Displacement of the sustentacular fragment in intra-articular calcaneal fractures

The impact of sustentaculum tali fracture on clinical outcome in patients affected by isolated calcaneal fractures

INTRODUCTION

The sustentaculum tali is displaced in almost half of calcaneal fractures and during surgical fixation represents one of the main reference points upon which the other bone has to be reduced. The purpose of this study was to investigate which subtalar joint fracture pattern is more frequently associated with sustentaculum tali involvement. Furthermore, correlation between postoperative clinical outcome and sustentaculum tali integrity was performed.

MATERIAL AND METHODS

Patients with isolated calcaneal fractures were analyzed. Sanders-type fracture and involvement of both sustentaculum tali and calcaneocuboid joint were detected on computed tomography imaging; postoperative AOFAS scores were analyzed according to sustentacular involvement.

RESULTS

Fifty calcaneus fractures in 47 patients were included in the final analysis. The sustentaculum tali was fractured in 18 cases (36.0%), thus contradicting its supposed constant position. Sanders type 3 and 4 fractures were more frequently associated with fractured sustentaculum than type 2 (p = 0.012). Sanders type 4 fractures were associated with displaced sustentacular fragment significantly more than type 2 and 3 (p = 0.043). Patients with intact sustentaculum tali reported significantly higher (p < 0.001) mean AOFAS scores than the uninjured group (84.4 ± 9.1 and 74.3 ± 9.5, respectively).

CONCLUSION

Sanders type 3 and 4 fractures were more frequently associated with sustentaculum tali and/or calcaneocuboid joint involvement than simpler fractures. Injury of sustentaculum tali was related to significant worse postoperative clinical outcomes, underlying the relevance of this fragment on clinical course.

[Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach]

OBJECTIVE

Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach.

INDICATIONS

Intra-articular dislocated calcaneus fractures.

CONTRAINDICATIONS

Fracture older than 14 days; poor soft tissue quality in the surgical area.

SURGICAL TECHNIQUE

Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath.

POSTOPERATIVE MANAGEMENT

Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing.

RESULTS

Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Study on Sustentaculum Tali Fragment Constancy in Intraarticular Calcaneus Fracture

OBJECTIVES

To establish reproducible measurements of the sustentaculum tali (ST) fragment regarding fracture classification and patient-related factors.

DESIGN

Retrospective.

SETTING

Trauma center, University Hospital.

PATIENTS

A retrospective analysis of the 142 fractured calcanei of 122 patients (101 men and 21 women) treated at our institution between 2012 and 2020 was performed. As control, 62 unaffected calcanei were used.

INTERVENTION

Radiographic images were evaluated twice within 2 weeks by 2 orthopaedic surgeons and 1 postgraduate student. Angulation and diastasis were used to distinguish ST fragment constancy based on computed tomography. Using these parameters, the prevalence of inconstant ST fragments was assessed. We also analyzed factors related to ST fragment inconstancy. Patient factors included age, body mass index, smoking, and diabetes. Radiographic factors included the Sanders classification, location of the outermost fracture line of the posterior facet, presence of an intraarticular fracture of the ST, and ST fragment width.

MAIN OUTCOME MEASUREMENTS

Angulation and diastasis were used to confirm the ST fragment constancy. Potential risks for inconstant ST fragment subsequently defined.

RESULTS

According to the criteria, ST fragment inconstancy was observed in 34.5%. ST fragment width was significantly smaller in the inconstant group ( P < 0.001). Severe comminution of the posterior facet ( P < 0.05), intraarticular fracture of the ST ( P < 0.001), and diabetes ( P < 0.05) were significantly higher in the inconstant group. The cut-off value of the ST fragment width was 20.5 mm.

CONCLUSIONS

In intraarticular calcaneus fractures, small ST fragment width, comminuted fracture, intraarticular fracture of the ST, and diabetes were associated with the inconstant group. The ST fragment was expected to be inconstant when the width was less than 20.5 mm.

