Prospective Computed Tomographic Analysis of Osteochondral Lesions of the Ankle Joint Associated With Ankle Fractures.

BACKGROUND: Osteochondral lesions (OCLs) associated with ankle fracture correlate with unfavorable outcome. The goals of this study were to detect OCLs following ankle fracture, to associate fracture type to OCLs and to investigate whether OCLs affect clinical outcome. METHODS: 100 ankle fractures requiring operative treatment were prospectively included (46 men, 54 women; mean age 44 ± 14 years, range 20-77). All ankle fractures (conventional radiography; 71 Weber B, 22 Weber C, 1 Weber A, 4 isolated medial malleolus and 2 isolated posterior malleolus fractures) were treated by open reduction and internal fixation. Multidetector computed tomography (CT) was performed postoperatively. For each OCL, the location, size, and Loomer OCL classification (CT modified Berndt and Harty classification) were determined. The subjective Foot and Ankle Outcome Scoring (FAOS) was used for clinical outcome at 1 year. RESULTS: OCLs were found in 10/100 ankle fractures (10.0%). All OCLs were solitary talar lesions. Four OCLs were located posteromedial, 4 posterolateral, 1 anterolateral, and 1 anteromedial. There were 2 type I OCLs (subchondral compression), 6 type II OCLs (partial, nondisplaced fracture) and 2 type IV OCLs (displaced fracture). Mean OCL size (largest diameter) was 4.4 ± 1.7 mm (range, 1.7 mm to 6.2 mm). Chi-square analysis showed no significant association between ankle fracture type and occurrence of OCLs. OCLs did occur only in Lauge-Hansen stage III/IV ankle fractures. There were no significant differences in FAOS outcome between patients with or without OCLs. CONCLUSIONS: Ten percent of investigated ankle fractures had associated OCLs on CT. Although no significant association between fracture type and OCL was found, OCLs only occurred in Lauge-Hansen stage III/IV ankle fractures. With the numbers available, OCLs did not significantly affect clinical outcome at 1 year according to FAOS. LEVEL OF EVIDENCE: Level IV, observational study.

Effect of syndesmosis injury in SER IV (Weber B)-type ankle fractures on function and incidence of osteoarthritis.

BACKGROUND: Syndesmosis fixation of Lauge-Hansen SER IV, Weber B ankle fractures is controversial. This study compared a matched pair of SER IV patients with stress proven syndesmotic injuries with the same number without stress proven syndesmotic injury in terms of functional, pain, and radiologic result. METHODS: The study was based on a RCT-study comparing syndesmotic transfixation to no fixation in SER IV (Weber B)-type ankle fractures. Twenty-four patients with a syndesmosis injury found on the intraoperative 7.5 Nm standardized external rotation test were compared to 24 patients with a stable syndesmosis. The pairs were matched by fracture morphology, sex, and age. The primary outcome measure was ankle function as assessed by the Olerud-Molander score. Weight-bearing plain radiographs and 3T MRI of the injured ankle were used to assess ankle joint congruity and osteoarthritis, according to Kellgren-Lawrence classification and cartilage defects. RESULTS: The Olerud-Molander score was 86 in syndesmosis injury patients and 90 in patients with normal syndesmosis (P = .28). The incidence of ankle joint osteoarthritis on plain radiographs was not significantly different between the groups (Grade I 5% vs 21%; Grade II 86% vs 75%; Grade III 9% vs 4%; P = .34). MRI scans showed TC joint cartilage defects in 54% of the patients: 12 (56%) in the syndesmosis injury group vs 13 (54%) in the group without syndesmosis injury (P > .9). CONCLUSION: After 4 to 6 years of follow-up, clinical and radiologic outcome were not different in patients with syndesmosis injury compared to patients with stable syndesmosis in SER IV (Weber B)-type ankle fractures. LEVEL OF EVIDENCE: Prognostic Level II, comparative study.

