Background
Sickle cell disease (SCD) is a multisystem disease, and the predominant articular manifestation is osteonecrosis (ON). Total hip arthroplasty (THA) is technically challenging, and the ...complication rates are high. In this retrospective study, we have analysed the outcome of THA in a cohort of patients with SCD at our institution.
Materials and methods
We identified 34 THAs between 1999 and 2016 in 30 patients (mean age 37 years) from our SCD database. Co-morbidities, both sickle and non-sickle-related, were documented. Complications and indications for revision surgery were analysed.
Results
An uncemented prosthesis was predominantly used. The mean follow-up was 10.5 years (range 1–18). Six patients had revision surgery (17.6%), 2 (5.8%) for Prosthetic Joint Infection (PJI), and 4 (11.7%) for osteolysis of the acetabular component.
Conclusion
Our revision rates were comparable to the published literature. Our combined sickle cell clinic and the coordinated multidisciplinary management have been successful in reducing morbidity.
Bone loss after avascular necrosis of the talus secondary to acute traumatic or chronic pathologies often requires surgical reconstruction. This study reports the early results of a sliding oblique ...hindfoot osteotomy for salvage procedures combined with tibiotalar arthrodesis to achieve a well-aligned, painless, plantigrade foot. All patients presenting to our institution with severe talus body defects requiring corrective surgery between January 2016 and August 2020 were included. An oblique osteotomy of the diseased talus was performed to correct anterior talus subluxation and prevent excessive loss of height at the tibiotalar apposition and to correct varus-valgus deformity. A retrograde hindfoot nail was used for intramedullary tibiotalocalcaneal arthrodesis. Patients were prospectively followed. Primary outcomes included assessment of mobility and union at 6 months. Secondary outcomes included 30-day postoperative complications, patient satisfaction and change in American Orthopaedic Foot & Ankle Society (AOFAS) score at 1-year postoperation. Nine patients underwent this procedure with a mean follow-up of 18 months (4-36 months). Average age was 66 (58-81) years. Mean body mass index was 33.7 (22-38) kg/m2. All patients went on to fusion and were ambulating at 6 months (n = 8). At 1 year, the mean improvement in AOFAS was 28.9 points (p < .05) (n = 7) and all patients were satisfied with the outcome of their treatment. This technique represents an alternative to conventional hindfoot salvage techniques showing predictable outcomes in complex hindfoot deformity with talar body collapse and anterior subluxation. Further quantitative studies are needed to define if this technique minimizes limb shortening/limb-length discrepancies when compared to traditional horizontal cuts.
Category:
Trauma; Hindfoot
Introduction/Purpose:
We prospectively assessed the impact of minimally invasive internal fixation of displaced intra-articular calcaneal fractures (DIACF) results in ...better health outcomes up to 2 years post- injury than non-operative management.
Methods:
All isolated calcaneal fractures were reviewed and the decision to treat was made by a multidisciplinary meeting. Operative-treatment protocol involved sinus-tarsi approach or per-cutaneous reduction & internal fixation under the care of a fellowship-trained-foot and ankle surgeon. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ5D-L scores were used to assess general and disease-specific outcomes respectively. Secondary outcome measures included return to work and return to leisure activity levels. Statistical analysis was performed to assess normality of data (Shapiro Wilk test/Q-Q plots). Propensity matching was conducted using nearest neighbour matching, followed by regression analysis and modelling to compare baseline covariates between the two different groups.
Results:
Between 2015-2019 total of 93 patients met the inclusion criteria. After propensity score matching 44 patients were found in the surgical/ treatment group. The mean age was 40 (vs. 43.3) in the surgical group, no significant difference in age, sex, peripheral vascular disease, smoking status, laterality, and baseline Bohlers and Guisane angle in the propensity score matched sample. The surgically treated group had a higher Sanders class(p<0.05), higher MOXFQ at 12 months (p<0.05) and EQ-5DL scores at 24 months(p<0.05) and were more likely to return to work at 12m (95% vs 77%)(p<0.05), and physical activity levels at 12m (57% vs 36%)(p=0.054). The wound complication rate was 14.8%, no patients required further surgery; whilst non-operative- treatment mandated surgery for arthritis (6), and or/an injection (7 vs.3).
Conclusion:
Both non-operative and operative treatments are valid in DIACF. MIS-surgery offers better functional outcomes for severer injury patterns, and a less-likely need for arthritis intervention at 2yrs.
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.
Category:
Trauma; Ankle
Introduction/Purpose:
Objectives: Ankle fractures associated with diabetes experience more complications with standard Open-Reduction-Internal-Fixation (ORIF) following ...AO-principles than those without diabetes. It is unclear if augmented/extended fixation strategies can improve this. This aim of this study was to understand utilisation of extended/augmented/ORIF techniques (e.g., hind-foot-nail (HFN) and present outcomes of ankle fractures associated with diabetes. Secondarily the study aimed to evaluate compliance with national guidelines on early post-operative weight bearing.
Methods:
Research, Design & Methods: A national-multicentre retrospective cohort study was conducted between Jan - Jun 2019 of 56 UK centres (10 Major-Trauma-Units and 46 Trauma-Units). Institutional approval was obtained by all centres. 1360 complex-ankle-fractures were enrolled. Demographics, fixation choice and surgical outcomes were obtained. Statistical analysis was performed including propensity matching comparing patients with and without diabetes.
