Fibula Research Articles

The anatomical basis and clinical application of improved fibula flap in repairing the heel defect

Objective To explore the methods and effects of using improved fibular flap to repair heel defect. Methods Adult leg specimens of 20 cases with red latex. Anatomical observation of the source of the peroneal artery, direction and distribution. In March, 2009 to October, 2012 6 cases of heel defect patients, were repaired with bone which with periosteum and blood supply mat in the folding of the bottom of fibula improved fibular flap The flaps area 5.0 cm × 8.0 cm -12.0 cm × 14.0 cm. Results Peroneal artery to the fibular head below the 7.30(3.40-10.94)cm began with direction and fibula perforators, crus middle wear vascular constant, the number were much, bone, skin perforators with an average of 5 (4-6), pipe diameter, the biggest skin perforators of 1.14 (0.92-1.58)mm, bone perforators was 1.10 (0.50-1.80)mm. Fibular flap survival all 6 cases, clinical Ⅰ healing of the wound, fibula transplantation, bone all osseous healing, no obvious absorption, were followed up for 6-36 months, an average of 12 months, flap good appearance, texture soft, heel plantar ulcers, necrosis, ascend a leg to walk normally. Conclusion Improvement of fibula flap is an ideal method to repair the heel defect cause the direction and the distribution of the peroneal artery are stable, and the periosteal bone blood supply is rich. Key words: Heel defect; Fibular flap; Reconstruction; Applied anatomy

Qualitative research onthe psychological experience of patients with fracture of tibia and fibula that treated with 3D printing individualized external fixation

Objective To explore preoperative psychological experience in patients with the tibia and fibula fracture that treated with 3D printing individualized external fixation, and provide theoretical basis for the medical treatment and care. Methods From December 2013 to November 2015, sevenpatentstreated with 3D printing individualized external fixation in Xi′an Honghui Hospital, Xi′an Jiaotong University Health Science Center were selected as the interview object. This qualitative study was completed by phenomenon research methods, and combined with a variety of forms of interview.Colaizzi content analysis method was used to analyze the contents of collected data, and sort and refine the theme. Results Four effective subjects were extracted about preoperative psychological experience in patients with the tibia and fibula fracture treated with 3D printing individualized external fixation, in turn were uncertainty effect of surgery; high expectations, but the lack of knowledge about 3D printing, economic burden of disease; longing for family support system. Conclusions Medical staff should pay attention to preoperative psychological feelings in patients with the tibia and fibula fracture treated with 3D printing individualized external fixation, deal with a targeted psychological nursing and coping style, provide an effective nursing intervention and health education. further more optimize the 3D external fixation cost, and incorporate the 3D external fixation into the social medical insurance category. Key words: Fracture of tibia and fibula; 3D printing; External fixation; Experience; Qualitative research

Evaluation of callus stiffness by axial load-share ratio to judge safe removal of external skeletal fixator

Objective To create a credible quantitative method to evaluate callus’s stiffness which can be used to judge appropriate time to remove external skeletal fixator safely. Methods Firstly, a model of tibial transverse fracture was built to determine the relationship between callus stiffness and loading on the external skeletal fixator on which pressure sensors and data collecting system were installed. The space between bone ends was imbedded respectively with materials with various degrees of stiffness to simulate the process of callus developing from hematoma to sclerosis. The whole unit was tested on the biomechanical test system BOSE 3510, with an axial load of 70 kg. Secondly, medical records of 21 patients were collected who had been treated by external skeletal fixation from September 2013 to March 2016, involving the tibia and fibula in 19 cases and the femur in 2. Twenty cases underwent treatment of fracture and one bone lengthening. Open fractures were treated in 16 cases, fracture and infection in 4 and bone defects in 2. In the different process of bone healing, changes in load-share ratio of external fixation were measured with different axial loading. Before removal of the external skeletal fixation, the load-share ratio of external fixation with full loading was measured to determine the appropriate time to remove the external skeletal fixator on the basis of the patients’ clinical situation and X-ray plain films. Results A linear equation resulted from the sim-ulative experiment: y=0.243x-564.882, with x representing the reading of pressure sensor and y representing loading value. The varying bone callus’s stiffness during the fracture healing process could be simulated by different materials. The axial load-share ratios were relevant to the callus stiffness. No such complications as refracture happened after removal of the external fixation in 18 patients who had a load-share ratio 10%, one had refracture after removal of external fixation and 2 had to sustain continuous treatment and follow-up without removal of the external fixation. Conclusions The axial load-share ratio may be an appropriate indicator in evaluation of the bone callus stiffness. It can be used to judge appropriate time to remove external skeletal fixator safely so as to effectively reduce the complications related to callus’s healing. It may be safe to remove the external skeletal fixation when the load-share ratio is < 10%. Key words: External fixators; Bony callus; Fracture healing; Load-share ratio; Safe removal time

