Technique for Foot Reconstruction with Custom-made Calcaneal Prosthesis in Primary Malignancy - A Case Report / Técnica de reconstrução do pé com prótese de calcâneo feita sob medida em câncer primário - Relato de caso

Abstract The foot is an uncommon location for osseous tumors, comprising ~ 3% of all skeletal tumors, which occur particularly around the calcaneum. Radical surgery creates a void in the foot which adversely affects the ability to salvage it. Calcaneal replacement surgeries are not commonly performed due to factors involving instability of the prosthesis, soft-tissue defects, and resultant failure, which can occur in the postoperative period. Thus, we herein report a rare case of synovial sarcoma arising from the sheath of the tibialis posterior tendon, with secondary involvement of the calcaneus bone. Considering the previous experiences of different surgeons, a custom-made prosthesis was designed with relevant modifications.

Resumo O pé é um local incomum para tumores ósseos, e compreende cerca de 3% de todos os tumores esqueléticos, em especial ao redor do calcâneo. A cirurgia radical cria um vazio no pé, o que afeta de forma negativa a capacidade de resgate do membro. As cirurgias de reconstrução do calcâneo não são comumente realizadas por causa da instabilidade da prótese, defeito de partes moles, e consequente possibilidade de insucesso pósoperatório. Assim, apresentamos aqui um caso raro de sarcoma sinovial originário da bainha do tendão tibial posterior com acometimento secundário do osso calcâneo. Considerando as experiências prévias de diferentes cirurgiões, projetamos uma prótese sob medida com modificações relevantes.

Application of intermittent flap opening in L-shaped surgical incision of calcaneal fracture / 中国骨伤

OBJECTIVE@#To explore clinical effect of intermittent flap opening technique in L-shaped incision of calcaneal fracture.@*METHODS@#From January 2017 to January 2019, 48 patients with Sanders typeⅡ to Ⅳ calcaneal fractures were treated by open reduction and internal fixation. According to different flap opening techniques, the patients were divided into control group and observation group, 24 patients in each group. In observation group, there were 17 males and 7 females, aged from 20 to 60 years old with an average of(45.12±9.56) years old;7 patients were typeⅡ, 10 patients were type Ⅲ and 7 patients were type Ⅳ according to Sanders classification;3 patients were C0, 16 patients were C1 and 5 patients were C2 according to Tscherne-Gotzen soft-tissue assessment;treated with intermittent flap technique. In control group, there were 19 males and 5 females aged from 20 to 60 years old with an average of (47.32±10.67) years old;7 patients were typeⅡ, 11 patients were type Ⅲ and 6 patients were type Ⅳ according to Sanders classification;2 patients were C0, 18 patients were C1 and 4 patients were C2 according to Tschemc-Gotzen soft-tissue assessment;treated with static flap opening technique. Operation time, flap retraction time, changes of Böhler angle and Gissane angle before and after operation at 3 days, and occurrence of incision complications were observed and compared between two groups.@*RESULTS@#All patients were followed up from 3 to 6 months with an average of(4.52±1.01) months. There were no significant differences in operation time, changes of Böhler angle and Gissane angle before and after operation at 3 days between the two groups(P>0.05);there was statistical difference in flap retraction time between two groups(P<0.05). Occurrence of incision complications in observation group was significantly lower than that in control group (P<0.05).@*CONCLUSION@#Intermittent flap opening technique is superior to static opening technique in reducing incision complications of lateral "L" approach of calcaneus. Single Kirschner wire opening does not affect the exposure, reduction and fixation of fracture during operation.

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.

Analysis of the curative effect of triple surgery under endoscope in the treatment of intractable heel pain / 中国骨伤

OBJECTIVE@#To investigate the clinical effect the treatment of arthroscopy-assisted calcaneal spur resection combined with plantar fascia release and calcaneal decompression in the treatment of the patients with intractable calcaneal pain.@*METHODS@#The clinical data of 50 patients with intractable heel pain from January 2016 to January 2019 were retrospectively analyzed, including 20 males and 30 females;aged from 40 to 68 years old with an average of (50.12±7.35)years old, the medical history ranged from 1 to 4 years. All patients underwent arthroscopy-assisted calcaneal spur resection combined with plantar fascia release and calcaneal decompression, and were followed up, the duration ranged from 24 to 60 months with an average of(42.00±3.28) months. All patients had obvious heel pain before surgery, and X-ray examinations often showed the presence of calcaneal spurs. In addition to the routine foot examination, the changes in the height and angle of the arch of the foot were also measured pre and post-operatively by X-ray, for the evaluation of clinical effect. The VAS system was used to evaluate the degree of foot pain;the AOFAS scoring system was used to comprehensively evaluate the foot pain, voluntary movement, gait and stability.@*RESULTS@#The VAS decreased from (8.75±1.24) before surgery to (5.15±2.35) at 3 months after surgery, (4.07±2.53) at 6 months after surgery, and (3.95±2.44) at the last fllow-up(P<0.05). The AOFAS score increased from (53.46±4.17) before surgery to(92.46±2.53) at 3 months after surgery, (96.33±2.46) at 6 months after surgery, and (97.05±2.37) at the last follow-up(P<0.05). The arch height was (41.54±1.15) mm before operation and (41.49±1.09) mm after the operation, the difference was not statistically significant(P>0.05). The internal arch angle of the foot arch was (121±6)° before operation and (122±7)° after operation. The difference was not statistically significant(P>0.05).@*CONCLUSION@#Arthroscopy-assisted calcaneal bone spurs resection combined with plantar fascia release and calcaneal decompression exhibited great clinical effect for treating intractable heel.

