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This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Fractures of the radial shaft associated with disruption of the distal radioulnar joint (DRUJ) are termed Galeazzi fractures. These fractures are unstable injuries requiring open reduction and internal fixation of the fracture to achieve optimal outcomes. DRUJ stability should be carefully assessed intraoperatively and addressed accordingly., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to incarceration of all the flexor tendons including the neurovascular bundle in the tibial fibular interosseous space; to date, only one such case has been published in the literature. A computed tomography scan in both bone and soft tissue windows was necessary to clarify the structures that were inhibiting repositioning. The decisive step for surgical treatment was removal of the trapped structures from the tibial fibular interosseous space by a dorsomedial approach. The malleolar joint was then reconstructed anatomically. After 12 weeks, the patient was fully mobile without restrictions in his daily professional activities., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Severe calcaneal malunions are debilitating conditions owing to substantial hindfoot deformity with subtalar arthritis and soft tissue imbalance. Type III malunions are best treated with a subtalar distraction bone block fusion. Additional osteotomies may be required for severe varus or superior displacement of the calcaneal tuberosity. Type IV malunions result from malunited calcaneal fracture-dislocations and require a 3-dimensional corrective osteotomy. Type V malunions warrant additional ankle debridement and reconstruction of the calcaneal shape to provide support for the talus in the ankle mortise. Accompanying soft tissue procedures include Achilles tendon lengthening, peroneal tendon release, and rerouting behind the lateral malleolus., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Arthroscopic treatment is an effective technique for osteochondral lesion of talus (OLT); however, some patients still suffer pain and limitation of activities after surgery. The purpose of this study was to evaluate the efficacy of extracorporeal shock wave therapy (ESWT) after ankle arthroscopy for OLT. We reviewed the clinical history of a series of 78 patients with OLT who underwent arthroscopic microfracture. ESWT was prescribed for 15 patients who complained of ankle pain and restriction of weightbearing activities 3 months postoperatively. The parameters assessed were visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale scores (before ESWT, at 6 and 12 weeks, and at last follow-up after ESWT) and magnetic resonance imaging (MRI) before and 1 year after ESWT. Follow-up was 27.8 ± 15.2 months. VAS and AOFAS scores showed a significant improvement at 12 weeks after ESWT and a progressive trend at last follow-up. Areas of lesions in sagittal plane in MRI were distinctly reduced at last follow-up. ESWT for osteochondral lesions of talus after arthroscopy results in good clinical outcomes., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Soft tissue injuries associated with malleolar fracture-dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture-dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot-ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p = .007), waiting time from admission to surgery (p < .001), gender (p = .005), and Tscherne soft tissue injury scores (p < .001). The mean AOFAS hindfoot-ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p = .094 and p = .126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture-dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot-ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Recent literature has reported an uncategorized hyperplantarflexion variant ankle fracture characterized by a posteromedial fragment separate from the posterior or medial malleolar fragments. The current study sought to determine whether the outcomes for surgically treated hyperplantarflexion variant fractures are similar to the more common supination external rotation (SER) IV fractures. A prospective registry of operatively treated ankle fractures was queried to create 2 age- and gender-matched cohorts: hyperplantarflexion variant and SER IV fractures. Each cohort had 23 patients (18 females), and matched pairs were within 2 years of age at the date of surgery. Patient demographics, comorbidities, and Foot and Ankle Outcomes Scores at minimum 12 months after the index surgery were compared. The cohorts were similar with respect to body mass index, the length of the clinical follow-up, medical comorbidities, dislocation rate, and postoperative articular incongruity (p > .05). Patient-reported outcomes demonstrated no statistically or clinically significant differences within any domain and were as follows: symptoms (70.8 versus 77.8, p = .11), pain (80.7 versus 85.0, p = .33), activities of daily living (83.7 versus 89.2, p = .23), sports (67.4 versus 73.4, p = .33), and quality of life (57.3 versus 63.9, p = .24) for the hyperplantarflexion and SER IV groups, respectively. No significant differences were found in the rang`e of motion for dorsiflexion (17.7° versus 18.1°, p = .52) or for plantarflexion (48.6° versus 47.1°, p = .71). Patients treated surgically for hyperplantarflexion variant ankle fractures have similar 1-year clinical outcomes when compared with the more common SER IV fracture patterns, provided that the injury is correctly identified preoperatively and treated appropriately., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Displaced talar neck fractures no longer constitute a surgical emergency; timing of definitive surgery has no bearing on the risk of osteonecrosis. Amount of initial fracture displacement is best predictor of osteonecrosis. Grossly displaced fractures or fracture-dislocations should be provisionally reduced, with or without temporary external fixation. Periosteal stripping should be limited to only that necessary to obtain anatomic reduction. Dissection within the sinus tarsi or tarsal canal should be avoided. Rigid internal fixation with solid cortical screws countersunk within the talar head and placed below the "equator" of the talar head is imperative for optimum stability., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The aim of our study was to compare gait in terms of foot loading and temporal variables after 2 different operative approaches (the extended lateral approach [ELA] and sinus tarsi approach). Twenty-two patients who sustained an intra-articular calcaneal fracture underwent plantar pressure distribution measurements 6 months after surgery. Measurements were performed while patients walked on the pedobarography platform. The values of dynamic variables were significantly lower on the operated limb in the ELA. In the sinus tarsi approach, no differences were observed between the operated and uninjured limbs (UIN) at peak pressure and at maximal vertical force. The values of temporal variables (contact time of the foot and of the heel) between the operated and UIN differed in the ELA. The hypothesis that differences in foot load between operated and UIN will be more significant in the ELA was confirmed. Our results showed that the differences in loading and temporal variables between the operated and the UIN persisted 6 months after surgery in both methods. The operated limb was less loaded, with the tendency to shift the load toward the midfoot and forefoot. After the less invasive sinus tarsi approach, the dynamic and temporal variables on the operated limb were nearly the same as those on the healthy one. The sinus tarsi surgical approach can be recommended for treatment of displaced calcaneal fractures., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Lisfranc fracture-dislocations can be devastating injuries with significant long-term sequelae with or without surgical intervention. The main goal of treatment is to minimize the common long-term complications including pain, progressive arch collapse, degenerative joint disease, hardware failure, and reoperation. Partial primary fusion involving the first, second, and third tarsometatarsal joints has become a common approach for primarily dislocation injuries, with open reduction and internal fixation (ORIF) favored for Lisfranc injuries involving fracture. ORIF commonly requires revision surgery for hardware removal or delayed fusion. Major revision creates hardship for the patient due to the prolonged recovery required, and even "simple" hardware removal can be traumatic to local nerve, artery, and tendon structures. A common injury pattern includes the findings of primary dislocation and instability of the first tarsometatarsal joint with oftentimes comminuted fracture to the second and third tarsometatarsal joints, which does not fit the standard surgical approach. We report a review of our preferred surgical approach consisting of medial column primary arthrodesis combined with central column ORIF and lateral column temporary pinning. We undertook an institutional review board-approved review of 35 consecutive Lisfranc injuries treated with this hybrid approach. Mean follow-up time was 22.14 ± 22.39 (range 2.5 to 84) months. All but 2 (5.71%) patients had radiographic evidence of union at 10 weeks. Complications included 3 with neuritis, 1 with medial column nonunion that was treated with a bone stimulator, and 1 with revision of second metatarsal nonunion. The present retrospective series highlights our experience with isolated primary fusion of the medial column in both subtle and obvious Lisfranc injuries., (Copyright © 2018 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Epidermal inclusion cysts are common epithelial cysts of the skin. The latter classically originate from progressive cystic ectasia of the infundibular portion of hair follicle. Therefore, these cysts are usually found in hairy regions and rarely in glabrous skin such as the palms and soles. The etiology of glabrous epidermal inclusion cysts appear to be different from that of those located in hairy regions. It has been suggested that implantation of epithelial cells into subcutaneous tissue, such as during trauma, is most likely the pathophysiologic basis. Epidermal inclusion cysts on the palms and soles are often misdiagnosed, leading to improper treatment. Therefore, we report a rare case of an epidermal inclusion cyst of the heel after minimally invasive surgery of a displaced intra-articular calcaneal fracture., (Copyright © 2018 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

