Radiographic Analysis of the Lateral Column Lengthening Procedure in Stage II Adult Acquired Flatfoot Deformity.

Adult acquired flat foot deformity (AAFD) is a progressive, tri-planar deformity involving collapse of the medial longitudinal arch, valgus deformity of the rear foot, and abduction of the mid-foot on the rear foot. There are a wide variety of surgical treatment options for this deformity, including lateral column lengthening (LCL) which results in tri-planar correction of AAFD. We retrospectively reviewed weightbearing preoperative radiographs and weight-bearing 6-week postoperative radiographs of 34 patients with stage II AAFD who underwent LCL (with and without concurrent procedures) with a minimum of 1-year of follow up. Outcomes, including complications and postoperative differences in 6 types of angle measurements were evaluated. Radiographic evaluation showed statistically significant differences in preoperative and postoperative measures in the following angles: calcaneal inclination, Meary's, Simmons, talocalcaneal, and metatarsus adductus (each p ≤ .05). Postoperative Engel's angle difference did not reach statistical significance (p = .07). Paired t tests showed TN coverage angles increased greater with LCL plus a Cotton osteotomy as compared to isolated LCL. Additionally, there was no significant difference in TN coverage angle based on LCL graft size (p = .20). Furthermore, the distance of the osteotomy from the calcaneocuboid joint on anteroposterior and lateral radiographs did not significantly predict TN coverage angle change. Our study suggests that LCL corrects AAFD in three planes while decreasing the metatarsus adductus angle. LCL appears to be more effective when performed with a Cotton osteotomy. Wedge size (6 mm, 8 mm, 10 mm) and osteotomy location did not demonstrate a relationship with postoperative TN coverage angle or incidence of lateral column overload.

First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction.

Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.

Radiographic Outcomes of Talonavicular Joint Arthrodesis With Varying Fixation Techniques in Stage III Adult Acquired Flatfoot Reconstruction.

Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

Radiographic Outcomes of Isolated Subtalar Joint Arthrodesis With Varying Fixation Technique.

Subtalar joint (STJ) arthrodesis is a well-established and accepted surgical procedure utilized for the treatment of various hindfoot conditions including primary or posttraumatic subtalar osteoarthritis, hindfoot valgus deformity, hindfoot varus deformity, complex acute calcaneal fracture, symptomatic residual congenital deformity, tarsal coalition, and other conditions causing pain and deformity about the hindfoot. Union rates associated with isolated subtalar joint arthrodesis are generally thought to be favorable, though reports have varied significantly, with non-union rates ranging from 0 to 46%. Various fixation constructs have been recommended for STJ arthrodesis. The purpose of this study was to compare radiographic union in a 2-screw fixation technique to a 3-screw fixation technique for patients undergoing primary isolated STJ arthrodesis. To this end, we retrospectively reviewed 54 patients; 26 in the 2-screw group and 28 in the 3-screw group. We found the median time to radiographic union to be 9 weeks for the 2-screw cohort and 7 weeks for the 3-screw cohort. Additionally, we found that the 2-screw fixation cohort had a radiographic non-union rate of 26.9% while the 3-screw cohort had no non-unions. We conclude that the use of a 3-screw construct for isolated STJ arthrodesis has a lower non-union rate and time to union when compared to the traditional 2-screw construct and should be considered as a fixation option for STJ arthrodesis.

Definitive fixation of open tibia fractures: Does reopening the traumatic wound increase complication rates?

