Curative effect of wide pedicled double-vessel flap of posterolateral calf in repair of soft tissue defect in hind foot / 中华显微外科杂志

Objective:To explore the curative effect of wide pedicled with double-vessel flap of posterior lateral calf in repair of soft tissue defect in hind foot.Methods:From January 2018 to June 2021, 12 patients with soft tissue defects on hind foot were reconstructed with double-vessel flaps pedicled perforator of peroneal artery and sural nerve nutrient vessels in the Department of Trauma Orthopaedics, No.940 Hospital of Chinese People's Liberation Army Joint Service Support Force. The patients were 8 males and 4 females, aged 9-45(27.17±12.14) years old. Time after injury to admission was 6-24(10.17±4.80) hours. Six patients were with simple soft tissue defects, 2 with tendon defects, 3 with bone defects and 1 with postoperative infection due to an open fracture. The sizes of soft tissue defect ranged from 4 cm×5 cm-8 cm×12 cm. Soft tissue defects were reconstructed by transfer of posterolateral calf flaps, and the bone defects were repaired by phase I or phase II bone grafts or antibiotic cement and membrane induction according to the wound surface. For larger bone defects, stage-II bone transport was carried out to restore the length of the hind foot. Defects of Achilles tendon were reconstructed by direct suture or tendon transposition. Foot functions were evaluated by American Orthopaedic Foot and Ankle Surgery(AOFAS) ankle-posterior sufficient scale, visual analogue scale(VSA) score and flap healing. All patients were included in postoperative follow-up regularly through outpatient clinic or via WeChat.Results:All 12 patients had postoperative follow-up that lasted for 6-24(12.92±6.22) months. One flap developed dark purple colour with swelling at the distal end of the flap 3 days after surgery. It eventually healed after removed some sutures from the pedicle together with blood-letting on the flap surface. Three flaps developed local infection, and they were cured after debridement, dressing change and the use of sensitive antibiotics. The remaining 8 patients had achieved good appearance of flaps and normal ankle function. According to AOFAS, scores of ankle-posterior sufficiency scale increased from 14-45(25.25±5.42) before surgery up to 65-96(75.92±7.73) at the final follow-up. Of the 12 patients, 8 were in excellent, 2 in good and 2 in fair. The VAS scores decreased from 5-8(6.55±1.13) before surgery down to 0-4(1.55±1.37) at the final follow-up. The difference had statistics significance( P<0.01). All patients had satisfactory recovery of ankle function, with the extension at 15-20 degrees and plantar flexion of 30-40 degrees. The donor site healed well and all skin grafts survived. Conclusion:The double-vessel flap pedicled with perforating branch of peroneal artery and nutrient vessels of sural nerve can be used for reconstruction of soft tissue defect of hind foot. It achieved good surgical effects with reliable blood supply, smooth venous return, strong anti-infection ability, satisfactory appearance at donor site and flap itself, as well as a good recovery of foot function.

Ankle Height Preservation with the Hind Foot Nail and Iliac Crest Bone Blocks in Patients with Sequelae of Partial or Complete Talus Bone Loss

@#Introduction: The management of talus bone loss in trauma is difficult and unsatisfactory. This study assessed whether the height of the ankle was preserved when entire or partial talar bone loss was managed with hind foot intramedullary nail augmented with autogenous rectangular or trapezoidal cortico-cancellous bone blocks from the iliac crest in the presence of active or latent infection. Materials and methods: Four patients were included in the study from January 2011 to December 2017. In the first stage, all four patients underwent debridement of the ankle, total or partial excision of the talus, and antibiotic-loaded bone cement spacer (ALBC) placement in the ankle joint. The second stage of the arthrodesis procedure was initiated six to eight weeks after the primary procedure, where these patients underwent arthrodesis with hindfoot nail and bone blocks from the iliac crest. Results: All patients were followed-up for an average of 17.6 months (range 12.0 – 32.0 months). The arthrodesis site had united in all these four patients. The AOFAS scores were satisfactory in all patients. One patient underwent nail removal after the arthrodesis site had united. Conclusions: The hind foot nail with iliac crest bone block maintains the ankle height and ensures successful arthrodesis. In patients with partial/ complete bone loss with suspicion or confirmation of infection, staging the arthrodesis procedure minimises the chance of complications.

