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BACKGROUND: The history and physical examination will usually direct a surgeon to the correct site of joint pathology. Imaging with plain radiographs and diagnostic injections help localize joint pathology more precisely. The presence of accessory communications between adjacent joints may reduce the sensitivity of these investigations. MATERIAL AND METHODS: We report on the findings of 389 arthrograms of the midfoot, hindfoot and ankle that were performed by a single radiologist over a 7-year period. Fluoroscopic guidance with radioopaque dye was used to confirm needle position before local anesthetic was injected. Images were closely studied to identify any communication between adjacent joints. RESULTS: The passage of contrast into adjacent joints confirmed the presence of an additional communication. In 13.9% of cases there was a communication between the ankle and subtalar joint. A communication between the talonavicular and the calcaneocuboid joint was observed in 42.3% of local injections. We identified previously unreported communications between the anterior subtalar and the naviculocunieform joints (8%), the anterior subtalar and the calcaneocuboid joints (9%) and the naviculocunieform and tarsometatarsal joints (1.1%). CONCLUSION: This study reinforces the typical incidence of known joint communications, describes previously unreported communications and highlights the importance of these communications particularly with the small joints of the midfoot. The possible presence of accessory communications must always be considered when performing isolated midfoot fusions relying upon diagnostic local anesthetic injections. [ABSTRACT FROM AUTHOR]

Introduction:The approach to the distal radius to apply a volar buttress plate for a volarly displaced distal radius fracture is a familiar procedure for orthopaedic surgeons. The stabilisation of distal tibia posterior malleolar fractures is commonly performed by inserting lag or cannulated screws into the posterior fragment from anteriorly.Method:We discuss the similarity of the application of a posterior buttress plate to the distal tibia via a posterolateral approach compared with a distal radial approach.Conclusions:The posterolateral approach is easy, safe and allows good access and accurate direct fracture reduction. We recommend this method be considered for the stabilisation of a posterior malleolar fracture. [ABSTRACT FROM AUTHOR]

BACKGROUND: This study evaluates and compares three-dimensional (3-D) changes in geometry of the first metatarsal (MT1) independent of soft tissue corrections of 5 common osteotomies: three distal (Chevron, Mitchell, and Wilson), one proximal (Stephens basal), and one combined proximal/distal (Scarf), using standardized synthetic bone models. MATERIALS AND METHODS: A digitizing system was used to measure and record points on the synthetic bone models in 3-D space. Computer vector analysis calculated 3-D rotations and translations of the MT1 head plus the conventional intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA). RESULTS: The Wilson and Mitchell's osteotomies produced significant shortening (p < 0.001) in contrast to the three other osteotomies. All the osteotomies produced a reduction in the 3-D IMA. The Scarf and Stephens basal osteotomies reduced the DMAA. All of the osteotomies resulted in lateral translations and depression of the MT1 head. While there were no significant (p > 0.05) translational differences between the Scarf and Stephens basal osteotomies, there were rotational differences, with the Stephens basal producing significantly more plantar flexion (p = 0.000) and pronation (p < 0.001) than the Scarf. CONCLUSION: This geometric study indicated many of the MT1 head changes following metatarsal osteotomy to be out-of-plane translational and multiplanar rotations which cannot be determined using AP radiographs alone. CLINICAL RELEVANCE: We advocate judicious choice of osteotomy to achieve the desired correction of hallux valgus in each individual. [ABSTRACT FROM AUTHOR]

Haemochromatosis is thought to be an uncommon condition which may present as a disabling symmetrical polyarthropathy. Early diagnosis can prolong life by preventing the development of co-morbidities. [ABSTRACT FROM AUTHOR]

An abstract of the article "Brainstem Syndrome Secondary to "Tumefactive" HIV Vasculitis," by G. Mamutse, A. Cadwgan, and M. B. Davies is presented.

Introduction: Titanium-based implants can be used to fill voids in bone reconstruction surgery. Through additive manufacturing (AM), it is possible to produce titanium implants with osteoconductive properties such as high porosity and low stiffness. AM facilitates a level of design flexibility and personalization that is not feasible with traditional techniques. Methods: In this study, osseointegration into titanium alloy (Ti-6Al-4V) lattices was investigated for 12 weeks post-implantation using a novel bicortical load-bearing ovine model. The objective was to assess the safety and efficacy of AM-fabricated implants using two lattice structures of contrasting stiffness spanning the full width of the femoral condyle. Results: This was achieved by evaluating implant osseointegration and bone-implant contact properties by histomorphometry, scoring local implant tissue responses via histopathology, and micro-computed tomography reconstruction. Discussion: We found that Ti-6Al-4V implants facilitated widespread and extensive osseointegration, with bone maturation ongoing at the conclusion of the trial period. Following the implantation period, no adverse clinical indications that could be directly ascribed to the presence of the implanted device were identified, as determined by macroscopic and microscopic observation., Competing Interests: Authors AF, EA, and MT were employed by Alloyed Ltd. MD and JM are consultants for Alloyed Ltd. The authors declare that financial support for the research and publication of this article was provided by Alloyed Ltd. Alloyed Ltd was involved in the design of the study but not in data analysis and interpretation. Author MA was employed by AccelLAB Inc. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Feldman, Assad, Davies, Mangwani, Alabort and Tuncer.)

