Modified hindfoot alignment radiological evaluation and application in the assessment of flatfoot.

BACKGROUND: Alignment is indispensable for the foot and ankle function, especially in the hindfoot alignment. In the preoperative planning of patients with varus or valgus deformity, the precise measurement of the hindfoot alignment is important. A new method of photographing and measuring hindfoot alignment based on X-ray was proposed in this study, and it was applied in the assessment of flatfoot. METHODS: This study included 28 patients (40 feet) with flatfeet and 20 volunteers (40 feet) from January to December 2018. The hindfoot alignment shooting stand independently designed by our department was used to take hindfoot alignment X-rays at 10 degree, 15 degree, 20 degree, 25 degree, and 30 degree. We measured the modified tibio-hindfoot angle (THA) at the standard hindfoot aligment position (shooting at 20 degree) and evaluated consistency with the van Dijk method and the modified van Dijk method. In addition, we observed the visibility of the tibiotalar joint space from all imaging data at five projection angles and evaluated the consistency of the modified THA method at different projection angles. The angle of hindfoot valgus of flatfoot patients was measured using the modified THA method. RESULTS: The mean THA in the standard hindfoot aligment view in normal people was significantly different among the three evaluation methods (P < .001). The results from the modified THA method were significantly larger than those from the Van Dijk method (P < .001) and modified Van Dijk method (P < .001). There was no significant difference between the results of the modified THA method and the weightbearing CT (P = .605), and the intra- and intergroup consistency were the highest in the modified THA group. The tibiotalar space in the normal group was visible in all cases at 10 degree, 15 degree, and 20 degree; visible in some cases at 25 degree; and not visible in all cases at 30 degree. In the flatfoot group, the tibiotalar space was visible in all cases at 10 degree, visible in some cases at 15 degree and 20 degree, and not visible in all cases at 25 degree and 30 degree. In the normal group, the modified THA was 4.84 ± 1.81 degree at 10 degree, 4.96 ± 1.77 degree at 15 degree, and 4.94 ± 2.04 degree at 20 degree. No significant differences were found among the three groups (P = .616). In the flatfoot group, the modified THA of 18 feet, which was visible at 10 degree, 15 degree and 20 degree, was 13.58 ± 3.57 degree at 10 degree, 13.62 ± 3.83 degree at 15 degree and 13.38 ± 4.06 degree at 20 degree. There were no significant differences among the three groups (P = .425). CONCLUSIONS: The modified THA evaluation method is simple to use and has high inter- and intragroup consistency. It can be used to evaluate hindfoot alignment. For patients with flatfeet, the 10 degree position view and modified THA measurement can be used to evaluate hindfoot valgus.

Cartilage Damage Pathological Characteristics of Diabetic Neuropathic Osteoarthropathy.

Background: Diabetic neuropathic osteoarthropathy (DNOAP) is a rare and easily missed complication for diabetes that leads to increased morbidity and mortality. DNOAP is characterized by progressive destruction of bone and joint, but its pathogenesis remains elusive. We herein aimed to investigate the pathological features and pathogenesis of the cartilages damage in DNOAP patients. Methods: The articular cartilages of eight patients with DNOAP and eight normal controls were included. Masson staining and safranine O/fixed green staining (S-O) were used to observe the histopathological characteristics of cartilage. The ultrastructure and morphology of chondrocytes were detected by electron microscopy and toluidine blue staining. Chondrocytes were isolated from DNOAP group and control group. The expression of receptor activator of nuclear factor kappaB ligand (RANKL), osteoprotegerin (OPG), interleukin-1 beta (IL-1ß), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and Aggrecan protein was evaluated by western blot. Reactive oxygen species (ROS) levels were measured using a 2',7'-dichlorofluorescin diacetate (DCFH-DA) probe. The percentage of apoptotic cells was determined by flow cytometry (FCM). The chondrocytes were cultured with different glucose concentrations to observe the expression of RANKL and OPG. Results: Compared with the control group, the DNOAP group showed fewer chondrocytes, subchondral bone hyperplasia, and structural disorder, and a large number of osteoclasts formed in the subchondral bone area. Moreover, mitochondrial and endoplasmic reticulum swellings were observed in the DNOAP chondrocytes. The chromatin was partially broken and concentrated at the edge of nuclear membrane. The ROS fluorescence intensity of chondrocyte in DNOAP group was higher than that in normal control group (28.1 ± 2.3 vs. 11.9 ± 0.7; P < 0.05). The expression of RANKL, TNF-α, IL-1ß, and IL-6 protein in DNOAP group was higher than that in normal control group, whereas OPG and Aggrecan protein were lower than that in normal control group (both P < 0.05). FCM showed that the apoptotic rate of chondrocyte in DNOAP group was higher than that in normal control group (P < 0.05). The RANKL/OPG ratio showed significant upward trend when the concentration of glucose was over than 15 mM. Conclusions: DNOAP patients tend to have severe destruction of articular cartilage and collapse of organelle structure including mitochondrion and endoplasm reticulum. Indicators of bone metabolism (RANKL and OPG) and inflammatory cytokines (IL-1ß, IL-6, and TNF-α) play an important role in promoting the pathogenesis of DNOAP. The glucose concentration higher than 15 mM made the RANKL/OPG ratio change rapidly.