Alterações óssea e articulares na hanseníase / Bone and joint changes in leprosy

Objetivou-se o presente trabalho de modo a contribuir para a prevenção, o diagnóstico precoce e tratamento apropriado das lesões ósseas e articulares na hanseníase, reduzindo o impacto mundial das doenças deformantes e mutilantes. Assim, foi realizada uma série de estudos retrospectivos longitudinais e de corte transversal em pacientes recém diagnosticados com Hanseníase ou que receberam poliquimioterapia (PQT) em dose fixa, com o fim de avaliar as osteoartropatias e seus mecanismos fisiopatogênicos. Foi observada uma progressão das acropatias ósseas durante e após a PQT. Em uma amostra de 93 pacientes multibacilares tratados, observou-se, clinicamente, uma prevalência de 7,5 por cento de absorção nas extremidades. Ao incluir os dados radiológicos na análise de 105 pacientes, a prevalência aumentou para 21,7 por cento. A progressão das acropatias encontrou-se associada à neuropatia periférica e suas complicações, à presença de episódios reacionais crônicos e à manutenção de níveis séricos elevados de fator de necrose tumoral alfa. A reabsorção óssea persistiu ativa em 50 por cento dos 30 pacientes avaliados após 5 anos do fim da PQT. Em pacientes com episódios reacionais prolongados ou recorrentes, avaliados com técnicas de medicina nuclear, detectaram-se freqüentes alterações ósseas e articulares principalmente de natureza inflamatória e uma elevada prevalência (27 por cento) de osteoporose lombar. Nestes pacientes, as áreas de predomínio de osso trabecular foram mais afetadas por osteopenia, enquanto nos pacientes virgens de tratamento avaliados, observou-se osteopenia predominantemente em áreas de osso compacto (80 por cento dos pacientes). Os supracitados resultados sugerem que a reação imunoinflamatória é um fator importante envolvido no acometimento ósseo e articular na hanseníase, a qual age isoladamente ou em conjunto com os mecanismos de natureza infecciosa, neurológica e vascular. Os pacientes com neuropatia periférica e episódios reacionais recorrentes devem ser acompanhados e avaliados radiologicamente após a alta terapêutica.

Evolución de las lesiones óseas en enfermos de Hansen en alta terapéutica: a propósito de 3 casos

En el presente artículo los autores intentan explicar cómo a pesar de que la lepra en la actualidad es una enfermedad que, con un diagnóstico precoz y con un tratamiento adecuado, tiene cura sin dejar ninguna secuela, para aquellos enfermos en los que ya existe una afectación neurológica, van a quedar unas lesiones tróficas que les van a acompañar durante el resto de su vida. Sin embargo, y a pesar de los grandes avances realizados en los últimos veinte años, estas lesiones óseas en miembros inferiores en enfermos en alta terapéutica siguen constituyendo un gran problema en el control de la enfermedad (AU)

[Long-term follow-up of osteoarthritis after conservative treatment of ankle fractures]. / Dugotrajno pracenje osteoartritisa nakon konzervativno lijecenog prijeloma gornjeg noznog zgloba.

In a period between 1982 and 1998 a total of 171 patients with ankle fracture were treated conservatively and rehabilitated in the same rehabilitation institution. All patients were seen at follow up in 1998 exactly at the date of the fracture in five groups with one, two, three, eleven and sixteen years from the fracture respectively. There were not significant differences in sex and age among groups. According to Danis-Weber's system, in the total material there were 53.8% type A, 40.9% type B and 5.3% type C fractures, and according to Lauge-Hansen's system there were 54.4% type SA, 34.5% type SE, 7.6% type PA and 3.5% type PE fractures. According to the Olerud's and Molander's scoring system there were the highest percentages of good results in all series (in average 52%) and there were not found significant differences between the results of the groups (P = 0.154). According to linear analogue scale of function there were the highest percentages of good results in all groups (in average 55.6%) and with significant differences between the results of the groups (P = 0.012). There were found significant differences between the results of late reductions of malleolar fragments of the groups (P = 0.028) with changing for the worse in groups with longer time interval from fracture. Posttraumatic osteoarthritis was found in first year after fracture already (41.5%). There were found significant differences between the results of the groups (P = 0.001) with severe degrees of osteoarthritis in groups with longer time from fracture.