Aim: Obesity has a significant impact on all-cause mortality rate and overall health care resource use (HCRU). These outcomes are also strongly linked to age, sex and local deprivation of the population. We aimed to establish the lifetime costs of obesity by demographic group/geographic area using published mortality rates and HCRU use for integrated care boards (ICB) in England in the context of costs of therapeutic intervention., Methods: Population and expected mortality rates by age, sex and deprivation were obtained from national data. Obesity class prevalence was taken from the health of the nation study. The published impact of obesity by age, group, sex and deprivation on mortality and HCRU were applied to estimate life years lost and lifetime HCRU [by sex, age band and body mass index (BMI) class for each ICB]. The year 2019 was chosen as the study basis data to avoid influences of COVID-19 pandemic on obesity rates with application of 2022/23 HCRU values. Outcomes including prevalence, deaths, life years lost, HCRU and lifetime HCRU were compared by age and sex groups across four BMI classes normal/underweight (BMI <25 kg/m 2 ), overweight (25-29.9 kg/m 2 ), obese class I and II (30-39.9 kg/m 2 ), and obese class III (≥40), with benchmarking being set against all population being BMI <25 kg/m 2 overall and by each of the 42 ICBs. We also associated future life with deaths to provide an estimate of 'future life years lost' occurring each year., Results: Total population aged >16 years was 45.4 million (51% female)., Prevalence: 13.7 million (28% of the total adult population) had a BMI ≥30 mg/m 2 and BMI ≥40 kg/m 2 were 1.50 million (12%) of these 1.0 million (68%) were female and of these 0.6 million 40% were women aged 16-49 years. In addition, 35% of those with a BMI ≥40 kg/m 2 were in the top deprivation quintile (i.e. overall 20%). Mortality was based on expected deaths of 518K/year, and modelling suggested that if a BMI <25 kg/m 2 was achieved in all individuals, the death rate would fall by 63K to 455K/year for the English population (12% reduction). For those with a BMI ≥40 kg/m 2 the predicted reduction was 12K deaths (54% lower); while in those aged 16-49 years with a BMI ≥40 kg/m 2 72% of deaths were linked to obesity. For future life years lost, we estimated 2.5 years were lost in people with BMI 30-39.9 kg/m 2 6.7 years when BMI ≥40 kg/m 2 . However, for those aged 16-49 years with a BMI ≥40 kg/m 2 , 8.3 years were lost. HCRU, for weight reduction, the annual HCRU decrease from BMI ≥40 kg/m 2 to BMI 30-39.9 kg/m 2 was £342 per person and from BMI 30-39.9 to 25-29.9 kg/m 2 the reduction was £316/person. However, lifetime costs were similar because of reduced life expectancy for obese individuals. In quality adjusted life years (QALY), overall, 791 689 future life years were lost (13.1% of all) in people with BMI ≥25 kg/m 2 and were related to excess weight. When the NICE £30 000 per QALY value was applied to the estimated total 791 689 future life years lost then the potential QALY value reduction lost was equivalent to £24 billion/year or £522/person in the obese population. For morbidly obese men and women the potential QALY value lost was £2864/person/year. Regarding geography, across the 42 ICBs, we observed significant variation in the prevalence of BMI ≥40 (1.8%-4.3%), excess mortality (11.6%-15.4%) and HCRU linked to higher BMI (7.2%-8.8%). The areas with the greatest impact on HCRU were in the north-west, north-east and Midlands of England, while the south shows less impact., Conclusion: The expected increases in annual HCRU because of obesity, when considered over a lifetime, are being mitigated by the increased mortality of obese individuals. Our data suggest that simple short-term HCRU reduction brought about through BMI reduction will be insufficient to fund additional specialist weight reduction interventions. The HRCUs associated with BMI are not in most cases related to short-term health conditions. They are a cumulative result over a number of years, so for age 16-49 years reducing BMI from ≥40 to 30-39.9 kg/m 2 might show an annual decrease in HCRU/person by £325/year for women and £80/year for men but this might not have immediately occurred within that year. For those aged >70 years reducing BMI from ≥40 to 30-39.9 kg/m 2 might show an annual decrease in HCRU/person by £777/year for women and £796/year for men but also may not be manifest within that year. However, for the morbidly obese men and women, the potential QALY value lost was £2864 per person per year with the potential for these funds to be applied to intensive weight management programmes, including pharmacotherapy., (© 2024 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Nucleation in small volumes of water has garnered renewed interest due to the relevance of pore condensation and freezing under conditions of low partial pressures of water, such as in the upper troposphere. Molecular simulations can in principle provide insight on this process at the molecular scale that is challenging to achieve experimentally. However, there are discrepancies in the literature as to whether the rate in confined systems is enhanced or suppressed relative to bulk water at the same temperature and pressure. In this study, we investigate the extent to which the size of the critical nucleus and the rate at which it grows in thin films of water are affected by the thickness of the film. Our results suggest that nucleation remains bulk-like in films that are barely large enough accommodate a critical nucleus. This conclusion seems robust to the presence of physical confining boundaries. We also discuss the difficulties in unambiguously determining homogeneous nucleation rates in nanoscale systems, owing to the challenges in defining the volume. Our results suggest any impact on a film's thickness on the rate is largely inconsequential for present day experiments.