3D mapping of intra-articular calcaneal fractures

To determine the pattern of intra-articular calcaneal fractures (ICFs) by a three-dimensional (3D) mapping and determine whether there were consistent fracture patterns and comminution zones. In this study, 67 patients with ICFS by CT scan were included. The calcaneal fractures fragments in CT were multiplanar reconstructed and virtual reduced. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a standard calcaneal template. The cohort included 26 (38.8%) left calcaneal fractures, 27 (40.30%) right calcaneal fractures, and 14 (20.9%) cases with bilateral fractures. Comminuted fractures accounted for 92.5%. Sagittal 3D mapping shows that the fracture line is mainly concentrated at the critical angle of Gissane and extending rear to the posterior of the tuberosity of the lateral wall and the anterior of the medial process of the calcaneus tuberosity but with more significant variation in the medial wall. The average angle of fracture lines concerning the long calcaneal axis (LCA) was 29.1° and 19.2° in the lateral and medial walls. Axial 3D mapping shows that fracture lines were primarily concentrated in the anterior area to the posterior joint facet and extending along the rear joint facet and calcaneus sulcus to the posteriorly of the tuberosity. The mean angle of fracture lines concerning the LAC was 11° in the axial wall. Our data provided elucidated that ICFs have consistent characteristic fracture patterns and comminution zones. This study provides visual guidelines for understanding fracture morphology, which may assist with fracture classification, preoperative planning, development of fixation concepts.

Two and three-dimensional CT mapping of the sustentacular fragment in intra-articular calcaneal fractures

The sustentaculum tali are tightly bound to the talus by the interosseous and deltoid ligament complex and have been considered a ''constant fragment". Yet there is a dearth of study on the anatomical patterns of the sustentacular segment. Consequently, this study is designated with the purpose of defining the prevalence and displacement of sustentacular fractures in intra-articular calcaneal fractures (ICFs) applying computed tomography (CT) mapping in both two-dimensional (2D) and three-dimensional (3D) conditions. From January 2019 to December 2020, the CT images of sixty-seven patients with eighty-one ICFs were retrospectively evaluated, besides, basic patient demographics and mechanisms of injury were documented. And the prevalence of sustentacular fractures was characterized in the sagittal or coronal CT planes. The subluxation, angulation, and translation of the portion of the sustentacular bone were noted. By decreasing rebuilt fracture fragments to suit a model of the sustentaculum tali, a 3D map was generated. Overall, the sustentacular fracture in 21 (25.9%) of the 81 ICFs, 15 (71.4%) were nondisplaced, 6 (28.6%) were displaced, and mean coronal angulation was 21.9°, and no comminuted. The relationship between sustentaculum tali and the talus was anatomically aligned in 71 (87.7%), and subluxation in 10 (12.3%). According to the research, 3D mapping demonstrated that most fracture lines start from the anterior of the sustentaculum tali, extending obliquely to the sulcus of the flexor halluces longus tendon. Moreover, this study provides a detailed description (displacement or articular dislocation) of the frequency of sustentacular fragments in ICFs. The finding disproves the ''constant'' theory of the sustentacular fragments, due to the fact that comminuted fracture of sustentaculum tali was rare. And the expertise of these fracture patterns may affect the progress of fixation concepts and surgical approaches. Moreover, we further speculated that the displacement of the sustentacular fragment was considerably more probable to emerge in the higher-order Sanders classification. Nevertheless, bigger sample size is required to further validate this position.

Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings

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

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.

The role of bone grafts in displaced intra-articular calcaneal fractures: A prospective study protocol

BACKGROUND:

Whether the bone graft is needed in treating the displaced intra-articular calcaneal fractures (DIACFs) is still controversial. Therefore, in our study, we will explore the results of 2 approaches for the DIACFs surgical treatment.

METHODS:

The present report follows the Consolidated Standards of Reporting Trials (CONSORT) guidelines. All patients will be assigned randomly into 2 different groups through tossing the coins. Three experienced surgeons are assigned randomly to each group to implement the surgeries utilizing any of the surgical approach. Assignments are concealed in a sealed opaque envelope. Patients who meet the following conditions will be included in this experiment: (1).. DIACFs (greater than 2 mm) involve Sanders Type IIC, Type IIB as well as some Type III; and (2).. surgical treatment can be implemented within 7 days after injury. Some patients with obvious swelling can wait for 2 weeks before operation; (3).. patients with closed fracture and; (4).. unilateral fracture. In the 2 groups, the patients will follow the standard postoperative protocols. Patients are asked to finish 2 questionnaires, namely, American Orthopaedic Foot and Ankle Society score and short form 36. The ranges of motion of the ankle and the subtalar joint will be also measured. Postoperative complications such as deep infection, wound infection, and wound edge necrosis, the injury of sural nerve, and hematoma are recorded.

RESULTS:

Our study can provide significant information on the necessity of bone graft in DIACFs internal fixation treatment.

TRIAL REGISTRATION:

This study protocol was registered in Research Registry (researchregistry6246).

Extended Sinus Tarsi Approach for Treatment of Displaced Intraarticular Calcaneal Fractures Compared to Extended Lateral Approach

BACKGROUND:

We compared the radiographic results and clinical outcomes of patients operated on via the extended sinus tarsi approach (ESTA) and the extended lateral approach (ELA) for treatment of displaced intraarticular calcaneal fractures.

