Intra-articular Calcaneal Fractures Research Articles

Is it necessary to graft the void defect during open reduction and internal fixation of calcaneal fractures?

There are still controversies on the effect of grafting during open reduction and internal fixation of calcaneal fractures. The aim of this study was to compare the radiological and functional outcomes in patients with or without intraoperative grafting. In a comparative retrospective study, among 442 operatively-treated calcaneal fractures, 60 patients with unilateral closed sanders type II intraarticular calcaneal fracture who underwent ORIF via lateral extensile approach using locking anatomical plates with at least 1year follow-up without any postoperative wound complication were enrolled. The patients were separated into 2 groups: with bone allograft and without bone allograft. The functional outcome of the patients was assessed using visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, foot function index (FFI), and short-form (SF-36) health survey. Radiographic variables included Böhler angle, Gissane angle, calcaneal width, calcaneal height, and talar declination angle. Also, the differences (delta) of these values in comparison to the uninjured foot were calculated. The mean age was 39.1 ± 12.7 (range, 13-67) years with 54 males, 90.0%. No statistically significant differences were detected in age, gender, affected side, and subtypes of calcaneal fractures between the two groups (p > 0.05). The average follow-up was 25.1 (range, 12-48) months. The differences for all radiographic measurements and also, the delta values between the groups were not statistically significant, except talar declination angle which was more in cases without grafting (p = 0.007). Although the differences between the two groups regarding AOFAS ankle-hindfoot scale (p = 0.257), VAS for pain (p = 0.645), and FFI (p = 0.261) were not statistically significant; the group with bone graft experienced less pain (19.7 ± 22.0) than the other group (26.7 ± 22.8). The difference between the groups was not statistically significant (p = 0.87) according to the SF-36 questionnaire. Incorporating allografts into the void defects during ORIF of displaced intraarticular calcaneal fractures may not improve functional outcomes and recover postoperative radiological parameters. Therefore, routine use of allograft to fill the defects during ORIF of calcaneus may not be recommended. Of note, that these findings solely relate to the treatment of Sanders type II fractures. Comparative retrospective study.

The Occurrence of Sustentaculum Tali Displacement in Intra-articular Calcaneal Fracture and Its Effect on Operation

The Occurrence of Sustentaculum Tali Displacement in Intra-articular Calcaneal Fracture and Its Effect on Operation

Comparison between intramedullary nail and conventional plate for displaced intra-articular calcaneal fractures: A meta-analysis.

This study aimed to compare the efficacy and safety of the intramedullary nail and conventional plate for the treatment of displaced intra-articular calcaneal fractures from clinical comparative trials. A comprehensive search of English databases was carried out in the Springer, PubMed, ScienceDirect, Web of Science, and Cochrane Library databases until September 2023. Studies on calcaneal fractures treated by an intramedullary nail or a plate were considered for inclusion. Endpoints included duration of operation, length of hospital stay, the Visual Analog Scale (VAS) score, postoperative functional score, radiological parameters, and complications. The mean difference (MD) and risk difference (RD) as the combined variables, as well as the 95% confidence intervals, (CIs) were calculated. Five retrospective controlled studies covering 473 feet at the one-year follow-up met the inclusion criteria. The meta-analysis demonstrated that there were significant differences in the duration of operation (MD: -10.81; 95% CI: -16.32, -5.31; p=0.0001), length of hospital stay (MD: -3.65; 95% CI: -4.35, -2.95; p<0.00001). No significant differences were found regarding postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (MD: 0.36; 95% CI: -3.89, 4.61; p=0.87), VAS (MD: 1.95; 95% CI: -0.30, 4.21; p=0.09), or postoperative Böhler angle (MD: 0.94; 95% CI: -0.04, 1.92; p=0.06) between the two groups. The incidence of total complications (RD: -0.31; 95% CI: -0.46, -0.17; p<0.0001) and wound-healing complications (RD: -0.16; 95% CI: -0.30, -0.03; p=0.02) were lower in the intramedullary nail group. There were no significant differences in the incidences of revision surgery, implant removal, superficial wound infection, deep infection, and nonunion. Compared to conventional plates, the intramedullary nail showed a shorter duration of operation, reduced length of hospital stay, and fewer postoperative total complications and wound-healing complications in treating displaced intra-articular calcaneal fractures.

