Value of ultrasound and magnetic resonance imaging in the assessment of Achilles tendon healing following percutaneous repair with the Dresden instrument.

BACKGROUND: Percutaneous Achilles tendon (AT) repair with the Dresden instrument is a safe and effective treatment for AT rupture within 15 days after injury. Follow-up includes clinical examination and imaging to assess the healing process and detect possible complications. The findings of each control visit determine the progression of the rehabilitation of each patient. METHODS: We assessed the postoperative findings of all patients who underwent AT with the Dresden technique from May 2022 to September 2023, during a follow-up period of 6 months. The study population included 40 male patients between 18 and 59 years of age. Ultrasound (US) and magnetic resonance imaging (MRI) were performed in all patients at day 15 postoperatively and then monthly for 6 months. RESULTS: All patients completed 6 months follow-up and 2 (5%) presented with postoperative wound dehiscence. No sural nerve lesions, reruptures, reoperations or other complications were seen. Both imaging methods showed excellent correlation of findings at all time points. Both methods were effective to assess the hematoma and structural changes of the healing process during the first 3 months. The use of US with Doppler was a useful tool to evaluate blood flow to the tendon stumps. After 3 months no significant morphological changes were observed but the US enabled a dynamic functional assessment of the tendon. After 4 months tissues showed homogenization and decrease of volume without further major changes. CONCLUSION: Both US and MRI proved to be excellent methods to assess the healing process after percutaneous AT repair. The US performed by an experienced investigator showed advantages over MRI in evaluating the gap between the tendon stumps, the possibility of evaluating the vascularity with Doppler US and assessing the functionality of the healing tendon with dynamic examination, besides being a cheap and easily accessible imaging method.

PATHOPHYSIOLOGY OF POSTTRAUMATIC ANKLE OSTEOARTHRITIS: A MULTICENTER PERSPECTIVE.

Besides the acute injury and trauma-induced macroscopic alterations, the evolution to posttraumatic ankle osteoarthritis (PTOA) is a complex process progressing at the tissue and molecular level. Furthermore, changes in the molecular pathways affect chondrocyte viability. Treatment modalities for PTOA focal or confined disease include innovative techniques. OBJECTIVE: Our purpose is to increase medical awareness based on scientific evidence of pathophysiology, molecular biology, and treatment of post-traumatic ankle osteoarthritis. METHODS: To support the perspectives of the experts, evidence from the scientific literature respected the PRISMA guidelines and the PICOS search strategy was used. We included case-control, cohort, experimental studies and case reports, written in English. RESULTS: The authors were homogeneously exposed to 282 selected abstracts and 114 full articles directly related to post-traumatic osteoarthritis after malleolar fractures. CONCLUSION: The pathophysiological factors involved in posttraumatic ankle osteoarthritis, such as biological, structural, mechanical, and molecular changes must be studied together, as the interaction between these factors determines the risk of progression of PTOA. Inhibition of a single catabolic molecule or cascade probably is not sufficient to alter the natural progression of the pathological process. Evidence level V, expert opinion.

A evolução para a osteoartrite pós-traumática do tornozelo (PTOA) a partir da lesão aguda e das alterações macroscópicas induzidas pelo trauma é um processo complexo, que progride em nível tecidual e molecular. Além disso, as alterações nas vias moleculares afetam a viabilidade dos condrócitos. As modalidades focais ou confinadas de tratamento para PTOA incluem técnicas inovadoras. Objetivo: Nosso objetivo é aumentar a conscientização médica, com base em evidências científicas de fisiopatologia, biologia molecular e tratamento da osteoartrite pós-traumática do tornozelo. Métodos: Para o embasamento das perspectivas dos autores experts, as evidências da literatura científica respeitaram as diretrizes Prisma e a estratégia de busca Picos foi empregada. Incluímos estudos de caso-controle, de coorte, experimentais e relatos de caso, escritos em inglês. Resultados: Os autores foram expostos de forma homogênea a 282 resumos e 114 artigos completos, diretamente relacionados à osteoartrite pós-traumática após fraturas maleolares. Conclusão: Os fatores fisiopatológicos envolvidos na osteoartrite pós-traumática do tornozelo, como alterações biológicas, estruturais, mecânicas e moleculares, devem ser estudados em conjunto, pois a interação entre esses fatores determina o risco de progressão da PTOA. A inibição de uma única molécula catabólica ou cascata provavelmente não é suficiente para alterar a progressão natural do processo patológico. Nível de evidência V, opinião do especialista.

The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II: a prospective study.