Efficacy of full ankle arthroscopy in treatment of Tillaux-Chaput fractures

Objective To investigate the clinical result of treating Tillaux-Chaput fractures using the full ankle arthroscopy technique. Methods A retrospective analysis was made on 21 patients with Tillaux-Chaput fractures followed up after treatment by the full ankle arthroscopy technique from May 2013 to May 2015. There were 16 males and 5 females, with the age range of 6-55 years [(25.5±12.8)years]. Right ankle was involved in 12 patients and left ankle in 4 patients. Sixteen patients had single Tillaux-Chaput fractures and 5 patients had combined proximal fibular fractures. Diagnosis of Tillaux-Chaput fractures was confirmed by X-rays in 18 patients an CT in 3 patients. Ankle arthroscopy was used through the anterolateral and anteriormedal approaches for closed reduction and internal fixation using one or two Herbert screws. Wound healing, bone union and visual analogue score (VAS) were detected postoperatively. Function assessment was performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system. Results All incisions healed by first intention, without evidence of nerve, vessel and tendon injuries. Period of follow-up was (15.3±7.1)months (range, 12-25 months). Fracture healed within 12 to 36 weeks [(22.6±4.6)weeks] after operation.VAS was (0.8±0.3)points after operation, obviously lower than preoperative (8.3±1.3)points (P<0.05). At the final follow-up, all patients regained normal ankle function and normal walking gait, without the presence of ankle pain and weight-bearing walking pain. AOFAS score was improved from preoperative (51.2±12.5)points to postoperative (92.7±16.5)points (P<0.05). Based on the AOFAS score, the results were excellent in 19 patients and good in 2 patients, with the excellent-good rate of 100%. Conclusion Full ankle arthroscopy by the anterolateral and anteriormedal approaches provides a precise and effective method for closed reduction and internal fixation of Tillaux-Chaput fractures and deserves clinical application. Key words: Ankle injuries; Arthroscopes; Surgical procedures, minimally invasive

Application of VSD combined with external fixator in the treatment of open tibial and fibular fractures in Tibet Plateau

Objective To investigate the therapeutic effect of VSD combined with external fixator in the treatment of open tibial and fibular fractures in Tibet plateau. Methods From August 2014 to August 2015, totally 16 cases of open tibial and fibular fractures were treated in our department, including 12 males and 4 females with an average 39.4 years-old. There were 4 cases of proximal and mid tibial fractures while 12 cases were distal fractures. Debridement, vacuum sealing drainage combined with external fixator for stabilization of fractures was performed in all patients after general condition was improved. A vacuum sealing drainage change or second stage wound closure or soft tissue coverage was undergone after 7 days. Bone union time by X-ray and complications were recorded. Results All wounds were healed by second stage.Twelve patients months were followed up (by calling back to the hospital) for an average 18 months (12 to 24 months), 4 cases were lost to follow-up. X-ray demonstrated that bone union was obtained at a mean 5.5th month (3 to 7 months). There were 9 cases (75%) obtained a first phase of fracture healing, while 3 cases (25%) of delayed healing. Pin-track infection was occurred in two patients and was cured by conservative treatment. No complications of deep infection, graft skin or flap necrosis, malunion, nonunion or osteomyelitis was seen during follow-up. Conclusions Vacuum sealing drainage combined with external fixator for treatment of open tibial and fibular fracture in Tibet can rapidly and effectively stabilize the fracture, and simultaneously safely and effectively seal the wound, reduce the wound healing time, promote fracture healing and lower the complication rates. Key words: Vacuum sealing drainage; External fixation; Tibia and fibula; Fractures, open; Tibet; Treatment outcome

