Transverse Weber A fracture atrophic non-union. A single centre case series.

INTRODUCTION: Weber A ankle fractures are isolated fibula fractures distal to the level of the ankle joint line. They are regarded as stable injuries that usually heal successfully without intervention. We have identified several patients that have developed symptomatic atrophic non-union of transverse Weber A fractures that are not simple avulsion fractures of the anterior talo-fibular ligament. We explored variations to the blood supply of the distal fibula as a potential cause of this rare complication. CASES: Five patients presented with ongoing ankle pain following a period of non-operative management. All shared a similar transverse atrophic non-union fracture pattern.Surgical management with open reduction and internal fixation with or without the use of bone graft achieved successful union and resolution of symptoms in all cases. CONCLUSIONS: Atrophic fracture non-unions usually result from a disruption to the blood supply at the site of injury. The arterial supply to the distal fibula consists of a complex of arterial loops which usually enable fracture healing. However, there are anatomical variations to the blood supply that potentially could account for the rare outcome of non-union of Weber A fracture patterns. Weber A fractures are generally benign ankle fractures that heal well with non-operative treatment. No alterations should be made to the management of such injuries, but patients should be counselled about the risk of a symptomatic non-union outcome.

How a Pandemic Changes Trauma: Epidemiology and Management of Trauma Admissions in the UK during COVID-19 Lockdown.

INTRODUCTION: On June 24 in the United Kingdom, there were 277,989 cases of COVID-19 and 39,369 deaths recorded. The government enforced a complete lockdown on March 23 that resulted in cessation of all elective admissions on 24th onward, with only acute trauma cases being admitted to hospital. This study aims to characterize the changes in trauma admissions during the first 5-week lockdown period. The hypothesis states that there would be a significant reduction in overall orthopedic trauma admissions, polytrauma, and high-energy outdoor trauma during this COVID-19 period. METHODS: All trauma admissions over nearly a 5-week period from March 23, 2020, to April 26, 2020, were collated as the "COVID cohort" and compared to the "control" group of patients from the same hospitals 1 year before between March 23, 2019, and April 26, 2019. Spinal admissions and pediatrics were excluded from the study as they were managed in other regional units. RESULTS: There was a 56% reduction in trauma admissions during the COVID-19 lockdown (133 vs. 304). A majority of the COVID cohort were admitted with fractures (89 vs. 164, P = 0.017, Chi-square test) from home with low-energy falls. Overall, fewer operations were performed than the year before. However, a greater proportion of admitted patients had a surgical orthopedic intervention rather than admission and nonoperative management. CONCLUSIONS: There was a reduction in admissions as well as reductions in high energy and occupational injuries. Elderly patients continued to fall at home or in care, sustaining hip fractures. This vulnerable group requires beds, orthogeriatric management followed by surgical intervention and social care. Orthogeriatric services must be maintained to ensure the best clinical outcomes for this group.

Treatment of Severe Avascular Necrosis of the Talus Using a Novel Keystone-Shaped 3D-Printed Titanium Truss Implant.

BACKGROUND: Avascular necrosis (AVN) of the talus most commonly occurs secondary to trauma. Significant bone loss and collapse in severe talar AVN remains an operative challenge. Tibiotalocalcaneal arthrodesis (TTC) using femoral head allograft is at risk of collapse and subsidence. The use of a void-filling titanium truss can mitigate against this. This study describes the use of a novel keystone shaped 3D-printed titanium truss for treatment of severe talar AVN. METHODS: Three patients with end-stage AVN of the talus were included. Each patient underwent a TTC arthrodesis with a custom-made, 3D-printed, keystone-shaped, truss implant in conjunction with a hindfoot intramedullary nail. Modified patient American Orthopaedic Foot & Ankle Society (AOFAS) scores were recorded at the preoperative, 6-month, 12-month, and annual postoperative timepoints. RESULTS: All patients progressed to satisfactory radiological union by one year. Mean follow up time was 32 months (24-48 months). Mean preoperative modified AOFAS score was 5. There was progressive improvement in AOFAS scores from 6 months postoperatively. Mean modified AOFAS score improved from 28 at 6 months to 37 at 2 years postoperatively. CONCLUSION: Custom-made 3D-printed titanium trusses provide promising outcomes for treating severe AVN of the talus. The "keystone" design is advantageous as it allows for bone stock preservation and conforms to the shape of the native calcaneum. All patients showed progressive improvements in outcomes at sequential time intervals postoperatively. The implant provides a strong mechanical structure resisting collapse and subsidence during the arthrodesis process. LEVEL OF EVIDENCE: Level IV, retrospective case series.

