Management of calcaneal malunion

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.

Y-shape osteotomy combined with subtalar arthrodesis for calcaneus malunion: a retrospective study

BACKGROUND

This retrospective study aimed to introduce a novel method for simultaneous Y-shape osteotomy combined with subtalar arthrodesis for calcaneus malunion and to evaluate the feasibility of this method.

METHODS

We retrospectively analysed the clinical and imaging data of 11 patients with calcaneus malunion treated using Y-shape osteotomy and subtalar arthrodesis who were admitted to our hospital from June 2018 to October 2020. The patients included 9 males and 2 females aged from 24 to 69 years old, with an average age of 42.18 years. The clinical and radiological results were assessed with the Visual Analogue Scale (VAS) pain score and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. In addition, functional recovery and general quality of life were evaluated using the 12-Item Short-Form Survey (SF-12).

RESULTS

All radiological parameters were significantly improved at the last follow-up, with increases of 14.37°, 9.18°, and 4.51 mm in the Böhler's angle, calcaneal pitch angle, and talocalcaneal height, respectively, and decreases of 6.39 mm and 6.18° in the calcaneal width and Hindfoot alignment angle (p < 0.05). The mean AOFAS and VAS scores at the last follow-up improved compared with those preoperatively, from 34.18 ± 9.53 to 84.18 ± 11.59 and from 6.90 ± 1.22 to 1.90 ± 1.13, respectively (p < 0.05). The SF-12 physical and mental health scores were 49.65 ± 6.84 and 52.68 ± 7.88, respectively. Furthermore, the early postoperative complications included skin necrosis in one and sural neuralgia in one patient, and the late postoperative complication included ankle pain in one patient. No other complications, such as implant discomforts, malunion, nonunion and re-fracture, were presented.

CONCLUSION

These results indicate that Y-shape osteotomy combined with subtalar arthrodesis is an effective new method for the treatment of calcaneal malunion. Advantages include improvement of the anatomic shape of the calcaneus and union rates for subtalar arthrodesis.

Complication Rates Are Similar Between Patients Aged <50 and >50 Years in Calcaneus Fractures Treated With the Sinus Tarsi Approach

Background:

The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years with an increased interest in shifting to less invasive approaches for calcaneal fracture fixation allowing for adequate fixation if complications do not arise. Although the ST approach has gained acceptance as standard for calcaneus fracture fixation, the literature surrounding early complications rates based on age differences for this specific approach and pathology is lacking. The objective of this study was to determine if rates of complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of closed calcaneus fractures using the ST approach.

Methods:

A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria were based on an age greater than 18 years, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative computed tomographic scan, and a minimum of 180 days’ follow-up. Patients were divided into 2 groups: those aged <50 years and those aged >50 years.

Results:

A total of 196 fractures were included with 114 fractures in the <50-year age group and 82 fractures in the >50-year age group. Mean age was 34.2 and 59.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.2% vs 4.4%, P = .204), superficial surgical site infection (1.2% vs 2.6%, P = .490), deep infection (9.8% vs 7.9%, P = .648), and nonunion (4.9% vs 3.5%, P = .633) compared with the younger group. Rates of 30-day readmission, unplanned reoperation, and symptomatic hardware were not significantly different. Postoperative Bohler and Gissane angles were not significantly different between both groups.

Conclusion:

Older patients with intraarticular calcaneus fractures treated via the ST approach maintain complication rates similar to those in younger individuals.

Level of Evidence:

Level III, retrospective study.

Staged Ilizarov distraction histogenesis and corrective reconstruction for severe malunited calcaneal fractures

PURPOSE

Severe calcaneal malunion is a clinical conundrum for the difficulty of calcaneal reconstruction without soft tissue complications. The aim of this study is to introduce the treatment strategy and preliminary results of staged Illizarov distraction histogenesis and corrective reconstruction for severe malunion of calcaneal fractures.

