OBJECTIVE:To explore surgical technique and mid-term efficacy of treating talar body fractures through lateral malleolus osteotomy approach with absorbable rod fixation. METHODS:From January 2021 to April 2023, clinical data of 25 patients with talar body fractures who underwent anatomical reduction with absorbable rods via the lateral malleolus osteotomy were retrospectively analyzed, included 15 males and 10 females;aged from 20 to 54 years old with an average of (34.3±8.2) years;8 patients were typeⅡand 17 patients were type Ⅲ according to Sneppen classification of talar body fractures. Fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and the occurrence of complications were evaluated. RESULTS:All 25 patients were followed up after operation, the follow-up period ranged from 24 to 52 months with average of(35.7±6.5) months. All patients were achieved fracture healing, and the healing time ranged from 12 to 18 weeks with an average of(15.1±1.7) weeks. AOFAS ankle-hindfoot score increased from (45.28±4.41) points before operation to (88.96±5.19) points at 2 years after operation;13 feet were excellent, 9 feet were good, and 3 feet were fair. VAS decreased from 8.0 (7.0, 9.0) points before operation to 2.0 (1.0, 2.5) points at 2 years after operation, and the differences at each follow-up time point were statistically significant(P<0.05). The imaging examinations showed all patients had good healing of talus body fractures and the osteotomy sites. The absorbable rods gradually degraded over a period of 20 to 24 months after operation, without any failure or displacement of internal fixation. No traumatic arthritis or talus necrosis occurred. CONCLUSION:The lateral malleolus osteotomy approach could provide a good surgical field, and achieve satisfactory reduction results for talus body fractures combined with absorbable rods for fixation. The postoperative functional recovery is satisfactory, and it avoids the need for secondary surgery to remove internal fixation. The mid-term efficacy is also good.

Whether patients with chronic ankle instability (CAI) can benefit from weight loss yielded by using glucagon-like peptide-1 receptor agonists (GLP1-RAs) has remained unclear. In this observational study, we recruited more than 2000 adults with CAI according to the selection criteria proposed by International Ankle Consortium with at least two-year follow up from three medical centers. The primary endpoint was the change from baseline of the Foot and Ankle Ability Measure (FAAM) sports subscale at the last follow up. Secondary endpoints included the change from baseline of Foot and Ankle Outcome Score (FAOS)/ Cumberland Ankle Instability Tool (CAIT)/ FAAM activities of daily living (ADL) subscale, number of ankle sprains during study period, incident ankle surgery in treatment of CAI. In this study, 71 out of 2018 patients who received semaglutide in purpose of treating type 2 diabetes (T2DM) and/or weight loss during the study period. After controlling baseline characteristics, the adjusted mean difference in change from baseline was 16.3 for FAAM sports subscale and 9.3 for FAAM ADL subscale. Likewise, the adjusted analysis of five subscales of FAOS showed similar results, all consistently favoring semaglutide group. For CAIT, patients in the semaglutide group had achieved statistically significant improvement compared with control group. The association of semaglutide exposure with improvement in FAAM sports and ADL subscales was mediated by the weight loss measured by BMI (mediation proportion: FAAM sports subscale, 31.2

OBJECTIVE:The treatment of talocalcaneal coalition (TCC) with pes planus deformity in adolescent patients still presents challenges. With the pes planus deformity untreated, the final clinical outcome would be compromised. Therefore, simultaneous correction of pes planus deformity seems to be of great importance. This study aimed to retrospectively evaluate the clinical efficacy of coalition resection combined with extra-osseous talotarsal stabilization (EOTTS) treatment for adolescent TCC with pes planus deformity. METHODS:Data was reviewed for patients of TCC and pes planus deformity treated by coalition resection and EOTTS from January 2018 to January 2024. Meary's angle and talar-1st metatarsal angle (T1MA) were measured to assess the alignment improvement (paired sample t-test). Visual analog scale (VAS) for pain (Wilcoxon signed rank test) and American Orthopedic Foot & Ankle Society ankle-hindfoot score (AOFAS-AHS) (paired sample t-test) were evaluated for the overall clinical outcomes. Time to return to sports activity and complications were also recorded. RESULTS:No early wound or soft tissue complications occurred. At 1-year follow-up, Meary's angle and T1MA improved from 13.4° ± 5.2° to 5.1° ± 3.4°, and from 14.7° ± 3.7° to 6.4° ± 2.5°, respectively. The median VAS score decreased from 5 to 0, while the AOFAS-AHS increased from 51.1 ± 8.9 to 90.1 ± 9.3 (all p < 0.05). Fifteen patients returned to sports at a median of 3 months (range: 2-4 months). One patient experienced sinus tarsi pain, which was resolved after implant removal at 14th month postoperatively. CONCLUSION:Simultaneous coalition resection and EOTTS for adolescent TCC with pes planus deformity achieves satisfactory clinical outcomes with minimal complications.

