Ankle Society Ankle-Hindfoot Scale Research Articles

A fibular notch approach for the treatment of ankle fractures involving the distal tibial plafond

BackgroundAlthough efficacy is related to many factors, the surgical approach is one of the most important intervention factors for complex ankle fractures. Ankle fractures involving the distal tibial plafond frequently present a surgical challenge in choosing which incisions will be best for surgical treatment. Here, we present an innovative fibular notch approach for the treatment of some specific ankle fractures and present a series of patients with either functional or radiographic outcomes.MethodsTwenty-two patients with distal tibial plafond fractures with concomitant fibular and distal tibiofibular syndesmosis injuries were treated through a fibular notch approach in this retrospective study. The details of the surgical technique were reviewed from the operative notes. Relevant data were reviewed from the medical records. The quality of fractures and syndesmosis reduction was examined using CT scans, and lateral stability of the ankle was assessed by physical examination and stress radiographs. The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score was implemented for clinical functional assessment.ResultsAll surgeries were successfully performed via the fibular notch approach as the primary approach with excellent intraoperative visualization. Postoperative radiography revealed satisfying restoration of all fractures and syndesmosis. All fractures healed with an average time of 17.3 ± 3.6 weeks. Mild posttraumatic osteoarthritis (PTOA) was present in 4 patients. The average AOFAS score was 88.8 at the last follow-up.ConclusionsThe fibular notch approach is a safe and reliable approach for the treatment of specific ankle fractures involving the distal tibial plafond. This approach provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries. Satisfactory radiographic and clinical results were observed, and further clinical and anatomical studies are recommended to ascertain the feasibility of this approach in the treatment of complex distal tibial fractures.

Arthroscopic evaluation after osteochondral autogenous transfer with osteotomy of medial malleolus for osteochondral lesion of the talar dome

BackgroundThe purpose of this study was to investigate the second-look arthroscopic evaluation after osteochondral autogenous transfer (OAT) for osteochondral lesion of the talar dome (OLT) with the criteria of the International Cartilage Repair Society (ICRS). MethodsTen patients (twelve ankles) with OLT underwent OAT with osteotomy of the medial malleolus. Clinical outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. The condition of the transplanted cartilage was evaluated at the time of second-look arthroscopy using the ICRS Cartilage Repair Assessment. ResultsThe AOFAS ankle-hindfoot scale was significantly improved from 65.1 ± 1.9 points before surgery to 98.1 ± 2.8 points at the time of second-look arthroscopy (p < 0.01). The ICRS Cartilage Repair Assessment was 11.4 points on average (9–12 points). ConclusionsThe OAT for OLT is considered to be a useful treatment even if invasion by medial malleolus osteotomy is added. Level of evidenceLevel IV, Case series.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study.

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Ankle Fracture Fixation with Use of WALANT (Wide Awake Local Anesthesia with No Tourniquet) Technique: An Attractive Alternative for the Austere Environment.

Wide awake local anesthesia with no tourniquet (WALANT) is a simple technique that has had successful application in hand surgery. When utilized in the plating of distal radial fractures, the WALANT technique has proven to be a cost-effective approach in orthopaedic trauma. The aim of the present study was to assess the applicability of the WALANT technique in open reduction and internal fixation of ankle fractures. Fifty-eight patients were recruited from October 2016 to September 2018. Fractures were categorized according to the OTA/AO classification. We did not include patients with Maisonneuve, talar, or posterior malleolar fractures. Mechanism of injury, fracture type, comorbidities, and complications were recorded. The surgical site was infiltrated to achieve local anesthesia using a solution of 0.9% normal saline solution and 2% lidocaine with 1:1,000,000 epinephrine. Functional outcomes were assessed at the time of fracture union with use of the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale. Thirty-nine patients (67%) were male and 19 (33%) were female, and the mean age was 46.79 ± 8.54 years. According to the OTA/AO classification, 36 fractures (62%) were 44C2, 11 (19%) were 44B2, 7 (12%) were 44C1, and 4 (7%) were 44B1 fractures. Average blood loss was 29.40 ± 7.38 mL, the mean operative time was 59.72 ± 7.19 minutes, and the mean intraoperative visual analogue scale (VAS) for pain was 1.24 ± 0.43 (range, 0 to 3). The mean time to union was 16.21 ± 3.52 weeks, with a mean AOFAS Ankle-Hindfoot Scale score of 86.38 ± 5.72. Three patients (5.2%) developed nonunion of a fracture site, 2 patients had a surgical site infection, and 1 noncompliant diabetic patient developed osteomyelitis. The WALANT technique is a safe technique for ankle fracture fixation and has been shown to be useful in foot and ankle surgery, particularly in limited-resource environments. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

WHICH CLINICAL OUTCOME SCORES ARE MORE FREQUENTLY USED IN THE LITERATURE ON OSTEOCHONDRAL LESIONS OF THE TALUS? A SYSTEMATIC REVIEW.

