Mean Time Of Bone Union Research Articles

Using 3D printing-assisted shaping titanium cages and Masquelet techniques to reconstruct calcaneal osteomyelitis complicated by extensive soft tissue and uncontrolled defects

ObjectiveTo investigate the clinical efficacy of three-dimensional (3D) printing-assisted shaping titanium cage combined with Masquelet technology in the treatment of calcaneal infectious defects. MethodsA retrospective analysis was performed of the data from nine patients with chronic calcaneal infection defects treated with distal gastronal flap coverage and one patient with free anterolateral thigh flap coverage, also using a 3D printing-assisted shaping titanium cage combined with both mask technology and rib autografting from January 2017 to January 2019. There were seven males and three females, with a mean age of 37 years (range, 17–52 years). The injury mechanism of the 10 patients included four motor vehicle incidents, four high fall injuries, and two rolling compactions. All patients were treated by two⁃stage procedures. The first stage included debridement, polymethyl methacrylate (PMMA) filling, and regional flap coverage. The soft tissue defect of the 10 cases included 80 cm2 in four cases and 56 cm2, 40 cm2, and 15 cm2 in each of two cases. The bone defect was 24 cm3 and 18 cm3 in each of four cases and 3 cm3 in two cases. The second stage was the mask technology of 3D printing-assisted shaping titanium cage combined with rib autografting. Time of bone union, calcaneus morphology, implant position, and the Maryland and AOFAS hind foot scores were recorded to evaluate the clinical outcome. ResultsAll 10 patients were followed up for a mean of 18.5 months (range, 12–30 months). Infection occurred in two patients 2 months after the first stage operation and were successfully treated by debridement and PMMA replacement. The incision of the other eight cases all healed successfully. Cultures from the 10 cases included five cases of methicillin-resistant Staphylococcus aureus, three cases of S. aureus, and one case each of Escherichia coli and Pseudomonas aeruginosa. All 10 patients exhibited calcaneus bone union after the second stage operation. The mean time for bone union was 4.32 (range, 3–8) months. Bone trabeculae were observed in a CT scan 13 (range, 10–22) months post-operation. The mean Maryland score at 12 months post-operation was 92 (range, 86–98) and the mean AOFAS ankle hind foot score was 89.8 (range, 83–100). ConclusionThree-dimensional printing-assisted shaping titanium cages and Masquelet technology may be effective methods for the treatment of infectious calcaneal defects.

Total hip arthroplasty associated with transverse subtrochanteric shortening osteotomy and conical stem fixation in Crowe type IV hip dysplasia.

Total hip arthroplasty (THA) in high-dislocated hip dysplasia is a surgical challenge, presenting difficulties in the biomechanical reconstruction of the hip. The purpose of the present study is to analyze clinical and radiological outcomes of a series of patients with Crowe type IV hip dysplasia who underwent a THA with transverse subtrochanteric shortening osteotomy and conical stem fixation in our Hip surgery unit. This non-interventional retrospective study included all patients diagnosed with Crowe type IV hip dysplasia who underwent a THA using a subtrochanteric shortening osteotomy and uncemented conical stem fixation between January 1, 2008, and December 31, 2015. Demographic, clinical and radiologic data were analyzed, including Harris Hip Score and Oxford Hip Score. Seventeen hips in 13 patients were included in the final analysis. All patients were women and mean age was 39years (range 35-45). Mean follow-up was 5.6years (range 1-8). Average length of the osteotomy was 3.4cm (range 3-4.5) and mean lowering of the center of rotation was 5.67cm (range 3.8-9.1). Mean time for bone union was 5.5months. No nerve palsy or non-union was detected at the end of follow-up period. The use of cementless conical stem fixation associated with a transverse subtrochanteric shortening osteotomy for treating Crowe type IV hip dysplasia permits to correct the rotational alterations of the femur and provides good stability of the osteotomy, with very low risk of nerve palsy and non-union rates.

External Locking Plate Fixation for Femoral Subtrochanteric Fractures.

