Introduction

There is a need for a standardised guideline to assist in optimal decision-making in diabetics who have acquired an ankle fracture. Through a critical analysis of the literature, a diagnostic and management algorithm that incorporates a quantitative scoring system is proposed and presented for consideration.

The quality of bone in the skeleton depends on the amount of bone, geometry, microarchitecture and material properties, and the molecular and cellular regulation of bone turnover and repair. This study aimed to identify material and structural factors that alter in fragility hip fracture patients treated with antiresorption therapies (FxAr) compared to fragility hip fracture patients not on treatment (Fx).

Bone from the intertrochanteric site, femoral head (FH: FxAr = 5, Fx = 8), compression screw cores and box chisel were obtained from patients undergoing hemi-arthroplasty surgery, FxAr (6f, 2m, mean 79 and range [64–89] years), and Fx (7f, 1m, age 85 [75–93] years). Control bone was obtained at autopsy (9f, 4m, 77 [65–88] years). Treated patients were on various bisphosphonates. Samples were resin-embedded, for quantitative backscattered electron imaging of the degree of mineralisation and assessment of bone architecture. Trabecular bone volume fraction (BV/TV) and architectural parameters were not significantly different between FxAr and Fx groups.

Both groups showed normal distributions of weight (wt) % Ca; however, the FxAr was less mineralised than the Fx and the control group (mean wt % Ca: FxAr = 24.3%, Fx = 24.8%, Control = 24.9%). When comparing the FH specimens only, we found that BV/TV in the FxAr was greater than the Fx group (18% vs 15%). All other parameters were not significantly different. In addition, the mineralisation was greater in the FxAr group compared to the Fx group (25.5 % vs 25.0%) but was not significantly different.

Collectively, these data suggest the effect on bone of antiresorptives may be different for patients on antiresorptive treatment that do not subsequently fracture. Assessment of bone material property data together with other bone quality measures may hold the key to better understanding of antiresorptive treatment efficacy.

A consensus for the best treatment for acute Achilles tendon ruptures has not yet been reached. Non-operative functional treatment using ankle foot orthosis has shown a reduction in re-rupture rate. This study aims to compare operative, cast immobilisation and functional treatment with cam- walker for acute Achilles tendon ruptures.

A retrospective review of medical records of patients with acute Achilles tendon rupture between 1999–2770 was carried out. Open repairs were carried out in the surgical group. In the cam- walker group, patients were immobilised in equines backslab for 2 weeks and then transferred to cam- walker with 3 heel-wedges giving plantar flexion of 20–30 degrees. One wedge was removed weekly after 4 weeks. After 6 weeks, patients removed the cam-walker at night. After 10 weeks, they mobilised in a shoe with a raise. After 12 weeks, the cam-walker was removed. There were 56 patients reviewed of whom 20 were treated operatively, 23 were treated non- operatively in a cast and 13 were treated functionally in a cam-walker. The average age of operative group was 39 years with average post operative immobilisation in a cast of 7.4 weeks. 15% had major complications with 2 DVTs and 1 re-rupture and 45% minor complications with 4 wound infections, 3 sural nerve damage and 2 patients complained of pain. The average age of non-operative group in a cast was 46 years with average immobilisation of 8 weeks. 12% had minor complications with 2 DVTs, 1 re-rupture and 12% healing complications with 1 non- healing and 2 delayed healing.

The average age of functional group treated with cam- walker was 44.5 years. They were immobilised in a cast for 2.5 weeks and cam-walker for 9 weeks. There were 35% major complications with 3 DVTs and no re-ruptures. 2 DVTs were treated and 1 DVT spontaneously resolved.

Metz et al. (2007) conducted a similar study and found that 34% of surgically treated patients suffered from complications other than rerupture. The main advantage they found with conservative treatment is the elimination of wound complications and intra-operative sural nerve damage. This retrospective review shows that surgical treatment provides a lower re-rupture rate but higher complication rate. A prospective study is currently underway to look at re-rupture rates and functional outcome after non-operative functional treatment with cam-walker.

The incidence of tarsal coalitions (TC) is not known. Most of the clinical studies report it as less then 1% but they disregard the asymptomatic coalitions. Two main theories have been elaborated regarding their etiology: 1) they result by incorporation of accessory bones into the nearby tarsals; 2) they occur as a result of the failure of differentiation and segmentation of the foetalmes-enchyme. Tarsal coalitions have been associated with degenerative arthritic changes. Computer tomography is the most commonly used diagnostic test in the detection of TC. The aims of our study were to establish the incidence of TC; the association between TC and accessory tarsal bones and between TC and tarsal arthritis; and to assess the sensitivity of CT as a diagnostic tool in TC. For this purpose we have undertaken coronal and sagittal CTs of 114 cadaveric feet which were subsequently dissected. The dissections identified 10 non-osseous tarsal coalitions, two talocalcaneal and eight calcaneonavicular. In nine cases we identified a synovial joint between the calcaneus and the navicular. We identified eight os trigonum, one accessory lateral malleolus bone, 38 sesamoid bones in the tendon of tibialis posterior and 19 sesamoid bones in the tendon of fibularis longus. Tarsal arthritis was identified in 37 cases. Both talocalcaneal coalitions were associated with talocal-caneal arthritis while none of the calcaneonavicular coalitions were associated with tarsal arthritis. The CT examination of five of the cases of calcaneonavicular coalitions showed one coalition and was suspicious of a coalition in another two instances. In conclusion our study demonstrated that the incidence of tarsal coalition is higher than previously thought (8.8%). The calcaneonavicular coalitions are more common (7%) but they do not seem to be associated with arthritic changes in the tarsal bones. The 7.9% of the calcaneonavicular synovial joint demonstrate that the “abnormality” of the calcaneonavicular space can take any form. Our preliminary CT results demonstrate a low sensitivity in the detection of nonosseous coalitions.