Functional outcome of displaced intra-articular calcaneal fractures: a comparison between open reduction/internal fixation and a minimally invasive approach featured an anatomical plate and compression bolts

Current Management of Intra-Articular Calcaneal Fractures

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

Open reduction and Kirschner wire fixation method using a cylindrical block of unidirectional porous β-tricalcium phosphate for tongue-shaped calcaneal fracture: Report of three cases

Background

The artificial bone grafts are performed on the defect after reduction of the calcaneal fracture. Generally, it is an artificial bone graft with an implant, and there are a few reports of an artificial bone graft without an implant.

Cases

We report three cases (42-year-old male, 67-year-old male, 21-year-old female) of a tongue-shaped calcaneal fracture treated using a cylindrical unidirectional porous β-tricalcium phosphate artificial bone (Affinos®, Kurare co Ltd., Hyougo, Japan) to surgically repair bone defects after reduction. The bone defect is often observed when fracture is reduced in calcaneal fracture. There were significant bone defects, which were then fixed using Affinos® (forming a cylindrical shape block; diameter 10 mm x height 20 mm) to support the bone fragment, an artificial β-tricalcium phosphate bone with a porosity of 57 % (pore size 25-300 μm), characterized by a novel unidirectional porous structure. Postoperative early rehabilitation started with partial load from 5 weeks after surgery and was full weight bearing at 9 weeks after surgery. There was no correction loss and good bone fusion was obtained. By 12 months postoperatively, patients were able to be walking without pain and absorption and bone fusion around the artificial bone were observed maintaining the morphology immediately after reduction. The result was a good clinical result of one excellent (92 points) and two good (81 and 84 points) 1 year after surgery in the postoperative AOFAS Ankle-Hindfoot Scale.

Conclusion

Affinos® has a frost-like structure, which endows it with good tissue invasive properties because of the capillary effect. Moreover, it has excellent osteoconduction capability. In these 3 cases, Affinos® showed good strength, affinity, absorption, and bone substitution in a tongue-shaped calcaneal fracture. Further prospective studies are required to confirm our findings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intra-Articular Calcaneal Fractures: Comparison between Mini-Invasive Approach and Kirschner Wires vs. Extensive Approach and Dedicated Plate-A Retrospective Evaluation at Long-Term Follow-Up

INTRODUCTION

Calcaneal fractures (CF) are the most common tarsal fractures, representing up to 75% of foot fractures and 2% of all fractures. The aim of this retrospective study is to analyze fixation with Kirschner wires through a mini-invasive approach and dedicated plate and screws through an extended approach at long-term follow-up.

MATERIALS AND METHODS

Patients were radiographically and clinically evaluated at final follow-up, by using the validated American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score for the clinical-functional assessment, the Short-Form 12 (SF-12) for the physical and psychological domain assessment, and the Visual Analog Scale (VAS) for pain.

RESULTS

In total, 38 patients (42 CF) met the inclusion criteria and were retrospectively evaluated and divided into two groups (Kirschner group and plate group) consisting of 19 patients each. The overall mean follow-up was 59.4 ± 11.8 months. The average values of the post-operative clinical outcomes of the two groups KG and PG were, respectively, 70.7 ± 11.9 and 70.1 ± 10.9 (AOFAS), 45.7 ± 6.8 and 46.5 ± 10.8 (SF-12 PCS), 54.7 ± 9.9 and 50.9 ± 11.8 (SF-12 MCS) at the final follow-up.

CONCLUSIONS

The present study showed that in the cases analyzed, the two surgical approaches used for the treatment of CF achieved comparable clinical outcomes. The only substantial difference found between the two groups of patients was the re-intervention rate that afflicted them.

Unilateral locking plate versus unilateral locking plate combined with compression bolt for Schatzker I-IV tibial plateau fractures: a comparative study

BACKGROUND

The quality and durability of fracture reduction play an important role in the functional prognosis of articulation. The purpose of this study was to investigate the radiological and clinical effects of compression bolts in the treatment of Schatzker I-IV tibial plateau fractures (TPFs).

METHODS

Between May 2015 and April 2018, a total of 96 consecutive adult patients with operatively treated Schatzker I-IV TPFs were included and divided into two groups according to the internal fixations: Group 1 (unilateral locking plate) and Group 2 (unilateral locking plate combined with compression bolt). Data on demographic and fracture characteristics, postoperative follow-up imaging, intraoperative indicators, postoperative reduction quality and durability, clinical outcomes, and complications were retrospectively collected and compared between the two groups.

RESULTS

There were no significant intergroup differences in preoperative baseline data, duration of operation, intra-operative blood loss, days in hospital, rate of immediate post-operative reduction loss, or complications. The time of fracture healing, the rate of secondary reduction loss, and the mean WOMAC score were significantly reduced compared with those in Group 1 (P = 0.024, 0.015, and 0.024, respectively). There were significant intergroup differences in the mean HSS score (89.0 ± 11.4 vs. 94.4 ± 6.7, P = 0.042), the mean Lysholm score (83.8 ± 9.6 vs. 88.4 ± 5.2, P = 0.027), and the mean SF-36 score (82.8 ± 12.5 vs. 90.5 ± 7.6, P = 0.001). Additionally, there were similar significant differences in subgroup analysis (only included patients with Schatzker II-III), except for WOMAC score.

CONCLUSION

Compared with unilateral locking plate fixation, unilateral locking plate combined with compressing bolt fixation can reduce the rate of secondary reduction loss, accelerate fracture healing, and show better clinical outcomes for patients with Schatzker I-IV TPFs.

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

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

Sinus tarsi approach versus the extended lateral approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis

BACKGROUND

The goal of this study was to review eligible randomized controlled trials to determine the efficacy of the sinus tarsi approach (STA) versus the extended lateral approach (ELA) for the treatment of displaced intra-articular calcaneal fractures (DIACF).

METHODS

Using appropriate keywords, we identified relevant studies using PubMed, the Cochrane Library, Embase, CNKI, VANFUN, and VIP. Key pertinent sources in the literature were also reviewed, and all articles published through June 2020 were considered for inclusion. For each study, we assessed odds ratios (ORs), mean difference (MD), and 95% confidence interval (95% CI) to assess and synthesize the outcomes.

