American Orthopaedic Foot And Ankle Society Ankle Research Articles

All-suture fixation of syndesmotic injuries: a case series.

To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. In the patients with 6weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.

Effectiveness analysis of percutaneous parallel screw fixation via posterolateral "safe zone" for Hawkins type Ⅰ- Ⅲ talar neck fractures

To explore the effectiveness of the percutaneous parallel screw fixation via the posterolateral "safe zone" for Hawkins type Ⅰ-Ⅲ talar neck fractures. A retrospective analysis was conducted on the clinical data from 35 patients who met the selection criteria of talar neck fractures between January 2019 and June 2021. According to the surgical method, they were divided into a study group (14 cases, using percutaneous posterolateral "safe zone" parallel screw fixation) and a control group (21 cases, using traditional open reduction and anterior cross screw internal fixation). There was no significant difference in gender, age, affected side, Hawkins classification, and time from injury to operation between the two groups ( P>0.05). The operation time, bone healing time, complications, and Hawkins sign were recorded, and the improvement of pain and ankle-foot function were evaluated by visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score at last follow-up. The overall quality of life was assessed by the short form of 12-item health survey (SF-12), which was divided into physical and psychological scores; and the satisfaction of patients was evaluated by the 5-point Likert scale. The operation time in the study group was significantly shorter than that in the control group ( P<0.05). All patients werefollowed up 13-35 months, with an average of 20.6 months; there was no significant difference in the follow-up time between the two groups ( P>0.05). The time of bone healing in the study group was shorter than that in the control group, and the positive rate of Hawkins sign (83.33%) was higher than that in the control group (33.33%), and the differences were significant ( P<0.05). In the control group, there were 2 cases of incision delayed healing, 7 cases of avascular necrosis of bone, 3 cases of joint degeneration, 1 case of bone nonunion, and 3 cases of internal fixation irritation; while in the study group, there were only 2 cases of joint degeneration, and there was a significant difference in the incidence of complications between the two groups ( P<0.05). At last follow-up, there was no significant difference in VAS score between the two groups ( P>0.05), but the SF-12 physical and psychological scores, AOFAS ankle and hindfoot scores, and patients' satisfaction in the study group were significantly better than those in the control group ( P<0.05). The treatment of Hawkins type Ⅰ-Ⅲ talar neck fractures with percutaneous parallel screw fixation via the posterolateral "safe zone" can achieve better effectiveness than traditional open surgery, with the advantages of less trauma, fewer complications, faster recovery, and higher patient satisfaction.

Comparison of different fibula procedures in tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a mid-term retrospective study.

Tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for severe tibiotalar and talocalcaneal arthritis has a high fusion rate; however, no studies have focused on how to handle the fibula intraoperatively to achieve better results. This study aimed to compare the efficacies of various fibular procedures. We retrospectively reviewed the cases of severe tibiotalar and talocalcaneal arthritis in adults treated with TTC arthrodesis using a retrograde intramedullary nail between January 2012 and July 2017. The patients were divided into three groups according to different fibular procedures: Fibular osteotomy (FO), fibular strut (FS), and fibular preservation (FP). Functional outcomes and pain were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analog scales (VAS), respectively. The operation time, fusion time, radiographic evaluation, and complications were also recorded. Fifty-eight patients with an average age of 53.2 (range, 32-69) years were enrolled in the final analysis. The numbers of patients enrolled in the three groups were 21, 19, and 18 in the FO, FS, and FP groups, respectively. The mean postoperative follow-up time was 66.0 (range, 60-78) months. All groups showed a high fusion rate (90.5% for FO, 94.7% for FS, and 94.4% for FP) and significant improvement in AOFAS ankle and hindfoot scores and VAS scores at the latest follow-up. There were no significant differences in these parameters among the three groups. The mean operation time of FS (131.3 ± 17.1min) was longer than that of FO (119.3 ± 11.7min) and FS (112.2 ± 12.6min), but the fusion time was shorter (15.1 ± 2.8 weeks for FS, 17.2 ± 1.9 weeks for FO, and 16.8 ± 1.9 weeks for FP). Statistically significant differences were observed in these parameters. TTC arthrodesis using a retrograde intramedullary nail is an effective procedure with a high rate of fusion to treat severe tibiotalar and talocalcaneal arthritis in adults; however, FSs can shorten fusion time when compared with FO and FP. Level 3.

