Safety and efficacy of tranexamic acid in children with cerebral palsy undergoing femoral varus derotational osteotomy: a double cohort study.

AIMS: The safety and efficacy of tranexamic acid (TXA) in reducing blood loss after total joint arthroplasty and spinal fusion surgery has been well documented. However, little data exist regarding the effectiveness of intraoperative TXA in children with cerebral palsy (CP). The aim of this double cohort study is to investigate the safety and efficacy of intraoperative TXA in reducing blood loss and transfusion requirements for children with CP undergoing a proximal unilateral or bilateral femoral varus derotational osteotomy (VDRO). PATIENTS AND METHODS: A retrospective review was performed of all paediatric theatre lists between May 2012 and January 2019 for all paediatric (< 16 years old) CP patients who underwent unilateral or bilateral VDRO combined with soft tissue release at our institution. Fifty-one patients were included in our study further subdivided into two individual groups, unilateral and bilateral VDRO. RESULTS: No statistically significant differences were found in demographics such as age, weight, ASA, GMFCS and antiepileptic medication between the groups. However, there were significant statistically differences in TBL and transfusion rates between the groups that received TXA and those that did not, both in unilateral [241 ml (TXA) vs. 369 ml (non-TXA)] and bilateral [287 ml (TXA) vs. 467 ml (non-TXA)] operations. CONCLUSION: TXA successfully reduced TBL (in both TXA subgroups) and the transfusion rates without associated complications. TXA's safety and efficacy should be explored further in adequately powered randomized controlled trials.

Reverse Ponseti-type treatment for children with congenital vertical talus: comparison between idiopathic and teratological patients.

Children with congenital vertical talus (CVT) have been treated with extensive soft-tissue releases, with a high rate of complications. Recently, reverse Ponseti-type casting followed by percutaneous reduction and fixation has been described, with excellent results in separate cohorts of children with CVT, of either idiopathic or teratological aetiology. There are currently no studies that compare the outcome in these two types. We present a prospective cohort of 13 children (21 feet) with CVT of both idiopathic and teratological aetiology, in which this technique has been used. Clinical, radiological and parent-reported outcomes were obtained at a mean follow-up of 36 months (8 to 57). Six children (nine feet) had associated neuromuscular conditions or syndromes; the condition was idiopathic in seven children (12 feet). Initial correction was achieved in all children, with significant improvement in all radiological parameters. Recurrence was seen in ten feet. Modification of the technique to include limited capsulotomy at the initial operation may reduce the risk of recurrence. The reverse Ponseti-type technique is effective in the initial correction of CVT of both idiopathic and teratological aetiology. Recurrence is a problem in both these groups, with higher rates than first reported in the original paper. However, these rates are less than those reported after open surgical release.

The three-dimensional morphometry of the odontoid peg and its impact on ventral screw osteosynthesis.

Ventral screw osteosynthesis is a common surgical method for treating fractures of the odontoid peg, but there is still no consensus about the number and diameter of the screws to be used. The purpose of this study was to develop a more accurate measurement technique for the morphometry of the odontoid peg (dens axis) and to provide a recommendation for ventral screw osteosynthesis. Images of the cervical spine of 44 Caucasian patients, taken with a 64-line CT scanner, were evaluated using the measuring software MIMICS. All measurements were performed by two independent observers. Intraclass correlation coefficients were used to measure inter-rater variability. The mean length of the odontoid peg was 39.76 mm (SD 2.68). The mean screw entry angle α was 59.45° (SD 3.45). The mean angle between the screw and the ventral border of C2 was 13.18° (SD 2.70), the maximum possible mean converging angle of two screws was 20.35° (SD 3.24). The measurements were obtained at the level of 66% of the total odontoid peg length and showed mean values of 8.36 mm (SD 0.84) for the inner diameter in the sagittal plane and 7.35 mm (SD 0.97) in the coronal plane. The mean outer diameter of the odontoid peg was 12.88 mm (SD 0.91) in the sagittal plane and 11.77 mm (SD 1.09) in the coronal plane. The results measured at the level of 90% of the total odontoid peg length were a mean of 6.12 mm (SD 1.14) for the sagittal inner diameter and 5.50 mm (SD 1.05) for the coronal inner diameter. The mean outer diameter of the odontoid peg was 11.10 mm (SD 1.0) in the sagittal plane and 10.00 mm (SD 1.07) in the coronal plane. In order to calculate the necessary screw length using 3.5 mm cannulated screws, 1.5 mm should be added to the measured odontoid peg length when anatomical reduction seems possible. The cross-section of the odontoid peg is not circular but slightly elliptical, with a 10% greater diameter in the sagittal plane. In the majority of cases (70.5%) the odontoid peg offers enough room for two 3.5 mm cannulated cortical screws.

Monitoring of cardiac function by serum cardiac troponin T levels, ventricular repolarisation indices, and echocardiography after conditioning with fractionated total body irradiation and high-dose cyclophosphamide.

OBJECTIVES: Highly differing rates of cardiac complications associated with high-dose cyclophosphamide (CY) have been reported, and only one clinical study has been performed on the cardiotoxic effects of CY monotherapy following total body irradiation (TBI). PATIENTS AND METHODS: We prospectively evaluated the potential cardiotoxic effects of conditioning with fractionated total body irradiation and high-dose cyclophosphamide (TBI/CY) by serial measurement of serum cardiac troponin T (cTnT), assessment of systolic and diastolic echocardiographic parameters and analysis of ventricular repolarisation indices (QT-dispersion and corrected QT-dispersion) in 30 adult patients with haematological malignancies undergoing haematopoietic stem cell transplantation. RESULTS: There was no evidence of pretreatment cardiac dysfunction in any patient. Although cTnT was determined serially for a median of 14 d after completion of conditioning, no elevated levels were observed. Echocardiographic parameters did not show any significant change at a median follow-up of 5 months except for one patient with evidence of impaired diastolic filling. No significant differences for mean values before and after high-dose CY were noted for ventricular repolarisation indices. Two patients had a significant increase in corrected QT-dispersion after CY without any other signs of cardiotoxicity. Congestive heart failure or arrhythmias were not observed. CONCLUSIONS: These data suggest that TBI/CY is safe with respect to cardiotoxicity in patients without pre-existing cardiac dysfunction. Hitherto unknown synergistic cardiotoxic effects of CY with other cytostatic drugs may constitute the major pathogenic factor of myocardial dysfunction after high-dose chemotherapy.