Patterns of Ankle Fractures Based on Radiographs and CT Images of 1000 Consecutive Patients.

Objectives: The knowledge of different types of ankle fractures based on plain radiographs and computed tomography (CT) images can help improve patients' management. Methods: This cross-sectional study assessed the plain radiographs and CT images of 1,000 consecutive patients observed in an emergency department between March 2015 and March 2020. Fractures were labeled as uni-, bi-, or trimalleolar. Malleolar fractures were classified into medial, lateral, and posterior ones based on Herscovici, Danis-Weber, and Mason and Molloy classifications, respectively. Bi- and trimalleolar fractures, on the other hand, were categorized according to the Lauge-Hansen classification. Results: This study included 1,000 patients with 1,003 ankle fractures. Of them, 901 were adults (mean±SD age: 41.6±16.7, male: 567 [62.9%]) with 904 fractures. In total, 53% of adult patients were 18 to 39 years old. Considering unilateral ankle fractures, the medial malleolar fracture was the most common unimalleolar fracture (62.6%), with Herscovici C being the most frequent subtype (65.3%). On the other hand, the most common type of lateral malleolar fracture was Danis-Weber type B (65.5%). There were also 209 (23.3%) bimalleolar and 114 (12.7%) trimalleolar fractures, 5.8% (16 fractures) of which could not be classified based on the Lauge-Hansen classification. Unimalleolar fractures were also observed in 87 (87.9%) children, with the medial malleolar fracture being the most common type (89.7%). Conclusion: Medial malleolar fractures were the most frequent malleoli in patients observed in the emergency department under study. Among bi- and trimalleolar ankle fractures, supination-external rotation and pronation-external rotation injuries were the most common patterns. The Lauge-Hansen classification was not applicable in 5.8% of bi- and trimalleolar fractures.

Prevalence and Predictors of Peroneal Tendon Instability Accompanying Calcaneal Fractures.

BACKGROUND: We aimed to find the prevalence of peroneal tendon instability (PTI) accompanying different types of calcaneal fractures and to determine predictors of PTI based on preoperative CT scanning. METHODS: In a retrospective cross-sectional study, preoperative CT scans of 400 consecutive calcaneal fractures undergoing surgery were reviewed for comminuted fragments in the lateral gutter of the ankle, fractures at the tip of the lateral malleolus, dislocated peroneal tendons, excessive displacement of the lateral calcaneal wall, calcaneal fracture-dislocation, superior peroneal retinaculum (SPR) avulsion fracture (fleck sign), and shape of the retromalleolar groove. The correlation of these variables with intraoperative SPR stress test, defined as the diagnostic criteria for PTI in calcaneal fractures, was evaluated. RESULTS: In total, 369 patients (mean age, 39 ± 13; range, 11-72 years), with 321 (87.0%) of them male, were included. Among all calcaneal fractures, 67 cases (16.7%) had associated PTI as confirmed intraoperatively by an SPR stress test. A statistically significant association was found between PTI in calcaneal fractures and comminuted fragments in the lateral gutter of the ankle (P = .03), dislocated peroneal tendons (P < .001), calcaneal fracture-dislocation (P < .001), SPR avulsion fracture (P < .001), and Sanders type IV of calcaneal fracture (P = .02). There was no statistically significant relationship between PTI and the mechanism of injury (P = .98), side of fracture (P = .30), uni- or bilateral calcaneal fractures (P = .27), a fracture at the tip of lateral malleolus (P = .69), shape of the retromalleolar groove (P = .78), or excessive displacement of the lateral calcaneal wall (P = .06). The most specific CT finding to predict PTI accompanying calcaneal fractures was calcaneal fracture-dislocation (99.1%). CONCLUSION: Following calcaneal fracture fixation, PTI was confirmed with intraoperative SPR stress test in one-sixth of cases. With the exception of calcaneal fracture-dislocation, preoperative findings on CT scanning and calcaneal fracture pathoanatomy are insufficient to diagnose PTI accompanying calcaneal fractures. LEVEL OF EVIDENCE: Level III, retrospective case control study.

