Intra-articular Calcaneal Fractures Research Articles

Treatment of Joint Depression Intraarticular Calcaneal Fractures with and without Graft

Intra-articular calcaneal fracture is one of the most challenging fractures in orthopedic surgery. The main complications of intra-articular calcaneal fractures are postoperative wound complications, subtalar arthritis, malalignment and subtalar stiffness.Conversion of the operative technique from the classic L shaped incision to the mini-invasive sinus tarsi approach renders the wound complications as less as possible. Subtalar arthritis can be minimized by anatomical reduction of the posterior facet. Malalignment can be simply prevented by calcaneal tuberosity reduction and fixation by percutanouscannulated screws. Early subtalar range of motion without weight bearing can overcome the subtalar stiffness.In this study, we included 20 patients with unilateral intra-articular calcaneal fracture without ipsilateral lesions. The patients were treated by open reduction and internal fixation through sinus tarsi approach. The patients were divided in two groups. The first group A were treated by the mentioned above technique without operative supplementation of iliac bone graft. The second group B were treated by the same technique with supplementation of iliac bone graft.Significant improvement was observed in the two groups regarding pain, AOFAS score. No significant difference between the two groups apart from that the group B treated with supplementation of iliac bone graft had earlier bone consolidation and consequently earlier weight bearing which allow for rapid return to daily activities.

Cost-Effectiveness of Operative Versus Nonoperative Management of Patients With Intra-articular Calcaneal Fractures.

To assess the costs, health gains, and cost-effectiveness of operative versus nonoperative treatment of calcaneal fractures over a 5-year time horizon from both US societal and payer perspectives. The societal perspective analysis included both direct medical costs and costs for missed work, whereas the health care payer perspective analysis included only direct medical costs associated with treatment and complications. A decision tree simulation model was developed to estimate the direct medical and indirect costs (2018 US$) and quality-adjusted life-years (QALYs) for treatment of patients sustaining intra-articular calcaneal fractures fixed with an extensile lateral approach. Direct medical costs were obtained from a large US health care system in Utah, Intermountain Healthcare, and indirect costs from the literature. Utility and probability parameters were also derived from the literature. Parameter uncertainty was explored using both one-way and probabilistic sensitivity analysis. From a US societal perspective, operative treatment costs less ($35,110 vs. $39,870) and yielded more QALYs (3.89 vs. 3.51) over 5 years compared with nonoperative treatment. At a willingness-to-pay threshold of $50,000 per QALY, operative fixation had an 89% probability of being cost-effective. From a health care payer perspective, operative management remained cost-effective as the incremental cost-effectiveness ratio is below the willingness-to-pay threshold of $50,000/QALY. From both US societal and health care payer perspectives, operative treatment of displaced intra-articular calcaneal fractures utilizing an extensile lateral approach is cost-effective at commonly accepted willingness-to-pay thresholds compared with nonoperative treatment over a 5-year time horizon. Patient variability may impact cost-effectiveness and should be explored in future research. Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcome of Minimally Invasive Osteosynthesis for Displaced Intra-articular Calcaneal Fractures Using Cannulated Screws: A Prospective Case Series

This prospective study sought to assess the functional and radiological outcomes of minimally invasive osteosynthesis using cannulated screws and to examine the effect of different parameters on the functional outcome. The Maryland foot score and the visual analog scale of pain were used to assess the functional outcomes and postoperative patient's satisfaction rate. Preoperative and postoperative Böhler's angle, angle of Gissane, calcaneal width, and height, were compared. The study included 46 fractures in 40 patients; 38 (95%) males and 2 (5%) females with a mean age of 34.8 ± 3 years. The mean time lapse to surgery was 3.2 ± 2.1 days. The mean duration of surgery was 39.8 ± 9.3 minutes. The mean follow-up period was 29.2 months. At final follow-up, the mean Maryland foot score was 85 ± 6.3. Satisfactory results were achieved in 91.3% of fractures, while unsatisfactory in 8.7%. The mean visual analog scale score of pain decreased from 7.3 ± 05 preoperatively to 1.2 ± 0.7 at the final follow-up, p <.001. Postoperatively, there was significant improvement of Böhler's angle, angle of Gissane, calcaneal width, and height, p < .001. Factors associated with better functional outcomes included reduced time lapse to surgery, p = .032, and more accurate restoration of the calcaneal parameters. Management of intra-articular calcaneal fractures by minimally invasive osteosynthesis using cannulated screws can achieve satisfactory functional and radiological outcomes. Better outcomes are associated with reduced time lapse to surgery, and accurate reduction and restoration of calcaneal angles, height, and width.

