Objective To explore the effectiveness of anterolateral thigh fasciocutaneous flap for repair of skin and soft tissue defect and simultaneous Achilles tendon reconstruction with modified methods of ilio-tibial bundle suture. Methods Between October 2009 and June 2011, 10 cases of Achilles tendon and soft tissue defects were treated. There were 7 males and 3 females, aged from 5 to 60 years (median, 40 years). Injury was caused by spoke in 5 cases, by heavy pound in 3 cases, and by traffic accident in 2 cases. The time between injury and admission was 2-24 hours (mean, 8 hours). The size of wound ranged from 11 cm × 7 cm to 18 cm × 10 cm; the length of Achilles tendon defect was 4-10 cm (mean, 7 cm). Three cases complicated by calcaneal tuberosity defect. After admission, emergency debridement and vacuum sealing drainage were performed for 5-7 days, anterolateral thigh fasciocutaneous flap transplantation of 11 cm × 7 cm to 20 cm × 12 cm was used to repair skin and soft tissue defects, and improved method of ilio-tibial bundle suture was used to reconstruct Achilles tendon. The flap donor site was closed directly or repaired with skin grafting to repair. Results All flaps and the graft skin at donor site survived, healing of wounds by first intention was obtained. All patients were followed up 6-18 months (mean, 10 months). The flap was soft and flexible; the flap had slight encumbrance in 3 cases, and the others had good appearance. At last follow-up, two-point discrimination was 2-4 cm (mean, 3 cm). The patients were able to walk normally. The range of motion (ROM) of affected side was (24.40 ± 2.17)° extension and (44.00 ± 1.94)° flexion, showing no significant difference when compared with ROM of normal side [(25.90 ± 2.33)° and (45.60 ± 1.84)° ] (t=1.591, P=0.129; t=1.735, P=0.100). According to Arner-Lindhoim assessment method for ankle joint function, all the patients obtained excellent results. Conclusion A combination of anterolateral thigh fasciocutaneous flap for repair of skin and soft tissue defects and simultaneous Achilles tendon reconstruction with modified methods of ilio-tibial bundle suture is beneficial to function recovery of the ankle joint because early function exercises can be done.
It is difficult to treat the intra-articular fracture of distal tibia or Pilion’s fracture. From 1987 to 1995, 43 cases of Pilon’s fracture were admitted and treated with different methods. After treatment, they had been followed up for 1 to 8 years. According to Riiedi’s Classification, , there were type Ⅰ 12 cases, type Ⅱ 21 cases and type Ⅲ 10 cases. The methods used on these patients included manual reduction and plaster of paris immobilization, calcaneous tubercle traction and plaster of paris immobilization, open reduction and internal fixation with Kirschner wires, and open reduction and internal fixation with AO plate. The outcome was evaluated according to Ovadias criteria, for type I fracture, 8 cases were treated with conservative method with a satisfactory rate of 79.17% and 4 cases were treated with operation with a satisfactory rate of 91.67%; for type Ⅱ, conservative method for 12 cases and the satisfactory rate was 33.33%, and operation for 9 cases witha satisfactory rate of 70.37%; for type Ⅲ, conservative method for 2 cases, with poor result, and operation for 8 cases with satisfactory rate of 79.17%. The indication for conservative treatment was type I fracture. It showed that for Pilons fracture, the outcome of open reduction and internal fixation was superior to that of the conservative treatment, especially in those having internal fixation with AO plate.
