股前外侧肌皮瓣修复足踝侧方组织缺损

Objective To explore the long-time clinical results and effection of free anterolateral thigh musculocutaneous flap for repairing the complex defects involving lateral or medial malleolar of the ankle and heel,especially for reconstructing stability of the ankle joints. Methods Thirteen patients with complex tissue defects,involving lateral or medial malleolar of the ankle and heel,were treated by free anterolateral thigh fasciomusculocutaneous flap.The fascia lata which was involved in the flap was fixed with the adjacent tissue of the recipient area.The descending branches of the lateral circumflex femoral vessels were anastomosed with the vessels in the recipient area.The largest area of the flap was 20 cm × 12 cm.The ankle joint was fixed in functional position with plaster in the early 3 months post-operatively.The following time ranged from 1.5 years to 20 years.The stability of the ankle joint were evatuated with the patients' objective feeling and clinical symptoms and imaging study.Results The stability of the ankle should be protected by external fixation in the early 3 months postoperatively,and was restored at 6 months usually.In all cases,ten cases were followed over 10 years,six cases were followed over 6 years,three cases were followed over 15 years.Though radiological discovering suggesting traumatic esteoarthritis exited in 3 cases with a follow-up more than 5 years,the clinical manifestations were fair and no one need undergo arthredesis. Conclusion Using ant erolateral thigh musculocutaneous flap for reconstructing the complex defects involving lateral or medial malleolar of the ankle and heel repairing stability of the joint and ovoiding off early arthrodosis of the joint is one of the favorable choice,especially for the teen-agers.     

股前外侧肌皮瓣修复足踝侧方组织缺损

Objective To explore the long-time clinical results and effection of free anterolateral thigh musculocutaneous flap for repairing the complex defects involving lateral or medial malleolar of the ankle and heel,especially for reconstructing stability of the ankle joints. Methods Thirteen patients with complex tissue defects,involving lateral or medial malleolar of the ankle and heel,were treated by free anterolateral thigh fasciomusculocutaneous flap.The fascia lata which was involved in the flap was fixed with the adjacent tissue of the recipient area.The descending branches of the lateral circumflex femoral vessels were anastomosed with the vessels in the recipient area.The largest area of the flap was 20 cm × 12 cm.The ankle joint was fixed in functional position with plaster in the early 3 months post-operatively.The following time ranged from 1.5 years to 20 years.The stability of the ankle joint were evatuated with the patients' objective feeling and clinical symptoms and imaging study.Results The stability of the ankle should be protected by external fixation in the early 3 months postoperatively,and was restored at 6 months usually.In all cases,ten cases were followed over 10 years,six cases were followed over 6 years,three cases were followed over 15 years.Though radiological discovering suggesting traumatic esteoarthritis exited in 3 cases with a follow-up more than 5 years,the clinical manifestations were fair and no one need undergo arthredesis. Conclusion Using ant erolateral thigh musculocutaneous flap for reconstructing the complex defects involving lateral or medial malleolar of the ankle and heel repairing stability of the joint and ovoiding off early arthrodosis of the joint is one of the favorable choice,especially for the teen-agers.     

Ankle arthrodesis:A systematic approach and review of the literature

Ankle arthrodesis is a common treatment used for patients with end-stage ankle arthritis(ESAA). The surgical goal of ankle arthrodesis is to obtain bony union between the tibia and talus with adequate alignment [slight valgus(0°-5°)], neutral dorsiflexion, and slight external rotation positions) in order to provide a pain-free plantigrade foot for weightbearing activities. There are many variations in operative technique including deferring approaches(open or arthroscopic) and differing fixation methods(internal or external fixation). Each technique has its advantage and disadvantages. Success of ankle arthrodesis can be dependent on several factors, including patient selection, surgeons' skills, patient comorbidities, operative care, etc. However, from our experience, the majority of ESAA patients obtain successful clinical outcomes. This review aims to outline the indications and goals of arthrodesis for treatment of ESAA and discuss both open and arthroscopic ankle arthrodesis. A systematic step by step operative technique guide is presented for both the arthroscopic and open approaches including a postoperative protocol. We review the current evidence supporting each approach. The review finishes with a report of the most recent evidence of outcomes after both approaches and concerns regarding the development of hindfoot arthritis.     

