Objective To investigate the effectiveness and biomechanical analysis of 3 fixation methods of screw anterior-posterior fixation (SAPF), screw posterior-anterior fixation (SPAF), and buttress plate fixation (BPF) in treatment of posterior Pilon fractures. Methods Fifteen fresh-frozen skeleto-ligamentous lower leg specimens were harvested to establish the models of posterior Pilon fracture, and then fracture was fixed with BPF (n=5), SAPF (n=5), and SPAF (n=5). Vertical force was loaded to internal fixation failure in a speed of 1 cm/minute with servohydraulic testing machine. The instantaneous loads of 1 mm and 2 mm steps and the failure modes were recorded. Between May 2008 and December 2011, 56 patients with posterior Pilon fracture were treated with SAPF (SAPF group) in 11 cases, or SPAF (SPAF group) in 26 cases, or BPF (BPF group) in 19 cases. There was no significant difference in age, gender, injury cause, side, disease duration, and complications among groups (P gt; 0.05). Clinical and radiographic examinations were used to assess the reduction and healing of fracture; the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) were used to evaluate the functional outcomes. Results No breaking or bending was observed in all specimens, fixation failure was caused by cancellous bone compression. The instantaneous loads of 1 mm and 2 mm steps were the largest in BPF group, larger in SPAF group, and smallest in SAPF group, showing significant differences among 3 groups (P lt; 0.05). A total of 47 cases were followed up 16-54 months (9 in SAPF group, 22 in SPAF group, and 16 in BPF group), with a mean time of 35.2 months. Fixation failure was found in 2 cases of SAPF group; the other cases obtain bony union within 3 to 4 months (mean, 3.2 months) with no fixation failure. The AOFAS score was significantly lower in SAPF group than in SPAF and BPF groups (P lt; 0.05), but no significant difference was found between SPAF and BPF groups (P gt; 0.05). The VAS score was significantly higher in SAPF group than in SPAF and BPF groups (P lt; 0.05), but no significant difference was found between SPAF and BPF groups (P gt; 0.05). Conclusion SAPF could not reach enough fixation strength for the posterior Pilon fracture; both SPAF and BPF could reach rigid fixation, and have good effectiveness. And from the biomechanical points, BPF could reach better fixation strength than screw fixations.
Objective To investigate the functional outcomes of buttress plate fixation and simple screws fixation for the treatment of supination-adduction type-II medial malleolar fractures so as to provide reference for selection of internal fixation. Methods Between March 2009 and December 2012, 53 patients with supination-adduction type-II medial malleolar fractures were treated with open reduction and internal fixation. Of them, buttress plate fixation was used in 30 cases (buttress plate fixation group), and screws fixation was used in 23 cases (screw fixation group). There was no significant difference in age, gender, injury cause, injury side, disease duration, and combined injuries between 2 groups (P>0.05). Complications and full weight-bearing time were recorded; the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) were used to evaluate the functional outcomes. Post-operative anteroposterior and lateral X-ray films were taken to evaluate fracture reduction and union condition. And the treatment failures were recorded. Results There was no significant difference in incision related complication rate and infection rate between 2 groups (P>0.05). The patients were followed up 46-91 months (mean, 64.5 months) in buttress plate fixation group and 44-86 months (mean, 59.5 months) in screw fixation group. The full weight-bearing time of the buttress plate fixation group was significantly shorter than that of screw fixation group (t=2.05,P=0.04). During follow-up time, malunion and nonunion occurred in 2 cases and 1 case of screw fixation group; anatomic reduction and bony union were observed in the other patients of 2 groups. The union time showed no significant difference between 2 groups (t=1.06,P=0.30). No significant difference was found in AOFAS score and good and excellent rate, VAS score, operation failure rate, and traumatic osteoarthritis rate between groups (P>0.05). Conclusion For patients with supination-adduction type-II medial malleolar fracture, the angle between fracture line and tibial axial line is too small to be fixed firmly with simple screws fixation, with a relatively higher failure rate. And buttress plate fixation can reach rigid fixation, and has better functional outcomes.
