A systematic review and meta-analysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures

Postoperative 3D computed tomographic evaluation of 92 calcaneal fracture reduction using the sinus tarsi technique and fixation with 3.5 mm cortical screws

BACKGROUND

Fixation of calcaneus through the sinus tarsi approach is increasingly popular due to the lower rate of wound complications. The use of postoperative CT provided a better evaluation tool than using plain radiography. Our objective of the present study is to evaluate the quality of fracture reductions by postoperative 3D CT scans after surgical intervention using the sinus tarsi approach and fixation with 3.5 cortical screws.

METHODS

Between January 2018 and April 2020, 86 consecutive patients with 92 closed displaced intra-articular calcaneal fractures underwent ORIF with 3.5 mm screws constructed via a minimally invasive sinus tarsi approach by a single foot and ankle surgeon.

RESULTS

The preoperative radiographic assessment found 36 joint depression type and 56 tongue type fractures according to the Essex-Lopresti classification. Preoperative CT assessment found 82 type II and 10 type III according to the Sander classification. Analysis of pre- and postoperative CT parameters showed that the height of the posterior facet, the length of the posterior facet, Gissane, and Bohler's angle were significantly improved. In addition, the means of posterior facet step-off in postoperative CT was 1.07, and 72% of posterior facet reductions were < 2 mm step-offs.

CONCLUSION

With postoperative CT scan assessment, the treatment of displaced intra-articular calcaneal fracture with 3.5 mm screws via sinus tarsi approach has achieved good quality of reduction. Therefore, the screws-only technique is an option for treating calcaneal fracture with less soft tissue damage and implant cost.

A Comparative Analysis of Between Percutaneous Cannulated Screw Fixation and Traditional Plate Internal Fixation in Treatment of Sanders II and III Calcaneal Fractures

The objective of this study is to compare the clinical efficacy of percutaneous cannulated screw fixation and traditional plate internal fixation in the treatment of Sanders II and III calcaneal fractures. The records of 64 patients were retrospectively analyzed. Thirty-three cases were fixed by percutaneous cannulated screws. Thirty-one cases were fixed with traditional steel plates. The preoperative preparation time of the screw group and plate group was 3 ± 1.7 days and 4.6 ± 2.1 days. The surgery time was 118.9 ± 43.8 minutes and 146.9 ± 47.6 minutes. The length of hospitalization was 8.7 ± 3.9 days and 17.0 ± 7.9 days. Intraoperative blood loss was 38.2 ± 27.7 mL and 67.1 ± 58.8 mL. The postoperative drainage volume of the plate group was 85.1 ± 53.7 mL, and no wound drainage was needed in the screw group after surgery. Postoperative wound complications occurred in 2 cases of the screw group and 8 cases of the plate group. The recovery effects of Gissane angle and Bohler angle are similar in the 2 groups. The excellent and good rate of the American Orthopaedic Foot and Ankle Society ankle-hindfoot Scale in the screw group was 96.8% at 12 months after surgery, whereas the rate was 93.5% in the plate group. Compared with the traditional plate internal fixation, the percutaneous cannulated screw group achieved a similar excellent and good rate of clinical treatment. It has the advantages of less trauma, less bleeding, low incidence of complications, short preoperative preparation, and hospitalization time.

Minimally Invasive Surgery vs Nonoperative Treatment for Displaced Intraarticular Calcaneal Fracture: A Prospective Propensity Score Matched Cohort Study With 2-Year Follow-up

BACKGROUND

Optimal management of displaced intraarticular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiologic outcomes of minimally invasive surgery vs nonoperative treatment in displaced intraarticular calcaneal fracture up to 2 years.

METHODS

All displaced intraarticular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma center were considered for inclusion. The decision to treat was made by a multidisciplinary team consisting of fellowship-trained orthopaedic surgeons. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction and internal fixation. Nonoperative protocol involved symptomatic management with no attempt at closed reduction. The Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions-5 Level (EQ-5D-5L) patient-reported outcome measures were used to assess foot and ankle and general health related quality of life outcomes, respectively, at 2-year follow-up. Radiographic assessment was performed based on preinjury and 12-week postinjury radiographs.

RESULTS

A total of 101 patients were included for analysis between August 2014 and January 2019. We propensity score matched 46 patients in the surgical cohort to 46 patients in the nonsurgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (P > .05); however, the surgical cohort had a significantly higher EQ-5D-5L Index score (P < .05) and return to work (91% vs 72%, P < .05) and physical activity rate (46 vs 35%, P < .05) despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. In addition, 14% of patients in the nonoperative cohort subsequently underwent arthrodesis compared with none of the patients in the surgical cohort.

CONCLUSION

In this study, we found that operative treatments were associated with low rates of surgical complication at 2 years and long-term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared with nonoperative treatment for less severe fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Treatment of displaced intra-articular calcaneal fractures using a sinus tarsi approach. Surgical technique

Calcaneal articular fractures are fractures classically associated with a high rate of complications and poor outcomes. Osteosynthesis of the calcaneus through a sinus tarsi approach has shown results equal to or superior to those of the extended approach, having become the new gold standard. The objective of this article is to detail step by step the surgical technique of osteosynthesis of intra-articular fractures of the calcaneus through a sinus tarsi approach, from the selection of the fracture, positioning of the patient, layout of the operating room and the fluoroscope, the entire surgical process until postoperative treatment. The surgical technique described below is described in 6 steps. Anatomical reduction of complex calcaneal fractures through an Sinus Tarsi Approach requires an understanding of the fracture and its associated deformities. Following the described sequence step by step will help to achieve a better reduction in order to achieve better functional results.

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study

BACKGROUND

Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction.

METHODS

This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate.

RESULTS

Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork.

CONCLUSION

Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane.

LEVEL OF EVIDENCE

III.

