Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis

Morphologic evaluation of vascular foramina in dry calcaneus

PURPOSE

The purpose of this study is to provide reference data regarding the morphology of vascular foramina (VF) of calcaneus among the Turkish population.

METHODS

This study was performed using 49 dry calcanei (26 right, 23 left). The number as well as the location of VF in relation of each surface of calcaneus were evaluated. The total length (TL), the distance between the most posterior point of calcaneus and the largest foramina on the medial (LMS), lateral (LLS), superior (LSS) and inferior (LIS) surfaces were measured and foraminal indexes of the largest foramina on the medial (FI1), lateral (FI2), superior (FI3) and inferior (FI4) surfaces were calculated.

RESULTS

The mean values of the TL, LMS, LLS, LSS, LIS were measured to be 74.83 ± 6.00 mm, 41.34 ± 4.78 mm, 31.18 ± 7.63 mm, 49.61 ± 13.40 mm, 39.25 ± 13.56 mm, respectively. The mean values of the FI1, FI2, FI3 and FI4 were calculated to be 55.40 ± 6.21%, 41.73 ± 10.06%, 66.01 ± 16.82%, 52.16 ± 16.80%, respectively. The maximum numbers of VF were detected most commonly on the lateral (28.29%) and medial (26.45%) surfaces, and least commonly on the anterior (0.98%) and posterior (8.29%) surfaces.

CONCLUSIONS

VF were observed to be most commonly located on the lateral and medial surfaces, and least commonly on the anterior and posterior surfaces. Having adequate knowledge of the morphologic and morphometric properties of the VF is important in regarding the surgical approaches to the calcaneus towards the aim of reducing the vascular damage, especially in lateral approaches for orthopedists and of using differential sign from cystic lesions for radiologists.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Patient Reported Outcome Measures (PROMs) in Surgery: Evaluation after Minimally Invasive Reduction and Percutaneous K-Wires Fixation for Intra-Articular Calcaneal Fractures

Background: The optimal surgical treatment of intra-articular calcaneal fractures (IACF) is still under debate. In the literature, results are based on clinical or radiographical findings. Few studies have evaluated the effect of patient expectations on patient-reported outcomes after surgery and little is known about outcomes directly reported by the patient who experienced it. Patient reported outcome measures (PROMs) may represent a viable and useful tool for evaluating the efficacy of the procedure and can be considered as an indicators of health-care quality. The aim of this study is to evaluate PROMs after minimally invasive reduction and percutaneous Kirschner-wires fixation for IACF, and to compare PROMs to pre-operative and last follow-up radiographic findings. Methods: 33 consecutive patients with IACF treated with minimally invasive reduction and percutaneous K-wires fixation were included. Data collection included demographics, pre-operative and last available Böhler and Gissane angle X-rays, foot function index (FFI), and foot and ankle outcome score (FAOS). Results: At a mean follow up of 36.7 months, the mean FFI score was 24.3 ± 19.9 and the mean FAOS score was 68 ± 24.8. Patients with better Gissane angle showed better activity limitations FFI subscores. Moreover, worse pre-operative Gissane and Böhler angle were significantly associated with a worse total FAOS score and subscores. Conclusions: Minimally invasive reduction and percutaneous K-wires fixation provided satisfactory PROMs. Despite these results, prospective randomized studies are required to confirm the validity and reliability of PROMs in evaluating different treatments.

Minimally Invasive Osteosynthesis of Intraarticular Calcaneus Fracture Augmented by Femoral Head Allograft: A Retrospective Study

Aim: The aim of this retrospective study is to report the results of minimally invasive osteosynthesis when used for the treatment of intraarticular calcaneus fracture. This old technique is regaining popularity recently with the multiple advances added by different institutes when it is used in the management of intraarticular calcaneus fracture.

Methods: Twenty-four patients who suffered from intraarticular calcaneus fractures between 2014 and 2019 were included. Twelve of them had Sanders II fractures (group A) and 12 had Sanders III + IV fractures (group B). The mean follow-up duration was 37.5 months. The mean age at presentation was 54.23 ± 12.48 years. The skin condition at presentation was poor (blood-filled blisters) in 25% of patients equally distributed between the two groups. The mean time to surgery was 5.6 days where patients with poor skin conditions were treated lately. The technique involved percutaneous ascending proximal-to-distal pinning of the calcaneus after reduction using a 2 cm mini-incision below the lateral malleolus and augmenting the fixation with femoral head cancellous allograft. The primary outcomes variables analyzed in this study are post-operative Bohler angle, post-operative Gissane angle, American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at long-term follow-up (Excellent>95, Good 75-94, Fair 51-74, poor 0-50), and the delta angle benefit score. The secondary outcomes included post-operative complications such as infection and osteoarthritis.