Quiste óseo unicameral de calcáneo derecho / Unicameral Bone Cysts of the Calcaneus

Introducción: El quiste óseo unicameral es una lesión pseudotumoral benigna de contenido líquido, que representa el 3 por ciento de todos los tumores primarios. El calcáneo es una localización poco frecuente y el tarso, es el hueso más afectado. Objetivo: Presentar un caso de quiste óseo unicameral del calcáneo derecho que se diagnosticó y trató en el Hospital Universitario Manuel Ascunce Domenech de Camagüey con evolución clínica favorable. Presentación del caso: Paciente masculino de 22 años, con antecedentes de salud y dolor en el calcañal derecho de dos meses de evolución, que se incrementó hasta dificultarle la marcha. A la exploración física se constató dolor a la palpación de la cara lateral del calcañal derecho, y no se recogió otro dato de interés. La tomografía axial computarizada mostró una lesión hipointensa osteolítica, amplia, con fractura anterosuperior, adelgazamiento de las corticales y con tabicado de la cámara del quiste. Se decidió tratamiento quirúrgico para excéresis y toma de muestra para biopsia, la cual reveló tejido fibroso vascularizado con osteoclastos, células gigantes multinucleadas, cristales de colesterol y hemosiderina, consistente con quiste óseo unicameral. Conclusiones: El quiste óseo unicameral es una lesión pseudotumoral benigna pero potencialmente invalidante, cuyo diagnóstico puede ser fortuito o por alguna fractura patológica. La evacuación con curetaje amplio e injerto óseo, o sus derivados, es la técnica más empleada. El paciente evolucionó de forma favorable y se clasificó como curado(AU)

Introduction: The unicameral bone cyst is a benign pseudotumoral lesion with liquid content, accounting for 3 percent of all primary tumors. The calcaneus is a rare location and the tarsus is the most affected bone. Objective: to report a case of unicameral bone cyst in a right calcaneus, which was diagnosed and treated at Manuel Ascunce Domenech Universitary Hospital in Camagüey with favorable evolution. Case report: This is the case of a 22-year-old male patient with health history of pain in his right calcaneus for two months. The pain increased and made it possible to walk. Physical examination revealed pain on palpation of the lateral aspect of the right heel, and no other data of interest was collected. A wide, hypointense osteolytic lesion was revealed by computerized axial tomography showing an anterosuperior fracture, cortical thinning, and septation of the cyst chamber. Surgery was decided for excising and biopsy sampling that revealed vascularized fibrous tissue with osteoclasts, multinucleated giant cells, cholesterol crystals and hemosiderin, consistent with a unicameral bone cyst. Conclusions: The unicameral bone cyst is a benign but potentially disabling pseudotumoral lesion. The diagnosis may be fortuitous or due to some pathological fracture. Removal with wide curettage and bone grafting, or its derivatives, is the most widely used technique. This patient evolved positively and he was classified as cured(AU)

Fracturas de calcáneo tipo IIC de Sanders en lengüeta: ¿Es la cirugía percutánea el tratamiento de elección? Evaluación funcional y radiográfica a corto plazo / Sanders type IIC tongue-type fractures of the calcaneus. Is percutaneous surgery the treatment of choice? Short-term functional and radiographic evaluation

Objetivos: Describir los resultados radiográficos, funcionales y las complicaciones de la cirugía percutánea en pacientes con fracturas de calcáneo tipo IIC de Sanders en lengüeta. materiales y métodos:Se evaluaron 9 fracturas articulares de calcáneo desplazadas en 9 pacientes con radiografías de pie, de frente y de perfil, y tomografía computarizada preoperatorias. Se tomaron radiografías de pie, de frente y perfil, sin carga en el posoperatorio inmediato y con carga a las semanas 6 y 12, y al final del seguimiento. Se midió el ángulo de Böhler y se cuantificó el grado de artrosis subastragalina y calcaneocuboidea. Se evaluaron las siguientes variables: puntaje AOFAS, complicaciones de la herida, lesión neurológica y necesidad de cirugías adicionales, como retiro del material de osteosíntesis y artrodesis subtalar. Resultados:El seguimiento fue de 21.1 meses. La edad promedio de los pacientes (3 mujeres y 6 hombres) era de 42 ± 12. El ángulo de Böhler preoperatorio fue de 7° (±6,2°) y de 33,6° (±4,1°) en el posoperatorio final (p <0,00001). Hubo una restricción leve de la movilidad subtalar en todos los pacientes. No se observó artrosis subtalar ni calcaneocuboidea. El puntaje AOFAS fue bueno en 4 pacientes y excelente en 5. Todos obtuvieron buenos y excelentes resultados. No se observaron infecciones de la herida, lesiones neurológicas ni complicaciones de la herida. Conclusión: La cirugía percutánea en fracturas de calcáneo tipo IIC de Sanders en lengüeta permite lograr una reducción adecuada con buenos resultados funcionales y bajas tasas complicaciones de parte blandas. Nivel de Evidencia: IV

