Calcaneal fractures: update on current treatments

Open reduction and Kirschner wire fixation method using a cylindrical block of unidirectional porous β-tricalcium phosphate for tongue-shaped calcaneal fracture: Report of three cases

Background

The artificial bone grafts are performed on the defect after reduction of the calcaneal fracture. Generally, it is an artificial bone graft with an implant, and there are a few reports of an artificial bone graft without an implant.

Cases

We report three cases (42-year-old male, 67-year-old male, 21-year-old female) of a tongue-shaped calcaneal fracture treated using a cylindrical unidirectional porous β-tricalcium phosphate artificial bone (Affinos®, Kurare co Ltd., Hyougo, Japan) to surgically repair bone defects after reduction. The bone defect is often observed when fracture is reduced in calcaneal fracture. There were significant bone defects, which were then fixed using Affinos® (forming a cylindrical shape block; diameter 10 mm x height 20 mm) to support the bone fragment, an artificial β-tricalcium phosphate bone with a porosity of 57 % (pore size 25-300 μm), characterized by a novel unidirectional porous structure. Postoperative early rehabilitation started with partial load from 5 weeks after surgery and was full weight bearing at 9 weeks after surgery. There was no correction loss and good bone fusion was obtained. By 12 months postoperatively, patients were able to be walking without pain and absorption and bone fusion around the artificial bone were observed maintaining the morphology immediately after reduction. The result was a good clinical result of one excellent (92 points) and two good (81 and 84 points) 1 year after surgery in the postoperative AOFAS Ankle-Hindfoot Scale.

Conclusion

Affinos® has a frost-like structure, which endows it with good tissue invasive properties because of the capillary effect. Moreover, it has excellent osteoconduction capability. In these 3 cases, Affinos® showed good strength, affinity, absorption, and bone substitution in a tongue-shaped calcaneal fracture. Further prospective studies are required to confirm our findings.

Do heel-unloading orthoses improve clinical outcomes in patients after surgical treatment of calcaneal fracture? A propensity-matched, multicenter analysis of the TRON database

BACKGROUND

Postoperative protocols after surgical treatment of calcaneal fracture have not been standardized to date. There are only a few reports on the efficacy of heel-unloading orthoses (HUOs; Mars shoe, Graffin orthosis), and thier efficacy is uncertain.

OBJECTIVES

The purpose of this study was to compare postoperative radiologic and clinical outcomes in patients with calcaneal fractures who used Graffin orthosis.

STUDY DESIGN

Multicenter retrospective study.

METHODS

We finally extracted 182 patients from a database of the Trauma Research Group of Nagoya and divided them into two groups: group C (underwent casting or splinting only) and group O (Graffin orthosis was used). A propensity score algorithm was used to match group C to group O in a 1:1 ratio. We evaluated American Orthopaedic Foot and Ankle Society (AOFAS) score at three and six months after surgery and at final follow-up. Differences in reduction of the Böhler angle between the two groups were evaluated radiographically. All data were analyzed with a t-test or Fisher's exact test. P < .05 was considered statistically significant.

RESULTS

The AOFAS score 3 months after surgery in group O was significantly higher than that in group C (69.57 vs. 77.22; P = .004). However, there were no statistically significant differences between group C vs. group O in AOFAS scores at 6 months after surgery and at final follow-up (81.92 vs. 85.67 and 89.18 vs. 88.13; P = .087 and 0.597, respectively). There was no significant statistical difference in the reduction of the Böhler angle (5.07 vs. 5.89; P = .529).

CONCLUSIONS

At 3 months postoperatively, the orthosis group showed predominantly better functional results. We believe that heel-unloading orthoses are useful for patients who require an early return to work and to daily life.

