Surgical management of the diabetic foot: The current evidence.

The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.

Is it time to drop royal patronage of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists?

Historically there is a strong, amiable and mutually respectful relationship between Australian and New Zealand obstetricians and gynaecologists (O&Gs) and the British O&G establishment represented by the Royal College of Obstetricians and Gynaecologists (RCOG). The 'Royal' prefix pays homage to this relationship. With the evolution of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), there have been suggestions that the Royal prefix no longer accurately reflects the raison d'être and aspirations of RANZCOG. This paper will explore the arguments in favour and against dropping the Royal prefix from RANZCOG.

Return to sport following toe phalanx fractures: A systematic review.

BACKGROUND: Evidence-based guidance on return to sport following toe phalanx fractures is limited. AIM: To systemically review all studies recording return to sport following toe phalanx fractures (both acute fractures and stress fractures), and to collate information on return rates to sport (RRS) and mean return times (RTS) to the sport. METHODS: A systematic search of PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, and Google Scholar was performed in December 2022 using the keywords 'Toe', 'Phalanx', 'Fracture', 'injury', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'. All studies which recorded RRS and RTS following toe phalanx fractures were included. RESULTS: Thirteen studies were included: one retrospective cohort study and twelve case series. Seven studies reported on acute fractures. Six studies reported on stress fractures. For the acute fractures (n = 156), 63 were treated with primary conservative management (PCM), 6 with primary surgical management (PSM) (all displaced intra-articular (physeal) fractures of the great toe base of the proximal phalanx), 1 with secondary surgical management (SSM) and 87 did not specify treatment modality. For the stress fractures (n = 26), 23 were treated with PCM, 3 with PSM, and 6 with SSM. For acute fractures, RRS with PCM ranged from 0 to 100%, and RTS with PCM ranged from 1.2 to 24 wk. For acute fractures, RRS with PSM were all 100%, and RTS with PSM ranged from 12 to 24 wk. One case of an undisplaced intra-articular (physeal) fracture treated conservatively required conversion to SSM on refracture with a return to sport. For stress fractures, RRS with PCM ranged from 0% to 100%, and RTS with PCM ranged from 5 to 10 wk. For stress fractures, RRS with PSM were all 100%, and RTS with surgical management ranged from 10 to 16 wk. Six cases of conservatively-managed stress fractures required conversion to SSM. Two of these cases were associated with a prolonged delay to diagnosis (1 year, 2 years) and four cases with an underlying deformity [hallux valgus (n = 3), claw toe (n = 1)]. All six cases returned to the sport after SSM. CONCLUSION: The majority of sport-related toe phalanx fractures (acute and stress) are managed conservatively with overall satisfactory RRS and RTS. For acute fractures, surgical management is indicated for displaced, intra-articular (physeal) fractures, which offers satisfactory RRS and RTS. For stress fractures, surgical management is indicated for cases with delayed diagnosis and established non-union at presentation, or with significant underlying deformity: both can expect satisfactory RRS and RTS.

Surgical Management of Jones Fractures in Athletes: Orthobiologic Augmentation: A Systematic Review and Meta-analysis of 718 Fractures.

