Treatment of displaced intra-articular calcaneal fractures using a sinus tarsi approach. Surgical technique. / Técnica quirúrgica del manejo de las fracturas de calcáneo a través de un abordaje del seno del tarso.

Calcaneal articular fractures are fractures classically associated with a high rate of complications and poor outcomes. Osteosynthesis of the calcaneus through a sinus tarsi approach has shown results equal to or superior to those of the extended approach, having become the new gold standard. The objective of this article is to detail step by step the surgical technique of osteosynthesis of intra-articular fractures of the calcaneus through a sinus tarsi approach, from the selection of the fracture, positioning of the patient, layout of the operating room and the fluoroscope, the entire surgical process until postoperative treatment. The surgical technique described below is described in 6 steps. Anatomical reduction of complex calcaneal fractures through an Sinus Tarsi Approach requires an understanding of the fracture and its associated deformities. Following the described sequence step by step will help to achieve a better reduction in order to achieve better functional results.

Factores etiopatogénicos y tratamiento de la enfermedad de Müller-Weiss / Etiopathogenic factors and treatment of Müller-Weiss disease

Antecedentes y objetivo: La enfermedad de Müller-Weiss (EMW) es una anomalía poco frecuente del escafoides tarsiano. Maceira y Rochera propusieron la teoría etiopatogénica más comúnmente aceptada, en la que estarían implicados factores displásicos, mecánicos y ambientales socioeconómicos. Se pretende describir las características clínicas y sociodemográficas de los pacientes de nuestro entorno con EMW, corroborar su asociación con los factores socioeconómicos descritos previamente, estimar la influencia de otros factores descritos en el desarrollo de la EMW, así como describir el tratamiento realizado. Materiales y métodos: Estudio retrospectivo de 60 pacientes diagnosticados de EMW en 2 hospitales terciarios de Valencia (España) entre los años 2010 y 2021. Resultados: Se incluyeron 60 pacientes, 21 (35,0%) hombres y 39 (65,0%) mujeres. En 29 (47,5%) casos la afectación fue bilateral. La media de edad de inicio de la sintomatología fue de 41,9±20,3 años. Durante la infancia, 36 (60,0%) pacientes sufrieron movimientos migratorios, y 26 (43,3%) problemas dentarios. La edad media de inicio laboral fue de 14,6±4,5 años. Se trataron de forma ortopédica 35 (58,3%) casos frente a 25 (41,7%) tratados quirúrgicamente, 11 (18,3%) mediante osteotomía de calcáneo y 14 (23,3%) con artrodesis. Conclusiones: Al igual que en la serie de Maceira y Rochera, encontramos una mayor prevalencia de EMW entre los nacidos alrededor de la Guerra Civil española y el periodo de movimientos migratorios masivos acontecidos en la quinta década del siglo xx. El tratamiento sigue sin estar bien establecido.(AU)

Background and aim: Müller-Weiss disease (MWD) is a rare anomaly of the tarsal scaphoid. Maceira and Rochera proposed the most commonly accepted etiopathogenic theory, in which dysplastic, mechanical, and socioeconomic environmental factors would be involved. The aim is to describe the clinical and sociodemographic characteristics of patients with MWD in our setting, corroborate their association with the socioeconomic factors previously described, estimate the influence of other factors involved in the development of MWD, and describe the treatment carried out. Materials and methods: Retrospective study of 60 patients diagnosed with MWD in 2 tertiary hospitals of Valencia (Spain) between 2010 and 2021. Results: Sixty patients were included, 21 (35.0%) men and 39 (65.0%) women. In 29 (47.5%) cases, the disease was bilateral. The mean age of onset of symptomatology was 41.9±20.3 years. During childhood, 36 (60.0%) patients suffered migratory movements, and 26 (43.3%) had dental problems. The mean age of onset was 14.6±4.5 years. Thirty-five (58.3%) cases were treated orthopedically versus 25 (41.7%) treated surgically, 11 (18.3%) by calcaneal osteotomy, and 14 (23.3%) with arthrodesis. Conclusions: As in the series of Maceira and Rochera, we found a higher prevalence of MWD among those born around the Spanish Civil War and the period of massive migratory movements that occurred in the fifth decade of the 20th century. Treatment is still not well established.(AU)

[Translated article] Aetiopathogenic factors and treatment of Müller-Weiss disease / Factores etiopatogénicos y tratamiento de la enfermedad de Müller-Weiss

