Short term clinical and patient reported outcomes following Virtual Fracture Clinic management of fifth metatarsal fractures.

INTRODUCTION: Fracture clinics are experiencing increased referrals and decreased capacity. Virtual fracture clinics (VFC) are an efficient, safe, and cost-effective solution for specified injury presentations. There is currently a lack of evidence to support the use of a VFC model in the management of 5th metatarsal base fractures. This study aims to assess clinical outcomes and patient satisfaction with the management of 5th metatarsal base fractures in VFC. We hypothesise that it is both safe and cost effectiveness. METHODS: Patients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture, between January 2019 and December 2019, were included. Patient demographics, clinic appointments, complication and operative rates were analysed. Patients received standardised VFC treatment; walker boot/full weight bearing, rehabilitation information and instructions to contact VFC if symptoms of pain persist after 4 months. Minimum follow-up was one year; Manchester-Oxford Foot Questionnaires (MOXFQ) were distributed. A basic cost analysis was performed. RESULTS: 126 patients met inclusion criteria. Mean age was 41.6 years (18-92). Average time from ED attendance to VFC review was 2 days (1 - 5). Fractures were classified according to the Lawrence and Botte Classification with 104 (82%) zone 1 fractures, 15 (12%) zone 2 fractures and 7 (6%) zone 3 fractures. At VFC, 125/126 were discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; pain the reason in all cases. There was 1 non-union during the study period. Average MOXFQ score post 1 year was 0.4/64, with only 11 patients scoring more than 0. In total, 248 face-to-face clinic visits were saved. CONCLUSION: Our experience demonstrates that the management of 5th metatarsal base fractures in the VFC setting, with a well-defined protocol, can prove safe, efficient, cost effective and yield good short term clinical outcomes.

Clinical outcomes and complications of the Zadek calcaneal osteotomy in Insertional Achilles Tendinopathy: A systematic review and meta-analysis.

BACKGROUND: The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (IAT) that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT. METHODS: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95 % confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). RESULTS: Ten studies with 232 patients were included. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia. CONCLUSIONS: The Zadek osteotomy is a safe and effective procedure for patients with IAT. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this. LEVEL OF EVIDENCE: II.

Functional Outcomes of Dorsal Bridge Plating for Lisfranc Injuries With Routine Implant Retention: A Major Trauma Center Experience.

OBJECTIVES: To assess medium-term functional outcomes and the complication profile for unstable Lisfranc injuries treated with dorsal bridge plate (DBP) fixation when implants are not routinely removed. DESIGN: Large single-center retrospective case series. SETTING: Level-1 Trauma Center, London, United Kingdom. PATIENTS: Consecutive cases of skeletally mature individuals with unstable Lisfranc injuries treated operatively between 2014 and 2019. INTERVENTION: Open reduction and DBP fixation with implants not routinely removed. MAIN OUTCOME MEASUREMENTS: Patient-reported outcome measures at final follow-up. The Manchester-Oxford Foot Questionnaire summary index was the primary outcome measure. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause reoperation rates were secondary outcome measures. Logistic regression models were used to identify risk factors that influenced outcomes. RESULTS: Eighty-five patients were included. Mean follow-up was 40.8 months (24-72). The mean Manchester-Oxford Foot Questionnaire Summary Index was 27.0 (SD 7.1) and mean AOFAS score 72.6 (SD 11.6). The presence of an intra-articular fracture was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both P < 0.001). Eighteen patients (21%) required implants removal, with this more likely in female patients (OR 3.89, 95% confidence interval, 1.27 to 12.0, P = 0.02). Eight patients (9%) required secondary arthrodesis. CONCLUSIONS: This is the largest series of Lisfranc injuries treated with DBP fixation reported to-date and the only to routinely retain implants. Medium-term outcomes are comparable to existing literature in which implants are routinely removed. The presence of an intra-articular fracture is a poor prognostic indicator. Implant removal is more likely to be needed in female patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Bullying in trauma and orthopaedics: a survey of staff in orthopaedic departments in the UK.

