An investigation of composition, morphology, mechanical properties, and microdamage accumulation of human type 2 diabetic bone.

This study investigates the biomechanics of type 2 diabetic bone fragility through a multiscale experimental strategy that considers structural, mechanical, and compositional components of ex vivo human trabecular and cortical bone. Human tissue samples were obtained from the femoral heads of patients undergoing total hip replacement. Mechanical testing was carried out on isolated trabecular cores using monotonic and cyclic compression loading and nanoindentation experiments, with bone microdamage analysed using micro-computed tomography (CT) imaging. Bone composition was evaluated using Raman spectroscopy, high-performance liquid chromatography, and fluorometric spectroscopy. It was found that human type 2 diabetic bone had altered mechanical, compositional, and morphological properties compared to non-type 2 diabetic bone. High-resolution micro-CT imaging showed that cores taken from the central trabecular region of the femoral head had higher bone mineral density (BMD), bone volume, trabecular thickness, and reduced trabecular separation. Type 2 diabetic bone also had enhanced macro-mechanical compressive properties under mechanical loading compared to non-diabetic controls, with significantly higher apparent modulus, yield stress, and pre-yield toughness evident, even when properties were normalised against the bone volume. Using nanoindentation, there were no significant differences in the tissue-level mechanical properties of cortical or trabecular bone in type 2 diabetic samples compared to controls. Through compositional analysis, higher levels of furosine were found in type 2 diabetic trabecular bone, and an increase in both furosine and carboxymethyl-lysine (an advanced glycation end-product) was found in cortical bone. Raman spectroscopy showed that type 2 diabetic bone had a higher mineral-to-matrix ratio, carbonate substitution, and reduced crystallinity compared to the controls. Together, this study shows that type 2 diabetes leads to distinct changes in both organic and mineral phases of the bone tissue matrix, but these changes did not coincide with any reduction in the micro- or macro-mechanical properties of the tissue under monotonic or cyclic loading.

Bilateral first metatarsophalangeal joint arthrodesis: An investigation of functional, surgical and radiological outcomes.

BACKGROUND: First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly utilised procedure. In this study, the authors aim to explore functional outcomes of patients undergoing nonsynchronous bilateral first MTPJ arthrodesis under the care of a single surgeon using a compression screw/locking plate construct. METHODS: This is a prospectively collected, retrospectively analysed case series of fifty five patients who underwent bilateral nonsynchronous first MTPJ arthrodesis. Clinical and radiological outcomes were assessed preoperatively and at a minimum of two years postoperatively. Clinical outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), the Self-Reported Foot and Ankle Score (SEFAS) and the Sports Questionnaire version 1 (SQ). Postoperative radiographs were used to assess evidence of union and compare both hallux valgus and intermetatarsal angles. Removal of hardware, revision surgery and correction of deformities were also recorded. RESULTS: Fifty five patients were included in the study. There was statistically significant improvements in all five facets of the FAOS (p value < 0.05). The mean postoperative SEFAS was 45.1. In total, patients participated in thirteen different sporting activities. This represented 92 patient specific activities preoperatively and 104 postoperatively. The most common activities were walking, cycling and swimming. Overall, 94.5% (N = 52) of the cohort were satisfied with their return to sport while 98.2% (N = 54) would recommend bilateral first MTPJ arthrodesis. Mean reductions in hallux valgus angles and intermetatarsal angles were noted at 18.87 and 4.69 degrees respectively. There was one non-union in the cohort which required revision surgery. One patient required removal of hardware. CONCLUSIONS: Bilateral first MTPJ arthrodesis is a safe and effective surgical option for patients with bilateral first MTPJ pathology. It has a high union rate, low complication rate and significantly improves clinical outcomes and allows patients reliably return to physical activities.

Outcomes following tibiotalocalcaneal arthrodesis using a solid posterior offset intramedullary nail in 44 patients with a minimum 30-month follow-up.

