Excision Of Fragment Research Articles

Assessment of ankle and hindfoot stability and joint pressures using a human cadaveric model of a large lateral talar process excision: a biomechanical study.

Lateral talar process fragment excision may be followed by hindfoot instability and altered biomechanics. There is controversy regarding the ideal fragment size for internal fixation versus excision and a concern that excision of a large fragment may lead to significant instability. The aim of this study was to assess the effect of a simulated large lateral talar process excision on ankle and subtalar joint stability.A custom-made seesaw rig was designed to apply inversion/eversion stress loading on 7 fresh-frozen human cadaveric lower legs and investigate them in pre-excision, 5 cm3 and 10 cm3 lateral talar process fragment excision states. Anteroposterior radiographs were taken to assess ankle and subtalar joint tilt and calculate angular change from neutral hindfoot alignment to 10-kg forced inversion/eversion. Ankle joint pressures and contact areas were measured under 30-kg axial load in neutral hindfoot alignment.In comparison to the pre-excision state, no significantly different mediolateral angular change was observed in the subtalar joint after 5 and 10 cm3 lateral talar process fragment excision in inversion and eversion. With respect to the ankle joint, 10-cm3 fragment excision produced significantly bigger inversion tibiotalar tilt compared with the pre-excision state, P = .04. No significant change of the ankle joint pressure and contact area was detected after 5 and 10-cm3 excision in comparison with the pre-excison state.An excision of up to 10 cm3 of the lateral talar process does not cause a significant instability at the level of the subtalar joint but might be a destabilizing factor at the ankle joint under inversion stress. The latter could be related to extensive soft tissue dissection required for resection.

Clinical and radiographic outcomes of femoral head fractures: excision vs. fixation of fragment in Pipkin type I: what is the optimal choice for femoral head fracture?

BackgroundIn this work, we present relatively long-term results of femoral head fractures with a specific focus on Pipkin type I fractures. MethodsFifty-nine femoral head fractures were treated according to modified Pipkin’s classification as follows: type I, small fragment distal to the fovea centralis (FC); type II, large fragment distal to the FC; type III, large fragment proximal to the FC; type IV, comminuted fracture. There were 15 cases of type I, 28 of type II, 9 of type III, and 7 of type IV fractures. Conservative treatment with skeletal traction was performed in 4 type II cases, excision of the fragment in 15 type I and 10 type II cases, fixation of the fragment in 14 type II and all 9 type III cases, and total hip replacement in all 7 type IV cases. The overall clinical and radiographic outcomes were evaluated using previously published criteria, focusing on the results in Pipkin type I fractures with relatively large fragments. ResultsBased on Epstein criteria, in type II fractures, excellent or good clinical results were seen in 6 of 10 patients (60.0 %) treated by excision of the fragment and 12 of 14 patients (85.7 %) treated by internal fixation (p=0.05). Also, excellent or good radiologic results were seen in 4 of 10 (40.0 %) patients treated by excision of the fragment and 12 of 14 (85.7 %) patients treated by internal fixation (p=0.03). ConclusionsEven in Pipkin type I fractures, if the fragment is large (modified Pipkin type II), early reduction and internal fixation can produce good results.

A new corporoplasty based on stratified structure of tunica albuginea for the treatment of congenital penile curvature - long-term results.

IntroductionThe aim of the study was to report long–term results of treatment of patients with congenital penile curvature (CPC) with a new corporoplasty based on stratified structure of tunica albuginea, in which corporal bodies are not opened.Material and methodsFrom October 2006 to September 2013, the authors operated on 111 adult men with CPC. Ventral curvature was detected in 65 patients, lateral in 34, and dorsal in 12. Skin was incised longitudinally on convex surface of curvature. In ventral curvature, dorsal neuro–vascular bundles (NVBs) were separated from tunica albuginea and elliptical fragments of external (longitudinal) layer of tunica were excised. The tunica was sutured with absorbable sutures, which invaginated the internal (transversal) layer of tunica. In dorsal curvature, excisions were performed on both sides of the urethra, in lateral curvature – on the convex penile surface.ResultsFollow–up period was from 12 to 84 months. The penis was completely straight in 109 out of 111 patients. In 2 patients (1.8%) recurrent curvature of up to 20 degrees was detected. Redo surgery was done in one individual (0.9%) at patient‘s request. Glandular sensation loss or erectile dysfunction was not detected in any patient during the period of observation.ConclusionsA new operation for correction of CPC, which consists of excision of an elliptical fragment of the external layer of the tunica albuginea and plication of the internal layer gives good short and long–term results. Surgery done without penetrating the corpora cavernosa is minimally invasive, which diminishes the potential risk of complications, especially intra– and postoperative bleeding.