May-Thurner syndrome (MTS) is a rare condition in which patients develop iliofemoral deep venous thrombosis owing to an anatomic variant in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine. Data regarding lower extremity trauma in patients with previously diagnosed MTS are rare. We discuss the operative approach for ankle trauma occurring 3 weeks after endovascular surgery for the treatment of MTS., (Copyright © 2018 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Syndesmotic injuries associated with ankle fractures are commonly treated with reduction and fixation using a transfixing screw. On rare occasions, however, progression to chronic instability of the syndesmosis is observed. Several surgical techniques have been applied in such cases but usually without a report on the results. We report a case of chronic syndesmotic instability and ankle joint osteoarthritis after ankle fracture-dislocation in a 21-year-old male patient who underwent distal tibiofibular arthrodesis. During the relatively long 4-year, 1-month follow-up period, the pain and activity improved from the patient's preoperative condition. Radiographs demonstrated cessation of arthritic changes in the ankle that had initially displayed joint space narrowing. Our findings suggest distal tibiofibular arthrodesis as an option to consider for the treatment of young and active patients with arthritic changes in the ankle joint with concomitant chronic instability of the syndesmosis., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Talus fracture of the medial tubercle of the posterior process is rare. This type of fracture can be easily missed, because it is difficult to identify on plain radiographs of the ankle. Oblique radiographs with external rotation, computed tomography, and magnetic resonance imaging (MRI) of the ankle are useful for making an accurate diagnosis. However, even with an early diagnosis, the treatment guidelines for talus fractures of the posterior medial tubercle have not yet been established. The flexor hallucis longus (FHL) tendon, which passes through the groove between the medial and lateral tubercles of the posterior process of the talus, can interpose between the fracture sites and interrupt fracture reduction. MRI might be the best imaging modality for the identification of the interposed FHL tendon. We report a case in which talus fracture of the posterior medial tubercle was treated by open reduction and internal fixation owing to an interposed FHL tendon that was confirmed by MRI. MRI is the recommended imaging study of choice for talus fractures of the posterior medial tubercle owing to the possibility of an interposed FHL tendon., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Displaced osteochondral fractures of the body of talus quite often require a malleolar osteotomy to gain access to the fracture fragment during internal fixation. We describe a case report in which access to a displaced osteochondral fracture of the lateral talar dome was achieved using an arthroscopy-assisted fibular tunnel approach. This technique resulted in satisfactory fracture healing and a satisfactory clinical outcome., (Copyright © 2017 The American College of Foot and Ankle Surgeons. All rights reserved.)

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The treatment goals of elbow fracture dislocations are congruent reduction of the ulnohumeral and radiocapitellar joints, stable fixation of the proximal ulna, stable fixation or arthroplasty of the radial head, and soft tissue repair. Fracture dislocations occur in patterns, and recognition of these patterns help guide surgical treatment. In patients with persistently unstable fractures after standard fixation, additional temporary joint spanning implants are useful to protect repairs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

High rates of postoperative wound infection (POWI) have been reported after surgery for calcaneal fractures. This is a retrospective cohort study to determine the causative pathogens of these infections and subsequent treatment strategies. In addition, microbacterial growth from superficial wound swabs and deep fluid or tissue cultures were compared. Patients with a unilateral surgically treated calcaneal fracture during a 15-year period were included. Patient, fracture, and surgical characteristics were collected from the electronic medical records. An infection was categorized as deep or superficial using the Centers for Disease Control and Prevention criteria. Secondary outcomes were wound edge necrosis and wound dehiscence. The collection of culture swabs, their results, and treatment strategies were documented. Of 357 patients, 92 (26%) developed a POWI; 55 (60%) deep and 37 (40%) superficial. The most frequent causative pathogens were Enterobacteriaceae and Staphylococcus aureus. Of the 55 patients with deep infection, 31 (56%) were treated with intravenous antibiotics and surgical debridement, 2 (4%) with intravenous antibiotics, and 22 (40%) with implant removal. In 33 of 92 patients (36%) with a