BACKGROUND: Tibiotalocalcaneal arthrodesis is frequently performed by foot and ankle surgeons in the management of complex ankle and hindfoot pathology. In this study, the authors describe the clinical and radiological outcomes of tibiotalocalcaneal arthrodesis using a solid posterior offset hindfoot arthrodesis nail. METHODS: Forty-four consecutive patients underwent tibiotalocalcaneal arthrodesis by a single surgeon operating in two centers. Clinical and radiological outcomes were assessed preoperatively and at 6-month, 12-month and final follow-up (mean 47 months). Clinical outcomes were assessed with VAS, AOFAS and MOXFQ scores. Serial radiographs were used to assess union at each follow-up visit. RESULTS: Forty-four patients attended 12-month and final follow-up (mean 47 months). A total of 44 (100%) ankle joints and 44 (100%) subtalar joints were completely united at 12-month follow-up. The VAS score improved significantly from a mean of 6.5 preoperatively to a mean of 0.98 at final follow-up (P = <0.0001). AOFAS score improved significantly from a mean of 36.4 preoperatively to a mean of 73 at final follow-up (P = <0.0001). MOXFQ score improved significantly from a mean of 44.5 preoperatively to a mean of 12.7 at final follow-up (P = <0.0001). The mean change in frontal plane alignment was 5.7 degrees (P = 0.005). A total of 6 patients (13.6%) had an adverse event during the course of the study. CONCLUSIONS: Tibiotalocalcaneal arthrodesis with a solid posterior offset hindfoot arthrodesis nail is a safe and effective surgical option for patients with severe ankle and hindfoot pathology. It has a high union rate, low complication rate and significantly improves clinical outcomes.

The Use of Dorsal Bridge Plate Fixation in the Operative Management of Lisfranc Injuries - A Retrospective Cohort Study at Medium Term Follow-Up.

INTRODUCTION: Traditionally, early surgical management of Lisfranc injuries with transarticular screws (TAS) was deemed to be the optimal treatment. However, concerns of potential iatrogenic articular cartilage disruption has led to discrepancies in opinion amongst surgeons, with many surgeons now utilizing dorsal bridge plates (DBP) for ORIF of Lisfranc injuries. OBJECTIVES: This study sought to investigate the clinical outcomes at medium-term follow-up of consecutive patients in our institution who underwent ORIF with DBP for Lisfranc injuries. METHODS: All consecutive patients who underwent ORIF with DBPs for Lisfranc injuries were identified. Outcomes of interest included; visual analogue scale (VAS), functional foot index (FFI), American Orthopaedic Foot & Ankle Surgeons (AOFAS) hindfoot scores, and complications. RESULTS: Overall, 37 consecutive patients (24 males) with a mean age of 34.8 ± 13.0 years underwent ORIF with DBPs for lisfranc injuries. After a mean 48.3 ± 28.7 months, the mean reported AOFAS and FFI scores were 77.4 ± 23.8 and 31.9 ± 32.7 respectively, with satisfactory reported pain scores as measured by VAS post-operatively at rest and whilst walking (2.2 ± 2.5 and 3.1 ± 2.6 respectively). The reported satisfaction rate was 86.5% (32/37). Overall, 25 patients (67.6%) had subsequent removal of metal or were listed for same, 88% (22/25) of whom did so electively in the absence of broken screws or infection. CONCLUSION: This study found that the use of Dorsal Bridge Plates for Open Reduction and Internal Fixation of Lisfranc Injuries resulted in satisfactory functional outcomes, high rates of patient-reported satisfaction and a low complication rate at medium-term follow-up. LEVEL OF EVIDENCE: Level IV; Retrospective Series of Consecutive Patients.

Girdlestone resection arthroplasty of the hip (GRA): a case series-outdated procedure or acceptable outcome?

