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Calcaneus fractures often occur because of accidents during exercise or activities. In general, the detection of the calcaneus fracture is still carried out manually through CT image observation, and as a result, there is a lack of precision in the analysis. This paper proposes a computer-aid method for the calcaneal fracture detection to acquire a faster and more detailed observation. First, the anatomical plane orientation of the tarsal bone in the input image is selected to determine the location of the calcaneus. Then, several fragments of the calcaneus image are detected and marked by color segmentation. The Sanders system is used to classify fractures in transverse and coronal images into four types, based on the number of fragments. In the sagittal image, fractures are classified into three types based on the involvement of the fracture area. The experimental results show that the proposed method achieves a high precision rate of 86%, with a fast computational performance of 133 frames per second (fps), used to analyze the severity of injury to the calcaneus. The results in the test image are validated based on the assessment and evaluation carried out by the physician on the reference datasets.

To systematically review current diagnostic imaging options for assessment of the Lisfranc joint. PubMed and ScienceDirect were systematically searched. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT) (four articles), and magnetic resonance imaging (MRI) (11 articles). Some articles discussed multiple modalities. The following data were extracted: imaging modality, measurement methods, participant number, sensitivity, specificity, and measurement technique accuracy. Methodological quality was assessed by the QUADAS-2 tool. Conventional radiography commonly assesses Lisfranc injuries by evaluating the distance between either the first and second metatarsal base (M1-M2) or the medial cuneiform and second metatarsal base (C1-M2) and the congruence between each metatarsal base and its connecting tarsal bone. For ultrasonography, C1-M2 distance and dorsal Lisfranc ligament (DLL) length and thickness are evaluated. CT clarifies tarsometatarsal (TMT) joint alignment and occult fractures obscured on radiographs. Most MRI studies assessed Lisfranc ligament integrity. Overall, included studies show low bias for all domains except patient selection and are applicable to daily practice. While conventional radiography can demonstrate frank diastasis at the TMT joints; applying weightbearing can improve the viewer’s capacity to detect subtle Lisfranc injury by radiography. Although ultrasonography can evaluate the DLL, its accuracy for diagnosing Lisfranc instability remains unproven. CT is more beneficial than radiography for detecting non-displaced fractures and minimal osseous subluxation. MRI is clearly the best for detecting ligament abnormalities; however, its utility for detecting subtle Lisfranc instability needs further investigation. Overall, the available studies’ methodological quality was satisfactory.

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Introduction: The incidence of Lisfranc injury is higher than previously estimated, and more than two- thirds of these injuries are caused by low-energy trauma. This low-energy mechanism, common to the athletic population, tends to be distinctly characterized by a primarily ligamentous Lisfranc injury. Bilateral weightbearing radiographs are widely accepted as the gold standard and are able to diagnose instability by contralateral comparison. However, contrary to radiography, CT imaging is not obscured by metatarsals overlapping each other and their adjacent tarsal bone and thus provides a better visualization of bony structure. This study’s purpose was to model a purely ligamentous Lisfranc joint injury to determine widening between the medial cuneiform (C1) and second metatarsal (M2) after each ligament dissection under non-weightbearing (NWB, 0 kg), partial weightbearing (PWB, 40 kgs.), and full weightbearing (FWB, 80 kgs.) conditions evaluated by weightbearing computed tomography (WBCT). Methods: Methods: Twelve paired through-knee cadavers were incised dorsally to visualize the Lisfranc joint complex. An intact ligament condition was the control (group 1). The dorsal ligament (group 2), interosseous ligament (group 3), and plantar ligament (group 4) were sequentially dissected. The twelve pairs were then equally randomized (groups 5a, 5b, and 5c). The first tarsometatarsal joint capsule (group 5a), the second tarsometatarsal joint capsule (group 5b), or the intercuneiform ligament (group 5c) was transected. The remaining intact ligaments of each subgroup were similarly randomized for transection (e.g., group 6ac: transection of the first tarsometatarsal joint, followed by transection of the intercuneiform ligament). Finally, the last ligament was transected (group 7). After each dissection, CT scans were taken for NWB, PWB, and FWB conditions. Distance between the lateral border of C1 and the medial border of M2 was used to evaluate diastasis for both coronal and axial views. Analysis of variance (ANOVA) tested for significant differences between all groups. Dependent t-test evaluated for significance of the weightbearing variable. Results: In group 1, C1-M2 distance was 3.9 mm (3.5-4.3, SD 0.3) for coronal imaging and 4.0 mm (3.6-4.5, SD 0.4) for axial imaging, and no statistically significant differences were found between paired feet (P = 0.61) or for weightbearing conditions (P = 0.34). In group 4, an average widening of 1.4-mm (0.8-2.1 mm, SD 0.4) and 1.8-mm (1.4-2.8 mm, SD 0.5) were observed for PWB and FWB in the coronal view, and an average widening of 1.5-mm (0.9-2.3 mm, SD 0.5) and 2.0-mm (1.4-3.0 mm, SD 0.5) were observed for PWB and FWB in the axial view, respectively. For the subsets of group 5, only 5c was found to have a majority of specimen (7/8, 87.5%) that had significant widening - at least 2 mm - between C1-M2 for the PWB condition in the axial view; for the FWB condition, significant widening was found in both the axial and coronal view. In groups 6ca, 6cb, and 7, a significant widening - at least 2 mm - was measured in both planes for the NWB condition. Conclusion: WBCT scans improve the ability to detect incomplete ligamentous Lisfranc injuries by comparing C1-M2 distance to the uninjured side. Widening exceeding 1 mm more than the normal contralateral side for the PWB condition could clinically indicate complete Lisfranc ligament injury (sensitivity 83.3%, specificity 88.9%, accuracy 87.5%).

