ObjectiveTo summarize the current status and progress of the treatment of chronic lateral ankle instability (CLAI). MethodsThe literature about the anatomical repair of CLAI at home and abroad was reviewed and summarized. ResultsBroström and its modified operations are the most common surgical treatment of CLAI. The operations showed satisfactory clinical outcomes in the short-, medium-, and long-term follow-up and low complication rate. Suture anchor technique and arthroscopic techniques are gradually used in Broström and its modified operations with satisfactory short-term effectiveness, but long-term effectiveness needs further observation because of the limitation of the short clinical application time. ConclusionBroström and its modified operations are effective, convenient, and safe to treat CLAI. Based on the researches of biomechanics and dynamic anatomy, the more personalized design of the rehabilitation program is the further research direction.
Objective To evaluate the effectiveness of Ilizarov external fixation and ankle arthrodesis in the treatment of late traumatic ankle arthritis. Methods Between June 2013 and June 2015, 27 patients with late traumatic ankle arthritis were treated with Ilizarov external fixation technique. There were 16 males and 11 females with an age of 27-69 years (mean, 45.7 years). Sixteen cases were on the left side, 11 on the right side. All the patients suffered from traumatic ankle fractures or ligament damages caused by initial traumas. After 6 months of standard conservative treatment, the results was invalid and all patients had ankle joint pain and movement disorders. The disease duration was 3-39 years (mean, 11.5 years). According to Takakura ankle arthritis staging, there were 16 cases in stage 3 and 11 cases in stage 4. The tibial-talar angle before operation was (102.55±4.02) ° measured on conventional double-feet loading anteroposterior and lateral X-ray films. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and foot joint score was 45.72±6.45, and the visual analogue scale (VAS) score was 8.61±1.96. Results All the patients were followed up 15-42 months (mean, 28.1 months). All ankles achieved bony fusion, the clinical healing time was 12.9 weeks on average (range, 11-18 weeks). No persistent bleeding in the incisions and needle tract occurred during the follow-up. There were 4 cases of mild needle infection, 2 cases of anterior dislocation of talus, and 3 cases with different degree of limited activity. No traumatic bone defect, bone disconnection, and false joint formation was observed. At 12 months after operation, the AOFAS ankle and foot joint score, VAS score, and tibial-talar angle were 80.53±9.14, 2.77±0.82, and (94.36±2.48)°, respectively, which were significantly improved when compared with preoperative ones (t=16.17, P=0.00; t=14.28, P=0.00; t=9.01, P=0.00). The effectivenss was excellent in 9 cases, good in 13 cases, and fair in 5 cases, with an excellent and good rate of 81.5%. Conclusion Satisfactory effectiveness can be obtained through Ilizarov external fixation and ankle arthrodesis in the treatment of traumatic ankle arthritis, showing certain application prospect, while long-term effectiveness should be comfirmed by large sample randomized controlled trials.
