The variation of anticoagulation prescribed in foot and ankle surgery in the UK - UK foot and ankle thrombo-embolism audit (UK-FATE).

INTRODUCTION: Venous thrombo-embolism (VTE) is a recognised complication of foot and ankle surgery. There are multiple possible anticoagulation treatments available in the UK to mitigate the risk of developing VTE. Our primary objective was to assess the variability of chemical anticoagulation prescribed in patients undergoing foot and ankle procedures. METHODS: This was a UK-based national, multicenter, prospective audit spanning a collection duration of 9 months on all foot and ankle procedures, carried out in 68 UK centers between 1st June 2022 and 30th November 2022, with a further 3-month follow up period. All patients who underwent a foot and ankle surgical procedure (including Achilles tendon rupture treatment) were included in this study. RESULTS: Data on a total of 13,569 patients was submitted. Following data cleansing, 11,363 patients were available for further analysis, with anticoagulation data available for 11,099 patients. There were eleven different chemical anticoagulation treatments recorded across the cohort. A total of 3630 (31.95 %) patients received no chemical anticoagulation. The patients receiving chemical anticoagulation medication could be split into 4 main groups. The most common chemical anticoagulation received was low molecular weight heparin (LMWH) (6303, 84.4 % of patients receiving chemical anticoagulation). Aspirin was given in 4.1 % (308 patients), a Factor Xa inhibitor in 10 % (744 patients) and other anticoagulants (e.g. Warfarin) in 1.5 % (114 patients). The overall VTE rate in this sub analysis of patients receiving chemical anticoagulation, was 1.1 % (83 cases out of 7469). There was no significant difference seen in incidence of VTE between types of anticoagulants, when confounding factors were considered. The duration of post-operative chemical prophylaxis used by participants for most chemical anticoagulants was 6 weeks (64.50 %). CONCLUSION: There was significant variability of chemical anticoagulants reported in the study, with five different categories of anticoagulants used (including no chemical anticoagulation), and none clearly superior/inferior. The duration of anticoagulation was consistent across types of thromboprophylaxis.

Characteristics of Patients Not Receiving Chemical Thromboprophylaxis Following Foot and Ankle Surgery: Data From the Multicenter, Prospective UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE).

BACKGROUND: Although the rate of venous thromboembolism (VTE) after foot and ankle surgery is low, multiple factors influence risk for individual patients. Furthermore, there are no clear guidelines on which patients may benefit from chemical thromboprophylaxis. Our aim was to assess patients not treated with chemical thromboprophylaxis after foot and ankle surgery, and to report on their specific patient and surgical risk factors for VTE. METHODS: This was a multicenter, prospective, national audit of patients undergoing foot and ankle surgery (including Achilles tendon ruptures) from 68 participating UK centers. The study was conducted between June 1, 2022, and November 30, 2022, with a further 3-month follow-up. Following data cleansing, 3309 patients were included who did not receive postoperative thromboprophylaxis. RESULTS: Most patients were elective cases (2589 patients, 78.24%) with ASA grade I or II (2679 patients, 80.96%), fully weightbearing postoperatively (2752 patients, 83.17%), and either without ankle splintage, or splinted in a plantigrade boot (2797 patients, 84.53%). The VTE rate was 0.30% overall (11 cases), with no VTE-related mortality. No single demographic, surgical, or postoperative factor was associated with reduced risk of VTE. However, patients who had elective or trauma surgery not involving the ankle, who were ASA grade I or II and who were weightbearing immediately postoperatively (without splinting or in a plantigrade boot) had a VTE rate of 0.05% (1 of 1819 patients), compared with 0.67% (10 of 1490 patients, P = .002). CONCLUSION: Patients not receiving chemical thromboprophylaxis had a low incidence of symptomatic VTE, although they do represent a curated group considered lower risk. Within this group we describe characteristics associated with a substantially lower risk of VTE. All patients should be assessed on an individual basis, and further work is required to substantiate our findings.

Chronic syndesmotic instability - Current evidence on management.