Hindfoot kinematics and kinetics - A combined in vivo and in silico analysis approach

BackgroundThe complex anatomical structure of the foot-ankle imposes challenges to accurately quantify detailed hindfoot kinematics and estimate musculoskeletal loading parameters. Most systems used to capture or estimate dynamic joint function oversimplify the anatomical structure by reducing its complexity. Research QuestionCan four dimensional computed tomography (4D CT) imaging in combination with an innovative foot manipulator capture in vivo hindfoot kinematics during a simulated stance phase of walking and can talocrural and subtalar articular joint mechanics be estimated based on a detailed in silico musculoskeletal foot-ankle model. MethodsA foot manipulator imposed plantar/dorsiflexion and inversion/eversion representing a healthy stance phase of gait in 12 healthy participants while simultaneously acquiring 4D CT images. Participant-specific 3D hindfoot rotations and translations were calculated based on bone-specific anatomical coordinate systems. Articular cartilage contact area and contact pressure of the talocrural and subtalar joints were estimated using an extended foot-ankle model updated with an elastic foundation contact model upon prescribing the participant-specific rotations measured in the 4D CT measurement. ResultsPlantar/dorsiflexion predominantly occurred at the talocrural joint (RoM 15.9±3.9°), while inversion/eversion (RoM 5.9±3.9°) occurred mostly at the subtalar joint, with the contact area being larger at the subtalar than at the talocrural joint. Contact pressure was evenly distributed between the talocrural and subtalar joint at the beginning of the simulated stance phase but was then redistributed from the talocrural to the subtalar joint with increasing dorsiflexion. SignificanceIn a clinical case study, the healthy participants were compared with four patients after surgically treaded intra-articular calcaneal fracture. The proposed workflow was able to detect small but meaningful differences in hindfoot kinematics and kinetics, indicative of remaining hindfoot pathomechanics that may influence the onset and progression of degenerative joint diseases.

Evaluation of Bohler Angle, SF-36, and VAS Score in Operative vs Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures: A Meta-analysis

Introduction: In the management of displaced intraarticular calcaneus fractures, there are two options available: operative or nonoperative treatment. To establish a consensus, a number of randomized and case-controlled trials have been conducted. The aim of this analysis is to utilize the most reliable clinical evidence to provide recommendations for the optimal management of these injuries. Method: Using predetermined criteria, the authors conducted a search to identify relevant studies. After reaching a consensus among the authors, only prospective and randomized clinical trials were included. The methodological quality of the selected literature was evaluated using the Cochrane collaboration tool for randomized controlled trials (RCTs) and the Newcastle Ottawa Score for prospective trials. The outcome measures included the Bohler angle, the SF-36, and the score on the visual analog scale. The significance level was set to.05 and the confidence intervals (CIs) were set to 95% using the RevMan, version 5.4 software. Result: Our analysis included 4 studies, in which 4 randomized controlled trials (RCTs) with a total of 662 patients were included. The results indicated that the operative group demonstrated superior clinical outcomes in terms of VAS score, Bohler Angle, and SF-36. Nevertheless, there were no statistically significant differences between the efficacy of operative and non-operative treatments in regards to VAS score, Bohler angle, and SF-36. Conclusion: The current evidence suggests that operative treatment offers an advantage over non-operative treatment. It is important for patients to be informed that the available data supports better outcomes with operative treatment. However, in the case of older patients with low activity demands, there may not be a significant difference in outcomes between operative and non-operative treatment. Keywords: Operative, Non-operative, Intra-articular, Calcaneal, Fracture

Balance and Weight Distribution over the Lower Limbs Following Calcaneal Fracture Treatment with the Ilizarov Method.

