American Orthopaedic Foot And Ankle Society Hindfoot Research Articles

Efficacy and Safety of Platelet-Rich Plasma Injection for Chronic Plantar Fasciitis: A Prospective Study on Functional Restoration and Pain Relief.

Background Heel discomfort and functional impairment are frequently caused by plantar fasciitis, and treating it can be extremely difficult for clinicians and occasionally have unfavorable clinical consequences. Recently, platelet-rich plasma (PRP) has been used as an alternative therapy for plantar fasciitis (PF) to reduce heel pain and improve functional restoration. We evaluated the current evidence concerning the efficacy and safety of PRP as a treatment for PF. Methodology This was a hospital-based prospective study on patients with plantar fasciitis with a symptom duration of six months or more with failed conservative therapy. All patients included in the study were assessed clinically and by a visual analog score (VAS) for heel pain, the Ankle-Hindfoot Scale (AHS) component of the American Orthopedic Foot and Ankle Society (AOFAS) and Foot and Ankle Ability Measure (FAAM) scores before injection, and at three weeks, three and six-months post-PRP treatment follow-up. Ultrasonography (USG) measurement of plantar fascia thickness was done pre-injection and at the six-month follow-up for clinical outcomes and any complications. Results The study included 25 patients with plantar fasciitis, with the majority (48%) in the age group of 21-30 years. Females accounted for 64% of the patientswhile males accounted for 36%. Most patients (56%) had a moderately active daily activity level. The study found that 16 patients had bilateral plantar fasciitiswhile nine had unilateral plantar fasciitis. Among the patients with bilateral plantar fasciitis, a total of 32 heels were affectedwhile the 9 patients with unilateral plantar fasciitis had 9 affected heels. Most female patients (75%) had bilateral plantar fasciitiswhile most male patients (56%) had unilateral plantar fasciitis. Before PRP therapy, both male and female patients reported high pain scores on theVASfor both heels. However, after PRP infiltration, the VAS scores significantly decreased at three weeks, three months, and six months post-injection, indicating pain relief. The AOFAS hindfoot and ankle scores and FAAM scores showed improvement over the follow-up period. Both male and female patients experienced significant improvements in functional outcomes, with increases in AOFAS (p-value 0.45) and FAAM scores (p-value 0.31) at three weeks, three months, and six months post-injection compared to baseline. Statistical analysis revealed a significant decrease in pain scores (73% pain relief), as well as significant improvements in AOFAS scores with an average of 22.33 from baseline (mean = 67.75±9.7) to final follow-up (mean = 90.08±7.9) and FAAM scores with an average of 23.72 from baseline (mean = 49.38±5.2) to final follow-up (mean = 73.10±5.2) after PRP infiltration. Conclusion The outcomes of a single dosage of PRP injections demonstrate clinically and statistically substantial improvements in functional outcome scores, plantar fascia thickness evaluated by USG, and VAS scores for heel pain. According to the results of this study, local PRP injection is an effective treatment for chronic plantar fasciitis.

Osteochondral Injury of the Talus Treated With Cell-Free Hyaluronic Acid-Based Scaffold (Hyalofast®) - A Reliable Solution.

Background: Osteochondral injuries commonly occur in load-bearing joints, mainly caused by traumatic incidents that can lead to detachment of the cartilage fragment either partial or complete.Objective: This study aims to review the long-term outcome of osteochondral injury of the talus treated with a cell-free hyaluronic acid-based scaffold (Hyalofast®, Anika Therapeutics Inc., Bedford, Massachusetts, USA).Method: This study evaluated the data of seven patients who underwent medial malleolus osteotomy, microfracture, and cell-free hyaluronic acid-based scaffold (HYALOFAST®) insertion between 2015 to 2018. All patients had an osteochondral lesion (OCL) grade III and IV of the talus based on Dipaola classification due to trauma. They were followed up for at least two years and assessed by the short form 36 health survey questionnaire (SF36) for both physical functioning and mental health, American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, and visual analog scale (VAS).Result: All patients were satisfied in terms of physical function, mental health, and pain after one month of surgery (p-value<0.05). There was also an improvement in AOFAS hindfoot and VAS scores from preoperative to postoperative. No complications were noted in the surgical site or bone union.Conclusion: Medial malleolus osteotomy, cell-free hyaluronic acid-based scaffold (HYALOFAST®) grafting, and microfracture are considered relatively easy techniques that are a good choice for patients with sizeable cartilage deficiency and provide a good functional outcome.