One stage anterior-posterior approach for traumatic atlantoaxial instability combined with subaxial cervical spinal cord injury

Objectives: To explore the clinical features of traumatic atlantoaxial instability combined with subaxial cervical spinal cord injury (CSCI), and to analyze the feasibility, indication and therapeutic effects of anterior-posterior approach in such cases.Methods: From March 2004 to September 2009, 16cases with this trauma were admitted and surgically treated in our department. Before surgery, skull traction was performed. Posterior atlantoaxial pedicle screw internal fixation and bone graft fusion were conducted to manage traumatic atlantoaxial instability. As for subaxial CSCI, anterior cervical corpectomy or discectomy decompression, bone grafting and internal fixation with steel plates were applied.Results: All operations were successful. The average operation time was 3 hours and operative blood loss 400 ml. Satisfactory reduction of both the upper and lower cervical spine and complete decompression were achieved. All patients were followed up for 12 to 36 months. Their clinical symptoms were improved by various levels. The Japanese Orthopaedic Association (JOA) scores ranged from 10to 16 one year postoperatively, 13.95±2.06 on average (improvement rate= 70.10% ). X-rays, spiral CT and MRI confirmed normal cervical alignments, complete decompression and fine implants' position. There was no breakage or loosening of screws, nor exodus of titanium mesh or implanted bone blocks. The grafted bone achieved fusion 3-6 months postoperatively and no atlantoaxial instability was observed.Conclusions: Traumatic atlantoaxial instability may combine with subaxial CSCI, misdiagnosis of which should be especially alerted and avoided. For severe cases, one stage anterior-posterior approach to decompress the upper and lower cervical spine, together with reposition, bone grafting and fusion, as well as internal fixation can immediately restore the normal alignments and stability of the cervical spine and effectively improve the spinal nervous function, thus being an ideal approach.     

股前外侧肌皮瓣修复足踝侧方组织缺损

目的 探讨总结应用股前外侧肌皮瓣修复足踝侧方软组织合并内、外踝组织缺损中重建踝关节稳定性的疗效与作用.方法 对13例因足踝侧方软组织合并内、外踝组织缺损伤病例应用股前外侧肌皮瓣修复,将组织瓣中的阔筋膜两侧部分折叠与受区相邻软组织间断缝合固定,旋股外侧血管降支与受区血管吻合,移植股前外侧肌皮瓣面积最大为20 cm×12 cm,术后3个月石膏继续固定维持踝关节于功能位.随访时间1.5至20年.从患者主观感受、临床症状与体征和影像学检查评估踝关节稳定情况.结果 术后早期3个月内踝关节稳定性仍需外固定维持扶助,半年后即可稳定.13例中获得5年以上随访10例、10年以上6例、15年以上3例(分别为15年、18年、20年).5年后均有影像学踝关节创伤性改变,但临床症状与之不完全呈现相关性,13例中目前尚无1例因功能受限需行关节融合术.结论 股前外侧肌皮瓣是修复足踝侧方软组织合并内、外踝组织缺损重建并维持踝骨关节稳定、避免早期关节融合,特别对青少年伤者是一种良好选择.