METHODS

From June 2014 to May 2020, 14 patients with severe calcaneal malunion treated with the staged strategy were retrospectively analyzed. At the first stage, calcaneal osteotomy and external fixation with Ilizarov frame were performed. The restoration of the approximate configuration of calcaneus and the expansion of contractural soft tissue were achieved by gradual calcaneal distraction. At the second stage, corrective reconstruction was performed and autogenous iliac crest bone graft was used. Clinical and radiographic outcomes were evaluated at final follow-up.

RESULTS

The average time of Ilizarov distraction and total fixation was 21.4 days and 41.0 days at first-stage treatment. At a mean follow-up of 33.1 months, the average American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score increased significantly from 24.0 to 72.4 (p < 0.01). And the mean visual analogue scale (VAS) score had improved remarkably from 8.2 to 2.4 (p < 0.01). Radiographs showed that talocalcaneal height, calcaneal width, calcaneal tuberosity height, hindfoot alignment angle, and talar declination angle were improved to a great extent (p < 0.01). Only one patient had minor pin site infection at first-stage treatment and one got superficial wound infection after second-stage surgery. No wound dehiscence, skin necrosis, or deep infection occurred.

CONCLUSION

Staged Ilizarov distraction histogenesis and corrective reconstruction is a safe and effective treatment strategy for reducing soft tissue complications and improving reconstruction results in surgical correction of severe calcaneal malunion.

Arthroscopic Subtalar Arthrodesis as a Treatment Strategy for Subtalar Arthritis: A Systematic Review

Arthroscopic subtalar arthrodesis is a relatively new technique which is increasingly being used by foot and ankle surgeons as an alternative to open surgery. However, there is still a lack of consensus with respect to the efficacy of the procedure. The purpose of this review was to ascertain (1) whether arthroscopic subtalar arthrodesis improves the functional outcome of treated patients and (2) how do the 2 techniques of subtalar arthroscopy (posterior and lateral) compare with each other. MEDLINE and Cochrane Library databases were accessed by 2 independent reviewers. Inclusion/exclusion criteria were predefined. National Institute of Health risk of bias assessment tool was used to determine the methodological quality of the included studies. A total of ten studies with 234 patients (240 feet) were included. The most common indication for arthroscopic subtalar fusion was posttraumatic subtalar arthritis. Weighted pre- and postoperative American Orthopaedic Foot and Ankle Society scores were 47 and 80.7, respectively. Average time to fusion was 10.2 weeks and weighted mean fusion rate was 95%. Pain secondary to prominent hardware and nonunion were the most common complications. Although improvement in functional scores was higher and complication rate lower with the posterior group, a better fusion rate was seen with the lateral approach. Arthroscopic fusion techniques have shown to be an effective alternative to open surgery. While there was a trend for better functional outcome with the posterior approach, randomized control trials comparing the 2 techniques are needed to better assess their respective outcomes.

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.

Corrective osteotomy and partial tarsal arthrodesis in two greyhounds with calcaneal malunion

OBJECTIVE

To describe the clinical presentation and outcome of two greyhounds with calcaneal malunions that were treated with corrective osteotomy and partial tarsal arthrodesis.

STUDY DESIGN

Short case series.

ANIMALS

Two adult racing greyhounds.

METHODS

Varus and recurvatum deformity of the calcaneus was ascribed to malunion of prior calcaneal fracture with concomitant central bone fracture that had been sustained during racing in both dogs. Both dogs exhibited severe, weight-bearing lameness and had radiographic evidence of moderate to severe osteoarthritis of the proximal intertarsal joint. A closing wedge corrective osteotomy and partial tarsal arthrodesis were performed with a 2.7-mm locking compression plate and cancellous autograft.

RESULTS

Calcaneal morphology and alignment of the common calcaneal tendon seemed restored postoperatively. The implant was removed in one dog, while the other dog experienced no postoperative complications. Lameness improved in both dogs, although residual intermittent lameness after heavy exercise was reported by owners of both dogs 1 year after surgery. Overall, owner satisfaction and outcome were considered good-to-excellent in both dogs.

