Progressive collapsing foot deformity (PCFD) is a common condition with an estimated prevalence of 3.3% in women greater than 40 years. Progressive in nature, symptomatic flatfoot deformity can be a debilitating condition due to pain and limited physical function; it has been shown to have one of the poorest preoperative patient reported outcome scores in foot and ankle pathologies, second to ankle arthritis. Operative reconstruction of PCFD can be performed in a single-stage manner or through multiple stages. The purpose of this study is to compare costs for non-staged (NS) flatfoot reconstructions, which typically require longer hospital stays, with costs for staged (S) reconstructions, where patients usually do not require hospital admission. To our knowledge, the comparison between single-staged and multi-staged flatfoot reconstructions has not been previously done. This study will run in conjunction with one that compares rates of complications and reoperation, as well as patient reported outcomes on function and pain associated with S and NS flatfoot reconstruction. Overall, the goal is to optimize surgical management of PCFD, by addressing healthcare costs and patient outcomes.

At our academic centre with foot and ankle specialists, we selected one surgeon who primarily performs NS flatfoot reconstruction and another who primarily performs S procedures. Retrospective chart reviews of patients who have undergone either S or NS flatfoot reconstruction were performed from November 2011 to August 2021. Length of operating time, number of primary surgeries, length of hospital admission, and number of reoperations were recorded. Cost analysis was performed using local health authority patient rates for non residents as a proxy for health system costs. Rates of operating room per hour and hospital ward stay per diem in Canadian dollars were used. The analysis is currently ongoing.

72 feet from 66 patients were analyzed in the S group while 78 feet from 70 patients were analyzed in the NS group. The average age in the S and NS group are 49.64 +/− 1.76 and 57.23 +/− 1.68 years, respectively. The percentage of female patients in the S and NS group are 63.89% and 57.69%, respectively. All NS patients stayed in hospital post-operatively and the average length of stay for NS patients is 3.65 +/− 0.37 days. Only 10 patients from S group required hospital admission.

The average total operating room cost including all stages for S patients was $12,303.12 +/− $582.20. When including in-patient ward costs for patients who required admission from S group, the average cost for operating room and in-patient ward admission was $14,196.00 +/− $1,070.01 after flatfoot reconstruction.

The average in-patient ward admission cost for NS patients was $14,518.83 +/− $1,476.94 after flatfoot reconstruction. The cost analysis for total operating room costs for NS patients are currently ongoing. Statistical analysis comparing S to NS flatfoot reconstruction costs are pending.

Preliminary cost analysis suggests that multi-staged flatfoot reconstruction costs less than single-staged flatfoot reconstruction. Once full assessment is complete with statistical analysis, correlation with patient reported outcomes and complication rate can guide future PCFD surgical management.

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported.

This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession.

Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded.

Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires.

Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications.

Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05.

We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months.

Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD.

For any figures or tables, please contact the authors directly.

Aim

To evaluate the outcome and complications of pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries.

The direction of penetration of the femoral head following total hip replacement has been shown at revision to be superomedial, superior or superolateral. However, it is important to study well functioning components to describe normal patterns of wear. The aim of this study was to characterise the 3D direction of penetration in standard and HXLPE.

A prospective double blind randomised control trial was conducted using Radiostereometric Analysis (RSA). Fifty-four subjects were randomised to receive hip replacements with either UHMWPE liners or HXLPE liners. All subjects received a cemented CPT stem and uncemented Trilogy acetabular component (Zimmer, Warsaw, IN, USA). The 3D penetration of the head into the socket was determined to a minimum of 7 years.

The direction of penetration between one and seven years was in a superior and lateral direction for both groups. In the HXLPE group there was no significant penetration in the coronal or sagittal planes (superiorly 0.009 mm/yr, 95% confidence interval, ±0.045, p1 = 0.68, laterally 0.003mm/yr, CI 0.031, p1 = 0.85). In the UHMWPE group there was significant penetration 0.059 mm/yr superiorly (CI 0.042, p1 = 0.01) and 0.049 mm/yr laterally (CI 0.044, p1 = 0.03). The anterior-posterior steady state penetration was not significant in either group (HXLPE p1 = 0.39, UHMWPE p1 = 0.37).

We have previously demonstrated that the penetration in the first year is creep-dominated and is in the proximal direction. From one year onwards the superolateral direction of penetration is probably due to wear. The steady-state wear direction is the same in both bearings types. It is likely that creep occurs in the direction of the Joint Reaction Force i.e. superomedial, whereas wear is perpendicular to the axis of rotation and therefore superolateral. This work may enable us to develop more accurate models for predicting wear in total hip arthroplasty.

Introduction

Humeral non-union may present a challenging problem. The instability from the un-united fracture leads to pain, disability and significant morbidity. The incidence of humeral shaft non-union as a complication of both operative and non-operative treatment is approximately 8% to 12%. This retrospective study reviews the results of surgical treatment of humeral fracture non-union performed by a single surgeon with a consistent surgical protocol.

To assess the efficacy of a combined orthoplastic approach to the management of severe grade III fractures of the lower limb, we looked at the functional and radiological outcome of 100 consecutive fractures from a specialist centre.

A prospective analysis was performed on 100 consecutive open tibial fractures (98 patients). An early decision was made by a specialist multidisciplinary team as to whether the injured limb was reconstructable.

In the reconstruction group there were 84 Gustilo grade IIIB/C injuries. Definitive skeletal stabilisation was most commonly with a circular frame (60%) or intramedullary nail (20%). The mean time to union was 26 weeks for diaphyseal fractures, 20 weeks for metaphyseal fractures and 10 weeks for ankle fractures. There was one aseptic non-union which is still undergoing treatment. The anterolateral thigh free flap was the most common soft tissue reconstruction used (42%). There were minimal surgical complications and only one free flap failure. Mean time to follow-up was 24 months. The mean limb functional score (modified enneking) was 83% of that of the normal limb and was not influenced by the site of fracture or type of fixation. The mean SF-36 score was 75 and there was a high return to employment (70%).

In the primary amputation group there were 16 grade IIIB/C injuries. Mean time to follow-up was 38 months. The mean SF-36 score for the below knee amputees was 58 and there was again a high return to employment (58%).

In the reconstruction group there is a 99% limb salvage rate with infection-free union to date and no delayed amputations. A higher return to functional activity/employment was achieved in the reconstruction group compared to the primary amputation group. Our results demonstrate that by using a combined orthoplastic approach in a specialist centre excellent results can be achieved for all patients presenting with severe open lower limb injuries.