Open calcaneal fractures are relatively rare, but most of them are potentially devastating with severe injury of soft tissue and comminuted bone. Its management is still challenging and controversial. Improper treatment will l ead to wound infection, osteomyelitis and even amputation. Preservation or repai r of soft-tissue to partly cover the hindfoot is the most important factor for the treatment. Another important factor is to restore the alignment and function of the hindfoot. Variables in determining outcomes of different cases include s everity and type of injury, wound location and treatment options. It is suggeste d that different measures should be taken according to different types of injury . This article reviews the current development and progress in the diagnosis and treatment of open calcaneal fractures.

Objective To compare treatments of intra-articular calcaneal fractures with and without bone graft in foot and ankle surgery.Methods A comprehensive search was conducted on line for all English research articles published from January 1990 through December 2010 dealing with open reduction and internal fixation with and without bone graft for intra-articular calcaneal fractures.Two reviewers evaluated each study to determine whether it was eligible for inclusion and collected the data of interest.Meta-analytic pooling of group results across studies was performed for the 2 treatments.Results The systematic review identified 32 qualified primary studies with 1281 fractures.No significant differences were found in postoperative infection, osteoarthritis or subtalar fusion between the 2 treatments ( P ＞ 0.05) .The average full weight-bearing time in bone graft treatment was significantly lower (5.4 weeks) than in non-graft treatment (10.5 weeks) .The mean B(o)hler angle was significantly larger and long-term loss of collapse significantly lower in bone graft treatment than in non-graft treatment.The bone graft treatment had a lower American Orthopaedic Foot and Ankle Society (AOFAS) score (71.4 points vs.80.5 points) but a higher Creighton score (89.9 points vs.81.0 points) compared with non-graft treatment.Pooled mean results showed no significant differences in the weighted excellent-to-good rate between the 2 treatments (excellent 35%, good 40%, fair 21% and poor 4% for the bone graft treatment versus excellent 34%, good 42%, fair 14%, and poor 10% for the non-graft treatment).Conclusions Open reduction and internal fixation with bone graft for intra-articular calcaneal fractures may lead to better reduction of B(o)hler angle and early return to full weight-bearing without increased risk of postoperative infection.However, since more cases of joint depression and comminuted fracture have been included in the bone graft group in the present study, a prospective controlled comparative study with a large scale of samples is still needed.

Objective To evaluate development of postoperative complications of calcanens fracture by employing Evidence-based medicine method so as to provide basis for clinical treatment strategy. Methods Eligible literatures on surgical treatment of calcalneus fractures from 1989 to 2008 were retrieved through Medline, Cochrane Database, Embase Database and Science Direct. The retrieved literatures were organized and analyzed by using SPSS14.0 and RevMan5 software. Results A total of 1823 literatures on calcaneus fractures were originally obtained based on preset retrieval conditions. With screening and evaluation, 29 clinical reports involving 2 661 patients (2 800 feet) met the criteria of meta-analysis. The results of recta-analysis indicated that the incidence rates (IR) and confidence interval (CI) of the complications that included infection (IC =8.6%, 95% CI =7.53-9.61), wound-edge necrosis (IC =2.6%, 95% CI =2.05-3.24), subtalar arthritis (IC =2.0%, 95% CI = 1.42-2.44), peroneal tendinitis (IC = 1.3% , 95% CI = 0.84-1.66), vascular or nerve damage (IC = 1.2%, 95% CI 0.81-1.62), osteotitis of calcaneus (IC = 1.0% ,95% CI 0. 60-1.33), non-union (IC =0.2%, 95% CI = 0. 04-0. 39) , malreduetion (IC = 0. 1%) and painful implants (IC = 0.7% , 95% CI = 0.4-1.03) respectively. Conclusion The postoperative complications of calcaneus fracture are common clinical problems, to which professional care without delay can attain satisfactory outcome.

