Although chronic lateral instability of the ankle is a common disorder, there are not many reports and researches on it in China. This is because most patients with the condition do not seek a thorough cure of it and consequently surgeons pay little attention to it. In this article, we discuss some of the problems about its diagnosis, describe and compare several surgical procedures for reconstruction of the lateral ligament. We hope this paper can help surgeons know more about how to make an accurate diagnosis of the chronic lateral instability of the ankle and how to deal with it.

Objective To introduce the diagnosis and treatment of the missed adolescent humeral capitellar fracture malunion.Methods Retrospectively analyzed 6 cases with missed adolescent capitellar fracture malunion treated by the author from Jul.2010 to Mar.2015 and their follow-up results.Among them, 5 were male and 1 was female.The average age is (14.33 ± 1.86) years, 4 were left-side and 2 were right.Results The average time from injury to the operation is (8.67 ± 3.88) months.Before operation, the average elbow flexion was (91.67° ±7.53°), the average elbow extension was (40.0° ± 8.94°), the average range of flexion and extension activities was (51.67° ±11.69°).Forearm rotation was not limited.Average M EPS score was (80.83 ± 4.92).Released the elbow in 3 cases with additional medial incision.The fragment was fixed by HCS.The lateral collateral ligament was repaired by suture anchors (2 cases) or by trans-os suture(4 cases).Three cases were fixed by DJDⅡ Stryker hinged external fixatorswhich were removed after 8 weeks.The average postoperative follow-up time was (39.33 ± 20.42) months.Postoperatively, the average elbow flexion was (138.33° ±7.528°), the average elbow extension was (5.0° ± 4.472°), the average range of flexion and extension activities was (133.33° ±9.832°).Forearm rotation is not limited.The average MEPS score was 100.Conclusions The adolescent capitellar fracture is prone to be missed and cause malunion, elbow stiffness or other complications which is very difficult to deal with.By complete elbow release, osteotomy and internal fixation, the lateral collateral ligament repair, and hinged external fixator if necessary, the final elbow function can be improved.

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.

Objective To explore factors influencing the restdts of operative treatment of unstable scapular neck fractures. Methods We reviewed 15 patients who had been diagnosed as the unstable scapular neck fracture and received operation from June 2001 to November 2007 in our department. Of them, 13 had full follow-up data, with a mean follow-up time of 45.1 (10 to 90) months. There were 8 cases of anatomic scapular neck fracture and 5 cases of surgical scapular neck fracture combined with injury to the superior shoulder suspensory complex. The shoulder posterior approach was adopted, exposing the fracture site between the in-fraspinatus and teres minors interval, to fix the scapular neck fracture along the scapular lateral border and si-multaneously fix the combined clavicle fracture, dislocation of the acromioclavicular joint and acromial process fracture. The results were evaluated by the absolute value of Constant-Murley rating system. Results The average absolute Constant-Murley score was 81.2 (40-98) points. Nine cases were evaluated as excellent and good, 2 cases as fair, and 2 cases as poor. The average forward elevation was 147.7°. Conclusions The degree of displacement is the main factor affecting the prognosis of the scapular neck fracture. Reduction and fixation of the displaced scapular neck fracture is the key to achieving good results.

Objective To compare the posterior midline approach and the combined lateral and medial approach usually used in elbow arthrolysis. Methods From January to December in 2009, 41 cases of elbow stiffness were treated and fully followed up by the same team in our hospital. The posterior midline approach was used in 21 cases, 15 males and 6 females, with an average age of 35.8 years (16 to 70 years). In this group, the total flexion-extension arc was ＜ 30° in 12 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Eight cases had ulnar symptoms. The combined lateral and medial approach was applied in 20 cases, 8 males and 12 females, with an average age of 38. 8 years (16 to 51 years). In this group, the total flexion-extension arc was ＜ 30° in 11 cases, 31° to 60° in 7 cases, and 61° to 90° in 2 cases. Five cases had ulnar symptoms. Results The 41 cases were followed up for 4 to 15 months (average, 7.9 months). In the posterior approach group, the mean preoperative flexion-extension ROM (27.6°± 25.7°) was improved to the postoperative 111.4°± 25.6°, the mean preoperative rotation ROM ( 152.9°± 46. 9°) to the postoperative 168.1°± 19. 1°, and the mean preoperative MEPS score (65.5 ± 11.5) to the postoperative 95.7 ±6.4. In the combined approach group, the mean flexion-extension ROM was improved from 35.5°± 25.0° preoperatively to 116. 5°± 19.1° postoperatively, the mean rotation ROM from 138.0°±55.7° preoperatively to 148.5°± 45.6° postoperatively, and the mean MEPS score from 66. 3 ± 13.0 preoperatively to 97.3 ± 7.0 postoperatively. The differences were statistically significant between preoperation and postoperation in both groups ( P ＜ 0. 05), but not statistically different between the 2 groups in the preoperative or postoperative values ( P ＞ 0. 05). In the posterior approach group, 5 patients had huge hematoma, 3 had wound dehiscence at the posterior elbow, and the others all had mild hematoma. But in the combined approach group, no wound complications were noted. Conclusion The combined lateral and medial approach should be used as far as possible in the elbow arthrolysis to avoid the likely complications when the posterior midline approach is used.