ABSTRACTObjective: This study aimed to identify the most used scales in the assessment of the clinical outcomes for the treatment of osteochondral lesions of the talus. Methods: We performed a systematic review of the PubMed/MEDLINE databases from September 1999 to September 2019, based on the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The research strategy was: osteochondral [All Fields], AND (“talus” [MeSH Terms] OR “talus” [All Fields]) AND lesion [All Fields]. Of the 364 articles found in the literature, 166 (45%) were included in the study and 198 (55%) excluded. In total, 23 clinical assessment tools were used in the studies. Results: We found 49.4% of the studies to use the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS Ankle-Hindfoot Scale) and 29.5% the Visual Analogue Scale (VAS). Conclusion: The use of AOFAS increased in relation to VAS in the last 6 years (p = 0.046), and these two scales, either alone or combined, were the most used for studying osteochondral lesions of the talus. Level of Evidence III, Systematic Review of Level II studies.

Biomechanical evaluation in runners with Achilles tendinopathy

OBJECTIVES:To evaluate the clinical characteristics, ground reaction force (GRF), and function of the plantar muscles and dorsiflexors of the ankle in runners with and without Achilles tendinopathy (AT) and in non-runners.METHODS:Seventy-two participants (42 men, 30 women; mean age: 37.3±9.9 years) were enrolled in this cross-sectional study and divided into three groups: AT group (ATG, n=24), healthy runners’ group (HRG, n=24), and non-runners’ group (NRG, n=24). Both ankles were evaluated in each group. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale was used for clinical and functional evaluation. GRF was evaluated using force plates and muscle strength was evaluated using an isokinetic dynamometer.RESULTS:The AOFAS scores were lower in the ATG. The strike impulse was higher in the ATG than in the HRG and NRG. However, GRF was similar among the groups. The ATG exhibited lower total work at 120°/s speed than the HRG. The peak torque in concentric dorsiflexion was lower in the NRG than in the ATG and HRG. The peak torque and total work in concentric plantar flexion were lower in the NRG than in the ATG. The peak torque and total work in eccentric plantar flexion were lower in the NRG than in the ATG and HRG.CONCLUSION:Runners with AT showed higher strike impulse, lower muscle strength of the plantar flexors, and higher clinical and functional damage.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon.

Background:The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture.Methods:A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up.Results:Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up (P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively (P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery.Conclusion:The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery.Level of Evidence:Level IV, retrospective case series.

Preliminary Results of Subtalar Arthroereisis with Vulpius Procedure for Symptomatic Flatfoot in Patients with Type I Osteogenesis Imperfecta.

In this retrospective study, we aim to assess the safety and feasibility of adapting subtalar arthroereisis (SA) for type I osteogenesis imperfecta (OI) patients with symptomatic flatfoot. From December 2013 to January 2018, six type I OI patients (five girls and one boy, 12 feet) with symptomatic flexible flatfoot were treated with SA and the Vulpius procedure. All the patients were ambulatory and skeletally immature with failed conservative treatment and unsatisfactory life quality. The median age at the time of surgery was 10 years (range 5–11), and the median follow-up period was 55 months (range 33–83). All functional and radiographic parameters improved (p < 0.05) after the procedure at the latest follow-up. The median American Orthopaedic Foot and Ankle Society ankle-hindfoot scale improved from 68 (range 38–80) to 95 (range 71–97). All of the patients ambulated well without significant complications. The weight-bearing radiographs showed maintained correction of the tarsal bone alignment with intact bony surfaces adjacent to implants during the post-operative follow-up period. This is the very first study on symptomatic flatfoot in pediatric patients with type I OI. Our data suggest that SA is a potentially viable approach, as functional improvements and maintained radiographic correction without significant complication were observed.

