BACKGROUND:Talus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series. METHODS:We retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded. RESULTS:The mean age was 35 years (range: 18-76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis. CONCLUSION:Our study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated.

The Bologna-Oxford (BOX®) total ankle arthroplasty (TAA) is a three-component mobile-bearing implant gaining popularity in Europe. We aimed to analyse the outcomes of this TAA. We retrospectively analysed data on 34 consecutive BOX® TAAs performed at a single centre with a mean follow-up of 58 months. Radiographic outcomes, such as periprosthetic lucency and alignment, were measured and recorded. Prospectively captured clinical scores and range of movement (ROM) were also recorded. There were significant improvements in patient-reported outcome scores recorded in the Manchester-Oxford Foot Questionnaire (MOxFQ) for pain (43.8 ± 20.2, p < 0.001), standing and walking (55.6 ± 19.8, p < 0.001), social activities (45.0 ± 26.9, p < 0.02) and visual analogue score (VAS) (3.1 ± 2.5, p < 0.001). Mean improvement in ROM postoperatively was 18.7° (p < 0.001), with post-operative dorsiflexion 8.8° (10°–25°) and plantar flexion 32.6° (20°–40°). There was evidence of asymptomatic lucency on five radiographs (15%), which was present in 10% at three years. Nine patients had complications (26%): six (18%) requiring secondary surgery and one requiring revision (3%) for infection. We have demonstrated 97% survivorship at a mean of 58 months. There are maintained improvements in clinical and radiological outcomes and reoperation that are consistent with the literature.

Purpose.To evaluate the outcome after percutaneous repair followed by accelerated rehabilitation for acute Achilles tendon ruptures.Methods.21 men and 9 women (mean age, 41 years) underwent percutaneous repair by a single senior surgeon for acute Achilles tendon ruptures, followed by early weight bearing and accelerated rehabilitation. Outcome measures included the Achilles tendon re-rupture rate, the Achilles tendon total rupture score (ATRS) at 3 and 6 months, the incidence of sural nerve injury, wound infection, wound dehiscence, patient satisfaction, and the time to return to pre-rupture activity.Results.The mean follow-up period was 12.5 months. The mean ATRS score improved from 57.65 at 3 months to 86.95 at 6 months (p<0.001). No patient had intra-operative complications, tendon re-rupture, sural nerve injury, wound dehiscence, or deep infection. Two patients developed a superficial wound infection, which was resolved with oral flucloxacillin. Two patients had a mass at the transverse incision, but neither had any symptoms or functional restriction. All patients were able to bear full weight comfortably without the walker boot at 8 weeks, and return to their work by 3 months. The mean time to return to pre-rupture activity, including sports, was 10.4 months. The mean satisfaction rate was 87% at 6 months.Conclusion.Percutaneous repair of the Achilles tendon followed by early weight bearing and accelerated rehabilitation achieves good functional outcome.

BACKGROUND The incidence of infected femoral artery pseudoaneurysms is likely to increase with increasing numbers of femoral artery interventions. METHODS Case report and review of literature. RESULTS We present a case of dehiscence of a vein patch repair of an infected femoral pseutoaneurysm treated with ligation of vessels and coverage by rectus abdominis muscle flap. CONCLUSION We consider the use of this flap as a good second line option for the coverage of exposed femoral vessels, in the presence of sepsis, particularly when the external iliac artery has been ligated.

OBJECTIVES:Conventional cardiopulmonary bypass causes haemodilution and is a trigger of systemic inflammatory reactions, coagulopathy and organ failure. Miniaturized cardiopulmonary bypass has been proposed as a way to reduce these deleterious effects of conventional cardiopulmonary bypass and to promote a more physiological state. The use of miniaturized cardiopulmonary bypass has been reported in low-risk patients undergoing valve and coronary artery bypass graft (CABG) surgery. However, little is known about its application in major aortic surgery.METHODS:From February 2007 to September 2010, 49 patients underwent major aortic surgery using the Hammersmith miniaturized cardiopulmonary bypass (ECCO, Sorin). Data were extracted from medical records to characterize preoperative comorbidities (EuroSCORE), perioperative complications and the use of blood products. The same data were collected and described for 328 consecutive patients having similar surgery with conventional cardiopulmonary bypass at the Bristol Heart Institute, our twinned centre, during the same period.RESULTS:The miniaturized cardiopulmonary bypass group had a median EuroSCORE of 8 [inter-quartile range (IQR): 5-11], 13% had preoperative renal dysfunction and 20% of operations were classified as emergency or salvage. Thirty-day mortalities were 6.4; and 69, 67 and 74% had ≥ 1 unit of red cells, fresh frozen plasma (FFP) and platelets transfused, respectively. Eight percent of patients experienced a renal complication, and 8% a neurological complication. The conventional cardiopulmonary bypass group was similar, with a EuroSCORE of 8 (IQR: 6-10); 30-day mortalities were 9.4; and 68, 62 and 74% had ≥ 1 unit of red cells, FFP and platelets transfused, respectively. The proportions experiencing renal and neurological complications were 14 and 5%.CONCLUSIONS:Our experience suggests that miniaturized cardiopulmonary bypass is safe and feasible for use in major aortic cardiac surgery. A randomized trial is needed to evaluate miniaturized cardiopulmonary bypass formally.