Introduction: Calcaneum fracture accounts for 2% of all fractures and 60% of all tarsal bone fractures. The most favored treatment for intra-articular fractures is open reduction and internal fixation using an extended lateral approach. The use of minimally invasive reduction and fixation of calcaneal fractures may have a role in this group of patients where there is a concern regarding wound healing and infection. Materials and Methods: This was a prospective study conducted from April 1, 2016, to April 30, 2018. Eighteen patients were included in the study. Preoperative and postoperative plain radiographs were compared for reduction parameters (improvement of Bohler's angle or Gissane's angle, the width of the calcaneus), Functional outcome was assessed using American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score and visual analog scale. Results: The patients followed up for an average of 15.56 ± 4.85 months. No significant differences in reduction were observed between the open and closed groups (P > 0.05). The average AOFAS scores of the two groups were 76.45 ± 6.83 and 84.65 ± 7.65 (open versus closed) (P = 0.087). The mean visual analog scores of the open and closed groups were 1.38 ± 1.15 and 0.75 ± 0.45 (P = 0.034). The complication rates of the open and closed groups were 33% (3/9) and 10% (1/9) (P = 0.0053). Conclusion: Closed reduction and percutaneous screw fixation have shown better results in terms of outcome and complications. However, multicenter controlled randomized clinical trials are still required prior to widespread practical implementation.

The talus, the second largest tarsal bone, has distinctive imaging characteristics and injury patterns. The predominantly extraosseous vascular supply of the talus predisposes it to significant injury in the setting of trauma. In addition, the lack of muscular attachments and absence of a secondary blood supply can lead to subsequent osteonecrosis. Although talar fractures account for less than 1% of all fractures, they commonly result from high-energy trauma and may lead to complications and long-term morbidity if not recognized and managed appropriately. While initial evaluation is with foot and ankle radiographs, computed tomography (CT) is often performed to evaluate the extent of the fracture, displacement, comminution, intra-articular extension, and associated injuries. Talar fractures are divided by anatomic region: head, neck, and body. Talar head fractures can be treated conservatively if nondisplaced, warranting careful radiographic and CT evaluation to assess rotation, displacement, and extension into the neck. The modified Hawkins-Canale classification of talar neck fractures is most commonly used due to its simplicity, usefulness in guiding treatment, and prognostic value, as it correlates associated malalignment with risk of subsequent osteonecrosis. Isolated talar body fractures may be more common than previously thought. The Sneppen classification further divides talar body fractures into osteochondral talar dome, lateral and posterior process, and shear and crush comminuted central body fractures. Crush comminuted central body fractures carry a poor prognosis due to nonanatomic reduction, bone loss, and subsequent osteonecrosis. Lateral process fractures can be radiographically occult and require a higher index of suspicion for successful diagnosis. Subtalar dislocations are often accompanied by fractures, necessitating postreduction CT. Familiarity with the unique talar anatomy and injury patterns is essential for radiologists to facilitate appropriate and timely management.

Skeletal tuberculosis developing after trauma is a rare occurrence.We report a rare case of posttraumatic tubercular osteomyelitis of mid-tarsal bone of the right foot. Patient was treated with regular dressing and anti-tubercular drugs. Posttraumatic skeletal tuberculosis should be considered in patient with non-healing ulcer.

The calcaneus is the most frequently fractured tarsal bone. Compartment syndrome (CS) complicates fractures and other injuries and is most commonly described in association with the lower leg. The long-term sequelae of CS of the foot can include toe clawing, permanent loss of function, persistent pain, muscle atrophy, contracture, painful warts, weakness, and sensory disturbances. The incidence and clinical significance of untreated CS after calcaneal fractures were questioned. All compliant patients treated by us for a calcaneus fracture underwent a physical examination and medical interview: 47 (49 fractures) were included in the final cohort (36 males, 11 females, mean age 49 ± 14.5 years, mean follow-up 23 ± 16 months). Missed CS sequelae were diagnosed by the presence of claw toes and plantar sensory deficits. The functional outcome and pain at rest and during activity were scored. Five patients (10%) had missed CS, and their functional score was significantly lower than for those without CS (52 ± 21.5 versus 77.4 ± 22 for no CS, p < .05). All missed CS cases were diagnosed in patients with a Sanders type 3 or 4 fracture. Intra-articular fracture was a significant factor associated with developing CS sequelae (p = .045). Untreated CS can cause muscle and nerve injury and contribute to a poor functional outcome. Because CS is more likely to develop after highly comminuted intra-articular fractures, these patients warrant close monitoring for CS development. Early detection and treatment might result in fewer late disabling sequelae of this injury.

