The impact of COVID-19 on foot and ankle surgery in a major trauma centre.

INTRODUCTION AND AIMS: COVID-19 has had a significant impact on orthopaedic surgery globally. This paper aims to evaluate the impact of COVID-19 on foot and ankle trauma in a major trauma centre. METHODS: A retrospective observational study of prospectively collected data was performed. All foot and ankle trauma patients over a 33 week period (1st December 2019-16th July 2020) were analysed. All patients with trauma classified by the AO/OTA as occurring at locations 43 and 81-88 were included. RESULTS: Over the 33 weeks analysed, there was a total of 1661 trauma cases performed; of these, only 230 (13.85%) were foot and ankle trauma cases. As percentage of cases during each period of lockdown, foot and ankle made up 15.20% (147 out of 967) pre-lockdown, 8.81% (17 out of 193) during lockdown and 13.17% (66 out of 501) post lockdown. This difference was statistically significant (p < .001). The most significant change in trauma management was the treatment of malleolar fractures. Further analysis showed that during the lockdown period 29 foot and ankle fractures were treated the same and 13 were treated differently, (i.e. 31% of fractures were treated conservatively, when the consultants preferred practice would have been surgical intervention). Of the 13 patients, 3 have had surgical management since lockdown has been eased. CONCLUSION: It is evident that the trauma case activity within foot and ankle was significantly reduced during the COVID-19 period. The consequences of change in management were mitigated due to a reduction in case load.

A comparison of leg length and femoral offset discrepancies in hip resurfacing, large head metal-on- metal and conventional total hip replacement: a case series.

BACKGROUND: A discrepancy in leg length and femoral offset restoration is the leading cause of patient dissatisfaction in hip replacement surgery and has profound implications on patient quality of life. The aim of this study is to compare biomechanical hip reconstruction in hip resurfacing, large-diameter femoral head hip arthroplasty and conventional total hip replacement. METHOD: Sixty patient's post-operative radiographs were reviewed; 20 patients had a hip resurfacing (HR), 20 patients had a Large Head Metal-on-metal (LHM) hip replacement and 20 patients had a conventional small head Total Hip Replacement (THR). The leg length and femoral offset of the operated and unoperated hips were measured and compared. RESULTS: Hip resurfacing accurately restored hip biomechanics with no statistical difference in leg length (P = 0.07) or femoral offset (P = 0.95) between the operated and non-operative hips. Overall HR was superior for reducing femoral offset discrepancies where it had the smallest bilateral difference (-0.2%, P = 0.9). The traditional total hip replacement was least effective at restoring the hip anatomy. CONCLUSION: The use of a larger-diameter femoral head in hip resurfacing does not fully account for the superior biomechanical restoration, as LHM did not restore femoral offset as accurately. We conclude that restoration of normal hip biomechanics is best achieved with hip resurfacing.

Kinematic assessment of hip movement when retrieving an object from the floor.

BACKGROUND: Activities that require extreme hip movement can dislocate hip implants in the early post operative phase. One such activity is retrieving an object from the floor. The aim of this study was to assess hip movement using four different techniques to accomplish this task. This assessment would identify the techniques least likely to cause a hip dislocation. METHODS: An electromagnetic tracker was used to measure the movement of 50 hips in 25 normal subjects. Sensors were attached over the iliac crest and the mid-shaft of the lateral thigh. Data was then collected for 3 repetitions of each of the following retrieval techniques:--1. Flexing forward to pick up an object between the feet. 2. Flexing to pick up an object lateral to the foot. 3. Squatting to pick up an object between the feet. 4. Kneeling on one knee to pick up beside the knee. RESULTS: Kneeling required a mean movement of 30.4 degree(s) flexion and 7.2 degree(s) external rotation. This was significantly less than all the other techniques (paired t-test, P << 0.001). Squatting required 87.4 degree(s) flexion and 10.1 degree(s) internal rotation. CONCLUSION: The study showed that squatting had the most flexion and internal rotation, whereas kneeling has the least flexion. Thus, to minimise the dislocation risk when retrieving an object from the floor, kneeling should be adopted and squatting should be avoided.

Is the 'driving test' a robust quality indicator of colonoscopy performance?

Colorectal cancer is a major cause of death in the western world and is currently the second commonest cause of death from malignant disease in the UK. Recently a "driving test" for colonoscopists wishing to take part in the National Health Service Bowel Cancer Screening Program has been introduced, with the aim of improving quality in colonoscopy. We describe the accreditation process and have reviewed the published evidence for its use. We compared this method of assessment to what occurs in other developed countries. To the authors' knowledge no other countries have similar methods of assessment of practicing colonoscopists, and instead use critical evaluation of key quality criteria. The UK appears to have one of the most rigorous accreditation processes, although this still has flaws. The published evidence suggests that the written part of the accreditation is not a good discriminating test and it needs to be improved or abandoned. Further work is needed on the best methods of assessing polypectomy skills. Rigorous systems need to be in place for the colonoscopist who fails the assessment.

Perforated carcinoma of the caecum presenting as necrotising fasciitis of the abdominal wall, the key to early diagnosis and management.

BACKGROUND: Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management. CASE PRESENTATION: We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall. CONCLUSION: This case highlights the importance of early aggressive debridement to healthy tissue limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction in order that aggressive initial surgery can be adequately performed.