Modified Brostrom-Evans-Gould technique for recurrent lateral ankle ligament instability

PURPOSE: To review the outcome of the modified Brostrom-Evans-Gould technique in patients with chronic lateral ankle ligament instability. METHODS: Between August 2003 and June 2005, 20 men aged 19 to 35 (mean, 23) years with chronic lateral instability affecting 21 ankles, underwent the modified Brostrom-Evans-Gould technique by a single surgeon. The mean follow-up period was 12 (range, 6-20) months. Patients were assessed preoperatively and postoperatively using the Kaikkonen Ankle Scoring Scale. RESULTS: Preoperatively, all patients had poor scores (<50). Postoperatively, 17 (81%) of the ankles attained excellent scores (85-100) and 4 (19%) attained good scores (70-84). CONCLUSION: The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability, particularly in the Asian population with a higher prevalence of generalised joint hyperlaxity.     

Reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft

Thirty-one consecutive ankles in 30 patients with chronic lateral ankle instability were reconstructed using a split peroneus brevis tendon graft. All patients had pain and instability despite adequate treatment and a rehabilitation program. Six patients had clinical and radiographic evidence of associated subtalar laxity. Four patients (four ankles) had prior Brostrom ligament reconstructions. The average time from the initial injury or treatment to surgery was 23 months. At a mean follow-up of 44 months (range, 24-64 months), the functional results included excellent in 20 ankles, good in 9, fair in 1, and poor in 1. Ankle stability, which did not deteriorate with time, was achieved in 30 of 31 ankles. This procedure is simple, safe, and reliable with a 94% good to excellent clinical result and 97% mechanical stability. It is an excellent reconstruction choice for those individuals with high demand ankles, with a longstanding ankle instability with or without subtalar instability, and for failed primary reconstruction.     

负压封闭引流在开放性足踝部骨折脱位中的应用

目的:探讨负压封闭引流(vacuum sealing drainage,VSD)技术治疗足踝部外伤后软组织缺损伴肌腱与骨外露的疗效。方法:2007年10月至2011年2月对397例(412足)开放性足踝部骨折、脱位伴软组织缺损患者采用VSD技术治疗。其中男301例,女96例;年龄20～73岁,平均36岁。按AO软组织损伤分型:Ⅰ型74足,Ⅱ型211足,Ⅲ型108足,Ⅳ型19足。受伤至手术时间2～12h,平均5.6h,平均治疗时间10个月(4～19个月)。结果:141例创面Ⅰ期愈合,97例Ⅱ期缝合;103例行Ⅱ期全厚皮片植皮术,25例行游离皮瓣转移术。术后感染34例,因感染拆除钢板3例。14例因第1跖骨外露,行剔骨皮瓣覆盖创面。22例因足趾坏死截趾术,10例前足坏死行跖附关节离断术。术后创面渗血3例。306例患者均获得随访,平均随访时间为10个月(3～20个月),创面愈合良好。结论:VSD技术治疗足踝部外伤后软组织缺损是简单、安全有效的方法,但不能代替清创和皮瓣转移。     

关节镜下自体半腱肌肌腱解剖重建踝关节外侧副韧带

目的 探讨关节镜下自体半腱肌肌腱重建踝关节外侧副韧带治疗慢性踝关节不稳定的方法及初期临床疗效。方法 将2015年12月至2017年2月我院收治的16例慢性踝关节不稳定病人纳入研究,其中男14例,女2例,年龄为（28.1±6.4）岁;术前应力位X线片提示距骨倾斜25.5°±5.5°（18°~35°）,距骨前移（10.1±1.8） mm（7~14 mm）。采用2.7 mm 30°短踝关节镜经前外侧入路观察,经前外侧辅助入路于腓骨远端和距骨外侧面距腓前韧带足印区制作骨隧道,跟骨外侧壁跟腓韧带止点处经皮透视制作骨隧道,取自体半腱肌肌腱对折编织成“Y”型,将移植物引入骨隧道,腓骨端使用袢钢板悬吊固定,距骨及跟骨端使用5.0 mm界面螺钉固定。术后早期功能锻炼,末次随访应用美国足踝外科医师协会（American Orthopedic Foot and Ankle Society, AOFAS）踝与后足功能评分系统评价踝关节功能;采用疼痛视觉模拟量表（visual analogue scale, VAS）评估疼痛情况;采用Sefton外侧副韧带重建疗效评价系统评估踝关节稳定性。结果 本组16例病人术后随访（16.8±4.3）个月（12~24个月）,均于术后3个月恢复正常体育活动,末次随访未观察到踝关节不稳定复发。AOFAS评分为（89.2±4.8）分,VAS评分为（0.7±0.6）分。依据Sefton评价标准：优9例,良5例,可2例,优良率为87.5%。结论 关节镜下自体半腱肌肌腱解剖重建踝关节外侧副韧带治疗慢性踝关节不稳定的近期疗效理想,并发症较少。     

