Mean American Orthopaedic Foot And Ankle Society Research Articles

Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies: a reliable technique.

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus. We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51). The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6(o) to 12.8(o) (p < 0.001) and from 22.1(o) to 7.1(o), respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23(o) to 9.7(o). The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients). These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202-7.

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

Diagnosis and treatment of anterior pilon fracture

Objective To investigate the diagnosis, operation characteristics and clinical effect of anterior Pilon fracture. Methods A retrospective analysis was carried out to analyze 13 patients who had been treated for anterior pilon fracture from September 2012 to March 2014. All had fresh closed fracture. Mean age was 39.8 years(range, 18-61 years). Injury resulted from high falls in 11 patients and falls in 2 patients. According to the preoperative imaging manifestations and four column fracture classification, the fracture type was mainly anterior column fracture. All underwent open reduction and internal fixation with buttress plates, and allograft bone was performed in 8 patients. At the last follow-up, American Orthopedic Foot and Ankle Society(AOFAS)ankle-hindfoot score and visual analogue scale(VAS)were employed for clinical evaluation. Results Mean period of follow-up was 15.7 months(range, 12-30 months). Mean AOFAS score was 91.38 points(range, 74-100 points). Excellent results were found in 10 patients, good in 2 and fair in 1, with the excellent-good rate of 92%. Mean VAS score was 1.08 points(range, 0-3 points). Traumatic arthritis occurred in 1 patient. Skin necrosis occurred in 1 patient, and was cured by dressing change. There were no complications such as infection, refracture or implant failure. Conclusions Mechanism of injury in anterior pilon fracture is vertical violence when the foot in dorsiflexion position. Imaging findings are mainly characterized by the compression in anterior articular surface of the distal tibia, which is often implicated in the anterior medial malleolus but in part is combined with lateral malleolus fracture. The fracture is the result of high energy injury, and can be diagnosed by mechanism of injury and imaging manifestations. Through anterior approach, open reduction and internal fixation with buttress plates plus allogenic bone grafting obtain satisfactory outcomes. Key words: Tibial fractures; Ankle injuries; Fracture fixation, internal

Posteromedial peroneal tendon groove deepening treatment of the chronic subluxation of the peroneal tendons

Objective To investigate the clinical curative result of the new method of postermedial deepen of the fibular groove in the treatment of chronic peroneal tendon subluxation. Methods From March 2006 to October 2012, 21 patients (15 male, 6 female) with chronic peroneal tendon subluxation via a novel method of postermedial deepen of the fibular groove. In this group: I grade 5 cases; II grade 9 cases; III grade 5 cases; IV grade 2 cases. All patients were followed up for at least 24 months. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score and visual analogue score (VAS) were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded. Results The average operation time was 50 minutes (30-70 minutes). The blood loss was 30-60 ml, average 40 ml. All incisions healed after operation, no case of incision infection, skin necrosis and sural nerve,vascular injuryed. Mean AOFAS score was significantly increased from (55.2±7.1) preoperative to (93.6±5.6) postoperative. 15 patients with excellent, good for 1 cases. The excellent and good rate was 100% (16/16). VAS score by an average of (5.3±2.1) points down to (1.2±1.1) points postperative. All the patients can wear normal shoes postoperative, waking with normal gait. No patients had peroneal tendon tenosynovitis, tendon adhesion, fracture of lateral malleolus and other serious complications, no dislocation recurrent, strength of the peroneal muscle returns to normal. Conclusion The novel method of postermedial deepen of the fibular groove in the treatment of chronic peroneal tendon subluxation was safe and effective for ankle instability with a relatively short time. Key words: Tendinopathy; Clinical protocols; Comparative effectiveness research

Simple articular extension did not affect the excellent results of MIPO in treating distal tibia fractures after 5 years

