Intra-articular fractures of the calcaneum: why such controversy?

Minimally Invasive Sinus Tarsi Approach for Open Reduction and Internal Fixation of Calcaneal Fractures: Complications, Risk Factors, and Outcome Predictors

Open reduction and internal fixation of displaced intraarticular calcaneal fractures remain the gold standard of treatment, but the traditional extensile approach has been associated with relatively frequent complications. The current study aims to evaluate the less invasive sinus tarsi approach and to elaborate on the associated complications, risk factors, and outcome predictors. A retrospective observational study was carried out among 39 patients diagnosed with calcaneal fractures that were operatively treated between January 2019 and January 2020 at a level-one trauma center in Riyadh, Saudi Arabia. Patients were assessed regarding the complications, pre- and postoperative Bohler's angle, Gissane’s angle, calcaneal height, and return to baseline function. Patients older than 60 years show significantly more complications compared to younger patients (p < 0.05). Type IV calcaneal fracture, according to Sander’s classification, showed significantly more complications than other types (p < 0.05). There were significant variations in pre- and postoperative Bohler's angle and calcaneal height (p < 0.05). These variations apply to the Gissane’s angle but do not rise to significant results (p > 0.05). Furthermore, the current study reports a significant moderate direct correlation between delay time and complication incidence (p < 0.05). In conclusion, the minimally invasive sinus tarsi approach has relatively low complications and excellent clinical and radiological outcomes. Older patients and those who are diagnosed with type IV calcaneal factures, besides those presented with more delay, are more associated with unfavorable complications.

Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center

Background

The aim of this retrospective monocentric study was to investigate the outcomes of surgically treated intra-articular calcaneus fractures in a maximum care trauma center.

Methods

One hundred forty patients who had undergone surgery for intra-articular calcaneal fractures between 2002 and 2013 were included. One hundred fourteen cases with 129 fractures were eligible to participate in the study of which 80 were available for a clinical and radiological follow-up. 34 patients were followed up by telephone interview only. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, Short Form 36 Health Status Survey (SF-36), complications, and subsequent surgeries.

Results

Mean follow-up was 91 months (range 12–183). The overall complication rate was 29% (37/129 ft). Disturbed wound healing (11%) and infection (5%) occurred most commonly. Non-union (4%) only occurred in smokers (p = 0.02). A high rate of posttraumatic subtalar arthritis (77%) and need for subsequent subtalar fusion (18%) without independent risk factors for subsequent subtalar fusion was found. The revision rate was high (60%) after primary fusion. Mean AOFAS-hindfoot score was 74 (Sanders I: 99, Sanders II: 74, Sanders III: 77, Sanders IV: 70). The postoperative Boehler angle improved significantly in all subgroups (p < 0.01). Patients with a decreased Boehler angle between postoperative images and the follow-up had significantly lower AOFAS hindfoot scores (p < 0.01).

Conclusions

Our data can aid decision-making in the treatment of calcaneal fractures. We advocate to use primary subtalar fusion with caution due to the high revision rate. Smoking status should always be considered.

Level of evidence: Level III, retrospective cohort study.

Calcaneal Fractures in Non-Racing Dogs and Cats: Complications, Outcome, and Associated Risk Factors

OBJECTIVE

To estimate the prevalence of complications and describe the outcome associated with calcaneal fractures in non-racing dogs and in cats.

STUDY DESIGN

Retrospective multicenter clinical cohort study.

ANIMALS

Medical records of client-owned dogs and cats (2004-2013).

METHODS

Medical records were searched and 50 animals with calcaneal fractures were included for analysis. Complications were recorded and an outcome score applied to each fracture. Associations between putative risk factors and both major complications, and final outcome scores were explored.

