Intra-articular Fractures Of Calcaneus Research Articles

Outcome of surgically treated intraarticular calcaneus fractures—SF-36 compared with AOFAS and MFS

There is no consensus as to which is the best treatment for intraarticular fractures of the calcaneus. Furthermore, few studies have assessed general health after calcaneus fractures. We therefore measured the state of general health after operation of calcaneal fractures and compared these data with usual foot-scores. We compared the general health of 71 patients with surgically treated calcaneal fractures 2.5 years after injury, with the general health of 71 people from the standard German population (German National Health Survey, 1998) using the SF-36 form. We compared the results of the examination with results of AOFAS Ankle Hindfoot Scale and Maryland Foot Score in the treated patients. In patients with calcaneal fractures, there were significant limitations regarding general health in all 9 elements of the SF-36 form. Correlations between SF-36 and foot-scores were strong regarding function and pain scales, but moderate for all other scales. Patients face significant limitations regarding general health after calcaneal fractures. The usual foot-scores measure only 2 dimensions of outcome: function and pain. To measure all dimensions of outcome, SF-36 is a better alternative.

Radial forearm free flap for coverage of postoperative lateral heel wounds after open reduction and internal fixation of the calcaneus

For intraarticular calcaneus fractures, open reduction and internal fixation has become commonplace for the reduction of morbidity of postinjury arthritis. Despite adequate surgical results, there are often associated postoperative wound complications. The purpose of this study was to describe a unique application of the radial forearm free flap for coverage of lateral postoperative heel defects seen after calcaneal fixation. Seven lateral heel wounds after open reduction of calcaneal fractures in 6 patients were covered with radial forearm free flaps. The technique used involved passage of the pedicle of the laterally placed flap anteriorly to the Achilles tendon so that it can be anastomosed to the posterior tibial artery. Flap application was 100% successful, with good functional and cosmetic results in all patients. The radial forearm free flap provides a quick, reliable, and easily harvested source of coverage for lateral heel wounds seen after open reduction and internal fixation of the calcaneus. Tunneling of the flap pedicle anterior to the Achilles tendon is simple and provides the additional advantages of access to reliable vessels, reduced scarring, and avoidance of further wound problems often seen with incisions used to access the anterior tibial artery.

Open reduction and internal fixation of calcaneal fractures with a low profile titanium calcaneal perimeter plate.

Forty-two intra-articular calcaneus fractures underwent open reduction and internal fixation with a low profile, titanium plate with a shape similar to the lateral aspect of the calcaneus. All 42 fractures healed without complication. There were no cases of hardware breakage. None of the patients were noted to have a loss of reduction. The plates were applied without bending and molded to the side of the calcaneus with tightening of the screws. No patient complained of symptomatic hardware during the follow-up period. With postoperative plain radiographs, the reduction was judged as anatomic in 35 patients, less than a 2 mm step off in six patients, and one patient with greater than 2 mm step off. Use of this new plate allows for easy application as it does not require contouring, is well tolerated without complaints of hardware prominence, and none of the hardware broke prior to fracture union.

Surgical treatments of intra-articular fracture of calcaneus

Surgical treatments of intra-articular fracture of calcaneus

The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures.

A wealth of clinical and experimental data suggests, that anatomical restoration of the posterior calcaneal facet is a major predictor of outcome after intra-articular calcaneus fractures. The value of subtalar arthroscopy was examined in three clinical study groups (I-III. (I) The subtalar joint was inspected arthroscopically in 28 patients during hardware removal one year after open reduction and internal fixation (ORIF). This procedure was accompanied by subtalar arthrolysis in all cases. (II) Open subtalar arthroscopy was performed to evaluate the quality of reduction after ORIF of intra-articular calcaneus fractures in 59 cases. Arthroscopy was performed after seemingly exact reconstruction of the posterior facet as judged visually and fluoroscopically. (III) Arthroscopically assisted percutaneous reduction and screw fixation (PRSF) was performed in 18 patients with Sanders II fractures. Reduction was achieved with a Schanz screw introduced percutaneously into the tuberosity fragment and controlled fluoroscopically, while fine corrections were made under arthroscopic guidance. (I) Clinical results after ORIF of intra-articular calcaneus fractures were highly correlated to the degree of residual incongruities and chondromalacia of the posterior facet as seen arthroscopically during hardware removal (P < 0.01). (II) In 13 of 59 cases (22.0%) during ORIF despite seemingly accurate reduction, steps between 1-2 mm were detected arthroscopically in the posterior calcaneal facet and reduction was repeated subsequently in these cases. (III) Fifteen patients who underwent arthroscopically guided PRSF were re-evaluated after a minimum of one year with excellent clinical results (94.1 pts. with the AOFAS scales). No wound complications were seen. Subtalar arthroscopy provides a most precise and thorough view of the posterior facet of the calcaneus both in assessing the quality of initial reduction as well as evaluation during hardware removal after intra-articular calcaneus fractures. It is more precise than intra-operative fluoroscopy and less time consuming than standard Brodén views during surgery. The use of arthroscopy allows anatomical percutaneous reduction and screw fixation of Sanders II fractures. It therefore provides a useful additional tool in treating intra-articular calcaneus fractures.

