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Alkaptonuria (AKU) is an extremely rare autosomal recessive metabolic disorder caused by deficiency of homogentisic acid oxidase and resulting in accumulation of homogentisic acid in collagenous structures. It is characterized by a triad of homogentisic aciduria, bluish-black discoloration of connective tissues (ochronosis) and arthropathy of large weight bearing joints. We report on a middle-aged female patient with bilateral severe ochronotic arthritis of both hips and shoulder joints requiring total joint replacements as staged procedures which were done without complications offering a complete pain relief and a satisfactory clinical and functional outcome. Ochronosis can cause severe arthropathy of peripheral joints. Multiple joint affection is common. Total joint replacement can yield persistent pain relief with complete functional recovery in patients with severe ochronotic arthropathy.

Clavicle fractures represent one of the most frequent type of fractures. However, there is no consensus on the treatment of these fractures and their relative indications for surgery. The purpose of this study is to determine whether surgical treatment of mid-diaphyseal clavicular fractures indeed results in fewer complications and better radiological outcomes, as current trends suggest, in comparison to conservative treatment. A retrospective multicenter study was conducted between January 2005 and April 2017, involving adult patients aged 16 to 75 years with mid-diaphyseal clavicular fractures. Out of a total of 715 clavicle fractures assessed, 220 met the inclusion criteria for this study. The research encompassed a matched-pair cohort, comparing clavicle fractures treated surgically and those managed conservatively. The consolidation rate was respectively 94.5% In the operative group, and 89.1% in the conservative group. There was no statistically significant difference in terms of consolidation (p-value: 0.219). The surgical group had an infection rate of 1.8%. Additionally, 31.8% of patients experienced hardware-related discomfort, and 43.6% required a secondary surgery to remove the plate. The results of this study reveal a similar rate of consolidation between the two treatment approaches. However, there is a noticeable but not significant difference in pseudarthrosis incidence in the conservative group, which is typically asymptomatic and does not usually require surgical intervention. On the other hand, patients who have undergone osteosynthesis often experience hardware-related discomfort and may require a subsequent procedure for hardware removal. Low profile dual plating might reduce this inconvenient.

The distal tibiofibular syndesmosis (DTFS) is frequently injured during ankle trauma. The sequelae can be significant, including chronic instability, early osteoarthritis and residual pain. The aim of this study is to summarize the current state knowledge about these injuries by answering four questions. They frequently occur in the context of an ankle sprain (20-40% of cases) or during various types of ankle fractures (20-100% of cases). They cannot be ruled out based solely on fracture type and must be investigated when a fibular or posterior malleolar fracture is present. Clinical examination and imaging are essential but do not provide a definitive diagnosis. Ultrasonography, CT scan and MRI have high sensitivity, but their static nature does not allow a treatment strategy to be defined. Dynamic radiographs must be taken, either with load or during a procedure. If instability is detected, stabilization is the general rule. In fracture cases, reduction is achieved by restoring the length and rotation of the distal fibular fragment, preferably during an open procedure. In sprain cases, reduction is not a problem unless there is ligament interposition. Tibiofibular fixation is done 1.5 to 3cm from the talocrural joint, while ensuring the reduction is perfect. The main complication-non-healing of the syndesmosis-is attributed to poor initial reduction. This or functional discomfort during weight bearing will require removal of the fixation hardware. In most cases, this allows functional recovery and correction of the inadequate reduction. Persistence of instability will require ligament reconstruction or fusion of the syndesmosis. Chronic instability can lead to ankle osteoarthritis. LEVEL OF EVIDENCE: V, expert opinion., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Ankle fractures are frequently treated using surgical interventions, and are associated with a high rate of postoperative complications. We wonder if complications can be anticipated and correlated to patient demographics, lifestyle, fracture or surgery related factors. We retrospectively reviewed all medical reports of patients who underwent ankle fracture surgery between 2013 and 2017. We focused our risks factors analysis on 5 common complications : poor wound healing, surgical site infection, malunion, nonunion and chronic pain. Multivariate logistic regression was performed to analyze significant risk factors for these complications. We identified 433 patients. Complications were present in 26% of the cases. The most frequent complication was poor wound healing (10%) associated with deep surgical site infection in 6%. Malunion was found in 7% and nonunion in 3%. Seven percent of patients suffered from chronic pain. More severe fractures happened to be a risk factor for poor wound healing (p = 0,032) and malunion (p < 0,001). Open fractures had respectively 6 to 9 times more mal- (p = 0,012) and nonunion (p = 0,018). Overweight patients with alcohol abuse were doubling their chances of cutaneous (p = 0,030) and infectious (p = 0,040) complications, and tripling their risks of ankle fracture nonunion (p = 0,003). Female and patients operated at night (p = 0,045) seemed to be more at risk to develop chronic pain (p = 0,028). Complications of ankle fracture treatment are frequent and their risks increases with more complex and open fractures. This study brings new evidence concerning the combined effect of overweight and alcohol abuse on poor wound healing, surgical site infection and non-union.

