Long-term outcomes of 1,730 calcaneal fractures: systematic review of the literature

Complication and Revision Rate in Complex Intraarticular Calcaneal Fractures: Extended Lateral vs Sinus Tarsi Approach

BACKGROUND

Adequate surgical treatment of intra-articular calcaneal fractures is challenging. Current clinical evidence on the superiority of either the extended lateral approach (ELA) or the sinus tarsi approach (STA) and their impact on radiologic and functional outcome remains inconclusive, and studies are characterized by low case numbers and short follow-up periods. We hypothesized that using STA would lead to fewer complications and revisions, without impairing fracture reduction or short- to midterm outcome.

METHODS

This retrospective cohort study included 241 patients with intra-articular calcaneal fractures receiving surgical therapy by ELA or STA from 2014 to 2020. A propensity score matching was performed to adjust for covariates distribution after which 140 complete data sets were available for analysis. The primary endpoint was the time to surgical revision. Secondary endpoints were time to complication, complication, as well as revision rate, operating room time, length of stay, and the radiologic and functional outcome (12-Item Short Form Health Survey [SF-12], Visual Analogue Scale for Foot and Ankle [VAS-FA]).

RESULTS

The hazard ratio for surgical revision was 1.74 (95% CI 0.82-3.68) and for complications 1.66 (95% CI 0.82-3.33), both indicating no difference. Radiologic outcome, assessed by remaining step (P = .437) and gap (P = .911) and the reduction grading (P = .564), as well as the functional outcome assessed by the SF-12 (P = .827) and the VAS-FA (P = .930) was comparable in both groups.

CONCLUSION

Compared with conventional ELA, the less invasive surgical technique via STA has similar short- to midterm complications and is associated with comparable anatomical reductions and functional outcomes. The propensity matching of the fracture severity gives us confidence to consider STA a suitable surgical approach in moderate and severe Sanders 3 and 4 type fractures.

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.

Effectiveness of accelerated rehabilitation surgical nursing on perioperative outcomes in patients with calcaneal fractures

This study aims to evaluate the impact of accelerated rehabilitation nursing on perioperative outcomes in patients with calcaneal fractures. A total of 101 patients with calcaneal fractures admitted from December 2020 to December 2022 were included in this study. Patients were randomly assigned to an observation group (OG) of 51 patients receiving accelerated rehabilitation surgical nursing and a control group (CG) of 50 patients receiving conventional surgical nursing. Outcomes assessed included patient satisfaction, visual analog scale (VAS) scores before and after surgery, swelling reduction time, and complication rates. The satisfaction rate in the OG was 96.07%, significantly higher than the 80.00% observed in the CG. Post-operative VAS scores at day 4 and 6 were significantly lower in the OG compared to the CG. Swelling reduction time was shorter in the OG (152.56 ± 25.22 hours) compared to the CG (170.76 ± 22.51 hours). Additionally, the complication rate in the OG was significantly lower at 7.84% compared to 24.00% in the CG (P < .05).the implementation of accelerated rehabilitation nursing significantly shortened the average length of hospital stay for patients in the observation group. In contrast, patients in the control group, who received conventional nursing care, had a relatively longer hospital stay. In the perioperative treatment of calcaneal fractures, accelerated rehabilitation surgical nursing can significantly improve patient satisfaction, reduce pain, shorten the time for swelling to subside, and lower the incidence of complications. Additionally, it can shorten the hospital stay for patients, demonstrating its efficacy and potential for broader clinical application.

A simple modified technique for screw fixation of displaced intra-articular calcaneus fracture through a sinus tarsi approach: a comparison with plate fixation

BACKGROUND

Plates and screws are frequently used for the fixation of displaced intra-articular calcaneus fracture (DIACF). In this study, we compared the outcomes of a modified screw fixation technique with plate fixation via a sinus tarsi approach (STA).

METHODS

A series of 187 DIACF patients who were treated via an STA using a plate fixation (n = 81) or a screw fixation (n = 106) were included. Screw fixation was done with two 2.7 mm screws and two 6.5 mm cannulated screws. Outcomes were evaluated radiographically and clinically. Clinical evaluations included pain assessment by Visual Analogue Scale (VAS) and functional assessment by the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire and Foot Function Index (FFI).

RESULTS

The mean final VAS was smaller in the screw group (P = 0.01). The mean AOFAS and FFI scores were not significantly different between the two groups (P = 0.17 and P = 0. 19, respectively). The mean improvement of Bohler's angle, but not the Gissane's angle, was significantly greater in the screw group (P = 0.014 and P = 0.09, respectively). The mean improvement of calcaneal length and height were not significantly different between the two groups (P = 0.78 and P = 0.22, respectively). The hardware removal rate was 14.8% in the plate group and 3.8% in the screw group (P = 0.007).

CONCLUSION

The modified screw fixation method provides lower pain, better radiographic outcome, and lower rate of hardware removal compared to plate fixation in the treatment of DIACF.

Outcomes of Percutaneous Fixation in Intra-articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures have been proven to be challenging for orthopaedic surgeons worldwide due to the poor clinical outcomes. Historically, the decision whether for fixation or conservative management depended mostly on the literature of the time, initially favouring conservative management but attitudes slowly shifted to operative intervention. Percutaneous fixation options have been increasingly popular for their ability for fracture reduction without skin and wound complications of the open method. A retrospective study of 17 patients with a total of 18 calcaneal fractures treated in our hospital by a single surgeon from January 2017 to December 2019 was conducted. Fixation was done percutaneously using cannulated screws, with the patients in a lateral position. Intraoperative imaging was done using a mini-image intensifier to visualise fracture reduction, and the O-arm was used in most cases. Using the Sanders classification, there were a total of 4 IIA, 3 IIB, 2 IIC, 2 IIIAB, and 7 IIIAC. Results showed that 16 calcaneal fractures (94%) had good to excellent outcomes with the American Orthopedic Foot and Ankle Society (AOFAS) score and Maryland Foot Score (MFS), while 14 calcaneal fractures (78%) showed good to excellent outcomes with the Kerr calcaneal score. There were no wound complications encountered in our series. However, there was one patient with a k-wire broken intraoperative and left in situ and there were two patients with prominent screws. Despite this, our experience with percutaneous fixation of displaced intra-articular calcaneal fractures has been generally favourable, allowing for good outcomes and satisfactory reduction of the fracture fragments.

Current Management of Intra-Articular Calcaneal Fractures

Intra-articular calcaneal fractures are debilitating injuries that can result in a dramatic effect on quality of life post-injury. Surgical intervention is generally advised when significant displacement or comminution is present but can present a host of complications secondary to the limited blood supply and fragility to the soft tissues following injury. Surgical approaches to calcaneal fractures generally include the lateral extensile approach, minimal incision (sinus tarsi approach), or percutaneous approach. Each approach presents risks and benefits; therefore, determining the optimal incisional approach should be based on patient comorbidities, fracture pathoanatomy, soft tissue envelope concerns, and patient pre-injury functional status.

Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management

OBJECTIVES

To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures.

PATIENTS AND METHODS

We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates.

RESULTS

Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups.

CONCLUSIONS

Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study

BACKGROUND

Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction.

METHODS

This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate.

RESULTS

Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork.

