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Checa-Betegón P, Valle-Cruz J, Llanos-Sanz S, Miguel-Miguel C, Sánchez-Del-Saz J, García-Coiradas J. External fixation in intra-articular fractures of the calcaneus: Is it a valid option as definitive treatment? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:201-208. [PMID: 37402889 DOI: 10.1007/s00590-023-03621-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/11/2023] [Indexed: 07/06/2023]
Abstract
INTRODUCTION The therapeutic management of calcaneal fractures is currently a major source of controversy in the literature. There is no consensus on the need to treat these injuries conservatively or surgically, nor on the criteria for deciding one option or the other. Although the gold standard has classically been the open approach and osteosynthesis, there are currently minimally invasive techniques that also report good results. Our objective is to present our results and experience with the MBA® Orthofix external fixator in a series of cases of calcaneal fractures. METHODS We performed a retrospective observational study in our center, between the years 2019 and 2021, of Sanders types II-IV calcaneal fractures operated with MBA® Orthofix external fixator. We recorded a total of 38 patients, 42 fractures. We registered demographic information, intraoperative, postoperative, radiological and functional parameters, using the American Orthopedic Foot and Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D and VAS scales. RESULTS A total of 26 men and 12 women were included, and the median age was 38 years. Mean follow-up was 24,4 months (6, 8-40, 1). The average time to surgery was 7 days and partial loading was started at 2.5 weeks after external fixation, which was removed at 9.2 weeks. The average Böhler angle correction was 7, 4°, Gissane - 12,2°, length 2 mm and calcaneal width was reduced by 5 mm. We recorded two superficial infections, one peroneal entrapment and three subtalar arthrodesis due to post-traumatic osteoarthritis. The AOFAS obtained was 79.1 + / - 15.7 points, MOXFQ 20.1 + / - 16.1 points, EQ-5D 0.84 + / - 0.2 and VAS 3.3 + / - 1.9. CONCLUSION The external fixator is an excellent surgical alternative for complex articular fractures of the calcaneus, obtaining clinical and radiological results comparable to other osteosynthesis techniques and significantly reducing soft tissue complications.
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Affiliation(s)
- P Checa-Betegón
- Department of Traumatology and Orthopaedic Surgery, Complex Trauma Unit, Hospital Universitario Clínico San Carlos, Carlos. Profesor Martín Lagos sn, 28040, Madrid, Madrid, Spain.
- Department of Traumatology and Orthopaedic Surgery, Complex Trauma Unit, Hospital Universitario Clínico San Carlos, Carlos. Profesor Martín Lagos sn, 28040, Madrid, Madrid, Spain.
| | - J Valle-Cruz
- Department of Traumatology and Orthopaedic Surgery, Complex Trauma Unit, Hospital Universitario Clínico San Carlos, Carlos. Profesor Martín Lagos sn, 28040, Madrid, Madrid, Spain
| | - S Llanos-Sanz
- Department of Traumatology and Orthopaedic Surgery, Complex Trauma Unit, Hospital Universitario Clínico San Carlos, Carlos. Profesor Martín Lagos sn, 28040, Madrid, Madrid, Spain
| | - C Miguel-Miguel
- Complejo Hospitalario de Navarrra., C. de Irunlarrea, 3, 31008, Pamplona, Spain
| | - J Sánchez-Del-Saz
- Department of Traumatology and Orthopaedic Surgery, Complex Trauma Unit, Hospital Universitario Clínico San Carlos, Carlos. Profesor Martín Lagos sn, 28040, Madrid, Madrid, Spain
| | - J García-Coiradas
- Department of Traumatology and Orthopaedic Surgery, Complex Trauma Unit, Hospital Universitario Clínico San Carlos, Carlos. Profesor Martín Lagos sn, 28040, Madrid, Madrid, Spain
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Pînzaru RM, Pavăl SD, Perțea M, Alexa O, Sîrbu PD, Filip A, Carp AC, Savin L, Forna N, Veliceasa B. Biomechanical Comparison of Conventional Plate and the C-Nail® System for the Treatment of Displaced Intra-Articular Calcaneal Fractures: A Finite Element Analysis. J Pers Med 2023; 13:jpm13040587. [PMID: 37108973 PMCID: PMC10141664 DOI: 10.3390/jpm13040587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
The C-Nail® system is a novel intramedullary fixation method for displaced intra-articular calcaneal fractures. The aim of this study was to evaluate the biomechanical performance of the C-Nail® system and compare it with conventional plate fixation for the treatment of displaced intra-articular calcaneal fractures using finite element analysis. The geometry of a Sanders type-IIB fracture was constructed using the computer-aided design software Ansys SpaceClaim. The C-Nail® system (Medin, Nové Mesto n. Morave, Czech Republic) and the calcaneal locking plate (Auxein Inc., 35 Doral, Florida) and screws were designed according to the manufacturer specifications. Vertical loading of 350 N and 700 N were applied to the subtalar joint surfaces to simulate partial weight bearing and full weight bearing. Construct stiffness, total deformation, and von Mises stress were assessed. The maximum stress on the C-Nail® system was lower compared with the plate (110 MPa vs. 360 MPa). At the bone level the stress was found to have higher values in the case of the plate compared to the C-Nail® system. The study suggests that the C-Nail® system can provide sufficient stability, making it a viable option for the treatment of displaced intra-articular calcaneal fractures.
