Displaced Intra-articular Calcaneus Fractures Research Articles

Surgeon Learning Curve for the Sinus Tarsi Approach to Intra-articular Calcaneus Fractures - Improvement with Experience.

To analyze the relationship between surgeon experience with the sinus tarsi approach (STA) and outcomes in the treatment of displaced intra-articular calcaneus fractures (DIACF). Single level 1 trauma center. Retrospective.Patients/Participants: 103 consecutive DIACF (OTA/AO 82C; Sanders II-IV) treated operatively using STA from 2015 to 2021. Open management using the STA performed by two fellowship-trained orthopaedic traumatologists. Quality of anatomic reduction based on postoperative CT scans and standard radiographs. Sixty-six patients met inclusion criteria. Patients were primarily men (75.8%) with mean age 41 years (range 20-71 years), including 14 smokers (21.2%), 9 diabetics (13.6%), and 10 open fractures (15.2%). Sanders III fractures were most common (68.2% vs 28.5% and 6.1% Sanders II/IV respectively). Reduction quality was predominantly Good (59.1%, n=39) or Excellent (25.8%, n=17). Complications included wound necrosis (1), superficial infection (1), deep infection (1), and symptomatic posttraumatic arthritis requiring arthrodesis (3). There was a 29.3% reduction in likelihood of surgical complication with each year in surgeon experience with the STA and an 8.9% reduction per case (p<0.001). The likelihood of achieving a Good or Excellent reduction was 1.8 and 2.3 times greater than achieving a Fair reduction, respectively, for each year increase in surgeon experience with the STA (p=0.012 and 0.007, respectively). For each successive case, there was a 1.2 times greater likelihood of achieving a Good reduction (p=0.03). Surgeon experience plays a critical role in outcomes. We found that outcomes (reduction, complications) improve with each cumulative case and year of experience with the STA to treat DIACF. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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. 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. 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. 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 II, prospective comparative study.

A Comparison Between Functional Results in Intra-Articular Displaced Calcaneus Fractures Managed with Conservative and Operative Treatment: A Randomized Controlled Trial

Aim: To make a comparison between functional results in intra-articular displaced calcaneus fractures which are treated conservatively and operative treatment Study design: A randomized controlled trial Place and Duration:This study was conducted at ward 17 JPMC Karachi from January 20221 to January 2022. Methodology: This study includes 32 individuals who had displaced intra-articular calcaneal fractures. These individuals were classified into two groups, each group with 16 individuals. They were randomly assigned to either operative or conservative treatment. Clinical results, as well as radiological results (Modified Rowe’s score), were assessed at a 1-year follow-up. Results: All results were measured using Modified Rowe’s score. With a 1-year follow-up of the operative group, according to Modified Rowe’s score, 6 individuals had excellent results representing 37.5%, 8 individuals had good results representing 50%, and only 2 individuals had satisfactory results representing 12.5%. On the other hand, with a 1-year follow-up of the conservative group, only 2 individuals had excellent results representing 12.5%, 7 individuals had good results representing 43.75%, 5 individuals had satisfactory results representing 31.25%, and 2 individuals had poor results representing 12.5%. A few challenges were seen in each group. In the operative group, delayed wound healing was a complication seen in 2 cases while in the conservative group, peroneal tendonitis, subtalar arthritis and malunion were seen as a complication. Conclusion: In conclusion, the operative group was seen to be more effective to cure displaced intra-articular calcaneus fractures rather than the comparative group. Only a few complications, better functional recovery, early rehabilitation, and early weight bearing were seen in the operative treatment. Keywords: Calcaneus fractures, functional outcome, rehabilitation, conservative treatment

Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures.

The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach. A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker's compensation claims. Plain radiographs were used to characterize injuries and review outcomes. Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker's compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union. In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion. Level IV, retrospective case series.