Despite considerable legacy issues, Girdlestone's resection arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical co-morbidities which preclude staged or significant surgical interventions, and/or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

A Rare Case of Naviculo-medial Cuneiform Coalition Treated with Naviculo-medial Cuneiform Arthrodesis: A Case Report.

CASE: A 19-year-old woman developed spontaneous onset of right midfoot pain in the absence of trauma. Conservative management including orthotics and steroid injection reduced, but did not resolve, pain. Weight-bearing x-ray and CT confirmed naviculo-medial cuneiform coalition. After failure of conservative treatment, the patient elected to undergo right naviculo-medial cuneiform arthrodesis and returned to normal activity without pain postoperatively and at 4-year follow-up. CONCLUSION: Naviculo-medial cuneiform coalition is a rare source of midfoot pain, but should be considered as a differential diagnosis. This case suggests that naviculo-medial cuneiform arthrodesis can successfully resolve symptoms if conservative measures fail.

Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures - A Systematic Review and Meta-Analysis.

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.

Functional Capabilities After First Metatarsal Phalangeal Joint Arthrodesis Using a Locking Plate and Compression Screw Construct.

Arthrodesis of the first metatarsal phalangeal joint (MTPJ) is a widely utilized surgical procedure for a wide array of metatarsal pathologies. This study aims to explore the functional limitations following first MTPJ arthrodesis, overall satisfaction and patient's abilities to achieve activities of daily living (ADL). This prospective cohort study assessed functional limitations as well as footwear and lifestyle restrictions using several questionnaires. One hundred and three participants who had a first MTPJ arthrodesis under the care of a single surgeon were recruited. Pre- and postoperative patient-reported outcome measures were recorded. The American Orthopaedic Foot and Ankle Score (AOFAS) and the Manchester-Oxford Foot Questionnaire were also used to further examine functional status. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were compared using preoperative and postoperative weightbearing radiographs and successful fusion was recorded. Complications were documented and are discussed in detail. The duration of follow-up was more than 12 months. There was one nonunion in the cohort while 2 patients experienced delay to fusion. Approximately 97% of patients were very satisfied with the procedure and their ability to achieve ADLs post operatively. A further 82.5% of patients were able to return to wearing nonadaptive footwear. The mean reduction in HVA and IMA was 21.78° and 6.84°, respectively. This study demonstrates the safe and successful use of a compression screw/locking plate construct for arthrodesis of the first MTPJ. Furthermore, the study provides clear evidence of high levels of functionality after the procedure with statistically significant differences (p value <.05) in all 4 facets of the AOFAS questionnaire as well as several notable differences in activity levels and footwear restrictions pre and postoperatively.

A Technique to Correct Troughing in a Z-Osteotomy for Hallux Valgus Correction.

A Z-osteotomy is a commonly performed procedure to correct mild-moderate hallux valgus. It is an effective procedure with high patient satisfaction rates. However, it is not without its challenges. One of the most frequently encountered issues during a Z-osteotomy is troughing of the first metatarsal. We present a simple surgical technique to correct troughing if it is encountered without the need for additional soft tissue or bony procedures.

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures.

BACKGROUND: Uncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA. METHODS: A retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment. RESULTS: Over the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004). CONCLUSION: UHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.

The Operative Treatment of Ankle Fractures: A 10-Year Retrospective Study of 1529 Patients.