Posterior Ring Apophysis Fracture Associated with Lumbar Disc Herniation Treated by Immobile Bony Fragment Excision: A Case Report

Study Design: A case report. Objectives: We report a case of posterior ring apophysis fracture (PRAF) with lumbar disc herniation treated by immobile bony fragment excision. Summary of Literature Review: PRAF causes severe radiculopathy, so treating with surgery is common. Materials and Methods: A 30-year-old male diagnosed with PRAF with lumbar disc herniation was treated with discectomy, but his clinical symptoms were not relieved. Consequently, bony fragment excision, extended laminectomy and interbody fusion were also done. Results: Radicular pain was relieved and showed good clinical outcome. Conclusions: When treating PRAF, bony fragment excision and extended laminectomy should be considered even if an immobile bony fragment exists.

Olecranon Nonunion after Operative Treatment of Fracture

Purpose: Olecranon nonunion after surgical management is relatively rare, but it leads to limitation of motion of joint or instability. This retrospective study was conducted in order to analyze the cause and result of treatment. Materials and Methods: We analyzed 11 cases treated for nonunion of olecranon fractures. Nonunion was classified according to the spot of the lesion and the extent of articular surface damage. Evaluation was performed using Mayo elbow performance score (MEPS), Oxford elbow score (OES), Disabilities of the Arm, Shoulder and Hand (DASH) scores, and the range of motion. Results: According to the spot of the lesion and the extent of articular surface damage, nonunion was categorized as IA (2 cases), IIA (5 cases), and IIIA (4 cases). One case of IA underwent nonunion fragment excision and the remaining cases were treated by bone grafting. A plate was used in seven cases and the other three cases had both plate and tension band wiring fixation. All nonunions finally became union. The 11 patients with one year follow-up had average MEPS of 87.7 points (range: 60-100 points), average OES of 43.2, and average DASH score of 18.8 points. Complications included limitation of motion (2 cases) and ulnar nerve symptoms (3 cases). Conclusion: Bone grafting and fixation by plate may be beneficial. In addition, excision can be useful in type I.

Bilateral isolated olecranon fractures after trauma: Report of two cases

Olecranon fractures represent approximately 10% of all fractures around the elbow in adults. Olecranon fractures occur by a fall or blunt trauma on the posterior tip of elbow, or by the forces generated by triceps muscle during a fall. Olecranon fractures were seen as unilateral fractures, however bilateral olecranon fractures were seen as pathological fractures. Anatomic restoration of the articular surface, repair of the extensor mechanism and full range of motion with stability are the main goals of treatment in olecranon fractures. Operative management should be performed when there is any articular incongruity or extensor mechanism deficit. Tension band fixation, intramedullary fixation, plating and proximal fragment excision are the main operative techniques which were used for the olecranon fractures. In this study, we reported two cases of bilateral traumatic olecranon fractures in patients without any concomitant systemic disease. Tension band wiring technique was used for the treatment of bilateral olecranon fractures. We preferred transcortical tension band wiring because it serves adequate stabilization and fragment compression with minimal instrumentation. When we reviewed the literature, we could not find isolated bilateral olecranon fractures in a patient without any concomitant disease. Treatment and rehabilitation of bilateral fractures served successful results with tension band wiring as unilateral fractures.

Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations.

