New perspectives on a subclinical form of visceral leishmaniasis

During an epidemiological study of visceral leishmaniasis in an endemic region of Brazil, new perspectives emerged on a subclinical form of the disease. A group of 86 children with antibody to Leishmania were identified. None of these children had a history of leishmaniasis. The children were segregated into four groups: One group remained asymptomatic (n = 20), whereas another developed classic kala-azar within weeks of the index serology (n = 15). The remaining 51 patients initially had subclinical disease; 13 (25%) of these patients progressed to classic kala-azar (mean, five months). The others (75%) resolved their illness after a prolonged period (mean, 35 months). The initial illness in the subclinical group was characterized by hepatomegaly, frequent splenomegaly, intermittent cough, diarrhea, and low-grade fever. Malaise and poor weight gain were common. Giemsa-stained smears and cultures of bone marrow aspirates were usually negative for Leishmania in the absence of symptoms of classic kala-azar.

A prospective study of visceral leishmaniasis in an endemic area of Brazil

The epidemiology, clinical patterns, and risk factors for visceral leishmaniasis were prospectively studied in an endemic area of Brazil. The prevalence of disease was 3.1% for children less than 15 years of age, and the annual incidence was 4.3 cases per 1,000 children. The number of children with disease fluctuated yearly and seasonally, and distribution of the disease varied within the endemic area. Risk factors included young age (median, three years) and malnutrition before the onset of disease. Intestinal parasitism, recent migration into the area, and house location within the area did not influence the progression of infection to disease. Serological testing indicated that 7.5% of children were infected with Leishmania each year and that the ratio of disease to infection was 1:18.5 for the whole area and 1:6.5 for the section with the highest prevalence of disease. Early diagnosis and therapy altered clinical patterns of the disease.

Hepatic artery thrombosis after orthotopic liver transplantation: a review of nonsurgical causes

Hepatic artery thrombosis (HAT) is one of the principal causes of morbidity and graft loss following liver transplantation. There are several risk factors for the development of HAT; technical aspects of the arterial anastomosis are important particularly for early thrombosis, but the improvement of surgical technique has lessened this problem. Apart from technical causes, other risk factors include a variety of conditions such as low donor/recipient age ratio, immunologic factors, clotting abnormalities, tobacco use, and infections. In particular, cytomegalovirus (CMV) infection of endothelial cells has been recently suggested as an infective cause of HAT, as it is known to be followed by a rapid procoagulant response. Thus, latent CMV in an allograft may become activated and promote or contribute to vascular thrombosis. This review evaluates these aspects, focusing on data relating CMV infection or viremia to HAT following liver transplantation.

Selection of a skin test antigen for American visceral leishmaniasis

Studies were designed to examine skin test responses to leishmanial antigens in American visceral leishmaniasis (AVL) in Brazil. We found that after recovery from AVL, patients had positive delayed hypersensitivity reactions to Leishmania. Different amounts of a soluble extract obtained from Leishmania donovani chagasi promastigotes were compared with whole L. d. chagasi promastigotes in persons with past AVL. The most effective soluble preparations tested contained 25 and 50 micrograms leishmanial protein. These produced positive responses in 95%-100% of the individuals with past AVL. The 25 micrograms protein dose was used in further studies. This preparation produced no positive responses in either normal controls, tuberculosis patients, or schistosomiasis patients, and less than 5% positive responses in persons with Chagas' disease. The same amount of soluble extract prepared from L. mexicana amazonensis produced 82% positive skin test responses in persons with past AVL. When persons living in an area endemic for AVL were skin tested with the 25 micrograms preparation of L. d. chagasi extract, 34.1% yielded positive tests with a low number of positive responses in young children and 48% positive in adults. Only 3.1% of the population studied had a history of AVL. We have found that positive delayed hypersensitivity response to a soluble Leishmania extract is a sensitive and specific indicator of previous infection with AVL.

