Vascularity of the lateral calcaneal flap: a cadaveric injection study

Calcaneal Fractures Management, Change of Clinical Practice in Recent Years from ELA to STA: A Systematic Review and Meta-Analysis

Background

Calcaneal fractures are serious injuries that mainly affect young, active people. As a result, these fractures may cause long-term impairment and have a major socioeconomic impact. The current updated systematic review and meta-analysis were conducted to evaluate the functional outcomes, re-operative risk, and complications associated with the treatment of displaced intra-articular calcaneal.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this meta-analysis. The literature search was carried out using PubMed, Cochrane, MEDLINE, Google Scholar, and the EMBASE databases with the appropriate keywords.

Results

A total of 13 studies were included in this review. The follow-up months were diverse, ranging between 12 and 65 months in sinus tarsi approach (STA) and 12 to 76 months in extended lateral approach (ELA) methods. Time to surgery was shorter for the STA when compared to ELA (MD: 3.48; 95% CI 2.43 to 4.53; p < 0.00001). No significant difference was observed in functional outcomes between STA and ELA (MD: 0.34; 95% CI: -0.37 to 1.04; p = 0.35 > 0.05; I2 = 88%). In comparison to the ELA, the STA has significantly less wound healing complications (RR: 0.20; 95% CI 0.11 to 0.36; p 0.00001; I2 = 0%).

Conclusion

In conclusion, the STA technique in treating calcaneal fractures was significantly safer and more effective when compared to the ELA methods. The STA method of treatment was found to have a lower risk of complications and an infection rate, as well as a shorter operating and recovery time.

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.

A nomogram for predicting post-operative wound complications after open reduction and internal fixation for calcaneal fractures

The purpose of our study was to determine the risk factors for post-operative wound complications (PWCs) after open reduction and internal fixation (ORIF) for calcaneal fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from calcaneal fractures and had been surgically treated for ORIF in our institution between January 2010 and January 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of PWCs, and a nomogram model was constructed to predict the risk of PWCs. The predictive performance and consistency of the model were evaluated by the Hosmer -Lemeshow (H-L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that smoking, limb swelling, angle of incision, and CRP were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.982 (95%CI 0.97-0.99). The H-L test revealed that the normogram prediction model had good calibration ability (P = .957). Finally, we found a correlation between PWCs and smoking, limb swelling, angle of incision, and CRP after ORIF for calcaneal fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high-risk patients, as interventions could be taken early to reduce the incidence of PWCs.

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.

Mid- to long-term outcome in patients treated with a mini-open sinus-tarsi approach for calcaneal fractures

BACKGROUND

While the extended lateral approach was the gold standard for treatment of calcaneal fractures for decades, the mini-open approach through the sinus tarsi gained popularity in recent years. Although widely used, there are only a few reports available in the literature reporting on mid- to long-term results. Therefore, the purpose of the study was to report on mid- to long-term radiographic and clinical outcomes of calcaneal fractures treated surgically using a mini-open sinus tarsi approach.

MATERIALS AND METHODS

In this retrospective review, radiographic and clinical outcome measures of 30 consecutive patients (34 fractures) were analyzed. Conventional radiographs were used to measure the Boehler's angle before and after surgical fixation. Computed tomography (CT) scans were analyzed to distinguish between joint depression and tongue-type calcaneal fractures. Each calcaneal fracture was additionally categorized according to the Sanders classification. The clinical outcome was measured using a 5-point Likert scale ranging from 0 (very unsatisfied) to 4 (very satisfied), the Visual Analog Scale (VAS) for pain, and the Maryland Foot Score.

RESULTS

The Boehler's angle improved from 12.6 degrees preoperatively to 26.3 degrees postoperatively (P < 0.001). Loss of sagittal reduction (i.e., a decline of the Boehler's angle of > 5 degrees) from postoperative to the last follow-up was evident in nine (26%) fractures. Out of 29 patients with an available satisfaction score, 20 (69%) were very satisfied, 8 (28%) were satisfied, and one (3%) was moderately satisfied. Satisfaction at the last follow-up declined with higher age at surgery. An overall low complication rate was evident, with painful hardware needing removal being the most common complication.

CONCLUSIONS

Approaching calcaneus fractures through the sinus tarsi provides satisfactory mid- to long-term radiographic and clinical outcomes, independent of the severity of the fractures according to the Sanders classification.

LEVEL OF EVIDENCE

Level IV, Retrospective Case Series.

Posterior to anterior malleolar extended lateral approach to the ankle (PAMELA): a cadaveric anatomic study

INTRODUCTION

The posterolateral approach is used in most cases of surgical treatment of ankle fractures involving the posterior and lateral malleoli. However, this approach does not allow access to the anterolateral structures of the ankle, which represent important landmarks to allow an anatomical reduction in case of complex ankle fracture. Our objective is to propose a novel surgical approach for optimal management of injuries including both a fracture of the posterior malleolus and a complex lesion of the lateral and/or anterolateral portions of the ankle.

METHODS

Cadaveric dissection, including a vascular study, was performed on eight specimens. Assessment included density of the vascular supply around the lateral malleolus, identification of the structures at risk, quality of exposure of the bony structures, and convenience of hardware fixation.

RESULTS

The cutaneous flap benefits from a rich interconnected arterial supply. Structures at risk, including the superficial peroneal and sural nerves, the lesser saphenous vein, and the peroneal artery are easily identified and protected. The interval between the peroneal tendons and the flexor hallucis longus muscle provides optimal access to the posterior malleolus. The lateral malleolus is exposed by retracting the peroneal tendons medially. An anterolateral arthrotomy, respecting the anterior talofibular and tibiofibular ligaments, offers a sharp view on the talo-tibio-fibular junction. Hardware placement can be done with optimal access to any exposed surfaces.

CONCLUSIONS

The PAMELA opens a new perspective in the optimal management of complex fractures of the ankle. The approach allows optimal exposure to address fractures of the posterior malleolus, of the lateral malleolus, and of the anterolateral portion of the ankle through a single incision. Application in clinical practice is the subject of a future study in our institution.

Randomized comparative study between extensile lateral and sinus tarsi approaches for the treatment of Sanders type 2 calcaneal fracture

AIMS

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

METHODS

Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler's angle and calcaneal width, and posterior facet reduction.

RESULTS

Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001).

CONCLUSION

The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286-293.

