OA pathophysiology has a vascular component consisting of venous stasis resulting in intraosseous hypertension and hypoxia. In response, osteoblasts change their cytokine expression, accelerating bone remodelling and cartilage breakdown consistent with OA. We have characterized circulatory kinetics in OA bone in animal models with dynamic contrast enhanced MRI (DCE-MRI) and ¹⁸F PET and have demonstrated venous stasis and reduced perfusion that temporally precede and spatially coincide with OA lesions. Osteoblast uptake of ¹⁸F is consistent with abnormal perfusion, bone remodelling, and severity of OA. Circulatory kinetics with DCE-MRI in humans with OA of the knee exhibit similar venous outflow obstruction. Venous stasis is associated with hypoxia in subchondral bone. As an example of the effects of hypoxia on OA osteoblasts, we have described upregulation of fibrinolytic peptides, but a deficiency in the upregulation of PAI-1, leading to the generation of plasmin by human OA osteoblasts exposed to hypoxia in vitro. Plasmin is a serine protease that has been shown to degrade cartilage in OA. Abnormal circulatory kinetics by DCE-MRI may be an imaging biomarker of OA. Pharmacologic modulation of venous stasis would have a salutary effect on the physicochemical microcirculation of subchondral osteoblasts and the pathophysiology of OA.

Introduction: Mönckeberg sclerosis or medial artery calcification (MAC) is a well known phenomenon associated with the diabetic and other altered blood parameters. However its consequence within the foot and specifically the 1st dorsal metatarsal artery has not previously been studied.

Materials and Methods: Nearly 1000 foot x-rays were studied over a nine month period in a busy District General Hospital to identify the prevalence of first dorsal metatarsal artery calcification. The electronic medical notes for all the patients were reviewed to confirm which patients were known to be diabetic. The patients with positive findings were then identified and their HbA1c, creatinine, and previous foot interventions recorded.

Results: 1.4% of the population studied had medial artery calcification of the 1st dorsal metatarsal artery. 93% were known diabetics and 100% had impaired glucose tolerance (a glucose plasma concentration of > 7.8mmol/l two hours post glucose loading). 79% have required previous podiatric care for foot ulceration and 64% had required surgical intervention for their diabetic feet. MAC has a high positive predictive value (92.9% (95% CI 69.2–98.7)) for diabetes, with a good specificity (99.9% (95%CI 99.4–100)) and low false positive rate (0.1% (05%CI 0.0–0.6)).

Discussion: Medial artery calcification in the first dorsal metatarsal artery is characteristic of impaired glucose metabolism, and if seen on routine x-ray should be an indication for screening of the patient. It should also be considered as a foot at risk sign in the established diabetic due to the high incidence of foot ulceration and need for surgical intervention in this group.

Conclusion: The prevalence of MAC seen on routine foot x-rays has been demonstrated in a large cohort of patients. The specificity and positive predictive value for diabetes has been calculated and the prevalence of these patients requiring surgical or specialist podiatric care recorded.

Introduction. Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal instability, and has an increased risk of ulceration leading to infection and amputation. However, surgical reconstruction may offer limb salvage and restauration of an ulcer-free, plantigrade stable foot for functional weight-bearing. We report on our case series according to a prospective protocol and analyse factors leading to a favourable outcome. Methods. We report a prospective follow-up of 62 patients undergoing Charcot reconstruction, May 2014- Jan 2022, by two surgeons. Peripheral vascular disease was routinely assessed using Duplex scan and major arterial disease was treated before reconstruction. Utilising 3D modelling, pre-operative planning and standardised osteotomies, we performed anatomical correction with radiological evidence. Definitive fixation was undertaken with internal fixation to stabilise the hindfoot. Multivariant analysis was performed to assess risk factors for failure (P>0.05 statistical significance). Results. 59 feet were included, 3 patients did not progress to definitive surgery and 3 patients had bilateral surgery. 62.7% patients were male with an average age of 56, 88.13% had Type 2 diabetes, 56% were hypertensive, 14% were on dialysis. Twenty (54.1%) single stage reconstructions had pre-operative ulceration, 3 pts had ischaemic heart disease and 36 pts had evidence of peripheral arterial disease. 81% of patients achieved normalisation of the 3 out of 4 anatomical angles (P<0.05). Two patients (3.1%) required metalwork removal for infection and limb salvage, 11 (18.6%) had delayed wound healing. Survivorship was 97% at 3yrs, and 94% at 6yrs, however if pre-existing vascular disease was present, it was 94% at 3yrs 85.3% at 6yrs. All patients were mobile at a 3 years mean follow up. Conclusion. Careful patient selection, multidisciplinary team and anatomic reconstruction led to predictable outcomes and functional limb salvage. Pre-operative vascular compromise led to a slight reduction in survivorship, but no major amputation

