Early weight bearing of calcaneal fractures fixated with locked plates: a radiographic review

Employing machine learning to enhance fracture recovery insights through gait analysis

This study aimed to explore the potential of gait analysis coupled with supervised machine learning models as a predictive tool for assessing post-injury complications such as infection, malunion, or hardware irritation among individuals with lower extremity fractures. We prospectively identified participants with lower extremity fractures at a tertiary academic center. These participants underwent gait analysis with a chest-mounted inertial measurement unit device. Using customized software, the raw gait data were preprocessed, emphasizing 12 essential gait variables. The data were standardized, and several machine learning models, including XGBoost, logistic regression, support vector machine, LightGBM, and Random Forest, were trained, tested, and evaluated. Special attention was given to class imbalance, addressed using the synthetic minority oversampling technique (SMOTE). Additionally, we introduced a novel methodology to compute the post-injury recovery rate for gait variables, which operates independently of the time difference between the gait analyses of different participants. XGBoost was identified as the optimal model both before and after the application of SMOTE. Before using SMOTE, the model achieved an average test area under the ROC curve (AUC) of 0.90, with a 95% confidence interval (CI) of [0.79, 1.00], and an average test accuracy of 86%, with a 95% CI of [75%, 97%]. Through feature importance analysis, a pivotal role was attributed to the duration between the occurrence of the injury and the initial gait analysis. Data patterns over time revealed early aggressive physiological compensations, followed by stabilization phases, underscoring the importance of prompt gait analysis. χ2 analysis indicated a statistically significant higher readmission rate among participants with underlying medical conditions (p = 0.04). Although the complication rate was also higher in this group, the association did not reach statistical significance (p = 0.06), suggesting a more pronounced impact of medical conditions on readmission rates rather than on complications. This study highlights the transformative potential of integrating advanced machine learning techniques like XGBoost with gait analysis for orthopedic care. The findings underscore a shift toward a data-informed, proactive approach in orthopedics, enhancing patient outcomes through early detection and intervention. The χ2 analysis added crucial insights into the broader clinical implications, advocating for a comprehensive treatment strategy that accounts for the patient's overall health profile. The research paves the way for personalized, predictive medical care in orthopedics, emphasizing the importance of timely and tailored patient assessments.

Outcomes of Early Weight Bearing in Displaced Intra-articular Calcaneus Fractures Treated with Screws-Only Fixation Technique

Background

Displaced intraarticular calcaneus fracture indicates surgical treatment. The current trend is open reduction and internal fixation with a plate or multiple screws through the sinus tarsi approach. Most postoperative protocols are prolonged non-weight bearing that causes a high socioeconomic burden. This study aims to determine the safety of the early weight-bearing protocol of screws-only fixation in calcaneal fracture.

Materials and Methods

Evaluate displaced intraarticular calcaneus fractures treated with screws-only technique via the sinus tarsi approach in our institution. The first group, from July 2017 to December 2018, allowed patients to start partial weight bearing as tolerated at 4 weeks after surgery. The second group prospectively from January 2019 to March 2020, which assign patients to keep non-weight bearing for 8 weeks. The functional outcomes (Thai Foot and ankle ability measure subjective form, FAAM) were measured 6 months after surgery. The radiographic outcome (Bohler's angle and Gissane angle) was measured on the first day postoperative and 6 months follow-up, and the changes in these angles were recorded.

Results

There were 28 patients in each group. The outcomes were collected and compared by a T-test. In the early weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 76.4 ± 14.8, 2.4 ± 3.5, and 6.6 ± 7.8, respectively. In the delayed weight-bearing group, The FAAM, Bohler's angle loss, and Gissane's angle change were 81 ± 14.8, 2 ± 1.8 and 2.6 ± 6.1, respectively. There was no statistically significant difference in FAAM score, Bohler's angle loss, and Gissane's angle change between early and delayed weight-bearing groups.

Conclusion

Screws fixation in calcaneal fracture may be safe to allow early weight-bearing protocol.

Can 3-Dimensional Printing for Calcaneal Fracture Surgery Decrease Operation Time and Improve Quality of Fracture Reduction?

We investigated whether 3-dimensional (3D) printed models can decrease operation time and improve the quality of reduction for calcaneal fractures. The study involved 48 patients with unilateral intra-articular calcaneal fractures, who were retrospectively case-matched according to Sander's classification, age, and sex. Group A (24 patients) was operated using 3D printed models as a preoperative and intraoperative tool, and group B (24 patients) was operated using standard techniques without 3D printed model. Operation time was significantly shorter for group A, compared to group B (82.3 ± 13.2 vs 91.4 ± 16.0, p = .036). The differences between the radiological parameters of operated calcaneus, compared to the normal side was similar between the 2 groups (Böhler angle, 5.3° ± 3.9° vs 4.2° ± 4.7°, p = .45, Gissane angle, 5.9° ± 12.5° vs 8.4° ± 11.0°, p = .54). The number of screws projecting more than 5 mm from the cortex was lower in group A than in group B (7/187, 4% vs 16/208, 8%, p = .11). The number of screw holes of the plate cut intraoperatively was significantly lower for group A compared to group B (1 vs 138). Although group A started weightbearing 3 to 4 weeks earlier than group B, the radiological parameters were similar between groups that early weightbearing was possible for group A using the 3D printed models (Böhler angle, - 1.5° ± 0.8° vs - 1.8° ± 1.2°, p = .28, Gissane angle, 2.5° ± 2.6° vs 3.5° ± 4.3°, p = .39). The operation time was shorter while using the 3D printed models, compared to that of the standard technique without using the 3D printed model. The radiological parameters were not statistically different, and the quality of fracture reduction seemed similar. However, with the use of 3D printed models, early weightbearing was possible without significant subsidence of reduced fragments or failure of fracture reduction, comparable to non-weightbearing cases.

Do heel-unloading orthoses improve clinical outcomes in patients after surgical treatment of calcaneal fracture? A propensity-matched, multicenter analysis of the TRON database

BACKGROUND

Postoperative protocols after surgical treatment of calcaneal fracture have not been standardized to date. There are only a few reports on the efficacy of heel-unloading orthoses (HUOs; Mars shoe, Graffin orthosis), and thier efficacy is uncertain.

OBJECTIVES

The purpose of this study was to compare postoperative radiologic and clinical outcomes in patients with calcaneal fractures who used Graffin orthosis.

STUDY DESIGN

Multicenter retrospective study.

METHODS

We finally extracted 182 patients from a database of the Trauma Research Group of Nagoya and divided them into two groups: group C (underwent casting or splinting only) and group O (Graffin orthosis was used). A propensity score algorithm was used to match group C to group O in a 1:1 ratio. We evaluated American Orthopaedic Foot and Ankle Society (AOFAS) score at three and six months after surgery and at final follow-up. Differences in reduction of the Böhler angle between the two groups were evaluated radiographically. All data were analyzed with a t-test or Fisher's exact test. P < .05 was considered statistically significant.

RESULTS

The AOFAS score 3 months after surgery in group O was significantly higher than that in group C (69.57 vs. 77.22; P = .004). However, there were no statistically significant differences between group C vs. group O in AOFAS scores at 6 months after surgery and at final follow-up (81.92 vs. 85.67 and 89.18 vs. 88.13; P = .087 and 0.597, respectively). There was no significant statistical difference in the reduction of the Böhler angle (5.07 vs. 5.89; P = .529).

CONCLUSIONS

At 3 months postoperatively, the orthosis group showed predominantly better functional results. We believe that heel-unloading orthoses are useful for patients who require an early return to work and to daily life.

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.

Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up

INTRODUCTION

This study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period.

METHODS

Patients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS).

RESULTS

In total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF-36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3-7) and 6 months (IQR, 3,25-6,75) for PSF and ORIF treated, respectively CONCLUSION: This long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.

Gait Alterations in Adults after Ankle Fracture: A Systematic Review

(1) Background: Ankle fracture results in pain, swelling, stiffness and strength reduction, leading to an altered biomechanical behavior of the joint during the gait cycle. Nevertheless, a common pattern of kinematic alterations has still not been defined. To this end, we analyzed the literature on instrumental gait assessment after ankle fracture, and its correlation with evaluator-based and patient-reported outcome measures. (2) Methods: We conducted a systematic search, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, of articles published from January 2000 to June 2021 in PubMed, Embase and PEDro on instrumental gait assessment after ankle fracture. (3) Results: Several changes in gait occur after ankle fracture, including a reduction in step length, swing time, single support time, stride length, cadence, speed and an earlier foot-off time in the affected side. Additionally, trunk movement symmetry (especially vertical) is significantly reduced after ankle fracture. The instrumental assessments correlate with different clinical outcome measures. (4) Conclusions: Instrumental gait assessment can provide an objective characterization of the gait alterations after ankle fracture. Such assessment is important not only in clinical practice to assess patients’ performance but also in clinical research as a reference point to evaluate existing or new rehabilitative interventions.

Plate fixation through the lateral extensile approach versus cannulated screw fixation through the sinus tarsi approach for calcaneal fracture: a multicenter, propensity score-matched TRON study

PURPOSE

For calcaneal fracture, plate fixation through lateral extensive approach (LEP) is the most common procedure performed to achieve anatomic reduction. However, wound complications sometimes occur after LEP. To reduce complications, minimally invasive operative methods with cannulated screw fixation through sinus tarsi approach (STS) were developed. The aim of this multicenter propensity-matched study was to compare the clinical and radiographic outcomes of LEP to those of STS for calcaneal fracture and to evaluate the incidence of postoperative complications including surgical site infection (SSI).

METHODS

We extracted 271 patients with calcaneal fracture undergoing surgery between January 2014 and March 2019 from our multicenter TRON database. We assessed the American Orthopedic Foot and Ankle Society (AOFAS) score at the final follow-up as the clinical outcome. We obtained the Bohler and Preis angles as radiographic parameters and also recorded the complications. We divided the subjects into two groups: LEP group and STS group. To adjust for baseline differences between the groups, a propensity score matching algorithm was used in a 1:1 ratio.

