Percutaneous Arthroscopic Calcaneal Osteosynthesis: A Minimally Invasive Technique for Displaced Intra-Articular Calcaneal Fractures

Subtalar joint arthroscopic-assisted reduction and cannulated screw fixation versus open reduction and internal fixation for treating displaced intra-articular calcaneal fractures

BACKGROUND

The treatment of calcaneal fractures is not uniform. This study aimed to compare the functional and imaging results of subtalar joint arthroscopic reduction combined with cannulated screw fixation (SJACF) and the extended lateral approach (ELA) for the treatment of Sanders type II and III displaced intra-articular calcaneal fractures (DIACFs).

METHODS

From January 2020 to January 2023, 60 patients with calcaneal fractures were treated with SJACF or ELA for foot and ankle surgery at the Second Affiliated Hospital of Anhui Medical University. Changes in calcaneal Böhler's angle, the Gissane angle, and calcaneal length, height, and width were recorded before, after, and at the 1-, 3-, 6-, 12-month, and last follow-up. The preoperative waiting time, operation time, length of hospital stay, and other data of each patient were analyzed. The visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores were used to evaluate clinical effects.

RESULTS

All 60 patients were followed up for at least 12 months. There was no statistical difference in baseline data (age, sex, fracture side, mechanism of injury, and classification) between groups (P > 0.05). The preoperative waiting time, length of hospital stay, and intraoperative fluoroscopy times were shorter in the SJACF group than in the ELA group; however, the operative time was greater in the SJACF group (P < 0.05). There were no significant differences in Böhler's angle, the Gissane angle, or calcaneal length, height, or width between the two groups at any time point (P > 0.05). These imaging values were significantly improved after surgery and at the last follow-up (P < 0.05). The VAS scores of the patients in the SJACF group were significantly different from those in the ELA group at the last follow-up (P < 0.05). The final AOFAS score and incidence of postoperative complications were better in the SJACF group; however, the difference was not significant (P > 0.05). Simultaneously, patients were able to return to work and achieve full weight-bearing earlier in the SJACF group (P < 0.05).

CONCLUSION

Both SJACF and ELA improved the clinical outcomes of patients with DIACFs. SJACF reduces surgical wounds and maintains effective reduction and strong internal fixation. It has the advantages of a reduced preoperative waiting time, shortened hospital stay, reduced intraoperative fluoroscopy time, alleviated postoperative pain, and accelerated patient recovery.

Short term efficacy of subtalar arthroscopy combined with medial calcaneal-talar joint distraction in minimally invasive treatment of diabetic patients with calcaneal fractures: a retrospective study

BACKGROUND

The surgical treatment and management of postoperative soft tissue complications in diabetic patients with displaced calcaneal fractures are still controversial. We aimed to evaluate the short-term efficacy of percutaneous minimally invasive screw fixation in treatment of diabetic patients with Sanders II and III calcaneal fractures under subtalar arthroscopy assisted by preoperative musculoskeletal ultrasonic locating lateral calcaneal branch (LCB) of the sural nerve and calcaneal-talar joint distraction device.

METHODS

The clinical data of 52 diabetic patients diagnosed with Sanders II or III calcaneal fractures from March 2016 to August 2020 were followed up and analyzed. There were 23 patients of type II and 29 patients of type III, 34 males and 18 females, with a mean age of 61.7 ± 14.5 years (range: 45-72 years). Preoperative musculoskeletal ultrasonography was routinely examined to locate LCB of the sural nerve. During surgery, we performed arthroscopic percutaneous prying reduction screw fixation assisted by medial calcaneal-talar joint distraction. Incision healing, local skin paraesthesia and other conditions were observed regularly at 3 days, 6, 12 months, and the last follow-up after surgery. Also, we measured the length, width, height, Böhler angle, and Gissane angle of the calcaneus on lateral and axial x-rays. Visual analogue pain scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score and Maryland score were used to evaluate the efficacy.

