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.

Ankle arthrodesis using the Taylor Spatial Frame for the treatment of infection, extruded talus and complex pilon fractures.

INTRODUCTION: The treatment of complex pilon fractures and talus fracture-dislocations present several challenges, like avoiding infection, achieving union, management of bone loss and function preservation. METHODS: Retrospective cohort review of fourteen patients who underwent ankle arthrodesis (AA) using the Taylor Spatial Frame (TSF) after pilon and talus fracture-dislocations. Ten tibiocalcaneal (TC) and four tibiotalar (TT) fusions were performed. Eleven of these cases were Gustilo III open fractures. Seven cases involved an open extruded talus. Four cases had established infections. There was a mean of 2.7 (range 0 - 8) operations prior to AA using TSF. The primary objective was to determine infection and union rates. Patient-reported outcomes (Short Form 36, SF-36) and functional outcomes (Ankle Osteoarthritis Score, AOS) were the secondary measures. RESULTS: Eradication and prevention of deep infection was achieved in all cases. Radiological union was achieved at a mean of 9 months (range 5 - 17). Solid AA was achieved in 12 of 14 cases using the TSF. Two TC fusions required a hindfoot fusion nail to achieve union. Eleven cases had concurrent bone transport, mean of 63 mm (range 33 - 180). Mean time of TSF treatment was 11.1 months (range 6 - 16). One case required delayed amputation. Eight patients were able to fully weight bear unaided after the treatment. Mean SF-36 was 65 (range 35 -100). Mean AOS was 36.5 (range 6.6 - 77.5) with 69.3% of scores graded good to excellent. Mean total number of operations was 5.9 (range 2 - 10). Minimum follow up time was 12 months (range 12 - 56). CONCLUSION: AA using TSF can be considered for complex pilon fractures and extruded talus. It has shown to be effective in achieving a solid fusion and infection eradication. While using the TSF in isolation, non-union must be suspected in TC fusions, absence of radiological signs of healing, massive bone loss, and possibly not using bone graft. Patients must be aware that while treatment of these injuries will be prolonged and carries the risk of many potential complications, it provides a good alternative to amputation.

First Metatarsophalangeal Joint Arthrodesis Using an Intraosseous Post and Lag Screw With Immediate Bearing of Weight.

Arthrodesis is the gold standard procedure for advanced arthrosis of the first metatarsophalangeal joint. Having a strong construct is preferable for allowing immediate bearing of weight, which facilitates patient rehabilitation. Plate and screw fixation is currently in favor but can lead to prominent metalware necessitating removal. The aim of this study is to report the results of a series of 54 first metatarsophalangeal joint arthrodeses performed in 52 patients treated with an implant composed of an intraosseous post and lag screw. All of the patients had a minimum follow-up of 1 year, and the indication for the surgery was end-stage hallux rigidus in 44 (81.5%) feet, severe hallux valgus in 8 (14.8%) feet, and rheumatoid arthritis in 2 (3.7%) feet. Arthrodesis was achieved in 52 (96.3%) feet at a mean of 61 ± 16 (range 39 to 201) days with nonunion observed in 2 (3.7%) feet; neither of the 2 patients had known risk factors. Metalware impinging on soft tissues necessitating removal was observed in 3 (5.6%) feet, and there were no cases of loss of position or implant breakage. The mean Manchester-Oxford Foot Questionnaire score improved from 46.4 ± 13.3 to 18.4 ± 9.4 (p < .001) at latest follow-up. In conclusion, our results suggest the intraosseous post and lag screw device was safe and effective, and it can be considered an alternative method of stabilizing the first metatarsophalangeal joint when undertaking arthrodesis surgery.

A Comparison of Two Designs of Postoperative Shoe on Function, Satisfaction, and Back Pain After Hallux Valgus Surgery.

