方真华医生的科普号

近日，在德国2019年足踝外科年会上，方真华主任受德国足踝外科年会执行主席Hazzybullah Waizy邀请，作了微创足踝外科的中国经验交流。方真华主任分别做了微创踝关节镜和跟腱2个专题发言，学术气氛热烈！

【健康提示】埃及旅游双脚意外扭伤 当地手术后右脚跑偏30度 春节回国手术 武汉医生帮扶正2018-02-18 11:13长江日报融媒体讯（通讯员荆彤 王莹 记者莫梓芫）“成阿姨，您腊月二十九做的手术，不能出院，今年在医院里过年，这个福字送给您祝您早日康复！“大年初一一早武汉市第四医院足踝外科医生护士给患者送祝福，可这位成阿姨却要把这个福字送给帮她把脚”扶正“的医生和护士。今年1月底，62岁的成阿姨和朋友们一起去埃及旅游，出国旅游本事件开心的事，可就在开罗游玩的第三天晚上6点多下旅游大巴准备回住处休息时，因为天黑下台阶时没看到地上有个坑，右脚先踩下去，脚踝使劲一扭，本想左脚踩下去能帮个忙，结果左脚也扭到了，当时便坐在地上怎么也站不起来。旅行社将成阿姨送到当地医院，检查显示右脚脚踝处胫骨粉碎性骨折，伤得很重，左脚也有扭伤。本想回国手术的成阿姨却因为当地保险和航班等原因不得不在当地手术。在埃及语言不通、饮食也不习惯成阿姨说，做完骨折内固定手术在医院住了10多天，他们就计划赶快回家、回到武汉。可这家怎么回也是个大问题，因为坐飞机必须将腿抬高，双腿刚做完手术打着石膏，在飞机上不能坐着只能躺着，无奈家人四处联系，最后帮成阿姨订到了特殊头等舱，上周成阿姨终于回到了武汉。“毕竟是在国外做的手术，语言不通和医生沟通得少，也不知道手术做的怎么样“成阿姨说一到家，第二天她就来到武汉市第四医院足踝外科找到方真华主任，想看看手术后双脚的恢复情况。“从X光片上看，患者右脚复位不理想”方真华介绍，患者胫骨远端碎掉的骨片没有完全拼好，打开石膏后看到，右脚外旋近30度，明显畸形。在成阿姨的强烈要求下，腊月二十九一早，医生手术将之前在国外用的钢板和螺钉取出，重新把碎掉的骨头拼好再、固定，不到两个小时手术结束。真是不比较看不出差距，在国外我们住的是私立医院，医疗硬件很不错，可从治疗效果看仍然比不上自己国家。成阿姨说，虽然今年不能回家只能在医院度过，可说什么也是在自己国家，自己的家乡，感谢医生帮我把脚“扶正“了。

【健康提示】海外打工意外摔伤脚三月未愈 飞行十小时回汉骨移植 小伙脚跟终落地2017-11-02 10:33长江日报融媒体讯(记者莫梓芫 通讯员荆彤 谭玉华)在海外做工意外受伤未得到有效治疗，三个月后右脚无法下地走路，无奈27岁小伙子小林经过了十多个小时的飞行回到家乡，10月30日在市第四医院接受手术，术中通过自体骨移植，医生帮小林成功保住了右脚跟骨关节。今年27岁的小林是十堰某单位的一位技术工人,今年初被单位外派去埃塞俄比亚做工程，6月中旬在工作时意外从5米多高的钢架上摔下，脚先着地，摔倒后右脚疼得站不起来。当地医院建议打石膏精养。但三个多月过去后，小林无法下地走路。多方考虑下，他经过了十多个小时的飞行回国治疗。市第四医院足踝外科方真华主任介绍，小林受伤时整个身体重量聚集在脚跟使得原本具有一定高度的跟骨被压宽，且受伤后未得到有效治疗使得跟骨骨折后畸形愈合。手术时，医生采用自体植骨的方式帮小林复位跟骨。方真华主任解释，患者受伤后的跟骨就像被压扁的面包一样表面变宽，手术按照跟骨原本的宽度将多余骨头截去。再将截掉的骨头填入跟骨使其恢复原本的高度，将其复位。方真华主任提醒，现在出国工作、读书的人越来越多，国外受伤后若伤口大量出血或出现感染等情况，一定要及时在当地治疗，不可硬扛，若出现像小林这样的骨伤患者，切不可自行判断伤情的严重忽略治疗，可以选择在当地治疗的同时，将当地拍摄的X光片拍照传回国内，进行专业咨询以得到进一步治疗。

踝关节韧带运动损伤患者的增多，对踝关节韧带的微创修复一直是外科医生努力的方向。方真华主任团队克服重重技术困难，目前对踝关节韧带损伤患者均采用了踝关节镜下微创修复，取得了良好的效果。外侧韧带修复的常规切口：外侧韧带修复的关节镜微创切口：镜下所见：踝关节镜手术：镜下修复：

2017-02-28 17:26 来源: 长江网 长江网讯(通讯员江维 记者 吴晓敏)踢球时感觉到脚外侧疼痛，起初以为是骨折了，到医院检查后发现，其实是“假骨折”,只是伤到了肌腱。 12岁的小吴，家住汉口，是一名足球特长生，家人为了让他在足球领域能取得成绩，从小就让他进行专业训练。最近在体校集训期间，由于训练强度大，小吴感觉到自己的脚外侧开始疼痛，忍了两天后症状还加重了。小吴的妈妈知道后，以为孩子是骨折了，便赶紧带着他来到市四医院骨科检查。 接诊的足踝外科方真华主任医师通过触诊检查后发现，小吴左脚的疼痛点不在骨头上，而是在肌腱，其实并没有骨折。结合另一只“好”脚的拍片结果，方真华分析，小吴妈妈担心的骨折其实就是骨垢引起的，小吴只需要回家休息一周时间，减少行走就可以了。 方真华介绍，大多数青少年，在骨骼生长发育时期，骨垢还没有完全闭合，在长时间高强度的运动下，小吴脚背部的筋腱就会出现明显的疼痛感，加上训练后又没有休息好，疼痛的症状就更严重了。 骨垢引起足部的疼痛并不可怕，一般情况下，只需要注意制动和休息，症状都会有所缓解。武汉市第四医院足踝外科方真华主任医师提醒，广大市民在进行足部相关运动时，如果出现疼痛或其他不适的症状时，应先停止任何活动，避免足部关节受到进一步的损伤。有条件时，应选择用冰袋对疼痛的部位进行冰敷，将炎症和肿胀程度控制在最小的范围，并及时到医院就诊。

严重拇外翻病例展示。

Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail with a valgus curveZhenhua Fang1, Leif Claaen2, Henning Windhagen2, K. Daniilidis2, Stukenborg-Colsman2, Hazibullah Waizy31 Department of Orthopedics in PuAi Hospital affiliated HuaZhong University of science and technology430030 ,WuHanChina2 Department of OrthopedicsHannover Medical SchoolAnna-von-Borries-Str. 1-730625 HannoverGermany3Clinic for foot and ankle surgeryHessing FoundationHessing Str. 1786199 AugsburgThe research was carried out in the department of orthopedics in Hannover Medical School, GermanyCorresponding AuthorFang Zhenhua1 E-Mail: bone_ghost@hotmail.comKey words: Tibiotalarcalcaneal Arthrodesis; Curve; Retrograde; Intramedullary Nail; UnionAbstractBackground: Many different techniques have been described for tibiotalocalcaneal arthrodesis (TTCA) in patients with severe hindfoot disorders such as failed ankle arthroplasty and failed ankle joint arthrodesis with subsequent subtalar arthritis. A straight retrograde intramedullary nail may result in interfering normal heel valgus position with a risk of