Objective: Our research aims to describe the functional and radiographic outcomes and complications of percutaneous surgery in Sanders type IIC tongue-type calcaneal fractures. materials and methods:9 articular displaced calcaneus fractures in 9 patients were evaluated with lateral and anteroposterior radiographs and preoperative axial computerized tomography. Non-weight-bearing foot radiographs ­lateral and anteroposterior­ were taken in the immediate postoperative period, and weight-bearing radiographs were taken at the sixth and twelfth weeks, and when finishing follow-up. Böhler's angle was measured, and subtalar and calcaneocuboid osteoarthritis grade was quantified. The AOFAS score, wound complications, neurological injuries, and the need for additional surgeries such as hardware removal and subtalar arthrodesis were considered. Results:3 women and 6 men complied with follow-up during 21.1 months. The patients' average age was 42 ±12. The preoperative Böhler angle was 7° (±6.2°) and the final postoperative angle was 33.6° (±4.1).(p<0.00001). Subtalar range of motion presented a minor restriction in every patient. Neither subtalar nor calcaneocuboid osteoarthritis was observed. The AOFAS score was good in 4 patients and excellent in 5 of them. 100% of the patients presented good and excellent outcomes. We did not record wound infections or complications. Conclusion: Percutaneous surgery in Sanders type IIC tongue-type calcaneal fractures allows us to reach a significant reduction with good functional outcomes and minor soft-tissue complications. Level of Evidence: IV

Staged surgery of Sanders type Ⅳ calcaneal fractures with soft tissue three-degree swelling / 中国骨伤

OBJECTIVE@#To compare the clinical efficacy of staged surgery on Sanders Ⅳ calcaneal fractures with soft tissue Ⅲ swelling.@*METHODS@#The clinical data of 76 patients with Sanders type Ⅳ closed calcaneal fracture with soft tissue three-degree swelling treated from June 2017 to May 2020 was retrospectively analyzed, including 54 males and 22 females, aged from 25 to 50 (38.16±10.24) years. The patients were divided into observation group and control group according to different treatment methods. Twenty-four patients in the observation group were treated by staged surgery stageⅠclosed prying traction reduction and Kirschner wire fixation, stageⅡopen reduction and internal fixation with titanium plate, including 17 males and 7 females, aged from 25 to 50 (36.12±9.56) years. There were 52 patients in the control group, including 37 males and 15 females, aged from 25 to 50 (38.32±10.67) years, these patients were treated with open reduction and internal fixation with titanium plate after the dermatoglyphic signs appeared. The swelling subsidence time, the length of hospitalization days, and the incidence of postoperative incision complications were compared between two groups. The Bhler angle, Gissane angle, and calcaneal varus angle were measured by X-ray before and 6 months after operation. American Orthopedic Foot and Ankle Society (AOFAS) about the ankle hindfoot score was used to evaluate the clinical efficacy.@*RESULTS@#All 76 patients were followed up for 8 to 12 (9.52±2.01) months. The swelling subsidence time and hospitalization days in observation group were (12.12± 3.24) d and (24.53±6.44) d, respectively, which in control group were (15.16±4.16) d and (29.46±9.61) d, with statistical difference between two groups (@*CONCLUSION@#Compared with open reduction and internal fixation with titanium plate after the appearance of dermatoglyphic signs, staged surgery for Sanders type Ⅳ calcaneal fractures with soft tissue three-swelling does not increase the risk of soft tissue complications, and can significantly shorten the patient's swelling subsidence time and hospitalization days, improve the quality of fracture reduction and short term function, and relieve pain.

