[Translated article] Better results in consolidation of hallux metatarsophalangeal arthrodesis with dorsal plate and interfragmentary compression screw.

BACKGROUND AND AIMS: The first metatarsophalangeal joint arthrodesis is indicated for the treatment of various pathologies as a technique to reduce pain and improve the support of the first radius. Numerous surgical techniques and fixation methods have been described, with the combination of a dorsal plate and an interfragmentary screw being the one that has shown to be the most stable construct in biomechanical studies. Our aim is to analyze the radiological results after metatarsophalangeal arthrodesis of the hallux using a dorsal plate associated or not with an interfragmentary screw. The differences in terms of consolidation rates and complications in patients diagnosed with hallux rigidus, hallux valgus, hallux varus and failure of previous surgeries were evaluated. MATERIALS AND METHODS: A retrospective cohort study of 55 patients with a mean age of 65.10 years in whom a dorsal plate was used was performed. Patients were divided into two groups depending on whether or not an interfragmentary screw was used. The minimum follow-up was 6 months after surgery. The assessment of the pre and postoperative radiological results was based on the variation of the hallux angle, the intermetatarsal angle and the dorsal metatarsophalangeal angle of the hallux, as well as the cases of nonunion identified in each study group. RESULTS: The radiological results, statistically significant differences (p<0.05) were only found in the dorsal metatarsophalangeal angle between both study groups. No statistically significant differences were found regarding the radiological evaluation of the pre and postoperative hallux angle and intermetatarsal angle. An equal decrease of each angles was observed in both study groups. Regarding the consolidation rate, statistically significant differences (p<0.05) were found between group A, which associated an interfragmentary screw, presenting a consolidation rate of 92%, and group B, which did not associate an interfragmentary screw, and that presented a union rate of 63%. CONCLUSION: Hallux metatarsophalangeal arthrodesis of the hallux with a dorsal plate and interfragmentary screw show best results regarding consolidation rate and complications compared to those cases in which an interfragmentary screw was not used.

[Translated article] Subtalar dislocations: Analysis of a case series. Our urgent treatment algorithm.

INTRODUCTION AND OBJECTIVES: Subtalar dislocations are a rare entity (<1%) in traumatic foot injuries. There is a loss of anatomical relationship between the talus, calcaneus and scaphoid. There are only small-published series. MATERIAL AND METHODS: We present a series of patients (N=13) with subtalar dislocations in which a descriptive analysis of the main epidemiological, clinical and radiological variables was carried out, from which an urgent treatment algorithm is proposed. Cases with fractures of the neck of the talus, body of the calcaneus, or isolated Chopart fracture-dislocations were excluded. RESULTS: The median age was 48.5 years with a predominance of males (69.23%). Five patients suffered falls or sprained ankles and the other eight suffered high-energy mechanisms. The medial dislocations (nine) predominated over the lateral ones (four). In addition, four patients presented open dislocations, two of them type IIIC that required amputation. CT scans were requested in 76.93% of patients and 10 presented associated bone lesions of the foot. Open reduction surgery was performed in all open lesions and in one case in which closed reduction failed. Five patients required a delta-type external fixator. Subchondral articular sclerosis was observed in 77.77% of cases; although only one required subtalar arthrodesis. CONCLUSIONS: Subtalar dislocations are a traumatic emergency that require early reduction and subsequent immobilisation. Transarticular temporary external fixation is a good immobilisation option in open dislocations. They are serious lesions with a high probability of early osteoarthritis.

Subtalar dislocations: Analysis of a case series. Our urgent treatment algorithm. / Luxaciones periastragalinas: análisis de una serie de casos. Nuestro algoritmo de tratamiento urgente.

