Complications of intraarticular calcaneal fractures

Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform

INTRODUCTION

The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures.

METHODS

This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type.

RESULTS

A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels.

CONCLUSIONS

Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

Current Management of Intra-Articular Calcaneal Fractures

Intra-articular calcaneal fractures are debilitating injuries that can result in a dramatic effect on quality of life post-injury. Surgical intervention is generally advised when significant displacement or comminution is present but can present a host of complications secondary to the limited blood supply and fragility to the soft tissues following injury. Surgical approaches to calcaneal fractures generally include the lateral extensile approach, minimal incision (sinus tarsi approach), or percutaneous approach. Each approach presents risks and benefits; therefore, determining the optimal incisional approach should be based on patient comorbidities, fracture pathoanatomy, soft tissue envelope concerns, and patient pre-injury functional status.

Minimally invasive technique for acute fixation and subtalar fusion of displaced intra-articular calcaneus fractures

Displaced intra-articular calcaneus fractures (DIACFs) are difficult injuries to treat and are often encountered by orthopedic surgeons. For DIACFs treated nonoperatively or with open reduction internal fixation (ORIF), a common complication is painful subtalar arthritis and the need for a secondary subtalar fusion, which prolongs the overall recovery time. One treatment option to address this sequela involves ORIF with subtalar fusion as the primary treatment. We describe a reproducible, minimally invasive surgical technique for primary ORIF with subtalar fusion when the calcaneal tuberosity is amendable to cannulated screw fixation to treat these complex calcaneal fractures. Our technique offers advantages compared to other techniques in that it avoids screw traffic, allows easy bony compression of the subtalar joint, and minimizes soft tissue damage via percutaneous screw fixation. Fourteen fractured calcanei in 12 patients underwent our technique and all achieved bony union with a median time to fusion of 107.5 days (range, 54-530 days). Eight patients returned to work with the remaining 4 patients having an unknown work status at last follow-up, although 2 of these 4 patients resumed normal activities. Only 1 patient experienced a complication, which was an infection after achieving bony union, and was treated with successful hardware removal and our infection protocol. Overall, we conclude our surgical technique offers a successful option in the treatment of DIACFs when the calcaneal tuberosity is amendable to cannulated screw fixation.

Functional outcomes after intramedullary nailing (C-Nail®) of severe calcaneal fractures with mean follow-up of 36 months

PURPOSE

Calcaneal fractures (CFs) are rare but potentially debilitating injuries. Apart from the open, far lateral or sinus tarsi approach, operative treatment can be performed minimally invasive and percutaneously with intramedullary nailing. In this study, we sought to investigate the functional outcome of severe CFs treated with the C-Nail® implant.

METHODS

Twenty-two CFs (9 × Sanders III and 8 × Sanders IV), operated between 2016 and 2019, were followed up with a mean duration of 36 (± 11) months. The AOFAS score, pre- and postoperative Böhler angles, wound healing disorders, and patient-reported outcome measures (PROMs) like pain levels and return to work/sport levels were assessed.

RESULTS

The mean AOFAS score was 72.0 (± 9.8). Four patients sustained wound healing disorders, yet no implant-associated surgical revision was required. Fifty percent of patients were pain-free within 1 year. Within 1 year, about 50% of the patients could return to sports, and about 80% of the patients could return to work. PROMs and functional results align with those from other implants reported in the literature.

CONCLUSION

Intramedullary nailing of severe CFs with the C-Nail® implant can be considered a safe treatment alternative that yields acceptable results at mid-terms.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

The impact of sustentaculum tali fracture on clinical outcome in patients affected by isolated calcaneal fractures

INTRODUCTION

The sustentaculum tali is displaced in almost half of calcaneal fractures and during surgical fixation represents one of the main reference points upon which the other bone has to be reduced. The purpose of this study was to investigate which subtalar joint fracture pattern is more frequently associated with sustentaculum tali involvement. Furthermore, correlation between postoperative clinical outcome and sustentaculum tali integrity was performed.

MATERIAL AND METHODS

Patients with isolated calcaneal fractures were analyzed. Sanders-type fracture and involvement of both sustentaculum tali and calcaneocuboid joint were detected on computed tomography imaging; postoperative AOFAS scores were analyzed according to sustentacular involvement.

RESULTS

Fifty calcaneus fractures in 47 patients were included in the final analysis. The sustentaculum tali was fractured in 18 cases (36.0%), thus contradicting its supposed constant position. Sanders type 3 and 4 fractures were more frequently associated with fractured sustentaculum than type 2 (p = 0.012). Sanders type 4 fractures were associated with displaced sustentacular fragment significantly more than type 2 and 3 (p = 0.043). Patients with intact sustentaculum tali reported significantly higher (p < 0.001) mean AOFAS scores than the uninjured group (84.4 ± 9.1 and 74.3 ± 9.5, respectively).

CONCLUSION

Sanders type 3 and 4 fractures were more frequently associated with sustentaculum tali and/or calcaneocuboid joint involvement than simpler fractures. Injury of sustentaculum tali was related to significant worse postoperative clinical outcomes, underlying the relevance of this fragment on clinical course.

[Possibilities and limits of intraoperative 2D imaging in trauma surgery]

BACKGROUND

The two-dimensional (2D) imaging represents an essential and cost-effective component of intraoperative position control in fracture stabilization, even in the era of new three-dimensional (3D) imaging capabilities.

OBJECTIVE

The aim of the present study, in addition to a current literature review, was to examine whether the intraoperative use of 2D images leads to a quality of fracture reduction comparable to postoperative computed tomographic (CT) analysis including 3D reconstructions.

MATERIAL AND METHODS

A comparative retrospective analysis of intraoperative 2D and postoperative 3D image data was performed on 21 acetabular fractures stabilized via a pararectus approach according to an established protocol using the Matta criteria.

RESULTS

The assessment of fracture reduction in intraoperative fluoroscopy compared with postoperative CT revealed a difference only in one case with respect to the categorization of the joint step reduction in the main loading zone.

CONCLUSION

In the intraoperative use of 2D imaging for fracture treatment it is important to select the correct adjustment planes taking the anatomical conditions into account in order to achieve optimum assessability. In this way, the reduction result can be adequately displayed in fluoroscopy and is also comparable to the postoperative CT control. In addition, depending on the findings, optional intraoperative dynamic fluoroscopic assessment can have a direct influence on the further surgical procedure.