Calcaneal V-shaped osteotomy combined with subtalar arthrodesis for Stephens Ⅱ and Ⅲ calcaneal fractures malunion

To investigate the effectiveness of calcaneal V-shaped osteotomy combined with subtalar arthrodesis in the treatment of Stephens Ⅱand Ⅲ calcaneal fracture malunion. The clinical data of 24 patients with severe calcaneal fracture malunion treated by calcaneal V-shaped osteotomy combined with subtalar arthrodesis between January 2017 and December 2021 were retrospectively analyzed. There were 20 males and 4 females with an average age of 42.8 years (range, 33-60 years). Conservative treatment of calcaneal fracture failed in 19 cases and operation failed in 5 cases. Stephens classification of calcaneal fracture malunion was type Ⅱ in 14 cases, and type Ⅲ in 10 cases. Preoperative Böhler angle of calcaneus was 4.0°-13.5° (mean, 8.6°), Gissane angle was 100°-152° (mean, 119.3°). The time from injury to operation was 6-14 months (mean, 9.7 months). American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analogue scale (VAS) score were used to evaluate the effectiveness before operation and at last follow-up. Bone healing was observed and the healing time was recorded. The talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were measured. Necrosis of the cuticle edge of the incision occurred in 3 cases, which were cured by dressing change and oral administration of antibiotic therapy. The other incisions healed by first intention. All the 24 patients were followed up 12-23 months, with an average of 17.1 months. The foot shape of the patients recovered well, the shoes were restored to the size before injury, and there was no anterior ankle impingement. Bone union was achieved in all patients, and the healing time ranged from 12 to 18 weeks, with an average of 14.1 weeks. At last follow-up, no adjacent joint degeneration occurred in all patients; 5 patients had mild foot pain during walking, which had no significant impact on daily life and work; no patient needed revision surgery. The AOFAS ankle and hindfoot score was significantly higher than that before operation ( P<0.001), the results were excellent in 16 cases, good in 4 cases, and poor in 4 cases, and the excellent and good rate was 83.3%. The VAS score, talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were significantly improved after operation ( P<0.001). Calcaneal V-shaped osteotomy combined with subtalar arthrodesis can effectively relieve hindfoot pain, correct talocalcaneal height, restore talus inclination angle, and reduce the risk of nonunion after subtalar arthrodesis.

A novel distractor-assisted reduction combined with the sinus tarsi approach for joint depression-type calcaneal fractures.

A novel percutaneous distractor with the advantage of axial and direct distraction was designed for the minimally invasive treatment of calcaneal fractures. The purpose of this study was to investigate the clinical results and complications of a novel distractor combined with sinus tarsi approach (STA) in treatment of the joint depression-type of calcaneal fractures. Fifty-four patients with the depression-type of calcaneal fractures (30 Sanders type II, 22 Sanders type III, 2 Sanders type IV) who were subjected to the novel distractor combined with STA were retrospectively assessed. Calcaneal height, width, and length; Bohler's angle; and the Gissane angle were evaluated pre-operatively and post-operatively. Clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) pain scores from the last follow-up. Complications were also recorded. Fifty-two patients achieved an average follow-up of 24.3months (range 18 to 34months), and two patients were lost to follow-up sixmonths post-operatively. There was significant difference between pre-operative and post-operative calcaneal height, width, and length; Bohler's angle; and Gissane angle (p < 0.01), but no significant difference was detected between the post-operative and normal side Bohler's angle (p > 0.05). The AOFAS ankle and hind foot score was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7 at the last follow-up. Nine (17.3%) patients developed complications: One experienced skin necrosis and two had screws loosening; three patients developed early degenerative changes of the subtalar joint; two had no symptoms; one had light pain around the subtalar joint without medical treatment; complex regional pain syndrome (CRPS) developed in one patient after sevenmonths post-operatively; and two developed transient ankle stiffness. The novel distractor combined with the STA effectively reconstructs the facet depression-type of calcaneal fractures (sanders type II and III) with minimal complications.

An Effective Technique for Managing the Calcaneus Osteomyelitis Combined with Soft-Tissue Defect.

