[Quality of life after calcaneal fractures. A matched-pairs trial with a standardised German control group]

Quality of life after fracture-related infection of the foot

BACKGROUND

Fracture related infection (FRI) of the foot is a serious hazard. Despite successful therapy, the physiological and psychological involvement seems to be high. Therefore, we aim to analyze the impact of an FRI of the foot on the quality of life after successful surgical therapy and infect eradication.

METHODS

In total, 25 patients from two German hospitals treated for FRI of the foot between March 2011 to January 2020 were retrospectively included. Quality of life was assessed by the German Short Form 36 (SF-36) and the EuroQol five-dimension three-level questionnaire (EQ-5D) as well as the ICD-10 based psychological symptom rating (ISR), and compared to a norm obtained from the general population of Germany.

RESULTS

3.0 years (range 0.7-7.9 years) following final surgery after fracture-related infection of the foot, the mean physical health component score (PCS) of the SF-36 was 35.6 ± 12.3, and the mean mental health component score (MCS) of the SF-36 reached a value of 41.3 ± 12.9. Both values were significantly lower than in the general population of Germany (p< .019). The mean scores of the ISR of the cohort crossed the threshold of mild symptom burden in total, as well as for the subscales depression and somatization. The mean EQ-5D VAS rating (62.1 ± 18.6) and the EQ-5D index value (0.66 ± 0.27) were significantly lower in comparison to a score of 72.9 ± 1.0 and 0.88 obtained from an age-matched reference population (p < .01).

CONCLUSION

FRI of the foot represents a major burden for the patient. Physical and mental well-being of affected patients is restricted albeit successful treatment in terms of infect eradication and bone union has been achieved after a mean follow-up of 3.0 years. A patient-centered treatment approach focusing on improvement of quality of life during and after treatment is therefore warranted.

Evaluation of Long-Term Quality of Life Using the Foot and Ankle Outcome Score (FAOS) Questionnaire in Patients Treated by Minimally Invasive Reduction and Percutaneous Stabilization of Intra-Articular Calcaneal Fractures

Background

Treatment of displaced intra-articular calcaneal fractures is controversial. Choosing the optimal surgical technique is very important for patient quality of life and activity. In this study, we asked the question: “What is the long-term quality of life of patients after intra-articular calcaneal fractures treated by minimally invasive reduction and percutaneous stabilization (MIRPS)?”.

Material/Methods

We included 51 patients – 45 males (88%) and 6 females (12%) – who underwent MIRPS of intra-articular calcaneal fractures. The males were ages 22–63 years, with a mean age of 46 years, while the females were aged 31–63, with a mean age of 47 years. The FAOS (Foot and Ankle Outcome Score) survey was used.

Results

Women’s FAOS scores were 72–95%, with a mean of 82%, and varied according to type of fracture, surgery method used, and comorbid fractures. Men’s FAOS scores were 50–95%, with a mean of 84%, and varied according to type of fracture, surgery method used, and comorbid fractures.

Conclusions

According to set criteria regarding the FAOS scale, mainly good and very good results were observed in patients treated surgically for intra-articular calcaneus fractures using MIRPS. Westhues’ method scored a significantly higher foot rating than W-R (Westhues’-Rąpała method). Patients with TTF (tongue-type fracture) scored higher in the FAOS than patients treated with JDTF (joint depression-type fracture). In other cases, no significant differences were observed.

[Outcome after surgical treatment of calcaneal fractures]

BACKGROUND

After controversial discussions in the literature about therapy regimens for calcaneal fractures, a retrospective study of patients operatively treated in a maximum care trauma center was conducted.

OBJECTIVE

Investigation of the influencing factors on the treatment quality of operatively treated patients with calcaneal fractures.

MATERIAL AND METHODS

Between 2005 and 2013 a total of 90 patients with calcaneal fractures were surgically treated in this hospital with locking plate osteosynthesis. A total of 48 patients with 55 fractures were retrospectively investigated. The assessment with respect to posttraumatic arthrosis was made radiologically and Böhler's and Gissane's angles were also determined. Clinically AOFAS and SF-36 scores were documented. The results were statistically tested with respect to possible risk factors.

