Calcaneus fractures: a review article

Three dimensional analysis of factors affecting the prognosis of calcaneal fractures

PURPOSE

Analyzing the correlation between patients' basic information, three-dimensional parameters after calcaneal fractures, and the prognosis of calcaneal fractures.

METHODS

A retrospective analysis was conducted on 43 patients with calcaneal fractures who underwent surgical treatment in the Foot and Ankle Surgery, Xi'an Honghui Hospital, from September 2019 to August 2022. Patient demographics including gender and age were collected, as well as the preoperative posterior articular surface collapse area, number of fracture fragments, length, width, height, and volume of the calcaneus obtained from preoperative three-dimensional imaging. Patients were followed up for VAS, AOFAS, and SF-36 scores. Correlation analysis was performed on the obtained data.

RESULTS

All 43 included patients received complete follow-up, including 40 males and 3 females, with an average follow-up time of 35.37 ± 10.73 months, and an average age of 43.98 ± 12.08 years. All patients' VAS, AOFAS, and SF-36 scores at the last follow-up showed no correlation with patient age, gender, or the area of posterior articular collapse, number of fracture fragments, length, width, height, or volume of the calcaneus.

CONCLUSIONS

The prognosis of calcaneal fractures is unrelated to three-dimensional factors such as patient age, gender, length, width, height, volume of the calcaneus, area of the posterior joint, and number of fracture fragments.

Prospective Clinical and Computed Tomography Evaluation of Calcaneus Fractures Treated Through Sinus Tarsi Approach

Background

The traditional lateral extensile approach to the calcaneus allows for excellent visualization but is associated with high wound complication rates. The sinus tarsi approach has been shown to produce similar radiographic outcomes with much lower rates of wound complications. The purpose of this study is to prospectively determine clinical and radiographic outcomes in calcaneus fractures treated with a sinus tarsi approach.

Methods

Twenty-nine patients with 30 calcaneus fractures underwent operative fixation through a sinus tarsi approach and were prospectively evaluated. Routine pre- and postoperative radiographs were obtained, in addition to computed tomography (CT) scans at 6 weeks and 12 months after surgery. Patient-reported outcomes including American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, Veterans Rand 12-Item Health Survey (VR-12), and Foot Functional Index (FFI) were recorded. Patients were followed for a minimum of 1 year postoperation.

Results

Twenty-one patients with 22 calcaneus fractures completed 1 year of follow-up. At 12 months postoperation, 20 of 22 patients (91%) had 0 to 2 mm of fracture displacement at the posterior facet on CT scans whereas 2 of 22 patients had 2 to 4 mm of fracture displacement. There was no significant change in posterior facet fracture displacement comparing 6-week and 12-month postoperative CT scans (P > .99). Mean postoperative Bohler angle was 26.1 degrees compared to 13.2 degrees preoperatively. All patients had complete union of fracture site. There were no major wound complications. Four of 22 patients (18.2%) had minor wound complications. AOFAS, FFI, and VAS pain scores improved postoperatively but were not found to correlate with Bohler angle or critical angle of Gissane.

Conclusion

We found that in select patients excellent anatomic alignment and good clinical outcomes with low wound complication rates can be achieved when fixing calcaneus fractures through the sinus tarsi approach.

Level of Evidence

Level II, prospective cohort study.

Outcomes of Early Weight Bearing in Displaced Intra-articular Calcaneus Fractures Treated with Screws-Only Fixation Technique

Background

Displaced intraarticular calcaneus fracture indicates surgical treatment. The current trend is open reduction and internal fixation with a plate or multiple screws through the sinus tarsi approach. Most postoperative protocols are prolonged non-weight bearing that causes a high socioeconomic burden. This study aims to determine the safety of the early weight-bearing protocol of screws-only fixation in calcaneal fracture.

Materials and Methods

Evaluate displaced intraarticular calcaneus fractures treated with screws-only technique via the sinus tarsi approach in our institution. The first group, from July 2017 to December 2018, allowed patients to start partial weight bearing as tolerated at 4 weeks after surgery. The second group prospectively from January 2019 to March 2020, which assign patients to keep non-weight bearing for 8 weeks. The functional outcomes (Thai Foot and ankle ability measure subjective form, FAAM) were measured 6 months after surgery. The radiographic outcome (Bohler's angle and Gissane angle) was measured on the first day postoperative and 6 months follow-up, and the changes in these angles were recorded.

Results

There were 28 patients in each group. The outcomes were collected and compared by a T-test. In the early weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 76.4 ± 14.8, 2.4 ± 3.5, and 6.6 ± 7.8, respectively. In the delayed weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 81 ± 14.8, 2 ± 1.8 and 2.6 ± 6.1, respectively. There was no statistically significant difference in FAAM score, Bohler's angle loss, and Gissane's angle change between early and delayed weight-bearing groups.

Conclusion

Screws fixation in calcaneal fracture may be safe to allow early weight-bearing protocol.

Assessment of clinical outcomes after reduction of depressed calcaneal fractures using the push-out molding technique

Introduction

As minimal invasive techniques for depressed calcaneal fracture treatment have become more common, great progress has been achieved with various surgical methods. While these techniques are still currently utilized, new methods have been developed. This study aimed to report the radiologic and clinical outcomes of depressed calcaneal fracture treatment with the "push-out molding" technique and to propose its clinical utility.

Materials and methods

From March 2009 to October 2020, a retrospective study was conducted with 52 patients, who received the "push-out molding" technique to treat depressed intra-articular calcaneal fractures (Sanders type II, III, IV). Exclusion criteria were as follows: patients with bilateral calcaneal fractures, open fractures, and a follow-up period <12 months. Radiologic parameters were assessed at following periods: preoperative, postoperative, 3-month follow-up, and last follow-up. Limitation of range of motion (ROM), subjective satisfaction, and complications were assessed at the last follow-up period. Repeated measures ANOVA was used to analyze values at preoperative, postoperative, 3-month, and last follow-up periods.

Results

Significant differences in the talo-calcaneal angle (p < 0.001), Böhler's angle (p=<0.001), Gissane's angle (p = 0.023), distance from the lower cortical border of calcaneus to the anterior (p=<0.001) and posterior (p=<0.001) points of posterior articular surface, calcaneal length (p = 0.019), and talo-calcaneal height (p=<0.001). Postoperatively, the posterior articular surface was well maintained, while 21.2% retained a ROM limitation by 20° or higher. Subjective satisfaction was as follows: excellent (42.3%), good (48.1%), fair (9.6%), and poor (0%).

Conclusion

The "push-out molding" is a simple technique with the advantage of not requiring much force to treat depressed calcaneal fractures. It can be used as a beneficial surgical technique with minimal damage to the soft tissue, owing to the reduction from the depressed interior part and less severe ROM limitation.

Risk factor of postoperative incision infection after plate internal fixation of calcaneal fractures: a retrospective study

BACKGROUND

This study aimed to investigate the risk factors for incision infection after plate internal fixation for calcaneal fractures by a traditional lateral L-shaped approach.