Objective To study the mechanism and characteristics of calcaneal fracture involving calcaneocuboid joint and its surgical clinical results. Methods 71 cases with 90 calcaneal fractures accompanied calcaneocuboid joint injury were reviewed in our hospital from February 1997 to April 2001, which included 61 ankles of 46 males and 29 ankles of 25 females with an average age of 38.7 years (range, 18 to 67 years). AP, lateral and axial view X-ray of both feet, broaden view X- ray of the affected foot, and CT scan were taken preoperatively. Among them, 45 ankles were examined with three dimensional reconstruction of CT as well. The calcaneocuboid joint injury were divided into 4 types as follows: typeⅠ(46/90) with one articular fracture line but no displacement; type Ⅱ(26/90) with one articular fracture line accompanied the displacement of fragment and the subluxation of calcaneocuboid joint; type Ⅲ (11/90) with two fracture articular lines, and the displacement of fragment as well as the subluxation of calcaneocuboid joint; and type Ⅳ (7/90) with three articular fracture lines and comminuted fracture or the subluxation of calcaneocuboid joint. Of 71 cases, 63 were operated at 3 to 7 days after injury, and 8 delayed at 10 to 14 days. The incision started at the middle point between the fibula and Achilles tendon proximal to the apex of lateral malleolus, and extended distally to the adjacent part of dorsal and plantar skin, then anterior to the base of fifth metatarsus. After the reduction of fractures, type Ⅰcalcaneal plate, designed by authours, was used for type Ⅰ,Ⅱand Ⅲ fractures, the anterior part of calcaneus was fixed with the vertical wing of plate; type Ⅱ calcaneal plate was used for type Ⅳfractures, the horizontal wing of plate was fixed to cuboid to stabilize the comminuted fragments of anterior calcaneus. Results Of 90 ankles, 78 were followed up for an average of 18.7 months (range, 12 to 32 months). The total excellent and good rate was 94.9% according to Marryland foot score. Furthermore, In type Ⅰ, the excellent and good rate was 100%, type Ⅱ 95.7%, type Ⅲ 88.9% and type Ⅳ 60%. Among the types Ⅳ fracture, 7 ankles obtained satisfied internal fixation, but in 4 of them the plates were broken after weight bearing walking. Conclusion The injury of calcaneocuboid joint is related with the severity of calcaneal fracture, attention should be paid and carried out with reliable internal fixation.

Objective To introduce the reconstruction of calcaneal thalamus by bone autograft and subtalar arthrodesis for severe deformities caused by malunion of calcaneal fractures and to discuss the indications and its advantages of the management. Methods From November 1998 to August 2002, 17 cases with 21 malunited calcaneal fractures were treated, which were 13 males and 4 females with an average age of 35.4 years( 25 to 45 years). Unilateral calcaneus was involved in 13 cases, and bilateral calcaneus was affected in 4 cases. The primary treatment was manipulation and immobilization with a cast in all patients. The interval from injury to the operation was on an average of 33.6 months(7 to 50.4 months). The common complaints were painful heels and walking difficulty. Furthermore, there was subluxation of talonavicular joint in 5 cases, protruded osteophyte and fragment from the lateral wall of calcaneus in 12 cases. Lateral, axial, and oblique roentgenograms were taken preoperatively, and three dimensional reconstruction of CT scan as well. Results The modified extended L-shaped approach lateral to calcaneus was used. The bulging lateral wall of calcaneus was excised and reserved for reconstruction of calcaneal thalamus if possible. While in some cases the bone autograft had to be harvested from iliac crest if the excised lateral wall was not available. After the cartilage of subtalar joint was removed completely, the calcaneal thalamus was reconstructed with the bone and fixed with 2 to 3 screws, the contour and position of calcaneus was conformed without valgus or varus by "C" arm intensifier. A short leg cast was used for immobilization one month after operation. Among the patients, 18 feet were followed up on an average of 14.5 months (9 to 22 months). The total excellent and good rate was 88.8% according to Maryland foot score system. Plain radiography showed that B hler angle, Gissane angle, talus inclining angle, width of calcaneus and height of calcaneal thalamus were restored to nearly normal. Conclusion The reconstruction of calcaneal thalamus by bone autograft combined with subtalar arthrodesis is an effective operation for severe malunion of calcaneal fractures, which can improve calcaneal abnormality, and make recovery of the shape of hind foot and functions satisfactorily.

[Objective]To discuss the operative treatment for adult flatfoot deformity with severe pain.[Method]From August 2002 to October 2004,operative treatment for 12 cases of unilateral adult flatfoot deformity with severe pain underwent operative treatment,which included 7 males and 5 females with an average age of 35 years(range,20 to 56 years),left side was involved in 8 cases,and right side was affected in 4 cases.According to etiological factor,stageⅡ~Ⅲ posterior tibial tendon dysfunction were 6 feet,congenital flatfoot were 3 feet,neurological flatfoot were 2 feet and postoperative equinovarus was 1 feet.Every case received special operative treatment,for instance lateral column lengthening,medial displacement calcaneal osteotomy,arthrodesis,repair posterior tibial tendon,sping ligament reefing,FDL tendon transfer and so on.All patients were fixed with plaster cast at inversion position for 4~6 weeks,then changed to plaster splint fixing at neutral position for 4 weeks.Functions of ankle and foot were evaluated before and after operation.[Result]All patients were followed up for an average of 22 months(ranged,16 to 28 months).The total excellent and good rate was 83.3% according to Marryland foot score.The specific index of X-ray improved obviously(P