RESULTS

A total of 9 patients (18.8%) were found with complications necessitating operative revision, with 8 patients requiring subtalar arthrodesis and 1 patient with a deep wound infection. Nicotine abuse and a long interval between trauma and reconstructive surgery were identified as factors that influenced the development of wound healing problems. The average AOFAS score was 68 points and the SF-36 was 58.86 points. A poor result in the scores was caused by the development of symptomatic arthritis and the type of insurance. In this cohort factors, such as age and complexity of fractures were not correlated with a poor result.

CONCLUSION

In this patient collective nicotine abuse and a long interval between trauma and surgery were risk factors for development of wound infections. Other factors with an influence on the outcome were the postoperative development of arthritis and the type of health insurance; however, patient age had no impact on the outcome.

Calcaneal fracture fixation using a new interlocking nail reduces complications compared to standard locking plates - Preliminary results after 1.6 years

INTRODUCTION

Surgical treatment of displaced intra-articular calcaneal fractures using a standard extended lateral approach for plate fixation is frequently associated with substantial wound healing complications and infections. This matched pairs analysis compares the new minimally-invasive calcaneal interlocking nailing technique to standard locking plate fixation in terms of reduction capacity, complication rates, and functional outcomes.

METHODS

Forty feet in 38 patients (mean patient age 52.5 years, range 27-78) were treated with calcaneal locking nail (LN)(n=20) or locking plate (LP)(n=20) and followed clinically and radiologically for 20 months. Follow-up included radiological assessments and functional evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Foot Function Index (R-FFI).

RESULTS

Times for surgery were similar for both techniques (LN 93min, range 34 to 175 vs. LP 101min, range 53 to 305). Length of hospital stay was significantly lower in the LN group (7.6 days, range 3 to 14 vs. LP 11 days, range 6 to 37). Time away from work was shorter by 3.5 days in LN group. LP group had superior range of motion in plantarflexion, eversion, and inversion at follow-up, while LP patients were superior in demonstrating a secure heelstrike (79% vs. LN 58%) and fewer needed permanent walking aids. AOFAS and FFI scores revealed no differences for both groups. Radiographs indicated an adequate reconstruction in both groups, followed by a slight loss of reduction at follow-up (LP 4.7° postoperative vs. follow-up; LN 5.1°). The overall complication rate between groups was significant with 5% complications in the LN group vs. 50% in the LP group (5% deep infection, 35% impaired wound healing, 5% hardware breakage, 5% superficial wound infection; LN: 5% superficial wound infection).

CONCLUSIONS

The new calcaneal interlocking nail shows promising results in terms of reduction capacity and safety. Use of the minimally invasive locking nail technique minimized the risk of postoperative wound complications and achieved superior functional outcomes compared with standard locking plate fixation via the extended lateral approach.

Gait characteristics and functional outcomes during early follow-up are comparable in patients with calcaneal fractures treated by either the sinus tarsi or the extended lateral approach

BACKGROUND

To overcome the substantial functional loss after calcaneal fractures (CF), surgical treatment currently consists of two strategies, namely the commonly used extended lateral approach (ELA) and the less invasive sinus tarsi approach (STA). Despite the comparable anatomical restoration, the biomechanical and functional outcome of these strategies during early rehabilitation has not yet been investigated.

RESEARCH QUESTION

To evaluate changes in gait characteristics and functional development in patients with CF treated by either STA or ELA.

METHODS

A total of 56 patients with unilateral CF were included in this retrospective study. 26 patients were treated by ELA while 30 patients underwent surgery through the STA. Functional and biomechanical measurements were performed at follow-up periods of three and six months. Foot and ankle kinetics and kinematics were extracted using instrumented gait analysis with a multi segment foot model. Physical and mental components of the Short Form 36 (SF-36) and total scoring of the AOFAS hindfoot scale were used for functional evaluation. Statistical analysis was performed using Mann Whitney and Student's t-test. Effect sizes of group differences were calculated using Cohen's d.