Prognostic factors of operatively treated Pilon fractures

Objective To investigate the prognostic factors influencing the clinical outcome of Pilon fracture. Methods A retrospective cohort study of Pilon fractures treated by open reduction and internal fixation from March 2009 to November 2013 was conducted. A total of 100 patients who were followed-up more than 1 year were included in the study, including 84 males and 16 females. The average age was 42.1 years (range, 14-75 years). According to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, the patients were divided into excellent clinical outcome group and non-excellent clinical outcome group. Patient-related factors (gender, age, diabetes, smoking, injury mechanism and associated injuries), fracture-related factors (fracture classification, open fracture, fibular fracture) and postoperative factors (quality of fracture reduction, return- to- work interval and complications) were evaluated. Results 34 cases including 30 males and 4 females had excellent clinical outcome with an average age of 37.3 years (range, 14-62 years). 66 cases including 54 males and 12 females had non-excellent clinical results with an average age of 44.6 years (range, 17-75 years). Univariate analysis showed that gender (P=0.567), diabetes (P= 0.296), smoking (P=0.807), injury mechanism (P=0.964), associated injuries (P=0.387) and complication (P=0.466) had no significant differences. There was a significant difference between the two groups including the age (P=0.017), fracture classification (P= 0.007), open fracture (P=0.017), fibular fracture (P=0.004), quality of fracture reduction (P< 0.001) and return-to-work interval (P=0.002). Univariate analysis showed that patients with shorter return-to-work interval and younger age had significant better clinical outcome. The ratio of high energy injury, open fractures, fibular fracture and non-optimal quality of reduction were significant higher in the non-excellent clinical outcome group. The multivariate analysis suggested that quality of the fracture reduction was an independent favorable prognostic factor. Conclusion The quality of fracture reduction was an independent favorable prognostic factor for the Pilon fracture patients which makes an excellent clinical outcome; the gender, fracture classification, open fracture, fibular fracture, return-to-work interval may also have influence on the outcome. Key words: Tibial fractures; Treatment outcome; Root cause analysis

The value of tap test for intraoperative diagnosis of the acute deltoid ligament injury

Objective To explore the value of the tap test for intraoperative assessment of the integrity of deltoid ligament. Methods Sixty-two consecutive patients who were suspected to have a combined deltoid ligament injury between March 2013 and August 2015 were enrolled in this prospective study. Gravity stress test was performed on those 62 cases preoperatively by three independent doctors. The diagnosis that at least two doctors agreed with was defined as a final result. After open reduction and internal fixation of fibular and posterior malleolus fracture, tap test was performed to evaluate the integrity of deltoid ligament intraoperatively. The sensitivity, specificity, positive predict value, negative predict value, false positive rate and false negative rate were calculated. The Kappa coefficient was used to determine inter-rater reliability. Results Among the 62 cases, gravity stress test before the surgery demonstrated that 47 (75.8%) of the 62 patients had a positive result, while tap test showed 52 (83.9%) cases got a positive result. Finally 48 (77.4%) cases were proved to be combined with deltoid ligament rupture by surgical exploration. Tap test had a sensitivity of 100%(48/48), a specificity of 71.4%(10/14), a positive predict value of 92.3%(48/52), a negative predict value of 100%(10/10), a false positive rate of 28.6%(4/14) and a false negative rate of zero(0/48), while gravity stress test had a sensitivity of 95.8%(46/48), a specificity of 92.9%(13/14), a positive predict value of 97.9%(46/47), a negative predict value of 86.7%(13/15), a false positive rate of 7.1%(1/14) and a false negative rate of 4.2%(2/48). The consistency between the observers and kappa coefficient of both tests were above 90% and 0.75. Conclusion Both tap test and gravity stress test had excellent inter-rater reliability. Tap test is sensitive and easy to manipulate, and allows us to reduce radiation exposure. Although its false positive rate is relatively higher than gravity stress test, it still has good application prospects in the intraoperative assessment of the integrity of the deltoid ligament. Key words: Ligaments; Wounds and injuries; Treatment outcome

Combined modified posteromedial and anterior approaches for the treatment of Rüedi-Allgöwer type III Pilon fractures

