High incidence of (osteo)chondral lesions in ankle fractures.

PURPOSE: To determine the incidence and location of osteochondral lesions (OCLs) following ankle fractures as well as to determine the association between fracture type and the presence of OCLs. Up to 50% of patients with ankle fractures that receive surgical treatment show suboptimal functional results with residual complaints at a long-term follow-up. This might be due to the presence of intra-articular osteochondral lesions (OCL). METHODS: A literature search was carried out in PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL to identify relevant studies. Two authors separately and independently screened the search results and conducted the quality assessment using the MINORS criteria. Available full-text clinical articles on ankle fractures published in English, Dutch and German were eligible for inclusion. Per fracture classification, the OCL incidence and location were extracted from the included articles. Where possible, OCL incidence per fracture classification (Danis-Weber and/or Lauge-Hansen classification) was calculated and pooled. Two-sided p values of less than 0.05 were considered statistically significant. RESULTS: Twenty articles were included with a total of 1707 ankle fractures in 1707 patients. When focusing on ankle fractures that were assessed directly after the trauma, the OCL incidence was 45% (n = 1404). Furthermore, the most common location of an OCL following an ankle fractures was the talus (43% of all OCLs). A significant difference in OCL incidence was observed among Lauge-Hansen categories (p = 0.049). Post hoc pairwise comparisons between Lauge-Hansen categories (with adjusted significance level of 0.01) revealed no significant difference (n.s.). CONCLUSION: OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45-47%, respectively). Moreover, the vast majority of post-traumatic OCLs were located in the talus (42.7% of all OCLs). A higher incidence of OCLs was observed with rotational type fractures. The clinical relevance of the present systematic review is that it provides an overview of the incidence and location of OCLs in ankle fractures, hereby raising awareness to surgeons of these treatable concomitant injuries. As a result, this may improve the clinical outcomes when directly addressed during index surgery. LEVEL OF EVIDENCE: IV.

Fifth Metatarsal Osteotomies for Treatment of Bunionette Deformity: A Meta-Analysis of Angle Correction and Clinical Condition.

We assessed which type of osteotomy would be most suited for correcting an increased fourth to fifth intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA) and would have the best results regarding the clinical condition and satisfaction. The study design was a systematic review and meta-analysis. The main outcome measures were the IMA, MPA, and American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal scale and satisfaction scores. A systematic search was performed in Medline, Embase, Cochrane, SPORTdiscus, and CINAHL up to September 2016. Prospective and retrospective studies that had evaluated the outcomes of fifth metatarsal osteotomies to correct a bunionette deformity at all patient ages were included. The outcomes were determined from clinical or radiographic evaluations. The search yielded 28 studies suitable for inclusion in our meta-analysis. All groups of osteotomies achieved significant IMA changes, with proximal osteotomies resulting in significantly greater changes than diaphyseal or distal osteotomies. The overall effect of osteotomies on the MPA was of a significant reduction. Proximal and diaphyseal osteotomies both resulted in significant differences in MPA correction compared with distal osteotomies. The incidence of major complications was the least in the distal osteotomy group. The overall mean success rate of bunionette surgery was 93%. The patients were most satisfied with proximal osteotomies, followed by distal and diaphyseal osteotomies (100% and 92%, respectively). In conclusion, every type of osteotomy has the capability of significantly reducing the fourth to fifth IMA and MPA. The fewest complications occurred with distal osteotomies, and the greatest satisfaction score was achieved with proximal osteotomies. However, only 1 study evaluated these results for proximal osteotomies. Distal osteotomies resulted in a high satisfaction rate and were the most represented osteotomy in our meta-analysis. Thus, when major IMA and MPA reduction is not required, the distal osteotomy could be the treatment of choice owing to its low complication rate.

Wilms Tumor Treatment Outcomes: Perspectives From a Low-Income Setting.

PURPOSE: Wilms tumor is the commonest renal malignancy in childhood. Survival in high-income countries is approximately 90%, whereas in low-income countries, it is less than 50%. This study assessed treatment outcomes of patients with Wilms tumor at a Kenyan academic hospital. PATIENTS AND METHODS: We conducted a retrospective medical record review of all children diagnosed with Wilms tumor between 2010 and 2012. Data on treatment outcomes and various sociodemographic and clinical characteristics were collected. RESULTS: Of the 39 patients with Wilms tumor, 41% had event-free survival, 31% abandoned treatment, 23% died, and 5% had progressive or relapsed disease. Most patients presented at an advanced stage: stage I (0%), II (7%), III (43%), IV (40%), or V (10%). The most likely treatment outcome in patients with low-stage (I to III) disease was event-free survival (67%), whereas in those with high-stage (IV to V) disease, it was death (40%). No deaths or instances of progressive or relapsed disease were recorded among patients with low-stage disease; their only reason for treatment failure was abandonment of treatment. Stage of disease significantly affected treatment outcomes (P = .014) and event-free survival estimates (P < .001). Age at diagnosis, sex, duration of symptoms, distance to hospital, and health insurance status did not statistically significantly influence treatment outcomes or event-free survival estimates. CONCLUSION: Survival of patients with Wilms tumor in Kenya is lower compared with that in high-income countries. Treatment abandonment is the most common cause of treatment failure. Stage of disease at diagnosis statistically significantly affects treatment outcomes and survival.

Influence of health insurance status on paediatric non-Hodgkin's lymphoma treatment in Kenya.

OBJECTIVE: Non-Hodgkin's lymphoma (NHL) is the most common childhood malignancy in sub-Saharan Africa. Survival rates for NHL are higher than 80% in high-income countries.This study explores treatment outcomes of children with NHL in Kenya, a sub-Saharan low-income country, and the association between health insurance status at diagnosis and treatment outcomes. DESIGN: This was a retrospective medical records study. All children diagnosed with NHL in 2010, 2011 and 2012 were included. Data on treatment outcomes and health insurance status at diagnosis were collected. RESULTS: Of all 63 patients with NHL, 35% abandoned treatment, 22% had progressive or relapsed disease, 14% died and 29% had event-free survival. Most patients (73%) had no health insurance at diagnosis. Treatment outcomes in children with or without health insurance at diagnosis differed significantly (p=0.005). The most likely treatment outcome in children with health insurance at diagnosis was event-free survival (53%), whereas in children without health insurance at diagnosis it was abandonment of treatment (44%). Crude HR for treatment failure was 3.1 (95% CI 1.41 to 6.60, p=0.005) for uninsured versus insured children. The event-free survival estimate was significantly higher in children with health insurance at diagnosis than in patients without health insurance at diagnosis (p=0.003). Stage of disease at diagnosis was identified as a confounder of this association (adjusted HR=2.4, 95% CI 0.95 to 6.12, p=0.063). CONCLUSIONS: Survival of children with NHL in Kenya is much lower compared with high-income countries. Abandonment of treatment is the most common cause of treatment failure. Health insurance at diagnosis was associated with better treatment outcomes and survival.