Minimally invasive plate osteosynthesis (MIPO) becomes popular for treating distal tibia fractures. Intra-articular extension was accused for result deterioration and was considered as an indication for open reduction and internal fixation (ORIF). Our hypothesis was that the simple intra-articular extension can be successfully treated percutaneously, MIPO can be successfully applied, and ORIF is not mandatory. We wanted to determine whether the presence of simple articular extension would change the reported excellent results of MIPO after 5 years follow-up. As extensive articular affection has different treatment strategies, the inclusion criteria for this prospective clinical series included distal tibia fractures with only simple intra-articular extension (AO/OTA 43-B1, B2, C1, and C2). From 43 patients we treated with MIPO using the AO medial distal tibia anatomical locked plate, 13 patients were excluded as they did not complete the follow-up, and only 30 patients were reported. Only seven fractures were open. The minimum follow-up period was 5 years. The outcome measurements included fracture healing, alignment, nonunion, infection, ankle range of motion (ROM), implant removal, ankle osteoarthritis (OA), unemployment, failure to return to daily activities or sports, and functional assessment as per the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. All the fractures united, but with delay in two patients. No articular step-off more than 2 mm could be detected in any patient. At the metaphysis, three patients (10 %) had angular deformities less than 5°, uni-planar in two patients and bi-planar in one patient. Three patients (10 %) developed a superficial infection. These three patients had their implants removed and had reduced ankle ROM. Twenty-eight patients (93.33) returned to their original job. Twenty-four patients (80 %) had returned to their pre-injury daily activity and sports. At the end of follow-up, no patient developed ankle osteoarthritis or had deterioration of his earlier satisfactory clinical and functional results. The mean AOFAS score was 90.8 ± 6 at the end of follow-up. After 5 years follow-up, MIPO was an excellent option for the challenging distal tibia fractures even with simple articular extension. With absence of OA, high percentage of the patients could keep excellent functional results, job, and activity.

The Result of Open Reduction and Mini-Plate Fixation for Displaced Talar Neck Fracture

Purpose: We evaluated the complications, radiological and clinical results after operative treatment using a mini-plate for fixation of displaced talar neck fractures. Materials and Methods: There were 20 cases of displaced talar neck fractures from May 2006 to December 2011; we performed a retrospective chart review of 15 patients treated by open reduction and internal fixation using a mini-plate who had more than 2 years of follow-up. According to Hawkin’s classification, there were 7 cases of type II fractures and 8 cases of type III fractures. During postoperative 12-16 weeks we checked magnetic resonance imaging. The assessment of clinical results was based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. Results: Mean union period was 11.6 weeks (10-15 weeks). Nonunion and malunion did not occur in all cases. The mean AOFAS score was 88.2 points (80-97 points). There were 5 cases of avascular necrosis. Of these, there were 3 cases of body collapse and 4 cases of post-traumatic arthritis. In the statistical analysis, there was no correlation between the elements including gender, Hawkin’s classification and union rates and clinical results. Conclusion: Mini-plate fixation of a displaced talar neck fracture is thought to be a good technique, with a low rate of malunion and also showed satisfactory results in radiological and clinical assessment.

Minimally invasive plating: a good option for distal tibia fractures with simple or no articular involvement

Background Despite great improvements in treatment procedures and implants, management of distal tibia fractures remains challenging. Objective The purpose of the present prospective study was to evaluate the use of minimally invasive plating for treating distal tibia fractures with simple or no articular involvement, and to suggest the factors that may improve the results. Patients and methods In this prospective, noncontrolled cohort study, 46 patients with distal tibia fractures (excluding AO 43-B3, 43-C3 fractures) were treated with the medial distal tibia anatomical locked plate. Only the results for 40 patients were reported in our study; the remaining six were excluded as they did not complete the follow-up. There were 28 men and 12 women, with a mean age of 37.5 years. According to the AO classification, there were 22 fractures of type A, 13 of type B, and five of type C. Seven fractures were open. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale was used for functional assessment. Results The mean follow-up period was 53.25 ± 9.53 months (range: 36-66 months). All the fractures united with acceptable alignment in a mean time of 17.17 weeks (range: 10-28 weeks). Five (12.5%) patients caught infections - three superficial and two deep. Secondary surgeries were carried out only for debridement or implant removal, but none to achieve union. Six (15%) patients had angular deformities less than or equal to 5°. None of these deformities required a secondary operation for correction. At the end of follow-up, the mean AOFAS score was 90. A total of 32 (80%) patients resumed their preinjury activity and sports and 37 (92.5%) were back to their previous employment. Conclusion Minimally invasive plating provides a secure, easily applied good solution for the challenging distal tibia fracture, even with simple articular extension. Surgeon experience and skill, efficient preoperative planning, and well-planned postoperative protocol are important for improving the outcome.