PURPOSE: Our objective was to evaluate the syndesmotic and fracture instability using conventional ankle computed tomography (CT) with stress maneuvers. METHODS: A consecutive sample of 123 individuals with an ankle sprain was assessed for eligibility. In total, 33 patients met the inclusion criteria. All patients underwent a magnetic resonance imaging (MRI) and CT scan with stress maneuvers (CTSM). The patterns of ligament tears f were classified using West Point grades I, IIA, IIB, III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. RESULTS: In MRI, two patterns of syndesmotic ligament injury predominated. A completely torn anterior inferior tibiofibular (AITFL) and interosseous tibiofibular ligaments (ITFL) and a completely torn AITFL were combined with a partially torn ITFL. In the neutral phase CTSM and during the stress phase the median difference of the narrowest tibiofibular distance between injured and uninjured syndesmoses was 0.2 mm (P = 0.057) and 2.3 mm (P < 0.0001), respectively. There was no association between the percentage of involvement of the posterior tibial joint surface in the posterior malleolar fracture and syndesmotic instability as measured with CTSM. CONCLUSION: The conventional computed tomography with external rotation and dorsiflexion represents a reproducible and accurate diagnostic option for detecting syndesmosis instability and fracture instability in acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II. LEVEL OF EVIDENCE: Prospective study among consecutive patients (Diagnosis); Level of evidence, 2.

Pathophysiology of posttraumatic ankle osteoarthritis: a multicenter perspective / Fisiopatologia da osteoartrite pós-traumática do tornozelo: perspectiva multicêntrica

ABSTRACT Besides the acute injury and trauma-induced macroscopic alterations, the evolution to posttraumatic ankle osteoarthritis (PTOA) is a complex process progressing at the tissue and molecular level. Furthermore, changes in the molecular pathways affect chondrocyte viability. Treatment modalities for PTOA focal or confined disease include innovative techniques. Objective: Our purpose is to increase medical awareness based on scientific evidence of pathophysiology, molecular biology, and treatment of post-traumatic ankle osteoarthritis. Methods: To support the perspectives of the experts, evidence from the scientific literature respected the PRISMA guidelines and the PICOS search strategy was used. We included case-control, cohort, experimental studies and case reports, written in English. Results: The authors were homogeneously exposed to 282 selected abstracts and 114 full articles directly related to post-traumatic osteoarthritis after malleolar fractures. Conclusion: The pathophysiological factors involved in posttraumatic ankle osteoarthritis, such as biological, structural, mechanical, and molecular changes must be studied together, as the interaction between these factors determines the risk of progression of PTOA. Inhibition of a single catabolic molecule or cascade probably is not sufficient to alter the natural progression of the pathological process. Evidence level V, expert opinion.

RESUMO A evolução para a osteoartrite pós-traumática do tornozelo (PTOA) a partir da lesão aguda e das alterações macroscópicas induzidas pelo trauma é um processo complexo, que progride em nível tecidual e molecular. Além disso, as alterações nas vias moleculares afetam a viabilidade dos condrócitos. As modalidades focais ou confinadas de tratamento para PTOA incluem técnicas inovadoras. Objetivo: Nosso objetivo é aumentar a conscientização médica, com base em evidências científicas de fisiopatologia, biologia molecular e tratamento da osteoartrite pós-traumática do tornozelo. Métodos: Para o embasamento das perspectivas dos autores experts, as evidências da literatura científica respeitaram as diretrizes Prisma e a estratégia de busca Picos foi empregada. Incluímos estudos de caso-controle, de coorte, experimentais e relatos de caso, escritos em inglês. Resultados: Os autores foram expostos de forma homogênea a 282 resumos e 114 artigos completos, diretamente relacionados à osteoartrite pós-traumática após fraturas maleolares. Conclusão: Os fatores fisiopatológicos envolvidos na osteoartrite pós-traumática do tornozelo, como alterações biológicas, estruturais, mecânicas e moleculares, devem ser estudados em conjunto, pois a interação entre esses fatores determina o risco de progressão da PTOA. A inibição de uma única molécula catabólica ou cascata provavelmente não é suficiente para alterar a progressão natural do processo patológico. Nível de evidência V, opinião do especialista.

Staged reconstruction of the hallux for infected non-union using bulk autograft and a customized implant: Case report.

This case report illustrates the outcome of a deep infection following internal fixation of a fracture of the big toe. Hallux amputation could be avoided through staged salvage procedure. This paper can assist readers on how to effectively and safely recognize and treat this type of injury.

