The engagement of orthopaedic surgeons in diabetic foot care in England.

AIMS: Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. METHODS: A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. RESULTS: Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). CONCLUSION: Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff.Cite this article: Bone Jt Open 2022;3(8):618-622.

The epidemiology and trends in the surgical management of calcaneal fractures in England between 2000 and 2017.

AIMS: This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries. PATIENTS AND METHODS: In England, the Hospital Episode Statistics (HES) data are recorded annually. Between 2000/01 and 2016/17, the number of adults admitted to an English NHS hospital with a calcaneal fracture and whether they underwent surgical treatment was determined. RESULTS: During this 17-year period, 62 858 patients were admitted to hospital with a calcaneal fracture. The male-to-female ratio was 2.66:1. The mean annual incidence was 10.5/100 000 for men and 3.8/100 000 for women. The results of the UK HeFT were published in July 2014. The percentage of patients admitted with a calcaneal fracture undergoing internal fixation was 7.31% (3792/51 859) before and 7.38% (534/7229) after its publication. This difference was not statistically significant (p = 0.94). Since 2015, there has been a significant increase in the percentage of calcaneal fractures treated by closed reduction and internal fixation, as opposed to open reduction and internal fixation, from 7.7% (292/3792) to 13.29% (71/534) (p < 0.001). CONCLUSION: This study documents the epidemiology and trends in surgical treatment of calcaneal fractures in England. We established that surgeons did not change their practice in terms of offering surgery to these patients in response to the results of the UK HeFT. There has been a significant (p < 0.001) increase in the number of calcaneal fractures being treated surgically using less invasive procedures.

Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy.

Charcot neuroarthropathy is a rare but serious complication of diabetes, causing progressive destruction of the bones and joints of the foot leading to deformity, altered biomechanics and an increased risk of ulceration. Management is complicated by a lack of consensus on diagnostic criteria and an incomplete understanding of the pathogenesis. In this review, we consider recent insights into the development of Charcot neuroarthropathy. It is likely to be dependent on several interrelated factors which may include a genetic pre-disposition in combination with diabetic neuropathy. This leads to decreased neuropeptides (nitric oxide and calcitonin gene-related peptide), which may affect the normal coupling of bone formation and resorption, and increased levels of Receptor activator of nuclear factor kappa-B ligand, potentiating osteoclastogenesis. Repetitive unrecognized trauma due to neuropathy increases levels of pro-inflammatory cytokines (interleukin-1ß, interleukin-6, tumour necrosis factor α) which could also contribute to increased bone resorption, in combination with a pre-inflammatory state, with increased autoimmune reactivity and a profile of monocytes primed to transform into osteoclasts - cluster of differentiation 14 (CD14). Increased blood glucose and loss of circulating Receptor for Advanced Glycation End-Products (AGLEPs), leading to increased non-enzymatic glycation of collagen and accumulation of AGLEPs in the tissues of the foot, may also contribute to the pathological process. An understanding of the relative contributions of each of these mechanisms and a final common pathway for the development of Charcot neuroarthropathy are still lacking. Cite this article: S. E. Johnson-Lynn, A. W. McCaskie, A. P. Coll, A. H. N. Robinson. Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy. Bone Joint Res 2018;7:373-378. DOI: 10.1302/2046-3758.75.BJR-2017-0334.R1.

The functional and dynamometer-tested results of transtendinous flexor hallucis longus transfer for neglected ruptures of the Achilles tendon at six years' follow-up.

