Prevalence, Characteristics, and Prognosis of Peripheral Arterial Disease in Patients With Diabetic Charcot Foot.

Charcot foot (CF) is a rare complication of diabetes associated with foot deformities and foot ulcers. Peripheral arterial disease (PAD) is a factor of poor prognosis in patients with diabetic foot ulcers (DFUs). However, PAD has infrequently been studied in CF. We aimed to determine the prevalence, the characteristics and the prognosis of PAD in a large group of patients with diabetic CF. We retrospectively compared 56 patients with diabetic CF to 116 patients with diabetic foot without CF. The prevalence of PAD in patients with CF was 66.1%. Compared to patients without CF, patients with CF had similar risks to have PAD (OR 0.98, 95%CI 0.50-1.94, p= .97) and neuro-ischemic DFUs (OR 1.19, 95%CI 0.57-2.49, p= .65), more risk to have lesions of distal arteries (OR 4.17, 95%CI 1.76-9.94, p= .001) and less risk to need revascularization (OR 0.14, 95%CI 0.06-0.36, p< .001). In patients with CF, PAD was strongly predicted by DFUs (OR 24.55, 95%CI 1.80-334.43, p= .016) and coronary artery disease (OR 17.11, 95%CI 1.75-167.43, p =.015). Survival rate and limb salvage rate in patients with CF were not worsened by PAD and by neuro-ischemic DFUs, respectively. In conclusion, we show that PAD should not be overlooked in patients with diabetic CF, especially in those having DFUs or coronary artery disease. PAD in patients with CF differed from that of patients without CF since it predominated in distal arteries and required less often revascularization.

Frequency and risk factors of complications after surgical treatment of ankle fractures : a retrospective study of 433 patients.

Ankle fractures are frequently treated using surgical interventions, and are associated with a high rate of postoperative complications. We wonder if complications can be anticipated and correlated to patient demographics, lifestyle, fracture or surgery related factors. We retrospectively reviewed all medical reports of patients who underwent ankle fracture surgery between 2013 and 2017. We focused our risks factors analysis on 5 common complications : poor wound healing, surgical site infection, malunion, nonunion and chronic pain. Multivariate logistic regression was performed to analyze significant risk factors for these complications. We identified 433 patients. Complications were present in 26% of the cases. The most frequent complication was poor wound healing (10%) associated with deep surgical site infection in 6%. Malunion was found in 7% and nonunion in 3%. Seven percent of patients suffered from chronic pain. More severe fractures happened to be a risk factor for poor wound healing (p = 0,032) and malunion (p < 0,001). Open fractures had respectively 6 to 9 times more mal- (p = 0,012) and nonunion (p = 0,018). Overweight patients with alcohol abuse were doubling their chances of cutaneous (p = 0,030) and infectious (p = 0,040) complications, and tripling their risks of ankle fracture nonunion (p = 0,003). Female and patients operated at night (p = 0,045) seemed to be more at risk to develop chronic pain (p = 0,028). Complications of ankle fracture treatment are frequent and their risks increases with more complex and open fractures. This study brings new evidence concerning the combined effect of overweight and alcohol abuse on poor wound healing, surgical site infection and non-union.

Surgical treatment of lateral ankle instability. Does allograft tendon have a better functional result?

Surgical treatment of lateral ankle instability can be performed with or without allograft. We compared these two technical options referring to patients' functional, radiological and ultrasound data. Forty patients were surgically treated for lateral pain- ful instability of the ankle. Twenty patients underwent ligamentoplasty using the Broström-Gould technique and twenty underwent a ligamentoplasty by allograft tendon. Patients were matched in age and gender. The assessment was done at 2.5 years postoperatively by functional scores (Olerud & Molander, and Foot & Ankle Outcome), dynamic x-rays (focused on varus and anterior drawer stress tests) and ultrasound examination (focused on anterior talo-fibular and calcaneo-fibular ligaments). No significant difference was found between the two techniques for all scores. Functional scores were more than 75% and the complication rate was low (<10%). Regarding the surgical technique, the tendon allograft could not prove to be more beneficial.

Can infection be predicted after intramedullary nailing of tibial shaft fractures?

Despite the progress in tibial fracture care, some patients contract infection following intramedullary nailing. We analyzed which risk factors could predict infection in 171 tibial fractures. The independent variables included age, gender, body mass index, and comorbidities, along with external factors of fracture pattern, nailing settings, and treatment processing time. A multiple logistic regression was used to identify infection risk factors. The risk of infection significantly increased according to the open grading, the fractures' classification, time until antibiotic administration, and time until nailing. Gustilo type I fractures presented a higher rate of infection than expected, explained by a longer delay before surgery. The probabilistic equation allows infection prediction with high sensitivity and specificity. In total, we showed that no antibiotics' prescription in emergency service and a transverse fracture pattern were predictors of infection. An infection risk score can be computed, aiding surgeons in decision making. Outcomes could improve keeping these observations in mind. Level of evidence: Retrospective cohort study. Level iii.

