[Calcaneal fractures: controversies and consensus]. / Fracturas de calcáneo: controversias y consensos.

Calcaneal fractures are the most common tarsal fractures and their treatment is still debated today. We intend in this update to highlight the points of controversy and clarify the consensus, especially in the treatment of intra-articular fractures, as well as to describe the management of major complications.

Las fracturas de calcáneo son las más frecuentes del tarso y su tratamiento sigue siendo hoy en día objeto de debate. Pretendemos en esta actualización destacar los puntos de controversia, así como clarificar los consensos, especialmente en el tratamiento de las fracturas intraarticulares, así como describir el manejo de las principales complicaciones.

Fracturas de calcáneo: controversias y consensos / Calcaneal fractures: controversies and consensus

Resumen: Las fracturas de calcáneo son las más frecuentes del tarso y su tratamiento sigue siendo hoy en día objeto de debate. Pretendemos en esta actualización destacar los puntos de controversia, así como clarificar los consensos, especialmente en el tratamiento de las fracturas intraarticulares, así como describir el manejo de las principales complicaciones.

Abstract: Calcaneal fractures are the most common tarsal fractures and their treatment is still debated today. We intend in this update to highlight the points of controversy and clarify the consensus, especially in the treatment of intra-articular fractures, as well as to describe the management of major complications.

[Aseptic loosening of total ankle replacement : Two-stage revision with bone augmentation of osseous defects and secondary prosthesis implantation]. / Aseptische Lockerung einer OSG-Endoprothese : Zweizeitiger Wechsel mit Knochenaugmentation ossärer Defekte und sekundärer Reimplantation.

OBJECTIVE: To remove loosened ankle prosthesis components, perform osseous defect augmentation, and reimplant definitive prosthesis components to preserve ankle range of motion. INDICATIONS: Aseptic loosening of the tibial and/or talar ankle prosthesis components with substantial bone defect. CONTRAINDICATIONS: General surgical/anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy, substantial nonreconstructable osseous defects with or without cysts on the tibial and/or talar side, noncompliance, primary total ankle replacement (TAR) using intramedullary fixation (stem fixation), severely reduced bone quality, insulin-dependent diabetes mellitus, smoking, unrealistic patients' expectations, high activity in sports. SURGICAL TECHNIQUE: Exposure of the ankle joint using the previous incision. Mobilization and removal of loosened prosthesis components. Debridement of bone stock. Assessment and measurement of osseous defects. Harvesting of iliac crest autograft. Screw fixation of iliac crest autograft. Placement of polyethylene inlay as a spacer. Wound closure in layers at the ankle and the iliac crest. Implantation of definitive prosthesis components. POSTOPERATIVE MANAGEMENT: A soft wound dressing. Thromboprophylaxis recommended. Mobilization on postoperative day 1 using a stabilizing walking boot/cast for 6 weeks (sole contact but no weight bearing). Clinical and radiographic follow-up 3 months postoperatively including computed tomography to assess osseous consolidation. After the second surgery, patient mobilization on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot/cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually. RESULTS: From January 2007 to December 2012, a two-stage revision TAR was performed in 5 patients (46.8 and 71.4 years). The time between the initial TAR and revision was 2.4-11.5 years. No intra-/perioperative complications. Substantial pain relief in all patients. Comparable preoperative and postoperative ankle range of motion.

[Supramalleolar osteotomy in asymmetric ankle osteoarthritis : Short-term clinical and radiographic results]. / Supramalleolare Osteotomie bei asymmetrischer Arthrose des oberen Sprunggelenks : Kurzfristige klinische und radiologische Ergebnisse.

BACKGROUND: The main indication for the supramalleolar osteotomy is asymmetric ankle osteoarthritis with concomitant supramalleolar valgus or varus deformity. The aim of this prospective study was to analyze short-term clinical and radiographic outcomes in patients with asymmetric ankle osteoarthritis. METHODS: A total of 16 patients with asymmetric ankle osteoarthritis and concomitant supramalleolar deformity - 7 patients with valgus deformity, 9 patients with varus deformity - were treated. Intraoperative and postoperative complications were recorded and analyzed. The clinical and radiographic outcomes were assessed after a mean follow-up of 3.6 ± 1.1 years. RESULTS: In 10 of 16 patients, removal of hardware was performed. The AOFAS hindfoot score increased significantly after surgery. All categories of the SF-36 score showed significant improvement. The average range of motion also increased significantly. Radiographic assessment showed neutral hindfoot alignment at the latest follow-up. The postoperative clinical outcomes were comparable in both patient groups. The time until complete osseous union was significantly longer in patients with opening wedge osteotomy. CONCLUSION: This prospective study demonstrated encouraging short-term results in patients with asymmetric ankle osteoarthritis who underwent supramalleolar osteotomy. In progressive ankle osteoarthritis, joint-nonpreserving treatment options including total ankle replacement or ankle arthrodesis should be discussed.

