Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach

Surgical treatment of intraarticular fractures of the calcaneus: comparison between flat plate and calcaneal plate

Objective

To evaluate the clinical results of surgical treatment of intraarticular fractures of the calcaneus, comparing the use of calcaneal plate and flat plate.

Methods

This was a retrospective study assessing the postoperative results of 25 patients between 2013 and 2015. Patients undergoing surgical treatment of intraarticular fractures of the calcaneus without concomitant surgical lesions were included. Patients who did not complete appropriate follow-up after surgery were excluded from the study.

Results

The unavailability of calcaneal plates at resource-limited settings, associated with the availability and lower cost of flat plates, may have been a confounding factor in the present study. However, there was no statistical difference between the outcomes of fractures treated with calcaneal plates or flat plates.

Conclusion

Statistical inference shows that, when calcaneal plates are not available, it is possible to use flat plates with similar clinical outcomes.

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.

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.

Minimally-invasive treatment of calcaneal fractures: A review of the literature and our experience

The optimal treatment of calcaneal fractures (CF) is currently controversial and is still under debate. It is well established that conservative treatment of these fractures is associated with poor results. Several surgical techniques are described in the literature; however, there is no consensus on which of these is more effective. The main goals of surgery are to restore the subtalar joint congruence, and calcaneal width, height, shape and alignment, thus avoiding medial and lateral impingement and enabling the patient to resume a normal lifestyle. ORIF is the most popular technique for these fractures, but it is associated with high rates of wound complications, hardware failure and infections. Several minimally-invasive techniques have been developed recently for the treatment of CF, with the common aim to be as simple, effective and inexpensive as possible and to reduce surgical times, complications and length of hospital stay.

Radiographic and CT Assessment of Reduction of Calcaneus Fractures Using a Limited Sinus Tarsi Incision

BACKGROUND

The lateral extensile incision for fixation of displaced intra-articular calcaneus fractures allows for fracture reduction but has been associated with high rates of soft tissue complications. This has prompted a search for less invasive methods of fracture fixation. The purpose of the present study was to determine the adequacy of reduction and rate of complications associated with operative fixation of calcaneal fractures using a limited sinus tarsi approach.

METHODS

A limited sinus tarsi incision with plate fixation was utilized for treatment of 39 displaced intra-articular calcaneal fractures in 35 consecutive patients as part of a single surgeon series. Imaging assessment of previously described fracture displacement measures was undertaken in preoperative and postoperative radiographs and CT. A retrospective chart review was conducted to identify postoperative complications.

RESULTS

Mean preoperative Bohler angle measurement was 7.7 (range, -26.0 to 30.0) degrees and the mean final postoperative standing Bohler angle was 25.5 (range, 12.3 to 37.7) degrees. Postoperative CT demonstrated that subtalar articular reduction was within 2 mm of anatomic in 91% of patients. There were 2 instances of superficial wound dehiscence (5.1%) and 1 deep infection (2.6%) that required debridement and complete hardware removal. Visual analog score (VAS) for pain averaged 3 of 10 in the 32 available patients at 1-year follow-up. Eight of these patients (25%) reported no pain (0/10) at final follow-up.

CONCLUSION

Operative fixation of displaced intra-articular calcaneal fractures utilizing the limited sinus tarsi approach resulted in acceptable fracture reduction and a low rate of complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Less wound complications of a sinus tarsi approach compared to an extended lateral approach for the treatment of displaced intraarticular calcaneal fracture: A randomized clinical trial in 64 patients

BACKGROUND

We conducted a prospective randomized clinical trial to compare the clinical and radiological outcomes of the sinus tarsi and extended lateral approaches for the surgical treatment of displaced intraarticular calcaneal fractures.

METHODS

Between January 2009 and January 2014, patients with displaced intraarticular calcaneal fracture were randomly assigned to receive surgical treatment by the sinus tarsi approach or the extended lateral approach using block randomization. We recorded and analyzed data on demographics, time to surgery, wound complications, Böhler angles pre- and postoperatively, and American Orthopedic Foot & Ankle Society score.

RESULTS

Sixty-four patients met the inclusion criteria and were randomly assigned to the 2 groups: 32 patients underwent sinus tarsi approach, and 32 patients the extended lateral approach. Baseline characteristics of both groups were similar. The time to surgery in the sinus tarsi approach group was significantly shorter than in the extended lateral approach group (P = 0.04). The wound complication rates were 6.3% and 31.2% in the sinus tarsi approach and extended lateral approach groups, respectively, which was significantly different (P = 0.01). Regarding the clinical outcomes, the groups did not differ significantly on walking visual analogue scale or American Orthopedic Foot & Ankle Society scores at 6 months and 1 year postoperatively. No significant differences existed between groups regarding the Böhler angle at different times and reduction quality of the articular surface and the medial wall.

CONCLUSION

Compared with the extended lateral approach, the sinus tarsi approach decreased wound complications and preoperative waiting time, and achieved similar functional and radiological outcomes for displaced intraarticular calcaneal fractures.