Geographical Differences in Wound Complication Rates Following the Sinus Tarsi Approach in Displaced Intra-articular Calcaneal Fractures: A Systematic Review of the Literature

Background

The sinus tarsi approach (STA) has gained popularity for the treatment of displaced intra-articular calcaneal fractures. No large studies comparing wound complications worldwide after STA surgery are available. The aim of this systematic review was to compare postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following STA surgery between continents and countries and their differences in climate.

Methods

A literature search was performed using the databases of PubMed, Embase, and the Cochrane Library. Studies published before January 1, 2000, including < 10 patients and written in a language other than English were excluded.

Results

In total, 86 studies containing 4,392 surgeries via STA from 20 different countries were included. The mean POWC was 5.9% and the mean POWI was 4.4%. The highest median POWC rate was in North America (8.5%) and the lowest in South America (2.0%). No significant differences were found in the POWC and POWI rates between countries (p = 0.178 and p = 0.570, respectively), but significant differences were found between the POWC and POWI rates between continents (p = 0.011 and p = 0.036, respectively). The number of surgeries per year and climate differences, as represented by mean local temperature, were not correlated with both the POWC/POWI rates and functional outcome scores.

Conclusions

Significant differences between the POWC and POWI rates were found between continents but not between individual countries. With a mean POWC of 5.9% and a mean POWI rate of 4.4%, STA has an intrinsic low risk for complications given the minimally invasive nature of the approach and is inevitably becoming the gold standard for calcaneal surgery.

Are the non-weight bearing guidelines for the after treatment of calcaneal fractures still decisive? A Dutch survey among orthopaedic and trauma surgeons

PURPOSE

The current rehabilitation for patients with surgically treated displaced intra-articular calcaneal fractures (DIACFs) consists of non-weightbearing for 8-12 weeks. The purpose of the present survey was to investigate the current pre-, peri- and post-operative practices among Dutch foot and ankle surgeons. Moreover, it aims to analyze whether surgeons comply to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) guidelines and which decision criteria were used in the determination of the start of weightbearing.

METHODS

A survey was distributed among Dutch trauma and orthopaedic surgeons to determine the most common practices in postoperative weightbearing in patients with DIACFs.

RESULTS

75 surgeons responded to the survey. 33% of the respondents adhered to the AO guidelines. 4% of the respondents strictly followed non-weightbearing guidelines, while 96% interpret the AO guidelines or their local protocol freely, in any frequency. When respondents tended to deviate from the AO guidelines or local protocol, a good patients' compliance to therapy was expected. 83% of the respondents started weightbearing on the fracture, based on reported patient complaints. 87% of the respondents did not see any relation between early weightbearing and the occurrence of complications, including loosening of osteosynthesis materials.

CONCLUSION

This study demonstrates that there is limited consensus on the rehabilitation for DIACFs. Moreover, it shows that most surgeons are inclined to interpret the current (AO) guideline or their own local protocol freely. New guidelines, supported with well-founded literature, could help surgeons in a more appropriate daily practice in weightbearing for the rehabilitation of calcaneal fractures.

Comparison of different intraoperative reduction monitoring methods in a cadaveric intraarticular calcaneal fracture model: 3D scan vs arthroscopy vs nanoscopy

AIMS

Visualization of the subtalar joint surface in surgical management of calcaneal factures remains a big challenge and anatomic reduction of the articular surface is essential for a good clinical outcome. We hypothesize that video-assistance can provide superior fracture reduction compared to fluoroscopy and that nanoscopy (NSC) achieves more extensive visualization compared to fracturoscopy (FSC).

METHODS

Ten human cadaveric feet with artificially pre-fractured intraarticular calcaneal fractures with involvement of the posterior facet were treated via a minimal invasive subtalar approach. After initial control of reduction by 2D fluoroscopy, the reduction was further analyzed intraoperatively by FSC and NSC. 3D Scan served as gold standard control of reduction. Need of revision of reduction after the different visualization techniques was recorded and the extent of visualization of the subtalar joint surface in the medio-lateral dimension was compared for FSC and NSC. To quantify access and visualization of the medial and posterior facet, a depth gauge was used to measure from laterally at the clinically widest portion of the calcaneus targeted to the sustentaculum tali. The distance in millimetres was referred to the complete medio-lateral distance seen on paracoronal CT at the widest portion of the calcaneus.

RESULTS

Fracture analysis in preoperative CT-scans according to Sanders classification revealed four type IC, two IIA, three IIC and one IIIAC fractures. Mean visualization of the medial and posterior facet was significantly improved with NSC (30.4 ± 3.78 mm) compared to FSC (23.6 ± 6.17 mm) (p = 0.008). An imperfect reduction requiring revision was more often required with NSC compared to FSC. Insufficient reduction using video-assistance was found in two cases.

CONCLUSION

In order to optimize subtalar joint reduction and congruency, video-assisted techniques, especially NSC, provide superior visualization and thus can improve reduction in the surgical treatment of intraarticular calcaneal fractures.

Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures

BACKGROUND

Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the (functional) outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA).

METHODS

A total of 239 patients (265 fractured calcanei) who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included.

RESULTS

Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups (APF vs SF/PF; 9.9% vs 22.9%/23.7%, P = .015). Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF.

CONCLUSION

The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Does the postoperative quality of reduction, regardless of the surgical method used in treating a calcaneal fracture, influence patients' functional outcomes?

BACKGROUND

The extensile lateral approach (ELA) and sinus tarsi approach (STA) are commonly utilized for surgically treating calcaneal fractures. This study compared the outcomes of ELA and STA in the management of calcaneal fractures and assessed the influence of postoperative quality of reduction on functional and pain scores.

METHODS

The study included 68 adults with Sanders type-II and type-III calcaneal fractures who underwent either ELA or STA surgery. Pre- and postoperative radiographs and computed tomography scans were analyzed, and functional and pain scores were evaluated using the Manchester Oxford Foot Questionnaire (MOXFQ), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and Visual Analogue Score (VAS) during follow-up visits.

