Late presentation of a paranasal sinus glass foreign body: a case report

Foreign bodies in the paranasal sinuses are rare and mostly related to maxillo-facial trauma. We treated a 47-year-old man with a late complication arising from a foreign body in the nasoethmoid sinus present for 16 years after a road traffic accident. Patients presenting with maxillo-facial injuries, especially those with lacerations due to glass or car wind-screen trauma should have thorough examination and appropriate imaging of the injury

Management of Warfarin Anticoagulation in Patients with Fractured Neck of Femur

Background. Most orthopaedic units do not have a policy for reversal of anticoagulation in patients with hip fractures. The aim of this study was to examine the current practice in a district general hospital and determine difference in the time to surgery, if any, with cessation of warfarin versus cessation and treatment with vitamin K. Methods. A retrospective review of the case notes between January 2005 and December 2008 identified 1797 patients with fracture neck of femur. Fifty seven (3.2%) patients were on warfarin at the time of admission. Patients were divided into 2 groups (A and B). Group A patients (16/57; 28%) were treated with cessation of warfarin only and group B patients (41; 72%) received pharmacological therapy in addition to stopping warfarin. Time to surgery between the two groups was compared. Results. The mean INR on admission was 2.9 (range 1.7–6.5) and prior to surgery 1.4 (range 1.0–2.1). Thirty eight patients received vitamin K only and 3 patients received fresh frozen plasma and vitamin K. The average time to surgery was 4.4 days in group A and 2.4 days in group B. The difference was statistically significant (P < .01). Conclusion. Reversal of high INR is important to avoid significant delay in surgery. There is a need for a national policy for reversing warfarin anticoagulation in patients with hip fractures requiring surgery. Vitamin K is safe and effective for anticoagulation reversal in hip fracture patients

Clinically useful finite element models of the natural ankle – a review

Background:Biomechanical simulation of the foot and ankle complex is a growing research area but compared to simulation of joints such as hip and knee, it has been under investigated and lacks consistency in research methodology. The methodology is variable, data is heterogenous and there are no clear output criteria. Therefore, it is very difficult to correlate clinically and draw meaningful inferences.Methods:The focus of this review is finite element simulation of the native ankle joint and we will explore: the different research questions asked, the model designs used, ways the model rigour has been ensured, the different output parameters of interest and the clinical impact and relevance of these studies.Findings:The 72 published studies explored in this review demonstrate wide variability in approach. Many studies demonstrated a preference for simplicity when representing different tissues, with the majority using linear isotropic material properties to represent the bone, cartilage and ligaments; this allows the models to be complex in another way such as to include more bones or complex loading. Most studies were validated against experimental or in vivo data, but a large proportion (40%) of studies were not validated at all, which is an area of concern.Interpretation:Finite element simulation of the ankle shows promise as a clinical tool for improving outcomes. Standardisation of model creation and standardisation of reporting would increase trust, and enable independent validation, through which successful clinical application of the research could be realised

What can we learn from the experiences and expectations of patients on growing waiting lists for planned care in the COVID-19 pandemic?

COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.MethodsA minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory.ResultsA total of 888 patients responded. Better health, pain, and mood scores were reported by upper limb patients. The longest waiters reported better health but poorer mood and anxiety scores. Overall, 82% had tried self-help measures to ease symptoms; 94% wished to proceed with their intervention; and 21% were prepared to tolerate deferral. Qualitative analysis highlighted the overall patient mood to be represented by the terms ‘understandable’, ‘frustrated’, ‘pain’, ‘disappointed’, and ‘not happy/depressed’. COVID-19-mandated health and safety measures and technology solutions were felt to be implemented well. However, patients struggled with access to doctors and pain management, quality of life (physical and psychosocial) deterioration, and delay updates.ConclusionThis is the largest study to hear the views of this ‘hidden’ cohort. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within the constraints of current resources. In response, we developed a reproducible local action plan to address highlighted issues.Cite this article: Bone Jt Open 2021;2(8):583–593

The UK Foot and Ankle COVID-19 National (FAlCoN) audit.