Ankle Osteoarthritis.

Osteoarthritis (OA) is characterized by a chronic, progressive and irreversible degradation of the joint surface associated with joint inflammation. The main etiology of ankle OA is post-traumatic and its prevalence is higher among young and obese people. Despite advances in the treatment of fractures around the ankle, the overall risk of developing post-traumatic ankle OA after 20 years is almost 40%, especially in Weber type B and C bimalleolar fractures and in fractures involving the posterior tibial border. In talus fractures, this prevalence approaches 100%, depending on the severity of the lesion and the time of follow-up. In this context, the current understanding of the molecular signaling pathways involved in senescence and chondrocyte apoptosis is fundamental. The treatment of ankle OA is staged and guided by the classification systems and local and patient conditions. The main problems are the limited ability to regenerate articular cartilage, low blood supply, and a shortage of progenitor stem cells. The present update summarizes recent scientific evidence of post-traumatic ankle OA with a major focus on changes of the synovia, cartilage and synovial fluid; as well as the epidemiology, pathophysiology, clinical implications, treatment options and potential targets for therapeutic agents.

Ankle Osteoarthritis / Osteoartrite do tornozelo

Abstract Osteoarthritis (OA) is characterized by a chronic, progressive and irreversible degradation of the joint surface associated with joint inflammation. The main etiology of ankle OA is post-traumatic and its prevalence is higher among young and obese people. Despite advances in the treatment of fractures around the ankle, the overall risk of developing posttraumatic ankle OA after 20 years is almost 40%, especially in Weber type B and C bimalleolar fractures and in fractures involving the posterior tibial border. In talus fractures, this prevalence approaches 100%, depending on the severity of the lesion and the time of follow-up. In this context, the current understanding of the molecular signaling pathways involved in senescence and chondrocyte apoptosis is fundamental. The treatment of ankle OA is staged and guided by the classification systems and local and patient conditions. The main problems are the limited ability to regenerate articular cartilage, low blood supply, and a shortage of progenitor stem cells. The present update summarizes recent scientific evidence of post-traumatic ankle OA with a major focus on changes of the synovia, cartilage and synovial fluid; as well as the epidemiology, pathophysiology, clinical implications, treatment options and potential targets for therapeutic agents.

Resumo A osteoartrite (OA) é caracterizada por uma degradação crônica, progressiva e irreversível da superfície articular, associada a inflamação articular. A principal etiologia da OA do tornozelo é pós-traumática e sua prevalência é maior entre os jovens e obesos. Apesar dos avanços no tratamento das fraturas ao redor do tornozelo, o risco geral de desenvolver OA pós-traumática do tornozelo após 20 anos do trauma é de quase 40%; especialmente nas fraturas bimaleolares de Weber tipo B e C e fraturas envolvendo a borda tibial posterior. Nas fraturas do tálus, essa prevalência se aproxima de 100%, dependendo da gravidade da lesão e do tempo de seguimento. Nesse cenário, é fundamental a compreensão atual das vias de sinalização moleculares envolvidas na senescência e apoptose dos condrócitos. O tratamento da OA do tornozelo é estagiado e guiado pelos sistemas de classificação, condições locais e do paciente. Os principais problemas são a limitada capacidade de regeneração da cartilagem articular, o baixo suprimento de sangue e a escassez de células-tronco progenitoras. A presente atualização resume evidências científicas básicas recentes da OA póstraumática do tornozelo, com foco principal nas alterações metabólicas da sinóvia, da cartilagem e do líquido sinovial. Epidemiologia, fisiopatologia, implicações clínicas, e opções de tratamento são também discutidas.

Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures.

Avulsion fractures of the calcaneal tuberosity represent a rare injury pattern that is caused by a powerful tension force from the Achilles tendon and is usually seen following minor trauma, especially in elderly patients. The objective of this study is to describe a surgical technique using cerclage wiring through cannulated screws in the treatment of extra- and intra-articular avulsion fractures of the calcaneal tuberosity and to present our results in a small patient's cohort. Through a 5.0 cm longitudinal skin incision over the posterolateral aspect of the calcaneus, after adequate debridement of the fracture fragments and while keeping the ankle in plantarflexion, the calcaneal tuberosity is anatomically reduced with the help of a periarticular reduction clamp and an accessory plantar longitudinal approach. Provisionally fixation is performed with K-wires. Definitive fixation is achieved with two parallel partially threaded 7.0 cannulated screws, which are positioned from the superior and posterior aspect of the tuberosity to the inferior and anterior aspect of the plantar surface of the calcaneus, and 1.5 mm cerclage wires that are pulled epiperiosteally to the plantar aspect of the calcaneus to avoid damage to local soft tissues. Alternatively, for smaller fracture fragments, two 3.5 mm partially threaded cannulated screws and 1.25 mm cerclage wires can be used. We also report the results of the procedure in a small cohort of four patients. All fractures healed in an anatomic position. There was no failure of fixation, loss of reduction, or need for secondary surgery, including hardware removal. At final follow-up, all patients had regained full plantar flexion range of motion and strength, with no gait or weight-bearing restrictions. In conclusion, the combination of cerclage wire and large diameter cannulated screws represents a promising option in the treatment of avulsion fractures of the calcaneal tuberosity, demonstrating good functional and radiographic results in our cohort of patients.

