Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions

Exposure of the Calcaneus in the Sinus Tarsi Approach Versus the Lateral Extensile Approach: A Cadaveric Study

BACKGROUND

The lateral extensile approach (LEA) is an operative approach for calcaneal fractures. High rates of wound complications have led to alternative approaches such as the sinus tarsi approach to grow in popularity. The LEA affords substantial visualization of the calcaneus. This visualization has never been compared in a quantitative manner with the sinus tarsi approach (STA). We aim to quantify the calcaneal visualization afforded by STA and LEA.

METHODS

Seven pair-matched, fresh-frozen, below-knee cadaver extremities were included. For each pair, one side received an LEA and the other side received an STA.

RESULTS

There were no statistically significant differences in the articular surfaces accessible between the 2 approaches. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (P = .02). The LEA allowed better exposure to the lateral wall (P = .01) and the dorsal tuberosity of the calcaneus (P = .04).

CONCLUSION

The STA allows for equivalent articular surface exposure when compared with the LEA. Although LEA allows for greater exposure of the lateral wall and dorsal tuberosity, direct visualization of these structures may not warrant the higher risk of wound complications. Surgeons should consider these differences when choosing an operative approach in the treatment of calcaneal fractures.Level of Evidence:Level III.

The Impact of De-Roofing of Lateral Calcaneal wall in Open Reduction and Internal Fixation of Intra-Articular Fractures: Clinico-Radiological Outcomes of a Novel Technique and Review of Literature

Background

Most displaced intra-articular calcaneus fractures need to be treated surgically but postoperative soft tissue complications limit to achieve of optimal functional outcomes. Certain mini-invasive techniques lead to better soft tissue healing but anatomical reduction gets compromised.

Objectives

We aim to evaluate the results of lateral wall de-roofing of the calcaneum to achieve good anatomical reduction as well as to minimise soft tissue complications in the internal fixation of calcaneal fractures.

Materials and Methods

Thirty-two patients (40 ft) with displaced intra-articular calcaneus fractures (10 were of Sanders type II, 16 were of type III, and 14 were of type IV) were treated between January 2018 and September 2021. All patients were managed surgically with open reduction and internal fixation using lateral extensile approach combined with de-roofing of the lateral wall. All patients were followed up for ≥1 year using functional parameters American Orthopaedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS) and radiological parameters (Bohler angle, Gissane angle, height of the calcaneus, width of the calcaneus and pitch of calcaneus).

Results

Out of 32 patients, one patient lost to follow-up. At 1 year follow-up, mean AOFAS hindfoot score was 86.2 ± 5 (Sanders type II: 91.2, Sanders type III: 87.6, and Sanders type III: 81.4), mean VAS score was 91.3 ± 2.1, mean Bohler angle (°) was 27.2 ± 4.7, mean Gissane angle (°) was 136.4 ± 5.2, mean calcaneus height was 46.2 ± 2.1 mm and mean calcaneus width was 45.1 ± 3.2 mm. Patients with decreased Bohler angle between postoperative images and follow-up had lower AOFAS hindfoot scores. Complications included persistent swelling (64.10%), stiffness (33.33%), superficial infections (5.12%), and wound dehiscence (10.25%).

Conclusion

Lateral wall de-roofing is a useful technique which allows the lateral wall to get flattened reducing soft tissue complications and providing bone graft as well. This approach also adequately exposes fracture fragments, subtalar and calcaneocuboid joints for good anatomical reduction. Hence, it can act as a useful adjunct in the internal fixation of intra-articular calcaneus fractures.

Level of Evidence

III.

Percutaneous reduction and cannulated screw fixation assisted by 3D printing technology of calcaneal fractures in children

BACKGROUND

Percutaneous reduction and cannulated screw fixation (PR + CSF) for treatment of calcaneal fractures in pediatric patients has been proven to achieve satisfactory outcomes with few complications. But it is also a difficult technology due to the limited exposure and surgeons are unable to reduce articular surface under direct vision. The purpose of this study was to analyze the outcomes of applying 3D printing technology to preoperative preparation and Intraoperative operating for the treatment of calcaneal fractures in children.

METHODS

Pediatric patients with calcaneal fractures from January 2010 to December 2018 were reviewed during study period. Preoperative radiographs and computed tomography scans were collected to classify the fractures, reconstruct 3D printed model and evaluate postoperative outcomes. The blood loss, operative time, number of fluoroscopies, surgeon and patient satisfaction were used to assess the effectiveness, feasibility and safety of 3D printing technology. Functional results were measured by American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score.

RESULT

12 patients (10 boys and 2 girls) with 17 fractures were involved in our study. There were significant differences in the average Böhler angle before operation compared with that after operation and at last follow-up (P < 0.001). Similarly, the calcaneal height and length postoperatively and at the end of follow-up time were proved to have significant difference (P < 0.05) compared to preoperative. CT scan showed good reduction of the posterior facet according to Goldzak index. The average subjective AOFAS hindfoot score was 94.1. Both patients and surgeon made sense of the 3D printed model that can help them getting more information about the factures and making preoperative plans. No wound complication was found in this study.

CONCLUSION

This study indicated that percutaneous reduction and cannulated screw fixation (PR + CSF) assisted by 3D printing technology in the treatment of calcaneal fractures in pediatric patients achieve good outcomes, with specific preoperative preparation, satisfactory functional recovery and fewer complications.

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

METHODS

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

RESULT

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

CONCLUSIONS

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

The statistical fragility of outcomes in calcaneus fractures: A systematic review of randomized controlled trials

INTRODUCTION

The purpose of this study was to utilize the fragility index to assess the robustness of randomized controlled trials (RCTs) evaluating the management of calcaneus fractures. We hypothesize that the dichotomous outcomes in calcaneus fracture literature will be statistically fragile and comparable to other orthopedic specialties.

METHODS

We performed a PubMed search for calcaneus fracture RCTs from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The fragility index (FI) of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient (FQ) was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

RESULTS

Of the 3003 studies screened, 97 met the search criteria, with 19 RCTs evaluating calcaneus fractures included in the analysis. Seventy-nine dichotomous outcomes with 30 significant (P < 0.05) outcomes and 49 with nonsignificant (P> 0.05) outcomes were identified. The overall FI and FQ of all outcomes were 6 (IQR 3-8) and 0.067 (IQR 0.032-0.100), respectively.