[Comparison of efficacy of platelet-rich plasma and extracorporeal shock wave for the treatment of chronic insertional Achilles tendinopathy].

OBJECTIVE: To compare clinical efficacy of platelet-rich plasma (PRP) and extracorporeal shock wave in treating chronic insertional Achilles tendinopathy. METHODS: From February 2019 to August 2021, 42 patients with chronic insertional Achilles tendinopathy were selected and divided into PRP group(20 patients, 28 feet) and shock wave group (22 patients, 29 feet). In PRP group, there were 12 males and 8 females, aged 47.00(28.00, 50.75) years old, and the courses of disease ranged 7.00(6.00, 7.00) months;PRP injection was performed in the Achilles tendon stop area of the affected side. In shock wave group, there were 16 males and 6 females, aged 42.00(35.75, 47.25) years old;and the courses of disease was 7.00(6.00, 8.00) months;shock wave was performed in Achilles tendon stop area of the affected side and triceps surae area. Visual analogue scale (VAS) and Victorian Institute of Sport Assessment-Achilles (VISA-A) were applied to evaluate clnical effect before treatment, 1, 3 and 6 months after treatment, and satisfaction of patients was investigated. RESULTS: VAS and VISA-A score in both groups were significantly improved at 1, 3 and 6 months after treatment than before treatment (P<0.05), VAS and VISA-A score in PRP group at 6 months after treatment were significantly higher than those at 1 and 3 months after treatment, and VAS and VISA-A score in shock wave group were lower than those at 1 and 3 months after treatment (P<0.05). There was no significant difference in VAS and VISA-A score between two groups before treatment, 1 and 3 months after treatment(P>0.05), while VAS and VISA-A score in PRP group were better than those in shock wave group at 6 months after treatment(P<0.05), and the satisfaction survey in PRP group was better than that in shock wave group(P<0.05). CONCLUSION: PRP injection has a good clinical effect on chronic insertional Achilles tendinopathy with high patient satisfaction, and medium-and long-term effect of PRP injection for the treatment of chronic insertional Achilles tendinopathy is better than that of extracorporeal divergent shock wave.

Supramalleolar Osteotomy vs Arthrodesis for the Treatment of Takakura 3B Ankle Osteoarthritis.

BACKGROUND: To compare the clinical/functional outcomes of supramalleolar osteotomy (SMOT) and ankle arthrodesis (AA) for the treatment of modified Takakura stage 3B ankle osteoarthritis. METHODS: Outcomes of 28 SMOT patients and 30 AA patients were reviewed at an average of 50 and 51 months, respectively. The baseline characteristics of the 2 groups were similar. The preoperative tibial articular surface angle and talar tilt angle in the SMOT group were 82.6 and 10 degrees and in the AA group, 83.9 and 9.1 degrees, respectively. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, 12-item Short-Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores, range of motion (ROM), radiologic parameters, and complications were compared. RESULTS: The AOFAS, VAS, and SF-12 MCS and PCS scores improved significantly postoperatively in both groups (P < .001). The VAS and SF-12 PCS scores indicate marginally better improvement in the AA group (P < .05). The patient satisfaction value (P = .028) and the possibility of repeated surgery value (P = .012) were also significantly higher in the AA group. The early (P = .905) and late (P = .181) complications did not significantly differ between the 2 groups. The reoperation rate was significantly higher in the SMOT group (P = .038). CONCLUSION: Both SMOT and AA showed improvements in function, pain, alignment, and quality of life after surgery. Patients in the AA group reported better pain relief, had a lower reoperation rate, and better hindfoot alignment during a short- to mid-term follow-up time. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Closed reduction and posterior percutaneous internal fixation for simple displaced talar neck fracture: a retrospective comparative study.