Calcaneus traction compression with orthopaedic reduction forceps combined with percutaneous minimally invasive treatment of intra-articular calcaneal fractures: An analysis of efficacy

BackgroundThe treatment of displaced calcaneal fractures is controversial.Open reduction and internal fixation are widely described as the gold standard in the literature,but these technique shave many complications,including skin necrosis,internal fixation leakage and deep infection and wound healing problems.Percutaneous reduction and unilateral external fixation have received increasing attention because they can provide a good, stable reduction and reduce the soft tissue complications caused by open surgery(such as deep infection and delayed wound healing).The purpose of this retrospective study was to evaluate the reduction imaging and clinical results of calcaneus traction compressionwith orthopaedic compression reduction forceps combined with percutaneous minimally invasive external fixation for intra-articular calcaneal fractures. MethodsThis was a retrospective analysis. A total of 35 patients with unilateral calcaneal fractures were divided into two groups: 1) the open reduction, internal fixation group (19 feet)and 2) the percutaneous minimally invasive, closed reduction external fixation group (16 feet).Evaluation of the reduction include dimaging measurements of the calcaneus length,width,and height,and the Bohler angle and Gissane angle before and after surgery.Clinical outcomes included the time of surgery,length of hospital stay,operation time,wound-related complications,the American Orthopaedic Foot and Ankle Society hindfoot score,the visual analogue score for pain, and the SF-36 score. ResultsThe average follow-up time was 25.52 ± 1.68 months.There was no significant difference in reduction between the open group and the closed group (P > 0.05).The operation time of the open group was significantly longer than that of the closed group(P = 0.0001).The length of hospitalization and waiting time for surgery in the open reduction group were significantly longer than those in the closed reduction group (P < 0.05).Incidence-related complications in the open group and closed group were 21.1 %(4/19) and 6.3 %(1/16),respectively (P = 0.0001).The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores in the open and closed groups were 81.35 ± 5.25 and 82.52 ± 4.78, respectively (P = 0.0875). The visual analogues cale (VAS) scores of the open group and the closed group were 1.81 ± 1.32 and 0.78 ± 0.91, respectively (P = 0.0412).The SF-36 scores were 80 ± 4.5 and 79 ± 4.2, respectively. ConclusionOur research shows that for various types of intra-articular calcaneal fractures compared with open reduction,internal plate fixation,calcaneus traction compression with orthopaedic reduction forceps combined with percutaneous minimally invasive external fixation is a simple and effective method for treating calcaneal fractures; not only can the calcaneus be corrected, but it can also provide notable imaging and clinical results.

Bone density of the calcaneus correlates with radiologic and clinical outcomes after calcaneal fracture fixation

BackgroundThis study aimed to determine whether bone density correlates with radiologic and clinical outcomes after screw fixation of displaced intra-articular calcaneal fractures (DIACF) with the sinus tarsi approach. Materials and methodsWe retrospectively evaluated 43 consecutive cases of unilateral DIACF between March 2015 and December 2017. Radiologic evaluations were performed using preoperative, postoperative, and last follow-up calcaneal lateral and axial radiographs. In all patients, preoperative CT scanning of both injured and uninjured calcaneus were performed at one scanning and dual x-ray absorptiometry (DXA) scans were obtained. Hounsfield unit (HU) measurement values were determined by placing an elliptical region of interest confined to the cancellous region of the uninjured calcaneus. Clinical outcomes were assessed at a minimum of 12 months postoperatively using Foot and Ankle Outcome Scores (FAOS). ResultsMean HU values of the uninjured calcaneus significantly correlated with bone mineral density scores obtained from DXA scans of the lumbar and femur (Spearman ρ = 0.656 - 0.748; p < 0.001 for both). Decreased HU values of the uninjured calcaneus significantly correlated with decreased Böhler's angle and widening of calcaneal width from postoperative to last follow-up. (Pearson r = 0.348, p = 0.022; Pearson r = -0.582, p < 0.001, respectively). Increased HU values of the uninjured calcaneus significantly correlated with improved clinical outcomes in three of five FAOS domains, including activities of daily living, sports, and quality of life (beta = 0.283 - 0.322; p < 0.05 for all). ConclusionDecreased preoperative bone density significantly correlated with decreased Böhler's angle, widening of calcaneal width, and inferior short-term clinical outcomes after screw fixation of DIACF. By quantifying bone density using HU value in area where DXA cannot be performed, such foot bones, determining whether different fixation methods or systemic treatments can be tailored to bone density could help in optimizing clinical outcomes. Level of Evidence: Level III, Retrospective case series

