Comparison of accuracy and precision between frame-based and frameless stereotactic navigation for deep brain stimulation electrode implantation

The accuracy and precision of frameless neuronavigation as compared to conventional frame-based stereotaxy for implantation of deep brain stimulation (DBS) electrodes were studied in 14 patients with essential tremor. DBS electrodes were implanted bilaterally in the ventrolateral thalamus [ventrointermediate nucleus (VIM)] in one procedure. Frameless neuronavigation was used on one side and the conventional frame-based technique on the other. Targeting was guided by MRI and CT imaging. Intraoperative stereotactic plain X-ray verified final electrode positions and electrode deviations from the planned target were measured. Clinical outcome was evaluated with the Essential Tremor Rating Scale. Thirteen of the patients were eligible for measuring electrode deviations and 10 of them were available for a clinical follow-up. Electrode deviations from target were larger using the frameless technique in the medial-lateral (x: 1.9 +/- 1.3 mm) and anterior-posterior (y:0.9 +/- 0.8 mm) directions as compared to the frame-based technique (x: 0.5 +/- 0.5 and y: 0.4 +/- 0.4 mm) but similar in the superior-inferior direction (z). The vector of deviation was 2.5 +/- 1.4 mm with the frameless technique and 1.2 +/- 0.6 with the frame-based technique. The differences were statistically significant (p < 0.05-0.001). The dispersion was larger with the frameless technique as represented by the larger standard deviations in all three planes. At clinical follow-ups, tremor reduction was similar irrespective of the implantation technique. It is concluded that conventional frame-based stereotaxy has higher accuracy/precision for hitting a small brain target than the frameless technique. However, the difference is relatively small and does not influence the clinical result of DBS electrode implantations in the VIM when treating tremor.     

Integration of preoperative and intraoperative functional brain mapping in a frameless stereotactic environment for lesions near eloquent cortex. Technical note

The authors present a method of incorporating preoperative noninvasive functional brain mapping data into the frameless stereotactic magnetic resonance (MR) imaging dataset used for image-guided resection of brain lesions located near eloquent cortex. They report the use of functional (f)MR imaging and magnetic source (MS) imaging for preoperative mapping of eloquent cortex in difficult cases of brain tumor resection such as those in which there are large expansive masses or in which reoperations are required and the anatomy is distorted from prior treatments. To correlate methods of preoperative and intraoperative mapping localization directly, the authors have developed techniques of importing preoperative MS and fMR imaging data into an image-guided frameless stereotactic computer workstation. The data appear as a seamless overlay on the same preoperative volumetric MR imaging dataset used for stereotactic guidance during the operation. Intraoperatively identified functional locations mapped by cortical stimulation are recorded as digitally registered points. This approach should prove useful in assessing the accuracy and reliability of various preoperative functional brain mapping techniques.     

Comparison of frame-based and frameless stereotactic hematoma puncture and subsequent fibrinolytic therapy for the treatment of supratentorial deep seated spontaneous intracerebral hemorrhage.

OBJECTIVE: This study compared the technical implications and clinical outcome of patients treated for an intracerebral hemorrhage using two minimally invasive procedures: frame-based stereotactic hematoma aspiration and frameless navigation-guided hematoma aspiration followed by fibrinolysis. METHODS: Thirty patients with a spontaneous supratentorial intracerebral hemorrhage, which was treated by a frame-based (n=15) and frameless (n=15) hematoma aspiration followed by subsequent fibrinolysis with urokinase, were retrospectively reviewed. The data for the two subsets of patients were analyzed with regard to hematoma reduction, Glasgow Coma Scale (GCS), and degree of weakness. RESULTS: In the frame-based stereotactic hematoma aspiration group, the volume of the hematoma was 15.4-100.0 mL (mean: 40.7+/-24.4), the GCS upon admission was 4-15 (mean: 10.1+/-3.0), and the grade of weakness upon admission was 1-5 (mean: 2.1+/-0.9). On the other hand, in the frameless navigation-guided hematoma aspiration group, the hematoma volume was 15.2-62.0 mL (mean: 30.0+/-15.2), the GCS upon admission was 7-15 (mean: 13.0+/-2.4), and the grade of weakness upon admission was 1-4 (mean: 2.3+/-1.2). The drainage catheter was in place for a mean duration of 5.1+/-2.4 days (range: 1-12 days). In the frame-based group, the initial hematoma was reduced by -115-88.5% (mean: 52+/-31.5) immediately after surgery, and 90.5% (41-100%) of the initial volume 14 days after surgery. In the frameless group, the initial hematoma was reduced by 11.7-90.8% (mean 57.3+/-25.1) immediately after surgery and 95.8% (87.7-100%) 14 days after surgery. The GCS score and the degree of weakness were evaluated 14 days after surgery, and the Glasgow outcome scale (GOS) score was evaluated at discharge. There were no statistically significant differences between the two groups. CONCLUSION: The frame-based group and the frameless group followed by fibrinolysis had similar outcomes, and both procedures effectively reduced the intracerebral hemorrhage volume within a short period of time. In addition, these procedures are simple, precise, safe, and brief with a very low rebleeding rate and mortality.     