Abstract：

Objective To explore the long-time clinical results and effection of free anterolateral thigh musculocutaneous flap for repairing the complex defects involving lateral or medial malleolar of the ankle and heel,especially for reconstructing stability of the ankle joints. Methods Thirteen patients with complex tissue defects,involving lateral or medial malleolar of the ankle and heel,were treated by free anterolateral thigh fasciomusculocutaneous flap.The fascia lata which was involved in the flap was fixed with the adjacent tissue of the recipient area.The descending branches of the lateral circumflex femoral vessels were anastomosed with the vessels in the recipient area.The largest area of the flap was 20 cm × 12 cm.The ankle joint was fixed in functional position with plaster in the early 3 months post-operatively.The following time ranged from 1.5 years to 20 years.The stability of the ankle joint were evatuated with the patients' objective feeling and clinical symptoms and imaging study.Results The stability of the ankle should be protected by external fixation in the early 3 months postoperatively,and was restored at 6 months usually.In all cases,ten cases were followed over 10 years,six cases were followed over 6 years,three cases were followed over 15 years.Though radiological discovering suggesting traumatic esteoarthritis exited in 3 cases with a follow-up more than 5 years,the clinical manifestations were fair and no one need undergo arthredesis. Conclusion Using ant erolateral thigh musculocutaneous flap for reconstructing the complex defects involving lateral or medial malleolar of the ankle and heel repairing stability of the joint and ovoiding off early arthrodosis of the joint is one of the favorable choice,especially for the teen-agers.     

Pedicle screw fixation with translaminar facet joint screws for the treatment of thoracolumbar fracture

Objective:To evaluate the efficacy of Cotrel-Dubeusset (CD) instrumentation combined with translaminar facet joint screw ( TLS ) in the treatment of thoracolumbar fracture. Methods: A total of six L2-L4 spines were used to establish unstable fracture model with three-dimensional range of motion ( ROM ) of the spines measured. Fixation with CD and fixation with CD combined with translaminar facet joint screw were achieved to compare their stability. Thirty cases of thoracolumbar fracture, in whom the anterior edge of vertebral body was compressed to 59% and the posterior edge compressed to 88%, were treated by pedicle screw fixation combined with TLS. Among them, 19 received posterolateral or anterior-posterior bone grafting Results- There was significant difference in ROM between the two techniques except that in extension. In Group CD TLS, ROM was 5.38% lower, lateral bending 4.91% lower and axial rotation 11.85 % lower than those in Group CD respectively. In the clinical group, the average anterior edge restored to 97 % and posterior edge to 98%. The duration of follow-up was 5-24 months (mean, 10 months). The rate of correction loss on the anterior edge was 4.5%. Among the 19 cases of bone grafting, all of them achieved bony fusion (mean fusion time, 4.3 month) with a correction loss rate of 3.4%. Conclusions:In the treatment of thoracolumbar fracture, pedicle screw fixation combined with TLS can strengthen the stability of pedicle screws, especially antirotation stability and enhance fusion rate and reduce correction loss.     

腓骨头复合组织瓣修复儿童内踝骨皮肤缺损四例

Objective To investigate the therapeutic effect of fibular head composite flap for bone and skin defect at medial malleolus in children. Methods From Aug. 2005 to Apr. 2009, 4 children cases(2 male, 2 famale, from 3 to 11 year) with bone and skin defect at medial malleolus were reconstructed with fibular head composite flaps pedicled with lateral inferior genicular vascular bundle. The skin defect was 3- 6 cm × 8-10 cm in size. Results All the 4 compostie flaps survived completely. The patients were followed up for 4 months to 4 years with good bony healing. Both esthetic and functional results were satisfactory in ankle joint. Conclusions The fibular head composite tissue flap has a good therapeutic effect for bone and skin defect at medial malleolus in children.     

腓骨头复合组织瓣修复儿童内踝骨皮肤缺损四例

Objective To investigate the therapeutic effect of fibular head composite flap for bone and skin defect at medial malleolus in children. Methods From Aug. 2005 to Apr. 2009, 4 children cases(2 male, 2 famale, from 3 to 11 year) with bone and skin defect at medial malleolus were reconstructed with fibular head composite flaps pedicled with lateral inferior genicular vascular bundle. The skin defect was 3- 6 cm × 8-10 cm in size. Results All the 4 compostie flaps survived completely. The patients were followed up for 4 months to 4 years with good bony healing. Both esthetic and functional results were satisfactory in ankle joint. Conclusions The fibular head composite tissue flap has a good therapeutic effect for bone and skin defect at medial malleolus in children.     

