Radiographic and functional outcomes after displaced intra-articular calcaneal fractures: a comparative cohort study among the traditional open technique (ORIF) and percutaneous surgical procedures (PS)

Postoperative complications after displaced intra-articular calcaneal fracture operations

BACKGROUND

The objective was to compare postoperative complications in the management of displaced intra articular calcaneal fractures (DIACF) between two groups; the open reduction and internal fixation (ORIF) group versus the percutaneous fixation (PF) group.

METHODS

A total of 243 DIACFs were diagnosed and 127 of them received operations either with ORIF 75 (59.1 %) or PF 52 (40.9 %) between 2004 and 2018. Postoperative complications, radiological Sanders's classification and improvement of Böhler's angle were analyzed.

RESULTS

Early complication rate (<6 weeks), rate of deep wound infections and wound edge necrosis were significantly better in PF than in ORIF patient group. There were no significant differences in late complications (>6 weeks from operation) nor in improvement of Böhler's angle.

CONCLUSION

Complication rate is lower when using PF technique while fracture reduction remains the same compared to the ORIF.

LEVEL OF EVIDENCE

IV retrospective cohort study at a single institution.

Impact of sustentaculum tali screw positioning on radiographic and functional outcomes in calcaneal fractures

BACKGROUND

To investigate whether accurate placement of sustentaculum tali screws have the impacts on the clinical efficacy of calcaneal fractures.

METHODS

A retrospective analysis of 72 cases (73 feet) of calcaneal fractures from September 2015 to September 2019 treated with open reduction and internal fixation with sustentaculum tali screws was conducted. Patients were divided into the sustentaculum tali fixation group (ST group) and the sustentaculum fragment fixation group (STF group) according to the location of the sustentaculum tali screw placement. The functional outcomes at preoperative, 7 days and 1 year postoperative were collected and analyzed.

RESULTS

In the ST group (40 feet), the Gissane's angle altered from (109.89 ± 12.13)° to (121.23 ± 9.34)° and (119.08 ± 8.31)° at 7 days and 1 year postoperative, respectively. For Böhler's angles altered from (11.44 ± 5.94)°, to (31.39 ± 7.54)°, and (30.61 ± 7.94)° at 7 days and 1 year postoperative, respectively. In the STF group (33 feet), Gissane's angle altered from (110.47 ± 14.45)°, to (122.08 ± 8.84)°, and (120.67 ± 9.07)° and Böhler's angle altered from (11.32 ± 6.77)°, to (28.82 ± 8.52)°, and (28.25 ± 9.13)° (P < 0.001). However, there was no statistically significant difference in functional outcomes at 1 week after surgery and 1 year after surgery (P > 0.05). The AOFAS scores at the final follow-up of the two groups: ST group (88.95 ± 6.16) and STF group (89.78 ± 8.76); VAS scores, ST group (0.83 ± 0.98) and STF group (1.03 ± 1.59), all differences were not statistically significant (P > 0.05).

CONCLUSION

The position of sustentaculum tali screws has no significant difference on the short-term clinical outcome in patients with calcaneal fractures, while reliable fixation of screws to sustentaculum tali fragment can achieve similar clinical outcome.

LEVEL OF EVIDENCE V

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study

BACKGROUND

Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction.

METHODS

This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate.

RESULTS

Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork.

CONCLUSION

Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane.

LEVEL OF EVIDENCE

III.

Finite element analyses of three minimally invasive fixation techniques for treating Sanders type II intra-articular calcaneal fractures

BACKGROUND AND OBJECTIVE

Calcaneal Sanders type II or III fractures are highly disabling with significant burden. Surgical treatment modalities include open reduction and internal fixation (ORIF) techniques and a variety of minimally invasive surgical (MIS) approaches. ORIF techniques are associated with complications and traditional MIS techniques need extensive intraoperative fluoroscopic procedures. The present study aims to investigate the effects of three different minimally invasive internal fixation (MIIF) techniques used to treat Sanders type II intra-articular calcaneal fractures using finite element analyses.

METHODS

A 64-row spiral computed tomography scan was used to observe the calcaneus of a healthy adult. The scanning data were imported into Mimics in a DICOM format. Using a new model of a Sanders type II-B intra-articular calcaneal fracture, three minimally invasive techniques were simulated. Technique A involved fixation using an isolated minimally invasive locking plate; Technique B used a minimally invasive locking plate with one medial support screw; and Technique C simulated a screw fixation technique using four 4.0-mm screws. After simulating a 640-N load on the subtalar facet, the maximum displacement and von Mises stress of fragments and implants were recorded to evaluate the biomechanical stability of different fixation techniques using finite element analyses.

RESULTS

After stress loading, the maximum displacements of the fragments and implants were located at the sustentaculum tali and the tip of sustentaculum tali screw, respectively, in the three techniques; however, among the three techniques, Technique B had better results for displacement of both. The maximum von Mises stress on the fragments was < 56 Mpa, and stress on the implants using the three techniques was less than the yield strength, with Technique C having the least stress.

CONCLUSION

All three techniques were successful in providing a stable fixation for Sanders type II intra-articular calcaneal fractures, while the minimally invasive calcaneal locking plate with medial support screw fixation approach exhibited greater stability, leading to improved enhancement for the facet fragment; however, screw fixation dispersed the stress more effectively than the other two techniques.

Three-dimensional printed cast assisted screw fixation of calcaneal fractures: a prospective study

BACKGROUND

Treatment of displaced intra-articular calcaneal fractures (DIACFs) with percutaneous screw fixation remains defective in some aspects. A novel three-dimensional (3D) printed cast was devised to assist screw placement. This study assessed the radiological and functional outcomes of 3D-printed cast assisted screw fixation for patients with DIACFs.