Achilles Tendon Region Defects: Delayed Composite Anterolateral Thigh Flap With Stripping of Fascia Lata: A Case Series

The purpose of this study was to evaluate the functional and physical functioning score out-comes of patients following microsurgical reconstruction of the yarrow region, using a combination of objective, subjective, and semi-subjective measurements. Between 2007 and 2018, 15 patients underwent delayed Achilles tendon region reconstruction with different anterolateral thigh flap types. Seven (7) patients underwent tendon and soft tissue re-construction with a chimeric anterolateral thigh flap (ALT) and rolled-up fascia lata, and 8 patients underwent soft tissue reconstruction and only tendon coverage with fascia lata. Follow-up assessments included maximal range of motion (MROM) (plantarflexion and dorsiflexion), the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale score, and the Med-ical Outcomes Study 36-item Short-Form Health Survey physical functioning subscore. A total of 15 patients (11 males and 4 females with a mean age of 39.86 years) were evaluated during a mean follow-up time of 23 months (SD = 7.12). The MROM for plantarflexion and dorsiflexion was 42.71 degrees (SD = 2.9) and 24.8 degrees (SD = 4.29), respectively, in patients who underwent composite ALT with a rolled-up fascia lata. The MROM for plantarflexion and dorsiflexion was 43 degrees (SD = 5.37) and 27.37 degrees (SD = 3.2), respectively, in patients who underwent fasciocutaneous ALT. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 82 for the first group and 86.87 for the second, whereas the mean Medical Outcomes Study 36-item Short-Form Health Survey scores were 82.57 and 81.5, respectively, for the 2 groups. Statistical analysis showed no significant difference between the 2 groups. The results of this case series suggest that the single-stage composite reconstruction with a fasciocutaneous flap with or without a strip of fascia lata is a safe and reliable strategy for composite reconstruction of the Achilles tendon region. Additional studies to evaluate these outcomes and instruments to evaluate functioning are necessary.

Knotless All-Inside Arthroscopic Modified Broström Procedure for Lateral Ankle Instability

One reported complication of the arthroscopic modified Broström operation is pain caused by the suture anchoring knot. We hypothesized that a knotless technique could reduce such pain. Therefore, in this study we evaluated the clinical and radiological outcomes after knotless all-inside arthroscopic modified Broström operation for lateral ankle instability. From July 2017 to November 2017, 28 patients were treated. Clinical and radiological features were evaluated preoperatively and 3, 6, and 12 months postoperatively using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale score, visual analogue scale score for pain, anterior talar drawer test, and talar tilt angle. The mean age of the 28 patients (14 men, 14 women) was 41.71 ± 17.19 years. Three (10.7%) complications, but no knot-associated pain, occurred. The clinical and radiological outcomes were significantly improved 12 months postoperatively compared with preoperative outcomes (all p < .05). Knotless all-inside arthroscopic modified Broström operation for lateral ankle instability avoided knot-associated pain and improved not only patient satisfaction but also clinical and radiological outcomes.

Clinical outcomes after arthroscopic microfracture for osteochondral lesions of the talus are better in patients with decreased postoperative subchondral bone marrow edema

Magnetic resonance imaging (MRI) findings of subchondral bone marrow edema (SBME) in osteochondral lesions of the talus (OLT) after arthroscopic microfracture are associated with poor clinical outcomes. However, the relationship between SBME volume change and clinical outcomes has not been analyzed. It was hypothesized that clinical outcomes correlated with SBME volume change and extent of cartilage regeneration in patients with OLT. 64 patients who underwent arthroscopic microfracture for OLT were followed up for more than 2years. SBME volume change was measured by comparing preoperative and 2-year follow-up MRI. Clinical outcomes were assessed using the visual analogue scale (VAS) and the American orthopedic foot and ankle society ankle-hindfoot scale (AOFAS) at the 2-year and final follow-up. To compare clinical outcomes, patients were categorized into two groups: decreased SBME (DSBME) group (cases without SBME on either MRI or with a decreased SBME volume between the MRIs) and increased SBME (ISBME) group (cases with new SBME on postoperative MRI or with an increased SBME volume between the MRIs). Additionally, the effects of age, sex, body mass index, symptom duration, OLT size, OLT location, containment/uncontainment, preoperative subchondral cysts, pre- and postoperative SBME volumes, and MRI observation of cartilage repair tissue score on clinical outcomes were analyzed. The DSBME group included 45 patients, whereas the ISBME group included 19. The mean age was 40.1 ± 17.2years, and mean follow-up period was 35.7 ± 18.3months. Preoperative SBME volume was significantly higher in the DSBME group, while the ISBME group had higher volumes at the final follow-up. In both groups, the VAS and AOFAS scores significantly improved at the final follow-up(p < 0.001, < 0.001). The VAS scores were significantly lower in the DSBME group at the 2-year andfinal follow-up (p = 0.004, 0.011), while the AOFAS scores were significantly higher (p = 0.019, 0.028). Other factors including cartilage regeneration did not affect clinical outcomes. SBME volume change correlated with clinical outcomes after arthroscopic microfracture for OLT. Clinical outcomes were worse in patients with new postoperative SBME and increased postoperative SBME volume. In patients with an unsatisfactory clinical course that show decreased SBME via postoperative MRI, an extended follow-up in a conservative manner could be considered. Level III.

