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

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

Global research trends and hotspots in calcaneal fracture: A bibliometric analysis (2000-2021)

Background

Calcaneal fracture is common and carries high morbidity and disability. Its treatment is therefore of vital concern. Many topics concerning calcaneal fracture remain controversial, and the subject has not yet been well-researched. We aim to analyze and illustrate the trends in development, overall knowledge structure, "hotspots," and research frontiers on the topic of calcaneal fracture.

Methods

Literature relating to calcaneal fracture published between 2000 and 2021 was retrieved from Science Citation Index Expanded (SCIE) database of the Web of Science. Three bibliometric tools (Bibliometrix, CiteSpace, and VOSviewer software) were used for analysis and the generation of knowledge maps. Annual trends in publication counts and the relative contributions of different countries, regions, institutions, authors, and journals, as well as keyword clusters, "hot topics," and research frontiers, were analyzed.

Results

A total of 1,687 publications were included in the analysis. The number of calcaneal fracture articles published worldwide each year was highest in 2019, with a total of 128 articles. The United States has made the greatest contribution to the field, with the largest number of publications and the highest H-index. Foot & Ankle International was the most productive journal, publishing a total of 167 articles on calcaneal fracture during the study period. Hebei Medical University of China and the University of California, San Francisco were the most prolific institutions. Professors T. Schepers, S. Rammelt, H. Zwipp, and Y. Z. Zhang have made remarkable contributions to the field. However, the degree of collaboration between researchers and among institutions was relatively low, and took place mainly in Europe and the Americas. All relevant keywords could be categorized into three clusters: studies of internal fixation, studies of fractures, and studies of osteoporosis. A trend of balanced and diversified development could be seen within these clusters. Keywords with ongoing "citation bursts," such as sinus tarsi approach, wound complications, minimally invasive technique, extensile lateral approach, surgical treatment, and plate, may continue to be research "hotspots" in the near future.

Conclusion

Based on current global trends, the number of publications on calcaneal fracture will continue to increase. Topics such as minimally invasive techniques and complications have become important hotspots of research. We recommend enhancing international communication and collaboration for future research in this field.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Level III.

CT-Based Classification Systems for Intra-Articular Calcaneal Fractures: The Inter- and Intraobserver Variations as well as Integrality

The aim of this study was to measure the inter- and intraobserver variations as well as integrality of the Zwipp, Crosby-Fitzgibbons, Sanders, and Eastwood-Atkins classification systems based on more accurate CT scans. Five hundred and forty-nine patients with intra-articular calcaneal fractures from January 2018 to December 2019 taken from a database in our level-I trauma center (3 affiliated hospitals) were included. For each case, normative CT (1 mm slices) scans were available. Four different observers reviewed all CT scans 2 times according to these 4 most prevalent fracture classification systems (FCSs) within a 2-month interval. For these 4 FCSs, the kappa [κ] coefficient was used to evaluate interobserver reliability and intraobserver reproducibility, and the percentage that can be classified was used to indicate integrality. The κ values were measured for Zwipp (κ = 0.38 interobserver, κ = 0.61 intraobserver), Crosby-Fitzgibbons (κ = 0.48 interobserver, κ = 0.79 intraobserver), Sanders (κ = 0.40 interobserver, κ = 0.57 intraobserver), and Eastwood-Atkins (κ = 0.44 interobserver, κ = 0.72 intraobserver). Furthermore, the integralities were calculated for Zwipp (100%), Crosby-Fitzgibbons (100%), Sanders (92%) as well as Eastwood-Atkins (89.6%). Compared with previous literatures, CT scanning with higher accuracy can significantly improve intraobserver reproducibility of Zwipp and Eastwood-Atkins FCSs, but it has no positive effect on variability of Sanders FCS and interobserver reliability of Crosby-Fitzgibbons FCS. In terms of integrality, Zwipp and Crosby-Fitzgibbons FCSs appear to be superior to the other 2 FCSs.

Percutaneous Prodding Reduction and K-Wire Fixation Via Sinus Tarsi Approach Versus ORIF for Sanders Type III Calcaneal Fractures: A Prospective Case-Controlled Trial