METHODS

The clinical data of 302 patients with calcaneal fractures who underwent surgical treatment in our hospital from January 2012 to June 2018 were retrospectively analysed, consisting of 177 males and 125 females. The enrolled patients were aged 21 to 75 years, with a mean age of 47.72 years. According to the Sanders classification, 108 patients were type II, 138 patients were type III, and 56 cases were type IV. A univariate analysis was conducted with sex, age, smoking history, history of diabetes, cause of injury, Sanders type, tension blisters, time from injury to surgery, preoperative haemoglobin, preoperative albumin, operation time, and bone grafting as possible risk factors. The factors with statistically significant differences were selected for multivariate binary logistic regression analysis. The clinical cut-off values of these risk factors were calculated using characteristic curves.

RESULTS

The follow-up lasted for at least 1 year for all patients, with a mean follow-up time of 15.8 months. The results demonstrated 7.9% (24/302) infection rate after plate internal fixation of calcaneal fractures by the traditional lateral L-shaped approach. Univariate analysis showed that a history of diabetes, preoperative albumin, preoperative haemoglobin, time from injury to surgery, and operation time were correlated with incision infection (p < 0.05). Additionally, multivariate regression analysis indicated that a shorter time from injury to surgery (OR = 1.475, 95% CI: 1.024-2.125, p = 0.037), lower preoperative albumin (OR = 1.559, 95% CI: 1.191-2.041, p = 0.001), and longer operation time (OR = 1.511, 95% CI: 1.219-1.874, p < 0.001) were risk factors for postoperative incision infection, and their cut-off values were 10.5 days, 38.5 g/L, and 84.5 minutes, respectively.

CONCLUSION

Longer preoperative stay and operation time were two risk factors for postoperative incision infection. However, lower preoperative albumin level is the highest risk factor in this study.

TRIAL REGISTRATION

The trial was registered in the China Clinical Trial Registry (ChiCTR2100047038).

Presurgical Perspective and Postsurgical Evaluation of Calcaneal and Talus Fractures

Fractures of the calcaneus and talus are severe injuries that usually result from high-energy trauma. The calcaneus and talus are essential for the transmission of body weight, so an optimal reduction and/or fixation of fractures is required to prevent disabling consequences. These fractures almost always have an articular involvement, and an anatomical reduction is required; any residual step-off would lead to joint incongruity and secondary arthrosis.The aims of imaging are first, to guide management by describing the fracture characteristics (e.g., location, displacement, fragments, articular involvement, soft tissue compromise), and second, to detect early and late surgical complications (e.g., infection, malunion, nonunion, arthrosis, hardware issues). Although radiographs remain the first-line imaging modality for the screening of ankle and foot trauma, computed tomography is almost always required for the initial management and follow-up of the patient.

Calcaneus fractures: An evaluation of the quality and reliability of online resources

AIM

To evaluate the reliability and quality of only resources available online on Calcaneal fractures.

METHODS

70 websites were identified using the search term 'Calcaneus fractures'. Google, Yahoo! and Bing were the three major search engines used for the study. Websites were classified by type and assessed for reliability and readability by means of DISCERN score, Journal of the Medical Association (JAMA) benchmark criteria and the presence or absence of HON-Code certification. In addition, a Calcaneus Fracture Specific Content Score (CFSCS) was designed in conjunction with two speciality trained foot & ankle surgeons in order to gauge content quality itself.

RESULTS

Academic websites made up the majority of URLs that were identified followed by Physician and Commercial. Overall mean DISCERN and JAMA scores were 49.8 (range 16-64) and 2.1 (range 0-4) respectively. Mean CFSCS was 18.3 (range 0-25). 30 of the total websites were HON-code certified. There was a statistically significant correlation identified between presence of HON-code certificate and DISCERN, JAMA and novel CFSCS (p<0.001).

CONCLUSION

There is an increasing tendency for patients to peruse online resources to understand their injuries and management options. This is particularly true for the younger cohort of patients in whom Calcaneus fractures occur more commonly. One must understand the varying quality of information available online in order to appropriately direct patients to areas of higher quality and reliability.

Malunited calcaneal fracture: the role and technique of osteotomy-a systematic review

PURPOSE

The research is aimed to introduce various corrective osteotomies utilized in treating calcaneal malunions in published papers, to further analyze the results, and to summarize recommended indications.

METHODS

The relevant research screening was conducted on the following search engines: the Cochrane Library, Web of Science, PubMed, Embase, Medline, and Academic Search Premier. Key words input included "calcaneal/calcaneus", "malunion," and "malunited fracture(s)" with Boolean operators "AND" and "OR." The inclusion criteria were researches containing surgical procedures treating calcaneal malunion with corrective osteotomy and published in the English language. For included research article, such information was extracted and analyzed: the type of calcaneal malunion, the time from initial injury to corrective surgery, the method of osteotomy, outcomes of each osteotomy (score systems, Bohler angle, talocalcaneal height and width of calcaneus, etc.), the function of the affected limb, post-operative complications, and patients' satisfaction. For included review, descriptive, commentary, or indicative sentences about corrective osteotomy were highlighted, analyzed, and summarized.

RESULTS

Ten research articles (170 patients with 184 feet) and nine reviews were included in this review, presenting seven types of corrective osteotomies (lateral wall exostectomy, Dwyer osteotomy, lateral wedge opening osteotomy, Romash osteotomy, tongue osteotomy, sagittal resection osteotomy, and modified Dwyer osteotomy).

CONCLUSION

A different corrective osteotomy with/without arthrodesis is recommended to be utilized based on the classification of the malunion and the condition of the cartilage in treating malunited calcaneal fractures. With adequate postoperative care and rehabilitation, the results of treatment could be associated with patients' satisfaction and good function.

Calcaneus fracture in a Middle Holocene individual from the eastern Pampa-Patagonian transition (Argentina)

Calcaneus fractures are scarcely reported in archaeological assemblages worldwide. The main goal of this paper is to present a study case related to a calcaneus fracture and a set of bone lesions recorded in an adult individual dated in the Middle Holocene (ca. 6000-3000 years BP). This individual was part of a hunter-gatherer society that inhabited the eastern Pampa-Patagonian transition (lower basin of Colorado river, Argentina). The individual was recovered at Tres Bonetes 1 site (TB1-E1). The causes of the injury and the stress it could have had generated in the individual are discussed. Macroscopic analysis and radiographic images were carried out and several bone alterations were detected (27.1%; 19/70). The lesions were located in the right ankle joint linked to an intra-articular calcaneus fracture. The main cause may have been a fall from height. The remodeled new bone formation indicates that the individual survived the stress event, but several sectors of the skeleton (e.g., spine, shoulders) were affected. The original morphological structure of the calcaneus was not restored and probably caused joint instability that affected the biomechanical behavior of the ankle. The individual must have suffered acute and severe pain and need help, care and assistance from other people.

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.

