OUTCOMES AFTER UNSTABLE FRACTURES OF THE ANKLE: WHAT'S NEW? A SYSTEMATIC REVIEW.

Background: Unstable ankle fractures are very frequent. Given the instability, they often require surgical treatment, but literature scarcely reports on the outcomes of their management. Questions/purposes: For this systematic review we asked: (1) What are the outcomes in treatment of unstable ankle fractures? (2) What about complications of treatment in unstable fractures? (3) What factors influence the outcomes? (4) What about the role of the posterior malleolus? Methods: The electronic databases PubMed, Scopus, and Embase were interrogated using the search terms "bimalleolar" or "trimalleolar" and "fracture". Studies were included if they reported on: (1) bimalleolar or trimalleolar fracture in adults; (2) treatment; (3) outcomes reported by scales; (4) follow-up. The final review included 33 studies. The quality of the studies was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. Results: All the outcomes of the thirty-three selected studies were analyzed. Discussion: Surgical fixation of unstable ankle fractures should always be performed within the first 48 hours from the trauma, preventing instability and post-traumatic osteoarthritis. Surgeon should consider factor may influence functional outcomes. Posterior malleolar fractures should be fixed regardless the size, considering some individual factors.

Subtalar arthroeresis with peek endorthesis in juvanile flexible flafoot: Short-term results.

A successful and minimally invasive treatment for adolescent flexible flatfoot is subtalar arthroeresis. This study examines the short-term results of subtalar arthroereisis with a new PEEK device (Pit'Stop®); additional research will be required to determine the device's true potential, but the preliminary findings are very encouraging, with a high success rate and a low complication rate (0.08).

Rare shear-type fracture of the talar head in a thirteen-year-old child - Is this a transitional fracture: A case report and review of the literature.

BACKGROUND: Talar fractures are exceedingly rare in childhood. There are very few studies on the clinical aspects, the long-term outcomes and the appropriate treatment of these fractures in pediatric patients. The mechanism of trauma consists of the application of a sudden dorsiflexion force on a fully plantar-flexed foot. Traumatic mechanism, symptoms and imaging of injuries of the talar head are similar to transitional fractures that are normally described at the distal epiphysis of the tibia: the so-called transitional fracture is defined as an epiphyseal injury when the growth plate has already started to close. CASE SUMMARY: A thirteen-year-old girl reported a high-energy trauma to her right foot, due to falling from her horse. X-rays at the Emergency Department were negative. Because of persistent pain, the patient was assessed by an orthopedic surgeon after two weeks and computed tomography scans revealed a misdiagnosed displaced shear-type fracture of the talar head. Hence, surgical open reduction and fixation with two headless screws was performed. The girl was assessed regularly, and plain films at follow-up revealed complete healing of the fracture. Within six months after surgery, the patient returned to pre-injury sport activities reporting no complications. CONCLUSION: Injuries of the talar head in childhood should be considered as transitional fractures. Open reduction with internal fixation aims to reduce malalignment and osteoarthritis. Computed tomography scans are recommended in these cases.

The Adipo-Fascial ALT Flap in Lower Extremities Reconstruction Gustillo IIIC-B Fractures. An Osteogenic Inducer?

RESULTS: Mean time from injury to flap coverage was 72 hours. The mean size of bone defects was 4-7,6 cm. All flaps were Antero Lateral Tight flaps, and the fracture sites did not have any evidence of infection. None of the patients was a smoker. A solid bone union was reached, and full wearing was in a mean of 11 (4-20) weeks after the injury. The lower limb was saved in 100% of the cases. CONCLUSION: Despite the goods results, further studies applied on a large number of patients are needed to confirm authors theory, however, we can consider the fascial ALT flap as a valid help for bone healing in 3B-C open tibial fractures.

Müller-Weiss disease: Four case reports.