游离肌皮瓣移植治疗难治性小腿和足部创伤后骨髓炎

Objective To evaluate the efficiency of free myocutaneous flap transfer for the treatment of refractory post-traumatic osteomyelitis of the lower leg and foot. Methods Eleven patients with refractory post-traumatic osteomyelitis of the lower legs and feet were treated between February 2004 and December 2007. There were 9 males and 2 females. The average age was 3.5 years. All patients had at least four to five unsuccessful surgical procedures and prolonged antibiotic treatment prior to presentation. The mean duration of osteomyelitis was 26 months (12-47 months). According to the Ciemy-Mader classification, there were 3 cases for ⅢA, 2 for ⅢBL, 4 for ⅥA and 2 for ⅥBL. After radical debridement, free myocutaneous flaps were immediately performed. Nine latissimus dorsi and 2 rectus abdominis myocutaneous flaps were used.External fixation was applied in 6 patients with skeletal instability due to tibial defects. Results An average follow-up was 3.5 years. Two cases suffered partial necrosis and were managed successfully with split-thickness skin grafts later. In 4 patients of presenting segmental bone defect, autogenous bone grafting was applied in one patient and achieved consolidation after 5 months; bone transplantation in 2 patients and achieved consolidation after 8 and 10 months; and vascularized fibula graft in one patient in whom the gap of the tibia was about 10 cm and achieved consolidation after 4 months. The other 7 patients of this group achieved bone consolidation without bone graft. Conclusion The cornerstone of the treatment of chronic osteomyelitis was to be the radical debridement of all involved necrotic and infected soft tissue and bone.The free myocutaneous flaps transfer which has the advantage of obliteration of dead space and stable coverage of the defect was a safe and viable treatment option in chronic osteomyelitis of the lower leg and foot.     

Treatment of Gustilo grade Ⅲ leg fractures by external fixation associated with limited internal fixation

Objective： To explore the clinical effects of external fixation associated with limited internal fixation on treatment of Gustilo grade Ⅲ leg fractures. Methods： From July 2006 to December 2008, 40 cases of Gustilo grade Ⅲ leg fractures were emergently treated in our unit with external fixation frames. Soft tissue injuries were grouped according to the Gustilo classification as ⅢA in 17 cases, ⅢB in 13 cases, and ⅢC in 10 cases. All the patients were debrided within 8 hours, and then fracture reposition was preformed to reestablish the leg alignment. Limited internal fixation with plates and screws were performed on all the Gustilo IliA cases and 10 Gustilo ⅢB cases at the first operation. But all the Gustilo ⅢC cases and 3 Gustilo ⅢB cases who had severe soft tissue injuries and bone loss only received Vacuum-sealing drainage （VSD）. Broad-spectrum antibiotics were regularly used and VSD must be especially maintained easy and smooth for one week or more after operation. Limited internal fixation and transplanted free skin flaps or adjacent musculocutaneous flaps were not used to close wounds until the conditions of the wounds had been improved. Results： The first operations were completed within 90-210 minutes （170 minutes on average）. The blood trans- fusions were from 400 ml to 1500 ml （those used for antishock preoperatively not included）. All the 40 patients in this study were followed up for 6-28 months, 20.5 months on average. The lower limb function was evaluated according to the comprehensive evaluation standards of leg function one year after operation and the results of 28 cases were excellent, 9 were good and 3 were poor. Conclusion： External fixation associated with limited internal fixation to treat Gustilo grade Ⅲ leg fractures can get satisfactory early clinical therapeutic effects.     

Arthrodèse talocrurale. Technique opératoire et retentissement sur les articulations sous-jacentes. À propos de 11 cas

