Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis

Minimally invasive K-wire fixation of displaced intraarticular calcaneal fractures through a minimal sinus tarsi approach

BACKGROUND

Displaced intra-articular calcaneal fractures are challenging injuries, and there is debate regarding the best method of treatment.

PATIENTS AND METHODS

Between January 2018 and January 2021, a prospective study was conducted on 46 patients with 56 displaced intraarticular calcaneal fractures that were treated with minimally invasive fixation using Kirschner wires (KWs) through the sinus tarsi approach.

RESULTS

The mean follow-up period was 22.36 months. The American Orthopaedic Foot and Ankle Society (AOFAS) score was adopted as a method of clinical evaluation; the mean AOFAS score was 78.4. All cases showed radiographic evidence of adequate healing, with no collapse till the final follow-up. Complications included persistent pain, subtalar arthritis, deep infection and superficial pin site infection.

CONCLUSION

The use of the sinus tarsi approach and percutaneous KWs represents a minimally invasive approach which expands the indications of surgery for displaced intra-articular calcaneal fractures with fewer treatment-related complications. Level of evidence (4) case series. Trial registration This study has been approved by the ethical research committee of the Faculty of Medicine, Tanta University, under the code: 35901/10/22.

Three-dimensional printed cast assisted screw fixation of calcaneal fractures: a prospective study

BACKGROUND

Treatment of displaced intra-articular calcaneal fractures (DIACFs) with percutaneous screw fixation remains defective in some aspects. A novel three-dimensional (3D) printed cast was devised to assist screw placement. This study assessed the radiological and functional outcomes of 3D-printed cast assisted screw fixation for patients with DIACFs.

METHODS

Patients with unilateral Sanders type II or III DIACFs admitted to a single-centre hospital underwent either 3D-printed cast assisted screw fixation (3D group) or minimally invasive plate fixation (control group) from September 2020 to November 2022. All patients were assessed at one, two, three, and six months of follow-up. Comparison between groups was conducted in operative duration, fluoroscopic times, radiographic measurements of the calcaneus, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score.

RESULTS

A total of 32 patients were enrolled (19 in the 3D group versus 13 in the control group). Significant differences were detected between the 3D group and control group in operative duration (53.63±8.95 min, 95.08±8.31 min, P <0.001), fluoroscopic times (7.37±1.21, 16.85±1.57, P <0.001). At a follow-up of six months, the 3D group showed better restoration than the control group in calcaneal width, height, Bohler angle, and AOFAS Ankle-Hindfoot scores (all P <0.001). No significant differences were shown in calcaneal length and Gissane angle (P >0.05). No wound-related complications occurred in either group.

CONCLUSION

The 3D-printed cast assisted screw fixation has shown superiority over minimally invasive plate fixation in the operative duration, fluoroscopic exposure, morphological restoration of the calcaneus, and functional outcomes in the treatment of DIACFs.

A novel distractor-assisted reduction combined with the sinus tarsi approach for joint depression-type calcaneal fractures

PURPOSE

A novel percutaneous distractor with the advantage of axial and direct distraction was designed for the minimally invasive treatment of calcaneal fractures. The purpose of this study was to investigate the clinical results and complications of a novel distractor combined with sinus tarsi approach (STA) in treatment of the joint depression-type of calcaneal fractures.

METHODS

Fifty-four patients with the depression-type of calcaneal fractures (30 Sanders type II, 22 Sanders type III, 2 Sanders type IV) who were subjected to the novel distractor combined with STA were retrospectively assessed. Calcaneal height, width, and length; Bohler's angle; and the Gissane angle were evaluated pre-operatively and post-operatively. Clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) pain scores from the last follow-up. Complications were also recorded.

RESULTS

Fifty-two patients achieved an average follow-up of 24.3 months (range 18 to 34 months), and two patients were lost to follow-up six months post-operatively. There was significant difference between pre-operative and post-operative calcaneal height, width, and length; Bohler's angle; and Gissane angle (p < 0.01), but no significant difference was detected between the post-operative and normal side Bohler's angle (p > 0.05). The AOFAS ankle and hind foot score was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7 at the last follow-up. Nine (17.3%) patients developed complications: One experienced skin necrosis and two had screws loosening; three patients developed early degenerative changes of the subtalar joint; two had no symptoms; one had light pain around the subtalar joint without medical treatment; complex regional pain syndrome (CRPS) developed in one patient after seven months post-operatively; and two developed transient ankle stiffness.

CONCLUSION

The novel distractor combined with the STA effectively reconstructs the facet depression-type of calcaneal fractures (sanders type II and III) with minimal complications.