Background: The biomechanical outcomes of intra-articular calcaneal fracture treatment have not been fully explored. The purpose of this study was to analyze pedobarographic assessments of balance and body weight distribution over the lower limbs in patients following calcaneal fracture treatment with the Ilizarov method and to compare the results with those of a control group. Materials and Methods: The data for our retrospective study came from cases of intra-articular calcaneal fractures treated with the Polish modification of the Ilizarov method in the period between 2021 and 2022. The experimental group (21 patients; 7 women, 14 men) included Sanders classification calcaneal fractures type 2 (n = 3), type 3 (n = 5), and type 4 (n = 13). The control group comprised 21 sex-matched healthy volunteers, with no significant differences from the experimental group in terms of age or BMI. The examination included an assessment of balance and weight distribution over the lower limbs. The device used was a FreeMED MAXI pedobarographic platform (SensorMedica). Results: The mean displacement of the center of gravity in the experimental group was significantly higher at 1307.31 mm than in the control group (896.34 mm; p = 0.038). The mean area of the center of gravity was not significantly different between the groups. An analysis of weight distribution over the operated and uninjured limb in the experimental group and the non-dominant and dominant limb, respectively, in the control group revealed no significant differences. We observed no significant differences in the percentage of weight distribution over the lower limbs between the operated limb in the experimental group and the non-dominant limb in the control group, or between the uninjured limb in the experimental group and the dominant limb in the control group. Conclusions: The use of the Ilizarov method in calcaneal fracture treatment helps normalize the percentage weight distribution in the lower limbs, with the results comparable with those obtained in the healthy control group. The mean displacement of the center of gravity was worse in the experimental group than in controls; whereas the mean area of the center of gravity was comparable between the two groups. Treatment of calcaneal fractures with the Ilizarov method does not help achieve completely normal static parameters of lower-limb biomechanics. Patients treated for calcaneal fractures with the Ilizarov method require longer and more intense rehabilitation and follow-up.

Comparison of the Radiographic and Clinical Outcomes between the Sinus Tarsi and Extended Lateral Approaches for Intra-Articular Calcaneal Fractures: A Retrospective Study.

The aim of this study was to compare the radiological and functional outcomes of the extended lateral and sinus tarsi approaches for managing displaced intraarticular calcaneal fractures. This retrospective study involved 44 patients with displaced intra-articular calcaneal fractures. The patients were treated with either the extended lateral or sinus tarsi approach and followed up for at least a year. The radiological and clinical outcomes were compared between the approaches. The waiting time for surgery was shorter and the complication rate was lower in the sinus tarsi approach group than in the other group. There were no significant differences in the American Orthopedic Foot and Ankle Society ankle-hindfoot score, Foot Function Index, or visual analog scale score between the groups. In both groups, the radiological outcomes (Böhler angle, calcaneal width, and calcaneal height) were better postoperatively than preoperatively. The sinus tarsi approach is a safe and effective alternative to the extended lateral approach for managing displaced intraarticular calcaneal fractures. It is associated with a lower complication rate and a shorter waiting time for surgery than the extended lateral approach, with similar functional and radiological outcomes.

Minimally Invasive Surgery vs Nonoperative Treatment for Displaced Intraarticular Calcaneal Fracture: A Prospective Propensity Score Matched Cohort Study With 2-Year Follow-up.

Optimal management of displaced intraarticular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiologic outcomes of minimally invasive surgery vs nonoperative treatment in displaced intraarticular calcaneal fracture up to 2 years. All displaced intraarticular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma center were considered for inclusion. The decision to treat was made by a multidisciplinary team consisting of fellowship-trained orthopaedic surgeons. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction and internal fixation. Nonoperative protocol involved symptomatic management with no attempt at closed reduction. The Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions-5 Level (EQ-5D-5L) patient-reported outcome measures were used to assess foot and ankle and general health related quality of life outcomes, respectively, at 2-year follow-up. Radiographic assessment was performed based on preinjury and 12-week postinjury radiographs. A total of 101 patients were included for analysis between August 2014 and January 2019. We propensity score matched 46 patients in the surgical cohort to 46 patients in the nonsurgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (P > .05); however, the surgical cohort had a significantly higher EQ-5D-5L Index score (P < .05) and return to work (91% vs 72%, P < .05) and physical activity rate (46 vs 35%, P < .05) despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. In addition, 14% of patients in the nonoperative cohort subsequently underwent arthrodesis compared with none of the patients in the surgical cohort. In this study, we found that operative treatments were associated with low rates of surgical complication at 2 years and long-term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared with nonoperative treatment for less severe fractures. Level III, retrospective cohort.

