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Rishikesh Gandhewar, Kalyan Vemulapalli Faculty of Medicine, Imperial College London, London, UKCorrespondence: Rishikesh Gandhewar; Kalyan VemulapalliFaculty of Medicine, Imperial College London, London, UKTel +44 781 793 5751; +44 750 241 7908Email kvv16@ic.ac.uk; rg2316@ic.ac.uk Latif Khan et al1 have highlighted absenteeism as an important issue amongst medical schools. Although the article originates from Pakistan, the authors state that this is a worldwide issue. The study focusses on lecture attendance. However, worldwide several teaching methods are employed including problem-based learning, team-based learning and video-recorded technologies. As UK medical students, we offer an alternative perspective on the conclusions of the study.We acknowledge several strengths of the study; however, we would like to share a few reflections. Given the range of teaching methods, it would have been appropriate to define the exact parameters of a lecture and therefore disclose the employment of other methods. We feel that this would provide a more holistic overview of student timetables, including total contact hours per week. Consequently, the relative importance of attending lectures compared to attending other teaching sessions for accruing appropriate skills and knowledge is unknown. If teaching occurred outside of lectures, the degree of absenteeism would not be accurate. Conversely, if solely lectures were employed, the conclusions drawn from this study may not be translatable to the rest of the world where other teaching methods are in place.View the original paper by Latif Khan and colleagues

This article aims to assess whether a detachable functional focused rigidity cast can he used as a one-off definitive treatment for proximal 5th metatarsal fractures. A prospective trial was carried out over a 2-year period. Forty-one patients with proximal 5th metatarsal fractures (tuberosity and Jones) were recruited and treated with a detachable focused rigidity cast after appropriate consent. Of the 39 patients with follow-up, six had a Jones fracture and 33 had tuberosity fractures. All 33 patients with tuberosity fractures achieved clinical union within 4-5 weeks (mean of 4.2 weeks). Four of the six patients with Jones fractures achieved clinical union in 8-12 weeks. One achieved union in 14 weeks and one underwent open reduction and internal fixation for delayed union. There were no complications related to the cast. The results support the use of a detachable focused rigidity cast as a one-off definitive treatment of tuberosity fractures of the 5th metatarsal. However, all the Jones fractures and the diaphyseal fractures should be referred to an orthopaedic team for further management. [ABSTRACT FROM AUTHOR]

Aims: Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE., Methods: This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE., Results: A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade., Conclusion: The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade., Competing Interests: J. Mangwani reports support from the Leicester Hospitals Charity, related to this study. J. Mangwani reports payment or honoraria for lectures, presentations, educational events from Orthosolutions, and royalties from Meshworks, unrelated to this study. K. Malhotra reports payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from NewClip Technics, unrelated to this study. L. W. Mason reports royalties or licenses, consulting fees, and patents planned, issued or pending from Orthosolutions, unrelated to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Competing Interests: None declared.