This review article discusses the current evidence on the management of chronic syndesmotic instability. Conservative treatment has a limited role, and surgical intervention is most commonly reported as the mainstay of treatment, however the literature consists of small case series and descriptions of operative techniques, and thus the evidence base for any treatment is weak. Surgical options include arthroscopic debridement alone, static fixation with cortical screws, dynamic fixation with suture-button devices, and ligamentous repair or augmentation.

A morphological review of medial malleolar fractures - A large single centre series.

BACKGROUND: Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. METHODS: Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records. Retrospective analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. RESULTS: A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). Herscovici type A fractures were significantly more frequently mal-reduced at time of surgery as compared to other fracture types (p = .003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who had been anatomically reduced. CONCLUSION: The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions. LEVEL OF EVIDENCE: Level 3 - Retrospective Cohort Study.

Consensus on managing open ankle fractures in the frail patient.

Aims: Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods: A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results: In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion: A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.

Posterior tibialis tendon entrapment as a complication of posterior malleolar fractures in complex ankle fractures.

Aims: Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis. Methods: The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently. Results: Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications. Conclusion: TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity.

The position, orientation, and relative size of the fibularis longus tubercle in normal patients: A weightbearing CT assessment.

The fibularis longus attaches to the base of the first metatarsal at the fibularis/peroneus longus tubercle (FLT/PLT). Theoretically, differences in FLT morphology may reflect changes in the function of the fibularis longus. This study defines the normal limits of the FLT position, orientation, and size in patients with morphologically normal foot anatomy. A retrospective analysis of 131 feet without deformity in 72 patients undergoing weightbearing CT (WBCT) at a single center was conducted. The position and morphology of the FLT was assessed with novel measurements including tubercle-floor distance, tubercle-metatarsal angle, and the angle between the floor and a line bisecting the FLT (bisecting angle). Roundness of the FLT was compared to a triangle limiting its shape (triangular ratio), with lower values indicating increasing roundness. We also report relative size of the FLT to the first metatarsal (X/Y ratio), and relative size of the first metatarsal and FLT to the second metatarsal (XY/Z ratio). There were no significant side to side differences for any measurement (p > 0.05). Mean values were: tubercle-floor distance 28.02 ± 2.63 mm, tubercle-metatarsal angle 32.7 ± 6.32 degrees, bisecting angle 65.58 ± 6.27 degrees, triangular ratio 0.69 ± 0.04, X/Y ratio 1.13 ± 0.20, and XY/Z ratio 3.44 ± -0.72. Bisecting angle strongly correlated with tubercle-metatarsal angle (Pearson correlation 0.840, p < 0.001) suggesting FLT rotation occurred independent of foot position. ICC was >0.943 for all measurements. This study reports the morphology of the FLT in individuals with normal feet. This normative data may be used in future studies examining differences between groups of patients with foot pathology, helping us better understand the role of fibularis longus in the development and treatment of foot disorders.

Chopart dislocations: a review of diagnosis, treatment and outcomes.

INTRODUCTION: Chopart injuries can be allocated into 4 broad groups, ligamentous injury with or without dislocation and fracture with or without dislocation, which must occur at the talonavicular joint (TNJ) and/or calcaneocuboid joint (CCJ). Chopart dislocations are comprised of pure-dislocations and fracture-dislocations. We aim to review the literature, to enable evidence-based recommendations. METHODS: A literature search was conducted to identify relevant articles from the electronic databases, PubMed, Medline and Scopus. The PRISMA flow chart was used to scrutinise the search results. Articles were screened by title, abstract and full text to confirm relevance. RESULTS: We identified 58 papers for analysis, 36 case reports, 4 cohort studies, 4 case series and 14 other articles related to the epidemiology, diagnosis, treatment and outcomes of Chopart dislocations. Diagnostic recommendations included routine imaging to contain computed tomography (CT) and routine examination for compartment syndrome. Treatment recommendations included early anatomical reduction, with restoration and maintenance of column length and joint congruency. For both pure-dislocations and fracture-dislocations urgent open reduction and internal fixation (ORIF) provided the most favourable long-term outcomes. CONCLUSIONS: Chopart dislocations are a complex heterogenous midfoot injury with historically poor outcomes. There is a relative paucity of research discussing these injuries. We have offered evidence-based recommendations related to the clinical and surgical management of these rare pathologies.

