Luxo-fractura de Chopart / Fracture-luxation de l'articulation de Chopart / Chopart luxo-fracture

La articulación de Chopart o transversa del tarso está constituida por la articulación calcaneocuboidea y la astragaloescafoidea. Las lesiones que ocurren en estas articulaciones se conocen como luxo-fractura de Chopart y son extremadamente raras. Entre las causas más frecuentes se encuentran los accidentes en motocicletas y las caídas de altura. El tratamiento es la reducción anatómica y fijación estable. La necrosis avascular del astrágalo, así como la artritis postraumática son las complicaciones más temidas. Con este trabajo se pretende describir la conducta y evolución perioperatoria de dos pacientes con luxo-fractura de Chopart, atendidos en el Servicio de Urgencias del Hospital Militar Central Dr Luis Díaz Soto. Fueron diagnosticados tempranamente y se les realizó reducción abierta más fijación interna con una recuperación en los primeros tres meses. La baja prevalencia de la luxo-fractura de Chopart requiere un diagnóstico adecuado y correcto para lograr un buen resultado clínico(AU)

The Chopart joint or transverse tarsus is constituted by the calcaneocuboid and the astragaloescafoidea joints. The injuries that occur in these joints are known as Chopart luxo-fracture and are extremely rare. Motorcycle accidents and falls from heights are among the most frequent causes of Chopart luxo-fractures. The treatment is the anatomical reduction and stable fixation. The avascular necrosis of the talus, as well as post-traumatic arthritis are the most feared complications. This paper aims to describe the behavior and perioperative evolution of two patients with Chopart luxo-fracture, treated in the Emergency Service at Dr Luis Díaz Soto Central Military Hospital. They were early diagnosed and underwent open reduction and internal fixation. They recovered in the first three months. The low prevalence of Chopart luxo-fracture requires adequate and correct diagnosis to achieve good clinical results(AU)

L'articulation de Chopart, ou médio-tarsienne, est constituée de deux articulations distinctes: l'articulation calcanéo-cuboïdienne et l'articulation astragalo-scaphoïdienne. Les lésions produites dans ces articulations sont connues comme des fractures-luxations de l'articulation de Chopart, et sont assez rares. Parmi les causes les plus fréquentes, on peut trouver les accidents du trafic (surtout, de moto) et les chutes de haut. Le traitement consiste généralement à une réduction anatomique et une fixation stable. La nécrose avasculaire de l'astragale et l'arthrite post-traumatique sont les complications les plus souvent à craindre. Le but de ce travail est de décrire le comportement et l'évolution péri-opératoire de deux patients atteints d'une fracture-luxation de l'articulation de Chopart, et traités au service d'urgence de l'hôpital militaire Dr Luis Díaz Soto. Ils sont rapidement diagnostiqués, et traités par réduction ouverte et fixation interne. Leur récupération est réussie en trois mois. La faible prévalence de la fracture-luxation de l'articulation de Chopart exige un diagnostic précis pour atteindre de bons résultats cliniques(AU)

Local infiltration of liposome bupivacaine in foot and ankle surgery: case-based reviews.

Foot and ankle surgical procedures, ranging from simple procedures, such as bunionectomy and correction of hammer toe, to more complex surgery, such as ankle fusion and ankle replacement, are extremely painful. Moreover, there is increasing interest in performing these procedures in an outpatient setting. Nerve blocks are extensively used in foot and ankle surgery, and commonly used techniques include sciatic nerve block with saphenous nerve augmentation; ankle block; and local, digital, or field block. Whereas more extensive blocks are associated with increased medical risk, higher cost, and delayed ambulation, more local approaches may not provide an adequate duration of effect. EXPAREL® (bupivacaine liposome injectable suspension) is an extended-release local anesthetic that can be infiltrated directly into the surgical site by the orthopedic surgeon to provide continuous and effective analgesia at the site of surgical injury for up to 72 hours. Two cases that illustrate the use of EXPAREL® in foot and ankle surgery are described. The first case involves ankle replacement in an active 58-year-old man with a 20-plus-year history of arthritis. The second case involves a young woman undergoing surgery for a talar neck fracture-dislocation with an open injury, dislocated subtalar joint, avascular talus, and considerable deformity. Both patients reported excellent control of postsurgical pain.

When something is not quite right: an ankle sprain.

Ankle sprains are a common musculoskeletal injury in sport. Older people are increasingly participating in sports such as running. The specificities of musculoskeletal injuries in older people pose a different diagnostic challenge from that in young people participating in the same activities. A clinical case is presented of a 64-year-old patient diagnosed with a grade 1, plantar flexion/inversion ankle sprain that was later diagnosed as a quite different and rare injury. Fractures of the fibular malleolus, talar neck and dome are possible differential diagnoses for an ankle sprain, as are talar dome chondral defects. Response to treatment may help to guide the diagnostic procedure when pain persists after appropriate treatment.

Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study.

BACKGROUND: Osteochondral lesions of the talus (OLT) frequently occur after ankle sprains in young patients participating in sports activities. These injuries may lead to chronic pain, joint swelling, and finally osteoarthritis, therefore, surgical repair is frequently needed. A collagen scaffold seeded with bone marrow-derived cells (BMDCs) harvested from patient's iliac crest and implanted into the OLT through a single arthroscopic procedure has been recently proposed as an effective treatment option. Nevertheless, BMDCs, embedded in an inflammatory environment, tend to differentiate toward a fibroblast phenotype with a consequential loss of mechanical characteristics. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been shown to promote anabolic chondrocyte activity, stimulate proteoglycan synthesis, and reduce the release of the most relevant pro-inflammatory cytokines. The aim of this randomized controlled trial was to evaluate the effects of PEMFs on clinical outcome in patients who underwent BMDCs transplantation for OLT. METHODS: Thirty patients affected by grade III and IV Outerbridge OLT underwent BMDCs transplantation. After surgery, patients were randomly assigned to either experimental group (PEMFs 4 hours per day for 60 days starting within 3 days after operation) or control group. Clinical outcome was evaluated with (American Orthopaedic Foot and Ankle Society) AOFAS score, Visual Analog Scale (VAS), and Short Form-36 (SF-36). RESULTS: Significantly higher AOFAS score was recorded in the experimental group both at 6 or 12 months follow-up. At 60 days and 6 and 12 months follow-up, significant lower pain was observed in the experimental group. No significant difference was found in SF-36 between groups. CONCLUSION: A superior clinical outcome was found in the experimental group with more than 10 points higher AOFAS score at final follow-up. Biophysical stimulation started soon after surgery aided patient recovery leading to pain control and a better clinical outcome with these improvements lasting more than 1 year after surgery. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Tratamiento artroscópico de las lesiones osteocondrales de astrágalo: estudio de 73 casos / Arthroscopic treatment of talus osteochondral lesions: study of 73 cases

Introducción y objetivo. El objetivo de nuestro estudio es analizar las distintas técnicas artroscópicas empleadas en el tratamiento de las lesiones osteocondrales de astrágalo. Material y método. Realizamos un estudio retrospectivo de 73 casos, intervenidos entre los años 2000 y 2011. Los pacientes se dividieron en 2 grupos: grupo A (51 pacientes), aquellos tratados mediante técnicas de estimulación osteocondral; grupo B (32 pacientes), tratados mediante técnicas de reparación. La edad media fue de 32,58 años (19-73) en el grupo A, y 36,50 años (19-58) en el grupo B. Se identifica predominio del sexo masculino y de lesiones mediales en ambos grupos. Resultados. Se evaluaron los resultados siguiendo la escala de la AOFAS de retropié, observando una mejoría clínica estadísticamente significativa (p < 0,001). Los valores preoperatorios fueron 48,77 (31-67) en el grupo A, y 58,08 (41-75) en el grupo B. Después de la intervención quirúrgica las puntuaciones ascendieron a 85,19 (60-100) en el grupo A, y 93,60 (80-100) en el grupo B. Conclusiones. La cirugía artroscópica es la técnica de elección en el tratamiento de las lesiones osteocondrales de tobillo, permite una correcta estadificación y tratamiento de las lesiones asociadas. El tratamiento artroscópico de las lesiones grado i , ii y, en ocasiones iii mediante técnicas de estimulación condral, y de lesiones grado iii y iv mediante técnicas de reparación ofrece buenos resultados con escasas complicaciones (11%) (AU)

Background and aim. The aim of our study is to analyze the different techniques used in arthroscopic treatment of talus osteochondral lesions. Material and method. We retrospectively analyzed 73 patients who underwent surgery between 2000 and 2011. Patients were divided in two groups: group A (51 patients), those treated with osteochondral stimulation techniques, and group B (32 patients), that were treated by repair techniques. The mean age was 32.58 (19-73) years in group A and 36.50 (19-58) in group B. It is identified male predominance and medial lesions in both groups. Results. Were evaluated according to the AOFAS ankle scoring scale, it is observed a statistically significant clinical improvement (P<.001). Preoperative values were 48.77 (31-67) in group A and 58.08 (41-75) in group B. After surgery scores amounted to 85.19 (60-100) in group A and 93.60 (80-100) in group B. Conclusions. Ankle arthroscopy is an excellent technique for the accurate staging of osteochondral lesions, and diagnosis and treatment of associated injuries. The arthroscopic treatment of lesions grade i , ii and sometimes iii , by stimulation techniques and chondral lesions grade iii and iv by replacement techniques, gives good results with few complications (AU)

Pulsed electromagnetic fields after arthroscopic treatment for osteochondral defects of the talus: double-blind randomized controlled multicenter trial.