BACKGROUND: The use of orthobiologics is expanding. However, the use of orthobiologic augmentation in primary fracture fixation surgery remains limited. Primary fracture fixation of the fifth metatarsal (Jones) in athletes is one of the rare situations where primary orthobiologic augmentation has been advocated. PURPOSE: To determine the effect of orthobiologic augmentation on the outcome of surgically managed Jones fractures in athletes. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through March 2021 to identify studies reporting on surgically managed Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the return to play (RTP) rate and time to RTP, whereas the secondary outcomes were time to union, union rate, and refractures. Data were presented by type of treatment (biologically augmented fixation or fixation alone). RESULTS: In the biologically augmented fixation group, successful RTP was reported in 195 (98.98%) of 197 fractures (odds ratio [OR], 97.5%; 95% CI, 95.8%-100%; I2 = 0), with a mean time to RTP of 10.3 weeks (95% CI, 9.5-11.1 weeks; I2 = 99%). In the group that received fixation without biological augmentation, successful RTP was reported in 516 (99.04%) of 521 fractures (OR, 98.7%; 95% CI, 97.8%-99.7%; I2 = 0], with a mean time to RTP of 9.7 weeks (95% CI, 7.84-11.53 weeks; I2 = 98.64%]. In the biologically augmented fixation group, fracture union was achieved in 194 (98.48%) of 197 fractures (OR, 97.6%; 95% CI, 95.5%-99.7%; I2 = 0%), with a mean time to fracture union of 9.28 weeks (95% CI, 7.23-11.34 weeks; I2 = 98.18%). In the group that received fixation without biological augmentation, fracture union was achieved in 407 (93.78%) of 434 fractures (OR, 97.4%; 95% CI, 96%-98.9%; I2 = 0%), with a mean time to fracture union of 8.57 weeks (95% CI, 6.82-10.32 weeks; I2 = 98.81%). CONCLUSION: Orthobiologically augmented surgical fixation of Jones fractures in athletes is becoming increasingly common, despite the lack of comparative studies to support this practice. Biologically augmented fixation of Jones fractures results in higher fracture union rates than fixation alone but similar rates of RTP and time to RTP. Although the current evidence recommends primary surgical fixation for the management of Jones fractures in athletes, further high quality comparative studies are required to establish the indication for orthobiologic augmentation.

Assessing the readability of online information about jones fracture.

BACKGROUND: Hand in hand with technological advancements, treatment modalities continue to grow. With the turn of the century, the internet has become the number one source of information for almost every topic. Thus, many patients look toward the internet as their primary source of information to learn about their respective medical conditions. The American Medical Association and National Institute of Health strongly recommend that online medical information be written at the 6th to 8th-grade level to aid comprehension by patients of all literacy backgrounds. AIM: To assess the readability of online information regarding Jones fracture. Our hypothesis is that the reading level of medical information published on websites far exceeds the recommended reading level of 6th-8th grade as proposed by the American Medical Associate and National Institute of Health. The result of this study can help us formulate improved recommendations for publishing more comprehensible material and, thus, eventually improve patient compliance and clinical outcomes. METHODS: The exact phrase "Jones fracture" was queried on the three most common search engines, Google, Yahoo!, and Bing, on December 28, 2022. As of December 2022, Google held 84%, Bing held 9%, and Yahoo! held 2% of the worldwide search engine market share. Web pages uniform resource locator from the first three pages of search results were recorded from each search engine. These web pages were classified according to academic, physician-sponsored, governmental and non-government organizations (NGO), commercial, and unspecified as per formally defined categories. Websites associated with an educational institution or medical organization were classified as academic. Websites with products for sale, corporate sponsorship, or advertisements were classified as commercial. Governmental websites or NGOs comprised those that received government subsidies or grants. Webpages that were independently owned by physicians or physician groups were respectively classed as physician sponsored. The remainder of websites that did not fall under the above categories were classified as unspecified. RESULTS: A total of 93 websites were analyzed for reading assessment. A whopping 44% of websites were commercial, followed by 22% of physician-sponsored websites. Third place belonged to non-government organization websites holding a 15% share. The academic website held a meager 9% portion, while unspecified sites were 3%. The table illustrates mean readability scores, along with average cumulative grade level. The average grade level was 10.95 ± 2.28 for all websites, with a range of 6.18 to 18.90. Since P values were more than 0.05, there was not a significant statistical difference between the first page results and the results of all pages. Thus, we can rationalize that readability scores are consistent throughout all pages of a website. CONCLUSION: Hand in hand with technological advancements, treatment modalities continue to grow. With the turn of the century, the internet has become the number one source of information for almost every topic. Thus, many patients look towards the internet as the primary source of information to learn about their respective medical conditions. Our study demonstrates that current online medical information regarding Jones fracture is written at an extraordinarily high-grade level, with an average grade level of all websites at 10.95, nearly an 10th-grade educational level. The American Medical Association and National Institute of Health strongly recommend that online medical information should be written at the 6th to 8th-grade level to aid comprehension by patients of all literacy backgrounds. On the contrary, most of the medical information evaluated was at an 10th-grade level, which far exceeds recommendations by AMA and NIH. This is particularly relevant because readability scores are directly proportional to the level of comprehension attained by readers, thus directly impacting patient outcomes. In conclusion, we suggest and encourage that all online reading materials should be re-written at the 6th to 8th-grade level in a public service effort to increase compliance with treatment goals and raise awareness of preventive measures.

