Safe zone for minimally invasive calcaneal osteotomy: an MRI study.

Hindfoot deformities are often surgically corrected with calcaneal osteotomy. These are increasingly performed via a minimally invasive approach. Identifying a neurovascular "safe zone" for this approach is important in reducing iatrogenic injury. We aimed to identify a safe zone for minimally invasive calcaneal osteotomy without neurovascular injury. Three individuals independently assessed 100 con- secutive magnetic resonance imaging ankle studies. The distance of the medial neurovascular bundle from the level of the centre of the Achilles tendon insertion was measured. The points measured were centralised in three planes (axial, sagittal and coronal). The three sets of observations were statistically analysed with confidence intervals and intraclass correlation coefficient was calculated. The mean distance measured by the three observers were 22.91 mm (range 18.2-28.5 mm); 22.81 mm (range 18.7-26.7 mm); and 23.41 mm (range 19.2- 28.4 mm); overall mean 23.0 mm. The mean inter- observer variation was 1.1 mm. 95% confidence interval for observer 1 ranges from 22.45-23.25 mm, observer 2 ranges from 22.52-23.1 mm and observer 3 ranges from 22.97-23.65 mm. Overall 95% confidence interval ranges from 22.8-23.2 mm. Intraclass correlation coefficient for inter-observer reliability is 0.7, indicating strong agreement between the observers. This radiological study suggests an anatomical "safe zone" for minimally invasive medial calcaneal osteotomy is at least 18 mm (mean: 23 mm) from the level of insertion of the Achilles tendon. Individual variation between patients must be taken in to consideration during preoperative planning.

Inferior scapula avulsion fracture: an unusual presentation of winged scapula.

Inferior scapula avulsion fractures are rare injuries, with few cases reported and only a small number managed operatively discussed in the literature. We report the case of a man in his 40s who fell from a height and presented with right-sided scapular winging and point tenderness at the inferior pole of his right scapula with no neurological deficit. Radiographs and CT diagnosed avulsion fracture of the inferior scapula. The patient underwent surgical fixation and, following a course of physiotherapy, successfully recovered with no residual winging and full range of movement.

Rare case of a low energy traumatic anterior dislocation of the native hip.

Anterior dislocations of the native hip are rare injuries, and normally a result of high energy trauma such as road traffic accidents. Delays in reduction of over 12 hours have been shown to increase the risk of avascular necrosis to the head of the femur significantly. We report the case of an elderly man who sustained an anterior dislocation of his native hip following a fall. The case highlights that prompt appropriate management can lead to excellent clinical outcomes.

A systematic review of anterior cruciate ligament primary repair rehabilitation.

BACKGROUND: Rehabilitation after surgery of the injured anterior cruciate ligament (ACL) is crucial for satisfactory outcomes. Many trials have investigated this process after ACL reconstruction. The treatment of acute ACL ruptures with a repair technique has recently regained interest, although very little information is available about appropriate rehabilitation for such patients. The objective of this review was to evaluate studies on rehabilitation following ACL repair. METHODS: A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for patients undergoing a rehabilitation programme after ACL repair. The review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO, Registration number: CRD42020173450). Elements of rehabilitation care we included in our strategy are postoperative bracing, home-based rehabilitation, strengthening exercises, proprioception and neuromuscular training. We searched PubMed, CINAHL, EMBASE, and the Cochrane Library for randomised trials of any form investigating rehabilitation protocols after repair of the injured ACL. Two reviewers independently assessed eligibility of trials. RESULTS: No trials were included. Available literature of lower evidence was included for discussion. CONCLUSIONS: No information is available from randomised trials to indicate whether there is any difference between rehabilitation protocols for patients who have undergone primary ACL repair.

Unusual presentation of atraumatic insufficiency pelvic fractures unmasking pregnancy-related osteoporosis: A case report.

