An evolution in the management of fractures of the ankle

Aims

There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety.

Patients and Methods

We performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracture which was fixed using a posteromedial approach. Five patients underwent initial temporary spanning external fixation. The outcome was assessed at a median follow-up of 29 months (interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were assessed for the quality of the reduction.

Results

The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm (IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting the medial forefoot, which resolved within three months.

Conclusion

We found that the posteromedial approach to the ankle for the surgical treatment of Haraguchi type 2 posterior malleolar fractures is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. Cite this article: Bone Joint J 2017;99-B:1496–1501.

Malignant bone tumours of the foot

Introduction Malignant osseous foot tumours are uncommon. Their oncological outcomes have been poorly documented in the literature so far. The aim of this study was to establish the incidence and to evaluate the oncological outcomes of such patients. Methods Our large orthopaedic oncology database was used to review 70 malignant osseous foot tumour patients. Results The age at diagnosis of malignant osseous foot tumours demonstrated a bimodal distribution peaking in the second and eighth decades of life. Overall, 55 primary malignant bone tumours of the foot (79%) were identified. The median duration from onset of symptoms to diagnosis was 52 weeks (interquartile range [IQR]: 17-104). Eight primary tumours (15%) underwent an accidental excision (ie intralesional excision of a malignant bone tumour where some of the tumour has been left behind, also known as a 'whoops procedure') prior to referral to our unit. Forty-six patients (84%) underwent surgery overall and thirteen of these developed recurrence or metastases. Seven of eight patients with a previous accidental excision underwent amputation. Fifteen osseous metastatic foot lesions were identified. The median length of foot symptoms to diagnosis was 24 weeks (IQR: 20-36 weeks). The median time to death following diagnosis of osseous foot metastases was 20.1 months (IQR: 11.3-27.8 months). Conclusions A high index of suspicion and awareness of clinical features of malignant osseous foot tumours are both essential to avoid diagnostic delays. Amputation is associated with a respectable outcome for patients who have undergone previous accidental excisions.

Optimal Generator Maintenance Scheduling Using a Hybrid Metaheuristic Approach

This paper presents an optimal approach for solving the generator maintenance scheduling (GMS) problem using a hybrid metaheuristic-based method. The GMS problem is formulated mathematically as a minimization problem of an aggregated objective function that handles both the reliability performance and the constraints violations. A new optimization approach, based on simulated annealing (SA) and ant colony optimization (ACO) is proposed to solve this problem. The optimization results for a 21-unit test system show that the proposed hybrid approach is more efficient than the standard SA and ACO methods and also genetic algorithms (GAs). It is also shown that the proposed approach is less sensitive to the variations of some control parameters and is more reliable than the other approaches.

Complications of tibio-talar-calcaneal fusion using intramedullary nails

BACKGROUND

Hindfoot nails are being increasingly used, however significant complications can occur. The purpose of this study was to assess the complications following the use of hindfoot nails at our institution.

METHODS

We identified patients from a retrospective database. All underwent hindfoot nailing under the care of the senior author. Details of complications were recorded.

RESULTS

We identified 52 patients undergoing 55 procedures. Mean follow up was 44.8 months (18-69). Forty patients achieved ankle fusion and 36 subtalar joint fusion. Complications included prominent metalwork in 13 patients, CRPS in five and one peri-prosthetic fracture. Nine developed deep infection, and of these limb salvage was achieved in six patients by removal of metalwork, debridement and insertion of antibiotic loaded cement beads. The remaining three patients underwent below knee amputation.

CONCLUSION

Significant complications can occur, although limb preservation was possible in most cases of deep infection. Hindfoot nailing should be reserved as salvage procedure.

Pgrmc1: new roles in the microglial mediation of progesterone-antagonism of estradiol-dependent neurite sprouting and in microglial activation

Pgrmc1 (progesterone receptor membrane component 1) is a multifunctional 22 kDa protein with heme-binding and P450-activating capacity which was recognized under different names for roles in cell motility during neural development and in cancer, and apoptosis. Pgrmc1 expression in microglia was recently shown by the present authors to mediate estrogen-progesterone interactions during axonal sprouting and to mediate microglial activation itself. We also discuss other functions of Pgramc1 in the nervous system and its possible relationship to the 18 kDa sigma-2 receptor (S2R).