Objective To explore the operation indication and clinical effect of combined modified posteromedial and anterior approaches for the treatment of Ruedi-Allgower type III Pilon fractures. Methods From January 2014 to March 2015, data of 16 Pilon fractures was retrospectively analyzed. There were 11 males and 5 females, with an average age of 43.5 years old (range, 19-62 years old). 9 patients were fall injuries, 5 patients were traffic injuries and 2 patients suffered from spraining injury. All of the fractures were closed type III according to Ruedi-Allgower classification with posterior Pilon fragment involved. A modified posteromedial approach, exploring fracture between flexor digitorum longus and flexor hallucis longus tendon, was employed to reduce and fix the posteromedial fragment, and an anterior approach (anteromedial, anterior intermediate, or anterolateral incision) was employed to reduce and fix the fibular fracture, depressed and anterior fragment. Burwell-Charnley radiological evaluation system and American Orthopaedic Foot and Ankle Society (AOFAS) functional scoring system were used for radiological and functional assessment respectively. Results The average time from injury to operation was 14.3 days (range10 to 20 days). Operating time was 120-240 min with an average time of 187.4 min. Intraoperative blood loss was 150-300 ml with an average of 218 ml. All patients were followed up, and the average duration of follow-up was 16.1 months (range, 12-24 months). Fracture healing time was 12-24 weeks with an average of 16.7 weeks. 13 patients got anatomical reduction, and 3 good reduction, with an anatomical reduction rate of 81.3% (13/16). The average AOFAS scale was 88.6, with an excellent good rate of 87.5% (14/16). Skin infection occurred in 1 patient and incision edge necrosis in 1 patient, which healed through dressing and debridement treatment. Conclusion Combined modified posteromedial and anterolateral approaches is a safe and effective method for the treatment of Ruedi-Allgower type III Pilon fractures, which can be recommended in clinical practice. Key words: Tibial fractures; Fracture fixation, internal; Treatment outcome

The clinical efficacy of Jiegu-Qili tablet combined with intramedullary interlocking nails in the treatment of the fracture of tibia and fibula

Objective To explore the effict of Jiegu-Qili tablet combined with intramedullary interlocking nails in the treatment of the fracture of tibia and fibula. Methods A total of 80 patients with fracture of tibia and fibula were selected, and were divided into two groups according to odd and even number of hospitalization. The surgery group (39 patients) was given intramedullary interlocking nails, the surgery and drug group (41 patients) was given Jiegu-Qili tablet combined with intramedullary interlocking nails. The perioperative parameters, the rate of fracture healing, knee scores and complications were evaluated during 12 months. Results The hospitalization (14.43 ± 2.47 d vs. 21.63 ± 3.16 d, t11.385, P0.01) and fracture healing time (5.22 ± 1.05 m vs. 9.75 ± 0.97 m, t20.016, P<0.05) of the surgery and drug group was shorter than that of the surgery group. The fracture healing rate of surgery and drug group (92.7% vs. 76.9%, χ23.894, P0.05) was higher than that of the surgery group. After 6 months surgery, the pain, activity, stability and KSS scores (21.60 ± 1.60 vs. 19.50 ± 1.90, 22.7 ± 2.8 vs.18.70 ± 2.40, 23.50 ± 2.40 vs. 19.40 ± 1.80, 89.20 ± 9.30 vs. 78.00 ± 8.30) of the surgery and drug group were higher than that of the surgery group (P0.05). There was no statistical significance on walking ability between two groups (21.40 ± 2.50 vs. 20.40 ± 2.20, P0.05). During 12 months follow-up, there were no statistical significance on complications between two group (7.3% vs.15.4%, χ21.303, P0.05). Conclusions In summary, the Jiegu-Qili tablet combined with intramedullary interlocking nails had a good therapeutic effect on the fracture of tibia and fibula. It could increase the speed of fracture healing, shorten the hospitalization, reduce the postoperative pain and improve the activity of patients. Key words: Intramedullary interlocking nails; Jiegu-Qili tablet; The fracture of tibia and fibula; Fracture healing rate; Complications

Bilateral big toe wrap-around flap for reconstruction of the defects of the finger

Objective To investigate the therapeutic effect of bilateral combined flap transfer in reconstruction and repairation of thumb and finger defects. Methods A partial fibular side wrap-around flap was harvested from both big toes. The flaps were tailored and designed based on measurements taken from the finger of the intact side. These two flaps were combined to reconstruct the defects of the finger. From March, 2008 to December, 2015, a total of 9 fingers (9 cases) which had defect degrees range from Ⅰ° to Ⅲ° underwent reconstruction surgeries in this way. Appearance, sensation and function of the thumb and foot flap were followed-up. Simultaneously how to improve the outcoming and success rate were explored and investigated. Results All 9 thumbs and fingers in 9 cases with these procedures were survived. No vascular crisis happened. All patients were followed up from 3 to 24 months. The reconstructed thumbs and fingers were all with abundant blood supply, having similar shape to the normal thumbs and fingers, good pain and temperature sensation, with two-point discrimination of 4-8 mm. All patients were satisfied with the thumb and finger shape, regained life and work ability as before. The donor sites had no obvious discomfort, and walking and weight-bearing function remained normal. Judged by the tentative evalution standard of function of upper limb, which was made by Chinese Medical Association for Surgery of the Hand. The results were excellent in 6, good in 2, fair in 1. Conclusion There is less damage on foot and most hand function recovery using bilateral combined flap transplantation to repair multiple fingers defect. Key words: Finger; Toe; Big toe wrap-around flap; Reconstruction; Microsurgical operation

