Day case ankle arthroplasty: are they safe and cost effective? A single-centre case-control study.

Background: Most patients who have an ankle replacement in the United Kingdom stay in hospital for 2-4 days. This study looked at the safety & cost-effectiveness of a day case ankle replacement pathway. Methods: This was a retrospective case-control study looking at day case pathway for ankle replacements set up in collaboration with anaesthetists, nurses and physiotherapists. Patients practiced mobilization with crutches before surgery. Patients were discharged home with enough analgesia, and reviewed within 2-5 days of discharge. Results: Twenty ankle replacements done between November 2017 and November 2019 were reviewed with a mean follow up of 38.4 months. None of these patients required to be readmitted within the first 28 days. No complications were related to the surgery being done as day case. Except one, all patients described the experience as excellent or good. Conclusion: Per case the cost savings are estimated to be £880 in comparison to 20 matched inpatient ankle replacements. We conclude that ankle replacements can be safely carried out as day case with appropriate patient selection, pre-operative education and a multi-disciplinary approach.

Midfoot arthritis- current concepts review.

Midfoot arthritis causes chronic foot pain and significant impairment of daily activities. Although post traumatic arthritis and primary osteoarthritis are the most common pathologies encountered, surgeons need to rule out inflammatory causes and neuropathic aetiology before starting treatment. Steroid Injections are invaluable in conservative management and have diagnostic value in guiding surgical treatment. For the definitive surgical option of fusion there are a variety of fixation devices available. A successful union is linked to a satisfactory outcome which most authors report to be in the range of 90% following the key principles of careful patient selection, pre-operative planning, adequate joint preparation and a stable fixation.

Non-whiplash soft tissue injuries following low-velocity impact collisions: A retrospective analysis.

Whiplash is the most common injury reported in low-velocity impact road traffic accidents, but claimants report a range of other soft tissue injuries and we looked at the prevalence of these and any patterns. We retrospectively reviewed reports from the medico-legal practice of an orthopaedic surgeon. We collected data on 609 claimants. Sixty-two per cent were women (p < 0.0001). Majority (90.3%) reported an injury to at least one other area than neck, and 48% of claimants reported shoulder pain. Hand/wrist injuries were almost exclusive to drivers (p = 0.0013). Those with knee injuries were older than those without (p = 0.001). There was a significant difference in the age of patients with different spinal injury patterns (p < 0.0001). Occupational status did not appear to influence the pattern of injuries (p = 0.06). Psychological symptoms were associated with a greater number of body parts injured (p < 0.01). Our data confirm a strong association between these soft tissue injuries and psychological symptoms.

Irreducible Dislocation of the Proximal Interphalangeal Joint of the Second Toe in a Six-Year-Old Child: A Case Report.

CASE: Closed reduction was unsuccessful in a 6-year-old girl with a dislocated proximal interphalangeal joint of the second toe. Surgical exploration revealed soft-tissue entrapment by a ruptured medial collateral ligament. After the entrapment was cleared, the joint was reduced but remained unstable. The ligament was repaired with an all-suture mini-anchor to restore stability. The patient had a good recovery, and normal toe function had been restored by 3 months. CONCLUSION: This rare case demonstrates the safety of the use of all-suture mini-anchors in treating similar injuries in children because they leave a minimal footprint and a minimal amount of foreign material.

Fibular insufficiency fracture: an under-reported complication of advanced tibialis posterior dysfunction.

We present a case of fibular insufficiency (stress) fracture in a patient with pre-existing asymptomatic advanced tibialis posterior dysfunction. The patient had severe planovalgus (flat foot) deformity but no pain before the injury; hence had never sought any treatment. She was first treated conservatively for the fracture which failed to control the deformity and had ongoing symptoms. She eventually required tibio-talo-calcaneal fusion. To the best of our knowledge, this is the first case report of this condition in the English literature. In patients with severe tibialis posterior dysfunction, weight-bearing axis passes directly from calcaneum to fibula making it vulnerable to fracture. Patients should be made aware of this risk even if they are asymptomatic and encouraged to use orthotic support for protection against insufficiency fractures.

The Association between Birthdays and Medical Emergencies.

BACKGROUND: Not many studies have examined the risk of emergency medical attendance during stressful life events or special days such as birthdays. This study looked at whether patients had a higher than normal chance of attending the emergency departments around their birthdays compared to the rest of the year. METHODS: Patient attendance data were collected from our accident and emergency department from April 2013 to March 2014. The birthday of individual patients was matched with their date of attendance to find out the number of patients attending emergency department on and around their birthdays. Chi-square test and binominal distribution test were used to compare birthday attendances with those occurring at other times of the year. RESULTS: A total of 1028 patients attended within the 7 days starting from their birthday (expected number 49, 211/52 = 946). This was found to be statistically significant (P = 0.0071). Road traffic accidents were more frequent on both the birthday week and the week after birthday. Medical emergencies, injury in a public place, 19-35 years age group and male patients showed similarly significant association but for the week after birthday only. CONCLUSIONS: People are more likely to present to emergency departments in the week starting from their birthday than any other week of the year. There is scope for public health initiatives such as sending health education information in the form of a birthday card to raise awareness of this risk.