RESULTS

Out of the total patients, 50 underwent ELA surgery while 18 underwent STA surgery. The anatomic (excellent) reduction was achieved in 33 (48.5%) patients. There were no significant differences between the ELA and STA groups concerning functional scores, pain scores, the proportion of excellent reduction, and complications. Additionally, anatomic reduction, compared to near or non-anatomic (good, fair, or poor) reduction, demonstrated a decrease in MOXFQ (unstandardized β coefficient: -13.83, 95% CI: -25.47 to -2.19, p = 0.021), an increase in AOFAS (unstandardized β coefficient: 8.35, 95% CI: 0.31 to 16.38, p = 0.042), and a reduction in VAS pain (unstandardized β coefficient: -0.89, 95% CI: -1.93 to -0.16, p = 0.095) scores.

CONCLUSION

In conclusion, we found no significant differences regarding complications, excellent reduction, and functional scores between STA and ELA surgeries. Therefore, STA may be an effective alternative for the treatment of calcaneal fractures in Sanders type II and type III calcaneal fractures. Furthermore, the anatomic reduction of the posterior facet correlated with improved functional scores, emphasizing the importance of achieving it for restoring foot function regardless of surgery type or time between injury and surgery.

Arthroscopy of Foot and Ankle: Subtalar Joint Arthroscopy in Intra-articular Calcaneal Fractures

The utilization of subtalar joint arthroscopy in intra-articular calcaneal fractures provides optimal visualization of articular surfaces for a more precise anatomical reduction, thus yielding better surgical outcomes. Current literature shows good functional and radiographic outcomes, fewer wound complications, and low incidence of post-traumatic arthritis with this technique than when utilizing an isolated lateral extensile incision of the calcaneus. As subtalar joint arthroscopy continues to grow in popularity and technological advancement, patients may benefit when surgeons incorporate this tool in conjunction with a minimally invasive technique for treatment of intra-articular calcaneal fractures.

Calcaneal Fractures Management, Change of Clinical Practice in Recent Years from ELA to STA: A Systematic Review and Meta-Analysis

Background

Calcaneal fractures are serious injuries that mainly affect young, active people. As a result, these fractures may cause long-term impairment and have a major socioeconomic impact. The current updated systematic review and meta-analysis were conducted to evaluate the functional outcomes, re-operative risk, and complications associated with the treatment of displaced intra-articular calcaneal.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this meta-analysis. The literature search was carried out using PubMed, Cochrane, MEDLINE, Google Scholar, and the EMBASE databases with the appropriate keywords.

Results

A total of 13 studies were included in this review. The follow-up months were diverse, ranging between 12 and 65 months in sinus tarsi approach (STA) and 12 to 76 months in extended lateral approach (ELA) methods. Time to surgery was shorter for the STA when compared to ELA (MD: 3.48; 95% CI 2.43 to 4.53; p < 0.00001). No significant difference was observed in functional outcomes between STA and ELA (MD: 0.34; 95% CI: -0.37 to 1.04; p = 0.35 > 0.05; I2 = 88%). In comparison to the ELA, the STA has significantly less wound healing complications (RR: 0.20; 95% CI 0.11 to 0.36; p 0.00001; I2 = 0%).

Conclusion

In conclusion, the STA technique in treating calcaneal fractures was significantly safer and more effective when compared to the ELA methods. The STA method of treatment was found to have a lower risk of complications and an infection rate, as well as a shorter operating and recovery time.

Biomechanical Comparison of Conventional Plate and the C-Nail® System for the Treatment of Displaced Intra-Articular Calcaneal Fractures: A Finite Element Analysis

The C-Nail® system is a novel intramedullary fixation method for displaced intra-articular calcaneal fractures. The aim of this study was to evaluate the biomechanical performance of the C-Nail® system and compare it with conventional plate fixation for the treatment of displaced intra-articular calcaneal fractures using finite element analysis. The geometry of a Sanders type-IIB fracture was constructed using the computer-aided design software Ansys SpaceClaim. The C-Nail® system (Medin, Nové Mesto n. Morave, Czech Republic) and the calcaneal locking plate (Auxein Inc., 35 Doral, Florida) and screws were designed according to the manufacturer specifications. Vertical loading of 350 N and 700 N were applied to the subtalar joint surfaces to simulate partial weight bearing and full weight bearing. Construct stiffness, total deformation, and von Mises stress were assessed. The maximum stress on the C-Nail® system was lower compared with the plate (110 MPa vs. 360 MPa). At the bone level the stress was found to have higher values in the case of the plate compared to the C-Nail® system. The study suggests that the C-Nail® system can provide sufficient stability, making it a viable option for the treatment of displaced intra-articular calcaneal fractures.

Does robot-assisted percutaneous hollow screw placement combined with tarsal sinus incision reduction in the treatment of calcaneal fracture perform better at a minimum two year follow-up compared with traditional surgical reduction and fixation?

PURPOSE

We aimed to evaluate the safety and efficacy of robot-assisted percutaneous hollow screw placement combined with tarsal sinus incisions for treating calcaneal fractures.

METHODS

Clinical data of 50 patients with calcaneal fractures treated from January 2018 to June 2020 were analyzed retrospectively. Twenty-six patients (26 feet) were included in the traditional group (traditional surgical reduction and internal fixation) and 24 (24 feet) in the robot-assisted group (robot-assisted internal fixation of tarsal sinus incision). The operation time, C-arm fluoroscopy dose, fracture healing time, Gissane angle, Böhler angle, calcaneal width, calcaneal height, visual analogue scale (VAS) scores, and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were compared between the groups preoperatively and two years postoperatively.