CONCLUSION

Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane.

LEVEL OF EVIDENCE

III.

Minimally invasive K-wire fixation of displaced intraarticular calcaneal fractures through a minimal sinus tarsi approach

BACKGROUND

Displaced intra-articular calcaneal fractures are challenging injuries, and there is debate regarding the best method of treatment.

PATIENTS AND METHODS

Between January 2018 and January 2021, a prospective study was conducted on 46 patients with 56 displaced intraarticular calcaneal fractures that were treated with minimally invasive fixation using Kirschner wires (KWs) through the sinus tarsi approach.

RESULTS

The mean follow-up period was 22.36 months. The American Orthopaedic Foot and Ankle Society (AOFAS) score was adopted as a method of clinical evaluation; the mean AOFAS score was 78.4. All cases showed radiographic evidence of adequate healing, with no collapse till the final follow-up. Complications included persistent pain, subtalar arthritis, deep infection and superficial pin site infection.

CONCLUSION

The use of the sinus tarsi approach and percutaneous KWs represents a minimally invasive approach which expands the indications of surgery for displaced intra-articular calcaneal fractures with fewer treatment-related complications. Level of evidence (4) case series. Trial registration This study has been approved by the ethical research committee of the Faculty of Medicine, Tanta University, under the code: 35901/10/22.

[Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach]

OBJECTIVE

Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach.

INDICATIONS

Intra-articular dislocated calcaneus fractures.

CONTRAINDICATIONS

Fracture older than 14 days; poor soft tissue quality in the surgical area.

SURGICAL TECHNIQUE

Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath.

POSTOPERATIVE MANAGEMENT

Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing.

RESULTS

Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Current Concepts about Calcaneal Fracture Management: A Review of Metanalysis and Systematic Reviews

Background: The fracture of the calcaneus is the most common traumatic lesion of the hindfoot and can cause severe disability with social and economic sequelae. Since 1980, an increasing number of studies and new technologies have led to an improvement in the management of calcaneal fractures, but treatment is still controversial. The purpose of this review was to investigate the secondary scientific literature to detect the optimal management of calcaneal fracture. Methods: A MEDLINE search via PubMed was conducted. A total of 4856 articles were identified, and only meta-analyses and systematic reviews were included. Results: 59 articles with more than 10,000 calcaneus fractures were examined, and the results were divided into various topics. Most articles agree on the superiority of surgical treatments compared to conservative ones. Moreover, minimally invasive access to the sinus tarsi showed better results and fewer complications than traditional extended lateral access. Also, reduction and osteosynthesis with percutaneous and/or minimally invasive techniques seem to provide better outcomes when compared to open treatments. Conclusions: The management of calcaneal fractures requires an individualized treatment plan based on the functional demands of the patient, the type of fracture, and associated injuries. New technologies and further studies can lead to an improvement in the management of calcaneal fractures.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study

BACKGROUND

Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures.

METHODS

Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5 cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4 mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7 mm cannulated partially threaded Charlotte^TM (Wright Medical Technology, Memphis, USA) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5 N, 10 N and 20 N force was measured in millimetres (mm).

RESULTS

2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88 ± 0.390 at 5 N and 1.7 ± 1.251 at 20 N) and the most stable construct (p < 0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04 ± 0.971 at 5 N and 11.24 ± 7.590 at 20 N) (p < 0.05).

CONCLUSION

This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Optimal posterior screw placement configuration in Sanders 2B calcaneal fractures: A biomechanical study

BACKGROUND

Calcaneal fractures can be high energy intra-articular injuries associated with joint depression. Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Minimally invasive approaches with indirect reduction of the calcaneal tuberosity to maintain the reduction using posterior screws is routinely being used in the treatment of joint depression fractures. Biomechanically, optimum screw numbers and configuration is not known. Biomechanical studies have evaluated and proposed different screw configurations, however, it is not clear which configuration best controls varus deformity. This study aims to determine the optimum screw configuration to control varus deformity in Sanders 2B calcaneal fractures.

METHODS

Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. After stabilising posterior facet with a single 4mm partial threaded screw, and applied an 8 hole contoured plate to stabilise the angle of Gissane, inserted one or two 7mm cannulated partially threaded Charlotte™ (Wright Medical Technology, Inc. 5677 Airline Road Arlington, TN) Headless Multi-use Compression (under image guidance) extra screws to control varus and subsidence deformity of the fracture. Coronal plane displacement of the dissociated calcaneal tuberosity fragment relative to the body when applying 5N, 10N and 20N force was measured in millimetres (mm).

RESULTS

2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.88±0.390 at 5N and 1.7±1.251 at 20N) and the most stable construct (p<0.05) when compared to other configurations. A single medial screw into the sustentaculum tali (conf. 3) resulted in the least stable construct and most displacement (4.04±0.971 at 5N and 11.24±7.590 at 20N) (p<0.05).

CONCLUSION

This study demonstrates the optimal screw configuration to resist varus in calcaneal fractures using minimally invasive techniques. Optimal stability is achieved using 2 screws; one located along the long axis of the calcaneus (varus control) and the other placed in the short axis directed towards the posterior facet of the calcaneus (control varus and subsidence). Further cadaver research would help evaluate optimal screw placement in simulated fractures to further assess reproducibility.

Outcomes of Early Weight Bearing in Displaced Intra-articular Calcaneus Fractures Treated with Screws-Only Fixation Technique

Background

Displaced intraarticular calcaneus fracture indicates surgical treatment. The current trend is open reduction and internal fixation with a plate or multiple screws through the sinus tarsi approach. Most postoperative protocols are prolonged non-weight bearing that causes a high socioeconomic burden. This study aims to determine the safety of the early weight-bearing protocol of screws-only fixation in calcaneal fracture.

Materials and Methods

Evaluate displaced intraarticular calcaneus fractures treated with screws-only technique via the sinus tarsi approach in our institution. The first group, from July 2017 to December 2018, allowed patients to start partial weight bearing as tolerated at 4 weeks after surgery. The second group prospectively from January 2019 to March 2020, which assign patients to keep non-weight bearing for 8 weeks. The functional outcomes (Thai Foot and ankle ability measure subjective form, FAAM) were measured 6 months after surgery. The radiographic outcome (Bohler's angle and Gissane angle) was measured on the first day postoperative and 6 months follow-up, and the changes in these angles were recorded.

Results

There were 28 patients in each group. The outcomes were collected and compared by a T-test. In the early weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 76.4 ± 14.8, 2.4 ± 3.5, and 6.6 ± 7.8, respectively. In the delayed weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 81 ± 14.8, 2 ± 1.8 and 2.6 ± 6.1, respectively. There was no statistically significant difference in FAAM score, Bohler's angle loss, and Gissane's angle change between early and delayed weight-bearing groups.

Conclusion

Screws fixation in calcaneal fracture may be safe to allow early weight-bearing protocol.

A windows technique for sustentaculum tali screw fixation using the sinus tarsi approach for calcaneal fractures: a cadaveric study

INTRODUCTION

The minimally invasive approach for displaced intra-articular calcaneal fractures is significantly reducing postoperative wound complications. One minimally invasive method, the sinus tarsi approach (STA) has been increasingly widely used. STA is, however, challenging due to its technical demands and the risk of injury to the sural nerve (SN). The purpose of this study was to identify the SN and its branches including their anatomical relationship to the STA as well as to describe an anatomical windows technique for STA including determination of the safe angle for screw insertion into the sustentaculum tali fragment.

