Journal club papers 2008

Journal Club Papers Reviewed in 2008
February 2008
Classic: J. H. Wedge and M. J. Wasylenko. The natural history of congenital disease
of the hip J.Bone Joint Surg.Br. 1979 Aug 61-B 3 (334-338)
Fifty-four adults with eighty hips affected by congenital disease which had not been
treated have been reviewed. Fifty-nine per cent of forty-two dislocated hips had fair or
poor grading scores. The incidence of osteoarthritis was markedly increased in the
presence of a well-developed false acetabulum. Unilateral dislocation led to valgus
deformity and degenerative changes in the ipsilateral knee in seven of twenty-two
patients. Dislocation did not increase the incidence of symptomatic lumbar spondylosis.
The height of the dislocated head on the ilium was not found to be related to the
prognosis for the hip, the knee or the lumbar spine and did not correlate with the
development of the false acetabulum. Frank congenital subluxation eventually led to
osteoarthritis of the hip.
Comment: Journal Club 26/2/08 Chosen as a 'Classic'
H. J. Jung, Y. B. Jung, E. C. Jang, et al. Transradioulnar single Kirschner-wire fixation
versus conventional Kirschner-wire fixation for unstable fractures of both of the distal
forearm bones in children J.Pediatr.Orthop. 2007 Dec 27 8 (867-872)
The purpose of this study was to introduce transradioulnar single Kirschner-wire (K-
wire) fixation technique for unstable fractures of both of the distal forearm bones in
children and to evaluate the differences in clinical and radiographic results of
osteosynthesis between this method and conventional K-wire fixation. Forty-one
patients (20 conventional K-wire fixation, 21 transradioulnar single K-wire fixation) were
reviewed who underwent a closed or mini-open reduction with K-wire fixation for
fractures of both of the distal forearm bones. Their mean age at operation was 10.7
years (range, 8-16 years). Surgical intervention was indicated (1) when in addition to a
complete ulnar fracture, the radius showed a 50% of displacement or greater, or 20-
degree angulation or greater, (2) when in addition to an incomplete ulnar fracture, the
radius was completely displaced, and (3) when reangulation was 15 degrees or greater
in any direction at follow-up. The minimum follow-up period was 2 years. Bony union
was achieved in both groups at approximately 7 weeks after surgery, and there were no
significant differences in the operative time, duration of hospitalization, and duration of
external support between the 2 groups. There were no major complications such as
nonunion, radioulnar synostosis, premature physeal closure, or redisplacement or
reangulation. Transradioulnar single K-wire fixation technique was a relatively simple
procedure with comparable outcomes compared with conventional K-wire fixation
technique. In addition, physeal injuries could be avoided, and there was no need for
passing across the fracture line. Thus, it is suggested that transradioulnar single K-wire
fixation technique can be a good alternative method for high-risk fractures of both of the
distal forearm bones in children.
Comment: Journal Club 26/2/08 Suggests that technique is effective and simpler than a
cross-wire technique. Results seemed equivalent yet needs a larger series.
R. W. Poolman, G. M. Kerkhoffs, P. A. Struijs, M. Bhandari and International
Evidence-Based Orthopedic Surgery Working,Group. Don't be misled by the
orthopedic literature : tips for critical appraisal Acta Orthop. 2007 Apr 78 2 (162-171)
Surgeons are constantly inundated with medical information. There are over 4,000
different journals in PubMed and over 10,000 new citations are added to the medical
literature every week. Unfortunately, not all studies are equally valid and nowadays
patients have free access to the medical literature, although most are not trained to
judge the validity of medical information on the internet Thus, surgeons, despite their
busy schedules, have no choice but to become familiar with the principles and practice
of critical appraisal to ensure well-informed decisions based upon evidence of the
highest quality. In this second article in our series, we provide tips for appraisal of the
validity of a published orthopedic study. We provide guidelines to avoid being misled by
the orthopedic literature, and also checklists for assessment of the reporting of a
published study.
Comment: Journal Club 26/2/08 Good guidance, useful paper to keep to refer to.
G. A. Schmale. Journal Scan: Journal of Pediatric Orthopaedics July - December 2006
Clin.Orthop. 2007 464 (256-261)
Here is one orthopaedist’s view of the top 10 most potentially influential papers from the
Journal of Pediatric Orthopaedics from July through December, 2006. Included are
papers that were thought to provide the most useful reports of new surgical techniques,
new modes of patient evaluation, new approaches to old problems, and new methods of
diagnosis. Of these “best papers” published in the top pediatric orthopaedic journal from
July through December 2006, one is Level I, two are Level II, one is Level III, and six
are Level IV or case series.
Comment: Journal Club 26/2/08
K. Tayton. Does the upper femoral epiphysis slip or rotate?J.Bone Joint Surg.Br. 2007
Oct 89 10 (1402-1406)
Although much has been published on the causes of slipped upper femoral epiphysis
and the results of treatment, little attention has been given to the mechanism of the slip.
This study presents the results of the analysis of 13 adolescent femora, and the
attempts to reproduce the radiological appearances of a typical slip. The mean age of
the skeletons was 13 years (11 to 15). It was found that the internal bony architecture in
the zone of the growth plate was such that a slip of the epiphysis on the metaphysis (in
the normal meaning of the word slip) could not take place, largely relating to the
presence of a tubercle of bone projecting down from the epiphysis. The only way that
the appearance of a typical slipped upper femoral epiphysis could be reproduced was
by rotating the epiphysis posteromedially on the metaphysis. The presence and size of
this peg-like tubercle was shown radiologically by CT scanning in one pair of intact
adolescent femurs.
Comment: Journal Club 26/2/08 Interesting look at an idea. However: No SCFE bones
examined, no obvious clinical consequence.