Antecedentes y objetivo: La enfermedad de Müller-Weiss (EMW) es una anomalía poco frecuente del escafoides tarsiano. Maceira y Rochera propusieron la teoría etiopatogénica más comúnmente aceptada, en la que estarían implicados factores displásicos, mecánicos y ambientales socioeconómicos. Se pretende describir las características clínicas y sociodemográficas de los pacientes de nuestro entorno con EMW, corroborar su asociación con los factores socioeconómicos descritos previamente, estimar la influencia de otros factores descritos en el desarrollo de la EMW, así como describir el tratamiento realizado. Materiales y métodos: Estudio retrospectivo de 60 pacientes diagnosticados de EMW en 2 hospitales terciarios de Valencia (España) entre los años 2010 y 2021. Resultados: Se incluyeron 60 pacientes, 21 (35,0%) hombres y 39 (65,0%) mujeres. En 29 (47,5%) casos la afectación fue bilateral. La media de edad de inicio de la sintomatología fue de 41,9±20,3 años. Durante la infancia, 36 (60,0%) pacientes sufrieron movimientos migratorios, y 26 (43,3%) problemas dentarios. La edad media de inicio laboral fue de 14,6±4,5 años. Se trataron de forma ortopédica 35 (58,3%) casos frente a 25 (41,7%) tratados quirúrgicamente, 11 (18,3%) mediante osteotomía de calcáneo y 14 (23,3%) con artrodesis. Conclusiones: Al igual que en la serie de Maceira y Rochera, encontramos una mayor prevalencia de EMW entre los nacidos alrededor de la Guerra Civil española y el periodo de movimientos migratorios masivos acontecidos en la quinta década del siglo xx. El tratamiento sigue sin estar bien establecido.(AU)

Background and aim: Müller-Weiss disease (MWD) is a rare anomaly of the tarsal scaphoid. Maceira and Rochera proposed the most commonly accepted etiopathogenic theory, in which dysplastic, mechanical, and socioeconomic environmental factors would be involved. The aim is to describe the clinical and sociodemographic characteristics of patients with MWD in our setting, corroborate their association with the socioeconomic factors previously described, estimate the influence of other factors involved in the development of MWD, and describe the treatment carried out. Materials and methods: Retrospective study of 60 patients diagnosed with MWD in 2 tertiary hospitals of Valencia (Spain) between 2010 and 2021. Results: Sixty patients were included, 21 (35.0%) men and 39 (65.0%) women. In 29 (47.5%) cases, the disease was bilateral. The mean age of onset of symptomatology was 41.9±20.3 years. During childhood, 36 (60.0%) patients suffered migratory movements, and 26 (43.3%) had dental problems. The mean age of onset was 14.6±4.5 years. Thirty-five (58.3%) cases were treated orthopedically versus 25 (41.7%) treated surgically, 11 (18.3%) by calcaneal osteotomy, and 14 (23.3%) with arthrodesis. Conclusions: As in the series of Maceira and Rochera, we found a higher prevalence of MWD among those born around the Spanish Civil War and the period of massive migratory movements that occurred in the fifth decade of the 20th century. Treatment is still not well established.(AU)

Incidence of Injuries Associated With Anterior Talofibular Ligament Injury Based on the Reporting of Magnetic Resonance Imaging.

Introduction This paper aims to report the incidence of ligamentous, tendon, and other structural injuries associated with an anterior talofibular ligament (ATFL) injury based on magnetic resonance imaging (MRI) findings. Methods The reports of all patients who underwent surgical treatment for ATFL injury between 2021 and 2022 at Changi General Hospital and had preoperative MRI ankle scans performed were analyzed in this retrospective study. Patients who had a preoperative MRI ankle scan performed with specific reporting of the ATFL, calcaneofibular ligament (CFL), deltoid ligaments, peroneal tendons, and the presence of an osteochondral defect (OCD) were included in this study. Patients who underwent surgery but did not have a preoperative MRI ankle scan done or had ankle fractures or systemic conditions affecting the same ankle were excluded. Results Eighty-six patients were included in this study, of which 59 were males and 27 were females. About 73.3% (63 of 86) of patients had sustained injuries in association with ATFL injury, and 58.1% (50 of 86) of patients suffered an associated injury to the calcaneofibular ligament (CFL). There were injuries to the superficial and deep deltoid ligaments in 29.1% (25 of 86) and 44.2% (38 of 86) of patients, respectively. The peroneal tendons were also injured in 17.4% (15 of 86) of patients. Lastly, there were also associated OCDs found in 19.8% (17 of 86) of patients. Conclusion There is a high incidence of injuries associated with an ATFL injury. The CFL and deltoid ligament complex are the most commonly injured structures in association with the ATFL. One in five patients will also have an associated OCD. The ATFL tends to be the only structure that is commonly addressed during surgery. Repair of the ATFL only may thus lead to poorer outcomes and persistent pain, if the underlying cause is due to the other concurrent injuries. Clinical evaluation of the other structures should thus be thoroughly performed to allow the addressing of any concurrent injuries in the same surgical setting to achieve better outcomes.

