Minimally-invasive treatment of intra-articular fractures of the calcaneum

Fracture surgery of the extremities with the intra-operative use of 3D-RX: a randomized multicenter trial (EF3X-trial)

BACKGROUND

Posttraumatic osteoarthritis can develop after an intra-articular extremity fracture, leading to pain and loss of function. According to international guidelines, anatomical reduction and fixation are the basis for an optimal functional result. In order to achieve this during fracture surgery, an optimal view on the position of the bone fragments and fixation material is a necessity. The currently used 2D-fluoroscopy does not provide sufficient insight, in particular in cases with complex anatomy or subtle injury, and even an 18-26% suboptimal fracture reduction is reported for the ankle and foot. More intra-operative information is therefore needed.Recently the 3D-RX-system was developed, which provides conventional 2D-fluoroscopic images as well as a 3D-reconstruction of bony structures. This modality provides more information, which consequently leads to extra corrections in 18-30% of the fracture operations. However, the effect of the extra corrections on the quality of the anatomical fracture reduction and fixation as well as on patient relevant outcomes has never been investigated.The objective of this study protocol is to investigate the effectiveness of the intra-operative use of the 3D-RX-system as compared to the conventional 2D-fluoroscopy in patients with traumatic intra-articular fractures of the wrist, ankle and calcaneus. The effectiveness will be assessed in two different areas: 1) the quality of fracture reduction and fixation, based on the current golden standard, Computed Tomography. 2) The patient-relevant outcomes like functional outcome range of motion and pain. In addition, the diagnostic accuracy of the 3D-RX-scan will be determined in a clinical setting and a cost-effectiveness as well as a cost-utility analysis will be performed.

METHODS/DESIGN

In this protocol for an international multicenter randomized clinical trial, adult patients (age > 17 years) with a traumatic intra-articular fracture of the wrist, ankle or calcaneus eligible for surgery will be subjected to additional intra-operative 3D-RX. In half of the patients the surgeon will be blinded to these results, in the other half the surgeon may use the 3D-RX results to further optimize fracture reduction. In both randomization groups a CT-scan will be performed postoperatively. Based on these CT-scans the quality of fracture reduction and fixation will be determined. During the follow-up visits after hospital discharge at 6 and 12 weeks and 1 year postoperatively the patient relevant outcomes will be determined by joint specific, health economic and quality of life questionnaires. In addition a follow up study will be performed to determine the patient relevant outcomes and prevalence of posttraumatic osteoarthritis at 2 and 5 years postoperatively.

DISCUSSION

The results of the study will provide more information on the effectiveness of the intra-operative use of 3D-imaging during surgical treatment of intra-articular fractures of the wrist, ankle and calcaneus. A randomized design in which patients will be allocated to a treatment arm during surgery will be used because of its high methodological quality and the ability to detect incongruences in the reduction and/or fixation that occur intra-operatively in the blinded arm of the 3D-RX. An alternative, pragmatic design could be to randomize before the start of the surgery, then two surgical strategies would be compared. This resembles clinical practice better, but introduces more bias and does not allow the assessment of incongruences that would have been detected by 3D-RX in the blinded arm.

TRIAL REGISTRATION

Dutch Trial Register NTR 1902.

Treatment of severe fractures of the calcaneus by reconstruction arthrodesis using the Vira System: Prospective study of the first 37 cases with over 1 year follow-up

PURPOSE

To study the surgical applicability and clinical results of the Vira System in treatment for severe fractures of the calcaneus.

METHODS

A total of 37 acute intra-articular fractures of the calcaneus treated by reconstruction and primary fusion with the minimally invasive Vira System. Of them, 33 patients were analysed over a 2-year period. All fractures were classified, according to the Sanders criteria, as grade IV. The mean age was 42.08 years. Four were bilateral fractures and three were open fractures. All the patients were evaluated, in a prospective manner, using the American Orthopaedic Foot and Ankle Society (AOFAS) scale, plain radiographs and CT scan studies.

RESULTS

The average AOFAS score 12 months after surgery was 75.43 points (SD: 13.9). In 31 cases, the result was considered good and very good, and in five and one case mild and poor. Most of the patients (81%) could wear normal shoes; the footprint and the alignment of the heel were considered normal in all cases but seven patients showed a mild valgus deviation. The Böhler angle improvement after surgery was significant (p=0.05) and it did not vary along the follow-up. Subtalar arthrodesis was achieved in all cases. Only one case needed bone grafting. Important post-surgical complications were not registered in this cohort.