RESULTS

52 patients were followed up for 23.7 ± 3.2 months (range: 20-28 months) without incision-related complications. Calcaneal radiographic parameters (length, width, height, Böhler/Gissane angle) were improved after surgery, and the differences were all statistically significant (P<0.05). There was no difference between calcaneal radiographic parameters at 6,12 months and the last follow-up compared with 3 days after surgery without significant loss in overall morphology (P>0.05). Postoperative VAS, AOFAS scores, and Maryland scores were significantly improved compared with those before surgery (P<0.05).

CONCLUSIONS

Preoperative ultrasonic locating LCB of the sural nerve and arthroscopic percutaneous minimally invasive screw fixation of Sanders II and III calcaneal fractures with the assistance of calcaneal-talar joint distraction have good short-term efficacy and clinical feasibility in diabetic patients.

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.

Arthroscopy of Foot and Ankle: Subtalar Joint Arthroscopy in Intra-articular Calcaneal Fractures

The utilization of subtalar joint arthroscopy in intra-articular calcaneal fractures provides optimal visualization of articular surfaces for a more precise anatomical reduction, thus yielding better surgical outcomes. Current literature shows good functional and radiographic outcomes, fewer wound complications, and low incidence of post-traumatic arthritis with this technique than when utilizing an isolated lateral extensile incision of the calcaneus. As subtalar joint arthroscopy continues to grow in popularity and technological advancement, patients may benefit when surgeons incorporate this tool in conjunction with a minimally invasive technique for treatment of intra-articular calcaneal fractures.

Biomechanical Comparison of Conventional Plate and the C-Nail® System for the Treatment of Displaced Intra-Articular Calcaneal Fractures: A Finite Element Analysis

The C-Nail® system is a novel intramedullary fixation method for displaced intra-articular calcaneal fractures. The aim of this study was to evaluate the biomechanical performance of the C-Nail® system and compare it with conventional plate fixation for the treatment of displaced intra-articular calcaneal fractures using finite element analysis. The geometry of a Sanders type-IIB fracture was constructed using the computer-aided design software Ansys SpaceClaim. The C-Nail® system (Medin, Nové Mesto n. Morave, Czech Republic) and the calcaneal locking plate (Auxein Inc., 35 Doral, Florida) and screws were designed according to the manufacturer specifications. Vertical loading of 350 N and 700 N were applied to the subtalar joint surfaces to simulate partial weight bearing and full weight bearing. Construct stiffness, total deformation, and von Mises stress were assessed. The maximum stress on the C-Nail® system was lower compared with the plate (110 MPa vs. 360 MPa). At the bone level the stress was found to have higher values in the case of the plate compared to the C-Nail® system. The study suggests that the C-Nail® system can provide sufficient stability, making it a viable option for the treatment of displaced intra-articular calcaneal fractures.

Screw fixation in the treatment of displaced intra-articular calcaneus fractures: a systematic review protocol

BACKGROUND

The Calcaneus is the largest bone of the foot and the most frequent tarsal bone to be fractured. Overall, it causes round about 10 cases per 100,000 residents per year mainly in men. Especially displaced intra-articular calcaneus fractures often have early and late complications and its associated disability. There are various strategies for the treatment of displaced intra-articular calcaneus fractures, but the gold standard is still subject of a long-standing controversy. Minimally invasive procedures became more common in an attempt to reduce the high rate of complications associated with open reduction and internal fixation. With the increase in minimally invasive techniques, screw fixation also gained in significance. The current literature does not sufficiently elucidate whether the screw fixation is superior to other treatment options especially in relation to adverse events, health-related quality of life and postoperative pain. This study aims to investigate benefits and harms of treating displaced intra-articular calcaneus fractures (types II, III and IV according to Sanders) with screw fixation in adults.

METHODS

A systematic review will be conducted based on the principles described in the Cochrane Handbook. We will include adults with displaced intra-articular calcaneus fractures of Sanders type II, III and IV. The surgical method of screw fixation shall be compared to other surgical interventions to stabilise calcaneus fractures. Primary outcomes are serious adverse events, health-related quality of life and postoperative pain level. MEDLINE, CENTRAL, CINAHL, Web of Science and bibnet.org, ClinicalTrial.gov and the World Health Organization International Clinical Trials Registry Platform (ICTR) will be searched. Screening and data extraction will be performed by two authors independently. A third author will arbitrate disputes. Risk of Bias will be assessed with the Cochrane tool. Meta-analysis will be performed if participants, interventions, comparisons and outcomes are sufficiently similar to ensure a result that is clinically meaningful.