[Translated article] Aetiopathogenic factors and treatment of Müller-Weiss disease.

BACKGROUND AND AIM: Müller-Weiss disease (MWD) is a rare anomaly of the tarsal scaphoid. Maceira and Rochera proposed the most commonly accepted etiopathogenic theory, in which dysplastic, mechanical, and socioeconomic environmental factors would be involved. The aim is to describe the clinical and sociodemographic characteristics of patients with MWD in our setting, corroborate their association with the socioeconomic factors previously described, estimate the influence of other factors involved in the development of MWD, and describe the treatment carried out. MATERIALS AND METHODS: Retrospective study of 60 patients diagnosed with MWD in 2 tertiary hospitals of Valencia (Spain) between 2010 and 2021. RESULTS: Sixty patients were included, 21 (35.0%) men and 39 (65.0%) women. In 29 (47.5%) cases, the disease was bilateral. The mean age of onset of symptomatology was 41.9±20.3 years. During childhood, 36 (60.0%) patients suffered migratory movements, and 26 (43.3%) had dental problems. The mean age of onset was 14.6±4.5 years. Thirty-five (58.3%) cases were treated orthopedically versus 25 (41.7%) treated surgically, 11 (18.3%) by calcaneal osteotomy, and 14 (23.3%) with arthrodesis. CONCLUSIONS: As in the series of Maceira and Rochera, we found a higher prevalence of MWD among those born around the Spanish Civil War and the period of massive migratory movements that occurred in the fifth decade of the 20th century. Treatment is still not well established.

Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions.

INTRODUCTION: In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. MATERIALS AND METHODS: Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8 mm (range 3-7 mm). DISCUSSION AND CONCLUSION: A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.

Technique for Foot Reconstruction with Custom-made Calcaneal Prosthesis in Primary Malignancy - A Case Report / Técnica de reconstrução do pé com prótese de calcâneo feita sob medida em câncer primário - Relato de caso

Abstract The foot is an uncommon location for osseous tumors, comprising ~ 3% of all skeletal tumors, which occur particularly around the calcaneum. Radical surgery creates a void in the foot which adversely affects the ability to salvage it. Calcaneal replacement surgeries are not commonly performed due to factors involving instability of the prosthesis, soft-tissue defects, and resultant failure, which can occur in the postoperative period. Thus, we herein report a rare case of synovial sarcoma arising from the sheath of the tibialis posterior tendon, with secondary involvement of the calcaneus bone. Considering the previous experiences of different surgeons, a custom-made prosthesis was designed with relevant modifications.

Resumo O pé é um local incomum para tumores ósseos, e compreende cerca de 3% de todos os tumores esqueléticos, em especial ao redor do calcâneo. A cirurgia radical cria um vazio no pé, o que afeta de forma negativa a capacidade de resgate do membro. As cirurgias de reconstrução do calcâneo não são comumente realizadas por causa da instabilidade da prótese, defeito de partes moles, e consequente possibilidade de insucesso pósoperatório. Assim, apresentamos aqui um caso raro de sarcoma sinovial originário da bainha do tendão tibial posterior com acometimento secundário do osso calcâneo. Considerando as experiências prévias de diferentes cirurgiões, projetamos uma prótese sob medida com modificações relevantes.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study / Configuración y localización óptima de los tornillos posteriores en las fracturas de calcáneo Sanders 2B: estudio biomecánico

Background: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. Methods: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm). Results: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations...(AU)