INTRODUCTION AND OBJECTIVES: Subtalar dislocations are a rare entity (<1%) in traumatic foot injuries. There is a loss of anatomical relationship between the talus, calcaneus and scaphoid. There are only small-published series. MATERIAL AND METHODS: We present a series of patients (N=13) with subtalar dislocations in which a descriptive analysis of the main epidemiological, clinical and radiological variables was carried out, from which an urgent treatment algorithm is proposed. Cases with fractures of the neck of the talus, body of the calcaneus, or isolated Chopart fracture-dislocations were excluded. RESULTS: The median age was 48.5 years with a predominance of males (69.23%). Five patients suffered falls or sprained ankles and the other eight suffered high-energy mechanisms. The medial dislocations (nine) predominated over the lateral ones (four). In addition, four patients presented open dislocations, two of them type IIIC that required amputation. CT scans were requested in 76.93% of patients and 10 presented associated bone lesions of the foot. Open reduction surgery was performed in all open lesions and in one case in which closed reduction failed. Five patients required a delta-type external fixator. Subchondral articular sclerosis was observed in 77.77% of cases; although only one required subtalar arthrodesis. CONCLUSIONS: Subtalar dislocations are a traumatic emergency that require early reduction and subsequent immobilization. Transarticular temporary external fixation is a good immobilization option in open dislocations. They are serious lesions with a high probability of early osteoarthritis.

Better results in consolidation of hallux metatarsophalangeal arthrodesis with dorsal plate and interfragmentary compression screw. / Mejores resultados en la consolidación de la artrodesis metatarsofalángica del hallux con placa dorsal y tornillo de compresión interfragmentario.

INTRODUCTION AND AIMS: The first metatarsophalangeal joint arthrodesis is indicated for the treatment of various pathologies as a technique to reduce pain and improve the support of the first radius. Numerous surgical techniques and fixation methods have been described, with the combination of a dorsal plate and an interfragmentary screw being the one that has shown to be the most stable construct in biomechanical studies. Our aim is to analyze the radiological results after metatarsophalangeal arthrodesis of the hallux using a dorsal plate associated or not with an interfragmentary screw. The differences in terms of consolidation rates and complications in patients diagnosed with hallux rigidus, hallux valgus, hallux varus and failure of previous surgeries were evaluated. MATERIAL AND METHODS: A retrospective cohort study of 55 patients with a mean age of 65.10 years in whom a dorsal plate was used was performed. Patients were divided into 2 groups depending on whether or not an interfragmentary screw was used. The minimum follow-up was 6 months after surgery. The assessment of the pre and postoperative radiological results was based on the variation of the hallux angle, the intermetatarsal angle and the dorsal metatarsophalangeal angle of the hallux, as well as the cases of nonunion identified in each study group. RESULTS: The radiological results, statistically significant differences (p<0.05) were only found in the dorsal metatarsophalangeal angle between both study groups. No statistically significant differences were found regarding the radiological evaluation of the pre and postoperative hallux angle and intermetatarsal angle. An equal decrease of each angles was observed in both study groups. Regarding the consolidation rate, statistically significant differences (p<0.05) were found between group A, which associated an interfragmentary screw, presenting a consolidation rate of 92%, and group B, which did not associate an interfragmentary screw, and that presented a union rate of 63%. CONCLUSIONS: Hallux metatarsophalangeal arthrodesis of the hallux with a dorsal plate and interfragmentary screw show best results regarding consolidation rate and complications compared to those cases in which an interfragmentary screw was not used.

Results of Transfibular Total Ankle Arthroplasty. A Series of 50 Implants.

Total ankle arthroplasty has become popular in the last few years. The lateral transfibular approach is an alternative to the traditional anterior approach. The purpose of this study was to evaluate our 50 first and consecutive clinical and radiological outcomes of transfibular total ankle replacements (Trabecular Metal Total AnkleR Zimmer Biomet, Warsaw, IN) with a follow-up of at least 3 years. This retrospective study included 50 patients. The main indication was post-traumatic osteoarthritis (n = 41). The mean age was 59 (range = 39-81). All patients were followed for at least 36 months postoperatively. Patients were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score and Visual analog scale (VAS) preoperatively and postoperatively. Range of motion and radiological measures were assessed as well. Postoperatively, patients demonstrated statistically significant improvement in the AOFAS score from 32 (range = 14-46) to 80 (range = 60-100) (p < .01) and VAS from 7.8 (range = 6.1-9.7) to 1.3 (range = 0-6) (p < .01). The average total range of motion increased significantly from 19.8° to 29.2° of plantarflexion and 6.8° to 13.5° of dorsiflexion. Alignment measured by alpha, beta, and gamma angles was satisfactorily achieved. No patient demonstrated any radiographic evidence of tibial or talar lucency at the final follow-up. Five patients (10%) experienced delayed wound healing. One patient (2%) developed a postoperative prosthetic infection. One patient (2%) developed fibular pseudoarthrosis and 2 patients (4%) suffered impingement. Two patients (4%) needed surgery for symptomatic fibular hardware. This study found excellent clinical and radiological results of transfibular total ankle replacement. This is a safe and effective option that allows the correction of sagittal and coronal malalignment.

