Search

Unlabelled: The Ponseti technique for treating clubfoot has been popularized for idiopathic clubfoot and more recently several syndromic causes of clubfoot. We asked whether it could be used to treat recurrent clubfoot following failed posteromedial release. We retrospectively reviewed 58 children (83 clubfeet) treated by the Ponseti technique for recurrent deformity after posteromedial release in three centers. The minimum followup was 24 months (average, 45 months; range, 24-80 months). We determined initial and final Pirani scores and range of motion of the ankle and subtalar joint. Plantigrade and fully corrected feet were obtained in 71 feet (86%); 11 feet obtained partial correction; one patient failed treatment and underwent another posteromedial release. Recurrences occurred in nine patients (12 feet or 14%). Initial Pirani scores improved in all but one patient; severity of deformity was also inferred by number of casts used for treatment. The age at treatment and numbers of casts did not influence the scores of Pirani et al. The scores were similar among the three orthopaedic surgeons.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The objective of this study was to analyze the treatment of recurrent valgus knee in fibular hemimelia patients with hemiepiphysiodesis and define associated variables for deformity relapse. Sixteen consecutive patients with fibular hemimelia treated with hemiepiphysiodesis (57 physis) were compared to 21 physis of idiopathic cases, in terms of magnitude, speed, and time of correction. Correction of valgus deformity was successfully achieved in all cases. In the fibular hemimelia group, children 4 years and younger had a bigger magnitude of correction than older ones (11° versus 6.9°) and greater speed (1° versus 0.6°), with statistical significance (P = 0.018 and P = 0.009, respectively), while time for correction was similar among these groups (11.6 months versus 12.3 months). Femoral distal physis corrected faster than proximal tibial physis (10.8 months versus 16.8 months), with statistical significance (P = 0.032). Thirty-three physis (57.9%) were isolated and 24 (42.1%) were tibia and femur. We found no statistical difference between the two groups regarding time for correction, magnitude, or speed (P = 0.526, P = 0.910, P = 0.803, respectively). Relapse was observed in 49 physis (86%) of the fibular hemimelia patients. These had a mean age of 5.5 years versus 3.9 years for those without a relapse, with statistical significance (P = 0.204). Relapse occurred after 2 years of the first procedure. Recurrent valgus deformity in fibular hemimelia can be successfully treated with single or multiple hemiepiphysiodesis with tension band plates in skeletally immature patients in an effective and gradual manner. Level of Evidence: Level III, therapeutic study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

