An Applied Anatomical Study on the Inferior Extensor Retinaculum of Ankle / Un Estudio de Anatomía Aplicada del Retináculo Extensor Inferior del Tobillo

SUMMARY: Through anatomical observations, the anatomical characteristics of the inferior extensor retinaculum of ankle (IER) of the ankle joint were elucidated, and its potential applications in treating lateral ankle instability or other conditions were discussed. A total of 12 adult foot specimens were dissected to expose the inferior extensor retinaculum of ankle, and a standard model was established. The pre-experimental scheme guided the recording of general findings, adjacent structures, lateral attachment in the tarsal sinus region, and influence on movement of inferior tendons. 1, attachment mean width: lateral band of IER 6.6±1.38 mm, oblique superomedial band of IER (32.3±3.97 mm), oblique inferomedial band of IER (30.0±5.30 mm) ; 2, mean length: lateral band of IER (78.1±4.20 mm) , oblique superomedial band of IER (14.2±0.80 mm), oblique inferomedial band of IER (71.8±2.61 mm); 3, maximum mean thickness: lateral band of IER (1.52±0.03 mm), oblique superomedial band of IER (0.89±0.05 mm), oblique inferomedial band of IER (0.73±0.16 mm); 4, the closest distance between IER and the tip of lateral malleolus: 23.9±0.83 mm; 5, mean width of the fiber tunnel:lateral fiber tunnel (11.9±1.16 mm), intermedium fiber tunnel (6.8±1.24 mm), medial fiber tunnel (8.6±0.79 mm); 6, mean distance from tunnel midpoint to lateral malleolar tip: lateral fiber tunnel (38.0±3.74 mm), intermedium fiber tunnel (69.8±4.15 mm), medial fiber tunnel (181.1±6.00 mm); 7, the distance between medial dorsal cutaneous nerve and the tip of lateral malleolus on the level of the IER (79.2±8.3 mm) the distance between intermediate cutaneous nerve of dorsum and the tip of lateral malleolus on the level of the IER (57.9±1.02 mm). The inferior extensor retinaculum of ankle is a crucial restraint unit of the anterior ankle tendon, and a comprehensive understanding of its anatomical characteristics holds significant implications for treating chronic ankle instability and exploring potential clinical applications.

A través de observaciones anatómicas, se dilucidaron las características anatómicas del retináculo extensor inferior (IER) de la articulación del tobillo y se discutieron sus posibles aplicaciones en el tratamiento de la inestabilidad lateral de esta articulación u otras afecciones. Se disecaron 12 muestras de pies de individuos adultos para exponer el retináculo extensor inferior del tobillo y se estableció un modelo estándar. El esquema preexperimental guió el registro de los hallazgos generales, las estructuras adyacentes, la inserción lateral en la región del seno tarsal y la influencia en el movimiento de los tendones inferiores. Se determino: 1. Ancho medio de inserción: banda lateral de IER (6,6 ± 1,38 mm), banda superomedial oblicua de IER (32,3 ± 3,97 mm), banda inferomedial oblicua de IER (30,0 ± 5,30 mm); 2. Longitud media: banda lateral de IER (78,1 ± 4,20 mm), banda superomedial oblicua de IER (14,2 ± 0,80 mm), banda inferomedial oblicua de IER (71,8 ± 2,61 mm); 3. Espesor medio máximo: banda lateral de IER (1,52 ± 0,03 mm), banda superomedial oblicua de IER (0,89 ± 0,05 mm), banda inferomedial oblicua de IER (0,73 ± 0,16 mm); 4. Distancia más próxima entre IER y el ápice del maléolo lateral: (23,9 ± 0,83 mm); 5.Ancho medio del túnel de fibra: túnel de fibra lateral (11,9 ± 1,16 mm), túnel de fibra intermedio (6,8 ± 1,24 mm), túnel de fibra medial (8,6 ± 0,79 mm); 6. Distancia media desde el punto medio del túnel hasta la punta del maléolor lateral: túnel de fibra lateral (38,0 ± 3,74 mm), túnel de fibra intermedio (69,8 ± 4,15 mm), túnel de fibra medial (181,1 ± 6,00 mm); 7. Distancia entre el nervio cutáneo dorsal medial y el a´pice del maléolo lateral en el nivel del IER (79,2 ± 8,3 mm); la distancia entre el nervio cutáneo intermedio dorsal y el ápice del maléolo lateral en el nivel del IER (57,9 ±1,02 mm). El retináculo extensor inferior del tobillo es una unidad de restricción crucial del tendón anterior del tobillo, y una comprensión integral de sus características anatómicas tiene implicaciones significativas para el tratamiento de la inestabilidad crónica del tobillo y la exploración de posibles aplicaciones clínicas.

An Assessment of Ankle Function, Oxidative Damage, and Inflammatory Factor Levels in Minimally Invasive Ankle Joint Fusion Surgery for the Treatment of Traumatic Ankle Osteoarthritis

SUMMARY: Traumatic ankle osteoarthritis is a degenerative condition resulting from traumatic injuries. The objective of this study was to evaluate the impact of minimally invasive ankle joint fusion surgery on ankle function, oxidative damage, and inflammatory factor levels in traumatic ankle osteoarthritis patients. A total of 112 traumatic ankle osteoarthritis patients treated in our hospital from January 2022 to January 2023 were enrolled. They were randomly rolled into a control group (Group C) and an experimental group (Group E), with the former undergoing conventional open ankle joint fusion surgery and the latter receiving minimally invasive ankle joint fusion surgery. A comparison was made between the two groups based on American Orthopedic Foot and Ankle Society (AOFAS), bony fusion rates, and visual analog scale (VAS) scores at pre-operation, and at 1, 2, and 3 months post-operation. Additionally, serum oxidative damage indicators and inflammatory factor levels were measured to evaluate the recovery effects in both groups. Relative to Group C, Group E showed drastically increased AOFAS scores and bony fusion rates (P<0.05), as well as greatly decreased VAS scores (P<0.05). Moreover, Group E exhibited more pronounced improvements in oxidative damage indicators and inflammatory factors versus Group C (P<0.05). Minimally invasive ankle joint fusion surgery drastically improves ankle function in traumatic ankle osteoarthritis patients and reduces levels of oxidative damage and inflammatory response. This provides an important clinical treatment option.