CONCLUSION

Corrective osteotomy and partial tarsal arthrodesis for treatment of malunited calcaneal fractures may be considered in dogs with clinical signs related to calcaneal malunion.

Endoscopic Lateral Calcaneal Ostectomy and Peroneal Tendon Decompression With the Patient in the Prone Position as Management of Subfibular Impingement After Calcaneal Fracture

Subfibular impingement is a common cause of lateral heel pain after calcaneal fracture. It can be caused by calcaneofibular impingement, peroneal impingement, or a combination thereof. It may not be easy to differentiate bony impingement from soft-tissue impingement. Simultaneous lateral calcaneal ostectomy and peroneal tendon decompression may increase the chance of pain relief. The purpose of this Technical Note was to report the technical details of endoscopic lateral calcaneal ostectomy and peroneal tendon decompression with the patient in the prone position. This technique is indicated for symptomatic subfibular impingement recalcitrant to conservative treatment. It has the advantages of being minimally invasive surgery and allowing early mobilization of the foot and ankle.

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.

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.

Salvaging the Unsalvageable Severe Malunion Deformity After Displaced Intra-Articular Calcaneal Fractures: What Options Exist?

A subset of calcaneal fractures is so severe that it may warrant primary conservative treatment. Unfortunately, nonoperative management of these fractures can lead to the development of a calcaneal malunion and cause significant patient morbidity. Surgical management of these deformities often requires increasingly complex reconstructive procedures. The goals of surgery include re-establishing calcaneal height, restoring the talocalcaneal relationship, and creating a stable, plantigrade foot. This article highlights the available surgical treatment options (including calcanectomy, calcaneal allograft transplantation, vascularized autografts, and calcaneal prostheses) for the management of severe calcaneal malunion deformities.

Management of Calcaneal Fracture Malunion with Bone Block Distraction Arthrodesis: A Systematic Review and Meta-Analysis

One of the most severe complications in calcaneal fractures is a malunion. When a malunion occurs, subtalar bone block distraction arthrodesis provides restoration of calcaneal height, length, correction of varus deformity, and elimination of subtalar joint arthritis. A systematic review showed the union rate for all procedures was 95.78%. The overall complication rate was 38% for all procedures. This is the first study to categorically break down complications with statistical analysis. The data presented indicate the level of difficulty of the subtalar distraction bone block arthrodesis for calcaneal malunions and may even suggest the need for newer techniques.

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.

Treatment of intraarticular calcaneal fractures by reconstruction plate. Results and complications of 86 fractures

OBJECTIVE

To evaluate the results of surgical treatment of intraarticular calcaneal fractures, and also to analyze the variables that influence the final clinical and radiological outcomes as well as the complications.

MATERIAL AND METHODS

We retrospectively analyzed 86 intraarticular calcaneal fractures in 78 patients, who underwent surgery with an extended lateral approach and reconstruction plate. The mean age was 48 years (16-74 years) and the mean follow-up was 4.6 years (9-99 months); 54 patients (69.2%) suffered falls from less than 3m in height or banal injuries and 24 patients (30.8%) falls from more than 3m in height or high energy-accidents. According to the Sanders classification we operated 12 (15%) typeII, 54 (62.8%) typeIII and 20 (23.2%) typeIV fractures.

RESULTS

The postoperative mean AOFAS score was 73.9 points, with good or excellent results in 57% of the patients. Twelve cases (14%) suffered surgical wound complications and 11 (12.8%) required subtalar arthrodesis. Significantly better results were obtained in the patients younger than 30 years old, patients that fell from less than 3m in height and patients with Sanders fractures types II and III compared to typeIV, which were associated with higher rate of subtalar arthrodesis.