Surgical treatment at adult acquired flatfoot stage IIB: Spring ligament repair. / Tratamiento quirúrgico del pie plano valgo adquirido del adulto en estadio IIB: papel de la reparación del «spring ligament¼.

BACKGROUND AND AIMS: The spring ligament has paramount role in supporting the arches and its fail causes the collapse of the medial longitudinal arc, inducing adult acquired flatfoot deformity. Our aim was to analyze the clinical and radiological outcomes of spring ligament repair and titanium wedges integration used in surgical osteotomies. MATERIAL AND METHODS: We performed a retrospective study of 23 cases with middle ages of 63, diagnosed with adult acquired flatfoot deformity stage IIB in RAM classification after ortho-prosthetic treatment failure, assessing the functional outcomes using the American Orthopedic Foot and Ankle Society scale and the radiological outcomes studying angles variation (talonavicular uncoverage, talo-first metatarsal angle and Meary axis). RESULTS: The mean preoperative American Orthopedic Foot and Ankle Society score of the sample was 52±10 and the postoperative 88±6 (p<0.05). The radiological outcomes showed a statistically significant improvement. CONCLUSION: Spring ligament repair associated to bone reconstruction offers large functional and radiological outcomes to adult acquired flatfoot deformity stage IIB treatment. Titanium wedges present an excellent bone integration.

[Translated article] Surgical treatment at adult acquired flatfoot stage IIB: Spring ligament repair.

BACKGROUND AND AIMS: The spring ligament has paramount role in supporting the arches and its fail causes the collapse of the medial longitudinal arc, inducing adult acquired flatfoot deformity. Our aim was to analyze the clinical and radiological outcomes of spring ligament repair and titanium wedges integration used in surgical osteotomies. MATERIAL AND METHODS: We performed a retrospective study of 23 cases with middle ages of 63, diagnosed with adult acquired flatfoot deformity stage IIB in RAM classification after ortho-prosthetic treatment failure, assessing the functional outcomes using the American Orthopedic Foot and Ankle Society scale and the radiological outcomes studying angles variation (talonavicular uncoverage, talo-first metatarsal angle and Meary axis). RESULTS: The mean preoperative American Orthopedic Foot and Ankle Society score of the sample was 52±10 and the postoperative 88±6 (p<0.05). The radiological outcomes showed a statistically significant improvement. CONCLUSION: Spring ligament repair associated to bone reconstruction offers large functional and radiological outcomes to adult acquired flatfoot deformity stage IIB treatment. Titanium wedges present an excellent bone integration.

Position statement relating ankle fractures in major outpatient surgery. / Documento de posicionamiento respecto a las fracturas de tobillo en cirugía mayor ambulatoria.

INTRODUCTION: The increase in the prevalence of osteoporosis associated with ageing, and sports and traffic accidents, are responsible for the increase in ankle fractures. This fact emphasises the need to protocolise their care in order to provide greater clinical benefit to patients, and better cost-benefit ratios to the health system. AIM AND METHOD: At present, there is no common framework for implementation of protocols and internal circuits of the Spanish centres for ankle fractures by means of major outpatient surgery (MOS), which is the final objective of this position paper. For this, the clinical and economic evidence of MOS, the local environment and the strategies for its implementation are reviewed, related to ankle fractures. CLINICAL AND ECONOMIC EVIDENCE: The results showed a better cost-benefit ratio in outpatients compared to traditional hospitalisation, with lower complications and readmission rates and therefore significant cost savings. BARRIERS AND STRATEGIES: General and specific barriers are reviewed, as well as strategies and circuits for proper implementation. RESULTS: The results show lower complication and readmission rates together with significant cost savings. It entails a better cost-benefit ratio in outpatient care compared to traditional hospitalisation. POSITION STATEMENT: The implementation of MOS contributes to improve the quality of care, and the satisfaction of both, patient and health care team, while optimising the utilisation of resources. Ankle fractures in patients selected for both the underlying pathology, anaesthetic risk, and the type of fracture can be operated satisfactorily under the MOS.

