Extracorporeal shock wave treatment in foot and ankle fracture non-unions - A review.

BACKGROUND: The authors reviewed the current evidence and conducted a comprehensive review on the use of extracorporeal shock wave therapy (ESWT) in the treatment of foot and ankle fracture non-unions. METHODS: Four databases were searched to identify relevant studies in the available literature. RESULTS: Eight studies were reviewed, demonstrating union rates of 65%-100% and 90-100% at 3- and 6-months following ESWT treatment respectively. No major complications were seen in any of the studies. Minor complications included local soft tissue swelling, petechiae, bruising and pain. CONCLUSIONS: The literature that is currently available is limited to case series of relatively small sample sizes, highlighting the need for a prospective randomised controlled trial to further investigate the efficacy of ESWT in the treatment of foot and ankle fracture non-unions.

What Is the Best Method to Differentiate Acute Charcot Foot From Acute Infection?

RECOMMENDATION: Differentiation between acute Charcot neuroarthropathy (CN) and acute infection/osteomyelitis is complex and requires multiple (>1) diagnostic criteria. These criteria include an emphasis on the presence of neuropathy, history, and physical examination. The absence of skin wounds and resolution of swelling/erythema with elevation makes the likelihood of infection very low. In unclear cases, laboratory testing, histologic examination and culturing of bone specimens, scintigraphy, and imaging, especially magnetic resonance imaging (MRI), may be of benefit. LEVEL OF EVIDENCE: Moderate. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Does Revascularization Prior to Foot and Ankle Surgery Reduce the Incidence of Surgical Site Infection (SSI)?

RECOMMENDATION: Several studies support the effect of peripheral vascular disease (PVD) on wound healing and surgical site infection (SSI). Despite this, there have been no specific studies proving the beneficial effect of revascularization on SSI prior to operative intervention in the setting of traumatic or elective foot and ankle surgery. The majority of studies on revascularization are in the setting of diabetic foot infection or established ischemia. We recommend that in the presence of an inadequate vascularization in the foot and ankle, vascular optimization should be undertaken prior to elective surgery. LEVEL OF EVIDENCE: Limited. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Should Treatment of Diabetic Foot Osteomyelitis Be Based on Bone Biopsies?

RECOMMENDATION: Yes. Bone biopsies play both a crucial diagnostic and interventional role in the management of diabetic foot infection. Although bone biopsies are not required in every case of diabetic foot infection, their most important role is in guiding accurate antibiotic treatment, as they provide more accurate microbiological information than superficial soft tissue samples in patients with diabetic foot osteomyelitis. LEVEL OF EVIDENCE: Moderate. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Effectiveness of surgical fixation for lateral compression type one (LC-1) fragility fractures of the pelvis: a systematic review.

OBJECTIVES: To undertake a systematic review of the evidence base for the effectiveness of surgical fixation of lateral compression (LC-1) fragility fractures of the pelvis compared with non-surgical approaches. SEARCHES: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and two international trials registers were searched up to January 2017 (MEDLINE to February 2019) for studies of internal or external fixation of fragility fractures of the pelvis. PARTICIPANTS: Patients with lateral compression pelvic fractures, sustained as the result of a low-energy mechanism, defined as a fall from standing height or less. INTERVENTIONS: Surgery using either external or internal fixation devices. Conservative non-surgical treatment was the defined comparator. OUTCOME MEASURES: Outcomes of interest were patient mobility and function, pain, quality of life, fracture union, mortality, hospital length of stay and complications (additional operative procedures, number and type of adverse events and serious adverse events). QUALITY ASSESSMENT AND SYNTHESIS: The Joanna Briggs Institute Checklist for Case Series was used to assess the included studies. Results were presented in a narrative synthesis. RESULTS: Of 3421 records identified, four retrospective case series met the inclusion criteria. Fixation types were not consistent between studies or within studies and most patients had more than one type of pelvic fixation. Where reported, mobility and function improved post-surgery, and a reduction in pain was recorded. Length of hospital stay ranged from 4 days to 54 days for surgical fixation of any type. Reported complications and adverse outcomes included: infections, implant loosening, pneumonia and thrombosis. Use of analgesia was not reported. CONCLUSIONS: There is insufficient evidence to support guidance on the most effective treatment for patients who fail to mobilise after sustaining an LC-1 fragility fracture. TRIAL REGISTRATION NUMBER: CRD42017055872.

Pre-operative digital templating in cemented hip hemiarthroplasty for neck of femur fractures.