Objective To evaluate the effectiveness of Ilizarov technique and tibiotalar or tibiocalcanean arthrodesis for one-stage treatment of ankle joints infection and bone defects. Methods Between January 2014 and April 2016, 14 patients with ankle joints infection and bone defects were treated by Ilizarov technique and tibiotalar or tibiocalcanean arthrodesis for one-stage. There were 12 males and 2 females with an average age of 39.8 years (range, 25-61 years). The causes of ankle infection included falling from height injury in 5 cases, falling injury in 4 cases, traffic accident injury in 1 case, crushing injury in 1 case, sprain injury in 1 case, and hematogenous reason in 2 cases. All the patients received surgery for 0-8 times (mean, 3.7 times) before admission. The modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was 30.25±3.54 before operation. The disease duration was 1-30 months (mean, 10.3 months). Results All the incisions healed by first intension without recurrence of infection, and two-stage bone grafting operation did not performed. One case felt slight local pain and swell of ankle joint after weight-bearing walking more than 30 minutes, and without special treatment. All the patients had different degree skin redness and swelling of Kirschner wire pinhole for 0-3 times, and relieved after symptomatic treatment. All the patients were followed up 6-27 months (mean, 16.8 months). Except for 2 cases who did not remove the external fixator (with external fixation time of 6 months and 8 months respectively), the other patients removed the external fixator at 6-14 months (mean, 9 months) after operation, all patients recovered the walk function and without ankle pain. The modified AOFAS ankle and hindfoot score after removal of external fixator (70.92±1.0) was significantly higher than preoperative one (t=–10.992, P=0.000). Conclusion It is a simple and effective method for one-stage treatment of ankle joints infection and bone defects by Ilizarov technique and tibiotalar or tibiocalcanean arthrodesis.
OBJECTIVE: To investigate the reparative and reconstructive method of post-traumatic lateral instability of the ankle. METHODS: From January 1992 to June 2000, 7 cases of male patients with ankle injury (aged 25-43 years) underwent Wetson-Jones modification. A bone tunnel was drilled through 2.5 cm upside the lateral malleolus tip and talus, and short peroneal tendon was cut to pass the tunnel to fix twining. RESULTS: All patients were followed up 2-10 years, 5 cases mineworkers changed to work on the ground, 2 patients returned to the original work, no traumatic arthritis occurred. According to Baird ankle joint scoring standard, the ankle function was excellent in all cases. CONCLUSION: Reformed Wetson-Jones modification can repair and reconstruct perfectly the traumatic instability of the ankle.
ObjectiveTo investigate the application of lateral malleolus hook-plate for the treatment of stageⅡsupination-adduction type medial malleolus fractures. MethodsBetween January 2011 and June 2013, 21 patients with stageⅡsupination-adduction type ankle fractures were treated with lateral malleolus hook-plate, including 12 males and 9 females with an average age of 55.5 years (range, 27-65 years). The injury causes were sprain in 17 cases and traffic accident in 4 cases. The mean time between injury and admission was 12.4 hours (range, 2-72 hours). The tibial distal medial articular surface collapse was found in 7 cases by CT examination and in 3 cases by X-ray film. Of 21 cases, there were 12 cases of low transverse fractures of lateral malleolus, 7 cases of short oblique fractures of lateral malleolus, and 2 cases of ankle joint lateral collateral ligament injury without fractures of lateral malleolus. After operation, the clinical outcome was evaluated according to the talus-leg angle, the recovery of Coin-sign continuity, inside-outside and top ankle gap, talus slope, American Orthopedic Foot and Ankle Society (AOFAS) score, Olerud-Molander score, Kofoed evaluation standards, and patient satisfaction. ResultsSeventeen cases were followed up 18.7 months on average (range, 12-25 months). Primary healing was obtained in 16 cases except 1 case of delayed healing. Fracture healed at an average of 14.6 weeks (range, 12-16 weeks). All cases achieved anatomical reduction, the continuity of Coin-sign, and consistency of inside and outside joint gap; no talus tilt occurred. There was no complication of reduction loss, loosening or breakage of internal fixation, or osteoarthritis during follow-up. The talus-leg angle of the affected side was significantly improved to (83.4±1.8)° at 1 week after operation from preoperative (74.8±7.1)° (t=5.370, P=0.000), but no significant difference was found when compared with normal side (83.8±2.3)° (t=0.676, P=0.509). The AOFAS score, Olerud-Molander score, and range of motion at 1 week, 3 months, and 1 year after operation were significantly improved when compared with preoperative ones (P < 0.05). According to Kofoed evaluation standard, the outcome was excellent in 15 cases and good in 2 cases; the excellent and good rate was 100%. According to patient satisfaction, the outcome was excellent in 13 cases, good in 3 cases, and poor in 1 case; the excellent and good rate was 94.1%. ConclusionThe use of lateral malleolus hook-plate for fixation of stageⅡsupination-adduction type medial malleolus fracture not only can effectively maintain anatomical reduction and supporting function, but also can prevent re-collapsing of the reset joint surface. The surgical method can not increase soft tissue complication, so it is a safe and effective method.