RESULTS

We included 15 RCTs, with a total of 847 patients in the STA group and 959 in the ELA group. The results found that after STA and ELA, no significant difference in changes of Böhler's angle (WMD: 0.746, 95% CI: - 0.316-1.809), Gissane angle (WMD: - 0.710, 95% CI: - 2.157-0.737), calcaneal heights (WMD: 0.378, 95% CI: - 1.973-2.728), calcaneal widths (SMD: - 0.431, 95% CI: - 1.604- 0.742), calcaneal lengths (WMD: 0.691, 95% CI: - 0.749-2.131). Besides, there was no significant difference in the incidence of complications between the STA group and the ELA group (RR: 0.592, 95% CI: 0.336-1.045).

CONCLUSION

There was no difference in clinical efficacy between STA and ELA in treating DIACF. Besides, there is still a need of large-sample, high-quality, long-term randomized controlled trials to confirm the conclusion.

LEVEL OF EVIDENCE

Level I-High-Quality Prospective Randomized Study.

Extensile lateral versus sinus tarsi approach for calcaneal fractures: A meta-analysis

BACKGROUND

Calcaneal fractures are the most common tarsal bone fracture, and are often accompanied by heel pain, local swelling, tenderness, and inability to walk or stand. Surgical intervention results in better reconstruction of the calcaneal anatomy and reduces future complications; however, the optimal incision approach is still controversial. The incision is exposed better with extensile lateral approach (ELA), while the sinus tarsi approach (STA) causes fewer complications. The purpose of this meta-analysis is to compare the outcomes of STA and ELA.

MATERIALS AND METHODS

Published trials comparing ELA and STA in calcaneal fractures were included in our analysis. The quality of each study was assessed using the revised Jadad scale and the Newcastle-Ottawa scale. Two researchers (CP and BY) independently extracted data from all selected studies. Fixed- or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine the heterogeneity of the included studies.

RESULTS

Calcaneal height and calcaneal width had high heterogeneity. Results showed that the incidence of incision complications in STA was lower than that in ELA (P < .001). There was high heterogeneity in operative time (I2 = 97%), length of hospital stay (I2 = 98%), Böhler angle (I2 = 80%), Gissane angle (I2 = 98%), and American Orthopaedic Foot & Ankle Society scores (I2 = 73%). No source of heterogeneity was found by sensitivity analysis, subgroup analysis, or regression analysis, and the random-effects model was used. STA operative time was significantly shorter than ELA (P < .001). Length of hospital stay after STA was significantly shorter than after ELA (P = .002). There was no statistical difference in the Böhler and Gissane angles between STA and ELA. Postoperative American Orthopaedic Foot & Ankle Society scores after STA were higher than after ELA (P = .01).

CONCLUSIONS

Results show that, compared with ELA, STA is superior for treating calcaneal fractures due to anatomical reduction of the calcaneus, reduction of incision complications incidence, and shortened operative time and postoperative stay.

Radiographic and clinical results of modified 2-incision sinus tarsi approach for treatment of calcaneus fracture

BACKGROUND

Sinus tarsi approach (STA) is the most commonly used minimally invasive surgery (MIS) in the treatment of displaced intra-articular calcaneal fracture (DIACF). However, there are some limitations related to its limited access. The goal of the present study is to describe a modified 2-incision STA and to evaluate the radiographic and clinical outcomes in the treatment of DIACF.

MATERIALS AND METHODS

Patients had a Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification 82-C, Sanders type II, III calcaneal fracture, and underwent modified 2-incision STA and internal fixation were included in this retrospective study. Serial radiographic measurements and clinical assessment were taken to evaluate the effectiveness of this technique.

RESULTS

Thirty-four feet of 33 patients treated between 2014 and 2019 were included with an average follow-up of 28.5 (range, 12-65) months. Mean preoperative Böhler's angle was 1.5 ± 10.0 (range, -26.0-16.9) degrees and mean final Böhler's angle was 29.8 ± 4.9 (range, 19.3-39.3) degrees with significant difference (P < .001). The average American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) pain score at last follow-up were 86.2 ± 5.0 (range, 76-97) and 1.6 ± 1.1 (range, 0-4), respectively. Major complications included 2 (5.9%) wound infections and 1 (2.9%) incomplete separation of the lateral wall prior to plate insertion.

DISCUSSION AND CONCLUSIONS

This modified 2-incision STA is a safe and effective procedure. It allows access to the posterior facet and posterior calcaneal tuberosity, appropriate restoration of blowout lateral wall, and easy placement of a standard calcaneal plate.

Open reduction internal fixation versus minimally invasive percutaneous fixation for calcaneus fractures: Mid-term outcomes and social consequences

OBJECTIVES

This study aims to evaluate the mid-term clinical, functional, radiological, and socioeconomic outcomes of calcaneus fractures treated with open reduction-internal fixation (ORIF) versus minimally invasive percutaneous fixation (MIPF).

PATIENTS AND METHODS

A total of 48 patients (34 males, 14 females; mean age: 44.05 years; range, 19 to 64 years) who underwent either ORIF or MIPF for calcaneus fractures between January 2010 and January 2016 were retrospectively analyzed. The patients were divided into two groups as the ORIF group (n=36) and MIPF group (n=12). The American Orthopaedic Foot & Ankle Society (AOFAS) score, Maryland Foot Score (MFS), and the Short Form-36 (SF-36) scores were assessed for the clinical assessment. The mean duration of operation, mean length of hospitalization, pedobarographic gait analysis, the incidence of contralateral knee pain, increased shoe size, and change of profession due to significant heel pain were also evaluated. The Böhler's angle, Gissane angle, and calcaneal varus were measured for radiological assessment.

RESULTS

There was a significant difference in the mean operation time (p=0.001) and length of hospitalization (p=0.001) between the two groups. There was no significant difference between the pre- and postoperative third-year Böhler's and Gissane angles (p=0.05, p=0.07, p=0.09, respectively). There were no significant differences between the postoperative first-, second-, and third-year AOFAS, MFS, and SF-36 scores (p=0.57, p=0.55 p=0.85, p=0.64, p=0.21, p=0.51, p=0.20, p=0.15, p=0.22, respectively). Thirteen patients in the ORIF group and five patients in the MIPF group changed their job due to significant heel pain. The increased shoe size was correlated with the residual calcaneal varus (p=0.001).

CONCLUSION

Both methods have pros and cons in the treatment of calcaneal fractures. Although MIPF is more advantageous in terms of operation duration and length of hospitalization, more favorable radiological results can be obtained with ORIF. Calcaneal varus should be corrected to prevent the increased shoe size and contralateral knee pain.