Ankle fractures are the second most common fracture of the lower limb and account for nearly 10% of all fractures. They range from simple to complex injuries and approximately 40% require surgical intervention. The aim of our study was to provide an up-to-date reference of the epidemiology, fracture, and fixation characteristics of operatively treated ankle fractures. We also sought to determine the number of patients undergoing further surgery through revision, implant removal, or ankle fusion. A retrospective observational study was conducted of 1529 consecutive patients that underwent operative intervention for an unstable ankle fracture between 2007 and 2017. Fractures of the distal tibia and pilon injuries were excluded. The mean age of patients was 41.8 years with 50.7% male. Unimalleolar fixation was performed in 60.1%, while bimalleolar and trimalleolar fixation was performed in 31.2% and 5%, respectively. Isolated syndesmotic fixation was performed in 3.8%. A posterior malleolus fracture was present in 28.6%, of which 31.6% underwent fixation. A further procedure was performed in 234 (15.3%) patients. Revision open reduction internal fixation was required in 1.4% and 0.8% underwent future ankle fusion. Treatment of ankle fractures makes up a sizeable part of orthopedic trauma practice with more than 1 in 7 patients requiring a second procedure. More complex fractures were predominantly seen in older females, while patients who suffered trimalleolar fractures have an increased likelihood of requiring future ankle fusion or revision. Despite this the rate of ankle fusion was <1%.

Osteoporotic Vertebral Fractures are Common in Hip Fracture Patients and are Under-recognized.

INTRODUCTION: The vertebrae are the most common site for osteoporotic fracture. While they can result in disability and increased mortality, only one-third present clinically. People with multiple fractures are at greater risk of future fractures. Most hip fracture patients are neither diagnosed nor treated for their underlying osteoporosis. Computed tomography (CT) studies are often performed on hospitalised patients, can be used to diagnose osteoporosis and are gaining popularity for opportunistic osteoporosis screening by measuring BMD and other bone strength indices. The aim of this study was to assess the prevalence of vertebral fractures on CT pulmonary angiograms (CTPA) in a cohort of hip fracture patients and whether this increased their diagnosis and treatment rates. METHODS: We retrospectively identified all hip fractures admitted to our institution between 2010 and 2017 to identify those who underwent CTPA scans. An independent, blinded consultant musculoskeletal radiologist reviewed the images for vertebral fractures and quantified severity using Genant criteria. Results were compared to the original radiology report, discharge diagnoses and treatment rates for osteoporosis. RESULTS: Eleven percent (225/2122) of patients had CTPA images available. Seventy percent (158) were female with a mean age of 78 years (SD: 11). The median length of stay for all patients was 16 days (1-301). Forty percent (90) of patients had at least one vertebral fracture present and 20% (46) had more than one fracture. Only one in 5 radiology reports noted the fractures. 24% of subjects had osteoporosis treatment recorded at hospital discharge and there was no difference between those with vertebral fractures to those without. CONCLUSION: Many hip fracture patients have undiagnosed spine fractures. A screening strategy which evaluates CT scans for fractures has potential to increase diagnosis and treatment rates of osteoporosis. However, more work is needed to increase awareness.

Impact of Type 2 Diabetes Mellitus on Human Bone Marrow Stromal Cell Number and Phenotypic Characteristics.

Human bone marrow-derived mesenchymal stromal cells (MSCs) have been investigated in numerous disease settings involving impaired regeneration because of the crucial role they play in tissue maintenance and repair. Considering the number of comorbidities associated with type 2 diabetes mellitus (T2DM), the hypothesis that MSCs mediate these comorbidities via a reduction in their native maintenance and repair activities is an intriguing line of inquiry. Here, it is demonstrated that the number of bone marrow-derived MSCs in people with T2DM was reduced compared to that of age-matched control (AMC) donors and that this was due to a specific decrease in the number of MSCs with osteogenic capacity. There were no differences in MSC cell surface phenotype or in MSC expansion, differentiation, or angiogenic or migratory capacity from donors living with T2DM as compared to AMCs. These findings elucidate the basic biology of MSCs and their potential as mediators of diabetic comorbidities, especially osteopathies, and provide insight into donor choice for MSC-based clinical trials. This study suggests that any role of bone marrow MSCs as a mediator of T2DM comorbidity is likely due to a reduction in the osteoprogenitor population size and not due to a permanent alteration to the MSCs' capacity to maintain tissue homeostasis through expansion and differentiation.

