Calcaneal fractures: radiological and CT evaluation and classification systems

A Comprehensive Review on Managing Fracture Calcaneum by Surgical and Non-surgical Modalities

This comprehensive review delves into the multifaceted landscape of calcaneal fractures, thoroughly examining their aetiology, clinical presentation, and diverse management strategies. Encompassing surgical and non-surgical approaches, the review scrutinises critical aspects such as patient compliance, rehabilitation protocols, and long-term follow-up considerations. Surgical modalities, propelled by recent innovations like minimally invasive techniques and advanced fixation materials, are juxtaposed with non-surgical interventions, emphasising the pivotal role of patient education and adherence to optimise outcomes. The synthesis of critical findings underscores the need for individualised care and multidisciplinary collaboration in clinical practice. Moreover, the review outlines recommendations for healthcare practitioners and identifies promising areas for future research, including biomechanical studies and telerehabilitation. This comprehensive exploration aims to contribute to the ongoing evolution of calcaneal fracture management, ultimately enhancing patient care and outcomes in this complex orthopaedic realm.

The causal relationship between autoimmune diseases and osteoporosis: a study based on Mendelian randomization

Objective

The relationship between different autoimmune diseases and bone mineral density (BMD) and fractures has been reported in epidemiological studies. This study aimed to explore the causal relationship between autoimmune diseases and BMD, falls, and fractures using Mendelian randomization (MR).

Methods

The instrumental variables were selected from the aggregated statistical data of these diseases from the largest genome-wide association study in Europe. Specifically, 12 common autoimmune diseases were selected as exposure. Outcome variables included BMD, falls, and fractures. Multiple analysis methods were utilized to comprehensively evaluate the causal relationship between autoimmune diseases and BMD, falls, and fractures. Additionally, sensitivity analyses, including Cochran's Q test, MR-Egger intercept test, and one analysis, were conducted to verify the result's reliability.

Results

Strong evidence was provided in the results of the negatively association of ulcerative colitis (UC) with forearm BMD. UC also had a negatively association with the total body BMD, while inflammatory bowel disease (IBD) depicted a negatively association with the total body BMD at the age of 45-60 years. Horizontal pleiotropy or heterogeneity was not detected through sensitivity analysis, indicating that the causal estimation was reliable.

Conclusion

This study shows a negative causal relationship between UC and forearm and total body BMD, and between IBD and total body BMD at the age of 45-60 years. These results should be considered in future research and when public health measures and osteoporosis prevention strategies are formulated.

A risk prediction model for postoperative recovery of closed calcaneal fracture: a retrospective study

OBJECTIVE

To explore the risk factors for postoperative recovery of closed calcaneal fracture and develop a prediction model.

METHODS

We retrospectively enrolled patients with closed calcaneal fracture from January 1, 2017 to December 31, 2020. Patients treated from 2017 to 2019 were selected as a training cohort and those in 2020 as a validation cohort. The outcome variable was the postoperative recovery evaluated by the Creighton-Nebraska calcaneal fracture scoring system. Multivariate logistic regression analysis was used to screen the risk factors of postoperative recovery. A risk prediction model was constructed in the training cohort and the corresponding nomogram was drawn. The model was validated internally using bootstrapping and externally by calculating the performance in the validation cohort.

RESULTS

A total of 659 patients with closed calcaneal fracture met the inclusion and exclusion criteria, which were divided into the training cohort (n = 509) and the validation cohort (n = 150). 540 cases (81.9%) patients recovered well after calcaneal fracture surgery. According to multivariate logistic regression analysis, female (OR = 2.525, 95% CI 1.283-4.969), > 60 years (OR = 6.644, 95% CI 1.243-35.522), surgery within 8-14 days after fracture (OR = 2.172, 95% CI 1.259-3.745), postoperative infection (OR = 4.613, 95% CI 1.382-15.393), and weight-bearing time longer than 3 months after surgery (4-6 months, OR = 2.885, 95% CI 1.696-4.907; 7-12 months, OR = 3.030, 95% CI 1.212-7.578; > 12 months, OR = 15.589, 95% CI 3.244-74.912) were independent risk factors for postoperative recovery of calcaneal fractures. The C-indices were 0.750(95% CI 0.692-0.808) in the training cohort and 0.688(95% CI 0.571-0.804) in the external validation cohort, and the C-index of internal validation was 0.715. The Hosmer-Lemeshow test showed good fitting of the model (all P > 0.05), which was consistent with the results of the calibration plots. Decision Curve Analysis indicated that the clinical effectiveness was the best when the threshold probability was between 0.10 and 0.45.