CONCLUSIONS

The literature surrounding calcaneus fractures may not be as statistically stable as previously thought. The sole reliance on the P value may depict misleading results. We, therefore, recommend reporting the P value in conjunction with the FI and FQ to give a robust contextualization of clinical findings in the calcaneus fracture literature.

Utilization of minimally invasive burr for surgical correction of calcaneus fracture malunion: A case report describing a novel technique

INTRODUCTION

Calcaneus fractures pose a significant treatment challenge to orthopaedic surgeons. Nonoperative treatment frequently leads to malunion, persistent pain, and development of subtalar arthritis, while operative treatment increases the risk of surgical-related complications, such as surgical site infection, without demonstrating superior outcomes.

PRESENTATION OF CASE

A 58-year-old male laborer presented three months after sustaining a left joint-depression type calcaneus fracture. He was initially treated nonoperatively but suffered from significant pain and dysfunction interfering with activities of daily living and inability to return to work. The patient was treated with a novel technique utilizing a minimally invasive burr to correct calcaneus fracture malunion. There were no reported post-operative complications, including infection or additional malunion, patient has returned to normal shoewear and his physically demanding career.

DISCUSSION

This is one of few studies documenting utilization of a minimally invasive burr for surgical correction of calcaneus fracture malunion. Restoration of calcaneal height and hindfoot alignment were achieved without evidence of subtalar arthritis on postoperative radiographs. Minimally invasive surgical procedures, especially with smaller incisions, have been found to be just as effective as open, though with significantly fewer wound and nerve complications.

CONCLUSION

Minimally invasive correction of calcaneus fracture malunion may be a viable option for surgical intervention, even in patients who are at higher risk of surgical complications such as infection. The indications for minimally invasive techniques are rapidly expanding and further studies are warranted to evaluate the use of minimally invasive techniques in foot and ankle surgery.

Is There a Borderline Value in the Radiological Findings of Patients With Calcaneal Malunion That May Help to Select an Appropriate Treatment Option?

BACKGROUND

Despite the constant evolution of technological support, operative techniques, and rehabilitation techniques after conservative treatment and operative treatment, a considerable number of patients with calcaneal fractures have constant pain, frequently resulting in loss of occupation. There are numerous options for the operative treatment of painful calcaneal malunion; however, very few publications suggest specific radiological measurements for pre- and postoperative planning-even fewer have statistically analyzed how these radiological measurements affect clinical outcomes.

METHODS

We performed a retrospective study of 100 patients after operative treatment of calcaneal malunion to determine the correlation between radiological measurements and clinical outcomes. Data were used to create an algorithm that would help to choose between in situ subtalar arthrodesis and complex reconstructive operations. The algorithm was then used to treat 27 prospective patients. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) were used for clinical assessment, whereas standard weightbearing anteroposterior (AP), lateral (LAT) ankle x-rays, and long axial hindfoot view were used for radiological assessment.

RESULTS

The talar declination angle was positively correlated with clinical outcome. Patients with talar declination angles less than 6.5 degrees showed worse results in AOFAS score than patients with a greater angle did (57.3 ± 15.3 and 81 ± 15.6, respectively).

CONCLUSION

The combination of subtalar arthrodesis with distraction bone block or calcaneal osteotomy in patients with calcaneal malunion and a talar declination angle less than 6.5 degrees showed better results than isolated in situ arthrodesis.

LEVEL OF EVIDENCE

Level III, retrospective cohort study, case series.

Malunited calcaneal fracture: the role and technique of osteotomy-a systematic review

PURPOSE

The research is aimed to introduce various corrective osteotomies utilized in treating calcaneal malunions in published papers, to further analyze the results, and to summarize recommended indications.

METHODS

The relevant research screening was conducted on the following search engines: the Cochrane Library, Web of Science, PubMed, Embase, Medline, and Academic Search Premier. Key words input included "calcaneal/calcaneus", "malunion," and "malunited fracture(s)" with Boolean operators "AND" and "OR." The inclusion criteria were researches containing surgical procedures treating calcaneal malunion with corrective osteotomy and published in the English language. For included research article, such information was extracted and analyzed: the type of calcaneal malunion, the time from initial injury to corrective surgery, the method of osteotomy, outcomes of each osteotomy (score systems, Bohler angle, talocalcaneal height and width of calcaneus, etc.), the function of the affected limb, post-operative complications, and patients' satisfaction. For included review, descriptive, commentary, or indicative sentences about corrective osteotomy were highlighted, analyzed, and summarized.

RESULTS

Ten research articles (170 patients with 184 feet) and nine reviews were included in this review, presenting seven types of corrective osteotomies (lateral wall exostectomy, Dwyer osteotomy, lateral wedge opening osteotomy, Romash osteotomy, tongue osteotomy, sagittal resection osteotomy, and modified Dwyer osteotomy).

CONCLUSION

A different corrective osteotomy with/without arthrodesis is recommended to be utilized based on the classification of the malunion and the condition of the cartilage in treating malunited calcaneal fractures. With adequate postoperative care and rehabilitation, the results of treatment could be associated with patients' satisfaction and good function.

Cost-utility analysis of extensile lateral approach versus sinus tarsi approach in Sanders type II/III calcaneus fractures

Background

Extensile lateral approach had been recognized as the gold standard technique for displaced intra-articular calcaneus fractures (DIACFs) while sinus tarsi approach had been increasingly valued by surgeons and comparative clinical outcome was shown in both techniques. Appropriate decisions could be made by the clinicians with the help of cost-utility analysis (CUA) about optimal healthcare for type II/III calcaneus fracture.

Method

A single-center, retrospective study was conducted in which basic characteristics, clinical outcomes, and health care costs of 109 patients had been obtained and analyzed. Changes in health-related quality of life (HRQoL) scores, validated by EuroQol five-dimensional-three levels (EQ-5D-3L), were used to enumerate quality-adjusted life years (QALYs). Cost-effectiveness was determined by the incremental cost per QALY.