La osteoartritis traumática del tobillo es una afección degenerativa resultante de lesiones traumáticas. El objetivo de este estudio fue evaluar el impacto de la cirugía mínimamente invasiva de fusión de la articulación talocrural sobre la función del tobillo, el daño oxidativo y los niveles de factor inflamatorio en pacientes con osteoartritis traumática del tobillo. Se inscribieron un total de 112 pacientes con artrosis traumática de tobillo tratados en nuestro hospital desde enero de 2022 hasta enero de 2023. Fueron divididos aleatoriamente en un grupo de control (Grupo C) y un grupo experimental (Grupo E), donde el primero se sometió a una cirugía de fusión de la articulación talocrural abierta convencional y el segundo recibió una cirugía de fusión de la articulación talocrural mínimamente invasiva. Se realizó una comparación entre los dos grupos según la Sociedad Estadounidense de Ortopedia de Pie y Tobillo (AOFAS), las tasas de fusión ósea y las puntuaciones de la escala visual analógica (EVA) antes de la operación y 1, 2 y 3 meses después de la operación. Además, se midieron los indicadores de daño oxidativo sérico y los niveles de factor inflamatorio para evaluar los efectos de la recuperación en ambos grupos. En relación con el grupo C, el grupo E mostró puntuaciones AOFAS y tasas de fusión ósea drásticamente aumentadas (P <0,05), así como puntuaciones VAS muy disminuidas (P <0,05). Además, el grupo E exhibió mejoras más pronunciadas en los indicadores de daño oxidativo y factores inflamatorios en comparación con el grupo C (P <0,05). La cirugía de fusión de la articulación talocrural mínimamente invasiva mejora drásticamente la función del tobillo en pacientes con osteoartritis traumática del tobillo y reduce los niveles de daño oxidativo y la respuesta inflamatoria. Esto proporciona una importante opción de tratamiento clínico.

Minimally Invasive Tibiotalocalcaneal Arthrodesis with Blocked Retrograde Intramedullary Nail - Report of Three Cases / Artrodese tibiotalocalcaneana minimamente invasiva com haste intramedular retrógrada bloqueada - Relato de três casos

Abstract Ankle osteoarthritis (AOA) is associated with pain and variable functional limitation, demanding clinical treatment and possible surgical indication when conservative measures are ineffective - arthrodesis has been the procedure of choice, because it reduces pain, restores joint alignment and makes the segment stable, preserving gait. The present study reports 3 cases (3 ankles) of male patients between 49 and 63 years old, with secondary AOA, preoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS AHS) of 27 to 39 points, treated by minimally invasive tibiotalocalcaneal arthrodesis using blocked retrograde intramedullary nail. Hospital stay was of 1 day, and the patients were authorized for immediate loading with removable ambulation orthotics, as tolerated. The physical therapy treatment, introduced since hospitalization, was maintained, prioritizing gait training, strength gain, and proprioception. Clinical and radiographic follow-up was performed at weeks 1, 2, 6, 12 and 24. After evidence of consolidation (between the 6th and 10th weeks), the orthotics were removed. One patient complained of pain in the immediate postoperative period and, at the end of the 1st year, only one patient presented pain during rehabilitation, which was completely resolved with analgesics. Currently, the patients do not present complaints, returning to activities without restrictions - one of them, to the practice of soccer and rappelling. The postoperative AOFAS AHS was from 68 to 86 points.

Resumo A osteoartrite do tornozelo (OAT) está associada a quadro álgico e limitação funcional variável, demandando tratamento clínico e eventual indicação cirúrgica quando as medidas conservadoras são inefetivas - a artrodese tem sido o procedimento de escolha, por reduzir a dor, restaurar o alinhamento articular e tornar o segmento estável, preservando a marcha. O presente estudo relata 3 casos (3 tornozelos) de pacientes do sexo masculino, com entre 49 e 63 anos de idade, portadores de OAT secundária, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS AHS, na sigla em inglês) pré-operatória de 27 a 39 pontos, tratados mediante artrodese tibiotalocalcaneana minimamente invasiva utilizando haste intramedular retrógrada bloqueada. A permanência hospitalar foi de 1 dia, e os pacientes foram autorizados para carga imediata com órteses removíveis para deambulação, conforme tolerado. O tratamento fisioterápico, introduzido desde o internamento, foi mantido, priorizando-se treino de marcha, ganho de força e propriocepção. Foi realizado acompanhamento clínico e radiográfico nas semanas 1, 2, 6, 12 e 24. Após evidências de consolidação (entre a 6ª e a 10ª semanas), as órteses foram retiradas. Um paciente queixou-se de dor no pós-operatório imediato e, ao final do 1° ano, apenas 1 paciente apresentou dor durante a reabilitação, resolvida completamente com analgésicos. Atualmente, os pacientes não apresentam queixas, retornando às atividades sem restrições - um deles, à prática de futebol e rapel. A AOFAS AHS pós-operatória foi de 68 a 86 pontos.

