Management of Ankle Charcot Neuroarthropathy: A Systematic Review

Background: Charcot neuroarthropathy is a non-infective, destructive process occurring in patients rendered insensate by peripheral neuropathy, which is caused mainly by diabetes. Repetitive trauma from standing and walking provides a neuro-traumatic stimulus that leads to dislocation, or peri-articular fracture, or both, within the ankle. This review concentrates on the management protocols regarding the ankle only. Methods: A Pubmed search for clinical trials performed to manage ankle Charcot neuroarthropathy and a systematic review of these articles were undertaken. Results: Twenty papers met the inclusion criteria: four of them describe non-surgical management, while the rest show different surgical management options of ankle Charcot neuroarthropathy. Conclusions: Surgical algorithms for the treatment of CN of the ankle are based almost entirely on level four. There is inconclusive evidence concerning the timing of treatment and the use of different fixation methods. Instability and ulceration are the main precursors for surgical interventions. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.

Biomechanical properties of a novel fixation system for intra-articular distal humerus fractures: a finite element analysis

Background The traditional strategy for fixing intra-articular distal humerus fractures is double plating placed in an orthogonal configuration, based on posterior approach. With a combined medial and lateral approach, a novel configuration of plating (combined anteromedial and anterolateral plating) has been used. In this study, we investigated the biomechanical properties of the novel plating by comparing it with some traditional strategies. Methods Based on the 3D morphology of a healthy subject’s humerus, models of three types of intra-articular distal humeral fractures were established using a variety of different internal fixation methods: (a) treatment of a simple intra-articular fracture of the distal humerus with the novel double plate and a traditional orthogonal plate; (b) treatment of a comminuted fracture of the lower distal humerus with the novel double plate, a traditional orthogonal plate and a traditional orthogonal plate combined with distally extended tension screws; (c) treatment of a coronal shear fracture of the distal humerus with the novel double plate, a traditional orthogonal plate and the intra-articular placement of three screws. The material properties of all plates and screws were isotropic and linearly elastic. The Poisson ratio of the implant and bone was 0.3, and the elastic modulus of the implant was 114,000 MPa. The axial loading is 200 N, the bending loading is 30 N and varus rotation is 7.5 Nm in the longitudinal direction. Results A simple model of intra-articular fracture of the distal humerus (AO C1 type) was established. Under all experimental conditions, the novel double plate showed greater stiffness than the orthogonal double plate. The axial straightening, bending compression and varus torsion increased by 18.00%, 16.00% and 44.00%, respectively. In the model of comminuted fracture of the lower distal humerus, the novel double plate showed the best stiffness under three experimental conditions (163.93 N/mm, 37.97 N/mm, 2697.84 N mm/°), and the stiffness of the traditional orthogonal plate combined with the distally extended tension screws was similar to that of the traditional orthogonal plate (121.21 N/mm, 32.61 N/mm, 1968.50 N mm/°). In the model of coronal shear fracture of the distal humerus, the novel double plate showed the best stiffness under all test conditions (194.17 N/mm, 38.46 N/mm, 2929.69 N mm/°), followed by the traditional plate (153.85 N/mm, 33.33 N/mm, 2650.18 N mm/°), while the stiffness of the three screws was the smallest (115.61 N/mm, 28.30 N/mm, 2180.23 N mm/°). Conclusions In terms of biomechanics, compared with other internal fixation methods, the novel combined anteromedial and anterolateral anatomical locking double-plate showed less stress, less displacement and greater stiffness. The novel double-plate method can be used to treat not only simple intra-articular fractures of the humerus but also complex comminuted fractures of the lower distal humerus and coronal shear fractures of the distal humerus, with a better effect than current traditional internal fixation methods.

