Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study.

BACKGROUND: Patient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF). PATIENTS AND METHODS: A UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching. RESULTS: One-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%). CONCLUSION: Only a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation. LEVEL OF EVIDENCE: III.

Surgical management of the acute severely infected diabetic foot - The 'infected diabetic foot attack'. An instructional review.

Diabetic Foot Infection (DFI), in its severest form the acute infected 'diabetic foot attack', is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This "diabetic foot attack" is characterised by acutely spreading infection and substantial soft tissue necrosis. In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, 'time is tissue', referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.

Infected open calcaneal fractures - A delayed reconstruction technique using calcium sulphate and hydroxyapatite antibiotic elucidating void filler.

Treating open calcaneal fractures remains challenging, particularly when involving bone loss and infection. CASE: We present the case of a 25-year-old woman who sustained an open AO 83-C2 calcaneal fracture with subsequent necrosis and presumed infection. Superseding necrosis and bone loss complicated the plan for definitive fixation. Residual bone was stabilised with Kirshner-wires and the void filled with a calcium sulphate and hydroxyapatite spacer, facilitating delayed surgical reconstruction. CONCLUSION: Using calcium sulphate and hydroxyapatite spacer, as part of a 2-stage process represents a strategy in the treatment of complex calcaneal fractures with possible infection, and bone and soft tissue loss. LEVEL OF CLINICAL EVIDENCE: 4.

Sclerostin does not play a major role in the pathogenesis of skeletal complications in type 2 diabetes mellitus.

In contrast to previously reported elevations in serum sclerostin levels in diabetic patients, the present study shows that the impaired bone microarchitecture and cellular turnover associated with type 2 diabetes mellitus (T2DM)-like conditions in ZDF rats are not correlated with changes in serum and bone sclerostin expression. INTRODUCTION: T2DM is associated with impaired skeletal structure and a higher prevalence of bone fractures. Sclerostin, a negative regulator of bone formation, is elevated in serum of diabetic patients. We aimed to relate changes in bone architecture and cellular activities to sclerostin production in the Zucker diabetic fatty (ZDF) rat. METHODS: Bone density and architecture were measured by micro-CT and bone remodelling by histomorphometry in tibiae and femurs of 14-week-old male ZDF rats and lean Zucker controls (n = 6/group). RESULTS: ZDF rats showed lower trabecular bone mineral density and bone mass compared to controls, due to decreases in bone volume and thickness, along with impaired bone connectivity and cortical bone geometry. Bone remodelling was impaired in diabetic rats, demonstrated by decreased bone formation rate and increased percentage of tartrate-resistant acid phosphatase-positive osteoclastic surfaces. Serum sclerostin levels (ELISA) were higher in ZDF compared to lean rats at 9 weeks (+40 %, p < 0.01), but this difference disappeared as their glucose control deteriorated and by week 14, ZDF rats had lower sclerostin levels than control rats (-44 %, p < 0.0001). Bone sclerostin mRNA (qPCR) and protein (immunohistochemistry) were similar in ZDF, and lean rats at 14 weeks and genotype did not affect the number of empty osteocytic lacunae in cortical and trabecular bone. CONCLUSION: T2DM results in impaired skeletal architecture through altered remodelling pathways, but despite altered serum levels, it does not appear that sclerostin contributes to the deleterious effect of T2DM in rat bone.

Scaphoid fracture non-union: a systematic review of surgical treatment using bone graft.

UNLABELLED: This systematic review assesses the quality and outcomes of published articles concerning bone graft surgery for scaphoid fracture non-union. Searches of the CENTRAL, MEDLINE, EMBASE, CINAHL and AMED databases captured 2710 articles. Each article was screened and 144 met our inclusion criteria. Data regarding source, study design, population, intervention, comparator and outcomes were extracted. There were 5464 scaphoid non-union outcomes within the 144 studies. Mean reported union rates for vascularized and non-vascularized bone graft were 84% and 80%, respectively. Avascular necrosis was diagnosed in several ways and, when present, the vascularized bone graft union rate was 74% compared with 62% with non-vascularized bone graft. Reported union rates vary considerably. These differences may be due to patient factors, fracture factors, treatment factors or study design failures or bias. We recommend that future researchers take into account the deficiencies of previous studies and use the suggested minimum data set in future studies. LEVEL OF EVIDENCE: II.

The acute vascular response to intramedullary reaming. Microsphere estimation of blood flow in the intact ovine tibia.

The tibial nutrient artery supplies 62% of cortical blood flow in the diaphysis and normal blood flow is centrifugal (Willans 1987). Intramedullary reaming destroys the nutrient artery and injures the endosteal surface of the cortex. Trueta (1974) suggested that the direction of blood flow can reverse from centrifugal to centripetal after loss of the endosteal supply. We examined this hypothesis by measuring cortical and periosteal blood flow after intramedullary reaming of the tibia in eight sheep, using 57Co radiolabelled microspheres. The unreamed contralateral tibiae served as a control group. Thirty minutes after reaming there was no significant change in cortical blood flow, but a sixfold increase in the periosteal flow. Our study confirms Trueta's hypothesis; after trauma or in other pathological states, flow can become centripetal.

1H and 31P NMR spectroscopy of phosphorylated model peptides.

The model peptides glycylglycyltyrosylalanine (Gly-Gly-Tyr-Ala), glycylglycylthreonylalanine (Gly-Gly-Thr-Ala) and glycylglycylserylalanine (Gly-Gly-Ser-Ala) were phosphorylated at the hydroxyl groups of their tyrosyl, threonyl and seryl residues, respectively, and characterized by 31P and 1H NMR spectroscopy. The pKa-value of the phosphoryl group in the tyrosine-containing peptide determined from the pH dependence of chemical shifts is 5.9, the 31P chemical shifts at low pH (4.0) and high pH (8.0) are -3.8 and 0.2 ppm, respectively. Phosphorylation also leads to significant shifts of the 1H NMR resonances of the tyrosine residue; the amide resonance is shifted -0.02 ppm, the H alpha resonance 0.06 ppm, the H beta resonances 0.10 and -0.04 ppm, the H delta resonances 0.02 ppm and the H epsilon resonances 0.26 ppm. The pKa-value of the phosphoryl group in the threonine peptide determined from the pH dependence of chemical shifts is 6.1; the 31P chemical shifts at low pH (4.0) and high pH (8.0) are -0.1 and 4.8 ppm, respectively. The corresponding values for the serine peptide are 6.1 (pKa), 0.6 ppm and 4.9 ppm. Phosphorylation also leads to significant shifts of the 1H NMR resonances of the threonine and serine residues. In the threonine residue the amide resonance is shifted 0.25 ppm, the H alpha-resonance -0.43 ppm, the H beta-resonance 0.03 ppm and the H gamma-resonance 0.09 ppm. In the serine residue the amide resonance is shifted 0.21 ppm, the H alpha-resonance -0.17 ppm, and the H beta-resonances 0.17 ppm.

Some human "carbohydrate-rich" serum proteins in protein-energy malnutrition.

The human serum proteins with a carbohydrate portion of more than 10 per cent in the molecule, alpha1-acid glycoprotein, alpha1-antichymotrypsin, alpha1B-glycoprotein and alpha2HS-glycoprotein were studied in thirteen cases of protein-energy malnutrition. The "acute phase reactant" proteins alpha1-acid glycoprotein and alpha1-antichymotrypsin were found to be increased above the controls, whereas the other "glycoproteins" either decreased or did not change significantly. Also albumin, prealbumin and transferrin were found to be low in the cases of protein-energy malnutrition.