PURPOSE: Open reduction and internal fixation (ORIF) is the most commonly used surgical technique for talar neck fracture, but there are high risks for complications and poor functional outcomes. In this study, we reported the closed reduction and percutaneous internal fixation (CRPIF) technique of the bilateral approach of the Achilles tendon for simple displaced talar neck fracture, in comparison with ORIF. METHODS: Data of 15 patients in the CRPIF group and 22 in the ORIF group were included. The American Orthopaedic Foot and Ankle Society (AOFAS) score, Visual Analog Scale (VAS) score, 12-item Short-Form Survey (SF-12) score, range of motion (ROM), complications, and radiographic results were recorded and compared. RESULTS: The mean follow-up in the CRPIF group was 33.9 months. Complications included two cases of avascular necrosis (AVN) and two cases of osteoarthritis. All patients achieved bony union and recovered their pre-operative mobility. The mean follow-up in the ORIF group was 39 months. Complications included two cases of bony nonunion, nine AVN, and seven cases of osteoarthritis. Moreover, the mobility of the ORIF group was significantly lower than the CRPIF group post-operatively. The AOFAS score, VAS score, and SF-12 physical component score (PCS) for the CRPIF group were better improved than those for the ORIF group (ALL, P < 0.05). CONCLUSIONS: The CRPIF technique of the bilateral approach of the Achilles tendon was an effective method for the treatment of simple displaced talar neck fractures. Compared with the ORIF, the limited blood supply of the talus was protected, provide better functional outcomes and biomechanical fixation, and lower incidence of resurgery and complication in the CRPIF.

Triplane osteotomy combined with talar non-weight-bearing area autologous osteochondral transplantation for osteochondral lesions of the talus.

BACKGROUND: Traditional medial malleolar osteotomy combined with autologous osteochondral transplantation (AOT) is mostly used in the treatment of osteochondral lesions of the talus (OLTs), but with high osteotomy and donor site complications. We hypothesis a new triplane medial malleolar osteotomy combined with AOT from non-weight-bearing area of the talus could be a promising choice for OLTs. METHODS: We reviewed all the symptomatic OLTs patients who received AOT with triplane osteotomy of the medial malleolus between September 2015 and December 2017 in our department. According to the inclusion and exclusion criteria, 23 patients (23 ankles), including 14 males and 9 females, were included in the study. The mean age was 35.6 years. The mean size of the lesion area was 141.5 mm2. According Ferkel's classification, including 5 type I, 11 typeIIa and 7 typeIIb. The visual analog scale (VAS) for pain during walking and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were used for the pre- and postoperative evaluations. In addition, the incorporation of the grafts was assessed by computed tomography (CT). RESULTS: All patients had a minimum follow-up of 22 months, with an average of 37.1 months. The mean time from osteotomy to full weight-bearing activity was 8.1 ± 2.3 weeks (range, 5-12 weeks). The mean VAS score improved from 5.6 ± 0.7 preoperatively to 0.7 ± 1.0 postoperatively (P < 0.01). The AOFAS ankle-hindfoot score improved significantly in all domains (P < 0.01). Twenty-one patients returned to sport at their previous level, and 2 returned at a lower level compared with preinjury (mean return to play, 7.4 months). According to CT, the medial malleolus recovered in all patients, and the graft was incorporated well. One patient suffered from flexor hallucis longus tendon discomfort due to internal fixation screw irritation posteromedial to the ankle. The general complication rate was 4.3% (1/23). CONCLUSIONS: These results indicate that AOT combined with medial malleolus triplane osteotomy maybe a viable option for OLTs. Patients could perform weight-bearing exercise and return to sport as early as possible, with a lower rate of complications at the osteotomy site and donor site. However, the large sample well-designed prospective comparative studies are still needed.

Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy.

BACKGROUND: There have been debates on the necessity of fibular osteotomy (FO) in supramalleolar osteotomy (SMOT) for the treatment of varus ankle osteoarthritis. The purpose of the current study was to compare the clinical and radiological outcomes between SMOT with and without FO in the treatment of varus ankle osteoarthritis. METHODS: The SMOT group included 39 patients, and the SMOT with FO group included 24 patients. The basic information reached no significant difference between groups. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS), modified Takakura stage and range of motion (ROM) were used for the functional evaluation. The radiologic parameters were assessed at the last follow-up to compare the degree of talar reduction between the two groups. RESULTS: Both groups achieved significant improvements in AOFAS scores, modified Takakura stage, as well as AOS pain and functional scores (P < 0.001). The ROM of the ankle joint in the SMOT group was significantly decreased (P = 0.022). In both groups, all of the radiological parameters were significantly improved (P < 0.01). The tibiofibular clear space (TFCS) was significantly widened in the SMOT group (P < 0.001). No significant difference was found between the two groups according to the functional outcomes. However, the talar tilt angle (TT) and hindfoot alignment angle (HFA) in the SMOT with FO group were significantly smaller than those in the SMOT group (P < 0.05). The TFCS was significantly widened in the SMOT group (P = 0.001). The medial displacement of the talus (MDT) was better reduced in the SMOT with FO group (P = 0.006). CONCLUSION: SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. If SMOT is combined with FO, talar tilt and medial displacement will be better reduced.

Ilizarov Gradual Distraction Correction for Distal Tibial Severe Varus Deformity Resulting from Epiphyseal Fracture: Case Report and Literature Review.

We present a case of a 13-year-old female with severe varus deformity and limb discrepancy resulting from epiphyseal fracture. The preoperative tibial articular surface angle was 64.1°, and the affected tibia was 14 mm shorter than the contralateral tibia. She underwent a medial open osteotomy and fibular osteotomy with gradual distraction correction using Ilizarov fixator. The deformity was corrected at 3 months, and the external fixator was removed when bony union was achieved 6 months postoperatively. At 9 months after surgery, the patient could play basketball without feeling pain. At the last follow-up, namely 36 months after the operation, the American Orthopaedic Foot and Ankle Society hindfoot-ankle score was improved from 58 to 90, the patient was pain free, and the radiological measurements were nearly normal. Ilizarov fixator gradual distraction correction for distal tibial severe varus deformity is a safe and cost-effective method that can yield excellent radiological and clinical outcomes.

Scarf Osteotomy for Correction of Hallux Valgus Deformity in Adolescents.

OBJECTIVE: To report the radiological and clinical outcomes of the modified scarf osteotomy for the treatment of hallux valgus deformity in adolescents. METHODS: This retrospective study analyzed 21 patients (31 feet) who underwent a modified scarf osteotomy for correcting juvenile hallux valgus deformity between March 2015 and January 2017. There were 3 male (3 feet) and 18 female (28 feet) patients. The average age at the time of surgery was 28.6 years (range, 20-35). Patients were postoperatively followed up in the outpatient department for 12-18 months. Clinical and radiological assessments were performed preoperatively and postoperatively at 1 year. Moreover, postoperative complications were recorded. Statistical analyses for differences between preoperative and postoperative values were performed. RESULTS: All the 21 patients were postoperatively followed up for 12-18 months, with an average of 13.2 ± 2.5 months. Clinical assessment showed that the American Orthopaedic Foot and Ankle Society score was increased from preoperative 58.0 ± 5.8 to postoperative 94.2 ± 6.6 points, respectively, and the visual analog scale score was remarkably decreased from preoperative 6.0 ± 2.0 to postoperative 1.5 ± 2.0 points at 1 year follow-up. Further radiological assessment showed that the hallux valgus angle was 37.5° ± 9.2°, 14.1° ± 6.5°, and 14.5° ± 6.5° before surgery, half a year after surgery, and 1 year after surgery, respectively; the intermetatarsal angle was 14.1° ± 4.4°, 4.8° ± 3.2°, and 5.5° ± 4.9°, respectively; and the distal metatarsal articular angle was 31.0° ± 3.5°, 7.2° ± 2.3°, and 7.5° ± 2.1°, respectively. They were significantly improved at half a year after surgery and 1 year after surgery compared to those before surgery. Complications occurred in two patients (9.5%) who had numbness on the skin of the edge of the medial incision, and the symptoms were relieved after 10 months. There was no clinical recurrence in all patients. One of the 31 feet had hallux varus, which was corrected in a second operation. Notably, a postoperative radiograph of a typical case whose both feet had hallux valgus deformity and underwent modified scarf osteotomy and additional Akin osteotomy showed adequate correction of the hallux valgus angle (HVA, 11°), intermetatarsal angle (IMA, 6°), and distal metatarsal articular angle (DMAA, 8°) on left foot compared to preoperative HVA (28°), IMA (13°), and DMAA (35°). CONCLUSION: The modified scarf osteotomy can effectively correct the adolescent hallux valgus deformity, which is worth popularizing.