Calcaneous interlocking nail treatment for calcaneous fracture: a multiple center retrospective study

BACKGROUND

Minimally invasive treatments for calcaneous fractures have the same outcomes and fewer complications. However, they are technically demanding, and there are a lack reduction tools. To overcome these problems, a calcaneous interlocking nail system was developed that can make reduction and fixation minimally invasive and effective. We retrospectively studied the calcaneous fracture variables intraoperatively and followed up to evaluate the outcomes of patients treated with the calcaneous interlocking nail system.

METHODS

All patients in 7 institutions between October 2020 and May 2021 who had calcaneous fractures treated with calcaneous interlocking nails were retrospectively analyzed. The patient characteristics, including age, sex, injury mechanism, Sanders type classification, smoking status, and diabetes were recorded. The calcaneous interlocking nail and standard surgical technique were introduced. The intraoperative variables, including days waiting for surgery, surgery time, blood loss, incision length, and fluoroscopy time, were recorded. The outcomes of complications, AOFAS scores and VAS scores were recorded and compared with other similar studies.

RESULTS

Fifty-nine patients were involved in this study; 54 were male; 5 were female; and they had an average age of 47.5 ± 9.2 years (range 25-70). 2 of these fractures were Sanders type I, 28 of these fractures were Sanders type II, 27 of these fractures were Sanders type III, and 2 of these were Sanders type IV. The surgery time was 131.9 ± 50.5 (30-240) minutes on average. The blood loss was 36.9 ± 41.1 (1-250) ml. The average incision length was 3.5 ± 1.8 (1-8) cm; 57 were sinus tarsi incisions; and 2 were closed fixations without incisions. The average fluoroscopy time was 12.3 ± 3.6 (10-25) seconds during the surgery. The VAS score of patients on the day after surgery was 2.4 ± 0.7 (1-3). The AOFAS ankle-hindfoot score in patients who had a follow-up of at 12 months was 93.3 ± 3.6(85-99). During the follow-up, all patients' functional outcomes were good. One patient had a superficial infection. The rate of complications of the 59 patients was 1.7% (1/59).

CONCLUSION

The calcaneous interlocking nail system can have satisfactory reduction and fixation in calcaneous fractures, even in Sanders type IV. The outcomes of follow-up showed good function. The calcaneous interlocking nail could be an alternative method for minimally invasive calcaneous fracture fixation.

Minimally Invasive Osteosynthesis of Intraarticular Calcaneus Fracture Augmented by Femoral Head Allograft: A Retrospective Study

Aim: The aim of this retrospective study is to report the results of minimally invasive osteosynthesis when used for the treatment of intraarticular calcaneus fracture. This old technique is regaining popularity recently with the multiple advances added by different institutes when it is used in the management of intraarticular calcaneus fracture.

Methods: Twenty-four patients who suffered from intraarticular calcaneus fractures between 2014 and 2019 were included. Twelve of them had Sanders II fractures (group A) and 12 had Sanders III + IV fractures (group B). The mean follow-up duration was 37.5 months. The mean age at presentation was 54.23 ± 12.48 years. The skin condition at presentation was poor (blood-filled blisters) in 25% of patients equally distributed between the two groups. The mean time to surgery was 5.6 days where patients with poor skin conditions were treated lately. The technique involved percutaneous ascending proximal-to-distal pinning of the calcaneus after reduction using a 2 cm mini-incision below the lateral malleolus and augmenting the fixation with femoral head cancellous allograft. The primary outcomes variables analyzed in this study are post-operative Bohler angle, post-operative Gissane angle, American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at long-term follow-up (Excellent>95, Good 75-94, Fair 51-74, poor 0-50), and the delta angle benefit score. The secondary outcomes included post-operative complications such as infection and osteoarthritis.

Results: The radiological results showed significant improvement of Bohler angle from 6.09° ± 21.6 pre-operatively, to 31.79° ± 14.1 postoperatively with a p-value <0.001. An adequate reduction was achieved in 54.16% to 70.8% of patients. There is a trend to normalization of overcorrected fracture especially Sanders II with a mean reduction of 12,71° ± 11,88 at one year post-operatively (p=0.05). AOFAS score at the last follow-up shows 20.83% poor results (AOFAS<50), 50% fair results (AOFAS between 51-74), 16.67% good results (AOFAS 75-94), and 12.5% excellent results (AOFAS>95. The satisfaction rate was 83.3% (45.8% partially satisfied, and 37.5% fully satisfied). The incidence of superficial infection (wound inflammation and pin tract infection) was more prevalent in higher group B (40%) compared to group A (0%) with p=0.014. Other complications including osteoarthritis and varus deformity were found in 95.8% and 58.3% of patients respectively at three-year follow-up.

