Subtalar Arthroscopy and Flurosocopy in Percutaneous Fixation of Intra-Articular Calcaneal Fractures: The Best of Both Worlds

Management of displaced intra-articular calcaneal fractures; current concept review and treatment algorithm

Calcaneum fractures are debilitating injuries with high complication rates and poor functional outcomes after both operative and non-operative management. The optimal management of such fractures is still highly debated in the literature with conflicting evidence on the preferred management of displaced intra-articular calcaneum fractures (DICAF). This article reviews the current concepts in the management of DIACF.

Reduced pre-operative skin oxygen saturation predicts revision after open reduction and internal fixation in calcaneal fractures : A reduced pre-operative oxygen saturation as measured by laser-Doppler spectrophotometry in 8 mm depth is associated with revision surgery after open reduction and internal fixation of calcaneal fractures through an extended lateral approach

PURPOSE

To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus.

METHODS

Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors.

RESULTS

Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64-1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision.

CONCLUSION

A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146.

Arthroscopic-assisted percutaneous fixation of intra-articular calcaneal fractures using an intraoperative distraction device

PURPOSE

To evaluate the quality of reduction and clinical outcomes by using Percutaneous Distractor and Subtalar Arthroscopy Closed Reduction followed by Internal Fixation (PDSA-CRIF) in the intra-articular calcaneal fracture.

METHODS

A consecutive case series of 453 patients with 507 displaced intra-articular calcaneal fractures was recruited in this retrospective study. We performed PDSA-CRIF to treat intra-articular calcaneal fractures. The quality of reduction was assessed by early postoperative Computed Tomography (CT) scans and measurement of serial Bohler's angles during follow-ups. Clinical outcomes were evaluated by Visual Analogue Scale (VAS) and the American Foot & Ankle Society ankle-hind foot scale (AOFAS) scoring system.

RESULTS

Fifty-nine patients (68 fractures) who had complete clinical data and follow-up of at least 12-months (mean: 14 months, range: 12-59 months) were finally included. Anatomical and near-anatomical reduction in subtalar articular surface which had less than 2 mm gap or step-off was found in 93% fractures. Unsatisfactory reduction was found in 7%.

CONCLUSION

Arthroscopic-assisted percutaneous fixation using a distraction device is effective in achieving positive short-term results in the displaced intra-articular calcaneal fractures. A multicenter, large sample, randomized control trial is needed to fully evaluate the long-term effects of PDSA-CRIF in comparison to other methods.

Arthroscopically Assisted Internal Fixation of Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date.

METHODS

A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications.

RESULTS

A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy.

CONCLUSIONS

Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.

Intra-articular Calcaneus Fractures: Current Concepts Review

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures.

Level of Evidence: Level V, expert opinion.

Percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures: Systematic review and surgical technique

BACKGROUND

The aim of this study was to systematically evaluate the available literature on technique and outcomes of percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures.

METHODS

A systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane Library database was performed, including studies from January 1985 to august 2018. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The surgical technique and perioperative management, clinical outcomes scores, radiographic outcomes and complication rate were evaluated.

RESULTS

Of 66 reviewed articles, 8 studies met the inclusion criteria. The included studies reported on the results of 152 patients. At last follow up the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot was ranging from 72.1 to 94.1. The complication rate was low, including only one superficial infection.

CONCLUSIONS

The studies included were of too little level of evidence to allow for data pooling or meta-analysis. However, the percutaneous arthroscopic calcaneal osteosynthesis seems to be a good option for displaced intra-articular calcaneal fractures with a low complication rate. Appropriately powered randomized controlled trials with long-term follow up are needed to confirm the efficacy of this technique.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

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.

Minimally invasive treatment of calcaneal fracture

Objective

This study was performed to analyze the outcomes of calcaneal fractures using a minimally invasive internal fixation method with a thin plate and bone grafting.