Despite the progress in tibial fracture care, some patients contract infection following intramedullary nailing. We analyzed which risk factors could predict infection in 171 tibial fractures. The independent variables included age, gender, body mass index, and comorbidities, along with external factors of fracture pattern, nailing settings, and treatment processing time. A multiple logistic regression was used to identify infection risk factors. The risk of infection significantly increased according to the open grading, the fractures' classification, time until antibiotic administration, and time until nailing. Gustilo type I fractures presented a higher rate of infection than expected, explained by a longer delay before surgery. The probabilistic equation allows infection prediction with high sensitivity and specificity. In total, we showed that no antibiotics' prescription in emergency service and a transverse fracture pattern were predictors of infection. An infection risk score can be computed, aiding surgeons in decision making. Outcomes could improve keeping these observations in mind. Level of evidence: Retrospective cohort study. Level iii.

Introduction: Intramedullary (IM) nailing is the gold standard treatment for tibial shaft fractures, but can be associated with various mechanical complications, including delayed union., Hypothesis: We believe that complications do not occur randomly, but in certain conditions that contribute to their development. Risk factors likely to predict delayed union can be identified to support prevention., Materials and Methods: A cohort of 171 fractures treated by IM nailing between 2005 and 2015 was reviewed retrospectively. Independent variables included intrinsic, patient-related factors and extrinsic factors such as those related to the fracture or surgery. A multiple logistic regression model was used to determine which factors can predict each type of complication., Results: Delayed union occurred in 22.8% of patients. Smoking and high-energy trauma were risk factors. Hardware breakage was significantly reduced (p<0.05) when the nail diameter was greater than 10mm. A nail diameter/reamer diameter ratio outside the recommended limits (0.80-0.99) was more likely to be associated with screw failure. Diabetes is a risk factor for hardware migration, which itself is associated with other complications., Discussion: Nonunion is the most common complication after IM nailing of tibial shaft fractures. Smoking cessation after a fracture is necessary in our opinion, even if the literature is ambivalent on this aspect and stopping to smoke once the fracture occurs may not be sufficient to prevent a poor outcome. Use of a nail diameter/reamer diameter between 0.80 and 0.99 favors union and prevents hardware breakage. Hardware migration in a diabetic patient may be a warning sign of other types of complications., Level of Evidence: Retrospective cohort study. Level IV., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: Lemierre syndrome is an uncommon, potentially lethal disorder combining acute oropharyngeal infection caused by Fusobacterium necrophorum, with jugular vein suppurative thrombosis, complicated by anaerobic sepsis with secondary multiple metastatic abscesses. Optimal treatment outcome with reduced or absence of sequelae can be achieved with early diagnosis., Case Report: We present a clinical case of Fusobacterium necrophorum abscess complicated with femoral vein thrombosis, called atypical localization of Lemierre syndrome. This uncommon disease was diagnosed on the basis of clinical, biological, and imaging tests, with a favorable outcome, after a well-orientated antibiotic and surgical course of therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Since its first description in 1936, Lemierre syndrome has been reported in locations other than its initial oropharyngeal site. Because optimal treatment outcome is dependent on early diagnosis, it is imperative for emergency physicians to be aware of this uncommon disease, because in many instances they are the