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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_9 | Pages 11 - 11
16 May 2024
Kendal A Brown R Loizou C Rogers M Sharp R Carr A
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Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative foot deformity. The pathophysiology and key cells involved are not fully understood. This is partly because the dense collagen matrix that surrounds relatively few resident cells limits the ability of previous techniques to identify and target those cells of interest. In this study, we apply novel single cell RNA sequencing (CITE-Seq) techniques to healthy and tendinopathic foot/ankle tendons. For the first time we have identified multiple sub-populations of cells in human tendons. These findings challenge the view that there is a single principal tendon cell type and open new avenues for further study. Healthy tendon samples were obtained from patients undergoing tendon transfer procedures; including tibialis posterior and FHL. Diseased tendon samples were obtained during debridement of intractable Achilles and peroneal tendinopathy, and during fusion of degenerative joints. Single cell RNA sequencing with surface proteomic analysis identified 10 sub-populations of human tendon derived cells. These included groups expressing genes associated with fibro-adipogenic progenitors (FAPs) as well as ITGA7+VCAM1- recently described in mouse muscle but, as yet, not human tendon. In addition we have identified previously unrecognised sub-classes of collagen type 1 associated tendon cells. Each sub-class expresses a different set of extra-cellular matrix genes suggesting they each play a unique role in maintaining the structural integrity of normal tendon. Diseased tendon harboured a greater proportion of macrophages and cytotoxic lymphocytes than healthy tendon. This inflammatory response is potentially driven by resident tendon fibroblasts which show increased expression of pro-inflammatory cytokines. Finally, identification of a previously unknown sub-population of cells found predominantly in tendinopathic tissue offers new insight into the underlying pathophysiology. Further work aims to identify novel proteins targets for possible therapeutic pathways


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_13 | Pages 5 - 5
17 Jun 2024
Aamir J Caldwell R Karthikappallil D Tanaka H Elbannan M Mason L
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Background. Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Methods. A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures. Results. A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p<0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p<0.001), third metatarsal (37% vs 61%, p<0.001) and fourth metatarsal (26% vs 43%, p<0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusion. From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning


Bone & Joint Open
Vol. 4, Issue 3 | Pages 188 - 197
15 Mar 2023
Pearson NA Tutton E Gwilym SE Joeris A Grant R Keene DJ Haywood KL

Aims. To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery. Methods. We undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes. Results. From 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of ‘being the same but different’ conveyed the substantial disruption to patients’ self-identity caused by their injury. Patient experience of ‘being the same but different’ was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future. Conclusion. Ankle injuries were disruptive, draining, and impacted on patients’ wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients. Cite this article: Bone Jt Open 2023;4(3):188–197


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_11 | Pages 12 - 12
4 Jun 2024
Chapman J Choudhary Z Gupta S Airey G Mason L
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Introduction. Treatment pathways of 5. th. metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Primary objective. To investigate the reliability of assessment of subtypes of 5. th. metatarsal fractures by different observers. Methods. Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5. th. metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5. th. metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis & Koch's description. All data was analysed using IBM SPSS v.27. Results. 878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively). Conclusions. Reliability of sub-categorising 5. th. metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration


The Bone & Joint Journal
Vol. 105-B, Issue 9 | Pages 985 - 992
1 Sep 2023
Arshad Z Haq II Bhatia M

Aims

This scoping review aims to identify patient-related factors associated with a poorer outcome following total ankle arthroplasty (TAA).

Methods

A scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-based literature search was performed in PubMed, Embase, Cochrane trials, and Web of Science. Two reviewers independently performed title/abstract and full-text screening according to predetermined selection criteria. English-language original research studies reporting patient-related factors associated with a poorer outcome following TAA were included. Outcomes were defined as patient-reported outcome measures (PROMs), perioperative complications, and failure.


Bone & Joint Research
Vol. 13, Issue 7 | Pages 315 - 320
1 Jul 2024
Choi YH Kwon TH Choi JH Han HS Lee KM

Aims

Achilles tendon re-rupture (ATRR) poses a significant risk of postoperative complication, even after a successful initial surgical repair. This study aimed to identify risk factors associated with Achilles tendon re-rupture following operative fixation.

