The Impact of the COVID-19 Pandemic and Lockdown on Adult Foot and Ankle Fractures Presenting to the Largest Trust in the United Kingdom

Background The COVID-19 pandemic induced unprecedented changes in medical practices, prompting a reassessment of their impact on adult foot and ankle fractures within the National Health Service (NHS). This study employs a retrospective observational approach, leveraging the Pathpoint™ eTrauma platform for a comprehensive analysis of prospectively collected data. Methods Data encompassing weekly fracture incidence, weekly surgical procedures, patient demographics, and mean wait time from injury presentation to surgery were systematically evaluated. The study population included all adults (18+) admitted during five distinct periods: pre-pandemic, national lockdown 1, post-lockdown, national lockdown 2, and national lockdown 3. Results An analysis of 434 foot and ankle fractures revealed that national lockdown 1 exhibited the lowest fracture incidence (4.97 per week) and surgeries performed (4.77 per week), reflecting a notable reduction in trauma cases and elective procedures. Conversely, post-lockdown displayed the highest fracture incidence (7.46 per week) and surgeries performed (6.31 per week), suggesting a resurgence in both trauma and elective surgical activities. The pre-pandemic cohort, characterized by the highest mean age (51.98 years) and mean wait time (8.74 days), served as a temporal baseline. Conclusion While the incidence of fractures decreased during all three national lockdowns compared to pre-pandemic or post-lockdown periods, a gradual increase was observed in subsequent lockdowns. Notably, mean wait times showed a significant reduction, reaching the lowest point (5.79 days) during national lockdown 3. These findings underscore the complex interplay between pandemic-related disruptions, evolving guidelines, and adaptive measures within the healthcare system, influencing the dynamics of foot and ankle fracture management.

Correlation Between Statin Use and Symptomatic Venous Thromboembolism Incidence in Patients With Ankle Fracture: A Machine Learning Approach

BACKGROUND

Identifying factors that correlate with the incidence of venous thromboembolism (VTE) has the potential to improve VTE prevention and positively influence decision-making regarding prophylaxis. In this study, we aimed to investigate the correlation between statin consumption and the incidence of VTE in patients who sustained an ankle fracture.

METHODS

In this retrospective, case-controlled study, cases were those who developed VTE and controls were those who had no VTE, and the ratio was 1:4. Patients' demographics, history of hyperlipidemia, and reported statins use were obtained. A random forest classifier (RFC) model was used to predict whether statin consumers were at risk of VTE after ankle fracture regardless of VTE prophylaxis administration based on statin consumption, body mass index (BMI), age, and biological sex.

RESULTS

Of the 1175 patients with ankle fractures, 238 had confirmed VTE (case group), and 937 had no symptomatic VTE (control group; ratio 1:4). Fifty (21%) cases and 407 (43%) controls were on a statin. Statin users had a significantly lower incidence of VTE after ankle fracture, odds ratio (OR) = 0.35, 95% CI: 0.25, 0.49, P < .001. Our model showed an area under the receiving operator curve (AUROC) of 78%, a sensitivity of 73%, and a specificity of 83% in predicting the risk of VTE. The importance of the predictors of VTE, other than the use of statins (model importance = 0.1), were age (model importance of 0.72), BMI (model importance of 0.24), and biological sex (model importance of 0.02).

CONCLUSION

Statins were significantly associated with a lower rate of VTE in our population of patients who sustained an ankle fracture.

LEVELS OF EVIDENCE

3.

Anterior Displacement of a Posterior Malleolar Fragment Through the Syndesmosis: A Case Report

Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.

Risk Factors Associated With Foot and Ankle Insufficiency Fractures in Postmenopausal Sedentary Women

BACKGROUND

Insufficiency fractures occur in bones with low elastic resistance. In contrast to stress fractures, which affect normal bones and have been extensively studied, insufficiency fractures of the foot and ankle have been the subject of little research. The objective of this study was to identify risk factors associated with the development of foot and ankle insufficiency fractures.