RESULTS

Operation time was significantly longer in the traditional group than in the robot-assisted group, while the intraoperative C-arm fluoroscopy dose was significantly lower in the robot-assisted than in the traditional group (P < 0.05). Both groups were followed up for 24-26 months (average, 24.9 months). Two years postoperatively, the Gissane angle, Böhler angle, calcaneal height, and calcaneal width improved significantly in both groups, without significant differences. Fracture healing time was not significantly different in both groups (P > 0.05). The two year postoperative VAS and AOFAS scores in both groups were significantly higher than the preoperative scores, but the robot-assisted group postoperative AOFAS scores were significantly higher than those in the traditional group (t =  - 3.775, P = 0.000).

CONCLUSION

Robot-assisted internal fixation of tarsal sinus incision is effective in treating calcaneal fractures with satisfactory long-term follow-up outcomes.

A windows technique for sustentaculum tali screw fixation using the sinus tarsi approach for calcaneal fractures: a cadaveric study

INTRODUCTION

The minimally invasive approach for displaced intra-articular calcaneal fractures is significantly reducing postoperative wound complications. One minimally invasive method, the sinus tarsi approach (STA) has been increasingly widely used. STA is, however, challenging due to its technical demands and the risk of injury to the sural nerve (SN). The purpose of this study was to identify the SN and its branches including their anatomical relationship to the STA as well as to describe an anatomical windows technique for STA including determination of the safe angle for screw insertion into the sustentaculum tali fragment.

METHODS

Thirty-two adult cadaveric legs were disarticulated at the knee and unpaired. STA was performed on each specimen. The anatomy and distribution of the sural nerve and its branches were identified in relation to the incision. Three surgical windows were identified and selected. Kirshner wires were inserted in pairs via each of the windows towards the center of the sustentaculum tali. The safe angle for wire insertion in relation to the SN or its branches was then measured as well as the appropriate intraoperative drilling angle.

RESULTS

The plantar branch presented in the distal window in none of the samples, while the dorsal branches presented in 37.5% and the main SN presented in only 6.25%. In the middle window, the dorsal branch presented most often (43.75%) followed by the plantar branch (25.00%) and the SN (21.88%). In the proximal window, the SN presented in 100% of the samples, while the dorsal branch presented in none and the plantar branch presented in about 15.63% of the specimens. All three windows had their own acceptable average angle for screw insertion towards the sustentaculum tali.

CONCLUSIONS

The distal window is the safest for surgical approach and for calcaneal surgery screw fixation in terms of avoiding sural nerve injury. In addition, that window provides a wide working angle for screw fixation.

Evaluation of the effects of using 3D - patient specific models of displaced intra - articular calcaneal fractures in surgery

BACKGROUND

It was aimed to compare conventional surgery and three-dimensional (3D) model-assisted surgery used in the treatment of calcaneal fractures.

MATERIALS & METHODS

A total of 37 patients with unilateral calcaneal fractures were randomly divided into two groups as a conventional surgery group (n: 19) and a 3D model-assisted surgery group (n: 18). The preoperative, postoperative and last follow up angles of the Bohler and Gissane, calcaneal width and facet height were measured. The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for both groups were recorded. Finally, the follow-up AOFAS scores were evaluated. A questionnaire was used to determine the perceptions of the resident doctors about the 3D model.

RESULTS

The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for 3D model-assisted surgery group were 83.3 ± 4.6 minutes, 83.6 ± 4.6 ml, 6.8 ± 1.4 times and 13.0 ± 0.8 weeks, and as for conventional group they were 130.0 ± 5.8 minutes, 105.1 ± 5.6 minutes, 11.7 ± 1.5 ml, 22.2 ± 2.4 times and 13.3 ± 0.8 weeks, respectively (p < 0.0001). The both groups significantly restored Bohler angle, Gissane angle, calcaneal width and calcaneal facet height after operation (p < 0.0001). The 3D model-assisted group was significantly more succesful in restoration and protection of achieved correction of calcanel facet height (p < 0.0001). The difference was determined among the groups at the final follow-up examination with respect to the amount of change according the values achieved post-op. were significant in Bohler angle (p < 0.001), calcaneal facet height (p < 0.0001) and calcaneal widht (p = 0.017). There was no significant difference between AOFAS scores of the two groups at last follow-up. Resident doctors exhibited high scores of overall satisfaction with the use of a 3D printing model.

CONCLUSIONS

Compared to the conventional group, the 3D model-assisted group provide successful intervention and reduce operation, instrumentation time and the fluoroscopy usage with less blood loss. Performing 3D-assisted surgery helps the quality of reduction during the surgery and stability of internal fixation to protect achieved reduction at follow-up more succesfully.

Complication Rates Are Similar Between Patients Aged <50 and >50 Years in Calcaneus Fractures Treated With the Sinus Tarsi Approach

Background:

The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years with an increased interest in shifting to less invasive approaches for calcaneal fracture fixation allowing for adequate fixation if complications do not arise. Although the ST approach has gained acceptance as standard for calcaneus fracture fixation, the literature surrounding early complications rates based on age differences for this specific approach and pathology is lacking. The objective of this study was to determine if rates of complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of closed calcaneus fractures using the ST approach.

Methods:

A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria were based on an age greater than 18 years, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative computed tomographic scan, and a minimum of 180 days’ follow-up. Patients were divided into 2 groups: those aged <50 years and those aged >50 years.

Results:

A total of 196 fractures were included with 114 fractures in the <50-year age group and 82 fractures in the >50-year age group. Mean age was 34.2 and 59.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.2% vs 4.4%, P = .204), superficial surgical site infection (1.2% vs 2.6%, P = .490), deep infection (9.8% vs 7.9%, P = .648), and nonunion (4.9% vs 3.5%, P = .633) compared with the younger group. Rates of 30-day readmission, unplanned reoperation, and symptomatic hardware were not significantly different. Postoperative Bohler and Gissane angles were not significantly different between both groups.

Conclusion:

Older patients with intraarticular calcaneus fractures treated via the ST approach maintain complication rates similar to those in younger individuals.

Level of Evidence:

Level III, retrospective study.

