Outcome of calcaneal fractures treated operatively and non-operatively. the effect of litigation on outcomes

Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform

INTRODUCTION

The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures.

METHODS

This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type.

RESULTS

A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels.

CONCLUSIONS

Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

Bone graft versus non-bone graft for treatment of calcaneal fractures: A protocol for meta-analysis

BACKGROUND

Calcaneal fractures are a prevalent form of injury caused by high-energy trauma. This study aimed at investigating whether bone graft and non-bone graft are essential for the internal fixation of calcaneal fractures. A meta-analysis of relevant clinical studies evaluated radiographic parameters, functional outcomes, and complications that offer practical recommendations on the suitability of bone grafts for the management of Calcaneal fractures.

METHODS AND ANALYSIS

This study performed a comprehensive search on PubMed, EMBASE, and Cochrane electronic to retrieve related clinical studies. The studies incorporated in our meta-analysis were identified after doing a preliminarily screening, reading of the full-text articles, and eliminating repeated studies. After quality assessment and data extraction, the standardized mean difference and risk ratio were selected as effect sizes. The data on Böhler angle, Gissane angle, calcaneal height, American Orthopaedic Foot and Ankle Society hindfoot scores, Maryland Foot Evaluation, and rate of wound infection were analyzed using Revman 5.3 software (Cochrane Collaboration).

RESULTS AND CONCLUSIONS

This study did not reveal any significant differences (P < .05) in both Böhler and Gissane angles, calcaneal height, American Orthopaedic Foot and Ankle Society hindfoot scores, Maryland foot evaluation, and rate of wound infection between the 2 groups. Due to the lack of a large sample of comparative studies, the use of bone grafting for the management of calcaneal fractures requires additional substantiation.

Socioeconomic Factors Influencing Self-reported Outcomes After Posterior Wall Fractures of the Acetabulum: Lessons Learned From a Hispanic Population

Introduction:

Demographic and socioeconomic factors are important determinants that may affect patient self-reported outcomes after acetabular fracture surgery. Hispanics, as a minority group, have an increased tendency to suffer demographic and socioeconomic disparities. At the present time, there is scant information regarding their role among Hispanic patients with acetabular fractures. The aim of this study was to investigate whether demographic or socioeconomic factors would affect satisfaction and self-reported functional outcomes in Hispanic patients who endured open reduction and internal fixation (ORIF) of posterior wall fractures of the acetabulum.

Methods:

A cross-sectional study of 78 patients with posterior wall fracture of the acetabulum treated with ORIF from 2011 to 2017 was performed. Data from demographics (age, sex, and body mass index [BMI]) and socioeconomic factors (household income, highest educational level achieved, employment status, type of medical insurance, workers' compensation involvement, and injury-related litigation process) were obtained and compared with the Short Musculoskeletal Form Assessment-46 (SMFA-46) questionnaire using a multivariable logistic regression analysis.

Results:

Unemployment was the most significant variable associated with dissatisfaction among 15 of the 46 responses of the SMFA-46 (P < 0.048). Patients who had an overweight or obese BMI and had an age of 41 years or older exhibited significantly worse outcomes in 7 of the 46 questions (P < 0.049). Finally, women were less likely to be satisfied in 1 of the 46 questions (P = 0.028). No notable difference was observed in any of the SMFA-46 responses regarding insurance plan, educational level, workers' compensation involvement, and injury-related litigation process.

Discussion:

A strong association exists between dissatisfaction after ORIF of posterior wall fractures of the acetabulum and employment status, BMI, and age among the Hispanic population. Addressing socioeconomic factors can be critical to overcome dissatisfaction and improve functional status among Hispanic patients with acetabular fractures.

Claims in orthopedic foot/ankle surgery, how can they help to improve quality of care? A retrospective claim analysis

Background

Orthopedic foot/ankle surgery is a high risk specialty when it comes to malpractice claims. This study aims to evaluate the incidence, characteristics and outcome of claims in this area.

Methods

This was a retrospective, 10-year claim analysis, with data from an anonymous database. Baseline claim/claimant characteristics were collected from all orthopedic foot/ankle-related cases.

Results

Of 460 claims in total, most were related to delay in/wrong diagnosis or to (complications of) elective surgical procedures. Whether a claim was settled was related to type of injury (fracture) and type of claim (diagnostic mistake). Median amount disbursed in settled claims was €12,549. Claim incidence did not increase over the years.