踝关节外侧不稳的手术修复

目的探讨踝关节外侧不稳手术治疗的效果。方法自1994年6月至2007年7月采用Watson—Jones手术和改进的Chrisman—Snook手术治疗踝关节不稳24例（踝）,其中11例采用Watson—Jones手术,13例采用Chrisman—Snook手术。结果除8例失访外,余16例获平均5年9个月（2．5—9年）随访,踝关节功能采用踝关节稳定度（50分）、踝关节内翻试验（25分）和踝关节抽屉试验（25分）等来评价,疗效优（85～100分）14例,良2例（70—84分）,无失败（〈69分）。还比较了Watson—Jones法与改进的Chrisman—Snook法疗效。术前、术后稳定度、踝内翻试验和抽屉试验两组数据的统计学分析（P〈0．01）有显著意义。本组无并发症发生。结论踝关节外侧不稳采用Watson-Jones手术和改进的Chrisman—Snook手术修复踝关节外侧韧带有良好疗效。     

Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass.

PURPOSE: Many women with polycystic ovarian syndrome (PCOS) are overweight. This study investigated the impact of weight loss surgery on the clinical manifestations of this disorder in morbidly obese women with PCOS-a major risk factor for the development of heart disease, stroke, and type II diabetes. METHODS: We reviewed the outcomes of women diagnosed with PCOS who had undergone weight loss surgery at the University of Pittsburgh between July 1997 and November 2001. We evaluated the changes in menstrual cycles, hirsutism, infertility, and type II diabetes. RESULTS: A total of 24 women with PCOS were included in the study. Their mean age was 34 +/- 9.7 years. The mean preoperative body weight was 306 +/- 44 lb, with a body mass index of 50 +/- 7.5. All patients were oligomenorrheic. Of the 24 patients, 23 were hirsute. All women underwent elective laparoscopic gastric bypass surgery. The mean follow-up period was 27.5 +/- 16 months. The mean excess weight loss at 1 year of follow-up was 56.7% +/- 21.2%. All women resumed normal menstrual cycles after a mean of 3.4 +/- 2.1 months postoperatively. Of the 23 women with hirsutism, 12 (52%) had complete resolution at a mean follow-up of 8 +/- 2.3 months, 6 (25%) had moderate resolution at a mean of 21 +/- 18 months, and 3 had minimal resolution at 34 +/- 14 months. Two women reported no change in their hirsutism at 32 +/- 7 months. Five women were able to conceive after surgery without the use of clomiphene. CONCLUSION: Gastric bypass surgery and its consequent weight loss results in significant improvement of multiple clinical problems related to PCOS.     