CONCLUSIONS

The Vira System is a useful option for the surgical treatment of severe fractures of the calcaneus, yielding good clinical and radiological results with a surgical procedure that is only minimally aggressive and has a low rate of complications.

Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures

OBJECTIVES

The purpose of this study is to assess the initial results of percutaneously reducing and fixing calcaneus fractures compared with a concurrent control group that was openly reduced and internally fixed through an extensile lateral approach.

DESIGN

Retrospective cohort study, consecutive series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

One hundred twenty patients with 125 intra-articular calcaneus fractures were selected as a consecutive series with treatment method randomized by surgeon and time of presentation.

INTERVENTION

Patients treated with open reduction and internal fixation (OR group) had an extended lateral approach and fractures were fixed with plates and screws. Patients treated with percutaneous reduction (PR group) had small incisions with indirect fragment manipulation, and the reduction achieved was secured with screws alone.

MAIN OUTCOME MEASUREMENT

Clinical and radiographic assessment.

RESULTS

There were 41 patients with 42 fractures in the OR group and 79 patients with 83 fractures in the PR group. There were no significant differences in sex, age, open fractures, fracture classification, or initial Bohler's angle between the two groups. Bohler's angle was improved after surgery by an average of 22.4 degrees in the OR group and 25.3 degrees in the PR group (P = 0.31). The average loss of reduction at healing (minimum 4 months postoperatively) was not significantly different between the two groups. Deep infection occurred in six of 42 of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 in the OR group and five of 83 in the PR group (P = 0.03). The need for late subtalar fusions (two of 26 and three of 41 with full 2-year follow-up) and implant removal (five of 42 and 10 of 83) was not significantly different.

CONCLUSIONS

The results of this study suggest that in comparison to open reduction, this method of percutaneously reducing and fixing calcaneus fractures minimizes complications and achieves and maintains extra-articular reductions as well as the standard extensile open reduction and internal fixation. Further study of this technique is warranted. This should include assessment of articular reduction and longer follow-up of a larger number of patients.

Osteosynthesis of displaced intra-articular fractures of the calcaneum: a long-term review of 47 cases

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders' classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler's angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders' classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler's angle.

Percutaneous treatment of less severe intraarticular calcaneal fractures

Percutaneous treatment of calcaneal fractures is intended to reduce soft tissue complications and postoperative stiffness of the subtalar joint. We assessed the complications, clinical hindfoot alignment, motion, functional outcome scores, and radiographic correction of percutaneous arthroscopically assisted reduction and screw fixation of selected, less severe fractures. We performed percutaneous reduction and screw fixation in 61 patients with Type II (Sanders et al.) calcaneal fractures. In 33 of 61 patients with displaced intraarticular fractures (types IIA and IIB), anatomic reduction of the subtalar joint was confirmed arthroscopically; these patients form the basis of this report. We observed no wound complications or infections. In two patients, one prominent screw was removed after 1 and 3 years, respectively. In one patient, arthroscopic arthrolysis was performed 1 year after the index procedure. Twenty-four of 33 patients (73%) were followed a minimum of 24 months (mean, 29 months; range, 24-67 months). The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score at last followup was 92.1 (range, 80-100). Böhler's angle and calcaneal width were reduced close to the values of the uninjured side. We believe percutaneous fixation is a reasonable alternative for moderately displaced Type II fractures provided adequate control over anatomic joint reduction with either subtalar arthroscopy or high-resolution (3-D) fluoroscopy.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Subtalar joint arthrodesis, ankle arthrodiastasis, and talar dome resurfacing with the use of a collagen-glycosaminoglycan monolayer

Intraarticular fractures of the calcaneus are a common injury to the hindfoot leading to posttraumatic arthrosis of the subtalar joint. Operative treatment with reduction and internal fixation at the time of initial presentation and once the soft tissue envelope is deemed suitable has become the standard of care for the surgical management of calcaneal fractures. However, numerous complications have been associated with calcaneal fractures, most notably subtalar joint arthrosis and calcaneal malunion. The authors describe a method of a delayed subtalar joint arthrodesis, ankle joint arthrodiastasis, and talar resurfacing with positive results for the management of painful posttraumatic concomitant arthrosis of the subtalar and ankle joints.