Tibialis posterior tendon entrapment in posterior malleolar and pilon injuries of the ankle: a retrospective analysis.

BACKGROUND: The Tibialis Posterior tendon (TPT) is the only tendon to encounter the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle, they often have been missed and present late. AIM: Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia, i.e. Pilon (PLM) and posterior malleolar fractures (PMF). METHODS: A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site, this was denoted as a minor entrapment and if ≥ 50% of the tendon was present in the fracture site was denoted as major. RESULTS: A total of 363 patients were identified for further analysis, 220 who had a PMF and 143 with PLM injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture line entered the TPT sheath, there was a 45% rate (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath (p < .001). There was no significant difference in TPT entrapment in PMF as compared to PML (p = 0.353). CONCLUSION: In our assessment, we found significant prevalence of 22% of TPT entrapment in fractures involving the posterior tibia. PMF and PLF had no statistically significant difference in the rate of TPT entrapment. Additionally, we found that there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider taking care assessing pre-operative imaging to seek to identify the TPT and to assess intraoperatively where entrapment does occur.

Patterns of major trauma admissions to a level 1 trauma centre: A five year database analysis.

INTRODUCTION: It is only in recent years that major trauma systems and networks have been operating in the UK. High-quality data is available from the Trauma Audit and Research Network (TARN) database, enabling regional analysis. Our aim was to analyse Trauma Team Activations within the Cheshire and Merseyside major trauma network and discuss the implications of these data on resource allocation, training and trauma prevention. METHODS: A retrospective analysis was performed for all patients requiring Trauma Team Activation (TTA) at a category one adult Major Trauma Centre (MTC) who were submitted to the TARN database from the 1st January 2015 to the 1st January 2020. Data collected included the date and time of arrival, location of injury and Injury Severity Score (ISS) in addition to routine demographic data. Dates of major sporting events and school holidays were obtained. RESULTS: 4811 patients were identified. The median age was 57 years; 65.8 % were male. The mean frequency of TTAs was 18.5 per week. Patterns identified include annual peaks during the summer months, October and December, weekly peaks on Thursdays and Sundays and daily peaks between 16:00 and 23:59 with 45.0 % of TTAs occurring between these hours. There were 5.9 additional TTAs per week during the Isle of Man TT races. The median ISS increased from 14 to 23 for TT race TTAs and from 14 to 36 for Manx Grand Prix TTAs. Those injured during the TT races were twice as likely to require surgery and those injured during the MGP required five additional days in intensive care. School holidays did not independently affect major trauma volumes. CONCLUSIONS: Major trauma in Cheshire and Merseyside did follow distinct patterns according to calendar month, day and time. Major motorsport increased trauma volumes and severity; school holidays did not. Such analysis could enable Major Trauma Centres to tailor the supply of trauma services to meet a predictable local demand for the benefit of our staff and patients.

An interpretable framework for sleep posture change detection and postural inactivity segmentation using wrist kinematics.

Sleep posture and movements offer insights into neurophysiological health and correlate with overall well-being and quality of life. Clinical practices utilise polysomnography for sleep assessment, which is intrusive, performed in unfamiliar environments, and requires trained personnel. While sensor technologies such as actigraphy are less invasive alternatives, concerns about their reliability and precision in clinical practice persist. Moreover, the field lacks a universally accepted algorithm, with methods ranging from raw signal thresholding to data-intensive classification models that may be unfamiliar to medical staff. This paper proposes a comprehensive framework for objectively detecting sleep posture changes and temporally segmenting postural inactivity using clinically relevant joint kinematics, measured by a custom-made wearable sensor. The framework was evaluated on wrist kinematic data from five healthy participants during simulated sleep. Intuitive three-dimensional visualisations of kinematic time series were achieved through dimension reduction-based preprocessing, providing an out-of-the-box framework explainability that may be useful for clinical monitoring and diagnosis. The proposed framework achieved up to 99.2% F1-score and 0.96 Pearson's correlation coefficient for posture detection and inactivity segmentation respectively. This work paves the way for reliable home-based sleep movement analysis, serving patient-centred longitudinal care.

