SYMPOSIUM: 2013 LIMB LENGTHENING AND RECONSTRUCTION SOCIETY What Risk Factors Predict Usage of Gastrocsoleus Recession During Tibial Lengthening?

Abstract Background Tibial lengthening is frequently associated with gastrocsoleus contracture and some patients are treated surgically. However, the risk factors associated with gastrocsoleus contracture severe enough to warrant surgery during tibial lengthening and the consistency with which gastrocsoleus recession (GSR) results in a plantigrade foot in this setting have not been well defined. Questions/purposes We compared patients treated with or without GSR during tibial lengthening with respect to (1) clinical risk factors triggering GSR use, (2) ROM gains and patient-reported outcomes, and (3) complications after GSR. Methods Between 2002 and 2011, 95 patients underwent tibial lengthenings excluding those associated with bone loss; 82 (83%) were available for a minimum followup of 1 year. According to our clinical algorithm, we performed GSR when patients had equinus contractures of greater than 10°while lengthening or greater than 0°before or after lengthening. Forty-one patients underwent GSR and 41 did not. Univariate analysis was performed to assess independent associations between surgical characteristics and likelihood of undergoing GSR. A multivariate regression model and receiver operating characteristic curves were generated to adjust for confounders and to establish risk factors and any threshold for undergoing GSR. Chart review determined ROM, patient-reported outcomes, and complications. Results Amount and percentage of lengthening, age, and etiology were risk factors for GSR. Patients with lengthening of greater than 42 mm (odds ratio [OR]: 4.13; 95% CI: 1.82, 9.40; p = 0.001), lengthening of greater than 13% of lengthening (OR: 3.88; 95% CI: 1.66, 9.11; p = 0.001), and congenital etiology (OR: 1.90; 95% CI: 0.86, 4.15; p = 0.109) were more likely to undergo GSR. Adjusting for all other variables, increased amount lengthened (adjusted OR: 1.05; 95% CI: 1.02, 1.07; p \ 0.001) and age (adjusted OR: 1.02; 95% CI: 0.99, 1.05; p = 0.131) were associated with undergoing GSR. Patients gained 24°of ankle dorsiflexion after GSR. Selfreported functional outcomes were similar between patients with or without GSR. Complications included stretch injury to the posterior tibial nerve leading to temporary and partial loss of plantar sensation in two patients

Do Radiographic and Clinical Parameters in the Setting of a Bunion Predict Second Ray Pathology?

Category: Bunion Introduction/Purpose: Hallux valgus deformity is well known to cause second ray pathology, commonly manifested as a second hammertoe or second tarsometatarsal (TMT) joint osteoarthritis (OA). This likely results from decreased weight-bearing capacity of the first metatarsal in the setting of worsening metatarsus primus varus, TMT joint hypermobility, or an excessively long second metatarsal or second toe. It is not known for sure, however, which radiographic and clinical factors in the setting of hallux valgus are protective of second ray pathology and which lead to second hammertoe, TMT joint OA, or both. We hypothesized that the formation of second ray pathology would be correlated with increasing age, increased body mass index (BMI), increased hallux valgus angle (HVA), increased intermetatarsal angle (IMA), and increased second metatarsal length. Methods: All consecutive patients who underwent operative reconstruction for symptomatic hallux valgus from January 2007 to July 2015 by the senior author were included. Patients were grouped into those with 1) bunion only 2) bunion with hammertoe and 3) bunion with second TMT joint OA. Preoperative age, sex, and BMI were recorded. Pre-operative HVA, IMA, metatarsus adductus angle (MAA), and first and second metatarsal lengths were measured on weight-bearing anteroposterior (AP) radiographs. Talar-first metatarsal angle was measured on weight-bearing lateral radiographs. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) were used to assess differences in continuous variables. Post hoc tests were conducted with Bonferroni technique. Associations between discrete variables and the study groups were analyzed using chi-square tests. Results: Increased age was associated with both hammertoe (P = 0.000) and TMT joint OA (P = 0.006). Increased BMI was associated with TMT joint OA (P = 0.016). Increased HVA was associated with both hammertoe (P = 0.039) and TMT joint OA (P = 0.038). When analyzed categorically, 29.7% of patients with TMT joint OA had a moderate HVA (30.0-39.9 degrees) whereas 22.2% of patients with a bunion only had a moderate HVA (P < 0.05). A one-degree increase in HVA was associated with a 5% chance of having a hammertoe as compared to a bunion only. MAA correlated with TMT joint OA (P = 0.048) (Table 1). Conclusion: Our data suggests that increased age (a surrogate for bunion duration) and increased HVA may predispose patients with hallux valgus to second hammertoe and TMT joint OA formation. Increased BMI may lead to the development of TMT joint OA. Increased MAA may predispose to hammertoe formation. Increased MAA may lead to TMT joint OA. Alternatively, increased MAA could result as a consequence of midfoot cartilage and bone loss in the setting of hallux valgus. This data can help surgeons better inform patients about the optimal timing of bunion reconstruction with or without concomitant second ray surgery