Results

One hundred nine patients were enrolled in our study including 62 in the ELA group and 47 in the STA group. There were no significant differences between these two groups in mean total cost, laboratory, and radiographic evaluation expense, surgery, anesthesia, and antibiotic expense. The expense of internal fixation materials ($3289.0 ± 543.9) versus ($2630.6 ± 763.7) and analgesia ($145.8 ± 85.6) versus ($102.9 ± 62.7) in ELA group were significantly higher than in the STA group (P < .001, P = .008, respectively). Visual Analogue Scale (VAS) scores showed significant difference at postoperative 3 and 5 days (P < .001). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and the Bohlers’ and Gissane angle showed no significant differences between the two groups before and after the operation. The cost-effectiveness ratios of ELA and STA were $8766.8 ± 2835.2/QALY and $7914.9 ± 1822.0/QALY respectively, and incremental cost-effectiveness ratio (ICERs) of ELA over STA was $32110.00/QALY, but both showed no significant difference.

Conclusion

Both ELA and STA techniques are effective operative procedures for the patients with calcaneus fracture. Moreover, STA seems to be more reasonable for its merits including less postoperative pain, and less expense of analgesia as well as internal fixation materials.

Level of evidence

5

Intra-articular Calcaneus Fractures: Current Concepts Review

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures.

Level of Evidence: Level V, expert opinion.

Subtalar fusion and exostectomy in calcaneus malunion: How we do it

Calcaneus malunion is a common sequela to calcaneal fractures and is a cause of pain and discomfort. Multiple approaches have been described to address the subtalar joint and the lateral wall. Type 2 malunion is the most commonly encountered problem, and is usually addressed by the sinus tarsi approach. This has some limitations, as exposure for lateral wall excision beneath the peroneal tendons maybe a problem. We have slightly modified the sinus tarsi approach by a more horizontal skin incision, which may even be extended proximally by 1-2 cm; this allows access to the lateral wall on either side of the peroneal tendons. The approach is described in detail.

Radiographic and Postoperative Outcomes of Plate Versus Screw Constructs in Open Reduction and Internal Fixation of Calcaneus Fractures via the Sinus Tarsi

BACKGROUND

Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high-energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatment, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study was to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures.

METHODS

After institutional review board approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and fractures with less than 6 weeks of postoperative weightbearing, which were excluded for radiographic outcomes. A total of 51 fractures underwent ORIF using cannulated screws alone (group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (group 2). Sixty-one fractures (41 vs 20, respectively) met criteria for radiographic comparison. The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, unplanned return to the operating room (OR), and cost comparison.

RESULTS

There was no statistically significant difference between preoperative Bohler angles for group 1 (14.4 degrees) versus group 2 (12.2 degrees) (P = .44), nor was there a significant difference between postoperative Bohler angles for group 1 (30.1 degrees) versus group 2 (27.1 degrees) (P = .14). Similarly, preoperative Gissane angles for group 1 (130.5 degrees) and group 2 (133.4 degrees) (P = .54) and postoperative Gissane angles for group 1 (118.2 degrees) and group 2 (119.8 degrees) (P = .44) showed no statistically significant difference. There were a total of 3 wound complications in group 1 versus 2 wound complications in group 2 (P = .66). There was no statistically significant difference in operative duration (P = .97) or the number of unplanned returns to the OR between the 2 groups (P = .68). Based on the implants used at this institution, and depending on the number of screws used, the estimated cost range of a plate construct was $1070 to $1235, while the estimated cost range of a cannulated screw construct was $717 to $1264.

CONCLUSION

When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Furthermore, the amount of angular correction achieved by initial reduction showed no statistically significant difference between groups, and the amount of reduction lost between initial and final postoperative radiographs showed no statistically significant difference between groups. With regard to the 2 techniques, there was no statistically significant difference in rates of postoperative complications and return to the OR. Our data suggest that fixation using cannulated screws alone versus sinus tarsi plate provides similar radiographic outcomes and risk of complications. The 2 techniques were also similar in terms of implant costs. Our results indicate that either technique effectively improved radiographic parameters.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Sagittal Resection Osteotomy With Bone Block Distraction Subtalar Fusion for Treatment of Malunited Calcaneal Fractures

The aim of this prospective study was to evaluate the results of combined lateral sagittal resection osteotomy with subtalar distraction fusion in heels with painful malunion of the os calcis. This case series included 22 patients (23 feet). The mean age of the patients was 37.52 years. Sixteen (69.6%) patients were initially treated conservatively, 5 (21.7%) patients were treated surgically, and 2 (8.7%) patients were missed. The mean time lapsed before surgery was 11.43 months. A wedge of bone was resected to reduce the width of the malunited os calcis and was used as a local graft for subtalar joint fusion and to increase the height of the os calcis. The mean follow-up period was 56.83 ± 6.09 months. According to the scoring system, satisfactory results were found in 18 (82.6%) patients, and 4 (17.4%) patients had unsatisfactory results. Postoperative radiographic assessment revealed an average increase in the heel height of 7.70 ± 1.22 mm and an average decrease in heel width of 8.39 ± 1.47 mm. The average correction in the coronal axis was approximately 8.04° ± 1.26°. Complications included infection and nonunion in 3 (13%) heels. Two heels still had residual varus postoperatively, and 1 patient had injury to the sural nerve. The restoration of heel height, the reduction in heel width, and the primary fracture pattern had a significant relation with the final score. This method is a successful method for the management of subtalar arthritis caused by malunited calcaneal fractures with broadening leading to lateral abutment.

Minimally invasive subtalar arthrodesis for traumatic subtalar arthritis

Objective

This study was performed to introduce a new method of minimally invasive subtalar arthrodesis (MISA) and assess its clinical effects on traumatic subtalar arthritis (TSA).

Methods

Fifteen patients (8 male and 7 female; age range, 36–56 years; mean age, 48.67 years) with TSA who underwent MISA were included. All patients were treated using a series instrument. The intraoperative and postoperative indexes were recorded.