Risk factors for surgical site infections with the Sinus Tarsi Approach in displaced intra-articular calcaneal fractures; a prospective cohort study with a minimum of one year follow-up

BackgroundIn the last decade, the sinus tarsi approach (STA) has gained interest over the extensile lateral approach (ELA) in the operative treatment of displaced intra-articular calcaneal fractures (DIACF's), mainly because of the lower rate of surgical site infections (SSIs). However, most studies are small and retrospective. The aim of this study was to evaluate the rate of SSIs of the STA in a large, prospective series of patients and to identify predictors for SSIs. MethodsIn this prospective cohort study, all consecutive patients who were operatively treated for a DIACF in our Level 1 trauma center between August 2012 and January 2019 were included and followed for at least one year. All operative procedures were performed by two specialized foot and ankle trauma surgeons using the STA. Using multinomial logistic regression, risk factors for SSIs were identified. ResultsA total of 237 calcaneal fractures in 214 patients were included, of which 179 underwent open reduction and internal fixation and 58 a primary arthrodesis. Most patients were male (73.6%) and the mean age was 45.9 years. There were 16 patients that developed a SSI (6.8%), of which 9 (3.8%) were deep and 7 (3%) were superficial infections. The multivariate analysis pointed out that surgery within one week after injury increased the chance of a SSI, as well as an ASA of 2 or higher and more than 150 cc of blood loss during the procedure. ConclusionThis study confirms the low risk of SSI in DIACFs treated via STA. Significant predictors for SSIs were surgery within one week after injury, ASA of 2 or higher and blood loss > 150cc.

Minimally invasive dual incision with mini plate internal fixation improves outcomes over 30\u2009months in 20 patients with Sanders type III calcaneal fractures

BackgroundCalcaneal Sanders type III or higher fractures traditionally have been treated with open reduction and internal fixation (ORIF); however, ORIF has associated complications. We investigated a combination of minimally invasive dual incision and internal fixation using mini plates for treating Sanders type III calcaneal fractures.MethodsTwenty patients with Sanders type III intra-articular calcaneal fractures with a posterior subtalar articular displacement > 2 mm were included. Surgical outcomes were assessed by visual analogue scale (VAS) pain score, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and calcaneal geometry, including Böhler and Gissane angles.ResultsThe Böhler angle, Gissane angle, and height and length of the calcaneus were increased following treatment. Based on the AOFAS score, 80% of cases had excellent or good outcomes. The mean postoperative VAS pain score was 1.6. Complications such as malunion or a screw positioning deviation occurred in 6 patients, and one patient experienced delayed wound healing. There were no wound infections.ConclusionsThese results indicate that minimally invasive dual incision with mini plate internal fixation may be an effective alternative to ORIF for treating Sanders type III calcaneal fractures. Advantages include improvement of calcaneal geometry and a lower rate of wound infections.

Outcomes of Minimally-Invasive Sinus Tarsi Approach for the Treatment of Intra-articular Calcaneal Fracture

Background: Open reduction and internal fixation is the standard surgical treatment of calcaneal fractures. However, it is associated with a high rate of wound problems. Objectives: In this study, we evaluated the clinical and radiologic outcomes, as well as the wound complication rates of sinus tarsi minimally-invasive approach in the treatment of intra-articular calcaneus fracture. Methods: In a retrospective study, 62 patients who were referred with an intra-articular calcaneus fracture and treated with a minimally-invasive sinus tarsi approach were included. The radiographic evaluations included the assessment of Bohler and Gissane angles before and after the surgery, as well as the height and length of the calcaneus. The clinical outcome was assessed with the American Orthopedic Foot and Ankle Society (AOFAS) questionnaire. Results: The Mean±SD age of the patients was 41.8±12.7 years. The Mean±SD follow-up of the patients was 21.3±10 ‎months. After 6 months, in 43 patients (69.3%) both Bohler’s and Gissane’s angles were significantly improved after the surgery (P=0.003 and P&lt;0.001, respectively). The calcaneus height was significantly improved after the surgery (P=0.009), as well. The Mean±SD AOFAS score of the patients was found 79.6±7. Wound infection was seen in only 1 case (1.6%). Delayed wound healing occurred in 4 cases (6.4%). No other wound complication such as dehiscence and skin necrosis was recorded. Conclusion: Minimally-invasive sinus tarsi approach is an efficacious procedure for the treatment of intra-articular calcaneus fracture with a minimized rate of wound complications.