A rare case of floated talar head accompanying medial subtalar dislocation.

INTRODUCTION AND IMPORTANCE: Concomitant medial subtalar dislocation and a rotated displaced talar neck fracture may result in poor outcomes. This study aimed to explain this extremely rare injury and assess the clinical outcomes following surgical treatment. CASE PRESENTATION: A 22-year-old Iranian man referred to the emergency department with a gross deformity and pain in his right foot and ankle after a falling from 2 m. Plain radiographs showed a rotated free talar head accompanying medial subtalar dislocation. Closed reduction was performed in the emergency department under sedation. Prompt open reduction and internal fixation of talar fracture was done, after removal of free osseocartilaginous fragments in the subtalar and talonavicular joints. At 25 months postoperatively, the clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and visual analogue scale for pain which were 73 and 3, respectively. In exam, the patient had a stiffed subtalar joint without talar osteonecrosis or collapse. CLINICAL DISCUSSION: Several osseous and soft tissue barriers could prevent a successful closed reduction of a subtalar dislocation. Associated cartilage injuries or fractures may result in poor clinical outcomes such as persistent pain, limping, osteoarthritis, and osteonecrosis. Immediate open reduction and rigid fixation of associated fractures and resection of small free osseocartilaginous fragments may prevent further soft tissue damages and preserve clinical functions. CONCLUSIONS: Satisfactory clinical outcome could be expected following proper on-time approach to a subtalar dislocation associated with a rotated displaced talar neck fracture.

Clinical outcomes following treatment of deep surgical site infection after fixation of calcaneal fractures: A retrospective case-control study.

INTRODUCTION: Deep surgical site infection (SSI) may be a complication of open reduction and internal fixation (ORIF) of calcaneal fractures. This study aimed to describe the characteristics of patients with deep SSI following ORIF of calcaneal fractures via extensile lateral approach (ELA). We compared clinical outcomes of these patients, with a minimum follow-up of one year after successful treatment of deep SSI with a matched control group. METHODS: In this retrospective case-control study, demographic data, fracture characteristics, bacterial pathogens, medical treatments and surgical approaches were collected, also the outcome was evaluated by the visual analog scale (VAS) for pain, foot function index (FFI) and AOFAS ankle-hindfoot score. The differences in Böhler and Gissane's angles between infected and contralateral feet were measured. By matching a control group of uninfected cases, clinical outcomes were compared between 2 groups using the Mann-Whitney U test. RESULTS: Among 331 calcaneus fractures in 308 patients (mean age, 38.0 ± 13.1; male/female ratio, 5.5), 21 had deep SSI (6.3 %). There were 16 (76.2 %) males and 5 (23.8 %) females with a mean age of 35.1 ± 11.7 years. Thirteen (61.9 %) patients had unilateral fractures. The most common Sanders Type was found to be type II. The most frequent type of detected microorganisms was Staphylococcus species. Intravenous antibiotic therapy, mostly clindamycin, imipenem and vancomycin, based on the microbiological results, was prescribed with a mean±SD duration of 28.1 ± 16.5 days. The mean number of surgical debridements was 1.8 ± 1.3. Implants needed to be removed in 16 (76.2 %) cases. Antibiotic-impregnated bone cement was applied in three (14.3 %) cases. The clinical outcomes of 15 cases (follow up, 35.5 ± 13.8; range, 12.6-64.5 months) were 4.1 ± 2.0, 16.7 ± 12.3 and 77.5 ± 20.8 for VAS for pain, FFI % and AOFAS ankle-hindfoot score, respectively. Comparing with the control group (VAS for pain, 2.3 ± 2.7; FFI %, 12.2 ± 16.6, and AOFAS, 84.6 ± 18.0), only VAS pain was statistically lower in this group (p-value: 0.012). The differences in Böhler and Gissane's angles between both feet of infected cases were - 14.3 ± 17.9 and - 7.7 ± 22.5 (worse in the infected side), respectively. CONCLUSION: Proper on-time approaches to deep infection following ORIF of calcaneal fractures may lead to acceptable clinical and functional outcomes. Sometimes aggressive approaches with intravenous antibiotic therapy, multiple sessions of surgical debridement, removal of implants and antibiotic impregnated cement are necessary to eradicate deep infection. LEVEL OF EVIDENCE: Level III.

