An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures

A novel minimally invasive percutaneous treatment for Essex-Lopresti joint depression-type DIACFs by ligamentotaxis

OBJECTIVE

To compare the clinical efficacy of minimally invasive percutaneous treatment by ligamentotaxis with traditional open reduction and internal fixation in the treatment of Essex-Lopresti joint depression-type displaced intra-articular calcaneal fractures (DIACFs).

METHODS

The medical records of patients with calcaneal fractures admitted to our department from January 2016 to December 2020 were retrospectively analyzed, and patients who met the inclusion criteria were finally included for analysis. Twenty-one patients underwent minimally invasive percutaneous treatment by ligamentotaxis (Group A), while eighteen patients were treated by traditional open reduction and internal fixation through an extended lateral approach (Group B). The preoperative waiting time, operative time, hospital stay, radiologic parameters (calcaneal height, width, length, Böhler angle and Gissane angle), American Foot and Ankle Surgery Association (AOFAS) hindfoot scores, Maryland Foot Score (MFS), visual analogue scale (VAS), and incidence of complications of the included patients were all recorded and analysed.

RESULTS

Thirty-nine patients with Essex-Lopresti joint depression type DIACFs were finally included. According to the Sanders classification, 22 were type II, 12 were type III and 5 were type IV. The preoperative waiting time and the hospital stay of Group A were 3.7 ± 1.6 d and 7.2 ± 1.7 d, respectively, which were significantly shorter than those of Group B (6.9 ± 2.0 d and 12.4 ± 1.5 d) (P < 0.05). There was no significant difference in the operative time between the two groups (88.8 ± 9.8 min vs. 91.3 ± 12.1 min; P > 0.05). No significant differences were shown in the radiological parameters (calcaneal height, width, length, Böhler angle and Gissane angle) or the satisfactory rate of joint surface reduction (SRJSR) of the two groups immediately postoperatively. All patients were followed up for 14 to 56 months [(30.2 ± 10.4) months]. All fractures healed. At the final follow-up, there were no significant differences in the radiological parameters or the SRJSR between the two groups (P > 0.05). No significant differences were shown in the AOFAS scores, MFS or VAS scores between the two groups [(89.5 ± 8.2) vs. (89.4 ± 9.0), P > 0.05; (87.5 ± 8.3) vs. (86.3 ± 8.9), P > 0.05; and (2.1 ± 1.2) vs. (2.2 ± 1.2), P > 0.05]. The excellent and good rates of the AOFAS scores and MFS were 90.5% and 85.7%, respectively, in Group A and 88.9% and 88.9%, respectively, in Group B (P > 0.05). Four patients experienced wound complications, including 1 superficial incision infection, 2 skin necrosis around the incision edge and 1 deep infection in Group B, while there were no wound complications in Group A (P < 0.05). One patient in each group suffered traumatic arthritis (P > 0.05).

CONCLUSIONS

In the assessment of Essex-Lopresti joint depression type DIACFs, minimally invasive percutaneous treatment by ligamentotaxis has similar clinical outcomes to traditional open reduction and internal fixation through an extended lateral approach. However, the former has the advantages of shorter preoperative waiting time and hospital stay, and lower incidence of incision complications.

Management of displaced intra-articular calcaneal fractures; current concept review and treatment algorithm

Calcaneum fractures are debilitating injuries with high complication rates and poor functional outcomes after both operative and non-operative management. The optimal management of such fractures is still highly debated in the literature with conflicting evidence on the preferred management of displaced intra-articular calcaneum fractures (DICAF). This article reviews the current concepts in the management of DIACF.

Percutaneous fixation of intraarticular joint-depression calcaneal fractures with different screw configurations - a biomechanical human cadaveric analysis

PURPOSE

The aim of this study was to assess the biomechanical performance of different screw configurations for fixation of Sanders type II B joint-depression calcaneal fractures.

METHODS

Fifteen human cadaveric lower limbs were amputated and Sanders II B fractures were simulated. The specimens were randomized to three groups for fixation with different screw configurations. The calcanei in Group 1 were treated with two parallel longitudinal screws, entering superiorly the Achilles tendon insertion, and two screws fixing the intraarticular posterior facet fracture line. In Group 2 two screws entered the tuberosity inferiorly to the Achilles tendon insertion and two transverse screws fixed the posterior facet. In Group 3 two screws were inserted along the bone axis, one transverse screw fixed the posterior facet and one oblique screw was inserted from the posteroplantar part of the tuberosity supporting the posterolateral part of the posterior facet. All specimens were biomechanically tested to failure under progressively increasing cyclic loading.

RESULTS

Initial stiffness did not differ significantly between the groups, P = 0.152. Cycles to 2 mm plantar movement were significantly higher in both Group 1 (15,847 ± 5250) and Group 3 (13,323 ± 4363) compared with Group 2 (4875 ± 3480), P ≤ 0.048. No intraarticular displacement was observed in any group during testing.

