Patient Outcomes of Virtual Foot and Ankle Telephone Clinics During COVID-19 Pandemic: 1 Year Experience.

COVID-19 pandemic has instigated to find alternative methods of assessing and treating patients with foot and ankle disorders. We have implemented virtual telephone clinic consultations along with the face-to-face consultations. It has reduced overcrowding in the busy outpatient waiting area and thus limiting close patient contact. The aim of this study is to audit the patient satisfaction outcomes, assess the feasibility and to find out the potential financial implications of introducing telephone clinic consultations for foot and ankle disorders. A total of 426 patients who had telephone consultations for foot and ankle disorders for a period of 1 year were included. Patients were given individual time slots for the consultations. The patient satisfaction outcomes were assessed using a structured questionnaire. The outcomes following the telephone consultation was audited. The financial cost was calculated for the study period. Following the telephone consultation 35% of the patients were discharged and 36% were given further face to face appointments. 97.5% were very satisfied or satisfied with the methodology and outcomes of the telephone consultation. Ninety-five percent of the patients commented that they would recommend telephone consultations for foot and ankle to their friends and family. The financial savings calculated during the study period was about £25,000 ($30,000). Virtual telephone clinic consultations are safe, efficient and cost effective with good patient satisfaction outcomes. It is an alternative or can be conducted adjunct to face to face consultations with adequate planning, training, good communication skills and proper documentation.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases.

BACKGROUND: Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success. METHODS: A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores. RESULTS: The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively. CONCLUSIONS: Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

Stenosing Tenosynovitis Following Ankle Fracture Causing Progressive Acquired Tibialis Posterior Dysfunction: A Case Report.

Stenosing tenosynovitis of the ankle with osseous bone formation following an open reduction and internal fixation of the ankle is a rare clinical condition. We report a case of adult-acquired flat foot following an open reduction and internal fixation of a bi-malleolar fracture due to tibialis posterior tendon dysfunction caused by stenosing tenosynovitis. This was managed by open excision of the bony tunnel and debridement, along with calcaneal osteotomy and distalization of the tendon, resulting in good functional outcomes.

A Novel Method for Treating Bilateral Freiberg's Disease of the Second Metatarsal: A Case Report.

Freiberg's infraction is osteonecrosis of the lesser metatarsal heads, most commonly affecting adolescent females. Bilateral Freiberg's disease is rare, with only a few cases reported. Conservative management is the mainstay of treatment. Surgical management includes the excision of osteophytes and loose chondral flaps, microfracture, corrective osteotomy, and debridement of the metatarsal head, often with unpredictable outcomes. We report a rare case of a 17-year-old girl with bilateral Freiberg's disease who was treated with Autologous Matrix-Induced Chondrogenesis (AMIC), achieving excellent radiological and functional outcomes.

The outcomes of constrained total hip arthroplasty for recurrent dislocation of hip hemiarthroplasty.

INTRODUCTION: The incidence of hemiarthroplasty dislocation for fracture neck of femurs ranges between 1 and 15% and the one-year mortality is 49- 70%. Revision of hemiarthroplasty to total hip replacement using a constrained liner has shown to improve the morbidity and mortality rates. The aim of the study was to assess whether conversion of dislocated hemiarthroplasty to total hip replacement improve functional and one year mortality. METHODS: A retrospective analysis of the number of patients who had recurrent dislocations of hemiarthroplasty for fracture neck of femurs were carried out. The data were obtained from NHFD (National Hip Fracture Database) and internal hospital computer systems (Medway, Theatre notes and PACS) between Dec 2008 and Dec 2020. Patient demographics including age, sex, Abbreviated Mental Test Score (AMTS), functional assessment, mortality at one and two years were documented. The risk factors which led to dislocations such as Parkinsons disease, Cerebrovascular accidents, Musculo-neuropathies and Alzheimer`s disease was also noted. RESULTS: A total of 3994 patients were admitted during the study period of which 1735 (43.4%) patients had hemiarthroplasty. Fifty-six (3.23%) patients had dislocation of hemiarthroplasty. The mean age was 81.4 years (range - 61 to 95). There were 40 (71.4%) females and 16 males (28.6%). The average AMTS score was 5.3. All 56 patients had closed manipulative reduction under anaesthesia within in 12 h of admission. Thirty-one patients (55.4%) went on to have recurrent dislocations of which 18 patients (58.4%) had total hip replacement using captive cup, 6 patients (19.4%) had open reduction,3 patients (9.7%) had excision arthroplasty procedure and four patients (12.5%) had no intervention, Eighteen patients who had total hip replacement with constrained captive for followed up to a minimum of two years (range2- 12 years). There were no intraoperative complications, dislocation or periprosthetic fractures in the follow up period. There was no mortality at the end of two years of follow up in this group, two-year mortality for the patients with alternative management for dislocated hemiarthroplasty was 76.67. CONCLUSION: Treatment of recurrent hemiarthroplasty dislocation by revising to a total hip replacement with a constrained liner gives good functional and mortality outcomes.

The crucial factors influencing the development and outcomes of postoperative delirium in proximal femur fractures.

Objective: The aim of this study is to find the incidence, risks, and reasons for prolonged length of hospital stay, short, long-term mortality, and the factors contributing to mortality of postoperative delirium in proximal femoral fractures. Methods: The data for the study was obtained from National Hip Fracture Database (NHFD) and internal hospital computer systems (Medway, ICE, Clinic letters) between January 2018 and December 2019. One hundred seventy-five patients were found have developed postoperative delirium. The outcomes measured were postoperative anemia, lower respiratory tract infection, urinary tract infection, acute kidney injury, urinary retention, cardiac event and stroke, alcohol or drug withdrawal, length of hospital stay, and 30 day and 1 year mortality. Results: The patients who developed delirium were 68 (38.9%) with American Society of Anesthesiologists (ASA) grade 4 and 94 (22.3%) without delirium (p < 0.05). The average length of stay after developing postoperative delirium was 19.69 days compared to 17.4 days for patients without delirium. The mortality at 30 days and 1 year was 10.9% and 37% in patients who had postoperative delirium compared to 2.1% and 2.8% to those without delirium, respectively. Conclusion: Postoperative delirium is three times more common in hip fractures. Early detection and timely management are crucial in the improvement of functional outcomes and mortality.