An anatomical study of three surgical approaches for posterolateral tibial plateau fracture

Objective To compare 3 lateral surgical approaches (supra fibular head approach, di-gastric fibular head osteotomy approach, and combined lateral femoral epicondylar osteotomy and submeniscal approach) in exposing the posterolateral tibia plateau in cadaveric specimens. Methods The above 3 published surgical approaches -- supra-fibular-head approach (group A, n=8), digastric fibular head os-teotomy approach (group B, n=8), and lateral femoral epicondylar osteotomy approach (group C, n=8) -- were performed in 8 fresh-frozen cadavers. Once exposure of the posterolateral tibia plateau was achieved in each specimen, the backward pull distance of the structures above the fibular head and the exposure area of tibial condyle after retraction were measured. The model of posterolateral splitting fracture of the tibial plateau was established to observe the manipulative difficulties in reduction and fixation of the posterolateral tibial plateau fracture. Results The backward pull distance of the structures above the fibular head was 10.61±0.97 mm, 15.41±1.05 mm, and 20.72±1.35 mm in groups A, B and C respectively while the exposure area after retraction was 107.55±13.89 mm2, 155.86±10.74 mm2, and 197.46±13.52 mm2 in the 3 groups respectively, showing statistically significant differences between groups (P< 0.05). It was not convenient for the surgical approach in group A to process the posterior wall of posterolateral tibial plateau under direct vision while operation under direct posterior vision could be done in groups B and C, especially in group C where the operation was the most convenient. Conclusions All the 3 approaches can be used for reduction and fixation of the posterolateral tibial plateau fracture. The supra-fibular-head approach gives the smallest exposure range which is inconvenient for treatment of the posterior wall of the posterolateral condyle of the tibial plateau. The digastric fibular head osteotomy approach and lateral femoral epicondylar osteotomy approach provide larger exposure ranges which facilitate convenient reduction and fixation but lead to slightly larger operative trauma. Key words: Tibia; Knee joint; Fracture fixation, internal; Autopsy; Surgical approach

Treatment of tibial plateau fractures with posterolateral collapse and posteromedial spilt

Objective To explore the treatment of tibial plateau fractures with posterolateral collapse and posteromedial spilt. Methods During the period from January 2009 to January 2015, 17 tibial plateau fractures with posterolateral collapse and posteromedial spilt were surgically treated. They were 12 males and 5 females, with an average age of 32.4 years (from 21 to 52 years). Anteroposterior and lateral radiographs as well as computed tomography (CT) images were obtained in the course of preoperative radio-logical evaluation to determine the collapse and displacement. After the posteromedial bone spilt fragments were reduced and fixated via the posteromedial approach, the posterolateral collapse fragments were exposed via the fibular osteotomy approach and stabilized by lateral buttress following reduction. Hospital for Special Surgery (HSS) functional score and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used at the final follow-ups to evaluate functional outcomes. Results Follow-ups with a mean duration of 18.3 months (range, from 12 to 24 months) were carried out in all the patients. All fractures healed within an average of 13.2 weeks (range, from 12 to 16 weeks). The HSS functional scores ranged from 60 to 100 points, averaging 89.6 points, giving 15 excellent cases, one good case and one fair case. The AOFAS functional scores ranged from 86 to 98 points, averaging 95.2 points. No loosening or breakage of the implants, or traumatic arthritis occurred in this series. Conclusion For tibial plateau fractures with posterolateral collapse and posteromedial spilt, a special type, it is an effective treatment to carry out open reduction and internal fixation of the posterolateral collapse fragments via the fibular osteotomy approach after reduction and stabilization of the posteromedial bone spilt fragments. Key words: Tibial fractures; Knee joint; Fracture fixation, internal; Osteotomy