RESULTS

Complications occurred in 27/50 fractures (61%) including 23 major and 4 minor complications. At final follow-up, 4 animals (10%) were sound, 27 (64%) had either intermittent or consistent mild weight-bearing lameness, 7 (17%) had moderate weight-bearing lameness, and 1 (2%) had severe weight-bearing lameness. Fractures managed using plates and screws had a lower risk of complications than fractures managed using pin and tension band wire, lag or positional screws or a combination of these techniques (Relative risk 0.16, 95% CI 0.02-1.02, P=.052). Non-sighthounds had reduced odds of a poorer outcome score than sighthounds (Odds ratio 0.11, 95% CI 0.02-0.50, P=.005) and fractures with major complications had 13 times the odds of a poorer outcome score (Odds ratio 13.4, 95% CI 3.6-59.5, P<.001).

CONCLUSION

This study reports a high occurrence of complications associated with calcaneal fracture stabilization in non-racing dogs and in cats, and a poorer outcome score was more likely in animals with complications. A more guarded prognosis should be given to owners of non-racing dogs or cats with calcaneal fractures than previously applied to racing Greyhounds with calcaneal fractures.

Comparative study on three surgical techniques for intra-articular calcaneal fractures: open reduction with internal fixation using a plate, external fixation and minimally invasive surgery

Objective

To evaluate, compare and identify the surgical technique with best results for treating intra-articular calcaneal fractures, taking into account postoperative outcomes, complications and scoring in the Aofas questionnaire.

Methods

This was a retrospective study on 54 patients with fractures of the calcaneus who underwent surgery between 2002 and 2012 by means of the following techniques: (1) open reduction with extended L-shaped lateral incision and fixation with double-H plate of 3.5 mm; (2) open reduction with minimal incision lateral approach and percutaneous fixation with wires and screws; and (3) open reduction with minimal incision lateral approach and fixation with adjustable monoplanar external fixator.

Results

Patients treated using a lateral approach, with fixation using a plate had a mean Aofas score of 76 points; those treated through a minimal incision lateral approach with screw and wire fixation had a mean score of 71 points; and those treated through a minimal incision lateral approach with an external fixator had a mean score of 75 points. The three surgical techniques were shown to be effective for treating intra-articular calcaneal fractures, without any evidence that any of the techniques being superior.

Conclusion

Intra-articular calcaneal fractures are complex and their treatment should be individualized based on patient characteristics, type of fracture and the surgeon's experience with the surgical technique chosen.

Medial fracture line significance in calcaneus fracture

In Sanders' classification of calcaneus fractures, the medial fracture line (subtype C) is close to the tarsal canal, which contains an artery for the talus and calcaneus. We hypothesized that because of this brittle vascular localization, patients with C line fracture patterns might describe radiologic subtalar arthritis more often and have more complaints. The purpose of the present study was to compare the results of C line fracture patterns with other types of calcaneus fractures. A total of 25 surgically treated feet were involved. Regarding Sanders' classification, group 1 included fractures involving the C line (11 feet), and group 2 included fractures not involving the C line (14 feet). Patient age at admission, trauma date, and interval until surgery were obtained from the patients' medical records. The Bohler angles were determined from the radiographs. At the last follow-up visit, the radiologist graded subtalar arthritis using computed tomography. For clinical follow-up, the American Orthopaedic Foot and Ankle Society and Maryland scores were assessed. No significant differences were found in mean age, follow-up period, delay to surgery, or postoperative Bohler angle between the 2 groups. The mean preoperative Bohler angle was significantly low for group 1. Although not significantly different, the mean American Orthopaedic Foot and Ankle Society and Maryland scores were lower for group 1 (81.9 and 84.3) than group 2 (87.8 and 92.0), and the median subtalar arthritis grade was greater for group 1 (score 2) than for group 2 (score 1.5). The worse results with C line fracture patterns despite satisfactory reduction might result from sinus tarsi artery damage. Angiographic investigations could clarify this theory in the future. Consequently, surgeons must inform and should hesitate to operate on patients with these highly comminuted C line calcaneus fractures.

Treatment of displaced intra-articular calcaneal fractures by ligamentotaxis: current concepts' review

INTRODUCTION

A large variety of therapeutic modalities for calcaneal fractures have been described in the literature. No single treatment modality for displaced intra-articular calcaneal fractures has proven superior over the other. This review describes and compares the different percutaneous distractional approaches for intra-articular calcaneal fractures. The history, technique, anatomical and fracture considerations, limitations and the results of different distractional approaches reported in the literature are reviewed.