Ultrasound-Guided Hydrodissection for Sural Neuropathy After Calcaneus Fracture Surgery: A Case Report

We present a case study of a 61-year-old man who experienced sural neuropathy following calcaneus fracture surgery, which was effectively treated using ultrasound-guided hydrodissection. Postoperatively, while the patient exhibited good bony fusion, he reported pain on the lateral side of the calcaneus. Ultrasound findings did not suggest any nerve discontinuity, but localized tenderness around the sural nerve was observed. After hydrodissection using 0.09% lidocaine, the patient's pain significantly decreased. Although hydrodissection alleviated the pain, complete resolution was achieved only post plate removal and neurolysis. This study represents the first report on the efficacy of hydrodissection for postoperative sural neuropathy, suggesting its potential as an effective treatment option.

Percutaneous fixation of displaced intraarticular fractures of the calcaneus. A retrospective case series study and a review of the literature

PURPOSE

To evaluate the outcome of displaced intraarticular calcaneal fractures (DIACFs) of a case series of patients who were treated with a percutaneous fixation technique.

MATERIALS AND METHODS

Eight patients were operated for DIACFs and they were evaluated for the outcome and complications in a mean follow up of 9 months (range: 6 - 12 months). At the last follow up the AOFAS score, the Boehlers' angle and the presence of any complication were noted. The time from injury to surgery was also reported. The correlation of the AOFAS score and the development of post traumatic subtalar arthritis to the type of fracture, to the post operative Boehler's angle and to the time from injury to surgery were investigated.

RESULTS

The overall mean AOFAS (Americal Orthopaedic Foot and Ankle Society) score was 84,625 (Range: 73 - 96). The mean AOFAS score of type II and type III fractures was 87,667 and 75,500 respectively. The mean AOFAS score for fractures with a postoperative Boehler's angle of less than 10° and more or equal to 10° was 76,750 and 92,500 respectively. This difference was found to be statistically significant. The mean AOFAS score for fractures who were treated less or equal to six days and more than six days post injury was 91,250 and 78 respectively. Two out of four patients with a post operative Boehler's angle less than 10° developed post traumatic subtalar arthritis. No patient out of four for whom a Boehler's angle of more than 10° has been achieved, developed subtalar arthritis. No infection occurred in any of the patients.

CONCLUSION

Percutaneous fixation is a safe and effective way of treating DIACFs. The outcome is directly related to the quality of reduction, which is significantly dependent to the timing of surgery. The earlier the fracture is operated the better the reduction by closed means is.

A risk prediction model for postoperative recovery of closed calcaneal fracture: a retrospective study

OBJECTIVE

To explore the risk factors for postoperative recovery of closed calcaneal fracture and develop a prediction model.

METHODS

We retrospectively enrolled patients with closed calcaneal fracture from January 1, 2017 to December 31, 2020. Patients treated from 2017 to 2019 were selected as a training cohort and those in 2020 as a validation cohort. The outcome variable was the postoperative recovery evaluated by the Creighton-Nebraska calcaneal fracture scoring system. Multivariate logistic regression analysis was used to screen the risk factors of postoperative recovery. A risk prediction model was constructed in the training cohort and the corresponding nomogram was drawn. The model was validated internally using bootstrapping and externally by calculating the performance in the validation cohort.

RESULTS

A total of 659 patients with closed calcaneal fracture met the inclusion and exclusion criteria, which were divided into the training cohort (n = 509) and the validation cohort (n = 150). 540 cases (81.9%) patients recovered well after calcaneal fracture surgery. According to multivariate logistic regression analysis, female (OR = 2.525, 95% CI 1.283-4.969), > 60 years (OR = 6.644, 95% CI 1.243-35.522), surgery within 8-14 days after fracture (OR = 2.172, 95% CI 1.259-3.745), postoperative infection (OR = 4.613, 95% CI 1.382-15.393), and weight-bearing time longer than 3 months after surgery (4-6 months, OR = 2.885, 95% CI 1.696-4.907; 7-12 months, OR = 3.030, 95% CI 1.212-7.578; > 12 months, OR = 15.589, 95% CI 3.244-74.912) were independent risk factors for postoperative recovery of calcaneal fractures. The C-indices were 0.750(95% CI 0.692-0.808) in the training cohort and 0.688(95% CI 0.571-0.804) in the external validation cohort, and the C-index of internal validation was 0.715. The Hosmer-Lemeshow test showed good fitting of the model (all P > 0.05), which was consistent with the results of the calibration plots. Decision Curve Analysis indicated that the clinical effectiveness was the best when the threshold probability was between 0.10 and 0.45.

CONCLUSIONS

Patients with female, > 60 years, surgery within 8-14 days after fracture, postoperative infection, and weight-bearing time longer than 3 months after surgery are more likely to have poor postoperative recovery. The risk prediction of fracture patients through this model might be translated into clinical guidance and application. Trial registration This study was registered on the Chinese Clinical Trial Registry (Registration number: ChiCTR-EPR-15005878).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methodology

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

Results

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

Conclusion

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

Effects of Hyaluronic Acid With Intra-articular Corticosteroid Injections in the Management of Subtalar Post-traumatic Osteoarthritis - Randomized Comparative Trial

We investigated the potential of exogenous hyaluronic acid (HA) associated with corticosteroid injections to improve pain and function for the treatment of post-traumatic subtalar osteoarthritis, in comparison with isolated intra-articular corticosteroid. Twenty-five symptomatic participants (50 ± 8 years) with a minimum follow-up of 1 year after surgery for calcaneus fractures were enrolled. Participants were randomly assigned into a therapeutic group that underwent isolated corticosteroid intra-articular subtalar injection (Corticosteroid Group, n = 12) or a combination of HA plus corticosteroid (HA+C Group, n = 13). All participants underwent three repeated injections with intervals of 1 week. We assessed the visual analog scale of pain (VAS) and the AOFAS scores at 4 moments: before treatment (pre), 4-, 12-, and 24-weeks following the last injection. HA+C Group showed lower VAS at the 12th (p = .003) and 24th weeks (p = .003) and greater AOFAS at the 4th (p = 0.040), 12th (p = .014), and 24th weeks (p = .021), in comparison to Corticosteroid Group. We observed a reduction in VAS in the Corticosteroid Group only at the 4th week (p = .007), compared with pretreatment values. In the HA+C Group, VAS presented lower levels at the 4- (p < .001), 12- (p < .001), and 24 weeks (p < .001). In the Corticosteroid Group, participants presented higher AOFAS score only at the 4th week (p < .001), while in the HA+C Group, the AOFAS scores were greater at the 4th, 12th, and 24th weeks compared to baseline (p < .001). The combination of exogenous HA and corticosteroid showed greater and longer analgesic effects and function improvement in comparison with isolated intra-articular corticosteroids.

