Mid-to long-term postoperative outcomes of ankle joint fusion in patients with haemophilia: A systematic review

INTRODUCTION AND AIM

The ankle joint is the most common site for haemophilic arthropathy. The aim of this study was to review the outcomes of ankle joint fusion in patients with haemophilia A or B. The primary outcome measures were union rates, time to union, perioperative blood loss/transfusion, postoperative complications and length of hospital stay (LOS). Secondary outcome measures were hind foot functional outcome scores and the visual analogue pain scale (VAS).

MATERIALS AND METHODS

A search of PubMed, Medline, Embase, Journals@Ovid and the Cochrane register was performed conforming to the PRISMA guidelines. Only human studies with a minimum follow-up of 1-year were included. The MINORS and ROBINS-1 tools were used for quality appraisal.

RESULTS

A total of 952 articles were identified and only 17 studies met the eligibility criteria after the screening. The mean age of the patients was 37.6 (SD 10.2). A total of 271 ankle fusions were performed with the open crossed-screw fixation being the most common technique. Union rates were 71.5%-100% at 2-6 months. The pooled postoperative complication and revision rates were 13.7% and 6.5%, respectively. The range of LOS was 1.8-10.6 days. The mean preoperative American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score was 35 (SD 13.1) whereas the mean postoperative AOFAS score was 79.4 (SD 5.3). The mean preoperative VAS was 6.3 (SD 1.6) while the mean postoperative VAS score was .9 (SD .4) across 38 ankle fusions.

CONCLUSION

Ankle arthrodesis offers improved pain and function in haemophilic ankle arthropathy with lower revision and complication rates than that reported in the literature for total ankle replacement.

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults

BACKGROUND

Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability.

METHODS

A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine.

RESULTS

Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization.

CONCLUSION

Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

Ultrasonography for the diagnosis of deltoid injury in supination external rotation ankle fractures - A scoping review

BACKGROUND

Lauge-Hansen supination external rotation (SER)-type ankle fractures are very common and account for up to 75% of all ankle fractures. Assessing deltoid integrity is key for surgical decision making. Ultrasound has been used recently to assess the integrity of the deltoid ligament and differentiate between SER II and SER IV fractures. The aim of this article is to review the literature for studies assessing the diagnostic accuracy of ultrasound in this group of patients.

METHODS

After registering the protocol with PROSPERO, Embase, Ovid MEDLINE, Web of Science Core Collection, and Google Scholar were systematically searched. Studies that satisfied the following inclusion criteria were assessed: (1) Adult patients (>16 years), (2) Acute SER-type ankle fractures assessed within 2 weeks of the injury, (3) Diagnostic accuracy studies. Risk of bias assessment was conducted and a narrative synthesis of the results presented.

RESULTS

A total of five studies satisfied our inclusion criteria and were included for review. These had a total of 175 patients studied. All studies showed a sensitivity of 100% and specificity of 90-100% for detecting a complete tear of the deltoid. All papers had a significant risk of bias inherent to the design. Only patients undergoing surgery were exposed to the gold standard of operative intervention.

CONCLUSION

Ultrasound scan has shown excellent diagnostic accuracy for detecting complete deltoid ruptures in SER ankle fractures. These results however should be interpreted with caution. Perhaps a different approach is needed to assess the efficacy of ultrasound scans in patient with SER type fractures.

The Impact of Harm Review Service on Patients Awaiting Elective Orthopaedic Foot and Ankle Surgery for More Than 52 Weeks

Background and objective

There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery.

Materials and methods

The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well.

Results

A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health.

Conclusion

This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

1145 Achilles Tendon Rupture Management: Improving Our Pathway

Background

Achilles tendon ruptures are the most common tendon injury which affect predominantly middle age males. The yearly incidence is 31/100,000, with a rising incidence due to an increasingly active older generation1. Conservative versus operative management options shows no significant difference in rates of re-rupture or length of rehabilitation2. Delays in imaging have been found to delay definitive treatment and led to multiple attendances in the outpatient clinic.

