Venous Thromboembolism Prophylaxis in Foot and Ankle Surgery: A Worldwide Survey.

Current recommendations on thromboprophylaxis for foot and ankle (FA) surgery are often inconsistent and generally based on weak evidence. The aim of this survey study was to evaluate the current practice among orthopedic surgeons regarding venous thromboembolism (VTE) prophylaxis following FA surgery. From February 2019 to March 2020, an online questionnaire was sent by e-mail to orthopedic societies across the world. The questionnaire was hosted by the International Society of Thrombosis and Haemostais RedCAP platform. Topics of interest were VTE rates following FA surgery, duration and type of thromboprophylaxis, bleeding complications, VTE risk factors for prophylaxis and use of risk assessment. A total of 693 FA orthopedic surgeons from all continents completed the survey of whom 392 (57%) performed more than 200 FA procedures per year. A total of 669/693 (97%) respondents stated that thromboprophylaxis is necessary in FA surgeries. When thromboprophylaxis was prescribed, half of surgeons prescribed it for the duration of immobilization. Acetylsalicylic acid, low molecular weight heparin and direct-oral anticoagulants were, in this order, the preferred choice. Acetylsalicylic acid and low molecular weight heparin were predominantly prescribed in North America and Europe, respectively. Previous deep vein thrombosis, immobility, obesity and inherited thrombophilia were considered the main risk factors indicative of thromboprophylaxis use. In this survey, most surgeons agree that thromboprophylaxis is indicated for FA surgery, but the prescription, type and duration of prophylaxis differs greatly with a large intercontinental discrepancy. These survey results could be a foundation for developing uniform guidelines to optimize thromboprophylactic strategies in FA procedures around the world.

Ankle arthroscopy does not elevate complication rates in ankle fractures.

INTRODUCTION: Ankle fractures rank as the second most common lower limb fractures, and surgical intervention is essential for unstable ankle fractures. The use of ankle arthroscopy in such cases offers several advantages. This study aim is to assess whether arthroscopy influenced on complication rates in 171 ankle fractures treated with arthroscopic assistance. METHODS: This retrospective epidemiological analysis encompassed adult ankle fractures between December 2018 and December 2021. Initially, 173 patients were considered, but two were excluded, leaving a final sample of 171 patients. Postoperative complications were categorized as major or minor. RESULTS: The study included 171 patients with surgically treated ankle fractures assisted by arthroscopy, comprising 76 females and 95 males, with an average age of 41.9 years. Syndesmosis injuries were treated in all diagnosed cases (55.0%), and deltoid ligament injuries received attention when identified (33.7%). Arthroscopic techniques were preferred over open techniques (47.4%). Ten patients experienced complications, consisting of 2 major and 8 minor complications (5.8%). DISCUSSION: Our study's epidemiological findings align with prior literature, demonstrating that intra-articular injuries accompany 63% to 79% of ankle fractures. Arthroscopy allows for both diagnosis and treatment within the same procedure, including joint lavage to reduce inflammation. We diagnosed 57 deltoid injuries and identified a statistical relationship between chondral, syndesmotic, and deltoid ligament injuries. Infection is a common complication in ankle fracture surgery, with rates ranging from 1.44% to 16%. Our study yielded a 5.8% complication rate, comprising 1.2% major and 4.6% minor complications. Patients undergoing ORIF with arthroscopic assistance had a lower prevalence of infection. CONCLUSION: The use of arthroscopic assistance in the surgical treatment of ankle fractures does not increase the overall complication rate. LEVEL OF EVIDENCE: IV.

Corin ankle arthroplasty: Case-series.