CONCLUSIONS

From a biomechanical perspective, posterior facet support by means of buttress or superiorly inserted longitudinal screws results in less plantar movement between the calcaneal tuberosity and the anterior fragments. Inferiorly inserted longitudinal screws are associated with bigger interfragmentary movements.

Minimally Invasive Sinus Tarsi Approach for Open Reduction and Internal Fixation of Calcaneal Fractures: Complications, Risk Factors, and Outcome Predictors

Open reduction and internal fixation of displaced intraarticular calcaneal fractures remain the gold standard of treatment, but the traditional extensile approach has been associated with relatively frequent complications. The current study aims to evaluate the less invasive sinus tarsi approach and to elaborate on the associated complications, risk factors, and outcome predictors. A retrospective observational study was carried out among 39 patients diagnosed with calcaneal fractures that were operatively treated between January 2019 and January 2020 at a level-one trauma center in Riyadh, Saudi Arabia. Patients were assessed regarding the complications, pre- and postoperative Bohler's angle, Gissane’s angle, calcaneal height, and return to baseline function. Patients older than 60 years show significantly more complications compared to younger patients (p < 0.05). Type IV calcaneal fracture, according to Sander’s classification, showed significantly more complications than other types (p < 0.05). There were significant variations in pre- and postoperative Bohler's angle and calcaneal height (p < 0.05). These variations apply to the Gissane’s angle but do not rise to significant results (p > 0.05). Furthermore, the current study reports a significant moderate direct correlation between delay time and complication incidence (p < 0.05). In conclusion, the minimally invasive sinus tarsi approach has relatively low complications and excellent clinical and radiological outcomes. Older patients and those who are diagnosed with type IV calcaneal factures, besides those presented with more delay, are more associated with unfavorable complications.

Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review

Because consensus on the optimal surgical treatment of tongue-type calcaneal fractures is lacking, this study aimed to compare outcomes and postoperative complications of open and closed surgical treatment of these fractures. For this cases series, all patients 18 years or older who underwent operative fixation of tongue-type calcaneal fractures at 2 level I trauma centers between 2004 and 2015 were considered eligible for participation. Data on explanatory and outcome variables were collected from medical records based on available follow-up. Additionally, a systematic literature review on surgical treatment of these fractures was conducted. Fifty-six patients (58 tongue-type fractures) were included. Open reduction internal fixation was performed in 33 fractures, and closed reduction internal (percutaneous) fixation was performed in 25. More wound problems and deep infections were observed with open treatment compared with the closed approach: 10 (30%) versus 3 (12%) and 4 (12%) versus 0 (0%) procedures, respectively. In contrast, revision and hardware removal predominated in patients with closed treatments: 4 (16%) versus 1 (3%) and 9 (36%) versus 8 (24%) procedures, respectively. The systematic literature review yielded 10 articles reporting on surgical treatment for tongue-type fractures, all showing relatively good outcomes and low complication rates with no definite advantage for either technique. Both open and closed techniques are suggested as accurate surgical treatment options for tongue-type calcaneal fractures. Surgical treatment should be individualized, considering both fracture and patient characteristics and the treating surgeon's expertise. We recommend attempting closed reduction internal fixation if deemed feasible, with conversion to an open procedure if satisfactory reduction or fixation is unobtainable.

Percutaneous Reduction and Hollow Screw Fixation Versus Open Reduction and Internal Fixation for Treating Displaced Intra-Articular Calcaneal Fractures

BACKGROUND We investigated the outcomes of displaced intra-articular calcaneal fractures (DIACFs) treated by percutaneous reduction and hollow screw fixation (PRHCF) versus open reduction and internal fixation (ORIF). MATERIAL AND METHODS Seventy-one patients were randomly allocated to group A (by PRHCF) and group B (by ORIF). Operative time, visual analogue scale (VAS) score, time from injury to operation, postoperative hospital stay, preoperative and postoperative radiographic measurements, and complications were recorded. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scores. RESULTS Finally, 59 patients were followed up for at least 12 months (range, 12-24 months). Group A showed significantly more advantages than group B in term of operative time, intraoperative blood loss, time to operation, postoperative hospital stay, and postoperative pain relief during the first 3 days (P<0.001). However, more intraoperative fluoroscopy was required in group A than in group B (P<0.001). The calcaneal width, height, length, Böhler angle, and Gissane angle in each group were significantly improved postoperatively (all P<0.001), although not significantly different in the postoperative comparisons between both groups. The AOFAS scores were slightly superior in group A than in group B (88.3 vs. 86.4, P=0.08). The rate of incidence of postoperative complications was lower in group A than in group B (3.2% vs. 10.8%, respectively; OR, 0.28, 95% CI, 0.03 to 2.84), although there was no significant difference (P=0.337). CONCLUSIONS PRHCF showed comparable clinical and radiological outcomes as ORIF, demonstrating it is a safe and effective alternative in treating DIACFs.