Supramalleolar osteotomy with medial distraction arthroplasty for ankle osteoarthritis with talar tilt.

BACKGROUND: An increased preoperative talar tilt (TT) angle was reported to be positively correlated with treatment failure after supramalleolar osteotomy (SMOT) for varus ankle osteoarthritis. Distraction arthroplasty was reported to have the ability to correct increased TT angles. The purpose of the current study was to compare the outcomes between SMOT with and without medial distraction arthroplasty (MDA) in the treatment of varus ankle osteoarthritis with increased TT angles. METHODS: We retrospectively reviewed the functional outcomes and radiological findings of 34 patients who underwent SMOT with or without MDA for varus ankle osteoarthritis with increased TT angles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Ankle Osteoarthritis Scale (AOS) scores were used for functional evaluation. The tibial anterior surface (TAS) angle, talar tilt (TT) angle, tibial medial malleolar (TMM) angle, talocrural (TC) angle, tibial lateral surface (TLS) angle, and hindfoot alignment (HFA) angle were evaluated preoperatively and at the time of the last follow-up. RESULTS: In the SMOT group, the AOFAS score and AOS pain and function scores were significantly improved (P < 0.01 for each) at a mean follow-up of 61 months. The TAS, TT, TC, TLS, and HFA angles were all significantly improved (P < 0.01 for each). Similarly, in the SMOT with MDA group, the AOFAS score, AOS pain and function scores, and the TAS, TT, TC, TLS, and HFA angles were all significantly improved postoperatively (P < 0.01 for each). When comparing the two groups, the postoperative TT angle was significantly smaller in the SMOT with MDA group (P = 0.023) than in the SMOT group. In addition, the failure rate of TT angle correction was significantly higher in the SMOT group (P = 0.016) than in the SMOT with MDA group. CONCLUSION: SMOT is a promising procedure for functional improvement and malalignment correction for varus ankle osteoarthritis, even in patients with increased talar tilt. If SMOT is combined with MDA, there can be an improvement in the correction of the increased talar tilt. LEVEL OF EVIDENCE: Level III, a retrospective comparative study.

Surgical treatment of ankle fracture with or without deltoid ligament repair: a comparative study.

BACKGROUND: Deltoid ligament (DL) rupture is commonly seen in clinical practice; however the need to explore and surgically repair it is still in debate. The objective of the current study is to compare the outcomes of surgical treatment of ankle fracture with or without DL repair. METHODS: Between 2009 and 2015, Seventy-four ankle fractures with DL rupture were identified and followed. Twenty patients were treated with surgical repair of the DL, while 54 were not. The pre- and post-operative medial clear space (MCS) were measured and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) were used for functional evaluation. According to the radiological malreduction of MCS, the odds ratio (OR) and 95% confidence interval (CI) for each potential relative factor were calculated. RESULTS: The mean followup time was 53.7 months. The mean MCS preoperatively, postoperatively, and at last followup time were 8.7 ± 2.4 (range, 6.2-14.8) mm, 3.7 ± 0.9 (range, 2.6-6.4) mm, 3.6 ± 1.0 (range, 2.6-6.8) mm, respectively. The mean AOFAS score was 86.4 ± 8.1 (range, 52-100) points, and the mean VAS was 1.4 ± 1.4 (range, 0-7) points. During followup, 14.9% (11/74) cases were found to be malreduced (MCS>5 mm), and 5.4% (4/74) went on to failure. Surgical repair of DL can significantly decrease the postoperative MCS (P<0.05), and can also decrease the malreduction rate (P<0.05). AO/OTA type-C ankle fractures showed a positive correlation with malreduction (OR = 4.38, P = 0.03). In this type of injury, surgical repair of the DL can significantly decrease the malreduction rate (P<0.05). No significant difference was found between the AO/OTA type-B fracture with or without DL repair. CONCLUSIONS: Surgical repair of the DL is helpful in decreasing the postoperative MCS and malreduction rate, especially for the AO/OTA type-C ankle fractures.