Objective To compare the short-term effectiveness of repairing distal tibiofibular syndesmosis with metal screws and absorbable screws. Methods A retrospective analysis was performed on the clinical data of 63 patients with ankle fracture combined with injury of the distal tibiofibular syndesmosis admitted between January 2017 and January 2020. Among them, 31 patients were treated with absorbable screw fixation of the distal tibiofibular syndesmosis (research group) and 32 patients were treated with metal screw fixation of the distal tibiofibular syndesmosis (control group). There was no significant difference in gender, age, cause of injury, surgical side, time from injury to operation, fracture type, preoperative visual analogue scale (VAS) score, and American Orthopaedic Foot & Ankle Society (AOFAS) score between the two groups (P>0.05). The operation time and fracture healing time were recorded and compared between the two groups. X-ray film was taken to evaluate the effect of ankle joint reduction and fixation. Olerud-Molander ankle fracture efficacy score (short for OM score), AOFAS score, and VAS score were used to evaluate the effectiveness. Results There was no significant difference in operation time between the two groups (t=−0.683, P=0.497). In the control group, 1 case of delayed healing and 1 case of poor healing occurred in the lateral incision after operation, which healed after dressing change; the rest of the patients had primary healing of the incision. Patients in both groups were followed up 12-24 months, with an average of 13.8 months. In the control group, 1 patient with fracture of pronation and external rotation walked with full weight bearing after removing the metal screw of the distal tibiofibular syndesmosis at 8 weeks after operation, the anatomical plate of the lateral malleolus was broken, and the lateral malleolus was fixed again and recovered after 5 months; 1 patient had mild ankle pain after operation, and the pain disappeared after removing the metal screw of the distal tibiofibular syndesmosis at 8 weeks. No complication such as nerve and blood vessel injury occurred in all patients. There was no significant difference in fracture healing time between the two groups (t=−1.128, P=0.264). The AOFAS and VAS scores significantly improved in both groups at 12 months after operation (P<0.05). There was no significant difference between the two groups in the OM scores, and the difference of AOFAS and VAS scores between before and after operation (P>0.05). Conclusion Using absorbable screws to repair the distal tibiofibular syndesmosis can effectively restore the ankle acupoint structure, prevent ankle instability, and restore good ankle function. There is no significant difference in effectiveness between absorbable screws and metal screws, and there is no need for secondary operation to remove screws.
ObjectiveTo study the effectiveness of tibial transverse transport combined with the antibiotics embedded bone cement in the treatment of chronic infection of foot and ankle with lower extremity ischemic diseases.MethodsA retrospective analysis was performed on 28 patients with ischemic diseases of lower extremities associated with chronic foot and ankle infection who were treated with tibial transverse transport combined with antibiotic bone cement between August 2015 and October 2019. There were 22 males and 6 females, with an average age of 65.6 years (range, 41-86 years). There were 25 cases of diabetic foot, 2 cases of arteriosclerosis obliterans, and 1 case of thromboangiitis obliterans. The course of infection ranged from 1 to 27 years, with an average of 14.9 years. The healing condition and time of foot and ankle in all patients were recorded and compared, and the Wagner grading and WIFi (W: lower extremity wound classification; I: ischemic classification; Fi: foot infection classification) grading were compared before and at last follow-up.ResultsThe wound surface of 1 diabetic foot patient improved at 111 days after operation, without purulent secretion, and lost follow-up. The remaining 27 cases were followed up 5 to 21 months (mean, 8.4 months). There was no necrosis in the tibial osteotomy incision and the local flap. After operation, 21 cases showed needle reaction of external fixator, but the needle infection gradually improved after the corresponding treatment. Among the 24 patients with diabetic foot, 1 died of multiple organ failure due to pulmonary infection. Acute lower extremity vascular embolism occurred in 1 case, and the foot was amputated due to acute gangrene. In the remaining 22 cases, the wound healing time of foot and ankle was 2.5-11.0 months (mean, 4.6 months). At last follow-up, Wagner grading and WIFi grading of the patients were significantly improved when compared with those before operation (P<0.05). One patient with thromboangiitis obliterans had foot and ankle healing at 6 months after operation. Two patients with lower extremity arteriosclerosis obliterans had foot and ankle healing at 16 and 18 months after operation, respectively.ConclusionTibial transverse transport combined with the antibiotics embedded bone cement is effective in treating chronic infection of foot and ankle with lower extremity ischemic diseases.
