Fibula nail fixation in ankle fractures with significant soft tissue compromise: a retrospective cohort study.

PURPOSE: Intramedullary fixation of lateral malleolar fractures has increased in popularity recently with the introduction of the fibula nail. It has been proposed as an alternative fixation method in fractures to minimise soft tissue injury. The aim of this study was to evaluate the clinical and patient-reported outcomes of those who had an ankle fracture with concurrent significant soft tissue damage, treated with a fibula nail. METHODS: Details of patients who were managed at our institution using a fibula nail were obtained from the trauma database. The Acumed Fibula Rod System (FRS) was used in all cases. Those who were less than 12 months following injury were excluded. Patients attended a follow-up clinic for measurement of range of movement, radiographs, and to complete MOX-FQ and EQ-5D questionnaires. RESULTS: Twenty patients were identified. Eleven attended for review in person, and a further eight completed questionnaires (questionnaire response rate 95%). The mean age was 59 years (range 19-91). Twelve fractures were open, all of which were initially managed using an external fixator. One patient developed deep infection necessitating fusion. The mean MOX-FQ and EQ-5D scores were 53.6 and 0.649, respectively, at a median of 40 months post-injury. The mean EQ-VAS was 70. The range of movement of the affected side was significantly less than the unaffected side (p < 0.001 on paired t-test). CONCLUSION: This study suggests that the FRS offers a reliable and acceptable alternative fixation technique for patients who have significant soft tissue injuries.

A comparative prospective cohort health economic analysis comparing ankle fusion, isolated great toe fusion and hallux valgus surgery.

BACKGROUND: This study assessed the health economics and outcomes of three common foot and ankle operations. METHODS: Between July 2013 and October 2014 all patients undergoing ankle fusion (AF) for osteoarthritis, first metatarsophalangeal joint fusion for osteoarthritis (MF) or hallux valgus surgery (HV) were included. Patients having additional procedures were excluded. Patients completed the Manchester-Oxford Foot Questionnaire (MOX-FQ), the EuroQol EQ-5D-5L questionnaire and the EQ-VAS on presentation and at least 6 months post-operatively. RESULTS: 63 patients undergoing AF (n=22), MF (n=22), or HV (n=32) completed preoperative and postoperative questionnaires. 76 completed preoperative questionnaires and 63 completed the follow up questionnaires. The follow up questionnaires were completed at a median of 12 months (range 6-24 months) following surgery. The mean age at surgery was 59 years (range 26-85 years). Pre-operative MOX-FQ and EQ-5D-5L scores differed significantly between the three groups with AF and MF patients reporting worse scores compared to HV patients. MOX-FQ and EQ-5D-5L significantly improved in all groups from pre-operative levels. MOX-FQ: AF from 53.8 (CI 56.8-50.8) to 22.9 (CI 30.9-14.9), MF from 43.0 (CI 46.4-39.6) to 12.1 (CI 18.3-5.9), HV from 35.4 (CI 39.0-31.7) to 15.6 (CI 21.1-10.1). EQ-5D-5L: AF from 0.30 (CI 0.43-0.17) to 0.66 (CI 0.77-0.55), MF from 0.45(CI 0.52-0.38) to 0.83 (CI 0.90-0.76), HV from 0.71(CI 0.74-0.68) to 0.82 (CI 0.88-0.76). There was no significant difference in the EQ-VAS suggesting it may not be representative of foot and ankle health. Health economics analysis using the EQ-5D-5L data to estimate quality-adjusted life years (QALYs) suggested all three procedures were favourable compared to threshold levels of cost-effectiveness. There were differences in estimated costs between the three operations with AF at £2950 (threshold cost <£5400) and MF at £1197 (threshold cost <£5780) and HV varying from £625 to £1688 (threshold cost <£1640). CONCLUSIONS: This study reveals that the joint-specific (MOX-FQ) and generic health (EQ-5D-5L) outcome scores of patients improved after AF, MF and HV. The greatest benefit from surgery was gained in the arthritic patient groups. In the future, the use of large population patient reported outcome measures data may also potentially have implications for prioritisation of healthcare provision, acting as an indicator of foot and ankle surgical procedures that produce the most benefit to patients.

Skating on thin ice: a study of the injuries sustained at a temporary ice skating rink.

In recent years, ice skating and temporary ice skating rinks have become increasingly popular. Regular elite competitors are known to be at risk of both acute and chronic injuries. It may be postulated that skaters at the temporary rinks are at high risk of acute injuries from falls due to both their lack of expertise and the inherent dangers of ice skating. Injuries sustained at skating rinks present a significant burden to local healthcare resources, in particular orthopaedic departments. For the first time, Cambridge hosted such a facility from November 24, 2007 through January 6, 2008. We sought to identify the most common injuries encountered and to quantify the orthopaedic burden. All Emergency Department or Fracture Clinic attendances for an eight-week period from the opening of the rink were investigated. Details of age, sex, injury and management were recorded for the 84 patients who sustained ice rink related injuries. A total of 85 injuries were recorded in 84 patients. Of these injuries 58% were fractures, of which 98% involved the upper limbs. Seven patients (8% of all injuries) required admission for operative fixation. On average, two injuries per day were seen in the Emergency Department or Fracture Clinic, with an average of one orthopaedic admission per week. It is evident that the ice rink in Cambridge has had an impact on local healthcare resources. The vast majority of injuries affected the upper limbs and were sustained following a fall on the out-stretched hand. We therefore encourage the education of skaters as to how to break their falls more safely and recommend the use of wrist protectors as a primary preventative measure.