We conducted a prospective randomized controlled trial to compare the radiological and clinical outcomes of Sanders type III calcaneal fractures treated with percutaneous prodding reduction and K-wire fixation via a sinus tarsi approach (PPRKF) versus open reduction and internal fixation (ORIF). Fifty-one patients with closed, unilateral, Sanders type III calcaneal fractures were randomly assigned to the PPRKF group (n = 26) or the ORIF group (n = 25). The clinical outcomes evaluated were time to surgery, blood loss, operative time, hospital stay, wound healing time, wound complications, and Maryland foot score. Radiological results were evaluated on lateral and axial X-rays and computed tomography images and included Böhler's angle, Gissane's angle, and calcaneal width. Compared with the ORIF group, the PPRKF group had shorter time to surgery, shorter operative time, less blood loss, shorter hospital stay, shorter wound healing time, and fewer wound complications (p < .001). The postoperative Böhler's angle, Gissane's angle, and calcaneal width in both groups were significantly better than those measured preoperatively (p < .001) and did not differ between the PPRKF group and ORIF group (p> .05). Regarding clinical results, there was no significant difference in Maryland foot score between the two groups at 12 months after surgery (p > .05). Both PPRKF and ORIF can result in satisfactory clinical function. PPRKF is superior to ORIF in reducing the time to surgery, operative time, blood loss, hospital stay, wound healing time, and wound complications.

Arthroscopic-assisted percutaneous fixation of intra-articular calcaneal fractures using an intraoperative distraction device

PURPOSE

To evaluate the quality of reduction and clinical outcomes by using Percutaneous Distractor and Subtalar Arthroscopy Closed Reduction followed by Internal Fixation (PDSA-CRIF) in the intra-articular calcaneal fracture.

METHODS

A consecutive case series of 453 patients with 507 displaced intra-articular calcaneal fractures was recruited in this retrospective study. We performed PDSA-CRIF to treat intra-articular calcaneal fractures. The quality of reduction was assessed by early postoperative Computed Tomography (CT) scans and measurement of serial Bohler's angles during follow-ups. Clinical outcomes were evaluated by Visual Analogue Scale (VAS) and the American Foot & Ankle Society ankle-hind foot scale (AOFAS) scoring system.

RESULTS

Fifty-nine patients (68 fractures) who had complete clinical data and follow-up of at least 12-months (mean: 14 months, range: 12-59 months) were finally included. Anatomical and near-anatomical reduction in subtalar articular surface which had less than 2 mm gap or step-off was found in 93% fractures. Unsatisfactory reduction was found in 7%.

CONCLUSION

Arthroscopic-assisted percutaneous fixation using a distraction device is effective in achieving positive short-term results in the displaced intra-articular calcaneal fractures. A multicenter, large sample, randomized control trial is needed to fully evaluate the long-term effects of PDSA-CRIF in comparison to other methods.

How Does Mechanism of Injury Relate to Similar Fracture Patterns in Bilateral Displaced Intra-articular Calcaneal Fractures?

Several biomechanical/cadaver studies have established a correlation between mechanism of injury and fracture classification in calcaneal fractures. However, this has never been backed up by clinical studies. In this study, the hypothesis is tested whether the alleged similar mechanism of injury for both feet in bilateral calcaneal fractures leads to similar fracture types. In this retrospective cross-sectional cohort study, patients with unilateral and bilateral calcaneal fractures treated between 2000 and 2017 were classified according to Essex-Lopresti and Sanders. Positive predictive values were computed, signifying the chance that the fracture type in the left foot corresponded to that in the right foot. These were compared to the a priori chance of a fracture type (percentage of fracture type in unilateral fractures) by constructing 95% confidence intervals of the positive predictive value of each fracture type. Of the 451 patients, 413 (91.6%) had unilateral and 38 (8.4%) bilateral calcaneal fractures. Mechanisms of injury were similar for uni- and bilateral fractures. Using the Essex-Lopresti fracture classification, 34 cases (90%) had the same classification in both feet, compared with 24 (63%) in the Sanders classification. The chance of a fracture type in the left, with the right foot as reference, was significantly larger than expected from a priori chance in the unilateral population. This leads to a new hypothesis, that, more than mechanism of injury, the magnitude of the impact and the position of the foot are important in predicting fracture classification in the calcaneus.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.

Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.

Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.

Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

Impact of percutaneous poking reduction combined with minimally invasive plate internal fixation on foot function and complications of patients with Sanders type II and III calcaneal fractures

OBJECTIVE

To investigate the impact of percutaneous poking reduction (PPR) combined with minimally invasive plate internal fixation on foot function and complications of Sanders type II and III calcaneal fractures (CFs).

METHODS

In this prospective study, 76 patients with Sanders type II and III CFs were randomly divided into the control group (n=38, "L" incision open reduction and plate internal fixation) and the study group (n=38, PPR combined with minimally invasive plate internal fixation (MIPIF)). The operation related indexes, skin necrosis rate, Gissane angle, Bohler angle, calcaneal height and ankle-hindfoot score before and after the operation were compared between the two groups. Complications of the two groups were recorded.

RESULTS

Compared with the control group, the operation time of the study group was significantly prolonged, but the intraoperative blood loss was significantly reduced, and the fracture healing time and hospitalization time were significantly shortened (P<0.05). The skin necrosis rate of the study group was slightly lower than that of the control group without statistical significance (P>0.05). The Gissane angle, Bohler angle and calcaneal height of the two groups increased 6 months after the operation, and the changes in the study group were more obvious than those in the control group (P<0.05). Six months after the operation, the ankle-hindfoot scores of the two groups significantly increased, and the changes of the study group were more significant than that of the control group (P<0.05). The total incidence of postoperative complications in the study group was significantly lower than that in the control group (P<0.05).

CONCLUSION

PPR combined with MIPIF can significantly promote the healing of Sanders type II and III CFs and the recovery of the Gissane angle and Bohler angle, effectively improve the foot function of patients and induce fewer complications, which is worthy of clinical promotion.

Efficacy of calcium phosphate cementing in the surgical treatment of Sanders Type II and III calcaneal fractures using screw fixation with sinus tarsi approach

OBJECTIVE

This study aimed to determine the effectiveness of calcium phosphate cementing in the surgical treatment of Sanders type II and III calcaneal fractures using screw fixation with sinus tarsi approach.

METHODS

In this retrospective study, 85 feet of 84 patients (74 males, 10 females; mean age 43 [17-61] years) in whom screw fixation was performed using the sinus tarsi approach for Sanders type II or III calcaneal fractures were included. The mean follow-up was 28 (14-39) months. Patients were categorized into 2 groups on the basis of whether calcium phosphate cement (CPC) was used. Group 1 had 37 patients with CPC (38 calcaneal fractures) and group 2 had 47 patients without CPC (47 calcaneal fractures). In the clinical assessment, the American Orthopedic Foot Ankle Society (AOFAS) hind foot score and the Maryland Foot Score (MFS) were used at the final follow-up. In the radiological assessment, Bohler's angle on plain radiograph and posterior facet step-off on computed tomography were measured pre-and postoperatively.

RESULTS

At the final follow-up, the mean Bohler's angle was 26.2° (20°-33°) in group 1 and 26° (17°-30°) in group 2 (P = 0.85). The mean posterior facet step-off was 1.6 (0-5) mm in group 1 and 1.5 (0-5) mm in group 2 (P = 0.85). The mean AOFAS score was 83.8 (59-100) in group 1 and 85.8 (60-100) in group 2 (P = 0.5). The mean MFS was 86.3 (66-100) in group 1 and 87.7 (66-100) in group 2 (P = 0.62).

CONCLUSION

Evidence from this study have shown that CPC may have no significant effect on clinical and radiological outcomes in the surgical treatment of Sanders type II and III calcaneal fractures using screw fixation with sinus tarsi approach.

A Development of the Essex-Lopresti Maneuver: Minimally Invasive Reduction and Fixation of Tongue-Type Calcaneal Fractures via a Single Incision

Tongue-type calcaneal fractures are a subset of displaced intraarticular calcaneal fractures. A reduction maneuver for this fracture pattern was described by Essex-Lopresti. The aim of this article is to describe a modification of this technique that allows reduction and fixation of tongue-type calcaneal fractures via a single, minimally invasive incision. We retrospectively reviewed all patients undergoing fixation utilizing this technique at our institution. We identified 13 fractures in 12 patients with a median follow-up of 12 months. Median Böhler angle was 3.5° preoperatively and 26.5° at final follow-up. The median AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score was 78. There were no complications or further surgeries in this series. We believe that reduction and fixation of tongue-type calcaneal fractures using this minimally invasive technique is safe and reliable and avoids the potential soft tissue problems of fixation with more extensive incisions.Levels of Clinical Evidence: Level IV.

Determining the Correlation Between Lateral Radiograph Morphology and the Outcome Following Surgically Treated Intra-Articular Calcaneal Fractures

Purpose. It is currently still common practice to obtain conventional radiographs in the follow-up of surgically treated displaced intra-articular calcaneal fractures at regular intervals. There is, however, insufficient evidence that these radiographs can be used to predict functional outcome. The aim of the current study was to evaluate the correlation between the most commonly used angles on lateral radiographs and disease-specific patient-reported outcome measures (PROMs). Methods. Two available databases, containing a total of 233 patients, were used in this study. Eleven angles on the lateral images of the preoperative and at 1-year follow-up radiographs were measured. The 6 most commonly used angles were also measured immediately postoperatively. These 6 most commonly used angles were correlated with PROMs (American Orthopaedic Foot and Ankle Society hindfoot score, Foot Function Index) by a Spearman's rho analysis. After a Bonferroni correction was applied, a P value of <.0042 was considered to be statistically significant. Results. After exclusion of bilateral fractures, primary arthrodesis, open fractures, wound infections, other wound complications, nonavailable radiographs, and nonresponders, 86 patients remained. No significant correlations were found between the measured angles on the preoperative and at 1-year follow-up radiographs and the PROMs. Conclusion. No apparent correlation between lateral radiograph morphology and outcome was detected. Therefore, long-term follow-up radiographs after confirmed healing may be restricted to patients with persistent complaints on indication.Levels of Evidence: Prognostic, Level IV: Retrospective.