Surgeon case volume and the risk of complications following surgeries of displaced intra-articular calcaneal fracture

PURPOSE

This study aimed to address the relationship between surgeon volume and the risk of complications following surgeries of displaced intra-articular calcaneal fractures (DIACFs).

METHODS

We retrospectively reviewed the medical records and the follow-up registers for patients who underwent open reduction and internal fixation with plate/screws in our center between January 2015 and June 2020. Surgeon volume was defined as the number of surgically treated calcaneal fractures within the past 12 months, and was dichotomized on basis of the optimal cut-off value. The outcome measure was the documented overall complications within 1 year after surgery. Four logistics regression models were constructed to examine the potential relationship between surgeon volume and complications.

RESULTS

Among 585 patients, 49 had documented complications, representing an overall rate of 8.4%. The overall complication rate was 20.0% (22/111) in patients operated on by the low-volume surgeons and 5.7% (27/474) by the high-volume surgeons, with a significant difference (p < 0.001). The 4 multivariate analyses showed steady and robust inverse volume-complication relationship, with OR ranging from 3.8 to 4.4. The restricted cubic splines adjusted for total covariates showed the non-linear fitting "L-shape" or "reverse J-shape" curve (p = 0.041), and the OR was reduced until 10 cases, beyond which the curve leveled.

CONCLUSIONS

Our findings reflected the important role of maintaining necessary operative cases, potentially informing optimized surgical care management.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.

The Association of Bohler's Angle With Postoperative Pain and Gender for Displaced Intra-Articular Calcaneal Fracture, Multicenter Retrospective Study-TRON Study

A relationship between Böhler angle (BA) before or after surgery and clinical outcomes remains unclear. This retrospective multicenter cohort study aimed to compare pain and functional outcomes between a group in which the reduction angle was preserved and a group in which the reduction angle was lost during follow-up, and to clarify the risk factors leading to loss of last follow-up BA. From 2014 to 2018, 271 cases of calcaneal fractures were surgically treated at ten facilities. We divided patients into Group L (lost reduction of fracture) and Group P (preserved reduction of fracture). We matched subjects between the 2 groups according to age, sex and BA before surgery and compared American Orthopedic Foot and Ankle Society (AOFAS) score between the groups. We investigated the correlation between the amount of BA loss and postoperative pain. The factors leading to loss of last follow-up BA were examined by logistic regression analysis. Ultimately, 112 patients were eligible. After matching, each group included 38 patients. There was no difference between the 2 groups in total AOFAS score. However, the pain component of AOFAS score at 6 months and 12 months were worse in group L than in group P (p = .011, p = .031, respectively). We also showed a weak correlation between the amount of BA loss and postoperative pain. Logistic regression analysis revealed that female and BA before surgery independently predicted loss of reduction (odds ratios: 4.66, 95% CI: 1.15-18.9 and odds ratios: 0.90, 95% CI: 0.82-0.99, respectively). We clarified that reduction and preservation of BA within its normal range should lead to decrease postoperative pain. Female and lower pre-BA were risk factors leading to loss of reduction of BA in operative treatment of calcaneal fractures.

Development of the center of pressure velocity in the healing process after intra-articular calcaneus fractures

BACKGROUND

Calcaneal fractures are among the most common foot injuries and sometimes develop manifold post-surgical complications. Restricted foot movement is one of the main functional limitations which often persists during long-term rehabilitation. Therefore, it is important to quantitatively monitor the biomechanical foot mobility after calcaneal fracture from an early stage in order to achieve an optimal therapeutic treatment.

RESEARCH QUESTION

Evaluation of the Center of Pressure velocity (v_COP) in patients after intrarticular calcaneal fractures during the healing progress from three to 24 months after surgery.

METHODS

A total of 20 patients with unilateral calcaneal fracture were investigated by means of pedobarography and marker-based gait analysis at three, six, 12 and 24 months after surgery. Data for v_COP [m/s], maximum external dorsal extension moments during stance (DEmoment_stance) and tibiotalar range of motion during mid stance (MS) and terminal stance (TS) were obtained. Functional evaluation was performed using clinical examination (e.g. calf circumference measurements) and patient-reported outcome measures (SF-36).

RESULTS

When compared to the healthy side, v_COP of the injured side showed a significant reduction during MS (3 months: 48%, p < 0.001; 6 months: 13%; p = 0.040) and an significant increase during TS (3 months: 110%, p < 0.001; 6 months: 43%, p < 0.001; 12 months: 17%, p = 0.012). DEmoment_stance of the fractured foot, showed a significant increase of 80% (p < 0.001) from three to 24 months after surgery, which correlated with v_COP at three and six months after surgery (p < 0.05; v_{COP MS:} 3 months: r = 0.876, 6 months: r = 0.685; v_{COP TS:} 3 months: r = -0.554, 6 months r = -0.626).

SIGNIFICANCE

v_COP might serve as an indicator for foot mobility and function during the early healing phase after calcaneal fractures. As v_COP can be obtained by pedobarography it is more readily accessible an less costly compared to foot function obtained by marker based gait analysis.

A nomogram for predicting post-operative wound complications after open reduction and internal fixation for calcaneal fractures

The purpose of our study was to determine the risk factors for post-operative wound complications (PWCs) after open reduction and internal fixation (ORIF) for calcaneal fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from calcaneal fractures and had been surgically treated for ORIF in our institution between January 2010 and January 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of PWCs, and a nomogram model was constructed to predict the risk of PWCs. The predictive performance and consistency of the model were evaluated by the Hosmer -Lemeshow (H-L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that smoking, limb swelling, angle of incision, and CRP were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.982 (95%CI 0.97-0.99). The H-L test revealed that the normogram prediction model had good calibration ability (P = .957). Finally, we found a correlation between PWCs and smoking, limb swelling, angle of incision, and CRP after ORIF for calcaneal fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high-risk patients, as interventions could be taken early to reduce the incidence of PWCs.

Percutaneous fixation of intraarticular joint-depression calcaneal fractures with different screw configurations - a biomechanical human cadaveric analysis

PURPOSE

The aim of this study was to assess the biomechanical performance of different screw configurations for fixation of Sanders type II B joint-depression calcaneal fractures.

METHODS

Fifteen human cadaveric lower limbs were amputated and Sanders II B fractures were simulated. The specimens were randomized to three groups for fixation with different screw configurations. The calcanei in Group 1 were treated with two parallel longitudinal screws, entering superiorly the Achilles tendon insertion, and two screws fixing the intraarticular posterior facet fracture line. In Group 2 two screws entered the tuberosity inferiorly to the Achilles tendon insertion and two transverse screws fixed the posterior facet. In Group 3 two screws were inserted along the bone axis, one transverse screw fixed the posterior facet and one oblique screw was inserted from the posteroplantar part of the tuberosity supporting the posterolateral part of the posterior facet. All specimens were biomechanically tested to failure under progressively increasing cyclic loading.

