Objective: This study aimed to investigate the role and effectiveness of using a low-position tourniquet in surgery for calcaneal fractures.Method: A retrospective analysis was conducted on 42 calcaneal fracture patients who underwent reduction and internal fixation with a plate via an L-shaped approach with low-position tourniquets between January 2018 and July 2020.All fractures were fresh, unilateral, and classified as Sanders III and IV.The patients, with an average age of 47.2 years, had no medical complications.The two groups were categorized based on the position of tourniquets during surgery.In one group, the tourniquets were placed on the proximal thighs (high-position tourniquet group, n=22), and in the other group, the tourniquets were positioned above the ankles (low-position tourniquet group, n=20).The following observations were made: operation time, tourniquet time, intraoperative bleeding and incision healing, postoperative fracture healing, ankle-hindfoot scoring system (AOFAS score) and visual analogue scale (VAS score), tourniquet complications such as soft tissue injury and deep venous thrombosis (DVT).Result: No significant differences in general condition, fracture type, and complications of the two groups before surgery were noted (P>0.05).Significantly less foot pain within two weeks after surgery and higher AOFAS scores for motion pain within four weeks after surgery were observed in the low-position tourniquet group compared to the high-position tourniquet group (P<0.05).However, there was no significant difference in AOFAS function scores twelve weeks after surgery between the two groups (P>0.05).Additionally, one case of DVT and two cases of soft tissue injuries were identified in the high-position tourniquet group, while no related complications were encountered in the low-position tourniquet group (P<0.05).Conclusion: The use of a low-position tourniquet in calcaneal fracture surgery ensures clear visibility during the procedure, reduces the incidence of early postoperative pain and related complications, and promotes functional rehabilitation.This new method is considered worthy of recommendation.

目的:探讨基于四柱理论分期治疗开放性pilon骨折的临床疗效.方法:回顾性分析2018年6月至2020年6月收治的20例胫骨开放性pilon骨折患者的临床资料.男18例,女2例;年龄37～48岁,平均(42.0±5.6)岁;左侧12例,右侧8例;距离第一次术后7～21 d,平均(14±7)d,通过二期个体化治疗.记录患者术前及术后1、6、12、24个月疼痛视觉模拟评分(VAS)和美国足踝外科协会(AOFAS)踝-中足评分.随访观察临床结果和并发症情况.结果:20例患者获得随访18～24个月,平均(21.0±2.8)个月.所有患者骨折均1期愈合,骨折愈合时间为12～20周,平均(14±4)周.术后18例切口愈合;1例出现伤口反复渗出,经扩创抗生素骨粉置入控制感染;1例外固定架松动,给予加强固定.无血管神经损伤.末次随访时平均VAS评分为(2.5±0.5)分,AOFAS评分为(85±8)分.结论:开放性pilon骨折通过分期处理,以四柱理论为依据,加速康复外科(ERAS)理念贯穿整个治疗周期,通过制定个体化治疗方案,针对性处理每一柱的骨块和软组织覆盖间的关系,可大幅提高患者的临床功能,降低致残率.