METHODS

Thirty-two adult cadaveric legs were disarticulated at the knee and unpaired. STA was performed on each specimen. The anatomy and distribution of the sural nerve and its branches were identified in relation to the incision. Three surgical windows were identified and selected. Kirshner wires were inserted in pairs via each of the windows towards the center of the sustentaculum tali. The safe angle for wire insertion in relation to the SN or its branches was then measured as well as the appropriate intraoperative drilling angle.

RESULTS

The plantar branch presented in the distal window in none of the samples, while the dorsal branches presented in 37.5% and the main SN presented in only 6.25%. In the middle window, the dorsal branch presented most often (43.75%) followed by the plantar branch (25.00%) and the SN (21.88%). In the proximal window, the SN presented in 100% of the samples, while the dorsal branch presented in none and the plantar branch presented in about 15.63% of the specimens. All three windows had their own acceptable average angle for screw insertion towards the sustentaculum tali.

CONCLUSIONS

The distal window is the safest for surgical approach and for calcaneal surgery screw fixation in terms of avoiding sural nerve injury. In addition, that window provides a wide working angle for screw fixation.

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.

Circular External Fixator Assisted Open Reduction Combined With Locking Plate Fixation for Intra-articular Comminuted Fractures of the Calcaneus

Comminuted fractures of the calcaneus are relatively common and generally require surgical treatment. The quality of fracture reduction is crucial. The extended lateral approach (ELA) can better expose the fracture end and facilitate the reduction of the fracture, while it has a higher risk of postoperative skin complications. In this study, the ELA was adopted, and the calcaneal comminuted fractures were treated with circular external fixator assisted reduction to achieve the purpose of good reduction of the fracture and fewer skin complications. During 64 months, a total of 61 cases of unilateral calcaneal fractures were treated by the same surgeon and followed up for 19.28 ± 5.28 months. During the operation, a circular external fixator was employed to fix the midfoot and the distal end of the tibia, and the calcaneal tubercle; then, the calcaneal tubercle was distracted to restore the 3-dimensional structure of the calcaneus. The ELA was utilized to reduce the articular surface fracture. The fracture was fixated with a locking plate. Postoperative radiographs were regularly reviewed. Meanwhile, Böhler's angle and Gissane's angle were measured. Visual analogue scale and American Orthopedic Foot and Ankle Society Score assessments were performed at the final follow-up. All fractures healed. The mean preoperative Böhler's angle was 9.3 ± 10.1 degrees; the mean Gissane's angle was 110.5 ± 14.7 degrees; the immediate postoperative mean Böhler's angle was 31.3 ± 5.5 degrees; mean Gissane's angle was 110.9 ± 5.9 degrees. Local superficial necrosis of surgical incision occurred in 2 cases, which healed well after dressing changes. Skin necrosis appeared in 1 case, where debridement and local flap transfer were performed. At the final follow-up, the mean visual analogue scale score was 1.48 ± 1.30, and the mean American Orthopedic Foot and Ankle Society Score was 90.16 ± 7.19. The ELA combined with a circular external fixator to assist in the reduction of calcaneal fractures achieved good reduction quality and effectively reduced postoperative complications.

Modified sinus tarsi approach with a variable-angle locking anterolateral plate for Sanders type II and III calcaneal fractures

BACKGROUND

We compared the effectiveness of the extensile lateral approach (ELA) and modified sinus tarsi approach (MSTA) with a variable-angle locking anterolateral plate in treating Sanders type II and III calcaneal fractures.

METHODS

We reviewed 45 DIACFs treated by a single surgeon from 2017 to 2020. Open reduction using ELA and MSTA was performed in 25 and 20 patients, respectively. Follow-up evaluations included radiological assessments and clinical evaluations.

RESULTS

Pre- and postoperative radiologic parameters for the calcaneus were significantly different. The average American Orthopaedic Foot and Ankle Society scores were 81.24 and 85.00, the mean visual analogue scale scores were 2.28 and 1.65, and the wound-related complication rates were 64.0% and 15.0% in the ELA and MSTA groups, respectively. Bony union was achieved in all cases.

CONCLUSIONS

For Sanders type II and III fractures, MSTA seems to be a safer and more satisfactory method, with fewer postoperative complications.

Sinus Tarsi Approach With Percutaneous Screw Fixation for Intra-Articular Calcaneal Fractures

The aim of this study was to evaluate the outcomes of surgical treatment of intra-articular calcaneal fractures by using the sinus tarsi approach combined with percutaneous medial reduction by leverage technique and percutaneous screw fixation. We assessed the outcomes of 29 patients treated using sinus tarsi approach with percutaneous screw fixation. All patients were evaluated both clinically and radiologically. The Böhler and Gissane angle were evaluated postoperatively using radiographs. During the median follow-up period of 27.0 ± 10.3 months, no cases with failure to reduce or displace hardware were detected. All cases achieved the restoration of a normal Böhler and Gissane angle. The median preoperative Böhler angle was 12.3° ± 2.5° while postoperatively it was 30.5° ± 5.7° (p < .01). The median preoperative Gissane angle was 98.1° ± 7.5°, which was 125.9° ± 3.6° postoperatively (p < .01). At the last follow-up, the median American Orthopedic Foot and Ankle Society hindfoot score was 87.7 ± 5.9, and the median Maryland foot score was 88.6 ± 5.9. Our technique for intra-articular calcaneal fractures can effectively correct calcaneal tuberosity outward displacement, medial wall overlapping, and the hindfoot varus deformity with less soft tissue damage. This technique is a good alternative for the treatment of calcaneal fractures, resulting in minimal soft tissue damage, few wound complications, and excellent radiological and clinical outcomes.

Comparison of the Curative Effect of Percutaneous Reduction with Plastic Calcaneal Forceps Combined with Medial External Fixation in the Treatment of Intra-Articular Calcaneal Fractures

Objective

To compare the clinical efficacy of percutaneous minimally invasive reduction combined with external fixation and a tarsal sinus approach to treat Sanders type II and III intra‐articular calcaneal fractures.

Methods

The clinical data of 64 patients with Sanders type II and III calcaneal fractures admitted to our hospital from January 2010 to January 2016 were retrospectively analyzed; data includedage, sex, body mass index. According to the surgical method, they were divided into the percutaneous minimally invasive reduction with internal and external fixation group (30 cases) and the tarsal sinus approach group (34 cases).The two groups of patients were compared in terms of the time tosurgery, length of hospital stay, intraoperative blood loss, operative duration, complications, radiographic features, including the heel bone length, width, height, Bohlerangle, Gissane angle, and calcaneal varus angle, and clinical efficacy indicators, including the American Orthopedic Foot and Ankle Society (AOFAS) score, the visual analog scale (VAS) pain score, health survey profile (SF‐36) score and Maryland ankle function score.