Surgical treatment for malignant lesions of the distal part of the esophagus and the esophagogastric junction

The treatment of 364 patients with carcinoma of the distal part of the esophagus and the esophagogastric junction is reported. Eighty-two percent of the patients were subjected to operation and the resect ability rate was 52%. At operation 230 patients had lymph node metastases and 115 patients had distant metastases to abdominal organs. The resection rate was significantly higher in patients with squamous cell carcinoma than in patients with adenocarcinoma, and about two-thirds of the resections were considered as curative treatment. The operative mortality rate for the entire period was high (24%), but the mortality decreased in the last 10-year period. The 5-year survival rate after resection was in the same level as in other series; the survival rate for patients with squamous cell carcinoma was considerably higher than for patients with adenocarcinoma.If surgical resection is not feasible, surgical bypass of the obstructing lesion is indicated. This alternative procedure gives satisfactory palliation in the majority of patients.

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Resumen Este informe se refiere al tratamiento de 364 pacientes con carcinoma de la porción distal del esófago y de la unión cardioesofágica. El 82% de los pacientes fué sometido a operación y la tasa de resección fué de 52%. En la operación se encontró que 230 pacientes tenían metástasis a ganglios linfáticos y que 115 tenían metástasis a órganos abdominales.La tasa de resección fué significativamente mayor en pacientes con carcinoma escamocelular que en los pacientes con adenocarcinoma, y alrededor de 2/3 de las resecciones fueron consideradas como tratamiento curativo. La mortalidad operatoria para la totalidad del período fué alta (24%), pero disminuyó en los últimos 10 anos. La tasa de supervivencia a cinco años después de la resección fué del mismo nivel que en otras series; la supervivencia fué considerablemente mayor en pacientes con carcinoma escamocelular que en los pacientes con adenocarcinoma.Cuando la resección quirúrgica no es practicable, está indicada una esofagogastrostomía de tipo bypass o la intubación. Estos procedimientos proveen una paliación satisfactoria en la mayoría de los pacientes al mejorar la calidad de la vida, la cual es bastante superior cuando el paciente puede corner y beber.

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Résumé Les auteurs font état du traitement de 364 malades atteints de cancer de la partie distale de l'oesophage et de la jonction oesophagogastrique. Quatre-vingt deux pour cent (82%) des malades ont été opérés, le taux de résection ne dépassant pas 52%. Lors de l'intervention 230 de ces sujets présentaient des métastases lymphatiques et 115 présentaient des métastases à distance au niveau des organes abdominaux. Le taux de résection fut plus élevé chez les sujets qui présentaient un cancer squameux par rapport à ceux qui présentaient un adénocarcinome. Environ 2/3 des résections furent considérés comme curatives. La mortalité opératoire au total s'est élevée à 24% mais son taux a sensiblement décru au cours des 10 dernières années. Le taux de survie à 5 ans est le même que celui publié dans d'autres séries. Il est à noter que le taux de survie chez les patients atteints de cancer squameux fut nettement plus élevé que celui des sujets porteurs d'un adénocarcinome.Si la résection chirurgicale est impossible il est indiqué d'établir un court-circuit digestif au-dessus de la lésion ou d'intuber celle-ci. Ces méthodes donnent une rémission satisfaisante dans la majorité des cas.