BACKGROUND: It is unknown if surgical approach or use of previous traumatic wounds for open fracture instrumentation has an impact on patient complications or outcomes. This study sought to compare infection and nonunion rates in the staged treatment of open tibia fractures where the traumatic wound was reopened during definitive fixation versus when they were not. METHODS: A retrospective review was performed on all patients at a single institution level 1 trauma center. All patients who had a minimum of 1 year clinical and radiographic outcomes were included. Primary outcome measures were incidence of infection and nonunion. Groups of patients were compared based on surgical approach for definitive fixation. RESULTS: A total of 96 patients were included - 48 patients received definitive treatment and wound closure during initial management of the open fracture (group 1), 22 patients had staged fixation through new incisions (group 2), and 26 patients had their traumatic wound reopened during definitive fixation (group 3). Rates of infection were 10.4%, 31.8% and 11.5% respectively (p = 0.15). Rates of nonunion were 20.8%, 27.3% and 30.8% (p = 1.0). No statistically significant differences in regards to primary outcomes were found between the staged fixation groups. Multiple logistic regression also showed no difference in infection or nonunion when controlling for known risk factors. CONCLUSION: For open tibia fractures that underwent staged fixation, no significant differences in infection or nonunion were observed between procedures that involved reopening the traumatic wound versus procedures performed through new incisions. The presence of a distal tibia periarticular fracture was found to be independently associated with infection risk.

Patient Radiation Exposure Associated With the Use of Computer Navigation During Spinal Fusion.

BACKGROUND: Calibration of computer navigation for spinal fusion is most commonly conducted using either a preoperative computed tomography (CT) scan or intraoperative O-arm scanning. This study aimed to directly compare patient radiation exposure from intraoperative O-arm use for pedicle screw placement versus typical diagnostic lumbar spine CT studies. METHODS: A retrospective review of patients undergoing O-arm navigated lumbar spine fusion procedures was performed to record radiation exposure as the primary outcome, as well as surgical and demographic details. The same was done for a control group of patients undergoing lumbar spine CT scans. RESULTS: A total of 83 patients undergoing lumbar spine fusion with O-arm navigation were included, as well as 105 unique patients who underwent a lumbar spine CT. The 2 groups were similar in terms of average age (60.2 versus 60.5, P = .90), average height (170 cm versus 169 cm, P = .50), and average weight (92.6 kg versus 90.9 kg, P = .62). Dose-length product for O-arm navigated procedures was 798.3 mGy-cm and 924.2 mGy-cm for CT scans (P = .064). Subgroup analysis revealed 18 patients who had both an O-arm navigated surgery and a lumbar spine CT. In this group the average dose-length product for O-arm surgeries was 806.2 mGy-cm and 822.1 mGy-cm for CT scans (P = .92) CONCLUSION: This study revealed no statistically or clinically significant differences between patient radiation exposure for O-arm operative navigation compared to lumbar spine CT. CLINICAL RELEVANCE: Given the similarity in radiation exposure, surgeons should rely on other factors to guide decision making in regard to mode of imaging for navigation. Knowledge of this comparison and total radiation exposure will also be useful for patient education and shared decision making in regard to navigated procedures.

Clinical Outcomes After Spine Surgery for Traumatic Injury in the Octogenarian Population.

OBJECTIVE: To review the surgical outcomes of the octogenarian population at a single institution after spinal traumatic injury. METHODS: Patients with both radiographic and clinical evidence of acute traumatic spine injury were reviewed using an institutional trauma survey to determine patient demographics and outcome data in a population of patients aged 80 years and older. RESULTS: Thirty-nine patients aged 80 years and older underwent surgical intervention for acute spinal trauma. There were 25 cases of cervical spine and 14 cases of thoracolumbar spine surgical intervention. Falls were the number one cause of acute spinal injury (31/39, 71%). Major respiratory disorders were the most common postoperative adverse event (12/39, 31%). Five patients experienced superficial wound dehiscence, fascial dehiscence, superficial infection, or delayed wound erosion. Patients were either discharged to home (10.5%), inpatient rehabilitation, (38.5%), skilled nursing facilities (17.9%), or long-term care facilities (17.9%). The postoperative mortality was 10.3%. CONCLUSIONS: Although the octogenarian population has increased risk for postoperative events after acute spinal injuries, surgical intervention may be worthwhile in the elderly population. Although direct surgical complication rates are not higher, medical risks are significantly higher after surgery.

When Transfusion Is Not an Option-the Challenges and Rewards.