Methods

This retrospective analysis included 21 patients treated using our minimally invasive approach. The outcome measures were the change in the Bohler and Gissane angles and the calcaneus width after fixation. The clinical outcomes were evaluated by the Maryland foot scoring system and assessment of soft tissue complications.

Results

The follow-up time was 12 to 18 months. The Bohler angle, Gissane angle, and width of the calcaneus were significantly different between the preoperative and postoperative periods. The rate of excellent and good outcomes was 85.7% according to the Maryland foot scoring system. The incidence of soft tissue complications was 14.3%.

Conclusion

Treatment of calcaneal fractures using a minimally invasive internal fixation method with a plate and bone grafting provides good to excellent clinical outcomes with few soft tissue complications.

Minimally invasive reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular calcaneal fractures: A systematic review of the literature

The aim of this article is to systematically identify and analyse research evidence available to compare the outcomes of minimally invasive reduction and percutaneous fixation (MIRPF) versus open reduction and internal fixation (ORIF) for displaced intra-articular calcaneal fractures.

Articles from 2000 to 2016 were searched through MEDLINE (PubMed), Cochrane Library, Embase, ScienceDirect, Scopus and ISI Web of Knowledge using Boolean logic and text words. Of the 570 articles identified initially, nine were selected including three randomized controlled trials and six retrospective comparative studies.

All nine studies had a total of 1031 patients with 1102 displaced intra-articular calcaneal fractures. Mean follow-up was 33 months. Of these, 602 (54.6%) were treated with MIRPF and 500 (45.4%) were treated with ORIF.

Overall incidence of wound-related complications in patients treated with MIRPF was 4.3% (0% to 13%) compared with 21.2% (11.7% to 35%) in the ORIF group

Functional outcomes were reported to be better in the minimally invasive group in all studies; however, the results did not reach statistical significance in some studies. All the studies had methodological flaws that put them at either ‘unclear’ or ‘high’ risk of bias for multiple domains.

Overall quality of the available evidence is poor in support of either surgical technique due to small sample size, flaws in study designs and high risk of bias for various elements. Individual studies have reported minimally invasive techniques to be an effective alternative with lower risk of wound complications and better functional outcomes.

Cite this article: EFORT Open Rev 2018;3:418-425. DOI: 10.1302/2058-5241.3.170043

Role of Subtalar Arthroscopy in Operative Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach

BACKGROUND

This study was conducted to evaluate the usefulness of subtalar arthroscopy in the operative treatment of Sanders type 2 calcaneus fractures using a sinus tarsi approach.

METHODS

Forty-six Sanders type 2 calcaneal fractures were consecutively treated using a sinus tarsi approach. Intraoperative fluoroscopy was used to evaluate fracture reduction in the first 23 patients (fluoroscopy group), and intraoperative fluoroscopy and subtalar arthroscopy were used in the latter 23 patients (arthroscopy group). Clinical evaluations were performed using a visual analog scale, the Ankle-Hindfoot Scale developed by the American Orthopaedic Foot & Ankle Society, and Short Form Health Survey. Radiographic evaluations were performed using calcaneal and lateral radiographs and computed tomography (CT) scans. Böhler's angles and calcaneal widths were compared between the groups. Reduction of the posterior facet was graded according to articular step, defect, and angulation of the posterior facet on CT.

RESULTS

At the last follow-up, clinical results as well as Böhler's angles and calcaneal widths were not different between the groups. On immediately postoperative CT, reduction of the posterior facet showed a higher-than-good grade in 17 feet (73.9%) in the fluoroscopy group and a higher-than-good grade in 22 feet (95.7%) in the arthroscopy group, and these values were significantly different between the groups ( P = .04).

CONCLUSION

A combined approach using fluoroscopy and subtalar arthroscopy showed better reduction of the posterior facet on CT than using fluoroscopy alone. Therefore, subtalar arthroscopy could be a useful method for detecting joint incongruence when using the sinus tarsi approach for Sanders type 2 calcaneal fractures.