Cochrane Corner

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents.

Three-dimensional printing technique aids screw insertion into the sustentaculum tali of the internal fixation of intra-articular calcaneal fractures

IntroductionTreating complex calcaneus fractures remains challenging. This study evaluated the influence of 3D printing and simulation on precision screw insertion into the calcaneus sustentaculum tali (ST). Hypothesis3D printing and simulation improve the treatment for calcaneal fracture. Patients and methodsThis retrospective cohort study included 85 patients admitted with 93 Sanders type II–IV intra-articular fractures from January 2015 to June 2020. Multi-slice computed tomography (MSCT) images were used in the conventional group, and MSCT data were used to construct a 3D model of the calcaneus to simulate screw insertion and verify parameter accuracy in the 3D group. ResultsThe designed parameters (upward and backward oblique angles and screw-path length) were similar to the actual values in the 3D group (p=0.428,0.287,0.585) but not in the conventional group (p=0.01,0.002,0.023). The Maryland foot functional score, accuracy rate, and average screw number were higher and operative time was shorter in the 3D group (p=0.005,0.007,0.000,0.000). DiscussionPreoperative simulation using the 3D printing model helped guide the screws into the ST more accurately, lending better-quality treatment for Sanders type II–IV calcaneal fractures. Level of proofIII; Retrospective case-control study.

Classification of intraarticular calcaneal fractures: comparison of two classification systems

PurposeAccurately classifying displaced intraarticular calcaneal fractures (DIACFs) is essential for orthopedic surgeons to choose optimal treatment methods and provide results evaluation and communication. Many authors studying used Sanders classification reported moderate intra- and interobserver reliability. Taking the software opportunity of 3D virtual exarticulation, Goldzak updated French tri-dimensional Utheza classification, providing an alternative framework for classifying DIACFs. The aim of this study was to compare the intra- and interobserver reliability of Sanders versus Goldzak classification systems.MethodsThe CT scans of 30 patients with displaced intraarticular calcaneal fractures, treated in the same trauma center between 2014–2018, were analyzed by 16 medical doctors (specialists and residents in orthopedic surgery, specialists and residents in radiology), and classified according to Sanders and Goldzak classifications. The same images were sent on two separate sessions, in a randomized order. Interobserver reliability and intraobserver reproducibility were assessed using Kappa statistics and Gwet’s AC1 coefficient.ResultsInterobserver reliability using Gwet reported a value of 0.36 for Goldzak classification and 0.30 for Sanders classification (corresponding to “fair assessment” in both cases). In absence of subclasses, “substantial assessment” was reported for Goldzak classification (Gwet of 0.61) and “moderate assessment” for Sanders classification (Gwet of 0.46). Goldzak system had a greater interobserver reliability in the group of radiology residents. Intraobserver reliability coefficient was 0.60 for Goldzak classification and 0.69 for Sanders classification, indicating a substantial agreement for both classifications.ConclusionDespite the better view of the fracture lines provided by 3D reconstructions, this study failed to prove the superiority of Goldzak classification compared to Sanders classification for DIACFs.