Unusual proximal fragment migration of an os peroneum fracture with associated peroneus longus tendon injury-a tree often hides a forest.

We report the case of a 55-year-old male patient who presented to the emergency department after sustaining a right ankle trauma. Swelling and tenderness of the lateral aspect of the right ankle were present on physical examination without evidence of motor or sensory deficit. Ankle radiographs were performed and showed two bony fragments, the first located postero-inferiorly to the cuboid bone while the second was adjacent to the tip of the lateral malleolus. The diagnosis of an os peroneum fracture was made with high suspicion of an associated peroneus longus tendon rupture. Computed tomography (CT) and magnetic resonance imaging (MRI) of the right ankle confirmed the diagnosis of a subtotal retracted tendinous rupture. Successful surgical repair of the injured tendon was performed. This article illustrates the imaging findings of an os peroneum fracture with its associated tendinous injury and reviews the literature.

Multiple Joint Replacements for Progressive Pseudorheumatoid Dysplasia: A Case Report.

Introduction: Progressive pseudorheumatoid dysplasia is a rare autosomal recessive disorder caused by a mutation in the Wnt1-inducible signaling protein 3 gene, with few cases reported. Case Report: We discuss the case of a 19-year-old Caucasian male patient with polyarticular involvement, including shoulders, elbows, wrists, hands, spine, hips, knees, and notably the ankles. Despite a well-conducted medical treatment, due to the rapid progression of his condition, the patient underwent bilateral total hip and knee arthroplasties, as well as left ankle replacement. Conclusion: This case report highlights the importance of conducting the diagnosis of these rare diseases and the important place of joint replacements in the recovery of joint functions, even in young patients.

Traumatic injuries of the distal tibiofibular syndesmosis.

The distal tibiofibular syndesmosis (DTFS) is frequently injured during ankle trauma. The sequelae can be significant, including chronic instability, early osteoarthritis and residual pain. The aim of this study is to summarize the current state knowledge about these injuries by answering four questions. They frequently occur in the context of an ankle sprain (20-40% of cases) or during various types of ankle fractures (20-100% of cases). They cannot be ruled out based solely on fracture type and must be investigated when a fibular or posterior malleolar fracture is present. Clinical examination and imaging are essential but do not provide a definitive diagnosis. Ultrasonography, CT scan and MRI have high sensitivity, but their static nature does not allow a treatment strategy to be defined. Dynamic radiographs must be taken, either with load or during a procedure. If instability is detected, stabilization is the general rule. In fracture cases, reduction is achieved by restoring the length and rotation of the distal fibular fragment, preferably during an open procedure. In sprain cases, reduction is not a problem unless there is ligament interposition. Tibiofibular fixation is done 1.5 to 3cm from the talocrural joint, while ensuring the reduction is perfect. The main complication-non-healing of the syndesmosis-is attributed to poor initial reduction. This or functional discomfort during weight bearing will require removal of the fixation hardware. In most cases, this allows functional recovery and correction of the inadequate reduction. Persistence of instability will require ligament reconstruction or fusion of the syndesmosis. Chronic instability can lead to ankle osteoarthritis. LEVEL OF EVIDENCE: V, expert opinion.

Irreducible ankle fracture dislocation due to posterior tibialis tendon interposition: Diagnostic and clues for early management - A case report.

Irreducible fracture dislocation of the ankle is a rare condition. Multiple cases have been described throughout the literature. Different known etiologies involve the distal fibula, deltoïd ligament and tendons of the posteromedial malleolar region. More specifically, trapping of the Posterior tibialis tendon has been described at several levels from the inside of the ankle joint, through the syndesmosis and in some cases in the fibula tibial interosseous space depending on the energy of trauma. We hereafter propose a case report and a review of previous cases of posterior tibialis tendon dislocation proximally in the interosseous space of the lower leg. The aim of this review is to point out common features and clues for early management in order to avoid overlooking these rare lesions as they may lead to major functional impairment of the ankle joint.

Predictors of mechanical complications after intramedullary nailing of tibial fractures.