Results

Patients in both groups were followed up for 12 to 50 months, with an average of 24.8 months.Bony union was achieved in all cases. The time to surgery, length of hospitalstay, intraoperative blood loss and incidence of incision‐related complications were significantly lower in the percutaneous minimally invasive medial external fixation group than in the tarsal sinus group (P < 0.01). At the last follow‐up, the calcaneal length, width, and height, Bohler angle, Gissane angle, and varus angle were significantly increased in both groups (P < 0.01), the calcaneal width was significantly lower after than before surgery (P < 0.01), and there were no statistically significant differences between the two groups (P > 0.05). As measures of clinical efficacy, the AOFAS, VAS, SF‐36 and Maryland scores were 85.28 ± 8.21, 0.84 ± 1.21, 82.95 ± 3.25 and 83.56 ± 3.32, respectively, at the last follow‐up in the percutaneous minimally invasive medial external fixation group and 83.32 ± 7.69, 1.85 ± 1.32, 80.71 ± 5.42, and 81.85 ± 2.41 in the tarsal sinus group, respectively, with no significant differences between the two groups (P > 0.05).

Conclusion

Under the condition of a good command of surgical indications and surgical skills, the use of plastic calcaneal forceps for percutaneous minimally invasive reduction combined with medial external fixation for the treatment of Sanders type II and III intra‐articular calcaneal fractures can achieve similar clinical effects as the tarsal sinus approach. However, the use of plastic calcaneal forceps for percutaneous minimally invasive reduction combined with internal and external fixation has advantages, such as fewer complications, less bloodloss, and a shorter operation, and thus has good safety and is worthy of clinical promotion.

Plate fixation through the lateral extensile approach versus cannulated screw fixation through the sinus tarsi approach for calcaneal fracture: a multicenter, propensity score-matched TRON study

PURPOSE

For calcaneal fracture, plate fixation through lateral extensive approach (LEP) is the most common procedure performed to achieve anatomic reduction. However, wound complications sometimes occur after LEP. To reduce complications, minimally invasive operative methods with cannulated screw fixation through sinus tarsi approach (STS) were developed. The aim of this multicenter propensity-matched study was to compare the clinical and radiographic outcomes of LEP to those of STS for calcaneal fracture and to evaluate the incidence of postoperative complications including surgical site infection (SSI).

METHODS

We extracted 271 patients with calcaneal fracture undergoing surgery between January 2014 and March 2019 from our multicenter TRON database. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score at the final follow-up as the clinical outcome. We obtained the Bohler and Preis angles as radiographic parameters and also recorded the complications. We divided the subjects into two groups: LEP group and STS group. To adjust for baseline differences between the groups, a propensity score matching algorithm was used in a 1:1 ratio.

RESULTS

After matching, there were 32 fractures in each group. There was no significant difference between the LEP versus STS group in AOFAS score at final follow-up (90 vs 90 points, p = 0.98) and in the Bohler and Pries angles (19.2 vs. 18.0 degrees, p = 0.74 and 16.0 vs. 17.5 degrees, p = 0.47). The rate of SSI in the LEP group was higher than that in the STS group (21.9% vs. 0.0%, p = 0.01).

CONCLUSION

For calcaneal fracture, STS provides similar fixation effectiveness and functional outcomes as LEP while reducing the likelihood of infection.

Local Random Pattern Flap Coverage for Implant Exposure following Open Reduction Internal Fixation via Extensile Lateral Approach to the Calcaneus

Background

Skin necrosis and implant exposure most often appear at the corner of Extensile Lateral Approach for open reduction and internal fixation (ORIF) for displaced intra-articular fracture of the calcaneus. Flap transfer is often used for coverage of this implant exposure. We introduced a new simple local random pattern flap to cover the implant exposure.

Methods

From March 2017 to March 2020, 12 patients with implant exposure after ORIF for displaced intra-articular fracture of the calcaneus were treated with this procedure. The sizes of the defects ranged from 2 × 2 cm² to 5 × 2 cm². A local random pattern flap was designed according to the defect size. The lower edge of the flap was along with the wound upper edge and extended distally. The upper horizontal incision of the flap was made at the lateral malleolus level with a length of 5–7 cm depending on the wound defect. Then the random pattern flap was elevated and transferred to cover the defect area.

Results

The mean follow-up duration was 6.3 months (ranging 4–13 months). All 12 flaps were uneventfully healed and all patients were able to wear shoes, and no debulking procedures were required.

Conclusion

The local random pattern flap could be a choice for surgeons when implant exposure at the corner of Extensile Lateral Approach to the Calcaneus occurs.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.

Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.

Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.

Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

Comparison of the modified sinus tarsi approach versus the extensile lateral approach for displaced intra-articular calcaneal fractures

Background

This study sought to assess and compare the clinical efficacy and complications of a modified sinus tarsi approach (MSTA) and the extensile lateral approach (ELA) in the treatment of displaced intra-articular calcaneal fractures.

Methods

This retrospective study enrolled 108 patients (117 feet) with Sanders II-IV calcaneal fractures, including 52 patients (56 feet) in the MSTA group and 56 patients (61 feet) in the ELA group. The functional and radiological results of the affected feet were analysed retrospectively. Functional evaluation included American Orthopaedic Foot and Ankle Society (AOFAS), visual analog scale (VAS), and Short Form-36 Health Survey (SF-36). Radiological evaluation included preoperative and postoperative changes in the Bohler Angle, Gissane Angle, length, width, and height of the calcaneus. The postoperative complications were also collected and analysed. The independent-samples t-test and analysis of variance (ANOVA) were employed to compare differences between the two groups. Differences within the same group were compared by paired Student's t-test, and categorical variables were compared using the chi-square test.

Results

The postoperative functional and radiological results showed that the mean AOFAS, VAS and physical component summary of SF-36 scores in the MSTA group were higher than those in the ELA group (P<0.05). After surgery, the Bohler and Gissane angles were significantly improved in both groups, as were the length, width, and height of the calcaneus; no statistically significant differences existed between the two groups. The incidences of wound healing complications and postoperative sural nerve injury were lower in the MSTA group than in the ELA group (P<0.000).

Conclusions

The MSTA can achieve similar effects to the ELA in terms of anatomical reconstruction and functional recovery. It also can also effectively reduce the incidences of wound healing complications and postoperative sural nerve injury, and shorten the length of hospital stay.

Minimally invasive surgery for intra-articular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor

BACKGROUND

A fracture of the calcaneus can be a painful and disabling injury. Treatment modalities may be conservative or operative. Surgical treatment strategies include open reduction and internal fixation (ORIF) techniques, as well as a variety of minimally invasive methods. The aim of this study was to evaluate the treatment options and post-treatment complication rates for intra-articular calcaneal fractures at the Traumacenter Linz over a 9-year period.

METHODS

All patients with calcaneal fractures treated at the Traumacenter Linz between 2007 and 2015 were included in this study. The patients records were retrospectively reviewed, and the data, including demographic parameters, cause of injury, and the time between injury and operative treatment were analyzed. The number of secondary operative interventions due to soft-tissue complications, hardware removal, and the long-term arthrodesis rate were evaluated.

RESULTS

A minimally invasive 2-point-distractor method was used in 85.8% (n = 182) of all operatively managed calcaneal fractures (n = 212) in our department. The majority of the operations (88.7%) were performed within 2 days after the accident. The secondary operation rate resulting from wound complications was 2.7% in the 2-point distractor group and 16.7% in the ORIF group. A secondary arthrodesis was performed in 4.7% (n = 9) of the subtalar joints in the entire study population.