IntroductionInternal fixation is the treatment of choice for subtrochanteric fractures in most conditions. However, it may be an unsuitable procedure for patients with poor health status, osteomyelitis, and surrounding soft tissue compromise. This study aimed to ascertain the viability and reliability of using external locking plate fixation for these difficult cases.MethodsEleven patients with femoral subtrochanteric fractures who received external locking plate fixation in our institute from January 2014 to December 2019 were enrolled in our study. The bone union time, wound complication, alignment, and necessity for narcotic agents were evaluated.ResultsThe average length of follow-up was 17.5 months (range, 14-26 months). The mean time for bone union was 17.7 weeks (range, 15-21 weeks). The indications included poor health condition, soft tissue compromise, and post-operative osteomyelitis. Pin tract infection was noted in two patients who were treated successfully with oral antibiotics administration and removal of the involved screws. Osseous union with varus deformity <10° was achieved in all patients except one. Three patients required an orally administered pain killer at the final visit. The average Harris Hip Score at one year post-operatively was 66.6 (range, 49-80).ConclusionsAlthough the current study only involved 11 patients, we believe that our method may serve as a valuable alternative for the treatment of a femoral subtrochanteric fracture in selected cases.Level of EvidenceLevel IV, retrospective case series

Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma: Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation.

In patients undergoing iliosacral resections, pelvic ring reconstruction can maintain stability of the pelvis and spinal column, which is expected to achieve good functional outcomes. However, no optimal reconstruction method has been established. We aimed to analyze the outcome of pelvic ring reconstruction using double-barreled free vascularized fibular graft (FVFG) and internal fixation after iliosacral resections in children. We retrospectively reviewed 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled FVFG after iliosacral resection. The fibular graft was placed between the supraacetabular region distally and the remaining ilium or sacrum proximally. The stability of the remaining pelvis and spinal column was provided by minimal spinal instrumentation. Eleven Type-I and 5 Type-I+IV resections were performed for 10 boys and 6 girls, who had a mean age of 13.4 years (range, 10 to 18 years). The mean follow-up was 49.8 months (range, 28 to 96 months). At the time of the final follow-up, 14 patients were alive and 2 patients had died of disease. The mean time for bone union was 9 months (range, 6 to 12 months). Graft hypertrophy was evident in all patients at 12 months. The median Musculoskeletal Tumor Society (MSTS) score at the time of the final follow-up was 80% (range, 60% to 96.6%). Seven patients had complications. Three complications required reoperation: 1 deep infection, 1 hematoma, and 1 wound dehiscence. Three patients had disease relapse in terms of lung metastases. This reconstruction method can achieve a high rate of bone union and can provide good functional outcomes following resection of pediatric pelvic Ewing sarcomas with iliosacral involvement. Complications are usually manageable without a need for revision surgical procedures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

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

Sinus tarsus mini incision approach with percutaneous reduction and fixation for Sanders II、III calcaneal fractures

Objective To explore the methods and clinical effect of the sinus tarsus mini incision approach with percutaneous fixation technique in the treatment of Sanders II, III calcaneus fractures. Methods From January 2015 to May 2016, the clinical data of 64 cases with Sanders II, III calcaneus fractures who were treated by sinus tarsus mini incision approach with percutaneous reduction and fixation were analyzed retrospectively. The average age was 46.64±10.51 years (range, 25-68) and 49 patients were males and 15 patients were females. According to Sander's classification, 39 patients were Sanders II and 25 were Sanders III fracture. Calcaneal varus was corrected and the length, width and height of bone were reduced by sinus tarsus mini incision approach with percutaneous fixation technique. Calcaneal fracture was treated by calcaneal bone plate combined with percutaneous screw fixation. Complications and operation procedure were recorded post-operation. Anteroposterior, lateral and axial views of preoperative and postoperative X-ray and CT scan were taken to assess the classification, restoration and intertion status of fracture. Radiological assessment was performed using Bohler's angle and Gissane's angle. Functional outcome was assessed using the Maryland foot score (MFS). Results All of the sixty-four patients were followed up for 12-18 months (average, 14.80±2.03). After surgery, only 4 cases of superficial necrosis of the incision were found, and the incisions were all healed and no infection occurred after surgery. No tendon tenosynovitis was seen after surgery. There were no fracture displacement, internal fixation failure, and fracture deformity healing cases. The mean time of bone union was 9.44±1.38 weeks (8-12 weeks) without fracture deformity healing case. The mean time of bone union was 9.17±1.16 weeks for the 23 cases with bone graft. For the 41 cases without bone graft, the bone healing average time was 9.91±1.62 weeks, and there is no statistically difference between cases with and without bone graft (t=1.936, P=0.061). Bohler's angle was 6.625°±4.904° (range, -5°-15°) preoperative, and improved to 31.031°±4.660° (range, 24°-40°), which had statistically significant difference (t=-28.863, P=0.000). Gissane's angle was from preoperative 76.094°±12.981° (range, 55°-105°) to 127.328°±6.486° (range, 115°-140°) at the time of the latest follow-up, and the difference had statistically significant (t=-28.246, P=0.000). Maryland Score: excellent 30 cases (22 cases of type II, 8 cases of type III), good 27 cases (15 of type II, 12 of type III), fair 7 cases (2 of type II, 5 of type III). The overall good rate was 89.06% (57/64). Conclusion The tarsal sinus minimally invasive small incision reduction and internal fixation combined with percutaneous reduction and fixation technique in the treatment of calcaneal fractures, exerts the advantages of small trauma, clear surgical exposure for reduction, reliable fixation, and low incision complications, which is applicable to treat the Sanders II, III calcaneal fractures. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal

Correction of flatfoot deformity by subtalar arthrodesis through single medial approach

Category: Hindfoot Introduction/Purpose: To study the clinical results using isolate medial approach to correct flatfoot deformity in subtalar joint arthrodesis. Methods: 14 patients with flatfoot deformity were treated using isolated subtalar joint arthrodesis from March 2011 to March 2014. There were 3 males and 11 females with an average age of 60.81 years (ranged from 51 to 75 years). They are all cases of posterior tibial tendon dysfunctions, 9 of Myerson type Ⅲ, 3 of Ⅱ(b) and 2 of Ⅱ(c). Results: The mean duration of surgery was 100.54 minutes (range, 91-124 minutes). 12 patients were followed up for 20.25 months in average (range from 12 to 48 months). All of the cases have healed well, and the mean time of bone union was 9.53 weeks (ranged from 8 to 17 weeks). No infection was found in any cases. A complication was observed 1 patient which is painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. The mean Kitaoka score increased from 43.67 to 80.81 Conclusion: Based on our experience with the procedure, the isolate subtalar joint arthrodesis is a useful alternative to triple arthrodesis for the correction of mild and some moderate flatfoot deformity.

Pasteurized autograft reconstruction after resection of periacetabular malignant bone tumours

BackgroundThe treatment of periacetabular malignant bone tumours is challenging. Many methods of reconstruction after internal hemipelvectomy have been reported and each method has its own limitations. The aim of this study was to evaluate the oncological and functional outcomes of pasteurized autograft reconstruction after resection of periacetabular malignant bone tumours.MethodsTen patients (six male, four female) with periacetabular malignant tumours, who underwent resection and reconstruction with pasteurized autograft, were retrospectively reviewed. The patients’ average age at diagnosis was 40 years (range 13–65 years). There were five patients with chondrosarcoma, three with osteosarcoma, one with Ewing’s sarcoma, and one with solitary metastatic thyroid carcinoma.ResultsAt the last follow-up, seven patients were alive (six with no evidence of the primary disease and one with lung metastasis for 5 months). The three other patients died of metastasis of the primary disease with a mean survival time of 12 (range 8–17) months postoperatively. The mean follow-up time for all patients was 45 (range 8–87) months. Local recurrence rate was 10%. The mean time of bone union was 12 (range 6–21) months after the operation. The mean Musculoskeletal Tumor Society score for all living patients at the last follow-up was 70.5% (range 43.3–86.7%).ConclusionsReconstruction with pasteurized autograft is a feasible method for treating periacetabular malignant bone tumours, with satisfactory oncological and functional outcomes and a relatively low incidence of complications.

