Tarsal decancellation in the residual resistant arthrogrypotic clubfoot.

INTRODUCTION: Conservatism is well recognised after Ponseti's method in the treatment of congenital clubfoot; however, this is not applicable to the complex and resistant arthrogrypotic type which challenges the orthopaedic surgeon. In such a type, soft tissue releases as fasciotomies, tenotomies, and capsulotomies, as well as osteotomies are insufficient, and joint fusions are not suitable in early childhood before skeletal maturity. PATIENTS AND METHODS: Twelve children (15 feet) with residual resistant arthrogrypotic clubfeet between 2-4 years of age were analysed clinically and radiographically. All of the cases received previous conservative Ponseti's method of treatment in their first year of life followed by soft tissue releases (plantar fasciotomy, posteromedial tenotomies, capsulotomies, and abductor hallucis release) before treatment by decancellation of the cuboid, the calcaneus, and the talus to correct the complex adduction, supination, varus, and equinus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values. RESULTS: A grading scheme for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 3.3 years. Six feet (40%) had excellent, six (40%) good, three (20%) fair, and no poor (0%) outcome. There was no major complication. There was significant improvement in the result (P > 0.035). CONCLUSIONS: Tarsal decancellation is particularly applicable to residual resistant clubfoot such as the arthrogrypotic type at an early age. It shortens the period of disability, improves the range of foot motion, and does not interfere with the foot bone growth.

Great toe metatarsophalangeal arthrodesis for hallux valgus deformity in ambulatory adolescents with spastic cerebral palsy.

BACKGROUND: Hallux valgus deformity is a common sequel of spastic cerebral palsy. METHODS: Twenty ambulatory patients (24 feet) suffering hallux valgus deformity, with painful forefoot and restricted footwear, secondary to spastic cerebral palsy acquired perinatally, were treated with great toe metatarsophalangeal (MTP) arthrodesis using percutaneous K-wires for fixation. The mean age at the time of surgery was 16.2 years (range 14-18 years). They were retrospectively evaluated for the results after arthrodesis at a mean interval of 3 years and 4 months (range 3-4 years) by physical examination and radiographs. RESULTS: All patients had a stable painless aligned great toe, with <10 degrees valgus, <20 degrees dorsiflexion and neutral rotation after arthrodesis, evidenced by improvement in pain, cosmesis, functional activity, footwear, callosities and hygiene, as well as by significant improvement in the measures of the MTP and the intermetatarsal angles (IMA) by postoperative radiographs. Neither non-union (pseudoarthrosis) nor recurrence of the deformity developed. Complications included superficial wound slough in a single case. Using the modified American Orthopaedic Foot Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale, 18 feet (75%) were classified as excellent and six feet (25%) as good. Neither fair nor poor cases were recorded. CONCLUSION: Hallux valgus deformity in adolescents with spastic cerebral palsy is best treated by great toe MTP arthrodesis to improve segmental foot malalignment and dynamic foot deviation.

Cost-effectiveness of active versus conservative colposcopic management of mild dyskaryosis.

Management of mild dyskaryosis remains controversial. In this study, we compared the cost-effectiveness of active versus conservative colposcopic management of women presenting with mild dyskaryosis in two different hospital settings. All women presenting in 2001 with a mild dyskaryotic smear and requiring colposcopy were studied in two different clinical settings (70 women at Darent Valley Hospital (DVH) and 327 at St George's Hospital (SGH)). At DVH, treatment is offered should there be any evidence of cervical intraepithelial neoplasia (CIN). On the other hand, a more conservative approach of cytological and colposcopical follow-up is offered to patients with evidence of low-grade disease at SGH. The outcome of both groups of patients was determined in terms of the number of colposcopy visits per patient, the risk of missing disease as a consequence of patients lost to follow-up and hospital costs as well as costs to patient over a four-year period. The majority (70%) of DVH patients had 1-2 colposcopy visits whereas the majority (60%) of SGH patients had 3-7 visits. At SGH 44% of untreated patients were lost to follow-up and an unknown number of those might have had high-grade disease. Active management is more cost-effective compared with conservative management ( pound323 and pound589 as cost per patient effectively treated in the two hospitals respectively). In conclusion, active management of low-grade disease is associated with lower hospital and patient costs compared with the conservative strategy.