Ankle fusion with tibiotalocalcaneal retrograde nail for fragility ankle fractures: outcomes at a major trauma centre.

PURPOSE: Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, and patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with retrograde ankle fusion nails. METHODS: A retrospective observational study was performed on patients who underwent intramedullary nailing with a tibiotalocalcaneal nail. Twenty patients met the inclusion criteria of being over sixty and having multiple co-morbidities. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, time to mobilisation and union, AOFAS and Olerud-Molander scores, and patient mobility were recorded. RESULTS: There were seven males and thirteen females, with a mean age of 77.82 years old, five of whom are type 2 diabetics. Thirteen patients returned to their pre-operative mobility state, and the average Charlson Co-morbidity Index (CCI) was 5.05. Patients with a low CCI are more likely to return to pre-operative mobility status (p = 0.16; OR = 4.00). All patients achieved radiographical union, taking on average between 92.5 days and 144.6 days. The mean post-operative AOFAS and Olerud-Molander scores were 53.0 and 50.9, respectively. There were four cases of superficial infection, four cases of broken or loose distal locking screws. There were no deep infections, periprosthetic fractures, nail breakages, or non-unions. CONCLUSION: Tibiotalocalcaneal nailing is an effective and safe option for managing unstable ankle fractures in the elderly. This technique leads to lower complication rates and earlier mobilisation than traditional fixation methods.

Retrograde tibiotalocalcaneal nailing for the treatment of acute ankle fractures in the elderly: a systematic review and meta-analysis.

Introduction: Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation. Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of TTC nailing for fragility ankle fractures. Methods: A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, and Web of Science, identifying 14 studies for inclusion. Studies including patients with a fragility ankle fracture, defined according to NICE guidelines as a low-energy fracture obtained following a fall from standing height or less, that were treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. This review was registered in PROSPERO (ID: CRD42021258893). Results: A total of 312 ankle fractures were included. The mean age was 77.3 years old. In this study, 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection was 10% (95% CI: 0.06-0.16), deep infection 8% (95% CI: 0.06-0.11), implant failure 11% (95% CI: 0.07-0.15), malunion 11% (95% CI: 0.06-0.18), and all-cause mortality 27% (95% CI: 0.20-0.34). The pooled mean post-operative Olerud-Molander ankle score was 54.07 (95% CI: 48.98-59.16). Egger's test (P = 0.56) showed no significant publication bias. Conclusion: TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent post-operative rehabilitation protocols. Prospective randomised control trials with long follow-up times and large cohort sizes are needed to guide the use of TTC nailing for ankle fractures.

Mesenchymal Stem Cell-Derived Extracellular Vesicles in Tendon and Ligament Repair-A Systematic Review of In Vivo Studies.

Tendon and ligament injury poses an increasingly large burden to society. This systematic review explores whether mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) can facilitate tendon/ligament repair in vivo. On 26 May 2021, a systematic search was performed on PubMed, Web of Science, Cochrane Library, Embase, to identify all studies that utilised MSC-EVs for tendon/ligament healing. Studies administering EVs isolated from human or animal-derived MSCs into in vivo models of tendon/ligament injury were included. In vitro, ex vivo, and in silico studies were excluded, and studies without a control group were excluded. Out of 383 studies identified, 11 met the inclusion criteria. Data on isolation, the characterisation of MSCs and EVs, and the in vivo findings in in vivo models were extracted. All included studies reported better tendon/ligament repair following MSC-EV treatment, but not all found improvements in every parameter measured. Biomechanics, an important index for tendon/ligament repair, was reported by only eight studies, from which evidence linking biomechanical alterations to functional improvement was weak. Nevertheless, the studies in this review showcased the safety and efficacy of MSC-EV therapy for tendon/ligament healing, by attenuating the initial inflammatory response and accelerating tendon matrix regeneration, providing a basis for potential clinical use in tendon/ligament repair.

Cambridge Protocol for Management of Segmental Bone Loss.

