Abstract

Residual club foot (CTEV) is a challenging deformity which may require transfer of the tibialis anterior tendon to a more lateral position. The senior author has developed a modified SPLATT for residual forefoot supination in CTEV.

We describe the SPLATT procedure and evaluate clinical and radiological outcomes of 11 patients(14 feet) (mean follow up 6.6 years; range 5.5–8.9) (mean age 6.9 years; range 2.9–10.0). Two patients had cerebral palsy, 1 spina bifida and 1 juvenile rheumatoid arthritis, the remaining 7 patients were ideopathic.

Outcome measures based on patient centred assessment of function and foot appearance, by using the patient applied assessments of Chesney, Utukuri and Laaveg & Ponsetti (there is increasing recognition that doctor-centred or radiograph-based scoring systems do not tally well with patient satisfaction).

Objective assessment of outcome was provided by measurement of certain radiological parameters on the immediate pre-operative and the follow up weight-bearing radiographs (1st ray angle, talar-1st metatarsal angle, talar-2nd metatarsal angle, talo-calcaneal angle). The calcaneal line passing through the medial 1/3 of the cuboid or medial to the fourth metatarsal was also noted. The Blecks grade was recorded (pre-op 100% moderate-severe; post-op 88% mild-moderate). Parents assessed outcome based upon ‘best level of activity’, functional limitation and willingness to recommend treatment to others.

Mean Chesney score at the time of follow up was 12.3 (8 to 15); mean Utukuri score was 15.8 (10 to 24); Laaveg and Ponsetti score was 81.5 (67 to 95). The best activity level achievable was ‘unlimited’ in 4 patients, ‘football’ in 4 patients, ‘running’ in 1 and limited by an associated condition in 2 patients (1 juvenile rheumatoid arthritis; 1 cerebral palsy related spastic paraparesis). All patients/parents indicated that they would undergo the same procedure again. One patient had delayed wound healing treated successfully with dressings.

The 1st ray angle pre-operatively was 61.2°(range 50–70°), post-operatively it was 62.1°(range 50–81°). The talar-1st metatarsal angle was 28.8°(range 15–44°) pre-operatively and 19.1°(range 4–34°) post-operatively. The pre and post–operative talar-2nd metatarsal angles were 22.5°(range 0–35°) and 12.3(range 0–29°) respectively, the talo-calcaneal angle was 17.5°(range 10–35°) and 13.7(range 5–20°) respectively. The pre and postoperative lateral talo-calcaneal angles were 34.5°(range 25–40°) and 30.6(range 13–45°).

The recognition that patient orientated subjective assessment is gaining in acceptance, and confirm patient satisfaction with function, cosmesis and pain levels with the SPLATT procedure. More traditional radiological outcome measures also confirm that the modified SPLATT is a safe, effective and acceptable procedure.

Metatarsus adductus (MA) is associated with a medially facing distal facet of the medial cuneiform (with a normal first metatarsal) and varus/adducted deformities of the metaphysis of the lesser metatarsals. A number of patients with severe symptomatic metatarsus adductus do not improve with time. A number of surgical techniques have been described but the series are small and use radiological rather functional outcomes. It is clear however that the failure and complication rate with these procedures is high. A combined medial cuneiform and lesser metatarsal basal closing wedge osteotomy has potential advantages over more commonly used procedures (including the combined cuneiform-calcaneal) osteotomy, by correcting at the level of deformity.

We reviewed a consecutive series of 15 cases (11 severe idiopathic metatarsus adductus, 4 with history of clubfoot) (all Bleck’s grade severe) treated with combined cuneiform-metatarsal osteotomies. Patients were followed up for a mean of 30 months using child-, parent and clinician-based outcome measures as well as radiological assessment. Outcomes are also compared to currently used and historical procedures.

Bleck’s grade improved to 65% normal 35% mild post op; Radiographic improvements (all p< 0.001); 1stray angle 30°→62°, 1stMT-Talar angle 43°→9°, 2ndMT-Talar angle 41°→8°, 2ndMT-Calcaneal angle 48°→14°, 5thMT-Calcaneal angle improved from 13°→3°. Mean postop scores; Chesney - 14 (12–15); Utukari – 13 (10–18); Laaweg – 93 (81–100); Vitale – 13 (10–14). None of the radiographic scores correlated with the clinical scores. All children gained improved levels of activity.

Our findings indicate that this technique can be used effectively in children > 4 years and is a safe alternative to historical procedures, with excellent radiographic/ clinical outcomes, and a low complication rate.

The main mode of failure of the acetabular component in total hip arthroplasty is aseptic loosening. Successive generations of cementation techniques have evolved to alleviate this problem.

This paper evaluates one such method, Negative Pressure Intrusion cementation. Two groups of machined bovine cancellous bone samples were created; experimental (n = 26) and control (n = 26). The experimental group was cemented using the negative pressure technique and control group was cemented in the absence of negative pressure. The relative cement intrusion depths were then assessed for each group using MicroCT. These samples were then further machined and tested to failure in torsion to estimate their mechanical properties.

Results show mean cement intrusion depth for the negative pressure group to be 8676μm and 6042 μm for the control group (p = 0.078). Mechanical testing also revealed a greater mean torque in the negative pressure group (1.6223Nm vs 1.2063Nm) (p = 0.095).

This work quantifies the effect of negative intra-osseous pressure on cement intrusion depth in cancellous bone and for the first time relates this to increased mechanical strength.

Metastatic bone disease is increasing in association with ever improving medical management of osteophylic malignant conditions. The precise timing of surgical intervention for secondary lesions in long bones can be difficult to determine. This paper aims to validate a classic scoring system.

All radiographs were examined twice by 3 orthopaedic oncologists and scored according to the Mirels’ scoring system. The Kappa statistic was used for the purpose of statistical analysis.

The results show agreement between observers (κ=0.35–0.61) for overall scores at the 2 time intervals. Inter-observer agreement was also seen with subset analysis of size (κ=0.27–0.60), site (κ=0.77–1.0) and nature of the lesion (κ=0.55–0.81). Similarly, low levels of intra-observer variability were noted for each of the 3 surgeons (κ=0.34, 0.39, 0.78 respectively).

These results validate the Mirels’ scoring system across a wide spectrum of malignant pathology. We continue to advocate its use in the management of patients with long bone metastases.