What are the long-term outcomes of lateral column lengthening for pes planovalgus in cerebral palsy?

BackgroundLateral column lengthening (LCL) is commonly performed on children and adolescents with cerebral palsy (CP) for correction of pes planovalgus (PPV). There are limited reports of the long-term outcomes of this procedure. The purpose of this study was to examine the long-term results of LCL for correction of PPV in individuals with CP by evaluating subjects when they had transitioned to adulthood and were entering the workforce.MethodsClinical assessments, quantitative gait analysis including the Milwaukee Foot Model (MFM) for segmental foot kinematics, and patient reported outcomes were collected from 13 participants with CP treated with LCL for PPV in childhood (average age 24.4 ± 5.7 years, average 15.3 ± 8.5 years since LCL). Additionally, 27 healthy adults average age 24.5 ± 3.6 years functioned as controls.ResultsStrength and joint range of motion were reduced in the PPV group (p < 0.05). Sixty nine percent showed operative correction of PPV based on radiologic criteria. Gait analysis showed reduced walking speed and stride length, as well as midfoot break and residual forefoot abduction. Patient reported outcomes indicated that foot pain was not the only factor that caused limited activity and participation. LCL surgery for PPV in childhood resulted in long-term operative correction. Decreased ankle passive range of motion and strength, subtalar joint arthritic changes, inefficient and less stable ambulation, and problems with participation (difficulties in physical function, education, and employment) were observed in the long-term.ConclusionThis study identified postoperative impairments and limitations to guide future clinical decision-making. These results provide clinicians and researchers the common residual and recurrent issues for these individuals as they age. The inclusion of contextual factors that influence the disease and impairments can equip these individuals with enhanced skills they need as they transition into adulthood.     

Results of operative therapy of idiopathic clubfoot using a dorsomedial approach with soft tissue preparation "à la carte"

INTRODUCTION: Several concepts have been published for therapy of idiopathic clubfoot. Actually the Cincinnati approach is the "gold-standard" in operative treatment of idiopathic clubfoot. Using this approach delayed wound healing and overcorrection are wellknown complications. During the last 30 years a dorsomedial approach is used in operative treatment of idiopathic clubfoot in our clinic. Using this approach a dorsal, medial and/or lateral release can be performed. Postoperatively a plaster cast is used. The following years a rigid therapy with orthosis and support is requested. PATIENTS AND METHOD: Between June 1986 and December 2000 130 clubfoot operations with soft tissue release were performed. 119/130 (91 %) patients could be clinically and radiologically followed-up after a mean of 4.5 years (min: 2, max: 17) including 65.5 % male and 34.5 % female patients. Average age at time of operation was 7.6 months. The findings were classified according to Dimeglio. To evaluate the clinical results the score according to Laaveg and Ponseti was used. X-rays with load (a. p. and lateral view) were evaluated preoperatively and at follow-up for a. p. and lateral talocalcaneal angle, talometatarsal-I-angle, calcaneometatarsal-V-angle and the angle of the first ray. Additionally complications and recurrences were documented. RESULTS: 21.8 % of the feet were classified IV degrees , 39.5 % III degrees and 38.7 % II degrees according to Dimeglio. Recurrent clubfoot was found in 7.6 % of all cases. All angles showed a significant improve. At latest follow-up 95.6 +/- 9.2 points according to the score of Laaveg and Ponseti were achieved. Flat top talus was found in 37 cases. CONCLUSION: The dorsomedial approach allows an excellent correction of clubfeet with a low rate of complications and recurrences in comparison to other studies.     