Case Report: Trans-Articular External Skeletal Fixation of the Hip for a Highly Comminuted Juxta-Articular Fracture of the Proximal Femur Caused by Gunshot Injury in a Cat

This report describes a novel surgical technique for trans-articular external skeletal fixation (TA-ESF) of the hip to stabilize a rare, highly comminuted juxta-articular fracture of the proximal femoral segment involving the metaphysis and diaphysis in a cat. A 2-year-old, castrated male, Korean shorthair cat was admitted for a left femoral fracture caused by gunshot injury. Radiographs and computed tomography (CT) scans revealed a highly comminuted proximal femoral diaphyseal fracture that involved the femoral neck and the greater trochanter. The left femoral head was intact on CT. Under fluoroscopic guidance, an intramedullary Steinmann pin was placed to align the femur, and five positive-profile, end-threaded pins were placed in the left hemipelvis and distal femur. A triangulated frame of connecting bars was constructed using Steinmann pins and epoxy resin for TA-ESF. This secured the pins placed in the pelvis and femur as well as the intramedullary pin, providing proximal femoral stabilization by trans-articular fixation of the hip. The cat began placing weight on the left pelvic limb 4 days postoperatively, and progressively obtained near-normal limb function by day 112. The TA-ESF was partially dismantled to a linear tie-in construct on day 64 and was completely removed on day 161. Final radiographs on day 161 revealed lack of bone healing in the proximal segment, especially femoral head and neck, despite functional recovery of the injured leg. At one year postoperatively, the cat had normal limb function without any noticeable complications. On follow-up 29 months after surgery, the owner reported that the cat had normal limb function without any noticeable complications. Despite insufficient bone healing in the cat, TA-ESF of the hip allowed for satisfactory functional recovery of this challenging juxta-articular fracture of the proximal femur, which was not amenable to stabilization with a traditional non-load-sharing fixation system.

Clinical efficacy of closed reduction and percutaneous parallel K-wire interlocking fixation of first metacarpal base fracture

Background This study aimed to explore the clinical efficacy of treating a first metacarpal base fracture by closed reduction and percutaneous parallel K-wire interlocking fixation between the first and second metacarpals. Methods Twenty patients treated by the abovementioned modified technique (modified technique group) and ten patients treated by the traditional percutaneous K-wire fixation technique (traditional technique group) from October 2015 to November 2019 at our institution were retrospectively reviewed. The patients’ average age was 38 years (range, 16–61 years). The mean follow-up period was 13 months (range, 10–18 months). At the final follow-up, the functional recovery of the injured hand was assessed and compared between the modified and traditional technique groups. In addition, the functional recovery of the injured hand was compared with that of the uninjured hand within the modified technique group. Results All patients recovered well, with no cases of infection or nonunion. Compared with the traditional technique group, the modified technique group had a shorter operative time, lower postoperative visual analogue scale pain score, better effective range of motion score of the first carpometacarpal joint (Kapandji score), and had almost no need for auxiliary plaster fixation, enabling functional exercise to be started earlier. Within the modified technique group, the mean hand grip strength, pinch strength, and Kapandji score on the injured side did not significantly differ to the values on the uninjured side in both the extra-articular and intra-articular fracture subgroups. While the abduction and flexion–extension arcs of the thumb on the injured hand were significantly smaller than those on the uninjured hand in both the extra-articular and intra-articular fracture subgroups, the patients felt clinically well with respect to daily activities and strength. Conclusion The percutaneous parallel K-wire and interlocking fixation technique is simple, effective, and economical for first metacarpal base fractures.

Local Random Pattern Flap Coverage for Implant Exposure following Open Reduction Internal Fixation via Extensile Lateral Approach to the Calcaneus

Background Skin necrosis and implant exposure most often appear at the corner of Extensile Lateral Approach for open reduction and internal fixation (ORIF) for displaced intra-articular fracture of the calcaneus. Flap transfer is often used for coverage of this implant exposure. We introduced a new simple local random pattern flap to cover the implant exposure. Methods From March 2017 to March 2020, 12 patients with implant exposure after ORIF for displaced intra-articular fracture of the calcaneus were treated with this procedure. The sizes of the defects ranged from 2 × 2 cm2 to 5 × 2 cm2. A local random pattern flap was designed according to the defect size. The lower edge of the flap was along with the wound upper edge and extended distally. The upper horizontal incision of the flap was made at the lateral malleolus level with a length of 5–7 cm depending on the wound defect. Then the random pattern flap was elevated and transferred to cover the defect area. Results The mean follow-up duration was 6.3 months (ranging 4–13 months). All 12 flaps were uneventfully healed and all patients were able to wear shoes, and no debulking procedures were required. Conclusion The local random pattern flap could be a choice for surgeons when implant exposure at the corner of Extensile Lateral Approach to the Calcaneus occurs.