RESULTS

After matching, there were 32 fractures in each group. There was no significant difference between the LEP versus STS group in AOFAS score at final follow-up (90 vs 90 points, p = 0.98) and in the Bohler and Pries angles (19.2 vs. 18.0 degrees, p = 0.74 and 16.0 vs. 17.5 degrees, p = 0.47). The rate of SSI in the LEP group was higher than that in the STS group (21.9% vs. 0.0%, p = 0.01).

CONCLUSION

For calcaneal fracture, STS provides similar fixation effectiveness and functional outcomes as LEP while reducing the likelihood of infection.

The importance of Böhler's angle in calcaneus geometry: A finite element model study

OBJECTIVES

Calcaneal fractures are the most common tarsal fractures following a foot-ankle trauma. The Böhler's angle is an important measurable angle before, during, and after surgery. In this study, we aimed to investigate correlation between Böhler's angle, calcaneal strength, and subtalar joint stress using a finite element analysis (FEA).

PATIENTS AND METHODS

Between January 2016 and December 2016, computed tomography (CT) scans were used with MIMICS® software for FEA. The ankle and foot of a 23-year-old male person with a height of 180 cm and weighing 80 kg was modeled as reference. Raw coronal CT images were obtained in Digital Imaging and Communications in Medicine format with the resolution of 512X512 pixels and 0.3-mm slice intervals in 135 kV. The structures including tibia, fibula and 26 other bones (talus, calcaneus, cuboid, navicular, three cuneiforms, five metatarsals, and 14 components of phalanges), cartilage and ligamentous tissues were modeled to form ankle joint. After determining Böhler's angle as 35 degrees for the reference model, a fracture line was created on calcaneus. Calcaneus was remodeled with the Böhler's angle of 45, 40, 30, 25, 20, 10, and 0 degrees respectively. All models were transferred to ANSYS software for FEA and the loads on the lower extremities with normal posture were applied on models.

RESULTS

Analysis of all models based in the reference model revealed that maximum tension values on calcaneus increased, while the Böhler's angle decreased, indicating a statistically significant difference. The decreased Böhler's angle indicated statistically significantly higher maximum tension values (p=0.04). Action force in subtalar joint was evaluated by comparing with the forces in reference model. The increased Böhler's angle was found to be associated with statistically significantly decreased amount of load on subtalar joint. The decreased Böhler's angle was related to the statistically significantly increased amount of load on subtalar joint.

CONCLUSION

Our study results suggest that decreased Böhler's angle increases the possibility of subtalar arthrosis, although overcorrection of the Böhler's angle seems not to increase the risk of subtalar arthrosis.

Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation

INTRODUCTION

This study aimed to analyze the clinical and radiological outcomes of early weight-bearing and rehabilitation after open reduction and internal fixation (OR/IF) of calcaneal fracture.

MATERIALS AND METHODS

This retrospective study was conducted on 78 patients with unilateral calcaneal fracture who underwent OR/IF. A mean follow-up period was 45.8 months (range 12-135). Two weeks after surgery, the range of motion (ROM) exercise was started, brace or heel off shoe was applied, and forefoot weight-bearing was allowed. Four weeks after surgery, tolerable weight-bearing ambulation without crutch was allowed. When the patient was not walking, the braces were removed to perform peritalar ROM exercises. Radiologic evaluation was performed by measuring the Böhler angle and incongruency of the subtalar joint surface. Paley grade was used to assess traumatic arthritis. Clinical evaluation was performed by measuring the foot and ankle outcome score (FAOS) and ankle ROM.

RESULTS

The mean postoperative Böhler angle was 31.7° (P < 0.001) at 2 weeks, 31.2° at 3 months, and 30.1° at the last (P = 0.4). The average Paley grade of the subtalar OA was 1.12. CT imaging revealed that the average step-off of the subtalar joint was 1.26 mm in coronal and 0.84 mm in sagittal. The average ROM results were as follows (contralateral, affected side): there was no significant difference in dorsiflexion [16.9° vs. 16° (P = 0.6)], whereas plantarflexion and inversion were significantly decreased [39.5° vs. 35.3° (P = 0.049) and 50.5° vs. 34.8° (P = 0.04)]. The average FAOS score was 86.1 points, and the highest score was "function" (mean 92.5 points).

CONCLUSIONS

Earlier rehabilitation after OR/IF is recommended for the treatment of calcaneal fracture.

Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation

Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.

Intra-articular calcaneal fractures. Do locking plates keep the reduction better than conventional plates?

INTRODUCTION

Since the development of locking plates, calcaneal fractures have been considered ideal for this type of fixation, due to the need to maintain the height of the subastragaline joint after depression fractures in a location where bone quality tends to be poor. However, there are no comparative studies that support the theoretical superiority of these plates over conventional plates. The aim of this study was to compare the results of intraarticular calcaneal fractures treated using locking plates vs. conventional plates in terms of radiological reduction, complications and number of reinterventions.

MATERIAL AND METHODS

We designed a comparative study of calcaneal fractures operated in our centre using the "L" approach. Two groups were established: group B, comprising 15 patients operated between 2010 and 2015 with calcaneal locking plates, and group A, comprising a stratified random sample of 23 patients taken from a historical cohort of 90 patients operated in our centre between 1997 and 2007 using conventional calcaneal plates. Demographic data were recorded (age, sex, diabetes mellitus, smoking) and data relating to the fracture (type of fracture according to Sander's classification system, complications, presurgical delay). To evaluate loss of reduction, varus angulation of the calcaneus (measured from the axial view), Böhler's angle and Gissane's angle were assessed radiographically. These angles were measured preoperatively, immediately postoperatively, and at the end of follow-up. Finally, we recorded complications and the number of reinterventions.