The use of ‘off-the-shelf’ foot orthoses in the reduction of foot symptoms in patients with early rheumatoid arthritis

BackgroundFoot pain in patients diagnosed with early rheumatoid arthritis is common.ObjectivesTo investigate effects of off-the-shelf foot orthoses on outcomes of swollen and tender joints, and pain, in patients with early rheumatoid arthritis.MethodsThirty-five patients with painful and swollen foot joints were recruited. None had previously used foot orthoses or had contraindications to their use. Any patients with concomitant musculoskeletal disease, endocrine disorders, and neurological disease, were excluded. At baseline, participants were prescribed a customised off-the-shelf foot orthosis with chair-side modifications. Data was collected at baseline, three and six months. Foot pain (using Visual Analogue Scale) and the number of tender and swollen foot joints was measured.ResultsThere was a trend towards a reduction in the number of swollen and tender joints by 3 months with a further improvement by 6 months. Statistically (p < 0.05) and clinically significant reductions in pain levels were also noted.ConclusionPatients diagnosed with early RA may benefit from using off-the-shelf foot orthoses with the majority of their pain reduction occurring within the first 3 months of use, but with some small further symptomatic improvement up to 6 months. There was a tendency to a reduction in swollen and tender joints although more studies are required to substantiate these findings.     

Laparoscopic vesico-ureteral reimplantation with Lich–Gregoir approach in children: medium term results of 159 renal units in 117 children

Purpose

Vesico-ureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Surgery is an important part of its management. Laparoscopic ureteric reimplantation using the Lich–Gregoir technique is an option for VUR. The aim of this study is to assess short- and medium-term outcomes of this approach.

Materials and methods

This is a retrospective study including all children with VUR treated by laparoscopic extravesical ureteral reimplantation with the Lich–Gregoir technique in University Hospital of Saint-Etienne from August 2007 to May 2016. Surgery was performed after the age of 12 months in cases with repeated urinary tract infection (UTI) and a deterioration of renal function. All patients were followed-up post operatively.

Results

117 children (92 girls, 25 boys) representing 159 renal units were included. The mean age at surgery was 47.1 months (±32.7 months). The mean follow-up was 59.3 months (±31 months). The resolution rate for VUR in terms of no febrile urinary UTIs was 98.3%. The mean operative time was 96 min (±37.7 min) for unilateral procedures and 128 min (±46.1 min) for bilateral procedures. The mean hospital stay was 25.3 h (±6.3 h). There was no difference between males and females regarding age, weight, renal function or follow-up duration.

Conclusions

Laparoscopic reimplantation with Lich–Gregoir technique is an efficient, quick and safe technique for the management of VUR. The success rate is comparable to open techniques with the advantages of laparoscopic approach; this can potentially be performed as a Day Case procedure.

     

Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail—The Kings’ Experience

Background

Corrective fusion for the unstable deformed hind foot and mid foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams.

The assessment of Buerger’s exercise on dorsal foot skin circulation in patients with vasculopathic diabetic foot ulcer by using wireless near-infrared spectroscope: a cohort prospective study

The improvement of peripheral circulation is crucial for the care of vasculopathic diabetic foot ulcer (DFU). Near-infrared spectroscopy (NIRS) was used to investigate the effects of Buerger’s exercise on dorsal foot skin circulation with novel technique of measuring the absorption difference in wavelength of light between oxy-hemoglobin (HbO₂) and deoxy-hemoglobin (HbR). Patients with vasculopathic DFU who could tolerate Buerger’s exercise three times a day at home for at least 8 weeks were enrolled (group A). They were divided into two subgroups: without previous percutaneous transluminal angioplasty (PTA) (group A1) vs. with previous PTA (group A2). Wireless NIRS were applied on patients’ dorsal foot to assess the peripheral circulation in follow-up clinics. The patients’ wound condition, follow-up time, and concentration of HbO₂ and total hemoglobin (HbT) before and after exercise rehabilitation program were documented. From May 2015 to February 2016, 14 patients with average age of 70.2?±?11.2 were enrolled in this study (group A), including eight without previous PTA (group A1), and six with previous PTA (group A2). The concentration of HbO2 and HbT were significantly increased after exercise rehabilitation program training in group A (p?=?0.024 in HbO₂, p?=?0.02 in HbT, n?=?14) and group A2 (p?=?0.021 in HbO₂, p?=?0.028 in HbT, n?=?6), while the concentration in group A1 were improved with borderline significance after exercise (p?=?0.055 in HbO₂, p?=?0.058 in HbT, n?=?8). The majority of the ulcers were either completely healed (11/14?=?78.57%) or improving (3/14?=?21.43%). Buerger’s exercise improved the peripheral circulation and wound condition in patients with vasculopathic DFU. The wireless apparatus is a novel and efficient tool to monitor rehabilitation program.     