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Affiliation(s)
- Roxana Maria Pînzaru
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Silviu Dumitru Pavăl
- Department of Computer Science and Engineering, “Gheorghe Asachi” Technical University, 27, Dimitrie Mangeron, 700050 Iasi, Romania
- Correspondence: (S.D.P.); (M.P.)
| | - Mihaela Perțea
- Department of Plastic Surgery and Reconstructive Microsurgery, Surgical Science (I), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
- Correspondence: (S.D.P.); (M.P.)
| | - Ovidiu Alexa
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Paul Dan Sîrbu
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Alexandru Filip
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Adrian Claudiu Carp
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Liliana Savin
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Norin Forna
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
| | - Bogdan Veliceasa
- Department of Orthopaedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania
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The effects of additional hollow cylinder coated to external fixator screws for treating pilon fracture: A biomechanical perspective. Injury 2021; 52:2131-2141. [PMID: 33745700 DOI: 10.1016/j.injury.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 02/02/2023]
Abstract
An external fixator is a promising medical device that could provide optimum stability and reduce the rate of complications in treating bone fracture during intervention period. It is noted that the biomechanics behaviour of device can be altered by introducing more features such as material suitability and additional components. Therefore, this study was conducted via finite element method to investigate the effects of additional hollow cylinder coated with external fixator screws in treating Type III pilon fracture. Finite element models which have been validated with experimental data were used to simulate stresses at the pin-bone interface and relative micromovement at interfragmentary fractures during swing (70 N load) and stance phases (350 N load). All bones and external fixators were assigned with isotropic material properties while the cartilages were simulated with hyper-elastic. For the hollow cylinder, polyethylene was assigned due to its properties which are equivalent to the bone. From the results, it is found that stresses at the pin-bone interface for the coated screws were reduced to 54% as compared to the conventional fixator. For the micromovement, there was no difference between both models, whereby the value was 0.03 mm. The results supported previously published literature, in which high stresses are unavoidable at the interface, fortunately, those stresses did not exceed the ultimate strength of bone, which is safe for treating patients. In conclusion, if patients are allowed to bear weight bearing, the external fixator with coated screws is a more favourable option to be fixed into the bone to avoid complications at the interface.
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Faria FF, Gruhl CEM, Ferro RR, Rached RN, Soni JF, Trevilatto P. Finite Element Analysis of a Controlled Dynamization Device for External Circular Fixation. Rev Bras Ortop 2021; 56:36-41. [PMID: 33627897 PMCID: PMC7895635 DOI: 10.1055/s-0040-1721368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 09/17/2020] [Indexed: 11/01/2022] Open
Abstract
Objective To virtually prototype a device for external circular fixation of long bone fractures with controlled dynamization made of two different materials and predict their mechanical behavior by using the finite element analysis (FEA) method. Method A software was used for 3D modeling two metal parts closely attached by a sliding dovetail joint and a high-density silicone damper. Distinctive FEAs were simulated by considering two different materials (stainless steel or titanium), modes (locked or dynamized) and loading conditions (static/point or dynamic/0.5 sec) with uniform 150 kg axial load on top of the device. Results The finite elements (FEs) model presented 81,872 nodes and 45,922 elements. Considering stainless steel, the maximum stress peak (140.98 MPa) was reached with the device locked under static loading, while the greatest displacement (2.415 × 10 -3 mm) was observed with the device locked and under dynamic loading. Regarding titanium, the device presented the maximum stress peak (141.45 MPa) under static loading and with the device locked, while the greatest displacement (3.975 × 10 -3 mm) was found with the device locked and under dynamic loading. Conclusion The prototyped device played the role of stress support with acceptable deformation in both locked and dynamized modes and may be fabricated with both stainless steel and titanium.