Schistosoma mansoni: assessment of morbidity before and after control

The literature on the assessment of morbidity due to Schistosoma mansoni infection is updated. Imaging techniques such as ultrasonography, echodoppler cardiography, computerized tomography (CT scan) and magnetic resonance imaging (MRI) introduced a new perspective, and expanded our knowledge on morbidity. Three well-defined syndromes caused by schistosomiasis mansoni have been described: the stage of invasion, acute schistosomiasis (Katayama fever), and chronic schistosomiasis. Complications of the acute and chronic syndromes have also been reported: pulmonary hypertension, neuroschistosomiasis, association with Salmonella, association with Staphylococci, viral hepatitis B, glomerulonephritis. In most individuals with hepatosplenic schistosomiasis the spleen is increased in size. Hepatosplenic schistosomiasis can, however, occur without splenomegaly. The definition of hepatosplenic schistosomiasis in endemic areas as the finding of S. mansoni eggs in the stools in an individual with hepatosplenomegaly is not satisfactory anymore. Many aspects of morbidity are expected to change after schistosomiasis control. Some are expected to change quickly (worm burden, Salmonella bacteremia, hepatosplenic schistosomiasis in children) whereas others shall remain for years (pulmonary hypertension, glomerulonephritis, neuroschistosomiasis). Intestinal schistosomiasis in individuals with low worm burdens is very difficult to diagnose and therefore laborious to control.

The role of different immunosuppression in the long-term histological outcome of HCV reinfection after liver transplantation for HCV cirrhosis

BACKGROUND

The effect of the type of immunosuppression on the course of posttransplant hepatitis C virus (HCV) infection is unclear. The aim of this study was to evaluate the histological outcome of posttransplant HCV infection with respect to initial immunosuppressive therapy in a cohort of 59 of 65 HCV positive transplant patients who survived at least 12 months.

METHODS

Initial immunosuppressive therapy was triple (cyclosporine or tacrolimus and azathioprine and prednisolone) in 41, double (cyclosporine and prednisolone) in 5, and single (cyclosporine or tacrolimus) in 13 patients. There was blinded histological evaluation, based on necroinflammatory activity (grading score:0-18) and fibrosis (staging score: 0-6). The median histological follow-up was 36 (12-72) months.

RESULTS

In the last liver biopsy, high necroinflammatory activity indicating chronic hepatitis (grading score > or =4) was found in 42 (71%) and severe fibrosis or cirrhosis (staging score > or =4) in 18 (30.5%) patients. High necroinflammatory activity was associated significantly with absence of pretransplant alcohol abuse (P=0.01) and relatively with occurrence of posttransplant acute lobular hepatitis C (P=0.055). Development of severe fibrosis or cirrhosis was significantly associated only with the type of initial immunosuppressive therapy. In particular, severe fibrosis or cirrhosis developed significantly more frequently in patients treated with triple or double (17/46 or 37%) than with single initial immunosuppressive therapy (1/13 or 7.7%) (adjusted for biopsy time: P=0.045).

CONCLUSIONS

Severe fibrosis or cirrhosis appears to develop in 30% of HCV transplant patients in a median of 3 years and to be associated with heavier initial immunosuppression.

Epidemiological aspects of three Trypanosoma cruzi zymodemes in Bahia State, Brazil

Culture forms of 104 stocks of Trypanosoma cruzi isolated in different regions of the State of Bahia were compared by electrophoresis of six enzymes. The three distinct combinations of isoenzyme patterns seen were designated ZI, Z2 and Z3. In an area of endemic Chagas's disease in eastern Bahia, T. cruzi Z1 was associated with sylvatic mammals and sylvatic triatomines, whereas T. cruzi Z2 was associated with a separate domestic cycleof transmission. T. cruzi Z1 was also found in sylvatic triatomines from other parts of the State. In contrast, in an area of the São Francisco Valley region of western Bahia, both T. cruzi Z1 and Z2 were isolated from man, domestic animals, and peridomestic rats. T. cruzi Z3 was isolated from an armadillo and from Panstrongylus geniculatus, a triatomine commonly found in armadillo burrows. Both T. cruzi Z1 and Z2 appeared to be pathogenic in man: T. cruzi Z1 was isolated from patients with acute Chagas's disease and from a single patient with chronic cardiac manifestations. T. cruzi Z2 was isolated from some asymptomatic individuals but was also associated with acute disease and chronic cardiac and digestive syndromes.

