This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular
This study aimed to establish the optimal fixation methods for calcaneal tuberosity avulsion fractures with different fragment thicknesses in a porcine model. A total of 36 porcine calcanea were sawed to create simple avulsion fractures with three different fragment thicknesses (5, 10, and 15 mm). They were randomly fixed with either two suture anchors or one headless screw. Load-to-failure and cyclic loading tension tests were performed for the biomechanical analysis.Aims
Methods
The August 2023 Foot & Ankle Roundup360 looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.
The February 2023 Foot & Ankle Roundup. 360. looks at: Joint inflammatory response in ankle and pilon fractures; Tibiotalocalcaneal fusion with a custom cage; Topical application of tranexamic acid can reduce blood loss in
The December 2022 Trauma Roundup360 looks at: Anterior approach for acetabular fractures using anatomical plates; Masquelet–Ilizarov for the management of bone loss post debridement of infected tibial nonunion; Total hip arthroplasty – better results after low-energy displaced femoral neck fracture in young patients; Unreamed intramedullary nailing versus external fixation for the treatment of open tibial shaft fractures in Uganda: a randomized clinical trial; The Open-Fracture Patient Evaluation Nationwide (OPEN) study: the management of open fracture care in the UK; Cost-utility analysis of cemented hemiarthroplasty versus hydroxyapatite-coated uncemented hemiarthroplasty; Unstable ankle fractures: fibular nail fixation compared to open reduction and internal fixation; Long-term outcomes of randomized clinical trials: wrist and calcaneus; ‘HeFT’y follow-up of the UK Heel Fracture Trial.
Aims. We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial. Methods. HeFT recruited 151 patients aged over 16 years with closed displaced, intra-articular fractures of the calcaneus. Patients with significant deformity causing fibular impingement, peripheral vascular disease, or other significant limb injuries were excluded. Participants were randomly allocated to open reduction and internal fixation (ORIF) or nonoperative treatment. We report Kerr-Atkins scores, self-reported difficulty walking and fitting shoes, and additional surgical procedures at 36, 48, and 60 months. Results. Overall, 60-month outcome data were available for 118 patients (78%; 52 ORIF, 66 nonoperative). After 60 months, mean Kerr-Atkins scores were 79.2 (SD 21.5) for ORIF and 76.4 (SD 22.5) for nonoperative. Mixed effects regression analysis gave an estimated effect size of -0.14 points (95% confidence interval -8.87 to 8.59; p = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p = 0.175), or on the type of shoes worn (p = 0.432) at 60 months. Additional surgical procedures were conducted on ten participants allocated ORIF, compared to four in the nonoperative group (p = 0.043). Conclusion. ORIF of displaced intra-articular
Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular
Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2
MicroRNAs (miRNAs) have been reported as key regulators of bone formation, signalling, and repair. Fracture healing is a proliferative physiological process where the body facilitates the repair of a bone fracture. The aim of our study was to explore the effects of microRNA-186 (miR-186) on fracture healing through the bone morphogenetic protein (BMP) signalling pathway by binding to Smad family member 6 (SMAD6) in a mouse model of femoral fracture. Microarray analysis was adopted to identify the regulatory miR of SMAD6. 3D micro-CT was performed to assess the bone volume (BV), bone volume fraction (BVF, BV/TV), and bone mineral density (BMD), followed by a biomechanical test for maximum load, maximum radial degrees, elastic radial degrees, and rigidity of the femur. The positive expression of SMAD6 in fracture tissues was measured. Moreover, the miR-186 level, messenger RNA (mRNA) level, and protein levels of SMAD6, BMP-2, and BMP-7 were examined.Objectives
Methods
We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft 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).Aims
Patients and Methods
The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee. All adult patients (18 to 75 years) undergoing IR after fracture fixation below the level of the knee between November 2014 and September 2016 were included as part of the WIFI (Wound Infections Following Implant Removal Below the Knee) trial, performed in 17 teaching hospitals and two university hospitals in The Netherlands. In this multicentre prospective cohort, the primary outcome was the difference in functional status before and after IR, measured by the Lower Extremity Functional Scale (LEFS), with a minimal clinically important difference of nine points.Aims
Patients and Methods
Aims. This paper documents the epidemiology of adults (aged more than 18 years) with a
Identifying predictors of compartment syndrome in the foot after
a fracture of the calcaneus may lead to earlier diagnosis and treatment.
The aim of our study was to identify any such predictors. We retrospectively reviewed 303 patients (313 fractures) with
a fracture of the calcaneus who presented to us between October
2008 and September 2016. The presence of compartment syndrome and
potential predictors were identified by reviewing their medical
records. Potential predictors included age, gender, concomitant
foot injury, mechanism of injury, fracture classification, time
from injury to admission, underlying illness, use of anticoagulant/antiplatelet
agents, smoking status and occupation. Associations with predictors
were analyzed using logistic regression analysis.Aims
Patients and Methods
The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function. Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery.Objectives
Methods
Objectives. This study aimed to investigate the functional effects of microRNA (miR)-214-5p on osteoblastic cells, which might provide a potential role of miR-214-5p in bone fracture healing. Methods. Blood samples were obtained from patients with hand fracture or intra-articular
Objectives. The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2
The purposes of this study were to clarify first, the incidence
of peroneal tendon dislocation in patients with a fracture of the
talus and second the factors associated with peroneal tendon dislocation. We retrospectively examined 30 patients (30 ankles) with a mean
age of 37.5 years, who had undergone internal fixation for a fracture
of the talus. Independent examiners assessed for peroneal tendon
dislocation using the pre-operative CT images. The medical records
were also reviewed for the presence of peroneal tendon dislocation.