RESULTS

Initial stiffness did not differ significantly between the groups, P = 0.152. Cycles to 2 mm plantar movement were significantly higher in both Group 1 (15,847 ± 5250) and Group 3 (13,323 ± 4363) compared with Group 2 (4875 ± 3480), P ≤ 0.048. No intraarticular displacement was observed in any group during testing.

CONCLUSIONS

From a biomechanical perspective, posterior facet support by means of buttress or superiorly inserted longitudinal screws results in less plantar movement between the calcaneal tuberosity and the anterior fragments. Inferiorly inserted longitudinal screws are associated with bigger interfragmentary movements.

Surgical Treatment Using Sinus Tarsi Approach with Anterolateral Fragment Open-Door Technique in Sanders Type 3 and 4 Displaced Intraarticular Calcaneal Fracture

Although various outcomes of the sinus tarsi approach have been reported, these are limited to the Sanders type 2 displaced intraarticular calcaneal fractures (DIACF) because of the limited visibility of the posterior facet joint. In this study we aimed to (1) introduce a sinus tarsi approach combined with an anterolateral fragment open-door technique that enables adequate visibility of the innermost and middle portion of the posterior facet joint, and (2) evaluate the radiographic and clinical outcomes of the patients treated with that technique. This is a retrospective case-series study performed on medical records of 25 patients who presented with the Sanders type 3 or 4 DIACF and were treated with the sinus tarsi approach. The radiologic measurements showed significant corrections of the Bohler’s angle, calcaneal width, length, height, and articular step-off in both X-rays and CTs in the last follow-up period. The mean AOFAS score was 90.08 ± 6.44 at the last follow-up. Among all the follow-up patients, two cases (8%) had acute superficial infections, and no other wound complications occurred. Therefore, we suggest that the Sanders type 3 or 4 DIACF could be successfully treated with the proposed technique with low complications and bring out effective clinical and radiologic outcomes.

Efficacy of Lesion Specific Portals in Endoscopic Treatment of Calcaneal Bone Cyst: A Case Report and Literature Review

Background: Calcaneal bone cysts rarely occur and most of them are known to be benign. Among them, simple bone cysts (SBCs) third most commonly occur in the calcaneus and of the many surgical treatment options, endoscopic curettage is recently gaining popularity among surgeons due to its advantages of minimal invasiveness and optimal visualization. As for portal placement for endoscopy, two lateral portals are considered a standard technique, but no rationale has been established for SBCs with abnormal geometry. This case report suggests an SBC with secondary aneurysmal change located outside the Ward’s triangle, as well as an appropriate endoscopic approach. Case Presentation: An 18-year-old male high school student presented with a main complaint of pain at the hind foot level for the past one year, without significant improvement from conservative treatment. An endoscopic curettage through the lesion specific two posterior portals and bone graft using allogeneic cancellous bone were performed. SBC with a secondary aneurysmal bone cyst was diagnosed on pathology. At a one-year follow-up, the patient was painless and had returned to his regular activities. Physical and radiographic examinations revealed that the lesion was completely healed without any evidence of recurrence. Conclusion: For calcaneal bone cysts located at the posterior aspect of the calcaneus, eccentrically medial and abnormally long anterior-posteriorly, we suggest an endoscopic procedure using lesion specific portals such as two posterior portals.

Novel Technique for Osteosynthesis of Tongue-Type Calcaneus Fractures in Osteoporotic Bone: A Case Report

CASE

A 75-year-old woman with osteoporosis sustained a low-energy mechanism tongue-type calcaneus fracture. Index surgical fixation with conventionally described cannulated screws was complicated by early screw pull-out despite concomitant Achilles lengthening procedure. Using a novel technique, revision fixation was performed using a 5.0-mm condyle bolt from a retrograde femoral nail system and 2 cannulated screws. She recovered uneventfully and demonstrated union at 7 months postoperatively.

CONCLUSION

Osteosynthesis of tongue-type calcaneus fractures using a condyle bolt can be a practical and readily available solution for primary and revision scenarios in osteoporotic tongue-type calcaneus fractures.

Biomechanical analysis of minimally invasive crossing screw fixation for calcaneal fractures: Implications to early weight-bearing rehabilitation

BACKGROUND

Minimally invasive fixation using crossing screws was believed to produce satisfactory clinical outcome whereas its stability in early weight-bearing remained controversial. This study aimed to analyze the biomechanical stability of minimally invasive fixation during balanced standing and walking stance, and provide evidence for early rehabilitation.

METHODS

A finite element model of foot-ankle-shank complex was reconstructed based on computed tomography and magnetic resonance images, and validated by plantar pressure of the model participant. A Sanders III calcaneal fracture was created on the model, and then fixed using crossing screws. The predicted stress distribution, fracture displacement, Bohler's angle and Gissane's angle were compared between the intact calcaneus and fracture model with the fixation.

FINDINGS

Postoperatively, the concentrated stress appeared at the junction of the calcaneus and its surrounding tissues (especially Achilles tendon, plantar fascia and ligaments) during standing and walking stances, and the stress exceeded the yield strength of trabecular bone. The longitudinal screws sustained the highest stresses and concentrated at the tips and the calcaneal tuberosity junction. The displacement of posterior joint facet, Bohler's angle, and Gissane's angle were within the acceptable range either standing or walking after the fixation.

INTERPRETATION

Early weight-bearing standing and walking after minimally invasive fixation may cause high stress concentration thereby induce calcaneus stress fractures and other complications like plantar fasciitis and heel pain, so it should not be supported. The peri-calcaneus tendons, i.e., Achilles tendon and plantar fascia, play key roles in the stabilization of the calcaneal fracture after operation.

Tranexamic Acid Use in Foot and Ankle Surgery

Background:

There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery.

Methods:

A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months.

Results:

Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05).

Conclusions:

The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised.

Level of Evidence:

Level IV, case series.

Results After Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Evolution of imaging in surgical fracture management

Intraoperative imaging has been advanced substantially over the last decades. It supports localization of the region of interest, verification of the preoperatively classified fracture pattern, identification of correct insertion point of the implant, placement of instruments and fixation material, and verification of correct fracture reduction and implant positioning. While conventional fluoroscopic 2D imaging remains the gold standard in intraoperative imaging, critical anatomical regions are predestined for intraoperative 3D imaging. Additional options such as perioperative virtual planning, simulation, and surgical training, 3D printing techniques and 3D augmented reality visualization may potentially open new windows to improve surgical results in fracture care. This manuscript presents an update on current and upcoming imaging techniques in orthopaedic and trauma surgery focusing on technical advances for decreasing malreduction, malalignment, and malposition, as well as tips and tricks for daily surgical practice in order to improve clinical outcomes and patients' and surgeons' safety.

