Use of the Ponseti method for recurrent clubfoot following posteromedial release

Background:

A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.

Materials and Methods:

A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.

Results:

Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.

Conclusion:

The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.     

Chronic kidney disease and postoperative mortality: a systematic review and meta-analysis

Whether renal dysfunction is an important factor in postoperative risk assessment has been difficult to prove. In an attempt to provide more compelling evidence, we conducted a systematic review comparing the risk of death and cardiac events in patients with and without chronic kidney disease who underwent elective noncardiac surgery. From electronic databases, web search engines, and bibliographies, 31 cohort studies were selected, evaluating postoperative outcomes in patients with chronic kidney disease. These patients had higher risks of postoperative death and cardiovascular events compared to those with preserved renal function. The pooled incidence of postoperative death was significantly less in those with preserved renal function than in those patients with chronic kidney disease. Meta-regression showed a graded relationship between disease severity and postoperative death. In adjusted analysis, chronic kidney disease had a similar strength of association with postoperative death as diabetes, stroke, and coronary disease. Our review identifies chronic kidney disease as an independent risk factor for postoperative death and cardiovascular events after elective, noncardiac surgery.     

Age affects outcomes in chronic kidney disease

Chronic kidney disease (CKD) is common among the elderly. However, little is known about how the clinical implications of CKD vary with age. We examined the age-specific incidence of death, treated end-stage renal disease (ESRD), and change in estimated glomerular filtration rate (eGFR) among 209,622 US veterans with CKD stages 3 to 5 followed for a mean of 3.2 years. Patients aged 75 years or older at baseline comprised 47% of the overall cohort and accounted for 28% of the 9227 cases of ESRD that occurred during follow-up. Among patients of all ages, rates of both death and ESRD were inversely related to eGFR at baseline. However, among those with comparable levels of eGFR, older patients had higher rates of death and lower rates of ESRD than younger patients. Consequently, the level of eGFR below which the risk of ESRD exceeded the risk of death varied by age, ranging from 45 ml/min per 1.73 m(2) for 18 to 44 year old patients to 15 ml/min per 1.73 m(2) for 65 to 84 year old patients. Among those 85 years or older, the risk of death always exceeded the risk of ESRD in this cohort. Among patients with eGFR levels <45 ml/min per 1.73 m(2) at baseline, older patients were less likely than their younger counterparts to experience an annual decline in eGFR of >3 ml/min per 1.73 m(2). In conclusion, age is a major effect modifier among patients with an eGFR of <60 ml/min per 1.73 m(2), challenging us to move beyond a uniform stage-based approach to managing CKD.     

Citrate clearance in children receiving continuous venovenous renal replacement therapy

Anticoagulation is usually indicated in patients receiving continuous renal replacement therapy (CRRT) to prevent clotting of the extra-corporeal circuit. While heparin is the most frequently used anticoagulant, regional citrate anticoagulation is becoming the preferred choice in those patients at high risk for bleeding. However, it has been widely claimed that to avoid citrate toxicity, CRRT with citrate anticoagulation should utilize diffusive clearance (e.g., continuous venovenous hemodialysis). We studied citrate clearance in five children who received citrate anticoagulation during CRRT with a COBE PRISMA machine and an M-60 (AN-69) filter. The blood flow rate ranged from 50 to 150 ml/min (2.1-8.0 ml/kg per min). Citrate was infused in the circuit circulation as an acid citrate dextrose (ACD) solution at a rate of 1.6-3.7% of the blood flow rate to maintain the circuit ionized calcium (iCa) <0.5 mmol/l. Calcium-free replacement fluid with reduced alkali (NaHCO3 20 mEq/l) was infused in pre-filter mode at a rate of 1,800-2,000 ml/h per 1.73 m(2). In a separate central line, CaCl2 (0.8%) was infused (rate 25-50% of ACD infusion) to maintain systemic iCa between 1.0 and 1.3 mmol/l. Citrate concentration was measured using an enzymatic assay. Total CRRT duration was 1,224 h. Twenty-four filters were changed due to clotting, with a mean filter life of 51 h. Mean (range) citrate levels (mmol/l) were (1) before initiating CRRT ( n=2): patient baseline 0.13 (0.1-0.15), (2) during CRRT ( n=7): circuit 4.54 (3.95-6.25), effluent 4.31 (3.95-5.46), and patient 0.69 (0.30-1.13). Sieving coefficients for urea and citrate were 0.88-0.97 and 0.88-1.0, respectively. Citrate clearance (31-38 ml/min per 1.73 m(2)) was similar to that of urea (31-38 ml/min per 1.73 m(2)), and when evaluated in two patients, remained unchanged after substituting half of the convective clearance [continuous venovenous hemofiltration (CVVH)] by diffusive clearance [continuous venovenous hemodiafiltration (CVVHDF)]. The post-filter citrate load (mean+/-SD) delivered to the five patients during CRRT was 1.06+/-0.62 mmol/kg per hour. With the exception of alkalosis in one patient, no other complications were observed. Renal function recovered in all patients. We conclude that citrate anticoagulation in children is feasible, effective, and safe. Sufficient citrate clearance to prevent its toxic accumulation is achieved by convective clearance (CVVH) alone and diffusive clearance (CVVHDF) does not appear to be mandatory when utilizing citrate anticoagulation during CRRT.     