Uptake of postplacental intrauterine device placement at cesarean deliveryAJOG Global Reports at a Glance

BACKGROUND: Several studies have investigated the effectiveness of intrauterine device placement at cesarean delivery as a contraceptive method. However, national-level use and outcomes of a postplacental intrauterine device at cesarean delivery are currently understudied in the United States. OBJECTIVE: This study aimed to examine the trends, characteristics, and outcomes of patients who received a postplacental intrauterine device at cesarean delivery. STUDY DESIGN: This retrospective cohort study used the National Inpatient Sample. The study cohort included patients who underwent cesarean delivery from October 2015 to December 2018. The exclusion criteria included hemorrhage, chorioamnionitis, uterine anomaly, hysterectomy, and permanent surgical sterilization. Eligible cases were grouped on the basis of the use of a postplacental intrauterine device at cesarean delivery. The primary outcome measures were temporal trends and characteristics associated with the use of a postplacental intrauterine device at cesarean delivery, assessed using the generalized estimating equation model in multivariable analysis. The secondary outcome measure was perioperative morbidity (leukocytosis, endometritis, myometritis, and sepsis). Propensity score matching was used to balance the baseline characteristics. RESULTS: Among 2,983,978 patients who met the inclusion criteria, 10,145 patients (0.3%) received a postplacental intrauterine device at cesarean delivery. The use of a postplacental intrauterine device increased from 0.1% in the fourth quarter of 2015 to 0.6% in the fourth quarter of 2018 (P<.001). In a multivariable analysis, the use of a postplacental intrauterine device increased by 14% every quarter-year (adjusted odds ratio, 1.14; 95% confidence interval, 1.13–1.15). In addition, (1) patient characteristics of young age, non-White race, obesity, tobacco use, lowest quartile median household income, and insured with Medicaid; (2) hospital characteristics of large bed capacity and urban teaching setting in Northeast region; and (3) pregnancy characteristics of early gestational age at cesarean delivery, hypertensive disease, previous cesarean delivery, multifetal pregnancy, grand multiparity, placenta previa, and nonelective cesarean delivery represented the independent characteristics associated with the use of a postplacental intrauterine device (all P<.05). A regression tree model identified 35 discrete patterns of the use of a postplacental intrauterine device based on 8 factors (time, race or ethnicity, primary expected payer, obesity, hospital bed capacity, hospital teaching status, hospital region, and previous cesarean delivery). There were 9 patterns, representing 8.8% of the study population, exhibiting a use rate of ≥1.0%, whereas there were 7 patterns, representing 16.0% of the study population, exhibiting no use of a postplacental intrauterine device (absolute rate difference from the highest group to the lowest group, 4.7%). In a propensity score–matched model, postplacental intrauterine device placement at cesarean delivery was not associated with increased risk of measured morbidity (any, 1.8% vs 1.7%; odds ratio, 1.06; 95% confidence interval, 0.66–1.69; P=.812), including postpartum endometritis (1.2% vs 1.0%; odds ratio, 1.19; 95% confidence interval, 0.67–2.14; P=.554). CONCLUSION: The use of a postplacental intrauterine device at cesarean delivery increased significantly in recent years in the United States