[Progression towards dislocations of foot bone lesions in leprosy]. / De l'évolution vers la dislocation des lésions osseuses du pied du lépreux.

From a series of 211 tarsal, medio-tarsal and metatarso-phalangeal dislocations, the authors, after having recalled the lesion mechanism, adopted a classification and gave a place to preventive conservative surgery in 52 cases. The early forms can have early limited arthrodesia. The developed lesions present indications of arthrodesia--isolated reconstruction or associated to spongy or cortico-spongy bone grafts. The late forms impose amputation even when the forefoot seems of good bone quality because the metatarsal-phalangial stiffness is the cause for the failure of the Wladimiroff-Mickulicz interventions.

Early functional treatment of supination-eversion stage-II ankle fractures: preliminary results.

The preliminary results of early functional treatment of 30 patients with a grade-II supination-eversion fracture of the ankle according to Lauge-Hansen are discussed. The treatment of all patients consisted of splint immobilization for one week, followed by the application of a functional brace (Push Brace Medium) and immediate full weight bearing and functional training. All fractures healed without complications. Ankle function, radiographic findings and anamnestic complaints were monitored. The loss of ankle function diminished to 3.2 degrees +/- 4.9 degrees plantar flexion and to 1.7 degrees +/- 5.3 degrees dorsal flexion after one year follow up, none of the patients had significant complaints of pain or swelling. Radiography showed consolidation with callus formation in all cases. The grade-II supination-eversion fracture is a stable fracture which allows early functional treatment with the support of a Push Brace Medium. This results in an inexpensive, simple and comfortable therapy. A prospective randomized clinical trial is necessary to show the advantages of functional treatment over cast immobilization. Long-term follow-up will have to ascertain the theoretic risk of posttraumatic osteo-arthritis.

[Osteoarticular lesions in leprosy (experience 1960-1982)]. / Lésions ostéo-articulaires dans la lèpre (expérience 1960-1982).

Bone changes are frequent in leprosy involving small distal bones of the limbs and, in advanced cases, some cranial bones. The various kinds of osteitis and their radiologic features are described as well as the arthritis to which they can give way. These changes may result directly from the infection by M. leprae indirectly through nerve damage and also by pyogenic infections. The therapeutic tactic is discussed according to this approach of the various types of bones and joint damage.

Acquired flatfoot in adults.

The main causes of the acquired flatfoot deformity in adults are reviewed. This condition can be extremely disabling; however, careful analysis combined with thoughtful conservative management or surgical treatment can usually enable the patient to maintain a functional level.

[The intraarticular fracture of the distal end of the tibia as a prognostic criterion (author's transl)]. / Das hintere Tibiakantenfragment als prognostisches Kriterium

Ankle fractures with injuries of the distal articular surface of the tibia have particularly unfavourable results. A follow-up of 103 cases shows, that even small marginal fragments of the lip of tibia produce posttraumatic athrosis. Results become statistically worse when the fragment is about 1/5 of the joint surface. Further there is a clear relationship between the number of the single injuries and the incidence of posttraumatic arthrosis. Thus the prognosis of ankle fractures is better described by the genetic classification of Lauge-Hansen than by the classification of Weber,

[The foot in leprosy]. / II piede lebbroso.

The more frequently occurring bone lesions of leprosy of the foot are described with illustrations from patients with leprosy seen some years previously in Sardinia. These cases are classified into groups depending on the presence of osteoporosis, osteitis, lesions with predominantly inflammatory manifestations, those with a spindle-shaped appearance and lastly those with pathological fractures. The anatomical relationship between cutaneous and bone lesions is outlined.