Functional and radiological outcomes in displaced heel fractures: Open reduction and internal fixation versus external fixation

Management of intra-articular heel fractures is controversial. The main goals of surgical treatment are restoring subtalar articular congruence and width, height, form and alignment of the heel. The gold standard is considered Open Reduction and Internal Fixation (ORIF), a complex technique with a high rate of complications. External Fixation (EF) could be a good alternative. In this study were identified 37 fractures in 35 patients (24 patients underwent ORIF and EF was performed in 13 cases) and the outcomes of the two techniques were compared. The mean surgical time for ORIF was 107.8 minutes, while for EF was 88.61 minutes and the ORIF group presented a higher rate of complications, despite of similar results in the mean postoperative AOFAS Ankle and Hindfoot Scale scores (73.31/100 points in the ORIF group and 75.40/100 points in the EF group). Fast learning curve, short surgery time and low complications rate make EF an alternative to ORIF in treating intraarticular heel fractures.

Extensile lateral versus sinus tarsi approach for displaced, intra-articular calcaneal fractures: a meta-analysis

Background

Operative management of displaced, intra-articular calcaneal fractures is associated with improved functional outcomes but associated with frequent complications due to poor soft tissue healing. The use of a minimally invasive sinus tarsi approach to the fixation of these fractures may be associated with a lower rate of complications and therefore provide superior outcomes without the associated morbidity of operative intervention.

Methods

We reviewed four prospective and seven retrospective trials that compared the outcomes from the operative fixation of displaced intra-articular calcaneal fractures via either an extensile lateral approach or minimally invasive fixation via a sinus tarsi approach.

Results

Patients managed with a sinus tarsi approach were less likely to suffer complications (OR = 2.98, 95% CI = 1.62–5.49, p = 0.0005) and had a shorter duration of surgery (OR = 44.29, 95% CI = 2.94–85.64, p = 0.04).

Conclusion

In displaced intra-articular calcaneal fractures, a minimally invasive sinus tarsi approach is associated with a lower complication rate and quicker operation duration compared to open reduction and internal fixation via an extensile lateral approach.

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus

BACKGROUND

Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique.

METHODS

153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed.

RESULTS

At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively ( P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement ( P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower.

CONCLUSION

This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The outcome of super-cutaneous locked plate fixation with percutaneous reduction of displaced intra-articular calcaneal fractures

INTRODUCTION

Supercutaneous (external) fixation with locking plate is utilized for fixation of long bone fractures. One retrospective study for open reduction and supercutaneous fixation of the calcaneus is reported. We prospectively evaluated the use of this method of fixation combined with percutaneous reduction.

MATERIALS AND METHODS

Between January 2014 and June 2015, 32 displaced calcaneus fractures in 30 patients were stabilized with percutaneous reduction and super-cutaneous fixation. They were 24 males and six females. The mean age was 37.9±5.7 years (21-55). All cases were closed. The time to surgery, complications, radiographic alignment, and time to radiographic union were recorded. Clinical results at the final follow-up were assessed by evaluating Bohler's angles for the radiographic alignment, and the system of the American Orthopedic Foot and Ankle Society (AOFAS) for the functional outcome.

RESULTS

According to the Sanders' classification, two cases were type II, 17 cases were type III and 13 cases were type IV. The preoperative average Bohler's angle was 10.57°±4.8. The postoperative X-ray films demonstrated that the average Bohler's angle improved to 29.07°±5.9 (p<0.001). At the time of radiologic healing (about 3 months), the plates and screws were removed under general anesthesia. The average follow-up was 13.2 months (11-18). Four cases (type IV) showed mal-union and heel pain. According to (AOFAS) rating, the fine score was 87.1±17.1 points.

CONCLUSION

Super-cutaneous fixation with percutaneous reduction of calcaneal fracture is an effective method in type II and III and can be effective with type IV but with less favorable results.

Is arthroscopic assisted percutaneous screw fixation as good as open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures?

BACKGROUND

This study compares the outcomes of calcaneal fracture surgery after open reduction internal fixation and plating (ORIF) versus arthroscopic assisted percutaneous screw fixation (APSF).

METHODS

Group I (N=12) underwent ORIF. Group II (N=15) underwent APSF. Anthropometric data, pre and post-operative stay, complications and duration off work were recorded in this retrospective case cohort study. Radiographs were analyzed for Bohler's, Gissane's angle and Sanders' classification. AOFAS Hindfoot and SF 36 scores were collected at final follow-up.

RESULTS

Anthropometric data, Bohler's and Gissane's angles, AOFAS and SF 36 scores were not significantly different. Pre-operative duration was 12.3 days in ORIF and 6.9 days in APSF. Post-operative duration was 7.3 days vs 3.8 days. Duration off work was 6.2 months vs 2.9 months.

CONCLUSION

The APSF group was able to have surgery earlier, go home faster, and return to work earlier. This study was not powered to demonstrate a difference in wound complication rates.

