Minimalinvasive Versorgung von Kalkaneusfrakturen

Early Surgery and Screw-Only Osteosyntheses in Minimally Invasive Treatment of Calcaneal Fractures-Risk or Benefit for Our Patients?

Background: This study aims to analyze the outcomes following the minimally invasive surgery of calcaneal fractures using screw-only osteosynthesis, as well as the impact of surgical timing. Methods: Between 2015 and 2020, 155 patients with 168 fractures were included. According to the Sanders classification, 48.21% of fractures were classified as Sanders 2, 33.33% as Sanders 3, and 10.11% as Sanders 4 fractures, with the remaining fractures unclassified. A total of 117 cases were treated on the day of admission or the following day. The surgeries followed a standardized protocol for fracture analysis, positioning, and X-ray techniques, primarily using a percutaneous approach with stab incisions. Osteosynthesis was mainly performed using screws, with five cases treated with K-wires for open fractures. Results: The mean Boehler's angle improved from 8.52° preoperatively to 25.00° postoperatively. Three superficial infections were observed. Deep infections occurred in three cases, all following open fractures. Secondary dislocation was noted in five patients-one due to a deep infection, and four attributed to clear technical failures. One case involved a questionable indication for a screw change (7.3 mm screw) after two weeks due to perforation of the medial wall. A total of 79 fractures were followed up for an average of 4 years and 3 months. The mean AOFAS score was 91.3, and the mean FAOS score was 88.7. Surgery within 7 days after admission showed no significant impact on the outcomes. Conclusions: Minimally invasive screw-only osteosynthesis with early surgical intervention offers favorable outcomes with minimal risk.

[Calcaneoplasty with radiofrequency cementing following balloon reduction]

The standard surgical procedure for complex calcaneal fractures is open reduction, internal reduction and internal stable angle plate osteosynthesis via a lateral approach. More recently, options for minimally invasive and percutaneous surgical strategies have been presented [4, 7]. As a possible procedural alternative for a covered, surgical treatment of calcaneal fractures, calcaneoplasty is discussed and applied in this context [5]. In this case series of five complex calcaneal fractures presented here, a balloon catheter was used for percutaneous reduction to restore the alignment of the calcaneus.This was followed by placement of PMMA cement in radiofrequency application and osteosynthesis using percutaneous cannulated screws. This Vicenti technique allows stable reduction and retention with early partial weight bearing with an overall low complication rate [17].

Evolution of imaging in surgical fracture management

Intraoperative imaging has been advanced substantially over the last decades. It supports localization of the region of interest, verification of the preoperatively classified fracture pattern, identification of correct insertion point of the implant, placement of instruments and fixation material, and verification of correct fracture reduction and implant positioning. While conventional fluoroscopic 2D imaging remains the gold standard in intraoperative imaging, critical anatomical regions are predestined for intraoperative 3D imaging. Additional options such as perioperative virtual planning, simulation, and surgical training, 3D printing techniques and 3D augmented reality visualization may potentially open new windows to improve surgical results in fracture care. This manuscript presents an update on current and upcoming imaging techniques in orthopaedic and trauma surgery focusing on technical advances for decreasing malreduction, malalignment, and malposition, as well as tips and tricks for daily surgical practice in order to improve clinical outcomes and patients' and surgeons' safety.