Hindfoot Fractures Research Articles

Catastrophic Talar Bone Loss from High Velocity Trauma Treated with Structural Tricorticate Fibula Autograft, Compression Frame and Midfoot Distraction Arthroplasty

Osteonecrosis is caused by the interruption of subchondral blood supply and can affect various bones in the human body. This case study details the treatment of a 37-year-old male with comminuted foot fractures, post-traumatic osteonecrosis, and previous surgeries who regained full weight-bearing ability and returned to work duties through a variety of techniques. Following the diagnosis of the disease through MRI scans, a surgical plan was devised for the patient: Pan-Talar Fusion Anterior Plate Reflect Anterior Flap Fibula Structural Autograft, lateral approach Complex frame compress ankle and distract mid-foot Distraction arthroplasty of midfoot The patient successfully achieved full weight-bearing and returned to work 11 months post-surgery. X-rays confirmed progressive bone healing and no hardware complications. This case demonstrates a successful treatment approach for complex hindfoot fractures, enabling full weight-bearing and return to work. Further research is needed to explore long-term outcomes and potential improvements in the surgical technique.

Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects.

To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments. Retrospective review. Rural outpatient surgical facility in Honduras. Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot. Flap healing, complications, and reoperations. Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication. The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Subtalar Distraction Arthrodesis in Post-Traumatic Indications

This manuscript aims to present the method of arthroscopic assisted subtalar arthrodesis and to evaluate the benefi ts of this surgery on our study population. In the period from 9/2007 to 1/2020, a total of 33 subtalar arthrodesis were performed in 31 patients aged 19-66 years (mean 48 years, median 50 years). The indication for arthrodesis was subtalar arthritis causing pain and gait disorders, or hindfoot deformities (most commonly after a calcaneus bone fracture). The arthroscopic assisted subtalar arthrodesis was performed with autologous tricortical bone block graft harvesting from the pelvis, supplemented by autologous cancellous bone graft. Stabilization was achieved by cannulated screws inserted in neutral ankle position. Patients in our retrospective study were followed up for a mean of 48 months (range, 24-130 months). The patients were evaluated preoperatively and at 2 years after surgery. The hindfoot angles and height (TCA - talocalcaneal angle, CIA - calcaneal inclination angle, TCH - talocalcaneal height) were evaluated on radiographs, bone union was assessed on radiographs and CT scans. The clinical assessment was performed using the ankle-hindfoot scale (AHS) of AOFAS (AOFAS score). The preoperative AOFAS score was 35-68 points (mean 52, median 54), the postoperative AOFAS score at 2 years after arthrodesis was 58-94 points (mean 82, median 82). Both the mean and median values of AOFAS score showed a signifi - cant progress from the poor result to the good and excellent result. After 2 years the TCA value decreased in 18 patients (56%) by no more than 3°. The CIA decrease observed in 21 patients (64%) was by 1° on average. The TCH decrease of 1-5 mm after 2 years since the surgery was seen in 16 patients. In 2 patients incomplete healing of arthrodesis was observed, manifested as a clinically asymptomatic non-union. No deep infection was reported. In agreement with the current literature, the arthroscopic subtalar arthrodesis has been confi rmed to be a safe method for the management of consequences of hindfoot fractures, with minimum complications and leading to accelerated bone fusion. Differences can be found in the approach, position, use of cancellous bone graft and surgical techniques. In recent years, prone position, posterior approaches, use of cancellous bone graft, distraction and fi xation with 2-3 screws divergently inserted into the bone prevail. The degree of healing of the bone fusion is generally an important factor. In our study population, non-healing was recorded in 2 patients, namely in the form of a clinically silent non-union. Neurological or early complications and/or osteosynthesis material failure occurred in up to a maximum of 10% of cases. The conclusive results of minimally invasive arthrodesis based on the AOFAS score have been confi rmed by us as well as by most authors. Our study confi rmed that the arthroscopic assisted subtalar arthrodesis is a successful, reliable and safe minimally invasive method, with minimum complications, leading to stable arthrodesis. subtalar arthrodesis, subtalar arthroscopy.

Prevalence of surgical site infection and risk factors in patients after foot and ankle surgery: A systematic review and meta-analysis.