S. R. Thomas, J. H. Wedge and R. B. Salter. Outcome at forty-five years after open
reduction and innominate osteotomy for late-presenting developmental dislocation of
the hip J.Bone Joint Surg.Am. 2007 Nov 89 11 (2341-2350)
BACKGROUND: A consecutive series of seventy-six patients (101 hips) underwent
primary open reduction, capsulorrhaphy, and innominate osteotomy for late-presenting
developmental dislocation of the hip. They were between 1.5 and five years old at the
time of surgery, which was done between 1958 and 1965. The present study was designed to review the outcome of these patients into middle age. METHODS: We located and reviewed the cases of sixty patients (eighty hips), which represents a 79% rate of follow-up at forty to forty-eight years postoperatively. Nineteen patients (twenty-four hips) had undergone total hip replacement, and three (three hips) had died of unrelated causes. The remaining thirty-eight patients (fifty-three hips) were assessed by the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and Oxford hip score questionnaires, physical examination, and a standing anteroposterior pelvic radiograph. The radiographs were analyzed to determine the minimum joint space width and the Kellgren and Lawrence score. Accepted indices of hip dysplasia were measured. RESULTS: With use of Kaplan-Meier survival analysis and with the end point defined as total hip replacement, the survival rates at thirty, forty, and forty-five years after the reduction were 99% (95% confidence interval, +/-2.4%), 86% (95% confidence interval, +/-6.9%), and 54% (95% confidence interval, +/-16.4%), respectively. The average Oxford hip score and WOMAC score for the surviving hips were 16.8 (range, 0 to 82) and 16.7 (range, 0 to 71), respectively. Of the fifty-one hips for which radiographs were available, thirty-eight demonstrated a minimum joint space width of >2.0 mm and thirteen demonstrated definite osteoarthritis on the basis of this criterion. Osteoarthritis, according to the system of Kellgren and Lawrence, was grade 0 or 1 in twenty-nine hips, grade 2 in seven hips, and grade 3 or 4 in fifteen hips. The average center-edge and acetabular angles were 40 degrees (range, 0 degrees to 61 degrees ) and 32 degrees (range, 20 degrees to 43 degrees ), respectively. With the numbers studied, no significant association was detected between outcome and the modifiable risk factors of body mass index or age at the time of surgery. Hips in patients with bilateral involvement were at significantly greater risk of failure (p = 0.02). CONCLUSIONS: This method of treatment achieves a 54% rate of survival of the hip at forty-five years. Two-thirds of the surviving hips have an excellent prognosis forty to forty-eight years after the index procedure according to the Kellgren and Lawrence score. Comment: Journal Club 26/2/08 Potentially a 'classic' paper. See the e-commentry M. Zenios, M. Ramachandran, B. Milne, D. Little and N. Smith. Intraoperative
stability testing of lateral-entry pin fixation of pediatric supracondylar humeral fractures
J.Pediatr.Orthop. 2007 Sep 27 6 (695-702)
The aims of this study were (1) to ascertain prospectively whether rotational instability
can be determined intraoperatively and (2) to quantify the incidence of rotational
instability after lateral-entry wire fixation in type-3 supracondylar humeral fractures in
children according to Wilkins modification of Gartland classification. (Fractures in
Children. Vol 3. 4th ed. 1996:669-750). Twenty-one consecutive patients admitted with
type-3 supracondylar fractures at the Children's Hospital at Westmead were surgically
treated according to a predetermined protocol. After closed fracture reduction, 2 lateral-
entry wires were inserted under radiographic control. Stability was then assessed by
comparing lateral fluoroscopic images in internal and external rotation. If the fracture
remained rotationally unstable, a third lateral-entry wire was inserted, and images were
repeated. A medial wire was used only if instability was demonstrated after the insertion
of 3 lateral wires. Rotational stability was achieved with 2 lateral-entry wires in 6 cases,
3 lateral-entry wires in 10 cases, and with an additional medial wire in 5 cases. Our
results were compared with a control group of patients treated at our hospital before the introduction of this protocol. No patients required a reoperation after the introduction of our protocol as opposed to 6 patients in the control group. On analysis of radiographs, the protocol resulted in significantly less fracture position loss as evidenced by change in Baumann angle (P < 0.05) and lateral rotational percentage (P < 0.05). We conclude that supracondylar fractures that are rotationally stable intraoperatively after wire fixation are unlikely to displace postoperatively. Only a small proportion (26%) of these fractures were rotationally stable with 2 lateral-entry wires. Comment: Journal Club 26/2/08 Points up the potential for some intraoperative assessment of stability yet their test led to quite large number having multiple pins. Used radiologic outcome not clinical. If the comparison group contained the cases that prompted the introduction of the protocol then regression to the mean is an explanation for the apparent improvement. April 2008
Classic: G. Nimon, D. Murray, M. Sandow and J. Goodfellow. Natural history of
anterior knee pain: a 14- to 20-year follow-up of nonoperative management
J.Pediatr.Orthop. 1998 Jan-Feb 18 1 (118-122)
We describe a consecutive series of girls with idiopathic anterior knee pain in
adolescence and who were treated nonoperatively. At a mean follow-up of 16 years,
22% had no pain, 71% thought that their symptoms were better than at presentation,
88% used analgesics rarely or not at all, and 90% continued to participate regularly in
sports. Nevertheless, about one in four of the patients continued to have significant
symptoms for < or = 20 years after presentation. No features were identified that
predicted those patients in whom symptoms would persist. We conclude that surgical
treatment of idiopathic anterior knee pain in adolescents is not justified until a procedure
has been shown to provide a better outcome than that reported here or until a way has
been found to distinguish the few patients who will not get better spontaneously from
the majority who will.
Comment: Journal Club 22/4/08 Good opportunity to be reminded of the evidence base
on which we commonly give advice
M. E. Domzalski, M. Inan, J. T. Guille, J. Glutting and S. J. Kumar. The proximal
femoral growth plate in Perthes disease Clin.Orthop.Relat.Res. 2007 May 458 (150-
158)
We hypothesized the extent of involvement of the proximal femoral growth plate in
Perthes disease determined the final radiographic outcome after containment by shelf
acetabuloplasty. We retrospectively evaluated the extent of growth plate involvement
using a modified version of the method described by Yasuda and Tamura. In our
modification, we used only the epiphyseal border for measurements, which was clearly
visible as a thin white line, unlike Yasuda and Tamura who used the metaphyseal and
epiphyseal borders. We could not clearly demarcate the metaphyseal border in the
radiographs of our patient population between 1944 and 1998, which consisted of 69
patients who had surgery at a mean age of 9 years (range, 6.0-14.1 years). From these
measurements, we formulated an index termed "growth plate involvement."