AimsThe primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.MethodsThis UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates.ResultsA total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19.ConclusionCOVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216-226

Ethnic differences in cellular and humoral immune responses to SARS-CoV-2 vaccination in UK healthcare workers: a cross-sectional analysis

Background: Few studies have compared SARS-CoV-2 vaccine immunogenicity by ethnic group. We sought to establish whether cellular and humoral immune responses to SARS-CoV-2 vaccination differ according to ethnicity in UK Healthcare workers (HCWs). Methods: In this cross-sectional analysis, we used baseline data from two immunological cohort studies conducted in HCWs in Leicester, UK. Blood samples were collected between March 3, and September 16, 2021. We excluded HCW who had not received two doses of SARS-CoV-2 vaccine at the time of sampling and those who had serological evidence of previous SARS-CoV-2 infection. Outcome measures were SARS-CoV-2 spike-specific total antibody titre, neutralising antibody titre and ELISpot count. We compared our outcome measures by ethnic group using univariable (t tests and rank-sum tests depending on distribution) and multivariable (linear regression for antibody titres and negative binomial regression for ELISpot counts) tests. Multivariable analyses were adjusted for age, sex, vaccine type, length of interval between vaccine doses and time between vaccine administration and sample collection and expressed as adjusted geometric mean ratios (aGMRs) or adjusted incidence rate ratios (aIRRs). To assess differences in the early immune response to vaccination we also conducted analyses in a subcohort who provided samples between 14 and 50 days after their second dose of vaccine. Findings: The total number of HCWs in each analysis were 401 for anti-spike antibody titres, 345 for neutralising antibody titres and 191 for ELISpot. Overall, 25.4% (19.7% South Asian and 5.7% Black/Mixed/Other) were from ethnic minority groups. In analyses including the whole cohort, neutralising antibody titres were higher in South Asian HCWs than White HCWs (aGMR 1.47, 95% CI [1.06–2.06], P = 0.02) as were T cell responses to SARS-CoV-2 S1 peptides (aIRR 1.75, 95% CI [1.05–2.89], P = 0.03). In a subcohort sampled between 14 and 50 days after second vaccine dose, SARS-CoV-2 spike-specific antibody and neutralising antibody geometric mean titre (GMT) was higher in South Asian HCWs compared to White HCWs (9616 binding antibody units (BAU)/ml, 95% CI [7178–12,852] vs 5888 BAU/ml [5023–6902], P = 0.008 and 2851 95% CI [1811–4487] vs 1199 [984–1462], P &lt; 0.001 respectively), increments which persisted after adjustment (aGMR 1.26, 95% CI [1.01–1.58], P = 0.04 and aGMR 2.01, 95% CI [1.34–3.01], P = 0.001). SARS-CoV-2 ELISpot responses to S1 and whole spike peptides (S1 + S2 response) were higher in HCWs from South Asian ethnic groups than those from White groups (S1: aIRR 2.33, 95% CI [1.09–4.94], P = 0.03; spike: aIRR, 2.04, 95% CI [1.02–4.08]). Interpretation: This study provides evidence that, in an infection naïve cohort, humoral and cellular immune responses to SARS-CoV-2 vaccination are stronger in South Asian HCWs than White HCWs. These differences are most clearly seen in the early period following vaccination. Further research is required to understand the underlying mechanisms, whether differences persist with further exposure to vaccine or virus, and the potential impact on vaccine effectiveness. Funding: DIRECT and BELIEVE have received funding from UK Research and Innovation (UKRI) through the COVID-19 National Core Studies Immunity (NCSi) programme (MC_PC_20060)

Research priorities in foot and ankle conditions: results of a UK priority setting partnership with the James Lind Alliance

