Objective:To examine the feasibility and clinical effect of all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture.Methods:This is a retrospective case series study. From February 2021 to February 2023, the clinical data of 24 patients (30 feet) with Achilles tendon contracture treated with all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening were analyzed retrospectively. There were 10 males and 14 females, aged (32.8±16.1) years (range: 9 to 62 years). There were 8 cases of left side only, 10 cases of right side only and 6 cases of bilateral. There were 14 cases (16 feet) of foot varus, 4 cases (6 feet) of foot valgus, and 6 cases (8 feet) without deformity. All patients underwent all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening. The surgical effects were evaluated using the maximum dorsal extension angle of ankle joint in knee extension position, the visual analogue scale (VAS) of pain, the American Orthopedic Foot and Ankle Society ankle-hindfoot score(AOFAS-AH). Paired sample t test was used to compare the scores before and after operation.Results:All patients successfully completed the operation, and the operation time of Achilles tendon lengthening was (22.0±5.7)minutes (range: 15 to 35 minutes) and the intraoperative blood loss was (6.5±2.7)ml (range: 2 to 15 ml). All patients primarily healing without any complications such as sural nerve injury, Achilles tendon rupture, important blood vessel injury, and obvious decrease of lift heel strength of achilles tendon. All 24 patients were followed up for (17.2±4.5) months (range: 12 to 28 months). One patient suffered from lift heel′s weakness in one foot after operation, and recovered after repeated lift heel functional exercises. The ankle dorsiflexion function of two patients with calf triceps spasm were not improved after operation, and it was obviously improved after botulinum toxin injection. At the last follow-up, the maximum dorsal extension angle of ankle joint in knee extension position increased from -9.2°±7.6°(range:-25° to 5°) preoperatively to 14.5°±7.0°(range:0° to 28°)( t=24.83, P<0.01); the VAS score was reduced from (4.5±1.7) points (range:1 to 8 points) preoperatively to (1.5±0.9) points (range:0 to 3 points) ( t=9.53, P<0.01), the AOFAS-AH was increased from (60.5±11.4)points (range:38 to 85 points) to (90.8±5.4) points (range:80-100 points)( t=14.21, P<0.01). Conclusions:All-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture not only provides Achilles tendon lengthening, but also avoids complications such as Achilles tendon rupture and sural nerve injury. It is an effective method for the treatment of Achilles tendon contracture.

Objective:To examine the feasibility and clinical effect of all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture.Methods:This is a retrospective case series study. From February 2021 to February 2023, the clinical data of 24 patients (30 feet) with Achilles tendon contracture treated with all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening were analyzed retrospectively. There were 10 males and 14 females, aged (32.8±16.1) years (range: 9 to 62 years). There were 8 cases of left side only, 10 cases of right side only and 6 cases of bilateral. There were 14 cases (16 feet) of foot varus, 4 cases (6 feet) of foot valgus, and 6 cases (8 feet) without deformity. All patients underwent all-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening. The surgical effects were evaluated using the maximum dorsal extension angle of ankle joint in knee extension position, the visual analogue scale (VAS) of pain, the American Orthopedic Foot and Ankle Society ankle-hindfoot score(AOFAS-AH). Paired sample t test was used to compare the scores before and after operation.Results:All patients successfully completed the operation, and the operation time of Achilles tendon lengthening was (22.0±5.7)minutes (range: 15 to 35 minutes) and the intraoperative blood loss was (6.5±2.7)ml (range: 2 to 15 ml). All patients primarily healing without any complications such as sural nerve injury, Achilles tendon rupture, important blood vessel injury, and obvious decrease of lift heel strength of achilles tendon. All 24 patients were followed up for (17.2±4.5) months (range: 12 to 28 months). One patient suffered from lift heel′s weakness in one foot after operation, and recovered after repeated lift heel functional exercises. The ankle dorsiflexion function of two patients with calf triceps spasm were not improved after operation, and it was obviously improved after botulinum toxin injection. At the last follow-up, the maximum dorsal extension angle of ankle joint in knee extension position increased from -9.2°±7.6°(range:-25° to 5°) preoperatively to 14.5°±7.0°(range:0° to 28°)( t=24.83, P<0.01); the VAS score was reduced from (4.5±1.7) points (range:1 to 8 points) preoperatively to (1.5±0.9) points (range:0 to 3 points) ( t=9.53, P<0.01), the AOFAS-AH was increased from (60.5±11.4)points (range:38 to 85 points) to (90.8±5.4) points (range:80-100 points)( t=14.21, P<0.01). Conclusions:All-inside endoscopic procedure through two portals combined with double-hemisection Achilles tendon lengthening for Achilles tendon contracture not only provides Achilles tendon lengthening, but also avoids complications such as Achilles tendon rupture and sural nerve injury. It is an effective method for the treatment of Achilles tendon contracture.