Background. Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below knee amputation; particularly in cases of severe soft tissue destruction. Aim. Assess the outcomes of combined ortho-plastics treatment of complex calcaneal osteomyelitis. Method. A retrospective review was performed of all patients who underwent combined single stage ortho-plastics treatment of calcaneal osteomyelitis (2008–2022). Primary outcome measures were osteomyelitis recurrence and BKA. Secondary outcome measures included flap failure, operative time, complications, length of stay. Results. 33 patients (16 female, 17 male, mean age = 54.4 years) underwent combined ortho-plastics surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (s.d. 24.3). 20 received a local flap, 13 received a free flap. Fracture-related infection (39%) and diabetic ulceration (33%) were the commonest causes. 54% of patients had already undergone at least one operation elsewhere. There were seven cases of recurrent osteomyelitis (21%); all in the local flap group. One patient required a BKA (3%). Recurrence was associated with increased mortality risk (OR 18.8 (95% CI 1.5–227.8), p=0.004) and reduced likelihood of walking independently (OR 0.14 (95% CI 0.02–0.86), p=0.042). Local flap reconstruction (OR 15 (95% CI 0.8–289.6), p=0.027) and peripheral vascular disease (OR 39.7 (95% CI 1.7–905.6), p=0.006) were associated with increased recurrence risk. Free flap reconstruction took significantly longer intra-operatively than local flaps (443 vs 174 minutes, p<0.001), but without significant differences in length of stay or frequency of out-patient appointments. Conclusions. Single stage ortho-plastic management was associated with 79% eradication of infection and 3% amputation in this complex and co-morbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. Whilst good outcomes can be achieved, this treatment requires high levels of in-patient and out-patient care

Aim. Calcaneal osteomyelitis remains a difficult condition to treat with high rates of recurrence and below knee amputation; particularly in cases of severe soft tissue destruction. This study assesses the outcomes of combined ortho-plastics treatment of complex calcaneal osteomyelitis. Method. A retrospective review was performed of all patients who underwent combined single stage ortho-plastics treatment of calcaneal osteomyelitis (2008- 2022). Primary outcome measures were osteomyelitis recurrence and BKA. Secondary outcome measures included flap failure, operative time, complications, length of stay. Results. 33 patients (16 female, 17 male, mean age = 54.4 years) underwent combined ortho-plastics surgical treatment for BACH “complex” calcaneal osteomyelitis with a median follow-up of 31 months (s.d. 24.3). 20 received a local flap, 13 received a free flap. Fracture-related infection (39%) and diabetic ulceration (33%) were the commonest causes. 54% of patients had already undergone at least one operation elsewhere. There were seven cases of recurrent osteomyelitis (21%); all in the local flap group. One patient required a BKA (3%). Recurrence was associated with increased mortality risk (OR 18.8 (95% CI 1.5–227.8), p=0.004) and reduced likelihood of walking independently (OR 0.14 (95% CI 0.02–0.86), p=0.042). Local flap reconstruction (OR 15 (95% CI 0.8–289.6), p=0.027) and peripheral vascular disease (OR 39.7 (95% CI 1.7–905.6), p=0.006) were associated with increased recurrence risk. Free flap reconstruction took significantly longer intra-operatively than local flaps (443 vs 174 minutes, p<0.001), but without significant differences in length of stay or frequency of out-patient appointments. Conclusions. Single stage ortho-plastic management was associated with 79% eradication of infection and 3% amputation in this complex and co-morbid patient group. Risk factors for failure were peripheral vascular disease and local flap reconstruction. Whilst good outcomes can be achieved, this treatment requires high levels of in-patient and out-patient care