Calcaneal Fractures-Which Approach for Which Fracture?

Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.

Articular calcaneal fractures: open or minimally invasive surgery, when the medial wall reduction is obtained percutaneously from the lateral side

PURPOSE

The purpose of this study was to compare the clinical outcomes of intra-articular calcaneal fractures with medial column displacement treated with different surgical techniques, namely extensile lateral approach (ELA) or sinus tarsi approach (STA), combined with percutaneous medial reduction.

METHODS

Ninety-six patients with intra-articular calcaneal fractures who were subjected to ELA or STA (45 in STA group and 51 in ELA group) were retrospectively assessed. Reduction of the posterior facet, calcaneal body, Böhler's angle, and Gissane's angle were evaluated. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analog scale (VAS). The complications, time to surgery, operative time, and blood loss were also assessed.

RESULTS

Incidence of wound complications, post-operative blood drainage, and time to the operation were significantly different between the two groups. There was no significant difference in the recovery of calcaneal anatomy and articular surface between the two groups. Similarly, no difference was detected in Böhler's and Gissane's angles between ELA and STA groups (P > 0.05). Finally, there was no difference in AOFAS and VAS scores between the two groups at the final follow-up (P > 0.05).

CONCLUSION

STA resulted in favourable radiological and clinical results with fewer wound complications and a shorter waiting time when compared to ELA. The percutaneous medial reduction technique is effective in reducing medial column displacement.

Radiographic and clinical results of modified 2-incision sinus tarsi approach for treatment of calcaneus fracture

BACKGROUND

Sinus tarsi approach (STA) is the most commonly used minimally invasive surgery (MIS) in the treatment of displaced intra-articular calcaneal fracture (DIACF). However, there are some limitations related to its limited access. The goal of the present study is to describe a modified 2-incision STA and to evaluate the radiographic and clinical outcomes in the treatment of DIACF.

MATERIALS AND METHODS

Patients had a Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification 82-C, Sanders type II, III calcaneal fracture, and underwent modified 2-incision STA and internal fixation were included in this retrospective study. Serial radiographic measurements and clinical assessment were taken to evaluate the effectiveness of this technique.

RESULTS

Thirty-four feet of 33 patients treated between 2014 and 2019 were included with an average follow-up of 28.5 (range, 12-65) months. Mean preoperative Böhler's angle was 1.5 ± 10.0 (range, -26.0-16.9) degrees and mean final Böhler's angle was 29.8 ± 4.9 (range, 19.3-39.3) degrees with significant difference (P < .001). The average American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) pain score at last follow-up were 86.2 ± 5.0 (range, 76-97) and 1.6 ± 1.1 (range, 0-4), respectively. Major complications included 2 (5.9%) wound infections and 1 (2.9%) incomplete separation of the lateral wall prior to plate insertion.

DISCUSSION AND CONCLUSIONS

This modified 2-incision STA is a safe and effective procedure. It allows access to the posterior facet and posterior calcaneal tuberosity, appropriate restoration of blowout lateral wall, and easy placement of a standard calcaneal plate.

Comparison of 5 Treatment Approaches for Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Bayesian Network Meta-Analysis

The choice of the best treatment method for displaced intra-articular calcaneal fractures (DIACFs) remains controversial. Using a network meta-analysis, this study aims to evaluate the radiographic characteristics, clinical effectiveness, and incision complications of nonoperative treatment, open reduction and internal fixation, minimally invasive reduction, and fixation. The studies were abstracted from Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software. Seventeen RCTs involving 1297 participants with 1354 fractures were included. A total of 5 treatments-extensile lateral approach (ELA), minimally invasive longitudinal approach (MILA), sinus tarsi approach (STA), percutaneous reduction and fixation (PRF), and nonoperative treatment-were analyzed. The treatments were ranked based on Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of recovery of Böhler's angle, the treatments were ranked as follows: MILA (75.3%), PRF (68.3%), ELA (54.7%), STA (51.6%), and nonoperative (0%). In terms of Böhler's angle after treatment, the treatments were ranked as follows: PRF (65.3%), ELA (64.0%), STA (63.5%), MILA (56.9%), and nonoperative (0.2%). In terms of American Orthopaedic Foot & Ankle Society score, the treatments were ranked as follows: PRF (87.0%), MILA (52.9%), STA (46.6%), ELA (40.4%), and nonoperative (23.1%). In terms of excellent and good satisfaction ratings, the treatments were ranked as follows: STA (96.2%), ELA (66.8%), PRF (34.9%), and nonoperative (2%). In terms of incision complications, the treatments were ranked as follows: PRF (84.1%), MILA (80.0%), STA (35.8%), and ELA (0.1%). Given the good results of the minimally invasive approach in terms of radiographic characteristics, clinical effectiveness and incision complications, the minimally invasive approach is a good alternative for DIACFs. More randomized controlled trials focused on DIACFs are needed to further examine this conclusion.

Evaluating Short-Term Outcomes Post-Intra-Articular Calcaneal Fracture Fixation via a Sinus Tarsi Approach in a Non-Exclusively Selected Cohort

Management of intra-articular calcaneal fractures remains a debated topic in orthopedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and postoperative fracture geometry with computed tomography used for preoperative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Fifty-eight intra-articular calcaneal fractures (53 patients; 5 bilateral, mean age = 46.91 years) with a mean follow-up of 35.4 months (6-57) were included. Five patients (9.4%) had wound complications; 2 superficial (3.7%), 3 deep (5.6%); 4 of whom were smokers. Smokers were statistically more likely to have wound infections than nonsmokers (p = .04). Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of postoperative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.

Comparison of the modified sinus tarsi approach versus the extensile lateral approach for displaced intra-articular calcaneal fractures

Background

This study sought to assess and compare the clinical efficacy and complications of a modified sinus tarsi approach (MSTA) and the extensile lateral approach (ELA) in the treatment of displaced intra-articular calcaneal fractures.