Postoperative complications after displaced intra-articular calcaneal fracture operations

BackgroundThe objective was to compare postoperative complications in the management of displaced intra articular calcaneal fractures (DIACF) between two groups; the open reduction and internal fixation (ORIF) group versus the percutaneous fixation (PF) group. MethodsA total of 243 DIACFs were diagnosed and 127 of them received operations either with ORIF 75 (59.1 %) or PF 52 (40.9 %) between 2004 and 2018. Postoperative complications, radiological Sanders’s classification and improvement of Böhler’s angle were analyzed. ResultsEarly complication rate (<6 weeks), rate of deep wound infections and wound edge necrosis were significantly better in PF than in ORIF patient group. There were no significant differences in late complications (>6 weeks from operation) nor in improvement of Böhler’s angle. ConclusionComplication rate is lower when using PF technique while fracture reduction remains the same compared to the ORIF. Level of evidenceIV retrospective cohort study at a single institution.

Evaluation of the outcome of displaced intraarticular calcaneal fractures treated with locking plate fixation: An observational study

Evaluation of the outcome of displaced intraarticular calcaneal fractures treated with locking plate fixation: An observational study

Correlation between Clinical Outcome and Radiologic Features After Open Reduction and Internal Fixation of Calcaneal Fractures.

We aimed to find probable correlation between postoperative radiologic variables and clinical outcomes of surgically treated calcaneal fractures. In a retrospective study, 70 unilateral displaced intraarticular calcaneal fractures in adults with follow-up more than 1 year were asked to have a visit. Weightbearing radiographs of both ankles were taken and radiologic parameters, including the differences in values in Böhler and Gissane angles in comparison with the uninjured side, and calcaneocuboid and subtalar joint arthritis based on the Kellgren-Lawrence grading scale, were evaluated. They were considered to find any correlation with clinical outcomes assessed by American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale, visual analogue scale, Foot Function Index, and Tegner Activity Scale. A total of 61 men (87.1%) and nine women (12.9%) with a mean age of 38.9 ± 12.7 years (range, 18-67 years) were included. Mean follow-up visit for the patients was 25.1 ± 12.7 months. Mean scores of American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale, visual analogue scale, Foot Function Index, and Tegner Activity Scale were 86.7 ± 12.9, 21.3 ± 22.2, 13.1 ± 15.4, and 5.2 ± 1.1, respectively. The mean Gissane angle and Böhler angle differences were -0.2 ± 8.6 and -3.7 ± 7.2, respectively. Regarding the calcaneocuboid arthritis, 50 (71.4%), 14 (20.0%), and six patients (8.6%) were categorized in grades 0, 1, and 2, respectively. Also, subtalar arthritis was seen in 15 (21.4%), 24 (34.3%), 20 (28.6%), and 11 patients (15.7%), categorized as grades 0, 1, 2, and 3, respectively. No statistical correlation was found between any of the radiologic variables and clinical scores. There was no significant correlation between Böhler and Gissane angles and the clinical outcomes in surgically treated calcaneal fractures. Also, functional outcomes do not change considerably among different grades of arthritis in calcaneocuboid and subtalar joints, at least during short- to mid-term follow-up periods. Radiologic findings after open reduction and internal fixation of calcaneal fractures are not predictors of function of the patients.

Two-pin Posterior Tuberosity to Medial Wall Reduction Technique in Calcaneal Fracture Using Sinus Tarsi Approach

Introduction: The purpose of this study was to describe a novel technique in the surgical treatment of displaced intra-articular calcaneal fractures using 2 Schanz pins to reduce the posterior tuberosity to the medial wall (constant fragment) and correcting the varus malalignment while using the sinus tarsi approach. Materials and Methods: Twelve patients with calcaneal fractures Sanders type 2 and 3 underwent surgical fixation using this technique at our center from January 2021 to September 2021. One Schanz pin was inserted into the constant fragment and another one was inserted into the posterior tuberosity from lateral to medial. By holding the 2 pins the fracture fragments were first disengaged by applying a distraction force. The heel was then brought out of varus by a combination of maneuvres. The posterior calcaneal tuberosity pin was pushed medially and then the 2 pins were held together with one hand. The ankle was then dorsiflexed to lock the reduction. Harris heel views were taken to ensure reduction. Results: The mean Bohler angle improved from 7.5 degrees preoperatively to 29 degrees postoperatively. The mean Visual Analog Scale was 2.3 out of 10 at 6 months’ follow-up. None of the patients had wound complications, sural nerve neuropraxia, or revision surgery due to malreduction. Discussion: The 2-pin posterior tuberosity to medial wall reduction technique in calcaneal fractures using the sinus tarsi approach is a useful maneuver that can be used by orthopedic surgeons to correct the varus malalignment which is a frequent problem in calcaneal fracture fixation.