The associations between the presence of dislocation with the patient
characteristics or radiological findings, including age, mechanism
of injury, severity of fracture, and fleck sign, were assessed using Fisher’s
exact tests.Aims
Patients and Methods
The continual cycle of bone formation and resorption
is carried out by osteoblasts, osteocytes, and osteoclasts under
the direction of the bone-signaling pathway. In certain situations
the host cycle of bone repair is insufficient and requires the assistance
of bone grafts and their substitutes. The fundamental properties
of a bone graft are osteoconduction, osteoinduction, osteogenesis,
and structural support. Options for bone grafting include autogenous
and allograft bone and the various isolated or combined substitutes
of calcium sulphate, calcium phosphate, tricalcium phosphate, and
coralline hydroxyapatite. Not all bone grafts will have the same
properties. As a result, understanding the requirements of the clinical
situation and specific properties of the various types of bone grafts
is necessary to identify the ideal graft. We present a review of
the bone repair process and properties of bone grafts and their
substitutes to help guide the clinician in the decision making process. Cite this article:
In this paper, we critically appraise the recent
publication of the United Kingdom Heel Fracture Trial, which concluded
that when patients with an absolute indication for surgery were
excluded, there was no advantage of surgical over non-surgical treatment
in the management of
Fresh-frozen allograft bone is frequently used
in orthopaedic surgery. We investigated the incidence of allograft-related
infection and analysed the outcomes of recipients of bacterial culture-positive
allografts from our single-institute bone bank during bone transplantation.
The fresh-frozen allografts were harvested in a strict sterile environment
during total joint arthroplasty surgery and immediately stored in
a freezer at -78º to -68º C after packing. Between January 2007
and December 2012, 2024 patients received 2083 allografts with a
minimum of 12 months of follow-up. The overall allograft-associated
infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts
taken before implantation revealed 21 (1.0%) positive findings.
The 21 recipients were given various antibiotics at the individual
orthopaedic surgeon’s discretion. At the latest follow-up, none
of these 21 recipients displayed clinical signs of infection following
treatment. Based on these findings, we conclude that an incidental positive
culture finding for allografts does not correlate with subsequent
surgical site infection. Additional prolonged post-operative antibiotic
therapy may not be necessary for recipients of fresh-frozen bone
allograft with positive culture findings. Cite this article:
The February 2015 Trauma Roundup. 360 . looks at: Evaluating the syndesmosis in ankle
The December 2014 Trauma Roundup. 360 . looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and
We present a review of litigation claims relating
to foot and ankle surgery in the NHS in England during the 17-year period
between 1995 and 2012. A freedom of information request was made to obtain data from
the NHS litigation authority (NHSLA) relating to orthopaedic claims,
and the foot and ankle claims were reviewed. During this period of time, a total of 10 273 orthopaedic claims
were made, of which 1294 (12.6%) were related to the foot and ankle.
1036 were closed, which comprised of 1104 specific complaints. Analysis
was performed using the complaints as the denominator. The cost
of settling these claims was more than £36 million. There were 372 complaints (33.7%) involving the ankle, of which
273 (73.4%) were related to trauma. Conditions affecting the first
ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective
practice. Overall, claims due to diagnostic errors accounted for
210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery
and 149 (13.5%) from alleged mismanagement. Our findings show that the incorrect, delayed or missed diagnosis
of conditions affecting the foot and ankle is a key area for improvement,
especially in trauma practice. Cite this article:
The October 2014 Foot &
Ankle Roundup360 looks at: multilayer compression bandaging superior for post-traumatic ankle oedema; compression stockings for ankle fractures; weight bearing ok in Achilles tendon ruptures; MRI findings can predict ankle sprain symptoms; salvage for malreduced ankle fractures; locking fibular plates are more expensive; is fixation better early or late in pilon
The August 2014 Foot &
Ankle Roundup360 looks at: calcaneotibial nail in ankle fractures; reamer irrigator aspirator for ankle fusion; periprosthetic bone infection; infection in ankle fixation; cheap and cheerful OK in MTP fusion plates; sliding fibular graft for peroneal tendon pathology and fusion for failed ankle replacement.
The August 2014 Trauma Roundup. 360 . looks at: On-table CT for
The June 2014 Foot &
Ankle Roundup. 360 . looks at: peroneal tendon tears associated with
The December 2013 Trauma Roundup. 360 . looks at: Re-operation for intertrochanteric hip fractures; Are twin incisions better than one round the acetabulum?; Salvage osteotomy for
The December 2013 Foot &
Ankle Roundup360 looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.
The October 2013 Foot &
Ankle Roundup. 360 . looks at: Operative treatment of
The August 2013 Foot &
Ankle Roundup. 360 . looks at: mobility, ankles and fractures; hindfoot nailing: not such a bad option after all?; little treatment benefit for blood injection in tendonitis; fixed bearing ankles successful in the short term; hindfoot motion following STAR ankle replacement; minimally invasive
The June 2013 Foot &
Ankle Roundup. 360 . looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open
We reviewed 59 bone graft substitutes marketed
by 17 companies currently available for implantation in the United Kingdom,
with the aim of assessing the peer-reviewed literature to facilitate
informed decision-making regarding their use in clinical practice.
After critical analysis of the literature, only 22 products (37%)
had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita),
Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question
the need for so many different products, especially with limited
published clinical evidence for their efficacy, and conclude that
there is a considerable need for further prospective randomised
trials to facilitate informed decision-making with regard to the
use of current and future bone graft substitutes in clinical practice. Cite this article:
The February 2013 Trauma Roundup360 looks at: the risk of ankle fractures; absorbable implants; minimally invasive heel fracture fixation; pertrochanteric fractures; arthroplasty and intracapsular hip fractures; and extensor mechanism disruption.