The treatment of the Cierny-Mader (C-M) type III-IV calcaneus osteomyelitis combining with the soft-tissue defect is sophisticated and difficult. The aim of this study is to introduce the application and availability of the modified distally based sural flap with an adipofascial extension to reconstruct these defects. We retrospectively reviewed the data of 37 patients with C-M type III-IV calcaneus osteomyelitis accompanied with soft-tissue defect between December 2004 and December 2019. A modified distally based sural flap with an adipofascial extension was conducted to reconstruct the defect. The patient's demographics, duration of the diseases, etiology, reconstruction outcomes, infection control rate, recurrence rate, amputation rate, and follow-up data were collected to evaluate the effectiveness and reliability of the modification. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale was applied to assess the function of the ankle and hindfoot. Thirty-four flaps survived uneventfully, 1 flap displayed marginal necrosis and 2 flaps (5.41%) developed partial necrosis. Using this modified flap alone or combining with some simple salvage methods reconstructed all of the defects successfully. The calcaneus osteomyelitis was cured successfully, and no recurrences were observed during the follow-up period. The AOFAS ankle and hindfoot scores were excellent in 27 patients and good in 8 patients. The distally based sural flap with an adipofacial extension is a simple and effective technique to reconstruct the calcaneus osteomyelitis combined with soft-tissue defect in 1 stage. Applications of the adipofacial extension to obliterate the dead space and the well-vascularized skin island to cover the defect are the guarantee of achieving good ankle and foot functions. However, this technique is not appropriate for the patients with calcaneum less than half weight-bearing area.

Evaluation of Donor Ankle Function after Harvesting Peroneus Longus Tendon Graft for Anterior Cruciate Ligament Reconstruction- A Prospective Cohort Study

Introduction: Primary full thickness Peroneus Longus Tendon Graft (PLTG) for Anterior Cruciate Ligament Reconstruction (ACLR) has been used with good clinical outcome. Recently, it is designated as a promising graft option for ACLR. The effect of harvesting PLTG on donor ankle function is still not completely understood. Peroneus Longus Tendon (PLT) is thought to play a major role in proprioceptive regulation of the ankle joint. All the studies till date did cross-sectional assessments of ankle and foot function at or after 6 months that might have overlooked the timely detection of donor site morbidities. Aim: To evaluate the ankle function and compare the affected and sound limb function in subjects with an ACLR with autologous PLTG starting at an early postoperative visit upto six months. Materials and Methods: A prospective cohort study was conducted at a tertiary rehabilitation centre from March 2019 to March 2021 including the follow-up evaluation. As per the inclusion criteria, 63 participants after ACLR with PLTG were considered for assessment using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hind foot scale and Foot and Ankle Ability Measure (FAAM) scale at 6 weeks, 3 months and 6 months post-ACLR follow-up. Comparison between sound and affected limbs was done during all follow-ups. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 18.0. Both FAAM and AOFAS ankle and foot scores were analysed with non parametric tests. Results: Mean age of 63 participants were 29.25 years. Median of AOFAS and FAAM score at 6 week, 3 month, and 6 month post- ACLR follow-ups were (88, 98 and 100) and (97.22, 98.80 and 100), respectively. Statistically significant increase in AOFAS and FAAM scores were observed at 3 month and 6 month as compared to 6 week follow-ups with p=0.001 and p-value=0.001 respectively. The group comparison between the affected and sound side functional scores at different study visits showed statistically significant greater values for the sound ankle than the affected ankle (FAAM: 6 week: p-value=0.001; 3 month: p-value=0.001; 6 month: p-value=0.001 and AOFAS p-value=0.001; p-value=0.001; p-value=0.001, respectively). Conclusion: The evaluation of functional outcomes showed gradual and linear improvement at subsequent postoperative visits and restores fully to 100% at 6 month indicating a near- normal to normal donor ankle function following ACLR with PLTG by 6 months. The group comparison showed only marginal but significant difference between affected and sound ankle function.

Management of Hepple Stage V Osteochondral Lesion of the Talus with a Platelet-Rich Plasma Scaffold

Category: Ankle Introduction/Purpose: There has been no consensus on the treatment or prognosis of Hepple stage V osteochondral lesions of the talus (OLTs), especially for lesions greater than 1.5 cm2 in size. The objective of this study was to investigate the clinical outcomes achieved upon application of a platelet-rich plasma (PRP) scaffold with a cancellous bone autograft for Hepple stage V OLTs. Methods: Fourteen patients (mean age, 39 years) were treated with a cancellous bone graft and a PRP scaffold between 2013 and 2015. The mean time to surgical treatment was 23.5 months. Ankle X-ray and magnetic resonance imaging were performed at the final follow-up. Functional outcomes were evaluated according to the Visual Analog Scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Short Form36 (SF-36) score.The range of motion (ROM) of the ankle joint and complications also were recorded. Results: Thirteen patients completed the full follow-up, with a mean follow-up duration of 18 months. MRI demonstrated the complete regeneration of subchondral bone and cartilage in all patients.The postoperative VAS, AOFAS ankle and hindfoot, and SF-36 scores were improved significantly (all 𝑃 &lt; 0.001) without obvious complications. Conclusion: We suggest that, for the Hepple stage V OLTs, management with cancellous bone graft and PRP scaffold may be a safe and effective treatment.