Introducción: Las fracturas de calcáneo suelen ser lesiones intraarticulares de alta energía asociadas con hundimiento articular. Además, se añade con frecuencia el estallido de la pared lateral, la superposición de la pared medial, la conminución y la pérdida de hueso bajo la carilla articular. La deformidad secundaria, como el varo del retropié, altera la biomecánica del pie. Nuestra comunidad utiliza cada vez más abordajes mínimamente invasivos con reducción indirecta de la tuberosidad del calcáneo para mantener la reducción mediante tornillos posteriores. Hay estudios que proponen diferentes configuraciones de tornillos, tras experimentación biomecánica, pero aún no es bien conocido qué configuración controla mejor la deformidad en varo. Este estudio tiene como objetivo determinar la configuración óptima del tornillo para controlar la deformidad en varo en las fracturas de calcáneo Sanders 2B. Método: Se prepararon modelos en Sawbone para replicar la fractura de Sanders tipo 2B, con pérdida de hueso central y con conminución. Se eliminó una cuña medial de 0,5cm de la tuberosidad calcánea para crear inestabilidad en varo. Tras estabilizar el ángulo de Gissane con un tornillo aislado parcialmente roscado de 4mm y una placa moldeada, se utilizaron tornillos de compresión multiuso Charlotte (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) sin cabeza, canulados y parcialmente roscados de 7mm insertados sobre una AK bajo escopia. El desplazamiento del plano sagital del fragmento de tuberosidad fracturado en comparación con el cuerpo al aplicar una fuerza de 5N, 10N y 20N se midió en milímetros (mm). Resultados: Dos tornillos insertados (un tornillo medial en el sustenaculum tali de inferior a superior y un tornillo lateral en el eje largo del astrágalo) proporciona el menor desplazamiento (0,88±0,390 a 5N y 1,7±1,251 a 20N) y resulta la construcción más estable (p<0,05) en comparación con otras configuraciones...(AU)

[Artículo traducido] Configuración y localización óptima de los tornillos posteriores en las fracturas de calcáneo Sanders 2B: estudio biomecánico / Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study

Background: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. Methods: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm). Results: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations...(AU)

Introducción: Las fracturas de calcáneo suelen ser lesiones intraarticulares de alta energía asociadas con hundimiento articular. Además, se añade con frecuencia el estallido de la pared lateral, la superposición de la pared medial, la conminución y la pérdida de hueso bajo la carilla articular. La deformidad secundaria, como el varo del retropié, altera la biomecánica del pie. Nuestra comunidad utiliza cada vez más abordajes mínimamente invasivos con reducción indirecta de la tuberosidad del calcáneo para mantener la reducción mediante tornillos posteriores. Hay estudios que proponen diferentes configuraciones de tornillos, tras experimentación biomecánica, pero aún no es bien conocido qué configuración controla mejor la deformidad en varo. Este estudio tiene como objetivo determinar la configuración óptima del tornillo para controlar la deformidad en varo en las fracturas de calcáneo Sanders 2B. Método: Se prepararon modelos en Sawbone para replicar la fractura de Sanders tipo 2B, con pérdida de hueso central y con conminución. Se eliminó una cuña medial de 0,5cm de la tuberosidad calcánea para crear inestabilidad en varo. Tras estabilizar el ángulo de Gissane con un tornillo aislado parcialmente roscado de 4mm y una placa moldeada, se utilizaron tornillos de compresión multiuso Charlotte (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) sin cabeza, canulados y parcialmente roscados de 7mm insertados sobre una AK bajo escopia. El desplazamiento del plano sagital del fragmento de tuberosidad fracturado en comparación con el cuerpo al aplicar una fuerza de 5N, 10N y 20N se midió en milímetros (mm). Resultados: Dos tornillos insertados (un tornillo medial en el sustenaculum tali de inferior a superior y un tornillo lateral en el eje largo del astrágalo) proporciona el menor desplazamiento (0,88±0,390 a 5N y 1,7±1,251 a 20N) y resulta la construcción más estable (p<0,05) en comparación con otras configuraciones...(AU)

Approach to Ankle Instability in Patients With a Negative Ankle MRI: A Case Series.

Objectives Injuries to the ankle ligaments are some of the most common musculoskeletal sports injuries. Ankle magnetic resonance imaging (MRI) is the standard diagnostic procedure in today's practice, but its reliability and validity remain controversial. The aim of this study was to explore the approach for patients with negative ankle MRI who continue to have symptoms of ankle instability despite conservative therapy. Methods A total of eight patients who were 14 years or older with negative ankle MRI who continue to have symptoms of ankle instability despite conservative therapy were admitted to our institution from January 1, 2015 to December 31, 2021. Results Eight patients with a mean age of 36, and a mean body mass index (BMI) of 37.7. All patients presented with ankle pain, locking, and giving way in variable severity. All the patients had a radiograph followed by an ankle MRI, which showed normal alignment of ankle joints without abnormality. Initially, all patients were treated conservatively but did not show any improvement. After that, they underwent an operation of lateral ankle ligament reconstruction by modified Brostrom technique, followed by casting and physiotherapy. The symptoms of ankle instability resolved in all patients. The ankle pain resolved completely in six patients, improved in one patient, and did not improve in one patient.  Conclusion Based on our results, we advocate reconstruction surgery by modified Brostrom technique for ligament repair in patients with clinical evidence of chronic ankle instability who have failed a trial of conservative management, even in the context of a normal ankle MRI.