BACKGROUND:Current research on the use of subtalar arthroereisis (SA) for pediatric flexible flatfoot primarily focuses on biomechanical modeling and three-dimensional (3D) printing, while studies combining 3D reconstruction with weightbearing CT (WBCT) for preoperative planning of SA remain limited. This study aims to evaluate the feasibility and clinical efficacy of 3D reconstruction technology combined with WBCT in the preoperative planning of SA in pediatric flexible flatfoot. METHODS:A prospective cohort study of 261 pediatric flexible flatfoot patients undergoing SA from January 2023 to August 2023 divided into a planning group (with preoperative planning) and a non-planning group (without preoperative planning). The planning group utilized the posterior arch angle, anterior arch angle, lateral longitudinal arch angle, medial longitudinal arch angle, and Meary's angle for preoperative rotation guidance and HyProCure size prediction, while the non-planning group relied on intraoperative trial molding. Data included demographics, surgical details, imaging indicators, clinical outcomes, and complications. RESULTS:In this study, 197 patients underwent 18-month follow-up, with 95 patients in the preoperative planning group and 102 patients in the non-planning group. Concerning patient outcomes, the postoperative imaging indicators in the planning group demonstrated excellent consistency with preoperative analysis reports. After controlling baseline characteristics, both groups showed significant clinical improvements, with the planning group outperforming the non-planning group in imaging and clinical outcomes, though not significantly. The planning group had shorter operative times and fewer intraoperative fluoroscopy exposures. Some patients in the non-planning group showed incomplete correction of imaging indicators, delayed wound healing, and sinus tarsi pain, with three requiring HyProCure removal and four needing size adjustments. No major complications occurred in the planning group. CONCLUSION:Preoperative planning integrating 3D reconstruction with WBCT presents a feasible and effective approach for pediatric flexible flatfoot patients undergoing SA. This approach can serve as a means to optimize surgical outcomes, minimize intraoperative fluoroscopy exposure and operative time, and mitigate the risks of complications and reoperation. LEVEL OF EVIDENCE:Level II, prospective cohort study.

Category: Hindfoot; Trauma Introduction/Purpose: Calcaneal Sanders type II or III fractures are highly disabling with significant burden. Surgical treatment modalities include open reduction and internal fixation (ORIF) techniques and a variety of minimally invasive surgical (MIS) approaches. ORIF techniques are associated with complications and traditional MIS techniques need extensive intraoperative fluoroscopic procedures. The present study aims to investigate the effects of three different minimally invasive internal fixation (MIIF) techniques used to treat Sanders type II intra-articular calcaneal fractures using finite element analyses. Methods: A 64-row spiral computed tomography scan was used to observe the calcaneus of a healthy adult. The scanning data were imported into Mimics in a DICOM format. Using a new model of a Sanders type II-B intra-articular calcaneal fracture, three minimally invasive techniques were simulated. Technique A involved fixation using an isolated minimally invasive locking plate; Technique B used a minimally invasive locking plate with one medial support screw; and Technique C simulated a screw fixation technique using four 4.0-mm screws. After simulating a 640-N load on the subtalar facet, the maximum displacement and von Mises stress of fragments and implants were recorded to evaluate the biomechanical stability of different fixation techniques using finite element analyses. Results: After stress loading, the maximum displacements of the fragments and implants were located at the sustentaculum tali and the tip of sustentaculum tali screw, respectively, in the three techniques; however, among the three techniques, Technique B had better results for displacement of both. The maximum von Mises stress on the fragments was < 56 Mpa, and stress on the implants using the three techniques was less than the yield strength, with Technique C having the least stress. Conclusion: All three techniques were successful in providing a stable fixation for Sanders type II intra-articular calcaneal fractures, while the minimally invasive calcaneal locking plate with medial support screw fixation approach exhibited greater stability, leading to improved enhancement for the facet fragment; however, screw fixation dispersed the stress more effectively than the other two techniques.

BACKGROUND:There is a high correlation between hallux valgus and pes planus deformity. We sought to evaluate the outcomes of simultaneous Scarf osteotomy and extraosseous talotarsal stabilization (EOTTS) for correcting adult hallux valgus with flexible pes planus deformity. MATERIALS AND METHODS:This retrospective study enrolled patients who had hallux valgus deformity with flexible pes planus and underwent combined Scarf osteotomy and EOTTS from January 2018 to October 2021. The hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, calcaneal pitch, and lateral talocalcaneal angles were assessed preoperatively and at 1-year follow-up. Clinical outcomes were evaluated using the visual analog scale (VAS) score for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score, and the Maryland foot score (MFS). Complications were recorded. RESULTS:This study included 25 patients, 19 women and 6 men, with a mean age of 44.3 years. The mean follow-up period was 14.6 months. The mean HVA, IMA, Meary's angle, calcaneal pitch, and lateral talocalcaneal angles improved significantly at 1-year follow-up (P<.001). The mean VAS score decreased from 5.8 to 1.0, whereas the mean AOFAS forefoot score and MFS increased from 52.3 to 88.9 and 61.2 to 89.3, respectively, at 1-year follow-up (P<.001). Two patients had arthroereisis implant removal as a consequence of sinus tarsi pain. No other complications were seen during the follow-up. CONCLUSION:Management of hallux valgus with flexible pes planus deformity with combined Scarf osteotomy and EOTTS can achieve satisfactory clinical and radiologic results with low complication and recurrence rates. [Orthopedics. 2025;48(1):37-43.].