Objective:To investigate the effect of deltoid ligament repair on the open reduction and internal fixation (ORIF) of ankle fracture with deltoid ligament injury.Methods:Retrospective cohort study. The clinical data of 110 patients with ankle fractures and deltoid ligament injuries who were successfully treated with ORIF in the Department of Foot and Ankle Surgery, Xuzhou Renci Hospital from January 2019 to January 2022 were included in this study. The patients comprised 85 males and 25 females, aged 23-63 years. Among the patients, 64 had Weber-B type while 46 had Weber-C type of fractures. The patients were divided into two groups, the ORIF group (ORIF treatment, 52 cases) and repair group (ORIF + triangular ligament repair, 58 cases) in accordance with whether the triangular ligament was repaired during the operation. The outcome indexes were as follows. (1) Baseline data, such as gender, age, type of injury, affected side, and fracture type, were compared between the two groups. (2) Operation time, intraoperative blood loss, hospital stay length, and incidence of complications were compared between the two groups. (3) During the 6-month follow-up after surgery, the short-term outcomes of different Danis-Weber types, including fracture healing time, media clear space (MCS), talar inclination angle, and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, were compared between the two groups. Excellent and good rates were calculated.Results:Surgery was successful in both groups, and incisions healed within one stage after surgery. All the patients were followed-up for 6-24 months, and none of them developed ankle instability or arthritis during this period. (1) No significant differences were found in the baseline data between the two groups (all P values >0.05). (2) Operation time in the repair group was (110.2±14.9) min, which was longer than that in the ORIF group, i.e., (98.6±12.1) min. The difference was statistically significance ( t=4.44, P<0.001). By contrast, the differences in intraoperative blood loss, hospital stay length, and the incidence rate of complications were not statistically significant (all P values >0.05). (3) The healing time of patients with Weber-B and Weber-C types of fractures in the repair group was (11.6±1.6) and (12.5±1.9) weeks, respectively, which were shorter than those in the ORIF group, i.e., (12.7±2.0) and (13.9±2.1) weeks, respectively. The differences were statistically significant ( t=2.24, 2.40, all P values <0.05). Intragroup comparison showed that patients with Weber-B and Weber-C types of fractures exhibited decreased MCS and talar inclination angle and significantly increased AOFAS score 6 months after surgery compared with their values before surgery. The differences were statistically significant (all P values <0.05). Comparison between the ORIF and repair groups showed no statistically significant differences in MCS, talar inclination angle, AOFAS score before and after surgery, and postoperative poor reduction rate between patients with Weber-B and Weber-C types of fractures (all P values >0.05). Postoperative MCS, talar inclination angle, and poor reduction rate in the repair group were lower than those in the ORIF group, whereas AOFAS score was higher than that in the ORIF group. The differences were statistically significant (all P values <0.05). (4) No significant differences were recorded in the excellent and good rates of ankle joint function recovery between patients with Weber-B and Weber-C types of fractures (all P values >0.05). Overall, the excellent and good rates of ankle joint function recovery 6 months after surgery were higher in the repair group (91.4%, 53/58) than in the ORIF group (76.9%, 40/52). The difference was statistically significant ( χ 2=4.40, P=0.036). Conclusion:Deltoid ligament repair during ORIF in patients with ankle fracture and deltoid ligament injury can significantly shorten fracture healing time, improve ankle joint function, and reduce the occurrence of mal-repositioning among patients with Weber-C type of fracture.

Objective:To compare the efficacy of staged versus elective operation for treating acute closed fracture-dislocation of tarsometatarsal joint complex.Methods:A retrospective cohort study was used to analyze the clinical data of 26 patients with acute closed fracture-dislocation of tarsometatarsal joint complex admitted to Tongji Hospital of Tongji University from January 2017 to January 2021, of whom 18 were males and 8 were females, aged 32-52 years [(44.3±5.2)years]. According to the time from injury to admission, 14 patients admitted within 8 hours after injury underwent staged surgical treatment (staged group), and 12 patients admitted more than 8 hours after injury underwent elective surgery (elective group). In the staged group, emergency reduction and temporary internal fixation with K-wire were done under the supervision of a C-arm X-ray machine in the first stage, while after the swelling subsided, open reduction and internal fixation were done for tarsometatarsal joint fracture-dislocation in the second stage. In the elective group, open reduction and internal fixation were performed for tarsometatarsal joint fracture-dislocation on a scheduled basis after the swelling subsided. The operation time, hospitalization time and fracture healing time were recorded. The visual analogue score (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) midfoot score were evaluated before operation, at 1, 6, 12 months after operation and at the final follow-up. The rate of complications was observed after operation.Results:All patients were followed up for 12-24 months [(18.5±3.8)months]. The operation time, hospitalization time and fracture healing time in the staged group were (77.3±5.6)minutes, (14.3±2.2)days and (12.3±1.2)weeks, respectively, significantly shorter than those in the elective group [(101.5±7.5)minutes, (20.3±5.2)days and (14.3±2.2)weeks] (all P<0.01). VAS significantly decreased and AOFAS midfoot score significantly increased in both groups as postoperative time increased (all P<0.05). There were no significant differences in VAS between the two groups before operation, at 12 months after operation or at the final follow-up (all P>0.05). The VAS at 1, 6 months after operation was (4.4±0.8)points and (2.1±0.4)points in the staged group, significantly lower than those in the elective group [(6.0±1.0)points and (3.5±0.6)points] (all P<0.01). There was no significant difference in preoperative AOFAS midfoot score between the two groups ( P>0.05). The AOFAS midfoot score at 1, 6, 12 months after operation and at the final follow-up was (67.6±4.5)points, (75.7±5.2)points, (83.6±2.2)points and (85.9±4.3)points in the staged group, significantly higher than those in the elective group [(60.2±3.9)points, (70.2±3.4)points, (75.4±3.3)points and (78.7±4.4)points] (all P<0.01). The rate of complications was 14.3% (2/14) in the staged group, significantly lower than that in the elective group [33.3% (4/12)] ( P<0.05). Conclusion:Compared to traditional elective surgery, staged surgery for acute closed fracture-dislocation of tarsometatarsal joint complex has the advantages of shortened operation time, hospitalization time and fracture healing time, eary pain relief, improved functional recovery of the foot and reduced postoperative complications.

