Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022.

Background: The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs). Methods: PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes. Results: 432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA. Conclusion: Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.

Reducing trauma theatre list delays through improved communication between orthopaedic teams and radiographers: A quality improvement project.

AIMS: This quality improvement project was performed to improve delays in starting our trauma theatre lists by implementing measures to improve effective communication between the surgical team and the theatre radiographers. MATERIALS AND METHODS: This was a quality improvement project performed prospectively for 30 orthopaedic trauma lists over two cycles. Only lists requiring fluoroscopy guidance (image intensifier) for the first case were included. Interventions included improvements in use of theatre booking forms with fluoroscopy request checkboxes, dedication of an allocated radiographer for the trauma lists, timely communication of the finalised theatre list order and radiographers participating in the team briefing. RESULTS: Improvements in the timing of fluoroscopy requests and prompt arrival of the radiographer to the theatre were achieved. Furthermore, there was elimination of radiographer-related surgical start time delays following implementation of the interventions. Nevertheless, only minimal improvements were achieved in the participation of the radiographers for the trauma theatre team briefings. CONCLUSION: Although reasons for trauma theatre delays are multifactorial, this quality improvement project has demonstrated that these delays can be reduced through improved communication between radiographers and the orthopaedic team. This is especially important for theatre cases requiring the use of an image intensifier.

Assessing Referrals to a Trauma and Orthopaedic Department: Evaluation of a Traffic Light System for Virtual Fracture Clinic in the Emergency Department and Urgent Care.

Background The Trauma and Orthopaedic (T&O) on-call service receives referrals from the emergency department (ED), general practice (GP) and urgent treatment centres (UTCs) and requests for inpatient reviews. The virtual fracture clinic (VFC) pathway allows ED and UTC clinicians to assess, discharge and refer when necessary. For VFC, the on-call orthopaedic consultant reviews the cases the next working day and makes an appropriate plan. This pathway consists of a traffic light system, in which practitioners can either safely discharge with written advice (green), refer to the VFC (yellow) or refer to the on-call team (red). Method The aim of this study was to assess how the VFC pathway was being utilised. All referrals to the T&O on-call team over three weeks were evaluated retrospectively. The following referrals were excluded: fractured femur, head injury, trauma calls and back pain pathway. The following data were collected: patient details, diagnosis, referral source, reason for referral, plan, double booking with VFC and appropriateness. Results A total of 191 referrals were analysed. Most referrals are from the ED (51%) and UTC (23%). Of the referrals, 39% were deemed to be inappropriate. Of the inappropriate referrals, 35% should have been referred directly to the VFC rather than the on-call team. A significant minority (7%) of inappropriate referrals were referred to the on-call team and VFC. Conclusion Education and collaboration are required with the ED and UTC to ensure the proper use of the VFC pathway. Immediate radiograph reporting may also be beneficial.

Mid-to long-term postoperative outcomes of ankle joint fusion in patients with haemophilia: A systematic review.

INTRODUCTION AND AIM: The ankle joint is the most common site for haemophilic arthropathy. The aim of this study was to review the outcomes of ankle joint fusion in patients with haemophilia A or B. The primary outcome measures were union rates, time to union, perioperative blood loss/transfusion, postoperative complications and length of hospital stay (LOS). Secondary outcome measures were hind foot functional outcome scores and the visual analogue pain scale (VAS). MATERIALS AND METHODS: A search of PubMed, Medline, Embase, Journals@Ovid and the Cochrane register was performed conforming to the PRISMA guidelines. Only human studies with a minimum follow-up of 1-year were included. The MINORS and ROBINS-1 tools were used for quality appraisal. RESULTS: A total of 952 articles were identified and only 17 studies met the eligibility criteria after the screening. The mean age of the patients was 37.6 (SD 10.2). A total of 271 ankle fusions were performed with the open crossed-screw fixation being the most common technique. Union rates were 71.5%-100% at 2-6 months. The pooled postoperative complication and revision rates were 13.7% and 6.5%, respectively. The range of LOS was 1.8-10.6 days. The mean preoperative American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score was 35 (SD 13.1) whereas the mean postoperative AOFAS score was 79.4 (SD 5.3). The mean preoperative VAS was 6.3 (SD 1.6) while the mean postoperative VAS score was .9 (SD .4) across 38 ankle fusions. CONCLUSION: Ankle arthrodesis offers improved pain and function in haemophilic ankle arthropathy with lower revision and complication rates than that reported in the literature for total ankle replacement.