Posterolateral approach for Maisonneuve injury associated with posterior malleolus fracture

Objective To investigate the surgical treatment of Maisonneuve injury associated with posterior malleolus fracture under direct visualization via the posterolateral approach. Methods Between January 2008 and June 2015, 27 patients with Maisonneuve injury associated with posterior malleolus fracture were treated at our department. They were 18 men and 9 women, aged from 20 to 60 years (average, 40.1 years). All fractures and syndesmoses received open reduction under direct visualization and internal fixation via the posterolateral approach. The posterior malleolus fractures were fixed with screws or plate and the syndesmoses fixed using cortical bone screws. Functional results were evaluated using the Baird-Jackson ankle scoring system. Results The patients were followed up for 8 to 30 months (average, 18 months). No wound infection, necrosis, dehiscence, lose of reduction or implant failure was found during follow-up visits. All cases got bony union at the last visit. The excellent and good rate was 92.6%. Conclusion Since the posterolateral approach allows good access to the Maisonneuve injury and posterior malleolus fracture under direct visualization, it facilitates accurate direct fracture reduction, stable fixation and early exercise. Key words: Fibula; Hock; Fractures, bone; Fracture fixation, internal; Posterolateral approach

CLINICAL APPLICATION OF AXIAL LOAD MECHANICAL TESTING IN REMOVING EXTERNAL FIXATOR AFTER TIBIA AND FIBULA FRACTURES SURGERY

To explore the efficacy and safety of the axial load mechanical testing for removing external fixator. Between January 2014 and August 2015, 27 patients with tibia and fibula fractures caused by trauma underwent an external fixation. Of 27 patients, 21 were male and 6 were female with the average age of 45 years (range, 19-63 years), including 7 cases of closed fracture and 20 cases of open fracture. X-ray film results showed spiral unstable fracture in 4 cases and comminuted unstable fracture in 23 cases. All patients underwent an external fixation. Bone nonunion occurred in 3 cases because of infection, and bone nonunion combined with bone defect occurred in 1 case, who received tibial osteotomy lengthening surgery. When X-ray film showed continuity high density callus formation at fracture site, axial load mechanical test was performed. If the axial load ratio of external fixator was less than 10%, the external fixator was removed. At 21-85 weeks after external fixation (mean, 44 weeks), axial load mechanical test was performed. The results showed that the axial load ratio of external fixation was less than 10% in 26 cases, and the external fixator was removed; at 6 weeks after removal of external fixator, the patients could endure full load and return to work, without re-fracture. The axial load ratio was 14% in 1 case at 85 weeks, and the X-ray film result showed that fracture did not completely heal with angular deformity; re-fracture occurred after removing external fixator, and intramedullary fixation was used. External fixator axial load mechanical testing may objectively reveal and quantitatively evaluate fracture healing, so it is safe and reliable to use for guiding the external fixator removal.

Supramalleolar osteotomy with fibular osteotomy in treatment of varus ankle arthritis

Objective To evaluate the functional and radiological outcomes of supramalleolar osteotomy (SMOT) with fibular osteotomy for mid-staged varus ankle arthritis. Methods From April 2009 to April 2014, data of twenty-two patients with mid-staged varus ankle osteoarthritis who were treated with SMOT combined with fibular osteotomy and were followed up at least one yearwere retrospectively analyzed. There were 5 males and 17 females with mean age of 52.4 years (range, 37-71 years). According to modified Takakura ankle osteoarthritis stage, there were 5 cases in stage II, 12 in stage IIIa and 5 stage in IIIb. The American orthopedic foot and ankle society (AOFAS) ankle-hind score, Maryland foot score and Ankle Osteoarthritis Scale (AOS) were used for pre-and postoperative functional evaluation, as well as the range of motion (ROM) of ankle joint on sagittal plane. The tibial anterior surface angle (TAS), talar tilt (TT), tibiocrural angle (TC), and tibial lateral surface angle (TLS) were evaluated pre-and postoperatively. Results The mean follow-up time was 36.6 (range, 17-55) months. Two cases had delay union. One case with postoperative pain and dysfunction was treated by ankle fusion. All of the osteotomy sites reached bony union with a mean time of 3.9 months (range, 3-8 months). The mean AOFAS score and Maryland score and AOS pain and function scores were improved significantly; the mean AOFAS score increased 31.7±12.5 points, the mean Maryland score increased 22.1±11.5 points, and the mean AOS pain and functional score reduced 16.1±7.4 and 15.6±6.9 respectively. Thirteen cases (62%) had improved on modified Takakura stages, 6 from stage II/III to stage I, 6 from stage III to stage II, and 1 from stage IIIb to stage IIIa. The ROM on sagittal plane increased from 32.8°±5.3° preoperatively to 35.7°±5.9° postoperatively.. For radiological evaluation, all the parameters were improved except TLS; the TAS reached a mean improvement of 7.2°±2.8°, the TT with a mean improvement of 4.4°±3.6°, the TC with a mean improvement of 9.8°±3.5°, the TLS with a mean improvement of 0.7°±1.2°. Conclusion SMOT combined with fibular osteotomy is promising with substantial functional improvement and malalignment correction for varus ankle arthritis; and is helpful even for those cases with large talar tilt angle. However, this procedure has no obvious improvement effect on the ROM of sagittal plane of ankle joint. Key words: Ankle joint; Osteoarthritis; Fibula; Osteotomy