Aims. The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome. Methods. A retrospective review was performed of consecutive patients treated for HA PJI at a tertiary referral centre with a mean 4.5 years’ follow-up (1.6 weeks to 12.9 years). Surgeries performed included debridement, antibiotics, and implant retention (DAIR) and single-stage revision. The effect of different factors on developing infection and treatment outcome was determined. Results. A total of 1,984 HAs were performed during the study period, and 44 sustained a PJI (2.2%). Multiple logistic regression analysis revealed that a higher CCI score (odds ratio (OR) 1.56 (95% confidence interval (CI) 1.117 to 2.187); p = 0.003), peripheral vascular disease (OR 11.34 (95% CI 1.897 to 67.810); p = 0.008), cerebrovascular disease (OR 65.32 (95% CI 22.783 to 187.278); p < 0.001), diabetes (OR 4.82 (95% CI 1.903 to 12.218); p < 0.001), moderate-to-severe renal disease (OR 5.84 (95% CI 1.116 to 30.589); p = 0.037), cancer without metastasis (OR 6.42 (95% CI 1.643 to 25.006); p = 0.007), and metastatic solid tumour (OR 15.64 (95% CI 1.499 to 163.087); p = 0.022) were associated with increasing PJI risk. Upon final follow-up, 17 patients (38.6%) failed initial treatment and required further surgery for HA PJI. One-year mortality was 22.7%. Factors associated with treatment outcome included lower preoperative Hgb level (97.9 g/l (SD 11.4) vs 107.0 g/l (SD 16.1); p = 0.009), elevated CRP level (99.1 mg/l (SD 63.4) vs 56.6 mg/l (SD 47.1); p = 0.030), and type of surgery. There was lower chance of success with DAIR (42.3%) compared to revision HA (66.7%) or revision with conversion to total hip arthroplasty (100%). Early-onset PJI (≤ six weeks) was associated with a higher likelihood of treatment failure (OR 3.5 (95% CI 1.2 to 10.6); p = 0.007) along with patients treated by a non-arthroplasty surgeon (OR 2.5 (95% CI 1.2 to 5.3); p = 0.014). Conclusion. HA PJI initially treated with DAIR is associated with poor chances of success and its value is limited. We strongly recommend consideration of a single-stage revision arthroplasty with cemented components. Cite this article: Bone Jt Open 2022;3(12):924–932

The pathophysiological basis of alterations in trabecular bone of patients with osteonecrosis of the femoral head (ONFH) remains unclear. ONFH has classically been considered a vascular disease with secondary changes in the subchondral bone. However, there is increasing evidence suggesting that ONFH could be a bone disease, since alterations in the functionality of bone tissue distant from the necrotic lesion have been observed. We comparatively studied the transcriptomic profile of trabecular bone obtained from the intertrochanteric region of patients with ONFH without an obvious aetiological factor, and patients with osteoarthritis (OA) undergoing total hip replacement in our Institution. To explore the biological processes that could be affected by ONFH, we compared the transcriptomic profile of trabecular bone from the intertrochanteric region and the femoral head of patients affected by this condition. Differential gene expression was studied using an Affymetrix microarray platform. Transcriptome analysis showed a differential signature in trabecular bone from the intertrochanteric region between patients with ONFH and those with OA. The gene ontology analyses of the genes overexpressed in bone tissue of patients with ONFH revealed a range of enriched biological processes related to cell adhesion and migration and angiogenesis. In contrast, most downregulated transcripts were involved in cell division. Trabecular bone in the intertrochanteric region and in the femoral head also exhibited a differential expression profile. Among the genes differentially expressed, we highlighted those related with cytokine production and immune response. This study identified a set of differently expressed genes in trabecular bone of patients with idiopathic ONFH, which might underlie the pathophysiology of this condition. Acknowledgements: This work was supported by grants PI18/00643 and PI22/00939 from ISCIII-FEDER, Ministerio de Ciencia, Innovación y Universidades (MICINN)-AES

Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery. Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery. Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41). Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remain a challenge. A novel surgical technique named Tibial Cortex Transverse Transport has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In present study, we aimed to explore the wound healing effects after undergoing this novel technique via multiple ways. A novel rat model of Tibial Cortex Transverse Transport was established with a designed external fixator and effects on wound healing were investigated. All rats were randomized into 3 groups, with 12 rats per group: sham group (negative control), fixator group (positive control) and Tibial Cortex Transverse Transport group. Laser speckle perfusion imaging, vessel perfusion, histology and immunohistochemistry were used to evaluate the wound healing processes. Gross and histological examinations showed that Tibial Cortex Transverse Transport technique accelerated wound closure and enhanced the quality of the newly formed skin tissues. In Tibial Cortex Transverse Transport group, HE staining demonstrated a better epidermis and dermis recovery, while immune-histochemical staining showed that Tibial Cortex Transverse Transport technique promoted local collagen deposition. Tibial Cortex Transverse Transport technique also benefited to angiogenesis and immunomodulation. In Tibial Cortex Transverse Transport group, blood flow in the wound area was higher than that ofother groups according to laser speckle imaging with more blood vessels observed. Enhanced neovascularization was seen in the Tibial Cortex Transverse Transport group with double immune-labelling of CD31 and α-SMA. The M2 macrophages at the wound site in the Tibial Cortex Transverse Transport group was also increased. Tibial cortex transverse transport technique accelerated wound healing through enhanced angiogenesis and immunomodulation

Aim. Knee arthrodesis (KA) and above knee amputation (AKA) have been used for salvage of failed total knee arthroplasty (TKA) in the setting of periprosthetic joint infection (PJI). The factors that lead to a failed fusion and progression to AKA are not well understood. The purpose of our study was to determine factors associated with failure of a staged fusion for PJI and predictive of progression to AKA. Method. We retrospectively reviewed a single-surgeon series of failed TKA for PJI treated with two-stage KA between 2000 and 2016 with minimum 2-year follow-up. Patient demographics, comorbidities, surgical history, tissue compromise, and radiographic data were recorded. Outcomes were additional surgery, delayed union, Visual Analog Pain scale (VAS) and Western Ontario and McMaster Activity score (WOMAC). No power analysis was performed for this retrospective study. Medians are reported as data were not normally distributed. Results. Fifty-one knees underwent fusion with median follow-up of 7 years (interquartile range (IQR) of 2–18 years). Median age was 71 years old (IQR 47 – 98), with a M:F ratio of 23:28. Median BMI was 34.3 kg/m2 (IQR 17.9–61). Infection was eradicated in 47 knees (92.2%); 24 knees (47.0%) required no additional surgery. 41 patients (83.6%) remained ambulatory after knee fusion, with 21% of these patients (10 total) requiring no ambulatory assistive device. Median VAS following arthrodesis was 4.6 (range 0–10). Median WOMAC was 36.2 (range 9–86). Three TKAs (5.9%) underwent AKA for overwhelming infection. Predictors of AKA were chronic kidney disease (OR 4.0, 95% CI 0.6–26.8), peripheral vascular disease (OR 3.5, 95% CI 0.3–44.7), AORI III bone loss (OR 2.6, 95% CI 0.4–35.2), instability (OR 2.2, 95% CI 0.2–15.9), and immunosuppression (OR 1.1, 95% CI 0.1–7.8). Tobacco use (OR 8.6, 95%CI 2.4–31.4), BMI>25 (OR 3.8, 95% CI 0.43–32.5) and instability prior to arthrodesis (OR 2.51, 95% CI 0.77–8.21) were associated with non-union. All other risk factors (gender, diabetes mellitus, chronic kidney disease, peripheral vascular disease, massive bone stock loss, and immunosuppression) were not associated with arthrodesis failure. Conclusions. Staged KA for PJI in severely compromised hosts provides a functional limb free of infection and rarely results in conversion to AKA. Given our small sample size, ability to establish statistical significance of predictive factors for AKA after PJI was limited, but CKD, peripheral vascular disease, AORI III bone loss, instability, and immunosuppression trended towards significance as predictors of failure of KA after PJI predisposing to AKA