Biomechanical stability of intramedullary technique for fixation of joint depressed calcaneus fracture

BACKGROUND

Internal fixation of the os calcis is often complicated by prolonged soft tissue management and posterior facet disruption. An ideal calcaneal construct would include minimal hardware prominence, sturdy posterior facet fixation and nominal soft tissue disruption. The purpose of this study was to develop such a construct and provide a biomechanical analysis comparing our technique to a standard internal fixation technique.

METHODS AND MATERIALS

Twenty fresh-frozen cadaver calcanei were used to create a reproducible Sanders type-IIB calcaneal fracture pattern. One calcaneus of each pair was randomly selected to be fixed using our compressive headless screw technique. The contralateral matched calcaneus was fixed with a nonlocking calcaneal plate in a traditional fashion. Each calcaneus was cyclically loaded at a frequency of 1 Hz for 4000 cycles using an increasing force from 250 N to 1000 N. An Optotrak motion capturing system was used to detect relative motion of the three fracture fragments at eight different points along the fracture lines. Horizontal separation and vertical displacement at the fracture lines was recorded, as well as relative rotation at the primary fracture line.

RESULTS

When the data were averaged, there was more horizontal displacement at the primary fracture line of the plate and screw construct compared to the headless screw construct. The headless screw construct also had less vertical displacement at the primary fracture line at every load. On average those fractures fixed with the headless screw technique had less rotation than those fixed with the side plate technique.

CONCLUSION

A new headless screw technique for calcaneus fracture fixation was shown to provide stability as good as, or better than, a standard side plating technique under the axial loading conditions of our model. Although further testing is needed, the stability of the proposed technique is similar to that typically provided by intramedullary fixation.

CLINICAL RELEVANCE

This fixation technique provides a biomechanically stable construct with the potential for a minimally invasive approach and improved post-operative soft tissue healing.

A staged treatment plan for the management of Type II and Type IIIA open calcaneus fractures

OBJECTIVE

To assess the results of a standardized staged treatment strategy for displaced open calcaneal fractures with medial wounds.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Fourteen displaced open Type II or Type IIIA Orthopaedic Trauma Association (OTA) 73 Type B or C calcaneal fractures treated between January 2000 and December 2007 who were managed with a standardized regimen.

INTERVENTION

Patients were treated in a staged fashion with antibiotics, irrigation, débridement, and percutaneous Kirschner wire fixation followed by definitive open reduction and internal fixation when soft tissues were amenable to fixation.

MAIN OUTCOME MEASURES

Data regarding demographics, injury characteristics, time to fixation, interventions, and treatment complications were documented. The complication rate, time to bony union, and additional procedures were determined.

RESULTS

There were four OTA 73B and 10 OTA 73C injuries with open Type II or Type IIIA wounds on the medial side. All patients had débridement, irrigation, and percutaneous fixation within 8 hours of presentation. Definitive fixation was carried out on average 18 days after initial presentation with 10 patients only requiring the initial débridement and stabilization procedure followed by definitive fixation All 14 patients underwent definitive fixation through an extensile lateral approach. A superficial infection developed in one patient and a deep infection in one patient. All patients went on to union at an average follow up of 19 months.

CONCLUSION

Open Type II and IIA wounds associated with displaced OTA Type 73 B or C calcaneal fractures represent high-energy injuries with potential increased risk for wound complications. In our series, a staged treatment strategy consisting of urgent débridement, provisional internal stabilization, and late definitive reconstruction offers a protocol that may reduce infections associated with open calcaneal fractures.

Complications when using threaded K-wire fixation for displaced intra-articular calcaneal fractures

A retrospective chart review was performed on patients treated at a level one trauma centre for displaced intra-articular calcaneal fractures by a single trauma surgeon between January 1998 and July 2007. Patients were treated with open reduction and internal fixation utilising the extended lateral incision and a new type of fixation not described before. Threaded 1.575 mm (0.062 in.) Kirschner wires (K-wires) were used for fixation post-operatively along with standard plates, screws and bone substitute. There were 278 fractures in 246 patients that were treated with ORIF for displaced intra-articular calcaneal fractures during this 9-year period. Standard calcaneal lateral approach and hardware was supplemented with percutaneous threaded K-wires. An average of 5.0 fully threaded 1.575 mm K-wires were inserted per calcaneal fracture. Five (1.8%) patients had a K-wire infection; 0.6% of all K-wires became infected and 3.1% of K-wires broke. Lateral calcaneal apical wound issues are minimised and patients experience an overall low complication rate. The fixation also ensures non-weightbearing compliance.

