This manuscript reviews the role of Vitamin D and its deficiency in pathology of the foot and ankle. Vitamin D is an essential vitamin which targets a number of tissues and organs, and plays an important role in calcium homeostasis. Vitamin D deficiency is common, particularly at higher latitudes where there is reduced exposure to ultraviolet B radiation. The effects of Vitamin D deficiency have been extensively studied but only a small portion of the literature has focused on the foot and ankle. Most of the evidence regarding the foot and ankle consists of retrospective studies which cannot determine whether Vitamin D deficiency is in fact the cause for the pathologies being investigated. The available evidence suggests that insufficient levels of Vitamin D may result in an increased incidence of foot and ankle fractures. The effects of Vitamin D deficiency on fracture healing, bone marrow edema syndrome, osteochondral lesions of the talus, strength around the foot and ankle, tendon disorders, elective foot and ankle surgery, and other foot and ankle conditions are less clear. Based on the available evidence, we are unable to recommend routine testing or supplementation of Vitamin D in patients presenting with foot and ankle pathology. However, Vitamin D supplementation is cheap, safe and may be of benefit in patients at high risk of deficiency. When it is supplemented the evidence suggests calcium should be co-supplemented. Further high-quality research is needed into the effect of Vitamin D in the foot and ankle. Cost-benefit analyses of routine testing and / or supplementation of Vitamin D for foot and ankle pathology are also required.
IntroductionPeriprosthetic femoral fractures (PFFs) present a significant burden on the health service. The incidence continues to rise globally as a result of an ageing population and an increase in the number of primary hip and knee arthroplasties being performed. This is a 10-year, retrospective, observational study that aims to better understand the outcomes of PFF in our district general hospital. Materials and methodsWe identified the demographic information of patients who had a PFF and looked at how the American Society of Anesthesiologists (ASA) score, time to operation, length of stay, complications, and mortality data vary depending on where the fracture is sited and the operative management employed. ResultsDuring the period between January 2011 and March 2021, we identified 214 cases of PFF. The mean age was 82.5 years with a female preponderance of 76%. Between 2011-2016 and 2017-2021, the number of cases of PFF increased and patients with an ASA score of 3 or more increased from 43% to 73%. Length of stay was longer in the proximal PFF revision group than in the proximal PFF fixation group. Overall PFF mortality rates at 30 days, 90 days, and one year were 6%, 10%, and 15%, respectively. ConclusionOver the 10-year period, there was a significant increase in the incidence of patients presenting with PFF with multiple comorbidities. Mortality rates were lower in proximal PFF patients who underwent revision procedures rather than fixation. The patient demographics, complication rates, and mortality rates were comparable to similar studies across different countries.
We present an extremely unusual case of an external biliary fistula in an 87-year-old woman who presented with a 1-day history of spontaneous green discharge from a 60-year-old appendicectomy scar. Examination revealed a sinus in the right iliac fossa overlying her appendicectomy scar, with a raised white cell count and C reactive protein. A CT scan revealed a complex fistula connecting the gallbladder to the subcutaneous tissue in the right flank, which further connected inferiorly with a fistula to the previous appendicectomy scar and a small iliopsoas collection. Endoscopic retrograde cholangiopancreatography revealed several stones in the common bile duct, which were removed using a balloon catheter. The patient was further managed with a long course of antibiotics and discharged with a long-term drainage bag. A literature search revealed no previously reported cases of an external biliary fistula communicating with an appendicectomy scar.
Delayed recognition of compartment syndrome can result in devastating consequences such as the need for amputation or even death. Nurses are at the frontline of patient care in the orthopedic department and it is essential that they have a high index of suspicion for compartment syndrome. In this publication we describe an easily replicable project to assess and improve the understanding of the condition by nurses on trauma wards. Our project involved a questionnaire to assess the ability of nurses to recognise the key clinical features of compartment syndrome. This initial questionnaire was followed by a one-week teaching programme within the department, after which the questionnaire was repeated. Our results demonstrate that nursing staff place a disproportionate emphasis on neurovascular compromise in recognising the condition. Only just over one half (11/21) could correctly identify 'pain out of proportion to the associated injury' as the key clinical feature. Unlike pain, neurovascular compromise is a late feature of compartment syndrome and overstating its importance may potentially contribute to delayed diagnosis. Our targeted educational week dramatically improved the number of correct responses. One month after the teaching week, 83% (19/23) of nurses correctly identified pain as the most important feature in compartment syndrome. We hope that improved knowledge of compartment syndrome by nurses will help to reduce delayed recognition and adverse outcomes.
As medical practitioners, we occasionally encounter patients who have misinformed their families of their medical histories. We describe a case of a patient whose age is in the mid-40s, who we believe had factitiously constructed a serious illness. This patient had suffered an acute exacerbation of chronic asthma and later died. When the partner was informed, the partner reported that they understood the patient had been regularly visiting our hospital for cancer treatment. No record of this could be found. This created an ethical dilemma of what could be told to the family. The patient was on the Organ Donor Register and would have been suitable to act as a donor, but to do so may have indirectly alerted the family to the patient's true condition. There was also the issue of whether the patient's children might seek unnecessary screening.
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