Craniosynostosis, the premature fusion of one of more of the cranial sutures, is relatively common, with an incidence of approximately 1 in 3,000 live births [3]. Although craniosynostosis typically occurs in an isolated manner, without accompanying anomalies, it is also a feature of more than 150 genetic syndromes, the most common of which is Muenke syndrome [4, 15, 19]. Of all patients with craniosynostosis, 8% are estimated to have Muenke syndrome; 24% of patients with craniosynostosis and a known genetic cause have Muenke syndrome [15, 19, 29]. Muenke syndrome is an autosomal dominant craniosynostosis syndrome due to the defining point mutation, c.749C>G, in the FGFR3 gene, resulting in p.Pro250Arg [1, 16]. The condition is characterized by coronal craniosynostosis (bilateral more often than unilateral), carpal and/or tarsal bone fusion, hearing loss, and developmental delay. Following surgical treatment of the craniosynostosis, individuals with Muenke syndrome are five times more likely than individuals with non-syndromic craniosynostosis to need transcranial reoperation for raised intracranial pressure [28]. Vitamin A, which is necessary for the synthesis of visual pigments and is an important component of membrane stability, is obtained from two sources: preformed vitamin A (derived from animal sources) and provitamin A (from carotenoids, fruits, and vegetables) [11, 12]. Preformed vitamin A is efficiently absorbed and used by humans at absorption rates of 70–90%. Provitamin A, derived from carotenoids and plant foods, is absorbed much less efficiently, at rates of 20–30% [12]. Vitamin A toxicity has traditionally been thought of as being unlikely to result from provitamin A due to its relatively poor absorption efficiency and the fact that the conversion of carotenoids to vitamin A is highly regulated. For this reason, carotenemia, a term used to describe excess levels of carotene (a source of provitamin A) in the blood, has been described as being benign aside from the yellow pigmentation of skin. There have been several reports of benign carotenemia secondary to carrot ingestion, the most common cause of carotenemia, as well as dietary dried seaweed, green beans, and nutrient supplementation [14, 17, 26, 27]. The association of vitamin A with intracranial hypertension is well established. In one study of idiopathic intracranial hypertension, affected patients had significant elevation of serum retinal (a derivative of vitamin A) compared to controls [13]. Vitamin A is also one of the known contributors to the pathophysiology of idiopathic intracranial hypertension, although its exact role has yet to be elucidated [8]. Hypervitaminosis A has also been associated with hydrocephalus, a known structural cause of increased intracranial pressure [22].

Background: Aggressive musculoskeletal tumors in the foot, such as diffuse-type giant cell tumors or extra-abdominal desmoid tumors, are difficult to treat because the foot does not have enough soft tissue to allow wide tumor resection. We reviewed the clinical behavior of diffuse-type giant cell tumor in the foot and evaluated the recurrence potential of these tumors from radiologic and pathologic perspectives. Methods: Six patients with a mean age of 37.6 years were included in this study. Radiologic studies, including sonography, computed tomography (CT), magnetic resonance imaging (MRI), and bone and gallium citrate scintigraphy, were obtained followed by surgical treatment and histologic evaluation of the tumor. Results: Recurrence occurred in three patients. Although CT and MRI findings were similar in the recurrent and nonrecurrent tumors, marked differences were found between the two by scintigraphy; positive radiotracer uptake to the affected foot with gallium citrate scintigraphy was noted only in recurrent tumors, although positive accumulation was seen in all patients with bone scintigraphy. Histologically, the necrotic area and mitotic activity were more apparent in recurrent than in the nonrecurrent tumors, and tumor cell dyscohesion was noted in the former, (the intercellular space was increased). Conclusions: Repeated recurrence with tumor invasion into tarsal bone resulted in breakage of the tarsal arch that supports the body's weight. Amputation would be necessary for patients in whom the disease had progressed to obtain local cure and relief of pain. In the present study, we found two features of the recurrence potential of diffuse-type giant cell tumors: sparse cell to cell contact on pathologic examination and positive accumulation in the tumor on gallium citrate scintigraphy. We concluded that giant cell tumors with these two features have a strong potential for local recurrence, and thus require intensive followup.

Background: The calcaneus is an important tarsal bone which is configured in such a way that it forms the calcaneal angle when a person stands erect. This angle is assessed in the evaluation of calcaneal fractures but literature is scanty on African subjects. Objective: To establish values for Malawians and compare them with those for Ugandans and Nigerians previously studied. Methods: 220 lateral radiographs of the ankle comprising 118 male and 102 female indigenous Malawians aged 18–54 years were examined and the angle measured. Results: The highest frequency of the angle occurred in the 30°–34° class limit with a mean and SD of 30.11°±6.29° (range, 14° to 45°). There was no difference in the angle between left and right feet ( P >0.5) and between male and female subjects ( P >0.5) as was the case with Nigerians. Significant differences were, however, observed between Malawian and Ugandan men, Malawian and Nigerian men, Malawian and Nigerian women ( P P Conclusion: Our study reinforces the need to establish the normal range of the angle in a given population. Also stressed is the clinical importance of the angle in orthopaedic practice. We recommend that the lower limit of the angle in a given population be represented by the mean–2SD, which was found to be 17.53° in our study.