Fusion Rates of Ankle Arthrodesis with Anterior Plate Fixation Based on Computerized Tomography and Clinical Outcomes

Category:Ankle; Ankle ArthritisIntroduction/Purpose:Ankle arthrodesis is a common treatment for tibiotalar joint arthritis and anterior plate fixation is often utilized. Prior series reporting on anterior plate fixation for ankle arthrodesis have been relatively small and none have exclusively used post-operative computerized tomography (CT) scans for confirmation of fusion. The purpose of this study was to determine radiographic and clinical outcomes of patients who underwent ankle arthrodesis with anterior plate fixation. The primary outcome of the study was whether or not successful arthrodesis was obtained based on a quantitation of the fusion mass on CT scan.Furthermore, correlation between ankle fusion and clinical outcomes along with complications were evaluated.Methods::Adult patients who underwent ankle arthrodesis with anterior plate fixation (including straight anterior and anterolateral plates) were eligible for this study. Charts were retrospectively reviewed and data was collected in a prospective fashion. In total, 102 patients were included in the study and obtained a CT scan at least 90 days after surgery. The primary outcome was tibiotalar fusion, defined as osseous bridging of 50% or more of the tibiotalar joint based on CT scan reviewed by a single musculoskeletal radiologist. Secondary outcomes included patient reported outcome measures (PROMs): the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Foot function index (FFI), Visual analog scale (VAS) pain score, and Coughlin satisfaction scale. Additional surgeries and complications including nonunion, painful hardware, tibial stress fractures, wound dehiscence, deep infection, superficial infection, and nerve injury/deficit were recorded.Results:Post-operative CT scans demonstrated tibiotalar fusion in 85 of 102 (83.3%) patients. Of the 17 (16.7%) patients who were classified as non-unions, only 8 (47.1%) of them were symptomatic. Five patients (3.9%) in the union group and 2 patients (7.1%) in the non-union group developed tibial stress fractures. In the union group, 13.3% of patients underwent at least one secondary procedure compared to 53.6% in the non-union group (p<0.001). FFI (p=0.04) and Coughlin (p=0.03) scores were statistically lower in patients who underwent secondary procedures. Eighty-six patients (84.3%) did not demonstrate fusion between the lateral talus and fibula by CT but PROM scores were not statistically different compared to patients who demonstrated talofibular fusion.Conclusion:Tibiotalar arthrodesis utilizing anterior plate fixation is a reliable procedure to achieve ankle fusion based on 50% osseous bridging on post-operative CT scan. However, our results utilizing the accuracy of CT scanning demonstrated a lower rate of ankle fusion than historically reports which are primarily based on plain film imaging. Rates of tibial stress fracture and post-operative wound complications are relatively low with anterior plating, supporting this ankle arthrodesis procedure. Post- operative evaluation of ankle fusions using CT scan should be highly consider regardless of technique.