Evaluation of Long-Term Quality of Life Using the Foot and Ankle Outcome Score (FAOS) Questionnaire in Patients Treated by Minimally Invasive Reduction and Percutaneous Stabilization of Intra-Articular Calcaneal Fractures

BackgroundTreatment of displaced intra-articular calcaneal fractures is controversial. Choosing the optimal surgical technique is very important for patient quality of life and activity. In this study, we asked the question: “What is the long-term quality of life of patients after intra-articular calcaneal fractures treated by minimally invasive reduction and percutaneous stabilization (MIRPS)?”.Material/MethodsWe included 51 patients – 45 males (88%) and 6 females (12%) – who underwent MIRPS of intra-articular calcaneal fractures. The males were ages 22–63 years, with a mean age of 46 years, while the females were aged 31–63, with a mean age of 47 years. The FAOS (Foot and Ankle Outcome Score) survey was used.ResultsWomen’s FAOS scores were 72–95%, with a mean of 82%, and varied according to type of fracture, surgery method used, and comorbid fractures. Men’s FAOS scores were 50–95%, with a mean of 84%, and varied according to type of fracture, surgery method used, and comorbid fractures.ConclusionsAccording to set criteria regarding the FAOS scale, mainly good and very good results were observed in patients treated surgically for intra-articular calcaneus fractures using MIRPS. Westhues’ method scored a significantly higher foot rating than W-R (Westhues’-Rąpała method). Patients with TTF (tongue-type fracture) scored higher in the FAOS than patients treated with JDTF (joint depression-type fracture). In other cases, no significant differences were observed.

Clinical radiological and functional outcome of calcaneal fractures undergoing fixation with contoured locking plate

Objectives: With the advancement in surgical technique and newer fixation devices the treatment outcome of calcaneal fractures have improved. Therefore it is paramount to identify the appropriate treatment techniques for better functional outcomes in terms of better stability and early weight bearing without pain. Hence this study was carried out to study the functional outcomes of displaced Intra-articular Calcaneal fractures, treated with operative management using contoured locking plate. Material and Methods: This study was carried out as a prospective study. Fifty (50 fractures) patients with acute, displaced Intra-Articular fractures of calcaneum aged above 18 years, were enrolled in the study. Open fractures and fractures older than two weeks were excluded. The functional outcome was measured by the “American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot scoring system” at twelve months. Results: Of the 50 patients, all were males. Five patients had bilateral fractures. 35 patients had left sided fractures, while 15 had right sided fractures and mode of injury for all the patients was fall from height. Post operatively all 50 patients had swelling, 20 patients had persisting pain, 5 had superficial infections and 2 had deep infection. Superficial infections healed with antibiotics and dressings, while the patient with deep infection had persistent pain and difficulty in walking with discharge from surgical wound site. Both of them underwent implant removal and debridement after a year. Of the 50, 32 had good results, 14 had fair results and 4 had poor results. Hence we conclude from the above findings that contoured plate fixation helps in improving the functional outcome of the patients in view of their physical and radiological findings. Conclusion: A relatively better functional outcome was observed in displaced and comminuted fractures in plating, provided that the Bohler's angle was restored. The technique of contoured plate fixation with a lateral approach is good with regards to fracture union and functional outcome.