Aims: Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture. Patients and Methods: We report a retrospective review of 20/32 patients who had undergone transtendinous FHL transfer between 2003 and 2011 for chronic TA rupture. Their mean age at the time of surgery was 53 years (22 to 83). The mean time from rupture to surgery was seven months (1 to 36). The mean postoperative follow-up was 73 months (29 to 120). Six patients experienced postoperative wound complications. Results: The mean postoperative Achilles tendon Total Rupture Score (ATRS) was 83 (40 to 100) and the mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 94.3 (82 to 100). Tegner scoring showed a mean reduction of one level from the pre-injury level of activity. There was a mean reduction of 24% (4 to 54) in dynamometer-measured strength of ankle plantarflexion, in comparison with the non-operated side. The hallux had a mean of only 40% (2 to 90) strength of plantarflexion in comparison with the contralateral side. Conclusion: We conclude that transtendinous FHL transfer for neglected TA ruptures, with a long harvest to allow reattachment of the triceps surae, provides reliable long-term function and good ankle plantarflexion strength. Despite the loss of strength in hallux plantar flexion, there is little comorbidity from the FHL harvest. Cite this article: Bone Joint J 2018;100-B:584-9.

Functional outcomes of conservatively managed acute ruptures of the Achilles tendon.

AIMS: This prospective cohort study aims to determine if the size of the tendon gap following acute rupture of the Achilles tendon shows an association with the functional outcome following non-operative treatment. PATIENTS AND METHODS: All patients presenting within two weeks of an acute unilateral rupture of the Achilles tendon between July 2012 and July 2015 were considered for the study. In total, 38 patients (nine female, 29 male, mean age 52 years; 29 to 78) completed the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon Total Rupture score (ATRS) six months after the completion of a rehabilitation programme. RESULTS: Patients with a gap ≥ 10 mm with the ankle in the neutral position had significantly greater peak torque deficit than those with gaps < 10 mm (mean 23.3%; 7% to 52% vs 14.3%; 0% to 47%, p = 0.023). However, there was no difference in ATRS between the two groups (mean score 87.2; 74 to 100 vs 87.4; 68 to 97, p = 0.467). There was no significant correlation between gap size and torque deficit (τ = 0.103), suggesting a non-linear relationship. There was also no significant correlation between ATRS and peak torque deficit (τ = -0.305). CONCLUSION: This is the first study to identify an association between tendon gap and functional outcome in acute rupture of the Achilles tendon. We have identified 10 mm as a gap size at which deficits in plantarflexion strength become significantly greater, however, the precise relationship between gap size and plantarflexion strength remains unclear. Large, multicentre studies will be needed to clarify this relationship and identify population subgroups in whom deficits in peak torque are reflected in patient-reported outcome measures. Cite this article: Bone Joint J 2017;99-B:87-93.

Outcome of limited forefoot amputation with primary closure in patients with diabetes.

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation. We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment.

Thromboprophylaxis in elective foot and ankle patients--current practice in the United Kingdom.

BACKGROUND: The incidence of venous thromboembolism (VTE) is unknown in elective foot and ankle surgery. The National Institute for Health and Clinical Excellence (NICE) recently published guidelines on reducing the risk of venous thromboembolism in surgical patients. This includes patients undergoing elective foot and ankle surgery. METHOD: In March 2010 we surveyed the current practice in VTE prophylaxis in elective foot and ankle surgery amongst members of the British Orthopaedic Foot and Ankle Society (BOFAS). RESULTS: The response rate was 84 (53%). The total number of elective foot and ankle operations performed by the surveyed group was 33,500 per annum. The estimated incidence of DVT, PE and fatal PE was 0.6%, 0.1% and 0.02%. In our study the number of patients needed to treat to prevent a single fatal PE is 10,000 although this figure is open to important bias. CONCLUSION: We question the applicability of the NICE guidelines to patients undergoing elective foot and ankle surgery. We consider that this data justifies the prospective study of the incidence of VTE in patients undergoing elective foot and ankle surgery, without the use of chemical thromboprophylaxis.

Association between glycated haemoglobin and the risk of lower extremity amputation in patients with diabetes mellitus-review and meta-analysis.