Impact of a preoperatively estimated prostate volume using transrectal ultrasonography on surgical and oncological outcomes in a single surgeon’s experience with robot-assisted radical prostatectomy

Background

To assess the impact of preoperatively estimated prostate volume (PV) using transrectal ultrasonography (TRUS) on surgical and oncological outcomes in robot-assisted radical prostatectomy (RARP).

Methods

We analyzed the experience of a single surgeon at our hospital who performed 436 RARPs without neoadjuvant hormone therapy between August 2006 and December 2013. Patients were divided into three groups according to their preoperative PV calculated using TRUS (PV ≤ 20 cm³: group 1, n = 61; 20 < PV < 50 cm³: group 2, n = 303; PV ≥ 50 cm³: group 3, n = 72).

Results

Blood loss was significantly higher in group 3 than in group 1 and group 2. In stage pT2 patients, the rate of positive surgical margin (PSM) was significantly lower in group 3 than in group 1. In addition, perioperative complications significantly increased with increasing PV, while the extraprostatic extension (EPE) rate significantly decreased with increasing PV. The preoperative biopsy Gleason score, prostate-specific antigen (PSA) density, and clinical T2 stage were inversely correlated with increasing PV. Biochemical recurrence-free survival after RARP was significantly lower in group 1 than in groups 2 and 3.

Conclusions

A large prostate size was significantly associated with increased blood loss and a higher rate of perioperative complications. A small prostate size was associated with a higher PSM rate, PSA density, Gleason score, EPE rate, and biochemical recurrence rate. These results suggest that RARP was technically challenging in patients with large prostates, whereas small prostates were associated with unfavorable oncological outcomes.

     

A rare cause of ‘drop foot’ in the pediatric age group: Proximal fibular osteochondroma a report of 5 cases

INTRODUCTION

The fibular nerve is the most frequent site of neural entrapment in the lower extremity and the third most common site in the body, following the median and ulnar nerves. The peroneal nerve is commonly injured upon trauma. Additionally, a dropped foot might be a symptom related to the central nervous system or spinal pathologies in pediatric patients. Entrapment of the peripheral nerve as an etiologic cause should be kept in mind and further analyzed in orthopedic surgery clinics.

PRESENTATION OF CASE

In this study, the evaluation and treatment results of five patients with no history of trauma, who underwent diagnostic procedures and treatment in various clinics (physical therapy and rehabilitation and neurosurgery), are reported. The patients underwent several treatments without diagnosis of the primary etiology. Upon initial consultation at our department, osteochondroma at the proximal fibula was detected after physical examination and radiologic assessment. During surgery, the peroneal nerve was dissected, starting from a level above the knee joint. Following nerve release, the osteochondroma was removed, including its cartilage cap. Consequently, recovery was observed in all five cases after surgery.

DISCUSSION

Many factors may cause non-traumatic neuropathies. However, due to their rare occurrence, lesions such as osteochondromas may be overlooked at non-orthopedic clinics. Nerve entrapment due to proximal fibular osteochondroma is rare. Surgical treatment planning plays a critical role in nerve entrapment cases.

CONCLUSION

Despite its frequent occurrence, a drop foot associated with peroneal nerve entrapment by an osteochondroma is not easily remembered and diagnosed. Especially in pediatric cases, inadequate clinical consultation and a lack of appropriate radiologic studies may result in a delay in diagnosing peroneal nerve lesions.     

Healthcare professionals’ perceptions of the role of a multidisciplinary approach in improving the care of patients with advanced chronic kidney disease

International Urology and Nephrology - To explore and understand the experiences of healthcare professionals (HCPs) delivering care in a multidisciplinary care (MDC) clinic for advanced chronic...     

Postoperative CT-scan 3D reconstruction of the calcaneus following lateral calcaneal lengthening osteotomy for flatfoot deformity in children. Is the surgical procedure potentially associated with subtalar joint damage?

Background

Several anatomical studies have shown that the articular facets of the calcaneus can present with different anatomy. This study assessed the 3D anatomy of lateral calcaneal lengthening (LCL) osteotomy in relation to the anterior and middle facet of the calcaneus in a group of skeletally immature patients treated for symptomatic flatfoot deformity.

