Fractures of the calcaneus: a review with emphasis on CT

Sustentaculum fracture fixation with lateral plate or medial screw fixation are equivalent

BACKGROUND

Fixation of sustentaculum tali fractures is important to maintain the biomechanical function of the subtalar joint. A common method of fixation is securing the sustentacular fragment by way of a laterally based locking plate (LP). A medial approach with a single screw (MS) has been proposed as an alternative method of fixation.

METHODS

Five pairs of formalin-preserved cadaveric ankles with the subtalar joint and interosseous ligaments intact ("osseous cadavers") and four pairs of fresh-frozen cadaveric ankles with soft-tissue preserved dissected from mid-tibia down ("soft tissue cadavers") were used in the study. The left ankle was randomly assigned to one of the two fixation methods (LP or MS), while the right ankle was the opposite. These same steps for fixation were repeated for six synthetic ankle models. All models were loaded with a body mass of 80 kg. Statistical differences between LP and MS stiffness were determined using a paired t-test in cadavers and un-paired t-tests in synthetic ankles.

RESULTS

For osseous cadaveric ankles, LP demonstrated a mean stiffness of 232.95(SD: 59.96) N/mm, while MS was 239.72(SD:131.09) N/mm (p = 0.9293). For soft tissue cadaveric ankles, LP mean stiffness was 133.58(SD:37.84) N/mm, while MS was 134.88(SD:20.75) N/mm (p = 0.9578). For synthetic ankles, LP mean stiffness was 220.40(SD:81.93) N/mm, while MS was 261.50(SD:100.21) N/mm (p = 0.6116).

CONCLUSIONS

Across all three models, there was no significant difference between LP and MS methods. Retrospective observational studies are recommended to assess patient outcomes from each of the methods.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

The effect of perioperative tranexamic acid (TXA) in patients with calcaneal fractures: a meta-analysis and systematic review of randomized controlled trials

BACKGROUND

Calcaneal fractures are a common orthopedic disease, account for approximately 2% of all bone fractures, and represent 60% of fractures of tarsal bones. Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that competitively blocks the lysine-binding sites of plasminogen, plasmin, and tissue plasminogen activator, delaying fibrinolysis and blood clot degradation. However, the effect of TXA on patients with calcaneal surgery remains controversial. Our objective was to evaluate the effectiveness of TXA in calcaneal fractures surgeries.

METHODS

The electronic literature databases of Pubmed, Embase, and Cochrane library were searched in December 2022. The data on blood loss, the stay in the hospital, the duration of surgery, hemoglobin, hematocrit, platelet count, prothrombin time, activated partial thromboplastin time, and wound complication were extracted. The Stata 22.0 software was used for the meta-analysis.

RESULTS

Four randomized controlled studies met our inclusion criteria. This meta-analysis showed that TXA significantly reduced postoperative blood loss during the first 24 h (p < 0.001), improved the level of hemoglobin (p < 0.001) and hematocrit (p = 0.03), and reduced the risk of wound complications (p = 0.04). There was no significant difference between the two groups regarding total and intraoperative blood loss, hospital stay, duration of surgery, platelet count, activated partial thromboplastin time, and prothrombin time.

CONCLUSION

TXA significantly reduced blood loss during the first 24 h postoperatively, improved the level of hemoglobin and hematocrit, and reduced the risk of wound complications. Given the evidence, TXA can be used in patients with calcaneal fractures and had the potential benefit of blood reduction.

PROTOCOL REGISTRATION

The protocol was registered in PROSPERO (registration No. CRD42023391211).

Fractures of the limbs: basic concepts for the emergency department

Traumatic injuries of the limbs are very common and account for a large number of imaging examinations, especially in emergency departments. These injuries can often be resolved if they are recognized and treated appropriately. Their diagnosis requires a complete clinical assessment and the correct interpretation of the appropriate imaging tests. Radiologists play an important role, especially in diagnosing lesions that can go undetected. To this end, radiologists need to know the normal anatomy and its variants, the mechanisms of injury, and the indications for different imaging tests, among which plain-film X-rays are the main technique for the initial evaluation. This article aims to review the relevant characteristics of limb fractures in adults and of lesions that can be associated with these fractures, as well as how to describe them to ensure appropriate clinical management.

Fixation of intra-articular calcaneal fractures: A comparative study of the postoperative outcome between HA/PPLA screws and locking plates

Background

Forged unsintered hydroxyapatite and poly l-lactic acid (F-u-HA/PLLA) screw is bioactivite, bioabsorbable, and radiopaque with high mechanical strength. Its efficacy has been previously demonstrated in the treatment of lateral humeral condylar, lateral tibial condylar, ankle, and patellar fractures. However, studies on its efficacy in treatment of calcaneal fractures is lacking. This study aimed to compare the postoperative results of F-u-HA/PLLA screw fixation and locking plate fixation for intra-articular calcaneal fractures.

Methods

From January 2013 to December 2019, 47 closed intra-articular fractures treated with either F-u-HA/PLLA screws (group S, 18 feet in 17 patients) or locking plates (group P, 29 feet in 28 patients) in a single trauma center were retrospectively reviewed. The sinus tarsi approach was used in both groups. The time to bone union, step-off, varus deformity, Bohler's angle, and width and height of the calcaneus were assessed after surgery. Ankle joint range of motion (ROM) and postoperative complications were also assessed.

Results

All fractures were successfully treated. The Kaplan-Meier curves of the two groups showed similar trends. The log-rank test showed no significant difference in the time to bone union between the two groups (p = 0.48). In the Cox proportional hazards model adjusted for preoperative width and Bohler's angle, the hazard ratio for bone union was not statistically significant (HR: 1.13, 95%CI: 0.50-2.56, p = 0.78). Other variables included step-off (group S: 2.0 vs group P: 2.2 mm, p = 0.84), varus deformity (2.0° vs. 3.0°, p = 0.7), Gissane's angle (103.5° vs 104.0°, p = 0.84), width (38.0 vs 34.8 mm, p = 0.12), height (42.1 vs 44.0 mm, p = 0.07), and ankle ROM degrees (dorsal flexion, 20.0° vs. 20.0°, p = 0.13; plantar flexion 40.0° vs 40.0°, p = 0.56), which were not significantly different between groups P and S. The Bohler's angle was smaller in group S than in group P (20.5° vs 27.0°, p < 0.01). No skin necrosis or infection was observed in either group.