On-Top Plasty in Post-Axial Polydactyly: A Case Report and Recommendation to Modify the Classifications.

Post-axial polydactyly (PAP) is almost always treated by ablation of the sixth ray since the ulnar duplicate is universally inadequate and the radial one is normal. We report a patient with bilateral PAP with skeletal abnormalities in both radial and ulnar duplicates. This unusual presentation cannot be classified according to previous classifications of PAP and precludes simple ablation as the treatment of choice. Both hands of this patient were treated by on-top plasty with excellent functional and cosmetic results. A modification of the previous classifications is recommended at the end of this article. Level of Evidence: Level V (Therapeutic).

Lisfranc fleck sign: characteristics and clinical outcomes following fixation using a percutaneous position Lisfranc screw.

BACKGROUND: Avulsion of the Lisfranc ligament, fleck sign, results in unstable Lisfranc injuries. This cross-sectional study was conducted to investigate the characteristics of Lisfranc injuries with fleck sign and the clinical and radiological outcomes following closed reduction and percutaneous screw fixation. METHODS: All consecutive operatively managed Lisfranc injuries with fleck sign were reviewed from 2016 to 2018. The injury pattern and characteristics of Lisfranc fleck sign were reviewed based on the preoperative CT scan. Postoperative complications besides radiological and clinical outcomes were assessed using visual analog scale (VAS) pain, American orthopedic foot and ankle society (AOFAS) midfoot scale, and foot function index (FFI). RESULTS: Thirty patients (20 males; mean age, 36.9 ± 17.0; range, 12-69 years) with mean follow-up 16.9 ± 7.4 (range, 6-31) months were enrolled. Among 12 cases with avulsed Lisfranc ligament from the second metatarsal base, only two cases had isolated second metatarsal base fracture in plantar medial part while others had concomitant avulsion fracture of plantar aspect of the adjacent third and/or fourth metatarsal base. Mean of postoperative VAS pain, AOFAS midfoot scale, and FFI were 1.03 ± 0.29, 91.43 ± 1.43, 24.43 ± 6.66, respectively. We had seven (23.3%) removal of screws, two (6.6%) broken screws, four (13.3%) pulled-out screws, and six (20%) lost reductions in the final follow-up with good clinical functions. CONCLUSION: Closed reduction and percutaneous fixation of the Lisfranc injuries with fleck sign by a single position screw could be a good surgical option with reliable and predictable outcomes without needing to remove the hardware, routinely.

Consequences of extensile lateral approach to the calcaneal fractures on balance and isokinetic strength of muscle groups crossing the ankle joint.