We describe the case of a young 27-year-old Caucasian female who presented in the third trimester of her first pregnancy with sudden and severe suprapubic and left-sided hip pain without history of trauma. She was eventually diagnosed with two insufficiency fractures of the pelvis. The underlying diagnosis was pregnancy-related osteoporosis. Her baby was delivered successfully at term, with an elective caesarean section. The diagnosis was eventually made using a magnetic resonance imaging scan. Pregnancy-related osteoporosis is relatively rare, and cases of patients presenting with insufficiency fractures of this condition are rarer still. Our case raises the importance of considering this diagnosis in females in the later stages of pregnancy, with severe sudden hip or pelvis pain. The patient gave informed written consent for the publication of this case.

Outcomes of Multiple Digit Proximal Interphalangeal Joint Swanson Arthroplasty Done at a Single Operation.

Background: Proximal interphalangeal joint (PIPJ) arthroplasty using a Swanson implant is commonly used for the treatment of PIPJ arthritis despite newer implants being available. Many patients develop arthritis in more than one digit and some tend to have multiple digits operated on in their lifetime. There is paucity of literature on the outcomes of multiple PIPJ arthroplasty in one sitting. The aim of this study is to determine the outcomes of PIPJ arthroplasty using a Swanson implant done for multiple digits at one sitting. Methods: We retrospectively reviewed the outcomes of multiple Swanson PIPJ arthroplasty during a single operation from 2008 to 2018 in 13 patients (43 arthroplasties). We compared pre- and post-operative results of flexion/extension arcs, grip and pinch strength and questionnaires subsequently compared QuickDASH (Disabilities of Arm, Shoulder and Hand), Patient Evaluation Measure (PEM) and Visual Analogue Score (VAS) scores. Data were analysed with a Mann-Whitney U test. Results: Patients on average attended 5.6 hand therapy sessions over 5.1 months post-operatively. Average flexion/extension arc improved from 31.9° pre-operatively to 37.2° post-operatively. Average grip strength increased from 7.2 kg to 10.2 kg. The QuickDASH, PEM and VAS scores improved in keeping with the reported literature. There were no implant failures. Conclusion: We demonstrate similar outcomes for multi-digit Swanson PIPJ arthroplasty compared to the literature for single digit Swanson PIPJ arthroplasty. We conclude that multi-digit arthroplasty in a single operation is safe and effective. Level of Evidence: Level IV (Therapeutic).

Comparison of Exeter stem offset size for total hip arthroplasty between males and females: A retrospective series of 780 hips.

Background: Many orthopaedic surgeons use a 'standard' stem offset length, typically 37.5 mm and 44 mm for females and males respectively, in total hip arthroplasty. With increasingly personalized surgery, 'standard' one-size-fits-all stem lengths may be outdated. This study aims to test whether pre-operative templating affects stem length choice and whether 'standard' stem sizes are therefore outdated. Methods: We performed a retrospective chart review of all total hip arthroplasty patients using Stryker's Exeter cemented femoral hip system in our centre between 2016 and 2020. Demographic and surgical data were collected. Data from surgeons who templated pre-operatively were compared to data from those who did not. Results: 780 patients were included (309 male, 471 female), average age 71.4 years (range 23-96). We found a significant difference between male and female offset lengths; more males had an offset length of 44 mm and more females had an offset length of 37.5 mm (p = 0.004). Among surgeons who did not template pre-operatively, 20.6% of female patients and 10.3% of male patients had other 'non-standard' offset lengths. Among surgeons who did template pre-operatively, the proportion of both female and male patients who had other 'non-standard' offset lengths was significantly higher (43.1% and 23.4%, respectively p < 0.05). Conclusions: The difference between templating and non-templating surgeons' stem choice revealed significant individual variability between males and females. 'Standard' offset lengths for males and females were still used in the majority of our cohort. However, with the emergence of mainstream robotic arthroplasty, we feel that pre-operative templating has become a minimum standard.

A Systematic 10-Year Review of the Use of Arthroscopy in the Assessment and Treatment of Intercarpal Ligament Injuries Associated with Acute Distal Radius Fracture.

