Outcome of Percutaneous Fixation of Calcaneal Fractures: A Prospective Analysis in an Indian Population

Extensible lateral approach versus sinus tarsi approach for sanders type II and III calcaneal fractures osteosynthesis: a randomized controlled trial of 186 fractures

AIMS

Which is the best extensile lateral (ELA) or sinus tarsi (STA) approach for osteosynthesis displaced intraarticular calcaneal fracture (DIACF) is still debatable. The current RCT's primary objective was to compare the complications incidence after open reduction and internal fixation of DIACFs through STA vs. ELA. The secondary objectives were the differences in intraoperative radiation exposure, time to fracture union, functional and radiological outcomes.

METHODS

Between August 2020 and February 2023, 157 patients with Sanders type II and III fractures were randomly assigned to either ELA (81 patients with 95 fractures) or STA (76 patients with 91 fractures). The primary outcome was the incidence of complications. The secondary outcomes were Böhler's and Gissane angles angle, fracture union, and American Orthopaedic Foot and Ankle Society (AOFAS) score.

RESULTS

No statistical differences between both groups regarding basic demographic data, injury characteristics, and fracture classification; however, patients in the STA group were operated upon significantly earlier (4.43 ± 7.37 vs. 7 ± 6.42 days, p = 0.001). STA's operative time was significantly shorter (55.83 ± 7.35 vs. 89.66 ± 7.12 min, p < 0.05), and no statistical difference regarding intraoperative radiation exposure. The time to fracture union was significantly shorter in STA (6.33 ± 0.8 vs. 7.13 ± 0.7 weeks, p = 0.000). Skin complications (superficial or deep infection) and Subtalar osteoarthritis were significantly higher in ELA (18.9% vs. 3.3%, p = 0.001) and (32.6% vs. 9.9%, p = 0.001), respectively. The radiological parameters were significantly better in STA postoperatively and at the last follow up. The AOFAS scores were significantly better in STA (83.49 ± 7.71 vs. 68.62 ± 7.05, respectively, p = 0.000).

CONCLUSION

During osteosynthesis of Sanders type II and III DIACFs, STA is superior to ELA in terms of operating earlier, shorter operative time, fewer complications, and better radiological and functional outcomes.

Postoperative complications after displaced intra-articular calcaneal fracture operations

BACKGROUND

The objective was to compare postoperative complications in the management of displaced intra articular calcaneal fractures (DIACF) between two groups; the open reduction and internal fixation (ORIF) group versus the percutaneous fixation (PF) group.

METHODS

A total of 243 DIACFs were diagnosed and 127 of them received operations either with ORIF 75 (59.1 %) or PF 52 (40.9 %) between 2004 and 2018. Postoperative complications, radiological Sanders's classification and improvement of Böhler's angle were analyzed.

RESULTS

Early complication rate (<6 weeks), rate of deep wound infections and wound edge necrosis were significantly better in PF than in ORIF patient group. There were no significant differences in late complications (>6 weeks from operation) nor in improvement of Böhler's angle.

CONCLUSION

Complication rate is lower when using PF technique while fracture reduction remains the same compared to the ORIF.

LEVEL OF EVIDENCE

IV retrospective cohort study at a single institution.

Comparison of the Outcomes of Plating, Screw Fixation, and Pinning in Sanders Type II Fractures: A Multicenter (TRON) Retrospective Study