LEVEL OF EVIDENCE

Level III, comparative series.

Calcaneal Fractures - Should We or Should We not Operate?

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.

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.].

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.

[New techniques in the operative treatment of calcaneal fractures]

The ideal treatment of displaced intra-articular calcaneal fractures is still controversially discussed. Because of the variable fracture patterns and the vulnerable soft tissue coverage an individual treatment concept is advisable. In order to minimize wound edge necrosis associated with extended lateral approaches, selected fractures may be treated percutaneously or in a less invasive manner while controlling joint reduction via a sinus tarsi approach. Fixation in these cases is achieved with screws, intramedullary locking nails or modified plates that are slid in subcutaneously. A thorough knowledge of the three dimensional calcaneal anatomy and open reduction maneuvers is a prerequisite for good results with less invasive techniques. Early functional follow-up treatment aims at early rehabilitation independent of the kind of fixation. Peripheral fractures of the talus and calcaneus frequently result from subluxation and dislocation at the subtalar and Chopart joints. They are still regularly overlooked and result in painful arthritis if left untreated. If an exact anatomical reduction of these intra-articular fractures is impossible, resection of small fragments is indicated.

Subtalar arthroscopy and fluoroscopy in percutaneous fixation of intra-articular calcaneal fractures

INTRODUCTION

Percutaneous fixation of intra-articular calcaneal fractures is traditionally assisted only by intraoperative fluoroscopy. Previous studies have demonstrated that the additional use of subtalar arthroscopy in anatomical reduction of the posterior calcaneal facet of the subtalar joint for less complex calcaneal fractures yielded positive results up to 2-year follow-up. This study aims to investigate long-term outcomes of these patients using similar evaluation parameters. We hypothesized that this novel technique with dual-imaging can provide sustainable, long-term benefits with good functional outcomes and significant restoration of the Bohler's angle.

METHODS

We performed a retrospective study of 15 Sanders II, AO-OTA 83-C2 intra-articular calcaneal fractures in 14 patients who underwent subtalar arthroscopy and fluoroscopy guided percutaneous fracture fixation with a minimum follow-up of 5 years. Outcome measures were assessed using the ankle and hindfoot NPRS, AOFAS ankle-hindfoot score, and SF-36 Physical Function subscale preoperatively and at 3 months, 6 months, 1 year, 2 years and 5-8 years postoperatively. The Bohler's angle was measured preoperatively, immediately postoperatively and at 5-8 years postoperatively.

RESULTS

We report excellent functional outcomes in all scores as well as continued improvements in the majority of patients across all time points with minimal subsidence of the corrected Bohler's angle over our study time frame.

CONCLUSION

Subtalar arthroscopy with intraoperative fluoroscopy in anatomical reduction of the posterior calcaneal facet of the subtalar joint is most useful in Sanders type II, AO-OTA 83-C2 fractures with excellent functional outcomes and good preservation of the corrected Bohler's angle on long-term follow-up.

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.

Review Article: Operative versus nonoperative treatment for displaced intraarticular calcaneal fracture: a meta-analysis of randomised controlled trials

We reviewed 8 randomised controlled trials that compared operative and non-operative treatment for displaced intra-articular calcaneal fractures. Patients with operative treatment were more likely to resume pre-injury work (relative risk [RR]=0.60, p=0.04), had fewer problems when wearing shoes (RR=0.42, p=0.0004), and had a higher physical component summary score of SF-36 (difference in means=6.75, p<0.0001) but a higher complication rate (RR=1.74, p=0.0005).

Percutaneous poking reduction and fixation versus open reduction and fixation in the treatment of displaced calcaneal fractures for Chinese patients: A systematic review and meta-analysis

PURPOSE

To compare the efficacy of percutaneous poking reduction and fixationwith open reduction and fixation in the treatment of displaced calcaneal fractures.

