Lateral ankle instability - repair/ reconstruct what's new.

Lateral ankle instability is a common condition which responds well to non-surgical management. However, the chronic symptomatic instability may require surgical intervention. The acceptable and practiced procedure is the Brostom Gould modification and it has a high patient satisfaction score. However, the current understanding and newer techniques for stabilising the lateral ligament complex has resulted in arthroscopic repairs, augmentation and tendon graft reconstructions. The literature does not provide an answer to the efficacy of these new techniques but there is some preliminary information favouring some of the latest procedures. It is now accepted practise to include ankle arthroscopy as a pre repair step. Augmentation of anatomical repair is also favoured in a select group of patients. This article provides an up to date account of the newer techniques for lateral ankle stabilisation.

Site of care and factors associated with mortality in unvaccinated Australian aged care residents during COVID-19 outbreaks.

BACKGROUND: Residential InReach presents an alternative to hospital admission for aged care residents swabbed for coronavirus disease 2019 (COVID-19), although relative outcomes remain unknown. AIMS: To compare rates and predictors of 28-day mortality for aged care residents seen by InReach with COVID-19, or 'suspected COVID-19' (sCOVID), including hospital versus InReach-based care. METHODS: Prospective observational study of consecutive patients referred to a Victorian InReach service meeting COVID-19 testing criteria between April and October 2020 (prevaccine availability). COVID-19 was determined by positive polymerase chain reaction testing on nasopharyngeal swab. sCOVID-19 was defined as meeting symptomatic Victorian Government testing criteria but persistently swab negative. RESULTS: There were no significant differences in age, sex, Clinical Frailty Score (CFS) or Charlson Comorbidity Index (CCI) between 152 patients with COVID-19 and 118 patients with sCOVID. Similar results were found for 28-day mortality between patients with COVID-19 (35/152, 23%) and sCOVID (32/118, 27%) (P = 0.4). For the combined cohort, 28-day mortality was associated with initial oxygen saturation (P < 0.001), delirium (P < 0.001), hospital transfer for acuity (P = 0.02; but not public health/facility reasons), CFS (P = 0.04), prior ischaemic heart disease (P = 0.01) and dementia (P = 0.02). For patients with COVID-19, 28-day mortality was associated with initial oxygen saturation (P = 0.02), delirium (P < 0.001) and hospital transfer for acuity (P = 0.01), but not public health/facility reasons. CONCLUSION: Unvaccinated aged care residents meeting COVID-19 testing criteria seen by InReach during a pandemic experience high mortality rates, including with negative swab result. Residents remaining within-facility (with InReach) experienced similar adjusted mortality odds to residents transferred to hospital for public health/facility-based reasons, and lower than those transferred for clinical acuity.

Patient outcomes in Tropical North Queensland after implementation of a dedicated orthopaedic trauma list.

BACKGROUND: To assess patient outcomes after the introduction of a regular orthopaedic-specific trauma list (OTL). METHODS: A retrospective analysis of 422 trauma cases was performed comparing patient outcomes after the introduction of the OTL. Four common traumatic injuries requiring operative intervention were considered; closed tibial fractures, intra-capsular neck of femur fractures, displaced paediatric supracondylar humeral fractures and hand tendon injuries. The outcomes assessed included time from patient referral to theatre, time from admission to theatre, operative times, time of day operation commenced, consultant involvement, hospital length of stay (LOS), returns to theatre and mortality. RESULTS: Tibial fractures had an increased time from admission to theatre (0.46 days pre-OTL versus 1.21 days post-OTL, P = 0.01), hand tendons injuries had an increase in time from referral to theatre (1.06 days pre-OTL versus 2.82 days post-OTL, P = 0.001). Consultant involvement increased for supracondylar procedures (27% pre-OTL versus 61% post-OTL, P < 0.001) and tendinous hand injury repairs (5% pre-OTL versus 37% post-OTL, P < 0.001). There was a decrease in cases starting after 17:00 hours; however, no group reached statistical significance. There was a reduction in complications and shorter inpatient LOS, however; these were not statistically significant. There was no difference in overall operative times after OTL implementation; however, individual group differences existed between registrars and consultants. CONCLUSION: Implementing regular orthopaedic trauma lists resulted in greater consultant involvement and was associated with decreased after-hours operating. Delays to theatre increased from both time of referral and admission; however, this was not correlated with increases in significant harm.

Development of Acute Decompensated Heart Failure Among Hospital Inpatients: Incidence, Causes and Outcomes.

BACKGROUND: We aimed to investigate the incidence, precipitants, and outcomes of acute decompensated heart failure (ADHF) that develops during the inpatient stay. METHODS: We undertook a case-control study in the medical, oncology, surgical, and orthopaedic wards of a tertiary referral hospital (February-May, 2016). Patients aged ≥18 years who developed ADHF during their inpatient stay were enrolled as cases. One control patient was matched to each case by age, gender, presenting complaint/surgery performed and co-morbidities. Multivariate regression was employed to determine variables associated with ADHF. RESULTS: The incidence of ADHF was 1.0% of patients. Eighty cases were well-matched to 80 controls (p>0.05). ADHF precipitants comprised infection (30%), inappropriate intravenous (IV) fluid and medication management (23.8% and 8.8%, respectively), tachyarrhythmia (12.5%), ischaemic heart disease (8.8%), renal failure (1.3%), and other/unclear causes (15%). Three variables were associated with ADHF: not having English as the preferred language (OR 3.5, 95%CI 1.2-9.8), a history of ischaemic heart disease (OR 3.3, 95%CI 1.2-9.1), and the administration of >2000ml of IV fluid on the day before the ADHF (OR 8.3, 95%CI 1.5-48.0). The day before the ADHF, cases were administered significantly more IV fluids than controls (median 2,757.5 versus 975ml, p=0.001). Medication errors mostly related to failure to restart regular diuretics. Cases had significantly greater length of stay (median 15 versus 6 days, p<0.001) and mortality (12.5% versus 1.3%, p=0.01). CONCLUSIONS: New onset ADHF is common and a substantial proportion of cases are iatrogenic. Cases experience significantly increased length of hospital stay, morbidity, and mortality.

Open rotator cuff repairs in patients 70 years and older.

BACKGROUND: Symptomatic rotator cuff tear is a commonly diagnosed problem in patients over the age of 70; however, there is controversy regarding the management of this condition. We set out to investigate whether this group has satisfactory results with operative management of their rotator cuff tears. METHODS: Retrospective review of one surgeon's patients who have undergone an open rotator cuff repair at age 70 or older. Outcome assessment included history of work and recreational activities, review of medical records, clinical examination, the Simple Shoulder Test (SST) and the Constant Shoulder Score (CSS). RESULTS: A total of 96 patients (104 shoulders) underwent open rotator cuff repair during the study period. Sixteen patients (16 shoulders) were lost to follow-up leaving 80 patients (88 shoulders) for review. Mean duration of symptoms was 18.3 months, mean age at surgery was 74.2 years and mean time to follow-up was 40.8 months. The mean SST and CSS scores were 9.8 and 80.1, respectively. In both tests, patients scored best in the pain relief categories and worst in strength-measuring areas. A total of 73 patients (92.7%) reported satisfaction with their surgery. None of these were limited by their shoulders in returning to pre-injury independence, work or recreations. They were either completely pain free or had only mild symptoms. CONCLUSION: Patients in our study reflected a high satisfaction rate of 92.7% as well as excellent pain relief and a high level of function when related to their daily activities, independence and recreations or work. LEVEL OF EVIDENCE: Level IV (observational study without control - retrospective study).