Etiopathogenic factors and treatment of Müller-Weiss disease. / Factores etiopatogénicos y tratamiento de la enfermedad de Müller-Weiss.

BACKGROUND AND AIM: Müller-Weiss disease (MWD) is a rare anomaly of the tarsal scaphoid. Maceira and Rochera proposed the most commonly accepted etiopathogenic theory, in which dysplastic, mechanical, and socioeconomic environmental factors would be involved. The aim is to describe the clinical and sociodemographic characteristics of patients with MWD in our setting, corroborate their association with the socioeconomic factors previously described, estimate the influence of other factors involved in the development of MWD, and describe the treatment carried out. MATERIALS AND METHODS: Retrospective study of 60 patients diagnosed with MWD in 2 tertiary hospitals of Valencia (Spain) between 2010 and 2021. RESULTS: Sixty patients were included, 21 (35.0%) men and 39 (65.0%) women. In 29 (47.5%) cases, the disease was bilateral. The mean age of onset of symptomatology was 41.9±20.3 years. During childhood, 36 (60.0%) patients suffered migratory movements, and 26 (43.3%) had dental problems. The mean age of onset was 14.6±4.5 years. Thirty-five (58.3%) cases were treated orthopedically versus 25 (41.7%) treated surgically, 11 (18.3%) by calcaneal osteotomy, and 14 (23.3%) with arthrodesis. CONCLUSIONS: As in the series of Maceira and Rochera, we found a higher prevalence of MWD among those born around the Spanish Civil War and the period of massive migratory movements that occurred in the fifth decade of the 20th century. Treatment is still not well established.

A comparison of effectiveness of sex estimation from the calcaneus and talus in a Thai population / Comparación de la efectividad de la estimación del sexo a partir del calcáneo y el talus en una población tailandesa

SUMMARY: Sex estimation is an important aspect of skeletal identification. In addition, previous studies have found that the sex estimation of each race is different. Thus, it is necessary to develop discriminant function equations for the estimation of sex for the Thai population. This study aims to investigate the relationship between width, length and height of the calcaneus and talus with regards to sex and compare the effectiveness of sex estimation between the calcaneus alone, the talus alone, and between both the calcaneus and talus. A total of 200 individuals (100 males and 100 females) were used in this study; ages ranged from 19 to 94 years. Thirteen variables of calcaneus and ten variables of talus were measured. The authors created discriminant function equations for the estimation of sex and tested the efficiency of the equations obtained by using a test group of 40 individuals (20 males and 20 females). By analyzing the mean values of the variables in the calcaneus and the talus, it was shown that males were significantly different from females (p0.05). A stepwise method was used to create 6 equations for sex estimation. The equations were categorized from between the calcaneus alone, the talus alone, and between both the calcaneus and the talus, providing a sex estimation accuracy of between 88.5 and 93.0 %. Using the test group, it was shown that discriminant function equations from the calcaneus alone, the talus alone, and the calcaneus and the talus together, can estimate sex at a high level of accuracy. Sex estimation accuracy was greater than 85 % in all equations. Therefore, the discriminant function equations from the calcaneus alone, the talus alone, and between both the calcaneus and the talus, from this study can be applied to the Thai population.

