The value of arthroscopy in the treatment of complex ankle fractures - a protocol of a randomised controlled trial

Background: An anatomical reconstruction of the ankle congruity is the important prerequisite in the operative treatment of acute ankle fractures. Despite anatomic restoration patients regularly suffer from residual symptoms after these fractures. There is growing evidence, that a poor outcome is related to the concomitant traumatic intra-articular pathology. By supplementary ankle arthroscopy anatomic reduction can be confirmed and associated intra-articular injuries can be treated. Nevertheless, the vast majority of complex ankle fractures are managed by open reduction and internal fixation (ORIF) only. Up to now, the effectiveness of arthroscopically assisted fracture treatment (AORIF) has not been conclusively determined. Therefore, a prospective randomised study is needed to sufficiently evaluate the effect of AORIF compared to ORIF in complex ankle fractures. Methods/design: We perform a randomised controlled trial at Munich University Clinic enrolling patients (18-65 years) with an acute ankle fracture (AO 44 A2, A3, B2, B3, C1 - C3 according to AO classification system). Patients meeting the inclusion criteria are randomised to either intervention group (AORIF, n = 37) or comparison group (ORIF, n = 37). Exclusion criteria are fractures classified as AO type 44 A1 or B1, pilon or plafond-variant injury or open fractures. Primary outcome is the AOFAS Score (American Orthopaedic Foot and Ankle Society). Secondary outcome parameter are JSSF Score (Japanese Society of Surgery of the Foot), Olerud and Molander Score, Karlsson Score, Tegner Activity Scale, SF-12, radiographic analysis, arthroscopic findings of intra-articular lesions, functional assessments, time to return to work/sports and complications. This study protocol is accordant to the SPIRIT 2013 recommendation. Statistical analysis will be performed using SPSS 22.0 (IBM). Discussion: The subjective and functional outcome of complex ankle fractures is regularly unsatisfying. As these injuries are very common it is essential to improve the postoperative results. Potentially, arthroscopically assisted fracture treatment can significantly improve the outcome by addressing the intra-articular pathologies. Given the absolute lack of studies comparing AORIF to ORIF in complex ankle fractures, this randomised controlled trail is urgently needed to evaluate the effectiveness of additional arthroscopy

The influence of knee position on ankle dorsiflexion - a biometric study

Background: Musculus gastrocnemius tightness (MGT) can be diagnosed by comparing ankle dorsiflexion (ADF) with the knee extended and flexed. Although various measurement techniques exist, the degree of knee flexion needed to eliminate the effect of the gastrocnemius on ADF is still unknown. The aim of this study was to identify the minimal degree of knee flexion required to eliminate the restricting effect of the musculus gastrocnemius on ADF. Methods: Bilateral ADF of 20 asymptomatic volunteers aged 18-40 years (50% female) was assessed prospectively at six different degrees of knee flexion (0 degrees, 20 degrees, 30 degrees, 45 degrees, 60 degrees, 75 degrees, Lunge). Tests were performed following a standardized protocol, non weightbearing and weightbearing, by two observers. Statistics comprised of descriptive statistics, t-tests, repeated measurement ANOVA and ICC. Results: 20 individuals with a mean age of 27 +/- 4 years were tested. No significant side to side differences were observed. The average ADF [95% confidence interval] for non weightbearing was 4 degrees{[}1 degrees-8 degrees] with the knee extended and 20 degrees [16 degrees-24 degrees] for the knee 75 flexed. Mean weightbearing ADF was 25 degrees[22 degrees-28 degrees] for the knee extended and 39 degrees[36 degrees-42 degrees] for the knee 75 degrees flexed. The mean differences between 20 degrees knee flexion and full extension were 15 degrees[12 degrees-18 degrees] non weightbearing and 13 degrees[11 degrees-16 degrees] weightbearing. Significant differences of ADF were only found between full extension and 20 degrees of knee flexion. Further knee flexion did not increase ADF. Conclusion: Knee flexion of 20 degrees fully eliminates the ADF restraining effect of the gastrocnemius. This knowledge is essential to design a standardized clinical examination assessing MGT

Do pre-operative radiologic assessment predict postoperative outcomes in patients with insertional Achilles tendinopathy?: a retrospective database study

