Total Talar Prosthesis Replacement after Talar Extrusion

Dislocation of the talus is a serious and extremely rare injury, with 86 cases reported in the published data in 20 years. The reference standard for case management involves replacement of the dislocated talus to restore the height and function of the tibiotalar joint. The risk of avascular necrosis remains very high, and the standard treatment in such cases is tibiotalar arthrodesis. We report the case of total dislocation of the talus, which was treated with the insertion of a custom total talar prosthesis affixed directly to the tibial cartilage at 6 months after injury. At the 2-year follow-up point, the preliminary results were rather encouraging, with well-functioning activity and an improved American Orthopaedic Foot and Ankle Society foot function scale score increasing from 11 to 77 of 100 and a Short-Form 36-item Health Survey score increasing from 17 to 82. Much longer follow-up periods are necessary to evaluate longer term trends.     

距骨颈骨折疗效分析

目的分析距骨颈骨折的特点、治疗及并发症。方法采用保守和手术方法治疗距骨颈骨折患者50例。Hawk ins分型:Ⅰ型8例,采用保守治疗;Ⅱ型32例、Ⅲ型10例,采用手术治疗。结果46例随访7个月~5年,平均3.2年。按Hawk ins疗效标准:优14例,良26例,可4例,差2例;优良率86.9%。术后发生距骨坏死6例,距下关节炎5例,踝部皮肤坏死2例,伤口感染5例。结论距骨颈骨折宜早期解剖复位固定。手术力求简单,应首先解决关节脱位,再进行骨折的复位和内固定。     

Complete Talar Dislocation Without Late Osteonecrosis: Clinical Case and Anatomic Study

Avascular necrosis is a well-known, severe complication postfracture or subluxation of the talus. Type and localization of injury often permit conclusions regarding the probability of bone necrosis. In the following case, talar neovascularization was demonstrated after severe trauma, resulting in an open pilon fracture of the right tibia and complete talar dislocation with consequent destruction of the most relevant blood supply. This example shows that even after apparently irreversible injury to the arterial circulation, immediate bony reconstruction with comprehensive soft tissue management is indicated and can lead to bony healing. The anatomy of intraosseus vascularization is reviewed and discussed.     

距骨尾部骨折及临床意义

通过距骨X线片及标本的观察 ,以证实距骨确有头颈体尾四部分 ,距骨后突骨折实际是距骨尾骨折。对 84 8张踝关节侧位片及 2 0 0例成人干燥距骨标本进行观察与测量。距骨从整体看形似乌龟 ,97%的距骨有距骨尾 ,其尾有长、中、短之分 ,其中距骨尾骨折 52例 ,占 6 8%。认为距骨应分为头、颈、体、尾四部分 ,对距骨尾部骨折手术切除是治疗的关键。这既符合解剖学上命名的完整性 ,又对临床诊断与治疗具有一定的指导意义     

Surgical Technique of Total Knee Arthroplasty without Soft Tissue Balance

Total knee arthroplasty (TKA) without soft tissue balance can create a balanced knee to a mechanical axis of near neutral with bone cuts, and remove osteophytes thoroughly. In this study, the authors present detailed steps for performing TKA. The attached video demonstrates the TKA procedure. The patient is a 77‐year‐old man who had suffered from knee pain for 12 years. Physical examination showed the Apley test to be positive and that the range of motion (ROM) decreased. An X‐ray filmed at the positive lateral of the knee joint and the double lower extremity revealed a progression of degenerative osteoarthritis with genu varum. The key point of no soft tissue release is to make a rectangular extensional space by osteotomy. In addition, the osteophytes, especially syndesmophytes, should be removed thoroughly. As a result, the ligaments can achieve ideal length and the flexion contracture can also be remedied. Moreover, in surgeries without soft tissue release, bone mass and normal tissue are retained. Patients are satisfied to the surgery not only with less blood loss, anterior knee pain and DVT, but also faster rehabilitation. In summary, TKA without soft tissue balance is an efficient procedure for patients with knee osteoarthritis which can result in good prognosis.     

Concomitant Talar Neck Fracture and Achilles Tendon Rupture

A 56-year-old man fell down 1 m from a ladder and sustained a forced dorsiflexion injury to his right ankle when his foot contacted a lower rung, which resulted in the rare combination of a Hawkins II fracture of the neck of the talus and a concomitant rupture of the Achilles tendon. Clinical examination and diagnostic imaging confirmed the injuries, and surgical fixation of the fracture and repair of the Achilles tendon were achieved by means of a posterior approach. Healing proceeded unremarkably, and, at 18 months postoperatively, the patient had regained full function despite a 5 degrees limitation of subtalar joint range of motion.     