Conclusion

Missed fracture diagnosis and “failed”/disappointing results of elective surgical procedures were the most common causes for claims. Sufficient knowledge of missed (foot) fractures and clear communication/expectation management before elective procedures could help to improve quality of healthcare and patient satisfaction.

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

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.

The Role of Allograft Bone in Foot and Ankle Arthrodesis and High-Risk Fracture Management

Allogenic bone graft has long been accepted as a standard of care in the surgical arthrodesis of the foot and ankle and treatment of certain high-risk, comminuted fracture types that have greater potential for delayed union or nonunion. It has been shown in multiple studies to be equivalent to autograft in regard to union rates without the morbidity associated with bone graft harvest. We present a retrospective study on the efficacy of an allogenic cancellous/periosteal cellular bone matrix with mesenchymal stem cells and angiogenic growth factors. The study includes a cohort of 41 procedures and 40 patients who underwent foot and ankle arthrodesis, fracture fixation, or a simultaneous combination of both. Radiographic consolidation of the fracture/fusion site was reviewed at regular intervals (first postoperative visit at 1 week and 4, 8, and 12 weeks and at regular intervals until healing was confirmed). Age, workmen's compensation insurance, diabetes, and nicotine use were evaluated as potential risk factors. Our retrospective study indicated that allograft bone has the potential to positively affect union rates in foot and ankle arthrodesis and certain high-risk fracture types that have potential for delayed union/nonunion. Levels of Evidence: Level IV.

Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: A meta-analysis of current evidence base

BACKGROUND

The relative efficacy of operative and nonoperative treatments for the displaced intra-articular calcaneal fractures (DIACF) remains uncertain.

OBJECT

We conducted a meta-analysis to compare the effectiveness of operative and nonoperative treatments in treating patients with DIACF.

METHODS

Databases including Cochrane Library, Medline, Embase, CBM, CNKI, and Google Scholar were searched. After independent study selection by 2 authors, data were extracted and collected independently. Comparisons were performed between operative treatment group and nonoperative treatment group. The quality of included studies was assessed using the Newcastle-Ottawa Scale. RevMan 5.3 was used for data analysis. The primary outcome measures were anatomical measures (changes in Böhler angle and calcaneal height and width), functional measures (shoe problems, resuming preinjury work, and residual pain), and complications (including superficial and deep wound infection, skin flap necrosis, neurovascular injury, secondary arthrodesis, reflex sympathetic dystrophy, osteotomy, thromboembolism, and compartment syndromes).

RESULTS

Eighteen trials (8 randomized controlled trials and 10 controlled clinical trials) including 1467 patients were considered. For anatomical measurements, the overall mean differences (MDs) for the mean Böhler angle, calcaneal height and width were 15.39 (95% confidence interval [CI] 9.12-21.67), 6.55 (95% CI 2.67-10.43), and 7.05 (95% CI -7.83 to -6.27), respectively. In functional measures, the overall effect MD of American Orthopedic Foot and Ankle Society was 6.23 (95% CI 5.22-17.67) and 0.38 (95% CI 0.22-0.67). The overall relative risks (RRs) of wearing shoes, resuming preinjury work, and having residual pain were 0.32 (95% CI 0.32-1.00), 0.56 (95% CI 0.40-0.77), and 0.90 (95% CI 0.68-1.20), respectively. The overall RR of the incidence of complications was 2.00 (95% CI 1.51-2.64).

CONCLUSION

Operative treatment of DIACF may lead to a higher incidence of complications but has better anatomical recovery when compared with nonoperative treatment.

Effect of Delay to Definitive Surgical Fixation on Wound Complications in the Treatment of Closed, Intra-articular Calcaneus Fractures

BACKGROUND

There are conflicting data regarding the benefits of delaying operative fixation of calcaneus fractures to decrease wound complication rates. The purpose of this study was to examine the effect of delaying fixation on wound complication rates as well as to identify other risk factors.

METHODS

A retrospective review at 4 institutions, including 24 surgeons, identified 405 closed, operatively treated, intra-articular calcaneus fractures. We compared fractures with and without wound complications with regards to patient demographics, medical risk factors, fracture severity, time to fixation, operative approach, primary subtalar arthrodesis, and surgeon experience.