INTRODUCTION Diagnosis and treatment of insertional tendinopathy of the Achilles tendon (IAT) remains a challenge. The aim of this study was to assess the influence of pre-operative radiological pathologies on the patient-reported outcomes following open debridement of all pathologies for IAT. MATERIALS AND METHODS In this IRB-approved retrospective correlation and comparative study, patients with pre-operative imaging were identified from the authors' retrospective IAT database comprising of 118 patients. All were treated by a standardized surgical treatment strategy utilizing a midline, transachillary approach and debridement of all pathologies. A total of fifteen radiologic parameters were measured on radiographs (RX) and MRI. The patient-reported outcomes were assessed using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G) and the general health questionnaire SF-12 at a minimum follow-up of 12~months. The data are presented as mean ± SD (95% CI). RESULTS 88 patients (74.6%) with an average age of 50 ± 12 (47-52) years were included. Radiographs were available in 68 patients and MRI in 53. The mean follow-up was 3.8 ± 1.9 (3.4-4.3) years. The overall VISA-A-G was 81 ± 22 (77-86), the SF-12 PCS 54 ± 7 (52-55), and the SF-12 MCS 52 ± 9 (50-54) points. None of the assessed radiological parameters had a significant influence on the patient-reported outcome following surgical treatment for IAT. CONCLUSION In this retrospective correlation study, no significant association was found between preoperative radiographic and MRI radiologic parameters for IAT and postoperative patient-reported outcomes (VISA-A-G and SF-12)

Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm

Acute ankle injuries are among the most common injuries in emergency departments. However, there are still no standardized examination procedures or evidence-based treatment. Therefore, the aim of this study was to systematically search the current literature, classify the evidence, and develop an algorithm for the diagnosis and treatment of acute ankle injuries. We systematically searched PubMed and the Cochrane Database for randomized controlled trials, meta-analyses, systematic reviews or, if applicable, observational studies and classified them according to their level of evidence. According to the currently available literature, the following recommendations have been formulated: i) the Ottawa Ankle/Foot Rule should be applied in order to rule out fractures; ii) physical examination is sufficient for diagnosing injuries to the lateral ligament complex; iii) classification into stable and unstable injuries is applicable and of clinical importance; iv) the squeeze-, crossed leg- and external rotation test are indicative for injuries of the syndesmosis; v) magnetic resonance imaging is recommended to verify injuries of the syndesmosis; vi) stable ankle sprains have a good prognosis while for unstable ankle sprains, conservative treatment is at least as effective as operative treatment without the related possible complications; vii) early functional treatment leads to the fastest recovery and the least rate of reinjury; viii) supervised rehabilitation reduces residual symptoms and re-injuries. Taken these recommendations into account, we present an applicable and evidence-based, step by step, decision pathway for the diagnosis and treatment of acute ankle injuries, which can be implemented in any emergency department or doctor's practice. It provides quality assurance for the patient and promotes confidence in the attending physician

Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies

PURPOSE Although simultaneous arthroscopy for the surgical treatment of acute isolated, unstable syndesmotic injuries has been recommended, little knowledge is present about the actual frequency of intra-articular pathologies for this injury. The aim of this study was to investigate the frequency and severity of intra-articular pathologies detected during arthroscopy and their subsequent treatment in acute isolated, unstable syndesmotic injuries. METHODS A retrospective chart review of patients treated by arthroscopic-assisted stabilization for acute isolated, syndesmotic instability was performed. The primary outcome parameter was the frequency of intra-articular pathologies. Secondary outcome parameters were the type of syndesmotic lesion (ligamentous/bony), severity of chondral lesions, MRI findings, treatment details, complications and the identification of factors associated with intra-articular pathologies. RESULTS Twenty-seven patients, 19% female, with a mean age of 37 ± 12~years met the inclusion criteria. 70% suffered isolated ligamentous injuries, the remaining suffered avulsion fractures of the syndesmosis. Chondral lesions occurred in 48% (ICRS grade II: 33%; ICRS grade IV 15%) and intra-articular loose bodies in 11% of patients. Overall, arthroscopy revealed intra-articular pathologies necessitating further treatment in 19% of patients. Neither the type of syndesmotic injury (bony vs. ligamentous; ns) nor the degree of ligamentous instability (West Point IIB vs. III; ns) had a significant influence on the occurrence of chondral lesions. One complication (SSI) occurred. Pre-operative MRI revealed a sensitivity/specificity of 100/79% for chondral lesions and 50/93% for loose bodies. CONCLUSION Intra-articular pathologies in acute isolated, unstable syndesmotic injuries occur in up to 50% of patients, 19% necessitated additional treatment. Simultaneous arthroscopy, independent of the pre-operative MRI findings, appears reasonable in highly active patients. LEVEL OF EVIDENCE Level III

Functional treatment for fractures to the base of the 5th metatarsal - influence of fracture location and fracture characteristics