Calcaneus fractures Sanders type II have been historically treated with various modalities. However, few studies compared these procedures directly. The multicenter (TRON group) retrospective study compared the radiographic and clinical outcomes of operative procedures using Kirschner wires (K-wires), cannulated cancellous screws (CCSs) and plates. Between 2014 and 2020, 121 patients with Sanders type II calcaneus fractures were surgically treated in our group using K-wire (Group K: n = 31), CCS (Group C: n = 60) or plate (Group p: n = 30) fixation. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score and infection after operation as clinical outcomes and Böhler's and Preiss' angles as radiographic outcomes. The AOFAS scores of the 3 groups showed a significant difference, with Group P showing significantly inferior scores to Group C at 6 months postoperatively and at the final follow-up examination (p = .015 and p < .001, respectively). The rate of infection did not differ to a statistically significant extent, but the incidence in Group P tended to be higher in comparison to the other groups. Among the three groups, Böhler's angle did not differ to a statistically significant extent immediately after the operation (p = .113) or at the final follow-up examination (p = .383). Postoperatively, Preiss' angle did not differ to a statistically significant extent (p = .251) but was significantly smaller in the Group C at the final follow-up examination (p = .0331). In Sanders type II calcaneus fracture, CCS fixation may obtain the best functional outcomes.

Evaluation of the result of articular facet reduction and intraoperative distraction for sanders type iv calcaneal fracture n polytraumatized patients

OBJECTIVE

Aim: The aim of this study is to evaluate the results of combined repositioning - open repositioning of the depressed articular facet combined with intraoperative two-vector distraction of the calcaneus with a new external fixation distraction apparatus and osteosynthesis with a calcaneal plate with angular stability of a Sanders IV type fracture..

PATIENTS AND METHODS

Materials and Methods: This study evaluates the results of sequential two-vector distraction with a repositioning apparatus for open reduction and internal fixation (ORIF) of a Sanders IV calcaneal fracture. The method was applied in the treatment of 25 patients with polytrauma with 30 Sanders IV calcaneal fractures treated in Astana multiprofile hospital No. 1 and National Scientific Centre of Traumatology. 1 and National Scientific Centre of Traumatology and Orthopaedics named after academician N.D. Batpenov (Republic of Kazakhstan) from 2018 to 2022.

RESULTS

Results: At final examination, the values of Bohler angle, Gissane, posterior articular facet tilt, width, height, and length of the calcaneus were significantly higher (p<0.001) preoperative values and were identical to postoperative values.

CONCLUSION

Conclusions: The mean VAS pain score was 2.14 (standard deviation 1.08 and range 1.5-5.5). The mean clinical outcome score on the AOFAS was 92.8 points (SD 5.7, range 74-97). Two-vector distraction of the calcaneus with external fixation apparatus in ORIF of Sanders IV type intra-articular fracture is an effective method of repositioning a three-dimensional deformity of the calcaneus.

Minimally Invasive Reduction of Intraarticular Calcaneal Fractures With Percutaneous Fixation Using Cannulated Screws Versus Kirschner Wires: A Retrospective Comparative Study

BACKGROUND

Several minimally invasive techniques were developed for management of intraarticular calcaneal fractures. This study aimed to compare the functional and radiological outcomes of 2 minimally invasive reduction and fixation techniques using cannulated screws or Kirschner wires (K-wires) for fixation.

METHODS

This study was a retrospective comparative review of patients with displaced intraarticular calcaneal fractures, who were treated with cannulated screws or K-wires techniques. Clinical and radiological data were collected and compared between both groups. Functional outcomes and patient satisfaction using the Maryland Foot Score (MFS) and the visual analogue scale (VAS) of pain, in addition to the complications, were compared between both groups.

RESULTS

In total, 70 patients were included in the study: 34 in the cannulated screws group, with a mean age of 35.2 ± 4 years, and 36 in the K-wires groups, with a mean age of 33.4 ± 3 years. The operative time was shorter in the K-wires group (40.5 ± 5.6 minutes) compared to the cannulated screw group (49.5 ± 4.5 minutes), P < .001. There were no statistically significant differences between both groups regarding the radiological parameters, including Bohler's angle, angle of Gissane, calcaneal width, height, or length. The mean MFS, mean VAS, and complications were not different between the 2 groups.

CONCLUSION

Treatment of displaced intraarticular calcaneal fractures with minimally invasive reduction and fixation using either cannulated screws or K-wires can achieve similar excellent functional and radiological outcomes, with high patient satisfaction. The use of K-wires has the advantage of reduced operative time than cannulated screws.