La estimación del sexo es un aspecto importante de la identificación esquelética. Estudios previos han encontrado que la estimación del sexo de cada raza es diferente. Por lo tanto, es necesario desarrollar ecuaciones de funciones discriminantes para la estimación del sexo de la población tailandesa. Este estudio tuvo como objetivo investigar la relación entre el ancho, el largo y la altura de los huesos calcáneo y talus con respecto al sexo y comparar la efectividad de la estimación del sexo entre el calcáneo solo, el talus solo y entre el calcáneo y el talus. Se utilizaron un total de 200 huesos de individuos adultos (100 hombres y 100 mujeres), cuyas edades oscilaron entre 19 y 94 años. Se midieron trece variables del calcáneo y diez variables del talus. Los autores crearon ecuaciones de funciones discriminantes para la estimación del sexo y probaron la eficiencia de ellas usando un grupo de prueba de huesos de 40 individuos (20 hombres y 20 mujeres). Al analizar los valores medios de las variables en el calcáneo y el talus, se demostró que los huesos de los hombres eran significativamente diferentes al de las mujeres (p0.05). Se utilizó un método paso a paso para crear 6 ecuaciones para la estimación del sexo. Las ecuaciones se clasificaron entre el calcáneo solo, el talus solo y entre el calcáneo y el talus, lo que proporcionó una precisión de estimación del sexo de entre 88,5 y 93,0 %. Usando el grupo de prueba, se demostró que las ecuaciones de funciones discriminantes del calcáneo solo, el talus solo y el calcáneo y el talus juntos pueden estimar el sexo con un alto nivel de precisión. La precisión de la estimación del sexo fue superior al 85 % en todas las ecuaciones. Por lo tanto, las ecuaciones de la función discriminante del calcáneo solo, el talus solo y entre el calcáneo y el talus de este estudio se pueden aplicar a la población tailandesa.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study.

BACKGROUND: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. METHODS: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm). RESULTS: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04±0.971 at 5N and 11.24±7.590 at 20N) (p<0.05). CONCLUSION: This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Talo-navicular and calcaneo-cuboid fusion with PEEK H-pode™ vs. Titanium Maxlock™ locking plates: Comparison of functional and radiographic outcomes.

BACKGROUND: Locking plates are increasingly used to achieve hindfoot fusion. The objective of this study was to compare hindfoot fusion outcomes with the PEEK H-pode™ (Biotech™) locking plate and the titanium Maxlock™ (Tornier-Wright™) locking plate. HYPOTHESIS: A polyetheretherketone (PEEK) H-pode™ locking plate provides similar fusion rates to a titanium Maxlock™ locking plate for talo-navicular and calcaneo-cuboid arthrodesis. METHODS: We conducted a retrospective comparative study in 39 patients (including 21 [54%] with pes planovalgus and 11 [28%] with neurological equinovarus deformities) who underwent talo-navicular and/or calcaneo-cuboid fusion, usually combined with subtalar fusion. The first 17 patients (January 2014-February 2016) were managed with Maxlock™ locking plates and the next 22 patients (March 2016-August 2018) with H-pode™ locking plates. These two cohorts of consecutive patients were comparable regarding age, sex distribution, body mass index, and comorbidities. At last follow-up more than 1year after surgery, we compared functional scores, pain intensity, and fusion assessed by radiographs and computed tomography (CT) (threshold set at 33%). RESULTS: Mean follow-up was 42months (range: 34-63months) in the Maxlock™ group and 25months (range: 12-36months) in the H-pode™ group. At last follow-up, the two groups were not significantly different for the mean values of the American Orthopedic Foot & Ankle Society score, European Foot & Ankle Society score, and visual analogue scale pain score. Neither were the two groups significantly different for talo-navicular and calcaneo-cuboid fusion by CT. In the Maxlock™ group, we found non-significant trends towards a higher proportion of patients with talo-navicular nonunion (18% vs. 5% in the H-pode™ group) and weaker talo-navicular fusion in patients with pes planovalgus (60.8% vs. 82.0%, respectively). Radiographic results overestimated the fusion rates. DISCUSSION: Talo-navicular and calcaneo-cuboid fusion was not significantly different with H-pode™ and Maxlock™ locking plates. CT was more accurate than standard radiography to assess fusion. These results underline the usefulness of PEEK locking plates for talo-navicular and calcaneo-cuboid fusion; moreover, the radiolucency of PEEK facilitates the interpretation of radiographs. LEVEL OF EVIDENCE: IV.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study. / [Artículo traducido] Configuración y localización óptima de los tornillos posteriores en las fracturas de calcáneo Sanders 2B: estudio biomecánico.