[Objective]To introduce the new concept of "terrible triad of the elbow",and report the preliminary results of 5 clinical cases.[Method]From April 2004 to March 2007,five cases met the diagnosis of terrible triad,with posterior dislocation of elbow complicated with radial head and ulnar coronoid fractures.The radial head fractures were 4 in type Ⅱ and I in type Ⅲ according to Mason classification,and Ⅰ in type Ⅰ,Ⅲ in type Ⅱ and 1 in type Ⅲ according to Schatzker classification.The ulnar coronoid fractures were Ⅰ in type Ⅰ,Ⅳ in type Ⅱ according to Regan-Morrey classification,and all 5 in type Ⅰ according to O'Driscoll classification.Four patients underwent surgical operations.The fractured radial head and ulnar coronoid were reduced and fixed with 3mm titanic lag screws or K wires,the lateral and medial collateral ligaments were repaired with Krachow sutures.A plaster of Paris was applied for 3 weeks after operation,in position with elbow flexion in 90 degrees and forearm rotation in neutral.Then physical exercise and rehabilitation program were carried out.[Result]Four operated patients were followed up for 3 months to 3 years,with healed fractures,stable elbow and no pain movement.The average range of elbow flexion-extension were 120 degrees,and forearm pronationsupination were 110 degrees,respectively.The functional outcome in 3 cases that followed up more than Ⅰ year was excellent in 2 and good in Ⅰ according to Mayo Elbow Performance Score(MEPS).The result of the un-operated case was poor in MEPS evaluation.Elbow instability and pain was the main complaint.[Conclusion]Terrible triad of posterior dislocation with radial head and ulnar coronoid fractures is a severe trauma to the elbow.Operative osteosythesis and ligament repair is mandatory for concentric reduction and elbow stability.

[Objective]To discuss the value and methods of severe hindfoot reconstruction in the treatment of hindfoot injures.[Method]Six cases with severe hindfoot injures were treated with hindfoot reconstruction.Among them, 4 patients were males and 2 females. Five cases were fallen from high places and 1 case by traffic accident. All cases associated with talus and calcancus comminuted fractures of type Ⅳ according to Sanders classification and calcaneocuboid, talocalcaneal and talonaviculare joint disorders.Four cases were associated with anterior and medial or plantar skin laceration,2 of anterior and medial skin laceration and 2 of plantar skin laceration. Among them, 1 were of anterior and medial skin avulsion wound and skin necrosis defect.1 were of plantar skin laceration and skin necrosis and bone exposure.[Result]Two cases' incisions without skin laceration were healed up. Among 4 cases incisions with skin laceration, 3 were primarily healed. One was Ⅱ-period healed. Two cases' skin laceration were healed by 1st incisions and 2 skin defects were healed by skin transplantation in 6 and 10 weeks after operation. The postoperative functional evaluation by AOFAS revealed excellent result in 1 foot, good in 3, fair in 2.[Conclusion]Hindfoot reconstruction is an effective method for severe hindfoot injures with the advantages of resoring function and outer aspect hindfoot satisfactorily.

[Objective] To research the plantar pressure distribution of the normal Chinese adult. [Method] The F-scan plantar pressure analysis system was used to collect plantar pressure distribution data of 100 volunteers who stand, walk, jog, go upstairs and downstairs.The plantar pressure distribution data of 5 kinds of physiological states, as well as influence of sex, height, body weight, body mass index and speed was analyzed. [Result] There's different characteristic between 5 kinds of states of the plantar pressure distribution in the Chinese normal adults. There's significant difference between static and dynamic. In four dynamic motions, the gait of walk was stalest, and it became unstable if speed up and go upstairs or downstairs. As for the influential factors of the plantar pressure distribution, there was non-significance of sex. But the speed had the significance. The height, the body weight, the BMI had weak correlation with the plantar pressure distribution. [Conclusion] The plantar pressure distribution of normal Chinese adults has the distinctive quality. The data obtained by this experiment, may provide the reference for the clinical plantar pressure analysis.

[Objective]To explore displacement and plantar pressure distribution of the forefoot before and after the plantar fascia and other plantar ligaments were sectioned.[Method]Seven fresh adult cadaveric feet were tested with the main plantar ligaments exposed,including the plantar fascia,spring ligament,short plantar ligament and long plantar ligament.The displacements of the metatarsals were recorded and calculated with digital speckle correlation measurement(DSCM),also F-scan insoles were put under the plantar aspect of the feet when the speciments were loaded to 700N vertically.The special shifts and plantar pressure data of the metatarsals was collected and stored before and after the main plantar ligaments were sectioned.[Result]The transverse movements of the metatarsals did not change significantly,the same as their vertical displacements except the first metatarsal after the plantar fascia was sectioned,while the peak pressure shifted laterally.When the four major plantar ligaments were all injured,all of the above changed significantly.[Conclusion]The plantar fasciotomy will not consequentially lead to collapse of the forefoot structure.But the redistribution of the plantar pressure and the compensation of other ligaments may result in later complication.