Comparison of sinus tarsi approach and extensile lateral approach for calcaneal fractures: A systematic review of overlapping meta-analyses

PURPOSE

Accumulated literature has reported the comparative efficacy of the sinus tarsi approach (STA) and the extensile lateral approach (ELA) for the treatment of calcaneal fractures (CFs). However, the best alternative treatment for CF is still inconsistent. Herein, the present systematic review of overlapping meta-analyses aims to achieve an evident conclusion by performing a comprehensive reanalysis of previous meta-analyses regarding the comparison of the STA and the ELA.

METHODS

We searched several databases, including Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov , OVID, and CNKI for the meta-analyses comparing the STA and the ELA for the treatment of CF. All related meta-analyses of randomized controlled trials and cohort studies were included. Two researchers independently assessed the quality of the articles and extracted the data. The Jadad decision algorithm was used to evaluate the evidence of the articles.

RESULTS

Ultimately, five meta-analyses were included in the present study. The Assessment of Multiple Systematic Reviews scores of these articles ranged from 5 to 9 with a median of 7. The analysis of best quality, Bai 2018, was selected based on the Jadad algorithm. In this article, the significant differences were found in wound complications and operating time, recovery of Böhler's angle, the American Orthopaedic Foot and Ankle Society scores, and the visual analog scale.

CONCLUSION

The clinical relevance of the present study is that both the STA and the ELA are effective in alleviating pain and improving functionality in the treatment of CF. However, due to a shorter operation duration and lower complication rates, the STA was indicated to be a superior alternative for CF treatment.

Bone graft versus non-bone graft for treatment of calcaneal fractures: A protocol for meta-analysis

BACKGROUND

Calcaneal fractures are a prevalent form of injury caused by high-energy trauma. This study aimed at investigating whether bone graft and non-bone graft are essential for the internal fixation of calcaneal fractures. A meta-analysis of relevant clinical studies evaluated radiographic parameters, functional outcomes, and complications that offer practical recommendations on the suitability of bone grafts for the management of Calcaneal fractures.

METHODS AND ANALYSIS

This study performed a comprehensive search on PubMed, EMBASE, and Cochrane electronic to retrieve related clinical studies. The studies incorporated in our meta-analysis were identified after doing a preliminarily screening, reading of the full-text articles, and eliminating repeated studies. After quality assessment and data extraction, the standardized mean difference and risk ratio were selected as effect sizes. The data on Böhler angle, Gissane angle, calcaneal height, American Orthopaedic Foot and Ankle Society hindfoot scores, Maryland Foot Evaluation, and rate of wound infection were analyzed using Revman 5.3 software (Cochrane Collaboration).

RESULTS AND CONCLUSIONS

This study did not reveal any significant differences (P < .05) in both Böhler and Gissane angles, calcaneal height, American Orthopaedic Foot and Ankle Society hindfoot scores, Maryland foot evaluation, and rate of wound infection between the 2 groups. Due to the lack of a large sample of comparative studies, the use of bone grafting for the management of calcaneal fractures requires additional substantiation.

A modified tarsal sinus approach for intra-articular calcaneal fractures

BACKGROUND

Plate fixation using traditional lateral L-shape approach for intra-articular calcaneal fractures is complicated by 30% of wound complications, and the lateral small incision techniques with a tarsal sinus approach cannot sufficiently address all the fragments. A modified tarsal sinus approach with combined advantages of traditional lateral L-shape and tarsal sinus approaches for the treatment of intra-articular calcaneal fractures was developed.

METHOD

This prospective study included 29 patients (13 Sanders type II and 16 type III) with calcaneal fractures were managed with this technique. Calcaneal height, width, length, Bohler's angle, and Gissane angle were measured preoperatively, postoperatively, and at 1-year follow-up. Functional outcomes were assessed based on American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score.

RESULTS

Twenty-nine patients with average follow-up time of 18 (range 13-29) months were included. The radiographs demonstrated significant corrections of the Bohler's angle and Gissane angle, calcaneal width, length, and height from preoperation to postoperation and 1-year follow-up. Among all follow-up patients, one case had skin necrosis but healed after dressing. Another case had symptoms of numbness in the sural innervation area, which disappeared after 5 months of physical therapy and drug therapy. One case showed degenerative changes of subtalar joint at 1-year follow-up. No other wound complications like incision infection (superficial or deep) and wound dehiscence occurred. At 1-year follow-up, the mean AOFAS score was 90.2 ± 17.7 (range 70-98) and the good and excellent rate was 89.7%.