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars 1,2 . However, their composition, formation and evolution remain poorly understood 3 . The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R ⊕ to 2.85R ⊕ . Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Acute Achilles tendon rupture is a common injury and when missed leads to the development of a chronic Achilles tendon rupture. Studies suggest surgical treatment (either repair or reconstruction) for most patients with a chronic Achilles rupture due to the functional deficit caused by the lack of an intact Achilles tendon. Numerous autograft options such as the flexor hallucis longus, hamstrings, peroneal and quadriceps tendon have been used to reconstruct the Achilles tendon, either as a tendon transfer or as an interposition graft. The choice of autograft used usually depends on the size of the defect left after debridement of the Achilles tendon edges, but is often dictated by surgeon preference and tissue availability. Currently, there is no consensus as to the best autograft option., Aims and Methodology: The aim of this study was to evaluate the various autograft options used to reconstruct the Achilles tendon, and the advantages and disadvantages of using each tendon, focussing specifically on the harvesting technique, anatomical and biomechanical properties. This was done by reviewing the current published literature, supplemented by carrying out anatomical dissection in the cadaveric lab., Results: The flexor hallucis longus is synergistically related to the Achilles tendon and biomechanically strong, however harvesting can result in weakness in big toe flexion. The peroneus brevis whilst being biomechanically strong is a much shorter tendon compared to the other autograft options. Similarly, the quadriceps tendon is also a strong tendon option, but may not be appropriate for larger chronic Achilles tendon rupture gaps. The semitendinosus tendon can be tripled/quadrupled to resemble the Achilles tendon, but is associated with higher risks of patient morbidity when harvesting the tendon., Conclusion: Treatment of chronic Achilles tendon ruptures remains a challenge. Each autograft option has its own unique advantages and disadvantages which should be considered on a case-specific basis. Further work is required to analyse the biomechanical properties of the autograft options to determine if one option is superior., Competing Interests: None., (Crown Copyright © 2023 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation. All rights reserved.)

Amorphous ices govern a range of cosmological processes and are potentially key materials for explaining the anomalies of liquid water. A substantial density gap between low-density and high-density amorphous ice with liquid water in the middle is a cornerstone of our current understanding of water. However, we show that ball milling "ordinary" ice I h at low temperature gives a structurally distinct medium-density amorphous ice (MDA) within this density gap. These results raise the possibility that MDA is the true glassy state of liquid water or alternatively a heavily sheared crystalline state. Notably, the compression of MDA at low temperature leads to a sharp increase of its recrystallization enthalpy, highlighting that H 2 O can be a high-energy geophysical material.

Crystal nucleation is one of the most fundamental processes in the physical sciences and almost always occurs heterogeneously with the aid of a nucleating substrate. No example of nucleation is more ubiquitous and impactful than the formation of ice, vital to fields as diverse as geology, biology, aeronautics, and climate science. However, despite considerable effort, we still cannot predict a priori the efficacy of a nucleating agent. Here we utilize deep learning methods to accurately predict nucleation ability from images of room temperature liquid water-generated from molecular dynamics simulations-on a broad range of substrates. The resulting model, named IcePic, can rapidly and accurately infer nucleation ability, eliminating the requirement for either notoriously expensive simulations or direct experimental measurement. In an online poll, IcePic was found to significantly outperform humans in predicting the ice nucleating efficacy of materials. By analyzing the typical errors made by humans, as well as the application of reverse interpretation methods, physical insights into the role the water contact layer plays in ice nucleation have been obtained. Moving forward, we suggest that IcePic can be used as an easy, cheap, and rapid way to discern the nucleation ability of substrates, also with potential for learning other properties related to interfacial water.

