The Effect of Sagittal and Coronal Balance on Patient-Reported Outcomes Following Mobile-Bearing Total Ankle Replacement.

Total ankle replacement (TAR) is an established technique for the treatment of end-stage ankle arthritis. The aims of TAR include pain relief, preservation of tibiotalar movement, protection of adjacent joints, and restoration of anatomic alignment in the coronal and sagittal planes. The aims of this study were to determine the relative importance of pre- and post-TAR coronal and sagittal balance on postoperative patient-reported outcome measures (PROMs). A total of 101 ankles in 99 patients were included in this retrospective cohort study. Patients were scored preoperatively and at a minimum of 2 years by using the Foot and Ankle Outcome Score (FAOS), the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, the Short Form-36 measures, and a set of radiographic measurements to define the sagittal and coronal alignment. There was no significant difference between the groups regarding the anterior or posterior translation of the talus preoperatively. There were no statistically significant correlations between any preoperative measure and any domain of the PROM data. Significant correlations were observed between postoperative medial distal tibial angle and the function domain of the FAOS and the AOFAS hindfoot-ankle score. Preoperative coronal and sagittal plane deformity are not markedly different, depending on the diagnosis. Preoperative deformity does not appear to correlate significantly with postoperative function, as measured by the PROM scores. Postoperative sagittal plane alignment does not correlate significantly with postoperative function, as measured by PROMs. Coronal plane alignment, as measured by the medial distal tibial angle, may be associated with postoperative function, as measured on the AOFAS hindfoot-ankle and FAOS function subscales.

How Knowledge Relates to Confidence in Orthopedics and Emergency Medicine Regarding Return to Sport and Rehabilitation in Foot and Ankle Trauma.

OBJECTIVE: The aim of this study was to survey the knowledge of registrars in emergency medicine and orthopedics on 5 common injuries to the foot and ankle and compare this knowledge, and self-reported confidence in giving it, with that of consultants and physiotherapists of various levels of experience. DESIGN: An online survey was used to gather the information using scenario-based open and closed questions. PARTICIPANTS: A total of 102 health care professionals, who regularly deal with sports injuries, were recruited. These included consultant orthopedic surgeons with a subspecialty interest in foot and ankle surgery, orthopedic surgeons in other specialties, extended scope physiotherapy practitioners (ESPs) in foot and ankle and general musculoskeletal practice, emergency medicine consultants, emergency medicine registrars, orthopedic registrars, senior physiotherapists, and junior physiotherapists. SETTING: The participants were drawn from various health care institutions in the North East of England. RESULTS: Consultant foot and ankle surgeons and extended scope practitioners in foot and ankle both scored significantly on knowledge of rehabilitation program design than either set of registrars. For 2 of the case scenarios, there was a significant difference in scores between either orthopedic consultants or ESPs and registrars (p < 0.05). For total score, there was a trend for extended scope practitioners to score higher than both sets of registrars, but this did not reach significance. Correlation coefficients for knowledge and self-reported confidence ranged between 0.009 and 0.33, demonstrating only weak positive linear correlation between scenario score and reported confidence in advice given. CONCLUSIONS: The most significant area of gaps in knowledge among the 2 groups of registrars was in the specifics of rehabilitation programs. There was markedly higher confidence with greater seniority. Registrars in emergency medicine and orthopedics are likely to benefit from case-based teaching in sports injury rehabilitation.

The effect of delay to surgery on morbidity, mortality and length of stay following periprosthetic fracture around the hip.

With the increasing prevalence of total hip arthroplasty and the increasing longevity of patients with implants in situ, periprosthetic fractures of the proximal femur are seen with greater frequency. They represent a challenging surgical problem, requiring combined arthroplasty and trauma skills in a potentially compromised surgical bed. We present data from the 82 consecutive patients with periprosthetic fractures around the hip presenting to two NHS Foundation Trusts in the period January 2009 to February 2014. Inpatient mortality across all sites was 11.0%. This increased to 17.1% at 1 year. There was no association between delay to surgery and either inpatient or 1 year mortality. Mean delay to surgery was 4.1 days in those without inpatient mortality, 5.2 days in those with (p=0.3075). Mean delay to surgery was 4.5 days in those with 1 year mortality, 4.16 days in those without (p=0.6203). The number of post-operative complications was not significantly positively correlated with increasing delay to surgery (Pearson correlation coefficient -0.04437). It would appear that a delay to order necessary equipment and obtain relevant surgical expertise for the treatment of these complex fractures is safe and not associated with increased mortality or post-operative complications.

An unusual complication of the Mackenzie approach for a Copeland hemiarthroplasty.

We report the case of a patient with end-stage osteoarthritis who received a successful Copeland resurfacing hemiarthroplasty through a Mackenzie anterosuperior approach, which involves taking the anterior portion of the deltoid attachment from the acromion along with an osteo-periosteal sleeve. The patient went on to develop severe subacromial impingement symptoms 4 months postoperatively. X-rays revealed a large anteroinferior acromial osteophyte that had not been present preoperatively and was deemed to represent a malunited osteo-periosteal sleeve from the Mackenzie approach.

Juvenile idiopathic arthritis in adulthood and orthopaedic intervention.

There have been marked changes in the management of juvenile idiopathic arthritis (JIA) over recent decades, mainly with earlier use of methotrexate (MTX). Our aim was to describe orthopaedic interventions in a large group of adults with JIA followed up over several decades. This was a retrospective observational study of adult JIA patients attending a teaching hospital clinic, with information collated on JIA subtype, disease duration, orthopaedic interventions, and exposure to MTX. The study included 144 patients with median disease duration of 19 years. Survival analysis showed that joint surgery was observed in the majority (75%) of patients with disease duration over 40 years with a trend for less joint surgery in patients with oligoarticular JIA. In total, 41 patients (28.5%) had received joint surgery, and 17/41 (41%) have required multiple procedures. Of those who have required joint surgery, 20/41 (48%) had started MTX in their adult years, with only 5/41 (12%), starting MTX prior to first joint replacement and none within 5 years of disease onset. Of the patients who have not had joint surgery to date, most (46/103, 45%) were receiving MTX or another immunosuppressive agent; in the majority of cases, MTX was started within 2 years of disease onset. Many adults with JIA require joint replacement surgery and ongoing immunosuppressive treatments, emphasising that JIA is not a benign disease. Many patients who have had joint replacement surgery have had exposure to MTX albeit after many years after disease onset; it remains to be seen whether patients who have received MTX therapy early in their disease course will ultimately have less requirement for joint surgery.