Modified Dorsal Approach in the Management of Lisfranc Injuries.

BACKGROUND: Open reduction and internal fixation of Lisfranc injuries has typically used multiple longitudinal incisions or a single transverse incision to approach the tarso-metatarsal joint (TMTJ). The incidence of wound-related complications is considerable. We describe a novel single-incision approach that utilizes subcutaneous windows to the medial TMTJ. METHODS: A retrospective review identified 150 patients who underwent open reduction and internal fixation for Lisfranc injuries, via the modified dorsal approach, at our center between January 2011 and June 2016. Removal of hardware (ROH) was routinely undertaken in 105 patients at a median of 210 days postoperatively. Medical records were reviewed to record patient demographics, mechanism of injury, and operative details. Outpatient notes were reviewed to identify wound-related complications, including delayed wound healing, superficial infection, wound dehiscence, deep infection, complex regional pain syndrome (CRPS), neuroma, and impaired sensation. Median age was 37 years (range, 19-78 years). Seventy-three percent of patients (110) were male. Most frequent mechanisms of injury were motor vehicle accident (MVA), 39%; motorbike accident (MBA), 19%; and fall, 18%. Sixteen percent (24) of injuries were open. Five patients required soft tissue reconstruction at the primary operation. Median follow-up was 144 (range, 27-306) weeks. RESULTS: Following the primary procedure, 14% of patients experienced wound-related complications including delayed healing (3%), superficial infection (5%), dehiscence (3%), complex regional pain syndrome (CRPS) (1%), and impaired sensation (1%). MBA injuries were at 15.1 times odds of superficial infection ( P =.01) than were MVA injuries. Following ROH, 13% of patients experienced wound-related complications, including delayed healing (2%), superficial infection (8%), dehiscence (1%), CRPS (2%), and neuroma (1%). Overall, 5 patients returned to surgery for soft tissue reconstruction for wound dehiscence. CONCLUSION: The modified dorsal approach using intervals to the midfoot offers a viable alternative with comparable wound complication rates to existing midfoot approaches. LEVEL OF EVIDENCE: Level IV, case series.

Radiographic Severity of Arthritis Affects Functional Outcome in Total Ankle Replacement (TAR).

BACKGROUND: It has been previously demonstrated that radiographic severity of arthritis predicts outcome following knee replacement. In certain circumstances, patients may undergo arthroplasty without severe radiographic disease. An example may be the patient with significant chondral damage unsuccessfully treated with arthroscopy. This patient may proceed to joint replacement when their radiographs would not normally merit such intervention. We investigated whether these findings were also applicable to total ankle replacements (TARs). METHODS: We retrospectively reviewed a single-surgeon, single-implant series of 178 TARs in 170 patients. Of them, 124 patients who took part in the hospital joint registry with a minimum 2-year follow-up were included for this study. The radiographic severity of arthritis was graded using the Kellgren-Lawrence classification. Preoperative weight-bearing radiographs were reviewed for severity of arthritis by 2 blinded observers: the first author and an independent colleague from the radiology department. Patients were grouped into 4 subgroups based on degree of severity of radiographic grading for arthritis-A, B, C, and D (for grades 1, 2, 3, and 4 grades, respectively). Data collected included Foot and Ankle Outcome Score (FAOS; pain, function, and stiffness), MOS 36-item Short-Form Health Survey (SF-36) scores, and patient satisfaction scores collected prospectively and at 1 and 2 years postoperation. RESULTS: Groups were similar in terms of demographic data (P > .1) and preoperative FAOS scores (P > .89) for pain, function and stiffness. Group D had the biggest improvement in all domains of FAOS. This reached significance in each domain when compared to group C. No significant differences were demonstrated in SF-36 scores. Overall, 91.1% of patients in group D were satisfied at 2 years, compared with 50.0% of patients in groups A, B, and C (P < .001). In addition, 93.9% of patients in group D felt that their quality of life had been improved by the surgery, compared to 47% of patients with groups A, B, and C (P < .001). Further, 77.3% of patients from group D said they would have the operation again, vs only 52.2% of patients with grade III or less (P = .014). Patients who were "very satisfied" or "somewhat satisfied" postoperatively had an average Kellgren-Lawrence (KL) grade of 3.9 preoperatively. In contrast the "very dissatisfied" and "somewhat dissatisfied" patients had an average KL grade of 2.9 (P < .05). CONCLUSION: Although this study does not explain all of the dissatisfaction in TAR, radiologic severity is an important factor that surgeons must consider when planning how best to treat their patients. There may be a different pathophysiology in this patient group that is not well served by arthroplasty. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Iliacus haematoma causing femoral nerve palsy: an unusual trampolining injury.