Clinical and functional outcomes of pre-contoured plate fixation in displaced intraarticular calcaneum fracture

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; We evaluated the clinical and functional outcome of intra-articular calcaneal fractures treated with pre-contoured plating. The functional outcome was measured by the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Twenty-five adult patients with displaced intra-articular calcaneus fractures, treated with by open reduction and internal fixation using pre-contoured plates, and those who were available for follow up were evaluated for the outcomes such as operative procedure, anatomical reduction, postoperative hospital stays early mobilization and functional outcome postoperatively. Follow-up was at three, six and twelve months radiological and clinical union were also considered.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Twenty-five adult patients presented with calcaneal fractures were operated during the study period. The mean time for union of fracture was 12.5±1.8 weeks. When we assessed the functional outcome in those patients who had radiological and clinical union using AOFAS score, we found that 16 out of 23 (64%) had good results with mean AOFAS score of 83.5±2.0 and 7/25 (28%) had fair results with mean score of 73.3±1.3, and 2/25 (8%) had poor results with mean score of 54.0±8.5. In 2 out of 16 (12.5%) patients, with good AOFAS scores, implants were removed after one and a half year from the day of surgery after confirming complete union of the fracture.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; We believe that pre-contoured reconstruction plate fixation for displaced intraarticular calcaneus fracture is excellent in terms of the union of the fracture, attaining anatomical reduction. It gives better outcomes concerning the function and range of movements.&lt;/p&gt;

Subtalar distraction arthroplasty with bone marrow aspirate concentrate (BMAC), preliminary results of a new joint preservation technique

IntroductionIsolated subtalar osteoarthritis (OA) is a debilitating condition usually occurring after trauma and particularly in the setting of an intraarticular calcaneal fracture. Currently, subtalar (talo-calcaneal joint) fusion surgery is the treatment of choice in managing subtalar OA after failure of conservative treatment. Unfortunately, subtalar fusion eliminates joint motion and increases the load over the adjacent midfoot and ankle joints, which affects the outcome of the surgery over time. Popular in the ankle, distraction arthroplasty offers another joint-preserving option, particularly important for active patients. In contrast to fusion as a salvage procedure, subtalar distraction arthroplasty allows the possibility of maintaining the function of the arthritic subtalar joint while reducing pain and improving the overall function of the foot and ankle. MethodsWe performed subtalar distraction arthroplasty using a circular external fixator combined with BMAC on seven patients with symptomatic and refractory subtalar OA. All these patients were interested in an alternative to fusion. We obtained clinical and radiographic data before and after surgery. Ankle Osteoarthritis Score (AOS) and the Marijnissen Distraction Clinical Score (MDCS) were obtained before surgery, after one year, and at latest follow-up. ResultsThe average age was 56 years (range 45–69). The mean duration of post-operative follow-up was 35.4 months (range 15.2–53.5). The inversion of the ankle joint changed from 16.9° (10°–25°) pre-operatively to 14.3° (10°–20°) post-operatively (P = 0.28), and the eversion from 5.6° (0°–10°) to 10.0° (0°–20°) (P = 0.17). We found an increase in subtalar joint space from 1.4 mm (0–3) to 2.6 mm (2–4) before and after surgery (P = 0.01), respectively. Finally, Pixel Density Ratio (PDR) increased from 0.87 (0.66–1.30) to 1.01 (0.89–1.18) (P = 0.19). Compared to pre-operative conditions, we observed a decrease in subchondral sclerosis on X-ray in all cases post-operatively.The AOS score for ankle pain improved from 58.8 (47–74) to 15.1 (0–31) (p < 0.01). The AOS score for ankle disability improved from 68.2 (57–81) to 16.1 (0–43.5) (p < 0.001). We found improvement in the MDCS over time for all measured parameters. The clinical condition improved from 1.4 (0–2) to 0.8 (0–2) after one year and to 0.3 (0–2) at the latest follow-up (p < 0.001). Mobility was measured as ROM in the treated ankle relative to each patient’s contralateral ankle. This increased from 35% (0–100) to 66% (15–120) to 76% (15–100) (p = 0.059). Function improved from 2.3 (0–3) to 1.3 (0–3) to 0.6 (0–3) (p < 0.001). Pain decreased from 7.4 (2–10) to 4.4 (2–8) to 2.1 (0–7) (p < 0.01). Complications include one patient with sensory neuralgia. ConclusionsPreliminarily, results of subtalar distraction arthroplasty as a new joint preservation technique are encouraging. Our research suggests the possibility of subtalar distraction arthroplasty as an effective treatment for symptomatic subtalar OA. Furthermore, this new operation does not eliminate the possibility of a future surgery like fusion. Subtalar distraction arthroplasty can be helpful in the management of subtalar OA in active patients who desire preservation of foot and ankle motion.

