Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study.

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

The Impact of COVID-19 on Bicycle-Related Injuries Managed at a Level 1 Major Trauma Center in London, United Kingdom.

Introduction The COVID-19 pandemic changed peoples' travel behaviors; an uptake in cycling was observed in the United Kingdom. The aim of this study was to assess the cycling-related orthopedic injuries presented to a major trauma center (MTC) before and during the COVID-19 pandemic. Method This retrospective observational single-center study analyzed referrals to the orthopedic department during a matched two-month period in 2019 and 2020. Data were collated on cycling-related injuries including demographic variables, mechanism of injury, anatomical area of injury, and the management of injury. The data were compared and statistical analysis was performed using the Pearson Chi-squared test to assess for significance. Results A total of 2409 patients were referred to the orthopedic department with injuries. A 35.6% decrease in total referrals was made during the COVID-19 pandemic. Analysis of cycling-specific injuries demonstrated a statistically significant increase in referrals to the orthopedic department during the COVID-19 pandemic. A statistically significant difference in upper limb trauma was also observed during the COVID-19 pandemic. Patterns of management, namely operative vs. non-operative management, did not demonstrate a difference in the two time periods. Discussion This study highlights that during the COVID-19 pandemic, cycling behavior changed with more patients suffering orthopedic injuries as a result. Orthopedic departments may need to plan for this change in behaviors with more capacity being created to manage the demand. Conclusion Cycling-related injuries referred to the orthopedic department increased during the pandemic.

The e-scooter pandemic at a UK Major Trauma Centre: A cost-based cohort analysis of injury presentation and treatment.

OBJECTIVES: The aim of the study was to describe injuries related to electric scooter at a Major-Trauma-Centre in the UK, We reviewed data from January 2020-December 2020. METHODS: All patient-records mentioning electric-scooter at a major-MTC. Records were reviewed, and data were stratified according to two groups: electric scooter riders and other road users. A predefined survey was completed in all cases where 'e-scooter or electric scooter' was present. This contained variables such as patient demographics, mechanism of injury (including head and body protection), acuity, intoxication, treatment facility and clinical utilisation. Among incidents involving electric scooters, summary statistics on continuous and categorical variables of interest were reported. Healthcare modelling utilising time driven activity-based costing and Patient-Level-Activity-Costing used to conduct a post hoc analysis of health provider costs. RESULTS: 202 e-scooter injuries were identified. Riders were more likely to be young males aged 18-35, a minority of reported cases being associated with the influence of alcohol or drugs (7.4%). They fall independently involving no other party (87%); sustaining both minor and major injuries; with a significant proportion requiring urgent and emergent surgery 23.7% (n = 40) with 60.1% (n = 121) requiring further secondary care follow-up; whilst 16% require immediate admission with a mean LOS of 5.9 days, including 8-ITU admissions. The overall mortality rate was 0.5% (n = 1), and cost per patient was £1482.46/patient, reducing to £927.25/patient if immediate surgery (<12 h s) was not required. CONCLUSION: Due to an emphasis on social distancing, changes in UK law, e-scooters injuries have increased. Most injuries are reported in riders, and are minor, however the mean health episode cost was over £1000.00/patient due to the minority of serious injuries. Research on interventions to prevent e-scooter injuries including protective clothing like helmet wearing is needed to address this growing area of concern, and unnecessary costly healthcare utilisation.

A Comparison of Trans-Articular Screw Versus Dorsal Bridge Plate Versus Compression Locking Plate Fixation in B2 Lis Franc Injuries: A 5-Year Experience in a Level 1 Trauma Center, in the United Kingdom.

This retrospective case series aimed to identify whether trans-articular screws, dorsal bridging plates or if a 4-corner compression plate offers better functional outcome after B2 Lis Franc injuries. Thirty-eight patients underwent surgical fixation for these injuries over 5 years in a Level 1 Trauma Centre. Patients were treated in 1 of 3 treatment arms: trans-articular screw, dorsal bridge plate, or 4-corner compression plate fixation. The primary outcome measures were the Manchester Oxford Foot and Ankle Questionnaire and the Euroqol- 5DL score and surgical results included postoperative complications and further surgery. Injury type, energy of mechanism, and open versus closed status were not significantly different within any fixation group. We achieved 94.7% (n = 36) good anatomical reduction. Finding significant improvement between plate fixation (both types) versus trans-articular screw groups treatment functional outcomes. A clinically crucial improvement in Manchester Oxford Foot & Ankle Questionnaire scores, and improved Euroqol- 5DL outcomes between 4-corner compression plate and trans-articular screw group. Overall, there was no significant difference in metalware failure, metalware removal and soft tissue complications. This study concludes that functional outcomes after Lis Franc fractures are not just dependent on the quality of anatomical reduction but are affected by fixation type. Further studies are required to provide qualitative analysis and assessment of dorsal bridge plate fixation versus 4-corner plate. Significantly, we have seen the 4-corner compression plate group reached the minimum clinically meaningful difference in the Manchester Oxford Foot and Ankle Questionnaire when compared to trans-articular screw fixation.

