Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey

The treatment of intra-articular calcaneal fractures is controversial and randomised clinical trials are scarce. Moreover, the socio-economic cost remains unclear. The aim of this study was to estimate the incidence, treatment preferences and socio-economic cost of this complex fracture in the Netherlands. This data may aid in planning future clinical trials and support education. The method of study was of a cross-sectional survey design. A written survey was sent to one representative of both the traumatology and the orthopaedic staff in each hospital in the Netherlands. Data on incidence, treatment modalities, complications and follow-up strategies were recorded. The socio-economic cost was calculated. The average response rate was 70%. Fracture classifications, mostly by Sanders and Essex-Lopresti, were applied by 29%. Annually, 920 intra-articular calcaneal fractures (0.4% incidence rate) were treated, mainly with ORIF (46%), conservative (39%) and percutaneous (10%) treatment. The average non-weight-bearing mobilisation was 9 weeks (SD 2 weeks). An outcome score, mainly AOFAS, was documented by 7%. A secondary arthrodesis was performed in 21% of patients. The socio-economic cost was estimated to be €21.5–30.7 million. Dutch intra-articular calcaneal fracture incidence is at least 0.4% of all fractures presenting to hospitals. Better insight into treatment modalities currently employed and costs in the Netherlands was obtained

The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review

Purpose: Although open reduction and internal fixation is currently considered the gold standard in surgical treatment of displaced intra-articular calcaneal fractures, various different approaches exist including the limited lateral approach. The aim of this systematic review was to combine the results of studies using the sinus tarsi approach, which is the most frequently applied limited lateral approach. Method: A literature search in the electronic databases of the Cochrane Library and Pubmed Medline, between January 1st 2000 to December 1st 2010, was conducted to identify studies in which the sinus tarsi approach or a modified sinus tarsi approach was utilized for the treatment of displaced intra-articular calcaneal fractures. The methodological quality of the included studies was assessed using the Coleman methodology score. Results: A total of eight case series reporting on 256 patients with 271 calcaneal fractures was identified. Overall good to excellent outcome was reached in three-quarters of all patients. An average complication rate of minor wound complications of 4.1% was reported and major wound complications in 0.7%. The need for a secondary subtalar arthrodesis occurred at an average rate of 4.3%. The average Coleman methodology score was 56.8 (range 39-72) points. Conclusion: The results, i.e. functional outcome and complication rates, of the sinus tarsi approach compare similarly or favourably to the extended lateral approach. Therefore, in the process of tailoring the best treatment modality to the right patient and the right fracture type, the sinus tarsi approach might be a valuable asset

Radiographic evaluation of calcaneal fractures: To measure or not to measure

Objective: The aim of this study was to correlate the functional outcome after treatment for displaced intra-articular calcaneal fracture with plain radiography. Design: The design was a prognostic study of a retrospective cohort with concurrent follow-up. Patients: A total of 33 patients with a unilateral calcaneal fracture and a minimum follow-up of 13 months participated. Patients filled in three disease-specific questionnaires, graded their satisfaction and the indication for an arthrodesis was noted. Standardised radiographs were made of the previously injured side and the normal (control) side. Different angles and distances were measured on these radiographs and compared with values described in the literature. The differences in values in angles and distances between the injured and uninjured (control) foot were correlated with the outcome of the questionnaires, and the indication for an arthrodesis. Results: None of the angles correlated with the disease-specific outcome scores. Of the angles only the tibiotalar angle correlated with the VAS (r=0.35, p=0.045) and only the absolute foot height correlated with the indication for an arthrodesis (odds=0.70, CI=0.50-0.99). Conclusion: In this study the radiographic evaluation correlated poorly with the final outcome. Measurements on plain radiographs seem not to be useful in determining outcome after intra-articular calcaneal fractures

Cauda equina syndrome in ankylosing spondylitis - Anatomical, diagnostic, and therapeutic considerations

This article describes a case of cauda equina syndrome associated with ankylosing spondylitis, and reviews 28 additional cases in the literature. The neurological symptoms appear late in the evolution of spondylitis, when it is at an inactive stage. The diagnosis is easily confirmed by myelography, with water-soluble contrast and performed in a supine position, and by computerized tomography (CT) scan of the lumbar spine. The typical features are a dilated lumbar sac with multiple dorsal diverticula. The pathogenesis of this entity remains the subject of speculation. Arachnoiditis with subsequent adhesions is the most likely explanation. No treatment has proved helpful so far. Surgery is not indicated. © 1981 Springer-Verlag.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Ischemic stroke associated with adenoviral infection in a 4-year-old boy

We present a case of childhood arterial ischemic stroke associated with proven adenoviral upper respiratory tract infection in a previously healthy 4-year-old boy. Adenoviral meningitis and encephalitis have been reported repeatedly, thus confirming the neuroinvasive capability of these viruses. However, an association between adenoviral infection and arterial ischemic stroke has not been described thus far. HIV and varicella zoster virus are the only microorganisms that have been consistently associated with arterial ischemic stroke in the absence of acute central nervous system infection. In HIV-infected individuals ischemic stroke can be caused by vasculitis and hypercoagulability. Granulomatous arteritis of the vessel wall causes post-varicella cerebral infarction and ischemic stroke after herpes zoster ophthalmicus. We suggest that in our patient a post-varicella cerebral infarction-like mechanism of adenoviral spread to the affected artery wall occurred through the ophthalmic branch of the trigeminal nerve. Adenoviruses are neuroinvasive and inflamed conjunctiva might have permitted introduction of the virus into ophthalmic nerve tissue. In consequence, the stenotic lesion of the artery might have been induced by the presence of adenovirus and the subsequent inflammatory reaction. We recommend a prompt quest for adenoviral infection in all previously healthy children with fever and clinical presentation compatible with ischemic stroke, because timely diagnosis and treatment could improve the outcome and hasten neurological recovery

Target of rapamycin signaling couples energy to oxygen sensing to modulate hypoxic gene expression in Arabidopsis

Plants respond to oxygen deprivation by activating the expression of a set of hypoxia-responsive genes (HRGs). The master regulator of this process is a small group of transcription factors belonging to group VII of the ethylene response factors (ERF-VIIs). ERF-VIIs are highly unstable under aerobic conditions due to the continuous oxidation of their characteristic Cys residue at the N terminus by plant cysteine oxidases (PCOs). Under hypoxia, PCOs are inactive and the ERF-VIIs activate transcription of the HRGs required for surviving hypoxia. However, if the plant exposed to hypoxia has limited sugar reserves, the activity of ERF-VIIs is severely dampened. This suggests that oxygen sensing by PCO/ERF-VII is fine-tuned by another sensing pathway, related to sugar or energy availability. Here, we show that oxygen sensing by PCO/ERF-VII is controlled by the energy sensor target of rapamycin (TOR). Inhibition of TOR by genetic or pharmacological approaches leads to a much lower induction of HRGs. We show that two serine residues at the C terminus of RAP2.12, a major ERF-VII, are phosphorylated by TOR and are needed for TOR-dependent activation of transcriptional activity of RAP2.12. Our results demonstrate that oxygen and energy sensing converge in plants to ensure an appropriate transcription of genes, which is essential for surviving hypoxia. When carbohydrate metabolism is inefficient in producing ATP because of hypoxia, the lower ATP content reduces TOR activity, thus attenuating the efficiency of induction of HRGs by the ERF-VIIs. This homeostatic control of the hypoxia-response is required for the plant to survive submergence.</jats:p