Joint instability leads to long-term alterations to knee synovium and osteoarthritis in a rabbit model.

OBJECTIVES: Joint instability is believed to promote early osteoarthritic changes in the knee. Inflammatory reactions are associated with cartilage degradation in osteoarthritis (OA) but their possible synergistic or additive effects remain largely unexplored. The goal of the present study was to investigate the in vivo effects of Botulinum Toxin A (BTX-A) induced joint instability on intraarticular alterations in an otherwise intact rabbit knee joint model. METHODS: Ten 1-year-old female New Zealand White rabbits (average 5.7 kg, range 4.8-6.6 kg) were randomly assigned to receive three monthly unilateral intramuscular injections of BTX-A (experimental group), or no treatment (control group). After 90 days, all knees were analyzed for specific mRNA levels using RT-qPCR. The synovium and cartilage tissue was assessed for histological alterations using the OARSI scoring system. RESULTS: Cartilage and synovial histology showed significant higher OARSI scores in the BTX-A group animals compared to the untreated controls and contralateral limbs. There were no differences between the untreated control and the contralateral experimental limbs. Gene expression showed significant elevations for collagen I, collagen III, nitric oxide, TGF-ß, IL-1 and IL-6 compared to the healthy controls. CONCLUSION: BTX-A induced joint instability in a muscle weakness model uniquely leads to alterations in gene expression and histological changes in the synovial membranes and cartilage in otherwise intact knee joints. These results lead to the conclusion that joint instability may promote an inflammatory intraarticular milieu, thereby contributing to the development of OA.

Termoablación por radiofrecuencia de osteomas osteoides del extremo proximal del fémur. Utilidad de la ecografía en casos seleccionados / Radiofrequency thermal ablation of osteoid osteomas of the proximal femur. Usefulness of ultrasound guidance in selected cases

Objetivo. Repasar la sintomatología y los hallazgos de imagen de los osteomas osteoides (OO) del extremo proximal del fémur, analizar los resultados de la técnica de la termoablación del nidus con ondas de radiofrecuencia en esa localización y describir la utilidad de la ecografía en la realización de la técnica en casos seleccionados. Material y método. Estudio descriptivo retrospectivo de una serie de 8 pacientes con OO del extremo proximal del fémur tratados mediante termoablación del nidus con ondas de radiofrecuencia desde 1998 hasta 2014. Resultados. El tiempo medio de evolución del dolor hasta la termoablación fue de 11,5 meses (rango: 5-18 meses). No hubo ninguna complicación y todos los pacientes refirieron la desaparición del dolor al día siguiente del procedimiento, con molestias que desaparecieron en la primera semana, salvo en uno, que se prolongaron más de un mes por la dificultad de la técnica. En la actualidad, con un seguimiento medio de 6 años y 2 meses (rango: 6-190 meses), todos los pacientes siguen asintomáticos y realizan una vida rigurosamente normal. Discusión. La termoablación con ondas de radiofrecuencia guiada por TC es un procedimiento seguro, eficaz y eficiente. Conclusiones. La presentación habitual de un OO del extremo proximal del fémur no difiere significativamente de la de un OO de otra localización y el diagnóstico es fácil cuando aquella se conoce. La termoablación del nidus con ondas de radiofrecuencia, que en casos seleccionados podría ayudarse de la ecografía para situar el electrodo en el centro del nidus, nos parece el tratamiento de elección por su eficacia y mínima morbilidad (AU)

