Medial external fixation for staged treatment of closed calcaneus fractures: Surgical technique and case series

Limb Reconstruction System Assisted Reduction and Internal Fixation for Intra-Articular Calcaneal Fractures: A New Application

BACKGROUND

Minimally invasive reduction and fixation of intra-articular calcaneal fractures poses great challenges for orthopaedic surgeons. The aim of the present study was to report the technical points, evaluate the efficacy of minimally invasive reduction and internal fixation assisted by the temporary limb reconstruction system (LRS) external fixator for intra-articular calcaneal fractures, and propose the indications of our protocol.

METHODS

In this retrospective study, a series of 34 consecutive closed and displaced intra-articular calcaneal fractures involving the articular surface were treated by this technology between June 2016 and April 2018. X-ray and computed tomography (CT) scans were performed before and after surgery to measure Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot. Postoperative complications were recorded. Imaging and clinical outcomes were comprehensively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system. After testing the normality of the data, Bohler's angle and the length of calcaneus were compared using the Wilcoxon signed-rank test. The height, width of the calcaneus, and the mechanical axis of the hindfoot were compared using the Paired-Samples t-test.

RESULTS

Thirty-two fractures were followed up for an average of 20.66 months (from 12 to 32 months). All fractures achieved stable reduction and bony union. The articular surface was reduced and fixed with direct vision through the sinus tarsi incision. No failure of internal fixation or loss of reduction was detected during follow-up. There were no soft tissue complications. Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot improved significantly. The AOFAS scores averaged 84.12 points; seven cases were rated excellent, 20 good, four fair, and one poor.

CONCLUSIONS

For intra-articular calcaneal fractures, minimally invasive surgery assisted with temporary LRS external fixation can reconstruct the calcaneal shape and the sub-talar articular surface. This simple surgical modality with limited complications may be helpful in the surgical treatment of most type II and III calcaneal fractures except comminuted fractures of the calcaneal tuberosity.

Technique and Early Outcomes for High-Energy Calcaneus Fractures Treated With Staged External Fixation to Combined Open Reduction Internal Fixation and Subtalar Arthrodesis

OBJECTIVE

(1) To present an effective surgical technique for the treatment of open and high-energy calcaneal fractures with significant soft tissue injuries. (2) To present complications with this technique and to evaluate patient-reported outcomes of staged external fixation followed by delayed reconstruction with open reduction internal fixation (ORIF) and subtalar arthrodesis.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Twelve patients with 13 calcaneus fractures associated with open traumatic wounds (10 patients) or other severe soft tissue injury (ie, fracture blisters) between April 2013 and December 2019.

INTERVENTION

All patients were treated with staged ankle-spanning external fixation and delayed reconstruction with ORIF with subtalar arthrodesis.

MAIN OUTCOME MEASURES

Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes are presented via the domains of physical function (PF), pain interference (PI), and depression (D) in addition to visual analog score. Complications with the injury and surgical procedure were reported as well.

RESULTS

Patients underwent initial stabilization on average 1.3 days (range, 0-12 days) from injury with stage II occurring on average 31.1 days (range, 18-42 days) from external fixation. Mean time to radiographic union was 5.6 months (range, 4-10 months). One-year mean PROMIS outcomes were as follows: PF final average of 37.4 with an average improvement of 12.2 (P < 0.01), PI final average of 62.2 with average improvement of 5.6 (P = 0.01), and D final average of 52.1 with average improvement of 6 (P = 0.12). Mean final visual analog score pain score was 3.6 with an average improvement of 2.25 (P = 0.01).

CONCLUSION

Staged treatment with initial external fixation followed by ORIF and subtalar arthrodesis in the setting of highly comminuted calcaneus fractures with significant soft tissue compromise effectively addresses both bony and soft tissue concerns while providing for positive outcomes postoperatively with regards to pain and function. There were minimal complications noted for this complex injury.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intra-articular Calcaneal Fracture Treatment With Staged Medial External Fixation

BACKGROUND

To compare the clinical and radiographic outcomes between the conventional delayed and staged approaches for intra-articular calcaneus fractures in which early definite fixation could not be performed because of severe soft tissue injury.

METHODS

From January 2015 to May 2019, a total of 32 cases with acute intra-articular calcaneal fractures met criteria and were enrolled in the study. We compared the outcomes of intra-articular calcaneal fractures that underwent delayed internal fixation between groups treated with a conventional delayed approach (non-EF group) vs a temporary medial external fixation (EF group). Clinical outcome measures included a 10-point visual analog scale score, the AOFAS score, and the Foot Function Index. Radiographic outcome measures included Böhler angle, talar declination angle, and calcaneal width. Reduction of the posterior facet was assessed on CT scans.

RESULTS

The first 15 (46.9%) were treated with a conventional delayed approach, and the latter 17 (53.1%) were treated with a staged approach with temporary medial external fixation. Clinical outcomes were not different between the groups at the last follow-up. The time from injury to definite internal fixation was shorter by an average of 3.8 days in the EF group (P = .001). The Böhler angle, talar declination angle, and calcaneal width were not different between the groups before surgery and at the last follow-up. Reduction of the posterior facet on CT scans was significantly better in the EF group than in the non-EF group (good/excellent = 94% vs 60%, respectively, P = .033).