The present systematic review and meta-analysis aimed to determine the prevalence of surgical site infection (SSI) and related factors in patients after foot and ankle surgery. A comprehensive, systematic search was conducted in different international electronic databases, such as Scopus, PubMed, Web of Science and Persian electronic databases such as Iranmedex and Scientific Information Database (SID) using keywords extracted from Medical Subject Headings such as 'Prevalence', 'Surgical wound infection', 'Surgical site infection' and 'Orthopaedics' from the earliest to 1 June 2023. The appraisal tool for cross-sectional studies (AXIS tool) evaluates the quality of the included studies. A total of 10 447 patients undergoing foot and ankle surgery participated in nine studies. The pooled prevalence of SSI in patients who underwent foot and ankle surgery was reported in nine studies was 4.2% (95% CI: 2.4%-7.2%; I2 = 96.793%; p < 0.001). The odds ratio of SSI prevalence in men was higher than that of women and was significant (OR: 1.335; 95% CI: 1.106-1.612; Z = 3.009; p = 0.003). The pooled prevalence of SSI in patients with hindfoot fracture sites reported in five studies was 4.9% (95% CI: 2.6%-8.9%; I2 = 90.768%; p < 0.001). The pooled prevalence of SSI in patients with diabetes mellitus (DM) reported in six studies was 9.1% (95% CI: 5.6%-14.6%; I2 = 73.957%; p = 0.002). The pooled prevalence of SSI in patients with hypertension (HTN) reported in five studies was 5.5% (95% CI: 2.5%-11.6%; I2 = 91.346%; p < 0.001). The pooled prevalence of SSI in patients with tobacco use reported in eight studies was 6.6% (95% CI: 4.1%-10.4%; I2 = 85.379%; p < 0.001). In general, the existing differences in the prevalence of SSI after foot and ankle surgery in different studies can be based on different risk factors such as comorbidities and gender. Therefore, it is suggested to design appropriate interventions to reduce SSI in these patients.

Prevalence and classification of accessory navicular bone: a medical record review.

The accessory navicular bone (ANB) is one of the most common accessory bones in the foot. Certain pathologies, such as posterior tibial tendon insufficiency are associated with ANB, and should be differentiated from midfoot and hindfoot fractures such as navicular tuberosity avulsion fractures. There are few studies addressing the prevalence and types of ANB in Saudi Arabia. Determine the prevalence and morphological variations of ANB and its relation with age and sex in patients visiting foot and ankle clinics. Medical record review SETTING: Orthopedic foot and ankle clinic at a university hospital. The presence of ANB was retrospectively analyzed in radiographs from patients who presented to the orthopedic foot and ankle at our university hospital from February 2010 to December 2020. The patients were stratified according to sex, age, and diagnosis. For each ANB, recorded information included site, size, classification, subtypes, and symptomatology. Purposive sampling was used to select the patients for the study (non-probability sampling). Prevalence of ANB in patients attending a foot and ankle clinic. 117 patients and 194 feet. ANB was analyzed in 1006 radiographs from 503 patients. ANB was detected in 117 (23.3%) patients and 194 (19.3%) feet Prevalence was significantly higher in females (67.5%) than in males (32.5%) (Z=5.359, P<.001). The ages ranged from 19 to 86 years, with a mean age of 48.26 (14.5) years. The most common site was bilateral (77 patients, 65.8 %). Type I was the most common type, with a prevalence of 42.1%. There were no significant differences in types in relation to sex, but all types and subtypes differed significantly from each other. ANB was common among patients presenting to the foot and ankle clinic, with an overall prevalence of 23.3%. It should be considered among the differential diagnosis in chronic foot pain, and should be differentiated from midfoot and hindfoot fractures. Further studies with a larger, randomized sample are needed, for more accuracy and to confirm the reported results. Retrospective chart review, non-probability sampling, and use of plain radiographs. None.

