Comparison of surgical outcomes of intra-articular calcaneal fractures by age

Intra-Articular Calcaneal Fractures: Comparison between Mini-Invasive Approach and Kirschner Wires vs. Extensive Approach and Dedicated Plate-A Retrospective Evaluation at Long-Term Follow-Up

INTRODUCTION

Calcaneal fractures (CF) are the most common tarsal fractures, representing up to 75% of foot fractures and 2% of all fractures. The aim of this retrospective study is to analyze fixation with Kirschner wires through a mini-invasive approach and dedicated plate and screws through an extended approach at long-term follow-up.

MATERIALS AND METHODS

Patients were radiographically and clinically evaluated at final follow-up, by using the validated American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score for the clinical-functional assessment, the Short-Form 12 (SF-12) for the physical and psychological domain assessment, and the Visual Analog Scale (VAS) for pain.

RESULTS

In total, 38 patients (42 CF) met the inclusion criteria and were retrospectively evaluated and divided into two groups (Kirschner group and plate group) consisting of 19 patients each. The overall mean follow-up was 59.4 ± 11.8 months. The average values of the post-operative clinical outcomes of the two groups KG and PG were, respectively, 70.7 ± 11.9 and 70.1 ± 10.9 (AOFAS), 45.7 ± 6.8 and 46.5 ± 10.8 (SF-12 PCS), 54.7 ± 9.9 and 50.9 ± 11.8 (SF-12 MCS) at the final follow-up.

CONCLUSIONS

The present study showed that in the cases analyzed, the two surgical approaches used for the treatment of CF achieved comparable clinical outcomes. The only substantial difference found between the two groups of patients was the re-intervention rate that afflicted them.

Complication Rates Are Similar Between Patients Aged <50 and >50 Years in Calcaneus Fractures Treated With the Sinus Tarsi Approach

Background:

The sinus tarsi (ST) approach for calcaneus fractures has gained popularity in recent years with an increased interest in shifting to less invasive approaches for calcaneal fracture fixation allowing for adequate fixation if complications do not arise. Although the ST approach has gained acceptance as standard for calcaneus fracture fixation, the literature surrounding early complications rates based on age differences for this specific approach and pathology is lacking. The objective of this study was to determine if rates of complications based on age varied for patients undergoing open reduction and internal fixation (ORIF) of closed calcaneus fractures using the ST approach.

Methods:

A retrospective review of patients undergoing ORIF for closed calcaneus fractures from 2012 to 2020 was performed. Inclusion criteria were based on an age greater than 18 years, surgical management of a closed calcaneus fracture using a ST approach, requirement of a preoperative computed tomographic scan, and a minimum of 180 days’ follow-up. Patients were divided into 2 groups: those aged <50 years and those aged >50 years.

Results:

A total of 196 fractures were included with 114 fractures in the <50-year age group and 82 fractures in the >50-year age group. Mean age was 34.2 and 59.7 years in the younger and older groups, respectively. The older group had similar rates of wound dehiscence (1.2% vs 4.4%, P = .204), superficial surgical site infection (1.2% vs 2.6%, P = .490), deep infection (9.8% vs 7.9%, P = .648), and nonunion (4.9% vs 3.5%, P = .633) compared with the younger group. Rates of 30-day readmission, unplanned reoperation, and symptomatic hardware were not significantly different. Postoperative Bohler and Gissane angles were not significantly different between both groups.

Conclusion:

Older patients with intraarticular calcaneus fractures treated via the ST approach maintain complication rates similar to those in younger individuals.

Level of Evidence:

Level III, retrospective study.

A nomogram for predicting post-operative wound complications after open reduction and internal fixation for calcaneal fractures

The purpose of our study was to determine the risk factors for post-operative wound complications (PWCs) after open reduction and internal fixation (ORIF) for calcaneal fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from calcaneal fractures and had been surgically treated for ORIF in our institution between January 2010 and January 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of PWCs, and a nomogram model was constructed to predict the risk of PWCs. The predictive performance and consistency of the model were evaluated by the Hosmer -Lemeshow (H-L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that smoking, limb swelling, angle of incision, and CRP were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.982 (95%CI 0.97-0.99). The H-L test revealed that the normogram prediction model had good calibration ability (P = .957). Finally, we found a correlation between PWCs and smoking, limb swelling, angle of incision, and CRP after ORIF for calcaneal fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high-risk patients, as interventions could be taken early to reduce the incidence of PWCs.

Expanding Indications of Primary Arthrodesis in Selected Individuals for Managing Complex Hindfoot Trauma During COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of outdoor activities, organized sports, and schools/colleges. Neglected hindfoot fractures have emerged as a consequence with increased frequency. Similarly, complex ankle and pilon fractures that require staged management, prolonged hospital stay, and soft-tissue care have emerged as a potential concern as prolonged exposure to healthcare setting adds to risk of acquiring as well as transmitting COVID-19 infection. The authors present their experience with expanding these indications for hindfoot arthrodesis as they encounter a greater number of neglected ankle and hindfoot trauma.