In myelomeningocele children, the incidence of equinocavovarus feet, considering all foot deformities, is 25-36%. Treatment options consist of extensive surgeries resulting in rigid feet with better alignment. Ponseti method expanded its indications since the early 2000s, including myelodysplastic feet. However, the literature on success, recurrence, and complication rates remains sparse. Therefore, a systematic review was performed in Pubmed, Scopus, Embase, Lilacs, and Web of Science databases on October 28, 2020 and July 11, 2023. Normality and sample proportion analysis with 95% confidence intervals were estimated. Risks of bias and the quality of studies were also evaluated. Success, recurrence, and complication rates were evaluated and analyzed. Eight case series were identified with 101 patients (176 feet). According to this model, the initial success rate was 93% (95% CI = 0.88-0.96) with I2 = 0%, and the final success was 63% (at 4.9 years of follow-up). Recurrence rate was 62% (95% CI = 50-72), and complication rate was 29% (95% CI = 22-38). Ponseti method for myelodysplastic clubfoot is effective (93% of initial correction). However, there are high complication and recurrence rates, and longer follow-up is needed to identify recurrences and urge for early intervention. Foot abduction brace should be used to avoid recurrences., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ferreira dos Santos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: This study shows the danger zone and the safety corridor in the lateral approach with bridge plating by measuring the distance between the lateral side of the plate positioned on the lateral aspect of the humerus and the radial nerve after it pierces the lateral intermuscular septum, in the different forearm positions., Methods: Forty arms of 20 human cadavers were used, the radial nerve was identified and marked on the lateral surface the radial nerve at the exit of the lateral intermuscular septum and anteriorisation of the nerve in relation to the humeral shaft and the lateral epicondyle was also marked. The distances were measured with a digital caliper. A submuscular extraperiosteal corridor was created, proximally between the biceps brachialis and deltoid muscle and distally between the triceps and brachioradialis muscle, followed by the positioning of the low contact large fragments contoured plate with 14 combined holes (fixed and cortical angle), inserted from distal to proximal. Measurements were performed in four positions (elbow flexion with forearm pronation, elbow flexion with forearm supination, elbow extension with forearm pronation and elbow extension with forearm supination)., Results: Significant statistical differences occurred with the different positions, and the elbow flexion with forearm supination was shown to be the position that provides the safest submuscular extraperiosteal corridor in a lateral approach of the humerus., Conclusion: The danger zone of radial nerve is an area that extends from 15 cm to 5 cm proximal to the lateral epicondyle and the safest way to create a submuscular and extraperiosteal corridor in the lateral region of the humerus is with the elbow in flexion and the forearm in supination., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objective: To evaluate patients with arthrogryposis submitted to extensive surgical treatment with a minimum of 10 years of follow-up regarding the clinical and radiological aspects and the quality of life, using the 36-Item Short Form (SF-36) and the Disease-Specific Instrument (DSI)., Methods: A retrospective study selected 33 patients, totaling 64 operated feet., Results: The mean age of the patients was 17.9 years (12-39 years), and the mean follow-up time was 14.8 years (11-17). Amyoplasia represented 78.7% of syndromic diagnoses. Isolated posteromedial lateral release (PMLR) was performed in 21.8% of the feet, 27.2% of which required additional bone surgery, and about 50 feet (78.1%) were submitted to PMLR, lateral column shortening, and/or talectomy. In total, 46 talectomies were performed (71.8% of the feet), out of which 44 were the first procedure of choice. SF-36 questionnaire was evaluated and showed that 93.9% of the patients did not have restrictive and disabling pain, and the same percentage considered themselves as healthy and had good expectations for the future., Conclusion: Arthrogrypotic feet are difficult to treat, require many recurrent surgical procedures, and relapses are the rule. Stiffness is a common feature of these feet, and residual deformities were frequent. Level of Evidence IV; Case Series, Therapeutic Studies. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: Evaluate whether the experience of the surgeon could reduce Ponseti treatment time, and a number of cast changes, and the evolution of the Pirani Score., Methods: 2 reference centers were evaluated. At Institution 1, 254 patients with idiopathic clubfoot (403 feet) were included, and at Institution 2, 32 patients (51 feet). At institution 1 (mentor), 3 intervals of 5 years each were analyzed. At the Institution 2 (trainee), 1 interval of 5 years was analyzed., Results: Patients treated by the mentor had fewer casts compared with the trainee (p < 0.001). At Institution 1, the three mentor intervals showed differences in the number of casts (p < 0.05). A statistically significant difference was observed only in the first mentor interval (2000 to 2005, average of 3.47 casts) compared with the 2 other intervals (2005 to 2010; average of 2.6 casts and 2011 to 2015; average of 2.79 casts; p < 0.0001). Pirani score decreases the most until the third clinic visit., Conclusion: The mentor's greater expertise was associated with fewer casts and shorter time to obtain correction in isolated clubfoot, especially right after the first 5 years of practice. Progression of the Pirani score in both institutions occurs between the first and the third casts. Level of Evidence III; Therapeutic Study, Retrospective Comparative Study ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Purpose: To evaluate and compare the results of surgical treatment for irreparable rotator cuff tear (IRCT) by the mini-open interposition procedure using fascia lata autograft against outcomes of the arthroscopic partial repair technique., Methods: An interventional, prospective, controlled, randomized, single-blinded study involving 2 study groups was conducted. The graft group (n = 20) underwent the mini-open interposition procedure using fascia lata autograft. The control group (n = 22) underwent arthroscopic partial repair. Patients were evaluated using the University of California Los Angeles (UCLA) Shoulder scale, the American Shoulder and Elbow Surgeons (ASES) score, the Constant-Murley (Constant) score, the visual analogue scale (VAS) pain score, active range of motion, frontal flexion strength, retear rates evaluated by magnetic resonance imaging analysis, occurrence of complications, and the minimal clinically important difference (MCID)., Results: The graft group had better UCLA (31.5 vs 28.18, P = .035) (100% exceeded the MCID for the graft group and 95% for the control group), ASES (88.62 vs 77.06, P = .016) (100% exceeded the MCID for both groups), Constant (78.85 vs 61.68, P < .001), and VAS (0.95 vs 2.59, P = .01) scores at the 24-month follow-up. For active forward elevation range, both groups showed no statistically significant differences (168.5 vs 164.54, P = .538). The results for active external and internal rotation were better in the graft group (60.25 vs 40, and 9.1 vs 6.9, P < .001), as was frontal flexion strength (4.24 vs 2.67, P = .005). The graft group also had lower retear rates (15% vs 45.5%, P = .033). No complications were reported., Conclusions: Outcomes of surgeries for IRCT by the mini-open interposition procedure using fascia lata autograft and by the arthroscopic partial repair technique showed good results in both groups over time and exceeded the MCID. However, most comparative outcomes between groups showed better results for the interposition procedure., Level of Evidence: Level I, randomized controlled trial., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Congenital femoral deficiency (CFD) is a challenging and complex condition that causes limb lengthening. We focused on the clinical and radiographic results of SUPERhip procedures in patients with congenital femoral deficiency type 1b, according to Paley's classification, prior to femoral lengthening., Methods: We reviewed all records and radiographs of patients who underwent this procedure between 2005 and 2020. We included 26 patients, with clinical and radiographic assessments performed during pre- and post-operative evaluations., Results: There were twenty-six patients (15 right vs. 11 left), with a mean age of 7 years (1-18). Most of the patients were female (17 patients; 65.4%). Twenty (76.9%) patients were undergoing their first procedure and six (23.1%) had already undergone a previous surgery. There was a significant improvement in all radiographic parameters, with the mean preoperative and postoperative Neck-Shaft Angle (NSA) being 72.3 ± 7.1° vs. 133.1 ± 12.7°, the Center-Edge Angle (CEA) 16.8 ± 9.8° vs. 33.5 ± 14.1°, and the Acetabular Index (AI) 27.8 ± 6.9° vs. 16.4 ± 6.8°, respectively. The complication rate was 15.4%, predominantly affecting patients under 5 years old., Conclusions: The SUPERhip procedure is an effective and reproducible technique for clinical and radiographic correction to a significant degree in patients with Paley's type 1b CFD, in preparation for bone lengthening surgery.