The arterial risk posed by the posterolateral approach: An anatomical cadaveric study of the fibular artery and its variability.

The posterior malleolus of the tibia is commonly accessed surgically through the posterolateral approach. This approach gives good access to the fibula and lateral aspect of the posterior tibia, however; there is little known on the vascular risks with this approach. The aim of this study was to assess and describe the anatomy of the fibular artery and its branches at the ankle region and relate it to the surgical access of the posterior malleolus. Eleven cadaveric foot and ankle specimens were dissected in layers, preserving the fibular artery, anterior tibial artery (ATA), and posterior tibial artery (PTA). Five distinct variations were found in the fibular artery: variable terminal branching with a hyperplastic fibular artery; a superficially located fibular artery; variation in the level and number of anastomoses; variation in the muscular branches; and a variable anterior perforating branch. The mean proximal distance from a horizontal line drawn through the medial protuberance of the medial malleolus of the tibia (horizontal line reference point-HLRP) to the posterior communicating branch of the fibular artery was 37.93 mm (range 19.03-85.43 mm). The mean proximal distance between HLRP and the anterior perforating branch of the fibular artery was 44.23 mm (range 35.44-62.32 mm). In 10 specimens, the fibular artery was immobile distal to its anterior perforating branch. The posterolateral approach specifically puts the fibular artery at risk and knowledge of its anatomy and variability is important when undertaking this approach. Understanding the common variations within the ankle's arterial anatomy can help surgeons protect these vessels from damage during the surgical approach.

Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study.

BACKGROUND: Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related "lockdown" restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England. METHODS AND FINDINGS: We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded. CONCLUSIONS: This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.

Association of Fusion of the First Metatarsophalangeal Joint and Pes Planus Deformity Correction.

BACKGROUND: There has been scant investigation on the relationship between the distal aspect of the medial longitudinal arch and pes planus deformity. The aim of this study was to investigate whether the reduction and stabilization of the distal aspect of the medial longitudinal arch through fusion of the first metatarsophalangeal joint (MTPJ) can subsequently improve pes planus deformity parameters. This could be useful in both further understanding the role of the distal medial longitudinal arch in patients with pes planus and planning operative intervention in patients with multifactorial medial longitudinal arch problems. METHODS: A retrospective cohort study was undertaken between January 2011 and October 2021, including patients undergoing first MTPJ fusion with a pes planus deformity on weightbearing preoperative radiographs. These were compared to postoperative images, and multiple pes planus measurements were taken for comparison. RESULTS: A total of 511 operations were identified for further analysis, with 48 feet meeting the inclusion criteria. There was a statistically significant reduction identified between the pre- and postoperative measurements of Meary angle (3.75 degrees, 95% CI 2.9-6.47 degrees) and talonavicular coverage angle (1.48 degrees, 95% CI 1.09-3.44 degrees). There was a statistically significant increase between the pre- and postoperative measurements of calcaneal pitch angle (2.32 degrees, 95% CI 0.24-4.41 degrees) and medial cuneiform height (1.25 mm, 95% CI 0.6-1.92 mm). Reduced intermetatarsal angle was significantly associated with an increase in first MTPJ angle postfusion. Many of the measurements made were found "almost perfectly" reproducible by the Landis and Koch description. CONCLUSION: Our results demonstrate that fusion of the first MTPJ is associated with improvement of medial longitudinal arch parameters of a pes planus deformity but not to levels considered to be clinically normal. Therefore, the distal aspect of the medial longitudinal arch could, to some degree, be a feature in the pes planus deformity etiology. LEVEL OF EVIDENCE: Level III, retrospective case control study.