Treatment of calcaneal fractures with closed reduction and the Endobutton-assisted technique: short-term analysis.

Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis. Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments. The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent. With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

Typing and operative management of malunion after midfoot injury

Objective To characterize clinical treatment of the malunion after midfoot injury.Methods A retrospective study was carried out of the 22 cases of malunion following complex midfoot injury who had been admitted to our hospitals from June 2004 through June 2012.They were 19 men and 3 women,16 to 65 years of age (mean,37.8 years).There were 6 cases of Lisfranc joint injury 7 cases of Lisfranc joint complex injury combined with cuboid compression fracture and 9 cases of Lisfranc joint complex injury combined with navicular fracture.Eight patients presented with poor soft tissue and massive scar at the dorsal foot.The foot deformity was categorized into 3 types and 3 subtypes repectively,with type Ⅰ indicating normal foot arch (type Ⅰa forefoot abduction,type Ⅰb forefoot adduction and type Ⅰc normal forefoot),type Ⅱ Pes Cavus deformity (type Ⅱa combination with forefoot abduction,type Ⅱb combination with forefoot adduction,and type Ⅱc normal forefoot),and type Ⅲ flatfoot deformity (type Ⅲa combination with forefoot abduction,type Ⅲb combination with forefoot adduction,and type Ⅲc normal forefoot).There were 2 cases of type Ⅰa,4 cases of type Ⅰc,9 cases of type Ⅱa,4 cases of type Ⅲ a,and 3 cases of type Ⅲc in our cohort.According to the malunion typing,fascio-cutaneous flap,osteotomy,joint arthrodesis,or realignment was used to correct deformity.Clinical outcomes were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS)midfoot score and visual analogue scale (VAS).Results All the patients were followed up for an average of 34.7 months (range,from 15 to 53 months).The mean VAS score was 2.0 points (range,from 0 to 6 points) and the mean AOFAS score was 83.9 points (range,from 73 to 94 points) at the last follow-up,giving an excellent to good rate of 81.8％.All cases obtained favorable functional outcomes without bone nonunion,except for one patient who still suffered from midfoot walking discomfort 3 years after operation.Conclusions Operative management of malunion following midfoot injury is effective and good results can only be obtained by stabilizing the injured joint,realignment and restoring foot arch.Our typing of the midfoot malunion is helpful in the operative treatment. Key words: Foot injuries; Foot deformities, acquired; Surgical procedures, operative

Endobutton elastic fixation for treatment of chronic syndesmotic instability

Objective To observe the clinical efficacy of Endobutton elastic fixation for treatment of chronic syndesmotic instability.Methods From January 2011 to January 2013,13 cases of chronic syndesmotic instability were treated by Endobutton elastic fixation in our department.They were 9 men and 4 women,aged from 32 to 46 years (average,37.5 years).The duration from injury to the operative treatment ranged from 3 to 6 months (average,3.8 months).After debridement of the medial gutter and the inferior tibiofibular space,2 Endobutton plates instead of traditional metal screws were used to stabilize the syndesmosis.Follow-up included clinical evaluation,X-ray and CT examination and image-based PACS 5.0 system measurement at 3 days,8 weeks and 6 months postoperation.The American Orthopaedic Foot and Ankle Society (AOFAS) score system was used for postoperative efficacy evaluation at 6 months postoperation.Results The patients were followed for 6 to 28 months,with an average of 16.0 months.All the malleolus fractures healed after an average of 11.5 weeks (from 10 to 17 weeks).No infection,faulty wound healing or phlebothrombosis happened in this group.Reduction of the syndesmosis was confirmed by X-ray and CT scan 3 days,8 weeks and 6 months after the surgery.The mean AOFAS score improved significantly from 49.5 points to 71.6 points,with 7 excellent cases,5 fine cases and one fair case.Conclusions Endobutton elastic fixation for chronic syndesmotic instability can preserve physiological fretting of the syndesmosis and avoid removal of hardware and further separation of the syndesmosis.It may also lead to fine functional recovery of the ankle,absence of significant complications and satisfactory outcomes in a short-term. Key words: Ankle joint; Fracture fixation, internal; Joint instability