Fractura del fragmento de Wagstaffe-Le Fort en un paciente con luxofractura de tobillo. Equivalente cuadrimaleolar. Reporte de un caso / Wagstaffe-Le Fort fracture in a patient with an ankle fracture-dislocation. Quadrimalleolar equivalent. Case repo

Se presenta el caso de una paciente que sufre una luxofractura del tobillo izquierdo con compromiso trimaleolar, pero, en la tomografía computarizada prequirúrgica, se documenta el compromiso adicional del tubérculo de Wagstaffe-Le Fort, por lo que se decide considerarlo como un equivalente cuadrimaleolar diferente de los descritos previamente con el compromiso del fragmento anterolateral de la tibia (Tillaux-Chaput). Este caso permite un enfoque de 360° de las lesiones de tobillo que afectan la congruencia articular y se propone un análisis osteo-ligamentario para su tratamiento definitivo, favoreciendo las reparaciones anatómicas para disminuir la necesidad de fijaciones transindesmales sin afectar el desenlace quirúrgico. Nivel de Evidencia: IV

In this article, we present the case of a patient who suffered a fracture-dislocation of the left ankle with trimalleolar involvement. However, the preoperative tomography revealed the additional involvement of the Wagstaffe-Le Fort tubercle, so it was decided to approach it as a quadrimalleolar equivalent different from those previously described, with involvement of the anterolateral fragment of the tibia (Tillaux-Chaput). This case allows for a 360° approach to ankle injuries that disrupt joint congruence, and an osteo-ligament analysis is proposed for its definitive treatment, prioritizing anatomical repairs to reduce the need for syndesmotic transfixation, without compromising surgical outcomes. Level of Evidence: IV

Compromiso de las articulaciones vecinas en la evolución alejada de la artrodesis de tobillo / Compromise of adjacent joints in long-term evolution of ankle arthrodesis

Introducción: La artrodesis tibioastragalina es una opción para tratar la artrosis de tobillo en pacientes que no responden a las medidas conservadoras. Su principal desventaja es el compromiso a mediano y largo plazo de las articulaciones vecinas. Objetivo: Determinar el compromiso de las articulaciones vecinas a mediano y largo plazo, y su impacto sobre los resultados funcionales en los pacientes con artrodesis de tobillo. Materiales y Métodos: Se evaluó a una serie de 11 pacientes (6 mujeres y 5 hombres). El diagnóstico inicial era artrosis postraumática (9 casos), artritis séptica (1 caso) y lesión osteocondral de astrágalo (1 caso). El promedio de edad al operarse era de 50 años. La media de seguimiento fue de 9 años. Se evaluó el compromiso radiográfico de las articulaciones vecinas. La función se valoró mediante la escala analógica visual para dolor, la escala de la AOFAS y un cuestionario simple de satisfacción. Resultados: Diez pacientes (91%) tenían artrosis en alguna de las articulaciones vecinas. El puntaje medio en la escala analógica visual fue de 2,6 y el de la escala de la AOFAS, de 71. Nueve refirieron estar muy satisfechos; uno, medianamente satisfecho y otro se manifestó insatisfecho. Conclusión: El compromiso de las articulaciones vecinas es muy frecuente a largo plazo, pero esto no repercute directamente en los resultados funcionales. Nivel de Evidencia: IV

Introduction: Tibiotalar arthrodesis is an option in the treatment of ankle osteoarthritis in patients who do not respond to conservative measures. Its main disadvantage is the compromise of adjacent joints in the medium and long term. Objective: To determine the involvement of adjacent joints in the medium and long term and its impact on functional outcomes in patients with ankle arthrodesis. Materials and Methods: We evaluated a series of 11 patients, 6 females and 5 males. The initial diagnosis was post-traumatic osteoarthritis (9 cases), septic arthritis (1 case), and osteochondral lesion of the talus (1 case). The mean age at the time of surgery was 50 years. The mean follow-up was 9 years. The radiographic compromise of the adjacent joints was evaluated. The patients were functionally evaluated using the Visual Analog Pain Scale (VAS), the AOFAS scale (American Orthopedic Foot and Ankle Score), and a simple satisfaction questionnaire. Results: 10 patients (91%) presented with osteoarthritis of one of the adjacent joints. The average score on the VAS was 2.6, while on the AOFAS scale, it was 71. Nine patients reported being very satisfied, one was moderately satisfied, and one was dissatisfied. Conclusion: The involvement of adjacent joints is very frequent in the long term, but this does not have a direct impact on the patient's functional outcomes. Level of Evidence: IV

Osteotomías supramaleolares en pacientes con artrosis de tobillo: resultados clínicos y radiográficos / Supramalleolar osteotomies for ankle osteoarthritis: Clinical and radiological outcomes

Introducción: Las osteotomías supramaleolares son una opción terapéutica para la artrosis asimétrica de tobillo. El objetivo de este artículo es describir los resultados clínicos, radiográficos y subjetivos obtenidos en pacientes con artrosis de tobillo sometidos a una osteotomía supramaleolar. Materiales y métodos: Estudio observacional descriptivo retrospectivo de pacientes sometidos a una osteotomía supramaleolar por artrosis de tobillo entre enero de 2010 y julio de 2017. Se analizaron las historias clínicas para recabar datos clínicos y radiográficos preoperatorios y posoperatorios. Resultados: Se incluyó a 13 pacientes: 8 con una desalineación del tobillo y retropié en valgo (61,5%) y 5 (38,5%) en varo. El puntaje medio posoperatorio de la escala analógica visual del grupo con deformidad en varo disminuyó de 9 ± 0,45 a 3 ± 1 (p <0,05) y de una media de 7,88 ± 0,35 a 2,15 ± 1,64 (p <0,05) en aquellos con deformidad en valgo. El puntaje medio de la escala de la AOFAS se modificó de 32,8 ± 16,2 antes de la cirugía a 82,1 ± 13,6 en el posoperatorio, en el grupo con deformidad en varo (p <0,05) y de 31 ± 17,3 a 93,1 ± 6,20, respectivamente, en aquellos con deformidad en valgo (p <0,05). Se constató la consolidación radiográfica en 12 pacientes (92,3%), en un promedio de 10.4 semanas. Conclusión:La osteotomía supramaleolar como tratamiento de la artrosis asimétrica de tobillo es una técnica predecible, con muy buenos resultados clínicos y radiográficos a corto y mediano plazo. Nivel de Evidencia: IV

