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Shen L, Wang Q, Chen J, Jiang Z. Risk factor of postoperative incision infection after plate internal fixation of calcaneal fractures: a retrospective study. BMC Musculoskelet Disord 2022; 23:1091. [PMID: 36514037 DOI: 10.1186/s12891-022-06072-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This study aimed to investigate the risk factors for incision infection after plate internal fixation for calcaneal fractures by a traditional lateral L-shaped approach. METHODS The clinical data of 302 patients with calcaneal fractures who underwent surgical treatment in our hospital from January 2012 to June 2018 were retrospectively analysed, consisting of 177 males and 125 females. The enrolled patients were aged 21 to 75 years, with a mean age of 47.72 years. According to the Sanders classification, 108 patients were type II, 138 patients were type III, and 56 cases were type IV. A univariate analysis was conducted with sex, age, smoking history, history of diabetes, cause of injury, Sanders type, tension blisters, time from injury to surgery, preoperative haemoglobin, preoperative albumin, operation time, and bone grafting as possible risk factors. The factors with statistically significant differences were selected for multivariate binary logistic regression analysis. The clinical cut-off values of these risk factors were calculated using characteristic curves. RESULTS The follow-up lasted for at least 1 year for all patients, with a mean follow-up time of 15.8 months. The results demonstrated 7.9% (24/302) infection rate after plate internal fixation of calcaneal fractures by the traditional lateral L-shaped approach. Univariate analysis showed that a history of diabetes, preoperative albumin, preoperative haemoglobin, time from injury to surgery, and operation time were correlated with incision infection (p < 0.05). Additionally, multivariate regression analysis indicated that a shorter time from injury to surgery (OR = 1.475, 95% CI: 1.024-2.125, p = 0.037), lower preoperative albumin (OR = 1.559, 95% CI: 1.191-2.041, p = 0.001), and longer operation time (OR = 1.511, 95% CI: 1.219-1.874, p < 0.001) were risk factors for postoperative incision infection, and their cut-off values were 10.5 days, 38.5 g/L, and 84.5 minutes, respectively. CONCLUSION Longer preoperative stay and operation time were two risk factors for postoperative incision infection. However, lower preoperative albumin level is the highest risk factor in this study. TRIAL REGISTRATION The trial was registered in the China Clinical Trial Registry (ChiCTR2100047038).
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Affiliation(s)
- Lei Shen
- Department of orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, China
| | - Qiang Wang
- Department of orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, China
| | - Jun Chen
- Department of orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, China
| | - Zhenhuan Jiang
- Department of orthopaedics, the Yixing People's Hospital, 75 Road Tongzhenguan, Yixing, Jiangsu, China.
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Hou J, Zhang N, Chen G, Wang Q, Zhang S, Yang K, Zang H. Circular External Fixator Assisted Open Reduction Combined With Locking Plate Fixation for Intra-articular Comminuted Fractures of the Calcaneus. J Foot Ankle Surg 2022; 62:437-443. [PMID: 36404256 DOI: 10.1053/j.jfas.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 10/07/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
Comminuted fractures of the calcaneus are relatively common and generally require surgical treatment. The quality of fracture reduction is crucial. The extended lateral approach (ELA) can better expose the fracture end and facilitate the reduction of the fracture, while it has a higher risk of postoperative skin complications. In this study, the ELA was adopted, and the calcaneal comminuted fractures were treated with circular external fixator assisted reduction to achieve the purpose of good reduction of the fracture and fewer skin complications. During 64 months, a total of 61 cases of unilateral calcaneal fractures were treated by the same surgeon and followed up for 19.28 ± 5.28 months. During the operation, a circular external fixator was employed to fix the midfoot and the distal end of the tibia, and the calcaneal tubercle; then, the calcaneal tubercle was distracted to restore the 3-dimensional structure of the calcaneus. The ELA was utilized to reduce the articular surface fracture. The fracture was fixated with a locking plate. Postoperative radiographs were regularly reviewed. Meanwhile, Böhler's angle and Gissane's angle were measured. Visual analogue scale and American Orthopedic Foot and Ankle Society Score assessments were performed at the final follow-up. All fractures healed. The mean preoperative Böhler's angle was 9.3 ± 10.1 degrees; the mean Gissane's angle was 110.5 ± 14.7 degrees; the immediate postoperative mean Böhler's angle was 31.3 ± 5.5 degrees; mean Gissane's angle was 110.9 ± 5.9 degrees. Local superficial necrosis of surgical incision occurred in 2 cases, which healed well after dressing changes. Skin necrosis appeared in 1 case, where debridement and local flap transfer were performed. At the final follow-up, the mean visual analogue scale score was 1.48 ± 1.30, and the mean American Orthopedic Foot and Ankle Society Score was 90.16 ± 7.19. The ELA combined with a circular external fixator to assist in the reduction of calcaneal fractures achieved good reduction quality and effectively reduced postoperative complications.