Lateral Extensile Approach Versus Minimal Incision Approach for Open Reduction and Internal Fixation of Displaced Intra-articular Calcaneal Fractures: A Meta-analysis

Treatment of displaced intra-articular calcaneal fractures remains controversial. Therefore, the purpose of this large meta-analysis was to report the outcomes of the lateral extensile approach versus the minimal incision approach including complications, anatomic reduction, functional outcomes, and timing and to report results when only randomized control trials were compared. Five electronic databases were searched for articles directly comparing the 2 above approaches. Inclusion criteria included articles published from January 2007 to April 2017, adults (>18 years old) with closed, Sanders type II or III fractures, mean follow-up time of ≥12 months, and ≥1 primary outcome reported. Seventeen randomized control trials and 10 retrospective studies were included. There were 2179 participants with 2274 fractures, and mean follow-up of 22.41 months. Our results revealed no statistically significant difference in Gissane's angle, calcaneal width, calcaneal length, deep infection, or subtalar stiffness. When taking into consideration only randomized control trials, there was no statistically significant difference between groups comparing postoperative Bohler's or Gissane's angle. There was a statistically significant difference in wound complications, superficial infection, sural nerve injury, visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores, operative time, time to operating room, calcaneal height, and postoperative Bohler's angle (when all studies were considered), all in favor of the minimal incision approach. These results remained statistically significant when only the randomized controlled trials were compared, with the exception of Bohler's angle and VAS and AOFAS scores. The results of this meta-analysis indicate that the minimal incision approach is a good alternative to the standard lateral extensile approach.

Morphometric variations of the lateral surface of calcaneus: Can standard plate sizes fit all?

PURPOSE

Displaced intraarticular fractures of the calcaneum often require plate fixation. The complex fractures are usually fixed with standard lateral plates and are approached via the extensile lateral approach which is fraught with the risk of wound complications. Oversized calcaneal plates produce tension on the wound closure site and can, thus result in wound healing problems. The current study analyses the morphometry of the lateral surface of the calcaneus for the ideal configuration of the calcaneal plates for Indian patients using a CT based analysis of intact calcanei.

METHODS

Fifty CT based studies of normal calcanei were retrospectively analyzed using Horos® software version 3.3.5. The cross-section of the lateral third of calcaneum was assessed for the morphometric measurements relevant to the dimensions of the standard plating devices for calcaneum. We measured the overall plating length of calcaneum, the vertical heights at the anterior process and calcaneal tuberosity, the height of the posterior facet, the lengths of the anterior process, and the posterior facet. The inclination angles of the posterior facet, cuboid facet were also measured. The findings were compared between male and female cases.

RESULTS

The mean plating length of the calcaneus was 60.06 ± 4.05 mm. The mean vertical height of the anterior process and the calcaneal tuberosity were 24.3 ± 2.71 mm and 39.48 ± 4.73, respectively. The length of the anterior process and the posterior facet were 21.36 ± 1.72 and 25.02 ± 4.17, respectively. The mean Gissane angle and the angle of inclination of posterior facet in relation to the plating length were 118.04 ± 5.99° and 47.3 ± 5.20°. The mean anterior slant angle of the cuboid facet was 96.64 ± 4.39°. Significant differences were observed in the measurements among male and female groups except for the angular parameters.

CONCLUSION

The current analysis suggests the individual morphometric variations of the lateral plating surface of the calcaneus. Although female calcanei have smaller dimensions compared to male calcanei, the angular parameters are comparable among the two groups. Considering the wide variations in the majority of the morphometric parameters, it is difficult to standardize the plate dimensions. However, a few serial increments in the plate dimensions can help in providing the best fit rather than an ideal fit. Also, the plates should be available with multiple inclination angles of the facet limbs according to the local population variations.

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.

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.

Joint-Sparing Surgical Management of Sanders IV Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures represent life-altering injuries. Difficulty obtaining and maintaining calcaneal morphology and the significant risk of wound healing complications with an extensile lateral incision exist. Open reduction with internal fixation as a joint-sparing approach has been studied. Closed manipulation to restore calcaneal morphology, intra-osseous fracture reduction, and rigid locked CALCANAIL fracture nail fixation have recently been applied to Sanders IV fracture patterns. Spontaneous conversion to primary subtalar joint arthrodesis using the same instrumentation remains unique to this system. This article reviews open and percutaneous approaches for joint-sparing and primary arthrodesis procedures to treat Sanders IV fracture patterns.

Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical)

Soft tissue defects and wound healing complications related to calcaneus fractures may result in significant morbidity. The management of these soft tissue complications requires following reconstructive principles that provide the requisites for preservation of the injured limb and the maximization of function. Soft tissue complications are addressed with methods that commensurate with the degree of injury, ranging from local wound care to free flap reconstruction. With the orthoplastic approach to both bone and soft tissue plastic reconstruction, outcomes for limb salvage are greatly enhanced. This article discusses in detail the reconstructive ladder for soft tissue injuries associated with calcaneus fractures.

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.

Lateral wall osteotomy combined with embedded biodegradable implants for displaced intra-articular calcaneal fractures

Background

The extensile lateral approach (ELA) has been widely used to treat displaced intra-articular calcaneal fractures (DIACFs) and remains the gold standard procedure. Orthopedic surgeons are extremely concerned of the high rate of wound complications. This study intended to report a new surgical technique of the lateral wall osteotomy combined with an embedded biodegradable implant for treating DIACFs and assess clinical and radiological results.

Methods

From May 2013 to December 2015, a total of 17 patients with 19 calcaneal fractures underwent surgical treatment using our new technique. Radiographic images, computed tomography (CT) scans, and magnetic resonance (MR) images of the operative limb were obtained to assess fracture healing and biodegradable implant degradation. American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at the last follow-up was obtained to assess functional result for all cases. Böhler’s and Gissane’s angles, width, and height of the injured calcaneus were analyzed using preoperative and last follow-up radiographic images.

Results

All radiological parameters were significantly improved at the last follow-up, with an increase of 15.58°, 8.38°, and 7.65 mm in Böhler’s angle, Gissane’s angle, and calcaneal height, respectively, and a decrease of 2.51 mm in calcaneal width (p < 0.05). Mean AOFAS score at the last follow-up was 84.37 ± 9.98, with 9, 6, and 4 feet, having excellent, good, and fair rates, respectively. None had nonunion, delayed union, or malunion after a mean follow-up of 34.69 ± 5.22 months. One superficial infection occurred 6 days post-surgery.

Conclusions

Osteotomy of the lateral wall of the calcaneus allows tension-free suturing and avoids damage to penetrating branches of the lateral calcaneal artery (LCA). Biodegradable implants are easy to reshape and do not require surgical removal. However, they should be limited to Sander’s type II and III fractures only.

Level of evidence

Level IV, case series without controls

Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery

BACKGROUND:

The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion.

METHODS:

Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format.

RESULTS:

Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA ( P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal.

CONCLUSION:

The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study.

CLINICAL RELEVANCE:

This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.

Extended Sinus Tarsi Approach for Treatment of Displaced Intraarticular Calcaneal Fractures Compared to Extended Lateral Approach

BACKGROUND:

We compared the radiographic results and clinical outcomes of patients operated on via the extended sinus tarsi approach (ESTA) and the extended lateral approach (ELA) for treatment of displaced intraarticular calcaneal fractures.

METHODS:

We retrospectively studied the utility of the ELA (46 patients, 52 feet) and the ESTA (56 patients, 64 feet) in patients operated on between January 2009 and March 2015. We evaluated pre- and postoperative x-rays and computed tomography (CT) data. Pain, patient-reported functional outcomes, satisfaction, and postoperative complications were investigated at the 3-year follow-up.

