Postoperative Cast Research Articles

Concurrent orthopedic and neurosurgical procedures in pediatric patients with spinal deformity

The management of pediatric patients with complex spinal deformity often requires both an orthopedic and a neurosurgical intervention. The reasons for multiple subspecialty involvement include, but are not limited to, the presence of a tethered cord requiring release or a syrinx requiring decompression. It has been common practice to perform these procedures in a staged manner, although there is little evidence in the literature to support separate interventions. We reviewed a series of consecutive patients who underwent spinal deformity correction and a neurosurgical intervention concurrently in an attempt to assess the safety, efficacy, and possible complications associated with such an approach. Eleven patients were reviewed who underwent concurrent orthopedic and neurosurgical procedures. Data were collected for patient demographics, preoperative diagnosis, procedures performed, intraoperative and perioperative complications, as well as any unexpected return to the operating room for any reason. Operative notes and anesthesia records were reviewed to determine estimated blood loss, surgical time, and the use of intraoperative neurological monitoring. Patient diagnoses included myelodysplasia (N=6), congenital scoliosis and/or kyphosis (N=4), and scoliosis associated with Noonan syndrome (N=1). Age at the time of surgery averaged 9 years 2 months (range=14 months to 17 years 2 months). Estimated blood loss averaged 605 ml (range=50-3000 ml). The operative time averaged 313 min (range=157-477 min). There were no intraoperative complications, including incidental dural tears or deterioration in preoperative neurological status. One patient developed a sore associated with postoperative cast immobilization that led to a deep wound infection. It appears that concurrent orthopedic and neurosurgical procedures in pediatric patients with significant spinal deformities can be performed safely and with minimal intraoperative and postoperative complications when utilizing modern surgical and neuromonitoring techniques. Level of evidence=Level IV.

Accuracy evaluation of surgical guides in implant dentistry by non-contact reverse engineering techniques

ObjectiveIn the paper laser scanning was used to evaluate, by indirect methods, the accuracy of computer-designed surgical guides in the oral implant supported rehabilitation of partially or completely edentulous patients. Materials and methodsFive implant supported rehabilitations for a total of twenty-three implants were carried out by computer-designed surgical guides, performed with the master model developed by muco-compressive and muco-static impressions. For all cases the surgical virtual planning, starting from 3D models obtained by dental scan DICOM data, was performed. The implants were inserted on the pre-surgical casts in the position defined in the virtual planning. These positions were acquired by three-dimensional optical laser scanning and compared with the laser scans of the intraoral impressions taken post-operatively. ResultsThe comparison between the post-surgical implant replica positions and the positions in the pre-operative cast, for the five patients, shows a maximum distance in the range 1.02–1.25mm, an average distance in the range 0.21–0.41mm and a standard deviation in the range 0.21–0.29mm. SignificanceThe results of this research demonstrate accurate transfer of implant replica position by virtual implant insertion into a pre-operative cast and a post-operative cast obtained from impressioning. In previous studies the evaluation of the implant positions have required a post-surgical CT scan. With the indirect methods by laser scanning technique, proposed in the paper, this extra radiation exposure of the patient can be eliminated.

Three‐Dimensional Accuracy of Guided Implant Placement: Indirect Assessment of Clinical Outcomes

Precise preoperative implant planning and its exact intraoperative transfer are crucial for successful implant-supported rehabilitation of partially or completely edentulous patients. In the present pilot study, optical laser scanning was used to evaluate deviations between three-dimensional computer-assisted planned and actual implant positions by indirect methods. Five patients receiving a total of 15 implants were included in this study. The used planning software was SimPlant 12.0 (Materialise Dental, Leuven, Belgium) to visualize the implant positions, and with an appropriate guided surgery protocol (Navigator™, Biomet 3i, Palm Beach Gardens, FL, USA) implant positions were implemented via tooth-supported stereolithografic surgical guides. All implants (Osseotite™, Biomet 3i) were inserted in a flapless approach and immediately provided with prefabricated temporary splinted restorations. Intraoral pickup impressions were taken postoperatively, and the implant positions of the master casts were compared with presurgical casts. Implant replica deviations were evaluated by three-dimensional optical laser scanning providing distances and angulations between implant replicas. Overall, the postsurgical implant replica positions were found to deviate from the positions in the preoperative cast by a mean of 0.46 ± 0.21 mm (range: 0.09-0.85 mm). Positional deviations were 0.27 ± 0.19 mm (range: 0.04-0.60 mm) along the x-axis representing the buccal-lingual directions, 0.15 ± 0.13 mm (range: 0.0-0.34 mm) along the y-axis representing the ventrodorsal direction, and 0.28 ± 0.19 mm (range: 0.02-0.59 mm) along the z-axis representing cranial and apical directions. Rotational deviations amounted to 14.04 ± 11.6° (range: 0.09-36.47°). The results of this pilot study demonstrate precise transfer of implant replica position by means of simulated guided implant insertion into a preoperative cast and a postoperative cast obtained from impressioning. Further studies are needed to identify appropriate evaluation techniques and mechanisms to increase the transfer precision of three-dimensional planning and guiding systems.

Kazakh Therapy on Differential Protein Expression of Achilles Tendon Healing in a 7-Day Postoperative Rabbit Model

To compare the effect of cast immobilization with that of early Kiymil arkili emdew (Kazakh exercise therapy) on the post-operative healing of Achilles tendon rupture in rabbits, and to observe the influence of early Kiymil arkili emdew on the differentially expressed proteins in the healing tendon. Forty-five New Zealand white rabbits were randomly divided into three groups (Arm A: control group; Arm B: postoperative immobilization group; and Arm C: postoperative early Kiymil arkili emdew group). After tenotomy, the rabbits of the two experimental groups received microsurgery to repair the ruptured tendons, and then received either cast immobilization or early Kiymil arkili emdew treatment. Achilles tendon tissue samples were collected 7 days after the surgery, and two-dimensional gel electrophoresis and MALDI-TOF-MS technique were used to analyze differentially expressed proteins in the tendon tissue of the three Arms. A total of 462.67 +/- 11.59, 532.33 +/- 27.79, and 515.33 +/- 6.56 protein spots were detected by the two-dimensional polyacrylamide gels in the Achilles tendon samples of the rabbits in Arms A, B, and C, respectively. Nineteen differentially expressed protein spots were randomly selected from Arm C. Among them, 7 were unique, and 15 had five times higher abundance than those in Arm B. These included annexin A2, gelsolin isoforms and alpha-1 Type III collagen. It was confirmed by western blot that gelsolin isoform b, annexin A2, etc. had specific and incremental expression in Arm C. The self-protective instincts of humans were overlooked in the classical postoperative treatment for Achilles tendon rupture with cast immobilization. Kiymil arkili emdew induced the specific and incremental expression of proteins in the repaired Achilles tendon in the early healing stage in a rabbit model, compared with those treated with postoperative cast immobilization. These differentially expressed proteins may contribute to the healing of the Achilles tendon via a mechanobiological mechanism caused by the application of Kiymil arkili emdew.

Proteomic Analysis of Differential Protein Expression of Achilles Tendon in a Rabbit Model by Two-Dimensional Polyacrylamide Gel Electrophoresis at 21 Days Postoperation

Postoperative early kinesitherapy has been advocated as an optimal method for treating Achilles tendon rupture. However, an insight into the rationale of how early kinesitherapy contributes to healing of Achilles tendon remains to be achieved, and research in the area of proteomic analysis of Achilles tendon has so far been lacking. Forty-two rabbits were randomized into control group, immobilization group, and early motion group, and received postoperative cast immobilization and early motion treatments. Achilles tendon samples were prepared 21 days following microsurgery, and the proteins were separated with two-dimensional polyacrylamide gel electrophoresis. Differentially expressed proteins were first recognized by PDQuest software, and then identified using peptide mass fingerprinting, tandem mass spectrometry, and database searching. A total of 463 ± 12, 511 ± 39, and 513 ± 80 protein spots were successfully detected in the two-dimensional polyacrylamide gels for the Achilles tendon samples of rabbits in the control group, immobilization group, and early motion group, respectively. There were 15, 8, and 9 unique proteins in these three groups, respectively, and some differentially expressed proteins were also identified in each group. It was indicated that some of the differentially expressed proteins were involved in various metabolism pathways and may play an important role in healing of Achilles tendon rupture. Postoperative early kinesitherapy resulted in differentially expressed proteins in ruptured Achilles tendon compared with those treated with postoperative cast immobilization. These differentially expressed proteins may contribute to healing of Achilles tendon rupture through a mechanobiological mechanism due to the application of postoperative early kinesitherapy.

Differentially expressed proteins on postoperative 3 days healing in rabbit Achilles tendon rupture model after early kinesitherapy

Objective Surgical repair of Achilles tendon (AT) rupture should immediately be followed by active tendon mobilization. The optimal time as to when the mobilization should begin is important yet controversial. Early kinesitherapy leads to reduced rehabilitation period. However, an insight into the detailed mechanism of this process has not been gained. Proteomic technique can be used to separate and purify the proteins by differential expression profile which is related to the function of different proteins, but research in the area of proteomic analysis of AT 3 days after repair has not been studied so far. Methods Forty-seven New Zealand white rabbits were randomized into 3 groups. Group A (immobilization group, n=16) received postoperative cast immobilization; Group B (early motion group, n=16) received early active motion treatments immediately following the repair of AT rupture from tenotomy Another 15 rabbits served as control group (Group C). The AT samples were prepared 3 days following the microsurgery. The proteins were separated employing two-dimensional polyacrylamide gel electrophoresis (2D-PAGE). PDQuest software version 8.0 was used to identify differentially expressed proteins, followed by peptide mass fingerprint (PMF) and tandem mass spectrum analysis, using the National Center for Biotechnology Information (NCBI) protein database retrieval and then for bioinformatics analysis. Results A mean of 446.33, 436.33 and 462.67 protein spots on Achilles tendon samples of 13 rabbits in Group A, 14 rabbits in Group B and 13 rabbits in Group C were successfully detected in the 2D-PAGE. There were 40, 36 and 79 unique proteins in Groups A, B and C respectively. Some differentially expressed proteins were enzyme with the gel, matrix-assisted laser-desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). We successfully identified 9 and 11 different proteins in Groups A and B, such as GAPDH, phosphoglycerate kinase 1, pro-alpha-1 type 1 collagen, peroxiredoxin 1, alpha-1-antiproteinase E a-1 and MAD2L1 binding protein, etc. And some with the molecular chaperone, oxidative stress, energy metabolism, signal transduction, coupled with the tendon cell expression and protein synthesis, proliferate, differentiate and are closely related to the AT healing. The GAPDH protein was further validated through Western blotting. It was indicated that some differentially expressed proteins were involved in various metabolism pathways and may play an important role in initial healing of AT rupture. Conclusion Differentially expressed proteins in rabbit healing AT model may contribute to 3 days healing of AT rupture through a new mechanobiological mechanism due to the application of postoperative early kinesitherapy.

Koronare Spaltluxationsfrakturen des Os hamatum und der Os metakarpale IV-Basis: eine seltene Form der karpometakarpalen Verletzung

Fractures of the hamate body and the base of the fourth metacarpal bone in the coronal plane with or without a dislocation of the base of the fifth metacarpal bone are rare. Clenched fist punches are considered to be the main cause. The diagnosis of the fracture dislocation is often missed on routine radiographs. Posterior-anterior, lateral, and oblique views are required for native radiological evaluation. A CT scan can help in the assessment of severity and for preoperative planning. Unless minimal displacement is present, non-surgical treatment does not lead to satisfying outcome. Displaced fractures of the hamate body and the base of the fourth metacarpal bone with or without subluxation of the hamatometacarpal joint should be stabilised by open reduction and internal fixation (ORIF). Controversy exists about the surgical treatment of choice. Screw or K-wire fixation with postoperative cast immobilisation for 6 weeks and consecutive hardware removal has been found to result in excellent clinical and radiological outcomes. This study presents 2 cases of coronal fractures of the body of the hamate and the base of the fourth metacarpal bone with subluxation of the hamatometacarpal V joint. Anatomy, epidemiology, classification, mechanism, clinical symptoms, diagnostic features, and therapy options for these injuries are discussed.