Results

Among all patients, the mean operation time was 59.67 ± 16.31 minutes and the mean intraoperative blood loss was 43.33 ± 52.87 mL. Four patients underwent iliac crest bone graft surgery, and one patient developed a complication involving fat liquefaction of the iliac crest wound. The mean bony fusion time among all patients was 3.5 months. According to the American Orthopaedic Foot and Ankle Society standard, an excellent outcome was obtained in eight patients and a good outcome was obtained in seven patients. The operation time and intraoperative blood loss were significantly different between patients who did and did not undergo iliac crest bone graft surgery.

Conclusion

MISA is a simple and effective method for the treatment of TSA.

Arthroscopic and Endoscopic Management of Common Complications After Displaced Intra-Articular Calcaneal Fractures

The list of late complications after calcaneal fracture that can be treated through arthroscopic and/or endoscopic approach continues to expand. The late complications of calcaneal fractures can be classified into 3 groups: (1) those causing focal hindfoot or ankle pain, (2) those causing functional deficit, and (3) those present with diffuse and poorly localized pain. Many group 1 and some group 2 complications can be managed arthroscopically and/or endoscopically. There are usually multiple coexisting sources of the pain. Careful evaluation and analysis of a problem and detailed surgical planning with combination of arthroscopic/endoscopic and open procedures are key to success.

Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most?

Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures.

Lateral bone flap approach for displaced intra-articular calcaneus fractures

BACKGROUND

The traditional extended lateral approach for calcaneus fractures can provide sufficient exposure for reduction, but complications are frequent. The minimally invasive approach does limited damage to the soft tissue and its complication rate is low, but provides limited surgical exposure for complicated fracture. Thus, an approach that could provide wide exposure with less soft tissue injury is important.

METHODS

The lateral bone flap approach, we proposed, involved the same incision as the extended lateral approach. After incision, osteotomy was performed around the lateral bulged wall of the calcaneus without dissection of soft tissue. The lateral wall was free from calcaneus and connected with the soft tissue, and the lateral bone flap was developed. The reduction of fracture and the fixation of plate were performed as usual. Next, the bone flap was reduced and sutured. This retrospective study of lateral bone flap approach included 63 cases of 58 patients with displaced intra-articular calcaneus fractures from January 2011 to January 2015. Clinical and radiological outcomes and complications were all recorded.

RESULTS

Radiological outcome was significantly improved at 3 months and 2 years post-operatively compared with that of pre-operatively (P < 0.01). The Maryland Foot Score at the last follow up was 87.2 ± 7.0. The excellent/good rate was 90.5%. One case of delayed wound healing occurred. No infection or sural nerve injury occurred.

CONCLUSION

The lateral bone flap approach is simple, safe and effective for displaced intra-articular calcaneus.

Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion

Background

We hypothesized that calcaneal reconstruction can relieve chronic pain due to calcaneal malunion. We report the mid-term follow-up results of calcaneal reconstruction for calcaneal malunion.

Methods

We reviewed the records of 10 male patients (10 ft) who underwent calcaneal reconstruction for calcaneal malunion between January 2009 and July 2014 at the mid-term follow-up. Talocalcaneal height and angle, calcaneal pitch, calcaneal width, Böhler angle, Stephens classification, and Zwipp classification were evaluated by three orthopedic doctors at each visit (pre-reconstruction, post-reconstruction, and at the last follow-up).

Results

The mean follow-up period was 67.1 months (range, 48–101 months). The sites of pain before reconstruction were lateral aspect (4 patients), plantar aspect (3 patients), diffuse pain (2 patients), and anterior aspect (1 patient). There was a significant difference in talocalcaneal height, talocalcaneal angle, calcaneal pitch, calcaneal width, and Böhler angle before and after reconstruction (p < 0.05). There was no significant difference between reconstruction and the last follow-up. Radiological measurement agreement was calculated to be moderate to strong (intraclass correlation coefficient: 0.659–0.988). Mean American Orthopedic Foot & Ankle Society Ankle and Hindfoot score improved from 66.50 ± 9.37 pre-reconstruction to 80.30 ± 8.52 at the last follow-up (p < 0.05). The mean visual analog scale score improved from 8.60 ± 1.43 before reconstruction to 3.40 ± 0.84 at the last follow-up (p < 0.05). Most patients were satisfied with the outcome postoperatively.

Conclusions

Our results showed substantial improvement in the clinical and radiological outcomes after calcaneal reconstruction of calcaneal malunion. This outcome was maintained until the mid-term follow-up. Therefore, calcaneal reconstruction may be a good option for the treatment of chronic pain caused by the malunion of a calcaneal fracture without severe subtalar arthritis. Further prospective studies are needed to test this theory.

Level of Evidence: Level IV, Retrospective Case Series.

The Effectiveness of Surgical Interventions in the Management of Malunited Calcaneal Fractures: A Systematic Review

Nonoperative management may result in calcaneal malunion with consequences of pain, deformity, and functional limitation. The aim of this review was to proffer an evidence-based scientific account of the effectiveness of contemporary surgical procedures in the management of malunited calcaneal fractures after initial conservative management. This systematic review included studies that evaluated the surgical procedures in the management of calcaneal malunion and systematically searched studies published between January 2005 and June 2016. The search was conducted using the following search engines: the Cochrane Library, Web of Science, PubMed/ MEDLINE, EMBASE, CINAHL, Academic Search Premier, and Open Grey. Methodologic assessment was conducted using the Cochrane Risk of Bias In nonrandomized Studies- of Interventions assessment tool version 7. Ten observational studies (212 patients) were included in this review. Five articles explored various means of achieving subtalar arthrodesis, 2 articles evaluated joint-sparing osteotomies, 1 examined corrective osteotomy for extra-articular os calcis malunion, and 2 articles explored combined procedures based on the Stephen and Sanders calcaneal malunion classification. Clinical and methodologic heterogeneity did not allow quantitative pooling of results. The overall risk of bias was considered moderate in 7 studies and 3 were considered at high risk of bias. The inability for any study to be considered at low risk of bias in this review might be mainly attributed to the lack of a valid and reliable outcome measure for the assessment of foot and ankle conditions. There is clear evidence that appropriately indicated procedures are effective in terms of pain alleviation, correction of deformity, and improved function. However, long-term outcomes may improve the acceptability to joint-preserving osteotomies, subtalar arthrodesis with the VIRA implant and subtalar distraction osteogenesis.