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

Background and objectiveCalcaneal Sanders type II or III fractures are highly disabling with significant burden. Surgical treatment modalities include open reduction and internal fixation (ORIF) techniques and a variety of minimally invasive surgical (MIS) approaches. ORIF techniques are associated with complications and traditional MIS techniques need extensive intraoperative fluoroscopic procedures. The present study aims to investigate the effects of three different minimally invasive internal fixation (MIIF) techniques used to treat Sanders type II intra-articular calcaneal fractures using finite element analyses.MethodsA 64-row spiral computed tomography scan was used to observe the calcaneus of a healthy adult. The scanning data were imported into Mimics in a DICOM format. Using a new model of a Sanders type II-B intra-articular calcaneal fracture, three minimally invasive techniques were simulated. Technique A involved fixation using an isolated minimally invasive locking plate; Technique B used a minimally invasive locking plate with one medial support screw; and Technique C simulated a screw fixation technique using four 4.0-mm screws. After simulating a 640-N load on the subtalar facet, the maximum displacement and von Mises stress of fragments and implants were recorded to evaluate the biomechanical stability of different fixation techniques using finite element analyses.ResultsAfter stress loading, the maximum displacements of the fragments and implants were located at the sustentaculum tali and the tip of sustentaculum tali screw, respectively, in the three techniques; however, among the three techniques, Technique B had better results for displacement of both. The maximum von Mises stress on the fragments was < 56 Mpa, and stress on the implants using the three techniques was less than the yield strength, with Technique C having the least stress.ConclusionAll three techniques were successful in providing a stable fixation for Sanders type II intra-articular calcaneal fractures, while the minimally invasive calcaneal locking plate with medial support screw fixation approach exhibited greater stability, leading to improved enhancement for the facet fragment; however, screw fixation dispersed the stress more effectively than the other two techniques.

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

BackgroundTreatment of displaced intra-articular calcaneal fractures (DIACFs) with percutaneous screw fixation remains defective in some aspects. A novel three-dimensional (3D) printed cast was devised to assist screw placement. This study assessed the radiological and functional outcomes of 3D-printed cast assisted screw fixation for patients with DIACFs.MethodsPatients with unilateral Sanders type II or III DIACFs admitted to a single-centre hospital underwent either 3D-printed cast assisted screw fixation (3D group) or minimally invasive plate fixation (control group) from September 2020 to November 2022. All patients were assessed at one, two, three, and six months of follow-up. Comparison between groups was conducted in operative duration, fluoroscopic times, radiographic measurements of the calcaneus, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score.ResultsA total of 32 patients were enrolled (19 in the 3D group versus 13 in the control group). Significant differences were detected between the 3D group and control group in operative duration (53.63±8.95 min, 95.08±8.31 min, P <0.001), fluoroscopic times (7.37±1.21, 16.85±1.57, P <0.001). At a follow-up of six months, the 3D group showed better restoration than the control group in calcaneal width, height, Bohler angle, and AOFAS Ankle-Hindfoot scores (all P <0.001). No significant differences were shown in calcaneal length and Gissane angle (P >0.05). No wound-related complications occurred in either group.ConclusionThe 3D-printed cast assisted screw fixation has shown superiority over minimally invasive plate fixation in the operative duration, fluoroscopic exposure, morphological restoration of the calcaneus, and functional outcomes in the treatment of DIACFs.