CONCLUSION

The modified tarsal sinus approach in the treatment of Sander's type II and III calcaneal fractures allowed adequate reduction and rigid fixation with low incidence of wound complications. Compared to sinus tarsi approach, this technique required shorter learning curve and was more easily mastered by young orthopedic surgeons. Thus, it was worthy of application clinically.

Computed Tomography Imaging-Based Preoperative Virtual Simulation for Calcaneal Fractures Reduction

Reduction of calcaneal fractures via a small incision approach at the sinus tarsi is technically difficult. This study was undertaken to determine if preoperative virtual simulation based on computed tomographic data improves reduction and reduces complications. Fifty-five patients with calcaneal fractures were treated via the sinus tarsi approach with minimally invasive plates between February 2013 and December 2015. DICOM files obtained from computed tomographic imaging preoperatively were imported into Superimage software, and virtual surgery was performed. Preoperative planning time, operative time, and complications were recorded. Clinical function was analyzed with radiology and with the American Orthopaedic Foot and Ankle Society and visual analogue scale scores. As a result, preoperative planning time was 30.7 ± 4.1 minutes, which increased with the severity of the fracture (Sanders III vs Sanders II: 34.2 ± 2.5 minutes vs 27.8 ± 2.7 minutes), which was in line with the real surgery, with a mean operative time of 86.7 ± 4.5 minutes (Sanders III vs Sanders II: 89.5 ± 2.7 minutes vs 84.3 ± 4.4 minutes). Radiologic results indicated that the calcaneal width, length, height, Böhler angle, and Gissane angle were significantly corrected from preoperatively to postoperatively. After a mean follow-up of 21.5 ± 6.1 months, no complications were observed. The mean American Orthopaedic Foot and Ankle Society score was 88.7 ± 4.0, with an excellent/good rate of 94.5% (52 of 55). The mean visual analogue scale score was 0.8 ± 0.9. In conclusion, preoperative virtual simulation may be efficient to promote accomplishment of sinus tarsi surgery, and this step may help improve outcomes for calcaneal fractures.

A minimally invasive (sinus tarsi) approach with percutaneous K-wires fixation for intra-articular calcaneal fractures in children

The aim of this study was to analyze the management of displaced intra-articular calcaneal fractures in children at our pediatric orthopedic and to determine the results following open reduction via minimally invasive sinus tarsi approach and fixation with Kirschner wires (K-wires). Overall, 25 available cases of calcaneal fractures in children with mean age of 9.8 years were treated by open reduction from January 2010 to December 2015. All patients were followed up from 12 to 30 months (mean: 19 months). Clinical functional outcomes were graded using the American Orthopedic Foot and Ankle Society hindfoot scores. Radiographic evaluation included measurement of the Bohler's angle and Gissane's angle of the calcaneus on the lateral view. All fractures healed within 3 months. According to the American Orthopedic Foot and Ankle Society foot scoring system, the mean scores of type II fractures were 92.7±2.1, type III 90.2±1.8, and type IV 89.7±2.7 at the latest follow-up. The preoperative and postoperative Bohler's angles were 17.1°±10.7° and 35.9°±6.7° in Sanders type II fractures, 14.4°±11.5° and 34.7°±8.5° in type III, 9.3°±9.7° and 35.1°±4.9° in type IV, respectively. The preoperative and postoperative Gissane's angles were 102.6°±11.5° and 125.7°±7.8° in Sanders type II fractures, 101.7°±9.1° and 117.5°±10.8° (P<0.05) in type III, and 104.7°±5.1° and 122.8°±9.1° (P<0.05) in type IV, respectively. No secondary arthrosis has been observed so far. No deep infection and wound necrosis occurred. One patient had superficial infection around K-wires that was managed using dressings. Treatment of calcaneal fractures in children by open reduction by sinus tarsi approach and K-wires fixation is a safe and effective method with low incidence of complications.

Sanders type 3-4 calcaneal fractures fixed with locking plate: does tri-cortical iliac bone autograft provide extra benefit for stabilization?

Objective

The aim of this study was to determine whether tri-cortical iliac bone autografting provided extra benefit for the stabilization in Sanders Type 3–4 calcaneal fractures fixed with locking plate.

Materials and methods

The study included 29 calcaneal fractures (Sanders Type 3/4=15/14). All fractures were fixed with locking plate using the extended lateral approach. Bone grafts were used in 16 (Group A; Sanders Type 3/4=7/9) and not used in 13 (Group B; Sanders Type 3/4=8/5) calcaneal fractures. As a grafting material, only tri-cortical iliac crest bone autograft was used. All operations were performed by the same surgeon. The same locking plate was used in all fractures. Calcaneal height and angle of Bohler and Gissane were measured in early postoperative and final control radiographs in both groups. Clinical evaluations were performed using the American Orthopedic Foot and Ankle Society ankle hind foot scale.

Results

There was no difference between the groups in terms of clinical results. Radiologically, the degree of change in Bohler’s angle, Gissane’s angle, and calcaneal height was not different between the groups.

Conclusion

Bone grafting does not affect the clinical and radiologic outcomes in Sanders Type 3–4 calcaneal fractures fixed with locking plate, and they provide no extra benefit to the stabilization. We think that fixation using locking plate is adequate and there is no need for bone grafting.

Risk factors for increased postoperative drainage of calcaneal fractures after open reduction and internal fixation: An observational study

Sufficient drainage is very important for preventing wound complications after open reduction and internal fixation (ORIF) of calcaneal fractures. However, the drainage amount varies among patients. The objective of this study was to identify factors associated with increased postoperative drainage after ORIF of calcaneal fractures.A retrospective study including 87 patients with 92 calcaneal fractures in our hospital was performed. Patients were divided into 2 groups based on whether they had increased drainage, which was defined as a total drainage of ≥340 mL (50th percentile). We gathered the following data on each patient: age; sex; smoking history; body mass index (BMI); American Society of Anesthesiologists (ASA) classification; fracture type; the time from injury to surgery; operative time; bone grafting; preoperative labs including prothrombin time (PT), activated partial thromboplastin time (APTT), hematocrit, and D-dimer level; and histories for hypertension, diabetes, and heart disease. Univariate analysis and multivariate logistic regression analysis were used to analyze the risk factors associated with increased drainage.Total drainage ranged from 105 to 1185 mL, and the average drainage for this cohort was 393.6 ± 232.4 mL (mean ± standard deviation). 57.6% (n = 53) of patients had increased drainage. Smoking history, Sanders type, operative time, and bone grafting were significantly associated with increased drainage on univariate analysis. Multivariate logistic regression analysis then demonstrated that active smoking and higher Sanders type were independent risk factors for increased drainage.Patients with calcaneal fractures who smoked or had a higher level of Sanders type had a higher risk of increased postoperative drainage. Therefore, we suggest that active precautions be taken for these patients to reduce the rate of postoperative wound complications.

Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: A meta-analysis of current evidence base

BACKGROUND

The relative efficacy of operative and nonoperative treatments for the displaced intra-articular calcaneal fractures (DIACF) remains uncertain.

OBJECT

We conducted a meta-analysis to compare the effectiveness of operative and nonoperative treatments in treating patients with DIACF.

METHODS

Databases including Cochrane Library, Medline, Embase, CBM, CNKI, and Google Scholar were searched. After independent study selection by 2 authors, data were extracted and collected independently. Comparisons were performed between operative treatment group and nonoperative treatment group. The quality of included studies was assessed using the Newcastle-Ottawa Scale. RevMan 5.3 was used for data analysis. The primary outcome measures were anatomical measures (changes in Böhler angle and calcaneal height and width), functional measures (shoe problems, resuming preinjury work, and residual pain), and complications (including superficial and deep wound infection, skin flap necrosis, neurovascular injury, secondary arthrodesis, reflex sympathetic dystrophy, osteotomy, thromboembolism, and compartment syndromes).

RESULTS

Eighteen trials (8 randomized controlled trials and 10 controlled clinical trials) including 1467 patients were considered. For anatomical measurements, the overall mean differences (MDs) for the mean Böhler angle, calcaneal height and width were 15.39 (95% confidence interval [CI] 9.12-21.67), 6.55 (95% CI 2.67-10.43), and 7.05 (95% CI -7.83 to -6.27), respectively. In functional measures, the overall effect MD of American Orthopedic Foot and Ankle Society was 6.23 (95% CI 5.22-17.67) and 0.38 (95% CI 0.22-0.67). The overall relative risks (RRs) of wearing shoes, resuming preinjury work, and having residual pain were 0.32 (95% CI 0.32-1.00), 0.56 (95% CI 0.40-0.77), and 0.90 (95% CI 0.68-1.20), respectively. The overall RR of the incidence of complications was 2.00 (95% CI 1.51-2.64).

CONCLUSION

Operative treatment of DIACF may lead to a higher incidence of complications but has better anatomical recovery when compared with nonoperative treatment.