Polymorphisms of GSTP1 and GSTT1, but not of CYP2A6, CYP2E1 or GSTM1, modify the risk for esophageal cancer in a western population

Esophageal cancer is among the most common and fatal tumors in the world. Eighty percent of esophageal tumors are esophageal squamous cell carcinoma (ESCC). Brazil is one of the high incidence areas in the West, where tobacco and alcohol consumption have been associated with ESCC. However, polymorphisms in xenobiotic metabolizing genes may also contribute to the risk. Therefore, in this study, we analyzed the risk of ESCC associated with tobacco and alcohol consumption and with polymorphisms of CYP2A6 (CYP2A6*2), CYP2E1 (CYP2E1*5B, CYP2E1*6), GSTP1 (Ile105Val), GSTM1 and GSTT1 null genotypes in 126 cases and 252 age- and gender-matched controls. Data on the amount, length and type of tobacco and alcohol consumed were collected, and DNA was extracted from blood lymphocytes from all individuals. Polymorphisms were analyzed by polymerase chain reaction (PCR)-multiplex (GSTM1 and T1), PCR-Restriction Fragment Length Polymorphism (CYP2E1*5B and *6 and GSTP1 Ile105Val) or allele-specific PCR amplification (CYP2A6*2). Risks were evaluated by multivariate conditional regression analysis. As expected, tobacco [odds ratio (OR) = 6.71, 95% confidence interval (95% CI) 3.08-14.63] and alcohol (OR = 16.98, CI 7.8-36.98) consumption, independently or together (OR = 26.91, CI 13.39-54.05) were risk factors. GSTP1 Ile105Val polymorphism was an independent risk factor (OR = 2.12, CI 1.37-3.29), whereas GSTT1 wild-type was an independent protective factor for ESCC (OR = 0.37, CI 0.16-0.79). There was approximately 80% statistical power to detect both results. There was no risk associated with CYP2A6, CYP2E1 and GSTM1 polymorphisms. In conclusion, this study suggests an opposite role of GSTP1 and GSTT1 polymorphisms for the risk for ESCC.

The influence of cytomegalovirus viraemia on the outcome of recurrent hepatitis C after liver transplantation

BACKGROUND

Several interrelated host and hepatitis C virus (HCV) associated factors have been proposed to explain the variable outcomes in HCV recurrence. Recent evidence suggests that cytomegalovirus (CMV) infection not only is co-factor in progression of HCV recurrence but may precipitate allograft rejection. We investigated whether short-term CMV viremia influences HCV recurrence, the number and grade of acute rejection episodes, and the histological course of HCV recurrence during the first year after orthotopic liver transplantation (OLT) for HCV-related cirrhosis.

METHODS

A cohort of 39 patients transplanted for cirrhosis HCV-related was analyzed. Patients were evaluated twice weekly for CMV infection by a blood polymerase chain reaction (PCR) assay. Triple therapy with cyclosporine or tacrolimus, azathioprine and prednisolone was the initial immunosuppressive regimen. Preemptive treatment with ganciclovir was started when two consecutive PCRs for CMV were positive. Liver biopsies were performed on day 7 after OLT or when indicated. A 3-day IV 1 g methilprednisolone was given to patients with moderate or severe rejection. Ishak's score was used to grade inflammation and to stage fibrosis.

RESULTS

Neither CMV viremia nor CMV disease after OLT for HCV-related cirrhosis adversely influenced the incidence and grade of acute rejection episodes nor the histological outcome of post transplant HCV recurrence, during the first year after liver transplantation.