Post-traumatic fishtail deformity of distal humerus-is there a risk for refracture?

We present the case of fishtail deformity of distal humerus in a 13-year-old boy presenting with a refracture 8 years after the original surgically treated lateral condyle fracture. This unusual incomplete vertical fracture of distal humerus starting at the apex of fishtail was treated non-surgically and went on to union but refractured yet again 12 months later. This also went on to full healing with conservative treatment, however the fishtail deformity persists. We discuss the possibility that fishtail deformity reflects an inherent weakness in the distal humerus. We suggest that children and parents should be warned about the potential risk for refracture, particularly if they participate in contact sports.

Simple foot holder saves your theatre practitioner's back: a technical tip.

We provide a simple technique for foot positioning during preoperative skin preparation. Prone headrest made of gel polymer is used to support the patient's leg to keep the foot up. This will protect your operating theatre practitioner's back avoiding any mechanical back strain. It will also save money by preventing sickness and reducing workplace litigation from back injuries.

Not all secondary bone tumours are secondaries. Concurrent metastatic breast carcinoma and chondrosarcoma of the femur.

We present a case of metastatic adenocarcinoma of the breast in a patient who sustained a pathological fracture of the distal femur. Histology of the distal femur lesion excised at the time of endoprosthetic replacement confirmed this to be a primary chondrosarcoma. We have reviewed the literature and identified previously documented cases of concurrent breast carcinoma and chondrosarcoma of bone. A high index of suspicion is warranted and the diagnosis must be first confirmed before rushing to internal fixation (therapeutic or prophylactic) assuming them to be secondary bone lesions from the known primary cancer even in patients with multiple metastases.

Painful sesamoid of the great toe.

The painful sesamoid can be a chronic and disabling problem and isolating the cause can be far from straightforward. There are a number of forefoot pathologies that can present similarly to sesmoid pathologies and likewise identifying the particular cause of sesamoid pain can be challenging. Modern imaging techniques can be helpful. This article reviews the anatomy, development and morphological variability present in the sesamoids of the great toe. We review evidence on approach to history, diagnosis and investigation of sesamoid pain. Differential diagnoses and management strategies, including conservative and operative are outlined. Our recommendations are that early consideration of magnetic resonance imaging and discussion with a specialist musculoskeletal radiologist may help to identify a cause of pain accurately and quickly. Conservative measures should be first line in most cases. Where fracture and avascular necrosis can be ruled out, injection under fluoroscopic guidance may help to avoid operative intervention.

Orthopaedics and diabetes.

With about 12% of orthopaedic patients being diabetic and a large proportion of them being obese as well, orthopaedic surgeons are commonly involved in managing diabetic patients in both outpatient and inpatient setting. This review summarizes current concepts in diabetes management including specific orthopaedic issues and future directions of diabetes management.

Sugioka transtrochanteric valgus osteotomy for hinge abduction in children.

UNLABELLED: We report our experience of Sugioka transtrochanteric valgus osteotomy (TVO) for hinge abduction in children. The advantages are early union with simple fixation and preservation of proximal femoral geometry. Lateral displacement of the greater trochanter improves abductor limp. A total of 24 patients of mean age 10.2 years underwent TVO. The neck shaft angle increased by mean 11.75 degrees. Migration index increased by mean 3.88%. Average limb length discrepancy at final follow-up was 10.8 mm. The mean modified Iowa hip score was 75.1. Our results indicate that Sugioka TVO is a successful procedure for hinge abduction of the hip. LEVEL OF EVIDENCE: Level IV (case series).

Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults.

BACKGROUND: Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. It is unclear whether one method is more effective than the other. OBJECTIVES: To compare compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2011), The Cochrane Library 2011, Issue 1, MEDLINE and EMBASE (both to February 2011) and trial registries for ongoing trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing compression plates and locked intramedullary nail fixation for humeral shaft fractures in adults. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial methodology and extracted data. Disagreement was resolved by discussion, or third party adjudication. Treatment effects were assessed using risk ratios for dichotomous data and mean differences for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using a fixed-effect model. MAIN RESULTS: Five small trials comparing dynamic compression plates with locked intramedullary nailing were included in this review. These involved a total of 260 participants undergoing surgery for either acute fractures or after early failure of conservative treatment. All five trials had methodological flaws, such as the lack of assessor blinding, that could have influenced their findings. There was no significant difference in fracture union between plating and nailing (five trials, RR 1.05; 95% CI 0.97 to 1.13). There was a statistically significant increase in shoulder impingement following nailing when compared with plating (five trials, RR 0.12; 95% CI 0.04 to 0.38). Intramedullary nails were removed significantly more frequently than plates (three trials, RR 0.17; 95% CI 0.04 to 0.76). There was no statistically significant difference between plating and nailing in operating time, blood loss during surgery, iatrogenic radial nerve injury, return to pre-injury occupation by six months or American Shoulder and Elbow Surgeons (ASES) scores.Two further small trials are awaiting classification. AUTHORS' CONCLUSIONS: The available evidence shows that intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There was insufficient evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.

