Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite varying anecdotal opinions, its association with different treatments, especially the Ponseti method, remains uncertain. This systematic review aimed to establish the aetiology and prevalence of FTT, as well as detailing management strategies and their efficacy.

A systematic review was conducted according to PRISMA guidelines to search for articles using MEDLINE, EMBASE and Web of Science until November 2021. Studies with original data relevant to one of three questions were included: 1) Possible aetiology 2) Prevalence following different treatments 3) Management strategies and their outcomes.

32 original studies were included, with a total of 1473 clubfeet. FTT may be a pre-existing feature of the pathoanatomy of some clubfeet as well as a sequela of treatment. It can be a radiological artefact due to positioning or other residual deformity. The Ponseti method is associated with a higher percentage of radiologically normal tali (57%) than both surgical methods (52%) and non-Ponseti casting (29%). Only one study was identified that reported outcomes after surgical treatment for FTT (anterior distal tibial hemiepiphysiodesis).

The cause of FTT remains unclear. It is seen after all treatment methods but the rate is lowest following Ponseti casting. Guided growth may be an effective treatment.

Key words:

Clubfoot, Flat-top talus, Ponseti method, guided growth

Disclosures: The authors have no relevant disclosures.

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur.

We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury.

74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94).

Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery.

Applying the concept of a regional trauma network to the UK paediatric trauma population has unique difficulties in terms of low patient volume and variation in paediatric service provision. In addition, no consensus exists as to which radiological investigations should be employed and an increasing trend towards computerised tomography raises concerns over radiation exposure. We carried out a retrospective review of all paediatric trauma calls from April 2010 and March 2013 around becoming a Major Trauma Centre. We aim to analyse the impact this has on trauma calls and assess the radiological investigations currently used in this population.

The number of yearly paediatric trauma calls doubled during our study and totalled 132. The commonest mechanisms of injury were road traffic collisions, fall from a height or fall off a horse. 91.7% of children had some form of radiological investigation; 67% plain radiograph, 37.1% trauma CT, 21.2% focused CT and 5.3% abdominal ultrasound scan. Of the 77 CT scans performed 57.1% were reported as normal and 54.5% of these patients were discharged home the same day. Five children re-attended the emergency department within 30 days with two positive findings; a subdural haematoma and a tibial plateau fracture.

The current use of harmful radiological investigations in paediatric trauma patients is not uniform. We propose implementation of radiology protocols and clinical guidance to imaging in paediatric trauma to limited radiation exposure.

The orientation of the acetabular component in metal-on-metal hip resurfacing arthroplasty affects wear rate and hence failure. Correct assessment of acetabular orientation is key in assessing the painful hip resurfacing. This study aimed to establish if interpretation of pelvic radiographs with TraumaCad software can provide a reliable alternative to computed tomography (CT) in measuring the acetabular inclination and version.

TraumaCad was used to measure the acetabular orientation on AP pelvis radiographs of 14 painful hip resurfacings. Four orthopaedic surgeons performed each measurement twice. These were compared with measurements taken from CT reformats performed by an experienced musculoskeletal radiologist. The correlation between TraumaCad and CT was calculated, as was the intra- and inter-observer reliability of TraumaCad.

There is strong correlation between the two techniques for the measurement of inclination and version (p<0.001). Intra- and inter-observer reliability of TraumaCad measurements are good (p<0.001). Mean absolute error for measurement of inclination was 2.1°. TraumaCad underestimated version compared to CT in 93% of cases, by 12.6 degrees on average.

When assessing acetabular orientation in hip resurfacing, the orthopaedic surgeon may use TraumaCad in the knowledge that it correlates well with CT and has good intra- and inter-observer reliability but underestimates version by 12° on average. This underestimation may be contributed to by the natural divergence of the X-ray beam, the short arc of the ellipse left exposed by the large diameter head, and the non-hemispherical resurfacing cup.

The femur is a common site for skeletal metastases. The Gamma2 nail has proved effective in relieving pain and restoring function. Little data exists on the use of the Gamma3 Long Nail (GLN) in this condition. Improved instrumentation is suggested to reduce operative time and facilitate minimally invasive surgery. This study reports a series of patients treated in a District General Hospital.

A retrospective casenote review was performed of all patients treated with the GLN for femoral metastatic disease over a five year period. Patients were followed-up for a minimum of one year. Functional level was assessed using the Parker Mobility Score (PMS).

12 patients underwent 15 nailings. Mean age was 75.4 years (median 75.7, range 61-92). In bilateral cases, the operations were performed during the same hospital admission. There were seven prophylactic nailings for impending fracture from proximal femoral lesions, seven procedures for actual fractures distal to the intertrochanteric line, and one basicervical fracture associated with multiple femoral metastases. Primaries were four prostate, two breast, two lung, one bowel, one bladder, one renal, and one myeloma.

Average anaesthetic time for all procedures was 134 mins (median 125, range 90-210). Average peri-operative drop in serum haemoglobin was 2.3g/dL (median 2.1, range 0.6-4.8). Five patients with actual fracture and one patient with impending fracture required blood transfusion, receiving 2.2 units on average.

In-hospital mortality rate was 0.83%, with only one patient not surviving to discharge. One year mortality was 83.3%. Only two patients were alive one year post-operation. Of the remaining patients, average survival was 3.2 months (median 3, range 1-6). Patients spent an average of 17 days on an acute orthopaedic unit (median 14, range 4-80). Two patients required further convalescence in a rehabilitation unit.

There were three surgical complications. Two impending fractures became complete, One intra-operatively and one post-operatively. In the case of basi-cervical fracture, the proximal screw cut out of the femoral head, requiring revision to a long-stem bipolar hemiarthroplasty. This was the only re-operation required in this series.

Average pre-operative PMS was 5.2 (median 4, range 2-9). Average peri-operative drop in PMS was two points (median 1.5, range 0-6). Of the 11 patients who survived to discharge, 10 were independently mobile and returned to their pre-operation residence. Nine required a change in walking aids. Only one patient reported post-operative pain.

This small patient series suggests that the Gamma3 Long Nail is a suitable treatment option for impending and actual metastatic femoral fractures in the District General setting. Length of stay, in-hospital mortality and re-operation rates compare favourably with published data on the Gamma2. There was a significant drop in Parker Mobility Score but all patients bar one were independently mobile and returned to their home. Anaesthetic time was not lower than with the Gamma2, suggesting little tangible benefit of the new instrumentation.