Acute surgical treatment of peroneus longus avulsion fracture of the first metatarsal base.

Acute avulsion fracture of the base of the first metatarsal is a rare occurrence, caused by an eccentric contraction of the peroneus longus tendon insertion. A number of case reports have been published outlining various treatment strategies for treating this rare injury. Management plans range from conservative to operative options and include both acute and delayed operative treatments.We present our operative management strategy of an acute avulsion fracture of the base of the first metatarsal. It includes a step-by-step approach including intraoperative clinical photographs and intraoperative image intensifier images. We explain the rationale behind our operative approach and provide insight on the importance of recognising and treating this injury. Initially, this avulsion fracture might seem innocuous but if left untreated may result in disabling functional foot problems.

Utilising Immersive Video Technology to improve Medical Student Education in an Operating Theatre Environment.

Background: Educational opportunities in operating theatres are finite resources, therefore utilising them effectively is essential. Immersive video technology (IVT) may achieve this by exposing students to high-fidelity scenarios. In this study, we describe impact of IVT on student understanding of an orthopaedic procedure, barriers to surgical education, appreciation of theatre logistics and its effect on career aspirations. Methods: Purposive sampling was used to recruit UK medical undergraduates. An electronic questionnaire was developed using previous studies in the field. Half of the questionnaire was completed prior to a three-minute video describing a surgical procedure, and the second half of the questionnaire was completed after. The study design allowed researchers to collect paired qualitative data on the impact of IVT on students' subjective understanding of carpal tunnel decompression surgery and interest in surgical careers. Results: Out of 980 contacted, 207 respondents completed the 'pre' and 'post' video questionnaires. Following the video intervention, understanding of operative principles increased from 3.3 ± 0.16 (95% CI:1-7) to 6.1 ± 0.16 (95% CI:3-10, p < 0.0001). 81% of respondents reported they would feel more confident attending a carpal tunnel decompression in theatre post-video, with 60% feeling less apprehensive and 72% stating they would feel more engaged if they were shown a short educational video beforehand. Interest in pursuing a career in surgery increased from 3.9 ± 0.30 (95% CI:1-10) before watching the video to 4.2 ± 0.28 (95% CI:1-10, p < 0.0001), post-video. Conclusions: This study supports the use of immersive multimedia to enhance medical education in surgery which may stimulate student interest in surgical careers.

The success of virtual clinics during COVID-19: A closed loop audit of the British orthopaedic association (BOAST) guidelines of outpatient orthopaedic fracture management.

COVID-19 has had profound management implications for orthopaedic management due to balancing patient outcomes with clinical safety and limited resources. The BOAST guidelines on outpatient orthopaedic fracture management took a pragmatic approach. At Great Western Hospital, Swindon, a closed loop audit was performed looking at a selection of these guidelines, to assess if our initial changes were sufficient and what could be improved. METHOD: An audit was designed around fracture immobilisation, type of initial fracture clinic assessment, default virtual follow up clinic and late imaging. Interventions were implemented and re-audited. RESULTS: Initially 223 patients were identified over 4 weeks. Of these, 100% had removable casts and 99% did not have late imaging. 96% of patients were initially assessed virtually or had initial orthopaedic approval to be seen in face to face clinic. 97% had virtual follow up or had documented reasons why not. The 26 patients who were initially seen face to face were put through a simulated virtual fracture clinic. 22 appointments and 13 Xray attendances could have been avoided. We implemented a change of requiring all patients to be assessed at consultant level before having a face to face appointment. The re-audit showed over 99% achievement in all areas. CONCLUSION: Virtual fracture clinics, both triaging new patients and follow-up clinics have dramatically changed our outpatient management, helping the most appropriate patients to be seen face to face. Despite their limitations, they have been well tolerated by patients and improved patient safety and treatment.

Outcome Measures Reported in Published Clinical Research Studies in Craniosynostosis: A Systematic Review.

CONTEXT: The fair comparison of treatment interventions for craniosynostosis across different studies is expected to be impaired by incomplete reporting and the use of inconsistent outcomes. OBJECTIVE: This review assessed the outcomes currently reported in studies of craniosynostosis, and whether these outcomes are formally defined and prespecified in the study methods. DATA SOURCES, SEARCH TERMS, AND STUDY SELECTION: Studies were sourced via an electronic, multi-database literature search for "craniosynostosis." All primary, interventional research studies published from 2011 to 2015 were reviewed. DATA EXTRACTION: Two independent researchers assessed each study for inclusion and performed the data extraction. For each study, data were extracted on the individual outcomes reported, and whether these outcomes were defined and prespecified in the methods. DATA SYNTHESIS AND RESULTS: Of 1027 studies screened, 240 were included and proceeded to data extraction. These studies included 18,365 patients.2192 separate outcomes were reported. Of these, 851 outcomes (38.8%) were clearly defined, 1394 (63.6%) were prespecified in the study methods."Clinical and functional" was the most commonly reported outcome theme (900 outcomes, 41.1%), and "patient-reported" outcomes the least (7 outcomes, 0.3%)."Duration of surgery" was the most commonly reported single outcome (reported 80 times). "Cranial index" was the most variably defined outcome (18 different definitions used). CONCLUSION: The outcomes reported following treatment interventions for craniosynostosis are incompletely and variably defined. Improving definitions for these outcomes may aid comparison of different management strategies and improve craniosynostosis care. Suboptimal prespecification of these outcomes in the study methods implied that outcome reporting bias cannot be excluded.