Anatomical calcaneal external fixator self-designed according to the morphology of heel / 中国修复重建外科杂志

Objective: The anatomical calcaneal external fixator was designed by measuring and calculating the morphological data of the heel. Methods: A total of 100 normal people were randomly selected to obtain 200 hind foot data, including 45 males and 55 females, with an average age of 43.9 years (range, 19-67 years). According to the principles of human engineering and local anatomy, the morphological data of the heel in the weight-bearing standing position and supine position were measured with the direct measurement mode. The heel length, heel width, heel height, medial ankle height, lateral ankle height, and calcaneal pitch angle (CPA) were measured by vernier calipers and ulnar markers in weight-bearing standing position, and the gender groups and left and right foot groups were compared; the shape of the hind foot in the supine position was measured by three-dimensional (3D) dot matrix inverse model method. According to the stereoscopic data of the comprehensive anatomical morphology of the heel, the anatomical calcaneal external fixator was designed with AutoCAD 2019 and other 3D industrial design softwares. Results: The measurements of shoe size, heel length, heel width, heel height, medial ankle height, lateral ankle height, and CPA in male were significantly higher than those in female ( P<0.05). There was no significant difference between the left and right feet in the other indexes except that the height of the medial malleolus of the left foot was significantly lower than that of the right foot ( t=-2.827, P=0.005). The measurement of 3D dot matrix inverse model in supine position showed that the heel part was non-circular arc edge, and many groups of arc edges fluctuate in a limited range. Based on the above data, an anatomical calcaneal external fixator was designed, which could fit the anatomic radian in theory, so as to be flexible in configuration. On this basis, the ordinary configuration, compression configuration, and orthodontic configuration were designed to meet the treatment needs of calcaneal fractures in different degrees. The ordinary configuration was suitable for patients with Sanders Ⅰ, ⅡA, and ⅡB calcaneal fractures with no or slight displacement of intra-articular fractures; the ordinary configuration was mainly used for simple fixing. The compression configuration was suitable for patients with Sanders ⅡC, ⅢA, and ⅢB, tongue fractures, and avulsion fractures with severe displacement of intra-articular fractures; the compression configuration used obliquely drawn console wires to fix the displaced bones. The orthodontic configuration was suitable for patients with Sanders ⅢC and Ⅳ calcaneal fractures with severe displacement of intra-articular fractures or severe calcaneal bone defects; the orthodontic configuration was a multi-module design, which took into account the stable fixation of the fracture and the arbitrary adjustment of the joint fixation angle. Conclusion: The hind foot is special for morphology, so the external fixator designed based on the vernier caliper measurement method and 3D dot matrix measuring plate measurement method is an anatomical type and its configuration can theoretically meet stable and flexible clinical needs.

Effect of preserving the integrity of peroneal tendon sheath on hindfoot function after calcaneus fracture surgery / 中国组织工程研究

