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Lim PK, Hacquebord J, Shafiq B, Gupta R. Management of Open Fractures of the Extremities and Pediatrics. J Am Acad Orthop Surg 2024:00124635-990000000-01028. [PMID: 38968700 DOI: 10.5435/jaaos-d-23-00757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 05/23/2024] [Indexed: 07/07/2024] Open
Abstract
The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations.
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Affiliation(s)
- Philip K Lim
- From the Department of Orthopaedic Surgery, UC Irvine, Irvine, CA (Lim and Gupta), the Department of Orthopaedic Surgery, NYU, New York, NY (Hacquebord), the Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD (Shafiq), and Hansjorg Wyss Department of Plastic Surgery, New York University, New York, NY (Hacquebord)
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Abstract
Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Michael P Swords
- Michigan Orthopedic Center, Sparrow Hospital, 2815 S. Pennsylvania Avenue, Suite 204 Lansing, MI 48910, USA
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Gao X, Fan HY, Huang R, Sui YQ, Li F, Yin HL. Management of Open Calcaneal Fractures with Medial Wounds by One-Stage Sequential Reduction and Frame Structure Fixation Using Percutaneous Kirschner Wires. Orthop Surg 2021; 13:225-236. [PMID: 33403804 PMCID: PMC7862139 DOI: 10.1111/os.12902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 12/02/2022] Open
Abstract
Objective To assess the clinical outcomes of open calcaneal fractures with medial wounds treated with one‐stage management, including early modern wound care, sequential reduction, and frame structure fixation using percutaneous Kirschner wires. Methods A total of 19 patients with open calcaneal fractures admitted to our hospital from May 2016 to March 2019 were selected in this study. Twelve type‐II and seven type‐IIIA medial open injuries were identified according to the classification of Gustilo and Anderson. Fractures were stratified by Sanders classification, including nine type‐II fractures, seven type‐III fractures, and three type‐IV fractures. All patients accepted one‐stage irrigation and debridement, sequential reduction of calcaneal fractures through the open medial wound, percutaneous Kirschner wire fixation, and primary closure of wounds covered with vacuum‐assisted closure (VAC) device. The Bohler angle, the Gissane angle, and the width of the calcaneus were compared before and after surgery. The functional results were evaluated according to the Paley and Hall score system, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Maryland Foot Score, and related complications. Results The follow‐up duration for all patients ranged from 14 to 28 months (mean, 22.7 months). The angle of Bohler and Giasane was increased from (−7.6° ± 15.0°) and (96.6° ± 7.6°) before surgery to (23.7° ± 6.1°) and (124.1° ± 7.1°) postoperatively (P < 0.05), respectively. Three cases of superficial infection and two cases of wound dehiscence were observed in our study, which were then successfully treated with wound debridement, VAC replacement, appropriate use of antibiotics, and delayed closure. The last follow‐up revealed three cases of lateral wall expansion and six cases of mild‐to‐moderate subtalar arthritis based on the Paley and Hall scoring system. According to the AOFAS ankle and hindfoot score, one case showed excellent results, 14 cases exhibited good results, and four cases displayed fair results, with the mean of 80.7 ± 6.7 points (range, 70–90). The Maryland Foot Score revealed one case of excellent outcomes, nine cases of good outcomes, and nine cases of fair outcomes with an average of 76.8 ± 8.6 points (range, 62–90). The mean VAS for pain was 1.8 ± 1.5 (range, 0–5), and a total of 14 patients complained of mild‐to‐moderate pain when walking for a more extended period. Severe complications, such as deep infection, osteomyelitis, and soft tissue necrosis, were not observed during follow‐up. Conclusions Collectively, one‐stage management allowed the direct restoration of calcaneal morphology with a minimal invasion of soft tissues in most open calcaneal fractures with medial wounds, and the functional outcomes were comparable to previous data.
