A morphological review of medial malleolar fractures - A large single centre series.

BACKGROUND: Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. METHODS: Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records. Retrospective analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. RESULTS: A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). Herscovici type A fractures were significantly more frequently mal-reduced at time of surgery as compared to other fracture types (p = .003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who had been anatomically reduced. CONCLUSION: The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions. LEVEL OF EVIDENCE: Level 3 - Retrospective Cohort Study.

Supramalleolar osteotomies for ankle arthritis: a systematic review.

INTRODUCTION: We investigated the mid-term outcomes of supramalleolar osteotomies regarding "survivorship" [before ankle arthrodesis (AA) or total ankle replacement (TAR)], complication rate and adjuvant procedures required. MATERIAL AND METHODS: PubMed, Cochrane and Trip Medical Database were searched from January 01, 2000. Studies reporting on SMOs for ankle arthritis, in minimum of 20 patients aged 17 or older, followed for a minimum of two years, were included. Quality assessment was performed with the Modified Coleman Methodology Score (MCMS). A subgroup analysis of varus/valgus ankles was performed. RESULTS: Sixteen studies met the inclusion criteria, with 866 SMOs in 851 patients. Mean age of patients was 53.6 (range 17-79) years, and mean follow-up was 49.1 (range 8-168) months. Of the arthritic ankles (646 ankles), 11.1% were classified as Takakura stage I, 24.0% as stage II, 59.9% as stage III and 5.0% as stage IV. The overall MCMS was 55.2 ± 9.6 (fair). Eleven studies (657 SMOs) reported on "survivorship" of SMO, before arthrodesis (2.7%), or total ankle replacement (TAR) (5.8%) was required. Patients required AA after an average of 44.6 (range 7-156) months, and TAR after 36.71 (range 7-152) months. Hardware removal was required in 1.9% and revision in 4.4% of 777 SMOs. Mean AOFAS score was 51.8 preoperatively, improving to 79.1 postoperatively. Mean VAS was 6.5 preoperatively and improved to 2.1 postoperatively. Complications were reported in 5.7% (44 out of 777 SMOs). Soft tissue procedures were performed in 41.0% (310 out of 756 SMOs), whereas concomitant osseous procedures were performed in 59.0% (446 out of 756 SMOs). SMOs performed for valgus ankles failed in 11.1% of patients, vs 5.6% in varus ankles (p < 0.05), with disparity between the different studies. CONCLUSIONS: SMOs combined with adjuvant, osseous and soft tissue, procedures, were performed mostly for arthritic ankles of stage II and III, according to the Takakura classification and offered functional improvement with low complication rate. Approximately, 10% of SMOs failed and patients required AA or TAR, after an average of just over 4 years (50.5 months) after the index surgery. It is debatable whether varus and valgus ankles treated with SMO reveal different success rates.

Simultaneous bilateral posteromedial tibial epiphysis stress fractures in a healthy young man: A case report.

We present a compelling case of simultaneous, bilateral tibial stress fractures occurring in a unique epiphyseal and posterior location, with unclear aetiology. An overweight, Caucasian male in his late 20s developed synchronous bilateral medial knee pain following an intense 10-day training regimen. His radiographies were normal, but MRI revealed almost identical bilateral stress fracture lines in the posteromedial tibial epiphyses. Bone mineral densitometry and a full metabolic and hormonal panel were performed to further investigate potential underlying metabolic bone disease. He was found to have normal bone mineral densitometry and low Vitamin D serum values. Symptomatology greatly improved with activity modification. There were no further complaints and complications at 12 months' follow-up. Diagnosis can be challenging and the treating physician should be acquainted with the basic science of stress fractures and main discriminating clinical, biochemical and radiological characteristics from insufficiency fractures, to avoid pitfalls in treatment decision.

Multifocal Epithelioid Hemangioendothelioma of the Foot and Ankle Developing a Postoperative Infection-Long-term Outcome: A Case Report.

A case of rare epithelioid hemangioendothelioma with multiple foot and ankle lytic lesions in a 41-year-old male is reported. The patient presented to our hospital after having received treatment elsewhere and developing a local postoperative infection. After thorough investigations and establishing the diagnosis, we initially treated the local infection and highlighted the potential risk of malignancy. Finally, respecting the patient's wishes, he was treated with consideration mostly of the pending foot and ankle fractures rather than the risk of malignancy. At 9.5 years postoperatively, the patient was clinically well and asymptomatic, without clinical, laboratory, or radiologic signs of malignancy, and the previous infection might have even played a remote role in that outcome. A review of the published data regarding the treatment of this unpredictable neoplasm is also presented.