Fractures in soccer: The current evidence, and how this can guide practice.

This article reviews the current evidence on traumatic fractures in soccer, and assesses how this can guide practice. The incidence of traumatic soccer-related fractures was found to be 0.64 to 0.71/1000 in the general population. Demographics vary between the general population and professional soccer players, with 68% of traumatic soccer fractures occurring in the upper extremity in the general population, and only 23% of traumatic soccer fractures occurring in the upper extremity in professional players. Within the general population, around 80% of traumatic soccer-related fractures are managed non-operatively, with 20% managed operatively. The optimal treatment method is determined by fracture location and configuration. There is an increasing role for primary operative treatment in unstable, non-displaced fracture types, to facilitate an accelerated return to soccer. Around 86% of soccer players return to sport post-fracture. Return times vary by fracture locations and playing level, with elite players having quicker return times than the general population. Regarding injury prevention, shin guards appear to confer substantial benefit against tibial diaphyseal fractures. However, further research is required to determine the optimal preventative measures against fractures in soccer.

The influence of heatwave temperatures on fracture patient presentation to hospital.

INTRODUCTION: As global warming continues at its current rate, heatwaves are likely to become an increasing phenomenon. At present, knowledge of the influence of heatwave temperatures on fracture patient presentation to hospital remains limited. METHODS: This was a retrospective descriptive epidemiology study performed through hospital database review, linked to meteorological data. Emergency Department and Fracture Patient Presentation Data was obtained for the adult (16+) South Glasgow population (population count - 525,839) and the adult (16+) population covered by the West of Scotland Major Trauma Centre (population count - 2,218,326) from May 2021 to August 2021. This was combined with maximum temperature data, along with humidity and humidex data. Humidex is a measure which quantifies the temperature experienced by the patient, through a combined score incorporating both maximum temperature and humidity RESULTS: During the study period, there was one temperature heatwave (19th to 25th July), and four humidex heatwaves (27th June to 3rd July, 15th to 17th July, 19th to 27th July, 22nd to 26th August). During the temperature heatwave, there was a significantly higher incidence of orthopaedic polytrauma patient presentation (IRR 2.37: p < 0.027), as well as ED patient presentation (IRR 1.07: p < 0.036). The humidex heatwaves were associated with a significantly higher incidence of orthopaedic polytrauma patient presentation (IRR 2.31: p < 0.002) and overall fracture patient presentation (IRR 1.18: p < 0.002). Positive correlations were found between orthopaedic polytrauma patient presentation vs temperature (R=0.217: p < 0.016), ED patient presentation vs temperature (R=0.427: p < 0.001), fracture patient presentation vs temperature (R=0.394: p < 0.001), and distal radius fracture patient presentation vs temperature (R=0.246: p < 0.006). CONCLUSION: This study finds that heatwave temperatures result in a significantly increased number of orthopaedic polytrauma patients presenting to a Major Trauma Centre. Given the significant resources these patients require for care, Major Trauma Centres should be aware of such findings, and consider staff and resources profiles in response.

Doctor, I fractured my ankle. When can I return to play? An updated systematic review.

INTRODUCTION: Ankle fractures in sport are common. Their optimal management is unclear, as is when patients can return to their sports activities. This systematic review provides a contemporary assessment of the literature on return to sports following acute traumatic ankle fractures managed both operatively and non-operatively. SOURCES OF DATA: We systematically searched Pubmed, Google Scholar, the Cochrane Library, EMBASE and CINAHL using the terms 'ankle fractures', 'ankle injuries', 'athletes', 'sports', 'return to sport', 'return to activity', 'operative management', 'non-operative management'. AREAS OF AGREEMENT: Thirteen retrospective studies fulfilled the inclusion criteria. The methodological quality of the studies was generally poor. The proportion of patients returning to sporting activity was high. In some studies, a quicker return to sporting activity was demonstrated in patients managed non-operatively. AREAS OF CONTROVERSY: The time to return to sporting activity and level of performance post-treatment are not universally recorded, and the optimal time to return to sport remains to be confirmed. GROWING POINTS: Conservative management for stable or undisplaced fracture may result in a higher proportion of patients returning to sport more quickly. AREAS TIMELY FOR DEVELOPING RESEARCH: Randomized controlled trials should compare conservative to surgical treatment for appropriately chosen fracture patterns. Future studies should routinely report the timing of return to sport, the level of performance reached, and the time to achieve this.