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Affiliation(s)
- Xu Gao
- Department of Orthopaedic Surgery, Qingdao University, Qingdao, China
| | - Hai-Yu Fan
- Department of Burn and Plastic Surgery, No. 971 Hospital of the People's Liberation Army (PLA), Qingdao, China
| | - Rui Huang
- Department of Second Orthopaedic Surgery, No. 971 Hospital of the People's Liberation Army (PLA), Qingdao, China
| | - Yong-Qiang Sui
- Department of State Key Laboratory for Marine Corrosion and Protection, Luoyang Ship Material Research Institute, Qingdao, China
| | - Fei Li
- Department of Second Orthopaedic Surgery, No. 971 Hospital of the People's Liberation Army (PLA), Qingdao, China
| | - Hai-Lei Yin
- Department of Second Orthopaedic Surgery, No. 971 Hospital of the People's Liberation Army (PLA), Qingdao, China
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Spierings KE, Min M, Nooijen LE, Swords MP, Schepers T. Managing the open calcaneal fracture: A systematic review. Foot Ankle Surg 2019; 25:707-713. [PMID: 30467055 DOI: 10.1016/j.fas.2018.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/24/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm. MATERIAL AND METHODS A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions. RESULTS A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points. CONCLUSION The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.
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Affiliation(s)
| | - Minoesch Min
- Trauma unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Lynn E Nooijen
- Trauma unit, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Tim Schepers
- Trauma unit, Academic Medical Center, Amsterdam, The Netherlands.
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Stupay KL, Briceño J, Velasco BT, Miller CP, Kwon JY. Tuber-to-Anterior Process Angle (TAPA): A cadaveric study and surgical technique for placing axial calcaneal screws. Injury 2019; 50:1398-1403. [PMID: 31147185 DOI: 10.1016/j.injury.2019.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/22/2019] [Accepted: 05/21/2019] [Indexed: 02/02/2023]
Abstract
We describe results of a cadaveric study and an accompanying surgical technique which simplifies posterior-to-anterior axial screw placement into the calcaneus, often utilized during fixation of displaced intra-articular calcaneus fractures or calcaneal osteotomies. By defining the Tuber-to-Anterior Process Angle (TAPA), this technique facilitates axial screw placement, thereby decreasing reliance on intraoperative fluoroscopy and reducing operative time.
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Affiliation(s)
- Kristen L Stupay
- Harvard Combined Orthopaedic Surgery Residency Program, Massachusetts General Hospital, Boston, MA, United States.
| | - Jorge Briceño
- Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Brian T Velasco
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | | | - John Y Kwon
- Beth Israel Deaconess Medical Center, Boston, MA, United States
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Leite CBG, Macedo RS, Saito GH, Sakaki MH, Kojima KE, Fernandes TD. Estudo epidemiológico das fraturas do calcâneo em um hospital terciário. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Leite CBG, Macedo RS, Saito GH, Sakaki MH, Kojima KE, Fernandes TD. Epidemiological study on calcaneus fractures in a tertiary hospital. Rev Bras Ortop 2018; 53:472-476. [PMID: 30027081 PMCID: PMC6052184 DOI: 10.1016/j.rboe.2018.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/20/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To analyze the epidemiology and characteristics of patients with calcaneus fractures. Methods This is a retrospective revision of patients with calcaneus fractures hospitalized in the Institute of Orthopedics and Traumatology of this institution between 2006 and 2010. Data such as age, gender, laterality, trauma mechanism, type of fracture, associated injuries, compound fractures, and time from injury to surgery were analyzed. Results The analysis of 52 patients showed that men were more commonly affected than women, at a ratio of 5.5:1. Bilateral fractures were observed in ten cases, resulting in a total of 62 calcaneus fractures. A fall from a height was the most frequent trauma mechanism (75%), followed by motorcycle accidents (11.5%) and automobile accidents (9.6%). The most frequent fractures were intra-articular, with 47 cases. Compound fractures were observed in 15 patients (28.9%). Non-surgical management was adopted for 11 patients while 41 patients underwent surgery. The mean time between trauma and the definitive treatment was 7.8 days (range: 0–21 days), and 58.5% of cases were treated within seven days. Conclusion Patients with calcaneus fractures, most commonly young men, were admitted to a high complexity care hospital, victims of a fall from a height with associated injuries. The great severity of these fractures is characterized by the high prevalence of bilateral (19.2%) and compound fractures (28.9%) in this population group.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Sousa Macedo
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Guilherme Honda Saito
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcos Hideyo Sakaki
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Kodi Edson Kojima
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Túlio Diniz Fernandes
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Abstract
The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.