Effectiveness analysis of Ilizarov external fixation and ankle arthrodesis in treatment of late traumatic ankle arthritis

To evaluate the effectiveness of Ilizarov external fixation and ankle arthrodesis in the treatment of late traumatic ankle arthritis. Between June 2013 and June 2015, 27 patients with late traumatic ankle arthritis were treated with Ilizarov external fixation technique. There were 16 males and 11 females with an age of 27-69 years (mean, 45.7 years). Sixteen cases were on the left side, 11 on the right side. All the patients suffered from traumatic ankle fractures or ligament damages caused by initial traumas. After 6 months of standard conservative treatment, the results was invalid and all patients had ankle joint pain and movement disorders. The disease duration was 3-39 years (mean, 11.5 years). According to Takakura ankle arthritis staging, there were 16 cases in stage 3 and 11 cases in stage 4. The tibial-talar angle before operation was (102.55±4.02) ° measured on conventional double-feet loading anteroposterior and lateral X-ray films. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and foot joint score was 45.72±6.45, and the visual analogue scale (VAS) score was 8.61±1.96. All the patients were followed up 15-42 months (mean, 28.1 months). All ankles achieved bony fusion, the clinical healing time was 12.9 weeks on average (range, 11-18 weeks). No persistent bleeding in the incisions and needle tract occurred during the follow-up. There were 4 cases of mild needle infection, 2 cases of anterior dislocation of talus, and 3 cases with different degree of limited activity. No traumatic bone defect, bone disconnection, and false joint formation was observed. At 12 months after operation, the AOFAS ankle and foot joint score, VAS score, and tibial-talar angle were 80.53±9.14, 2.77±0.82, and (94.36±2.48)°, respectively, which were significantly improved when compared with preoperative ones ( t=16.17, P=0.00; t=14.28, P=0.00; t=9.01, P=0.00). The effectivenss was excellent in 9 cases, good in 13 cases, and fair in 5 cases, with an excellent and good rate of 81.5%. Satisfactory effectiveness can be obtained through Ilizarov external fixation and ankle arthrodesis in the treatment of traumatic ankle arthritis, showing certain application prospect, while long-term effectiveness should be comfirmed by large sample randomized controlled trials.

The anatomy and clinical applications of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy

Objective To evaluate the effectiveness of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy using different technique. Methods Sixty-four embalmed feet of 32 cadavers were analyzed and classified anatomically with respect to the individual cross links in the Henry's knot. These three techniques were then combined to determine the total potential tendon graft length obtainable using single incision, double incision and minimally invasive incision. From January, 2012 to June, 2015, 10 patients (10 feet) with chronic Achilles tendinopathy were treated with double incision technique. The score was 63.04 ±7.75 according to American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system. Results Only two different configurations were found. Type 1, a tendinous slip branched from the FHLT to the FDLT was 96.9% (62 of 64 feet) . Type 2, a slip branched from the FHLT to the FDLT and another slip from the FDLT to FHLT was 3.1% (2 of 64) . The average length of the FHLT graft available from a single incision measured (5.08±1.09) cm, double incision technique measured (6.72 ± 1.02) cm, and minimally invasive incision measured (17.49 ± 1.80) cm. The difference between the lengths obtained from these three techniques was statistically significant. Ten patients were followed-up 12-36 months (mean, 13.7 months) . At 12 months after operation, the AOFAS ankle and hindfoot score was 93.28 ± 3.72, showing significant difference when compared with that before operation. The results were excellent in 6 cases, good in 3 cases, and fair in 1 case with an excellent and good rate of 90%. No sural nerve injury, posterior tibial nerve injury, medial plantar nerve injury, and lateral plantar nerve injury occurred. Conclusion In over 96% of the feet, a proximal to distal connection from the FHLT to the FDLT was found, which might contribute to the residual function of the lesser toes after FDLT transfer. The distal stump of the FHLT tendon should be sutured onto the FDLT tendon under tension to enable a co-activation of the great toe, preserved hallux plantar flexion. Chronic Achilles tendinopathy reconstruction with flexor hallucis longus tendon harvested using double incision technique offers a desirable outcome in operative recovery, tendon fixation, preserved hallux plantar flexion and less complications. Key words: Flexor hallucis longus; Flexor digitorum longus; Achilles tendon disorders; Tendon transfer