Introduction: Supramalleolar osteotomies are a treatment option for asymmetric ankle osteoarthritis. Our work aims to describe the clinical, radiographic, and subjective outcomes obtained in patients with ankle osteoarthritis who underwent a supramalleolar osteotomy (SMOT). Materials and methods: Retrospective, observational, and descriptive study on patients who underwent SMOT for ankle osteoarthritis between January 2010 and July 2017. The patients' clinical records were analyzed. Results: We included 13 patients who underwent SMOT, 8 patients with valgus (61.5%) and 5 (38.5%) with varus rearfoot and ankle misalignment. The mean varus VAS score decreased from 9 ± 0.45 to 3 ± 1 postoperatively (p <0.05) and, in valgus deformities, from a mean 7.88 ± 0.35 to 2.15 ±1.64 postoperatively (p <0.05). The mean AOFAS score changed from 32.8 ± 16.2 to 82.1 ± 13.6 postoperatively in the varus deformity group (p <0.05) and from 31 ± 17.3 preoperatively to 93.1 ± 6.20 postoperatively in the valgus deformity group (p <0.05). Twelve patients (92.3%) achieved radiographic union in an average time of 10.4 weeks. Conclusion:Supramalleolar osteotomy as a treatment for asymmetric ankle osteoarthritis is a predictable technique with very good clinical and radiological outcomes in the short and medium term. Level of Evidence: IV

Asistencia artroscópica y fijación interna percutánea en fracturas de Maisonneuve. Evaluación por imágenes de los resultados / Arthroscopy and percutaneous internal fixation in Maisonneuve fractures. Imaging evaluation

Introducción: La fractura de Maisonneuve es una lesión caracterizada por la fractura subcapital del peroné asociada a una lesión capsuloligamentaria de tobillo. Su tratamiento supone la restauración de la anatomía ósea y capsuloligamentaria normal para restablecer las fuerzas de contacto tibioastragalinas fisiológicas. Esta calidad de reducción puede ser difícil de alcanzar, sobre todo, con técnicas percutáneas. Objetivo: Evaluar mediante imágenes la calidad de la reducción de fracturas de Maisonneuve reducidas en forma cerrada (bajo visualización directa artroscópica) y fijadas por vía percutánea. Materiales y Métodos: Se analizaron radiografías e imágenes de tomografía computarizada preoperatorias y posoperatorias, comparativas de los tobillos operado y sano. Resultados: Se evaluaron 13 fracturas. Los parámetros radiográficos posoperatorios (espacio claro medial, solapamiento tibioperoneo distal, espacio claro tibioperoneo) no registraron diferencias, excepto por el intervalo tibioperoneo anterior que aumentó en un caso. La medición tomográfica posoperatoria del solapamiento tibioperoneo distal y el intervalo tibioperoneo anterior reveló que todas las reducciones eran satisfactorias. Dos pacientes tenían valores alterados en la sindesmosis tibioperonea distal con diferencia >2 mm respecto del tobillo sano. Conclusión: Recomendamos la asistencia artroscópica para el manejo de la fractura de Maisonneuve como herramienta de control intraoperatorio para una fijación percutánea más segura. Nivel de Evidencia: IV

Introduction: Maisonneuve fracture (MF) is an injury characterized by the subcapital fracture of the fibula associated with a capsuloligamentous injury of the ankle. Treatment involves the restoration of normal bone and capsuloligamentous anatomy in order to reestablish physiological tibiotalar contact forces. This quality of reduction can be difficult to achieve, especially with percutaneous techniques. Objective: To evaluate the quality of reduction in Maisonneuve fractures reduced in a closed manner (under direct arthroscopic visualization) and fixed percutaneously. Materials and Methods: We analyzed comparative preoperative and postoperative radiographs and CT scans of the operated and healthy ankles. Results: 13 fractures were evaluated. Radiographic parameters of postoperative procedures (medial clear space, distal tibiofibular overlap, tibiofibular clear space) did not register differences except for the anterior tibiofibular space, which had increased in 1 case. Postoperative tomographic measurements of tibiofibular clear space and anterior tibiofibular space showed 100% satisfactory reductions. Two patients presented altered distal tibiofibular overlap values with a difference greater than 2 mm compared to the healthy ankle. Conclusion: We recommend arthroscopy for the management of MF as an intraoperative control tool for safer percutaneous fixation. Level of Evidence: IV

Fractura de tibia como complicación del uso de un dispositivo de fijación elástica en la sindesmosis / Tibial fracture as a complication of the use of an elastic fixation device in the syndesmosis

La fijación elástica en las lesiones de la sindesmosis es un procedimiento que se realiza ampliamente y brinda buenos resultados. Presentamos un caso de una fractura de tibia como complicación de la fijación elástica de la sindesmosis, su tratamiento y una revisión bibliográfica en la cual no hemos encontrado reportes sobre esta complicación. Nivel de Evidencia: IV

Elastic fixation in syndesmosis injuries is a widely performed procedure with good outcomes. We report a case of a tibial fracture as a complication of the elastic fixation of the syndesmosis, its treatment, and a literature review, in which we have not found reports of this complication. Level of Evidence: IV

Reconstrucción de defectos óseos en la región del tobillo mediante la técnica de Masquelet. Presentación de casos / Use of Masquelet technique for the reconstruction of bone defects in the ankle. Case report

Los defectos óseos segmentarios en la región del tobillo y el pie representan un desafío dadas sus características anatómicas con limitada vascularización y pobre cobertura muscular. La técnica descrita por Masquelet para el tratamiento de defectos óseos segmentarios en huesos largos ha logrado excelentes resultados. Sin embargo, se han publicado pocos estudios sobre su uso en la región del pie y tobillo. La técnica de la membrana inducida ofrece una alternativa terapéutica válida para resolver problemas de difícil solución en Ortopedia, como los defectos óseos. Permite tratarlos sin necesidad de procedimientos complejos, como el uso de injertos óseos vascularizados o de callotasis, con una alta tasa de consolidación, conservando la longitud del miembro y con una buena función. Entre enero de 2016 y diciembre de 2018, tres pacientes con defectos óseos segmentarios fueron tratados mediante la técnica de Masquelet en nuestra institución. Pese a que no podemos probar que este procedimiento es el más indicado en este tipo de casos, sí podemos afirmar que se logró la consolidación en todos los pacientes y se resolvió el defecto óseo, lo que nos anima a seguir utilizando esta misma técnica. Nivel de Evidencia: IV