     

Mammotome微创旋切系统对乳腺病灶诊治的临床研究

目的：探讨超声引导下Mammotome微创旋切系统在乳腺病灶诊治中的临床价值,分析并发症产生的原因并探讨防治对策。方法：回顾性研究2007年5月—2010年6月198例（共677处）乳腺病灶进行超声引导下Mammotome微创旋切术患者的临床资料,评价其在乳腺病灶诊断和治疗中价值,分析其并发症的处理及预防。结果：2例患者乳腺病灶未完全切除,切除成功率为99.0%。病理结果示乳腺良性病灶665处（98.2%）、恶性病灶12处（1.8%）,10例患者（5.1%）行手术治疗。术后皮下淤血14例（7.1%）、局部病灶残留1例（0.5%）、局部血肿2例（1.0%）,无感染、气胸、皮肤破损等严重并发症。结论：Mammotome系统对乳腺病灶进行微创切除安全有效、美容效果佳,且术后并发症少,易于处理,值得在临床推广使用。     

微通道和标准通道PCNL治疗复杂性肾结石的比较

目的探讨与评价微通道和标准通道经皮肾镜碎石取石术（PCNL）两种方法治疗复杂性肾结石的安全性和临床疗效。方法我们采用标准通道（22F）和微通道（18F）PCNL治疗复杂性。肾结石49例,并记录碎石取石时间,结石取净率及手术并发症。结果49例患者均Ⅰ期成功建立经皮肾通道,标准通道组21例中,17例Ⅰ期碎石取石成功,4例行Ⅱ期碎石,平均碎石手术时间为（75±25）min。微通道组28例中,18例Ⅰ期手术成功,10例行Ⅱ期碎石,碎石时间为（92±31）min,两组比较有显著性差异（P〈0．05）;术后检测血红蛋白（Hb）,标准通道组20例（20／21）Hb下降〈30g／L,微通道组26例（26／28）Hb下降〈30g／L,两组比较无显著性差异（P〉0．05）;标准通道组结石清除率85．7％（18／21）,微通道组82．2％（23／28）,两组比较无显著性差异（P〉0．05）。结论标准通道和微通道PCNL治疗复杂性。肾结石疗效确切,均具有损伤小、恢复快、结石清除率高,并发症少等优点,但采用标准通道能缩短取石时间,两者结合效果更好。     

术中三维影像脊柱导航引导半椎体切除及椎弓根螺钉置入矫治儿童先天性脊柱侧后凸畸形

目的:探讨术中实时三维影像脊柱导航引导下后路椎弓根螺钉置入及半椎体切除矫治儿童先天性脊柱侧后凸畸形的临床疗效。方法:自2010年5月~2013年4月,对18例儿童先天性半椎体脊柱侧后凸畸形患者进行术中实时三维影像脊柱导航引导下进行脊柱矫形手术。其中,男7例,女11例,年龄7.6±2.9岁。术中在实时三维影像脊柱导航引导下经后路置入椎弓根螺钉并切除半椎体后进行矫形。术后通过CT评价椎弓根螺钉位置及半椎体切除情况,术前、术后摄脊柱正侧位X线片,评价矫形效果。结果:手术时间216±55min,术中出血量732±378ml。18例患者共置入椎弓根螺钉127枚(4~12枚/例)。术后CT证实124枚椎弓根螺钉位置准确,置钉准确率97.6%;1枚椎弓根螺钉穿破椎弓根内侧皮质,2枚椎弓根螺钉穿破椎弓根外侧皮质。1例出现椎弓根螺钉切割,1例出现血气胸,置入胸腔闭式引流。无神经损伤并发症病例,无螺钉误置而引起的并发症。术后CT证实18例患者半椎体均完整切除。18例中有16例获得随访,随访时间18.5±8.0个月。16例术前测量冠状面节段性侧凸Cobb角44.5°±11.4°,术后为9.3°±4.7°,末次随访时为9.7°±5.0°,矫正率为(78.2±7.8)%。节段性后凸Cobb角术前测量为32.2°±7.3°,术后为7.2°±3.5°,末次随访节时为7.7°±3.9°,矫正率为(76±9.4)%。侧凸及后凸矫正与术前相比均有统计学意义(P0.01)。末次随访时16例患者均获得骨性融合。结论:术中实时三维影像脊柱导航引导经后路矫治先天性脊柱侧后凸畸形半椎体切除完整,置入椎弓根螺钉准确率高,安全性高,畸形矫正效果满意。     