METHODS:

We retrospectively studied the utility of the ELA (46 patients, 52 feet) and the ESTA (56 patients, 64 feet) in patients operated on between January 2009 and March 2015. We evaluated pre- and postoperative x-rays and computed tomography (CT) data. Pain, patient-reported functional outcomes, satisfaction, and postoperative complications were investigated at the 3-year follow-up.

RESULTS:

Neither the postoperative nor 3-year follow-up Böhler angles, nor the calcaneal width, differed significantly between the 2 groups (both P > .05). However, the maximum step-off of the posterior facet on the 3-month CT follow-up of the ESTA group was significantly less than that of the ELA group ( P < .05). We found no significant between-group differences in terms of postoperative translation ( P = .232) or angulation ( P = .132) of the sustentacular fragment on the 3-month CT follow-up. At the 3-year follow-up, we found no significant between-group difference in the mean visual analog scale pain score at rest ( P = .641) or during weightbearing ( P = .525). We found no significant between-group difference in the Foot Function Index (FFI) ( P = .712) or self-reported satisfaction ( P = .823). The ELA group experienced significantly more wound complications ( P = .041) and nonunions ( P = .041) than the ESTA group. Four instances of superficial peroneal nerve injury were reported in the ESTA group ( P = .127).

CONCLUSION:

Compared with the ELA, the ESTA afforded comparable, favorable radiological results and clinical outcomes, associated with fewer wound complications and nonunions. We suggest that the ESTA is an effective operative option when treating displaced, intraarticular calcaneal fractures.

LEVEL OF EVIDENCE:

Level III, comparative study.

Anatomic Locking Plate for Displaced Intraarticular Calcaneal Fracture: Design and Application

Calcaneal fracture can lead to long-term disability and have a considerable economic effect. Most calcaneal fractures are intraarticular fractures involving the posterior facet of the subtalar joint. Treating displaced intraarticular calcaneal fractures is complicated because of the lack of an optimal treatment option. Internal fixation typically involves screw-and-plate implants, which can be unfavorable owing to the lack of an anatomic design and the intraoperative bending required for the plate to contour to the irregular surface of the calcaneus. We assessed the outcomes of 30 patients treated using innovative, anatomically designed calcaneal locking plates and the perceived advantages for surgeons. Postoperative computed tomography images of the affected feet were obtained, and the functional performance was recorded. The mean average Böhler angle had increased significantly from 16.8° ± 14.9° to 28.5° ± 9.4° (p < .001). The mean average maximal fracture gap and maximal step-off in the posterior facet of the subtalar joint in the coronal computed tomography images also decreased significantly from 2.8 ± 3.7 mm to 0.8 ± 1.3 mm (p < .01) and from 3.3 ± 2.8 mm to 0.8 ± 1.2 mm (p < .001), respectively. The mean average American Orthopaedic Foot and Ankle Ankle-Hindfoot scale score was 93.9 ± 7.1 at the final follow-up visit. In addition, the surgical time was reduced because bending the plate was not required and the quality of reduction could be assessed easily by examining the gap between the cortex and the plate. The results were promising, revealing that the anatomic locking plate can be used effectively in the treatment of displaced intraarticular calcaneal fractures using simple reduction techniques with a potentially shortened operating time.

Pathoanatomy of the Tongue-Type Calcaneus Fracture: Assessment Using 2- and 3-Dimensional Computed Tomography

OBJECTIVE

To define the pathoanatomy of the tongue-type calcaneus fracture and assess the appropriateness of percutaneous techniques in addressing all planes of deformity in this injury.

DESIGN

Retrospective cohort.

SETTING

ACS Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-six displaced Sanders 2B and 2C tongue-type calcaneus fractures identified from an initial cohort of 1118 calcaneus fractures treated over a 16-year period.

MAIN OUTCOME MEASUREMENTS

We reviewed cross-sectional imaging and documented the presence of a varus/valgus (coronal plane) or adduction/abduction (axial plane) position of the tongue fragment in relation to the intact posterior facet, with greater than 10 degrees of angulation being diagnostic of displacement.

RESULTS

When assessing for displacement and angulation in the coronal plane, 98% of tongue fragments were either in a position of valgus (77%) or neutral (21%), with a mean valgus angulation of 17.3 degrees. In the axial plane, 98% of tongue pieces were in a position of adduction (64%) or neutral (34%), with an average angulation into adduction of 15.0 degrees. Sanders 2B fractures were more likely to be in a position of valgus and adduction than those of 2C fractures.