BACKGROUND/AIMS: An orthopaedic department requires good teamwork and communication to function. This is undermined by bullying and harassment, which may affect the victim's health and career. METHODS: A 26-item questionnaire was sent to all delegates who registered for a free orthopaedic webinar teaching series via email and social media. This study includes the responses from all those who had worked in a UK orthopaedic department. RESULTS: There were 168 respondents from varying backgrounds; 17.9% had experienced bullying or harassment in their orthopaedic department, while 36.3% had witnessed it. Women and people from ethnic minority backgrounds suffered 10.2% and 6.9% higher rates of bullying than their male or white counterparts respectively. CONCLUSIONS: The results demonstrate that despite attempts to reduce bullying in orthopaedics, it remains prevalent, and particularly affects women and those from ethnic minority backgrounds. Orthopaedic departments must adapt to reflect changes in society.

Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre.

INTRODUCTION: The Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London. METHODS: This is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications. RESULTS: Of the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates. CONCLUSION: Coronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.

Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre.

AIMS: Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes. METHODS: A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure. RESULTS: Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double. CONCLUSION: This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates.

Minimally Invasive Hallux Valgus Surgery-A Systematic Review and Assessment of State of the Art.

Minimally invasive techniques in the treatment of hallux valgus deformity have seen growing popularity since the 1990s. The purpose of this article is to assess the existing body of literature as to the safety and efficacy of minimally invasive techniques and identify areas for further development. The appeal of minimizing soft tissue damage, reducing surgical time, and faster recovery is currently offset by the initial learning curve and a lack of high-quality studies regarding minimally invasive techniques. There is currently insufficient evidence to recommend one minimally invasive technique over another and further high-level evidence studies are warranted.

Outcomes Following Total Ankle Arthroplasty: A Review of the Registry Data and Current Literature.

End-stage ankle arthritis has a significant effect on function and quality of life. Total ankle arthroplasty continues to emerge as a safe and effective treatment of ankle arthritis. Ankle arthroplasty preserves motion at the ankle joint, while still achieving the primary goal of pain relief. With encouraging outcomes and improved implant longevity, there has been significant improvement on the results of first-generation implants. Further high-quality studies are required to clarify outcomes post ankle arthroplasty. This article reviews the latest data from national registries and the wider literature to evaluate the current status with outcomes of modern total ankle replacements.

Turf toe: A clinical update.

Turf toe is a condition that describes injury to the plantar metatarsophalangeal-sesamoid complex of the great toe.It is a relatively rare and debilitating condition, particularly seen in American footballers after the introduction of harder, artificial 'turf' surfaces.Turf toe represents a significant injury to the hallux and requires a high index of suspicion.If unrecognized, it can lead to chronic problems including reduced push-off strength, persistent pain, progressive deformity and eventual joint degeneration.Patients with chronic injuries may have worse outcomes, and therefore early, accurate diagnosis and initiation of treatment play a vital role.A multidisciplinary team approach is key for successful return to sport. Cite this article: EFORT Open Rev 2018;3:501-506. DOI: 10.1302/2058-5241.3.180012.

Unilateral Adolescent Pes Planus After a Bimalleolar Ankle Fracture: A Case Report.

We present the case of a 14-year-old female who presented with unilateral pes planus 30 months after a bimalleolar ankle fracture dislocation. At surgery, the tibialis posterior tendon was encased in fracture callus within the syndesmosis and required reconstruction using flexor digitorum longus transfer. Dislocation of the tibialis posterior tendon and entrapment within the tibiofibular syndesmosis has been previously reported. To our knowledge, this is the first case report tibialis posterior tendon syndesmotic entrapment presenting with unilateral pes planus.

Combined Type II Odontoid Fracture With Axis Anterior Arch Fracture: A Case Report in an Elderly Patient.

Associated fractures of the atlas and axis are frequent, particularly in the elderly patients following a simple low-energy fall. This injury can be easily misdiagnosed on initial plain radiographs, and therefore computed tomography scan is a useful adjunct in patients with a degenerative spine. There is still no consensus as to the optimal treatment of combined axis-atlas fractures, and the majority of authors propose a therapeutic strategy dependent on the odontoid fracture pattern. We describe a combined atlas and axis fracture in a 92-year-old patient who was managed with nonoperative treatment in a rigid collar. The association of C1 anterior arch with a C2 type II odontoid fracture is a rare combination, which to our knowledge has never been reported following nonoperative treatment. There was a good functional outcome at 1-year follow-up with the fracture progressing to a fibrous nonunion of the odontoid process.

Tuberculosis of the Cuboid: A Case Report and Review of the Literature.