Background: To review the impact that arthroscopy has made on the assessment and treatment of intercarpal (scapholunate [SL] or lunotriquetral [LT]) ligament injuries associated with acute distal radius fractures (DRF). Methods: A systematic review of EMBASE, MEDLINE and COCHRANE databases for articles published between 2011 and 2021 was performed (PROSPERO ID: CRD42021273293) which included studies reported assessment and outcomes of intercarpal ligament injuries associated with acute DRF. Methodological quality was evaluated. The rate of concomitant injury detection, role of arthroscopy and different clinical outcome assessment measurements used were compared between studies. Results: A total of 20 articles were included with data from 1,346 patients (1,358 wrists). A total of 1,024 intra-articular fractures were included and 294 extra-articular fractures (40 not specified). There was a heterogeneous mix of studies; 10 comparative and 10 non-comparative. Some studies investigated initial assessment findings only, while others assessed radiological outcomes, functional outcomes or both domains over 0.3-99 months. The overall rate of SL ligament injury associated with DRF was 35.3%, while LT ligament injury overall was 18.2%. More frequent were concomitant triangular fibrocartilage complex (TFCC) injuries (44.8%), although this review did not aim to review these. The role of arthroscopy was reviewed, which included assistance in anatomic reduction of the articular surface and systematic inspection of the surrounding soft tissues. Included studies investigated either assessment or assessment and management of intercarpal ligament injury. Meaningful meta-analysis in this heterogeneous group of studies was not possible. Outcomes of comparative studies were described in detail. Conclusions: This review suggests that arthroscopy may have a role in improving reduction of intra-articular DRF and diagnosing and managing soft tissue injuries associated with such fractures. Randomised studies are needed to evaluate whether the detection of intercarpal ligament injury in acute distal radial fractures through arthroscopic assessment alters current management and improves clinical outcome. Level of Evidence: Level III (Therapeutic).

A Study Investigating Whether BMI Is Associated With Acetabular Bone Size: Big Bones or a Big Myth?

Background There is a common conception held by patients with a high body mass index (BMI) that they have "big bones". Some people hold the assumption that their weight is attributed to larger bone stock rather than adipose tissue. It was the suspicion of the surgeons at our unit that this is often not the case. We therefore conducted a study investigating if there is any association between BMI and acetabular bone size. Methods We conducted a retrospective chart review of all patients undergoing total hip arthroplasty using the Trident acetabular system from Stryker at our tertiary level 1 trauma centre between September 2016 and August 2020. Patient demographic and surgical data were collected, and the association of BMI, height, and weight, with acetabular cup size was investigated using Pearson's correlation coefficient and chi-square test for independence. Results A total of 418 patients were included in this study (52.4% female; age: 20-93 years; mean age: 62.51 years), with a mean BMI of 29.55 kg/m2(range: 14.95-52.32 kg/m2). A weak positive association between BMI and cup size, which was statistically significant (r = 0.107; n = 418; p = 0.02). The chi-square test for independence was used to study the association between obesity and cup size (large vs small), which demonstrated no significant difference (p = 0.08). There was a moderately strong positive association between height and cup size (r = 0.551; n = 418; p < 0.01). There was a weak positive association between weight and cup size, which was statistically significant (r = 0.355; n = 418; p < 0.01). Conclusion Our study suggests that there is indeed a weakly positive linear association between BMI and cup size among total hip arthroplasty patients. This effect was, however, more significant for height and weight, and there was no significant association between obese and non-obese groups with small versus large cup size implanted. We therefore conclude that clinically there is no significant relationship between obesity and acetabular bone size and that the "big bones" claim is indeed fallacious.

A Novel Method of Treatment for a Mal-United Galeazzi Fracture With Dislocation of the Distal Radioulnar Joint Using Scarf Osteotomy.