RESULTS

Wound complications were observed in 21% (87/405) of fractures, of which 33% (29/87) required operative intervention. Male sex (P = .032), smoking (P = .028), and the extensile lateral approach (P < .001) were associated with higher complication rates. Fractures treated with an extensile lateral approach had an overall wound complication rate of 32.1%, while those treated with a sinus tarsi or percutaneous approach had an overall wound complication rate of 8.3% (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.9-9.5; P < .001). Among patients treated with an extensile lateral approach, delayed operative fixation did not decrease wound complication rates despite comparable fracture severity across time points. In contrast, among fractures treated with less invasive approaches, delayed fixation beyond 2 weeks resulted in a significantly increased wound complication rate of 15.2% as compared to a wound complication rate of only 2.1% among fractures treated within a week of injury (OR, 3.2; 95% CI, 1.3-9.5; P = .01). This was observed despite similar fracture severity across time points. Primary subtalar arthrodesis did not impact complication rates. A higher wound complication rate among senior surgeons was likely secondary to their predilection for the extensile lateral approach.

CONCLUSION

Delaying definitive fixation of closed, intra-articular calcaneus fractures did not decrease wound complication rates when using the extensile lateral approach, and we found an increased wound complication rate when using less invasive approaches.

LEVEL OF EVIDENCE

Level III, observational study.

Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial

OBJECTIVE

To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal fractures.

DESIGN

Pragmatic, multicentre, two arm, parallel group, assessor blinded randomised controlled trial (UK Heel Fracture Trial).

SETTING

22 tertiary referral hospitals, United Kingdom.

PARTICIPANTS

151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to operative (n=73) or non-operative (n=78) treatment.

MAIN OUTCOME MEASURES

The primary outcome measure was patient reported Kerr-Atkins score for pain and function (scale 0-100, 100 being the best possible score) at two years after injury. Secondary outcomes were complications; hindfoot pain and function (American Orthopaedic Foot and Ankle Society score); general health (SF-36); quality of life (EQ-5D); clinical examination; walking speed; and gait symmetry. Analysis was by intention to treat.

RESULTS

95% follow-up was achieved for the primary outcome (69 in operative group and 74 in non-operative group), and a complete set of secondary outcomes were available for 75% of participants. There was no significant difference in the primary outcome (mean Kerr-Atkins score 69.8 in operative group v 65.7 in non-operative group; adjusted 95% confidence interval of difference -7.1 to 7.0) or in any of the secondary outcomes between treatment groups. Complications and reoperations were more common in those who received operative care (estimated odds ratio 7.5, 95% confidence interval 2.0 to 41.8).

CONCLUSIONS

Operative treatment compared with non-operative care showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures.Trial registration Current Controlled Trials ISRCTN37188541.

Can tibial plateau fractures be reduced and stabilised through an angiosome-sparing antero-lateral approach?

INTRODUCTION AND AIM

Tibial plateau fractures (TPFs) are an independent, non-modifiable risk factor for surgical site infections (SSIs). Current antero-lateral approaches to the knee dissect through the anterior tibial angiosome (ATA), which may contribute to a higher rate of SSIs. The aim of this study was to develop an angiosome-sparing antero-lateral approach to allow reduction and fixation of lateral TPFs and to investigate its feasibility in a consecutive cohort.

METHODS

Twenty cadaveric knees were dissected to define the position of the vessels supplying the ATA from the lateral tibial condyle to the skin perforators. Based on these results, an angiosome-sparing surgical approach to treat lateral TPFs was developed. Fifteen consecutive patients were subsequently treated through this approach. Clinical outcomes included assessment of SSI and Lysholm score. Fracture healing and stability were assessed using the Rasmussen score and radiostereometric analysis (RSA).

RESULTS

At the latest follow-up between 1 and 4 years, there was no report of SSI. Nine patients (60%) had good or excellent Lysholm scores. The mean Rasmussen score at final follow-up was 17 (median 18, range 14-18) with 10 patients (66%) graded as excellent. Fracture fragment migration measured using RSA was below 2mm in all cases.

DISCUSSION

This study has demonstrated that an angiosome-sparing antero-lateral approach to the lateral tibial plateau is feasible. Adequate stability of these fracture types was achieved by positioning a buttress plate away from the bone and superficial to the regional fascial layer as an 'internal-external fixator'.

CONCLUSION

The angiosome-sparing approach developed was able to be used in a prospective cohort and the clinical results to date are encouraging. Future clinical studies need to investigate the potential benefits of this surgical approach when compared with the previously described antero-lateral approaches.

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study

BACKGROUND

Lateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach.

PATIENTS AND METHODS

All nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score.

RESULTS

Fractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5mm (interquartile range=4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach.

CONCLUSION

This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.

Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary?

