[New techniques in the operative treatment of calcaneal fractures]

Efficacy of Sinus Tarsal Approach Compared With Conventional L-Shaped Lateral Approach in the Treatment of Calcaneal Fractures: A Meta-Analysis

Background: This study aims to compare the efficacy of the sinus tarsal approach (STA) with that of the conventional L-shaped lateral approach (CLSLA) in the treatment of calcaneal fractures by meta-analysis.

Methods: PubMed, Embase, Web of Science, the Chinese National Knowledge Infrastructure, and China Wanfang database were searched to collect clinical randomized or non-randomized controlled trials of STA and CLSLA in the treatment of calcaneal fractures from January 2010 to May 2020. The data were analyzed by Stata 15.0 software.

Results: A total of 12 clinical trials were included, all of which were retrospective studies, including 961 patients. The results showed that when STA was compared with CLSLA, there was no difference in operation time with mean difference (MD) = −5.51 [95% confidence interval (CI): −12.57 to 1.55, P > 0.05], less bleeding during operation with MD = −18.49 (95% CI:−23.79 to −13.18), no difference in Böhler angle after an operation with MD = 0.78 (95% CI: −0.09 to 1.65) and in Gissane angle with MD = −0.07 (95% CI: −1.90 to 1.77), no difference in American Orthopedic Foot and Ankle Society score with MD = 2.16 (95% CI: −1.07 to 5.38), higher-excellent and better rate of Maryland food function with relative ratio = 1.12 (95% CI: 1.04 to 1.20), and lower of incidence of postoperative complications with relative ratio = 0.23 (95% CI: 0.14–0.37).

Conclusion: STA was more effective than CLSLA in the treatment of calcaneal fractures. Moreover, STA had advantages in less intraoperative bleeding, higher-excellent and better rate of Maryland foot function, lower incidence of postoperative complications, and higher safety.

Cement-augmented screw fixation for calcaneal fracture treatment: a biomechanical study comparing two injectable bone substitutes

Background

The role of cement-augmented screw fixation for calcaneal fracture treatment remains unclear. Therefore, this study was performed to biomechanically analyze screw osteosynthesis by reinforcement with either a calcium phosphate (CP)-based or polymethylmethacrylate (PMMA)-based injectable bone cement.

Methods

A calcaneal fracture (Sanders type IIA) including a central cancellous bone defect was generated in 27 synthetic bones, and the specimens were assigned to 3 groups. The first group was fixed with four screws (3.5 mm and 6.5 mm), the second group with screws and CP-based cement (Graftys® QuickSet; Graftys, Aix-en-Provence, France), and the third group with screws and PMMA-based cement (Traumacem™ V+; DePuy Synthes, Warsaw, IN, USA). Biomechanical testing was conducted to analyze peak-to-peak displacement, total displacement, and stiffness in following a standardized protocol.

Results

The peak-to-peak displacement under a 200-N load was not significantly different among the groups; however, peak-to-peak displacement under a 600- and 1000-N load as well as total displacement exhibited better stability in PMMA-augmented screw osteosynthesis compared to screw fixation without augmentation. The stiffness of the construct was increased by both CP- and PMMA-based cements.

Conclusion

Addition of an injectable bone cement to screw osteosynthesis is able to increase fixation strength in a biomechanical calcaneal fracture model with synthetic bones. In such cases, PMMA-based cements are more effective than CP-based cements because of their inherently higher compressive strength. However, whether this high strength is required in the clinical setting for early weight-bearing remains controversial, and the non-degradable properties of PMMA might cause difficulties during subsequent interventions in younger patients.

Late Treatment of Displaced Intra-Articular Calcaneus Fractures: Successful Management With Anatomic Reduction

INTRODUCTION

The aim of this study was to evaluate the results of displaced intra-articular calcaneus fractures treated more than 25 days after injury by open reduction and internal fixation (ORIF) using a lateral extensile surgical approach.

METHODS

Twenty patients identified by retrospective review of our trauma database were treated with ORIF for a displaced intra-articular calcaneus fracture more than 25 days after injury. OTA/AO 82-B and 82-C fracture patterns were included. All had ORIF by a lateral extensile approach. Bohler's angle was measured on injury radiographs, after operative fixation and the final follow-up and compared with the Bohler's angle of the contralateral uninjured extremity. Patients completed a Musculoskeletal Function Assessment (MFA) to evaluate the functional outcome.