Background: Hepatocellular Carcinoma (HCC) is a malignancy with increasing incidence and morbidity. For patients with a poor prognosis, engagement with advanced care planning and end-of life (EOL) services (I.e., palliative care, hospice) can address physical, financial, and social complications of a terminal diagnosis. Minimal data exist on the demographics of the patients being referred to and enrolling in EOL services for HCC., Aims: We aim to report the relationship between demographics and EOL service referral., Methods: Retrospective review of a prospectively maintained high-volume liver center registry of patients diagnosed with HCC from 2004 to 2022. EOL services eligible patients were defined as BCLC stage C or D, evidence of metastases, and/or transplant ineligible., Results: Black patients were more likely to be referred than white patients (OR 1.47 (1.03, 2.11)). Once referred, patients were significantly more likely to be enrolled if they had insurance coverage, though no other factors in models were significant. There were no significant differences in survival among those referred who did or did not enroll, after controlling for other factors., Conclusion: Black patients were more likely to be referred compared to white patients and patients who were insured were more likely to be enrolled. Whether this is indicative of black patients being appropriately referred at a higher rate, being offered EOL care instead of aggressive treatment, or other unknown factors warrants further study., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: To date, there are no systematic reviews on the utility of surgical management for plantar fasciitis to guide best practice. This review aimed to evaluate the operative options for plantar fasciitis and their effectiveness., Methods: A systematic review and network meta-analysis were carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool., Results: 17 studies involving 865 patients were included. Surgical options considered were open and endoscopic plantar fasciotomy, gastrocnemius release, radiofrequency microtenotomy and dry needling. All interventions resulted in improvement in VAS and AOFAS scores. No major complications were seen from any treatment modality., Conclusions: Surgical interventions are effective in providing short- to medium-term symptomatic relief for plantar fasciitis refractory to non-operative management. Current evidence is equivocal regarding treatment choice. Further large randomised studies are required to establish long-term outcomes and a management algorithm., Level of Evidence: Level III., (© 2023. Crown.)

Introduction: Polypectomy technique, for diminutive lesion resection, is variable among colonoscopists using either cold snare polypectomy (CSP) or cold forceps polypectomy (CFP). While it is well described that CSP is a preferred technique to resect small lesions, there is little data evaluating the impact resection techniques have on metachronous adenoma burden. The aim of this study was to evaluate the rate of incomplete resection attributable to CSP and CFP of diminutive adenomas., Methods: This is a 2-center retrospective cohort study evaluating the segmental incomplete resection rate (S-IRR) of diminutive tubular adenomas (TA). S-IRR was calculated by subtracting the segmental metachronous adenoma rate in a specific colonic segment without adenoma from segments with adenoma on index colonoscopy. The primary outcome was the S-IRR of diminutive TA resected by CSP or CFP on index colonoscopy., Results: A total of 1,504 patients were included in the analysis: 1,235 with TA <6 mm and 269 with TA 6-9 mm as the most advanced lesion. The S-IRR in a segment that had a <6-mm TA incompletely resected by CFP on index colonoscopy was 13%. The S-IRR in a segment that had a <6-mm TA incompletely resected by CSP was 0%. Among 12 included colonoscopists, the range of overall S-IRR was 1.1%-24.4% with an average S-IRR of 10.3%., Discussion: S-IRR was 13% higher with CFP resection of diminutive TA than with CSP. A proposed S-IRR metric of <5% is a target goal for all diminutive polyp resection because 3/12 colonoscopists achieved this low rate. S-IRR can be used as a methodology to compare and quantify the difference in segmental metachronous adenoma burden across various polypectomy removal methods., (Copyright © 2023 by The American College of Gastroenterology.)