Conclusion: The combination of minimally invasive osteosynthesis and femoral head allograft for the treatment of intraarticular calcaneus fractures seems to give fair to good functional results. Radiological data demonstrated that when the Bohler angle is over-reduced >40°, there was a tendency to autocorrection over time. This may be due to progressive depression of the angle over time as weight bearing is authorized; however, this must be analyzed carefully due to the low number of patients who were overreduced (seven patients). Our study demonstrates that this technique has a low early complication rate (especially low infection and soft tissue problems) but carries high long-term complications such as osteoarthritis and hindfoot varus.

An evaluation of the efficacy of the locked plate with bone grafting in Sanders type III and IV intra-articular calcaneus fractures

Objective:

To demonstrate the efficacy of locking plate osteosynthesis performed by an L-shaped lateral approach in patients with Sanders type III and IV intra-articular calcaneal fractures with posterior facet displacement.

Methods:

Fifty-three patients with Sanders type III or IV unilateral calcaneal fractures treated with locking plates and additional bone grafting were included in the study. Böhler and Gissane angles, and heel height values were measured on the radiological examinations. Clinical results of the patients were evaluated using the American Orthopaedic Foot and Ankle Society and Maryland evaluation criteria. The presence of arthrosis was investigated with Broden’s view. Preoperative and postoperative values were evaluated.

Results:

The mean Gissane angle was 119.32°, the mean Böhler angle was 9.47° and the mean heel height was 40.82 mm on radiographs at initial presentation of the patients. The mean Gissane angle was 114.63°, the mean Böhler angle was 23.33° and the mean heel height was 47.84 mm on the early postoperative radiographs of the patients. In patients, a mean 4.69° recovery was achieved in the Gissane angle, 13.86° in Böhler angle and 7.02 mm in heel height. On the most recent follow-up, Böhler angle was 21.49°, Gissane was 114.88° and the mean heel height was 46.95 mm. The mean American Orthopaedic Foot and Ankle Society score and Maryland score were 86.91 and 86.53, respectively, on the last follow-up.

Conclusion:

Internal fixation and grephonage using low-profile locking plates provides good functional results to patients since it facilitates anatomic restoration of the subtalar joint and correction of calcaneal height, width and varus/valgus heel.

Cannulated screw fixation versus plate fixation in treating displaced intra-articular calcaneus fractures: a systematic review and meta-analysis

BACKGROUND

Operative treatment has become the current trend for displaced intra-articular calcaneus fracture (DIACF), while using cannulated screw fixation or plate fixation is still controversial for treating DIACF. The purpose of this meta-analysis is to compare the outcome of the two fixation methods.

METHODS

We searched literature comparing cannulated screw fixation and plate fixation from PubMed, Embase, Web of Science, and Cochrane Library. Only randomized controlled trials were included. The outcomes of post-operative function, radiological measurement, time efficiency, and wound complications were pooled in the meta-analysis.

RESULT

Seven RCTs with 902 cases of DIACF were included. Pooled results showed the two fixation methods that had similar function satisfactory of AOFAS score (RR = 0.95, 95% CI = [0.83, 1.09], P = 0.47, I² = 0%) and Maryland Foot score (RR = 0.93, 95% CI = [0.68, 1.28], P = 0.66, I² = 84%). Compared to plate fixation, cannulated screw fixation had better improvement of Bohler's angle (WMD = 0.56, 95% CI = [0.20, 0.91], P = 0.002, I² = 34%) and Gissane's angle (WMD = 1.36, 95% CI = [0.56, 2.16], P = 0.0008, I² = 7%), better recovery of calcaneal height (WMD = 0.49, 95% CI = [0.02, 0.95], P = 0.04, I² = 6%), shorter time to operation (WMD =  - 2.91, 95% CI = [- 4.99, - 0.84], P = 0.006, I² = 97%), less operation time (WMD =  - 21.58, 95% CI = [- 37.31, - 5.85], P = 0.007, I² = 98%), reduced length of hospital stay (WMD =  - 2.00, 95% CI = [- 3.69, - 0.31], P = 0.02, I² = 97%), and less wound complications (RR = 0.16, 95% CI = [0.08, 0.32], P < 0.00001, I² = 0%).

CONCLUSION

Cannulated screw fixation and plate fixation have similar postoperative functional satisfactory. Cannulated screw fixation is superior to plate fixation in reduction quality, time efficiency, and wound complications.

Could percutaneous fixation with crossed Schanz pins be an alternative to open reduction in the treatment of intra-articular calcaneal fractures?

PURPOSE

Despite modern operative techniques and a considerable number of studies in the literature, the best treatment for calcaneal fractures remains an enigma for orthopaedic surgeons. The purpose of the study was to compare clinical and radiographic outcomes between anatomic calcaneal plate (ACP) fixation and crossed Schanz pin (CSP) fixation in the treatment of Sanders type II and III displaced intra-articular calcaneus fractures (DICFs).