LEVELS OF EVIDENCE

Level III: Retrospective comparative study.

A prospective comparative study between percutaneous cannulated screws and Kirschner wires in treatment of displaced intra-articular calcaneal fractures

Purpose

Several minimally invasive procedures were used to treat displaced intra-articular calcaneal fractures (DIACFs). No agreement among different authors about either the ideal fixation method or which technique is minimally invasive. The aim of this study was to compare functional and radiographic outcomes of two minimally invasive techniques in treatment of Sanders type II and III DIACFs by using K-wires or cannulated screws without bone grafts.

Methods

A prospective randomized controlled study was conducted on 28 patients (34 feet) with Sanders type II or III DIACFs, treated by closed reduction and fixation using cannulated screws or K-wires, at the Orthopedics Department of Sohag University Hospital, between April 2020 and February 2022. Functional assessment was done by American Orthopedic Foot and Ankle Society (AOFAS) score and VAS for pain. Radiographic assessment was done by measurement of three calcaneal angles (Gissane, Böhler’s, and posterior facet inclination angles) and three calcaneal distances (height, length, and width of the calcaneus).

Results

Mean ages of patients at the time of operation were 34.8 years for the cannulated screw group and 36.6 years for the K-wire group. A vast majority of patients were males (78.6%). Involvement of the right side in the cannulated screw group was 57.1% and that in the K-wire group was 47.9%. Mean operative time was significantly shorter among the K-wire group (42 min) compared to the cannulated screw group (57 min). Mean AOFAS score was higher among the cannulated screw group (85.9 points) compared to the K-wire group (75.8 points). Final VAS was significantly better among the cannulated screw group compared to the K-wire group. Mean time of radiographic union in the cannulated screw group was 8.9 weeks and that in the K-wire group was 10.1 weeks.

Conclusion

Both techniques avoided wound complications associated with ORIF with the advantage of a shorter hospital stay. Patients in the cannulated screw group had better functional and radiographic outcomes and a lower rate of subtalar arthritis than patients in the K-wire group. K-wires had advantages of reduced operative time, and easy removal as an outpatient procedure.

Percutaneous Cannulated Screw Fixation vs. Plating With Minimally Invasive Longitudinal Approach After Closed Reduction for Intra-Articular Tongue-Type Calcaneal Fractures: A Retrospective Cohort Study

Objective

Displaced intra-articular tongue-type fractures are often treated with surgical interventions, and there is a lack of consensus regarding the surgical approach. This retrospective cohort study aimed to compare percutaneous cannulated screw (PCS) fixation and plating with a minimally invasive longitudinal approach (MILA) after closed reduction for the treatment of tongue-type calcaneal fractures.

Materials and Methods

A total of 77 patients with intra-articular tongue-type calcaneal fractures between September 2015 and July 2019 were included in this study. They were randomly allocated into two groups: PCS fixation (n = 32) and MILA (n = 45). The outcome measures included demographic variables, operation time (OT), preoperative time (POT), hospital stay time (HST), blood loss, visual analog scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, postoperative complications, and imaging parameters. The patients were clinically examined at 1, 3, 6, and 12 months, with a final follow-up period of 27 months.

Results

No significant differences were observed during the follow-up in calcaneal length, height, Gissane's and Böhler's angles, VAS scores, AOFAS hindfoot scores, or complication rates between the two groups. However, the postoperative VAS scores in the PCS group were significantly lower than those in the MILA group (p < 0.05). Furthermore, the OT, POT, and HST in the PCS group were significantly shorter than those in the MILA group (p < 0.05). Blood loss was lower in the PCS group than those in the other group (p = 0.044). However, postoperative calcaneal widening was significantly smaller in the MILA group than that in the PCS group (p < 0.001).

Conclusions

After closed reduction for the treatment of tongue-type calcaneal fractures, PCS fixation was superior to MILA in terms of OT, POT, HST, blood loss, pain, and degree of comfort. Meanwhile, MILA has the advantage of restoring the calcaneal width. Under the same rehabilitation program, the two approaches showed similar abilities in maintaining the closed reduction.

