No abstract

The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age even after previous unsuccessful nonsurgical treatment.

Treatment with the Ponseti method corrects congenital idiopathic clubfeet in the majority of patients. However, some feet do not respond to the standard treatment protocol. We describe the characteristics and treatment results of these complex idiopathic clubfeet. We identified 50 patients (75 clubfeet) from 762 consecutive patients treated at five institutions. Clinically, complex clubfeet were defined as having rigid equinus, severe plantar flexion of all metatarsals, a deep crease above the heel, a transverse crease in the sole of the foot, and a short and hyperextended first toe. The Achilles' tendon was exceptionally tight and fibrotic up to the middle of the calf. Correction was achieved in all patients by modifying the Ponseti manipulation and casting technique. Correction required an average of five casts (range, 1-10 casts). Two patients (4%) not initially recognized as having complex clubfeet had a posterior release with tendo Achillis lengthening. There were seven relapses that responded to casting. Three patients had a second tenotomy. Modifying the treatment protocol for complex clubfeet successfully corrected the deformity without the need for extensive corrective surgery.

Untreated acetabular dysplasia following treatment for developmental dysplasia of the hip (DDH) leads to early degenerative joint disease. Clinicians must accurately and reliably recognise dysplasia in order to intervene appropriately with secondary acetabular or femoral procedures. This study sought early predictors of residual dysplasia in order to establish empirically-based indications for treatment. DDH treated by closed or open reduction alone was reviewed. Residual hip dysplasia was defined according to the Severin classification at skeletal maturity. Future hip replacement in a subset of these patients was compared with the Severin classification. Serial measurements of acetabular development and subluxation of the femoral head were collected, as were the age at reduction, type of reduction, and Tonnis grade prior to reduction. These variables were used to predict the Severin classification. The mean age at reduction in 72 hips was 16 months (1 to 46). On the final radiograph, 47 hips (65%) were classified as Severin I/II, and 25 as Severin III/IV (35%). At 40 years after reduction, five of 43 hips (21%) had had a total hip replacement (THR). The Severin grade was predictive for THR. Early measurements of the acetabular index (AI) were predictive for Severin grade. For example, an AI of 35 degrees or more at two years after reduction was associated with an 80% probability of becoming a Severin grade III/IV hip. This study links early acetabular remodelling, residual dysplasia at skeletal maturity and the long-term risk of THR. It presents evidence describing the diagnostic value of early predictors of residual dysplasia, and therefore, of the long-term risk of degenerative change.

Orthopedic implant-related bacterial infections are associated with high morbidity that may lead to limb amputation and exert significant financial burden on the healthcare system. Staphylococcus aureus is a dominant cause of these infections, and increased incidence of community-associated methicillin-resistant S. aureus (CA-MRSA) is being reported. The ability of S. aureus to attach to the foreign body surface and develop a biofilm is an important determinant of resistance to antibiotic prophylaxis. To gain insight on CA-MRSA biofilm properties, USA300 biofilm maturation and dispersal was examined, and these biofilms were found to exhibit pronounced, quorum-sensing mediated dispersal from a glass surface. For comparison of biofilm maturation on different surface chemistries, USA300 biofilm growth was examined on glass, polycarbonate, and titanium, and minimal differences were apparent in thickness, total biomass, and substratum coverage. Importantly, USA300 biofilms grown on titanium possessed a functional dispersal mechanism, and the dispersed cells regained susceptibility to rifampicin and levofloxacin treatment. The titanium biofilms were also sensitive to proteinase K and DNaseI, suggesting the matrix is composed of proteinaceous material and extracellular DNA. These studies provide new insights on the properties of CA-MRSA biofilms on implant materials, and indicate that quorum-sensing dispersion could be an effective therapeutic strategy. ß