Jonas R. Rudzki

Factors Predictive of Outcome After Use of the Ponseti Method for the Treatment of Idiopathic Clubfeet

BACKGROUND The nonoperative technique for the treatment of idiopathic congenital talipes equinovarus (clubfoot) described by Ponseti is a popular method, but it requires two to four years of orthotic management. The purpose of this study was to examine the patient characteristics and demographic factors related to the family that are predictive of recurrent foot deformities in patients treated with this method. METHODS The cases of fifty-one consecutive infants with eighty-six idiopathic clubfeet treated with use of the Ponseti method were examined retrospectively. The patient characteristics at the time of presentation, such as the severity of the initial clubfoot deformity, previous treatment, and the age at the initiation of treatment, were examined with use of univariate logistic regression analysis modeling recurrence. Demographic data on the family, including annual income, highest level of education attained by the parents, and marital status, as well as parental reports of compliance with the use of the prescribed orthosis, were studied in relation to the risk of recurrence. RESULTS The parents of twenty-one patients did not comply with the use of orthotics. Noncompliance was the factor most related to the risk of recurrence, with an odds ratio of 183 (p < 0.00001). Parental educational level (high-school education or less) also was a significant risk factor for recurrence (odds ratio = 10.7, p < 0.03). With the numbers available, no significant relationship was found between gender, race, parental marital status, source of medical insurance, or parental income and the risk of recurrence of the clubfoot deformity. In addition, the severity of the deformity, the age of the patient at the initiation of treatment, and previous treatment were not found to have a significant effect on the risk of recurrence. CONCLUSION Noncompliance and the educational level of the parents (high-school education or less) are significant risk factors for the recurrence of clubfoot deformity after correction with the Ponseti method. The identification of patients who are at risk for recurrence may allow intervention to improve the compliance of the parents with regard to the use of orthotics, and, as a result, improve outcome. LEVEL OF EVIDENCE Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Partial-Thickness Rotator Cuff Tears

Partial-thickness tears of the rotator cuff have been diagnosed with increased frequency because of a heightened awareness of the condition by clinicians and improved diagnostic methods. Research into the causes, natural history, and optimal treatment of this condition lags behind that of full-thickness tears. However, despite the limitations in the existing literature, there has emerged a consensus among shoulder experts that partial-thickness rotator cuff tears should be aggressively treated in the active athlete because of the unfavorable natural history of these lesions and success of accepted surgical algorithms. This review will provide an overview of the theories regarding the origins of partial-thickness rotator cuff tears, discuss the relative accuracy of accepted diagnostic techniques, and summarize the indications and methods of operative repair with an emphasis on the results of various treatment approaches.

Complications of treatment of acromioclavicular and sternoclavicular joint injuries.

Although common, AC joint injuries and their treatments are not benign. The injury itself and both nonsurgical and surgical treatments may result in complications yielding persistent pain, deformity, or dysfunction. Sternoclavicular joint injuries are far less common and are typically the result of higher energy trauma. As such, the associated complications may be more serious. Familiarity with the potential complications of these injuries can help the treating physician to develop strategies to minimize their incidence and sequelae.

Chondrocyte Death and Cartilage Degradation after Autologous Osteochondral Transplantation Surgery in a Rabbit Model

Background Autologous osteochondral transplantation surgery requires an impact force on the graft that may cause chondrocyte death and matrix degradation. This study attempted to determine the degree to which this occurs in a rabbit model shortly after the procedure. Hypothesis Impaction of a press-fit autologous osteochondral graft in vivo results in chondrocyte necrosis, apoptosis, and matrix degradation at early time points. Study Design Controlled laboratory study. Methods Twenty New Zealand White rabbits underwent unilateral osteochondral transplantation (OT) surgeries, and 10, bilateral sham surgeries. Fifteen animals were sacrificed at time zero (10 sham-0 limbs, 10 OT-0 limbs), and 15, 4 days after surgery (10 sham-4 limbs, 10 OT-4 limbs). Chondrocyte viability/necrosis was determined with cell vital staining. Chondrocyte apoptosis was determined by TUNEL, Bcl-2, and M30 assays. Cartilage matrix degradation was determined by routine light and polarized light microscopy and COL2-3/4Cshort immunohistochemistry. Statistical analysis was performed with a 2-way analysis of variance (P < .05). Results There were significantly fewer viable cells in OT-4 than in sham-4. A similar difference in cell viability was found in OT-0 versus sham-0. There were more TUNEL-positive cells in OT-4 as compared with OT-0, sham-0, and sham-4; however, there was little or no staining of Bcl-2 and M30. Mankin scores were higher in both OT groups versus both sham groups at time zero and day 4. The OT-4 group had positive staining for COL2-3/4Cshort that corresponded with a loss of collagen birefringence at the superficial zone. Conclusion Osteochondral transplantation procedures performed by tamping a press-fit graft induce chondrocyte necrosis and matrix metalloproteinase—mediated cartilage matrix degradation. However, apoptosis was not found to a major contributor to cell death in this model. Clinical Relevance Results of osteochondral transplantation procedures may be improved by atraumatic insertion and fixation techniques or by pharmacologic agents that can block these degradative processes.