BACKGROUND: Calcaneal fracture is the most common patella fracture. Traditionally, surgical treatment via an enlarged lateral approach is the gold standard method for the treatment of calcaneal fractures. However, this method can lead to joint stiffness and peroneal tendon adhesion to different extents, resulting in postoperative foot pain. OBJECTIVE: To investigate the effect of preserving the integrity of peroneal tendon sheath on hindfoot movement during open reduction and internal fixation of calcaneus fractures. METHODS: A total of 160 patients with displaced intra-articular calcaneus fractures who were admitted to the Department of Foot and Ankle Surgery, Affiliated Hospital of Binzhou Medical University from July 2016 to September 2017 were randomly divided into a control group and an experimental group. The classical lateral “L” incision was used in both groups. In the control group, the calcaneus was exposed by traditional dynamic retraction of the fibular tendon, while the experimental group was treated by static retraction with the preservation of fibular tendon sheath. The trial protocol was approved by the Ethics Committee of the Affiliated Hospital of Binzhou Medical University on February 18, 2016 with the approval No. 2016-G026-01. RESULTS AND CONCLUSION: There were 156 patients with complete follow-up data, 78 in the control group and 78 in the experimental group. The visual analogue scale scores on the first day, Bohler angle and Gissane angle at the 3rd month, and ankle dorsiflexion and plantar flexion angle at the 6th month of internal fixation were similar in the two groups. Hind foot valgus and varus angles at the 6th month of internal fixation and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores at the 1st year of internal fixation in the experimental group were better than those in the control group. Meanwhile, the excellent and good rate of Maryland hindfoot scoring system in the experimental group was higher than that in the control group at the last follow-up. There were four cases of incision complications in the control group (one case of infection and three cases of necrosis) and two cases of necrosis in the experimental group. These findings indicate that calcaneus fracture surgery with preserving the integrity of peroneal tendon sheath can significantly improve the mobility of the hindfoot, and improve the patient’s satisfaction, and meanwhile do not increase the incidence of incision complications.

Factores pronósticos asociados a los resultados de la artrodesis subastragalina / Pronostic factors associated with the results of subtalar arthrodesis

Resumen: Introducción: La artrodesis subastragalina o astrágalo calcánea, es un procedimiento de estabilización quirúrgica en la patología aislada de la articulación subastragalina que no responde a tratamiento conservador, su objetivo es obtener una fusión sólida de la articulación para eliminar o aminorar el dolor y mejorar la función, normalizando la distribución de cargas del pie y su alineación. Existen variables estudiadas que interfieren en el resultado quirúrgico de los pacientes tratados con artrodesis subastragalina como son: el tabaquismo, edad, sexo, artrosis, IMC, rehabilitación, material de osteosíntesis y la técnica quirúrgica. Objetivo: Conocer los factores pronósticos asociados a los resultados de la artrodesis subastragalina. Material y métodos: Estudio retrospectivo, longitudinal, descriptivo con revisión de expedientes y elaboración de estadística descriptiva de casos tratados de Agosto de 2012 a Enero de 2016 con artrodesis subastragalina para identificar factores pronósticos que afecten el resultado. Resultados: Se analizaron 29 pies, reportándose una artrodesis exitosa en 21 casos (72.4%), en 82.8% la técnica quirúrgica fue adecuada. La tasa de complicaciones fue de 20.7%. En la escala de la Sociedad Ortopédica Americana de Pie y Tobillo (AOFAS) 55.2% se reportaron como resultado muy bueno, 27.6% bueno y sólo 17.2% regular, se encontraron como factores asociados el sexo y la rehabilitación postoperatoria al buen resultado. Discusión: La artrodesis subastragalina brinda alivio en cuanto al dolor y mejoría en alineación, en nuestro servicio este procedimiento presenta una tasa de éxito de 72.4%, entre los factores asociados con significancia estadística fue la rehabilitación y el sexo.

Abstract: Introduction: Subtalar arthrodesis is a surgical stabilization procedure in the isolated pathology of the subastragaline joint that does not respond to conservative treatment, its goal is to obtain a solid fusion of the joint to eliminate or improve pain and function, normalizing the distribution of foot loads and alignment of the foot. There are studied variables that interfere with the surgical outcome of patients treated with subtalar arthrodesis such as: smoking, age, sex, osteoarthritis, BMI, rehabilitation, osteosynthesis material and surgical technique. Objective: To know the prognostic factors associated with the results of subastragaline arthrodesis. Material and methods: Retrospective, longitudinal, descriptive study with review of files and conducting descriptive statistics of treated cases of August 2012- Jan 2016 with subtalar arthrodesis to identify predictive factors affecting the outcome. Results: 29 feet were analyzed, reporting a successful arthrodesis in 21 cases (72.4%), in 82.8% the surgical technique was adequate. The complication rate was 20.7% On the AOFAS scale 55.2% were reported as a very good result, 27.6% good and only 17.2% regular. The factors associated with good outcome were sex and postoperative rehabilitation. Discussion: The subtalar arthrodesis provides improvement in pain and alignment, at our service this procedure presents a success rate of 72.4%, among the factors associated with statistical significance was rehabilitation and sex.