Foot and ankle fractures during childhood: review of the literature and scientific evidence for appropriate treatment / Fraturas do tornozelo e do pé na infância: revisão da literatura e evidências científicas para o tratamento adequado

ABSTRACT Foot and ankle fractures represent 12% of all pediatric fractures. Malleolar fractures are the most frequent injuries of the lower limbs. Hindfoot and midfoot fractures are rare, but inadequate treatment for these fractures may results in compartment syndrome, three-dimensional deformities, avascular necrosis and early post-traumatic arthritis, which have a significant impact on overall foot and ankle function. Therefore, the challenges in treating these injuries in children are to achieve adequate diagnosis and precise treatment, while avoiding complications. The objective of the treatment is to restore normal anatomy and the correct articular relationship between the bones in this region. Moreover, the treatment needs to be planned according to articular involvement, lower-limb alignment, ligament stability and age. This article provides a review on this topic and presents the scientific evidence for appropriate treatment of these lesions.

RESUMO As fraturas do tornozelo e do pé representam 12% de todas as fraturas pediátricas. Fraturas maleolares são as lesões mais frequentes dos membros inferiores; fraturas do retropé e mediopé são raras, mas o seu tratamento inadequado pode resultar em síndrome de compartimento, deformidades tridimensionais, necrose avascular e osteoartrose pós-traumática precoce, as quais apresentam impacto significativo na função global do tornozelo e pé. Portanto, os desafios no tratamento dessas lesões na criança são o diagnóstico adequado e tratamento preciso para se evitarem as complicações. O objetivo do tratamento é restaurar a anatomia normal e a relação articular correta entre os ossos da região. Além disso, o tratamento deve ser planejado de acordo com acometimento articular, o alinhamento dos membros inferiores, a estabilidade ligamentar e a idade. O algoritmo de tratamento dos traumas complexos do tornozelo e pé na infância é descrito. Este artigo apresenta uma revisão sobre o tema e as evidências científicas para o tratamento adequado dessas lesões.

NON-UNIONS AFTER FIXATION OF HUMERAL FRACTURES USING HACKETHAL'S BUNDLE NAILING TECHNIQUE

ABSTRACT Objective: The aim of the study was to identify factors contributing to the development of non-union after fixation of diaphyseal humeral fractures using Hackethal's intramedullary nailing technique. Methods: In the time period from 2001 to 2010 156 patients with diaphyseal humeral fractures were treated surgically using Hackethal's technique. Six of them (3.8%) developed non-union. This group included three women and two men aged 63-69 years and one woman aged 37 years. The following parameters of the patients were recorded: age, gender, comorbidities, substance abuse, mechanism of injury, fracture type and location according to the AO/ASIF classification, and the operative technique. Results: A non-union developed in six patients treated with Hackethal´s method (3.8%). Five of six non-unions (83%) were observed in patients in their sixties. In the subgroup of sexagenarians, non-union developed in 20.8% of surgically treated patients, as compared to 3.8 % in entire group. In the union group, fractures have been caused by high energy trauma in 52% of patients. In patients who developed non-union, high energy trauma caused 67% of fractures. With correct surgical technique the development of a non-union was observed in 0.7% of patients, with incorrect technique in 35.7% (p<0.001). Conclusion: Treatment of diaphyseal humeral fractures with Hackethal's intramedullary elastic bundle nailing resulted in an overall high union rate. Factors contributing to the development of non-union were extension of this method to AO type B3 and C fractures and technical imperfection during implantation. Level of Evidence III, Prospective, Case-Control Study.

NON-UNIONS AFTER FIXATION OF HUMERAL FRACTURES USING HACKETHAL'S BUNDLE NAILING TECHNIQUE.