Sural nerve injury may occur during the posterolateral approach to the ankle during fracture fixation. We aimed to map its location in a posterolateral approach in cadaveric specimens. A posterolateral approach was used in 28 cadaver legs with the incision made halfway between the medial border of the fibula and the lateral border of Achilles tendon, extending proximally from the tip of the lateral malleolus. The sural nerve was identified and the distance from the distal tip of the incision to where it crossed the incision proximally was measured. The mean distance was 3.4 ± 1.2 (range 0.5-7.0) cm. In 22 cases (78.5%), the distance from the lowest part of the incision to the inferior part of the nerve was between 2.7 and 4.5 cm. The nerve did not cross the incision in 2 cases. We have demonstrated that the sural nerve crossed the posterolateral incision between 2.7 and 4.5 cm proximal to the tip of the fibula in the majority of cases. However, there remains individual anatomical variation, and we would recommend that care should be taken to look for the nerve closer to the Achilles tendon proximally and nearer the fibula distally. We hope that this information can help surgeons plan their approach and minimize iatrogenic injury to the sural nerve., (Copyright © 2022 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery, though the predictors of shunt response remain debated. Currently, radiological features play an important role in the diagnosis of iNPH, but it is not well established which radiological markers most precisely predict shunt responsive iNPH., Objective: To conduct a systematic review and meta-analysis to identify radiological predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most predictive radiological features., Methods: Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating radiological predictors of shunt response in iNPH patients. Included studies were assessed using the ROBINS-1 tool, and eligible studies were evaluated using a univariate meta-analysis., Results: Overall, 301 full-text papers were screened, of which 28 studies were included, and 26 different radiological features were identified, 5 of these met the inclusion criteria for the meta-analysis: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The meta-analysis showed that only callosal angle and periventricular white matter changes significantly differentiated iNPH shunt responders from non-responders, though both markers had a low diagnostic odds ratio (DOR) of 1.88 and 1.01 respectively. None of the other radiological markers differentiated shunt responsive from shunt non-responsive iNPH., Conclusion: Callosal angle and periventricular changes are the only diagnostically effective radiological predictors of shunt responsive iNPH patients. However, due to the DORs approximating 1, they are insufficient as sole predictors and are advised to be used only in combination with other diagnostic tests of shunt response. Future research must evaluate the combined use of multiple radiological predictors, as it may yield beneficial additive effects that may allow for more robust radiological shunt response prediction., (© 2022. The Author(s).)

Foot drop secondary to common peroneal neuropathy is frequently due to trauma or external compression. Ankle sprains are a rarer cause of this pathology and are extremely uncommon in the paediatric population. We present two cases of acute isolated unilateral foot drop in children, both following minimal trauma. Prompt investigation with magnetic resonance imaging (MRI), electromyography (EMG) and nerve conduction studies can assist in localising the level of the lesion and indicate prognosis. Both patients made a full recovery with the use of ankle-foot orthoses and physiotherapy. This case series highlights that although rare, common peroneal nerve palsy can occur in children following relatively minor trauma. Clinicians should identify this pathology early with a detailed clinical assessment and focussed investigations to increase the potential for a favourable recovery and avoid secondary problems., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shah et al.)