Radiographic results were classified as described by Stulberg et al A growth plate involvement index less than 0.25 resulted in a good radiographic outcome. We found 93.2% sensitivity and 100% specificity in predicting Stulberg's outcomes. The growth plate involvement index is a reliable and reproducible measurement method and may be used prospectively as a useful prognostic factor to predict radiographic outcomes after containment acetabuloplasty. Comment: Journal Club 22/4/08 Message seemed clear but overly complicated by too much confusing details on analysis & conclusions would need further work to substantiate S. Palmu, P. E. Kallio, S. T. Donell, I. Helenius and Y. Nietosvaara. Acute patellar
dislocation in children and adolescents: a randomized clinical trial J.Bone Joint
Surg.Am. 2008 Mar 90 3 (463-470)
BACKGROUND: The treatment of acute patellar dislocation in children is controversial.
Some investigators have advocated early repair of the medial structures, whereas
others have treated this injury nonoperatively. The present report describes the long-
term subjective and functional results of a randomized controlled trial of nonoperative
and operative treatment of primary acute patellar dislocation in children less than
sixteen years of age. METHODS: The data were gathered prospectively on a cohort of
seventy-four acute patellar dislocations in seventy-one patients (fifty-one girls and
twenty boys) younger than sixteen years of age. Sixty-two patients (sixty-four knees)
without large (>15 mm) intra-articular fragments were randomized to nonoperative
treatment (twenty-eight knees) or operative treatment (thirty-six knees). Operative
treatment consisted of direct repair of the damaged medial structures if the patella was
dislocatable with the patient under anesthesia (twenty-nine knees) or lateral release
alone if the patella was not dislocatable with the patient under anesthesia (seven
knees). All but four patients who underwent operative treatment had a concomitant
lateral release. The rehabilitation protocol was the same for both groups. The patients
were seen at two years, and a telephone interview was conducted at a mean of six
years and again at a mean of fourteen years. Fifty-eight patients (sixty-four knees; 94%)
were reviewed at the time of the most recent follow-up. RESULTS: At the time of the
most recent follow-up, the subjective result was either good or excellent for 75%
(twenty-one) of twenty-eight nonoperatively treated knees and 66% (twenty-one) of
thirty-two operatively treated knees. The rates of recurrent dislocation in the two
treatment groups were 71% (twenty of twenty-eight) and 67% (twenty-four of thirty-six),
respectively. The first redislocation occurred within two years after the primary injury in
twenty-three (52%) of the forty-four knees with recurrent dislocation. Instability of the
contralateral patella was noted in thirty (48%) of the sixty-two patients. The only
significant predictor for recurrence was a positive family history of patellar instability.
The mode of treatment and the existence of osteochondral fractures had no clinical or
significant influence on the subjective outcome, recurrent patellofemoral instability,
function, or activity scores. CONCLUSIONS: The long-term subjective and functional
results after acute patellar dislocation are satisfactory in most patients. Initial operative
repair of the medial structures combined with lateral release did not improve the long-
term outcome, despite the very high rate of recurrent instability. A positive family history
is a risk factor for recurrence and for contralateral patellofemoral instability. Routine
repair of the torn medial stabilizing soft tissues is not advocated for the treatment of
acute patellar dislocation in children and adolescents. Comment: Journal Club 22/4/08 Good paper - common clinical condition in which treatment dilemma exists, good study design (randomisation might have been improved, type of surgery may have evolved since) conclusions useful - eCommentary is of limited value. R. W. Poolman, B. A. Petrisor, R. K. Marti, G. M. Kerkhoffs, M. Zlowodzki and M.
Bhandari. Misconceptions about practicing evidence-based orthopedic surgery Acta
Orthop. 2007 Feb 78 1 (2-11)
One of a series of articles on EBM in orthopaedic surgery & this one deals with six
common misconceptions about EBM: (1) EBM ignores clinical expertise, (2) EBM is not
possible without randomized ontrolled trials (RCTs), (3) EBM is all about statistics and
numbers, (4) the usefulness of applying EBM to individual patients is limited, (5)
keeping up to date and finding the evidence is impossible for busy clinicians, and (6)
EBM is not evidence-based. Shows how most of the criticisms have their roots in a
misunderstanding of the concepts of EBM and are discussed point-by-point in the article
with appropriate examples and discussion applied to orthopaedic practice.
Comment: Journal Club 22/4/08 Excellent overview well worth retaining and revisiting.
N. M. Walker, N. J. Ward and R. H. Richards. Audit of elective paediatric clinic
referrals from primary care February 2002-September 2006 J.Pediatr.Orthop.B 2007
Nov 16 6 (447-450)
Our large district general hospital organized additional Waiting List Initiative clinics for
paediatric orthopaedic referrals. A prospective audit examined pathology, investigations
and disposal, and the implications of Waiting List Initiative clinics, particularly the
increased workload for other specialties and disciplines. Variations of normal
development were the most common presenting complaints, with the majority
discharged following initial consultation. Local protocols, providing guidance to primary
care physicians, covered common paediatric orthopaedic problems. We compared
these guidelines with the referrals received to establish the referral quality and quantify
the extra work generated. Few examples of inappropriate referrals were found,
suggesting that referring physicians utilize the guidelines.
Comment: Journal Club 22/4/08 Simple audit Not all would agree with the guidelines
J. G. Wright, S. Yandow, S. Donaldson, L. Marley and Simple Bone Cyst Trial
Group. A randomized clinical trial comparing intralesional bone marrow and steroid
injections for simple bone cysts J.Bone Joint Surg.Am. 2008 Apr 90 4 (722-730)
BACKGROUND: Simple bone cysts are common benign lesions in growing children that
predispose them to fracture and are sometimes painful. The purpose of this trial was to
compare rates of healing of simple bone cysts treated with intralesional injections of
bone marrow with rates of healing of those treated with methylprednisolone acetate.
