Current Concepts on Subtalar Instability.

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Missed Tillaux Fracture and Syndesmosis Injury in Adult: Arthroscopic Assisted Reduction and Fixation.

Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Missed Tillaux Fracture and Syndesmosis Injury in Adult: Arthroscopic Assisted Reduction and Fixation / Fratura de Tillaux não percebida e lesão por sindesmose em adultos: Redução e fixação artroscópica assistida

Abstract Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Resumo As fraturas de Tillaux são fraturas da margem lateral da tíbia distal, geralmente relatadas em crianças entre 12 e 14 anos. Como fraturas intra-articulares, requerem redução e fixação anatômica para evitar complicações pós-traumáticas. Como o mecanismo de lesão é a rotação externa do pé na perna, essas lesões são comumente associadas a outras fraturas ou lesões ligamentares. Atualmente, a artroscopia está sendo cada vez mais utilizada para auxiliar e melhorar o tratamento cirúrgico das fraturas do tornozelo. Os autores descrevem um acompanhamento de 12 meses de um caso raro de uma fratura não percebida de Tillaux associada a lesão por sindesmose em um paciente de politrauma com 76 anos de idade, tratado com sucesso por redução e fixação interna assistida por artroscopia.

The calcaneofibular ligament has distinct anatomic morphological variants: an anatomical cadaveric study.

PURPOSE: The purpose of this study was to investigate if the calcaneofibular ligament (CFL) presents morphologic variants and measure the morphometrics of the ligament and its footprints METHODS: An anatomical study of 47 fresh-frozen below-the-knee ankle specimens was performed. Lateral ankle structures were dissected to expose the CFL. Overdissection was avoided to not modify the native morphology. The morphology (number and orientation of CFL bundles) and measurements of CFL insertions were recorded with ankle secured in neutral position. RESULTS: Four distinct morphological-oriented shapes of the CFL were observed. These included single bundle, Y-shape double bundle, V-shape double bundle, and associated with the lateral talocalcaneal ligament. The most frequent CFL morphology observed was the single bundle and the Y-shape double bundle, present in 21 (44.7%) and 13 (27.7%) ankles. The V-shape double bundle and the CFL double bundle associated with the lateral talocalcaneal ligaments were less common, appearing only in eight (17.0%) and five (10.6%) ankles. The CFL length was higher in single bundle and Y-shaped double bundle CFL variants, about 30 mm each. Footprint morphometrics were heterogenous amongst the different CFL variants. CONCLUSION: The CFL presents four distinct morphological-oriented shapes. The double bundle, V-shaped and Y-shaped CFL variants are uncommon and poorly reported in the literature. Their relation to the lateral talocalcaneal ligament and the inferior fascicle of the anterior talofibular ligament requires further research. The CFL morphology provides detailed knowledge of CFL anatomy that can improve diagnostic procedures. Furthermore, this information can fine-tune graft selection and sizing and allow a more precise anatomic placement during surgical reconstruction.

The distance from the peroneal tendons sheath to the sural nerve at the posterior tip of the fibula decreases from proximal to distal.

PURPOSE: The aim of this study is to compare the distance from the peroneal tendons sheath to the sural nerve in different points proximally and distally to the tip of the fibula. METHODS: Ten fresh-frozen lower extremities were dissected to expose the nerves and tendons. Having the posterior tip of the fibula as a reference, the distance between the tendons sheath and the sural nerve was measured in each point with a tachometer with three independent different observers. Two measures were taken distally at 1.5 and 2 cm from fibula tip and 3 measures were performed proximally at 2, 3, and 5 cm from fibula tip. Data were described using means, standard deviations, medians, and minimum and maximum values. RESULTS: The average distance between distance between the fibula tip and sural nerve is 16.6 ± 4.4 mm. The average distance between peroneal tendons sheath and the sural nerve at 5 cm, 3 cm, and 2 cm from the proximal fibular tip was 29.6 ± 3.2 mm, 24.2 ± 3.6 mm, and 19.7 ± 2.7 mm, respectively. The average distance between the peroneal tendons sheath and the sural nerve at 2 cm and 1.5 cm distal to fibular tip was 9.1 ± 3.5 mm and 7.8 ± 3.3 mm, respectively. CONCLUSION: The distance from the peroneal tendons sheath to the sural nerve decreases from proximal to distal. As the distance between the peroneal tendons sheath and the sural nerve decreases from proximal to distal, performing the tendoscopy portal more distally would increase the risk of nerve iatrogenic injury.

Percutaneous Osteotomies in Hallux Valgus: A Systematic Review.