Background: Talus fractures are devastating injuries in both adults and children. Well recognised complications such as avascular necrosis (AVN), post-traumatic arthritis and non-union contribute to patient morbidity. This systematic review aimed to assess the literature on these injuries in children and their associated incidence, classification, management and outcome., Methods: A systematic review of Embase and Medline databases was carried out in accordance with PRISMA guidelines. Inclusion criteria were clinically orientated studies looking at talus fractures in paediatric patients (less than 18 years old). Exclusion criteria were conference abstracts, opinion-based reports, articles not published in English and articles published prior to 1980. Data extracted included patient demographics, fracture classification, management and outcomes., Results: 31 studies were included encompassing 143 patients and 167 fractures with a mean age of 11.9 years (1.2-18). The majority of fractures (43.7%, n = 73) were of the talar neck. 70.6% (n = 101) were managed operatively. The overall rate of AVN was 15.4% (n = 22), with a 96.5% union rate. Observed rates of AVN were 5.7% in Hawkin's 1, 11.8% in Hawkin's 2, 53.3% in Hawkin's 3 and 0 in Hawkin's 4 injuries. All cases of non-union occurred in children over 12 years, and seven children required arthrodesis (1x pantalar, 1x subtalar and 5x subtalar and tibiotalar) with a mean age of 14.4 years (9-17)., Conclusions: Talus fractures are rare but potentially devastating injuries in children. This systematic review has shown comparable rates of AVN in children to their adult counterparts, with higher rates of non-union and arthrodesis in adolescent patients. A lower threshold for operative intervention to achieve anatomical reduction in these patients should be considered., Competing Interests: Declaration of Competing Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Hip fractures are the most common reason for inpatient orthopaedic trauma admission. Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite this, there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients. This is of paramount medicolegal importance in a high-risk patient population., Aim: To quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process., Methods: Two hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined outcomes were analyzed over a 30-d postoperative period. COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors., Results: COVID-19 positive patients had more intensive care admissions (27% vs 5%, P < 0.001), longer inpatient stays (median 23 d vs 9 d, P < 0.001) and a higher 30-d mortality (29% vs 10%, P = 0.001) than COVID-19 negative patients. Postoperative complications were evident in 74.5% of COVID-19 positive patients. 35.3% of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7% developing acute respiratory distress syndrome (ARDS) and 9.8% experiencing symptomatic thromboembolic events., Conclusion: The COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery. COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications (including lower respiratory tract infection, ARDS, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and higher risk of mortality. Further, clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Introduction: Calcaneal fractures are rare in children. These fractures are often misdiagnosed as a consequence of their subtle clinical and radiographic presentation. The purpose of this paper was to identify prognostic factors on the basis of type of fracture, age and treatment. This would enable suggestions to be made with regards to treatment for these fractures., Methods: A full literature search was performed to find studies that were clinically orientated, in the English language and involved children (under the age of 16). Studies with no outcome data were excluded., Results: There were a total of 284 patients reviewed in 26 peer-review publications. Two hundred and eight patients had intra-articular fractures. The non-operatively managed joint depression type fractures had poor outcomes in 21% of patients. In those who underwent surgical fixation for these fractures, 3 patients had reduced subtalar motion, and three had pain, one of whom required a subtalar arthrodesis at 7 months. In the tongue type fracture group, the outcomes were similar in those treated operatively and non-operatively. Extra-articular fractures were found to be much less common than the intra-articular fractures. They also became less common in older children. Generally, the outcomes were good, irrespective of treatment. Only 2 patients with type 1B fractures had poorer outcomes., Discussion: This is a rare injury and outcomes may be poorer in those who do not have adequate anatomical reduction. Displaced intra-articular fractures in all age groups should be considered for anatomical reduction of the articular surface, to guarantee good outcomes and prevent future pain and arthritis. Extra-articular fractures in children are less severe, do well with conservative treatment, and rarely require operative intervention., Competing Interests: Declaration of Competing Interest None to declare, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Competing Interests: The authors report no conflicts of interest in this communication.

Oxygen (O 2 ) is both an indispensable metabolic substrate and a regulatory signal that controls the activity of Hypoxia-Inducible Factor 1α (Hif1a), a mediator of the cellular adaptation to low O 2 tension (hypoxia). Hypoxic cells require Hif1a to survive. Additionally, Hif1a is an inhibitor of mitochondrial respiration. Hence, we hypothesized that enhancing mitochondrial respiration is detrimental to the survival of hypoxic cells in vivo. We tested this hypothesis in the fetal growth plate, which is hypoxic. Our findings show that mitochondrial respiration is dispensable for survival of growth plate chondrocytes. Furthermore, its impairment prevents the extreme hypoxia and the massive chondrocyte death observed in growth plates lacking Hif1a. Consequently, augmenting mitochondrial respiration affects the survival of hypoxic chondrocytes by, at least in part, increasing intracellular hypoxia. We thus propose that partial suppression of mitochondrial respiration is crucial during development to protect the tissues that are physiologically hypoxic from lethal intracellular anoxia., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family doctors and any other doctor who has to deal with foot and ankle problems in adults.