The Galeazzi fracture is an unstable fracture-dislocation of the forearm. There have been reports of non-union of the radius despite rigid internal fixation with a plate. We present the case of a 25-year-old male who fell from his bicycle, sustaining a closed Galeazzi fracture-dislocation. Definitive surgical fixation involved internal fixation using a six-hole dynamic compression plate. Post-operatively, the patient noted a significant reduction in pronation. The fracture had united but with approximately 5 mm of radial shortening. The operating consultant formulated a surgical plan to resolve the complex nature of this mal-united Galeazzi fracture. A scarf-type osteotomy would correct the deformity and reduce the risk of non-union. Clinically and radiographically, the scarf osteotomy had healed by three months. The patient was very pleased that he underwent revision surgery, as the pain from the wrist resolved and the range of movement improved.

Pushing the Surgical Limits: Primary Total Knee Arthroplasty Using Rotational Prosthesis in a 96-Year-Old Lady with End-Stage Osteoarthritis.

We present the case of a 96-year-old patient treated for severe osteoarthritis with primary total knee arthroplasty (TKA) using a rotational prosthesis. The patient had significant medical comorbidities and her independence was limited due to her severe functional immobility. This case demonstrates that TKA can be a safe procedure with good outcomes in nonagenarians with severe osteoarthritis. Thorough discussion of treatment options is crucial for elderly patients with multiple medical comorbidities. TKA in the nonagenarian population can restore function and independence for patients which may reduce the burden on social care.

Orthopedic injuries associated with use of electric scooters in the UK: A dangerous trend? Case series and review of the literature.

BACKGROUND: Electric scooters (e-scooters) are becoming increasingly common in major urban areas worldwide. Cities in some countries have even piloted programmes to promote their use to reduce general vehicular traffic. There have, however, been widespread media reports outlining concerns about their safety. We decided to investigate these concerns by reviewing the records of patients who presented to our center, a Level 1 Major Trauma Center in the United Kingdom, with orthopedic injuries associated with e-scooter use. METHODS: We reviewed the electronic medical records of all patients who presented to our center from January 2018 to January 2020 with e-scooter associated fractures. Demographic, injury, and surgical data were collected to characterize the types of e-scooter-related fractures and to investigate the frequency of such injuries over the duration of our search. A literature review of MEDLINE and EMBASE was performed to investigate specifically orthopedic injuries caused by electric scooter use. RESULTS: Six patients were identified (3 male, 3 female; mean age 35.43 years) who had sustained a variety of injuries. The presentation and clinical outcomes are presented. Three patients required operative management, and three patients were managed conservatively. CONCLUSION: This case series demonstrates an increasing frequency of significant orthopedic injury associated with e-scooter use treated at our center over the course of two years. This small series highlights an important problem given that this increase has occurred despite electric scooter usage in public spaces being illegal. Legalization might result in further increase in the incidence of injury.

COVID-19 antibody tests: statistical implications.

The coronavirus disease 2019 (COVID-19) pandemic has had significant implications for society, with the introduction of restrictive social measures. Antibody tests provide a way of identifying patients who have been previously exposed to the virus and thus may have a degree of immunity. This is important in the development of public health policy, as local and national bodies seek to relax social restrictions in an attempt to mitigate the socioeconomic impact of the pandemic. This article explores the essential statistical concepts used to interpret the findings of diagnostic investigations, with examples illustrated using COVID-19 antibody tests.

New drug, new problem: do hip fracture patients taking NOACs experience delayed surgery, longer hospital stay, or poorer outcomes?