Introduction: Freiberg's osteochondrosis is an uncommon cause of foot pain. Following a national survey circulated by the British Foot and Ankle Society it was found that no classification is used to guide surgical treatment. This study aimed to create a simple, reproducible CT based classification to preoperatively plan whether an osteotomy is required., Methods: A retrospective review of 24 CT scans of new Freiberg's diseasediagnoses over a 10 year period was conducted. These images were assigned a study number and anonymised. The scans were then reviewed in their entirety by three independent specialists who determined whether an osteotomy would be of benefit. The sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx was identified and divided the articular surface into 2 zones - plantar and dorsal and this formed the basis for our classification. These sagittal slices were then reviewed independently by two surgeons to determine if patients had disease in one or both zones and re-reviewed two weeks later to assess intra-observer reliability., Results: All 24 cases involved the second metatarsal. From reviewing the sagittal CT slices, it was felt that 18 patients were suitable for osteotomy and 6 were suitable for debridement +/- arthroplasty alone. The current classification demonstrated that 18 patients had disease confined to zone 1 only and the remaining patients had disease in both zones. Inter-observer reliability assessment had 95.8% agreement (Krippendorff's Alpha 0.897). Intra-observer reliability was 100%. Correlation of those observed to have isolated zone 1 disease and suitability for osteotomy was absolute (Pearson r = 1)., Conclusion: Dividing the metatarsal head into two zones on the widest sagittal slice of the CT scan offers an easy reproducible way to preoperatively plan surgical treatment for Freiberg's osteochondrosis. Patients with isolated zone 1 disease should be suitable for an osteotomy., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Foot and ankle pathology if not treated appropriately and in a timely manner can adversely affect both disability and quality adjusted life years. More so in the low- and middle-income countries where ambulation is the predominant means of getting around for the majority of the population in order to earn a livelihood. This has necessitated the equipping of the new generation of orthopaedic surgeons with the expertise and skills set to manage these conditions. To address this need, surgeons from the British Orthopaedic Foot & Ankle Society (BOFAS) and College of Surgeons of Eastern, Central and Southern Africa (COSECSA) transferred the "Principles of Foot and Ankle Surgery" course to an African regional setting. The course was offered to surgical trainees from 14-member countries of the COSECSA region and previously in the UK. The faculty was drawn from practicing surgeons experienced in both surgical education and foot and ankle surgery. The course comprises didactic lectures, case-based discussions in small groups, patient evaluations and guided surgical dissections on human cadavers. It was offered free to all participants. The feasibility of the course was evaluated using the model defined by Bowen considering the eight facets of acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. At the end of the course participants were expected to give verbal subjective feedback and objective feedback using a cloud based digital feedback questionnaire. The course content was evaluated by the participants as "Poor", "Below average", "Average", "Good" and "Excellent", which was converted into a value from 1-5 for analysis. The non-parametric categorical data was analysed using the Two-sample Wilcoxon rank-sum (Mann-Whitney) test, and significance was considered to be p < 0.05., Results: Six courses in total were held between 2018 and 2020. Three in the UK and three in the COSECSA region. There were 78 participants in the three UK courses and 96 in the three courses run in the COSECSA region. Hundred percent of the UK participants and 97% of the COSECSA participants completed the feedback. Male to female ratio was 4:1 for the UK courses and 10:1 for the COSECSA Courses. In both regions all the participants responded that they would recommend the course to their colleagues. Among the COSECSA participants 91% reported that the course was pitched at the right level, which is similar to the 89% of the UK participants (p = 0.28)., Conclusion: The BOFAS Principles of Foot and Ankle Surgery course design provides core knowledge, with an emphasis on clinical examination techniques of the foot and ankle, while at the same time, caters for the anticipated difference in the local clinical case mix and resources. This study establishes that by attending the course surgical trainees can achieve their learning goals in foot and ankle surgery with the same high quality qualitative and quantitative feedback in both regions. This would improve their clinical practice and confidence. The multifaceted approach adopted in this course blending didactic teaching, small group discussions, interactive sessions, case-based discussions, cadaveric surgical skills training printed educational materials and feedback helped fulfil these educational objectives. Working in partnership with local expert orthopaedic surgeons from a number of Sub-Saharan countries, was key to adapting the course to local pathology and the COSECSA setting., (© 2022. The Author(s).)