The “T-construct” for spinopelvic fixation in neuromuscular spinal deformities. Preliminary results of a prospective series of 15 patients

We present the results of a prospective series of 15 patients treated for neuromuscular spinal deformities with an original spinopelvic construct using two sacral screws and two iliac screws. Results were compared to a prospective cohort of 62 patients treated for neuromuscular spinal deformities by spinopelvic fixation using iliosacral screws. From November 2005 to June 2007, the clinical data of every patient who underwent spinopelvic fixation for treatment of a neuromuscular spinal deformity were recorded prospectively. Fifteen patients weighting less than 35 kg were operated on with a special segmental construct using two sacral screws and two iliac screws for pelvic anchorage. Sixty-two patients had spinopelvic fixation using iliosacral screws. Severity of the curve (Cobb angle) and reducibility were statistically equal in both groups. Operative time and blood loss were statistically identical in both groups. Curve correction was similar in both groups and postoperative pelvic obliquity ranged between 2° and 4°. No significant loss of correction was noted at the last follow-up. Fifteen patients had early postoperative infection of the posterior wound requiring re-operation. Despite a high rate of infectious complications, optimal correction of pelvic obliquity requires extension of spinal instrumentation to the pelvis. Pelvic fixation with the "T-construct" did provide effective and improved spinal stabilization in these patients, while reducing the need for a postoperative cast or brace. As a result, patients had a favorable postoperative course with early mobilization and return to a comfortable sitting position.

“Does the Outcome of Adolescent Idiopathic Scoliosis Surgery Justify the Rising Cost of the Procedures?”

As the cost of medical care has steady risen, patients, insurance companies, and the government, have all appropriately questioned the benefit of the care provided versus the cost. Expensive treatments such as surgery for spinal deformity have been especially scrutinized. This article reviews the history of spinal implant usage in deformity surgery, including the benefits of these implants to the patient and also the associated costs. The paper was presented at the One Day Course during the 2009 Pediatric Orthopaedic Society of North America annual meeting in Boston. A review was conducted regarding the benefits and costs of the care provided to patients as spinal implants became more clinically effective. Compared with postoperative casting, spinal implants provide better deformity correction and better stability of the fusion mass with resulting lower rates of secondary surgery, mostly because of fewer pseudarthoses. Many of these advantages were achieved with the less-expensive second and third-generation implants. Unfortunately, patient outcomes when the latest, most expensive implants are used are not significantly different from outcomes when older, less-expensive implants are used. Although the cost of spinal deformity surgery has risen the benefit to the patient from modern spinal implants has also increased. Nevertheless, patient outcomes have not improved in proportion to the increase in costs. Outcomes from the newest, all pedicle screw constructs are not significantly better than outcomes from the older, less-expensive hybrid constructs. Rising expenses and dramatic variation in the cost of the same implant have led payors, hospitals, and the government to question the value added to the care of the patient. Some implant costs should fall as hospitals use competitive bidding. Surgeons should help their hospitals in the competitive bidding process and declare a willingness to switch to an equivalent system if price differences are excessive. Level IV Economic Analysis.

The Treatment of Supracondylar Humeral Fractures With Elastic Stable Intramedullary Nailing (ESIN) in Children

