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 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 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 introduce calcaneal osteotomy without subtalar fusion for calcaneal malunion and to discuss its indications, advantages and disadvantages. Methods From November 1998 to May 2003, 24 cases with 26 calcaneal malunion for 1 to 9 months were treated by calcaneal osteotomy without subtalar fusion. The average age was 32.6 years (range, 28 to 42 years). All patients underwent radiography including plain, axial and lateral views for calcaneus, oblique view for foot and three-dimensional CT imaging reconstruction. According to Sanders classification, 13 cases were of type Ⅱ(9Ⅱb, 4Ⅱc), 13 of type Ⅲ(8 Ⅲac, 5 Ⅲbc). Through the modified lateral L-shaped approach, the protruding lateral wall of calcaneus was resected and the posterior subtalar facet was reduced by elevating the fragment of the posterior subtalar facet upwards and backwards. The defect of calcaneus was filled with bone autografts. Iliac crest bone graft was used in 19 feet and the bone graft resected from the extruding lateral wall of calcaneus in 7 feet. The calcaneus was fixed with plate and screw. Results 21 feet were followed up for an average of 14.5 months (range, 9 to 22 months). No complications such as wound infection, screw breakage and calcaneum varus were found postoperatively. The average time for bone healing was 11.2 weeks (range, 10.5 to 13.3 weeks). The postoperative functional evaluation by Maryland foot score system revealed excellent result in 8 feet, good in 10, fair in 3. The rate of excellent to good results was 86%. Plain radiographs showed the nearly complete restoration of Bhler angle, Gissane angle, talus inclining angle, calcaneal width and height of the calcaneal thalamus. Conclusion Calcaneal osteotomy without subtalar fusion is an effective method for calcaneal malunion with advantages of correcting deformity markedly, restoring the function and the outer aspect of hindfoot satisfactorily.

Objective To investigate the properties of hind foot motion and it's changes in ankle or subtalar joint arthrodesis. Methods Eight fresh frozen adult leg-foot specimens were mounted in a coordinated system, a Steinmann pin was perforated across the calcaneus as a marker. The displacements of the marked points in the coordinated system were recorded when subtalar or ankle joint was fixed respectively. Through matrix translation and Euler equation, the angle of the calcaneus rotation were calculated, representing the motion of the subtalar and ankle joints in different condition, Statistical analysis were also taken between different conditions. Results Three dimensional (3-D) motion was observed in hind foot motion. The range of motion with ankle joint fixation was: inversion 15.99??2.81?, eversion 8.62??1.90?, dorsiflexion 3.70??1.00?, plantar flexion 5.87??1.39?, adduction 7.64??2.04?, and abduction 3.99??1.78?. When subtalar joint was fixed, they were: 7.13??1.07?, 5.52??0.85?, 17.09??2.87?, 30.75??5.04?, 10.77??1.56?, and 6.54??1.88? respectively. While they were 22.62??3.21?, 40.88??5.77?, 18.87??3.89?, 9.12??2.05?, 17.48??2.26? and 11.47??2.29?, when no joint was fixed. Arthrodeses of ankle or subtalar joint would affect the hindfoot motion significantly (P

Objective To introduce the method of arthroscopically assisted closed reduction and percutaneous screw fixation for intra-articular calcaneal fractures and to discuss its clinical indications, advantages and disadvantages. Methods From February 2003 to December 2004, 12 unilateral intra-articular calcaneal fractures were treated with the method of arthroscopically assisted closed reduction and percutaneous screw fixation. 7 cases were males and 5 cases were females. The average age was 36.8 years (range, 23-61 years). 8 feet were on right side and 4 feet were on left side. The mechanism of injury was fall from a height in 11 cases and vehicle accident in 1 case. According to Sanders classification, 8 cases were type Ⅱ fractures(1 type ⅡA, 5 type ⅡB, 2 type ⅡC) and 4 cases were type Ⅲ fractures(2 type ⅢAB,1 type ⅢAC,1 type ⅢBC). Results Arthroscopy in the operation showed the fracture space and step were less than 1 mm. The preoperative X-ray film showed that B?觟hler angle was 18.4??5.8?, Gissane angle was 109.1??10.2?, calcaneal width was (35.9?2.2) mm. The postoperative X-ray film demonstrated that B?觟hler angle was 25.4??3.5?, Gissane angle was 118.1??6.4?, calcaneal width was (32.3?1.1) mm. The average follow-up of nine patients was 17.4 months (range, 10-25 months). According to Maryland foot score, all patients had satisfactory results with the mean score of 92.5 score (range, 82-100 score), 6 were excellent and 3 were good. None of the patients had re-displacement of fracture, significant lame or other late complications. They regained normal shape of foot and wore normal footwear. Conclusion Arthroscopically assisted closed reduction and percutaneous screw fixation is an effective and applicable minimal-invasive treatment for Sanders type Ⅱ and selected type Ⅲ intra-articular calcaneus fractures. It can significantly reduce the risk of soft tissue injury and other complications while ensuring satisfactory reduction of the posterior calcaneal facet of the subtalar joint and reliable fixation.

[Objective]To investigate the curative effect and methods of distal tibial fracture by operation.[Method]From May 2004 to Feb.2005,30 cases of distal tibial fracture were treated in the department.All cases were treated with open reduction,internal fixation with medial anatomic plates,and with bone-grafting prophylacticly in all cases.The operation would be done on 10~14 days after fracture.They were followed up and analyzed retrospectively.[Result]All cases were followed up for 8～17 months(average 13.9 months).All wounds were primary healing and all fractures obtained bone-union.Twenty-two cases were the excellent,6 cases were the good according to Mazur's criteria.The excellent and good rate was 93.3%.All cases had no severe complication,such as wound infection,cutaneous necrosis and bone non-union.[Conclusion]Anatomic plate of distal tibia is a perfect choice for treatment of distal tibial fracture.Operative juncture and prophylactic bone grafting were very important to obtain satisfactory effect.

Objective To investigate the clinical results of resection of periacetabular tumors and reconstruction with fibular autograft. Methods Eight patients with tumors around acetabular were treated surgically in Tongji Hospital between January 1999 and April 2003. The series comprised 5 males and 3 females, with an average age of 39.6 years old (range, 21-65 years old). One patient was diagnosed with osteosarcoma, 2 with chondrosarcoma, 3 with metastatic bone tumor, 1 with giant cell tumor(GCT), and 1 with aneurysmoid bone cyst. There were ⅠB in one patient, ⅡB in 3 patients according to Enneking surgical staging in four primary malignant tumors patients. The tumors involved the zones Ⅱ of Enneking classification in 5 patients, the zonesⅠand Ⅱin 3 patients. All the 8 patients with periacetabular tumors underwent resection and reconstruction with fibular autograft(including 3 cases of a free vascularized fibular graft). Functional results were evaluated according to the system of the Musculoskeletal Tumor Society. Results Bony union occurred 15.2 weeks (range 14-16 weeks) in 5 patients reconstructed with non-vascularized fibular graft and 13.6 weeks (range 12-15 weeks) in 3 patients reconstructed with vascularized fibular graft after the initial surgery. Five of them were followed up ranged from 14 to 42 months (mean 28 months). There were continuously disease-free without complications during follow-up. At the final followup, the average functional score was 22 (range 18-27) according to the system of the Musculoskeletal Tumor Society. The good and excellent rate of functional results was 100%. Conclusion Tumor resection and reconstruction by fibular autograft is an effective treatment for patients with periacetabular tumors. Satisfactory postoperative function was obtained, and relief of pain and walking independently could be achieved with a high level of patient satisfaction.

[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.