damaging the lateral plantar neurovascular structures, which extremely limits its use. A curved retrograde intramedullary nail is supposed to overcome the above shortcomings. The purpose of this study was to investigate the effects of TTCA using a curved retrograde intramedullary nail by a single surgeon series.Methods: From June 2009 to January 2012, there were 23 patients who had undergone TTCA using an intramedullary nail with a valgus curve by the same senior surgeon (HW). Twenty-two patients were available for analysis in our study, with a mean follow-up of 22.3 (range, 6.8 to 38) months. The main outcome measurements included EQ-5D functional scores, the American Foot and Ankle Society ankle-hindfoot scale (AOFAS), radiologic assessment and clinical examination.Results: Bony union and a plantigrade foot were achieved in 100% subjects, with a mean time to union of 3.9 (range, 2.4 to 6.2) months. Structural bone graft was used in all patients. Postoperative radiologic results showed a good hindfoot alignment in all patients. Complications occurred in 1 case of delayed wound healing without a deep infection. The mean postoperative EQ-5DTM functional score and AOFAS ankle-hindfoot score was 69.33(range, 20 to 90) and 69.9 (range, 45 to 85 ) points, respectively. No revision surgery was asked in our cohort.Conclusions: Based on the present study, the TTCA using a short, retrograde, curved intramedullary nail is an acceptable technique in obtaining solid fusion and a good hindfoot alignment.IntroductionTibiotalocalcaneal arthrodesis (TTCA) is indicated in patients with complex hindfoot deformity, failed ankle arthroplasty, and failed ankle joint arthrodesis with subsequent subtalar arthritis.(1-4) It has been shown to be an effective treatment option for pain relief and correction of hindfoot malalignment.(2, 5) Many alternative fixations such as crossed cancellous screws,(6) angle bladed plates,(7) external frames,(8) and intramedullary nails(1, 2, 4, 9, 10) have been reported for TTCA combined with bone graft. External fixations, compression screws and plates are usually associated with longer periods of non- or partial weight-bearing postoperatively and low bony fusion rates.(7, 11) Compared with other fixations, the intramedullary nail had more popularity due to its stabilization and compression, which could be capable of generating compression to increase fusion rates especially in patients with poor bone quality. (11-13)Historically, straight retrograde intramedullary nails have been associated with many complications such as plantar neurovascular damage, poor hindfoot alignments, and stress reactions especially in the region of tibia isthmus.(5, 11, 14-16) Those complications extremely limit the clinical use of a straight retrograde nail when performing a TTCA. Recently, a curved retrograde nail has been reported to avoid those complications efficiently through the cadaveric and clinical studies, which lateralizes the entry point, thus potentially reducing the risk of damage to the lateral plantar nerve. Meanwhile, the valgus curve of this nail also contributes to maintain the physiological hindfoot valgus .