METHODS

This was a retrospective observational study of collected data from the trauma unit of our hospital. Inclusion criteria included all trauma classified by the AO/OTA as occurring at locations 43, and who underwent subtalar and ankle arthrodesis. This included distal tibia, malleolar, talus, and calcaneus fractures. These patients were followed up to at least 6 months till complete fracture union.

RESULTS

A total of 18 patients underwent arthrodesis of either the ankle or subtalar joint between March and October 2020. Mean age of patients undergoing arthrodesis of the hindfoot was 69.2 years (43-84 years). Indications for the procedure included Displaced and comminuted intra-articular distal tibia fractures in elderly (6 patients), Malunited ankle fractures (2 patients), Neglected Ankle fractures managed conservatively (3 patients), Calcaneus fractures (5 patients), and neglected Talus body fracture (2 patients). All patients were followed up to at least 6 months and everyone went onto successful painless union between 3 and 6 months of the arthrodesis procedure without any significant complications.

CONCLUSION

In summary, COVID-19 pandemic has led to a change in paradigm of trauma management and foot and ankle management is no different than other musculoskeletal trauma systems. The authors propose an expansion of indications for hindfoot arthrodesis in managing complex hindfoot trauma in pandemic situation.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures

Aim and objective

The purpose of this study was to compare clinical results following complex proximal, midshaft, and distal tibial fractures and investigate whether there are differences in outcomes between these locations.

Materials and methods

Patients between 18 years and 65 years of age and minimum follow-up of 12 months with complex tibial fractures treated with a circular ring fixator were included. Functional outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) functional and bone scores, Foot Function Index (FFI), Four Step Square Test (FSST), and Timed Up and Go Test (TUG). Quality of life was assessed by the EQ-5D score.

Results

A total of 45 patients were included: proximal fractures, n = 11; midshaft fractures, n = 17; and distal fractures, n = 17. ASAMI functional (p = 0.8) and bone scores (p = 0.3) were not different. Excellent and good bone scores were achieved in >90% in all groups. FFI was 30.9 + 24.7 in the proximal group, 33.9 + 27.7 in the midshaft group, and 28.8 + 26.9 in the distal group (p = 0.8). TUG was 9.0 + 2.7 sec in the proximal group, 9.0+3.5 in the midshaft group, and 8.5+2.0 in the distal group (p = 0.67). FSST was 10.7 + 2.5 sec in the proximal, 10.3 + 3.8 in the midshaft, and 8.9 + 1.8 in the distal fracture groups (p = 0.5). EQ-5D index value was highest in the distal (0.72), lowest in the proximal (0.55), and 0.70 in the midshaft fracture groups (p = 0.001). EQ-5D VAS was significantly different between the proximal (65) and midshaft (82.3) (p = 0.001) and between the distal (75) and proximal (65) fracture groups (p = 0.001).

Conclusions

The results of this study suggest that the functional outcomes between proximal, midshaft, and distal complex tibial fractures are comparable. Their ability to ambulate afterward is comparable to age-related normative data, but complex tasks are more difficult and better compared to the ambulating ability of a healthy population aged 65 to 80 years. Patients with proximal tibial fractures had significantly more disability by at least one functional level and/or one health dimension.

How to cite this article

Naude JJ, Manjra MA, Birkholtz F, et al. Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):32-40.

Novel Technique for Osteosynthesis of Tongue-Type Calcaneus Fractures in Osteoporotic Bone: A Case Report

CASE

A 75-year-old woman with osteoporosis sustained a low-energy mechanism tongue-type calcaneus fracture. Index surgical fixation with conventionally described cannulated screws was complicated by early screw pull-out despite concomitant Achilles lengthening procedure. Using a novel technique, revision fixation was performed using a 5.0-mm condyle bolt from a retrograde femoral nail system and 2 cannulated screws. She recovered uneventfully and demonstrated union at 7 months postoperatively.

CONCLUSION

Osteosynthesis of tongue-type calcaneus fractures using a condyle bolt can be a practical and readily available solution for primary and revision scenarios in osteoporotic tongue-type calcaneus fractures.

Intra-articular Calcaneus Fractures: Current Concepts Review

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures.

Level of Evidence: Level V, expert opinion.

Hindfoot Injuries: How to Avoid Posttraumatic Varus Deformity?

