The Ponseti method has become the gold standard of care for the treatment of congenital club foot. Despite numerous articles in MEDLINE reporting results from around the globe there are still crucial details of the Ponseti method which seem to be less commonly known or considered. The Ponseti method is not only a detailed method of manipulation and casting but also of preventing and treating relapse. Recommendations on how to correct complex club foot have resulted in an almost 100 % initial correction rate. The foot abduction brace is crucial for preventing relapse and is still a challenge for families and sometimes doctors alike. Experience and knowledge on how to support the parents, how to set and apply the brace in the best possible way and how to solve problems that can be encountered during the bracing period are essential to ensure compliance. Regular follow-up visits are necessary to be able to detect early signs of recurrence and prevent full relapse by enforcing abduction bracing, recasting or performing tibialis anterior tendon transfer. Recent midterm outcome studies have shown that by following the Ponseti treatment regime in all aspects it is possible to prevent open joint surgery in almost all cases. The body of literature of the last decade has evaluated many steps and aspects of the Ponseti method and gives valuable answers to questions encountered in daily practice. This review of the current literature and recommendations on the different aspects of the Ponseti method aims to promote understanding of the treatment regime and its’ details.

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The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations.

• A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. People interested in the research are advised to contact the author for the final version of the publication, or visit the DOI to the publisher's website. • The final author version and the galley proof are versions of the publication after peer review. • The final published version features the final layout of the paper including the volume, issue and page numbers.

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Contested cultural property : the return of nazi spoliated art and human remains from public collections

The effectiveness of a single 6.5 or seven-millimeter diameter screw for the promotion of premature physeal closure and the provision of stability of a slipped capital femoral epiphysis was investigated. Physeal fusion was demonstrated in forty-nine (92 per cent) offlfty-three hips after fixation with a single screw. Premature fusion ofthe involved physis, compared with the uninvolved, contralateral physis, was documented (p < 0.001). Epiphyseal stability, as measured by the lateral head shaft angle, was maintained in all except one hip. An analysis of twenty-nine hips for which there was a complete set of radiographs, that were in patients who had no endocrine problems, and that were the first hips entered into the study when the patient had bilateral involvement, revealed an average time to closure of the physeal line of thirteen months. A longer time to physeal fusion was correlated with increasingly eccentric placement of the screw (r = 0.44, p = 0.016) and increasing severity of the slip (r = -0.536, p = 0.003). There was no correlation between the age at the time of the operation, race, or sex and the time to physeal fusion. Only one patient had penetration by a screw, and no chondrolysis, avascular necrosis, or other serious *No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. tChildren’s Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, Pennsylvania 15213. Please address requests for reprints to Dr. Timothy Ward. tUniversity of Minnesota Medical Center, 420 Delaware Street. SE., Minneapolis, Minnesota 55414. §Children’s Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, Michigan 48201. problems developed. Fixation with a single 6.5 or sevenmillimeter-diameter screw provided adequate epiphyseal stability and promoted premature physeal fusion in our patients, while decreasing the rate of complications compared with that reported to be associated with fixation with multiple screws or pins. Fixation with multiple pins or screws has been widely accepted as treatment for either acute or chronic slipped capital femoral epiphysis. The advantages of fixation with multiple pins include a shortened operative time and diminished loss of blood compared with the more extensive procedures of open bone-grafting or osteotomy’732 ’. The objectives of treatment with multiple pins or screws are the prevention of further slipping of the epiphysis and the promotion of premature fusion of the physis. However, since Walters and Simon3 first called attention to the problem of unrecognized penetration by pins, a disturbingly high prevalence of both recognized and unrecognized penetration by pins has been reported24754252t’25. Some authors have reported penetration by pins and clustering of pins to be factors in the subsequent development of chondrolysis and avascular necrosis325; others have found no such association27. Stambough et al.25, Ordeberg et al.2’, and Bennet et al.2 reported that the over-all rate of complications after fixation with pins or screws for the treatment of slipped capital femoral epiphysis is directly related to the number of pins or screws inserted. The use of a single screw for fixation of a slipped epiphysis should decrease the prevalence of penetration by screws and the volume of the femoral head that is occupied by metal. If the goals of epiphyseal stabilization and premature closure of the

Fixation with a single screw for slipped capital femoral epiphysis.

