Jitendra Mangwani

Understanding risks and complications in the management of ankle fractures

Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.

Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review.

Ankle osteoarthritis is less common than hip or knee osteoarthritis; however, it is a relatively common presentation and is predominantly related to previous trauma. Treatments have traditionally consisted of temporizing measures such as analgesia, physiotherapy, and injections until operative treatment in the form of arthrodesis is required. More recently, interest has been increasing in both nonoperative and alternative operative options, including joint-sparing surgery, minimal access arthrodesis, and new arthroplasty designs. The present systematic instructional review has summarized the current evidence for the treatment options available for ankle osteoarthritis.

What is the evidence for chemical thromboprophylaxis in foot and ankle surgery? Systematic review of the English literature

Venous thromboembolism (VTE) is a well documented complication following lower limb trauma and surgery. The incidence of VTE in hip and knee surgery has been well studied, whereas the incidence in foot and ankle surgery is less clear. There is debate as to which cases require prophylaxis and what is the most effective means by which this is achieved. We performed a systematic review of the published English literature on VTE prophylaxis in foot and ankle surgery using MEDLINE, EMBASE, CINHAL, Cochrane Library, without date restrictions up to December 2012. From 988 citations, 25 papers fulfilled the inclusion criteria. Conclusions were drawn on the incidence (symptomatic and asymptomatic VTE), location (distal vs. proximal), associated risk factors, timing of VTE, role of mechanical and pharmacological prophylaxis and cost effectiveness of the treatment. Our review showed that the overall incidence of symptomatic VTE in foot and ankle surgery is low (0-0.55%). There is increased incidence in foot and ankle trauma patients with the highest incidence reported in tendo-achilles surgery. The reported risk factors include previous history of VTE, immobilisation, high BMI, age, co morbidities, contraceptive pill, and air-travel. There is a cumulative effect resulting in higher risk when two or more risk factors are present.

Role of prophylactic antibiotics in lesser toe fusion surgery: A prospective randomised controlled trial

BACKGROUND This prospective randomised controlled trial was performed to determine whether the incidence of local infection is reduced in patients who are administered prophylactic antibiotics for lesser toe fusion surgery. METHODS 100 adult patients undergoing toe fusion surgery that required K-wires to be left in situ for 4-6 weeks were randomly allocated into those who received prophylactic antibiotics (Group 1, n=48) and those who did not (Group 2, n=52). Patients were followed up regularly and during each visit K-wire insertion sites were assessed for signs of pin tract infection. RESULTS The mean age of Group 1 was 58.0 (SD 17.5) and Group 2 was 62.7 years (SD 14.7). The overall infection rate was 4%. Three patients (6.2%) in Group 1 and one patient (1.9%) in Group 2 developed signs of infection, which required treatment by oral antibiotics. All infections were low grade. There were no features suggestive of osteomyelitis in any of the patients. CONCLUSION The overall infection rate in lesser toe fusion surgery is low and that using prophylactic antibiotics does not reduce the incidence. Inappropriate use of antibiotics, however, may contribute to the development of antibiotic resistance and adds to healthcare costs.

Delayed presentation of a loose body in undisplaced paediatric talar neck fracture.

Fractures of the talus are rare in children. A high index of suspicion is needed to avoid missing such an injury, which is not an uncommon occurrence especially with undisplaced fractures. We present an unusual case of an undisplaced talar neck fracture in a five-year-old child leading to a delayed presentation of a symptomatic osteochondral loose body in the ankle joint. To our knowledge there are no reports in the literature of osteochondral loose bodies occurring in conjunction with an associated undisplaced talar neck fracture in either children or adults. The loose body was removed using anterior ankle arthroscopy. The child had an uneventful post operative recovery and regained full range of movement and function of his ankle joint and was discharged at one year follow-up. We aim to highlight the need to have a low threshold to further evaluate symptomatic children after fracture healing of an undisplaced talar neck fracture for a possible associated loose body in the ankle joint.

Diagnosis and Treatment of Tuberculosis of the Foot and Ankle − a Literature Review

Foot osteoarticular tuberculosis is uncommon. Late diagnosis and sub-optimal management can lead to significant morbidity, deformity and even death. Preservation of life, limb and function can be achieved with prompt diagnosis and treatment. In 1882, Robert Koch published his discovery of mycobacterium tuberculosis as the causative agent of tuberculosis (TB), and showed the disease was infectious rather than inherited. Over two centuries later, TB remains one of the top 10 causes of death worldwide. Whilst in 90% of cases TB infects the respiratory system, in 10% it is extrapulmonary and can infect the skeletal, nervous, lymphatic and genitourinary systems. The spine is the most frequently affected site in the musculoskeletal system and this is known as Potts disease. The foot and ankle is affected in only 0.13% cases of extrapulmonary TB. A high index of suspicion is thus required. This infrequency in incidence, heterogeneity of its presentation along with the difficulty in early diagnosis often causes significant delays in its treatment and hence results in a considerable disability. The medical treatment is well established but the role of surgery, its usefulness and its correct timing remain controversial. The main diagnostic issues include imaging being non-specific. Plain radiographs remain the first line imaging modality. MRI and CT scans provide greater detail and capture the disease at an earlier stage. Microbiological testing has low sensitivity and specificity becasue TB lesions are paucibacillary. Bone biopsy is of significant diagnostic value as it not only allows histological examination to detect granulomas but enables sensitivity and resistance testing of anti-tuberculous therapy (ATT). Issues relating to treatment include timing, duration, combination of chemotherapy and the challenge of multi drug resistant tuberculosis MDR-TB. The selection and timing of appropriate surgical techniques and optimal duration of follow-up are further points to consider. In this article we aim to review the literature on diagnosis and treatment of foot and ankle TB.