Background Varus ankle osteoarthritis is a degenerative condition characterized by varus deformity of the ankle joint, severely damaging patients’ quality of life. supramalleolar osteotomy (SMOT) has become one of the most commonly used joint-preserving surgeries for the treatment of varus ankle osteoarthritis. Both SMOT with Ilizarov technique and SMOT with internal fixation can be employed to correct varus deformity; however, there is limited literature comparing the efficacy of these two methods. Methods We retrospectively analyzed the clinical data of 52 patients (52 feet) who underwent SMOT for varus ankle osteoarthritis between August 2018 and June 2022. The patients were divided into two groups based on the surgical approach: the SMOT with Ilizarov technique group (treatment group, n = 19, 19 feet) and the SMOT with internal fixation group (control group, n = 33, 33 feet). Clinical evaluation parameters, including the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Score (AOS), Visual Analogue Scale (VAS), and ankle joint range of motion (ROM), were compared between the two groups. Radiographic parameters, including tibial articular surface angle (TAS), tibial lateral surface angle (TLS), talar tilt (TT), tibiocrural angle (TC), tibial medial malleolar angle (TMM), hindfoot alignment angle (HAA), and modified Takakura stage, were also compared. Furthermore, complications such as infection, delayed healing, and nonunion were recorded and compared between the two groups. Results Preliminary results showed that both SMOT with Ilizarov technique and SMOT with internal fixation significantly improved clinical scores and radiographic parameters. All 52 patients (52 feet) were followed up for an average of 39.19 ± 10.82 weeks. In the postoperative period, 50 patients achieved grade I wound healing, while 2 patients in the control group experienced wound infection. Both groups showed statistically significant improvements in AOFAS ankle-hindfoot score, AOS, VAS, and ROM at the last follow-up (P < 0.001). TAS, TT, TC, TMM, HAA, and modified Takakura stage also significantly improved compared to preoperative measurements (P < 0.001). At the last follow-up, no statistically significant differences were observed between the two groups in terms of AOFAS ankle-hindfoot score, AOS functional score, VAS, TAS, TLS, TT, TC, TMM, or modified Takakura stage. However, the treatment group demonstrated significantly greater improvements in AOS pain score (P = 0.011), ROM (P = 0.024), and HAA (P = 0.031) compared to the control group. Correlations were observed between the changes in TT, TC, and the last follow-up AOFAS ankle-hindfoot score, VAS, and AOS pain score in the radiographic results. Conclusion This study suggests preliminarily that SMOT with Ilizarov technique is a more effective treatment option for varus ankle osteoarthritis compared to SMOT with internal fixation. For moderate to severe cases of varus ankle osteoarthritis, SMOT with Ilizarov technique provides satisfactory outcomes by correcting both bone and soft tissue deformities, achieving better restoration of ROM, superior correction of hindfoot alignment, and minimizing postoperative complications compared to SMOT with internal fixation. Additionally, it minimizes postoperative complications. Improvements in TT and TC during SMOT may lead to better clinical outcomes. Trial registration: The registration number was ChiCTR1900020579, and date of registration was 2019-01-09.

Objectives:With positive outcomes recorded, the mixed reality (MR) technology has lately become popular in orthopedic surgery. However, there are few studies that specifically address the utility of MR in talocalcaneal coalitions (TCC) resection. Our goal in this retrospective study is to assess certain data while examining the viability of using MR to treat TCC resection. Methods:Six consecutive patients with TCC diagnosed by computed tomography (CT) for which nonoperative therapy had failed and MR system assisted TCC resection were included in this study from March 2021 to December 2021. The feasibility and accuracy of TCC resection were assessed by post-operation radiography. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) score were used to assess the recovery condition and pain level pre- and post-operation. Results:The surgeon can accurately resect the TCC according to the preoperatively determined range by superimposing the holographic model with the actual anatomy of the TCC using an MR system. Additionally, no additional x-ray was necessary while operating. Mean follow-up was 10.3 months, with a minimum of 6 months. There is a significant difference between the preoperative AOFAS score of 53.4 ± 3.8 and the 6-month follow-up AOFAS score of 97.3 ± 2.2 (p < 0.05). There is also a significant difference between the preoperative VAS score of 8.1 ± 0.7 and the 6-month follow-up VAS score of 1.7 ± 0.4 (p < 0.05). All individuals had clinical subtalar mobility without stiffness following surgery. Conclusion:While the TCC resection operation is being performed, the application of MR technology is practicable, effective, and radiation-free, giving surgeons satisfactory support.