CONCLUSIONS

Our data supported the assumption that severe wound complications would be less likely to occur after minimally invasive treatment compared to ORIF treatment. The rate of secondary arthrodesis in the study cohort was comparable to that in the literature.

LEVEL OF EVIDENCE

IV.

Functional Outcome Estimation of Calcaneum Fractures Treated by Open Reduction and Internal Fixation with Plate and Screws in A Tertiary Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Calcaneum fractures constitute about 60% of all tarsal bone fractures. Intra-articular fractures account for 70% of all calcaneal fractures. There are controversies regarding the operative treatment of calcaneum fractures. Therefore this study aimed to estimate the functional outcomes of calcaneum fractures treated by open reduction and internal fixation with plate and screws.

METHODS

This descriptive, cross-sectional study was carried out at the tertiary care center in the western region of Nepal among the patients with displaced intra-articular calcaneum fractures from February 2017 to July 2020 after approval from the Institutional review committee. Convenient sampling was done to reach the sample size. Fifteen cases were included in the study. Data were recorded in proforma and Data analysis was done in the statistical package for social sciences. The American Orthopedic Foot and Ankle Society Hindfoot score was used to assess the final outcome.

RESULTS

According to the American Orthopedic Foot and Ankle Society hindfoot scores, there were five excellent (33.33%), seven good (46.66%), two fair (13.33%) and one poor (6.66 %) results.

CONCLUSIONS

In displaced intra-articular calcaneum fractures, open reduction and internal fixation with plates and screws result in a good number of satisfactory outcomes with very few unsatisfactory results. Hence it can be a better option of treatment in displaced intra-articular calcaneum fractures.

[Anatomical calcaneal external fixator self-designed according to the morphology of heel]

OBJECTIVE

The anatomical calcaneal external fixator was designed by measuring and calculating the morphological data of the heel.

METHODS

A total of 100 normal people were randomly selected to obtain 200 hind foot data, including 45 males and 55 females, with an average age of 43.9 years (range, 19-67 years). According to the principles of human engineering and local anatomy, the morphological data of the heel in the weight-bearing standing position and supine position were measured with the direct measurement mode. The heel length, heel width, heel height, medial ankle height, lateral ankle height, and calcaneal pitch angle (CPA) were measured by vernier calipers and ulnar markers in weight-bearing standing position, and the gender groups and left and right foot groups were compared; the shape of the hind foot in the supine position was measured by three-dimensional (3D) dot matrix inverse model method. According to the stereoscopic data of the comprehensive anatomical morphology of the heel, the anatomical calcaneal external fixator was designed with AutoCAD 2019 and other 3D industrial design softwares.

RESULTS

The measurements of shoe size, heel length, heel width, heel height, medial ankle height, lateral ankle height, and CPA in male were significantly higher than those in female ( P<0.05). There was no significant difference between the left and right feet in the other indexes except that the height of the medial malleolus of the left foot was significantly lower than that of the right foot ( t=-2.827, P=0.005). The measurement of 3D dot matrix inverse model in supine position showed that the heel part was non-circular arc edge, and many groups of arc edges fluctuate in a limited range. Based on the above data, an anatomical calcaneal external fixator was designed, which could fit the anatomic radian in theory, so as to be flexible in configuration. On this basis, the ordinary configuration, compression configuration, and orthodontic configuration were designed to meet the treatment needs of calcaneal fractures in different degrees. The ordinary configuration was suitable for patients with Sanders Ⅰ, ⅡA, and ⅡB calcaneal fractures with no or slight displacement of intra-articular fractures; the ordinary configuration was mainly used for simple fixing. The compression configuration was suitable for patients with Sanders ⅡC, ⅢA, and ⅢB, tongue fractures, and avulsion fractures with severe displacement of intra-articular fractures; the compression configuration used obliquely drawn console wires to fix the displaced bones. The orthodontic configuration was suitable for patients with Sanders ⅢC and Ⅳ calcaneal fractures with severe displacement of intra-articular fractures or severe calcaneal bone defects; the orthodontic configuration was a multi-module design, which took into account the stable fixation of the fracture and the arbitrary adjustment of the joint fixation angle.

CONCLUSION

The hind foot is special for morphology, so the external fixator designed based on the vernier caliper measurement method and 3D dot matrix measuring plate measurement method is an anatomical type and its configuration can theoretically meet stable and flexible clinical needs.

An experimental study on the digital precision of internal fixation via the sinus tarsi approach for calcaneal fractures

OBJECTIVE

To investigate the effectiveness and accuracy of internal fixation of calcaneal fractures with a three-dimensional (3-D) printing navigation module via the sinus approach.

METHODS

Eleven lateral lower extremity specimens were used in the experiment and divided into the digital design (DD) group ( n = 11) and the real surgery (RS) group ( n = 11). For the DD group, thin-section computed tomography (CT) scans, virtual fracture modeling, virtual bone plate fixation, sinus occlusal module design, and navigation module design were performed for the cadaver specimens. A 3-D navigation module was printed using a 3-D printer. For the RS group, the sinus approach incision was made, and the navigation module was used to assist the placement of screw fixation and anatomically locked bone plate fixation. Thin-layer CT scans, 3-D reconstructions, and reconstruction of the nail paths were performed in the RS group and 3-D registered with the DD group. 3-D coordinate values for the screw entry and exit points in the RS and DD groups were recorded, and the corresponding offset values of the screw points were calculated. The number of qualified nails at different accuracy levels was counted. The χ² test was used to compare the data for the DD and RS groups to obtain the accuracy level for both groups when p > 0.05, which is the critical value for experimental accuracy.

RESULTS

A total of 11 bone plates were placed and 120 screws were locked. None of them protruded from the inferior articular surface. The screw entry and exit point offsets were 1.71 ± 0.11 mm and 3.10 ± 0.19 mm, respectively. When the accuracy requirement for the entry point was 3.8 mm, there was no statistically significant difference between the two groups ( p > 0.05). Similarly, the accuracy of the exit point of the screw could only reach 6.6 mm.

CONCLUSION

Internal fixation of calcaneal fractures via the sinus tarsi approach with an anatomical locking plate based on the 3-D printing navigation module can achieve accurate screw placement and good overall internal fixation.

Post-Traumatic Hindfoot Arthritis

The hindfoot is functionally defined as the articulations between the talus, calcaneus, navicular, and cuboid. It is a biomechanically important peritalar unit for shock absorption and propulsion with the subtalar and talonavicular joint essential to its function. The primary cause of hindfoot arthritis is post-traumatic. Other causes include long-term misalignment such as adult-acquired flatfoot, cavus foot, and inflammatory arthritis. Prevention of post-traumatic hindfoot arthritis is the primary objective. Anatomical reduction and fixation of articular hindfoot fractures is the preferred pathway. This article discusses the principles of treatment of hindfoot arthritis. When post-traumatic changes cannot be managed by nonsurgical means, an anatomical well-aligned arthrodesis is indicated. This article addresses the principles of managing this condition, which have been championed by Professor Sigvard T. Hansen. New approaches and techniques are discussed that achieve the goals of a stable, functional plantigrade foot.