[3D navigated osteosynthesis of calcaneal fractures. Open and minimally invasive techniques]

BACKGROUND

It is hypothesized that misplacement of sustentacular screws during osteosynthesis of intraarticular calcaneal fractures can be reduced with the help of navigation. A method for three-dimensional (3D) navigated placement of sustentacular screws for treating intraarticular calcaneal fractures is presented and evaluated.

MATERIAL AND METHODS

11 consecutive patients with 15 intraarticular calcaneal fractures were treated using 3D navigation. In 12 cases osteosynthesis was done through an extended lateral approach; in three cases, it was achieved through a minimally invasive percutaneous approach. For verification and documentation of the placed screws, a second 3D scan was performed.

RESULTS

A total of 20 screws were placed using 3D navigation. None of the navigated screws was misplaced. Extra operating time due to navigation averaged 11.9 minutes (+/-2.2 min).

CONCLUSION

Through a combination of intraoperative 3D imaging and navigation, placement of sustentacular screws is possible and can yield precise and reliable results. Especially in minimally invasive treatment, a high quality of osteosynthesis can be achieved.

Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases

A retrospective analysis of 24 cases of minimally invasive, open reduction, and internal fixation of intra-articular calcaneal fractures is presented. Collected data included articular step-off, medial wall displacement, and Boehler's angle, in addition to other descriptive characteristics of the fracture and case series. The operative technique is described in detail including the optimal screw constructs. Arthroscopic assistance was used in 10 of the cases. The articular step-off of the posterior facet, medial wall displacement, and Boehler's angle all displayed statistically significant change between the preoperative and postoperative periods (P < .0001). These results were consistent with the goal of restoration of articular congruity, calcaneal morphology, and calcaneal height. There were no soft tissue complications. The mean overall follow-up duration was 2.8 years (range 1 to 10 years). Of the 18 patients who were followed for more than 1 year (range 1.0 to 10 years), none went on to subtalar fusion. The results of this study suggest that a minimally invasive approach can improve radiographic parameters consistent with the ultimate goals of operative reduction of calcaneal fractures, and can be used to achieve satisfactory results with minimal risk of wound complication.

LEVEL OF CLINICAL EVIDENCE

4.

Treatment of displaced intra-articular calcaneal fractures by ligamentotaxis: current concepts' review

INTRODUCTION

A large variety of therapeutic modalities for calcaneal fractures have been described in the literature. No single treatment modality for displaced intra-articular calcaneal fractures has proven superior over the other. This review describes and compares the different percutaneous distractional approaches for intra-articular calcaneal fractures. The history, technique, anatomical and fracture considerations, limitations and the results of different distractional approaches reported in the literature are reviewed.

METHOD

Literature review on different percutaneous distractional approaches for displaced intra-articular calcaneal fractures.

RESULTS

Eight studies in which application of a distraction technique was used for the treatment of calcaneal fractures were identified. Because of the use of different classification, techniques, and outcome scoring systems, a meta-analysis was not possible. A literature review reveals overall fair to poor result in 10-29% of patients. Ten up to 26% of patients are unable to return to work after percutaneous treatment of their fracture. A secondary arthrodesis has to be performed in 2-15% of the cases. Infectious complications occur in 2-15%. Some loss of reduction is reported in 4-67%.

CONCLUSION

Percutaneous distractional reduction and fixation appears to be a safe technique with overall good results and an acceptable complication rate, compared with other treatment modalities for displaced intra-articular calcaneal fractures. A meta-analysis, based on Cochrane Library criteria is not possible, because of a lack of level 1 and 2 trials on this subject.

Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.

Does intraoperative fluoroscopic 3D imaging provide extra information for fracture surgery?