(1, 4, 9, 11)The current study of one single surgeon series (HW) was performed to explore whether the clinical advantages could be obtained in TTCA using a curved retrograde intramedullary nail. We present the results of TTCAs with such a nail in 22 patients.Material and methodsBetween June 2009 and January 2012, twenty-three TTCAs in 23 consecutive patients were performed by the same senior surgeon (HW) in our foot and ankle department. Twenty-two patients were eligible in our study. The study protocol was approved by the Ethics Committee of our hospital and all the patients consented to the use of their data for research purposes.Average age of the cohort was 62.2(range, 46 to 79) years, with a male: female ratio of 10:12. The mean follow-up time is 22.3 (range, 6.8 to 38) months.The indications of TTCA using a curved nail in our study included patients who suffered arthritis affecting the ankle and subtalar joint, severe talar avascular necrosis, failed ankle arthroplasty and arthrodesis associated with secondary subtalar joint arthritis, and hindfoot deformities that are refractory to other treatments (Table 1).The description of the TTCA nailA retrograde, curved, interlocking nail, made of titanium (Stryker, Duisburg, Germany) was used in the present study (Figure 1). This design provides one angle stable lateral, one angle stable posterior-to-anterior calcaneal screw, as well as a conventional talar screw for distal fixation. The TTCA nail could be adjusted with following conditions: internal or external compression, or without compression in the operation procedure. Talocalcaneal joint compression was provided by an external compression device, which fixed on the target arm. Tibiotalar joint compression and angle stability was produced through a dynamic compression screw in the nail. The angle stability is attributed to an endcap locked onto the distal posterior to anterior calcaneal screw.(10) This nail had a 5-degree valgus curve to accommodate the physiological hindfoot valgus. In terms of the nail axis, external torsion of the calcaneal longitudinal axis was reflected in the 10- degree external rotation if the posterior-to-anterior calcaneal screw could be correctly inserted from posteromedial to anterolateral direction.(10)Surgical techniqueOf the 22 patients, 3 patients who suffered from failed ankle arthroplasty were performed in the supine position, with a sandbag under ipsilateral buttock and other 19 patients were in a prone position. Tourniquet hemostasis was used at the thigh in all operations. The post-lateral approach was applied to access the ankle and subtalar joints (Figure 2). The distal fibular was resected at the level of the syndesmosis with an oscillating saw. The articular surfaces of the ankle and subtalar joints were thoroughly resected to ensure contact between viable bleeding bones. The autologous bone graft harvested from the resected distal fibular were performed to fill bony defects. Percutaneous Achilles tendon lengthening was performed as needed. A 1.5-cm longitudinal incision was applied in the heel pad lateral to the midline.(10) A hemostat was used to bluntly dissect down to the calcaneus. The ideal entry point in the calcaneus was at the junction of the lateral one-third and medial two-thirds, which corresponded to the mid-point of medullary canal of the tibia (Figure 3).