Anatomical study on reconstruction of calcaneus fibula ligament / 中国骨伤

OBJECTIVE@#To measure anatomical data of calcaneofibular ligament (CFL), relevant data of CFL attachment to provide an anatomical basis for CFL reconstruction.@*METHODS@#Twenty-seven adult ankle specimens were selected, including 11 males and 16 females, aged from 22 to 71 years old with an average of (41.6±17.2) years old;9 cases on the left side and 18 cases on the right side. The specimens reserved at least 20 cm above ankle joint and a complete foot, and exclude deformities, fractures, incomplete development and degenerative lesions. CFL was performed detailed anatomical observation, morphological parameters of CFL was measured, and coordinates of fibula side and calcaneal side of CFL in the coordinate axis were measured. The distance between fibula insertion of CFL and fibula tip, distance between calcaneal insertion of CFL and lateral calcaneal nodule, and Angle between CFL and long axis of fibula were also measured.@*RESULTS@#In these 27 specimens, CFL cases were all single bundles and the length of CFL was (32.83 ± 8.19) mm. The center point of fibula attachment in CFL was(2.87± 1.21) mm proximal with a coefficient of variation of 42.16% and (2.08±1.34) mm anteriorly with a coefficient of variation of 64.42%. The center point of calcaneal attachment region of CFL was located on coordinate axis on the distal end (15.32±5.33) mm, with a coefficient of variation of 34.79%, and the posterior part (6.38±2.15) mm, with a coefficient of variation of 33.86%. The distance between center point of fibula attachment and fibula tip was (4.81±0.82) mm. The distance between center point of calcaneal attachment area of CFL and lateral calcaneal nodules was(17.25±3.12) mm. Angle between CFL and fibula axis is (43 ±18)° .@*CONCLUSION@#According to anatomical studies, we could locate the fibula and calcaneal attachment of CFL by anatomical markers around ankle joint. However, the location of CFL attachment has a large variation, and the anatomical characteristics need to be considered in anatomical reconstruction.

Case control study on the application of artificial bone and autogenous bone in internal fixation of complex calcaneal fracture with special-shaped plate / 中国骨伤

OBJECTIVE@#To compare clinical effects of artificial bone and autogenous bone in internal fixation of complex calcaneal fracture with profitated plate.@*METHODS@#From April 2015 to April 2019, 60 patients with complex calcaneal fractures were treated with open reduction and heteromorphic plate internal fixation, and were divided into experiment group and control group by implant bone substitutes, and 30 patients in each group. In experiment group, there were 21 males and 9 females aged from 18 to 71 years old with an average of (36.85±7.42) years old;19 patients were classified to type Ⅲ and 11 patients were type Ⅳ according to Sanders classification;implanted with artificial bone. While in control group, there were 23 males and 7 females aged from 20 to69 years old with an average of (37.26±7.38) years old;18 patients were classified to type Ⅲ and 12 patients were type Ⅳ according to Sanders classification; implanted with autogenous bone. Operation time, intraoperative blood loss, drying time of incision, fracture healing time and complications were compared between two groups, changes of preoperative and postoperative Böhler angle and Gissane angle were also compared, and Maryland scoring was applied to evaluate recovery of affected foot.@*RESULTS@#Both of two groups were followed up from 3 to 15 months with an average of (10.15±2.67) months. Operation time and intraoperative blood loss in experiment group were (89.32±12.43) min, (101.64±5.13) ml, respectively;while in control group were (112.45±13.82) min, (119.01±5.26) ml, respectively;and there were statistical difference between two groups (@*CONCLUSION@#Artificial bone and autogenous bone in internal fixation of complex calcaneal fracture with irregular plate have similar function in promoting fracture healing, drying time of incision, fracture healing time and complications, while artificial bone has better effects in reducing intraoperative blood loss, shorten operation time.

Case control study on anatomical locking plate and ordinary steel plate for the treatment of closed calcaneal fracture with SandersⅡand Ⅲ / 中国骨伤

OBJECTIVE@#To compare clinical efficacy between anatomical locking plate (ALP) and ordinary steel plate (OSP) in treating closed calcaneal fractures with SandersⅡ and Ⅲ.@*METHODS@#From May 2016 to May 2018, 68 patients with closed Sanders typeⅡ and Ⅲ calcaneal fractures were retrospectively analyzed, and were divided into anatomical locking plate group (ALP group) and ordinary steel plate group (OSP group) according to two kinds of plate fixation, and 34 patients in each group. In ALP group, there were 21 males and 13 females aged from 20 to 63 years old with average of (35.16±8.45) years old; 14 patients were typeⅡand 20 patients were type Ⅲaccording to Sanders classification;treated with ALP. In OSP group, there were 20 males and 14 females aged from 19 to 63 years old with average of (35.05±8.39) years old;19 patients were typeⅡand 15 patients were type Ⅲ according to Sanders classification;treated with OSP. Operative time, intraoperative blood loss and complications between two groups were observed and compared;preoperative and postoperative Böhler angle and gissane angle were also compared;American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hind foot scores, foot and ankle disability index (FADI) scores were applied to evaluate clinical effect.@*RESULTS@#All patients were followed up from 11 to 14 months with an average of (12.06±0.81) months. There were no statistical differences in opertive time, intraoperative blood loss, incision infection and refracture rate in complications between two groups (@*CONCLUSION@#Compared with OSP, ALP in treating SandersⅡ and Ⅲ calcaneal fractures could achieve better therapeutic effect, avoid screw loosening, reduce complications, and improve limb function in further.