Methods

This retrospective cohort study analyzed a total of 43,287 patients from national health claims data spanning 2008 to 2018, focusing on patients who underwent surgical treatment for primary Achilles tendon rupture. Short-term ATRR was defined as cases that required revision surgery occurring between six weeks and one year after the initial surgical repair, while omitting cases with simultaneous infection or skin necrosis. Variables such as age, sex, the presence of Achilles tendinopathy, and comorbidities were systematically collected for the analysis. We employed multivariate stepwise logistic regression to identify potential risk factors associated with short-term ATRR.


The Bone & Joint Journal
Vol. 106-B, Issue 1 | Pages 46 - 52
1 Jan 2024
Hintermann B Peterhans U Susdorf R Horn Lang T Ruiz R Kvarda P

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

Methods

This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up.


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 475 - 481
1 May 2024
Lee M Lee G Lee K

Aims

The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan.

Methods

We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured.


Bone & Joint Open
Vol. 5, Issue 3 | Pages 227 - 235
18 Mar 2024
Su Y Wang Y Fang C Tu Y Chang C Kuan F Hsu K Shih C

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Methods

We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1249 - 1256
1 Nov 2024
Mangwani J Houchen-Wolloff L Malhotra K Booth S Smith A Teece L Mason LW

Aims

Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE.

Methods

This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE.


The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1127 - 1132
1 Jun 2021
Gray J Welck M Cullen NP Singh D

Aims

To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

Methods

We carried out a retrospective search of our records from 2000 to 2019 of patients seen in our adult tertiary referral foot and ankle unit with a diagnosis of functional dystonia.


Bone & Joint Open
Vol. 2, Issue 3 | Pages 150 - 163
1 Mar 2021
Flett L Adamson J Barron E Brealey S Corbacho B Costa ML Gedney G Giotakis N Hewitt C Hugill-Jones J Hukins D Keding A McDaid C Mitchell A Northgraves M O'Carroll G Parker A Scantlebury A Stobbart L Torgerson D Turner E Welch C Sharma H

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Methods

A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods.


Bone & Joint Open
Vol. 2, Issue 4 | Pages 216 - 226
1 Apr 2021
Mangwani J Malhotra K Houchen-Wolloff L Mason L

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Methods

This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_21 | Pages 39 - 39
1 Apr 2013
Bhamra J Khan W Hardingham T
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Introduction. Mesenchymal stem cells (MSCs) are a potential source of cells for the repair of articular cartilage and osteochondral defects (OCD) in the ankle. Synovial tissue has been shown to be a rich source of MSCs with the ability to undergo chondrogenic differentiation. Although these cells represent a heterogenous population, clonal populations have not been previously studied. Methods. MSCs were isolated from synovial tissue of a patient undergoing joint arthroplasty and expanded in culture. Six clonal populations were also isolated and expanded. The cells from the mixed parent population and the derived clonal populations were characterised for stem cell surface epitopes, and then cultured in chondrogenic mediums. Various assays were determined to analyse for features of differentiation. Results. Cells from the mixed parent population and the derived clonal populations stained strongly for markers of adult mesenchymal stem cells including CD44, CD90 and CD105, and they were negative for the haematopoietic marker CD34 and for the neural and myogenic marker CD56. Interestingly, a variable number of cells were also positive for the pericyte marker 3G5 both in the mixed parent and clonal populations. The clonal populations exhibited a variable chondrogenic response. Conclusion. Pericytes are a candidate stem cell in many tissues and our results show that all six clonal populations derived from the heterogenous synovium population express the pericyte marker 3G5. The chondrogenic potential of synovial tissue could be optimised by the identification of clonal populations with a propensity to differentiate down particular differentiation pathways. Our study demonstrates a role for MSCs in of osteochondral defects (OCDs) and areas of focal cartilage damage in the ankle joint


