from the site of care, age at presentation, number of casts needed for the initial correction, need for tenotomy, and family demographic variables. Of eighteen infants from a rural area who had early recurrence, fourteen were Native American. The families of these children, like those of all of the children with early recurrence, discontinued orthotic use earlier than was recommended by the physician. Discontinuation of orthotic use was related to recurrence, with an odds ratio of 120 (p < 0.0001), in patients living in a rural area. Native American ethnicity, unmarried parents, public or no insurance, parental education at the high-school level or less, and a family income of less than $20,000 were also significant risk factors for recurrence in patients living in a rural area. Intrinsic factors of the clubfoot deformity were not correlated with recurrence or discontinuation of bracing. Compliance with the orthotic regimen after cast treatment is imperative for the Ponseti method to succeed. The striking difference in outcome in rural Native American patients as compared with the outcomes in urban Native American patients and children of other ethnicities suggests particular problems in communicating to families in this subpopulation the importance of bracing to maintain correction. An examination of communication styles suggested that these communication failures may be culturally related.

Results of treatment of idiopathic clubfoot in older infants using the Ponseti method: a preliminary report

The Ponseti method has become a well-established technique for the treatment of clubfoot presenting in the neonatal period. A few reports have discussed the result of this method in older age group. The purpose of this study is to present the results and clinical experience of using the Ponseti method in the treatment of idiopathic congenital talipes equinovarus in infants presented between 4 and 13 months of age with a history of failed manipulations. Thirty-two feet in 20 infants (12 males; eight females) with idiopathic congenital clubfeet were treated using the Ponseti method with minor modifications. The average age at presentation was 7 months (range from 4 to 13 months). We used the Pirani scoring system to assess the feet. After an average follow-up of 19 months, the ultimate overall results were satisfactory in 31 feet. The Pirani score improved from an average of 4.3 (range: 3-6) at presentation to a final follow-up average of 0.5 (range: 0-1). One foot had unsatisfactory result with a pretreatment score of 5.5 and a final score of 3. The results were also presented in terms of the number of casts applied, the need for tenotomy of tendo Achillis, recurrence of the deformity and the ultimate requirement for surgical release. The use of the Ponseti method in older-aged infants with idiopathic congenital clubfoot seems to be an effective method of treatment, obviating the need for extensive surgery.

Ponseti Treatment for Idiopathic Clubfoot: Minimum 5-year Followup

Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5-9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents' perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5 degrees or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents' satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of idiopathic club foot using the Ponseti method

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.

Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity

We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of > or =5 predicted the need for tenotomy (p < 0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey. We believe that the Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme.

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet.

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

Predicting the Need for Tenotomy in the Ponseti Method for Correction of Clubfeet

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores ≥5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of ≥5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.

The Sequoia Circular Fixator for Limb Lengthening

With the Sequoia fixator, lengthenings can be achieved based on the clinical facts of the case. The device is a modular apparatus that can perform corrections in several planes, and, if necessary, in a septic environment. In our opinion, a "lengthener surgeon" is one who can foresee problems and take appropriate steps to prevent them. Likewise, the surgeon must act as the coordinator of an entire team. A successful lengthening is 5% surgery and 95% postoperative nursing and physiotherapy care. In the future, a number of changes will simplify postoperative management: 1. Composite carbon rings will make the frames radiolucent and one third lighter than those made of stainless steel. Automatic tensioners will help maintain steady tension on the wires. 2. Digital analysis of the callus will provide norms of consolidation, allowing faster fixator removal and conversion to an orthosis. 3. Incorporating the foot in the frame to overcome equinus will eliminate the need for tenotomy. We believe that monolateral and ring fixators can work together in certain locations. That is why we proposed, at the 18th Societé Internationale de Chirurgie Orthopédique et Traumatologique meeting, a combined monolateral-ring construct that can be used for lengthening throughout the proximal femoral metaphysis.

Total Hip Arthroplasty in Congenital Dislocated Hips

Experience with six typical cases demonstrates that total arthroplasty for congenital dislocated hips may be associated with malalignment of the ipsilateral knee, leg-length inequality, pelvic obliquity and structural changes in the lumbosacral spine. The preoperative planning may include computerized tomography scan to obtain accurate information about the optimal placement of the socket and the size and shape of the prosthetic components. Loosening of the stem or socket rather than polyethylene wear is the expected cause of late failure. The design of the femoral component should fit the canal and the shape of the proximal femur. Biological causes for failure, such as granulomatous reaction to wear, particles, and infection, are known but were not encountered in the present series of cases. The surgical technique is designed to obtain complete coverage of the socket in the available bone. A supplementary bone graft provides additional bone stock and is especially important for revision operations. Orientation of the components, stability of the joint, the need for tenotomy of contracted structures, and the improvement of abduction and flexion muscle power are also important considerations. Elderly patients with degenerated, painfully dislocated hips that are refractory to conservative treatment, may be candidates for arthroplasty.