Sternal fractures and thoracic injury: an analysis of 288 sternal fractures attending a major trauma centre.

INTRODUCTION: Sternal fractures (SF) are uncommon injuries usually associated with a significant mechanism of injury. Concomitant injury is likely, and a risk of mortality is substantial. AIM: Our aim in this study was to identify the risk factors for mortality in patients who had sustained sternal fractures. METHODS: We conducted a single centre retrospective review of the trust's Trauma Audit and Research Network Database, from May 2014 to July 2021. Our inclusion criteria were any patients who had sustained a sternal fracture. The regions of injury were defined using the Abbreviated Injury Score. Pearson Chi-Squared, Fisher Exact tests and multivariate regression analyses were performed using IBM SPSS. RESULTS: A total of 249 patients were identified to have sustained a SF. There were 19 patients (7.63%) who had died. The most common concomitant injuries with SF were Rib fractures (56%), Lung Contusions (31.15%) and Haemothorax (21.88%). There was a significant increase in age (59.93 vs 70.06, p = .037) and admission troponin (36.34 vs. 100.50, p = .003) in those who died. There was a significantly lower GCS in those who died (10.05 vs. 14.01, p < .001). On multi regression analysis, bilateral rib injury (p = 0.037, OR 1.104) was the only nominal variable which showed significance in mortality. CONCLUSION: Sternal Fractures are uncommon but serious injuries. Our review has identified that bilateral rib injuries, increase in age, low GCS, and high admission troponin in the context of SF, were associated with mortality.

Posterolateral Approach to Posterior Malleolar Fractures: A Literature Review.

This study reviews the current evidence on the indications and outcomes of the posterolateral approach in the treatment of posterior malleolar fractures. PubMed and Google Scholar search engines were used to construct a review of the literature for all studies detailing the posterolateral approach for posterior malleolar fracture fixation. A total of 11 studies met our inclusion criteria. In total, 332 fractures were identified. Overall superficial infection occurred in 4.5%, skin necrosis in 4.5%, and nerve injury in 4.5%. Hardware irritation that required removal occurred in 13.6%. None of the hardware removals involved posterior malleolus fixation. A total of 51 (15.4%) cases of arthritis were reported, follow-up ranged from a mean of 5.3 months to a mean 7.9 years. Regardless the majority of patient reported outcomes were excellent/good at final follow-up. Thresholds for joint reduction were not uniformly described or even quantified at all in some of the included studies. Variable indications for fixation were reported without reference to posterior malleolus fracture morphology. The posterolateral approach provides a satisfactory approach for fracture reduction with similar complication rates to that reported for other ankle fracture approaches. Further research is required on posterior malleolus fracture morphology, optimal fracture fixation and longer term functional and radiological outcomes.Levels of Evidence: Level III: Systematic review of retrospective cohort studies.

Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension.

BACKGROUND: Multiple authors have highlighted the increased incidence of occult posterior malleolar fractures (PMFs) with spiral tibial shaft fractures, although other reported associated risks of intra-articular extension have been limited. The aim of our study is to investigate both PMFs and non-PMFs intra-articular extensions associated with tibial diaphyseal fractures to try to determine any predictive factors. METHODS: We undertook a retrospective review of a prospectively collected database. The inclusion criteria for this study were any patient who had sustained a diaphyseal tibial fracture, who had undergone surgery during the study period and who had also undergone a CT scan in addition to plain radiographs. The study time period for this study was between 01/01/2013 and 9/11/2021. RESULTS: Out of 764 diaphyseal fractures identified, 442 met the inclusion criteria. A total of 107 patients had PMF extensions (24.21%), and a further 128 patients (28.96%) had intra-articular extensions that were not PMF's. On multivariate analysis, spiral tibial fracture subtypes of the AO/OTA classification (OR 4.18, p < 0.001) and medial direction of tibial spiral from proximal to distal (OR 4.38, p < 0.001) were both significantly associated with PMF. Regarding intra-articular fractures, multivariate analysis showed significant associations with non-spiral (OR 4.83, p < 0.001) and distal (OR 15.32, p < 0.001) tibial fractures and fibular fractures that were oblique (OR 2.01, p = 0.019) and at the same level as tibia fracture (OR 1.83, p = 0.045) or no fracture of the fibular (OR 7.02, p < 0.001). CONCLUSION: In our study, distal tibial articular extension occurs in almost half of tibial shaft fractures. There are very few fracture patterns that are not associated with some type of intra-articular extension, and therefore, a low threshold for preoperative CT should be maintained.