Sanders II–III calcaneal fractures fixed with locking plate in elderly patients

PurposeTo evaluate the clinical outcomes of locking calcaneal plate in treating calcaneal fracture (Sanders II–III) in elderly patients. MethodsFrom October 2012 to December 2013, 23 elderly patients suffering from calcaneal fracture (Sanders II–III) were treated and followed up. There were 15 males and 8 females with the mean age of 68.5 years (range: 65–79 years). According to Sander's classification, 16 cases (16 feet) were type II fractures and 7 cases (7 feet) were type III fractures. Anteroposterior, lateral and axial views of X-ray were taken to detect the calcaneum. CT scan was done to assess the amount of comminution and articular depression. Radiological assessment was performed using Bohler's angle and Gissane's angle. Functional outcome was assessed using the Maryland foot score. ResultsAll the patients were followed up for 13.7 months on average (10–20 months). The mean time of bone union was 3.2 months (3–4 months). The mean time of complete weight bearing was 3.2 months (3.1–4.0 months). The soft tissue necrosis was found in 1 case. The mean Bohler's angle and Gissane's angle were 25.31° and 117.5° respectively. The overall excellent to good rate was 82.6%. ConclusionOpen reduction and internal fixation with locking calcaneal plate can obtain good functional outcome for Sanders II–III calcaneal fractures in elderly patients.

Nailing or plating for subtrochanteric femoral fractures: a non-randomized comparative study

The aim of the present study was to compare the outcomes of reverse less invasive stabilization system for distal femur (LISS-DF) plates and proximal femoral nail antirotation (PFNA) in the treatment of patients with subtrochanteric fracture. Thirty-one patients with 32 fractures were included in this study. The PFNA group consisted of 16 patients, and the reverse LISS-DF plate group consisted of 15 patients. Intraoperative data such as surgical time (min), amount of blood transfusion (units and erythrocyte suspensions) and radiation time (seconds) were noted. Time elapsed until fracture consolidation (weeks), time until full weight bearing (weeks), mean Harris hip score and length of stay (LOS) at hospital (days) were recorded postoperatively. The reverse LISS-DF group had a significantly longer elapsed time until fracture consolidation (p < 0.05). The mean radiation time was significantly longer (p < 0.05), and the Harris hip scores at last control were significantly higher (p < 0.05) compared with the PFNA group. No significant differences were determined in terms of complications and re-operation rates. This study demonstrated that in the reverse LISS-DF-treated group, the mean time for bone union was longer and weight bearing was delayed. Considering the surgical technique, minimal surgical approach, reduced amount of blood transfusion and superior functional results following surgery, we concluded that the PFNA system offers advantages over reverse LISS-DF plating in the treatment of subtrochanteric femur fractures.

Surgery for fractures of the medial process of calcaneal tuberosity

Objective To investigate the therapeutic outcomes of open reduction and internal fixation for fractures of the medial process of calcaneal tuberosity.Methods From January 2010 to January 2012,12 patients with fracture of the medial process of calcaneal tuberosity at 13 sides were treated by our department.They were 10 males and 2 females,with an average age of 30.5 years (range,20 to 39 years).One of the male patients suffered from bilateral fractures of the medial process of calcaneal tuberosity.The surgical treatments included open reduction,internal fixation by mini-plate or screws.In our cases,isolate screw fixation was used in 8 fractures,and mini-plate fixation was used in 5 fractures.Results Ten patients with 11 fractures were followed up for 14 months on average (range,12 to 24 months).All the cases healed uneventfully.No infection or fixation failure was found.The mean time of bone union was 11 weeks (range,8 to 13 weeks).Full weight bearing was achieved in a mean time of 12 weeks (range,9 to 14 weeks) with no obvious pain or discomfort.According to the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale,the mean score was 90.4 (range,84 to 100) at the final follow-up.Conclusions In the treatment of fractures of the medial process of calcaneal tuberosity,anatomic reduction and stable internal fixation is the key to recovery of the calcaneal morphology and normal gait.A suitable therapeutic strategy based on the fracture pattern can benefit the clinical outcomes. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal; Internal fixators

Comparison of lateral and posterior surgical approach in management of extra-articular distal humeral shaft fractures