ObjectiveTo evaluate the advantage of single posterolateral approach for exposing the fragments of lateral malleolus and posterior malleolus in treating bimalleolar and trimalleolar fractures. MethodsBetween January 2013 and June 2015, 47 patients with ankle fractures were treated. Of 47 cases, 16 were male and 31 were female with an average age of 47.7 years (range, 25-65 years); the locations were the left side in 21 cases and the right side in 26 cases. According to types system of Lauge-Hansen, 11 cases were rated as pronation-external rotation and 36 cases as supination-external rotation. There were 9 cases of bimalleolar fractures and 38 cases trimalleolar fractures. CT examination showed that posterior malleolus fracture involved more than 35% of the joint surface in 11 cases, and 9 cases had comminuted posterior malleolus fracture. Of 47 cases, 44 had fresh fractures with a mean disease course of 4 days (range, 8 hours to 7 days), and 3 had old fracture with the disease course of 43, 58, and 62 days respectively. Posterior malleolus fractures were fixed with T-type plates in 12 cases, one-third tubular plates in 10 cases, and cannulated screws in 25 cases. ResultsThe operation time was 60-100 minutes (mean, 80 minutes); the bleeding volume was 50-100 mL (mean, 72 mL). Primary healing of incision was obtained in all patients, and no postoperative complications of infection, cutaneous necrosis, deep venous thrombosis, and sural nerve injury occurred. The CT examinations after operation showed anatomical reduction of fractures. All patients were followed up from 12 to 20 months (mean, 16 months). No fixation failure or reduction loss was found at last follow-up. All patients could walk normally. The active dorsiflexion of the affected ankles was within 5° less than normal side in 43 cases (91.5%) and 5-10° less than normal side in 4 cases (8.5%). The passive dorsiflexion of the affected ankles was within 5° less than normal side in 44 cases (93.6%) and 5-10° less than normal side in 3 cases (6.4%). According to the Olerud-Molander scoring system, the results were excellent in 40 cases, good in 5 cases, and fair in 2 cases; and the excellent and good rate was 95.7% at last follow-up. ConclusionThe single posterolateral approach could simultaneously expose the fragments of lateral malleolus and posterior malleolus, with less complication of the incision, short operation time, and clear exposure of posterior malleolus. The surgery could be performed under direct vision. It especially is suitable for bimalleolar and trimalleolar fractures with lateral malleolus and posterior malleolus.
Objective To summarize the function of fibula in stability of ankle joints.Methods Recent original articles were extensively reviewed, which were related to the physiological function and biomechanical properties of fibula, the influence of fibular fracture on stability of ankle joints and mechanism of osteoarthritis of ankle joints. Results The fibula had the function of weightbearing; and it was generally agreed that discontinued fibula could lead to intra articular disorder of ankle joint in children; but there were various viewpoints regarding the influence of fibular fracture on the ankle joint in adults. Conclusion Fibula may play an important role in stability of ankle joint.
Objective To evaluate the influence of lateral hinge fracture (LHF) on the early effectiveness of supramalleolar osteotomy (SMO) and to explore the related risk factors for LHF. Methods A total of 39 patients (39 feet) with varus-type ankle osteoarthritis treated with SMO between January 2016 and December 2022 were analyzed retrospectively. There were 10 males and 29 females, aged from 41 to 71 years (mean, 57.7 years). According to Takakura stage, there were 6 feet in stage Ⅱ, 19 feet in stage Ⅲa, and 14 feet in stage Ⅲb. The LHF was recognized by the immediate postoperative X-ray film. The osteotomy healing time and the changes of pain visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and tibiotalar angle (TT) before and after operation were compared between patients with and without LHF. The age, gender, affected side, body mass index, Takakura stage, preoperative VAS score, preoperative AOFAS score, preoperative TAS, preoperative TLS, preoperative TT, SMO correction angle, osteotomy distraction, distance from medial osteotomy to ankle joint line (MD), and distance from lateral osteotomy to ankle joint line (LD) were compared between with and without LHF patients, and further logistic regression analysis was used to screen the risk factors of LHF during SMO. Results All patients were followed up 12-54 months (mean, 27.1 months). During operation, 13 feet developed LHF (group A) and 26 feet did not develop LHF (group B). X-ray film reexamination showed that 1 patient in group A complicated with tibial articular surface cleft fracture had delayed osteotomy and healed successfully after plaster fixation; the osteotomy of other patients healed, and there was no significant difference in healing time between the two groups (P>0.05). At last follow-up, there were significant differences in VAS score, AOFAS score, TAS, TLS, and TT of the two groups when compared with preoperative ones (P<0.05), but there was no significant difference in the changes of above indicators before and after operation between the two groups (P>0.05). The differences in SMO correction angle, osteotomy distraction, and LD between with and without LHF patients were significant (P<0.05), and further logistic regression analysis showed that excessive LD was the risk factor of LHF during SMO (P<0.05). Conclusion Too high or too low lateral hinge position during SMO may lead to LHF, but as long as appropriate treatment and rehabilitation measurements are taken, the early effectiveness is similar to that of patients without LHF.