Introduction. Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail. Materials & Methods. A retrospective cohort study was performed based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiological and clinical outcomes, and adverse events. Factors influencing radiological and clinical outcomes were analysed. Results. 47 patients were included, with a mean follow-up of three years. The mean age at time of surgery was 63.6 years. Patients had a median of two previous surgeries. The median LOS was 8.5 days, and median EFT was 237 days. Where simultaneous limb lengthening was performed, the average lengthening was 2.9cm, increasing the EFT by an average of 4 months. Primary and final union rates were 91.5% and 95.7% respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and re-operations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. Conclusions. Complex ankle fusion using circular frames can achieve good outcomes in complicated clinical scenarios, however patients can expect a prolonged time in the frame and high rates of adverse events. Multiple risk factors were identified for poorer outcomes, which should be considered in patient counselling and prognostication

Introduction. Surgical reconstruction of deformed Charcot feet carries high risk of non-union, metalwork failure and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. Methods. We retrospectively analysed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between 2007 and 2019 in our unit. Patient demographics, co-morbidities, weightbearing status and post-operative complications were noted. Metalwork breakage, non-union, deformity recurrence, concurrent midfoot reconstruction and the measurements related to intramedullary nail were also recorded. Results. There were 70 patients with mean follow up of 50±26 months. Seventy-two percent were fully weightbearing at 1 year post-operatively. The overall union rate was 83%. Age, BMI, HbA1c and peripheral vascular disease did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the non-united group (0.90±0.06 and 0.86±0.09, respectively; p = 0.03). Supplemental compression devices were used for 33% of those in the united compared to 8% in the non-united group (p = 0.04). All patients in the non-union group did not have a miss-a-nail screw. Metalwork failure was seen in 13 patients(19%). There was a significantly greater distal screw metalwork failure in those with supplementary bridging of tibia to midfoot (23% vs. 3%; p = 0.001). An intact medial malleolus was found more frequently in those with intact metalwork (77% vs. 54%, respectively; p = 0.02) and those with union (76% vs. 50%; p = 0.02). Broken metalwork occurred more frequently in patients with non-unions (69% vs. 8%; p < 0.001) and deformity recurrence (69% vs. 9%; p < 0.001). Conclusion. Satisfactory clinical and radiographic outcomes occur in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail, supplementary compression and miss-a-nail screws. An intact medial malleolus is protective against non-union and metalwork failure. Broken metalwork is linked to deformity recurrence and non-union

Tourniquet use in total knee arthroplasty (TKA) remains a subject of considerable debate. A recent study questioned the need for tourniquets based on associated risks. However, the study omitted analysis of crucial tourniquet-related parameters which have been demonstrated in numerous studies to be associated with safe tourniquet use and reduction of adverse events. The current utilization and preferences of tourniquet use in Canada remain unknown. Our primary aim was to determine the current practices, patterns of use, and opinions of tourniquet use in TKA among members of the Canadian Arthroplasty Society (CAS). Additionally, we sought to determine the need for updated best practice guidelines to inform optimal tourniquet use and to identify areas requiring further research. A self-administered survey was emailed to members of the CAS in October 2021(six-week period). The response rate was 57% (91/161). Skip logic branching was used to administer a maximum of 59 questions related to tourniquet use, beliefs, and practices. All respondents were staff surgeons and 88% were arthroplasty fellowship trained. Sixty-five percent have been in practice for ≥11 years and only 16% for 50 TKA/year, 59% have an academic practice, and >67% prefer cemented TKA. Sixty-six percent currently use tourniquets, 25% no longer do but previously did, and 9% never used tourniquets. For those not using tourniquets, the most common reasons are potential harm/risks and publications/conferences. Among current users, 48% use in all cases and an additional 37% use in 76-99% of cases. The top reason for use was improved visualization/bloodless field (88%), followed by performing a cemented TKA, used in training, and faster operative times. The main patient factor influencing selective tourniquet use was peripheral vascular disease and main surgical factors were operative duration and cementless TKA. The most frequent adverse events reported were bruising/pinching under the tourniquet and short-term pain, which majority believed were related to improper tourniquet use (prolonged time, high-pressures, poor cuff fit), yet only 8% use contoured tourniquets and 32% don't use limb protection. Despite substantial evidence in literature that tourniquet safety and probability of harm are affected by tourniquet time and pressure, only 83% and 72% of respondents believe reducing tourniquet time and pressure respectively reduce the probability of harm. In addition, no surgeon utilizes personalized limb occlusion pressure which has been demonstrated to substantially reduce tourniquet pressure while being safe and effective. Furthermore, 62% always use fixed pressure and 37% will modify the pressure based on patient parameters, most often systolic blood pressure and limb size. Almost all (88%) were interested in new evidence-based guidelines regarding these parameters. Tourniquet use in TKA remains prevalent among arthroplasty surgeons in the CAS; however tremendous practice variability regarding several key parameters required for optimal use exists. Current best practices of tourniquet use regarding personalized pressures, time, and type are not being utilized across Canada. There is considerable interest and need for further research and updated guidelines regarding key parameters of safe tourniquet usage to optimize tourniquet use in TKA

