Background Data: A new pilon fracture classification system based on CT scan data was recently published, showing almost perfect interobserver and intraobserver agreement among the authors who developed it. However, an independent assessment has not been done. Objective: To do an independent agreement evaluation of the new pilon fracture classification system with physicians with different levels of expertise in the management of pilon fractures. Methods: Seventy-one cases of acute pilon fracture were retrospectively collected. Fractures were classified by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents) using CT scans according to the morphological grading of the new pilon fracture classification system developed by Leonetti et al. Cases were presented to the same evaluators in a random sequence after a 6-week interval to determine intraobserver agreement. The kappa coefficient (κ) was used to determine agreement among evaluators. Results: The interobserver agreement was substantial regarding the main fracture type (I, II, III, or IV), with an overall κ value of 0.69 (0.65 to 0.72). When including the II and III subtypes, the overall agreement was still substantial, with a κ value of 0.61 (95% confidence interval: 0.58 to 0.64). The intraobserver agreement was substantial when considering the main fracture categories (I, II, III, or IV), with a κ value of 0.78 (confidence interval: 0.72 to 0.84), and full agreement at the type level was observed in 76% (324/426) of evaluations. There was no notable difference between the foot and ankle surgeons and orthopaedic surgery residents in the interobserver and intraobserver agreement. Conclusion: The new classification system demonstrated substantial interobserver and intraobserver agreement between evaluators with different levels of expertise in the management of pilon fractures. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice.

Category: Basic Sciences/Biologics; Trauma Introduction/Purpose: There is still no consensus regarding which is the best classification system for the management of tibial plafond fractures. The goal of this study is to perform a independent agreement evaluation to compare two recently published systems: Leonetti/Tigani and the new AO classification. Methods: Seventy-five patients with tibial plafond fracture and preoperative CT scan were included. Six raters with different level of expertise (two foot and ankle surgeons and three orthopedic surgery residents) classified the fractures using CT scans according to the morphological grading of both systems. The Leonetti/Tigani classification system considers four types (I, II, III and IV) and six subtypes (I, IIF, IIS, IIIF, IIIS, IV). The AO system considers three types (A, B, C) and nine subtypes (A1, A2, A3, B1, B2, B3, C1, C2, C3). After six weeks all cases were randomly re-evaluated by the same raters. The kappa coefficient (κ) was used to determine the degree of reliability. Results: Inter-observer reliability: strong using the Leonetti/Tigani classification system considering types, with a κ of 0,65 (0,60 - 0,69), and subtypes, with a κ of 0,62 (0,58 - 0,66). Reliability for the AO system was strong considering types with a κ of 0,72 (0,66 - 0,78), but moderate when including subtypes with a κ of 0,54 (0,50 - 0,57). Intra-rater reliability: Almost perfect using the Leonetti/Tigani classification considering both types and subtypes with a κ of 0,94 (0,88- 1,01) and 0,94 (0,89- 0,96), respectively. Reliability for the AO system was almost perfect considering types with a κ of 0,83 (0,75- 0,92), but strong when including subtypes with a κ of 0,61 (0,57- 0,66). No statistically significant difference between different levels of expertise. Conclusion: The system proposed by Leonetti/Tigani demonstrated a strong and almost perfect inter and intra-rater reliability, respectively. Although the new AO classification has a strong inter-rater reliability when including the main categories, it only reached a moderate reliability when including subtypes.

Macrodystrophia lipomatosa (ML) is a rare cause of local gigantism affecting hands or feet of congenital non-hereditary origin and unknown etiology. The main characteristic of this disease is the overgrowth of the mesenchymal structures as bone, tendons, vessels, nerves and, predominantly, the fibroadipose tissue. The low frequency of this pathology implies a difficulty to establish management guidelines. The most recommended treatment for this condition is the reductive surgery as an alternative to amputation of the affected segment. Our objective is to report the clinical results of the reductive surgery in four patients with ML in the forefoot. Methods: Four cases of ML surgically treated in our center between 2008 and 2016 were retrospectively analyzed after approval from our institutional review board. For each case, clinical history at admission, pre and post-operative radiographs and pre and post-operative clinical images were obtained. Results: Patients were adults between 28 and 38 years old and followed between 1 and 4 years. The toes involved were: 1 hallux, 2 second toes and 1 fourth toe. All had failed conservative treatment prior to surgery. SURGICAL TECHNIQUE: An extensile dorsal approach preserving the neurovascular bundles was performed. Bone was resected until a harmonic appearance of the toe related to the rest of the foot was obtained. In one case, removal of the distal phalanx was necessary to achieve adequate reduction. The remnant soft tissue was resected from dorsal and distal. Skin was closed using non-absorbable sutures. Wound dehiscence was observed in 2 patients and managed conservatively. No major complications were observed. All the patients were satisfied and able to wear regular shoes postoperatively. Conclusion: The reductive surgery for adults with symptomatic ML of the foot offers good functional results. The extensile dorsal approach allows an excellent surgical exposure, preservation of neurovascular supply and adequate tissue resection. Based on our clinical results and the high satisfaction observed in our 4 patients, we suggest reductive surgery as a good alternative to amputation in selected patients with ML.

Category: Ankle, Trauma Introduction/Purpose: Dislocation of the proximal tibiofibular joint (PTFJ) in association with ankle fracture is an infrequent injury. The mechanism involves a pronation-external rotation injury in which the energy exits through the PTFJ instead of the proximal fibula, like in a Maissoneuve fracture. Early diagnosis and treatment is of paramount importance to avoid complications such as pain, posterolateral knee instability and peroneal nerve injury due to chronic traction by the dislocated fibular head. In addition, an anatomical reduction of the PTFJ is mandatory to restore the fibular length in order to obtain anatomic reduction at the ankle. The objective is to report 3 cases with PTFJ dislocation in association with ankle fracture and to provide a treatment guide based on the management of these patients. Methods: Three cases of PTFJ dislocation in association with ankle fracture, surgically treated in our institution between 2009 and 2016, were retrospectively analyzed. For each case, clinical history at admission, pre and post operative radiographs and computed tomography (CT) were obtained. Clinical follow up time was between 1 and 6 years. Results: Diagnosis of the PTFJ dislocation required a high degree of suspicion. All the patients had subtle radiographic abnormalities at the PTFJ, thus requiring a CT of the knee to confirm the diagnosis. The first surgical step was to perform an open reduction of the PTFJ. Common peroneal nerve was identified and retracted. Reduction was performed with a clamp and for fixation we used one cortical positioning screw from the fibula to the tibia. After the achievement of an anatomic reduction, the second step was to approach the ankle according the specific fracture pattern. Anatomical reduction was obtained in all the patients checked by ankle and knee CT. At final follow up none of the patients had knee pain, and all returned to their activities. Conclusion: The PTFJ dislocation in association with ankle fracture is an infrequent injury and should be considered as a Maissoneuve equivalent fracture in terms of mechanism and diagnosis. A high index of suspicion is needed and the diagnosis is confirmed with a knee CT. As the Essex Lopresti injury of the upper extremity, this type of lesion requires proximal and distal stabilization. Our recommended treatment, based on the good clinical results of our 3 patient, is open reduction and screw fixation of the PTFJ as the first step in order to allow anatomical reduction of the distal injury at the ankle.