Purpose. To review symptoms and imaging findings of proximal femoral osteoid osteomas (OO); to analyse the results of a thermal ablation technique for radiofrequency of the nidus in this location; and to describe usefulness of ultrasound guidance in selected cases. Material and method. Descriptive and retrospective study consisting of 8 patients with OO in the proximal epiphysis of the femur, which were treated by thermal ablation of the nidus with radiofrequency waves from 1998 to 2004. Results. The mean pain period until the performance of the thermal ablation was 11.5 months (range 5-18 months). There were no complications, and all patients stated that the pain was gone by the day following the procedure, with some discomfort during the first week, except for one where it lasted more than one month due to technique difficulties. At present, with a mean follow up of 6 years and 2 months (range 6-190 months), all patients remain asymptomatic and live a rigorous normal life. Discussion. Thermal ablation with CT-guided radiofrequency waves is a safe, effective and efficient procedure. Conclusion. Normal appearance of a proximal femoral OO does not differ significantly from other location osteomas and its diagnosis is easier with previous knowledge. Thermal ablation of the nidus with radiofrequency waves, that may be performed using ultrasound guidance, appears to be the elective treatment of choice due to its efficiency and minimum morbidity (AU)

[Dwyer osteotomy : Lateral sliding osteotomy of calcaneus]. / Dwyer-Osteotomie : Laterale Verschiebeosteotomie des Kalkaneus.

OBJECTIVE: To correct the underlying inframalleolar varus deformity and to restore physiologic biomechanics of the hindfoot. INDICATIONS: Neurologic, posttraumatic, congenital, and idiopathic cavovarus deformity. In patients with end-stage ankle osteoarthritis with varus heel malposition as additional single-stage procedure complementing total ankle replacement. Severe peroneal tendinopathy with concomitant cavovarus deformity. CONTRAINDICATIONS: General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g., Charcot arthropathy), end-stage osteoarthritis of the subtalar joint, severely reduced bone quality, high age, insulin-dependent diabetes mellitus, smoking. SURGICAL TECHNIQUE: The lateral calcaneus cortex is exposed using a lateral incision. The osteotomy is performed through an oscillating saw. The posterior osteotomy fragment is manually mobilized and shifted laterally. If needed, a laterally based wedge can be removed and/or the osteotomy fragment can be translated cranially. The osteotomy is stabilized with two cannulated screws, followed by wound closure. POSTOPERATIVE MANAGEMENT: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated step by step. RESULTS: Between January 2009 and June 2013, a Dwyer osteotomy was performed in 31 patients with a mean age of 45.7 ± 16.3 years (range 21.5-77.4 years). All patients had a substantial inframalleolar cavovarus deformity with preoperative moment arm of the calcaneus of -17.9 ± 3.3 mm (range -22.5 to -10.5 mm), which has been improved significantly to 1.6 ± 5.9 mm (range -16.9 to 9.9 mm). Significant pain relief from 6.3 ± 1.9 (range 4-10) to 1.1 ± 1.1 (range 0-4) using the visual analogue scale was observed. The American Orthopaedic Foot and Ankle Society score significantly improved from 33.1 ± 14.2 (range 10-60) to 78.0 ± 10.5 (range 55-95).

[Total ankle replacement in patients with bleeding disorders]. / Endoprothetischer Ersatz des oberen Sprunggelenks bei Patienten mit Gerinnungsstörungen.

BACKGROUND: Total ankle replacement (TAR) is a well-accepted treatment option in patients with end-stage ankle osteoarthritis. However, published literature on patients with bleeding disorders treated with TAR is limited. Therefore, we carried out this prospective study to analyze mid-term postoperative results in patients with bleeding disorders treated by TAR. METHODS: A total of 34 patients with end-stage ankle osteoarthritis--14 patients with hemophilia type A and 20 patients with von Willebrand disease (VWD)--treated by TAR were included in this prospective study. The mean age of patients was 46.0 ± 9.0 years. Intraoperative and postoperative complications were recorded. The postoperative pain relief and functional results including range of motion (ROM) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were assessed after a mean follow-up of 6.3 ± 3.4 years. Additionally, the quality of life was analyzed using the SF-36 questionnaire. The alignment of prosthesis components was assessed using weight-bearing conventional radiographs. The results were compared with those obtained in the control group, including 72 and 33 patients with post-traumatic and rheumatoid ankle osteoarthritis respectively. RESULTS: One patient sustained an intraoperative medial malleolar fracture. In total, three revision surgeries were necessary in our patient cohort. There was significant pain relief from 8.2 ± 0.8 to 0.9 ± 1.0, as assessed using a visual analog scale. All categories of the SF-36 score showed significant improvement. The average ROM increased from 20.1° ± 6.9° to 27.5° ± 7.4°. The AOFAS hindfoot score increased from 34.5 ± 10.0 to 82.4 ± 10.2 of a maximum of 100 points. Radiographic assessment showed the neutral alignment of prosthesis components in all patients. The postoperative clinical and radiographic outcomes were comparable in both patients with hemophilia and those with VWD. Patients with bleeding disorders had significantly higher pain relief and significantly lower ROM than the patients in the control group with ankle osteoarthritis of post-traumatic or rheumatoid etiology. CONCLUSION: Our prospective study revealed encouraging mid-term outcomes after TAR in patients with bleeding disorders. However, this surgery should be limited to highly experienced foot and ankle surgeons. Furthermore, this patient cohort requires a multidisciplinary approach to ensure a good outcome.