Diabetes mellitus is a risk factor for complications after operative management of ankle fractures. Generally, diabetic sequelae such as neuropathy and nephropathy portend greater risk; however, the degree of risk resulting from these patient factors is poorly defined. We sought to evaluate the effects of the diabetic sequelae of neuropathy, chronic kidney disease (CKD), and peripheral vascular disease (PVD) on the risk of complications following operative management of ankle fractures. Using a national claims-based database we analyzed patients who had undergone operative management of an ankle fracture and who remained active in the database for at least two years thereafter. Patients were divided into two cohorts, those with a diagnosis of diabetes and those without. Each cohort was further stratified into five groups: neuropathy, CKD, PVD, multiple sequelae, and no sequelae. The multiple sequelae group included patients with more than one of the three sequelae of interest: CKD, PVD and neuropathy. Postoperative complications were queried for two years following surgery. The main complications of interested were: deep vein thrombosis (DVT), surgical site infection, hospital readmission within 90 days, revision internal fixation, conversion to ankle fusion, and below knee amputation (BKA). We identified 210,069 patients who underwent operative ankle fracture treatment; 174,803 had no history of diabetes, and 35,266 were diabetic. The diabetic cohort was subdivided as follows: 7,506 without identified sequelae, 8,994 neuropathy, 4,961 CKD, 1,498 PVD, and 12,307 with multiple sequelae. Compared to non-diabetics, diabetics without sequelae had significantly higher odds of DVT, infection, readmission, revision internal fixation and conversion to ankle fusion (OR range 1.21 – 1.58, p values range Compared to uncomplicated diabetics, diabetics with neuropathy alone and diabetics with multiple sequelae were found to have significantly higher odds of all complications (OR range 1.18 – 31.94, p values range < 0.001 - 0.034). Diabetics with CKD were found to have significantly higher odds of DVT, readmission, and BKA (OR range 1.34 – 4.28, p values range < 0.001 - 0.002). Finally, diabetics with PVD were found to have significantly higher odds of DVT, readmission, conversion to ankle fusion, and BKA (OR range 1.62 - 9.69, p values range < 0.001 - 0.039). Diabetic patients with sequelae of neuropathy, CKD or PVD generally had higher complication rates than diabetic patients without these diagnoses. Unsurprisingly, diabetic patients with multiple sequalae are at the highest risk of complications and had the highest odds ratios of all complications. While neuropathy is known to be associated with postoperative complications, our analysis demonstrates that CKD represents a significant risk factor for multiple complications following the operative management of ankle fractures and has rarely been discussed in prior studies