CONCLUSION

The staged approach using medial external fixation for displaced intra-articular calcaneus fractures could be an effective method to decrease the time to definitive internal fixation and obtain optimal reduction of the posterior facet.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings

The hindfoot consists of the talus and calcaneus, spans the tibiotalar to transverse tarsal joints, and is critical for support of body weight and absorption and transfer of physiologic loads during bipedal movements. Hindfoot fractures account for approximately 17% of foot and ankle fractures, with calcaneal fractures being more common than talar fractures. Hindfoot fractures are usually caused by high-impact axial loads such as falls from heights and motor vehicle accidents, and understandably, they are often seen in patients with polytrauma. Long term, these fractures have implications in development of posttraumatic osteoarthrosis with associated pain and stiffness, affecting daily living activities. An overview of the talus and calcaneus is presented, with emphasis on fractures with articular involvement-namely, the tibiotalar and subtalar joints. Articular talar and calcaneal injuries can also alter hindfoot alignment, causing ankle and foot function abnormalities. Optimal treatment-that is, restoration of articular surfaces and hindfoot alignment followed by rigid fixation until fracture union-is dependent on an accurate understanding of the injury that is well depicted with imaging, radiography and CT in particular. The discussion of talar and calcaneal fractures includes a review of the normal anatomy, epidemiologic factors, classification systems, and imaging and pathologic-anatomic features of common injury patterns. This review is intended to aid surgical management and restoration of articular and hindfoot alignment for optimal ankle and foot function, thereby reducing patient morbidity in these often devastating injuries. ^©RSNA, 2022.

Staged Management of Severely Displaced Calcaneal Fractures With Transarticular Pinning: A Damage Control Strategy

BACKGROUND

Severely displaced calcaneal fractures can result in considerable morphology derangement and may be accompanied by soft tissue compromise. Delayed operative restoration of the calcaneal morphology may result in acute retensioning of the damaged soft tissue with associated wound-related complications. In this study, we describe a staged treatment of displaced intra-articular calcaneal fractures that uses temporary transarticular Kirschner wire (K-wire) fixation and staged conversion to definite fixation.

METHODS

We identified all of the patients who were treated at our institution for calcaneal fractures between 2015 and 2019. A total of 17 patients with 20 calcaneal fractures were selectively treated with 2-stage management. Temporary transarticular K-wire fixation was performed 24 hours after the injury to restore calcaneal morphology and the surrounding soft tissue. After the soft tissue was considered safe, delayed open reduction and internal fixation was performed. The time to definite surgery, radiographic alignment, wound complications, time to radiographic union, and hindfoot American Orthopaedic Foot & Ankle Society (AOFAS) scores were recorded.

RESULTS

The average follow-up period was 17 months (range, 12-43). The average Böhler angle increased from a mean of -22 degrees (range, -109 to 25) to 25 degrees (range, 0 to 47) after temporary transarticular K-wire fixation. The mean time from temporary pinning to conversion to definite internal fixation was 20 (range, 10-32) days. There were no immediate postoperative complications. The average time to radiographic union was 13.7 (range, 10-16) weeks. The mean AOFAS score was 87 (range, 55-100). No infections or wound complications were reported during the follow-up period.

CONCLUSION

Temporary transarticular pinning for staged calcaneal fracture treatment is safe and effective in restoring the calcaneal morphology. This novel and relatively simple method may facilitate delayed operation and decrease wound-related complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Frame-Assisted Reduction of a B-Type Pilon Fracture Dislocation: Talar Body Incarceration on an Intact Fibula: A Case Report

CASE

We describe an irreducible anterolateral tibiotalar dislocation with an AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association) B-type pilon fracture. The injury was initially treated with closed reduction, using a medializing force achieved with an external fixator to unhinge the talar body from the fibula, followed by temporary stabilization. Definitive fixation was performed once the soft tissues had recovered.

CONCLUSION

This unique irreducible pilon fracture dislocation pattern is important to recognize to prevent iatrogenic complications associated with multiple failed closed reduction attempts. Frame-assisted, percutaneous, or open maneuvers may be required to facilitate a reduction. Staged treatment with temporization in an external fixator may be required.

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.

Limited Approaches to Calcaneal Fractures

PURPOSE OF REVIEW

To review literature published in the last 3 years related to minimally invasive approaches to calcaneal fracture fixation.

RECENT FINDINGS

Numerous randomized control trials, cohort studies, and meta-analyses have been done in the last 3 years comparing surgical treatment of calcaneus fractures. These studies indicate minimally invasive procedures decrease wound complication rates and achieve similar radiographic and clinical outcomes to open reduction internal fixation. In comparing different surgical treatment methods to non-operative treatment, operative management has increased complication rates but may lead to better functional outcomes in certain patient populations. Optimal treatment for displaced intra-articular calcaneus fractures continues to be debated. Current literature would suggest that the decision to operate be based on patient and fracture characteristics and surgeon capabilities. Minimally invasive techniques aim to improve patient reported outcomes and quality of life while decreasing complications and offer another option for surgeons in the treatment of displaced intra-articular calcaneal fractures.