BACKGROUND: Inherent characteristics of extensile lateral approach (ELA) for fixation of displaced intraarticular calcaneal fractures together with delayed or probably insufficient physical therapy programs may lead to weakness of the muscle groups crossing the ankle joint. Peroneal tendons might be involved more than others because of possible postoperative adhesions. The aim of this study was to evaluate the isokinetic strength of the muscle groups crossing the ankle joint and also to assess balance and functional ability in this group of patients. METHODS: Based on a pilot study, 23 patients undergone open reduction and internal fixation (ORIF) via ELA and 22 healthy subjects as the control group participated in this observational cross-sectional study. Patients more than 20 years of age with at least 12 months passed their unilateral closed intraarticular calcaneal fracture fixation without any postoperative complications like infection or wound dehiscence were included. Patients with history of concomitant lower extremity injury, spine trauma or surgery, cases underwent removal of calcaneal plates, and cases with neuromuscular or vestibular dysfunction were excluded. The outcome was assessed by isokinetic parameters such as peak torque, peak torque normalized to body weight, mean power and total work modified star excursion balance test, triple hop for distance test, and evertor-to-invertor (E/I) strength ratio. Isokinetic tests were performed at 60 and 120°/s. RESULTS: Greater strength was observed in all muscles in the control group at 60°/s (p < 0.05). Evertors and invertors were weaker in the operated group at 120°/s in comparison to the dorsiflexors and plantarflexors. Modified star excursion (p: 0.003) and triple hop tests (p: 0.001) were lower in the operated group. E/I ratio was not statistically significant between the two groups at 60°/s (p: 0.44) and 120°/s (p: 0.62). CONCLUSIONS: Strength deficit in all muscle groups crossing the ankle joint, and not evertors in isolation, in addition to balance and functional impairments would be seen one year following ORIF of calcaneal fracture via ELA. A long-term rehabilitation program emphasizing different kinds of contraction at low and high speeds and balance training in these patients is highly recommended.

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures.

INTRODUCTION: Postoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach. METHODS: Forty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects. RESULTS: PNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic. CONCLUSION: Peripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.

Different types and epidemiological patterns of calcaneal fractures based on reviewing CT images of 957 fractures.

INTRODUCTION: Calcaneal fractures may have lifelong debilitating sequences, if not treated properly. Identifying different types of calcaneal fractures based on the computed tomography (CT) scans can increase our conception about these fractures. METHODS: In a cross-sectional study, the available CT images of all consecutive patients with the diagnosis of calcaneal fracture, from January 2015 to December 2018, were reviewed to determine different patterns and types of these fractures. RESULTS: CT images of 886 patients (mean age, 41.29 ± 14.9; range, 3-89 years; male/female, 4.86; pediatric: 3.7%) with 957 calcaneal fractures were evaluated. The peak incidence of calcaneal fractures was seen in patients between 30 to 39 years of age (29%). The rate of open fractures and bilateral involvements were 2.4% and 8.0%, respectively. Among 680 (71.0%) intra-articular calcaneal fractures, subtalar calcaneal fractures were the most common type (94.3%). The majority of intra-articular subtalar calcaneal fractures were displaced (95.0%) with calcaneocuboid joint (CCJ) involvement (59.9%). Fracture lines were extended to the CCJ in about 86.9% of Sanders type IV, 66.3% of type III, and 60.2% of type II. Among 261 extra-articular fractures (27.3%), calcaneal body fracture (55.6%) was the most frequent type, followed by medial tubercle fracture (24.1%), calcaneal tuberosity fracture (10.4%), Degan type I anterior process fractures (5.4%), Degan type II anterior process fracture (3.4%), and isolated lateral tubercle fracture (1.1%). Most of bilateral calcaneal fractures were intra-articular subtalar fractures with involvement of CCJ. Although majority of intra-articular calcaneal fractures were displaced; less than half of the extra-articular fractures were displaced. CONCLUSION: Displaced intra-articular subtalar calcaneal fractures with CCJ involvement are the most frequent type of unilateral and bilateral calcaneal fractures. It appears that there is a correlation between Sanders type and the probability of CCJ involvement. Unlike intra-articular subtalar calcaneal fractures, the CCJ in the majority of extra-articular calcaneal body fractures was intact. LEVEL OF EVIDENCE: Level IV.

