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Ahluwalia R, Lewis TL, Musbahi O, Reichert I. Minimally Invasive Surgery vs Nonoperative Treatment for Displaced Intraarticular Calcaneal Fracture: A Prospective Propensity Score Matched Cohort Study With 2-Year Follow-up. Foot Ankle Int 2024; 45:456-466. [PMID: 38415605 DOI: 10.1177/10711007241230550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Optimal management of displaced intraarticular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiologic outcomes of minimally invasive surgery vs nonoperative treatment in displaced intraarticular calcaneal fracture up to 2 years. METHODS All displaced intraarticular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma center were considered for inclusion. The decision to treat was made by a multidisciplinary team consisting of fellowship-trained orthopaedic surgeons. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction and internal fixation. Nonoperative protocol involved symptomatic management with no attempt at closed reduction. The Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions-5 Level (EQ-5D-5L) patient-reported outcome measures were used to assess foot and ankle and general health related quality of life outcomes, respectively, at 2-year follow-up. Radiographic assessment was performed based on preinjury and 12-week postinjury radiographs. RESULTS A total of 101 patients were included for analysis between August 2014 and January 2019. We propensity score matched 46 patients in the surgical cohort to 46 patients in the nonsurgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (P > .05); however, the surgical cohort had a significantly higher EQ-5D-5L Index score (P < .05) and return to work (91% vs 72%, P < .05) and physical activity rate (46 vs 35%, P < .05) despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. In addition, 14% of patients in the nonoperative cohort subsequently underwent arthrodesis compared with none of the patients in the surgical cohort. CONCLUSION In this study, we found that operative treatments were associated with low rates of surgical complication at 2 years and long-term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared with nonoperative treatment for less severe fractures. LEVEL OF EVIDENCE Level III, retrospective cohort.
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Affiliation(s)
- Raju Ahluwalia
- King's College Hospital (Denmark Hill), Kings College Hospital NHS Foundation Trust, London, United Kingdom
- King's College Hospital NHS Foundation Trust, London, United Kingdom
- Surgical and Trauma Academic Research (STAR) Alliance, King's College Hospital, London, United Kingdom
| | - Thomas Lorchan Lewis
- King's College Hospital (Denmark Hill), Kings College Hospital NHS Foundation Trust, London, United Kingdom
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Omar Musbahi
- King's College Hospital (Denmark Hill), Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ines Reichert
- King's College Hospital (Denmark Hill), Kings College Hospital NHS Foundation Trust, London, United Kingdom
- King's College Hospital NHS Foundation Trust, London, United Kingdom
- Surgical and Trauma Academic Research (STAR) Alliance, King's College Hospital, London, United Kingdom
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Yeomans D, Lewis TL, Pearkes T, Stone B, Hepple S, Riddick A, Harries W, Kelly M, Winson I, Robinson P. Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:823-832. [PMID: 37715837 DOI: 10.1007/s00590-023-03716-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/27/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction. METHODS This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate. RESULTS Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork. CONCLUSION Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daniel Yeomans
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK.
| | | | - Tim Pearkes
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Bradley Stone
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Steve Hepple
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Andrew Riddick
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | | | - Michael Kelly
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Ian Winson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Peter Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Nguyen MQ, Broström A, Iversen MM, Harboe K, Paulsen A. Assessing the content validity of the Manchester-Oxford Foot Questionnaire in surgically treated ankle fracture patients: a qualitative study. J Orthop Surg Res 2023; 18:941. [PMID: 38066592 PMCID: PMC10704649 DOI: 10.1186/s13018-023-04418-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Roughly 10% of fractures in adults are ankle fractures. These injuries are found in both sexes and present with different fracture characteristics. The treatment varies with the patients' biology and fracture type, and the goals are to restore stability, prevent pain and maintain ankle function. Clinicians generally use outcomes like assessment of radiography, pain level, or function. The use of patient-reported outcome measures is increasing, and the Manchester-Oxford Foot Questionnaire (MOXFQ) has been shown to have good measurement properties when validated in patients with foot and ankle disorders. However, the instrument has not been validated for ankle fracture patients. This study aims to assess the content validity of the items in MOXFQ in surgically treated ankle fracture patients. METHODS A qualitative deductive design was used to investigate patients' response process of the MOXFQ. Individual interviews were conducted using cognitive interviewing based on the theoretical framework of the 4-step model by Tourangeau. Adult patients that were surgically treated for an ankle fracture between four weeks and 18 months were purposively sampled, and interviews followed a semi-structured interview guide. The predetermined categories were comprehension, retrieval, judgement, and response. RESULTS Seventeen respondents (65% females) were interviewed. Respondents' age ranged from 27 to 76 years. Some of the respondents in the early recovery phase were limited by post-operative restrictions and did not find the items in the walking/standing domain relevant. Respondents that were allowed weight-bearing as tolerated (WBAT) were able to recall relevant information for most items. Respondents with time since surgery more than 12 months had less pain and remembered fewer relevant episodes in the recall period. Items in the social interaction domain contained ambiguous questions and were generally considered less important by respondents. The summary index score lacked important concepts in measuring overall quality of life. CONCLUSIONS Pain was a central concept in the post-operative recovery of ankle fracture patients. The MOXFQ-subscales for pain and walking/standing had acceptable content validity in patients that were allowed WBAT. The social interaction-subscale and the summary index score had insufficient content validity for this patient population.
