Pediatric flexible flatfoot: Does obesity influence the outcomes of arthroereisis?

BACKGROUND Childhood obesity has emerged in the last decades as an important public health problem worldwide.Although relationships between obesity and flatfoot have been shown,no studies have investigated the influence of obesity on arthroereisis outcomes.AIM To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants.METHODS This retrospective study included one hundred and sixty-nine pediatric patients(10-14 years old)who underwent subtalar arthroereisis(PEEK PitStop®device)for severe flexible flatfoot.Exclusion criteria were additional procedures,revision of previous corrective surgeries,rigid flatfoot with severe deformity,and neurologi-cal or post-traumatic flatfoot.Preoperative/postoperative European Foot and Ankle Society(EFAS)and visual analogue scale(VAS)scores were determined;radiographic assessment was conducted on weight-bearing foot X-rays:Kite angle,first metatarsal-talus angle,Meary angle,calcaneal pitch angle and lateral talo-calcaneal angle were analyzed.RESULTS EFAS and VAS scores improved post-operatively in the whole population.Only seven cases with complications were reported.Radiographic assessment revealed an improvement in all angles.Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes:Relationships were reported between BMI and postoperative EFAS/VAS scores,postoperative calcaneal pitch angle,Kite angle,Meary angle and talo-first meta-tarsal angle.CONCLUSION Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children,obesity significantly influences clinical and radiographic outcomes of arthroereisis,and obese children tend to perceive more pain and discomfort.

Müller-Weiss disease:Four case reports

BACKGROUND Müller-Weiss disease(MWD)is an idiopathic foot condition characterized by spontaneous tarsal“scaphoiditis”in adults.Frequently bilateral and affecting females during the 4th-6th decades of life,the pathogenesis of MWD remains unclear:It has been traditionally considered a spontaneous osteonecrosis of the navicular.The typical presentation of MWD is a long period of subtle discomfort followed by prolonged standing,atraumatic,disabling pain.Currently,there is no gold standard for the treatment of patients with MWD.Most support initial conservative therapy.Operative treatment should be considered for failure of conservative therapies longer than 6 months.The indication for surgery is severity of symptoms rather than severity of deformities.Operative treatment options include core decompression,internal fixation of the tarsal navicular,open or arthroscopic triple fusion,talo-navicular or talo-navicular-cuneiform arthrodesis,and navicular excision with reconstruction of the medial column.CASE SUMMARY In this study,we report four patients affected by MWD.Clinical and radiographic assessment,follow-up and treatment are reported.CONCLUSION As it is frequently misdiagnosed,MWD is challenging for orthopedic surgeons.Early diagnosis and effective treatment are mandatory to avoid sequelae.

Synovial chondromatosis of the foot: Two case reports and literature review

BACKGROUND Primary synovial chondromatosis(PSC) is a rare arthropathy of the synovial joints characterized by the formation of cartilaginous nodules, which may detach and become loose bodies within the joint and may undergo secondary proliferation. PSC of the foot and ankle is exceedingly rare, with only a few cases reported in the literature. The diagnosis may be difficult and delayed until operative treatment, when it is confirmed by histological assessment. PSC may degenerate into chondrosarcoma. Operative treatment is the gold standard aiming to minimize pain, improve function, prevent or limit progression of arthritis. Surgical treatment consists in debridement by arthrotomic or arthroscopic management, but there is no consensus in the literature about timing of surgery and surgical technique. Thus, the aim of this study is to report the outcomes of the surgical treatment of two cases, together with a literature review.CASE SUMMARY We report two cases of patients affected by PSC of the foot in stage III, according to the Milgram classification: the former PSC localized in the ankle that underwent open surgery consisted of loose bodies removal;the latter in the subtalar joint, and the choice of treatment was the arthrotomy and debridement from loose bodies, in addition to the subtalar arthrodesis. Both patients returned to complete daily and working life after surgery.CONCLUSION Synovial chondromatosis is a rare benign pathology, even rarer in the ankle joint and especially in the foot. Surgery should be minimal in patients with ankle PSC,choosing the correct timing, waiting if possible until stage III. More aggressive and early surgery should be performed in patients with PSC of the foot,particularly the subtalar joint, due to the high risk of arthritic evolution.

Liver function tests and metabolic-associated fatty liver disease:Changes in upper normal limits,does it really matter?

BACKGROUND Metabolic-associated fatty liver disease(MAFLD)is the commonest cause of abnormal liver function tests(LFTs).Current upper normal of limit(UNL)of LFTs was derived from a“healthy”population,where undiagnosed MAFLD and viral hepatitis might be suspected.AIM To evaluated potential implications of changes in UNL of alanine aminotransferase(ALT)in MAFLD.METHODS We retrospectively assessed consecutive first referrals with a diagnosis of MAFLD from 2010 to 2017.The conventional UNL of ALT was 45 IU/L for men and 34 IU/L for women,while a low UNL of ALT was 30 IU/L for men and 19 IU/L for women.The UNL of aspartate aminotransferase(AST)was 40 IU/L.RESULTS Total 436 patients were enrolled;of these,288 underwent liver biopsy.Setting a lower UNL reduced the percentage of those with significant disease despite normal ALT;specifically,patients with advanced fibrosis(F≥F3)or definite“metabolic-associated steato-hepatitis(MASH)”(NAS≥5)within normal ALT decreased from 10%to 1%and from 28%to 4%respectively.However,the proportion of those with elevated ALT and no evidence of advanced fibrosis or“definite MASH”increased from 39%to 47%and from 3%to 19%.Overall,LFTs performed poorly in distinguishing“definite MASH”from simple steatosis(receiver operating characteristic areas under the curves 0.59 for ALT and 0.55 for AST).CONCLUSION Liver function tests might both under-and overestimate MASH-related liver disease.Reducing the UNL might not be beneficial and imply an increase in healthcare burden.Risk stratification in MAFLD should rely on a combination of risk factors,not on LFTs alone.