METHODS: Of ninety patients randomly allocated to treatment with either a bone-
marrow or a methylprednisolone acetate injection, seventy-seven were followed for two
years. The primary outcome, determined by a radiologist who was blind to the type of
treatment, was radiographic evidence of healing. The cyst was judged to be either not
healed (grade 1 [a clearly visible cyst] or grade 2 [a cyst that was visible but multilocular
and opaque]) or healed (grade 3 [sclerosis around or within a partially visible cyst] or
grade 4 [complete healing with obliteration of the cyst]). Patient function was assessed with use of the Activity Scale for Kids, and pain was assessed with the Oucher Scale. RESULTS: Sixteen (42%) of the thirty-eight cysts treated with methylprednisolone acetate healed, and nine (23%) of the thirty-nine cysts treated with bone marrow healed (p = 0.01). There was no significant difference between the treatment groups (p > 0.09) with respect to function, pain, number of injections, additional fractures, or complications. CONCLUSIONS: Although the rate of healing of simple bone cysts was low following injection of either bone marrow or methylprednisolone, the latter provided superior healing rates. Comment: Journal Club 22/4/08 Excellent paper with good design, no notable failings, valid conclusions. June 2008
Classic: T. A. Malvitz and S. L. Weinstein. Closed reduction for congenital dysplasia
of the hip. Functional and radiographic results after an average of thirty years J.Bone
Joint Surg.Am. 1994 Dec 76 12 (1777-1792)
The functional and radiographic results of closed reduction in 152 congenitally
dislocated hips of 119 patients who had been managed between 1938 and 1969 were
reviewed retrospectively. The average age of the patients at the time of the reduction
was twenty-one months (range, one to ninety-six months). At the time of the latest
follow-up evaluation, the average age was thirty-one years (range, sixteen to fifty-six
years). The average duration of follow-up was thirty years (range, fifteen to fifty-three
years). At the latest follow-up evaluation, the Iowa hip rating averaged 91 points (range,
38 to 100 points) and the Harris hip score averaged 90 points (range, 33 to 100 points).
Thirty-five hips were rated Severin Class I; thirty-five, Class II; twenty-eight, Class III;
fifty-three, Class IV; and one, Class VI. Disturbance of growth in the proximal end of the
femur occurred in ninety-one hips (60 per cent). Eight contralateral hips that had
appeared normal also demonstrated disturbance of proximal femoral growth. In many
hips, partial physeal arrest could not be determined for ten to twelve years after the
reduction. Seventeen hips (twelve patients) had a total replacement when the patients
were an average age of thirty-six years (range, nineteen to fifty-three years). Sixty-five
hips (43 per cent) had radiographic evidence of degenerative joint disease. Patients
who did not have a growth disturbance of the proximal end of the femur or evidence of
subluxation tended to function extremely well for many years despite a radiographic
result that was less than anatomical. Function tended to deteriorate with time, even in
the absence of disturbance of growth in the proximal end of the femur. Despite
generally good function at the latest follow-up evaluation, the prognosis for these
patients remained guarded.
Comment: Journal Club 17/6/08 'classic' for June
T. Terjesen and V. Halvorsen. Long-term results after closed reduction of latedetected
hip dislocation: 60 patients followed up to skeletal maturity Acta Orthop. 2007 Apr 78 2
(236-246)
BACKGROUND: This retrospective study was undertaken because there is limited
knowledge about the long-term results after closed reduction of late-detected hip
dislocation. The aims were to evaluate the outcome after skeletal maturity and to find predictive factors for good and poor results. PATIENTS AND METHODS: The material included 60 patients (78 hips, 53 girls) treated during the period 1958-62. The primary treatment was skin traction for 36 (16-76) days. Closed reduction was performed in all hips except 4 that needed open reduction. The mean age at reduction was 20 (4-65) months. Hip spica plaster was worn for 9 (6-20) months. Within 3 years of the start of treatment, derotation femoral osteotomy was performed because of increased femoral anteversion in 35 patients. Later, 28 patients underwent additional surgery on the femur or acetabulum to improve femoral head coverage. Radiographs at the time of diagnosis and during follow-up to skeletal maturity were assessed. The average age of the patients at the most recent follow-up was 26 (15-42) years. RESULTS: The femoral head coverage normalized during the primary treatment and then decreased somewhat during the remaining growth period. The dysplasia of the acetabulum improved markedly during the first year after reduction. It continued to improve, but to a much lesser degree, until 8-10 years of age. A satisfactory radiographic outcome at skeletal maturity (Severin grades I and II) was obtained in 63% of the hips. Early derotation osteotomy of the femur did not improve the outcome. Avascular necrosis of the femoral head occurred in 14% of the hips. Risk factors for unsatisfactory outcome at skeletal maturity were high initial dislocation, steep acetabulum 1 year after reduction, reduced femoral head coverage at age 8-10 years, and avascular necrosis. INTERPRETATION: The specific risk factors and the radiographic outcome--with satisfactory long-term results in nearly two-thirds of the patients--would be valuable for comparison with outcome studies after more modern treatment regimes. Comment: Journal Club 17/6/08 compare with Malvitz & Weinstein 1994 'classic'. Kadir Bahadir Alemdaroglu, Serkan Iltar, Oguzhan Cimen, Mehmet Uysal, Ender
Alagoz and Dogan Atlihan. Risk Factors in Redisplacement of Distal Radial Fractures
in Children J Bone Joint Surg Am 2008 June 1 90 6 (1224-1230)
Background: The causes of redisplacement following closed treatment of distal
metaphyseal radial fractures in children are still controversial. Various risk factors and
radiographic indices have been suggested to predict redisplacement. The aims of this
study were to prospectively identify the causes of redisplacement and to test the
accuracy of previously described radiographic indices and our new method, the "three-
point index." Methods: This prospective study included seventy-five displaced or
severely angulated distal radial fractures in seventy-four children under the age of
fifteen years. Age, gender, initial complete displacement of the radius, an associated
ulnar fracture, the accuracy of the reduction, the maximum degree of obliquity of the
fracture line in the sagittal or coronal plane, and the distance to the physis were
examined as possible risk factors. Logistic regression analysis was utilized to search for
risk factors. We also calculated the cast index, padding index, Canterbury index, gap
index, and three-point index on the radiographs of each reduction. The sensitivity,
specificity, negative predictive value, and positive predictive value were calculated for
each test. Results: Initial complete displacement and the degree of obliquity of the
fracture were the most important risk factors for redisplacement. Fractures that were
completely displaced initially were 11.7 times more likely to redisplace than were
angulated but incompletely displaced fractures. A 20{degrees} oblique fracture was 4.9
times more likely to redisplace and a 30{degrees} oblique fracture was 10.9 times more
likely to redisplace than was a 0{degrees} true transverse fracture. The three-point index was superior to the other radiographic indices for predicting redisplacement, with a sensitivity of 94.7%, a specificity of 95.2%, a negative predictive value of 98.4%, and a positive predictive value of 85.7%. The gap index was the next-best measure, but it had a sensitivity of 63.2%, a specificity of 76.2%, a negative predictive value of 87.3%, and a positive predictive value of 44.4%. Conclusions: Initial complete displacement and the degree of obliquity of the fracture line are the dominant factors affecting redisplacement. Our new radiographic index, the three-point index, should be used to predict redisplacement and assess the quality of the cast treatment of these fractures. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence. Comment: Journal Club 17/6/08 Various indices used; Suggests good sensitivity, specificity, etc for three point index, ?use for audit Goo Hyun Baek, Ji Hyeung Kim, Moon Sang Chung, Seung Baik Kang, Young Ho
Lee and Hyun Sik Gong. The Natural History of Pediatric Trigger Thumb J Bone Joint
Surg Am 2008 May 1 90 5 (980-985)
Background: Pediatric trigger thumb is a condition of flexion deformity of the
interphalangeal joint in children. Although the surgical outcome is satisfactory, the
indications for nonoperative treatment for this condition are not clear. The aim of the
present study was to determine the rate of resolution of untreated pediatric trigger
thumb. Methods: Data on seventy-one thumbs in fifty-three children were collected
prospectively. The dates of the first visits ranged from April 1994 to March 2004.