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Affiliation(s)
- Jiguang Hou
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China.
| | - Nan Zhang
- Department of Anesthesiology, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Guodong Chen
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Qi Wang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Shenghua Zhang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Kun Yang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Hongwei Zang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
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Steelman K, Bolz N, Feria-Arias E, Meehan R. Evaluation of patient outcomes after operative treatment of intra-articular calcaneus fractures. SICOT J 2022; 7:65. [PMID: 34981738 PMCID: PMC8725541 DOI: 10.1051/sicotj/2021065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Percutaneous reduction with fixation and open reduction internal fixation are often used to treat intra-articular calcaneus fractures with no consensus on the preferred method. Open techniques have been associated with an increased risk of wound complications, while percutaneous techniques may result in inferior reduction capabilities. These injuries pose a challenge to patients as they often result in poor patient outcomes. We retrospectively analyzed patient outcomes of a single surgeon's experience in treating these injuries at a busy urban Level 1 trauma center. METHODS Patients with intra-articular calcaneus fractures managed operatively over 10 years with a minimum six-month follow-up were included. Patients were divided into two cohorts based on operative technique: closed reduction and percutaneous fixation (CRPF) or open reduction internal fixation (ORIF). Descriptive analysis of each cohort included postoperative infection, the need for repeat operations, development of post-traumatic subtalar arthritis, and reduction capabilities as assessed by Bohler's angle. RESULTS Sixty-two patients were included in this study, with 33 patients in the CRPF group and 29 patients in the ORIF group. Infection requiring a return to the operating room occurred in 1 (3%) CRPF and 7 (24%) ORIF patients. Instrumentation was removed in 23 (70%) CRPF and 9 (31%) ORIF patients. Clinical subtalar arthritis developed in 10 (30%) CRPF and 7 (24%) ORIF patients, requiring arthrodesis in 2 (6%) and 5 (17%) patients, respectively. Both techniques had acceptable restoration of Bohler's angle immediately postoperatively and at final follow-up. CONCLUSIONS Percutaneous reduction with fixation and open reduction internal fixation may both be considered for the surgical treatment of intra-articular calcaneal fractures. Indications for each technique may vary between surgeons, and each has its own set of risk factors and complications, however, both have been shown to result in an acceptable reduction. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Kevin Steelman
- Detroit Medical Center, Department of Orthopaedic Surgery, Harper University Hospital, 3990 John R, Detroit, MI 48201, USA
| | - Nicholas Bolz
- Detroit Medical Center, Department of Orthopaedic Surgery, Harper University Hospital, 3990 John R, Detroit, MI 48201, USA
| | - Enrique Feria-Arias
- Detroit Medical Center, Department of Orthopaedic Surgery, Harper University Hospital, 3990 John R, Detroit, MI 48201, USA
| | - Robert Meehan
- Detroit Medical Center, Department of Orthopaedic Surgery, Harper University Hospital, 3990 John R, Detroit, MI 48201, USA
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Varol A, Oc Y, Kilinc BE. An evaluation of the efficacy of the locked plate with bone grafting in Sanders type III and IV intra-articular calcaneus fractures. SAGE Open Med 2021; 9:20503121211040954. [PMID: 34434558 PMCID: PMC8381430 DOI: 10.1177/20503121211040954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/30/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Ali Varol
- Department of Orthopaedics and
Traumatology, Health Science University, Istanbul Fatih Sultan Mehmet Training and
Research Hospital, Istanbul, Turkey
| | - Yunus Oc
- Department of Orthopaedics and
Traumatology, Beykent University Faculty of Medicine, Istanbul, Turkey
| | - Bekir Eray Kilinc
- Department of Orthopaedics and
Traumatology, Health Science University, Istanbul Fatih Sultan Mehmet Training and
Research Hospital, Istanbul, Turkey
- Bekir Eray Kilinc, Department of
Orthopaedics and Traumatology, Health Science University, Istanbul Fatih Sultan
Mehmet Training and Research Hospital, Icerenkoy District Zubeyde Hanim Street
No: 1 B-43 PC:34752, Atasehir, Istanbul, Turkey.
