Posterior tibialis tendon entrapment as a complication of posterior malleolar fractures in complex ankle fractures.

Aims: Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis. Methods: The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently. Results: Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications. Conclusion: TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity.

A morphological review of medial malleolar fractures - A large single centre series.

BACKGROUND: Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. METHODS: Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records. Retrospective analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. RESULTS: A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). Herscovici type A fractures were significantly more frequently mal-reduced at time of surgery as compared to other fracture types (p = .003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who had been anatomically reduced. CONCLUSION: The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions. LEVEL OF EVIDENCE: Level 3 - Retrospective Cohort Study.

Chopart dislocations: a review of diagnosis, treatment and outcomes.

INTRODUCTION: Chopart injuries can be allocated into 4 broad groups, ligamentous injury with or without dislocation and fracture with or without dislocation, which must occur at the talonavicular joint (TNJ) and/or calcaneocuboid joint (CCJ). Chopart dislocations are comprised of pure-dislocations and fracture-dislocations. We aim to review the literature, to enable evidence-based recommendations. METHODS: A literature search was conducted to identify relevant articles from the electronic databases, PubMed, Medline and Scopus. The PRISMA flow chart was used to scrutinise the search results. Articles were screened by title, abstract and full text to confirm relevance. RESULTS: We identified 58 papers for analysis, 36 case reports, 4 cohort studies, 4 case series and 14 other articles related to the epidemiology, diagnosis, treatment and outcomes of Chopart dislocations. Diagnostic recommendations included routine imaging to contain computed tomography (CT) and routine examination for compartment syndrome. Treatment recommendations included early anatomical reduction, with restoration and maintenance of column length and joint congruency. For both pure-dislocations and fracture-dislocations urgent open reduction and internal fixation (ORIF) provided the most favourable long-term outcomes. CONCLUSIONS: Chopart dislocations are a complex heterogenous midfoot injury with historically poor outcomes. There is a relative paucity of research discussing these injuries. We have offered evidence-based recommendations related to the clinical and surgical management of these rare pathologies.

Tibialis posterior tendon entrapment in posterior malleolar and pilon injuries of the ankle: a retrospective analysis.

BACKGROUND: The Tibialis Posterior tendon (TPT) is the only tendon to encounter the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle, they often have been missed and present late. AIM: Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia, i.e. Pilon (PLM) and posterior malleolar fractures (PMF). METHODS: A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site, this was denoted as a minor entrapment and if ≥ 50% of the tendon was present in the fracture site was denoted as major. RESULTS: A total of 363 patients were identified for further analysis, 220 who had a PMF and 143 with PLM injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture line entered the TPT sheath, there was a 45% rate (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath (p < .001). There was no significant difference in TPT entrapment in PMF as compared to PML (p = 0.353). CONCLUSION: In our assessment, we found significant prevalence of 22% of TPT entrapment in fractures involving the posterior tibia. PMF and PLF had no statistically significant difference in the rate of TPT entrapment. Additionally, we found that there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider taking care assessing pre-operative imaging to seek to identify the TPT and to assess intraoperatively where entrapment does occur.

A Breast Cancer Image Classification Algorithm with 2c Multiclass Support Vector Machine.

Breast cancer is the most frequent type of cancer in women; however, early identification has reduced the mortality rate associated with the condition. Studies have demonstrated that the earlier this sickness is detected by mammography, the lower the death rate. Breast mammography is a critical technique in the early identification of breast cancer since it can detect abnormalities in the breast months or years before a patient is aware of the presence of such abnormalities. Mammography is a type of breast scanning used in medical imaging that involves using x-rays to image the breasts. It is a method that produces high-resolution digital pictures of the breasts known as mammography. Immediately following the capture of digital images and transmission of those images to a piece of high-tech digital mammography equipment, our radiologists evaluate the photos to establish the specific position and degree of the sickness in the breast. When compared to the many classifiers typically used in the literature, the suggested Multiclass Support Vector Machine (MSVM) approach produces promising results, according to the authors. This method may pave the way for developing more advanced statistical characteristics based on most cancer prognostic models shortly. It is demonstrated in this paper that the suggested 2C algorithm with MSVM outperforms a decision tree model in terms of accuracy, which follows prior findings. According to our findings, new screening mammography technologies can increase the accuracy and accessibility of screening mammography around the world.

Sternal fractures and thoracic injury: an analysis of 288 sternal fractures attending a major trauma centre.

INTRODUCTION: Sternal fractures (SF) are uncommon injuries usually associated with a significant mechanism of injury. Concomitant injury is likely, and a risk of mortality is substantial. AIM: Our aim in this study was to identify the risk factors for mortality in patients who had sustained sternal fractures. METHODS: We conducted a single centre retrospective review of the trust's Trauma Audit and Research Network Database, from May 2014 to July 2021. Our inclusion criteria were any patients who had sustained a sternal fracture. The regions of injury were defined using the Abbreviated Injury Score. Pearson Chi-Squared, Fisher Exact tests and multivariate regression analyses were performed using IBM SPSS. RESULTS: A total of 249 patients were identified to have sustained a SF. There were 19 patients (7.63%) who had died. The most common concomitant injuries with SF were Rib fractures (56%), Lung Contusions (31.15%) and Haemothorax (21.88%). There was a significant increase in age (59.93 vs 70.06, p = .037) and admission troponin (36.34 vs. 100.50, p = .003) in those who died. There was a significantly lower GCS in those who died (10.05 vs. 14.01, p < .001). On multi regression analysis, bilateral rib injury (p = 0.037, OR 1.104) was the only nominal variable which showed significance in mortality. CONCLUSION: Sternal Fractures are uncommon but serious injuries. Our review has identified that bilateral rib injuries, increase in age, low GCS, and high admission troponin in the context of SF, were associated with mortality.