Preoperative measures of bone mineral density from digital wrist radiographs.

AIMS: Assessment of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) is a well-established clinical technique, but it is not available in the acute trauma setting. Thus, it cannot provide a preoperative estimation of BMD to help guide the technique of fracture fixation. Alternative methods that have been suggested for assessing BMD include: 1) cortical measures, such as cortical ratios and combined cortical scores; and 2) aluminium grading systems from preoperative digital radiographs. However, limited research has been performed in this area to validate the different methods. The aim of this study was to investigate the evaluation of BMD from digital radiographs by comparing various methods against DXA scanning. METHODS: A total of 54 patients with distal radial fractures were included in the study. Each underwent posteroanterior (PA) and lateral radiographs of the injured wrist with an aluminium step wedge. Overall 27 patients underwent routine DXA scanning of the hip and lumbar spine, with 13 undergoing additional DXA scanning of the uninjured forearm. Analysis of radiographs was performed on ImageJ and Matlab with calculations of cortical measures, cortical indices, combined cortical scores, and aluminium equivalent grading. RESULTS: Cortical measures showed varying correlations with the forearm DXA results (range: Pearson correlation coefficient (r) = 0.343 (p = 0.251) to r = 0.521 (p = 0.068)), with none showing statistically significant correlations. Aluminium equivalent grading showed statistically significant correlations with the forearm DXA of the corresponding region of interest (p < 0.017). CONCLUSION: Cortical measures, cortical indices, and combined cortical scores did not show a statistically significant correlation to forearm DXA measures. Aluminium-equivalent is an easily applicable method for estimation of BMD from digital radiographs in the preoperative setting. Cite this article: Bone Joint Res 2021;10(12):830-839.

Return to sport following surgical management of triangular fibrocartilage tears: a systematic review.

INTRODUCTION: This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears. SOURCES OF DATA: A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'. AREAS OF AGREEMENT: In all of the 10 studies included, conservative management for 6 weeks to 6 months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears. AREAS OF CONTROVERSY: The optimal treatment modalities for TFC tears remain to be defined. GROWING POINTS: Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears. AREAS TIMELY FOR DEVELOPING RESEARCH: Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.

Hip hemi-arthroplasty for neck of femur fracture: What is the current evidence?

This editorial reviews and summarises the current evidence (meta-analyses and Cochrane reviews) relating to the use of hip hemi-arthroplasty for neck of femur fractures. Regarding the optimal surgical approach, two recent meta-analyses have found that posterior approaches are associated with: higher rates of dislocation compared to lateral and anterior approaches; and higher rates of re-operation compared to lateral approaches. Posterior approaches should therefore be avoided when performing hip hemi-arthroplasty procedures. Assessing the optimal prosthesis head component, three recent meta-analyses and one Cochrane review have found that while unipolar hemi-arthroplasty can be associated with increased rates of acetabular erosion at short-term follow-up (up to 1 year), there is no significant difference between the unipolar hemi-arthroplasty and bipolar hemi-arthroplasty for surgical outcome, complication profile, functional outcome and acetabular erosion rates at longer-term follow-up (2 to 4 years). With bipolar hemi-arthroplasty being the more expensive prosthesis, unipolar hemi-arthroplasty is the recommended option. With regards to the optimal femoral stem insertion technique, three recent meta-analyses and one Cochrane Review have found that, while cemented hip hemi-arthroplasties are associated with a longer operative time compared to uncemented Hip Hemi-arthroplasties, cemented prostheses have lower rates of implant-related complications (particularly peri-prosthetic femoral fracture) and improved post-operative outcome regarding residual thigh pain and mobility. With no significant difference found between the two techniques for medical complications and mortality, cemented hip hemi-arthroplasty would appear to be the superior technique. On the topic of wound closure, one recent meta-analysis has found that, while staples can result in a quicker closure time, there is no significant difference in post-operative infections rates or wound healing outcomes when comparing staples to sutures. Therefore, either suture or staple wound closure techniques appear equally appropriate for hip hemi-arthroplasty procedures.