Objective The study aims to investigate the functional outcome of the lateral approach for insertional Achilles tendinitis (IAT) with Haglund deformity. Methods From January 2016 to September 2019, 14 cases of IAT with Haglund deformity that resisted conservative treatment received surgery in our department. A lateral approach was used to debride the bony and soft tissue and reattach the insertion of the Achilles tendon. The Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Score (AOFAS), and Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A) were used to evaluate clinical outcomes. Result The mean patient age was 39.57 years at the time of surgery. The mean follow-up was 14.74 months. The mean VAS score significantly decreased from 4.86 ± 0.86 preoperatively to 1.21 ± 1.58 postoperatively ( P < 0.001). The mean AOFAS score significantly improved from 66.64 ± 6.23 preoperatively to 90.21 ± 11.50 postoperatively ( P < 0.001). The mean preoperative and the last follow-up VISA-A were 66 (range 56.75–69.25) and 86 (range 75.75–97.00) points, respectively ( P < 0.05). Conclusion The lateral approach was effective and safe for IAT with Haglund deformity. Moreover, the mid-term functional outcome was promising. Level of Clinical Evidence IV

急性Lisfranc损伤是足踝创伤中的重要损伤类型,具有一定的误、漏诊率,且一旦延误诊治,可能导致畸形愈合、创伤性关节炎等远期并发症,严重影响患者生活质量.近年来,随着对Lisfranc损伤认识的加深,其整体治疗效果已明显改善,但在分型、影像学检查及手术治疗方面仍存在一定的局限性及争议.因此,本文将探讨急性Lisfranc损伤的诊疗现状及可能的发展趋势,以提高此类损伤的疗效.

Objective:To investigate the efficacy of osteochondral fragment fixation using bioabsorbable pins for Hepple Ⅱ osteochondral lesions of the talus (OLT) in adolescents.Methods:Retrospective case analysis was used. The clinical data and follow-up results of 13 adolescent patients (13 feet) with Hepple Ⅱ OLT were all treated with osteochondral fragment fixation using bioabsorbable pins admitted to Shanghai Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2017 to December 2021 were retrospectively analyzed. There were 7 males and 6 females, with 13 right feet. The age was (14.85±2.23) years old, ranged from 12 to 18 years old. According to the American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) and SF-36 score before operation and at the last follow-up were used to evaluate the efficacy and function of the patients. Measurement data with normal distribution were represented as mean ± standard deviation( ± s), and the comparison between groups was conducted using the t-test; The mearsurement data with skewness distribution were expressed by M( Q1, Q3), and rank-sum test was used for inter-group comparison. Results:Thirteen adolescent patients (13 feet) with Hepple Ⅱ OLT underwent surgery successfully and were followed up for (25.54±9.95) months. All wounds healed by first intention, and no complications such as wound infection and delayed healing occurred. Preoperative AOFAS ankle-posterior foot score, VAS and SF-36 score were 58.62±3.55, 7.00 (6.50, 8.00) and 68.38±4.81, respectively. At the last follow-up, the scores were 97.38±2.73, 1.00 (0.00, 1.00), 91.15±4.28, respectively, and the results were significantly improved at the last follow-up, with the difference between the two groups statistically significant( P<0.05). Conclusion:Osteochondral fragment fixation using bioabsorbable pins which can promote cartilage repair, significantly improve symptoms, and achieve better clinical satisfaction with fewer complications, is a safe and effective surgical treatment option for Hepple Ⅱ OLT in adolescents with satisfactory short-term clinical outcomes.

Abstract Purpose Degenerative joint disease (DJD) of the ankle is a chronic disease that can severely limit function and cause debilitating pain, and with the development of digital medicine, 3D printing patient-specific instrumentation has been used in many subjects. The purpose of the study was to compare the clinical and radiographic outcomes of 3D-printed patient-specific guides with the traditional open- wedge supramalleolar osteotomy . Materials and methods We retrospectively analyzed 10 patients with varus ankle osteoarthritis treated by open wedge supramalleolar osteotomy via 3D patient-specific instrument (PSI group) and 14 patients treated via the traditional method (control group). The demographic data and the pre- and post-operative TAS, TT, TLS angle were recorded. The AOFAS and VAS score were acquired pre-operatively and at the last follow-up time. Results All patients were obtained after surgery 49.4 ± 8.3 months (36–62) follow-up. The TAS, TT, TLS angle and VAS, AOFAS score was comparable pre-operatively between two groups(p＞0.05). The VAS and AOFAS score was statistically improved at the last follow-up time in both cohorts. And the TAS angle was significantly increased post-operatively in the overall cohort. The TT,TLS angle was also ameliorated, though insignificantly. The intraoperative fluoroscopy time, estimated blood loss, and operating time was statistically less in the PSI group in the two cohorts. The post-operative TAS, TT, TLS angle and VAS, AOFAS score at the last follow-up time was comparable between the two cohorts. Conclusion 3D-printed patient-specific guides have a short operation time, low intraoperative blood loss and less fluoroscopy frequency. Patient-specific guides can assist in facilitating doctor-patient communication, shortening the learning curve, reducing surgery time, and correcting varus deformity accurately. And the functional outcome was non-inferior to the traditional method.

