Fractures of the proximal fifth metatarsal account for 25% of metatarsal fractures, with a significant number occurring as stress fractures in sports. Fracture pattern recognition and correct management are important to avoid potential complications, considering the tendency towards poor bone-healing. Zone-3 fractures usually occur as chronic overuse lesions, with non-union rates of 25-28%. Torg further classifies these fractures according to their healing potential, with type-3 describing a complete obliteration of the medullary canal by sclerotic bone. We present a case of a 24year-old male professional athlete (futsal) with a zone-3 Torg-3 fracture non-union, previously submitted to two surgical interventions. The initial fracture was diagnosed following a period of overuse and consecutive sprains, when percutaneous screw fixation was first attempted. However, the athlete returned to practice earlier than recommended, with consequent failure of osteosynthesis. Revision surgery, with plating and autologous graft implantation was performed. After resolution of a wound complication, the athlete resumed training maintaining residual complains. A second non-union was diagnosed; management with hyperbaric chamber, ultrasound, growth-factors, magnetotherapy, insoles failed. The patient was then admitted for a third intervention using a novel grafting technique that we describe. First reaming of the medullary canal and fracture site curettage were performed. Then a cylindrical bone graft, from the calcaneus, mixed with bone marrow aspirate concentrate was introduced into the medullary canal, followed by plate fixation. Partial weightbearing was initiated at 6-weeks. After a 4-month follow-up, complete bone healing was present (CT-scan) with a painless functional foot, allowing the athlete to resume practice.

Introduction: bilateral complex fractures of tibial plafond are very rare and the treatment is high-demanding. Case report: a 50yrs old male patient was taken to hospital after a fall at work: imaging demonstrated complex factures of bilateral tibial plafonds. A primary damage control by external fixators was performed. After a few days, the patient underwent to ORIF with medial tibia plate (right), ORIF with autologous bone graft and anterolateral tibia plate plus fibular plate (left). At one-month, dehiscence of left tibial incision was treated by plastic surgeons with VAC therapy and a left thigh flap. Because of necrosis of this flap, plastic surgeons performed a second right thigh flap. Fistulae of the skin were treated by oral antibiotics. One year later, devices were removed from left ankle because poor tolerance. The patient fell again rifracturing his left tibia: radical bone debridement was performed with positioning of antibiotic cemented spacer. After six weeks, the bone defect was treated with bone transport by circular external fixator (Ilizarov technique). After nine months, the fixator was removed and an under-knee-cast was positioned. Patient newly crashed fracturing at dock point. Thus, TTC arthrodesis with nail and synthesis with proximal tibia MIPO plate were ultimately performed. Discussion: Complex fracture of tibial plafond should be treated only by skilled surgeons, even more if bilateral. Complications should be expected: surgeon has to consider several approaches for treatment.

A 44-year-old-male presented to the emergency department with right ankle pain following a high energy workplace accident. Physical examination revealed ankle deformity with skin intact. No neurovascular abnormalities were observed. Ankle dislocation was confirmed with plain radiographs (Fig 1 - Left). Closed reduction was attempted immediately; however, the talus appeared to be displaced laterally and anteriorly. Provisional external fixation was performed the following morning. Postoperative X-ray and CT showed persistent ankle subluxation, syndesmotic widening and a lateral malleolar fragment. After 14 days of anti-inflammatory and corticotherapy treatment, soft tissues were amenable to definitive surgery. Through a medial incision the following findings were noted: the medial ligamentous complex was completely detached from the talus and tibialis posterior tendon was dislocated laterally, impeding reduction (Fig. 1 - Right). A lateral incision was performed to reduce the tendon prior gentle longitudinal traction of the talus. The syndesmosis was fixed using a one-third tubular plate and 2 cortical screws. Syndesmosis and medial ligamentous complex were reattached using sutures and 2 suture anchors, one to fibula and another to the talus. There were no postoperative neurological or vascular deficits. A short leg splint was applied for 6 weeks postoperatively. Ten weeks after surgery, the syndesmotic screws and one-third tubular plate were removed and full weight-bearing was permitted. At 6 months after surgery the patient walked independently without discomfort, and achieved a nearly complete ankle joint range of motion.

Introduction: open fracture of the talus with extrusion is rare. In this report, we present a case of a talar fracture in semi-professional young cyclist. Case report: a 24yrs old male semi-professional cyclist fell off a bike crushing into a gutter. Taken to trauma center hospital, imaging demonstrated complex facture of the talus with extrusion. Patient immediately underwent to debridement: grass blades and soil was found in the ankle. A damage control with external fixation was performed. Because of the fall into a gutter, intravenous antibiotics and antifungal drugs were started. A week later, talar necrosis was found during a second-look surgery: we decided to completely excise the talus and fill the gap with vancomycin-gentamycin cemented pearls. After eight weeks, no local signs of infection were reported, confirmed by blood tests: thus, antibiotic pearls were removed and the talar gap was filled by cadaveric femoral head, specifically modeled, and autologous iliac bone graft. Then, TTC arthrodesis with retrograde nail and anterior plate was performed. After six months, imaging reported the fusion of the tibio-graft-calcaneal arthrodesis and the patient returned gradually to his daily and sport activities. Discussion: Complex fracture of talar with extrusion should be treated only expertized surgeons in trauma centers. Step-by-step planned surgery leads to better successful outcomes.