RESULTS

Comparisons between ELA and STA showed no significant difference regarding the biomechanical and functional outcome. Within-group comparisons showed significant (p < 0.05) improvements from three to six month follow-up. Ankle joint and hindfoot kinematics showed increased mobility during walking of up to 34% and 26%, respectively. Maximum ankle joint moment also improved by up to 34% while vertical ground reaction force increased by 8%. Functional outcome only revealed significant changes in the physical component of SF-36.

SIGNIFICANCE

ELA and STA treatments revealed comparable functional improvements in patients with unilateral intraarticular calcaneal fractures during early rehabilitation. The less invasive STA provides adequate restoration of dynamic foot function and could serve as a viable alternative to the commonly used ELA.

Patient-reported health-related quality of life after a displaced intra-articular calcaneal fracture: a systematic review

BACKGROUND

A displaced intra-articular calcaneal fracture (DIACF) is known for having a negative influence on the daily activities of patients. A health-related quality of life (HRQoL) outcome instrument is used to quantify the impact of DIACF. It seems that these studies used restrictive inclusion criteria and observe specific patient groups; consequently, an increased risk of bias that results in incorrect estimation of the impact. Therefore, we will systematically review the current literature.

MATERIALS AND METHODS

A systematic search was performed in PubMed, Embase and Cochrane library. Inclusion criteria were studies reporting DIACF and HRQoL, measured with SF-36, SF-36v2, EQ-5D or EQ-6D. The identified articles were critically appraised for their relevance and validity. The overall risk of bias was determined. The studies with a low to medium risk of bias were used for data extraction.

RESULTS

32 articles were available for the critical appraisal. 13 articles had a medium risk of bias. All studies reported the SF-36 and two studies also reported the EQ-5D.

CONCLUSIONS

This systematic review indicates that DIACF is a life-changing event for most patients. The HRQoL is substantially lower in comparison to the period before the trauma and to the general population, in particular the subdomains related to the physical domain are affected. In addition, this review reveals that the identified studies have a medium to high risk of bias. Consequently, it is challenging to make reliable and valid conclusions. Therefore, we provided recommendations to decrease the risk of bias in order to improve future research.

Long-term results of surgically treated calcaneal fractures: an analysis with a minimum follow-up period of twenty years

PURPOSE

Long-term results after treatment of calcaneal fractures are rare. For this reason, we conducted a retrospective follow-up after a minimum of 20 years post surgery.

METHODS

Between 1990 and 1994, a total of 66 patients received surgical treatment for displaced calcaneal fractures. At that time, osteosynthesis was performed using small, one-third tubular plates. After collecting empirical data, we conducted a follow-up at least 20 years post surgery using X-ray imaging and clinical questionnaires (AOFAS and SF-36 questionnaire).

RESULTS

It was possible to recruit a total of 22/66 patients (33 %) after a mean of 22 years (range, 20-24) post surgery. With regard to the AOFAS scores (mean value, 74 points), 12 showed very good or good results, four showed average and six poor results. Patients with orthopaedic shoes also had low AOFAS scores. The Boehler's angle had been increased from +2° prior to surgery to +21° post-operatively. At the time of follow-up, the mean value was +17°. The angle correlated with the AOFAS score. Also, the SF-36 physical score was clearly reduced when compared to a general population, and correlated significantly with the AOFAS score.

CONCLUSION

There is still no evidence that open reduction and internal fixation of calcaneal fractures results in better outcomes than conservative therapy. This has been confirmed by our long-term results that provided disillusioning results: in a small population, only 55 % of the patients showed very good or good clinical overall results. Furthermore, SF-36 showed impaired physical subscores, which correlated significantly with the AOFAS.

