Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study.

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

The King's Sliding Hindfoot Osteotomy for the Treatment of Talus Body Defects-Results of a New Technique in Tibiotalocalcaneal Arthrodesis.

Bone loss after avascular necrosis of the talus secondary to acute traumatic or chronic pathologies often requires surgical reconstruction. This study reports the early results of a sliding oblique hindfoot osteotomy for salvage procedures combined with tibiotalar arthrodesis to achieve a well-aligned, painless, plantigrade foot. All patients presenting to our institution with severe talus body defects requiring corrective surgery between January 2016 and August 2020 were included. An oblique osteotomy of the diseased talus was performed to correct anterior talus subluxation and prevent excessive loss of height at the tibiotalar apposition and to correct varus-valgus deformity. A retrograde hindfoot nail was used for intramedullary tibiotalocalcaneal arthrodesis. Patients were prospectively followed. Primary outcomes included assessment of mobility and union at 6 months. Secondary outcomes included 30-day postoperative complications, patient satisfaction and change in American Orthopaedic Foot & Ankle Society (AOFAS) score at 1-year postoperation. Nine patients underwent this procedure with a mean follow-up of 18 months (4-36 months). Average age was 66 (58-81) years. Mean body mass index was 33.7 (22-38) kg/m2. All patients went on to fusion and were ambulating at 6 months (n = 8). At 1 year, the mean improvement in AOFAS was 28.9 points (p < .05) (n = 7) and all patients were satisfied with the outcome of their treatment. This technique represents an alternative to conventional hindfoot salvage techniques showing predictable outcomes in complex hindfoot deformity with talar body collapse and anterior subluxation. Further quantitative studies are needed to define if this technique minimizes limb shortening/limb-length discrepancies when compared to traditional horizontal cuts.

Charcot foot reconstruction outcomes: A systematic review.

BACKGROUND: Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS: We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS: A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS: Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.

Total hip arthroplasty in osteonecrosis secondary to sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) is a multisystem disease, and the predominant articular manifestation is osteonecrosis (ON). Total hip arthroplasty (THA) is technically challenging, and the complication rates are high. In this retrospective study, we have analysed the outcome of THA in a cohort of patients with SCD at our institution. MATERIALS AND METHODS: We identified 34 THAs between 1999 and 2016 in 30 patients (mean age 37 years) from our SCD database. Co-morbidities, both sickle and non-sickle-related, were documented. Complications and indications for revision surgery were analysed. RESULTS: An uncemented prosthesis was predominantly used. The mean follow-up was 10.5 years (range 1-18). Six patients had revision surgery (17.6%), 2 (5.8%) for Prosthetic Joint Infection (PJI), and 4 (11.7%) for osteolysis of the acetabular component. CONCLUSION: Our revision rates were comparable to the published literature. Our combined sickle cell clinic and the coordinated multidisciplinary management have been successful in reducing morbidity.

Magnetic resonance imaging of cortical bone with ultrashort TE pulse sequences.

PURPOSE: Normal adult cortical bone has a very short T(2) and characteristically produces no signal with pulse sequence echo times (TEs) routinely used in clinical practice. We wished to determine whether it was possible to use ultrashort TE (UTE) pulse sequences to detect signal from cortical bone in human subjects and use this signal to characterise this tissue. SUBJECTS AND METHODS: Seven volunteers and 10 patients were examined using ultrashort TE pulse sequences (TE=0.07 or 0.08 ms). Short and long inversion as well as fat suppression pulses were used as preparation pulses. Later echo images were also obtained as well as difference images produced by subtracting a later echo image from a first echo image. Saturation pulses were used for T(1) measurement and sequences with progressively increasing TEs for T(2)* measurement. Intravenous gadodiamide was administered to four subjects. RESULTS: Signal in cortical bone was detected with UTE sequences in children, normal adults and patients. This signal was usually made more obvious by subtracting a later echo image from the first provided that the signal-to-noise ratio was sufficiently high. Normal mean adult T(1)s ranged from 140 to 260 ms, and mean T(2)*s ranged from 0.42 to 0.50 ms. T(1) increased significantly with age (P<.01). Increased signal was observed after contrast enhancement in the normal volunteer and the three patients to whom it was administered. Reduction in signal from short T(2) components was seen in acute fractures, and increase in signal in these components was seen with new bone formation after fracture malunion. In a case of osteoporosis, bone cross-sectional area and signal level appeared reduced. CONCLUSION: Signal can be detected from normal and abnormal cortical bone with UTE pulse sequences, and this can be used to measure its T(1) and T(2)* as well as observe contrast enhancement. Difference images are of value in increasing the conspicuity of cortical bone and observing abnormalities in disease.

Magnetic resonance imaging of periosteum with ultrashort TE pulse sequences.

PURPOSE: To assess the values of pulse sequences with ultrashort echo times (0.08 msec) for detecting and characterizing periosteum. MATERIALS AND METHODS: Two normal volunteers aged 33 and 58 years and 12 patients aged seven to 55 years were studied. A total of 10 of the patients had contrast enhancement with intravenous Gadodiamide. Two ovine tibias were examined before and after the periosteum was stripped from the bone. RESULTS: High signal regions were observed adjacent to cortical bone in all parts of the skeleton imaged. They were generally more conspicuous after fat suppression and contrast administration. In the ovine tibia there was a reduction in the high signal normally seen at the surface of the bone after periosteal stripping. The detached periosteum produced a high signal. Mean T(2)* values for adult human periosteum ranged from 5.3 to 11.4 msec. After enhancement the signal intensity increased. In two patients with tibial fractures, increased periosteal signal was seen and this showed marked enhancement. Signals from periosteum could be simulated by fat, contrast-enhanced blood and artifacts. CONCLUSION: The periosteum can be visualized with ultrashort echo time pulse sequences in health and disease.