Segmental bone defects in the foot and ankle represent a challenge due to their anatomical characteristics, limited vascularization, and poor muscle coverage. The technique described by Masquelet has shown excellent results for the treatment of segmental bone defects in long bones. However, there are few studies in the literature on its use in the foot and ankle. The induced membrane technique offers a valid treatment alternative to solve bone defects. It allows treatment without the need for complex procedures, such as vascularized bone grafts or distraction osteogenesis, with a high rate of consolidation, preserving the length and function of the limb. Although we cannot prove that this procedure is the most indicated for the treatment of bone defects, we can affirm that all our patients have achieved consolidation, which encourages us to continue performing this same technique. Level of Evidence: IV

Complejo ligamentoso lateral de la articulación talocrural (tobillo): biometría y patrones de división / Lateral ankle ligamentous complex: biometrics and division patterns

El complejo ligamentoso lateral de la articulación talocrural o «tobillo» (CLT) contempla básicamente tres estructuras denominadas como ligamento talofibular anterior (LTFA), ligamento calcaneofibular (LCF) y ligamento talofibular posterior (LTFP). En los últimos artículos publicados en relación con la morfología del CLT, se clasifica al LTFA en tres tipos, basada en el número de bandas o fascículos. Esta variabilidad morfológica plantea nuevos desafíos de estudios anatómicos en la biomecánica y estabilidad de la región talocrural. El objetivo de este estudio fue profundizar la anatomía de este complejo, en base a disecciones por capa que nos permitan visualizar las relaciones existentes entre estos ligamentos y estructuras aledañas. Se utilizaron 10 piezas congeladas pertenecientes al Departamento de Anatomía y Medicina Legal de la Facultad de Medicina de la Universidad de Chile, cuyos ligamentos fueron localizados y medidos en ancho y longitud. Para el LTFA se observó un patrón único en 5 muestras, bifurcado en 4, mientras que en un caso se visualizó un patrón trifurcado. El conocimiento del complejo ligamentoso lateral de tobillo, así como de su dirección, biometría y bandas o fascículos son un importante aporte para la imagenología, rehabilitación, clínica y cirugías que aborden esta región.

SUMMARY: The lateral ankle complex (LAC) basically includes three structures called anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In recent works published in relation to the morphology of LAC, ATFL is classified into three types, based on the number of bands or fascicles. This morphological modification poses new challenges for anatomical studies in biomechanics and ankle stability. The objective of this is to deepen in greater detail the anatomy of this complex, based on dissections by layer that allow us to study the existing relationships between these ligaments and surrounding structures. 10 frozen pieces belonging to the Department of Anatomy and Legal Medicine of the Faculty of Medicine of the University of Chile were used; whose ligaments were located and measured in width and length. For ATFL, a single pattern was found in 5 samples, bifurcated in 4, while a trifurcated pattern was seen in one case. Knowledge of the lateral ligamentous complex of the ankle, as well as its direction, biometry and bands or fascicles, are an important contribution to imaging, rehabilitation, clinics and surgeries that address this region.

Radiographic diagnosis of distal fibula avulsion fractures: Comparison of ankle X-ray and three-dimensional reconstruction of CT / 北京大学学报(医学版)

OBJECTIVE@#To investigate the difference in sensitivity between X-ray and three-dimensional reconstruction of computed tomography (3D-CT) for the diagnosis of distal fibular avulsion fracture, and the radiographic presentation of the ossicle.@*METHODS@#From January to October 2018, 92 patients with distal fibular avulsion fracture were visited for surgical treatment in Department of Sports Medicine, Peking University Third Hospital, and 60 cases were finally enrolled according to the inclusion and exclusion criteria. Intraoperative detection was regarded as the gold standard, and the diagnostic sensitivity of preoperative ankle X-ray and 3D-CT for the distal fibular avulsion fractures was statistically determined. The ossicle maximum diameter as well as the degree of its displacement were also measured. On 3D-CT, the distance from the ossicle center point to the anterior fibular tuberosity (a), the distance to the fibular tip (b), and the a/b value was used to present the ossicle displacement.@*RESULTS@#Among the 60 patients, 36 and the 52 patients were correctly detected by X-ray and 3D-CT, respectively, and the sensitivities was 60.0% and 86.7%, respectively (P=0.004). The mean diameter of the ossicle on X-ray and 3D-CT was (9.2±3.9) mm and (10.5±3.2) mm, respectively. The mean distance from the ossicle center to the anterior fibular tuberosity (a) was (17.5±3.6) mm and the mean distance to the fibular tip (b) was (17.4±4.8) mm, with mean a/b values of 1.1±0.7. The intraclass correlation coefficients (ICC) for each measurement ranged from 0.891-0.998 with a high degree of consistency.@*CONCLUSION@#Compared with X-ray, 3D-CT has higher sensitivity in diagnosing distal fibular avulsion fractures, can help clinicians evaluate ossicle's location and choose surgical methods, and is recommended to be performed in patients with suspected distal fibula avulsion fractures in clinical practice.

Ankle arthritis: joint-preserving surgery and total ankle arthroplasty / 中国修复重建外科杂志

Ankle arthritis affects approximately 1% of the adult population worldwide and represents a serious global disease burden. However, compared with hip arthritis and knee arthritis, the clinical understanding and treatment of ankle arthritis are still in their infancy. For end-stage ankle arthritis, ankle arthrodesis was considered as the "gold standard" in the past. However, ankle arthrodesis will result in loss of joint mobility, altered gait, limited daily activities, and accelerated degeneration of adjacent joints. Therefore, how to preserve the range of motion of the ankle joint while relieving pain is the key to the treatment of ankle arthritis. Currently, the surgical treatment of ankle arthritis includes arthroscopic debridement, periarticular osteotomies, osteochondral transplantation, ankle distraction arthroplasty, ankle arthrodesis, and total ankle arthroplasty. The choice of treatment should be individualized and based on various factors such as the patient's symptoms, signs, imaging performance, complaints, and financial situation. However, there are no guidelines that give clear treatment recommendations. Therefore, it is necessary to conduct extensive and in-depth discussions on the diagnosis and treatment of ankle arthritis.