Objective To evaluate the operative procedure and the cl inical effectiveness of open reduction and internal fixation in the treatment of posterior malleolus fractures. Methods Between June 2005 and December 2008, 46 patients with posterior malleolus fractures were treated with open reduction and internal fixation and followed up. There were 29 males and 17 females with an average age of 47.7 years (range, 19-76 years). Fractures were caused by sprain in 17 cases, by fallingin 15 cases, by traffic accident in 12 cases, and by other reasons in 2 cases. The locations were left ankle in 25 cases and right ankle in 21 cases. There were 6 simple posterior malleolus fractures, 13 lateral and posterior malleolus fractures, and 22 trimalleolar fractures, and 5 lateral and posterior malleolus fractures accompanying by injury of deltoid l igament of ankle. According to Lauge- Hansen classification system, 13 cases and 9 cases were rated as supination-external rotation type III and type IV respectively, and 18 cases as pronation-external rotation type IV. According to Naoki’s classification of posterior malleolus fractures, there were 29 cases of posterolateral-obl ique type, 11 cases of medial-extension type, and 6 cases of small-shell type. Seven patients underwent emergency operation and 39 patients underwent selective operation. Results Two patients developed superficial infection, which was cured after dressing change, and the other incisions healed by first intention. Forty-six patients were followed up 37 months on average (range, 18-63 months). All fractures healed after 3 to 6 months (mean, 4.3 months). One patient developed lateral suralcutaneous nerve injury, and 9 patients had mild weight-bearing pain or discomfort. The results of American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score were excellent in 17 cases, good in 21 cases, and fair in 8 cases with an excellent and good rate of 83%. The mean visual analogue scale (VAS) score was 1.9 (range, 0-5). Conclusion The anatomic reduction and internal fixation can achieve the satisfactory results in the treatment of posterior malleolus fractures. The best treatment and fixation methods should be chosen based on different types of posterior malleolus fractures.
ObjectiveTo study the effect of different degrees of distal tibial varus and valgus deformities on the tibiotalar joint contact, and to understand the role of fibular osteotomy. MethodsEight cadaveric lower legs were used for biomechanical study. Nine conditions were included: normal ankle joint (group A), 10° varus (group B), 5° varus (group C), 5° valgus (group D), 10° valgus (group E) with fibular preserved, and 10° varus (group F), 5° varus (group G), 5° valgus (group H), and 10° valgus (group I) after fibular osteotomy. The joint contact area, contact pressure, and peak pressure were tested; and the translation of contact force center was observed. ResultsThe joint contact area, contact pressure, and peak pressure had no significant difference between group A and groups B to E (P>0.05). After fibular osteotomy, the contact area decreased significantly in groups F and I when compared with group A (P < 0.05); the contact pressure increased significantly in groups F, H, and I when compared with group A (P < 0.05); the peak pressure increased significantly in groups F and I when compared with group A (P < 0.05). There were two main anterior-lateral and anterior-medial contact centers in normal tibiotalar joint, respectively; and the force center was in anterior-lateral part, just near the center of tibiotalar joint. While the fibula was preserved, the force center transferred laterally with increased varus angles; and the force center transferred medially with increased valgus angles. However, the force center transferred oppositely to the medial part with increased varus angles, and laterally with increased valgus angles after fibular osteotomy. ConclusionFibular osteotomy facilitates the tibiotalar contact pressure translation, and is helpful for ankle joint realignment in suitable cases.