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Affiliation(s)
- Michael Q Nguyen
- Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway.
- Department of Orthopedic Surgery, The Fracture Registry of Western Norway, Stavanger University Hospital, Helse Vest RHF, Stavanger, Norway.
| | - Anders Broström
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Marjolein M Iversen
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Centre on Patient-Reported Outcomes, Department of Research and Development, Haukeland University Hospital, Helse Bergen HF, Bergen, Norway
| | - Knut Harboe
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Anesthesia, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
| | - Aksel Paulsen
- Department of Orthopedic Surgery, Stavanger University Hospital, Helse Stavanger HF, Stavanger, Norway
- Department of Orthopedic Surgery, The Fracture Registry of Western Norway, Stavanger University Hospital, Helse Vest RHF, Stavanger, Norway
- Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Song G, Gu W, Shi Z, Li X, Fu S, Yu X, Song F. Finite element analyses of three minimally invasive fixation techniques for treating Sanders type II intra-articular calcaneal fractures. J Orthop Surg Res 2023; 18:902. [PMID: 38012759 PMCID: PMC10683123 DOI: 10.1186/s13018-023-04244-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Calcaneal Sanders type II or III fractures are highly disabling with significant burden. Surgical treatment modalities include open reduction and internal fixation (ORIF) techniques and a variety of minimally invasive surgical (MIS) approaches. ORIF techniques are associated with complications and traditional MIS techniques need extensive intraoperative fluoroscopic procedures. The present study aims to investigate the effects of three different minimally invasive internal fixation (MIIF) techniques used to treat Sanders type II intra-articular calcaneal fractures using finite element analyses. METHODS A 64-row spiral computed tomography scan was used to observe the calcaneus of a healthy adult. The scanning data were imported into Mimics in a DICOM format. Using a new model of a Sanders type II-B intra-articular calcaneal fracture, three minimally invasive techniques were simulated. Technique A involved fixation using an isolated minimally invasive locking plate; Technique B used a minimally invasive locking plate with one medial support screw; and Technique C simulated a screw fixation technique using four 4.0-mm screws. After simulating a 640-N load on the subtalar facet, the maximum displacement and von Mises stress of fragments and implants were recorded to evaluate the biomechanical stability of different fixation techniques using finite element analyses. RESULTS After stress loading, the maximum displacements of the fragments and implants were located at the sustentaculum tali and the tip of sustentaculum tali screw, respectively, in the three techniques; however, among the three techniques, Technique B had better results for displacement of both. The maximum von Mises stress on the fragments was < 56 Mpa, and stress on the implants using the three techniques was less than the yield strength, with Technique C having the least stress. CONCLUSION All three techniques were successful in providing a stable fixation for Sanders type II intra-articular calcaneal fractures, while the minimally invasive calcaneal locking plate with medial support screw fixation approach exhibited greater stability, leading to improved enhancement for the facet fragment; however, screw fixation dispersed the stress more effectively than the other two techniques.
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Affiliation(s)
- Guoxun Song
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China
| | - Wenqi Gu
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China
| | - Zhongmin Shi
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China.
| | - Xueqian Li
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China
| | - Shaoling Fu
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China
| | - Xiaowei Yu
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China
| | - Facheng Song
- National Key Laboratory for Manufacturing Systems Engineering, Xian Jiaotong University, Xi'an, 710054, Shanxi Province, People's Republic of China.
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Dislozierte intraartikuläre Kalkaneusfrakturen. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Hou J, Zhang N, Chen G, Wang Q, Zhang S, Yang K, Zang H. Circular External Fixator Assisted Open Reduction Combined With Locking Plate Fixation for Intra-articular Comminuted Fractures of the Calcaneus. J Foot Ankle Surg 2022; 62:437-443. [PMID: 36404256 DOI: 10.1053/j.jfas.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 10/07/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Jiguang Hou
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China.
| | - Nan Zhang
- Department of Anesthesiology, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Guodong Chen
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Qi Wang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Shenghua Zhang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Kun Yang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Hongwei Zang
- Department of Orthopaedics, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
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A prospective comparative study between percutaneous cannulated screws and Kirschner wires in treatment of displaced intra-articular calcaneal fractures. INTERNATIONAL ORTHOPAEDICS 2022; 46:2667-2683. [PMID: 35960344 PMCID: PMC9556432 DOI: 10.1007/s00264-022-05521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/15/2022] [Indexed: 10/26/2022]
Abstract
Abstract
Purpose
Several minimally invasive procedures were used to treat displaced intra-articular calcaneal fractures (DIACFs). No agreement among different authors about either the ideal fixation method or which technique is minimally invasive. The aim of this study was to compare functional and radiographic outcomes of two minimally invasive techniques in treatment of Sanders type II and III DIACFs by using K-wires or cannulated screws without bone grafts.
Methods
A prospective randomized controlled study was conducted on 28 patients (34 feet) with Sanders type II or III DIACFs, treated by closed reduction and fixation using cannulated screws or K-wires, at the Orthopedics Department of Sohag University Hospital, between April 2020 and February 2022. Functional assessment was done by American Orthopedic Foot and Ankle Society (AOFAS) score and VAS for pain. Radiographic assessment was done by measurement of three calcaneal angles (Gissane, Böhler’s, and posterior facet inclination angles) and three calcaneal distances (height, length, and width of the calcaneus).
Results
Mean ages of patients at the time of operation were 34.8 years for the cannulated screw group and 36.6 years for the K-wire group. A vast majority of patients were males (78.6%). Involvement of the right side in the cannulated screw group was 57.1% and that in the K-wire group was 47.9%. Mean operative time was significantly shorter among the K-wire group (42 min) compared to the cannulated screw group (57 min). Mean AOFAS score was higher among the cannulated screw group (85.9 points) compared to the K-wire group (75.8 points). Final VAS was significantly better among the cannulated screw group compared to the K-wire group. Mean time of radiographic union in the cannulated screw group was 8.9 weeks and that in the K-wire group was 10.1 weeks.
Conclusion
Both techniques avoided wound complications associated with ORIF with the advantage of a shorter hospital stay. Patients in the cannulated screw group had better functional and radiographic outcomes and a lower rate of subtalar arthritis than patients in the K-wire group. K-wires had advantages of reduced operative time, and easy removal as an outpatient procedure.
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Outcomes of modified chevron osteotomy for hallux valgus. Foot Ankle Surg 2022; 28:514-517. [PMID: 35227590 DOI: 10.1016/j.fas.2022.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/20/2021] [Accepted: 02/16/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to detect the effect of a modified chevron osteotomy on hallux valgus (HV) deformity at five-year follow up. METHODS Twenty patients with symptomatic HV who underwent modified chevron osteotomy between June 2014 and January 2016 were included in the present study. The minimum follow-up duration was five years. Each patient was evaluated preoperatively, six weeks postoperatively and five years postoperatively using the visual analog scale (VAS) pain score, the American Orthopedic Foot & Ankle Society (AOFAS) score and cosmetic and radiological outcomes. RESULTS The AOFAS score improved from 54.40 ( ± 4.58) preoperatively to 94.30 ( ± 2.15) six weeks postoperatively (p < 0.001) and 96.95 ( ± 1.54) five years postoperatively (p < 0.001). The VAS scores decreased from 6.30 ( ± 1.17) preoperatively to 0.15 ( ± 0.37) five years postoperatively (p < 0.001). The mean intermetatarsal angle improved from 16.00° ( ± 2.20°) preoperatively to 4.15° ( ± 1.22°) six weeks postoperatively (p < 0.001) and 4.40° ( ± 1.39°) five years postoperatively (p < 0.001). The mean HV angle also improved, from 32.70° ( ± 5.34°) preoperatively to 4.80° ( ± 1.40°) six weeks postoperatively (p < 0.001) and 5.20° ( ± 1.32°) five years postoperatively (p < 0.001). The cosmetic results were either excellent or good in 19 patients (95%). There was no recurrence in this study during the five postoperative years. CONCLUSION A modified chevron osteotomy can achieve successful correction of moderate-to-severe HV, with excellent outcomes at five-year follow up.
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