Patients were diagnosed with pediatric trigger thumb during initial outpatient department
visits. During the present study, no treatment such as passive stretching or splinting
was applied. The amount of flexion deformity at the thumb interphalangeal joint was
measured at every six-month follow-up visit, and the duration of follow-up was at least
two years after diagnosis. The end point of follow-up was when the deformity caused
pain or secondary deformity or prevented normal use of the hand. The median duration
of follow-up was forty-eight months. Results: Of the seventy-one trigger thumbs, forty-
five (63%) resolved spontaneously. The median time from the initial visit to resolution
was forty-eight months. There was no significant difference in the pattern of resolution
between patients with unilateral and bilateral trigger thumb. Although resolution was not
observed in the remaining twenty-six thumbs, flexion deformities improved in twenty-two
thumbs. For the first two years after the initial visit, the mean flexion deformity
significantly decreased over the one-year intervals (p 60% of patients. Moreover, the
flexion deformity can be expected to show an improving pattern in patients who do not
have resolution. This information may help both parents and surgeons to make
decisions regarding the treatment of pediatric trigger thumb. Level of Evidence:
Prognostic Level IV. See Instructions to Authors for a complete description of levels of
evidence.
Comment: Journal Club 17/6/08 Good, confirms Dunsmuir & Sherlock to which
reference is made
N. N. Bhatia, G. Chow, S. J. Timon and H. G. Watts. Diagnostic modalities for the
evaluation of pediatric back pain: a prospective study J.Pediatr.Orthop. 2008 Mar 28 2
(230-233)
The commonly taught premise that pediatric back pain frequently has an underlying diagnosis has been recently challenged. Previous studies have suggested that up to 84% of children with low back pain have associated serious diagnoses. Children with back pain, therefore, have frequently undergone exhaustive diagnostic testing. There have been few prospective studies, however, about the diagnosis rate and appropriate diagnostic methods for back pain in children. This study prospectively examines the rate of diagnosis for pediatric back pain and the value of various diagnostic studies for this problem. METHODS: All patients presenting to our institution with a chief complaint of back pain were evaluated for the study. Inclusion criteria consisted of age younger than 18 years, no previous back surgery, no previous diagnosis given, and duration of pain longer than 3 months. Seventy-three patients were enrolled in the study, and an algorithm was created for diagnostic evaluation. The algorithm incorporated commonly used diagnostic techniques including radiographs, magnetic resonance imaging, computed tomography, bone scan, and laboratory studies. The end point was considered to be either (1) a definitive diagnosis or (2) no diagnosis and no symptomatic or clinical changes during a 2-year period. RESULTS: Fifty-seven patients (78.1%) ended with no diagnosis. Of the remaining 16, 9 were diagnosed with spondylolysis with or without spondylolisthesis. Three other patients had abnormal laboratory values but no definitive diagnosis. Other diagnoses included Scheuermann disease (n = 2), osteoid osteoma (n = 1), and a herniated disk (n = 1). CONCLUSIONS: This investigation is the largest prospective study of diagnostic modalities in pediatric back pain to date. Contrary to most of the previously published data, most of our patients ended the study with no definitive diagnosis. In addition, the most of the diagnoses were made at initial physical examination or via initial plain radiographs. No diagnoses were missed using our algorithm. These results suggest that pediatric back pain frequently does not carry a definitive diagnosis and that exhaustive diagnostic protocols may not be necessary for this problem. LEVEL OF EVIDENCE: Prospective study; Level 2 clinical evidence. Comment: Journal Club 17/6/08 Useful, suggests appropriate investigation and confirms lack of definitive diagnosis is common, unless perhaps <5 Eric J. Wall, Viral Jain, Vagmin Vora, Charles T. Mehlman and Alvin H. Crawford.
Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral
Fractures J Bone Joint Surg Am 2008 June 1 90 6 (1305-1313)
Background: In vitro mechanical studies have demonstrated equal or superior fixation of
pediatric femoral fractures with use of titanium elastic nails as compared with stainless
steel elastic nails, and the biomechanical properties of titanium are often considered to
be superior to those of stainless steel for intramedullary fracture fixation. We are not
aware of any clinical studies in the literature that have directly compared stainless steel
and titanium elastic nails for the fixation of pediatric femoral fractures. The purpose of
the present study was to compare the complications associated with the use of similarly
designed titanium and stainless steel elastic nails for the fixation of pediatric femoral
fractures. Methods: A group of fifty-six children with femoral fractures that were treated
with titanium elastic nails was compared with another group of forty-eight children with
femoral fractures that were treated with stainless steel elastic nails. Both nail types were
of similar design, and a similar retrograde insertion technique was used. The groups
were compared with regard to complications as well as insertion and extraction time.
