Differential efficacy of subtalar fusion with three operative approaches.

BACKGROUND: There are many existing operative approaches for subtalar fusion; however, no optional strategy of operative approach has been developed yet. This study aimed to analyze the differential clinical efficacy of subtalar fusion with three operative approaches. METHODS: The clinical data of 102 patients from April 2008 to April 2012 were analyzed prospectively. These patients were divided into three groups with the random number table: group A, group B, and group C. The following parameters were compared among three groups: effective exposure area and exposure time of subtalar joint, intraoperative bleeding volume, postoperative complications, fusion time, fusion rate, AOFAS score and VAS score before and after operation. RESULTS: In the exposure area score, there was no statistically significant difference between group A and group C (P > 0.05) ,but with a statistically significant difference between group A/C and group B (P < 0.05). In exposure time and intraoperative bleeding volume, there was no statistically significant difference between group A and group B (P > 0.05) but with a statistically significant difference between group A/B and group C (P < 0.05). In three groups, there was a statistically significant difference in both AOFAS score and VAS score before operation and at 6 months/12 months/last visit after operation (P < 0.05). The incidence of complications in the three groups was 8.8%, 12.5% and 19.4%. No statistically significant differences in fusion rate and fusion time were observed among the three groups (P > 0.05). CONCLUSION: Three operative approaches have different indications, All the three operative approaches do not influence the fusion rate and fusion time of subtalar joint. The lateral tarsal sinus approach is inferior to the posterior-lateral L approach and the approach from the inferior tip of fibula to the basilar part of the fourth metatarsal bone in the exposure area, while the lateral tarsal sinus approach and the approach from the inferior tip of fibula to the basilar part of the fourth metatarsal bone are superior to the posterior-lateral L approach in the exposure time, intraoperative bleeding volume, and incidence of complications.

A prospective study of midfoot osteotomy combined with adjacent joint sparing internal fixation in treatment of rigid pes cavus deformity.

BACKGROUND: Midfoot osteotomy has been previously confirmed to be a good method to correct pes cavus. How to fix the osteotomy and which point to choose for the procedure has been a focus for most surgeons. The aim of this study was to analyse the outcomes of a series of patients who had been treated for pes cavus deformity using midfoot osteotomy combined with adjacent joint sparing internal fixation. MATERIALS AND METHODS: Between 2008 and 2012, 17 patients with a mean age of 16.8 years (12-36 years) were tracked after treatment by midfoot osteotomy combined with adjacent joint sparing internal fixation with three cannulated screws between the Lisfranc line and Cyma line. Clinical outcomes were assessed by measuring improvements of appearance and function, American Orthopedic Foot and Ankle Society (AOFAS) scores, and radiographic changes. RESULTS: The mean follow-up time was 25.3 months (range, 10-50). The mean healing time from the osteotomy was 7.8 weeks (range, 6-12). The appearance and weight-bearing function were significantly improved in all patients. At a final follow-up, the mean AOFAS score was 75.8/100 points (range, 63-90). The mean Meary's angle, calcaneal pitch angle, tibiotalar angle, and Hibb's angle values improved from 26.3 to 5.5, 44.5 to 28.3, 133.1 to 100.8 and 66.9 to 41.1, respectively. Adjacent joints presented no obviously arthritic degeneration at the follow-up. Subjectively, 94.1% of patients were very satisfied or satisfied with minor reservations. Objective outcomes were excellent or good in 88.2% of feet. CONCLUSION: For the treatment of rigid pes cavus deformity, extra-articular midfoot osteotomy combined with adjacent joint sparing internal fixation is effective and safe. This surgical technique is especially effective with low rates of arthritic degeneration and joint stiffness in the adjacent joints and little reduction of ankle and foot flexibility.

[Short-term effectiveness of suture anchor after debridement of extensor tendon insertion for recalcitrant lateral epicondylitis].