Influence of posterior malleolar fragment morphology on the outcomes of trimalleolar fractures: A systematic review and meta-analysis.

BACKGROUND: Trimalleolar fractures are generally considered to have inferior outcomes among ankle injuries. Historically, emphasis was placed on the size of the posterior malleolar fracture (PMF) to guide surgical decision-making and predict outcomes. Recent studies have suggested that the morphology of the PMF fragment is more important than its size. The aim of this systematic review was to determine if the outcomes of trimalleolar fractures depend on the morphology of the PMF as per the Haraguchi classification system after surgical fixation. METHODS: A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Title and abstracts were screened, and data from eligible studies were extracted. Meta-regression and pooled analysis was performed using appropriate computer software. RESULTS: 11 studies with 597 patients were included in the final analysis. Pooled mean AOFAS score was 87.43 (95% CI 84.24-90.62) after a mean follow-up of 31.6 months. Univariate and multivariate meta-regression analysis demonstrated that as the percentage of Haraguchi type 1 patients increased, there was a statistically significant improvement in outcome scores. A similar trend was noted for Haraguchi type 3 fractures, and a reverse trend was observed for Haraguchi type 2 injuries, although neither were statistically significant. CONCLUSION: Our review suggests that the outcomes of trimalleolar fractures after surgical fixation may depend on the morphology of the PMF, with Haraguchi type 1 fractures having overall superior functional outcomes than Haraguchi type 2 and 3 injuries. Future studies need to done to conclusively prove or refute these findings.

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (UK-FAlCoN) audit.

OBJECTIVES: The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns. SETTING: This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020. PARTICIPANTS: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection). RESULTS: 10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd's Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways. CONCLUSIONS: There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

Hallux Valgus Interphalangeus Measurement: Comparison of the 2 Radiographic Methods.

BACKGROUND: To determine the reliability of Delta PP (difference in medial and lateral proximal phalanx wall length) compared with HIA (hallux interphalangeal angle) in the assessment of HVI (hallux valgus interphalangeus) in both preoperative and postoperative radiographs. METHODS: This was a retrospective observational study of 186 feet with hallux valgus. The number of cases required to adequately power the study was 128. Preoperative and postoperative hallux alignment were evaluated by 2 different radiological parameters, Delta PP and HIA. Interobserver variability was assessed independently by 2 authors and compared using a intraclass correlation coefficient. RESULTS: The intraclass correlation coefficient was more than 0.8 for all parameters, thus both HIA and Delta PP measurement provide reliable and reproducible data. Mean HIA significantly increased following surgical correction of hallux valgus. In comparison, the mean Delta PP decreased after correction. This postoperative increase in HIA indicates that preoperative HIA underestimates the magnitude of HVI and therefore is an inaccurate tool for measuring HVI's contribution to the TVDH (total valgus deformity of the hallux) and to preoperative planning. However, the Delta PP was a greater determinant of the phalanx deformity's contribution to the TVDH. CONCLUSION: The outcome of our study shows that both HIA and Delta PP are reproducible when assessing the HVI deformity; however, Delta PP quantifies the amount of correction obtained more precisely. The additional benefit of measuring the Delta PP is that it allows for accurate planning in determining the dimensions of the medial-based wedge of the Akin osteotomy that needs to be resected. LEVELS OF EVIDENCE: Level 4.