Hansen教授首先命名了后Pilon骨折[1],之后有Klammer、俞光荣、Switaj等[2-4]多位学者报道了这种特殊类型的踝关节骨折,并提出了后Pilon骨折的分型、特点及治疗策略,目前并未达成共识[5-6].踝关节骨折中后踝骨折发生率为7％～44％,由旋转暴力合并垂直暴力造成的后Pilon样骨折以及垂直暴力造成的后Pilon骨折统称为变异的后Pilon骨折,此类骨折占比估计为6％～20％[7-8],通常发生于女性和老年患者.

目的 探讨俯卧位后内侧入路联合外侧入路切开复位内固定治疗后Pilon骨折的临床疗效.方法 回顾性分析自2016-05-2019-05诊治的32例闭合性后Pilon骨折,腓骨骨折采用标准外侧入路解剖复位并坚强内固定,后内侧切口以踝关节为中心,位于胫骨远端后内侧缘和跟腱内侧之间,切口近端平行于胫骨后内侧缘,切口远端平行于胫后肌腱走行方向,后外侧骨块和后内侧骨块复位后用克氏针临时固定,选用预先塑形好的T形接骨板放置于后侧骨块固定.结果 32例均获得随访,随访时间平均15(6～24)个月.术后2例出现内侧切口皮下脂肪液化,加强换药后切口愈合,其余患者切口均一期愈合.随访期间未出现内固定松动、骨折不愈合、骨折畸形愈合等并发症.骨折愈合时间为8～12周,平均10周.末次随访时踝与后足功能AOFAS评分为83～98分,平均91.5分.结论 越来越多的骨科医师重视后Pilon骨折后侧柱的解剖重建及患者踝关节功能恢复,采用俯卧位后内侧入路联合外侧入路切开复位内固定治疗后Pi-lon骨折可取得良好的疗效.

OBJECTIVE:To compare minimally invasive and traditional Chevron osteotomy in treating patients with mild to moderate hallux valgus.METHODS:Clinical data of 36 patients (36 feet) with mild to moderate hallux valgus from January 2019 to February 2021 were retrospectively analyzed, and divided into minimally invasive osteotomy(minimally invasive group) and traditional Chevron osteotomy(traditional group). There were 16 patients in minimally invasive group, including 1 male and 15 females, aged from 36 to 60 years old with an average of(49.0±9.5) years old;9 were mild and 7 were moderate according to Mann classification;treated with minimally invasive osteotomy with hollow screw fixation. There were 20 patients(20 feet) in traditional group, including 2 males and 18 females, aged from 38 to 65 years old with an average of(50.0±9.2) years old;11 were mild and 9 were moderate according to Mann classification;treated with traditional Chevron osteotomy. Hallux valgus angle (HVA), intermetatarsal angle (IMA) before and after operation at 12 months bewteen two groups were observed and compared, and American Orthopedic Foot and Ankle Society (AOFAS) forefoot score and visual analogue scale (VAS) before and after operation at 6 weeks and 12 months between two groups were compared.RESULTS:Thirty-six patiens were followed up from 14 to 30 months with an average of (21.00±5.77) months. All incisions were healed well at stageⅠwithout infection. There were no significant differences in HVA, IMA, AOFAS forefoot scores and VAS before and after operation at 12 months between two groups(P>0.05). However, AOFAS forefoot scores and VAS of minimally invasive group was significantly better than that of traditionl group at 6 weeks after operation (P<0.05). Postoperative HVA, IMA, AOFAS forefoot scores and VAS at 12 months bewteen two groups were improved better than that of preoperation(P<0.05).CONCLUSION:Compared with traditional Chevron osteotomy, minimally invasive osteotomy has less trauma and quicker recovery. Both of them has similar clinical effects, and could receive satisfactory clinical effects, while treatment of minimally invasive osteotomy should pain attention to learning curve.