Methods

This retrospective study enrolled 108 patients (117 feet) with Sanders II-IV calcaneal fractures, including 52 patients (56 feet) in the MSTA group and 56 patients (61 feet) in the ELA group. The functional and radiological results of the affected feet were analysed retrospectively. Functional evaluation included American Orthopaedic Foot and Ankle Society (AOFAS), visual analog scale (VAS), and Short Form-36 Health Survey (SF-36). Radiological evaluation included preoperative and postoperative changes in the Bohler Angle, Gissane Angle, length, width, and height of the calcaneus. The postoperative complications were also collected and analysed. The independent-samples t-test and analysis of variance (ANOVA) were employed to compare differences between the two groups. Differences within the same group were compared by paired Student's t-test, and categorical variables were compared using the chi-square test.

Results

The postoperative functional and radiological results showed that the mean AOFAS, VAS and physical component summary of SF-36 scores in the MSTA group were higher than those in the ELA group (P<0.05). After surgery, the Bohler and Gissane angles were significantly improved in both groups, as were the length, width, and height of the calcaneus; no statistically significant differences existed between the two groups. The incidences of wound healing complications and postoperative sural nerve injury were lower in the MSTA group than in the ELA group (P<0.000).

Conclusions

The MSTA can achieve similar effects to the ELA in terms of anatomical reconstruction and functional recovery. It also can also effectively reduce the incidences of wound healing complications and postoperative sural nerve injury, and shorten the length of hospital stay.

Long-term results of displaced intra-articular calcaneal fractures treated with minimal invasive surgery using percutaneous screw fixation

INTRODUCTION

Over the last 20 years, minimally invasive surgery using Percutaneous Screw Fixation (PSF) has been performed increasingly frequently in the treatment of Displaced Intra-Articular Calcaneal Fractures (DIACFs). The purposes of this study were to assess the long-term postoperative outcomes of mobility, foot function, stability, pain and patient satisfaction.

METHODS

All patients had DIACFs and underwent PSF between 1998 and 2006 according to the method reported by Forgon and Zadravecz. Functional outcomes, range of motion and change in footwear were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients completed a general health status form (Short Form-36 [SF-36]) and visual analogue scale (VAS) for patient satisfaction. Anatomical restoration was assessed based on the pre- and postoperative radiographic images.

RESULTS

Sixty-six patients with an DIACF were observed in the period 1998-2006. Patients who had open fractures, died or were <18 years of age at trauma were excluded. A total of 46 patients were asked to complete the questionnaires, during the last quarter of 2018. Of these patients, 27 with 29 DIACFs responded (58%). Nineteen were males, and the mean age at trauma was 45 years. Seven cases were classified as Sanders type II, 14 as Sanders type III, and 8 as Sanders type IV. The mean pre- and postoperative Böhler angles were 10 ͦ and 26 ͦ, respectively. The average follow-up period was 16 years, and at the follow-up, the mean AOFAS, MFS, SF-36 and VAS scores were 76, 74, 63 and 7.7 points, respectively. In comparison to the results at 5-10 years postoperatively in a previous study, we observed a decline in the average AOFAS and MFS scores by 8 and 11 points, respectively. Patient satisfaction decreased by 0.1 points and general health by 14 points.

CONCLUSION

The long-term results of this study show relatively good functional outcomes is two-thirds of the treated patients. According to the reported scores, patients described their level of function as essentially normal. PSF should therefore be considered as a good option in patients with DIAC fractures, especially in patients with Sanders II and III fractures.

LEVEL OF EVIDENCE

Therapeutic Level III.

Comparison of sinus tarsi approach and extensile lateral approach for calcaneal fractures: A systematic review of overlapping meta-analyses

PURPOSE

Accumulated literature has reported the comparative efficacy of the sinus tarsi approach (STA) and the extensile lateral approach (ELA) for the treatment of calcaneal fractures (CFs). However, the best alternative treatment for CF is still inconsistent. Herein, the present systematic review of overlapping meta-analyses aims to achieve an evident conclusion by performing a comprehensive reanalysis of previous meta-analyses regarding the comparison of the STA and the ELA.

METHODS

We searched several databases, including Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov , OVID, and CNKI for the meta-analyses comparing the STA and the ELA for the treatment of CF. All related meta-analyses of randomized controlled trials and cohort studies were included. Two researchers independently assessed the quality of the articles and extracted the data. The Jadad decision algorithm was used to evaluate the evidence of the articles.

RESULTS

Ultimately, five meta-analyses were included in the present study. The Assessment of Multiple Systematic Reviews scores of these articles ranged from 5 to 9 with a median of 7. The analysis of best quality, Bai 2018, was selected based on the Jadad algorithm. In this article, the significant differences were found in wound complications and operating time, recovery of Böhler's angle, the American Orthopaedic Foot and Ankle Society scores, and the visual analog scale.

CONCLUSION

The clinical relevance of the present study is that both the STA and the ELA are effective in alleviating pain and improving functionality in the treatment of CF. However, due to a shorter operation duration and lower complication rates, the STA was indicated to be a superior alternative for CF treatment.

The role of bone grafts in displaced intra-articular calcaneal fractures: A prospective study protocol

BACKGROUND:

Whether the bone graft is needed in treating the displaced intra-articular calcaneal fractures (DIACFs) is still controversial. Therefore, in our study, we will explore the results of 2 approaches for the DIACFs surgical treatment.