Dual plating or dual plating combined with compression bolts for bicondylar tibial plateau fractures: a retrospective comparative study

The aim of this study was to compare secondary loss of reduction outcomes in dual plating fixation and dual plating combined with compression bolt fixation for bicondylar tibial plateau fractures (TPFs). We performed a retrospective study from January 2015 to April 2019. A consecutive series of 72 bicondylar TPFs underwent surgical treatment and was divided into two groups: group 1 (dual plating, n = 46) and group 2 (dual plating combined with compression bolts, n = 26). The outcomes collected included demographic characteristics, imaging characteristics, intraoperative indicators, clinical outcomes and reduction quality after surgery. Functional outcome was rated according to the Hospital for Special Surgery (HSS) score and Lysholm score. The secondary loss of reduction rate in group 2 was reduced compared with that in group 1 (P = 0.025), and the mean HSS score of group 2 was higher than that of group 1 (P = 0.013). The rate of complications was 30.4% (14/46) in group 1 and 30.8% (8/26) in group 2 (P = 0.976). Compared with single dual plating fixation, dual plating combined with compressing bolt fixation reduced the secondary loss of reduction rate for patients with bicondylar TPFs and showed better functional outcomes.

Lateral Extensile Approach Versus Minimal Incision Approach for Open Reduction and Internal Fixation of Displaced Intra-articular Calcaneal Fractures: A Meta-analysis

Treatment of displaced intra-articular calcaneal fractures remains controversial. Therefore, the purpose of this large meta-analysis was to report the outcomes of the lateral extensile approach versus the minimal incision approach including complications, anatomic reduction, functional outcomes, and timing and to report results when only randomized control trials were compared. Five electronic databases were searched for articles directly comparing the 2 above approaches. Inclusion criteria included articles published from January 2007 to April 2017, adults (>18 years old) with closed, Sanders type II or III fractures, mean follow-up time of ≥12 months, and ≥1 primary outcome reported. Seventeen randomized control trials and 10 retrospective studies were included. There were 2179 participants with 2274 fractures, and mean follow-up of 22.41 months. Our results revealed no statistically significant difference in Gissane's angle, calcaneal width, calcaneal length, deep infection, or subtalar stiffness. When taking into consideration only randomized control trials, there was no statistically significant difference between groups comparing postoperative Bohler's or Gissane's angle. There was a statistically significant difference in wound complications, superficial infection, sural nerve injury, visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores, operative time, time to operating room, calcaneal height, and postoperative Bohler's angle (when all studies were considered), all in favor of the minimal incision approach. These results remained statistically significant when only the randomized controlled trials were compared, with the exception of Bohler's angle and VAS and AOFAS scores. The results of this meta-analysis indicate that the minimal incision approach is a good alternative to the standard lateral extensile approach.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Limited Open Reduction and Internal Fixation of Calcaneal Fractures

BACKGROUND

The treatment of displaced intra-articular calcaneal fractures remains a challenge and the optimal approach is still controversial. The main reason to avoid the extended lateral approach is the high complication rate due to wound healing problems. We report on 16 years of experience with a standardized limited open reduction and internal fixation technique.

METHODS

Between 2001 and 2017, we prospectively followed 240 consecutive patients operatively treated for a displaced intra-articular calcaneal fracture. Patients with open, multiple, bilateral, extra-articular, and Sanders IV fractures and those lost to follow-up were excluded. A lateral subtalar approach was used, with a cast for 8 weeks and full weightbearing allowed after 12 weeks. Follow-up examinations were scheduled until 24 months. Subjective and clinical assessment included gait abnormality, subtalar and ankle range of motion, and stability and alignment. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was calculated. Alignment was analyzed on standard radiographs. In total, 131 patients were excluded. The remaining 109 patients were followed for a minimum of 24 months (34.4 ± 14.2 [range, 24-102] months).

RESULTS

The mean AOFAS score was 87 ± 13 (range, 32-100). "Excellent" and "good" results, as well as hindfoot motion with "normal/mild" and "moderate" restrictions, were seen in 80% of patients. Early reoperations were performed for insufficient reduction (2 patients), delayed wound healing (debridement, 3 patients), and hematoma (1 patient). Late revisions were arthrodesis (3 patients), medializing calcaneal osteotomy (1 patient), and implant removal (53 patients; 49%).

CONCLUSION

The presented approach has remained unmodified for 16 years and resulted in consistently good functional results. The main disadvantage was the high rate of heel screw removal.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Mini-plate fixation via sinus tarsi approach is superior to cannulated screw in intra-articular calcaneal fractures: A prospective randomized study

OBJECTIVE

Intra-articular displaced calcaneal fractures are common fractures and are often treated with surgical interventions. Sinüs tarsi approach provides secure access to lateral wall and joint facets. The aim of the study is to compare cannulated screw (CS) fixation and mini-plate (MP) fixation via sinus tarsi approach with Sanders types 2 and 3 fracture of calcaneus.

METHODS

Sixty patients with Sanders types 2 and 3 calcaneal fracture underwent surgical intervention were randomly allocated into two groups as group MP fixation and group CS fixation regarding osteosynthesis method for 5-year period. Open reduction via sinüs tarsi approach was performed in both groups. Demographic variables, time to surgery (TS), operation duration (OD), length of hospital stay (LOS), surgical complications, and reoperations were recorded. Pre- and postoperative Gissane and Böhler angles; calcaneal length, height, and width; ankle anterior-posterior (AP) and lateral X-rays; and computed tomography were also recorded for radiological evaluation and fracture characteristics. Maryland Foot Score (MFS) was used to evaluate functional outcomes.

RESULTS

Preoperative age, type of fracture, calcaneal length, height, and Gissane and Böhler angles, TS, LOS, and OD were not different between the groups. The postoperative calcaneal widening was significantly better restored in group MP compared with that of group CS. The incidence of reoperation and algoneurodystrophy was statistically higher in group CS than group MP. MFS in group MP was also higher than group CS at final visit.

CONCLUSION

MP fixation via sinus tarsi approach is superior to CS fixation in Sanders types 2 and 3 calcaneal fractures.

A systematic review and meta-analysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures

BACKGROUND

The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017).

RESULTS

Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I²=0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes.

CONCLUSIONS

The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF.