Bridging hard callus at 48 days in an open femoral shaft fracture with segmental defect treated with a first-stage Masquelet technique: I wasn't expecting that.

The Masquelet technique is a strategy for management of segmental bone defects. It is a two-stage procedure that involves inducing a synovial-like membrane that can be used for a bone graft. Segmental bone defects can occur following trauma and can accompany traumatic brain injury. There is a well-documented, albeit debated, association between traumatic brain injury and increased rate of new bone formation. Here, we present a case of unexpected callus formation in a segmental femoral fracture. The patient had a traumatic brain injury and was treated with the first stage of the Masquelet technique. Owing to the amount of large callus, a second stage of the Masquelet was not required. The patient recovered well from the injury and at 16-week follow-up was able to partially weight bear. A case similar to this has not previously been reported within the literature.

The effect of becoming a major trauma centre on outcomes for elderly hip fracture patients.

Twenty-two major trauma centres (MTCs) became operational across England on 1st April 2012. The aim of this study was to ascertain whether becoming an MTC has affected outcomes for elderly hip fracture patients at our institution. Eight hundred and twenty-four patients aged ≥60 years who sustained 841 consecutive hip fractures over a two-year period were included. There were 381 fractures during the year prior to (pre-MTC group), and 460 fractures during the year after (post-MTC group) becoming an MTC. Outcomes analysed were time to theatre, length of acute hospital stay, post-operative complications, and mortality at 30, 120 and 365 days. No statistically significant difference was found in median length of stay between the two groups (13 days vs 14 days, p=0.2888). In the post-MTC group there was a significant increase in median delay to theatre for medically fit patients (25.5h vs 31.5h, p<0.0001), and there was a significant increase in post-operative medical complications (29.7% vs 37.6%, p=0.0160). There was no statistically significant difference in overall mortality rates, however 30-day mortality rose from 4.7% to 8.0% (p=0.0678). These results suggest that becoming an MTC has led to a significant increase in the delay to surgical management of our hip fracture patients with consequent increases in morbidity and mortality.

The effect of recombinant human fibroblast growth factor-18 on articular cartilage following single impact load.

The aim of this in vitro study was to ascertain the effect of recombinant human Fibroblast Growth Factor-18 (rhFGF18) on the repair response of mechanically damaged articular cartilage. Articular cartilage discs were harvested from healthy mature horses (n = 4) and subjected to single impact load (SIL). The impacted explants, together with unimpacted controls were cultured in modified DMEM ± 200 ng/ml rhFGF18 for up to 30 days. Glycosaminoglycan (GAG) release into the media was measured using the dimethylmethylene blue (DMMB) assay. Aggrecan neopepitope CS846, collagen type II synthesis (CPII) and cleavage (C2C) were measured by ELISA. Histological analysis and TUNEL staining were used to assess repair cell number and cell death. Impacted explants treated with rhFGF18 showed significantly more GAG and CS846 release into the media (p < 0.05), there was also a significant decrease in C2C levels at Day 20. Loaded sections treated with rhFGF18 had more repair cells and significantly less cell death (p < 0.001) at Day 30 in culture. In an in vitro damage/repair model, rhFGF18 increases the proteoglycan synthesis, the repair cell number and prevents apoptosis at Day 30. This suggests that rhFGF18 may be a good candidate for enhancement of cartilage repair following mechanical damage.

An Unusual Cause of Lateral Knee Pain following Total Knee Replacement.

A 70-year-old male underwent elective total knee replacement for osteoarthritis. At initial review six weeks after surgery the prosthesis was functioning well and he was asymptomatic. He reattended clinic four months postoperatively having developed worsening pain on the lateral aspect of the knee but without any loss of function or stiffness of the joint. He subsequently underwent arthroscopy where synovial folds in the lateral gutter were debrided and entirely alleviated his symptoms. This is an unusual cause of pain following total knee replacement which has not been previously reported.

Tourniquet failure during total knee replacement due to arterial calcification: case report and review of the literature.

Use of a tourniquet for performing surgery in order to create a bloodless surgical field and reduce blood loss has been in use for many years. Tourniquets may fail perioperatively for various reasons, leading to ongoing bleeding. An important cause of tourniquet failure is calcification of the underlying artery. A patient undergoing total knee replacement surgery in whom the tourniquet failed, secondary to femoral artery calcification is reported. The implications of tourniquet use in patients with arterial calcification, including acute distal ischaemia, aneurysm formation and vessel fracture will be discussed. Recommendations include: thorough vascular assessment of all patients preoperatively, awareness of the possibility of tourniquet failure particularly in vasculopaths, and the provision of an alternative perioperative management plan such as use of a cell saver device, should the tourniquet fail.