Lateral Extensile Approach Versus Minimal Incision Approach for Open Reduction and Internal Fixation of Displaced Intra-articular Calcaneal Fractures: A Meta-analysis

Treatment of displaced intra-articular calcaneal fractures remains controversial. Therefore, the purpose of this large meta-analysis was to report the outcomes of the lateral extensile approach versus the minimal incision approach including complications, anatomic reduction, functional outcomes, and timing and to report results when only randomized control trials were compared. Five electronic databases were searched for articles directly comparing the 2 above approaches. Inclusion criteria included articles published from January 2007 to April 2017, adults (>18 years old) with closed, Sanders type II or III fractures, mean follow-up time of ≥12 months, and ≥1 primary outcome reported. Seventeen randomized control trials and 10 retrospective studies were included. There were 2179 participants with 2274 fractures, and mean follow-up of 22.41 months. Our results revealed no statistically significant difference in Gissane's angle, calcaneal width, calcaneal length, deep infection, or subtalar stiffness. When taking into consideration only randomized control trials, there was no statistically significant difference between groups comparing postoperative Bohler's or Gissane's angle. There was a statistically significant difference in wound complications, superficial infection, sural nerve injury, visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores, operative time, time to operating room, calcaneal height, and postoperative Bohler's angle (when all studies were considered), all in favor of the minimal incision approach. These results remained statistically significant when only the randomized controlled trials were compared, with the exception of Bohler's angle and VAS and AOFAS scores. The results of this meta-analysis indicate that the minimal incision approach is a good alternative to the standard lateral extensile approach.

Outcomes of management of displaced intra-articular calcaneal fractures

Despite the advances in operative management, displaced intra-articular calcaneal fractures (DIAFCs) are often associated with long term sequelae, permanent disability, a considerable reduction in quality of life, and a high socio-economic cost. Randomized controlled trials have shown that patient reported outcomes of surgery are no better than those of nonoperative management. Methodological flaws and selection bias may have influenced the results, however, and subgroup analysis showed that some patients could benefit from surgery, whilst patients' preference can be the decisive factor in choosing a management modality. Fractures with significant lateral wall displacement predisposing to impingements often require surgery, and management has to be individualized and tailored to the patient. Surgery does not usually achieve excellent results, though it exposes the patient to potential risks and complications. Wound healing problems and infections affect around 20% of patients when the extensile lateral approach has been used. Sinus tarsi approach and minimally invasive surgery may be viable alternatives, offering similar results with fewer wound complications, but most of the available studies are of low to moderate quality. Late subtalar joint arthrodesis is often required: however, such procedure would be less technically difficult and could result in better foot function should the shape of the calcaneus have been anatomically restored with surgery in the acute phase.

Value of modified axial review radiograph in diagnosing calcaneal fractures

To investigate the value of modified calcaneal axial radiograph—the horizontal calcaneal axial radiograph in diagnosing calcaneal fractures, patients who had acute calcaneal fractures or internal fixation were enrolled, and three groups were established, including the acute fracture group (n = 20), the internal fixation group (n = 20), and the healthy control group (n = 20). All the subjects had regular and modified calcaneal axial radiograph for comparison. In analysis of the results, all volunteers could have ankle dorsiflexion at different degrees. When the ankle was at 30º dorsiflexion for regular axial radiograph, the subtalar joint and the sustentaculum tali could not be clearly displayed. The calcaneus was elongated if the tube tilted in a larger angle but shortened if the tube titled in a smaller angle. When the ankle was at neutral (0º dorsiflexion) location with the tube tilting 45° cephalad or when the ankle was at 20° plantarflexion with the tube tilting 35° cephalad, the subtalar joint, sustentaculum tali, calcaneal body and internal and external calcaneal processes could all be clearly demonstrated. No significant difference (P = 0.79) existed in displaying the bony anatomical structures in regular compared with modified calcaneal axial radiography. For patients with acute calcaneal factures or with internal fixation, the modified calcaneal axial radiography could display more significantly clearly (P = 0.001) bony anatomical structures than the regular one. In conclusion, the modified calcaneal axial radiograph can be performed easily and can clearly show the bony structure of the calcaneus and surrounding bones without adding pain to the patients with calcaneal fractures.

Plantar Medial Avulsion Fracture of the Calcaneus With Acute Tarsal Tunnel: Case Report and Technique Tip

Level of Evidence: Level V, expert opinion.

Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures

BACKGROUND

The plantar fascia attaches to the tuberosity of the calcaneus, which produces a distinct plantar medial avulsion (PMA) fracture fragment in certain calcaneal fractures. We hypothesized that tongue-type fractures, as described by the Essex-Lopresti classification, were more likely to be associated with this PMA fracture than joint depression fractures.

METHODS

A retrospective chart review was performed at 2 distinct Level I trauma centers to identify patients sustaining calcaneal fractures. Radiographs were then reviewed to determine the Essex-Lopresti classification, OTA classification, and presence of a PMA fracture.

RESULTS

The review yielded 271 total patients with 121 (44.6%) tongue-type (TT), 110 (40.6%) joint depression (JD), and 40 (14.8%) fractures not classifiable by the Essex-Lopresti classification. In the TT group, 73.6% of the patients had the PMA fracture whereas only 8.2% of JD and 15.0% of nonclassifiable fractures demonstrated a PMA fragment ( P < .001).

CONCLUSION

Plantar medial avulsion fractures occurred in 38.4% of the calcaneal fractures reviewed with a significantly greater proportion occurring in TT (73.6%) as opposed to JD (8.2%). Given the plantar fascia attachment to the PMA fragment, there may be clinical significance to identifying this fracture and changing treatment management; however, this requires further investigation.

LEVEL OF EVIDENCE

Level III, comparative study.

Salvaging the Unsalvageable Severe Malunion Deformity After Displaced Intra-Articular Calcaneal Fractures: What Options Exist?

A subset of calcaneal fractures is so severe that it may warrant primary conservative treatment. Unfortunately, nonoperative management of these fractures can lead to the development of a calcaneal malunion and cause significant patient morbidity. Surgical management of these deformities often requires increasingly complex reconstructive procedures. The goals of surgery include re-establishing calcaneal height, restoring the talocalcaneal relationship, and creating a stable, plantigrade foot. This article highlights the available surgical treatment options (including calcanectomy, calcaneal allograft transplantation, vascularized autografts, and calcaneal prostheses) for the management of severe calcaneal malunion deformities.

Böhler's Angle-Comparison Between the pre- and Postoperative in Displaced Intra-Articular Calcaneal Fractures

Objective  To compare pre- and postoperative variation of radiographic measurements of the Böhler angle (BA) in fractures with two types of deviations: severe and moderate. Methods  Pre- and postoperative BAs in 31 calcaneal fracture radiographs were retrospectively analyzed. A total of 4 patients were female (6.5%) and 26 were male (83.9%), with age ranging from 23 to 72 years old, and a mean age of 44.5 years old. Results  The results show that the postoperative BA was significantly larger than the preoperative BA ( p  = 0.000). At the intraevaluator and overall assessments, the postoperative BA was, on average, 10.6° higher than the preoperative measure. The postoperative angle was, on average, 108% higher than the preoperative angle. In the global assessment, the agreement between evaluators was excellent, both regarding the estimated point value (0.98) and the intraclass correlation (ICC) confidence interval (CI). Conclusion  In the global analysis, the postoperative BAs were, on average, significantly higher than the preoperative measurements. The farther from the normal range (20° to 40°) the preoperative angle is, the greater the difference after the surgery. When the preoperative angle was normal, the postoperative angle was, on average, 1.28 times the preoperative measurement. If the preoperative BA was abnormal, the postoperative angle was, on average, 17.3 times the preoperative measurement. It was demonstrated that more severe fractures present better anatomic results when compared with moderate fractures. The present study also confirms a good interobserver correlation for the BA.