Background: Avascular necrosis (AVN) of the talus most commonly occurs secondary to trauma. Significant bone loss and collapse in severe talar AVN remains an operative challenge. Tibiotalocalcaneal arthrodesis (TTC) using femoral head allograft is at risk of collapse and subsidence. The use of a void-filling titanium truss can mitigate against this. This study describes the use of a novel keystone shaped 3D-printed titanium truss for treatment of severe talar AVN., Methods: Three patients with end-stage AVN of the talus were included. Each patient underwent a TTC arthrodesis with a custom-made, 3D-printed, keystone-shaped, truss implant in conjunction with a hindfoot intramedullary nail. Modified patient American Orthopaedic Foot & Ankle Society (AOFAS) scores were recorded at the preoperative, 6-month, 12-month, and annual postoperative timepoints., Results: All patients progressed to satisfactory radiological union by one year. Mean follow up time was 32 months (24-48 months). Mean preoperative modified AOFAS score was 5. There was progressive improvement in AOFAS scores from 6 months postoperatively. Mean modified AOFAS score improved from 28 at 6 months to 37 at 2 years postoperatively., Conclusion: Custom-made 3D-printed titanium trusses provide promising outcomes for treating severe AVN of the talus. The "keystone" design is advantageous as it allows for bone stock preservation and conforms to the shape of the native calcaneum. All patients showed progressive improvements in outcomes at sequential time intervals postoperatively. The implant provides a strong mechanical structure resisting collapse and subsidence during the arthrodesis process., Level of Evidence: Level IV, retrospective case series., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Introduction: Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated 43% talar body access with a single incision and without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach., Methods: The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. A mark was made on the talar dome where an instrument could be placed 90 degrees to the talar surface. The talus was subsequently disarticulated and high-resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid was documented using the mark made on the talar surface. ImageJ software was used to calculate the surface area exposed with each approach., Results: The mean percentage area of talar dome available through the transligamentous approach was 77.3% (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1, 2, 3, 5 & 6 with partial access to Zones 4, 8 & 9., Conclusion: The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zones 4,7 and 8, the posteromedial corner., Level of Clinical Evidence: V., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

The freezing of water into ice is one of the most important processes in the physical sciences. However, it is still not understood at the molecular level. In particular, the crystallization of cubic ice ([Formula: see text])-rather than the traditional hexagonal polytype ([Formula: see text])-has become an increasingly debated topic. Although evidence for [Formula: see text] is thought to date back almost 400 y, it is only in the last year that pure [Formula: see text] has been made in the laboratory, and these processes involved high-pressure ice phases. Since this demonstrates that pure [Formula: see text] can form, the question naturally arises if [Formula: see text] can be made from liquid water. With this in mind, we have performed a high-throughput computational screening study involving molecular dynamics simulations of nucleation on over 1,100 model substrates. From these simulations, we find that 1) many different substrates can promote the formation of pristine [Formula: see text]; 2) [Formula: see text] can be selectively nucleated for even the mildest supercooling; 3) the water contact layer's resemblance to a face of ice is the key factor determining the polytype selectivity and nucleation temperature, independent of which polytype is promoted; and 4) substrate lattice match to ice is not indicative of the polytype obtained. Through this study, we have deepened understanding of the interplay of heterogeneous nucleation and ice I polytypism and suggest routes to [Formula: see text] More broadly, the substrate design methodology presented here combined with the insight gained can be used to understand and control polymorphism and stacking disorder in materials in general., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Elderly patients who present with an inability to weight bear following a fall, with normal radiographs, should be appropriately investigated to rule out an occult hip fracture (OHF). We aim to identify both the range and incidence of the differential diagnosis of acute traumatic hip pain in a large series of patients investigated for OHF. A retrospective analysis of consecutive patients investigated for an OHF with magnetic resonance imaging (MRI) was performed. Dedicated musculo- skeletal radiologists reported the MRI scans. All diagnoses including hip fractures, other fractures and soft tissue injuries were recorded. Case notes were reviewed for all patients to identify subsequent complications, management and outcomes. A total of 157 patients fulfilled the inclusion criteria. 52 (33%) patients had a fracture of the proximal femur. The majority of patients with proximal femoral fractures required surgical intervention. 9 patients who had fractures of the greater trochanter of the femur without fracture extension across the femoral neck were managed non-operatively. 40 (25%) patients had fractures of the pelvis, with a combined pubic rami and sacral fracture occurring frequently. The most common diagnosis was a soft tissue injury alone that was seen in 60 (38%) patients imaged. Injuries to the gluteal muscle group, iliopsaos complex and trochanteric bursa were most prevalent. All patients with soft tissue injuries or fractures of the pelvis were successfully managed non-operatively. This study highlights a wide range of differential diagnoses in elderly patients presenting with acute traumatic hip pain. The proximal femur was fractured in 33% of patients imaged for OHFs in our series. The most common diagnosis was a soft tissue injury around the hip and pelvis ; these injuries can be successfully managed without surgery.

