[A prospective study on treatment of Sanders type and calcaneal fractures with interlocking intramedullary nail fixation system]

Objective

To explore the effectiveness of interlocking intramedullary nail fixation system for Sanders type Ⅱ and Ⅲ calcaneal fractures by comparing with open surgery.

Methods

Forty patients (40 feet) with Sanders type Ⅱ and Ⅲ calcaneal fractures, who were admitted between May 2020 and December 2022 and met the selection criteria, were included in the study. They were randomly allocated into control group and minimally invasive group using a random number table method, with 20 cases in each group. The patients were treated with the interlocking intramedullary nail fixation system in the minimally invasive group and with steel plate internal fixation via a lateral L-shaped incision in the control group. There was no significant difference between the two groups ( P>0.05) in terms of gender, age, fracture classification and side, cause of injury, time from injury to admission, and preoperative width, length, height, Böhler angle, and Gissane angle of the calcaneus. The operation time, intraoperative blood loss, incision length, hospital stay, fracture healing time, incidence of complications, as well as pre- and post-operative imaging indicators (Böhler angle, Gissane angle, width, height, and length of the calcaneus) and American Orthopaedic Foot and Ankle Society (AOFAS) score of foot were recorded and compared between the two groups.

Results

The incision length, operation time, and hospital stay of the minimally invasive group were significantly shorter than those of the control group, and the intraoperative blood loss significantly reduced ( P<0.05). All patients of the two groups were followed up, with the follow-up time of 8-12 months (mean, 10.2 months) in the minimally invasive group and 8-12 months (mean, 10.4 months) in the control group. No complication occurred in the minimally invasive group after operation. One case of incision epidermal necrosis and 1 case of traumatic arthritis occurred in the control group after operation. However, there was no significant difference in the incidence of complications between the two groups ( P>0.05). At last follow-up, the AOFAS score was significantly higher in the minimally invasive group than in the control group ( P<0.05). Imaging examination showed that the calcaneal fractures of the two groups healed, and there was no significant difference in healing time between the two groups ( P>0.05). Compared with preoperative conditions, the Böhler angle and Gissane angle of the calcaneus in the two groups significantly increased, the width narrowed, and the height and length increased at 3 days after operation and the last follow-up, with significant differences ( P<0.05). There was no significant difference between 3 days after operation and last follow-up ( P>0.05). There was no significant difference between the two groups at each time point ( P>0.05).

Conclusion

The interlocking intramedullary nail fixation system in treatment of Sanders type Ⅱ and Ⅲ calcaneal fractures has the advantages of minimal trauma, shortened hospital stay, reliable fracture reduction and fixation, and satisfactory foot function recovery.

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study

BACKGROUND

Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction.

METHODS

This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate.

RESULTS

Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork.

CONCLUSION

Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane.

LEVEL OF EVIDENCE

III.

Primary arthrodesis versus open reduction and internal fixation following intra-articular calcaneal fractures: a weight-bearing CT analysis

PURPOSE

To compare primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) in displaced intra-articular calcaneal fractures (DIACFs), based on clinical outcome and 2D and 3D geometrical analyses obtained from weight-bearing (WB) cone-beam CT images.

MATERIALS AND METHODS

In this prospective study, 40 patients with surgically treated calcaneal fractures were included, consisting of 20 PA and 20 ORIF patients. Weight-bearing cone-beam CT-images of the left and right hindfoot and forefoot were acquired on a Planmed Verity cone-beam CT-scanner after a minimum of 1-year follow-up. Automated 2D and 3D geometric analyses, i.e., (minimal and average) talo-navicular joint space, calcaneal pitch (CP), and Meary's angle (MA), were obtained for injured and healthy feet. Clinical outcomes were measured using the EQ5D and FFI questionnaires.

RESULTS

Overall, there were no differences in baseline patient characteristics apart from age (p < 0.005). The calcaneal pitch in 2D after treatment by ORIF (13.8° ± 5.6) was closer to the uninjured side (18.1° ± 5.5) compared to PA (10.9° ± 4.5) (p < 0.001). Meary's angle in 2D was closer to the uninjured side (8.7° ± 6.3) after surgery in the PA cohort (7.0° ± 5.8) compared to the ORIF cohort (15.5° ± 5.9) (p = 0.046). In 3D measurements, CP was significantly decreased for both cohorts after surgery (- 4.09° ± 6.2) (p = 0.001). MA was not significantly affected overall or between cohorts in 3D. Clinical outcomes were not significantly different between the ORIF and PA cohorts. None of the radiographic measurements in 2D or 3D correlated with any of the clinical outcomes studied.

CONCLUSION

Three-dimensional WB CT imaging enables functional 2D and 3D analyses under natural load in patients with complex calcaneal fractures. Based on clinical outcome, both PA and ORIF appear viable treatment options. Clinical correlation with geometrical outcomes remains to be established.

External fixation in intra-articular fractures of the calcaneus: Is it a valid option as definitive treatment?

INTRODUCTION

The therapeutic management of calcaneal fractures is currently a major source of controversy in the literature. There is no consensus on the need to treat these injuries conservatively or surgically, nor on the criteria for deciding one option or the other. Although the gold standard has classically been the open approach and osteosynthesis, there are currently minimally invasive techniques that also report good results. Our objective is to present our results and experience with the MBA® Orthofix external fixator in a series of cases of calcaneal fractures.

METHODS

We performed a retrospective observational study in our center, between the years 2019 and 2021, of Sanders types II-IV calcaneal fractures operated with MBA® Orthofix external fixator. We recorded a total of 38 patients, 42 fractures. We registered demographic information, intraoperative, postoperative, radiological and functional parameters, using the American Orthopedic Foot and Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D and VAS scales.

