Intraneural ganglion cysts of the peroneal nerve.

BACKGROUND: Intraneural ganglion cysts of the peroneal nerve are rare, and there is lack of evidence for the surgical management of this entity. We performed this study to evaluate the imaging, diagnosis, treatment and outcome of seven patients with intraneural ganglion cysts of the peroneal nerve. MATERIALS AND METHODS: We retrospectively studied the files of seven patients with intraneural ganglion cysts of the peroneal nerve, diagnosed and treated from 2016 to 2019. Diagnostic approach included clinical examination of the leg and foot, magnetic resonance imaging, nerve conduction studies, surgical excision of the cyst and histological examination. The mean follow-up was 2 years (range 1-3.5 years). We evaluated the time and methods for surgical treatment, and the clinical outcomes of the patients. RESULTS: All patients presented symptoms of peripheral compression neuropathy; three patients presented with foot drop. The intraneural ganglion cysts were excised in all cases in addition to knee articular nerve branch transection to avoid cysts recurrence. Postoperatively, all patients experienced complete neurological recovery without clinical evidence of intraneural ganglion cysts recurrences. CONCLUSION: The treating physicians should be aware of intraneural ganglion cysts of the peroneal nerve in patients presenting with limb weakness, sensory deficits at the lateral and anterior side of the leg and foot, paresis or paralysis of the foot and ankle. MR imaging is the imaging modality of choice for a clear and accurate preoperative diagnosis to avoid misdiagnosis and wrong treatment. In case of doubt, these patients should be managed in an orthopedic oncology setting with microsurgery facilities available for complete excision of the intraneural ganglion cyst.

Bilateral Hoffa Fractures of the Medial Femoral Condyles: A Case Report and Review of the Literature.

Introduction: Intra-articular distal femoral fractures in the coronal plane, widely described as Hoffa fractures, are a rare entity. Lateral femoral condyles are mostly affected, while diagnosis can be challenging. Bilateral medial femoral condyle fractures are exceedingly scarce, with only one case being published in recent literature. Case Report: We present a case of a white 65-year-old man with bilateral medial femoral condyle Hoffa fractures caused by a crush injury. The patient was treated operatively by two different teams operating simultaneously on both sides, with good clinical and radiological outcomes after a follow-up period of 3 months. Conclusion: A literature review was conducted to analyze the potential mechanism of injury, diagnostic methods, and therapeutic approach. Bilateral medial Hoffa fractures are rare injuries concerning the orthopedic trauma field and this is the first case described, that was treated operatively with good functional outcomes.

A Review of Current Concepts of the Anterolateral Complex of the Knee.

The anterolateral complex (ALC) of the knee has gained increased interest over the last decades due to the high revision rates of anterior cruciate ligament reconstruction (ACLR). Furthermore, in patients with an ACL tear, the injury of at least one of the ALC's anatomic structures has been shown to be significantly higher, thus affecting its secondary stabilizing role at the knee joint. As such, ACLR augmentation techniques, that embrace the ALC, have been proposed recently, and indications for these procedures are still evolving. This review aims to present and discuss the most current anatomical, biomechanical, and imaging data, current reconstruction techniques, and the clinical results of ALC reconstruction.

Treatment of Infected Tibial Metaphyseal Nonunions Using the Ilizarov Method: Protocol for a Prospective Nonrandomized Study.

BACKGROUND: The management of infected metaphyseal nonunion of the tibia is devastating, especially when associated with significant bone loss, poor soft tissues, draining sinuses, axial deformity, knee or ankle joint stiffness, limb discrepancy, and multiresisted pathogens. A systematic review, performed recently by the primary investigators but not yet published, yielded the lack of studies in the field and the huge heterogeneity of the presented results. We found several bias and controversies such as no clear definition of the exact part of the tibia where the nonunion was located, the pathogen causing the fracture-related infection, the number of previous interventions and time to presentation, and the exact type of treatment methods including the use of muscle flaps or bone grafting. Time to final union as a functional score is another important but missing data. OBJECTIVE: The proposed study is designed to evaluate a sufficient number of patients with infected metaphyseal tibial nonunions using various general health, functional, and bone scores. METHODS: This prospective clinical trial study, with a minimum follow-up period of 36 months, focuses on the effectiveness of the Ilizarov method after radical nonunion debridement and targeted antibiotic therapy in patients with infected metaphyseal tibial nonunions. The primary outcomes would be the definite healing of nonunion and infection-free results. Secondary outcomes would be limb alignment and discrepancy, alteration in the patient's quality of life, and functional results. A power analysis calculated a minimum of 11 patients to obtain statistical power, but we aim to include at least 25 patients. Limb discrepancy, clinical validation of infection eradication and fracture healing, radiographic validation, and patient-reported outcome measures will be highlighted and correlated. Statistical analysis of the results will offer data missing from the literature so far. Measurements are scheduled at specific times for each patient: preoperatively, 3 and 6 months postoperatively, 1 month after Ilizarov frame removal, and once per semester afterward until the end of the follow-up period (minimum 36 months). Laboratory evaluation will be assessed once per month. Any complication will be reported and treated when it occurs. RESULTS: The trial has already started. It was funded in June 2020. As of May 2022, 19 participants have been recruited and no major complications have been noticed yet. Data analysis will be performed after data collection ends, and results will be published afterward. CONCLUSIONS: An infected metaphyseal tibial nonunion is a rare condition with limited treatment options and many controversies. There is no consensus in the literature about the best treatment strategy, and this lack of evidence should be fulfilled. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 30905788; https://www.isrctn.com/ISRCTN30905788. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39319.