Comparative study on curative effect of minimally invasive locking plate for the treatment of intra-articular calcaneal fractures via sinus tarsi approach / 中国骨伤

OBJECTIVE@#To compare clinical efficacy of minimally invasive locking plate and anatomic locking plate in treating intra-articular calcaneal fractures via sinus tarsi approach.@*METHODS@#A retrospective analysis was conducted of 48 patients with intra-articular calcaneal fractures treated with surgery via sinus tarsi approach from July 2016 to June 2017. According to differernt methods of internal fixation, the patients were divided into minimally invasive locking plate group and anatomic locking plate group. In minimally invasive locking plate group, there were 14 males and 10 females, aged from 27 to 46 years old with an average age of (38.70±5.58) years old, 18 patients were typeⅡand 6 patients were type Ⅲ according to Sanders classification. In anatomic locking plate group, there were 17 males and 7 females, aged from 26 to 46 years old with an average age of (37.10±6.44) years old, 16 patients were typeⅡ and 8 patients were type Ⅲ according to Sanders classification. Operative time, visual analogue scale (VAS), postoperative complications between two groups were compared, and Böhler angle, Gissane angal, calcaneal width and height were recorded and compared between two groups at 1 week after operation and final follow up. The functional effect was assessed according to Maryland foot function score at final follow up.@*RESULTS@#All patients were followed up for (14.10±1.94) months (ranged 12 to 18 months). All patients were obtained bone union from 8 to 16 weeks with an average of (10.60±2.25) weeks. Operation time, VAS score and complication rate in minimally invasive locking plate group were (69.50±7.51) min, (2.80±1.07) and 2 cases respectively, and (77.50±7.15) min, (3.80±1.09) and 8 cases in anatomic locking plate group respectively, there were statistical difference between two groups (@*CONCLUSION@#Compare with anatomic locking plate, minimally invasive locking plate via sinus tarsi approach for Sanders typeⅡ and Ⅲ intra-articular calcaneal fractures could obtain similar reliable fixation and functional recovery with more simple operation, shorter operative time, lighter postoperative pain and less complications.

Finite element optimization analysis of minimally invasive screw treatment for Sanders typeⅡcalcaneal fracture / 中国骨伤

OBJECTIVE@#To explore biomechanical characteristics of minimally invasive different screw fixations in treating Sanders typeⅡcalcaneal fractures.@*METHODS@#Dicom data of calcaneus by CT scan were input into Mimics 21.0 software and Ansys15.0 software to construct three-dimensional finite element digital model of calcaneus;this model was input into UG NX 10.0 software, and calcaneus was cut according to Sanders classification to establish Sanders typeⅡ calcaneus model with posterior articular surface collapse;then simulated minimally invasive screw internal fixation after calcaneal fracture:a screw from posterior articular surface was used to outside-in fix sustentaculum tali, other 4 screws were used to fix calcaneus by different methods through calcaneal tuberosity, and 4 different calcaneal models were obtained. Under the same conditions, 4 types of internal fixation models were loaded respectively, and nonlinear finite element analysis was performed to calculate the stress distribution of different internal fixation models.@*RESULTS@#Under the same condition of loading, the model 3 had smaller displacement value, maximum calcaneus displacement value and maximum equivalent stress value of the screw than other three internal fixation models, and the stress was more dispersed.@*CONCLUSION@#In minimally invasive screw internal fixation of calcaneus fracture, after 1 sustentaculum tali screw fixation, 2 screws crossed fix posterior articular surface from calcaneal tuberosity, 2 screws fix parallelly calcaneocuboid joint from calcaneal tuberosity are more suitable for biomechanical requirements, and could provide basic theory for clinical treatment.

Biomechanical comparison of plantar-to-dorsal and dorsal-to-plantar screw fixation strength for subtalar arthrodesis / Comparação biomecânica da força de fixação de parafuso com orientação de plantar para dorsal e vice-versa para artrodese subtalar

ABSTRACT Objective To compare screw fixation strength for subtalar arthrodesis. Methods Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP Group), and the other foot, plantar to dorsal orientation (PD Group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix ® 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD Groups using Student's t test, with p=0.05 used to determine statistical significance. Results Statistical analysis demonstrated that the mean torque to failure slightly favored the DP Group (37.3Nm) to the PD Group (32.2Nm). However, the difference between the two groups was not statistically significant (p=0.55). Conclusion In subtalar arthrodesis, there is no significant difference in construct strength between dorsal-to-plantar and plantar-to-dorsal screw orientation. The approach chosen by the surgeon should be based on factors other than the biomechanical strength of the screw orientation.

RESUMO Objetivo Comparar a força de fixação dos parafusos para artrodese subtalar. Métodos Oito pares de pés de cadáveres frescos foram submetidos à artrodese da articulação subtalar com dois parafusos canulados de 7,3mm. A randomização foi usada para atribuir a orientação do parafuso, de modo que um pé em cada par foi designado com orientação de dorsal para plantar (Grupo DP), e o outro pé com orientação de plantar para dorsal (Grupo PD). Técnica cirúrgica padrão com radioscopia foi usada para os procedimentos. Após a fixação, cada amostra foi testada até a falha com um dispositivo Bionix®858 MTS, aplicando força axial descendente a uma distância para criar torque. O torque de falha foi comparado entre os Grupos DP e PD, usando o teste t de Student, com p=0,05 usado para determinar significância estatística. Resultados A análise estatística demonstrou que a média do torque até a falha favoreceu ligeiramente o Grupo DP (37,3Nm) em relação ao PD (32,2Nm). No entanto, a diferença entre os dois grupos não foi estatisticamente significativa (p=0,55). Conclusão Na artrodese subtalar, não há diferença significativa na força de compressão entre as orientações dos parafusos dorsal-plantar e plantar-dorsal. A abordagem escolhida pelo cirurgião deve ser baseada em outros fatores, sem preocupação com a força biomecânica da orientação dos parafusos.