DISCUSSION

Due to the increasing use of minimally invasive techniques and the increasing use of screw fixation instead of open reduction and plate fixation, it is important to analyse the benefits and harms of screw fixation for calcaneus fractures. Screw fixation could, in the future, help to operate in a less invasive and tissue preserving manner while still achieving an adequate functional result for the patient SYSTEMATIC REVIEW REGISTRATION: CRD42021244695.

Arthroscopic-assisted percutaneous fixation of intra-articular calcaneal fractures using an intraoperative distraction device

PURPOSE

To evaluate the quality of reduction and clinical outcomes by using Percutaneous Distractor and Subtalar Arthroscopy Closed Reduction followed by Internal Fixation (PDSA-CRIF) in the intra-articular calcaneal fracture.

METHODS

A consecutive case series of 453 patients with 507 displaced intra-articular calcaneal fractures was recruited in this retrospective study. We performed PDSA-CRIF to treat intra-articular calcaneal fractures. The quality of reduction was assessed by early postoperative Computed Tomography (CT) scans and measurement of serial Bohler's angles during follow-ups. Clinical outcomes were evaluated by Visual Analogue Scale (VAS) and the American Foot & Ankle Society ankle-hind foot scale (AOFAS) scoring system.

RESULTS

Fifty-nine patients (68 fractures) who had complete clinical data and follow-up of at least 12-months (mean: 14 months, range: 12-59 months) were finally included. Anatomical and near-anatomical reduction in subtalar articular surface which had less than 2 mm gap or step-off was found in 93% fractures. Unsatisfactory reduction was found in 7%.

CONCLUSION

Arthroscopic-assisted percutaneous fixation using a distraction device is effective in achieving positive short-term results in the displaced intra-articular calcaneal fractures. A multicenter, large sample, randomized control trial is needed to fully evaluate the long-term effects of PDSA-CRIF in comparison to other methods.

Arthroscopically Assisted Internal Fixation of Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date.

METHODS

A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications.

RESULTS

A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy.

CONCLUSIONS

Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.

Treatment of Displaced Intra-articular Calcaneal Fractures With an Interlocking Nail (C-Nail)

OBJECTIVES

To assess the outcome of the sinus tarsi approach and C-Nail fixation of displaced intra-articular calcaneal fractures (DIACFs).

DESIGN

Prospective study.

SETTING

University Trauma Department.

PATIENTS

Sixty-four patients (mean age 44.3 years, 48 men and 16 women) with 75 DIACFs were treated between October 1, 2016 and December 31, 2018.

INTERVENTION

In all cases, the posterior facet was reduced through the sinus tarsi approach and fixed with one or 2 screws. After reducing all fragments to the articular block, the final fixation was performed percutaneously with C-Nail, locked with 6 screws.

MAIN OUTCOME MEASUREMENTS

Patients were assessed for restoration of the Böhler angle, complications, and overall fracture reduction. To assess the functional outcome, we used the Mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score and Maryland Foot Score after 12 months.

RESULTS

The Böhler angle improved from -0.5 degrees preoperatively to 28.6 degrees postoperatively. The articular step-off was reduced from 5.4 mm preoperatively to 0.6 mm postoperatively. The postoperative radiologic calcaneal score was 2.9, on average. Superficial wound edge necrosis was seen in 3 patients (4%) and superficial infection was observed in one (1.3%). After a 1-year follow-up, we recorded a mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score of 90.2 and a mean Maryland Foot Score of 91.2.

CONCLUSIONS

After obtaining an anatomic reduction of the articular surface of the posterior facet with lag screws, the C-Nail represented a viable alternative to plate stabilization in the treatment of DIACFs, combining primary stability with low soft tissue complications.