Category: Hindfoot, Trauma Introduction/Purpose: Calcaneus fractures are common injuries of the foot and account for approximately sixty percent of all tarsal bone fractures. Anatomic reduction of the articular surface is associated with good long-term outcomes. Unfortunately, there is a high rate of complications following surgical fixation due to the fragile soft tissue envelope surrounding these injuries. External fixation of joint depression calcaneus fractures allows for restoration of morphology and preservation of soft tissues. The purpose of this work is to determine if acute external fixation in the management of joint depression calcaneus fractures leads to decreased postoperative complications and better outcomes. Methods: Patients were identified using the appropriate procedure codes over a ten year span at a level one trauma center. Those under the age of eighteen and underwent nonoperative treatment were excluded. Electronic medical records were reviewed to obtain, basic demographic data, comorbidities, and injury specifics. Calcaneus fractures were classified as open or closed and using the Essex-Lopresti classification system. Operative reports were reviewed to determine which patients initially underwent external fixation versus open reduction internal fixation (ORIF), furthermore any staged operative interventions were also noted. Electronic records were also reviewed to determine the length of follow up and incidence of postoperative complications. Bivariate analysis was used to identify an association between collected variables and postoperative complications (wound dehiscence, hardware failure, infection, nonunion). Multivariate logistic regression analysis was used to determine if patients treated with acute external fixation were associated with lower postoperative complication rates. Results: 152 calcaneus fractures were identified and included for analysis. The average age was thirty-eight and the majority of patients were male (111/152 = 73%). Average follow up was approximately five months. Seventeen percent (26/152) were open fractures. Twenty-six (17%) were treated initially with external fixation and eleven of these were a staged ORIF. The overall complication rate was 11% (17/152) with the most common complication being wound dehiscence. Only one complication occurred in the group initially managed with external fixation. Statistical analysis revealed that open fractures were associated with increased postoperative complication rates in a bivariate and multivariate model. Conclusion: External fixation of joint depression calcaneus fractures restores height and preserves the soft tissue envelope. Although there was only one complication in the external fixation group, the difference in complication rates was not statistically significant based on initial treatment. The low number of patients treated with external fixation initially and the short follow up are limitations of this study. Further work is needed with a larger patient cohort in a prospective setting. Acute external fixation may prove to be a useful tool to help prevent postoperative complications following joint depression calcaneus fractures.

We report on three sibs presenting with spondylocarpotarsal synostosis, short-trunk dwarfism of postnatal onset, scoliosis, unsegmented thoracic vertebrae with unilateral bar, and carpal bone fusion. Tarsal bone fusion and dental abnormalities were noted in some of them, indicating pleiotropy and intrafamilial variability. Lens opacities, rarefaction of retinal pigmentation, and narrowing of retinal vessels, detected in two patients, are findings that have not been described to date in this condition.

The os calcis is the most frequently fractured tarsal bone. In 1992 Sanders developed a classification system based on coronal and axial computed tomography (CT) scans of the calcaneus. This classification is the one used most frequently today in treatment decision making and reporting of results. The objective of this study was to assess the degree of interobserver variability in using this classification system. Thirty CTs of calcaneal fractures were chosen randomly from the past 5 years in 2 tertiary care centers. The CTs were reviewed by 3 orthopedic surgeons and one senior orthopedic resident who classified the fractures according to Sanders' classification. The results were first tabulated and analyzed by using a weighted κ test including the subcategories. The weighted κ value achieved was .56, with a 95% confidence interval of .45–.67. The subcategories of the classification were then further combined and a second weighted κ test was performed to assess agreement between general classes. The weighted κ value achieved was .48, with a 95% confidence interval of 0.37–0.59. We concluded that Sanders' classification system did prove to achieve moderate agreement among users, thus representing a useful classification system. (The Journal of Foot & Ankle Surgery 42(1):21–23, 2003)

As the largest tarsal bone and the most inferior bone in the body, the calcaneus is responsible for supporting the axial load from the weight of the body. It is most commonly fractured after a fall from a height in which axial loads exceed its support capacity. Calcaneal fractures account for 60% of all tarsal fractures. Conventional radiography is commonly used for initial evaluation of calcaneal injury but has the typical disadvantages of two-dimensional imaging. Modern assessment of calcaneal fractures relies heavily on multidetector computed tomography (CT), which allows better visualization and characterization of fracture lines and fragment displacement. Calcaneal fractures observed at CT have been divided into intra- and extraarticular fractures on the basis of subtalar joint involvement. The Sanders classification system for intraarticular fractures is the most commonly used system because it correlates with clinical outcomes and involves less interobserver variability. The classification of extraarticular fractures has been less controversial and makes use of anatomic landmarks on the calcaneus to divide the bone into anterior, middle, and posterior areas. Soft-tissue involvement is an important aspect of calcaneal fracture assessment because it has been linked with poor functional outcomes. Familiarity with the normal anatomy of the calcaneus, the classification of calcaneal fractures, and the various complications of these fractures is essential for treatment assessment, especially if surgical intervention is required.