ABSTRACTBackgroundFemoral head fractures are an uncommon but severe injury. These high-energy injuries typically occur in association with traumatic hip dislocations. Initial treatment includes urgent concentric reduction; however, controversy exists regarding specific fracture management. The well-known complications of avascular necrosis (AVN), posttraumatic arthritis (PTA), and heterotrophic ossification can leave patients with a significant functional loss of their affected hip. The purpose of this study is to evaluate the clinical and radiographic outcomes of femoral head fractures.MethodsA retrospective review was performed at our institution assessing all patients who presented from 2007 to 2015 with a femoral head fracture associated with a hip dislocation and at least 6 months of clinical and radiographic follow-up. Twenty-two patients met our inclusion criteria. There were 15 males and 7 females with an average age of 36 years (range: 17–55). The average follow-up time was 18 months (range: 6–102). Fractures were classified according to the Pipkin classification. The Thompson and Epstein score was used to determine functional outcomes.ResultsThere were five, Pipkin I, 3 Pipkin II, 0 Pipkin III, and 14 Pipkin IV, femoral head fractures. Sixteen patients were successfully closed reduced in the emergency department (ED) and six patients required open reduction after failed reduction in the ED. Four patients (18%) were successfully treated with closed reduction alone and 18 patients (82%) required operative intervention. Of those undergoing operative intervention, one patient underwent excision of the femoral head fragment, seven underwent open reduction internal fixation (ORIF) of the femoral head, nine underwent ORIF of the acetabulum, and one underwent ORIF of the femoral head and the acetabulum. Nine patients (41%) had an uneventful postoperative course. Two patients (9%) developed AVN, both requiring total hip arthroplasty (THA). Five patients (23%) developed PTA, two eventually requiring a THA. Two patients (9%) had sciatic nerve palsy. One patient (5%) developed a postoperative infection and four patients (18%) developed heterotrophic ossification (HO), none requiring operative treatment. Two patients (9%) had persistent anterolateral (AL) thigh numbness. Overall functional results were excellent in six patients (27%), good in six (27%), fair in seven (32%), and poor in three patients (14%). Four patients (18%) required a THA.ConclusionFemoral head fractures are a rare injury with well-known complications. Early diagnosis and concentric reduction are the prerequisites for successful treatment. This study adds to the growing literature on femoral head fractures associated with hip dislocations in efforts to define treatment plans and to guide patient expectations.How to cite this articleDel Core MA, Gross B, Ahn J, et al. Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations. Strategies Trauma Limb Reconstr 2019;14(1):6–10.

Osteochondral Autograft Plug Transfer for Treatment of Osteochondritis Dissecans of the Capitellum in Adolescent Athletes

Objectives:Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive over-head sports and can profoundly affect both ability to return to play and long-term elbow function. Large, unstable defects, defined as those greater than 1 cm in size, have unproven or poor long term outcomes with surgical interventions such as fragment excision, microfracture or attempted fixation. Treatment of similarly sized OCD lesions in the knee with osteochondral autograft plug transfer has proven both effective and safe. While interest has developed for expansion of its use to the elbow, it has yet to be adequately studied. The goal of this study is to evaluate clinical outcomes and return to play in adolescent athletes treated with osteochondral autograft plug transfer from the knee for large, unstable OCD defects of the capitellum.Methods:Inclusion Criteria: 1) Inability to participate in competitive sports 2) OCD defect of the capitellum that was either unstable on MRI or in patients who had failed 6 months of conservative treatment 3) Defect measuring at least 1 cm in area on diagnostic arthroscopy 4)Reconstruction of capitellar OCD with osteochondral autograft plug transfer 5) Minimum of 6 months post-operative follow-up. Data collection included chart review, determination of return to play, elbow range of motion, and DASH outcomes. The surgical technique was the same for all patients. It included initial diagnostic elbow arthroscopy, including loose body removal, followed by posterolateral approach to the elbow with lateral collateral ligament takedown from lateral epicondyle and eventual suture anchor repair, preparation of the capitellar osteochondral defect and appropriate plug transfer from the lateral trochlear ridge of the ipsilateral knee through a lateral approach. All patients followed the same post operative protocol, consisting of splint immobilization for 2 weeks, conversion to a hinged elbow brace for 4 weeks with progressive range of motion, and resumption of throwing and strengthening exercises at 3 months.Results:A cohort of 11 patients with a minimum of 6 months post procedure was identified. All patients were available for evaluation at an average 22.7 months follow up (range 6-49 months). Average age at the time of surgery was 14.5 years (range 13-17 years). The group consisted of 10 males and 1 female, all of which were involved in competitive athletics. Average return to play was 4.4 months (range 3-7 months). All athletes returned to at least their same level of play as pre-operatively. 3 have received Division 1 college scholarships (gymnastics, lacrosse and baseball pitcher). Of the 5 pitchers, 4 returned to pitching. The average DASH score was 1.36 (95% CI 0.59-2.12) and the average Sport Specific DASH score was 1.7 (95% CI -1.78-5.17). There were statistically significant improvements in elbow flexion from 125.45 degrees to 141.36 degrees (p=0.009) and extension from 20.45 degrees to 4.55 degrees (p=0.006). There was one adverse event. This consisted of a superficial wound infection, which resolved with surgical debridement and antibiotics and did not adversely affect eventual return to play. There were no complications or donor site morbidity related to graft harvest.Conclusion:Treatment of large, unstable osteochondritis dissecans lesions of the capitellum in adolescent athletes allows reliable return to high level of sports, is safe and has excellent long-term clinical outcomes.