Objective To summarize the short-term effectiveness of the surgical treatment for grade III pronation-external rotation ankle fractures. Methods Between October 2011 and May 2015, 36 patients with pronation-external rotation ankle fractures (grade III) were treated with internal fixation and repair of the anterior lower tibiofibular ligament, including 21 males and 15 females with an average age of 45.2 years (range, 21-72 years). Injury was caused by sprain in 19 cases, by traffic accident in 6 cases, and by falling from height in 11 cases. All patients had closed fractures, with no blood vessel and nerve injury. The locations were the left ankle in 13 cases and the right ankle in 23 cases. The time from injury to operation was 3 to 10 days (mean, 6.5 days). At last follow-up, ankle function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) ankle-foot score, and the improvement of pain was evaluated by visual analogue scale (VAS). Results Primary healing of incision was obtained in all patients, no incision infection and skin necrosis occurred. Twenty-eight patients were followed up 12-36 months (mean, 17.5 months). X-ray films showed bone union was achieved within 2.6-5 months (mean, 3.2 months). No fracture of internal fixation and disruption of tibiofibular diastasis occurred. At last follow-up, according to AOFAS score for ankle function evaluation, the pain score was 36.3±2.9, the function score was 44.3±3.2, the ligament condition score was 9.2±0.5, and the total score was 89.8±6.6; the results were excellent in 11 cases, good in 15 cases, and fair in 2 cases. VAS score was 1.6±0.5. The range of motion of the ankle was (13±5)° in dorsiflexion and (38±9)° in planteroflexion. Conclusion Repair of anterior tibial ligament is an effective method to treat tibiofibular diastasis injury in the surgical treatment of grade III pronation-external rotation ankle fractures, with convenient operation, and satisfactory short-term effectiveness.
Objective By comparing with traditional L-shaped plate, to explore the effectiveness of new Pilon plate in the treatment of type C Pilon fracture.Methods A clinical data of 57 patients with type C Pilon fractures who met the selection criteria between May 2018 and January 2020 was analyzed retrospectively. Thirty-two patients were treated with new Pilon plate (trial group) and 25 patients with traditional L-shaped plate (control group). There was no significant difference in gender, age, cause of injury, fracture side and type, the interval between injury and operation between the two groups (P>0.05). The operation time and complications of the two groups were recorded. X-ray films were taken after operation to assess the quality of fracture reduction according to the Burwell-Charnley classification and fracture healing. Ankle function was evaluated according to Johner-Wruhs scoring standard and American Orthopaedic Foot and Ankle Society (AOFAS) score.Results The operations of the two groups were completed successfully, and the operation time of the trial group was significantly shorter than that of the control group (t=–3.025, P=0.005). After operation, the incision necrosis occurred in 2 cases of the control group, and the incisions of other patients in both groups healed by first intention. All patients were followed up 8-16 months, with an average of 10.1 months. There was no significant difference in follow-up time between the two groups (t=0.433, P=0.667). X-ray films showed that the ankle reduction of the trial group was rated as excellent in 28 cases and good in 4 cases, with an excellent and good rate of 100%, while in the control group, the ankle reduction was rated as excellent in 15 cases, good in 5 cases, and fair in 5 cases, with an excellent and good rate of 80.0%. There was a significant difference in the excellent and good rate of fracture reduction between the two groups (Z=–2.565, P=0.010). The fracture healed in both groups, and the healing time was (16.59±3.78) weeks in the trial group and (17.80±3.81) weeks in the control group, and there was no significant difference between the two groups (t=–1.191, P=0.239). At last follow-up, according to Johner-Wruhs scoring standard, the ankle joint function in the trial group was evaluated as excellent in 25 cases and good in 7 cases, with an excellent and good rate of 100%; the AOFAS score was 90.9±4.5. In the control group, 16 cases were excellent, 5 cases were good, and 4 cases were fair, and the excellent and good rate was 84.0%; the AOFAS score was 85.2±10.0. The ankle function scores of the trial group was superior to that of the control group (P<0.05). During follow-up, except for 1 case of ankle traumatic arthritis in the control group, there was no complication such as ankle malunion, plate loosening and fracture, or fracture reduction loss in both groups.Conclusion Compared with the traditional L-shaped plate, the new Pilon plate in the treatment of type C Pilon fracture has the advantages of high reduction quality, reliable fixation, less irritation to soft tissue, high fracture healing rate, and satisfactory functional recovery of ankle joint.