Total hip replacement for arthritis following tuberculosis of hip

AIM: To present the results of total hip arthroplasty (THA) for post tubercular arthritis of the hip joint.METHODS: Sixty-five patients (45 male, 20 female) with previously treated tuberculosis of the hip joint underwent cementless THA for post tubercular arthritis. The average age at the time of THA was 48 years (range 29 to 65 years). Erythrocyte sedimentation rate, C reactive protein, chest X-ray and contrast enhanced magnetic resonance imaging were done preoperatively to confirm resolution of the disease and to rule out any residual disease. Intra-operative samples were taken for microbiological examination, polymerase chain reaction (PCR) and histological examination. Patients were started on anti-tubercular drugs one week before the operation and continued for 6 mo post operatively. The patients were followed up clinically using the Harris hip score as well as radiologically for any loosening of the implants, osteolysis and any recurrence of tuberculosis. Any complications especially the recurrence of the infection was also recorded.RESULTS: The mean interval from completion of antitubercular therapy for tuberculosis to surgery was 4.2 years (range, 2-6 years). Preoperatively, 17 patients had ankylosis whereas 48 patients had functional but painful range of motion. The mean surgical time was 97 min (range, 65-125) whereas the mean blood loss was 600 mL (range, 400-900 mL). The average follow up was 8.3 years (range 6-11 years). The average Harris Hip score improved from 27 preoperatively to 91 at the final follow up. Seventeen patients had acetabular protrusion which was managed with impaction grafting and cementless acetabular cup. The bone graft had consolidated in all these 17 patients at the follow up. Two patients developed discharging sinuses at 9 and 11 mo postoperatively respectively. The discharge tested positive for tuberculosis on the PCR. Both these patients were put on antitubercular therapy for another year. Both of them recovered and had no evidence of any loosening or osteolysis on X-rays. There were no other complications recorded.CONCLUSION: Total hip replacement restores good function to patients suffering from post tubercular arthritis of the hip.     

Thromboembolic disease: variability of interobserver agreement in the interpretation of CT venography with CT pulmonary angiography

OBJECTIVE: The objective of this study was to determine interobserver agreement in the diagnosis of acute deep venous thrombosis on CT venography performed in addition to CT pulmonary angiography. SUBJECTS AND METHODS: One hundred forty-six CT venograms of 144 patients (mean age, 61.74 years) clinically suspected of having pulmonary embolism were analyzed prospectively and independently by two experienced thoracic and body imaging radiologists and later by consensus of the two radiologists. The CT venography protocol consisted of 5-mm-thick axial images at 20-mm intervals from the popliteal fossa to the renal veins. Images were acquired 3-4 min after the start of 100-150 mL of undiluted contrast medium administration at 4 mL/sec. Thirteen venous segments were analyzed in each patient. There were 1586 analyzable venous segments. RESULTS: Interobserver agreement, with the patient as the unit of analysis, was moderately good (kappa, 0.59; 95% confidence interval [CI], 0.39-0.78). Kappa values were similar for CT venography studies performed with 150 mL of contrast medium and 4-min delay (kappa, 0.62; 95% CI, 0.30-0.88) and with 3-min delay and 100 mL of contrast medium (kappa, 0.56; 95% CI, 0.32-0.80). Interobserver disagreement occurred in 17 (12%) of 146 CT venography studies. Findings of 11 CT venography studies were interpreted as negative, and six were interpreted as positive after consensus interpretation. CONCLUSION: Interobserver agreement for deep venous thrombosis with CT venography is moderately good.     

Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!

Background

Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI.

Materials and methods

Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1–6 requiring MV in the National Trauma Data Bank 2007–2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity.

Results

Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07–1.08).

Conclusions

Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence.