Endoscopic excision of symptomatic nonunion of anterior calcaneal process

Factors influencing functional outcome of fractures of the anterior process of the calcaneus

INTRODUCTION

Fractures of the anterior process of the calcaneus (APC) are easily overlooked in clinical practice. Most patients have good to excellent clinical outcome after conservative treatment, while some patients may have persisting symptoms and unfavorable functional outcomes. The aim of this study was to identify the risk factors associated with unfavorable functional outcome after conservative treatment in APC fractures.

METHODS

All patients presenting with APC fractures and receiving conservative treatment from April 2019 to April 2020 were retrospectively assessed. The primary outcome measurement was the ankle joint function assessed using Karlsson Scoring System at 2 years post-injury. The risk factors associated with unfavorable functional outcomes (Karlsson score ≤ 80) were evaluated by logistic regression analysis.

RESULTS

In total, 84 patients were included with a mean age of 40 years. 26 (31%) patients presented with unfavorable functional outcome at 2 years post-injury. In multivariate logistic regression, concomitant fractures of talonavicular (TN) joints and older age were significantly associated with unfavorable functional outcome (p<0.05). Patients with concomitant fractures of TN joints had an odds ratio of 3.623 for unfavorable functional outcome. The optimal cutoff age for an unfavorable outcome was ≥ 47.5 years, with an odds ratio of 5.010.

CONCLUSION

Most patients with APC fractures achieved good to excellent results when treated conservatively. Attention should be paid to those with concomitant fractures of TN joints and with age ≥ 47.5 years, which might lead to unfavorable functional recovery.

LEVEL OF EVIDENCE

IV; case series.

Lateral endoscopy of the sinus tarsi: Anatomy, technique and current indications

Numerous pathologies are reported in the lateral mid- and hind-foot. Access to the sinus tarsi is difficult, making lateral endoscopy the preferred approach. The present technical note describes the anatomy, technique and current indications for lateral endoscopy of the sinus tarsi.

Introduction of a modified Degan classification to specify treatment algorithms in fractures of the anterior process of the calcaneus

BACKGROUND

Fractures of the anterior process of the calcaneus are often missed, and their treatments and results receive little attention in the current literature. The aim of this study was to specify treatment algorithms through a modification of the Degan classification.

METHODS

Between 2009 and 2019, patients with APC fractures were retrospectively analyzed. The Degan classification was used and modified. Type III fractures were further divided into subgroups A (not displaced) and B (displaced). The type of treatment and complications were recorded. Return to work and posttraumatic osteoarthritis were determined as primary and secondary outcome parameters, respectively.

RESULTS

Forty-one patients with 43 fractures were included. Follow-up averaged 35,5 months (range 1,5-152 months). Fractures were eight type I, six type II, 15 type IIIA and 14 type IIIB. The fracture was initially recognized in 29 (70,7%) patients, and missed in 12 (29,3%) patients, respectively. Overall, the delayed diagnosed fractures had a significantly higher complication rate (p < 0,000) than the initially diagnosed fractures and received surgical treatment significantly (p < 0,009) more often. After surgical treatment of 13 type IIIB, one nonunion occurred. Six missed type IIIA fractures were treated surgically after delayed diagnosis because of persistent symptoms. Two type I fractures required arthrodesis of the Chopart joint. Four patients did not return to work during the follow-up (3 missed type IIIA fractures, 1 type II fracture).

CONCLUSION

Missed APC type IIIA fractures are at risk to develop complications, which is why computed tomography diagnostics should be performed if there is any clinical suspicion.

Arthroscopic Resection of Too-Long Anterior Process (TLAP) of the Calcaneus, Anterior Subtalar Synovectomy, Debridement of the Sinus Tarsi, and Posterior Subtalar Adhesiolysis Via Anterolateral Subtalar and Dorsolateral Midtarsal Portals

Lateral heel pain can have numerous causes and many of them are intra-articular pathologies of the anterior and posterior subtalar joint. Frequently, there is not a single pathology that account for the lateral heel pain and combination of different pathologies can occur. Symptomatic too-long anterior process of the calcaneus, sinus tarsi syndrome, and subtalar arthrofibrosis can be precipitated by repeated sprain. Cases recalcitrant to conservative treatment are indicated for surgery. The purpose of this Technical Note is to report a 2-portal arthroscopic approach to address these pathologies.

Arthroscopic Debridement and Microfracture of Osteochondral Lesion of the Talar Head

Osteochondral lesions of the talar head can be classified into 4 types according to their location. A type 1 lesion is located at the anterior part of the talar head. Surgical debridement and microfracture are indicated for symptomatic type 1 lesions if conservative treatment fails to relieve the pain. The purpose of this technical note was to describe the details of arthroscopic debridement and microfracture of the symptomatic type 1 osteochondral lesion of the talar head and the kissing lesion at the navicular bone. The procedure is performed through the standard portals of talonavicular arthroscopy and has the advantages of minimally invasive surgery of better cosmetic results and less surgical trauma.

Fractures of the anterior process of the calcaneum; a review and proposed treatment algorithm

BACKGROUND

There remains a lack of recognition of these fractures, which leads to a delay in diagnosis and appropriate management.

METHODS

A comprehensive literature search was performed. Following inclusion and exclusion criteria, 23 studies were available for analysis.

RESULTS

Delay in diagnosis is common and has a negative impact on outcome. If an APC fracture is suspected; anteroposterior, lateral and oblique plain radiographs should be requested. Further investigation with computed tomography or magnetic resonance imaging is indicated if plain radiographs are inconclusive and patient remains symptomatic. Non-operative measures are usually adequate for most undisplaced fractures, however surgical intervention maybe required for large, intra-articular fractures in the acute setting and for non-union.

CONCLUSIONS

A treatment algorithm is suggested that may help with the diagnosis and management of these injuries.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic and Endoscopic Management of Common Complications After Displaced Intra-Articular Calcaneal Fractures

The list of late complications after calcaneal fracture that can be treated through arthroscopic and/or endoscopic approach continues to expand. The late complications of calcaneal fractures can be classified into 3 groups: (1) those causing focal hindfoot or ankle pain, (2) those causing functional deficit, and (3) those present with diffuse and poorly localized pain. Many group 1 and some group 2 complications can be managed arthroscopically and/or endoscopically. There are usually multiple coexisting sources of the pain. Careful evaluation and analysis of a problem and detailed surgical planning with combination of arthroscopic/endoscopic and open procedures are key to success.

Arthroscopic Management of Osteochondral Lesion of Plantar Medial Talar Head

Osteochondral lesions of the talar head can be classified into 4 types: type 1 is located at the anterior part of the talar head, type 2 is at the plantar side of the talar head, type 3 is at the plantar lateral side of the talar head, and type 4 is at the plantar medial aspect of the talar head. The purpose of this Technical Note is to describe the details of arthroscopic management of an osteochondral lesion of the plantar medial talar head. It includes arthroscopic synovectomy of the medial recess of the anterior subtalar joint, debridement, and microfracture of the osteochondral lesion.

Endoscopic resection of symptomatic os calcaneus secundarius

Os calcaneus secundarius is an accessory ossicle resulting from a secondary ossification center of the anterior facet of the calcaneus. It may cause chronic pain and limitation in inversion motion after inversion ankle sprain. Excision of the ossicle is indicated if the symptoms do not resolve with conservative treatment. A case of symptomatic os calcaneus secundarius, which was successfully resected endoscopically, is presented.

Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer

The midtarsal (Chopart) joint complex consists of the talonavicular and calcaneocuboid joints and their stabilizing ligaments. Detailed assessment of this complex at MRI can be challenging owing to frequent anatomic variation and the small size of the structures involved. Nevertheless, a wide spectrum of pathologic conditions affect the joint complex, and its imaging evaluation deserves more thorough consideration. This review focuses on MRI evaluation of normal ligamentous anatomy and common variations about the Chopart joint, presenting practical imaging tips and potential diagnostic pitfalls. Imaging findings across a spectrum of traumatic Chopart joint injuries are also reviewed, from midtarsal sprains to Chopart fracture-dislocations. Midtarsal sprains-commonly associated with ankle inversion injuries-are emphasized, along with their often predictable radiographic and MRI injury patterns. Online DICOM image stacks are available for this article. ^©RSNA, 2018.

[Fractures of the anterior process of the calcaneus-frequently overlooked injuries following ankle sprains]

Fractures to the anterior process of the calcaneus (PAC) have long been considered rare injuries and have received little attention in clinical research. On the contrary, recent studies have reported a distinct higher incidence, especially following ankle sprains. Decisive reasons are that fractures of the PAC are regularly missed on plain radiographs and that a clinical differentiation from injuries to the lateral ankle ligaments is difficult. With the broad availability of cross-sectional imaging modalities fractures of the PAC are diagnosed more frequently and more reliably. The purpose of this review is to give an overview on the diagnostics, classification and treatment recommendations to this topic and discuss the studies available. To date no evidence-based recommendations are available for the treatment of fractures of the PAC. The few case reports and case series published, predominantly recommend conservative treatment; however, the treatment regimens vary considerably, ranging from immobilization in a lower leg cast (2-10 weeks) to early functional treatment with full weight-bearing. The surgical treatment by open reduction and internal fixation has been described primarily for large dislocated fractures. Surgical excision is considered mainly in cases of persistent pain or symptomatic non-union following non-operative treatment. For both, non-operative and operative treatment, the case reports and case series report satisfactory outcomes for the majority of patients. Nevertheless, comparative studies and patient-rated outcome measures are missing. Therefore, evidence-based recommendations cannot be given.