RESULTS

A total of 26 men and 12 women were included, and the median age was 38 years. Mean follow-up was 24,4 months (6, 8-40, 1). The average time to surgery was 7 days and partial loading was started at 2.5 weeks after external fixation, which was removed at 9.2 weeks. The average Böhler angle correction was 7, 4°, Gissane - 12,2°, length 2 mm and calcaneal width was reduced by 5 mm. We recorded two superficial infections, one peroneal entrapment and three subtalar arthrodesis due to post-traumatic osteoarthritis. The AOFAS obtained was 79.1 + / - 15.7 points, MOXFQ 20.1 + / - 16.1 points, EQ-5D 0.84 + / - 0.2 and VAS 3.3 + / - 1.9.

CONCLUSION

The external fixator is an excellent surgical alternative for complex articular fractures of the calcaneus, obtaining clinical and radiological results comparable to other osteosynthesis techniques and significantly reducing soft tissue complications.

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.

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.

Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach

INTRODUCTION

Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA.

METHODS

Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes.

RESULTS

Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach.

CONCLUSION

Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.

Incidence and clinical results of tendinous injuries in calcaneus and pilon fractures

PURPOSE

The aims of this study were: (1) to define the incidence of tendinous injuries in calcaneus and pilon fractures with different fracture severity and (2) to determine the clinical impact of such injuries.

STUDY DESIGN AND METHODS

CT-scans of 121 patients with calcaneus and pilon fractures were retrospectively analyzed over a 4-year period. The tendinous injuries were identified and correlated with the type of fracture (location and classification). Clinical analysis was performed using the American Orthopedic Foot and Ankle Society (AOFAS) and SF-36 (Short Form-36 Health Survey) scores.

RESULTS

Tendinous injuries were observed in 36% of all CT-scans analyzed, with the most common injury being incarceration (n = 20) and dislocation (n = 24). Calcaneus fractures sanders type 3/4 were 9 times more prone to tendon injury (p < 0.001; OR 8.67; 95% CI 2.49-30.24). Pilon fractures Ruedi-Allgower type 2/3 were 8 times more prone to tendon injury (p = 0.005; OR 7.5; 95% CI 1.72-32.80). No significant differences (p > 0.05) were found in AOFAS and SF-36 scores between patients with/without tendon injuries for fractures with the same severity.

CONCLUSION

The incidence of tendon injuries in calcaneus/pilon fractures is high and may be underreported. Calcaneus fractures are prone to peroneal tendon injury. In pilon fractures, it is important to look for tibialis posterior tendon injury, especially entrapment. The presence of tendinous injuries does not affect function and pain for the same type of calcaneus and pilon fractures at the long term.

LEVEL OF EVIDENCE

Level 3 retrospective study.

A novel distractor-assisted reduction combined with the sinus tarsi approach for joint depression-type calcaneal fractures

PURPOSE

A novel percutaneous distractor with the advantage of axial and direct distraction was designed for the minimally invasive treatment of calcaneal fractures. The purpose of this study was to investigate the clinical results and complications of a novel distractor combined with sinus tarsi approach (STA) in treatment of the joint depression-type of calcaneal fractures.

METHODS

Fifty-four patients with the depression-type of calcaneal fractures (30 Sanders type II, 22 Sanders type III, 2 Sanders type IV) who were subjected to the novel distractor combined with STA were retrospectively assessed. Calcaneal height, width, and length; Bohler's angle; and the Gissane angle were evaluated pre-operatively and post-operatively. Clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) pain scores from the last follow-up. Complications were also recorded.

RESULTS

Fifty-two patients achieved an average follow-up of 24.3 months (range 18 to 34 months), and two patients were lost to follow-up six months post-operatively. There was significant difference between pre-operative and post-operative calcaneal height, width, and length; Bohler's angle; and Gissane angle (p < 0.01), but no significant difference was detected between the post-operative and normal side Bohler's angle (p > 0.05). The AOFAS ankle and hind foot score was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7 at the last follow-up. Nine (17.3%) patients developed complications: One experienced skin necrosis and two had screws loosening; three patients developed early degenerative changes of the subtalar joint; two had no symptoms; one had light pain around the subtalar joint without medical treatment; complex regional pain syndrome (CRPS) developed in one patient after seven months post-operatively; and two developed transient ankle stiffness.

CONCLUSION

The novel distractor combined with the STA effectively reconstructs the facet depression-type of calcaneal fractures (sanders type II and III) with minimal complications.

Management of the Subtalar Joint Following Calcaneal Fracture Malunion

Subtalar joint arthrosis is common following intra-articular calcaneus fractures. The appropriate management of pain secondary to posttraumatic arthritis depends on the status of the remaining posterior facet articular cartilage, the magnitude of any residual joint displacement and distortions in the overall morphology of the calcaneus. In select circumstances, joint-preserving surgical techniques may be considered including lateral wall exostectomy, far lateral posterior facet joint debridement, and intra-articular osteotomies. When the subtalar joint is not salvageable, some form of arthrodesis procedure is pursued. Occasionally, an extra-articular osteotomy may be necessary in combination with arthrodesis to correct deformity.

Screw fixation in the treatment of displaced intra-articular calcaneus fractures: a systematic review protocol

BACKGROUND

The Calcaneus is the largest bone of the foot and the most frequent tarsal bone to be fractured. Overall, it causes round about 10 cases per 100,000 residents per year mainly in men. Especially displaced intra-articular calcaneus fractures often have early and late complications and its associated disability. There are various strategies for the treatment of displaced intra-articular calcaneus fractures, but the gold standard is still subject of a long-standing controversy. Minimally invasive procedures became more common in an attempt to reduce the high rate of complications associated with open reduction and internal fixation. With the increase in minimally invasive techniques, screw fixation also gained in significance. The current literature does not sufficiently elucidate whether the screw fixation is superior to other treatment options especially in relation to adverse events, health-related quality of life and postoperative pain. This study aims to investigate benefits and harms of treating displaced intra-articular calcaneus fractures (types II, III and IV according to Sanders) with screw fixation in adults.