The treatment of rigid equinocavovarus foot deformities caused by neurologic disorders is often difficult and relapse is common.We asked whether the Ilizarov technique could be used for correction of neurologic equinocavovarus foot deformities resulting in improved foot and ankle function and patient satisfaction.The neurologic equinocavovarus foot deformities of 26 patients (mean age, 18.7 years; 29 feet) were treated using the Ilizarov technique. Nine feet were treated by distraction histiogenesis only with limited soft tissue release, whereas 20 feet needed additional osteotomy and/or tendon transfer/lengthening. Minimum followup was 12 months (mean, 72.9 months; range, 12-155 months).The mean time required for deformity correction was 27.1 days (range, 14-47 days) and the mean time for stabilization in the apparatus was 23.2 days (range, 7-53 days). A painless, stable, and plantigrade result was obtained by 22 patients (24 feet). Mild residual foot deformity was observed in the remaining five feet of four patients. Six patients (six feet) experienced postoperative complications. Three patients (four feet) experienced recurrence of the deformity requiring surgical correction.Ilizarov soft tissue distraction with or without callotasis of tarsal bone(s) allows a greater degree of correction of neurologic equinocavovarus foot deformities. However, to reduce the risk of recurrence after fixator removal, it may be necessary to overcorrect the deformity while in the fixator, to use nighttime splinting, and most importantly, to eliminate neuromuscular imbalance, if necessary, by combining arthrodesis with or without tendon transfer.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Extremity problems in 120 ostrich chicks were investigated in this study. Fledglings were followed for 1 year and extremity problems were evaluated as congenital or acquired. In the study, congenital lower extremity problems were found in 17.5% of the cases (both extremities extended sideways in 10 cases, 1 extremity extended sideways in 3 cases, one leg extended forward and the other back in 4 cases, big toe retrovert in 2 cases, 5th toe deviated towards underneath of the big toe, totaling to 21 cases) and acquired lower extremity problems in 19.64% of the cases (tibiotarsal luxation in 6 cases, tarsal bone fracture in 1 case, fractures in radius-ulna in 1 case, injuries of the extremities in 9 cases and arthritis in the tarsal joint in 2 cases and in proximal interphalangeal joint in 3 cases, totaling to 22 cases). Extremity problems were found in 43 (35.83%) ostrich chicks out of 120 (congenital in 21 cases and acquired in 22). Of these 43 cases, it was observed that 29 (67.44%) were healed with the treatment applied, whereas, 14 (32.56%) did not heal. It was concluded in the study that the extremity problems causing great economic losses in ostrich husbandry can be minimized with prevention, early diagnosis and proper treatment.

The histologic and histochemical features of quinolone-induced arthropathy were studied using 14 skeletally immature Beagle dogs (3 to 4 months old) dosed orally with difloxacin at 300 mg/kg body weight once daily for 1, 2, 5, or 7 days. A placebo was given to eight other age-matched Beagle dogs that served as controls. A scoring technique that included lesion size and histologic features was used to determine the progression of lesions. Articular-epiphyseal cartilage complexes on the femoral and humeral heads and tibial tarsal bone were identified as predilection sites. Within predilection sites on femoral and humeral heads, lesions developed in specific areas. Lesions appeared within 2 days of the onset of treatment, and lesion scores increased with time. Grossly, the lesions were raised, fluid-filled vesicles on the articular surface. Histologic changes included vesicle formation with loss of proteoglycan, clumping of unmasked collagen, and degeneration and necrosis of chondrocytes. In lesions with higher scores, chondrocytes were often in clusters or they were undergoing metaplasia toward spindle-shaped cells. Although dissolution of matrix and necrosis of chondrocytes were typical of all lesions, smaller lesions had histologically normal chondrocytes adjacent to small vesicles. In sections stained with toluidine blue, proteoglycan was aggregated with collagen fibrils or was absent from the matrix adjacent to vesicles. Unique features, such as biomechanical forces, may predispose specific areas of articular cartilage to develop lesions.

The calcaneous is the largest tarsal bone in the foot and plays an important role in walking and running. Motor vehicle crashes and falls from elevation have been associated with calcaneal fractures. Although not life-threatening, these injuries may result in permanent disability. This study used the Crash Injury Research and Engineering Network (CIREN) database to describe calcaneal fractures and concomitant lower extremity skeletal injury patterns for occupants involved in motor vehicle crashes. Sixty-three drivers and 7 front row passengers with calcaneal fractures were identified in the CIREN database during 1997-2005. Almost all these occupants were involved in severe (based on the delta V and vehicle crush) frontal or off-set frontal crashes with toe pan intrusion. Eighty-four percent of the calcaneal fractures were intra-articular or partially articular. Overall, 93% of occupants also had injury to other body regions with 84% having other lower extremity fractures. One year after the crash, most occupants had not returned to their prior level of physical functioning. Surgically managing patients with calcaneal fractures for an optimal outcome remains a challenge for orthopedic surgeons. Because lower extremity injuries, including calcaneal fractures, may cause permanent disability, it is important to prevent these injuries through structural improvements in motor vehicle design.