METHODS

Reports of studies using case-controlled trials (CCT) to compare the percutaneous poking reduction and fixation with the open reduction and fixation in the management of calcaneal fractures were retrieved from the Cochrane Library, PubMed Database, CNKI, Chinese Biomedical Database, Wanfang Data (from January of 2005 to August of 2015). Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.0 was used for data-analysis.

RESULTS

Fifteen articles were included in the meta-analysis. Comparison of the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of calcaneal fractures revealed statistical significance in the incidence of complications after operation [RR = 0.32, 95% CI (0.20, 0.5), p < 0.05]. However, there were neither statistical significance in the degrees of recovery for calcaneal Bohler angle [WMD = -1.65, 95% CI (-3.43, 0.14), p > 0.05] and calcaneal Gissane angle [WMD = -3.21, 95% CI (-6.75, 0.33), p > 0.05], nor statistical significance in the rate of good foot function after operation [RR= 0.95, 95% CI (0.90, 1.00), p > 0.05].

CONCLUSION

For the treatment of calcaneal fractures, percutaneous poking reduction and fixation is su- perior to open reduction and fixation in terms of the incidence of postoperative complications. But both techniques can obtain satisfactory clinical function.

Minimally-invasive treatment of calcaneal fractures: A review of the literature and our experience

The optimal treatment of calcaneal fractures (CF) is currently controversial and is still under debate. It is well established that conservative treatment of these fractures is associated with poor results. Several surgical techniques are described in the literature; however, there is no consensus on which of these is more effective. The main goals of surgery are to restore the subtalar joint congruence, and calcaneal width, height, shape and alignment, thus avoiding medial and lateral impingement and enabling the patient to resume a normal lifestyle. ORIF is the most popular technique for these fractures, but it is associated with high rates of wound complications, hardware failure and infections. Several minimally-invasive techniques have been developed recently for the treatment of CF, with the common aim to be as simple, effective and inexpensive as possible and to reduce surgical times, complications and length of hospital stay.

A Protocol for Percutaneous Transarticular Fixation of Sanders Type II and III Calcaneal Fractures With or Without an Added Mini-Open Approach

Intra-articular fracture of the calcaneus is one of the most displeasing fractures if not properly managed. Open reduction and internal fixation have been associated with a high incidence of postoperative soft tissue complications. Closed reduction and percutaneous fixation have resulted in a greater incidence of postoperative subtalar osteoarthritis with improper reduction of the articular surface. In the present study, a mini-open approach was used in cases of failure of articular surface restoration with closed reduction. A total of 64 feet in 57 consecutive patients with an intra-articular calcaneal fracture underwent the proposed minimally invasive surgical protocol. Of the 57 patients, 7 (12.3%) had bilateral fractures. According to Sanders classification, 33 (51.6%) fractures were type II and 31 (48.4%) were type III. Seven (12.3%) patients had wedge fractures of the dorsolumbar spine without neurologic manifestations. The postoperative evaluation included radiographs and completion of the Maryland Foot Score and visual analog scale for pain. The mean follow-up period was 16 (range 12 to 36) months. The mean operative time was 42 (range 35 to 60) minutes. The mean period until union of the fracture was 12 (range 10 to 16) weeks. The clinical results according to the Maryland Foot Score revealed 52 (81%) with satisfactory (27 excellent and 25 good) and 12 (19%) with unsatisfactory (10 fair and 2 poor) results. The mean visual analog scale score was 1.5 ± 0.3 when radiographic fracture healing was observed. Six patients (9.4%) developed superficial pin tract infections that responded to local care and parenteral antibiotic therapy and resolved completely after removal of the Kirschner wires. In conclusion, the presented surgical protocol combining closed reduction with or without an added mini-open approach and percutaneous fixation improves the functional outcome and minimizes the incidence of complications.

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.