We report the case of a 15-year-old boy who presented to accident and emergency following a trampolining injury. Initially, the patient was discharged, diagnosed with a soft tissue injury, but he re-presented 48 h later with worsening low back pain and neurological symptoms in the left leg. Subsequent MRI revealed a left iliacus haematoma causing a femoral nerve palsy. The patient was managed conservatively and by 6 months post injury all symptoms had resolved. This is the first reported case of an iliacus haematoma causing a femoral nerve palsy, after a trampolining injury. We believe this case highlights to our fellow clinicians the importance of a detailed history when assessing patients with trampolining injuries to evaluate the true force of injury. It also acts as a reference for clinicians in managing similar cases in future.

Management of significant and widespread, acute subcutaneous emphysema: should we manage surgically or conservatively?

BACKGROUND: Subcutaneous emphysema of a limb after acute injury is classically associated with gas gangrene. Delayed management can result in amputation and death. Typically caused by a clostridial infection, patients are unwell, with rapidly spreading clinical signs, abnormal laboratory results, and cultures positive. There are reports of widespread subcutaneous emphysema of a limb in well-appearing patients, with blood parameters within normal limits; however, the optimum management of this type of case is unclear. OBJECTIVE: Our objectives were to present 4 new cases of acute subcutaneous emphysema in well-appearing patients managed with early surgery, review the literature, and discuss the management decisions in cases of acute subcutaneous emphysema in clinically well patients. CASE REPORTS: Here we present a case series of 4 patients, all with penetrating injuries to the upper limb resulting in widespread subcutaneous emphysema within 24 h of injury. Mean age was 33 years. All were fit and well, with the exception of one with type 1 diabetes, no cardiorespiratory compromise, and no significant derangement of laboratory investigations. X-ray studies showed widespread gas within the soft tissues. All were treated aggressively with immediate surgical fasciotomy of the upper limb, thorough debridement, and washout as required. Gram stains revealed pus cells (polymorphonuclear leucocytes) in all, but organisms in only one case (Gram-positive cocci and bacilli). Prolonged culture grew organisms in all. All patients had a second washout and closure plus 6 weeks of antibiotics. All survived and had fully functioning limbs. Why should an emergency physician be aware of this? We recommend having a low threshold for rapid referral to an appropriate surgical speciality, allowing prompt and radical surgical management of this type of presentation, even in the presence of a well patient.

Finding reproducible cluster partitions for the k-means algorithm.

K-means clustering is widely used for exploratory data analysis. While its dependence on initialisation is well-known, it is common practice to assume that the partition with lowest sum-of-squares (SSQ) total i.e. within cluster variance, is both reproducible under repeated initialisations and also the closest that k-means can provide to true structure, when applied to synthetic data. We show that this is generally the case for small numbers of clusters, but for values of k that are still of theoretical and practical interest, similar values of SSQ can correspond to markedly different cluster partitions. This paper extends stability measures previously presented in the context of finding optimal values of cluster number, into a component of a 2-d map of the local minima found by the k-means algorithm, from which not only can values of k be identified for further analysis but, more importantly, it is made clear whether the best SSQ is a suitable solution or whether obtaining a consistently good partition requires further application of the stability index. The proposed method is illustrated by application to five synthetic datasets replicating a real world breast cancer dataset with varying data density, and a large bioinformatics dataset.

Training improves acoustic pattern perception.

Pitch changes that occur in speech and melodies can be described in terms of contour patterns of rises and falls in pitch and the actual pitches at each point in time. This study investigates whether training can improve the perception of these different features. One group of ten adults trained on a pitch-contour discrimination task, a second group trained on an actual-pitch discrimination task, and a third group trained on a contour comparison task between pitch sequences and their visual analogs. A fourth group did not undergo training. It was found that training on pitch sequence comparison tasks gave rise to improvements in pitch-contour perception. This occurred irrespective of whether the training task required the discrimination of contour patterns or the actual pitch details. In contrast, none of the training tasks were found to improve the perception of the actual pitches in a sequence. The results support psychological models of pitch processing where contour processing is an initial step before actual pitch details are analyzed. Further studies are required to determine whether pitch-contour training is effective in improving speech and melody perception.

Use of non-verbal communication skills to improve nursing care.

This article describes non-verbal communication (NVC), its nursing assessment and its use with people who have a learning disability. A nursing diagnosis of altered non-verbal communication is outlined and a new wellness diagnosis is proposed of potential for enhanced non-verbal communication. The use and encouragement of non-verbal communication with people who have limited verbal comprehension is discussed. Nurses are considered an important focus for change; for enhancing a person's non-verbal skills, for improving their learning environment and for ultimately improving their social development.