An experimental study on the digital precision of internal fixation via the sinus tarsi approach for calcaneal fractures

OBJECTIVE

To investigate the effectiveness and accuracy of internal fixation of calcaneal fractures with a three-dimensional (3-D) printing navigation module via the sinus approach.

METHODS

Eleven lateral lower extremity specimens were used in the experiment and divided into the digital design (DD) group ( n = 11) and the real surgery (RS) group ( n = 11). For the DD group, thin-section computed tomography (CT) scans, virtual fracture modeling, virtual bone plate fixation, sinus occlusal module design, and navigation module design were performed for the cadaver specimens. A 3-D navigation module was printed using a 3-D printer. For the RS group, the sinus approach incision was made, and the navigation module was used to assist the placement of screw fixation and anatomically locked bone plate fixation. Thin-layer CT scans, 3-D reconstructions, and reconstruction of the nail paths were performed in the RS group and 3-D registered with the DD group. 3-D coordinate values for the screw entry and exit points in the RS and DD groups were recorded, and the corresponding offset values of the screw points were calculated. The number of qualified nails at different accuracy levels was counted. The χ² test was used to compare the data for the DD and RS groups to obtain the accuracy level for both groups when p > 0.05, which is the critical value for experimental accuracy.

RESULTS

A total of 11 bone plates were placed and 120 screws were locked. None of them protruded from the inferior articular surface. The screw entry and exit point offsets were 1.71 ± 0.11 mm and 3.10 ± 0.19 mm, respectively. When the accuracy requirement for the entry point was 3.8 mm, there was no statistically significant difference between the two groups ( p > 0.05). Similarly, the accuracy of the exit point of the screw could only reach 6.6 mm.

CONCLUSION

Internal fixation of calcaneal fractures via the sinus tarsi approach with an anatomical locking plate based on the 3-D printing navigation module can achieve accurate screw placement and good overall internal fixation.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

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

Talar-sided osteochondral lesion of the subtalar joint following the intra-articular calcaneal fracture: study via a modified computed tomography mapping analysis

INTRODUCTION

This study is to report the prevalence of osteochondral lesions in subtalar joint following intra-articular calcaneal fracture, including the relationship between fracture severity and lesion characteristics, using modified computed tomography (CT) mapping analysis.

METHODS

Thirty patients with intra-articular calcaneal fracture who were preoperatively imaged with modified CT mapping analysis were recruited. The presence of talar-sided osteochondral lesions (OLTS) of subtalar joint was noted with lesion area defined by Akiyama's mapping classification. Lesion severity was assessed via Ferkel's classification, and fracture severity via Sanders' classification.

RESULTS

Lesions were found in 28 patients (93.3%), mostly at anterior [16 (57.1%) lesions] or central [13 (46.4%) lesions] areas of posterior talar facet. Most common grade of lesion severity was grade I (mild) seen in 24 (80%) patients. Most fractures were classified as Sanders' grade III and IV with 12 (40%) and 12 (40%) patients noted, respectively. High severity of fracture denoted by Sanders' grade IV showed a trend of higher prevalence of OLTS at anterior and central sites of posterior talar facet (P = 0.181). Lesion severity was significantly higher in patients with double lesions than patients with single lesions (P = 0.005). However, OLTS were not significantly related with osteoarthritic changes in follow-up radiographs (P > 0.05).

CONCLUSIONS

The prevalence of OLTS is very high following intra-articular calcaneal fractures. Most lesions occur at anterior or central area of posterior talar facet and are more likely to occur in patients with higher fracture severity. Lesion severity was significantly higher in patients with double lesions than patients with single lesions.

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.

Extended Sinus Tarsi Approach for Treatment of Displaced Intraarticular Calcaneal Fractures Compared to Extended Lateral Approach

BACKGROUND:

We compared the radiographic results and clinical outcomes of patients operated on via the extended sinus tarsi approach (ESTA) and the extended lateral approach (ELA) for treatment of displaced intraarticular calcaneal fractures.

METHODS:

We retrospectively studied the utility of the ELA (46 patients, 52 feet) and the ESTA (56 patients, 64 feet) in patients operated on between January 2009 and March 2015. We evaluated pre- and postoperative x-rays and computed tomography (CT) data. Pain, patient-reported functional outcomes, satisfaction, and postoperative complications were investigated at the 3-year follow-up.

RESULTS:

Neither the postoperative nor 3-year follow-up Böhler angles, nor the calcaneal width, differed significantly between the 2 groups (both P > .05). However, the maximum step-off of the posterior facet on the 3-month CT follow-up of the ESTA group was significantly less than that of the ELA group ( P < .05). We found no significant between-group differences in terms of postoperative translation ( P = .232) or angulation ( P = .132) of the sustentacular fragment on the 3-month CT follow-up. At the 3-year follow-up, we found no significant between-group difference in the mean visual analog scale pain score at rest ( P = .641) or during weightbearing ( P = .525). We found no significant between-group difference in the Foot Function Index (FFI) ( P = .712) or self-reported satisfaction ( P = .823). The ELA group experienced significantly more wound complications ( P = .041) and nonunions ( P = .041) than the ESTA group. Four instances of superficial peroneal nerve injury were reported in the ESTA group ( P = .127).

CONCLUSION:

Compared with the ELA, the ESTA afforded comparable, favorable radiological results and clinical outcomes, associated with fewer wound complications and nonunions. We suggest that the ESTA is an effective operative option when treating displaced, intraarticular calcaneal fractures.

LEVEL OF EVIDENCE:

Level III, comparative study.

Pseudarthrosis of the Calcaneus: Advantages of Regenerative Medicine in the Management of a Rare Entity, A Case Report and Review of Literature

Background:

The follow-up of calcaneal fractures has shown that they are difficult to manage and lead to multiple complications such as malunion and subtalar osteoarthritis. Pseudarthrosis of the calcaneus is an extremely rare complication, which was described in the literature through case reports.

In the existing literature, only seven studies, including thirteen patients have reported the nonunion. However, to the best of our knowledge, no study elucidates the role of new techniques of regenerative medicine such as Bone Marrow Concentrates (BMC) or Platelet Rich Plasma (PRP) in the management.

Methods:

We report a case of a patient with a pseudarthrosis after a calcaneal fracture treated with BMC injection in the non-union site, without the need for surgical approach.