Objective:To investigate the functional outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic talocalcaneal coalition.Methods:The study was a retrospective case-series research.The data of 17 adult patients (17 feet) with symptomatic talocalcaneal coalitions,treated with PASTA from March 2018 to February 2022 in Xuzhou Central Hospital were collected.This procedure involved 10 males and 7 females,aged (42.4±7.5) years(range:31 to 58 years).There were 9 cases on the right side and 7 cases on the left side.According to the Rozansky classification,there were 4 cases of type Ⅰ,7 cases of type Ⅱ, 3 cases of type Ⅲ,3 cases of type Ⅳ.The following items such as wound healing and bony union of the subtalar joint were observed.Clinical assessment was performed using pain visual analogue scale (VAS),American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and 36-item short form health survey (SF-36) scores.The paired t test was used for data comparison. Results:The follow-up time was (24.8±6.9) months(range:12 to 40 months).There were no complications such as wound infection,deep vein thrombosis,nonunion,or screw breakage.One patient with preoperative spasm,relieved after the second surgical procedure (peroneal brevis tendon lengthening).The union time of the subtalar joint was (8.8±2.2) weeks(range:6 to 12 weeks).At the final follow-up,the VAS decreased from 6.4±1.3 to 1.3±0.9 ( t=14.114, P<0.01), the AOFAS ankle-hindfoot score increased from 49.0±8.1 to 90.0±5.1 ( t=38.782, P<0.01),and the SF-36 score increased from 50.8±9.5 to 91.0±4.9 ( t=20.468, P<0.01). Conclusion:PASTA for adult patients presenting with symptomatic talocalcaneal coalition offers advantages of minimal trauma,fast recovery,and few complications,which is an effective method.

Objective:To investigate the functional outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic talocalcaneal coalition.Methods:The study was a retrospective case-series research.The data of 17 adult patients (17 feet) with symptomatic talocalcaneal coalitions,treated with PASTA from March 2018 to February 2022 in Xuzhou Central Hospital were collected.This procedure involved 10 males and 7 females,aged (42.4±7.5) years(range:31 to 58 years).There were 9 cases on the right side and 7 cases on the left side.According to the Rozansky classification,there were 4 cases of type Ⅰ,7 cases of type Ⅱ, 3 cases of type Ⅲ,3 cases of type Ⅳ.The following items such as wound healing and bony union of the subtalar joint were observed.Clinical assessment was performed using pain visual analogue scale (VAS),American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and 36-item short form health survey (SF-36) scores.The paired t test was used for data comparison. Results:The follow-up time was (24.8±6.9) months(range:12 to 40 months).There were no complications such as wound infection,deep vein thrombosis,nonunion,or screw breakage.One patient with preoperative spasm,relieved after the second surgical procedure (peroneal brevis tendon lengthening).The union time of the subtalar joint was (8.8±2.2) weeks(range:6 to 12 weeks).At the final follow-up,the VAS decreased from 6.4±1.3 to 1.3±0.9 ( t=14.114, P<0.01), the AOFAS ankle-hindfoot score increased from 49.0±8.1 to 90.0±5.1 ( t=38.782, P<0.01),and the SF-36 score increased from 50.8±9.5 to 91.0±4.9 ( t=20.468, P<0.01). Conclusion:PASTA for adult patients presenting with symptomatic talocalcaneal coalition offers advantages of minimal trauma,fast recovery,and few complications,which is an effective method.