Purpose: The aim of this systematic review was to address the Ponseti method in arthrogrypotic clubfoot treatment and evaluate the success, complication, and recurrence rates., Method: A systematic review was performed in the PubMed, Scopus, Embase, and Web of Science databases on 9 January 2023, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Success, recurrence, and complication rates were evaluated and analyzed. Risks of bias and the quality of the studies were also evaluated., Results: Five case series, including 53 patients (102 feet), were identified. According to this model, the initial success rate was 91% (95% confidence interval = 0.79-0.96) with I 2  = 43%, and the final success was 68% (at 5.8 years of follow-up). Recurrence rate was 30% (95% confidence interval = 0.14-0.52)., Conclusion: Ponseti method is indicated in the initial treatment of arthrogrypotic clubfeet, as it is a minimally invasive method with a high correction rate (91%). However, a high recurrence rate (30%) requires early detection and adequate treatment., Level of Evidence: Level III., Prospero Protocol: CRD42020210373., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: The Ponseti method of treatment for clubfoot which utilizes serial manipulations and casting in order to achieve correction of the deformity has become increasingly popular due to its robust track record of success without the need for surgical intervention and is considered the gold standard for clubfoot treatment. Exposure of new technology in the scientific literature is associated with the diffusion and adoption of that technology in clinical practice. The aim of this study sought to identify tendencies in the thematic changes in medical literature regarding the treatment of congenital clubfoot over a period of twenty-three years, from 1997 to 2021., Methods: The Medline databases were searched for articles containing the keyword "clubfoot". Articles from 1997 to 2021 were identified and analyzed by institutions which published the articles, and whether treatment was with the Ponseti method or surgical interventions. We also observed in order the geographic diffusion of the Ponseti method., Results: 2067 articles were found in Pubmed referencing clubfoot, and in these publications 577 addressed the Ponseti method and 273 articles discussed surgical treatment. From 1997 - 2000, the only articles discussing the Ponseti Method were from Iowa,in the United States. The increasing number of publications about the Ponseti method and the decrease in publications about surgical treatment for clubfoot occurred after 2003. In 1997, only one country had a publication regarding the Ponseti method; by 2018, 24 countries published articles on the method., Conclusion: These results suggest a trend of dissemination of knowledge to additional countries, reflecting the more widespread usage of the method throughout the world, and global outreach as a result of the work of Ponseti International Association. Level of Evidence: II ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2023.)

Purpose: Evaluate the functional health status and quality of life of patients diagnosed with Müller-Weiss disease and, secondarily, determine the influence of factors such as gender, social status, race, body mass index, and surgical and non-surgical treatment in patient outcome., Methods: This study included 30 affected feet (18 patients) with follow-up from 2002 to 2016. Five patients were excluded from reassessment, resulting in 20 feet (13 patients). Questionnaires for functional and quality of life assessments were administered, and statistical analysis was performed., Results: Patients with obesity had poor functional results and low quality of life rates. Regarding quality of life, mainly in the mental health domain, there was a significant difference (p < 0.001) that was not observed in other domains investigated, except for surgical treatment, which was superior to non-surgical treatment in terms of the physical domain (p = 0.024). Bilateral treatment was also superior to unilateral treatment in Coughlin's classification (71.4% versus 66.7%)., Conclusions: Müller-Weiss disease evolved with poor functional results and low quality of life rates in patients with obesity, with no method of treatment influence on patient outcome, except for the SF-12 physical domain, where surgical treatment showed better results than conservative treatment., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: This study investigated the incidence of AVN in patients with cerebral palsy who underwent a hip reconstruction surgery (soft tissue release, femur and pelvic osteotomies) and its impact on quality of life., Methods: Retrospective study, with clinical and radiographic analysis of 104 patients (128 hips) GMFCS IV and V with a minimum two year follow-up. Reimers migration percentage, the amount of abduction, acetabular index, and the neck-shaft angle were collected before and after surgery. Modified Tönnis classification was used to analyze the hips before surgery, and the Bucholz and Ogden classification was used to identify hips with AVN. Function and quality of life were investigated with the CPCHILD questionnaire after surgery., Results: The mean age of participants at surgery was 120.1 months (72-184), and it was not related with AVN (p = 0.946). AVN signs were observed in 62 hips (48.5%). The mean pre-op Reimers value was 68.7% (16-100) in normal hips and 83.1% (0-100) in hips with AVN (p = 0.003). All hips considered as Tönnis IV before surgery developed AVN (p = 0.006). The amount of abduction did not differ between hips that developed AVN and those that did not (p = 0.313). Patients who developed AVN had lower scores of quality of life (p = 0.023) and comfort (p = 0.025) according to the CPCHILD questionnaire., Conclusion: We observed a relationship between the greater pre-operative severity according to the Reimers index and the modified Tonnis classification and the development of AVN., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: This study aims to investigate the clinical-functional results of a new surgical technique, Percutaneous Endoscopic Lumbar Interbody Fusion (PELIF), in patients with a clinical diagnosis of low back or sciatic pain and segmental instability who were submitted to surgery using this technique assisted by the attending physician., Materials and Methods: Patients completed a consent form and were clinically and radiographically re-assessed by independent evaluators using the visual analog scale (VAS) for pain, the Oswestry Disability Index (ODI), and the SF-36 Quality of Life Score in the pre- and postoperative periods. Their medical records were also reviewed for surgical time, length of hospital stay, need for blood transfusion, return to work, and radiographic fusion evaluation., Results: In the group of 19 patients with 33 levels operated, VAS and ODI decreased from 10.0 and 64% to 2.0 and 28%, respectively. The SF-36 showed significantly higher scores in 5 of its 7 domains at the end of the follow-up as compared to the preoperative period scores. Only 1 case of pseudoarthrosis was diagnosed radiographically., Conclusions: Percutaneous Endoscopic Lumbar Interbody Fusion (PELIF) has been shown to be a safe and efficient technique for the treatment of patients with segmental instability associated with low back or sciatic pain. Level of Evidence VI; Therapeutic Study; Case Series., Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: Insufficiency fractures occur in bones with low elastic resistance. In contrast to stress fractures, which affect normal bones and have been extensively studied, insufficiency fractures of the foot and ankle have been the subject of little research. The objective of this study was to identify risk factors associated with the development of foot and ankle insufficiency fractures., Methods: The study included 55 postmenopausal sedentary women with foot and ankle insufficiency fractures and 51 women in the control group. The data collected were the fracture site, body mass index, use of corticosteroids, T scores of the femur and lumbar spine measured by bone densitometry, and serum 25-OH vitamin D level. The calcaneal pitch (CP), talar-first metatarsal, and metatarsus adductus (MA) angles were measured on radiographs., Results: In 49 patients (89%), fractures occurred in the metatarsals. All metatarsals were affected, and the most common fracture site was the base of the fifth metatarsal, with 21 cases (33%). Twenty patients (36%) in the study group reported chronic use of corticosteroids and had lower bone mineral density levels than controls ( P < .05). The factors associated with fracture development ( P < .05) were the CP and MA angles and low lumbar bone mineral density., Conclusion: Insufficiency fractures in this population were associated with low bone mineral density and unfavorable biomechanical characteristics such as pes cavus and metatarsus adductus., Level of Evidence: Level IIIB, case-control study.