Results: The radiological results showed significant improvement of Bohler angle from 6.09° ± 21.6 pre-operatively, to 31.79° ± 14.1 postoperatively with a p-value <0.001. An adequate reduction was achieved in 54.16% to 70.8% of patients. There is a trend to normalization of overcorrected fracture especially Sanders II with a mean reduction of 12,71° ± 11,88 at one year post-operatively (p=0.05). AOFAS score at the last follow-up shows 20.83% poor results (AOFAS<50), 50% fair results (AOFAS between 51-74), 16.67% good results (AOFAS 75-94), and 12.5% excellent results (AOFAS>95. The satisfaction rate was 83.3% (45.8% partially satisfied, and 37.5% fully satisfied). The incidence of superficial infection (wound inflammation and pin tract infection) was more prevalent in higher group B (40%) compared to group A (0%) with p=0.014. Other complications including osteoarthritis and varus deformity were found in 95.8% and 58.3% of patients respectively at three-year follow-up.

Conclusion: The combination of minimally invasive osteosynthesis and femoral head allograft for the treatment of intraarticular calcaneus fractures seems to give fair to good functional results. Radiological data demonstrated that when the Bohler angle is over-reduced >40°, there was a tendency to autocorrection over time. This may be due to progressive depression of the angle over time as weight bearing is authorized; however, this must be analyzed carefully due to the low number of patients who were overreduced (seven patients). Our study demonstrates that this technique has a low early complication rate (especially low infection and soft tissue problems) but carries high long-term complications such as osteoarthritis and hindfoot varus.

Bone Tissue Engineering in the Treatment of Bone Defects

Bones play an important role in maintaining exercise and protecting organs. Bone defect, as a common orthopedic disease in clinics, can cause tremendous damage with long treatment cycles. Therefore, the treatment of bone defect remains as one of the main challenges in clinical practice. Today, with increased incidence of bone disease in the aging population, demand for bone repair material is high. At present, the method of clinical treatment for bone defects including non-invasive therapy and invasive therapy. Surgical treatment is the most effective way to treat bone defects, such as using bone grafts, Masquelet technique, Ilizarov technique etc. In recent years, the rapid development of tissue engineering technology provides a new treatment strategy for bone repair. This review paper introduces the current situation and challenges of clinical treatment of bone defect repair in detail. The advantages and disadvantages of bone tissue engineering scaffolds are comprehensively discussed from the aspect of material, preparation technology, and function of bone tissue engineering scaffolds. This paper also summarizes the 3D printing technology based on computer technology, aiming at designing personalized artificial scaffolds that can accurately fit bone defects.

Impact of Psychosocial and Economic Factors on Functional Outcomes After Operative Calcaneus Fractures

OBJECTIVES

To report functional outcome scores after operative intraarticular calcaneus fracture and to determine risk factors associated with worse outcomes.

DESIGN

Retrospective study.

SETTING

Urban Level 1 trauma center.

PATIENTS AND PARTICIPANTS

Ninety-six patients with 114 calcaneus fractures treated by a single surgeon over a 14-year period.

INTERVENTION

Surgical treatment with open reduction and internal fixation with lateral extensile approach or percutaneous reduction and fixation.

MAIN OUTCOME MEASUREMENTS

Functional outcome scores as assessed by the Musculoskeletal Function Assessment (MFA) and the Foot Function Index (FFI) after mean 56 months follow-up.

RESULTS

Seventy-two patients (75%) completed functional outcome questionnaires. Patients with functional outcome data were more often employed (86% vs. 67%, P = 0.07), but were no different in terms of age, sex, medical history, mechanism of injury, or injury characteristics. The mean FFI score was 30 (range: 2-89), and the mean MFA score was 28 (range: 2-80). One-third of patients reported scores >30 on the FFI, MFA, or both. Age, sex, tobacco use, mechanism of injury, fracture pattern, open injury, and postoperative infection were not associated with outcome scores. Alcohol abuse and failure to return to work were associated with worse (higher) FFI scores. Alcohol abuse, psychiatric illness, unemployment (before and after injury), polytrauma, and posttraumatic osteoarthrosis were associated with worse (higher) MFA scores.

CONCLUSIONS

Polytrauma, alcohol abuse, psychiatric illness, work status, and posttraumatic osteoarthrosis were predictors of poor functional outcomes. The findings of this study add to previous literature that has demonstrated the importance of social, behavioral, and environmental factors on recovery after orthopaedic injury.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of Displaced Intra-Articular Calcaneal Fractures: A Comparative Study of Open and Minimally Invasive Surgery

Objectives

The ideal treatment of displaced intra-articular calcaneal fractures continues to be a subject of debate. The aim of the study was to compare the radiological outcome, cumulative radiation exposure, surgical time, time to surgery, wound healing times and cost involved in minimally invasive surgery (MIS) and open reduction internal fixation (ORIF) for calcaneal fractures.