LEVEL OF EVIDENCE

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

Percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures: Systematic review and surgical technique

BACKGROUND

The aim of this study was to systematically evaluate the available literature on technique and outcomes of percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures.

METHODS

A systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane Library database was performed, including studies from January 1985 to august 2018. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The surgical technique and perioperative management, clinical outcomes scores, radiographic outcomes and complication rate were evaluated.

RESULTS

Of 66 reviewed articles, 8 studies met the inclusion criteria. The included studies reported on the results of 152 patients. At last follow up the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot was ranging from 72.1 to 94.1. The complication rate was low, including only one superficial infection.

CONCLUSIONS

The studies included were of too little level of evidence to allow for data pooling or meta-analysis. However, the percutaneous arthroscopic calcaneal osteosynthesis seems to be a good option for displaced intra-articular calcaneal fractures with a low complication rate. Appropriately powered randomized controlled trials with long-term follow up are needed to confirm the efficacy of this technique.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

Results After Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures

BACKGROUND

Operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. In the past years, there has been a trend toward less invasive surgical approaches. Percutaneous and arthroscopically assisted calcaneal osteosynthesis (PACO) combines the advantages of visualization of the posterior facet of the subtalar joint with a minimally invasive approach.

METHODS

We conducted a follow-up of 25 patients with 26 calcaneal fractures (Sanders II and III), treated with PACO with a minimum follow-up of 12 months. The median age was 44 years (range, 21-72) and the follow-up period 15 months (12-33). Our clinical outcomes were the Manchester-Oxford Foot Questionnaire (MOxFQ), the Calcaneus Fracture Scoring System (CFSS), the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, the Short-Form-36 (SF-36), the visual analog scale (VAS) for pain, and the number of complications. Radiographs on follow-up were obtained to evaluate the reduction of the fractures as well as osteoarthritis of the subtalar joint.

RESULTS

The median MOxFQ score was 26.6 (0-76.6), the CFSS score 85 (26-100), and the AOFAS score 85 (50-100). The VAS pain score was 0 (0-5.7) at rest and 4.1 (0-8.2) during activity. The Böhler angle improved from a mean (SD) of 3.5 (12.3) degrees preoperatively to 27.7 (10.5) degrees postoperatively. The follow-up radiographs showed subsidence of the fractures and a Böhler angle of 20.3 (12.9) degrees. There were no wound-healing complications. Two patients had additional surgery with screw removal due to prominent hardware.

CONCLUSION

Our results suggest that PACO gives good clinical outcomes and a low risk of complications in selected calcaneal fractures. Prospective long-term studies will be necessary to better document the potential advantages and limitations of this operating technique.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A modified tarsal sinus approach for intra-articular calcaneal fractures

BACKGROUND

Plate fixation using traditional lateral L-shape approach for intra-articular calcaneal fractures is complicated by 30% of wound complications, and the lateral small incision techniques with a tarsal sinus approach cannot sufficiently address all the fragments. A modified tarsal sinus approach with combined advantages of traditional lateral L-shape and tarsal sinus approaches for the treatment of intra-articular calcaneal fractures was developed.

METHOD

This prospective study included 29 patients (13 Sanders type II and 16 type III) with calcaneal fractures were managed with this technique. Calcaneal height, width, length, Bohler's angle, and Gissane angle were measured preoperatively, postoperatively, and at 1-year follow-up. Functional outcomes were assessed based on American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score.

RESULTS

Twenty-nine patients with average follow-up time of 18 (range 13-29) months were included. The radiographs demonstrated significant corrections of the Bohler's angle and Gissane angle, calcaneal width, length, and height from preoperation to postoperation and 1-year follow-up. Among all follow-up patients, one case had skin necrosis but healed after dressing. Another case had symptoms of numbness in the sural innervation area, which disappeared after 5 months of physical therapy and drug therapy. One case showed degenerative changes of subtalar joint at 1-year follow-up. No other wound complications like incision infection (superficial or deep) and wound dehiscence occurred. At 1-year follow-up, the mean AOFAS score was 90.2 ± 17.7 (range 70-98) and the good and excellent rate was 89.7%.