RESULTS:

Neither the postoperative nor 3-year follow-up Böhler angles, nor the calcaneal width, differed significantly between the 2 groups (both P > .05). However, the maximum step-off of the posterior facet on the 3-month CT follow-up of the ESTA group was significantly less than that of the ELA group ( P < .05). We found no significant between-group differences in terms of postoperative translation ( P = .232) or angulation ( P = .132) of the sustentacular fragment on the 3-month CT follow-up. At the 3-year follow-up, we found no significant between-group difference in the mean visual analog scale pain score at rest ( P = .641) or during weightbearing ( P = .525). We found no significant between-group difference in the Foot Function Index (FFI) ( P = .712) or self-reported satisfaction ( P = .823). The ELA group experienced significantly more wound complications ( P = .041) and nonunions ( P = .041) than the ESTA group. Four instances of superficial peroneal nerve injury were reported in the ESTA group ( P = .127).

CONCLUSION:

Compared with the ELA, the ESTA afforded comparable, favorable radiological results and clinical outcomes, associated with fewer wound complications and nonunions. We suggest that the ESTA is an effective operative option when treating displaced, intraarticular calcaneal fractures.

LEVEL OF EVIDENCE:

Level III, comparative study.

Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis

Peroneal tendon instability associated with an intraarticular calcaneal fracture is a common injury that still often passes undiscovered by both radiologists and orthopedic surgeons. Timely identification of this injury will guide the choice of surgical technique used and treatment of patients. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through June 2017 for any observational or experimental studies that reported the prevalence/incidence of peroneal tendon subluxation/dislocation with a calcaneus fracture with regard to fracture classifications and the significance of the fleck sign. Nine studies were included, with 1027 patients and 1050 calcaneus fractures. The overall prevalence of peroneal instability (PI) in association with a calcaneus fracture was 29.3%. An increasing prevalence of PI increased the severity of the calcaneus fractures, 5.4% in Sanders I, 19% in Sanders II, 39.4% in Sanders III, and 49.5% in Sanders IV. The presence of a fleck sign is a strong indicator of PI, with a prevalence of 54.7%. The computed tomography findings can overestimate the presence of PI compared with the intraoperative findings. The global reported prevalence of peroneal tendon instability associated with intraarticular calcaneal fractures is high and increases with increasing severity of the calcaneus fracture.

Wound and Sural Nerve Complications of the Sinus Tarsi Approach for Calcaneus Fractures

Background The purpose of this study was to evaluate the optimal timing and measures of the sinus tarsi approach for calcaneus fractures to avoid iatrogenic injury of the sural nerve and to assess for wound complications.

METHODS

A case series of 53 patients with calcaneus fractures treated by a single surgeon with the sinus tarsi approach was retrospectively analyzed. On the basis of the delay time from injury to surgery, patients were classified into 4 groups: immediate (0-3 days), early (4-6 days), intermediate (7-14 days), and late (14-18 days). All patients were followed for at least 1 year to observe wound conditions. The rate of wound complications and iatrogenic sural nerve injury was described. Incisions were classified into 2 groups: group A included patients with incisions extending posterior to the lateral malleolus, and group B included patients with incisions confined anterior to the lateral malleolus. The rates of nerve injury were compared between both groups. Forty-three patients with 52 Sanders type II fractures were included.

RESULTS

The average time to surgery from injury was 8.8 days (range, 0-18 days). The overall postoperative rate of wound complications was 5.8% (3 of 52). In the immediate group, deep infections and wound necrosis were found in 2 of 8 fractures (25%). In the early group, 1 of 15 fractures developed superficial infection (6.7%). In the intermediate and late groups, no wound complication was identified. Iatrogenic sural nerve injury was recorded in 5 of 52 patients (9.6%). Group A had 33% (4 of 12) nerve injuries and group B had 2.5% (1 of 40) ( P = .009). In 70% of cases, a main branch of the sural nerve was directly under the incision.

CONCLUSIONS

The sinus tarsi approach was generally effective and safe for calcaneus fractures. However, it was relatively risky to perform open reduction and internal fixation by the sinus tarsi approach within 6 days of injury. Because the sural nerve is in the vicinity of the approach, iatrogenic injury should be avoided by the use of careful planning and meticulous manipulations. Level of Evidence Therapeutic; Level III, comparative study.

Classification system of the tibiofibular syndesmosis blood supply and its clinical relevance

Due to the lack of anatomical studies concerning complexity of the tibiofibular syndesmosis blood supply, density of blood vessels with further organization of syndesmotic vascular variations is presented in clinically relevant classification system. The material for the study was obtained from cadaveric dissections. We dissected 50 human ankles observing different types of arterial blood supply. Our classification system is based on the vascular variations of the anterior aspect of tibiofibular syndesmosis and corresponds with vascular density. According to our study the mean vascular density of tibiofibular syndesmosis is relatively low (4.4%) and depends on the type of blood supply. The highest density was observed among ankles with complete vasculature and the lowest when lateral anterior malleolar artery was absent (5.8% vs. 3.5%, respectively). Awareness of various types of tibiofibular syndesmosis arterial blood supply is essential for orthopedic surgeons who operate in the ankle region and radiologists for the anatomic evaluation of this area. Knowledge about possible variations along with relatively low density of vessels may contribute to modification of treatment approach by the increase of the recommended time of syndesmotic screw stabilization in order to prevent healing complications.

Soft tissue micro-circulation in the healthy hindfoot: a cross-sectional study with focus on lateral surgical approaches to the calcaneus

PURPOSE

Open reduction and internal fixation (ORIF) using an extended lateral approach combined with plate osteosynthesis represents the current gold standard in calcaneal fracture treatment, but it is associated with a wound complication rate of up to 30%. Literature suggests that micro-circulation is one of the key factors for sufficient wound healing. The aim of this study was to evaluate soft tissue micro-circulation of the hindfoot in healthy volunteers to determine influencing factors and to identify hypoxic or hypoperfused areas in non-trauma situations, with special attention to surgical approaches.

METHODS

Micro-circulation of the lateral hindfoot of 125 participants was non-invasively measured at 2 and 8 mm depths, utilizing a Micro-Lightguide O2C® spectrophotometer. Blood flow (BF [AU]) and oxygen saturation (SO2 [%]) of ten measurement points (MPs) were documented. Demographic factors (age, gender, body mass index [BMI], systolic/diastolic blood pressure, smoking, and pack-years) and regional differences with special regard to surgical approaches (extended lateral approach, Palmer approach, Ollier approach, and a self-modified extended lateral approach) were analyzed.