Midfoot arthrodesis.

BACKGROUND: Surgery for midfoot arthritis is challenging and technically demanding, especially in the presence of deformity. METHODS: Thirty patients (30 feet) with symptomatic midfoot arthritis and deformities, underwent arthrodesis, along with adjuvant procedures to realign the hindfoot and forefoot where needed. RESULTS: Union was achieved in 28 out of 30 (93.3%) patients. Mean time to union was 12.9 weeks (range 10-18). Five patients (16.6%) developed postoperative complications and six patients (20%) required unplanned surgical procedures. Orthotics was needed postoperatively in 14 patients (34%). Fourteen out of 30 patients rated their outcome as excellent (47%), 13 out of 30 as good (43%) and 3 out of 30 (10%) as fair or poor. CONCLUSIONS: Although the vast majority of patients rated their outcome as good or excellent, the foot is not completely normal, with residual pain from the adjacent joints, need for unplanned surgery and use of orthotics postoperatively.

Naviculocuneiform joint arthrodesis in a cohort of 36 patients.

BACKGROUND: Arthrodesis of the naviculocuneiform joint (NCJ) can be performed in isolation or in conjunction with arthrodesis of other joints, often in the presence of deformity. In the literature there is relative rarity of articles reporting on results and complications of NCJ arthrodesis. PATIENTS AND METHODS: Thirty-six patients (36 feet) with symptomatic NCJ arthritis underwent arthrodesis. Mean age was 59.1 years (SD 13.1; range 26-78) and 24 were women. Adjuvant procedures were performed simultaneously in 29 patients, whilst 17 had planovalgus and 1 had cavovarus foot deformity. RESULTS: Union of the NCJ arthrodesis was achieved in 35 out of 36 (97.2 %) patients, whilst one patient developed non-union. Mean time to union was 13.1 weeks (SD 3.8; range 8-24). Two patients (5.6 %) developed deep infection and 5 patients (13.9 %) required secondary surgical procedures. Twenty-three patients (63.9 %) rated the outcome as good or excellent, 11 (30.6 %) as fair and 2 (5.6 %) as poor. CONCLUSIONS: NCJ arthrodesis was part of a more complex procedure in most of the patients. Whilst union was achieved in almost all patients and complication rate was acceptable, only 64 % rated their outcome as good or excellent. LEVEL OF CLINICAL EVIDENCE: IV.

Converting 1st metatarsophalangeal joint fusion to interposition arthroplasty. Mid-term results of a case series.

BACKGROUND: Fusion of the first metatarsophalangeal (MTP) joint has been considered as the gold standard for treatment of advanced hallux rigidus. The main disadvantage is the restriction of movement which may not be as favorable as anticipated by several patients. The purpose of this study was to report clinical and functional outcomes on patients who were treated with interposition arthroplasty after a 1st MTP joint fusion which had not fulfilled their expectations. METHODS: Between 2009 and 2014, 11 patients who were not satisfied by 1st MTP joint fusion for hallux rigidus, underwent a conversion to interposition arthroplasty. After removal of hardware, the fusion was taken down by removal of a bone block from the fused joint. A fascia lata graft was interposed. Intraoperative and postoperative complications, range of motion of the first MTP joint, length of first ray, and patients' satisfaction were recorded as the primary outcomes. RESULTS: Mean age was 34 years (range, 24-42 y). The mean ± SD AOFAS/H/MTP/IP score was 61 ± 5.5 preoperatively, 90.5 ± 4.5 at one year and 92 ± 4 at five years postoperatively (p < 0.001). The mean ± SD VAS-FA score was 91 ± 3.5 preoperatively, 94.5 ± 2.5 at one year and 95 ± 2.5 at five years postoperatively (p > 0.05). Mean ROM at the final follow-up was 58° ± 5° of dorsiflexion and 27° ± 4° of plantarflexion. No inter- or postoperative complications were encountered. The length of the hallux was decreased by a mean of 1.5 mm (range, 1-2.5 mm). All patients were satisfied with the overall outcome, walking ability and shoe-wear convenience and graded their condition as excellent (9 cases) or good (2 cases). CONCLUSIONS: Converting a 1st MTP joint fusion to interposition arthroplasty with a fascia lata allograft could be a safe alternative with promising results in selected cases especially in relatively young and athletic population. LEVEL OF EVIDENCE: Level IV retrospective case series.

Post-traumatic missing talus: Staged allograft interposition and fusion. Should we fuse the "talo-navicular" joint?

Complete talar dislocation-extrusion is an uncommon sequela of high-energy trauma. When the talus is unavailable for reimplantation, a staged treatment plan with the use (a) of an antibiotic cement spacer, followed by (b) tibiotalocalcaneal fusion with bone allograft interposition, may ensure a good clinical outcome.