Methods

This was a retrospective study of 39 calcaneum operated in our unit during 2012 to 2019, of which 20 had undergone ORIF and 19 had been operated upon following MIS.

Results

A total of 39 calcanea (37 patients) were operated, of which 20 had open procedure and 19 had MIS procedure, including one bilateral surgery in each group. Mean age of the patients in the MIS group was 42.18 years (range: 15-68 years) and that of the patients in the open group was 43 years (range: 21-75 years). Of the fractures, 53.84% (n = 21) was Sanders type III, 28.20% (n = 11) was type II and 17.94% (n = 7) was type IV. There was no statistically significant difference in the mean correction of Bohler’s angle and Gissane’s angle between the groups. The mean cost for implant used for each open procedure was £882.79, and the implant cost for each MIS procedure was £142.89. Mean utilisation of cumulative X-ray dose was significantly higher in MIS (0.764 mGy) in comparison to open surgery (0.392 mGy). The average surgical time for MIS was 64.9 minutes and that of open surgery was 106.3 minutes. Average waiting time for MIS was 6.6 days and that for ORIF was 9.8 days. Wound healing was quicker (average 13.4 days) in MIS than ORIF (average 17.2 days). All these differences were statistically significant.

Conclusions

Minimally invasive calcaneal fracture surgery is quicker and cheaper and can be performed earlier. It is associated with early wound healing, although it requires higher cumulative radiation dose.

Patient-specific instrument-assisted minimally invasive internal fixation of calcaneal fracture for rapid and accurate execution of a preoperative plan: A retrospective study

Background

Traditional methods for minimally invasive internal fixation (MIIF) of calcaneal fractures require extensive intraoperative fluoroscopy, and fracture recovery is usually not ideal. We developed a new surgical procedure using digital surgical simulation and constructed a patient-specific instrument (PSI) for calcaneal fracture that we used during the operation. This study investigated whether PSI-assisted MIIF of calcaneal fracture enables rapid and accurate execution of the preoperative plan.

Methods

We retrospectively analyzed patients with Sanders type III or IV fresh calcaneal fractures who had undergone PSI-assisted MIIF at our hospital from January 2016 to December 2018. We analyzed perioperative data including intraoperative fluoroscopy time, concurrence of internal fixation actual usage (IFAU) with the preoperative plan, surgery time, and complications. We also compared pre- and postoperative actual measurements from X-ray radiographs and computed tomography images including Böhler, Gissane, and calcaneus valgus angles; subtalar joint width; and calcaneal volume overlap ratio with the preoperative design. All patients had been followed up and their American Orthopedic Foot and Ankle Score (AOFAS) score was available.

Results

Mean intraoperative fluoroscopy time was 3.95 ± 1.78 h; IFAU in 16 patients (16 ft) was the same as the preoperative plan; mean surgery time was 28.16 ± 10.70 min; and none of the patients developed complications. Böhler, Gissane, and calcaneus valgus angles and subtalar joint width did not differ between pre- and postoperative plans; however, the actual preoperative values of each of these parameters differed significantly from those measured postoperatively. The calcaneal volume overlap ratio with the preoperative design was 91.2% ± 2.3%. AOFAS scores increased with time, with significant differences in the score at each time point.

Conclusions

The newly developed PSI-assisted calcaneal fracture MIIF method can rapidly and accurately execute the preoperative plan.

Minimally invasive dual incision with mini plate internal fixation improves outcomes over 30 months in 20 patients with Sanders type III calcaneal fractures

Background

Calcaneal Sanders type III or higher fractures traditionally have been treated with open reduction and internal fixation (ORIF); however, ORIF has associated complications. We investigated a combination of minimally invasive dual incision and internal fixation using mini plates for treating Sanders type III calcaneal fractures.

Methods

Twenty patients with Sanders type III intra-articular calcaneal fractures with a posterior subtalar articular displacement > 2 mm were included. Surgical outcomes were assessed by visual analogue scale (VAS) pain score, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and calcaneal geometry, including Böhler and Gissane angles.

Results

The Böhler angle, Gissane angle, and height and length of the calcaneus were increased following treatment. Based on the AOFAS score, 80% of cases had excellent or good outcomes. The mean postoperative VAS pain score was 1.6. Complications such as malunion or a screw positioning deviation occurred in 6 patients, and one patient experienced delayed wound healing. There were no wound infections.

Conclusions

These results indicate that minimally invasive dual incision with mini plate internal fixation may be an effective alternative to ORIF for treating Sanders type III calcaneal fractures. Advantages include improvement of calcaneal geometry and a lower rate of wound infections.