METHODS

Patients with unilateral Sanders type II or III DIACFs admitted to a single-centre hospital underwent either 3D-printed cast assisted screw fixation (3D group) or minimally invasive plate fixation (control group) from September 2020 to November 2022. All patients were assessed at one, two, three, and six months of follow-up. Comparison between groups was conducted in operative duration, fluoroscopic times, radiographic measurements of the calcaneus, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score.

RESULTS

A total of 32 patients were enrolled (19 in the 3D group versus 13 in the control group). Significant differences were detected between the 3D group and control group in operative duration (53.63±8.95 min, 95.08±8.31 min, P <0.001), fluoroscopic times (7.37±1.21, 16.85±1.57, P <0.001). At a follow-up of six months, the 3D group showed better restoration than the control group in calcaneal width, height, Bohler angle, and AOFAS Ankle-Hindfoot scores (all P <0.001). No significant differences were shown in calcaneal length and Gissane angle (P >0.05). No wound-related complications occurred in either group.

CONCLUSION

The 3D-printed cast assisted screw fixation has shown superiority over minimally invasive plate fixation in the operative duration, fluoroscopic exposure, morphological restoration of the calcaneus, and functional outcomes in the treatment of DIACFs.

Prevalence and Associated Factors of Ankle-Foot Pain Among Nurses Working in Surgical Units of Comprehensive Specialized Hospitals in Amhara Regional State, Northwest Ethiopia, 2022

Background

Ankle-foot pain is a serious public health concern among nurses and has a significant impact on the quality of the health care service delivery system. However, little is known about the prevalence and factors associated with ankle-foot pain among nurses working in surgical units in Ethiopia.

Purpose

The study aimed to assess the prevalence and associated factors of ankle-foot pain among nurses working in surgical units of comprehensive specialized hospitals in Amhara regional state, Northwest Ethiopia, 2022.

Participants and Methods

An institution-based cross-sectional study was conducted among 409 nurses working in surgical units of comprehensive specialized hospitals, from May 15 to June 7, 2022. A simple random sampling technique was employed. Data were collected by five BSc nurses using a structured self-administered questionnaire. The collected data were entered into Epi-data version 4.6 and exported to SPSS version 23 for analysis. The descriptive statistics and bivariable and multivariable logistic regression analyses were computed. Finally, variables were declared as statistically significant at P < 0.05 using the odds ratio and 95% CI.

Results

The prevalence of ankle-foot pain among nurses working in surgical units was 51.8% (95% CI = 46.9-57.5). More than 10 years of working experience [AOR = 3.48, 95% CI = 1.35-8.92], working 48 or more hours per week [AOR = 2.69, 95% CI = 1.27-6.00], prolonged standing [AOR = 5.72, 95% CI = 3.20-10.25], high physical job demand [AOR = 2.41, 95% CI = 1.53-3.80], and low job control [AOR = 2.34, 95% CI = 1.47-3.71] had statistically significant association with ankle-foot pain.

Conclusion

This study found that ankle-foot pain was common among nurses working in surgical units. Having more years of work experience, working more hours per week, prolonged standing, high physical job demand, and low job control were statistically associated with ankle-foot pain.

Emergency surgery of intra-articular calcaneal fractures using sinus tarsi approach with modified reduction technique

BACKGROUND

The purpose of this study was to evaluate emergency surgery of calcaneal fractures using the sinus tarsi approach (STA) with modified reduction technique in terms of complication rates, iconography results and functional outcome.

METHODS

We evaluated the outcomes of 26 patients treated in an emergency using STA with modified reduction technique. For that, we assessed Böhler´s angle, Gissane angle, reduction of the calcaneal body, and posterior facet, the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, complications, preoperative time, operative time, and in-hospital time.

RESULTS

Recovery of calcaneal anatomy and articular surface were found at final follow-up. The mean Böhler´s angle at final follow-up were 30.68° ± 3.69°, of which was 15.02° ± 3.88° preoperatively (p < 0.001). The mean Gissane angle at final follow-up were 114.54° ± 11.16° of which was 88.86° ±10.96° preoperatively (p < 0.001). All cases had the varus/valgus angle of the tuber within 5 degrees. At the final follow-up, the mean AOFAS score was 89.23 ± 4.63, and the VAS score was 22.73 ± 6.5.

CONCLUSIONS

Emergency surgery using STA with modified reduction technique is reliable, effective, and safe for treatment of calcaneal fractures. This technique can bring good clinical outcomes and a low rate of wound complications, reducing the in-hospital time, costs, and accelerating rehabilitation.

Outcomes of U-shaped internal fixation in the treatment of avulsion fracture of calcaneal tubercle

BACKGROUND

The purpose of this study was to analyze the efficacy of U-shaped internal fixation for calcaneal tubercle fracture after nearly 3 years of case follow-up and data collection.

METHOD

We retrospectively analyzed the collected data from 16 patients with avulsion fracture of calcaneal tubercle between December 2018 and February 2021 at our institute. All patients were required to conform to regular follow up postoperatively. X-ray film was applied to all cases. The American Orthopaedic Foot and Ankle Association (AOFAS) score, Cedell score and the visual analog scale (VAS) were used to evaluate functional results.

RESULTS

All patients achieved bone union. The preoperative AOFAS score was 26.34 ± 3.34, which was significantly different from 91.38 ± 6.15 half a year after operation (p = 0.003). The preoperative Cedell score was 31.05 ± 4.18 and the score half a year after operation was 92.17 ± 5.39(p = 0.011). The VAS score was 8.91 ± 1.51 before operation and decreased to 0.58 ± 1.31 half a year after operation (p = 0.014).

CONCLUSIONS

In the treatments of calcaneal tubercle fracture, U-shaped internal fixation is a new attempt. Through the short-term follow-up study, we found that its therapeutic effect is excellent, which is a recommended treatment in clinic.

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.