Arthroscopic findings associated with the unstable ankle

Before lateral ankle stabilization, arthroscopic surgery was performed on 54 patients (55 ankles) with chronic ankle instability. All patient charts, x-rays, operative reports, and surgical videotapes were reviewed. A detailed questionnaire was answered by all patients. The study population included 31 males and 23 females, with a mean age of 31 years (range, 14-64 years). The right ankle was involved in 64% of cases. Average follow-up was 9.6 months. Arthroscopic surgery was performed using small joint instrumentation including 30 degrees and 70 degrees 2.7-mm arthroscopes and a 30 degrees 1.9-mm arthroscope. At surgery, 51 ankles (93%) had intra-articular abnormalities including loose bodies (12), synovitis (38), osteochondral lesions of the talus (9), ossicles (14), osteophytes (6), adhesions (8), and chondromalacia (12). The most common arthroscopic procedures were synovectomy, removal of loose bodies and ossicles, excision and drilling of osteochondral lesions, debridement of the lateral gutter, excision of osteophytes, and removal of adhesions and scar tissue. There was a 25% incidence of chondral injuries, which differs considerably from the results of Taga et al., who found chondral injuries in 95% of ankles with lateral instability. Overall, there were excellent or good results in 96% of ankles. The incidence of excellent results was lower in the worker's compensation patients because of a greater incidence of complaints of pain with activity. There was no correlation between the presence of osteochondral lesions or amount of talar tilt and results.     

Pulmonary function before and after anterior spinal surgery in adult idiopathic scoliosis.

BACKGROUND: Little is known about the long term effects of anterior spinal surgery on pulmonary function in adult patients with idiopathic scoliosis. A study was therefore undertaken of pulmonary function before and after anterior spinal surgery in this group of patients. METHODS: Fourteen patients (12 women) of mean age 26.5 years (range 17-50, 10 > or = 20 years) were studied. All 14 patients underwent thoracotomy and anterior arthrodesis, and five also underwent posterior arthrodesis. Scoliosis curves and lung volumes were measured preoperatively and at a mean follow up of 32 months (range 14-49) after surgery. RESULTS: At long term follow up after surgery the mean (SD) Cobb angle of the thoracic curve improved from 59 degrees (25 degrees) to 39 degrees (18 degrees), a correction of 31%. Despite this there was a fall in mean forced vital capacity (FVC) of 0.21 litres (95% confidence interval 0.04 to 0.38). In the patients who underwent anterior surgery without posterior surgery (n = 9) there was a fall in mean FVC of 0.31 litres (95% confidence interval 0.12 to 0.50); mean forced expiratory volume in one second and total lung capacity were also reduced and there was an increase in mean residual volume. CONCLUSIONS: Forced vital capacity is reduced at long term follow up in adult patients with idiopathic scoliosis who undergo anterior spinal surgery. The fall in FVC is small and is unlikely to be of clinical significance in patients with reasonable lung function in whom surgery is planned for prevention of curve progression or improvement of cosmetic appearance and pain. However, surgical intervention should not be undertaken in an attempt to improve pulmonary function.     

Endoprosthesis of the ankle joint. Indications and long-term results

The treatment of a post-traumatic, progressively more painful ankle joint causes increasing disablement. It might require alternatives to conventional surgery if a patient does not consent to ankle arthrodesis to alleviate the pain. Therefore, we report on a retrospective study of 10 patients (age 25-73 years at the time of surgery). All of them refused arthrodesis; thus 10 total ankle arthroplasties were performed between 1982 and 1989. 5 women and 5 men were treated who have been suffering from severe post-traumatic arthrosis for 3-46 years. Since performance of a single-axis arthroplasty (ICLH prosthesis) in each patient, the mean follow-up has been 4.6 years. One year after surgery, the results could be considered good or excellent in 9 of the 10 patients; only 1 person experienced local wound infection, which led to removal of the implant 4 months later and ultimately to arthrodesis. Two years later, 7 patients are eligible for follow-up because 1 underwent surgery in February 1989. Another patient experienced aseptic loosening after 18 months; he was admitted to our hospital for arthrodesis. Three years after endoprosthetic surgery, all except 1 woman with occasional pain and stiffness were found to have satisfactory results on follow-up. The relief of pain was gratifying in all patients, with ankle function well maintained (at least 0-0-30 degrees). At present, the prosthesis is still functional in 6 patients (surgery 1.5-8 years ago). They can go about their usual daily business without apparent pain and with appropriate function; 2 of them, however, show radiolucent lines on standard X-rays of the ankle, suggesting some loosening.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Syme amputation: success in elderly diabetic patients with palpable ankle pulses