环锯切骨融合距舟关节治疗距舟关节疼痛

 
目的 评价环锯切骨融合距舟关节治疗距舟关节疼痛的临床效果及对邻近关节的影响。
方法 1999年6月至2009年6月,对应用环锯切骨融合距舟关节治疗距舟关节疼痛的24例资料完整患者进行回顾性分析,男13例,女11例;年龄37～72岁,平均45岁;创伤后距舟关节炎15例,风湿性关节炎6例,退变性关节炎3例。应用美国足踝关节协会（AOFAS）踝-后足评分、视觉模拟评分（visual analogue scale,VAS）、Graves评分对患足功能、疼痛及对周围关节的影响进行评价。
结果 24例患者均获得随访,随访时间10～120个月,平均48个月。术后1例患者出现足部刀口皮肤边缘坏死,经换药延迟拆线3周愈合。AOFAS评分从术前平均45.2分提高至术后平均84.5分,术后优良率为87.5%;VAS疼痛评分从术前8.1分下降至术后2.4分。患者主观在疼痛感受、外观变化、行走距离、穿鞋体验方面均有改善。23例患者对手术效果表示满意,仅有1例患者不满意。术后6个月影像学检查显示23例完全融合（成功率95.8%）,1例未融合患者使用大一号环锯经取髂骨骨柱回植融合。Graves评分显示1度改变8例,2度改变1例。
结论 环锯切骨融合距舟关节创伤小、融合效果满意,对治疗单纯性距舟关节疼痛性病变可取得满意的临床效果。     

Arthroscopically Assisted Transfibular Talar Dome Fixation With a Headless Screw

We describe an articular talar dome fracture treated with the use of an arthroscopically assisted placement of a transfibular Acutrak screw (Accumed, Hillsboro, OR). This minimally invasive technique can be used to avoid the large incision used in the traditional open reduction and internal fixation of these fractures. Accurate reduction and stable fixation of fractures of the articular surface of the talus is a must, and this technique allows this while avoiding the morbidity of the open approach.     

Arthroscopically Assisted Anterior Treatment of Symptomatic Large Talar Bone Cyst

Symptomatic cystic lesions of the talus are rare. The traditional operations usually do not provide visualization to reveal the deep structure of the lesion and could cause cartilage damage or other severe traumatic injury. We report an operative technique to reach the cystic lesion without talar cartilage damage, remove the lesion, and fill defect with a bone graft assisted by anterior arthroscopy and evaluate its safety and reliability for future study. Seven cases of talar bone cyst were included. The patients were placed in the supine position after anesthesia induction and noninvasive ankle traction was applied. Standard anteromedial and anterolateral portals were established to observe the ankle; the distal end of the medial approach was moderately enlarged to 2 to 3 cm. The biopsy specimen of the cyst was obtained under arthroscopic guidance; the cyst wall was abraded and the sclerotic rim drilled. Arthrocare radiofrequency ablation was performed to prevent recurrence. The defect was tightly impacted with autologous or allograft cancellous bone. All cysts in these cases were located in the medial talus; anteroposterior radiographs and computed tomographic coronary scan showed a cyst diameter of >1?cm. Intraoperative inspection showed a tiny chondral gap on the talar dome in 1 case and on the medial wall of talus in 1 case; no cartilage injury was found in the remainder. Two cases were impacted with grafted autogenous iliac bone into the talar defect and 5 cases with allograft cancellous bone. Computed tomography confirmed that the cysts had healed, with no signs of recurrence found in any patient at 1 year postoperatively. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score increased from 65 preoperatively to 91 points postoperatively, a statistically significant difference (p?<?.01). No complications developed and no reoperations were required postoperatively. Arthroscopically assisted anterior treatment with autologous or allograft bone graft is an effective method for symptomatic large talar bone cysts.     

距骨体剪力骨折和粉碎骨折的治疗分析

目的:研究距骨体骨折的治疗方法和临床疗效。方法:自1988年10月至2005年9月,采用石膏外固定、切开复位内固定、胫-距-跟关节融合术治疗34例距骨体剪力骨折和粉碎骨折。男19例,女15例,年龄13～55岁,平均28.8岁。伤后至治疗时间3～14d,平均6d。石膏外固定10例,切开复位内固定18例,Ⅰ期Blair胫-距-跟融合术6例。采用Hawkins评分标准,从疼痛、关节活动度和跛行等方面来评定疗效。结果:34例均获得随访,时间3～19年,平均5.04年。术后患者伤口均愈合良好。按Hawkins评分标准:优6例,良9例,可11例,差8例。距骨缺血性坏死15例,踝关节炎18例,距下关节炎14例。结论:移位小于3mm骨折宜石膏外固定,手法复位后骨折移位大于3mm应切开复位内固定,关节面不能修复的粉碎骨折宜采用Blair胫-距-跟融合术。距骨体剪力骨折和粉碎骨折预后差。