Fracture-dislocations of the tarsometatarsal (Lisfranc) joints are frequently overlooked or misdiagnosed at initial presentation. This is a comparative cohort study over a period of five years comparing primary open reduction and internal fixation in 22 patients (23 feet) with secondary corrective arthrodesis in 22 patients (22 feet) who presented with painful malunion at a mean of 22 months (1.5 to 45) after injury. In the first group primary treatment by open reduction and internal fixation for eight weeks with Kirschner-wires or screws was undertaken, in the second group treatment was by secondary corrective arthrodesis. There was one deep infection in the first group. In the delayed group there was one complete and one partial nonunion. In each group 20 patients were available for follow-up at a mean of 36 months (24 to 89) after operation. The mean American Orthopaedic Foot and Ankle Society midfoot score was 81.4 (62 to 100) after primary treatment and 71.8 (35 to 88) after corrective arthrodesis (t-test; p = 0.031). We conclude that primary treatment by open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results, earlier return to work and greater patient satisfaction than secondary corrective arthrodesis, which remains a useful salvage procedure providing significant relief of pain and improvement in function.

When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8-7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24°. Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively.

Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal ("Jones fractures") require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.

Chondroitin sulphate (CS) has an anti-inflammatory effect and increases the regeneration ability of injured bone. The goal of this study was to characterize the material properties and osteoconductive potency of calcium phosphate bone cements modified with CS. The early interface reaction of cancellous bone to a nanokristalline hydroxyapatite cement containing type I collagen (HA/Coll) without and with CS (HA/Coll/CS) in a rat tibia model was evaluated. Cylindrical implants were inserted press-fit into defect of the tibial head. Six specimens per group were analyzed at 2, 4, 7, 14, and 28 days. HA/Coll/CS composite cylinders showed a 15% increase in compressive strength and by investigations with powder X-ray diffraction more nontransformed cement precursor was found. The microstructures of both types of implants were similar. A significantly higher average number of TRAP positive osteoclasts and ED1 positive mononuclear cells were observed in the interface around HA/Coll/CS implants on day 4 and 7 (p < 0.05). At 28 days the direct bone contact and the percentage of newly formed bone were significantly higher around HA/Coll/CS implants (p < 0.05). The addition of CS appears to enhance bone remodelling and new bone formation around HA/Coll composites in the early stages of bone healing. Possible mechanisms are discussed.

The addition of chondroitin sulphate (CS) to bone cements with calcium phosphate has lead to an enhancement of bone remodeling and an increase in new bone formation in small animals. The goal of this study was to verify the effect of CS in bone cements in a large animal model simulating a clinically relevant situation of a segmental cortical defect of a critical size on bone-implant interaction and bone remodeling. The influence of adding CS to hydroxyapatite/collagen (HA/Col) composites on host response was assessed in a standard sheep tibia model. A midshaft defect of 3 cm was created in the tibiae of 14 adult female sheep. The defect was filled with a HA/Col cement cylinder in seven animals and with a CS-modified hydroxyapatite/collagen (HA/Col/CS) cement cylinder in seven animals. In all cases the tibia was stabilized with an interlocked universal tibial nail. The animals in each group were analyzed with X-rays, CT scans, histology, immunohistochemistry, and enzymehistochemistry, as well as histomorphometric measurements. The X-ray investigation showed a significantly earlier callus reaction around the HA/Col/CS implants compared to HA/Col alone. The amount of newly formed bone at the end point of the experiment was significantly larger around HA/Col/CS cylinders both in the CT scan and in the histomorphometric analysis. There were still TRAP-positive osteoclasts around the HA/Col implants after 3 months. The number of osteopontin-positive osteoblasts and the direct bone contact were significantly higher around HA/Col/CS implants. We conclude that addition of CS enhances bone remodeling and new bone formation around HA/Col composites. The addition of components of the extracellular matrix to hydroxyapatite cements containing type I collagen (HA/Col) has proved effective in stimulating bone cell activity and increasing the osteoconductive properties of HA/Col composites. 1,2 However, the application of full components (such as proteins of the extracellular matrix) is limited by the availability and quality of species-specific proteins, the sparse information about the necessary concentration of proteins and also by the high costs of a large amount of proteins. 3,4 Therefore, some investigators have added only the functional component of proteins of the extracellular matrix to HA/Col, obtaining similar enhanced bone remodeling, and increased bone cell activity around these composites. [3][4][5][6] Particularly, the addition of chondroitin sulphate seems to have a prominent role compared to other functional components such as rgd peptide, phosphoserin, or sodium-citrate. [3][4][5] Chondroitin sulphate (CS) is an important glycosaminoglycane found in the extracellular matrix of bone, 7 predominantly as a part of large proteoglycans like decorin and aggrecan. CS consists of repeating disaccharide units of D-glucuronic acid linked to N-acetylgalactosamine. The galactosamine residues are sulphated in position 4 or 6. The active functional groups like sulphate and carboxyl groups are believed to interact w...