Arthroscopic Excision of Bone Fragments in a Neglected Fracture of the Lateral Process of the Talus in a Junior Soccer Player

Fractures of the lateral process of the talus are uncommon and often overlooked. Typically, they are found in adult snowboarders. We report the case of an 11-year-old male soccer player who complained of lateral ankle pain after an inversion injury 6 months earlier. He did not respond to conservative treatment and thus underwent arthroscopic excision of fragments of the talar lateral process. The ankle was approached through standard medial and anterolateral portals. A 2.7-mm-diameter 30° arthroscope was used. Soft tissues around the talus were cleared with a motorized shaver, and the lateral aspect of the talar process was then visualized. The lateral process presented as an osseous overgrowth, and a loose body was impinged between the talus and the calcaneus. The osseous overgrowth was resected piece by piece with a punch, and the loose body was removed en block. The patient returned to soccer 5 weeks after the operation. This case exemplifies 2 important points: (1) This type of fracture can develop even in children and not only in snowboarders. (2) Arthroscopic excision of talar lateral process fragments can be accomplished easily, and return to sports can be achieved in a relatively short time.

Arthroscopic Treatment of Talar Body Fractures

Talar fractures can be severe injuries with complications leading to functional disability. Open reduction–internal fixation remains the treatment of choice for displaced talar fractures. Arthroscopic evaluation of the fracture and articular surfaces can play an important role in the treatment of these fractures. Arthroscopic reduction–internal fixation (ARIF) is increasingly used for certain intra-articular fracture types through the body. The minimally invasive nature of ARIF and high accuracy are enviable attributes of an evolving technique. This technical note describes arthroscopic evaluation of 2 intra-articular talar head fractures, using posterior portals, with ARIF performed in 1 case and excision of the fracture fragments in the other case.

Osteochondritis Dissecans of the Elbow

Osteochondritis dissecans (OCD) of the elbow is an increasingly recognized cause of elbow pain and dysfunction in adolescent athletes. This is particularly common in gymnasts and throwing athletes, and it may curtail an athlete's career and lead to subsequent degenerative arthritis. Patients present with elbow pain and stiffness and may have mechanical symptoms. The capitellum is most commonly affected, and typical radiographic findings may be seen on x-rays or magnetic resonance imaging. Nonoperative management is successful for most patients with stable lesions. Operative intervention is indicated for patients with unstable osteochondral defects. Various operative techniques have been described, including fragment excision with or without marrow stimulation, fragment fixation, osteochondral autograft transfer, and distal humeral osteotomy. Arthroscopy has become increasingly utilized for the diagnosis and management of elbow OCD. Although elbow arthroscopy is technically demanding, it allows complete evaluation of the elbow joint and treatment of concomitant elbow pathology via a minimally invasive approach. After review of alternative operative interventions, we describe our preferred technique of arthroscopic debridement and drilling for capitellar OCD.