CONCLUSION

The modified tarsal sinus approach in the treatment of Sander's type II and III calcaneal fractures allowed adequate reduction and rigid fixation with low incidence of wound complications. Compared to sinus tarsi approach, this technique required shorter learning curve and was more easily mastered by young orthopedic surgeons. Thus, it was worthy of application clinically.

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

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.

Role of Subtalar Arthroscopy for Displaced Intra-Articular Calcaneal Fractures

Subtalar arthroscopy has an important role in enhancing the reduction of the posterior facet in percutaneous and open approaches of displaced intra-articular calcaneal fractures. In the percutaneous approach, arthroscopically assistant percutaneous approach must be selected carefully for mild-to-moderately displaced fractures. In the open approach, there is still little evidence of the utility of subtalar arthroscopy. Therefore, intraoperative arthroscopy should always be used in conjunction with fluoroscopy to achieve reduction and assess the internal fixation placement.

The Effectiveness of Surgical Interventions in the Management of Malunited Calcaneal Fractures: A Systematic Review

Nonoperative management may result in calcaneal malunion with consequences of pain, deformity, and functional limitation. The aim of this review was to proffer an evidence-based scientific account of the effectiveness of contemporary surgical procedures in the management of malunited calcaneal fractures after initial conservative management. This systematic review included studies that evaluated the surgical procedures in the management of calcaneal malunion and systematically searched studies published between January 2005 and June 2016. The search was conducted using the following search engines: the Cochrane Library, Web of Science, PubMed/ MEDLINE, EMBASE, CINAHL, Academic Search Premier, and Open Grey. Methodologic assessment was conducted using the Cochrane Risk of Bias In nonrandomized Studies- of Interventions assessment tool version 7. Ten observational studies (212 patients) were included in this review. Five articles explored various means of achieving subtalar arthrodesis, 2 articles evaluated joint-sparing osteotomies, 1 examined corrective osteotomy for extra-articular os calcis malunion, and 2 articles explored combined procedures based on the Stephen and Sanders calcaneal malunion classification. Clinical and methodologic heterogeneity did not allow quantitative pooling of results. The overall risk of bias was considered moderate in 7 studies and 3 were considered at high risk of bias. The inability for any study to be considered at low risk of bias in this review might be mainly attributed to the lack of a valid and reliable outcome measure for the assessment of foot and ankle conditions. There is clear evidence that appropriately indicated procedures are effective in terms of pain alleviation, correction of deformity, and improved function. However, long-term outcomes may improve the acceptability to joint-preserving osteotomies, subtalar arthrodesis with the VIRA implant and subtalar distraction osteogenesis.

Limited Approaches to Calcaneal Fractures

PURPOSE OF REVIEW

To review literature published in the last 3 years related to minimally invasive approaches to calcaneal fracture fixation.

RECENT FINDINGS

Numerous randomized control trials, cohort studies, and meta-analyses have been done in the last 3 years comparing surgical treatment of calcaneus fractures. These studies indicate minimally invasive procedures decrease wound complication rates and achieve similar radiographic and clinical outcomes to open reduction internal fixation. In comparing different surgical treatment methods to non-operative treatment, operative management has increased complication rates but may lead to better functional outcomes in certain patient populations. Optimal treatment for displaced intra-articular calcaneus fractures continues to be debated. Current literature would suggest that the decision to operate be based on patient and fracture characteristics and surgeon capabilities. Minimally invasive techniques aim to improve patient reported outcomes and quality of life while decreasing complications and offer another option for surgeons in the treatment of displaced intra-articular calcaneal fractures.