Clinics in diagnostic imaging (170)

A 30-year-old woman presented with a six-month history of left posterior heel pain. Physical examination revealed a tender, inflamed and indurated posterior heel with a visible bony prominence of the posterosuperior aspect of the calcaneus. Lateral ankle radiography showed a prominent left posterosuperior calcaneal tuberosity and thickening of the distal Achilles tendon outline. Magnetic resonance imaging demonstrated high-signal inflammatory fluid in the retrocalcaneal bursa, increased signal intensity and thickening of the Achilles tendon, and prominence of the posterior calcaneus tuberosity with reactive marrow oedema. The findings are consistent with Haglund's deformity. The patient underwent hind foot surgery after failing a six-month course of conservative therapy. There was no further recurrence of symptoms after surgery. The clinical and radiological features of Haglund's deformity are described, including a short discussion of other causes of hind foot pain.

Manejo del retropié plano valgo flexible con la férula tipo UCBL en pacientes pedátricos: [revisión] / Management of the flexible flat hindfoot valvus with orthesis type UCBL in pediatric patients: [review]

El tratamiento de las diversas deformidades del pie varia según las patologías y es precisamente en el niño por su gran plasticidad biológica, en quien se pueden aplicar los diferentes resursos que se poseen para el tratamiento ortopédico conservador. En el presente trabajo se plantea una alternativa para el tratamiento del retropié valgo, con la férula termo formada tipo UCBL (University of California Biomechanics Laboratory. Demostrar la utilidad de la férula tipo UCBL en el tratamiento conservador del retropié valgo para postegar y/o evitar tratamientos quirúrgicos por deformidades severas. La muestra utilizada fue de 15 pacientes (6 niñas, 9 niños, con edades entre 2 años 6 meses y 10 años) con disfunción del brazo de palanca por pérdida de la rigidez ósea, debido a la subluxación de la articulación sub-astragalina (retropié valgo flexible), en quienes se utilizó la férula termoformada tipo UCBL con seguimiento promedio de 12 a 36 meses. Se evaluó clínicamente la flexibilidad del pié y la maniobra de Silverskiold y radiologicamente en bípeda estación estática, el ángulo Costa-Bertani, Astrágalo calcáneo y astrágalo-1er metatarsiano. 10 pacientes presentaron mejoría clínica y radiológica, 5 de los casos no evidenciaron cambios, sin embargo, mantuvieron su flexibilidad. La férula resultó útil, inclusive en los casos donde no se demostró corrección radiológica, ya que evitó estructuración de la deformidad.

The adequate treatment for foot deformities varies depending on the pathology, and because of the high plasticity found in children, it is in this age group where the available conservative treatment resources can be applied. An alternative for the valgus hindfoot treatment is presented in this paper, using the UCBL (University of California Biomechanies Laboratory) thermoshaped orthesis. To prove utility of the thermoformed UCBL type orthesis in the treatment of flexible pes valgus in orden to avoid fuseverity deformities. The study included 15 patients (6 female, 9 male, ages between 2 years 6 months and 10 years) with lever-arm dysfunction due to loss of bony rigidity with sub-astragaline joint subluxation (flexible valgus hindfoot), in whom UCBL thermoshaped orthesis was indicated with an average follow up between 12 to 36 monts. Foot flexibility was clinical evaluated; also Silverskiold maneuver and static bipedestation x-rays angles were measured. Ten patients showed clinical and radiological improvement, 5 patients showed no change, although flexibility was maintained. The UCBL orthesis was useful, even in cases were no radiological change was observed, because it avoided structuration of bony deformity.