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Affiliation(s)
- Fernando Ferraz Faria
- Escola de Ciências da Vida, Departamento de Ciências da Saúde, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Carlos Eduardo Miers Gruhl
- Escola de Ciências da Vida, Departamento de Ciências da Saúde, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Rafaela Rebonato Ferro
- Departamento de Ortopedia e Traumatologia, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Rodrigo Nunes Rached
- Programa de Pós-Graduação em Odontologia, Faculdade de Ciências da Vida, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Jamil Faissal Soni
- Programa de Pós-Graduação em Medicina, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
| | - Paula Trevilatto
- Programa de Pós-Graduação em Odontologia, Faculdade de Ciências da Vida, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Paraná, Brazil
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Ma D, Huang L, Liu B, Liu Z, Xu X, Liu J, Chu T, Pan L. Efficacy of Sinus Tarsal Approach Compared With Conventional L-Shaped Lateral Approach in the Treatment of Calcaneal Fractures: A Meta-Analysis. Front Surg 2021; 7:602053. [PMID: 33585545 PMCID: PMC7873930 DOI: 10.3389/fsurg.2020.602053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background: This study aims to compare the efficacy of the sinus tarsal approach (STA) with that of the conventional L-shaped lateral approach (CLSLA) in the treatment of calcaneal fractures by meta-analysis. Methods: PubMed, Embase, Web of Science, the Chinese National Knowledge Infrastructure, and China Wanfang database were searched to collect clinical randomized or non-randomized controlled trials of STA and CLSLA in the treatment of calcaneal fractures from January 2010 to May 2020. The data were analyzed by Stata 15.0 software. Results: A total of 12 clinical trials were included, all of which were retrospective studies, including 961 patients. The results showed that when STA was compared with CLSLA, there was no difference in operation time with mean difference (MD) = −5.51 [95% confidence interval (CI): −12.57 to 1.55, P > 0.05], less bleeding during operation with MD = −18.49 (95% CI:−23.79 to −13.18), no difference in Böhler angle after an operation with MD = 0.78 (95% CI: −0.09 to 1.65) and in Gissane angle with MD = −0.07 (95% CI: −1.90 to 1.77), no difference in American Orthopedic Foot and Ankle Society score with MD = 2.16 (95% CI: −1.07 to 5.38), higher-excellent and better rate of Maryland food function with relative ratio = 1.12 (95% CI: 1.04 to 1.20), and lower of incidence of postoperative complications with relative ratio = 0.23 (95% CI: 0.14–0.37). Conclusion: STA was more effective than CLSLA in the treatment of calcaneal fractures. Moreover, STA had advantages in less intraoperative bleeding, higher-excellent and better rate of Maryland foot function, lower incidence of postoperative complications, and higher safety.
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Affiliation(s)
- Dongmei Ma
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Lei Huang
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Bin Liu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Zhigang Liu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Xin Xu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Jianfeng Liu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Tianyue Chu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
| | - Liming Pan
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, China
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O’Hara NN, Isaac M, Slobogean GP, Klazinga NS. The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis. PLoS One 2020; 15:e0227907. [PMID: 31940334 PMCID: PMC6961943 DOI: 10.1371/journal.pone.0227907] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.
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Affiliation(s)
- Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marckenley Isaac
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Gerard P. Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Niek S. Klazinga
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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El-Hawary A, Kandil YR, Ahmed M, Elgeidi A, El-Mowafi H. Distraction subtalar arthrodesis for calcaneal malunion. Bone Joint J 2019; 101-B:596-602. [DOI: 10.1302/0301-620x.101b5.bjj-2018-1306.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity. Patients and Methods We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44). Results The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group. Conclusion Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602.
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Affiliation(s)
- A. El-Hawary
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Y. R. Kandil
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - M. Ahmed
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - A. Elgeidi
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - H. El-Mowafi
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Affiliation(s)
- A H R W Simpson
- Bone & Joint Research, London, UK; George Harrison Law Professor of Orthopaedic Surgery; Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - H Frost
- School of Health and Social Care Edinburgh Napier University, Edinburgh, UK
| | - J Norrie
- Director, Edinburgh Clinical Trials Unit, (ECTU) Co-Director, Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Chiu YC, Chung TC, Wu CH, Tsai KL, Jou IM, Tu YK, Ma CH. Chopart amputation with tibiotalocalcaneal arthrodesis and free flap reconstruction for severe foot crush injury. Bone Joint J 2018; 100-B:1359-1363. [DOI: 10.1302/0301-620x.100b10.bjj-2018-0118.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot. Patients and Methods Between January 2012 to December 2016, 12 patients (nine male; three female, mean age 38.58 years; 26 to 55) with severe foot crush injury underwent treatment in our institute. All patients were followed-up for at least one year. Their medical records, imaging, visual analogue scale score, walking ability, complications, and functional outcomes one year postoperatively based on the American Orthopedic Foot and Ankle Society (AOFAS) and 36-Item Short-Form Health Survey (SF-36) scores were reviewed. Results The mean length of follow-up was 18.6 months (13 to 28). Two patients had a local infection, flap necrosis was seen in one patient, and one patient experienced a skin graft wound healing delay. Of the 12 patients, one had persistent infection and eventually required below-knee amputation, but pain-free walking was achieved in all the other patients. The mean one-year postoperative AOFAS and SF-36 scores were 75.6 (68 to 80) and 82 (74 to 88), respectively. Conclusion Although our sample size was small, we believe that this treatment method may be a valuable alternative for treating severe foot crush injuries. Cite this article: Bone Joint J 2018;100-B:1359–63.
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Affiliation(s)
- Y-C. Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - T-C. Chung
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - C-H. Wu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - K-L. Tsai
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-M Jou
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Y-K. Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - C-H. Ma
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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