Conclusion

Postoperative results of F-u-HA/PLLA screw fixation using the sinus tarsi approach for intra-articular calcaneal fractures were as good as those of locking plate fixation.

Minimally Invasive Osteosynthesis of Intraarticular Calcaneus Fracture Augmented by Femoral Head Allograft: A Retrospective Study

Aim: The aim of this retrospective study is to report the results of minimally invasive osteosynthesis when used for the treatment of intraarticular calcaneus fracture. This old technique is regaining popularity recently with the multiple advances added by different institutes when it is used in the management of intraarticular calcaneus fracture.

Methods: Twenty-four patients who suffered from intraarticular calcaneus fractures between 2014 and 2019 were included. Twelve of them had Sanders II fractures (group A) and 12 had Sanders III + IV fractures (group B). The mean follow-up duration was 37.5 months. The mean age at presentation was 54.23 ± 12.48 years. The skin condition at presentation was poor (blood-filled blisters) in 25% of patients equally distributed between the two groups. The mean time to surgery was 5.6 days where patients with poor skin conditions were treated lately. The technique involved percutaneous ascending proximal-to-distal pinning of the calcaneus after reduction using a 2 cm mini-incision below the lateral malleolus and augmenting the fixation with femoral head cancellous allograft. The primary outcomes variables analyzed in this study are post-operative Bohler angle, post-operative Gissane angle, American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at long-term follow-up (Excellent>95, Good 75-94, Fair 51-74, poor 0-50), and the delta angle benefit score. The secondary outcomes included post-operative complications such as infection and osteoarthritis.

Results: The radiological results showed significant improvement of Bohler angle from 6.09° ± 21.6 pre-operatively, to 31.79° ± 14.1 postoperatively with a p-value <0.001. An adequate reduction was achieved in 54.16% to 70.8% of patients. There is a trend to normalization of overcorrected fracture especially Sanders II with a mean reduction of 12,71° ± 11,88 at one year post-operatively (p=0.05). AOFAS score at the last follow-up shows 20.83% poor results (AOFAS<50), 50% fair results (AOFAS between 51-74), 16.67% good results (AOFAS 75-94), and 12.5% excellent results (AOFAS>95. The satisfaction rate was 83.3% (45.8% partially satisfied, and 37.5% fully satisfied). The incidence of superficial infection (wound inflammation and pin tract infection) was more prevalent in higher group B (40%) compared to group A (0%) with p=0.014. Other complications including osteoarthritis and varus deformity were found in 95.8% and 58.3% of patients respectively at three-year follow-up.

Conclusion: The combination of minimally invasive osteosynthesis and femoral head allograft for the treatment of intraarticular calcaneus fractures seems to give fair to good functional results. Radiological data demonstrated that when the Bohler angle is over-reduced >40°, there was a tendency to autocorrection over time. This may be due to progressive depression of the angle over time as weight bearing is authorized; however, this must be analyzed carefully due to the low number of patients who were overreduced (seven patients). Our study demonstrates that this technique has a low early complication rate (especially low infection and soft tissue problems) but carries high long-term complications such as osteoarthritis and hindfoot varus.

Approach to Displaced Intra-Articular Calcaneus Fractures After Attempted Suicide Among Patients With Psychiatric Disorders: Nonsurgical or Surgical?

Displaced intra-articular calcaneus fracture is one of the injurious events in psychiatric patients after high-jump suicide attempts. These patients are reported to have poorer compliance and worse postoperative outcomes compared to those with no psychiatric condition.  We aimed to compare nonsurgical and surgical treatment with respect to functional and radiological outcomes and complications in this patient. We evaluated medical records of 42 psychiatric patients who had displaced intra-articular calcaneal fractures after high-jump suicide attempt. 20 (54%) of these were treated nonsurgically and further 17 patients (46%) received surgical intervention. We compared to nonsurgical and surgical approaches statistically. The mean follow-up period were 30.4 ± 8.02 months and 31.8 ± 7.5 months in the nonsurgical and surgical groups, respectively. Böhler's angle was significantly higher in the surgical group (30.4 ± 6.4) than that in the nonsurgical group (16.1 ± 3.7) (p = .001). AOFAS scores and supination levels were significantly higher in the surgical group than that in the nonsurgical group (p ≤ .05). During the follow-up period, one patient from the surgical group re-attempted high-jump suicide and died, and another one caused the subtalar joint to re-collapse after full weightbearing on the first postoperative day. Surgical treatment of displaced intra-articular calcaneal fractures following a high-jump suicide attempt in psychiatric patients may not cause increased complication rates. However, behavioral manifestations of the psychiatric disorder might be associated with several complications. Should any surgical intervention be decided, minimal invasive approach would be the appropriate choice.

CT-Based Classification Systems for Intra-Articular Calcaneal Fractures: The Inter- and Intraobserver Variations as well as Integrality

The aim of this study was to measure the inter- and intraobserver variations as well as integrality of the Zwipp, Crosby-Fitzgibbons, Sanders, and Eastwood-Atkins classification systems based on more accurate CT scans. Five hundred and forty-nine patients with intra-articular calcaneal fractures from January 2018 to December 2019 taken from a database in our level-I trauma center (3 affiliated hospitals) were included. For each case, normative CT (1 mm slices) scans were available. Four different observers reviewed all CT scans 2 times according to these 4 most prevalent fracture classification systems (FCSs) within a 2-month interval. For these 4 FCSs, the kappa [κ] coefficient was used to evaluate interobserver reliability and intraobserver reproducibility, and the percentage that can be classified was used to indicate integrality. The κ values were measured for Zwipp (κ = 0.38 interobserver, κ = 0.61 intraobserver), Crosby-Fitzgibbons (κ = 0.48 interobserver, κ = 0.79 intraobserver), Sanders (κ = 0.40 interobserver, κ = 0.57 intraobserver), and Eastwood-Atkins (κ = 0.44 interobserver, κ = 0.72 intraobserver). Furthermore, the integralities were calculated for Zwipp (100%), Crosby-Fitzgibbons (100%), Sanders (92%) as well as Eastwood-Atkins (89.6%). Compared with previous literatures, CT scanning with higher accuracy can significantly improve intraobserver reproducibility of Zwipp and Eastwood-Atkins FCSs, but it has no positive effect on variability of Sanders FCS and interobserver reliability of Crosby-Fitzgibbons FCS. In terms of integrality, Zwipp and Crosby-Fitzgibbons FCSs appear to be superior to the other 2 FCSs.

Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings

The hindfoot consists of the talus and calcaneus, spans the tibiotalar to transverse tarsal joints, and is critical for support of body weight and absorption and transfer of physiologic loads during bipedal movements. Hindfoot fractures account for approximately 17% of foot and ankle fractures, with calcaneal fractures being more common than talar fractures. Hindfoot fractures are usually caused by high-impact axial loads such as falls from heights and motor vehicle accidents, and understandably, they are often seen in patients with polytrauma. Long term, these fractures have implications in development of posttraumatic osteoarthrosis with associated pain and stiffness, affecting daily living activities. An overview of the talus and calcaneus is presented, with emphasis on fractures with articular involvement-namely, the tibiotalar and subtalar joints. Articular talar and calcaneal injuries can also alter hindfoot alignment, causing ankle and foot function abnormalities. Optimal treatment-that is, restoration of articular surfaces and hindfoot alignment followed by rigid fixation until fracture union-is dependent on an accurate understanding of the injury that is well depicted with imaging, radiography and CT in particular. The discussion of talar and calcaneal fractures includes a review of the normal anatomy, epidemiologic factors, classification systems, and imaging and pathologic-anatomic features of common injury patterns. This review is intended to aid surgical management and restoration of articular and hindfoot alignment for optimal ankle and foot function, thereby reducing patient morbidity in these often devastating injuries. ^©RSNA, 2022.

Management of displaced intra-articular calcaneal fractures; current concept review and treatment algorithm

Calcaneum fractures are debilitating injuries with high complication rates and poor functional outcomes after both operative and non-operative management. The optimal management of such fractures is still highly debated in the literature with conflicting evidence on the preferred management of displaced intra-articular calcaneum fractures (DICAF). This article reviews the current concepts in the management of DIACF.

Systematic Review of Operative vs Nonoperative Treatment of Displaced Intraarticular Calcaneal Fractures

Background:

Management of displaced intraarticular calcaneus fractures can be operative or nonoperative. Several randomized and case-controlled trials have been recently conducted in order to reach a consensus. The purpose of this analysis is to provide recommendations for the management of these injuries based on the best available clinical evidence.

Methods:

An up-to-date search was conducted using predefined eligibility criteria. The Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) was followed. Randomized and prospective clinical trials were only included after agreement among all authors. Relevant literature was appraised for methodologic quality using the Cochrane collaboration tool for the randomized controlled trials (RCTs) and Newcastle Ottawa Score for the prospective trials. Outcome measures included American Orthopaedic Foot & Ankle Society ankle-hindfoot score, visual analog scale score, return to activity, complications, residual pain, and development of arthritis. RevMan, version 5.3.5 software, was used for data analysis. A P value of <.05 was considered statistically significant, and CIs were set at 95%.

Results:

A total of 13 studies and 1251 patients were included in our analysis. This involved 10 RCTs and 3 prospective clinical trials. Shoe fitting problems and failure to return to activity favored the operative group. No other studied variables showed clear superiority of a specific treatment approach.

Conclusion:

The best evidence available at this time favors an advantage to operative treatment. Patients should be informed that the clear differences are centered on comfort of shoe wear and return to desired activity level.Level of Evidence: Level II, meta-analysis of RCT and Prospective Cohort studies.

Cannulated cancellous screw fixation for the management of sustentaculum tali fracture: A case report

INTRODUCTION

An isolated sustentaculum tali fracture is a rare manifestation of orthopaedic injury involving the supporting bone of the middle calcaneal facet. Globally, the incidence is estimated to be less than 1% of all calcaneus fractures.

PRESENTATION OF CASE

We reported a 42-year-old man with persistent ankle pain and instability on the right foot following a week after a motorcycle accident. The Computed tomography evaluation showed an avulsion of the medial sustentaculum tali on the right calcaneus bone. An open reduction and internal fixation procedure was performed using two cannulated cancellous screws applied across the lateral wall through the sustentaculum bone medially. The subjective postoperative evaluation showed that the patient responded well and gradually returned to daily routine activities without pain and instability.

DISCUSSION AND CONCLUSION

Surgical approach using the cannulated cancellous screw to establish a firm fixation of sustentaculum tali fracture fragment into calcaneus bone and to prevent pathological movement.

The value of Gissane`s angle in the population of Central Serbia

Background/Aim. Determining the value of Gissane?s angle (GA) plays a role in the diagnosis and prognosis of heel fractures, determining treatment methods, and assessing the outcome of surgical treatment. Normal values of the GA vary in relation to ethnicity, age, and gender of the examined group, which indicates its anthropometric significance. The aim of this study was to determine the range of normal GA values in the population of Central Serbia. Methods. GA was determined on lateral radiography of the foot of 145 subjects of both sexes (67 women and 78 men), with subjects divided into 6 age groups. The patients included in the study did not have a calcaneus fracture. The obtained results were processed in the Graph Pad program. Results. The average value of GA in Central Serbia was 110.8? ? 8.1?, ranging from 93? to 132.9?. The mean value of GA decreased with age, and no difference was observed between women and men, except in the youngest age group, where women had higher GA values than men. Conclusion. The results of the study showed a wide range of normal GA values, as well as the existence of a difference in subjects of different ages and sex.

3D printing-assisted extended lateral approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis

BACKGROUND

Three-dimensional (3D) printing technology has developed rapidly in orthopaedic surgery and effectively achieves precise and personalized surgery. The purpose of this meta-analysis was to assess the efficacy of 3D printing technology in the management of displaced intra-articular calcaneal fractures (DICFs) by extended lateral approach (ELA).

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Library, CNKI, VIP, and VANFUN databases were searched up to October 2020. All clinical studies comparing traditional surgery and 3D printing-assisted surgery in the management of DICFs were obtained, evaluating the quality of the included studies and extracting data. For each study, we assessed odds ratios (ORs), standard mean difference (SMD), and 95% confidence interval (95% CI) to assess and synthesize the outcomes.