The aim of our work was to evaluate our tibiotalar arthrodesis technique and its effects on distal joints in treating ankle arthrosis secondary to a neglected injury or septic arthritis. From January 1996 to June 1999, we performed 26 tibiotalar arthrodeses. The inclusion criteria were arthrosis caused by a neglected injury or sequelae of osteoarthritis, a complete clinical and radiological evaluation, a normal subtalar joint, internal fixation by X cancellous bone screws and follow-up greater than six months. The series presented 11 cases (7 men and 4 women). The average age was 46. The average follow-up was 21 months (6 to 54 months). Using an anterior approach to the ankle, our arthrodesis technique consisted of joint surface resection and fixation by X cancellous bone screws. We maintained the ankle in neutral position. A plaster cast was applied for 12 weeks, with weight bearing allowed at week 10. Our patients were clinically evaluated according to the Duquennoy scoring system, the radiological determination of bone fusion and the appearance of the subtalar joint. The outcomes were good in 81.8% of the cases, with fusion in 9 cases obtained over on average period of 12.4 weeks. Two cases of pseudarthrodesis were observed. Posterior subtalar arthrosis occurred in 45.4% of the cases after an average of 12 months. Tibiotalar arthrodesis is a safe alternative for the treatment of neglected injuries and septic arthritis of the ankle after the occurrence of subtalar arthrosis in the long-term.     

Percutaneous arthrodesis

It has been generally accepted that residual cartilage and subchondral bone has to be removed in order to get bony fusion in arthrodeses. In 1998 we reported successful fusion of 11 rheumatoid ankles, all treated with percutaneous fixation only. In at least one of these ankle joint there was cartilage left. This was confirmed by arthrotomy in order to remove an osteophyte, which hindered dorsiflexion. More than 25 rheumatoid patients with functional alignment in the ankle joint have subsequently been operated on with the percutaneous technique, and so far we have had only one failure. Patients with rheumatoid arthritis are known to sometimes fuse at least their subtalar joints spontaneously, and the destructive effect of the synovitis on the cartilage could contribute to fusion when using the percutaneous technique. In a rabbit study we therefore tested the hypothesis that even a normal joint can fuse merely by percutaneous fixation. The patella was fixated to the femur with lag screw technique without removal of cartilage, and in 5 of 6 arthrodeses with stable fixation bony fusion followed. Depletion of synovial fluid seemed to be the mechanism behind cartilage disappearance. The stability of the fixation achieved at arthrodesis surgery is an important factor in determining success or failure. Dowel arthrodesis without additional fixation proved to be deleterious. A good fit of the bone surfaces appears necessary. In the ankle joint, it would be technically demanding to retain the arch-shaped geometry of the joint after resection of the cartilage. Normally the joint surfaces are resected to produce flat osteotomy surfaces that are thus easier to fit together, encouraging healing to occur. On the other hand it is considered an advantage to preserve as much subchondral bone as possible, as the strong subchondral bone plate can contribute to the stability of the arthrodesis. Ankle arthrodesis can be successfully performed in patients with rheumatoid arthritis by percutaneous screw fixation without resection of the joint surfaces. This procedure has two advantages: first, it is less surgically traumatic, second, both the arch-shaped geometry and the subchondral bone are preserved, and thus both could contribute to the postoperative stability of the construct. Intuitively, preservation of the arch-shape should increase rotational stability. The results of our experimental sawbone study indicate that the arch shape and the subchondral bone should be preserved when ankle arthrodesis is performed. The importance of this is likely to increase in weak rheumatoid bone. In a finite element study the initial stability provided by two different methods of joint preparation and different screw configurations in ankle arthrodesis, was compared. Better initial stability is predicted for ankle arthrodesis when joint contours are preserved rather than resected. Overall, inserting the two screws at a 30-degree angle with respect to the long axis of the tibia and crossing them above the fusion site improved stability for both joint preparation techniques. The question rose as to whether patients with osteoarthritis could also be operated on solely by percutaneous fixation technique. The first metatarsophalangeal joint in patients with hallux rigidus was chosen as an appropriate joint to test the percutaneous technique. In this small series we have shown that it is possible to achieve bony fusion with a percutaneous technique in an osteoarthrotic joint in humans, but failed to say anything about the fusion rate.     