Objective: To analyze the profiles of the individuals who access the website regarding congenital clubfoot (CC) information and the first ten years of Ponseti method implementation in Brazil., Methods: This is a retrospective documentary study, with quantitative database analysis, from 2002 to 2012. Parents or caregivers completed a semi-structured questionnaire regarding the main difficulties encountered, the search for different professionals in the area, and what were the main questions the reader might have when searching on a technical website., Results: In total, 94% of participants had a family member or acquaintance with CC, most participants were women (74%), higher education level (40%), married (75%), income above one minimum wage (80%), working in administrative positions (21%,) and living in the urban area (99%). Of the participants, 44% sought three or more physicians at the beginning of treatment, and an average of 77% of the participants used health insurance or a private physician., Conclusion: The participants' profile regarding CC is composed of women, married, living in urban areas, predominantly from Southeastern Brazil, higher education level, with income above 1.5 minimum wages, and who were treating their children with a private physician. Level of Evidence II, Retrospective study., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: To identify the main challenges of the family of a child with meningomyelocele (MMC) and correlate the Zarit Burden Interview (ZBI) scale with the World Health Organization Quality of Life-BREF (WHOQOL - BREF)., Methods: Questionnaires were sent through an online platform to groups of parents and caregivers of children with MMC. Four WHOQOL-BREF domains were evaluated: physical, psychological, social and environmental., Results: All correlations among the domains of the WHOQOL-BREF questionnaire with the Zarit Burden Interview (ZBI) scale were negative and significant with a higher magnitude value for ZBI × psychological domain with - 57.4% correlation (p < 0.001)., Conclusion: The results of this study suggest the quality of life of mothers and caregivers of children with meningomyelocele is affected regarding functional capacity, emotional aspect, and mental health. Despite this, the participants present a positive view of their lives. The most common difficulties faced by caregivers were: performing bladder catheterization, providing general care, financial burden, and accessibility. Level of Evidence V, Expert opinion., Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: Complex clubfoot is a term used to describe those feet that present after treatment with a short first metatarsal, severe plantar flexion of all metatarsals, rigid equinus, and deep folds through the sole of the foot and above the heel. Ponseti has described a modification of his original technique for the treatment of the deformity. Few series have reported the treatment outcomes of this group of patients. The purpose of this study is to analyze mid-term results and complications of a large multicenter cohort., Methods: Patients with complex clubfoot treated at 6 tertiary-care institutions with a minimum of 1-year follow-up were retrospectively analyzed. Demographic data, previous treatment, number of casts, Achilles tenotomy, recurrences, complications, and additional procedures were documented. The patients were clinically evaluated at the time of presentation, after treatment, and at the last follow-up according to the Pirani score. All variables had a nonparametric distribution and are thus described as median (interquartile range (IQR), minimum-maximum). A comparison between the variables was performed using a Mann-Whitney U test, the change within each group was performed with a Wilcoxon-designated range test. A P-value <0.05 was used to indicate statistical significance., Results: One hundred twenty-four feet (79 patients) were evaluated. The median age at initial treatment was 7 months (IQR, 15; min-max, 1 to 53 mo). The mean follow-up was 49 months (IQR, 42; min-max, 12 to 132 mo). A median of 5 casts (IQR, 5; min-max, 3 to 13) was required for correction. Percutaneous tenotomy of the Achilles tendon was performed in 96% of the feet. One hundred twenty-two feet (98%) were initially corrected; 2 feet could not be corrected and required a posteromedial release. The Pirani score improved significantly from a pretreatment mean of 6 points (IQR, 1; min-max, 4.5 to 6) to 0.5 (IQR, 0.5; min-max, 0 to 2.5) at the last follow-up (P <0.001). Seven feet (6%) presented minor complications related to casting. Relapses occurred in 29.8% (37/124). In this subgroup, the number of casts required at initial treatment was higher (6; IQR, 5; min-max, 1 to 12 vs. 4 IQR, 4; min-max, 1 to 13; P<0.001), and follow-up was significantly longer (62 mo; IQR, 58; min-max, 28 to 132 vs. 37 mo; IQR, 48, min-max, 7 to 115; P<0.001)., Conclusions: Ponseti method is safe and effective for the correction of complex clubfeet. Early diagnosis and strict adherence to the Ponseti principles are key to achieve deformity correction. Patients with complex clubfoot require frequent follow-up because of a higher recurrence rate., Level of Evidence: Level III-therapeutic study.

Objective: Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years., Results: Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance., Conclusion: The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age. Level of Evidence: IV ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2020.)