RESULTS

Three RCTs and nine retrospective studies involving 732 patients were included met our inclusion criteria with 366 patients in the 3D group and 366 patients in the conventional group. The meta-analysis showed that there were significant differences of the operative time in the 3D group [SMD =  - 1.86, 95% CI (- 2.23, - 1.40), P < 0.001], intraoperative blood loss [SMD =  - 1.26, 95% CI (- 1.82, - 0.69), P < 0.001], the number of intraoperative X-ray exposures [SMD =  - 0.66, 95% CI (- 1.20, - 0.12), P < 0.001], postoperative complications [OR = 0.49, 95% CI (0.31, 0.79), P < 0.001], excellent and good rate of calcaneal fracture outcome [OR = 4.09, 95% CI (2.03, 8.22), P < 0.001].

CONCLUSION

The current study indicates that 3D printing-assisted ELA surgery showed a better rate of excellent and good outcome, shorter operation time, less intraoperative blood loss, fewer intraoperative fluoroscopies, fewer complications. Besides, there is still a need for large-sample, high-quality, long-term randomized controlled trials to confirm the conclusion.

Computed Tomography for Calcaneal Fractures: Adding Value to the Radiology Report

Computed tomography (CT) is nowadays the cornerstone for fracture pattern delineation in calcaneal fracture, and for operative planning. It is often challenging for radiologists in generating clinically oriented and meaningful CT reports to the orthopedic surgeon. The article aims to review the commonly encountered calcaneal injuries and highlight the key points in the description of these injuries and implications of the underlying classification system with respect to the surgeon's perspective. A thorough understanding of the pathoanatomy and potential complications of calcaneal fractures also helps radiologists in tailoring the radiology report in contribution to overall patient's management and prognostication. By doing so, we suggest ways in which the radiologists can add value to the radiology report.

An evaluation of the efficacy of the locked plate with bone grafting in Sanders type III and IV intra-articular calcaneus fractures

Objective:

To demonstrate the efficacy of locking plate osteosynthesis performed by an L-shaped lateral approach in patients with Sanders type III and IV intra-articular calcaneal fractures with posterior facet displacement.

Methods:

Fifty-three patients with Sanders type III or IV unilateral calcaneal fractures treated with locking plates and additional bone grafting were included in the study. Böhler and Gissane angles, and heel height values were measured on the radiological examinations. Clinical results of the patients were evaluated using the American Orthopaedic Foot and Ankle Society and Maryland evaluation criteria. The presence of arthrosis was investigated with Broden’s view. Preoperative and postoperative values were evaluated.

Results:

The mean Gissane angle was 119.32°, the mean Böhler angle was 9.47° and the mean heel height was 40.82 mm on radiographs at initial presentation of the patients. The mean Gissane angle was 114.63°, the mean Böhler angle was 23.33° and the mean heel height was 47.84 mm on the early postoperative radiographs of the patients. In patients, a mean 4.69° recovery was achieved in the Gissane angle, 13.86° in Böhler angle and 7.02 mm in heel height. On the most recent follow-up, Böhler angle was 21.49°, Gissane was 114.88° and the mean heel height was 46.95 mm. The mean American Orthopaedic Foot and Ankle Society score and Maryland score were 86.91 and 86.53, respectively, on the last follow-up.

Conclusion:

Internal fixation and grephonage using low-profile locking plates provides good functional results to patients since it facilitates anatomic restoration of the subtalar joint and correction of calcaneal height, width and varus/valgus heel.

Automatic analysis system of calcaneus radiograph: Rotation-invariant landmark detection for calcaneal angle measurement, fracture identification and fracture region segmentation

BACKGROUND AND OBJECTIVE

Calcaneus is the largest tarsal bone to withstand the daily stresses of weight-bearing. The calcaneal fracture is the most common type in the tarsal bone fractures. After a fracture is suspected, plain radiographs should be taken first. Bohler's Angle (BA) and Critical Angle of Gissane (CAG), measured by four anatomic landmarks in lateral foot radiograph, can guide fracture diagnosis and facilitate operative recovery of the fractured calcaneus. This study aims to develop an analysis system that can automatically locate four anatomic landmarks, measure BA and CAG for fracture assessment, identify fractured calcaneus, and segment fractured regions.

METHODS

For landmark detection, we proposed a coarse-to-fine Rotation-Invariant Regression-Voting (RIRV) landmark detection method based on regressive Multi-Layer Perceptron (MLP) and Scale Invariant Feature Transform (SIFT) patch descriptor, which solves the problem of fickle rotation of calcaneus. By implementing a novel normalization approach, the RIRV method is explicitly rotation-invariance comparing with traditional regressive methods. For fracture identification and segmentation, a convolution neural network (CNN) based on U-Net with auxiliary classification head (U-Net-CH) is designed. The input ROIs of the CNN are normalized by detected landmarks to uniform view, orientation, and scale. The advantage of this approach is the multi-task learning that combines classification and segmentation.

RESULTS

Our system can accurately measure BA and CAG with a mean angle error of 3.8^○ and 6.2^○ respectively. For fracture identification and fracture region segmentation, our system presents good performance with an F1-score of 96.55%, recall of 94.99%, and segmentation IoU-score of 0.586.

CONCLUSION

A powerful calcaneal radiograph analysis system including anatomical angles measurement, fracture identification, and fracture segmentation can be built. The proposed analysis system can aid orthopedists to improve the efficiency and accuracy of calcaneus fracture diagnosis.

Evaluating Short-Term Outcomes Post-Intra-Articular Calcaneal Fracture Fixation via a Sinus Tarsi Approach in a Non-Exclusively Selected Cohort

Management of intra-articular calcaneal fractures remains a debated topic in orthopedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and postoperative fracture geometry with computed tomography used for preoperative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Fifty-eight intra-articular calcaneal fractures (53 patients; 5 bilateral, mean age = 46.91 years) with a mean follow-up of 35.4 months (6-57) were included. Five patients (9.4%) had wound complications; 2 superficial (3.7%), 3 deep (5.6%); 4 of whom were smokers. Smokers were statistically more likely to have wound infections than nonsmokers (p = .04). Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of postoperative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.