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Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus, Dresden, Germany,Address for correspondence: Prof. Stefan Rammelt, University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany. E-mail:
| | - Bruce J Sangeorzan
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
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Sonmez MM, Armagan R, Ugurlar M, Eren T. Allografts versus Equine Xenografts in Calcaneal Fracture Repair. J Foot Ankle Surg 2017; 56:510-513. [PMID: 28242215 DOI: 10.1053/j.jfas.2017.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Indexed: 02/03/2023]
Abstract
Displaced intra-articular calcaneal fractures are difficult to treat. We determined the functional results and complications of using allografts or equine xenografts in treating these fractures. We reviewed patients seen at our center from May 2011 to December 2014 with Sanders type III or IV unilateral calcaneal fractures treated with locking plates and an additional bone allograft or equine xenograft. A minimum of 1 year after surgery, a history of infection and functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society clinical rating system. Changes in the Gissane angle (GA) and Böhler angle were assessed from radiographs. Of the 91 eligible patients, 15 were lost to follow-up, leaving a sample of 76 patients (42 males): 45 received allografts (19 for type III and 26 for type IV fractures) and 31 received xenografts (20 for type III and 11 for type IV fractures). The mean age was about 40 years in both groups. After ≥1 year of follow-up, the proportion of patients in the American Orthopaedic Foot and Ankle Society scoring categories did not differ significantly between the 2 groups (mean ankle score, 86.5 in the allograft group and 85.1 in the xenograft group), and the American Orthopaedic Foot and Ankle Society functional outcomes were good or excellent in 69% and 68%, respectively (p = .986). The groups did not differ in the incidence of superficial or deep infection (p = 1.000). The Böhler angles were significantly decreased in the xenograft group. Xenografts might be preferred for repairing intra-articular calcaneal fractures because they can perform as well as allografts, avoid donor site morbidities, and are more available and less expensive than allografts.
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Affiliation(s)
- Mehmet Mesut Sonmez
- Doctor, Department of Orthopaedics, Hamidiye Sisli Etfal Training and Research Hospital, Istanbul, Turkey.
| | - Raffi Armagan
- Doctor, Department of Orthopaedics, Hamidiye Sisli Etfal Training and Research Hospital, Istanbul, Turkey
| | - Meric Ugurlar
- Doctor, Department of Orthopaedics, Hamidiye Sisli Etfal Training and Research Hospital, Istanbul, Turkey
| | - Tugrul Eren
- Associate Professor, Department of Orthopaedics, Hamidiye Sisli Etfal Training and Research Hospital, Istanbul, Turkey
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Alexandridis G, Gunning AC, Leenen LPH. Patient-reported health-related quality of life after a displaced intra-articular calcaneal fracture: a systematic review. World J Emerg Surg 2015; 10:62. [PMID: 26719760 PMCID: PMC4696241 DOI: 10.1186/s13017-015-0056-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/21/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND A displaced intra-articular calcaneal fracture (DIACF) is known for having a negative influence on the daily activities of patients. A health-related quality of life (HRQoL) outcome instrument is used to quantify the impact of DIACF. It seems that these studies used restrictive inclusion criteria and observe specific patient groups; consequently, an increased risk of bias that results in incorrect estimation of the impact. Therefore, we will systematically review the current literature. MATERIALS AND METHODS A systematic search was performed in PubMed, Embase and Cochrane library. Inclusion criteria were studies reporting DIACF and HRQoL, measured with SF-36, SF-36v2, EQ-5D or EQ-6D. The identified articles were critically appraised for their relevance and validity. The overall risk of bias was determined. The studies with a low to medium risk of bias were used for data extraction. RESULTS 32 articles were available for the critical appraisal. 13 articles had a medium risk of bias. All studies reported the SF-36 and two studies also reported the EQ-5D. CONCLUSIONS This systematic review indicates that DIACF is a life-changing event for most patients. The HRQoL is substantially lower in comparison to the period before the trauma and to the general population, in particular the subdomains related to the physical domain are affected. In addition, this review reveals that the identified studies have a medium to high risk of bias. Consequently, it is challenging to make reliable and valid conclusions. Therefore, we provided recommendations to decrease the risk of bias in order to improve future research.