(1) A guide wire was placed into calcaneus with a physiological 5° valgus curve under fluoroscopic guidance when an assistant was maintained the neutral position for arthrodesis, passing through the subtalar joint. The direction was supposed to be changed into straight after the guide wire went into the talar. While an assistant maintained the optimum position, a cannulated reamer was employed to increase the size of the canal to 1 mm above the diameter of the nail, passing through the subtalar and ankle joints. In this procedure, the main concerns were to avoid anterior and posterior subluxation, which could be resolved by placing the talus correctly in the ankle joint. External rotation was adjusted to match that of the contralateral foot ranging from 5 to 10 degrees. The nail was inserted under fluoroscopic guidance. A plantigrade foot, without pronation or supination of the forefoot was the goal for alignment. One transverse locking screw was placed into talus firstly. Two proximal locking screws were then inserted into tibia under fluoroscopic guidance and positioned at the superior end of the nail from medial to lateral with the target device. A shaft screw is inserted into the oblong hole at the distal end of the nail for compression. When the compression screw is inserted axially into the distal end of the nail, it pushes against the shaft screw to generate compression between the resected bone surfaces. The distal screw of calcaneus is placed from lateral to medial with the target device after the compression procedure is finished. At last, the posterior-to-anterior calcaneal screw is inserted from posteromedial to anterolateral direction. Wound closure was performed in a standard procedure.For failed ankle arthrodesis cases, the iliac-crest bone graft were required because the distal fibular have been resected in primary surgery.A below-knee orthotic was used for a minimum of 6 weeks for immobilization (non-weightbearing for 2 weeks, partial weightbearing with 10kg for 4 weeks) and finally fully weightbearing for additional 6 weeks. A screw removal was not schedule for dynamisation. The X-ray result and other medical co-morbidities were recorded when patients came to the clinic for follow-up at 6 weeks, 3 moths, 6 months, and 1-year after surgery.Ankle and hindfoot radiographs, including weight-bearing lateral and antero-posterior ankle views as well as the calcaneus axis view, were performed preoperatively and postoperatively (Figure 4). Hindfoot alignment was described in terms of the calcaneus axis with regard to the distal tibial axis on the calcaneus axis view (Saltzman). Measurements were based on digitized radiographs with Ortho-Tool Cedara 1 Report 5.2 P14 software (Cedara Software Corporation, Milwaukee, WI). The radiographic union was characterized by bone trabeculae crossing the joint with joint line obliteration and consolidation.(16) Delayed union was defined as lacking of radiographic bony consolidation after the 3-month follow-up investigation. Clinical union was defined as pain-free loss of passive or active movement at the subtalar and ankle joints.(5, 12)Patients were asked about their satisfaction with their outcomes and treatment procedures. We completed the EQ-5D-3L questionnaire in the latest follow-up. This questionnaire comprises the following 5 dimensions (mobility, self care, usual activities, pain/discomfort, anxiety/depression). Each dimension has 3 levels: no problems, some problems, and extreme problems, which measure the health-related quality of life.(17, 18) Other points analyzed the time of orthotic support, requirement for analgesics during follow-up.Statistic analysis was performed using SPSS 17.0 (SPSS Inc., Chicago, IL). The T test was performed to test to compare the data. Significance was established as P<0.05.