Stress fractures of the foot - current evidence on management.

Stress fractures are a consequence of repeated submaximal loads with inadequate time for recovery and biologic repair or remodelling. The foot and ankle complex (FAC) represents a common site for development of stress fractures. Whilst the overall incidence of stress fractures is low, they are prevalent in athletes and military personnel causing significant time away from sports or work. Within these populations, certain stress fractures directly correlate to specific activities. Factors that commonly influence these fractures include an acute increase in new repetitive physical activity combined with muscle fatigue, training errors or improper athletic techniques, which challenge the regenerative and remodelling capacity of bone. Depending on the site that is subject to repetitive loading, various biomechanical factors can result in abnormal concentration of forces to specific areas of the FAC resulting in stress fracture. Decreased bone marrow density (BMD) is a major biologic cause for developing stress fractures. The female athlete triad comprising eating disorder, amenorrhea and osteoporosis in competitive athletes also predisposes to stress fractures. Vitamin D deficiency is also postulated to be the cause of these fractures and may contribute to poor healing. Clinical presentation is usually with vague pain of insidious onset which worsens with activity and improves with rest. Diffuse tenderness over the affected bone is common with only a minority having any visible swelling. Plain radiographs are the first line of investigation but rarely reveal an obvious fracture. MRI scans aid in diagnosis and CT scans help in treatment and characterisation of the fracture and monitor healing. Management relates to the site of injury, which stratifies them into high or low-risk. Stress fractures of the calcaneus, cuboid and cuneiforms are classed as low-risk fractures as they usually heal with simple activity modification or short duration of non-weight bearing. Stress fractures of the navicular, talus and hallucal sesamoids are classed as high-risk fractures due to higher rates of non-union and prolonged recovery time. Metatarsal fractures can be considered high or low-risk depending on location. These warrant aggressive management, often requiring surgical intervention. Adjuncts such as vitamin D supplements, external shockwave therapy, low-intensity pulsed ultrasound therapy have been used with varying success but there remains little supportive evidence of superiority in the available literature.

Closed Tibial shaft fractures treated with the Ilizarov method: A ten year case series.

OBJECTIVES: To review the outcomes of patients treated with the Ilizarov method for an isolated, closed, simple diaphyseal, Tibial fracture at our institution over the last decade. METHODS: The Ilizarov frame database was used to identify 76 skeletally mature patients who sustained an isolated, closed, extra-articular, simple, diaphyseal Tibial fracture; the injury also known as a "nail-able Tibial fracture." RESULTS: The average age of the patient was 38 (17-70). All 76 patients progressed to union. The average time until union was 148 (55-398) days. The coronal and sagittal alignment was 3° (0-17°) and 4° (0-14°) respectively. No patient suffered from compartment syndrome. No patient developed septic arthritis. No patient had documented anterior knee pain or secondary knee specialist input post frame removal. On average, there were 9(4-29) follow up appointments and 10(5-26) radiographs post frame application. There is a 59% chance of a patient having a difficulty post frame application. The malunion rate was 5%. Persisting pinsite infection post frame removal occurred in 5 patients (6.5%). Drilling of the pinsite sequestrum resolved the infection in four of these patients, giving a deep infection rate of 1.3%. CONCLUSIONS: The Ilizarov method has a role to play in the treatment of simple closed Tibial shaft fractures in patients who need to kneel. Patient education is a priority however; the patient must be made aware of the difficulty rate associated with the Ilizarov method when compared to the complication profile of alternative treatments.

Operative procedures for fissure in ano.

BACKGROUND: Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy. OBJECTIVES: To determine the best technique for fissure surgery. SEARCH METHODS: The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2011), Medline (Pubmed) and Embase were searched March to 2011. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.A total of four new trials were included in this update of the review. SELECTION CRITERIA: All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. All studies must also be randomised. If crude data were not presented in the report, the authors were contacted and crude data obtained. DATA COLLECTION AND ANALYSIS: The two most commonly used end points in all reported studies were treatment failure and post-operative incontinence both to flatus and faeces. These are the only two endpoints included in the meta-analysis. MAIN RESULTS: Four trials, encompassing 406 patients were included in this update, with now a total of 2056 patients in the review from 27 studies that describe and analyze 13 different operative procedures. These operative techniques used by these studies include closed lateral sphincterotomy, open lateral internal sphincterotomy, anal stretch, balloon dilation, wound closure, perineoplasty, length of sphincterotomy and fissurectomy. Two new procedures in the update, similar to anal stretch were described- sphincterolysis and controlled intermittent anal dilatation. A new comparison was described, comparing the effects of unilateral internal sphincterotomy and bilateral internal sphincterotomy.Manual Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined analyses of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence Unilateral internal sphincterotomy was shown to be more likely to result in treatment failure compared to bilateral internal sphincterotomy, but there is no significant difference in the risk of incontinence.Sphincterotomy was less likely to result in treatment failure when compared to fissurectomy, but there was no significant difference when considering post-operative incontinence.When comparing sphincterotomy to sphincterolysis, there was no significant difference between the two procedures both in treatment failure and risk of incontinence; the same is the case when comparing sphincterotomy with controlled anal dilation. AUTHORS' CONCLUSIONS: Manual anal stretch should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision. Bilateral internal sphincterotomy shows promise, but needs further research into its efficacy.