patient's initial point of contact with medical care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: To evaluate the incidence and the risk of transmitting a virus through a bone allograft from a living donor., Material and Methods: A total 7032 femoral heads have been collected from 24 Belgian institutions. The tissue along with the screening blood tests were systematically sent to the bank. Serological screening included: for HIV, a HIV1-2 antibody test; for HBV, a HBS antigen and HBS and Hbcore antibodies; for HCV, a HCV antibody test. Syphilis was also screened with a non-specific and a specific assays. HTLV1-2 screening was recommended but not obligatory., Results: From the 7032 femoral heads, 1066 (15.2%) implants were definitively excluded. Hundred forty-six femoral heads, representing 2.1% of all grafts and 13.9% of the excluded ones, were discarded for positive serological testing associated with a risk of disease transmission. There were 2 donors who tested positive for HTLV1-2. The prevalence of HIV in the femoral head donor population was six times lower than in the general one. The prevalence of hepatitis B and C was similar but far higher than HIV. The risk was computed to be 0.54 out of 1 × 10(5) for HIV and HCV without quarantine or tissue processing. For HBV, the risk was 0.77 out of 1 × 10(5)., Conclusion: Current standards of tissue banking incorporated safety and quality as their main features. This policy is now regulated at the European level. With a multi-step screening-policy, stringent donor selection guidelines, the risk of viral transmission trough a tissue is minimized.

Background: The AES (Ankle Evolutive System) is a cobalt-chromium three-component ankle prosthesis with a hydroxyapatite coating, similar to the Buechel-Pappas ankle prosthesis, but with some modifications. Our objective was to assess its medium term follow-up results as well as its complications., Methods: 21 patients (mean age of 57.6 years) were operated by a total ankle arthroplasty (TAA), using the AES implant, according to the standard technique. Only 18 patients were included. The other three patients were excluded from the study: two had been revised for avascular talar necrosis and one patient was happy with her outcome but could not present for logistic reasons at the last follow-up. Indications for surgery included posttraumatic osteoarthritis, primary osteoarthritis, hemochromatosis, rheumatic arthritis and osteoarthritis as a sequel of ankle instability. All patients were analyzed clinically and radiologically. Special attention was given to the presence or not of areas of osteolysis around the implants as well on conventional radiography as on CT-scan imaging, according to a specific protocol., Results: The mean follow-up was 39.4 months. Average American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 52.2 preoperatively to 86.6 postoperatively. No intra-operative complications or early complications have been noted. Delayed complications were the following: one valgus malalignment, one recurrent painful anterior heterotrophic bone formation. Above all, we noted on conventional X-ray the presence of osteolysis in 77% (14) of our patients, with a size of 0.5-1cm or greater on conventional X-ray. The most vulnerable area seemed to be the posterior tibial plafond. The four remaining patients did not show any cyst formation on X-ray but did also, just as the other 14 patients, on the CT-scan. CT-scan, on the contrary, found more osteolysis in the body of the talus, underneath the implant, an area masked on conventional X-ray. Only one patient was revised with allograft bone filling of a symptomatic osteolysis, without the need for implant removal., Conclusions: This retrospective study shows a high frequency of delayed appearance of osteolysis (77%) in 18 AES total ankle arthroplasties. Fortunately at this moment and considering one revision, this considerable amount of asymptomatic osteolysis could not warrant a durable uncomplicated outcome., (Copyright 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)