The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up.

BACKGROUND: Ankle fractures are a common injury and the main cause of post-traumatic ankle arthritis. The prevalence of obesity is increasing worldwide, and this population is known to have poorer short and midterm outcomes after ankle fractures. Our objective is to assess long-term patient-reported outcomes in patients with operatively treated ankle fractures, and the effect of BMI on these results using the new and validated patient-reported outcome questionnaire, the Manchester Oxford foot and ankle questionnaire (MOXFQ). METHODS: We performed a retrospective review of all ankle fractures treated operatively in a ten-year period from 2002-2012. The MOXFQ and SF-12 were sent to all patients and were obtained, on average, 11.1 years after surgery (range 5.3-16.2 years). RESULTS: Two thousand fifty-five ankle fractures were reviewed, of which 478 (34%) patients completed the questionnaires. The mean age was 48.1 ± 15.5 years, 52% were men and the mean BMI was 26.1 ± 4.5 kg/m2. Of the 478, 47% were of normal weight, 36% were overweight, and 17% were obese. Overall, 2.1% were type A, 69.9% B, and 24.9% type C fractures. There were no significant differences in the type of fracture between the BMI groups. Comparing obese and non-obese patients, there were large differences in MOXFQ pain (33 ± 29 vs. 18.7 ± 22.1, effect size 0.55), and function scores (27.3 ± 29 vs. 12.5 ± 21.1, effect size 0.58). No differences in complications and reoperations rates were observed. The BMI value at surgery correlated more strongly with the MOXFQ pain score than the BMI at follow-up (Spearman's Rho 0.283 vs. 0.185, respectively). CONCLUSION: These findings reveal that obese patients have significant worse long-term outcomes, namely increased pain, poorer function, and greater impairment in everyday life after an operatively treated ankle fracture. Moreover, pain and function linearly declined with increasing BMI. Our findings appear to indicate that increased BMI at surgery is an important contributor to adverse outcome in the operative management of rotational ankle fractures. LEVEL OF EVIDENCE: III.

Operatively treated ankle fractures in Switzerland, 2002-2012: epidemiology and associations between baseline characteristics and fracture types.

BACKGROUND: Ankle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types. METHODS: We performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012. RESULTS: Two thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age. CONCLUSION: Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.

Development and psychometric performance of the French language version of the Manchester-Oxford Foot Questionnaire (MOXFQ).

BACKGROUND: The Manchester-Oxford Foot Questionnaire (MOXFQ) is a 16-item patient-reported outcome measure (PROM) validated for use in patients with foot and ankle pathologies. It contains three sub-scores for pain, walking/standing and social interaction dimensions. The aim of this study was to develop a French language version of the MOXFQ and to assess its psychometric properties in patients affected by foot and ankle pathologies. METHODS: According to guidelines, forward and backward independent translations were performed. The final French version was pre-tested in 45 patients. The French MOXFQ and the Short-form 36 Health Survey (SF-36) were filled in by 149 patients. A retest was performed in 39 patients. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by factor analysis, and through correlations of MOXFQ scales with SF-36 scales. RESULTS: Internal consistency coefficients were high with Cronbach's alpha ranging from 0.79 and 0.94. Test-retest ICCs were between 0.74 and 0.93. No floor or ceiling effects were observed. The correlations between French MOXFQ and French SF-36 subscales were moderate ranging from -0.33 to -0.71. CONCLUSIONS: The French translation of the MOXFQ revealed good psychometric properties. Our French version proved to be a reliable instrument which can be used for evaluation of patients with foot and ankle disorders. LEVEL OF EVIDENCE: II.

Accuracy of cone-beam computed tomography for syndesmosis injury diagnosis compared to conventional computed tomography.