Osteosynthesis or primary arthrodesis for displaced intra-articular calcaneus fractures Sanders type IV - A systematic review

BACKGROUND

Displaced intra-articular calcaneus fractures (DIACF) Sanders type IV represent a challenge in its management and questions remain about the best treatment option available. This study aimed to compare the outcomes of primary subtalar arthrodesis (PSTA) and osteosynthesis in these fractures.

METHODS

Studies concerning DIACF Sanders type IV, from 2005 to 2020 were systematically reviewed. Only studies evaluating functional outcomes with American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS) score were admitted allowing for results comparison.

RESULTS

In total, 9 studies met the inclusion criteria. These reported on the results of 142 patients, from which 41 submitted to PSTA and 101 to osteosynthesis, with an average follow-up period over 2 years. We found a significant moderate negative correlation between the reported AOFAS score and the Coleman Methodology Score obtained. Late subtalar arthrodesis was 13.63% of the total osteosynthesis performed.

CONCLUSIONS

Clinical outcomes after PSTA and osteosynthesis, for the treatment of Sanders type IV fractures, do not seem very different, yet careful data interpretation is crucial. Additional powered randomized controlled trials are necessary to assess which surgical strategy is better.

Percutaneous Prodding Reduction and K-Wire Fixation Via Sinus Tarsi Approach Versus ORIF for Sanders Type III Calcaneal Fractures: A Prospective Case-Controlled Trial

We conducted a prospective randomized controlled trial to compare the radiological and clinical outcomes of Sanders type III calcaneal fractures treated with percutaneous prodding reduction and K-wire fixation via a sinus tarsi approach (PPRKF) versus open reduction and internal fixation (ORIF). Fifty-one patients with closed, unilateral, Sanders type III calcaneal fractures were randomly assigned to the PPRKF group (n = 26) or the ORIF group (n = 25). The clinical outcomes evaluated were time to surgery, blood loss, operative time, hospital stay, wound healing time, wound complications, and Maryland foot score. Radiological results were evaluated on lateral and axial X-rays and computed tomography images and included Böhler's angle, Gissane's angle, and calcaneal width. Compared with the ORIF group, the PPRKF group had shorter time to surgery, shorter operative time, less blood loss, shorter hospital stay, shorter wound healing time, and fewer wound complications (p < .001). The postoperative Böhler's angle, Gissane's angle, and calcaneal width in both groups were significantly better than those measured preoperatively (p < .001) and did not differ between the PPRKF group and ORIF group (p> .05). Regarding clinical results, there was no significant difference in Maryland foot score between the two groups at 12 months after surgery (p > .05). Both PPRKF and ORIF can result in satisfactory clinical function. PPRKF is superior to ORIF in reducing the time to surgery, operative time, blood loss, hospital stay, wound healing time, and wound complications.

Outcome of Minimally Invasive Osteosynthesis for Displaced Intra-articular Calcaneal Fractures Using Cannulated Screws: A Prospective Case Series

This prospective study sought to assess the functional and radiological outcomes of minimally invasive osteosynthesis using cannulated screws and to examine the effect of different parameters on the functional outcome. The Maryland foot score and the visual analog scale of pain were used to assess the functional outcomes and postoperative patient's satisfaction rate. Preoperative and postoperative Böhler's angle, angle of Gissane, calcaneal width, and height, were compared. The study included 46 fractures in 40 patients; 38 (95%) males and 2 (5%) females with a mean age of 34.8 ± 3 years. The mean time lapse to surgery was 3.2 ± 2.1 days. The mean duration of surgery was 39.8 ± 9.3 minutes. The mean follow-up period was 29.2 months. At final follow-up, the mean Maryland foot score was 85 ± 6.3. Satisfactory results were achieved in 91.3% of fractures, while unsatisfactory in 8.7%. The mean visual analog scale score of pain decreased from 7.3 ± 05 preoperatively to 1.2 ± 0.7 at the final follow-up, p <.001. Postoperatively, there was significant improvement of Böhler's angle, angle of Gissane, calcaneal width, and height, p < .001. Factors associated with better functional outcomes included reduced time lapse to surgery, p = .032, and more accurate restoration of the calcaneal parameters. Management of intra-articular calcaneal fractures by minimally invasive osteosynthesis using cannulated screws can achieve satisfactory functional and radiological outcomes. Better outcomes are associated with reduced time lapse to surgery, and accurate reduction and restoration of calcaneal angles, height, and width.