Background:Long recovery time, large scar, postoperative swelling and pain are possible side effects of open reduction internal fixation (ORIF) for tarsal navicular fractures. Early exercise instruction is made possible by the use of an intraoperative robot-assisted percutaneous invasive closed reduction internal fixation. The goal of the trial was to determine whether percutaneous screw internal fixation with robot assistance might be used to treat navicular fractures.Methods:27 patients with navicular fractures had surgical treatment between June 2019 and December 2021. Of those, 20 instances were treated with ORIF, while 7 cases had robot-assisted percutaneous screw internal fixation. At the final follow-up, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and the visual analogue scale (VAS) score were compared to determine outcomes and function.Results:Follow-up was obtained in all 27 patients after surgery, with a mean follow-up time of 21.81 months, ranging from 15 to 29 months . In the 7 instances of robot-assisted group, percutaneous guide wire insertion and screw placement only needed one attempt and the depth and position of the implant were both satisfactory. In the ORIF group, there were two patients who sustained cutaneous nerve injuries. The AOFAS score and the VAS score of the group receiving robot-assisted navigation percutaneous screw fixation were 92.25 ± 2.22 and 0.75 ± 0.25 respectively at the last follow-up, while 82.25 ± 7.15 and 0.50 ± 0.29 were the respective values for the ORIF group.Conclusion:Intraoperative robot-assisted percutaneous closed reduction internal fixation for tarsal navicular fractures can accomplish exact localization of fracture site, reduce soft tissue damage and operative time. According to current view, this method offers fewer complications, a faster recovery after surgery, and more patient satisfaction.

With the increasing of athletic injuries every year, the incidence of low-energy Lisfranc injuries has also increased. The clinical manifestations of this type of injury are often insidious, and the detection rate of regular imaging techniques is low, as a result, the clinical misdiagnosis rate is relatively high. Once the diagnosis and treatment are delayed, it may result in malunion or traumatic arthritis, leading to pain and functional disability, seriously affecting the patient′s quality of life, and ultimately requiring joint fusion for salvage. In view of this, this article will review the progress in diagnosis, classification and treatment of low-energy Lisfranc injuries to improve the clinical outcomes of such injuries.

Background: Chronic ankle instability (CAI) is a common sequela following an acute lateral ankle sprain (LAS). To treat an acute LAS more effectively and efficiently, it is important to identify patients at substantial risk for developing CAI. This study identifies magnetic resonance imaging (MRI) manifestations for predicting CAI development after a first episode of LAS and explores appropriate clinical indications for ordering MRI scans for these patients. Methods: All patients with a first-episode LAS who received plain radiograph and MRI scanning within the first 2 weeks after LAS from December 1, 2017 to December 1, 2019 were identified. Data were collected using the Cumberland Ankle Instability Tool at final follow-up. Demographic and other related clinical variables, including age, sex, body mass index, and treatment were also recorded. Univariable and multi-variable analyses were performed successively to identify risk factors for CAI after first-episode LAS. Results: A total 131 out of 362 patients with a mean follow-up of 3.0 & PLUSMN; 0.6 years (mean & PLUSMN; SD; 2.0-4.1 years) developed CAI after first-episode LAS. According to multivariable regression, development of CAI after first-episode LAS was associated with 5 prognostic factors: age (odds ratio (OR) = 0.96, 95% confidence interval (95%CI): 0.93-1.00, p = 0.032); body mass index (OR =1.09, 95%CI: 1.02-1.17, p = 0.009); poste-rior talofibular ligament injury (OR = 2.17, 95%CI: 1.05-4.48, p = 0.035); large bone marrow lesion of the talus (OR = 2.69, 95%CI: 1.30-5.58, p = 0.008), and Grade 2 effusion of the tibiotalar joint (OR = 2.61, 95%CI: 1.39-4.89, p = 0.003). When patients had at least 1 positive clinical finding in the 10-m walk test, anterior drawer test, or inversion tilt test, they had a 90.2% sensitivity and 77.4% specificity in terms of detecting at least 1 prognostic factor by MRI. Conclusion: MRI scanning is valuable in predicting CAI after first-episode LAS for those patients with at least 1 positive clinical finding in the 10-m walk test, anterior drawer test, and inversion tilt test. Further prospective and large-scale studies are necessary for validation.

目的 通过三维有限元分析评价跟骨微创锁定接骨板的稳定性,并评价采用跟骨微创锁定接骨板治疗Sanders Ⅱ型跟骨关节内骨折的临床疗效.方法 建立三种微创锁定接骨板固定Sanders Ⅱ型跟骨关节内骨折的三维有限元模型,模拟加载700 N应力后进行三维有限元分析,评价微创锁定接骨板的生物力学稳定性.自2020年1月至2021年5月,珠海市第五人民医院共收治26例Sanders Ⅱ型跟骨关节内骨折患者,其中男17例,女9例,平均年龄(43.3±8.2)岁(21～61岁).所有患者择期行经跗骨窦切口有限切开复位跟骨微创锁定接骨板内固定.术后定期随访复查摄片,测量B?hler角及Gissane角,同时采用美国骨科足踝外科协会(AOFAS)踝关节与后足评分及视觉模拟量表评分(VAS)评估治疗效果,并记录相关并发症.结果 三维有限元分析结果显示内植物的最大应力值均低于其屈服强度,三种固定方式的骨块最大移位值均位于载距突.临床研究中2例患者失随访,其余24例患者获平均14.5个月(12～18个月)随访.除1例患者出现伤口延迟愈合外,余未见软组织并发症.术后3个月复查摄片明确骨折端愈合.术后末次随访时摄片B?hler角从术前10.9°±5.3.增加至术后末次随访时31.3°±2.3°(P＜0.05),而Gissane角从术前108.3.±24.2.改善至术后末次随访时113.3.±5.5°(P＞0.05).末次随访时AOFAS踝关节与后足评分平均为(88.9±6.6)分(76～100分),VAS平均(1.0±0.9)分(0～3分).除1例患者复查CT见关节面复位欠佳外,余患者未见骨不连、畸形愈合、固定失效、创伤性关节炎等并发症.结论 采用跟骨微创锁定接骨板固定治疗Sanders Ⅱ型跟骨关节内骨折具有创伤小、术后并发症少、固定稳定性可靠等优势,是一种安全、有效的治疗技术.