Arthroscopic Bone Marrow Stimulation for the Treatment of Osteochondral Lesions of the Talus Shows Promising Clinical Outcomes Over 10 Years

Category:Arthroscopy; AnkleIntroduction/Purpose:Arthroscopic bone marrow stimulation (BMS) has been considered as the 1st-line treatment for osteochondral lesions of the talus (OLT) with its simplicity, cost-effectiveness, low complication rate and successful clinical results in numerous studies. However, there were few studies which had investigated long-term clinical outcomes about the arthroscopic BMS. The purpose of this study is to evaluate the long-term outcomes of arthroscopic BMS for OLT and to identify prognostic factors that affect the outcomes.Methods:A retrospective analysis was performed for 202 ankles (189 patients) who underwent arthroscopic BMS as a primary surgery for the OLT between January 2001 and December 2008 with more than 10 years of follow-up. Visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales, Foot and Ankle Outcome Score (FAOS) were assessed as clinical outcomes and re-operation data were collected. The clinical scores were compared along the stream of time. Kaplan-Meier plot and log rank test showed survival outcomes of OLT in the long-term follow-up. Factors associated with revision surgery were evaluated with multivariate Cox proportional hazard regression model.Results:The VAS scales were improved from 7.11 +- 1.73 (preoperatively) to 1.51 +- 1.61 (3 to 6 years after BMS), and 2.00 +-1.67 (over 10 years after BMS) (P < 0.001). Also the AOFAS ankle-hindfoot scale were also improved from 58.39 +- 13.7373 (preoperatively) to 85.85 +- 10.31 (3 to 6 years after BMS), and 82.56 +- 11.62 (over 10 years after BMS) (P < 0.001). FAOS at final follow-up was compatible with those of other literatures with short- and mid-term follow-up. Re-operation rate was 5.94 % (12 / 202 ankles). According to multivariate regression analysis, significant factors associated with the revision surgery were large- size (greater than 150mm2) OLT (P = 0.009) and body mass index greater than 25 kg/m2 (P = 0.014).Conclusion::Arthroscopic bone marrow stimulation is an effective and reliable operative procedure for the primary treatment of osteochondral lesions of the talus with favorable long-term outcomes at a mean follow-up of 13.9 years. Therefore, we recommend this procedure for the 1st-line treatment of the OLT. Success of arthroscopic BMS depends on the size of the OLT and the body mass index of patients.

Modified Bunnell suture repair versus bundle-to-bundle suture repair for acute Achilles tendon rupture: a prospective comparative study of patients aged

BackgroundThis study aimed to compare the operative outcome of percutaneous repair (modified Bunnell suture technique) versus open repair (bundle-to-bundle suture technique) of acute Achilles tendon rupture.MethodsSeventy-two consecutive patients who underwent surgical treatment of Achilles tendon rupture were evaluated in this prospective study. Thirty-six patients were treated using the bundle-to-bundle suture technique (group A), and 36 patients were treated using the modified Bunnell suture technique (group B). All patients underwent functional examination comprising measurement of the calf muscle circumference and performance of the single-leg heel-rise test. The length and diameter of the Achilles tendon were compared between the injured and uninjured sides on magnetic resonance imaging. The number of single-leg heel rises (height > 5 cm) performed within 15 s was compared between the injured and uninjured sides. The ankle range of motion was also recorded. The Achilles tendon total rupture score (ATRS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale score, and visual analog scale (VAS) pain score were used to evaluate the clinical outcome at 12 months postoperatively.ResultsA total of 61 patients were followed up. The mean follow-up duration did not significantly differ between group A (23.73 ± 2.81 months) and group B (22.61 ± 3.96 months). However, there were significant differences between groups in the heel-rise test (group A, 1.74 ± 0.96; group B, 2.37 ± 1.42) and length of the Achilles tendon (group A, 11.98 ± 1.64 cm; group B, 11.11 ± 1.74 cm). The calf circumference of the injured side was significantly larger in group A than in group B (p = 0.043). The cross-sectional diameter of the Achilles tendon was significantly smaller in group A than group B. At final follow-up, there were no significant differences between the two groups in the ATRS, AOFAS score, or VAS score. One patient in group A had delayed wound healing, which resolved in 40 days.ConclusionsPatients with acute Achilles tendon rupture treated with open repair (bundle-to-bundle suture technique) achieved a better clinical outcome regarding the heel-rise test and calf circumference compared with those treated with percutaneous repair (modified Bunnell suture technique).Trial registrationChinese Clinical Trial Registry, ChiCTR2000035229, 8/4/2020, Retrospectively registered.

Comparison of suture-button and screw fixation in the treatment of ankle syndesmotic injuries: Cohort study protocol.