OBJECTIVE: To analyze the short-term effectiveness of repairing musculus extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC) tendon using suture anchor after debridement of extensor tendon insertion for recalcitrant lateral epicondylitis. METHODS: Between March 2009 and May 2011, 10 patients (10 elbows) with recalcitrant lateral epicondylitis received repair of the ECRB and EDC tendon to the lateral epicondyle using a single suture anchor after debridement of extensor tendon insertion. There were 6 males and 4 females with an average age of 45.4 years (range, 36-57 years). The dominant elbow was involved in 8 patients and nondominant elbow in 2 patients; there were 4 manual workers and 6 ordinary workers. The disease duration ranged from 8 to 24 months (mean, 12.3 months). All patients had epicondylus lateralis humeri pain, local swelling and tenderness, and positive Mill sign. The average elbow range of motion (ROM) was 11.3 degrees (range, 0-30 degrees) in extension and was 132.5 degrees (range, 120-145 degrees) in flexion. Preoperative MRI showed external humeral epicondylitis in all patients. RESULTS: Primary wound healing was obtained in all patients without complications of infection, leakage of joint fluid, and stiffness of elbow. Ten patients were followed up 4 to 23 months with an average of 12 months (more than 12 months in 7 cases). The time to return to work was (3.75 +/- 0.95) months for manual workers and was (2.91 +/- 0.20) months for ordinary workers, showing no significant difference (t = 1.715, P = 0.180). Compared with preoperation, the mean visual analogue scale (VAS) score significantly decreased (P < 0.05), and Mayo score and the grip strength of dominant and nondominant significantly increased (P < 0.05), but no significant difference was found when compared with non-surgical side at last follow-up (P > 0.05). At last follow-up, the average ROM was -1.5 degrees (range, 0-10 degrees) in extension and was 150.5 degrees (range, 140-160 degrees) in flexion. CONCLUSION: To suture anchor for repairing the ECRB and EDC after debridement is a satisfactory procedure to treat recalcitrant lateral epicondylitis. It can effectively prevent loss of the forearm extensor strength, relieve the pain, recover the grip strength, and obtain good results.

[Percutaneous achilles tendon lengthening through double hemisection in the treatment of achilles contracture syndrome].

OBJECTIVE: To explore the surgical approach of percutaneous double hemisection and evaluate its clinical efficacies. METHODS: From May 2006 to November 2011, a total of 59 patients were recruited. There were 36 males and 21 females with a mean age of 38.2 years (range: 8 - 62). Forty-two varus and 6 valgus feet underwent percutaneous double hemisection. The 0.5 cm coracoid incision was adopted at the medial and lateral aspects of Achilles tendon. Percutaneous double hemisection was employed according to the deformity angles of varus and valgus feet. Manipulative correction was applied slowly until 30° dorsiflexion of ankle. Short leg cast was immobilized for 5 weeks at 30° dorsiflexion of ankle. The force of Achilles tendon, motion of ankle and Hannover Achilles tendon scores were followed up. RESULTS: Fifty-two patients were followed up for a mean period of 16.5 months (range: 6 - 60). Seven patients were lost. At the end of follow-up, 48 patients with varus and valgus deformities were corrected effectively. When compared with the normal side, the force of Achilles of the operated side of 50 patients had no change while that of 2 patients decreased slightly; the motion of ankle joint increased from (2.8 ± 0.3)° preoperatively to (28.5 ± 1.4)° postoperatively (P < 0.05); the Hannover Achilles Tendon Scores rose from (68.5 ± 3.5) preoperatively to (82.6 ± 4.2) points postoperatively (P < 0.05). The outcomes were excellent (n = 44), very good (n = 5), good (n = 2) and poor (n = 1). The excellent and good rate was 94.2%. CONCLUSION: As an effective therapy for Achilles tendon contracture syndrome, percutaneous double hemisection has fewer complications and a faster recovery.

[Excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular for treatment of flatfoot related with accessory navicular].

OBJECTIVE: To analyze the excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular for the treatment of flatfoot related with accessory navicular and to evaluate its effectiveness. METHODS: Between May 2006 and June 2011, 33 patients (40 feet) with flatfoot related with accessory navicular were treated. There were 14 males (17 feet) and 19 females (23 feet) with an average age of 30.1 years (range, 16-56 years). All patients had bilateral accessory navicular; 26 had unilateral flatfoot and 7 had bilateral flatfeet. The disease duration ranged from 7 months to 9 years (median, 24 months). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-midfoot score was 47.9 +/- 7.3. The X-ray films showed type II accessory navicular, the arch height loss, and heel valgus in all patients. All of them received excision of accessory navicular and reconstruction of posterior tibial tendon insertion on navicular with anchor. RESULTS: All patients got primary wound healing without any complication. Thirty patients (36 feet) were followed up 6-54 months with an average of 23 months. All patients achieved complete pain relief at 6 months after surgery and had good appearance of the feet. The AOFAS ankle-midfoot score was 90.4 +/- 2.0 at last follow-up, showing significant difference when compared with preoperative score (t=29.73, P=0.00). X-ray films showed that no screw loosening or breakage was observed. There were significant differences in the arch height, calcaneus inclination angle, talocalcaneal angle, and talar-first metatarsal angle between pre-operation and last follow-up (P < 0.01). CONCLUSION: The excision of accessory navicular with reconstruction of posterior tibial tendon insertion on navicular is a good choice for the treatment of flatfoot related with accessory navicular, with correction of deformity, excellent effectiveness, and less complications.