Background. The reverse camber shoe is commonly used after hallux valgus corrective surgery to offload the forefoot but is associated with back pain and poor compliance. Recent designs of postoperative shoes may obviate the need for a reverse camber. The purpose of this study was to compare the effects of a reverse camber shoe and a noncambered shoe with transitional rigidity after hallux valgus correction. Methods. A cohort of 80 feet was prospectively studied undergoing surgery at a single NHS trust. The first 40 feet received the reverse cambered Jura Medical Off-loader Heel shoe and the subsequent 40 feet received the noncambered DonJoy Podalux shoe. No demographic differences existed between the groups and data were collected at 2 weeks, 6 weeks, and 6 months. The Manchester-Oxford Foot Questionnaire (MOXFQ), a 5-question survey and dichotomous question about back pain was used to assess clinical outcome and radiographs were reviewed by 2 orthopaedic surgeons to monitor for loss of correction. Results. Both groups experienced comparable improvements in MOXFQ and shoe satisfaction from 2 weeks compared with 6 weeks. Six patients experienced back pain in the reverse cambered shoe group and none in the noncambered shoe group. Five patients stopped using the reverse cambered shoe during the first 6 weeks after surgery and none stopped using their prescribed noncambered shoe. No loss of corrections were observed in either group. Conclusion. Both shoe designs gave equal foot specific functional and radiological outcomes, but the noncambered shoe with transitional rigidity was associated with less back pain and better compliance. Levels of Evidence: Level II: Prospective comparative study.

Predictors for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary nailing.

PURPOSE: The aim of our study was to determine predictive factors and requirement for perioperative blood transfusion in elderly patients with extra capsular hip fractures treated with cephalo-medullary device. METHODS: Seventy-nine patients with extra capsular hip fractures treated with cephalo-medullary nailing were included in the study. Age, sex, ASA grade, timing of surgery, preoperative and postoperative haemoglobin, length of hospital stay, fracture type, number of units transfused and 30-day mortality were recorded. RESULTS: The mean age was 82.3 years. Forty-seven patients underwent a short nail and 32 patients a long nail; 53.4% patients required blood transfusion postoperatively. Transfusion was required in 71.8% of the long nails (p < 0.05), 65.8% patients above the age of 80 (p < 0.05), 100% of the patients with hemoglobin below 90 g/L and 20 patients with a ASA grade of 3 (p < 0.05). 78.5% patients with A2 fracture and 75% of A3 fractures needed blood transfusion (p > 0.05). Length of hospital stay in non-transfusion group was 13 days and in transfusion group was 19 days (p < 0.05). 55.1% operated within 36 h and 47.6% operated after 36 h of admission needed transfusion (p > 0.05). Thirty-day mortality in patients needing blood transfusion was 5% and in non-transfusion group was 3.7% (p > 0.05). CONCLUSION: Patient age, ASA grade, preoperative haemoglobin and length of nail are reliable predictors for perioperative blood transfusion in extra capsular hip fractures in elderly patients treated with cephalo-medullary nailing and reinforce a selective transfusion policy.

Retrospective comparison of functional and radiological outcome, between two contemporary high flexion knee designs.

INTRODUCTION: Patient satisfaction after total knee replacement (TKR) depends on the amount of pain relief and the functional activities achieved. An important criterion of good functional outcome is the amount of flexion achieved and whether the patient can manage high flexion activities. In order to increase the amount of safe flexion, various implant designs have been developed. This study aims to compare the outcome after TKR using two contemporary high flexion knee designs: Sigma CR150 High Flex Knee prosthesis (Depuy, Warsaw, Indiana) and NexGen High Flex Knee prosthesis (Zimmer, Warsaw, Indiana). MATERIAL: A retrospective study was conducted with 100 cases of each design and their functional and radiological outcome was assessed after two years of follow-up. RESULTS: The two groups had comparable results in terms of subjective satisfaction, range of motion achieved and radiological outcome. Depuy group fared better than Zimmer in terms of functional outcome (modified Oxford knee score). CONCLUSION: Depuy group was found to have fared better than Zimmer in terms of functional outcome. However, it is very difficult to rate one design above the other based on our small sample size and short duration of follow-up.

Patellar nonunions: Comparison of various surgical methods of treatment.