BACKGROUND: Total Ankle Arthroplasty (TAA) is complex and can bring a wide variety of complications. Implant revision rates can vary from 4% to 8% in 5 years. Recent publications have shown good results in the short and intermediate follow-up and high patient satisfaction. The pre- and postoperative evaluation of these patients should include physical examination and objective radiographic measurements, which may have predictive value for implant failures and survivorship. In this paper we will present the results obtained with 29 patients treated with the Zennith (Corin Group, UK) total ankle prosthesis in Brazil. METHODS: This paper presents the results obtained with 29 patients treated with the Corin-Zennith prosthesis in three tertiary hospitals in Brazil, with an average follow-up of 5 years. The patients were submitted to clinical and radiographic evaluation. There were seventeen women and twelve men, ranging in age from 35 to 76 years, who were submitted to surgical treatment between January 16, 2013 and May 5, 2017. RESULTS: Seven patients (24%) presented cysts, being 4 (13.7%) tibial cysts and 3 (10.3%) tibial and talar cysts. Six patients (20.6%) presented talar subsidence and 3 (10.3%) presented tibial subsidence. Three patients (10.3%) presented component wear. VAS reduced and AOFAS and ROM increased in the post-operative period. The development of Cysts was associated with the theta angle and the difference in LTS (between the post and preoperative period) was associated with tibial subsidence. The complications rate was 44.8%, the revision rate was 6.9% and the survivorship rate was 93.1%. CONCLUSION: The Corin-Zennith prosthesis demonstrated to be a safe implant for improving functional parameters. Functional outcomes were not influenced for most commonly measured radiographic parameters. Further studies are needed to better understand these associations.

Is Second Metatarsal Protrusion Related to Metatarsophalangeal Plantar Plate Rupture?

OBJECTIVE. The purpose of this study was to determine whether the relative length of protrusion of the second metatarsal, measured on MRI and weight-bearing foot radiography, predicts the diagnosis of second metatarsophalangeal (MTP) joint plantar plate (PP) tear on MRI. MATERIALS AND METHODS. We retrospectively evaluated 166 consecutive patients (211 feet). Patients had undergone weight-bearing foot radiography and forefoot MRI. Using the Coughlin method, two independent observers measured second meta-tarsal protrusion length on radiography and MRI. MRI findings were classified as normal PP, complete PP tear, or degenerative or partial PP tear. RESULTS. Patients had a mean age of 47 ± 14.6 (SD) years, and 131 (78.9%) were women. MRI measurements were highly correlated with radiographic measurements (r = 0.882; 95% CI, 0.866-0.898; p < 0.001). A significant correlation was found between length of protrusion and cases classified as either normal PP or PP tear. Patients with a normal PP had a mean protrusion length of 4.11 ± 1.35 mm on radiographs and 2.61 ± 1.31 mm on MR images, whereas those with a PP tear had a mean protrusion length of 4.75 ± 1.53 and 3.05 ± 1.34 mm, respectively. ROC curve analysis showed that protrusion length cutoff values of 5.47 mm measured on radiographs and 3.17 mm on MR images were correlated with MTP PP tear. CONCLUSION. We identified a linear correlation between second metatarsal protrusion measured on MRI and that measured on radiography, with values about 35% higher for the latter. Our study showed an association between length of protrusion of the second metatarsal and PP rupture and identified a cutoff value for the second meta-tarsal overlength that is associated with these tears.

Rotational biplanar Chevron osteotomy.

INTRODUCTION: The Chevron osteotomy is a reliable and popular osteotomy for treating hallux valgus worldwide. Many modifications have been described, but none of them address the rotational deformity of the first metatarsal. The objective of this study is to describe a variation of biplanar Chevron osteotomy which can address first metatarsal rotation when necessary. METHODS: The indications for the Rotational Biplanar Chevron Osteotomy (RBCO) are mild to moderate hallux valgus deformity associated with hallux pronation related to internal rotation of the first metatarsal bone. We describe a technique that uses a medial based wedge parallel to the plantar limb of the osteotomy in order to make the distal fragment free to correct rotation. RESULTS: The more recent concern about hallux valgus surgery is the very interesting concept that this deformity really occurs in three different planes, and we may have mistreated the rotation component with our current techniques. Many authors have revisited many common techniques in order to adapt them to correct metatarsal pronation. To our best knowledge, this is the first paper to describe a modification of the Chevron osteotomy to address the rotation of the first metatarsal. CONCLUSION: We can conclude that the rotational biplanar Chevron osteotomy can be an useful tool in the treatment of mild hallux valgus associated with metatarsal pronation.

Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears.

BACKGROUND: Rupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair. METHODS: A retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12months. RESULTS: No major complications were observed. The average time to return to sport was 9months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair. CONCLUSIONS: Open and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.

Prospective study of the " Inside-Out" arthroscopic ankle ligament technique: Preliminary result.