Surgical complications of intra-articular calcaneal fracture treatment

Introduction: The authors present complications following surgical treatment of intra-articular calcaneus fractures, in regards to the surgical technique employed, based on their own clinical material. Materials and methods: The techniques analyzed included the Westhues’ technique and its modifi cation with additional bone stabilization by Kirschner wires and the percutaneous stabilization by Rapala. The research material covered the years from 1990 to 2012 and consists of 82 operated patients - 68 men (83%) and 14 women (17%). Analyzed calcaneus fractures were divided using the Essex-Lopresti classifi cation. Results: The authors of the article indicate that the most frequently registered complications of surgical treatment of intra-articular calcaneus fractures in early observation were thromboembolic complications and local infl ammatory reactions of the skin at the point of incision and placing the stabilizing material. During the long-term follow-up, the post-thrombotic syndrome and algodystrophic disorders were the most common. Conclusions: Factors contributing to the occurrence of the complications registered were fracture morphology, fixation of bone fragments by an excessive number of stabilizing materials and prolonged immobilization of the operated limb. Cite this article as: Golec P., Tomaszewski K.A., Nowak S., Dudkiewicz Z. Surgical complications of intra-articular calcaneal fracture treatment. Med Rehabil 2016; 20(2): 25-30.

Current management options for displaced intra-articular calcaneal fractures: Non-operative, ORIF, minimally invasive reduction and fixation or primary ORIF and subtalar arthrodesis. A contemporary review

BACKGROUND

Management of Displaced Intra-articular Calcaneal Fractures (DIACFs) continues to be technically demanding. The literature has not been definitive in its guidance for surgeons dealing with these injuries. Recent publications have further added to the lack of clarity. This review is intended to summarise the present state of knowledge, and provide some genuine guidance for clinicians.

OBJECTIVES

To review previous research, focussing on articles published within the last fifteen years, and summarise the findings to aid surgeons in managing DIACFs with choosing best management for patients.

METHODS

We reviewed the best evidence and literature, focussing on articles published within the last fifteen years, and summarised findings into workable recommendations. Variables of (1) patient, (2) the associated soft tissue injury and (3) the fracture characteristics were used to aid surgeons in choosing the best of the available options for each patient that presents with a DIACF.

AUTHORS SUMMARY

Management of DIACFs can best be divided into four broad categories: (i) non-operative management, (ii) open reduction and internal fixation, (iii) minimally invasive reduction and fixation, and (iv) primary subtalar arthrodesis. The evolution of the literature would suggest orthopaedic surgeons managing calcaneus fractures should have an expert's knowledge, surgical expertise and the latest techniques to cover these four options, to tailor the treatment of DIACFs to the individual patient.

Effectiveness of MIS technique as a treatment modality for open intra-articular calcaneal fractures: A prospective evaluation with matched closed fractures treated by conventional technique

Twenty-five displaced intra-articular calcaneal fractures in 21 patients, aged 15-55 years were included in this study. Sanders' type I fractures, severe crushing or partial amputation, were excluded from the study. Patients were divided into group 1 (open fractures treated by MIS), and group 2 (closed fractures treated by ORIF). Group 1 had 16 and group 2 had 9 cases. Seven of 25 fractures (28%) developed wound related issues postoperatively. One patient (11.1%) in group 2 had wound margin necrosis, while 6 patients (37.5%) in group 1 developed pin tract and/or wound infection. At 1-year follow-up, the mean MFS for group 1 was 79 and mean MFS for group 2 was 84.4 (66.67% were good). The AOFAS score for group 1 was 77.37 and for group 2 was 86.1. The Bohlers' angle was restored in 81.16% cases in group 1 and 88.8% in group 2, while Gissane angle was restored in 68.75% of group 1 cases and 77.79% of group 2 cases. This study shows that acceptable fracture reduction can be obtained and maintained by MIS technique and it can be used as the primary definitive treatment option in open calcaneal fractures.

Biomechanical Performance of Lateral Versus Dual Locking Plates for Calcaneal Fractures

Given the high rates of wound complications with a standard lateral extensile incision, small dual incision techniques might result in less soft tissue destruction. The goal of the present study was to compare the biomechanical performance between a single locking plate and a dual locking plating system for an intra-articular calcaneal fracture model. A Sanders IIB type joint depression calcaneal fracture was created in 10 paired, fresh-frozen, cadaveric calcanei (age 47 ± 12, range 35 to 78 years). The calcanei of each pair were randomly assigned for fixation using either a lateral locking reconstruction plate or lateral and medial locking reconstruction plates. The specimens were axially loaded in cyclic fashion for 1000 cycles, followed by load to failure. The relative fragment movement was monitored optically in both the sagittal and the coronal planes. The amount of overall construct displacement increased with cycling, although no difference was found between the plating techniques. For fragment movement during cycling, the lateral joint fragment migrated anteroinferiorly along the fracture line relative to the tuberosity fragment for dual plated specimens by a small, but statistically significant, amount. This same translation was smaller for lateral plated specimens but was not found to be significant. During load to failure testing, no statistically significant differences were found for construct stiffness. A tendency was seen toward more interfragmentary motion in the sagittal plane (lateral joint fragment movement relative to the fracture line), with less movement overall in the coronal plane (anterior fragment translation and twist) for dual plating, although the difference from the lateral plate was not statistically significant. The present study demonstrated that for this calcaneal fracture model, the dual plating technique experienced a small amount of fragment translation during cycling that was significantly different statistically from that with lateral plating but was not clinically relevant. During the load to failure, the dual plating technique was comparable to the lateral plate. Thus, dual plating could be a viable biomechanical option for fracture reduction if avoidance of a large extensile lateral approach associated with lateral plating is warranted.