Pathogenesis and potential relative risk factors of diabetic neuropathic osteoarthropathy.

Diabetic neuropathic osteoarthropathy (DNOAP) is an uncommon, but with considerable morbidity and mortality rates, complication of diabetes. The real pathogenesis is still unclear. The two popular theories are the neuro-vascular theory and neuro-traumatic theory. Most theories and pathways focused on the uncontrolled inflammations that resulted in the final common pathway, receptor activator of nuclear factor κß ligand (RANKL)/osteoprotegerin (OPG) axis, for the decreased bone density in DNOAP with an osteoclast and osteoblast imbalance. However, the RANKL/OPG pathway does not explain all the changes, other pathways and factors also play roles. A lot of DNOAP potential relative risk factors were evaluated and reported in the literature, including age, gender, weight, duration and type of diabetes, bone mineral density, peripheral neuropathy and arterial disease, trauma history, and some others. However, most of them are still in debates. Future studies focus on the pathogenesis of DNOAP are still needed, especially for the genetic factors. And, the relationship between DNOAP and those potential relative risk factors are still need to further clarify.

Supramalleolar Osteotomy With Distraction Arthroplasty in Treatment of Varus Ankle Osteoarthritis With Large Talar Tilt Angle: A Case Report and Literature Review.

We treated a 57-year-old female with modified Takakura stage 3B varus ankle osteoarthritis. Her preoperative talar tilt angle was 21.3°. The patient wished to avoid ankle joint arthrodesis or replacement. Therefore, medial opening wedge supramalleolar osteotomy with fibular osteotomy was used for her varus ankle osteoarthritis. Also, fixed medial distraction arthroplasty was performed to improve her talar tilt. After 3 months, the external device was removed, and the patient was allowed partial weightbearing and began full weightbearing 4 months postoperatively after the osteotomy site had reached bony union radiographically. At the 3-year follow-up visit, a radiograph showed the medial ankle joint space enlargement had been maintained. The talar tilt angle had decreased to 3.3°, and the modified Takakura stage had improved to stage 1. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score had improved from 26 points preoperatively to 85 points at 3 years postoperatively. Our findings suggested that good clinical and radiologic results can be achieved with supramalleolar osteotomy combined with distraction arthroplasty in the treatment of varus ankle osteoarthritis with a large talar tilt angle.

[Modified limited L incision with distraction bone block arthrodesis for subtalar osteoarthritis].

OBJECTIVE: To evaluate the functional outcomes of modified limited "L" incision beside the Achilles tendon with distraction bone block arthrodesis in treatment of subtalar osteoarthritis. METHODS: From March 2009 to September 2012, a total of 22 cases of old calcaneus fractures with subtalar osteoarthritis were treated with modified limited "L" incision and distraction bone block arthrodesis including 13 males and 9 females with a mean age of 35.3 years old (ranged 22 to 49). The mean time from calcaneal fracture was 21 months (ranged 11 to 32). According to the Stephens-Sanders classification, 16 cases were type II and 6 were type III. The modified-AOFAS ankle-hindfoot score was used for functional outcomes evaluation. RESULTS: There was one incision necrosis and no infection, implant failure, bone-graft absorbed or talus necrosis was note at the follow-up time. A total of 21 cases were followed up for a mean time of 29 months (ranged from 18 to 46 months). All of the cases reached a bony union within 4 months postoperation. The mean modified-AOFAS ankle-hindfoot score was 82.6 points (ranged from 66 to 92 points),reached a significantly improvement in comparing with the mean preoperative score (50.8 points,ranged from 32 to 65 points, P < 0.01). CONCLUSION: The modified limited"L" incision beside the Achilles tendon with distraction bone block arthrodesis is an acceptable and alternative treatment method for subtalar osteoarthritis. This method is easy to use and with less complication. It can correct the main pathological changes and reach good functional outcomes.