EFAS Score -Validation of Persian Version by the Score Committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: The Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in nine European languages (English, German, French, Italian, Polish, Dutch, Swedish, Finnish, Turkish). From other languages under validation, the Persian version finished data acquisition and underwent further validation. METHODS: The Persian version of the EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Persian version (completed during initial validation study in nine other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory. RESULTS: The internal consistency was confirmed in the Persian version (Cronbach's Alpha 0.82). The Standard Error of Measurement (SEM) was 0.38 and is similar to other language versions. Between baseline and follow-up, 97% of patients showed an improvement on their EFAS score, with excellent responsiveness (effect size 1.93). CONCLUSIONS: The Persian EFAS Score version was successfully validated in patients with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Can We Release All Calcaneal Attachments of the Superior Peroneal Retinaculum During Extensile Lateral Approach to the Calcaneus?

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle.

PURPOSE: The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan. METHODS: Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans. RESULTS: Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively. CONCLUSIONS: In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount. LEVEL OF EVIDENCE: Level IV.

Bone Graft Harvesting From the Calcaneus Using Lateral Wall Corticotomy Technique by an Osteotome.

Background: The aim of this study was to evaluate the complications following calcaneal autologous bone graft harvesting using an osteotome in patients who underwent foot and ankle surgery with follow-up of at least 1 year. Methods: In a cohort study, all consecutive patients underwent forefoot or midfoot surgeries in conjunction with harvesting bone graft from the calcaneus using lateral wall corticotomy technique by an osteotome from 2015 till 2018 were asked to follow. The outcome and morbidity were assessed by visual analogue scale (VAS) pain, numbness in territory of the sural nerve, surgical site numbness or tenderness, infection, hematoma formation, or pathologic fracture. Also any possible restrictions on wearing desired shoes were asked. Results: Totally, 50 patients (11 males, 39 females; 29 right foot, 21 left foot) with the mean age of 48.2 ± 13.8 years (range 8-66 years) were assessed. There were no major complications on donor site such as infection, hematoma formation, or pathologic fracture. The following results were seen; 90% without any pain (VAS 0/10), 96% without numbness at the incision site, 96% without point tenderness on lateral of heel, 98% without paresthesia or numbness in the sural nerve territory, and 84% were able to wear their favorite shoes. Forty-one (82%) cases said if they need another foot surgery, they would permit to harvest bone graft from their heel. Conclusions: Autologous bone graft harvesting from the calcaneus using lateral wall corticotomy technique by an osteotome could be a useful method with very low complications.Levels of Evidence: Therapeutic, level IV: cohort, case series.

Peroneal Tendons Rupture in a Closed Talar Body Fracture: A Rare Injury.

The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.

American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language.

We evaluated the reliability and validity of the Persian translation of the American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal joint scale (AOFAS Hallux MTP-IP). The translated AOFAS Hallux MTP-IP scale form was completed for 101 patients with hallux deformities; the subjective questions were answered by the patients, whereas the orthopedic foot and ankle surgeon and his assistant answered the objective questions. The validated Persian version of the 36-Item Short Form Survey Instrument (SF-36) was used for validity assessment. Eighty-five females and 16 males with a mean age of 49 years were enrolled. Hallux valgus and hallux rigidus was the diagnosis in 73 and 28 patients, respectively. Intrarater reliability had a high level of correlation (rho >0.6) for all subscales and total score. Although the correlation between the total score of the AOFAS Hallux MTP-IP scale and role: physical subscale of SF-36 was the highest (rho = 0.47), the total score of AOFAS Hallux MTP-IP scale and the other 7 domains of SF-36 had a correlation ranging between -0.17 and 0.43. Moreover, the correlation between total score of AOFAS-Hallux MTP-IP and SF-36 physical component summary scale was 0.50, which was higher than the correlation between total score of AOFAS and SF-36 mental component summary scale (rho = 0.35). Convergent validity was approved for MTP joint motion (0.59), IP joint motion (0.51), and callus (0.56) items of AOFAS-Hallux MTP-IP. Spearman's rank correlation coefficient between all items of the functional subscale of AOFAS Hallux MTP-IP scale with its own subscales was higher than the coefficient between these items and other subscales, including pain and alignment (discriminate validity). Floor and ceiling effects were calculated as 2% and 1%, respectively. Our findings indicate that the translated Persian version of the AOFAS Hallux MTP-IP scale is a reliable instrument, but its validity is not satisfactory.