Posttraumatic hindfoot varus may result from nonoperative treatment or inadequate reduction and fixation of talar and calcaneal fractures. Adequate visualization of the talar neck via bilateral approaches is essential in avoiding malreduction. In cases of medial comminution of the talar neck, lag screws must be avoided and the use of single or double plates should be considered. A Schanz screw introduced into the calcaneal tuberosity is instrumental in realigning shortening, varus, or valgus deformity of the heel. Special attention should be paid to addressing impaction of the medial facet of both the talus and calcaneus to avoid hindfoot varus.

Surgical Management of Displaced Intra-Articular Calcaneal Fractures: What Matters Most?

Displaced intra-articular calcaneal fractures are severe, complex injuries that can cause significant long-term functional impairment. Despite the controversies of whether these fractures should be treated operatively or nonoperatively, functional improvement can be seen with confounding variables that can be controlled by the surgeon. This article reviews prognostic factors that are associated with good functional outcomes following operatively treated displaced intra-articular calcaneal fractures.

Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex

Aim

The purpose of this study was to compare the functional and radiological outcomes of complex tibia fractures treated with two different hexapod fixators.

Material and methods

This is a retrospective comparative study of patients treated for complex tibial fractures between 2010 and 2015. Inclusion criteria was patients between 18 years and 60 years of age, who sustained a complex comminuted open or closed tibial fracture with or without bone loss, who had a minimum of 12 months’ follow-up, and who have been treated definitively using either Taylor Spatial Frame (TSF) or TrueLok-Hexapod System (TL-HEX). The outcome measures were Association for the Study and Application of the Method of Ilizarov (ASAMI) score, foot function index (FFI), EQ5-D, four-step square test (FSST), and timed up and go (TUG) test. Descriptive statistics were used to assess patient demographic information. Categorical variables (ASAMI and EQ5D-5L) were analysed using the χ² test. Continuous variables (FFI, functional tests, and radiographic outcomes) were analysed with two-tailed Student’s t tests.

Results

In all, 24 patients were treated with the TL-HEX and 21 with the TSF. The mean time for external fixation was 219 ± 107 days (TL-HEX) and 222 ± 98 days (TSF). Union occurred in 92% (TL-HEX) and 100% (TSF). The mean follow-up was 777 ± 278 days (TL-HEX) and 1211 ± 388 days (TSF). Using the ASAMI scores, there were 17 excellent and 6 good results for the TL-HEX and 10 excellent and 11 good results for the TSF (p = 0.33). The FFI was 30 ± 28.7 (TL-HEX) and 26.1+23.9 (TSF) (p = 0.55). The EQ5D was 0.67 ± 0.3 (TL-HEX) and 0.73 ± 0.2 (TSF) (p = 0.43). The mean TUG and FSST were 9.2 ± 3.2 and 10 ± 2.9 seconds (TL-HEX) and 8.4 ± 2.3 and 9.6 ± 3.1 seconds (TSF) (p = 0.34 and 0.69).

Conclusion

The results of this study suggest that both hexapod external fixation devices have comparable clinical, functional, and radiographic outcomes. Either fixator can be used for the treatment of complex tibial fractures, anticipating good and excellent clinical outcomes in approximately 80% patients.

Level of evidence

Therapeutic level III

How to cite this article

Naude J, Manjra M, Birkholtz FF, et al. Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. Strategies Trauma Limb Reconstr 2019;14(3):142–147.

Incidence and predictors of surgical site infection after ORIF in calcaneus fractures, a retrospective cohort study

BACKGROUND

Occurrence of calcaneus fractures is on the up trend. Owing to its unique anatomical morphology and limited soft-tissue envelope, management of calcaneus fractures is a challenge to the orthopaedic surgeon, and surgical site infection (SSI) is one of the serious postoperative complications. In order to decrease the incidence of wound breakdown and improve clinical outcomes, it is necessary to understand which factors were associated with SSI. The aim of this study was to identify predictors of SSI and quantify the incidence of SSI in calcaneus fractures following open reduction and internal fixation (ORIF).

METHODS

This retrospective study was performed at a level 1 trauma center from January 2014 to June in 2017. Data of adult patients with calcaneus fractures treated by ORIF were extracted from the electronic medical records. A total of 681 patients were collected. We reviewed the patients' demographics, characteristics of fracture, treatment-related variables, and indexes of laboratory examination. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.

RESULTS

Sixty-six patients developed SSI in this study. The overall incidence of SSI after ORIF of calcaneus fracture was 9.7%, with 2.9% for deep infection and 6.8% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were open fracture (odds ratio = 9.48, 95% CI = 4.53-19.85, P = 0.00007), high-energy injury (odds ratio = 2.07, 95% CI = 1.16-3.70, P = 0.01437), ASA class 3 or higher (odds ratio = 3.50, 95% CI = 1.18-10.37, P = 0.02401), and intraoperative temperature < 36.0 °C (odds ratio = 1.69, 95% CI = 1.13-2.28, P = 0.04410).