Background and objective Calcaneal Sanders type II or III fractures are highly disabling with significant burden. Surgical treatment modalities include open reduction and internal fixation (ORIF) techniques and a variety of minimally invasive surgical (MIS) approaches. ORIF techniques are associated with complications and traditional MIS techniques need extensive intraoperative fluoroscopic procedures. The present study aims to investigate the effects of three different minimally invasive internal fixation (MIIF) techniques used to treat Sanders type II intra-articular calcaneal fractures using finite element analyses. Methods A 64-row spiral computed tomography scan was used to observe the calcaneus of a healthy adult. The scanning data were imported into Mimics in a DICOM format. Using a new model of a Sanders type II-B intra-articular calcaneal fracture, three minimally invasive techniques were simulated. Technique A involved fixation using an isolated minimally invasive locking plate; Technique B used a minimally invasive locking plate with one medial support screw; and Technique C simulated a screw fixation technique using four 4.0-mm screws. After simulating a 640-N load on the subtalar facet, the maximum displacement and von Mises stress of fragments and implants were recorded to evaluate the biomechanical stability of different fixation techniques using finite element analyses. Results After stress loading, the maximum displacements of the fragments and implants were located at the sustentaculum tali and the tip of sustentaculum tali screw, respectively, in the three techniques; however, among the three techniques, Technique B had better results for displacement of both. The maximum von Mises stress on the fragments was < 56 Mpa, and stress on the implants using the three techniques was less than the yield strength , with Technique C having the least stress. Conclusion All three techniques were successful in providing a stable fixation for Sanders type II intra-articular calcaneal fractures, while the minimally invasive calcaneal locking plate with medial support screw fixation approach exhibited greater stability, leading to improved enhancement for the facet fragment; however, screw fixation dispersed the stress more effectively than the other two techniques.

Osteochondral lesion of talus (OLT) is a foot and ankle disease characterized by ankle pain, which may impact the joint function and life quality. If managed improperly, it may lead to a further ankle arthritis, severely compromising the prognosis. The therapeutic effect of conservative treatment for OLT is still uncertain. Surgery is still the main treatment modality for OLT with various techniques. However, the optimized surgical technique is still inconclusive, furthermore, regeneration and repair of cartilage after debridement is also a great challenge for the treatment of OLT. Platelet-rich plasma (PRP) with good repair effect on cartilage injury is gradually applied in the treatment of OLT. However, there still lacks the unified understanding of the technique and specification of PRP for the treatment of OLT. Therefore, National Orthopedics Center of Shanghai Sixth People′s Hospital allied Foot Ankle Basic Research & Orthopedics Group, Chinese Association of Orthopedic Surgeons; Foot and Ankle Committee of Chinese Association of Sports Medicine Physicians; and Foot and Ankle Group of Orthopedic Specialized Branch of Shanghai Medical Association to organize related experts to formulate the Expert consensus on platelet- rich plasma treatment for osteochondral lesion of talus ( version2023). Fifteen recommendations were put forward upon PRP preparation, indications, contraindications and treatment methods of PRP for OLT, so as to standardize the PRP treatment for OLT.