METHODS

A systematic review will be conducted based on the principles described in the Cochrane Handbook. We will include adults with displaced intra-articular calcaneus fractures of Sanders type II, III and IV. The surgical method of screw fixation shall be compared to other surgical interventions to stabilise calcaneus fractures. Primary outcomes are serious adverse events, health-related quality of life and postoperative pain level. MEDLINE, CENTRAL, CINAHL, Web of Science and bibnet.org, ClinicalTrial.gov and the World Health Organization International Clinical Trials Registry Platform (ICTR) will be searched. Screening and data extraction will be performed by two authors independently. A third author will arbitrate disputes. Risk of Bias will be assessed with the Cochrane tool. Meta-analysis will be performed if participants, interventions, comparisons and outcomes are sufficiently similar to ensure a result that is clinically meaningful.

DISCUSSION

Due to the increasing use of minimally invasive techniques and the increasing use of screw fixation instead of open reduction and plate fixation, it is important to analyse the benefits and harms of screw fixation for calcaneus fractures. Screw fixation could, in the future, help to operate in a less invasive and tissue preserving manner while still achieving an adequate functional result for the patient SYSTEMATIC REVIEW REGISTRATION: CRD42021244695.

Recovery of the medial gastrocnemius muscle after calcaneus fracture differs between contractile and elastic components

BACKGROUND

Calcaneal fractures result in severe functional impairments and walking restrictions. Postoperative evaluation mainly focusses on the restoration of calcaneal anatomy while ankle plantar flexor insufficiency remains largely neglected. This study aims to investigate biomechanical and morphologic adaptions of elastic and contractile components of the gastrocnemius medialis after unilateral calcaneal fracture.

METHODS

20 Patients (BMI: 27.6 ± 3.1 kgm^-2, Age: 50 ± 12 years) were measured using gait analysis and portable ultrasound over a follow-up of three, six and twelve months after surgery. Data comparison was performed using 20 matched healthy controls (BMI: 26.2 ± 2.9 kgm^-2, Age: 48 ± 11 years). Static and dynamic behavior of the gastrocnemius muscle tendon unit, muscle fascicle and the serial-elastic element as well ankle joint kinematics and kinetics were analyzed.

FINDINGS

Within patients, a significant (p < 0.05) increase in fascicle length (by 67%) during single support and a decrease of serial elastic element shortening (by 20%) during push off was found between three and twelve months follow-up comparisons. Patients showed differences for fascicle lengthening and pennation angle increase during single support after three and six months compared to healthy controls. A smaller shortening of the serial-elastic element (by 29%) and muscle-tendon unit (by 16%) persisted even for the twelve month comparisons.

INTERPRETATION

Patients with calcaneal fracture showed an incomplete restoration of the medial gastrocnemius dynamic morphological behavior. While muscle fascicle contraction almost recovered, the serial elastic component still showed restrictions regarding its shortening behavior. Limited foot mobility and plantarflexor strength as well as lowered responsiveness of elastic tissues to mechanical loading are regarded as key mechanisms.

Factors associated with return to duty and need for subsequent procedures after calcaneus open reduction internal fixation in the military

INTRODUCTION

Calcaneus fractures can be devastating injuries, and operative treatment is fraught with complications. We are unaware of any studies evaluating all calcaneus fractures, both open and closed, treated operatively in the military. The purpose of this study is to evaluate all calcaneus fractures that required open reduction internal fixation to determine soldiers' ability to return to work and the need for additional surgeries.

METHODS

All active-duty patients undergoing open reduction internal fixation of calcaneus fractures from 2010-2016 were identified utilizing the Military Health System Management Analysis and Reporting Tool (M2). Armed Forces Health Longitudinal Technology Application (AHLTA) was utilized to determine comorbid medical conditions, subsequent procedures, surgical outcomes, and duty status within the military.

RESULTS

Three hundred seventy-five active-duty service members who met our inclusion/exclusion criteria were identified. One hundred fifty-one patients (55.1%) sustained their calcaneus fracture as a result of a blast injury. One hundred sixty (59.3%) patients required separation from the military as a result of their injury. Among patients who required a subsequent procedure, thirty-four patients (9.1%) required a subtalar arthrodesis, and thirty-two patients (8.5%) eventually required a below knee amputation. Blast as mechanism of injury was the single most predictive variable for patients requiring separation from the military (Odds Ratio 16.2, p< .001), requiring a subsequent procedure (Odds Ratio 8.4, p < .001), and for requiring a below knee amputation (Odds Ratio 47.3, p < .001).

CONCLUSION

Calcaneus fractures treated operatively in the military are often caused by blast injuries, and have a high rate of requiring subsequent procedures, amputation, and separation from the military.

Severe Calcaneus Injury Probability Curves Due to Under-Body Blast

The lower extremity is the most frequently injured body region to mounted soldiers during underbody blast (UBB) events. UBB events often produce large deformations of the floor and subsequent acceleration of the lower limb that are not sufficiently mitigated by the combat boot, leaving the calcaneus bone vulnerable to injury. Biomechanical experiments simulating UBB loading scenarios were conducted in a laboratory environment using isolated postmortem human subject (PMHS) leg components. Each leg component was tested twice: one sub-injurious test followed by a injury-targeted test. This enabled the use of interval censoring for each specimen in the survival statistical analysis to generate the human injury probability curves (HIPCs). Foot contact forces were measured in both the hindfoot and forefoot. Strains and acoustic emission signals at the calcaneus and distal tibia were utilized to determine injury timing. The footplate velocities of the injury tests ranged 8-13 m/s with time-to-peak velocity of 1.8-2.5 ms while the velocities of non-injury tests ranged from 4 to 6 m/s with the same time-to-peak. The majority of the injuries were severe calcaneus fractures (Sanders III-IV). Secondary injuries included fractures to the distal tibia, talus, cuboid and cuneiform. These injury outcomes were found to be consistent with those reported in UBB injury literature. The HIPCs for the severe calcaneus fracture were developed using the vertical heel contact force as the injury correlation measure through survival analysis statistical method in the form of lognormal function. This work represents the first set of HIPCs dedicated to the severe calcaneus fracture using the biomechanical force measurement closest to the injury location. This injury probability curve will enable biomechanical response validation of computational models, development of ATD injury assessment reference curve, and injury prediction capability for computational models or ATDs in the UBB environment.