Results:

Four months after treatment, the patient was ambulant without support and was completely pain-free. Moreover, after one year the radiological follow up by CT scan showed a satisfactory filling of the non union.

Conclusion:

In one case, we try to highlight the advantage of our therapeutic alternatives, which are having a good union while avoiding the complications of surgical approaches and without sacrificing the subtalar joint when it is possible.

Chronic traumatic ankle and foot osteomyelitis: a nationwide case-control study

BACKGROUND

Osteomyelitis (OM) is an atypical consequence of ankle-foot trauma which is associated with long-term mental and physical morbidity and persistent pain. This study aimed to assess the health status of OM patients with war-related ankle-foot injuries.

METHODS

A total of 1129 veterans with ankle-foot injuries participated in a case-control study (2014-2016). Thirty patients with chronic OM of the ankle-foot were compared with 90 non-OM participants as the control group. Quality of life (QOL), life satisfaction and the ability to perform basic and instrumental activities of daily living were measured using the following questionnaires: short-form health survey (SF-36), satisfaction with life scale (SWLS), activity of daily living (ADL) and instrumental activity of daily living (IADL), respectively. OM patients were categorized according to their risk factors as A, B and C hosts using a modified version of the Cierny and Mader classification system. The one sample t-test, 2-independent sample t-test, ANOVA, Pearson correlation coefficient and multiple linear regression analyses were applied to analyze the data.

RESULTS

Ankle-foot pain leading to surgery (P < 0.001) and orthosis usage (P = 0.039) were more common in OM patients. There was no significant difference between the two groups in the prevalence of pulmonary and cardiovascular diseases or kidney failure and other related diseases. OM patients showed a significantly lower level of mental health compared to non-OM respondents (P = 0.025). Approximately, 70.0% of ankle-foot injured veterans were dissatisfied with their life, and there was no difference between the two groups (P > 0.05). Mobility was significantly lower in the OM patients than in the control group (P = 0.023). Life satisfaction (P = 0.001) and the ability to perform daily activities were the determinants for poor physical (P = 0.018) and mental (P = 0.012) health-related quality of life. According to the Cierny and Mader classification system, they were all included in the type C host classification, with one major and/or three or more minor risk factors.

CONCLUSIONS

A low level of quality and satisfaction of life and ability to perform activities of daily living were observed in OM patients with war-related ankle-foot injuries. Surgeries of the ankle and foot due to pain were much more common in OM patients than in non-OM participants. Since all the participants were classified as the C-host, health policy planning seems to be necessary.

Timing of initiating manual therapy and therapeutic exercises in the management of patients after hindfoot fractures: a randomized controlled trial

Study design

Randomized clinical trial.

Background

Patients with fractures to the talus and calcaneus report decreased functional outcomes and develop long-term functional limitations. Although physical therapy is typically not initiated until six weeks after fixation, there's little research on the optimal time to initiate a formal physical therapy program.

Objectives

To assess whether initiating physical therapy including range of motion (ROM) and manual therapy two weeks post-operatively (EARLY) vs. six weeks post-operatively (LATE) in patients with fixation for hindfoot fractures results in different clinical outcomes.

Methods

Fifty consecutive participants undergoing operative fixation of a hindfoot fracture were randomized to either EARLY or LATE physical therapy. Outcomes, including the American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS), the Lower Extremity Functional Scale (LEFS), active ROM, swelling, and pain, were collected at three and six months and analyzed using linear mixed-modeling to examine change over time. Adverse events were tracked for 12 months after surgery.

Results

The EARLY group demonstrated significantly larger improvements for the AOFAS (p = .01) and the LEFS (p = .01) compared to the LATE group. Pairwise comparison of the LEFS favors the EARLY group at 6 months [7.5 (95%CI -.01 to 15.0), p = .05]. There were no differences between the groups with regard to ROM, pain, and swelling. The LATE group incurred increased adverse events in this study.

Conclusion

Initiating early physical therapy may improve long-term outcomes and mitigate complications in patients after hindfoot fractures.

Level of Evidence

Therapy, level 2b.

Displaced Intra-articular Calcaneal Fractures: Classification and Treatment

The calcaneus is the most commonly fractured tarsal bone. Displaced intraarticular calcaneal fractures are usually caused by a fall from height with one or both heels directly hitting the ground. Displaced intra-articular calcaneal fractures are complex and highly disabling injuries. There is ongoing debate regarding the optimal treatment for each type of displaced intra-articular calcaneal fracture. This review aims to summarize the classification of, various treatment options for, prevention of perioperative complications in, and management algorithms for displaced intra-articular calcaneal fractures. [Orthopedics. 2017; 40(6):e921-e929.].

The sinus tarsi approach in displaced intra-articular calcaneal fractures

INTRODUCTION

Although the extended lateral approach is typically considered the gold standard of treatment for intra-articular calcaneal fractures, a limited lateral approach may be a good alternative in select cases.

METHODS

Forty-seven consecutive patients with intra-articular calcaneal fractures treated using the sinus tarsi approach between March 2010 and April 2015 were retrospectively reviewed. The functional outcomes [including arc range of motion, Visual Analog Scale (VAS) score, and the American Orthopedic Foot and Ankle Society ankle/hindfoot (AOFAS) score], bony outcomes (bony restoration and bony union), and complications were evaluated.

RESULTS

The mean one-year postoperative VAS and AOFAS scores were 0.54 (range 0-3.0), and 94.0 (range 80-100), respectively. The VAS and AOFAS scores were correlated with the degree of reduction of the posterior facet joint and the amount of Bohler angle restoration. Bony union was achieved in every case. The mean union time was 3.2 months (range 3-4 months). There were no major soft tissue complications. Three cases of minor soft tissue complications healed with no need for subsequent procedures. Painful hardware at the posterior calcaneal tuberosity was the most common complication, which occurred in seven cases.

CONCLUSIONS

The sinus tarsi approach may be a good option to treat intra-articular calcaneal fractures in select cases (Sanders type II and III) while preventing the major soft tissue complications of the extended lateral approach. Level of evidence IV.

Functional outcomes and quality of life in patients with subtalar arthrodesis for posttraumatic arthritis

INTRODUCTION

Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries.

MATERIALS AND METHODS

This is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions.

RESULTS

Forty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53-72). Quality of life was significantly lower when compared to a reference population (p<0.001).

CONCLUSION

Satisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.

Can operations achieve good outcomes in elderly patients with Sanders II-III calcaneal fractures?