CONCLUSION

The SSI incidence was high (9.7%) for calcaneus fractures following ORIF. External fixation plays an important role in the treatment of severely displaced and depressed intra-articular or open calcaneus fractures. Increased ASA class and intraoperative hypothermia were associated with wound breakdown, and elaborative evaluation of fracture and soft-tissue damage was vitally necessary in this at-risk population.

Calcaneal Fractures - Should We or Should We not Operate?

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature

INTRODUCTION

Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences.

METHODS

A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied.

RESULTS

3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or ≥10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01).

CONCLUSION

Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.

Open Reduction Assisted With an External Fixator and Internal Fixation With Calcaneal Locking Plate for Intra-articular Calcaneal Fractures

BACKGROUND

The extensile lateral approach (ELA) has been considered to be a standard approach for displaced intra-articular calcaneal fractures (DICF) because it provides excellent exposure and allows direct reduction of the depressed posterior facet fragment. But continuous retraction during surgery needs sufficient manpower and may cause ischemia. Failure of rigid fixation of DICF will not allow for early weight bearing and may lead to a loss of reduction. To avoid these disadvantages, this study presents open reduction assisted with an external fixator and internal fixation with a calcaneal locking plate.

METHODS

A series of 58 patients with 62 DICFs were treated over a period of 49 months. All patients were clinically and radiologically followed up with a mean follow-up of 35 (range 29-42) months. Clinical follow-up included visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and ability to work. Radiologic follow-up included axial and lateral radiographs and measurements of the Bohler angle and Gissane angle.

RESULTS

At the final follow-up, all fractures had healed. The mean VAS score was 2.9 (range 0 to 8, SD 1.9) and the average AOFAS score was 71 (range 55-85, SD 8.1). The mean postoperative Bohler angle immediately after the surgery was 28.3 degrees (range 13.0-44.6, SD 7.0), which decreased to 27.5 degrees (range 12.2-43.3, SD 7.0) at the final follow-up, and the mean postoperative Gissane angle after the surgery was 116.3 degrees (range 94.9-131.5, SD 9.0) which finally increased to 118.4 degrees (range 94.5-135.8, SD 9.3). No statistically significant differences regarding Bohler and Gissane angles were found between different Sanders fracture types ( P>.05).

CONCLUSION

The presented operative technique was found to provide comparable reduction of Sanders type II-IV injuries.

LEVEL OF EVIDENCE

Level III, case control study.

Complications of Intra-articular Calcaneal Fractures in Adults: Key Points for Diagnosis, Prevention, and Treatment

Calcaneal fractures are complex injuries with high complication rates and they can lead to serious disability. The proper management remains controversial and complications may occur regardless of the chosen type of treatment (operative or nonoperative). The present article reviews the studies that are related to the complications of calcaneal fractures. The incidence, the diagnosis, the prevention and the treatment of these complications were researched and analyzed, with the use of PubMed database, abstracts and original articles in English than investigate the etiology. The aim of the article is to discuss the most suitable management of the complications of calcaneal fractures and recommend a specific treatment as well as prevention methods.

LEVELS OF EVIDENCE

Level IV.

Complications in operative fixation of calcaneal fractures

OBJECTIVE

The purpose of this study focused on a number of factors that have been implicated in calcaneal complications and find the incidence of wound complications.

METHODS

This was a retrospective study. A total of 162 patients (176 feet) who underwent calcaneal fractures between 2007 and 2012 were included. The patient's personal details, age, time from injury to surgery, cause of injury, type of fracture, operative details, operating and tourniquet times were collected from hospital computers and paper records. Evidence of complications including wound infection, wound necrosis, pain, malunion, nonunion, impingement, loss of fixation, ect were studied.

RESULTS

Forty-seven of one hundred and seventy-six fractures (26.704%) had complications, wound infection was noted in seven fractures (3.977%), twelve fractures developed necrosis (6.818%), 14 fractures (7.955%) developed pain. Malunion was found in five fractures (2.841%), nonunion in two fractures (1.136%) and loss of fixation in four fractures (2.272%). Three neurologic injury was also seen in our study (1.705%). Operating time, time from injury to surgery and type of fracture had some association with complications in operative fixation of calcaneal fractures, which showed a statistically significant improvement (P=0.000, 0.031, 0.020, respectively), but there were no evidence that age and tourniquet time affect the incidence of complication after calcaneal fracture surgery (P=0.119, 0.682, respectively).

CONCLUSIONS

Despite developments in the surgical treatment of calcaneal fracture, wound complications still remain inevitable. Advanced imaging techniques, less invasive surgical procedures, wealth of anatomical knowledge, surgical experience and better postoperative care should be ensured.