Minimally Invasive Plate Osteosynthesis for Fractures of Distal Tibia

&lt;title&gt;Abstract&lt;/title&gt;&lt;sec&gt;&lt;title&gt;Objectives&lt;/title&gt;&lt;p&gt;This study analyzed clinical and radiologic results, and complications of minimally invasive plate osteosynthesis(MIPO) for distal tibia fracture.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;Methods&lt;/title&gt;&lt;p&gt;16 patients (17 cases) who were performed MIPO for distal tibia fractures between January 2007 and June 2011, postoperative followed up at least for one year, were selected for this study. The average age was 55.0(26-76) years old and the average period of followup was 15.1(6-27) months. Most of the patients were encouraged to perform ankle dorsiflexion and straight leg raising exercise on splints, from the next day of the operation. As radiologic evaluation, we checked period until bone union, degree of angulation. And postoperative complications were also checked. For functional evaluation of the ankles, American Orthopaedic Foot and Ankle Society(AOFAS) score was used.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;Results&lt;/title&gt;&lt;p&gt;16 of the 17 cases were achieved primary bone union, and average period of bone union in all the cases was 17.4 (12-42) weeks. Mean varus/valgus angulation after the bone union was 0.8 degrees and mean anteroposterior(AP) angulation was 1.8 degrees. Mean AOFAS score was 85.2(71-95) points; 5 cases of excellent, 10 cases of good, 1 case of fair, showing that 93.8% of the patients represented at least good AOFAS scores. As complications, there were 2 cases of superficial infection, and each 1 case of nonunion and skin irritation. There were no cases of deep infection, metal breakage, nor limb length discrepancy.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;Conclusions&lt;/title&gt;&lt;p&gt;MIPO for distal tibia fracture is considered to be an effective operative method, because of its high bone union rate and low complications by minimal disruption of soft tissue and improved bone fixation strength. Also, for earlier return to daily life, ankle joint exercise should be started as soon as possible after the operation.&lt;/sec&gt;

Short-term results of ankle arthrodesis using anterior double plating system

Objective To report short-term outcomes of ankle arthrodesis using anterior double plating system.Methods From September 2009 to October 2011,15 patients with end-stage arthritis of the ankle were treated by ankle arthrodesis with anterior double plating system in our department.They were 10 males and 5 females,aged from 22 to 59 years (average,39.2 years).Nine cases were post-traumatic arthritis,3 osteoarthritis and 3 rheumatoid arthritis.The ankle function was assessed preoperation and at the last follow-up in all patients according to the ankle and hindfoot scoring of American Orthopaedic Foot and Ankle Society (AOFAS); bone union was assessed by radiographs.Results The follow-up periods for the 15 patients lasted from 9 to 18 months (average,13 months).Bone union was obtained in all at the last follow-up.The fusion time ranged from 9 to 28 weeks (average,14 weeks).The mean AOFAS score increased significantly from preoperative 36.1 ± 8.1 points to 82.7 ± 6.3 points at the last follow-up (t =23.961,P =0.000).All the 15 patients achieved primary healing of incision and were free of complications like infection or local skin necrosis.No implant failure was observed at the last follow-up.Conclusions The anterior double plating system is an effective method to achieve solid ankle arthrodesis,with advantages of clear operative field,simplicity,rigid fixation and high fusion rate.Its short-term efficacy is definite particularly in patients with severe bone defect or loss of bone stock. Key words: Ankle joint; Osteoarthritis; Arthrodesis; Bone plates

Outcomes of autologous osteo-periosteal cylinder graft transplantation for Hepple V osteochondral lesions of the talus