Concomitant multiple closed contiguous physeal injuries in a limb with an undescribed ‘distractional-separation’ type with vascular compromise: a report of two cases

Introduction: Though physeal injuries are common in children, concomitant multiple closed contiguous physeal injuries in a limb along with vascular compromise are rare. An associated distractional-separation type of physeal injury is being documented for the first time. We present here two such cases. Materials and methods: Two children, aged 6 months and 3 years, respectively, suffered a roadside high velocity trauma and thus form the part of this case report. Results: Because of the delay in seeking treatment and, or, the nature of injuries, it was associated with a tragic complication—an amputation in both cases. Conclusion: Although, the limb in our cases could not be salvaged, these reports describe these unusual injury patterns for the first time and re-emphasize the awareness of urgent recognition of the associated vascular insult.     

Jaboulay’s technique contrasted with a novel hydrocelectomy technique using a vessel sealer in the treatment of adult hydrocele: a prospective randomized study

International Urology and Nephrology - The study aims to compare the clinical efficacy, complications, and patient satisfaction rates of two open hydrocelectomy techniques, Jaboulay’s...     

One-stage and posterior approach for correction of moderate to severe scoliosis in adolescents associated with Chiari I malformation: is a prior suboccipital decompression always necessary?

Priority of neurological decompression was regarded as necessary for scoliosis patients associated with Chiari I malformation in order to decrease the risk of spinal cord injury from scoliosis surgery. We report a retrospective series of scoliosis associated with Chiari I malformation in 13 adolescent patients and explore the effectiveness and safety of posterior scoliosis correction without suboccipital decompression. One-stage posterior approach total vertebral column resection was performed in seven patients with scoliosis or kyphosis curve >90° (average 100.1° scoliotic and 97.1° kyphotic curves) or presented with apparent neurological deficits, whereas the other six patients underwent posterior pedicle screw instrumentation for correction of spinal deformity alone (average 77.3° scoliotic and 44.0° kyphotic curves). The apex of the scoliosis curve was located at T7–T12. Mean operating time and intraoperative hemorrhage was 463 min and 5,190 ml in patients undergoing total vertebral column resection, with average correction rate of scoliosis and kyphosis being 63.3 and 71.1%, respectively. Mean operating time and intraoperative hemorrhage in patients undergoing instrumentation alone was 246 min and 1,450 ml, with the average correction rate of scoliosis and kyphosis being 60.8 and 53.4%, respectively. The mean follow-up duration was 32.2 months. No iatrogenic neurological deterioration had been encountered during the operation procedure and follow-up. After vertebral column resection, neurological dysfunctions such as relaxation of anal sphincter or hypermyotonia that occurred in three patients preoperatively improved gradually. In summary, suboccipital decompression prior to correction of spine deformity may not always be necessary for adolescent patients with scoliosis associated with Chiari I malformation. Particularly in patients with a severe and rigid curve or with significant neurological deficits, posterior approach total vertebral column resection is likely a good option, which could not only result in satisfactory correction of deformity, but also decrease the risk of neurological injury secondary to surgical intervention by shortening spine and reducing the tension of spinal cord.     

Comment on “Treatment of diabetic foot ulcers in a frail population with severe co-morbidities using at-home photobiomodulation laser therapy: a double-blind,randomized, sham-controlled pilot clinical study”

Lasers in Medical Science -     

Surgical treatment of Scheuermann’s kyphosis using a combined antero-posterior strategy and pedicle screw constructs: efficacy,radiographic and clinical outcomes in 111 cases

Introduction

There is sparse literature on how best to correct Scheuermann’s kyphosis (SK). The efficacy of a combined strategy with anterior release and posterior fusion (AR/PSF) with regard to correction rate and outcome is yet to be determined.

Materials and methods

A review of a consecutive series of SK patients treated with AR/PSF using pedicle screw–rod systems was performed. Assessment of demographics, complications, surgical parameters and radiographs including flexibility and correction measures, proximal junctional kyphosis angle (JKA + 1) and spino-pelvic parameters was performed, focusing on the impact of curve flexibility on correction and clinical outcomes.