Total ankle replacement in patients with von Willebrand disease: mid-term results of 18 procedures.

von Willebrand disease (VWD) is a recognized cause of secondary ankle osteoarthritis (OA). Few studies have examined orthopaedic complications and outcomes in VWD patients treated for end-stage ankle OA with total ankle replacement (TAR). To determine the clinical presentation, intraoperative and postoperative complications and evaluate the mid-term outcome in VWD patients treated with TAR. Eighteen patients with VWD with mean age 47.3 years (range = 34.0-68.7) were treated for end-stage ankle OA with TAR. The mean duration of follow-up was 7.5 years (range = 2.9-13.2). Intraoperative and perioperative complications were recorded. Component stability was assessed with weight-bearing radiographs. Clinical evaluation included range of motion (ROM) tests using a goniometer and under fluoroscopy using a lateral view. Clinical outcomes were analysed by a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score and Short Form (36) Health Survey (SF-36) health survey. One patient sustained an intraoperative medial malleolar fracture. In two patients delayed wound healing was observed. Two secondary major surgeries were performed. Pain level decreased from 8.2 ± 0.9 (range = 7-10) preoperatively to 1.1 ± 1.2 (range = 0-4) postoperatively. Significant functional improvement including ROM was observed. All categories of SF-36 score showed significant improvement in quality of life. Mid-term results of TAR in patients with VWD are encouraging. The total rate of intraoperative and postoperative complications was 33.3%. However, longer term outcomes are necessary to fully understand the clinical benefit of TAR in patients with VWD.

Characterization of the collagen component of cartilage repair tissue of the talus with quantitative MRI: comparison of T2 relaxation time measurements with a diffusion-weighted double-echo steady-state sequence (dwDESS).

OBJECTIVES: The purpose of this study was to characterize the collagen component of repair tissue (RT) of the talus after autologous matrix-induced chondrogenesis (AMIC) using quantitative T2 and diffusion-weighted imaging. METHODS: Mean T2 values and diffusion coefficients of AMIC-RT and normal cartilage of the talus of 25 patients with posttraumatic osteochondral lesions and AMIC repair were compared in a cross-sectional design using partially spoiled steady-state free precession (pSSFP) for T2 quantification, and diffusion-weighted double-echo steady-state (dwDESS) for diffusion measurement. RT and cartilage were graded with modified Noyes and MOCART scores on morphological sequences. An association between follow-up interval and quantitative MRI measures was assessed using multivariate regression, after stratifying the cohort according to time interval between surgery and MRI. RESULTS: Mean T2 of the AMIC-RT and cartilage were 43.1 ms and 39.1 ms, respectively (p = 0.26). Mean diffusivity of the RT (1.76 µm(2)/ms) was significantly higher compared to normal cartilage (1.46 µm(2)/ms) (p = 0.0092). No correlation was found between morphological and quantitative parameters. RT diffusivity was lowest in the subgroup with follow-up >28 months (p = 0.027). CONCLUSIONS: Compared to T2-mapping, dwDESS demonstrated greater sensitivity in detecting differences in the collagen matrix between AMIC-RT and cartilage. Decreased diffusivity in patients with longer follow-up times may indicate an increased matrix organization of RT. KEY POINTS: • MRI is used to assess morphology of the repair tissue during follow-up. • Quantitative MRI allows an estimation of biochemical properties of the repair tissue. • Differences between repair tissue and cartilage were more significant with dwDESS than T2 mapping.

Radiofrequency thermal ablation of osteoid osteomas of the proximal femur. Usefulness of ultrasound guidance in selected cases.