Early effectiveness of a new minimally invasive plate in treatment of varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the early effectiveness of a new minimally invasive plate in the treatment of varus-type ankle arthritis.@*METHODS@#A clinical data of 15 patients with varus-type ankle arthritis who met the selection criteria between March 2021 and October 2021 were retrospectively analyzed. All the patients were treated with medial open-wedge supramalleolar osteotomy and fibular osteotomy. The osteotomies were fixed with the new minimally invasive plate. There were 7 males and 8 females with an average age of 49.8 years (range, 16-71 years). The causes of ankle arthritis included post-fracture deformity in 1 case, sprain in 8 cases, and acquired clubfoot in 1 case; and 5 cases were without obvious factors. The disease duration ranged from 1 to 12 years, with an average of 4.1 years. Comparisons were made between pre-operation and the last follow-up in the Takakura staging, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, foot function index (FFI), visual analogue scale (VAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and talar tilt (TT).@*RESULTS@#All incisions healed by first intention. All patients were followed up 7-18 months (mean, 12.8 months). At last follow-up, the AOFAS ankle-hindfoot score, FFI, VAS score, and Takakura staging significantly improved when compared with the preoperative ones ( P<0.05). X-ray films showed that the osteotomy healed at 3 months after operation. At last follow-up, TAS significantly increased and TT decreased when compared with the preoperative ones ( P<0.05), and the difference in TLS between pre- and post-operation was not significant ( P>0.05). Complications included 1 case of intraoperative screw breakage and 2 cases of nerve injury of the affected foot. None of the patients complained of significant discomfort at the plate placement during follow-up, and no loosening of the internal fixator occurred. Eleven patients were very satisfied with the effeectiveness, while 4 were relatively satisfied.@*CONCLUSION@#The new minimally invasive plate for the varus-type ankle arthritis has good early effectiveness in relieving ankle pain, correcting deformity, improving limb alignment and ankle function, and reducing the incidence of postoperative incisional complications.

Short-term effectiveness of calcaneal lateral displacement osteotomy with lateral ligament repair in treatment of Takakura stage Ⅱ varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of calcaneal lateral displacement osteotomy with lateral ligament repair in the treatment of Takakura stage Ⅱ varus-type ankle arthritis.@*METHODS@#A retrospective analysis was performed on the clinical data of 13 patients with Takakura stage Ⅱ varus-type ankle arthritis treated with calcaneal lateral displacement osteotomy with lateral ligament repair between January 2016 and December 2020. There were 6 males and 7 females aged 31-65 years, with an average age of 53.6 years. The preoperative tibial-ankle surface angle (TASA) was (88.13±1.01)°, medial distal tibial angle (MDTA) was (86.36±1.49)°, tibial talar surface angle (TTSA) was (6.03±1.63)°, talar tilting angle (TTA) was (81.95±2.15)°, and tibiocalcaneal axis angle (TCAA) was (-5.74±6.81)°. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) score was 56.3±7.1 and the pain visual analogue scale (VAS) score was 3.7±0.5. AOFAS scores, VAS scores, TTSA, TTA, and TCAA were compared between pre- and post-operatively.@*RESULTS@#All 13 patients were followed up 14-41 months, with an average of 28.7 months. The osteotomies healed in all patients. The last follow-up revealed TTA, TTSA, and TCAA to be (88.27±1.19)°, (-0.13±1.37)°, and (2.09±5.10)° respectively, the AOFAS score was 84.3±4.2 and the VAS score was 0.7±0.5, all showing significant improvement when compared to preoperative values ( P<0.05).@*CONCLUSION@#For patients with Takakura stage Ⅱ varus-type ankle arthritis, calcaneal lateral displacement osteotomy with lateral ligament repair can correct the lower limb force line, regain ankle stability, and achieving good short-term effectiveness.

Effectiveness and risk factors of supramalleolar osteotomy in treatment of varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To assess the effectiveness of supramalleolar osteotomy (SMOT) as a therapeutic intervention for varus-type ankle arthritis, while also examining the associated risk factors that may contribute to treatment failure.@*METHODS@#The clinical data of 82 patients (89 feet) diagnosed with varus-type ankle arthritis and treated with SMOT between January 2016 and December 2020 were retrospectively analyzed. The patient cohort consisted of 34 males with 38 feet and 48 females with 51 feet, with the mean age of 54.3 years (range, 43-72 years). The average body mass index was 24.43 kg/m 2 (range, 20.43-30.15 kg/m 2). The preoperative tibial anterior surface angle (TAS) ranged from 77.6° to 88.4°, with a mean of 84.4°. The modified Takakura stage was used to classify the severity of the condition, with 9 feet in stage Ⅱ, 41 feet in stage Ⅲa, and 39 feet in stage Ⅲb. Clinical functional assessment was conducted using the Maryland sore, visual analogue scale (VAS) score, and psychological and physical scores in Health Survey 12-item Short From (SF-12). Radiology evaluations include TAS, talar tilt (TT), tibiocrural angle (TC), tibial medial malleolars (TMM), tibiocrural distance (TCD), tibial lateral surface angle (TLS), and hindfoot alignment angle (HAA). The results of clinical failure, functional failure, and radiology failure were statistically analyzed, and the related risk factors were analyzed.@*RESULTS@#The operation time ranged from 45 to 88 minutes, with an average of 62.2 minutes. No complication such as fractures and neurovascular injuries was found during operation. There were 7 feet of poor healing of the medial incision; 9 pin tract infections occurred in 6 feet using external fixator; there were 20 cases of allograft and 3 cases of autograft with radiographic bone resorption. Except for 1 foot of severe infection treated with bone cement, the remaining 88 feet were primary healing, and the healing area was more than 80%. All patients were followed up 24-82 months, with an average of 50.2 months. Maryland score, VAS score, SF-12 psychological and physiological scores, and TAS, TC, TLS, TCD, TT, TMM, HAA, and Takakura stage were significantly improved at last follow-up ( P<0.05). Postoperative clinical failure occurred in 13 feet, functional failure in 15 feet, and radiology failure in 23 feet. Univariate analysis showed that obesity, TT>10°, and Takakura stage Ⅲb were risk factors for clinical failure, HAA≥15° and Takakura stage Ⅲb were risk factors for functional failure, and TT>10° was risk factor for radiographic failure ( P<0.05). Further logistic regression analysis showed that TT>10°, HAA≥15°, and TT>10° were risk factors for clinical failure, functional failure, and radiographic failure, respectively ( P<0.05).@*CONCLUSION@#SMOT is effective in the mid- and long-term in the treatment of varus-type ankle arthritis, but it should be used with caution in patients with obesity, severe hindfoot varus, severe talus tilt, and preoperative Takakura stage Ⅲb.