Results

111 patients were eligible with a mean age of 23 years, follow-up of 24 months and an average of eight levels fused. Cobb angle at fusion level was 68° preoperatively and 37° postoperatively. Flexibility on traction films was 34 % and correction rate 47 %. Postoperative and follow-up Cobb angles were highly correlated with preoperative bending films (r = 0.7, p < 0.05). Screw density rate was 87 %, with increased correction with higher screw density (p < 0.001, r = 0.4). Patients with an increased junctional kyphosis angle (JKA + 1) were at higher risk of revision surgery (p = 0.049). 22 patients sustained complication, and 21 patients had revision surgery. 42 patients with ≥24 months follow-up were assessed for clinical outcomes (follow-up rate for clinical measures was 38 %). This subgroup showed no significant differences regarding baseline parameters as compared to the whole group. Median approach-related morbidity (ArM) was 8.0 %, SRS-sum score was 4.0, and ODI was 4 %. There was a significant negative correlation between the SRS-24 self-image scores and the number of segments fused (r = −0.5, p < 0.05). Patients with additional surgery had decreased clinical outcomes (SRS-24 scores, p = 0.004, ArM, p = 0.0008, and ODI, p = 0.0004).

Conclusion

The study highlighted that AR/PSF is an efficient strategy providing reliable results in a large single-center series. Results confirmed that flexibility was the decisive measure when comparing surgical outcomes with different treatment strategies. Findings indicated that changes at the proximal junctional level were impacted by individual spino-pelvic morphology and determined by the individually predetermined thoracolumbar curvature and sagittal balance. Results stressed that in SK correction, reconstruction of a physiologic alignment is decisive to achieving good clinical outcomes and avoiding complications.     

‘Long’ pressure reactivity index (L-PRx) as a measure of autoregulation correlates with outcome in traumatic brain injury patients

Background  

Cerebral autoregulation and, consequently, cerebrovascular pressure reactivity, can be disturbed after traumatic brain injury (TBI). Continuous monitoring of autoregulation has shown its clinical importance as an independent predictor of neurological outcome. The cerebral pressure reactivity index (PRx) reflects that changes in seconds of cerebrovascular reactivity have prognostic significance. Using an alternative algorithm similar to PRx, we investigate whether the utilization of lower-frequency changes of the order of minutes of mean arterial blood pressure (MAP) and intracranial pressure (ICP) could have a prognostic value in TBI patients.     

Endovascular Treatment of a Haemodynamically Unstable Massive Pulmonary Embolism using Fibrinolysis and Fragmentation. Experience with 111 Patients in a Single Centre. Why don’t we follow ACCP Recommendations?

IntroductionFibrinolysis is recommended in several consensus documents for the treatment of hemodynamically-unstable massive pulmonary embolism (MPE).Material and methodsA total of 111 patients were treated in a single center from January 2001 to December 2009. Fifty-five were male and 56 female, all diagnosed with hemodynamically-unstable MPE (systolic arterial pressure > 90 mmHg) with at least two of the following criteria: Miller index > 0, ventricular dysfunction, and need for vasoactive drugs. Local fibrinolysis with urokinase was performed in all cases as was fragmentation with a pig-tail catheter in most. An inferior vena cava (IVC) filter was implanted in 94 patients as a prophylactic measure.ResultsTechnical success was 100%. The Miller index improved from 0.7 ± 0.12, pre-treatment, to 0.09 ± 0.16. Mean pulmonary arterial pressure went from 39.93 ± 7.0 mmHg to 20.47 ± 3.3 mmHg at the 30-90 day follow-up. Ninety-four patients had IVC filters implanted, 79% of which were withdrawn satisfactorily. Seven patients died: 3 due to neoplasia; 3 due to right cardiac failure at 1, 7 and 30 days; and another died of a brain hemorrhage within the first 24 hours. There were complications in 12.6% of the cases, of which 4.5% were major.ConclusionLocal fibrinolysis with fragmentation achieves rapid normalization of the pulmonary pressure and is a safe and effective method for the treatment of hemodynamically-unstable MPE.