The Syme amputation is an old operation that has been used during this century primarily as a means of treating traumatic injuries to the forefoot in military patients. In 1984 we made a deliberate attempt to perform the operation in a highly selective group of dysvascular patients with forefoot necrosis who happened to have a palpable posterior tibial pulse. We reviewed the charts of 26 patients who underwent a one-stage (3 patients) or two-stage (23 patients) Syme amputation. The mean age was 60 years, (range 32 to 74 years). There were 17 insulin-dependent diabetic patients, and 3 diet-controlled diabetic patients. Twenty-two patients (85%) had a palpable posterior tibial pulse before surgery. Fourteen patients (54%) underwent a preliminary Ray (4) or transmetatarsal (10) amputation to rid the forefoot of an active infection. Overall, 20 patients (77%) had successful Syme amputations. Nineteen of 22 patients (85%) with a palpable posterior tibial pulse had a successful amputation in contrast to one out of four patients (25%) who did not have a palpable pulse before surgery (p = 0.04). The mean follow-up of all patients was 23 months. The durability of the operation was demonstrated in finding that only one patient in 20 initially successful Syme amputations required revision to the below-knee level. The two-stage Syme amputation can be a very gratifying operation with success rates approaching 85%, even if offered to elderly diabetic patients. The single most important feature for success is to limit the operation to those patients with a palpable posterior tibial pulse before operation.     

Return to athletic activity after foot and ankle surgery: a preliminary report on select procedures.

One hundred thirty-eight "athletic" patients from the author's practice underwent retrospective review of their foot and ankle surgery that was performed from 1990 to 1997 to evaluate the time to return to activity. Athletes were defined as follows: professional, varsity college and high school, runners amassing more than 25 miles per week, or those involved in regular competition. No recreational athletes were included. Average follow-up for the group as a whole was 49.4 months, (range, 12-108 months). One hundred seventeen of the 138 patients were able to be contacted and/or had been evaluated by September 1998. One hundred thirteen patients considered their surgery a success. All but two patients were able to return to the desired level of performance. Twenty-three of the patients increased their activity level after surgery. Twenty-eight athletes underwent Achilles tendon-related surgery (average follow-up was 44.5 months). Runners undergoing peritenolyses had an average return to activity of 4.0 weeks (range, 3-6 weeks). Patients undergoing Achilles procedure involving bone resection had an average return to activity of 13.8 weeks (range, 10-20 weeks). Forty-four bunionectomy procedures were performed, including 31 first metatarsal osteotomies. The group's average follow-up was 52.9 months (range, 13-100 months), and average return to activity for the first metatarsal osteotomies was 8.9 weeks. There were 48 rearfoot procedures. Lateral ankle stabilization procedures returned to activity on an average of 10 weeks (range, 7-16 weeks), while excised ossicles (os tibiale externum, os trigonum) had an average return to activity of 9.1 weeks (range, 8-14 weeks). Seven neuroma patients (via dorsal approach) had a return to activity of 4.0 weeks (range, 2.5-6 weeks), sesamoidectomy 7.5 weeks (range, 4-10 weeks), and Valenti arthroplasty of 6.5 weeks (range, 4-12 weeks), respectively. There were minimal complications. Two patients in the Achilles surgery group required revision surgery. One patient with a bunionectomy had postoperative hallux limitus. Eight patients had symptomatic screws removed.     

V-Y slide of the common extensor origin for lateral elbow tendonopathy

Twenty-two patients (23 limbs) with chronic lateral elbow tendonopathy were examined retrospectively after surgical management. Thirteen men and 9 women with an average age of 43 years (range, 32-54 years) had a mean follow-up time of 41.2 months (range, 9-97 months). All patients underwent at least 6 months of nonsurgical treatment without favorable response. V-Y slide of the common extensor origin was done for all patients. Sixteen patients (17 elbows) were examined after surgery and 6 were interviewed by telephone. None of the patients had major complications or permanent loss of elbow motion. A pain rating scale of 1 to 10 (10 being the worst) showed a difference from a rating of 9.0 (range, 7-10) before surgery to 1.4 (range, 0-4) after surgery. Grip strength increased from 57 lb (range, 5-125 lb) to 99 lb (range, 60-135 lb). Five patients (23%) reported some degree of cold intolerance. Twenty-one patients (95%) returned to their preoperative occupation with 1 patient not returning to work because of elbow pain caused by heavy and repetitive elbow stress especially from vibrating tools. Twenty-one patients (95%) reported no limitations in daily activities; 1 patient reported difficulty with opening jars. Seven people (32%) reported limitations in high-demand recreational activities. All patients were rated as poor before surgery and excellent or good after surgery by a grading scale. All patients were satisfied with the outcome of surgery. After surgical treatment for lateral elbow tendonopathy, pain relief and restoration of elbow function can be achieved. V-Y slide of the extensor origin has low morbidity, does not violate the joint space or lateral stabilizing ligaments of the elbow, allows adequate release, and has a high rate of satisfaction.     