Matrine inhibits the invasive properties of human osteosarcoma cells by downregulating the ERK-NF-κB pathway.

Matrine has been used in anti-inflammatory and anticancer therapies for a long time. However, the antimetastatic effect and molecular mechanism(s) of matrine on osteosarcoma are still unclear. Therefore, the aim of this study was to assess the effects of matrine and related mechanism(s) on osteosarcoma cells. In the study, we found that matrine inhibited the proliferation of osteosarcoma cells in vivo and in vitro and inhibited tumor cell metastasis in vitro at cytotoxic doses. Matrine also decreased the expression of the matrix metalloproteinases-2 and 9, decreased p50 and p65 nuclear translocation, and decreased the phosphorylated level of I-κ-B (IκB)-ß. In addition, matrine reduced the phosphorylated levels of extracellular signal-regulated kinase 1/2 proteins, which regulate the invasion of poorly differentiated cancer cells. Finally, when U2OS cells were grown as xenografts in nude mice, intragastric administration of matrine induced a significant dose-dependent decrease in tumor growth. These results show the anticancer properties of matrine, which include the inhibition of invasion and proliferation of human osteosarcoma cells.

Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes.

BACKGROUND: The goal of this study was to discuss the outcomes of treating calcaneal fracture malunion by restoring the subtalar joint with a reconstructive osteotomy. METHODS: From May 2005 to November 2008, 24 patients (26 feet) with calcaneal malunions after a displaced intra-articular calcaneal fracture were treated by osteotomy and autogenous bone graft. The subtalar joint was preserved. The mean time from initial injury to reconstructive operation was 5.7 months (95% confidence interval, 4.5-8.8 months). The displaced posterior facet was restored through a reconstructive osteotomy, whereas the bone defect in the calcaneus after reduction was filled with the exostosis that had been removed; iliac bone graft was used if necessary. All patients were evaluated clinically and radiographically at a minimum of 24 months. Twenty patients (21 feet) were followed for a mean of 34.2 months (29.0-39.4 months). RESULTS: According to American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, the average score was 85.9 points (95% confidence interval, 81.5-90.4 points), which was significantly higher than the preoperative assessment. Radiographs showed that Böhler's angle, Gissane's angle, talus declination angle, and width and height of calcaneus were improved to a great extent. Six patients had wound edge necrosis, and 2 had superficial infection. One patient required a subtalar fusion for subtalar arthritis at 2 years after surgery. CONCLUSIONS: Restoring the subtalar joint with a reconstructive osteotomy and autogenous bone graft was an effective treatment method for selected calcaneal fracture malunions. It reconstructed calcaneal morphology and preserved the subtalar joint. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Open reduction and internal fixation of intra-articular calcaneal fractures in children.

Calcaneal fractures are rare injuries in children and adolescents, and fractures with displaced intra-articular fracture patterns are even more rare. The purpose of this study was to report 9 intra-articular calcaneal fractures in 8 children (mean age, 12.6 years; range,10-15 years) treated with open reduction and internal fixation (ORIF) and to examine cases reported in the literature to better define the classification characteristics and operational outcomes of this uncommon fracture. Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. Clinical and radiographic examinations were performed at postoperative follow-up, and functional outcome was assessed with the modified American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Mean follow-up was 47 months (range, 21-72 months). Mean time to union was 9.2 weeks (range, 8-12 weeks). Mean modified AOFAS score was 65.2 points (range, 53-68 points). One foot experienced a minor complication.After a systematic review of the literature, 4 studies with a total of 35 patients (37 fractures) were included. All fractures were caused by high-energy injuries. Based on the Essex-Lopresti classification, 40.5% (15/37) were tongue-type fractures and 59.5% (22/37) were joint depression-type fractures. Based on the Sanders classification, 62.2% (23/37) of fractures were 2 parts, 32.4% (12/37) were 3 parts, and 5.4% (2/37) showed comminution. No significant difference was found in classification information between children and adults. The authors concluded that the characteristics of intra-articular calcaneal fractures in children are similar to those in adults, and operative treatment of these fractures yields good results with few complications.