RESULTS

The SO2 assessments at 2- and 8-mm depths revealed higher values in males (p = 0.043; p = 0.025). There was a correlation between higher age and lower 2 mm BF (p = 0.044). Smoking history and number of pack-years did not predict micro-circulation. BF at the 2 mm depth was highest in the regions of Palmer and Ollier approach (p < 0.001). The MP at the distal calcaneal tuberosity showed significantly higher values regarding all parameters (SO2 (2 mm), p < 0.001; SO2 (8 mm), p = 0.001; BF (2 mm), p < 0.001; BF (8 mm), p < 0.001), compared to the surrounding area.

CONCLUSIONS

In non-trauma situations, young males were associated with better micro-circulatory supply of the lateral hindfoot. There was a trend for higher blood flow in regions of the Palmer and Ollier approach. The distal calcaneal tuberosity was clearly superior in all micro-circulatory parameters when compared to the surrounding area.

The Posterolateral Approach for Calcaneal Fractures

BACKGROUND

Conventionally, the extended lateral approach (ELA) served as the standard extensile approach for intraarticular calcaneal fracture fixation. However, this approach has a high rate of wound complications. The purpose of this study was to describe an alternative approach, the posteriorlateral approach (PLA) and compare it to the ELA regarding soft tissue complications and functional outcome.

MATERIALS AND METHODS

32 patients operated through PLA and 66 patients treated through ELA were included in this retrospective study. Major and minor soft tissue complications up to 3 months postoperatively were recorded. Eighteen patients of the PLA group and 32 patients of the ELA group were available for 1-year functional outcome assessment with the American Foot and Ankle Score (AOFAS) score.

RESULTS

The PLA group had no major complications requiring surgical intervention. Six patients (19%) had minor wound complications. The ELA group had 8 (12%) major complications and 9 (14%) minor complications. There were no significant differences in AOFAS scores at 1-year followup. PLA is a safe and efficient approach for open reduction and internal fixation of displaced intraarticular calcaneal fractures.

CONCLUSION

In selected cases when fracture comminution and displacement may not be adequately treated through a less invasive approach, it is a good alternative with less concern about wound complications as in ELA.

Reconstruction of fingers after electrical injury using lateral tarsal artery flap

Objective

Electrical injuries to the fingers account for the majority of total severe burns that occur each year. While several types of flaps have been used in covering finger defects, all have limitations or disadvantages. The purpose of this study was to introduce our clinical experiences of using the lateral tarsal artery (LTA) flap to successfully restore fingers after electrical injury.

Patients and methods

From 2005 to 2012, 10 patients with 14 severe electrical burns to their fingers, including six thumbs and four index and four middle fingers, were treated with LTA flap. The wound size ranged from 2.0×3.0 cm to 3.5×5.0 cm. The flap with free tendon graft was used to repair the tendon defect in four cases, free nerve graft was used to repair the feeling defect in two cases, and the flap with nerve was used to repair the feeling defect in two cases. All the patients were followed up for 3 months to 2 years.

Results

All skin flaps adhered successfully and there were no complications. All patients were satisfied with the esthetic appearance and functional outcome of the finger reconstruction.

Conclusion

LTA flap is a reliable method to restore fingers after severe electrical injuries.

A modified minimally invasive technique for intra-articular displaced calcaneal fractures fixed by transverse and axial screws

The management of displaced, intra-articular calcaneal fracture represents a surgical challenge to even an experienced orthopedic surgeon. Plate osteosynthesis using an extended lateral approach is complicated by soft tissue problems, while those treated by closed reduction and percutaneous pinning cannot address all the intra-articular fragments sufficiently. The objective of our study is to evaluate restoration of subtalar joint and long-term functional outcomes in intra-articular displaced calcaneal fractures treated with transverse subcondral screws through a small incision on lateral aspect of calcaneus and percutaneously placed axial screws through the calcaneal tuberosity. Forty-five intra-articular calcaneal fractures were managed with this minimally invasive technique. Calcaneal height, width, length, Bohler's angle, and Gissane angle were measured preoperatively and last follow-up visit. Functional outcomes were assessed on the basis of American Orthopedic Foot and Ankle Society (AOFAS) ankle/hind foot score. Preoperative calcaneal length, height, width, Bohler's angle, and Gissane angle were improved from 68.62 ± 2.64 to 72.44 ± 2.63 mm, 39.28 ± 2.72 to 32.37 ± 2.65 mm, 47.04 ± 2.56 to 49.55 ± 2.45 mm, 12.66° ± 2.86° to 26.93° ± 2.57°, 123.91° ± 3.13° to 96.06° ± 3.92°, respectively, after surgery with P value <0.001. There were 21 (46.7%) excellent, 17 (37.8%) good, 4 (8.8%) fair, and 3 (6.7%) poor outcomes based on AOFAS ankle/hindfoot scores. Time to unite the fracture was 11.06 ± 1.82 weeks (range 8-16 weeks), and all fractures were united without major complications. Minimally invasive technique through a small incision on lateral aspect of calcaneus gives a moderately good exposure for anatomical restoration of Sander's type II and III calcaneal fractures fixed with both transverse and axial screws under fluoroscopic guidance.

Sinus tarsi approach versus extensile lateral approach for displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

Background

The extensile lateral approach (ELA) has been widely performed for displaced intra-articular calcaneal fractures (DIACFs), and wound complications remain a significant problem. As a minimal incision technique, the sinus tarsi approach (STA) was designed to overcome this disadvantage. There were already many reports about this approach but the conclusions were not completely consistent. Based on the current evidence, we performed this meta-analysis to compare the STA with ELA in the management of DIACF and expected to draw a certain and meaningful conclusion.

Methods

All potentially relevant randomized controlled trials (RCTs) and cohort studies (CSs) were searched in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrial.gov. The desirable outcomes including wound complications, excellent and good rate, secondary surgery rate and Böhler’s angle were extracted. RCT studies were assessed using the Risk of Bias Tool recommended by the Cochrane Collaboration, and cohort studies were evaluated using the Newcastle–Ottawa Scale. The data of RCTs and cohorts were pooled respectively using the fixed-effect model or random-effect model. Mean differences with 95% confidence intervals (CIs) were calculated for continuous data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data. Statistical heterogeneity was assessed with the Q test and I². Sensitivity analysis was developed to assess the reliability of pooled results.

Results

Seven studies including two RCTs and five CSs were eligible for the meta-analysis. No matter RCTs or CSs, the pooled data all showed that STA group had a lower incidence of wound complications than that in the ELA group and no significant difference was found in excellent and good rate and the recovery of Böhler’s angle between the two groups. The CSs also showed that the STA group had a lower incidence of secondary surgeries than that in the ELA group.

Conclusions

Through a STA, we not only can reduce the problems in wound healing but also achieve nearly the same adequate restoration of DIACF along with the similar functional outcomes compared with through an ELA.