Background

The aim of this retrospective study was to determine the need for bone grafting in the surgical treatment of displaced intra-articular calcaneal fractures. We reviewed 390 cases of displaced intra-articular calcaneal fractures treated with plate osteosynthesis with or without autologous iliac bone grafting, and compared outcomes and complications related to fracture stabilization.

Materials and methods

Three hundred ninety patients with displaced intra-articular calcaneal fractures that were treated with plate osteosynthesis from December 2002 to December 2010 were reviewed. Two hundred two patients (group A) were treated by osteosynthesis with autologous bone grafting, and 188 patients (group B) were treated by osteosynthesis without bone grafting. One hundred eighty-one patients with an AO type 73-C1 fracture (Sanders type II), 182 patients with an AO type 73-C2 fracture (Sanders type III), and 27 patients with an AO type 73-C3 fracture (Sanders type IV) were included in this study. Bohler’s angle, the crucial angle of Gissane, and calcaneal height in the immediate postoperative period and at the 2-year follow-up were compared. Any change in the subtalar joint status was documented and analyzed. The final outcomes of all patients were evaluated by the AOFAS Ankle–Hindfoot Scale and compared in both groups.

Results

The mean full weight-bearing time in group A (with bone grafting) was significantly lower (median 6.2 months, range 2.8–9.2 months) than that in group B (without bone grafting; median 9.8 months, range 6.8–12.2 months). The immediate-postoperative Bohler’s angle and that at the 2-year follow-up were significantly higher in group A. The loss of Bohler’s angle after 2 years was significantly lower in group A (mean 3.5°; 95 % CI 0.8°–6.2°) than in group B (mean 6.2°; 95 % CI 1.0°–11.2°). The average change in the crucial angle and the average change in calcaneal height were not statistically significant for either group. The infection rate in the bone grafting group was higher, though statistically insignificantly so, than in the nongrafting group (8.3 vs. 6.3 %). No significant difference was found between the groups in terms of the rates of good reduction, postoperative osteoarthritis, and subtalar fusion. Regarding the efficacy outcomes, the mean AOFAS score was lower (mean 76.4 points; 95 % CI 65.8–82.9 points) in group A than in group B (mean, 81.6 points; 95 % CI, 72.3–88.8 points), but this difference was not significant (p > 0.05).

Conclusions

Bohler’s angle showed improved restoration and the patients returned to full weight-bearing earlier when bone grafting was used in the treatment of intra-articular calcaneal fracture. However, the functional outcomes and complication rates of both groups were similar.

Primary fusion in worker's compensation intraarticular calcaneus fracture. Prospective study of 169 consecutive cases

PURPOSE

To study the results of reconstruction and primary fusion in worker's compensation intraarticular calcaneus fractures.

PATIENTS AND METHODS

We carried out a prospective study of 169 acute intraarticular calcaneus fractures treated by reconstruction and primary fusion with the minimally invasive Vira® system, in severe calcaneus fractures. The evaluation was performed by clinical, radiological and biomechanical analysis.

RESULTS

AOFAS score averaged 77.26 points at the end of follow up. Forty-two cases (24.9%) obtained excellent results, 108 (63.9%) good, 12 (7.1%) mild and 7 (4.1%) poor. The improvement in Börder's angle after surgery was significant (p = 0.05) and this did not vary during the follow up. Subtalar arthrodesis was achieved in all cases and only three cases needed bone grafting. Five major post-surgical complications were observed, and one deep infection in a case of open Gustilo Grade III fracture. In the kinetic study, the support time of the operated foot was lower than that of the contralateral foot (p<0.21). The axial force of the heel contact and the single limb support of the operated foot reduced the toe-off axial forces. In the foot with arthrodesis the posterior forces increased (p <0.01). The pressures were lower in the region of the heel and the mid-foot and in the external part of the forefoot, and increased in the big toe.

CONCLUSIONS

Calcaneal workplace injuries are challenging to treat. Primary subtalar fusion with a minimally invasive method allows rapid recovery for these patients with a satisfactory clinical, functional and radiological outcome.

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

PURPOSE

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

METHODS

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

RESULTS

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the Böhler angle (P < 0.0001), more stable calcaneal height (P = 0.0009) and width (P < 0.00001). Moreover, fewer surgically treated patients needed increased shoe size (P = 0.0004) and more were able to resume pre-injury work (P = 0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P = 0.49). However, operative management was associated with a higher risk of complications (P = 0.008).