METHODS

Consecutive 65 patients (49 males, 16 females) who underwent surgery for DCIFs between January 2009 and February 2013 were retrospectively evaluated. The patients were divided into two groups as ACP and CSP according to the operative technique. The groups were compared in terms of demographic features, injury mechanism, operation time, fluoroscopy exposure, complications, full weight-bearing time, functional, and radiological outcomes.

RESULTS

VAS-rest score did not differ significantly between the groups while the VAS-activity score was significantly higher in the CSP group (p = 0.001 and p = 0.645, respectively). Foot Function Index (FFI) was significantly lower, Maryland Foot Score (MFS) and the American Orthopaedic Foot and Ankle Society-hindfoot score (AOFAS) were significantly higher in the ACP group (p = 0.047, p = 0.016, and p < 0.001, respectively). While no difference was observed between the preoperative and the early post-operative (1st day) Böhler angle and Gissane angle, both were significantly higher in the ACP group at the post-operative last control (p < 0.001 and p < 0.001, respectively).

CONCLUSION

Although crossed Schanz pin fixation shortens the operation time in displaced intra-articular calcaneus fractures compared to anatomic calcaneal plate, increased fluoroscopy exposure rates and low functional and radiological outcomes are disadvantageous of crossed Schanz pin. Anatomic calcaneal plate is still a better technique for preserving the alignment and elevating the displaced intra-articular segment for good to excellent mid-term results.

Sinus Tarsi Approach for Calcaneal Fractures: The New Gold Standard?

Displaced intra-articular calcaneal fractures are among the most difficult articular fractures to treat, with a high rate of potential complications. Is important to restore calcaneus posterior facet anatomy as well as calcaneus width, length, and height. The extensile lateral approach provides excellent fracture visualization and allows reduction of the displaced fracture fragments, but high complication rate has been described with this approach, so many studies favor the sinus tarsi approach. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion toward this less invasive approach, which can be considered the new gold standard.

Comparing open reduction and internal fixation versus closed reduction using dual-point distraction and percutaneous fixation for treating calcaneal fractures

Objectives

This study aims to compare the early clinical, functional and radiographic outcomes of a small cohort of patients with calcaneal fractures treated with closed reduction using a dual- point distraction system and the traditional lateral approach.

Patients and methods

We prospectively treated 40 patients with calcaneus fractures who presented to our emergency department between January 2017 and February 2018. In total, 35 patients (22 males, 13 females; median age 39.8 years; range, 19 to 57 years) were included in this study since five patients were not followed up. Fractures were classified according to the Sanders classification system using computer tomography images. Clinical outcomes including postoperative two-week visual analog scale (VAS) score, sickness absence period, operating time and complication rate were recorded.

Results

The mean follow-up period was 24 months. Closed reduction using dual-point distraction and percutaneous fixation (group 1) was performed in 17 patients, whereas the extended lateral approach (group 2) was used in 18 patients. There were no significant differences between both groups in age, follow- up outcomes and Sanders classification. Operating time was significantly shorter in group 1 than in group 2. At postoperative two weeks, VAS scores were significantly lower in group 1 than in group 2. The complication rate and sickness absence period were significantly lower in group 1 than in group 2.

Conclusion

Closed reduction using dual-point distraction can be preferred owing to many advantages including considerably decreased risk of wound complications, sickness absence period and length of hospital stay as well as superior postoperative rehabilitation with a low pain score.

Short-Term Radiographic Outcomes of Calcaneus Fractures Treated With 2-Incision, Minimally Invasive Approach

BACKGROUND

The treatment of displaced, intra-articular calcaneus fractures is controversial. The extensile lateral approach has been historically preferred because it provides excellent exposure and visualization for fracture reduction. However, soft tissue complications with this approach can lead to poor outcomes for patients. Recently, there has been an interest in the minimally invasive treatment of calcaneus fractures. The purpose of the present study was to determine the radiographic reduction of displaced, intra-articular calcaneus fractures and the rate of complications using a 2-incision, minimally invasive approach.

METHODS

A dual-incision, minimally invasive approach with plate and screw fixation was utilized for the treatment of 32 patients with displaced, intra-articular calcaneus fractures. Preoperative and postoperative calcaneal measurements were taken to assess fracture reduction. Additionally, a retrospective chart review was performed to assess for complications.

RESULTS

The mean preoperative Bohler's angle measurement was 12.9 (range, -5 to 36) degrees and the final postoperative Bohler's angle was 31.7 (range, 16-40) degrees. One patient (3.1%) had postoperative numbness related to the medial incision in the calcaneal branch sensory nerve distribution. Two patients (6.2%) had a wound infection treated with local wound care and oral antibiotics, while 1 patient (3.1%) had a deep infection that required a secondary surgery for irrigation and debridement. Two patients (6.2%) returned to the operating room for removal of symptomatic hardware.