BACKGROUND: Syndesmosis injury can lead to ankle mortise instability and early osteoarthritis. Several multiple detector computed tomography (MDCT) methods for measurement have been developed. Weight-bearing cone beam CT (WB CBCT) is an emerging technique that offers the possibility of upright-position scanning and lower doses. This study sought to assess the diagnostic accuracy of WB CBCT in syndesmose injury compared to MDCT, with instability confirmed via manual testing upon arthroscopic examination. METHODS: Three musculoskeletal radiologists with different levels of expertise prospectively analyzed 11 MDCT and eight WB CBCT scans of the same trauma-afflicted ankles with clinical suspicion of syndesmosis lesion over a period of 5 months. They evaluated 10 methods of measurement in both sides. Syndesmosis was considered pathological on arthroscopic examination in four patients. Correlation between readers was evaluated with intra-class correlation testing (p < 0.05 was considered significant). Capacity of discrimination was assessed by area under the curve (AUC) for all methods. RESULTS: Inter-observer agreement was near excellent for both WB CBCT and MDCT for the anterior tibio-fibular (TF) distance (ICC = 0.781 and 0.831, respectively), posterior TF distance (ICC = 0.841 and 0.826), minimal TF distance (ICC = 0.899 and 0.875), and TF surface (ICC = 0.93 and 0.84). AUC were better for MDCT than WB CBCT in assessing syndesmosis instability for: anterior TF distance (ROC = 0.869 vs. 0.555, p = 0.01), minimal TF distance (ROC = 0.883 vs. 0.608, p = 0.02) and antero-posterior fibular translation (ROC = 0.894 vs. 0.467, p = 0.006). CONCLUSIONS: MDCT demonstrated better ability to distinguish pathological syndesmosis than WB CBCT, with the antero-posterior fibular translation the best discriminating measurement. The physiological widening of the contralateral syndesmosis occurring with the WB CBCT upright position may explain these results.

[Total ankle arthroplasty†: update]. / La prothèse totale de cheville†: mise au point.

Total ankle prosthesis is increasingly recognized in the management of severe osteoarthritis and has established itself as a valid alternative to arthrodesis. However, this procedure remains delicate, indications must be targeted, and the complex surgical technique requires specific expertise from the surgeon. In recent years, ankle arthroplasty has undergone a major expansion, with improvements in design and surgical techniques. New technologies have also emerged, offering tailor-made planning and instrumentation possibilities. The influence of these techniques on long-term results has yet to be demonstrated, but benefits such as reduced operating time and improved surgical accuracy are interesting. The purpose of this article is to provide an update on ankle prosthesis in the treatment of ankle osteoarthritis.

La prothèse totale de cheville est de plus en plus reconnue dans la prise en charge de l'arthrose et s'est imposée comme une alternative à l'arthrodèse. Cependant, cette chirurgie reste délicate, les indications doivent être ciblées et la technique chirurgicale exige une expertise du chirurgien. Au cours des dernières années, la prothétique de cheville a connu un essor important et les nouvelles technologies ont fait leur apparition offrant des possibilités de planification et d'instrumentation sur mesure. L'influence de ces techniques sur les résultats au long terme reste à démontrer mais les avantages, comme la diminution du temps opératoire et l'amélioration de la précision chirurgicale, sont intéressants. Le but de cet article est de faire une mise au point sur la prothèse de cheville dans le traitement de l'arthrose de cheville.

Ultrasonography of the Sural Nerve: Normal and Pathologic Appearances.

Ultrasonography (US) of peripheral nerves has gained wide popularity because of the increased definition of modern high-frequency electronic transducers, as well as the well-known advantages of US, which include easy availability, low cost, and the possibility of realizing a dynamic examination. Traditionally, US has been deployed to assess the major nerves of the limbs. More recently, US has also been used to assess the normal appearance and pathologic changes of smaller subcutaneous nerves. The sural nerve is a small sensory nerve in the subcutaneous tissues of the calf that can be affected by a variety of disorders. This pictorial essay illustrates the normal anatomy of the sural nerve, the technique for its examination by US, as well as the US appearance of its main pathologic changes.

Clinical and epidemiological differences between implant-associated and implant-free orthopaedic infections.