Short-Term Radiographic Outcomes of Calcaneus Fractures Treated With 2-Incision, Minimally Invasive Approach

BACKGROUND

The treatment of displaced, intra-articular calcaneus fractures is controversial. The extensile lateral approach has been historically preferred because it provides excellent exposure and visualization for fracture reduction. However, soft tissue complications with this approach can lead to poor outcomes for patients. Recently, there has been an interest in the minimally invasive treatment of calcaneus fractures. The purpose of the present study was to determine the radiographic reduction of displaced, intra-articular calcaneus fractures and the rate of complications using a 2-incision, minimally invasive approach.

METHODS

A dual-incision, minimally invasive approach with plate and screw fixation was utilized for the treatment of 32 patients with displaced, intra-articular calcaneus fractures. Preoperative and postoperative calcaneal measurements were taken to assess fracture reduction. Additionally, a retrospective chart review was performed to assess for complications.

RESULTS

The mean preoperative Bohler's angle measurement was 12.9 (range, -5 to 36) degrees and the final postoperative Bohler's angle was 31.7 (range, 16-40) degrees. One patient (3.1%) had postoperative numbness related to the medial incision in the calcaneal branch sensory nerve distribution. Two patients (6.2%) had a wound infection treated with local wound care and oral antibiotics, while 1 patient (3.1%) had a deep infection that required a secondary surgery for irrigation and debridement. Two patients (6.2%) returned to the operating room for removal of symptomatic hardware.

CONCLUSION

Operative fixation of displaced, intra-articular calcaneus fractures treated with a 2-incision, minimally invasive approach resulted in acceptable fracture reduction with a minimal rate of complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most?

Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures.

Computed Tomography Imaging-Based Preoperative Virtual Simulation for Calcaneal Fractures Reduction

Reduction of calcaneal fractures via a small incision approach at the sinus tarsi is technically difficult. This study was undertaken to determine if preoperative virtual simulation based on computed tomographic data improves reduction and reduces complications. Fifty-five patients with calcaneal fractures were treated via the sinus tarsi approach with minimally invasive plates between February 2013 and December 2015. DICOM files obtained from computed tomographic imaging preoperatively were imported into Superimage software, and virtual surgery was performed. Preoperative planning time, operative time, and complications were recorded. Clinical function was analyzed with radiology and with the American Orthopaedic Foot and Ankle Society and visual analogue scale scores. As a result, preoperative planning time was 30.7 ± 4.1 minutes, which increased with the severity of the fracture (Sanders III vs Sanders II: 34.2 ± 2.5 minutes vs 27.8 ± 2.7 minutes), which was in line with the real surgery, with a mean operative time of 86.7 ± 4.5 minutes (Sanders III vs Sanders II: 89.5 ± 2.7 minutes vs 84.3 ± 4.4 minutes). Radiologic results indicated that the calcaneal width, length, height, Böhler angle, and Gissane angle were significantly corrected from preoperatively to postoperatively. After a mean follow-up of 21.5 ± 6.1 months, no complications were observed. The mean American Orthopaedic Foot and Ankle Society score was 88.7 ± 4.0, with an excellent/good rate of 94.5% (52 of 55). The mean visual analogue scale score was 0.8 ± 0.9. In conclusion, preoperative virtual simulation may be efficient to promote accomplishment of sinus tarsi surgery, and this step may help improve outcomes for calcaneal fractures.

The use of bidirectional rapid reductor in minimally invasive treatment of bicondylar tibial plateau fractures: preliminary radiographic and clinical results

BACKGROUND

Minimally invasive treatment of complex tibial plateau fracture represents one of the most challenging problems in orthopedic surgery. We intended to describe the percutaneous surgery involving an originally designed traction device which might facilitate the closed reduction for bicondylar tibial plateau fractures. Further, to assess the clinical outcomes of this minimally invasive technique.

METHODS

Between December 2015 and July 2016, Twenty-one patients, mean age 43.71 ± 13.80 years, suffering from a bicondylar tibial plateau fracture (AO/OTA 41-type C) were included. All fractures were firstly reduced by skeletal traction with the aid of bidirectional rapid reductor, and residual depressed fragments were treated with minimally invasive bone tamp reduction. We then evaluated at a minimum follow-up of one year: (1) the rate of complications, (2) the radiographic outcomes (the amount of depression, tibial plateau widening, tibial plateau angle and posterior slope angle) and (3) the clinical outcome (Rasmussen scoring system).

RESULTS

All patients had their fractures healed without secondary displacement. No instrument-related complications occurred during operation. Post-operatively, superficial infection was found in two patients and donor-site morbidity was found in one patient. We observed a < 5 mm step-off in 100% of patients and a < 5 mm plateau widening in 95.5% of patients. Three patients were considered indicative of malalignment with TPA > 90° or PSA > 15°. At last evaluation, the Rasmussen clinical score was excellent in 11 patients (52.3%), good in 9 (42.9%) and fair in 1 (4.8%), and the radiological score was excellent in seven patients (33.3%), good in 14 (66.7%).

CONCLUSIONS

The bidirectional rapid reductor facilitates the minimally invasive treatment of bicondylar tibial plateau fracture. The patients exhibited excellent functional recovery. These results should be validated with a larger group of patients and longer period results.

TRIAL REGISTRATION

ChiCTR-OPC-16008011 .

Extensile lateral versus sinus tarsi approach for displaced, intra-articular calcaneal fractures: a meta-analysis

Background

Operative management of displaced, intra-articular calcaneal fractures is associated with improved functional outcomes but associated with frequent complications due to poor soft tissue healing. The use of a minimally invasive sinus tarsi approach to the fixation of these fractures may be associated with a lower rate of complications and therefore provide superior outcomes without the associated morbidity of operative intervention.

Methods

We reviewed four prospective and seven retrospective trials that compared the outcomes from the operative fixation of displaced intra-articular calcaneal fractures via either an extensile lateral approach or minimally invasive fixation via a sinus tarsi approach.

Results

Patients managed with a sinus tarsi approach were less likely to suffer complications (OR = 2.98, 95% CI = 1.62–5.49, p = 0.0005) and had a shorter duration of surgery (OR = 44.29, 95% CI = 2.94–85.64, p = 0.04).

Conclusion

In displaced intra-articular calcaneal fractures, a minimally invasive sinus tarsi approach is associated with a lower complication rate and quicker operation duration compared to open reduction and internal fixation via an extensile lateral approach.

