George Smith

Biomechanical Comparison of Intramedullary Fibular Nail Versus Plate and Screw Fixation

Background: Clinical evidence has shown that percutaneous ankle fracture fixation using an intramedullary fibular nail results in good outcomes at 1 year and reduces postoperative wound complications in patients with vulnerable soft tissues. Confirmatory biomechanical evidence of its strength when used to secure a supination external rotation (SER) IV (AO/OTA 44B-type) fracture, compared with traditional plates and screws, is currently lacking. Methods: Twenty cadaveric lower limbs (10 cadavers) had a SER IV injury surgically created. One leg was randomly allocated to fixation with a fibular nail and the other a lag screw and neutralization plate. A mechanical testing apparatus subjected all lower limbs to an axially loaded supination external rotation force to failure. Results: Superior ultimate torque to failure was demonstrated with a trend toward increased energy absorption in the nail group (P = .28 and .07, respectively). No difference was demonstrated in angle at failure. All specimens in the plate group lost reduction at the bone-metal interface as a result of screw pullout. In contrast, all specimens in the nail group failed because of disruption of the lateral ligaments. Conclusions: This study demonstrated greater torque to failure and better maintenance of the fibular construct for the intramedullary fibular nail compared to standard plating. Clinical Relevance: These results suggest that the previously documented clinical benefits of the fibular nail are complemented by biomechanical properties that compare favorably to standard techniques.

Closing the gap on Achilles tendon rupture: A cadaveric study quantifying the tendon apposition achieved with commonly used immobilisation practices

The relative benefits of surgical and conservative treatment of Achilles tendon rupture are widely debated. With modern conservative management protocols, the re-rupture risk appears to fall to one similar to surgical repair with negligible loss of function. Conservative management typically employs a period of time in an equinus cast with sequential ankle dorsiflexion in a functional orthosis. The optimal duration of immobilisation and rate of dorsiflexion is unknown. We aimed to quantify the change in Achilles tendon approximation achieved in common immobilisation techniques to assist the design of rehabilitation protocols. Twelve fresh-frozen cadaveric specimens had 2.5cm of Achilles tendon excised. The gap between the tendon ends were measured via windowed full equinus casts and compared with functional boots with successively removed heel wedges. The greatest tendon apposition was achieved with the equinus cast. Each wedge removed decreased the reapproximation by approximately 5mm. This paper supports the early use of maximal equinus casting in early management of acute Achilles tendon ruptures.

A comparative prospective cohort health economic analysis comparing ankle fusion, isolated great toe fusion and hallux valgus surgery

BACKGROUNDnThis study assessed the health economics and outcomes of three common foot and ankle operations.nnnMETHODSnBetween July 2013 and October 2014 all patients undergoing ankle fusion (AF) for osteoarthritis, first metatarsophalangeal joint fusion for osteoarthritis (MF) or hallux valgus surgery (HV) were included. Patients having additional procedures were excluded. Patients completed the Manchester-Oxford Foot Questionnaire (MOX-FQ), the EuroQol EQ-5D-5L questionnaire and the EQ-VAS on presentation and at least 6 months post-operatively.nnnRESULTSn63 patients undergoing AF (n=22), MF (n=22), or HV (n=32) completed preoperative and postoperative questionnaires. 76 completed preoperative questionnaires and 63 completed the follow up questionnaires. The follow up questionnaires were completed at a median of 12 months (range 6-24 months) following surgery. The mean age at surgery was 59 years (range 26-85 years). Pre-operative MOX-FQ and EQ-5D-5L scores differed significantly between the three groups with AF and MF patients reporting worse scores compared to HV patients. MOX-FQ and EQ-5D-5L significantly improved in all groups from pre-operative levels.nnnMOX-FQnAF from 53.8 (CI 56.8-50.8) to 22.9 (CI 30.9-14.9), MF from 43.0 (CI 46.4-39.6) to 12.1 (CI 18.3-5.9), HV from 35.4 (CI 39.0-31.7) to 15.6 (CI 21.1-10.1). EQ-5D-5L: AF from 0.30 (CI 0.43-0.17) to 0.66 (CI 0.77-0.55), MF from 0.45(CI 0.52-0.38) to 0.83 (CI 0.90-0.76), HV from 0.71(CI 0.74-0.68) to 0.82 (CI 0.88-0.76). There was no significant difference in the EQ-VAS suggesting it may not be representative of foot and ankle health. Health economics analysis using the EQ-5D-5L data to estimate quality-adjusted life years (QALYs) suggested all three procedures were favourable compared to threshold levels of cost-effectiveness. There were differences in estimated costs between the three operations with AF at £2950 (threshold cost <£5400) and MF at £1197 (threshold cost <£5780) and HV varying from £625 to £1688 (threshold cost <£1640).nnnCONCLUSIONSnThis study reveals that the joint-specific (MOX-FQ) and generic health (EQ-5D-5L) outcome scores of patients improved after AF, MF and HV. The greatest benefit from surgery was gained in the arthritic patient groups. In the future, the use of large population patient reported outcome measures data may also potentially have implications for prioritisation of healthcare provision, acting as an indicator of foot and ankle surgical procedures that produce the most benefit to patients.