Aims. Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remains a challenge. A novel surgical technique named ‘tibial cortex transverse transport’ (TTT) has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In the present study, we explored the potential biological mechanisms of TTT surgery using various techniques in a rat TTT animal model. Methods. A novel rat model of TTT was established with a designed external fixator, and effects on wound healing were investigated. Laser speckle perfusion imaging, vessel perfusion, histology, and immunohistochemistry were used to evaluate the wound healing processes. Results. Gross and histological examinations showed that TTT technique accelerated wound closure and enhanced the quality of the newly formed skin tissues. In the TTT group, haematoxylin and eosin (H&E) staining demonstrated a better epidermis and dermis recovery, while immunohistochemical staining showed that TTT technique promoted local collagen deposition. The TTT technique also benefited to angiogenesis and immunomodulation. In the TTT group, blood flow in the wound area was higher than that of other groups according to laser speckle imaging with more blood vessels observed. Enhanced neovascularization was seen in the TTT group with double immune-labelling of CD31 and α-Smooth Muscle Actin (α-SMA). The number of M2 macrophages at the wound site in the TTT group was also increased. Conclusion. The TTT technique accelerated wound healing through enhanced angiogenesis and immunomodulation. Cite this article: Bone Joint Res 2022;11(4):189–199

The burden of hospital length of stay (LOS) and readmissions for total hip arthroplasty (THA) patients has resulted in great scrutiny. The purpose of this study was to determine our patients' LOS and hospital readmissions over the past 7 years. The second purpose was to determine what comorbidities affected the LOS and readmissions of 1440 THA patients. 1440 THA patients were retrospectively reviewed. The group included 622 males, 818 females. The average age of the cohort was 60 years (12 to 94 years). Ninety-day hospital readmissions were measured for the patients. Fisher's exact test, independent Sample t-test and Spearman correlation coefficients were used to determine associations of patient characteristics and comorbidities with readmission status and LOS with comorbidity status. The LOS decreased over the time of the study (p=0.02), however; readmissions remained constant at approximately 6% (p=0.73). The mean LOS for patients not readmitted was significantly shorter than for those readmitted (3.2 vs. 4.4 days; p=0.0003). Comorbidities associated with a longer hospital stay included diabetes (p=0.0052), hypertension (p=0.04), coronary artery disease (p=0.0034), congestive heart failure (p=0.0012), peripheral vascular disease (p=0.015), chronic obstructive pulmonary disease (p=0.016), renal disease (p=0.009), and mental illness (p=0.03). Increased body mass index (BMI) was not associated with a significant increase in LOS (r=0.01, p=0.83). Increased readmission rates were associated with comorbidities including hypertension (p=<0.0001), coronary artery disease (p=<0.0001), congestive heart failure (p=0.0007), peripheral vascular disease (p=<0.0001), chronic obstructive pulmonary disease (p=0.003), asthma (p=0.0128), renal disease (p=0.0001), and mental illness (p=0.0147). Obesity was not associated with increased readmission rates until the patients were morbidly obese (>40 BMI; p=0.03). Although the LOS decreased over the time of the study, this did not result in an adverse increase in readmission rates. Several comorbidities including hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and mental illness were all associated with both a longer LOS and an increase in readmission rates. Asthma was associated with increased readmission rates only and diabetes was associated with an increased LOS only. BMI was not associated with readmission rates unless the BMI exceeded 40 and had no significant effect on LOS at any BMI level

Abstract. Objectives. Currently, the golden standard for the management of ankle fractures is open reduction and internal fixation (ORIF), a procedure which preserves joint anatomy and function. However, ORIF is associated with high risk of infection, especially in the elderly population, who tend to suffer from osteoporosis and vascular disease. Studies recommend hindfoot nailing (HFN) as a safe and efficient management alternative for this demographic. Unlike ORIF, HFN allows immediate weight-bearing, which has been linked to a lower rate of complications. This study aims to evaluate the outcomes of hindfoot nailing in ankle fractures using a case series of 43 patients. Methods. This is a retrospective study with a sample size of 43 patients, that have a mean age of 77.3 years and several medical conditions. These patients experienced ankle fractures that were treated with HFN. Data collected included injury patterns, operative complications, rate of radiological union, comorbidities and changes in mobility and housing before and after surgery. Results. Before their fracture, 62.8% of patients mobilised using a walking stick or a wheeled frame. Following surgery, 52.4% experienced decreased level of mobility. 50% of patients achieved radiological union at the time of data analysis, whereas 52.4% of patients reported a post-operative complication, most commonly soft tissue or bone infection. Conclusions. Our study has a large sample size compared to previous research. The follow-up period varies depending on patient attendance to follow-up clinical appointments. Our patient cohort exhibits significantly lower rates of radiological union, higher incidence of complications and poor post-operative functional outcomes associated with HFN. These data contradict previous studies suggesting HFN for the surgical management of ankle fractures in the elderly and frail population and demonstrate that a more thorough evaluation of HFN is needed