Early minimally invasive percutaneous fixation of displaced intra-articular calcaneal fractures with a percutaneous angle stable device

The Minimally Invasive Reduction and Osteosynthesis System(®) (MIROS) is a percutaneous angle stable device for the treatment of fractures. The aim of the present study was to evaluate the clinical and radiographic results of an early minimally invasive osteosynthesis with the MIROS device. A total of 40 consecutive patients were treated for an intra-articular fracture of the calcaneus. We evaluated the clinical and radiographic outcomes after treatment of intra-articular calcaneal fractures with the MIROS hardware. Soft tissue damage was noted. The patients completed the American Orthopaedic Foot and Ankle Society survey at 12 and 24 months and underwent radiologic evaluations. A statistically significant association between the American Orthopaedic Foot and Ankle Society score and type of soft tissue lesion. A Sanders type II, III, and IV fracture was found in 15, 20, and 15 of 50 fractures, respectively. Postoperatively, restoration of the posterior facet was reached in 13 of 15, 18 of 20, and 11 of 15 with a type II, III, and IV fracture, respectively. The American Orthopaedic Foot and Ankle Society scale mean score was 85 at the final follow-up visit. No significant association was found between the score and the preoperative variables (p > .09), although patients with bilateral fractures had a significantly lower score. The MIROS device for early treatment of intra-articular calcaneus fractures resulted in excellent clinic and radiologic results. The standardized technique we have reported, with the elastic wires acting as a girder for the fractured and displace subtalar joint and the collapsed lateral calcaneal wall, has permitted early weightbearing with positive stimuli for the bone healing. The drainage effect of the percutaneous wires likely prevented compartment syndrome when applied within the first hours after the trauma.

Heel displaced intra-articular fractures treated with mini-calcaneal external fixator

INTRODUCTION

Treatment of displaced heel fractures is controversial; however, ORIF is widely described in the literature to be the gold-standard. Percutaneous reduction and monolateral external fixation is gaining increasing attention because it provides a good and stable reduction, and minimises soft tissue complications due to open surgery, such as deep infections and delays in wound healing. The aim of this study was to show that the new Orthofix Calcaneal Minifixator (six pins) provides a greater stability than the four-pin version to enable a better and more stable reduction, an earlier weight-bearing (30 days) and improved functional outcomes.

METHODS

A series of 69 consecutive closed heel intraarticular displaced fractures treated with the new Orthofix Calcaneal Minifixator were evaluated. Patients were assessed clinically with the Maryland Foot Score and radiologically with standard radiographs.

RESULTS

The clinical results at follow-up were excellent in 37 cases (53.6%), good in 27 (39.2%), fair in two (2.9%) and poor in three (4.3%). The mean preoperative Böhler's angle was 5.2˚ (range 0-18˚) and the mean postoperative value was 28.5˚ (range 16-38˚).

CONCLUSION

The excellent functional outcomes were despite some radiological images of imperfect posterior facet anatomical reduction and seemed to correlate with the use of a good and stable minimally-invasive surgical technique. This technique enabled early weight-bearing, minimised complications, respected the delicate biology of this anatomical site and restored the good heel volume and Böhler angle.

Management of intraarticular calcaneal fractures by minimally invasive sinus tarsi approach-early results

ABSTRACT

The operative treatment of displaced intraarticular calcaneal fractures has been a controversial topic. Soft tissue conditions and concomitant disease must be considered in these patients. The minimally invasive sinus tarsi approach is a valid therapeutic solution that guarantees stability, anatomic reduction of the fracture and soft tissue preservation. Twenty-five closed calcaneal fractures in 20 patients were treated with open reduction and internal fixation using the sinus tarsi approach (including fixation with cannulated screws). All fractures healed by the time of final follow-up at 18 months. The time to union judged both clinically and radiographically, averaged 3 months. Mean Maryland foot scores were: 95 in type II; 91 in type III; and 83 in type IV fractures. Advantages offered by this new approach include a less invasive incision while still permitting good visualization and anatomic reduction of articular surfaces and with few complications.

KEY WORDS

Intraarticular calcaneal fractures, sinus tarsi approach, Sanders classification.