Secondary subaortic stenosis in heart defects without any initial subaortic obstruction: a multifactorial postoperative event.

BACKGROUND/OBJECTIVE: Secondary subaortic stenosis (SSS) can occur after surgery for various congenital heart defects with or without initial left ventricular outflow tract obstruction (LVOTO). The objective of this study was to highlight the anatomical lesions and surgical procedures associated with the development of SSS after surgery on defects without initial LVOTO. METHODS: A retrospective study of 4710 patients was performed (1984-2005). The criterion for inclusion was a fixed subaortic obstruction requiring surgery, after an open- or closed-heart operation. The criterion for exclusion was an LVOTO at the time of the first operation. RESULTS: Twenty-eight patients were studied. The mean age at initial surgery was 32 months (4 days-47 years; median: 2 months). SSS occurred after three main types of surgery: repair of coarctation of the aorta, repair of AVSD and LV-aorta rerouting for double outlet right ventricle or transposition of great arteries. The mean delay of occurrence was 4.4 years (2 months-19 years). Frequently associated initial anatomical conditions were coarctation of the aorta (40%), lesions of the mitral valve (32%), bicuspid aortic valve (21%) and left superior vena cava (LSVC) (14%). Preoperative anatomical lesions of the LVOT were present in 93% of the cases. After the initial operation, only one patient had a mean echo-Doppler pressure gradient across the LVOT>20 mmHg. SSS was most frequently a subaortic membrane (n=23). The mean pressure gradient across SSS at the time of reoperation was 47+/-29 mmHg. Five patients developed a second SSS after 7.4 years (mean). One patient developed a third SSS. No patient died. When compared with patients without SSS, significant risk factors for SSS were low age at surgery (32 vs 74.9 months, p<10(-4)), pre-existing coarctation of the aorta (40 vs 10%, p<10(-4)), bicuspid aortic valve (21 vs 6%, p=0.002) and LSVC (14 vs 4%, p=0.02). CONCLUSIONS: SSS development is multifactorial, depending on initial anatomical lesions and initial surgery. Low age at initial surgery, coarctation of the aorta, bicuspid aortic valve and LSVC significantly increase the risk of SSS. These elements warrant long-term follow-up for early detection of SSS.     

自体腓骨短肌腱重建距腓前韧带和跟腓韧带治疗慢性踝关节外侧不稳定

目的:探讨自体腓骨短肌腱重建距腓前韧带和跟腓韧带治疗慢性踝关节外侧不稳定的临床疗效.方法:回顾性分析2016年7月至2019年7月采用自体腓骨短肌腱解剖重建距腓前韧带和跟腓韧带治疗的42例慢性踝关节外侧不稳定患者,其中男30例,女12例;年龄25～46(37.6±12.4)岁;左足15例,右足27例;受伤至手术时间3～...     