Background: The aim of this project was to analyse whether a CT influences surgical planning in ankle fracture involving the posterior malleolus., Methods: Twenty consecutive patients with fractures involving the posterior malleolus were retrospectively selected and had their plain radiographs and CT scan anonymised. Initially, radiographs alone were presented to nine trauma surgeons to formulate a surgical plan individually. After a minimum of 6 weeks, the same process was repeated with CT scans available., Results: The surgical approach for ankle fracture fixation changed in 32.7% of cases following CT scan review. A CT scan altered the decision to stabilise the posterior malleolus in 25.6% and the decision of whether to stabilise the syndesmosis in 16.6% of cases., Conclusions: This study demonstrates that a pre-operative CT scan changes the surgical approach in 32.7% of cases and therefore we recommend use of CT scanning in this subset of ankle injuries., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed., Competing Interests: Disclosure The authors have nothing to disclose., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Surveys have shown that super-Earth and Neptune-mass exoplanets are more frequent than gas giants around low-mass stars, as predicted by the core accretion theory of planet formation. We report the discovery of a giant planet around the very-low-mass star GJ 3512, as determined by optical and near-infrared radial-velocity observations. The planet has a minimum mass of 0.46 Jupiter masses, very high for such a small host star, and an eccentric 204-day orbit. Dynamical models show that the high eccentricity is most likely due to planet-planet interactions. We use simulations to demonstrate that the GJ 3512 planetary system challenges generally accepted formation theories, and that it puts constraints on the planet accretion and migration rates. Disk instabilities may be more efficient in forming planets than previously thought., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Aims: Fractures and dislocations of the midfoot are relatively uncommon but can be life changing injuries. Within the literature, there has been scant specific reference to the identification and management of medial ray injuries in midfoot trauma. Moreover, it is appreciated that these injuries are associated with poor outcomes. We aim to clearly define these injury characteristics and demonstrate fixation techniques., Patients and Methods: A retrospective review of the case notes and imaging was conducted for operatively treated midfoot injuries between January 2013 and January 2018., Results: 161 patients were identified, 31 of these with imaging and operative diagnosis suggestive of medial ray injury. Studying these 31 injuries revealed five patterns of injury., Conclusion: When treating midfoot trauma, it is important to fully understand the injury pattern as this dictates the principles and techniques of fixation. Identification and knowledge of these five injury patterns will aid surgeons in future management of these injuries and may improve treatment outcomes., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Many white dwarf stars show signs of having accreted smaller bodies, implying that they may host planetary systems. A small number of these systems contain gaseous debris discs, visible through emission lines. We report a stable 123.4-minute periodic variation in the strength and shape of the Ca ii emission line profiles originating from the debris disc around the white dwarf SDSS J122859.93+104032.9. We interpret this short-period signal as the signature of a solid-body planetesimal held together by its internal strength., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Aims: Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot., Patients and Methods: We undertook a retrospective review of 285 consecutive patients presenting over an eight- year period with a fracture of the navicular. Five common patterns of injury were identified and classified according to the radiological features. Type 1 fractures are dorsal avulsion injuries related to the capsule of the talonavicular joint. Type 2 fractures are isolated avulsion injuries to the tuberosity of the navicular. Type 3 fractures are a variant of tarsometatarsal fracture/dislocations creating instability of the medial ray. Type 4 fractures involve the body of the navicular with no associated injury to the lateral column and type 5 fractures occur in conjunction with disruption of the midtarsal joint with crushing of the medial or lateral, or both, columns of the foot., Results: In order to test the reliability and reproducibility of this new classification, a cohort of 30 patients with a fracture of the navicular were classified by six independent assessors at two separate times, six months apart. Interobserver reliability and intraobserver reproducibility both had substantial agreement, with kappa values of 0.80 and 0.72, respectively., Conclusion: We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. We have shown that this system is reliable and reproducible and have described the rationale for the subsequent treatment of each type. Cite this article: Bone Joint J 2018;100-B:176-82., (©2018 The British Editorial Society of Bone & Joint Surgery.)