Computational Biomechanical Analysis of Postoperative Calcaneal Fractures with Different Placement of the Sustentaculum Screw

ObjectiveTo evaluate the computational biomechanical analysis of intra‐articular calcaneal fractures with different fixation status of the sustentaculum plate screw, when the finite element modeling of calcaneal fractures were fixed by the lateral locking plate.MethodsThe normal right foot of a male (age: 36 years; height: 174 cm; body weight: 65 kg) was scanned by the CT scanner. As the computational biomechanical study, the three‐dimensional finite element model of the simplified Sanders type‐II calcaneal fracture was built. Fixation with the lateral calcaneal locking plate and screws was simulated using a finite element software package according to clinical operation. According to the different placement of the sustentaculum plate screw, the models were categorized as the accurate fixation group, marginal fixation group, and non‐fixation group. The loading of 650 N with the vertical axial compression was applied to simulate the standing phase with single foot. The Von Mises stress distribution, maximal displacement, and contact area of the subtalar joint were analyzed among three groups.ResultsThe pressure distribution of the subtalar joint facet was inhomogeneous. The stress concentration of the calcaneus was located at the medial zone of the posterior subtalar joint facet. The peak Von Mises stress distribution in three groups was similar at the subtalar joint facet of 4.9 MPa, 5.1 MPa, and 5.4 MPa. In the accurate fixation group, the contact area on the posterior articular facet was 277.1 mm2; the maximal displacement was 0.18 mm. The contact area of the marginal fixation group was 265.3 mm2 on the posterior facet, where the maximal displacement was 0.23 mm. In the non‐fixation group, the contact area was 253.8 mm2; the maximal displacement was 0.25 mm. There was a slight change in the contact area of the subtalar joint and no prominent displacement of the calcaneus could be detected among the three groups.ConclusionsThe biomechanical results, including the peak stress distribution, contact area, and maximal displacement of subtalar joint, were similar whether the screw is placed exactly within the sustentaculum tali or not, when the calcaneal fractures were fixed by the lateral locking plate. The sustentaculum plate screw had less effect on the biomechanical performance of the calcaneus.

Arthroscopy-assisted percutaneous reduction and screw fixation for displaced intra-articular calcaneal fractures

Objective: To investigate the surgical technology and clinical efficacy of using the all-inside arthroscopic treatment of intra-articular displaced calcaneal fracture. Methods: A retrospective analysis was made of 46 patients (46 feet) with intra-articular displaced calcaneal fractures treated by modified all-inside arthroscopic from December 2015 to December 2017 in Xuzhou Central Hospital. Twenty-eight cases (28 feet) were male and 18 cases (18 feet) were female, aged from 19 to 60 years (mean (39±13) years). The time from injury to operation was 1 to 10 days (mean (4.5±2.2) days). The pre-operative visual analogue scale (VAS) of pain ranged from 4 to 8 points, mean (6.3±1.8) points. No other combined injuries were found in the affected feet in all patients. All patients were treated with anterolateral, lateral and posterolateral approaches of arthroscopically assisted reduction for calcaneal fractures, and fixed with hollow screw. Main outcome measures included the pain, foot appearance, and the scores of the American Orthopedic Foot & Ankle Society (AOFAS) Scale and the Maryland Scale. Paired t test was used when the data before and after the operation were compared. Results: All incisions healed in one stage without postoperative complications such as nerve, vessel and tendon injury. The mean follow-up period ranged from 12 to 36 months, mean (21±9) months. Postoperatively X-ray showed complete fracture healing time was 8 to 12 weeks, mean (10.4±2.3) weeks. At the last follow-up, the ankle and talocalcaneal joints movement and appearance were ideal, and no traumatic arthritis was found. The VAS score of talocalcaneal joint was 0. AOFAS score increased from 58±13 to 96±9 and Maryland score increased from 72±11 to 98±8 after the operation, the differences were all significant (t=15.958, 12.496, both P<0.05). Conclusion: The all-inside arthroscopic treatment of the intra-articular displaced calcaneal fracture is an effective and precise method, with accurately outcomes, precise reduction and minimally postoperative complications.