Percutaneous and minimally invasive surgery is one of the greatest advances in the operating field of orthopedic since the late 1990s. The potential advantages include a shorter operative time, quicker recovery, and reduced hospital stay compared with traditional open surgery. However, scientific validation of the safety and efficacy of hallux valgus (HV) percutaneous surgery remains inconclusive. The objective of the present study was to systematically review the published data and clinical evidence for percutaneous HV surgery, evaluate the scientific method of the reports, and clarify the indications, safety, efficacy, and potential risks of these surgical techniques. Two reviewers independently identified the studies using a PubMed search, with the keywords "hallux valgus," "osteotomy," "minimally invasive," and "percutaneous." Quality assessment was performed using the Coleman methodology scale, and each study was assigned a level of evidence and grade of recommendation. Eighteen studies were included and reported a total of 1534 procedures for percutaneous HV surgery on 1397 patients. Of the 18 studies, 14 (77.8%) were level IV, 2 (11.1%) were level III, and 2 (11.1%) were level II. Overall, the average angle correction of the HV deformity improved postoperatively. Regarding the complications, although some investigators revealed no major complications, others described deformity recurrence in 7.8%, stiffness of the first metatarsophalangeal joint in 9.8%, malunion in 4% to 8.7%, and infection rates ranging from 1.9% to 14.3%. The main indication for percutaneous HV surgery is the correction of mild deformities. The complication rate was elevated even in experienced surgeons. In conclusion, future research in percutaneous techniques should include adequately sized randomized control trials, standardization of treatment protocols, and the use of validated tools for the measurement of clinical outcomes.

Guidelines for the management of neuroendocrine tumours by the Brazilian gastrointestinal tumour group.

Neuroendocrine tumours are a heterogeneous group of diseases with a significant variety of diagnostic tests and treatment modalities. Guidelines were developed by North American and European groups to recommend their best management. However, local particularities and relativisms found worldwide led us to create Brazilian guidelines. Our consensus considered the best feasible strategies in an environment involving more limited resources. We believe that our recommendations may be extended to other countries with similar economic standards.

Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study.

PURPOSE: The purpose of this study was to determine the clinical utility of three bony tubercles: fibular obscure tubercle, talar obscure tubercle and tuberculum ligamenti calcaneofibularis, to serve as anatomical landmarks for defining the precise location of the origins and insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). METHODS: Twelve lower extremity cadaveric specimens were procured. The detectability of the tubercles was tested using palpation and fluoroscopy with subsequent confirmation after dissection. If the tubercles were present, then distances from the identified tubercles to the footprint centres and the intersection of the ATFL and CFL were measured to allow precise localization of the ATFL and CFL origin and intersection sites. Further, if the tubercles were not detectable, then an attempt to provide an alternative means of localizing ATFL and CFL origin and insertion sites was made by measuring distances between alternative landmarks and other important structures. All the measurements were performed by two researchers, and the results were averaged. RESULTS: The fibular obscure tubercle existed and was detectable in all specimens. It was located 1.3 mm proximal to the articular tip of the fibula, 2.7 mm to the intersection of the ATFL and CFL, 3.7 mm distal to the ATFL and 4.9 mm proximal to the CFL origins. The talar obscure tubercle existed 58 % of specimens and was detectable in 57 %. The talar obscure tubercle was located 1.4 mm to the ATFL. The ATFL insertion point was located 60 % of the distance from the inferolateral corner to the anterolateral corner of the of talar body along the anterior border of the talar lateral articular facet. The tuberculum ligamenti calcaneofibularis existed in 33 % of specimens and was detectable in 8 %. The CFL inserted 17 mm on a perpendicular projected line distal from the subtalar joint. CONCLUSIONS: The fibular obscure tubercle was clinically relevant and reliable bony landmark of the ATFL and CFL origin location. However, the talar obscure tubercle was less reliable and the tuberculum ligamenti calcaneofibularis was rarely available and as such alternative landmarks for the ATFL and CFL insertion location should be utilized. The present study describes the utility of clinically relevant bony landmarks that may assist in identifying the origins and insertions of the ATFL and CFL to facilitate minimally invasive ankle stabilization surgery.

Long-term Follow-up of Dorsal Wedge Osteotomy for Pediatric Freiberg Disease.

BACKGROUND: Treatment for Freiberg disease has been largely conservative despite availability of various operative options for severe or refractory cases. The aim of this study was to evaluate the long-term results of pediatric patients with symptomatic Freiberg disease treated with intra-articular dorsal wedge osteotomy. METHODS: Pediatric patients treated for Freiberg disease with surgery between January 1982 and 1999 were identified and selected for long-term clinical evaluation. Patients were evaluated regarding operative satisfaction and clinical outcome, performed according to the American Orthopaedic Foot & Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal scale and range of motion (ROM) of metatarsophalangeal (MTP) joint. Patients had radiographic assessment of degenerative joint status with anteroposterior and oblique foot x-ray. Twenty patients (18 female, 2 male; mean age 15.2 years; range 12-17 years) were identified. The mean follow-up period was 23.4 (range 15-32) years. RESULTS: The clinical outcomes of our patients were classified as excellent in 16 (80%) and good in 4 (20%). The AOFAS mean score was 96.8 (range 91-100) points at the last clinical appointment. A negative correlation between AOFAS score and time of follow-up (r's = -0.61, P < .001) was found. Also, a strong negative correlation was found between Smillie classification and AOFAS final score (r's = -0.88, P < .001). CONCLUSION: The patients were very satisfied with pain and quality of life at a mean follow-up time of 23.4 years. To our knowledge, this is the first long-term follow-up report supporting the procedure described by Gauthier and Elbaz as a good option for operative treatment of Freiberg disease. LEVEL OF EVIDENCE: Level IV, retrospective case series.