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.

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?

Open Reduction Assisted With an External Fixator and Internal Fixation With Calcaneal Locking Plate for Intra-articular Calcaneal Fractures

BACKGROUND

The extensile lateral approach (ELA) has been considered to be a standard approach for displaced intra-articular calcaneal fractures (DICF) because it provides excellent exposure and allows direct reduction of the depressed posterior facet fragment. But continuous retraction during surgery needs sufficient manpower and may cause ischemia. Failure of rigid fixation of DICF will not allow for early weight bearing and may lead to a loss of reduction. To avoid these disadvantages, this study presents open reduction assisted with an external fixator and internal fixation with a calcaneal locking plate.

METHODS

A series of 58 patients with 62 DICFs were treated over a period of 49 months. All patients were clinically and radiologically followed up with a mean follow-up of 35 (range 29-42) months. Clinical follow-up included visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and ability to work. Radiologic follow-up included axial and lateral radiographs and measurements of the Bohler angle and Gissane angle.

RESULTS

At the final follow-up, all fractures had healed. The mean VAS score was 2.9 (range 0 to 8, SD 1.9) and the average AOFAS score was 71 (range 55-85, SD 8.1). The mean postoperative Bohler angle immediately after the surgery was 28.3 degrees (range 13.0-44.6, SD 7.0), which decreased to 27.5 degrees (range 12.2-43.3, SD 7.0) at the final follow-up, and the mean postoperative Gissane angle after the surgery was 116.3 degrees (range 94.9-131.5, SD 9.0) which finally increased to 118.4 degrees (range 94.5-135.8, SD 9.3). No statistically significant differences regarding Bohler and Gissane angles were found between different Sanders fracture types ( P>.05).

CONCLUSION

The presented operative technique was found to provide comparable reduction of Sanders type II-IV injuries.

LEVEL OF EVIDENCE

Level III, case control study.

Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation

PURPOSE

Early post-operative exercise and weight-bearing activities are found to improve the functional recovery of patients with displaced intra-articular calcaneal fractures (DIACFs). We hypothesized that early functional exercise after surgery might have a secondary reduction effect on the subtalar joint, in particular the smaller fracture fragments that were not fixed firmly. A prospective study was conducted to verify this hypothesis.

METHODS

From December 2012 to September 2013, patients with unilateral DIACFs were enrolled and received a treatment consisting of percutaneous leverage and minimally invasive fixation. After surgery, patients in the study group started exercising on days two to three, using partial weight bearing starting week three, and full weight bearing starting week 12. Patients in the control group followed a conventional post-operative protocol of partial weight bearing after week six and full weight bearing after the bone healed. Computed tomography (CT) scanning was performed at post-operative day one, week four, week eight, and week 12 to reconstruct coronal, sagittal, and axial images, on which the maximal residual displacements of the fractures were measured. Function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale at the 12th post-operative month.

RESULTS

Twenty-eight patients in the study group and 32 in the control group were followed up for more than 12 months; their data were collected and used for the final analysis. Repeated-measures analysis of variance (ANOVA) of the maximal residual displacements of the fracture measured on CT images revealed significant differences between the study and the control groups. There were interaction effects between group and time point. Except for the first time point, the differences between the groups at all studied time points were significant. In the study group, the differences between all studied time points were significant. Strong correlations were observed between the AOFAS score at post-operative month 12 and the maximal residual displacement of the fractures on the CT images at postoperative week 12.

CONCLUSIONS

Early functional exercise and weight bearing activity can smooth and shape the subtalar joint and reduce the residual displacement of the articular surface, improving functional recovery of the affected foot. Therefore, early rehabilitation functional exercise can be recommended in clinical practice.

Clinical Comparison of Extensile Lateral Approach and Sinus Tarsi Approach Combined with Medial Distraction Technique for Intra-Articular Calcaneal Fractures

OBJECTIVE

To study and compare the clinical outcomes of open reduction and internal fixation via extensile L-shape incision and limited open reduction via the sinus tarsi approach using the medial distraction technique for intra-articular calcaneal fractures.

METHODS

We performed a retrospective review of 65 intra-articular calcaneal fractures treated operatively between March 2012 and February 2015. Patients were divided into two groups: 28 were in the sinus tarsi approach group and 37 were in the extensile lateral approach group. All patients were asked to return for a research visit that included radiography and clinical evaluation. The postoperative function was evaluated using the ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) and the visual analogue scale (VAS).

RESULTS

No significant difference was found in demographics between the two groups. The corrected value of the calcaneal varus angle between the two groups is statistically significant (P < 0.05). The overall wound complication rate was 3.6% in the minimally invasive group versus 13.5% in the extensile group. Four patients in the extensile lateral approach group had developed hindfoot varus deformity at last follow-up. At the last follow-up, the average AOFAS ankle and the hindfoot score of the minimal group was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7, while that of the extensile lateral approach group was 83.2 ± 5.6 and 2.3 ± 1.0, respectively.

CONCLUSION

Limited open reduction via the sinus tarsi approach for intra-articular calcaneal fractures could reduce the incidence of wound complications effectively, and the medial distraction technique is helpful for correcting the calcaneus varus deformity.

Minimally invasive percutaneous osteosynthesis versus ORIF for Sanders type II and III calcaneal fractures: a prospective, randomized intervention trial

Background

This randomized controlled trial compared the clinical outcomes and complications of a novel minimally invasive percutaneous osteosynthesis (MIPO) with those of conventional treatment via an extended L-shaped lateral approach for calcaneal fractures.

Methods

Sixty-four patients with displaced intraarticular calcaneal fractures were enrolled. The patients were randomly allocated to receive either MIPO (29 patients) or open reduction and internal fixation via an extended L-shaped lateral approach (35 patients). The same calcaneal plate (AO Synthes, Oberdorf, Switzerland) was used in both groups. The primary clinical outcomes included operative time, VAS postoperatively, and wound healing complications. Secondary clinical outcomes included time to operation, length of incision, postoperative drainage, length of hospital stay, medical expense, AOFAS score, and SF-36 score. Preoperative and postoperative calcaneal height, width, and length, Bohler’s angle, and Gissane’s angle were compared.

Results

The operative time in the MIPO group was 52.5 ± 11.1 min, which was significantly shorter than 82.8 ± 16.2 min in the conventional treatment group (P < 0.001). One week postoperatively, the VAS value was 3.2 ± 1.4 in the MIPO group, which was lower than that in the conventional treatment group, 3.9 ± 1.3 (P = 0.038). In the conventional treatment group, 13 of 35 fractures (37.1%) had wound healing problems, whereas this issue occurred in only 2 of 29 fractures (6.7%) in the MIPO group (P = 0.004). In the MIPO group, deep and superficial infections occurred in none of the cases and 1 of 29 (3.4%) patients, respectively. Length of incision in the MIPO group was shorter than that in the conventional treatment group (4.2 ± 0.6 vs. 10.9 ± 1.5 cm; P < 0.001). Hospital stay was 9.7 ± 2.8 days in the MIPO group and 11.7 ± 2.6 days in the conventional treatment group (P = 0.004). At the last follow-up, the SF-36 scores and AOFAS scores in the two groups were comparable (P > 0.05). The postoperative radiographic data, the Bohler’s angle, Gissane’s angle, and calcaneal height, width, and length in the two groups were comparable (P > 0.05).

