In this randomised controlled trial, we evaluated the role of elastic compression using ankle injury stockings (AIS) in the management of fractures of the ankle. A total of 90 patients with a mean age of 47 years (16 to 79) were treated within 72 hours of presentation with a fracture of the ankle, 31 of whom were treated operatively and 59 conservatively, were randomised to be treated either with compression by AIS plus an Aircast boot or Tubigrip plus an Aircast boot. Male to female ratio was 36:54. The primary outcome measure was the functional Olerud–Molander ankle score (OMAS). The secondary outcome measures were; the American Orthopaedic Foot and Ankle Society score (AOFAS); the Short Form (SF)-12v2 Quality of Life score; and the frequency of deep vein thrombosis (DVT).

Compression using AIS reduced swelling of the ankle at all time points and improved the mean OMAS score at six months to 98 (95% confidence interval (CI) 96 to 99) compared with a mean of 67 (95% CI 62 to 73) for the Tubigrip group (p < 0.001). The mean AOFAS and SF-12v2 scores at six months were also significantly improved by compression. Of 86 patients with duplex imaging at four weeks, five (12%) of 43 in the AIS group and ten (23%) of 43 in the Tubigrip group developed a DVT (p = 0.26).

Compression improved functional outcome and quality of life following fracture of the ankle. DVTs were frequent, but a larger study would be needed to confirm that compression with AISs reduces the incidence of DVT.

Cite this article: Bone Joint J 2014; 96-B:1062–9.

Background: Confusion occurs in up to 60% of patients following neck of femur fracture, delaying hospital discharge. We investigated venous – arterial circulation shunts (v-aCS) and the influence of cerebral embolism before and during surgery on subsequent cognitive function.

Methods: Cerebral emboli were counted in 16 patients with an inter-trochanteric or Garden III/IV fracture by transcranial Doppler (TCD) monitoring over 1 hour pre-operatively and intra-operatively. A v-aCS was diagnosed when 1 or more microbubbles were detected in the middle cerebral artery by TCD following intravenous injection of a microbubble emulsion. Cognitive function was investigated by a battery of computerised tests preoperatively and at 5 days postoperatively.

Results: Cerebral emboli were detected in 9 of 16 patients preoperatively (median 2, range 1–23) and in 10 patients during surgery (median 10, range 4 – 617). A v-aCS was associated with preoperative emboli in 9 patients (p=0.036, Fisher’s Exact) and intraoperative emboli in 10 patients (p=0.011, Fisher’s Exact). Cognitive function deteriorated following surgery only in patients with emboli, with the median (range) overall reaction times increasing from 3220ms (1926–5868) to 7493ms (4690–15992) [p=0.008]. The overall accuracy deteriorated from 2.57 to 2.37 (NS).

Conclusion: Cerebral embolism is common following femoral neck fracture in patients with a v-aCS and was associated with a deterioration in cognitive function.

Background: Cerebral emboli may be detected by transcranial Doppler (TCD) in patients undergoing hip arthroplasty. Venous – arterial circulation shunts (v-aCS), cerebral embolism and postoperative organ dysfunction were investigated in elective hip arthroplasty.

Methods: TCD was used to identify v-aCS in (i) elective hip arthroplasty (n=45), (ii) abdominal aortic aneurysm surgery (AAA) (n=20) and (iii) transurethral resection of prostate (TURP) (n=10). A v-aCS was diagnosed when 1 or more microbubbles were detected in the middle cerebral artery by TCD following intravenous injection of a microbubble emulsion. TCD was also used to monitor for intraoperative cerebral emboli (ICE). Cognitive function was measured by a battery of computerised tests before and 5 days after surgery. Troponin T, AST, ALP, Bilirubin, Creatinine, Urea and Creatinine clearance were measured pre-operatively and 24 and 48 hours post-operatively.

Results: Cerebral embolism occurred in 26 of 45 patients during hip arthroplasty (median 4, range 1 – 368) but not during AAA or TURP surgery. Cerebral embolism only occurred in patients with a v-aCS (p< 0.001) and was strongly associated with the size of the v-aCS (rs=0.8, p< 0.001). The number of ICE had no influence on Troponin T, renal function, liver function or cognitive function.

Conclusion: Cerebral embolism is common in patients with a v-aCS during hip arthroplasty. There was no evidence of cerebral or multi-organ damage due to paradoxical embolism.

After total knee replacement a 57-year-old woman developed increasing pain in her left calf on exercise. This was due to erosion of the popliteal artery by a spur of cement. Removal of the spur with resection and Dacron grafting of the damaged section of the vessel cured her symptoms.