Clinical evaluation of tibiocalcaneal arthrodesis with retrograde intramedullary nail fixation in diabetic patients.

OBJECTIVE: The aim of this study was to evaluate clinical and functional outcomes in diabetic patients undergoing tibiocalcaneal arthrodesis using a retrograde nail. METHODS: A total of 12 diabetic patients [8 men and 4 women; mean age at intervention: 56.8 years (range: 27-76 years)] who underwent tibiocalcaneal arthrodesis by a retrograde nail were enrolled in this study. The indication for surgery was massive talar osteonecrosis in four patients, Charcot arthropathy in another four patients, and various severe ankle/hindfoot derangements in four patients. All surgeries were performed by the same surgeon. All patients were evaluated by their American Orthopedic Foot and Ankle Score (AOFAS) score, and radiographic follow-up was performed. RESULTS: The mean follow-up time was 59.5 months (range: 27-121 months). Ten patients (83.3%) healed and were able to walk with full weight bearing without crutches. Among them, nine patients (75%) achieved union with solid bone healing. The mean overall improvement in the AOFAS score was 72.5% (preoperatively: 40 points vs postoperatively: 69 points; p<0.001). We observe a complication in 50% of our patients. Minor complications included two cases of dehiscence of the surgical wound, one case of soft tissue irritation owing to hardware protrusion, and one cause of lymphedema. Two patients had deep infection and underwent surgical removal of hardware, debridement, and antibiotic treatment: one healed after the treatment but never recovered full weight bearing and the other one died from other complications. These two deep infections occurred after 23 months of follow-up. CONCLUSION: Tibiocalcaneal arthrodesis using retrograde nails is a salvage technique extremely effective in ankle and hindfoot disorders in a diabetic patient. This procedure allows good functional outcomes and pain relief. When correctly indicated, it is a safe procedure with good clinical outcomes and low risk of below-knee amputation. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Lateral collateral ligament repair : Anatomical ligament reinsertion with augmentation using inferior extensor retinaculum flaps.

OBJECTIVE: For chronic lateral ankle instability an anatomical repair procedure of the lateral collateral ligaments (LCL) of the ankle with augmentation by an inferior extensor retinaculum (IER) flap is proposed. INDICATIONS: To treat the mechanical parts of an instable ankle involving both LCL and subtalar joint ligament damage. CONTRAINDICATIONS: This technique is not suitable when the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are in a poor anatomical condition (exhaustive preoperative lesion mapping mandatory). SURGICAL TECHNIQUE: This technique combines the reinsertion of the remnants of the lateral ligaments of the ankle, the ATFL and the CFL using anchors, with augmentation using an inferior extensor retinaculum flap fixed in a tunnel by an interference screw. This flap works as an actual neoligament, providing not only reinforcement and collagen input but also peripheral stabilization of the subtalar joint by its calcaneal insertion and reinforcing the CFL stabilizing effect. POSTOPERATIVE MANAGEMENT: Following immediate immobilization in an ankle-foot orthosis, proprioceptive physiotherapy exercises are initiated with a return to sports depending on the type of sport. RESULTS: The postoperative outcomes and long-term follow-up results of this technique are discussed.

Allograft for the treatment of traumatic severe bone loss in the lateral femoral condyle: A case report.

BACKGROUND: Open articular fractures are an important issue due to their increasing incidence, along with the rise in motorcycle accidents. Oncology experience with allograft in orthopedics may be extended to cases of traumatic bone loss. CLINICAL CASE: A 37-year-old man with an open fracture of the distal femur and proximal tibia presented a massive bone loss of the lateral femoral condyle after a motorcycle accident. Following Damage Control Surgery, a considerable lateral femoral condyle allograft was used to restore the joint anatomy. RESULTS: After an intensive rehabilitation program and two subsequent arthroscopic arthrolyses, the patient resumed walking without aids and recovered from stiffness (R.O.M. 0-130°). An MRI performed at median follow-up, revealed a favorable integration of the allograft. DISCUSSION: Allografts are a reasonable reconstructive option for young individuals with massive bone loss. An appropriately sized allograft is essential to restore an acceptable function as seen in the herein case.

Return to sport activity after anterior cruciate ligament reconstruction in skeletally immature athletes with manual drilling original all inside reconstruction at 8 years follow-up.