ObjectiveTo investigate the clinical application of the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap in repair of foot and ankle defects.MethodsBetween October 2014 and October 2018, 18 cases with foot and ankle defects were treated. There were 12 males and 6 females with an average age of 32.8 years (range, 8-56 years). There were 11 cases of traffic accident injuries, 3 cases of falling from height injuries, and 4 cases of heavy objects injuries. The wound was at the dorsum of the foot in 9 cases, the heel in 4 cases, the lateral malleolus in 5 cases. The time from injury to flap repair was 7-34 days (mean, 19 days). The size of wound ranged from 6.0 cm×2.5 cm to 11.0 cm×6.0 cm. The foot and ankle defects were repaired with the peroneal artery terminal perforator propeller flap in size of 6 cm×3 cm-18 cm×7 cm, which donor site was repaired with the anterior tibial artery perforator propeller flap in size of 8 cm×3 cm-16 cm×6 cm.ResultsOne patient had a hemorrhagic swelling in the peroneal artery terminal perforator propeller flap, and survived after symptomatic treatment. All recipient and donor sites healed by first intention. Eighteen patients were followed up 6-15 months (mean, 12.5 months). At last follow-up, the shape, color, texture, and thickness of the flaps in the donor sites were similar with those in the recipient sites. There were only linear scars on the donor sites. The two-point discrimination of the peroneal artery terminal perforator propeller flap ranged from 10 to 12 mm (mean, 11 mm). According to American Orthopaedic Foot and Ankle Society (AOFAS) score criteria, the results were excellent in 15 cases and good in 3 cases, with an excellent and good rate of 100%.ConclusionThe foot and ankle defects can be repaired with the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap. The procedure is not sacrificing the main vessel and can avoid the skin grafting and obtain the good ankle function.
ObjectiveTo compare the effectiveness of flexible fixation and rigid fixation in the treatment of ankle pronation-external rotation fractures with distal tibiofibular syndesmosis.MethodsA retrospective analysis was made on the clinical data of 50 patients with ankle pronation-external rotation fractures and distal tibiofibular syndesmosis treated between January 2013 and December 2015. Suture-button fixation was used in 23 patients (flexible fixation group) and cortical screw fixation in 27 patients (rigid fixation group). There was no significant difference in age, gender, weight, side, fracture type, and time from trauma to surgery between 2 groups (P>0.05). The operation time, medial clear space (MCS), tibiofibular clear space (TFCS), tibiofibular overlap (TFO), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Disability Index (FADI) score were compared between 2 groups.ResultsThe operation time was (83.0±9.1) minutes in the flexible fixation group and was (79.6±13.1) minutes in the rigid fixation group, showing no significant difference (t=1.052, P=0.265). All patients achieved healing of incision by first intention. The patients were followed up 12-20 months (mean, 14 months). The X-ray films showed good healing of fracture in 2 groups. There was no screw fracture, delayed union or nounion. The fracture healing time was (12.1±2.5) months in the flexible fixation group and was (11.3±3.2) months in the rigid fixation group, showing no significant difference between 2 groups (t=1.024, P=0.192). Reduction loss occurred after removal of screw in 2 cases of the rigid fixation group. At last follow-up, there was no significant difference in MCS, TFCS, TFO, AOFAS score and FADI score between 2 groups (P>0.05).ConclusionSuture-button fixation has similar effectiveness to screw fixation in ankle function and imaging findings, and flexible fixation has lower risk of reduction loss of distal tibiofibular syndesmosis than rigid fixation.