Objective To study advantages and disadvantages of the super-cutaneous calcaneal locking plate in the treatment of calcaneal fractures. Methods Between October 2007 to June 2008, 12cases of calcaneal fracture were treated with a super-cutaneous calcaneal locking plate. According to the Sanders classification system, 8 cases were of type ⅡA, one case of type ⅡB, one case of type ⅡC, one case of type Ⅲ AC, and one case of type Ⅳ. All the cases were fresh fractures. The skin incision was made from the distal tip of the fibula to the base of the fourth metatarsal. In direct observation of the posterior facet and anterior tuberosity, the articular fragments were reduced anatomically. Then the reduced calcaneus was fixed by a super-cutaneous calcaneal locking plate. After bone union was confirmed 3 months after the operation by the CT scans and X-ray films, the super-cutaneous plates and screws were removed in clinic. Results The average time of follow-up was 16 months with a span from 12 to 20 months. There were no incision or pin-hole infections. The reduction of the articular surface and bone union were good. One type ⅡA developed lateral wall exostosis which resulted in peroneal tendonitis and stenosis followed by obvious walking pain. The preoperative X-ray films of the 12 patients showed that the average B(o)hler angle was 11.9°±9.4° and the Gissane angle 86. 8°± 7. 7°. Their postoperative X-ray files demonstrated that the B(o)hler angle was improved to 29. 4°± 7.0° and the Gissane angle to 115.8°± 7.7°, with a significant difference ( P ＜ 0. 01 ). According to the Ankle Hindfoot Clinical Rating System of the American Orthopaedic Foot and Ankle Society (AOFAS),their average score was 91 points (68 to 100 points). Conclusions Using a super-cutaneous calcaneal locking plate to treat calcaneal fractures can result in limited invasion, a low rate of skin infection, satisfactory reduction of the articular surface and stable fixation. Since the fixation can be removed without re-hospitalization, it is a cheaper and less painful alternative for the treatment of displaced intra-articular calcaneal fractures.

Objective To compare the clinical outcomes of open reduction and internal fixation (ORIF) with total elbow arthroplasty (TEA) for type C inter-condylar fractures of the distal humerus in the elderly. Methods Twenty-two patients who were treated with ORIF or TEA from April 2003 to September 2009 were included in the study. All fractures were OTA classification 13C. Among them, 10 patients who were treated with ORIF were follow up for 8-56 months, while 12 patients who were treated with TEA were followed up for 15-54 months. The Mayo elbow performance score (MEPS) and the complications were compared. Results Using the MEPS, there were 2 in excellent, 4 in good, 4 in fair in the patients treated with ORIF. Complications included heterotopic ossifications (2 cases) and ulnar nerve dysfunction (2 cases).There were 6 in excellent, 4 in good, 2 in fair in the patients treated with TEA. Complications included 1heterotopic ossification (1 case), ulnar nerve dysfunction (1 case), the weakness of musculus triceps brachii (1 case). The patients treated with TEA had significantly better range of motion (107.5° vs 84.5°, P=0.007),also had better MEPS (87.9 vs 75.5, P=0.047) than those with ORIF had ones. Conclusion TEA is a liable option for type C inter-condylar fractures of the distal humerus in the elderly.