OBJECTIVE: Anterior cruciate ligament (ACL) tears are common injuries in adolescent athletes, especially in those who bear high stress on their knees due to shearing forces. The goal of the surgical procedures in skeletally immature patients is to restore joint stability avoiding the adverse effects on the growth process. The aim of this study was to verify the return of the skeletally immature professional athletes to sports in the long-term, following ACL reconstruction with the original all-inside technique and with manual drilling. METHODS: This study included 24 athletes (14 boys, 10 girls; mean age: 13.15 years, range: 9-14 years) who had radiographic evidence of open physes, were less than 14 years of age at the time of surgery and those with a minimum follow-up of eight years. All patients completed a questionnaire, the IKDC subjective knee evaluation form, and Tegner Activity Scale. Biomechanical outcomes of the KT-1000 arthrometer, gait analysis, and stabilometric and isokinetic results were also evaluated. A plain radiograph of both lower limbs was taken to obtain a precise measurement of the limb length and mechanical axis angles. RESULTS: The patients returned to sport activities in a mean time of 6.43 months. No rerupture or resurgery due to growth abnormalities was observed. The mean difference in length between the operated and contralateral legs was 0.4 (range: -0.2 to 0.7) cm. The mean side-to-side difference measured with the KT-1000 arthrometer was 5.2 (range: 3.5 to 7) mm in the preoperative and 0.8 (range: 0 to 2.5) mm in the postoperative measurements. CONCLUSION: In conclusion, the original all-inside technique with manual drilling with a half tunnel and short graft seems to be a very effective technique for the surgical management of ACL injuries in pediatric/adolescent athletes. A good rate of return to sports at pre-injury levels or higher, high patient satisfaction and a decent motor and proprioceptive function is possible as shown by our analysis. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

A Study of Inflammatory/Necrosis Biomarkers in the Fracture of the Femur Treated with Proximal Femoral Nail Antirotation.

Pertrochanteric fractures are common injuries in adults and source of morbidity and mortality among the elderly. Different surgical techniques were recommended for their treatment but undoubtedly they add an additional inflammatory trauma along the fracture itself. Many attempts to quantify the degree of approach-related trauma are carried out through measurements of systemic inflammatory parameters. In this study we prospectively analyzed laboratory data of 20 patients over eighty with pertrochanteric fracture of the femur treated with proximal femoral nail antirotation (PFNA). This is an excellent device for osteosynthesis because it can be easily and quickly inserted by a mini-incision providing stable fixation and early full mobilization. Serum tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP), and plasma creatin kinase (CK) were evaluated 1 hour preoperatively and 24 hours postoperatively. Our results show that PFNA did not induce significant increments in serum levels of inflammatory cytokines TNF-α and IL-6; CRP was elevated preoperatively in correlation with waiting time for surgery; CRP and CK showed a significant increment in the first postoperatory day; CK increment was correlated with surgical time length. We conclude that, for the markers we analyzed, PFNA shows a low biomechanical-inflammatory profile that represents an advantage over other techniques.

Treatment and outcome of open dislocation of the ankle with complete talar extrusion: a case report.

BACKGROUND: Open total talar extrusion is a severe, disabling ankle injuries. The most appropriate treatment (reimplantation versus talar body removal and tibiocalcaneal arthrodesis) is still a controversial challenge; outcomes and fearful potential complications are not predictable. OBJECTIVE: To report the case of an open ankle dislocation with talar extrusion, focusing on treatment modality and outcomes. METHOD: Immediate reduction, surgical debridement and external fixation were performed under antibiotic coverage. Wound closure was achieved with accurate debridement, postoperative strict clinical surveillance and meticulous handling of medications. The patient maintained external fixator for three weeks, then kept non-weight bearing with a cast for an additional four weeks. RESULTS: The patient's wound healed with no complications. Full weight-bearing was gained at 12 weeks postoperation. At 18 months postoperatively, the patient did not develop any infection or a vascular necrosis, which are the major complications associated to talar extrusion. CONCLUSIONS: Good treatment procedure for a such severe open trauma, based on accurate debridement, wound care and stable temporary immobilization with external fixation allow reduction of infection risk and made preservation of extruded talus a successful option to preserve function and normal hindfoot anatomy at first instance. Talectomy should be considered as a salvage procedure.