Percutaneous Arthroscopic Calcaneal Osteosynthesis: A Minimally Invasive Technique for Displaced Intra-Articular Calcaneal Fractures

The management of calcaneal fracture remains challenging. Open surgery has been fraught with high infection rates and soft tissue complications. More minimally invasive procedures have reduced this risk, but the patient outcomes after treatment of displaced calcaneal fractures have remained relatively unsatisfactory. We present a method for the management of Sanders grade II and III calcaneal fractures: percutaneous arthroscopic calcaneal osteosynthesis. Thirty-three fractures in 30 patients who had presented to our tertiary foot and ankle trauma center in central London were treated with percutaneous arthroscopic calcaneal osteosynthesis for calcaneal fractures, and the data were prospectively collected. The mean patient age at injury was 39 years. The mean follow-up period was 24 months. Of our patients, 58% were smokers at injury. Of the 33 fractures, 46% were classified as grade II and 54% as grade III. The mean length of stay was 1.92 days. At the final follow-up visit, the mean Böhler angle had increased from 11.10° (range 2° to 24°) to 23.41° (range 15° to 35°). The modified American Orthopaedic Foot and Ankle Society scale score was 72.18 (range 18 to 100), the calcaneal fracture scoring system score was 79.34 (range 42 to 100), and the visual analog scale score was 29.50 (range 0 to 100). We had a single case of a superficial port site infection and 2 cases of prominent screws, which were removed. No cases of deep infection developed, and no conversion to subtalar fusion was required. This technique significantly reduced the incidence of postoperative wound complications. Direct visualization of the fracture site allowed accurate restoration of the articular surface and correction of heel varus. Furthermore, it was associated with a high self-reported functional outcome and a return to preinjury employment levels. Also, the results did not appear to be influenced by tobacco consumption.

Bionic plate design for calcaneal fracture treatment. A biomechanical analysis and first clinical results

PURPOSE

Calcaneal fracture treatment is challenging. Implant failure is one problem encountered with plate osteosynthesis. Therefore a new "bionic" plate was developed, which imitates the trabecular orientation of the human calcaneus. The aim of this study was to biomechanically test this new plate in comparison to a "standard" calcaneal locking plate and present the first clinical results.

METHODS

Six "bionic" and six "standard" calcaneal plates were biomechanically tested for stability and fatigue using synthetic calcanei. Between 4/2012 and 04/2013 the first ten consecutive patients meeting the inclusion criteria were treated with the novel implant and followed-up clinically and radiologically. The 12-month follow-up results are reported.

RESULTS

The "bionic" plate design showed significantly higher fatigue life (68%), load to failure (100%) and reduced displacement under load (90%) if compared to a "standard" locking plate. No major complications were seen; most notably there was no implant failure and no loss of reduction. Mean AOFAS/hindfoot score was 79 (69-86).

CONCLUSIONS

The novel plate architecture offers higher stability and load tolerance while being more resistant to fatigue. The preliminary clinical results are promising. These findings will have to be proved by larger clinical trials.

Factors affecting long-term treatment results of displaced intraarticular calcaneal fractures: a post hoc analysis of a prospective, randomized, controlled multicenter trial

OBJECTIVES

To study the factors affecting long-term treatment results of displaced intraarticular calcaneal fractures (DIACFs).

DESIGN

A post hoc analysis.

SETTINGS

Tertiary care teaching hospitals.

PATIENTS

Eight to twelve years of results from a randomized controlled multicenter trial of operative versus nonoperative treatment (n = 56) were divided into 2 groups: the superior 50% results (n = 28) and the inferior 50% results (n = 28), regardless of the treatment given. The determinant of this division was a visual analog score for pain and function.

INTERVENTIONS

The operative treatment consists of open reduction and internal fixation, whereas the nonoperative treatment consists of nonweight bearing and early range of motion exercise.

MAIN OUTCOME MEASUREMENTS

A visual analog score for pain and function, the short-form 36 (SF-36) general health outcome questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Olerud-Molander score. We compared age, sex, fracture type (Sanders classification), treatment given, Böhler angle, residual articular surface step-off at healing, type of occupation, and injury insurance between the 2 groups.

RESULTS

Patients of the superior group had higher physical SF-36, AOFAS, and Olerud-Molander score than in the inferior group. Operative treatment, better Böhler angle and articular surface restoration, light labor/retirement, and absence of injury insurance were more common in the superior group. Age, sex, pretreatment Böhler angle, and fracture type were comparable in the superior and inferior groups.

CONCLUSIONS

The decision making for definitive treatment of intraarticular calcaneal fractures is multifactorial with a spectrum of results and trends such as patient demographic features that should be considered in choosing the best treatment option.