The aim of this study was to compare the clinical effect of operative treatment and nonoperative treatment for elderly patients with Sanders II-III calcaneal fractures.The study consisted of 60 patients with Sanders II-III calcaneal fractures who were treated in our institution from January 2007 to April 2012. The clinical effect between the operative treatment group of 32 patients and the nonoperative treatment group of 28 patients was studied. Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height were measured before and after treatment, and these indexes were also measured on the uninjured foot. All patients were followed-up for at least 2 years, and at the last follow-up, we evaluated foot function that was assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score system. A 10-cm visual analog scale (VAS) was used to measure the degree of pain.Böhler angle, Gissane angle, calcaneal width, and calcaneal height, which were preoperatively and postoperatively measured, had a significant difference in the operative group (P < .001), but there was no significant difference between pretreatment and post-treatment in the nonoperative group. Subtalar joint motion was measured pre-treatment and post-treatment and had a significant difference in the 2 groups. When we compared the values of Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height between post-treatment and the uninjured foot, there was no significant difference in the operative group, but there was a significant difference in the nonoperative group. The values measured after treatment in the 2 groups had a significant difference. Finally, the AOFAS score in the operative group and the nonoperative group were 83.4 ± 9.7 and 74.7 ± 10.3, respectively, and there was a significant difference (P < .001). Also, the 10-cm VAS had a significant difference between the 2 groups.Good clinical result could be obtained with operative treatment in elderly patients with Sanders II-III calcaneal fractures. Open reduction and internal fixation should be performed if there is no surgical contraindication.

Outcome evaluation of minimally invasive surgery versus extensile lateral approach in management of displaced intra-articular calcaneal fractures: A randomised control trial

BACKGROUND

Minimally invasive surgery has a significant and evolving role in the treatment of DIACFs, but there is limited literature on this topic.

OBJECTIVES

To compare the clinico-radiological outcomes of DIACFs fixed with MIS technique with ORIF.

METHODS

This randomised control trial (RCT) included 21 closed Sanders type 2 and 3 DIACFs which were selected from 70 who presented. Extensile lateral approach was used in the ORIF group; while MIS techniques included either percutaneous reduction or small incisions with indirect fragment manipulation.

MAIN OUTCOME MEASUREMENT

AOFAS hindfoot score, pre-operative and postoperative radiology.

RESULTS

There were 9 fractures in the Extensile group and 12 in the MIS group, with both groups having comparable demography, fracture classification, surgery delay & initial radiology. Bohler's angle improved after surgery by an average of 18.44 with ORIF and 14.67 with MIS (p=0.28). Mean AOFAS in the MIS group was 82.58 (66.67% good and 33.33% fair) and was 89.56 (44.44% excellent, 55.56% good, 0 fair/poor) with ORIF (p=0.034). Two patients who underwent ORIF had a major complication (one deep infection and Sural nerve injury each) while none in the MIS group.

CONCLUSIONS

MIS methods minimized soft tissue complications and achieved comparable radiological reductions but clinical outcomes were poorer, with percutaneous methods having the worst outcomes.

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus

BACKGROUND

Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique.

METHODS

153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed.

RESULTS

At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively ( P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement ( P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower.

CONCLUSION

This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Managing Complications of Calcaneus Fractures

Calcaneus fractures remain among the most complicated fractures for orthopedic surgeons to manage because of the complexity of various fracture patterns, the limited surrounding soft tissue envelope, and the prolonged rehabilitation issues impacting function after successful treatment. Despite this, appropriate management of complications associated with calcaneus fractures is critical for the complete care of this injury, whether treated operatively or nonoperatively. The authors present the common complications encountered with fractures of the calcaneus and management thereof.

Surgical treatment of intraarticular fractures of the calcaneus: comparison between flat plate and calcaneal plate

Objective

To evaluate the clinical results of surgical treatment of intraarticular fractures of the calcaneus, comparing the use of calcaneal plate and flat plate.

Methods

This was a retrospective study assessing the postoperative results of 25 patients between 2013 and 2015. Patients undergoing surgical treatment of intraarticular fractures of the calcaneus without concomitant surgical lesions were included. Patients who did not complete appropriate follow-up after surgery were excluded from the study.

Results

The unavailability of calcaneal plates at resource-limited settings, associated with the availability and lower cost of flat plates, may have been a confounding factor in the present study. However, there was no statistical difference between the outcomes of fractures treated with calcaneal plates or flat plates.

Conclusion

Statistical inference shows that, when calcaneal plates are not available, it is possible to use flat plates with similar clinical outcomes.

Surgical Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach

BACKGROUND

Calcaneum is the most commonly fractured tarsal bone. The optimal treatment for displaced calcaneus fractures involving the posterior facet is surgical. The extensile lateral approach is commonly preferred because it provides sufficient exposure of the subtalar facet. However, this technique has the risk of complications such as wound necrosis and sural nerve injury. Various minimally invasive approaches, such as sinus tarsi approach, limited posterior approach, and percutaneous approach, have been introduced to reduce possible complications. This study was prospectively performed to evaluate the results of the sinus tarsi approach for Sanders Type 2 calcaneal fractures using postoperative computed tomography (CT).

MATERIALS AND METHODS

Between October 2012 and December 2013, 20 Sanders Type 2 calcaneal fractures were consecutively treated using a sinus tarsi approach and checked using CT preoperatively, immediately postoperatively, and at 12 months after surgery. Clinical evaluations were performed using the visual analog scale (VAS) and the ankle-hindfoot score developed by the American Orthopaedic Foot and Ankle Society (AOFAS). Radiographic evaluations were performed using calcaneus lateral and axial radiographs, hindfoot alignment radiograph, and CT. Changes in Böhler's angles and calcaneal widths were evaluated both preoperatively and at last followup. Reduction of the posterior facet was graded according to articular step, defect, and angulation of the posterior facet in CT.

RESULTS

VAS and AOFAS scores were significantly improved at 1 year after surgery but did not improve further. Böhler's angles and calcaneal widths were significantly improved after surgery. Böhler's angle was significantly smaller at the last followup than immediately after surgery, whereas calcaneal width was maintained. Reduction of the posterior facet was graded excellent in five feet (25%), good in ten (50%), and fair in five (25%) on immediately postoperative CT. Two feet (10%) had transient sural nerve injury which resolved within 3 months. Five feet (20%) had subfibular pain due to a prominent screw heads.

CONCLUSION

Surgical management using a sinus tarsi approach produced good clinical and radiographic results and low wound complications for Sanders type 2 calcaneal fractures. It is important to have stable fixation and to achieve sufficient reduction of calcaneal width for the prevention of loss of reduction and lateral subfibular impingement.