The Association of Bohler's Angle With Postoperative Pain and Gender for Displaced Intra-Articular Calcaneal Fracture, Multicenter Retrospective Study-TRON Study

A relationship between Böhler angle (BA) before or after surgery and clinical outcomes remains unclear. This retrospective multicenter cohort study aimed to compare pain and functional outcomes between a group in which the reduction angle was preserved and a group in which the reduction angle was lost during follow-up, and to clarify the risk factors leading to loss of last follow-up BA. From 2014 to 2018, 271 cases of calcaneal fractures were surgically treated at ten facilities. We divided patients into Group L (lost reduction of fracture) and Group P (preserved reduction of fracture). We matched subjects between the 2 groups according to age, sex and BA before surgery and compared American Orthopedic Foot and Ankle Society (AOFAS) score between the groups. We investigated the correlation between the amount of BA loss and postoperative pain. The factors leading to loss of last follow-up BA were examined by logistic regression analysis. Ultimately, 112 patients were eligible. After matching, each group included 38 patients. There was no difference between the 2 groups in total AOFAS score. However, the pain component of AOFAS score at 6 months and 12 months were worse in group L than in group P (p = .011, p = .031, respectively). We also showed a weak correlation between the amount of BA loss and postoperative pain. Logistic regression analysis revealed that female and BA before surgery independently predicted loss of reduction (odds ratios: 4.66, 95% CI: 1.15-18.9 and odds ratios: 0.90, 95% CI: 0.82-0.99, respectively). We clarified that reduction and preservation of BA within its normal range should lead to decrease postoperative pain. Female and lower pre-BA were risk factors leading to loss of reduction of BA in operative treatment of calcaneal fractures.

Local administration of epsilon-aminocaproic acid reduces post-operative blood loss from surgery for closed, Sanders III-IV calcaneal fractures

Purpose

To investigate whether local administration of epsilon-aminocaproic acid (EACA) is effective and safe in reducing the post-operative blood loss in surgery for Sanders III–IV calcaneal fractures.

Methods

Patients with Sanders III–IV calcaneal fractures who were hospitalized in our hospital from January 2016 to February 2021 and underwent open reduction internal fixation (ORIF) via lateral approach with an L-shaped incision were included in the current study. Eighty five patients were randomly divided into two groups, EACA group (43) and control group (42). Twenty milliliters of 5% EACA solution or normal saline was perfused into the incision of patients in EACA group and control group, respectively. The volume of post-operative drainage was investigated as the primary outcome. Post-operative blood test, coagulation test, and wound complications were analyzed as the secondary outcomes.

Results

The volume of post-operative drainage at 24 and 48 h was 164.8 ± 51.4 ml, 18.9 ± 3.8 ml for patients in EACA group, and 373.0 ± 88.1 ml, 21.2 ± 4.4 ml for patients in the control group, respectively. EACA greatly reduced the post-operative blood loss compared to the control (normal saline). The difference between the two groups was statistically significant. No statistically significant difference was found between EACA group and control group with regard to the pre-operative, baseline characteristics. Post-operative blood test results demonstrated that haemoglobin and hematocrit were significantly higher in EACA compared to those of control group. No significant difference was found between EACA group and control group in terms of the platelet counts, prothrombin time (P.T.), activated partial prothrombin time (APTT), and wound complications.

Conclusion

Local administration of EACA is effective in post-operative blood loss reduction in ORIF surgeries for Sanders III–IV types of calcaneal fractures without increasing the incidence of periwound complication.

The value of Gissane`s angle in the population of Central Serbia

Background/Aim. Determining the value of Gissane?s angle (GA) plays a role in the diagnosis and prognosis of heel fractures, determining treatment methods, and assessing the outcome of surgical treatment. Normal values of the GA vary in relation to ethnicity, age, and gender of the examined group, which indicates its anthropometric significance. The aim of this study was to determine the range of normal GA values in the population of Central Serbia. Methods. GA was determined on lateral radiography of the foot of 145 subjects of both sexes (67 women and 78 men), with subjects divided into 6 age groups. The patients included in the study did not have a calcaneus fracture. The obtained results were processed in the Graph Pad program. Results. The average value of GA in Central Serbia was 110.8? ? 8.1?, ranging from 93? to 132.9?. The mean value of GA decreased with age, and no difference was observed between women and men, except in the youngest age group, where women had higher GA values than men. Conclusion. The results of the study showed a wide range of normal GA values, as well as the existence of a difference in subjects of different ages and sex.