Surgical treatment of hiatus hernia and gastroesophageal reflux disease in complex cases using robotic-assisted laparoscopic surgery: a prospective study/consistent experience in a single institution

The aim of this study was to report our experience in robotic-assisted surgery of hiatus hernia and gastroesophageal reflux disease in a large series of complex cases. From March 2009 until July 2010, 21 patients were operated due to hiatus hernia or reflux disease using robotic-assisted surgery at Albert Einstein Hospital, S?o Paulo, Brazil. All patients were selected for the robotic approach because of the complexity of the cases (associated co-morbidity) such as: previous major upper abdominal surgery in 6 patients, hiatus hernia with paraesophageal involvement in 8 patients, obesity with a body mass index of over 29 kg/m² in 8 patients, and previous hiatus hernioplasty in 3 patients. Optimal trocar positioning, operating and setup times, conversion rate, intraoperative complications, and perioperative morbidity and mortality rate were analyzed. The mean operating time was reduced from 316 to 195 min after five procedures and the setup time from 20 to 10 min after five procedures. There were no conversions in this group of patients and also no complication or need of blood transfusion. Robotic-assisted fundoplication is feasible, safe and effective for treating hiatus hernias and gastroesophageal reflux disease, especially in complex cases because improved dissection in the esophageal hiatus region compensates for long operating times. Disadvantages are the high costs, the time to master the setup/system, and the necessity of exact trocar positioning.     

Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients

OBJECTIVE: The goal of this report is to illustrate the use of radial artery grafts as bypass conduits in the management of complex intracranial aneurysms and to describe a new "pressure distension technique" to eliminate postoperative vasospasm, which was a common problem early in our experience. METHODS: This study included a series of 17 patients who were surgically treated between 1994 and January 2001 for complex intracranial aneurysms. Five patients were surgically treated without the pressure distension technique; for 12 patients, the technique was used to reduce postoperative vasospasm. Fourteen of the patients had anterior circulation aneurysms, and three had posterior circulation aneurysms. Five of the patients had undergone previous attempts at direct clipping or excision and reconstruction of the aneurysm in question, and embolization had been performed for one patient with a carotid-cavernous fistula. Thirteen patients underwent permanent revascularization combined with proximal occlusion, trapping, or clipping, and four patients underwent temporary revascularization for cerebral protection during anticipated prolonged occlusion of the parent vessel during aneurysm dissection. Surgical techniques are described, with particular reference to vessel collection and bypass techniques. RESULTS: The outcomes for this group of patients, considering the complexity of the aneurysms and their "inoperability," with respect to direct clipping, were satisfactory. The aneurysms were completely obliterated for all patients, and the grafts were patent for all except one patient on postoperative angiograms. There were two deaths, one attributable to systemic sepsis and the other attributable to cardiac arrest during a transbronchial biopsy. The postoperative Glasgow Outcome Scale scores were either better or the same for all other patients, compared with their preoperative scores. Three of the five patients treated before the institution of the pressure distension technique experienced vasospasm of the graft, with two of those patients requiring angioplasty. For one of those patients, angioplasty led to rupture of the graft. Vasospasm was not observed for any of the 12 patients for whom the pressure distension technique was used. We observed no morbidity related to radial artery collection. CONCLUSION: Revascularization techniques are occasionally necessary for the surgical treatment of complicated intracranial aneurysms. The merits of the use of the radial artery as a bypass conduit are discussed. Radial artery grafts should be considered as alternatives to saphenous vein and superficial temporal artery grafts. The problem of vasospasm of the artery has been solved with the pressure distention technique.     

STA-ACA bypass using the contralateral STA as an interposition graft for the treatment of complex ACA aneurysms: report of two cases and a review of the literature

Bypass surgery has been used as a remedy for the complex cerebral aneurysm, which was unsolved with the clipping method. However, little has been reported about bypass options for anterior cerebral artery (ACA) aneurysms. The authors experienced two patients with complex ACA aneurysms, large fusiform and large thrombosed aneurysms involving the distal A1 and proximal A2 segments, respectively. To achieve complete obliteration of the aneurysm, we performed a superficial temporal artery (STA)-ACA bypass using contralateral STA as interposition grafts with endovascular trapping without any ischemic events. These cases show that STA-ACA bypass using contralateral STA interposition graft is a feasible option to maintain blood supply to the ACA territory if a proximal ACA lesion requires trapping.     