Assessment of Clinical Outcomes After Mini-Open Reduction of Depressed Calcaneal Fractures Using the Push-Out Molding Technique

Category: Trauma; Hindfoot Introduction/Purpose: As minimal invasive techniques for depressed calcaneal fracture treatment have become more common, great progress has been achieved with various surgical methods. While these techniques are still currently utilized, new methods have been developed. This study aimed to report the radiologic and clinical outcomes of depressed calcaneal fracture treatment with the “push-out molding” technique and to propose its clinical utility. Methods: From March 2009 to October 2020, a retrospective study was conducted with 52 patients, who received the “push-out molding” technique to treat depressed intra-articular calcaneal fractures (Sanders type II, III, IV). Exclusion criteria were as follows: patients with bilateral calcaneal fractures, open fractures, and a follow-up period &lt; 12 months. Radiologic parameters were assessed at following periods: preoperative, postoperative, 3-month follow-up, and last follow-up. Limitation of range of motion (ROM), subjective satisfaction, and complications were assessed at the last follow-up period. Repeated measures ANOVA was used to analyze values at preoperative, postoperative, 3-month, and last follow-up periods. Results: Significant differences in the talo-calcaneal angle (p &lt; 0.001), Böhler’s angle (p= &lt; 0.001), Gissane’s angle (p = 0.023), distance from the lower cortical border of calcaneus to the anterior (p= &lt; 0.001) and posterior (p= &lt; 0.001) points of posterior articular surface, calcaneal length (p = 0.019), and talo-calcaneal height (p= &lt; 0.001). Postoperatively, the posterior articular surface was well maintained, while 21.2% retained a ROM limitation by 20° or higher. Subjective satisfaction was as follows: excellent (42.3%), good (48.1%), fair (9.6%), and poor (0%). Conclusion: The “push-out molding” is a simple technique with the advantage of not requiring much force to treat depressed calcaneal fractures. It can be used as a beneficial surgical technique with minimal damage to the soft tissue, owing to the reduction from the depressed interior part and less severe ROM limitation.

Evaluation of outcome in closed intra-articular calcaneal fractures managed by open reduction and internal fixation with modified sinus tarsi approach.

The main goals of treating a calcaneal fracture are to make the subtalar articular surface flat again, improve the biomechanical properties, and return the outward shape of the calcaneus to normal. There are two types of treatment options available for calcaneal fractures: conservative and surgical. Despite evidence from the literature that surgical treatment has benefits of its own, complications such as postoperative infection and necrosis etc can occur. To reduce wound problems and provide appropriate reduction, minimally invasive procedures such the sinus tarsi approach and modified sinus tarsi approach have been developed. This study was done to evaluate outcome of closed intra-articular calcaneal fractures managed by the modified sinus tarsi approach since sufficient literature mentioning clinical, functional, and radiological outcomes and complications related to this surgical approach is not available.

The effect of postoperative immobilization in a plaster of Paris back-slab on the surgical wound-healing following the open reduction and plate and screw fixation of the closed calcaneal fractures: a randomised controlled study

Background: Intraarticular calcaneal fractures often need open reduction and internal fixation with plate osteosynthesis. Wound complication is one of the common problems encountered following this. It affects the outcome adversely. Our study was done to assess if a postoperative back-slab can offer any significant difference in the incidence of wound complications. Methods: Out of 42 patients with unilateral intraarticular calcaneal fractures, 20 were provided postoperative slab and continued for six weeks. The remaining 22 patients were not provided any plaster. All patients were followed-up for two years. Results: The incidence of wound dehiscence was 2 in the plaster group as well as 8 in the non-plaster group and this was statistically significant (p=0.02). Also, significantly lower heel widening was reported in the plaster group (p=0.03). Although there was no significant difference in the patient-reported outcome (Maryland Foot Score) and the incidence of pain between the two groups, the occurrence of neurological deficit following surgery and the postoperative range of movements were comparable in these two groups. Conclusions: Thus, it may be concluded that postoperative plaster application for the initial six weeks could be a low-cost yet effective way to reduce wound complications following plate osteosynthesis in intraarticular calcaneal fractures.