Poking reduction cannulated screw for the treatment of SandersⅡ calcaneal fracture / 中国骨伤

OBJECTIVE@#To evaluate clinical effect of poking reduction cannulated screw based on Pingle orthopedic muscle-bone interoperability balance theory in treating Sanders Ⅱ calcaneal fracture.@*METHODS@#From October 2014 to December 2017, 28 patients with Sanders Ⅱ calcaneal fracture were treated with poking reduction cannulated screw guided by Pingle orthopedic muscle-bone interoperability balance theory, including 20 males and 8 females, aged from 24 to 55 years old with an average of (37.2±3.9) years old. Calcaneal width, Bhler angle, and Gissane angle were measured before and after operation, and Maryland Score before and 6 months after operation were compared.@*RESULTS@#All patients were followed up from 12 to 16 months with an average of (13.7±1.3) months. All fractures healed normally, and healing time ranged from 9 to 12 weeks with an average of (10.2±1.3) weeks. No postoperative wound infection, cortical necrosis, or osteomyelitis occurred. The width of the calcaneus decreased from (34.15±2.58) mm before surgery to (30.49±2.37) mm after surgery, Bhler angle increased from (14.16±3.27)° before operation to (31.95±3.07)°after operation, Gissane angle decreased from (128.45±9.04)° before operation to (120.83±8.15)° after operation. Maryland Score was 15.68±4.73 before operation, and was improved to 88.32±2.65 at 6 months after operation;19 patients got excellent result, 6 good, 2 fair and 1 poor.@*CONCLUSION@#Poking reduction cannulated screw based on Pingle orthopedic muscle-bone interoperability balance theory in treating Sanders Ⅱ calcaneal fracture has certain clinical effects, high acceptation of patient, and without special demand for soft tissue around fracture. But it should avoid choosing severe comminuted Sanders Ⅲand Ⅳcalcaneal fracture.

Osteotomia de alongamento da coluna lateral do calcâneo para tratamento do pé plano flexível sintomático de crianças e adolescentes: revisão sistemática / Calcaneal lateral column lengthening osteotomy for symptomatic flexible flatfoot in children and adolescents: a systematic review

RESUMO O pé plano flexível é condição frequente na criança pequena e apresenta forte tendência para correção espontânea, ou tornar-se moderado ou leve no adulto, o que não causará problemas futuros. Entretanto, em uma pequena proporção de casos a deformidade é mais grave, não melhora, o que pode levar ao comprometimento do desempenho mecânico, deformidade e, eventualmente, dor. Nestes casos o tratamento cirúrgico deve ser considerado. O objetivo desta revisão sistemática foi avaliar os resultados da literatura no tratamento do pé plano flexível sintomático da criança ou adolescente por um procedimento bastante frequente que é a osteotomia de alongamento da coluna lateral do calcâneo. Foi realizada busca sistemática eletrônica nas bases de dados PubMed, Web of Science, Cochrane, CINAHL, SciELO, SCOPUS e LILACS por artigos publicados entre março de 1975 e setembro de 2016. Após aplicação dos critérios de elegibilidade, os artigos selecionados foram avaliados quanto aos resultados clínicos, radiográficos e complicações. Dos 341 artigos encontrados nas bases de dados, apenas oito estudos foram selecionados, segundo os critérios de inclusão e exclusão, com um total de 105 pacientes e 167 pés tratados. Somente três autores realizaram estudo prospectivo, mas sem caso controle ou aleatorização. A maioria das publicações no período avaliado é composta por estudos descritivos ou série de casos (nível de evidência III ou IV), com grandes variações metodológicas, mas com alto índice de satisfação dos pacientes e cirurgiões, em relação aos resultados. Entretanto, são necessárias pesquisas com desenho prospectivo, aleatorizado, grupo controle adequado e critérios de avaliação validados.

ABSTRACT Flexible flatfoot is a common condition in small children, which shows a strong tendency to spontaneously correct with their growth or to become moderate or mild in adults, which will not cause future problems. However, in a small number of cases, this condition is more severe, does not improve spontaneously, which may cause mechanical impairment, deformity, and, eventually, pain. In such cases, surgical treatment should be considered. The aim of this systematic review was to evaluate the literature results on the treatment of the symptomatic flexible flatfoot in children or adolescents through a very frequent procedure: calcaneal lateral column lengthening osteotomy, A systematic electronic search in PubMed, Web of Science, Cochrane, CINAHL, SciELO, SCOPUS and LILACS databases was performed. We searched articles published between March 1975 and September 2016. After applying the eligibility criteria, the selected publications were evaluated in relation to their clinical and radiographic results and complications. We found 341 articles in the mentioned databases, but selected only eight studies, according to the inclusion and exclusion criteria. These studies included a total of 105 patients and 167 treated feet. Only three authors performed prospective studies, but without case-control or randomization. The majority of publications were descriptive studies or case series (level of evidence III or IV), with great methodological variations, but with a high satisfaction rate on the part of both patients and surgeons in relation to the results. However, more prospective and randomized studies are required, with adequate control groups and validated evaluation criteria.

