Réduction et vissage percutanés des fractures thalamiques du calcaneus sous contrôle arthroscopique et fluoroscopique

Arthroscopic-Assisted Open Reduction Internal Fixation

The indications for arthroscopy have expanded over the years. Arthroscopic-assisted open reduction internal fixation in the setting of acute trauma is gaining popularity with foot and ankle surgeons. It serves to facilitate direct visualization of fracture fragments and allows for precise articular reduction with minimal soft tissue insult. Current evidence reports a high incidence of chondral injury with ankle fractures. Arthroscopy performed at the time of open reduction internal fixation allows for joint inspection and potential treatment of these posttraumatic defects.

[New techniques in the operative treatment of calcaneal fractures]

The ideal treatment of displaced intra-articular calcaneal fractures is still controversially discussed. Because of the variable fracture patterns and the vulnerable soft tissue coverage an individual treatment concept is advisable. In order to minimize wound edge necrosis associated with extended lateral approaches, selected fractures may be treated percutaneously or in a less invasive manner while controlling joint reduction via a sinus tarsi approach. Fixation in these cases is achieved with screws, intramedullary locking nails or modified plates that are slid in subcutaneously. A thorough knowledge of the three dimensional calcaneal anatomy and open reduction maneuvers is a prerequisite for good results with less invasive techniques. Early functional follow-up treatment aims at early rehabilitation independent of the kind of fixation. Peripheral fractures of the talus and calcaneus frequently result from subluxation and dislocation at the subtalar and Chopart joints. They are still regularly overlooked and result in painful arthritis if left untreated. If an exact anatomical reduction of these intra-articular fractures is impossible, resection of small fragments is indicated.

Introduction of a New Locking Nail for Treatment of Intraarticular Calcaneal Fractures

OBJECTIVES

To reduce the complication rate associated with open reduction and internal fixation of displaced intraarticular calcaneal fractures through extensile approaches, a locking nail system (C-Nail) was developed for internal fixation.

DESIGN

Prospective case-control study.

SETTING

Two level I trauma centers (university hospital) and 1 large regional hospital in the Czech Republic and Germany.

PATIENTS

One hundred three patients (89 male and 14 female; mean age, 45.6 years) with 106 calcaneal fractures were treated between February 2011 and October 2013.

INTERVENTION

In all 106 cases, the stainless steel C-Nail with a length of 65 mm, a diameter of 8 mm, and 7 locking options was used for internal fixation. Previous reduction of the posterior facet was performed in 15 cases percutaneously, assisted by arthroscopy and fluoroscopy, and in 91 cases by a sinus tarsi approach. The reduced joint surface was fixed by 1 or 2 compression screws. All other fragments were fixed after reduction and temporary K-wire fixation with the C-Nail introduced percutaneously through the tuberosity and 5 to 6 interlocking screws. The latter were introduced into the sustentacular, the tuberosity, and the anterior process fragments with an aiming device consisting of 3 arms.

MAIN OUTCOME MEASURES

Patients were assessed for complications, restoration of Böhler angle, posterior facet reduction with postoperative computed tomography, and weight-bearing radiographs at 6 months. Functional outcome was assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale after 6 and 12 months for all patients.

RESULTS

Wound edge necrosis was seen in 2 cases (1.9%), and soft tissue infection was observed in 1 case (0.9%). Böhler angle improved from 7.3 degree preoperatively to 28.7 degree at 6 months. The posterior facet step-off was reduced from 5.3 mm preoperatively to 0.7 mm postoperatively. The average AOFAS score averaged 89.5 at 6-month and 92.6 at 12-month follow-up.

CONCLUSIONS

The C-Nail is a new locking system for treatment of displaced intraarticular calcaneal fractures combining a primary stability with reduced soft tissue complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reliability of a rating scale for assessing alignment of the posterior facet after surgical repair of joint depression fractures of the calcaneus

Radiographs are frequently used to classify joint depression calcaneal fractures and assess the degree of repair of such injuries. To associate the degree of repair with clinical outcomes such as foot-related quality of life and subjective patient satisfaction, it would be useful to have a valid measuring instrument that has been shown to reliably categorize the alignment of the posterior facet of the calcaneus. To be considered valid, the measurement must have inter-rater and intrarater reliability. In an effort to demonstrate the validity of a coronal plane computed tomographic measurement for categorizing the alignment of the posterior facet after repair of joint depression fractures of the calcaneus, we measured the inter-rater and intrarater reliability of the classification system.