Does the position of a sustentacular screw influence the stability of a plate osteosynthesis of a calcaneal fracture? A biomechanical study

The purpose of the study was to compare the stability of the plate osteosyntheses of intra-articular calcaneal fractures using various types of a sustentacular screw insertions. A geometrical model of a calcaneal fracture was created. The fracture was fixed with a plate and screws with a uniform distribution. The individual models differed regarding the position of the sustentacular screw. The screw was inserted using three different variants: Model A: into the tip of sustentaculum tali, Model B: under the sustentaculum tali, and Model C: into the inferior peripherial rim of the sustentacular fragment. In all three variants, the screw was either locked into the plate via threads or unlocked. The model was loaded with force in the vertical direction. The stiffness of individual models was evaluated using the finite element method, which was expressed as the maximum force (F_max) that the system was able to transmit and by determining the magnitude and distribution of reduced stress (σ_red) on the individual parts of the model of a fixed calcaneal fracture. The greatest stiffness of the system was observed in the Model B (F_max = 335.8 N). The least stiffness was observed in Model C (F_max = 296.3 N). This model also produced the greatest load on bone tissue was observed (σ^max_red = 67.5 MPa). The least load on bone tissue was measured in Model B (σ^max_red = 53.7 MPa). The load on the plate was similar in all three models (814.0-820.0 MPa). The analyses suggest that in a plate osteosynthesis of a calcaneal fracture, the insertion of a sustentacular screw under the tip of the sustentaculum tali is acceptable in terms of osteosynthesis stability. This sustentacular screw position reduces the risk of the screw penetrating into the talocalcaneal joint.

Sanders classification of calcaneal fractures in CT images with deep learning and differential data augmentation techniques

BACKGROUND

Classification of the type of calcaneal fracture on CT images is essential in driving treatment. However, human-based classification can be challenging due to anatomical complexities and CT image constraints. The use of computer-aided classification system in standard practice is additionally hindered by the availability of training images. The aims of this study is to 1) propose a deep learning network combined with data augmentation technique to classify calcaneal fractures on CT images into the Sanders system, and 2) assess the efficiency of such approach with differential training methods.

METHODS

In this study, the Principle component analysis (PCA) network was selected for the deep learning neural network architecture for its superior performance. CT calcaneal images were processed through PCA filters, binary hashing, and a block-wise histogram. The Augmentor pipeline including rotation, distortion, and flips was applied to generate artificial calcaneus fractured images. Two types of training approaches and five data sample sizes were investigated to evaluate the performance of the proposed system with and without data augmentation.

RESULTS

Compared to the original performance, use of augmented images during training improved network performance accuracy by almost twofold in classifying Sanders fracture types for all dataset sizes. A fivefold increase in the number of augmented training images improved network classification accuracy by 35%. The proposed deep CNN model achieved 72% accuracy in classifying CT calcaneal images into the four Sanders categories when trained with sufficient augmented artificial images.

CONCLUSION

The proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of computer-aided system in assisting physicians in evaluating calcaneal fracture types.

Peroneal Tendon Subluxation and Dislocation in Calcaneus Fractures

The present study investigated the relationship between type of calcaneal fractures and subluxation or dislocation of peroneal tendon. Also, we investigated clinical outcomes of patients with both calcaneal fractures and dislocations or subluxations of peroneal tendons in early surgical treatments (at the time of surgery for calcaneal fractures) and delayed surgical treatment (at the time of surgery for calcaneal plate removal) for dislocations or subluxations of peroneal tendons. We included 151 patients with calcaneal fractures who were followed for ≥2 years after surgery. Among them, 21 cases (13.9%) required reduction for peroneal tendon subluxation or dislocation. Reductions of peroneal tendons were performed at the time of surgery for calcaneal fractures in 11 cases, whereas the other 10 cases were performed during surgery for calcaneal implant removal. As classified by Essex-Lopresti, 94 cases (62.3%) were joint depression type and 17 (18.1%) were accompanied by dislocations or subluxations of peroneal tendons, whereas 57 (37.7%) were tongue type and 4 (7.0%) were accompanied by dislocations or subluxations of peroneal tendons. As classified by the Sanders system, 96 cases (63.6%) were Sanders A fracture lines, and 18 (18.8%) were accompanied by dislocations or subluxations of peroneal tendons. In 55 cases (36.4%) without Sanders A fracture lines, 3 (5.5%) were accompanied by dislocations or subluxations of peroneal tendons. In conclusion, calcaneal fractures with peroneal tendon dislocations are more common in joint depression type and Sander A type. Also, after a ≥2-year follow-up period, there were no significant differences in visual analog scale or foot and ankle outcome score whether reduction of peroneal tendons was done with reduction of fracture or removal of implant of calcaneus.

Simplifying the complicated heel-an emergency imaging approach to calcaneal fractures

The calcaneum is the most inferior and largest tarsal bone and supports the axial load of the weight of the body. Calcaneal fractures formulate 60% of the tarsal fractures and are frequently encountered in almost all trauma centres. It becomes imperative to understand and report calcaneal fractures in a structured fashion for better clinical and treatment outcomes for the patients. Radiologists should be well acquainted with calcaneal fractures and their various classifications and should develop an algorithmic approach for diagnosing and reporting heel fractures.

Imaging the patient with heel pain

Heel pain is a common presentation in primary care and affects a wide range of the population but predominantly elderly, obese and athletic patients. History and clinical assessment are paramount in the management of this condition but the presentation can confound clinicians, necessitating the use of imaging to confirm or clarify the diagnosis when there is clinical uncertainty. This article illustrates the various conditions producing heel pain to help clinicians determine the appropriate imaging modality to image the common causes of heel pain. A linked article detailing the management of heel pain is included in this issue ( https://doi.org/10.12968/hmed.2019.80.4.196 ).

Real-Time Automated Segmentation and Classification of Calcaneal Fractures in CT Images

Calcaneus fractures often occur because of accidents during exercise or activities. In general, the detection of the calcaneus fracture is still carried out manually through CT image observation, and as a result, there is a lack of precision in the analysis. This paper proposes a computer-aid method for the calcaneal fracture detection to acquire a faster and more detailed observation. First, the anatomical plane orientation of the tarsal bone in the input image is selected to determine the location of the calcaneus. Then, several fragments of the calcaneus image are detected and marked by color segmentation. The Sanders system is used to classify fractures in transverse and coronal images into four types, based on the number of fragments. In the sagittal image, fractures are classified into three types based on the involvement of the fracture area. The experimental results show that the proposed method achieves a high precision rate of 86%, with a fast computational performance of 133 frames per second (fps), used to analyze the severity of injury to the calcaneus. The results in the test image are validated based on the assessment and evaluation carried out by the physician on the reference datasets.