Osteotomy for malunion of intra-articular ankle fracture assisted by 3D printing relay template

Objective To explore the effectiveness of our self-designed 3D printing relay template in the treatment of malunion of irregular intra-articular ankle fractures. Methods From October 2013 to October 2015, our self-designed 3D printing relay template was used in 14 patients with severe malunion of intra-articular ankle fracture to assist their intra-articular osteotomy. They were 10 males and 4 females, with an average age of 40.5 years (from 34 to 59 years). Thin slice CT scan was preformed preoperatively for all the ankles involved. The computer fictitious tibial and fibular models for location and osteotomy navigation templates were acquired from the data of CT scan after processing, design and reconstruction by software. After the navigation templates which fit the size of solid ankle were printed by a 3D printer, they were ster-ilized and reserved. The guide plates were used in turn during operation. The irregular malunited bone blocks in the posterior malleolus were completely resected along the osteotomy template. After fracture reduction, the bone blocks were stabilized with internal fixation. Fracture union time was recorded. Scores of visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) and the short form-36 (SF-36), ankle ROM and complications were also recorded at the final follow-ups. Results The 14 patients obtained an average follow-up of 28.6 months (from 14 to 35 months). Bony union was achieved after an average of 3.7 months (from 3 to 6 months). At the final follow-ups, on average, VAS score (2.2±0.8), AOFAS ankle and hindfoot score (81.1±6.8), SF-36 score (82.5±5.2), dorsal extension (27.5°±2.5°), and plantar flexion (24.2°±6.3°) were significantly improved compared with the preoperative values (6.3±1.8, 43.1±12.0, 37.6±9.9, 14.1°±3.8° and 14.4°±3.9°, respectively) (P< 0.05). No implant failure, soft tissue complications or post-traumatic arthritis occurred during the follow-up. Conclusion Since our self-designed 3D printing relay templates for osteotomy can accurately position the fracture lines of the distal tibia via limited incision and invasion, they help a lot in precise osteotomy and anatomical reduction of malunited intra-articular ankle fracture, preventing incidence of traumatic arthritis. Key words: Ankle joint; Fractures, bone; Surgery, computer-assisted; 3D printing

Management of Hepple Stage V Osteochondral Lesion of the Talus with a Platelet-Rich Plasma Scaffold.

There has been no consensus on the treatment or prognosis of Hepple stage V osteochondral lesions of the talus (OLTs), especially for lesions greater than 1.5 cm2 in size. The objective of this study was to investigate the clinical outcomes achieved upon application of a platelet-rich plasma (PRP) scaffold with a cancellous bone autograft for Hepple stage V OLTs. Fourteen patients (mean age, 39 years) were treated with a cancellous bone graft and a PRP scaffold between 2013 and 2015. The mean time to surgical treatment was 23.5 months. Ankle X-ray and magnetic resonance imaging were performed at the final follow-up. Functional outcomes were evaluated according to the Visual Analog Scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Short Form 36 (SF-36) score. The range of motion (ROM) of the ankle joint and complications also were recorded. Thirteen patients completed the full follow-up, with a mean follow-up duration of 18 months. MRI demonstrated the complete regeneration of subchondral bone and cartilage in all patients. The postoperative VAS, AOFAS ankle and hindfoot, and SF-36 scores were improved significantly (all P < 0.001) without obvious complications. We suggest that, for the Hepple stage V OLTs, management with cancellous bone graft and PRP scaffold may be a safe and effective treatment.

Anatomic reconstruction of lateral ligament with tendon allograft for chronic lateral ankle instability