Objective To establish the finite element model of varus-type ankle arthritis and to implement the finite element mechanical analysis of different correction models for tibial anterior surface angle (TAS) in supramalleolar osteotomy. Methods A female patient with left varus-type ankle arthritis (Takakura stage Ⅱ, TAS 78°) was taken as the study object. Based on the CT data, the three-dimensional model of varus-type ankle arthritis (TAS 78°) and different TAS correction models [normal (TAS 89°), 5° valgus (TAS 94°), and 10° valgus (TAS 99°)] were created by software Mimics 21.0, Geomagic Wrap 2021, Solidworks 2017, and Workbench 17.0. The 290 N vertical downward force was applied to the upper surface of the tibia and 60 N vertical downward force to the upper surface of the fibula. Von Mises stress distribution and stress peak were calculated. Results The finite element model of normal TAS was basically consistent with biomechanics of the foot. According to biomechanical analysis, the maximum stress of the varus model appeared in the medial tibiotalar joint surface and the medial part of the top tibiotalar joint surface. The stress distribution of talofibular joint surface and the lateral part of the top tibiotalar joint surface were uniform. In the normal model, the stress distributions of the talofibular joint surface and the tibiotalar joint surface were uniform, and no obvious stress concentration was observed. The maximum stress in the 5° valgus model appeared at the posterior part of the talofibular joint surface and the lateral part of the top tibiotalar joint surface. The stress distribution of medial tibiotalar joint surface was uniform. The maximum stress of the 10° valgus model appeared at the posterior part of the talofibular joint surface and the lateral part of the top tibiotalar joint surface. The stress on the medial tibiotalar joint surface increased. Conclusion With the increase of valgus, the stress of ankle joint gradually shift outwards, and the stress concentration tends to appear. There was no obvious obstruction of fibula with 10° TAS correction. However, when TAS correction exceeds 10° and continues to increase, the obstruction effect of fibula becomes increasingly significant.
Objective To investigate the effectiveness of the lower abdominal conjoined flap with bilateral superficial inferior epigastric arteries (SIEA) for repairing the large soft tissue defects on the foot and ankle. Methods The clinical data of 18 patients with large soft tissue defects on foot and ankle treated between October 2017 and January 2020 were retrospectively analyzed, including 12 males and 6 females; the age ranged from 25 to 62 years, with a median age of 35 years. The causes of injury included machine injury in 9 cases, traffic accident injury in 5 cases, cutting injury in 2 cases, and electric injury in 2 cases. All wounds were accompanied by exposure of blood vessels, tendons, bones, and joints. Wound located at ankle in 8 cases, dorsum of foot in 6 cases, and sole in 4 cases. In the emergency department, complete debridement (the defect area after debridement was 15 cm×10 cm to 25 cm×16 cm) and vacuum sealing drainage on the wound was performed. The time from debridement to flap repair was 3-10 days, with an average of 5 days. According to the defect location and scope, the lower abdominal conjoined flap with bilateral SIEA was prepared. The size of the flap ranged from 15 cm×10 cm to 25 cm×16 cm. The length of vascular pedicle was 4.5-7.5 cm, with an average of 6.0 cm; the thickness of the flap was 0.5-1.2 cm, with an average of 0.8 cm. The abdominal donor site was closed in one-stage. Results One flap was altered as the conjoined flap with the bilateral superficial circumflex iliac artery because of the absence of the SIEA in one side. Except for 1 case of skin flap with distal necrosis, the flap healed after two-stage skin grafting repair; the rest skin flaps survived, and the wounds of the donor and recipient sites all healed by first intention. All patients were followed up 12-28 months, with an average of 16 months. The skin flap had a satisfactory appearance and soft texture, without abnormal hair growth or obvious pigmentation. Only linear scars were left at the donor site, and no complication such as abdominal hernia occurred. The foot and ankle function was satisfactory. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) scores were rated as excellent in 16 cases and good in 2 cases. Conclusion The lower abdominal conjoined flap with bilateral SIEA is an ideal flap for repairing large defects of foot and ankle with less morbidity scarcely, which ascribed to its ease of dissection, adjustable thinness, and concealed donor site, as well as the flexible perforator match.