Characteristics of intercalary fragment in posterior malleolus fractures

BackgroundThe purpose of the study is to investigatethe prevalence of posterior malleolus intercalary fragment (ICF) in adult ankle fractures; to analyze the morphological characteristics of ICF; and its mechanism.MethodsRetrospectively, 247 cases of posterior malleolus fractures (PMF) were included in 369 cases of adult ankle fractures. The prevalence of ICF, relationship between type of ankle fracture, posterior malleolar fracture and the ICF was studied.ResultsAmong 369 cases, the ICF was found in 43% of the PMF and 29% of the hospitalized unstable ankle fractures. Position of ICF is posterolateral in 68 (64%), mid posterior in 20 (19%) and posteromedial in 18 (17%) cases. The prevalence of ICF was 70% in Bartoníček classification type III fractures, which was significantly higher than type I, II and IV.ConclusionsThe highest incidence occurs in Bartoníček III type fracture. The study helps in further understanding and treatment of the PMF.Level of evidenceLevel IV, case series.     

New classification of the distal attachment of the fibularis brevis — Anatomical variations and potential clinical implications

BackgroundAlthough the lateral compartment of the leg is characterized by a high degree of morphological variation, very little information exists on the morphological variability of the fibularis brevis muscle (FBM) and fibularis digiti quinti (FDQ). The main aim of the study was to characterize the morphology of the FBM tendon and its accessory bands, to classify them and to determine the incidence of FDQ. The work attempts to determine the relationship between the types of the insertion of the FBM tendon and the occurrence of FDQ.MethodsClassical anatomical dissection was performed on 102 lower limbs fixed in 10% formalin solution. The morphology of the insertion of the FBM and of the FDQ was evaluated.ResultsThe FBM was present in all specimens. Two types of insertion were observed, the most common being Type I (70.6%): a single distal attachment in which the tendon inserts into the tuberosity at the base of the fifth metatarsal bone. The second most common was Type II (29.4%); this group was divided into three subtypes (A–C). The FDQ was present in 17.7% of specimens and always with Type I FBM.ConclusionBoth the FBM tendon and FDQ present significant morphological variation. Two main types of the FBM tendon determine the presence of the FDQ.Level of evidenceII Basic Science Research.     

Posterolateral plate fixation with Pantalarlock® is more stable than nail fixation in tibiotalocalcaneal arthrodesis in a biomechanical cadaver study

BackgroundDespite the promising results of ankle joint arthroplasty, the tibiotalocalcaneal (TTC) arthrodesis remains an established procedure in treatment of combined pathology of the ankle and subtalar joint. Despite the promising results in biomechanical investigations, nonunion rates of up to 24% are described in recent studies. The objective of this work was a comparative study of the biomechanical properties of the posterolateral plate fixation with retrograde intramedullary nail fixation.MethodsTwenty four fresh-frozen human lower leg specimens (12 pairs) were used for the comparative biomechanical testing. Every specimen was preconditioned with 100 N over 200 cycles. After every 250 cycles the force was increased by 50 N from 200 to 600 N. This was followed by cyclic loading in dorsi-/plantiflexion with 800 N for 3000 cycles. All specimens were subjected to bone densitometry (DXA) and computed tomography.ResultsSignificantly higher number of spacimens with nails (4) failed during the cycling testing in dorsi-/plantarflexion and futher two during the cyclic testing with 800 N. Two specimens with plates failed during the cyclic testing with 800 N. Statistical analysis showed that the specimens with the plate were significantly more stable in each test direction. The Pearson correlation demonstrated for the specimens with plate a linear relationship between the stiffness and the determined bone density.ConclusionsThe results demonstrate a significantly superior stiffness of the Pantalarlock®-plate in all testing directions compared with the HAN nail. Probably the position of the plate on the tension side of the joint and the combination of locking and lag screws provide the higher stiffness of the plate system. The correlation of the stiffness with bone density leads to more predictable results of the plate arthrodesis. We hope for a reduction of the pseudarthrosis rate and shorten the postoperative treatment phase. The authors expect advantages in the treatment of high risk patients with severe deformity of the ankle, bone defects, neuropathic deformity, poor bone quality and osteoporosis.     

