155 Audit of Functional Outcome of Mason and Molloy Type 2 Posterior Malleolar Ankle Fractures Treated with Open Reduction and Internal Fixation Using A Posterolateral Approach

Introduction

It has been shown that direct fixation of the posterior malleolus improves functional outcomes. Our aim was to audit the functional outcome of patients with these fractures which were fixed with an isolated posterolateral approach.

Method

A consecutive case series of patients who underwent direct fixation of the posterior malleolus using a posterolateral approach between 20/12/2012 and 23/1/2020 was identified. Fractures were classified according to Mason and Molloy classification based on preoperative CT. Type 2a and 2b fractures were included. Functional outcome was assessed using Olerud-Molander score.

Result

18 patients were included. Mean age at time of surgery was 52 years (range 20 to 75 years). 56% (n = 10) were female. Mean follow up was 18.1 months (range 4.2 months to 7.2 years). OMAS score for type 2a fractures (n = 9) was 71.1 (95% CI 65.3 to 77.0). OMAS score for type 2b fractures (n = 9) was 67.8 (95% CI 54.6 to 81.0). There was no significant difference between groups (p = 0.65).

Conclusions

Fixation of Mason and Molloy Type 2 fractures using an isolated posterolateral approach results in satisfactory functional results for the majority of patients. Further prospective comparative study is needed to identify which patients benefit most from alternative approaches.

900 An Audit of Effectiveness of Inhaled Methoxyflurane (Penthrox) Use for Reduction of Shoulder Dislocation

Introduction

Shoulder dislocation is a painful injury best treated by early closed reduction. Patients often require intravenous sedation, with airway monitoring in a safe setting. We implemented methoxyflurane inhalational analgesia (Penthrox) to aid shoulder dislocation reduction without the need for sedation and evaluated the effectiveness and adverse events.

Method

Patients presenting to the minor injury’s unit at Wrexham Maelor Hospital between 01/04/2020 and 26/05/2020 with only shoulder dislocation were included. Patients had Penthrox and underwent closed reduction. Pre and post reduction shoulder radiographs were reviewed to determine reduction success and time between radiographs was evaluated. Adverse events were recorded. Reduction success and times between radiographs were compared to a consecutive retrospective cohort of patients who underwent closed shoulder dislocation reduction with sedation before implementing Penthrox.

Results

22 patients were included. Mean patient age was 44.6 years. Majority were male (72%). Penthrox was used in 11 patients. All patients had their shoulder dislocation reduced successfully. Mean time between reduction radiographs for the Penthrox group was 40.8 min (95%CI 27.4 to 54.3). This was shorter than the intravenous sedation group mean 157.7 minutes (95%CI 92.3 to 223.2, p = 0.0026). No documented adverse events with Penthrox.

Conclusions

Simple shoulder dislocations can be reduced safely, quickly, and effectively using Penthrox.

Antagonistic control of Caenorhabditis elegans germline stem cell proliferation and differentiation by PUF proteins FBF-1 and FBF-2

Stem cells support tissue maintenance, but the mechanisms that coordinate the rate of stem cell self-renewal with differentiation at a population level remain uncharacterized. We find that two PUF family RNA-binding proteins FBF-1 and FBF-2 have opposite effects on Caenorhabditis elegans germline stem cell dynamics: FBF-1 restricts the rate of meiotic entry, while FBF-2 promotes both cell division and meiotic entry rates. Antagonistic effects of FBFs are mediated by their distinct activities toward the shared set of target mRNAs, where FBF-1-mediated post-transcriptional control requires the activity of CCR4-NOT deadenylase, while FBF-2 is deadenylase-independent and might protect the targets from deadenylation. These regulatory differences depend on protein sequences outside of the conserved PUF family RNA-binding domain. We propose that the opposing FBF-1 and FBF-2 activities serve to modulate stem cell division rate simultaneously with the rate of meiotic entry.