Short-term effectiveness of TiRobot combined with O-arm navigation system in minimally invasive treatment of hindfoot fracture

To investigate the short-term effectiveness of TiRobot combined with O-arm navigation system in the minimally invasive treatment of hindfoot fracture. Between March 2019 and March 2021, 25 patients with hindfoot fractures were admitted. There were 14 males and 11 females, with an average age of 51.7 years (range, 19-76 years). The causes of injuries included falling from height in 17 cases and traffic accident in 8 cases. The interval between injury and operation was 1-3 days (mean, 2.1 days). There were 16 cases of calcaneus fracture, 7 cases of talus fracture, and 2 cases of calcaneus and talus fractures. According to Sanders classification criteria, the calcaneus fractures were classified as type Ⅱ in 10 cases and type Ⅲ in 8 cases; according to the Hawkins classification criteria, the talus fractures were classified as type Ⅱ in 4 cases and type Ⅲ in 5 cases. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 48.1±9.1. During operation, the fractures were fixed with the percutaneous cannulated screws with the assistance of the TiRobot combined with the O-arm navigation system. The operation time, hospital stay, and the occurrence of related complications were recorded. X-ray films were reviewed to evaluate the fracture healing and the occurrence of talus osteonecrosis, and the width, length, height, Böhler's angle, and Gissane's angle of the calcaneus were measured; AOFAS ankle-hindfoot score was used to evaluated the foot function. The operation time ranged from 47 to 71 minutes (mean, 60.5 minutes). The length of hospital stay ranged from 2 to 5 days (mean, 3.4 days). All incisions healed by first intention. All patients were followed up 12-24 months (mean, 17.3 months). One patient demonstrated hypoesthesia on the lateral side of foot after operation and recovered after symptomatic treatment. All fractures healed confirmed by X-ray films and the healing time ranged from 10 to 16 weeks (mean, 11.8 weeks). No talus osteonecrosis occurred during follow-up. There were significant differences in the width, length, height, Böhler's angle, and Gissane's angle of the calcaneus between pre-operation and at last follow -up ( P<0.05). At last follow-up, AOFAS ankle-hindfoot score was 91.2±5.0, the difference was significant when compared with preoperative score ( t=22.169, P<0.001). The results were excellent in 16 cases and good in 9 cases, with an excellent and good rate of 100%. TiRobot combined with O-arm navigation system for minimally invasive treatment of hindfoot fractures can obtain the satisfactory short-term effectiveness, with the advantages of less surgical trauma, precise fixation, and fewer complications.

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.

Treatment of Complex Hindfoot Trauma with Hindfoot Nail

Category:Hindfoot; TraumaIntroduction/Purpose:Pilon fractures are often associated with severe bone comminution and soft tissue compromise. As a result, surgical salvage procedures such as hindfoot nailing may be indicated for patients who are not candidates for standard fixation techniques such as open reduction and internal fixation (ORIF). The purpose of this review was to access outcomes associated with complex hindfoot trauma acutely treated with hindfoot nailing.Methods:A case series at a Level I trauma center was performed to identify trauma patients with complex hindfoot fractures who underwent hindfoot nailing as definitive treatment after initial external fixation between 2012 and 2020. Indications included a combination of patient comorbidities, fracture severity, and soft tissue injury. Exclusion criteria included follow-up less than 3 months. Post-operative radiographs were interpreted by a fellowship-trained foot and ankle surgeon. Primary outcome measures included unplanned reoperation/revision and deep infection. Deep infection was defined as any patient requiring surgical debridement after definitive fixation with positive cultures or the presence of positive cultures at the time of planned surgery. Fractures were classified using the AO/OTA classification and injury characteristics and postoperative complications were recorded via chart review.Results:Twenty-six of 29 of identified patients met inclusion criteria. The most common AO/OTA classification was 43C (62%). The average age was 55 years (range, 31-94) and the most common mechanism of injury was motor vehicle crash (38%). Thirteen fractures (50%) were open with Gustilo Anderson grade IIIA fractures being the most common (38%). The overall deep infection rate was 15% with fifty percent of cases positive for a history of diabetes mellitus or smoking. Unplanned reoperations occurred in seven (27%) cases. Among these, a total of four (57%) occurred due to the development of deep infection, two (29%) were nonunions, and one (14%) was indicated for hardware failure. Below the knee amputation occurred in one patient with nonunion (4%), which was a grade IIIA open pilon fracture with significant bone loss. Union was achieved in the majority of patients (92%).Conclusion:Treatment of complex hindfoot trauma with intramedullary nailing has a high union rate as a salvage procedure in a poor host. Surgeons should consider this treatment in patients that are not candidates for standard open reduction and internal fixation techniques.

