Percutaneous Fixation of Intraarticular Calcaneus Fractures

Comparison between screw fixation and plate fixation via sinus tarsi approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis

BACKGROUND

Optimal surgical fixation for displaced intra-articular calcaneal fractures (DIACF) remains a subject of debate, particularly regarding the superiority between screw fixation and plate fixation via the sinus tarsi approach (STA). This review aims to determine the preferred treatment for DIACF and compare the outcomes of minimally invasive surgery options.

METHODS

Our study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on distal intra-articular fractures of the calcaneus (DIACFs) that were fixed using cannulated screws or plates via STA. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, and complications.

RESULT

A total of 728 patients from 7 studies met the inclusion criteria. Among them, 435 patients underwent screw fixation via STA, and 373 patients underwent plate fixation via STA. The study found no statistically significant differences between the screw fixation and the plate fixation via sinus tarsi approach (STA) in terms of AOFAS scores, Bohler's angle, Gissane's angle, sural nerve injury, secondary subtalar arthrodesis and reoperation. Compared with screw fixation, plate fixation via STA can reduce reduction loss of Bohler's angle (WMD = - 1.64, 95% CI = [- 2.96, - 0.31], P = 0.06, I2 = 59%), lower the incidence of fixation failure (OR = 0.32, 95% CI = [0.13, 0.81], P = 0.78, I2 = 0%), and decrease intra-articular step-off (WMD = - 0.52, 95% CI = [- 0.87, - 0.17], P = 0.66, I2 = 0%).

CONCLUSIONS

Plate fixation demonstrates superior capability in restoring calcaneal width, maintaining Bohler's angle, and minimizing intra-articular step-off, thereby maintaining better reduction of the subtalar articular surface. In addition, plate fixation exhibits the modest complication rate and a low incidence of fixation failure. Therefore, we recommend the use of plate fixation through the STA, especially for complex and comminuted intra-articular calcaneal fractures.

Comparison between Percutaneous Screw Fixation and Plate Fixation via Sinus Tarsi Approach for Calcaneal Fractures: An 8-10-Year Follow-up Study

Objective

To assess the long‐term outcomes after percutaneous reduction (PR) and screw fixation versus plate fixation via the sinus tarsi approach (STA) for displaced intra‐articular calcaneal fractures (DIACF).

Methods

This retrospective study included a total of 150 patients (June 2008–August 2011), comprising 85 men and 65 women (mean age, 38.4 years), who were assigned to the PR group or the STA group. The inclusion criteria were DIACF (>2 mm) including Sanders type II and III, closed fracture, unilateral fracture, no history of smoking or no smoking during hospitalization and 3 months after surgery, and follow‐up time not less than 8 years. The exclusion criteria were clear surgical contraindications (severe cardiovascular and cerebrovascular diseases), local or systemic infection symptoms, diagnosis with diabetes or lower extremity vascular disease, and Sanders type IV or open fractures. Outcomes were assessed by means of the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scores, radiographic images, and postoperative complications.

Results

The mean follow‐up period was 8.7 years (range, 8.0–10.0 years). The AOFAS scores in the PR group during the follow‐up period were 54.2 ± 5.1, 85.8 ± 4.0, 88.1 ± 3.8, 87.9 ± 3.6, 87.8 ± 3.9, 86.9 ± 3.9, respectively, and in the STA group were 55.0 ± 5.6, 84.5 ± 5.2, 87.1 ± 3.8, 86.9 ± 3.8, 87.7 ± 3.3, and 87.6 ± 2.8, respectively. There was no significant difference in AOFAS scores, Bohler's angle, Gissane's angle, calcaneal length, and height between the two groups (P > 0.05). The good to excellent rate of the PR group (80.8%) was less than that of the STA group (91.7%) (P = 0.055). For Sanders III fractures, the good to excellent rate of the PR group (33.3%) was less than that of the STA group (76.9%) (P = 0.029). For calcaneal width recovery, the STA group performed better than the PR group (P < 0.05). The incidence of postoperative complications in the PR group (12.8%) was lower than that in the STA group (27.8%) (P = 0.026), of which the incidence of wound complications was 3.8% in the PR group and 13.9% in the STA group (P = 0.041). In addition, there was no significant difference in other postoperative complications such as sural nerve injury, peroneus longus and brevis muscle injury, calcaneal valgus symptoms, lateral impingement symptoms, and subtalar arthritis (P > 0.05).

Conclusion

From the 8–10‐year follow‐up results of PR and STA as surgical procedures for the treatment of DIACF, it was found that there was no significant difference in the overall efficacy between them. STA was found to be superior to the PR in terms of the recovery of calcaneal width, providing more stable fixation for Sanders III fractures. PR was found to be more effective in reducing wound complications.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Paradigm Shift for the Surgical Management of Calcaneal Fractures?

Calcaneal fractures account for up to 75% of all foot fractures and 1% to 2% of all fractures. Approximately 75% of calcaneal fractures are intraarticular, resulting in a prolonged recovery, more pain, and disability. The most common mechanism of injury includes falls from a height and motor vehicle accidents. This article reviews studies that compare nonoperative with operative treatment. The literature continues to support surgical intervention; however, these injuries can still be managed nonoperatively in certain clinical scenarios. This article focuses on the surgical management of intraarticular calcaneal fractures and highlights the sinus tarsi approach.

Comparison of percutaneous cannulated screw fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial

BACKGROUND

The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs.

METHODS

Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC (N = 42) or MISTA (N = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded.