Outcome of Minimally Invasive Open and Percutaneous Techniques for Repair of Calcaneal Fractures: A Systematic Review

Percutaneous and minimally invasive open techniques for the treatment of calcaneal fractures are now frequently used with good results, although a comparison between these different techniques has not yet been performed. The aim of the present review was to search for studies evaluating the outcomes of patients after treatment with percutaneous and minimally invasive open techniques for calcaneal fractures. A search was performed using PubMed/MEDLINE, Embase, and the Cochrane Library. Studies from the previous 15 years in English were included. Data on the Sanders classification, operation technique, infection rate, American Orthopaedic Foot and Ankle Society ankle-hindfoot score, radiographic evaluation, and follow-up were extracted. The techniques were divided into 4 groups: minimally invasive open, percutaneous reduction and screw osteosynthesis, external fixation, and other. Forty-six studies were included, with 1776 patients and 2018 calcaneal fractures. Of the 2018 fractures, 924 (46%) were classified as Sanders II, 558 (28%) as Sanders III, and 245 (12%) as Sanders IV; the fractures of 291 patients(14%) were not classified or were classified as complete extra-articular. Of the 46 studies, 15 used a minimally invasive open technique, 19 evaluated the outcome of percutaneous reduction and screw osteosynthesis, 10 investigated the results of an external fixation system, and 2 studies used other operative techniques. The median infection rate was 3% (range 0% to 33%). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 83 (range 67 to 94). The median angle of Böhler postoperatively was 24° (range 14° to 35°) and had increased after operative treatment, with a median of 16° (range 0° to 39°). The percutaneous reduction and screw osteosynthesis and minimal invasive open technique resulted in significantly better outcomes compared with external fixation and other techniques. In conclusion, percutaneous reduction and screw osteosynthesis and minimal invasive open techniques have the best outcomes for the minimal invasive open surgical treatment of calcaneal fractures.

Comparison of percutaneous cannulated screw fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial

BACKGROUND

The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs.

METHODS

Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC (N = 42) or MISTA (N = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded.

RESULTS

The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group (p < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group (p < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group (p < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures (p < 0.05).

CONCLUSION

The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs.

TRIAL REGISTRATION

ChiCTRIOR16008512 . 21 May 2016.

Predicting loss of height in surgically treated displaced intra-articular fractures of the calcaneus

PURPOSE

The goal of calcaneal fracture surgery is to restore its anatomy and good foot function. However, loss of height of the subtalar joint can occur post-operatively, as expressed by a decrease in Böhler's angle (BA). The aim of this study was to identify potential factors associated with a post-operative decrease in BA.

METHODS

All consecutive adult patients treated with open reduction and internal fixation (ORIF) by an extended lateral approach (ELA) between 2000 and 2013 were retrospectively included. Primary outcome was the occurrence of a calcaneal collapse, defined as a postoperative decrease of ≥10° in BA. The BA was measured pre-operatively, directly following surgery and at one year follow-up. Patient characteristics (body mass index, diabetes mellitus, smoking/alcohol/substance abuse, American Society of Anaesthesiologist classification), fracture classification and treatment characteristics: per-operative increase in BA and occurrence of post-operative wound infection (POWI) were collected.

RESULTS

A total of 262 patients with 276 calcaneal fractures were included. A calcaneal collapse occurred in 46 cases (17%). The median preoperative BA, per-operative increase in BA and post-operative decrease in BA were, respectively, 2°, 27° and 4°. A calcaneal collapse was seen more often following a per-operative increase of >25° in BA, but no significant association was found (p = 0.056). Uni- and multivariate analysis showed that patients with substance abuse and those with POWI had significantly more calcaneal collapse (p < 0.05). No association was found between substance abuse and the occurrence of POWI (p = 0.293).

CONCLUSIONS

In nearly one in six patients with an intra-articular calcaneal fracture treated with ORIF by an ELA, a post-operative collapse of ≥10° was found during follow-up. Calcaneal collapse was correlated with the occurrence of a POWI and substance abuse.

Advances in Surgical Management of Intra-articular Calcaneus Fractures

Intra-articular calcaneus fractures are commonly sustained after high-energy trauma, and a variety of techniques exists for anatomic reduction and surgical fixation. Traditional approaches using an extended L-shaped lateral incision with lateral plating for open reduction and internal fixation have relatively high complication rates. Common complications include hematoma formation, skin edge necrosis, wound breakdown, and superficial or deep infection. As a result, less invasive techniques have been developed in recent years, including limited-incision sinus tarsi open reduction and internal fixation, percutaneous fixation, and arthroscopic-assisted fixation. These techniques are associated with lower complication rates and equivalent clinical and radiographic outcomes in certain fracture patterns and patient populations.

High incidence of post-operative infection after 'sinus tarsi' approach for treatment of intra-articular fractures of the calcaneus: a 5 year experience in an academic level one trauma center

BACKGROUND

The optimal management of displaced intra-articular calcaneal fractures remains a topic of debate among trauma surgeons. The purpose of this study was to assess the safety of the sinus tarsi approach in regard to the incidence of deep infection and amputation following open reduction and internal fixation intra-articular calcaneal fractures.

METHODS

We conducted a retrospective chart review of all patients with displaced intra-articular calcaneus fractures treated with internal fixation through the sinus tarsi approach in a five year period. All surgeries were performed in a single level one trauma center by a single orthopedic trauma fellowship trained surgeon.

RESULTS

Seventeen patients with an average age of 36.6 ± 13.6 years (range 12-61 years) met the inclusion criteria. The time between injury and surgery was on average 6.1 days (range 1-22 days). Average follow up was 116 ± 78.2 days (range 3-276 days). Two patients (11.7%) had diabetes mellitus. None of the patients required amputation. Three patients (17.6%) developed deep infection and underwent subsequent formal irrigation and debridement, two of these requiring multiple repeat surgeries in addition to hardware removals. Negative pressure wound therapy and long term antibiotics via peripherally inserted central catheter (PICC) were necessary in these three patients with wound infections.

CONCLUSION

The sinus tarsi approach for intra fixation intra-articular calcaneal fractures is safe as compared to the traditional extensile approach in regard to flap necrosis and amputation. However, the rate of deep infection was higher than previously described in the literature.