POWI, both superficial and deep cultures were obtained, with a microorganism not cultured from the superficial swab 13 (39%) times. In conclusion, we found that one quarter of patients with operative calcaneal fracture treatment developed a POWI, mainly caused by Enterobacteriaceae or S. aureus. Physicians should not rely on the results of superficially obtained cultures for adequate treatment of deep infection. Because the spectrum of sensitivity profiles varies greatly between hospitals and countries, we recommend empiric antibiotic treatment of both gram-positive and gram-negative microorganisms on suspicion of deep infection., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Avulsion fractures of the calcaneal tuberosity are predominantly seen in patients with poor bone quality, the commonly used lag screw fixation might not be strong enough even with bony fragments of sufficient size. We present a case of a closed displaced avulsion fracture of the calcaneal tuberosity due to blunt trauma to the calf in a 74-year-old female. Open reduction and internal fixation with two 3.5-mm cannulated cortical screws with washers was performed, and anatomic reduction was achieved. Without further trauma, secondary displacement of the fracture occurred on day 3. Revision was performed with a single 3.5-mm cortical screw and transosseous fixation with 2 suture anchors, followed by partial weightbearing for 6 weeks. At 12 weeks postoperative, the fracture had completely healed, and she was doing well at 16 months after the revision surgery. Transosseous suture anchor fixation of an osteoporotic avulsion fracture of the calcaneal tuberosity seems to provide better and stronger fixation than that using lag screws., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The key to successful treatment of perilunate injuries is to achieve early anatomic reduction and maintain the carpal alignment. Open surgery may lead to capsular scarring and joint stiffness. Furthermore, there is increased chance of damage of the already tenuous blood supply to scaphoid and the torn ligaments. Recently, arthroscopic-assisted management of perilunate injuries has been suggested. This article describes the surgical technique and outcome of this minimally invasive approach for perilunate injuries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Several serious complications can occur after talar neck fractures. However, these fractures are extremely rare in children. We present a pediatric low-energy Hawkins type III fracture-dislocation that had excessive displacement accompanied by neurovascular and tendon entrapment. A 9-year-old male patient referred to our hospital 5 hours after jumping off a swing in a children's playground. An excessively displaced talar neck fracture-dislocation was observed at the initial evaluation. The patient underwent urgent surgery. The tibialis posterior flexor digitorum longus tendons, posterior tibial artery, and tibial nerve were entrapped at the fracture site. The talar neck fracture was reduced using open reduction. The neurovascular structures and tendons were removed from the fracture site. The fracture was fixed using two 4.5-mm cannulated screws. The patient was able to bear full weight at 10 weeks postoperatively. At 6 months, the patient was able to walk unassisted with full ankle range of motion. However, at 2 years, his American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score had decreased to 72 points, and we observed avascular necrosis in the talar head. In conclusion, talar fractures are rare but can lead to serious complications. In the pediatric population, even low-energy trauma, such as had occurred in our patient, can result in severe displaced fracture-dislocations. After severe displaced fracture-dislocations, important soft tissue structures can become entrapped between fracture fragments, and surgeons should be aware of this situation when considering using closed reduction., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not universally accepted, although many have agreed that any displacement warrants anatomic reduction and fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention. The patient was treated with prompt open reduction and internal fixation and had an excellent functional outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough exploration of the zone of injury is required to identify and adequately address any surrounding pathologic features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never been previously reported and emphasizes the importance of understanding the local anatomy and how restoration of the distorted anatomy is vital to optimize patient function., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Irreducible ankle fracture-dislocations are very rare entities. The present case report demonstrates an unusual finding of tibialis posterior and flexor digitorum longus tendons interposed in the tibiofibular joint impairing successful closed reduction of ankle fracture-dislocation. A 45-year-old patient presented with a bimalleolar pronation-external rotation ankle fracture-dislocation after a motorcycle accident. Attempts to perform closed reduction before surgery were unsuccessful. Subsequent