Progesterone antagonism of neurite outgrowth depends on microglial activation via Pgrmc1/S2R

Neuronal plasticity is regulated by the ovarian steroids estradiol (E2) and progesterone (P4) in many normal brain functions, as well as in acute response to injury and chronic neurodegenerative disease. In a female rat model of axotomy, the E2-dependent compensatory neuronal sprouting is antagonized by P4. To resolve complex glial-neuronal cell interactions, we used the "wounding-in-a-dish" model of neurons cocultured with astrocytes or mixed glia (microglia to astrocytes, 1:3). Although both astrocytes and mixed glia supported E2-enhanced neurite outgrowth, P4 antagonized E2-induced neurite outgrowth only with mixed glia, but not astrocytes alone. We now show that P4-E2 antagonism of neurite outgrowth is mediated by microglial expression of progesterone receptor (Pgr) membrane component 1 (Pgrmc1)/S2R, a putative nonclassical Pgr mediator with multiple functions. The P4-E2 antagonism of neurite outgrowth was restored by add-back of microglia to astrocyte-neuron cocultures. Because microglia do not express the classical Pgr, we examined the role of Pgrmc1, which is expressed in microglia in vitro and in vivo. Knockdown by siRNA-Pgrmc1 in microglia before add-back to astrocyte-neuron cocultures suppressed the P4-E2 antagonism of neurite outgrowth. Conditioned media from microglia restored the P4-E2 activity, but only if microglia were activated by lipopolysaccharide or by wounding. Moreover, the microglial activation was blocked by Pgmrc1-siRNA knockdown. These findings explain why nonwounded cultures without microglial activation lack P4 antagonism of E2-induced neurite outgrowth. We suggest that microglial activation may influence brain responses to exogenous P4, which is a prospective therapy in traumatic brain injury.

A complication of the use of an intra-osseous needle

Intraosseous needles provide an important alternative to intravenous access for administration of drugs, fluids and blood products in the emergency management of trauma patients. This case report highlights one potential complication of the use of one brand of IO needle.

An audit of the effectiveness of postoperative radiographs—do they make a difference?

We examined the impact of postoperative radiographs after repair of facial fractures on immediate postoperative management. This was completed in two parts: first we did a retrospective study from January to July 2001, and secondly a prospective observational study for the remainder of 2001. All patients who had a general anaesthetic for the treatment of a facial fracture were included. The intervention was postoperative radiographs before discharge. The outcome measure was whether the patient had to return to theatre within a month. A total of 257 patients were included of whom 3 (1.2%) returned to theatre for correction of the initial procedure. In each case this was based on the postoperative clinical findings. No patient was returned to theatre solely on the evidence of an immediate postoperative radiograph. In line with official guidelines, we suggest that postoperative radiographs must not be used routinely, but only when they are required clinically. This minimises the risk to patients, and may lead to speedier discharge and appreciable savings.

Improved resuscitation training of senior house officers in oral and maxillofacial surgery

All healthcare professionals are expected to be competent at cardiopulmonary resuscitation. In a previous study [Br J Oral Maxillofac Surg 1999; 37: 1], senior house officers in oral and maxillofacial surgery (OMFS) expressed dissatisfaction about their training in resuscitation, and we now report the results of a follow-up survey. The amount of training in resuscitation has increased in the 5 years since the initial questionnaire, and 77% of the 73 respondents (n=56) been given such training in the 12 months before the present survey, compared to 48% in the previous study. Fifty-one (70%) now think that they would feel confident if required to resuscitate a patient who had a cardiorespiratory arrest, and this has increased from 47%. Despite this, 70 (96%) of senior house officers in OMFS stated that they wanted further training in cardiopulmonary resuscitation.

Viral infection of the thymus

We have examined infection of the thymus during congenitally acquired chronic lymphocytic choriomeningitis virus (LCMV) infection of mice, a classic model of antigen-specific T-cell tolerance. Our results show that (i) infection starts at the fetal stage and is maintained throughout adulthood, and (ii) this chronic infection of the thymus can be eliminated by transfer of virus-specific cytotoxic T lymphocytes (CTL) that infiltrate the thymus and clear all viral products from both medullary and cortical regions. Elimination of virus from the thymus results in abrogation of tolerance. During the fetal stage, the predominant cell type infected is the earliest precursor of T cells with a surface phenotype of Thy1+ CD4- CD8- J11d+. In the adult thymus, infection is confined primarily to the cortisone-resistant thymocytes present in the medullary region. The infected cells are CD4+ and J11d+. The presence of J11d, a marker usually associated with immature thymocytes, on infected single positive CD4+ "mature" thymocytes is intriguing and suggests that infection by this noncytolytic virus may affect development of T cells. There is minimal infection of the CD8+ medullary thymocytes or of the double positive (CD4+ CD8+) cells present in the cortex. Infection within the cortex is confined to the stromal cells. Interestingly, there is infection of the double negative (CD4- CD8-) thymocytes in the adult thymus, showing that even during adulthood the newly developing T cells are susceptible to infection by LCMV. Virus can be eliminated from the thymuses of these carrier mice by adoptive transfer of medullary region first and then from the thymic cortex. This result clearly shows the need to reevaluate the widely held notion that mature T cells are unable to reenter the thymus. In fact, in our experiments the donor T cells made up to 20 to 30% of the total cells in the thymus at 5 to 7 days after the transfer. The number of donor T cells declined as virus was eliminated from the thymus, and at 1 month posttransfer, the donor T cells were hardly detectable. The results of this study examining the dynamics of viral infection and clearance from the thymus, the primary site of T-cell development, have implications for understanding tolerance induction in chronic viral infections.