Establishment of finite element model of varus-type ankle arthritis and biomechanical analysis of different correction models for tibial anterior surface angle / 中国修复重建外科杂志

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.

Short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis.@*METHODS@#The clinical and radiographic data of patients with moderate to severe varus-type ankle arthritis, who were admitted between May 2017 and November 2021 and treated with total ankle arthroplasty (TAA) using INBONE TM Ⅱ prosthesis, was retrospectively analyzed. A total of 58 patients (58 ankles) met the selection criteria and were included in the study. Among them, there were 24 males and 34 females, with an average age of 62.6 years (range, 41-85 years). According to the preoperative tibiotalar angle (TTA), the patients were divided into a moderate varus group (group A, TTA 5°-15°, n=34) and a severe varus group (group B, TTA>15°, n=24). There was no significant difference in gender, side, etiology, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, ankle dorsiflexion, plantarflexion, and total range of motion, and tibial lateral surface angle (TLS) between the two groups ( P>0.05). Yet the patients in group A were younger than group B, the degrees of oesteoarthritis (Takakura stage) and ankle pain [visual analogue scale (VAS) score] were milder, and the TTA, talar tilt angle (TT), hindfoot alignment angle (HAA) were smaller while the tibial articular surface angle (TAS) was larger, showing significant differences ( P<0.05). The pre- and post-operative VAS score, AOFAS score, the occurrence of early and late complications, the radiographic parameters of the ankle (TTA, TAS, TT, HAA, TLS), ankle dorsiflexion, plantarflexion, and total range of motion were recorded and compared.@*RESULTS@#All patients were followed up 19-72 months, with an average of 38.9 months. Compared with the preoperative data, the VAS score of all patients significantly decreased ( P<0.05); the AOFAS score, ankle dorsiflexion range of motion, and total range of motion significantly increased ( P<0.05); and the TTA, TAS, TT, HAA, and TLS significantly improved at last follow-up ( P<0.05); but there was no significant difference in plantarflexion range of motion ( P>0.05). Early complications occurred in 13 patients, and only 1 patient underwent revision surgery due to a larger size of the talar component. At last follow-up, there was no significant difference in the difference of clinical parameters before and after operation between the two groups ( P>0.05); there was a significant difference in the difference of other radiographic parameters ( P<0.05) except TLS. No significant difference in the incidence of complications between the two groups was found ( P>0.05).@*CONCLUSION@#TAA using the INBONE TM Ⅱtotal ankle prosthesis is an effective treatment for moderate or severe varus-type ankle arthritis, and good clinical and radiographic results can be obtained. Correcting bony deformities and balancing soft tissue are the keys to successful surgery.

Comparison of clinical effect and postopertaive incisions between No-touch technique and traditional retractor in treating calcaneal fracture / 中国骨伤

OBJECTIVE@#To compare clinical efficacy of No-touch technique and traditional retractor in treating calcaneal fracture.@*METHODS@#Clinical data of 74 calcaneal fracture patients with closed Sanders typeⅡ to Ⅳ were retrospectively analyzed from July 2019 to June 2021. According to different treatment methods, the patients were divided into No-touch group and conventional group, 37 patinets in each group. In No-touch group, there were 25 males and 12 females, aged from 19 to 70 years old with an average of (42.64±14.16) years old;17 patients were typeⅡ, 14 patinets with type Ⅲ, 6 patients with type Ⅳ according to Sanders fracture classification;three 2.0 mm Kirschner wires were implanted into the talus body, talus neck, and cuboid bone, and the flap was turned upward to expose the operation area. In conventional group, there were 30 males and 7 females, aged from 19 to 67 years old with an average of (41.56±11.38) years old;17 patients with typeⅡ, 12 patients with type Ⅲ, 8 patients with type Ⅳ according to Sanders fracture classification;the operation was completed by exposing the operation area with traditional retractor. Operation time, postoperative incision complications, postoperaive American Orthopedic Foot and Ankle Society (AOFAS) ankle hind foot score at 6 months between two groups were compared.@*RESULTS@#Seventy-four patients were followed up, and follow-up time in No-touch group ranged from 6 to 17 months with an average of(9.57±2.72) months, while in conventional group ranged from 6 to 16 months with an averge of(9.14±2.71) months, and no difference in follow-up between two groups (P>0.05). Operation time in No-touch group (55.67±7.94) min was shorter than that in conventional group (70.16±9.41) min (P<0.05);four patients in No-touch group occurred incision complications, while 8 patients in normal group, and had statistically difference(P<0.05). Daily activities and support, maximum walking distance (block), ground walking, limited degree of flexion, extension and valgus, foot alignment and total score of AOFAS scores in No-touch group was significantly higher than that of conventional group (P<0.05). There were no significant difference in pain degree, abnormal gait and ankle hind foot stability between two groups(P>0.05). According to AOFAS score, 19 patients got excellent result, 16 good and 2 poor in No-touch group;while 9 excellent, 24 good, and 4 poor in conventional group, and no difference between two groups (P>0.05).@*CONCLUSION@#Compared with traditional retractor in treating calcaneal fracture, No-touch technology could significantly shorten operation time, reduce incidence of postopertive complications, while two methods could improve excellent and good rate of ankle joint function recovery after operation.