Evaluation of the short-term results of closed reduction and percutaneous K-wires fixation of displaced intra-articular calcaneal fractures (DIACF)

PURPOSE

Optimum management of displaced intra-articular calcaneal fractures (DIACF) still controversial. Open surgery carries the risk of wound complications, while non-operative management has a high incidence of arthrosis. To avoid these complications, minimally invasive and percutaneous fixation was introduced. The purpose of this study was to prospectively evaluate the short term clinical and radiological outcomes after closed reduction and percutaneous fixation of DIACF using K-wires.

PATIENTS AND METHODS

Outcomes of twenty patients were evaluated at the final follow up. A functional assessment using the AOFAS scoring system. Radiological parameters recorded included three angles (Böhler's, Gissane and posterior facet inclination angles) and three distances (calcaneal length, height and width). Any complications were reported at any follow-up.

RESULTS

The mean patient's age was 33 ± 15.2 years, 8 (40%) patients with type II fractures, 10 (50%) patients with type III fractures, and 2 (10%) with type IV fracture according to Sanders classification. After a mean follow-up of 9 months, the mean AOFAS score was 84, excellent in 9 patients (45%), good in 9 (45%), and fair in 2 (10%). At the final follow-up the Böhler's angle, Gissane angle and PFIA was 25.1° ± (5.2), 119.9° ± (9.4) and 51.7° ± (5.9) respectively and the calcaneal height, length and width was 41.8 mm ± (2.1), 75.1 mm ± (3.01) and 40.9 mm ± (2.6) respectively. We had no cases of deep infection, 20% had significant subtalar arthritis.

CONCLUSION

The closed reduction and percutaneous fixation technique for DIACF management offered acceptable clinical and radiographic outcomes, with fewer complications when compared to other management options.

Clinical and Radiological Outcomes of Minimally Invasive Reduction and Percutaneous K-wire Fixation for Intra-articular Calcaneal Fractures

There has been much controversy over the optimal operative treatment of intra-articular calcaneal fractures. Open reduction and internal fixation is associated with a high incidence of postoperative soft tissue complications. This study sought to evaluate the outcomes of indirect reduction and percutaneous K-wire fixation for displaced intra-articular calcaneal fractures. This was a prospective study of 40 consecutive patients with 44 Sanders type II or III intra-articular calcaneal fractures who had undergone closed or mini-open reduction and percutaneous K-wire fixation from 2013 to 2016. The Maryland Foot Score and visual analog scale score for pain were used to assess functional outcomes and postoperative patient satisfaction. Twenty-two patients were men and 18 patients were women, with a mean age of 34.5 years. According to the Sanders classification, 26 fractures were type II and 18 were type III. Mean follow-up was 31.9 months. The clinical outcome was satisfactory for 36 fractures (81.8%) and unsatisfactory for 8 fractures (18.2%). Mean time of radiological union was 8.7 weeks. Mean full weight-bearing time was 13 weeks. Mean visual analog scale score was 1.4 when radiographic fracture healing was detected. Repeated follow-up radiographs showed no loss of reduction or collapse of the posterior facet. Closed or mini-open reduction and percutaneous K-wire fixation of Sanders type II or III calcaneal fractures has excellent functional outcomes with minimal soft tissue complications. [Orthopedics. 2020; 43(2): 97-101.].