Effects of Local Administration of Tranexamic Acid on Reducing Postoperative Blood Loss in Surgeries for Closed, Sanders III-IV Calcaneal Fractures: A Randomized Controlled Study

PURPOSE

To investigate whether local administration of tranexamic acid (TXA) is effective in postoperative blood loss reduction in surgeries for Sanders III-IV calcaneal fractures.

METHODS

Calcaneal fracture patients who were hospitalized in our hospital from August 2014 to April 2018 and underwent open reduction internal fixation (ORIF) via lateral approach with an L-shaped incision were included in the present study. 53 Patients were randomly divided into three groups, groups A (17), B (17) and C (19). Twenty milliliters of 10 mg/ml and 20 mg/ml TXA solution were perfused into the incision of patients in group A and group B, respectively. Twenty milliliters of saline were perfused into the incision of patients in group C as control. The volume of postoperative drainage, postoperative blood test, coagulation test, and wound complications were analyzed to evaluate the effectiveness of local administration of TXA on blood loss reduction.

RESULTS

The amount of drainage at 24 and 48 h after the procedure was 110 ± 170, 30 ± 10 ml and 130 ± 160, 20 ± 17 ml for patients in group A and group B, respectively. The corresponding numbers for patients in group C were 360 ± 320, 20 ± 10 ml. The difference between group A and group C was statistically significant, so was the difference between group B and group C. No statistically significant difference was found between group A and group B. Postoperative blood test results revealed that the levels of hemoglobin and hematocrit were significantly higher in group A and group B when each compared to that of group C. In contrast, no difference was found between group A and group B. No significant difference was found between each experimental group and the control group in terms of platelet counts, prothrombin time (P.T.), activated partial prothrombin time (APTT), and wound complications.

CONCLUSION

Local administration of TXA is effective in the reduction of postoperative blood loss in surgeries for Sanders III-IV types of calcaneal fractures without notably associated side effects.

Sanders classification of calcaneal fractures in CT images with deep learning and differential data augmentation techniques

BACKGROUND

Classification of the type of calcaneal fracture on CT images is essential in driving treatment. However, human-based classification can be challenging due to anatomical complexities and CT image constraints. The use of computer-aided classification system in standard practice is additionally hindered by the availability of training images. The aims of this study is to 1) propose a deep learning network combined with data augmentation technique to classify calcaneal fractures on CT images into the Sanders system, and 2) assess the efficiency of such approach with differential training methods.

METHODS

In this study, the Principle component analysis (PCA) network was selected for the deep learning neural network architecture for its superior performance. CT calcaneal images were processed through PCA filters, binary hashing, and a block-wise histogram. The Augmentor pipeline including rotation, distortion, and flips was applied to generate artificial calcaneus fractured images. Two types of training approaches and five data sample sizes were investigated to evaluate the performance of the proposed system with and without data augmentation.

RESULTS

Compared to the original performance, use of augmented images during training improved network performance accuracy by almost twofold in classifying Sanders fracture types for all dataset sizes. A fivefold increase in the number of augmented training images improved network classification accuracy by 35%. The proposed deep CNN model achieved 72% accuracy in classifying CT calcaneal images into the four Sanders categories when trained with sufficient augmented artificial images.

CONCLUSION

The proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of computer-aided system in assisting physicians in evaluating calcaneal fracture types.

Functional Outcome Estimation of Calcaneum Fractures Treated by Open Reduction and Internal Fixation with Plate and Screws in A Tertiary Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Calcaneum fractures constitute about 60% of all tarsal bone fractures. Intra-articular fractures account for 70% of all calcaneal fractures. There are controversies regarding the operative treatment of calcaneum fractures. Therefore this study aimed to estimate the functional outcomes of calcaneum fractures treated by open reduction and internal fixation with plate and screws.

METHODS

This descriptive, cross-sectional study was carried out at the tertiary care center in the western region of Nepal among the patients with displaced intra-articular calcaneum fractures from February 2017 to July 2020 after approval from the Institutional review committee. Convenient sampling was done to reach the sample size. Fifteen cases were included in the study. Data were recorded in proforma and Data analysis was done in the statistical package for social sciences. The American Orthopedic Foot and Ankle Society Hindfoot score was used to assess the final outcome.