Short-Term Outcomes of Open Reduction and Internal Fixation for Sanders Type III Calcaneal Fractures With and Without Bone Grafts

Calcaneal fractures, often caused by a fall from a height, are the most common injuries encountered by orthopedic surgeons. Currently, open anatomic reduction and internal fixation (ORIF) is considered a valuable treatment of displaced intraarticular fractures of the calcaneus; however, the need for bone grafting in the treatment is still controversial. Therefore, in the present study, we investigated the outcomes of 2 methods (with and without bone grafting) used for the surgical treatment of Sanders type III calcaneal fractures. From January 2013 to September 2015, 57 cases (55 patients) with displaced Sanders type III calcaneal fractures (53 unilateral and 2 bilateral) were enrolled. The patients were divided into 2 groups: group I was treated by ORIF with bone grafting (n = 28) and group II was treated by ORIF without bone grafting (n = 29). The radiologic evaluation included Böhler's angle, Gissane's angle, and the height and width of the calcaneum. In addition, the American Orthopaedic Foot and Ankle Society questionnaires and visual analog scale were completed by the patients. During the follow-up period, no differences were found in the outcome measures (Böhler's angle, p = .447; Gissane's angle, p = .599; calcaneal height, p = .065; calcaneal width p = .077; and American Orthopaedic Foot and Ankle Society questionnaires, p = .282) with or without bone grafting. The only difference between the 2 groups was the occurrence of postoperative pain (p = .024 and p = ≤ .05), which was greater in the patients who had undergone bone grafting. We have provided evidence that bone grafting with internal fixation in the treatment of intraarticular calcaneal fractures failed to improve the restoration of Böhler's angle or Gissane's angle. No statistically significant difference was found in the short-term outcomes between the 2 methods used for the surgical treatment of Sanders type III calcaneal fractures.

"All-Inside" Arthroscopic Treatment of Tillaux-Chaput Fractures: Clinical Experience and Outcomes Analysis

We investigated all-inside ankle arthroscopy for Tillaux-Chaput fractures. We retrospectively evaluated 19 patients (12 males [63.2%] and 7 [36.8%] females; 11 right [57.9%] and 8 left [42.1%] ankles) treated from May 2013 to January 2016. Their mean age was 28.1 (range 10 to 55) years. Sixteen (84.2%) had single Tillaux-Chaput fractures and 3 (15.8%) had combined proximal fibular fractures; 17 (89.5%) were diagnosed radiographically and 2 (10.5%) by computed tomography. Anterolateral and anteromedial ankle arthroscopy was used for closed reduction and internal fixation with 1 or 2 Herbert screws. Joint function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. All 19 patients healed by first intention without nerve, vessel, or tendon injuries. The follow-up was 19.0 (range 12 to 25) months; fracture union was achieved by 23.5 (range 12 to 36) weeks. At the last follow-up, the 19 patients had no restrictions in ankle function and range of motion, with no ankle or walking pain. The AOFAS score changed from 52.8 to 91.7 points, with an excellent/good rate of 100%. These results suggest that anterolateral and anteromedial all-inside ankle arthroscopy is a precise and effective method for closed reduction and internal fixation of Tillaux-Chaput fractures.

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.

Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery

Although numerous studies have linked smoking with lower extremity wound and bone healing complications, a comprehensive study on the effects of smoking in foot and ankle surgery has not yet been reported. The purpose of the present study was to report the results of our systemic literature review, identifying the effects of tobacco use on common foot and ankle procedures. The systematic literature review was performed according to guidelines set by the PRIMSA statement (Preferred Reporting Items for Systematic Review and Meta-Analyses). Smoking, as a single risk factor, was analyzed and used to compare adverse outcomes in the postoperative setting of foot and ankle surgery. We reviewed 528 abstracts that met our initial identification criteria. After an extensive review process, 46 of the articles (8.71%) met the eligibility requirements to be included in the present study. Distal bunionectomy with osteotomy, first metatarsophalangeal joint arthrodesis, Lapidus bunionectomy, toe amputation, transmetatarsal amputation, Syme's amputation, open reduction internal fixation (ORIF) of calcaneal fractures, ankle fracture ORIF, pilon fracture ORIF, subtalar arthrodesis, rearfoot arthrodesis, tibiocalcaneal arthrodesis, ankle arthrodesis, total ankle arthroplasty, and plastic surgery procedures and their respective negative association with smoking was identified and described in our review. Our systematic literature review revealed that procedures involving arthrodesis, fracture ORIF, and plastic surgery were associated with negative outcomes in smokers. Procedures that did not involve osseous unions such as total ankle arthroplasty and amputations did not appear to have negative outcomes associated with smoking.

