Risk Factors for Nonunion After First Metatarsophalangeal Joint Arthrodesis With a Dorsal Locking Plate and Compression Screw Construct: Correction of Hallux Valgus Is Key.

First metatarsophalangeal joint (MTPJ) arthrodesis is currently the gold standard technique for advanced hallux rigidus. This retrospective study aimed to identify the risk factors for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. Between April 2014 and April 2019, 165 consecutive patients (28 men and 137 women; mean age, 60 (range, 28-84) years) who underwent 178 primary first MTPJ arthrodeses were retrospectively reviewed. All arthrodeses were performed using either a dorsal locking plate with an integrated compression screw (Anchorage CP plate, Stryker, n = 97) or a dorsal locking plate (Anchorage V2 plate, Stryker, n = 81) with a separate compression screw (4 mm cannulated ACE screw). Union was defined as bone bridging across the fusion site on at least 2 of the 3 standard foot radiographs (anteroposterior, lateral, oblique) and no MTPJ movement or pain during clinical examination. Potential risk factors for nonunion were analyzed with the use of univariate and multivariate analyses. The overall nonunion rate was 6.2% (11 of 178 cases). The risk factors identified in the univariate analysis included preoperative hallux valgus deformity, postoperative residual hallux valgus deformity, and diabetes (p < .05). Multivariate analysis confirmed that postoperative residual hallux valgus deformity (odds ratio 6.5; p= .015) and diabetes (odds ratio 7.4; p = .019) are independent risk factors for nonunion after first MTPJ arthrodesis. Diabetes is the most important independent risk factor for nonunion after first MTPJ arthrodesis with a dorsal locking plate and compression screw construct. A residual postoperative hallux valgus deformity is associated with a significantly increased risk for nonunion. It is therefore crucial to correct the hallux valgus deformity to a hallux valgus angle of less than 20°.

Pes Planus Deformity and Its Association With Hallux Valgus Recurrence Following Scarf Osteotomy.

BACKGROUND: Hallux valgus recurrence is an unsatisfactory complication, with many causes postulated. This study investigated the effect of pes planus on recurrence after scarf osteotomy. METHODS: A total of 183 feet were retrospectively reviewed. All patients were treated with a scarf osteotomy and if required Akin osteotomy. We measured preoperative lateral talus first metatarsal angle (T1MA) to study pes planus; an angle of under -4 degrees was considered pes planus. We measured pre and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and sesamoid location. In total 164 feet were suitable for inclusion, with follow-up of at least 6 months (10 males and 154 females, mean age: 52 years). RESULTS: Recurrence frequency (HVA greater than 15 degrees) was 27 feet (16%). Hallux valgus recurrence was not influenced by gender (P value = .66) or preoperative IMA (P value = .48). Preoperative HVA greater than 35 degrees was associated with increased frequency of recurrence (P value = .004). Those with T1MA less than -10 degrees demonstrated progression in HVA and deterioration in sesamoid location up to 6 months postoperatively (P value = .038). HVA did not progress beyond 6 months. The prevalence of recurrent hallux valgus with normal T1MA was 1%, in T1MA -4 to -10 degrees it was 29% and in T1MA less than -10 degrees it was 47% (P value <.001). Breaks in T1MA less than -4 degrees were found at the naviculocuneiform joint in 68% of feet in this series. CONCLUSION: The prevalence of hallux valgus recurrence correlated with the severity of pes planus. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The effect of training on fracture clinic efficiency and patient access.

OBJECTIVE: The aim of this study was to assess the effect of education and use of a referral protocol on fracture clinic referral pathways, function, and patient care in the emergency department. METHODS: At Craigavon Area Hospital, a district general hospital, 58 new patient referrals were reviewed by the attending orthopedic surgeon at the fracture clinic. Each case was reviewed with regards to diagnosis, appropriateness of review time, and actual review time. Following this, the senior author performed a 1-hour teaching program in the ED utilizing a referral protocol. The study was then repeated in 63 patients to evaluate any improvement in patient treatment. RESULTS: Following the teaching program, a statistically significant improvement was found in interpretation of protocol (p=0.02), review time suggested (<0.00), and proportion of patients that actually receive an appropriate review time (p=0.004). No significant change was found with regards to grade of ED clinician referring the patient. CONCLUSION: The use of a simple education program and referral protocol may provide a significant improvement in appropriateness of patient referrals in the emergency department. This leads to a significant increase in patients referred with correct diagnoses, timeliness of review times, and subsequently improved patient care.

Predictors for Readmission up to 1 Year Following Hip Fracture.

BACKGROUND: At Altnagelvin, a district general hospital in Northern Ireland, we have observed that a significant number of hip fracture admissions are later readmitted for treatment of other medical conditions. These readmissions place increasing stress on the already significant burden that orthopedic trauma poses on national health services. OBJECTIVES: The aim of this study was to review a series of consecutive patients managed at our unit at least 1 year prior to the onset of the study. Also, we aimed to identify predictors for raised admission rates following treatment for hip fracture. PATIENTS AND METHODS: We reviewed a prospective fracture database and online patient note system for patient details, past medical history, discharge destination and routine blood tests for any factors that may influence readmission rates up to 1 year. Data were analyzed using SPSS software. RESULTS: Over 2 years, 451 patients were reviewed and 23 were managed conservatively. There was a 1-year readmission rate of 21%. Most readmission diagnoses were medical including bronchopneumonia, falls, urosepsis, cardiac exacerbations and stroke. Prolonged length of stay and discharge to a residential, fold or nursing home were found to increase readmission rate. Readmission diagnoses closely reflected the perioperative diagnoses that prolonged length of stay. Increased odds radio and risk of readmission were also found with female gender, surgery with a cephalomedullary nail, hip hemiarthroplasty or total hip replacement, time to surgery < 36 hours, alcohol consumption, smoking status, Hb drop > 2 g/dL and also if a blood transfusion was received. CONCLUSIONS: Our results indicate that hip fracture treatment begins at acute fracture clerk in, with consideration of comorbid status and ultimate discharge planning remaining significant predictors for morbidity and subsequent readmission.