We report a series of 143 patients who underwent limited open Achilles tendon repair using the Achillon device at a mean follow-up of 25 months. All patients attending our institution with a diagnosis of acute Achilles tendon rupture were considered for operative repair using the Achillon jig unless they declined surgery or met the exclusion criteria. Following surgery patients were contacted and asked to complete an Achilles Tendon Rupture Score (ATRS). The clinical records were reviewed for evidence of complications, demographic information and evidence of re-rupture. Statistical analysis of subgroups including age at presentation, delay to surgery and patients with complications was carried out using the Kruskal Wallis non-parametric test. We report no re-ruptures at a mean of 25 months (minimum 12 months) following surgery. The mean ATRS score was 84/100 (range 15-100). There was no statistical significance between any of the subgroups analyzed. In conclusion, acute Achilles repair using the Achillon jig is safe, with a low re-rupture rate, excellent ATRS scores at a minimum of 12 months post-operatively and low complications. The incidence of sural nerve injury is much lower than published series of percutaneous Achilles tendon repair without the use of a jig., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Aims: The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast. Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior., Patients and Methods: A total of 60 patients were randomised to receive four weeks of treatment, 36 in a double elasticated bandage (symptomatic treatment group) and 24 in a below-knee walking cast (immobilisation group). The primary outcome measure used was the validated Visual Analogue Scale Foot and Ankle (VAS-FA) Score. Data were analysed by a clinician, blinded to the form of treatment, at presentation and at four weeks, three months and six months after injury. Loss to follow-up was 43% at six months. Multiple imputations missing data analysis was performed., Results: At four weeks and six months, symptomatic treatment proved non-inferior in terms of primary outcome., Take Home Message: Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. Significant loss to follow-up with this injury could be expected in longer term. Cite this article: Bone Joint J 2016;98-B:806-11., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background: As in all fields of surgery, advances in orthopaedic surgery develop toward less invasive surgical techniques. The advantages of smaller incisions include minimal soft tissue dissection allowing procedures to be performed as outpatient surgery. There is the assumption that this leads to a quicker recovery time permitting an earlier return to work. As with any new surgical technique, there is an associated learning curve. This study looked into the outcome of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) performed at a University Hospital., Methods: Thirty patients underwent minimally invasive surgery for DMMO. There were 13 males and 17 females with an average age of 60 years. More than one metatarsal osteotomy was done in all cases to facilitate the moulding of the metatarsal head to the correct alignment with full weight bearing. The outcome was measured with the Manchester-Oxford Foot Questionnaire (MOXFQ), patient-reported outcome (PRO), and visual analog scale (VAS) pain score. Minimum follow up was 1 year., Results: At the final review, the average MOXFQ score was an excellent 31. Average improvement in VAS score was 3.5, which ranged from 10 to -7. The VAS was affected by 2 patients whose pain worsened after the operation. There were 4 complications, one each of nonunion, malunion, transfer metatarsalgia, and soft tissue ossification., Conclusion: The 3 most common complications of foot and ankle surgery are infection, wound dehiscence, and skin ulcer or blister. Intra-articular metatarsal osteotomies are commonly associated with stiffness due to scarring and consequently hammertoes. By reducing the soft tissue injury in minimally invasive surgery, these risks can be potentially minimized. Minimally invasive DMMO produced good patient satisfaction, functional improvement, and low complication rates in most cases., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2015.)

Background: Lower-limb immobilization has been implicated as an etiologic factor for a venous thromboembolism (VTE). Most of the current literature encourages the use of thromboprophylaxis with injectable low-molecular-weight heparin (LMWH) in trauma patients. Injectable anticoagulants have inherent problems of producing pain and bruising. They are also difficult to administer, leading to low compliance. Oral anticoagulants are therefore gaining popularity for use as thromboprophylactic agents in hip and knee arthroplasty patients. There are not enough studies in the literature, however, to support their use in ambulatory trauma patients whose ankle fractures are being managed nonoperatively on an outpatient basis., Methods: This study evaluated the efficacy of oral anticoagulants for preventing VTE in ambulatory trauma patients who required temporary lower limb immobilization for non-operative management of their ankle fractures. A total of 200 consecutive patients who presented to the fracture clinic with an ankle fracture that was managed in a plaster cast were included in this study. These patients were assessed for risk of developing VTE and high risk patients were administered an oral anticoagulant to prevent VTE., Results: There was only one case of an isolated distal DVT among the 200 patients., Conclusions: This study shows that an oral anticoagulant was a safe alternative to injectable LMWH as a thromboprophylactic agent for ambulatory trauma patients requiring temporary lower limb immobilization for non-operative management of an ankle fracture., (Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Dorsal talus avulsion fractures occurring along the supination line of the foot can cause pain and discomfort. Examination of the foot and ankle using the Ottawa ankle rules does not include examination of the talus, an injury here is easily missed causing concern to the patient. This is a retrospective study carried out in a major trauma centre to look at the assessment and diagnosis of all patients with a dorsal talus and navicular avulsion fractures over a one year period. Nineteen patients with an isolated dorsal talus avulsion fracture and five patients with an isolated dorsal navicular fracture were included. The correct diagnosis was made in 12 of patients with isolated dorsal talus avulsion fractures, 7 patients were given an incorrect diagnosis after misreading of the radiograph. Four patients with a dorsal navicular avulsion fracture were given the correct diagnosis. If not correctly diagnosed on presentation patients can be overly concerned that a 'fracture was missed' which can lead to confusion and anxiety. Therefore these injuries need to be recognised early, promptly diagnosed, treated symptomatically and reassurance given. We recommend the routine palpation of the talus in addition to the examination set out in the Ottawa Ankle Rules and the close inspection of plain radiographs to adequately diagnose an injury in this area., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Quadriceps tendon ruptures are uncommon injuries, occurring most frequently in males over 40 years and associated with obesity, renal failure and steroids. Literature states that ultrasonography and magnetic resonance imaging have a role in diagnosis. We discuss the contrasting advantages and disadvantages of each imaging modality and establish their diagnostic value., Materials and Methods: A closed loop audit cycle was performed over 68 months by reviewing all patients presenting with a suspected acute quadriceps tendon ruptures to a Teaching Hospital., Results: Sixty-six patients were included in the study; 4/47 patients in the initial audit period were inaccurately diagnosed, either clinically or by ultrasonography, leading to surgical exploration identifying an intact quadriceps tendon. This highlighted the need for improved pre-operative diagnosis and a recommendation to increase the use of magnetic resonance imaging. In the second cycle, the use of magnetic resonance imaging increased from 4 to 42% (p = 0.0004) and misdiagnosis fell from 4/47 (9%) to 1/19 (5%). Ultrasonography was shown to be highly sensitive (1.0) but the specificity of this modality was only 0.67 with a positive predictive value of 0.88. Magnetic resonance imaging displayed a sensitivity of 1.0, a specificity of 1.0 and a positive predictive value of 1.0., Conclusion: We propose that all patients who have a suspected quadriceps tendon rupture after clinical examination and radiography should either proceed directly to magnetic resonance imaging or be initially assessed by ultrasound, and in those with positive findings, a supplementary magnetic resonance imaging to eliminate false positive diagnoses.