Cirugía de las hernias: efectividad y coste para el sostenimiento del sistema sanitario / Hernia surgery: effectiveness and cost for the maintenance of the health system

Resumen Introducción: Las hernias son patologías muy frecuentes en un Servicio de Cirugía General (SCG); su tratamiento y costes son muy diferentes, dependiendo del cirujano, si hay hospitalización (CH) o cirugía mayor ambulatoria (CMA). Objetivo principal es el estudio de costes-resultados y de coste-efectividad de las hernias de pared abdominal (no pericolostómicas) realizadas por el SCG. Materiales y Método: Estudio descriptivo, longitudinal, observacional y retrospectivo. Intervenidas 370 hernias de pared abdominal, del 1 de octubre de 2015 al 30 de septiembre de 2016; seguimiento postquirúrgico hasta el 30 de octubre 2016 (1 a 12 meses). Resultados: 79,4% varones, media 59,95 años, 51,90% ASA II, 55,8% anestesia local, 59,72% hernias inguinales, 36,94% hernias inguinales unilaterales indirectas, 55,17 minutos por intervención, 54,44% por CMA, 4,77 días de estancia media en ingresados. Complicaciones perioperatorias 2,3%, tempranas 4,8% (5 reintervenciones) y tardías 12,8% (3 reintervenciones por recidiva). Altas 95,41%, tiempo medio 6,59 semanas. Coste de material de 109,87 € (hernia inguinal simple) hasta 370,41 € (eventración). Coste mediana quirófano 338,80 €. Coste/día CMA 807,30 € y con ingreso 1056,03 €. Mediana coste de hernia inguinal simple 422,69 € y de eventración 709,89 €. Mediana coste por complicación de hernia inguinal 1405,81 € y de eventración 8350,88 €. Mediana coste por proceso con CMA 1213,98 € y con ingreso 3689,80 €. Conclusión: Intervenciones de hernia inguinal unilateral simple, crural y umbilical, con técnica libre de tensión, material protésico, sin drenaje, CMA, anestesia local (con/sin sedación) y sin complicaciones resultan las más coste-efectivas (mejor relación coste-benefcio y coste-efectividad).

Introduction: Hernias are very frequent pathologies in a General Surgery Service (GSS); its treatment and costs are very different, depending on the surgeon, if there is admission (SH) or major outpatient surgery (MOS). A) Main objective. Study costs of (non-pericolostomic) abdominal wall hernia surgical procedures in the GSC (cost-outcome ratio and the cost-efectiveness). Materials and Method: Descriptive, longitudinal, observational and retrospective study. Abdominal wall hernias treated between 1st October, 2015 and 30th September, 2016; after surgery follow up until 30th October, 2016 (1 to 12 months). In total 370 hernia surgeries were performed. Results: 79.4% of males, mean 59.95 years, 51.90% of ASA II, 55.8% local anesthesia, 59.72% inguinal hernias, 36.94% indirect unilateral inguinal hernias, 55.17 minutes for surgeon, 54.44% for MOS, 4.77 days of average stay in admitted patients. Perioperative complications 2.3%, early 4.8% (with 5 reoperations) and late 12.8% (3 reinterventions due to relapse). 95.41% discharge, mean time 6.59 weeks. Material costs vary from €109.87 (simple inguinal hernia) to €370.41 (eventrations). Median surgery room cost €338.80. Cost/day MOS €807.30 and with income €1056.03. Median cost of simple inguinal hernia €422.69 and eventration €709.89. Median cost due to inguinal hernia complication €1405.81 and eventration €8350.88. Median cost per process MOS € 1213.98 and that of SH €3689.80. Conclusion: The interventions of simple unilateral inguinal hernia, crural and umbilical, using a tension-free technique, prosthetic material, without drainage, MOS, local anesthesia (with/without sedation) and without complications are the most cost-efective (better cost-beneft and cost-efectiveness ratio).