Making Things Easier: A Simple Novel Method to Fix a Dorsiflexion Osteotomy of the First Metatarsal.

A first ray dorsiflexion osteotomy is commonly performed for cavovarus foot correction. There are multiple techniques to fix this osteotomy, ranging from wires, screws, and plates or a combination of these. We present our results using a varisation staple (Biomet©) as an alternative fixation device. We performed a retrospective outcome analysis of a consecutive series of 10 cavovarus feet that underwent a dorsiflexion osteotomy (dorsal closing wedge) of the first metatarsal fixed with two varisation staples. The results were measured at a mean three monthly follow-ups and included union and complication rates, as well as clinical and radiographic assessment of cavus deformity correction. There was a 100% union rate with no complications or cases of delayed union. No metalwork removal was requested in any case at follow-up. First ray dorsiflexion osteotomies are most commonly fixed using a 3.5mm cortical screw. We demonstrate that our alternative and novel technique using varisation staples achieved a 100% union rate while avoiding the prominent hardware complications known to occur with cortical screws or plates.

Ankle Home Stay Programme:- A review of ankle fracture management and costs at a busy district general hospital.

INTRODUCTION: Patients suffering ankle fractures provide a common economic and time burden to modern healthcare in the UK. They continue to be admitted to await operative intervention and may have to wait days before an operation occurs. Unnecessary bed stay is one are that may be subject to cost savings if the safety of the patient is maintained. PATIENT AND METHODS: We prospectively collected data on 23 patients over a four-month period identifying their admission status, length of stay, and time to operative intervention. We were able to cost analyse the patients journey from admission to discharge, postoperative intervention. We then instilled the Ankle Home Stay Programme, identifying patients safe to be discharged who were able to re-attend for their operation. Seventeen patients were enrolled in this and a subsequent cost-analysis was compared to the pre-intervention cohort. RESULTS: Pre Ankle Home Stay Programme demonstrated cost per patient of admitted patients to be £2690 and £1347 for patients managed in the outpatient setting. Implementation of the pathway maintained this cost saving with those in the outpatient setting costing £1781 per patient and those admitted costing £2855. CONCLUSIONS: Patients can be safely managed in the outpatient setting, with regular clinic review before formal operative intervention as opposed to blanket admission to an acute inpatient bed. This is cost saving in a healthcare system with finite resources focussed on improving use of economic resources. It also maintains patient care with select admission criteria onto the pathway and regular review to ensure standards are maintained.

Clinical audit of ankle fracture management in the elderly.

INTRODUCTION: Ankle fractures in the osteoporotic patient are challenging injuries to manage, due to a combination of poor soft tissue, peripheral vascular disease and increased bone fragility, often resulting in more complex fracture patterns. I aim to audit current practice and introduce change by producing recommendations to help improve longer-term functional outcomes. PATIENTS AND METHODS: A retrospective 3-week audit was conducted reviewing results of ankle fracture management in 50 patients aged between 50 and 80 years. Patients admitted for either manipulation under anaesthesia (MUA)/application of cast or open-reduction and internal fixation (ORIF) were considered. Medical notes, including discharge summaries, were used for data extraction. RESULTS: From the 50 patients included within the cohort, forty-two patients (84%) underwent surgical intervention, with eight patients (16%) managed non-operatively. Malunion (63%) and failed fracture fixation (25%) were more commonly reported in patients managed non-operatively. Surgery performed by trainee surgeons was unlikely to prolong theatre time with no statistical significance observed with the consultant led cohort (p = 0.380). However, incidence of fracture malunion and failed fixation were significantly higher following surgery without consultant supervision in the junior trainee group (p = 0.043). CONCLUSIONS: Poor bone quality and associated co-morbidity can present technical difficulties when managing patients surgically. However, our results have shown considerably improved anatomical reduction rates following internal fixation in eligible patients, irrespective of age or gender.

How to make an academic poster.

Academic posters are an excellent way to showcase your work at conferences and meetings. They can be used in poster presentations and serve as a summary of your project. In this how to article, we demonstrate how trainees can make and deliver a successful academic poster.