Bone Mineral Is More Heterogeneously Distributed in the Femoral Heads of Osteoporotic and Diabetic Patients: A Pilot Study.

Osteoporosis is associated with systemic bone loss, leading to a significant deterioration of bone microarchitecture and an increased fracture risk. Although recent studies have shown that the distribution of bone mineral becomes more heterogeneous because of estrogen deficiency in animal models of osteoporosis, it is not known whether osteoporosis alters mineral distribution in human bone. Type 2 diabetes mellitus (T2DM) can also increase bone fracture risk and is associated with impaired bone cell function, compromised collagen structure, and reduced mechanical properties. However, it is not known whether alterations in mineral distribution arise in diabetic (DB) patients' bone. In this study, we quantify mineral content distribution and tissue microarchitecture (by µCT) and mechanical properties (by compression testing) of cancellous bone from femoral heads of osteoporotic (OP; n = 10), DB (n = 7), and osteoarthritic (OA; n = 7) patients. We report that though OP cancellous bone has significantly deteriorated compressive mechanical properties and significantly compromised microarchitecture compared with OA controls, there is also a significant increase in the mean mineral content. Moreover, the heterogeneity of the mineral content in OP bone is significantly higher than controls (+25%) and is explained by a significant increase in bone volume at high mineral levels. We propose that these mineral alterations act to exacerbate the already reduced bone quality caused by reduced cancellous bone volume during osteoporosis. We show for the first time that cancellous bone mineralization is significantly more heterogeneous (+26%) in patients presenting with T2DM compared with OA (non-DB) controls, and that this heterogeneity is characterized by a significant increase in bone volume at low mineral levels. Despite these mineralization changes, bone microarchitecture and mechanical properties are not significantly different between OA groups with and without T2DM. Nonetheless, the observed alterations in mineral heterogeneity may play an important tissue-level role in bone fragility associated with OP and DB bone. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Cemented Proximal Femoral Replacement for the Management of Non-Neoplastic Conditions: A Versatile Implant but Not Without Its Risks.

BACKGROUND: The demand for revision arthroplasty continues to grow. Proximal femoral bone loss poses a significant challenge to surgeons and proximal femoral replacements (PFRs) are one option to address this problem. The aim of our study is to assess the reoperation, complication, and mortality rates following PFR for treatment of non-neoplastic conditions. METHODS: A retrospective observational study was conducted of a consecutive group of patients treated with a PFR for non-neoplastic conditions between 2010 and 2018. Mortality was confirmed using the Irish national death events publication service. RESULTS: Over the 8-year study period, 79 PFRs in 78 patients were performed. Mean age of patients was 78.3 years (standard deviation 11.9), of which 37.2% were male. Periprosthetic fracture was the most common indication for PFR (63.3%). The 30-day mortality rate was 7.6% (6 patients), of which bone cement implantation syndrome occurred in 4 patients. One-year mortality was 12.7%. Complications occurred in 22.8%. CONCLUSION: A cemented PFR is a versatile prosthesis in the armamentarium of a revision arthroplasty surgeon that allows immediate full weight-bearing. However, it may appropriately be considered a last resort procedure that poses specific risks that must be explained to patients and family. We present the short-term outcomes on one of the largest series of PFR to date.

Breaking Bad: A Comparative Descriptive Analysis of Periprosthetic Fractures Around Cemented and Uncemented Femoral Stems.

BACKGROUND: Periprosthetic fractures are most commonly classified according to the Vancouver classification system and more recently the Unified Classification System. The aim of this study is to provide a descriptive analysis of fracture patterns in femoral periprosthetic fractures (PPFs) by femoral stem fixation. METHODS: A retrospective observational study of all femoral PPFs over a 10-year period at our institution was conducted. Presenting radiographs were examined to assess the fracture pattern. RESULTS: Over the 10-year period, 138 femoral PPFs that underwent operative treatment were examined. Mean age of patients was 78 years with 45.7% male and median American Society of Anaesthesiologists grade 3. The femoral stem fixation was cemented in 83 patients and uncemented in 55 patients. Uncemented femoral stems most commonly caused a simple oblique fracture pattern (69.1%) with a more comminuted pattern seen in cemented fixation (59%). CONCLUSION: Fracture patterns differ according to femoral stem fixation. A simple "sickle-like" oblique fracture pattern was more commonly seen in uncemented stems while cemented tapered stems resulted in a comminuted "axe splitting" pattern.