CONCLUSION

CMV viremia as detected by PCR does not affect the progression of HCV recurrence in liver grafts.

Immunohistochemical detection of p53 protein expression as a prognostic indicator in Wilms tumor

BACKGROUND

Mutations of the tumor suppressor gene p53 are commonly found in several kinds of human cancer. In some types of neoplasms, accumulation of p53 protein has been reported to correlate with more aggressive clinical behavior. The role of p53 expression in Wilms tumors (WT) is not clear yet, but most studies have confirmed its correlation with anaplasia and advanced stage disease.

PROCEDURE

Ninety-seven WT were evaluated for p53 expression by immunohistochemistry in formalin-fixed paraffin-embedded tissue and correlated with outcome. Tumors were classified as p53-Negative (p53-N) when no positivity was observed or only few cells showed weak positivity (0/1+) and p53-Positive (p53-P) when there was a diffuse and strong nuclear positivity (2+/3+).

RESULTS

p53-P was detected in 13 out of 97 tumors and was associated with disease relapse (39 vs.17%; P = 0.06) but not with anaplasia. Among p53-N patients only 5% had metastatic disease compared with 31% of the p53-P sample. (P = 0.038). Overall survival was 94% for patients with p53-N vs. 85% for patients with p53-P at 1 year (P = 0.34).

CONCLUSIONS

p53 expression in Wilms tumor detected by immunohistochemistry seems to be associated with advanced disease and relapse.

Brassica napus lines with rearranged Arabidopsis mitochondria display CMS and a range of developmental aberrations

Numerous Brassica napus (+) Arabidopsis thaliana somatic hybrids were screened for male sterility and aberrant flower phenotypes. Nine hybrids were selected and backcrossed recurrently to B. napus. The resulting lines displayed stable maternal inheritance of flower phenotypes. Nuclear and organellar genomes were characterized molecularly using RFLP analysis. No DNA from A. thaliana was found in the nuclear genome after six back-crosses, whilst the mitochondrial genomes contained rearranged DNA from both A. thaliana and B. napus. Each line tested had a unique RFLP pattern of the mitochondrial DNA (mtDNA) that remained unchanged between the BC(3) and BC(6) generation. The plastid genomes consisted of B. napus DNA. Five lines of the BC(5) generation were subjected to more comprehensive investigations of growth, morphology and fertility. On the basis of these investigations, the five CMS lines could be assigned to two groups, one represented by three lines displaying reduced vegetative development, complete male sterility, and homeotic conversions of stamens into feminized structures. The second group, represented by the other two lines, were not completely male-sterile but still displayed severely affected flower morphologies. These two lines did not display any reduction in vegetative development. For both groups only stamens and petals suffered from the morphological and functional aberrations, while the sepals and pistils displayed normal morphology. All plants were fully female-fertile. Different rearrangements of the mitochondrial genome disturbed nuclear-mitochondrial interactions and led to various types of aberrant growth and flower development. The existence of numerous CMS lines with different mitochondrial patterns involving a species with a sequenced genome offers new opportunities to investigate the genetic regulation of CMS and its associated developmental perturbations.

Schistosomiasis and associated infections

In hospital-based series viral hepatitis B has been frequently described in association with schistosomiasis whilst in field-based studies the association has not been confirmed. The association between schistosomiasis and Salmonella bacteraemia has been well documented. More recently, acute schistosomiasis has been shown to be a facilitating factor in the genesis of pyogenic liver abscesses caused by Staphylococcus aureus. New evidences indicate an interaction between the acquired immunodeficiency syndrome (AIDS) and schistosomiasis. In this paper, data on the association of schistosomiasis with other infections are updated.

Acute schistosomiasis: report on five singular cases

The cases of five patients with unusual manifestations of acute schistosomiasis mansoni are described in this paper. One patient developed skin lesions, three displayed diverse lung involvement, and one presented pyogenic liver abscesses caused by Staphylococcus aureus.