INTRODUCTION: Intramedullary (IM) nailing is the gold standard treatment for tibial shaft fractures, but can be associated with various mechanical complications, including delayed union. HYPOTHESIS: We believe that complications do not occur randomly, but in certain conditions that contribute to their development. Risk factors likely to predict delayed union can be identified to support prevention. MATERIALS AND METHODS: A cohort of 171 fractures treated by IM nailing between 2005 and 2015 was reviewed retrospectively. Independent variables included intrinsic, patient-related factors and extrinsic factors such as those related to the fracture or surgery. A multiple logistic regression model was used to determine which factors can predict each type of complication. RESULTS: Delayed union occurred in 22.8% of patients. Smoking and high-energy trauma were risk factors. Hardware breakage was significantly reduced (p<0.05) when the nail diameter was greater than 10mm. A nail diameter/reamer diameter ratio outside the recommended limits (0.80-0.99) was more likely to be associated with screw failure. Diabetes is a risk factor for hardware migration, which itself is associated with other complications. DISCUSSION: Nonunion is the most common complication after IM nailing of tibial shaft fractures. Smoking cessation after a fracture is necessary in our opinion, even if the literature is ambivalent on this aspect and stopping to smoke once the fracture occurs may not be sufficient to prevent a poor outcome. Use of a nail diameter/reamer diameter between 0.80 and 0.99 favors union and prevents hardware breakage. Hardware migration in a diabetic patient may be a warning sign of other types of complications. LEVEL OF EVIDENCE: Retrospective cohort study. Level IV.

Low haemoglobin at admission is associated with mortality after hip fractures in elderly patients.

AIMS: Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery. PATIENTS AND METHODS: All consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery. RESULTS: We included 829 patients; the mean age was 81 years (sd 11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01). CONCLUSION: Our results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into account in perioperative management. Cite this article: Bone Joint J 2019;101-B:1122-1128.

Clinical and demographic profile of admitted victims in a tertiary hospital after the 2015 earthquake in Nepal.

BACKGROUND: In 2015, an earthquake killing 9,000 and injuring 22,000 people hit Nepal. The Tribhuvan University Teaching Hospital (TUTH), a reference tertiary hospital, was operational immediately after the earthquake. We studied the profile of earthquake victims admitted in TUTH and assessed what factors could influence hospital length of stay. METHODS: An earthquake victim dataset was created based on patient records, with information on sex, age, date of admission and discharge, diagnosis, and surgical intervention. We performed an initial descriptive overview of the earthquake victims followed by a time-to-event analysis to compare length of hospital stay in different groups, using log rank test and cox regression to calculate Hazard Ratios. RESULTS: There were in total 501 admitted victims, with the peak of admissions occurring on the fifth day after the earthquake. About 89% had injury as main diagnosis, mostly in lower limbs, and 66% of all injuries were fractures. Nearly 69% of all patients underwent surgery. The median length of hospital stay was 10 days. Lower limb and trunk injuries had longer hospital stays than injuries in the head and neck (HR = 0.68, p = 0.009, and HR = 0.62 p = 0.005, respectively). Plastic surgeries had longer hospital stays than orthopaedic surgeries (HR = 0.57 p = 0.006). Having a crush injury and undergoing an amputation also increased time to discharge (HR = 0.57, p = 0.013, and HR = 0.65 p = 0.045 respectively). CONCLUSIONS: Hospital stay was particularly long in this sample in comparison to other studies on earthquake victims, indirectly indicating the high burden TUTH had to bear to treat these patients. To strengthen resilience, tertiary hospitals should have preparedness plans to cope with a large influx of injured patients after a large-scale disaster, in particular for the initial days when there is limited external aid.

Value of a radiographic score for the assessment of healing of nailed femoral and tibial shaft fractures: A retrospective preliminary study.

OBJECTIVES: To assess the value of a radiographic score for the detection of delayed union in nailed fractures. METHODS: The modified radiographic union score (mRUS) values were determined by three separate radiologists on 259 radiographic sets of 58 nailed tibial or femoral fractures obtained at different timepoints after fracture (mean of 4.5 radiographic sets per fracture). A surgeon determined fracture outcome (normal or delayed union) at a mean of 192days after injury. Mean radiographic scores obtained at different timepoints after fracture were compared between fractures with normal or abnormal healing at follow-up. RESULTS: The mean score values increased significantly over time for fractures with normal healing for all readers (p<0.001). The mean score values determined 11-14 weeks after injury were higher in fractures with normal healing than in fractures with delayed union at follow-up (p<0.05). Scoring of radiographs obtained at about 3 months after injury or later enabled detection of fractures with delayed union with a sensitivity of 0.63-0.77 and a specificity of 1.0 (area under curve: 0.77- 0.88). CONCLUSIONS: The mRUS score can contribute to the detection of delayed union at a delay of about 3 months after injury in nailed shaft fractures.