CONCLUSIONS

Patients with female, > 60 years, surgery within 8-14 days after fracture, postoperative infection, and weight-bearing time longer than 3 months after surgery are more likely to have poor postoperative recovery. The risk prediction of fracture patients through this model might be translated into clinical guidance and application. Trial registration This study was registered on the Chinese Clinical Trial Registry (Registration number: ChiCTR-EPR-15005878).

Intraoperative Foot Positioning During Percutaneous Calcaneal Fixation: A Technical Note

Percutaneous screw fixation is a good modality for operative management of extra-articular and some intra-articular fractures of the calcaneum amenable to closed reduction. Tongue-type calcaneal fractures with a dislocated posterior facet are usually treated with percutaneous fixation. When treating calcaneal fractures with substantial soft tissue compromise, particularly open fractures, percutaneous reduction techniques are crucial. They also provide patients with local or systemic contraindications to open reduction with a therapeutic option. We describe the intraoperative positioning of the foot using a lithotomy stirrup during percutaneous fixation of the calcaneal fractures with minimum manipulation of the foot and C-arm and consistent imaging.

Outcomes of U-shaped internal fixation in the treatment of avulsion fracture of calcaneal tubercle

BACKGROUND

The purpose of this study was to analyze the efficacy of U-shaped internal fixation for calcaneal tubercle fracture after nearly 3 years of case follow-up and data collection.

METHOD

We retrospectively analyzed the collected data from 16 patients with avulsion fracture of calcaneal tubercle between December 2018 and February 2021 at our institute. All patients were required to conform to regular follow up postoperatively. X-ray film was applied to all cases. The American Orthopaedic Foot and Ankle Association (AOFAS) score, Cedell score and the visual analog scale (VAS) were used to evaluate functional results.

RESULTS

All patients achieved bone union. The preoperative AOFAS score was 26.34 ± 3.34, which was significantly different from 91.38 ± 6.15 half a year after operation (p = 0.003). The preoperative Cedell score was 31.05 ± 4.18 and the score half a year after operation was 92.17 ± 5.39(p = 0.011). The VAS score was 8.91 ± 1.51 before operation and decreased to 0.58 ± 1.31 half a year after operation (p = 0.014).

CONCLUSIONS

In the treatments of calcaneal tubercle fracture, U-shaped internal fixation is a new attempt. Through the short-term follow-up study, we found that its therapeutic effect is excellent, which is a recommended treatment in clinic.

Does robot-assisted percutaneous hollow screw placement combined with tarsal sinus incision reduction in the treatment of calcaneal fracture perform better at a minimum two year follow-up compared with traditional surgical reduction and fixation?

PURPOSE

We aimed to evaluate the safety and efficacy of robot-assisted percutaneous hollow screw placement combined with tarsal sinus incisions for treating calcaneal fractures.

METHODS

Clinical data of 50 patients with calcaneal fractures treated from January 2018 to June 2020 were analyzed retrospectively. Twenty-six patients (26 feet) were included in the traditional group (traditional surgical reduction and internal fixation) and 24 (24 feet) in the robot-assisted group (robot-assisted internal fixation of tarsal sinus incision). The operation time, C-arm fluoroscopy dose, fracture healing time, Gissane angle, Böhler angle, calcaneal width, calcaneal height, visual analogue scale (VAS) scores, and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were compared between the groups preoperatively and two years postoperatively.

RESULTS

Operation time was significantly longer in the traditional group than in the robot-assisted group, while the intraoperative C-arm fluoroscopy dose was significantly lower in the robot-assisted than in the traditional group (P < 0.05). Both groups were followed up for 24-26 months (average, 24.9 months). Two years postoperatively, the Gissane angle, Böhler angle, calcaneal height, and calcaneal width improved significantly in both groups, without significant differences. Fracture healing time was not significantly different in both groups (P > 0.05). The two year postoperative VAS and AOFAS scores in both groups were significantly higher than the preoperative scores, but the robot-assisted group postoperative AOFAS scores were significantly higher than those in the traditional group (t =  - 3.775, P = 0.000).

CONCLUSION

Robot-assisted internal fixation of tarsal sinus incision is effective in treating calcaneal fractures with satisfactory long-term follow-up outcomes.