Sanders classification of calcaneal fractures in CT images with deep learning and differential data augmentation techniques

BACKGROUND

Classification of the type of calcaneal fracture on CT images is essential in driving treatment. However, human-based classification can be challenging due to anatomical complexities and CT image constraints. The use of computer-aided classification system in standard practice is additionally hindered by the availability of training images. The aims of this study is to 1) propose a deep learning network combined with data augmentation technique to classify calcaneal fractures on CT images into the Sanders system, and 2) assess the efficiency of such approach with differential training methods.

METHODS

In this study, the Principle component analysis (PCA) network was selected for the deep learning neural network architecture for its superior performance. CT calcaneal images were processed through PCA filters, binary hashing, and a block-wise histogram. The Augmentor pipeline including rotation, distortion, and flips was applied to generate artificial calcaneus fractured images. Two types of training approaches and five data sample sizes were investigated to evaluate the performance of the proposed system with and without data augmentation.

RESULTS

Compared to the original performance, use of augmented images during training improved network performance accuracy by almost twofold in classifying Sanders fracture types for all dataset sizes. A fivefold increase in the number of augmented training images improved network classification accuracy by 35%. The proposed deep CNN model achieved 72% accuracy in classifying CT calcaneal images into the four Sanders categories when trained with sufficient augmented artificial images.

CONCLUSION

The proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of computer-aided system in assisting physicians in evaluating calcaneal fracture types.

Extensile approach versus minimally invasive technique in management of calcaneus fractures

BACKGROUND

Calcaneus fracture is one of the important fractures in orthopedic surgery. Here we aimed to investigate and compare the extensile approach and minimally invasive technique in patients with calcaneus fractures.

METHODS

This is a randomized clinical trial that was performed in 2019 in Kashani and Alzahra hospitals in Isfahan, Iran. The study population consisted of 30 patients with intraarticular calcaneus fractures. Thirty patients were divided into two groups. In the first group, surgery was performed using the minimally invasive technique and in the second group, the extensile approach was performed. Patients were followed for 12 months. Data regarding the duration of surgery, Boehler and Gisan angles, quality of joint reduction, subtalar joint movement, the incidence of soft-tissue complications and pain of the patients were measured and compare between two groups.

RESULTS

A total number of 30 patients entered the study and were divided into two groups each containing 15 patients. The duration of operation in the extensile approach group was significantly higher than the minimally invasive group (P = 0.03). The severity of pain and mean Boehler angle were significantly higher in the minimally invasive group than in the extensile approach group (P = 0.001 and P = 0.002 respectively). The quality of reduction was also significantly better in the extensile approach group than minimally invasive (P = 0.01) but the extensile approach group had more soft tissue complications than the minimally invasive group (P = 0.006).

CONCLUSION

Extensile approach was associated with lower pain, lower Boehler angle and better quality of reduction compared to minimally invasive technique but also higher operation duration and surgical site complications. We suggest that the extensile approach should be used in patients with calcaneus fractures with attention to possible complications.

Biomechanical analysis of minimally invasive crossing screw fixation for calcaneal fractures: Implications to early weight-bearing rehabilitation

BACKGROUND

Minimally invasive fixation using crossing screws was believed to produce satisfactory clinical outcome whereas its stability in early weight-bearing remained controversial. This study aimed to analyze the biomechanical stability of minimally invasive fixation during balanced standing and walking stance, and provide evidence for early rehabilitation.

METHODS

A finite element model of foot-ankle-shank complex was reconstructed based on computed tomography and magnetic resonance images, and validated by plantar pressure of the model participant. A Sanders III calcaneal fracture was created on the model, and then fixed using crossing screws. The predicted stress distribution, fracture displacement, Bohler's angle and Gissane's angle were compared between the intact calcaneus and fracture model with the fixation.

FINDINGS

Postoperatively, the concentrated stress appeared at the junction of the calcaneus and its surrounding tissues (especially Achilles tendon, plantar fascia and ligaments) during standing and walking stances, and the stress exceeded the yield strength of trabecular bone. The longitudinal screws sustained the highest stresses and concentrated at the tips and the calcaneal tuberosity junction. The displacement of posterior joint facet, Bohler's angle, and Gissane's angle were within the acceptable range either standing or walking after the fixation.

INTERPRETATION

Early weight-bearing standing and walking after minimally invasive fixation may cause high stress concentration thereby induce calcaneus stress fractures and other complications like plantar fasciitis and heel pain, so it should not be supported. The peri-calcaneus tendons, i.e., Achilles tendon and plantar fascia, play key roles in the stabilization of the calcaneal fracture after operation.

Comparing less invasive plate fixation versus screw fixation of displaced intra-articular calcaneus fracture via sinus tarsi approach

PURPOSE

The purpose of this study was to compare the post-operative radiographic and clinical outcomes of less invasive plate fixation versus screw fixation of displaced intra-articular calcaneus fractures (DIACFs) via sinus tarsi approach.

METHODS

A total of 165 consecutive DIACFs that underwent open reduction internal fixation via sinus tarsi approach from 2013 to 2018 were reviewed at least a two year follow-up. The methods of fixation were divided into two groups: less invasive plate fixation versus screw fixation of calcaneus fracture (59 vs 106, respectively). The radiographic outcomes including pre- and post-operative Bohler's and Gissane's angles were evaluated. The post-operative function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, the Olerud and Molander Scale and the Visual Analogue Scale (VAS). The complications, the rates of implant removal and cost were also compared.

RESULTS

The average follow-up was 44.2 months in the plate groups and 47.9 months in the screw groups (P > 0.05). There was no significant difference in the Bohler's angle and Gissane's angle between the plate group and screw group during the pre-operation and the last follow-up. There was no significant difference in the final AOFAS score, Olerud and Molander score and VAS score between the two groups (P > 0.05). The total incidence of complications was 6.7% in the plate group and 6.6% in the screw group (P > 0.05). The rates of implant removal and total cost during the hospitalization in the plate group were significantly higher compared with screws group (P < 0.05).

