The Use of Hindfoot Nails for Elderly Complex Distal Tibial and Ankle Fractures.

Elderly patients who sustain complex ankle or distal tibial fractures are often frail and comorbid and need surgery to contain the talus underneath the tibia in order to protect the soft tissue envelope and allow early unrestricted weightbearing. We performed a retrospective observational review of patients >65 years old who underwent a hindfoot nail fixation of an ankle or distal tibial fracture in our institution. Data collected included: injury sustained, open or closed injury, ASA grade, age at time of surgery, length of stay, postoperative mortality, complications, and further treatment. The primary outcome was reoperation. Secondary outcomes were infection and 1 year mortality. Seventy hind foot nailing procedures were undertaken. Sixty-three out of 70 patients were female. The average age of those who died within 1 year of surgery was 84 years. Forty-five out of 70 were open injuries. Eleven out of 70 patients died with 1 year of surgery (range 1-358 days postsurgery). Five out of 70 (7%) patients developed an infection. Four out of 5 of these injuries were open. Three out of 5 underwent removal of the nail due to infection. Two out of 5 had the infection suppressed with antibiotics. Ten out of 70 (14%) patients underwent locking bolt removal due to it backing out or being prominent and causing wound healing issues. Two out of 70 (3%) patients went on to have below knee amputations. Both were due to ongoing wound problems following open fractures. The hindfoot nail is an important implant when treating complex ankle and distal tibial fractures in an elderly population. It facilitates early mobilization to avoid deconditioning and other medical complications.

Magnetic resonance imaging in the evaluation of suspected hip sepsis in children.

Background: Rapid and accurate diagnosis of musculoskeletal infection in children is critical to enable appropriate, targeted surgical interventions. Distinguishing between septic arthritis, myositis, and osteomyelitis around the hip can be difficult using clinical criteria and ultrasound scan alone. Materials and methods: We performed a retrospective 5-year observational review of selective magnetic resonance imaging scanning for hip sepsis in a pediatric tertiary referral center. Included were children with atraumatic hip pain with symptom duration <2 weeks, minimum of two positive modified Kocher's criteria, and a hip effusion on ultrasound. All cases were followed up to discharge. We evaluated hip ultrasound and magnetic resonance imaging findings, operative procedures, microbiology results, duration of treatment, outcomes, and complications. Results: Fifty-one patients, 55% male, with a mean age 6.4 (0-16) years were included. Thirty-nine underwent magnetic resonance imaging scan for suspected septic arthritis of the hip; 24 prior to surgical washout (pre-emptive), and 15 afterwards (postoperative). In the pre-emptive group, 1/24 had septic arthritis, 7/24 had osteomyelitis, 6/24 had myositis, 5/24 had osteomyelitis and myositis, and 5/24 had no evidence of infective pathology. In the postoperative group, 3/15 had myositis, 3/15 had osteomyelitis, 3/15 had re-accumulation of the hip effusion requiring repeat washout, 3/15 had myositis and osteomyelitis, and 1/15 had septic arthritis of a contiguous joint. Conclusion: Pre-emptive magnetic resonance imaging scanning avoided unnecessary hip washout in 23 cases and enabled targeted drainage of an alternative focus in four of those. Magnetic resonance imaging scanning after hip washout indicated that four cases required further surgery to drain a different focus of infection.