Pre-operative digital templating allows the surgeon to foresee any anatomical anomalies which may lead to intra-operative problems, and anticipate appropriate instruments and implants required during surgery. Although its role is well-established in successful elective total hip arthroplasty, little work has been done on its use in hip hemiarthroplasty in neck of femur fractures. We describe our initial experience of digital templating in 40 consecutive patients who have undergone cemented hip hemiarthroplasty, assessing templating accuracy between templated implant sizes to actual implant sizes. 81% of implanted heads were templated to within two head sizes, and 89% of implanted stems were templated to within two sizes. Although there was a moderately strong correlation of 0.52 between templated and actual head sizes, this correlation was not demonstrated in femoral stem sizes. Mean leg length discrepancy was -2.5mm (S.D. 8.5), and the mean difference in femoral offset between the operated and non-operated hip was -1mm (S.D. 4.4). Digital templating is a useful adjunct to the surgeon in pre-operative planning of hip hemiarthroplasty in the restoration of leg length and femoral offset. However, its accuracy is inferior to that of elective total hip arthroplasty.

Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? - A Systematic Review.

We undertook a systematic review of 11 randomised controlled trials comparing patient outcomes in total knee arthroplasty in those who had undergone pre-operative physiotherapy-based interventions against control groups. Results show that there is little evidence that pre-operative physiotherapy brings about significant improvements in patient outcome scores, lower limb strength, pain, range of movement and hospital length of stay following total knee arthroplasty. The overall quality of the studies was moderate to poor, mostly due to the small sample sizes.

Custom cementless THA in patients with Legg-Calve-Perthes Disease.

Legg-Calve-Perthes disease is characterized by osteonecrosis of the femoral head during childhood. Outcomes of total hip arthroplasty (THA) for these patients are less satisfactory than for those with primary osteoarthritis, often complicated by young patient age, multi-planar deformities and previous childhood surgery. To our knowledge no one has reported the long-term outcomes of cementless custom-made THA in patients with Legg-Calve-Perthes disease. We reviewed 15 THAs with an average follow-up of ten years. Survivorship rates of the femoral and acetabular components were 100% and 79% respectively. Mean Harris Hip Scores improved from 41 preoperatively to 80 at final follow-up. With excellent functional outcome, custom-made cementless prostheses should be considered as a treatment option for osteoarthritis secondary to Legg-Calve-Perthes disease in the presence of abnormal proximal femoral and acetabular anatomy.

Trilogy of gastrointestinal atresias: a case report and review of the literature.

This is a case report of a child with a rare combination of pyloric and colonic atresias, imperforate anus, hypoganglionosis of the rectum and sigmoid colon, unilateral multicystic dysplastic kidney, bilateral sensorineural deafness, spondyloepimetaphyseal dysplasia, subglottic stenosis, growth failure, and limb anomalies.

Assessing results after distal radius fracture treatment: a comparison of objective and subjective tools.

OBJECTIVES: Functional outcomes following distal radius fractures are directly influenced by the choice of outcome assessment instruments used. Our objective was to compare scoring systems in measuring patient functional outcomes and to determine which scoring system compared most favorably with the widely used Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. METHODS: In all, 108 patients between May 2004 and November 2006 were treated operatively following distal radius fractures. Follow-up was at 3 months, 6 months, 1 year, and 2 years postsurgery, during which anatomical and functional assessments were performed. Patient outcomes were recorded using DASH, Green and O'Brien system, Gartland and Werley system, and Sarmiento radiological scoring system. RESULTS: There was a stronger correlation between the Green and O'Brien scoring system and DASH (r = -.54) than Gartland and Werley and DASH (r = .44). The Green and O'Brien scoring system was more demanding so patients rated "excellent" or "good" had better functional outcome than those bearing the same grade in the Gartland and Werley system. Nonetheless, the Green and O'Brien score and Gartland and Werley score showed good correlation with each other (r = .66). The Sarmiento radiological score had no significant correlation with any of the other scoring systems. Significant predictors of the DASH score were function (r = .42), power grip (r = .41), pain (r = .37), and range of motion (r = .28). CONCLUSION: The Green and O'Brien scoring system correlated most strongly with the DASH score. Radiological scoring (reflecting anatomical deformity) was not significantly correlated with functional outcome. While subjective parameters "pain" and "function" are influenced by psychosocial factors and thus highly variable, it is paramount to include subjective tools in outcome assessment in future studies on wrist fractures.