Management of open elbow fractures: experiences and outcomes from a UK major trauma center.

HYPOTHESIS AND BACKGROUND: Open fractures about the elbow are an infrequent but complex injury with limited existing literature. The aims of the study were to review the treatment strategies of open elbows fractures, functional outcome and complication rates associated with the injury, and correlate the outcome with the topography of the fracture. METHODS: Patients (n = 21) with open elbow fractures injuries over a 2-year period were analyzed. They were assessed regarding the orthoplastic characteristics of their injury as well any other associated injuries. Outcomes were assessed objectively (achievement of bony union, range of movement, infection status, need for further procedures) and subjectively (Oxford Elbow Score, EQ-5D, EQ-VAS). RESULTS: The commonest grade of open injury was grade 3 (43%). Associated orthopedic injuries were present in 62% and associated system injuries in 57%. Almost half of the patients were noted to have had a significantly increased presenting mortality risk as per Injury Severity Score assessment. Mean time to first wound débridement was 31 hours. There were no cases of deep or chronic infection. Complete bony union was noted in 85% of patients, and 48% of patients required removal of metalwork. Subgroup analysis of the cohort by fracture topography (single unipolar elbow bone injury vs. multiple elbow bony injuries) demonstrated no significant difference (P > .05) regarding rate of complication or final Oxford Elbow Score, EQ-5D or EQ-VAS. Patients with injuries that involved the distal humerus had the highest rate for further procedures (P < .05). The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4, 0.54, and 62.18, respectively. DISCUSSION: Open elbow injuries are usually from high-energy trauma and often combined with other significant injuries. As a result, the timelines to elbow surgery were often delayed. However, this did not impact the local infection rates nor did it necessitate further surgery, but made achieving all British Orthopaedic Association Standards for Trauma targets difficult. Chronic infection was not an issue in this cohort. Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures. This is most commonly in the form of removal of metalwork and fibrinolysis. End outcomes for patients with open elbow fractures can be positive, despite the notable presenting Injury Severity Score. A subspecialist elbow and orthoplastic approach whenever possible is advocated.

Variation in the clinical commissioning of surgery for three common hand conditions in England.

The surgical referral policies for patients with trigger finger, ganglion removal and Dupuytren's disease were collected for all Clinical Commissioning Groups in England. The aim was to assess whether there was variation in the policies across England, resulting in inequality in patients' access to surgery. Data were collected between October 2018 and January 2019 and compared with national guidelines. Analysis of the results showed that for all three conditions, surgical commissioning policies varied depending on the locality. The results also show that despite the existence of national guidelines, they are not implemented. This has the potential to lead to variation in surgical referral and access to services for patients in different localities in England.Level of evidence: III.

Diagnostic challenge of the non-specific presentation of adult intussusception.

The following report will discuss the diagnosis and management of non-specific abdominal pain in a 77-year-old woman who presented to a district general hospital in South London. CT imaging demonstrated ileo-colic intussusception with free air and fluid indicating perforation. The images of the specimen clearly show the ileal tumour within the intussusception. Thus, the patient underwent an emergency right hemicolectomy and formation of a double-barrelled ileostomy. Histology subsequently confirmed this was secondary to a colonic adenocarcinoma. This case report is unique as it highlights that intussusception in adults is very difficult to accurately diagnose based on clinical features (due to non-specific findings) and even with radiology can be challenging. This is also the first documented case of the site of perforation not being directly involved with the site of intussusception. The perforation site was in fact distal to the intussusception. At the time of surgery, it was noted that the patient had significantly faecal loading up to her rectum. The resulting closed loop was the cause of her perforation.

Leg length discrepancy: the importance of a complete history and examination.

A 26-year-old woman with a 1-year history of right knee pain had failed to respond to analgesia and activity modification in the community. Her general practitioner referred her to the orthopaedic department for specialist review. A thorough history revealed that she had multiple orthopaedic interventions as a child. The patient had significant postoperative infection of the left knee following knee surgery at 7 years of age. Examination demonstrated the presence of a limp, scoliosis and suspected leg length discrepancy. Plain film radiography confirmed the presence of leg length discrepancy, with the right limb measuring 30 mm longer than the left. The leg length discrepancy was likely secondary to a growth arrest of the left knee following the postoperative infection in childhood. The patient was managed with physiotherapy and heel raises and received regular orthopaedic follow-up.