Open reduction and internal fixation (ORIF) is a popular method for treatment of displaced Lisfranc injuries. However, even with anatomic reduction and solid internal fixation, treatment does not provide good outcomes in certain severe dislocations. The purpose of this study was to compare ORIF and primary arthrodesis (PA) of the first tarsometatarsal (TMT) joint for Lisfranc injuries with the first TMT joint dislocation. Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. They were 50 males and females with a mean age of 40.7 years and randomized to ORIF group and PA group. Outcome measures included radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, Foot and Ankle Ability Measure (FAAM) Sports subscale, visual analog scale (VAS), and the 36-Item Short Form Health Survey (SF-36). Complications and revision rate were also analyzed. Forty patients were treated by ORIF, while PA group includes 38 cases. Patients were followed up for 37.8(range, 24–48) months. At final follow-up, the mean AOFAS midfoot score (P < 0.01), the FAAM Sports subscale (P < 0.01), the physical function score (P < 0.05), and the Bodily Pain score of SF-36 (P < 0.05) after ORIF treatment were significantly lower than PA group. The mean VAS score in ORIF group was higher (P < 0.01). In ORIF group, redislocation of the first TMT joint was observed in ten cases, and thirteen patients had pain in midfoot. No redislocation and no hardware failure were identified in PA group. PA of the first TMT joint provided a better medium-term outcome than ORIF for Lisfranc injuries with the first TMT dislocation. Possible complications and revision could be avoided by PA for dislocated first ray injuries.

目的 探讨损伤控制理论指导下踝关节前外侧入路钢板内固定治疗Gustilo Ⅱ、ⅢA型开放性胫骨远端骨折的临床疗效.方法 回顾性分析自2018-05-2020-03诊治的6例Gustilo Ⅱ、ⅢA型开放性胫骨远端骨折,在损伤控制理论指导下一期急诊手术,彻底清创,清除污染严重的软组织和骨碎片,二期选择经腓骨前方的踝关节前外侧入路切开直视下复位骨折,选择胫骨前外侧L形解剖钢板进行固定.结果 6例均获得随访,随访时间平均11(5～18)个月.末次随访时踝与后足功能AOFAS评分77～92分,平均85.3分;疼痛VAS评分1～3分,平均1.7分.结论 损伤控制理论指导下采用踝关节前外侧入路钢板内固定治疗开放伤口位于胫骨内侧的Gustilo Ⅰ～ⅢA型胫骨远端骨折可取得满意疗效,可.在有效复位及固定骨折的基础上尽可能降低感染概率,促进骨折愈合.

全球20~79岁的糖尿病患者数量已经超4.9亿，其中超过70%的患者大于50岁。中国糖尿病患者约1.2亿，约占总人口的11% [ 1] 。由于年龄、步态异常、视力障碍、骨质疏松及其他因素，糖尿病患者的踝关节骨折发病率要高于非糖尿病患者 [ 2] 。据文献报道，老年踝关节骨折的1年病死率高达12%，81%的患者存在3种及以上严重的合并症 [ 3] 。对于医生而言，踝关节骨折合并糖尿病治疗存在挑战，笔者阅读近年来发表文献和临床自身经验，总结了此类骨折的临床特点和治疗进展。