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Reduced pre-operative skin oxygen saturation predicts revision after open reduction and internal fixation in calcaneal fractures : A reduced pre-operative oxygen saturation as measured by laser-Doppler spectrophotometry in 8 mm depth is associated with revision surgery after open reduction and internal fixation of calcaneal fractures through an extended lateral approach. INTERNATIONAL ORTHOPAEDICS 2021; 45:2355-2363. [PMID: 34357432 DOI: 10.1007/s00264-021-05157-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus. METHODS Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors. RESULTS Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64-1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision. CONCLUSION A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146.
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Park CH, Yan H, Park J. Randomized comparative study between extensile lateral and sinus tarsi approaches for the treatment of Sanders type 2 calcaneal fracture. Bone Joint J 2021; 103-B:286-293. [PMID: 33390020 DOI: 10.1302/0301-620x.103b.bjj-2020-1313.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. METHODS Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler's angle and calcaneal width, and posterior facet reduction. RESULTS Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). CONCLUSION The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286-293.
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Affiliation(s)
- Chul Hyun Park
- College of Medicine, Yeungnam University, Daegu, Republic of Korea, Daegu, Korea
| | - Hongfei Yan
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Jeongjin Park
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
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Seat A, Seat C. Lateral Extensile Approach Versus Minimal Incision Approach for Open Reduction and Internal Fixation of Displaced Intra-articular Calcaneal Fractures: A Meta-analysis. J Foot Ankle Surg 2021; 59:356-366. [PMID: 32131003 DOI: 10.1053/j.jfas.2019.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 08/12/2019] [Indexed: 02/03/2023]
Abstract
Treatment of displaced intra-articular calcaneal fractures remains controversial. Therefore, the purpose of this large meta-analysis was to report the outcomes of the lateral extensile approach versus the minimal incision approach including complications, anatomic reduction, functional outcomes, and timing and to report results when only randomized control trials were compared. Five electronic databases were searched for articles directly comparing the 2 above approaches. Inclusion criteria included articles published from January 2007 to April 2017, adults (>18 years old) with closed, Sanders type II or III fractures, mean follow-up time of ≥12 months, and ≥1 primary outcome reported. Seventeen randomized control trials and 10 retrospective studies were included. There were 2179 participants with 2274 fractures, and mean follow-up of 22.41 months. Our results revealed no statistically significant difference in Gissane's angle, calcaneal width, calcaneal length, deep infection, or subtalar stiffness. When taking into consideration only randomized control trials, there was no statistically significant difference between groups comparing postoperative Bohler's or Gissane's angle. There was a statistically significant difference in wound complications, superficial infection, sural nerve injury, visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores, operative time, time to operating room, calcaneal height, and postoperative Bohler's angle (when all studies were considered), all in favor of the minimal incision approach. These results remained statistically significant when only the randomized controlled trials were compared, with the exception of Bohler's angle and VAS and AOFAS scores. The results of this meta-analysis indicate that the minimal incision approach is a good alternative to the standard lateral extensile approach.
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Affiliation(s)
- Andrea Seat
- Resident PGY-3, Department of Podiatry, Jesse Brown VA Medical Center, Chicago, IL.
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Wilkinson BG, Marsh JL. Minimally Invasive Treatment of Displaced Intra-Articular Calcaneal Fractures. Orthop Clin North Am 2020; 51:325-338. [PMID: 32498951 DOI: 10.1016/j.ocl.2020.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Minimally invasive surgical techniques are increasingly used for definitive treatment of displaced intra-articular calcaneal fractures. These approaches have been shown to minimize soft tissue injury, preserve blood supply, and decrease operative time. These methods can be applied to all calcaneal fractures and have particular advantages in patients with higher than usual risks to the soft tissues. The literature suggests that results of limited soft tissue dissection approaches provide equivalent outcomes to those obtained with the extensile lateral approach. We predict that as imaging and other techniques continue to improve, more calcaneal fractures will be treated by these appealing safer techniques.