METHOD

Literature review on different percutaneous distractional approaches for displaced intra-articular calcaneal fractures.

RESULTS

Eight studies in which application of a distraction technique was used for the treatment of calcaneal fractures were identified. Because of the use of different classification, techniques, and outcome scoring systems, a meta-analysis was not possible. A literature review reveals overall fair to poor result in 10-29% of patients. Ten up to 26% of patients are unable to return to work after percutaneous treatment of their fracture. A secondary arthrodesis has to be performed in 2-15% of the cases. Infectious complications occur in 2-15%. Some loss of reduction is reported in 4-67%.

CONCLUSION

Percutaneous distractional reduction and fixation appears to be a safe technique with overall good results and an acceptable complication rate, compared with other treatment modalities for displaced intra-articular calcaneal fractures. A meta-analysis, based on Cochrane Library criteria is not possible, because of a lack of level 1 and 2 trials on this subject.

Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases

A retrospective analysis of 24 cases of minimally invasive, open reduction, and internal fixation of intra-articular calcaneal fractures is presented. Collected data included articular step-off, medial wall displacement, and Boehler's angle, in addition to other descriptive characteristics of the fracture and case series. The operative technique is described in detail including the optimal screw constructs. Arthroscopic assistance was used in 10 of the cases. The articular step-off of the posterior facet, medial wall displacement, and Boehler's angle all displayed statistically significant change between the preoperative and postoperative periods (P < .0001). These results were consistent with the goal of restoration of articular congruity, calcaneal morphology, and calcaneal height. There were no soft tissue complications. The mean overall follow-up duration was 2.8 years (range 1 to 10 years). Of the 18 patients who were followed for more than 1 year (range 1.0 to 10 years), none went on to subtalar fusion. The results of this study suggest that a minimally invasive approach can improve radiographic parameters consistent with the ultimate goals of operative reduction of calcaneal fractures, and can be used to achieve satisfactory results with minimal risk of wound complication.

LEVEL OF CLINICAL EVIDENCE

4.

Treatment of displaced intra-articular calcaneal fractures with triangular tube-to-bar external fixation: long-term clinical follow-up and radiographic analysis

Sixty-six feet (62 patients) with displaced intra-articular calcaneal fractures underwent manual reduction and distraction with the use of a triangular tube-to-bar external fixation device and were retrospectively reviewed at a minimum of 1-year post-operative. Final radiographic follow-up revealed complete consolidation in all fractures, maintenance of reduction, and limited degenerative osteoarthrosis about the subtalar joint. Our results indicate that with proper application and attention to detail, restoration of calcaneal morphology using triangular tube-to-bar external fixation should be considered a viable alternative in the treatment of displaced intra-articular fractures of the calcaneus.

Minimally-invasive treatment of intra-articular fractures of the calcaneum

We describe the results of 287 intra-articular fractures of the calcaneum in 247 patients treated by minimally-invasive reduction and K-wire fixation between 1994 and 2003. There were 210 men (85%) and 37 women (15%). The most common cause of injury was a fall from a height in 237 patients (96%). Fracture classification was based on the method described by Sanders and Essex-Lopresti. All patients were operated on within 21 days of injury and 89% (220) within 48 hours. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement and satisfactory overall alignment) in 212 (73.9%) fractures.

There were 20 cases (7%) of superficial pin-track infection and five (1.7%) of deep infection. All healed at a mean of 6 weeks (3 to 19). Loss of reduction was observed in 13 fractures (4.5%) and a musculocutaneous flap was needed in three (1%).

The results were evaluated in 176 patients (205 fractures) with a mean age of 44.3 years (13 to 67), available for follow-up at a mean of 43.4 months (25 to 87) using the Creighton-Nebraska Health Foundation Assessment score. The mean score was 83.9 points (63 to 100). There were 29 (16.5%) excellent, 98 (55.7%) good, 26 (14.8%) fair and 23 (13%) poor results. A total of 130 patients (73.9%) were able to return to their original occupation at a mean of 5.6 months (3.2 to 12.5) after the injury.