INTRODUCTION: Segmental long bone defects are some of the most challenging to surgically reconstruct; however, there is no clear guidance on which of the myriad of techniques is superior in a given clinical context. We describe three cases of segmental bone loss presenting to a major trauma center and have use these to develop a treatment algorithm for the sub-acute management of such fractures. CASE REPORT: Case 1 - Acute shortening and delayed lengthening using lengthening intramedullary (IM) nail to treat diaphyseal non-union of the femur with associated 3 cm shortening. Case 2 - 15 cm traumatic bone loss of femur, failed Masquelet, treated with IM nail, monolateral external-fixation and cable with a mean lengthening rate of 46 days/cm. Case 3 - 12 cm tibial traumatic bone loss, failed Masquelet, treated with fine wire frame with a mean lengthening rate of 49 days/cm. CONCLUSION: As our cases illustrate; attempting complicated, definitive management in the acute phase generates complications and necessitates re-intervention. As such, we have developed a treatment algorithm for traumatic segmental bone loss. We recommend waiting 6 weeks and reimaging to check for evidence of spontaneous bone formation before deciding on definitive treatment. First-line treatment for femoral defects <4 cm is acute limb shortening with delayed lengthening using lengthening IM nail. First-line treatment for femoral defects >4 cm is lengthening over nail with monolateral external fixator. First-line treatment of tibial segmental bone defects in our hands is fine wire circular frames which provide excellent scope for soft tissue coverage and deformity correction. Treatment times of over 2 years in a frame are not uncommon and patients must diligently comply with pin sites management and lengthening protocols. This is the first paper providing an algorithm to guide surgeons in choosing the best lower limb reconstruction options in the sub-acute setting; considering the skill set and resources of the center in which one works.

Development of a novel risk score to predict mortality in patients admitted to hospital with COVID-19.

Patients hospitalised with COVID-19 have a high mortality. Identification of patients at increased risk of adverse outcome would be important, to allow closer observation and earlier medical intervention for those at risk, and to objectively guide prognosis for friends and family of affected individuals. We conducted a single-centre retrospective cohort study in all-comers with COVID-19 admitted to a large general hospital in the United Kingdom. Clinical characteristics and features on admission, including observations, haematological and biochemical characteristics, were used to develop a score to predict 30-day mortality, using multivariable logistic regression. We identified 316 patients, of whom 46% died within 30-days. We developed a mortality score incorporating age, sex, platelet count, international normalised ratio, and observations on admission including the Glasgow Coma Scale, respiratory rate and blood pressure. The score was highly predictive of 30-day mortality with an area under the receiver operating curve of 0.7933 (95% CI 0.745-0.841). The optimal cut-point was a score ≥ 4, which had a sensitivity of 78.36% and a specificity of 67.59%. Patients with a score ≥ 4 had an odds ratio of 7.6 for 30-day mortality compared to those with a score < 4 (95% CI 4.56-12.49, p < 0.001). This simple, easy-to-use risk score calculator for patients admitted to hospital with COVID-19 is a strong predictor of 30-day mortality. Whilst requiring further external validation, it has the potential to guide prognosis for family and friends, and to identify patients at increased risk, who may require closer observation and more intensive early intervention.

Prospective assessment of a critical appraisal teaching programme on medical students' confidence and performance in appraising medical literature.

BACKGROUND: Previous research has demonstrated that medical students have insufficient knowledge of critical appraisal, a fundamental aspect of evidence-based medicine. We aimed to enhance medical students' critical appraisal skills using an innovative mixed-methods programme. METHODS: We designed a 2-day, mixed-methods, national teaching programme, including an interactive lecture and workshop, quiz and viva-style examination. Course efficacy was assessed using pre- and post-course confidence questionnaires and a quiz adapted from the validated Berlin Questionnaire. Data were analysed primarily using Wilcoxon Signed Ranks test. RESULTS: Fifty-nine participants from 17 medical schools completed the programme. Pre- and post-course scores demonstrated significant improvement in confidence (median score 5 vs 8; p < 0.001) and quiz performance (median score 9 vs 13; p < 0.001). CONCLUSION: Our study demonstrates the efficacy of a novel mixed-methods programme in teaching medical students about critical appraisal. Implementation of our approach within the undergraduate curriculum should enhance the uptake of these fundamental skills.

Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture.

Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03-0.07), coronal plane malunion (5%, CI: 0.03-0.08), deep (5%, CI: 0.03-0.11) and superficial (6%, CI: 0.03-0.11) infections, and secondary procedures (8%, CI: 0.04-0.18).When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits. Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040.

Evaluating the usefulness and utility of a webinar as a platform to educate students on a UK clinical academic programme.

BACKGROUND: The Academic Foundation Programme (AFP) is the first step of the UK's national integrated clinical academic pathway; however, the application process can be unclear. We evaluated webinars as a teaching medium to enhance knowledge and confidence of prospective applicants. METHODS: Medical students were invited to attend a free webinar. The webinar was designed by a former academic foundation trainee, outlining the UK integrated clinical academic pathway and how to apply to the AFP. An online questionnaire-based cross-sectional study was conducted pre- and post-webinar. RESULTS: In total, 118 out of 199 (59.3% response rate) attendees filled out the pre-webinar questionnaire, while 64 out of 199 attendees (32.2% response rate) filled out the post-webinar questionnaire. Of these 83.1% had never previously attended a medical education webinar, and 92.3% agreed webinars offer flexibility and convenience, saving time and money on travel. Matched pre- and post-webinar data showed an increase in participants' knowledge (p < 0.0001) and confidence (p < 0.001). CONCLUSIONS: This study has demonstrated the utility of a focused webinar in enhancing medical students' knowledge and confidence in AFP applications. Webinars are a rarely utilised yet highly acceptable way to engage millennial students and could be used to enhance engagement with clinical academia.

Selection and Application of Tissue microRNAs for Nonendoscopic Diagnosis of Barrett's Esophagus.

BACKGROUND & AIMS: MicroRNA (miRNA) is highly stable in biospecimens and provides tissue-specific profiles, making it a useful biomarker of carcinogenesis. We aimed to discover a set of miRNAs that could accurately discriminate Barrett's esophagus (BE) from normal esophageal tissue and to test its diagnostic accuracy when applied to samples collected by a noninvasive esophageal cell sampling device. METHODS: We analyzed miRNA expression profiles of 2 independent sets of esophageal biopsy tissues collected during endoscopy from 38 patients with BE and 26 patients with normal esophagus (controls) using Agilent microarray and Nanostring nCounter assays. Consistently up-regulated miRNAs were quantified by real-time polymerase chain reaction in esophageal tissues collected by Cytosponge from patients with BE vs without BE. miRNAs were expressed from plasmids and antisense oligonucleotides were expressed in normal esophageal squamous cells; effects on proliferation and gene expression patterns were analyzed. RESULTS: We identified 15 miRNAs that were significantly up-regulated in BE vs control tissues. Of these, 11 (MIR215, MIR194, MIR 192, MIR196a, MIR199b, MIR10a, MIR145, MIR181a, MIR30a, MIR7, and MIR199a) were validated in Cytosponge samples. The miRNAs with the greatest increases in BE tissues (7.9-fold increase in expression or more, P < .0001: MIR196a, MIR192, MIR194, and MIR215) each identified BE vs control tissues with area under the curve (AUC) values of 0.82 or more. We developed an optimized multivariable logistic regression model, based on expression levels of 6 miRNAs (MIR7, MIR30a, MIR181a, MIR192, MIR196a, and MIR199a), that identified patients with BE with an AUC value of 0.89, 86.2% sensitivity, and 91.6% specificity. Expression level of MIR192, MIR196a, MIR199a, combined that of trefoil factor 3, identified patients with BE with an AUC of 0.93, 93.1% sensitivity, and 93.7% specificity. Hypomethylation was observed in the promoter region of the highly up-regulated cluster MIR192-MIR194. Overexpression of these miRNAs in normal esophageal squamous cells increased their proliferation, via GRHL3 and PTEN signaling. CONCLUSIONS: In analyses of miRNA expression patterns of BE vs non-BE tissues, we identified a profile that can identify Cytosponge samples from patients with BE with an AUC of 0.93. Expression of MIR194 is increased in BE samples via epigenetic mechanisms that might be involved in BE pathogenesis.