urgent open reduction and internal fixation surgical management revealed interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint. In irreducible fracture-dislocation of the ankle with severe lateral displacement of the talus, one should be aware of the possibility of soft tissue interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Chopart joint injuries have a profound effect on global foot function. Surgical treatment aims at joint reconstruction and axial alignment with restoration of the normal relationship of the lateral and medial foot columns. Internal fixation is tailored to the individual fracture pattern and achieved with resorbable pins, Kirschner wires, screws, and/or anatomically shaped minifragment plates. If instability persists, temporary joint transfixation may be achieved with Kirschner wires or bridge plating. Primary fusion sacrifices essential joints and should be reserved for severe initial cartilage damage. Corrective fusion becomes necessary for malunited Chopart joint injuries with rapidly evolving posttraumatic arthritis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The treatment of calcaneus fractures is controversial. Historically, most operatively treated fractures have been approached with a lateral extensile incision requiring delay in operative treatment until swelling has improved. There is a current trend and interest in small incision approaches allowing, and in some cases requiring, earlier operative fixation. Clinical scenarios amenable to consideration for early fixation are reviewed. The sinus tarsi surgical approach and reduction techniques are outlined in detail., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Traumatic ankle fractures and dislocations that fail closed reduction present a challenging set of circumstances that can potentially lead to unnecessary complications and require surgical intervention. Interposition of adjacent tendons occurs rarely and can obstruct the anatomic realignment. Because of the potential for neurovascular compromise and possible skin tension necrosis, an irreducible fracture dislocation must be addressed with open reduction and internal fixation. The present case details an unusual, low-energy, external rotation ankle fracture and dislocation that was incapable of skeletal traction relocation. The present report also details the intraoperative finding of a complex injury pattern., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Fractures and dislocations of the cuneiform bones are rare injuries to the midtarsal foot. The injury severity is often unclear, and the prognostic factors are unknown. The purpose of the present study was to characterize our insights of the diagnostics, therapy, and fracture patterns. We questioned whether the number of involved cuneiform bones and the type of injury would affect the clinical outcome. With this information, we aimed to develop a classification system for injuries of the cuneonavicular joint. Five patients who had sustained complex fracture-dislocation of the cuneiform bones were prospectively registered, underwent surgery, and were followed. We reviewed the published data and found 47 reports that included 55 patients to improve the informative value of our study. The injury mechanisms and therapy were evaluated, and the postoperative limitations and pain were assessed. The clinical outcome was correlated with the number of involved cuneiforms and the fracture/dislocation pattern. Direct trauma was associated with isolated fracture, and indirect injury was associated with isolated dislocations. Occasionally, these injuries were overlooked on conventional radiographs, and closed reduction frequently failed. The number of cuneiform bones involved and the type of injury were shown to affect the clinical outcome. We devised an easily applicable classification system for injuries to the cuneiform bones using this information. All cases were classified as isolated fractures (1), isolated dislocations (2), or fracture-dislocations (3) involving 1 (A), 2 (B), or 3 (C) cuneiform bones. The classification system we propose will facilitate a better understanding of the fracture patterns at the cuneonavicular joint line and is a good prognostic tool that requires validation in clinical settings., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Traditionally, Lisfranc fracture dislocations have been treated with transarticular screw fixation. A more recent development has been the use of dorsal bridging plates. The aim of the present study was to compare the radiologic outcomes for these 2 methods. Currently, no data comparing the outcomes of these 2 treatment options have been reported. A total of 62 patients were treated for Lisfranc fracture dislocations during a 6-year period. The inclusion criteria included ≥6 months of follow-up data available. Each fracture was classified using the Hardcastle classification system. Each fracture was also allocated into 1 of 4 groups: transarticular screw fixation, dorsal plating, a combination of plate and screw fixation, and nonoperative management. The outcome measures included the Kellgren-Lawrence grading of osteoarthritis and the Wilppula classification of anatomic reduction. In terms of