RESULTS

The mean number of days from injury to fixation was 33.4 days (range, 26-58 days). A total of 18/20 patients were available for follow-up (mean 26.1 months; range 12.5-100 months). Eleven injuries were joint depression (82-C), and 7 injuries were tongue type (82-B) fracture patterns. The reason for delayed presentation was delayed transfer to our institution (11 patients), hemodynamic instability from polytrauma (2 patients), excessive fracture blisters (2 patients), and sepsis (1 patient). Bohler's angle at the time of injury was a mean of 10.9 degrees, which corrected to a mean of 33.3 after operative fixation but decreased to a mean of 28.1 at the time of the final follow-up. The mean Bohler angle was 32.3 on the contralateral uninjured side. The mean MFA score was 16.5 (range, 1-34). There were no wound infections or subtalar arthrodesis procedures performed.

CONCLUSIONS

ORIF by a lateral extensile approach is a safe and viable option for patients presenting in a delayed fashion with a displaced intraarticular calcaneus fracture. Marked improvement in the Bohler angle, acceptable functional outcome, and low complication rates can be expected when surgery is performed by an experienced surgeon.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Calcaneal Fractures - Should We or Should We not Operate?

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Interlocking Nail Fixation for the Treatment of Displaced Intra-Articular Calcaneal Fractures

Introduction

Less invasive restoration of joint congruity and calcaneal shape in displaced intra-articular calcaneal fractures via a sinus tarsi approach followed by percutaneous internal fixation with an interlocking nail results in a low rate of soft-tissue complications and good short-term outcomes¹ (Video 1).

Indications & Contraindications

Step 1 Patient Placement

Place the patient in the lateral decubitus position, supporting the involved extremity with a soft radiolucent pillow, flex the contralateral knee, check with fluoroscopy before draping, and obtain lateral radiographs.

Step 2 Incision

Use a sinus tarsi approach for control of the articular reduction.

Step 3 Percutaneous Manipulation of the Main Fragments

Percutaneously manipulate the main fragments to facilitate reduction of the main tuberosity fragment toward the sustentacular fragment and subsequent joint reduction.

Step 4 Joint Reduction with Direct Manipulation of the Main Fragments through the Sinus Tarsi Approach

Reduce the joint with direct manipulation of the main fragments through the sinus tarsi approach.

Step 5 Joint Fixation with Screws

Check the congruency of the posterior subtalar joint facet, stabilize the posterior facet with 2 screws, reduce the tuberosity against the joint block and anterior process, and temporarily fix with Kirschner wires.

Step 6 Introduction of the Intramedullary Nail

Make a 10-mm vertical incision below the attachment of the Achilles tendon, direct the guidewire toward the center of the calcaneocuboid joint, place the guidewire centrally within the calcaneal body, ream over the guidewire, and introduce the intramedullary nail with the attached aiming device.

Step 7 Locking of the Nail

Use the aiming device to position the proximal Kirschner wire into the sustentacular fragment, place the nail so that it hits the sustentaculum tali properly, insert a second Kirschner wire through the other hole of the guiding arm, exchange the wires after drilling for locking screws, apply an end cap to extend the length of nail, if needed, and then verify proper reduction and implant position fluoroscopically.

Step 8 Postoperative Management

Manage the patient with continuous passive motion and active range-of-motion exercises of the ankle beginning on postoperative day 2 and allow partial weight-bearing of 20 kg for 6 to 10 weeks.

Results

Recently, we reported on 103 patients with 106 intra-articular calcaneal fractures treated with the C-Nail by 4 senior surgeons from February 2011 to October 2013¹.

Pitfalls & Challenges

Early Fixation of Calcaneus Fractures

The treatment of calcaneus fractures is controversial. Historically, most operatively treated fractures have been approached with a lateral extensile incision requiring delay in operative treatment until swelling has improved. There is a current trend and interest in small incision approaches allowing, and in some cases requiring, earlier operative fixation. Clinical scenarios amenable to consideration for early fixation are reviewed. The sinus tarsi surgical approach and reduction techniques are outlined in detail.