Identification of Postoperative Step-Offs and Gaps With Brodén's View Following Open Reduction and Internal Fixation of Calcaneal Fractures

BACKGROUND

To date, there is no consensus regarding which postoperative imaging technique should be used after open reduction and internal fixation of an intra-articular calcaneal fracture. The aim of this study was to clarify whether Brodén's view is sufficient as postoperative radiologic examination to assess step-offs and gaps of the posterior facet.

METHODS

Six observers estimated the size of step-offs and gaps on Brodén's view in 42 surgically treated intra-articular calcaneal fractures. These findings were compared to postoperative CT scans (gold standard). Inter- and intraobserver reliability were calculated and compared using intraclass correlation coefficients (ICCs).

RESULTS

An accuracy of approximately 75% for both step-offs and gaps was found in foot and ankle experts. Less experienced observers correctly identified step-offs and gaps in approximately 62% of cases on fluoroscopy and in 48% on radiographs. Interobserver reliability for intraoperative fluoroscopy as well as postoperative radiographs was fair for step-offs, whereas interobserver reliability for gaps was excellent. Intraobserver reliability showed a low level of agreement for intraoperative fluoroscopy, in contrast to postoperative radiographs with excellent agreement for step-offs and good agreement for gaps.

CONCLUSION

Our results show that especially for more experienced foot and ankle surgeons, in the majority of fractures, Brodén's view accurately showed step-offs and gaps following open reduction and internal fixation. Interobserver reliability showed a fair level of agreement for step-offs and excellent agreement for gaps. Intraobserver reliability was only enough for radiographs, not for fluoroscopy.

LEVEL OF EVIDENCE

Level IV, case series.

Deep learning and SURF for automated classification and detection of calcaneus fractures in CT images

BACKGROUND AND OBJECTIVES

The calcaneus is the most fracture-prone tarsal bone and injuries to the surrounding tissue are some of the most difficult to treat. Currently there is a lack of consensus on treatment or interpretation of computed tomography (CT) images for calcaneus fractures. This study proposes a novel computer-assisted method for automated classification and detection of fracture locations in calcaneus CT images using a deep learning algorithm.

METHODS

Two types of Convolutional Neural Network (CNN) architectures with different network depths, a Residual network (ResNet) and a Visual geometry group (VGG), were evaluated and compared for the classification performance of CT scans into fracture and non-fracture categories based on coronal, sagittal, and transverse views. The bone fracture detection algorithm incorporated fracture area matching using the speeded-up robust features (SURF) method, Canny edge detection, and contour tracing.

RESULTS

Results showed that ResNet was comparable in accuracy (98%) to the VGG network for bone fracture classification but achieved better performance for involving a deeper neural network architecture. ResNet classification results were used as the input for detecting the location and type of bone fracture using SURF algorithm.

CONCLUSIONS

Results from real patient fracture data sets demonstrate the feasibility using deep CNN and SURF for computer-aided classification and detection of the location of calcaneus fractures in CT images.

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.

Pathoanatomy of the Tongue-Type Calcaneus Fracture: Assessment Using 2- and 3-Dimensional Computed Tomography

OBJECTIVE

To define the pathoanatomy of the tongue-type calcaneus fracture and assess the appropriateness of percutaneous techniques in addressing all planes of deformity in this injury.

DESIGN

Retrospective cohort.

SETTING

ACS Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-six displaced Sanders 2B and 2C tongue-type calcaneus fractures identified from an initial cohort of 1118 calcaneus fractures treated over a 16-year period.

MAIN OUTCOME MEASUREMENTS

We reviewed cross-sectional imaging and documented the presence of a varus/valgus (coronal plane) or adduction/abduction (axial plane) position of the tongue fragment in relation to the intact posterior facet, with greater than 10 degrees of angulation being diagnostic of displacement.

RESULTS

When assessing for displacement and angulation in the coronal plane, 98% of tongue fragments were either in a position of valgus (77%) or neutral (21%), with a mean valgus angulation of 17.3 degrees. In the axial plane, 98% of tongue pieces were in a position of adduction (64%) or neutral (34%), with an average angulation into adduction of 15.0 degrees. Sanders 2B fractures were more likely to be in a position of valgus and adduction than those of 2C fractures.

DISCUSSION

The tongue-type calcaneus fracture most often displaces into a position of plantarflexion, valgus, and adduction. Knowledge of this deformity may aid in achieving successful closed reduction when using the Essex-Lopresti maneuver or other less invasive techniques.

Calcaneal fractures: radiological and CT evaluation and classification systems

Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)

Patterns of superior articular facet and morphometric study of Nepalese dry Calcanei

Introduction: The three important articulating facets in the superior aspect of the calcaneum are the anterior, middle and posterior articulating facet. Descriptions of the posterior talar facet on the dorsum of the calcaneus are similar. However, there are differences when facet for the head of the talus on the calcaneus is considered. Four types (pattern I, II, III, IV) of calcaneus having different talar facets are reported in the literature. Objective: This study aims to describe the calcaneal bone by measuring its dimensions and determining the variations of talar articulating facet. Materials and methods: Overall 142 calcanei (68 right, 74 left) with unidentified gender, were assessed. Vernier calipers and Goniometry were used. Results: In this study Type I calcaneus (56.34 %) was the most prevalent type with Type II calcaneus (42.25 %) as the second most common type followed by Type IV (1.41 %) as the third frequently found pattern of calcaneus. Conclusion: Type I calcaneus was the most frequent type in the Nepalese showing similarity to the results of the studies performed in Spanish, American, African and various Indian population. Bohler's angle of the right and left calcanei was 34.92° ± 8.09° and 35.4° ± 7.30° respectively. Development of database of calcaneal measurements in various populations is recommended.

