The role of intramedullary fixation in ankle fractures - A systematic review.

BACKGROUND: Ankle fractures are one of the most commonly occurring fractures in the elderly population. The overall incidence has been reported to be up to 184 fractures per 100,000 persons per year, of which 20-30% occur in the elderly. Medical co-morbidities, osteoporosis, suboptimal skin quality and poor toleration of non-weight bearing status all contribute to difficulties in managing these injuries in this population. Intramedullary implants are advantageous as they utilise smaller incisions, minimise soft tissue disruption and may allow early weight bearing. This systematic review aims to analyse the use of both fibula nails and talo-tibial-calcaneal (TTC) implants in the management of fragility ankle fractures. METHODS: We conducted a systematic review of the literature using the online databases Medline and EMBASE on 26th December 2015. Only studies assessing ankle fractures that were treated with either an intramedullary fibula nail or TTC implant were included. Studies must have reported complications, patient mobility status or a functional outcome measure. Studies were excluded if the intramedullary device utilised was an adjunct to plate fixation or where a variety of surgical treatments were included in the study. The included studies were appraised with respect to a validated quality assessment scale. RESULTS: Our search strategy produced 350 studies although only 17 studies met inclusion criteria; ten assessed a fibula nail and seven assessed a standard hindfoot nail, a TTC implant. 15 studies were case series, the overall quality of the studies was low and only one randomised controlled trial was reviewed. The mean Olerud and Molander Ankle Score for fibula nail studies ranged from 58 to 97 and the complication rate from 0 to 22%. Two comparative studies reported a statistically significant increase in complication rate with plate fixation but similar functional outcomes. Studies assessing TTC implants reported a mean Olerud and Molander Ankle Score of 50-62 and complication rate from 18 to 22.6%. CONCLUSION: The studies reviewed suggest that fibula nails may be capable of producing similar functional outcomes with lower rates of complications to plate fixation. TTC implants produce lower functional outcomes but this may be acceptable in a subgroup of patients at high risk or with reduced pre-injury mobility. However, the low quality of evidence reviewed, the variation in patients included, implant used and outcome scores measured restricts the ability to draw definitive conclusions. Further comparative studies are required to explore the role of these implants further.

Learning anatomy of the foot and ankle using sagittal plastinates: A prospective randomized educational trial.

BACKGROUND: Foot and ankle anatomy is highly complex and presents a considerable educational challenge for the medical student or junior doctor. The successful interpretation of cross-sectional radiological images requires a detailed knowledge of anatomy and spatial relationships. Plastic-impregnated cadaveric prosection slices, known as 'sagittal plastinated slices', or 'SPS', are becoming popular as an adjunct to traditional anatomical teaching methods. OBJECTIVES: To compare the impact of SPS versus conventional anatomy teaching resources (dry bones and whole cadaveric feet) on learners' ability to correctly identify structures of the foot and ankle on sagittal MRI images. METHODS: Randomized educational study using sequential exploratory mixed-methods. RESULTS: The intervention group anatomy test scores were a mean of 1.2 higher after the educational intervention, compared to 0.7 for the control group (scores out of 14), but this was not statistically significant (p=0.41). Learners reported that the SPS intervention was most useful to augment and refine their knowledge after a teaching session using conventional resources. CONCLUSION: The qualitative results showed that SPS provide a valuable adjunct to traditional teaching methods in both anatomy and radiology of the foot and ankle, which should be used after teaching with traditional methods.

A novel technique for the treatment of infected metalwork in orthopaedic patients using skin closure over irrigated negative pressure wound therapy dressings.

INTRODUCTION: There has been recent interest in the use of negative pressure wound therapy (NWPT) as an adjunct to parenteral antibiotics in the treatment of infection in orthopaedic patients with metalwork in situ. To address some of the limitations of standard NPWT in this situation, the senior author has developed a modified method of treatment for infected metalwork (excluding arthroplasty) in orthopaedic patients that includes irrigation and skin closure over the standard NPWT dressing. METHODS: This retrospective study examined the outcome of a case series of 16 trauma and orthopaedic patients with deep infection involving metalwork in whom this modified form of NPWT was used. In conjunction with standard parenteral antibiotic therapy and a multidisciplinary approach, this modified technique included serial debridements in theatre, irrigation and negative pressure dressings over a white polyvinyl alcohol foam (KCI, Kidlington, UK) as well as closure of the skin over the foam. RESULTS: Among the 16 patients, there was a variety of upper and lower limb as well as spinal trauma and elective cases. In all 16 patients, there was successful resolution of the infection with no early or unplanned removal of any metalwork required. CONCLUSIONS: Patients with infected metalwork are a heterogeneous group, and often suffer high morbidity and mortality. The modified NPWT technique shows potential as an adjunct in the treatment of complex orthopaedic patients with infected metalwork.