Screws Only Primary Subtalar Arthrodesis for Calcaneus Fractures

Category:Hindfoot; TraumaIntroduction/Purpose:The initial management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem. The results of open reduction internal fixation (ORIF) have been disappointing. Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using screws alone through a sinus tarsi approach.Methods:A retrospective study of all patients from 2013-2019 who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was utilized in all cases consisting of only screws, no plates were utilized. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data was collected. Worker's compensation (WC) claims were noted and analyzed separately. Plain radiographs were assessed preoperatively and post-operatively and Sander's classification was used to characterize injuries. Patient reported outcomes (PROs), complications, and need for revision surgeries was also noted and analyzed at final follow-up.Results:In total, forty-eight DIACFs underwent PSTA with a median follow-up of 194 days. Median time to weight-bearing was 60 days post-operatively. Three fractures were documented as Sanders II, 22 as Sanders III, and 23 as Sanders IV. Seventy-five percent of the WC group returned to work compared to just 58.3% in the non-WC group (p=0.0003). Patients in the WC group were more likely to have had an abnormal pre-operative Bohler's angle (p=0.047) but the two groups did not differ significantly in postoperative Gissane or Bohler angles. Nearly 85% (N=41) achieved >=2 zones of fusion on radiographs by final follow up and 95.8% (N=46) had at least one. Four patients had a complication and 3 required a return to the operative room.Conclusion:Utilizing Screws only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach shows promising results with high rates of return to work and fusion, even in the workers' compensation population.

Operative Versus Non-Operative Management of Closed, Displaced Intra-Articular Calcaneus Fractures: a Randomized Control Trial

Aim: To determine whether internal fixation &amp; open reduction are superior to non-operative treatment for displaced intra-articular calcaneal fractures. Study Design: Randomized controlled trial Place and duration: This study was conducted at Muhammad Medical College and Hospital Mirpurkhas, Pakistan from 2019 and 2020 Methodology: Patients' Kerr-Atkins scores for pain and function at two years following injury were used as the main outcome measure in this study. Complications, hindfoot discomfort and function general health, life ‘quality, clinical examination, walking speed, &amp; symmetry of gait were all considered secondary outcomes. A treatment-oriented approach to analysis was used. Results: Total 151 patients were taken for this study. There were 95 percent follow-ups for the primary outcome (69 for patients who had surgery and 74 for those who had not), and 75 percent of patients fulfilled all secondary goals. There was no statistical difference in the primary outcome or any of the secondary outcomes between the both groups. Patients who had surgery experienced greater problems and needed additional surgeries Conclusions: Two years following surgery, individuals with a typical displaced intra-articular calcaneus fracture exhibited no clinical or functional improvement, and the risk of comorbidities rose. Open reduction plus internal fixation for these fractures is not suggested based on these results. Keywords: Displaced intra-articular calcaneus fractures, Operative management, Nonoperative management

Cannulated screw fixation versus plate fixation in treating displaced intra-articular calcaneus fractures: a systematic review and meta-analysis.

Operative treatment has become the current trend for displaced intra-articular calcaneus fracture (DIACF), while using cannulated screw fixation or plate fixation is still controversial for treating DIACF. The purpose of this meta-analysis is to compare the outcome of the two fixation methods. We searched literature comparing cannulated screw fixation and plate fixation from PubMed, Embase, Web of Science, and Cochrane Library. Only randomized controlled trials were included. The outcomes of post-operative function, radiological measurement, time efficiency, and wound complications were pooled in the meta-analysis. Seven RCTs with 902 cases of DIACF were included. Pooled results showed the two fixation methods that had similar function satisfactory of AOFAS score (RR = 0.95, 95% CI = [0.83, 1.09], P = 0.47, I2 = 0%) and Maryland Foot score (RR = 0.93, 95% CI = [0.68, 1.28], P = 0.66, I2 = 84%). Compared to plate fixation, cannulated screw fixation had better improvement of Bohler's angle (WMD = 0.56, 95% CI = [0.20, 0.91], P = 0.002, I2 = 34%) and Gissane's angle (WMD = 1.36, 95% CI = [0.56, 2.16], P = 0.0008, I2 = 7%), better recovery of calcaneal height (WMD = 0.49, 95% CI = [0.02, 0.95], P = 0.04, I2 = 6%), shorter time to operation (WMD = - 2.91, 95% CI = [- 4.99, - 0.84], P = 0.006, I2 = 97%), less operation time (WMD = - 21.58, 95% CI = [- 37.31, - 5.85], P = 0.007, I2 = 98%), reduced length of hospital stay (WMD = - 2.00, 95% CI = [- 3.69, - 0.31], P = 0.02, I2 = 97%), and less wound complications (RR = 0.16, 95% CI = [0.08, 0.32], P < 0.00001, I2 = 0%). Cannulated screw fixation and plate fixation have similar postoperative functional satisfactory. Cannulated screw fixation is superior to plate fixation in reduction quality, time efficiency, and wound complications.

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

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). 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. 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). 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.