CONCLUSIONS

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

PURPOSE

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

METHODS

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

RESULTS

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the Böhler angle (P < 0.0001), more stable calcaneal height (P = 0.0009) and width (P < 0.00001). Moreover, fewer surgically treated patients needed increased shoe size (P = 0.0004) and more were able to resume pre-injury work (P = 0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P = 0.49). However, operative management was associated with a higher risk of complications (P = 0.008).

CONCLUSIONS

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

PURPOSE

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

METHODS

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

RESULTS

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the Böhler angle (P < 0.0001), more stable calcaneal height (P = 0.0009) and width (P < 0.00001). Moreover, fewer surgically treated patients needed increased shoe size (P = 0.0004) and more were able to resume pre-injury work (P = 0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P = 0.49). However, operative management was associated with a higher risk of complications (P = 0.008).

CONCLUSIONS

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.

Treatment of displaced intraarticular calcaneal fractures with or without bone grafts: A systematic review of the literature

BACKGROUND

The necessity of bone grafts in the treatment of intraarticular calcaneal fractures continues to be one of the most debated topics in foot and ankle surgery. The purpose of this study was to determine whether there are sufficient objective cumulative data in the literature to compare the two methods and if the bone graft was needed in surgical treatment of intraarticular calcaneal fractures.

MATERIALS AND METHODS

A comprehensive search of all relevant articles from 1990 to 2010 was conducted. Two reviewers evaluated each study to determine its suitability for inclusion and collected the data of interest. Meta-analytic pooling of group results across studies was performed for the two treatment methods.

RESULTS

The systematic review identified 32 primary studies with 1281 fractures, which contained 4 comparative studies, 13 with bone grafts, and 15 without bone grafts in treatment methods. The infection rate in bone graft group was higher through statistically insignificant than in non-graft group (8.3% vs. 6.3%) No significant difference was found between good reduction rate, postoperative osteoarthritis rate, and subtalar fusion rate. The average full weight-bearing time in bone graft group was significantly lower (5.4 months) than in non-graft group (10.5 months). The mean postoperative Böhler's angle was significantly higher in bone graft group (lose due to collapse was significancy less). For the efficacy outcomes, the bone graft group had a lower American Orthopaedic Foot and Ankle Society Score (AOFAS) (71.4 points vs. 80.5 points) but a higher Creighton score (89.9 points vs. 81.0 points) compared with non-graft group. Pooled mean results showed 35% of the patients in bone graft group had an excellent result, 40% had a good result, 21% had a fair result, and 4% had a poor result. In the non-graft group, the corresponding values were 34, 42, 14, and 10%, respectively.

CONCLUSIONS

The operative treatment of intraarticular calcaneal fractures with bone grafts could restore the Böhler's angle better and the patients could return to full weight bearing earlier. However, the functional and efficacy outcomes appear to be similar between the two treatment groups. There were more joint depression and comminuted fractures in the bone graft group, and the mean followup time was shorter. Large sample comparative studies are still needed.

Posttraumatic arthrodesis of the subtalar joint--outcome in workers compensation and rates of non-union

BACKGROUND

Regardless of the simple surgical technique, the success of the subtalar arthrodesis is limited by the rate of non-unions of the arthrodesis. The functional outcome of workers compensation is known to be poorer compared to patients without pending litigation. The aim of this study was to quantify the rate of non-unions and to determine risk factors leading to failure of the osseous consolidation after arthrodesis of the subtalar joint. The outcome assessed is a general health assessment with the SF-36 questionnaire and more illness specific with the AOFAS hindfoot score. Secondly, the influence of the health insurance status of the patients with or without worker's compensation on the outcome was tested.

METHODS AND RESULTS

The inclusive criterion was an arthrodesis of the subtalar joint with and without autologous cancellous bone grafting and screw osteosynthesis. This cohort study included the clinical course of 115 patients with posttraumatic osteoarthritis from 2000 to 2006. The average age of the patients (n=115) was 47±11.0 years, 83% of the treated patients were men. 68% of the patients suffered of secondary osteoarthritis after calcaneal fracture. The time interval from trauma to presenting at the physician due to therapy resistant pain was in the average 5.5±9.9 years. After primary arthrodesis (n=101) of the subtalar joint osseous consolidation was proved in 55% cases, consolidation was questionable in 21% and the rate of no consolidation with revision was remarkable high with 24%. The duration of osseous consolidation was proved by plain projection radiography or computer tomography and clinical reduction of pain. For primary arthrodesis osseous consolidation was reached after 6.4±6.3 month, after secondary arthrodesis osseous consolidation was reached after 9.4±13.1 month. After revision surgery 57% of the arthrodesis healed, 12% the osseous consolidation was questionable, and the failure rate was still 12%.