Semi-open reduction and percutaneous fixation is an effective treatment for displaced intra-articular fractures of the calcaneum.

The use of Ilizarov technique and other types of external fixation for the treatment of intra-articular calcaneal fractures

Treatment of severely comminuted calcaneal fractures with soft tissue compromise is still a controversial issue among surgeons. Complications of open reduction internal fixation have been well reported in the literature with a fairly high incidence of posttraumatic osteoarthritis of the subtalar joint, symptomatic hindfoot stiffness (especially when fixed in varus), wound dehiscence, and potential for the development of osteomyelitis caused by the extensive soft tissue trauma inherent with these injuries. For these reasons, closed treatment techniques using minimally invasive reduction procedures with application of ring-type fine-wire external fixation have recently gained popularity.

Fractures of the calcaneus: a review with emphasis on CT

The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures. Advances in cross-sectional imaging, particularly in computed tomography (CT), have given this modality an important role in identifying and characterizing calcaneal fractures. Fracture characterization is essential to guide the management of these injuries. Calcaneal fractures have characteristic appearances based on the mechanism of injury and are divided into two major groups, intraarticular and extraarticular. Most calcaneal fractures (70%-75%) are intraarticular and result from axial loading that produces shear and compression fracture lines. Of the two major systems for classifying intraarticular fractures-Hannover and Sanders-the latter is used most often and is helpful in treatment planning and determining prognosis. Extraarticular fractures account for about 25%-30% of calcaneal fractures and include all fractures that do not involve the posterior facet. The article describes in detail calcaneal anatomy, mechanism of calcaneal injuries and their associated fracture patterns, CT features of intra- and extraarticular fractures, and management implications. Familiarity with calcaneal anatomy and fracture patterns is essential for radiologists to guide the treating physicians.

Functional evaluation of intraarticular severely comminuted fractures of the calcaneus with gait analysis

Twenty-one patients (23 feet) treated nonsurgically for severely comminuted intraarticular fractures of the calcaneus were evaluated prospectively with a clinical scoring scale and computerized gait analysis. All patients had Sanders type III and type IV fractures. The treatment protocol consisted of no closed reduction, immobilization in removable splint, physiotherapy after edema subsided, and weightbearing after 8 weeks. All patients had a minimum follow-up of 2 years (mean, 38 months). Clinical results were good in 2 patients, fair in 3 patients, and poor in 16 patients. Gait analysis showed that patients were at high risk of gastrocnemius weakness and ankle and knee instability. These results may be useful for comparison with the results of other methods, such as open reduction and internal fixation, nonsurgical closed reduction, and arthrodesis.

Three-dimensional and two-dimensional computerized tomographic demonstration of calcaneus fractures

The objective of the study was to illustrate the diagnostic quality of three-dimensional computed tomography (3DCT) and to document its usefulness for detecting gross changes in articular surfaces of the calcaneus and posterior articular facet (PAF). Superior view 3DCT images of 51 calcanei in 39 different patients were reviewed based on bony fragments produced by primary fracture lines and involvement of the PAF. Of 49 intraarticular fractures examined, there were two severely comminuted and 47 comminuted fractures. Main characteristics of both groups were described. Important findings best seen on 3DCT images were the number and configuration of displaced PAF fragments, fracture lines separating the anterior process and the middle facet, and the extension of fracture lines into the calcaneocuboid facet. The double density sign seen in plain x-rays was identified as a double articular sign in 3DCT images.

Open reduction for intra-articular calcaneal fractures: evaluation using computed tomography

Radiographic and computed tomography features of unilateral intra-articular calcaneal fractures after open reduction and internal fixation were compared with late functional outcomes to identify prognostic factors. Sixty-one of 67 patients treated between 1997 and 2002 could walk painlessly postoperatively (average, 19.7 months). Functional results (Laasonen's criteria) were excellent or good in 92.5%. Factors associated with better functional results were lower age (p = .0227), greater Böhler angle at the time of injury (p < .0001), lower Sanders' grade (p = .0497), increased height of fractured regions (p = .0249), better reduction of the posterior facet (p = .0126), and better reduction of the calcaneocuboid joint (p = .0023). Only the latter two were found to be surgical prognostic factors.

Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management

OBJECTIVE

To report on all complications experienced by patients with displaced intra-articular calcaneal fractures (DIACFs) following nonoperative management or open reduction internal fixation (ORIF).

DESIGN

Prospective, randomized, multicenter study.

SETTING

Four level I trauma centers.

PATIENTS

The patient population consisted of consecutive patients, age 17 to 65 at the time of injury, presenting to 1 of the centers with DIACFs between April 1991 and December 1998.

INTERVENTIONS

Patients were randomized to the nonoperative treatment group or to operative reduction using a lateral approach to the calcaneus.

MAIN OUTCOME MEASUREMENTS

Follow-up for patients was at 2 weeks, 6 weeks, 3 months, 12 months, 24 months, and once greater than 24 months following injury. At each follow-up interval, patients were assessed for the development of major and minor complications. After a minimum of 2-year follow-up, patients were asked to fill out a validated visual analogue scale questionnaire (VAS) and a general health review (SF-36).

RESULTS

There were 226 DIACFs (206 patients) in the ORIF group with 57 of 226 (25%) fractures (57 of 206 patients [28%]) having at least 1 major complication. Of 233 fractures (218 patients) nonoperatively managed, 42 (18%) (42 of 218 patients [19%]) developed at least 1 major complication (indirectly resulting in surgery).

CONCLUSION

Complications occur regardless of the management strategy chosen for DIACFs and despite management by experienced surgeons. Complications are a cause of significant morbidity for patients. Outcome scores in this study tend to support ORIF for calcaneal fractures. However, ORIF patients are more likely to develop complications. Certain patient populations (WCB and Sanders type IV) developed a high incidence of complications regardless of the management strategy chosen.

The use of subtalar arthroscopy in open reduction and internal fixation of intra-articular calcaneal fractures

Congruency of the subtalar joint is a major predictor of outcome after intra-articular calcaneal fractures. Because of the irregular shape of the posterior joint facet, minor steps may be overlooked with direct vision or intra-operative fluoroscopy during open reduction and internal fixation (ORIF). In a preliminary series of 15 subtalar arthroscopies during hardware removal after ORIF of intra-articular calcaneal fractures, patients with visible steps of 1 mm or more had significantly inferior functional results compared to those with an intact subtalar joint (117 vs. 158 points with the 200-point score, 71.3 vs. 91.2 points with the Maryland Foot Score, P<0.01). Congruency of the posterior facet was controlled arthroscopically in 47 intra-articular calcaneus fractures after open reduction and temporary K-wire-fixation. In 12 cases (25.5%), despite seemingly correct reduction as judged fluoroscopically, incongruencies in the posterior calcaneal facet were detected and reduction was repeated, temporarily removing the K-wires. After anatomical reduction a standard AO calcaneal plate was fixed to the lateral wall. Intra-operative arthroscopy appears to be useful in detecting minor incongruencies after ORIF of intra-articular calcaneus fractures. In the hands of an experienced surgeon it is less time demanding than intra-operative X-rays and more precise than fluoroscopy.

Fractures of the calcaneus

Displaced fractures of the calcaneous are relatively common injuries that remain a treatment enigma. Virtually all aspects of the management of calcaneal fractures are a source of debate. Contemporary imaging, reduction, and fixation techniques attempt to improve the long term results of these injuries. The complex fracture fragments displace in predictable patterns. Meticulous surgical technique, restoration of extra- and intra-articular anatomy, and obtaining rigid fracture fixation are critical to obtaining satisfactory operative results. This article extensively reviews the controversies and summarizes the current opinions in the management of displaced calcaneal fractures.