Risk factors of wound infection after open reduction and internal fixation of calcaneal fractures

The aim of this study was to investigate the risk factors of wound infection after open reduction and internal fixation of calcaneal fractures.In all, 299 patients with 318 calcaneal fractures who underwent open reduction and internal fixation by a single surgeon were grouped according to different outcomes. We gathered the data on each patient including sex, age, injury mechanism, body mass index (BMI), time to operation, fracture type, associated injuries, treatment course, tourniquet time, blood loss, bone graft (yes or no), diabetes (yes or no), smoking history, and complications. Univariate analysis and multivariable analysis were used to determine the association between risk factors and wound infection.Patients who met the entry criteria included 267 males and 32 females with a mean age of 38.6 years. Among them, 5.3% (n = 17) suffered wound infection, and all of the wounds healed after different treatments. According to the univariate analysis, the patients who developed wound infections were active smokers, more obese (higher BMI), had a longer time from injury to operation, and longer tourniquet time. Multivariate analysis indicated that a higher BMI, delayed operation, and active smoking were independent risk factors for wound infection after open reduction and internal fixation of calcaneal fractures.Patients with calcaneal fractures who were smokers and had a higher BMI had a high risk of wound infections. We suggested that surgeons wait to operate until swellings of the injured foot improved, and we also suggested the operation should be within 14 days after the injury.

Can operations achieve good outcomes in elderly patients with Sanders II-III calcaneal fractures?

The aim of this study was to compare the clinical effect of operative treatment and nonoperative treatment for elderly patients with Sanders II-III calcaneal fractures.The study consisted of 60 patients with Sanders II-III calcaneal fractures who were treated in our institution from January 2007 to April 2012. The clinical effect between the operative treatment group of 32 patients and the nonoperative treatment group of 28 patients was studied. Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height were measured before and after treatment, and these indexes were also measured on the uninjured foot. All patients were followed-up for at least 2 years, and at the last follow-up, we evaluated foot function that was assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score system. A 10-cm visual analog scale (VAS) was used to measure the degree of pain.Böhler angle, Gissane angle, calcaneal width, and calcaneal height, which were preoperatively and postoperatively measured, had a significant difference in the operative group (P < .001), but there was no significant difference between pretreatment and post-treatment in the nonoperative group. Subtalar joint motion was measured pre-treatment and post-treatment and had a significant difference in the 2 groups. When we compared the values of Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height between post-treatment and the uninjured foot, there was no significant difference in the operative group, but there was a significant difference in the nonoperative group. The values measured after treatment in the 2 groups had a significant difference. Finally, the AOFAS score in the operative group and the nonoperative group were 83.4 ± 9.7 and 74.7 ± 10.3, respectively, and there was a significant difference (P < .001). Also, the 10-cm VAS had a significant difference between the 2 groups.Good clinical result could be obtained with operative treatment in elderly patients with Sanders II-III calcaneal fractures. Open reduction and internal fixation should be performed if there is no surgical contraindication.

Restoring the Anatomy of Calcaneal Fractures: A Simple Technique With Radiographic Review

Displaced, intra-articular fractures of the calcaneus result in gross deformity of the hindfoot, which must be reduced during surgical fixation. Described techniques aimed at restoring the normal anatomy of the calcaneus have mostly been focused on percutaneous methods, which are not without complication. Described in this report is a method of anatomic reduction during open reduction and internal fixation of these injuries, which uses a lamina spreader to simultaneously reduce calcaneal varus, restore calcaneal height, reduce the subtalar joint, and restore normal calcaneal width. Additionally, 6 patients with 7 calcaneal fractures were identified that underwent this technique, and radiographic review was performed. Varus deformity of the calcaneus was measured as 93.8 ± 4.3° (range 88.1° to 100.5°) preoperatively and 83.3 ± 3.7° (range 77.8° to 89.4°) postoperatively, with a mean difference of 10.9 ± 5.6° (range 1.3° to 17.3°; P = .0564). Bohler's angle was measured as 16.5 ± 16.9° (range -7.5° to 37.9°) preoperatively and 33.3 ± 12.5° (range 20.5° to 54.5°) postoperatively, the mean difference being 16.7 ± 15.0° (range 0.4° to 39.9°; P = .0288). Critical angle of Gissane was measured as 108.8 ± 14.0° (range 93.1° to 132.4°) preoperatively and 123.3 ± 6.6° (range 113.9° to 134.4°) postoperatively, with a mean difference of 16.2 ± 9.1° (range 5.8° to 29.7°; P = .0004).

LEVELS OF EVIDENCE

Level IV: Retrospective.

Percutaneous poking reduction and fixation versus open reduction and fixation in the treatment of displaced calcaneal fractures for Chinese patients: A systematic review and meta-analysis

PURPOSE

To compare the efficacy of percutaneous poking reduction and fixationwith open reduction and fixation in the treatment of displaced calcaneal fractures.