Anterior distal tibial plafond-plasty for the treatment of posttraumatic ankle osteoarthritis with anterior translation of the talus

Posttraumatic ankle osteoarthritis (OA) represents a significant challenge to orthopedic surgeons, especially in cases of anterior talar translation and concomitant impaction of the anterior distal tibial plafond. The aim of this study was to evaluate the clinical outcomes of an intra-articular osteotomy for the management of these patients. A total of 21 patients meeting our criteria were retrospectively reviewed. Sixteen patients sustained initial pilon fractures, while five patients had Weber type C ankle fractures. Anterior distal tibial plafond-plasty was performed to address the impaction and anterior translation of the talus. The American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) score were utilized as clinical outcomes. The lateral talar station (LTS), tibial lateral surface (TLS) angle, tibial anterior surface angle and talocrural angle were evaluated pre- and postoperatively. The modified Kellgren-Lawrence score was used for the evaluation of sagittal ankle OA. The average age at surgery was 35 years, and the average follow-up duration was 34 months. The AOFAS hindfoot score increased from 26 to 71 (p < 0.01), and the VAS score improved from 7 to 2 (p < 0.01). The LTS improved from 9.0 to 2.3 mm (p < 0.01), and the TLS angle improved from 72° to 81° (p < 0.01). Of the 21 patients, 18 showed improvement in or no worsening of ankle OA on the sagittal plane, while 3 developed advanced ankle OA. A congruent ankle joint on the sagittal plane could be achieved by anterior distal tibial plafond-plasty. This is a valuable treatment option for the salvage of posttraumatic ankle OA with anterior translation of the talus.

PO 18101 - Talar body reconstruction for nonunions and malunions

Introduction: Talar body and neck nonunions and malunions may undergo reconstructive surgery when joint cartilage is still viable and no talar collapse or infection has occurred. This is a rare condition, and studies supporting the procedure have a small number of cases. Objective: To report a case series of six patients who underwent talar reconstructions. Methods: Six patients with talar malunions or nonunions who underwent surgical treatment were reviewed in this retrospective study. There were three nonunions and two malunions of the talar body and one malunion of the talar neck. Clinical evaluation included all the parameters used in the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale. Arthritic degeneration of the ankle joint was assessed according to a modified Bargon scale. Results: The mean follow-up was 86 months (range 24-282 months). There were no cases of postoperative avascular necrosis of the talus. Four of the six patients in our series required a subtalar fusion as part of the reconstructive procedure. The average preoperative AOFAS hindfoot score was 34; at the time of the last evaluation, it was 74. The mean preoperative score on the modified Bargon scale for the tibiotalar joint was 1.17. At the last follow-up, it rose to 1.33. Three different deformities of the talus were identified: (a) flattening of the talus; (b) extra-articular step; (c) intraarticular step. Conclusion: Reconstruction of talar nonunions and malunions improved function in selected patients with a low risk of complications. Three different anatomical patterns of talar nonunions and malunions were identified.

Revision Surgery for Metal Component Failure in Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Metal component failure in total ankle arthroplasty(TAA) is difficult to treat. Traditionally, to an arthrodesis has been advocated. Revision TAA surgery has become more and more common with availability of revision implants and refinement of bone conserving primary implants. It this study, patient reported results and clinical outcomes are analyzed for patients undergoing revision total ankle arthroplasty. Methods: We retrospectively reviewed prospectively collected data on 45 patients (cases) with a mean age of 63.7 +/-10.2 years who developed loosening or collapse of either major metal component in the primary total ankle arthroplasty. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. Prospectively collected patient reported outcomes measures including the American Orthopaedic Foot and Ankle Society(AOFAS) hindfoot score, Visual Analog Scale (VAS), Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and the Foot and Ankle Outcomes Score (FAOS) questionnaires were collected. Clinical data was collected through thorough review of the electronic medical record to identify clinical failure defined as explant and second revision or conversion to arthrodesis or amputation. Results: The causes of failure of primary TAA in this study were aseptic loosening of both components (40%), talar component subsidence/loosening (37.7%), tibial loosening (8.8%), coronal talar subluxation (8.8%) and talar malrotation (2.2%). Twenty-four patients (53.3%) underwent revision of all components, nineteen (42.2%) just the talar and polyethylene components, and two (4.4%) the tibial and polyethylene components. The average time to revision was 5.56 years +/- 5.71 with a follow-up of 3.02 years +/- 1.25 after revision. Ten (22.2%) revision arthroplasties required further surgery; five required conversion to arthrodesis and five required second revision TAA. VAS scores, SF36 scores, SMFA scores, AOFAS Hindfoot scores, and FAOS all improved after revision surgery but took 2 years to reach scores comparable to 1 year after primary TAA. Conclusion: Clinical and patient reported results of revision ankle arthroplasty after metal component failure were comparable to those after primary ankle arthroplasty. In our series, 22.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prosthesis performed similarly when used in revision scenarios. Patients recovered faster from primary ankle arthroplasty when compared to revision ankle arthroplasty but all scores were comparable by the two-year follow-up visit after revision arthroplasty surgery.