Objective To evaluate the short-term effectiveness of Scarf osteotomy and Akin osteotomy combined with soft tissue procedures for hallux valgus associated with mild to moderate metatarsus adductus. Methods The clinical data of 30 patients (48 feet) who were diagnosised hallux valgus associated with mild to moderate metatarsus adductus and treated by Scarf osteotomy and Akin osteotomy combined with soft tissue procedures between February 2013 and May 2015 were analyzed retrospectively. There were 2 males (2 feet) and 28 females (46 feet) with an average age of 29.4 years (range, 18-50 years). The disease duration was 3-12 years (mean, 6.1 years). The degree of metatarsal adductus was assessed by Sgarlato’s measurement and Yu et al classification criteria, and the degree of metatarsal adductus was mild in 20 feet and moderate in 28 feet. Preoperative X-ray examination showed that the hallux valgus angle (HVA) was (39.4±5.6)°, the first-second intermetatarsal angle (1-2IMA) was (15.2±3.5)°, the metatarsus adductus angle (MAA) was (21.2±3.7)°. The American Orthopaedic Foot and Ankle Society (AOFAS) score was 51.7±10.0, and visual analogue scale (VAS) score was 4.9±2.7 before operation. Postoperative complications and the union time of osteotomies were recorded. At last follow-up, the HVA, 1-2IMA, and MAA were measured on X-ray films, and the AOFAS scores and VAS scores were recorded, then compared them with preoperative ones. Roles - Maudsley score was used to investigate patients’ satisfaction. Results All the incisions healed by first intention. Thirty patients were followed up 24-27 months (mean, 26.4 months). Three patients (4 feet) occured metatarsalgia, and the pain relieved after treated by Custom-Made Orthotics. All the osteotomies were unoin, the healing time was 2-4 months (mean, 2.7 months). At last follow-up, the HVA and the 1-2IMA were (13.2±3.1)° and (5.1±2.3)°, respectively, showing significant differences when compared with preoperative ones (t=14.606, P=0.000; t=22.356, P=0.000); the MAA was (21.0±3.4)° and there was no significant difference when compared with preoperative one (t=0.789, P=0.434). The AOFAS and VAS scores were 91.8±7.5 and 1.1±1.0, respectively, showing signifiant differences when compared with preoperative ones (t=13.787, P=0.000; t=14.781, P=0.000). Satisfaction survey showed that 28 patients were very satisfied and satisfied (93.3%), and 2 cases were not satisfied (6.7%). Conclusion The short-term effectiveness of Scarf osteotomy and Akin osteotomy combined with soft tissue procedures for hallux valgus associated with mild to moderate metatarsus adductus is satisfactory, and no correction is required for metatarsal adductus.
ObjectiveTo investigate the short-term effectiveness of talonavicular joint arthrodesis and calcaneus osteotomy in the treatment of Müller-Weiss disease. MethodsBetween June 2015 and February 2017, 14 patients diagnosed Müller-Weiss disease, who were ineffective on conservative treatment, were treated with talonavicular joint arthrodesis and calcaneus osteotomy. There are 3 males and 11 females, with an average age of 46.2 years (range, 35-56 years). According to the Maceira grading criteria, 5 patients were rated as stage Ⅲ and 9 patients as stage Ⅳ. The disease duration ranged from 4 to 12 years (mean, 7 years). Preoperative X-ray films showed that all patients were not accompanied with adjacent joint arthritis. The hindfoot axis on Saltzman view was (9.8±2.8)°, calcaneal pitch angle (CPA) on lateral position was (14.7±5.1)°, Meary angle on lateral position was (4.8±2.8)°, and talar 1 meta-tarsal angle (T1MA) on anteroposterior position was (25.0±7.3)°. Preoperative visual analogue scale (VAS) score was 5.9±1.5, American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot score was 58.8±17.6. ResultsAll patients were followed up 14-27 months (mean, 22.3 months). Medial numbness and incision infection occurred in 2, 2 cases, respectively. The other patients had no obvious discomfort. At last follow-up, VAS score was 1.6±1.3 and AOFAS score was 90.6±2.7, showing significant differences when compared with preoperative ones (t=8.18, P=0.00; t=–6.95, P=0.00). X-ray films showed that the talonavicular joint and calcaneus osteotomy achieved bony healing. The hindfoot axis on Saltzman view was (–2.5±2.7)°, CPA on lateral position was (25.0±5.2) °, Meary angle on lateral position was (2.6±2.1)°, T1MA on anteroposterior position was (8.1±3.8)°. There was no significant difference in Meary Angle between pre- and post-operation (t=1.53, P=0.15). And there were significant differences in the hindfoot axis, CPA, and T1MA between pre- and post-operation (t=11.93, P=0.00; t=–8.89, P=0.00; t=8.05, P=0.00). ConclusionFor Müller-Weiss disease patients without adjacent joint arthritis, who are ineffective on conservative treatment, the satisfied short-term effectiveness can be obtained when treated by talonavicular joint arthrodesis and calcaneus osteotomy.