Tuberculosis (TB) remains a major global health problem. According to a recent World Health Organization report, it ranks as the second leading cause of death from an infectious disease worldwide. According to the "UK Health Protection Agency Tuberculosis in the UK: 2012 Report," 8963 cases were reported in the United Kingdom in 2011. London had the greatest proportion of cases in the United Kingdom and the greatest rate of disease. TB affecting the foot is rare, affecting about 10% of all skeletal TB cases. However, owing to the current patterns of global immigration, with significant volumes of people migrating out of endemic countries, it has become a disease that physicians and surgeons in developed countries should be more aware of in today's practice. To the best of our knowledge, we present the first adult case of TB of the cuboid in the United Kingdom and the first adult case documented outside of India. We present the case details and the results of a thorough review of the literature. TB of the foot and ankle poses a diagnostic challenge because of the propensity of TB to mimic other pathologic entities radiologically. Tissue diagnosis and antitubercular medication is the mainstay of diagnosis and treatment, respectively.

Diagnostic value of magnetic resonance imaging in thoracic outlet syndrome.

PURPOSE. To evaluate the diagnostic value of magnetic resonance imaging (MRI) in thoracic outlet syndrome (TOS). METHODS. Medical records of 30 women and 10 men aged 18 to 68 (mean, 38) years who presented with unilateral (n=35) and bilateral (n=5) TOS and underwent 42 surgical decompressions of the right (n=23) and left (n=19) sides were reviewed. MRI findings were compared with intra-operative findings to evaluate the diagnostic value of MRI. RESULTS. MRI findings correlated poorly with intra-operative findings. Of the 42 cases, MRI and intra-operative findings were matched in 17 and not matched in 25. MRI appeared normal but intra-operative findings were in fact positive for TOS in 23 of 24 cases. The sensitivity and specificity of MRI in diagnosing TOS were 41% and 33%, respectively, whereas its positive and negative predictive values were 89% and 4%, respectively. CONCLUSION. Sensitivity and specificity of MRI in diagnosing TOS are low. Diagnosis should be based on a holistic approach including history, clinical examination, and radiological findings.

Pathological fracture in osteosarcoma: is it always an indication for amputation?

BACKGROUND: The presence of a pathological fracture due to osteosarcoma (OS) has been considered a high risk factor for dissemination and an indication for immediate amputation. With current neoadjuvant chemotherapy regimens there is a trend towards limb salvage procedures in selected cases. The aim of this study is to assess the outcome of patients treated with amputation versus patients treated with limb salvage surgery focusing on local recurrence, mortality rates and metastatic dissemination. MATERIAL AND METHODS: A retrospective study of patients with OS treated at our institution was performed. Fifteen patients with a mean age of 25.6 years (8 to 66) were identified with an average follow up of 7 years (2 to 29). Patients were treated either with amputation (8) or limb salvage procedure (6). One patient was not treated surgically. RESULTS: Four patients developed local recurrence (1 in the amputation group and 3 in the limb salvage group, treated with secondary amputation). Six patients developed pulmonary metastasis (4 in the amputation group and 2 in the limb salvage) and 3 patients died (all of them in the amputation group). CONCLUSIONS: 1. A pathologic fracture in an OS is not always a contraindication for limb salvage because the oncologic results are acceptable. 2. In selected cases limb salvage has similar success rates to amputation.

Quality of consent form completion in orthopaedics: are we just going through the motions?

Consent plays a vital role in every aspect of medicine and surgery, facilitating the patient in making informed decisions about their treatment. The recently published Reference Guide to Consent, by the Department of Health (DH), notes that, although not a legal requirement, the completion of consent forms is good practice, particularly in interventions such as surgery. In addition, the Parliamentary and Health Service Ombudsman noted that a significant number of complaints about consent involved the complainant feeling that they did not fully understand what was going to happen. It was often found that there was no documentation to clarify what the patient was told, when and by whom. We have performed an audit of 71 randomly selected consent forms, elective and trauma cases within our district general hospital orthopaedics department. Our data demonstrate that a significant number of consent forms were incorrectly or insufficiently completed. This could not only leave the patient confused about their procedure but also leaves the doctor open to litigation, with little in the way of documentation support. Minor changes in consenting methods and more precise documentation could significantly improve patient experience and satisfaction.