Ankle arthrodesis using the Taylor Spatial Frame for the treatment of infection,extruded talus and complex pilon fractures

IntroductionThe treatment of complex pilon fractures and talus fracture-dislocations present several challenges, like avoiding infection, achieving union, management of bone loss and function preservation.MethodsRetrospective cohort review of fourteen patients who underwent ankle arthrodesis (AA) using the Taylor Spatial Frame (TSF) after pilon and talus fracture-dislocations. Ten tibiocalcaneal (TC) and four tibiotalar (TT) fusions were performed. Eleven of these cases were Gustilo III open fractures. Seven cases involved an open extruded talus. Four cases had established infections. There was a mean of 2.7 (range 0 – 8) operations prior to AA using TSF. The primary objective was to determine infection and union rates. Patient-reported outcomes (Short Form 36, SF-36) and functional outcomes (Ankle Osteoarthritis Score, AOS) were the secondary measures.ResultsEradication and prevention of deep infection was achieved in all cases. Radiological union was achieved at a mean of 9 months (range 5 – 17). Solid AA was achieved in 12 of 14 cases using the TSF. Two TC fusions required a hindfoot fusion nail to achieve union. Eleven cases had concurrent bone transport, mean of 63 mm (range 33 - 180). Mean time of TSF treatment was 11.1 months (range 6 - 16). One case required delayed amputation. Eight patients were able to fully weight bear unaided after the treatment. Mean SF-36 was 65 (range 35 -100). Mean AOS was 36.5 (range 6.6 – 77.5) with 69.3% of scores graded good to excellent. Mean total number of operations was 5.9 (range 2 – 10). Minimum follow up time was 12 months (range 12 - 56).ConclusionAA using TSF can be considered for complex pilon fractures and extruded talus. It has shown to be effective in achieving a solid fusion and infection eradication. While using the TSF in isolation, non-union must be suspected in TC fusions, absence of radiological signs of healing, massive bone loss, and possibly not using bone graft. Patients must be aware that while treatment of these injuries will be prolonged and carries the risk of many potential complications, it provides a good alternative to amputation.     

Surgical treatment for the type II and III truncus: complete division of the truncal root with primary repair using absorbable suture

A simplified technique for repair of type II and III truncus arteriosus applicable in neonates is described. The method is particularly useful in those patients in whom the pulmonary artery orifices arise from the posterior wall of the truncal root. Advances in two-dimensional echocardiography have provided an accurate means of determining the exact anatomy preoperatively. At operation, isolation of the pulmonary orifices on a button of posterior truncal wall is accomplished by complete division of the main truncal root. Primary closure of the new ascending aorta is made possible by extensive mobilization of the aorta and pulmonary orifices. Early postoperative follow-up indicates that the use of a new absorbable suture for primary repair of the aortic root allows for normal growth.     

Cost-effectiveness analysis of newer anticholinergic drugs for urinary incontinence vs oxybutynin and no treatment using data on persistence from the Swedish prescribed drug registry

Study Type – Therapy (cost effectiveness) Level of Evidence 2a What's known on the subject? and What does the study add? Anticholinergic drugs are a common treatment alternative in urinary incontinence, which results in large costs for caregivers. So far, most cost‐effectiveness analyses of anticholinergic drugs have focused on small putative differences between the newer anticholinergics. This study takes a novel approach by treating the clinical effects of the newer alternatives as similar and evaluating them as a group in relation to no treatment and oxybutynin (immediate release). It also uses registry data to account for persistence.

OBJECTIVE

• ? To analyse the cost‐effectiveness of newer anticholinergic drugs in relation to oxybutynin immediate release (IR) and no treatment for patients with urgency urinary incontinence.

PATIENTS AND METHODS

• ? A decision analytic model was constructed.
• ? Results were collected from randomized trials and combined with registry data on persistence of medicine use and estimated number of severe adverse events.
• ? The setting corresponds to Swedish clinical practice.
• ? The costs and effects of the treatment options were analysed over a period of 1 year. Costs included drug costs, treatment costs and costs for pad use. Patients' utilities were based on treatment effect and the lack or presence of adverse events.