Objective:To introduce the surgical techniques and treating results of the old “terrible triad”of the elbow.Methods:A retrospective analysis of 1 1 cases of old “terrible triad”of the elbow treated by the author from March 2009 to February 2014 were performed,with 9 males and 2 females;mean age was (31.82 ±8.66)years (17-45 years).The average time after injury was (6.36 ±2.50) weeks (4-12 weeks),with 7 cases on the left and 4 right.The combined injury included 2 cases with distal radius fractures,1 with ankle fractures,fractures of the distal radius and the head injury (minor epidural hematoma,no surgery),and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation,and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures:2 cases were type Ⅰ,5 were type Ⅱ,4 were type Ⅲ. Classification of the coronoid process:Regan &Morrey:1 was type Ⅰ,10 were type Ⅱ;according to O’Driscoll classification,all the fractures were tip fracture,one was the first subtype,10 were the second subtype.The elbow were released,the coronoid process were fixed by lasso suture combined with Kirschner wires.Radial head fractures were resected in 1 case,and replaced in 1 case,3 cases with no
treatment,6 cases with osteotomy and 3.0 mm headless compression screw (HCS)fixation.The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicon-dyles,No.2 Ethibon was used in 2 cases through bone holes,and suture anchorsin the other 9 cases.All the patients were fixed by Stryker DJDⅡhinged external fixator to protect the bone and soft tissue.Re-sults:The average follow-up time was (38.36 ±21.92)months (19-77 months).All the patients had no obvious pain,instability and ulnar nerve symptoms in the last follow-up.The average elbow flexion was 134.09°±12.41°(100°-140°),average extension was -15.91°±14.46°(-40°-0°),range of flexion and extension was 118.18°±23.80°(70°-140°).Average pronation was 70.91°±26.63° (20°-90°),supination was 70.91°±26.63°(20°-100°).The range of motion (ROM)of forearm rotation was 150.91°±43.00°(40°-180°).Average Mayo elbow performance score (MEPS)was 96.36 ±5.04 (85 -100).X-ray showed that no degenerative changes.Five patients had heterotopic os-sifications,according to Hastings and Graham grading:1 case was grade Ⅰ,3 cases were grade ⅡA, 1 case was ⅡB.Conclusion:The old “terrible triad”of elbow with no operative history is difficult to treat.The elbow’s functions and stabilization can be recovered by thorough elbow release,repair of coro-noid process and anterior capsule,radial head fractures,lateral collateral ligament and the common ex-tensor tendon insertion,combined with hinged external fixator.Joint stiffness and heterotopic ossification are common complications.

Objective:To discuss the diagnosis,differential diagnosis,classification methods and treat-ment of the capitellar fractures of the distal humerus.Methods:In the study,28 adult patients with the capitellar fractures were treated in Beijing Jishuitan Hospital from Sep.2008 to Jan.2014.There were 10 females and 18 males with an average age of 34 years (range:14-66 years).According to Dubber-ley classification:ⅠA type in 6 cases,ⅠB type in 2 cases,ⅡA type in 8 cases,ⅡB type in 4 cases,ⅢA type in 4 cases,and ⅢB type in 4 cases.Sixteen patients were treated with a single Kochr approach,1 with a lateral approach combined with a medial approach,2 combined with anterior elbow approach and 9 combined with posterior median approach.All of the fractures were fixed with Herbert screws,7 cases with support plates,and 4 cases with the hinged elbow external fixator.All of the pa-tients were followed up for clinical examination and radiograph check.They were evaluated with Broberg-Morrey score system.Results:The average follow-up time was 28.5 months (range 12 -72 months). The average bone union time was 8 weeks.The average ulnohumeral motion was 1 12°(60°-150°)and forearm rotation was 145°(100°-170°).The average Broberg-Morrey score was 92.5 points (range:62-100 points).The excellent and good rate was 91.8%.The complications of traumatic arthritis was in 2 cases and elbow stiffness was in 2 cases.Conclusion:Attention should be paid to the diagnosis and differential diagnosis of capitellar fractures without missing the combined injury.According to Dubberley classification,appropriate surgical approach and the internal and external fixed methods could be chosen. Early postoperative,reasonable and effective exercise is helpful to the recovery of elbow joint function.

Objective:To investigate the clinical efficacy and outcomes of two separate vertical wiring combined with tension band and Kirschner-wire plus cerclage wire in the treatment of displaced inferior pole fractures of the patella.Methods:From January 201 3 to January 201 5,1 5 consecutive patients (mean age 54.5 years)with inferior pole fractures of the patella were retrospectively included in this study.All the patients underwent open reduction and internal fixation by separate vertical wiring com-bined with tension band and Kirschner-wire plus cerclage wire through longitudinal incision,4.5 d (range:3.1 -5.9 d)after initial injury.A safety check for early knee range of motion was performed before wound closure.The complications including infection,nonunion,loss of fixation and any wire breakage or irritation from implant were recorded.Anteroposterior and lateral views of the knee joint ob-tained during the follow-up were used to assess bony union based on the time when the fracture line disap-peared.At the time of the final outpatient follow up,functional evaluation of the knee joint was conduc-ted by B?stman system.Results:The follow-up time was 1 3.1 months (range:1 2 -1 9 months)after surgery on average,immediate motion without immobilization in all the cases was allowed and there was no case of reduction loss of the fracture and wire breakage.There was no case of irritation from the im-plant.At the final follow-up,the average range of motion (ROM)arc was 1 26.7°(range:1 1 5°-1 40°),the average ROMlag versus contralateral healthy leg was 1 0.3°(range:0°-35°).The mean B?stman score at the last follow-up was 28.9 (range:27 -30),and graded excellent in most cases. Conclusion:Two separate vertical wiring is an easy and effective method to reduce the displaced inferior pole fracture of patella.Augmentation of separate vertical wiring with tension band and Kirschner-wire plus cerclage wire in these patients provides enough strength to protected the early exercise of the knee joint and uneventful healing.By this surgical treatment,excellent results in knee function can be expec-ted for cases of displaced inferior pole fractures of the patella.