Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments.

PURPOSE: Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS: A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS: A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION: There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE: Level IV.

Trends Over Time in the Use, Carbon Footprint and Costs of Facet Joint Injections and Medial Branch Blocks to Manage Lumbar Pain in England: Retrospective Analysis of an Administrative Dataset.

STUDY DESIGN: Retrospective analysis of an administrative dataset. OBJECTIVE: This study aims to investigate changing practice over a six-year period in the use of repeated lumbar facet joint injections/medial branch blocks in England. METHODS: Patient data were extracted from the Hospital Episodes Statistics database for the period 1st April 2015 to 31st March 2021 for the index lumbar injection and for repeat lumbar injections performed within one year of the first. The exposure of interest was two injections within 180 days or three within one year. Patients aged <17 years and where the body site was listed as cervical, thoracic or sacral were excluded. RESULTS: Data were available for 134,249 patients of which, 8,922 (6.6%) had either two injections within 180 days or three injections within one year. First injections fell from 42,511 in 2015/16 to 13,368 in 2019/20 as did the number of repeat injections: 4,018 to 424 for the same period. If all years had the same carbon footprint as 2019/20, 2.8 kilotons of CO2e would have been saved over the five years, enough to power 2,575 average UK homes for 1 year. The financial cost of injections decreased from £27.6 million in 2015/16 to £7.9 million in 2019/20. CONCLUSIONS: The number of patients having repeated lumbar injections has decreased over time but has not been eliminated. More work is needed to educate patients and clinicians regarding alternative and more effective treatments.

The effect of bone growth onto massive prostheses collars in protecting the implant from fracture.

Limb-sparing distal femoral endoprotheses used in cancer patients have a high risk of aseptic loosening. It had been reported that young adolescent patients have a higher rate of loosening and fatigue fracture of intramedullary stems because the implant becomes undersized as patients grow. Extracortical bone growth into the grooved hydroxyapatite-coated collar had been shown to reduce failure rates. The stresses in the implant and femur have been calculated from Finite Element models for different stages of bone growth onto the collar. For a small diameter stem without any bone growth, a large stress concentration at the implant shoulder was found, leading to a significant fracture risk under normal walking loads. Bone growth and osseointergration onto the implant collar reduced the stress level in the implant to safe levels. For small bone bridges a risk of bone fracture was observed.

Anterior humeral circumflex artery avulsion with brachial plexus injury following an isolated traumatic anterior shoulder dislocation.

A 70-year-old man presented to accident and emergency with an isolated anteriorly dislocated shoulder, in the absence of a concomitant fracture. There was no neurovascular deficit at presentation, and the shoulder was reduced under sedation, using the Kocher's technique. Following this, the patient developed signs of hypovolaemic shock. Clinical examination revealed an expanding fullness in the deltopectoral area, with compromise of the limb neurovascular status. CT imaging confirmed an expanding haematoma from the axillary vessels, restricting left lung expansion. Once resuscitated, the patient was transferred to theatre for exploration of the bleeding vessels. Intraoperative findings included an avulsed anterior circumflex humeral artery that was subsequently ligated. Postoperatively, the patient developed axillary, radial, median and ulnar nerve neuropraxia, which improved clinically prior to discharge. The patient was ultimately discharged home after a lengthy inpatient stay.

Total proximal interphalangeal joint arthroplasty for osteoarthritis versus rheumatoid arthritis--a systematic review.

Osteoarthritis (OA) and rheumatoid arthritis (RA) of the proximal interphalangeal joints (PIPJ) can be treated with arthroplasty, although the complicated anatomy of the joint makes surgery challenging. Controversy exists regarding outcomes in relation to disease aetiology. This study aims to compare functional outcomes and re-operation rates in these two conditions. The electronic databases MEDLINE, EMBASE, Cochrane database and Google scholar were searched in accordance with PRISMA. The study quality was assessed using the Methodological Index for Non-Randomised Studies (MINOR). A total of 16 studies were reviewed including 506 cases in the OA and 542 in the RA group. Five studies assessed function and patient satisfaction, demonstrating a non-significant improvement in the OA group. Five studies reported re-operation rate; three showing it to be lower in the OA group and two reporting similar rates. This review suggests that those undergoing PIPJ arthroplasty for OA may have a better functional outcome and lower re-operation rate.