INTRODUCTION: Neck of femur fractures are common in the comorbid, often anticoagulated, elderly. Non-vitamin K antagonist oral anticoagulants (NOACs) may affect patient outcomes. We aimed to evaluate whether hip fracture patients admitted on warfarin or NOAC therapy were at risk of operative delay, prolonged length of stay, or increased mortality. METHODS: We collected data for 845 patients admitted to our centre between October 2014 and December 2016. Multivariable linear regression analysis was performed to test the association between warfarin and NOAC therapy on time to surgery and length of stay. Variables in the regression model were age, sex, admission AMTS, pre-fracture mobility, ASA score, fracture type, and operation type. Fisher's exact test was used to evaluate whether warfarin or NOAC therapy delayed surgery beyond 36 or 48 hours, or decreased 30-day, 6-month, or 12-month survival. RESULTS: Time to surgery was delayed in anticoagulated patients (p = 0.028). NOAC therapy was independently associated with increased time to surgery beyond 36 hours (p = 0.001), although not beyond 48 hours (p = 0.355), whereas warfarin therapy was not associated with either. Anticoagulation did not increase length of stay (p = 0.331). Warfarin therapy significantly reduced 30-day survival (p = 0.007), but NOAC therapy did not (p = 0.244). Neither warfarin nor NOAC therapy affected further survival. CONCLUSIONS: NOAC therapy delays time to surgery beyond the NHS England 'Best Practice Tariff' in hip fracture patients. We aim to prospectively investigate long-term outcomes. Without a NOAC antidote, policy must change to ensure time-appropriate surgery for patients on NOACs. Preoperative involvement of the haematology team is essential.

Trends in post-mastectomy breast reconstruction types at a breast cancer tertiary referral centre before and after introduction of acellular dermal matrices.

BACKGROUND: Reconstructive breast surgery has continued to evolve over the last decade with a key change being the adoption of acellular dermal matrices (ADMs) as an adjunct for implant-based procedures. This retrospective observational study assesses the effect of ADMs on post-mastectomy reconstructive practice performed in a single institution. METHODS: We conducted a review of all patients undergoing breast reconstruction at a University Teaching Hospital for an 18-month period before and after adopting ADMs. Demographic, procedural and complication data for these two cohorts were compared (χ2 and Student's t-tests). RESULTS: A total of 264 women (336 breasts), mean age 47.5 years, were identified: 137 before and 127 after the introduction of ADM. Implant-only reconstructions increased from 16% to 52% following the adoption of ADM (p < 0.01), whereas the proportion of both latissimus dorsi and deep inferior epigastric perforator flap reconstructions decreased significantly (31%-11% and 49%-34%, respectively, p < 0.01). The rate of early complications for the implant-only procedures was not significantly different with or without ADM (26% versus 20%, respectively, p = 0.44), despite there being no difference in the rate of adjuvant radiotherapy (22% versus 35%, respectively, p = 0.30). CONCLUSIONS: This study showed that since ADM introduction to our centre, more breast reconstructions have been of the implant-only type with consequent reductions in the more complex and expensive autologous techniques. Implant-only procedures that incorporated ADM use had similar complication rates to those that did not.

Brodie abscess of the femoral capital epiphysis in a 2-year-old child caused by Kingella kingae.

We report the case of a Brodie abscess of the femoral capital epiphysis from which Kingella kingae was isolated. This is to the best of our knowledge the first report of a Brodie abscess of the femoral capital epiphysis from which K. kingae was isolated.

Radius and Ulna Stress Fractures in a Patient with Neuromyelitis Optica: A Case Report.

INTRODUCTION: Stress fractures are more common in the weight-bearing bones of the lower limb and are particularly prevalent in athletes. Whereas, those of the upper limb are usually reported as unique events in rare circumstances. CASE REPORT: We present a case of a 40-year-old White British female with neuromyelitis optica (NMO) who mobilized in a wheelchair and presented to our center in April 2016 with a week-long history of a hot, swollen, and unstable right forearm. Plain radiographs demonstrated fractures of both the radius and ulna of the dominant right arm. These were managed by open reduction and internal fixation to facilitate mobility and transfer using the forearm. Intra-operatively, these were confirmed to be fatigue fractures, and there was evidence that the fracture was several days old. The neurological deficit in this patient had led to a delayed presentation owing to the lack of pain. Unfortunately, this construct failed within 8days, and a refixation was performed 2months later. 1year following the revision, no further problems have been reported, and there has been satisfactory union. CONCLUSION: This is the first report in the published literature of a stress fracture in a patient with NMO. We recommend screening for stress fractures with a nuclear bone scan in patients who mobilize in atypical ways, particularly if their sensation is compromised. The use of constructs stronger than those routinely applied to the upper limb should also be considered if patients are weight bearing through their arms.