Percutaneous, arthroscopically-assisted osteosynthesis of calcaneus fractures.

The development of major and minor wound complications is a major concern in the open reduction and internal fixation of displaced intra-articular calcaneus fractures. Percutaneous, arthroscopically assisted screw osteosynthesis was developed to minimize the surgical approach without risking inadequate reduction of the subtalar joint. The method was applied in selected cases of displaced intra-articular calcaneus fractures with one fracture line crossing the posterior calcaneal facet (Sanders type II fractures). Between March 1998 and July 2000, 15 patients were treated with that method. Percutaneous leverage was carried out with a Schanz screw introduced into the tuberosity fragment (the Westhues maneuver) under direct arthroscopic and fluoroscopic control. After anatomic reduction was achieved, the fragments were fixed with three to six cancellous screws introduced via stab incisions. The functional results of 10 patients at a minimum of 1 year follow-up are good to excellent, with an average AOFAS ankle-hindfoot score of 93.7 (range 87-100) and an average Maryland Foot Score of 95.8 (range 93-100). Overall patient comfort and satisfaction were superior to open reduction for similar fracture patterns, and the in-hospital time could be reduced. Percutaneous, arthroscopically assisted osteosynthesis offers exact assessment of the articular surface and allows anatomical reduction while adhering to the principles of minimally invasive surgery. The short-term results are excellent, while long-term results with greater patient cohorts are awaited.

The use of subtalar arthroscopy in open reduction and internal fixation of intra-articular calcaneal fractures

Congruency of the subtalar joint is a major predictor of outcome after intra-articular calcaneal fractures. Because of the irregular shape of the posterior joint facet, minor steps may be overlooked with direct vision or intra-operative fluoroscopy during open reduction and internal fixation (ORIF). In a preliminary series of 15 subtalar arthroscopies during hardware removal after ORIF of intra-articular calcaneal fractures, patients with visible steps of 1 mm or more had significantly inferior functional results compared to those with an intact subtalar joint (117 vs. 158 points with the 200-point score, 71.3 vs. 91.2 points with the Maryland Foot Score, P<0.01). Congruency of the posterior facet was controlled arthroscopically in 47 intra-articular calcaneus fractures after open reduction and temporary K-wire-fixation. In 12 cases (25.5%), despite seemingly correct reduction as judged fluoroscopically, incongruencies in the posterior calcaneal facet were detected and reduction was repeated, temporarily removing the K-wires. After anatomical reduction a standard AO calcaneal plate was fixed to the lateral wall. Intra-operative arthroscopy appears to be useful in detecting minor incongruencies after ORIF of intra-articular calcaneus fractures. In the hands of an experienced surgeon it is less time demanding than intra-operative X-rays and more precise than fluoroscopy.

Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach.

This is a review of 183 patients with 218 displaced intraarticular fractures of the calcaneus treated by open reduction and internal fixation. One hundred and ninety four (89%) wounds underwent primary uneventful healing. Twenty-four wounds (11%) required local wound care. One deep infection occurred in a neuropathic foot that required below-knee amputation. No free-tissue transfers, local tissue flaps or skin grafts were needed in patients who presented initially with a closed fracture. Ninety-five fractures (43.5%) required subsequent surgical procedures (hardware removal-88/95 [93% of secondary procedures]). Six patients (2.8%) had postoperative sural nerve findings. Seventeen procedures other than hardware removal were performed. There were five subtalar fusions including two subtalar distraction bone-block arthrodeses. There were seven claw toe correction procedures, four calcaneal valgus osteotomies for varus malunions and one subtalar arthrolysis at the time of hardware removal. These results suggest internal fixation of displaced intra-articular calcaneus fractures using a single lateral approach is a safe, reliable method of treatment.