results, radiologic osteoarthritis is not associated with the type of injury according to the Hardcastle classification nor with having an open or closed fracture. The Hardcastle classification is not associated with the type of fixation used. Fractures fixed with a combination of plates and screws had a 3.01 (95% confidence interval 1.036 to 8.74) increased risk of having stage 3 or 4 radiologic osteoarthritis compared with being fixed solely with bridging plates (p = .009). Multivariate analysis revealed that this increased risk of osteoarthritis was dependent on the quality of reduction, with good reductions having a 18.2 (95% confidence interval 15.9 to 21.8) times decreased risk of severe osteoarthritis compared with fair or poor reductions, independent of the type of fixation used (p < .0001). No radiologic benefits were found when comparing plate or screw fixation for Lisfranc fracture dislocations (although screw fixation might be associated with a less planus foot and fewer complications). Instead, a good anatomic reduction was the only predictor of the radiologic outcome, and the Hardcastle classification of fractures did not predict the surgery type or radiologic outcome. Finally, treatment with combination plates and screws resulted in worse radiologic outcomes, possibly owing to more complex fracture patterns., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The purpose of our investigation was to prospectively review and compare the early outcomes of Sanders II and III closed displaced intra-articular calcaneal fractures (DIACFs) in a group of patients treated by open reduction and internal fixation with plate and screws using the extended lateral approach or the sinus tarsi approach (STA). Thirty-eight patients with DIACFs were prospectively enrolled and operatively treated using either the extended lateral approach or the STA. Patients underwent a careful clinical and radiographic examination and were evaluated according to the American Orthopaedic Foot and Ankle Society score, visual analog scale, and the Foot Function Index. The results from our study showed similar clinical and radiographic outcomes between the 2 groups. In our series, Sanders II and III DIACFs were sufficiently exposed using the STA to achieve anatomic reduction and stable fixation. The STA group had a lower incidence of wound complications (p ≥ .05), the surgical procedure was faster, and the waiting time to surgery was shorter (p ≤ .05). Despite the limited number of patients and the short follow-up period, our results suggest that the STA is a useful method for the treatment of DIACFs, with a low incidence of complications and results comparable to those for patients treated using the extended lateral approach., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Previous investigators have questioned the reliability of plain radiographs in assessing the accuracy of ankle fracture reduction when these were compared with the computed tomography (CT) evaluation in the preoperative setting, in particular, in fractures with syndesmosis injuries or trimalleolar fragments. The role of CT assessment, however, has not been investigated in the early postoperative setting. In the early postoperative setting, reduction still relies most commonly on fluoroscopy and plain radiographs alone. In the present study, we hypothesized that early postoperative CT assessment of ankle fractures with syndesmosic injuries and posterior malleolar fragments can add valuable information about the joint congruity compared with plain radiographs alone and that this information could affect the decisions regarding the need for early revision surgery. A total of 352 consecutive operated ankle fractures were reviewed. Of these, 68 (19%) underwent early postoperative CT assessment and were studied further to identify the causes that prompted revision surgery. Of the 68 cases, despite acceptable reduction found on the plain radiographs, 20 (29%) underwent early (within 1 week) revision surgery after studying the CT scans, which revealed malreduction of the syndesmosis, malreduction of the posterior lip fragment, and intra-articular fragments. We concluded that in ankle fractures involving disruptions of the syndesmosis or posterior malleolar fragments, early postoperative CT assessment could be justified, because it will reveal malreduction and prompt early revision intervention for a substantial proportion of these patients., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Cuneiform dislocation associated with Lisfranc injury is a very rare injury. Dislocation over the midfoot due to a seizure has not been previously reported in published studies. A 35-year-old female presented with an intercuneiform dislocation and Lisfranc fracture-dislocation after a generalized seizure. Immediate close reduction of the dorsally dislocated cuneiforms was performed, followed by definitive treatment to restore the foot arches. A proposed underlying pathophysiology of dislocation due to seizure in terms of the biomechanics is discussed. The purpose of our report was to present the unusual etiology of this form of cuneiform dislocation and Lisfranc joint complex injury., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)