Proximity of the Lateral Calcaneal Artery With a Modified Extensile Lateral Approach Compared to Standard Extensile Approach

BACKGROUND

The extensile lateral approach (EL) has been associated with increased wound complications such as apical necrosis which may be due partially from violation of the lateral calcaneal artery (LCA). Traditionally, the vertical limb has been placed half-way between the fibula and Achilles tendon, which may be suboptimal given the proximity to the LCA. We hypothesized that placing the vertical limb further posterior (ie, modified EL [MEL]) would increase the distance from the LCA. The purposes of this study were to quantify the location of the LCA in relation to the vertical limb of the traditional EL approach and to determine if utilizing the MEL approach endangered the LCA to a lesser extent.

METHODS

20 cadavers were used. For the EL approach, the fibula and Achilles tendon were palpated and a line parallel to the plantar foot was drawn between the two. A vertical line (VL), representing the vertical limb of the approach, was drawn at the midway point as a perpendicular extending proximally from the junction of the glabrous/non-glabrous skin (JGNG). For the MEL approach, the anterior border of the Achilles tendon was palpated and a similar vertical line (MVL) was drawn 0.75 cm anterior. Dissection was performed and if the LCA was identified crossing the line VL/MVL, the distance from the JGNG was documented.

RESULTS

For the EL approach, the LCA was identified in 17/20 (85%) cadavers at an average distance of 5.0 cm (range 3-7 cm, SD = 1.3 cm) from JGNG. For the ML approach, the LCA was identified in 4/20 (20%) cadavers at an average distance of 5.9 cm (range 3-6.5 cm, SD = 1.7 cm) from the JGNG ( P < .001).

CONCLUSIONS

The LCA was encountered 4 times more often during the EL approach as compared to the MEL approach.

CLINICAL RELEVANCE

A modification of the EL approach may decrease iatrogenic injury to the LCA and may decrease wound complications.

The lateral calcaneal artery as an alternative recipient vessel option for heel and lateral foot reconstruction

BACKGROUND

Clinical outcomes of consecutive use of the lateral calcaneal artery (LCA) as a recipient vessel for microsurgical reconstruction have not been reported. This study aimed to evaluate the feasibility and safety of the LCA as a recipient vessel for microsurgical foot reconstruction based on anatomical study of CT angiography and clinical results of using this vessel as the recipient.

METHODS

Anatomic study was performed using CT angiography of 61 lower extremities (31 patients). The emerging point, course, and diameter of the LCA were evaluated using 3-D reconstructed images. The LCA was used as the recipient artery in 17 consecutive patients with a mean age of 59 years (range: 23-77 years). Thoracodorsal artery perforator flap was used in most cases (16 of 17), and clinical outcomes were evaluated.

RESULTS

The LCA emerged 31.1 ± 9.8 mm proximal and 14.7 ± 5.0 mm posterior to the tip of the fibula and traversed 13.9 ± 2.7 mm posterior to the posterior margin of the lateral malleolus. The accompanying vein was used for venous outflow in five patients and the small saphenous vein was used in the remaining cases. Emergent re-operation was performed in one case due to venous thrombosis, and salvage was successful. All flaps except for one with partial flap necrosis completely survived. During a mean follow-up of 13 months, all but one of the patients were able to wear shoes and walk.

CONCLUSIONS

The LCA may be safely used as a recipient vessel for microsurgical heel and lateral foot reconstruction.

LEVEL OF EVIDENCE

IV.

Extensile Lateral Approach for the Operative Management of a Displaced Intra-Articular Calcaneus Fracture

Calcaneal fractures account for approximately 1.2% of all fractures and 60% of all tarsal bone fractures. Almost 75% present as displaced, intra-articular fractures. Because of the complex articular and osseous anatomy, the vulnerable soft-tissue envelope, and the technically challenging approach needed for fixation, these fractures are often treated nonoperatively, resulting in poor outcomes. These poor outcomes can include entrapment of the posterior tibial and sural nerves, impingement, dislocation or entrapment of peroneal tendons, a widened heel with a loss of height, hindfoot varus or valgus, formation of painful exostoses, development of posttraumatic arthritis of the subtalar and calcaneocuboid joints, and impingement of the ankle joint. The current scientific literature supports fixation of displaced, intra-articular fractures. The principles of surgical fixation consist of reconstructing the height (obtained by improving the Böhler angle), narrowing the width, reconstructing the length, correcting any varus deformity of the tuberosity, and anatomically reducing the joint. However, at the time of initial presentation, there is often substantial swelling, with or without fracture blisters, that needs to be resolved prior to surgical fixation. During this waiting period, radiographic and computed tomography (CT) evaluations should be performed to assess the fracture pattern. Once re-epithelialization of the blisters and wrinkling of the skin are noted, open reduction and internal fixation (ORIF) can be performed. The steps to an ORIF consist of (1) the use of an extensile lateral incision, with a subperiosteal dissection, that develops a full-thickness fasciocutaneous flap; (2) removal of the lateral wall, to allow visualization of the impacted joint; (3) removal of the lateral third or half of the joint to allow visualization of the medial two-thirds or half of the joint; (4) disimpaction of the medial half of the joint to its normal height, along with medialization of the tuberosity; (5) anatomic reduction of the posterior facet and fixation with lag screw(s); (6) possible use of a bone graft and replacement of the lateral wall; (7) spanning the calcaneus with a plate and screws; and (8) closure of the fasciocutaneous flap and skin over a drain.

Less wound complications of a sinus tarsi approach compared to an extended lateral approach for the treatment of displaced intraarticular calcaneal fracture: A randomized clinical trial in 64 patients

BACKGROUND

We conducted a prospective randomized clinical trial to compare the clinical and radiological outcomes of the sinus tarsi and extended lateral approaches for the surgical treatment of displaced intraarticular calcaneal fractures.

METHODS

Between January 2009 and January 2014, patients with displaced intraarticular calcaneal fracture were randomly assigned to receive surgical treatment by the sinus tarsi approach or the extended lateral approach using block randomization. We recorded and analyzed data on demographics, time to surgery, wound complications, Böhler angles pre- and postoperatively, and American Orthopedic Foot & Ankle Society score.

RESULTS

Sixty-four patients met the inclusion criteria and were randomly assigned to the 2 groups: 32 patients underwent sinus tarsi approach, and 32 patients the extended lateral approach. Baseline characteristics of both groups were similar. The time to surgery in the sinus tarsi approach group was significantly shorter than in the extended lateral approach group (P = 0.04). The wound complication rates were 6.3% and 31.2% in the sinus tarsi approach and extended lateral approach groups, respectively, which was significantly different (P = 0.01). Regarding the clinical outcomes, the groups did not differ significantly on walking visual analogue scale or American Orthopedic Foot & Ankle Society scores at 6 months and 1 year postoperatively. No significant differences existed between groups regarding the Böhler angle at different times and reduction quality of the articular surface and the medial wall.

CONCLUSION

Compared with the extended lateral approach, the sinus tarsi approach decreased wound complications and preoperative waiting time, and achieved similar functional and radiological outcomes for displaced intraarticular calcaneal fractures.