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

The "Open-Envelope" Approach: A Limited Open Approach for Calcaneal Fracture Fixation

BACKGROUND

Minimally invasive surgery (MIS) has a significant and evolving role in the treatment of displaced intra articular calcaneal fractures (DIACFs), but there is limited literature on this subject. The objective was hence to assess the clinicoradiological outcomes of DIACFs fixed with an innovative open-envelope MIS technique.

MATERIALS AND METHODS

42 closed Sanders Type 2 and 3; DIACFs were included in this study. The Open-envelope approach was developed, which is essentially a limited open, dual incision, modified posterior longitudinal approach allowing excellent visualisation and direct fragment manipulation. The main outcome measures were American Orthopaedic Foot and Ankle Score (AOFAS) hindfoot score and preoperative and postoperative radiological angles.

RESULTS

The Bohler angle improved from a preoperative mean of 14.3° (range 0°-28°) to a postoperative mean of 32.46° (range 22°-42°). The Gissane angle improved from a preoperative mean of 135.83° to a postoperative mean of 128.33°. The postoperative improvement in Bohler and Gissane angles was highly significant (P < 0.001). The AOFAS scores at 6 months were excellent in nine patients, good in 15 patients, and fair in six patients. Three patients had residual valgus deformity of the heel.

CONCLUSIONS

Open-envelope technique minimized soft tissue complications and achieved acceptable radiological reductions with good clinical outcomes.

Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis

Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.

Comparison of calcaneus joint internal and external fractures in open surgery and minimal invasive methods in patients

Surgical management of calcaneal fractures has various complications. In recent years, minimally invasive surgeries have been utilized for a wide range of surgical procedures on different body parts significantly declining complications. This paper compares surgical outcomes of calcaneal fracture management between the open reduction and internal fixation technique (ORIF) and the MIS technique. In this randomized clinical trial forty patients with calcaneus fractures were randomly assigned to two equal groups; ORIF group and MIS group. Patients were followed for 1 year post-operatively. Gissane and Bohler’s angles, AOFAS questionnaire, pain intensity, ability to conduct previous activities and various complications like wound healing complications and irritation with shoe wear were assessed in the final post-operative visit. Eventually data obtained from the two groups were compared. All patients obtained fracture union. Bohler’s and Gissane angles significantly increased and decreased, respectively, after the operation in both groups (p˂0.05), however, no significant difference was found between the two research groups. AOFAS scores and pain intensity was similar in both groups, however, surgical duration in the MIS group was significantly less than the ORIF group (P=0.021). Only one patient from the ORIF group was not able to resume his previous occupation. 12 patients from the ORIF group and five patients from the MIS group experienced irritation from shoe wear (p=0.025). In the ORIF group, 4 patients suffered from wound healing complications, however, none of the patients of the MIS group had wound complications (p=0.035). In conclusion, based on the results, it can be concluded that the MIS technique demonstrated better functional and radiographic outcomes as well as a more favorable complication profile, thus, it is recommended for the management of calcaneus fractures.

Comparison of Calcaneal Exposure Through the Extensile Lateral and Sinus Tarsi Approaches

The purpose of this study was to compare the exposure of the posterior facet with the extensile lateral (EL) approach compared with the sinus tarsi (ST) approach. We hypothesized that the ST approach will provide a similar exposure of the posterior calcaneal facet. A total of 8 sequential ST then EL approaches were performed on cadavers. Calcaneal landmarks were identified by visualization or palpation. Calibrated digital photographs of the posterior facet and lateral calcaneal body were obtained from standardized positions and used to calculate the exposed surface area. No significant difference was found in the average square area of the posterior facet exposed with the 2 approaches. Significantly more of the lateral calcaneal body was seen with the EL approach. Excluding the posterior facet superomedial quadrant, all the landmarks were visualized in 100% of approaches. The superomedial corner was visualized in significantly more of the cadavers with the EL approach and was palpable in 12.5% of the remaining cadavers in both approaches. Whereas the ST approach exposes less of the lateral wall of the calcaneus, it exposes similar amounts of the posterior facet when compared with the EL approach.

LEVELS OF EVIDENCE

Therapeutic, Level V.

The effect of time to post-operative weightbearing on functional and clinical outcomes in adults with a displaced intra-articular calcaneal fracture; A systematic review and pooled analysis

BACKGROUND

Post-operative weightbearing guidelines for displaced intra-articular calcaneal fractures (DIACF) have been pragmatically developed in the past, however hardly adapted to current health care insights. A period of six to nine weeks of non-weightbearing is usually recommended. It is unknown whether an earlier start of weightbearing is advisable.

OBJECTIVES

The primary aim was to evaluate the effect of time to post-operative weightbearing on Böhler's angle. Secondary aims were to determine the effect on functional outcome (e.g., The American Orthopedic Foot and Ankle Society Scale), post-operative pain score, complications (e.g., infections, nonunion, implant removal), and revision surgeries. Finally, the effect of bone void filling on these outcomes was investigated.

DATA SOURCE

A literature search was performed on January 24, 2017 in the Cochrane Library, Medline Ovid, Embase, Web of Science, Google Scholar, and CINAHL.

LITERATURE SELECTION

Studies reporting on operatively treated patients with a DIACF and time to weightbearing were eligible for inclusion. Studies were excluded when not reporting primary data, solely reporting on open fractures, bilateral fractures, or polytrauma patients. Based upon the time to starting partial weightbearing, patient cohorts were stratified into very early (0-4 weeks), early (4-6 weeks), intermediate (6-8 weeks), or late (8-12 weeks) start of partial weightbearing.

DATA EXTRACTION

Two investigators extracted data independently using a predefined data sheet.

RESULTS

After applying exclusion criteria, 72 studies remained eligible for analysis. Böhler's and Gissane's angles, calcaneal height, AOFAS, pain scores, and complications had overlapping confidence intervals in all weightbearing groups.

CONCLUSION

The adverse sequelae which are assumed to be associated with starting partial weightbearing already within six weeks after internal fixation of calcaneal fractures, is not supported by literature data. This systematic review suggests that early weightbearing does not result in impaired outcomes compared with more conservative weightbearing regimes.