RESULTS

There were no differences in terms of age, sex or fracture type between the 2 groups. There was greater loss of varus angulation in group A, 0.6 vs. 0.41°, and there was greater reduction in Böhler's angle in group A, 3.79 vs. 2.6°, while Gissane's angle decreased more in group B, 4.13 vs. 2.52°. There were no significant differences in the proportion of complications and reinterventions between the 2 groups.

CONCLUSION

In our study we observed no significant differences between the 2 groups in terms of radiological reduction, complications or number of reinterventions. However, we did observe a greater loss of reduction of Böhler's angle in the patients who were operated using conventional plates.

Fine Wire Circular Fixation for Displaced Intra-Articular Calcaneal Fractures: A Systematic Review

Intra-articular calcaneal fractures represent an ongoing challenge for the orthopedic community, with the benefits of the previous "gold standard" treatment of open reduction and internal fixation having been called into question in several large randomized controlled trials. Fine wire circular fixation may represent a useful alternative treatment for these injuries, combining minimally invasive application with rigid fixation, which allows the possibility of early weight bearing We performed a systematic review of published studies that used circular fixation for calcaneal fractures and recorded functional outcomes at follow-up. In a total of 11 studies with 255 calcaneal fractures for which there was follow-up, our inclusion criteria were met: 8.2% of fractures were bilateral, 11.9% of fractures were open fractures, and 12.6% of patients had multiple orthopedic injuries. Functional outcomes were assessed with the use of a variety of tools across the different studies, but outcomes compared favorably with those seen with open reduction and internal fixation. Although pin site infections were common (22.6%), serious complications, including deep infection (0.8%), wound infection (1.6%), and complex regional pain syndrome (0.8%), were exceedingly rare. The results suggest that this is a viable alternative treatment for calcaneal fractures, but higher-quality randomized controlled trials are required before the technique can enter mainstream use.

[A new continuous gait analysis system for ankle fracture aftercare]

BACKGROUND

Correct aftercare following lower extremity fractures remains a controversial issue. Reliable, clinically applicable weight-bearing recommendations have not yet been defined. The aim of the current study was to establish a new gait analysis insole during physical therapy aftercare of ankle fractures to test patients' continuous, long-term compliance to partial weight-bearing restrictions and investigate whether patients can estimate their weight-bearing compliance.

MATERIALS AND METHODS

The postoperative gait of 14 patients after operative treatment of Weber B-type ankle fractures was monitored continuously for six weeks (OpenGO, Moticon GmbH, Munich). All patients were instructed and trained by physical therapists on how to maintain partial weight-bearing for this time. Discontinuous (three, six and twelve weeks) clinical (patient questionnaire, visual analogue pain score [VAS]) and radiographic controls were performed.

RESULTS

Despite the set weight-bearing limits, individual ranges for overall weight-bearing (range 5-107% of the contralateral side) and patient activity (range 0-366 min/day) could be shown. A good correlation between weight-bearing and pain was seen (r_s = -0.68; p = <0.0001). Patients significantly underestimated their weight-bearing time over the set limit (2.3 ± 1.4 min/day vs. real: 12.6 ± 5.9 min/day; p < 0.01).

CONCLUSIONS

Standardized aftercare protocols and repeated training alone cannot ensure compliance to postoperative partial weight-bearing. Patients unconsciously increased weight-bearing based on their pain level. This study shows that new, individual and possibly technology-assisted weight-bearing regimes are needed. The introduced measuring device is feasible to monitor and steer patient weight-bearing during future studies.

Böhler's Angle-Comparison Between the pre- and Postoperative in Displaced Intra-Articular Calcaneal Fractures

Objective  To compare pre- and postoperative variation of radiographic measurements of the Böhler angle (BA) in fractures with two types of deviations: severe and moderate. Methods  Pre- and postoperative BAs in 31 calcaneal fracture radiographs were retrospectively analyzed. A total of 4 patients were female (6.5%) and 26 were male (83.9%), with age ranging from 23 to 72 years old, and a mean age of 44.5 years old. Results  The results show that the postoperative BA was significantly larger than the preoperative BA ( p  = 0.000). At the intraevaluator and overall assessments, the postoperative BA was, on average, 10.6° higher than the preoperative measure. The postoperative angle was, on average, 108% higher than the preoperative angle. In the global assessment, the agreement between evaluators was excellent, both regarding the estimated point value (0.98) and the intraclass correlation (ICC) confidence interval (CI). Conclusion  In the global analysis, the postoperative BAs were, on average, significantly higher than the preoperative measurements. The farther from the normal range (20° to 40°) the preoperative angle is, the greater the difference after the surgery. When the preoperative angle was normal, the postoperative angle was, on average, 1.28 times the preoperative measurement. If the preoperative BA was abnormal, the postoperative angle was, on average, 17.3 times the preoperative measurement. It was demonstrated that more severe fractures present better anatomic results when compared with moderate fractures. The present study also confirms a good interobserver correlation for the BA.