Pedobarography in the Assessment of Postoperative Calcaneal Fracture Pressure With Gait

The purpose of the present study was to evaluate the benefits and importance of pedobarography in the diagnosis and treatment of plantar pressure changes in the postoperative follow-up of calcaneus fractures treated with open reduction and internal fixation. The 28 patients included 23 males (82%) and 5 females (18%). The clinical evaluation was performed using the American Orthopaedic Foot and Ankle Society hindfoot scoring system. The Böhler and Gissane angles were measured on the preoperative and postoperative radiographs. In the postoperative follow-up period (mean ± standard deviation 22.25 ± 10.8 months), all the patients underwent analysis with a dynamic pedobarogram. Because the arch index of the operated feet was 29.73% and that of the nonoperated feet was 28.94%, a similar slightly low arch was seen in both feet (p = .078). When the plantar surface maximum pressures were evaluated, a significant reduction was seen in the operated feet in the second, third, fourth, and fifth metatarsals and the medial hindfoot (p < .05). Displaced intra-articular calcaneus fractures resulted in a significant reduction in maximum pressure of the second, third, fourth, and fifth metatarsals and the medial hindfoot. Also, the hindfoot pressure was lateralized. Pedobarography is a simple and useful method for the diagnosis of plantar pressure changes occurring postoperatively.

Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures

BACKGROUND

The treatment of displaced, intraarticular calcaneal fractures (DIACFs) remains challenging and the best treatment choices remain controversial. The majority of patients will have some lasting functional restrictions. However, it is unclear which patient- or surgeon-related factors predict long-term function.

QUESTIONS/PURPOSES

We determined (1) the impact of patient- and surgeon-related factors on function of patients after internal fixation of DIACFs and (2) whether severity of injury correlated with subsequent function.

METHODS

We retrospectively reviewed all 210 patients operatively treated for 242 DIACFs between 2000 and 2003; of these, 127 patients (60%) with 149 fractures were available for followup at a minimum of 69 months (average, 95 months; range, 69-122 months). Severity of injury was quantified by the classifications of Sanders and Zwipp Function was quantified using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, an adjusted Zwipp score, the Foot Function Index (FFI), and the SF-36 physical and mental component summary (PCS and MCS) scores.

RESULTS

At latest followup, the median AOFAS score was 77, the median Zwipp score was 60, the median FFI was 27, and the median SF-36 PCS and MCS scores were 44 and 55, respectively. The foot-related scores and the SF-36 PCS negatively correlated with the severity of injury, work-related injuries, and bilateral fractures.

CONCLUSIONS

We found the severity of a DIACF related to subsequent foot function and quality of life. Both fracture severity classifications predicted function. Anatomic reconstruction of the shape and articular surfaces of the calcaneus leads to predictable function in the medium to long term.

Results of dynamic pedobarography following surgically treated intra-articular calcaneal fractures

OBJECTIVE

To investigate the clinical outcome and gait analysis findings by dynamic pedobarography in patients following surgically treated single, closed, dislocated intra-articular calcaneal fractures.

DESIGN

Retrospective single-center study with 26 patients. The average follow-up period was 34 months (range 18-61 months). We used the Zwipp score and a score based on a visual analog scale (VAS) to assess the subjective and objective clinical outcome. Dynamic pedobarography (EMED-M, 38 × 42 cm, four sensors per square centimeter, 50 Hz; Novel GmbH., Munich, Germany) was performed to retrieve gait patterns. Analysis was performed using the Emed-Software (Novel GmbH., Munich, Germany).

RESULTS

For the Zwipp score (±200 points), the average was +54.4 points (±48.2); for the VAS score (0-100 points), the average was 58.3 points (±24.3). There was limited mobility in the upper and lower ankle joint. Pedobarography showed a clearly disturbed gait with increased pressure for the fractured side (157 vs. 119 kPa) in the midfoot region (71.8 vs. 68 kPa) and under fifth metatarsal bone (234 vs. 160 kPa). The gait line was lateralized. The force-time-integral (fractured vs. healthy side) showed significant differences for the medial (18 vs. 7 N s) and lateral (61 vs. 36 N s) midfoot region.