Supracondylar humeral fractures are the most common elbow fractures in children. In case of displacement and instability, the standard procedure is closed reduction and percutaneous Kirschner wire fixation. As Kirschner wire fixation requires postoperative cast immobilization, does not allow early mobilization, and is associated with the risk of damage of the ulnar nerve, innovative techniques should be evaluated. Therefore, the aim of the study was to assess both radiologic and functional outcome of supracondylar humeral fractures treated by elastic stable intramedullary nailing (ESIN) in a large pediatric cohort. Retrospective review of children who underwent closed reduction and ESIN of displaced supracondylar humeral fractures in our institution between 2001 and 2009. One hundred twenty-seven children (mean age 6.1 y) with types II (60.6%), III (23.6%), and IV (15.7%) fractures according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Pediatric Comprehensive Classification were included. One hundred and eighteen patients (92.9%) had healing of fracture without any limitation in range of motion and 9 patients (7.1%) had some minor degree of long-term functional deficit (7 children with flexion and 2 with extension deficit). Two children had clinical cubitus varus deformity. No iatrogenic damage to the ulnar nerve occurred and no secondary reduction or a change of surgical strategy was necessary. Postoperative radiologic evaluation showed antecurvation in 1 case, recurvation in 3 cases, as well as cubitus varus deformity and rotation deformity in 1 child each. Antegrade ESIN is a technique suitable for all types of supracondylar humeral fractures with good functional results. The advantages include the avoidance of iatrogenic ulnar nerve injury, low rates of cubitus varus, cast-free treatment, and the possibility to evaluate clinical motion at all times postoperatively. Although biased toward milder forms of supracondylar fractures, our data clearly suggest that if closed reduction is possible, intramedullary nailing in these children is more than an alternative to Kirschner wire fixation as the standard procedure. IV.

Postoperative Cast Necessity after a Lapidus Arthrodesis

The incidence of non union following a first tarsometatarsal arthrodesis (Lapidus procedure) has decreased significantly with modern techniques of minimal bone resection, meticulous bone surface preparation and rigid internal fixation. We evaluated whether a postoperative wedge shoe would increase our non-union rate. Nineteen adult female patients (27 feet; eight bilateral, five simultaneous) undergoing a first tarsometatarsal arthrodesis for hallux valgus associated with a hypermobile first ray or for recurrent hallux valgus were managed postoperatively by allowing them to bear weight in a wedge shoe instead of a cast. Radiographs were evaluated for signs of fusion. All 27 feet went on to successful union after 6 to 24 weeks. There was one superficial wound infection and one case of recurrence of the hallux valgus. Based on our results, we allow adult patients undergoing a Lapidus type procedure to be managed in a postoperative wedge shoe.

L’inchiodamento endomidollare nell’infanzia

Elastic stable intramedullary nailing has become a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescent. The reasons include rare necessity of a postoperative cast, primary bone union with avoidance of growth plate injuries and minimal invasive surgery.

Fracture of trapezium with trapeziometacarpal subluxation

Fractures of trapezium are reportedly rare, less than 5% of all carpal bones fractures. A vertical sagittal fracture type is encountered in about 20% of cases. This fracture type is unstable and is usually displaced like a Bennett’s fracture. Open reduction and internal fixation is admitted to be the best method of treatment, but it has always been augmented with a postoperative cast immobilization to temporary stabilize the trapeziometacarpal joint. We describe a case of displaced vertical sagittal fracture of the trapezium with trapeziometacarpal subluxation treated by open reduction and internal fixation of the trapezial fracture, associated with temporary stabilization of the trapeziometacarpal joint using two percutaneous intermetacarpal Kirschner wires.

Journal Scan: Journal of Pediatric Orthopaedics

Here is my view of the top-10 most potentially influential papers from the Journal of Pediatric Orthopaedics from 2007. Included are the papers that were thought to provide the most useful examinations of treatments and outcomes.

Wound Complications From Idiopathic Clubfoot Surgery

Treatment protocols using the Turco and the Cincinnati incisions are widely used for the surgical correction of clubfoot deformity. However, it is unclear which surgical approach leads to fewer wound problems. We therefore sought to determine which treatment method led to a lower incidence of wound complications. A retrospective chart review of 217 consecutive patients (308 feet) who underwent a primary posteromedial release for the treatment of idiopathic clubfoot under the age of 24 months via either the modified Turco or Cincinnati treatment methods was used to document the incidence of postoperative wound complications. The modified Turco protocol involved immediate postoperative casting in neutral, whereas the Cincinnati method involved staged casting with the foot initially in equinus, then to neutral with a cast change 7 days later. A significantly lower incidence of wound complications was seen in the Cincinnati treatment group when compared with the modified Turco treatment method (6.9% vs 19.6%, respectively, P < 0.003). When patients were stratified based on immediate versus staged postoperative casting methods, there was a significantly lower incidence of wound complications (P < 0.05) in feet in the Cincinnati treatment group versus the modified Turco treatment method; however, the statistical populations were markedly unequal. Among all feet treated with the Cincinnati method, patients who underwent a staged cast change had significantly fewer wound problems when compared with those who underwent immediate casting with the foot in neutral (5.1% vs 16.7%, respectively, P < 0.04). In the surgical correction of idiopathic clubfoot, the incidence of wound complications is significantly decreased with the use of the Cincinnati treatment method rather than the modified Turco treatment protocol. Whether this effect is a result of the incision or the postoperative casting protocol is unclear.