Availability of the lateral calcaneal region as a donor site of free flaps

INTRODUCTION

Various methods have been used for the coverage of soft-tissue defects, such as local and free flaps, as well as perforator flaps performed using even supermicrosurgery. However, the techniques have some limitations regarding flap size and location when used to reconstruct small defects. We introduced the lateral calcaneal region as a donor site for free flaps in order to overcome these disadvantages and presented the results from a series of cases.

PATIENTS AND METHODS

A retrospective chart review was performed on 10 patients with small soft-tissue defects who underwent reconstruction with a lateral calcaneal free flap between January 2011 and May 2014. The reconstruction was performed on the defects at medial and lateral plantar area, dorsum of the foot, great toes and preauricular area.

RESULTS

The size of the flaps ranged from 2.5 × 2.5 cm to 4.5 × 4.5 cm. The flaps exhibited complete survival in five cases. Partial necrosis occurred in three cases, two cases healed with secondary intention, and one case required a skin graft. The donor sites were treated with skin grafts and healed completely, with no complications.

CONCLUSION

Lateral calcaneal free flaps have several advantages, such as anatomically constant pedicles, a pliable and thin texture, and the ability to be used as sensory flaps. They therefore represent an alternative option when conventional local or free flaps are not suitable, especially in cases of small defects. © 2016 Wiley Periodicals, Inc. Microsurgery 37:494-501, 2017.

Peroneal Tendon Instability in Intra-Articular Calcaneus Fractures: A Retrospective Comparative Study and a New Surgical Technique

OBJECTIVE

To compare the prevalence of peroneal tendon instability as determined by intraoperative evaluation versus preoperative computed tomography (CT) scans, and to identify specific risk factors that correlate with tendon instability.

DESIGN

Retrospective comparative study.

SETTING

Level 1 trauma hospital.

PATIENTS

Patients with operatively treated intra-articular calcaneus fractures managed between January 1, 2002 and December 31, 2012 were reviewed for evidence of peroneal tendon instability. Of 254 fractures, 155 intra-articular calcaneus fractures met inclusion criteria and were available for final analysis.

INTERVENTION

Operative notes were reviewed to confirm intraoperative testing for superior peroneal retinaculum (SPR) integrity and peroneal tendon stability. Preoperative CT scan and plain radiographs were evaluated for presence of peroneal tendon dislocation, fibular fracture or "fleck" sign, excessive lateral wall displacement, and/or calcaneal fracture-dislocation.

MAIN OUTCOME MEASURES

Peroneal tendon stability was determined with intraoperative assessment of the intact SPR and its confluence with the peroneal tendon sheath. The incidence of peroneal tendon instability on intraoperative assessment was compared with preoperatively identified tendon dislocation on CT scan. Prevalence of peroneal tendon dislocation was determined using each diagnostic method. Risk factors for tendon instability were identified using a multivariate regression model.

RESULTS

There was significantly higher prevalence of peroneal tendon instability as determined by preoperative imaging (30%; n = 47/155) compared with intraoperative retinaculum testing (11.6%; n = 18/155) (P < 0.001). Intraoperative tendon instability was significantly associated with increased fracture classification severity, fibular fracture/"fleck" sign, and fracture-dislocation.

CONCLUSIONS

Intraoperative evaluation of the SPR should be used in conjunction with preoperative imaging for diagnosis of peroneal instability in the setting of operatively treated, intra-articular calcaneus fractures.

LEVEL OF EVIDENCE

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

Use of Lateral Calcaneal Flap for Coverage of Hindfoot Defects: An Anatomical Appraisal

Lateral calcaneal flap is an established surgical option for coverage of lateral calcaneum and posterior heel defects. Lateral calcaneal flap vascularization and innervations are based on lateral calcaneal artery neurovascular bundle, that is, lateral calcaneal artery, small saphenous vein, and sural nerve. Anatomical research has allowed exploration of its many advantages but can also lead to its various modifications, permitting a wide variety of clinical applications. In this paper the authors report an anatomical and clinical study on lateral calcaneal artery course and lateral calcaneal flap clinical applications. Anatomic part of our study focused on lateral calcaneal artery course and optimization of surgical technique for flap harvesting. Data were used for design of lateral calcaneal flap in 5 patients. Our results were satisfactory in terms of coverage adequacy, perioperative morbidity, and functional and aesthetical outcome.

Lateral Calcaneal Artery Flaps in Atherosclerosis: Cadaveric Study, Vascular Assessment and Clinical Applications

BACKGROUND

Soft tissue defects of the lateral malleolus (LM) and Achilles tendon pose difficult reconstructive problems due to the bony prominence and limited local tissue available. The objectives were to study the anatomical landmarks of the lateral calcaneal artery (LCA) and patency of LCA in atherosclerotic patients.

METHODS

Part I: Thirty-four cadaveric feet were dissected to identify the LCA. The distance between the LCA and the most prominent point of the LM was measured horizontally (LCAa-LM), obliquely (LCAb-LM), and vertically (LCAc-LM). Part II: Thirty-two patients were divided in 2 groups as nonatherosclerotic and atherosclerotic groups. The LCA was assessed by both Doppler ultrasonography and computed tomographic angiography (CTA). Part III: Clinical applications were demonstrated.

RESULTS

Part I: Mean distances of LCAa-LM, LCAb-LM, and LCAc-LM were 24.76, 33.68, and 35.03 mm, respectively. The LCA originated 94.12% from the peroneal artery. Part II: Doppler ultrasonography detected the LCA at 90.62% and 87.50% in nonatherosclerotic and atherosclerotic groups, respectively, whereas 100.00% and 93.75%, respectively, were detected by CTA. No statistically significant difference was found in the patency of the LCA between nonatherosclerotic and atherosclerotic patients. Part III: Clinical applications were performed in atherosclerotic patients.

CONCLUSIONS

The LM is a reliable point to identify the LCA, and the LCA flap can be raised safely in atherosclerotic patients. Preoperative CTA should be performed in severely atherosclerotic patients or cases of major lower extremity vascular injuries.

Open surgical management of high energy ipsilateral fractures of the fibula and calcaneus

BACKGROUND

Simultaneous ipsilateral fractures of the calcaneus and fibula are the result of high-energy injuries. Open surgical treatment of both fractures can be performed with incisions based on the described blood supply of the lower extremity.

METHODS

A retrospective review for all patients with ipsilateral fractures of the calcaneus and fibula was performed over an eight-year period. Thirty-eight patients were identified. Eleven patients (28.9%) were treated with open reduction and internal fixation through two separate incisions. Average follow-up was 48.8 weeks.

RESULTS

Two patients (18.1%) required a secondary procedure. Three patients (27.2%) developed incisional cellulitis that resolved with oral antibiotics and one patient required local wound care. All fractures united.

CONCLUSIONS

Ipsilateral fractures of the calcaneus and fibula require open reduction and internal fixation when closed or percutaneous treatment is not appropriate. We describe an operative approach based on the angiosomes of the lower extremity that allows for treatment of these complex injuries and report the associated complications.

Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification

OBJECTIVE

The primary purpose of this study was to determine whether the Sanders computed tomography (CT) scan classification was still prognostic for outcome when long-term (10-20 years) radiographic and functional data of patients after open reduction and internal fixation for Sanders type II versus type III displaced intra-articular calcaneal fractures (DIACFs) were compared. The secondary purpose was to assess whether a bone graft or a locked plate was needed to maintain a reduction over time.

DESIGN

Prognostic case-control study.

SETTING

Level I trauma hospital.

PATIENTS

Patients with operatively treated Sanders type II/III DIACF managed between January 1, 1990, and December 31, 2000, by a single surgeon were identified from a prospectively gathered database. Skeletally mature patients with a closed isolated DIACF and a minimum of 10-year follow-up were included in this analysis. All fractures were classified according to Essex-Lopresti and Sanders. Of 638 fractures, 208 met the inclusion criteria.

INTERVENTION

Surgery consisted of a lateral extensile approach, posterior facet reduction, and lag screw fixation, followed by reduction of the anterior process and tuberosity with the application of a nonlocked lateral plate. Neither bone graft nor locking plates were used.

MAIN OUTCOME MEASURES

Articular congruity and overall reduction were assessed by CT scan and plain radiography (Böhler and Gissane angle) immediately postoperatively and at the final follow-up examination in all patients. Functional assessment and outcome scores were obtained [AOFAS-AHS, the Maryland Foot Score, Short Form-36 (SF-36), Ankle Osteoarthritis Score (AOS), and Visual Analog Scale (VAS)], and all complications and/or subsequent surgeries were noted. A subtalar (ST) arthrodesis was considered a treatment failure and was used as the determining outcome variable for comparing the 2 groups (II vs.

III) RESULTS

One hundred eight fractures in 93 patients were available for follow-up at a minimum of 10 years (52%). Average follow-up was 15.22 years (range, 10.5-21.2 years). Eighty were joint depression (J) and 28 were tongue-type (T) fractures. There were 70 Sanders type II and 38 Sanders type III fractures. On immediate postoperative CT scan, posterior facet reduction was anatomic in 103 fractures (95%), near anatomic in 3 fractures (1-3 mm), and approximate in 2 fractures (3-5 mm step). There were no failed reductions (>5 mm step). Long-term results indicated that only 3 fractures settled, but no plates failed. There was 1 missed peroneal tendon dislocation. Seven patients had sural neuritis. Twelve fractures (11%) required local wound care for apical necrosis. One patient had a dehiscence resulting in osteomyelitis, requiring a ST fusion. Thirty-one fractures (29 patients) developed ST arthritis, requiring an arthrodesis (30 ST, 1 triple) for unrelenting pain (VAS, 8-10) during the follow-up period, resulting in an overall long-term failure rate of 29%. Further breakdown by fracture type revealed that an ST fusion was performed in 47% of type III fractures (18/38) versus only 19% of type II (13/70) fractures (P = 0.002). Type III fractures were 4 times more likely to need a fusion compared with type II fractures (relative risk = 3.94; 95% confidence interval, 1.64-9.48). The remaining 66 patients (77 fractures) who did not require a fusion were evaluated for long-term functional outcome. Of these, only 1 patient used a cane and had a limp. Seventy-seven percent of the nonfused group (51/66) were within the US norm for the SF-36 PCS, with 46% (30/66) above the norm. The average AOFAS-AHS was 75. The average VAS was 1.75, with scores of 0-1 (very little or no pain) seen in 56% of this subset of patients (37/66).

CONCLUSIONS

Based on the results of this comparative analysis, the Sanders classification remains prognostic; after a minimum of 10 years, type III fractures were 4 times more likely to need a fusion than type II fractures. Secondarily, it seems that neither a locked plate nor a bone graft is required to maintain a reduction over time, as virtually no loss of reduction was seen in this series (3/108, 0.9%). The "joint first" surgical treatment did not adversely affect calcaneocuboid joint outcome. Based on these results, if severe posttraumatic ST arthritis does not occur, long-term (10-20 years) functional results with mild pain, minimal alterations in activities of daily living or work, and essentially normal shoe wear can be expected from a properly performed open reduction and internal fixation. Patients must be counseled regarding difficulty with uneven ground and an inability to return to vigorous sports activities.

LEVEL OF EVIDENCE

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

Low Wound Complication Rates for the Lateral Extensile Approach for Calcaneal ORIF When the Lateral Calcaneal Artery Is Patent

BACKGROUND

Historically, the lateral extensile approach for calcaneal fracture osteosynthesis has had relatively high rates of wound healing problems. The vascular territory (angiosome) of the lateral foot is now known to be dependent upon the lateral calcaneal branch of the peroneal artery (LCBP artery). We postulated that patency of the LCBP artery may have a profound positive impact on incisional wound healing for calcaneal open reduction and internal fixation (ORIF).

METHODS

Ninety consecutive calcaneal fractures that met operative criteria were preoperatively evaluated for the presence of a Doppler signal in the LCBP artery and were followed for the development of wound healing problems.

RESULTS

Among these 90 fractures, 85 had a positive preoperative Doppler signal along the course of the LCBP artery (94%) and 5 had no Doppler signal (6%). All patients underwent ORIF via a lateral extensile approach. Overall, incisional wound healing problems occurred in 6 of 90 calcaneal incisions (6.5%). All 5 feet that exhibited an absent Doppler signal in the LCPB artery developed an incisional wound healing complication (5/6, approximately 83%): 2 large apical wounds and 3 major dehiscence/slough. However, among the 84 feet that possessed a positive preoperative Doppler signal in the LCBP artery, there was only 1 (1/84, approximately 1%) incisional wound healing problem (P < .0001, Fischer's exact test). Smokers with a positive Doppler signal in the LCBP artery did not develop a wound healing complication.

CONCLUSIONS

This study suggests a strong link to low incisional wound healing complications for the lateral extensile approach to the calcaneus when a preoperative Doppler signal is present in the LCBP artery. We believe this simple examination should be routinely performed prior to calcaneal ORIF.

LEVEL OF EVIDENCE

Level III, comparative case series.

Dual-incision approach for repair of peroneal tendon dislocation associated with fractures of the calcaneus

Dislocation of the peroneal tendons associated with calcaneus fractures should be repaired during fracture fixation to prevent complications. The only documented approach for repair is by proximal extension of the vertical limb of the lateral extensile approach to the calcaneus. However, enlarging the inherently fragile calcaneus flap places it at further risk of damage. Using a separate anterior incision to repair the dislocation, thus avoiding problems caused by excessive flap elevation, seemed intuitive. This approach proved technically effective and reliable in producing favorable outcomes in a series of 14 patients.

Management of displaced intra-articular calcaneal fractures using the limited open sinus tarsi approach and fixation by screws only technique

PURPOSE

Evaluation of management of the displaced intra-articular calcaneal fractures (DIACF) Sanders types II and III by using minimally invasive sinus tarsi approach and fixation by screws only technique.

