Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes. Cite this article:
Autologous osteochondral transplantation (AOT) is an effective treatment for large Osteochondral Lesions of the Talus (OLT), however little is reported on an athletic population, who are likely to place higher demands on the reconstruction. The aim is to report the outcomes of large OLT (>150mm2) within an athletic population. The study population was limited to professional or amateur athletes (Tegner score >6) with an OLT of size 150mm2 or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included Return to Sport, VAS and FAOS Scores. In addition, graft incorporation was evaluated by MRI using MOCART scores at 12 months post-surgery. 38 athletes including 11 professional athletes were assessed. Mean follow-up was 46 months. Mean lesion size was 249mm2. 33 patients returned to sport at their previous level and one did not return to sport (mean return to play 8.2 months). Visual analogue scores improved from 4.53 pre-operatively to 0.63 post-operatively (p=0.002). FAOS Scores improved significantly in all domains (p< 0.001). Two patients developed knee donor site pain, and both had three osteochondral plugs harvested. Univariant analysis demonstrated no association between pre-operative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport (AUC=0.89). Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favourable return to sport levels, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation and further research is required to optimise this technique. Our data also suggests that patients should be aware of the increased risk of developing knee donor site pain when three osteochondral plugs are harvested.
This work examines the Upper limb (UL) blast-mediated traumatic amputation (TA) significance from recent operations in Afghanistan. It is hypothesized that the presence of an UL amputation at any level is an independent predictor of torso injury. A joint theatre trauma registry search was performed to determine the number of British casualties with TA and their associated injuries. UL TA accounted for 15.7% of all amputations; distributed: shoulder disarticulation 2.5%, trans-humeral 30%, elbow disarticulation 10%, trans-radial 20% and hand 37.5%. The presence of an UL amputation was more likely in dismounted casualties (P=0.015) and is a predictor of an increased number of total body regions injured and thoracic injuries (P 0.001 and P 0.026 respectively). An increased Injury Severity Score (ISS) was seen in patients with multiple amputations involving the UL (UL TA present ISS=30, no UL TA ISS=21; P=0.000) and the ISS was not significantly different whether mounted or dismounted (P=0.806). The presence of an upper limb amputation at any level should insight in the receiving clinician a high index of suspicion of concomitant internal injury; especially thoracic injury. Therefore with regards to blast mediated TA the injury patterns observed reflect a primary and tertiary blast mechanism of injury.
The explosive device has successfully been used by terrorists globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of, high lethality and target accuracy. This aim of this study was to analyse the demographics and casualty figures of terrorist bombings worldwide. Analysis of the Global Terrorism Database and a PubMed search (keywords “terrorist”, and/or “suicide”, and/or “bombing”) from 1970 to date was performed. Of 58,095 reported terrorist explosions worldwide, 5.08% were suicide bombings. Incidents per year is increasing (P<0.01). PubMed identified 41 publications reporting 167 incidents. Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe ranked 4th in the number of terrorist related explosion (13.2%). Differing injury patterns were seen in open, confined and building collapse incidents. Terrorist bombings continue to be a threat and are increasing in the Middle East and Europe. Suicide bombings are becoming an increased threat with greater casualty figures per incident seen. This data assists in the planning of security, logistics, casualty evacuation and care.
Military personnel operating on high speed marine craft are exposed to Whole-Body Vibration (WBV). Additionally planing craft operate at speeds with minimal contact of the hull with warer making the crew vulnerable to mechanical shock. An association between Low Back Pain (LBP) and exposure to WBV has been extensively reported in civilian literature. LBP is reported by military personnel operating on planing craft leading to downgrades and potential discharge. There is a clear need to understand the impact prolonged exposure has on our population operating these craft. We performed a bibliographical search of the PubMed database for records using a combination of keywords. Abstracts were screened for relevance and references cited in retrieved papers reviewed. There is no consensus in the literature on the potentially pivotal pathological process behind the association. Evidence from professional driving suggests current safe operating exposure levels require review to protect against long-term damage however with little evidence concerning the unique environment in which boats crews operate, the parity of these environments require investigation to allow direct comparison. Due to the prevalence of LBP in this population a need exists to establish the pathological process and add to the evidence base driving safe operating exposure levels.
General Duties Medical Officers (GDMO) deploy to singleton posts on a variety of platforms with, in some cases, limited orthopaedic exposure. The aim of this paper is to investigate the type of orthopaedic conditions presenting to a GDMO at sea onboard a Royal Fleet Auxiliary (RFA) platform to gain a better understanding of the breadth and chronicity of cases. This information can then be utilised when planning the New Entry Medical Officer programme to ensure GDMO pre-deployment teaching is pitched appropriately. All cases contained in a prospective database over a four-month period at sea were interrogated and data pertaining to orthopaedic cases was collected. Data analysis revealed that almost a fifth of cases were orthopaedic related with back and knee problems accounting for 50%. The case mix was similar to that seen by Primary Healthcare Practitioners ashore with only one case requiring medical evacuation from the ship. The data revealed that the comparably older civilian population on RFA platforms present with a wide breadth and chronicity of problems and with increasing numbers of GDMOs deploying on these platforms the data demonstrated the need to ensure teaching covers the management of common acute and chronic conditions as well as emergencies.
Primary Care Trusts across the country are being encouraged to ration service provision due to austerity measures. Obesity has been suggested as a rationing tool with poor clinical outcomes sited as justification. There is, however, a lack of evidence in the literature pertaining to clinical outcomes post elective foot and ankle surgery in patients with an increased Body Mass Index (BMI). All patients undergoing elective foot and ankle surgery at Queen Alexandra Hospital, Portsmouth are entered into a prospective database, which includes their BMI at time of assessment in clinic. From this, we analysed the notes of all patients with a BMI ≥30, excluding any not operated on between July 2007 and August 2009 or with a BMI of <30 at time of surgery, to determine whether there was an increased incidence of peri- or post-operative complications. Included in the study were 109 patients with a mean age of 54 (range 21 - 79). Female patients accounted for 63% of those notes reviewed and the mean BMI was 34 (range 30 - 50). A mixture of hindfoot and forefoot procedures were carried out (20 different procedures). Median length of stay was 0 nights (range 0 – 15 days). The causes for excessive length of stays (>4 nights) included a pre operative Lower Respiratory Tract Infection missed prior to intubation and the initiation of CPAP post operatively in a patient with known Obstructive Sleep Apnoea. We found 3 cases of post operative Venous Thrombo-embolism within 3 months of surgery and 1 proven wound infection in a non-insulin dependent diabetic patient. Also noted were 3 non-unions, all requiring further surgery. Based on our historical evidence of infective and thrombo-embolic complications in patients with a BMI <30, we conclude that peri- and post-operative complications in obese patients occur no more frequently than in a patient population with a BMI <30.