Background: In this article, we report the outcomes of patients with deep venous thrombosis in the lower limbs treated with the oral anticoagulant rivaroxaban or warfarin, focusing on the recanalization rate (measured with duplex ultrasound) and the incidence of postthrombotic syndrome., Methods: This was a prospective, consecutive, randomized, blind cohort study of patients admitted with deep venous thrombosis to the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. The patients were randomized into 2 groups and treated with oral anticoagulation for 6 months: either rivaroxaban (group 1) or warfarin (group 2). The study was registered at clinicaltrials.gov under NCT 02704598., Results: Eighty-eight patients with deep venous thrombosis were admitted to the Vascular Surgery Department and randomized into the 2 groups. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. Four patients were excluded from the study during follow-up because of a diagnosis of ovarian cancer (1 patient), head and neck cancer (1 patient), lung cancer (1 patient), and stomach cancer (1 patient). Therefore, 84 patients were evaluated: 46 patients in group 1 and 38 in group 2. The incidence of postthrombotic syndrome was 17.9% (15 cases) in the total cohort, but was significantly higher in group 2 (11 cases, 28.9%) than in group 1 (4 cases, 8.7%; P < .001; odds ratio, 4.278). The rate of total venous recanalization at 360 days was 40.5% (34 patients) in the total cohort, but was significantly higher in group 1 (35 patients, 76.1%) than in group 2 (5 patients, 13.2%; P < .001). The incidence of partial venous recanalization was 46.4% and was significantly higher in group 2 (28 patients, 73.7%) than in group 1 (11 patients, 23.9%; P = .016). Five patients in the total cohort (6%) showed no venous recanalization, all of them in group 2 (P = .016)., Conclusion: In this study, patients who received oral rivaroxaban displayed a lower incidence of postthrombotic syndrome and a better total vein recanalization rate after 6 and 12 months than patients who received warfarin., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The prevalence of untreated congenital clubfoot among children older than walking age is higher in developing countries due to limited resources for early care after birth. The Ponseti method represents an intervention option for older, untreated children., Methods: A metanalysis was conducted of observational studies selected through a systematic review of articles included in electronic databases (Medline, Scopus, Embase, Lilacs, and the Cochrane Library) until June 2017. A pooling analysis of proportions with 95% confidence intervals (CIs) and a publication bias assessment were performed as routine. Estimates of success, recurrence, and complication rates were weighted and pooled using the random effects model., Results: Twelve studies, including 654 feet diagnosed with congenital clubfoot in children older than walking age (older than 1 year old), were included for analysis. The rate of satisfactory outcomes found via a cluster metanalysis of proportions using the random effects model was 89% (95% CI = 0.82-0.94, p < 0.01), relative to the total analysed. The recurrence rate was 18% (95% CI = 0.14-0.24, p = 0.015), and the rate of casting complications was 7% (95% CI = 0.03-0.15, p = 0.19)., Conclusion: Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The results obtained exhibited considerable heterogeneity., Competing Interests: The authors have declared that no competing interests exist.

Objective: To evaluate the impact of physical activity on the use of the health system and the quality of life in sedentary elderly., Methods: A prospective interventional study was carried out between March 2010 and February 2011 with 100 subjects (60-90 years of age,) divided into active group (AG) and control group (CG). During this period, AG performed physical exercise twice a week in 60-minute sessions and the CG remained sedentary with observation of their activities. Before and after the study, all subjects were clinically evaluated and completed a quality of life questionnaire., Results: Eighty-nine subjects (AG = 44; CG = 45) were analyzed. AG had fewer visits to emergency room (p = 0.0056), hospitalizations (p = 0.0011), length of hospital stay (p = 0.0012) and fewer subsidiary tests (p = 0.0236) compared to the CG. The quality of life score analyzed before and after physical activity increased in AG compared to CG (p < 0.0001) and among subjects in AG (p < 0.0001), with no change in the CG., Conclusion: The intervention of a physical activity program for sedentary elderly can contribute to reduce the use of the health system and improve the quality of life. Level of evidence II, Therapeutics Studies. Prospective comparative study. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: Patients with metastatic bone lesions have a limited life expectancy. These metastatic lesions compromise the proximal femur, and fractures are quite common. The survival of these patients depends on the behavior of the primary tumor. The aim of this study was to evaluate the quality of life of patients with extensive metastatic lesion of the proximal femur with pathological or imminent fracture, treated with non-conventional endoprosthesis., Methods: From May 2008 to August 2012, twenty-five (25) patients with bone metastases of the proximal femur, with pathological or imminent fracture were recruited into this study. These patients had survived for at least six weeks after surgery and the TESS questionnaire (Toronto Extremity Salvage Score) was administered., Results: The final score of the TESS was an average of 57 points (SD 23.78 points). There was no significant difference in TESS values considering: sex, presence of fracture, or site of the bone lesion., Conclusion: The TESS questionnaire provides information about the function and quality of life of patients with malignant tumors of the lower limbs, from the patient's perspective. The results can be considered positive, when compared to the limited life expectancy and complexity of this group of patients. Level of evidence III, Therapeutic studies, retrospective comparative study. , Competing Interests: All authors declare no potential conflict of interest related to this article.

The aim of this study was to develop mucoadhesive pellets on a thiolated pectin base using the extrusion-spheronization technique. Thiolation of pectin was performed by esterification with thioglycolic acid. The molecular weight and thiol group content of the pectins were determined. Pellets containing pectin, microcrystalline cellulose, and ketoprofen were prepared and their mucoadhesive properties were evaluated through a wash-off test using porcine intestinal mucosa. The in vitro ketoprofen release was also evaluated. Thiolated pectin presented a thiol group content of 0.69 mmol/g. Thiolation caused a 13% increase in polymer molecular weight. Pellets containing thiolated pectin were still adhering to the intestinal mucosa after 480 min and showed a more gradual release of ketoprofen. Conversely, pellets prepared with nonthiolated pectin showed rapid disintegration and detached after only 15 min. It can be concluded that thiolated pectin-based pellets can be considered a potential platform for the development of mucoadhesive drug delivery systems for the oral route., (Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: The Ponseti method has been shown to be the most effective treatment for congenital clubfoot. The current challenge is to establish sustainable national clubfoot treatment programs that utilize the Ponseti method and integrate it within a nation's governmental health system. The Brazilian Ponseti Program (Programa Ponseti Brasil) has increased awareness of the utility of the Ponseti method and has trained >500 Brazilian orthopaedic surgeons in it., Methods: A group of 18 of those surgeons had been able to reproduce the Ponseti clubfoot treatment, and compiled their initial results through structured spreadsheet., Results: The study compiled 1040 patients for a total of 1621 feet. The average follow-up time was 2.3 years with an average correction time of approximately 3 months. Patients required an average of 6.40 casts to achieve correction., Conclusions: This study demonstrates that good initial correction rates are reproducible after training; from 1040 patients only 1.4% required a posteromedial release., Level of Evidence: Level IV.

