The aim of this study was to evaluate the long-term outcomes of patients who had sustained an unstable ankle fracture with a posterior malleolus fracture (PMF) and without (N-PMF).

Adult patients presenting to a single academic trauma centre in Edinburgh, UK, between 2009 and 2012 with an unstable ankle fracture requiring surgery were identified. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary measures included Euroqol-5D-3L Index (Eq5D3L), Euroqol-5D-VAS and Manchester Oxford Foot Questionnaire (MOXFQ).

There were 304 patients in the study cohort. The mean age was 49.6 years (16.3–78.3) and 33% (n=100) male and 67% (n=204) female. Of these, 67% (n=204) had a PMF and 33% did not (n=100). No patient received a computed tomography (CT) scan pre-operatively. Only 10% of PMFs (22/204) were managed with internal fixation. At a mean of 13.8 years (11.3 – 15.3) the median OMAS score was 85 (Interquartile Range 60 – 100). There was no difference in OMAS between the N-PMF and PMF groups (85 [56.25 – 100] vs 85 [61.25 – 100]; p = 0.580). There was also no difference for MOXFQ (N-PMF 7 [0 – 36.75] vs PMF 8 [0–38.75]; p = 0.643), the EQ5D Index (N-PMF 0.8 [0.7 – 1] vs PMF 0.8 [0.7 – 1]; p = 0.720) and EQ5D VAS (N-PMF 80 [70 – 90] vs PMF 80 [60 – 90]; p = 0.224).

The presence of a PMF does not affect the long-term patient reported outcomes in patients with a surgically managed unstable ankle fracture.

Background

Undisplaced Lisfranc-type injuries are subtle but potentially unstable fracture-dislocations with little known about the natural history. These injuries are often initially managed conservatively due to lack of initial displacement and uncertainty regarding subsequent instability at the tarsometatarsal joints (TMTJ). The aim of this study was to determine the secondary displacement rate and the need for delayed operative intervention in undisplaced Lisfranc injuries that were managed conservatively at initial presentation.

Abstract

Abstract

Abstract

Abstract

Early changes within articular cartilage during human idiopathic osteoarthritis are poorly understood. However alterations to chondrocyte morphology occur with the development of fine cytoplasmic processes and cell clusters, potentially playing a role in cartilage degeneration. The aggrecanase ADAMTS-4 (A disintegrin and metalloproteinase with thrombospondin motifs-4) has been implicated as an important factor in cartilage degradation, so we investigated the relationship between chondrocyte morphology and levels of ADAMTS-4 in both non-degenerate and mildly osteoarthritic human cartilage.

Human femoral heads were obtained following consent from patients undergoing hip arthroplasty following femoral neck fracture. Cartilage explants of normal (grade 0; G0) and mildly osteoarthritic (grade 1; G1) cartilage were labelled with the cytoplasmic dye CMFDA (5-chloromethylfluorescein-diacetate). Explants were cryosectioned (30μm sections), and labelled for ADAMTS-4 by fluorescence immunohistochemistry. Sections were imaged with confocal microscopy, allowing the semi-quantitative analysis of ADAMTS-4 and 3D visualisation of in situ cell morphology.

With cartilage degeneration from G0 to G1, there was a decrease in the proportion of chondrocytes with normal rounded morphology (P<0.001) but an increase in the proportion of cells with processes (P<0.01) and those in clusters (P<0.001;[4(1653)]; femoral heads:cells). Although average levels of ADAMTS-4 for all cells was the same between G0 and G1 (P>0.05), a change was evident in the distribution curves for cell-specific ADAMTS-4 labelling. Cell-by-cell analysis showed that ADAMTS-4 levels were higher in chondrocytes with cytoplasmic processes compared to normal cells (P=0.044) however cells in clusters had lower levels than normal cells (P=0.003;[3(436)]). Preliminary data suggested that ADAMTS-4 levels increased with larger chondrocyte clusters.

These results suggest complex heterogeneous changes to levels of cell-associated ADAMTS-4 with early cartilage degeneration – increasing in cells with processes and initially decreasing in clusters. Increased levels of ADAMTS-4 are likely to produce focal areas of matrix weakness potentially leading to early cartilage degeneration.

Determine the infection risk of nonoperative versus operative repair of extraperitoneal bladder ruptures in patients with pelvic ring injuries. Pelvic ring injuries with extraperitoneal bladder ruptures were identified from a prospective trauma registry at two level 1 trauma centers from 2014 to 2020. Patients, injuries, treatments, and complications were reviewed. Using Fisher's exact test with significance at P value < 0.05, associations between injury treatment and outcomes were determined.

Of the 1127 patients with pelvic ring injuries, 68 (6%) had a concomitant extraperitoneal bladder rupture.

All patients received IV antibiotics for an average of 2.5 days. A suprapubic catheter was placed in 4 patients. Bladder repairs were performed in 55 (81%) patients, 28 of those simultaneous with ORIF anterior pelvic ring. The other 27 bladder repair patients underwent initial ex-lap with bladder repair and on average had pelvic fixation 2.2 days later. Nonoperative management of bladder rupture with prolonged Foley catheterization was used in 13 patients. Improved fracture reduction was noted in the ORIF cohort compared to the closed reduction external fixation cohort (P = 0.04).