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Affiliation(s)
- Brandon G Wilkinson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - John Lawrence Marsh
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Zhan J, Hu C, Zhu N, Fang W, Jing J, Wang G. A modified tarsal sinus approach for intra-articular calcaneal fractures. J Orthop Surg (Hong Kong) 2020; 27:2309499019836165. [PMID: 30885093 DOI: 10.1177/2309499019836165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Plate fixation using traditional lateral L-shape approach for intra-articular calcaneal fractures is complicated by 30% of wound complications, and the lateral small incision techniques with a tarsal sinus approach cannot sufficiently address all the fragments. A modified tarsal sinus approach with combined advantages of traditional lateral L-shape and tarsal sinus approaches for the treatment of intra-articular calcaneal fractures was developed. METHOD This prospective study included 29 patients (13 Sanders type II and 16 type III) with calcaneal fractures were managed with this technique. Calcaneal height, width, length, Bohler's angle, and Gissane angle were measured preoperatively, postoperatively, and at 1-year follow-up. Functional outcomes were assessed based on American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score. RESULTS Twenty-nine patients with average follow-up time of 18 (range 13-29) months were included. The radiographs demonstrated significant corrections of the Bohler's angle and Gissane angle, calcaneal width, length, and height from preoperation to postoperation and 1-year follow-up. Among all follow-up patients, one case had skin necrosis but healed after dressing. Another case had symptoms of numbness in the sural innervation area, which disappeared after 5 months of physical therapy and drug therapy. One case showed degenerative changes of subtalar joint at 1-year follow-up. No other wound complications like incision infection (superficial or deep) and wound dehiscence occurred. At 1-year follow-up, the mean AOFAS score was 90.2 ± 17.7 (range 70-98) and the good and excellent rate was 89.7%. CONCLUSION The modified tarsal sinus approach in the treatment of Sander's type II and III calcaneal fractures allowed adequate reduction and rigid fixation with low incidence of wound complications. Compared to sinus tarsi approach, this technique required shorter learning curve and was more easily mastered by young orthopedic surgeons. Thus, it was worthy of application clinically.
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Affiliation(s)
- Junfeng Zhan
- 1 Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China.,2 Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Chuanzhen Hu
- 3 Department of Orthopaedics Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Nan Zhu
- 2 Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Wang Fang
- 2 Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Juehua Jing
- 2 Department of Orthopaedics, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Gang Wang
- 1 Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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Buzzi R, Sermi N, Soviero F, Bianco S, Campanacci DA. Displaced intra-articular fractures of the calcaneus: ORIF through an extended lateral approach. Injury 2019; 50 Suppl 2:S2-S7. [PMID: 30770121 DOI: 10.1016/j.injury.2019.01.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Displaced intra-articular calcaneal fractures (DIACF) represent a challenging and controversial issue in traumatology. Conservative treatment has been recommended to avoid surgical problems and complications. The final result, however, is often a painful malunioun of the calcaneus with peroneal impingement. Surgical treatment is gaining acceptance since it offers a chance to restore bone anatomy improving function as long as complications are avoided. MATERIAL AND METHOD We reviewed a series of 59 DIACF treated by a single surgeon during a 9 years period. A clinical and radiological follow-up was obtained in 44 cases (74,6%) (average of 5,5 years; range 2-9). There were 29 males and 15 females with an average age of 54 years (range 25-74). Patients were operated through an extended l-shaped lateral approach and fixation was achieved with lag screws and plate. Outcome measures method included the AOFAS score, the Maryland Foot Score, the Foot Function Index and the SF-36. RESULTS The average AOFAS score was 80,5 points. The result was excellent in 18 cases (40,9%), good in 14 cases (31,8%), fair in 10 cases (22,7%) and poor in 2 (4,6%). The mean score for pain was 33,5/40 points, for function 40/50 and for alignment 7/10. Pain was absent in 17 cases (38%), 19 patients (43%) had no functional limitations and 11 (25%) could walk on uneven ground without difficulties. The average FFI score was 25/100 points. The average MFS score was 89/100 points. Subtalar motion was reduced. Reconstruction of the calcaneus was anatomic in 20 cases (45,5%) with an improved clinical outcome. Eight patients (17%) had minor wound healing complications. Three patients (6,8%) required a subtalar arthrodesis after the procedure. CONCLUSIONS Ostheosytesis through an extended lateral approach restored bone morphology with a reasonable complications rate. The clinical results were good but a normal function and complete subtalar motion were rarely achieved.
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Affiliation(s)
- Roberto Buzzi
- Department of Traumatology and General Orthopedics, Azienda Ospedaliera Universitaria Careggi, Largo P. Palagi 1, 50134, Firenze, Italy
| | - Niccolò Sermi
- Department of Traumatology and General Orthopedics, Azienda Ospedaliera Universitaria Careggi, Largo P. Palagi 1, 50134, Firenze, Italy
| | | | - Stefano Bianco
- Department of Traumatology and General Orthopedics, Azienda Ospedaliera Universitaria Careggi, Largo P. Palagi 1, 50134, Firenze, Italy
| | - Domenico A Campanacci
- Department of Orthopedic Oncology, Azienda Ospedaliera Universitaria Careggi, Largo P. Palagi 1, 50134 Firenze, Italy.