Surgically repaired Achilles tendon ruptures with postoperative mobile ankle cast: a 12-month follow-up study with an isokinetic and a dynamic muscle function test

Seventeen patients (15 men and 2 women) with surgically repaired Achilles tendon ruptures had a mobile cast applied for 6 weeks after the operation that allowed free ankle joint motion. A 12-month follow-up study was performed, with measurements of isokinetic muscle torque in a modified Cybex II dynamometer and a dynamic heel-raise test of muscle fatigue. A majority of the patients were weaker on the treated side in both the isokinetic and the heel-raise tests. The isokinetic plantar flexion torque showed larger differences at an angular velocity of 12°/s than at 90°/s. Seven of the patients in the heel-raise test showed considerable differences between the treated and untreated sides, but our analysis could not explain this with any Certainty.

SINGLE-STAGE POSTERIOR CIRCUMSPINAL DEBRIDEMENT AND RECONSTRUCTION FOR THORACIC AND LUMBAR SPINAL INFECTIONS

Anterior debridement and fusion is an accepted method to treat spinal infections. However, rehabilitation after anterior debridement and fusion is prolonged because of minor primary instability, making postoperative bed rest, casting, and orthotic devices necessary. To shorten and simplify the postoperative period, several authors have reported the addition of anterior or dorsal instrumentation, the latter referring to anterior–posterior exposure. In our opinion, single posterior circumspinal exposure can be used to debride and reconstruct the spine, and posterior fixation can also be added through it. Twelve patients who had infections of the thoracic and lumbar spine were treated surgically at Sohag University Hospital, Egypt. The patients were seven males and five females with a mean age of 47.5 years. Eight patients were infected in the thoracic spine, while the other four were infected in the lumbar spine. All patients were operated through a single posterior exposure. Posterior stabilization by transpedicular screw fixation was performed. Anterior dissection enabled debridement of the lesion and evacuation of any abscess. Then, reconstruction of the anterior column was performed followed by posterior fusion. Causative organisms were tuberculosis (TB) in eight patients, while bacteriologic testing of intraoperative samples did not find germs in four patients. The mean follow-up time was 12.7 months (range, 3–32 months). At the end of follow-up, 11 patients were still living, while 1 patient died 3 months postoperatively due to complications during a kidney operation. No active infection occurred by the end of follow-up. In conclusion, in cases of thoracic and lumbar spinal infections, single posterior exposure — although technically demanding — is sufficient to debride the infected material, decompress the neural elements, and reconstruct the spine both anteriorly and posteriorly.