寰枢椎不稳的颈后路手术治疗

目的 对寰枢椎不稳的颈后路手术治疗进行探讨。方法 共78例患者,男57例,女21例;年龄3－78岁,平均42岁。其中齿突骨折（新鲜骨折、陈旧骨折、骨不连）38例,齿突游离小骨15例,寰椎横韧带断裂8例,寰枢椎肿瘤6例,枕颈部发育畸形6例,寰椎椎弓陈旧性骨折5例。78例均行颈后路手术,包括枕颈融合术32例,其中单纯植骨融合11例,辅以CD－Cervical内固定11例,Cervifix内固定10例;寰枢椎融合术46例,其中钢丝钛缆内固定37例（9例同时行寰枢椎经关节间隙螺钉内固定术）,Apofix椎板夹内固定9例。结果 78例均获随访,时间6个月－18年,平均38．4个月。骨性愈合75例,不愈合3例。术前合并神经系统症状38例,术后症状消失或基本消失20例,明显改善11例,轻度改善3例,无改善2例,加重2例。结论 对于由寰枢椎骨折脱位、畸形、肿瘤及横韧带断裂等引起的寰枢椎不稳,应早期进行后路融合术。充分控制寰枢椎活动,精心准备植骨床是保证手术成功的关键。     

Management of failed total ankle replacement with a retrograde short femoral nail: a case report

Arthrodesis of the ankle joint after failed total ankle replacement using internal fixation with plates and screws is problematic because of the significant bone loss. An external fixator has the disadvantage of prolonged treatment until complete consolidation, frequently complicated by pin track infections. Recently an intramedullary fixation has been described for tibio-talo-calcaneal arthrodesis for posttraumatic osteoarthritis of the ankle joint. We report on the use of this technique plus bone graft in a case of failed total ankle replacement complicated by cystic talus degeneration and a massive bony defect. The advantages include early mobilization and weightbearing provided by the stability of the fixation.     

Technic and results of covered ankle joint arthrodesis with autocompression angle plates

In 1973, Mittelmeier introduced a new technique of arthrodesis of the ankle joint by internal osteosynthesis using an autocompression plate with additional compression screwing of fibula to tibia and talus in order to avoid the disadvantages of previous operative methods of arthrodesis by bone splinting or external fixation (longer cast immobilisation, handicap by external fixator, danger of bone hole osteomyelitis a.o.). Regarding this new technique, the fibula works as a petiolated well vascular bone chip which bridges the joint. Representation of the special operative technique of covered autocompression arthrodesis of the upper ankle joint rsp. - in case of special indication - the combined arthrodesis of the upper and lower ankle joint. Representation of our casuistry of 43 patients who underwent this operation. With the exception of one case (osteomyelitis recidivation with following pseudarthrosis) a fast bony consolidation of the arthrodesis was achieved. In the meantime the osteosynthesis material is removed in 35 cases. One third of the patients gets along with conventional shoes.     

Implantable Electrical Bone Stimulation for Arthrodeses of the Foot and Ankle in High-Risk Patients: A Multicenter Study

This study assessed arthrodesis procedures performed in the foot and ankle of high-risk patients following implantation of an internal electrical bone stimulator. Criteria defining patients as "high risk" included diabetes, obesity, habitual tobacco and/or alcohol use, immunosuppressive therapy, and previous history of nonunion. Standard arthrodesis protocol of bone graft and internal fixation was supplemented with the implantable electrical bone stimulator. A retrospective, multicenter review was conducted of 26 patients (28 cases) who underwent 28 forefoot and hindfoot arthrodeses from 1998 to 2002. Complete fusion was defined as bony trabeculation across the joint, lack of motion across the joint, maintenance of hardware/fixation, and absence of radiographic signs of nonunion or pseudoarthrosis. Radiographic consolidation was achieved in 24 of the 28 cases at an average 10.3+/-4.0 weeks. Followup averaged 27.2 months. Complications included 2 patients who sustained breakage of the cables to the bone stimulator. Five patients underwent additional surgery. Four of the 5 patients had additional surgery in order to achieve arthrodesis. All 4 went on to subsequent arthrodesis. This study demonstrates how arthrodesis of the foot and ankle may be enhanced by the use of implantable electrical bone stimulation.     