ObjectiveThe objective of this study was to compare treatment results and complication rates between lateral and posterior approaches in surgical treatment of extra-articular distal humeral shaft fractures. Material and methodsBetween June 2008 and May 2012, a total of 68 patients with extra-articular distal humeral shaft fractures were treated by lateral and posterior approaches. Of the patients, 30 were operated by a lateral approach (group I) and 26 patients were operated by a posterior approach (group II). There was no statistical significance between the two groups in sex distribution, age, the mechanism of the injury, injured arms, AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) classification, and the time from injury to surgery (P>0.05). Operation time, intraoperative bleeding volume, hospitalisation, clinical outcomes, and complications were compared between the two groups. The elbow functional results were evaluated by the Mayo Elbow Performance Score (MEPS). ResultsAll patients were followed up. The average of follow-up in group I was 15.53±2.636 months (range, 12–22 months), and was 16.12±2.889 months (range, 12–22 months) in group II. There was no significant difference in the operation time, intraoperative bleeding time, and hospitalisation between the two groups (P>0.05). In group I, the mean time of bone union was 12.87±1.852 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 139.20°±3.274° (range, 134–146°), the mean degrees of elbow extension was 4.77°±1.906° (range, 0–8°), and the mean points of MEPS was 87.00±7.724 (range, 70–100 points). In group II, the mean time of bone union was 12.96±2.218 weeks (range, 10–16 weeks), the mean degrees of elbow flexion was 137.85°±4.076° (range, 130–145°), the mean degrees of elbow extension was 5.15°±2.327° (range, 0–9°), and the mean points of MEPS was 86.15±7.656 (range, 70–100 points). There was no significant difference in the bone union, range of elbow flexion, range of elbow extension and MEPS between the two groups (P>0.05). The overall complication rate in group I was lower than that in group II (P=0.041). ConclusionsBoth lateral and posterior surgical approaches acquired satisfied treatment results in the management of extra-articular distal humeral shaft fractures, and there was a lower complication rate using the lateral approach.

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

Prognostic Classification of Fifth Metatarsal Stress Fracture Using Plantar Gap

There have been diverse results even in same Torg type of fifth metatarsal stress fractures. Eighty-six cases with a fifth metatarsal stress fracture that were treated with modified tension band wiring from January 2003 to May 2009 were evaluated retrospectively. Each case was classified according to Torg's classification and a new classification. Using the new proposed classification, cases were subdivided into complete fracture and incomplete fracture. The cases of incomplete fracture were subdivided based on presence or absence of plantar gap more than 1 mm. After surgery, bone union was determined by CT. Statistical analysis of the Torg classification and time for bone union as well as the proposed new classification and time for bone union was performed. There was a significant difference in the time for bone union among the three Torg types (P = 0.004). The mean time for bone union in group A (complete fracture, n = 32) was 67.5 ± 28.8, and it was 103.2 ± 47.7 for group B (incomplete fracture, n = 54). There was a significant difference in time for bone union between them (P < 0.001). The mean time for bone union in group B1 (incomplete fracture, plantar gap less than 1 mm, n = 16) was 73.9 ± 26.7, and it was 115.5 ± 45.4 for group B2 (incomplete fracture, plantar gap 1 mm or more, n = 38). There was a significant difference in time for bone union between them (P < 0.001). The results of this study suggest that the classification incorporating the plantar gap might be used for classification of fifth metatarsal stress fractures. Level III, retrospective comparative series.

Composite biological reconstruction following total calcanectomy of primary calcaneal tumors

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy or aggressive benign tumor increasingly possible. However, reconstructions of the calcaneus remain a major surgical challenge because of the rarity and specific anatomy of this condition. we retrospectively reviewed 4 patients who had primary calcaneal tumors and underwent total calcanectomy and reconstructions with use of composite of allograft and vascularized osteocutaneous fibular grafts between 2007 and 2010. The diagnoses included chondrosarcoma in 1, fibrosarcoma in 1, aggressive osteoblastoma in 1, and giant-cell tumor in 1. Wide resection margins were achieved in all patients. The mean age at the time of the operation was 32.1 years. Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score. The median duration of follow-up was 24.5 months. No local recurrence occurred in this series and all patients had no evidence of disease at the time of final follow-up. Limb salvage was achieved in all patients. Revision surgery was necessary in two patients because of complications (skin flap necrosis and infection). The average MSTS 93 score and AOFAS score were 91.7% and 87.5 at the final follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. The overall mean time for bone union was 9.5 months. The mean time to full-weight bearing was 7 months. Vascularized fibular flaps in combination with massive allografts provide an excellent option for biological reconstruction after total calcanectomy in tumor situation and have proven to be a successful limb salvage procedure, which result in earlier patient recovery and return of function. Therapeutic Level IV.