One-stage surgical treatment for thumb osteomyelitis accompanied with soft tissue defects: free flap transplantation from fibular side of the big toe

Objective To investigate the indications and efficacy of one-stage surgical treatment for phalanx osteomyelitis of the thumb by debridement and soft tissue defect coverage with fibular flap from the big toe. Methods From May 2013 to May 2015, 11 cases of phalanx osteomyelitis of the thumb with soft tissue defect were treated. After thorough debridement, the bone defect was filled with a non-vascularized bone graft while a flap from the fibular side of the big toe was transferred to cover the soft tissue defect all in the same stage. Postoperative evaluations included cure of osteomyelitis, motor function of the thumb, and the sensation, color and texture of the flap. Results All the patients were follow-up for 4 to 12 months, with an average of 8 months. The osteomyelitis was effectively cured, with no recurrence. Range of motion of the thumb returned to normal. The flaps survived completely, with satisfactory sensation, appearance and texture. Conclusion One-stage thorough debridement, artificial bone grafting with sensitive antibiotics and transfer of fibular flap from the big toe can shorten the treatment time for phalanx osteomyelitis of the thumb with soft tissue defects. The cost is lower while the outcomes are good. Key words: Osteomyelitis; Finger injuries; Surgical flaps; Soft tissue defect

Research advances of the classification and treatment of posterior malleolus fractures

The posterior malleolus plays an important role in the stability and function of the ankle joint. Approximately 7% to 44% of ankle joint fractures are accompanied by posterior malleolus fractures. The current published data suggest a poor outcome for ankle fractures involving the posterior malleolus. Inappropriate reduction of the posterior malleolus fragment may result in symptomatic malunion requiring corrective osteotomy. The posterior malleolus fractures were categorized into three types by Haraguchi: the posterolateral-oblique fractures(Type I), the transverse medial-extension fractures(Type II)and the small-shell fractures(Type III). Mangnus divided posterior malleolus fractures into two basic types: posterolateral and posteromedial types. Bartonicek classified the posterior malleolus fractures into four types on the basis of CT scan and 3D reconstructions, and taking into account the location, shape, size of the fragment and the integrity of the fibular notch: extraincisural fragment with an intact fibular notch(Type I), posterolateral fragment extending into the fibular notch(Type II), posteromedial two-part fragment involving the medial malleolus(Type III)and large posterolateral triangular fragment(Type IV). The fracture lines associated with posterior malleolus fractures appear to be highly variable. So far, no generally accepted clinically relevant classification of posterior malleolus fractures exists, and the indications of the operative management of these fractures were often determined by the size of the fragment. The anteroposterior and lateral views were used to evaluate the fractures of the fibular and the medial malleolus, as well as the rupture of the ligament and the presence of subluxation or dislocation of the talus. The determination of proper surgical approach and the internal fixation should take into account the size, shape and displacement of the posterior fragment by CT scans, through CT and 3D reconstructions. The aim of treatment for posterior malleolus fractures is to reduce the displaced fragments ana-tomically, and to restore the stability of the tibiotalar joint and the distal tibiofibular syndesmosis.