Limited Open Reduction and Internal Fixation of Calcaneal Fractures

BACKGROUND

The treatment of displaced intra-articular calcaneal fractures remains a challenge and the optimal approach is still controversial. The main reason to avoid the extended lateral approach is the high complication rate due to wound healing problems. We report on 16 years of experience with a standardized limited open reduction and internal fixation technique.

METHODS

Between 2001 and 2017, we prospectively followed 240 consecutive patients operatively treated for a displaced intra-articular calcaneal fracture. Patients with open, multiple, bilateral, extra-articular, and Sanders IV fractures and those lost to follow-up were excluded. A lateral subtalar approach was used, with a cast for 8 weeks and full weightbearing allowed after 12 weeks. Follow-up examinations were scheduled until 24 months. Subjective and clinical assessment included gait abnormality, subtalar and ankle range of motion, and stability and alignment. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was calculated. Alignment was analyzed on standard radiographs. In total, 131 patients were excluded. The remaining 109 patients were followed for a minimum of 24 months (34.4 ± 14.2 [range, 24-102] months).

RESULTS

The mean AOFAS score was 87 ± 13 (range, 32-100). "Excellent" and "good" results, as well as hindfoot motion with "normal/mild" and "moderate" restrictions, were seen in 80% of patients. Early reoperations were performed for insufficient reduction (2 patients), delayed wound healing (debridement, 3 patients), and hematoma (1 patient). Late revisions were arthrodesis (3 patients), medializing calcaneal osteotomy (1 patient), and implant removal (53 patients; 49%).

CONCLUSION

The presented approach has remained unmodified for 16 years and resulted in consistently good functional results. The main disadvantage was the high rate of heel screw removal.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effect of Surgeon and Hospital Volume on Complications After Operative Tarsal Fracture Repair

OBJECTIVE

To determine whether increased surgeon and hospital volume is associated with lower rates of complications after tarsal fractures.

DESIGN

Retrospective cohort study of the State Inpatient Databases.

SETTING

Two hundred ninety-nine hospitals in Florida (2005-2012) and New York (2006-2008).

PATIENTS/PARTICIPANTS

Four thousand one hundred thirty-two tarsal fractures that underwent fixation by 1223 surgeons.

INTERVENTION

Surgical repair of tarsal fractures.

MAIN OUTCOME MEASUREMENTS

Composite of readmission for infection requiring operative treatment, wound dehiscence, nonunion, avascular necrosis, or amputation within 2 years of the index procedure.

RESULTS

The mean age was 44 (±15) years, a majority were men (70%) and white (69%), and the mean number of Charlson comorbidities was 0.21 (±0.58). Multivariable logistic regression demonstrated a reduction in the likelihood of complications by 9% for each 5 additional surgeries performed by the operating surgeon [odds ratio (OR), 0.91 per 5 surgeries; 95% confidence interval (CI), 0.82-0.99]. Other factors associated with complications included increased age (OR, 1.23 per 10 years; 95% CI, 1.10-1.36), male sex (OR, 1.56; 95% CI, 1.12-2.17), open fractures (OR, 2.84; 95% CI, 1.92-4.19), number of Charlson comorbidities (OR, 1.23; 95% CI, 1.02-1.48), income quartile (OR, 1.48; 95% CI, 1.00-2.17), uninsured (OR, 2.47; 95% CI, 1.39-4.39), and other government program insurance (OR, 1.52; 95% CI, 1.06-2.18).

CONCLUSIONS

We observed a significant inverse relationship between surgeon volume and complication rates when controlling for patient and injury characteristics. In contrast to previous research, a volume-outcome relationship was not observed at the hospital level. These results suggest that such complex injuries should be triaged to the most experienced providers.

LEVEL OF EVIDENCE

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

A systematic review and meta-analysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures

BACKGROUND

The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017).

RESULTS

Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I²=0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes.

CONCLUSIONS

The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF.

Intra-articular calcaneal fractures. Do locking plates keep the reduction better than conventional plates?

INTRODUCTION

Since the development of locking plates, calcaneal fractures have been considered ideal for this type of fixation, due to the need to maintain the height of the subastragaline joint after depression fractures in a location where bone quality tends to be poor. However, there are no comparative studies that support the theoretical superiority of these plates over conventional plates. The aim of this study was to compare the results of intraarticular calcaneal fractures treated using locking plates vs. conventional plates in terms of radiological reduction, complications and number of reinterventions.

MATERIAL AND METHODS

We designed a comparative study of calcaneal fractures operated in our centre using the "L" approach. Two groups were established: group B, comprising 15 patients operated between 2010 and 2015 with calcaneal locking plates, and group A, comprising a stratified random sample of 23 patients taken from a historical cohort of 90 patients operated in our centre between 1997 and 2007 using conventional calcaneal plates. Demographic data were recorded (age, sex, diabetes mellitus, smoking) and data relating to the fracture (type of fracture according to Sander's classification system, complications, presurgical delay). To evaluate loss of reduction, varus angulation of the calcaneus (measured from the axial view), Böhler's angle and Gissane's angle were assessed radiographically. These angles were measured preoperatively, immediately postoperatively, and at the end of follow-up. Finally, we recorded complications and the number of reinterventions.

RESULTS

There were no differences in terms of age, sex or fracture type between the 2 groups. There was greater loss of varus angulation in group A, 0.6 vs. 0.41°, and there was greater reduction in Böhler's angle in group A, 3.79 vs. 2.6°, while Gissane's angle decreased more in group B, 4.13 vs. 2.52°. There were no significant differences in the proportion of complications and reinterventions between the 2 groups.

CONCLUSION

In our study we observed no significant differences between the 2 groups in terms of radiological reduction, complications or number of reinterventions. However, we did observe a greater loss of reduction of Böhler's angle in the patients who were operated using conventional plates.

Comparison of plate, calcanealplasty and external fixation in the management of calcaneal fractures

OBJECTIVE

Managing displaced intra-articular calcaneal fractures remains controversial. The purpose of this study is to compare and identify the surgical technique with the best outcomes for the treatment of intra-articular calcaneal fractures.

MATERIALS AND METHODS

This is a retrospective multicentric study conducted between February 2000 and June 2014 in 206 patients with intra-articular calcaneal fractures presenting to the outpatient or emergency department of three different orthopaedic departments. The patients were treated with one of the following techniques: 1. Open reduction and internal fixation with screws and plate; 2. Percutaneous reduction and monolateral external fixation; and 3. Balloon-assisted reduction, pin fixation and tricalcium phosphate augmentation.

RESULTS

Patients treated with open reduction and internal fixation using an extensive lateral approach had a mean AOFAS score of 71 points; those treated through a minimal incision and reduction and fixation with an external fixator had a mean score of 83.1 points; and those treated with the balloon-assisted reduction, pin fixation and tricalcium phosphate augmentation had a mean score of 78.75 points. No statistically difference was found comparing the three types of treatment.

CONCLUSION

Displaced intra-articular calcaneal fractures are still technically demanding injuries to manage. The results of this study suggest that in comparison to open reduction, a percutaneous reduction and fixation leads to higher but not statistical functional scores minimizing the wound-healing complications.