To provide a simple, reliable method for the three-dimensional quantification of pincer-type hip deformity.

Sir: Free tissue transfer is now a routine procedure in reconstructive surgery. Arterial and venous occlusions are common complications requiring revision surgery and flap salvage. Flap salvage rates remain approximately 50 percent,1 and salvage of the affected tissue depends largely on the time to reexploration. Assessing the viability of tissues by monitoring circulatory changes during harvesting and following transfer of free flaps is essential. Devices designed to augment clinical assessment (standard method) could lead to prompt surgical intervention and improved salvage rates. Popular adjuvant techniques include external and implantable Doppler monitoring and laser Doppler flowmetry.2 However, no method has proven to be more reliable than clinical assessment, and this supports the need to seek alternatives.1 Near-infrared spectroscopy exploits the relative transparency of biological tissue in the near-infrared wavelength range. Near-infrared light is capable of penetrating tissue and can still be detected on remission, following absorption by the primary light-absorbing molecules (chromophores) in biological tissues, oxyhemoglobin and deoxyhemoglobin. These chromophores have different absorption spectra in the near-infrared wavelength range (600 to 900 nm). Provided that at least two wavelengths are used, it is possible to resolve changes in oxyhemoglobin and deoxyhemoglobin, and their sum, total hemoglobin based on the amount of light absorption. Near-infrared spectroscopy is capable of noninvasively monitoring and differentiating between venous, arterial, and total occlusion of a skin flap.1 The parameters most commonly reported in the literature are tissue oxygen saturation, which represents oxygen delivery and consumption, and total hemoglobin, which reflects changes in blood tissue volume and tissue perfusion. We recently reviewed the literature systematically to determine whether near-infrared spectroscopy responses differ between successful and failing tissue flaps.1–8Figure 1 illustrates the difference between successful and failing tissue flaps in terms of longitudinal changes in tissue oxygen saturation measured using near-infrared spectroscopy. In successful flaps, an initial increase in tissue oxygen saturation is observed in the first 2 hours postoperatively, following which levels return to preoperative values. This can be explained by two mechanisms: (1) the autonomic denervation of cutaneous vessels during skin flap dissection and (2) the inflammatory reaction at the wound margin. Both result in local vasodilation.7 Several studies7,8 report an increase in total hemoglobin following successful free flap surgery, maintained up to 48 hours postoperatively, with subsequent recovery of levels toward preoperative values thereafter.Fig. 1.: Tissue hemoglobin oxygen concentration (StO2) in surviving and failing flaps. The data represent the mean preoperative and postoperative tissue oxygen saturation levels.It remains unclear whether increases or decreases in tissue oxygen saturation are more predictive of a failing flap. There appears to be little difference between preoperative and postoperative tissue oxygen saturation levels in flaps that ultimately fail. The early rise in tissue oxygen saturation levels observed in successful flaps is not observed in failing flaps. Postoperative increases in total hemoglobin occur in almost all breast flaps that ultimately fail.7 Failing flaps demonstrate a greater total hemoglobin increase than surviving flaps. The most likely explanation for excessive increases in total hemoglobin in failing flaps is associated venous congestion. Near-infrared spectroscopy is capable of providing useful information regarding tissue hemodynamics, especially with respect to the measure of tissue oxygen saturation in surviving flaps. However, there is limited current evidence that near-infrared spectroscopy is able to differentiate the specific cause for flap failure. However, near-infrared spectroscopy has been used successfully to guide early reoperation, at which point the source of flap failure can be determined. Further validation studies are necessary to determine sensitivity, specificity, and the differences in tissue hemodynamics between various tissue flaps, before the use of near-infrared spectroscopy can be fully endorsed as a clinical tool. Ali Najefi, B.Sc. Royal Wolfson Image Computing Laboratory and Department of Bio Surgery and Surgical Technology Imperial College London Daniel R. Leff, M.B.B.S. Royal Wolfson Image Computing Laboratory and Department of Bio Surgery and Surgical Technology Imperial College London Biomedical Optics Research Laboratory Department of Medical Physics and Bioengineering University College London Marios Nicolaou, Ph.D. Biomedical Optics Research Laboratory Department of Medical Physics and Bioengineering University College London Charles Nduka, M.A., M.D. Queen Victoria Hospital East Grinstead, West Sussex, United Kingdom Guang-Zhong Yang, Ph.D. Biomedical Optics Research Laboratory Department of Medical Physics and Bioengineering University College London Ara W. Darzi, F.R.C.S., F.A.C.S. Royal Wolfson Image Computing Laboratory and Department of Bio Surgery and Surgical Technology Imperial College London London, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.