Congenital absence of one or both cruciate ligaments (CL) is an uncommon anomaly. It has been described in patients with associated congenital deformities such as short femur, congenital thrombocytopaenia and absent radius syndrome [1, 2]. An association with tibial and fibular hemimelia has also been reported [3, 4]. Fibular hemimelia is a rare congenital, non-inherited disorder. Most of the series previously reported concern less than ten patients. The largest series consists of 81 patients [3]. The disorder may present in a variety of patterns ranging from minimal hypoplasia of the fibula (type I) to its complete absence (type II) [4]. Congenital anomalies involving the ipsilateral lower limb are frequently associated [3]; these include congenital shortening of the femur, valgus angulation of the knee, small and high-riding or absent patella, hypoplasia of the lateral femoral condyle, ball-and-socket ankle joint, tarsal bone coalition and absence of the lateral rays of the forefoot. Associated upper limb anomalies are less frequent. The incidence of visceral malformations seems to be very low (two malformations in 81 patients in the largest series) [3]. In addition to skeletal changes, soft tissue abnormalities can be observed. The actual incidence of intraarticular knee abnormalities is unknown, mostly because MRI and arthroscopy were rarely performed in the previous series [4]. Nevertheless, CL aplasia seems to be a quite frequent associated finding. In a series of five patients with fibular hemimelia, Laor et al. reported four patients Case report

The study by Moon et al. investigated areas largely unknown about clubfoot regarding the heterogeneity of soft-tissue pathoanatomy and response to treatment. Despite the knowledge, now established, that management with the Ponseti method is preferable to comprehensive surgery1, in that it leads to better outcomes in adulthood, many questions remain in terms of why some children are more difficult to treat or why the deformity rapidly recurs after correction with casting. Clearly, we need a better understanding of the variety of soft-tissue abnormalities in the limb that are associated with clubfoot to improve diagnosis, prognosis, and treatment. Magnetic resonance imaging (MRI) has been used in the evaluation of clubfoot deformity for many years, mainly for the study of tarsal bone morphology and alignment. It also has been used in prognosticating and effectively demonstrating the progression of clubfoot treatment. It was not until recently that investigators began using MRI for soft-tissue evaluation of congenital clubfoot2. The current study identified several categories of soft-tissue abnormalities associated with treatment resistance. Over the last two decades, the Ponseti method has been popularized and applied successfully to the treatment of congenital and pathologic clubfoot. However, even in the congenital group, those without any apparent generalized neuromuscular abnormality, varying degrees of response to the Ponseti method have been demonstrated, with some children experiencing rapid recurrence and requiring further casting and repeat heel-cord tenotomy. Differences in foot morphology or stiffness have been implicated in the previous literature, …

Nine fresh-frozen foot specimens were studied to determine the mechanical behavior of the foot using calcaneocuboid distraction arthrodesis, an operation designed for treatment of posterior tibial tendon dysfunction with flatfoot deformity. Flatfoot deformity was created in cadaveric specimens, and to simulate toe-off phase of gait, loads were applied to the plantar surface of the foot and six tendons. Three-dimensional tarsal bone positions were determined with a magnetic tracking system. With ligament sectioning, flatfoot deformity was observed and average arch height decreased 53 +/- 3.5 mm. Height arch increased after calcaneocuboid distraction arthrodesis an average of 3.2 +/- 3.6 mm and was less than normal arch at an average of 2.1 +/- 2.4 mm. Metatarsotalar alignment compared with flatfoot improved after calcaneocuboid distraction arthrodesis in adduction and inversion to the extent that these were not significantly different from intact foot positions. Calcaneotalar position improved after calcaneocuboid distraction arthrodesis in adduction and inversion. Calcaneocuboid alignment compared with flatfoot improved after calcaneocuboid distraction arthrodesis in adduction, plantar flexion, and eversion, but compared with an intact foot was overcorrected in all three planes of motion. Arch alignment in simulated toe-off phase of gait in cadaveric feet was improved significantly with calcaneocuboid distraction arthrodesis but was not reduced anatomically.