PURPOSE: To review symptoms and imaging findings of proximal femoral osteoid osteomas (OO); to analyse the results of a thermal ablation technique for radiofrequency of the nidus in this location; and to describe usefulness of ultrasound guidance in selected cases. MATERIAL AND METHOD: Descriptive and retrospective study consisting of 8 patients with OO in the proximal epiphysis of the femur, which were treated by thermal ablation of the nidus with radiofrequency waves from 1998 to 2004. RESULTS: The mean pain period until the performance of the thermal ablation was 11.5 months (range 5-18 months). There were no complications, and all patients stated that the pain was gone by the day following the procedure, with some discomfort during the first week, except for one where it lasted more than one month due to technique difficulties. At present, with a mean follow up of 6 years and 2 months (range 6-190 months), all patients remain asymptomatic and live a rigorous normal life. DISCUSSION: Thermal ablation with CT-guided radiofrequency waves is a safe, effective and efficient procedure. CONCLUSION: Normal appearance of a proximal femoral OO does not differ significantly from other location osteomas and its diagnosis is easier with previous knowledge. Thermal ablation of the nidus with radiofrequency waves, that may be performed using ultrasound guidance, appears to be the elective treatment of choice due to its efficiency and minimum morbidity.

Propuesta de algoritmo global de tratamiento del hallux rigidus según la medicina basada en la evidencia / Proposed global treatment algorithm for hallux rigidus according to evidence-based medicine

Introducción. El hallux rigidus es la artrosis más frecuente en el pie y tobillo. Existen numerosas revisiones respecto al tratamiento quirúrgico, pero escasas publicaciones que aborden la eficacia del tratamiento conservador. Objetivo. Presentar un algoritmo global de tratamiento completo para todos los grados de esta enfermedad. Métodos. Revisión sistemática de la evidencia disponible hasta octubre de 2013 utilizando las siguientes fuentes: Pubmed y PEDro database (physiotherapy evidence database) de artículos sobre tratamiento de hallux rigidus que comuniquen sus resultados y de los que pudieran obtenerse grados de recomendación. Resultados. Obtuvimos 112 artículos sobre tratamiento conservador y 609 sobre tratamiento quirúrgico. Finalmente solo 4 cumplían los criterios de inclusión. Conclusiones. El uso de ortesis a medida o modificaciones del calzado, la infiltración con hialuronato, la queilectomía en grados moderados y la artrodesis metatarsofalángica en grados avanzados, son los únicos procedimientos contrastados con grado de evidencia B o moderada en el tratamiento del hallux rigidus (AU)

Introduction. Hallux rigidus is the most common arthritis of the foot and ankle. There are numerous reviews on the surgical treatment, but few publications that address the effectiveness of conservative treatment. Objective. To present a comprehensive algorithm for treatment of all grades of this disease. Methods. Literature search in the following sources: Pubmed and PEDro database (physiotherapy evidence database) until October 2013 for articles on treatment hallux rigidus to record levels of evidence. Results. A total of 112 articles were obtained on conservative treatment and 609 on surgical treatment. Finally, only 4 met the inclusion criteria. Conclusions. The use of orthoses or footwear modifications, infiltration with hyaluronate, cheilectomy in moderate degrees and the metatarsophalangeal arthrodesis for advanced degrees, are the only procedures contrasted with grade B or moderate evidence in the treatment of hallux rigidus (AU)

[Proposed global treatment algorithm for hallux rigidus according to evidence-based medicine]. / Propuesta de algoritmo global de tratamiento del hallux rigidus según la medicina basada en la evidencia.

INTRODUCTION: Hallux rigidus is the most common arthritis of the foot and ankle. There are numerous reviews on the surgical treatment, but few publications that address the effectiveness of conservative treatment. OBJECTIVE: To present a comprehensive algorithm for treatment of all grades of this disease. METHODS: Literature search in the following sources: Pubmed and PEDro database (physiotherapy evidence database) until October 2013 for articles on treatment hallux rigidus to record levels of evidence. RESULTS: A total of 112 articles were obtained on conservative treatment and 609 on surgical treatment. Finally, only 4 met the inclusion criteria. CONCLUSIONS: The use of orthoses or footwear modifications, infiltration with hyaluronate, cheilectomy in moderate degrees and the metatarsophalangeal arthrodesis for advanced degrees, are the only procedures contrasted with grade B or moderate evidence in the treatment of hallux rigidus.