DISCUSSION

The tongue-type calcaneus fracture most often displaces into a position of plantarflexion, valgus, and adduction. Knowledge of this deformity may aid in achieving successful closed reduction when using the Essex-Lopresti maneuver or other less invasive techniques.

Displaced Intra-articular Calcaneal Fractures: Classification and Treatment

The calcaneus is the most commonly fractured tarsal bone. Displaced intraarticular calcaneal fractures are usually caused by a fall from height with one or both heels directly hitting the ground. Displaced intra-articular calcaneal fractures are complex and highly disabling injuries. There is ongoing debate regarding the optimal treatment for each type of displaced intra-articular calcaneal fracture. This review aims to summarize the classification of, various treatment options for, prevention of perioperative complications in, and management algorithms for displaced intra-articular calcaneal fractures. [Orthopedics. 2017; 40(6):e921-e929.].

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?

Treatment of displaced intra-articular calcaneus fractures: a current concepts review

Displaced Intra-Articular Calcaneus fractures (DIACFs) represent a source of tremendous disability to the patient, economic burden to the society and a treatment challenge to the average orthopaedic surgeon. To date, no single approach is universally applicable to all calcaneus fractures. Despite a plethora of published meta-analyses and recent randomized controlled trials, the literature is still unclear and offers conflicting recommendations. The aim of this current concepts review is to assess the latest available data and offer pragmatic and practical recommendations to address some of the issues surrounding DIACFs.

Current Controversies in Management of Calcaneus Fractures

Displaced intraarticular fractures of the calcaneus represent a technically challenging injury. Although there is conflicting evidence regarding advantages and disadvantages of operative versus nonoperative treatment, a growing body of literature suggests operative management with near-anatomic reduction of the posterior facet and restoration of overall calcaneal morphology offers greater potential for superior short- and long-term outcomes. A thorough understanding of calcaneal anatomy, fracture pattern, and associated injuries, along with careful selection of surgical approach and timing to surgery are critical to minimize the risk of complication and maximize potential for optimal outcomes.

Surgical treatment of intra-articular calcaneal fractures

Most intra-articular calcaneal fractures are a result of high-energy trauma. The operative management of calcaneal fractures has been based on achieving anatomic reduction and minimizing complications of the compromised soft tissue envelope. The traditional extensile lateral approach offers advantages of achieving adequate fracture reduction with the risk of wound-healing complications and infection. Limited open reduction and internal fixation techniques with or without using external fixation focuses on achieving fracture reduction with less risk of wound complications but higher risk of malunion. This article discusses key points of operative management for various intra-articular calcaneal fracture patterns and clinical presentations.

Anatomic Alignment and Integrity of the Sustentaculum Tali in Intra-Articular Calcaneal Fractures: Is the Sustentaculum Tali Truly Constant?

BACKGROUND

In an intra-articular calcaneal fracture, the sustentaculum tali is generally thought to remain tightly bound to the talus by the interosseous talocalcaneal ligaments, spring ligament, and deltoid ligament, providing a "constant" fragment that remains anatomically aligned. The extensile lateral approach is commonly used for reduction based on this assumption, but because it provides only limited access to the medial aspect of the calcaneus, indirect fracture reduction is required to restore an anatomic relationship of these fragments to the sustentacular fragment. The purpose of this study was to determine the prevalence and displacement of sustentacular fractures in patients with an intra-articular calcaneal fracture, and thus determine whether the sustentacular fragment can be accurately considered as constant and can be consistently relied on to maintain anatomic alignment.

METHODS

All patients with an intra-articular calcaneal fracture who presented to two level-I trauma centers from 2006 to 2012 were included in the study if computed tomography scanning was performed. The presence or absence of a sustentacular fracture was documented, along with the displacement and the comminution of any such fracture and the subluxation or dislocation of the sustentaculum tali.

RESULTS

Sustentacular fractures were present in ninety-four (44.3%) of the 212 patients who met the inclusion criteria. Seventy-two (76.6%) of the sustentacular fractures were nondisplaced, eleven (11.7%) were displaced, and ten (10.6%) were comminuted. The articulation between the sustentaculum tali and the talus was anatomically aligned in 166 (78.3%) of the calcaneal fractures, subluxated in forty-three (20.3%), and dislocated in two (0.9%).

CONCLUSIONS

This study provides a detailed description of the frequency of sustentacular fractures, the displacement of such fractures, and articular subluxation or dislocation associated with intra-articular calcaneal fractures. Fixation by means of a lateral approach may be compromised when the sustentaculum tali is fractured or subluxated. A medial approach or combined medial and lateral approaches may be considered in such circumstances. Special attention should be paid to the integrity and alignment of the sustentacular fragment prior to surgical fixation.

LEVEL OF EVIDENCE

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