Objective:To investigate the efficacy of TiRobot navigation combined with ankle arthroscopy in the reduction and internal fixation of Hawkins type Ⅱ talus neck fracture.Methods:From January 2019 to September 2020, a total of 13 patients with Hawkins type Ⅱ talus neck fracture were admitted to Department of Foot and Ankle Surgery, Xuzhou Renci Hospital. They were 8 males and 5 females, with a mean age of 35.8 years (from 22 to 61 years). All fractures were reduced and fixated using TiRobot navigation combined with ankle arthroscopy. Time for fracture reduction assisted by intraoperative arthroscopy, time for internal fixation assisted by TiRobotic navigation, fracture union time and complications were recorded. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used at the last follow-up to evaluate the functional outcomes.Results:All the operations were finished within 2 hour. The primary screw placement succeeded in all. The time for fracture reduction assisted by intraoperative arthroscopy averaged 52.8 min (from 43 to 66 min) and the time for internal fixation assisted by TiRobotic navigation 43.6 min (from 33 to 55 min). All the patients were followed up for an average 13.3 months(from 12 to 15 monhs). They obtained bony union within 3 months. One patient developed traumatic subtalar arthritis with mild pain and was treated conservatively. None of the patients had complications like incision infection or talus necrosis. The average AOFAS ankle-hindfoot score was 91.0 points (from 83 to 94 points) at the last follow-up.Conclusion:In the reduction and internal fixation of Hawkins type Ⅱ talus neck fracture, TiRobot navigation combined with ankle arthroscopy shows advantages of minimal invasion, accurate reduction and screw placement, and limited complications, leading to fine short-term functional outcomes.

Müller-Weiss Disease (MWD) is a rare foot disease with unclear etiology but frequently occurred in women. Due to the resistance to conservative treatment, surgical therapy has gradually occupied a necessary position in the clinical management of MWD. Joint fusion surgery is a commonly used treatment for MWD, which could effectively alleviate pain, correct deformation, and restore function. A total of 12 MWD patients (III-V stage) were enrolled in this study. All patients showed no significant improvement in conservative treatment and further received the triple and talonavicular arthrodesis. All patients were followed up with an average follow-up of 16.8 ± 1.19 months (mean ± SD). The triple and talonavicular arthrodesis significantly ameliorated the pain and walking dysfunction in the affected foot. The American Orthopedic Foot Andankle Society (AOFAS) scores dramatically increased from 43.4 ± 16.1 to 85.3 ± 6.2. Meanwhile, the conducting of triple and talonavicular arthrodesis improved the X-ray length (15.5 ± 0.8 vs. 14.3 ± 0.9 cm) and arch height (18.6 ± 0.9 vs. 10.2 ± 0.7 mm) and reduced the Meary-Tomeno angle (1.3 ± 2.5 vs. 2.14 ± 4.8°). The triple and talonavicular arthrodesis achieved a satisfying therapeutic effect on MWD patients at the III-V stage, which improved patients' outcomes and the quality of life.

Objective:To investigate the effect of low tourniquet on ankle fracture surgery.Methods:The data of 44 patients with ankle fracture (21 males and 23 females) who were admitted between April 2018 and May 2020 in Tongji Hospital Affiliated to Tongji University were retrospectively analyzed. The patients were aged 18-57 years (average of 42.8 years). The patients were equally divided into two groups, namely, the high and low tourniquet groups, according to the location of tourniquet binding. Both groups were treated with open reduction and internal fixation. Operation time, tourniquet time, intraoperative and postoperative bleeding, and complications (ecchymosis, soft tissue mass, blister, skin ulcer, and lower extremity deep venous thrombosis) were also observed. Pain in the affected limb was evaluated by visual analog scale (VAS) on the 1st, 3rd, 7th, and 14th days after operation. Ankle flexion, back extension, ankle range of motion, and ankle-hindfoot function with American Orthopedic Foot and Ankle Association (AOFAS) score were observed for 4 weeks, 12 weeks, 6 months, and 12 months postoperatively.Results:The operation was successfully completed in both groups. No significant differences in operation time, tourniquet time, and bleeding volume were observed (all P values >0.05). In the high tourniquet group, one case of ecchymosis at the tourniquet compression site, one case of soft tissue mass, and one case of deep venous thrombosis were found by color Doppler ultrasonography. No related complications occurred in the low tourniquet group. No significant differences in the VAS scores of limb pain between the two groups were noted on the 1st, 3rd, and 7th days after operation (all P values >0.05). On the 14th day after operation, the VAS score of the low tourniquet group was lower than that of the high tourniquet group ( t=2.41, P=0.020). All patients were followed up for 6-24 months with an average of 15.8 months. During follow-up, incisions in the two groups had no infection and healed. No complications, such as loosening and fracture of the internal fixation, occurred. No significant difference in fracture healing time was found between the two groups ( t=0.94, P=0.351). At 4 weeks after operation, the ankle flexion, back extension, ankle range of motion, and AOFAS ankle hindfoot score of the low tourniquet group were significantly higher than those in the high tourniquet group (all P values < 0.05). No significant differences in ankle flexion, back extension, ankle range of motion, and AOFAS ankle-hindfoot score were found between the two groups at 12 weeks, 6 months, and 12 months after operation (all P values >0.05). Conclusion:The application of low tourniquet in ankle fracture surgery can ensure a good operation interface, improve the early range of motion and clinical function of the ankle joint after operation, and reduce the occurrence of limb pain and related complications caused by traditional tourniquet. Thus, low tourniquet is a new method worthy of recommendation.