< p="">ResultsThe mean operation time is 128 (range, 72 to 214) minutes.UnionsRadiographic and clinical unions were obtained in 100% (22/22) patients, with a mean time to union of 3.9 (range, 2.4 to 6.2) months. Two patients had delayed radiographic union at ankle joint (union at 5 and 6.2 months, respectively)Correction of deformity (Figure 5)Preoperatively, there were 15 patients with mean 15.29±14.21 degrees of varus hindfoot deformity and 5 patients with mean 11.16±9.61 degrees of valgus hindfoot deformity. Postoperatively, 100% patients in our cohort achieved a plantigrade foot. Satisfactory hindfoot with varus and valgus of less than five degrees was achieved in 100% patients. Compared to the preoperative angle, there is a significant statistic difference in the postoperative valgus angle of hindfoot alignment was 3.73±1.06 degrees (P=0.003) in preoperative varus deformity patients, and 3.99±0.96 degrees (P=0.045) in preoperative valgus deformity patients, respectively.Functional scoreDue to lack of the sagittal motion (flexion plus extension) and coronal motion (inversion plus eversion) of hindfoot, the highest AOFAS ankle-hindfoot score after TTCA was 86. We got the evaluation of functional score in seventeen patients. The mean postoperative EQ-5DTM functional score was 69.33(range, 20 to 90) and the mean postoperative AOFAS ankle-hindfoot score was 69.9 (range, 45 to 85 ) points at the latest follow-up. Two patients required a walking aid (elbow crutch or cane). Eight patients have slight or severe difficulty on uneven terrain, stairs, inclines, and ladders. Obvious or marked gait abnormality was observed in 6 patients.When questioned about pain, mild pain occurred in 5 patients. Meanwhile, no patients complain severe pain. The left patients were pain-free. 21 of 22 ( 95%) patients declared that they would undergo the operation again.Complications90.9% (21/22) patients were satisfied with their outcome and treatment procedures in the latest follow-up. One dissatisfied patient was with superficial delayed wound healing without signs of infection. One patient encountered soft tissue irritation, resulting from the screw of the calcaneal. She recovered immediately and satisfied with the result after we removed the screw. Non-union including both ankle and subtalar joints didn’t occur in our study. By the time of the latest follow-up, cortical stress reactions including a complete fracture around the proximal locking screws and the proximal tip of the nail were not observed.ConclusionBased on the present study, the TTCA using a short, retrograde, curved intramedullary nail may be an acceptable technique in obtaining solid fusion with minimal complications. However, the results of long-term follow-up are necessary to provide definitive information such as adjacent degenerative arthritis in the future.REFERENCES1. Budnar VM, Hepple S, Harries WG, et al. Tibiotalocalcaneal arthrodesis with a curved, interlocking, intramedullary nail. Foot & ankle international. 2010;31:1085-1092.2. Boer R, Mader K, Pennig D, et al. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clinical Orthopaedics and Related Research. 2007;463:151-156.3. Carrier DA, Harris CM. Ankle arthrodesis with vertical Steinmann's pins in rheumatoid arthritis. Clinical Orthopaedics and Related Research. 