Comparing less invasive plate fixation versus screw fixation of displaced intra-articular calcaneus fracture via sinus tarsi approach.

The purpose of this study was to compare the post-operative radiographic and clinical outcomes of less invasive plate fixation versus screw fixation of displaced intra-articular calcaneus fractures (DIACFs) via sinus tarsi approach. A total of 165 consecutive DIACFs that underwent open reduction internal fixation via sinus tarsi approach from 2013 to 2018 were reviewed at least a twoyear follow-up. The methods of fixation were divided into two groups: less invasive plate fixation versus screw fixation of calcaneus fracture (59 vs 106, respectively). The radiographic outcomes including pre- and post-operative Bohler's and Gissane's angles were evaluated. The post-operative function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, the Olerud and Molander Scale and the Visual Analogue Scale (VAS). The complications, the rates of implant removal and cost were also compared. The average follow-up was 44.2months in the plate groups and 47.9months in the screw groups (P> 0.05). There was no significant difference in the Bohler's angle and Gissane's angle between the plate group and screw group during the pre-operation and the last follow-up. There was no significant difference in the final AOFAS score, Olerud and Molander score and VAS score between the two groups (P> 0.05). The total incidence of complications was 6.7% in the plate group and 6.6% in the screw group (P> 0.05). The rates of implant removal and total cost during the hospitalization in the plate group were significantly higher compared with screws group (P< 0.05). The less invasive plate fixation versus screw fixation of DIACFs via sinus tarsi approach contributed comparable quality of reduction, complications and post-operative functional outcomes. The less invasive plate technique was significantly higher in terms of implant costs and the rate of implant removal.

Cost-utility analysis of extensile lateral approach versus sinus tarsi approach in Sanders type II/III calcaneus fractures

BackgroundExtensile lateral approach had been recognized as the gold standard technique for displaced intra-articular calcaneus fractures (DIACFs) while sinus tarsi approach had been increasingly valued by surgeons and comparative clinical outcome was shown in both techniques. Appropriate decisions could be made by the clinicians with the help of cost-utility analysis (CUA) about optimal healthcare for type II/III calcaneus fracture.MethodA single-center, retrospective study was conducted in which basic characteristics, clinical outcomes, and health care costs of 109 patients had been obtained and analyzed. Changes in health-related quality of life (HRQoL) scores, validated by EuroQol five-dimensional-three levels (EQ-5D-3L), were used to enumerate quality-adjusted life years (QALYs). Cost-effectiveness was determined by the incremental cost per QALY.ResultsOne hundred nine patients were enrolled in our study including 62 in the ELA group and 47 in the STA group. There were no significant differences between these two groups in mean total cost, laboratory, and radiographic evaluation expense, surgery, anesthesia, and antibiotic expense. The expense of internal fixation materials ($3289.0 ± 543.9) versus ($2630.6 ± 763.7) and analgesia ($145.8 ± 85.6) versus ($102.9 ± 62.7) in ELA group were significantly higher than in the STA group (P < .001, P = .008, respectively). Visual Analogue Scale (VAS) scores showed significant difference at postoperative 3 and 5 days (P < .001). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and the Bohlers’ and Gissane angle showed no significant differences between the two groups before and after the operation. The cost-effectiveness ratios of ELA and STA were $8766.8 ± 2835.2/QALY and $7914.9 ± 1822.0/QALY respectively, and incremental cost-effectiveness ratio (ICERs) of ELA over STA was $32110.00/QALY, but both showed no significant difference.ConclusionBoth ELA and STA techniques are effective operative procedures for the patients with calcaneus fracture. Moreover, STA seems to be more reasonable for its merits including less postoperative pain, and less expense of analgesia as well as internal fixation materials.Level of evidence5

Functional outcome in non-operative management of displaced Intra-articular calcaneal fractures (Diacf’s)