Review of the radiology in randomised controlled trials in open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures

The aim of this study was to assess the radiological evaluation of all prospective, randomised, controlled trails of displaced intraarticular calcaneal fractures. A systematic review of the literature, of which only three of 296 references were randomised and controlled, were examined in a blinded fashion. All had preoperative coronal CT for Sander's classification and used a lateral surgical approach or conservative treatment. Thordason (15 patients/11 controls) used interoperative lateral and axial X-rays. Bohler's angle increased on average from 11 to 26 degrees (P<0.001) postoperatively, but decreased (9-8 degrees ) in the conservative group. The posterior facet residual displacement was 1.1 and 4.7 mm, respectively. O'Farrell (12 patients/12 controls) showed 8 out of 12 had Bohler's and Gissane's angle partially or fully restored postoperatively, and not conservatively. Parmar (25 patients/31 controls) used preoperative lateral radiographs, but failed with CT to grade the postoperative reduction, whilst the conservative group was unaltered. There was no systematic, blinded assessment of the change in radiology by the operative intervention. Overall there was weak evidence to support ORIF. In conclusion, there are only three randomised, controlled studies involving small numbers of patients, which showed improved plain radiographic anatomical alignment, in the postoperative but not conservative group. Further prospective randomised, controlled trials with independent and blinded assessment with accurate CT and clinical evaluation will be required before ORIF can be adopted as the best practice.

Calcaneus fractures with subluxation of the posterior facet. A surgical indication

The charts and radiographs of 118 patients with 126 intraarticular fractures of the calcaneus were reviewed retrospectively. Eleven of 126 (8.7%) calcaneal fractures had injuries consisting of intraarticular calcaneal fracture, lateral subluxation or dislocation of the posterior facet, fracture extension into the calcaneocuboid joint, peroneal tendon subluxation, subluxation of the talus in the ankle mortise, and complete disruption of the anterior talofibular and calcaneal fibular ligaments or fracture of the lateral malleolus. There were six women and five men. The average age was 40 years (range, 17-65 years). The mechanism of injury was a motor vehicle accident in eight and a fall from a height in three. According to the classification of Sanders et al eight fractures were Type II, one was Type III, and two were Type IV. Followup at an average of 26 months (range, 14-38 months) showed that eight of 11 patients (72.7%) had either good or excellent results. When lateral subluxation of the posterior facet of the calcaneus is identified with a preoperative computed tomography scan, operative management is indicated, and the surgeon should search for associated injuries that should be addressed at the time of surgery.

Internal architecture of the calcaneus: implications for calcaneus fractures

STUDY DESIGN

Fourteen cadaveri specimens were sectioned to analyze the internal architecture of the human calcaneus. We described the arrangement and orientation of trabecular patterns within the calcaneus and made multiple measurements of its cortical thickness.

OBJECTIVE

To characterize the internal architecture of the calcaneus and correlate these findings with well-described patterns of calcaneus fracture in order to better understand the fracture mechanics of this common fracture.

METHODS

Fourteen dry, frozen, human calcanei were sectioned using a saw. In each the coronal, sagittal and axial planes, we sectioned separate specimens into slices of 0.5 mm thickness. High-resolution radiographic images were taken of the sectioned specimens. The internal trabecular arrays were described and measurements of cortical thickness were recorded. The correlation between these findings and the known pattern of calcaneal fractures was analyzed.

RESULTS

A dominant trabecular pattern running antero-posteriorly along the long axis of the calcaneus was observed. In the posterior tuberosity the trabeculae were arranged parallel to the posterior border. There was an area of sparse or absent mineralization in the anterior part of the calcaneus corresponding to the "neutral triangle" described by Wood and Harty 10, 23. The thickest sites of the calcaneal cortex were the lower pole of the posterior tuberosity, the upper surface at the angle of Gissane, and the lateral surface below the anterior portion of the posterior facet.

CONCLUSION

The trabecular architecture of the calcaneus is created by applied stress in concordance with Wolff's law. The weakest plane of resistance to stress is parallel to these organized trabeculae or through areas lacking trabeculae. This study demonstrates that the primary and secondary fracture lines commonly encountered in calcaneus fractures correlates with the internal architectural map of the calcaneal trabecular patterns.