Clinical outcomes following treatment of deep surgical site infection after fixation of calcaneal fractures: A retrospective case-control study

INTRODUCTION

Deep surgical site infection (SSI) may be a complication of open reduction and internal fixation (ORIF) of calcaneal fractures. This study aimed to describe the characteristics of patients with deep SSI following ORIF of calcaneal fractures via extensile lateral approach (ELA). We compared clinical outcomes of these patients, with a minimum follow-up of one year after successful treatment of deep SSI with a matched control group.

METHODS

In this retrospective case-control study, demographic data, fracture characteristics, bacterial pathogens, medical treatments and surgical approaches were collected, also the outcome was evaluated by the visual analog scale (VAS) for pain, foot function index (FFI) and AOFAS ankle-hindfoot score. The differences in Böhler and Gissane's angles between infected and contralateral feet were measured. By matching a control group of uninfected cases, clinical outcomes were compared between 2 groups using the Mann-Whitney U test.

RESULTS

Among 331 calcaneus fractures in 308 patients (mean age, 38.0 ± 13.1; male/female ratio, 5.5), 21 had deep SSI (6.3 %). There were 16 (76.2 %) males and 5 (23.8 %) females with a mean age of 35.1 ± 11.7 years. Thirteen (61.9 %) patients had unilateral fractures. The most common Sanders Type was found to be type II. The most frequent type of detected microorganisms was Staphylococcus species. Intravenous antibiotic therapy, mostly clindamycin, imipenem and vancomycin, based on the microbiological results, was prescribed with a mean±SD duration of 28.1 ± 16.5 days. The mean number of surgical debridements was 1.8 ± 1.3. Implants needed to be removed in 16 (76.2 %) cases. Antibiotic-impregnated bone cement was applied in three (14.3 %) cases. The clinical outcomes of 15 cases (follow up, 35.5 ± 13.8; range, 12.6-64.5 months) were 4.1 ± 2.0, 16.7 ± 12.3 and 77.5 ± 20.8 for VAS for pain, FFI % and AOFAS ankle-hindfoot score, respectively. Comparing with the control group (VAS for pain, 2.3 ± 2.7; FFI %, 12.2 ± 16.6, and AOFAS, 84.6 ± 18.0), only VAS pain was statistically lower in this group (p-value: 0.012). The differences in Böhler and Gissane's angles between both feet of infected cases were - 14.3 ± 17.9 and - 7.7 ± 22.5 (worse in the infected side), respectively.

CONCLUSION

Proper on-time approaches to deep infection following ORIF of calcaneal fractures may lead to acceptable clinical and functional outcomes. Sometimes aggressive approaches with intravenous antibiotic therapy, multiple sessions of surgical debridement, removal of implants and antibiotic impregnated cement are necessary to eradicate deep infection.

LEVEL OF EVIDENCE

Level III.

Delayed Surgical Treatment of Displaced Intra-Articular Calcaneal Fractures in Major Trauma Is Safe and Effective

BACKGROUND

To assess whether delaying operative fixation through the sinus tarsi approach resulted in a decreased wound complications rate or could hinder the quality of reduction in subjects with Sanders type II and III displaced intra-articular calcaneus fractures.

METHODS

From January 2015 to December 2019, all polytrauma patients were screened for eligibility. We divided patients into two groups: Group A, treated within 21 days after injury; Group B, treated more than 21 days after injury. Wound infections were recorded. Radiographic assessment consisted of serial radiographs and CT scans: postoperatively (T0) and at 12 weeks (T1) and at 12 months after surgery (T2). The quality of reduction of the posterior subtalar joint facet and calcaneal cuboid joint (CCJ) was classified as anatomical and non-anatomical. A post hoc power calculation was performed.

RESULTS

A total of 54 subjects were enrolled. Four wound complications (three superficial, one deep) were identified in Group A; two wound complications (one superficial one deep) were identified in Group B. According to "mean interval between trauma and surgery" and "duration of intervention", there was a significant difference between the groups (p < 0.001). There were no significant differences between Groups A and B in terms of wound complications or quality of reduction.

CONCLUSIONS

The sinus tarsi approach is a valuable approach for the surgical treatment of closed displaced intra-articular calcaneus fractures in major trauma patients who need delayed surgery. The timing of surgery did not negatively influence the quality of the reduction and the wound complication rate.

LEVEL OF EVIDENCE

level II, prospective comparative study.

Comparing Calcaneus Fracture Radiographic Outcomes and Complications after Percutaneous Pin versus Screw Fixation

Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. Although screws are thought to provide greater stability, limited data exists directly comparing fixation success of these implants. Medical record data from 53 patients (62 total fractures) surgically treated with percutaneous screws (28 fractures) or K-wires (34 fractures) for joint-depression calcaneus fractures at a large tertiary hospital were retrospectively reviewed. Bohler's angle and calcaneal varus were assessed from available radiographs at time of injury, postoperatively, and at final follow-up, and joint congruity was assessed postoperatively and at final follow-up. Complications were also extracted. There were no statistical differences in patient characteristics between surgical groups although a higher proportion of patients treated with K-wires compared to screws had other associated injuries (79% vs 42%, p = .01). A higher proportion of fractures treated with screws compared to K-wires maintained joint congruity at the final follow-up (69% vs 32%, p = .005). However, there were no statistically detectable differences in other postoperative radiographic metrics (p > .05). In conclusion, joint congruity was more often maintained with screw fixation although there was no statistical difference in restoration and maintenance of Bohler's angle or varus alignment. The difference in radiographic metrics was not correlated with secondary procedures, namely subtalar arthrodesis, and may not be clinically significant. Neither group was completely effective in attaining and maintaining reduction, and additional fixation strategies should be considered if feasible based on patient, injury, and soft tissue characteristics.

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.