Though uncommon, iatrogenic hallux varus is most often the result of overresection of the medial eminence, overtranslation of an osteotomy, overrelease of the lateral soft tissues, or overtightening of the medial tissues. It is not always symptomatic, as the degree of deformity can be well tolerated. For soft-tissue reconstructions, releases have little role to play unless minor deformity is detected early on and the longevity of tendon transfer and tenodesis remains unknown. For bony reconstruction, arthrodesis is the recommended salvage technique., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Prompted by the success of hip and knee arthroplasty, total ankle replacement (TAR) has become increasingly popular as a treatment for end stage arthritis of the ankle. A 3-grade classification of complications to assist in prediction of early implant failure has been proposed. We have compared the experience of a tertiary referral center in the United Kingdom to the proposed system., Methods: A retrospective review of the Sheffield Foot and Ankle Unit TAR database was performed from 1995 to 2010. All complications were recorded and categorized using Glazebrook et al's proposed system of increasing severity. Low-grade complications including postoperative bone fracture, intraoperative bone fracture, and wound healing problems rarely lead to revision. Medium-grade complications, technical error and subsidence, lead to failure <50% of the time. High-grade complications--deep infection, aseptic loosening, and implant failure--lead to revision >50% of the time. In our center, 217 TAR were implanted in 198 patients with a minimum follow-up of 30 months., Results: The complication rate was 23%, with a revision rate of 17%. All complications recorded in our study except intraoperative bone fracture and wound healing had a failure rate of at least 50%., Conclusion: Unfortunately most complications associated with TAR have a significant impact on the life span of a TAR. Glazebrook et al's proposed 3-tier system did not reliably reflect our experience. Hence, we would categorize complications as either high or low risk for early failure of TAR., Level of Evidence: Level IV, case series.

We consider the implications of a model for long-duration gamma-ray bursts in which the progenitor is spun up in a close binary by tidal interactions with a massive black-hole companion. We investigate a sample of such binaries produced by a binary population synthesis, and show that the model predicts several common features in the accretion on to the newly formed black hole. In all cases, the accretion rate declines as approximately t(-5/3) until a break at a time of order 10(4) s. The accretion rate declines steeply thereafter. Subsequently, there is flaring activity, with the flare peaking between 10(4) and 10(5) s, the peak time being correlated with the flare energy. We show that these times are set by the semi-major axis of the binary, and hence the process of tidal spin-up; furthermore, they are consistent with flares seen in the X-ray light curves of some long gamma-ray bursts.

Flexor digitorum longus (FDL) is the primary flexor of the lateral four toes. It is a reliable source of tendon for transfer surgery. We present a case whereby a patient who required a reconstruction for adult acquired flatfoot deformity using FDL as a dynamic structure for transfer was found to have an absent FDL tendon at the time of operation, necessitating the use of flexor hallucis longus (FHL) instead. This unusual finding prompted us to investigate the frequency of absence of the FDL tendon. We reviewed our hospital MRI database of foot and ankle images specifically looking for patients with absence of this tendon. After randomization, 756 images were reviewed independently by two surgeons and a consultant musculoskeletal radiologist. No instances of an absent FDL tendon were identified. In conclusion, the frequency of absence of the FDL tendon is less than 1 in 750. Surgeons who require FDL for tendon transfer surgery need not image the foot preoperatively to anticipate the need for the use of FHL as an alternative., (Copyright © 2012 Wiley Periodicals, Inc.)