Objective To ascertain the priorities of research in surgical interventions and aftercare in foot and ankle conditions in adults, from inclusive viewpoints of patients, carers, allied professionals and clinicians, as a collaboration with James Lind Alliance (JLA) Priority Setting Partnership. Setting A UK-based national study organised through British Orthopaedic Foot and Ankle Society (BOFAS).Design A cross-section of both medical and allied professionals, with patient involvement, submitted their ‘top priorities’ pertaining to foot and ankle pathology, using both paper and web-based formats, which were synthesised into the primary priorities. Following this, workshop-based reviews were used to determine the top 10 priorities.Participants Adult patients, carers, allied professionals and clinicians who have experienced or managed foot and ankle conditions in the UK.Methods A transparent and well-established process developed by JLA was carried out by a steering group of 16 members. A broad survey was designed and disseminated to the public via clinics, BOFAS meetings and website, JLA platforms and electronic media to establish potential research priority questions. Surveys were analysed and initial questions were categorised and cross-referenced with the literature. Those questions that were out of scope and sufficiently answered by research were excluded. The unanswered questions were ranked by the public via a second survey. The top 10 questions were finalised via an extensive workshop.Results 472 questions from 198 responders were received from the primary survey. 71% (140) from healthcare professionals, 24% (48) from patients and carers and 5% (10) from other responders. 142 questions were out of scope, leaving 330 questions. These were summarised into 60 indicative questions. Reviewing against current literature, 56 questions were left. From the secondary survey, there were 291 respondents: 79% (230) healthcare professionals and 12% (61) patients and carers. After the secondary survey, the top 16 questions were brought to the final workshop to finalise the top 10 research questions. The top 10 questions were: What are the best outcome measures (ways of assessing the effect of the treatment) after foot and ankle surgery? What treatment is the best for Achilles tendon pain? What is the best treatment (including surgery) for tibialis posterior dysfunction (tendon on the inner side of the ankle), leading to a successful long-term outcome? Should physiotherapy be provided following foot and ankle surgery and is there an optimal amount needed to restore function after foot and ankle surgery? At what stage should a patient with ankle instability (ie, an ankle that keeps giving way) be considered for surgical treatment? How effective are steroid injections in improving pain from arthritis in the foot and ankle? What is the best surgery for bone and cartilage defects in the talus? What is better, ankle fusion or ankle replacements? What is the success of surgical lengthening of the calf muscle in improving forefoot pain? What is the best time to start weight bearing after ankle fusion/replacement surgery?Conclusion Top 10 themes included outcomes following interventions, for example, range of movement, reduction in pain, rehabilitation, which included physiotherapy to optimise post intervention outcomes, rehabilitation and condition-specific treatments. These questions will aid to guide national research into foot and ankle surgery. It will also help national funding bodies to prioritise areas of research interest to improve patient care

The UK Foot and Ankle COVID-19 National (FAlCoN) Audit – Regional Variations in COVID-19 Infection and National Foot and Ankle Surgical Activity

Category: Other; Ankle; Ankle Arthritis; Arthroscopy; Basic Sciences/Biologics; Bunion; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; Trauma Introduction/Purpose: Aims: This paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down. Methods: Patients &amp; Methods: This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured. Results: 6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n=35). The rate of COVID-19 infection was highest during lockdown (2.11%, n=16) and lowest after lockdown (0.16%, n=3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID- 19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown Conclusion: National surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country. </jats:sec

The UK Foot and Ankle COVID-19 National Audit – Rate of COVID-19 Infection and 30 Day Mortality in Foot and Ankle Surgery in the UK

Category: Diabetes; Other Introduction/Purpose: The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods: Design: Multicentre retrospective national audit. Setting: UK-based study on foot and ankle patients who underwent surgery between the 13th January to 31st July 2020 - examining time periods pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. Participants: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Main Outcome Measures: Variables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results: 6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30- day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection. Conclusion: COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. </jats:sec