Clinical application of the sinus tarsi approach in the treatment of intra-articular calcaneal fracture

To observe the clinical outcome of the sinus tarsi approach in the operative treatment of intra-articular calcaneal fractures.Forty-nine intra-articular calcaneal fractures in 45 patients were managed surgically with sinus tarsi approach. The anatomical plate and compression bolts were applied in 14 feet. The anatomical plate and screws were applied in 35 feet. Maryland foot score system was used to evaluate the function of the hindfoot at the followup.The reduction of the posterior facet was graded as nearly anatomical (less than 2 mm articular displacement) in 46 feet (93.9%). The width, height, and Böhler angle were significantly improved in all patients (P < .01). After a mean follow-up period of 18.7 months (14.5-29 months), the Maryland foot scores were: 34 feet scored 90-100 points (excellent), 6 feet scored 80-90 points (good), 6 feet scored 70-80 points (fair), and 3 feet scored 60-70 points (poor). Incision-edge necrosis occurred in 2 cases. One case suffered from incomplete medial plantar nerve injury. One case suffered from heel pad branch of the tibial nerve injury. Six cases suffered from sural nerve injury, and 4 cases sustained a lateral wound dehiscence due to a hematoma. No case suffered from lateral impingement syndrome. Up to now, no patient had to accept subtalar arthrodesis.Sinus tarsi approach provides good exposure to the subtalar joint. Open reduction and internal fixation of calcaneus fractures through a sinus tarsi approach allows adequate reduction with low risk of wound-healing complications.

Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: A meta-analysis of current evidence base

BACKGROUND

The relative efficacy of operative and nonoperative treatments for the displaced intra-articular calcaneal fractures (DIACF) remains uncertain.

OBJECT

We conducted a meta-analysis to compare the effectiveness of operative and nonoperative treatments in treating patients with DIACF.

METHODS

Databases including Cochrane Library, Medline, Embase, CBM, CNKI, and Google Scholar were searched. After independent study selection by 2 authors, data were extracted and collected independently. Comparisons were performed between operative treatment group and nonoperative treatment group. The quality of included studies was assessed using the Newcastle-Ottawa Scale. RevMan 5.3 was used for data analysis. The primary outcome measures were anatomical measures (changes in Böhler angle and calcaneal height and width), functional measures (shoe problems, resuming preinjury work, and residual pain), and complications (including superficial and deep wound infection, skin flap necrosis, neurovascular injury, secondary arthrodesis, reflex sympathetic dystrophy, osteotomy, thromboembolism, and compartment syndromes).

RESULTS

Eighteen trials (8 randomized controlled trials and 10 controlled clinical trials) including 1467 patients were considered. For anatomical measurements, the overall mean differences (MDs) for the mean Böhler angle, calcaneal height and width were 15.39 (95% confidence interval [CI] 9.12-21.67), 6.55 (95% CI 2.67-10.43), and 7.05 (95% CI -7.83 to -6.27), respectively. In functional measures, the overall effect MD of American Orthopedic Foot and Ankle Society was 6.23 (95% CI 5.22-17.67) and 0.38 (95% CI 0.22-0.67). The overall relative risks (RRs) of wearing shoes, resuming preinjury work, and having residual pain were 0.32 (95% CI 0.32-1.00), 0.56 (95% CI 0.40-0.77), and 0.90 (95% CI 0.68-1.20), respectively. The overall RR of the incidence of complications was 2.00 (95% CI 1.51-2.64).

CONCLUSION

Operative treatment of DIACF may lead to a higher incidence of complications but has better anatomical recovery when compared with nonoperative treatment.

Functional outcome after calcaneus fractures: a comparison between polytrauma patients and isolated fractures

BACKGROUND

Displaced intra-articular calcaneal fractures (DIACFs) can have long-term consequences in terms of foot pain and disability. This injury frequently occurs in the context of polytrauma patients and its influence in long-term functional prognosis is well known. The purpose of this study is to compare the etiology, severity, and functional outcome of the operated DIACFs between polytrauma patients and isolated cases.

METHODS

Eighty-six patients with operated displaced intra-articular calcaneal fractures through open reduction and internal fixation (ORIF) were managed at our institution between January 1, 2008 and December 31, 2015. Eighty patients completed the follow-up, nine of them with both calcaneus operated (89 calcaneus) by ORIF with a plate. Two groups were established; one included 11 (14%) polytrauma patients, three of them with operated bilateral calcaneus, and 69 (86%) patients without polytrauma diagnosis. Severity of trauma, injury patterns, psychiatric background, associated fractures, second surgeries and functional questionnaire (adjusted American Orthopedic Foot and Ankle Society - AOFAS - ankle-hindfoot scale and SF-36) were collected. A detailed comparative statistical analysis is provided.

RESULTS

There was significant statistical relationship between polytrauma patients and those with psychiatric comorbidities, severe trauma or severe injury, but not with second surgeries, later subtalar arthrodesis or outcome measures. Only calcaneal fractures with comminution according to Sanders classification was associated with second surgeries and later subtalar arthrodesis. The AOFAS score was solely related to trauma severity (71.5 vs 77; p = 0.29) and calcaneal fracture's comminution according to Sanders classification (79.4 type II and 79.3 type III vs 69.2 type IV; p = 0.000 and p = 0.008, respectively) and SF-36 score only with trauma severity (67.4 vs 78.1; p = 0.00) and psychiatric comorbidities (62.2 vs 75.8; p = 0.048).

CONCLUSION

No differences in outcome measures and second surgeries were found between polytrauma patients and isolated fractures. For DIACFs, the severity of the impact was correlated with a higher number of second surgeries and worse functional outcomes. Following a DIACF, patients with psychiatric comorbidities presented worse health-related quality of life than people without this background.

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.].

Open Reduction Assisted With an External Fixator and Internal Fixation With Calcaneal Locking Plate for Intra-articular Calcaneal Fractures

BACKGROUND

The extensile lateral approach (ELA) has been considered to be a standard approach for displaced intra-articular calcaneal fractures (DICF) because it provides excellent exposure and allows direct reduction of the depressed posterior facet fragment. But continuous retraction during surgery needs sufficient manpower and may cause ischemia. Failure of rigid fixation of DICF will not allow for early weight bearing and may lead to a loss of reduction. To avoid these disadvantages, this study presents open reduction assisted with an external fixator and internal fixation with a calcaneal locking plate.

METHODS

A series of 58 patients with 62 DICFs were treated over a period of 49 months. All patients were clinically and radiologically followed up with a mean follow-up of 35 (range 29-42) months. Clinical follow-up included visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and ability to work. Radiologic follow-up included axial and lateral radiographs and measurements of the Bohler angle and Gissane angle.