LEVEL OF EVIDENCE

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

Prognostic value of computed tomography classification systems for intra-articular calcaneus fractures

BACKGROUND

There are several published computed tomography (CT) classification systems for calcaneus fractures, each validated by a different standard. The goal of this study was to measure which system would best predict clinical outcomes as measured by a widely used and validated musculoskeletal health status questionnaire.

METHODS

Forty-nine patients with isolated intra-articular joint depression calcaneus fractures more than 2 years after treatment were identified. All had preoperative CT studies and were treated with open reduction and plate fixation using a lateral extensile approach. Four different blinded reviewers classified injuries according to the CT classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders. Functional outcomes evaluated with a Musculoskeletal Functional Assessment (MFA). The mean follow-up was 4.3 years.

RESULTS

The mean MFA score was 15.7 (SD = 11.6), which is not significantly different from published values for midfoot injuries, hindfoot injuries, or both, 1 year after injury (mean = 22.1, SD = 18.4). The classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders, the number of fragments of the posterior facet, and payer status were not significantly associated with outcome as determined by the MFA. The Sanders classification trended toward significance. Anterior process comminution and surgeon's overall impression of severity were significantly associated with functional outcome.

CONCLUSIONS

The amount of anterior process comminution was an important determinant of functional outcome with increasing anterior process comminution significantly associated with worsened functional outcome (P = .04). In addition, the surgeon's overall impression of severity of injury was predictive of functional outcome (P = .02), as determined by MFA.

LEVEL OF EVIDENCE

Level III, comparative series.

Posterior facet cartilage injury in operatively treated intra-articular calcaneus fractures

BACKGROUND

Direct visualization of the posterior facet in displaced intra-articular calcaneus fractures (DIACF) frequently shows partial or full thickness cartilage delamination. This is felt to be secondary to the depression of an osteoarticular segment of the posterior facet within the calcaneal body and the subsequent contact with fracture edges as it impacts caudally. The purpose of this study was to determine the frequency of cartilage injury and if it correlates with fracture classification.

METHODS

A single surgeon prospective, observational series of 28 patients with 28 DIACFs was reviewed for patient demographic and injury data, radiographic fracture characterization, and intraoperative observation of articular injury size, depth, and location over the time period of February 2010 to December 2012. Observations were correlated with the OTA and Sanders classification systems.

RESULTS

Age, sex, mechanism of injury, and depth and location of cartilage injury were not significantly different between the 13 OTA/Sanders type 2 and 15 type 3 DIACFs evaluated in this study. Posterior facet articular cartilage delamination was found in 77% of type 2 and 100% of type 3 fractures (P = .09). Location of cartilage injury was common (56%) along the distal, lateral aspect of the posterior facet (P < .05). The percentage area of cartilage injury was significantly larger in type 3 fractures (3.1%) then type 2 (1.3%) (P < .02).

CONCLUSIONS

DIACFs had a consistent location of posterior facet articular cartilage delamination along the distal lateral aspect of the osteoarticular fragment. This lesion was larger in OTA/Sanders classification type 3 fractures compared to type 2 fractures.

LEVEL OF EVIDENCE

Level IV, prospective, observational series.

Arthroscopic reduction and percutaneous fixation of selected calcaneus fractures: surgical technique and early results

OBJECTIVES

To highlight a technique combining fluoroscopy and arthroscopy to aid percutaneous reduction and internal fixation of selected displaced intra-articular calcaneal fractures, assess outcome scores, and compare this method with other previously reported percutaneous methods.

DESIGN

Retrospective review of all patients treated by this technique between June 2009 and June 2012.

SETTING

A tertiary care center located in Brisbane, Queensland, Australia.

PATIENTS

Thirteen consecutive patients were treated by this method during this period. All patients had a minimum of 13 months follow-up and were available for radiological checks and assessment of complications; functional outcome scores were available for 9 patients.

INTERVENTION

The patient was placed in a lateral decubitus position. Reduction was achieved with the aid of both intraoperative fluoroscopy and subtalar arthroscopy and held with cannulated screws in orthogonal planes. The patient was mobilized non-weight bearing for 10 weeks.

MAIN OUTCOME MEASUREMENT

Outcomes measured were improvement in Bohler angle, postoperative complications, and 3 functional outcome scores (American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Foot Function Index, and Calcaneal Fracture Scoring System).

RESULTS

Mean postoperative improvement in Bohler angle was 18.3 degrees, with subsidence of 1.7 degrees. Functional outcome scores compared favorably with the prior literature. Based on available postoperative computed tomography scans (8/13), maximal residual articular incongruity measured 2 mm or less in 87.5% of our cases.

CONCLUSIONS

Early results indicate that this technique, when combined with careful patient selection, offers a valid therapeutic option for the treatment of a distinct subset of displaced intra-articular calcaneal fractures, with diminished risk of wound complications. Large, prospective multicenter studies will be necessary to better evaluate the potential benefits of this technique.