Conclusions

Compared with conventional ORIF, the advantages of MIPO are a considerably shortened operating time and hospital stay, decreased postoperative pain, and reduced risk of wound healing complications.

Review Article: Operative versus nonoperative treatment for displaced intraarticular calcaneal fracture: a meta-analysis of randomised controlled trials

We reviewed 8 randomised controlled trials that compared operative and non-operative treatment for displaced intra-articular calcaneal fractures. Patients with operative treatment were more likely to resume pre-injury work (relative risk [RR]=0.60, p=0.04), had fewer problems when wearing shoes (RR=0.42, p=0.0004), and had a higher physical component summary score of SF-36 (difference in means=6.75, p<0.0001) but a higher complication rate (RR=1.74, p=0.0005).

Treatment of calcaneal fractures with closed reduction and the Endobutton-assisted technique: short-term analysis

BACKGROUND

Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis.

METHODS

Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments.

RESULTS

The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent.

CONCLUSIONS

With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

Extensile Lateral Approach for the Operative Management of a Displaced Intra-Articular Calcaneus Fracture

Calcaneal fractures account for approximately 1.2% of all fractures and 60% of all tarsal bone fractures. Almost 75% present as displaced, intra-articular fractures. Because of the complex articular and osseous anatomy, the vulnerable soft-tissue envelope, and the technically challenging approach needed for fixation, these fractures are often treated nonoperatively, resulting in poor outcomes. These poor outcomes can include entrapment of the posterior tibial and sural nerves, impingement, dislocation or entrapment of peroneal tendons, a widened heel with a loss of height, hindfoot varus or valgus, formation of painful exostoses, development of posttraumatic arthritis of the subtalar and calcaneocuboid joints, and impingement of the ankle joint. The current scientific literature supports fixation of displaced, intra-articular fractures. The principles of surgical fixation consist of reconstructing the height (obtained by improving the Böhler angle), narrowing the width, reconstructing the length, correcting any varus deformity of the tuberosity, and anatomically reducing the joint. However, at the time of initial presentation, there is often substantial swelling, with or without fracture blisters, that needs to be resolved prior to surgical fixation. During this waiting period, radiographic and computed tomography (CT) evaluations should be performed to assess the fracture pattern. Once re-epithelialization of the blisters and wrinkling of the skin are noted, open reduction and internal fixation (ORIF) can be performed. The steps to an ORIF consist of (1) the use of an extensile lateral incision, with a subperiosteal dissection, that develops a full-thickness fasciocutaneous flap; (2) removal of the lateral wall, to allow visualization of the impacted joint; (3) removal of the lateral third or half of the joint to allow visualization of the medial two-thirds or half of the joint; (4) disimpaction of the medial half of the joint to its normal height, along with medialization of the tuberosity; (5) anatomic reduction of the posterior facet and fixation with lag screw(s); (6) possible use of a bone graft and replacement of the lateral wall; (7) spanning the calcaneus with a plate and screws; and (8) closure of the fasciocutaneous flap and skin over a drain.

Biomechanical Performance of Lateral Versus Dual Locking Plates for Calcaneal Fractures

Given the high rates of wound complications with a standard lateral extensile incision, small dual incision techniques might result in less soft tissue destruction. The goal of the present study was to compare the biomechanical performance between a single locking plate and a dual locking plating system for an intra-articular calcaneal fracture model. A Sanders IIB type joint depression calcaneal fracture was created in 10 paired, fresh-frozen, cadaveric calcanei (age 47 ± 12, range 35 to 78 years). The calcanei of each pair were randomly assigned for fixation using either a lateral locking reconstruction plate or lateral and medial locking reconstruction plates. The specimens were axially loaded in cyclic fashion for 1000 cycles, followed by load to failure. The relative fragment movement was monitored optically in both the sagittal and the coronal planes. The amount of overall construct displacement increased with cycling, although no difference was found between the plating techniques. For fragment movement during cycling, the lateral joint fragment migrated anteroinferiorly along the fracture line relative to the tuberosity fragment for dual plated specimens by a small, but statistically significant, amount. This same translation was smaller for lateral plated specimens but was not found to be significant. During load to failure testing, no statistically significant differences were found for construct stiffness. A tendency was seen toward more interfragmentary motion in the sagittal plane (lateral joint fragment movement relative to the fracture line), with less movement overall in the coronal plane (anterior fragment translation and twist) for dual plating, although the difference from the lateral plate was not statistically significant. The present study demonstrated that for this calcaneal fracture model, the dual plating technique experienced a small amount of fragment translation during cycling that was significantly different statistically from that with lateral plating but was not clinically relevant. During the load to failure, the dual plating technique was comparable to the lateral plate. Thus, dual plating could be a viable biomechanical option for fracture reduction if avoidance of a large extensile lateral approach associated with lateral plating is warranted.

Does axial view still play an important role in dealing with calcaneal fractures?

Background

The study aimed to analyze the role of axial view in different phases of treatment and demonstrate whether axial view is still useful in evaluating the calcaneal fractures.

Methods

156 patients with suspected unilateral calcaneal fractures were enrolled in the study, axial and lateral view of the affected foot and single axial view of the unaffected foot were gained. 16 were excluded due to unsatisfying axial radiograph. The remain 140 patients were eventually included into the study. Two separate assessments were conducted on two occasions with a three weeks interval to diagnose fractures. Lateral views were assessed firstly, and lateral combined with axial views were assessed three weeks later. Each of the 140 sets was evaluated by one of 6 surgeons randomly. Sensitivity and specificity value were compared between the two assessments. A new value Z which can directly reflect the degree of bulge on the calcaneal lateral wall on the axial view were introduced into the study. Z value of the 140 unaffected feet were measured. Data of another group of 31 patients who confirmed their lateral hindfoot pain caused by widening of calcaneus was reviewed. Liner regression was employed to analyze the relationship between angle Z and the severity of lateral pain.

Results

According to the two assessments, without axial view, specificity value will be significantly lower in diagnosing calcaneal fractures (p = 0.024) and sensitivity value will be significantly lower in distinguishing intra-articular fractures (p < 0.001). The normal threshold of angle Z was estimated from 98.06° to 100.64° (p <0.001). Liner regression shows that the lateral hindfoot pain will obviously aggravate along with the increasing of angle Z value (p <0.001).

Conclusions

Axial view is useful in diagnosing a patient with suspected calcaneal fracture especially for distinguishing intra-articular fractures and selection for CT scan. With the introduction of angle Z, axial view can get excellent performance in intra-operative assessment as well as in post-operative follow up procedure. Axial view can still play an irreplaceable role in assessing and evaluating calcaneal fractures, and can be employed as an essential reference during surgical procedure .

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-015-0004-6) contains supplementary material, which is available to authorized users.

Heel displaced intra-articular fractures treated with mini-calcaneal external fixator

INTRODUCTION

Treatment of displaced heel fractures is controversial; however, ORIF is widely described in the literature to be the gold-standard. Percutaneous reduction and monolateral external fixation is gaining increasing attention because it provides a good and stable reduction, and minimises soft tissue complications due to open surgery, such as deep infections and delays in wound healing. The aim of this study was to show that the new Orthofix Calcaneal Minifixator (six pins) provides a greater stability than the four-pin version to enable a better and more stable reduction, an earlier weight-bearing (30 days) and improved functional outcomes.