Functional outcome and patient satisfaction after displaced intra-articular calcaneal fractures: a comparison among open, percutaneous, and nonoperative treatment

The aim of the present study was to compare the outcomes of patients with a displaced calcaneal fracture treated by open reduction and internal fixation (ORIF), percutaneous treatment, or nonoperative methods. A retrospective cohort study was conducted at a level I trauma center of patients with a displaced intra-articular calcaneal fracture treated from January 1, 2002 to December 31, 2011. The patient-reported outcome measures included the Foot Function Index, American Orthopaedic Foot and Ankle Society hindfoot scale, Short Form-36, the EQ-5D from the EuroQol Group, and a 10-point visual analog scale. Clinical data were collected from 169 patients, and questionnaires were obtained from 78 patients (18 nonoperatively, 27 ORIF, and 33 percutaneously). The late intervention rate was significantly greater in the percutaneous group (n = 18; 30%) than in the ORIF group (n = 6; 12%) or the nonoperative group (n = 8; 13%; p = .030). Significantly more disability was reported in the nonoperative group (median Foot Function Index score, 40 points) than in the ORIF group (median, 16 points; p = .010) or in the percutaneous group (median, 21 points; p = .034). In conclusion, the operatively treated patients (ORIF and percutaneous treatment) reported better functional outcome scores (Foot Function Index and American Orthopaedic Foot and Ankle Society hindfoot scale) than did the nonoperatively treated patients.

Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis

PURPOSE

The optimal treatment of calcaneal fractures is controversial. A specific subgroup of healthy patients has good outcomes with open reduction and internal fixation using an extensile lateral approach. However, there are many patients who do not fit into this category. Consequently, they are either denied surgical intervention or put at significant risk of developing complications as a result of open surgical intervention. Minimally invasive reduction and fixation (MIRF) of calcaneal fractures can restore the height, width, length and shape of the hindfoot in addition to restoring the orientation of the posterior facet of the calcaneus (Böhler's angle).

METHODS

We present a series of 31 patients treated with minimally invasive reduction and fixation technique using threaded K wires and Steinmann pins as an alternative treatment method in patients who are not suitable for open reduction and internal fixation.

RESULTS

The mean time to surgery from injury was six days (range one to ten days). The mean duration of surgery was 35 minutes (range 11-52 minutes). The mean followup was 14.9 months (range of seven to 30 months). The mean change in Böhler's angle and length of the calcaneus from intra-operative fixation to final followup were 18.7° and 4.7 mm, respectively. The complication rate was low and there was one case of a superficial wound infection and no cases of deep infection or peroneal impingement in this series.

CONCLUSION

The MIRF technique with the use of threaded K wires has not been previously described in the literature. In our experience, the operative time is short and can be safely performed even in the presence of extensive soft tissue swelling in the immediate period following injury. The infection risk is low and calcaneal morphology was improved and maintained in terms of Böhler's angle. This technique is suitable to be considered in patients who have significant medical co-morbidities (smokers, diabetics, peripheral vascular disease) and in those patients who are not suitable for an extensile lateral approach and internal fixation.

External fixation with supercutaneous calcaneal locking plate for displaced intra-articular calcaneal fractures

OBJECTIVE

The purpose of this study was to retrospectively evaluate patients who had open reduction and external fixation of displaced intra-articular calcaneal fractures with supercutaneous calcaneal locking plates used as external fixators.

METHODS

Between October 2007 and June 2009, 25 cases were performed. According to the Sanders classification system, 17 cases were type IIA and there were two cases each of type IIB, type IIC, type IIIAC, and type IV. Three months after surgery, when imaging studies confirmed bone union, the plates and screws were removed in the outpatient clinic. The average time of follow-up was 36 (range, 33 to 48) months.

RESULTS

Two cases (8%) had superficial wound necrosis and no pin tract infections were noted. The reduction of the articular surface and bone union were good. Two cases of type IIA developed lateral wall exostosis, which resulted in peroneal tendinitis. The preoperative x-rays of the 25 patients had an average Böhler's angle of 12° ± 9° and Gissane's angle of 87° ± 8°. Their postoperative x-ray films demonstrated that the Böhler angle improved to 30° ± 7° and the Gissane angle to 116° ± 7° (p < .01). According to the Ankle-Hindfoot Clinical Rating System of the American Orthopaedic Foot and Ankle Society (AOFAS), their average score was 91 (range, 68 to 100) points.

CONCLUSION

Using a supercutaneous calcaneal locking plate to treat calcaneal fractures caused limited tissue irritation, a low rate of local skin infection, satisfactory reduction of the articular surface, stable fixation, and an overall reduced cost.

Functional outcome of displaced intra-articular calcaneal fractures: a comparison between open reduction/internal fixation and a minimally invasive approach featured an anatomical plate and compression bolts

BACKGROUND

The purpose of this study is to assess the clinical results of a minimally invasive treatment featured the concept of internal compression, including an anatomic plate and multiple compression bolts compared with open reduction and internal fixation for displaced intra-articular calcaneal fractures (DIACFs).