CONCLUSION

The less invasive plate fixation versus screw fixation of DIACFs via sinus tarsi approach contributed comparable quality of reduction, complications and post-operative functional outcomes. The less invasive plate technique was significantly higher in terms of implant costs and the rate of implant removal.

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

Bone density of the calcaneus correlates with radiologic and clinical outcomes after calcaneal fracture fixation

BACKGROUND

This study aimed to determine whether bone density correlates with radiologic and clinical outcomes after screw fixation of displaced intra-articular calcaneal fractures (DIACF) with the sinus tarsi approach.

MATERIALS AND METHODS

We retrospectively evaluated 43 consecutive cases of unilateral DIACF between March 2015 and December 2017. Radiologic evaluations were performed using preoperative, postoperative, and last follow-up calcaneal lateral and axial radiographs. In all patients, preoperative CT scanning of both injured and uninjured calcaneus were performed at one scanning and dual x-ray absorptiometry (DXA) scans were obtained. Hounsfield unit (HU) measurement values were determined by placing an elliptical region of interest confined to the cancellous region of the uninjured calcaneus. Clinical outcomes were assessed at a minimum of 12 months postoperatively using Foot and Ankle Outcome Scores (FAOS).

RESULTS

Mean HU values of the uninjured calcaneus significantly correlated with bone mineral density scores obtained from DXA scans of the lumbar and femur (Spearman ρ = 0.656 - 0.748; p < 0.001 for both). Decreased HU values of the uninjured calcaneus significantly correlated with decreased Böhler's angle and widening of calcaneal width from postoperative to last follow-up. (Pearson r = 0.348, p = 0.022; Pearson r = -0.582, p < 0.001, respectively). Increased HU values of the uninjured calcaneus significantly correlated with improved clinical outcomes in three of five FAOS domains, including activities of daily living, sports, and quality of life (beta = 0.283 - 0.322; p < 0.05 for all).

CONCLUSION

Decreased preoperative bone density significantly correlated with decreased Böhler's angle, widening of calcaneal width, and inferior short-term clinical outcomes after screw fixation of DIACF. By quantifying bone density using HU value in area where DXA cannot be performed, such foot bones, determining whether different fixation methods or systemic treatments can be tailored to bone density could help in optimizing clinical outcomes.

LEVEL OF EVIDENCE

Level III, Retrospective case series.

Percutaneous reduction and screw fixation for all types of intra-articular calcaneal fractures

INTRODUCTION

This study compares the outcomes of consecutive of patients with Sanders II and III and IV calcaneal fractures that were stabilized by either close reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF).

MATERIALS AND METHODS

Group I (N = 49) underwent close reduction internal fixation (CRIF). Group II (N = 39) underwent open reduction internal fixation (ORIF). The clinical outcomes included time to operation, operative duration, visual analog score (VAS), length of hospital stay, wound-related complications and AOFAS SF-36 score. Preoperative and postoperative radiographic measures also were compared.

RESULTS

The duration of operation in the CRIF group was considerably shorter than in ORIF group (P = 0.0001). Postoperatively, at seventh day, the VAS in the CRIF group (4.2 ± 1.1) was meaningfully lower than those of the ORIF patients group (4.7 ± 1.2, P = 0.04). Totally, the prevalence of wound complications in CRIF group was significantly lower than in ORIF group. In final follow-up visit after one year, AOFAS scores and SF-36 scores between groups were comparable. Comparable radiographic measures were found in both groups. There was no significant difference between groups regarding preoperative radiographic measures (P > 0.05), while in postoperative imaging acceptable calcaneal fracture reduction was found in both groups.

CONCLUSION

We believed that for treatment of various types of calcaneal fracture compared with ORIF the percutaneous reduction and screw fixation may lead to shorter hospital stay, decreased subtalar joint stiffness and earlier weight bearing along with much favorable patients' satisfaction.

Wrong Foot Forward - A Rare Injury by Indian Tiffin Box

INTRODUCTION

Although the penetrating injuries to the foot are common and sometimes they may be associated with calcaneum fracture, this case highlights a very rare injury by relatively harmless "Indian tiffin box."

CASE REPORT

A 30-year-old man was admitted to our hospital with a history of stepping over the Indian tiffin box. He presented with a tiffin box embedded in his right sole with food particles (pulses) inside the wound. It was associated with undisplaced, extra-articular fracture of calcaneus. Contamination with food particles and delayed presentation had added extra risk of infection. Aggressive management by wound lavage, debridement, and intravenous antibiotics has prevented the delayed complication like osteomyelitis.

CONCLUSION

Harmless-looking tiffin box can cause significant injury. Evaluation and proper management of soft-tissue involvement, especially heel pad, is very important due to its association to outcome. Proper documentation is equally important to avoid tricky medicolegal situations.

Steinmann pin retractor-assisted reduction with circle plate fixation via sinus tarsi approach for intra-articular calcaneal fractures: a retrospective cohort study

Background

Sinus tarsi approach and mini-calc plate have been used for intra-articular calcaneal fractures. However, the sinus tarsi approach has limited exposure to the lateral wall, which makes it challenging to obtain an excellent anatomic reduction of the calcaneal body. What is more! To restore the width of the calcaneal body entirely and prevent the heel varus simultaneously with mini-calc plate was tough as well. Aimed to solve the aforementioned problems, our study focused on using the Steinmann pin retractor for reduction and the circle plate for fixation via the sinus tarsi approach.

Methods

From March 2017 to January 2019, 15 patients with closed calcaneal fractures were treated with the method of Steinmann pin retractor-assisted reduction and circle plate fixation via the sinus tarsi approach. All these patients received a positive postoperative clinical and radiological evaluation.

Results

A postoperative follow-up was done for each of the 15 patients, and the following scores and parameters were observed: value of visual analogue scale (VAS) was 1.44 ± 0.63, and The American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot score was 84.31 ± 5.03 at the last follow-up. The Böhler angle (30.81 ± 3.56°), width (37.83 ± 4.87 mm), length (87.4 ± 3.33 mm), and height (86.23 ± 5.36 mm) of the calcaneus were improved significantly in comparison with preoperative values (− 0.94 ± 10.06°, 45.67 ± 5.68 mm, 82.72 ± 5.54 mm, 76.32 ± 7.98 mm), and these parameters were maintained excellently after 6–19 months’ follow-up.