There were 5 (7%) deep infections. Deep infection was associated with nonoperative management of bladder rupture (P = 0.003) and use of a suprapubic catheter (P = 0.02). Not repairing the bladder increased odds of infection 17-fold compared to repair (OR 16.9, 95% CI 1.75 – 164, P = 0.01).

Operative repair of extraperitoneal bladder ruptures substantially decreases risk of infection in patients with pelvic ring injuries. ORIF of anterior pelvic ring does not increase risk of infection and results in better reductions compared to closed reduction. Suprapubic catheters should be avoided if possible due to increased infection risk later. Treatment algorithms for pelvic ring injuries with extraperitoneal bladder ruptures should recommend early bladder repair and emphasize anterior pelvic ORIF.

The development of cytoplasmic processes from in situ chondrocytes is a characteristic feature of early osteoarthritis in human cartilage. The processes involve cytoskeletal elements and are distinct from the short primary cilia described in human chondrocytes. Vimentin is an intermediate filament playing an essential structural and signal-transduction role. We determined cellular levels and distribution of vimentin in chondrocytes of different morphologies in non-degenerate and mildly osteoarthritic cartilage.

Femoral heads were obtained after consent from patients undergoing hip arthroplasty following femoral neck fracture. Cartilage explants were graded as non-degenerate (grade 0;G0) or mildly osteoarthritic (grade 1;G1) and labelled with the cytoplasmic dye CMFDA (5-chloromethylfluorescein-diacetate) for cell shape. Explants were cryosectioned and labelled for vimentin by fluorescence immunohistochemistry. In situ chondrocyte morphology was identified by confocal microscopy as either normal (rounded/elliptical) or abnormal (with one or more cytoplasmic process of ≥2µm) and vimentin levels and distribution determined semi-quantitatively and related to chondrocyte morphology.

When all cells in G0 and G1 cartilage were compared, there was no difference between average levels of vimentin per cell (P=0.144)[6(261)];femoral heads:cells). When cells were separated on the basis of morphology, there was no difference between vimentin levels in cells with one or more cytoplasmic process compared to those of normal morphology (P>0.05;[6(261)]). However vimentin levels were much greater at the base of cytoplasmic processes compared to distant areas of the same cells (P=0.021)[5(29)]).

Although overall levels of chondrocyte vimentin do not change in these early stages of osteoarthritis, the formation and structure of these substantial chondrocyte cytoplasmic processes involves changes to its distribution. These morphological changes are similar to those occurring during chondrocyte de-differentiation to fibroblasts reported in osteoarthritis which results in the formation of mechanically-inferior fibro-cartilage. Alterations to chondrocyte vimentin distribution either directly or indirectly may play a role in cartilage degeneration.

Cartilage degeneration and loss are key events in the initiation and progression of osteoarthritis (OA). Changes to chondrocyte volume and morphology (in the form of cytoplasmic processes) and thus cell phenotype are implicated, as they lead to the production of a mechanically-weakened extracellular matrix. The chondrocyte cytoskeleton is intimately linked to cell volume and morphology and hence we have investigated alterations to levels and distribution of chondrocyte F-actin that occur during early OA.

The femoral heads (FH) from hip joints (N=16) were obtained with ethical permission and patient consent following femoral neck fracture. Cartilage was assessed as grade 0 (non-degenerate) and grade 1 (superficial fibrillation) using OARSI criteria. In situ chondrocyte volume and F-actin distribution were assessed using the fluorescent indicators (5-chloromethyl fluorescein diacetate (CMFDA)) and phalloidin, and imaged and quantified by confocal microscopy, Imaris^TM and ImageJ software.

There were no differences between the volume or total F-actin levels of in situ chondrocytes within the superficial zone of grade 0 (n=164 cells) compared to grade 1 (n=145) cartilage (P>0.05). However, a more detailed analysis of phalloidin labelling was performed, which demonstrated significant increases in both intense punctuate (IP) or intense areas (IA) (P<0.0001; P=0.0175 respectively). A preliminary analysis of IP and IA F-actin labelling suggested that while the former did not appear to be associated with changes to chondrocyte morphology, most of the cytoplasmic processes were associated with the presence of IA at the starting point of the protrusion.

These results demonstrate marked changes to F-actin distribution in chondrocytes in the very early stages of cartilage degeneration as occurs in OA. These subtle changes are probably an early indication of a change to the chondrocyte phenotype and thus worthy of further study as they may lead to deleterious alterations to matrix metabolism and ultimately cartilage weakening.

Articular cartilage has poor repair potential and the tissue formed is mechanically incompetent. Mesenchymal stromal cells (MSCs) show chondrogenic properties and the ability to re-grow cartilage, however a viable human model for testing cartilage regeneration and repair is lacking. Here, we describe an ex vivo pre-clinical femoral head model for studying human cartilage repair using MSCs.