PURPOSE: Although there have been many publications regarding the risk factors for implant-associated orthopaedic infections, none have investigated how clinical presentations and epidemiology may differ between infections with and without osteosynthetic material. METHODS: We pooled clinical data from several databases of adult patients with orthopaedic infections hospitalized at Geneva University Hospitals from January 2004 to December 2014. RESULTS: Among 2740 episodes of orthopaedic infections, 76% were implant-free osteoarticular or soft tissue infections. Among the 665 (24% of the total episodes) infections that involved osteosynthetic material, 319 (49%) were total joint arthroplasties, 143 single plates, and 50 single nails. The remainders were mixed implant infections, pins, wires, screws, cerclages or spondylodeses. The implant-associated, compared to the implant-free, infections were significantly more frequently associated with female sex, older age, bacteraemia and skin commensal infections, e.g. coagulase-negative staphylococci, corynebacteria or propionibacteria. In contrast, implant-associated infections were significantly less frequently associated with immune suppression, abscess formation, infections due to Staphylococcus aureus or streptococci, polymicrobial pathogens and foot infections. The serum CRP levels at admission were similar (median 82 vs. 75 mg/L). CONCLUSIONS: Compared to implant-free infections, implant-associated orthopaedic infections are more likely monomicrobial, bacteraemic and due to skin commensals. They involve more often female and older patients, but are less often associated with immune suppression, abscess formation and foot infections.

Diabetic foot infections: recent literature and cornerstones of management.

PURPOSE OF REVIEW: Diabetes mellitus has reached pandemic levels and will continue to increase worldwide. Physicians and surgeons should know to manage one of its most prevalent complications, the diabetic foot infection (DFI), in a scientifically based and resource-sparing way. We performed a nonsystematic review of recent scientific literature to provide guidance on management of DFIs. RECENT FINDINGS: Studies in the past couple of years provide data on which recommendations for diagnosing and treating DFI are based, especially with validated guidelines and reviews of the microbiology and selected aspects of the complex DFI problem. Recent literature provides approaches to prevention and studies support more conservative surgical treatment. Unfortunately, there have been virtually no new therapeutic molecules, antibiotic regimens, randomized trials, or surgical techniques introduced in the recent past; we briefly discuss how this may change in the future. SUMMARY: Recent scientific evidence on DFI strongly supports the value of multidisciplinary and some new care models, guideline-based management, more preventive approaches, and confirms several established therapeutic concepts. In contrast, there has been almost no new substantial information regarding the optimal antibiotic or surgical management in recent literature.

[Isolated lesions of the distal tibiofibular syndesmosis]. / Lésions isolées de la syndesmose tibio-fibulaire distale.

A tibiofibular syndesmotic injury is rare, accounting 6 % of ankle sprain. The diagnosis can be difficult and is often likened to a lateral ankle sprain. Clinical signs are more subtle and pains are located above the joint line tibiotalar. These lesions should be considered in athletes with pain or trauma to the ankle. Late diagnosis is associated with significant morbidity up to osteoarthritis of the ankle. The management of these lesions is paramount and surgery may be necessary. The purpose of our article is to highlight this condition to increase the diagnosis rate and get our patients optimum recovery.

Les lésions de la syndesmose tibio-fibulaire sont rares, totalisant 6 % des entorses de la cheville sans fracture associée. Le diagnostic peut être difficile et est souvent assimilé à une entorse de la cheville. Ces lésions doivent être considérées chez les athlètes présentant des douleurs ou un traumatisme en torsion de la cheville. Les signes cliniques sont plus subtils et les douleurs se localisent au-dessus de la ligne articulaire tibio-talienne. Un diagnostic tardif est associé à une morbidité significa-tive pouvant aller jusqu'à une arthrose de la cheville. La prise en charge de ces lésions est primordiale et une chirurgie peut être nécessaire. Le but de cet article est de mettre en exergue cette pathologie pour augmenter son taux de diagnostics et obtenir chez nos patients une récupération optimum.

Oropharyngeal Kingella kingae carriage in children: characteristics and correlation with osteoarticular infections.