Objectives— To define the release of nitric oxide (NO), prostaglandin E2 (PGE2), and the neutral metalloproteinases (NMPs) in horses with subchondral cystic lesions (SCL) and to study bone resorption triggered by conditioned media of fibrous tissue of SCL in vitro. Study Design— Equine explant cultures of fibrous tissue of SCL, and synovial membrane and articular cartilage of normal horses and horses affected with moderate and severe osteoarthritis were performed. NO, PGE2, and NMP concentrations of media samples were measured, and osteoclast formation and activation was studied in vitro. Animals— Experiment 1: 32 horses with SCL (n = 8), normal joints (7), and joints with moderate (7) and severe (10) osteoarthritis (OA). Experiment 2: 22 horses with SCL (n = 3), normal joints (7), and chip fractures (12). Experiment 3: Conditioned media of fibrous tissue from 3 horses with SCL of the medial femoral condyle (n = 1), distal metacarpal bone (1), and tarsal bone (1). Methods— Determinations of local mediator concentrations were made with the Griess assay for NO and an enzyme immunoassay kit for PGE2 concentrations in biological fluids. Enzyme activities were assessed with radiolabeled substrates indicating collagenolytic, gelatinolytic, and caseinolytic activities. The resorption pit assay was used to assess osteoclast recruitment and activity. Results— Fibrous tissue of SCL produced NO, PGE2, and NMPs. Of all the variables measured, PGE2 concentrations were the highest in cystic tissue of SCL compared with synovial membrane and articular cartilage from normal joints and joints with chip fractures, indicating that this mediator may play an important role in pathological bone resorption associated with SCL. These findings were supported by the observation that conditioned media of SCL tissue were capable of recruiting osteoclasts and increasing their activity. Conclusion— Fibrous tissue of SCL released NO, PGE2, and NMPs into the culture media. It is suspected that intralesional fibrous tissue may play an active role in the pathological process of bone resorption occurring in SCL in horses and may be partly responsible for the maintenance, slow healing rate, and expansion of these lesions. Clinical relevance— Understanding the pathogenesis of SCL will help to establish successful therapy in horses affected with SCL.

The goal of this study was to compare the capabilities of conventional radiography, CT, and MR imaging in revealing ligamentous and bony changes in patients after hyperflexion injuries.Forty-nine patients with hyperflexion injuries of the foot were included in our study. Conventional radiography, weight-bearing radiography, CT, and MR imaging were performed. All images were reviewed with respect to ligamentous and bony abnormalities and alignment alterations. Eleven patients with joint malalignment underwent surgery, which is considered the gold standard in these patients. Five patients with joint malalignment refused surgery.For all 49 patients, conventional radiographs revealed 33 metatarsal and 20 tarsal fractures. Eight patients presented with tarsometatarsal joint (Lisfranc's joint) malalignment. Weight-bearing radiographs showed joint malalignment in the same eight patients only. CT showed 41 tarsal fractures and 53 metatarsal fractures. Joint malalignment was evident in 16 patients. MR imaging revealed 41 metatarsal fractures and 18 metatarsal bone bruises. Tarsal bones were fractured at 39 sites and there were nine tarsal bone bruises. Metatarsal fractures were mostly localized in the second metatarsal bone; tarsal fractures, in the cuboid. Joint malalignment was evident in 16 patients; in 11 of these 16 patients, Lisfranc's ligament was disrupted. Surgery confirmed bony and ligamentous changes and joint malalignment in 11 patients.Conventional radiographs including weight-bearing images are not sufficient for routine diagnostic workup of patients with acute hyperflexion injuries of the foot. CT should serve as the primary imaging technique for such patients.

Calcaneal fracture, the most common tarsal bone fracture, occurs predominantly in manual labors and subsequently has got considerable socioeconomic implications. Treatment modality which can offer early weight bearing and early return to work is therefore needed for those patients. We have used a biplanar percutaneous external fixator for treating calcaneal fractures without operative and per operative visualization of the fractures. We have treated 17 calcaneal fractures in 16 patients, 12 intra articular and five extra articular, with our percutaneous external fixator system without preoperative X-ray control or reduction. Functional outcome was measured using the American Orthopaedic Foot and ankle society Hind foot score. All fractures united with a mean of 55 days. Partial weight bearing was possible in a mean of 1.8 days and full bearing was possible in a mean of 11.6 days. All the patients were returned to their original work within six weeks. Minor infectious complications occurred in 17.6 percent of cases. The average AOFAS score at six months follow up was 83.8. We conclude that our percutaneous external fixator technique for fracture calcaneum is an effective alternative to the currently available – surgical and conservative treatment modalities especially in lower socio economic labor population who need to return to their job as early as possible. Level of Evidence – IV Case series.