Objective:To explore the basic rules of hemodynamics of the multi-territory flap in the early stage.Methods:In this paper, based on the prototype of the free flaps and vascularized pedicled transpositional flaps. The angiosome theory was applied as a basis to systematically analyze the blood flow pathway, the resistance network, and the series or parallel connection mode between each resistance network within the flap, according to the knowledge of fluid mechanics and current pathway, and finally the mathematical model was used for deduction.Results:Based on the model, it can be concluded that a dynamic flow balance can be achieved in the arteries and veins of the multi-territory flap in the early stage and the flap could be divided into four areas: the effective microcirculation zone, the venous stasis zone, the relative ischemic zone and the absolute ischemic zone. And the following inferences can be drawn: (1) The blood supply to the vascular pedicle is constant by pressure rather than by flow. (2) The resistance of the flap varies by the position or the relative position of the arterial vascular pedicle and venous vascular pedicle. (3) The flow velocity decrease gradually from the pedicle to the distal end. (4) The main factors that lead to distal flap necrosis vary depending on the region in which they are located: the venous stasis zone is mainly due to obstructed venous return, and the relative and absolute ischemic zones are mainly due to insufficient arterial blood supply.Conclusions:The basic rules and characteristics of hemodynamics of the multi-territory flap in the early stage can be well explained by this theoretical model, the pedicled artery and vein of the flap can achieve a dynamic balance of flow, and the blood flow gradually decreases from the pedicle to the distal end. The survival range of the flap depends on the pressure difference between the artery and vein as well as the resistance of the blood flow path in the flaps. The distal necrotic area of the flap can be divided into venous stasis area and arterial insufficiency area.

Objective:To investigate the clinical efficacy of arthroscopic treatment of acute closed noninsertional rupture of Achilles tendon.Methods:The clinical and imaging data of 30 patients (30 feet) with acute closed noninsertional rupture of Achilles tendon who were treated with all-inside arthroscopic technique at the Department of Hand and Foot Microsurgery,Xuzhou Central Hospital from June 2018 to June 2020 were analyzed retrospectively. There were 26 males and 4 females,aged (38.3±8.5)years old(range:19 to 66 years). There were 22 cases on the right side and 8 cases on the left side. The duration from injury to surgery was (2.1±1.4) days (range:1 to 7 days).All patients were treated with all-inside arthroscopic technique.The function of the ankle and the foot was assessed using visual analogue scale (VAS),the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale and the Achilles tendon total rupture score (ATRS). The Arner-Lindholm score system was used to evaluate the excellent and good rate of clinical effect. Paired sample t test or rank-sum test was used for data comparison. Results:The patients were followed up for (18.6±2.2)months(range:12 to 28 months).All the wounds healed at the first stage.No complication such as infection,sural nerve injury or re-rupture happened.Two patinets felt mild pain after a long time exercise, and were alleviated by microwave therapy and stretching the Achilles tendon consistently.Another patient was unable to do a sustained single stance heel raise,which was recovered after repeated function practice.At the last follow-up,the VAS ( M(IQR)) decreased from 6(5) preoperatively to 0(1)( Z=6.512, P<0.01),the AOFAS ankle hindfoot scale improved from 60.6±8.3 preoperatively to 96.3±4.8( t=-29.774, P<0.01),and the ATRS improved from 61.7±7.8 preoperatively to 97.1±2.3 ( t=-53.661, P<0.01).According to the Arner-Lindholm score system,27 cases were excellent,3 cases were good,and the excellent and good rate was 100%. Conclusions:The all-inside arthroscopic technique not only ensures the quality of tendon ananstomosis,but also avoids injury to the sural nerve.It has the advantages of small trauma,faster recovery and fewer complications.