Vasculopathy of small muscular arteries in pediatric patients after bone marrow transplantation

Bone Marrow Transplant (BMT) is a critical therapeutic intervention for a variety of diseases occurring in the pediatric patient. Complications of allogeneic BMT include graft-versus-host disease (GVHD), infection, drug toxicity, thrombotic microangiopathy, and veno-occlusive disease. With solid organ transplantation, chronic vascular rejection has emerged as a major factor limiting long-term survival of the graft. We present a vasculopathy of small muscular arteries in 6 patients after allogeneic BMT. Cases include 4 boys and 2 girls ranging in age from 4 months to 13 years with full or partial human leukocyte antigen matching. Five of the 6 transplants were from related donors. The vasculopathy occurred 13 to 418 days after transplant and was noted in surgical specimens (2) and at autopsy (4). It was seen in the gastrointestinal tract and lung in 3 cases each. Vascular changes in small muscular arteries include concentric intimal or medial hyperplasia with luminal narrowing, prominent myxoid change, extravasated red blood cells, and presence of some foamy histiocytes with no evidence of thrombotic microangiopathy. Vasculopathy contributed to intestinal compromise requiring surgical intervention 3 times in 1 patient, and diffuse alveolar damage with hemorrhage in another. All 6 patients are dead. The cause of this unusual vasculopathy present in patients after BMT is likely to be multifactorial, involving effects of irradiation, chemotherapy, cyclosporine, and GVHD. Together these may create a negative synergy which produces an obliterative arteriopathy that should be recognized as a pathological entity and may be a harbinger of a poor prognosis.

Pseudarthrosis of a Thirty-nine-Year-Old Dens Fracture Causing Myelopathy

Treatment of fractures of the odontoid process of the axis (the dens) has the potential to stabilize a critical injury or result in a high degree of morbidity or even death. We present the case of a patient in whom myelopathy developed more than thirty-nine years after he sustained a dens fracture while playing football. This case is unique because of the prolonged asymptomatic interval between the injury and the development of the myelopathy, during which time the patient worked as a manual laborer. The late onset of progressive myelopathy after a dens fracture is considered uncommon1,2 and, to our knowledge, this case represents the second longest delay between a dens fracture and the onset of myelopathy in the English-language literature. The myelopathy resolved after surgical stabilization, and the four-year clinical and radiographic follow-up data are presented. Our patient was notified that data concerning this case would be submitted for publication. Afifty-five-year-old man who performed manual labor working as a machine operator presented to an orthopaedic surgeon with a chief symptom of difficulty using his upper and lower limbs. He reported the insidious onset of increasing neck pain at the base of the skull over the preceding several years, which had been associated with progressively worsening bilateral upper and lower-extremity weakness for the previous three months. The patient had been unable to work or participate in his normal activities of daily living for approximately two months because of the arm weakness. The musculoskeletal history revealed that he had sustained a cervical spine fracture at the age of sixteen years while playing football, which was treated with a neck brace for approximately three months. On physical examination, the patient appeared to be a well-developed, well-nourished man with a range of motion of the neck of 45° of rotation …

Hindfoot Containment Orthosis for Management of Bone and Soft-Tissue Defects of the Heel

Background: Bone, soft-tissue, and nerve deficits of the weightbearing surface of the foot are frequent sequelae from foot trauma or diabetes mellitus and present challenging treatment issues. Injury to the specialized, shock-absorbing, heel-pad tissue containing spirally arranged fat chambers is particularly difficult to manage. Appropriate footwear modifications and shoe inserts for protection of this skin are essential to the long-term management of bone and soft-tissue defects of the heel. This study evaluated the performance of a new custom total contact foot orthosis (Hindfoot Containment Orthosis, HCO) which was designed to contain the soft tissues of the heel, reduce shear forces, redistribute weightbearing load, and accommodate bone or soft-tissue deformity of the heel. Methods: Twenty-two patients treated with HCO were retrospectively reviewed. Followup averaged 26 months. The effectiveness of the orthosis was assessed by how well the integrity of the soft tissue was maintained (e.g. the number of ulcerations since dispensing the orthosis), the number of refabrications of the orthosis that were required, and whether or not revision surgery was required. Results: Ten patients had superficial ulcerations. No patient required revision surgery. A total of 62 refabrications of the orthoses in 22 patients were required over a 2-year period. Overall results were good in 17 (77%) patients, fair in four (18%), and poor in one. Conclusions: The HCO is effective for preservation of soft-tissue integrity of the heel pad after bony or soft-tissue injury. Important factors in achieving success with the HCO are patient compliance and periodic monitoring for refabrication of the orthosis to accommodate skeletal growth, change in foot size or shape, and compression or wear of insert materials.