METHODS:

The present report follows the Consolidated Standards of Reporting Trials (CONSORT) guidelines. All patients will be assigned randomly into 2 different groups through tossing the coins. Three experienced surgeons are assigned randomly to each group to implement the surgeries utilizing any of the surgical approach. Assignments are concealed in a sealed opaque envelope. Patients who meet the following conditions will be included in this experiment: (1).. DIACFs (greater than 2 mm) involve Sanders Type IIC, Type IIB as well as some Type III; and (2).. surgical treatment can be implemented within 7 days after injury. Some patients with obvious swelling can wait for 2 weeks before operation; (3).. patients with closed fracture and; (4).. unilateral fracture. In the 2 groups, the patients will follow the standard postoperative protocols. Patients are asked to finish 2 questionnaires, namely, American Orthopaedic Foot and Ankle Society score and short form 36. The ranges of motion of the ankle and the subtalar joint will be also measured. Postoperative complications such as deep infection, wound infection, and wound edge necrosis, the injury of sural nerve, and hematoma are recorded.

RESULTS:

Our study can provide significant information on the necessity of bone graft in DIACFs internal fixation treatment.

TRIAL REGISTRATION:

This study protocol was registered in Research Registry (researchregistry6246).

Fixation by Open Reduction and Internal Fixation or Primary Arthrodesis of Calcaneus Fractures: Indications and Technique

The quest for the best treatment of displaced intraarticular calcaneal fractures continues. The open reduction and internal fixation of displaced intraarticular calcaneal fractures yields the best results if anatomic reduction is obtained and complications are avoided. The sinus tarsi approach is becoming the new gold standard. In cases with severe comminution or when anatomic reduction cannot be obtained, a primary subtalar arthrodesis is a valuable option, if the overall anatomy of the calcaneus is corrected first. This review discusses the open reduction and internal fixation of displaced intraarticular calcaneal fractures and the indications and technique of the primary arthrodesis.

Intraoperative Effect of 2D vs 3D Fluoroscopy on Quality of Reduction and Patient-Related Outcome in Calcaneal Fracture Surgery

BACKGROUND

Three-dimensional (3D) fluoroscopy is thought to be advantageous in the open reduction and internal fixation (ORIF) of calcaneal fractures. The goal of this multicenter randomized controlled trial was to investigate the clinical effect of additional intraoperative 3D fluoroscopy on postoperative quality of reduction and fixation and patient-reported outcome as compared to conventional 2-dimensional (2D) fluoroscopy in patients with intra-articular fractures of the calcaneus.

METHODS

Patients were randomized to 3D or conventional 2D fluoroscopy during operative treatment of calcaneal fractures. Primary outcome was the difference in quality of fracture reduction and implant position on postoperative computed tomography (CT). Secondary endpoints included intraoperative corrections (prior to wound closure), complications, and revision surgery (after wound closure). Function and patient-reported outcome were evaluated after surgery and included range of motion, Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short-Form 36 (SF-36) questionnaires, and Kellgren-Lawrence posttraumatic osteoarthritis classification. A total of 102 calcaneal fractures were included in the study in 100 patients. Fifty fractures were randomized to the 3D group and 52 to the 2D group.

RESULTS

There was a statistically significant difference in duration of surgery between the groups (2D 125 min vs 3D 147 min; P < .001). After 3D fluoroscopy, a total of 57 intraoperative corrections were performed in 28 patients (56%). The postoperative CT scan revealed an indication for additional revision of reduction or implant position in 69% of the 3D group vs 60% in the 2D fluoroscopy group. At 2 years, there was no difference in number of revision surgery, complications, FAOS, AOFAS score, SF-36 score, or posttraumatic osteoarthritis.

CONCLUSION

The use of intraoperative 3D fluoroscopy in the treatment of intra-articular calcaneal fractures prolongs the operative procedures without improving the quality of reduction and fixation. There was no benefit of intraoperative 3D fluoroscopy with regard to postoperative complications, quality of life, functional outcome, or posttraumatic osteoarthritis.Level of Evidence: Level I, prospective randomized controlled study.

Results After Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures

BACKGROUND

Operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. In the past years, there has been a trend toward less invasive surgical approaches. Percutaneous and arthroscopically assisted calcaneal osteosynthesis (PACO) combines the advantages of visualization of the posterior facet of the subtalar joint with a minimally invasive approach.

METHODS

We conducted a follow-up of 25 patients with 26 calcaneal fractures (Sanders II and III), treated with PACO with a minimum follow-up of 12 months. The median age was 44 years (range, 21-72) and the follow-up period 15 months (12-33). Our clinical outcomes were the Manchester-Oxford Foot Questionnaire (MOxFQ), the Calcaneus Fracture Scoring System (CFSS), the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, the Short-Form-36 (SF-36), the visual analog scale (VAS) for pain, and the number of complications. Radiographs on follow-up were obtained to evaluate the reduction of the fractures as well as osteoarthritis of the subtalar joint.

RESULTS

The median MOxFQ score was 26.6 (0-76.6), the CFSS score 85 (26-100), and the AOFAS score 85 (50-100). The VAS pain score was 0 (0-5.7) at rest and 4.1 (0-8.2) during activity. The Böhler angle improved from a mean (SD) of 3.5 (12.3) degrees preoperatively to 27.7 (10.5) degrees postoperatively. The follow-up radiographs showed subsidence of the fractures and a Böhler angle of 20.3 (12.9) degrees. There were no wound-healing complications. Two patients had additional surgery with screw removal due to prominent hardware.

CONCLUSION

Our results suggest that PACO gives good clinical outcomes and a low risk of complications in selected calcaneal fractures. Prospective long-term studies will be necessary to better document the potential advantages and limitations of this operating technique.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Minimally invasive dual incision with mini plate internal fixation improves outcomes over 30 months in 20 patients with Sanders type III calcaneal fractures

Background

Calcaneal Sanders type III or higher fractures traditionally have been treated with open reduction and internal fixation (ORIF); however, ORIF has associated complications. We investigated a combination of minimally invasive dual incision and internal fixation using mini plates for treating Sanders type III calcaneal fractures.

Methods

Twenty patients with Sanders type III intra-articular calcaneal fractures with a posterior subtalar articular displacement > 2 mm were included. Surgical outcomes were assessed by visual analogue scale (VAS) pain score, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and calcaneal geometry, including Böhler and Gissane angles.