Background: Fractures to the base of the fifth metatarsal are common, but their treatment remains controversial. Especially for Lawrence and Botte (L&B) type II fractures, there is conflicting evidence and consequently no consensus. Further, many authors consider displacement, articular involvement, and number of fragments an indication for surgery, although evidence is missing. The aim of this study was to evaluate the outcome of functional treatment for all L&B type I and II fractures. Of special interest were the influence of (1) the fracture location (L&B type I vs. II) and (2) the fracture characteristics (displacement, intra-articular involvement, communition) on the subjective outcome. Methods: Retrospective registry study with a prospective follow-up. Patients with an acute, isolated, epi-metaphyseal fracture to the fifth metatarsal bone (L&B type I and II) treated by full weightbearing with a minimum follow-up of 6 months were included. Fracture location (L&B type I and II) and characteristics (displacement 2 mm, intra-articular involvement, and number of fragments) were assessed. Outcome parameters were return to work, return to sports, VAS-FA, and SF-12. The influence of the fracture (1) location and (2) -characteristics on these parameters was tested. Results: Thirty-nine patients (40 +/- 15 years, 56% female) were enrolled with a mean follow-up of 22 +/- 10 months. L&B type I fractures occurred in 59%, type II in 41%. Thirty-one percent of all fractures were dislocated, 74% intra-articular, and 41% multi-fragmentary. Patients returned to work after 17 +/- 12 days, to sports after 53 +/- 22 days. The VAS-FA score at the final follow-up was 96 +/- 4, SF-12 PCS score 57 +/- 5 and MCS score 51 +/- 8. No complications were reported, no patient required surgery. None of the assessed outcome parameters differed significantly between (1) the different fracture locations (L&B type I vs. II) or (2) the different fracture characteristics (displacement, intra-articular involvement, and number of fragments). Conclusions: (1) Both, L&B I and II fractures featured excellent results with immediate full weightbearing. Consequently, L&B type I and II fractures should be summarized as epi-metaphyseal fractures. (2) Fracture displacement, articular involvement, and number of fragments did not influence the outcome. Therefore, functional treatment should be recommended for all epi-metaphyseal fractures

Расчетно-экспериментальное определение поля нейтронного излучения в защите из полиэтилена

Целью представленной работы является верификация кода PHITS для моделирования параметров нейтронного поля от закрытого 239Pu-Be источника нейтронов, расположенного в защите из полиэтилена. Верификация выполнена путем сравнения результатов расчета с экспериментальными данными. Верифицируемая лабораторная установка состоит из двух основных компонентов. Первым является 239Pu-Be источник нейтронов, а вторым – полиэтиленовая защита в форме четырехугольной призмы формы ("призма"). Разработанная расчетная модель для программы PHITS повторяет конфигурацию установки. Поток тепловых и быстрых нейтронов рассчитывался программой для точек, расположенных на оси облучательного канала "призмы", в диапазоне от 1 до30 см от ее боковой поверхности, с шагом равным 1 см. Эксперименты по измерению потоков нейтThe purpose of this work is verification of PHITS-code calculations for the simulation of neutron field parameters from the sealed 239Pu-Be source in polyethylene shielding. The verification was made by means of comparison of calculation results with the experimental data. The laboratory model consists of two main components. The first component is the 239Pu-Be source and the second component is the polyethylene prism. An identical PHITS model was generated to simulate the laboratory case. The neutron flux for both thermal and fast neutrons was calculated by PHITS code for every 1 cm in the range from 0 to 30 cm in front of the irradiation channel of the prism. Experiments have been performed in TPU laboratory. The neutron flux was measured in the laboratory for thermal neutrons at discre

Disseminated cancer cells detected by immunocytology in lymph nodes of NSCLC patients are highly prognostic and undergo parallel molecular evolution

In melanoma, immunocytology (IC) after sentinel lymph node disaggregation not only enables better quantification of disseminated cancer cells (DCCs) than routine histopathology (HP) but also provides a unique opportunity to detect, isolate, and analyse these earliest harbingers of metachronous metastasis. Here, we explored lymph node IC in non-small cell lung cancer (NSCLC). For 122 NSCLC patients, 220 lymph nodes (LNs) were split in half and prepared for IC and HP. When both methods were compared, IC identified 22% positive patients as opposed to 4.5% by HP, revealing a much higher sensitivity of IC (p < 0.001). Assessment of all available 2,952 LNs of the same patients by HP uncovered additional patients escaping detection of lymphatic tumour spread by IC alone, consistent with the concept of skip metastasis. A combined lymph node status of IC and complete HP on a larger cohort of patients outperformed all risk factors in multivariable analysis for prognosis (p < 0.001; RR = 2.290; CI 1.407–3.728). Moreover, isolation of DCCs and single-cell molecular characterization revealed that (1) LN-DCCs differ from primary tumours in terms of copy number alterations and selected mutations and (2) critical alterations are acquired during colony formation within LNs. We conclude that LN-IC in NSCLC patients when combined with HP improves diagnostic precision, has the potential to reduce total workload, and facilitates molecular characterization of lymphatically spread cancer cells, which may become key for the selection and development of novel systemic therapies. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland