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

Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management

OBJECTIVES

To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures.

PATIENTS AND METHODS

We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates.

RESULTS

Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups.

CONCLUSIONS

Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.

Circular External Fixator Assisted Open Reduction Combined With Locking Plate Fixation for Intra-articular Comminuted Fractures of the Calcaneus

Comminuted fractures of the calcaneus are relatively common and generally require surgical treatment. The quality of fracture reduction is crucial. The extended lateral approach (ELA) can better expose the fracture end and facilitate the reduction of the fracture, while it has a higher risk of postoperative skin complications. In this study, the ELA was adopted, and the calcaneal comminuted fractures were treated with circular external fixator assisted reduction to achieve the purpose of good reduction of the fracture and fewer skin complications. During 64 months, a total of 61 cases of unilateral calcaneal fractures were treated by the same surgeon and followed up for 19.28 ± 5.28 months. During the operation, a circular external fixator was employed to fix the midfoot and the distal end of the tibia, and the calcaneal tubercle; then, the calcaneal tubercle was distracted to restore the 3-dimensional structure of the calcaneus. The ELA was utilized to reduce the articular surface fracture. The fracture was fixated with a locking plate. Postoperative radiographs were regularly reviewed. Meanwhile, Böhler's angle and Gissane's angle were measured. Visual analogue scale and American Orthopedic Foot and Ankle Society Score assessments were performed at the final follow-up. All fractures healed. The mean preoperative Böhler's angle was 9.3 ± 10.1 degrees; the mean Gissane's angle was 110.5 ± 14.7 degrees; the immediate postoperative mean Böhler's angle was 31.3 ± 5.5 degrees; mean Gissane's angle was 110.9 ± 5.9 degrees. Local superficial necrosis of surgical incision occurred in 2 cases, which healed well after dressing changes. Skin necrosis appeared in 1 case, where debridement and local flap transfer were performed. At the final follow-up, the mean visual analogue scale score was 1.48 ± 1.30, and the mean American Orthopedic Foot and Ankle Society Score was 90.16 ± 7.19. The ELA combined with a circular external fixator to assist in the reduction of calcaneal fractures achieved good reduction quality and effectively reduced postoperative complications.

Surgical experience as a decisive factor for the outcome of calcaneal fractures using locking compression plate: results of 3 years

INTRODUCTION

Calcaneal fractures account for 60-75% of all tarsal fractures and represent surgical challenges because of their frequency and complexity. Despite standardized procedures and new implants, literature reports high revision rates and unsatisfactory results. The study aims to describe the role of the surgeon with respect to the clinical outcome.

METHODS

Between 2014 and 2017, 94 calcaneal fractures (all type AO C1-3) were re-examined in 86 patients (67 male and 19 female; mean age: 51 years). The treatment was always carried out by means of locking compression plate via the extensile lateral approach. A comparison was made between treatment by an experienced (ES) and less experienced surgeon (LES). Annually, the ES performed at least 30 procedures for calcaneus fracture treatment as compared to < 10 operations performed by the LES.

RESULTS

The mean AOFAS, VAS FA, and Kiel Score in the ES group were 77.0 (SD 15.9), 69.0 (SD 18.8), and 65.0 (SD 20.6), respectively. The corresponding values in the LES group were 68.1 (SD 21.0), 60.3 (SD 22.4), and 53.0 (SD 21.9) (p < 0.05). The operation time was on average 14 min shorter in the ES group than the LES group (p < 0.05).

CONCLUSION

The significantly better scores, along with shorter operation time, shorter duration of incapacity to work, and lower complication rate prove the importance of having an experienced surgeon perform complex intra-articular calcaneal fracture repairs. The extensile lateral approach is still considered the standard method.

LEVEL OF EVIDENCE

Level III, comparative series.

Joint-Sparing Surgical Management of Sanders IV Displaced Intra-Articular Calcaneal Fractures

Displaced intra-articular calcaneal fractures represent life-altering injuries. Difficulty obtaining and maintaining calcaneal morphology and the significant risk of wound healing complications with an extensile lateral incision exist. Open reduction with internal fixation as a joint-sparing approach has been studied. Closed manipulation to restore calcaneal morphology, intra-osseous fracture reduction, and rigid locked CALCANAIL fracture nail fixation have recently been applied to Sanders IV fracture patterns. Spontaneous conversion to primary subtalar joint arthrodesis using the same instrumentation remains unique to this system. This article reviews open and percutaneous approaches for joint-sparing and primary arthrodesis procedures to treat Sanders IV fracture patterns.