Objective To investigate the effectiveness of calcaneal V-shaped osteotomy combined with subtalar arthrodesis in the treatment of Stephens Ⅱand Ⅲ calcaneal fracture malunion. MethodsThe clinical data of 24 patients with severe calcaneal fracture malunion treated by calcaneal V-shaped osteotomy combined with subtalar arthrodesis between January 2017 and December 2021 were retrospectively analyzed. There were 20 males and 4 females with an average age of 42.8 years (range, 33-60 years). Conservative treatment of calcaneal fracture failed in 19 cases and operation failed in 5 cases. Stephens classification of calcaneal fracture malunion was type Ⅱ in 14 cases, and type Ⅲ in 10 cases. Preoperative Böhler angle of calcaneus was 4.0°-13.5° (mean, 8.6°), Gissane angle was 100°-152° (mean, 119.3°). The time from injury to operation was 6-14 months (mean, 9.7 months). American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analogue scale (VAS) score were used to evaluate the effectiveness before operation and at last follow-up. Bone healing was observed and the healing time was recorded. The talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were measured. Results Necrosis of the cuticle edge of the incision occurred in 3 cases, which were cured by dressing change and oral administration of antibiotic therapy. The other incisions healed by first intention. All the 24 patients were followed up 12-23 months, with an average of 17.1 months. The foot shape of the patients recovered well, the shoes were restored to the size before injury, and there was no anterior ankle impingement. Bone union was achieved in all patients, and the healing time ranged from 12 to 18 weeks, with an average of 14.1 weeks. At last follow-up, no adjacent joint degeneration occurred in all patients; 5 patients had mild foot pain during walking, which had no significant impact on daily life and work; no patient needed revision surgery. The AOFAS ankle and hindfoot score was significantly higher than that before operation (P<0.001), the results were excellent in 16 cases, good in 4 cases, and poor in 4 cases, and the excellent and good rate was 83.3%. The VAS score, talocalcaneal height, talus inclination angle, Pitch angle, calcaneal width, and hindfoot alignment angle were significantly improved after operation (P<0.001). ConclusionCalcaneal V-shaped osteotomy combined with subtalar arthrodesis can effectively relieve hindfoot pain, correct talocalcaneal height, restore talus inclination angle, and reduce the risk of nonunion after subtalar arthrodesis.
ObjectiveTo compare the clinical and radiographic outcomes of bioabsorbable screw and metallic screw for Maisonneuve fracture.MethodsThe clinical data of 68 patients of Maisonneuve fracture treated with open reduction and internal fixation between October 2012 and October 2016 were retrospectively analyzed. Metallic screw fixation was used in 37 cases (group A) and absorbable screw fixation was used in 31 cases (group B). There was no significant difference in age, gender, weight, operated side, cause of injury, time from injury to operation, and complications between the two groups (P>0.05). At last follow-up, the tibiafibular clear space (TFCS), tibiafibular overlap (TFO), medial clear space (MCS), and syndesmotic malreduction rate were recorded. And the dorsiflexion and plantar-flexion range of motion, pain visual analogue scale (VAS) score, ankle and hind foot score of American Orthopaedic Foot and Ankle Society (AOFAS), and Olerud-Molander (OM) score were recorded.ResultsAll patients were followed up 25-43 months, with an average of 32.3 months. There was no significant difference in the operation time between the two groups (t=1.229, P=0.282). All the fractures healed, and there was no significant difference in fracture healing time between the two groups (t=1.367, P=0.413). At last follow-up, the syndesmotic malreduction rate of group A was 16.2% (6/37), showing no significant difference when compared with group B [6.2% (2/31)] (χ2=1.549, P=0.213). There were 3 complications in group A, 1 was superficial wound infection, 1 was local heterotopic ossification due to failure to remove the screws in time, 1 was local heterotopic ossification of the screws; and there were 2 complications in group B, 1 was rejection and 1 was local heterotopic ossification of the screws. There was no significant difference in the incidence of complications between the two groups (χ2=0.068, P=0.794). There was no significant difference in TFCS, MCS, TFO, ankle dorsiflexion and plantar-flexion range of motion, AOFAS score, OM score, and VAS score between the two groups at last follow-up (P>0.05).ConclusionCompared with metallic screw, absorbable screws provide adequate fixation and functional recovery with avoiding screw removal and lower syndesmotic malreduction.
ObjectiveTo investigate the effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy.MethodsThe clinical data of 21 patients with unilateral foot drop secondary to peroneal nerve palsy between October 2009 and September 2016 was retrospectively analyzed. There were 12 males and 9 females with an average age of 32.1 years (range, 23-47 years). The causes of peroneal nerve injury were iatrogenic injury in 7 cases, tibiofibular fractures combined with compartment syndrome in 5 cases, nerve exploration surgery after stab or cut injury in 3 cases, direct violence in 4 cases, and the fibular head fracture in 2 cases. The average time from injury to operation was 5.6 years (range, 2-8 years). There was 1 case of hallux valgus and 5 cases of toe flexion contracture. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, Foot and Ankle Ability Measure (FAAM) scores, range of motion (ROM), and dorsiflexion strength of ankle joint were used to evaluated the ankle function. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, and hindfoot alignment angle.ResultsAll incisions healed by first intention. All patients were followed up 18-42 months (mean, 30.2 months). The dorsiflexion strength of ankle joint recovered from grade 0 to grade 3-4 after operation. There was no patient with a postoperative flat foot deformity and claw toe during follow-up. There was no significant difference in Meary angle, calcaneal pitch angle, and hindfoot alignment angle between pre- and post-operation (P>0.05). The AOFAS score, FAAM score, and ROM of dorsiflexion significantly improved at last follow-up when compared with preoperative values (P<0.05); while there was no significant difference in ROM of plantar-flexion between pre- and post-operation (t=4.239, P=0.158). There were significant differences in AOFAS score, FAAM score, and ROM of dorsiflexion between affected and healthy sides (P<0.05); but no significant difference in ROM of plantar-flexion was found (t=2.319, P=0.538).ConclusionTibialis posterior tendon transfer is an effective surgical option for foot drop secondary to peroneal nerve palsy. And no postoperative flat foot deformity occurred at short-term follow-up.