The results of conservative treatment of intra-articular fractures in the calcaneum

Objectives: We evaluated the results of conservative treatment for displaced intra-articular fractures of the calcaneum and investigated the implications of radiologic and clinical signs on the outcome. Methods: Thirty-three patients (18 males, 15 females; mean age 38 years; range 18 to 61 years) with displaced intra-articular calcaneum fractures were treated with cast immobilization and non-weight bearing. According to the modified Essex-Lopresti classification, the fractures were type-a (n=2), type-b1 (n=5), type-b2 (n=4), type-c1 (n=11), type-c2 (n=7), and type-d (n=4). The results were evaluated using the protocol and scoring system by Rowe et al. The mean follow-up was 3.8 years (range 1.5 to 8 years). Results: Excellent or good results were achieved in 22 patients (66%), while 11 patients (34%) had fair or poor results. Type-b2, type-c2, and type-d fractures were associated with worsening results. Increased heel width, decreased Bohler angle, and male sex were associated with unsatisfactory results; however, no relationship was found between secondary osteoarthrosis and unsatisfactory results. Conclusion: Our results suggest that conservative management of displaced intra-articular fractures of the calcaneus is unsatisfactory.

Treatment of intra-articular calcaneus fractures with a para-articular external fixator]

Operative treatment of the calcaneus is still in discussion. For a better management of soft tissue problems an optimized fixator frame for primary treatment of calcaneus fractures was developed in the Dept. of trauma surgery University of Kiel. A one-plane bilateral construction with one insertion point in the tibia and two in the tuberosity of calcaneus is used. It allows efficient reduction by ligamentotaxis, stable fixation and active motion in ankle joint. We treated 40 patients with 45 calcaneus fractures. In 25 cases the fixator was definite and later plate or screw fixation was performed 20 times. 35 patients with 40 fractures were examined by means of the "Kiel score for calcaneus fractures". Patients who were treated definite reached better longterm-results on average than patients who underwent a secondary open osteosynthesis. Concrete guidelines for the therapy of intraarticular calcaneus fractures are presented.

Calcaneus fractures with subluxation of the posterior facet. A surgical indication.

The charts and radiographs of 118 patients with 126 intraarticular fractures of the calcaneus were reviewed retrospectively. Eleven of 126 (8.7%) calcaneal fractures had injuries consisting of intraarticular calcaneal fracture, lateral subluxation or dislocation of the posterior facet, fracture extension into the calcaneocuboid joint, peroneal tendon subluxation, subluxation of the talus in the ankle mortise, and complete disruption of the anterior talofibular and calcaneal fibular ligaments or fracture of the lateral malleolus. There were six women and five men. The average age was 40 years (range, 17-65 years). The mechanism of injury was a motor vehicle accident in eight and a fall from a height in three. According to the classification of Sanders et al eight fractures were Type II, one was Type III, and two were Type IV. Followup at an average of 26 months (range, 14-38 months) showed that eight of 11 patients (72.7%) had either good or excellent results. When lateral subluxation of the posterior facet of the calcaneus is identified with a preoperative computed tomography scan, operative management is indicated, and the surgeon should search for associated injuries that should be addressed at the time of surgery.

Operative Treatiment with Open Reduction and Heterogenous bone graft to the Acute Displaced Intra-articular Calcaneus Fractures

Operative Treatiment with Open Reduction and Heterogenous bone graft to the Acute Displaced Intra-articular Calcaneus Fractures

The "low contact plate" for stabilizing the dislocated intra-articular calcaneus fractures

Open reduction and internal fixation of intraarticular calcaneus fractures have been increasingly emphasized in recent years. Operation of most of these fractures is via an extended lateral approach. Different implants are used to stabilize the often complex fractures. We have developed a low contact plate that is specially designed for calcaneal fractures. Because the design is based on the anatomy of the calcaneus, all types of fractures can be treated. The plate has a large number of holes to accommodate screw fixation. Our results in 36 cases were comparable to those of other series using open reduction and internal fixation with plates and the demands on the plate were fulfilled.