A new molecule, LQFM048, originally designed through molecular hybridization using green chemistry approach, is in development as a photoprotective agent. Eye irritation, skin toxicity and genotoxicity evaluations are mandatory for predicting health risks. In this context, the purpose of this study was to investigate the eye irritation potential of LQFM048 by combining Short Time Exposure (STE), Bovine Corneal Opacity and Permeability (BCOP) associated with corneal histomorphometry and Hen's Egg Test-Chorioallantoic Membrane (HET-CAM). Additionally, skin toxicity was evaluated by interleukin-18 production in the HaCaT keratinocyte, Local Lymph Node Assay (LLNA:BrdU-ELISA) method, 3T3 Neutral red uptake (NRU) assay and in vivo phototoxicity test. Genotoxic potential of LQFM048 was also analyzed by cytokinesis-block micronucleus assay (MNvit test-cytoB) in HepG2 cells. Our results showed that LQFM048 did not induce eye irritation and it was classified as UN GHS No Category for both STE and BCOP assays and non-irritating for HET-CAM test. LQFM048 showed non-potential skin sensitization with stimulation index (SI=0.7) in the LLNA:BrdU-ELISA method. Corroborating in vivo tests, it did not promote significant cytotoxicity in HaCaT cells and it showed similar levels of IL-18 when compared to control. Furthermore, LQFM048 induced non-phototoxic potential with photo-irritation factor (PIF) and mean photo effect (MPE) of 1 and -0.138, respectively, for 3T3 cells. Similarly, it was not phototoxic for in vivo testing with or without exposure to UVA, showing SI values of 1 and 1.2, respectively. The micronucleus test showed that LQFM048 was not genotoxic, under the conditions tested.In conclusion, LQFM048, a heterocyclic compound obtained through an environmentally acceptable simple synthetic route, seems to be safe for human use, especially for the development of a new sunscreen product, since it is neither an eye irritant, nor a contact allergen, nor mutagenic and nor phototoxic., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Cavus foot is usually related to neurologic abnormalities and then requires complete clinical and imaging evaluation. It is important to identify whether the deformity is flexible or rigid, and combine different soft tissue and bony techniques to accomplish the best lasting results. On rigid feet, it is crucial to determine the apex of the deformity to guide the bony procedures indicated for each specific case. Tarsectomies are preferred to arthrodesis in these rigid feet with the aim of achieve a plantigrade foot., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Tuberculosis is a disease affecting millions of people throughout the world. One of the main problems in controlling the disease is the low efficacy of the Bacillus Calmette-Guérin (BCG) vaccine in protecting young adults. The development of new vaccines that induce a long-lasting immune response or that stimulate the immunity induced by BCG may improve the control of tuberculosis., Methods: The use of microstructured liposomes containing HspX, with or without MPL or CpG DNA adjuvants, as vaccines for tuberculosis was evaluated. The HspX-specific humoral and cellular immune responses to the different vaccine formulations were compared., Results: All vaccines containing liposome microparticles and HspX were immunogenic. Vaccines formulated with CpG DNA and HspX induced the strongest humoral and cellular immune responses, mainly by inducing interferon-γ and tumor necrosis factor-α expression by both CD4(+) and CD8(+) T cells. HspX and MPL mainly induced CD8(+) T-cell activation and specific humoral responses. When evaluated the protective efficacy of the formulations against Mycobacterium tuberculosis challenge, the microstructured liposome containing L-HspX and L-HspX-CPG DNA reduced both lung inflammatory lesions and the bacterial load., Conclusion: We have thus demonstrated, for the first time, the use of microstructured liposomes as an adjuvant and delivery system for a vaccine formulation against tuberculosis., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this work was the development of a multicompartimental nanocarrier for the simultaneous encapsulation of paclitaxel (PTX) and genistein (GEN), associating antiangiogenic and cytotoxic properties in order to potentiate antitumoral activity., Method: Polymeric nanocapsules containing PTX were obtained by interfacial deposition of preformed polymer and coated with a phospholipid bilayer entrapping GEN. Physical-chemical and morphological characteristics were characterized, including size and size distribution, drug entrapment efficiency and drug release profile. In vivo studies were performed in EAT bearing Swiss mice., Results: Entrapment efficiency for both drugs in the nanoparticles was approximately 98%. Average particle diameter was 150 nm with a monomodal distribution. In vitro assays showed distinct temporal drug release profiles for each drug. The dose of 0.2 mg/kg/day of PTX resulted in 11% tumor inhibition, however the association of 12 mg/kg/day of GEN promoted 44% tumor inhibition and a 58% decrease in VEGF levels., Conclusions: Nanoparticles containing GEN and PTX with a temporal pattern of drug release indicated that the combined effect of cytotoxic and antiangiogenic drugs present in the formulation contributed to the overall enhanced antitumor activity of the nanomedicine.

This study aimed to analyze the perceptions of parents of children with clubfoot regarding the Ponseti method of treatment, and identify aspects of treatment that families found most difficult. Thirty families of children with clubfoot were treated with the Ponseti method over a 4-year period, and questionnaires were distributed at the conclusion of treatment. The most difficult components of treatment were identified. However, these challenges did not impact treatment outcome negatively. We hypothesize that a strong physician-patient relationship and high levels of parental education may decrease perceived difficulties of treatment with the Ponseti method.