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Hordyk PJ, Fuerbringer BA, Roukis TS. Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures. Clin Podiatr Med Surg 2019; 36:163-171. [PMID: 30784528 DOI: 10.1016/j.cpm.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Performing a thorough clinical evaluation following an acute displaced intra-articular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns.
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Affiliation(s)
- Peter J Hordyk
- Podiatric Medicine and Surgery Department, Gundersen Healthcare System, 1330 North Superior Avenue, Tomah, WI 54660, USA
| | - Brent A Fuerbringer
- Podiatric Medicine and Surgery Department, Gundersen Healthcare System, 1330 North Superior Avenue, Tomah, WI 54660, USA
| | - Thomas S Roukis
- Orthopaedic Center, Gundersen Health System, Mail Stop: CO2-006, 1900 South Avenue, La Crosse, WI 54601, USA.
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Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical). Clin Podiatr Med Surg 2019; 36:323-337. [PMID: 30784540 DOI: 10.1016/j.cpm.2018.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Soft tissue defects and wound healing complications related to calcaneus fractures may result in significant morbidity. The management of these soft tissue complications requires following reconstructive principles that provide the requisites for preservation of the injured limb and the maximization of function. Soft tissue complications are addressed with methods that commensurate with the degree of injury, ranging from local wound care to free flap reconstruction. With the orthoplastic approach to both bone and soft tissue plastic reconstruction, outcomes for limb salvage are greatly enhanced. This article discusses in detail the reconstructive ladder for soft tissue injuries associated with calcaneus fractures.
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Landsman A, Melick G, Pundu A. Intra-Articular Calcaneal Fractures: A Literature Review of Atraumatic Incisional Considerations. Clin Podiatr Med Surg 2019; 36:185-195. [PMID: 30784530 DOI: 10.1016/j.cpm.2018.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
When calcaneal fractures occur, the treating physician is faced with many decisions that are required to bring about a good clinical outcome. From a surgical perspective, decisions must be made regarding whether or not fixation is necessary, and if so, what will be used. Implicit in that thought process is planning of the surgical approach. This article shows that there are numerous considerations, including the level of edema, condition of the soft tissue envelope, posttrauma time, and circulation. These factors should play a significant role in planning the surgical incision, and may dictate the repair options available to the surgeon.
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Affiliation(s)
- Adam Landsman
- Division of Podiatric Surgery, Cambridge Health Alliance, Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02139, USA.
| | - Garrett Melick
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA
| | - Anusha Pundu
- Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA
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Yang Y, Zhou X, Zhang M, Zhou Y, Wang B, Yuan C. Lateral wall osteotomy combined with embedded biodegradable implants for displaced intra-articular calcaneal fractures. J Orthop Surg Res 2019; 14:74. [PMID: 30841896 PMCID: PMC6402087 DOI: 10.1186/s13018-019-1111-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background The extensile lateral approach (ELA) has been widely used to treat displaced intra-articular calcaneal fractures (DIACFs) and remains the gold standard procedure. Orthopedic surgeons are extremely concerned of the high rate of wound complications. This study intended to report a new surgical technique of the lateral wall osteotomy combined with an embedded biodegradable implant for treating DIACFs and assess clinical and radiological results. Methods From May 2013 to December 2015, a total of 17 patients with 19 calcaneal fractures underwent surgical treatment using our new technique. Radiographic images, computed tomography (CT) scans, and magnetic resonance (MR) images of the operative limb were obtained to assess fracture healing and biodegradable implant degradation. American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at the last follow-up was obtained to assess functional result for all cases. Böhler’s and Gissane’s angles, width, and height of the injured calcaneus were analyzed using preoperative and last follow-up radiographic images. Results All radiological parameters were significantly improved at the last follow-up, with an increase of 15.58°, 8.38°, and 7.65 mm in Böhler’s angle, Gissane’s angle, and calcaneal height, respectively, and a decrease of 2.51 mm in calcaneal width (p < 0.05). Mean AOFAS score at the last follow-up was 84.37 ± 9.98, with 9, 6, and 4 feet, having excellent, good, and fair rates, respectively. None had nonunion, delayed union, or malunion after a mean follow-up of 34.69 ± 5.22 months. One superficial infection occurred 6 days post-surgery. Conclusions Osteotomy of the lateral wall of the calcaneus allows tension-free suturing and avoids damage to penetrating branches of the lateral calcaneal artery (LCA). Biodegradable implants are easy to reshape and do not require surgical removal. However, they should be limited to Sander’s type II and III fractures only. Level of evidence Level IV, case series without controls
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Affiliation(s)
- Yang Yang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Xiaoxiao Zhou
- Department of Orthopedics, Zhoupu Hospital, Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Mengqin Zhang
- Intensive Care Unit, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Yichi Zhou
- Department of Orthopedics, CR & WISCO General Hospital, Wuhan, Hubei, China
| | - Bin Wang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China.
