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.

Introduction: Periprosthetic bone loss may lead to major complications in total hip arthroplasty (THA), including loosening, migration, and even fracture. This study analysed the influence of femoral implant designs on periprosthetic bone mineral density (BMD) after THA. Methods: The results of all previous published studies reporting periprosthetic femoral BMD following THA were compiled. Using these results, we compared percent changes in bone loss as a function of: femoral stem fixation, material, and geometry. Results: The greatest bone loss was in the calcar region (Gruen Zone 7). Overall, cemented stems had more bone loss distally than noncemented stems, while noncemented stems had more proximal bone loss than cemented stems. Within noncemented stems, cobalt-chromium (CoCr) stems had nearly double the proximal bone loss compared to titanium (Ti) alloy stems. Finally, within noncemented titanium alloy group, straight stems had less bone loss than anatomical, tapered, and press-fit designs. Discussion: The findings from the present study quantified percent changes in periprosthetic BMD as a function of fixation method, alloy, and stem design. While no one stem type was identified as ideal, we now have a clearer understanding of the influence of stem design on load transfer to the surrounding bone.

Background: Developed at the University of Iowa in 1950, the Ponseti method to manage idiopathic clubfoot deformity was slow to gain wide acceptance until the mid-1990s. There is a paucity of intermediate and long-term outcome studies involving this technique, with nearly all such studies coming from a single institution. The purpose of this study is to report the contemporary outcome of patients with clubfoot deformity whose feet were managed with the Ponseti method and who were followed to ≥5 years old, to provide outcome expectations for parents and for clinicians managing patients with idiopathic clubfoot. Methods: Families of infants seen in our clinic diagnosed with idiopathic clubfoot since July 2006 were prospectively invited to participate in our institutional review board-approved study. Patients who received no prior outside treatment and had a minimum follow-up to the age of 5 years were included. Demographic, treatment, and outcome data were collected. To provide an array of outcome measures, both the Dallas outcome criteria and the Roye disease-specific instrument (DSI) were used. Results: One hundred and one patients met the inclusion criteria. The mean length of follow-up (and standard deviation) was 81.1 ± 17.1 months. Initial correction was achieved in all feet. Thirty-seven percent of families reported that they were adherent with the bracing protocol; 68% of patients had ≥1 relapse, and 38% underwent a tendon transfer. With the Dallas criteria, 62% had outcomes rated as good, 38% had outcomes rated as fair, and no patient had an outcome rated as poor. With the Roye DSI, most families were generally very satisfied with the function and appearance of the feet. Conclusions: Satisfactory results at intermediate follow-up were achieved using the Ponseti method. However, despite a better understanding of the Ponseti method and the importance of longer post-corrective brace use, the need for anterior tibial tendon transfer remains an important adjunct to the Ponseti method. Brace adherence also continues to be a critical clinical issue. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A successful outcome for the treatment of idiopathic clubfoot is believed to require adequate adherence to brace use. Previous studies have relied on parental reporting of brace application. We used temperature sensors to determine the adherence to the bracing protocol, the accuracy of parent-reported use, and differences in adherence between patients who experienced relapse of deformity and those who did not. Using wireless sensors attached to brace sandals, we monitored brace wear over a 3-month period in this cross-sectional study involving 48 patients in 4 age-based groups: 6 to 12 months (Group 1), >1 to 2 years (Group 2), >2 to 3 years (Group 3), and >3 to 4 years (Group 4). Parents were blinded to the purpose of the sensors. The mean number of hours of daily brace use as measured by the sensors was compared with the physician-recommended hours and parent-reported hours of brace use. Sensors were retrieved from 44 of 48 patients. Overall, the median brace use recorded by the sensors was 62% (range, 5% to 125%) of that recommended by the physician, and 77% (range, 6% to 213%) of that reported by the parents. For Groups 1 to 3, the difference between the physician-recommended and measured number of hours of daily brace use was significant (p ≤ 0.002), and the difference between the parent-reported and measured number of hours of daily brace use was also significant (p ≤ 0.013). Eight (18%) of the 44 patients who completed the study experienced relapse during the period of monitoring; most importantly, the mean number of hours of brace wear for these patients, 5 hours per day (median, 4; and standard deviation [SD], 3 hours per day) was significantly lower than the 8 hours per day for those who did not experience relapse (median, 9; and SD, 5 hours per day) (p = 0.045). The present study objectively quantified the number of daily hours of post-corrective brace wear for patients with clubfoot in varying age groups and provides an estimate of the number of hours required to avoid relapse. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: Determining the magnitude of displacement in pediatric lateral humeral condyle fractures can be difficult. The purpose of this study was to (1) assess the effect of forearm rotation on true fracture displacement using a cadaver model and to (2) determine the accuracy of radiographic measurements of the fracture gap. Methods: A non-displaced fracture was created in three human cadaveric arms. The specimens were mounted on a custom apparatus allowing forearm rotation with the humerus fixed. First, the effect of pure rotation on fracture displacement was simulated by rotating the forearm from supination to pronation about the central axis of the forearm, to isolate the effects of muscle pull. Then, the clinical condition of obtaining a lateral oblique radiograph was simulated by rotating the forearm about the medial aspect of the forearm. Fracture displacements were measured using a motion-capture system (true-displacement) and clinical radiographs (apparent-displacement). Results: During pure rotation of the forearm, there were no significant differences in fracture displacement between supination and pronation, with changes in displacement of <1.0 mm. During rotation about the medial aspect of the forearm, there was a significant difference in true displacements between supination and pronation at the posterior edge ( p < 0.05). Conclusion: Overall, true fracture displacement measurements were larger than apparent radiographic displacement measurements, with differences from 1.6 to 6.0 mm, suggesting that the current clinical methods may not be sensitive enough to detect a displacement of 2.0 mm, especially when positioning the upper extremity for an internal oblique lateral radiograph.