Displaced intra-Articular calcaneus fractures (DIACFs) represent a source of potential disability to the patient, economic burden to the society and a treatment challenge to the average orthopedic surgeon. Despite lack of evidence whether operative management is superior to non-operative management, there is a trend favoring the former. This was a 2 year retrospective study & a 1 year prospective study of 37 patients with 44 displaced intra-articular calcaneal fractures managed non-operatively to observe the functional outcome of intra-articular fractures of calcaneus in adults in an Indian population. Each patient was followed up at 3, 6, 9 months and 1 year from injury. Appropriate lateral and axial view x-rays done at 3 months and 1 year follow-ups and radiological assessment done. Retrospective patients from previous two years were re-assessed with appropriate x-rays and functional outcome scoring done. The AOFAS score was assessed and recorded at each of these follow-ups. In our study of 37 patients with 44 displaced intra-articular calcaneal fractures, AOFAS clinical outcome at 1 year was excellent in 7 cases (15.91%), good in 29 cases (65.91%), fair in 7 cases (15.91%) and poor in one case (2.27%). Complications were seen in 11 patients at one year follow-up but none of the patients with complications required any surgical intervention and the average AOFAS functional outcome score at 1 year was 80.43 (Good). We hereby conclude that non-operative management of intra-articular calcaneal fractures continues to be an acceptable mode of treatment with low complications and comparable functional outcome with less complications.

Which is the best treatment for displaced intra-articular calcaneal fractures

Category: Trauma Introduction/Purpose: 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. Open reduction and internal fixation (ORIF), minimally invasive surgery (MIS), external fixator (EF), external fixator combined with limited internal fixation (EFLIF) and non-surgical treatment (NST) are mostly used for the treatment of DIACFs. However, no single approach is universally applicable to all calcaneus fractures. More over, previous studies was still unclear and have offered conflicting recommendations. The purpose of this study is to comprehensively review the literature and ascertain the relative efficacy and safety of ORIF, MIS, EF, EFLIF and NST for patients with DIACFs using a Bayesian network meta-analysis. Methods: We will comprehensively search PubMed, EMBASE, Cochrane Library, Medline, Science Direct, CBM and CNKI from the inception dates to January 01, 2018, to include potentially relevant randomized controlled trials (RCTs) and cohort studies (CSs) that evaluated interventions for treating adults with DIACFs. The quality of included studies was assessed using the Newcastle-Ottawa Scale and the risk of bias according to the Cochrane Handbook. After independent study selection by 2 authors, data were extracted and collected independently. The primary outcome measures were anatomical measures, functional measures, and complications. The data of RCTs and CSs were pooled respectively using the fixed-effect model or random-effect model. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data. Statistical heterogeneity was assessed with the Q test and I2. Sensitivity analysis was developed to assess the reliability of pooled results. Results: Seventeen trials (5 RCTs and 12 CSs) including 2369 patients were considered in the study. EFLIF had significantly the highest AOFAS Ankle Hindfoot Scale (MD, 9.54 [95% CI, 5.97 to 17.42]) and lower total incidence of complications (RR, 1.65 [95% CI, 1.27 to 2.54]) than ORIF, MIS, EF and NST. Moreover, EFLIF resulted in a lower incidence of additional surgery (RR, 3.47 [95% CI, 2.28 to 6.95]) than ORIF and NST. The rank of anatomical recovery was: EFLIF, ORIF, EF, MIS and NST. The rank of functional recovery was: EFLIF, ORIF, MIS, EF and NST. For reduction in total incidence of complications, the rank was: EFLIF, NST, EF, MIS and ORIF. Conclusion: EFLIF has the highest probability of improving the functional outcome and reducing the total incidence of complications and additional surgery among the five interventions for treating adults with DIACFs.

Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures

Introduction: Calcaneum fractures account for approximately 2% of all fractures, with displaced intra-articular fractures comprising 60% to 75% of these injuries. There are many methods of stabilization of calcaneal fractures, each having their own merits and demerits. The plate fixation has improved the functional results, limited indication for bone grafting, and shortened the duration of treatment. Materials and Methods:30 displaced calcaneal fractures were surgically treated in GMC Jammu between January 2015 and May 2017 were included in this study. Ten were excluded due to lack of follow up, which left the study group of 20 displaced intraarticular calcaneus fractures. Only closed fractures were included in this study. Fractures were classified according to Sanders Classification and only Sanders type 2 and type 3 fractures were included in this study. The extended lateral incision was used in all patients. All patients were evaluated according to the Maryland foot score and on their last follow-up day. Results: The average follow-up time was 18 months (12 to 24 months). Twelve fractures were Sanders type 2 (60%), 8 were type 3 (40%). According to Maryland foot score, very good results were obtained in 6 patients (3.33%) and good results in 4 patients (20%) in Sanders type 2 fractures; good results were obtained in 8 patients (40%) and average results in 2 fractures (10%) in Sanders type 3 fractures. Conclusion: In light of both the available literature and our own experience, we conclude that open reduction and a stable fixation method yield more satisfactory results when compared to the conservative treatment methods in the treatment of displaced intraarticular calcaneus fractures.