Outcome after total ankle arthroplasty with a minimum of five years follow-up: A systematic review and meta-analysis

BACKGROUND

Total ankle arthroplasty (TAA) is increasingly gaining recognition as an alternative to ankle arthrodesis in the treatment of end-stage ankle arthritis. Despite high rates of adverse events during early inception, newer generations of uncemented prosthesis and design modifications have improved outcomes. Questions remain regarding the long-term outcomes and implant survivorship of TAA.

AIM

This analysis aims to establish an updated review of intermediate and long-term clinical outcome and complication profile of TAA.

PATIENTS AND METHODS

A multi database search was performed on 14th October 2018 according to PRISMA guidelines. All articles that involved patients undergoing uncemented TAA with 5 years minimum follow-up, reported clinical outcome or complication profile of TAA were included. Seventeen observational studies were included in the review, with 1127 and 262 ankles in the 5 and 10 years minimum follow-up groups respectively.

RESULTS

Mean difference between pre- and post-operative AOFAS score was 43.60 (95%CI: 37.51-49.69, p<0.001) at 5 years minimum follow-up. At 5 years minimum follow-up, pooled proportion (PP) of prostheses revision for any reason other than polyethylene exchange was 0.122 (95%CI: 0.084-0.173), all cause revision was 0.185 (95%CI: 0.131-0.256), unplanned reoperation was 0.288 (95%CI: 0.204-0.390) and all infection was 0.033 (95%CI: 0.021-0.051). At 10 years minimum follow-up, PP of prostheses revision for any reason other than polyethylene exchange was 0.202 (95%CI: 0.118-0.325), all cause revision was 0.305 (95%CI: 0.191-0.448), unplanned reoperation was 0.422 (95%CI: 0.260-0.603) and all infection was 0.029 (95%CI: 0.013-0.066).

CONCLUSION

Despite good intermediate and long-term functional outcome measures, TAA has relatively higher revision surgery prevalence with longer follow-up periods. Further research should be directed towards identifying patient populations that would best benefit from TAA and those at greatest risk of requiring revision surgery.

Hindfoot endoscopic release of the posterior ankle capsuloligamentous structures improves ankle dorsiflexion range, function and pain in patients with painful limitation of ankle dorsiflexion

Objective

To evaluate the effect of arthroscopic release of the posterior capsuloligamentous structures on ankle dorsiflexion and function in patients with painful limitation of ankle dorsiflexion.

Methods

A prospective consecutive case series of 13 adult patients with painful limitation of ankle dorsiflexion were included. None had clinically relevant gastrocnemius, soleus or Achilles contracture. Patients with anterior bony impingement or ankle degeneration on CT scan were excluded. All patients underwent combined anterior and posterior ankle arthroscopies with resection of posterior capsuloligamentous structures and the posterior fibulotalocalcaneal ligament. Ankle range of motion was assessed 2 years postoperatively. Foot and Ankle Outcome Scores (FAOS) were used to assess functional outcome.

Results

The median patient age at surgery was 26 years (range 19–44). At 2 years postsurgery, the ankle dorsiflexion range had increased by 15 degrees (range 0–25, p<0.0001). FAOSs completed at a median of 44 months postsurgery (range 26–72) significantly improved. Median improvements were 19 points for pain (range 6–67, p=0.0004), 14 points for symptoms (range 0–36, p=0.0005), 15 points for activities of daily living (range 6–35, p<0.0001), 45 points for sport (range 20–55, p<0.0001) and 50 points for quality of life (range 13–62, p<0.0001).

Conclusions

Hindfoot endoscopic release of the posterior ankle structures, including the posterior fibulotalocalcaneal ligament, is an effective technique for improving ankle dorsiflexion range in patients with painful limitation of ankle dorsiflexion.

Level of evidence

IV.

Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: A meta-analysis and systematic review of randomised controlled trials

BACKGROUND

Ankle syndesmotic injuries can be surgically managed with syndesmosis screws (SS) or suture button (SB) fixation. We performed a meta-analysis of randomized controlled trials (RCTs) aiming to compare the clinical and complication profiles of both modalities.

METHODS

A multi-database search up to 4th of March 2018 was performed according to PRISMA guidelines. All RCTs comparing both techniques and published in English were included.

RESULTS

Five RCTs with a total of 280 patients (140 SB, 140 SS) were included for analysis. SB had a statistically significant higher AOFAS score at 1 year (mean difference=5.46, 95% CI=0.40-10.51, p=0.03) and lower implant failure rate (OR=0.03, 95% CI=0.01-0.15, p<0.001). Infection and wound issues were marginally higher with SB (OR=1.4, 95% CI=0.4-4.85, p=0.60). No other parameters showed statistically significant difference.

CONCLUSIONS

Both constructs yielded similar clinical outcomes. The 1 year AOFAS score was higher in SB but clinical significance is unlikely. SB had significantly fewer implant failures.

LEVEL OF EVIDENCE

Level I.

Evaluation of a Chemiluminescence Method for Measuring Alkaline Phosphatase Activity in WholeMilk of Multiple Species and Bovine Dairy Drinks: Interlaboratory Study

Alkaline phosphatase (ALP) is a ubiquitous enzyme in milk with timetemperature destruction similar to that of certain pathogens destroyed in pasteurization. Measurement of ALP to indicate proper pasteurization is a common practice. Recently the public health level for ALP was decreased to 350 mU/L, a level below the sensitivity of older colorimetric ALP methods. This study was conducted within the structure of the International Dairy Federation and the International Organization for Standardization to evaluate the reproducibility of the chemiluminescence method (Charm PasLite) for ALP at 50, 100, 350, and 500 mU/L in whole milk of multiple species to meet new regulations in the United States and proposed regulations in the European Union (EU). Fifteen laboratories from 8 countries evaluated bovine, goat, sheep, and buffalo milk, bovine skim milk, 20% fat cream, and 2% fat chocolate milk. At ALP levels of 350 and 500 mU/L, the average relative standard deviation for repeatability (RSDr) was 7.5%, and the average relative standard deviation of reproducibility was (RSDR) 15%. For ALP at 100 and 50 mU/L, the average RSDr values were 10.5 and 12.6%, respectively, and the average RSDR values were 18 and 25%, respectively. The limit of detection was 20 mU/L. Results are comparable to those obtained with other enzymatic photo-activated system methods such as the fluorometric method. Results indicate that the method is suitable for measuring ALP in the milk of multiple species and in dairy drinks at U.S. and proposed EU levels.

Accuracy of the skyline view for detecting dorsal cortical penetration during volar distal radius fixation

Fractures of the distal radius are commonly treated using volar locking plates. Several complications have been associated with this procedure, including extensor tendon irritation and rupture. It has been suggested that prominence of screws past the dorsal cortex may contribute to this complication. This study aimed to determine the ability of the skyline view to demonstrate screws penetrating the dorsal cortex. A volar locking plate was applied to a synthetic forearm model. Lateral, oblique, and skyline views were obtained, with the distal screws both beneath and 1 mm beyond the dorsal cortex. The images were shown to orthopaedic trainees who were asked to decide if screws penetrated the dorsal cortex. Subjects were correct in 83% of cases using the skyline view compared with 77% (p = 0.05, lateral) and 50% (p < 0.01, oblique). This study demonstrates the skyline view of the distal radius could be a useful and accurate addition to routine intraoperative fluoroscopy views.

Multiple penetrating aortic ulcers involving the aortic arch and brachiocephalic artery

Penetrating aortic ulcers are frequently observed in the descending thoracic and abdominal aorta. They are uncommon in the aortic arch, and they are extremely rare in the major branches of the aorta. We present the case of a 71-year-old woman who presented with multiple penetrating aortic ulcers affecting both the aortic arch and the brachiocephalic artery, and its successful treatment.