BACKGROUND: The aim of this study was to investigate changes in oropharyngeal K. kingae carriage during the first 4 y of life, including seasonal variation and comparison of asymptomatic carriage with cases of invasive osteoarticular infections (OAI). METHODS: Oropharyngeal bacterial K. kingae carriage was screened in 744 healthy children aged 7-48 mo between January 2009 and December 2012. Oropharyngeal swabs were analyzed by rt-PCR targeting the DNA of K. kingae RTX toxin, epidemiological characteristics of asymptomatic carriers and OAI case patients were recorded. RESULTS: The carriage prevalence showed no significant difference between age groups or seasons. Compared with asymptomatic carriers, OAI cases were more likely to be aged from 7 to 12 mo (OR = 2.5; 95% CI (1.2-5.0)) and 13-24 mo (OR = 2.2; 95% CI (1.2-3.9)), and less likely over 36 mo (OR = 0.2; 95% CI (0.1-0.7)). Fewer OAI cases were identified in spring compared to asymptomatic carriers (OR = 0.3; 95% CI (0.1-0.7)), while more were detected in autumn (OR = 2.5; 95% CI (1.4-4.4)). CONCLUSION: Although oropharyngeal K. kingae colonization is a prerequisite for further invasive infection, this epidemiological study emphasizes that the carriage rate variations do not correlate with the variations of OAI incidence by gender, season, or age group.

Factors affecting bone mineral mass loss after lower-limb fractures in a pediatric population.

BACKGROUND: The purpose of this study was to assess the effects of the durations of cast immobilization and non-weight-bearing periods, and decreases in vigorous physical activity (VPA) on bone mineral parameters in a pediatric population treated for a lower-limb fracture. METHODS: Fifty children and teenagers who had undergone a cast-mediated immobilization for a leg or ankle fracture were prospectively recruited. The durations of cast immobilization and non-weight-bearing periods were recorded for each participant. Dual-energy x-ray absorptiometry scans were performed at the time of fracture treatment (baseline) and at cast removal. Physical activity during cast immobilization was assessed using accelerometers. RESULTS: A strong negative correlation was found between the total duration of cast immobilization and decreases in both calcaneal bone mineral density (BMD) (r=-0.497) and total lower-limb bone mineral content (BMC) (r=-0.405). A strong negative correlation was also noted between the durations of the non-weight-bearing periods and alterations in calcaneal BMD (r=-0.420). No apparent correlations were found between lower BMD and BMC and decreased VPA. CONCLUSIONS: Bone mineral loss was correlated to the total duration of cast immobilization for all measurement sites on the affected leg, whereas it was only correlated to the durations of non-weight-bearing periods for calcaneal BMD and total lower-limb BMC. However, no correlations were noted between bone mineral loss and decreased VPA.

[Severe osteoarticular infections with Staphylococcus aureus producer of Panton-Valentine Leukocidine in children]. / Infections ostéo-articulaires sévères d staphylocoque doré producteur de leucocidine de Panton-Valentine chez l'enfant.

Emerging strain of Stapylococcus aureus (S. aureus) producer of the Panton-Valentine Leukocidine (PVL+) are becoming a new issue in public health. Those bacteria are accountable for serious cutaneous infection with a necrotic evolution, necrotizing pneumonia and severe osteoarticular infection. These last infections can be life-threatening and are at high risk of complications. Therefore, a multidisciplinary approach is necessary, in addition with an aggressive chirurgical treatment. We are here reporting 3 cases of osteoarticular infections by S. aureus PVL+ sensitive to methicilline, which illustrate the difficulties encountered in the management and treatment, as well as the potential for serious orthopedics complications.

Do Patients With Functional Hallux Limitus Have a Low-Lying or Bulky FHL Muscle Belly?