[Triple arthrodesis with osteotomy for the treatment of stage IIB and stage III adult-acquired flatfoot deformity].

OBJECTIVE: To analyze the clinical outcomes of triple arthrodesis with osteotomy in the treatment of Stage IIB and Stage III adult-acquired flatfoot. METHODS: The authors reviewed 10 cases of adult-acquired flatfoot, including 3 cases of stage IIB adult-acquired flatfoot and 7 cases of stage III adult-acquired flatfoot. They were treated by triple arthrodesis with osteotomy of subtalar joint (STJ), talonavicular joint (TNJ) and calcaneocuboid joint (CCJ). The combined medial and lateral incisions were used to obtain adequate exposure for CCJ, STJ and TNJ. Then the cartilages of CCJ, STJ and TNJ were completely denuded and osteotomies to restore their proper alignments. The optimal positioning of hindfoot could be achieved and fixed by Kirschner wires. Two cannulated screws of 7.3 mm were delivered through the plantar aspect of heel to fix STJ. And then two 4.5 mm cannulated screws individually fixed TNJ and CCJ distal to proximal. Clinical evaluations were based on the AOFAS ankle-hindfoot scale and subjective assessments of pains, function, cosmesis and overall satisfaction. Radiographic evaluations included measurements of anterior-posterior talo-first metatarsal angle, lateral talocalcaneal angle, lateral talo-first metatarsal angle and an assessment of time to union for all arthrodeses. RESULTS: All patients were followed-up with a mean time of 13.2 (6 - 21) months. The average AOFAS ankle-hindfoot scale improved from 39.4 ± 4.4 preoperatively to 83.7 ± 2.6 postoperatively (P < 0.01). And the patients experienced subjective improvements in pain, function and cosmesis. Overall, all patients were satisfied. Radiographically, the rate of bone healing was 100%. The anterior-posterior talo-first metatarsal angle, lateral talocalcaneal angle and lateral talo-first metatarsal angle statistically improved. No complication, such as infection and un-union, was reported. CONCLUSION: Triple arthrodesis with osteotomy is an effective procedure for the treatment of stage IIB and III adult-acquired flatfoot deformity. It may relieve pains, correct structural deformities and obtain excellent clinical outcomes.

[Medial displacement calcaneal osteotomy with mini-incision for the treatment of acquired flexible flatfoot caused by posterior tibial tendon dysfunction].

OBJECTIVE: To investigate the clinical outcomes of medial displacement calcaneal osteotomy with mini-incision for the treatment of acquired flexible flatfoot caused by posterior tibial tendon dysfunction. METHODS: From 2005 to 2009, 10 patients (13 feet) of acquired flexible flatfoot with obvious heel valgus underwent medial displacement calcaneal osteotomy with mini-incision. The lateral skin incision of 3.0 - 4.5cm was made to explore the lateral calcaneal wall. Calcaneal osteotomy was performed from inferior and lateral to superior and medial, perpendicular to the longitudinal axis of calcaneal body. The distal segment was displaced medially for 1/3-1/2 width of calcaneal body and fixed by two parallel cannulated screws. All patients were evaluated at 6 weeks, 3 months, 6 months, 12 months and every 6 months pre- and post-operatively by clinical examinations and radiological studies. All patients were physically examined with an extended protocol of questionnaires and the AOFAS Ankle & Hindfoot Scales. The lateral view of full foot allowed an assessment of bone healing, calcaneus inclination angle (CI), talocalcaneal angle (TC) and talar first metatarsal angle (TMT). The AP view of full foot allows assessment of TC and TMT. The heel varus/valgus alignment could be evaluated on the axial radiographs of hindfoot. RESULTS: With a mean postoperative follow-up period of 20.3 months (range 7 - 55 Ms), all patients had bone union as confirmed by clinical examination and radiology. The AOFAS rating scale improved from a pre-operative mean of 50.3 to a mean of 80.2 at 6 months and a mean of 84.2 at last follow-up, without any complication of infection, nerve injure and so on. All radiographic parameters were statistically significant (P < 0.001), including CI, TC and TMT on the lateral view and TC and TMT on the AP view. The heel varus/valgus was corrected on the axial view. CONCLUSION: The medial displacement calcaneal osteotomy with mini-incision is a recommended procedure for the treatment of acquired flexible flatfoot with excellent clinical outcomes, correction of deformity and fewer complications.