BACKGROUND: Osteochondral talar defects usually affect athletic patients. The primary surgical treatment consists of arthroscopic debridement and microfracturing. Although this is mostly successful, early sport resumption is difficult to achieve, and it can take up to one year to obtain clinical improvement. Pulsed electromagnetic fields (PEMFs) may be effective for talar defects after arthroscopic treatment by promoting tissue healing, suppressing inflammation, and relieving pain. We hypothesize that PEMF-treatment compared to sham-treatment after arthroscopy will lead to earlier resumption of sports, and aim at 25% increase in patients that resume sports. METHODS/DESIGN: A prospective, double-blind, randomized, placebo-controlled trial (RCT) will be conducted in five centers throughout the Netherlands and Belgium. 68 patients will be randomized to either active PEMF-treatment or sham-treatment for 60 days, four hours daily. They will be followed-up for one year. The combined primary outcome measures are (a) the percentage of patients that resume and maintain sports, and (b) the time to resumption of sports, defined by the Ankle Activity Score. Secondary outcome measures include resumption of work, subjective and objective scoring systems (American Orthopaedic Foot and Ankle Society--Ankle-Hindfoot Scale, Foot Ankle Outcome Score, Numeric Rating Scales of pain and satisfaction, EuroQol-5D), and computed tomography. Time to resumption of sports will be analyzed using Kaplan-Meier curves and log-rank tests. DISCUSSION: This trial will provide level-1 evidence on the effectiveness of PEMFs in the management of osteochondral ankle lesions after arthroscopy. TRIAL REGISTRATION: Netherlands Trial Register (NTR1636).

Nonunion of a Hawkin's group II talar neck fracture without avascular necrosis.

The authors present an unusual case of talar neck nonunion without avascular necrosis following a Hawkin's group II fracture. A review of the literature and treatment of this rare complication are discussed. The nonunion was treated by debridement and iliac crest bone grafting to the defect and external electrical bone stimulation. The deformity of the rearfoot caused by the fracture nonunion was addressed by using a triple arthrodesis utilizing the Synthes 7.3-mm cannulated screw system.

Ankle and subtalar fusion utilizing a tricortical bone graft, bone stimulator, and external fixator after avascular necrosis of the talus.

A unique ankle and subtalar fusion was performed on a patient with avascular necrosis of the talus. The body of the talus was removed and replaced with an autogenous tricortical bone graft. Healing was aided by the use of a bone stimulator and external fixator. The authors believe this fusion to be a more stable fusion than others used to treat avascular necrosis of the talus.

[Indications and clinical results of electromagnetically-induced alternating current stimulation of poorly reacting pseudarthroses]. / Indikation und klinische Ergebnisse der elektromagnetisch induzierten Wechselstromstimulation reaktionsarmer Pseudarthrosen.

The authors present first results of clinical application of electromagnetically induced alternating-current voltage in 37 pseudarthroses showing poor reaction. The pseudarthroses had been persisting for two years on an average, the clinical pre-treatment time was seven months, the number of preceding operations was 2.76, eleven patients had been already operated by us one or several times without electric stimulation. Most of the pseudarthroses were contaminated; they were treated by sequestrotomy and immediate fixation with plate or marrow nail and autologous spongiosa graft. The alternating-current carrier was implanted in the bone with two electrodes each. When the wound was healed, the induction of alternating current was continued at home with a loan apparatus for three times 45 minutes to three times 2 hours daily. The electric treatment was performed during 6.7 months, the ossification was finished after 4.7 months, and the lower extremity could be fully loaded after five months. The recovery rate after one single operation is 89.2%. Repeated operations included, the total rate of recovery is 97.3%, no amputations. The review of literature shows that the method is favorable as to the stationary treatment time, the number of necessary surgical interventions, and the number of amputations.

Fracture nonunion.

The management of nonunion represents a complex clinical situation requiring an understanding of the pathophysiology. Before initiating treatment, the nonunion must be assessed radiographically. Further evaluation by radionuclide imaging and CT may be applicable. Only then can proper treatment, whether by immobilization, internal fixation with or without incorporation of bone grafts, or electrostimulation, be instituted.