Can Bohler’s Angle Predict the Functional Results of Intra-Articular Displaced Calcaneal Fractures?

Introduction: Intra-articular fractures need to be anatomically reduced. In intra-articular calcaneal fractures, Bohler’s angle can be used as a tool to achieve articular congruity intraoperatively. But a debate exists whether surgical restoration of Bohler’s angle to normal range in calcaneal fractures can ensure good functional outcome. Many studies have found no correlation between Bohler’s angle and the ultimate functional outcome. . Aim: To investigate whether correlation exists between the operative restoration of Bohler’s angle and the functional outcome. Materials and Methods: Forty patients with closed intra-articular displaced calcaneal fracture were studied. The injury was classified according to Sanders classification. Preoperative and postoperative Bohler’s angle was determined from radiographs. The functional outcome was assessed using American Orthopaedic Foot and Ankle Society (AOFAS) hind foot score and Visual Analogue Scale (VAS). Results: Forty patients were enrolled in the study with a follow up period of 12 months. As per Sanders classification, there were 14 Type II, 14 Type III and 12 Type IV fractures. The Bohler’s angle preoperatively did not correlate with functional outcome. Postoperative Bohler’s angle correlated significantly with AOFAS hind foot score and Visual analogue scale. Conclusion: Intraoperative restoration of Bohler’s angle to >18 degrees correlated strongly with the ultimate functional outcome. Therefore, aim of treatment in calcaneal fractures should be restoration of Bohler’s angle to near normal value.

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

Terapia de ondas de choque frente a infiltración corticosteroidea en el tratamiento de la fascitis plantar crónica

BackgroundChronic plantar fasciitis (CPF) is a painful condition where the primary goal of treatment is relieve the pain and restore function. Extracorporeal shockwaves therapy (ESWT) has shown efficacy in the treatment of plantar fasciitis with reported few side effects compared to other conservative methods. The purpose of the study is to compare the response to treatment of ESWT against corticosteroid infiltration for PF using VAS (Visual Analogue Scale) and AOFAS (American Orthopedic Foot and Ankle Society's) hind foot scales. Materials & methodsSixty patients with PF were randomized to receive ESWT (group A, n=36) or corticosteroid infiltration (group B, n=24) through a program of random number generation. They were evaluated with VAS and AOFAS hind foot scales before treatment, immediately after treatment and at 3, 6 and 12 months post treatment. ResultsThe two groups were similar in demographic characteristics. Both groups improved during treatment and follow-up period. The mean VAS decreased from 8 to 1.68 (p <0.001) in group A and 6.75 to 1.31 (p <0.001) in group B and presented a mean increase in AOFAS scale from 50.3 to 67.8 (p <0.001) in group A and 51.3 to 66 (p <0.001) in group B at 12 months follow up. At 3 months, the B group presented a lower average score in VAS when compared with patients in group A (1.12 vs 1.96; p=0.035). Finally, follow-up improvement was seen in both groups with no significant differences. DiscussionESWT and corticosteroid injections are both effective in reducing symptoms and increased functionality when applied to patients diagnosed with CPF. Evidence levelII.