Recurrent hepatitis C after liver transplantation

Cirrhosis due to hepatitis C is now the commonest indication for liver transplantation in Western Europe and in the United States. Graft reinfection is almost universal. The natural history of recurrent hepatitis C ranges from minimal damage to cirrhosis in a few months or years. Different virus and host immune factors are involved in the pathogenesis of hepatitis and are determinants of the outcome. The association between immunosuppression and severity of HCV recurrence is conflicting and remains to be evaluated fully. The treatment of recurrent HCV disease with IFN or ribavirin, as monotherapy, is ineffective. Preliminary results from combination therapy, however, are encouraging. Currently, a reasonable approach would be to treat patients with histological and clinical disease progression. New approaches for the prophylaxis of recurrent hepatitis C are under evaluation but whether this treatment will influence the severity of liver disease or the outcome of recurrence is still unknown.

Pyogenic liver abscesses and acute schistosomiasis mansoni: report on 3 cases and experimental study

Three children with acute schistosomiasis mansoni developed pyogenic liver abscesses. The abscesses were diagnosed by ultrasonography and confirmed during laparotomy. Staphylococcus aureus were the sole bacteria isolated from the abscesses. An experimental study was carried out in mice to establish whether schistosomiasis is a predisposing cause for pyogenic liver abscesses. Seventeen mice (group 1) were infected with 40 Schistosoma mansoni cercariae (LE strain) and 60 d later inoculated intravenously with a strain of Staph. aureus, isolated from a patient with bacteraemia; 17 mice infected with Sch. mansoni (group 2), 19 infected with bacteria alone (group 3), and 18 uninfected mice (group 4), served as controls. Thirteen group 1 mice (77%) developed multiple liver abscesses while none was observed in the controls. These results indicate that acute schistosomiasis mansoni concurrent with Staph. aureus bacteraemia favours the colonization of the liver by bacteria and the development of pyogenic hepatic abscesses.

Management of recurrent hepatitis C after liver transplantation

Hepatitis C virus (HCV) reinfection is almost universal in patients transplanted for HCV-related cirrhosis. The medium-term survival after orthotopic liver transplantation (OLT) is similar to other transplanted patients, but the long-term survival remains uncertain. The prevention and an effective treatment of progressive liver disease are the primary aims in HCV recurrence. Interferon and ribavirin, as monotherapy or in combination, have been tried to treat or prevent HCV recurrence. Preliminary studies suggest a better chance of initial HCV clearance and better results in preventing HCV recurrence with combination therapy. IFN or ribavirin, as monotherapy, may normalize liver enzymes, but only gives rise to a transient virological response, without histological improvement. Combination IFN and ribavirin may be able to prevent progression of HCV-related graft disease, but indications and duration of treatment need further evaluation. No clear association between type and dose of immunosuppressive and outcome of post-transplant HCV recurrence has been found. Strategies to minimize the effects of immunosuppressive drugs include dose reduction of all agents and the selective discontinuation of individual agents. Initial immunosuppression with a single drug may inhibit or delay the severe fibrosis, and further investigation with a single immunosuppressive regimen to evaluate the outcome of recurrent hepatitis C should be performed. The recent evidence that mycophenolate may have an antiviral effect needs a clinical confirmation. Retransplantation survival is better with early retransplantation, and for indications not directly related to viral recurrence.