Objective:To investigate the clinical efficacy of arthroscopic treatment of acute closed noninsertional rupture of Achilles tendon.Methods:The clinical and imaging data of 30 patients (30 feet) with acute closed noninsertional rupture of Achilles tendon who were treated with all-inside arthroscopic technique at the Department of Hand and Foot Microsurgery,Xuzhou Central Hospital from June 2018 to June 2020 were analyzed retrospectively. There were 26 males and 4 females,aged (38.3±8.5)years old(range:19 to 66 years). There were 22 cases on the right side and 8 cases on the left side. The duration from injury to surgery was (2.1±1.4) days (range:1 to 7 days).All patients were treated with all-inside arthroscopic technique.The function of the ankle and the foot was assessed using visual analogue scale (VAS),the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale and the Achilles tendon total rupture score (ATRS). The Arner-Lindholm score system was used to evaluate the excellent and good rate of clinical effect. Paired sample t test or rank-sum test was used for data comparison. Results:The patients were followed up for (18.6±2.2)months(range:12 to 28 months).All the wounds healed at the first stage.No complication such as infection,sural nerve injury or re-rupture happened.Two patinets felt mild pain after a long time exercise, and were alleviated by microwave therapy and stretching the Achilles tendon consistently.Another patient was unable to do a sustained single stance heel raise,which was recovered after repeated function practice.At the last follow-up,the VAS ( M(IQR)) decreased from 6(5) preoperatively to 0(1)( Z=6.512, P<0.01),the AOFAS ankle hindfoot scale improved from 60.6±8.3 preoperatively to 96.3±4.8( t=-29.774, P<0.01),and the ATRS improved from 61.7±7.8 preoperatively to 97.1±2.3 ( t=-53.661, P<0.01).According to the Arner-Lindholm score system,27 cases were excellent,3 cases were good,and the excellent and good rate was 100%. Conclusions:The all-inside arthroscopic technique not only ensures the quality of tendon ananstomosis,but also avoids injury to the sural nerve.It has the advantages of small trauma,faster recovery and fewer complications.

Objective:To explore the basic rules of hemodynamics of the multi-territory flap in the early stage.Methods:In this paper, based on the prototype of the free flaps and vascularized pedicled transpositional flaps. The angiosome theory was applied as a basis to systematically analyze the blood flow pathway, the resistance network, and the series or parallel connection mode between each resistance network within the flap, according to the knowledge of fluid mechanics and current pathway, and finally the mathematical model was used for deduction.Results:Based on the model, it can be concluded that a dynamic flow balance can be achieved in the arteries and veins of the multi-territory flap in the early stage and the flap could be divided into four areas: the effective microcirculation zone, the venous stasis zone, the relative ischemic zone and the absolute ischemic zone. And the following inferences can be drawn: (1) The blood supply to the vascular pedicle is constant by pressure rather than by flow. (2) The resistance of the flap varies by the position or the relative position of the arterial vascular pedicle and venous vascular pedicle. (3) The flow velocity decrease gradually from the pedicle to the distal end. (4) The main factors that lead to distal flap necrosis vary depending on the region in which they are located: the venous stasis zone is mainly due to obstructed venous return, and the relative and absolute ischemic zones are mainly due to insufficient arterial blood supply.Conclusions:The basic rules and characteristics of hemodynamics of the multi-territory flap in the early stage can be well explained by this theoretical model, the pedicled artery and vein of the flap can achieve a dynamic balance of flow, and the blood flow gradually decreases from the pedicle to the distal end. The survival range of the flap depends on the pressure difference between the artery and vein as well as the resistance of the blood flow path in the flaps. The distal necrotic area of the flap can be divided into venous stasis area and arterial insufficiency area.