CONCLUSION

Operative fixation of displaced, intra-articular calcaneus fractures treated with a 2-incision, minimally invasive approach resulted in acceptable fracture reduction with a minimal rate of complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Reduction and functional outcome of open reduction plate fixation versus minimally invasive reduction with percutaneous screw fixation for displaced calcaneus fracture: a retrospective study

Background

Minimally invasive surgery has become popular because of the lower incidence of wound complications. However, achieving an anatomic reduction that provides a satisfactory outcome is difficult using minimally invasive surgery. Our study aimed to evaluate the reduction and clinical outcomes of closed reduction and percutaneous fixation treatment using a closed reduction traction device for displaced intra-articular calcaneal fractures compared with traditional open reduction plate fixation using an extended lateral approach.

Methods

A total of 40 patients and 45 feet with calcaneus fractures from 2012 to 2016 were studied. The open reduction plate fixation group (24 feet) was compared to the closed reduction percutaneous fixation group (21 feet) with a traction device. The reduction assessments included length, width, height, Bohler’s angle, Gissane’s angle, and varus or valgus angle before and after surgery. The clinical outcomes included the American Orthopaedic Foot and Ankle Society hindfoot score and the visual analog score for pain, length of stay, and complication rate.

Results

The patients were followed up for an average of 16.53 ± 3.95 months. No significant differences in reduction were observed between the open and closed groups (P > 0.05). The American Orthopaedic Foot and Ankle Society scores of the two groups were 80.29 ± 6.15 and 83.62 ± 6.95 (open versus closed) (P = 0.0957). The visual analog scores of the open and closed groups were 1.50 ± 1.22 and 0.81 ± 0.87 (P = 0.0364). The lengths of stay in the open and closed groups were 9.63 ± 2.72 days and 6.71 ± 1.85 days (P = 0.0002). The complication rates of the open and closed groups were 20.8% (5/24) and 4.8% (1/21) (P < 0.0001).

Conclusions

The closed reduction percutaneous fixation with traction device method may provide equivalent reduction results and superior outcomes for the length of stay, VAS score, and complication rate for displaced intra-articular calcaneal fractures.

Sinus Tarsi Approach with Subcutaneously Delivered Plate Fixation for Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures can be treated with open reduction and internal fixation through various methods, including the extensile lateral approach, sinus tarsi approach, percutaneous reduction and fixation, external fixation, and calcaneoplasty. Although the gold standard is the extensile lateral approach, this method has significant wound-healing complications associated with it. Literature shows that the reduction achieved through minimally invasive techniques is equal to that achieved with the extensile lateral approach, while reducing the amount of postoperative complications. This article outlines a technique that uses the sinus tarsi approach with subcutaneous plate fixation.

Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures

Fractures of the calcaneus are detrimental injuries, often caused by high-energy trauma. To best restore the functionality of a limb and allow normal ambulation, it is recommended to repair displaced intra-articular calcaneus fractures surgically. This article presents several methods of reduction and repair of the calcaneus. Traditionally, calcaneal fractures have been repaired through a lateral extensile incision that has been shown to have a high percentage of wound healing complications. In recent times, there has been a shift toward minimally invasive and sinus tarsi incisional approaches in the repair of calcaneus fractures.

Minimally invasive fixation for displaced intra-articular fractures of calcaneum: a short-term prospective study on functional and radiological outcome

INTRODUCTION

Studies have demonstrated a decrease in the incidence of late consequences and the socio-economic burden of intra-articular fractures of calcaneum when treated by surgical fixation. Operative management of displaced intra-articular calcaneal fractures (DIACF) pose significant challenges such as technical difficulty, wound healing and long-term pain and disability.

MATERIALS AND METHODS

All patients presenting to the ER with DIACF over a period of 2 years and matching the inclusion criteria were enrolled in the study. Percutaneous fixation with 4 mm CC screw was undertaken with a minimally invasive sinus tarsi approach. All patients were available for a minimum follow-up of 24 months. Six radiological parameters were assessed, and functional outcome was evaluated using AOFAS score.

RESULTS

Thirty-four patients with 42 calcaneal fractures were included in the study, and all patients were available for minimum follow-up period. All radiological parameters were attained within anatomic normal range and maintained at 24 months of follow-up. AOFAS score showed a mean value of 90.10 which is considered an excellent outcome. Superficial wound infection was seen in two patients, but no patients required a revision surgery.

CONCLUSION

Displaced intra-articular fractures pose a treatment dilemma, more so in cases of soft tissue complications like open injury or blisters. Percutaneous screw fixation with limited sinus tarsi incision has shown good functional and radiological outcome with minimal complications and can be undertaken without delay.