Damage control orthopaedics in the context of battlefield injuries: The use of temporary external fixation on combat trauma soldiers

The purpose of this study was to analyze the use of temporary external fixation within the perspective of a damage control orthopedics attitude in the management of battlefield extremity injuries. Damage control orthopaedics (DCO) is a valuable treatment option for easy and rapid limb fracture stabilization in an unfavorable surgical environment. Sixteen French soldiers wounded on the battlefield between 2004 and 2009 and managed by damage control orthopedics were included in this retrospective series. All patients were males with a mean age of 30 years (20-53 years). Eighteen external fixators were applied on the theater of operations for multiple injuries (five cases), closed fractures of the pelvis or long bones (three cases) and open osteoarticular lesions (ten cases). After medical evacuation from original theater, conversion to internal fixation was possible in five cases. External fixation was maintained in thirteen cases due to the severity of the lesions or infectious complications. Bone union was achieved in all cases. The mean time for bone union was 2.8 months (2 to 3 months) in case of conversion to internal fixation, and 6.3 months (1.5 to 17 months) when external fixation was extended. To achieve bone union, three devices were removed after a three or four month period and converted to rigid internal fixation associated with bone grafting. No case of septic complication was observed after early conversion. The only case of post-conversion infection occurred after three months of external fixation. After a mean follow-up of 19 months (6 to 49 months) all patients recovered functional autonomy and thirteen could return to duty. When possible, early conversion from external to internal fixation improves bone union and functional recovery after war limb injuries in properly selected patients.

The Plantar Gap

Background: There have been diverse results, even in the same Torg type classification, in cases with fifth metatarsal stress fracture. Hypothesis: The “plantar gap” is correlated with the time for bone union and complications. It might be used for a prognostic factor. Study Design: Cohort study; Level of evidence, 3. Methods: Seventy-five cases with a fifth metatarsal stress fracture treated with modified tension band wiring from January 2003 to December 2008 were evaluated retrospectively. This consecutive series of patients included 71 male and 2 female patients with a mean of 19.8 years of age at the time of surgery. All of the enrolled patients were elite-level athletes. Each case was classified according to Torg classification and the degree of plantar gap was also measured. After the surgery, bone union was determined by computed tomography findings. Statistical analysis of the Torg classification and time for bone union, as well as plantar gap and time for bone union, was performed. Results: The mean time for bone union for each Torg type was 71.05 ± 21.77 days for type I, 104.48 ± 54.62 days for type II, and 122.92 ± 51.75 days for type III. There was a significant difference in the time for bone union among the 3 Torg types (P = .008). The mean time for bone union in group A (plantar gap <1 mm) was 71.21 ± 29.95 days and it was 126.4 ± 51.99 days for group B (plantar gap ≥1 mm) (significantly different; P < .001). In addition, there was a positive correlation of the time for bone union with the degree of plantar gap (ρ = .661, P < .001). In cases with Torg type II classification, there was a significant difference in the time for bone union between groups A and B (P < .001) In addition, there was a strong correlation between the time for bone union and the degree of plantar gap (ρ = .657, P < .001). There were 8 cases of nonunion in Torg type II, and 1 case in Torg III. With regard to the plantar gap, there was 1 case of nonunion in group A, and 8 cases in group B. Conclusion: The results of this study suggest that the plantar gap might be used for prognosis in cases with a fifth metatarsal stress fracture, even in patients with the same Torg classification.