A Pilot Randomised Comparison of Dexamethasone 96mg vs 16mg per day for Malignant Spinal-cord Compression Treated by Radiotherapy: TROG 01.05 Superdex Study

AIM

To test the viability of a full-scale randomised comparison of two steroid doses given with radiotherapy for malignant spinal-cord compression (MSCC), to test Internet randomisation and to compare different functional outcome measures.

MATERIALS AND METHODS

A log of screened patients at eight recruiting centres was maintained. Patients were randomised via the Superdex website to either 96 mg or 16 mg daily of dexamethasone. Radiotherapy treatment was 30 Gy in 10 fractions. Outcomes assessed used ambulation, Barthel Index ambulation, Functional Independence Measure (FIM) ambulation and Functional Improvement Score (FIS) at 1 month.

RESULTS

One hundred and thirty-one patients were screened. Ninety-three (71%) were ineligible, 65% of these were because duration of prior steroid use was greater than 12 h, failure to meet strict definition of magnetic resonance imaging, defined MSCC, multi-level disease or previous spinal-cord compression treatment. Twenty of the 38 eligible patients were randomised, including seven outside standard office hours. There was a high rate of serious adverse events (n = 9), but only one was considered likely to be related to study medication. At baseline, 75% were ambulant, 70% had FIM ambulation scores greater than 5 and 50% had Barthel Index ambulation scores greater than 2. At day 28, including all randomised patients (by scoring four dead patients as non-ambulant), ambulation scores by the various definitions were 60%, 45% and 40%, respectively. For the 16 patients evaluable at day 28, the mean FIS was -1.4. Median survival was 69 days and 1-year survival 13%.

CONCLUSION

Web randomisation was successful; however, the high ineligibility rate precludes a full-scale dexamethasone dose trial in Australia. Choice of measure of ambulation has potentially significant effects on outcomes and implications for the design of any future MSCC trials. Referral delays are of concern.

Vascularity in asthmatic airways: relation to inhaled steroid dose

BACKGROUND

There is an increase in vascularity in the asthmatic airway. Although inhaled corticosteroids (ICS) are an effective anti-inflammatory treatment in asthma, there are few data on any effects on structural changes.

METHODS

Endobronchial biopsy specimens from seven asthmatic subjects not receiving ICS and 15 receiving 200-1500 microg/day beclomethasone dipropionate (BDP) were immunohistochemically stained with an anti-collagen type IV antibody to outline the endothelial basement membrane of the vessels. These were compared with biopsy tissue from 11 non-asthmatic controls (four atopic and seven non-atopic).

RESULTS

There was a significant increase in the density of vessels (number of vessels/mm2 of lamina propria) in the asthmatic subjects not on ICS compared with non-asthmatic controls (mean 485 (interquartile range (IQR) 390-597) versus 329 (IQR 248-376) vessels/mm2, p<0.05; 95% CI for the difference 48 to 286). There was no significant difference between asthmatic subjects on ICS and those not on ICS or control subjects in the number of vessels/mm2 (mean 421 (IQR 281-534)). However, patients who received >/=800 microg/day BDP tended to have a reduced number of vessels/mm2 compared with patients not on ICS and those receiving </=500 microg/day BDP (mean 366 (IQR 153-608) versus 494 (IQR 391-583), p = 0.08; 95% CI for the difference -31 to 288). Similarly, there was an increase in the percentage of lamina propria occupied by vessels in asthmatic patients not on ICS compared with controls (mean 15.6% (IQR 13.1-18.0) versus 10.1% (IQR 8.4-13.3), p<0.01; 95% CI for the difference 2.4 to 9.3) but a significant decrease in the percentage of lamina propria occupied by vessels was detected in asthmatic patients on ICS (mean 11.4% (IQR 9.1-14.9), p<0.01; 95% CI for the difference 0.7 to 7.7) compared with those not on ICS. The density of vessels correlated significantly with both airway hyperresponsiveness and percentage change in forced expiratory volume in one second (FEV1) after bronchodilator (r = -0. 38 for PD20 methacholine and r = 0.49 for change in percentage FEV1 after bronchodilator versus number of vessels/mm2, p<0.05).