CONCLUSIONS

We consider that open reduction and internal fixation of intraarticular fractures of the calcaneus with reconstruction plate is a valid treatment alternative. Given the complications described and the secondary subtalar arthrodesis rate, we recommend a meticulous technique carried out by experienced surgeons.

Endoscopic Management of Calcaneofibular Impingement and Posterior Ankle Impingement Syndrome Caused by Malunion of Joint Depressed-Type Calcaneal Fracture

Identification of the correct source of symptoms is the key in formulating the correct treatment plan for heel pain after calcaneal malunion. Calcaneofibular and posterior ankle impingements can occur due to malunion of a joint depressed-type calcaneal fracture. The purpose of this Technical Note is to report the technical details of posterior and lateral decompression through the posteromedial and posterolateral portals using posterior ankle endoscopy.

Displaced Intra-articular Calcaneal Fractures: Classification and Treatment

The calcaneus is the most commonly fractured tarsal bone. Displaced intraarticular calcaneal fractures are usually caused by a fall from height with one or both heels directly hitting the ground. Displaced intra-articular calcaneal fractures are complex and highly disabling injuries. There is ongoing debate regarding the optimal treatment for each type of displaced intra-articular calcaneal fracture. This review aims to summarize the classification of, various treatment options for, prevention of perioperative complications in, and management algorithms for displaced intra-articular calcaneal fractures. [Orthopedics. 2017; 40(6):e921-e929.].

Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation

PURPOSE

Early post-operative exercise and weight-bearing activities are found to improve the functional recovery of patients with displaced intra-articular calcaneal fractures (DIACFs). We hypothesized that early functional exercise after surgery might have a secondary reduction effect on the subtalar joint, in particular the smaller fracture fragments that were not fixed firmly. A prospective study was conducted to verify this hypothesis.

METHODS

From December 2012 to September 2013, patients with unilateral DIACFs were enrolled and received a treatment consisting of percutaneous leverage and minimally invasive fixation. After surgery, patients in the study group started exercising on days two to three, using partial weight bearing starting week three, and full weight bearing starting week 12. Patients in the control group followed a conventional post-operative protocol of partial weight bearing after week six and full weight bearing after the bone healed. Computed tomography (CT) scanning was performed at post-operative day one, week four, week eight, and week 12 to reconstruct coronal, sagittal, and axial images, on which the maximal residual displacements of the fractures were measured. Function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale at the 12th post-operative month.

RESULTS

Twenty-eight patients in the study group and 32 in the control group were followed up for more than 12 months; their data were collected and used for the final analysis. Repeated-measures analysis of variance (ANOVA) of the maximal residual displacements of the fracture measured on CT images revealed significant differences between the study and the control groups. There were interaction effects between group and time point. Except for the first time point, the differences between the groups at all studied time points were significant. In the study group, the differences between all studied time points were significant. Strong correlations were observed between the AOFAS score at post-operative month 12 and the maximal residual displacement of the fractures on the CT images at postoperative week 12.

CONCLUSIONS

Early functional exercise and weight bearing activity can smooth and shape the subtalar joint and reduce the residual displacement of the articular surface, improving functional recovery of the affected foot. Therefore, early rehabilitation functional exercise can be recommended in clinical practice.

Synovitis of the Tarsal Canal: An Uncommon Cause of Lateral Heel Pain After Triple Arthrodesis

Lateral heel pain after triple arthrodesis can have numerous causes, including nonunion of the fusion site, hindfoot malalignment, degenerative arthritis in adjacent joints, and deep infection. We present a case of lateral heel pain after triple arthrodesis due to synovitis of the tarsal canal that was successfully treated with anterior subtalar arthroscopy.

Complications of Intra-articular Calcaneal Fractures in Adults: Key Points for Diagnosis, Prevention, and Treatment

Calcaneal fractures are complex injuries with high complication rates and they can lead to serious disability. The proper management remains controversial and complications may occur regardless of the chosen type of treatment (operative or nonoperative). The present article reviews the studies that are related to the complications of calcaneal fractures. The incidence, the diagnosis, the prevention and the treatment of these complications were researched and analyzed, with the use of PubMed database, abstracts and original articles in English than investigate the etiology. The aim of the article is to discuss the most suitable management of the complications of calcaneal fractures and recommend a specific treatment as well as prevention methods.