HLA class II alleles and chronic hepatitis C virus infection

The aim of this study was to investigate association of human leucocyte antigens (HLA)-DRB1 and DQB1 polymorphisms with hepatitis C virus (HCV) infection and with the occurrence of severe liver fibrosis/cirrhosis in chronically infected patients. Ninety-nine white patients, from southeast Brazil, with confirmed HCV chronic infection were included in the study. Severe fibrosis/cirrhosis (METAVIR scores F3-F4) was present in 49 patients. HLA-DRB1 specificities and DRB1*11 and DQB1* alleles were determined by PCR-SSP, and their frequencies were compared between patients and a control group of 103 healthy white Brazilian individuals. The results confirmed previous reports of the association of DRB1*11 and DQB1*03 with protection from chronic HCV infection, but did not confirm their association with protection from severe fibrosis/cirrhosis. Furthermore, the results suggested that the polymorphic sites on HLA molecules responsible for protection from chronic HCV infection are encoded not only by the DRB1*1101 and DQB1*0301, as suggested in the literature, but also by other DRB1*11 and DQB1*03 alleles. Thus, we hypothesized that the common polymorphic residues shared by different DRB1*11 and/or DQB1*03 alleles might be responsible for selection of viral epitopes for presentation to CD4(+) T cells, leading to an efficient immune response against the virus.

[The Queixadinha Project: morbidity and control of schistosomiasis in an endemic area in the northeast of Minas Gerais, Brazil]

In an endemic area for schistosomiasis in the northeast of the state of Minas Gerais in Brazil 516 individuals have been submitted to clinical and laboratory examination, ultrasonography of the abdomen and dopplerecocardiography in order to define the morbidity of schistosomiasis before and after treatment. A high prevalence of schistosomiasis (66.3%) and of severe disease (9.5% with palpable spleens) were recorded. Ultrasonography classified liver periportal fibrosis as light (19.4%), moderate (27.6%) and intense (6.8%), and 46.0% presented no periportal fibrosis. Twenty one out of the 53 individuals (39.6%) with palpable spleens did not present liver fibrosis on ultrasound. Periportal lymph nodes were described in 33.8% of the population and anti-KLH antibodies were found in the serum of 40.7%. Urinary alterations compatible with the glomerulopathy of schistosomiasis were observed in 4.5% of the population, and 11.7% of the individuals examined by dopplerecocardiography had pulmonary hypertension. Twelve months after treatment for schistosomiasis the prevalence of the disease dropped from 66.3% to 25.0%. In Queixadinha, a profile of the morbidity of schistosomiasis has just been established.

Midline nasal mass in infancy: a nasal glioma case report

Congenital midline nasal masses are rare anomalies that occur in about one in 20,000-40,000 live births. The most common are dermoid/epidermoid tumors, nasal cerebral heterotopias (nasal gliomas), and nasal encephaloceles; some have an actual or potential central nervous system connection. Nasal gliomas are CNS masses of neurogenic origin which have lost their intracranial connections and present as an obvious external or intranasal mass at birth without associated surgical symptoms. Careful evaluation is required to confirm the diagnosis and appropriate management. The interpretation of CT and MR images can be difficult but is useful in differentiating nasal gliomas from other congenital nasal masses. The presence of a fibrous stalk may be associated with cranial defects and CSF leak. Excisional biopsy allows histopathologic diagnosis and is the definitive treatment. They are benign lesions, and recurrences are rare, so conservative cosmetic surgical techniques should be chosen for gliomas where there is no proven intracranial extension. The authors report an illustrative nasal glioma case in a one-year-old male infant with extranasal and intranasal components, and discuss the therapeutic options.

Schistosomiasis mansoni is associated with pyogenic liver abscesses in the state of Minas Gerais, Brazil

The association between pyogenic liver abscesses and schistosomiasis has been confirmed by clinical and experimental studies. In this retrospective study of 78 patients with pyogenic liver abscesses the association with schistosomiasis has been investigated. Pyodermitis, a known focus of bacteremia, was observed in 19 patients (24%). Blood eosinophilia was observed in 30 patients (39%). Staphylococcus aureus was cultured from abscesses in 17 out of 38 patients (45%). Forty-one out of 57 patients (53%) had stool examination. Schistosoma mansoni was the main parasite identified. Eggs of S. mansoni were also identified in liver biopsies in 7 out of 19 patients who did the exam. The large number of young patients with liver abscesses described here is different from what has been observed in developed countries. This clinical study provide support for the concept that granulomas of S. mansoni in the liver are foci for colonization with S. aureus, which in presence of staphylococcal bacteremia can form liver abscesses.