1991;23:10-14.4. Haaker R, Kohja EY, Wojciechowski M, et al. Tibio-talo-calcaneal arthrodesis by a retrograde intramedullary nail. Ortop Traumatol Rehabil. 2010;12:245-249.5. Chou LB, Mann RA, Yaszay B, et al. Tibiotalocalcaneal arthrodesis. Foot & ankle international. 2000;21:804-808.6. Zwipp H, Rammelt S, Endres T, et al. High union rates and function scores at midterm followup with ankle arthrodesis using a four screw technique. Clinical Orthopaedics and Related Research. 2010;468:958-968.7. Hanson TW, Cracchiolo A, 3rd. The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot & ankle international. 2002;23:704-710.8. Santangelo JR, Glisson RR, Garras DN, et al. Tibiotalocalcaneal arthrodesis: a biomechanical comparision of multiplanar external fixation with intramedullary fixation. Foot & ankle international. 2008;29:936-941.9. Richter M. Computer-assisted surgery (CAS)-guided correction arthrodesis of the ankle and subtalar joint with retrograde nail fixation. Oper Orthop Traumatol. 2011;23:141-150.10. Muckley T, Klos K, Drechsel T, et al. Short-term outcome of retrograde tibiotalocalcaneal arthrodesis with a curved intramedullary nail. Foot & ankle international. 2011;32:47-56.11. Muckley T, Ullm S, Petrovitch A, et al. Comparison of two intramedullary nails for tibiotalocalcaneal fusion: anatomic and radiographic considerations. Foot & ankle international. 2007;28:605-613.12. Millett PJ, O'Malley MJ, Tolo ET, et al. Tibiotalocalcaneal fusion with a retrograde intramedullary nail: clinical and functional outcomes. Am J Orthop. 2002;31:531-536.13. Morrey BF, Wiedeman GP, Jr. Complications and long-term results of ankle arthrodeses following trauma. The Journal of bone and joint surgery American volume. 1980;62:777-784.14. Thordarson DB, Chang D. Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot & ankle international. 1999;20:497-500.15. Anderson T, Linder L, Rydholm U, et al. Tibio-talocalcaneal arthrodesis as a primary procedure using a retrograde intramedullary nail: a retrospective study of 26 patients with rheumatoid arthritis. Acta Orthopaedica. 2005;76:580-587.16. Goebel M, Muckley T, Gerdesmeyer L, et al. [Intramedullary nailing in tibiotalocalcaneal arthrodesis]. Unfallchirurg. 2003;106:633-641.17. Nan L, Johnson JA, Shaw JW, et al. A comparison of EQ-5D index scores derived from the US and UK population-based scoring functions. Med Decis Making. 2007;27:321-326.18. Carr-Hill RA. Health related quality of life measurement--Euro style. Health Policy. 1992;20:321-328; discussion 329-332.19. Mears DC, Gordon RG, Kann SE, et al. Ankle arthrodesis with an anterior tension plate. Clinical Orthopaedics and Related Research. 1991:70-77.20. Hammett R, Hepple S, Forster B, et al. Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures. Foot & ankle international. 2005;26:810-815.21. Kile TA, Donnelly RE, Gehrke JC, et al. Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot & ankle international. 1994;15:669-673.22. Bibbo C, Lee S, Anderson RB, et al. Limb salvage: the infected retrograde tibiotalocalcaneal intramedullary nail. Foot & ankle international. 2003;24:420-425.23. Mader K, Verheyen CC, Gausepohl T, et al. Minimally invasive ankle arthrodesis with a retrograde locking nail after failed fusion. Strategies Trauma Limb Reconstr. 2007;2:39-47.24. Mann RA, Chou LB. Tibiocalcaneal arthrodesis. Foot & ankle international. 