METHODS

A series of 69 consecutive closed heel intraarticular displaced fractures treated with the new Orthofix Calcaneal Minifixator were evaluated. Patients were assessed clinically with the Maryland Foot Score and radiologically with standard radiographs.

RESULTS

The clinical results at follow-up were excellent in 37 cases (53.6%), good in 27 (39.2%), fair in two (2.9%) and poor in three (4.3%). The mean preoperative Böhler's angle was 5.2˚ (range 0-18˚) and the mean postoperative value was 28.5˚ (range 16-38˚).

CONCLUSION

The excellent functional outcomes were despite some radiological images of imperfect posterior facet anatomical reduction and seemed to correlate with the use of a good and stable minimally-invasive surgical technique. This technique enabled early weight-bearing, minimised complications, respected the delicate biology of this anatomical site and restored the good heel volume and Böhler angle.

Balloon-assisted reduction, pin fixation and tricalcium phosphate augmentation for calcanear fracture

Two-thirds of hindfoot fractures involve the calcaneus. The best treatment for intraarticular fractures is still debated. The goal of treatment has been focussed for years on the anatomical reduction of the articular surface. Open reduction and internal fixation enables the surgeon to view the articular surface directly, but it is associated with a high rate of wound breakdown and infection. Therefore, length, width and angular replacement of the great tuberosity are actually the main parameters to consider when treating this type of fracture. This is a report of our experience of 20 patients treated with a minimally invasive technique of reduction using an inflatable bone tamp filled with tricalcium phosphate, with a mean follow-up of 12.25 months (range 7-26 months). Percutaneous K-wires were used to help reduction and to direct balloon inflation. Surgical goals were restoration of the mechanical stability for earlier full weight-bearing and patient mobilisation.

Calcaneotalar ratio: a new concept in the estimation of the length of the calcaneus

Maintaining the calcaneal length after calcaneal fractures is vital to restoring the normal biomechanics of the foot, because it acts as an important lever arm to the plantarflexors of the foot. However, estimation of the length of the calcaneus to be reconstructed in comminuted calcaneal fractures can be difficult. We propose a new method to reliably estimate the calcaneal length radiographically by defining the calcaneotalar length ratio. A total of 100 ankle radiographs with no fracture in the calcaneus or talus taken in skeletally mature patients were reviewed by 6 observers. The anteroposterior lengths of the calcaneus and talus were measured, and the calcaneotalar length ratio was determined. The ratio was then used to estimate the length of the calcaneus. Interobserver reliability was determined using Cronbach's α coefficient and Pearson's correlation coefficient. The mean length of the calcaneus was 75 ± 0.6 mm, and the mean length of the talus was 59 ± 0.5 mm. The calcaneotalar ratio was 1.3. Using this ratio and multiplying it by the talar length, the mean average estimated length of the calcaneus was within 0.7 mm of the known calcaneal length. Cronbach's α coefficient and Pearson's correlation coefficient showed excellent interobserver reliability. The proposed calcaneotalar ratio is a new and reliable method to radiographically estimate the normal length of the calcaneus when reconstructing the calcaneus.

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Bohler's angle's role in assessing the injury severity and functional outcome of internal fixation for displaced intra-articular calcaneal fractures: a retrospective study

Background

Controversy exits over the role of Böhler’s angle in assessing the injury severity of displaced intra-articular calcaneal fractures and predicting the functional outcome following internal fixation. This study aims to investigate whether a correlation exists between Böhler’s angle and the injury severity of displaced calcaneal fractures, and between surgical improvement of Böhler’s angle and functional outcome.

Methods

Patients treated operatively for unilateral closed displaced intra-articular calcaneal fractures from January 1, 2004 to March 31, 2008 were identified. The Böhler’s angles of both calcaneus were measured, and the measurement of the uninjured foot was used as its normal control. The difference in the value of Böhler’s angle measured preoperatively or postoperatively between the angle of the injured foot and that of the contralateral calcaneus were calculated, respectively. The change in Böhler’s angle by ratio was calculated by dividing the difference value of Böhler’s angle between bilateral calcaneus by its normal control. The injury severity was assessed according to Sanders classification. The functional outcomes were assessed using American Orthopaedic Foot & Ankle Society hindfoot scores.

Results

274 patients were included into the study with a mean follow-up duration of 71 months. According to Sanders classification, the fracture pattern included 105 type II, 121 type III and 48 type IV fractures. According to American Orthopaedic Foot & Ankle Society hindfoot scoring system, the excellent, good, fair and poor results were achieved in 104, 132, 27, and 11 patients, respectively. The preoperative Böhler’s angle, difference value of Böhler’s angle between bilateral calcaneus, and change in Böhler’s angle by ratio each has a significant correlation with Sanders classification (rs=−0.178, P=0.003; rs=−0.174, P=0.004; rs=−0.172, P=0.005, respectively), however, is not correlated with functional outcome individually. The three postoperative measurements were all found to have a significant correlation with American Orthopaedic Foot & Ankle Society hindfoot scores (rs=0.223, P<0.001; rs=0.224, P<0.001; rs=0.220, P<0.001, respectively). However, these correlations were all weak to low.

Conclusions

There was a significant correlation between preoperative Böhler’s angle and the injury severity of displaced intra-articular calcaneal fractures, but only postoperative Böhler’s angle parameters were found to have a significant correlation with the functional recovery.

A minimally invasive technique for the reduction of calcaneal fractures using the Endobutton®

Calcaneal fractures are very common injuries, and closed reduction-percutaneous pinning, open reduction-internal fixation, and primary arthrodesis are the procedures used in the surgical treatment of these injuries. The aim of surgical treatment is to restore the normal biomechanics of the Achilles tendon and rearfoot by anatomic reduction of the articular surfaces. Minimization of the soft tissue complications commonly associated with the open treatment of calcaneal fractures can be achieved using indirect closed reduction and Kirschner wire or screw-assisted minimally invasive percutaneous osteosynthesis methods. In the present report, we describe a technique for the treatment of calcaneal fractures associated with soft tissues that are at risk of complications and present the cases of 3 patients treated with indirect, minimally invasive reduction of comminuted calcaneal fractures with the Endobutton(®) fixation device. From our experience with this method, we believe it will be useful in cases of acute calcaneal fracture with pronounced soft tissue injury localized to the hindfoot.

Functional outcome of displaced intra-articular calcaneal fractures: a comparison between open reduction/internal fixation and a minimally invasive approach featured an anatomical plate and compression bolts

BACKGROUND

The purpose of this study is to assess the clinical results of a minimally invasive treatment featured the concept of internal compression, including an anatomic plate and multiple compression bolts compared with open reduction and internal fixation for displaced intra-articular calcaneal fractures (DIACFs).