Displaced intra-articular fractures of the calcaneus: ORIF through an extended lateral approach

INTRODUCTION

Displaced intra-articular calcaneal fractures (DIACF) represent a challenging and controversial issue in traumatology. Conservative treatment has been recommended to avoid surgical problems and complications. The final result, however, is often a painful malunioun of the calcaneus with peroneal impingement. Surgical treatment is gaining acceptance since it offers a chance to restore bone anatomy improving function as long as complications are avoided.

MATERIAL AND METHOD

We reviewed a series of 59 DIACF treated by a single surgeon during a 9 years period. A clinical and radiological follow-up was obtained in 44 cases (74,6%) (average of 5,5 years; range 2-9). There were 29 males and 15 females with an average age of 54 years (range 25-74). Patients were operated through an extended l-shaped lateral approach and fixation was achieved with lag screws and plate. Outcome measures method included the AOFAS score, the Maryland Foot Score, the Foot Function Index and the SF-36.

RESULTS

The average AOFAS score was 80,5 points. The result was excellent in 18 cases (40,9%), good in 14 cases (31,8%), fair in 10 cases (22,7%) and poor in 2 (4,6%). The mean score for pain was 33,5/40 points, for function 40/50 and for alignment 7/10. Pain was absent in 17 cases (38%), 19 patients (43%) had no functional limitations and 11 (25%) could walk on uneven ground without difficulties. The average FFI score was 25/100 points. The average MFS score was 89/100 points. Subtalar motion was reduced. Reconstruction of the calcaneus was anatomic in 20 cases (45,5%) with an improved clinical outcome. Eight patients (17%) had minor wound healing complications. Three patients (6,8%) required a subtalar arthrodesis after the procedure.

CONCLUSIONS

Ostheosytesis through an extended lateral approach restored bone morphology with a reasonable complications rate. The clinical results were good but a normal function and complete subtalar motion were rarely achieved.

Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures can be treated with open reduction and internal fixation through various methods, including the extensile lateral approach, sinus tarsi approach, percutaneous reduction and fixation, external fixation, and calcaneoplasty. Although the gold standard is the extensile lateral approach, this method has significant wound-healing complications associated with it. Literature shows that the reduction achieved through minimally invasive techniques is equal to that achieved with the extensile lateral approach, while reducing the amount of postoperative complications. This article outlines a technique that uses the sinus tarsi approach with subcutaneous plate fixation.

Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most?

Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures.

Should the Extended Lateral Approach Remain Part of Standard Treatment in Displaced Intra-articular Calcaneal Fractures?

The aim of this study was to evaluate the results of open reduction and internal fixation through the extended lateral approach (ELA) in displaced intra-articular calcaneal fractures and to determine whether this approach should remain part of standard therapy. This retrospective cohort study included 60 patients with 64 displaced intra-articular calcaneal fractures who underwent surgical treatment through the ELA. Outcome measures were the visual analog scale foot and ankle (VAS FA), the American Orthopedic Foot and Ankle Society (AOFAS) score, surgical site infections (SSIs), and reoperations. We determined the AOFAS score for 40 patients with 42 fractures, and 42 patients with 44 fractures completed the VAS FA questionnaire. The mean VAS FA score was 61.0 ± 23.4 and the median AOFAS score was 83 (range 33 to 100), with 55% good to excellent scores. We found 10.9% superficial SSIs successfully treated with antibiotics. In 4.7% of patients a deep SSI was diagnosed, wherefore premature implant removal was necessary. Patients with an SSI did not have significantly lower VAS FA or AOFAS scores than did patients without an SSI (p = .318 and p = .766, respectively). Implant removal in absence of SSIs was necessary in 17 patients because of pain, and 3 patients needed secondary arthrodesis because of persistent pain. We concluded that the ELA proved to be a safe procedure, and moreover the most common complications did not influence the long-term outcomes of patients. However, recent literature demonstrates that less invasive techniques seem to exceed the ELA with respect to wound complications.

Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion

Background

We hypothesized that calcaneal reconstruction can relieve chronic pain due to calcaneal malunion. We report the mid-term follow-up results of calcaneal reconstruction for calcaneal malunion.

Methods

We reviewed the records of 10 male patients (10 ft) who underwent calcaneal reconstruction for calcaneal malunion between January 2009 and July 2014 at the mid-term follow-up. Talocalcaneal height and angle, calcaneal pitch, calcaneal width, Böhler angle, Stephens classification, and Zwipp classification were evaluated by three orthopedic doctors at each visit (pre-reconstruction, post-reconstruction, and at the last follow-up).

Results

The mean follow-up period was 67.1 months (range, 48–101 months). The sites of pain before reconstruction were lateral aspect (4 patients), plantar aspect (3 patients), diffuse pain (2 patients), and anterior aspect (1 patient). There was a significant difference in talocalcaneal height, talocalcaneal angle, calcaneal pitch, calcaneal width, and Böhler angle before and after reconstruction (p < 0.05). There was no significant difference between reconstruction and the last follow-up. Radiological measurement agreement was calculated to be moderate to strong (intraclass correlation coefficient: 0.659–0.988). Mean American Orthopedic Foot & Ankle Society Ankle and Hindfoot score improved from 66.50 ± 9.37 pre-reconstruction to 80.30 ± 8.52 at the last follow-up (p < 0.05). The mean visual analog scale score improved from 8.60 ± 1.43 before reconstruction to 3.40 ± 0.84 at the last follow-up (p < 0.05). Most patients were satisfied with the outcome postoperatively.

Conclusions

Our results showed substantial improvement in the clinical and radiological outcomes after calcaneal reconstruction of calcaneal malunion. This outcome was maintained until the mid-term follow-up. Therefore, calcaneal reconstruction may be a good option for the treatment of chronic pain caused by the malunion of a calcaneal fracture without severe subtalar arthritis. Further prospective studies are needed to test this theory.

Level of Evidence: Level IV, Retrospective Case Series.

Analysis of the Frequency and Mechanism of Injury to Warfighters in the Under-body Blast Environment

During Operation Iraqi Freedom and Operation Enduring Freedom, improvised explosive devices were used strategically and with increasing frequency. To effectively design countermeasures for this environment, the Department of Defense identified the need for an under-body blast-specific Warrior Injury Assessment Manikin (WIAMan). To help with this design, information on Warfighter injuries in mounted under-body blast attacks was obtained from the Joint Trauma Analysis and Prevention of Injury in Combat program through their Request for Information interface. The events selected were evaluated by Department of the Army personnel to confirm they were representative of the loading environment expected for the WIAMan. A military case review was conducted for all AIS 2+ fractures with supporting radiology. In Warfighters whose injuries were reviewed, 79% had a foot, ankle or leg AIS 2+ fracture. Distal tibia, distal fibula, and calcaneus fractures were the most prevalent. The most common injury mechanisms were bending with probable vehicle contact (leg) and compression (foot). The most severe injuries sustained by Warfighters were to the pelvis, lumbar spine, and thoracic spine. These injuries were attributed to a compressive load from the seat pan that directly loaded the pelvis or created flexion in the lumbar spine. Rare types of injuries included severe abdominal organ injury, severe brain injury, and cervical spine injury. These typically occurred in conjunction with other fractures. Mitigating the frequently observed skeletal injuries using the WIAMan would have substantial long-term benefits for Warfighters.