Background:Syndesmotic injuries account for a significant number of ankle injuries. There is no consensus regarding the recommended method of treatment. The purpose of this study was to evaluate:(1)functional outcomes,(2)implant survivorship,(3)complications, and(4)radiographic analysis in patients who underwent fixtion with either syndesmotic screw or suture-button technique by the same experienced surgeon.Methods:This study was performed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology checklist. The records of 200 patients with ankle fractures who had undergone surgical treatment in our clinics between January 2014 and January 2018 were retrospectively investigated. This retrospective cohort study was approved by the institutional review board in the 2nd Hospital of Jilin University. The primary outcome measure was the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale and the Foot Function Index. Secondary outcome measures included visual analog scale score, complications, range of movement of ankle, reoperations, and radiologic outcomes. For statistical comparison of the clinical and radiologic findings between the 2 groups, we used SPSS, version 21.0 (SPSS, Chicago, IL), statistical software. P Values of < .05 were considered statistically significant.Conclusion:The hypothesis was that the SB technique would achieve better functional outcomes as compared to the syndesmotic screw technique after surgery.Trial registration:This study protocol was registered in Research Registry (researchregistry5793).

Medium-term results of calcaneus lengthening in idiopathic symptomatic flat foot in children and adolescents.

Purpose Calcaneus lengthening can be used in symptomatic flat foot in children, but few details on its medium-term results and complementary procedures are available.MethodsA total of 20 flexible, symptomatic, idiopathic valgus flat feet (in 15 children; mean age 13.9 years (10 to 17)) were operated on. Complementary procedures were based on preoperative and intraoperative analyses. Radiographic measurements were obtained preoperatively and with at least four years follow-up.ResultsAt a mean of 8.3 years (4 to 15) postoperatively, 13 feet had good clinical and radiological results, with significant improvement in American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale scores and radiological measurements. Seven feet had residual pain. Six of them had no osteotomy of the first cuneiform.ConclusionCalcaneus lengthening with adequate complementary musculo-tendinous and/or bone procedures according to preoperative and intraoperative foot deformation leads to good medium-term results. Forefoot supination is the most frequent residual defect. If present intraoperatively, first cuneiform pronation-flexion osteotomy is indicated.Level of evidenceIV

Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans

BackgroundTo explore the application and clinical efficacy of surgical approach strategies in open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans.MethodsThis retrospective cohort study included data of 25 patients with closed complex tibial Pilon fractures treated from October 2011 to March 2014, including 19 males and 6 females aged 18–54 years (average 39.5 years). According to classification criteria of the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), 4 patients were type 43C1, 10 type 43C2, and 11 type 43C3. Surgical approaches were selected based on fracture line distribution and bone displacement revealed by axial CT scans, and an open reduction method was adopted for internal fixation of the bone plates. Postoperatively, Burwell-Charnley radiographic criteria were used to determine fracture reduction quality. Functional evaluation was performed using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Complications, fracture union time, and the AOFAS scores at last follow-up were recorded.ResultsThe 25 included patients were followed for 22–60 months postoperatively (average follow-up 33.9 months). Of these, 19 patients achieved anatomical reduction of the articular surface, 5 achieved good reduction, and one achieved fair reduction. Two patients developed superficial infection on the anteromedial incision and delayed union but recovered well after local dressing change and oral administration of antibiotics. Another patient developed deep infection on the anterolateral incision, which was controlled by debridement, catheter irrigation, and intravenous antibiotic injection. All fractures healed well and average union time was 2.8 months (range, 2–3 months). No fracture malunion or internal fixation failures were found at last follow-up. All 25 patients had AOFAS scores ranging from 80 to 100 at last follow-up (average 88.4). Overall, 15 patients were excellent, 10 good, and 0 fair or poor, with excellent and good rates of 100%.ConclusionsSurgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications.

Combined Posteromedial and Posterolateral Approaches for 2-Part Posterior Malleolar Fracture Fixation.