Major complications were defined as malunion with sagittal angulation of >15{degrees} and coronal angulation of >10{degrees}, nail irritation requiring revision surgery, infection, delayed union, and rod breakage. Minor complications were defined as nail irritation or superficial infection not requiring surgery. Results: The malunion rate was nearly four times higher in association with the titanium nails (23.2%; thirteen of fifty-six) as compared with the stainless steel nails (6.3%; three of forty-eight) (p = 0.017, chi-square test; odds ratio = 4.535 [95% confidence interval, 1.208 to 17.029]). The rate of major complications was 35.7% (twenty of fifty-six) for titanium nails and 16.7% (eight of forty-eight) for stainless steel nails. The rates of minor complications were similar for the two groups, as were the insertion times and extraction times. The supplier price of one titanium nail ranges from $259 to $328, depending on size, whereas the price of one stainless steel nail would be $78 in current United States dollars. Conclusions: Our results indicate that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. Comment: Journal Club 17/6/08 Interesting comparison in a clinical setting that seemed valid M. Zlowodzki, R. W. Poolman, G. M. Kerkhoffs, P. Tornetta 3rd, M. Bhandari and
International Evidence-Based Orthopedic Surgery Working Group. How to interpret
a meta-analysis and judge its value as a guide for clinical practice Acta Orthop. 2007
Oct 78 5 (598-609)
The purpose of this article is to educate the reader about how to interpret a meta-
analysis. We explain important aspects of conducting a meta-analysis as described in
the guidelines for the reporting of meta-analyses of randomized controlled trials
(QUOROM). An understanding of the basic terminology and concepts of a meta-
analysis can help readers to evaluate the quality of a meta-analysis and to assess the
potential relevance of its results for an individual patient.
Comment: Journal Club 17/6/08 Third paper in EBM series by this group
September 2008
Classic: T. Widhe. Foot deformities at birth: a longitudinal prospective study over a 16-
year period J.Pediatr.Orthop. 1997 Jan-Feb 17 1 (20-24)
In a prospective study of 2,401 newborns, the incidence of foot deformities was 4%, of
which three fourths were various forms of adductus anomalies. At age 16 years, the
children with a foot deformity and a random sample of those with normal feet as
newborns were examined by dynamic foot pressure (EMED) and gait analysis (Vifor).
The natural course of all congenital foot deformities, except clubfoot, was favorable. The
importance of monitoring the children during the entire growth period is shown by the
fact that at age 6 years, 87%, and at 16 years, 95% of the adductus deformities had
resolved.
Comment: Journal Club 30/9/08
F. Chotel, P. Braillon, F. Sailhan, et al. Bone stiffness in children: part II. Objectives
criteria for children to assess healing during leg lengthening J.Pediatr.Orthop. 2008 Jul-
Aug 28 5 (538-543)
BACKGROUND: The decision when to remove the frame after limb lengthening through
standard distraction osteogenesis remains a challenge. Multiple studies have attempted
to find objective criteria to assess bone healing after fracture or bone lengthening.
However, there is a paucity of such data for the pediatric population. The purpose of this
study was to correlate data obtained after dual-energy x-ray absorptiometry (DXA)
measurement and bending stiffness in children to find an end-point value for the safe
removal of an external fixation device. METHODS: We investigated 16 consecutive
children aged between 5.5 and 16.7 years who had 22 lengthenings by callotasis.
Twelve femurs and 10 tibiae were lengthened with a monoplane Orthofix external
fixator. Fifty simultaneous measurements of bending bone stiffness measured with an
Orthometer and DXA scans (bone mineral content [BMC], bone mineral density,
volumetric bone mineral density, BMC/1 cm, Area/1 cm, BMC/1 cm, Area) were
obtained during healing process. Four femoral fractures were reported after the removal
of the external fixation device. Linear regression analysis was used to calculate the
squared correlation coefficients for the relation between the DXA scans and the
mechanical tests measuring bone stiffness. RESULTS: The bone stiffness
measurement of the intact bone was compared with consecutive measurements of the
bone stiffness of the regenerate, and it was expressed as a percentage (coefficient). We
compared the BMC of the regenerate with the same bone area of the opposite limb. The
best correlation was observed for anteroposterior (AP) bone stiffness coefficient and
BMC coefficient (R = 0.82). The linear equation was BMC coefficient = 0.5 x AP
stiffness coefficient + 30. The end point of 75% of BMC of the regenerate corresponds
to 75% of the AP stiffness on DXA scanning; this is the time when we should consider
safe removal of the fixator. CONCLUSIONS: Our method of comparing bone stiffness
and DXA measurements gives an objective healing end point for every patient
irrespective of his or her size. This method could allow noninvasive measurement of the
end point and identified at-risk population of children, reducing regenerate fracture after
bone lengthening.
Comment: Journal Club 30/9/08
V. De Brauwer and P. Moens. Temporary hemiepiphysiodesis for idiopathic genua
valga in adolescents: percutaneous transphyseal screws (PETS) versus stapling
J.Pediatr.Orthop. 2008 Jul-Aug 28 5 (549-554)
BACKGROUND: Genua valga are not merely a cosmetic problem but also predispose
to gonarthrosis in adult life. In our retrospective study of 25 patients, we reviewed our
present technique of medial hemiepiphysiodesis using percutaneous screws and
compared it with our own results of stapling. METHODS: Clinical evaluation was
performed by estimation of the intermalleolar distance, radiological assessment by
measuring the hip-knee-ankle angle until skeletal maturity. Average chronological age
at the time of surgery was 14.5 years for boys and 12.7 years for girls. Average bone
age (main indicator for timing of surgery) was 14.3 years for boys and 12.8 years for
girls. RESULTS: There is an average rebound phenomenon after removal of the screws
of 2 degrees in one third of our patients. In another third of our patients' population,
however, we observed a progression of correction of an average of 2 degrees. More
than 90% of the patients were satisfied. None received revision surgery. There was only one person with an uncosmetic scar. CONCLUSIONS: Percutaneous screws as treatment of idiopathic genua valga in children seem to be as safe and reliable as stapling but are a less invasive and a more cosmetic treatment. Comment: Journal Club 30/9/08 L. M. Dijksman, R. W. Poolman, M. Bhandari, R. Goeree, J. E. Tarride and
International Evidence-Based Orthopaedic Surgery Working Group. Money
matters: what to look for in an economic analysis Acta Orthop. 2008 Feb 79 1 (1-11)
Surgeons have the difficult task of deciding which treatment or procedure is best for
their patients, while considering the expenses in their department. Increasing costs of
healthcare, decreasing health resources, an aging population, and an increased rate of
diffusion of new technologies are forcing them to provide cost-efficient, high-quality
care. Economic evaluations can be a useful tool to help them provide “value for money”,
and to help in deciding which new surgical procedures should be implemented.