Arthroscopic posterior subtalar arthrodesis for salvage of posttraumatic arthritis following calcaneal fractures

BACKGROUND

Subtalar arthrodesis is a treatment option for pain due to posttraumatic arthritis following calcaneal fractures. The goal of this study is to examine the results of arthroscopic subtalar arthrodesis for posttraumatic arthritis following calcaneal fractures.

PATIENTS AND METHODS

We performed a retrospective case series reviewing 37 consecutive patients (36 male) treated for posttraumatic arthritis following calcaneal fractures by arthroscopic subtalar arthrodesis. The fractures were due to high-energy injuries in 81% of cases, and 12 fractures (32.4%) had been previously treated with internal fixation. Average follow-up was 57.5 months.

RESULTS

Average American Orthopedic Foot and Ankle Society (AOFAS) scores significantly improved from 49.0 ± 10.9 points preoperatively to 76.0 ± 8.0 points at final follow-up. Average time to union was 12.5 weeks. Six patients (16.2%) suffered complications: superficial wound infection (2.7%), symptomatic hardware that warranted removal (5.4%) and nonunion (8.1%) presented nonunion. All three cases had prior internal fixation through an extensile lateral approach, and fused after a repeat surgery.

CONCLUSION

Arthroscopic subtalar arthrodesis offers consistent improvement in cases of posttraumatic arthritis following calcaneal fractures, with a union rate similar to published series of open arthrodesis. We observed more nonunions in patients who had been treated previously with internal fixation. In spite of this, we continue to recommend arthroscopic subtalar arthrodesis, as it preserves the soft tissue envelope better than open techniques.

[Application and research progress of subtalar distraction bone block arthrodesis in treatment of calcaneus fracture malunion]

Objective

To review the application and research progress of subtalar distraction bone block arth-rodesis in the treatment of calcaneus fracture malunion.

Methods

The recent literature concerning the history, surgical technique, postoperative complication, indications, and curative effect of subtalar distraction arthrodesis with bone graft block interposition in the treatment of calcaneus fracture malunion was summarized and analyzed.

Results

Subtalar distraction bone block arthrodesis is one of the main ways to treat calcaneus fracture malunion, including a combined surgery with subtalar arthrodesis and realignment surgery for hindfoot deformity using bone block graft. The advantage is on the base of subtalar joint fusion, through one-time retracting subtalar joint, the posterior articular surface of subtalar joint implants bone block can partially restore calcaneal height, thus improving the function of the foot. Compared with other calcaneal malunion treatments, subtalar distraction arthrodesis is effective to correct complications caused by calcaneus fracture malunion, and it can restore the height of talus and calcaneus, correct loss of talocalcaneal angle, and ease pain.

Conclusion

Subtalar distraction bone block arthrodesis has made remarkable progress in the treatment of calcaneus fracture malunion, but it has the disadvantages of postoperative nonunion and absorption of bone block, so further study is needed.

Calcaneal Fracture Management: Extensile Lateral Approach Versus Small Incision Technique

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.

Managing Complications of Calcaneus Fractures

Calcaneus fractures remain among the most complicated fractures for orthopedic surgeons to manage because of the complexity of various fracture patterns, the limited surrounding soft tissue envelope, and the prolonged rehabilitation issues impacting function after successful treatment. Despite this, appropriate management of complications associated with calcaneus fractures is critical for the complete care of this injury, whether treated operatively or nonoperatively. The authors present the common complications encountered with fractures of the calcaneus and management thereof.

Current Controversies in Management of Calcaneus Fractures

Displaced intraarticular fractures of the calcaneus represent a technically challenging injury. Although there is conflicting evidence regarding advantages and disadvantages of operative versus nonoperative treatment, a growing body of literature suggests operative management with near-anatomic reduction of the posterior facet and restoration of overall calcaneal morphology offers greater potential for superior short- and long-term outcomes. A thorough understanding of calcaneal anatomy, fracture pattern, and associated injuries, along with careful selection of surgical approach and timing to surgery are critical to minimize the risk of complication and maximize potential for optimal outcomes.

Comparison Between Sinus Tarsi Approach and Extensile Lateral Approach for Treatment of Closed Displaced Intra-Articular Calcaneal Fractures: A Multicenter Prospective Study

The purpose of our investigation was to prospectively review and compare the early outcomes of Sanders II and III closed displaced intra-articular calcaneal fractures (DIACFs) in a group of patients treated by open reduction and internal fixation with plate and screws using the extended lateral approach or the sinus tarsi approach (STA). Thirty-eight patients with DIACFs were prospectively enrolled and operatively treated using either the extended lateral approach or the STA. Patients underwent a careful clinical and radiographic examination and were evaluated according to the American Orthopaedic Foot and Ankle Society score, visual analog scale, and the Foot Function Index. The results from our study showed similar clinical and radiographic outcomes between the 2 groups. In our series, Sanders II and III DIACFs were sufficiently exposed using the STA to achieve anatomic reduction and stable fixation. The STA group had a lower incidence of wound complications (p ≥ .05), the surgical procedure was faster, and the waiting time to surgery was shorter (p ≤ .05). Despite the limited number of patients and the short follow-up period, our results suggest that the STA is a useful method for the treatment of DIACFs, with a low incidence of complications and results comparable to those for patients treated using the extended lateral approach.

Distraction subtalar arthrodesis

There is a high potential for disability following calcaneal fracture. This potential exists whether a patient is treated with conservative or operative management. Subfibular impingement and irritation of the peroneal tendon and sural nerve may also be present. Posttraumatic arthritis of the subtalar joint can occur. In patients with symptomatic calcaneal malunion, systematic evaluation is required to determine the source of pain. Nonsurgical treatment may be effective. One surgical treatment option is subtalar distraction arthrodesis. High rates of successful arthrodesis and patient satisfaction have been reported with this surgical option in correctly selected patients.

Comparative study of subtalar arthrodesis after calcaneal frature malunion with autologous bone graft or freeze-dried xenograft

Background

Calcaneal fracture malunion may evolve into arthrosis and severe foot deformities. The aim of this study was to identify differences in bony union following corrective subtalar arthrodesis with interposition of autologous tricortical bone graft or freeze-dried bovine xenograft.