Radiological and Clinical Effectiveness of a Novel Calcaneal Fracture Brace after Intra-articular Calcaneal Fracture Surgery

Background

After calcaneal fracture surgery, a short leg splint and cast are typically applied. However, these restrict joint exercises, which is inconvenient for patients. In addition, there is a risk of complications, such as pressure ulcers or nerve paralysis with a short leg cast. In this study, we evaluated clinical and radiological outcomes of the use of a specially designed calcaneal brace after calcaneal fracture surgery.

Methods

From among patients who underwent open reduction and internal fixation for calcaneal fracture between July 9, 2013 and May 31, 2017, 102 patients who wore a calcaneal fracture brace (group A) and 82 patients who wore a postoperative short leg cast (group B) were randomly chosen for this study. Radiological changes and clinical factors were compared between the two groups. After swelling at the surgical site decreased, a special calcaneal brace was applied to patients in group A. They were allowed to perform early weight bearing and joint motion. Patients in group B were immobilized in a short leg cast and were told to avoid weight bearing for 6 weeks. In each group, the Böhler's angle and Gissane's angle were measured and compared using postoperative and final follow-up radiographs. Pain (measured using a visual analogue scale [VAS]) and ankle joint range of motion (dorsiflexion, plantar flexion, eversion, and inversion) were measured serially until the final follow-up visit.

Results

There were no significant differences in the Böhler's angle or Gissane's angle between the two groups as measured postoperatively and at the final follow-up (paired t-test). Differences in the VAS pain score and eversion were also statistically nonsignificant between the two groups. However, group A had a significantly higher range of dorsiflexion (p = 0.021), plantar flexion (p = 0.012), and inversion (p = 0.045) of the ankle than group B (independent t-test).

Conclusions

Application of the calcaneal fracture brace after open reduction and internal fixation of a calcaneal fracture not only maintained the fracture reduction but allowed for greater joint motion than the short leg cast. Thus, the calcaneal fracture brace can be considered an effective postoperative management option that enables early resumption of daily activities and facilitates postoperative joint motion.

Management of Intra-Articular Calcaneal Fractures: Clinical Results of Reduction Technique Using a Bone Spreader

The purpose of the present study was to examine the clinical results of surgery for intra-articular calcaneal fractures using a calcaneal locking plate and a bone spreader as a reduction tool. Ten patients with intra-articular calcaneal fractures were treated. An extended lateral approach was used. The reduction of the intra-articular fragments of the posterior facet was temporarily held using a bone spreader and Kirschner wires. Internal fixation was achieved with a locking calcaneal plate. Böhler's angle and Preiss' angle were assessed on the day of injury and the day of the final follow-up examination. The step off and gap of the posterior facet were assessed on the day of injury and the first week after surgery. The functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society ankle hindfoot scale score. The mean Böhler's angle ranged from 2.1° ± 11.0° to 30.4° ± 5.0° (p < .0001), the mean Preiss' angle ranged from 23.5° ± 4.5° to 15.5° ± 2.9° (p < .0001), the mean step off ranged from 4.0 ± 1.9 mm to 0.1 ± 0.2 mm (p = .0002), and the mean gap ranged from 2.6 ± 1.0 mm to 1.2 ± 0.6 mm (p = .0035). The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was 89.2 (range 85 to 100) at a mean of 14.3 months after surgery. Our results suggest that a locking calcaneal plate can be used to restore and reduce an intra-articular calcaneal fracture and achieve good clinical results.

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.

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.

Posterior Facet Settling and Changes in Bohler's Angle in Operatively and Nonoperatively Treated Calcaneus Fractures

BACKGROUND

Patients with calcaneus fractures often exhibit settling of the posterior facet with a corresponding decrease in Bohler's angle (BA) following either operative or nonoperative treatment. Both injury BA and postoperative BA have been shown to be prognostic for outcomes; however, the demographic and surgeon-specific factors that may contribute to settling have not been critically examined in the literature. The purpose of this study was to identify these causative factors.

METHODS

234 patients with intra-articular calcaneus fractures were analyzed. All patients had preoperative plain radiographs, at least 5 months of orthopedic follow-up, and computed tomography scanning performed. BA was measured on the injury radiographs for all patients. For operatively treated patients, BA was measured on the immediate postoperative radiographs and compared with the last available radiograph. For nonoperatively treated patients, BA was measured on the last available radiograph. All patients were fully weightbearing at the time of final follow-up but not on initial radiographs due to their recent injury. Demographic data including age, gender, energy of injury mechanism, tobacco use, diabetes, osteoporosis, rheumatoid arthritis, and substance/alcohol abuse were retrospectively collected. Fractures were classified using the Essex-Lopresti and Sanders classifications. Time to full weightbearing was documented, as were any reports of noncompliance with weightbearing restrictions. For patients treated operatively, type of fixation (calcaneal-specific perimeter plate, nonperimeter plate, screw fixation), use of locking screws, use of bone graft or graft substitutes, and the number of screws supporting the posterior facet were documented.