Biomechanical stability of intramedullary technique for fixation of joint depressed calcaneus fracture

BACKGROUND

Internal fixation of the os calcis is often complicated by prolonged soft tissue management and posterior facet disruption. An ideal calcaneal construct would include minimal hardware prominence, sturdy posterior facet fixation and nominal soft tissue disruption. The purpose of this study was to develop such a construct and provide a biomechanical analysis comparing our technique to a standard internal fixation technique.

METHODS AND MATERIALS

Twenty fresh-frozen cadaver calcanei were used to create a reproducible Sanders type-IIB calcaneal fracture pattern. One calcaneus of each pair was randomly selected to be fixed using our compressive headless screw technique. The contralateral matched calcaneus was fixed with a nonlocking calcaneal plate in a traditional fashion. Each calcaneus was cyclically loaded at a frequency of 1 Hz for 4000 cycles using an increasing force from 250 N to 1000 N. An Optotrak motion capturing system was used to detect relative motion of the three fracture fragments at eight different points along the fracture lines. Horizontal separation and vertical displacement at the fracture lines was recorded, as well as relative rotation at the primary fracture line.

RESULTS

When the data were averaged, there was more horizontal displacement at the primary fracture line of the plate and screw construct compared to the headless screw construct. The headless screw construct also had less vertical displacement at the primary fracture line at every load. On average those fractures fixed with the headless screw technique had less rotation than those fixed with the side plate technique.

CONCLUSION

A new headless screw technique for calcaneus fracture fixation was shown to provide stability as good as, or better than, a standard side plating technique under the axial loading conditions of our model. Although further testing is needed, the stability of the proposed technique is similar to that typically provided by intramedullary fixation.

CLINICAL RELEVANCE

This fixation technique provides a biomechanically stable construct with the potential for a minimally invasive approach and improved post-operative soft tissue healing.

Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases

A retrospective analysis of 24 cases of minimally invasive, open reduction, and internal fixation of intra-articular calcaneal fractures is presented. Collected data included articular step-off, medial wall displacement, and Boehler's angle, in addition to other descriptive characteristics of the fracture and case series. The operative technique is described in detail including the optimal screw constructs. Arthroscopic assistance was used in 10 of the cases. The articular step-off of the posterior facet, medial wall displacement, and Boehler's angle all displayed statistically significant change between the preoperative and postoperative periods (P < .0001). These results were consistent with the goal of restoration of articular congruity, calcaneal morphology, and calcaneal height. There were no soft tissue complications. The mean overall follow-up duration was 2.8 years (range 1 to 10 years). Of the 18 patients who were followed for more than 1 year (range 1.0 to 10 years), none went on to subtalar fusion. The results of this study suggest that a minimally invasive approach can improve radiographic parameters consistent with the ultimate goals of operative reduction of calcaneal fractures, and can be used to achieve satisfactory results with minimal risk of wound complication.

LEVEL OF CLINICAL EVIDENCE

4.

Calcaneal fracture classification: a comparative study

Comparing different types of calcaneal fractures, associated treatment options, and outcome data is currently hampered by the lack of consensus regarding fracture classification. A systematic search for articles dealing with calcaneal fracture was performed, and the prevalence of use of each classification system determined. Twelve observers classified 30 intra-articular calcaneal fractures according to the 3 most prevalent classification systems; interobserver reliability (kappa [kappa] statistic) and the correlation of the system with the choice of treatment and clinical outcomes were calculated. Forty-nine conventional and 15 computerized tomographic scan classification systems were identified. The most prevalent systems were the Essex-Lopresti, Zwipp, Crosby, and Sanders classifications; and none of these showed a direct correlation with treatment, although each of these systems showed positive correlations with outcome. Moderate interobserver agreement and variability were found for the Crosby and Sanders classifications (overall kappa = 0.48), whereas interobserver reliability among radiologists was poor for the Essex-Lopresti classification (overall kappa = 0.26). Four classifications systems showed positive correlations with outcome, but no correlation with choice of treatment. The Sanders and Crosby classifications displayed comparable, moderate interobserver variability among surgeons and radiologists, and both of these systems are likely to be useful for classification of intra-articular calcaneal fractures.

LEVEL OF CLINICAL EVIDENCE

5.

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.