Predictive Factors of Poor Outcome in Sanders Type III and IV Calcaneal Fractures Treated with an Open Reduction and Internal Fixation with Plate: A Medium-Term Follow-Up

Background: Consensus on the treatment for severely comminuted calcaneus fractures has yet to be found. This study aims to analyze the functional and radiological short- and medium-term outcomes of displaced calcaneus fractures of type III and IV treated with ORIF, and to identify, if present, the early predictors of unfavorable outcomes. Methods: Thirty-three calcaneal fractures were included, 23 type III and 10 type IV, according to Sanders classification. AOFAS scales for ankle and hindfoot and SF-12 were used. Böhler and Gissane angles were analyzed before and after surgery. Results: The minimum follow-up was six years. The mean AOFAS score at six months was 16.5 points (24.2 ± 10.8 vs 10.8 ± 9.5; p = 0.03) with better outcomes in patients with Sanders type III fractures. This difference decreased in the subsequent follow-up. Likewise, the mental and physical score of SF-12 had the same trend. Two wound infections and no deep infections were recorded in the Sanders type III fracture group. Instead, in the Sanders type IV group, there were four wound infections and one deep infection. Conclusions: Clinical and radiological outcomes in Sanders Type III and Type IV calcaneus fractures treated with plate and screws were very similar in long-term follow-up. If ORIF provided better short- to medium-term follow-up in Sanders type III fracture, these benefits have been lost in six years. Polytrauma and psychiatric patients showed significantly lower clinical outcomes in long-term follow-up, appearing as the most reliable negative predictors.

Consequences of extensile lateral approach to the calcaneal fractures on balance and isokinetic strength of muscle groups crossing the ankle joint

BACKGROUND

Inherent characteristics of extensile lateral approach (ELA) for fixation of displaced intraarticular calcaneal fractures together with delayed or probably insufficient physical therapy programs may lead to weakness of the muscle groups crossing the ankle joint. Peroneal tendons might be involved more than others because of possible postoperative adhesions. The aim of this study was to evaluate the isokinetic strength of the muscle groups crossing the ankle joint and also to assess balance and functional ability in this group of patients.

METHODS

Based on a pilot study, 23 patients undergone open reduction and internal fixation (ORIF) via ELA and 22 healthy subjects as the control group participated in this observational cross-sectional study. Patients more than 20 years of age with at least 12 months passed their unilateral closed intraarticular calcaneal fracture fixation without any postoperative complications like infection or wound dehiscence were included. Patients with history of concomitant lower extremity injury, spine trauma or surgery, cases underwent removal of calcaneal plates, and cases with neuromuscular or vestibular dysfunction were excluded. The outcome was assessed by isokinetic parameters such as peak torque, peak torque normalized to body weight, mean power and total work modified star excursion balance test, triple hop for distance test, and evertor-to-invertor (E/I) strength ratio. Isokinetic tests were performed at 60 and 120°/s.

RESULTS

Greater strength was observed in all muscles in the control group at 60°/s (p < 0.05). Evertors and invertors were weaker in the operated group at 120°/s in comparison to the dorsiflexors and plantarflexors. Modified star excursion (p: 0.003) and triple hop tests (p: 0.001) were lower in the operated group. E/I ratio was not statistically significant between the two groups at 60°/s (p: 0.44) and 120°/s (p: 0.62).

CONCLUSIONS

Strength deficit in all muscle groups crossing the ankle joint, and not evertors in isolation, in addition to balance and functional impairments would be seen one year following ORIF of calcaneal fracture via ELA. A long-term rehabilitation program emphasizing different kinds of contraction at low and high speeds and balance training in these patients is highly recommended.

The Association of Bohler's Angle With Postoperative Pain and Gender for Displaced Intra-Articular Calcaneal Fracture, Multicenter Retrospective Study-TRON Study

A relationship between Böhler angle (BA) before or after surgery and clinical outcomes remains unclear. This retrospective multicenter cohort study aimed to compare pain and functional outcomes between a group in which the reduction angle was preserved and a group in which the reduction angle was lost during follow-up, and to clarify the risk factors leading to loss of last follow-up BA. From 2014 to 2018, 271 cases of calcaneal fractures were surgically treated at ten facilities. We divided patients into Group L (lost reduction of fracture) and Group P (preserved reduction of fracture). We matched subjects between the 2 groups according to age, sex and BA before surgery and compared American Orthopedic Foot and Ankle Society (AOFAS) score between the groups. We investigated the correlation between the amount of BA loss and postoperative pain. The factors leading to loss of last follow-up BA were examined by logistic regression analysis. Ultimately, 112 patients were eligible. After matching, each group included 38 patients. There was no difference between the 2 groups in total AOFAS score. However, the pain component of AOFAS score at 6 months and 12 months were worse in group L than in group P (p = .011, p = .031, respectively). We also showed a weak correlation between the amount of BA loss and postoperative pain. Logistic regression analysis revealed that female and BA before surgery independently predicted loss of reduction (odds ratios: 4.66, 95% CI: 1.15-18.9 and odds ratios: 0.90, 95% CI: 0.82-0.99, respectively). We clarified that reduction and preservation of BA within its normal range should lead to decrease postoperative pain. Female and lower pre-BA were risk factors leading to loss of reduction of BA in operative treatment of calcaneal fractures.

A historical review of calcaneal fractures: from the crucifixion of Jesus Christ and Don Juan injuries to the current plate osteosynthesis

PURPOSE

Calcaneal fractures are one of the most challenging injuries to treat and one of the most divisive. The purpose of this historical review is to highlight the evidence of calcaneal fracture and its treatment through history.

METHODS

Archaeological, religious, artistic, literary and historical accounts were searched for descriptions of calcaneal fracture to give a thorough overview of the subject. The scientific literature was searched to highlight the evolution of treatment techniques.