LEVEL OF EVIDENCE

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

Primary subtalar joint arthrodesis for comminuted fractures of the calcaneus

Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored.

Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach

PURPOSE

Post-operative wound infections (PWI) following calcaneal fracture surgery can lead to prolonged hospital stay and additional treatment with antibiotics, surgical debridement or implant removal. Our aim was to determine the incidence of superficial and deep PWI and to identify risk factors (RF).

METHODS

This study is a retrospective case series. All consecutive patients from 2000 to 2010 with a closed unilateral calcaneal fracture treated with open reduction and internal fixation (ORIF) by an extended lateral approach were included. Patient, fracture, trauma and peri-operative characteristics were collected, including RF such as smoking, diabetes mellitus, time to operation, pre-operative in- or outpatient management and wound closure technique. The primary end point was a PWI as defined by the US Centers for Disease Control and Prevention.

RESULTS

A total of 191 patients were included of which 47 patients (24.6%) had a PWI; 21 (11.0%) and 26 (13.6%) patients had a superficial and deep wound infection, respectively. American Society of Anesthesiologists (ASA) classification higher than ASA 1 was associated with an increased risk. Placement of a closed suction drain at the end of surgery was associated with less PWI (35% vs 15%, p = 0.002). In this study, none of the previously reported RF were associated with an increased risk for PWI.

CONCLUSIONS

ORIF of displaced calcaneal fractures is associated with a high rate of PWI of 25%. Factors that were associated with an increased risk were ASA classification other than 1 and absence of a closed suction drain placement. A closed suction drain may be a protective measure to avoid wound complications.

Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach

PURPOSE

Post-operative wound infections (PWI) following calcaneal fracture surgery can lead to prolonged hospital stay and additional treatment with antibiotics, surgical debridement or implant removal. Our aim was to determine the incidence of superficial and deep PWI and to identify risk factors (RF).

METHODS

This study is a retrospective case series. All consecutive patients from 2000 to 2010 with a closed unilateral calcaneal fracture treated with open reduction and internal fixation (ORIF) by an extended lateral approach were included. Patient, fracture, trauma and peri-operative characteristics were collected, including RF such as smoking, diabetes mellitus, time to operation, pre-operative in- or outpatient management and wound closure technique. The primary end point was a PWI as defined by the US Centers for Disease Control and Prevention.

RESULTS

A total of 191 patients were included of which 47 patients (24.6%) had a PWI; 21 (11.0%) and 26 (13.6%) patients had a superficial and deep wound infection, respectively. American Society of Anesthesiologists (ASA) classification higher than ASA 1 was associated with an increased risk. Placement of a closed suction drain at the end of surgery was associated with less PWI (35% vs 15%, p = 0.002). In this study, none of the previously reported RF were associated with an increased risk for PWI.

CONCLUSIONS

ORIF of displaced calcaneal fractures is associated with a high rate of PWI of 25%. Factors that were associated with an increased risk were ASA classification other than 1 and absence of a closed suction drain placement. A closed suction drain may be a protective measure to avoid wound complications.

Indications for implant removal following intra-articular calcaneal fractures and subsequent complications

INTRODUCTION

Implant removal following operative calcaneal fracture treatment has received little attention in the literature. The aim of the current retrospective cohort study was to assess the indications and number of wound complications following calcaneal plate removal.

METHODS

All consecutive adult patients who had their plate and screws removed following the operative treatment of a closed uni- or bilateral intra-articular calcaneal fracture using a stainless steel nonlocking calcaneal plate between 2000 and 2011 were included.

RESULTS

In 102 patients (46% of the total number of operated calcaneal fractures) implants were removed. Implant removal was performed in 75 patients for symptomatic reasons, in 10 patients due to implant malposition and in 19 patients because of a persistent wound infection or fistula. Following implant removal 17 (16%) patients had a wound complication (2 wound dehiscence, 15 culture positive wound infections). In 6 patients (9%) a wound complications was seen following implant removal after uncomplicated fracture surgery. Implant removal for active infection or plate fistula displayed an infection rate of 8 out of 19 (42%).

CONCLUSION

Implant removal after an intra-articular calcaneal fracture treated with open reduction and internal fixation via an extended lateral approach was followed by a wound complication in 1 of every 10 patients without a preexisting wound infection. Infection rates were especially high in patients in whom the implants were removed for an active wound problem.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures

BACKGROUND

The treatment of displaced, intraarticular calcaneal fractures (DIACFs) remains challenging and the best treatment choices remain controversial. The majority of patients will have some lasting functional restrictions. However, it is unclear which patient- or surgeon-related factors predict long-term function.