Introduction: The mandibular condylar surface is made up of four layers, i.e., an external layer composed of dense connective tissue, followed by a layer of undifferentiated cells, hyaline cartilage and bone. Few studies have demonstrated the behavior of the condylar cartilage when the mandible is positioned posteriorly, as in treatments for correcting functional Class III malocclusion., Objective: The aim of this study was to assess the morphologic and histological aspects of rat condyles in response to posterior positioning of the mandible., Methods: Thirty five-week-old male Wistar rats were selected and randomly divided into two groups: A control group (C) and an experimental group (E) which received devices for inducing mandibular retrusion. The animals were euthanized at time intervals of 7, 21 and 30 days after the experiment had began. For histological analysis, total condylar thickness was measured, including the proliferative, hyaline and hypertrophic layers, as well as each layer separately, totaling 30 measurements for each parameter of each animal., Results: The greatest difference in cartilage thickness was observed in 21 days, although different levels were observed in the other periods. Group E showed an increase of 39.46% in the total layer, reflected by increases in the thickness of the hypertrophic (42.24%), hyaline (46.92%) and proliferative (17.70%) layers., Conclusions: Posteriorly repositioning the mandible produced a series of histological and morphological responses in the condyle, suggesting condylar and mandibular adaptation in rats.

The aim of this study was to evaluate the shear bond strength (SBS) of polycrystalline ceramic brackets (PCB) bonded after bleaching treatment using different composite resins and enamel etching times. A total of 144 bovine incisors were randomly divided into two study groups (n = 72, each) as follows: G1, enamel bleached with 35% hydrogen peroxide, and G2 (control group), enamel unbleached. After the bleaching treatment, the samples were stored in artificial saliva for 14 days. These groups were further divided into two subgroups (n = 36, each) as follows: GA, brackets bonded with Transbond XT (3M) and GB, brackets bonded with Filtek Z250 (3M). For each resin used, three different etching times with 37% phosphoric acid (15, 30 and 60 seconds) were tested. SBS tests were performed using a universal testing machine (EMIC), and the adhesive remnant index (ARI) score was verified. Significant differences among the three experimental conditions and interactions between the groups were observed. The type of composite resin accounted for 24% of the influence on the bond strength, whereas the etching time and bleaching treatment accounted for 14.5% and 10% of the influence on bond strength, respectively. The ARI revealed that the most common area of adhesion failure was at the composite resin-bracket interface. The type of composite resin, etching time and external bleaching significantly influenced the SBS of PCB on enamel, even after 14 days of saliva storage.

The isoflavone genistein (GEN) is a natural product with potential applications for skin cancer treatment and chemoprevention; however its high lipophilicity and chemical instability limits its clinical use. Therefore, attempts towards protecting GEN against degradation and increasing its penetration in the skin might be a valid approach. In this work, GEN loaded-PLA nanocapsules (GEN-NC) were prepared by interfacial deposition of preformed polymer (nanoprecipitation); physicochemical characterization and stability studies for 90 days were conducted. GEN-NC were incorporated into semi-solid formulations and permeation experiments were carried out using porcine ear skin. GEN-NC optimized formulation presented a mean diameter of 139 +/- 7.31 nm, polydispersity index of 0.128 +/- 0.08, encapsulation efficiency of 89.63 +/- 2.27% and drug loading from 0.6 to 1.4 w/w%. Stability studies demonstrated that nanocapsules did not exhibit aggregation during the 90 days of the assay, however, a drop in encapsulation efficiency was observed in the first 10 days. Permeation experiments demonstrated that a higher amount of GEN reaches deeper layers of the skin and increased penetration was achieved when GEN-NC were incorporated in a semi-solid gel formulation, indicating that GEN-NC might be a promising nanocarrier system for skin delivery of GEN.

Background: Clubfoot is the most common extremity birth defect. It causes the feet of affected individuals to point inward and downward, preventing them from walking normally. Neglected clubfoot causes disabilities that result in a lack of social integration, creating a psychological and financial burden for the family and community. Clubfoot has been effectively treated through the Ponseti method, a treatment utilizing serial casts to correct the deformity followed by use of an abduction brace for approximately 2-4 years. sustained use of the brace is necessary to prevent relapse and ensure a successful outcome. Brace compliance in the setting of limited resources in the developing world can be challenging. The purpose of this study was to identify the barriers to bracing compliance in southeastern Brazil. In addition to socioeconomic and cultural barriers, this study also looked at improper prescribing practices by physicians as a potential cause of noncompliance. The study sought to identify the role of physician education in the use of the Ponseti method and physicians' knowledge of the bracing process., Purpose of the Study: Identify the barriers to bracing adherence that could negatively impact the treatment of children with clubfoot., Methods: Forty-five orthopedists from several centers in southeastern Brazil were interviewed. Physicians were asked about their training in the Ponseti method, their protocol when prescribing the brace, their evaluation of its importance, and a series of open-ended questions designed to identify the positive and negative qualities of local braces. They were also asked what they perceived to be the biggest challenges to sustained brace use., Results: sixteen of the physicians interviewed were orthopedic residents, and 29 had completed their residencies. Of these two groups, only 25% and 65%, respectively, appropriately prescribe the abduction brace for patients, with the majority recommending use of the brace for an inadequate period of time. The high costs and delays in acquisition of the brace and a lack of orthopedic stores able to adequately construct the orthotic, also present considerable barriers to sustained brace use., Conclusions: Many of the causes of noncompliance with bracing protocol stem from systemic inequities and challenges, rather than a lack of collaboration from the families themselves. Furthermore, insufficient prescription of the brace by physicians may represent a major barrier to bracing compliance in southeastern Brazil. This research indicates a need to evaluate physician training and continuing medical education in order to ensure that physicians are adequately utilizing the brace.