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults.

BACKGROUND: Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability. METHODS: A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine. RESULTS: Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization. CONCLUSION: Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

Traumatic subtalar joint dislocation.

Although uncommon, subtalar joint dislocations remain a frequently missed orthopaedic emergency. Detailed soft tissue and neurovascular assessment is important and these should be documented as appropriate. Failure of urgent reduction might lead to increased risk of conversion to an open injury as a result of pressure necrosis of the overlying skin, risk of talar avascular necrosis and risk of neurovascular compromise. A computed tomography scan is needed in all cases following successful closed or open reduction to identify associated occult foot and ankle fractures. The goal of treatment is to reduce the risk of soft tissue and neurovascular compromise and achieve a supple, painless foot. This article highlights the importance of early identification of this injury and institution of appropriate management according to the latest evidence, to reduce the risk of complications and lead to the best outcomes.

Retraction: Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing.

[This retracts the article DOI: 10.7759/cureus.28036.].

Charcot-Marie-Tooth Disease as a Risk Factor for Periprosthetic Fractures in Tibiotalocalcaneal Fusion With Intramedullary Nailing.

Introduction The treatment for severe fixed hindfoot osteoarthritis secondary to Charcot-Marie-Tooth disease (CMT) is tibiotalocalcaneal (TTC) arthrodesis. In our centre, we have noticed a disproportionate rate of periprosthetic fractures in CMT patients following TTC arthrodesis with retrograde hindfoot nailing. The aim of this study was to test this hypothesis by evaluating our local cohort of TTC arthrodesis with retrograde hindfoot nailing. Methods A retrospective review of patients who had TTC arthrodesis with intramedullary nailing was conducted over a seven-year period. Results There were 45 patients (30 male, 15 female) in our cohort. Forty-one patients achieved radiological and clinical fusion of their TTC arthrodesis. All three patients who had CMT sustained periprosthetic fracture at the tip of the nail at an average of four (range: 2.5-6) months from index operation. In comparison, no patients in the rest of the cohort sustained periprosthetic fractures. The nail position of the patients with CMT was central in both planes in all three patients. None of the patients with CMT had abutment of the cortex on either plane. Conclusion We found that there was a disproportionate rate of periprosthetic fractures in CMT patients in our cohort of TTC arthrodesis with retrograde hindfoot nailing. This suggests that CMT is a significant risk factor. The authors propose a longer nail to reduce the lever arm, with a long period of protected weight bearing till union, followed by consideration of elective removal of the nail to prevent this phenomenon from occurring.

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes.

Introduction Operation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines. Methods This was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes. Results Our documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05). Conclusion The use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

Outcomes of the Treatment of Fracture Non-union Using Combined Magnetic Field Bone Growth Stimulation: Experiences From a UK Trauma Unit.

INTRODUCTION: Fracture non-union is a distressing diagnosis for both patients and clinicians. Several methods have been tried to help promote bone healing. Some of the non-operative strategies include the use of pulsed ultrasound and electrical or magnetic bone stimulators. This study aimed at assessing the outcomes of patients treated with combined magnetic field (CMF) bone stimulators. METHODS: All patients with confirmed fracture non-union treated using a CMF bone growth stimulator between May 2019 and December 2021 were included in the study. These were followed up at regular three-month intervals and monitored for signs of clinical and radiological union. The minimum patient follow-up was six months. Our primary outcome measure was union rates following CMF treatment. The secondary outcome measures were time to union and fracture type/configuration in relation to non-union. RESULTS: A total of 29 patients were included. Of the patients, 52% were female. The average age of the patients was 53.42 years (SD: 17.66 years). Four were excluded because their follow-up period was less than six months. Patients were started on CMF bone growth stimulant treatment between four and 27 months from the initial fracture (mean: 11.56 months). The majority of the patients had tibial shaft (21%), distal femur (17%), ankle (10%) and distal humerus (10%) fractures. The overall success rate was 84% (n=21), with a mean time to union of 6.62 months. CONCLUSION: Bone growth stimulators using combined magnetic fields are a viable treatment option for established fracture non-union. They can result in improved outcomes and can avoid risks and costs associated with surgical options to treat non-union. However, more studies need to be conducted to establish the efficacy of these methods conclusively.