Minimally invasive treatment of calcaneal fractures of Sanders II&III with subtalar arthroscopy assisted by self-designed retractor and reducer

Objective To evaluate the minimally invasive treatment of calcaneal fractures of Sanders Ⅱ&Ⅲ by closed reduction or a sacral sinus arc-shaped minimally invasive incision under subtalar arthroscopy assisted by a self-designed cervical retractor and a self-designed reducer to expose and assist the reduction followed by internal fixation with hollow nails and Kirschner wires. Methods From June 2016 to February 2018, 53 patients (60 feet) were treated at Department of Hand and Foot Surgery, Central Hospital of Linyi for closed intra-articular calcaneal fractures. Of them, 24 (28 feet) received the minimally invasive treatment and 29 (32 feet) open surgery via the conventional lateral L-shaped incision. The 2 groups were compared in terms of Bohler angle, Gissane angle, and the width, length and height of the calcaneus before operation, one week after operation and at the final follow-up, as well as in terms of preoperative preparation time, operation time, surgical bleeding volume, incision complications, subtalar joint stiffness, and ankle- hindfoot score of the American Foot and Ankle Surgery Association (AOFAS). Results The 2 groups were comparable because there were no significant differences between them in the preoperative general data (P>0.05). All the patients were followed up for 10 to 22 months (average, 16 months). The Bohler angles, Gissane angles, and the widths, lengths and heights of the calcaneus after operation and at the final follow- up were significantly better than the preoperative values in the minimally invasive group (all P 0.05). Conclusion The minimally invasive treatment of calcaneal fractures of Sanders Ⅱ&Ⅲ by closed reduction or a sacral sinus arc-shaped minimally invasive incision under subtalar arthroscopy assisted by a self-designed cervical retractor and a self-designed reducer to expose and assist the reduction followed by internal fixation with hollow nails and Kirschner wires can lead to satisfactory clinical results, because this method shortens significantly the time for hospitalization and leads to less invasion, fewer complications, accurate reposition and reliable fixation. Key words: Arthroscopy; Calcaneus; Fractures, bone; Fracture fixation, internal

Determining the Correlation Between Lateral Radiograph Morphology and the Outcome Following Surgically Treated Intra-Articular Calcaneal Fractures

Purpose. It is currently still common practice to obtain conventional radiographs in the follow-up of surgically treated displaced intra-articular calcaneal fractures at regular intervals. There is, however, insufficient evidence that these radiographs can be used to predict functional outcome. The aim of the current study was to evaluate the correlation between the most commonly used angles on lateral radiographs and disease-specific patient-reported outcome measures (PROMs). Methods. Two available databases, containing a total of 233 patients, were used in this study. Eleven angles on the lateral images of the preoperative and at 1-year follow-up radiographs were measured. The 6 most commonly used angles were also measured immediately postoperatively. These 6 most commonly used angles were correlated with PROMs (American Orthopaedic Foot and Ankle Society hindfoot score, Foot Function Index) by a Spearman’s rho analysis. After a Bonferroni correction was applied, a P value of <.0042 was considered to be statistically significant. Results. After exclusion of bilateral fractures, primary arthrodesis, open fractures, wound infections, other wound complications, nonavailable radiographs, and nonresponders, 86 patients remained. No significant correlations were found between the measured angles on the preoperative and at 1-year follow-up radiographs and the PROMs. Conclusion. No apparent correlation between lateral radiograph morphology and outcome was detected. Therefore, long-term follow-up radiographs after confirmed healing may be restricted to patients with persistent complaints on indication.Levels of Evidence: Prognostic, Level IV: Retrospective

Percutaneous reduction and screw fixation for all types of intra-articular calcaneal fractures.

This study compares the outcomes of consecutive of patients with Sanders II and III and IV calcaneal fractures that were stabilized by either close reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF). Group I (N = 49) underwent close reduction internal fixation (CRIF). Group II (N = 39) underwent open reduction internal fixation (ORIF). The clinical outcomes included time to operation, operative duration, visual analog score (VAS), length of hospital stay, wound-related complications and AOFAS SF-36 score. Preoperative and postoperative radiographic measures also were compared. The duration of operation in the CRIF group was considerably shorter than in ORIF group (P = 0.0001). Postoperatively, at seventh day, the VAS in the CRIF group (4.2 ± 1.1) was meaningfully lower than those of the ORIF patients group (4.7 ± 1.2, P = 0.04). Totally, the prevalence of wound complications in CRIF group was significantly lower than in ORIF group. In final follow-up visit after one year, AOFAS scores and SF-36 scores between groups were comparable. Comparable radiographic measures were found in both groups. There was no significant difference between groups regarding preoperative radiographic measures (P > 0.05), while in postoperative imaging acceptable calcaneal fracture reduction was found in both groups. We believed that for treatment of various types of calcaneal fracture compared with ORIF the percutaneous reduction and screw fixation may lead to shorter hospital stay, decreased subtalar joint stiffness and earlier weight bearing along with much favorable patients' satisfaction.