BACKGROUND: Lateral ankle ligament injury is among the most common orthopedic injuries. The objective of this study is to present the preliminary prospective results of treatment using the "Inside-Out" variant of the fully arthroscopic Broström-Gould technique. METHODS: Twenty six patients were included: 20 male and 6 female, aged 19-60 years, mean 41 years. All patients had positive "anterior drawer" and "talar tilt" tests. When necessary, cartilage injuries were treated with microfracture and arthroscopic resection for anterior impingement; three patients had hindfoot varus, on whom Dwyer osteotomy was performed; one patient had peroneal tendinopathy and was treated with tendoscopic debridement and another one had partial injury of the deltoid ligament, which was treated by direct repair. Two arthroscopic surgery portals were used; the anteromedial and anterolateral. After careful inspection of the joint, the anterior surface of the fibula was cleaned to resect the remains of the anterior talo-fibular ligament. An anchor with two sutures was placed on the anterior aspect of the fibula, 1cm from the distal apex of the malleolus. The sutures were passed through the remnant of the anterior talo-fibular ligament as well as the extensor retinaculum using special curved needles. Duncan knots were used to tie the ligament and the inferior extensor retinaculum while the ankle was kept in a neutral position. Patients were kept immobilized non-weight bearing for 2 weeks and were then allowed to start weight bearing in a removable protective boot for 4 weeks. The patients were able to return to sporting activities 6 months after surgery. RESULTS: After a mean follow-up of 27 months (range 21-36 months), patients were functionally evaluated using the American Orthopedics Foot and Ankle Society (AOFAS) ankle score. The mean preoperative value was 58 points, while the mean postoperative value increased to 90 points. One patient had paresthesia in the superficial fibular nerve area, which resolved spontaneously. CONCLUSION: Despite the limited cohort and the relatively short follow-up period, the use of the "inside-out" arthroscopic technique may be considered as a valid option for the treatment of chronic ankle instability.

Second and Third Metatarsophalangeal Plantar Plate Tears: Diagnostic Performance of Direct and Indirect MRI Features Using Surgical Findings as the Reference Standard.

OBJECTIVE: The objective of our study was to assess the diagnostic performance and associations of the direct and indirect MRI features of the metatarsophalangeal (MTP) joint that are thought to be related to tears of the plantar plate (PP) using surgical findings as the reference standard. MATERIALS AND METHODS: We retrospectively included 23 patients with symptomatic instability of lesser MTP joints who had undergone preoperative 1.5-T MRI and surgical assessment. The MRI examinations were independently assessed by two musculoskeletal radiologists. Using the surgical data as the reference standard, we calculated the sensitivity, specificity, and accuracy of each MRI feature in the detection of PP tears. Multivariate logistic regression analysis was performed to identify which MRI features were independently associated with PP tears. Interobserver reliability was assessed using kappa statistics. RESULTS: Forty-five lesser MTP joints were included. The presence of pericapsular fibrosis was highly sensitive (91.2%), specific (90.9%), and accurate (91.1%) for the diagnosis of PP tears. With a cutoff value of 0.275 cm, the PP-proximal phalanx distance had a sensitivity of 64.7%, specificity of 90.9%, and accuracy of 71.1% in diagnosing PP tears. CONCLUSION: In patients with clinical features indicating lesser MTP joint instability, some direct and indirect MRI features exhibited good to excellent diagnostic performance in detecting the presence of PP tears.

Etiology, Clinical Assessment, and Surgical Repair of Plantar Plate Tears.

The plantar plate has recently gained more attention as an important structure contributing to lesser metatarsophalangeal joint stability. This has prompted a significant growth of interest in the anatomy and biomechanics of the plantar plate and in the diagnosis and treatment of its injuries. Improved understanding of plantar plate function and predictable patterns of degeneration and failure has led to the development of a clinical staging and surgical grading system of plantar plate lesions. Relatively recent innovations allow the surgeon to access and repair plantar plate tears directly with reinsertion onto the base of the proximal phalanx. The addition of direct plantar plate repair represents a significant advance in the surgical restoration of alignment and functional stability of the lesser metatarsophalangeal joint.

Lesser metatarsal phalangeal joint arthroscopy: anatomic description and comparative dissection.