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Affiliation(s)
- G. Alexandridis
- Department of Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - A. C. Gunning
- Department of Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - L. P. H. Leenen
- Department of Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Gusic N, Fedel I, Darabos N, Lovric Z, Bukvic N, Bakota B, Lemac D. Operative treatment of intraarticular calcaneal fractures: Anatomical and functional outcome of three different operative techniques. Injury 2015; 46 Suppl 6:S130-3. [PMID: 26606987 DOI: 10.1016/j.injury.2015.10.061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Management of the intraarticular calcaneal fracture is a challenge. The optimal method of treatment remains controversial. This study evaluates the anatomical and functional postoperative outcomes of displaced intraarticular calcaneal fractures that have been treated using three different techniques of ORIF. PATIENTS AND METHODS Between 2004 and 2011 we treated 143 patients with calcaneal fractures, 40 of these patients (28%) were treated conservatively. This is a retrospective study of the remaining 103 patients (72%) who were operated on consecutively, mainly by one surgeon (NG). Calcaneal fractures were classified according to the Sanders classification. Three types of osteosynthesis were used: standard anatomical plate (SP), locking anatomical plate (LCP) and standard anatomical plate with autologous bone graft (SP+ABG). Clinical outcome was assessed one year after the operation: anatomical reduction was evaluated according to the analysis of Bohler's angle at final follow-up, and functional assessment was conducted using the Maryland Foot Score (MFS). RESULTS The fractures were classified as follows: 35 (34%) Sanders type II, 47 (45.6%) Sanders type III and 21 (20.4%) Sanders type IV. The SP was used in 67 (65%) fractures, LCP in 16 (15.5%) and SP+ABH in 20 (19.4%). The correlation test showed a weak association between the Sanders fracture type and the operation technique (Pearson correlation coefficient r=0.26). The non-parametric tests showed that the fracture type did not significantly influence the postoperative Bohler's angle outcome (p=0.132), or the type of operation (p=0.664). Excellent or good reduction of the posterior calcaneal facet was achieved in all operated fractures. One year after the operation, the distribution of Bohler's angle was normal with a mean 31.9° (SD 4.84) in all three groups. There was no significant difference in the functional postoperative outcome in terms of MFS in the three groups (p=0.601), but the Sanders fracture type had significant influence on the functional postoperative outcome in terms of MFS (p=0.001). CONCLUSION In the representative sample of 103 operatively treated intraarticular calcaneal fractures, anatomical and functional postoperative efficacy outcomes appeared to be similar in all three treatment groups. High-grade displaced intraarticular calcaneal fractures (Sanders IV) had worse functional results irrespective of the type of operation. The optimal method for management of intraarticular calcaneal fracture is operative, using the standard anatomic calcaneal plate. Autologous bone grafting is not required. Large sample comparative studies are still needed.
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Affiliation(s)
- N Gusic
- Department for Traumatology and Orthopaedics, Pula County Hospital, Negrijeva 6, HR-52100 Pula, Croatia.
| | - I Fedel
- Department for Traumatology and Orthopaedics, Pula County Hospital, Negrijeva 6, HR-52100 Pula, Croatia.
| | - N Darabos
- University Clinic for Traumatology, Clinical Hospital Centre "Sisters of Charity", Draskoviceva ulica 19, HR-10000 Zagreb, Croatia.
| | - Z Lovric
- Department for Traumatology and Orthopaedics, University Hospital Dubrava, Av. Gojka Suska 6, HR-10040 Zagreb, Croatia.
| | - N Bukvic
- Department for Pediatric Trauma and Orthopaedics, Clinical Hospital Rijeka, Croatia, Istarska 43a, HR-51000 Rijeka, Croatia.
| | - B Bakota
- Department for Traumatology and Orthopaedics, Karlovac County Hospital, Karlovac, Croatia.
| | - D Lemac
- Department for Traumatology and Orthopaedics, University Hospital Dubrava, Av. Gojka Suska 6, HR-10040 Zagreb, Croatia.