Medium-term outcome after mini-open reduction and transarticular Kirschner wire fixation for displaced fractures of calcaneus

Background The management of calcaneal fractures has been a controversial topic. Open reduction and internal fixation is associated with a high incidence of postoperative soft tissue complications. Minimally invasive open reduction and internal fixation by K-wires through a minimally invasive sinus tarsi approach is a valid therapeutic line of treatment that guarantees stability and anatomic fracture reduction with minimal complications. The aim of our study is to evaluate the outcome of mini-open reduction and transarticular percutaneous K-wire fixation of displaced intraarticular calcaneal fractures. Patients and methods This prospective case series study was conducted on 220 (156 men and 64 women) patients with intraarticular calcaneal fractures, who were managed by mini-open reduction and fixation via multiple transarticular K-wires. Mean age was 40 years. Mean follow-up period was 57 months. The following variables were assessed: preoperative and postoperative Bohler angle, angle of Gissane, calcaneal height, and Maryland Foot Score. Results Patients were operated on within a mean time of 3 days of injury. All fractures healed after an average of 10 weeks. There were 14 cases of pin-tract infection. The Maryland Foot Score rated 142 (64.5%) patients as excellent, 59 (27%) as good, and 19 (8.5%) as fair. There was significant improvement in Bohler angle, calcaneal height, and calcaneal width. Patients returned to the routine daily activities after an average time of 4 months. Conclusion We believe mini-open reduction and transarticular percutaneous K-wire fixation is an effective treatment method for cases of displaced intraarticular calcaneal fractures.

Clinical and Radiological Outcomes of Minimally Invasive Reduction and Percutaneous K-wire Fixation for Intra-articular Calcaneal Fractures.

There has been much controversy over the optimal operative treatment of intra-articular calcaneal fractures. Open reduction and internal fixation is associated with a high incidence of postoperative soft tissue complications. This study sought to evaluate the outcomes of indirect reduction and percutaneous K-wire fixation for displaced intra-articular calcaneal fractures. This was a prospective study of 40 consecutive patients with 44 Sanders type II or III intra-articular calcaneal fractures who had undergone closed or mini-open reduction and percutaneous K-wire fixation from 2013 to 2016. The Maryland Foot Score and visual analog scale score for pain were used to assess functional outcomes and postoperative patient satisfaction. Twenty-two patients were men and 18 patients were women, with a mean age of 34.5 years. According to the Sanders classification, 26 fractures were type II and 18 were type III. Mean follow-up was 31.9 months. The clinical outcome was satisfactory for 36 fractures (81.8%) and unsatisfactory for 8 fractures (18.2%). Mean time of radiological union was 8.7 weeks. Mean full weight-bearing time was 13 weeks. Mean visual analog scale score was 1.4 when radiographic fracture healing was detected. Repeated follow-up radiographs showed no loss of reduction or collapse of the posterior facet. Closed or mini-open reduction and percutaneous K-wire fixation of Sanders type II or III calcaneal fractures has excellent functional outcomes with minimal soft tissue complications. [Orthopedics. 2020; 43(2): 97-101.].

Radiographic Analysis of Intra-articular Fractures of the Calcaneus in patients undergoing Minimally Invasive Surgical Treatment in a Tertiary Hospital.

Objective This paper aims to evaluate patients with articular calcaneal fractures treated with a minimally invasive surgical technique between January 2015 and August 2016, with emphasis on radiographic results. Methods Retrospective study of 49 patients with 64 displaced calcaneal fractures treated with open reduction by minimal lateral access to the subtalar joint and minimal fixation. Pre- and postoperative radiographic studies were performed to measure the angles of Böhler and Gissane. Results The average angle of Böhler before surgery was 2.5°, increasing to an average value of 25.3° after the minimally invasive surgical treatment. The average angle of Gissane before surgery was 136.3°, decreasing to an average value of 114.3° after the procedure. Conclusion The minimally invasive surgical technique improves the radiographic parameters of intra-articular calcaneal fractures, with appropriate anatomical restoration of anatomical shape.