Objective To study the outcomes of autologous osteo-periosteal cylinder graft transplan- tation for Hepple V osteochondral lesions of the talus （OLT） with large subchondral cyst. Methods The da- ta of 27 consecutive patients of OLT with subchondral cyst was retrospectively analyzed who were treated by autologous osteo-periosteal cylinder graft transplantation from October 2007 to September 2011. There were 26 males and 1 female with an average age of 35.8 years （range, 22-53 years）. Visual analogue score （VAS） for pain during daily activities, the American Orthopaedic Foot and Ankle Society （AOFAS） ankle and hind- foot score, and subjective satisfaction were investigated. The plain radiographs, magnetic resonance imaging （MRI） of the ankle, and second look arthroscopy were analyzed. Results All the 26 patients were followed up for 22.4 months. At the last follow-up, the VAS score decreased from 5.4±1.0 points preoperatively to 0.8±0.8 points postoperatively, and the mean （50%） AOFAS score improved from 73.9±3.1 points preopera- tively to 93.0±6.5 points postoperatively. In 26 cases, the radiolucent area of cysts disappeared on plain ra- diographs. The mean magnetic resonance observation of cartilage repair tissue （MOCART） score was 57.2, though small subchondral bone cyst was still found in 3 cases on postoperative MRI. The mean （50%） ICRS arthroscopic score of cartilage repair was 9.2 points according to second look arthroscopy of 18 cases. There were 16 cases receiving excellent effect, 8 good and 2 fair. The excellent and good rate was 92.3%（24/26）. There were no major complications. Conclusion Autologous osteo-periosteal cylinder graft transplantation could repair the osteochondral defects. It yields satisfactory results, and is suitable for treating OLT with large subchondral cyst. Key words: Talus; Osteochondritis; Transplantation, autologous; Bone cysts

Surgical treatment of ankle fractures associated with complete rupture of the deltoid ligament

Objective To investigate the surgical procedure and clinical outcome of treatment of ankle fractures associated with completer rupture of the deltoid ligament.Methods From January 2006 to December 2010,we treated 48 cases of ankle fracture associated with complete rupture of the deltoid ligament rupture.They were 26 males and 22 females,with an average age of 44.2 years (range,17 to 74 years).According to the Lauge-Hansen classification,there were 14 cases of supination-external rotation type Ⅳ,12 pronation-external rotation type Ⅲ,16 pronation-external rotation type Ⅳ and 5 pronation-abduction type Ⅲ.According to the AO/OTA system,there were one case of 43-B2,3 cases of 44-B2,16 44-B3,7 44-C1,844-C2,and 13 44-C3.Reduction and fixation of the fracture and repair of the ruptured ligament were conducted simultaneously for all patients.Clinical examinations,radiographs,American Orthopaedic Foot and Ankle Society(AOFAS) ankle-hindfoot scores and visual analogue scale (VAS) were used for outcome measurement.Results All wounds healed at the first stage.Forty-three patients were followed up for 12 to 32 months,with an average of 19 months.The mean time for bone union was 13.2 weeks (range,10 to 16 weeks).The mean AOFAS ankle-hindfoot score at the last follow-up was 93.4 points (range,83 to 100 points).The mean VAS score was 1.2 points (range,0 to 6 points).There was no ankle instability.Conclusion To achieve satisfactory outcomes for patients with ankle fractures associated with complete rupture of the deltoid ligament,a proper surgical procedure should be chosen according to reasonable preoperative evaluation and a proper suture technique according to the rupture site of the deltoid ligament. Key words: Ankle joint; Fractures fixation, internal; Suture techniques; Deltoid ligament

Clinical outcome and changes in gait pattern after pilon fractures.

Axial burst fractures of the distal tibia are challenging to treat and often lead to restricted function of the lower limb. The purpose of this study was to investigate the clinical outcome and changes in gait pattern in such patients. Thirty-five patients in a level 1 trauma centre were followed up clinically and by gait analysis. The American Orthopaedic Foot and Ankle Society (AOFAS), visual analogue scale (VAS) foot and ankle scale and Phillips scores were applied. Dynamic pedography (emed-M; Novel, Germany) with analyses of load, pressure and force-time integral were undertaken to investigate possible changes in gait pattern. Mean follow-up was 50 (19-100) months. Mean AOFAS, VAS foot and ankle and Phillips scores were 65, 63 and 55 points, respectively. There were clear correlations between fracture severity in the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and functional outcome in AOFAS (-0.63; p < 0.01), VAS foot and ankle scale (-0.56; p < 0.01) and Phillips (-0.64; p < 0.01) scores. There was a high correlation of 0.74 (p < 0.01) between the severity of the injury in the AO-classification and onset of post-traumatic arthrosis. Dynamic pedography revealed lesser load bearing for the total foot, medial foot, heel, first metatarsal and medial forefoot for the affected limb, and increased load bearing was seen in the lateral midfoot region. Fractures of the tibial pilon lead to restricted function of the lower limb. Clinical outcome correlates with fracture severity in the AO classification, the onset of post-traumatic arthrosis and changes in gait patterns.