Conclusion

Our present study suggested that Steinmann pin retractor-assisted reduction with circle plate fixation via the sinus tarsi approach may serve as a safe and effective method for Sanders type II and type III calcaneus fractures. The Böhler angle, height, length, and body of the calcaneus were excellently restored postoperatively and maintained at last follow-up and rare postoperative complications.

Trial registration

This study has been registered. The unique identifying number is research registry 5092.

Three-dimensional computed tomography analysis and functional results of calcaneal fractures treated by an intramedullary nail

BACKGROUND

Intramedullary calcaneal nailing is used to treat displaced intra-articular calcaneal fractures. The main goal of the study was to assess the reduction of tomography and secondary goals were patient functional scores and complication rates.

METHODS

The functional outcome and restoration of the radiographic parameters were evaluated post-operatively, at three months, at one year, and at the last follow-up. The morphology of the posterior facet was evaluated post-operatively, at one year and at the last follow-up by CTs.

RESULTS

Twenty-six patients were included. The mean follow-up was 2.8 years. The mean AOFAS-AHS was 79 at the last follow-up. The mean calcaneal height index and length rose respectively from 0.44 to 0.86 and 83 to 87 mm, and the width decreased from 50 to 46 mm.

CONCLUSION

The radiographic parameters were restored. The AOFAS-AHS was comparable with other series. This study confirms the efficiency of this procedure with lower rate of complications.

The effect of a heel-unloading orthosis in short-term treatment of calcaneus fractures on physical function, quality of life and return to work - study protocol for a randomized controlled trial

BACKGROUND

There are no standardized therapy guidelines for rehabilitation of calcaneus fractures. While there is consensus on non or partial weight-bearing, the use of supporting devices such as specific foot ankle orthosis is still a matter of debate. Recently, a heel-unloading orthosis ("Settner shoe") was introduced for aftercare of these fractures, allowing walking by shifting the load to the middle-foot and forefoot. This orthosis enables early mobilization of patients suffering from either one-sided or two-sided fractures. The Settner shoe can be applied in non-operative therapy and after surgery. Specifically in calcaneus fractures, early regain of physical activity has been highlighted as one of the key factors for quality of life and the ability to return to work. Thus, we hypothesize that mobilization with the Settner shoe results in improved quality of life and greater physical activity within the first 3 months.

METHODS

This is going to be analyzed by a randomized controlled study comparing treatment with and without this specific orthosis. The secondary outcome measure is the time point of return to work in patients aged between 18 and 60 years, with calcaneus fracture. Furthermore, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 3-dimensional gait analysis, and the Euroqol-5 dimension-3 level (EQ-5D-3 L) questionnaire for quality of life are assessed.

DISCUSSION

This is the first trial applying a standardized rehabilitation protocol in patients with calcaneus fractures, aiming to improve the non-operative part of treatment by use of an orthosis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03572816 . Registered on 27 July 2018.

Reduction and functional outcome of open reduction plate fixation versus minimally invasive reduction with percutaneous screw fixation for displaced calcaneus fracture: a retrospective study

Background

Minimally invasive surgery has become popular because of the lower incidence of wound complications. However, achieving an anatomic reduction that provides a satisfactory outcome is difficult using minimally invasive surgery. Our study aimed to evaluate the reduction and clinical outcomes of closed reduction and percutaneous fixation treatment using a closed reduction traction device for displaced intra-articular calcaneal fractures compared with traditional open reduction plate fixation using an extended lateral approach.

Methods

A total of 40 patients and 45 feet with calcaneus fractures from 2012 to 2016 were studied. The open reduction plate fixation group (24 feet) was compared to the closed reduction percutaneous fixation group (21 feet) with a traction device. The reduction assessments included length, width, height, Bohler’s angle, Gissane’s angle, and varus or valgus angle before and after surgery. The clinical outcomes included the American Orthopaedic Foot and Ankle Society hindfoot score and the visual analog score for pain, length of stay, and complication rate.

Results

The patients were followed up for an average of 16.53 ± 3.95 months. No significant differences in reduction were observed between the open and closed groups (P > 0.05). The American Orthopaedic Foot and Ankle Society scores of the two groups were 80.29 ± 6.15 and 83.62 ± 6.95 (open versus closed) (P = 0.0957). The visual analog scores of the open and closed groups were 1.50 ± 1.22 and 0.81 ± 0.87 (P = 0.0364). The lengths of stay in the open and closed groups were 9.63 ± 2.72 days and 6.71 ± 1.85 days (P = 0.0002). The complication rates of the open and closed groups were 20.8% (5/24) and 4.8% (1/21) (P < 0.0001).

Conclusions

The closed reduction percutaneous fixation with traction device method may provide equivalent reduction results and superior outcomes for the length of stay, VAS score, and complication rate for displaced intra-articular calcaneal fractures.

Ipsilateral Pilon and Calcaneus Fractures: Treatment with Circular Frame without Spanning Ankle Joint

This case report describes the treatment of a 48-year-old female patient, smoker, with a closed comminuted pilon fracture (AO/OTA 43-C2.1) and ipsilateral displaced intra-articular calcaneus fracture (AO/OTA 82-C3). Two independent circular frames were applied in a way to preserve tibiotalar range of motion (ROM). The posterior facet of the calcaneus fracture was reduced through a small incision anterior to the tip of the distal fibula. A frame consisting of a two-third ring was applied to the talus and a footplate to the calcaneus was used to hold the reduction of the posterior facet and to correct varus and length. Pilon fracture was similarly reduced with a percutaneous reduction technique and stabilized with the standard two Taylor spatial frame (TSF) rings. During the course of treatment, the tibiotalar joint ROM was maintained. The frame for the calcaneus fracture was removed 10 weeks after the surgery and the frame for the pilon fracture was removed 16 weeks after the surgery. The patient’s last follow-up was 34 months after the injury. She was ambulating independently without limp and she had resumed the preinjury activity level. She had symmetric tibiotalar ROM and 50% reduction in subtalar ROM. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot score was 76. Radiographs revealed healed pilon and calcaneus fractures, normal alignment of tibiotalar and subtalar joints, with some arthritic changes present to tibiotalar and subtalar joints. In conclusion, utilization of a “below the ankle” frame for the calcaneus fracture and a standard two-ring frame for the pilon fracture helps to avoid soft tissue complications and preserves tibiotalar ROM.

Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures

Fractures of the calcaneus are detrimental injuries, often caused by high-energy trauma. To best restore the functionality of a limb and allow normal ambulation, it is recommended to repair displaced intra-articular calcaneus fractures surgically. This article presents several methods of reduction and repair of the calcaneus. Traditionally, calcaneal fractures have been repaired through a lateral extensile incision that has been shown to have a high percentage of wound healing complications. In recent times, there has been a shift toward minimally invasive and sinus tarsi incisional approaches in the repair of calcaneus fractures.

Deep learning and SURF for automated classification and detection of calcaneus fractures in CT images

BACKGROUND AND OBJECTIVES

The calcaneus is the most fracture-prone tarsal bone and injuries to the surrounding tissue are some of the most difficult to treat. Currently there is a lack of consensus on treatment or interpretation of computed tomography (CT) images for calcaneus fractures. This study proposes a novel computer-assisted method for automated classification and detection of fracture locations in calcaneus CT images using a deep learning algorithm.

METHODS

Two types of Convolutional Neural Network (CNN) architectures with different network depths, a Residual network (ResNet) and a Visual geometry group (VGG), were evaluated and compared for the classification performance of CT scans into fracture and non-fracture categories based on coronal, sagittal, and transverse views. The bone fracture detection algorithm incorporated fracture area matching using the speeded-up robust features (SURF) method, Canny edge detection, and contour tracing.

RESULTS

Results showed that ResNet was comparable in accuracy (98%) to the VGG network for bone fracture classification but achieved better performance for involving a deeper neural network architecture. ResNet classification results were used as the input for detecting the location and type of bone fracture using SURF algorithm.

CONCLUSIONS

Results from real patient fracture data sets demonstrate the feasibility using deep CNN and SURF for computer-aided classification and detection of the location of calcaneus fractures in CT images.

Comparison of sinus tarsi approach versus extensile lateral approach for displaced intra-articular calcaneal fractures Sanders type IV

PURPOSE

Displaced intra-articular calcaneus fractures Sanders type IV(DIACFS IV) can result in an unsatisfactory prognosis and a high complication rate. Our investigation intends to compare the outcomes of DIACFS IV treated by open reduction and internal fixation (ORIF) via sinus tarsi approach (STA) with these via extensile lateral approach (ELA).

METHODS

Sixty-nine patients (82 ft) with DIACFS IV who were treated with ORIF (29 in STA group and 40 in ELA group) were retrospectively assessed. Median follow-up was 50 months in two groups. Radiographic results were reviewed pre-operatively and post-operatively, and relative complications were collected. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analog scale (VAS).

RESULTS

The wound-healing complication rate was 14.28% in STA group and 34.04% in ELA group (p = .043), and overall complication rate was 54% and 77% (p = .056), respectively. Seven cases of sural nerve injury only occurred in ELA group. The post-operative radiographs of the calcaneus (Böhler's angle, height, width, and length) were significantly different from those measured pre-operatively in each group. And these data were parallel between the two groups. In STA and ELA groups, the average AOFAS was 75.45 versus 72.44 (p = .496), and the mean VAS was 23.95 versus 30.93 (p = .088), respectively.

CONCLUSION

Similar clinical and radiographic outcomes are achieved between STA and ELA. And STA has a lower incidence of wound healing complication and sural nerve injury. Therefore, ORIF via STA can be a considerable management for DIACFS IV.

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.

Wrong Foot Forward - A Rare Injury by Indian Tiffin Box

Introduction

Although the penetrating injuries to the foot are common and sometimes they may be associated with calcaneum fracture, this case highlights a very rare injury by relatively harmless "Indian tiffin box."

Case Report

A 30-year-old man was admitted to our hospital with a history of stepping over the Indian tiffin box. He presented with a tiffin box embedded in his right sole with food particles (pulses) inside the wound. It was associated with undisplaced, extra-articular fracture of calcaneus. Contamination with food particles and delayed presentation had added extra risk of infection. Aggressive management by wound lavage, debridement, and intravenous antibiotics has prevented the delayed complication like osteomyelitis.

Conclusion

Harmless-looking tiffin box can cause significant injury. Evaluation and proper management of soft-tissue involvement, especially heel pad, is very important due to its association to outcome. Proper documentation is equally important to avoid tricky medicolegal situations.

Incidence and predictors of surgical site infection after ORIF in calcaneus fractures, a retrospective cohort study

BACKGROUND

Occurrence of calcaneus fractures is on the up trend. Owing to its unique anatomical morphology and limited soft-tissue envelope, management of calcaneus fractures is a challenge to the orthopaedic surgeon, and surgical site infection (SSI) is one of the serious postoperative complications. In order to decrease the incidence of wound breakdown and improve clinical outcomes, it is necessary to understand which factors were associated with SSI. The aim of this study was to identify predictors of SSI and quantify the incidence of SSI in calcaneus fractures following open reduction and internal fixation (ORIF).

METHODS

This retrospective study was performed at a level 1 trauma center from January 2014 to June in 2017. Data of adult patients with calcaneus fractures treated by ORIF were extracted from the electronic medical records. A total of 681 patients were collected. We reviewed the patients' demographics, characteristics of fracture, treatment-related variables, and indexes of laboratory examination. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.