METHODS

Reports of studies using case-controlled trials (CCT) to compare the percutaneous poking reduction and fixation with the open reduction and fixation in the management of calcaneal fractures were retrieved from the Cochrane Library, PubMed Database, CNKI, Chinese Biomedical Database, Wanfang Data (from January of 2005 to August of 2015). Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.0 was used for data-analysis.

RESULTS

Fifteen articles were included in the meta-analysis. Comparison of the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of calcaneal fractures revealed statistical significance in the incidence of complications after operation [RR = 0.32, 95% CI (0.20, 0.5), p < 0.05]. However, there were neither statistical significance in the degrees of recovery for calcaneal Bohler angle [WMD = -1.65, 95% CI (-3.43, 0.14), p > 0.05] and calcaneal Gissane angle [WMD = -3.21, 95% CI (-6.75, 0.33), p > 0.05], nor statistical significance in the rate of good foot function after operation [RR= 0.95, 95% CI (0.90, 1.00), p > 0.05].

CONCLUSION

For the treatment of calcaneal fractures, percutaneous poking reduction and fixation is su- perior to open reduction and fixation in terms of the incidence of postoperative complications. But both techniques can obtain satisfactory clinical function.

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.

Sanders II-III calcaneal fractures fixed with locking plate in elderly patients

PURPOSE

To evaluate the clinical outcomes of locking calcaneal plate in treating calcaneal fracture (Sanders II-III) in elderly patients.

METHODS

From October 2012 to December 2013, 23 elderly patients suffering from calcaneal fracture (Sanders II-III) were treated and followed up. There were 15 males and 8 females with the mean age of 68.5 years (range: 65-79 years). According to Sander's classification, 16 cases (16 feet) were type II fractures and 7 cases (7 feet) were type III fractures. Anteroposterior, lateral and axial views of X-ray were taken to detect the calcaneum. CT scan was done to assess the amount of comminution and articular depression. Radiological assessment was performed using Bohler's angle and Gissane's angle. Functional outcome was assessed using the Maryland foot score.

RESULTS

All the patients were followed up for 13.7 months on average (10-20 months). The mean time of bone union was 3.2 months (3-4 months). The mean time of complete weight bearing was 3.2 months (3.1-4.0 months). The soft tissue necrosis was found in 1 case. The mean Bohler's angle and Gissane's angle were 25.31° and 117.5°respectively. The overall excellent to good rate was 82.6%.

CONCLUSION

Open reduction and internal fixation with locking calcaneal plate can obtain good functional outcome for Sanders II-III calcaneal fractures in elderly patients.

Regression analysis of controllable factors of surgical incision complications in closed calcaneal fractures

BACKGROUND

In surgeries of closed calcaneal fractures, the lateral L-shaped incision is usually adopted. Undesirable post-operative healing of the incision is a common complication. In this retrospective study, controllable risk factors of incision complications after closed calcaneal fracture surgery through a lateral L-shaped incision are discussed and the effectiveness of clinical intervention is assessed.

MATERIALS AND METHODS

A review of medical records was conducted of 209 patients (239 calcaneal fractures) surgically treated from June 2005 to October 2012. Univariate analyses were performed of seven controllable factors that might influence complications associated with the surgical incision. Binomial multiple logistic regression analysis was performed to determine factors of statistical significance.

RESULTS

Twenty-one fractures (8.79%) involved surgical incision complications, including 8 (3.35%) cases of wound dehiscence, 7 (2.93%) of flap margin necrosis, 5 (2.09%) of hematoma, and 1 (0.42%) of osteomyelitis. Five factors were statistically significant : The time from injury to surgery, operative duration, post-operative drainage, retraction of skin flap, bone grafting, and patients' smoking habits. The results of multivariate analyses showed that surgeries performed within 7 days after fracture, operative time > 1.5 h, no drainage after surgery, static skin distraction, and patient smoking were risk factors for calcaneal incision complications. The post-operative duration of antibiotics and bone grafting made no significant difference.

CONCLUSION

Complications after calcaneal surgeries may be reduced by postponing the surgery at least 7 days after fracture, shortening the time in surgery, implementing post-operative drainage, retracting skin flaps gently and for as short a time as possible, and prohibiting smoking.

The role of computed tomography in the diagnosis and treatment of calcaneal fractures

The intra articular fractures represent a challenge for the orthopaedic surgeons. Because of the three-articulary surfaces, the calcaneus represents a permanent subject of discussion about the investigation and treatment opportunities. In a retrospective audit of patients hospitalized in our clinic, I tried to identify the opportunity of the CT scan as a preoperative investigation protocol in calcaneal fractures, the results showing that the CT scan represents a mandatory standard in calcaneal fractures.