Results of Non-operative and Operative Management Of Apophyseal Avulsion Fractures of the Hip and Pelvis in Adolescent Athletes

Objectives:Apophyseal avulsion fractures of the hip and pelvis occur almost exclusively in the adolescent population, with greater numbers being seen recently as the popularity and intensity of youth sports increases. Limited evidence exists detailing the demographics or distribution of these fractures by injury site. The goal of the current study was to present a comprehensive perspective on 437 of these fractures, including the indications and clinical course of 25 cases that underwent surgical intervention.Methods:All cases of an apophyseal avulsion fracture of the hip or pelvis between the years of 1981-2012 at a tertiary care pediatric center underwent radiographic and chart review, including operative details for that sub-population. Demographic data was analyzed, along with radiographic displacement, healing times, and return to sports for both groups.Results:413 patients underwent definitive non-operative treatment, 72% of which were male. The mean age was 14.5 years. The anatomic site of injury was well-distributed: AIIS 29%, ASIS 27%, ischial tuberosity 17%, lesser trochanter 15%, and iliac crest 11%. Half of all injuries occurred during one of three different athletic activities (soccer 26%, track 13%, baseball/softball 11%), with a wide range of sports in the overall cohort. In the 287 nonop cases with adequate follow up data to confirm mean radiographic union and time of return to sports (RTS), healing occurred at 2.7 months and RTS at 2.8 months respectively. The mean age of the cohort of 25 patients who ultimately required operative treatment was 15.7 years, with 72% of cases being initially treated with nonoperative measures. The ischial tuberosity was the most common (64%) anatomic site with others including AIIS 16%, iliac crest 16%, and ASIS 4%. Excision of the apophyseal fragment was the intervention pursued for 48% of cases, with the mean time to union of 4.8 months in 11 cases which underwent fixation and had adequate follow up data.Conclusion:In over 400 cases of apophyseal avulsion fractures in an adolescent population, 94% were successfully treated nonoperatively, with mean times of healing and return to sports under 3 months. Most cases requiring surgery failed primary conservative care, many of which underwent fragment excision, rather than fixation, due to the chronic nature of their preoperative period. Better understanding of the rare indications for early fixation and functional outcome measures of both nonoperative and operative management of these injuries is warranted, particularly given their increasing frequency paralleling a rise in overuse and youth sports injuries.

Tibial eminence fractures in the paediatric population: A systematic review

IntroductionWe present a systematic review of the literature for the management of tibial eminence fractures in the paediatric population. Our aims were to assess modalities of injury, treatment options available and their associated complications.Materials and methodsWe found 740 relevant citations in the English literature up to 1 October 2012, of which 36 full text articles met our inclusion criteria.ResultsOur results show that skiing, sports and motor vehicle accidents are increasingly common modes of injury, in addition to the commonly described fall off of a bicycle. Most studies advocate non-operative management for type I Meyer’s and McKeever’s fractures and reduction and internal fixation for type II and III fractures. Better long-term results have been reported with arthroscopic surgery compared to open surgery. There is no consensus as to which type of fixation is best suited for tibial eminence fractures; methods available include excision of the bony fragment, K-wire, screw and, absorbable suture fixation, and more recently, suture anchor and meniscal arrow. The main complications reported include arthrofibrosis, non-union, mal-union, pain and severe laxity. Early post-operative range of motion exercises have been shown to reduce the incidence of arthrofibrosis.ConclusionAs all papers report results from small case series, Level I studies are required to produce more definitive evidence for the management of paediatric tibial eminence fractures.

Novel Techniques in Treating Calcaneal Tuberosity Fractures

ABSTRACT Calcaneal tuberosity fractures comprise only 1 to 2% of all calcaneal fractures. Treatment of these injuries has traditionally included open reduction and internal fixation with various means including lag screws, suture anchors and K-wires. We report on a series of cases treated with excision of the tuberosity fragment with repair of the Achilles tendon supplemented by a flexor hallucis longus tendon transfer. Parekh S, Bertrand T, Zura R, Adams S, Yan A. Novel Techniques in Treating Calcaneal Tuberosity Fractures. The Duke Orthop J 2014;4(1):3-7.