Achilles tendinopathy and plantar fasciopathy: Are we ignoring calcaneal bone morphology? - A radiological assessment of calcaneal parameters.

BACKGROUND: A radiological study was conducted to determine whether calcaneal morphological differences contribute to the pathophysiology of Achilles tendinopathy and plantar fasciopathy. This study is aimed to support our new hypothesis to explain the pathophysiology leading to recalcitrant disease and also to identify the role of calcaneal osteotomy for treating these conditions. MATERIALS AND METHODS: Calcaneal width and height distance deviation from centre of ankle joint rotation was measured on standardised lateral weight bearing Ankle radiographs. A comparison was made between control group and study group to identify the differences in measured parameters. RESULTS: Significant difference (P = 0.05) was observed in calcaneal width distance in study group with Achilles tendinopathy. In Plantar fasciopathy the vertical distance was reduced suggesting flattening of arch in study group. However, the difference was not statistically significant. CONCLUSION: The study identifies the importance of evaluating calcaneal morphology for patients with recalcitrant Achilles tendinopathy and plantar fasciopathy. A new hypothesis is proposed to explain the high stresses produced in entire Achilles -calcaneus -plantar fascia unit which leads to chronic inflammatory response and intra substance degeneration.

Autologous Conditioned Plasma and Hyaluronic Acid Injection for Isolated Grade 4 Osteochondral Lesions of the Knee in Young Active Adults.

OBJECTIVES: To compare the short-term benefits and results of autologous conditioned plasma (ACP) and hyaluronic acid (HA) injection in osteochondral defects in the knee of young adults. The effectiveness of intra-articular platelet-rich plasma (PRP) injections has been evaluated in osteoarthritis. However, few studies investigated its efficacy in knee osteochondral defects. METHODS:  This is a retrospective analysis of prospectively collected data. A matched cohort of 30 patients in each group was studied. Group 1 received three HA injections at weekly intervals, and group 2 received three ACP injections at two weekly intervals. We measured Kujala, Lysholm, Oxford, and visual analog scale (VAS) scores at baseline, six, 12, and 36 months to assess function and pain. RESULTS:  Most lesions were in the medial femoral condyles in both groups, followed by lateral femoral condyle and patellofemoral regions. In group 1 (HA), the mean pre-injection scores for Kujala, Lysholm, and Oxford improved significantly at six and 12 months. The scores decreased at 36 months, however, they remained significantly better than the baselines (P < 0.05). The pre-injection VAS scores continued to improve significantly from 6.06±0.785 to 3.40±0.912 at 36 weeks. In group 2 (ACP), VAS and the outcome scores showed a consistent and statistically significant improvement from pre-injection to 36 months.  Conclusions: Our study confirms the short-term clinical benefits of using ACP for symptomatic osteochondral defects of the knee. Further high-quality comparative studies with longer follow-ups are needed to ascertain whether ACP is beneficial in the long term.

Does the ASA grading influence the outcomes of best practice tariff in fracture neck of femurs.

OBJECTIVES: The aim of this study is to find the significance of different ASA grades in achieving the Best Practice Tariff (BPT) and their outcomes in patients with fracture neck of femur. METHODS: A retrospective study over a five years period. Patient demographics, ASA grading, hospital admission timing, time to theatre and discharge date were recorded. The 30 day mortality rate and length of stay were calculated for each ASA grades for patients who met and failed BPT. RESULTS: 1798 patients were included in the study. 54% was ASA grade 3, grade 4 represented 22% and grade 2, 19%. The mean AMT score was 6.4 who met BPT and 4.4 who failed BPT (p<0.001). 319 patients with ASA≤2 met BPT and 53 patients failed to meet BPT. In ASA ≥3, 1200 patients who met BPT and 225 patients failed BPT. The 30-day mortality in patients with ASA≤2 who met BPT was 2.57% and those who failed were 1.92%. In ASA ≥3 the 30-day mortality was 12.63% and who failed BPT was 25% which is statistically significant. CONCLUSION: In patients with ASA≥3 the 30-day mortality is significantly higher in those who failed BPT compared to ASA≤2 patients whether they achieved BPT or not.

A Missed Diagnosis of Bilateral Simultaneous Spontaneous Intracapsular Neck of Femur Fractures in a Rheumatoid Arthritis Patient.

Bilateral spontaneous simultaneous fractures of the neck of femurs are extremely rare, and only a few cases have been reported in literature. They are usually following high-energy trauma or may be due to an underlying pathological process such as frailty, osteomalacia, rickets, and chronic renal disease. They can also occur following epilepsy and electric shock. We report a 79-year-old gentleman who presented with sudden onset of bilateral hip pain with a background of rheumatoid arthritis and long-term steroid treatment. The bilateral hip fractures were missed initially and later presented with completely displaced fractures of the neck of femurs. He underwent a single-stage bilateral cemented hemiarthroplasty and made a good recovery. Bilateral simultaneous fractures of the hip in patients with rheumatoid arthritis have not been reported in literature so far, and the diagnosis can be easily overlooked. In patients with bilateral hip pain, one should have a high index of suspicion. Further appropriate cross-sectional imaging in the form of CT or MRI should also be considered.