Treatment of Sanders typeⅡto Ⅲ calcaneal fractures with percutaneous reduction and minimally invasive calcaneal screw fixation / 中国骨伤

OBJECTIVE@#To investigate clinical effect of percutaneous reduction combined with internal fixation of calcaneal nail in treating Sanders typeⅡto Ⅲ calcaneal fractures.@*METHODS@#From July 2017 to August 2019, clinical data of 98 patients with Sanders typeⅡto Ⅲ calcaneal fractures treated were retrospectively analyzed, and divided into observation group and control group according to different surgical methods. In observation group, there were 35 males and 21 females, aged from 23 to 58 years old with an average of (34.50±7.81) years old;29 patients with Sanders typeⅡand 27 patients with Sanders type Ⅲ;30 patients on the left side and 26 patients on the right side;the time from fracture to operation ranged from 1 to 4 days with an average of (3.45±0.54) days;and treated with percutaneous reduction combined with internal fixation of calcaneal nail system. In control group, there were 25 males and 17 females, aged from 25 to 60 years old with an average of (35.27±7.64) years old;23 patients with Sanders type Ⅱ and 19 patients with Sanders type Ⅲ;24 patients on the left side and 18 patients on the right side;the time from fracture to operation ranged from 2 to 5 days with an average of (3.42±0.62) days;and treated with open reduction and internal fixation. Operation time, blood loss, hospital stay, fracture healing time, and postoperative visual analogue scale (VAS) at 1 day, preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Böhler angle, Gissane angle and calcaneus width, and postoperative complications were compared between two groups.@*RESULTS@#All patients were followed up from 13 to 18 months with an average of (15.6±2.2) months. There were significant differences in operation time, blood loss, hospital stay, fracture healing time and postoperative VAS at 1 day between two groups (P<0.05). There was statistical difference in postoperative AOFAS score at 12 months between two groups (P<0.05), and AOFAS score at 12 months after operation was higher than that before operation (P<0.05). According to AOFAS score, 21 patients got excellent result, 30 good and 5 moderate in observation group, and 10 excellent, 22 good, 7 moderate and 3 poor in control group, which had statistical difference between two groups (P<0.05). Postoperative Böhler angle, Gissane angle and calcaneus width at 6 months were better than that before operation between two groups(P<0.05). One patient in observation and 20 patients in control group occurred skin numbness after operation, and 14 patients occurred skin necrosis in control group, there were obvious difference between two groups(P<0.01).@*CONCLUSION@#Compared with open reduction and internal fixation, percutaneous reduction combined with internal fixation system in treating Sanders typeⅡto Ⅲ calcaneal fractures is feasible for fracture repair without waiting for foot deswelling, which could accurately restore normal shape and position of the fractured heel bone, completely eliminate fracture malunion, and reduce postoperative complications. Therefore, it could shorten operation time, hospital stay, fracture healing time, reduce amount of blood loss, promote postoperative recovery, and less complications, high safety, which could be used as a choice of orthopedic surgery for foot and ankle trauma.

Meta-analysis of clinical efficacy of ankle arthrodesis and total ankle arthroplasty in the treatment of end-stage ankle arthritis / 中国骨伤

OBJECTIVE@#To systematically review the clinical efficacy of total ankle arthroplasty (TAA) and ankle arthrodesis (AA) in the treatment of end-stage ankle arthritis.@*METHODS@#The PubMed, EMBASE and Cochrane Library databases were searched for articles published in the treatment of end-stage ankle arthritis with AA or TAA from the establishment of the database to June 2021. Bias risk tool was used to evaluate the quality of the literature. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale(AOFAS), visual analog scale (VAS), ankle osteoarthritis scale(AOS), gait analysis (pace, frequency, stride), range of motion (ROM), satisfaction, complications and reoperation rate were analyzed by meta-analysis between AA and TAA groups by RevMan 5.3 software.@*RESULTS@#A total of 12 articles were included, including 1 050 patients in the AA group and 3 760 patients in the TAA group, totaling 4 810 patients. Meta-analysis showed that the total score of AOFAS[MD=-3.12, 95%CI(-9.02, 2.96), P=0.31], pain score [MD=1.60, 95%CI(-1.35, 4.54), P=0.29], alignmentl score[MD=-0.04, 95%CI(-0.52, 0.44), P=0.88], VAS[MD=0.10, 95%CI(-0.49, 0.68), P=0.74], and AOS total score [MD=-4.01, 95%CI(-8.28, 0.25), P=0.06], the difference was not statistically significant (P>0.05). The score of AOFAS functional in TAA group was significantly higher than that in TAA group[MD=44.22, 95%CI(-8.01, -0.43), P=0.03]. There was no significant difference in gait analysis between the two groups (P>0.05). Postoperative ROM [MD=-4.93, 95%CI(-6.35, -3.52), P<0.000 01] and change in ROM from preoperative to follow-up[MD=-5.74, 95%CI(-8.88, -2.61), P=0.0003] between two groups, the difference was statistically significant. There was no significant difference in satisfaction between the two groups [OR=1.011, 95%CI(0.46, 2.23), P=0.98]. Complications [OR=1.61, 95%CI(1.26, 2.06), P=0.0002] and non-revision reoperation [OR=1.61, 95%CI(1.17, 2.21), P=0.003] were significantly lower in the TAA group than in the AA group. There was no significant difference in the rate of revision and reoperation(P>0.05) between the two groups [OR=1.02, 95%CI(0.37, 2.78), P=0.97].@*CONCLUSION@#The clinical efficacy of AA is similar to that of TAA, but the non revision reoperation rate and main surgical complications of TAA are significantly reduced. Therefore, further high-quality methodological research and long-term follow-up are needed to confirm this conclusion.