RESULTS

At the final follow-up, all fractures had healed. The mean VAS score was 2.9 (range 0 to 8, SD 1.9) and the average AOFAS score was 71 (range 55-85, SD 8.1). The mean postoperative Bohler angle immediately after the surgery was 28.3 degrees (range 13.0-44.6, SD 7.0), which decreased to 27.5 degrees (range 12.2-43.3, SD 7.0) at the final follow-up, and the mean postoperative Gissane angle after the surgery was 116.3 degrees (range 94.9-131.5, SD 9.0) which finally increased to 118.4 degrees (range 94.5-135.8, SD 9.3). No statistically significant differences regarding Bohler and Gissane angles were found between different Sanders fracture types ( P>.05).

CONCLUSION

The presented operative technique was found to provide comparable reduction of Sanders type II-IV injuries.

LEVEL OF EVIDENCE

Level III, case control study.

Radiological study of the secondary reduction effect of early functional exercise on displaced intra-articular calcaneal fractures after internal compression fixation

PURPOSE

Early post-operative exercise and weight-bearing activities are found to improve the functional recovery of patients with displaced intra-articular calcaneal fractures (DIACFs). We hypothesized that early functional exercise after surgery might have a secondary reduction effect on the subtalar joint, in particular the smaller fracture fragments that were not fixed firmly. A prospective study was conducted to verify this hypothesis.

METHODS

From December 2012 to September 2013, patients with unilateral DIACFs were enrolled and received a treatment consisting of percutaneous leverage and minimally invasive fixation. After surgery, patients in the study group started exercising on days two to three, using partial weight bearing starting week three, and full weight bearing starting week 12. Patients in the control group followed a conventional post-operative protocol of partial weight bearing after week six and full weight bearing after the bone healed. Computed tomography (CT) scanning was performed at post-operative day one, week four, week eight, and week 12 to reconstruct coronal, sagittal, and axial images, on which the maximal residual displacements of the fractures were measured. Function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale at the 12th post-operative month.

RESULTS

Twenty-eight patients in the study group and 32 in the control group were followed up for more than 12 months; their data were collected and used for the final analysis. Repeated-measures analysis of variance (ANOVA) of the maximal residual displacements of the fracture measured on CT images revealed significant differences between the study and the control groups. There were interaction effects between group and time point. Except for the first time point, the differences between the groups at all studied time points were significant. In the study group, the differences between all studied time points were significant. Strong correlations were observed between the AOFAS score at post-operative month 12 and the maximal residual displacement of the fractures on the CT images at postoperative week 12.

CONCLUSIONS

Early functional exercise and weight bearing activity can smooth and shape the subtalar joint and reduce the residual displacement of the articular surface, improving functional recovery of the affected foot. Therefore, early rehabilitation functional exercise can be recommended in clinical practice.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

MAIN OUTCOME MEASUREMENT

AOFAS hindfoot score, pre-operative and postoperative radiology.

RESULTS

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

CONCLUSIONS

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

Sinus tarsi approach versus extensile lateral approach for displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base

Background

The extensile lateral approach (ELA) has been widely performed for displaced intra-articular calcaneal fractures (DIACFs), and wound complications remain a significant problem. As a minimal incision technique, the sinus tarsi approach (STA) was designed to overcome this disadvantage. There were already many reports about this approach but the conclusions were not completely consistent. Based on the current evidence, we performed this meta-analysis to compare the STA with ELA in the management of DIACF and expected to draw a certain and meaningful conclusion.

Methods

All potentially relevant randomized controlled trials (RCTs) and cohort studies (CSs) were searched in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrial.gov. The desirable outcomes including wound complications, excellent and good rate, secondary surgery rate and Böhler’s angle were extracted. RCT studies were assessed using the Risk of Bias Tool recommended by the Cochrane Collaboration, and cohort studies were evaluated using the Newcastle–Ottawa Scale. The data of RCTs and cohorts were pooled respectively using the fixed-effect model or random-effect model. Mean differences with 95% confidence intervals (CIs) were calculated for continuous data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data. Statistical heterogeneity was assessed with the Q test and I². Sensitivity analysis was developed to assess the reliability of pooled results.

Results

Seven studies including two RCTs and five CSs were eligible for the meta-analysis. No matter RCTs or CSs, the pooled data all showed that STA group had a lower incidence of wound complications than that in the ELA group and no significant difference was found in excellent and good rate and the recovery of Böhler’s angle between the two groups. The CSs also showed that the STA group had a lower incidence of secondary surgeries than that in the ELA group.

Conclusions

Through a STA, we not only can reduce the problems in wound healing but also achieve nearly the same adequate restoration of DIACF along with the similar functional outcomes compared with through an ELA.

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

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

LEVELS OF EVIDENCE

Level IV.

Treatment of calcaneal fractures with closed reduction and the Endobutton-assisted technique: short-term analysis

BACKGROUND

Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis.

METHODS

Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments.

RESULTS

The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent.

CONCLUSIONS

With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

Comparison of percutaneous cannulated screw fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial

BACKGROUND

The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs.

METHODS

Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC (N = 42) or MISTA (N = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded.

RESULTS

The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group (p < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group (p < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group (p < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures (p < 0.05).

CONCLUSION

The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs.

TRIAL REGISTRATION

ChiCTRIOR16008512 . 21 May 2016.

Operative treatment of intraarticular calcaneal fractures: Anatomical and functional outcome of three different operative techniques

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.

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.

Does axial view still play an important role in dealing with calcaneal fractures?

Background

The study aimed to analyze the role of axial view in different phases of treatment and demonstrate whether axial view is still useful in evaluating the calcaneal fractures.

Methods

156 patients with suspected unilateral calcaneal fractures were enrolled in the study, axial and lateral view of the affected foot and single axial view of the unaffected foot were gained. 16 were excluded due to unsatisfying axial radiograph. The remain 140 patients were eventually included into the study. Two separate assessments were conducted on two occasions with a three weeks interval to diagnose fractures. Lateral views were assessed firstly, and lateral combined with axial views were assessed three weeks later. Each of the 140 sets was evaluated by one of 6 surgeons randomly. Sensitivity and specificity value were compared between the two assessments. A new value Z which can directly reflect the degree of bulge on the calcaneal lateral wall on the axial view were introduced into the study. Z value of the 140 unaffected feet were measured. Data of another group of 31 patients who confirmed their lateral hindfoot pain caused by widening of calcaneus was reviewed. Liner regression was employed to analyze the relationship between angle Z and the severity of lateral pain.