RESULTS

• ? No treatment was the least costly treatment but also resulted in the fewest number of quality adjusted life years (QALYs).
• ? Treatment with newer anticholinergic drug medications is the most costly option but also the most efficient treatment. Sensitivity analyses showed that the results were robust.
• ? Treatment with newer anticholinergics resulted in a cost per QALY gained of €21 045 compared with no treatment and no effect and €65 435 compared with no treatment and placebo effect. Compared with oxybutynin IR, the cost per QALY gained was €37 119. These calculations are based on relatively low pad costs, resulting in higher costs per QALY for the original drugs.

CONCLUSIONS

• ? The newer anticholinergic medications are likely to be cost effective in relation to oxybutynin IR.
• ? The cost‐effectiveness of the newer anticholinergics compared with no treatment depends on assumptions of the effect of no treatment, the severity of the treated condition and the treated individual's risk of adverse events.
• ? Treatment is less likely to be cost effective for elderly persons or for persons otherwise at higher risk for adverse events.

     

Percutaneous pinning using threaded pins as a treatment option for unstable two- and three-part fractures of the proximal humerus: a retrospective study

A retrospective study was designed to evaluate the results of closed reduction and percutaneous pinning using threaded pins as a treatment option for fractures of the humeral head. Patients who suffered two- and three-part fractures of the proximal humerus treated by this method of fixation were included. Fifty patients (32 females and 18 males) with an average age of 50 years were clinically evaluated at an average of 2.5 years after this procedure (range 1–4 years). The Constant score was used to evaluate the clinical outcome. Preoperative and postoperative X-rays were also assessed. Out of 50 patients, 18 (36%) obtained excellent results, 17 (34%) good results, eight (16%) fair results and seven (14%) achieved only poor results. The average Constant score was 81 (range 60–100). Fractures confined to the surgical or anatomical neck generally did better than those associated with a greater tuberosity fragment (average score 86 versus 78). Patients who required shaft stabilisation and in addition to reduction and fixation of the greater tuberosity showed a lower average score (68). There were no cases of avascular necrosis, neurovascular complications or deep infections. A significant loss of fracture position due to failure of internal fixation occurred in seven cases, three of these patients underwent revision surgery. Closed reduction and percutaneous pinning offers a good fracture position and stability with minimal soft tissue damage. We recommend that displaced two- and three- part fractures of the humeral head should be treated in this manner. However these patients should be monitored closely for a period of four weeks, since secondary displacement and failure of fixation can occur in this period. Careful patient selection may minimise these complications.

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Résumé Etude retrospective de la réduction à foyer fermé et de la fixation percutanée avec des broches filetées des fractures à deux et trois fragments de l’extrémité supérieure de l’humérus. Method : 50 patients, d’age moyen 50 ans, ont été évalués cliniquement à un délai moyen de 2,5 ans après l’opération.Le score de Constant ainsi que les radiographies pré et post opératoires ont été utilisés pour l’appréciation. ResultsSur 50 patients 18 obtenaient un excellent résultat, 17 un bon résultat, 8 un résultat moyen et 7 un mauvais résultat. Le score de Constant moyen était de 81 (de 60 à 100). Les fractures isolées du col anatomique ou chirurgical avaient un meilleure évolution que celles associées à une fracture de la grosse tubérosité ( score de 86 au lieu de 78).Les patients qui ont nécessité une réduction et une fixation de la grosse tubérosité en plus de la stabilisation diaphysaire avaient un score moyen plus bas (68). Il n’y avait pas de nécrose, d’infection profonde ni de trouble neurovasculaire. Une perte de réduction est survenu dans 7 cas avec nécessité de reprise chirurgicale 3 fois. Conclusions : la réduction fermée avec fixation par broches percutanées permet une bonne stabilisation de la fracture avec un minimum de dommages aux parties molles. Nous préconisons ce traitement pour les fractures à 2 et 3 fragments de la tête humérale en recommandant une surveillance étroite pendant les 4 premières semaines car le déplacement secondaire et l’échec de la fixation représente un écueil sérieux de la méthode.

     

The ultrasonography evaluation of talar dysplasia as a potential prognostic factor for predicting the course and outcomes of clubfoot deformity treatment using Ponseti technique

Objective

The aim of this study was to assess the role of sonographic evaluation of Talar dysplasia in predicting the outcome of standard Ponseti method in the treatment of clubfoot deformity.