| | - Chiting Yuan
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
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Sirisreetreerux N, Sa-Ngasoongsong P, Kulachote N, Apivatthakakul T. Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery. Foot Ankle Int 2019; 40:224-230. [PMID: 30317877 DOI: 10.1177/1071100718802255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion. METHODS: Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format. RESULTS: Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA ( P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal. CONCLUSION: The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study. CLINICAL RELEVANCE: This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.
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Affiliation(s)
- Norachart Sirisreetreerux
- 1 Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Paphon Sa-Ngasoongsong
- 1 Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noratep Kulachote
- 1 Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Theerachai Apivatthakakul
- 2 Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,3 Excellence Center in Osteology Research and Training Center (ORTC), Chiang Mai University, Chiang Mai, Thailand
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Surgical approaches to the calcaneus and the sural nerve: There is no safe zone. Foot Ankle Surg 2018; 24:517-520. [PMID: 29409272 DOI: 10.1016/j.fas.2017.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sural nerve related symptoms following the extensile lateral approach to the calcaneus (ELA) and the sinus tarsi approach (STA) are a known postoperative complication despite awareness of the course the sural nerve. While the main trunk of the sural nerve and its location relative to the approaches have been previously described, the nerve gives rise to lateral calcaneal branches (LCBs) and an anastomotic branch (AB) that may be at risk of injury. The purpose of this study was to describe the course of the sural nerve, its LCBs and the AB in relation to the ELA and STA. METHODS 17 cadaveric foot specimens were dissected, exposing the sural nerve, the LCBs and the AB. A line representing the ELA and STA incision was then created. It was noted if the line crossed the sural nerve trunk, any of the LCBs, and the AB, and at what distance they were crossed using the distal tip of the fibula as a reference. RESULTS The sural nerve was identified in all specimens, and the main trunk was noted to cross the path of the ELA in no specimens and the path of the STA in 2 (12%) specimens. At least one LCB of the sural nerve was identified in all specimens. The ELA crossed the path of at least one LCB in 15 specimens (88%). An AB was present in 9 specimens (53%). If an AB was present, this was crossed by the STA in every instance. CONCLUSIONS The ELA and the STA traverses the path of either the main trunk of the sural nerve, the LCBs, or the AB in the majority of specimens, potentially accounting for the presence of sural nerve postoperative symptoms regardless of the approach used.
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Soft tissue micro-circulation in the healthy hindfoot: a cross-sectional study with focus on lateral surgical approaches to the calcaneus. INTERNATIONAL ORTHOPAEDICS 2018; 42:2705-2713. [PMID: 29931550 DOI: 10.1007/s00264-018-4031-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 06/12/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Open reduction and internal fixation (ORIF) using an extended lateral approach combined with plate osteosynthesis represents the current gold standard in calcaneal fracture treatment, but it is associated with a wound complication rate of up to 30%. Literature suggests that micro-circulation is one of the key factors for sufficient wound healing. The aim of this study was to evaluate soft tissue micro-circulation of the hindfoot in healthy volunteers to determine influencing factors and to identify hypoxic or hypoperfused areas in non-trauma situations, with special attention to surgical approaches. METHODS Micro-circulation of the lateral hindfoot of 125 participants was non-invasively measured at 2 and 8 mm depths, utilizing a Micro-Lightguide O2C® spectrophotometer. Blood flow (BF [AU]) and oxygen saturation (SO2 [%]) of ten measurement points (MPs) were documented. Demographic factors (age, gender, body mass index [BMI], systolic/diastolic blood pressure, smoking, and pack-years) and regional differences with special regard to surgical approaches (extended lateral approach, Palmer approach, Ollier approach, and a self-modified extended lateral approach) were analyzed. RESULTS The SO2 assessments at 2- and 8-mm depths revealed higher values in males (p = 0.043; p = 0.025). There was a correlation between higher age and lower 2 mm BF (p = 0.044). Smoking history and number of pack-years did not predict micro-circulation. BF at the 2 mm depth was highest in the regions of Palmer and Ollier approach (p < 0.001). The MP at the distal calcaneal tuberosity showed significantly higher values regarding all parameters (SO2 (2 mm), p < 0.001; SO2 (8 mm), p = 0.001; BF (2 mm), p < 0.001; BF (8 mm), p < 0.001), compared to the surrounding area. CONCLUSIONS In non-trauma situations, young males were associated with better micro-circulatory supply of the lateral hindfoot. There was a trend for higher blood flow in regions of the Palmer and Ollier approach. The distal calcaneal tuberosity was clearly superior in all micro-circulatory parameters when compared to the surrounding area.