Epidemiology of open fractures in sport: One centre's 15-year retrospective study.

AIM: To describe the epidemiology of sport-related open fractures from one centre's adult patient population over a 15-year period. METHODS: A retrospective review of a prospectively-collected database was performed: The database contained information all sport-related open fractures, sustained from 1995 to 2009 in the Edinburgh, Mid and East Lothian Populations. RESULTS: Over the 15-year period, there were 85 fractures recorded in 84 patients. The annual incidence of open sport-related fractures was 0.01 per 1000 population. The mean age at injury was 29.2 years (range 15-67). There were 70 (83%) males and 14 females (17%). The 6 most common sports were soccer (n = 19, 22%), rugby (n = 9, 11%), cycling (n = 8, 9%), hockey (n = 8, 9%); horse riding (n = 6, 7%) and skiing (n = 6, 7%). The five most common anatomical locations were finger phalanges (n = 30, 35%); tibial diaphysis (n = 19, 23%); forearm (n = 12, 14%); ankle (n = 7, 8%) and metacarpals (n = 5, 6%). The mean injury severity score was 7.02. According to the Gustilo-Anderson classification system, 45 (53%) fractures were grade 1; 28 (33%) fractures were grade 2; 8 (9%) fractures were grade 3a; and 4 (5%) fractures were grade 3b. Out of the total number of fractures, 7 (8%) required plastic surgical intervention as part of management. The types of flaps used were split skin graft (n = 4), fasciocutaneous flaps (n = 2); and adipofascial flap (n = 1). CONCLUSION: We analysed the epidemiology of open fractures secondary to sport in one centre over a 15-year period. Soccer and rugby were the most common causative sports while fractures of the finger phalanx and of the tibial diaphysis were the most common sites. Open fractures are uncommon in sport; however, when they are sustained they usually occur on muddy sport fields or forest tracks and therefore must be treated appropriately. It is important that clinicians and sports therapists have knowledge of these injuries, in order to ensure they are managed optimally.

Return to sport following tibial plateau fractures: A systematic review.

AIM: To systemically review all studies reporting return to sport following tibial plateau fracture, in order to provide information on return rates and times to sport, and to assess variations in sporting outcome for different treatment methods. METHODS: A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, MEDLINE, PEDro, Scopus, SPORTDiscus and Web of Science was performed in January 2017 using the keywords "tibial", "plateau", "fractures", "knee", "athletes", "sports", "non-operative", "conservative", "operative", "return to sport". All studies which recorded return rates and times to sport following tibial plateau fractures were included. RESULTS: Twenty-seven studies were included: 1 was a randomised controlled trial, 7 were prospective cohort studies, 16 were retrospective cohort studies, 3 were case series. One study reported on the outcome of conservative management (n = 3); 27 reported on the outcome of surgical management (n = 917). Nine studies reported on Open Reduction Internal Fixation (ORIF) (n = 193), 11 on Arthroscopic-Assisted Reduction Internal Fixation (ARIF) (n = 253) and 7 on Frame-Assisted Fixation (FRAME) (n = 262). All studies recorded "return to sport" rates. Only one study recorded a "return to sport" time. The return rate to sport for the total cohort was 70%. For the conservatively-managed fractures, the return rate was 100%. For the surgically-managed fractures, the return rate was 70%. For fractures managed with ORIF, the return rate was 60%. For fractures managed with ARIF, the return rate was 83%. For fractures managed with FRAME was 52%. The return rate for ARIF was found to be significantly greater than that for ORIF (OR 3.22, 95%CI: 2.09-4.97, P < 0.001) and for FRAME (OR 4.33, 95%CI: 2.89-6.50, P < 0.001). No difference was found between the return rates for ORIF and FRAME (OR 1.35, 95%CI: 0.92-1.96, P = 0.122). The recorded return time was 6.9 mo (median), from a study reporting on ORIF. CONCLUSION: Return rates to sport for tibial plateau fractures remain limited compared to other fractures. ARIF provides the best return rates. There is limited data regarding return times to sport. Further research is required to determine return times to sport, and to improve return rates to sport, through treatment and rehabilitation optimisation.

Lower limb stress fractures in sport: Optimising their management and outcome.