Surgical treatment of intraarticular fractures of the calcaneus: comparison between flat plate and calcaneal plate / Tratamento cirúrgico das fraturas intra-articulares do calcâneo: comparação dos resultados entre placa reta e placa própria para calcâneo

ABSTRACT OBJECTIVE: To evaluate the clinical results of surgical treatment of intraarticular fractures of the calcaneus, comparing the use of calcaneal plate and flat plate. METHODS: This was a retrospective study assessing the postoperative results of 25 patients between 2013 and 2015. Patients undergoing surgical treatment of intraarticular fractures of the calcaneus without concomitant surgical lesions were included. Patients who did not complete appropriate follow-up after surgery were excluded from the study. RESULTS: The unavailability of calcaneal plates at resource-limited settings, associated with the availability and lower cost of flat plates, may have been a confounding factor in the present study. However, there was no statistical difference between the outcomes of fractures treated with calcaneal plates or flat plates. CONCLUSION: Statistical inference shows that, when calcaneal plates are not available, it is possible to use flat plates with similar clinical outcomes.

RESUMO OBJETIVO: Avaliar os resultados clínicos do tratamento cirúrgico das fraturas intra-articulares do calcâneo (TCFIAC) e comparar o uso de placa própria para calcâneo (PPC) e placa reta (PR) . MÉTODOS: Estudo retrospectivo que avaliou o resultado pós-operatório de 25 pacientes entre 2013 e 2015. Foram incluídos pacientes submetidos ao TCFIAC e que não apresentavam lesões cirúrgicas concomitantes. Pacientes que não foram devidamente acompanhados no pós-operatório foram excluídos da análise. RESULTADOS: A indisponibilidade da PPC em serviços com recursos limitados, associada à disponibilidade e ao menor custo da PR, pode ter sido fator de confusão no presente estudo. Contudo, não houve diferença estatística entre os resultados das fraturas tratadas com PPC ou PR. CONCLUSÃO: A inferência estatística permite concluir que, na ausência da PPC, é possível usar a PR com desfechos clínicos semelhantes.

Retalho plantar medial: uma série de casos / The medial plantar flap: a case series

Introdução: A cobertura do pé e especialmente da região do calcâneo são desafios técnicos para o cirurgião devido ao alto grau de especialização dos tecidos envolvidos e à relativa imobilidade dos tecidos próximos. Métodos: No presente estudo, apresentamos nossa experiência com uso do retalho baseado na artéria plantar medial para cobertura de defeitos teciduais no pé, especialmente na região de apoio plantar no calcâneo. Doze retalhos da artéria plantar medial feitos de 2001 a 2013 no Hospital Regional da Asa Norte, Brasília, DF, foram incluídos. Resultados: Dos 12 pacientes, 10 eram homens e dois eram mulheres. As indicações foram perda traumática do coxim do calcâneo em 10 pacientes e dorso do pé em dois casos. Todos os retalhos foram elevados como retalhos pediculados fasciocutâneos baseados na artéria plantar medial. Todos os retalhos cicatrizaram sem maiores complicações, exceto um caso com perda parcial. A área doadora foi coberta com enxerto de pele parcial e houve um caso de perda parcial do enxerto. Os retalhos apresentaram uma sensibilidade protetora levemente inferior ao lado normal. Conclusão: De acordo com os resultados, o retalho plantar medial é uma boa opção para cobertura do pé, especialmente do calcâneo. A versatilidade do retalho permite a cobertura de defeitos no calcâneo sobre o tendão de Aquiles e apoio plantar, assim como o dorso do pé. A cobertura da região de apoio plantar com pele de textura similar e sensibilidade protetora confere a esse retalho uma grande vantagem sobre outros retalhos para reconstrução dessa região.

Introduction: Reconstructive coverage of foot defects, especially those of the calcaneus region, is a unique technical challenge for the surgeon due to the high degree of specialization of the tissues involved and the relative immobility of the proximal tissues. Methods: In the present study, we present our experience with the use of the flap based on the medial plantar artery to cover tissue defects in the foot, especially in the region of the calcaneal fat pad. Twelve medial plantar artery flaps constructed from 2001 to 2013 at the As a Norte Regional Hospital, Brasília, DF, were included. Results: Of the 12 patients with the medial plantar artery flaps, 10 were men and 2 were women. The indications were traumatic tissue loss of the plantar fat pad in 10 patients and of the dorsum of the foot in two cases. All flaps were elevated as fasciocutaneous pedicle flaps based on the medial plantar artery. All the flaps healed without major complications, except one case that involved partial loss . The donor area was covered with a partial skin graft and there was one case of partial graft loss. The flap displayed a slightly lower protective sensitivity than the normal side. Conclusion: According to the results, the medial plantar flap is a good option for covering traumatic foot defects, especially those affecting the calcaneus. The versatility of the flap allows the coverage of defects of the calcaneus (e.g., the Achilles tendon and plantar fat pad regions), as well as those affecting the dorsum of the foot. The coverage of the plantar fat pad region with skin of similar texture and protective sensitivity confers to the medial plantar flap a large advantage over other flaps for reconstruction of this region.