LCP distal ulna hook plate as alternative fixation for fifth metatarsal base fracture

Intramedullary screw fixation is the most common treatment for fifth metatarsal base fractures. Screw application does not achieve accurate reduction in fracture with small fragments, osteoporotic bone, or Lawrence zone 1 fractures, however. On the basis of similar anatomical architectures between the distal ulna and the fifth metatarsal base, the purpose of this study was to assess the results of a locking compression plate (LCP) distal ulna hook plate in stabilizing displaced zone 1 or 2 fifth metatarsal base fractures. Nineteen patients with Lawrence zone 1 (n=12) or 2 (n=7) fractures of the fifth metatarsal base were treated surgically with an LCP distal ulna hook plate. The patients were evaluated clinically and radiographically, and functional outcomes were graded by using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scoring system. Radiographic bony union was obtained in all patients, at an average of 7.4weeks. The mean AOFAS midfoot score improved from 26 (range, 0-45) preoperatively to 94 (range, 72-100) points at the final follow-up. There were three patients with post-traumatic cubometatarsal arthrosis and one patient with sural nerve neuropraxia. In our experience, the distal ulna hook plate achieves a high rate of bony consolidation and anatomically suitable fixation in zone 1 or 2 fifth metatarsal base fractures. We also suggest that the LCP distal ulna hook plate should be considered as an alternative treatment in multifragmentary, osteoporotic, and tuberosity avulsion (zone 1) fifth metatarsal base fractures.

Percutaneous cannulatedscrew fixation with subtalar fusion for treatment of post-traumatic subtalar arthritisunder arthroscope

：Objective To investigatethe clinical outcome of arthroscopic percutaneous cannulated screw fixation with subtalarfusion in the treatment of post-traumatic subtalar arthritis. Methods The study involved12 patients (five males and seven females) with severe post-traumatic subtalar arthritisadmitted to our hospital from April 2006 to December 2009. The patients were at age rangeof 28-68 years ( mean 45.6 years). All patients had the history of conservative treatmentbut failed in pain alleviation.Then, the percutaneous cannulated screw fixation plussubtalar fusion was selected. The ande and hind foot of all patients were evaluatedpreoperatively and postoperatively by the American Orthopedic Foot and Ankle Society(AOFAS) scoring system. Imaging assessment was carried out by X-ray examination.ResultsThe patients were followed up for mean 21.2 months (range 6-48 months), which showedthatthe mean AOFAS ankle-hindfoot scale was increased from (54.67 ± 5.28 ) points (range43-61 points)preoperatively to (89.17 ±3.56) points (range 78-95 points) at finalfollow-up, with excellence rate of 93%. Eleven patients got good fusion with the mean timeof 12.4 weeks (range 9-15 weeks). Only one patient had nonunion, with the pain in thelateral malleolus. The subtalar joint of the patient got union after plasterimmobilization for three months, which was proved by X-ray examination. Conclusions Thearthroscopic percutaneous cannulated screw fixation and subtalar fusion can acquire goodclinical outcomes and hence is a recommended procedure for post-traumatic subtalararthritis.

Effect of Ankle Arthritis on Clinical Outcome of Lateral Ankle Ligament Reconstruction in Cavovarus Feet