Methods

We prospectively evaluated 12 patients who underwent subtalar arthrodesis, six patients received autografts and 6 received freeze-dried bovine xenografts. After a mean followup of 58 weeks, the patients were clinical assessed using AOFAS scale and the visual analog scale (VAS) for pain and for final radiographic parameters measurement. Two blind raters evaluated the length of time required for solid union of the arthrodesis and graft integration by retrospective radiographic examination.

Results

In the autograft group, AOFAS score improved from a preoperative average of 37 to 64 points postoperatively (p = 0.02) and mean VAS score improved from 4.7 to 1.9 (p = 0.028). In the xenograft group, AOFAS score improved from 38 to 74 points (p = 0.02) and VAS from 5.5 to 2.7 (p = 0.046). Solid union was achieved in all cases in the autograft group at an average of 5.3 weeks and in five cases in the xenograft group at 8.8 weeks (p = 0.077). Graft integration occurred after an average of 10.7 weeks in the autograft group and 28.8 weeks in the xenograft group (p = 0.016).

Conclusion

With the numbers available, no significant difference could be detected in the length of time required for solid union of subtalar arthrodesis between groups, although time to integration of freeze-dried bovine xenografts was statistically higher. Clinical and functional improvement was observed in both groups.

Simultaneous use of lateral calcaneal ostectomy and subtalar arthroscopic debridement for residual pain after a calcaneal fracture

Inadequate primary treatment of calcaneal fractures frequently results in persistent, residual pain. This can be caused by subtalar arthritis, an increased calcaneal width, and/or calcaneal fibular impingement of the peroneal tendons. Many patients experience multiple disorders simultaneously, requiring a combination of procedures to treat the injury. The purpose of the present study was to evaluate the clinical outcomes of arthroscopic debridement with lateral calcaneal ostectomy for residual pain after a calcaneal fracture. Four feet (4 patients) were treated with arthroscopic debridement and lateral calcaneal ostectomy. The patients were 3 males and 1 female, with a mean age of 55.3 ± 14.1 years. The mean follow-up duration was 33.5 ± 10.5 months postoperatively. Three patients received worker's compensation as a result of their condition. The patients were examined for improvement in pain levels using the numeric pain intensity scale and healing was assessed using the Japanese Society of Surgery of the Foot score. The mean Japanese Society of Surgery of the Foot score improved from 64.5 ± 13.8 preoperatively to 82.5 ± 7.1 postoperatively. The mean postoperative numeric pain intensity scale score was 2.3 ± 1.9. No complications, such as deep infection or problems with wound healing, were observed in any of the patients. The simultaneous use of arthroscopic subtalar debridement and lateral calcaneal ostectomy is a valuable intervention for the treatment of residual pain after a calcaneal fracture in patients who present with increased calcaneal width and mild or no degenerative changes in the subtalar joint.

[Joint-preserving osteotomy for calcanean malunions]

BACKGROUND

Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis.

METHODS

Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint.

RESULTS

While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects.

CONCLUSION

In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

The treatment of calcaneal malunion

The surgical treatment of calcaneal malunion is technically very demanding and requires a careful assessment of the exact cause of the problem. A number of different surgeries are available depending on the precise cause of symptoms. The results are reasonable and justify surgery in an otherwise disabled group of patients. Calcaneal malunion surgery should not be performed by the occasional surgeon, as the price of error is usually amputation.

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Mid-term follow up results of subtalar distraction arthrodesis using a double bone-block for calcaneal malunion

PURPOSE

This study was designed to evaluate the mid-term results and efficacy of subtalar distraction double bone-block arthrodesis for calcaneal malunion.

MATERIALS AND METHODS

From January 2004 to June 2007, we operated on 6 patients (10 cases). There were 5 males (9 cases) and 1 female (1 case), four of which presented with bilateral calcaneal malunion. Seven cases were operated on initially. The period between initial injury and arthrodesis was 23 months, and the average follow up period was 58 months. In operation, we applied an extensile lateral approach and arthrodesis was performed through a tricortical double bone-block and cannulated screws. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale was used for clinical evaluation. In radiologic analysis, plain X-ray and CT were examined to assess union and various parameters.

RESULTS

The mean age of the patients was 41 years. All cases achieved radiologic union at the final follow-up. The mean AOFAS Ankle-Hindfoot scale (maximum of 94 points) increased from 43.3 points preoperatively to 85.4 points at the final follow-up. The radiologic analysis of the pre- and postoperative standing lateral radiographs showed improvements of 5.6 mm in talo-calcaneal height, 1.8° in talocalcaneal angle, 5.1° in talar declination angle and 5.3° in talo-first metatarsal angle.

CONCLUSION

Subtalar distraction two bone-block arthrodesis provides overall good results not only in the short term but also the mid-term with significant improvement in clinical and radiologic outcomes. This procedure warrants consideration for managing calcaneal malunion with loss of height and subtalar arthritis.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

Arthroscopic management of late complications of calcaneal fractures

PURPOSE

To review retrospectively the results of arthroscopic management of late complications of calcaneal fractures.

METHODS

Fifty patients (32 males, 18 females) with late complications of calcaneal fractures were managed arthroscopically. The median age at the time of arthroscopic surgery was 45 (19-63) years old. Detailed history taking, physical examination, standing lateral radiograph of the foot and axial view of the calcaneus and computed tomogram study were performed in all of the patients in order to identify the sources of symptoms. The arthroscopic treatment was then planned accordingly. The patients were assessed according to the AOFAS ankle-hindfoot score and the standing radiographs of the foot and ankle, both preoperatively and at the latest follow-up consultation.

RESULT

A median of 1 arthroscopic procedure was performed for each patient (range, 1-4). The median follow-up after the latest arthroscopic surgery was 49 (range, 24-85 months) months. In all of the cases, the symptoms improved after the arthroscopic surgery and all the arthrodesis sites healed. The overall median preoperative AOFAS ankle-hindfoot score was 60.5 (27-75). The overall median AOFAS ankle-hindfoot score at the time of latest follow-up was 90 (73-100).

CONCLUSIONS

The arthroscopic approach focuses on the patient's symptoms. It is a feasible approach to alleviate patient's symptoms. Detailed history taking and clinical examination to determine the sources of the patient's symptoms are the keys to success.