Surgical treatment of the cuboid fractures

Objective To explore the operative methods of open reduction and fixation for the cuboid fractures. Methods The study involved 12 patients with cuboid fractures treated from October 2006 to October 2008. There were seven males and five females, at average age of 38.5 years (range 18-70 years). All patients had closed fractures, including 10 with compression fracture and two with sagittal fractures. The surgical treatments included open reduction, internal fixation by plate, screw or K-wire.Results Ten patients were followed up for 15 months on average ( range 12-24 months), which showed one stage wound healing, with mean time of bone union for 10 weeks ( range 8-15 weeks). No infection was found in any patient. The weight load walk began at 12 weeks ( range 8-18 weeks), with no obvious pain. According to American orthopaedic foot and ankle society (AOFAS) midfoot scale, the mean score was 88.6 (range 73-100). Conclusion Anatomic reduction and stable internal fixation of the cuboid fractures is the key point for recovery of foot form, stabilization and function of the feet. Key words: Tarsal bones; Fracture fixation, internal; Follow-up studies

Clinical treatment of Gustilo III open tibial fractures

Objective To study treatment protocols for Gustilo Ⅲ open tibial fractures. Methods Forty-six cases of open tibial fracture were treated surgically. They were 30 males and 16 females, with an average age of 31.2 years (range, 16 to 55 years) . The average time from injury to surgery was 8.5 hours (range, 4 to 24 hours). By Gustilo classification, there were 22 cases of ⅢA, 17 cases of ⅢB, and 7 cases of ⅢC. By AO classification, there were 3 cases of A3, 7 cases of B2, 9 cases of B3, 5 cases of C1, 11cases of C2, and 11 cases of C3. All the patients underwent debridement to clean the wounds. Two cases underwent vacuum-sealing drainage (VSD) before re-debridement. Flaps of different kinds were used. External fixation was used in 23 cases, plating in 11 and internal fixation with interlocking intramedullary nails in 12. Results All the patients were followed up for an average of 14. 2 months (range, 8 to 24 months).Satisfactory healing was obtained in 39 cases. Superficial infection occurred in 2 cases, skin edge necrosis occurred in 2 cases, deep infection occurred in 2 cases which was controlled by VSD. The infection rate was 10. 9%. The mean time of bone union was 4.5 months in 41 cases. Three cases of original external fixation were changed into intramedullary nail fixation and healed in 4 months. One case of plate breakage had to change into external fixation and healed 5 months later. One case of malunion was corrected by osteotomy. By Johner-Wruhs classification, 29 cases obtained excellent results, 14 good, 2 fair and one poor, with a good to excellent rate of 93.5%. Conclusion To achieve fine curative effects and prognosis, developing a good surgical plan may be more significant than following the strict requirement on timing of surgery. Key words: Tibial fractures; Fractures, open; Surgical flaps

Surgical treatment of flatfoot resulting from calcaneal fractures malunion

To explore the operative approach and efficacy of flatfoot after calcaneal fractures malunion. A total of 116 flatfoot patients after old calcaneal fractures were treated from January 1998 to January 2008. There were 94 males and 22 females with an average age of 33.5 years old (range: 16 - 46). They included unilateral flatfoot after old calcaneal fractures (n = 110) and bilateral flatfoot after old calcaneal fractures (n = 6). The surgical treatments included open reduction, calcaneal osteotomy without subtalar fusion or a reconstruction of calcaneal thalamus and subtalar arthrodesis. A total of 101 patients were followed up for an average of 14 months (range: 12 - 24). No wound healing problem or infection was observed. Solid union was obtained without redislocation in all patients. The mean time of bone union was 12 weeks (range: 10 - 14). The mean time of complete weight loading was 13 weeks (range: 11 - 15 weeks). The height of foot arch increased from 4.2 mm ± 1.7 mm to 14.1 mm ± 4.1 mm (P < 0.05). Calcaneal inclination angle increased from 11.2° ± 2.5° to 19.1° ± 4.4° (P < 0.05). Bohler angle increased from 5.4° ± 3.5° to 25.8° ± 5.2° (P < 0.05). Meary angle recovered from 22.2° ± 4.4° to 5.1° ± 3.2° (P < 0.05). The mean AOFAS Ankle and Hindfoot score increased from 33.4 (range: 27 - 43) to 85.8 (range: 78 - 98). As to flatfoot after old calcaneal fractures, surgical treatment has a favorable efficacy. A customized operative approach may achieve a satisfactory outcome.