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Monaco SJ, Calderone M, Fleming JJ. Paradigm Shift for the Surgical Management of Calcaneal Fractures? Clin Podiatr Med Surg 2018; 35:175-182. [PMID: 29482788 DOI: 10.1016/j.cpm.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Spencer J Monaco
- Premier Orthopaedics, 400 McFarlan Road, Suite 100, Kennett Square, PA 19348, USA
| | - Michael Calderone
- Premier Orthopaedics, 400 McFarlan Road, Suite 100, Kennett Square, PA 19348, USA
| | - Justin J Fleming
- University Orthopaedic Associates, 2 World's Fair Drive, Somerset, NJ 08873, USA.
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Downey MW, Lai TC, Fleming JJ. Primary Arthrodesis in Severely Comminuted Fractures. Clin Podiatr Med Surg 2018; 35:233-257. [PMID: 29482792 DOI: 10.1016/j.cpm.2017.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
At present there is controversy regarding the appropriate treatment of severely comminuted fractures of the lower extremity. Even with near-perfect anatomic reduction of severely comminuted fractures, development of posttraumatic arthritis is still present at an increased rate. Primary fusion of comminuted fractures of the foot and ankle creates successful and predictable outcomes, which dismisses the chance of developing posttraumatic arthritis and decreases complications and the need for revisional procedures.
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Affiliation(s)
- Michael W Downey
- Trinity Foot & Ankle Specialists, 5801 Oakbend Trail #140, Fort Worth, TX 76132, USA.
| | - Ted C Lai
- Shore Orthopaedic University Associates, 24 MacArthur Boulevard, Somers Point, NJ 08244, USA
| | - Justin J Fleming
- University Orthopaedic Associates, 2 World's Fair Drive, Somerset, NJ 08873, USA
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Backes M, Spierings KE, Dingemans SA, Goslings JC, Buckley RE, Schepers T. Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature. Injury 2017; 48:2329-2335. [PMID: 28826650 DOI: 10.1016/j.injury.2017.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/06/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences. METHODS A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied. RESULTS 3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or ≥10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01). CONCLUSION Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.
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Affiliation(s)
- M Backes
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - K E Spierings
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - S A Dingemans
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - R E Buckley
- Department of Surgery, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - T Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Ellis-McConnell W, Taylor A, Kelly P, Meyr AJ. Quantitative Assessment of Peroneal Artery Pressure at the Ankle With Noninvasive Vascular Testing. J Foot Ankle Surg 2017; 56:551-554. [PMID: 28262467 DOI: 10.1053/j.jfas.2017.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Indexed: 02/03/2023]
Abstract
Although the foot and ankle derives its arterial supply from a combination of the anterior tibial artery (ATA), posterior tibial artery (PTA), and peroneal artery (PA), the focus of clinical examination techniques and noninvasive vascular testing is primarily on the ATA and PTA and not on the PA. The objectives of the present investigation were to evaluate the feasibility of incorporating an assessment of the PA into a noninvasive vascular testing protocol and to collect normative data of pressure measurements of the PA at the ankle. We attempted to locate a Doppler signal of the PA posterior to the lateral malleolus in consecutive patients undergoing our institution's standard protocol for lower extremity noninvasive vascular testing using the ankle-brachial index and photoplethysmography. An audible signal of the PA with an available pressure measurement recording posterior to the lateral malleolus was found in a large majority (92.0%) of the studied legs with peripheral arterial disease. We also found pressure measurements in the PA generally equivalent to that of the ATA and PTA. The mean ± standard deviation systolic pressure of the PA was 130.33 ± 44.74 (range 54 to 255) mm Hg, with a corresponding ankle-brachial index of 0.92. The results of the present investigation provide unique information on a potentially underappreciated aspect of lower extremity vascular anatomy with the potential to affect rearfoot surgical decision making and planning.