The decision to develop a formal Bloodless Medicine Program to attract and effectively care for patients who decline blood transfusion was made in 1998 by clinical and administrative leaders at our flagship hospital, Allegheny General Hospital, part of the Allegheny Health Network. The Bloodless Medicine Program has more than 20 years of experience in caring for this sometimes challenging patient population and with this experience has provided extensive insight into best practices related to effective, safe, patient blood management. Patient blood management is a patient-centered, evidence-based approach to transfusion that seeks to provide the right care, in the right setting, in the right way, every time. It includes honoring the wishes of patients who decline blood products in their care, that is, "bloodless" medicine. Encouraging patients to participate in their own health care decisions is a vital part of safe, compassionate care. When called upon to provide care to a patient who declines a common therapy such as blood transfusion, clinicians must often develop alternative strategies to achieve the desired results. Their willingness to think creatively and push boundaries has resulted in significant advancement of clinical knowledge and practice related to the use of blood products for all patients. Nurses who advocate for the best care for their patients are a vital component of any successful patient blood management program.

Short-Term Follow-Up Mammography in Breast Conservation Therapy Likely Leads to Unnecessary Downstream Workup: A Longitudinal Study.

PURPOSE: To analyze the effect of post-radiation therapy (XRT) mammographic timing and radiation technique in relation to additional downstream workup for 569 breast conservation therapy patients treated with adjuvant XRT after their initial surveillance mammogram (MMG). METHODS AND MATERIALS: From January 2011 to December 2014, 569 breast cancer patients treated with breast conservation surgery and adjuvant XRT with a follow-up MMG were reviewed. Patients were stratified by the time interval until their first post-XRT MMG, and by XRT technique-whole breast (472), accelerated partial breast (96), conventional fractionation (373), hypofractionation (94), surgical cavity boosts (407), or no boost (66). The primary endpoint was further imaging after the initial MMG. RESULTS: Additional workup for those receiving an MMG within 3 months of completing XRT was 51% (73 of 143), compared with 40% (84 of 210) with MMG between 3 and 6 months and 34.5% (75 of 216) with MMG after 6 months (P=.04). Radiation boost to the postoperative bed was associated with further downstream imaging, whereas accelerated partial-breast irradiation and hypofractionated treatment were not. CONCLUSIONS: Breast conservation therapy patients who underwent screening MMG before 6 months after completion of XRT were more likely to undergo downstream workup, including additional biopsies. Accelerated and hypofractionated radiation techniques were not associated with supplementary workup. Further study is needed to assess appropriate selection of high-risk patients and possible negative implications of earlier post-XRT screening MMG.

Immunoglobulin allotypes influence IgG antibody responses to hepatitis C virus envelope proteins E1 and E2.

Immunoglobulin (Ig) GM and KM allotypes-genetic markers of gamma and kappa chains, respectively-are associated with the outcome of hepatitis C virus (HCV) infection, but the underlying mechanisms are not well understood. We hypothesized that GM and KM allotypes could contribute to the outcome of HCV infection by influencing the levels of IgG antibodies to the HCV glycoproteins E1E2. We serologically allotyped 100 African American individuals with persistent HCV infection for GM and KM markers and measured anti-E1E2 antibodies. Subjects with the GM 1,17 5,13 phenotype had significantly higher levels of anti-E1E2 antibodies than subjects who lacked this phenotype (p = 0.008). Likewise, subjects with the KM 1-carrying phenotypes had higher levels of anti-E1E2 antibodies than subjects who lacked these phenotypes (p = 0.041). Median titers were fourfold higher in persons expressing both GM 1,17 5,13 and KM 1-carrying phenotypes compared with those who lacked these phenotypes (p = 0.011). Interactive effects of these GM-KM phenotypes were previously found to be highly significantly associated with spontaneous HCV clearance. Results presented here show that Ig allotypes contribute to the interindividual differences in humoral immunity to the HCV epitopes, a finding that may provide a mechanistic explanation for their involvement in the outcome of HCV infection.