Results

According to the two assessments, without axial view, specificity value will be significantly lower in diagnosing calcaneal fractures (p = 0.024) and sensitivity value will be significantly lower in distinguishing intra-articular fractures (p < 0.001). The normal threshold of angle Z was estimated from 98.06° to 100.64° (p <0.001). Liner regression shows that the lateral hindfoot pain will obviously aggravate along with the increasing of angle Z value (p <0.001).

Conclusions

Axial view is useful in diagnosing a patient with suspected calcaneal fracture especially for distinguishing intra-articular fractures and selection for CT scan. With the introduction of angle Z, axial view can get excellent performance in intra-operative assessment as well as in post-operative follow up procedure. Axial view can still play an irreplaceable role in assessing and evaluating calcaneal fractures, and can be employed as an essential reference during surgical procedure .

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-015-0004-6) contains supplementary material, which is available to authorized users.

Functional outcome and patient satisfaction after displaced intra-articular calcaneal fractures: a comparison among open, percutaneous, and nonoperative treatment

The aim of the present study was to compare the outcomes of patients with a displaced calcaneal fracture treated by open reduction and internal fixation (ORIF), percutaneous treatment, or nonoperative methods. A retrospective cohort study was conducted at a level I trauma center of patients with a displaced intra-articular calcaneal fracture treated from January 1, 2002 to December 31, 2011. The patient-reported outcome measures included the Foot Function Index, American Orthopaedic Foot and Ankle Society hindfoot scale, Short Form-36, the EQ-5D from the EuroQol Group, and a 10-point visual analog scale. Clinical data were collected from 169 patients, and questionnaires were obtained from 78 patients (18 nonoperatively, 27 ORIF, and 33 percutaneously). The late intervention rate was significantly greater in the percutaneous group (n = 18; 30%) than in the ORIF group (n = 6; 12%) or the nonoperative group (n = 8; 13%; p = .030). Significantly more disability was reported in the nonoperative group (median Foot Function Index score, 40 points) than in the ORIF group (median, 16 points; p = .010) or in the percutaneous group (median, 21 points; p = .034). In conclusion, the operatively treated patients (ORIF and percutaneous treatment) reported better functional outcome scores (Foot Function Index and American Orthopaedic Foot and Ankle Society hindfoot scale) than did the nonoperatively treated patients.

Bony destructive injuries of the calcaneus: long-term results of a minimally invasive procedure followed by early functional exercise: a retrospective study

Background

Bony destructive injury of the calcaneus (BDIC) represents one of the most severe comminuted fractures of the calcaneus in which soft tissue coverage remains intact. The features of this injury include a collapsed articular surface, significant widening, severe loss of height and an unrecognisable outline of the calcaneus. This study aims to present the long-term outcomes of BDIC treated in a minimally invasive fashion followed by supervised early exercise.

Methods

Twelve patients with unilateral BDICs were treated at our institution. The main surgical procedures included percutaneous traction and leverage reduction and internal compression fixation with anatomic plates and compression bolts. Early functional exercise was encouraged to mould the subtalar joint. The height, length and width of the calcaneus; Böhler’s and Gissane’s angles; reduction of the articular surfaces; and functional recovery of the affected feet were assessed.

Results

The height, length and width of the calcaneus were substantially restored. The mean Böhler’s and Gissane’s angles of the affected calcaneus were 24.5 and 122.8 degrees, respectively. Five patients regained anatomical or nearly anatomical reduction of their posterior facets. Residual articular displacement of more than 3 mm was noted in three patients. Patients were followed for a mean of 93.9 months. The mean American Orthopaedic Foot and Ankle Society score was 83.8. Nine patients showed excellent or good results. Radiographic evidence of post-traumatic subtalar arthritis was observed in four cases. However, no subtalar arthrodesis was required.

Conclusions

BDICs can be treated effectively with percutaneous reduction and internal compression fixation followed by early active exercise. This protocol resulted in satisfactory radiological and functional outcomes.

Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach

BACKGROUND

The optimal treatment for displaced intra-articular fractures of the calcaneus remains controversial. This study aims to assess the clinical outcomes of a minimally invasive longitudinal approach compared with the sinus tarsi approach in the surgical treatment of these fractures.

METHODS

Patients with a displaced intra-articular fracture of the calcaneus who were admitted to the trauma center of our hospital from September 2009 through April 2010 were randomly assigned to treatment using one of these two surgical techniques. All patients underwent the same standardized postoperative rehabilitation protocol. Functional outcome was assessed by using the American Orthopaedic Foot & Ankle Society scores. Linear regression analysis was performed to identify the potential influencing factors for functional outcomes.

RESULTS

One hundred and sixty-seven patients who met the inclusion criteria were included in the study. Thirty-seven patients were lost to follow-up for various reasons, and the remaining 130 patients were followed for an average of twenty-seven months. Sixty-nine fractures in sixty-three patients were treated using a minimally invasive longitudinal approach (the MILA group), and seventy-two feet in sixty-seven patients were treated with a sinus tarsi approach (the STA group). The two groups were comparable in terms of age, sex, fracture type, and time from injury to operation. The operative time in the MILA group was significantly shorter than that in STA group (p < 0.05). Wound-healing complications were 2.9% in the MILA group and 12.5% in the STA group. The average time to the start of progressive weight-bearing exercise was 5.3 weeks in the MILA group and 5.6 weeks in the STA group (p > 0.05). The good and excellent results in the two groups were comparable for the Sanders type-II and III calcaneal fractures (p > 0.05), but the good to excellent rate in the STA group was significantly higher for the Sanders type-IV fractures (p < 0.05). Linear regression analysis showed that surgical technique, Sanders classification, and the time to the start of weight-bearing activity have a significant influence on functional outcomes.

CONCLUSIONS

Outcomes are similar for the minimally invasive longitudinal and sinus tarsi surgical approaches in the treatment of Sanders type-II and III displaced intra-articular fractures of the calcaneus, with the benefit of a lower complication rate and shorter operative time for the minimally invasive technique. For Sanders type-IV fractures, however, the sinus tarsi approach appears to be the treatment of choice.