PURPOSE: The aim of this article is to describe the normal arthroscopic anatomy of the lesser metatarsophalangeal (MTP) joints and compare it with that seen in open dissection in cadaveric models. METHODS: We performed arthroscopic examination of 18 MTP joints of 6 normal fresh frozen feet. The second, third, and fourth MTP joints were studied because of the higher incidence of pathologic conditions found in these joints. During arthroscopy, each anatomic structure identified was named and marked with different colored sutures using straight suture needles. After the arthroscopic procedure of identification and marking, each MTP joint was dissected, and all the anatomic structures were grossly identified. With these data, the correlation between the arthroscopic and the direct visualization of a normal MTP joint was established. RESULTS: Considering the joint regions, we found that the examination accuracy of the medial gutter was 91%, whereas the central joint accuracy reached 100% and the accuracy of the lateral gutter was 98%. The overall arthroscopic accuracy for the lesser MTP joints was 96%. CONCLUSIONS: There is a high level of anatomic accuracy at the lesser MTP joint with arthroscopy. CLINICAL RELEVANCE: The high overall level of anatomic accuracy of lesser MTP joint arthroscopy (96%) allows us to consider this resource as a valuable tool in the diagnosis and treatment of these joints, expanding the spectrum of indications using this method.

Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables.

Although metatarsophalangeal (MTP) plantar plate tears are common, they are still often missed. The purpose of this study is to find the best clinical variables to define and grade the plantar plate injuries. Sixty-eight patients (100 MTP joints) were graded arthroscopically and divided into five groups (0 to IV) according to the anatomical classification. Their medical records were reviewed to establish correlations of clinical findings with the anatomical lesions. The positive correlations found were acute pain, widening of the interdigital space, loss of ground touch, positivity of the MTP joint drawer test, reduction of the toe purchase, and toe supination. The drawer test is the most reliable and accurate tool to classify and grade the plantar plate lesion, followed by ground touch and rotational deformities. It is possible to improve the accuracy of diagnosis of plantar plate tears by means of the combination of both clinical history and physical examination data.

Talus Osteochondral Defect Treatment With Biological Scaffold.

Talus Osteochondral defects (OCDs) are challenging and there is no consensus in literature regarding which is the best method of treatment. New techniques coming from regenerative medicine are being considered good alternatives of treatment and are being used exponentially in orthopaedic surgery. Platelet-rich fibrin (PRF) is the second generation of platelet concentrates. It has a convenient method of acquisition and can be used to create a biological scaffold which is able to seal up cavitary lesions. In this article, the authors describe a talus OCD treated with a biological scaffold, reporting the technique details and its results clinical and radiological results. The case report objective is to portray the use of this kind of biological material, its advantages, and limitations.Level of Evidence: Level 5.

Hallux valgus in males--part 1: demographics, etiology, and comparative radiology.

BACKGROUND: The high frequency of hallux valgus deformities in females is well known and has been widely reported in the literature. This finding tends to obscure the importance and the characteristic details of hallux valgus deformities in males. The severity of the deformity, its onset at an earlier age, and its inheritability seem to be more frequent in males, but there are no reports in the literature to substantiate these concepts. The purpose of this study was to analyze these questions in regard to males with hallux valgus. METHODS: The records and plain radiographs of 31 males (53 feet) with a diagnosis of hallux valgus that were treated over a 20-year period (1985-2005) were analyzed. During that same period, the senior author (CN) performed 812 procedures for the correction of hallux valgus deformities in women. In order to compare gender-related differences associated with this deformity, 31 women's charts-paired by age and affected side-were randomly selected and both clinical and radiological data were statistically compared. RESULTS: The onset of the complaints of first ray pain in males was equally distributed by decades, indicating that the deformity begins earlier in this group. Among males, we found 68% of the subjects had a familial history of bunion deformities-58% were maternal and 10% were fraternal. In the control group of females, only 35% of the women reported inheritance of the deformity. No correlation with footwear was found among males. The radiographic measurements were significantly higher in the male group, which included the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the tarsal metatarsal angle (TMA). The main gender difference was found to be the DMAA with first metatarsophalangeal (MTP) joint congruence being much more common in males (males = 57%, females = 30%). No correlations were found for metatarsus primus varus or pes planus. CONCLUSION: Based on our observations, we conclude that hallux valgus in males is commonly hereditary in nature and is mainly transmitted by the mother, with early onset and higher severity when compared to women. We report a female/male ratio of 15:1. The main intrinsic factor associated with a hallux valgus deformity in males is a high DMAA. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Hallux valgus in males--part 2: radiographic assessment of surgical treatment.