Objective To observe the efficacy of tendon allograft reconstruction of chronic lateral ankle instability (CLAI). Methods We retrospectively reviewed the 30 CLAI patients who had received tendon allograft reconstruction of lateral ligament between January 2013 and January 2014. They were 12 men and 18 women, aged from 23 to 45 years (average, 35.3 years). Their American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Karlsson-Peterson score, Sefton articular stability scale, anterior talar translation and talar tilt angle were compared between preoperation and the last follow-up. Results Of this series, 26 cases (26 ankles) were followed up for an average period of 20.3 months (from 15 to 27 months). Follow-up at 6 weeks after surgery showed they could complete non-weight-bearing walking and follow-up at 12 weeks observed that they achieved weight-bearing walking. X-ray films showed negative results of stress ankle varus test and anterior drawer test. At the last follow-up, all patients recovered normal life without obvious discomfort. Their AOFAS ankle and hindfoot score (87.1±4.9), Karlsson-Peterson score (89.6±4.5), Sefton articular stability scale (grade Ⅱ), anterior talar translation (3.5±0.4 mm) and talar tilt angle (3.9 °±0.9°) at the last follow-up were significantly improved in comparison with the preoperative values (56.3±11.0, 51.1±7.5, grade Ⅳ, 7.6±0.8 mm, 14.3°±2.2°, respectively)(P<0.05). The follow-up showed 15 excellent, 6 good and 5 poor ankles, yielding a patient satisfaction rate of 80.8%. Conclusions Anatomic reconstruction with tendon allograft is safe and effective for chronic lateral ankle instability. Key words: Transplantation, allogeneic; Ankle joint; Bone screws; Tendon; Anatomic reconstruction

Application of poly-axial calcaneal locking plate for Sanders type IV intra-articular calcaneal fractures

Objective To investigate the technique and clinical outcome of a polyaxial locking plate for treatment of Sanders IV intra-articular calcaneal fractures. Methods From January 2012 to July 2014, 17 cases of Sanders IV intra-articular calcaneal fractures were treated in our department. There were 14 males and 3 females with a mean age of 34.7 year-old (range, 18-49 years). Routine radiographic examination including X-ray and CT scanning was taken pre-operatively. Not until was the soft tissue condition improved, an open reduction and internal fixation with poly-axial locking plate would be performed. Regular X-ray was taken for measurement of the Bohler’s angle during the follow-up. Overall functional evaluation was carried out according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system. Complications were also recorded. Results All wounds were healed at the primary stage with no soft tissue complications of infection or skin necrosis. 13 patients had been followed-up for 12 to 36 months, with an average of 24 months. The X-ray found the bone union at an average time of 12 weeks (range, 9-16 weeks). The average Bohler's angle was improved from 12.0°±4.2° (range, 5°-20°) preoperatively to 33.2°±4.6° (range, 26°-42°) postoperatively. The mean AOFAS ankle and hindfoot score at the latest follow-up was 82.2±5.4 (range, 70-90). The mean score of VAS was 1.2±1.0 (range, 0-3). 4 patients suffered from subtalar posttraumatic arthritis with a mild pain when walking for a long distance, which could be relieved by NSAIDs. Conclusion Treatment of Sanders IV intra-articular calcaneal fractures with a poly-axial locking plate could obtain a stable fixation and an acceptable clinical outcome, which is a safe and effective method. Key words: Calcaneus; Fractures, bone; Internal fixators; Fracture fixation, internal

SHORT-TERM EFFECTIVENESS OF Hyprocure SUBTALAR STABILIZATION IN TREATMENT OF ADOLESCENT FLEXIBLE FLATFOOT

To evaluate the short-term effectiveness of Hyprocure subtalar stabilization for adolescent flexible flatfoot. Between December 2013 and September 2015, 14 cases (26 feet) of adolescent flexible flatfoot were treated with Hyprocure subtalar stabilization. There were 10 males (18 feet) and 4 females (8 feet) with the average age of 14.5 years (range, 12-18 years). There were 12 cases (24 feet) of congenital flatfoot and 2 cases (2 feet) of flatfoot caused by neurological diseases. The preoperative pain visual analogue scale (VAS) was 4.2±0.4; the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and foot function score was 72.2±12.3. Simple Hyprocure subtalar stabilization was used in 8 feet, and a combination of minimally invasive percutaneous Achilles tendon lengthening or gastrocnemius lysis, preposing of posterior tibial tendon and spring ligament tightening surgery, or open dorsal medial cuneiform osteotomy and bone graft in 18 feet. The VAS score and AOFAS ankle and foot function score were used to evaluate the effectiveness. The talus-the first metatarsal angle (T1MT), the talus-the second metatarsal angle (T2MT), and talonavicular coverage angle (TCA) were measured on the anteroposterior X-ray film; the Meary's angle, calcaneal inclination angle (CI), and the talar declination (TD) were measured on the lateral X-ray film. All incisions healed well. Two cases (2 feet) had tarsal sinus pain, which was cured after symptomatic treatment. All patients were followed up 5-24 months (mean, 14.5 months). Pain was obviously relieved. At last follow-up, VAS score was significantly decreased to 1.4±0.3 (t=27.676, P=0.000). AOFAS ankle and foot function score was significantly increased to 94.5±10.8 (t=7.765, P=0.000). The postoperative X-ray film showed that medial arch was elevated after the Hyprocure subtalar stabilization was placed in tarsal sinus. At last follow-up, the T1MT, T2MT, TCA, Meary's angle, and TD were significantly improved when compared with preoperative ones (P<0.05); CI has no significant improvement (t=0.109, P=0.598). Hyprocure subtalar stabilization is simple, effective for adolescent flexible flatfoot, the short-term effectiveness is good. But the indications should be strictly controlled, treatment should be individualized, corresponding auxiliary soft tissue and bone surgery is needed. The long-term effectiveness needs further follow-up.