目的 探讨平乐正骨手法在内侧柱移位Sanders Ⅱ、Ⅲ型跟骨骨折切开复位内固定术中的应用价值.方法 回顾性分析自2018-03-2019-05采用跟骨外侧L形切口复位内固定治疗的51例(54足)内侧柱移位的Sanders Ⅱ、Ⅲ型骨折,术中应用平乐正骨手法辅助复位,先左右旋转跟骨后结节观察内侧柱复位情况,内侧柱骨折嵌插移位矫正后,施以折顶手法外翻跟骨后结节矫正内翻畸形,同时使用撬拨手法下压斯氏针恢复B?hler角.如果合并轴向短缩则予以轴向牵引手法,内侧柱复位后用斯氏针经后结节临时固定.结果 51例均获得随访,随访时间平均13.66(12～19)个月.术后X线片或CT显示49足内侧壁复位良好,5足复位不良;45足后关节面解剖复位,6足后关节面旋转移位1～2 mm,3足后关节面分离移位1～2 mm.骨折愈合时间11～16周,平均12.53周.末次随访时Maryland足部评分结果:优44足,良8足,可2足,优良率96.3％.末次随访时B?hler角、Gissane角、跟骨长度、跟骨宽度、跟骨高度均较术前明显改善,差异有统计学意义(P＜0.05).结论 跟骨外侧L形切口切开复位内固定治疗内侧柱移位的Sanders Ⅱ、Ⅲ跟骨骨折术中采用平乐正骨手法复位可有效恢复跟骨解剖形态,进而减少或避免术后内翻畸形的发生.

