Staples and locking plates provide comparable outcomes for fixation of first metatarsal dorsiflexion osteotomies in pes cavovarus.

BACKGROUND: One commonly encountered deformity within the cavovarus foot is plantarflexion of the first metatarsal which may be a primary or secondary deformity. Correcting the plantarflexion may be achieved through a dorsiflexion osteotomy although the optimal fixation device for this osteotomy has not been determined. This clinical study compared the outcomes using staples and locking plates. METHODS: A retrospective evaluation was performed of 52 feet that had undergone dorsiflexion osteotomy of the first metatarsal as part of a cavovarus foot correction with a minimum follow-up of two years. Data was collected on deformity correction, complications and cost-analysis. RESULTS: As a cohort, Meary's angle improved from 13.4° to 7.72° (p < 0.001), Hibbs' angle improved from 117.1° to 124.2° (p < 0.001) and navicular height dropped from 52.7 mm to 47.7 mm (p < 0.001) while calcaneal inclination changed from 20.9° to 21.2° but this did not reach significance (p = 0.66). These indices and the number of complications were not significantly different between the staple and locking plate group. The overall cost of using staples was less than using locking plates. CONCLUSIONS: Both staples and locking plates are effective devices for fixation of the first metatarsal after a dorsiflexion osteotomy in cavovarus foot surgery. They were both able to provide comparable fixation, although staples were less expensive to use in our study.

Pes cavovarus in Charcot-Marie-Tooth compared to the idiopathic cavovarus foot: A preliminary weightbearing CT analysis.

BACKGROUND: Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT). METHODS: A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction. RESULTS: Significant differences were observed between CMT-PC or I-PC and controls (p<0.05). Two-dimensional measurements were similar in CMT-PC and I-PC, except for forefoot arch angle (p=0.04). 3D measurements (foot and ankle offset, calcaneal offset and hindfoot alignment angle) demonstrated that CMT-PC exhibited more severe hindfoot varus malalignment than I-PC (p=0.03, 0.04 and 0.02 respectively). CONCLUSIONS: CMT-related cavovarus and idiopathic cavovarus feet are morphologically different from healthy feet, and CMT feet exhibit increased forefoot supination and hindfoot malalignment compared to idiopathic forms. The use of novel three-dimensional analysis may help highlight subtle structural differences in patients with similar foot morphology but aetiologically different pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intraobserver and interobserver reliability of cone beam weightbearing semi-automatic three-dimensional measurements in symptomatic pes cavovarus.

INTRODUCTION: Pes cavovarus is a three-dimensional (3D) foot deformity. New 3D semi-automatic measurements utilising weightbearing computerised topography (WBCT) images have recently been proposed to assess hindfoot alignment, but reliability in pes cavovarus has never been investigated. The aim of this study was to assess intraobserver and interobserver reliability of the foot ankle offset (FAO), calcaneal offset (CO) and hindfoot alignment angle (HAA) in pes cavovarus. METHODS: Anonymised WBCT datasets from 51 feet (17 Charcot-Marie-Tooth related cavovarus, 17 idiopathic cavovarus and 17 controls) were retrospectively reviewed. Three observers (two senior foot and ankle fellows and one orthopaedic resident) independently measured FAO, CO and HAA using dedicated software, with measurements repeated two weeks apart. Subgroup analysis was performed to assess whether aetiology or severity of varus deformity and level of seniority affected reliability. RESULTS: Mean values for intra and interobserver reliability for FAO (r=0.98; ICC: 0.99), CO (r=0.97; ICC: 0.98) and HAA measurements (r=0.97; ICC: 0.98) were excellent. Subgroup analyses showed that FAO, CO and HAA's intra (r/ρ range, 0.77-0.95) and interobserver (ICC range, 0.88-0.98) reliability remained excellent in patients with Charcot-Marie-Tooth related cavovarus, idiopathic pes cavovarus and normal feet, regardless of the severity of deformity. No difference was found in FAO, CO and HAA mean values from three observers (p>0.05 in all cases). DISCUSSION: This study demonstrates that 3D semi-automatic measurements of WBCT images have excellent intra and interobserver reliability in the assessment of hindfoot alignment in pes cavovarus. Aetiology and severity of deformity, and level of seniority do not affect reliability of these measurements. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Reducing Allogenic Blood Transfusion in Pediatric Scoliosis Surgery:: Reporting 15 Years of a Multidisciplinary, Evidence-Based Quality Improvement Project.

STUDY DESIGN: Retrospective review of prospectively collected spinal surgery and transfusion databases. OBJECTIVES: To evaluate the efficacy of a care pathway developed at our institution since 2003 with a focus on reducing the need for blood transfusions in children undergoing scoliosis correction surgery. The care pathway includes nurse-led clinics facilitating preoperative hemoglobin optimization, intraoperative cell salvage, the use of tranexamic acid, and a transfusion criteria awareness program. METHODS: Retrospective review of our institution's prospectively recorded spinal surgery and transfusion databases including all cases of scoliosis surgery in patients 18 years and younger between 2001 and 2015. RESULTS: A total of 1039 procedures were included in the analysis. Overall, 24.4% of patients received a transfusion. The proportion of patients transfused was 89.2% in 2001-2003, 39.6% in 2004-2006, 16.5% in 2007-2009, 15.6% in 2010-2012, and 20.1% in 2013-2015. The volume of blood products transfused in those undergoing transfusion was 9.1 units in 2001-2003, 4.8 units in 2004-2006, 5.0 units in 2007-2009, 2.3 units in 2010-2012, and 2.1 units in 2013-2015. A multivariate logistic regression demonstrated adjusted odds ratios for the probability of receiving any transfusion of 5.45 (95% confidence interval 3.62-8.11) for patients with neuromuscular diagnoses and 11.17 (5.02-24.86) for those undergoing combined anterior and posterior surgical approach. CONCLUSIONS: We have demonstrated over a 15-year period that the introduction of a multifaceted, multidisciplinary pathway can dramatically and sustainably reduce the need for blood transfusions and their attendant risks in pediatric scoliosis surgery. This data lends weight to the adoption of such a care pathway in pediatric scoliosis surgery.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures.

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.