We present the case of a 14-year-old female who presented with unilateral pes planus 30 months after a bimalleolar ankle fracture dislocation. At surgery, the tibialis posterior tendon was encased in fracture callus within the syndesmosis and required reconstruction using flexor digitorum longus transfer. Dislocation of the tibialis posterior tendon and entrapment within the tibiofibular syndesmosis has been previously reported. To our knowledge, this is the first case report tibialis posterior tendon syndesmotic entrapment presenting with unilateral pes planus., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: A sleeve fracture classically describes an avulsion of cartilage or periosteum with or without osseous fragments and usually occurs at the inferior margin of the patella. Tibial tubercle sleeve fractures in the skeletally immature are extremely rare., Case Presentation: In this report the authors describe a 12-year-old boy with no systemic disease and no steroid use who sustained bilateral proximal tibial sleeve fractures whilst playing football. Both ruptures were associated with rupture of the medial patellofemoral ligament and tear of the medial retinaculum. Treatment was performed with primary end-to-end repair, reinforcement with bone anchors and cerclage wires with an excellent outcome., Conclusions: We feel this rare, currently unclassified variant of a tibial tubercle avulsion fracture should be recognised and consideration taken to adding it to existing classification systems.

Tuberculosis (TB) remains a major global health problem. According to a recent World Health Organization report, it ranks as the second leading cause of death from an infectious disease worldwide. According to the "UK Health Protection Agency Tuberculosis in the UK: 2012 Report," 8963 cases were reported in the United Kingdom in 2011. London had the greatest proportion of cases in the United Kingdom and the greatest rate of disease. TB affecting the foot is rare, affecting about 10% of all skeletal TB cases. However, owing to the current patterns of global immigration, with significant volumes of people migrating out of endemic countries, it has become a disease that physicians and surgeons in developed countries should be more aware of in today's practice. To the best of our knowledge, we present the first adult case of TB of the cuboid in the United Kingdom and the first adult case documented outside of India. We present the case details and the results of a thorough review of the literature. TB of the foot and ankle poses a diagnostic challenge because of the propensity of TB to mimic other pathologic entities radiologically. Tissue diagnosis and antitubercular medication is the mainstay of diagnosis and treatment, respectively., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Although various congenital abnormalities have been described, congenital absence of calf musculature is extremely rare, with only one report on its complete absence. We are the first to describe a case of congenital absence of muscles of the superficial posterior compartment of the calf presenting in a toddler. The child presented with a history of a painless limp, however no significant difference was found in functional gait analysis. We suggest that such cases should be monitored and parents can be reassured that no immediate treatment is required.

The World Health Organisation (WHO) recommends routine use of a surgical safety checklist prior to all surgical operations. The aim of this study was to prospectively audit checklist use in orthopaedic patients before and after implementation of an educational programme designed to increase use and correlate this with early complications, mortality and staff perceptions. Data was collected on 480 patients before the educational program and 485 patients after. Pre-training checklist use was 7.9%. The rates of early complications and mortality were 8.5% and 1.9%, respectively. Forty-seven percent thought the checklist improved team communication. Following an educational program, checklist use significantly increased to 96.9% (RR12.2; 95% CI 9.0-16.6). The rate of early complications and mortality was 7.6% (RR 0.89; 95% CI 0.58-1.37) and 1.6% (RR 0.88; 95% CI 0.34-2.26), respectively. Seventy-seven percent thought the checklist improved team communication. Checklist use was not associated with a significant reduction in early complications and mortality in patients undergoing orthopaedic surgery. Education programs can significantly increase accurate use and staff perceptions following implementation.

A sleeve fracture occurs when a ''sleeve'' of cartilage or periosteum is avulsed with or without an osseous fragment, an injury most commonly reported in the patella. Proximal tibial sleeve fractures are extremely rare and we present a case in an adolescent male who had concomitant osteochondral as well as chondral fractures of his patella. Sleeve fractures present in the skeletally immature, and may look relatively benign on radiographs, but misdiagnosis may lead to adverse consequences. Clinicians should have a high index of suspicion if a child or adolescent presents with a knee injury with clinical concerns regarding the extensor mechanism. Given that the ''sleeve'' of the injury contains tissue with osteogenic potential, we recommend that displaced proximal tibial sleeve fractures should be managed operatively to avoid dysfunction of the extensor mechanism. These patients should also have perioperative assessment for occult osteochondral and chondral injuries that are potentially repairable and thus may have implications for prognosis.