The "Open-Envelope" Approach: A Limited Open Approach for Calcaneal Fracture Fixation

BACKGROUND

Minimally invasive surgery (MIS) has a significant and evolving role in the treatment of displaced intra articular calcaneal fractures (DIACFs), but there is limited literature on this subject. The objective was hence to assess the clinicoradiological outcomes of DIACFs fixed with an innovative open-envelope MIS technique.

MATERIALS AND METHODS

42 closed Sanders Type 2 and 3; DIACFs were included in this study. The Open-envelope approach was developed, which is essentially a limited open, dual incision, modified posterior longitudinal approach allowing excellent visualisation and direct fragment manipulation. The main outcome measures were American Orthopaedic Foot and Ankle Score (AOFAS) hindfoot score and preoperative and postoperative radiological angles.

RESULTS

The Bohler angle improved from a preoperative mean of 14.3° (range 0°-28°) to a postoperative mean of 32.46° (range 22°-42°). The Gissane angle improved from a preoperative mean of 135.83° to a postoperative mean of 128.33°. The postoperative improvement in Bohler and Gissane angles was highly significant (P < 0.001). The AOFAS scores at 6 months were excellent in nine patients, good in 15 patients, and fair in six patients. Three patients had residual valgus deformity of the heel.

CONCLUSIONS

Open-envelope technique minimized soft tissue complications and achieved acceptable radiological reductions with good clinical outcomes.

Management of Intra-Articular Calcaneal Fractures: Clinical Results of Reduction Technique Using a Bone Spreader

The purpose of the present study was to examine the clinical results of surgery for intra-articular calcaneal fractures using a calcaneal locking plate and a bone spreader as a reduction tool. Ten patients with intra-articular calcaneal fractures were treated. An extended lateral approach was used. The reduction of the intra-articular fragments of the posterior facet was temporarily held using a bone spreader and Kirschner wires. Internal fixation was achieved with a locking calcaneal plate. Böhler's angle and Preiss' angle were assessed on the day of injury and the day of the final follow-up examination. The step off and gap of the posterior facet were assessed on the day of injury and the first week after surgery. The functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society ankle hindfoot scale score. The mean Böhler's angle ranged from 2.1° ± 11.0° to 30.4° ± 5.0° (p < .0001), the mean Preiss' angle ranged from 23.5° ± 4.5° to 15.5° ± 2.9° (p < .0001), the mean step off ranged from 4.0 ± 1.9 mm to 0.1 ± 0.2 mm (p = .0002), and the mean gap ranged from 2.6 ± 1.0 mm to 1.2 ± 0.6 mm (p = .0035). The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was 89.2 (range 85 to 100) at a mean of 14.3 months after surgery. Our results suggest that a locking calcaneal plate can be used to restore and reduce an intra-articular calcaneal fracture and achieve good clinical results.

Comparison of calcaneus joint internal and external fractures in open surgery and minimal invasive methods in patients

Surgical management of calcaneal fractures has various complications. In recent years, minimally invasive surgeries have been utilized for a wide range of surgical procedures on different body parts significantly declining complications. This paper compares surgical outcomes of calcaneal fracture management between the open reduction and internal fixation technique (ORIF) and the MIS technique. In this randomized clinical trial forty patients with calcaneus fractures were randomly assigned to two equal groups; ORIF group and MIS group. Patients were followed for 1 year post-operatively. Gissane and Bohler’s angles, AOFAS questionnaire, pain intensity, ability to conduct previous activities and various complications like wound healing complications and irritation with shoe wear were assessed in the final post-operative visit. Eventually data obtained from the two groups were compared. All patients obtained fracture union. Bohler’s and Gissane angles significantly increased and decreased, respectively, after the operation in both groups (p˂0.05), however, no significant difference was found between the two research groups. AOFAS scores and pain intensity was similar in both groups, however, surgical duration in the MIS group was significantly less than the ORIF group (P=0.021). Only one patient from the ORIF group was not able to resume his previous occupation. 12 patients from the ORIF group and five patients from the MIS group experienced irritation from shoe wear (p=0.025). In the ORIF group, 4 patients suffered from wound healing complications, however, none of the patients of the MIS group had wound complications (p=0.035). In conclusion, based on the results, it can be concluded that the MIS technique demonstrated better functional and radiographic outcomes as well as a more favorable complication profile, thus, it is recommended for the management of calcaneus fractures.

Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis

Background

The ideal treatment for comminuted intraarticular calcaneal fractures is still debated. Open reduction and internal fixation (ORIF) is the most popular surgical procedure; however, wound complications, implant choice, and infection remain major concerns. This study aimed to demonstrate the results of an innovative, minimally invasive surgical procedure, namely, a closed reduction technique using large-diameter Steinmann pins and percutaneous calcaneoplasty using injectable calcium sulfate cement (MIIG X3, Wright Medical Technology, Inc., Arlington, TN), in patients with comminuted calcaneal fractures.