Treatment of Displaced Intra-articular Calcaneal Fractures with the Intramedullary Nail

Category: Trauma Introduction/Purpose: In 2010, a new closed reduction, internal fixation procedure for displaced intra-articular calcaneus fractures (DIACF) was developed with an intramedullary nail introduces through a channel in the calcaneal tuberosity. The goal was to reduce the rate of skin complications following principles of open reduction procedures. The aim of this prospective mono-centric study was to assess the occurrence of complications and the functional results using the AOFAS-AHS score. The secondary objectives were to assess first the restoration of the Böhler and Gissane angles on X-ray and shape of the calcaneus (Height, length, width) on CT scans, then thalamic reduction on 3D CT scans based on Goldzak’s global articular reduction classification. Methods: 26 Patients were included prospectively between 2014 and 2016 with analysis of X-rays and CT scans. Two were lost to follow-up and 2 patients sustained a secondary subtalar arthrodesis. After positioning a distractor and drilling, reduction was done with tamps and spatula. The nail was then introduced and locked with screws in the tuberosity and the constant fragment. After 3 weeks of non-weight bearing and 3 weeks with hindfoot off-loading shoe, full weight bearing was allowed. The functional outcome and restoration of the radiographic angles were evaluated postoperatively, at 3 months, 1 year and at the last follow-up. Global calcaneal shape and thalamic surface were evaluated postoperatively, at 1 year and at the last follow-up. The following early complications (delayed healing, infection, annoyed material, sural nerve lesion) and later complications (painful stiffness of the subtalar joint, hindfoot varus malalignment and calcaneofibular conflict) were recorded. Results: Mean follow up was 2.4 years. The mean AOFAS-AHS score was 79 ± 12 [100; 61] in the 22 patients examined. The mean Böhler angle rose from -1.29°± 18° [-35; 28] pre-operatively to 33°± 6° [22; 44] post-operatively. The mean calcaneal height index and length rose respectively from 0.44± 0,18 [0,12; 0,83] to 0.86± 0,22 [0,46; 1,1] and 82,4± 5,4 [72; 93] mm to 86,7mm ±4,6 [76; 97], and the width decreased from 49,8± 4,8 [38; 59] to 46,3± 3,7 [38; 55] mm. The Goldzak global articular reduction assessment was excellent in 39% of cases, good in 42% of cases and poor in 19% of cases. One case of deep infection was reported. Three patients needed device removal and two sustained a secondary subtalar arthrodesis. Conclusion: Our prospective study on this new device has the longest time of follow-up. The results confirm the effectiveness and the reliability over time of the procedure to restore the global shape and the thalamic surface with a low rate of complications and quick return to activities. It appears to be an excellent compromise between the respect of the principles of reduction as applied in the ORIF procedures, and the low cutaneous risk of percutaneous procedures. A subsequent study, with a larger number of patients, will enable analysis of the correlation between the radiological markers and the AOFAS-AHS.

Sanders II/III Calcaneus Fractures in Laborers: A Cost-Effectiveness Analysis and Call for Effectiveness Research.

This study compares the cost and cost-effectiveness of treatments options for Sanders II/III displaced intra-articular calcaneus fractures (DIACFs) in laborers. Literature on Sanders type II and III fractures was reviewed to determine complication rates and utility values for each treatment option. Costs were calculated using Medicare reimbursement and implant prices from our institution. Monte Carlo simulations were used to analyze a decision tree to determine the cost and cost-effectiveness of each treatment from a societal perspective. Sensitivity analysis was performed on all variables. Minimally invasive open reduction internal fixation (ORIF) (sinus tarsi approach with 4 screws alone) was least expensive ($23,329), followed by nonoperative care ($24,530) and traditional ORIF using extensile lateral approach ($27,963) (P < 0.001); this result was most sensitive to time out of work. Available cost-effectiveness data were limited, but our analysis suggests that minimally invasive ORIF is a dominant strategy, and traditional ORIF is superior to nonoperative care (incremental cost-effectiveness ratio $57,217/quality-adjusted life year). Our findings suggest that minimally invasive ORIF (sinus tarsi approach) is the least expensive option for managing Sanders II/III displaced intra-articular calcaneus fractures, followed by nonoperative care. Our cost-effectiveness results favor operative management but are highly sensitive to utility values and are weakened by scarce utility data. We therefore cannot currently recommend a treatment course based on value, and our primary conclusion must be that more extensive effectiveness research (ie, health-related quality of life data, not just functional outcomes) is desperately needed to elucidate the value of treatment options in this field. Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Closed Reduction and Percutaneous Fixation of Calcaneal Fractures in Children.