BACKGROUND: Nonunion of patella is an uncommon entity prevalent more commonly in developing countries. Many of them have a functional knee joint and only those with a wide gap and failed extensor mechanism need surgery. We report an analysis of nonunion of fracture patella treated by 3 surgical method. MATERIALS AND METHODS: 35 patients of nonunion/delayed union of patella with significant gap and failure of quadriceps mechanism, underwent three different methods surgically: 1) V-Y plasty and tension band wiring (n=10); 2) patellar traction followed by tension band wiring without V-Y plasty (n=15); and 3) patellar traction followed by partial or total patellectomy (n=10). We compared the results of the treatment in terms of Knee Society Score (KSS), Melbourne patella score, time of union, pain, range of movement, quadriceps power, and ability to do daily activities and complications encountered. RESULTS: The 15 cases of patellar traction followed by tension band wiring showed the best results in terms of time to return to normal activities and complications encountered. Cases with patellectomy showed the next best results but they had a longer period of rehabilitation with ultimately lesser patient satisfaction. V-Y plasty gave the worst results both in complication rate and function return. CONCLUSION: Preoperative patellar traction followed by tension band wiring is a good procedure giving better results than either patellectomy or V-Y plasty.

Antibiotic-impregnated articulating cement spacer for infected total knee arthroplasty.

BACKGROUND: Standard treatment of chronic infected total knee arthroplasty (TKA) is a two-stage revision, the first step being placement of an antibiotic-impregnated cement spacer. Here we describe the results of a new technique (modification of the Goldstien's technique) for intraoperative manufacture of a customized articulating spacer at minimal cost and with relatively good conformity and longevity. MATERIALS AND METHODS: Thirty-six infected knees underwent this procedure from June 2002 to May 2007. The technique consists of using the freshened femur and tibia interface as molds wrapped in a tin foil for manufacturing the two components of the spacer with antibiotic-impregnated methyl methycrylate cement. We used the spacer and the femoral component of the trial set of a TKA system to mold them to perfect articulation. We also reinforced the spacer with a K-wire scaffold to prevent fracture of the cement mantle in the last 21 cases. RESULTS: All 36 knees showed excellent results in terms of infection control, mobility, and stability. There was significant improvement in the WOMAC and Knee Society Scores (20 and 39 points respectively). There were two fractures of the spacers in the initial 15 cases that did not have K-wire scaffolding but none in the last 21 that had reinforcement. CONCLUSION: This technique provides a more conforming spacer, with good range of motion and stability. The reinforcement helps in preventing the fracture of the cement mantle and is cost effective.

Outcome of radial head preserving operations in missed Monteggia fracture in children.

BACKGROUND: The dislocated radial head in missed Monteggia fracture loses its concave articular surface and displays hypertrophic changes and flattened humeral capitellum configuration, thereby limiting the range of motion. We evaluated the results of open reduction in missed Monteggia fractures by various techniques. MATERIALS AND METHODS: Sixty-three missed Monteggia fractures were included in the analysis. We performed four combinations of operation: Group I: 22 patients treated with modified Hirayama ulnar osteotomy plus annular ligament reconstruction with free Palmaris longus grafting; Group II:18 patients treated with modified Hirayama ulnar osteotomy plus annular ligament reconstruction by the Bell Tawse's procedure; Group III-9: patients treated with only modified Hirayama's osteotomy; and Group IV: 14 patients treated with transverse osteotomy of ulna and annular ligament reconstruction by the Bell Tawse's procedure. During followup these cases were assessed for the following parameters: 1) range of motion and 2) mayo elbow performance index (MEPI). Results were noted on follow ups at 3, 6, 12 months and then on yearly basis. Sixty-three patients were followed up for an average duration of 5.6 years (range 3-8 years). RESULTS: The mean range of motion was increased by 45°, 30°, 45°, 20° for Group I, II, III and IV respectively. The average increase in MEPI scores was also almost on the same lines. There was one case of frank dislocation in group III and six cases of subluxation, two each in Groups II, III, and IV. For Annular ligament reconstruction, amongst two procedures, Groups II and IV (Bell Tawse group), had a significant extension lag contributing to the lower increase in the range of motion as compared to the Palmaris longus reconstruction group (group I). CONCLUSION: Hirayama's osteotomy is inherently more stable than the simple transverse osteotomy and it should be combined with annular ligament reconstruction. Palmaris longus graft for ligament reconstruction provides more stability as compare to Bell Towse's procedure.