Extended trochanteric osteotomy via the direct lateral approach in revision hip arthroplasty

A review of the results of the extended trochanteric osteotomy through a modified direct lateral approach in revision total hip arthroplasty was done. We reviewed 44 patients (45 procedures) at a minimum of 2 years followup (mean, 3.8 years; range, 2.1-7.2 years). There were 26 men and 18 women with a mean age at the time of surgery of 70.8 years (range, 36.9-90.4 years). Indications for use of the trochanteric osteotomy included facilitation of cement removal (25 procedures), proximal femoral varus deformity (14 procedures), trochanteric malposition (five procedures), and previous trochanteric osteotomies with significant bony overgrowth (three procedures). The mean length of the osteotomy was 133.9 mm. The mean migration of the osteotomized fragment was 2.1 mm (range, 0-20 mm) with significantly more proximal migration seen with the use of cerclage wires when compared with cables. There were two cases of trochanteric escape, for which the patients required repeat open reduction internal fixation. There were two late fractures of the greater trochanter. One femoral component had early subsidence for which the patient required re-revision with a further extended trochanteric osteotomy. The mean time to union of the remaining 40 hips was 10.3 months (range, 6-24 months). There only was one dislocation postoperatively. The extended trochanteric osteotomy through the modified direct lateral approach in revision total hip arthroplasty is a reproducible and reliable technique with a lower dislocation rate but a higher incidence of trochanteric fracture and escape than previously described with its use in the posterior approach.     

A comparison of lateral popliteal versus lateral midfemoral sciatic nerve blockade using ropivacaine 0.5%

BACKGROUND AND OBJECTIVES: The midfemoral approach to the sciatic nerve (MF) is a new technique that has been used for postoperative analgesia after knee surgery. The aim of the present study was to compare efficacy, performance time, and patient acceptance of the midfemoral approach to that of the lateral approach at the level of the popliteal fossa (popliteal block [PB]). METHODS: Sixty-three patients were enrolled in this prospective, randomized study. Thirty-two patients received a lateral sciatic nerve block (group PB) and 31 patients a midfemoral block (group MF). Ropivacaine 0.5% (30 mL) was used in both groups. RESULTS: The quality of nerve blockade was comparable in both groups. Onset of sensory block for peroneal and tibial nerves was significantly shorter in group MF than in group PB, 5 (1-20) minutes and 5 (1-20) minutes versus 10 (1-40) minutes and 10 (1-45) minutes, respectively. Onset of motor block in both territories was also shorter in group MF compared with PB, 6 (2-35) minutes and 5 (2-55) minutes versus 15 (2-60) minutes and 15 (2-60) minutes, respectively (P <.05). There was no difference in duration of sensory and motor blockade, 16 (7-32) hours versus 16 (6-43) hours and 16 (8-32) hours versus 16 (6-25) hours. There was no significant difference between both groups with respect to difficulty of nerve block performance. Patient discomfort during needle puncture was also similar. CONCLUSIONS: The midfemoral approach to the sciatic nerve for ankle and foot surgery resulted in a reliable anesthetic, comparable to that of the lateral popliteal approach. This technique is simple, safe, and provides postoperative analgesia as effective as that obtained with the lateral approach.     

小切口解剖重建踝关节外侧韧带复合体治疗慢性外踝不稳的临床疗效

目的:探讨解剖重建踝关节外侧韧带复合体治疗慢性外踝不稳的临床疗效。方法:自2005年9月至2010年3月,采用解剖重建距腓前韧带及跟腓韧带手术治疗慢性外踝不稳29例,男24例,女5例;年龄15～35岁,平均24岁;病史7个月～10年,平均10个月。主要临床表现为踝关节反复扭伤。查体时29例均有踝关节的内翻增加以及距骨前移增加,内翻活动度比健侧平均增加(12.5±3.2)°。术中先在踝关节镜下处理关节内病变。移植物为自体股薄肌腱,距骨止点以锚钉在骨表面固定,移植物通过腓骨远端的骨隧道,跟骨止点以挤压钉在骨隧道内固定。术后通过观察患者症状的变化、距骨内翻和前移的程度改变以及影像学变化来评价疗效,并以AOFAS后足功能评分评价踝关节功能。结果:所有患者手术成功,无骨折及感染发生。所有患者获得随访,时间16～60个月,平均28个月。终末随访时无踝关节不稳定或活动受限。术后踝关节内翻角度比对侧增加值为(2.5±0.8)°,低于术前(t=12.3,P=0.012);距骨前移距离(3.5±0.8)mm,较术前(16.3±4.0)mm下降(t=18.6,P=0.002);距骨倾斜角(4.5±1.0)°,较术前(17.5±3.6)°下降(t=9.7,P=0.035);AOFAS后足功能评分(92.8±6.2)分,较术前(48.0±6.7)分升高(t=25.3,P=0.001)。所有患者无严重并发症出现,对疗效满意。结论:自体股薄肌腱移植解剖重建踝关节外侧韧带复合体的手术方式符合解剖学重建理念,手术创伤小,术后恢复快,无严重并发症。该手术临床效果可靠,术后踝关节稳定性恢复良好,踝关节功能明显改善。     

