The acute Charcot foot in diabetics: Diagnosis and management.

Acute Charcot foot is a diagnostic challenge.The exact pathophysiology is not fully understood.Acute Charcot foot is often present with a history of trauma or cellulitis which does not respond to antibiotics.The condition is best managed within a multidisciplinary team.The mainstay of the treatment is mechanical off-loading and total contact casting.Surgery is reserved for select cases. Cite this article: EFORT Open Rev 2018;3:568-573. DOI: 10.1302/2058-5241.3.180003.

Vitamin D and Calcium Supplementation in Elderly Patients Suffering Fragility Fractures; The Road not Taken.

BACKGROUND: Calcium and Vitamin D supplementation in elderly patients may decrease the risk of hip fracture by up to one-third. Many patients suffering fragility fractures do not go on to receive this treatment despite clear recommendations from the National Institute for Health and Clinical Excellence (NICE). The aim of this study was to audit the proportion of patients admitted with a hip fracture who had suffered a previous fragility fracture and were taking calcium and vitamin D supplements, with the standard being that all of these patients should have been taking bone protection. We also aimed to assess the Vitamin D levels of patients admitted with a hip fracture to our unit. METHODS: Patients were prospectively added to a database over a 12-month period. Serum vitamin D levels (25-OH D3) were measured on admission and case-notes were reviewed for pre-injury social function and mobility. RESULTS: 147 patients were included in the study. Median age was 85 years (Interquartile range 79 - 90 (Range 53 - 100 years)). Only eighteen patients (11.4%) were taking calcium and vitamin D supplementation on admission. Forty seven patients (29%) had documented evidence of a previous fragility fracture within the last seven years. Only fourteen of these patients (19%) were receiving calcium and vitamin D supplementation. One hundred and twenty two patients were deficient in Vitamin D (76%). Twenty five patients (16%) had insufficient Vitamin D. Only the remaining 14 patients (8%) had sufficient vitamin D. CONCLUSION: Vitamin D deficiency is endemic amongst patients suffering hip fractures. Very few patients who had suffered a previous fragility fracture were taking Calcium and Vitamin D supplements when admitted with a hip fracture several years later. This is an opportunity missed.

The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures.

BACKGROUND: Distinguishing stable supination-external rotation (SER) 2 from unstable SER 4 ankle fractures, using standard radiographs, is controversial. Examination under anaesthesia (EUA), gravity-stress (GS) and weight-bearing (WB) radiographs can aid surgical decision-making. We evaluated the effect of three methods of fracture stability assessment. METHODS: Radiographs and case-notes of 312 consecutive patients with SER 2/4 fractures were reviewed. We recorded ankle stability assessment (plain film (PF) and EUA vs. GS vs. WB radiographs), management (conservative vs. operative), unplanned surgery and complications. RESULTS: Forty five percent assessed with GS underwent surgery (6% for PF/EUA, 4% for WB; P=0.0001). Amongst GS patients, 11% underwent additional surgery (0.1% PF/EUA, 0% WB; P=0.0001). Complications occurred in 2% of the WB group (8% for PF/EUA, 22% for GS; P=0.007). CONCLUSION: This study associates GS assessment with higher rates of surgery and complications. Subsequent studies may determine the longer term effect stability assessments have on post-traumatic arthritis.

Ankle arthroscopy to manage sequelae after ankle fractures.

PURPOSE: The role of ankle arthroscopy in managing the consequences of ankle fractures is yet to be fully established. This study aims to assess this procedure in terms of the accuracy of preoperative diagnosis, re-operation rate and patient-reported outcomes. METHODS: Sixty-six patients were identified [mean age 40 years (SD 13 years)] who had undergone ankle arthroscopy following a fracture of the distal tibia or fibula. Medical case notes were reviewed to ascertain details of the index injury, intra-operative findings and identify any further procedures. Patients were then contacted using a standardized questionnaire to assess satisfaction and return to normal function. RESULTS: Injury occurred in a mean of 2 years 10 months before arthroscopy (SD 13 months, min 6 months). Forty-nine of 66 fractures (74 %) had been managed operatively. The commonest indication for arthroscopy was anterior impingement (45 %) followed by degenerative change (30 %) and osteochondral lesions (OCL) (18 %). Intra-operative findings revealed an unexpected OCL or frank degenerative change in 20 % of patients. Using a Kaplan-Meier estimate 1 year after arthroscopy, 10 % of patients had undergone further surgery. This had increased to 34 % by 4 years after arthroscopy. Four patients underwent ankle fusion. Questionnaires were completed by 55/66 patients (84 %). Only 28 patients (50 %) felt surgery allowed them to return to normal activity. Thirty-nine patients reported a benefit from surgery (75 %) whilst 43 were satisfied (77 %) and 48 (86 %) would recommend the procedure to a friend. CONCLUSIONS: Intra-articular pathology was significantly underestimated preoperatively for one patient in five. Arthroscopy improved symptoms in 75 % of patients who complain of ankle symptoms after fracture of the ankle or distal tibia. However, further procedures were required in 34 % of patients. The findings of this study help guide patient counselling and operative decision-making in this challenging group of patients. LEVEL OF EVIDENCE: IV.

Successful arthroscopic decompression and synthetic grafting of a posterior talar cyst: a case report.

We describe the endoscopic management of a large talar cyst using synthetic allograft gel. Three and a half years later the patient has returned to sport and repeat MRI demonstrates no further collapse of the cyst.

Perioperative management of elderly patients suffering a hip fracture.

Preparing elderly patients for emergency hip fracture surgery is a significant challenge for hospital staff. This article discusses the principles of preoperative care in these patients, and the rationale for such strategies, based on evidence and current guidelines. Such guidance increasingly reflects a national standard of care.

The results of total hip arthroplasty for fractured neck of femur in octogenarians.

The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.

A comparative study of radiation dose and screening time between mini C-arm and standard fluoroscopy in elective foot and ankle surgery.

BACKGROUND: Mini C-arm devices have gained popularity in extremity surgery. There is little evidence of the benefits of this technique in the clinical setting of foot and ankle surgery. We used dose area product (DAP) to compare radiation usage between mini C-arm and standard fluoroscopy. METHODS: We prospectively reviewed 127 cases requiring intra-operative screening during elective foot and ankle surgery. RESULTS: Mini C-arm was used in 55 patients and standard fluoroscopy in 72 patients. There was a statistically significant reduction in mean DAP using the mini C-arm, 3.46 Gy cm² vs 7.43 Gy cm² (P=0.0013). There was no difference in screening time. The annual saving from using the mini C-arm could be £9391, saving the total cost of the device over 5 years. CONCLUSION: The mini C-arm reduces radiation risk and costs when compared to standard fluoroscopy. We recommend its regular use in foot and ankle surgery.