Results

The Böhler angle, Gissane angle, and height and length of the calcaneus were increased following treatment. Based on the AOFAS score, 80% of cases had excellent or good outcomes. The mean postoperative VAS pain score was 1.6. Complications such as malunion or a screw positioning deviation occurred in 6 patients, and one patient experienced delayed wound healing. There were no wound infections.

Conclusions

These results indicate that minimally invasive dual incision with mini plate internal fixation may be an effective alternative to ORIF for treating Sanders type III calcaneal fractures. Advantages include improvement of calcaneal geometry and a lower rate of wound infections.

Impact of 3D Printed Calcaneal Models on Fracture Understanding and Confidence in Orthopedic Surgery Residents

OBJECTIVE

To determine if three-dimensionally printed (3Dp) fracture models can improve orthopedic trainee education.

DESIGN

A prospective comparison study of orthopedic trainees and attending surgeons was performed, where a range of calcaneal fractures were used for creating anonymized 3Dp models. Study participants rotated through workstations viewing computed tomography images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. Diagnosis, time for evaluation, confidence of fracture understanding, perceived model accuracy, and proposed treatment were compared using a standardized questionnaire.

PARTICIPANTS

Sixteen resident trainees and 5 attending surgeons participated in this study. Attending surgeons were required to have fellowship training in trauma or foot and ankle surgery and manage calcaneal fractures as part of their current practice.

RESULTS

Junior residents had the slowest time of assessment (mean = 121 ± 54 seconds) and lowest percentage of correct diagnoses (69%), although these findings did not reach significance compared to the other residency years. Residents displayed higher levels of confidence in fracture understanding with increasing residency year of training (p < 0.0001), and this confidence was greater for cases that included a 3Dp model (p < 0.03). Perceived accuracy of cases with 3Dp models was significantly higher than cases without 3Dp models (7.0 vs 5.5 p < 0.001).

CONCLUSIONS

This study found that 3Dp models increase the perceived accuracy of fracture assessment, though no statistically significant improvement in diagnostic accuracy was observed. The 3Dp models did improve trainee confidence, although this effect diminished with increasing residency year. In orthopedic residency training programs, 3Dp models of complex fractures can be a valuable educational tool, especially for junior trainees.

Limited Open Reduction and Internal Fixation of Calcaneal Fractures

BACKGROUND

The treatment of displaced intra-articular calcaneal fractures remains a challenge and the optimal approach is still controversial. The main reason to avoid the extended lateral approach is the high complication rate due to wound healing problems. We report on 16 years of experience with a standardized limited open reduction and internal fixation technique.

METHODS

Between 2001 and 2017, we prospectively followed 240 consecutive patients operatively treated for a displaced intra-articular calcaneal fracture. Patients with open, multiple, bilateral, extra-articular, and Sanders IV fractures and those lost to follow-up were excluded. A lateral subtalar approach was used, with a cast for 8 weeks and full weightbearing allowed after 12 weeks. Follow-up examinations were scheduled until 24 months. Subjective and clinical assessment included gait abnormality, subtalar and ankle range of motion, and stability and alignment. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was calculated. Alignment was analyzed on standard radiographs. In total, 131 patients were excluded. The remaining 109 patients were followed for a minimum of 24 months (34.4 ± 14.2 [range, 24-102] months).

RESULTS

The mean AOFAS score was 87 ± 13 (range, 32-100). "Excellent" and "good" results, as well as hindfoot motion with "normal/mild" and "moderate" restrictions, were seen in 80% of patients. Early reoperations were performed for insufficient reduction (2 patients), delayed wound healing (debridement, 3 patients), and hematoma (1 patient). Late revisions were arthrodesis (3 patients), medializing calcaneal osteotomy (1 patient), and implant removal (53 patients; 49%).

CONCLUSION

The presented approach has remained unmodified for 16 years and resulted in consistently good functional results. The main disadvantage was the high rate of heel screw removal.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Steinmann pin retractor-assisted reduction with circle plate fixation via sinus tarsi approach for intra-articular calcaneal fractures: a retrospective cohort study

Background

Sinus tarsi approach and mini-calc plate have been used for intra-articular calcaneal fractures. However, the sinus tarsi approach has limited exposure to the lateral wall, which makes it challenging to obtain an excellent anatomic reduction of the calcaneal body. What is more! To restore the width of the calcaneal body entirely and prevent the heel varus simultaneously with mini-calc plate was tough as well. Aimed to solve the aforementioned problems, our study focused on using the Steinmann pin retractor for reduction and the circle plate for fixation via the sinus tarsi approach.

Methods

From March 2017 to January 2019, 15 patients with closed calcaneal fractures were treated with the method of Steinmann pin retractor-assisted reduction and circle plate fixation via the sinus tarsi approach. All these patients received a positive postoperative clinical and radiological evaluation.

Results

A postoperative follow-up was done for each of the 15 patients, and the following scores and parameters were observed: value of visual analogue scale (VAS) was 1.44 ± 0.63, and The American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot score was 84.31 ± 5.03 at the last follow-up. The Böhler angle (30.81 ± 3.56°), width (37.83 ± 4.87 mm), length (87.4 ± 3.33 mm), and height (86.23 ± 5.36 mm) of the calcaneus were improved significantly in comparison with preoperative values (− 0.94 ± 10.06°, 45.67 ± 5.68 mm, 82.72 ± 5.54 mm, 76.32 ± 7.98 mm), and these parameters were maintained excellently after 6–19 months’ follow-up.

Conclusion

Our present study suggested that Steinmann pin retractor-assisted reduction with circle plate fixation via the sinus tarsi approach may serve as a safe and effective method for Sanders type II and type III calcaneus fractures. The Böhler angle, height, length, and body of the calcaneus were excellently restored postoperatively and maintained at last follow-up and rare postoperative complications.

Trial registration

This study has been registered. The unique identifying number is research registry 5092.

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.