RESULTS

According to the American Orthopedic Foot and Ankle Society hindfoot scores, there were five excellent (33.33%), seven good (46.66%), two fair (13.33%) and one poor (6.66 %) results.

CONCLUSIONS

In displaced intra-articular calcaneum fractures, open reduction and internal fixation with plates and screws result in a good number of satisfactory outcomes with very few unsatisfactory results. Hence it can be a better option of treatment in displaced intra-articular calcaneum fractures.

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.

Wrong Foot Forward - A Rare Injury by Indian Tiffin Box

Introduction

Although the penetrating injuries to the foot are common and sometimes they may be associated with calcaneum fracture, this case highlights a very rare injury by relatively harmless "Indian tiffin box."

Case Report

A 30-year-old man was admitted to our hospital with a history of stepping over the Indian tiffin box. He presented with a tiffin box embedded in his right sole with food particles (pulses) inside the wound. It was associated with undisplaced, extra-articular fracture of calcaneus. Contamination with food particles and delayed presentation had added extra risk of infection. Aggressive management by wound lavage, debridement, and intravenous antibiotics has prevented the delayed complication like osteomyelitis.

Conclusion

Harmless-looking tiffin box can cause significant injury. Evaluation and proper management of soft-tissue involvement, especially heel pad, is very important due to its association to outcome. Proper documentation is equally important to avoid tricky medicolegal situations.

Short-Term Outcomes of Open Reduction and Internal Fixation for Sanders Type III Calcaneal Fractures With and Without Bone Grafts

Calcaneal fractures, often caused by a fall from a height, are the most common injuries encountered by orthopedic surgeons. Currently, open anatomic reduction and internal fixation (ORIF) is considered a valuable treatment of displaced intraarticular fractures of the calcaneus; however, the need for bone grafting in the treatment is still controversial. Therefore, in the present study, we investigated the outcomes of 2 methods (with and without bone grafting) used for the surgical treatment of Sanders type III calcaneal fractures. From January 2013 to September 2015, 57 cases (55 patients) with displaced Sanders type III calcaneal fractures (53 unilateral and 2 bilateral) were enrolled. The patients were divided into 2 groups: group I was treated by ORIF with bone grafting (n = 28) and group II was treated by ORIF without bone grafting (n = 29). The radiologic evaluation included Böhler's angle, Gissane's angle, and the height and width of the calcaneum. In addition, the American Orthopaedic Foot and Ankle Society questionnaires and visual analog scale were completed by the patients. During the follow-up period, no differences were found in the outcome measures (Böhler's angle, p = .447; Gissane's angle, p = .599; calcaneal height, p = .065; calcaneal width p = .077; and American Orthopaedic Foot and Ankle Society questionnaires, p = .282) with or without bone grafting. The only difference between the 2 groups was the occurrence of postoperative pain (p = .024 and p = ≤ .05), which was greater in the patients who had undergone bone grafting. We have provided evidence that bone grafting with internal fixation in the treatment of intraarticular calcaneal fractures failed to improve the restoration of Böhler's angle or Gissane's angle. No statistically significant difference was found in the short-term outcomes between the 2 methods used for the surgical treatment of Sanders type III calcaneal fractures.

Epidemiological study on calcaneus fractures in a tertiary hospital

Objective

To analyze the epidemiology and characteristics of patients with calcaneus fractures.

Methods

This is a retrospective revision of patients with calcaneus fractures hospitalized in the Institute of Orthopedics and Traumatology of this institution between 2006 and 2010. Data such as age, gender, laterality, trauma mechanism, type of fracture, associated injuries, compound fractures, and time from injury to surgery were analyzed.

Results

The analysis of 52 patients showed that men were more commonly affected than women, at a ratio of 5.5:1. Bilateral fractures were observed in ten cases, resulting in a total of 62 calcaneus fractures. A fall from a height was the most frequent trauma mechanism (75%), followed by motorcycle accidents (11.5%) and automobile accidents (9.6%). The most frequent fractures were intra-articular, with 47 cases. Compound fractures were observed in 15 patients (28.9%). Non-surgical management was adopted for 11 patients while 41 patients underwent surgery. The mean time between trauma and the definitive treatment was 7.8 days (range: 0–21 days), and 58.5% of cases were treated within seven days.