Arthroscopic Repair of Small and Medium-Sized Bony Bankart Lesions

Background: There has been no study about treatment guidelines for arthroscopic repair according to the size of bony Bankart lesions of less than 25% of the glenoid width. Purpose: To evaluate the results of arthroscopic repair for bony Bankart lesions managed with different repair techniques based on their size. Study Design: Case series; Level of evidence, 4. Methods: Between March 2005 and February 2009, 44 of 52 consecutive patients with bony Bankart lesions with a size of less than 25% of the entire glenoid were managed with an arthroscopic approach. Of those patients, 34 (77%) were available for outcome analysis at a minimum 24 months’ follow-up (mean, 34 months; range, 24-60 months). The size of the fragment was measured by computed tomography (CT) and classified as small (<12.5% of the inferior glenoid width) and medium (12.5%-25%). Sixteen lesions were classified as small (small group), and 18 were classified as medium (medium group). For small lesions, capsulolabral repair using suture anchors without excision of the bony fragment was performed. For medium lesions, anatomic reduction and fixation using suture anchors was performed, and the adequacy of reduction was assessed by CT postoperatively. The visual analog scale (VAS) for pain score and modified Rowe score for bony Bankart repair were compared and the postoperative recurrence rate investigated. Results: One patient from the small group (6.3%) and 1 patient without anatomic reduction of the bony fragment in the medium group (5.6%) experienced traumatic redislocations. The mean VAS score improved from 1.7 preoperatively to 0.5 at final follow-up, and the mean Rowe score improved from 59 to 91 (both P < .001). The mean postoperative Rowe scores increased from 58 to 92 in the small group and from 60 to 91 in the medium group (both P < .001). Residual joint incongruity measuring ≤2 mm on both axial and coronal scans, which was considered an anatomic reduction, was present in 14 cases (77.8%) in the medium group. In the medium group, the mean postoperative Rowe scores increased from 60 to 95 in cases of anatomic reduction compared with an increase from 56 to 76 in cases of nonanatomic reduction. The Rowe score was statistically correlated with anatomic reduction of medium-sized bony fragments (P = .046). Conclusion: In small Bankart lesions, restoration of capsulolabral soft tissue tension alone may be enough, whereas in medium lesions, the osseous architecture of the glenoid should be reconstructed for more functional improvement and less pain.

Arthroscopic treatment of osteochondral lesion of olecranon

Osteochondral lesions (OCLs) are rarely seen in the elbow joint. These lesions are most commonly seen in the capitellum and radial head [5]. Although their exact mechanism is not very well understood, repetitive microtrauma and ischaemia are accepted as the two main aetiological factors [1, 5]. The term ‘‘osteochondral lesion’’ was used in this text, because it seems recently to cover all the definitions used for osteochondral abnormalities. Generally, the treatment aims for the pain relief and the return of the patient to the previous level of activities. Conservative follow-up and different surgical methods are possible for the treatment. The surgical treatment options include arthroscopic debridement, drilling, fragment excision or fixation, and osteochondral autografting. Among surgical modalities, arthroscopic excision of the fragments and subchondral abrasion or drilling of the lesion resulted in satisfactory short-term clinical outcomes [1, 2]. Case report

Chronic (Ten Years) Ischial Tuberosity Avulsion Fracture Nonunion Treated with Fragment Excision and Simultaneous Primary Repair of the Hamstring Tendon