Quality of life and clinical-radiological long-term results after implant-associated infections in patients with ankle fracture: a retrospective matched-pair study

BackgroundAnkle fractures are frequently occurring injuries. Despite the relatively simple operative technique, patients often suffer from postoperative complications. Little is known about postoperative treatment of implant-associated infections of the ankle. Therefore, this study shows and evaluates a treatment algorithm in long- and short-term outcomes compared to infection-free patients.MethodsData from patients of over 20 years of a level 1 trauma center and university hospital was retrospectively analyzed including age, gender, comorbidities, smoking status, fracture classification, number of revisions, length of in-patient stay due to fracture and infection, and results of microbiological specimen with the length of antibiotic treatment. Moreover, present long-term outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, the Ankle Osteoarthritis Score, and the Short Form 36 score and compared to a matched-pair infection-free patient cohort.ResultsForty-four patients could be retrospectively evaluated (51% male, 49% women, mean age 46 ± 17 years). Most of the cases were Weber B fractures (38%) following an in-patient stay from 51 ± 4.3 days after primary treatment and 77 ± 10.0 days after secondary treatment in our hospital. Microbiological specimen showed in 77% Staphylococcus aureus with following intravenous antibiotic treatment for 13.9 ± 3.1 days in mean. Common comorbidities/risk factors were cardiovascular disease (28%), smoking (15%), and diabetes (18%). Cure of infection and clinical and radiographic osseous consolidation could be documented for all cases.Patients with implant-associated infections had significantly more risk factors than infection-free patients (1.1/0.33; p = .02 per patient). The matched-pair group showed significantly better long-term outcome in mean regarding the Ankle Osteoarthritis Score (2.0 ± 1.2/13.9 ± 4.7) and AOFAS hindfoot score (96.7 ± 1.9/87.3 ± 3.4).ConclusionImmediate revision surgery with aggressive debridement, microbiological diagnostics, antibiotic therapy, and use of a drain until osseous consolidation is reached with following removal of the implant in patients with implant-associated infections after ankle fracture and open reduction internal fixation lead to cure of infection and fair long-term outcome in all cases. Special care must be taken of risk factors like diabetes and smoking.Trial registration24/2008BO2

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

Return to physical activity after gastrocnemius recession.

AIMTo prospectively investigate the time taken and patients’ ability to resume preoperative level of physical activity after gastrocnemius recession.METHODSEndoscopic gastrocnemius recession (EGR) was performed on 48 feet in 46 consecutive sportspersons, with a minimum follow-up of 24 mo. The Halasi Ankle Activity Score was used to quantify the level of physical activity. Time taken to return to work and physical activity was recorded. Functional outcomes were evaluated using the short form 36 (SF-36), American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot score and modified Olerud and Molander (O and M) scores respectively. Patient’s satisfaction and pain experienced were assessed using a modified Likert scale and visual analogue scales. P-value < 0.05 was considered statistically significant.RESULTSNinety-one percent (n = 42) of all patients returned to their preoperative level of physical activity after EGR. The mean time for return to physical activity was 7.5 (2-24) mo. Ninety-eight percent (n = 45) of all patients were able to return to their preoperative employment status, with a mean time of 3.6 (1-12) mo. Ninety-six percent (n = 23) of all patients with an activity score > 2 were able to resume their preoperative level of physical activity in mean time of 8.8 mo, as compared to 86% (n = 19) of patients whose activity score was ≤ 2, with mean time of 6.1 mo. Significant improvements were noted in SF-36, AOFAS hindfoot and modified O and M scores. Ninety percent of all patients rated good or very good outcomes on the Likert scale.CONCLUSIONThe majority of patients were able to return to their pre-operative level of sporting activity after EGR.

Endoscopic gastrocnemius recession procedure using a single portal technique: a prospective study of fifty four consecutive patients.

Gastrocnemius recession has become a popular procedure to treat the equinus ankle caused by a tight gastrocnemius. The aim of our study was to prospectively evaluate the safety and efficacy of the endoscopic gastrocnemius recession procedure using a single portal technique. The endoscopic gastrocnemius recession procedure was performed on 56 feet in 54 consecutive patients through a single lateral portal using the Smart Release Endoscopic Carpal Tunnel Release System. The minimum follow-up was 12 months. Functional outcomes were assessed with the Short Form 36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot score and modified Olerud and Molander (O&M) score. A modified Likert scale and visual analogue scores (VAS) were used to evaluate patient satisfaction and pain scores, respectively. Postoperative morbidities were documented for wound complications, scar hypersensitivity, sural nerve deficit and plantar flexion weakness. A p-value <0.05 was considered statistically significant. Endoscopic gastrocnemius recession procedure performed through a single lateral portal was successfully performed in all cases. Seven out of the eight component scores of the SF-36 questionnaire showed significant improvements. The AOFAS Hindfoot score showed a significant improvement of 20.69 ± 19.20. The modified O&M score also revealed significant improvements in eight out of nine component scores. There was a significant improvement of 3.79 ± 2.49 in VAS scores. A total of 91.07 % of all cases reported good or very good outcomes on the Likert scale. Eleven complications were recorded (three cases of unsatisfactory operative scar, three cases of sural nerve dysesthesia and five cases of subjective plantar flexion weakness with complete resolution in two out of the five patients.). This study demonstrates that the endoscopic gastrocnemius recession procedure performed through a single portal technique has low morbidity with good to excellent results. Level III, retrospective study.