Objective:To evaluate the clinical outcome of all arthroscopic autogenous tendon suspended fixation for Myerson type III chronic noninsertional achilles tendon rupture in elderly patients.Methods:Data of 18 patients with Myerson type III chronic noninsertional Achilles tendon rupture who had performed all arthroscopic autogenous tendon suspended fixation from February 2016 to February 2019 in Department of Hand and Foot Microsurgery, Xuzhou Central Hospital were retrospectively analyzed. There were 12 males and 6 females (right side, 10 cases and left side, 8 cases) aged from 60 to 79 years with a median of 65.3 years. The mean injury-to-surgery time was 12 weeks (range, 6-32 weeks). All the patients were treated by all arthroscopic autogenous tendon suspended fixation. The function of the ankle and the foot was assessed using visual analogue scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) foot and ankle score and the achilles tendon total rupture score (ATRS), and the excellent and good rate was evaluated according to Arner-Lindholm score.Results:All patients healed at the first stage without any complications such as infection, sural nerve injury or tend re-rupture. The mean follow-up period was 18.6 months (range, 12-50 months). At the latest follow-up, all achilles tendons were healed with the VAS score reduced from 4 (1, 7) preoperatively to 0 (0, 1) postoperatively ( Z=2.334, P< 0.05); the AOFAS ankle and hindfoot score was improved from 60.3±9.7 (range, 40-83) preoperatively to 92.6±4.3 (range, 86-100) postoperatively ( t=34.541, P< 0.05); the ATRS score was improved from 55.7±10.6 (range, 42-80) preoperatively to 93.1±3.2 (range, 88-100) postoperatively ( t=64.773, P< 0.05); one patient was unable to stand on tiptoe of the single injured limb, because he could stand it, no further treatment was given; another patient complained of mild pain after a long time walking,which was alleviated by stretching the achilles tendon consistently. According to the score of Arner-Lindholm, 14 cases were excellent, 4 cases were good, and the excellent and good rate was 100% (18/18). Conclusion:All arthroscopic autogenous tendon suspended fixation for Myerson type III chronic noninsertional achilles tendon rupture in elderly patients is an effective method, which has the advantages of less trauma, faster recovery and fewer complications.

Objective:To evaluate the clinical outcome of the reconstruction of Myerson type Ⅲ chronic Achilles tendon rupture by using the total arthroscopic technique combined with free semitendinosus tendon and gracilis tendon autograft.Methods:Clinical data of 32 patients(32 ankles) with Myerson type Ⅲ chronic Achilles tendon rupture who were treated by using the total arthroscopic technique combined with free semitendinosus tendon and gracilis tendon autograft at Department of Hand and Foot Microsurgery, Xuzhou Central Hospital from September 2013 to September 2018 were analyzed retrospectively.There were 28 males and 4 females, aged 45.5 years old(range: 22 to 69 years old), 12 cases in the right side and 20 in the left.All patients were treated by using the total arthroscopic technique combined with free semitendinosus tendon and gracilis tendon autograft for Myerson type Ⅲ chronic Achilles tendon rupture reconstruction.The functional recovery of the ankle was evaluated according to ankle-hindfood score of American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale, Achilles tendon total rupture score (ATRS), visual analogue scale (VAS).Arner-Lindholm score was used to evaluate the excellent and good rate.The quantitative data were compared using t-test or Wilcoxon test. Results:The 32 patients were followed up for 33 months (range: 15 to 72 months).No serious postoperative complications such as infection, sural nerve injury or tend re-rupture outcomes were reported.Three patients complained of mild pain when after a minimum sitting, walking or jogging, which were completely relieved by simple physical therapy or continuous stretching of Achilles tendon.At the last follow-up, the VAS decreased from 3 (5) ( M ( QR) ) preoperative to 0 (3) ( Z=1.357, P<0.01) and AOFAS ankle hindfoot scale improved from 58.6±13.5 preoperative to 95.5±4.0 ( t=16.9, P=0.00), ATRS improved from 47.5±9.3 preoperative to 96.6±3.3 ( t=25.661, P<0.01).According to the score of Arner-Lindholm, 20 cases were excellent, 12 cases were good, and the excellent and good rate was 100%. Conclusion:The reconstruction of Myerson type Ⅲ chronic Achilles tendon rupture by using the total arthroscopic technique combined with free semitendinosus tendon and gracilis tendon autograft has the advantages of safety, reliability, effectiveness and minor injury.