Total fibula dislocation: A rare variant of a Bosworth fracture-dislocation injury.

To our knowledge and from our review of the literature, this is a previously unreported variant of a Bosworth fracture - total fibula dislocation. A 45 year old male presented after a high energy external rotation injury to his lower leg and was diagnosed with a total fibula dislocation with the distal fibula dislocated and incarcerated posteriorly to the tibia. Definitive management was operative with fixation of the proximal tibiofibular joint and repair of the posterolateral corner structures as well as fixation distally of the syndesmosis injury. A graded rehabilitation programme was followed and 6 months postoperatively the patient was hill walking and jogging. Bosworth fracture-dislocations are rare injuries that can often be missed during the initial presentation, especially when there is no fracture associated with a dislocation. An underappreciation for the severity of this injury can have major sequelae and the clinician should have a high index of suspicion when diagnosing this injury. An appreciation for Bosworth fracture dislocations and their variations are important for the trauma surgeon.

Hallux valgus interphalangeus: reliability of radiological assessment.

BACKGROUND: Reliable radiographic measurement of hallux valgus interphalangeus (HVI) deformity has a role in guiding surgical management. HVI can be assessed using: The aim of the study is to investigate the reliability of these radiological parameters. METHODS: Seventy foot radiographs in patients pre and post hallux valgus corrective surgery were assessed by 3 observers. HVI was assessed using the radiological measurements described above. Two-way random, single measure intra-class correlation coefficients were calculated to assess agreement. RESULTS: Inter-observer reliability showed good agreement for DASA [ICC=0.77(0.61-0.88)], and excellent for HIA [ICC=0.92(0.85-0.96)] and PDPA [ICC=0.91(0.84-0.96)]. Intra-observer reliability was excellent for all angles; DASA [ICC=0.88 (0.76-0.95)], HIA [ICC=0.94(0.86-0.97)] and PDPA [ICC=0.83(0.65-0.92)]. CONCLUSIONS: Reliability is good to excellent among these three radiological techniques for assessing HVI. The HIA and PDPA are slightly more reliable.

Management of anticoagulation in hip fractures: A pragmatic approach.

Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures.The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents.We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration.Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy.The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal.The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties.Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients. Cite this article: EFORT Open Rev 2017;2:394-402. DOI: 10.1302/2058-5241.2.160083.

Litigation related to casting in Orthopaedics-An analysis of claims against the National Health Service in England.

Orthopaedic casts have been used to treat musculoskeletal conditions for hundreds of years and are still a fundamental component of treating a variety of disorders. As surgical techniques have advanced the frequency of use of orthopaedic casts has declined. With Orthopaedics being is one of the most litigious specialties in medicine we sough to evaluate how this related to casting in Orthopaedics and how we could learn from past mistakes. We analysed litigation claims related to Orthopaedic casts from 1995 to 2010 in which the claims were closed. 43 cases were related to orthopaedic casts. The total costs of these claims were over £2.3 million with an average total cost of £48,500 per claim. The most common cause for claim was harm caused when a cast was applied too tight and secondly from removing the cast. This is the first study to evaluate litigation claims related to Orthopaedic casts and highlights potential complications that if avoided will certainly improve the care of the patients and avoid unnecessary litigation.

Pre-operative urinary tract infection: is it a risk factor for early surgical site infection with hip fracture surgery? A retrospective analysis.

OBJECTIVE: The aims of the current study were to determine whether pre-operative urinary tract infections in patients presenting acutely with neck of femur fractures resulted in a delay to surgery and whether such patients were at increased risk of developing post-operative surgical site infections. DESIGN: A retrospective review of all patients presenting with a neck of femur fracture, at a single centre over a one-year period. The hospital hip fracture database was used as the main source of data. SETTING: UK University Teaching Hospital. PARTICIPANTS: All patients (n = 460) presenting across a single year study period with a confirmed hip fracture. OUTCOME MEASURES: The presence of pre-operative urinary tract infection, the timing of surgical intervention, the occurrence of post-operative surgical site infection and the pathogens identified. RESULTS: A total of 367 patients were operated upon within 24 hours of admission. Urinary infections were the least common cause of delay. A total of 99 patients (21.5%) had pre-operative urinary tract infection. Post-operatively, a total of 57 (12.4%) patients developed a surgical site infection. Among the latter, 31 (54.4%) did not have a pre-operative urinary infection, 23 (40.4%) patients had a pre-operative urinary tract infection, 2 had chronic leg ulcers and one patient had a pre-operative chest infection. Statistically, there was a strong relationship between pre-operative urinary tract infection and the development of post-operative surgical site infection (p-value: 0.0005). CONCLUSION: The results of our study indicate that pre-operative urinary tract infection has a high prevalence amongst those presenting with neck of femur fractures, and this is a risk factor for the later development of post-operative surgical site infection.

Are "Patellofemoral Symptoms" Truly Related to the Patellofemoral Joint?

PURPOSE: The pattern of symptoms of knee osteoarthritis has been thought to be indicative of specific compartment involvement. This study investigated whether there was a true correlation between patellofemoral joint (PFJ) symptoms and unicompartmental patellofemoral arthritis. MATERIALS AND METHODS: A prospective analysis of 34 patients rendered to be suffering from PFJ osteoarthritis and subsequently undergoing unicompartmental patellofemoral arthroplasty (PFA) was performed. A control cohort of 32 patients suffering from medial tibiofemoral joint (MTFJ) osteoarthritis was included in the analysis. Four questions derived from the Oxford knee score questionnaire, traditionally deemed to be indicative of PFJ osteoarthritis, were combined to create a PFJ subscore and statistically analyzed for their potential relationship with PFJ osteoarthritis and outcomes following PFA. RESULTS: The PFJ subscore indicated slightly worse pathology in patients undergoing PFA compared to MTFJ replacement, but the difference was not significant (9.7 and 9.6, respectively; p=0.851). The improvement in PFJ symptoms was higher in those undergoing PFA compared to MTFJ surgery; however, the difference was not statistically significant (3.7 and 2.2 respectively, p=0.074). CONCLUSIONS: We were unable to prove that these symptoms were predictive of PFJ pathology in the preoperative setting, nor were they useful in interpreting which symptoms would likely improve following PFA.

Neuroblastoma: a rare cause of a limping child. How to avoid a delayed diagnosis?

UNLABELLED: Neuroblastoma is the most common solid extracranial tumor of childhood. Even though >25% of presentations are orthopaedic in nature, ranging from a limp to lower limb paralysis, neuroblastoma is a rare cause of limping in childhood and can therefore be easily missed by the admitting orthopaedic surgeon. Four cases of metastatic neuroblastoma are reported who all presented with hip pain within the last 3 years at Royal Manchester Children's Hospital. They all posed a diagnostic dilemma and an alternative diagnosis was initially made. A simple screening examination of the abdomen after ultrasonographic hip examination for sepsis would have led to an earlier diagnosis in all 4 cases. We suggest that including the abdomen in children undergoing a hip sonographic examination in those who are slightly atypical in nature or have indications of malignancy may lead to an early diagnosis of this rare cause of hip pain. LEVEL OF EVIDENCE: IV.