Human Foot-Ankle Injuries and Associated Risk Curves from Under Body Blast Loading Conditions

Under body blast (UBB) loading to military transport vehicles is known to cause foot-ankle fractures to occupants due to energy transfer from the vehicle floor to the feet of the soldier. The soldier posture, the proximity of the event with respect to the soldier, the personal protective equipment (PPE) and age/sex of the soldier are some variables that can influence injury severity and injury patterns. Recently conducted experiments to simulate the loading environment to the human foot/ankle in UBB events (~5ms rise time) with variables such as posture, age and PPE were used for the current study. The objective of this study was to determine statistically if these variables affected the primary injury predictors, and develop injury risk curves. Fifty belowknee post mortem human surrogate (PMHS) legs were used for statistical analysis. Injuries to specimens involved isolated and multiple fractures of varying severity. The Sanders classification was used to grade calcaneus severity and the AO/OTA classification for distal tibia fracture. Injury risk curves were developed using survival regression analysis and covariates were included whenever statistically significant (p<0.05). With peak force as the injury predictor and age and boot as covariates, the model was statistically significant. However, boot use changed the pattern of injury from predominately calcaneus to predominantly tibia. Also, a severity based risk curve showed tolerance differences between calcaneus (minor/major) and tibia (severity-I/ severity- II) injuries. The tibia demonstrated higher tolerance as compared to either minor or major calcaneus injury. These findings can play a vital role in development of safety systems to mitigate injuries to the occupant.

Demographics, Mechanisms of Injury, and Concurrent Injuries Associated With Calcaneus Fractures: A Study of 14 516 Patients in the American College of Surgeons National Trauma Data Bank

BACKGROUND

This study uses the American College of Surgeons National Trauma Data Bank (NTDB) to update the field on the demographics, injury mechanisms, and concurrent injuries among a national sample of patients admitted to the hospital department with calcaneus fractures.

METHODS

Patients with calcaneus fractures in the NTDB during 2011-2012 were identified and assessed.

RESULTS

A total of 14 516 patients with calcaneus fractures were included. The most common comorbidity was hypertension (18%), and more than 90% of fractures occurred via traffic accident (49%) or fall (43%). A total of 11 137 patients had concurrent injuries. Associated lower extremity fractures had the highest incidence and occurred in 61% of patients (of which the most common were other foot and ankle fractures). Concurrent spine fractures occurred in 23% of patients (of which the most common were lumbar spine fractures). Concurrent nonorthopaedic injuries included head injuries in 18% of patients and thoracic organ injuries in 15% of patients.

CONCLUSION

This national sample indicates that associated injuries occur in more than three quarters calcaneus fracture patients. The most common associated fractures are in close proximity to the calcaneus. Although the well-defined association of calcaneus fractures with lumbar spine fractures was identified, the data presented highlight additional strong associations of calcaneus fractures with other orthopaedic and nonorthopaedic injuries.

LEVELS OF EVIDENCE

Prognostic, Level III: Retrospective review of a prospectively collected cohort.

Multiple abnormalities in the feet and associated changes elsewhere in the skeleton: The case of 3A-7 from a Capsian Site in Algeria

A skeleton with a number of abnormalities is described involving full discussion of alternative diagnoses. In this complex case, the primary diagnosis is of avulsion of the stem of the bifurcate ligament causing a fracture of the anterior process of the calcaneus. The bilateral fracture identified in Skeleton 3A-7 from Site 12, a Capsian site in Algeria, is a result of the feet being inverted and plantar flexed: the fracture is prone to non-union, which is asymmetrical here. There is also a separate anatomical variation of the feet, 3rd cuneiform and 3rd metatarsal coalition, which was not the cause of trauma. The bifurcate ligament is a major stabilizer of the lateral transverse talar joint, and the trauma could lead to further issues: however, multiple other traumatic changes in 3A-7 most likely occurred at the same time, rather than as the result of pre-existing foot trauma. The asymmetry of the calcaneal condition and asymmetry of the sequelae of the original trauma led to long bone asymmetry, the result of locomotor difficulties.

The effect of ankle posture on the load pathway through the hindfoot

The foot–ankle complex is frequently injured in a wide array of debilitating events such as car crashes. Numerical models and experimental tests have been used to assess injury risk, but most do not account for the variations in ankle posture that frequently occur during these events. In this study, the positions of the bones of the foot–ankle complex (particularly, the hindfoot) were quantified over a range of postures. Computed tomography scans were taken of a male cadaveric leg under axial loading with the ankle in five postures in which fractures are commonly reported. The difference in the location of the talus and calcaneus between the neutral and each repositioned posture was quantified, and substantial rotations and displacements were observed for all postures tested (talus: 3°–21.5°, 1.5–10.5 mm; calcaneus: 10°–20°, 1.5–24.5 mm). Strains were also recorded at six locations on bones of the ankle during testing and were found to be highest in the calcaneus during inversion-external rotation and highest in the talus during eversion-external rotation. Postural changes likely affect the load pathway of the foot–ankle complex, potentially altering the stress and strain fields from that of the neutral case and changing the location of fracture. This highlights the need for injury-predicting studies examining the effect of these positional changes and to develop revised injury criteria accounting for the most vulnerable conditions.

Is arthroscopic assisted percutaneous screw fixation as good as open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures?

BACKGROUND

This study compares the outcomes of calcaneal fracture surgery after open reduction internal fixation and plating (ORIF) versus arthroscopic assisted percutaneous screw fixation (APSF).

METHODS

Group I (N=12) underwent ORIF. Group II (N=15) underwent APSF. Anthropometric data, pre and post-operative stay, complications and duration off work were recorded in this retrospective case cohort study. Radiographs were analyzed for Bohler's, Gissane's angle and Sanders' classification. AOFAS Hindfoot and SF 36 scores were collected at final follow-up.

RESULTS

Anthropometric data, Bohler's and Gissane's angles, AOFAS and SF 36 scores were not significantly different. Pre-operative duration was 12.3 days in ORIF and 6.9 days in APSF. Post-operative duration was 7.3 days vs 3.8 days. Duration off work was 6.2 months vs 2.9 months.

CONCLUSION

The APSF group was able to have surgery earlier, go home faster, and return to work earlier. This study was not powered to demonstrate a difference in wound complication rates.