3D技术辅助下半肩置换治疗老年性肱骨近端粉碎性Neer Ⅳ型骨折

目的：观察比较借助3D打印技术行半肩置换术与切开复位锁定钢板治疗中老年性肱骨近端粉碎性骨折（Neer Ⅳ型）的肩关节功能、并发症、临床效果。方法：2012年3月至2018年4月收治31例中老年肱骨近端粉碎性骨折（Neer Ⅳ型）,男4例,女27例;年龄55～94岁,平均71岁;病程1～3年。其中采用切开复位锁定钢板内固定（ORIF组）20例,采用3D打印技术辅助下半肩置换术（HA组）11例。通过CT数据借助Mimics软件,在计算机上模拟骨折重建,测量出骨折端到肱骨头高度,大结节到肱骨头高度,肱骨头后倾角,辅助半肩置换。术后随访,行X线检查,观察两组并发症发生率,并对肩关节功能进行Neer评分。结果：31例患者获得随访,时间1～3年,平均2年。HA组无假体松动、断裂和下沉,人工肱骨头完好,大小结节骨折不愈合1例,Neer评分84.18±3.55;ORIF组肱骨近端骨吸收8例,骨折不愈合1例,内固定松动1例,Neer评分55.91±10.78;两组肩关节功能Neer评分比较,差异有统计学意义（P<0.05）。结论：3D技术辅助半肩置换与切复锁定钢板固定治疗中老年肱骨近端粉碎性骨折（Neer Ⅳ型）并发症少,功能恢复较切复内固定好。     

Varus talar tilt combined with an internal rotation pivot stress assesses the supination instability vector in lateral ankle ligaments’ injury — cadaver study

BackgroundThe lack of consensus on the relevance of the varus talar tilt test (VTTT) might be due to the divergence between the insufficiency vector of lateral ankle instability and the direction of this clinical test. Our hypothesis is that the VTTT is more accurate to diagnose lateral ankle ligaments rupture when it's applied with a pre-positioning of the foot in internal rotation (IR).MethodsWe compared, in 12 cadaver ankles, the varus opening during a classic VTTT with the same test starting in an IR pivot, using a new arthrometer.ResultsThe classic VTTT caused a 13° tilt after ATFL section and 23,8° after ATFL and CFL section. The application of a VTTT with an IR prepositioning caused a 21,2° tilt after ATFL section (p = 0,002) and 29,5° after ATFL and CFL section (p = 0,006).ConclusionThe VTTT is better to identify lateral ankle ligaments' insufficiency when it's applied with a pre-positioning of the foot in internal rotation. The resulting vector is similar to the supination trauma.     

老年骨质疏松性陈旧胸腰椎骨折伴后凸畸形后路截骨矫形的术式选择

目的：观测Smith-Petersen截骨（SPO）、经椎弓根截骨（PSO）和全椎体切除截骨（VCR）3种术式治疗老年骨质疏松性陈旧胸腰椎骨折伴后凸畸形的矫形效果和临床疗效,探讨截骨矫形术式选择。方法：自2015年6月至2017年8月对8例老年骨质疏松性陈旧胸腰椎骨折伴后凸畸形患者后路截骨矫形术,患者均为陈旧性骨质疏松性胸腰椎骨折（>6个月）,经过严格保守治疗3个月无效,包括应用非甾体类消炎镇痛药物、抗骨质疏松药物、针灸等。其中男3例,女5例;年龄66~83岁,平均73.4岁;病程8~60个月,平均34.6个月。8例患者共8个椎体骨折。骨折节段：T₁₀ 1个;T₁₁ 1个;T₁₂ 3个;L₁ 2个,L₂ 1个。8例患者均表现为单节段椎体陈旧性骨折楔形变引起的脊柱后凸畸形。患者胸腰段局部后凸和疼痛症状均呈渐进性发展,表现为中枢性矢状位失衡。术式选择上采用SPO截骨3例,PSO截骨3例,VCR截骨2例。通过影像学测量分析矫形效果,包括术前后脊柱后凸Cobb角,伤椎局部后凸角（localized kyphosis,LK）,胸椎后凸角（thoracic kyphosis,TK）,腰椎前凸角（1umbar lordosis,LL）,骶骨水平角（sacral tilt angle,ST）及骶骨后上角至脊柱矢状轴线的距离（sagittal vertical axis,SVA）。采用疼痛视觉模拟评分（VAS）评估疼痛情况,应用Oswestry功能障碍指数（ODI）分析临床疗效。结果：8例患者术后均获得随访,时间8~24个月,平均13.5个月。所有患者腰背疼痛症状明显减轻或消失,VAS评分由术前的5~8分（平均6.5分）降低至末次随访时的1~4分（平均1.88分）,评分明显改善。ODI评分由术前的36~78分（平均60.25分）降低至末次随访时10~32分（平均20.38分）,功能评分明显进步。随访期间X线检查可见部分患者术后植骨融合椎间隙高度稍微降低,植骨均骨性愈合,未见明显矫正度数丢失和内固定松动失败,胸腰段后凸畸形明显改善。T₁₀-L₂ Cobb角平均值由术前的25.3°矫正至2.8°,矫正率89.3%。LK由术前的平均43.4°改善为术后的7.1°,平均矫正率为86.2%。TK由术前的平均49.9°改善为术后的30.6°。LL由术前的平均43.6°减小为术后的30.8°。ST由术前的平均24.0°改善为术后的32.1°。SVA由术前平均6.23 cm减小为术后的2.40 cm。结论：针对不同病理特征和畸形程度的老年骨质疏松性陈旧胸腰椎骨折伴后凸畸形患者,选用SPO、PSO或VCR矫治均可取得良好矫形效果及临床疗效。