Matrix-associated stem cell transplantation is successful in treating talar osteochondral lesions.

PURPOSE: Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to try and treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix-associated stem cell transplantation (MAST) is one such treatment described for larger lesions > 15 mm2 or failed alternative therapies. This cohort study describes a 3 year review of the outcomes of talar lesions treated with MAST. METHODS: A review of all patients treated with MAST by a single surgeon was conducted. Pre-operative radiographs, MRIs, and FAOS outcome questionnaire scores were reviewed. Intraoperative classification was undertaken to correlate with imaging. Post-operative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment, and progression to ankle fusion. RESULTS: In this study, 38 OCLs in 32 patients were identified. Median patient age was 35 years of which (68.8%) were male. Median length of follow-up was 36.7 months (range 12-64 months). (83%) returned to playing sport. Twenty-three patients underwent MAST in the setting of a failed previous operative attempt, with just nine having MAST as a first option. Nine patients out of 32 had a further procedure. Improvements were seen in all domains of the FAOS (p < 0.05). CONCLUSION: MAST has demonstrated encouraging results in lesions which prove challenging to treat, even in a "failed microfracture" cohort. LEVEL OF EVIDENCE: IV.

The burden of hardware removal in ankle fractures: How common is it, why do we do it and what is the cost? A ten-year review.

BACKGROUND: Ankle fractures account for 9% of all fractures and 40% require surgical management. The ankle is the most common site of hardware removal. The purpose of our study was to investigate the incidence, indication and economic cost associated with removal of hardware from the ankle. METHODS: We conducted a ten-year retrospective review of 1482 patients treated by open reduction internal fixation for an unstable ankle fracture. Skeletally immature patients were excluded. Data collected was cross referenced from patient medical records, the radiological and electronic patient database. The casemix and hospital inpatient enquiry system (HIPE) were used to calculate costs. RESULTS: The mean age was 39.9 years with 53.6% male. 185 patients (12.5%) underwent hardware removal with unplanned removal performed in 6% of cases. The average cost of removal was €1113. CONCLUSION: Removal of hardware continues to be a common operation with significant costs to all involved. More than one in 10 patients underwent future removal of hardware. LEVEL OF EVIDENCE: Level 3.

Role of anti-oxidant (vitamin-C) in post-operative pain relief in foot and ankle trauma surgery: A prospective randomized trial.

BACKGROUND: Post-operative pain may adversely affect a patient's quality of life. Studies have shown that vitamin C, being an anti-oxidant and neuro-modulating agent, can help to reduce pain in a variety of clinical settings. The objective of this randomized controlled trial was to assess the effectiveness of vitamin C in reducing post-operative pain, analgesia requirements and improving functional outcome. METHODS: Patients with isolated foot and ankle trauma, who had undergone surgery, were randomly assigned to receive either vitamin C 500mg or a placebo tablet twice a day. VAS score, analgesia requirement and functional outcome were assessed during their regular follow up. Results were compared and analyzed at the end of 3 months. RESULTS: The group which received vitamin C, showed improvement in VAS score at the end of second and sixth week of follow up, reduced analgesia requirements and improved functional outcome as compared to the placebo group. CONCLUSIONS: This study shows that the supplementation of vitamin C in patients undergoing surgery for foot and ankle trauma helps to reduce analgesic requirements, improve VAS scores and achieve better functional outcome.