Methods

From January 2012 to January 2014, 20 patients (three women, 17 men) with comminuted calcaneus fractures (Sanders classification type III and Essex-Lopresti classification joint-depression type fracture) were included. Plain films and CT scans were obtained preoperatively in all patients. The operation was performed within three days post-injury, and patients were not allowed to bear weight until three months postoperatively. During this period, the patients were educated on how to perform bed exercises for joints above the surgical site, including muscle strengthening and body conditioning. Early active range of motion exercises for the ankle and forefoot began 3 to 6 weeks postoperatively. All patients were followed up regularly. The results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and Böhler’s angle of the calcaneus.

Results

After an average follow-up of two years, none of the patients required further surgery or experienced soft tissue complications. The clinical results were rated good to excellent on the AOFAS scale in 80% of the cases (16 of 20 patients), and most patients had pain relief and returned to their former daily activities at the same level as before the injury.

Conclusions

A modified Essex-Lopresti procedure with percutaneous calcaneoplasty appears to be a safe and effective procedure to treat comminuted calcaneal fractures with acceptable functional results. Long-term outcomes and additional cases using this technique are required to support our conclusion.

Treatment of displaced intra-articular calcaneus fractures: a current concepts review

Displaced Intra-Articular Calcaneus fractures (DIACFs) represent a source of tremendous disability to the patient, economic burden to the society and a treatment challenge to the average orthopaedic surgeon. To date, no single approach is universally applicable to all calcaneus fractures. Despite a plethora of published meta-analyses and recent randomized controlled trials, the literature is still unclear and offers conflicting recommendations. The aim of this current concepts review is to assess the latest available data and offer pragmatic and practical recommendations to address some of the issues surrounding DIACFs.

Outcome evaluation of minimally invasive surgery versus extensile lateral approach in management of displaced intra-articular calcaneal fractures: A randomised control trial

BACKGROUND

Minimally invasive surgery has a significant and evolving role in the treatment of DIACFs, but there is limited literature on this topic.

OBJECTIVES

To compare the clinico-radiological outcomes of DIACFs fixed with MIS technique with ORIF.

METHODS

This randomised control trial (RCT) included 21 closed Sanders type 2 and 3 DIACFs which were selected from 70 who presented. Extensile lateral approach was used in the ORIF group; while MIS techniques included either percutaneous reduction or small incisions with indirect fragment manipulation.

MAIN OUTCOME MEASUREMENT

AOFAS hindfoot score, pre-operative and postoperative radiology.

RESULTS

There were 9 fractures in the Extensile group and 12 in the MIS group, with both groups having comparable demography, fracture classification, surgery delay & initial radiology. Bohler's angle improved after surgery by an average of 18.44 with ORIF and 14.67 with MIS (p=0.28). Mean AOFAS in the MIS group was 82.58 (66.67% good and 33.33% fair) and was 89.56 (44.44% excellent, 55.56% good, 0 fair/poor) with ORIF (p=0.034). Two patients who underwent ORIF had a major complication (one deep infection and Sural nerve injury each) while none in the MIS group.

CONCLUSIONS

MIS methods minimized soft tissue complications and achieved comparable radiological reductions but clinical outcomes were poorer, with percutaneous methods having the worst outcomes.

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus

BACKGROUND

Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique.

METHODS

153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed.

RESULTS

At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively ( P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement ( P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower.

CONCLUSION

This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

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.

Current management options for displaced intra-articular calcaneal fractures: Non-operative, ORIF, minimally invasive reduction and fixation or primary ORIF and subtalar arthrodesis. A contemporary review

BACKGROUND

Management of Displaced Intra-articular Calcaneal Fractures (DIACFs) continues to be technically demanding. The literature has not been definitive in its guidance for surgeons dealing with these injuries. Recent publications have further added to the lack of clarity. This review is intended to summarise the present state of knowledge, and provide some genuine guidance for clinicians.

OBJECTIVES

To review previous research, focussing on articles published within the last fifteen years, and summarise the findings to aid surgeons in managing DIACFs with choosing best management for patients.

METHODS

We reviewed the best evidence and literature, focussing on articles published within the last fifteen years, and summarised findings into workable recommendations. Variables of (1) patient, (2) the associated soft tissue injury and (3) the fracture characteristics were used to aid surgeons in choosing the best of the available options for each patient that presents with a DIACF.

AUTHORS SUMMARY

Management of DIACFs can best be divided into four broad categories: (i) non-operative management, (ii) open reduction and internal fixation, (iii) minimally invasive reduction and fixation, and (iv) primary subtalar arthrodesis. The evolution of the literature would suggest orthopaedic surgeons managing calcaneus fractures should have an expert's knowledge, surgical expertise and the latest techniques to cover these four options, to tailor the treatment of DIACFs to the individual patient.