BACKGROUND: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures. METHODS: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5 cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4 mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7 mm cannulated partially threaded CharlotteTM (Wright Medical Technology, Memphis, USA) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5 N, 10 N and 20 N force was measured in millimetres (mm). RESULTS: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88 ± 0.390 at 5 N and 1.7 ± 1.251 at 20 N) and the most stable construct (p < 0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04 ± 0.971 at 5 N and 11.24 ± 7.590 at 20 N) (p < 0.05). CONCLUSION: This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Tratamiento de pseudoartrosis postquirúrgica en la base del segundo metatarsiano mediante autoinjerto de calcáneo: caso clínico / Treatment of postsurgical pseudoarthrosis in the base of the second metatarsal with calcaneus autograft: a case report

Los procesos de no-unión postquirúrgicos en pie y tobillo no son infrecuentes debido a la gran cantidad de procedimientos quirúrgicos mediante osteotomías o artrodesis que se realizan anualmente. Ocasionalmente, estos procedimientos no tienen una estabilización óptima del foco de fractura y pueden acabar degenerando en un proceso de no-unión. Presentamos el caso de una paciente a la que se le realizaron osteotomías en la base de los metatarsianos menores por cirugía mínimamente invasiva para el tratamiento de metatarsalgia, que derivó en el desarrollo de pseudoartrosis dolorosa en la base del segundo metatarsiano y de no-unión en el 4.º metatarsiano. Se realizó tratamiento quirúrgico consistente en la utilización de autoinjerto corticoesponjoso de calcáneo y estabilización con placa de bloqueo dorsal para 2.º metatarsiano y estabilización con placa dorsal de bloqueo para el 4.º metatarsiano. La radiología mostró integración del injerto a las 8 semanas y los resultados clínicos fueron muy satisfactorios tras 5 años de seguimiento. El autoinjerto de calcáneo con estabilización rígida por medio de placa de bloqueo dorsal puede ser un tratamiento efectivo para el tratamiento de la no unión y pseudoartrosis en la base de los metatarsianos.(AU)

Postsurgical nonunions of the foot and ankle are not uncommon because of the large number of procedures by means of osteotomies and arthrodesis that are performed annually. We present a clinical case of a patient who developed a painful nonunion in the base of the second metatarsal after a minimally invasive surgical procedure for metatarsalgia within a base osteotomy that developed a painful pseudoartrhosis of the 2nd metatarsal and also a nonunion of the 4th metatarsal. The patient was treated with the use of an autograft of corticocancellous bone from ipsilateral calcaneus that was fixated with a dorsal locking plate for the 3rd metatarsal and also with stabilization by means of a dorsal locking plate of the 4th metatarsal. Radiology showed good integration of the graft at 8 weeks and clinical results were excellent after 5 years of followup. Autograft from calcaneus fixed with a locking dorsal plate can be an effective treatment of nonunions in the base of the metatarsals.(AU)

Retrograde calcaneo-talo-tibial nail, subtalar arthrodesis and fibula transposition in the treatment of traumatic bone and articulatory defect of the distal tibia and talocrural joint: A case report.

High-energy trauma of the lower leg can cause conditions such as bone defects, loss of the articular surface or a complex soft tissue injury. Given the type of the injury, as well as the often poor general status of the patient, the initial treatment usually consists of debridement and external fixation. The role of the retrograde calcaneo-talo-tibial nail is acknowledged in the treatment of post-traumatic arthritis of the talocrural joint, rheumatic arthritis, the neuropathic joint as well as some other conditions. We present a case of a thirty-five-year-old man with a lower leg fracture and significant bone defect associated with the loss of the articular surface of the distal tibia which was treated with a retrograde calcaneo-talo-tibial nail. Due to the lack of an adequate implant on the market, an inversely introduced tibial nail was used. Following the nailing of the fracture and the recovery of the soft tissue, transposition of the ipsilateral fibula was performed. Nowadays, different methods for bone defect reconstruction are available such as distraction osteogenesis, bone transport, and the Masquelet technique. However, the calcaneo-talo-tibial nail and transposition of the fibula is another feasible and effective option, especially for unreconstructable joint surfaces.

Investigation of the relationship between foot deformities and radiographic measurements of the talus and calcaneus / Investigación de la relación entre las deformidades del pie y las mediciones radiográficas del talo y del calcáneo