Comparative study on three surgical techniques for intra-articular calcaneal fractures: open reduction with internal fixation using a plate, external fixation and minimally invasive surgery / Estudo comparativo entre três técnicas cirúrgicas para fraturas intra-articulares de calcâneo: redução aberta e fixação interna com placa, fixação externa e minimamente invasiva

To evaluate, compare and identify the surgical technique with best results for treating intra-articular calcaneal fractures, taking into account postoperative outcomes, complications and scoring in the Aofas questionnaire. METHODS: This was a retrospective study on 54 patients with fractures of the calcaneus who underwent surgery between 2002 and 2012 by means of the following techniques: (1) open reduction with extended L-shaped lateral incision and fixation with double-H plate of 3.5 mm; (2) open reduction with minimal incision lateral approach and percutaneous fixation with wires and screws; and (3) open reduction with minimal incision lateral approach and fixation with adjustable monoplanar external fixator. RESULTS: Patients treated using a lateral approach, with fixation using a plate had a mean Aofas score of 76 points; those treated through a minimal incision lateral approach with screw and wire fixation had a mean score of 71 points; and those treated through a minimal incision lateral approach with an external fixator had a mean score of 75 points. The three surgical techniques were shown to be effective for treating intra-articular calcaneal fractures, without any evidence that any of the techniques being superior. CONCLUSION: Intra-articular calcaneal fractures are complex and their treatment should be individualized based on patient characteristics, type of fracture and the surgeon's experience with the surgical technique chosen.

Avaliar, comparar e identificar a técnica cirúrgica com melhor resultado para o tratamento de fraturas intra-articulares do calcâneo, levando em consideração evolução pós-operatória, complicações e pontuação no questionário Aofas. MÉTODOS: Estudo retrospectivo de 54 pacientes com fraturas de calcâneo operados entre e 2002 e 2012 com as técnicas 1) redução aberta com incisão lateral alargada em "L" e fixação com placa duplo "H" de 3,5 mm, 2) redução aberta por incisão lateral econômica e fixação percutânea com fios e parafusos e 3) redução aberta por incisão lateral econômica e fixação com fixador externo monoplanar regulável. RESULTADOS: Pacientes tratados pela via de acesso lateral e fixação com placa tiveram média de 76 pontos na escala Aofas, em pacientes tratados pela via de acesso lateral econômica e fixação com fios e parafuso a média foi de 71 e nos pacientes tratados com via de acesso lateral e fixador externo foi de 75 pontos. As três técnicas cirúrgicas demostraram-se efetivas no tratamento da fratura intra-articular do calcâneo, sem evidência de superioridade de uma técnica sobre as demais. CONCLUSÃO: A fratura intra-articular do calcâneo é uma fratura complexa e seu tratamento deve ser individualizado, baseado nas características do paciente, no tipo de fratura e na experiência do cirurgião com a técnica operatória escolhida.

Calcanectomia subtotal para tratamento de úlcera de pressão com osteomielite associada: relato de 2 casos / Subtotal calcanectomy for the treatment of calcaneal pressure sores with associated osteomyelitis: a report of 2 cases

Introdução: Feridas em pés são muito frequentes e requerem abordagem multidisciplinar para a sua prevenção, tratamento e reabilitação. Quando acometem o calcâneo, oferecem dificuldade ainda maior e podem apresentar complicação com a ocorrência de osteomielite. Debridamento de tecido desvitalizado e antibioticoterapia são etapas obrigatórias para o tratamento. Na reconstrução, retalhos locais ou livres são necessários. Porém, nem todos os pacientes, devido a condições sistêmicas ou de vascularização local, são candidatos a esse tipo de reconstrução e acabam sendo submetidos a amputações. Relato de caso: Os autores relatam dois casos nos quais foram utilizadas calcanectomias subtotais para o tratamento de feridas em calcâneo. Em ambos os casos, foram evitadas as amputações.

Introduction: Feet wounds are very common and require multidisciplinary approach for prevention, treatment and rehabilitation. When involving the calcaneus, they offer even greater difficulty and may complicate with osteomyelitis. Debridement of devitalized tissue and antibiotics are important steps for treatment. For the reconstruction, local or free flaps are needed. However, not all patients, due to systemic conditions or local blood supply, are not candidates for this type of reconstruction and some times are submitted to amputations. Cases Report: The authors report two cases in which subtotals calcanectomies were used for the treatment of wounds in the calcaneus. In both cases, amputations were avoided.