1995;16:401-405.25. Berend ME, Glisson RR, Nunley JA. A biomechanical comparison of intramedullary nail and crossed lag screw fixation for tibiotalocalcaneal arthrodesis. Foot & ankle international. 1997;18:639-643.26. Mader K, Pennig D, Gausepohl T, et al. Calcaneotalotibial arthrodesis with a retrograde posterior-to-anterior locked nail as a salvage procedure for severe ankle pathology. The Journal of bone and joint surgery American volume. 2003;85-A Suppl 4:123-128.Table 1: Indications for TTCA in the present studyClassificationsUnderlying diagnosisNumbers of patientsArthritisPrimary osteoarthritis (OA)Posttraumatic osteoarthritisSevere talar avascular necrosis391Failed ankle arthroplastyFailed ankle arthroplasty with progressive subtalar arthritis3Failed ankle arthrodesis with progressive subtalar arthritisFailed ankle arthrdesis with screwsFailed TTCA with a nail41DeformityIdiopathic canovarus with secondary OA1Table 2: The literatures about TTCA (more than 20 patients) using retrograde nails including curved nails and straight nails.AuthorsNumbersofTTCAsThe type of the retrograde nailUnionRateComplicationRateFunctionOutcome(Postoperative)(AOFAS hindfoot-ankle)Satisfactorywith resultsBundnar et al.(1)45Curved89%21%69.7678%Mükley et al.(10)55Curved96%25%66.893%Goebel et al.(16)29Straight90%21%7179%Anderson et al.(15)26Five retrograde nails*96%23%6492%Hammett et al.(20)49Humeral nails87%20%6382%Boer et al.(2)50Curved96%4%7092%Remarks: AOFAS (The American Orthopedic Foot & Ankle Society);* Five different designs of the nail included the flanged Thornton nail (originally designed for hip fracture), the revision nail (Smith & Nephew, Memphis, TN), the Biomet ankle arthrodesis nail (Biomet Orthopedics, Warsaw, IN), the AIM nail (DePuy Orthopedic, Warsaw, IN), and the humerus nail (Synthes, Obersdorf, Switzerland).Figure legendsFigure 1: Photograph of a TTCA nail with a distal valgus curve (TTC fusion nail, Stryker, Duisburg, Germany)Figure 2. The intraoperative photographs show the procedure of TTCA in a 71-year-old woman with failed ankle arthroplasty and progressive subtalar arthritis. The photograph showing (A) the post-lateral approach; (B) removal of the ankle prosthesis; (C) thorough resection of articular surfaces of the ankle and subtalar joints ;(D) bone defection; (E) a cannulated reamer was employed to increase the size of the canal to 1 mm above the diameter of the nail, passing through the subtalar and ankle joints under fluoroscopic guidance; (F) bony defects filled with the autologous bone graft harvested from the resected distal fibular.Figure 3: The plantar facet of the calcaneus shows the ideal entry point (the slim arrow) for a curved retrograde nail with regard to the tibial medullary canal (the bold arrow) and the adjacent lateral nerve vascular bundle (yellow line).Figure 4: The AP (A) and lateral (B) radiographs of ankle show the prosthesis loosening in a 48-year-old man with a failed ankle arthroplasty. Postoperative 5 months’ AP (C) and lateral (D) radiographs show bone ununion and the subtalar joint destruction caused by the screw after the ankle arthrodesis. Three months postoperative AP (E) and lateral (F) radiographs of the third operation show bony union at both subtalar and ankle joints after a TTCA using a curved retrograde intramedullary nail, with a good alignment of hindfoot.Figure 5: Comparisons of radiological results of hindfoot alignment.