AIMS/HYPOTHESIS: Diabetes increases the risk of lower extremity amputation (LEA). Although epidemiological studies report positive associations between glycaemia and LEA, the magnitude of the risk is not adequately quantified and clinical trials to date have not provided conclusive evidence about glucose lowering and LEA risk. We synthesised the available prospective epidemiological data on the association between glycaemia measured by HbA(1c) and the risk of LEA in individuals with diabetes. METHODS: We searched electronic databases and reference lists of relevant articles. We considered prospective epidemiological studies that had measured HbA(1c) level and assessed LEA as an outcome among diabetic individuals without acute foot ulcerations or previous history of amputation. Of 2,548 citations identified, we included 14 studies comprising 94,640 participants and 1,227 LEA cases. We abstracted data using standardised forms and obtained data from investigators when required. Data included characteristics of study populations, HbA(1c) assay methods, outcome and covariates. Study-specific relative risk estimates were pooled using random-effects model meta-analysis; heterogeneity was explored with meta-regression analyses. RESULTS: The overall RR for LEA was 1.26 (95% CI 1.16-1.36) for each percentage point increase in HbA(1c). There was considerable heterogeneity across studies (I (2) 76%, 67-86%; p < 0.001), which was not accounted for by recorded study characteristics. The estimated RR was 1.44 (95% CI 1.25-1.65) for type 2 diabetes and 1.18 (95% CI 1.02-1.38) for type 1 diabetes; however, the difference was not statistically significant (p = 0.09). We found no strong evidence for publication bias. CONCLUSIONS/INTERPRETATION: There is a substantial increase in risk of LEA associated with glycaemia in individuals with diabetes. In the absence of conclusive evidence from trials, this paper provides further epidemiological support for glucose-lowering as a strategy to reduce amputation in a population without acute foot ulceration or former amputation; it also provides disease modellers with estimates to assess the overall burden of hyperglycaemia.

Surgical aspects of the diabetic foot.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis.

We performed two independent, randomised, controlled trials in order to assess the potential benefits of immediate weight-bearing mobilisation after rupture of the tendo Achillis. The first trial, on operatively-treated patients showed an improved functional outcome for patients mobilised fully weight-bearing after surgical repair. Two cases of re-rupture in the treatment group suggested that careful patient selection is required as patients need to follow a structured rehabilitation regimen. The second trial, on conservatively-treated patients, provided no evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular, there was no evidence of tendon lengthening or a higher re-rupture rate. We would advocate immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the tendo Achillis.

Increased expression of aggrecan and biglycan mRNA in Achilles tendinopathy.

OBJECTIVES: To determine the expression of mRNA encoding the proteoglycans aggrecan, versican, biglycan and decorin in mid-tendon samples of chronic painful Achilles tendinopathy and ruptured Achilles tendons, compared with normal tendons. METHODS: Total RNA isolated from frozen tendon samples (14 normal, 13 painful, 14 ruptured) was assayed by relative quantitative reverse transcription polymerase chain reaction for aggrecan, versican, biglycan and decorin mRNA, normalized using 18S rRNA. Differences between sample groups were tested by univariate analysis of variance with age as co-variate. RESULTS: In normal tendon samples expression of each of the proteoglycan mRNA decreased with increasing age. Decorin mRNA was the most highly-expressed of the proteoglycan mRNA, while versican mRNA expression was higher (3.8-fold) than that of aggrecan. In painful tendinopathy both aggrecan and biglycan mRNA expression increased (more than 10-fold and 5-fold, respectively) compared with normal tendon samples, but levels of versican and decorin mRNA were not significantly changed. In ruptured tendons the levels of aggrecan, biglycan and versican mRNA were not changed compared with normal tendon samples, but decorin mRNA decreased markedly. CONCLUSIONS: Increased aggrecan and biglycan mRNA expression in painful tendinopathy resembles the pattern in fibrocartilaginous regions of tendon, and may reflect an altered mechanical environment at the site of the lesion. Increased aggrecan mRNA expression may underlie the increase in glycosaminoglycan observed in painful tendinopathy.