Minimally invasive fixation for displaced intra-articular fractures of calcaneum: a short-term prospective study on functional and radiological outcome

INTRODUCTION

Studies have demonstrated a decrease in the incidence of late consequences and the socio-economic burden of intra-articular fractures of calcaneum when treated by surgical fixation. Operative management of displaced intra-articular calcaneal fractures (DIACF) pose significant challenges such as technical difficulty, wound healing and long-term pain and disability.

MATERIALS AND METHODS

All patients presenting to the ER with DIACF over a period of 2 years and matching the inclusion criteria were enrolled in the study. Percutaneous fixation with 4 mm CC screw was undertaken with a minimally invasive sinus tarsi approach. All patients were available for a minimum follow-up of 24 months. Six radiological parameters were assessed, and functional outcome was evaluated using AOFAS score.

RESULTS

Thirty-four patients with 42 calcaneal fractures were included in the study, and all patients were available for minimum follow-up period. All radiological parameters were attained within anatomic normal range and maintained at 24 months of follow-up. AOFAS score showed a mean value of 90.10 which is considered an excellent outcome. Superficial wound infection was seen in two patients, but no patients required a revision surgery.

CONCLUSION

Displaced intra-articular fractures pose a treatment dilemma, more so in cases of soft tissue complications like open injury or blisters. Percutaneous screw fixation with limited sinus tarsi incision has shown good functional and radiological outcome with minimal complications and can be undertaken without delay.

Anatomic Locking Plate for Displaced Intraarticular Calcaneal Fracture: Design and Application

Calcaneal fracture can lead to long-term disability and have a considerable economic effect. Most calcaneal fractures are intraarticular fractures involving the posterior facet of the subtalar joint. Treating displaced intraarticular calcaneal fractures is complicated because of the lack of an optimal treatment option. Internal fixation typically involves screw-and-plate implants, which can be unfavorable owing to the lack of an anatomic design and the intraoperative bending required for the plate to contour to the irregular surface of the calcaneus. We assessed the outcomes of 30 patients treated using innovative, anatomically designed calcaneal locking plates and the perceived advantages for surgeons. Postoperative computed tomography images of the affected feet were obtained, and the functional performance was recorded. The mean average Böhler angle had increased significantly from 16.8° ± 14.9° to 28.5° ± 9.4° (p < .001). The mean average maximal fracture gap and maximal step-off in the posterior facet of the subtalar joint in the coronal computed tomography images also decreased significantly from 2.8 ± 3.7 mm to 0.8 ± 1.3 mm (p < .01) and from 3.3 ± 2.8 mm to 0.8 ± 1.2 mm (p < .001), respectively. The mean average American Orthopaedic Foot and Ankle Ankle-Hindfoot scale score was 93.9 ± 7.1 at the final follow-up visit. In addition, the surgical time was reduced because bending the plate was not required and the quality of reduction could be assessed easily by examining the gap between the cortex and the plate. The results were promising, revealing that the anatomic locking plate can be used effectively in the treatment of displaced intraarticular calcaneal fractures using simple reduction techniques with a potentially shortened operating time.

Epidemiological study on calcaneus fractures in a tertiary hospital

Objective

To analyze the epidemiology and characteristics of patients with calcaneus fractures.

Methods

This is a retrospective revision of patients with calcaneus fractures hospitalized in the Institute of Orthopedics and Traumatology of this institution between 2006 and 2010. Data such as age, gender, laterality, trauma mechanism, type of fracture, associated injuries, compound fractures, and time from injury to surgery were analyzed.

Results

The analysis of 52 patients showed that men were more commonly affected than women, at a ratio of 5.5:1. Bilateral fractures were observed in ten cases, resulting in a total of 62 calcaneus fractures. A fall from a height was the most frequent trauma mechanism (75%), followed by motorcycle accidents (11.5%) and automobile accidents (9.6%). The most frequent fractures were intra-articular, with 47 cases. Compound fractures were observed in 15 patients (28.9%). Non-surgical management was adopted for 11 patients while 41 patients underwent surgery. The mean time between trauma and the definitive treatment was 7.8 days (range: 0–21 days), and 58.5% of cases were treated within seven days.

Conclusion

Patients with calcaneus fractures, most commonly young men, were admitted to a high complexity care hospital, victims of a fall from a height with associated injuries. The great severity of these fractures is characterized by the high prevalence of bilateral (19.2%) and compound fractures (28.9%) in this population group.

Management of Intra-Articular Calcaneal Fractures: Clinical Results of Reduction Technique Using a Bone Spreader

The purpose of the present study was to examine the clinical results of surgery for intra-articular calcaneal fractures using a calcaneal locking plate and a bone spreader as a reduction tool. Ten patients with intra-articular calcaneal fractures were treated. An extended lateral approach was used. The reduction of the intra-articular fragments of the posterior facet was temporarily held using a bone spreader and Kirschner wires. Internal fixation was achieved with a locking calcaneal plate. Böhler's angle and Preiss' angle were assessed on the day of injury and the day of the final follow-up examination. The step off and gap of the posterior facet were assessed on the day of injury and the first week after surgery. The functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society ankle hindfoot scale score. The mean Böhler's angle ranged from 2.1° ± 11.0° to 30.4° ± 5.0° (p < .0001), the mean Preiss' angle ranged from 23.5° ± 4.5° to 15.5° ± 2.9° (p < .0001), the mean step off ranged from 4.0 ± 1.9 mm to 0.1 ± 0.2 mm (p = .0002), and the mean gap ranged from 2.6 ± 1.0 mm to 1.2 ± 0.6 mm (p = .0035). The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was 89.2 (range 85 to 100) at a mean of 14.3 months after surgery. Our results suggest that a locking calcaneal plate can be used to restore and reduce an intra-articular calcaneal fracture and achieve good clinical results.

The primary stability of different implants for intra-articular calcaneal fractures: an in vitro study

Background

Calcaneal fractures account for around 2% of all fractures and most of them are intra-articular fractures. Many implants have been used in the fixation of calcaneal fractures, but their biomechanical stability has not yet been well investigated. The aim of this study was to compare the primary stability of four fixations of calcaneal fracture.

Methods

Eight cadaveric calcaneus samples were used to simulate the Sanders’ types III fracture pattern and fixed through four different implants, namely, K-wires, cannulated screws (CS), absorbable screws (AS), and plate-screw system (PSS). Each specimen was then placed into a custom-made jig and was loaded through a material testing machine to simulate the physiological condition. The primary stability was measured in the vertical direction as the stiffness and anterior–posterior direction as the calcaneocuboid force. One-way analysis of variance was used for data analysis.

Results

The results showed the highest stiffness of 634 (383–891; SD 226) N/mm in the intact model. It was significantly higher than the models fixed with K-wires, CS or PSS. There was no significant difference in vertical stiffness between fractures fixed with AS and the intact model or other fixed models. The intact model showed the lowest calcaneocuboid force of 153 (120–218; SD 39) N, while the fractures fixed with AS showed the greatest force of 242 (146–398; SD 84) N. The significance was only detected between these two models.

Conclusions

The global stiffness was similar when the calcaneal fractures were fixed by K-wires, CS and PSS. The stability of the AS fixation differed along both the vertical and anterior–posterior directions, and was greatly influenced by the bone quality. AS for fracture fixation should be designed with greater strength and pull-out resistance.