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

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

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

Suture anchors in treatment of chronic lateral ankle instability using modified Brostr(o)m technique

Objective To discuss the application of suture anchors in the treatment of chronic lateral ankle instability using the modified Brostr(o)m technique.Methods From May 2009 to May 2011,we admitted 16 patients with ankle sprain of degree Ⅲ who had had little improvement after conservative treatment for more than 6 months and deteriorated into chronic lateral ankle instability.They were 7 men and 9 women,aged from 19 to 31 years (average,23.6 years).They all had mild swelling,pain and instability at the lateral ankle.We treated them with suture anchors using the modified Brostr(o)m technique.The pre-and post-operative ankle functions were evaluated by American Orthopaedic Foot and Ankle Society(AOFAS) scores.The patients' subjective feeling after operation was evaluated by the Good grading system.Results The patients were followed up for 6 to 24 months (average,16 months).The AOFAS ankle and hindfoot score improved significantly from preoperative 65.00 ± 6.65 points to postoperative 92.06 ± 3.13 points,the talar antedisplacement from preoperative 11.38 ±2.23 mm to postoperative 3.19 ± 1.1 mm,and the talar tilt angle from preoperative 13.44° ± 2.25° to postoperative 4.69° ± 1.35° (P ＜ 0.05).By the Good grading system for postoperative symptoms,there were 8 cases of grade Ⅰ,6 cases of grade Ⅱ,2 cases of grade Ⅲ and no case of grade Ⅳ,giving a good to excellent rate of 87.5％.Conclusion Suture anchors and modified Brostr(o)m technique is a reasonable and effective surgical method for the treatment of chronic lateral ankle instability. Key words: Sports medicine; Bone nails; Lateral ligament, ankle

Early Prospective Results of the Salto-Talaris™ Total Ankle Prosthesis

ABSTRACT Background Several fixed-bearing total ankle arthroplasty (TAA) systems are available in the United States (US). We report on the early clinical results of the largest known US cohort of patients who received a Salto-Talaris total ankle replacement for end-stage ankle arthritis. Methods We prospectively followed 67 TAA patients with a minimum clinical follow-up of 2 years. Patients completed standardized assessments, including visual analog scale (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot score, short form (36) health survey (SF-36), and the short musculoskeletal function assessment (SMFA), along with physical examination, functional assessment, and radiographic evaluation, preoperatively and yearly thereafter through most recent follow-up. Results Implant survival was 96% using metallic component revision, removal, or impending failure as endpoints, with a mean follow-up of 2.81 years. Three patients developed aseptic loosening, all involving the tibial component. Of these, one underwent revision to another fixed-bearing TAA system, one patient is awaiting revision surgery, and the other patient has remained minimally symptomatic and fully functional without additional surgery. Forty-five patients underwent at least one additional procedure at the time of their index surgery. The most common concurrent procedure performed was a deltoid ligament release (n = 21), followed by removal of previous hardware (n = 16) and gastrocnemius recession (n = 11). Eight patients underwent additional surgery following their index TAA, most commonly debridement for medial and/or lateral impingement (n = 4). Patients demonstrated significant improvement in VAS, AOFAS hindfoot, several SF-36 subscales, SMFA, and functional scores at most recent follow-up (p &lt; 0.001). Conclusion Early clinical results indicate that the Salto-Talaris fixed-bearing TAA system can provide significant improvement in pain, quality of life, and standard functional measures in patients suffering from end-stage ankle arthritis. The majority of patients underwent at least one concurrent procedure, most commonly to address varus hindfoot deformity, hardware removal, or equinus contracture. Schweitzer Jr KM, Adams Jr SB, Viens NA, Queen RM, Easley ME, DeOrio JK, Nunley II JA. Early Prospective Results of the Salto-Talaris™ Total Ankle Prosthesis. The Duke Orthop J 2012;2(1):23-34.