CONCLUSION

The outcome measures of the patients with SF-36 and the more functional related AOFAS hindfoot score showed poor outcome rates after subtalar fusion in posttraumatic osteoarthritis. The AOFAS hindfoot score was 47±24 points after primary arthrodesis and 46±17 points after secondary arthrodesis of the subtalar joint. The patients regained their former ability to work only in 30% after fusion of the subtalar joint. If revision surgery was necessary 8% of the patients got back to their work prior to the injury.

Association between CT imaging at follow-up and clinical outcomes in heel fractures

The reliability of CT data for calcaneal fractures was evaluated, quantifying five CT parameters and investigating their association with clinical outcomes. Fifty-four intra-articular calcaneal fractures surgically treated were considered. Vertical and longitudinal alignment, calcaneal body height, position of sustentaculum tali and subtalar joint congruity were evaluated at 49 months (27-94) follow-up. Each parameter was then quantified and its association with the clinical outcome assessed by the Maryland Foot Score was evaluated. Better clinical outcomes showed a significant association with vertical/longitudinal realignment and with restoration of the calcaneal height. No significant association emerged with reconstruction of the thalamic joint facet congruity. Three-dimensional reconstruction of the calcaneus, in terms of vertical and longitudinal alignment, restoration of the height of the heel body even irrespective of a perfect joint congruity, seems today to be the main goal of the treatment.

Treatment of severe fractures of the calcaneus by reconstruction arthrodesis using the Vira System: Prospective study of the first 37 cases with over 1 year follow-up

PURPOSE

To study the surgical applicability and clinical results of the Vira System in treatment for severe fractures of the calcaneus.

METHODS

A total of 37 acute intra-articular fractures of the calcaneus treated by reconstruction and primary fusion with the minimally invasive Vira System. Of them, 33 patients were analysed over a 2-year period. All fractures were classified, according to the Sanders criteria, as grade IV. The mean age was 42.08 years. Four were bilateral fractures and three were open fractures. All the patients were evaluated, in a prospective manner, using the American Orthopaedic Foot and Ankle Society (AOFAS) scale, plain radiographs and CT scan studies.

RESULTS

The average AOFAS score 12 months after surgery was 75.43 points (SD: 13.9). In 31 cases, the result was considered good and very good, and in five and one case mild and poor. Most of the patients (81%) could wear normal shoes; the footprint and the alignment of the heel were considered normal in all cases but seven patients showed a mild valgus deviation. The Böhler angle improvement after surgery was significant (p=0.05) and it did not vary along the follow-up. Subtalar arthrodesis was achieved in all cases. Only one case needed bone grafting. Important post-surgical complications were not registered in this cohort.

CONCLUSIONS

The Vira System is a useful option for the surgical treatment of severe fractures of the calcaneus, yielding good clinical and radiological results with a surgical procedure that is only minimally aggressive and has a low rate of complications.

External fixation for displaced intra-articular fractures of the calcaneum

A minimally-invasive procedure using percutaneous reduction and external fixation can be carried out for Sanders' type II, III and IV fractures of the os calcis. We have treated 54 consecutive closed displaced fractures of the calcaneum involving the articular surface in 52 patients with the Orthofix Calcaneal Mini-Fixator. Patients were followed up for a mean of 49 months (27 to 94) and assessed clinically with the Maryland Foot Score and radiologically with radiographs and CT scans, evaluated according to the Score Analysis of Verona. The clinical results at follow-up were excellent or good in 49 cases (90.7%), fair in two (3.7%) and poor in three (5.6%). The mean pre-operative Böhler's angle was 6.98 degrees (5.95 degrees to 19.86 degrees), whereas after surgery the mean value was 21.94 degrees (12.58 degrees to 31.30 degrees) (p < 0.01). Excellent results on CT scanning were demonstrated in 24 cases (44.4%), good in 25 (46.3%), fair in three (5.6%) and poor in two (3.7%). Transient local osteoporosis was observed in ten patients (18.5%), superficial pin track infection in three (5.6%), and three patients (5.6%) showed thalamic displacement following unadvised early weight-bearing. The clinical results appear to be comparable with those obtainable with open reduction and internal fixation, with the advantages of reduced risk using a minimally-invasive technique.