Outcome of Minimally Invasive Open and Percutaneous Techniques for Repair of Calcaneal Fractures: A Systematic Review

Percutaneous and minimally invasive open techniques for the treatment of calcaneal fractures are now frequently used with good results, although a comparison between these different techniques has not yet been performed. The aim of the present review was to search for studies evaluating the outcomes of patients after treatment with percutaneous and minimally invasive open techniques for calcaneal fractures. A search was performed using PubMed/MEDLINE, Embase, and the Cochrane Library. Studies from the previous 15 years in English were included. Data on the Sanders classification, operation technique, infection rate, American Orthopaedic Foot and Ankle Society ankle-hindfoot score, radiographic evaluation, and follow-up were extracted. The techniques were divided into 4 groups: minimally invasive open, percutaneous reduction and screw osteosynthesis, external fixation, and other. Forty-six studies were included, with 1776 patients and 2018 calcaneal fractures. Of the 2018 fractures, 924 (46%) were classified as Sanders II, 558 (28%) as Sanders III, and 245 (12%) as Sanders IV; the fractures of 291 patients(14%) were not classified or were classified as complete extra-articular. Of the 46 studies, 15 used a minimally invasive open technique, 19 evaluated the outcome of percutaneous reduction and screw osteosynthesis, 10 investigated the results of an external fixation system, and 2 studies used other operative techniques. The median infection rate was 3% (range 0% to 33%). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 83 (range 67 to 94). The median angle of Böhler postoperatively was 24° (range 14° to 35°) and had increased after operative treatment, with a median of 16° (range 0° to 39°). The percutaneous reduction and screw osteosynthesis and minimal invasive open technique resulted in significantly better outcomes compared with external fixation and other techniques. In conclusion, percutaneous reduction and screw osteosynthesis and minimal invasive open techniques have the best outcomes for the minimal invasive open surgical treatment of calcaneal fractures.

Patient-reported health-related quality of life after a displaced intra-articular calcaneal fracture: a systematic review

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.

Sanders II type calcaneal fractures: a retrospective trial of percutaneous versus operative treatment

OBJECTIVE

The purpose of this study was to compare the clinical results of percutaneous reduction and Steinman pin fixation for Sanders II calcaneal fractures with those of operative management through an extensile lateral approach.

METHODS

Fifty-three patients treated with standard open reduction and internal fixation (ORIF group) and 54 patients who had undergone percutaneous reduction and Steinman pin fixation (CRIF group) were retrospectively reviewed. There were no differences between the groups regarding sex, age or fracture classification. Pain and functional outcome were evaluated with a visual analogue scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) scores. Wound complications and radiological results were compared.

RESULTS

At a mean follow-up of 40.4 months (24 to 56 months), there were no differences between the two groups in mean AOFAS score, VAS score or radiologically determined variables. Two cases of deep infection and six of poor wound healing occurred in the ORIF group and none in the CRIF group. Subtalar and ankle motion was found to be better in the CRIF group.

CONCLUSIONS

Percutaneous reduction and Steinman pin fixation minimizes complications and achieves functional outcomes comparable to those of the open techniques in patients with Sanders II calcaneal fractures.

Calcaneal fractures: selection bias is key

In this paper, we critically appraise the recent publication of the United Kingdom Heel Fracture Trial, which concluded that when patients with an absolute indication for surgery were excluded, there was no advantage of surgical over non-surgical treatment in the management of calcaneal fractures. We believe that selection bias in that study did not permit the authors to reach a firm conclusion that surgery was not justified for most intra-articular calcaneal fractures.

Advances in Surgical Management of Intra-articular Calcaneus Fractures

Intra-articular calcaneus fractures are commonly sustained after high-energy trauma, and a variety of techniques exists for anatomic reduction and surgical fixation. Traditional approaches using an extended L-shaped lateral incision with lateral plating for open reduction and internal fixation have relatively high complication rates. Common complications include hematoma formation, skin edge necrosis, wound breakdown, and superficial or deep infection. As a result, less invasive techniques have been developed in recent years, including limited-incision sinus tarsi open reduction and internal fixation, percutaneous fixation, and arthroscopic-assisted fixation. These techniques are associated with lower complication rates and equivalent clinical and radiographic outcomes in certain fracture patterns and patient populations.