Ischial tuberosity avulsion fractures are infrequent injuries that primarily affect adolescent athletes1-8. Ischial avulsions can be easily mistaken for hamstring injuries and therefore missed on initial presentation1,6. Whereas some of these fractures heal spontaneously, they often can progress to painful nonunion1,2,9,10. Painful nonunion of an ischial avulsion fracture is generally treated operatively with open reduction and internal fixation. To our knowledge, three years is the longest time span reported in the literature between ischial tuberosity avulsion fracture injury and nonunion repair1,2,8,9,11,12. We present a case of a chronic ischial tuberosity avulsion fracture nonunion with a ten-year delay between the initial injury and definitive surgical management via fragment excision and primary hamstring repair. This case report presents a viable option for repair of chronic, painful ischial tuberosity avulsion nonunion. Furthermore, it demonstrates that patients can benefit from this procedure, even after an extensive interval from the index injury. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A twenty-seven-year-old professional skater presented with chronic pain in the right buttock. She reported that the pain had intensified after reinjuring the buttock during a roller derby scrimmage three weeks prior to presentation. Pertinent past medical history included an ischial avulsion fracture diagnosed ten years prior at an outside institution, which had been treated conservatively. Of note, she had experienced chronic pain in the ischial region throughout her adult life. On physical examination, she had tenderness posteriorly and medially over the ischium. She had pain with resisted leg extension and resisted knee flexion, and decreased range of motion at the hip. There was no tenderness in the …

Chronic Symptomatic Os Subfibulare in Children

Some children have persistent pain and instability following inversion injuries of the ankle. Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. The purpose of this study was to evaluate the intraoperative findings and long-term outcomes of patients treated operatively for symptomatic avulsion injuries or a symptomatic os subfibulare. Twenty-three patients presented with chronic ankle pain and instability, tenderness anterior and distal to the lateral malleolus, and imaging studies (magnetic resonance imaging and/or stress radiographs) suspicious for avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. After unsuccessful nonoperative treatment, all patients underwent excision of the osseous fragments, anatomic reconstruction of the anterior talofibular ligament with use of drill holes through the lateral malleolus, and a modified Broström procedure. The mean age of the patients was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing a mean delay in diagnosis and treatment of 3.2 years. At a mean follow-up of 4.5 years (range, 2.1 to 13.2 years), the mean Foot and Ankle Outcome Score was 91.4 (range, 87 to 98) out of 100, with all but one patient returning to the preinjury recreational level. Only one patient had a long-term complication. In children with chronic pain and instability associated with an os subfibulare, surgical excision of the os subfibulare combined with reconstruction of the anterior talofibular ligament and a modified Broström procedure was effective in restoring ankle stability, eliminating pain, and permitting return to the preinjury functional level.

HIGH INCIDENCE OF HAMATE HOOK FRACTURES IN UNDERWATER RUGBY PLAYERS: DIAGNOSTIC AND THERAPEUTIC IMPLICATIONS

Hamate hook fractures are rare injuries but appear to occur frequently in underwater rugby, the reason for which was investigated in this study. High-level underwater rugby players with hook fractures diagnosed during a five-year interval (2005-2010) were studied retrospectively. Medical data on these patients were reviewed for information on the mechanism of injury, type of fracture, radiological imaging, treatment, and outcome. In ten patients, hook fractures of the leading hand were confirmed by computed tomography, all of which were associated with specific injuries during underwater rugby games. Conservative treatment resulted in delayed healing or non-union, wherefore fragment excision and open reduction and internal fixation was performed in ten and five patients, respectively, while two patients declined surgery. After surgery, all patients were able to play underwater rugby again. In underwater rugby, hook fractures occur frequently due to high and repeated forces applied to the leading hand during games.

Bipartite talus: A case series and algorithm for treatment

Bipartite talus is a rare condition of uncertain aetiology, with various treatment options described. We report five symptomatic bipartite talus cases in four male patients warranting surgical management. All patients were reviewed by an independent assessor. The youngest patient presented with bilateral lesions without sub-talar arthrosis. He was treated twice by internal fixation with bone grafting. The left side failed to unite. The second patient presented with isolated sub-talar osteoarthritis. He underwent fragment excision and sub-talar arthrodesis with bone graft. The third patient presented aged 55 with severe hind-foot osteoarthritis, and underwent tibio-talar-calcaneal fusion. The final patient was treated with fragment excision and sub-talar arthrodesis. All patients reported symptom improvement or resolution post-operatively. Four cases showed evidence of radiographic union. We suggest a treatment rationale of fragment fusion if large enough, or excision if not, with associated limited fusion if the adjacent joints are markedly degenerate.