Method

A retrospective analysis was performed patients diagnosed with an Achilles tendon rupture from September 2016 to February 2017 throughout the East Kent Trust. Patients were identified via clinical coding of ED attendance. Following implementation of the pathway in October 2018, a second retrospective analysis of patients identified between October 2018 and March 2019 was performed. Patients with re-ruptures or < 16 years old were excluded from the study.

Results

Following introduction of the pathway, there has been a 100% increase in the number of ultrasound scans performed, with the rupture gap size documented in 50% of these. The time to decision for conservatively managed patients dropped from 8 to 2 days. The number of clinic appointments also dropped from 3 to 2 with the management of patients predominantly in the plaster room.

Conclusions

The pathway has streamlined the process for patients following their injury. The majority of patients are seen by a senior clinician within 72 hours and a treatment plan clarified. The use of surgical care practitioner led clinics have allowed continuity of care for these patients and swift escalation when required.

Sub-Acute Syndesmotic Injury: A Review and Proposed Treatment Algorithm

Sub-acute syndesmotic injuries are classified as from six weeks to six months from the initial injury date and can be considered a distinct group of patients; however, they are often mistreated and progress to chronic injuries with significant sequelae. The authors performed a comprehensive literature search on the MEDLINE database. The search yielded 165 studies up to January 2021, after the application of inclusion/exclusion criteria. This yielded 10 studies with a total of 156 relevant patients for review. We found that a delay in diagnosis is common and has a negative impact on outcomes. If a sub-acute syndesmotic injury is suspected and plain radiographs are inconclusive, magnetic resonance imaging is indicated if there is still an index of suspicion. Surgical intervention should aim to restore normal length and rotational alignment of the fibula whilst also addressing the need to debride tissues within the joint and syndesmosis. Syndesmosis must then be adequately reduced and stabilised with syndesmotic screw fixation, and augmentation with tendon/ligament reconstruction should be considered. All studies showed an average improvement in functional outcome measures post-operatively. The only study to compare sub-acute and chronic patients' functional outcomes post-operatively showed significant improvement in the sub-acute cohort; highlighting the importance of early intervention. We suggest a treatment algorithm that may help with the diagnosis and management of these injuries. We believe this will help all healthcare professionals to standardise care. Further research is required to assess sub-acute injury outcomes with tendon/ligamentous augmented reconstruction, as no level 1 or 2 studies currently exist.

Lisfranc injury: A review and simplified treatment algorithm

BACKGROUND

Lisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries.

METHODS

A comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature.

RESULTS

Delay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies.

CONCLUSION

A simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries.

LEVEL OF EVIDENCE

Level 5.

Bipartite talus: a case series and algorithm for treatment

BACKGROUND

Bipartite talus is a rare condition of uncertain aetiology, with various treatment options described.

METHODS

We report five symptomatic bipartite talus cases in four male patients warranting surgical management. All patients were reviewed by an independent assessor.

RESULTS

The youngest patient presented with bilateral lesions without sub-talar arthrosis. He was treated twice by internal fixation with bone grafting. The left side failed to unite. The second patient presented with isolated sub-talar osteoarthritis. He underwent fragment excision and sub-talar arthrodesis with bone graft. The third patient presented aged 55 with severe hind-foot osteoarthritis, and underwent tibio-talar-calcaneal fusion. The final patient was treated with fragment excision and sub-talar arthrodesis. All patients reported symptom improvement or resolution post-operatively. Four cases showed evidence of radiographic union.

CONCLUSIONS

We suggest a treatment rationale of fragment fusion if large enough, or excision if not, with associated limited fusion if the adjacent joints are markedly degenerate.