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 44 - 44
1 Sep 2012
Townshend D Ng P Wing K Penner M Younger A
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Introduction. Single photon emission computed tomography (SPECT) can be used to create a three dimensional image of a radiopharmaceutical bone scan. This combined with high resolution CT scan (SPECT-CT) with bone windows allows the linking of the information obtained in both investigations. The multiplanar anatomical information provided by CT is therefore linked with the functional, biological information of bone scintigraphy. The painful total ankle replacement has a number of potential causes of discomfort including impingement and loose components. Correct identification of the source of pain will assist surgeons in treating the source of the pain while avoiding unnecessary surgery. We present our experience of the use of SPECT-CT to investigate patients with ongoing pain following Total Ankle Replacement (TAR). Materials and Methods. A retrospective analysis of all patients having SPECT-CT for continuing pain following TAR. Scans were requested in addition to plain radiographs, joint aspiration and blood testing. Results: A total of 12 patients were identified. The scan proved helpful in all cases. 5 patients showed increased uptake around one or both prostheses signifying loosening which was not apparent on plain films. Gutter impingement was identified in 4 patients. One patient had a talo-navicular non-union, one patient demonstrated sub-talar joint arthrosis and one patient showed no bony abnormality but soft tissue impingement at arthroscopy. Discussion. SPECT-CT provides a useful adjunctive investigation in the work-up of the patient with ongoing pain in a TAR, particularly in the cases of component loosening where plain x-rays may be limited. The SPECT-CT assists in the correct anatomical localization of the pain and has assisted in identifying the correct surgical treatment. Disadvantages include cost and availability of scanners


Bone & Joint Research
Vol. 9, Issue 9 | Pages 613 - 622
1 Sep 2020
Perucca Orfei C Lovati AB Lugano G Viganò M Bottagisio M D’Arrigo D Sansone V Setti S de Girolamo L

Aims

In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy.

Methods

A total of 68 Sprague Dawley rats received a single injection of type I collagenase in Achilles tendons to induce the tendinopathy and then were daily exposed to PEMFs (1.5 mT and 75 Hz) for up to 14 days - starting 1, 7, or 15 days after the injection - to identify the best treatment option with respect to the phase of the disease. Then, 7 and 14 days of PEMF exposure were compared to identify the most effective protocol.


The Bone & Joint Journal
Vol. 102-B, Issue 12 | Pages 1689 - 1696
1 Dec 2020
Halai MM Pinsker E Mann MA Daniels TR

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

Methods

A matched cohort of patients similar for demographics and components used but differing in preoperative coronal-plane tibiotalar valgus deformity ≥ 15° (valgus, n = 50; 52% male, mean age 65.8 years (SD 10.3), mean body mass index (BMI) 29.4 (SD 5.2)) or < 15° (control, n = 50; 58% male, mean age 65.6 years (SD 9.8), mean BMI 28.7 (SD 4.2)), underwent TAA by one surgeon. Preoperative and postoperative radiographs, Ankle Osteoarthritis Scale (AOS) pain and disability and 36-item Short Form Health Survey (SF-36) version 2 scores were collected prospectively. Ancillary procedures, secondary procedures, and complications were recorded.


The Bone & Joint Journal
Vol. 101-B, Issue 3 | Pages 348 - 352
1 Mar 2019
Patel S Malhotra K Cullen NP Singh D Goldberg AJ Welck MJ

Aims

Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views.

Patients and Methods

A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation.


The Bone & Joint Journal
Vol. 101-B, Issue 5 | Pages 596 - 602
1 May 2019
El-Hawary A Kandil YR Ahmed M Elgeidi A El-Mowafi H

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Patients and Methods

We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44).


The Bone & Joint Journal
Vol. 101-B, Issue 2 | Pages 140 - 146
1 Feb 2019
Humphrey JA Woods A Robinson AHN

Aims

This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries.

Patients and Methods

In England, the Hospital Episode Statistics (HES) data are recorded annually. Between 2000/01 and 2016/17, the number of adults admitted to an English NHS hospital with a calcaneal fracture and whether they underwent surgical treatment was determined.