RESULTS

For over 2500 years, the only available option was conservative treatment due to the high risk of infection and limb loss in a world without antibiotics, plastic surgery techniques and adequate osteosynthesis devices. At the beginning of the twentieth century, treatment was still rather crude, consisting of closed reduction by impaction by a Cotton's mallet, immobilisation of the foot into presses and strict bed rest in a plaster cast for five weeks. Only in the case of untreatable pain, triple arthrodesis could be employed. Regardless, the results were dismal. The debate on the superiority of open reduction and primary subtalar arthrodesis over open and closed reduction spans the entire history of medicine.

CONCLUSION

The long path of history has brought great improvement in the treatment of calcaneus fracture, but the debate about the best treatment is far from being over. There is a lack of good quality randomised control trials conducted according to an agreed set of outcome scores despite some excellent efforts. Therefore, despite the attempts made over the years and new, more precise prognostic scores, the outcomes of each technique in use today are as unique as the individuals who suffer from a calcaneal fracture.

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.

Calcaneal Fractures-Which Approach for Which Fracture?

Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.

C-Nail versus plate osteosynthesis in displaced intra-articular calcaneal fractures-a comparative retrospective study

Background

Locking plate osteosynthesis via an L-shaped lateral approach is the gold standard in treating displaced intra-articular calcaneal fractures. High complication rates are known for this approach. The most frequent complications are wound edge necrosis and superficial wound infections. To reduce complication rates, a locking intramedullary nail (C-Nail) was developed that can be implanted minimally invasively via a sinus tarsi approach.

We compared the postoperative complication rate and the outcome of plate osteosynthesis versus C-Nail in displaced intra-articular calcaneal fractures.

Methods

All patients with calcaneal fractures who received osteosynthesis with either plate or C-Nail between January 2016 and October 2019 in our institution were retrospectively analyzed. A subgroup analysis was performed with matched pairs (matching Sanders type, age, Böhler’s angle postoperative in normal range, 33 pairs). Endpoints were postoperative complication rate, bone healing, full weight-bearing and functional outcome. Treatment groups were compared using Fisher’s exact test for binary data, and Mann-Whitney U-test for continuous data. A p-value < 0.05 was considered statistically significant.

Results

One hundred and one calcaneal fractures were included (C-Nail n = 52, plate n = 49). Patients with C-Nail developed significantly less postoperative complications (p = 0.008), especially wound edge necrosis (p < 0.001). Screw malposition was found more often in the C-Nail group. The rates of achieving full weight-bearing as well as bone healing were comparable in both groups, but in each case significant faster in the C-nail subgroup. The results of the matched-pairs analysis were comparable.

Conclusions

The postoperative complication rate was significantly lower in the C-Nail group. The C-Nail appears to be a successful alternative in the treatment of calcaneal fractures, even in Sanders IV fractures because of the minimal-invasive implantation as well as the high primary stability. Long-term analysis of this new implant including elaboration on functional outcome is planned.

Trial registration

Deutsches Register Klinischer Studien (DRKS) DRKS00020395. Date of registration 3 January 2020.

Sanders classification of calcaneal fractures in CT images with deep learning and differential data augmentation techniques

BACKGROUND

Classification of the type of calcaneal fracture on CT images is essential in driving treatment. However, human-based classification can be challenging due to anatomical complexities and CT image constraints. The use of computer-aided classification system in standard practice is additionally hindered by the availability of training images. The aims of this study is to 1) propose a deep learning network combined with data augmentation technique to classify calcaneal fractures on CT images into the Sanders system, and 2) assess the efficiency of such approach with differential training methods.

METHODS

In this study, the Principle component analysis (PCA) network was selected for the deep learning neural network architecture for its superior performance. CT calcaneal images were processed through PCA filters, binary hashing, and a block-wise histogram. The Augmentor pipeline including rotation, distortion, and flips was applied to generate artificial calcaneus fractured images. Two types of training approaches and five data sample sizes were investigated to evaluate the performance of the proposed system with and without data augmentation.

RESULTS

Compared to the original performance, use of augmented images during training improved network performance accuracy by almost twofold in classifying Sanders fracture types for all dataset sizes. A fivefold increase in the number of augmented training images improved network classification accuracy by 35%. The proposed deep CNN model achieved 72% accuracy in classifying CT calcaneal images into the four Sanders categories when trained with sufficient augmented artificial images.

CONCLUSION

The proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of computer-aided system in assisting physicians in evaluating calcaneal fracture types.

Could percutaneous fixation with crossed Schanz pins be an alternative to open reduction in the treatment of intra-articular calcaneal fractures?

PURPOSE

Despite modern operative techniques and a considerable number of studies in the literature, the best treatment for calcaneal fractures remains an enigma for orthopaedic surgeons. The purpose of the study was to compare clinical and radiographic outcomes between anatomic calcaneal plate (ACP) fixation and crossed Schanz pin (CSP) fixation in the treatment of Sanders type II and III displaced intra-articular calcaneus fractures (DICFs).

METHODS

Consecutive 65 patients (49 males, 16 females) who underwent surgery for DCIFs between January 2009 and February 2013 were retrospectively evaluated. The patients were divided into two groups as ACP and CSP according to the operative technique. The groups were compared in terms of demographic features, injury mechanism, operation time, fluoroscopy exposure, complications, full weight-bearing time, functional, and radiological outcomes.

RESULTS

VAS-rest score did not differ significantly between the groups while the VAS-activity score was significantly higher in the CSP group (p = 0.001 and p = 0.645, respectively). Foot Function Index (FFI) was significantly lower, Maryland Foot Score (MFS) and the American Orthopaedic Foot and Ankle Society-hindfoot score (AOFAS) were significantly higher in the ACP group (p = 0.047, p = 0.016, and p < 0.001, respectively). While no difference was observed between the preoperative and the early post-operative (1st day) Böhler angle and Gissane angle, both were significantly higher in the ACP group at the post-operative last control (p < 0.001 and p < 0.001, respectively).

CONCLUSION

Although crossed Schanz pin fixation shortens the operation time in displaced intra-articular calcaneus fractures compared to anatomic calcaneal plate, increased fluoroscopy exposure rates and low functional and radiological outcomes are disadvantageous of crossed Schanz pin. Anatomic calcaneal plate is still a better technique for preserving the alignment and elevating the displaced intra-articular segment for good to excellent mid-term results.

Application of medial column classification in treatment of intra-articular calcaneal fractures

BACKGROUND

There are many types of treatments for calcaneal fractures, including conservative treatment, conventional surgical treatment, and minimally invasive surgery. The choice of specific treatment options is still controversial. Open reduction and internal fixation are currently the most commonly used surgical procedures in the clinic. A good fracture reduction effect can be achieved by using the lateral extension incision of the calcaneus; however, many studies have reported a high incidence of postoperative incision complications. Although there are many methods for the classification of intra-articular calcaneal fractures, it is generally believed that the computed tomography (CT) classification proposed by Sanders has high application value in the selection of treatment methods and evaluation of prognosis of calcaneal fractures. However, this method has no clear guiding significance for the choice of surgical incision and surgical plan.

AIM

To explore the application and clinical efficacy of medial column classification in the treatment of intra-articular calcaneal fractures.

METHODS

From July 2017 to July 2018, 91 patients, including 60 males and 31 females aged 27 to 60 years, were enrolled. All participants had closed intra-articular calcaneal fracture, and their surgical options were selected under the guidance of medial column classification. The patients’ fractures were classified according to the Sanders classification: Type II, 35 cases; Type III, 33 cases; and Type IV, 23 cases. Among them, 53 patients had medial column displacement (shortened varus) and underwent open reduction and internal fixation with L-lateral incision of the calcaneus; 38 patients had no displacement of the medial column and underwent open reduction and internal fixation with tarsal sinus incision. The calcaneus Böhler angle, Gissane angle, length, width, height, and step thickness of the articular surface were evaluated by X-ray and three-dimensional CT before and after surgery and at the last follow-up. Foot function recovery was assessed by the Maryland foot scoring criteria.

RESULTS

All patients were followed for 5 to 14 mo, with an average of 10.5 ± 2.9 mo. The fractures of all patients healed, and the healing time was 10 to 19 wk, with an average of 10.8 ± 1.5 wk. One patient developed wound infection 1 wk after surgery and was actively debrided and implanted with antibiotic calcium sulfate to control the infection. The patient's fracture healed 5 mo after surgery. One patient developed a sural nerve injury, and the symptoms disappeared 3 mo after surgery. The patients were assessed according to the Maryland foot scoring system: Excellent in 77 cases, good in 10, and fair in 4. The excellent and good rate was 95.6%.

CONCLUSION

Medial column classification can effectively guide the surgical selection for intra-articular fractures of the calcaneus.

Paediatric calcaneal fractures: A guide to management based on a review of the literature

INTRODUCTION

Calcaneal fractures are rare in children. These fractures are often misdiagnosed as a consequence of their subtle clinical and radiographic presentation. The purpose of this paper was to identify prognostic factors on the basis of type of fracture, age and treatment. This would enable suggestions to be made with regards to treatment for these fractures.

METHODS

A full literature search was performed to find studies that were clinically orientated, in the English language and involved children (under the age of 16). Studies with no outcome data were excluded.

RESULTS

There were a total of 284 patients reviewed in 26 peer-review publications. Two hundred and eight patients had intra-articular fractures. The non-operatively managed joint depression type fractures had poor outcomes in 21% of patients. In those who underwent surgical fixation for these fractures, 3 patients had reduced subtalar motion, and three had pain, one of whom required a subtalar arthrodesis at 7 months. In the tongue type fracture group, the outcomes were similar in those treated operatively and non-operatively. Extra-articular fractures were found to be much less common than the intra-articular fractures. They also became less common in older children. Generally, the outcomes were good, irrespective of treatment. Only 2 patients with type 1B fractures had poorer outcomes.

DISCUSSION

This is a rare injury and outcomes may be poorer in those who do not have adequate anatomical reduction. Displaced intra-articular fractures in all age groups should be considered for anatomical reduction of the articular surface, to guarantee good outcomes and prevent future pain and arthritis. Extra-articular fractures in children are less severe, do well with conservative treatment, and rarely require operative intervention.

Surgical treatment of displaced intraarticular calcaneal fractures by a minimally invasive technique using a locking nail: A preliminary study

BACKGROUND

The aim of this retrospective study was to evaluate the outcome of patients with intra-articular calcaneal fractures treated using a minimally invasive locking nail (Calcanail^®).

METHODS

Between January 2016 and April 2017, 15 patients (9 men and 6 women) with a calcaneal fracture were consecutively treated with Calcanail^®. The Böhler angle was recorded on standard X-rays pre- and post-operatively. The articular reduction of the posterior facet was evaluated with the Goldzak index in a CT scan 3 months post-operatively. The mean age of the patients was 53 years (range, 24-78). Mean final follow-up was 18 months (range, 12-24).

RESULTS

Six fractures were classified as Sanders II, 7 as Sanders III and 2 as Sanders IV. In 13 out of the 15 patients treated, the post-operative Böhler angle was of more than 20°. Goldzak index was deemed as excellent in 73.5% of the cases (11 patients), good in 20% of cases (3 patients), and poor in 6.5% (1 patient). Post-operative mean AOFAS score was 85 (range, 60-96).

CONCLUSIONS

The Calcanail^® provides good restoration of the subtalar joint and the calcaneal angles with the advantages of a minimally invasive approach. It was effectively used in Sanders types II and III, even in the presence of poor cutaneous conditions.

Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

BACKGROUND

The main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management.

METHODS

From January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed.

RESULTS

27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49-119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7-7). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0-11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9-10). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%).

CONCLUSIONS

Despite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.

Calcaneal fracture fixation using a new interlocking nail reduces complications compared to standard locking plates - Preliminary results after 1.6 years

INTRODUCTION

Surgical treatment of displaced intra-articular calcaneal fractures using a standard extended lateral approach for plate fixation is frequently associated with substantial wound healing complications and infections. This matched pairs analysis compares the new minimally-invasive calcaneal interlocking nailing technique to standard locking plate fixation in terms of reduction capacity, complication rates, and functional outcomes.

METHODS

Forty feet in 38 patients (mean patient age 52.5 years, range 27-78) were treated with calcaneal locking nail (LN)(n=20) or locking plate (LP)(n=20) and followed clinically and radiologically for 20 months. Follow-up included radiological assessments and functional evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Foot Function Index (R-FFI).

RESULTS

Times for surgery were similar for both techniques (LN 93min, range 34 to 175 vs. LP 101min, range 53 to 305). Length of hospital stay was significantly lower in the LN group (7.6 days, range 3 to 14 vs. LP 11 days, range 6 to 37). Time away from work was shorter by 3.5 days in LN group. LP group had superior range of motion in plantarflexion, eversion, and inversion at follow-up, while LP patients were superior in demonstrating a secure heelstrike (79% vs. LN 58%) and fewer needed permanent walking aids. AOFAS and FFI scores revealed no differences for both groups. Radiographs indicated an adequate reconstruction in both groups, followed by a slight loss of reduction at follow-up (LP 4.7° postoperative vs. follow-up; LN 5.1°). The overall complication rate between groups was significant with 5% complications in the LN group vs. 50% in the LP group (5% deep infection, 35% impaired wound healing, 5% hardware breakage, 5% superficial wound infection; LN: 5% superficial wound infection).

CONCLUSIONS

The new calcaneal interlocking nail shows promising results in terms of reduction capacity and safety. Use of the minimally invasive locking nail technique minimized the risk of postoperative wound complications and achieved superior functional outcomes compared with standard locking plate fixation via the extended lateral approach.

Real-Time Automated Segmentation and Classification of Calcaneal Fractures in CT Images

Calcaneus fractures often occur because of accidents during exercise or activities. In general, the detection of the calcaneus fracture is still carried out manually through CT image observation, and as a result, there is a lack of precision in the analysis. This paper proposes a computer-aid method for the calcaneal fracture detection to acquire a faster and more detailed observation. First, the anatomical plane orientation of the tarsal bone in the input image is selected to determine the location of the calcaneus. Then, several fragments of the calcaneus image are detected and marked by color segmentation. The Sanders system is used to classify fractures in transverse and coronal images into four types, based on the number of fragments. In the sagittal image, fractures are classified into three types based on the involvement of the fracture area. The experimental results show that the proposed method achieves a high precision rate of 86%, with a fast computational performance of 133 frames per second (fps), used to analyze the severity of injury to the calcaneus. The results in the test image are validated based on the assessment and evaluation carried out by the physician on the reference datasets.

The Results of Physical, Radiologic, Pedabarographic, and Quality-of-Life Assessments in Patients with Surgically Treated Intraarticular Calcaneus Fractures

Calcaneal fractures are complex injuries and have historically had a poor prognosis that results in substantial disability. However, no studies have been performed that analyze both the radiographic and plantar pressure changes after treatment of intraarticular calcaneus fracture. Patients with an intrarticular calcaneus fracture treated at our institution during the study period were identified from computerized hospital records. A total of 36 patients (34 males) completed physical examination and radiographic and dynamic pedobarographic assessments. The follow-up period was from 13 to 82 months (median 38 months). The mean pain score at rest was 3.7 and during activity was 4.0 on a 10-cm visual analogue scale. The mean range of motion of the subtalar joint was restricted. The mean American Orthopaedic Foot and Ankle Society function scale score was 68.1; the mean Short Form-36 physical score was 41.8; and the mental score was 44.9. Pedabarographic results showed that the mean maximum force in the midfoot, forefoot, and toes (p = .001; p = .04; p = .002) and peak pressure in the midfoot, forefoot (p = .001; p = .007), and contact area of the midfoot and toes (p = .038; p = .004) were significantly increased in the injured foot. Radiologic findings showed hindfoot varus, forefoot adductus, and an increase in the medial arch. Even after appropriate anatomic realignment with open reduction and internal fixation of calcaneus fractures, residual differences in plantar pressures and radiographic measures are noted compared to uninjured foot.

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.

Short-Term Outcomes of Open Reduction and Internal Fixation for Sanders Type III Calcaneal Fractures With and Without Bone Grafts

Calcaneal fractures, often caused by a fall from a height, are the most common injuries encountered by orthopedic surgeons. Currently, open anatomic reduction and internal fixation (ORIF) is considered a valuable treatment of displaced intraarticular fractures of the calcaneus; however, the need for bone grafting in the treatment is still controversial. Therefore, in the present study, we investigated the outcomes of 2 methods (with and without bone grafting) used for the surgical treatment of Sanders type III calcaneal fractures. From January 2013 to September 2015, 57 cases (55 patients) with displaced Sanders type III calcaneal fractures (53 unilateral and 2 bilateral) were enrolled. The patients were divided into 2 groups: group I was treated by ORIF with bone grafting (n = 28) and group II was treated by ORIF without bone grafting (n = 29). The radiologic evaluation included Böhler's angle, Gissane's angle, and the height and width of the calcaneum. In addition, the American Orthopaedic Foot and Ankle Society questionnaires and visual analog scale were completed by the patients. During the follow-up period, no differences were found in the outcome measures (Böhler's angle, p = .447; Gissane's angle, p = .599; calcaneal height, p = .065; calcaneal width p = .077; and American Orthopaedic Foot and Ankle Society questionnaires, p = .282) with or without bone grafting. The only difference between the 2 groups was the occurrence of postoperative pain (p = .024 and p = ≤ .05), which was greater in the patients who had undergone bone grafting. We have provided evidence that bone grafting with internal fixation in the treatment of intraarticular calcaneal fractures failed to improve the restoration of Böhler's angle or Gissane's angle. No statistically significant difference was found in the short-term outcomes between the 2 methods used for the surgical treatment of Sanders type III calcaneal fractures.

Minimally invasive reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular calcaneal fractures: A systematic review of the literature

The aim of this article is to systematically identify and analyse research evidence available to compare the outcomes of minimally invasive reduction and percutaneous fixation (MIRPF) versus open reduction and internal fixation (ORIF) for displaced intra-articular calcaneal fractures.

Articles from 2000 to 2016 were searched through MEDLINE (PubMed), Cochrane Library, Embase, ScienceDirect, Scopus and ISI Web of Knowledge using Boolean logic and text words. Of the 570 articles identified initially, nine were selected including three randomized controlled trials and six retrospective comparative studies.

All nine studies had a total of 1031 patients with 1102 displaced intra-articular calcaneal fractures. Mean follow-up was 33 months. Of these, 602 (54.6%) were treated with MIRPF and 500 (45.4%) were treated with ORIF.

Overall incidence of wound-related complications in patients treated with MIRPF was 4.3% (0% to 13%) compared with 21.2% (11.7% to 35%) in the ORIF group

Functional outcomes were reported to be better in the minimally invasive group in all studies; however, the results did not reach statistical significance in some studies. All the studies had methodological flaws that put them at either ‘unclear’ or ‘high’ risk of bias for multiple domains.

Overall quality of the available evidence is poor in support of either surgical technique due to small sample size, flaws in study designs and high risk of bias for various elements. Individual studies have reported minimally invasive techniques to be an effective alternative with lower risk of wound complications and better functional outcomes.

Cite this article: EFORT Open Rev 2018;3:418-425. DOI: 10.1302/2058-5241.3.170043

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.

Comparative Study of Intramedullary Hammertoe Fixation

BACKGROUND

Temporary Kirschner wire fixation (K-wire) is a widely used, low-cost fixation method for the correction of hammertoe deformity. Reported complications associated with K-wires prompted the development of new implants over the past decade. However, there is a lack of literature on comparative studies analyzing functional outcomes using validated questionnaires. The purpose of this study was to analyze functional outcomes in patients who had undergone proximal interphalangeal joint fusion using 2 types of intramedullary implant, the Smart Toe and the TenFuse, and to compare them with the outcomes in patients treated with standard K-wire fixation.

METHODS

A retrospective review of operative hammertoe correction by a single surgeon was performed in 96 patients followed for more than 12 months. Functional outcome was assessed using the Foot Function Index (FFI), the Short Form 36 (SF-36), and the 10-point visual analog scale (VAS) validated questionnaires. Complications and fusion rates were also evaluated. Several patients in the study underwent corrections in different toes; thus, a total of 186 toes were included in the study. From these, 65 toes (34.9%) were treated with K-wire fixation, 94 (50.5%) with Smart Toe titanium implant, and 27 (14.5%) with TenFuse allograft implant.

RESULTS

No statistically significant differences in functional outcome and incidence of complications were observed among the 3 fixation groups, although the 2 intramedullary implants were associated with greater fusion rates and patient satisfaction. Breakage of the Smart Toe implant was significantly higher than that of the other fixations, with 10.6% of implants breaking within the first year postoperatively. SF-36 and VAS scores decreased 12 months after surgery for the 3 types of fixation, with no statistically significant differences observed.

CONCLUSION

The use of Smart Toe and TenFuse implants provided operative outcomes comparable to those obtained using a K-wire fixation and slightly better patient satisfaction. Our results suggest that utilization of these implants for hammertoe correction was a reasonable choice that provided good alignment, pain reduction, and improved function at final follow-up. However, they are more expensive than K-wires. For this reason, in-depth cost-benefit studies would be required to justify their use as a standard treatment.

LEVEL OF EVIDENCE

Level III, comparative series.

Treatment of intraarticular calcaneal fractures by reconstruction plate. Results and complications of 86 fractures

OBJECTIVE

To evaluate the results of surgical treatment of intraarticular calcaneal fractures, and also to analyze the variables that influence the final clinical and radiological outcomes as well as the complications.

MATERIAL AND METHODS

We retrospectively analyzed 86 intraarticular calcaneal fractures in 78 patients, who underwent surgery with an extended lateral approach and reconstruction plate. The mean age was 48 years (16-74 years) and the mean follow-up was 4.6 years (9-99 months); 54 patients (69.2%) suffered falls from less than 3m in height or banal injuries and 24 patients (30.8%) falls from more than 3m in height or high energy-accidents. According to the Sanders classification we operated 12 (15%) typeII, 54 (62.8%) typeIII and 20 (23.2%) typeIV fractures.

RESULTS

The postoperative mean AOFAS score was 73.9 points, with good or excellent results in 57% of the patients. Twelve cases (14%) suffered surgical wound complications and 11 (12.8%) required subtalar arthrodesis. Significantly better results were obtained in the patients younger than 30 years old, patients that fell from less than 3m in height and patients with Sanders fractures types II and III compared to typeIV, which were associated with higher rate of subtalar arthrodesis.

CONCLUSIONS

We consider that open reduction and internal fixation of intraarticular fractures of the calcaneus with reconstruction plate is a valid treatment alternative. Given the complications described and the secondary subtalar arthrodesis rate, we recommend a meticulous technique carried out by experienced surgeons.