Results:
316pts (23.2%) had diabetes, 7.4% had neuropathy, with a mean age 63.9yrs (vs.49.3yrs in non-diabetes), with greater frailty >4 (24% vs.14% (non-diabetes) (p<0.03). 79.7% underwent standard AO-principles-ORIF; those with peripheral neuropathy were more likely to undergo extended/augmented-techniques. Overall wound complications were higher with diabetes (15.8% vs. 8.8% (p<0.02). 13% of patients with diabetes underwent augmented/extended techniques without a difference in complications to a matched control group without diabetes.
Conclusion:
Diabetic ankle fractures occur in older, frailer persons; whilst lower than expected neuropathy rates suggest a need for improved assessment. Contrary to current guidelines most patients remain non-weightbearing post-surgery. Extended/Augmented surgical techniques can allow earlier weight-bearing without increasing complications. MDT screening/management may improve surgical selection and under-utilisation of these techniques and promote early mobilisation.
Purpose
A formalised, universally accepted, radiological staging system of gleno-humeral joint osteonecrosis (ON) is lacking. Consequently, there is absence of a standardised management strategy. The ...aim is to propose a simple radiological staging system of gleno-humeral joint ON based on principles of the Association Research Circulation Osseous (ARCO) Society and review of clinical practice.
Methods
A radiographic and clinical review of 45 patients with haematological-induced gleno-humeral ON was performed. The related management plans were analysed and categorised.
Results
Analysis divided the disease into stages 0–4. Non-interventional management was the first-line treatment in stages 1–2. If unsuccessful, arthroscopic core decompression was performed. Patients with stages 3–4 were initially managed conservatively. If unsuccessful, in younger patients, arthroscopic joint debridement and capsular release was trialled. In older patients, or where this approach failed, shoulder arthroplasty was advised.
Conclusion
The simple radiological classification assessed is useful to the provision of a standardised staged management strategy of gleno-humeral ON.
Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed ...as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications.
We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques.
A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation.
Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
•A number of methods are used (internal fixation, external fixation and combined) for surgical reconstruction in Charcot Foot.•Most studies are case series from specialist centres with wide variation in patient selection and lacking controlled studies.•Studies report improved patient recorded outcome measures with surgical intervention.•Amputation rates following surgical reconstruction are reportedly low.•Post-operative complication rates are conspicuously high reflecting the complex surgical nature in these patients.
Normal adult cortical bone has a very short T
2 and characteristically produces no signal with pulse sequence echo times (TEs) routinely used in clinical practice. We wished to determine whether it ...was possible to use ultrashort TE (UTE) pulse sequences to detect signal from cortical bone in human subjects and use this signal to characterise this tissue.
Seven volunteers and 10 patients were examined using ultrashort TE pulse sequences (TE=0.07 or 0.08 ms). Short and long inversion as well as fat suppression pulses were used as preparation pulses. Later echo images were also obtained as well as difference images produced by subtracting a later echo image from a first echo image. Saturation pulses were used for T
1 measurement and sequences with progressively increasing TEs for T
2* measurement. Intravenous gadodiamide was administered to four subjects.
Signal in cortical bone was detected with UTE sequences in children, normal adults and patients. This signal was usually made more obvious by subtracting a later echo image from the first provided that the signal-to-noise ratio was sufficiently high.
Normal mean adult T
1s ranged from 140 to 260 ms, and mean T
2*s ranged from 0.42 to 0.50 ms. T
1 increased significantly with age (
P<.01).
Increased signal was observed after contrast enhancement in the normal volunteer and the three patients to whom it was administered.
Reduction in signal from short T
2 components was seen in acute fractures, and increase in signal in these components was seen with new bone formation after fracture malunion. In a case of osteoporosis, bone cross-sectional area and signal level appeared reduced.
Signal can be detected from normal and abnormal cortical bone with UTE pulse sequences, and this can be used to measure its T
1 and T
2* as well as observe contrast enhancement. Difference images are of value in increasing the conspicuity of cortical bone and observing abnormalities in disease.
Aims
Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated ...with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy.
Methods
Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq).
Results
Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation.
Conclusion
These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients.
Cite this article:
Bone Joint Res
2023;12(10):657–666.
We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen ...foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who underwent 3 phase bone scintigraphy with "High Resolution" SPECT/CT. The imaging demonstrated that Stage 0 Charcot foot has a distinct bone pathology, which can be classified into three groups: (1) fractures on Computed Tomography (CT) with accompanying focal uptake of tracer on SPECT, (2) bony abnormalities apart from fracture on CT with focal uptake of tracer on SPECT, and (3) normal CT but focal bony uptake of tracer on SPECT. The CT component of SPECT/CT detected bony fractures in 59% of patients. Early treatment with below knee cast and follow-up for 24 months showed only 4 patients who developed Stage 1 Eichenholtz Charcot foot. Our findings support the use of 3 phase bone scintigraphy with SPECT/CT in the characterization and early diagnosis of CN. Stage 0 Charcot foot has a distinct bone pathology which requires urgent treatment to prevent progression to Stage 1 Eichenholtz Charcot foot. If SPECT/CT is unavailable, CT alone will detect bone fracture in 59% patients.
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