Having a pacemaker has been seen an absolute contraindication to having an MRI scan. This has become increasingly difficult in clinical practice as insertion of pacemakers and implantable cardiac defibrillators is at an all time high. Here we outline a case where a 71-year-old male patient with a permanent pacemaker needed to have an MRI scan to ascertain the aetiology of his condition and help guide further management. Given this clinical dilemma, an emergency clinical ethics consultation was arranged. As a result the patient underwent an MRI scan safely under controlled conditions with a consultant cardiologist and radiologist present. The results of the MRI scan were then able to tailor further treatment. This case highlights that in certain conditions an MRI can be performed in patients with permanent pacemakers and outlines the role of clinical ethics committees in complex medical decision making.

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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. Patients & methods This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13 th January and 31 st July 2020. Data was examined pre- UK national lockdown, during lockdown (23 rd March to 11 th 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. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods. Conclusions 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. Clinical relevance This paper highlights a significant regional variation in COVID-19 infection rates and peak of COVID-19 infections across the country; this data may be useful in planning response to subsequent waves. The cumulative COVID-19 infection rates suggest that the risk of contracting COVID-19 in patients undergoing foot and ankle surgery is not insignificant. The marked decrease in, and slow recovery of elective activity seen will need to be considered when planning restoration of elective foot and ankle services.

Abstracts / Injury Extra 42 (2011) 95-169 Results: 88 patients were trialled between May 2007 and April 2010. 80% (n = 70) of patients were successfully treated as day cases, 17% (n = 15) were discharged on the day of operation but required hospital beds for out-of-hours management and 3% (n = 3) required overnight admission. 58% (n = 51) of patients were successfully contacted within a week of operation. 94% (n = 48) achieved good postoperative pain control, experiencing no or mild pain only. 2% (n = 1) experienced other post-operative symptoms, such as nausea.100% of patients were satisfied with their treatment. 100% of patients were happy their procedure was completed as a day case.Conclusion: ACL tears are common traumatic injuries. We conclude that the significant majority of ACL reconstructions can successfully be completed as a day case procedures, reducing the need for hospital.Objective: To assess the usefulness of radiographs alone to evaluate acute midfoot/forefoot injuries. We believe that foot injuries are often under-estimated and that CT scans should be routinely obtained to aid in their management and avoid additional morbidity for patients.Materials and methods: In 26 months, 255 patients had foot injuries requiring X-rays. Of these patients, 94 (37%) had primary radiographs indicating midfoot or forefoot fractures, and 28 had subsequent CT scans. Radiographs were retrospectively reevaluated with respect to fracture location, type, mechanism of injury and then compared with CT results.Results: Of 255 patients, 213 (84%) had one or more fractures in their foot. A total of 397 fractures were seen with 105 patients having Os Calcis (41%) fractures. 94 patients (37%) had midfoot/forefoot fractures which included the 28 patients with subsequent CT scans. 56 patients (22%) had no injury. Of those patients with midfoot/forefoot injuries, 61 fractures were seen on plain radiographs and an additional 74 were identified on CT scanning.The major mechanism of injury in these patients was Road Traffic Accident (26 patients [28%]). Commonly missed individual fractures on plain radiography were Metatarsal (29), Cuboid (12) and Cuneiform fractures (11). Nine of the 29 (31%) metatarsal bone fractures involved missed fracture-dislocations of the Lisfranc joint. Other new fractures included Talus (4), Navicular (3), Os Calcis (2) and Tibia (2). 48 required operative fixation, including 20 patients that underwent CT scanning.We found that the sensitivity of radiographs in detection of midfoot fractures was low at 44%, and only 50% in forefoot injuries.Conclusion: In patients with high energy foot injury, and those with suspected complex injury, the sensitivity of radiography is only moderate at best. We suggest that CT scanning as the primary imaging modality would lead to a decrease in their morbidity.

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