Knee Capsule Anatomy: An MR Imaging and Cadaveric Study.

This research focuses on the anatomical insertion of the synovial capsule around the knee. The attachments of the capsule were measured in 50 knee MR imaging studies with large intraarticular effusion. Corresponding measurements were performed in 20 fresh frozen cadaveric specimens, for validation. Femoral and tibial capsular reflections were defined as the distances between the attachment sites of the capsule and the femoral or tibial joint line and they were recorded in three coronal planes (anterior/middle/posterior). On MR imaging, the lateral/medial femoral capsular reflection mean values were 6.5/4.57 cm, 2.74/1.74 cm and 1.52/1.99 cm in the anterior, middle and posterior plane, respectively. MR imaging-based measurements did not differ significantly compared to corresponding cadaveric measurements. The mean values of the lateral/medial tibial capsular reflection on MR imaging were 0.09/0.11 cm, 0.34/0.26 cm and 0.62/0.34 cm in the anterior, middle and posterior plane, respectively. On cadaveric dissection, the maximum mean value was 1.45 cm, measured on the lateral side of the anterior plane. Apart from the lateral aspect of the posterior plane, MR imaging measurements were significantly lower, compared to the corresponding cadaveric measurements. The greatest femoral and tibial capsular reflections were found on the anterior and lateral side of the anterior plane. MR imaging appears to underestimate the distal extent of the knee capsule. Anatomical details of the knee capsule should be considered for safe insertion of external fixator pins.

Morton's interdigital neuroma: instructional review.

The terminology 'Morton's neuroma' may represent a simplification of the clinical condition as the problem may not be a benign tumour of the nerve, but neuropathic foot pain associated with the interdigital nerve.Foot and ankle pathomechanics leading to metatarsalgia, clinical examination and differential diagnosis of the condition and imaging of the condition, for differential diagnosis, are discussed.Nonoperative management is recommended initially. Physiotherapy, injections (local anaesthetic, steroid, alcohol), cryotherapy, radiofrequency ablation and shockwave therapy are discussed.Operative treatment is indicated after nonoperative management has failed. Neuroma excision has been reported to have good to excellent results in 80% of patients, but gastrocnemius release and osteotomies should be considered so as to address concomitant problems.Key factors in the success of surgery are correct diagnosis with recognition of all elements of the problem and optimal surgical technique. Cite this article: EFORT Open Rev 2019;4:14-24. DOI: 10.1302/2058-5241.4.180025.

Stability in ankle fractures: Diagnosis and treatment.

Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures.Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures.Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus.Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively.Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057.

Rehabilitation exercise program after surgical treatment of pectoralis major rupture. A case report.

OBJECTIVE: To present a rehabilitation exercise program and suggest a schedule of activities for daily living and participation in sports after surgical treatment of a pectoralis major rupture. DESIGN: A single case study. SETTING: Hospital-based study, Thessaloniki, Greece. PARTICIPANTS: We present a 30-year-old male athlete (height, 196 cm; weight, 90 kg; right hand dominant) with a complete rupture of the pectoralis major tendon after a fall. REHABILITATION EXERCISE PROGRAM: The athlete received a post-operative rehabilitation exercise program for 16 weeks. During the program, there was a gradual increase in the exercise program regime and load across the sessions according to the specific case demands. MAIN OUTCOME MEASURES: Shoulder function was evaluated using Constant score. RESULTS: Magnetic resonance imaging (MRI) confirmed the diagnosis and the patient had surgical treatment repairing-reattaching the tendon back to its insertion using a bone anchor. At the end of the rehabilitation exercise program, the patient had full range of movement, normal muscle power and a return back to his previous level of athletic activities achieved. CONCLUSIONS: Post-operatively, a progressive rehabilitation protocol contributed to the patients' full recovery and allowed an early return to activities of daily living and participation in sports.

Multifocal epithelioid hemangioendothelioma of the foot and ankle: a case report.

We report on a 41-year-old man with multiple epithelioid hemangioendothelioma of the left foot and ankle. The patient was treated with curettage and fixation with 2 separate plates, but later developed local infection. Owing to the potential for malignancy, below-knee amputation was suggested, but the patient declined and was treated symptomatically with close monitoring. The patient underwent removal of the plates, excision of the distal fourth of the fibula, intralesional curettage of all lesions, and fusion of the ankle and subtalar joints with a retrograde intramedullary nail. After 5.5 years, the patient had recovered well and had no evidence of malignancy. The tumour was considered definitively benign.