Post-Operative Outcomes of Circular External Fixation in the Definitive Treatment of Tibial Plafond Fractures: A Systematic Review.

Tibial plafond fractures (TPFs) are uncommon but potentially devastating injuries to the ankle. Operative treatments include internal and external fixation modalities. This article provides a systematic review of the clinical and functional outcomes of TPFs treated specifically with circular external fixation (CEF). A literature search of medical databases from inception to 13th November 2020 was performed. Original studies written in the English language reporting clinical, radiological, and functional outcome data of TPF treated with CEF were included. Patient demographics, fracture classification, open fractures, post-operative complications, clinical outcomes, radiological outcomes, and functional outcomes were collected. Quality and risk of bias were assessed using standardised scoring tools.In total, 16 studies were included. One prospective randomised study was identified. Collated data of 303 patients were analysed. The mean time to union was 21 weeks. Malunion occurred in 12.4%. The rate of deep infection was 4.8%, but no amputations were recorded. The risk of minor soft tissue infection (including pin-site infections) was 54%. Almost two-thirds achieved good-to-anatomic reduction radiologically. Approximately one-third reported excellent functional outcome scores. The quality of the studies was deemed satisfactory. A moderate risk of bias was acknowledged. This systemic review provides a summary of outcome data regarding CEF as a treatment for TPF. It highlights CEF as an acceptable treatment option with comparable results to that of internal fixation. Further higher-quality evidence is advised.

The Impact of Harm Review Service on Patients Awaiting Elective Orthopaedic Foot and Ankle Surgery for More Than 52 Weeks.

Background and objective There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. Materials and methods The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients' mental health and their perception of the service was assessed as well. Results A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. Conclusion This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review.

BACKGROUND: Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients. METHODS: After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented. RESULTS: A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention. CONCLUSION: Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.

Computed Tomography Scan Architectural Measurements in Adult Foot and Ankle Surgery: A Narrative Review for Orthopaedic Trainees.

CT scan plays an important role in adult foot and ankle surgery. Plain radiographs are usually the first-line imaging modality for assessing foot and ankle bone and joint architectural abnormalities. However, despite the fact that a CT scan is more expensive and associated with higher radiation exposure, it offers better imaging quality for the assessment of bony lesions in orthopaedics and trauma. Evidence has shown that more accurate measurements can be obtained from a CT scan compared to plain radiographs. Weight-bearing multi-detection CT scanning goes the extra mile by providing a more detailed assessment, especially for intra-articular fractures, and mirrors the real-life foot and ankle dynamics compared to conventional non-weight-bearing CT scans. It also has a relatively lower radiation dose compared to conventional CT scans. CT scan is the best modality for assessing bony lesions whereas MRI is better for soft tissue pathology. An understanding of the role of CT scan in the anatomical assessment of the foot and ankle will help improve communication between orthopaedic surgeons, radiologists, and radiographers. A thorough understanding of when to use a CT scan compared to the other imaging modalities will also lead to better surgical outcomes, reduced cost, and reduced risk from radiation exposure. This review article analyzes the role of CT in assessing relevant radiographic architectural measurements for diagnosis and surgical planning in adult foot and ankle surgery.

Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly.

Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury. In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications. A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure. Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.

Sub-Acute Syndesmotic Injury: A Review and Proposed Treatment Algorithm.

Sub-acute syndesmotic injuries are classified as from six weeks to six months from the initial injury date and can be considered a distinct group of patients; however, they are often mistreated and progress to chronic injuries with significant sequelae. The authors performed a comprehensive literature search on the MEDLINE database. The search yielded 165 studies up to January 2021, after the application of inclusion/exclusion criteria. This yielded 10 studies with a total of 156 relevant patients for review. We found that a delay in diagnosis is common and has a negative impact on outcomes. If a sub-acute syndesmotic injury is suspected and plain radiographs are inconclusive, magnetic resonance imaging is indicated if there is still an index of suspicion. Surgical intervention should aim to restore normal length and rotational alignment of the fibula whilst also addressing the need to debride tissues within the joint and syndesmosis. Syndesmosis must then be adequately reduced and stabilised with syndesmotic screw fixation, and augmentation with tendon/ligament reconstruction should be considered. All studies showed an average improvement in functional outcome measures post-operatively. The only study to compare sub-acute and chronic patients' functional outcomes post-operatively showed significant improvement in the sub-acute cohort; highlighting the importance of early intervention. We suggest a treatment algorithm that may help with the diagnosis and management of these injuries. We believe this will help all healthcare professionals to standardise care. Further research is required to assess sub-acute injury outcomes with tendon/ligamentous augmented reconstruction, as no level 1 or 2 studies currently exist.