Varus malunion following surgery for intra-articular calcaneal fracture: Pearls and pitfalls

Objective To analyze the causes and countermeasures for varus malunion by retrospectively evaluating the surgery for intra-articular calcaneal fractures.Methods Between April 2011 and March 2013,totally 50 patients with intra-articular calcaneal fracture were enrolled into our study.They were 31 men and 19 women,25 to 64 years of age (average,44.8 years).When soft tissue swelling subsided,a limited open reduction and internal fixation(ORIF) via a sinus tarsi incision or an ORIF via a classical lateral extensile L-shape approach was performed.The alignment of hindfoot was evaluated and the yarus angle was measured via calcaneal axial view.Overall functional evaluation was carried out in the patients with varus malunion in terms of visual analogue scale (VAS) and the ankle and hind-foot score of American Orthopaedic Foot and Ankle Society (AOFAS) at the last follow-up.Results Totally there were 27 cases of varus malunion,with a mean varus of 16.0° (from 8° to 25°).The average AOFAS ankle and hindfoot score was 49.8 (from 30 to 70) and the VAS score was 3.0 (from 1 to 8).Of them,24 were treated with the classical lateral extensile L-shape approach and 3 with limited ORIF.The varus malunion was caused by improper reduction in 21 cases and by secondary reduction loss due to screw convergence in 6 cases.Conclusions Unskillful reduction and fixation are pitfalls leading to calcaneal varus malunion.Surgeons should pay more attention to anatomic reduction and proper and stable fixation of the calcaneal medial column. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal; Malunion

Acutrak headless compression screws for treatment of fifth metatarsal base fracture

Objective To investigate the methods and effects in repairing fracture of the fifth metatarsal base bone with Acutrak headless compression screws.Methods From May 2006 to October 2012,75 patients with fracture of the fifth metatarsal base bone were reduced and fixed using Acutrak headless compression screws.There were 38 males and 37 females with a mean age of 36 years (range,21-65 years).Injury arose from fall from height (35 cases),road traffic accidents (23 cases),and fall of heavy objects (17 cases).Fracture of the left foot occurred in 29 cases and the right foot in 46 cases.Results were evaluated using American Orthopedic Foot and Ankle Society (AOFAS) ankle and midfoot score.Results Seventy-two patients were followed up for mean 15 months (range,13 months5 years).Operative incision obtained primary healing without any complications.Mean AOFAS ankle and midfoot score increased to (93.0 ± 6.5) points (range,79-100 points) at postoperative 1 year,compared with the preoperative (28.0 ± 3.9) points (range,0-42 points) (t =7.650,P ＜ 0.05).Muscle force and valgus or abduction of mid-forefoot of the affected and unaffected sides demonstrated no significant difference after operation.Conclusion Acutrak headless compression screw system shows advantages of rigid fixation,few complications,and early healing in treatment of the fifth metatarsal base fracture. Key words: Metatarsal bones; Fracture fixation, internal; Bone screws

Cannulated screws combined with transposition of cuboid periosteal flap pedicled with fascia and lateral tarsal artery in the treatment of talus neck fractures