Operative vs. Nonoperative Treatment of Intra-Articular Fractures of the Calcaneus: A Prospective Randomized Trial

Thirty patients with displaced, intra-articular calcaneus fractures were randomized to operative or nonoperative treatment. All patients had two or three major articular fragments of the posterior facet (Sanders type II or III). Nonoperative treatment included early mobilization and delayed weightbearing. Operative treatment involved open reduction and rigid internal fixation with a plate and screws through an extensile, L-shaped lateral approach followed by early mobilization and delayed weightbearing. Fifteen operative patients were evaluated at an average of 17 months follow-up and 11 nonoperative patients were seen at 14 months average follow-up. In the operative group, there were 7 excellent results, 5 good results, 2 fair results, and 1 poor result, and in the nonoperative group there was 1 excellent result, 3 good results, 1 fair result, and 6 poor results (difference significant as P < 0.01). A functional scoring system of 0-100 points was developed based upon the responses to an outcome assessment questionnaire. The average functional score for the operative group was far superior at 86.7, compared with 55.0 for the nonoperative group (P < 0.0001). Subtalar range of motion averaged 20 degrees for the operative group and 17 degrees for the nonoperative group with pain on extremes of motion of 25% of the operative patients compared with 100% of the nonoperative patients. This study is the first prospective, randomized trial to demonstrate the superior results of current operative treatment with early mobilization compared with nonoperative treatment.

Open reduction and internal fixation of the calcaneus using minifragment plates.

During a 4-year period, 35 nonconsecutive intraarticular fractures of the calcaneus were fixed with 2.7-mm minifragment plates and 3.5-mm small fragment screws through an extended lateral approach. There were 25 type II and 10 type III fractures by the classification system of Sanders. The reduction of the facet was anatomic in 91%. The reduction of the tuberosity was acceptable (< or = 5 degrees of angulation) in all cases. Early motion was begun in the ankle, subtalar, and midfoot joints in all cases. Two patients had minor edge necrosis amenable to local treatment. There were no deep infections. Using the Maryland foot score, there were 77% good or excellent results. The small size of the minifragment plates allows for their application to a wide variety of fracture patterns. They are also low profile and are therefore easy to cover. Multiple plates were used in many cases without steric interference. They provided rigid enough fixation to allow aggressive early motion exercises without loss of reduction or hardware failure in any case. Minifragment plates with small fragment screws are effective for the fixation of intraarticular calcaneus fractures through an extended lateral approach.

Intra-Articular Fractures of Calcaneus: Treatment with Canulated Screws

Intra-Articular Fractures of Calcaneus: Treatment with Canulated Screws

Surgical Treatment of the Intra-Articular Calcaneus Fracture

The acute displaced intra-articular calcaneus fracture should be approached on a rational basis. Minimally displaced fractures are best treated with early motion and delayed bearing of weight. Reconstructible, displaced fractures are probably best treated with exact open reduction and internal fixation, assuming contraindications such as poor skin condition or underlying disease are not present. The severely displaced, Sanders-type IV fractures remain a dilemma, and these may demonstrate a role for primary fusion in select instances. If one chooses to treat a calcaneus fracture surgically, it should be recognized that the result will be related to the exactness of the reduction. This surgery is very challenging, with an arduous learning curve. Importantly, if one cannot obtain an anatomic reduction, the patient may have been better off treated nonoperatively.

CT-Klassifikation intraartikulärer Kalkaneusfrakturen

93 patients with 102 intraarticular calcaneus fractures (ICF) were examined by CT from 1986 to 1992. The images were evaluated with the use of a modified classification based on the number of fractured heel bone facets (2 facets in 4.8%, 3 facets in 53.9%, 4 facets in 32.3%, comminution in 8.8% of the fractures), the involvement of the calcaneus-cuboid joint (60.8%) and the fracture mechanism (tongue-type in 28.4%, joint depression in 62.7%) with the weight-bearing calcaneal compartments taken into special consideration. In that way, each intraarticular calcaneus fracture could be scored, enabling a fast diagnosis comprising factors relevant for the therapy and prognosis.

観血的整復と骨移植を行ったしょう骨骨折の成績

観血的整復と骨移植を行ったしょう骨骨折の成績

Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system.

Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system.