Improving the quality of the surgical preoperative assessment in a district general hospital.

At Leicester General Hospital, England, patients are assessed by a team of junior doctors for elective colorectal and hepatobiliary procedures. After a number of same day cancellations, a large discrepancy was identified between the findings at the preoperative assessment clinic and the anaesthetic assessment on the day of surgery. After a multidisciplinary meeting was held, three interventions were decided on with an aim to bring the preoperative assessment in line with the anaesthetic assessment. Firstly, a set of guidelines was written and introduced for the junior doctors to use as a reference when assessing patients. Secondly, a proforma was designed specifically to prompt users to include essential details which were being missed in the assessment, having audited 100 patients' notes. Thirdly, a preoperative investigation "calculator" was recommended for each patient to simplify compliance with the National Institute for Health and Care Excellence (NICE) guidance for preoperative assessment. Before and after each intervention was introduced, a cohort of 50 patients were followed looking for differences in findings in the history, examination, investigations, and fitness for surgery between the preoperative assessment in clinic and the anaesthetic assessment on the day of surgery. Initially 68% of patients were compliant for details in the history, 76% for examination, 32% for choice of preoperative investigations, and 100% for fitness for surgery decision. After all three interventions had been introduced, 96% of patients were compliant for history, 94% for examination findings, 88% had the correct choice of preoperative investigations, and 100% had the same decision on fitness for surgery. The interventions described proved to be cheap and effective methods of improving the quality of the preoperative assessment, bringing it in line with the anaesthetic assessment and reducing the risk of same day cancellations.

Knowledge of cervical cancer and attendance at cervical cancer screening: a survey of Black women in London.

BACKGROUND: Women from ethnic minority backgrounds are less likely to attend cervical screening, but further understanding of ethnic inequalities in cervical screening uptake is yet to be established. This study aimed to explore the socio-demographic and ethnicity-related predictors of cervical cancer knowledge, cervical screening attendance and reasons for non-attendance among Black women in London. METHODS: A questionnaire was completed by women attending Black and ethnic hair and beauty specialists in London between February and April 2013. A stratified sampling frame was used to identify Black hair specialists in London subdivisions with >10% Black population (including UK and foreign-born). Fifty-nine salons participated. Knowledge of cervical cancer risk factors and symptoms, self-reported screening attendance and reasons for non-attendance at cervical screening were assessed. RESULTS: Questionnaires were completed by 937 Black women aged 18-78, describing themselves as being predominantly from African or Caribbean backgrounds (response rate 26.5%). Higher educational qualifications (p < .001) and being born in the UK (p = .011) were associated with greater risk factor knowledge. Older age was associated with greater symptom knowledge (p < .001). Being younger, single, African (compared to Caribbean) and attending religious services more frequently were associated with being overdue for screening. Women who had migrated to the UK more than 10 years ago were less likely to be overdue than those born in the UK. Of those overdue for screening who endorsed a barrier (67/133), 'I meant to go but didn't get round to it' (28%), fear of the test procedure (18%) and low risk perception (18%) were the most common barriers. CONCLUSIONS: Ethnicity, migration and religiosity play a role in predicting cervical screening attendance among women from Black backgrounds. African women, those born in the UK and those who regularly attend church are most likely to put off attending. Additional research is needed to explore the attitudes, experiences and beliefs that explain why these groups might differ.

Aeration of the abdominal wall for treatment of necrotising fasciitis.

A patient diagnosed with extensive abdominal wall necrotising fasciitis from a perianal abscess was managed with a novel aeration technique using adapted 36-French tubes. A total of 14 drains were placed in the plane of the transversalis fascia after surgical debridement. The drains were left open to allow drainage of liquefactive contents and aeration of the abdominal wall tissues. An extended course of intravenous antibiotics were administered and the patient was ventilated in the intensive therapy unit. The patient was reoperated after 2 weeks, at which time the drains were removed. The patient made a full recovery, and was discharged with follow-up.