METHODS

The study included 55 postmenopausal sedentary women with foot and ankle insufficiency fractures and 51 women in the control group. The data collected were the fracture site, body mass index, use of corticosteroids, T scores of the femur and lumbar spine measured by bone densitometry, and serum 25-OH vitamin D level. The calcaneal pitch (CP), talar-first metatarsal, and metatarsus adductus (MA) angles were measured on radiographs.

RESULTS

In 49 patients (89%), fractures occurred in the metatarsals. All metatarsals were affected, and the most common fracture site was the base of the fifth metatarsal, with 21 cases (33%). Twenty patients (36%) in the study group reported chronic use of corticosteroids and had lower bone mineral density levels than controls (P < .05). The factors associated with fracture development (P < .05) were the CP and MA angles and low lumbar bone mineral density.

CONCLUSION

Insufficiency fractures in this population were associated with low bone mineral density and unfavorable biomechanical characteristics such as pes cavus and metatarsus adductus.

LEVEL OF EVIDENCE

Level IIIB, case-control study.

Effects of microsurgical repair treatment on the clinical efficacy, complications, and flap follow-up scores of patients with exposed steel plates after surgery for foot and ankle fractures

BACKGROUND

Treatment of exposed steel plates after surgery for foot and ankle fractures is complicated. This study aims to analyze the effects of microsurgical repair treatment on the clinical efficacy, complications, and flap follow-up scores of patients with exposed steel plates following foot and ankle fracture surgery.

METHODS

Eighty-two patients with exposure of steel plates after surgical treatment for foot and ankle fractures in our hospital from March 2017 to March 2018 were included in this study. The patients were divided into a study group (43 patients who received microsurgical repair) and a control group (39 patients who received conventional repair surgery). We compared the clinical efficacy, complication rate, flap followup score, recovery of ankle-hindfoot function and ankle function before treatment and at 3 and 6 months after treatment, and patient satisfaction between the two groups.

RESULTS

The clinical effectiveness rate in the study group was 95.35%, which was higher than the control group (76.92%) (P<0.05). The flap appearance, texture, and elasticity scores in the study group were higher than those in the control group (P<0.05). After treatment, the American Orthopedic Foot and Ankle Society (AOFAS) score and Baird ankle score increased significantly in both groups, and reached a peak at 6 months after treatment. The peak scores of the study group were considerably higher than those of the control group at each period after treatment (P<0.05). The incidence of complications in the study group (6.98%) was lower than the control group (25.64%) (P<0.05). Patient satisfaction was higher in the study group (97.67%) than the control group (79.49%) (P<0.05).

CONCLUSIONS

Microsurgical repair of exposed steel plates after surgery for foot and ankle fractures has a significant clinical effect. It can improve the flap follow-up scores, accelerate healing of the ankle, improve aesthetics, and reduce the incidence of complications. It is therefore worthy of widespread use in clinics.

Thromboprophylaxis in Ambulatory Trauma Patients With Foot and Ankle Fractures: Prospective Study Using a Risk Scoring System

Lower-limb immobilization has been implicated as an etiological factor for venous thromboembolic events (VTEs). However, there is no patient-centered scoring system available for risk assessment in ambulatory trauma patients with temporary lower-limb immobilization. A patient questionnaire scoring system has been developed for ambulatory patients with foot and ankle fracture being managed nonoperatively as outpatients by temporary lower-limb immobilization. Patients are classed as either high or low risk for developing a VTE and offered low-molecular-weight heparin (LMWH) accordingly. This is a prospective study of 150 patients with a follow-up of 6 months. Only 3 patients developed VTEs: one was noncompliant with medicine, one was started on LMWH 2 days after getting a plaster cast, and the third was not started on LMWH in spite of family history of VTEs. This study showed that using this scoring system, LMWH can be used safely and effectively as a thromboprophylactic agent for ambulatory trauma patients requiring temporary lower-limb immobilization to manage foot and ankle fractures. It is a step toward developing a validated clinical prediction score to enable risk assessment in ambulatory trauma patients who are managed non-operatively with temporary lower limb immobilization.

LEVELS OF EVIDENCE

Prognostic, Level IV: Case series.