Long-term outcomes of 1,730 calcaneal fractures: systematic review of the literature

The objective of the present study was to review the current data on the long-term outcomes of calcaneal fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation. The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2011 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of calcaneal fractures. Of 59 initially relevant studies, 25 met our inclusion criteria. A total of 1,730 fractures were identified in 1,557 patients. The mean sample size-weighted follow-up period was 4.6 years. The findings from the present review support current clinical practice that displaced calcaneal fractures are treated surgically from 1 level I evidence study, 1 level II, and multiple studies with less than level II evidence, with open reduction and internal fixation as the method of choice. If the fracture is less complex, percutaneous treatment can be a good alternative according to current level 3 and 4 retrospective data.

The subtalar distraction bone block arthrodesis following the late complications of calcaneal fractures: a systematic review

INTRODUCTION

The late complications following a displaced intra-articular calcaneal fractures includes painful arthrosis for which a subtalar fusion might be considered. In case of malalignment due to loss of height and varus deformity a reconstructive arthrodesis is necessary. The primary aim of the current review study was to assess the functional outcome of the subtalar distraction bone block arthrodesis in the management of late complications of displaced intra-articular calcaneal fractures.

METHODS

The literature was searched for studies in which a subtalar distraction bone block arthrodesis was used in the management of persistent complaints following a displaced intra-articular calcaneal fractures, after its first description in 1988 up to November 1st 2011. The methodological quality of the included studies was assessed using the Coleman Methodology Score.

RESULTS

Twenty-one studies reporting on 456 patients were identified. In 93 percent the procedure was a salvage procedures following the late complications of a calcaneal fracture (372 cases). Duration of follow-up ranged from 21 to 108 months (average 40 months). Union rates were reported with an overall average of 96% (range 83-100%). The average modified AOFAS score (maximum 94 points) was 73 points at final follow-up (range 64-83 points). Six studies reported pre- and post-reconstruction AOFAS outcome scores with an average increase of 44.2 points. Wound complications occurred in approximately 6%. With the exception of one study all were level 4 retrospective case series, with an average Coleman Methodology Score of 55 (range 41-79) points.

CONCLUSIONS

The subtalar distraction bone block arthrodesis is a technically demanding procedure which, in the right hands, provides an overall good result. This is reflected in a significant increase in outcome scores post-operatively. Although most complications are considered minor, there are several pitfalls which should be recognized and avoided.

Distraction arthrodesis of subtalar joint using a laterally placed hinged distractor

Many joint-depressive, neglected calcaneal fractures need distraction arthrodesis of the subtalar joint. Because the calcaneal tuberosity is usually malunited in the varus position, more distraction is required on the medial side to place the tuberosity in the everted position before insertion of a bone graft. Traditionally, a distractor is placed on the medial side to achieve this task. However, the medially placed distractor hinders with the positioning of the extremity and exposure of the main operative site, which is commonly on the lateral side. We introduce a technique to avoid this burden by placing a hinged distractor device on the lateral aspect of the foot while maintaining the correction of the varus deformity.

[Calcaneus fractures]

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

Subjective results after surgical treatment for displaced intra-articular calcaneal fractures

We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up duration of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, Foot Function Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis was that good subjective results could be predicted and obtained in patients with specific characteristics if anatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A number of specific subgroup analyses were undertaken. The study confirmed that Böhler angle restoration and the quality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. In contrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The main weaknesses of the present study included its retrospective nature, the lack of a control group managed nonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed the radiographic measurement and categorized the quality of the surgical reconstruction.

Calcaneal reconstruction for the late complication of calcaneus fracture

Calcaneal fracture is the most common fracture in the tarsal bones. Treatment is difficult because the patterns of fracture are various and complications occur frequently. The purpose of this study was to evaluate the clinical results of calcaneal reconstruction for chronic complications after calcaneal fracture. rom September 2001 to November 2004, calcaneal reconstruction was performed in 24 patients (25 feet). We reviewed 21 patients (22 feet) who could be followed up >2 years postoperatively. Patients who underwent subtalar arthrodesis and simple bone resection were excluded. Patients who underwent calcaneal sliding osteotomy were included. Nineteen men and 2 women ranged in age from 27 to 54 years (mean, 44.4 years). The mean interval between the first operation and reconstructive operation was 11.2 months (range, 3-31 months). The mean follow-up period after calcaneal reconstruction was 29.8 months (range, 24-38 months). Böhler angle, calcaneal pitch, and talocalcaneal height were checked pre- and postoperatively. The most common patient report was pain on the inferior aspect of the lateral malleolus (16 patients) and calcaneal tuberosity (3 patients). All the mean values of talocalcaneal height, calcaneal pitch, and Böhler angle improved, which was statistically significant. In the postoperative period, 10 patients were very satisfied, 9 were satisfied, and 3 were not satisfied. Although pain did not completely resolve, all patients were satisfied postoperatively.

Optimal double screw configuration for subtalar arthrodesis: a finite element analysis

PURPOSE

The subtalar arthrodesis using screws has been performed to manage traumatic subtalar arthritis. Even though clinically there might not have been big difference between using single screw or double screws for subtalar arthrodesis, a double screw fixation is expected to bring a better initial stability in a mechanical view. This study aimed to assess the optimal configuration of double screw fixation for subtalar arthrodesis.

METHODS

From the CT-scanned images of an ankle of a Korean male (21 year old), polygon models of the talus and calcaneus were reconstructed. The polygon models were converted to tetrahedron finite elements. Young's modulus was assigned locally to each element based on the Hounsfield unit, and a Poisson's ratio of 0.4 was commonly. Four fixation configurations of double screw subtalar arthrodesis were modeled by combination of a same placement of a neck screw and one of four different placements of a dome screw, i.e., anterolateral (AL), anteromedial (AM), posterolateral (PL), and posteromedial (PM) placements. External and internal rotation torques of 4 N-m were applied when evaluating the stability of each fixation configuration.