Objective:To propose a new classification of posterior malleolus fracture to further clarify its pathoanatomy.Methods:Twenty fresh frozen cadaver specimens of normal morphology of lower limbs were selected and dissected and the extent of the tibial insertion of posterior malleolus associated ligaments was measured. At the same time, a retrospective case series analysis was made on the clinical and CT information of 296 patients with posterior malleolus fracture treated at Tongji Hospital of Tongji University from January 2012 to July 2020 or at Karamay Central Hospital from January 2018 to July 2020. The percentage of articular involvement of the fracture, proximal displacement of the posterior malleolus fracture and extent of posterior talar subluxation were measured. A clinically practical new classification system for posterior malleolus fracture was created by correlating posterior malleolus associated ligaments with CT images of posterior malleolus fracture. The new classification included three types: type I was posterior malleolus fracture with only the tibial insertion of inferior transverse tibiofibular ligament involved; type II was posterior malleolus fracture with both the tibial insertions of inferior transverse tibiofibular ligament and posterior inferior tibiofibular ligament involved, which was divided into subtypes IIA and IIB based on the presence of articular cartilage and subchondral bone damage, compression or Die-Punch fragments; type III was posterior malleolus fracture that involved all the tibial insertions of inferior transverse tibiofibular ligament, posterior inferior tibiofibular ligament and posterior tibiotalar ligament, which was sub-classified into subtypes III A and III B according to number of fracture fragments. Anatomic characteristics of the extent of the tibial insertion of posterior malleolus associated ligament, CT imaging parameters for posterior malleolus fracture and corresponding fracture typing were determined. In addition, the new classification system for posterior malleolus fracture was compared with Haraguci classification and Mason classification.Results:Posterior malleolus associated ligaments included the posterior inferior tibiofibular ligament, inferior transverse tibiofibular ligament and posterior tibiotalar ligament from posterolateral to posteromedial tibia. The posterior inferior tibiofibular ligament was attached to the posterolateral tibia and the distance between the highest point of its tibial insertion and the joint line was (45.2±5.6)mm. The inferior transverse tibiofibular ligament was attached to the posterior distal tibia and the distance between the highest point of its tibial insertion and the joint line was (5.5±1.0)mm. The posterior tibiotalar ligament was attached to the posterior colliculus and intercollicular groove of the medial malleolus and the distance between the center of its tibial insertion and the intercollicular groove was (2.5±0.6)mm. Among 296 patients with posterior malleolus fracture, there were 36 patients with type I, 229 with type II (150 type IIA, 79 type IIB) and 31 with type III (11 type IIIA, 20 type IIIB). The percentage of articular involvement of the fracture, proximal displacement of posterior malleolus fracture and extent of posterior talar subluxation in type IIB fracture were significantly greater than those in type II A fracture [23.7(18.6, 28.8)% vs. 18.4(12.7, 21.7)%, 4.1(2.1, 6.0)mm vs. 1.9(0.2, 3.0)mm, 4.7(1.5, 6.2)mm vs. 2.3(1.1, 3.0)mm] (all P<0.01). The proximal displacement of posterior malleolus fracture and extent of posterior talar subluxation in type III fracture were significantly greater than those in type II fracture [7.2(6.0, 8.2)mm vs. 2.7(0.4, 4.0)mm, 10.1(6.0, 15.0)mm vs. 3.1(1.1, 5.0)mm] (all P<0.01). The new classification for posterior malleolus fracture combined the posterior malleolus ligament and injury mechanism of posterior malleolus fracture as compared with Haraguchi classification, which not only further detailed the classification, but also was more practical in clinic for increased the severity of injury was elevated with higher classification level. The new classification was more comprehensive as compared with Mason classification for it mainly added the type of simple-rotation-type posterior malleolus fracture (type IIA of the new classification). Conclusions:In combination with posterior malleolus associated ligaments, injury mechanism and fracture morphology, posterior malleolus fracture is divided into three types. The new classification system more comprehensively describes pathoanatomy of posterior malleolus fracture that contributes to related basic research and clinical diagnosis and treatment.

腓骨肌萎缩症在我国已确定为罕见病.由于该病较为罕见,国内骨科界对其认识参差不齐,外科治疗缺乏循证医学的指导意见,欠缺规范化.为更好地认识与治疗该病,避免其并发症的发生,同时为获得更好的疗效,中华医学会骨科学分会足踝外科学组,国际矫形与创伤外科学会中国部足踝外科学会,中国医疗保健国际交流促进会骨科分会足踝外科学部,中国研究型医院学会足踝医学专业委员会,中国医师协会骨科医师分会足踝外科、基础研究与矫形学组联合邀请国内知名专家,参考国内外相关的最新研究成果,研究探讨了该病的病理特点、病程发展规律、检查流程与诊断标准,提出外科治疗的策略与方法,最终形成本共识,以促进我国在该领域的进一步研究和提高腓骨肌萎缩症的诊疗水平.