SUMMARY: The weight of the body is transmitted to the foot through the subtalar joint and talus. Considering the important location of the talus and calcaneus, the morphological structures of these bones may affect the biomechanics of the subtalar joint. At the same time, the morphological structure of these bones is important in some common foot deformities. We aimed to investigate whether the various measurements of the talus and calcaneus are associated with different foot deformities in this study. In this study, radiography images of 158 (72 male and 86 female) patients within the mean age of 44 years were retrospectively examined. Eleven different measurements of the talus and calcaneus were obtained from the lateral and antero-posterior radiographs of the patients. A total of 158 patient's routine clinic radiographs were retrospectively assessed, which have calcaneal spur (n=63), hallux valgus (n=32) and control group (n=63). We determined that the body height of the calcaneus, maximum width of the head of the talus, minimum anterior width of the calcaneus were significantly different between calcaneal spur group and control group. Maximum length fibular malleolar facet of the talus was significantly different between age groups. And we determined that the calcaneal index was significantly different between hallux valgus group and control groups. Also all measurements were significantly different between males and females. As a result, some measurements that significantly determine the morphology of the talus and calcaneus were found to be significant between deformity groups and control groups. We think that our study will contribute to the literature as it is the first study in which the measurements obtained from the radiographic images of the talus and calcaneus are associated with foot deformities.

El peso del cuerpo se transmite al pie a través de la articulación subtalar y el talo. Teniendo en cuenta la importante ubicación del talo y el calcáneo, las estructuras morfológicas de estos huesos pueden afectar la biomecánica de la articulación subtalar. Al mismo tiempo, la estructura morfológica de estos huesos es importante en algunas deformidades comunes del pie. Nuestro objetivo fue investigar si las diversas medidas del talo y el calcáneo están asociadas con diferentes deformidades del pie en este estudio. Se examinaron retrospectivamente imágenes radiográficas de 158 pacientes (72 hombres y 86 mujeres) con una edad promedio de 44 años. Se obtuvieron once medidas diferentes del talo y el calcáneo a partir de las radiografías lateral y anteroposterior de los pacientes. Se evaluaron retrospectivamente un total de 158 radiografías clínicas de rutina de los pacientes, los cuales tenían espolón de calcáneo (n=63), hallux valgus (n=32) y grupo control (n=63). Determinamos que la altura del cuerpo del calcáneo, el ancho máximo de la cabeza del talo, el ancho anterior mínimo del calcáneo fueron significativamente diferentes entre el grupo con espolón calcáneo y el grupo control. La longitud máxima de la faceta maleolar fíbular del talo era significativamente diferente entre los grupos de edad. También determinamos que el índice calcáneo fue significativamente diferente entre el grupo de hallux valgus y los grupos controles. Además, todas las medidas fueron significativamente diferentes entre hombres y mujeres. Como resultado, algunas medidas que determinan la morfología del talo y el calcáneo resultaron significativas entre los grupos de deformidad y los grupos controles. Estimamos que nuestro estudio contribuirá a la literatura debido a que es el primer reporte en el que las medidas obtenidas de las imágenes radiográficas del talo y el calcáneo se asocian con deformidades del pie.

Current concepts in the surgical management of chronic ankle lateral ligament instability.

Background/aims: Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI). Methods: The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI. Results: Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes. Conclusion: Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Tuberculosis ósea en calcáneo. Caso clínico / Bone tuberculosis in calcaneus. Clinical case

La tuberculosis extra pulmonar osteoarticular es una entidad infrecuente (16%), y aquellas de compromiso extravertebral son a su vez muy infrecuentes. Presentamos el caso clínico de un paciente masculino de 68 años de edad, con hipertensión arterial sistémica y enfermedad renal crónica, que presenta aproximadamente 1 año de evolución tórpida con dolor en retropié izquierdo, empeorando luego de infiltración con esteroide, con aumento de volumen, limitación funcional, y lesión ulcerosa con exudado purulento en cara medial. Siendo evaluado de forma clínica y con estudios de imagen por diferentes facultativos, hasta realizar toma de biopsia y cultivo óseo con diagnóstico de Tuberculosis ósea en calcáneo izquierdo. Tratado de manera quirúrgica, y actualmente cumpliendo tratamiento antituberculoso, con evolución satisfactoria recuperando movilidad articular, sin dolor y disminución del volumen de retropié(AU)

Osteoarticular extrapulmonary tuberculosis is a rare entity (16%), and those with extravertebral involvement are in turn very rare. We present the clinical case of a 68-years-old male patient with systemic arterial hypertension and chronic kidney disease, who presents approximately 1 year of torpid evolution with pain in the left hindfoot, worsening after steroid infiltration, with increased volume, limitation functional, and ulcerative lesion with purulent exudate on the medial side. He was being evaluated clinically and with imaging studies by different doctors, until taking a biopsy and bone culture with a diagnosis of Bone Tuberculosis in the left calcaneus. Surgically treated, and currently undergoing antituberculous treatment, with satisfactory evolution recovering joint mobility, without pain and decrease in rearfoot volume(AU)