Surgical complications of intra-articular calcaneal fracture treatment

Introduction: The authors present complications following surgical treatment of intra-articular calcaneus fractures, in regards to the surgical technique employed, based on their own clinical material. Materials and methods: The techniques analyzed included the Westhues’ technique and its modifi cation with additional bone stabilization by Kirschner wires and the percutaneous stabilization by Rapala. The research material covered the years from 1990 to 2012 and consists of 82 operated patients - 68 men (83%) and 14 women (17%). Analyzed calcaneus fractures were divided using the Essex-Lopresti classifi cation. Results: The authors of the article indicate that the most frequently registered complications of surgical treatment of intra-articular calcaneus fractures in early observation were thromboembolic complications and local infl ammatory reactions of the skin at the point of incision and placing the stabilizing material. During the long-term follow-up, the post-thrombotic syndrome and algodystrophic disorders were the most common. Conclusions: Factors contributing to the occurrence of the complications registered were fracture morphology, fixation of bone fragments by an excessive number of stabilizing materials and prolonged immobilization of the operated limb. Cite this article as: Golec P., Tomaszewski K.A., Nowak S., Dudkiewicz Z. Surgical complications of intra-articular calcaneal fracture treatment. Med Rehabil 2016; 20(2): 25-30.

Calcaneal Tuberosity Fixation Using a Locking Compression Hook Plate

Calcaneal tuberosity fractures account for 1% to 3% of all calcaneal fractures. Surgical fixation is particularly challenging owing to osteoporosis and numerous comorbidities and risk factors in this patient population. Numerous techniques have been proposed; however, we describe the use of a locking compression hook plate in the treatment of type 2 fracture patterns. This has the advantage of providing stable fixation in osteoporotic bone, avoiding the disadvantages of soft tissue and metalwork irritation that have been described with other techniques.

Statistical, Morphometric, Anatomical Shape Model (Atlas) of Calcaneus

The aim was to develop a morphometric and anatomically accurate atlas (statistical shape model) of calcaneus. The model is based on 18 left foot and 18 right foot computed tomography studies of 28 male individuals aged from 17 to 62 years, with no known foot pathology. A procedure for automatic atlas included extraction and identification of common features, averaging feature position, obtaining mean geometry, mathematical shape description and variability analysis. Expert manual assistance was included for the model to fulfil the accuracy sought by medical professionals. The proposed for the first time statistical shape model of the calcaneus could be of value in many orthopaedic applications including providing support in diagnosing pathological lesions, pre-operative planning, classification and treatment of calcaneus fractures as well as for the development of future implant procedures.

Imaging of the subtalar joint

Imaging of the subtalar joint can be challenging because of its complex planar anatomy. This article reviews the anatomy and common anatomic variants as seen with different imaging techniques. Although radiography remains the initial mode of imaging, computed tomography and MRI are frequently needed to better delineate the joint anatomy and improve the sensitivity and the specificity of detection of joint pathology. A short review of arthrographic techniques and various examples of imaging of common pathology involving this joint are also included.

Operative vs nonoperative treatment of displaced intra-articular calcaneal fracture: A meta-analysis of randomized controlled trials

AIM: To investigate clinical efficacy of displaced intra-articular calcaneal fracture (DIACF) following operation and nonoperation.

METHODS: Literature search was performed of PubMed and Cochrane Library by two independent authors to identify randomized controlled trials (RCTs) comparing operative vs nonoperative treatment of DIACF from inception to December 31^st, 2013. RCT quality was evaluated by the modified Jadad scale. Dichotomous variables were pooled using risk ratios by review manager 5.3 software. Fixed-effects or random-effects models were adopted with P > 0.05 or P≤ 0.05 for heterogeneity tests, respectively.

RESULTS: Eight RCTs comprising 767 cases met inclusion criteria. Results revealed that more surgically treated patients could resume pre-injury job (P = 0.006). No statistical differences were found between the two groups in residual pain (P = 0.33), shoe fitting problems (P = 0.07), limited walking distance (P = 0.56) or secondary late arthrodesis (P = 0.38). However, operative treatment was associated with a higher complication rate (P = 0.003). Subgroup analyses of specific complications revealed that except for a higher risk of superficial wound problems (P < 0.0001) in operative group, the two groups had similar complication rate in deep wound infection (P = 0.34), compartment syndrome (P = 0.46), thromboembolism (P = 0.32), reflex sympathetic dystrophy (P = 0.51) or traumatic arthritis secondary to DIACF (P = 0.43).

CONCLUSION: Current evidence demonstrates that compared with operative treatment, conservative treatment of DIACF lead to similar clinical outcomes regarding residual pain, shoe fitting, walking distance and secondary subtalar arthrodesis but a significantly lower complication rate.

Superior peroneal retinacular injuries in calcaneal fractures

Calcaneal fractures are injuries that occur generally as the result of high-energy mechanisms, and, as such, the presence of concurrent injuries should be suspected. The presence of peroneal tendon and superior retinacular injuries has been underreported. We sought to report the incidence of peroneal tendon pathologic features in our population of patients with calcaneal fractures, with emphasis on the method of identification. Furthermore, we sought to identify whether specific fracture patterns were more commonly associated with this pathologic finding. Of the 97 cases, 13 (13.4%) required repair of the superior peroneal retinaculum, 11 of which demonstrated the Sanders A fracture line. Our findings have demonstrated an incidence of pathologic features, in particular, with the presence of the Sanders A fracture line, that warrants attention to potentially help improve the outcome of these devastating injuries.

Calcaneal avulsion fractures: a case series of 33 patients describing prognostic factors and outcomes

BACKGROUND

The purpose of this study was to evaluate prognostic predictors of complications and need for secondary surgery in a series of calcaneal avulsion fractures.

METHODS

Thirty-three patients who sustained extra-articular calcaneal avulsion fractures from 2002 to 2011 were retrospectively identified. Main outcome measurement was need for secondary surgical procedures. Secondary complications such as soft tissue complications and loss of fixation were noted. Prognostic factors for outcome measures were identified.

RESULTS

There was a need for secondary operations in 12 cases. Of those, 10 (83%) had wound complications and 5 (41.7%) had failure of fixation. Two subjects required below knee amputation. Of the entire cohort of 33 patients, 13 (39.4%) had soft tissue complications. Of the 22 that underwent surgery, 6 (27%) had failure of fixation. Increased age was significantly associated with wound complications (P = .029). Hypothyroidism (P = .003), peripheral vascular disease (P = .022), and presence of more than one comorbidity (P = .005) were significantly associated with need for secondary surgical intervention. Skin compromise at presentation was significantly associated with soft tissue complication (P = .036) and failure of fixation (P = .046).

CONCLUSIONS

Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries.

LEVELS OF EVIDENCE

Prognostic, Level II: Retrospective Analysis.