RESULTS

There was a statistically significant amount of settling within the operative and nonoperative groups, but there was no statistically significant difference in settling of BA between the groups. The average settling of BA for the operative and nonoperative group was 8 degrees. Age greater than 50 years, diabetes, and alcohol abuse were all statistically significant and independent predictors of BA settling irrespective of treatment.

CONCLUSION

The amount of BA settling between the operative and nonoperative group was not significant and showed an average decrease of 8 degrees in each group. However, the amount of settling that we found, irrespective of treatment, increased with patient age, alcohol abuse, and diabetes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Predicting loss of height in surgically treated displaced intra-articular fractures of the calcaneus

PURPOSE

The goal of calcaneal fracture surgery is to restore its anatomy and good foot function. However, loss of height of the subtalar joint can occur post-operatively, as expressed by a decrease in Böhler's angle (BA). The aim of this study was to identify potential factors associated with a post-operative decrease in BA.

METHODS

All consecutive adult patients treated with open reduction and internal fixation (ORIF) by an extended lateral approach (ELA) between 2000 and 2013 were retrospectively included. Primary outcome was the occurrence of a calcaneal collapse, defined as a postoperative decrease of ≥10° in BA. The BA was measured pre-operatively, directly following surgery and at one year follow-up. Patient characteristics (body mass index, diabetes mellitus, smoking/alcohol/substance abuse, American Society of Anaesthesiologist classification), fracture classification and treatment characteristics: per-operative increase in BA and occurrence of post-operative wound infection (POWI) were collected.

RESULTS

A total of 262 patients with 276 calcaneal fractures were included. A calcaneal collapse occurred in 46 cases (17%). The median preoperative BA, per-operative increase in BA and post-operative decrease in BA were, respectively, 2°, 27° and 4°. A calcaneal collapse was seen more often following a per-operative increase of >25° in BA, but no significant association was found (p = 0.056). Uni- and multivariate analysis showed that patients with substance abuse and those with POWI had significantly more calcaneal collapse (p < 0.05). No association was found between substance abuse and the occurrence of POWI (p = 0.293).

CONCLUSIONS

In nearly one in six patients with an intra-articular calcaneal fracture treated with ORIF by an ELA, a post-operative collapse of ≥10° was found during follow-up. Calcaneal collapse was correlated with the occurrence of a POWI and substance abuse.

Biomechanical Performance of Lateral Versus Dual Locking Plates for Calcaneal Fractures

Given the high rates of wound complications with a standard lateral extensile incision, small dual incision techniques might result in less soft tissue destruction. The goal of the present study was to compare the biomechanical performance between a single locking plate and a dual locking plating system for an intra-articular calcaneal fracture model. A Sanders IIB type joint depression calcaneal fracture was created in 10 paired, fresh-frozen, cadaveric calcanei (age 47 ± 12, range 35 to 78 years). The calcanei of each pair were randomly assigned for fixation using either a lateral locking reconstruction plate or lateral and medial locking reconstruction plates. The specimens were axially loaded in cyclic fashion for 1000 cycles, followed by load to failure. The relative fragment movement was monitored optically in both the sagittal and the coronal planes. The amount of overall construct displacement increased with cycling, although no difference was found between the plating techniques. For fragment movement during cycling, the lateral joint fragment migrated anteroinferiorly along the fracture line relative to the tuberosity fragment for dual plated specimens by a small, but statistically significant, amount. This same translation was smaller for lateral plated specimens but was not found to be significant. During load to failure testing, no statistically significant differences were found for construct stiffness. A tendency was seen toward more interfragmentary motion in the sagittal plane (lateral joint fragment movement relative to the fracture line), with less movement overall in the coronal plane (anterior fragment translation and twist) for dual plating, although the difference from the lateral plate was not statistically significant. The present study demonstrated that for this calcaneal fracture model, the dual plating technique experienced a small amount of fragment translation during cycling that was significantly different statistically from that with lateral plating but was not clinically relevant. During the load to failure, the dual plating technique was comparable to the lateral plate. Thus, dual plating could be a viable biomechanical option for fracture reduction if avoidance of a large extensile lateral approach associated with lateral plating is warranted.

Early minimally invasive percutaneous fixation of displaced intra-articular calcaneal fractures with a percutaneous angle stable device

The Minimally Invasive Reduction and Osteosynthesis System(®) (MIROS) is a percutaneous angle stable device for the treatment of fractures. The aim of the present study was to evaluate the clinical and radiographic results of an early minimally invasive osteosynthesis with the MIROS device. A total of 40 consecutive patients were treated for an intra-articular fracture of the calcaneus. We evaluated the clinical and radiographic outcomes after treatment of intra-articular calcaneal fractures with the MIROS hardware. Soft tissue damage was noted. The patients completed the American Orthopaedic Foot and Ankle Society survey at 12 and 24 months and underwent radiologic evaluations. A statistically significant association between the American Orthopaedic Foot and Ankle Society score and type of soft tissue lesion. A Sanders type II, III, and IV fracture was found in 15, 20, and 15 of 50 fractures, respectively. Postoperatively, restoration of the posterior facet was reached in 13 of 15, 18 of 20, and 11 of 15 with a type II, III, and IV fracture, respectively. The American Orthopaedic Foot and Ankle Society scale mean score was 85 at the final follow-up visit. No significant association was found between the score and the preoperative variables (p > .09), although patients with bilateral fractures had a significantly lower score. The MIROS device for early treatment of intra-articular calcaneus fractures resulted in excellent clinic and radiologic results. The standardized technique we have reported, with the elastic wires acting as a girder for the fractured and displace subtalar joint and the collapsed lateral calcaneal wall, has permitted early weightbearing with positive stimuli for the bone healing. The drainage effect of the percutaneous wires likely prevented compartment syndrome when applied within the first hours after the trauma.