RESULTS

The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group (p < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group (p < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group (p < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures (p < 0.05).

CONCLUSION

The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs.

TRIAL REGISTRATION

ChiCTRIOR16008512 . 21 May 2016.

Closed Reduction and Percutaneous Fixation of Calcaneal Fractures in Children

Open reduction and internal fixation has been widely used to treat displaced intra-articular calcaneus fractures in children. However, the complications of surgical trauma and the wound created through the extended lateral approach cannot be ignored. This study analyzed the outcomes of displaced intra-articular calcaneal fractures in children treated with closed reduction and percutaneous fixation. Medical records of pediatric patients who had displaced intra-articular calcaneus fractures and underwent closed reduction and percutaneous fixation at the study institution between January 2008 and January 2013 were reviewed. Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. Clinical outcomes and radiographic findings were assessed at postoperative follow-up. The study included 14 displaced intra-articular calcaneal fractures in 11 patients (7 boys and 4 girls). Mean patient age was 11.18 years (range, 6-16 years), and average follow-up time was 42.8 months postoperatively (range, 12-72 months). There were 6 tongue-type fractures and 8 joint depression-type fractures, based on the Essex-Lopresti classification, and there were 11 type II and 3 type III fractures, based on the Sanders classification. Average Böhler angle was 8.00° (range, -5° to 18°) preoperatively and 30.79° (range, 26° to 40°) postoperatively (P<.001). Average subjective American Orthopaedic Foot and Ankle Society hindfoot score was 65.7 (range, 52-68). No patients had wound breakdown or infection. In the treatment of displaced intra-articular calcaneal fractures in pediatric patients, closed reduction and percutaneous fixation achieved good outcomes, with few complications. [Orthopedics. 2016; 39(4):e744-e748.].

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

AUTHORS SUMMARY

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

Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach

Background

Two common surgical approaches included the sinus tarsi and extensile lateral are used for displaced intra-articular calcaneal fractures. However, few studies have compared outcome of treated by the two approaches. The purpose of this study was to compare the outcome between these two approaches for Sanders type-II and type-III fractures.

Methods

This retrospective cohort study was performed from 2004 to 2011. Open reduction and internal fixation using the sinus tarsi and extensile lateral approach was studied in 100 cases (40 sinus tarsi and 60 extensile lateral) with displaced intra-articular calcaneal fractures. All patients were evaluated both clinically and radiologically.

Results

Median Böhler and Gissane angle were improved to 26.5 degree (4.6 to 45), 115.5 degree (101.2 to 127.4) in the sinus tarsi group and 25.3 degree (3.7 to 44.6), 119.0 degree (73.5 to 145.6) in extensile lateral group at the final follow-up, respectively. Median calcaneal height, length, and width in the sinus tarsi and extensile lateral groups showed improvement to 45.1 mm (23.2 to 54.1), 75.9 mm (64.9 to 90.3), 37.6 mm (29.2 to 53.9) and 46.5 mm (32.7 to 59.5), 76.1 mm (67.3 to 97.9), 39.3 mm (29.2 to 47.8) at the final follow-up, respectively. Median AOFAS score was checked to 90 points (76 to 94) in the sinus tarsi group and 86 points (76 to 94) in the extensile lateral group at the final follow-up. No significant differences in clinical and radiologic outcomes were observed between the two groups. However, wound complication rate (13.3%) in the extensile lateral group was significantly higher compared to the sinus tarsi group (p-value = 0.022).

Conclusions

The final clinical and radiographic outcomes between the two approaches for Sanders type-II and type-III intra-articular calcaneal fractures were comparable and equally successful. The selective sinus tarsi approach appears to be an effective and reliable method for the treatment of Sanders type-II and type-III fractures.

Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures

BACKGROUND

The optimal method for treating intra-articular fractures of the calcaneus remains controversial. Extensile approaches allow excellent fracture exposure, but high rates of wound complications are seen. Newer minimally invasive techniques for calcaneus fracture fixation offer a potentially lower wound complication rate, but long-term clinical results are not available. The aim of this study was to compare the outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation via an extensile approach versus those with a minimally invasive sinus tarsi approach.

METHODS

We performed a retrospective review of all intra-articular calcaneal fractures treated operatively between October 2005 and December 2008. A total of 112 fractures were found that met our inclusion criteria; 79 were treated with an extensile lateral approach and 33 via a minimally invasive approach based on surgeon preference. Chart and radiographic results were thoroughly reviewed on all 112 fractures, specifically for wound healing complications and the need for further surgeries within the study period. Additionally, all patients were contacted and asked to return for a research visit that included radiography, clinical examination, and quality of life questionnaires (Short Form 36 [SF-36], foot function index [FFI], visual analog scale [VAS] pain). A total of 47 of 112 (42%) patients returned for a research visit (31 extensile, 16 minimally invasive).

RESULTS

The 2 groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, workers' compensation status). In the extensile group, 53% of fractures were Sanders II and 47% were Sanders III, whereas in the minimally invasive group 61% were Sanders II and 39% were Sanders III. The overall wound complication rate was 29% in the extensile group (9% required operative intervention) versus 6% in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20% of the extensile group required a secondary surgery within the study period versus 2% in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84% of patients in the extensile group were satisfied with their result versus 94% in the minimally invasive group (P = .32). Both groups had 100% union rates, and no differences were noted in the final postoperative Bohler's angle and angle of Gissane.

CONCLUSION

Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.