A Unique Technique for Precise Targeting in Treatment of Rare Bifocal Intraosseous Ganglion Cysts of the Talus: A Case Report and Review of the Literature.

BACKGROUND This article presents a rare case of 2 separate intraosseous ganglion cysts of the talus in a 51-year-old man, treated with a unique technique of precise lesion targeting to avoid extensive bone loss and minimize articular chondral injury of the talus. CASE REPORT Two separate intraosseous ganglion cysts of the talus were diagnosed in a 51-year-old man with chronic ankle pain. A single straight-line incision with an entry point through the talonavicular joint was created to spare the precarious blood supply of the talus network. The 2 distinct subchondral lesions were approached under fluoroscopic control for curettage and autologous bone grafting using the anterior cruciate ligament tibial guide in a pair-of-compasses fashion. In almost 5 years of follow-up the patient has been asymptomatic. Magnetic resonance imaging has revealed no signs of degenerative changes in the ankle or the talonavicular joint, and the intraosseous edema has almost disappeared. CONCLUSIONS To the best of our knowledge, this case is the first report of 2 distinct intraosseous ganglion cysts of the talus. We recommend the precise targeting technique used in our case for treating intraosseous talar lesions with intact articular cartilage.

A Case of Reconstruction of a Type IIIc Open Tibial Fracture with Bone Loss and Warm Ischemia Time of 13 Hours: Quality of Life and Review of the Literature.

BACKGROUND The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. CASE REPORT We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. CONCLUSIONS The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.

A Novel Treatment of a 65-Year-Old Woman with a Neglected Type IIIB Open Fracture of the Tibia with Inadequate Soft Tissue Coverage and Periosteal Stripping Requiring an Ilizarov Approach to Bone and Soft Tissue Lengthening and Reconstruction: A Case Report and Review of the Literature.

BACKGROUND Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. CASE REPORT We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. CONCLUSIONS This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.

Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture.

The human body undergoes several physiological adaptations as a result of the aging process. Amongst other organs, the skeleton is also affected and when bone fragility is present, an increase in both morbidity and mortality has been reported. Identification of risk factors to calculate the probability for a given patient to develop a fragility fracture it is therefore of paramount importance. Moreover, the existence of an in house protocol for diagnostic work up using biochemical tests and imaging investigations is essential. In the herein study we discuss a diagnostic protocol that has been developed in our clinic based on knowledge from the literature and our clinical experience.

Modified porous tantalum rod technique for the treatment of femoral head osteonecrosis.

AIM: To study a modified porous tantalum technique for the treatment of osteonecrosis of the femoral head. METHODS: The porous tantalum rod was combined with endoscopy, curettage, autologous bone grafting and use of bone marrow aspirates from iliac crest aspiration in 49 patients (58 hips) with a mean age of 38 years. The majority of the patients had idiopathic osteonecrosis, followed by corticosteroid-induced osteonecrosis. Thirty-eight hips were of Steinberg stage II disease and 20 hips were of stage III disease. Patients were followed for 5 years and were evaluated clinically with the Merle D'Aubigne and Postel score and radiologically. The primary outcome of the study was survival based on the conversion to total hip arthroplasty (THA). Secondary outcomes included deterioration of the osteonecrosis to a higher disease stage at 5 years compared to the preoperative period and identification of factors that were associated with survival. The Kaplan-Meier survival analysis was performed to evaluate the survivorship of the prosthesis, and the Fisher exact test was performed to test associations between various parameters with survival. RESULTS: No patient developed any serious intraoperative or postoperative complication including implant loosening or migration and donor site morbidity. During the 5-year follow up, 1 patient died, 7 patients had disease progression and 4 hips were converted to THA. The 5-year survival based on conversion to THA was 93.1% and the respective rate based on disease progression was 87.9%. Stage II disease was associated with statistically significant better survival rates compared to stage III disease (P = 0.04). The comparison between idiopathic and non-idiopathic osteonecrosis and between steroid-induced and non-steroid-induced osteonecrosis did not showed any statistically significant difference in survival rates. The clinical evaluation revealed statistically significantly improved Merle d'Aubigne scores at 12 mo postoperatively compared to the preoperative period (P < 0.001). The mean preoperative Merle d'Aubigne score was 13.0 (SD: 1.8). The respective score at 12 mo improved to 17.0 (SD: 2.0). The 12-mo mean score was retained at 5 years. CONCLUSION: The modified porous tantalum rod technique presented here showed encouraging outcomes. The survival rates based on conversion to THA are the lowest reported in the published literature.