Multiple abnormalities in the feet and associated changes elsewhere in the skeleton: The case of 3A-7 from a Capsian Site in Algeria

A skeleton with a number of abnormalities is described involving full discussion of alternative diagnoses. In this complex case, the primary diagnosis is of avulsion of the stem of the bifurcate ligament causing a fracture of the anterior process of the calcaneus. The bilateral fracture identified in Skeleton 3A-7 from Site 12, a Capsian site in Algeria, is a result of the feet being inverted and plantar flexed: the fracture is prone to non-union, which is asymmetrical here. There is also a separate anatomical variation of the feet, 3rd cuneiform and 3rd metatarsal coalition, which was not the cause of trauma. The bifurcate ligament is a major stabilizer of the lateral transverse talar joint, and the trauma could lead to further issues: however, multiple other traumatic changes in 3A-7 most likely occurred at the same time, rather than as the result of pre-existing foot trauma. The asymmetry of the calcaneal condition and asymmetry of the sequelae of the original trauma led to long bone asymmetry, the result of locomotor difficulties.

Arthroscopic Resection of Too-Long Anterior Process of the Calcaneus

A too-long anterior process (TLAP) of the calcaneus is an elongated anteromedial process of the calcaneus impinging the navicular or the talar head. TLAP can cause recurrent ankle sprain, peroneal muscle spasm, or persistent tarsal pain in adolescents. Arthroscopic resection is indicated if the symptoms do not respond to conservative treatment. It has the advantage of assessment of completeness of bone resection and treatment of associated lesions of the adjacent joints. The purpose of this technical note is to report an arthroscopic approach of the resection of the TLAP with the lateral midtarsal portal as the viewing portal.

Resection of Small Avulsion Fractures of the Anterior Process of the Calcaneus for Refractory Complaints

Minor injuries of the anterior process of the calcaneus occur frequently and most heal uneventfully. The present series reports on 6 patients with persistent complaints after anterior process avulsion fractures. The avulsed fragments of the anterior process at the calcaneocuboid joint were surgically excised in all, which resolved the complaints completely in 4 patients and reduced the complaints significantly in 2. If conservative measures fail and the complaints are refractory, debridement of the anterior process avulsion fractures at the calcaneocuboid joint could be a viable option.

Small joint arthroscopy in foot and ankle

The clinical application of small joint arthroscopies (metatarsophalangeal joint, Lisfranc joint, Chopart joint, and interphlangeal joint) in the foot has seen significant advancements in the past decades. This article reviews the clinical indications, technical details, outcomes, and potential complications of small joint arthroscopies of the foot.

Stress fracture of the anterior process of the calcaneus: a case report

Stress fracture of the anterior process of the calcaneus is rare. We present a case of a 14-year-old female basketball player who suffered a stress fracture of the anterior process of the calcaneus that was not associated with a calcaneonavicular coalition. After conservative treatment failed, drilling of the fracture site was required to facilitate healing. A possible cause of this rare type of stress fracture seemed to be a long anterior process of the calcaneus.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Case study.

Arthroscopic management of late complications of calcaneal fractures

PURPOSE

To review retrospectively the results of arthroscopic management of late complications of calcaneal fractures.

METHODS

Fifty patients (32 males, 18 females) with late complications of calcaneal fractures were managed arthroscopically. The median age at the time of arthroscopic surgery was 45 (19-63) years old. Detailed history taking, physical examination, standing lateral radiograph of the foot and axial view of the calcaneus and computed tomogram study were performed in all of the patients in order to identify the sources of symptoms. The arthroscopic treatment was then planned accordingly. The patients were assessed according to the AOFAS ankle-hindfoot score and the standing radiographs of the foot and ankle, both preoperatively and at the latest follow-up consultation.

RESULT

A median of 1 arthroscopic procedure was performed for each patient (range, 1-4). The median follow-up after the latest arthroscopic surgery was 49 (range, 24-85 months) months. In all of the cases, the symptoms improved after the arthroscopic surgery and all the arthrodesis sites healed. The overall median preoperative AOFAS ankle-hindfoot score was 60.5 (27-75). The overall median AOFAS ankle-hindfoot score at the time of latest follow-up was 90 (73-100).

CONCLUSIONS

The arthroscopic approach focuses on the patient's symptoms. It is a feasible approach to alleviate patient's symptoms. Detailed history taking and clinical examination to determine the sources of the patient's symptoms are the keys to success.