Background: Functional hallux limitus (FHLim) refers to a limitation of hallux dorsiflexion when the first metatarsal head is under load, whereas physiologic dorsiflexion is measured in the unloaded condition. Limited excursion of the flexor hallucis longus (FHL) in the retrotalar pulley has been identified as a possible cause of FHLim. A low-lying or bulky FHL muscle belly could be the cause of this limitation. However, to date, there are no published data regarding the association between clinical and anatomical findings. The purpose of this anatomical study is to correlate the presence of FHLim and objective morphologic findings through magnetic resonance imaging (MRI). Methods: Twenty-six patients (27 feet) were included in this observational study. They were divided into 2 groups, based on positive and negative Stretch Tests. In both groups, we measured on MRI the distance from the most inferior part of the FHL muscle belly and the retrotalar pulley as well as the cross-sectional area of the muscle belly 20, 30, and 40 mm proximal to the retrotalar pulley. Results: Eighteen patients had a positive Stretch Test and 9 patients had a negative Stretch Test. The mean distance between the most inferior part of the FHL muscle belly and the retrotalar pulley was 6.0 ± 6.4 mm for the positive group and 11.8 ± 9.4 mm for the negative group (P = .039). The mean cross section of the muscle measured at 20, 30, and 40 mm from the pulley were 190 ± 90, 300 ± 112, and 395 ± 123 mm2 for the positive group and 98 ± 44, 206 ± 72, and 294 ± 61mm2 for the negative group (P values .005, .019, and .017). Conclusion: Based on these findings, we can conclude that patients with FHLim do have a low-lying FHL muscle belly causing limited excursion in the retrotalar pulley. However, the mean volume of the muscle belly was comparable in both groups, and therefore bulkiness was not found to be a contributing factor. Level of Evidence: Level III, observational study.

Return to sport after surgery for osteochondral lesions of the talar dome. Results of a multicenter prospective study on 58 patients.

INTRODUCTION: Osteochondral lesions of the talar dome (OLTD) are most often found in patients for whom the return to sports activities is the main issue. Two types of surgery have been distinguished at present, bone marrow stimulation techniques and mosaicplasty techniques. The size of the lesion indicating the need for bone marrow stimulation as the required surgical procedure has recently been decreased (<1cm). The main objective of this study was therefore to evaluate the return to sport after OLTD surgery. Our hypothesis is that surgery of osteochondral lesions of the talar dome allows the resumption of sports activities in the majority of cases. MATERIAL AND METHODS: This multicenter prospective study was conducted across 10 French centers specializing in foot and ankle surgery. All patients aged 18 to 65 with symptomatic OLTD resistant to thorough medical treatment for at least 6 months, justifying surgery, were included from June 2018 to September 2019. In addition to the usual demographic data, the practice of sport and level (professional, competitive, leisure) were systematically investigated preoperatively. A common protocol for surgical management and postoperative follow-up had previously been established according to the arthrographic stage of the lesion. The most recent recommendations based on size, but also depth, were taken into account. The primary endpoint was return to sport. RESULTS: A final functional evaluation with the AOFAS (American Orthopedic Foot & Ankle Society) score was performed at a minimum of 12 months. Of 58 sports patients, 70.6% returned to sport (41/58) with an average delay of 4.3 months. A high AOFAS functional score (p=0.02) and a stage 1 lesion (p=0.006) were the only preoperative criteria significantly associated with a return to sport. No other factor was predictive of a return to sport. CONCLUSION: Our prospective study shows that 70.6% of sports patients returned to sport after OLTD surgery according to a surgical protocol and standardized follow-up. LEVEL OF EVIDENCE: II.

Iatrogenic transfer metatarsalgia after hallux valgus surgery: a comprehensive treatment algorithm.

Current literature has described many of the complications following hallux valgus surgery and their treatment options. Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet. Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique. We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication. With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

Osteochondral lesion of the talus: What are we talking about?

INTRODUCTION: The analysis of osteochondral lesions of talus (OLT) is currently mostly descriptive, not permitting an understanding of the different nosological frameworks of these lesions. Better knowledge of the characteristics of patients with OLT should make it possible to optimize the surgical indications and anticipate the associated lesions, which should not be overlooked. The main objective of this study was, therefore, to assess the characteristics of patients with OLT, and to analyze the lesions encountered. HYPOTHESIS: OLTs correspond to variable entities responding to specific treatments. MATERIAL AND METHOD: This was a prospective multicenter descriptive study including all patients operated on for an OLT, aged between 15 and 65 years, across 10 French specialist centers. The demographic, clinical and radiological data of the patients were analyzed. RESULTS: OLTs predominantly affect males and patients in their thirties. Two types of OLT should be distinguished: a lateral OLT; smaller and more superficial, most often presenting with painful instability, in the context of trauma, and a medial OLT; more frequent, wider and deeper. DISCUSSION: Two nosological frameworks exist for OLTs, and correspond to precise surgical indications: medial lesions of more than 10mm2 and more than 5mm in depth, with isolated anteromedial pain and significant functional impairment, most often idiopathic, generally requiring treatment by osteochondral autografts. Lateral lesions less than 5mm in depth and less than 10mm2, often superficial, following trauma or ankle laxity, associated with lateral ligament damage in one-third of cases, and a clinical presentation associated to instability and pain, requiring treatment most often by microfracture with associated ligament repair. LEVEL OF EVIDENCE: III.