OBJECTIVE: The aim of the study was to identify factors contributing to the development of non-union after fixation of diaphyseal humeral fractures using Hackethal's intramedullary nailing technique. METHODS: In the time period from 2001 to 2010 156 patients with diaphyseal humeral fractures were treated surgically using Hackethal's technique. Six of them (3.8%) developed non-union. This group included three women and two men aged 63-69 years and one woman aged 37 years. The following parameters of the patients were recorded: age, gender, comorbidities, substance abuse, mechanism of injury, fracture type and location according to the AO/ASIF classification, and the operative technique. RESULTS: A non-union developed in six patients treated with Hackethal´s method (3.8%). Five of six non-unions (83%) were observed in patients in their sixties. In the subgroup of sexagenarians, non-union developed in 20.8% of surgically treated patients, as compared to 3.8 % in entire group. In the union group, fractures have been caused by high energy trauma in 52% of patients. In patients who developed non-union, high energy trauma caused 67% of fractures. With correct surgical technique the development of a non-union was observed in 0.7% of patients, with incorrect technique in 35.7% (p<0.001). CONCLUSION: Treatment of diaphyseal humeral fractures with Hackethal's intramedullary elastic bundle nailing resulted in an overall high union rate. Factors contributing to the development of non-union were extension of this method to AO type B3 and C fractures and technical imperfection during implantation. Level of Evidence III, Prospective, Case-Control Study.

Foot and ankle fractures during childhood: review of the literature and scientific evidence for appropriate treatment.

Foot and ankle fractures represent 12% of all pediatric fractures. Malleolar fractures are the most frequent injuries of the lower limbs. Hindfoot and midfoot fractures are rare, but inadequate treatment for these fractures may results in compartment syndrome, three-dimensional deformities, avascular necrosis and early post-traumatic arthritis, which have a significant impact on overall foot and ankle function. Therefore, the challenges in treating these injuries in children are to achieve adequate diagnosis and precise treatment, while avoiding complications. The objective of the treatment is to restore normal anatomy and the correct articular relationship between the bones in this region. Moreover, the treatment needs to be planned according to articular involvement, lower-limb alignment, ligament stability and age. This article provides a review on this topic and presents the scientific evidence for appropriate treatment of these lesions.

As fraturas do tornozelo e do pé representam 12% de todas as fraturas pediátricas. Fraturas maleolares são as lesões mais frequentes dos membros inferiores; fraturas do retropé e mediopé são raras, mas o seu tratamento inadequado pode resultar em síndrome de compartimento, deformidades tridimensionais, necrose avascular e osteoartrose pós-traumática precoce, as quais apresentam impacto significativo na função global do tornozelo e pé. Portanto, os desafios no tratamento dessas lesões na criança são o diagnóstico adequado e tratamento preciso para se evitarem as complicações. O objetivo do tratamento é restaurar a anatomia normal e a relação articular correta entre os ossos da região. Além disso, o tratamento deve ser planejado de acordo com acometimento articular, o alinhamento dos membros inferiores, a estabilidade ligamentar e a idade. O algoritmo de tratamento dos traumas complexos do tornozelo e pé na infância é descrito. Este artigo apresenta uma revisão sobre o tema e as evidências científicas para o tratamento adequado dessas lesões.

Are locking plates better than non-locking plates for treating distal tibial fractures?

BACKGROUND: Locking and non-locking plates has been used for distal tibia fracture osteosynthesis. Sufficient evidence to favor one implant over the other is lacking in the current literature. Our aim is to compare them in terms of fracture healing, alignment, functional outcome, complications. METHODS: Sixty-eight patients operated on using a percutaneous plate were retrospectively reviewed. They were divided into two groups: in group 1 (28 patients) a 4.5mm narrow conventional dynamic compression plate (DCP) was used. In group 2 (40 patients) a titanium locked compression plate (LCP) was used. RESULTS: Mean time to union was 16.2 and 15.4 weeks for group 1 and 2, respectively (p=0.618). 11 patients (39.3%) in group 1 and 4 patients (10%) in group 2 showed malalignment (p=0.016). AOFAS scores at follow up were 89 and 88 in groups 1 and 2, respectively. Implant removal was necessary in 9 cases (32.1%) and 4 cases (10%) in group 1 and group 2, respectively (p=0.042). Three patients (10.7%) in group 1 and three patients (7.5%) in group 2 had an infection. CONCLUSIONS: Both plating systems have similar results in terms of time to union, infection, and AOFAS scores. The LCP seems superior with respect to alignment and the need for implant removal.