Study of the relation between the posterior malleolus fracture and the development of osteoarthritis. / Estudio de la relación de la fractura del maléolo posterior y el desarrollo de artrosis.

BACKGROUND AND AIMS: At least 10% of ankle fractures involve the posterior malleolus of the tibia, which has been related to poorer long-term prognosis. Our aim was to analyse the clinical and functional outcomes of ankle fractures involving the posterior edge, treated surgically without direct reduction of the third malleolus. MATERIAL AND METHODS: We performed a retrospective study of 45 patients aged under 60, who we classified into three groups in terms of the percentage of joint involvement of the posterior fragment (<10%, 10%-25% and >25%) assessing the functional outcomes using the visual analogue pain scale (VAS), the AOFAS scale (American Orthopedic Foot and Ankle Society) of the ankle and hindfoot and the global health questionnaire SF-36; we also analysed the degree of osteoarthritis with weight-bearing radiography, at least one year following the injury. RESULTS: The mean VAS pain score of the sample was 1.1 (0-5) at rest and 3 (0-8) on exercise; 88.4±10.1 on the AOFAS scale, and 68.5±19.3 points on the SF-36. Up to 18% of the patients developed radiographically significant osteoarthritis in the short and medium term (between 12 and 73months, with a mean of 33months). Of the patients, 55.6% had involvement of between 19% and 25% of the joint surface. We found that a larger posterior fragment size related to a greater degree of early-onset osteoarthritis (P<.03) and poorer AOFAS scores (P<.01). CONCLUSION: Ankle fractures involving the posterior malleolus seem to contribute to the development of early-onset osteoarthritis with functional limitation in young adults.

Treatment algorithm for Charcot foot and surgical technique with circular external fixation.

BACKGROUND: Charcot neuroarthropathy (CNA), commonly known as Charcot foot, is one of the most debilitating complications of diabetes mellitus. Patients with plantar ulcer and osteomyelitis (OM) due to Charcot foot represent a high cost for health systems and society in general. The amputation risk for ulcerated Charcot patients is 12 times higher than general population under 65 years old. MATERIAL AND METHODS: In this article we present the CNA treatment protocol we use in our center. We also make a detailed description of the surgical technique «single stage surgery¼ with circular external fixation. RESULTS: Our CNA treatment protocol covers the most common presentations of this severe neuropathic complication. With the «single stage surgery¼ using circular external fi xation we achieve an ulcer-free foot, successful treatment of the OM, correction of the deformity, diminished the cost of treatment, avoided amputation and prevented recurrence of the ulcer. CONCLUSIONS: The use of a treatment algorithm based on the current literature, can be an invaluable tool in the treatment of these complex patients. The circular external fixation has proven to be the only reliable tool for treating complex Charcot foot in the context of poor bone stock, active ulcers, soft tissues problems and OM.

ANTECEDENTES: La neuroartropatía de Charcot, comúnmente llamado «pie de Charcot¼, es una de las complicaciones más incapacitantes de la diabetes mellitus. Los pacientes con úlceras plantares y osteomielitis representan un gasto elevado para los diferentes sistemas de salud y la sociedad en general. El riesgo de amputación en estos pacientes es 12 veces más elevado que en la población general menor de 65 años. MATERIAL Y MÉTODOS: En el presente trabajo mostramos el algoritmo de tratamiento de nuestro centro y también presentamos de manera detallada la técnica quirúrgica de un solo tiempo con fijación externa circular. RESULTADOS: Nuestro algoritmo de tratamiento cubre la mayor parte de las presentaciones clínicas de esta complicación. Con la cirugía en un solo tiempo y el uso de la fijación externa circular se ha logrado desaparecer las úlceras, tratar satisfactoriamente la osteomielitis, corregir la deformidad, disminuir costos, prevenir recurrencias y evitar las amputaciones. CONCLUSIONES: El uso de un algoritmo de tratamiento basado en la literatura actual es de suma utilidad para este grupo de pacientes. La fijación externa circular ha demostrado ser una herramienta confiable en el tratamiento integral de estos casos.