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

BackgroundDuring 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.MethodsThis 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.ResultsA 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.ConclusionIn 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.

Computer-Controlled Cooling in Operatively Treated Ankle or Hindfoot Fractures: A Retrospective Case-Control Study

Ankle and hindfoot fractures are often associated with a considerable amount of pain and need for systemic analgesics. Cooling devices have been developed to reduce swelling, pain, analgesics need, and complications. The primary aim was to examine the effect of cooling versus no cooling on pain levels in adult patients treated operatively for an ankle or hindfoot fracture. Secondary aims were to assess the effect of cooling on (1) analgesics use, (2) patient satisfaction, (3) hospital length of stay (HLOS), (4) the rate of complications, and (5) the rate of secondary interventions. In this single center, retrospective case-control study patients who used a computer-controlled cooling device before and after surgery of an ankle or hindfoot fracture between January 1, 2015 and January 1, 2017 were included. Matched patients without using cooling served as control. Patient, injury and treatment characteristics, pain scores and analgesics use during hospital admission were extracted from patient's medical files. Pain scores in the cooling group (18 patients) did not statistically differ from the non-cooling group (17 patients). After surgery, less patients in the cooling group used paracetamol (p=.041), and nonsteroidal anti-inflammatory drugs (p=.006). Patient satisfaction of both groups was eight out of ten points. The total HLOS was 14 days (P25-P75 9.0-17.3) in the cooling group and 9 days (P25-P75 5.0-16.5) in the non-cooling group. This was mostly contributable to the difference in preoperative HLOS (8 days; P25-P75 4.8-13.0 versus 4 days; P25-P75 2.0-7.0) and time to surgery (13.5 days; P25-P75 9.3-16.3) versus 8 days; P25-P75 2.5-12.0). Complications and revision surgery did not differ. Patients with ankle or hindfoot fractures seem to benefit from computer-controlled cooling, since equal pain sensation is feasible with less analgesics postoperatively, whereas rates of complications and revision surgeries were comparable in both groups. Patients were highly satisfied with cooling.

Influence of tendon injuries on the clinical outcome of ankle and hindfoot fractures

BackgroundAssociations of tendon injuries with ankle and hindfoot fractures is a current concern and recent research has linked specific fractures with specific tendon injuries, despite its functional impact being unknown. The purpose of this study is to assess that impact. MethodsComputed tomography scans of patients with ankle and hindfoot fractures were reviewed for tendon injuries. Patients were clinically evaluated with the Visual Analogue Scale (VAS) and the Manchester–Oxford Foot Questionnaire (MOXFQ), via a telephonic interview. ResultsEighty-five patients were included in the study. The mean age was of 49.9 ± 16.5 (14–80) years and there were 43 females (50,6%). Mean follow-up was of 43,7 ± 15,1 (24,4–82,2) months. Tendon injuries were identified in 23 patients (27,1%) and the most common lesion was tendon entrapment. The tibialis posterior tendon (TP) was injured in 18 patients (21,2%) and comprised 58,1% of all tendon injuries. Tendon injuries were mostly associated with pilon fractures, which was the most common fracture type (44,7%). There was no clinical difference between patients with a tendon injury [VAS of 4,3 ± 2,6 (0–8) and MOXFQ score of 35,1 ± 22,4 (5–80)], and those without [VAS of 3,9 ± 2,5 (0–10) and MOXFQ of 34,3 ± 26,0 (0–95), respectively (p = 0,281 and 0,689)]. ConclusionTendon injuries were present in 27% of patients with ankle and hindfoot injuries. The most frequently injured tendon was the TP in association with pilon fractures, with entrapment being the most common lesion. These lesions, however, do not seem to reflect in a worse functional outcome at two years of follow-up.

Catastrophic Hindfoot Collapse after Tibiotalocalcaneal Nailing: A Case Series

The use of a tibiotalocalcaneal retrograde hindfoot nail without joint preparation has been utilized in this population with promising results. This procedure, however, does not come without complications. It is often difficult to place the nail in the proper position within the calcaneus, talus, and tibia as medial translation is difficult without preparing the joints for fusion. This may contribute to increased nail failure rates and specifically hindfoot fractures. Three cases of hindfoot nail failure are described in patients treated with this technique.