Background: After hearing about the reproducible and excellent results of the Ponseti method for clubfoot treatment, a group of Brazilian orthopaedic surgeons organized and participated in a standardized national program to teach the Ponseti technique in 21 different cities across Brazil., Methods: A total of 21 Ponseti symposiums were organized in a standard fashion from January, 2007 to December, 2008. They consisted of a two-day program with lectures, hands-on cast application, and discussion of local clinical cases presented by orthopaedic surgeons. Thirteen Brazilian orthopaedic surgeons, who had been trained by the University of Iowa or centers recognized by them, taught the method. Financial support for travel was provided by an English charity: La Vida (Vital Investment for Developing Aid in Latin America). The physicians who attended the symposiums answered questionnaires before and after the training., Results: About 7% of the 8000 orthopaedic surgeons in Brazil (556 orthopaedic surgeons) were trained. These orthopaedic surgeons stated that they had treated about 4905 babies in the previous year via other methods, including extensive surgery. Seventeen percent of the surgeons did not know about the Ponseti technique at the start of the symposium. Eighty-eight percent reported they felt able to treat children with the Ponseti technique after the symposium. Ninety-four percent of respondents reported that the symposium changed their way of treating clubfoot, Conclusions: These Ponseti symposiums brought about an exchange of medical information and empowered the participants. This program is a good educational tool which can be used in eradicating neglected clubfoot in Brazil.

Gómez-López-Hernández (GLH) syndrome or cerebello-trigeminal dysplasia is a neurocutaneous syndrome whose etiology is unknown at the present time. We report two additional Brazilian patients, including the oldest one known to date (age 29). Here, we review the expanded phenotype in four patients with new clinical, psychiatric, radiological, and molecular investigations. One patient may have hypomania within the bipolar spectrum disorder with onset in childhood and adolescence. Primary growth hormone (GH) deficiency was ruled out in all patients, although one of them might have developed secondary GH deficiency due to partial hypopituitarism following severe hydrocephalus. Brain magnetic resonance angiography disclosed no azygous anterior cerebral artery (ACA) but only normal variants. Molecular analysis of the lysosomal acid phosphatase gene (ACP2) was performed, but no pathogenic mutations were identified. We present an overview of the phenotypic features of all patients described to date. There are currently 12 unrelated patients reported in the literature, 5 of whom are Brazilian. We discuss new molecular insights and speculate about the pathogenesis of GLH syndrome., ((c) 2008 Wiley-Liss, Inc.)

Background: Nerve injury is one of the most serious complications associated with limb-lengthening. We examined the risk, assessment, and treatment of nerve lesions associated with limb-lengthening., Methods: We retrospectively studied the records on 814 limb-lengthening procedures. Nerve lesions were defined by clinical signs and symptoms of motor function impairment, sensory alterations, referred pain in the distribution of an affected nerve, and/or positive results of quantitative sensory testing with use of a pressure specified sensory device., Results: Seventy-six (9.3%) of the limbs had a nerve lesion. Eighty-four percent of the nerve lesions occurred during gradual distraction, and 16% occurred immediately following surgery. The pressure specified sensory device showed 100% sensitivity and 86% specificity in the detection of nerve injuries. The patients in whom the lesion was diagnosed with this method, or with this method as well as with nerve conduction studies, had significantly faster recovery than did those diagnosed on the basis of clinical symptoms or nerve conduction studies alone (p = 0.02). Patients undergoing double-level tibial lengthening and those with skeletal dysplasia were at higher risk for nerve lesions (77% and 48%, respectively). Nerve decompression was performed in fifty-three cases (70%). The time between the diagnosis and the surgical decompression was strongly associated with the time to recovery (p = 0.0005). Complete clinical recovery was achieved in seventy-four of the seventy-six cases., Conclusions: Early detection based on signs and symptoms or testing with a pressure specified sensory device improves the prognosis for nerve injury that occurs during limb-lengthening. Of the methods that we used to identify neurologic compromise, testing with the pressure specified sensory device was the most sensitive. Aggressive early treatment (slowing the rate of lengthening and/or performing decompression) allows continued lengthening without incurring permanent nerve injury. When indicated, decompression of the affected nerve should be performed as soon as possible, thereby improving the chances of and shortening the time to complete recovery.

A total of 841 children, aged 10 days to 5 years, seen at a primary health care centre in Ribeirão Preto, Brazil, were studied in order to compare the methods of Gomez, Waterlow, Shakir, and Kanawati and McLaren and to determine the correlation between the Brazilian and the National Center for Health Statistics (NCHS) reference populations, which are frequently used in Brazil. Anthropometric measurements (weight, height, arm circumference, and head circumference) were made and personal data were obtained in order to evaluate nutritional status according to the above methods. The two reference populations were compared by the method of Gomez. The NCHS and the Brazilian reference populations were concordant. Comparison of the methods of Gomez and Shakir showed a very mild agreement in the evaluation of nutritional status. Comparison of Waterlow 'wasting' with Kanawati & McLaren and with Gomez showed a mild agreement.

OBJECTIVE: To evaluate the use of the 10th percentile of weight for age as a cut off point for detection of children under nutritional risk, especially for programs of alimentary supplementation. METHODS: 841 children with age between 10 days and 60 months were studied in a primary health care center located in the periphery of Ribeirão Preto, SP, Brazil. It was a cross-sectional study that included age, sex, weight and height, later computing the z scores of weight for age, height for age and weight for height, on the basis of the data of the NCHS. Through 2x2 type tables, where the results in relation with the 10th percentile (above or below this cut off point) and other indices were compared (above or below - 2 z scores), the capacity of 10th percentile of weight for age to detect children with various anthropometric deficits was estimated. RESULTS: The false negative results were always very low, between 0 and 1%, in opposition to the false positive results, that varied from 76.3 to 90.5%. The values of sensitivity/specificity have been 100/85.9%; 93.3/83.8%; 82.9/85.7%, respectively for deficits of weight for age, weight for height and height for age. CONCLUSIONS: The 10th percentile of weight for age was found adequate for population screening of children with weight for the age and weight for the height deficits (high sensitivity), but these children must be better evaluated later on (too many false positive results). For height for age deficits, the 10th percentile resulted inadequate.