This study investigated the clinical efficacy of combined posteromedial and posterolateral approaches for repair of 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. This case series report included 27 Weber B with Haraguchi type II patients with medial and lateral malleolar fractures combined with 2-part posterior malleolar fractures. Patients were treated with open reduction and internal fixation through a combination of posteromedial and posterolateral approaches from January 2015 to January 2018. There were 11 males and 16 females, with an average age of 61.5 years (range, 53-67 years). The procedures were performed on prone patients under spinal anesthesia. The medial, lateral, and posterior malleolar fractures were exposed through posteromedial and posterolateral approaches performed at the same time. The lateral malleolar fracture was fixed using a plate, the medial malleolar fracture was fixed using screws, and the posterior malleolar fracture was fixed using a plate or cannulated screws according to the size of the fragments. We performed follow-up on 22 patients for an average of 30 months (range, 18-48 months). Primary healing of the incisions was achieved in all cases, and no infection was found. The mean time of bone union was 12.5 weeks (range, 10-15 weeks). The mean time from the operation to full weightbearing was 13 weeks (range, 11-16 weeks). We used the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale to score patient outcomes; the mean score was 85.4 (range, 80-92) at the final follow-up. No significant pain was found at the final follow-up. This study showed that satisfactory outcomes were achieved with combined posteromedial and posterolateral approaches. Therefore, we believe this approach was a good alternative strategy to repair 2-part posterior malleolar fractures associated with medial and lateral malleolar fractures. Level IV, retrospective case series.

Achilles tendon-splitting approach and double-row suture anchor repair for Haglund syndrome

BackgroundHaglund syndrom is characterized as a painful posterosuperior deformity of the heel with possible causes as tight Achilles tendon, high-arched foot and tendency to walk on the outside of the heel. Surgical treatment may be recommended in cases where of insufficient response to nonoperative treatment. This study aims to evaluate the clinical and radiographic results of central Achilles tendon splitting and double-row suture anchor technique in the surgical treatment of patients with Haglund syndrome. Methods27 patients with Haglund syndrome who underwent central Achilles tendon splitting and double-row suture anchor were retrospectively evaluated. The results were evaluated by the pre- and post-operative American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and visual analogue scale (VAS). All patients were evaluated radiographically to assess lateral talus-first metatarsal angle (TMTA), Calcaneal pitch angle (CPA), and the Fowler-Philip angle (FPA) preoperatively and postoperatively. ResultsThe mean preoperative AOFAS score was 47 ± 7 points; at the end of the follow-up period, it increased to 92 ± 4 points (p < 0.001). The mean preoperative VAS score was 9 ± 0.9 points; at the end of the follow-up period, it was 2 ± 0.6 points (p < 0.001). The lateral TMTA (preoperative: 5° ± 2°; follow-up: 4° ± 2°; p < 0.001), CPA (preoperative: 21° ± 5°; follow-up: 20° ± 5°; p = 0.005) and FPA (preoperative: 55° ± 6°; follow-up: 32° ± 3°; p < 0.001) values decreased at the end of the follow-up period. ConclusionIn the absence of an improvement to nonoperative treatment methods, central Achilles tendon-splitting approach appears to be an effective and safe treatment option. Level of evidenceLevel IV, retrospective case series.

Silver acupuncture for myofascitis: A protocol for systematic review and meta-analysis.

Background:This systematic review aims to evaluate the effectiveness and safety of silver acupuncture in treatment of myofascitis.Methods:Electronic databases of all silver acupuncture for myofascitis will be searched at PubMed, Cochrane Library, Springer, Embase, China National Knowledge Infrastructure, Wanfang, and Chinese Biological Medical disc from inception to March 31, 2020, with language restricted in Chinese and English. The primary outcome is visual analog scale, a short pain scale with sensitivity and comparability. Secondary outcomes included Clinical Assessment Scale for Cervical Spondylosis, Japanese Orthopaedic Association Scores, Oswestry dysfunction index, American Orthopaedic Foot and Ankle Society-Ankle Hindfoot scale, Foot and Ankle Ability Measure, The Cumberland ankle instability tool, Pittsburgh sleep quality index, self-rating anxiety scale, self-depression rating scale, and follow-up relapse rate. The systematic review and searches for randomized controlled trials of this therapy for myofascitis. The Cochrane RevMan V5.3 bias assessment tool is implemented to assess bias risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). Mean difference, standard mean deviation, and binary data will be used to represent continuous results.Results:This study will provide a comprehensive review and evaluation of the available evidence for the treatment of myofascitis with this therapy.Conclusion:This study will provide new evidence to evaluate the effectiveness and side effects of silver acupuncture for myofascitis. Due to the data are not personalized, no formal ethical approval is required.Ethics and dissemination:There is no requirement of ethical approval and it will be in print or disseminated by electronic copies.PROSPERO registration number:CRD42020151476