Percutaneous Arthroscopic Calcaneal Osteosynthesis: A Minimally Invasive Technique for Displaced Intra-Articular Calcaneal Fractures

The management of calcaneal fracture remains challenging. Open surgery has been fraught with high infection rates and soft tissue complications. More minimally invasive procedures have reduced this risk, but the patient outcomes after treatment of displaced calcaneal fractures have remained relatively unsatisfactory. We present a method for the management of Sanders grade II and III calcaneal fractures: percutaneous arthroscopic calcaneal osteosynthesis. Thirty-three fractures in 30 patients who had presented to our tertiary foot and ankle trauma center in central London were treated with percutaneous arthroscopic calcaneal osteosynthesis for calcaneal fractures, and the data were prospectively collected. The mean patient age at injury was 39 years. The mean follow-up period was 24 months. Of our patients, 58% were smokers at injury. Of the 33 fractures, 46% were classified as grade II and 54% as grade III. The mean length of stay was 1.92 days. At the final follow-up visit, the mean Böhler angle had increased from 11.10° (range 2° to 24°) to 23.41° (range 15° to 35°). The modified American Orthopaedic Foot and Ankle Society scale score was 72.18 (range 18 to 100), the calcaneal fracture scoring system score was 79.34 (range 42 to 100), and the visual analog scale score was 29.50 (range 0 to 100). We had a single case of a superficial port site infection and 2 cases of prominent screws, which were removed. No cases of deep infection developed, and no conversion to subtalar fusion was required. This technique significantly reduced the incidence of postoperative wound complications. Direct visualization of the fracture site allowed accurate restoration of the articular surface and correction of heel varus. Furthermore, it was associated with a high self-reported functional outcome and a return to preinjury employment levels. Also, the results did not appear to be influenced by tobacco consumption.

Surgical treatment of calcaneal fractures of Sanders type II and III by a minimally invasive technique using a locking plate

The aim of the present study was to investigate the outcomes of surgical treatment of calcaneal fractures of Sanders type II and III using a minimally invasive technique and a locking plate. We reviewed 33 feet in 33 consecutive patients with Sanders type II and III calcaneal fractures who had undergone a minimally invasive technique using percutaneous reduction and locking plates. All operations were performed by the same surgeons. The postoperative evaluation included radiographs, determination of restoration of Böhler's angle and Gissane's angle, and administration of the American Orthopaedic Foot and Ankle Society ankle-hind foot scale, Maryland Foot Score, and visual analog scale of pain. The mean visual analog scale score was 1.6 ± 1.4 when radiographic fracture healing was observed. The median functional score of the 33 patients (33 feet) reached 82 (interquartile range 80 to 99) at the last follow-up evaluation according to the American Orthopaedic Foot and Ankle Society ankle-hind foot scale and 89 (interquartile range 80 to 99) according to Maryland Foot Score. All cases achieved restoration of a normal Böhler's angle and Gissane's angle. Postoperative superficial infections occurred in 2 patients, subtalar arthritis developed in 2, and no soft tissue necrosis was observed. For Sanders type II and III fractures of the calcaneus bone, treatment with a minimally invasive technique combining percutaneous reduction and locking plate fixation provided satisfactory clinical results, with a lower incidence of complications. However, longer term studies with a larger sample size and more randomized controlled trials are required to define the superiority of our minimally invasive technique compared with conventional surgical treatment of calcaneal fractures.