Arthroscopic assessment of the syndesmosis following ankle fracture.

A Maisonneuve ankle fracture without convincing evidence of syndesmotic injury on plain radiographs is described. Stress views and computerised tomography (CT) were also negative. A high index of suspicion led to ankle arthroscopy, which revealed a diastasis, and also an osteochondral fragment. This was treated with two percutaneous diastasis screws and removal of the osteochondral fragment. This case suggests that ankle arthroscopy should be considered as part of the management of syndesmotic injury where conventional imaging techniques fail to show syndesmotic disruption.

The proximal extent of the ankle capsule and safety for the insertion of percutaneous fine wires.

We have assessed the proximal capsular extension of the ankle joint in 18 patients who had a contrast-enhanced MRI ankle arthrogram in order to delineate the capsular attachments. We noted consistent proximal capsular extensions anterior to the distal tibia and in the tibiofibular recess. The mean capsular extension anterior to the distal tibia was 9.6 mm (4.9 to 27.0) proximal to the anteroinferior tibial margin and 3.8 mm (-2.1 to 9.3) proximal to the dome of the tibial plafond. In the tibiofibular recess, the mean capsular extension was 19.2 mm (12.7 to 38.0) proximal to the anteroinferior tibial margin and 13.4 mm (5.8 to 20.5) proximal to the dome of the tibial plafond. These areas of proximal capsular extensions run the risk of being traversed during the insertion of finewires for the treatment of fractures of the distal tibia. Surgeons using these techniques should be aware of this anatomy in order to minimise the risk of septic arthritis.

Is epidural anaesthesia acceptable at total hip arthroplasty? A study of the rates of urinary catheterisation.

Epidural anaesthesia, with and without opiate, is widely used in total hip arthroplasty (THA). It may cause urinary retention, leading to catheterisation, and a subsequent increase in the likelihood of deep infection. We investigated prospectively the rate of urinary catheterisation in patients after THA performed under general anaesthesia, with or without peri-operative fentanyl and bupivacaine opiate epidural anaesthesia. Of 173 patients, 75 received general anaesthesia alone and 98 both general and epidural management. The post-operative rate of catheterisation was 14.7% in those who received general anaesthesia alone and 13.3% in those who received both. Our findings suggest that the rate of post-operative urinary catheterisation does not increase when general anaesthesia is supplemented by epidural anaesthesia using fentanyl and bupivicaine.

Versican splice variant messenger RNA expression in normal human Achilles tendon and tendinopathies.

OBJECTIVES: Versican is the principal large proteoglycan expressed in mid-tendon, but its role in tendon pathology is unknown. Our objective was to define the expression of versican isoform splice variant messenger ribonucleic acid (mRNA) in normal Achilles tendons, in chronic painful tendinopathy and in ruptured tendons. METHODS: Total RNA isolated from frozen tendon samples (normal n = 14; chronic painful tendinopathy n = 10; ruptured n = 8) was assayed by relative quantitative reverse transcriptase polymerase chain reaction (RT-PCR) for total versican, versican variants V0, V1, V2, V3 and type I collagen alpha1 mRNA, normalized to glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Differences between sample groups were tested by Wilcoxon statistics. RESULTS: Painful and ruptured tendons showed a significant decrease (median 2-fold) in the expression of versican mRNA, in contrast to an increased expression (median 8-fold) of type I collagen alpha1 mRNA in painful tendons. Versican splice variants V0 and V1 mRNA were readily detected in normal samples, V3 levels were substantially lower, and V2 levels were more variable. Each of V1, V2 and V3 mRNA showed significant decreases in expression in painful and ruptured tendons, but V0 was not significantly changed. CONCLUSIONS: Changes in versican expression relative to that of collagen, and alterations in the balance of versican splice variants, may contribute to changes in matrix structure and function in tendinopathies.