BACKGROUND: In an early report on this patient cohort, we concluded that a hallux valgus deformity in males is frequently hereditary in nature. An increase in the distal metatarsal articular angle (DMAA) was observed to be the major defining characteristic of hallux valgus in males. In this follow-up study, our goal was to evaluate the effectiveness of surgical treatment for this cohort of male patients. METHODS: Data from 50 feet of male patients with hallux valgus who were surgically treated by the same surgeon between 1985 and 2005 were retrospectively analyzed. The technique was algorithmically chosen according to the severity and complexity of the deformity. Thus, 10 chevron osteotomies, 9 biplanar chevron osteotomies, 12 Mitchell osteotomies, 9 scarf osteotomies, and 10 basilar first metatarsal osteotomies were performed. The average follow-up was 10 years (range, 2-20). RESULTS: After analyzing the angular radiological parameters, sesamoid subluxation, and the articular congruency, most procedures proved to have achieved adequate correction of the angular deformities. When examining each of the procedures separately, 4 of the 5 procedures had similar corrective capacities; the scarf osteotomy however had decidedly inferior results. The improvement in the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score demonstrated the clinical and functional improvement. CONCLUSIONS: The algorithm was based mainly upon the presence of increased DMAA and increased severity of angular deformities. We conclude that hallux valgus deformities in males were adequately corrected with the selected techniques. Greater difficulty or resistance to surgical treatment could not be detected when we contrasted our results to females. The scarf osteotomy proved to have an inferior corrective capacity compared to the other techniques used in this series. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

MRI evaluation of the MTP plantar plates compared with arthroscopic findings: a prospective study.

BACKGROUND: Instability of the lesser metatarsophalangeal (MTP) joints has been widely reported and plantar plate insufficiency is a key part of this pathologic process. The diagnosis is made clinically but can be aided by imaging studies, particularly magnetic resonance imaging (MRI); however, the sensitivity and accuracy of this method compared to direct visualization of these lesions has not yet been established, nor has interobserver accuracy of MRI been assessed for evaluation of plantar plate pathology. In this study, our goals were to identify the accuracy of the MRI in describing plantar plate tears when compared to direct arthroscopic visualization using an anatomic grading system and to test the influence of an anatomic grading system in the accuracy of the MRI readings. METHODS: We evaluated the clinical exam, MRI scans, and arthroscopic findings of 35 patients with lesser MTP instability. RESULTS: Using an anatomic grading system, a distinct improvement in the radiological evaluation and interpretation occurred. Knowledge of the pattern of plantar plate tears by a radiologist enabled them to locate and describe the type of tears of the plantar plate on the MRI. The amount of training and the experience of the radiologist were also important factors in our study. The senior radiologists had much better levels of accuracy (Group A, 77.0%; Group B, 88.5%) than less experienced radiologists. CONCLUSION: Prior knowledge of the pathophysiology and morphological types of lesions of the plantar plates was helpful for accurate identification and description of the tears by the radiologist. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Mini Open Fasciotomy for Chronic Exertional Compartment Syndrome: A Prospective Case Series.

Chronic exertional compartment syndrome (CECS) is a challenging pathology that causes pain and physical limitations. Fasciotomy is the gold standard and different techniques have been described. Techniques that allow a fast return to sports and low recurrence rates are of great interest for the athletic population. This is a prospective case series presenting a mini open surgical technique and its results regarding the level of return to sports and quality of life in 13 patients. A specific CECS questionnaire was applied and analyzed concerning the distance patients were able to run before and after treatment, Tegner score, Medical Outcomes Short-Form Health Survey (SF-36), and epidemiological measures. The minimum follow-up was 12 months. The mean distance the patients were able to run per week following the surgical treatment improved from 14.1 to 38.1 km (P = .042) and the mean Tegner score improved from 3.92 to 7.08 (P = .01). Notably, 12 out of 13 patients were satisfied or very satisfied with the outcome. In this sample, the mini open technique improved patients' sports performance and quality of life and minimized pain. Chronic exertional compartment syndrome can be safely approached using a mini open technique with a good rate of satisfaction and return to sport.Levels of Evidence: IV.