Fracture surgery of the extremities using 2D fluoroscopy frequently fails to detect the suboptimal positioning of implants and joint incongruities. The use of intraoperative 3D-rotational X-ray (3D-RX) imaging with a new X-ray device potentially reveals these failures. We compared 50 intraoperative (2D) results of surgery and certainty about the effectiveness of different aspects of fracture reduction as interpreted from conventional (2D) methods versus intraoperative 3D-RX in 42 distal extremity fractures by means of a surgery questionnaire. In addition, we investigated the need for revision surgery based on postoperative radiological findings in 81 patients. After fracture reduction, just before a 3D-RX scan, the surgeon preoperatively assessed the result of surgery. Three months after surgery, the 3D-RX scan was judged by three experienced surgeons independently. Intraoperative 3D-RX showed significantly more information as to screw positioning and rotation of the fracture reduction than the conventional method (p < 0.005). None of the 81 patients in whom 3D-RX was performed needed surgical revision based on postoperative radiological examinations. Intraoperative 3D-RX with this new device scanning offers additional information about extremity fracture reduction as compared to conventional intraoperative 2D imaging, and may reduce the need for revision surgery. The value of 3D-RX on functional outcomes still needs to be assessed.

Percutaneous fixation of forefoot, midfoot, hindfoot, and ankle fracture dislocations

Open reduction with rigid internal fixation is the basic principle for surgical management in foot and ankle trauma. High-risk patients present a surgical dilemma for the foot and ankle surgeon because the possible complications are magnified in this patient population. Percutaneous fixation is a unique alternative for achieving anatomic stabilization without increased physical strain to the patient. The significant advantages of percutaneous fixation include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and decreasing the potential risk for infection. This article provides an overview of percutaneous surgical fixation methods and their role in foot and ankle trauma for the high-risk patient.

Percutaneous screw configuration versus perimeter plating of calcaneus fractures: a cadaver study

BACKGROUND

Percutaneous screw configuration has been used clinically to reduce the high rate of wound complications associated with the extensile approach of standard open reduction and internal plate fixation. The aim of this cadaveric biomechanical study was to compare the strength of the standard perimeter plating with that of the percutaneous screw configuration for a Sanders type-2B calcaneus fracture.

MATERIALS AND METHODS

Ten pairs of fresh-frozen cadaveric lower limbs were prepared and osteotomized to create a Sanders type-2B fracture. Of each pair, one specimen underwent open reduction and internal fixation with standard perimeter plating; the other was stabilized with the percutaneous screw configuration. Each foot was compressed axially via the talar dome (1 mm/sec) until failure occurred. Differences in treatment groups were analyzed for significance (p < 0.05) using paired t-tests.

RESULTS

Construct stiffness was 158 +/- 85 and 113 +/- 60 N/mm for the plate and percutaneous fixation, respectively (p = 0.18). Failure occurred at an average of 1156 +/- 513 and 1064 +/- 540 N for the plate and percutaneous construct, respectively (p = 0.65).

CONCLUSION

The results suggest that open reduction and internal fixation with percutaneous screw configuration for Sanders type-2B calcaneus fractures provides a strength similar to that of perimeter plating.

CLINICAL RELEVANCE

Percutaneous screw fixation of calcaneus fractures may provide fracture reduction similar to plate fixation.

Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years

INTRODUCTION

To reduce complications, a minimally invasive technique for the treatment of dislocated intraarticular fractures of the calcaneus was used. Therefore previously described closed reduction and internal fixation techniques were combined and modified.

MATERIALS AND METHODS

Sixty-seven out of 92 calcaneal fractures could be retrospectively evaluated with an average follow-up time of 5.7 years (minimum 2-10 years follow-up). For radiographic evaluation, plain radiographs and CT scans were obtained. The Zwipp score was used for clinical evaluation. Sanders type II, III and IV fractures were diagnosed.

RESULTS

Length of surgery averaged 61 min (range 20-175 min). The incidence of subtalar arthritis was correlated to the severity of fracture. Böhler's angle was restored in 70.1% (47 of 67) of the cases. On the last follow-up evaluation the average Zwipp score was 130 points (range 48-186 points). The majority (77.7%) of patients were content with their treatment result. The rate of significant complications was 6.5%.

DISCUSSION

Compared to open techniques the presented minimally invasive technique showed comparable results with a low rate of serious complications and is a viable alternative for the treatment of intraarticular, dislocated calcaneal fractures.

Symptomatic nonunion after fracture of the calcaneum

We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.