METHODS

We retrospectively analyzed 329 patients (383 feet) who were identified from trauma inpatient database in our hospital for DIACFs from January 2004 to December 2009. Of them, 148 patients (170 feet) were treated with open reduction and internal fixation (OR group), which involved using a traditional L-shaped extended lateral approach, and fractures were fixed by plate and screws from January 2004 to December 2006; 181 patients (213 feet) were treated with a minimally invasive approach featured the concept of calcaneal internal compression (CIC group), which was achieved by an anatomic plate and multiple compression bolts through a small lateral incision from January 2007 to December 2009. Postoperative complications were recorded. During follow-up, pain and functional outcome were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) scores and compared between the two groups. Subsequent subtalar arthrodesis and early implant removal were performed when indicated. Routine hardware removal was scheduled for all patients at 1-year follow-up.

RESULTS

There were no significant differences in sex, age, and fracture classification (Sanders classification) between the two groups. Wound healing complications were 4 of 213 (1.88%) in CIC group and 20 of 170 (11.76%) in OR group. Subtalar arthrodesis had to be performed in one case in OR group. Four cases in CIC group and four cases in OR group had the hardware removed earlier due to complications. The average time after surgery to start weight-bearing exercise is 5.64 weeks in CIC group and 9.38 weeks in OR group (p < 0.001). The mean AOFAS score is higher in CIC group than in OR group, although the difference is not statistically significant (87.53 vs. 84.95; p = 0.191). The overall results according to the AOFAS scoring system were good or excellent in 185 of 213 (86.85%) in CIC group and 144 of 170 (84.71%) in OR group. The subjective portion of the AOFAS survey answered by patients showed statistically significant difference in activity limitation and walking surface score (7.31 vs. 7.02 and 3.72 vs. 3.42; p < 0.05) but not in pain and walking distance between the two groups (32.72 vs. 32.29 and 4.37 vs. 4.42; p > 0.05).

CONCLUSION

The study results suggest that this minimally invasive approach featured the concept of the calcaneal internal compression can achieve functional outcome as good as, if not better than the open techniques. It is proved to be an effective alternative treatment for DIACFs.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Management of calcaneal fractures: what have we learnt over the years?

Calcaneal fractures result, in many cases, in, subtalar joint stiffness and severe disability. Diagnosis is usually made by X-ray, but more accurately by a computed tomography (CT) scan. In the last years, much has been known regarding its physiopathology and osteosynthesis. Although new developments in osteosynthesis materials have been made, calcaneus fractures still remains in dispute of those advocating non-operative treatment and those defending open reduction and internal fixation. Less invasive surgery, arthroscopy and three-dimensional (3D) fluoroscopy are very important for reduction accuracy and soft-tissue damage avoidance. In this article, the physiopathology, diagnosis, classification and treatment of calcaneus fractures are updated. Nevertheless, systematic reviews have shown no evidence about what treatment is better.

Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures

OBJECTIVES

The purpose of this study is to assess the initial results of percutaneously reducing and fixing calcaneus fractures compared with a concurrent control group that was openly reduced and internally fixed through an extensile lateral approach.

DESIGN

Retrospective cohort study, consecutive series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

One hundred twenty patients with 125 intra-articular calcaneus fractures were selected as a consecutive series with treatment method randomized by surgeon and time of presentation.

INTERVENTION

Patients treated with open reduction and internal fixation (OR group) had an extended lateral approach and fractures were fixed with plates and screws. Patients treated with percutaneous reduction (PR group) had small incisions with indirect fragment manipulation, and the reduction achieved was secured with screws alone.

MAIN OUTCOME MEASUREMENT

Clinical and radiographic assessment.

RESULTS

There were 41 patients with 42 fractures in the OR group and 79 patients with 83 fractures in the PR group. There were no significant differences in sex, age, open fractures, fracture classification, or initial Bohler's angle between the two groups. Bohler's angle was improved after surgery by an average of 22.4 degrees in the OR group and 25.3 degrees in the PR group (P = 0.31). The average loss of reduction at healing (minimum 4 months postoperatively) was not significantly different between the two groups. Deep infection occurred in six of 42 of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 in the OR group and five of 83 in the PR group (P = 0.03). The need for late subtalar fusions (two of 26 and three of 41 with full 2-year follow-up) and implant removal (five of 42 and 10 of 83) was not significantly different.

CONCLUSIONS

The results of this study suggest that in comparison to open reduction, this method of percutaneously reducing and fixing calcaneus fractures minimizes complications and achieves and maintains extra-articular reductions as well as the standard extensile open reduction and internal fixation. Further study of this technique is warranted. This should include assessment of articular reduction and longer follow-up of a larger number of patients.

[3D navigated osteosynthesis of calcaneal fractures. Open and minimally invasive techniques]

BACKGROUND

It is hypothesized that misplacement of sustentacular screws during osteosynthesis of intraarticular calcaneal fractures can be reduced with the help of navigation. A method for three-dimensional (3D) navigated placement of sustentacular screws for treating intraarticular calcaneal fractures is presented and evaluated.

MATERIAL AND METHODS

11 consecutive patients with 15 intraarticular calcaneal fractures were treated using 3D navigation. In 12 cases osteosynthesis was done through an extended lateral approach; in three cases, it was achieved through a minimally invasive percutaneous approach. For verification and documentation of the placed screws, a second 3D scan was performed.

