Quality of Life and Clinical Evaluation of Calcaneoplasty with a Balloon System for Calcaneal Fracture at 5 Years of Follow-Up

Primary subtalar arthrodesis in displaced intra-articular calcaneal fracture: a systematic review

Calcaneus fractures are severe injuries often resulting from traumatic falls or motor vehicle accidents. Surgical treatment through open reduction and internal fixation (ORIF) is considered the standard approach for displaced intra-articular calcaneal fractures (DIACFs), but it is associated with many complications. Our study aimed to review the current literature available on primary subtalar arthrodesis (PSA) as a first-line treatment for DIACFs, mostly Sanders type IV. In this study, we conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The keywords were searched in PubMed, MEDLINE and the Cochrane Library. This review included articles where primary arthrodesis was performed in calcaneal fractures, with or without associated implants. Nine articles were included in the review. The total population comprised 184 patients with 192 calcaneal fractures. The mean age was 44.9 ± 6.9 years old. The mean follow-up period was 30.28 ± 15.29 months when reported. The mean time to surgery was 13.33 ± 7.02 days from injury. All studies reported a good fusion rate (between 94 and 100%) and an average fusion time of 4.05 ± 2.19 months. The mean American Orthopedic Foot & Ankle Society (AOFAS) score was 71.26 ± 8, and the mean Visual Analog Scale (VAS) score for pain was 3.26 ± 0.91. Primary arthrodesis of the subtalar joint for treating DIACFs, mostly Sanders type IV, provides good results due to the avoidance of further procedures, reduced postoperative pain, and a high rate of bony union. However, success heavily depends on factors such as patient comorbidities and addressing hindfoot deformity. Further studies with larger patient populations and more standardized protocols are necessary to draw definitive conclusions about the best management strategies for DIACFs. Systematic review, level III of evidence.

3D simulation of percutaneous sustentaculum tali screw insertion in calcaneal fractures

BACKGROUND

In calcaneal fractures, the percutaneous screw fixation (PSF) is currently considered to be the better choice, but it is difficult to accurately place the screw into the sustentaculum tali (ST) during the operation. In this study, the ideal entry point, angle, diameter and length of the screw were calculated by simulating the operation process.

METHODS

We retrospectively collected the calcaneus computed tomography (CT) scans of 180 adults, DICOM-formatted CT-scan images of each patient were imported into Mimics software to establish calcaneus model. Virtual screws were placed on the lateral of the posterior talar articular surface (PTAS), the lateral edge of the anterior process of calcaneus (APC), and the calcaneal tuberosity, respectively, the trajectory and size of the screws were calculated.

RESULTS

The mean maximum diameter of the PTAS screw was 42.20 ± 3.71 mm. The vertical distance between the midpoint of the APC optimal screw trajectory and the lowest point of the tarsal sinus was 10.67 ± 1.84 mm, and the distance between the midpoint of the APC optimal screw trajectory and the calcaneocuboid joint was 5 mm ~ 19.81 ± 2.08 mm. The mean maximum lengths of APC screws was 44.69 ± 4.81 mm, and the Angle between the screw and the coronal plane of the calcaneus from proximal to distal was 4.72°±2.15° to 20.52°±3.77°. The optimal point of the maximum diameter of the calcaneal tuberosity screw was located at the lateral border of the achilles tendon endpoint. The mean maximum diameters of calcaneal tuberosity screws was 4.46 ± 0.85 mm, the mean maximum lengths of screws was 65.31 ± 4.76 mm. We found gender-dependent differences for the mean maximum diameter and the maximum length of the three screws.

CONCLUSIONS

The study provides effective positioning for percutaneous screw fixation of calcaneal fractures. For safer and more efficient screw placement, we suggest individualised preoperative 3D reconstruction simulations. Further biomechanical studies are needed to verify the function of the screw.

Percutaneous balloon calcaneoplasty versus open reduction and internal fixation (ORIF) for intraarticular SANDERS 2B calcaneal fracture: Comparison of primary stability using a finite element method

INTRODUCTION

Fractures of the calcaneus are common, with 65% being intra-articular, which can lead to a major impairment of the patient's quality of life. Open reduction and internal fixation with locking plates can be considered as gold-standard technique but has a high rate of post-operative complications. Minimally invasive calcaneoplasty combined with minimally invasive screw osteosynthesis is largely drawn from the management of depressed lumbar or tibial plateau fractures. The hypothesis of this study is that calcaneoplasty associated with minimally invasive percutaneous screw osteosynthesis presents biomechanical characteristics comparable with conventional osteosynthesis.

MATERIALS AND METHODS

Eight hind feet were collected. A SANDERS 2B fracture was reproduced on each specimen, while four calcanei were reduced by a balloon calcaneoplasty method and fixed with a lateral screw, four others were manually reduced and fixed with conventional osteosynthesis. Each calcaneus was then segmented for 3D finite element modeling. A vertical load was applied to the joint surface in order to measure the displacement fields and the stress distribution according to the type of osteosynthesis.

RESULTS

Analyses of the intra-articular displacement fields showed lower overall displacements in calcaneal joints treated with calcaneoplasty and lateral screw fixation. Better stress distribution was found in the calcaneoplasty group with lower equivalent joint stresses. These results could be explained by the role of the PMMA cement as a strut, enabling better load transfer.

CONCLUSION

Balloon Calcaneoplasty combined with lateral screw osteosynthesis has biomechanical characteristics at least comparable to locking plate fixation in the treatment of SANDERS 2B calcaneal joint fractures in terms of displacement fields and stress distribution under the premise of anatomical reduction.

Predictive Factors of Poor Outcome in Sanders Type III and IV Calcaneal Fractures Treated with an Open Reduction and Internal Fixation with Plate: A Medium-Term Follow-Up

BACKGROUND

Consensus on the treatment for severely comminuted calcaneus fractures has yet to be found. This study aims to analyze the functional and radiological short- and medium-term outcomes of displaced calcaneus fractures of type III and IV treated with ORIF, and to identify, if present, the early predictors of unfavorable outcomes.

METHODS

Thirty-three calcaneal fractures were included, 23 type III and 10 type IV, according to Sanders classification. AOFAS scales for ankle and hindfoot and SF-12 were used. Böhler and Gissane angles were analyzed before and after surgery.

RESULTS

The minimum follow-up was six years. The mean AOFAS score at six months was 16.5 points (24.2 ± 10.8 vs 10.8 ± 9.5; p = 0.03) with better outcomes in patients with Sanders type III fractures. This difference decreased in the subsequent follow-up. Likewise, the mental and physical score of SF-12 had the same trend. Two wound infections and no deep infections were recorded in the Sanders type III fracture group. Instead, in the Sanders type IV group, there were four wound infections and one deep infection.

CONCLUSIONS

Clinical and radiological outcomes in Sanders Type III and Type IV calcaneus fractures treated with plate and screws were very similar in long-term follow-up. If ORIF provided better short- to medium-term follow-up in Sanders type III fracture, these benefits have been lost in six years. Polytrauma and psychiatric patients showed significantly lower clinical outcomes in long-term follow-up, appearing as the most reliable negative predictors.