Reconstruction of thumb and fingertip defects with wrap-around flap from the big toe

Objective To evaluate the method and clinical outcomes of big toe composite tissue flap transplantation with fibular branch of the proper plantar artery as feeding vessel for coverage of thumb and finger tip defects. Methods From January 2013 to June 2015, 6 cases with thumb tip defects and 9 cases with fingertip defects were repaired by the big toe composite tissue flap transplantation with anastomosing fibular branch of the proper plantar artery to the feeding vessel. Donor site of the big toe was covered by a tibial side flap. Results All 15 wrap-around flaps from the big toe survived. Postoperative follow-up ranged from 3 to 14 months. All the reconstructed digits had favorable functions and nail growth. The reconstructed nail was smooth in 13 cases and uneven in 2 cases. Scar hyperplasia and contracture was seen in 1 case. There is no abrasion or ulceration of the flaps that covered the donor site. Conclusion Big toe composite tissue flap transplantation with fibular branch of the proper plantar artery as feeding vessel is a less invasive and reliable method for coverage of thumb and fingertip defects. Key words: Surgical flaps; Finger injuries; Proper plantar artery

On the existence of non‐microbiotherian Australidelphian marsupials (Diprotodontia) in the Eocene of Patagonia

AbstractA diverse assemblage of extinct mammals of early–middle Eocene age (Ypresian–Lutetian boundary) come from the Patagonian localities of La Barda and Laguna Fría around Paso del Sapo in northwestern Chubut Province (Argentina). Metatherians are well represented, mostly by dental remains of ‘Didelphimorphia’, Paucituberculata, Sparassodonta, Microbiotheria, and Polydolopimorphia. Here we analyse three calcanea and one astragalus referable to the same, indeterminate taxon, from La Barda, showing the fusion of their ectal and sustentacular facets. This facet arrangement characterizes the Australidelphia, a marsupial clade represented by Microbiotheria from South America and Antarctica, plus all Australasian lineages. Other australidelphian features shown by these tarsals include: in the calcanea, a reduced peroneal process and a tripartite cuboid facet; in the astragalus, a round, very small astragalar head in relation to the body; a convex trochlea with a half for the tibia and half, in slightly lower position, for the fibula. Their size and other anatomical features suggest that the new tarsals cannot be referred to the Microbiotheria. Phylogenetic analysis suggests that the La Barda taxon lies within the Australidelphia, and that it is either closely related or belongs to, the Diprotodontia. The existence of advanced australidelphians in Patagonia adds further evidence of the close relationship between Patagonia, Antarctica, and Australia during the Late Cretaceous – early Palaeogene.

Epidemiological study on the incidence of deep vein thrombosis associated with fracture sites

Objective To retrospectively analyze the incidence of deep vein thrombosis and investigate the epidemiological characteristics of DVT associated with fracture sites. Methods The clinical records were retrospectively analyzed from February 2009 to February 2013 in Tianjin Hospital. The general data, clinical diagnosis, fracture site, injury mechanism, DVT occurrence time and complications were recorded. All the data were summarized, and the overall incidence of DVT and incidence of DVT in different fracture site were calculated according to the different site of the fracture classification. Results 1 543 fractures patients had happened DVT of 24 049 patients during four years. The overall incidence of DVT was 6.41% (1 543/24 049). In 1 543 DVT patients, there were 713 lower extremity fractures, 790 around hip fractures and 40 upper extremity fractures. The highest overall incidence of DVT was 12.33% (790/6 408) in around hip fractures, the overall incidence of DVT in lower extremity fractures (6.02%, 713/11 837) was obvious higher than upper extremity fractures (0.69%, 40/5804). In lower extremity fractures, the highest incidence of DVT fracture site was distal of femoral shaft with 23.04% (165/716), followed by 14.72% (178/1 209) of femoral shaft fractures, patella fracture was 7.27% (110/1 513), tibial plateau fracture was 5.83% (79/1 355), tibia and fibula fracture was 2.86% (91/3 180), ankle fracture was 2.60% (55/2 116), calcaneus fracture was 1.17% (15/1 281), forefoot fracture was 4.28% (20/467). In upper extremity fractures, the highest fracture site of incidence of DVT was shoulder fracture with 2.97% (9/303), other all upper extremity fractures were less than 1%. Conclusion The incidence of DVT is closely related to fracture site, there is significant difference between different sites of fractures. The fracture site such as distal of femoral shaft, femoral shaft, around of hip joint and pelvic should be been the key sites to prevent for DVT. Key words: Venous thrombosis; Fractures, bone; Risk factors; Epidemiologic studies