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Affiliation(s)
| | - Amanda Taylor
- Vascular Technician, Temple University Hospital Vascular Laboratory, Temple University Hospital, Philadelphia, PA
| | - Patrick Kelly
- Vascular Technician, Temple University Hospital Vascular Laboratory, Temple University Hospital, Philadelphia, PA
| | - Andrew J Meyr
- Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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Kiewiet NJ, Sangeorzan BJ. Calcaneal Fracture Management: Extensile Lateral Approach Versus Small Incision Technique. Foot Ankle Clin 2017; 22:77-91. [PMID: 28167066 DOI: 10.1016/j.fcl.2016.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Calcaneal fracture management has historically been a controversial topic and represents an area of sustained interest over the past several decades. The authors review current methods for calcaneal fracture fixation with an extensile lateral approach and small incision techniques. Early reports of small incision techniques have reported promising outcomes and reduced risks for complications. These techniques may be beneficial to reduce the risk of soft tissue complications and improve the rate of recovery.
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Affiliation(s)
- Nathan J Kiewiet
- Drisko, Fee, and Parkins Orthopedic Surgery, 19550 East 39th Street, Suite 410, Independence, MO 64057, USA.
| | - Bruce J Sangeorzan
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, Seattle, WA 98104, USA
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Kwon JY, Gonzalez T, Riedel MD, Nazarian A, Ghorbanhoseini M. Proximity of the Lateral Calcaneal Artery With a Modified Extensile Lateral Approach Compared to Standard Extensile Approach. Foot Ankle Int 2017; 38:318-323. [PMID: 27923213 DOI: 10.1177/1071100716674695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The extensile lateral approach (EL) has been associated with increased wound complications such as apical necrosis which may be due partially from violation of the lateral calcaneal artery (LCA). Traditionally, the vertical limb has been placed half-way between the fibula and Achilles tendon, which may be suboptimal given the proximity to the LCA. We hypothesized that placing the vertical limb further posterior (ie, modified EL [MEL]) would increase the distance from the LCA. The purposes of this study were to quantify the location of the LCA in relation to the vertical limb of the traditional EL approach and to determine if utilizing the MEL approach endangered the LCA to a lesser extent. METHODS 20 cadavers were used. For the EL approach, the fibula and Achilles tendon were palpated and a line parallel to the plantar foot was drawn between the two. A vertical line (VL), representing the vertical limb of the approach, was drawn at the midway point as a perpendicular extending proximally from the junction of the glabrous/non-glabrous skin (JGNG). For the MEL approach, the anterior border of the Achilles tendon was palpated and a similar vertical line (MVL) was drawn 0.75 cm anterior. Dissection was performed and if the LCA was identified crossing the line VL/MVL, the distance from the JGNG was documented. RESULTS For the EL approach, the LCA was identified in 17/20 (85%) cadavers at an average distance of 5.0 cm (range 3-7 cm, SD = 1.3 cm) from JGNG. For the ML approach, the LCA was identified in 4/20 (20%) cadavers at an average distance of 5.9 cm (range 3-6.5 cm, SD = 1.7 cm) from the JGNG ( P < .001). CONCLUSIONS The LCA was encountered 4 times more often during the EL approach as compared to the MEL approach. CLINICAL RELEVANCE A modification of the EL approach may decrease iatrogenic injury to the LCA and may decrease wound complications.
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Affiliation(s)
- John Y Kwon
- 1 Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tyler Gonzalez
- 2 Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Matthew D Riedel
- 2 Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Ara Nazarian
- 1 Beth Israel Deaconess Medical Center, Boston, MA, USA
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Ghorbanhoseini M, Kwon JY. Percutaneous Method to Determine Optimal Surgical Approach for Delayed Treatment of Calcaneus Fracture. Foot Ankle Int 2017; 38:76-79. [PMID: 27654044 DOI: 10.1177/1071100716667318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - John Y Kwon
- 2 Harvard Medical School, BIDMC, Carl J. Shapiro Department of Orthopaedics, Boston, MA, USA
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Abstract
Intra-articular calcaneus fractures are commonly sustained after high-energy trauma, and a variety of techniques exists for anatomic reduction and surgical fixation. Traditional approaches using an extended L-shaped lateral incision with lateral plating for open reduction and internal fixation have relatively high complication rates. Common complications include hematoma formation, skin edge necrosis, wound breakdown, and superficial or deep infection. As a result, less invasive techniques have been developed in recent years, including limited-incision sinus tarsi open reduction and internal fixation, percutaneous fixation, and arthroscopic-assisted fixation. These techniques are associated with lower complication rates and equivalent clinical and radiographic outcomes in certain fracture patterns and patient populations.
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