Introduction Targeting joint destruction induced by osteoclasts (OCs) is critical for management of patients with rheumatoid arthritis (RA). Since phosphoinositide 3-kinase (PI3-K) plays a critical role in osteoclastogenesis and bone resorption, we examined the effects of ZSTK474, a novel phosphoinositide 3-kinase (PI3-K)-specific inhibitor, on murine OCs in vitro and in vivo. Methods The inhibitory effect of ZSTK474 on OC formation was determined and compared with other PI3-K inhibitors by counting tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells after culturing murine bone marrow monocytic OC precursors, and RAW264.7 cells. Activation of Akt and expression of nuclear factor of activated T cells (NFAT) c1 in cultured RAW264.7 cells were examined. The suppressing effect of ZSTK474 on bone resorption was assessed by the pit formation assay. The in vivo effects of ZSTK474 were studied in collagen-induced arthritis (CIA) in the mouse. Oral daily administration of ZSTK474 was started either when more than half or when all mice developed arthritis. Effects of ZSTK474 were evaluated using the arthritis score and histological score of the hind paws. Results ZSTK474 inhibited the differentiation of bone marrow OC precursors and RAW264.7 cells in a dose-dependent manner. The inhibitory effect of ZSTK474 was much stronger than that of LY294002, the most commonly used PI3-K inhibitor. In addition, ZSTK474 suppressed the bone resorbing activity of mature OCs. Moreover, oral daily administration of ZSTK474, even when begun after the development of arthritis, ameliorated CIA in mice without apparent toxicity. Histological examination of the hind paw demonstrated noticeable reduction of inflammation and of cartilage destruction in ZSTK474-treated mice. ZSTK474 also significantly decreased OC formation adjacent to the tarsal bone of the hind paw. Conclusions These findings suggest that inhibition of PI3-K with ZSTK474 may potentially suppress synovial inflammation and bone destruction in patients with RA.

Operations for deformity and functional disturbance of the lower limbsWhat are important in treating the lower limbs, unlike the treatment of the upper limbs, are to secure the stability in the normal limb position and how to treat plantar ulcer. Moreover, these two factors are so intimately correlated with each other that it is necessary to perform the treatment by considering them.a) Peroneal palsy: Transference of the posterior tibial muscle is most common. Elongation of the Achilles tendon is often necessary. Carayon's procedure that transfers the flexor digitorum longus muscle to the extensor hallucis longus and extensor digitorum longus muscles may also be performed.b) In the case where all the muscles at and below the level of the leg except for the triceps surae muscle are paralyzed, tenodesis on the anterior side of the crural bones, involving the crural bones, ankle joint and instep, should be performed, while the triceps surae muscle is split longitudinally into two, one of which is passed on the medial side of the tibia to be transferred to the anterior tibial muscle.c) Paralytic talipes equinovarus: Triple arthrodesis is performed for correction of the varus position. and transference of the posterior tibial muscle for talipes equinus.d) Unstable ankle joint: In the presence of tibial and peroneal paralysis, the stability of the ankle joint may have been impaired over a long period. In such a case the brace will be but on but arthrodesis of the ankle joint may also be considered.e) Neuroarthrepathy (what is called Charcot's joint-like disintegration of tarsal bone) It the stages of disintegration are classed into the stage of development, the stage of coalescence and the stage of reconstruction, it is the stage of reconstruction that is most suitable for arthrodesis of the ankle joint, while no surgery should be performed in the stage of development. Pantalar arthrodesis and talo-tibial fusion by the use of Kunntscher's nail has proved the procedure giving good results.f) Flat foot: If the longitudinal arch of the foot becomes flat due to some cause, flat foot and abductus deformity of the anterior and middle portions of the foot occur, often leading not only to a disturbance in gait but also to incurable plantar ulceration. In such cases, the longitudinal arch of the foot is recontructed by arthrodesis of Chopart joint and the abductus deformity of the anterior and middle portions of the foot are corrected: these operations result in decreased recurrence of the ulcer.g) In the case where marked disintegration of bone is noted in the part from near the Chopart joint to the peripheral area, associated with incurable ulcer, and where it is difficult to perform arthrodesis, Boyd's amputation is indicated.h) Deformity of the metatarsal heads and toes: For the hallux valgus separation of the abductor hallucis muscle, arthrodesis of the IP joint, tenodesis of the extensor muscle, and fusion of the part from the base of the lst metatarsal bone to the Chopart joint should be performed, depending on the condition in each case. In the case where there is disintegration of bone the area around the metatarsal head associated with plantar ulceration, fusion of the metatarsal bones with the toes may be performed.i) Clawtoe: Girdlestone's procedure will do in the case where the contracture is not severe, but elongation of the extensor muscles of the toes and tenodesis to the metatarsal bones must often be additionally performed in the cases with severe contracture.

Arthrodesis created by destruction of the articular surfaces of the distal intertarsal and tarsometatarsal joints by repeated insertion of a drill was studied in one limb of each of nine horses. Postoperatively, the horses were housed in box stalls for 8 weeks and then confined to a paddock for 19 weeks. Clinical and radiographic evaluations were performed prior to surgery, immediately following surgery, and at 2,4, 6, 8,10,12,16, 20, and 27 weeks following surgery. There was a statistically significant positive correlation between decreasing degree of lameness and increasing radiographic evidence of bony fusion; fusion of the distal intertarsal and tarsometatarsal joints was present in five horses 27 weeks after surgery. The horses lost weight during the first 8 weeks after surgery. Flexion of the treated tarsal joints was decreased significantly at the end of the experiment. Complications encountered included fracture of the third tarsal bone (five horses), instability of the tarsus (four horses), septic arthritis (three horses), and diarrhea (four horses). Arthrodesis, with this method of surgical drilling of the distal intertarsal and tarsometatarsal joints, is not recommended because of severe pain, prolonged convalescence, and high incidence of complications.