LEVELS OF EVIDENCE

Level IV.

Complications in operative fixation of calcaneal fractures

OBJECTIVE

The purpose of this study focused on a number of factors that have been implicated in calcaneal complications and find the incidence of wound complications.

METHODS

This was a retrospective study. A total of 162 patients (176 feet) who underwent calcaneal fractures between 2007 and 2012 were included. The patient's personal details, age, time from injury to surgery, cause of injury, type of fracture, operative details, operating and tourniquet times were collected from hospital computers and paper records. Evidence of complications including wound infection, wound necrosis, pain, malunion, nonunion, impingement, loss of fixation, ect were studied.

RESULTS

Forty-seven of one hundred and seventy-six fractures (26.704%) had complications, wound infection was noted in seven fractures (3.977%), twelve fractures developed necrosis (6.818%), 14 fractures (7.955%) developed pain. Malunion was found in five fractures (2.841%), nonunion in two fractures (1.136%) and loss of fixation in four fractures (2.272%). Three neurologic injury was also seen in our study (1.705%). Operating time, time from injury to surgery and type of fracture had some association with complications in operative fixation of calcaneal fractures, which showed a statistically significant improvement (P=0.000, 0.031, 0.020, respectively), but there were no evidence that age and tourniquet time affect the incidence of complication after calcaneal fracture surgery (P=0.119, 0.682, respectively).

CONCLUSIONS

Despite developments in the surgical treatment of calcaneal fracture, wound complications still remain inevitable. Advanced imaging techniques, less invasive surgical procedures, wealth of anatomical knowledge, surgical experience and better postoperative care should be ensured.

Corrective Osteotomies for Malunited Tongue-Type Calcaneal Fractures

Displaced tongue-type fractures of the calcaneus can lead to severe pain and disability if not treated appropriately. Failure to reduce articular displacement may require subtalar joint arthrodesis with subsequent loss of function. The subtalar joint is crucial for normal foot and ankle function. In selected cases, if the malunited joint is still in good condition, it is preserved by corrective osteotomy. A joint-preserving osteotomy with axial realignment is a treatment option for malunited tongue-type calcaneal fractures encountered early on, before the development of subtalar arthrosis in carefully selected patients.

Subtalar joint arthrodesis: open and arthroscopic indications and surgical techniques

Arthrodesis of the subtalar joint can be performed via both open and arthroscopic techniques. Both groups of procedures have their own relative indications and contraindications, as well as complications. Good results have been reported for both general procedures, although some studies suggest superiority with arthroscopic subtalar arthrodesis.

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.

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.

Ankle arthritis: review of diagnosis and operative management

The diagnostic and therapeutic options for ankle arthritis are reviewed. The current standard of care for nonoperative options include the use of nonsteroidal antiinflammatory drugs, corticosteroid injections, orthotics, and ankle braces. Other modalities lack high-quality research studies to delineate their appropriateness and effectiveness. The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the superiority in functional outcomes of total ankle arthroplasty is increasing. The next few years will enable more informed decisions and, with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.

Postoperative complications after closed calcaneus fracture treated by open reduction and internal fixation: a review

OBJECTIVE

To review postoperative complications reported after closed calcaneus fracture treated by open reduction and internal fixation (ORIF).

METHODS

Postoperative complications reported in the literature between 1995 and 2012 were identified. Papers were retrieved from publicly available databases and included in this study if they met the following criteria: clinical research of cases of closed calcaneus fracture treated by ORIF; ≥10 cases; detailed information about complications, treatment and follow up.