Conclusion

Patients with calcaneus fractures, most commonly young men, were admitted to a high complexity care hospital, victims of a fall from a height with associated injuries. The great severity of these fractures is characterized by the high prevalence of bilateral (19.2%) and compound fractures (28.9%) in this population group.

Clinical observation of biomimetic mineralized collagen artificial bone putty for bone reconstruction of calcaneus fracture

This study investigated clinical outcomes of biomimetic mineralized collagen artificial bone putty for bone reconstruction in the treatment of calcaneus fracture. Sixty cases of calcaneal fractures surgically treated with open reduction and internal fixation in our hospital from June 2014–2015 were chosen and randomly divided into two groups, including 30 cases treated with biomimetic mineralized collagen artificial bone putty as treatment group, and 30 cases treated with autogenous ilia as control group. The average follow-up time was 17.2 ± 3.0 months. The results showed that the surgery duration and postoperative drainage volume of treatment group were significantly lower than control group; there were no statistically significant differences in the fracture healing time, American Orthopaedic Foot and Ankle Society scores at 3 and 12 months after surgery, Böhler’s angle, Gissane’s angle and height of calcaneus between the two groups. There were no significant differences in wound complication and reject reaction between the two groups, while significant difference in donor site complication. As a conclusion, the implantation of biomimetic mineralized collagen artificial bone putty in the open reduction of calcaneal fracture resulted in reliable effect and less complications, which is suitable for clinical applications in the treatment of bone defect in calcaneal fractures.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Complications in operative fixation of calcaneal fractures

OBJECTIVE

The purpose of this study focused on a number of factors that have been implicated in calcaneal complications and find the incidence of wound complications.

METHODS

This was a retrospective study. A total of 162 patients (176 feet) who underwent calcaneal fractures between 2007 and 2012 were included. The patient's personal details, age, time from injury to surgery, cause of injury, type of fracture, operative details, operating and tourniquet times were collected from hospital computers and paper records. Evidence of complications including wound infection, wound necrosis, pain, malunion, nonunion, impingement, loss of fixation, ect were studied.

RESULTS

Forty-seven of one hundred and seventy-six fractures (26.704%) had complications, wound infection was noted in seven fractures (3.977%), twelve fractures developed necrosis (6.818%), 14 fractures (7.955%) developed pain. Malunion was found in five fractures (2.841%), nonunion in two fractures (1.136%) and loss of fixation in four fractures (2.272%). Three neurologic injury was also seen in our study (1.705%). Operating time, time from injury to surgery and type of fracture had some association with complications in operative fixation of calcaneal fractures, which showed a statistically significant improvement (P=0.000, 0.031, 0.020, respectively), but there were no evidence that age and tourniquet time affect the incidence of complication after calcaneal fracture surgery (P=0.119, 0.682, respectively).

CONCLUSIONS

Despite developments in the surgical treatment of calcaneal fracture, wound complications still remain inevitable. Advanced imaging techniques, less invasive surgical procedures, wealth of anatomical knowledge, surgical experience and better postoperative care should be ensured.

Operative treatment of intraarticular calcaneal fractures: Anatomical and functional outcome of three different operative techniques

INTRODUCTION

Management of the intraarticular calcaneal fracture is a challenge. The optimal method of treatment remains controversial. This study evaluates the anatomical and functional postoperative outcomes of displaced intraarticular calcaneal fractures that have been treated using three different techniques of ORIF.

PATIENTS AND METHODS

Between 2004 and 2011 we treated 143 patients with calcaneal fractures, 40 of these patients (28%) were treated conservatively. This is a retrospective study of the remaining 103 patients (72%) who were operated on consecutively, mainly by one surgeon (NG). Calcaneal fractures were classified according to the Sanders classification. Three types of osteosynthesis were used: standard anatomical plate (SP), locking anatomical plate (LCP) and standard anatomical plate with autologous bone graft (SP+ABG). Clinical outcome was assessed one year after the operation: anatomical reduction was evaluated according to the analysis of Bohler's angle at final follow-up, and functional assessment was conducted using the Maryland Foot Score (MFS).