Infinity Ankle Arthroplasty Early Latin-America Experience and Patient Outcomes.

INTRODUCTION: The promising data from Ankle Arthroplasty are consequence of the evolution of instruments and implants. Recent studies have shown good results in the short and intermediate follow-up, in addition to high patient satisfaction. The aim of this study is to present the results obtained with 49 cases treated with the Infinity total ankle prosthesis in 2 South America countries. METHODS: This is a case series of 48 patients (27 women and 22 men), treated with 49 Infinity prostheses in Brazil and Colombia. They underwent surgical treatment between April 1, 2016, and January 18, 2020. We used the visual-analogue pain scale (VAS), the AOFAS score for ankle and hindfoot and the measurement of range of motion (ROM) in the pre- and post-surgical period. The radiological evaluation was performed on ankle radiographs in anteroposterior and lateral views, obtained in orthostasis, measuring the parameters suggested by Hintermann. Average follow-up was 4 years. RESULTS: VAS reduced from an average of 7.94 to 1.98; AOFAS increased from 28.02 to 83.16 and ROM increased from 11.45 to 28.08. Distal Tibial Slope is higher for higher improvements in VAS and lower for higher improvements in AOFAS and ROM. We observed 4 wound infections, 1 intra-op medial malleolus fracture. No bone cysts, tibial or talar components subsidence, polyethylene component wear or failure were observed. No salvation procedures were required in this series. DISCUSSION: This study results corroborates literature data showing great improvements in pain, functional pattern, and movement. CONCLUSION: Infinity Ankle Arthroplasty is a safe and reproducible procedure with good outcomes at a short-term follow-up. LEVEL OF EVIDENCES: 4 - Case series.

Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals.

INTRODUCTION: Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.

Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency.

BACKGROUND: Anatomical dissection of the second metatarsophalangeal (MTP) joint suggests that the plantar plate is the major stabilizing structure of the joint due to its central location and multiple important attachments. Many surgical procedures have been recommended when conservative treatment has failed, but some have had limited clinical success. The aim of our prospective study was to show the results obtained in the treatment of a group of patients with plantar plate tears by direct repair through a dorsal approach combined with a Weil metatarsal osteotomy with a minimum followup of 12 months. METHODS: We prospectively treated 28 patients (55 MTP joints) with lesser MTP joint instability, but only 22 patients (40 MTP joints) were treated by the direct repair of the plantar plate and were included in the study. All of them had initial complaints of acute forefoot pain with the subsequent development of deformity and instability of the MTP joints. All patients were evaluated clinically, radiographically, (plain radiographs and MRI exam), and by MTP joint arthroscopy. With this data, a direct correlation between the clinical staging and the anatomical grading for plantar plate dysfunction of each patient was determined RESULTS: The plantar plate of the second MTP joint was the most commonly affected joint (63%), and Grade III type tear (transverse and/or longitudinal extension tear) was the most frequent type. With the surgical treatment, we were able to markedly improve the parameters studied (pain, medial or dorsomedial deviation of the toe, joint stability, muscle balance, and joint congruence) to acceptable levels, The AOFAS score improved substantially from an average of 52 points preoperatively to 92 points postoperatively. CONCLUSION: The direct plantar plate repair combined with a Weil osteotomy and lateral soft tissue reefing can restore the normal alignment of the MTP joint. We have demonstrated that the anatomic repair of the plantar plate can correct the deviation of the affected toe (medial, dorsal, dorsomedial or dorsolateral), which lead to diminished pain with improved functional scores.

Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective.

OBJECTIVE: The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objective of this study is to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent forefoot magnetic resonance imaging and describe the main abnormalities found. The hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries. METHODS: A retrospective cross-sectional study was conducted with 85 patients (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging using a specific protocol to study metatarsophalangeal plantar plate. The experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main magnetic resonance imaging findings. RESULTS: A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury. CONCLUSION: Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.