To the Editor: The mechanism of Lisfranc injury is complex and may cause different patterns of fractures or dislocation of the midfoot complex. Abduction force injury is a special injury pattern, which may cause the fracture or (and) dislocation of the lateral column of the Lisfranc joint, especially the cuboid.[1-3] However, the anterolateral calcaneus is less commonly involved. Since the fragment of the calcaneocuboid (CC) joint facet is too uncon- spicuous to manifest on a plain X-ray, and surgeons always pay more attention to the Lisfranc joint, anterolateral calcaneal compression fracture and even Chopart joint injuries are often overlooked, which may lead to a delayed surgical management, chronic foot deformities, and functional disability. Treatment for this special pattern of injury has rarely been reported and remains a challenge for foot and ankle surgeons. Gajendran et al[4] reported a case of an unusual variant of a nutcracker fracture of the anterolateral calcaneus and navicular, and resulting in the compromised final outcomes with a conservative treatment. The crucial and difficult point of the management for the lateral column injury is the reduction and fixation of the facet fragment, which is small, compressed, and sometimes comminuted. We hypothesized that the rafting fixation technique for the compression fragment with a minifragment plate could achieve a stable fixation and obtain an acceptable clinical outcome for this pattern of injury. Thirteen patients were enrolled in our study. Among them, 5/13 cases (38.5%) of calcaneal involvement were missed on the initial X-ray. After a thorough evaluation, open reduction and internal fixation were performed in all patients until the soft tissue condition was improved. In this study, all the patients underwent the final follow-up for a mean period of 27.69 ± 14.41 months postoperatively (range: 12–60 months). Two patients suffered from an early soft-tissue complication and were cured by conservative management. The plain radiographs showed a bony union in all patients at 3rd month postoperatively [Figure 1D].Figure 1: (A) A 29-year-old manual laborer with a high activity demand suffered from a motor vehicle accident. The preoperative X-ray showed a Lisfranc injury with an unapparent anterolateral calcaneal fracture (a, b). 3D-CT showed the Lisfranc injury (c), and a compressed fragment of the CC joint on the anterolateral calcaneus (d). (B) A medial approach was used to access the firstand second TMT joint. The instability of the medial-middle intercuneiform joint was detected, which was reduced and secured with an intercuneiform screw firstly. After the reduction and fixation of the medial cuneiform— second metatarsal base, the unstable medial column was also stabilized with a bridging plate (a). The third TMT joint was exposed via a lateral approach and fixed with another bridging plate (b). (C) An additional lateral longitudinal incision was made for the exposure of the CC joint. After the displaced articular fragment was accessed (a), reduction and rafting fixation with a mini-fragment plate was performed (b). (D) The postoperative X-ray of 3rd month demonstrated a solid bone union with an anatomical restoration of the midfoot alignment and the CC joint facet (a,b). 3D-CT: three-dimensional computed tomography; CC: calcaneocuboid; TMT: tarsometatarsal.The average Visual Analogue Scale (VAS) score of the final follow-up was significantly improved (1.8 ± 1.4 postoperative vs. 5.9 ± 1.3 pre-operative, t = 17.05, P < 0.05). The final American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score was 82.1 ± 10.9 (range: 56.0–97.0). All patients returned to work at an average of 7.5 ± 2.2 months postoperatively (range: 5–12 months). The symptoms and AOFAS midfoot score had a correlation with the time of returning to work (r = 0.744 and 0.871, respectively, P < 0.05). Twelve cases obtained an implant removal on the average of 11th month postoperatively (range: 8–14 months), three of which was found an implant breakage during the removal with no obvious symptoms. Two cases (15.4%) of posttraumatic arthritis of the Lisfranc joint were observed and suffered from a moderate symptom, which was relieved by application of analgesic medication and orthosis support. Three patients (23.1%) complained about the midfoot rigidness. No complications of nonunion, malunion, or midfoot deformity were noted during the follow-up. To our knowledge, the most common pattern of the lateral column compression fracture is the “nutcracker fracture” of cuboid, which may cause the shortening of the lateral column and forefoot deformity with a high complication rate. However, the injury involving both the Chopart joint and Lisfranc joint is not so common. In Ponkilainen et al's[5] study, they reported that only 5.8% of midfoot injuries involved both of these joints. The detailed mechanism of this special fracture is still unknown. We considered that an abduction force still played an important role. The calcaneal compression fracture is easily neglected. Any misdiagnosis and improper management may lead to a symptomatic posttraumatic arthritis and functional limitation. Diagnosis from an X-ray sometimes is difficult. In this study, 5/13 cases (38.5%) of anterolateral calcaneal fracture were neglected on the initial plain X-ray. We considered that two reasons might cause the misdiagnosis. First, surgeons tend to pay more attention to the Lisfranc joint and possible involvement of the Chopart joint could be overlooked; thus, detailed physical examination is also a crucial method to avoid misdiagnosis. The anterolateral calcaneal fracture should be strongly suspected when any tenderness is detected on the lateral side of the foot. Furthermore, the fragment sometimes might be too small to be manifested on the plain X-ray. Therefore, we suggest that three-dimensional computed tomography scanning be routinely applied to evaluate midfoot injuries. The essence of the management of midfoot complex injuries is the anatomical restoration of midfoot alignment and facet with a stable fixation. Reduction and fixation of the Lisfranc joint are generally performed first. Although a primary arthrodesis for ligamentous Lisfranc injury is recommended in recent years,[6,7] we still prefer an open reduction and internal fixation (ORIF) than primary arthrodesis for prevention of an early degeneration of the adjacent joints. Moreover, the patients in our country have a low acceptance level of primary arthrodesis. Management of the anterolateral calcaneal compression fracture is not easy, since the facet fragments are sometimes very small and comminuted. Dhillon et al[8] reported three cases of crush fractures of the anterior end of the calcaneus, in which acceptable clinical outcomes were achieved. In their study, K-wires were implanted for fixation of fractures, and a fixator was used to restore the length of the lateral column. However, we consider that this fixation technique still remains controversial. K-wire fixation or fixator is not stable enough and may cause some soft tissue problems, that is, pin tract infection. Screw fixation is an alternative for small fragment fixation. Nevertheless, if the fragment is too small or comminuted, or the patient also has osteoporosis, screw fixation may cause a high rate of failure. The mini-fragment plate system is our preference, which has several advantages. First, rafting fixation along the CC joint may provide rigid support for the fragment to prevent further re-displacement. Additionally, the compression effect of the plate can stabilize the fragment even without screw fixation into the fragment, which also could limit displacement. No cases of implant failure and redisplacement of compression fragments occurred in our patients. Furthermore, plate fixation also facilitates implant removal in the future. We achieved satisfactory outcomes by virtue of the anatomical reduction and stable fixation. The average VAS score was significantly improved than the preoperative one (P < 0.05) and most patients obtained a good to excellent AOFAS midfoot score. And all of them returned to work at an average of 7.5 months postoperatively. Furthermore, we found that limited symptoms and satisfactory AOFAS score indicated less time of returning to work, which had a significant correlation. The complications still remain an issue for midfoot injury. For Lisfranc complex injuries, by consequence of high- energy trauma, the postoperative complication rate is still relatively high despite of a proper treatment.[9,10] In the present study, although we achieved a satisfactory clinical outcome in most of our patients, two cases (15.4%) of the three-column Lisfranc complex injury still developed into posttraumatic arthritis during follow-up. However, the symptoms were moderate and controlled conservatively, therefore no salvage procedure was needed. Implant removal is another point. Removing the implant too early may cause the instability of the midfoot, while a long period of bridging fixation may cause a too rigid joint with no difference of arthrodesis. Three patients who removed their implants over 12 months postoperatively complained about a rigid midfoot. It may also cause an implant breakage. In this study, the implant breakage was demonstrated in three cases who removed the implants over 10 months without any symptoms. We suggest that the Lisfranc screw and intercuneiform screw should be removed before the full weight-bearing, while the final removal procedure should be performed earlier than 10 months. The clinical evidence of best removal time is still limited and attempted to be discovered in the future studies. This study still had some limitations. First, the sample size was small because of the rarity of this pattern of injury. Second, we did not perform a comparative analysis, and our evaluation is not comprehensive. Third, the long-term clinical outcomes of this pattern of injury remain unclear. Furthermore, the current classification system is another problem. The three-column classification system is simple and precise in its description of tarsometatarsal joint disruption.[11] However, this system only limits to the Lisfranc injury. For the midfoot complex injury involving the Chopart joint, whether this theory could extend to it is still under discussion. We attempt to modify the classification system based on more cadaver anatomy research and biomechanical study. Finally, the detailed mechanism of this pattern of injury is still undiscovered. We hope to overcome these limitations in our future work. In conclusion, Lisfranc injury with an anterolateral calcaneal compression fracture is not common with a high rate of misdiagnosis. Thorough evaluation of the entire midfoot complex including both Lisfranc and Chopart joints is vital in clinical work. ORIF remains the gold standard for this pattern of injury, and acceptable clinical outcomes can be obtained with proper management. Conflicts of interest None. Funding This study was supported by grants from the Biomedicine Supporting Program of Shanghai ‘Science and Technology Innovation Plan’ (No. 19441902400), the Key Research and Development Program of National Ministry of Science and Technology (No. 2018YFC2001504), the scientific research project of Shanghai Municipal Health Commission (No. 201940367), the scientific research project of Health and Family Planning Commission of Pudong New Area (No. PW2018B-01).