Patient satisfaction in a nurse-led rheumatology clinic

BACKGROUND The Ponseti method is the preferred technique to manage idiopathic clubfoot deformity; however, there is no consensus on the expected relapse rate or the percentage of patients who will ultimately require a corrective surgical procedure. The objective of the present systematic review was to determine how reported rates of relapsed deformity and rates of a secondary surgical procedure are influenced by each study's length of follow-up. METHODS A comprehensive literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify relevant articles. The definition of relapse, the percentage of patients who relapsed, the percentage of feet that required a surgical procedure, and the mean duration of follow-up of each study were extracted. Pearson correlations were performed to determine associations among the following variables: mean follow-up duration, percentage of patients who relapsed, percentage of feet that required a joint-sparing surgical procedure, and percentage of feet that required a joint-invasive surgical procedure. Logarithmic curve fit regressions were used to model the relapse rate, the rate of joint-sparing surgical procedures, and the rate of joint-invasive surgical procedures as a function of follow-up time. RESULTS Forty-six studies met the inclusion criteria. Four distinct definitions of relapse were identified. The reported relapse rates varied from 3.7% to 67.3% of patients. The mean duration of follow-up was strongly correlated with the relapse rate (Pearson correlation coefficient = 0.44; p < 0.01) and the percentage of feet that required a joint-sparing surgical procedure (Pearson correlation coefficient = 0.59; p < 0.01). Studies with longer follow-up showed significantly larger percentages of relapse and joint-sparing surgical procedures than studies with shorter follow-up (p < 0.05). CONCLUSIONS Relapses have been reported to occur at as late as 10 years of age; however, very few studies follow patients for at least 8 years. Notwithstanding that, the results indicated that the rate of relapse and percentage of feet requiring a joint-sparing surgical procedure increased as the duration of follow-up increased. Longer-term follow-up studies are required to accurately predict the ultimate risk of relapsed deformity. Patients and their parents should be aware of the possibility of relapse during middle and late childhood, and, thus, follow-up of these patients until skeletal maturity may be warranted. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review.

BACKGROUND To evaluate the effectiveness of shelf acetabuloplasty in the containment of extruded hips without hinge abduction in early stages of Legg-Calve-Perthes disease, we present a retrospective series of 44 patients (45 hips) treated between August 1999 and February 2010, which included 34 boys and 10 girls with a mean age at diagnosis of 7.4 years (range, 3.9 to 15.3). METHODS All patients presented with sclerosis or early fragmentation stages. The average time from diagnosis to surgery was 2.1 months (range, 0 to 8.2) and the mean time to heal was 40.4 months (range, 20 to 82.2). The Reimer migration and the deformity indices were measured on initial, preoperative, postoperative, and healed x-rays. The average deformity index at 3 of those 4 timepoints was significantly related to their final Stulberg classification. CE angles increased and Sharp angles decreased significantly as a result of treatment. RESULTS At the healed stage and consistent with other published series, 84.4% of patients were Stulberg III or less, denying any pain, and with full range of movement, whereas 15.6% were classified as Stulberg IV. CONCLUSIONS We defend that shelf acetabuloplasty should be performed early in the disease and, uniquely, we propose that the indication for treatment should be guided by the deformity and the Reimer migration indices. LEVEL OF EVIDENCE LEVEL OF EVIDENCE IV.

Shelf acetabuloplasty for containment in the early stages of Legg-Calve-Perthes disease.

Background: slipped upper femoral epiphysis (SUFE) has an incidence of 1-7 per 100,000 adolescents in the UK and its link with obesity well established. With a rising number of paediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the prevalence of vitamin D deficiency in SUFE patients presenting to an orthopaedic department in the UK and whether a low vitamin D level increases the time to proximal femoral physeal fusion, post-surgical fixation. Methods: a total of 27 paediatric patients, with a female to male ratio of 17:10 and a mean age of 11.5 years (SD 1.99), range 8 to 16 years, presented with a SUFE and had their vitamin D level assessed during the study period, June 2007 to July 2012 (inclusive). The majority of these patients (85.2%) were assessed as vitamin D deficient, with a serum 25-(OH)D 50% physeal fusion on anteroposterior radiography post-surgical fixation quoted in the literature is 9.6 months with no reported vitamin D deficiency or insufficiency. Results: in our study the median time to physeal fusion in the vitamin D deficient and insufficient patients was 25 months, interquartile range 17-43 (mean of 29 months, SD 16.8). A negative correlation was also observed between vitamin D level and the time taken for physeal fusion following surgical fixation. Conclusion: we conclude that a high prevalence of vitamin D deficiency has been observed in our SUFE patients. Comparing the time taken for physeal closure as 9.6 months in the literature with vitamin D deficient patients, this is prolonged. Indeed a negative correlation between vitamin D level and time to physeal fusion has been demonstrated. This study highlights the need for regular vitamin D status assessment in SUFE patients in order to allow early implementation of treatment with vitamin D supplementation. The impact of vitamin D screening and supplementation on SUFE outcomes should be investigated further.

Vitamin D Deficiency in Slipped Upper Femoral Epiphysis: Time to Physeal Fusion.

Diagnosis and management of developmental hip dysplasia

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Treatment and prevention of hip dysplasia in infants and young children.

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