Management of tibialis anterior tendon rupture: Recommendations based on the literature review.

Tibialis anterior tendon (TAT) rupture is a rare injury that commonly diagnosed late due to mild clinical signs and symptoms. Management of TAT rupture is a topic without a clear consensus in the literature. This current concept review tries to shed some light on the data and treatment. Our extensive literature review identified 81 case reports and case series from 1905 to 2018. Several reported management techniques with their advantages and disadvantages were analyzed and our treatment recommendations are given based on current available evidences. LEVELS OF EVIDENCE: IV.

Agreement between Sanders classification of intraarticular calcaneal fractures and assessment during the surgery.

BACKGROUND: Sanders classification, based on the number of displaced fractured fragments of posterior facet, can predict the prognosis of calcaneal intraarticular fractures. The aim of the study was assessing not only intraobserver reproducibility and interobserver reliability of Sanders classification but also the agreement between preoperative reported types based on computed tomography (CT) scan and direct observation during the surgery. METHODS: In this cross-sectional study, preoperative CT scans of 100 patients with intra-articular calcaneal fracture operated by a single surgeon were studied by two orthopedic and trauma surgeons (A & B), twice with an interval of three weeks. Their result were compared with each other and with the number of displaced fractured fragments recorded in the operation notes. Quadratic weighted kappa test was used to check the agreement between two observers and between the observers and the surgeon. RESULTS: Intraobserver reproducibility for Sanders classification of intraarticular calcaneal fractures was found to be good to excellent (A1-A2: 0.91 and B1-B2: 0.75). There was a moderate agreement between the two observers (A1-B1: 0.56, A1-B2:0.58, A2-B1:0.48, and A2-B2:0.51). The agreement between reported types of Sanders classification and the number of displaced fractured fragments seen during the surgery was fair (A1-surgeon: 0.27, A2-surgeon: 0.29, B1-surgeon: 0.38, and B2-surgeon: 0.50). CONCLUSIONS: Agreement between Sanders classification and what is real during surgery is fair. Hence, Sanders classification as determined in the widest cut of coronal CT scan extended posteriorly should be cautiously interpreted for surgery.

Simvastatin increases temozolomide-induced cell death by targeting the fusion of autophagosomes and lysosomes.

Temozolomide (TMZ) is a chemotherapy agent used to treat Grade IV astrocytoma, also known as glioblastoma (GBM). TMZ treatment causes DNA damage that results in tumor cell apoptosis and increases the survival rate of GBM patients. However, chemoresistance as a result of TMZ-induced autophagy significantly reduces this anticancer effects over time. Statins are competitive inhibitors of HMG-CoA reductase, the rate-limiting enzyme of the mevalonate (MEV) cascade. Statins are best known for their cholesterol (CH)-lowering effect. Long-term consumption of statins, prior to and in parallel with other cancer therapeutic approaches, has been reported to increase the survival rate of patients with various forms of cancers. In this study, we investigated the potentiation of TMZ-induced apoptosis by simvastatin (Simva) in human GBM cell lines and patient GBM cells, using cell monolayers and three-dimensional cell culture systems. The incubation of cells with a combination of Simva and TMZ resulted in a significant increase in apoptotic cells compared to cells treated with TMZ alone. Incubation of cells with CH or MEV cascade intermediates failed to compensate the decrease in cell viability induced by the combined Simva and TMZ treatment. Simva treatment inhibited the autophagy flux induced by TMZ by blocking autophago-lysosome formation. Our results suggest that Simva sensitizes GBM cells to TMZ-induced cell death in a MEV cascade-independent manner and identifies the inhibition of autophagosome-lysosome fusion as a promising therapeutic strategy in the treatment of GBM.