RESULTS

Among the four fixation configurations, the fixation configuration of a neck screw plus a PM dome screw had the least translation of 0.9 and 0.8 mm for external and internal rotational torques of 4 N-m, respectively. The fixation configuration of a neck screw plus a PM dome screw showed the least rotation of 5.0° and 4.8° for external and internal rotational torques of 4 N-m, respectively. The divergence angle or the contact length did not solely match well to the better stability. However, the integration of both the divergence angle of 2 screws and the contact length between screw and bones were proportionally related to the better rotational stability.

CONCLUSION

A posteromedial dome screw combined with a neck screw can be the best surgical choice, which will bring out excellent union rate of the subtalar arthrodesis as well as the best mechanical stability.

Hindfoot arthrodesis for management of bone loss following calcaneus fractures and nonunions

Massive bone loss following calcaneal fractures is a challenging condition to treat, especially if nonunion is present. Meticulous preoperative examination and imaging are crucial for accurate preoperative planning. If performed, successful outcomes can be achieved with the strategies outlined in this article.

Management of calcaneal malunion

The potential for disabling malunion following calcaneal fracture is high, regardless whether a patient is treated nonsurgically or surgically. Fracture displacement typically results in loss of hindfoot height, varus heel position, and widening of the hindfoot, with possible subfibular impingement and irritation of the peroneal tendon and/or sural nerve. Frequently, the subtalar joint develops posttraumatic arthritis. In symptomatic patients with calcaneal malunion, systematic evaluation is required to determine the source of pain. Nonsurgical treatment, such as activity modification, bracing, orthoses, and injection, is effective in many patients. Surgical treatment may involve simple ostectomy, subtalar arthrodesis with or without distraction, or corrective calcaneal osteotomy. A high rate of successful arthrodesis and of patient satisfaction has been reported with surgical management.

Endoscopic treatment of calcaneo-fibular impingement

The calcaneo-fibular impingement syndrome is frequent after calcaneal fracture and is linked to the decreased space between the tip of the fibula and the lateral wall of the calcaneus. The reasons for the painful symptoms are mixed with both bony and soft tissue involvement. The abnormal bony contact between the lateral calcaneal cortex and the tip of the fibula depends mainly on the size and localization of the lateral exostosis of the calcaneal wall. The soft tissue impingement is due to the fibrosis and scar tissues in the lateral gutter and to the compression of the peroneal tendons in the retromalleolar groove and under the tip of the malleolus. A 2-portal endoscopic technique is described for the treatment of calcaneo-fibular impingement with bone resection, soft tissue debridement and peroneal tendons release. One of the advantages of this endoscopic technique is the possibility of an assessment and treatment of associated lesions in the same procedure. A subtalar joint fusion can be done before if needed under arthroscopic control. As this endoscopic technique is very efficient to relieve symptoms of calcaneo-fibular impingement and is focused on the most relevant symptoms, it can thus be indicated for most of cases of calcaneal malunions, whatever the type of malunion and depending of the painful symptoms.

Comparison of surgical outcomes of intra-articular calcaneal fractures by age

BACKGROUND

Internal fixation is an accepted treatment for displaced fractures of the calcaneus. Operative intervention in older patients, however, is traditionally discouraged in the literature. The purpose of this study was to compare the outcomes of internal fixation of intra-articular fractures of the calcaneus on the basis of patient age.

METHODS

One hundred and seventy-five patients (191 fractures) who underwent internal fixation between 1992 and 2007 for a displaced, intra-articular calcaneal fracture were identified. The American Society of Anesthesiologists score, the fracture pattern, and the mechanism of injury were recorded. Each patient was contacted to complete a follow-up survey from which clinical outcome scores were calculated. One hundred and forty-six patients with 158 fractures were available for follow-up and were divided into two groups for comparison. Group I consisted of 108 fractures in patients who were less than fifty years old. Group II was composed of fractures in fifty patients who were fifty years of age or older.

RESULTS

The mean duration of follow-up was 8.98 years. The average patient age was thirty-six years for Group I and fifty-eight years for Group II. The average adjusted American Orthopaedic Foot & Ankle Society score was 64 for Group I and 75 for Group II. The mean calcaneal fracture scoring system score was 66 for Group I, and 76 for Group II. Similarly, the average Foot Function Index was 24 and 15 for Groups I and II, respectively. Each clinical outcome measure suggests significantly better outcomes for Group II as compared with Group I (all p < 0.05). Overall, the complication rates were similar between groups. Conversion to subtalar fusion was 15% for Group I and 8% for Group II.

CONCLUSIONS

In this series, outcomes of older patients are at least equivalent to those of younger patients undergoing internal fixation for an intra-articular calcaneal fracture. Operative intervention appears to be a reasonable option for displaced calcaneal fractures in older patients. Physiologic age should be considered when evaluating older patients, and individualized treatment plans remain critical because patients with low physical demands or who have medical complications may be better candidates for nonoperative treatment. Prospective studies are needed in this area.

Minimally invasive, no hardware subtalar arthrodesis with autogenous posterior iliac bone graft

Sixteen patients underwent minimally invasive subtalar arthrodesis through a mini-invasive approach with posterior iliac graft between 2004 and 2006. No hardware was used to transfix the arthrodesis and partial weight bearing was allowed immediately. The primary indication for surgery was the squeal of fracture os calcis in terms of subtalar joint arthritis, loss of heel height, malalignment of the hindfoot, and pain with weight bearing. There were 12 male and 4 female patients with a mean age of 30 (range 17-52). Patients were followed up for a period of 40.8 months (range 36-48 months). The mean interval from injury to fusion was 2 (+0.6) years ranging from 6 months to 6 years post fracture. The average clinical rating scale based on the American Orthopaedic Foot and Ankle Society (AOFAS) improved from 36 preoperatively to 78 at the latest follow-up (P < 0.05). Union rate was 94%. Radiographic evaluation revealed a mean increase in calcaneal inclination of 6.25 + 8.3 degrees (P < 0.07) and a mean increase in the lateral talocalcaneal angle of 7.42 + 10.2 degrees (P < 0.08). Complications were graft nonunion in 1 patient and transient tendoachilles tendinitis in another. This technique can be used to decrease the morbidity associated with the late complications of os calcis fractures by aligning the hindfoot, restoring the heel height and correcting calcaneal and talar inclination. It offers the advantage of early weight bearing while avoiding hardware complications.