METHODS

We retrospectively analyzed 329 patients (383 feet) who were identified from trauma inpatient database in our hospital for DIACFs from January 2004 to December 2009. Of them, 148 patients (170 feet) were treated with open reduction and internal fixation (OR group), which involved using a traditional L-shaped extended lateral approach, and fractures were fixed by plate and screws from January 2004 to December 2006; 181 patients (213 feet) were treated with a minimally invasive approach featured the concept of calcaneal internal compression (CIC group), which was achieved by an anatomic plate and multiple compression bolts through a small lateral incision from January 2007 to December 2009. Postoperative complications were recorded. During follow-up, pain and functional outcome were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) scores and compared between the two groups. Subsequent subtalar arthrodesis and early implant removal were performed when indicated. Routine hardware removal was scheduled for all patients at 1-year follow-up.

RESULTS

There were no significant differences in sex, age, and fracture classification (Sanders classification) between the two groups. Wound healing complications were 4 of 213 (1.88%) in CIC group and 20 of 170 (11.76%) in OR group. Subtalar arthrodesis had to be performed in one case in OR group. Four cases in CIC group and four cases in OR group had the hardware removed earlier due to complications. The average time after surgery to start weight-bearing exercise is 5.64 weeks in CIC group and 9.38 weeks in OR group (p < 0.001). The mean AOFAS score is higher in CIC group than in OR group, although the difference is not statistically significant (87.53 vs. 84.95; p = 0.191). The overall results according to the AOFAS scoring system were good or excellent in 185 of 213 (86.85%) in CIC group and 144 of 170 (84.71%) in OR group. The subjective portion of the AOFAS survey answered by patients showed statistically significant difference in activity limitation and walking surface score (7.31 vs. 7.02 and 3.72 vs. 3.42; p < 0.05) but not in pain and walking distance between the two groups (32.72 vs. 32.29 and 4.37 vs. 4.42; p > 0.05).

CONCLUSION

The study results suggest that this minimally invasive approach featured the concept of the calcaneal internal compression can achieve functional outcome as good as, if not better than the open techniques. It is proved to be an effective alternative treatment for DIACFs.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Percutaneous reduction and fixation of an intra-articular calcaneal fracture using an inflatable bone tamp: description of a novel and safe technique

Calcaneal fractures are common injuries involving the hind foot and often a source of significant long-term morbidity. Treatment options have changed throughout the ages from periods of preferred nonoperative management to closed reduction with a mallet, and more recently, open reduction and anatomic internal fixation. The current treatment of choice; however, is often debated, as open management of these fractures carries many risks to include wound breakdown and infection. A less invasive form of surgical management through small incisions, while maintaining the ability to obtain joint congruency, anatomic alignment, and restore calcaneal height and width would be ideal. We propose a novel form of fracture reduction using an inflatable bone tamp and percutaneous fracture fixation. Preoperative planning and experienced fluoroscopy is crucial to successful management using this method. Although we achieved successful radiographic outcome in this case, long-term functional outcome of this technique are yet to be published.

Open reduction and internal fixation of OTA type C2-C4 fractures of the calcaneus with a triple-plate technique

The purpose of this study was to present a surgical technique of open reduction and internal fixation of displaced intra-articular calcaneal fractures with 3 AO mini-fragment plates and to evaluate the clinical and radiological outcome of a consecutive group of patients after a mean follow-up of 41.7 months. A series of 54 patients (16 women and 38 men) with 62 calcaneal fractures were treated over a period of 6.5 years. Forty-five patients with 50 calcaneal fractures were completely clinically and radiologically followed up. Clinical follow-up included assessment of range of motion, pain according to a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score, and the short-form 36 health survey. Radiological follow-up included plain axial and lateral radiographs and measurement of the Böhler's angle and Gissane's angle. Independent Student's t test and paired Student's t test were used alongside the chi-square test to compare clinical and radiological data and score values between different groups of patients. Eleven patients showed breakage of the osteosynthesis material during the healing process and 2 patients sustained deep wound infection requiring revision surgery. At the final follow-up all fractures had healed. The average range of motion was supination 26.4° (range 0° to 50°; SD 11.6°), pronation 15.4° (range 0° to 30°; SD 6.4°), dorsal extension 14.3° (range -10° to 30°; SD 8.0°), and plantarflexion 39.6° (range 20° to 65°; SD 11.7°). Patients with OTA type C4 fractures achieved significantly lower supination (p < .01) and plantarflexion (p < .01) compared with other fracture types. The mean visual analog scale pain score was 3.6 (range 0 to 8; SD 2.3) points, average American Orthopaedic Foot and Ankle Society hindfoot score was 70.8 (range 33 to 100; SD 17.1) points, and the mean short-form 36 score was 60.98 (range 22.9 to 93.0; SD 18.4) points. The mean postoperative Böhler's angle was 28.9° (range 8° to 38°; SD 7.1°), which decreased to 23.6° (range 4° to 34°; SD 8.7°) at the final follow-up, and the mean postoperative Gissane's angle was 108.6° (range 80° to 140°; SD 11.8°), which finally decreased to 102.4° (range 72° to 126°; SD 12.7°). No statistically significant differences regarding Böhler's and Gissane's angles were found between different OTA fracture types. In conclusion, the presented surgical technique was found to provide comparable and adequate reduction of OTA type C2-C4 injuries based on statistically insignificant differences in radiographic measures of postoperative fracture reduction. Greater limitation in subtalar motion was observed in OTA type C4 fractures in comparison with less severe fractures (p < .01).

Early weight bearing of calcaneal fractures fixated with locked plates: a radiographic review

The use of locked plate technology in the calcaneus has been shown in previous studies to provide greater stability than that of nonlocking plates. The purpose of this study is to examine the radiographic effects of early weight bearing of calcaneal fractures repaired with locked plating. A retrospective review was performed of 17 calcaneal fractures repaired with locked plate fixation over a 2-year period. A chart and radiographic review evaluated the time the patient was kept non-weight bearing and the Bohler's angle at first postoperative visit and final postoperative visit. Change in Bohler's angle was used to evaluate for bone subsidence. Standard reduction and fixation techniques were performed to realign all components of the intra-articular calcaneal fracture using a titanium locking calcaneal fracture plate. Patients returned for follow-up examinations postoperatively and underwent radiographic examination. A weight-bearing short fracture walker boot was applied, and the patient began protected weight bearing at approximately 4 to 5 weeks. The charts and radiographs of 17 intra-articular fractures were reviewed. The average Bohler's angle at first postoperative visit was 30.12° in comparison to the average at final visit of 28.47 °. The average time the patient was kept non-weight bearing after the procedure was 4.8 weeks. The average time of follow-up was 237.7 days. There were no cases of significant bone subsidence or collapse noted. Calcaneal fractures can have significant morbidity associated with the injury and its care. This study examined early weight bearing of calcaneal fractures fixated with locked plating. Under radiographic review, there was no significant loss of calcaneal height, joint reduction, or fixation stability noted. These results are thought to be due to the inherent stability of the locked plate construct.

The infected calcaneus

Infections in and around the calcaneus can be quite challenging for the patients and physicians involved. These infections arise because of multiple potential etiologies including chronic pressure, trauma, and postsurgical wound-healing complications. The impediments to healing can be equally as diverse depending on patients' comorbidities, such as smoking, diabetes, and open injury. In this article the authors review the anatomy of the calcaneus and surrounding soft tissue, patient risk factors, and various treatment options that can be used through a multidisciplinary approach. The common limiting factor for most of these patients is the delicate soft-tissue envelope, and occasionally, the lack thereof. The ultimate goal is an infection-free limb with durable soft-tissue coverage and maximal maintenance of function.