Human femoral heads (FHs) were obtained following femoral neck fracture with ethical permission/patient consent and full-depth cartilage wells made using a 3mm biopsy punch. Pancreas-derived mesenchymal stromal cells (P-MSC) were prepared in culture media at ~5000 cells/20µl and added to each well and leakage prevented with fibrin sealant. After 24hrs, the sealant was removed and medium replaced with StemPro^TM chondrogenesis differentiation medium. The FHs were incubated (37^oC;5% CO₂) for 3wks, followed by a further 3wks in standard medium with 10% human serum with regular medium changes throughout. Compared to wells with medium only, A-MSCs produced a thin film across the wells which was excised en-block, fixed with 4% paraformaldehyde and frozen for cryo-sectioning.

The cell/tissue films varied in thickness ranging over 20-440µm (82±21µm; mean±SEM; N=3 FHs). The thickness of MSC films abutting the cartilage wells was variable but generally greater (15-1880µm) than across the wells, suggesting an attachment to native articular cartilage. Staining of the films using safranin O (for glycosaminoglycans; quantified using ImageJ) was variable (3±8%; mean±SEM; N=3) but in one experiment reached 20% of the adjacent cartilage. A preliminary assessment of the repair tissue gave an O'Driscoll score of 10/24 (24 is best).

These preliminary results suggest the ex vivo femoral head model has promise for studying the capacity of MSCs to repair cartilage directly in human tissue, although optimising MSCs to produce hyaline-like tissue is essential.

Supported by the CSO (TCS/17/32).

Abstract

Abstract

Abstract

Abstract

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail.

The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open.

The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture.

A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

Cite this article: Bone Joint J 2014; 96-B:817–22.

Introduction

Minimally invasive Achilles tendon repair has recently gained popularity amongst foot and ankle surgeons. This study aims to quantify the risk of sural nerve injury when using the Achillon device (Integra), as well as delineate its anatomical relationship to the Achilles tendon.

The internal fixation of osteochondral fragments in fractures normally utilizes intra-articular screws inserted through a pilot hole drilled into cartilage/bone. This trauma causes cartilage injury leading to chondrocyte death. We have quantified the cell death following cartilage drilling and identified irrigation conditions that can protect chondrocytes. Articular cartilage of bovine metacarpophalangeal joints of 3yr-old cows was irrigated in the presence/absence of saline of various compositions. Holes were then made using a standard 1.5mm drill (Ortho Solutions Ltd.) at 18,000 rpm through the articular cartilage into bone. Osteochondral explants were then harvested and cultured in Dulbecco's Modified Eagle's Medium containing chloromethylfluorescein-di-acetate and propidium iodide (10uM each), to label living chondrocytes green and dead cells red, respectively. Axial images were taken by confocal microscopy and the width of the zone of cell death (ZCD) around the hole determined. With no irrigation, new drills caused a ZCD of 171±25um, which was increased when drills used 50+ times were tested (279±31um;p=0.03). With saline irrigation, the ZCD was reduced for old drills (150±6um;p=0.016) but not for new drills (124±8um) suggesting the heating effect of the old drills caused additional chondrocyte death. However for new drills, the ZCD was further reduced significantly to 82±7um when the osmolarity of the saline irrigation solution was raised to 480mOsm using sucrose. Data are mean±s.e.m., from at least 5 separate experiments each with a minimum of 3 replicates. The results demonstrate a chondroprotective effect of raising the osmolarity of saline used during drilling of cartilage which could be clinically beneficial.

Hip fractures are a major cause of morbidity and mortality in the elderly and are thought to represent an increasing cohort of our patients. It is estimated that the cost of caring for each patient for their hospital admission is €10,000. There is significant regional and international variation in the incidence rates of such injuries, depending on age, sex and ethnic variations in populations. Recent Irish literature would suggest that the rates in Ireland are exponentially increasing while in the US the rate may be decreasing. The length of stay of such patients is also an important issue especially in the current economic environment. The aim of this study was to define the incidence of hip fractures in the South East. The aim was also to examine any changes to their length of stay that have occurred in a 11 years period.

Independent searches of the operating theatre register and the HIPE (hospital in-patient enquiry scheme) database were undertaken for the time period. Population data was obtained from central census office and the HSE South East offices.

The combined incidence of hip fractures in 2008 and 1998 was 96.06 and 100.90 per 100,000 respectively. The male to female ratio in 2008 was 1:2.67, while in 1998 it was 1:3.04. 13% of the patients in 2008 where under 65 years of age, while in 1998 this figure was 8%. In 1998 the mean length of stay was 17.15. By 2008 this had increased to 23.95 days. The dramatic increase in acute hospital length of stay over the period was estimated to have a burden of more than 14 million euros on health board fund.

This study provides data on a large patient group which is of paramount importance. Health service resources can be allocated appropriately in the future in terms of acute and step-down care based on this data set and results.

Purpose

To investigate the effect of obesity on functional outcome following total ankle arthroplasty.