Comment: Journal Club 30/9/08
R. T. Freeman, A. M. Wainwright, T. N. Theologis and M. K. Benson. The outcome
of patients with hinge abduction in severe Perthes disease treated by shelf
acetabuloplasty J.Pediatr.Orthop. 2008 Sep 28 6 (619-625)
BACKGROUND: The management of patients with Perthes disease remains
controversial. In children with hinge abduction and the potential for remodeling, we have
performed a shelf acetabuloplasty, in an effort to contain the hip and allow remodeling.
We report our medium-term results in a consecutive series of 27 children with severe
Perthes disease and arthrographically proven hinge abduction. This is the first report in
the English literature to look specifically at the results of treating patients with hinge
abduction in severe Perthes disease by shelf acetabuloplasty. METHODS: Twenty-
seven consecutive children with unilateral Perthes disease and arthrographically proven
hinge abduction were treated with a shelf acetabuloplasty. These patients have been
prospectively reviewed with a clinical examination and radiographic assessment
including Catterall, Salter Thompson, and Herring's lateral pillar classification.
Radiological measurements included percentage acetabular cover, medial joint space,
and femoral head size ratio. RESULTS: The mean postoperative follow-up was 62
months (range, 26-125 months). All patients were Catterall grade III or IV and lateral
pillar grade B or C and had arthrographically proven hinge abduction at the time of
surgery. At final follow-up, 14 hips were Stulberg grades 1 and 2; 10 hips, grade 3; and
3 hips, grades 4 and 5. The medial joint space decreased from a preoperative ratio of
1.9 to 1.4 (P = 0.002), and the percentage acetabular cover increased from 81%
preoperatively to 97% postoperatively (P < 0.001). CONCLUSION: These results
suggest overall good outcomes from a group of patients with severe Perthes disease as
measured by the Stulberg grading when compared with historical controls. We suggest
that shelf acetabuloplasty is a straight forward surgical procedure with good medium-
term results in patients with severe Perthes disease who have proven hinge abduction
preoperatively. LEVEL OF EVIDENCE: Level IV case series.
Comment: Journal Club 30/9/08
J. Kessler. A new flexible brace used in the Ponseti treatment of talipes
equinovarus.J.Pediatr.Orthop.B 2008 17 5 (247-250)
The objective was to introduce a flexible brace abduction brace in the Ponseti treatment
of clubfeet. Eight patients undergoing Ponseti treatment for talipes equinovarus were
assessed. Brace compliance and incidence of relapses were assessed. Patients first
used rigid abduction braces, but because of brace noncompliance were switched to a
new flexible brace. Seven of 11 feet with compliance issues in a rigid brace had
improved compliance when switching to the flexible brace. All seven feet with initial
deformity relapse are deformity-free after switching to flexible bracing. This new flexible
clubfoot brace may improve compliance in Ponseti clubfoot treatment.
Comment: Journal Club 30/9/08
December 2008
Classic: Enneking WF, Spanier SS, Goodman MA. Current concepts review. The
surgical staging of musculoskeletal sarcoma. J Bone Joint Surg Am 1980;
Sep;62(6):1027-30.
The concept of staging malignant tumors arose in response to the need for meaningful
assessment of various methods of treatment in end-result studies. Its purpose was to
ensure that lesions of comparable prognostic import were used to evaluate methods of
management, so that one form of treatment was not inadvertently biased by inclusion of
a preponderance of favorable lesions while another method was adversely weighted on
the basis of lesions with unfavorable predictors. The system proposed here clearly
stages lesions ac cording to risk to the patients, facilitates surgical planning, and is
relevant to analysis of end results. It currently forms the basis of ongoing inter-
institutional investigations that are being conducted by the Musculoskeletal Tumor
Society.
Journal Club 9/12/08
Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of
skeletal fractures in child abuse: systematic review. BMJ 2008; Oct 2;337:a1518.
OBJECTIVES: To systematically review published studies to identify the characteristics
that distinguish fractures in children resulting from abuse and those not resulting from
abuse, and to calculate a probability of abuse for individual fracture types. DESIGN:
Systematic review. DATA SOURCES: All language literature search of Medline, Medline
in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences
Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online
for original study articles, references, textbooks, and conference abstracts until May
2007. STUDY SELECTION: Comparative studies of fracture at different bony sites,
sustained in physical abuse and from other causes in children <18 years old were
included. Review articles, expert opinion, postmortem studies, and studies in adults
were excluded. Data extraction and synthesis Each study had two independent reviews
(three if disputed) by specialist reviewers including paediatricians, paediatric
radiologists, orthopaedic surgeons, and named nurses in child protection. Each study
was critically appraised by using data extraction sheets, critical appraisal forms, and
evidence sheets based on NHS Centre for Reviews and Dissemination guidance. Meta-
analysis was done where possible. A random effects model was fitted to account for the
heterogeneity between studies. RESULTS: In total, 32 studies were included. Fractures
resulting from abuse were recorded throughout the skeletal system, most commonly in
infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more
common in cases of abuse. Once major trauma was excluded, rib fractures had the
highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The
probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54
(0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type
showed that supracondylar humeral fractures were less likely to be inflicted. For femoral
fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54),
depending on the definition of abuse used, and the developmental stage of the child
was an important discriminator. The probability for skull fractures was 0.30 (0.19 to
0.46); the most common fractures in abuse and non-abuse were linear fractures.
Insufficient comparative studies were available to allow calculation of a probability of
abuse for other fracture types. CONCLUSION: When infants and toddlers present with a
fracture in the absence of a confirmed cause, physical abuse should be considered as a
potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive
cause. During the assessment of individual fractures, the site, fracture type, and
developmental stage of the child can help to determine the likelihood of abuse. The
number of high quality comparative research studies in this field is limited, and further
prospective epidemiology is indicated.
Journal Club 9/12/08 Excellent example of a systematic review.
Menon MR, Walker JL, Court-Brown CM. The epidemiology of fractures in
adolescents with reference to social deprivation. J Bone Joint Surg Br 2008;
Nov;90(11):1482-6.
A relationship between social deprivation and the incidence of fracture in adolescents
has not previously been shown. We have used a complete fracture database to identify
adolescents who sustained fractures in 2000. The 2001 Scottish census was used to
obtain age-specific population and deprivation data according to the Carstairs score.