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Dhillon MS, Gahlot N, Satyaprakash S, Kanojia RK. Effectiveness of MIS technique as a treatment modality for open intra-articular calcaneal fractures: A prospective evaluation with matched closed fractures treated by conventional technique. Foot (Edinb) 2015. [PMID: 26209469 DOI: 10.1016/j.foot.2015.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Twenty-five displaced intra-articular calcaneal fractures in 21 patients, aged 15-55 years were included in this study. Sanders' type I fractures, severe crushing or partial amputation, were excluded from the study. Patients were divided into group 1 (open fractures treated by MIS), and group 2 (closed fractures treated by ORIF). Group 1 had 16 and group 2 had 9 cases. Seven of 25 fractures (28%) developed wound related issues postoperatively. One patient (11.1%) in group 2 had wound margin necrosis, while 6 patients (37.5%) in group 1 developed pin tract and/or wound infection. At 1-year follow-up, the mean MFS for group 1 was 79 and mean MFS for group 2 was 84.4 (66.67% were good). The AOFAS score for group 1 was 77.37 and for group 2 was 86.1. The Bohlers' angle was restored in 81.16% cases in group 1 and 88.8% in group 2, while Gissane angle was restored in 68.75% of group 1 cases and 77.79% of group 2 cases. This study shows that acceptable fracture reduction can be obtained and maintained by MIS technique and it can be used as the primary definitive treatment option in open calcaneal fractures.
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Affiliation(s)
- Mandeep Singh Dhillon
- Department of Orthopaedics, PGIMER (Post Graduate Institute of Medical Education and Research), Chandigarh 160012, India.
| | - Nitesh Gahlot
- Department of Orthopaedics, PGIMER (Post Graduate Institute of Medical Education and Research), Chandigarh 160012, India.
| | | | - Rajendra Kumar Kanojia
- Department of Orthopaedics, PGIMER (Post Graduate Institute of Medical Education and Research), Chandigarh 160012, India.
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Bevevino AJ, Dickens JF, Potter BK, Dworak T, Gordon W, Forsberg JA. A model to predict limb salvage in severe combat-related open calcaneus fractures. Clin Orthop Relat Res 2014; 472:3002-9. [PMID: 24249536 PMCID: PMC4160503 DOI: 10.1007/s11999-013-3382-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Open calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern. QUESTIONS/PURPOSES We developed two decision support tools, an artificial neural network and a logistic regression model, based on presenting data from severe combat-related open calcaneus fractures. We then determined which model more accurately estimated the likelihood of amputation and which was better suited for clinical use. METHODS Injury-specific data were collected from wounded active-duty service members who sustained combat-related open calcaneus fractures between 2003 and 2012. One-hundred fifty-five open calcaneus fractures met inclusion criteria. Median followup was 3.5 years (interquartile range: 1.5, 5.1 years), and amputation rate was 44%. We developed an artificial neural network designed to estimate the likelihood of amputation, using information available on presentation. For comparison, a conventional logistic regression model was developed with variables identified on univariate analysis. We determined which model more accurately estimated the likelihood of amputation using receiver operating characteristic analysis. Decision curve analysis was then performed to determine each model's clinical utility. RESULTS An artificial neural network that contained eight presenting features resulted in smaller error. The eight features that contributed to the most predictive model were American Society of Anesthesiologist grade, plantar sensation, fracture treatment before arrival, Gustilo-Anderson fracture type, Sanders fracture classification, vascular injury, male sex, and dismounted blast mechanism. The artificial neural network was 30% more accurate, with an area under the curve of 0.8 (compared to 0.65 for logistic regression). Decision curve analysis indicated the artificial neural network resulted in higher benefit across the broadest range of threshold probabilities compared to the logistic regression model and is perhaps better suited for clinical use. CONCLUSIONS This report demonstrates an artificial neural network was capable of accurately estimating the likelihood of amputation. Furthermore, decision curve analysis suggested the artificial neural network is better suited for clinical use than logistic regression. Once properly validated, this may provide a tool for surgeons and patients faced with combat-related open calcaneus fractures in which decisions between limb salvage and amputation remain difficult.
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Affiliation(s)
- Adam J. Bevevino
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Jonathan F. Dickens
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Benjamin K. Potter
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Theodora Dworak
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Wade Gordon
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Jonathan A. Forsberg
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
- />Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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