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Evidence-based rationale for percutaneous fixation technique of displaced intra-articular calcaneal fractures: a systematic review of clinical outcomes

Displaced intra-articular fractures of the calcaneus are complex and have a high degree of morbidity. Percutaneous fixation techniques have been advocated in an effort to minimize postoperative complications. We performed a systematic review of the clinical outcomes to describe and ascertain the different techniques and clinical outcomes for percutaneous treatment of displaced intra-articular calcaneal fractures. A review was performed using PubMed and Google Scholar, from January 2000 to December 2012, with studies ranging from case reports to prospective studies. The inclusion criteria consisted of percutaneous fixation techniques with objective findings (Sander's classification and Bohler's angle measurements) and clinical outcome scoring and complication and subtalar fusion rates. The exclusion criteria included studies with open or limited open procedures, the use of external fixation, the use of bone substitutes alone, and pathologic or open fractures. Data and evidence with a combination of objective findings and clinical outcomes are lacking. Several techniques for percutaneous fixation have been described, including Schanz pins and Kirschner wires, cannulated screws, arthroscopically guided percutaneous fixation, and application of bone substitute. A myriad of techniques are available for percutaneous intra-articular calcaneal fixation. The results from the current data appear to be promising; however, the lack of statistical power and inconsistent documentation have made it difficult to determine any superiority. The complication rates were much lower than those with open procedures, regardless of the technique. The percutaneous fixation technique appears to be a favorable option for displaced intra-articular calcaneal fractures.

Extended indications for foot and ankle arthroscopy

Advances in foot and ankle arthroscopy have allowed surgeons to diagnose and treat a broadening array of disorders that were previously limited to open procedures. Arthroscopy of the posterior ankle, subtalar joint, and first metatarsophalangeal joint and tendoscopy can be used to address common foot and ankle ailments, with the potential benefits of decreased pain, fast recovery, and low complication rates. Posterior ankle and subtalar arthroscopy can be used to manage impingement, arthrofibrosis, synovitis, arthritis, fractures, and osteochondral defects. First metatarsophalangeal joint arthroscopy can address osteophytes, chronic synovitis, osteochondral defects, and degenerative joint disease. Tendoscopy is a minimally invasive alternative for evaluation and débridement of the Achilles, posterior tibial, flexor hallucis longus, and peroneal tendons.

Maximizing safety in screw placement for posterior facet fixation in calcaneus fractures: a cadaveric radio-anatomical study

BACKGROUND

Successful screw fixation of reduced posterior facet fragments to the unexposed, nondisplaced sustentaculum tali avoids breaching the subtalar joint or disrupting surrounding soft tissue structures. Safe passage for screw fixation through this narrow bony corridor has not been rigorously defined.

METHODS

Computed tomography scans of 8 cadaveric feet were digitally reconstructed in 3-D; 3.5-mm-diameter screws were simulated, aiming at the center of the sustentaculum tali from 5 locations (0%, 25%, 50%, 75%, and 100%) along the posterolateral facet joint. The range of entry points, screw paths trajectories, and screw lengths that did not breach the subtalar joint or the medial calcaneal cortex were evaluated.

RESULTS

To prevent violation of the subtalar joint or the medial calcaneal cortex while reaching the center of the sustentaculum tali, screws must be inserted at least 5 mm below the joint line. Screw placement 15 ± 1 mm below the posterior facet measured perpendicular to the joint line provided the widest safe corridor with the trajectory of the ranges from 6 to 36 degrees parallel to the joint depending on the location along the posterior facet and 20 ± 2 degrees perpendicular to the joint at all locations. The average maximal length of screws placed at the ideal entry points ranged from 44 to 46 mm, longest at the 100% location and shortest at the 25% location.

CONCLUSIONS

Operative guidelines facilitating instrumentation into the sustentaculum tali have been defined applying to most calcanei, assuming the fractures are well reduced: screws, approximately 40 mm in length, should be started 15 mm below the posterior facet measured perpendicular to the joint line and aimed 20 degrees perpendicular to the joint line toward the joint and 6 to 36 degrees anteversion parallel to the joint line increasing at each position from anterior to posterior.