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by "high" and "low" risk. "Low risk" stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. "High risk" stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.

Femoral Neck Stress Fractures in Sport: A Current Concepts Review.

Femoral neck stress fractures (FNSFs) account for 3% of all sport-related stress fractures. The commonest causative sports are marathon and long-distance running. The main types of FNSF are compression-sided, tension-sided and displaced. The most common reported symptom is exercise-related groin pain. Radiographs form the first line of investigation, with MRI the second-line investigation. The management of FNSFs is guided by the location and displacement of the fracture. Delay in diagnosis is common and increases the likelihood of fracture displacement. Sporting outcomes are considerably worse for displaced fractures. Education programmes and treatment protocols can reduce the rates of displaced FNSFs. This article aims to provide a current concepts review on the topic of FNSFs in sport, assess the current evidence on the epidemiology and pathophysiology of these injuries, detail the current recommendations for their imaging and management, and review the recorded sporting outcomes for FNSFs in the existing literature. From this study, we conclude that although FNSFs are a rare injury, they should be considered in all athletes presenting with exercise-related hip pain, because delay in diagnosis and subsequent fracture displacement can significantly impair future return to sport. However, when detected early, FNSFs show promising results in terms of return-to-sport rates and times.

Return to Sport After Tibial Shaft Fractures: A Systematic Review.

CONTEXT: Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. OBJECTIVE: To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. DATA SOURCES: OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. STUDY SELECTION: Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. RESULTS: A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01). CONCLUSION: The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.

Freezing and non-freezing cold weather injuries: a systematic review.

INTRODUCTION: The debilitating impact of cold weather on the human body is one of the world's oldest recorded injuries. The severe and life-changing damage which can be caused is now more commonly seen recreationally in extreme outdoor sports rather than in occupational settings such as the military. The diagnosis and treatment of these injuries need to be completed carefully but quickly to reduce the risk of loss of limb and possibly life. Therefore, we have conducted a systematic review of the literature surrounding cold weather injuries (CWIs) to ascertain the epidemiology and current management strategies. SOURCES OF DATA: Medline (PubMED), EMBASE, CINHAL, Cochrane Collaboration Database, Web of Science, Scopus and Google Scholar. AREAS OF AGREEMENT IMMEDIATE FIELD TREATMENT: The risk of freeze thaw freeze injuries. Delayed surgical intervention when possible. Different epidemiology of freezing and non-freezing injuries. AREAS OF CONTROVERSY: Prophylatic use of antibiotics; the use of vasodilators surgical and medical. GROWING POINTS: The use of ilioprost and PFG2a for the treatment of deep frostbite. AREAS TIMELY FOR DEVELOPING RESEARCH: The treatment of non-freezing CWIs with their long-term follow-up.

Smartphone apps for spinal surgery: is technology good or evil?

PURPOSE: The increased utilization of smartphones together with their downloadable applications (apps) provides opportunity for doctors, including spinal surgeons, to integrate such technology into clinical practice. However, the clinical reliability of the medical app sector remains questionable. We reviewed available apps themed specifically towards spinal surgery and related conditions and assessed the level of medical professional involvement in their design and content. METHOD: The most popular smartphone app stores (Android, Apple, Blackberry, Windows, Samsung, Nokia) were searched for spinal surgery-themed apps, using the disease terms Spinal Surgery, Back Surgery, Spine, Disc Prolapse, Sciatica, Radiculopathy, Spinal Stenosis, Scoliosis, Spinal Fracture and Spondylolisthesis. RESULTS: A total of 78 individual spinal surgery themed apps were identified, of which there were six duplicates (N = 72). According to app store classifications, there were 57 (79 %) medical themed apps, 11 (15 %) health and fitness themed apps, 1 (1 %) business and 3 (4 %) education themed apps. Forty-five (63 %) apps were available for download free of charge. For those that charged access, the prices ranged from £0.62 to £47.99. Only 44 % of spinal surgery apps had customer satisfaction ratings and 56 % had named medical professional involvement in their development or content. CONCLUSIONS: This is the first study to specifically address the characteristics of apps related to spinal surgery. We found that nearly half of spinal surgery apps had no named medical professional involvement, raising concerns over app content and evidence base for their use. We recommend increased regulation of spinal surgical apps to improve the accountability of app content.