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

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

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

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

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

Minimally invasive treatment and internal fixation vs. extended lateral approach in calcaneus fractures of thalamic interest

The extended lateral side approach is a common technique in the surgical treatment of calcaneal fractures, with thalamic collapse offering a good exposure of the fractured site; however, it can be burdened with complications due to soft tissue trauma. The present study aimed to compare patients treated with minimally invasive osteosynthesis through a minimum lateral approach and internal fixation with patients that were treated using internal fixation with an extended lateral side approach in cases of intra-articular calcaneal fractures with thalamic fracture. Patients were evaluated preoperatively and postoperatively by performing clinical and imagistic examinations, with radiography scans of the anterior-posterior calcaneal profile and computer tomography. Furthermore, preoperative and postoperative analyses of the Böhler angle on the radiological profile, complications and duration of the hospital admission for both groups were performed. There were 36 patients (39 calcaneal fractures) in group 1 and 24 patients (29 calcaneal fractures) in group 2. The results demonstrated no statistically significant differences in the preoperative (P=0.72) and postoperative (P=0.20) Böhler angle values. The postoperative Böhler angle average values were 26.9 in group 1 and 29.3 in group 2. A total of 11 patients were treated with Kirschner wires inserted in the calcaneus, and in 2/ll cases, one of the brooches registered a migration movement. There were no cases of material migration in the fractures that were stabilized by inserting Kirschner brooches up to the astragalus and cuboid bones. Taken together, the results of the present study demonstrated no significant differences in the Böhler angle values between the minimally invasive and open reduction techniques. However, the antibiotic therapy period, as well as the infection rate were lower in patients that were treated using the minimally invasive technique, suggesting that this technique was superior with respect to lower complication rates and improved functional results.

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

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

Plate fixation through the lateral extensile approach versus cannulated screw fixation through the sinus tarsi approach for calcaneal fracture: a multicenter, propensity score-matched TRON study

PURPOSE

For calcaneal fracture, plate fixation through lateral extensive approach (LEP) is the most common procedure performed to achieve anatomic reduction. However, wound complications sometimes occur after LEP. To reduce complications, minimally invasive operative methods with cannulated screw fixation through sinus tarsi approach (STS) were developed. The aim of this multicenter propensity-matched study was to compare the clinical and radiographic outcomes of LEP to those of STS for calcaneal fracture and to evaluate the incidence of postoperative complications including surgical site infection (SSI).

METHODS

We extracted 271 patients with calcaneal fracture undergoing surgery between January 2014 and March 2019 from our multicenter TRON database. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score at the final follow-up as the clinical outcome. We obtained the Bohler and Preis angles as radiographic parameters and also recorded the complications. We divided the subjects into two groups: LEP group and STS group. To adjust for baseline differences between the groups, a propensity score matching algorithm was used in a 1:1 ratio.

RESULTS

After matching, there were 32 fractures in each group. There was no significant difference between the LEP versus STS group in AOFAS score at final follow-up (90 vs 90 points, p = 0.98) and in the Bohler and Pries angles (19.2 vs. 18.0 degrees, p = 0.74 and 16.0 vs. 17.5 degrees, p = 0.47). The rate of SSI in the LEP group was higher than that in the STS group (21.9% vs. 0.0%, p = 0.01).

CONCLUSION

For calcaneal fracture, STS provides similar fixation effectiveness and functional outcomes as LEP while reducing the likelihood of infection.

Value of modified axial review radiograph in diagnosing calcaneal fractures

To investigate the value of modified calcaneal axial radiograph—the horizontal calcaneal axial radiograph in diagnosing calcaneal fractures, patients who had acute calcaneal fractures or internal fixation were enrolled, and three groups were established, including the acute fracture group (n = 20), the internal fixation group (n = 20), and the healthy control group (n = 20). All the subjects had regular and modified calcaneal axial radiograph for comparison. In analysis of the results, all volunteers could have ankle dorsiflexion at different degrees. When the ankle was at 30º dorsiflexion for regular axial radiograph, the subtalar joint and the sustentaculum tali could not be clearly displayed. The calcaneus was elongated if the tube tilted in a larger angle but shortened if the tube titled in a smaller angle. When the ankle was at neutral (0º dorsiflexion) location with the tube tilting 45° cephalad or when the ankle was at 20° plantarflexion with the tube tilting 35° cephalad, the subtalar joint, sustentaculum tali, calcaneal body and internal and external calcaneal processes could all be clearly demonstrated. No significant difference (P = 0.79) existed in displaying the bony anatomical structures in regular compared with modified calcaneal axial radiography. For patients with acute calcaneal factures or with internal fixation, the modified calcaneal axial radiography could display more significantly clearly (P = 0.001) bony anatomical structures than the regular one. In conclusion, the modified calcaneal axial radiograph can be performed easily and can clearly show the bony structure of the calcaneus and surrounding bones without adding pain to the patients with calcaneal fractures.