Open reduction and internal fixation has been widely used to treat displaced intra-articular calcaneus fractures in children. However, the complications of surgical trauma and the wound created through the extended lateral approach cannot be ignored. This study analyzed the outcomes of displaced intra-articular calcaneal fractures in children treated with closed reduction and percutaneous fixation. Medical records of pediatric patients who had displaced intra-articular calcaneus fractures and underwent closed reduction and percutaneous fixation at the study institution between January 2008 and January 2013 were reviewed. Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. Clinical outcomes and radiographic findings were assessed at postoperative follow-up. The study included 14 displaced intra-articular calcaneal fractures in 11 patients (7 boys and 4 girls). Mean patient age was 11.18 years (range, 6-16 years), and average follow-up time was 42.8 months postoperatively (range, 12-72 months). There were 6 tongue-type fractures and 8 joint depression-type fractures, based on the Essex-Lopresti classification, and there were 11 type II and 3 type III fractures, based on the Sanders classification. Average Böhler angle was 8.00° (range, -5° to 18°) preoperatively and 30.79° (range, 26° to 40°) postoperatively (P<.001). Average subjective American Orthopaedic Foot and Ankle Society hindfoot score was 65.7 (range, 52-68). No patients had wound breakdown or infection. In the treatment of displaced intra-articular calcaneal fractures in pediatric patients, closed reduction and percutaneous fixation achieved good outcomes, with few complications. [Orthopedics. 2016; 39(4):e744-e748.].

Sinus Tarsi Approach for Calcaneus Fractures

For decades the optimal treatment of intra-articular calcaneus fractures has been debated in the literature with no definitive solution reached. Although improved implant design and surgical techniques have led some to advocate for operative treatment, high rates of wound complications, particularly with use of the extensile lateral approach, have been touted as reasons to avoid operative fixation of calcaneus fractures. Given the advent of newer lower profile implants, better fixation techniques and improved surgical approaches that preserve the lateral vascular supply to the calcaneus, fewer complications and improved functional outcomes are more commonly reported in patients with operatively treated calcaneus fractures. Minimally invasive approaches, including the sinus tarsi approach, are being frequently used to treat displaced intra-articular calcaneus fractures with promising results. The literature has shown that through the use of these approaches, there has been a decreased rate of wound complications, hematoma formation, surgical time, and equivalent functional outcomes to the extensile lateral approach. This article focuses on describing the sinus tarsi approach, surgical technique, and outcomes.

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

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. 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. 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). 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 IV, prospective, observational series.

Intra-articular Calcaneal Fractures Treated Nonoperatively and Followed Sequentially for 2 Decades

To assess the sequential and long-term patient outcome after nonoperative treatment of a displaced intra-articular calcaneal fracture, and to determine if initial results remain stable or deteriorate in the second decade after the injury. Retrospective case series with sequential follow-up at 2 time points a decade apart. University teaching hospital. At the first follow-up in 1990, hind feet were assessed with a computerized tomographic (CT) scan, radiographs, and with a 100 point score, the Iowa calcaneal score (ICS). At the second follow-up in 2000, the ICS was repeated and the patients completed the visual analog scale and the SF-36 questionnaire. In 1990, 15 of 24 hind feet had good or excellent results on the ICS. Sixteen of 19 patients returned to their preinjury level of employment. Subtalar arthrosis on the CT scan correlated with lower average scores [64 points vs. 82 points (P < 0.035)]. Ten years later in 2000, the average ICS had decreased from 74 points to 64 points (P < 0.03); however, in patients with no or minimal arthrosis detected on the 1990 CT scan, the scores remained stable with an average of 82 points, in 1990, and an average of 81 points in 2000 (P < 0.61). These results suggest that after nonoperative treatment of closed displaced intra-articular calcaneus fractures, clinical results correlate with the presence of subtalar arthrosis on CT scans [except for those with grade V (spontaneous fusion)]. Patients with arthrosis grades III and IV have increased pain and deterioration in function in the second decade after injury compared with those with minimal arthrosis (grades I or II) or those who spontaneously fused their subtalar joint. Patients without arthrosis have good outcomes that remained stable over greater than 2 decades of follow-up.