Patients with idiopathic cavovarus deformity and lateral ankle ligament instability often present with varying degrees of ankle arthritis. The purpose of this study was to determine whether the severity of degenerative change would impact the clinical outcome in patients treated operatively for both cavovarus deformity and lateral ankle ligament instability. Twenty-two patients were treated with lateral ankle ligament reconstruction and realignment foot osteotomy. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Karlsson and Peterson (KP) scoring scale, Visual Analog Scale (VAS) for pain, and level of satisfaction were obtained. Preoperative and postoperative ankle radiographs were reviewed and graded using the van Dijk score. Patients with Grade 0 and I arthritis preoperatively were grouped together as ``no to minimal arthritis'' (Group 1) and those with Grade II and III arthritis preoperatively as ``moderate to severe arthritis'' (Group 2). There were 14 ankles in Group 1 and eight ankles in Group 2. Mean followup was 60.4 months. Mean AOFAS and KP scores were significantly improved in Group 1 compared to Group 2 at latest followup, while VAS pain scale trended lower in Group 1. There were 12 excellent/good results, one fair result, and one poor result in Group 1. Patients in Group 2 had three excellent/good results, two fair results, and three poor results. One of 14 patients in Group 1 had progression of arthritis, while five of eight patients in Group 2 either had progression of arthritis or required an ankle fusion. Patients treated with lateral ankle ligament reconstruction and cavovarus realignment osteotomy with no to minimal preoperative tibiotalar arthritis have higher clinical scores and increased satisfaction compared to patients with more advanced preoperative tibiotalar arthritis. A cautious and realistic approach should be followed when recommending surgical treatment for this patient population.

Long-term efficacy analysis of minimal incision osteotomy for treatment of hallux valgus

Objective To evaluate the long-term results of minimal incision osteotomy for hallux valgus.Methods From February 1996 to May 1999,372 cases(705 feet)with hallux valgus were treated with minimal incision osteotomy.Seventy-nine cases after surgery were followed up for more than 5 years,including 6 males(10 feet)and 73 females(140 feet)with an average age of 47 years(range,13-75 years).The average follow-up time was 7.5 years(range,5.3-13.2 years).The preoperative and postoperative hallux valgus angles(HVA),intermetatarsal angles(IMA),the tibial sesamoid position(TSP),American orthopedic foot and ankle society(AOFAS)score,range of movement of the first metatarsophalangeal joint,and lateral metatarsalgia etc.were observed and measured.And the clinic outcome were studied and evaluated.Results Based on Wen Jian-min's clinic curative effect evaluation criterion(2001),56 feet(37.3%)were excellent,88 feet(58.7%)good ,6 feet(4.0%)fair.The rate of excellent or good was 96.0%(144/150).The postoperative mean AOFAS score was 84.20±4.32 points(range,60-100 points).The mean HVA decreased from 33.28 to 12.31 degrees,the mean IMA from 11.75 to 6.80 degrees.The TSP was corrected from an average preoperative grade of 4.29 to a grade of 3.07 at final follow-up.There are no nonunion or delayed union of osteotomy,avascular necrosis of the 1st metatarsal head,infection,hallux varus.Four feet(2.7%)had numbness in the medial of the big toe.The 1st metatarsophalangeal joint range of motion decreased from 70.20 to 69.53 degrees.There were 97 feet(64.7%)with the 2-5 metatarsalgia before operation,and 35 feet(23.3%)disappeared,54 feet(36.0%)improved,8 feet(5.3%)aggravated after operation.Conclusion Minimal incision osteotomy technique is sound and reliable method to treat hallux valgus.The osteotomy technique is simple,and could provide satisfactory long-term results with lower complication rate. Key words: Hallux valgus; Surgical procedures,minimally invasive; Treatment outcome

Is nonoperative treatment still indicated for Jones fracture?

The issue of whether to treat Jones fracture surgically or nonsurgically is still controversial. In our institution, most acute Jones fractures are treated conservatively. This study assessed the functional outcomes of patients with acute Jones fractures that were treated conservatively by means of radiographic assessment, a physician-based scoring system and patient-based questionnaires. In this study, 25 patients with Jones fracture treated in our institution between January 2002 to December 2006, were retrospectively reviewed. Injuries were classified according to Jones' original description and the Torg classification. A simple patient satisfaction questionnaire was completed. Radiographic assessment of fracture union was recorded. Outcome instruments used were (a) the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating systemand (b) the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle outcome questionnaire. Of the 25 patients reviewed, 60% were very satisfied with the outcome, 28% were satisfied, 8% were fairly satisfied, and 4% were very dissatisfied. Based on radiographic and clinical assessments, one patient had delayed union and was treated surgically. The functional outcome scores were: mean AOFAS clinical rating score of 95.6 ± 7.7% (P < 0.005), mean AAOS foot and ankle score of 97.0 ± 4.4% (P < 0.005) and mean AAOS shoe comfort score of 90.2 ± 19.6% (P < 0.005). Acute Jones fracture can be treated conservatively with good functional outcome.