Use and Abuse of Flexible Intramedullary Nailing in Children and Adolescents

Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescents for many reasons including the following: no need for postoperative cast, primary bone union with avoidance of growth plate injury, and minimum invasive surgery. The principle is to introduce 2 elastic nails, titanium or stainless steel, into the medullary canal through a metaphyseal approach. The bended nails must have their maximum of curve at the level of the fracture, and their orientation, most often face to face, is in charge of the reduction and, so far, the stabilization, of the fracture. The usual size of the nails is equal to 0.4 times the diameter of the medullary canal. As far as possible, a bigger diameter is better than a thinner one. Most fractures of the femur are treated with a bipolar retrograde ESIN when some distal fractures need an antegrade subtrochanteric approach. Forearm fractures need a combined retrograde radial and antegrade ulnar through the posterolateral part of the olecranon. Humerus and tibial diaphyseal fractures may also be treated with ESIN. Complications are mainly caused by technical errors including too-thin nails, asymmetry of the frame, and malorientation of the implants. Nonunion was never observed in fractures of the femur and the forearm; osteomyelitis rate is 2%, and mean overgrowth of the femur is less than 10 mm before the age of 10 years. Indications of ESIN are fractures of the diaphysis: all the fractures of the femur between the age of 6 years and the end of growth except for the severe open grade III fractures, all the unstable fractures of the forearm, and some unstable fractures of the humerus and the tibia during adolescence or before the end of growth. In addition, ESIN is indicated in polytraumatism and multiple injuries. The good results of this reliable technique are obtained when surgeons have a good knowledge of it, especially in the understanding of the principle of the correction of the fracture and its stability.

Operative management of congenital talipes equinovarus deformity: experience and reason

Background: Congenital talipes equinovarus is the most common congenital anomaly of the foot and ankle. The prevalence of this condition in our environment is not known due to dearth of medical literature on the subject. The aim of this study was to determine the outcome of our operative management of resistant talipes equinovarus by elongation of tendo-Achilles and posteromedial soft tissue release. Methods: We present a retrospective review of congenital talipes equinovarus treated by Elongation of tendo Achilles (ETA) and Posterior Medial Release(PMR) at National Orthopaedic Hospital Enugu over a 6- year period (January1995- December 2000). Results: There were 63(68%) males and 30(32%) females with mean age of 2.06 years at presentation (range 1/12-18years). There was positive family history in 6(7%) patients. More than half of the patients 63(68%) came without any formal referral. The mode of delivery was spontaneous vaginal delivery in 81(87%) and the first child appears to be more affected 22(24%). The deformities on presentation varied from talipes equinovarus 50(54%) to frank equinus in 3(3%) and fifty-four (58%) were bilateral. Sixty- three (68%) had initial treatment ranging from serial casting in 46(50%) to massage by traditional bonesetter in 2(2%) and the average duration of this initial treatment was 20weeks (range 2-106weeks). The average age at surgery was 2.5years (range 3/12-24 years). All patients received postoperative cast for an average of 13 weeks. The commonest post- operative complication was medial wound breakdown. The average duration of follow-up was 30 weeks (range3weeks-3years). Some patients were lost to follow-up immediately the cast was removed. As at last visit 90% were walking pain-free and do not require special shoe. The commonest residual deformity as at last visit was forefoot adduction in 17(18%) patients. Conclusion: Elongation of tendo-Achilles and posteromedial soft tissue release are common operative procedures for CTEV. The short-term result of these procedures appears very good in our environment. However, the long-term result cannot be effectively analyzed due to high rate of loss to follow-up Orient Journal of Medicine Vol. 18(1&2) 2006: 24-29

Most scaphoid non-unions heal with bone chip grafting and Kirschner-wire fixation: Thirty-nine patients reviewed 10 years after operation

Many recommend to operate scaphoid pseudarthroses with wedge grafts and screw fixation. These are difficult operations. We have employed a simpler procedure and wished to review our results with regard to healing and long-term clinical results. We reviewed 39 unselected scaphoid pseudarthroses which had been operated with Kirschner-wire fixation and bone chip transplantation 10 (3.5-12) years previously. Postoperative cast treatment was 15 (11-30) weeks. Four pseudarthroses failed to unite, one of which was after a trans-scaphoid perilunar dislocation. In another the pins were dislocated by an injury while the arm was in plaster. There were no other complications. All 14 proximal pseudarthroses united. There was no loss of grip strength but some loss of key-pinch strength and wrist mobility. Most patients reported no or little pain and none used analgesics because of wrist pain. The disability of the arm, shoulder and hand (DASH) score was 2 (0-33). Very few cases of mild arthrosis had arisen after operation. Three patients would not have consented to operation if they had known the outcome in advance. Kirschner-wire fixation and bone chip grafting of scaphoid pseudarthroses is an undemanding operation with few complications that produces good long-term results. Results are excellent also for proximal pole pseudarthroses.