RESULTS

A total of 20 screws were placed using 3D navigation. None of the navigated screws was misplaced. Extra operating time due to navigation averaged 11.9 minutes (+/-2.2 min).

CONCLUSION

Through a combination of intraoperative 3D imaging and navigation, placement of sustentacular screws is possible and can yield precise and reliable results. Especially in minimally invasive treatment, a high quality of osteosynthesis can be achieved.

Treatment of displaced intra-articular calcaneal fractures by ligamentotaxis: current concepts' review

INTRODUCTION

A large variety of therapeutic modalities for calcaneal fractures have been described in the literature. No single treatment modality for displaced intra-articular calcaneal fractures has proven superior over the other. This review describes and compares the different percutaneous distractional approaches for intra-articular calcaneal fractures. The history, technique, anatomical and fracture considerations, limitations and the results of different distractional approaches reported in the literature are reviewed.

METHOD

Literature review on different percutaneous distractional approaches for displaced intra-articular calcaneal fractures.

RESULTS

Eight studies in which application of a distraction technique was used for the treatment of calcaneal fractures were identified. Because of the use of different classification, techniques, and outcome scoring systems, a meta-analysis was not possible. A literature review reveals overall fair to poor result in 10-29% of patients. Ten up to 26% of patients are unable to return to work after percutaneous treatment of their fracture. A secondary arthrodesis has to be performed in 2-15% of the cases. Infectious complications occur in 2-15%. Some loss of reduction is reported in 4-67%.

CONCLUSION

Percutaneous distractional reduction and fixation appears to be a safe technique with overall good results and an acceptable complication rate, compared with other treatment modalities for displaced intra-articular calcaneal fractures. A meta-analysis, based on Cochrane Library criteria is not possible, because of a lack of level 1 and 2 trials on this subject.

Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.

Minimally-invasive treatment of intra-articular fractures of the calcaneum

We describe the results of 287 intra-articular fractures of the calcaneum in 247 patients treated by minimally-invasive reduction and K-wire fixation between 1994 and 2003. There were 210 men (85%) and 37 women (15%). The most common cause of injury was a fall from a height in 237 patients (96%). Fracture classification was based on the method described by Sanders and Essex-Lopresti. All patients were operated on within 21 days of injury and 89% (220) within 48 hours. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement and satisfactory overall alignment) in 212 (73.9%) fractures.

There were 20 cases (7%) of superficial pin-track infection and five (1.7%) of deep infection. All healed at a mean of 6 weeks (3 to 19). Loss of reduction was observed in 13 fractures (4.5%) and a musculocutaneous flap was needed in three (1%).

The results were evaluated in 176 patients (205 fractures) with a mean age of 44.3 years (13 to 67), available for follow-up at a mean of 43.4 months (25 to 87) using the Creighton-Nebraska Health Foundation Assessment score. The mean score was 83.9 points (63 to 100). There were 29 (16.5%) excellent, 98 (55.7%) good, 26 (14.8%) fair and 23 (13%) poor results. A total of 130 patients (73.9%) were able to return to their original occupation at a mean of 5.6 months (3.2 to 12.5) after the injury.

Semi-open reduction and percutaneous fixation is an effective treatment for displaced intra-articular fractures of the calcaneum.

Open reduction for intra-articular calcaneal fractures: evaluation using computed tomography

Radiographic and computed tomography features of unilateral intra-articular calcaneal fractures after open reduction and internal fixation were compared with late functional outcomes to identify prognostic factors. Sixty-one of 67 patients treated between 1997 and 2002 could walk painlessly postoperatively (average, 19.7 months). Functional results (Laasonen's criteria) were excellent or good in 92.5%. Factors associated with better functional results were lower age (p = .0227), greater Böhler angle at the time of injury (p < .0001), lower Sanders' grade (p = .0497), increased height of fractured regions (p = .0249), better reduction of the posterior facet (p = .0126), and better reduction of the calcaneocuboid joint (p = .0023). Only the latter two were found to be surgical prognostic factors.

Is there a reliable outcome measurement for displaced intra-articular calcaneal fractures?

BACKGROUND

The treatment of displaced intra-articular calcaneal fractures remains controversial, because of difficulties in assessing the outcome. The goal of this study, therefore, was to compare different outcome measurements with gait analysis, using dynamic pedography.

METHODS

Twenty patients with operatively treated displaced intra-articular calcaneal fractures were followed up clinically and radiographically. In addition, foot pressure was measured using dynamic pedography.

RESULTS

No significant difference was found between the two clinical outcome scores used (p = 0.08); both revealed good results. Dynamic pedography, however, showed a shift of the maximum impact and roll-off of the foot to the lateral side, as well as a widening of these zones in the heel and on the sole in 14 of 20 patients.

CONCLUSION

These results indicate that traditional outcome measurements underestimate functional deficits in our patients. Monitoring plantar pressure distribution might therefore be a useful tool for assessing foot function in these patients.