Surgical reconstruction for chronic lateral instability of the ankle

We have treated 56 patients (56 ankles) for symptomatic chronic lateral ankle instability by the surgical reconstruction procedure. The operation included lateral shift of the entire lateral capsule-ligament complex, suture to anterior border of fibula, and reinforcement by an elevated periosteal flap of distal fibula. These patients were reviewed at a mean period of 3.1 years (range, 9 months to 5 years) after the operation. There were 29 males and 27 females with an average age of 29 years (range, 16-49 years). The clinical results were graded according to the AOFAS Ankle-Hindfoot scales. There were 35 patients who were excellent (above 90 points), 16 who were good (between 76 and 90 points), 4 who were fair (between 60 and 75 points), and 1 who was poor (below 60 points). The excellent and good results amounted to 91.1% (51/56). Therefore, we concluded that symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method.     

Paraesophageal hernia after Nissen fundoplication: a real complication in pediatric patients

Eighty-nine pediatric patients aged 6 weeks to 20 years (mean, 3.8 years) who underwent Nissen fundoplication were reviewed. Follow-up, including upper gastrointestinal (GI) series, was obtained in 55 patients (61.8%). Fifteen patients developed paraesophageal hernia (PEH) (16.8%). PEH was diagnosed between 4 and 36 months following fundoplication (mean, 17 months). Patients were divided into three groups: A, those with significant mental dysfunction (45); B, those with previous tracheoesophageal fistula (12); and C, others (32). Incidence of PEH is 20% for group A, 16.8% group B, and 12.5% group C. Combining groups B and C, 5 of 25 patients (20%) who underwent fundoplication at less than 1 year of age developed PEH, whereas one of 19 older patients (5.3%) developed PEH. One of 25 patients (4%) who had crural repair at fundoplication developed PEH, whereas 14 of 64 patients without crural repair (21.9%) developed PEH. At surgery, PEH occurred at the left posterolateral aspect of esophagus. We conclude that (1) follow-up after fundoplication should continue for 36 months and include upper GI series; (2) patients under one year of age undergoing fundoplication may be at a higher risk for PEH; and (3) technical refinement including crural repair may be required to prevent PEH.     

踝关节完全脱位的治疗

目的 探讨踝关节完全脱位的损伤机制与疗效.方法 2003年1月至2008年12月共收治39例踝关节完全脱位患者,男25例,女14例;年龄14～69岁,平均31.6岁.闭合性脱位10例,开放性脱位29例;伴踝关节骨折23例.按距骨移位方向分类:内侧脱位15例,外侧脱位10例,踝关节后脱位10例,旋转分离向上脱位4例.保守治疗7例,闭合复位短腿石膏固定6周;手术治疗32例,包括骨折脱位复位内固定22例,其中行外侧副韧带修复6例,三角韧带修复3例;单纯行三角韧带修复2例;单纯行外侧副韧带修复6例;内外侧韧带同时修复2例.下胫腓联合螺钉固定7例.因踝部皮肤缺损二期行皮瓣移植7例,二期小腿下端截肢2例.采用美国足踝外科协会(AOFAS)踝与后足评分系统评价术后疗效. 结果 35例患者术后获1～4年(平均26个月)随访.伴骨折者骨折愈合时间平均为14周(6～25周).术后随访发现踝关节不稳定5例,创伤性关节炎3例.术后AOFAS踝与后足评分平均为86.5分(48～96分). 结论 踝关节完全脱位早期应注意骨折脱位的复位固定和韧带的修复,防止后期关节不稳定和创伤性关节炎的发生.开放性脱位常伴有皮肤坏死,及时皮瓣移植对防止关节感染尤为重要.