Objective:To investigate the clinical effect of repairing the Achilles tendon cicatrix tissue for the treatment of chronic Achilles tendon ruptures.Methods:A cross-sectional study was conducted on 21 patients with chronic Achilles tendon ruptures who had been treated operatively at the Department of Orthopedics, First Affiliated Hospital of the University of Science and Technology of China, from August 2018 to July 2021. Among the patients, 17 were males and 4 were females, aged 20-73 (43.5±16.0) years old. Eleven cases were on the right side, and 10 cases were on the left side. All cases were used to heal chronic Achilles tendon ruptures by repairing the Achilles tendon cicatrix tissue. The operation time, incision length, postoperative complications, and time of return to daily activities and sports were recorded. The American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) were compared before and after the last follow-up. The Achilles tendon complete rupture score (ATRS), Arner-Lindholm score, and single-legged heel rise height test were recorded in the last follow-up.Results:The operation time of patients was 30-50 minutes (average of 41.1 minutes), and the incision was 4-7 cm long (average of 5.6 cm). No serious complications, such as infection, sural nerve injury, or re-rupture, were observed after operation. All patients were followed up for 6-40 months (mean of 18.5 months). The average time of return to daily activities was (4.4±0.7) months, and the average time of return to sports was (11.1±1.5) months. The AOFAS ankle-hindfoot score increased from the preoperative (63.5±6.9) to (89.9±4.8) in the last follow-up with statistical significance( t=-14.45, P<0.001). VAS decreased from preoperative 4 (3,4) to 0(0,1)in the last follow-up with statistical significance ( Z=5.69, P<0.001). The mean ATRS in the last follow-up was (92.7±3.6) points. The Arner-Lindholm score was excellent in 15 cases and good in 6 cases, and the good rate was 100%. The positive rate of the single-legged heel rise height test was 9.52%(2/21), and the average single-foot calf raise recovery time was 4-7 (5.1±0.9) months. Conclusion:The application of repairing the Achilles tendon cicatrix tissue in the treatment of chronic Achilles tendon ruptures has satisfactory clinical efficacy and shows the advantages of safety and few complications.

第五跖骨基底部撕脱性骨折若不及时进行有效治疗，会造成如骨折延迟愈合或不愈合、足底压力分布异常等严重并发症，从而影响患者的生活质量，而其损伤机制尚未阐明。为此，笔者采用回顾性病例系列研究分析2012年8月至2019年8月同济大学附属同济医院收治的74例第五跖骨基底部撕脱性骨折患者的CT扫描数据及临床资料，利用Mimics 17.0软件将所有第五跖骨基底部撕脱性骨折患者的CT数据进行重建，再利用3-Matic软件在所有患者的第五跖骨立体图形中一一标识骨折线，绘制骨折线热图。探讨第五跖骨基底部撕脱性骨折中的骨折线三维立体分布特点，为第五跖骨基底部撕脱性骨折损伤机制的研究提供参考。

目的 探讨急诊手术治疗Logsplitter损伤的注意事项,降低此类损伤患者的致残率.方法 回顾性分析自2015-07-2018-09急诊手术治疗的18例Logsplitter损伤,急诊清创后复位骨折,先复位胫距关节,再解剖复位外踝(改良Gustilo Ⅰ～ⅢA型骨折采用重建钢板或外踝解剖钢板固定,改良Gustilo ⅢB型患者的外踝骨折根据伤口情况原则上不选择钢板内固定),接着复位内踝并固定,复位胫距关节(足底用直径2.5 mm克氏针固定胫距跟关节),最后固定下胫腓关节.结果 18例均获得随访,随访时间平均9(8～12)个月.1例伤口感染形成骨髓炎,扩创后置入骨粉与万古霉素,感染得到控制,骨折愈合.1例皮肤缺损出现骨外露,皮瓣修复伤口,骨折骨性愈合.骨折愈合时间平均12(10～16)周.末次随访时疼痛VAS评分为0～3分,平均1.8分;足踝功能AOFAS评分为74～90分,平均81分.结论 通过个体化制定详细周密的术前计划和术中操作步骤,急诊手术治疗开放性Logsplitter损伤可取得较好的疗效.

跟骨骨折是创伤骨科常见疾病,多需手术治疗.目前对其切口的研究较多,有跗骨窦切口、L型切口及各种改良切口等,各有利弊.纵观跟骨切口历史,跟骨外侧扩大L形切口仍然是治疗跟骨骨折的金标准,但目前受到其他切口的挑战,由于该切口的并发症较多,临床上对其运用仍持谨慎观点.本文就跟骨L形切口手术术前皮肤准备、切口设计、术中软组织保护、术后管理、切口观察及补救措施进行系统阐述,旨在减少跟骨切口的并发症,提高术后的临床效果.