Objective:To evaluate the mid-term efficacy of surgery for sub-acute injury to distal tibiofibular syndesmosis associated with ankle fracture.Methods:From July 2014 to October 2019, 14 patients were treated at Foot & Ankle Section, Department of Orthopaedics, Shanghai Sixth People’s Hospital for sub-acute injury to distal tibiofibular syndesmosis associated with ankle fracture.There were 11 males and 3 females, aged from 17 to 61 years (mean, 35.9 years).According to Danis-Weber classification, 6 cases were type B and 8 type C; according to Lauge-Hansen classification, 7 cases belonged to supination-external rotation, one to pronation-abduction, and 6 to pronation-external rotation (Maisonneuve fracture in 4).The syndesmosis injury was treated by fixation with distal tibiofibular screws in 11 cases, by Tightrope elastic fixation in one, by hybrid fixation with distal tibiofibular screws and Tightrope in one, and by distal tibiofibular fusion in one.Postoperative complications were recorded.Their visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (AOFAS-AH) were compared between preoperation and the last follow-up.Results:The 14 patients were followed up for 24 to 85 months (mean, 46.8 months). Of the 9 patients whose distal tibiofibular screws had been removed (including one with hybrid fixation), wound infection occurred in one after removal of all the internal fixation, distal tibiofibular widening in 2, ankle degeneration in 5 and fibular nonunion in one. Of the other 3 patients whose distal tibiofibular screws had not been removed, screw breakage happened in 2, screw loosening in one and distal tibiofibular widening in one. The VAS scores were significantly improved from preoperative 6.8±0.9 to 1.4±1.3 at the last follow-up; the AOFAS-AH scores were increased significantly from preoperative 35.3±6.3 to 86.8±11.7 at the last follow-up (both P<0.001). According to AOFAS-AH scores, 8 cases were excellent, 4 good and 2 moderate. Conclusion:Surgery for sub-acute injury to distal tibiofibular syndesmosis associated with ankle fracture can restabilize the distal tibiofibular syndesmosis and ankle joint, reduce pain and improve ankle function, leading to fine mid-term efficacy.