Introduction. Open fractures are fortunately rare but pose an even greater challenge due to poor soft tissues, in addition to poor bone quality. Co-morbidities and pre-existing medical conditions, in particular, peripheral vascular diseases make them often unsuitable for free flaps. We present our experience in treating severe open fractures of tibia with Acute Intentional Deformation (AID) to close the soft tissues followed by gradual correction of deformity to achieve anatomical alignment of the tibia and fracture healing with Taylor Spatial Frame. Materials and Methods. We treated 4 geriatric (3 female and 1 male) patients with Gustillo-Anderson III B fractures of the tibia between 2017–18. All were unfit to undergo orthoplastic procedures (free flap or local flaps). The age range is 69 yrs to 92 years. Co-morbidities included severe rheumatoid arthritis, multiple sclerosis and heart failure. The procedure involved wound debridement, application of two ring Taylor Spatial Frame, acute deformation of the limb on the table to achieve soft-tissue closure/approximation. Regular neurovascular assessments were performed in the immediate post-operative period to monitor for compartment syndrome and nerve compression symptoms. After 7–10 days of latent period, the frame was gradually manipulated, according to a method we had previously published, to achieve anatomical alignment. The frame was removed in clinic after fracture healing. Results. Time in frame ranged from 1.5 months to 7 months. In one patient (92 yr old with an open fracture of the ankle) hindfoot nail was inserted after soft-tissue closure was achieved at 1.5 months, and frame removed. We achieved complete healing of soft tissue wounds without any input from plastic surgeons in all patients. All fractures healed in anatomical alignment. 3 patients had one episode of superficial pin infection each requiring 5 days of oral antibiotics. None of the patients developed a deep infection. Conclusions. Acute intentional deformation (AID) with Taylor Spatial Frame achieves good closure of soft tissues in physiologically compromised geriatric patients who were deemed unfit for plastic surgery. We also achieved fracture healing in all four cases without any major complications

Aims: The aims of this study were to 1) determine if vacuum assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, 2) if it helps debride wounds and 3) if it prevents the need for further surgery. Materials and Methods: 15 patients were reviewed, average age 49.3yrs at an average of 6.3 months (1–18months). Ten patients had diabetes (8 IDDM) with 5 patients having grade 3 ulcers (Wagner-Meggitt). All wounds were surgically debrided prior to the application of the VAC therapy. The VAC therapy was applied according to the manufacturers instrucrtions. The main outcome measures were 1) time to satisfactory wound closure 2) change in the wound surface area and 3) need for further surgery. Results: Satisfactory healing was achieved in 11 patients (73.3%). 10 were diabetic, 5 patients had peripheral vascular disease and 5 patients had both. The time to satisfactory healing was 2.5 months, average 1–6 months. The average size of the wound ulcer was 7.41cm2 (2–10cm2) prior to treatment and 1.58cm2 (0–2cm2) following treatment in an average of 2.5 months. VAC therapy helped debride all non healing wounds following surgical debridement. In 10 patients, the need for further radical surgery, namely amputation, was avoided. Conclusion: VAC therapy is a useful adjunct to the standard treatment of chronic wound /ulcers in patients with diabetes with or without periphearl vascular disease. Its use in foot and ankle surgery leads to a quick wound closure and in some cases avoids the need for further surgery with a potential for limb salvage

The February 2013 Spine Roundup. 360 . looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses