AOFAS Score Research Articles

The Interosseous Talocalcaneal Ligament Injury Findings in Lateral Ankle Instability with Sinus Tarsi Pain

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Lateral ankle instability (LAI) with concomitant sinus tarsi pain is a quite common finding. However, there has been few studies evaluating the subtalar arthroscopic findings for LAI with sinus tarsi pain. The purpose of the study is to evaluate the ST arthroscopic findings of chronic ankle instability with sinus tarsi syndrome. We hypothesized that chronic ankle instability with sinus tarsi pain is highly associated with interosseous talocalcaneal ligament (ITCL) tear which may be the cause for subtalar instability (STI).Methods:The study is based on 104 LAI with sinus tarsi pain ankles who had performed lateral ankle ligament stabilization. i.e. Modified Brostrum procedure (MBP), lateral ankle reconstruction (LAR) or subtalar ligament reconstruction (STR) with subtalar arthroscopic (STA) examinations from 2007 to 2018. The STA has been mainly focused on the ITCL injury and debridement of the ITCL tears and synovitis were performed when present. VAS pain score, AOFAS, Karlsson-Peterson functional score were evaluated.Results:According to the ST arthrosopic findings, ITCL tears were present in 94% (98/104) of the ankles. Lateral ankle instability (LAI), subtalar instability (STI), and LAI and STI combined were 32%, 30% and 38% respectively. MBP, LAR and STR were performed in 23%, 22% and 56% respectively. VAS pain score was improved from 5.3 to 1.9 (p<0.05). AOFAS score was improved from 67 to 89 (p<0.05), while K-P score improved from 50 to 83 (p<0.05). Sinus tarsi pain was relieved in 65% of the patients.Conclusion:We found the high incidence of the ITCL tears (98%) in LAI with sinus tarsi pain, and also diagnosed the STI in 68% of the ankles. We believe that in case of LAI with sinus tarsi pain, ST arthroscopic evaluation for ITCL tears is necessary and the possibility

Minimum 2 Year Prospective Follow-Up on a Laterally Placed Trabecular Metal Total Ankle Arthroplasty

Category:Ankle, Ankle ArthritisIntroduction/Purpose:The laterally placed trabecular metal ankle replacement is placed using a jig and a fibular osteotomy. The tibia and talus are reamed to match the curved contour of the replacement. The lateral approach was advocated to reduce the wound complications of the anterior approach. Additional fixation is achieved using two rails on the tibial and talar component.This study outlines the outcomes of 121 ankles followed prospectively with minimum 2 years follow up.Methods:121 total ankles were consented to enrollment in a prospective study on outcomes. 10 centers were involved in the prospective study. Enrollment was from 2014 to 2016. 3 patients underwent revision and 5 withdrew (1 death, 2 lost to follow up and 2 requested discontinuation).Demographics were obtained at baseline. The average age was 59.9 at the time of surgery. 48% were male and BMI averaged 29.2. 12.4% had inflammatory arthropathy. EQ5D, AOFAS, AOS scores were obtained preoperatively and at 6 weeks, 6 months, and yearly there after. Revision of metal components for infection or loosening were secondary end points. Statistical significance was tested by the Wilcoxon Signed Rank Test 26 and set at p= 0.05. 95% confidence intervals are given.Of 113 cases, 113 were followed at 6 weeks, 113 at 1 year, and 100 at 2 years and 67 at 3 years.Results:AOS Outcomes improved from 59.7 (SD 20.6) to 22 (SD 18) at 6 months, 18.6 (SD 19.6) at 1 year, 19.8 (SD 21) at 2 years and 21.3 (SD 25) at 3 years. AOFAS scores and EQ5 D scores showed similar improvements at all time points. The improvements were significant compared to baseline at all time points (see figure).Survivorship was .98 at 1 year (CI .92 to .99), and .96 at 2 and 3 years (CI .90 to .99). 3 components were revised, a tibial component (loosening), a talar component (instability), and a polyethylene liner (infection).Conclusion:The laterally placed trabecular metal total ankle arthroplasty has demonstrated reliable improvements in outcome and an excellent survivorship at minimum 2 years follow up. Longer term follow up and larger series will be required to clearly outline its outcome. This early outcome demonstrates very promising outcomes at 3 years and low revision rates.

Functional outcome in non-operative management of displaced Intra-articular calcaneal fractures (Diacf’s)

Displaced intra-Articular calcaneus fractures (DIACFs) represent a source of potential disability to the patient, economic burden to the society and a treatment challenge to the average orthopedic surgeon. Despite lack of evidence whether operative management is superior to non-operative management, there is a trend favoring the former. This was a 2 year retrospective study & a 1 year prospective study of 37 patients with 44 displaced intra-articular calcaneal fractures managed non-operatively to observe the functional outcome of intra-articular fractures of calcaneus in adults in an Indian population. Each patient was followed up at 3, 6, 9 months and 1 year from injury. Appropriate lateral and axial view x-rays done at 3 months and 1 year follow-ups and radiological assessment done. Retrospective patients from previous two years were re-assessed with appropriate x-rays and functional outcome scoring done. The AOFAS score was assessed and recorded at each of these follow-ups. In our study of 37 patients with 44 displaced intra-articular calcaneal fractures, AOFAS clinical outcome at 1 year was excellent in 7 cases (15.91%), good in 29 cases (65.91%), fair in 7 cases (15.91%) and poor in one case (2.27%). Complications were seen in 11 patients at one year follow-up but none of the patients with complications required any surgical intervention and the average AOFAS functional outcome score at 1 year was 80.43 (Good). We hereby conclude that non-operative management of intra-articular calcaneal fractures continues to be an acceptable mode of treatment with low complications and comparable functional outcome with less complications.

Functional and Radiographic Outcomes after the Removal of Suture-Button Fixation Device in the Treatment of Syndesmosis Diastasis

Category:TraumaIntroduction/Purpose:Suture-button fixation device (TightRope, Arthrex, Naples, Florida) is devised to obviate the need for second operation for removal in the treatment of syndesmosis diastasis, but considerable removal rate has been reported.Nevertheless, functional and radiographic outcomes after suture-button fixation device removal has not yet been well documented. Therefore, the purpose of this study is to investigate the functional and radiographic outcomes of syndesmosis fixation treated with suture-button device before and after device removal.Methods:The records of 30 patients with syndesmosis injury who underwent suture-button fixation and later device removal between August 2009 and September 2017 were investigated. The mean postoperative time to device removal was 11.9 months (range, 7-19). In plain radiograph, tibiofibula clear space (TFCS), tibiofibula overlap (TFO), and medial clear space (MCS) were measured at three specific follow-up period; immediate postoperative (F1), just before device removal (F2), and at least three months after device removal (F3). For subgroup of 18 patients with CT scans, the Anterior to posterior (A/P) ratio (Normal range: 0.8 -1.2) was measured to investigate malreduction of syndesmosis and they were divided into two groups according to their accuracy of reduction. Additionally, functional outcomes were recorded and compared using American Orthopedic Foot and Ankle (AOFAS) score. Repeated measurement analysis of variance was performed to statistically compare the data and statistical significance was set at P < 0.05.Results:In plain radiographs, TFCS, TFO, MCS at three specific follow-up period showed no significant differences. In CT analysis at immediate postoperative period, 6 cases (30%) revealed malreduction, but 5 of them showed spontaneous reduction at follow- up just before device removal. Malreduced patients (n = 6) had a mean A/P ratio of 1.28 (range, 0.78 -1.52) at F1, 1.08 (range, 0.81- 1.21) at F2, and 1.08 (range, 0.83 -1.22) at F3 (F1, F2: p = 0.021, F1, F3: p = 0.032, F2, F3: p > 0.05). Patients with initial adequate reduction (n = 12) continued to have a reduced syndesmosis during the follow-up period and after the device removal. The AOFAS score did not change significantly before and after removal.Conclusion:Our investigation showed that the removal of suture-button device for syndesmosis fixation at average 1-year postoperative time does not bring out reduction loss or functional changes. Thus, removal is advisable for the patients with irritation or discomfort related to device. Furthermore, malreduced syndesmosis after tightrope fixation may have possibility of spontaneous reduction during the follow-up period.

Subtalar Arthroereisis for Correction of Flexible Flatfoot in Children: A Retrospective Comparative 5- Year Follow-Up Study

Category:HindfootIntroduction/Purpose:Subtalar arthroereisis for the treatment of flexible flatfoot in children is controversial. Self-locking implants are utilised worldwide aiming to limit subtalar joint movement and foot pronation. Recently two reviews have focused on the lack of comparative studies in literature and the poor-quality evidence available regarding these devices. In this study, performed on children diagnosed with flexible flatfoot and treated with subtalar arthroereisis, the two aims were: 1) to compare pre and postoperative radiographic measurements in order to assess the efficacy of arthroereisis in the correction of flatfoot; 2) to compare clinical outcomes between patients operated and normal controls at mid-term follow-up. Our hypothesis was that subtalar arthroereisis achieves flatfoot correction and that at the longest follow-up patients operated do not differ from normal controls.Methods:This is a single-centre single-surgeon retrospective comparative study, ethics committee approved. Fortysix feet from 24 continuous patients (5 females; 22 left and 24 right) treated at mean age of 11 years (range 8 to 15) with subtalar arthroereisis for flexible flatfoot were reviewed at a follow up of 51 months (range, 25 to 73) and compared with 23 feet from 13 controls (ratio 2:1, matched by age and body mass index). Radiographically, the following measurements were recorded and compared on pre and postoperative films: talonavicular coverage angle and talocalcaneal divergence angle on dorsoplantar view; Dijan-Annonier angle, Méary line, calcaneal pitch and talocalcaneal divergence angle on lateral views. Clinically, a goniometric assessment of ankle and hindfoot range of motion, AOFAS score and VAS-FA score were utilised in patients operated and normal controls (mean values ± standard deviation). Paired 2-tailed Student t tests were used to assess differences.Results:All radiographic measurements demonstrated improvement after surgery (p .001), except for the talonavicular coverage angle (p .812). At longest follow-up, patients and controls had 35.8° ± 3.8 vs 44.1° ± 2.8 of plantarflexion (p .092), 13° ± 1.7 vs 14.5° ± 2 of dorsiflexion (p .312), 16.5° ± 2 vs 18.7° ± 1.6 of inversion (p .124) and 10.6° ± 1.6 vs 11.8° ± 1.3 of eversion (p .073). AOFAS values were similar at 94.7 points ± 3.9 (patients) and 99.3 points ± 1.3 (controls) (p .083). All the items from VAS-FA showed no differences in two groups, except for frequency and intensity of pain during physical activity (p .053 and p .032, respectively) and ability to stand on leg for long time (p .004).Conclusion:Our study showed that subtalar arthroereisis significantly improves flexible flatfoot deformity, with a satisfactory correction of hindfoot alignment and longitudinal arch but no significant amelioration of the foot abduction. Although at 4 years of time patients do clinically well, they may still experience some limitations compared to normal individuals. It is therefore crucial to consider these anatomical and functional elements when counseling young patients and family about surgery, in order to address preoperatively and realistically their expectations.

A Clinical Sign for Diagnosis of the Hypermobile First Ray

Category:Midfoot/ForefootIntroduction/Purpose:The aim of this study is to describe a new clinical sign for diagnosis of hypermobility of the first tarsometatarsal joint (TMTJ). We propose a method of qualifying and quantifying the degree of hypermobility of the first tarsometatarsal joint which is easily reproducible and does not require the use of specific medical devices.Methods:23 patients were examined and graded positive for hypermobility of the first ray by a heterogenous group of doctors using this method. This clinical sign of hypermobility of the 1st tarsometatarsal joint is then quantified by measuring the amount of dorsal displacement using a bedside ruler. All patients underwent Lapidus procedure for fusion of the 1st tarsometatarsal joint. Clinical results are documented at 2 years post surgery.Results:All 23 patients diagnosed with hypermobility of the first ray had a mean dorsal displacement of 7.95 ± 0.20 mm. Clinical results showed significant improvement in visual analogue scores and AOFAS scores at 2 years.Conclusion:Diagnosis of the hypermobility of the first ray can be made clinically using this easily reproducible method. The degree of subluxation of the 1st tarsometatarsal joint can be quantified without the use of cumbersome medical equipment.

Interpositional Arthroplasty for Hallux Rigidus: A Systematic Review

Category:Midfoot/ForefootIntroduction/Purpose:Hallux rigidus is a common degenerative joint condition of the foot. In advanced stages of the disease, extensive procedures have been utilized including Keller arthroplasty, interpositional arthroplasty (IPA), arthrodesis, total joint replacement or synthetic cartilage replacement. IPA is a surgical procedure that attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, there is still a paucity of overall clinical data regarding outcomes and complication rates following IPA procedure for the treatment of hallux rigidus.The purpose of the current study was to systematically review the outcomes of IPA in the treatment of hallux rigidus.Methods:A systematic search of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes collected and analysed included: AOFAS score, VAS score, SF36 score, range of motion, radiographic parameters, and postoperative complications. The level and quality of evidence were recorded and assessed.Results:Sixteen studies with a total of 433 patients met inclusion/exclusion criteria. The mean AOFAS improved from 56.8±7.3 (range, 43.2-64.3) preoperatively to 84.0±6.7 (range, 71.6-90.0) postoperatively. The preoperative weighted mean total ROM was 37.7±16.2 degrees and the postoperative weighted mean total ROM was 60.3±13.4 degrees. Five studies examined joint space narrowing on plain radiographs. The mean preoperative joint space was 1.2±0.2 mm (range, 1 -1.5) and the mean postoperative joint space was 2.5±0.5 mm (range, 1.9-3). The complication rate was 18.2% with metatarsalgia as the most commonly reported complication. One study was Level III and 15 studies were Level IV.Conclusion:This systematic review demonstrates improvement in functional and ROM outcomes following IPA. The procedure however has a high complication rate. There is a low level and quality of evidence in the current literature with inconsistent reporting of data. Therefore, further well designed studies must be carried out to determine the efficacy of IPA in the treatment of hallux rigidus.

Arthroscopic Repair of Lateral Ankle Ligament for Chronic Lateral Ankle Instability: A Systematic Review and Meta-Analysis

Category:Ankle, Arthroscopy, SportsIntroduction/Purpose:Open modified Broström-Gould procedure is generally accepted as the gold-standard treatment for chronic lateral ankle instability. Recently an arthroscopic lateral ankle ligament repair technique has become increasingly popular in an effort to reduce post-operative pain and facilitate early recovery. The purpose of the current systematic review was to evaluate the current evidence on arthroscopic lateral ankle ligament repair techniques and to compare the clinical outcomes of arthroscopic and open techniques for chronic lateral ankle instability with meta-analysis.Methods:A systematic search of MEDLINE and EMBASE databases was performed during August 2017. Included studies were evaluated with regard to level of evidence (LOE) and quality of evidence (QOE) using the Coleman Methodology Score. Variable reporting outcome data, clinical outcomes, and percentage of patients who returned to sport at previous level were also evaluated. Comparative studies were compared using RevMan version 5.3, and a p-value of < 0.05 was considered statistically significant.Results:Twelve studies for a total of 421 ankles were included; 92% of studies were LOE III or IV and the QOE in all studies was of poor or fair quality. There were three comparative studies of open and arthroscopic repair procedures, with two Level III studies and one Level I study. There was a significant difference in favor of arthroscopic repair at final follow-up for the Karlsson- Peterson score (MD; 2.59, 95%CI, -0.19 to 2.36, I2=0%, p=0.10) and the AOFAS score (MD; 1.50, 95%CI, 0.41 to 2.59, I2=0%, p=0.007) in the comparative studies. The overall complication rate was 13.4% in the included studies but in the comparative studies there was no statistically significant difference between open and arthroscopic repair (12.1% vs 11.4%, p=0.90).Conclusion:The current systematic review demonstrated that arthroscopic lateral ankle ligament repair may yield favorable clinical outcomes and may be superior to open procedure in the short-term, but there is no clinical evidence to support the advantages of the arthroscopic procedure over the open procedure in the mid- long-term follow-up. There was a relatively high complication rate associated with the arthroscopic procedures, with a 13.4% complication rate, although recent comparative studies demonstrated similar complication rates.

Percutaneous Chevron/Akin (Peca) Versus Open Scarf/Akin (Sa) Osteotomies Treatment in Hallux Valgus: A Systematic Review and Meta-Analysis of 137 Feet

Category:BunionIntroduction/Purpose:The surgical treatment of hallux valgus presents several techniques described in the literature. Recently the percutaneous technique appeared as a less invasive option in the correction of the deformity and more and more used by the surgeons.Methods:The meta-analysis was performed through studies found from the systematic review of articles included in electronic databases (Medline, Scopus, Embase and the Cochrane Library) until June 2018 (Systematic Review Registry PROSPERO: CRD42018096613). The pooled analysis was synthesized from clinical outcomes such as visual analogue scale of pain and AOFAS score, radiographic outcomes and evaluation of complications, with 95% confidence interval. The pooled data were weighted using the fixed model effect.Results:Two studies, including 137 feet with hallux valgus diagnosis were added in the analysis, comparing open surgery using the Scarf and Akin (SA) technique versus the percutaneous Chevron and Akin (PECA). In the synthesis of the result, pain in the perioperative period was lower in the PECA group, with a reduction of 1.96 points in the fixed effect model (95% CI = -2.28 to - 1.65, p = 0.53, i2 = 0%, t2 = 0), without presenting differences between techniques in the radiographic result, nor in the risk of complications. The PECA technique demonstrated longer radioscopy time when compared to SA.Conclusion:The use of the percutaneous method (PECA) to correct hallux valgus when compared to the open technique (SA) demonstrated less pain in the perioperative period, similar potential of radiographic correction and an equal risk of complications, with a longer radioscopy time.

Bilateral Sander IV calcaneus fractures: Primary fusion or fixation?

Category:TraumaIntroduction/Purpose:Primary subtalar fusion for Sander IV calcaneus fractures was considered to be the standard of care till recent past. Presently debate is on whether to manage Sander IV calcaneus fracture cases with primary subtalar fusion or with open reduction and internal fixation. Bilateral Sander IV calcaneus fractures are seen in cases with fall from height. No study has ever been conducted till date to compare the results of primary fusion of a Sander IV calcaneus fracture on one side and open reduction and internal fixation on another side in cases with bilateral Sander IV calcaneus fractures. We present a study comparing the results of primary fusion versus open reduction and internal fixation for bilateral sander IV calcaneus fracture cases.Methods:Twelve cases with bilateral closed Sander IV calcaneus fractures where included in the present study. Cases were operated between four to six weeks by a single surgeon after the appearance of wrinkles. All right sided fractures underwent open reduction and internal fixation with proximal tibia grafting. While all left-sided fractures underwent subtalar fusion with the use of ipsilateral anterior iliac crest grafts. Cases were followed up for 24 months.Results:Though operative time was more in the fusion group wound problems were equal in both the groups. Four months of average time to union was the same in both the groups and so was time to return to work. At two years, the AOFAS score was slightly better in the fusion group but it was not statistically significant.Conclusion:Primary subtalar fusion is with almost similar results as those with open reduction and internal fixation in bilateral Sander IV at 24 months. Long term follow up with more number of cases is required to prove the benefit of one over other.

Comparative study between the efficacy of platelet-rich plasma therapy and corticosteroid injection in the treatment of planter fasciitis

Background: Planter fasciitis is the common cause of heel pain and is the disabling disease in its chronic form. Various treatment modalities are available including medical therapies and surgical procedures. This study was designed to compare the efficacy of PRP therapy with corticosteroid injection in the treatment of chronic planter fasciitis. Methods: Total of 40 patients with chronic plantar fasciitis were included in the study and were divided into 2 groups. In the PRP group (n=20), 3ml PRP preparation was made from the patient’s blood and injected in a single dose. In the steroid group (n=20), a single dose of 2ml (40mg) methylprednisolone was given. Clinical evaluation was made using the American Foot and Ankle Score (AFAS) and the visual analog scale (VAS).Results: Both groups were similar in terms of age, gender and side involvement. Mean preinjection VAS, AOFAS scores in steroid and PRP group were 8.1±1.2, 68.1±9.5 and 7.9±1.2, 67.5±9.2 respectively. Post injection the scores improved in both the groups, with slightly more improvement of scores in PRP group than in steroid group, however no significant difference in scores of VAS and AOFAS could be detected between the two groups.Conclusion: The local injection with steroid or PRP preparation was equally effective in terms of pain and functional outcomes in the treatment of chronic planter fasciitis.Level of evidence: II Prospective randomized clinical trail.

Intra-Operative 3-Dimensional Imaging (O-arm) in Foot and Ankle Trauma Surgery: Report of 2 Cases and Review of the Literature

Background: Intraoperative two-dimensional (2D) fluoroscopy is the standard imaging modality available to orthopaedic surgeons worldwide. It is well-accepted, however, multiplanar 3 dimensional (3D) CT scanning is superior to 2D imaging for visualising joint surfaces and is now a fundamental feature of the pre-operative planning of intra-articular fractures. Objective: We present two cases in which the use of 3D intraoperative imaging and the O-arm® (Medtronic, Minneapolis, USA) led to immediate intraoperative revision to optimise fixation and articular congruity. A review of the current literature is also provided. Methods: During the trial period of the O-arm at our major trauma centre, intra-operative imaging was used in the lower limb trauma setting. The O-arm was used intra-operatively in a comminuted pilon fracture and a displaced talus fracture. We recorded all the intra-operative events, including quality of reduction, implant positioning and operation time. Each patient was followed-up for 12 months post-operation and was finally assessed with x-rays and the AOFAS score. Results: In both the cases, either fracture reduction or the implant position/usage that was observed with 2D fluoroscopy was revised following a 3D intra-operative scan. No postoperative complications were noted and the healing process was uneventful. X-rays at the final follow-up were excellent and acceptable for the talus and pilon fracture, respectively, with corresponding clinical results and AOFAS score. Conclusion: Although frequently used in spinal surgery, to the best of our knowledge, the use of intra-operative 3D techniques in lower limb trauma is sparse and sporadically reported. We present our cases in which the most current innovative imaging techniques influenced intra-operative outcomes without compromising patient safety. We feel that this is a real example of how innovation can positively influence patient care.

Comparison of deltoid ligament repair and syndesmotic fixation in malleolar fractures

Introduction: The aims were to assess residual deltoid ligament instability after lateral malleolus osteosynthesis and to compare the outcomes of deltoid suture and syndesmotic fixation. Methods: A consecutive series of 65 eligible patients with a displaced or minimally displaced fibula fracture identified on a stress radiograph were prospectively enrolled. The patients were randomized into two groups, namely, group I (deltoid repair) and group II (syndesmotic fixation). We assessed the competence of the deltoid ligament intraoperatively using a manual stress test. Only the patients with residual medial instability (Medial Clear Space greater than 4 mm) were randomly assigned for treatment by deltoid ligament repair with anchor or syndesmotic fixation. Results: Of all the patients, 60 (92.2%) had positive preoperative manual stress test results. After fracture osteosynthesis, the test results were still positive in 13 (21.6%) patients, 8 (13.3%) patients from group I, both superficial and deep layers sutured with a bone anchor, and 5 patients (8.3%) from group II, stabilized with a syndesmotic 4-cortical screw. At the end of the surgery, a new manual stress test was performed, which proved stability in all the patients. The average follow-up period was 23.5 months. In groups I and II, the AOFAS scores were 95 and 93, the EQ-5D measures were 0.758 and 0.743, the visual analogue scale (VAS) scores were 16.7 and 19.2, and the Medial Clear Space values were 2.7 ± 0.5 mm and 2.6 ± 0.4 mm, respectively, without statistically significant differences. Conclusion: In 21.6% of cases, residual medial instability persisted after osteosynthesis of the lateral malleolus. The deltoid repair and syndesmotic fixation groups showed similar functional and radiological outcomes. Level of Evidence II; Therapeutic Studies; Prospective Comparative Study.

Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature

ObjectiveThe aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation. MethodsWe searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well. ResultsAverage AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant. ConclusionPercutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved. Level of EvidenceLevel III, Therapeutic Study.

Arthroereisis for Symptomatic Flexible Flatfoot Deformity in Young Children: Radiological Assessment and Short-Term Follow-Up

The purpose of this study is to recognize those young patients with symptomatic flexible flatfoot deformity who need treatment and to provide radiological evidence that arthroereisis is capable of relocating the talus properly over the calcaneus. We included 28 feet in 14 children who underwent subtalar arthroereisis in association with percutaneous triple-hemisection Achilles tendon lengthening. Selected for arthroereisis were children with symptomatic flexible flatfoot deformity who complained of foot and leg pain, had decreased endurance in sports activities and long walks, who did not respond to conservative treatment modalities for at least 6 months, and in whom at radiological assessment on stance position with the medial arch support orthosis the talonavicular joint lateral subluxation still remained, with Meary's angle in anteroposterior (A/P) and lateral view remaining increased. The mean age at surgery was 10.71 ± 1.58 (range 8 to 14) years. The minimum follow-up duration was 19 months, with mean follow-up duration of 35.14 ± 9.82 (range 19 to 60) months. For estimation of the efficacy of the surgical procedure, the American Orthopaedic Foot and Ankle Society (AFOAS) rating scale was used preoperatively and postoperatively in all patients. The mean preoperative AFOAS ankle-hind foot rating score was 65.14 ± 7.16 (range 58 to 75) points. The mean postoperative AFOAS score was 88.851 ± 5.61 (range 83 to 97) points and the 2-tailed p value <.0001. After arthroereisis surgical treatment, all AOFAS scores and all foot angles improved significantly, except the calcaneal inclination angle which improved slightly.

Fully threaded headless compression screw versus partially threaded cancellous lag screw in medial malleolus fractures: clinical and radiological outcomes

The aim of this study was to evaluate the clinical and radiological results of medial malleolar fractures, which were treated with fully threaded headless compression screws and to compare the clinical and radiological results of this screws and partially threaded cancellous lag screws. Sixty-one patients who attended the final follow-up examination were included in the study. Group 1 comprised 29 patients applied with fully threaded headless compression screws and Group 2 comprised 32 patients with partially threaded cancellous lag screws. Radiological evaluation was made with standard radiographs. The clinical evaluations were applied using the AOFAS ankle hindfoot scale. Pain or sensitivity by touching over the medial malleolus was recorded and scored according to Visual Analog Scale. No significant differences were determined between the groups with respect to age, gender, fracture type, follow-up time, bone union time and AOFAS scores. The medial sensitivity associated with implant irritation was significantly lower in Group 1. There was no need for removal of the fixation material in any patient of Group 1. The results of this study showed satisfactory results in the two fixation techniques in medial malleolar fractures. However, the rates of medial sensitivity associated with implant irritation were lower in the group where fully threaded headless compression screws were used. Therefore, to prevent postoperative patient dissatisfaction caused by persistent medial sensitivity associated with implant irritation, despite successful surgical treatment, the primary choice may be fully threaded headless compression screws.

Clinical investigate of functional exercise immediate after operation for Achilles tendon rupture

To investigate clinical effect of partly weight-bearing walking and functional exercise immediatly after operation for Achilles tendon rupture(ATR) on function of ankle joint and rate of fragmentation of Achilles tendon, through comparing effect of partly weight-bearing walking and functional exercise immediatly at 2 weeks after operation for Achilles tendon rupture. Sixty-four patients with ATR selected from March 2012 to March 2013 were randomly divided into two groups. There were 34 patients in treatment group, including 18 males and 16 females with an average age of 41.4±7.6, they began to do functional exercise and walk on fields with partly weight-bearing at two days after operation; there were 30 patients in control group, including 16 males and 14 females with an average age of 39.9±7.6, and they were immobilized with plaster in plantar flexion at two weeks after operation, and started to do functional exercise and walk on fields with partly weight-bearing at two weeks after operation. Two groups were performed by the same doctor with the same operation. The rate of fragmentation of Achilles tendon, and AOFAS score and complications between two groups were observed and compared. AOFAS score in treatment group at two weeks after operation was 74.3±3.9, which in control group was 71.7±4.2, and had statistical differences between two groups; AOFAS score in treatment group at one year after operation was 93.3±3.9, which in control group was 92.0±4.1, and had no statistical significance. No Achilles tendon fragmentation in treatment group occurred at three years after operation, and 1 patient occurred in control group. Two patients in treatment group occurred complications after operation, and 1 patient occurred in control group, however, there was no statistical significance between two groups. Functional exercise immediate after operation for Achilles tendon rupture(ATR) patients in the early days, the AOFAS scores is higher than the fixing for two weeks, and does not increase the rate of fragmentation of Achilles tendon and complication after operation, and benefits for function recovery.