Rupture of the extensor hood of the fifth toe: a rare injury.

Closed injuries of the extensor hood of the lesser toes are rare and seldom reported in the literature. We present the case of a woman aged 25 years who presented to the orthopaedic fracture clinic with a 2-week history of pain in the left fifth toe and inability to extend following a ballet dancing session. Investigations showed no fracture on plain radiographs, but an ultrasound scan demonstrated rupture to the extensor hood of the little toe. Successful surgical repair of the extensor hood was performed, and the patient made a good recovery with return to dancing activities.

Are Hindfoot Procedures More Painful than Forefoot – A Prospective Cohort Study in Foot and Ankle Reconstructive Surgery?

Category: Other Introduction/Purpose: Several variables are thought to have an effect on the post-operative pain relief after reconstructive foot and ankle surgery. In the past decade, the role of regional nerve blocks in the management of post-operative pain has become established. The technique(s) of regional blocks varies between centers and the published literature on this subject is inconsistent. More recently, image guided regional nerve blocks for post-op pain relief in F&A surgery have gained popularity. Traditionally, hindfoot reconstructive procedures are deemed to be more painful than the surgery involving the rest of the foot. This prospective study was carried out to examine this question. Methods: 143 patients undergoing elective foot and ankle surgery were prospectively studied. In addition to the demographics, the details of the anaesthetic used were also recorded. 70 patients received peripheral nerve blockade with guidance either by a nerve stimulator or ultrasonography. The procedures were categorised into those belonging to the forefoot, midfoot, hindfoot or combined. The magnitude of pain was recorded immediately post-operatively, at 6 hours and at 24 hours after the surgery, using the visual analog scale (VAS, 0 as ‘no pain’ and 10 as ‘ the worst possible pain’). All adverse effects were recorded. The patients’ satisfaction at two weeks after surgery was also assessed. Kruskal-Wallis test was used to perform non-parametric analysis between the groups. For categorical data, Pearson’s Chi-square test was used. Significant difference was demonstrated by a p-value < 0.05. Results: There was no difference in post-operative, 6 hours or 24 hours VAS in the patients having the hindfoot surgery or those having surgery involving the rest of the foot. Although patients who underwent peripheral nerve block had a satisfactory initial pain relief, they experienced significantly more pain at 24 hours than those who did not have a block (Table 1). There was no significant difference in the hospital stay or patient satisfaction at two weeks. In total, 94% patients were satisfied with their anaesthetic and would not mind having it again. Conclusion: This study provides evidence that contrary to the popular belief, hindfoot surgery is not more painful than the surgery involving the rest of the foot. Our results showed that patients who received peripheral nerve block probably had rebound pain at 24 hours after the surgery. Further studies are needed to explore this relationship. The detailed information provided by this study about the mean (and SD) VAS at various time points after surgery can be used to predict post-operative pain based on various pre-operative surgical and anaesthetic parameters.

Short versus ‘Standard’ Scarf Osteotomy for Hallux Valgus Correction

Category: Bunion Introduction/Purpose: Scarf osteotomy is an established procedure for correction of hallux valgus deformity. The technique has evolved and is effectively used for all grades of deformities. Short osteotomy (short scarf/modified chevron) and single screw fixation is an effective option for correction of mild to moderate hallux valgus deformity leading to lesser soft tissue disruption, smaller scar and being cost effective. Aim of this study was to compare radiological parameters of hallux valgus correction by a ‘standard’ scarf osteotomy and 2-screw fixation with a short osteotomy and single screw fixation Methods: We performed a retrospective review of prospectively collected data. The cases were identified from theatre log. 37 consecutive patients, operated between January 2013 and December 2014, were included. All had mild deformity as defined by maximum pre-operative intermetartarsal angle of 13 degrees. 16(43%) had short osteotomy with single screw fixation (Group 1) and the remaining 21 (57%) had ‘standard’ scarf osteotomy with 2 screw fixation (Group 2). Preoperative and final postoperative weight bearing radiographs were independently reviewed by both authors. Radiological parameters assessed were Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), Distal Metatarsal Articular Angle (DMAA) and Medial Sesamoid position.Sesamoid position was determined by dividing metatarsal head into three equal sections and recorded as more than 50% of medial sesamoid in a section. The three grades were 3(lateral), 2(central) and 1(medial).Both groups were comparable for distribution of age and pre-operative radiological measures. Mean duration of X-Ray follow up was 3 months (range 2-12). SPSS version 20 was used to perform statistical analysis. Results: Mean age of patients was 49 years +/- 13 years. Mean improvement in radiological measures in degrees was - HVA from 24.4 to 10.9 (Group 1) and 35.3 to 12.6 (Group 2), IMA 10.0 to 3.3 (Group 1) and 10.5 to 5.4 (Group 2), DMAA 8.5 to 5.4 (Group 1) and 10.9 to 5.8 (Group 2), Medial Sesamoid position changed from 3 to 1 for both groups. Wilcoxon Signed Rank test showed all these improvements to be significant. T-test showed that both groups were comparable, with no statistically significant difference, for improvements in all radiological parameters. Conclusion: Short osteotomy with single screw fixation is equally effective in correction of symptomatic mild hallux valgus deformity as compared to ‘standard’ scarf osteotomy with the advantage of a smaller scar, lesser soft tissue disruption. We believe it is also cost effective because of potential reduction in duration of surgery and the cost of the implant.