Management of calcaneal fractures: systematic review of randomized trials

INTRODUCTION

The optimal management of calcaneal fractures is controversial, as correlation between anatomical restoration and outcome has not been proven, and complications after surgery are frequent.

SOURCES OF DATA

MEDLINE, EMBASE, CINAHL, Google scholar, the Cochrane Controlled Trials Register, and the Cochrane Musculoskeletal Injuries Group Trials Register were searched using the keywords 'calcaneal' and 'fractures', without time limits or restriction to language. Randomized and quasi-randomized trials were included. Two separate comparisons were identified in the trials: operative versus non-operative management (five studies), and impulse compression versus no impulse compression (one study). Two reviewers independently assessed trial quality, with a 12-item scale used by the Cochrane Collaboration.

AREAS OF AGREEMENT

Results showed no difference in residual pain, but favoured surgical management on ability to return to the same work and to wear the same shoes as before the fracture. Surgery reduced the need for subsequent subtalar fusion. workers' compensation affected outcome.

AREAS OF CONTROVERSY

It is unclear whether general health outcome measures, injury specific scores and radiographic parameters improve after operative management, and whether the benefits of surgery outweigh the risks.

GROWING POINTS

The existing trials are of relatively poor quality.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is still a need for a carefully designed large-scale trial comparing surgery and non-operative management. Other forms of fixation (external fixation or minimally invasive internal fixation) should be compared with 'conventional' surgery. Trials investigating joint reconstruction versus primary subtalar fusion for highly comminuted fractures, and impulse compression versus placebo could be of value.

Percutaneous screw configuration versus perimeter plating of calcaneus fractures: a cadaver study

BACKGROUND

Percutaneous screw configuration has been used clinically to reduce the high rate of wound complications associated with the extensile approach of standard open reduction and internal plate fixation. The aim of this cadaveric biomechanical study was to compare the strength of the standard perimeter plating with that of the percutaneous screw configuration for a Sanders type-2B calcaneus fracture.

MATERIALS AND METHODS

Ten pairs of fresh-frozen cadaveric lower limbs were prepared and osteotomized to create a Sanders type-2B fracture. Of each pair, one specimen underwent open reduction and internal fixation with standard perimeter plating; the other was stabilized with the percutaneous screw configuration. Each foot was compressed axially via the talar dome (1 mm/sec) until failure occurred. Differences in treatment groups were analyzed for significance (p < 0.05) using paired t-tests.

RESULTS

Construct stiffness was 158 +/- 85 and 113 +/- 60 N/mm for the plate and percutaneous fixation, respectively (p = 0.18). Failure occurred at an average of 1156 +/- 513 and 1064 +/- 540 N for the plate and percutaneous construct, respectively (p = 0.65).

CONCLUSION

The results suggest that open reduction and internal fixation with percutaneous screw configuration for Sanders type-2B calcaneus fractures provides a strength similar to that of perimeter plating.

CLINICAL RELEVANCE

Percutaneous screw fixation of calcaneus fractures may provide fracture reduction similar to plate fixation.

Secondary soft tissue compromise in tongue-type calcaneus fractures

OBJECTIVES

Open wounds occur with calcaneus fracture from direct application of force and from tearing along the medial side of the fracture as the tuberosity displaces laterally. Secondary soft tissue injury can also occur from pressure of the displaced fracture fragments. Tongue-type fractures of the calcaneus lead to variable amounts of displacement of the posterior tuberosity. This displacement may threaten the posterior soft tissue envelope. Because many calcaneus fractures are splinted initially and immobilized for several weeks until swelling resolves, failure to acutely recognize the potential for posterior skin breakdown may lead to severe soft tissue morbidity. The purpose of this study was to determine the incidence of posterior skin involvement in tongue-type calcaneus fractures and to determine the patient and fracture characteristics that lead to high-risk situations.

SETTING

University level I trauma center.

PATIENTS/PARTICIPANTS

All tongue-type calcaneus fractures treated at 1 institution between 2002 and 2007 were identified from a trauma registry. Of 954 patients with calcaneal fractures, 139 tongue-type calcaneus fractures in 127 patients formed the study group.

INTERVENTION

Patient demographics, comorbidities, injury mechanism, fracture displacement, and time to presentation were evaluated. Those injuries that were associated with posterior, secondary soft tissue breakdown were identified and compared to those without breakdown.

MAIN OUTCOME MEASUREMENTS

Univariate analysis and stepwise multinomial logistic regressions were used to identify significant predictors of posterior soft tissue compromise.

RESULTS

Twenty-nine fractures (21%) had some degree of posterior skin compromise at presentation, including 12 with threatened skin, 10 with partial thickness breakdown, and 7 with full thickness breakdown. Six soft tissue coverage procedures and one amputation resulted. Patients with posterior skin compromise were less likely to have a fall mechanism (P = 0.001), had significantly greater fracture displacement (P = 0.007), were more likely to smoke (P = 0.039), and were more frequently referred on a delayed basis (P = 0.007). Those with threatened posterior skin who were treated emergently with percutaneous reduction did not progress to soft tissue compromise.

CONCLUSION

A high incidence (21%) of posterior skin compromise occurs in tongue-type calcaneus fractures. These should be treated with immediate reduction, plantarflexion splinting, and close monitoring. Although mechanism, displacement, and time to presentation were significantly correlated with posterior skin involvement, the surgeon should be aware of this potential complicating factor in all tongue-type fractures.

[Imaging of traumatic injuries of the foot and ankle]

Traumatic injuries of the foot and ankle are frequent and constitute a true public health problem with over 6000 daily cases in France. The complex anatomy of this area and its association to other injuries in polytraumatized patients can lead to delayed diagnosis with worsened functional prognosis. Accurate diagnosis relies on good knowledge of osseous and ligamentous lesions and their associations and sometimes requires the use of additional imaging techniques including US and CT.

The use of nanocrystalline hydroxyapatite for the reconstruction of calcaneal fractures: Preliminary results

The purpose of this investigation was to evaluate the feasibility of a nanocrystalline hydroxyapatite compound in the treatment of calcaneal fractures with osseous defects after reduction. The study included 21 patients, representing 24 closed intraarticular calcaneus fractures with large defects remaining after operative reduction. All cases were supplemented with the hydroxyapatite bone substitute and stabilized with a calcaneal honeycomb plate. Radiographs were taken at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively, with specific attention given to measurement of Gissane's angle, Böhler's angle, and calcaneal height. A postoperative subjective and objective evaluation of the fracture, using the Creighton Nebraska Health Foundation scale, was performed 1 year postoperatively. Böhler's angle improved from a mean 8.6 +/- 5.3 degrees preoperatively to an immediate postoperative mean result of 31.5 +/- 6.5 degrees and 27.7 +/- 8.6 1 year postoperatively. The mean Creighton-Nebraska functional score was 86 +/- 10 at the 1-year follow-up evaluation. These results suggest that open reduction with plate fixation combined with nanocrystalline hydroxyapatite augmentation presents a good and reliable surgical technique for treatment of calcaneus fractures.