Safety of malleolar osteotomies in surgery for osteochondral lesions of the talus.

The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs. HYPOTHESIS: The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol. MATERIALS AND METHOD: This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated. RESULTS: No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series. DISCUSSION: There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded. LEVEL OF EVIDENCE: IV.

Proposal of a new CT arthrographic classification system of osteochondral lesions of the talus.

BACKGROUND: Surgical treatment of osteochondral lesions of the talus (OLT) is warranted if medical treatments fail, achieving good results in around 85% of cases. Numerous classification systems, based on all possible imaging modalities (radiography, MRI, CT scan, scintigraphy, and CT arthrography), have been proposed to guide surgical treatments, but none has proven to be superior. A recent study demonstrated the prognostic value of CT arthrography by accurately describing the subchondral bone plate. A systematic review of the literature has brought new criteria to predict good outcome following bone marrow stimulation surgical techniques: lesions should measure less than 1 centimeter in size and 5 millimeters in depth. Based on these data, we are proposing a new simple, 3-stage CT arthrographic classification system of OLT. MATERIALS AND METHODS: After a brief overview of the classification, 60 CT-arthrographies of ankles with OLT were organized according to this new CT arthrographic classification system by four surgeons (two juniors and two seniors). Two imaging assessments were performed one month apart. Statistical analysis was performed using the Fleiss' kappa coefficient to determine the inter- and intraobserver agreement. RESULTS: An excellent inter- and intraobserver agreement was found with overall Fleiss' kappa coefficients of 0.897 and 0.847, respectively. CONCLUSION: The results of our study showed an excellent inter- and intraobserver agreement for this new CT arthrographic classification system of OLT. The principal advantage of this new classification system, based on the latest data in the literature, is its ability to easily distinguish lesions that are more amenable to bone marrow stimulation techniques. LEVEL OF EVIDENCE: II.

Muscular Versus Non-Muscular Free Flaps for Soft Tissue Coverage of Chronic Tibial Osteomyelitis.

BACKGROUND: Eradication of chronic tibial osteomyelitis necessitates aggressive debridement is often followed by soft tissue reconstruction. Muscular flaps are said to be more effective than non-muscular flaps for infection treatment, while fasciocutaneous and perforator flaps are considered to be less invasive and offering a better aesthetic result. METHODS: In this study, we reviewed 24 consecutive cases of chronic tibial osteomyelitis treated according to a specific protocol in a tertiary hospital. Soft tissue coverage was done with either muscular or non-muscular free flaps. Infection recurrence and complications were compared between different flap types. Additionally, we assessed the long-term functional and aesthetic results and patient's satisfaction. RESULTS: Muscular flap was used in 13 patients (13 latissimus dorsi and 1 serratus anterior) and 11 patients underwent fasciocutaneous/perforator flaps [1 anterolateral thigh flap, 4 lateral arm flaps, 5 thoracodorsal artery perforator (TAP) flaps and 1 radial forearm flap]. Infection was resolved for 84.6% of patients in the muscular flaps group and 90.9% in the non-muscular flaps group. None of the patients with muscular flaps were satisfied with the aesthetic appearance of their reconstructed leg when compared to 83.3% of patients with non-muscular flaps. Also, a slight regain of touch sensitivity was acknowledged in the non-muscular flap group compared to the muscular. CONCLUSION: In this study of adult chronic tibial osteomyelitis cases, we demonstrated that fasciocutaneous and perforator free flaps offer a comparable efficacy to the muscle flaps for infection treatment, with a significantly higher patient satisfaction and aesthetic result.