Effect of muscle weakness and joint inflammation on the onset and progression of osteoarthritis in the rabbit knee.

OBJECTIVES: Interactions between mechanical and non-mechanical independent risk factors for the onset and progression of Osteoarthritis (OA) are poorly understood. Therefore, the goal of the present study was to investigate the in vivo effects of muscle weakness, joint inflammation and the combination on the onset and progression of OA in a rabbit knee joint model. MATERIALS AND METHODS: Thirty 1-year-old female New Zealand White rabbits (average 5.7 kg, range 4.8-6.6 kg) were divided into four groups with one limb randomly assigned to be the experimental side: (1) surgical denervation of the vastus lateralis (VL) muscle; (2) muscle weakness induced by intramuscular injection of Botulinum toxin A (BTX-A); (3) intraarticular injection with Carrageenan to induce a transient inflammatory reaction; (4) combination of Carrageenan and BTX-A injection. After 90 days, cartilage histology of the articular surfaces were microscopically analyzed using the Osteoarthritis Research Society International (OARSI) histology scoring system. RESULTS: VL denervation resulted in significantly higher OARSI scores in the patellofemoral joint (group 1). BTX-A administration resulted in significant cartilage damage in all four compartments of the knee (group 2). Carrageenan did not cause significant cartilage damage. BTX-A combined with Carrageenan lead to severe cartilage damage in all four compartments. CONCLUSION: Muscle weakness lead to significant OA in the rabbit knee. A transient local inflammatory stimulus did not promote cartilage degradation nor did it enhance OA progression when combined with muscle weakness. These results are surprising and add to the literature the conclusion that acute inflammation is probably not an independent risk factor for OA in this rabbit model.

Osteonecrosis of distal tibia in open dislocation fractures of the ankle.

INTRODUCTION: Open ankle dislocation fractures are one of the most severe injuries of the ankle. Development of posttraumatic arthrosis is well known. However, there are just a few case reports describing evidence of posttraumatic osteonecrosis (PON) of distal tibia. The pathophysiological mechanism remains unclear and the question of morphologic or personal risk factors cannot be answered. The goal of this study was to evaluate the morphologic characteristics of open dislocated ankle fractures in correlation with the development of PON to facilitate early identification of patients with higher risk of posttraumatic osteonecrosis. MATERIAL AND METHODS: In this study data from 28 patients with open dislocation fractures of the ankle between 1975 and 2006 found at our databases were evaluated retrospectively. For each patient we documented personal data, mechanism of injury, type of lateral malleolar fracture, severity of open fracture, degree of tibiotalar dislocation, presence of medial malleolar fracture, presence of deltoid ligament rupture, time until joint reduction and kind of surgical treatment. We also documented clinical complications and number of surgeries. Presence of PON was examined by radiographs, magnetic resonance imaging (MRI) or histological analysis. RESULTS: Within 12 out of 28 patients with open ankle dislocation fractures a PON of the distal tibia could be found. Nine out of 15 patients with high-energy trauma and 12 out of 19 patients with type C fibular fracture developed PON. 73% of male patients and 88% of the patients with type III soft tissue damage according to Gustillo developed PON. However, if patients suffered from type C fibular fracture, total talus dislocation and grade III soft tissue damage ("necrotic triad") PON was developed in 100% of cases. Other patient's characteristics like late joint reduction, postoperative infection or bimalleolar fracture showed no higher proportion of patients with PON. CONCLUSION: In this study we were able to identify clinical manifestations and risk factors for the development of PON of the distal tibia. All indentified risk factors were associated with heavy fracture mechanisms leading most likely to a serious devascularisation of at least parts of the distal tibial epiphysis. With regard to presented results early identification of patients with higher risk of PON might be possible and maybe additional treatment options can be initialised to protect patients from this process.

Propuesta de algoritmo terapéutico para hallux rigidus / Treatment algorithm proposed for hallux rigidus

El hallux rigidus es la artrosis más frecuente en el pie y tobillo y la segunda afectación más importante de la primera articulación metatarsofalángica tras el hallux valgus. Si no se trata, puede producir importantes alteraciones en la marcha, movilidad y actividades de la vida diaria. Pretendemos en este artículo de revisión presentar un algoritmo de tratamiento completo para todos los grados de esta enfermedad, tras una concienzuda revisión bibliográfica.