Regression analysis determined the relationship between the incidence of fractures and
social deprivation. We analysed 1574 adolescents with fractures (1083 male, 491
female). The incidence of fractures in this group was 21.8 per thousand (31.0 male,
13.1 female). Social deprivation predicted the incidence in adolescent males and
females. The incidence of fractures of the proximal upper limb and distal radius in
females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20
years of age were more likely to sustain fractures of the hand and carpus if they lived in
economically depressed neighbourhoods.
Journal Club 9/12/08
Murase T, Oka K, Moritomo H, Goto A, Yoshikawa H, Sugamoto K. Three-
dimensional corrective osteotomy of malunited fractures of the upper extremity with use
of a computer simulation system. J Bone Joint Surg Am 2008; Nov;90(11):2375-89.
BACKGROUND: Three-dimensional anatomical correction is desirable for the treatment
of a long-bone deformity of the upper extremity. We developed an original system,
including a three-dimensional computer simulation program and a custom-made
surgical device designed on the basis of simulation, to achieve accurate results. In this
study, we investigated the clinical application of this system using a corrective
osteotomy of malunited fractures of the upper extremity. METHODS: Twenty-two
patients with a long-bone deformity of the upper extremity (four with a cubitus varus
deformity, ten with a malunited forearm fracture, and eight with a malunited distal radial
fracture) participated in this study. Three-dimensional computer models of the affected
and contralateral, normal bones were constructed with use of data from computed
tomography, and a deformity correction was simulated. A custom-made osteotomy
template was designed and manufactured to reproduce the preoperative simulation
during the actual surgery. When we performed the surgery, we placed the template on
the bone surface, cut the bone through a slit on the template, and corrected the
deformity as preoperatively simulated; this was followed by internal fixation. All patients
underwent radiographic and clinical evaluations before surgery and at the time of the
most recent follow-up. RESULTS: A corrective osteotomy was achieved as simulated in
all patients. Osseous union occurred in all patients within six months. Regarding cubitus
varus deformity, the humerus-elbow-wrist angle and the anterior tilt of the distal part of
the humerus were an average of 2 degrees and 28 degrees, respectively, after surgery.
Radiographically, the preoperative angular deformities were nearly nonexistent after
surgery. All radiographic parameters for malunited distal radial fractures were
normalized. The range of forearm rotation in patients with forearm malunion and the
range of wrist flexion-extension in patients with a malunited distal radial fracture
improved after surgery. CONCLUSIONS: Corrective osteotomy for a malunited fracture
of the upper extremity with use of computer simulation and a custom-designed
osteotomy template can accurately correct the deformity and improve the clinical
outcome.
Journal Club 9/12/08 Elegant technology, simpler methods may be equivalent e.g see
Price & Knapp JPO 2006 26(2) pp 193 on Osteotomy for malunited forearm shaft
fractures in children.
Raney EM, Freccero DM, Dolan LA, Lighter DE, Fillman RR, Chambers HG.
Evidence-based analysis of removal of orthopaedic implants in the pediatric population.
J Pediatr Orthop 2008; Oct-Nov;28(7):701-4.
BACKGROUND: Requested project of the Pediatric Orthopaedic Society of North
America Evidenced-Based Medicine Committee. METHODS: The English literature was
systematically reviewed for scientific evidence supporting or disputing the common
practice of elective removal of implants in children. RESULTS: Several case series
reported implant removal, but none contained a control group with retained implants. No
articles reported long-term outcomes of retained implants in large numbers. Several
small series describe complications associated with retained implants without evidence
of causation. The existing literature was not amenable to a meta-analysis. By compiling
data from the literature, it is possible to calculate a complication rate of 10% for implant
removal surgery. The complication rate for removal of implants placed for slipped capital
femoral epiphysis is 34%. Articles regarding postmarket implant surveillance and basic
science were also reviewed. CONCLUSIONS: There is no evidence in the current
literature to support or refute the practice of routine implant removal in children.
Journal Club 9/12/08 Not a good example of a Systematic review see Acta
Orthopaedica 2007;78(5):59 & contrast with methods used for BMJ 2008;337:a1518
Richards BS, Faulks S, Rathjen KE, Karol LA, Johnston CE, Jones SA. A
comparison of two nonoperative methods of idiopathic clubfoot correction: the Ponseti
method and the French functional (physiotherapy) method. J Bone Joint Surg Am 2008;
Nov;90(11):2313-21.
BACKGROUND: In the treatment of idiopathic clubfeet, the Ponseti method and the
French functional method have been successful in reducing the need for surgery. The
purpose of this prospective study was to compare the results of these two methods at
one institution. METHODS: Patients under three months of age with previously
untreated idiopathic clubfeet were enrolled. All feet were rated for severity prior to
treatment. After both techniques had been described to them, the parents selected the
treatment method. Outcomes at a minimum of two years were classified as good (a
plantigrade foot with, or without, a heel-cord tenotomy), fair (a plantigrade foot that had
or needed to have limited posterior release or tibialis anterior transfer), or poor (a need
for a complete posteromedial surgical release). Two hundred and sixty-seven feet in
176 patients treated with the Ponseti method and 119 feet in eighty patients treated with
the French functional method met the inclusion criteria. RESULTS: The patients were
followed for an average of 4.3 years. Both groups had similar severity scores before
treatment. The initial correction rates were 94.4% for the Ponseti method and 95% for
the French functional method. Relapses occurred in 37% of the feet that had initially
been successfully treated with the Ponseti method. One-third of the relapsed feet were
salvaged with further nonoperative treatment, but the remainder required operative
intervention. Relapses occurred in 29% of the feet that had been successfully treated
with the French functional method, and all required operative intervention. At the time of
the latest follow-up, the outcomes for the feet treated with the Ponseti method were
good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the
French functional method were good for 67%, fair for 17%, and poor for 16%.
CONCLUSIONS: Nonoperative correction of an idiopathic clubfoot deformity can be
maintained over time in most patients. Although there was a trend showing improved
results with use of the Ponseti method, the difference was not significant. In our
experience, parents select the Ponseti method twice as often as they select the French
functional method.
Journal Club 9/12/08 Good comparison of non-operative methods not done by
originators and similar results, authors recognise that would have been better if
randomised.

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