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.

Fall-induced fractures of the calcaneus and foot in older people: nationwide statistics in Finland between 1970 and 2013 and prediction for the future

BACKGROUND

Although fall-induced fractures of elderly persons are a major problem, epidemiologic knowledge on their time trends is limited. We assessed the trends in fall-induced fractures of the calcaneus and foot in older Finns between 1970 and 2013.

METHODS

The current trends in the number and incidence (per 100,000 persons) of fall-induced fractures of the calcaneus and foot of older Finns were determined by taking into account individuals 50-year-olds or older who were admitted to Finnish hospitals for primary treatment of such injury in 1970-2013.

RESULTS

The number and raw incidence of these fractures increased considerably between 1970 and 2013, from 64 (number) and 5.6 (incidence) in 1970, to 325 and 15.0, respectively, in 2013. The age-adjusted incidence of fracture was higher in men than women and showed a clear rise in both sexes in 1970-2013, from 7.2 to 15.2 in men (111% increase), and from 4.3 to 13.9 in women (223% increase). A similar rise was observed in the age-specific incidences. If trends in the age-specific fracture incidence continue at the same rate as were observed in 1970-2013, and the 50-year-old or older population increases as predicted (by 15% by the year 2030), the annual number of fall-induced fractures of the calcaneus and foot in this population will be 1.8 times higher in the year 2030 (580 fractures) than it was in 2013 (325 fractures).

CONCLUSIONS

The number of fall-induced fractures of the calcaneus and foot among Finns 50 years of age or older has risen sharply between 1970 and 2013 with a rate that cannot be explained merely by demographic changes. Further studies should examine the reasons for the rise and possibilities for fracture prevention.

Reduction and internal fixation of displaced intra-articular calcaneal fractures with a locking nail: a prospective study of sixty nine cases

PURPOSE

The best treatment for intra-articular fractures of the calcaneus is still debated. The aims of this study were to determine whether intrafocal reduction of thalamic fractures is effective, to evaluate whether a locking nail is able to maintain reduction of the articular surface and to analyse the functional results of this original method.

METHODS

This prospective study assessed 69 fractures treated with a locking fracture nail in 63 cases and with primary subtalar fusion in six (Calcanail (®), FH). Articular congruity and global reduction of the calcaneus was assessed in all patients by computed tomography (CT) scan three months postoperatively. Functional results were evaluated according to the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS-AHS) and all complications recorded.

RESULTS

For the 63 fracture nails, the average AOFAS score was 85.9 at a mean final follow-up of 12 months. Only three secondary fusions were performed. For the six comminuted fractures requiring primary fusion, the average AOFAS score was 75.9 at the last follow-up.

CONCLUSIONS

The posterior intrafocal approach for both reduction and locked nailing of intra-articular calcaneal fractures has been proven as an effective and reliable procedure.

Percutaneous Arthroscopic Calcaneal Osteosynthesis: A Minimally Invasive Technique for Displaced Intra-Articular Calcaneal Fractures

The management of calcaneal fracture remains challenging. Open surgery has been fraught with high infection rates and soft tissue complications. More minimally invasive procedures have reduced this risk, but the patient outcomes after treatment of displaced calcaneal fractures have remained relatively unsatisfactory. We present a method for the management of Sanders grade II and III calcaneal fractures: percutaneous arthroscopic calcaneal osteosynthesis. Thirty-three fractures in 30 patients who had presented to our tertiary foot and ankle trauma center in central London were treated with percutaneous arthroscopic calcaneal osteosynthesis for calcaneal fractures, and the data were prospectively collected. The mean patient age at injury was 39 years. The mean follow-up period was 24 months. Of our patients, 58% were smokers at injury. Of the 33 fractures, 46% were classified as grade II and 54% as grade III. The mean length of stay was 1.92 days. At the final follow-up visit, the mean Böhler angle had increased from 11.10° (range 2° to 24°) to 23.41° (range 15° to 35°). The modified American Orthopaedic Foot and Ankle Society scale score was 72.18 (range 18 to 100), the calcaneal fracture scoring system score was 79.34 (range 42 to 100), and the visual analog scale score was 29.50 (range 0 to 100). We had a single case of a superficial port site infection and 2 cases of prominent screws, which were removed. No cases of deep infection developed, and no conversion to subtalar fusion was required. This technique significantly reduced the incidence of postoperative wound complications. Direct visualization of the fracture site allowed accurate restoration of the articular surface and correction of heel varus. Furthermore, it was associated with a high self-reported functional outcome and a return to preinjury employment levels. Also, the results did not appear to be influenced by tobacco consumption.