An analysis of virtual fracture clinics in orthopaedic trauma in the UK during the coronavirus crisis.

Virtual fracture clinics (VFC) are advocated by new orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature, as well as recommendations on introducing a VFC service during the coronavirus pandemic and into the future.A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify nine relevant publications related to VFC.The Glasgow model, initiated in 2011, has become the benchmark. Clinical efficiency can be improved, reducing the number of emergency department (ED) referrals seen in VFC by 15-28% and face-to-face consultations by 65%. After review in the VFC, 33-60% of patients may be discharged. Some studies have shown no negative impact on the ED; the time to discharge was not increased. Patient satisfaction ranges from 91-97% using a VFC service, and there may be cost-saving benefits annually of £67,385 to £212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited; 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%).We propose a pathway integrating the VFC model, whilst having senior orthopaedic decision makers available in the ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice. Cite this article: EFORT Open Rev 2020;5:442-448. DOI: 10.1302/2058-5241.5.200041.

Orthopaedic Trainee Opinion on the Current Procedure-based Assessment Compared to its Predecessor: A UK Trauma Centre Perspective.

Background Procedure-based assessments (PBAs) were introduced as a formative assessment of surgical performance. UK trainees are currently expected to complete at least 20 PBAs each training year. A new PBA tool was introduced in August 2016 in order to address several criticisms with its predecessor. These included mandatory written feedback and increasing the number of global levels of assessment. Objectives Our study sought to identify the impact of these modifications to the PBA tool on its perceived utility as a formative assessment of surgical skill. Study design & methods Orthopaedic trainee registrars (ST3-ST8) holding a UK National Training Number (NTN) at a major UK trauma centre were invited to take part in the study. Each trainee completed an anonymous questionnaire that was designed to elicit the view of trainees towards the old and new PBA. Results Twelve trainees took part in the study. Most of them admitted receiving good quality feedback from their trainer using both tools (75% old PBA; 83% ew PBA). Most trainees (58%) felt that written feedback did not encourage verbal feedback from their trainer. Overall, trainees felt the new PBA global rating scale levels had made it a more accurate measure of surgical performance and allowed them to better appreciate the gradual improvement in their surgical skills throughout their training. Conclusions Fifty per cent of the trainees believed that the new PBA overall was a better formative assessment of surgical skill than its predecessor. A significant factor has been the introduction of a new global rating score rather than efforts to improve feedback. Further work should look to identify whether these views match those of other UK-based trainees on a larger scale.

Current concepts in the management of recurrent anterior gleno-humeral joint instability with bone loss.

The management of recurrent anterior gleno-humeral joint instability is challenging in the presence of bone loss. It is often seen in young athletic patients and dislocations related to epileptic seizures and may involve glenoid bone deficiency, humeral bone deficiency or combined bipolar lesions. It is critical to accurately identify and assess the amount and position of bone loss in order to select the most appropriate treatment and reduce the risk of recurrent instability after surgery. The current literature suggests that coracoid and iliac crest bone block transfers are reliable for treating glenoid defects. The treatment of humeral defects is more controversial, however, although good early results have been reported after arthroscopic Remplissage for small defects. Larger humeral defects may require complex reconstruction or partial resurfacing. There is currently very limited evidence to support treatment strategies when dealing with bipolar lesions. The aim of this review is to summarise the current evidence regarding the best imaging modalities and treatment strategies in managing this complex problem relating particularly to contact athletes and dislocations related to epileptic seizures.

A delayed presentation of Boerhaave's syndrome with mediastinitis managed using the over-the-scope clip.

Boerhaave syndrome is a spontaneous perforation of the oesophagus secondary to forceful emesis. Surgery has been advocated in delayed presentations of Boerhaave's syndrome with mediastinitis. The over-the-scope clip (OTSC) by OVESCO(®) (Tubingen, Germany) has been used in the endoscopic management of gastrointestinal bleeds, fistulae and anastamotic leaks. We describe the successful endoscopic use of the OTSC in a delayed presentation of Boerhaave syndrome with mediastinitis. A 69-year-old gentleman underwent a computerised tomography scan, which demonstrated a lower oesophageal perforation and mediastinitis 7 days after admission, having presented with forceful emesis and chest discomfort. During endoscopy the defect was visualized and successfully closed using the OTSC. This resulted in a favourable outcome and is a technique not previously described in the literature to manage this condition.