Residual clubfoot in children.

The deformities encountered in any patient who has residual clubfoot comprise various degrees of equinus, varus, adduction, supination, cavus, and toe deformity. Joint flexibility or stiffness, tarsal dysmorphism, articular incongruence, and progressive degrees of degeneration may be present. Add to this the scars of previous attempts at correction and various etiologic factors, and surgeons can find that treatment solutions are far from straightforward. A philosophy of careful history, examination, investigation, and surgery à la carte will provide a safe foundation for treating patients who have these often complex and difficult problems. A surgical strategy progressing from proximal to distal, performing soft tissue surgery before fixed deformity occurs, extra-articular osteotomies to correct bony deformity, and augmentation with rebalancing of soft tissue-deforming forces will help improve pain and function for many patients. Joint fusions should be reserved as a last salvage option to avoid future degeneration of adjacent joints.

Do we need radiological guidance for hip joint injections?

Intra-articular injections are widely used in treatment of early hip osteoarthritis and may help to offset the need for a joint replacement. Most orthopaedic surgeons do this under radiological guidance while some rheumatologists and pain specialists do it without. Our study was aimed at assessing accuracy of blind intra-articular injections to the hip joint. Forty-three hips in 40 consecutive patients who had hip injections were included in the study. The anatomical landmarks were marked and the needle was placed from an antero-lateral approach. Radio-opaque dye was then injected and the position of the needle was checked under image intensifier. The success rate of blind injections was 65.1%. Obese patients, patients with severe grade 4 arthritis with no joint space and those with flexion deformity were the majority of failed cases. We propose that hip injections should be carried out by trained specialists under radiological guidance.

Orthopaedic training worldwide: how they compare? A pilot study.

INTRODUCTION: Advances in Orthopaedics and changing concepts should result in regular review and if necessary restructuring of training programmes periodically to accommodate these changes. However, most countries have orthopaedic training programmes which have remained unchanged over decades. There is very little information available in the literature concerning orthopaedic training programmes worldwide. AIM: The aim of this study was to collect information concerning various training programmes worldwide for comparison. The top ten countries by population and all G8 countries were selected. A survey in the form of a questionnaire was disseminated to a selection of trainees and trainers from these countries and responses tabulated for analysis. Significant variation was evident in training structure, time spent on training and training environment. CONCLUSION: There is a need for constant monitoring of training programmes worldwide to accommodate the ever-changing world of Orthopaedics which could potentially be of mutual benefit to trainees, trainers and the population at large of the countries involved.

Secondary prevention of osteoporosis after Colles fracture: Current practice.

OBJECTIVES: Colles fracture in the elderly is accepted as evidence of osteoporosis. NICE (National Institute of Clinical Excellence) recommends osteoporosis treatment in all fragility fractures over 75 without a DXA (Dual Energy X-ray Absorptiometry) scan and after DXA scan in younger patients. All clinicians involved in the patient's care are said to be responsible for this. METHODS: We reviewed current practice in United Kingdom to find out the role played by orthopaedic surgeons in organising this treatment. We sent a questionnaire to 150 BOTA (British Orthopaedic Trainees Association) members by e-mail. RESULTS: The response rate excluding bounced mails was 63%. Only 5% of respondents prescribed osteoporosis treatment and 32% requested general practitioner to do this. Twenty-four percent referred the patients for either DXA or to an osteoporosis service. Although 86% were aware of NICE guidelines regarding osteoporosis, only 35% thought it could amount to negligence on the surgeon's part for not dealing with this. Fourteen percent worked in hospitals having an osteoporosis service which co-ordinated further management of these patients. Eleven percent expressed concerns over the source of funding for the management of osteoporosis and said that this was the reason for not offering treatment themselves. CONCLUSION: This survey highlights the importance of concrete local protocols in management of osteoporosis especially secondary prevention after an osteoporotic fracture. At present, it appears to be safe practice to indicate this in correspondence to patient's general practitioner and inform the patient as well.

Medial impingement after ankle replacement.

Ankle replacements appear to offer a good alternative to fusion for most arthritic conditions. Use of mobile bearings has significantly improved results of ankle replacement. Ankle replacements still have a significant minor-complication rate which does not seem to affect the long-term outcome. Medial impingement as a complication has been reported with popular designs. We reviewed the senior author's first five years of Buechel-Pappas ankle replacements looking at AOFAS scores, VAS scores, patient satisfaction, learning curve of the surgeon and complications. Eight patients out of a total of 34 reported symptoms of medial impingement at follow-up. Four patients underwent revision surgery for this. Ankle replacements have a significant proportion of minor complications, one of which is medial impingement. Whether this is due to implant design, residual arthritis in medial recess or soft-tissue pathology is uncertain but revision surgery may be required.