Minimally invasive percutaneous osteosynthesis versus ORIF for Sanders type II and III calcaneal fractures: a prospective, randomized intervention trial

Background

This randomized controlled trial compared the clinical outcomes and complications of a novel minimally invasive percutaneous osteosynthesis (MIPO) with those of conventional treatment via an extended L-shaped lateral approach for calcaneal fractures.

Methods

Sixty-four patients with displaced intraarticular calcaneal fractures were enrolled. The patients were randomly allocated to receive either MIPO (29 patients) or open reduction and internal fixation via an extended L-shaped lateral approach (35 patients). The same calcaneal plate (AO Synthes, Oberdorf, Switzerland) was used in both groups. The primary clinical outcomes included operative time, VAS postoperatively, and wound healing complications. Secondary clinical outcomes included time to operation, length of incision, postoperative drainage, length of hospital stay, medical expense, AOFAS score, and SF-36 score. Preoperative and postoperative calcaneal height, width, and length, Bohler’s angle, and Gissane’s angle were compared.

Results

The operative time in the MIPO group was 52.5 ± 11.1 min, which was significantly shorter than 82.8 ± 16.2 min in the conventional treatment group (P < 0.001). One week postoperatively, the VAS value was 3.2 ± 1.4 in the MIPO group, which was lower than that in the conventional treatment group, 3.9 ± 1.3 (P = 0.038). In the conventional treatment group, 13 of 35 fractures (37.1%) had wound healing problems, whereas this issue occurred in only 2 of 29 fractures (6.7%) in the MIPO group (P = 0.004). In the MIPO group, deep and superficial infections occurred in none of the cases and 1 of 29 (3.4%) patients, respectively. Length of incision in the MIPO group was shorter than that in the conventional treatment group (4.2 ± 0.6 vs. 10.9 ± 1.5 cm; P < 0.001). Hospital stay was 9.7 ± 2.8 days in the MIPO group and 11.7 ± 2.6 days in the conventional treatment group (P = 0.004). At the last follow-up, the SF-36 scores and AOFAS scores in the two groups were comparable (P > 0.05). The postoperative radiographic data, the Bohler’s angle, Gissane’s angle, and calcaneal height, width, and length in the two groups were comparable (P > 0.05).

Conclusions

Compared with conventional ORIF, the advantages of MIPO are a considerably shortened operating time and hospital stay, decreased postoperative pain, and reduced risk of wound healing complications.

Complications of Intra-articular Calcaneal Fractures in Adults: Key Points for Diagnosis, Prevention, and Treatment

Calcaneal fractures are complex injuries with high complication rates and they can lead to serious disability. The proper management remains controversial and complications may occur regardless of the chosen type of treatment (operative or nonoperative). The present article reviews the studies that are related to the complications of calcaneal fractures. The incidence, the diagnosis, the prevention and the treatment of these complications were researched and analyzed, with the use of PubMed database, abstracts and original articles in English than investigate the etiology. The aim of the article is to discuss the most suitable management of the complications of calcaneal fractures and recommend a specific treatment as well as prevention methods.

LEVELS OF EVIDENCE

Level IV.

Minimally-invasive treatment of calcaneal fractures: A review of the literature and our experience

The optimal treatment of calcaneal fractures (CF) is currently controversial and is still under debate. It is well established that conservative treatment of these fractures is associated with poor results. Several surgical techniques are described in the literature; however, there is no consensus on which of these is more effective. The main goals of surgery are to restore the subtalar joint congruence, and calcaneal width, height, shape and alignment, thus avoiding medial and lateral impingement and enabling the patient to resume a normal lifestyle. ORIF is the most popular technique for these fractures, but it is associated with high rates of wound complications, hardware failure and infections. Several minimally-invasive techniques have been developed recently for the treatment of CF, with the common aim to be as simple, effective and inexpensive as possible and to reduce surgical times, complications and length of hospital stay.