Chevron osteotomy versus Scarf osteotomy for the efficacy of radiographic and clinical in moderate and severe hallux valgus:a systematic review

To evaluate efficacy of radiographic and clinical of Chevron osteotomy versus Scarf osteotomy for hallux valgus at moderate and severe degree. Randomized controlled trial (RCT) about Chevron and Scarf osteotomy for hallux valgus, in PubMed, Embase, Cochrane Library, CBM, CNKI, Wanfang Data were searched by computer from establishing database to June 2018. According to inclusion and exclusion criteria, two researchers independently screened the literatures, evaluated risk of bias and extracted related observation index, RevMan 5.3.5 software was used to perform Meta-analysis. Postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), AOFAS score, complications and patients' satisfaction degree between Chevron and Scarf osteotomy. Six RCT literatures were included, involving 507 patients, 92.5% patients were at moderate and severe degree, and 261 patients were performed by Chevron osteotomy and 246 patients were performed by Scarf osteotomy. Meta analysis results showed that Chevron osteotomy was better than Scarf osteotomy in correcting HVA [MD=-1.95, 95%CI(-2.64, -1.27), P<0.000 01]. While there were no statistical differences in IMA [MD=-0.42, 95%CI(-1.04, 0.21), P=0.19], DMAA[MD=0.78, 95%CI(-0.72, 2.29), P=0.31], AOFAS score [MD=2.47, 95%CI(-2.38, 7.33), P=0.32], complications [RR=1.09, 95%CI(0.54, 2.20), P=0.82], and patients' satisfaction degree [RR=1.00, 95%CI(0.96, 1.05), P=0.92]. Chevron osteotomy, which has advantages in simple operation, shorten metatarsal bone, less trauma, was better in correcting HVA of hallux valgus at moderate and severe degree, and had similar effects in IMA, DMAA, AOFAS score, complications and patients' satisfactory degree.

Ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures

To explore clinical effects of ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures. From January 2015 to March 2017, 20 patients with acute closed Achilles tendon rupture were treated by minimal traverse-cross technique repair with ultrasound guided. Among them, including 13 males and 7 females, aged from 28 to 49 years old with an average of(31.3 ±4.5) years old. All patients were single side injury. Fifteen patients on the left side and 5 patients were on the right side. The time from injury to operation ranged from 1 to 5 days with an average of (2.5±0.7) days. Operative time, postoperative complications were observed, and AOFAS score before and after operation at 12 months were compared. All patients were followed up for 12 to 27 months with an average of(15.2±4.9) months. Operative time ranged from 33 to 65 min with an average of(43.7±5.6) min. Incision of one patient were continued oozing and improved after changing dressings, other patients were healed at stage I. No sural nerve irritation symptoms and palindromic rapture of heel tendon occurred. AOFAS score was improved from 65.2±7.4 before operation to 97.7±4.7 after operation at 12 months (t=22.5, P<0.01); 18 patients got excellent results and 2 good. Ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures, which promise minimal incision, protect sural nerve, ensure quality of tendon anastomosis and fixation, and is a ideal method for repairing acute closed Achilles tendon ruptures.

Observation of different modalities of treatment in closed pilon fractures in adults

Tibial Pilon fractures are challenging injuries for the orthopaedic surgeon to manage successfully. The main challenges in the management of these fractures are compromised skin and soft tissue envelope, comminuted fracture, displacement of fragments, metaphyseal region of fracture. In our prospective study, we have done different modalities of treatment of closed pilon fracture with no or minimal soft tissue injury in adults and observed the final functional score and complication rates. 20 patients were followed up to 12-24 month.12 cases (60%) unite in between 16-20 weeks,4 cases (20%) are unite in 12-16 weeks and rest 20% cases unite after 20 weeks. Complication like superficial thrombophlebitis in 2 cases which treated conservatively. Superficial skin infection in one case of primary ORIF and 2 cases of MIPPO. Deep infection occure in 1 case of ring fixator. Final functional outcome in our study according to AOFAS Score, 11 patients (55%) had excellent result and 6 cases (30%) good& 3 had fair (15%) result.