颈后路手术治疗上位颈椎不稳定型损伤

目的:探讨上颈椎不稳定损伤后路手术方法及其疗效。方法:59例中,采用枕颈融合术27例,其中辅以CD-Cervical或Cervifix内固定11例;实施寰枢椎融合术29例,其中7例行C1/2侧块关节螺钉固定,8例行Apofix椎板夹固定;进行C_(2、3)椎板、棘突间植骨Axis内固定3例,均为Hangman氏骨折。结果:51例获随访,平均3.5年。骨性愈合47例,不愈合4例。术前合并神经系统症状29例,术后症状消失和明显改善共22例,加重1例。结论:对于上颈椎不稳定型损伤应早期进行植骨内固定,认真准备植骨床和可靠的内固定是保证手术成功的关键。     

Arthrodesis with external fixation in the unstable or misaligned Charcot ankle in patients with diabetes mellitus

The unstable or misaligned Charcot ankle with or without chronic foot ulceration is a major clinical challenge. When it cannot be accommodated with an ankle foot orthosis, surgical treatment is indicated in order to avoid leg amputation. This requires extensive soft tissue release and bony resection to realign the foot and arthrodesis with internal or external fixation. The guidance in the literature favors internal fixation. This article reports results with external fixation in 11 patients (12 feet) over a period of 12 years. External fixation was chosen as the surgical option because of the presence of foot ulcers with the attendent risk of infection. There were 7 tibio-talar and 5 tibio-calcaneal fusions. Compression was applied for 6 weeks with an external frame according to Charnley, followed by 6 weeks with total-contact cast. Weight bearing with a rigid leather brace was allowed after 12 weeks. In one case, transtibial amputation was required due to loosening of the distal pins from osteopenic disintegrating bone. In 11 cases (92%), the foot was successfully realigned and independent walking with a brace retained during the follow-up of median 48 months (10-102 months). Bony union took place in 5 out of 7 cases with tibio-talar fusion and in 1 out of 5 with tibio-calcaneal fusion. The functional result in cases with fibrous union was, however, satisfactory. Although meaningful comparisons of series are difficult to conduct and interpret from, the limb salvage rate was similar to results with internal fixation. The authors consider the results to be encouraging and to be used to develop a higher level of evidence.     

Ankle arthrodesis using Ilizarov ring fixators: a review of 22 cases

BACKGROUND: Orthopaedic surgeons are being increasingly confronted with complex ankle problems that cannot be reliably treated by conventional arthrodesis procedures. The Ilizarov technique can be an alternative salvage method in such cases. METHODS: Twenty-two Ilizarov tibiotalar arthrodeses were retrospectively reviewed. There were 16 men and six women (mean age 49 years). The underlying pathology was infection after internal fixation of ankle or plafond fractures in 16 patients, posttraumatic ankle arthritis in five, and septic arthritis after an infected Achilles tendon repair in one. Five patients had at least one failed previous arthrodesis. Primary iliac crest bone grafting was done in two patients. Proximal tibial lengthening was done in six patients. RESULTS: Twenty-one patients were followed for an average of 29 months. A solid fusion was achieved in all patients by the end of treatment. The external fixation time averaged 27.7 (range 12 to 84) weeks. The mean time spent in a foot frame was 22.3 weeks. Complications occurred in 11 patients, including two nonunions that healed after revision and renewed frame application and four pin track infections. CONCLUSIONS: The use of the Ilizarov frame provides a successful salvage method that offers solid bony fusion, optimal leg length, and eradication of infection in complex ankle pathology or failed previous arthrodesis.     

经椎板关节突螺钉固定治疗下腰椎不稳

目的探讨关节突螺钉固定在下腰椎退行性不稳定患者手术中应用的临床效果。方法对19例退行性腰椎不稳患者采用后路椎板开窗减压，椎间植骨融合，经椎板关节突螺钉固定。结果19例随访6—36个月（平均21个月），椎间植骨融合率6个月时为86％，1年时为93％，临床症状消失，满意率92％。未出现断钉。结论采用后路椎板减压，经椎板关节突螺钉固定加椎间植骨能提高椎间融合率，使小关节稳定，解除临床症状。