CLINICAL RELEVANCE

The operative guidelines described in this study may assist surgeons in the placement of screws for the fixation of posterior facet fragments to the sustentaculum tali.

The fate of Böhler's angle in conservatively-treated displaced intra-articular calcaneal fractures

PURPOSE

Although the predictive value of Böhler's angle on outcome remains subject of debate, the initial angle at the time of trauma still guides treatment. Changes in Böhler's angle during follow-up are frequently reported following surgical treatment of displaced intra-articular calcaneal fractures (DIACF). The aim of the present study was to determine the changes in Böhler's angle as a measure of secondary fracture displacement following conservative management of DIACF.

METHODS

Thirty-eight patients with a total of 44 displaced intra-articular calcaneal fractures treated conservatively with a minimum of two lateral radiographs during follow-up were analysed. Böhler's angle at different follow-up times was measured by three observers. The change in angle was compared with the angle at trauma, and influence of trauma mechanism and common calcaneal fracture classifications were determined.

RESULTS

The results showed a significant decline over time of the Böhler's angle in conservatively-treated patients of more than 11° on average at a mean follow-up of 29.2 weeks. This decrease was not related to gender, the initial angle, or the Essex-Lopresti or Sanders classification. A statistically significantly higher decrease was detected in high energetic trauma compared with low energetic trauma.

CONCLUSION

The conservative treatment of displaced intra-articular calcaneal fractures is still a viable option, yet a significant secondary displacement in time should be taken into account, as reflected in a decrease of Böhler's angle of 11° up to one year following trauma.

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

PURPOSE

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

METHODS

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

RESULTS

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the Böhler angle (P < 0.0001), more stable calcaneal height (P = 0.0009) and width (P < 0.00001). Moreover, fewer surgically treated patients needed increased shoe size (P = 0.0004) and more were able to resume pre-injury work (P = 0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P = 0.49). However, operative management was associated with a higher risk of complications (P = 0.008).

CONCLUSIONS

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

PURPOSE

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

METHODS

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

RESULTS

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the Böhler angle (P < 0.0001), more stable calcaneal height (P = 0.0009) and width (P < 0.00001). Moreover, fewer surgically treated patients needed increased shoe size (P = 0.0004) and more were able to resume pre-injury work (P = 0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P = 0.49). However, operative management was associated with a higher risk of complications (P = 0.008).

CONCLUSIONS

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.

Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

PURPOSE

Controversy still surrounds the optimal treatment for patients with displaced intra-articular calcaneal fractures (DIACF). An up-to-date meta-analysis was performed to evaluate clinical effectiveness of surgical treatment for DIACF compared with nonsurgical treatment.

METHODS

We systematically searched four electronic databases (Medline, BIOSIS, Cochrane library and Google Scholar) to identify randomised controlled trials (RCTs) and clinical controlled trials (CCTs) in which surgical treatment was compared with nonsurgical treatment of DIACF from 1980 to 2011. Trial quality was assessed using the modified Jadad scale and effective data were pooled for meta-analysis.

RESULTS

Ten studies (six RCTs and four CCTs) with a total of 891 participants were screened. Results showed that surgical treatment was superior to nonsurgical treatment in better recovery of the Böhler angle (P < 0.0001), more stable calcaneal height (P = 0.0009) and width (P < 0.00001). Moreover, fewer surgically treated patients needed increased shoe size (P = 0.0004) and more were able to resume pre-injury work (P = 0.004) than the nonsurgical patients. No significant difference was identified between the two methods regarding the incidence of residual pain (P = 0.49). However, operative management was associated with a higher risk of complications (P = 0.008).

CONCLUSIONS

Although surgical repair may increase the complication probability, it is the price that has to be paid for better reconstruction of the calcaneus and better functional results. Taken as a whole, surgery is probably the optimal choice in DIACF treatment.