ATM polymorphisms as risk factors for prostate cancer development

The risk of prostate cancer is known to be elevated in carriers of germline mutations in BRCA2, and possibly also in carriers of BRCA1 and CHEK2 mutations. These genes are components of the ATM-dependent DNA damage signalling pathways. To evaluate the hypothesis that variants in ATM itself might be associated with prostate cancer risk, we genotyped five ATM variants in DNA from 637 prostate cancer patients and 445 controls with no family history of cancer. No significant differences in the frequency of the variant alleles at 5557G>A (D1853N), 5558A>T (D1853V), ivs38-8t>c and ivs38-15g>c were found between the cases and controls. The 3161G (P1054R) variant allele was, however, significantly associated with an increased risk of developing prostate cancer (any G vs CC OR 2.13, 95% CI 1.17–3.87, P=0.016). A lymphoblastoid cell line carrying both the 3161G and the 2572C (858L) variant in the homozygote state shows a cell cycle progression profile after exposure to ionising radiation that is significantly different to that seen in cell lines carrying a wild-type ATM gene. These results provide evidence that the presence of common variants in the ATM gene, may confer an altered cellular phenotype, and that the ATM 3161C>G variant might be associated with prostate cancer risk.

Germline mutations in fumarate hydratase (FH) do not predispose to prostate cancer

Inherited susceptibility to prostate cancer has been linked to a number of chromosomal regions, however no genes have been unequivocally shown to underlie reported linkages. The putative gene localised to chromosome 1q42-q43, has been designated PCaP. We have recently shown that germline mutations in the fumarate hydratase (FH) gene located on 1q43 cause smooth muscle tumours and renal cell carcinoma. It is conceivable that germline FH mutations might confer an increased risk of prostate cancer and underlie linkage of prostate cancer to PCaP. To examine this proposition we have analysed the entire coding region of FH in 160 prostate cancer cases in 77 multiple case families. No pathogenic mutations in FH were identified in any of the cases. This data makes it highly unlikely that mutations in FH confer susceptibility to prostate cancer.

Activation of transcription by HIV-1 Tat protein tethered to nascent RNA through another protein

The human immunodeficiency virus type I (HIV-1) nuclear protein Tat is a potent activator of viral gene transcription. Activation by Tat requires a cis-acting element, the transactivation response (TAR) site, located immediately downstream of the transcription start site. Several observations suggest that TAR functions as the nascent RNA product of the HIV long-terminal-repeat promoter (for a review, see ref. 6). Indeed, Tat protein and several cellular proteins bind directly to nascent TAR RNA in vitro. The significance of these in vitro interactions remains to be established. Here we report that Tat can activate transcription when bound to nascent RNA through the RNA-binding domain of another HIV-1 protein, Rev. Rev is a sequence-specific RNA-binding protein, which interacts with the viral RNA element RRE (refs 11-15). A Tat-Rev fusion protein efficiently activates transcription from an HIV-1 promoter derivative, in which TAR has been replaced by the RRE. We conclude that activation of transcription by Tat can occur by direct binding to nascent RNA, and that the sole function of TAR may be to provide a Tat-binding site. Our results further suggest that cellular proteins that bind specifically to TAR RNA or TAR DNA may not be essential for Tat-responsiveness.

In vivo and in vitro expression of U7 snRNA genes: cis- and trans-acting elements required for RNA polymerase II-directed transcription

Three of five genes coding for U7 small nuclear (sn) RNA of the sea urchin Psammechinus miliaris were shown to be expressed during early embryogenesis by microinjection into sea urchin eggs followed by fertilization. Both in vivo and in nuclear extracts of blastula embryos, a minimal promoter of 80 bp of 5' flanking sequence is essential for their expression. Sequences upstream of position -80 enhance transcription in vivo, but not in vitro, approximately 5-fold. In vitro, transcription initiates at nucleotide +1 of the U7 snRNA and is directed by RNA polymerase II. Protein-DNA binding studies and site-directed mutagenesis demonstrate the presence of multiple proteins interacting with sequences between -57 and -26, which are essential for selection of the correct initiation site and for efficient in vitro transcription. Three of these factors recognize a TATA-like regulatory element between positions -53 and -45, suggesting a role for TATA-binding proteins in the initiation of sea urchin U7 snRNA transcription.