Evaluation of Crizotinib Treatment in a Patient With Unresectable GOPC-ROS1 Fusion Agminated Spitz Nevi

Importance

Spitz nevi are benign melanocytic neoplasms that classically present in childhood. Isolated Spitz nevi have been associated with oncogenic gene fusions in approximately 50% of cases. The rare agminated variant of Spitz nevi, thought to arise from cutaneous genetic mosaicism, is characterized by development of clusters of multiple lesions in a segmental distribution, which can complicate surgical removal. Somatic single-nucleotide variants in the HRAS oncogene have been described in agminated Spitz nevi, most of which were associated with an underlying nevus spilus. The use of targeted medical therapy for agminated Spitz nevi is not well understood.

Observations

A girl aged 30 months presented with facial agminated Spitz nevi that recurred rapidly and extensively after surgery. Owing to the morbidity of further surgery, referral was made to a molecular tumor board. The patient's archival nevus tissue was submitted for extended immunohistochemical analysis and genetic sequencing. Strong ROS1 protein expression was identified by immunohistochemistry. Consistent with this, analysis of whole-genome sequencing data revealed GOPC-ROS1 fusions. These results indicated likely benefit from the oral tyrosine kinase inhibitor crizotinib, which was administered at a dosage of 280 mg/m2 twice daily. An excellent response was observed in all lesions within 5 weeks, with complete flattening after 20 weeks.

Conclusions and Relevance

Given the response following crizotinib treatment observed in this case, the kinase fusion was believed to be functionally consequential in the patient's agminated Spitz nevi and likely the driver mutational event for growth of her nevi. The repurposing of crizotinib for GOPC-ROS1 Spitz nevi defines a new treatment option for these lesions, particularly in cases for which surgery is relatively contraindicated.

Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis

AIM

This study aimed to evaluate the clinical outcomes and the trans-syndesmotic screw frequency after trimalleolar ankle fractures with a posterior malleolus fracture involving <25% of the articular surface.

MATERIAL AND METHODS

Retrospective comparative study. Patients with trimalleolar ankle fracture who underwent surgery between January 2011 and January 2018 were identified within the departments' fracture database. General demographics, treatment details, and fracture specific details (CT-scans) were assessed. Patients were grouped per the posterior malleolus fragment treatment: osteosynthesis (group 1) and non-osteosynthesis (group 2).

RESULTS

64 patients, 58.6 ± 17.8 years (range: 23-75), 68.8% female were eligible and follow up time was 43.1 ± 22.2 (range 24-96) months. The mean size of the posterior malleolus fragment was 14.7 ± 5.3% (range: 5-24). Posterior malleolus fragment treatment distribution: osteosynthesis (group 1) 31.2% and non- osteosynthesis (group 2) 68.8%. Group 1 showed significantly better clinical outcomes (p<0.05), AOOS (93.9 ± 5.79 (range: 73-99), AOFAS (91.5 ± 6.22 (range: 72-100) and VAS (0.8 ± 1.22 (range: 0-5) compared to Group 2, AOOS (84.25±8.34 (range: 63-100); AOFAS (84.75±8.05 (range: 58-100) and VAS (1.7 ± 1.38 (range: 0-6). Osteosynthesis of the posterior malleolus fragment significantly reduced the frequency of trans-syndesmotic screw (0%) compared to non-osteosynthesis posterior malleolus fragment (15.9%) (p < 0.05). The EQ-5D score was better in group 1 (1.08±0.27 (range: 1-2.2) compared to group 2 (1.27 ± 0.27 (range: 1-2.4) but with no statistical significance (p> 0.15).

CONCLUSION

Posterior malleolus fragments (<25% of the articular surface) have significantly better clinical outcomes and significant decrease in trans-syndesmotic screw need following osteosynthesis.