Post-Traumatic Hindfoot Arthritis.

The hindfoot is functionally defined as the articulations between the talus, calcaneus, navicular, and cuboid. It is a biomechanically important peritalar unit for shock absorption and propulsion with the subtalar and talonavicular joint essential to its function. The primary cause of hindfoot arthritis is post-traumatic. Other causes include long-term misalignment such as adult-acquired flatfoot, cavus foot, and inflammatory arthritis. Prevention of post-traumatic hindfoot arthritis is the primary objective. Anatomical reduction and fixation of articular hindfoot fractures is the preferred pathway. This article discusses the principles of treatment of hindfoot arthritis. When post-traumatic changes cannot be managed by nonsurgical means, an anatomical well-aligned arthrodesis is indicated. This article addresses the principles of managing this condition, which have been championed by Professor Sigvard T. Hansen. New approaches and techniques are discussed that achieve the goals of a stable, functional plantigrade foot.

Poor prognosis for infectious complications of surgery for ankle and hindfoot fracture and dislocation. A 34-case series

IntroductionAnkle and hindfoot fractures are associated with high rates of complications, and of infection in particular, for which rates of 1% to 48% are reported. HypothesisTreatment of bone and joint infection (BJI) secondary to surgery for ankle or hindfoot fracture is at high risk of failure. We analyzed results of treatment of BJI in this context. Material and methods33 patients (34 cases) were treated for ankle or hindfoot BJI between 2010 and 2015. Cure was defined by absence of fistula and of local or general inflammatory signs and by normal C-reactive protein level, at a minimum 2 years’ follow-up. Fusion without infection was counted as success; recurrent infection and amputation were counted as failure. Mean age at trauma was 52 years (range, 16–85 years). Median time to diagnosis of BJI was 44 days (range, 2–830 days). ResultsMean follow-up was 20 months (range, 3–59 months). Twenty-two patients were cured (65%). Seven cases required joint fusion (21%). The failure rate was 15%, including 5 transtibial amputations. Skin cover flap was required for 15 patients (44%), at a median 33 days (range, 0–167 days). DiscussionDespite its retrospective design and small numbers, the present study confirmed the poor prognosis of BJI following surgery for ankle and/or hindfoot fracture. Patients need to be informed of this. Type of study and level of evidenceIV, retrospective observational.

Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial.

Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients. To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture. In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling. There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -86.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%. A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation. Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310-319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864.

Stentoplasty of calcaneal fractures: Surgical technique and early outcomes

Calcaneus is the most common site of hindfoot fracture, frequently caused by fall from height or high energy trauma. The therapeutic strategy ranged from non-operative to ORIF (Open Reduction Internal Fixation). Indications for percutaneous fixation include soft tissue damage or relative contraindications to open surgery. Minimally invasive percutaneous calcaneoplasty should be an alternative to ORIF aiming to reach a stable reduction, early functional recovery and short hospital stay. The aim of our study was to evaluate the clinical and radiographic outcomes of calcaneus fractures treated with balloon calcaneoplasty (BCP) by using a new generation vertebral augmentation system, VBS™-Vertebral Body Stent-DePuy Synthes. A total of 10 patients treated with VBS™ system were recruited for the study. Nine fractures were caused by a fall from height and one case by traffic accident. The mean follow-up was 8.9 months (range 2.6–23.1). The fractures were categorized according to Sanders and Essex-Lopresti classifications (5: type II, 3: type III and 2: type IV; 9: “joint depression” type and 1 case “tongue” type). Radiographic measurement (Böhler’s and Gissane’s angles) were evaluated at both pre-operative and immediate postoperative time. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score as well as a subjective evaluation (Visual Analog Scale, VAS) were used for the clinical assessment at the last follow-up. Mean preoperative Böhler’s angle was 12.3 ± 8.41° (95% CI 6.3–18.3°), whereas mean preoperative Gissane’s angle was 123.66 ± 20.47° (95% CI 109.0–138.3°). At postoperative follow-up mean Böhler’s angle increased to 21.51 ± 4.17° (95% CI 18.5–24.5°; p < 0.01), and mean postoperative Gissane’s angle was 121.74°±6.82° (95% CI 116.8°-126.6°). Mean AOFAS at the last follow-up was 70.4 ± 17.44 (95% CI 57.9–82.8).Our study demonstrates that percutaneous calcaneoplasty using VBS™ is an effective treatment for calcaneus fracture and capable to implement correction manoeuvre with clinical and radiographic outcomes comparable with other percutaneous stentoplasty.