RESULTS

Sixty-six patients developed SSI in this study. The overall incidence of SSI after ORIF of calcaneus fracture was 9.7%, with 2.9% for deep infection and 6.8% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were open fracture (odds ratio = 9.48, 95% CI = 4.53-19.85, P = 0.00007), high-energy injury (odds ratio = 2.07, 95% CI = 1.16-3.70, P = 0.01437), ASA class 3 or higher (odds ratio = 3.50, 95% CI = 1.18-10.37, P = 0.02401), and intraoperative temperature < 36.0 °C (odds ratio = 1.69, 95% CI = 1.13-2.28, P = 0.04410).

CONCLUSION

The SSI incidence was high (9.7%) for calcaneus fractures following ORIF. External fixation plays an important role in the treatment of severely displaced and depressed intra-articular or open calcaneus fractures. Increased ASA class and intraoperative hypothermia were associated with wound breakdown, and elaborative evaluation of fracture and soft-tissue damage was vitally necessary in this at-risk population.

Screw tip augmentation leads to improved primary stability in the minimally invasive treatment of displaced intra-articular fractures of the calcaneus: a biomechanical study

PURPOSE

To investigate if the stability of minimally invasive screw osteosynthesis of displaced intra-articular calcaneal fractures (DIACF) can be effectively increased by an innovative approach to screw tip augmentation.

METHODS

In eight-paired human cadaver hindfoot specimens, DIACF of Sanders type IIB were treated with either standard screw osteosynthesis or with bone cement augmentation of the screw tips in the main fragments. The instrumented specimens were subjected to a cyclic loading protocol (9000 cycles, with stepwise increasing loads, 100-1000 N). The interfragment motions were quantified as tuber fragment tilt (TFT) and posterior facet inclination angle (PFIA) using a 3-D motion analysis system. Böhler's angle (BA) was evaluated from X-rays. A load-to-failure test was performed after the cyclic loading protocol.

RESULTS

All but one specimen of the augmented group withstood more cycles than the respective specimens of the non-augmented group. Mean cycles to failure for the failure criterion of 5° TFT were 7299 ± 1876 vs. 3864 ± 1810, corresponding to loads of 811 N ± 195 vs. 481 N ± 180, (P = 0.043). There were no significant differences observed in the PFIAs. The failure criterion of 5° BA was reached after a mean of 7929 cycles ± 2004 in the augmented group and 4129 cycles ± 2178 in the non-augmented group, corresponding to loads of 893 N ± 200 vs. 513 N ± 218, (P = 0,090). The mean load-to-failure of the four specimens in the augmented group that completed the cyclic loading was 1969 N over a 1742-2483 N range.

CONCLUSION

Screw tip augmentation significantly improved the mechanical stability of the calcanei after osteosynthesis in terms of decreased tuber fragment tilts and less changes in Böhler's angle.

The sinus tarsi approach in displaced intra-articular calcaneal fractures

INTRODUCTION

Although the extended lateral approach is typically considered the gold standard of treatment for intra-articular calcaneal fractures, a limited lateral approach may be a good alternative in select cases.

METHODS

Forty-seven consecutive patients with intra-articular calcaneal fractures treated using the sinus tarsi approach between March 2010 and April 2015 were retrospectively reviewed. The functional outcomes [including arc range of motion, Visual Analog Scale (VAS) score, and the American Orthopedic Foot and Ankle Society ankle/hindfoot (AOFAS) score], bony outcomes (bony restoration and bony union), and complications were evaluated.

RESULTS

The mean one-year postoperative VAS and AOFAS scores were 0.54 (range 0-3.0), and 94.0 (range 80-100), respectively. The VAS and AOFAS scores were correlated with the degree of reduction of the posterior facet joint and the amount of Bohler angle restoration. Bony union was achieved in every case. The mean union time was 3.2 months (range 3-4 months). There were no major soft tissue complications. Three cases of minor soft tissue complications healed with no need for subsequent procedures. Painful hardware at the posterior calcaneal tuberosity was the most common complication, which occurred in seven cases.

CONCLUSIONS

The sinus tarsi approach may be a good option to treat intra-articular calcaneal fractures in select cases (Sanders type II and III) while preventing the major soft tissue complications of the extended lateral approach. Level of evidence IV.

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.

The prognostic value of radiologic parameters for long-term outcome assessment after an isolated unilateral calcaneus fracture

OBJECTIVE

The current retrospective case-control study examines the prognostic value of radiologic parameters for long-term clinical outcome assessment after a calcaneus fracture.

METHODS

In the authors' trauma department 262 adult patients with an isolated calcaneus fracture were treated from 1995 to 2005. Using conventional x-ray and computed tomography imaging. the calcaneal fractures were classified according to Sanders system. In addition, Boehler's and Gissane's angles were measured before and after therapy and the Larsen stage of subtalar arthrosis was determined. After a mean follow-up interval of 9.5 years, 44 patients were available for clinical and radiological assessment.

RESULTS

At the time of trauma the average age of the study group was 52 (range, 29-79) years. Thirty-seven patients were treated operatively and seven conservatively. Patients with a negative Boehler's angle, upon admission, exhibited significantly worse results using four of the five clinical scoring systems than patients with a preserved or slight reduced Boehler's angle. Operative treatment in patients whose Boehler's angle was elevated to normal range or beyond exhibited %worse better results than patients with an over-correction of Boehler's angle. In 11 cases, two primary and nine secondary subtalar arthrodeses were performed. The degree of subtalar arthrosis as per Larsen was increased 2.54 ± 1.14 in the course of hospital admission, arthrodesis and/or follow up examination. The results show no significant difference between operative and conservative treatment.

CONCLUSIONS

Boehler's angle at time of admission appears to be a valuable prognosticator for functional long-term results after calcaneus fracture. An operative over-correction of a reduced Boehler's angle should be avoided.

Weight bearing after a periarticular fracture: what is the evidence?

Orthopedic surgeons frequently provide weight-bearing recommendations to guide patient recovery following lower extremity fractures. This article discusses the available literature regarding the effects of early weight bearing on fracture healing, patient compliance with weight bearing restrictions, and the effect of different weight bearing protocols following acetabular, tibial plateau, tibial plafond, ankle, and calcaneus fractures.