Treatment strategies for osteochondral lesions of the talus: A review of the recent evidence.

BACKGROUND: There has been no consensus regarding the treatment of osteochondral lesions of the talus, there has been many attempts to formulate a treatment pathway, with multiple proposed modalities and adjuncts used. OBJECTIVES: The aim of this paper was to investigate the evidence published in the recent history, identify the relevant papers, review and summarize the findings, to help clarify the available operative treatment options and their respective efficacies based on the level of evidence provided. STUDY DESIGN & METHODS: A literature search through electronic databases MEDLINE and EMBASE was done, these databases were screened for publications and papers form June 2004 to June 2019. Key words were utilised in the search 'talus, talar, tibia, cartilage, osteochondral, ankle, osteochondritis dissecans, articular cartilage'. Studies on adults aged 18-60 years were included. Exclusion criteria were studies with less than 10 patients, or no clear outcome was recorded. Papers were reviewed by the authors and data extracted as per a pre-defined proforma. RESULTS: Following screening, 28 published articles were included and reviewed. Of these publications 5 were level I, 7 level II, 4 level III and 12 level IV. The total number of patients was 1061 patients. Treatment modalities included arthroscopic microfracture, drilling, hyaluronic acid injection, platelet rich plasma, osteochondral autologous transplantation (OAT), vascularised free bone graft among others. The most common functional measures used to assess efficacy were the Visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle (AOFAS) score. Follow up ranged from 26 weeks upto 4 years. CONCLUSIONS: Despite the abundance of treatment options, high level evidence (level I) remains limited and does not conclude a definitive treatment modality as superior to others. Further research, in the form highly organised randomised clinical trials, is needed to help improve the efficacy and develop new treatment modalities in the future.

COVID-19 - Changes in the presentation and management of shoulder and elbow trauma in a UK district general hospital orthopaedic department.

INTRODUCTION: COVID-19 has had a significant impact on healthcare systems. We aim to quantify the impact of this outbreak on shoulder and elbow trauma in our institution. METHODS: We prospectively collected data on patients presenting to our hospital with shoulder and elbow injuries during COVID-19. This included the number of attendances to the emergency department, fracture clinic, inpatient admissions and operative treatments. This was compared to a pre-COVID-19 period. We also assessed the efficacy of telephone clinics. RESULTS: There has been a noticeable decrease in the number of emergency department and fracture clinic attendances with upper limb complaints. The number of in-person fracture clinic reviews also decreased, with a reciprocal exponential increase in telephone consultations. We recorded a decrease in the number of shoulder and elbow trauma procedures performed. There was a small increase in the proportion of injuries treated conservatively during COVID-19. Our telephone clinics yielded a diagnosis and management plan in many cases and patient perspective appeared favourable. CONCLUSION: We have noted significant change in the upper limb caseload. Certain injuries have reduced, likely due to COVID-19 lockdown. Moreover, we consider several changes to current practices could be taken forward after the pandemic.

The role of interscalene brachial plexus block anaesthesia in arthroscopic shoulder surgery; a prospective study.

The choice of anaesthetic in shoulder surgery is an evolving field of research which has important implications for patient outcomes. We have performed a prospective study to assess the usability of an interscalene brachial plexus block (ISBPB) with sedation as the primary anaesthetic and analgesic for arthroscopic shoulder surgery. Our study assessed the requirements of analgesia peri-operatively and post operatively and found that patients had no requirement (n = 30) and minimal requirements with a low pain score (visual analogue score; mean 2.4, range 2-5) respectively. We also found that patients spent a short amount of time in recovery (31 min mean, range 21-48 min) and were able to be discharged on the same day. Our findings suggest that ISBPB with sedation is a viable option in arthroscopic shoulder surgery for a variety of procedures with positive effects for patient outcomes and mobility.

Lisfranc injury: A review and simplified treatment algorithm.

BACKGROUND: Lisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries. METHODS: A comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature. RESULTS: Delay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies. CONCLUSION: A simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries. LEVEL OF EVIDENCE: Level 5.