CONCLUSIONS

We found only an average clinical outcome and clear pathological gait patterns in our cohort with lateralization of the gait line.

Do changes in dynamic plantar pressure distribution, strength capacity and postural control after intra-articular calcaneal fracture correlate with clinical and radiological outcome?

Fractures of the calcaneus are often associated with serious permanent disability, a considerable reduction in quality of life, and high socio-economic cost. Although some studies have already reported changes in plantar pressure distribution after calcaneal fracture, no investigation has yet focused on the patient's strength and postural control.

METHOD

60 patients with unilateral, operatively treated, intra-articular calcaneal fractures were clinically and biomechanically evaluated >1 year postoperatively (physical examination, SF-36, AOFAS score, lower leg isokinetic strength, postural control and gait analysis including plantar pressure distribution). Results were correlated to clinical outcome and preoperative radiological findings (Böhler angle, Zwipp and Sanders Score).

RESULTS

Clinical examination revealed a statistically significant reduction in range of motion at the tibiotalar and the subtalar joint on the affected side. Additionally, there was a statistically significant reduction of plantar flexor peak torque of the injured compared to the uninjured limb (p<0.001) as well as a reduction in postural control that was also more pronounced on the initially injured side (standing duration 4.2±2.9s vs. 7.6±2.1s, p<0.05). Plantar pressure measurements revealed a statistically significant pressure reduction at the hindfoot (p=0.0007) and a pressure increase at the midfoot (p=0.0001) and beneath the lateral forefoot (p=0.037) of the injured foot. There was only a weak correlation between radiological classifications and clinical outcome but a moderate correlation between strength differences and the clinical questionnaires (CC 0.27-0.4) as well as between standing duration and the clinical questionnaires. Although thigh circumference was also reduced on the injured side, there was no important relationship between changes in lower leg circumference and strength suggesting that measurement of leg circumference may not be a valid assessment of maximum strength deficits. Self-selected walking speed was the parameter that showed the best correlation with clinical outcome (AOFAS score).

CONCLUSION

Calcaneal fractures are associated with a significant reduction in ankle joint ROM, plantar flexion strength and postural control. These impairments seem to be highly relevant to the patients. Restoration of muscular strength and proprioception should therefore be aggressively addressed in the rehabilitation process after these fractures.

Prognostic value of four classifications of calcaneal fractures

BACKGROUND

The purpose of this study was to assist surgeons treating calcaneal fractures in choosing the most predictive fracture classification and clinical outcome tool.

MATERIALS AND METHODS

For 152 patients (189 calcaneal fractures; average followup, 9.9 years), all fractures were classified in accordance with the Essex-Lopresti, OTA, Regazzoni, and Sanders classifications and matched with the following scores: AOFAS score, CNHF, FOA, MFS, Rowe, MFA, SF-36, and VAS.

RESULTS

The Essex-Lopresti classification showed no statistically significant relation with any of the clinical scores (p > 0.05). The OTA classification related statistically significant with the MFS (p = 0.006), AOFAS score (p = 0.013), FOA (p = 0.019), Rowe (p = 0.0027), and MFA score (p = 0.03). The Regazzoni classification correlated with the AOFAS score (p = 0.003), MFS (p = 0.002), Rowe (p = 0.002), CNHF (p = 0.0001), FOA (p = 0.003), MFA score (p = 0.002), and VAS (p = 0.005). The Sanders classification corrrelated with the AOFAS score (p = 0.007), MFS (p = 0.001), Rowe (p = 0.001), CNHF (p = 0.024), FOA (p = 0.021), MFA score (p = 0.036), and VAS (p = 0.014).

CONCLUSION

Compared to radiological based classifications, the CT based classifications, especially the Regazzoni and Sanders classifications, exhibited higher prognostic value compared to ultimate outcome scores.