QUESTIONS/PURPOSES

We determined (1) the impact of patient- and surgeon-related factors on function of patients after internal fixation of DIACFs and (2) whether severity of injury correlated with subsequent function.

METHODS

We retrospectively reviewed all 210 patients operatively treated for 242 DIACFs between 2000 and 2003; of these, 127 patients (60%) with 149 fractures were available for followup at a minimum of 69 months (average, 95 months; range, 69-122 months). Severity of injury was quantified by the classifications of Sanders and Zwipp Function was quantified using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, an adjusted Zwipp score, the Foot Function Index (FFI), and the SF-36 physical and mental component summary (PCS and MCS) scores.

RESULTS

At latest followup, the median AOFAS score was 77, the median Zwipp score was 60, the median FFI was 27, and the median SF-36 PCS and MCS scores were 44 and 55, respectively. The foot-related scores and the SF-36 PCS negatively correlated with the severity of injury, work-related injuries, and bilateral fractures.

CONCLUSIONS

We found the severity of a DIACF related to subsequent foot function and quality of life. Both fracture severity classifications predicted function. Anatomic reconstruction of the shape and articular surfaces of the calcaneus leads to predictable function in the medium to long term.

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

A review of the foot function index and the foot function index - revised

BACKGROUND

The Foot Function Index (FFI) is a self-report, foot-specific instrument measuring pain and disability and has been widely used to measure foot health for over twenty years. A revised FFI (FFI-R) was developed in response to criticism of the FFI. The purpose of this review was to assess the uses of FFI and FFI-R as were reported in medical and surgical literature and address the suggestions found in the literature to improve the metrics of FFI-R.

METHODS

A systematic literature search of PubMed/Medline and Embase databases from October 1991 through December 2010 comprised the main sources of literature. To enrich the bibliography, the search was extended to BioMedLib and Scopus search engines and manual search methods. Search terms included FFI, FFI scores, FFI-R. Requirements included abstracts/full length articles, English-language publications, and articles containing the term "foot complaints/problems." Articles selected were scrutinized; EBM abstracted data from literature and collected into tables designed for this review. EBM analyzed tables, KJC, JM, RMS reviewed and confirmed table contents. KJC and JM reanalyzed the original database of FFI-R to improve metrics.

RESULTS

Seventy-eight articles qualified for this review, abstracts were compiled into 12 tables. FFI and FFI-R were used in studies of foot and ankle disorders in 4700 people worldwide. FFI Full scale or the Subscales and FFI-R were used as outcome measures in various studies; new instruments were developed based on FFI subscales. FFI Full scale was adapted/translated into other cultures. FFI and FFI-R psychometric properties are reported in this review. Reanalysis of FFI-R subscales' confirmed unidimensionality, and the FFI-R questionnaires' response categories were edited into four responses for ease of use.

CONCLUSION

This review was limited to articles published in English in the past twenty years. FFI is used extensively worldwide; this instrument pioneered a quantifiable measure of foot health, and thus has shifted the paradigm of outcome measure to subjective, patient-centered, valid, reliable and responsive hard data endpoints. Edited FFI-R into four response categories will enhance its user friendliness for measuring foot health.

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

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

Subjective results after surgical treatment for displaced intra-articular calcaneal fractures

We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up duration of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, Foot Function Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis was that good subjective results could be predicted and obtained in patients with specific characteristics if anatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A number of specific subgroup analyses were undertaken. The study confirmed that Böhler angle restoration and the quality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. In contrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The main weaknesses of the present study included its retrospective nature, the lack of a control group managed nonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed the radiographic measurement and categorized the quality of the surgical reconstruction.

Open Reduction and Internal Fixation of Intra-Articular Calcaneal Fractures Via an Extensile Lateral Approach

Introduction

Although displaced intra-articular calcaneal fractures were historically treated nonoperatively because of unreliable outcomes, they are now commonly treated with open reduction and internal fixation (ORIF).

Step 1 Preoperative Planning and Operative Setup

Coronal images are most helpful.

Step 2 Incision and Soft-Tissue Management

Elevate the flap using the "no-touch" technique to minimize wound complications.

Step 3 Reduce Posterior Facet and Perform Provisional Stabilization

Achieve anatomic reduction of the medial calcaneal wall before proceeding with the remainder of the fracture reduction.

Step 4 Apply Lag Fixation and a Lateral Neutralization Plate

Use a traditional nonlocking plate and be sure that at least one lag screw achieves purchase.

Step 5 Close Wound

Use the "no-touch" technique, with the goal of tension-free wound closure.

Step 6 Postoperative Care

Watch closely for drainage or delayed healing.

Results & Preop/Postop Images

ORIF is a viable treatment option for displaced intra-articular calcaneal fractures without contraindication for older patients.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.