Objective To investigate the surgical techniques and clinical efficacy of cannulated screws combined with transposition of cuboid periosteal flap pedicled with fascia and lateral tarsal artery in the treatment of talus neck fractures.Methods From March 2008 to June 2011,12 cases with talus neck fractures were treated with cannulated screws combined with transposition of cuboid periosteal flap pedicled with fascia and lateral tarsal artery.External fixation in functional position for 12-14 weeks,and the load time was determined by X-ray fracture healing.Functional results were assessed according to AOFAS (American Orthopaedic Foot and Ankle Society) score at last follow-up.Results Twelve cases were followed up for an average of 24 months (12 to 48 months).One case of skin flap necrosis healed by dressing.All the fractures healed,and the mean healing time was 20 weeks (16 to 24 weeks).AOFAS ankle and hindfoot mean postoperative score was 82.5 (ranging from 55 to 96) points.Among them 4 cases were excellent,good in 5 cases,fair in 3 cases.Two cases presented with mild posttraumatic subtalar arthritis and pain relief after oral anti-inflammatory analgesic.One case with avascular necrosis of talus body,and X-ray displayed sclerosis of talus body,but no collapse,and the patient was told to reduce weight and regularly followed up.Conclusion The application of cannulated screws combined with transposition of cuboid periosteal flap pedicled with fascia and lateral tarsal artery for the treatment of talus neck fractures is an effective treatment,which can improves the blood supply of the talus body and reduces the occurrence of avascular necrosis of the talus. Key words: Talus ; Fractures ; Lateral tarsal artery; Cuboid ; Periosteal flap; Transposition

Short-Term Outcomes of Arthroscopic Synovectomy for Hemophilic Ankle Arthropathy

Purpose: This study reports on the results of clinical and radiological evaluation of arthroscopic synovectomy in hemophilic ankle arthropathy. Materials and Methods: Between September 2006 and December 2008, arthroscopic synovectomy was performed on 35 ankle joints in 33 patients with hemophilic ankle arthropathy. The mean follow-up period was 30 months. The range of motion of joint and frequency of intra-articular bleeding and factor dose were evaluated for this study. American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hind foot score and subjective satisfaction were used for clinical assessment. Arnolf and Hilgartner classification was used for radiological assessment. Results: The mean dorsiflexion and plantar flexion were 10.1, 30.1, respectively, at preoperation and 11.3, 28.2, respectively on the final day of follow-up with no significant difference in the range of motion. The mean frequency of hemarthrosis decreased significantly to 0.6 times per month postoperative (p<0.05). The mean amount of factor replacement decreased from 5,320 units/mo preoperative to 4,568 units/mo postoperative with no significance difference. AOFAS ankle and hind foot score was improved to 90 points postoperative with significance. On radiologic evaluation, 33 cases showed no significant changes, while two cases had progressed at the last follow-up. Conclusion: Arthroscopic synovectomy for recurrent hemarthrosis in hemophilic ankle arthropathy is a useful method for familiar procedure, decreasing bleeding episodes and subjective satisfaction.

The clinical outcomes comparison of limited open reduction via a sinus tarsi approach and open reduction internal fixation via a lateral extensile L-shape incision for the treatment of Sanders type II calcaneal fracture

Objective To evaluate the clinical outcomes of limited open reduction via sinus tarsi approach and traditional open reduction internal fixation of the treatment for Sanders type Ⅱ calcaneal fracture.Methods Between February 2010 and February 2011,30 patients were enrolled into our study and were divided into minimal invasive and traditional groups randomly.Each group consisted of 15 patients.When soft tissue swelling subsided,the patients of mininal invasive group were performed a limited ORIF via a sinus tarsi incision,while those traditional groups were performed ORIF via a classical lateral extensile L-shape approach.X-rays were taken in the regular follow-up,B(o)hler and Gissane angle were measured.The final curative effect was comprehensively assessed according to visual analogue scale (VAS),the ankle and hind-foot score of American Orthopaedic Foot and Ankle Society (AOFAS) and SF-36 at the last follow-up,with the complications recorded.Results The average time of the follow-up was 16.9 nonths and 19.9months respectively in two groups.Superficial skin necrosis occurred in 2 cases in traditional group.X-ray demonstrated bone union 3 months after the operation in both groups.And no implant failure occurred.The B(o)hler angle of minimal invasive group was 13.1°±3.8° and the traditional group was 14.9°±4.3°,the Gissane angle of minimal invasive group was 28.1°±7.8° and the traditional group was 26.2°±8.2°.The average AOFAS ankle and hindfoot score of minimal invasive group at final follow-up was 91.2±15.9,and the average VAS score was 1.7±1.3,while the traditional group was 82.4±14.7 and 1.9±2.1 respectively.But SF-36 score in minimal invasive group (79.5±12.1) was higher than that in traditional group (70.2±12.4).Four patients in minimal invasive group and 15 in traditional group suffered from varying degrees of subtalar joint stiffness.Conclusion No significant difference was found between the two groups in the short-term efficacy of the treatment for Sanders type Ⅱ calcaneal fracture.However,minimal invasive technique has the advantages of lower soft tissue complication rate and lower suhtalar joint stiffness rate. Key words: Calcaneus; Fractures; Prospective studies