CONCLUSION

These findings suggest that ICS, especially at higher doses, may reduce airway wall vascularity in asthmatic subjects but further longitudinal intervention studies are required to confirm this suggestion.

The patients' perception of quality in surgery

The benefits of measuring patient satisfaction have been increasingly acknowledged in recent years. A range of techniques has been used including analysis of complaints made by patients and/or relatives, focus group interviews following discharge, postal and telephone surveys, face-to-face interviews and critical incident analysis. Both quantitative and qualitative methodologies are often employed in patient-satisfaction research. It is suggested that a two-tier approach of methods can increase validity and reliability (i.e. utilizing qualitative approaches in order to develop a quantitative tool). Surgery will benefit through the identification of quality benchmarks based on this type of research. There must be an emphasis on incorporating the results of patient satisfaction studies into practice and the monitoring of improvements based on the identified benchmarks.

Minimisation of aminoglycoside toxicity in patients with cystic fibrosis

BACKGROUND

There is evidence that administration of higher doses of aminoglycosides given less frequently improves the bactericidal effect and reduces the potential to cause side effects. To investigate this, a prospectively randomised open label therapeutic trial was undertaken in stratified groups of patients with cystic fibrosis to examine the efficacy and toxic potential of an aminoglycoside dosing regimen designed to generate high peak drug concentrations at 12 hourly intervals compared with conventional dosing at eight hourly intervals.

METHODS

Patients in group A received tobramycin eight hourly using a dose aimed at generating a peak concentration of 10 mg/l with trough concentrations below 2 mg/l, and those in group B received the total daily dose required to achieve eight hourly target concentrations administered as two equal 12 hourly doses. Clinical outcomes measured and assessed included vestibular symptoms, hearing and renal function, length of hospital stay, readmission rate, and mortality.

RESULTS

Twenty nine patients were recruited during a six month period, 20 to group A and nine to group B. The average peak tobramycin level was higher in group B (12.5 (2.2) mg/l) than in group A (7.9 (1.9) mg/l), whilst the average trough level was higher in group A (0.8 (0.3) mg/l) than in group B (0.5 (0.2) mg/l). There was a difference in the number of ototoxic events between patients in group A (seven of 18, 38.9%) and group B (none of eight), but no difference was found in other outcome measures assessed.

CONCLUSIONS

These results suggest that 12 hourly high peak aminoglycoside dosing may be less toxic than equivalent eight hourly dosing, without any apparent difference in efficacy.

Early diagnosis of airways obstruction

Cochcrane, G. M., Prieto, F., Hickey, B., Benatar, S. R., and Clark, T. J. H.Thorax, 29, 389-393. Early diagnosis of airways obstruction. Three simple tests, maximum expiratory flow volume curve, maximum expiratory volume time curve and `closing volume', were used to detect early airways obstruction in 21 smokers. A high proportion had abnormal values for MEF<sub>75%</sub>, MEF<sub>50%</sub>, and FET (86%, 71%, and 62% respectively) with a relatively normal FEV<sub>1</sub>. There was a good correlation between tests of small airways obstruction obtained from the forced expiratory manoeuvre. The measurement of `closing volume' (phase 4/VC%) was less satisfactory as there were difficulties with interpretation of the records in half of the studies. We conclude that the forced expiratory manoeuvre can be used to detect early airways obstruction as well as providing FEV₁ and vital capacity.

The importance of early diagnosis of airways obstruction is not yet clear and further information is required about its natural history, and its relation to smoking habits and to the more advanced and less reversible stages of airways obstruction. It may be possible to use early detection to prevent the development of disabling chronic obstructive bronchitis.