RESULTS

The fractures were classified as follows: 35 (34%) Sanders type II, 47 (45.6%) Sanders type III and 21 (20.4%) Sanders type IV. The SP was used in 67 (65%) fractures, LCP in 16 (15.5%) and SP+ABH in 20 (19.4%). The correlation test showed a weak association between the Sanders fracture type and the operation technique (Pearson correlation coefficient r=0.26). The non-parametric tests showed that the fracture type did not significantly influence the postoperative Bohler's angle outcome (p=0.132), or the type of operation (p=0.664). Excellent or good reduction of the posterior calcaneal facet was achieved in all operated fractures. One year after the operation, the distribution of Bohler's angle was normal with a mean 31.9° (SD 4.84) in all three groups. There was no significant difference in the functional postoperative outcome in terms of MFS in the three groups (p=0.601), but the Sanders fracture type had significant influence on the functional postoperative outcome in terms of MFS (p=0.001).

CONCLUSION

In the representative sample of 103 operatively treated intraarticular calcaneal fractures, anatomical and functional postoperative efficacy outcomes appeared to be similar in all three treatment groups. High-grade displaced intraarticular calcaneal fractures (Sanders IV) had worse functional results irrespective of the type of operation. The optimal method for management of intraarticular calcaneal fracture is operative, using the standard anatomic calcaneal plate. Autologous bone grafting is not required. Large sample comparative studies are still needed.

Administration of Tranexamic Acid Reduces Postoperative Blood Loss in Calcaneal Fractures: A Randomized Controlled Trial

The present randomized controlled trial was undertaken to evaluate the effect of tranexamic acid (TXA) on reducing postoperative blood loss in calcaneal fractures. A total of 90 patients with a unilateral closed calcaneal fracture were randomized to the TXA (n = 45) and control (n = 45) groups. The corresponding groups received 15 mg/kg body weight of TXA or placebo (0.9% sodium chloride solution) intravenously before the skin incision was made. Open reduction and internal fixation was performed for all patients and selective bone grafting was performed. The patients were examined 3 months after surgery. The intraoperative and postoperative blood loss, blood test results, and wound complications were compared between the 2 groups. The complications of TXA were also investigated. No statistically significant differences were found in the baseline characteristics between the TXA and control groups. Also, no significant difference was noted in the intraoperative blood loss between the 2 groups. However, in the TXA group, the postoperative blood loss during the first 24 hours was significantly lower than that in the control group (110.0 ± 160.0 mL versus 320.0 ± 360.0 mL; p < .001). The incidence of wound complications was also reduced compared with that in the control group (7.3% versus 23.8%; p = .036). No significant difference was found in the incidence of thromboembolic events or adverse drug reactions between the 2 groups. We concluded that preoperative single-dose TXA can effectively reduce postoperative blood loss and wound complications in patients with calcaneal fractures and that no significant side effects developed compared with the control group.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Minimally invasive (sinus tarsi) approach for open reduction and internal fixation of intra-articular calcaneus fractures in children: surgical technique and case report of two patients

Calcaneus fractures in children differ from those in adults. Most calcaneus fractures in children can be managed nonoperatively, with good long-term results expected. The width and height of the calcaneus can remodel with time in children. Recently, there has been a trend toward operative treatment of displaced intra-articular fractures of the calcaneus in children to correct the articular deformity. Studies of calcaneal fracture fixation in children used an extended lateral approach, with its possible complications. In the present report, we describe the operative treatment of 2 children (12 and 13 years old), who had a displaced intra-articular fracture of the calcaneus, using a minimally invasive sinus tarsi approach. Adequate reduction was obtained in both cases with no soft tissue complications or implant discomfort. Fixation was obtained using 3.5-mm cortical screws. Anatomic joint alignment was restored. The children were followed up until they had both resumed their full activities with no complications. We recommend this approach for operative treatment of displaced intra-articular fractures of the calcaneus, because it addresses the intra-articular displacement, which is the most important element of the deformity in children.