Outcomes of midfoot and hindfoot fractures in multitrauma patients

IntroductionMultitrauma patients suffering hindfoot fractures, including calcaneal and talar fractures, often result in poor outcomes. However, less is known about the outcomes following midfoot fracture in the mutitrauma population. This study aims to describe the epidemiology of midfoot fractures in multitrauma patients and to compare the outcomes of midfoot and hindfoot fractures in this population. MethodsData about multitrauma patients (Injury Severity Score >12) sustaining a unilateral midfoot or hindfoot fracture were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and from retrospective review of medical records at a major trauma centre. Further outcome data were obtained via a survey using the American Academy of Orthopedic Surgeons Foot and Ankle Score (AAOS FAS) and the 12-item Short Form Health Survey (SF-12). Results122 multitrauma patients were included; 81 with hindfoot fractures and 41 with midfoot fractures. The median ISS (IQR) was 22 (17–29) and 27 (17–24) for the hindfoot and midfoot groups, respectively (p = 0.23). Hindfoot and midfoot fractures were commonly associated with intracranial injuries (80.3%), spine injuries (60.7%), ipsilateral lower extremity injuries (24.6%) and pelvic injuries (16.4%). The mean (SD) time to follow up was 4.5 (±2.7) years. There were no differences in mean SF-12 physical (37.97 vs 35.22, p = 0.33) or mental (46.90 vs 46.67, p = 0.94) component summary scores between the groups. There were no differences in mean AAOS FAS standard scores (69.3 vs 69.1, p = 0.97) or shoe comfort scores (median 40 vs 40 p = 0.18) between the groups. ConclusionFunctional outcomes in multitrauma patients with midfoot or hindfoot fractures were comparable. These findings suggest that midfoot fractures should be treated with the same degree of due diligence as hindfoot fractures in the multitrauma patient.

O 055 - Morphologic changes and musclestructural behaviour after hindfoot fracture: A follow-up investigation

O 055 - Morphologic changes and musclestructural behaviour after hindfoot fracture: A follow-up investigation

Timing of initiating manual therapy and therapeutic exercises in the management of patients after hindfoot fractures: a randomized controlled trial

Study designRandomized clinical trial.BackgroundPatients with fractures to the talus and calcaneus report decreased functional outcomes and develop long-term functional limitations. Although physical therapy is typically not initiated until six weeks after fixation, there’s little research on the optimal time to initiate a formal physical therapy program.ObjectivesTo assess whether initiating physical therapy including range of motion (ROM) and manual therapy two weeks post-operatively (EARLY) vs. six weeks post-operatively (LATE) in patients with fixation for hindfoot fractures results in different clinical outcomes.MethodsFifty consecutive participants undergoing operative fixation of a hindfoot fracture were randomized to either EARLY or LATE physical therapy. Outcomes, including the American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS), the Lower Extremity Functional Scale (LEFS), active ROM, swelling, and pain, were collected at three and six months and analyzed using linear mixed-modeling to examine change over time. Adverse events were tracked for 12 months after surgery.ResultsThe EARLY group demonstrated significantly larger improvements for the AOFAS (p = .01) and the LEFS (p = .01) compared to the LATE group. Pairwise comparison of the LEFS favors the EARLY group at 6 months [7.5 (95%CI −.01 to 15.0), p = .05]. There were no differences between the groups with regard to ROM, pain, and swelling. The LATE group incurred increased adverse events in this study.ConclusionInitiating early physical therapy may improve long-term outcomes and mitigate complications in patients after hindfoot fractures.Level of Evidence: Therapy, level 2b.

Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years.

ObjectivesThe surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function.MethodsFollow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery.ResultsIn 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months).The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351).Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001).ConclusionsAt five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes.Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2.