RESULTS

Twenty-one clinical reports were analysed (2046 cases). Reported complications (and incidence rates) were: infection and skin flap necrosis (13.6%); neurovascular injury (2.8%); post-traumatic arthritis (1.2%); malreduction/implant problems (0.8%); nonunion (0.1%).

CONCLUSIONS

Postoperative complications after closed calcaneus fracture are common clinical problems that cannot always be avoided. They can even be life altering, due to the requirement for long-term treatment or amputation and their economic impact on the patient. Complications should be diagnosed and treated promptly, to achieve satisfactory outcomes. Nonsurgical treatment (e.g. local wound care, drugs or physical therapy) can be attempted. If such measures fail, surgical treatment (e.g. debridement, skin flap transplantation, implant removal, re-opening of the reduction and internal fixation or subtalar joint arthrodesis) should be considered.

Surgical Management of Calcaneal Malunion

Calcaneal malunion is a common complication after conservative treatment or incorrect surgical treatment of calcaneal fracture. The typical pathoanatomies of calcaneal malunion are subtalar joint incongruity, loss of calcaneal height, arch collapse, varus or valgus deformity of the calcaneus, heel widening and so on. Calcaneal malunion often needs to be treated surgically. The classification of calcaneal malunion and the detailed clinical and radiographical assessment play important roles for surgical option. The main surgical methods include in situ subtalar arthrodesis, reconstruction of calcaneal thalamus and subtalar arthrodesis, calcaneal osteotomy with subtalar arthrodesis, corrective calcaneal osteotomy without subtalar arthrodesis. Each option has its different indications, advantages and disadvantages. Thus, the surgical treatment should be individualised.

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.

Reconstruction of calcaneal fracture malunion with osteotomy and subtalar joint salvage: technique and outcomes

BACKGROUND

The goal of this study was to discuss the outcomes of treating calcaneal fracture malunion by restoring the subtalar joint with a reconstructive osteotomy.

METHODS

From May 2005 to November 2008, 24 patients (26 feet) with calcaneal malunions after a displaced intra-articular calcaneal fracture were treated by osteotomy and autogenous bone graft. The subtalar joint was preserved. The mean time from initial injury to reconstructive operation was 5.7 months (95% confidence interval, 4.5-8.8 months). The displaced posterior facet was restored through a reconstructive osteotomy, whereas the bone defect in the calcaneus after reduction was filled with the exostosis that had been removed; iliac bone graft was used if necessary. All patients were evaluated clinically and radiographically at a minimum of 24 months. Twenty patients (21 feet) were followed for a mean of 34.2 months (29.0-39.4 months).

RESULTS

According to American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, the average score was 85.9 points (95% confidence interval, 81.5-90.4 points), which was significantly higher than the preoperative assessment. Radiographs showed that Böhler's angle, Gissane's angle, talus declination angle, and width and height of calcaneus were improved to a great extent. Six patients had wound edge necrosis, and 2 had superficial infection. One patient required a subtalar fusion for subtalar arthritis at 2 years after surgery.

CONCLUSIONS

Restoring the subtalar joint with a reconstructive osteotomy and autogenous bone graft was an effective treatment method for selected calcaneal fracture malunions. It reconstructed calcaneal morphology and preserved the subtalar joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Management of calcaneal fractures: what have we learnt over the years?

Calcaneal fractures result, in many cases, in, subtalar joint stiffness and severe disability. Diagnosis is usually made by X-ray, but more accurately by a computed tomography (CT) scan. In the last years, much has been known regarding its physiopathology and osteosynthesis. Although new developments in osteosynthesis materials have been made, calcaneus fractures still remains in dispute of those advocating non-operative treatment and those defending open reduction and internal fixation. Less invasive surgery, arthroscopy and three-dimensional (3D) fluoroscopy are very important for reduction accuracy and soft-tissue damage avoidance. In this article, the physiopathology, diagnosis, classification and treatment of calcaneus fractures are updated. Nevertheless, systematic reviews have shown no evidence about what treatment is better.