Complications of Intra-articular Calcaneal Fractures in Adults: Key Points for Diagnosis, Prevention, and Treatment

Calcaneal fractures are complex injuries with high complication rates and they can lead to serious disability. The proper management remains controversial and complications may occur regardless of the chosen type of treatment (operative or nonoperative). The present article reviews the studies that are related to the complications of calcaneal fractures. The incidence, the diagnosis, the prevention and the treatment of these complications were researched and analyzed, with the use of PubMed database, abstracts and original articles in English than investigate the etiology. The aim of the article is to discuss the most suitable management of the complications of calcaneal fractures and recommend a specific treatment as well as prevention methods.

LEVELS OF EVIDENCE

Level IV.

Is arthroscopic assisted percutaneous screw fixation as good as open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures?

BACKGROUND

This study compares the outcomes of calcaneal fracture surgery after open reduction internal fixation and plating (ORIF) versus arthroscopic assisted percutaneous screw fixation (APSF).

METHODS

Group I (N=12) underwent ORIF. Group II (N=15) underwent APSF. Anthropometric data, pre and post-operative stay, complications and duration off work were recorded in this retrospective case cohort study. Radiographs were analyzed for Bohler's, Gissane's angle and Sanders' classification. AOFAS Hindfoot and SF 36 scores were collected at final follow-up.

RESULTS

Anthropometric data, Bohler's and Gissane's angles, AOFAS and SF 36 scores were not significantly different. Pre-operative duration was 12.3 days in ORIF and 6.9 days in APSF. Post-operative duration was 7.3 days vs 3.8 days. Duration off work was 6.2 months vs 2.9 months.

CONCLUSION

The APSF group was able to have surgery earlier, go home faster, and return to work earlier. This study was not powered to demonstrate a difference in wound complication rates.

Radiographic and functional outcomes after displaced intra-articular calcaneal fractures: a comparative cohort study among the traditional open technique (ORIF) and percutaneous surgical procedures (PS)

BACKGROUND

Open reduction with internal fixation (ORIF) and percutaneous surgery (PS) are the most common surgical procedures for the treatment of displaced intra-articular calcaneal fractures. The purpose of this retrospective study was to compare the clinical and radiological results of these techniques and to verify the prognostic value of the radiographic measurement tools proposed in the literature.

METHODS

A consecutive series of 104 calcaneal fractures was included in this analysis. Essex-Lopresti and Sanders classifications were used to evaluate the injuries, and their prognostic correlation was tested. Böhler's angle was measured pre- and postoperatively and evaluated as radiological outcome. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society hindfoot scale (AOFAS), Maryland Foot Scale (MFS), 17-Foot Function Index (FFI), Short Form-36 (PCS), and a 10-point visual analogue scale (VAS).

RESULTS

A total of 87 fractures (5 bilateral), 54 in males and 28 in females, were evaluated with a mean follow-up of 77.0 months. Overall mean age was 51.6 years old. The most frequent cause of trauma was a fall from a height. According to Essex-Lopresti, there were 58 joint depression fractures, 26 tongue, and 3 comminute. According to Sanders: 37 type II, 31 type III, and 19 type IV. Patients were divided into three groups according to surgical treatment: 19 in the ORIF group, 35 in the PS Screw group, and 33 in PS K-wire group. The ORIF group obtained significantly better results (82 AOFAS, 86 MFS, 19.6 FFI, 46.2 PCS, 8 VAS) with respect to the PS K-wire group (74 AOFAS, 76 MSF, 26.4 FFI, 40.8 PCS, 6 VAS). The PS Screw group obtained intermediate results (79 AOFAS, 82 MFS, 22.4 FFI, 41.6 PCS, 7 VAS). The restoration of the Böhler's angle was achieved most frequently (p = 0.02) in the ORIF group, without better clinical results.

CONCLUSION

The results were best in the ORIF group, despite its risk of complications, inferior in the PS Screw group, however without statistical significance (p > 0.05), and worse in the PS K-wire group. Finally, our data confirmed the prognostic correlation between the two radiographic classifications used and the clinical outcomes.

Complications in operative fixation of calcaneal fractures

OBJECTIVE

The purpose of this study focused on a number of factors that have been implicated in calcaneal complications and find the incidence of wound complications.

METHODS

This was a retrospective study. A total of 162 patients (176 feet) who underwent calcaneal fractures between 2007 and 2012 were included. The patient's personal details, age, time from injury to surgery, cause of injury, type of fracture, operative details, operating and tourniquet times were collected from hospital computers and paper records. Evidence of complications including wound infection, wound necrosis, pain, malunion, nonunion, impingement, loss of fixation, ect were studied.

RESULTS

Forty-seven of one hundred and seventy-six fractures (26.704%) had complications, wound infection was noted in seven fractures (3.977%), twelve fractures developed necrosis (6.818%), 14 fractures (7.955%) developed pain. Malunion was found in five fractures (2.841%), nonunion in two fractures (1.136%) and loss of fixation in four fractures (2.272%). Three neurologic injury was also seen in our study (1.705%). Operating time, time from injury to surgery and type of fracture had some association with complications in operative fixation of calcaneal fractures, which showed a statistically significant improvement (P=0.000, 0.031, 0.020, respectively), but there were no evidence that age and tourniquet time affect the incidence of complication after calcaneal fracture surgery (P=0.119, 0.682, respectively).

CONCLUSIONS

Despite developments in the surgical treatment of calcaneal fracture, wound complications still remain inevitable. Advanced imaging techniques, less invasive surgical procedures, wealth of anatomical knowledge, surgical experience and better postoperative care should be ensured.

Surgical complications of intra-articular calcaneal fracture treatment

Introduction: The authors present complications following surgical treatment of intra-articular calcaneus fractures, in regards to the surgical technique employed, based on their own clinical material. Materials and methods: The techniques analyzed included the Westhues’ technique and its modifi cation with additional bone stabilization by Kirschner wires and the percutaneous stabilization by Rapala. The research material covered the years from 1990 to 2012 and consists of 82 operated patients - 68 men (83%) and 14 women (17%). Analyzed calcaneus fractures were divided using the Essex-Lopresti classifi cation. Results: The authors of the article indicate that the most frequently registered complications of surgical treatment of intra-articular calcaneus fractures in early observation were thromboembolic complications and local infl ammatory reactions of the skin at the point of incision and placing the stabilizing material. During the long-term follow-up, the post-thrombotic syndrome and algodystrophic disorders were the most common. Conclusions: Factors contributing to the occurrence of the complications registered were fracture morphology, fixation of bone fragments by an excessive number of stabilizing materials and prolonged immobilization of the operated limb. Cite this article as: Golec P., Tomaszewski K.A., Nowak S., Dudkiewicz Z. Surgical complications of intra-articular calcaneal fracture treatment. Med Rehabil 2016; 20(2): 25-30.