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.

Weight bearing after a periarticular fracture: what is the evidence?

Orthopedic surgeons frequently provide weight-bearing recommendations to guide patient recovery following lower extremity fractures. This article discusses the available literature regarding the effects of early weight bearing on fracture healing, patient compliance with weight bearing restrictions, and the effect of different weight bearing protocols following acetabular, tibial plateau, tibial plafond, ankle, and calcaneus fractures.

Bohler's angle's role in assessing the injury severity and functional outcome of internal fixation for displaced intra-articular calcaneal fractures: a retrospective study

Background

Controversy exits over the role of Böhler’s angle in assessing the injury severity of displaced intra-articular calcaneal fractures and predicting the functional outcome following internal fixation. This study aims to investigate whether a correlation exists between Böhler’s angle and the injury severity of displaced calcaneal fractures, and between surgical improvement of Böhler’s angle and functional outcome.

Methods

Patients treated operatively for unilateral closed displaced intra-articular calcaneal fractures from January 1, 2004 to March 31, 2008 were identified. The Böhler’s angles of both calcaneus were measured, and the measurement of the uninjured foot was used as its normal control. The difference in the value of Böhler’s angle measured preoperatively or postoperatively between the angle of the injured foot and that of the contralateral calcaneus were calculated, respectively. The change in Böhler’s angle by ratio was calculated by dividing the difference value of Böhler’s angle between bilateral calcaneus by its normal control. The injury severity was assessed according to Sanders classification. The functional outcomes were assessed using American Orthopaedic Foot & Ankle Society hindfoot scores.

Results

274 patients were included into the study with a mean follow-up duration of 71 months. According to Sanders classification, the fracture pattern included 105 type II, 121 type III and 48 type IV fractures. According to American Orthopaedic Foot & Ankle Society hindfoot scoring system, the excellent, good, fair and poor results were achieved in 104, 132, 27, and 11 patients, respectively. The preoperative Böhler’s angle, difference value of Böhler’s angle between bilateral calcaneus, and change in Böhler’s angle by ratio each has a significant correlation with Sanders classification (rs=−0.178, P=0.003; rs=−0.174, P=0.004; rs=−0.172, P=0.005, respectively), however, is not correlated with functional outcome individually. The three postoperative measurements were all found to have a significant correlation with American Orthopaedic Foot & Ankle Society hindfoot scores (rs=0.223, P<0.001; rs=0.224, P<0.001; rs=0.220, P<0.001, respectively). However, these correlations were all weak to low.

Conclusions

There was a significant correlation between preoperative Böhler’s angle and the injury severity of displaced intra-articular calcaneal fractures, but only postoperative Böhler’s angle parameters were found to have a significant correlation with the functional recovery.

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

BACKGROUND

The purpose of this study is to assess the clinical results of a minimally invasive treatment featured the concept of internal compression, including an anatomic plate and multiple compression bolts compared with open reduction and internal fixation for displaced intra-articular calcaneal fractures (DIACFs).

METHODS

We retrospectively analyzed 329 patients (383 feet) who were identified from trauma inpatient database in our hospital for DIACFs from January 2004 to December 2009. Of them, 148 patients (170 feet) were treated with open reduction and internal fixation (OR group), which involved using a traditional L-shaped extended lateral approach, and fractures were fixed by plate and screws from January 2004 to December 2006; 181 patients (213 feet) were treated with a minimally invasive approach featured the concept of calcaneal internal compression (CIC group), which was achieved by an anatomic plate and multiple compression bolts through a small lateral incision from January 2007 to December 2009. Postoperative complications were recorded. During follow-up, pain and functional outcome were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) scores and compared between the two groups. Subsequent subtalar arthrodesis and early implant removal were performed when indicated. Routine hardware removal was scheduled for all patients at 1-year follow-up.

RESULTS

There were no significant differences in sex, age, and fracture classification (Sanders classification) between the two groups. Wound healing complications were 4 of 213 (1.88%) in CIC group and 20 of 170 (11.76%) in OR group. Subtalar arthrodesis had to be performed in one case in OR group. Four cases in CIC group and four cases in OR group had the hardware removed earlier due to complications. The average time after surgery to start weight-bearing exercise is 5.64 weeks in CIC group and 9.38 weeks in OR group (p < 0.001). The mean AOFAS score is higher in CIC group than in OR group, although the difference is not statistically significant (87.53 vs. 84.95; p = 0.191). The overall results according to the AOFAS scoring system were good or excellent in 185 of 213 (86.85%) in CIC group and 144 of 170 (84.71%) in OR group. The subjective portion of the AOFAS survey answered by patients showed statistically significant difference in activity limitation and walking surface score (7.31 vs. 7.02 and 3.72 vs. 3.42; p < 0.05) but not in pain and walking distance between the two groups (32.72 vs. 32.29 and 4.37 vs. 4.42; p > 0.05).