METHODS

Open reduction using the limited lateral approach and internal fixation using screws only was studied in 33 patients with unilateral isolated simple DIACF with a mean age of 35 years (15 type II patients and 18 type III patients). All patients were evaluated both clinically and radiologically.

RESULTS

With a mean follow-up period of 28.8 months (range 12-53 months), no cases of failure of reduction or displacement of hardware were detected. The mean AOFAS was 91.73 points while the mean MFS was 95.09 points. Twenty-eight patients were able to resume their pre-injury level of work while the remaining five refrained to sedentary jobs. The mean pre-operative Bohlers' angle was 2.8° (range from -38º to 24º) while postoperatively it was 19.4° (range 5º to 49º). There was no statistically significant difference when comparing the results (AOFAS p-value 1.00, MFS p-value 0.81) between Sanders' type II and III fractures. One patient had postoperative superficial wound infection. Seven patients complained of prominent screw heads. Complex regional pain syndrome occurred in seven patients and was treated successfully at six months duration.

CONCLUSION

The limited open sinus tarsi approach can be used successfully to treat displaced Sanders type II and III fractures. It allows for adequate visualization and reduction. Fixation by screws only is also sufficient. It also clearly avoids the major wound complication problems.

Extended lateral approach for intra-articular calcaneal fractures: an inverse relationship between surgeon experience and wound complications

The current reference standard for the treatment of displaced intra-articular calcaneal fractures is open reduction and internal fixation using an extended lateral approach. In the present retrospective study, we evaluated the results of a consecutive series of patients treated in the same fashion from June 2005 to September 2011 using a subcuticular single-layer closure technique. We also determined the risk factors for the development of wound complications and the rate of wound complications. Also, we assessed which patient, fracture, and surgical characteristics affected these complications. During the 75-month study period, we operated on 53 displaced intra-articular calcaneal fractures in 50 patients using the extended lateral approach. The incision was closed using the subcuticular technique in 49 cases (92.45%). In the subcuticular closure group 2 (4.1%) deep infections and 2 (4.1%) superficial wound complications (1 dehiscence and 1 infection) occurred. Wound edge or flap necrosis was not encountered. The use of bone-void filler and the experience of the surgical team were significantly (p < .001 and p = .026, respectively) associated with the occurrence of wound complications. The subcuticular single-layer suture technique is a suitable closure technique in the treatment of displaced intra-articular calcaneal fractures. It was associated with a low complication rate combined with the extended lateral approach. The effect of bone void fillers on the incidence of complications should receive more attention in future research. The association between wound complications and the experience level of the surgical team supports the need for centralization of this complex injury.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report

PURPOSE

The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate.

METHODS

Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate.

RESULTS

For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient.

CONCLUSION

Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.

Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography-based study

BACKGROUND

Open reduction and internal fixation (ORIF) of calcaneal fractures using an extended lateral approach results in soft tissue disruption and theoretically subtalar joint stiffness. A minimally invasive sinus tarsi approach for posterior facet exposure and percutaneous screw fixation of the calcaneal body has been implemented. This report details the reduction and stability of the internal fixation resulting from this approach.

METHODS

Twenty-one consecutive patients (18 male, 3 female, 45 ± 16 years) with 22 calcaneal fractures underwent ORIF with minimal exposure through the sinus tarsi for reduction, lateral plate fixation, and percutaneous screw fixation. There were nine Sanders type II fractures and 13 type III fractures. Sixteen fractures had calcaneocuboid joint involvement. Nineteen patients (19 fractures) were available for follow-up (mean, 32 ± 14 months). Two computed tomography scans were obtained on each patient, one immediately postoperatively and one after a minimum of 1 year, to evaluate reduction and fixation stability, respectively. The posterior facet and calcaneocuboid joint were graded excellent, good, fair, or poor, according to articular step, defect, and angulation. Any change was considered loss of stability. Similarly, on a conventional two-dimensional radiograph, more than 5° of Bohler's angle difference was defined as loss of calcaneal height.

RESULTS

Postoperative posterior facet and calcaneocuboid joint reduction was good (step < 1 mm, defect < 5 mm, angulation < 5°) or excellent (no step, defect, angulation) in 14/22 (64%) and 11/16 fractures, respectively. At follow-up, no loss of reduction at the posterior facet and calcaneocuboid joint was noted. More than 5° of Bohler's angle decrease was found in three patients.

CONCLUSION

Even complex calcaneal fractures can be sufficiently exposed by a minimally invasive sinus tarsi approach for anatomic reduction and stable fixation. Most patients had good or excellent functional results, which may have resulted from minimal soft tissue disruption.

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

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

Vascular anatomy of the tibiofibular syndesmosis

BACKGROUND

Injuries to the tibiofibular syndesmosis commonly cause prolonged ankle pain and disability. Syndesmotic injuries are associated with slower healing rates compared with rates for other ankle ligament injuries and typically result in longer time away from sports. To our knowledge, the vascular supply to the syndesmosis and its clinical implication have not previously been studied. The purpose of this study was to describe the vascular supply to the tibiofibular syndesmosis with use of a method of chemical debridement of cadaveric specimens.

METHODS

Twenty-five matched pairs of adult cadaver legs, fifty legs total, were amputated below the knee. India ink, followed by Ward Blue Latex, was injected into the anterior tibial, peroneal, and posterior tibial arteries under constant manual pressure to elucidate the vascular supply of the ankle syndesmotic ligaments. Chemical debridement was performed with 6.0% sodium hypochlorite to remove soft tissue, leaving bones, ligaments, and casts of the vascular anatomy intact. The vascular supply to the syndesmosis was evaluated and recorded.

RESULTS

The anterior vascularity of the syndesmosis was clearly visualized in forty-three of fifty specimens. The peroneal artery supplied an anterior branch (the perforating branch) that perforated the interosseous membrane, an average of 3 cm proximal to the ankle joint. This branch provided the primary vascular supply to the anterior ligaments in twenty-seven specimens (63%). The anterior tibial artery provided additional contribution to the anterior ligaments in the remaining sixteen specimens (37%).

CONCLUSIONS

The location of the perforating branch of the peroneal artery places it at risk when injury to the syndesmosis extends to the interosseous membrane 3 cm proximal to the ankle joint. In the majority of specimens, injury to this vessel would result in loss of the primary blood supply to the anterior ligaments.

[Calcaneus fractures]

Fractures of the calcaneus generally occur in the setting of high-energy trauma, resulting in complex, three-dimensionally oriented fracture patterns. Surgical treatment is typically indicated for displaced intra-articular fractures, permitting restoration of calcaneal height, width and overall morphology, in addition to the posterior facet articular surface where possible, and enabling late in situ arthrodesis as a means of salvage in the event of post-traumatic arthritis. The present article briefly discusses our preferred methods for the management of calcaneal fractures. An English full text version of this article is available at SpringerLink as supplemental.