Treatment algorithm for Charcot foot and surgical technique with circular external fixation / Algoritmo de tratamiento para el pie de Charcot y técnica quirúrgica con fijación externa circular

Abstract: Background: Charcot neuroarthropathy (CNA), commonly known as Charcot foot, is one of the most debilitating complications of diabetes mellitus. Patients with plantar ulcer and osteomyelitis (OM) due to Charcot foot represent a high cost for health systems and society in general. The amputation risk for ulcerated Charcot patients is 12 times higher than general population under 65 years old. Material and methods: In this article we present the CNA treatment protocol we use in our center. We also make a detailed description of the surgical technique «single stage surgery¼ with circular external fixation. Results: Our CNA treatment protocol covers the most common presentations of this severe neuropathic complication. With the «single stage surgery¼ using circular external fixation we achieve an ulcer-free foot, successful treatment of the OM, correction of the deformity, diminished the cost of treatment, avoided amputation and prevented recurrence of the ulcer. Conclusions: The use of a treatment algorithm based on the current literature, can be an invaluable tool in the treatment of these complex patients. The circular external fixation has proven to be the only reliable tool for treating complex Charcot foot in the context of poor bone stock, active ulcers, soft tissues problems and OM.

Resumen: Antecedentes: La neuroartropatía de Charcot, comúnmente llamado «pie de Charcot¼, es una de las complicaciones más incapacitantes de la diabetes mellitus. Los pacientes con úlceras plantares y osteomielitis representan un gasto elevado para los diferentes sistemas de salud y la sociedad en general. El riesgo de amputación en estos pacientes es 12 veces más elevado que en la población general menor de 65 años. Material y métodos: En el presente trabajo mostramos el algoritmo de tratamiento de nuestro centro y también presentamos de manera detallada la técnica quirúrgica de un solo tiempo con fijación externa circular. Resultados: Nuestro algoritmo de tratamiento cubre la mayor parte de las presentaciones clínicas de esta complicación. Con la cirugía en un solo tiempo y el uso de la fijación externa circular se ha logrado desaparecer las úlceras, tratar satisfactoriamente la osteomielitis, corregir la deformidad, disminuir costos, prevenir recurrencias y evitar las amputaciones. Conclusiones: El uso de un algoritmo de tratamiento basado en la literatura actual es de suma utilidad para este grupo de pacientes. La fijación externa circular ha demostrado ser una herramienta confiable en el tratamiento integral de estos casos.

Predicting syndesmotic injuries in ankle fractures: a new system based on the medial malleolar focus.

The early establishment of the diagnosis of a syndesmotic injury is essential for treatment selection. However, such injuries may not be apparent radiographically. Previous studies have attempted to describe correlations between medial malleolar fracture geometry and syndesmotic disruption. The main objective of this study was to create predictive models for assessing syndesmotic injuries based on an originally described angle, i.e., the medial crural-focal angle (MCFA). This study included 138 ankle fractures involving the medial malleolus. Any measure from the plain radiograph that could potentially lead to the suspicion of a syndesmotic disruption was recorded, and the newly described MCFA (formed by the main line of the medial malleolus fracture and a line perpendicular to the bearing surface of the tibial plafond) was also recorded. The inter- and intraobserver reliabilities were obtained using Krippendorff's alpha coefficients. To examine the predictive abilities of every parameter, several statistical methods were applied including logistic regression, an ad hoc clinical rule, and discriminant analysis. After variable selection, we obtained the best possible logistic model. The variables that were found to be statistically significant were the MCFA, the tibiofibular clear space (TFCS) and the type of injury in the Lauge-Hansen (L-H) classification. This model was tested by cross validation, which revealed a mean percentage of correctly classified patients of 88%. A simpler and more intuitive alternative model was sought that was based solely on the influences of the MCFA and the TFCS. Our study revealed that an absence of syndesmotic disruptions when the MCFA was under 60°, and there were no uninjured patients with tibiofibular clear space values over 6mm. Cross-validation revealed that the mean percentage of patients who were correctly classified with this model was 86%. The application of discriminant analysis to this combination of variables resulted in a function was able to correctly classify a mean of 84% of patients. In conclusion, three models that can predict syndesmotic injury using parameters from preoperative plain radiographs were obtained and validated. The MCFA measurement was in these models and found to be a reliable technique.