CONCLUSION

The study results suggest that this minimally invasive approach featured the concept of the calcaneal internal compression can achieve functional outcome as good as, if not better than the open techniques. It is proved to be an effective alternative treatment for DIACFs.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of platelet-rich plasma combined with allograft bone in the management of displaced intra-articular calcaneal fractures: a prospective cohort study

To investigate whether platelet-rich plasma (PRP) when used with allograft bone improves the management outcome of displaced intra-articular calcaneal fractures. Over a 7-year period, all displaced type III calcaneal fractures admitted in our department (276 fractures in 254 patients) were randomly divided into three groups according to the plan of management: autograft alone (n = 101), allograft combined with PRP (n = 85), or allograft alone (n = 90). Radiographic imaging and three-dimensional computed tomography were used to assess the thalamic portion, Bohler's angle, the crucial angle of Gissane, and the height, width and length of the calcaneum. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind-foot scoring system was used to evaluate the hind foot function at 12, 24, and 72 months postsurgery. At 12 months no significant difference existed in outcome amongst the treatment groups (p > 0.05). However, at 24 and 72 months the results of the autograft, and the allograft combined with PRP, were similar and both were significantly better than that of the allograft alone (p < 0.05). PRP augmented the favorable outcome of allografts in the management of displaced calcaneal fractures, and matched that of autograft used alone. The findings of this study thus support the clinical use of PRP in conjunction with allograft in the treatment of displaced intra-articular calcaneal fractures.

Calcaneal fractures: update on current treatments

Calcaneal fractures represent 2% of all fractures and account for approximately 60% of all tarsal injuries. Motor vehicle collisions and falls are the major causes of these large force compression injuries, causing widening of the heel, loss of heel height, and articular surface displacement. A correlation has been shown between restoration of normal anatomy and satisfactory functional outcome. Once the basic principles of calcaneal fractures are understood, including the anatomy, the radiographic findings, and the challenges that these complicated fractures present, the physician can then be ready with the armamentarium that allows for a patient-specific and injury-specific plan.

Open reduction and internal fixation of OTA type C2-C4 fractures of the calcaneus with a triple-plate technique

The purpose of this study was to present a surgical technique of open reduction and internal fixation of displaced intra-articular calcaneal fractures with 3 AO mini-fragment plates and to evaluate the clinical and radiological outcome of a consecutive group of patients after a mean follow-up of 41.7 months. A series of 54 patients (16 women and 38 men) with 62 calcaneal fractures were treated over a period of 6.5 years. Forty-five patients with 50 calcaneal fractures were completely clinically and radiologically followed up. Clinical follow-up included assessment of range of motion, pain according to a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score, and the short-form 36 health survey. Radiological follow-up included plain axial and lateral radiographs and measurement of the Böhler's angle and Gissane's angle. Independent Student's t test and paired Student's t test were used alongside the chi-square test to compare clinical and radiological data and score values between different groups of patients. Eleven patients showed breakage of the osteosynthesis material during the healing process and 2 patients sustained deep wound infection requiring revision surgery. At the final follow-up all fractures had healed. The average range of motion was supination 26.4° (range 0° to 50°; SD 11.6°), pronation 15.4° (range 0° to 30°; SD 6.4°), dorsal extension 14.3° (range -10° to 30°; SD 8.0°), and plantarflexion 39.6° (range 20° to 65°; SD 11.7°). Patients with OTA type C4 fractures achieved significantly lower supination (p < .01) and plantarflexion (p < .01) compared with other fracture types. The mean visual analog scale pain score was 3.6 (range 0 to 8; SD 2.3) points, average American Orthopaedic Foot and Ankle Society hindfoot score was 70.8 (range 33 to 100; SD 17.1) points, and the mean short-form 36 score was 60.98 (range 22.9 to 93.0; SD 18.4) points. The mean postoperative Böhler's angle was 28.9° (range 8° to 38°; SD 7.1°), which decreased to 23.6° (range 4° to 34°; SD 8.7°) at the final follow-up, and the mean postoperative Gissane's angle was 108.6° (range 80° to 140°; SD 11.8°), which finally decreased to 102.4° (range 72° to 126°; SD 12.7°). No statistically significant differences regarding Böhler's and Gissane's angles were found between different OTA fracture types. In conclusion, the presented surgical technique was found to provide comparable and adequate reduction of OTA type C2-C4 injuries based on statistically insignificant differences in radiographic measures of postoperative fracture reduction. Greater limitation in subtalar motion was observed in OTA type C4 fractures in comparison with less severe fractures (p < .01).

Locking plate technology and its use in foot and ankle surgery

This article discusses the history of conventional plating, plate biomechanics, and screw function to provide better understanding of osseous physiology and biology using locking plates. The peer-reviewed and non-peer-reviewed literature have been researched to decipher and share the most pertinent information on this topic.