Hallux rigidus is the most frequent arthrosis of the foot and ankle and the second most important condition involving the first metatarsophalangeal joint after hallux valgus. If left untreated, it may cause important alterations in gait, mobility and activities of daily living. The purpose of this review article is to describe a complete treatment algorithm for all grades of this condition, after a thorough bibliographic review.

[Treatment algorithm proposed for hallux rigidus]. / Propuesta de algoritmo terapéutico para hallux rigidus.

Hallux rigidus is the most frequent arthrosis of the foot and ankle and the second most important condition involving the first metatarsophalangeal joint after hallux valgus. If left untreated, it may cause important alterations in gait, mobility and activities of daily living. The purpose of this review article is to describe a complete treatment algorithm for all grades of this condition, after a thorough bibliographic review.

[Treatment of isolated fractures of the olecranon: percutaneous double-screw fixation versus conventional tension band wiring]. / Behandlung von isolierten Olekranonfrakturen: Perkutane Doppelschraubenosteosynthese vs. konventionelle Zuggurtung.

BACKGROUND: Isolated fractures of the olecranon account for 7-10% of all osseous injuries in adults. These fractures are usually treated surgically by conventional tension band wiring. The percutaneous double-screw fixation is an optional treatment in patients with two fragment olecranon fractures with some postoperative advantages. PATIENTS AND METHODS: A total of 13 patients with isolated fractures of the olecranon (Schatzker-Schmelling type A) treated by percutaneous double-screw fixation were included in this prospective study. The mean age of patients was 43.6 ± 11.0 years. Intraoperative and postoperative complications were recorded. Functional results were assessed after a mean follow-up of 38.2 ± 11.5 months using the Quick-DASH score. The results were compared with those obtained in the control group including 26 patients treated by conventional tension band wiring. RESULTS: No intraoperative complications were observed in both groups. In the group with percutaneous double-screw fixation the scar length was significantly shorter (2.4 ± 0.4 cm vs. 11.0 ± 1.8 cm, p < 0.001) and the hardware removal was substantially less frequent that in the group with conventional tension band wiring with 38.5 % and 73.1 %, respectively. At the minimum follow-up of 2 years comparable functional results were obtained in both groups (Quick-DASH score 2.3 vs. 0.0 points, respectively, p = 0.155); however, the range of elbow motion was significantly higher in the group with percutaneous double-screw fixation (extension/flexion 145° vs. 130°, p < 0.001; pronation/supination 165° vs. 155°, p < 0.001). CONCLUSIONS: The percutaneous double-screw fixation is a safe and viable treatment option in patients with isolated fractures of the olecranon (Schatzker-Schmelling type A). The functional results regarding DASH scores obtained using this technique were comparable with those observed in patients with conventional tension band wiring; however, range of elbow motion and cosmetic results were significantly better in the patient group with percutaneous double-screw fixation.

[Evidence-based treatment of combined rotator cuff and SLAP lesions]. / Evidenzbasierte Behandlung der kombinierten Rotatorenmanschetten- und SLAP-Läsion.

PURPOSE: In the face of improved radiological and arthroscopic techniques the diagnosis and treatment of SLAP lesions has recently gained much interest. Originally described as an (isolated) injury of the overhead athlete, it was only recently that the association of SLAP and rotator cuff defects was described in up to 40 % of cases. This study addresses the question of the evidence-based treatment of such frequent, combined lesions. METHODS: Based on a systematic review of the online databases PubMed, EMBASE, CINAHL and Cochrane Library we identified clinical studies on the treatment of combined SLAP and rotator cuff lesions. Study quality was assessed using levels of evidence and a modified Jadad score. Clinical outcome was assessed through scores and range of motion assessments. RESULTS: We included 7 studies of 374 patients with a mean age of 53 ± 11 years followed for 35 ± 13 months. Combined lesions have a significant negative effect on isolated rotator cuff or SLAP repair. Patients older than 45 years of age had a significantly better clinical result after biceps tenotomy than SLAP repair with concomitant rotator cuff repair. Biceps tenotomy plus rotator cuff repair showed significantly better range of motion for flexion and rotation than SLAP plus rotator cuff repair. CONCLUSION: The frequent combination of SLAP and rotator cuff injury should be considered during assessment and informed consent of shoulder patients. While young patients and isolated SLAP lesions show excellent clinical results after elective repair, combined lesions should be treated with biceps tenotomy and/or debridement plus rotator cuff repair in patients older than 45 years.