BACKGROUND: Müller-Weiss disease (MWD) is an idiopathic foot condition characterized by spontaneous tarsal "scaphoiditis" in adults. Frequently bilateral and affecting females during the 4th-6th decades of life, the pathogenesis of MWD remains unclear: It has been traditionally considered a spontaneous osteonecrosis of the navicular. The typical presentation of MWD is a long period of subtle discomfort followed by prolonged standing, atraumatic, disabling pain. Currently, there is no gold standard for the treatment of patients with MWD. Most support initial conservative therapy. Operative treatment should be considered for failure of conservative therapies longer than 6 months. The indication for surgery is severity of symptoms rather than severity of deformities. Operative treatment options include core decompression, internal fixation of the tarsal navicular, open or arthroscopic triple fusion, talo-navicular or talo-navicular-cuneiform arthrodesis, and navicular excision with reconstruction of the medial column. CASE SUMMARY: In this study, we report four patients affected by MWD. Clinical and radiographic assessment, follow-up and treatment are reported. CONCLUSION: As it is frequently misdiagnosed, MWD is challenging for orthopedic surgeons. Early diagnosis and effective treatment are mandatory to avoid sequelae.

Synovial chondromatosis of the foot: Two case reports and literature review.

BACKGROUND: Primary synovial chondromatosis (PSC) is a rare arthropathy of the synovial joints characterized by the formation of cartilaginous nodules, which may detach and become loose bodies within the joint and may undergo secondary proliferation. PSC of the foot and ankle is exceedingly rare, with only a few cases reported in the literature. The diagnosis may be difficult and delayed until operative treatment, when it is confirmed by histological assessment. PSC may degenerate into chondrosarcoma. Operative treatment is the gold standard aiming to minimize pain, improve function, prevent or limit progression of arthritis. Surgical treatment consists in debridement by arthrotomic or arthroscopic management, but there is no consensus in the literature about timing of surgery and surgical technique. Thus, the aim of this study is to report the outcomes of the surgical treatment of two cases, together with a literature review. CASE SUMMARY: We report two cases of patients affected by PSC of the foot in stage III, according to the Milgram classification: the former PSC localized in the ankle that underwent open surgery consisted of loose bodies removal; the latter in the subtalar joint, and the choice of treatment was the arthrotomy and debridement from loose bodies, in addition to the subtalar arthrodesis. Both patients returned to complete daily and working life after surgery. CONCLUSION: Synovial chondromatosis is a rare benign pathology, even rarer in the ankle joint and especially in the foot. Surgery should be minimal in patients with ankle PSC, choosing the correct timing, waiting if possible until stage III. More aggressive and early surgery should be performed in patients with PSC of the foot, particularly the subtalar joint, due to the high risk of arthritic evolution.

Failure of dual radius hydroxyapatite-coated acetabular cups.

INTRODUCTION: Many kind of hydroxyapatite-coated cups were used, with favorable results in short term studies; it was supposed that its use could improve osteointegration of the cup, enhancing thus stability and survivorship. The purpose of this study is to analyze the long term behavior of the hemispheric HA coated, Dual Radius Osteonics cup and to discuss the way of failure through the exam of the revised components and of both periacetabular and osteolysis tissue. MATERIALS AND METHODS: Between 1994 and 1997, at the Department of Orthopedic Sciences of the Insubria University, using the posterolateral approach, were implanted 276 Dual Radius Osteonics in 256 patients, with mean age of 63 years. RESULTS: At a mean follow-up of 10 years (range 8-12 years), 183 cups in 165 patients, were available for clinical and radiographical evaluation. 22 Cups among the 183 were revised (11%). The cause of revision was aseptic loosening in 17 cases, septic loosening in one case, periprosthetic fracture in another case, osteolysis and polyethylene wear in two cases and, finally, recurrent dislocations in the last one. In the remaining patients, mean HHS increased from a preoperative value of 50.15 to a postoperative value of 92.69. The mean polyethylene wear was 1.25 mm (min. 0.08, max 3.9 mm), with a mean annual wear of 0.17 mm. The mean acetabular migration on the two axis was 1.6 mm and 1.8 mm. Peri-acetabular osteolysis were recorded in 89% of the implants (163 cases). The cumulative survivorship (revision as endpoint) at the time was 88,9%. CONCLUSION: Our study confirms the bad behavior of this type of cup probably related to the design, to the method of HA fixation. The observations carried out on the revised cup confirm these hypotheses but did not clarify if the third body wear could be a further problem. Another interesting aspect is the high incidence of osteolysis, which are often asymptomatic becoming a problem for the surgeon as the patient refuses the possibility of a revision.