Intra-articular Calcaneal Fractures Research Articles

A novel minimally invasive percutaneous treatment for Essex-Lopresti joint depression-type DIACFs by ligamentotaxis

ObjectiveTo compare the clinical efficacy of minimally invasive percutaneous treatment by ligamentotaxis with traditional open reduction and internal fixation in the treatment of Essex-Lopresti joint depression-type displaced intra-articular calcaneal fractures (DIACFs).MethodsThe medical records of patients with calcaneal fractures admitted to our department from January 2016 to December 2020 were retrospectively analyzed, and patients who met the inclusion criteria were finally included for analysis. Twenty-one patients underwent minimally invasive percutaneous treatment by ligamentotaxis (Group A), while eighteen patients were treated by traditional open reduction and internal fixation through an extended lateral approach (Group B). The preoperative waiting time, operative time, hospital stay, radiologic parameters (calcaneal height, width, length, Böhler angle and Gissane angle), American Foot and Ankle Surgery Association (AOFAS) hindfoot scores, Maryland Foot Score (MFS), visual analogue scale (VAS), and incidence of complications of the included patients were all recorded and analysed.ResultsThirty-nine patients with Essex-Lopresti joint depression type DIACFs were finally included. According to the Sanders classification, 22 were type II, 12 were type III and 5 were type IV. The preoperative waiting time and the hospital stay of Group A were 3.7 ± 1.6 d and 7.2 ± 1.7 d, respectively, which were significantly shorter than those of Group B (6.9 ± 2.0 d and 12.4 ± 1.5 d) (P < 0.05). There was no significant difference in the operative time between the two groups (88.8 ± 9.8 min vs. 91.3 ± 12.1 min; P > 0.05). No significant differences were shown in the radiological parameters (calcaneal height, width, length, Böhler angle and Gissane angle) or the satisfactory rate of joint surface reduction (SRJSR) of the two groups immediately postoperatively. All patients were followed up for 14 to 56 months [(30.2 ± 10.4) months]. All fractures healed. At the final follow-up, there were no significant differences in the radiological parameters or the SRJSR between the two groups (P > 0.05). No significant differences were shown in the AOFAS scores, MFS or VAS scores between the two groups [(89.5 ± 8.2) vs. (89.4 ± 9.0), P > 0.05; (87.5 ± 8.3) vs. (86.3 ± 8.9), P > 0.05; and (2.1 ± 1.2) vs. (2.2 ± 1.2), P > 0.05]. The excellent and good rates of the AOFAS scores and MFS were 90.5% and 85.7%, respectively, in Group A and 88.9% and 88.9%, respectively, in Group B (P > 0.05). Four patients experienced wound complications, including 1 superficial incision infection, 2 skin necrosis around the incision edge and 1 deep infection in Group B, while there were no wound complications in Group A (P < 0.05). One patient in each group suffered traumatic arthritis (P > 0.05).ConclusionsIn the assessment of Essex-Lopresti joint depression type DIACFs, minimally invasive percutaneous treatment by ligamentotaxis has similar clinical outcomes to traditional open reduction and internal fixation through an extended lateral approach. However, the former has the advantages of shorter preoperative waiting time and hospital stay, and lower incidence of incision complications.

Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures

BackgroundThis study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA). MethodsWe retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors. ResultsThe overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23–10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62–20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28–36.79) were demonstrated as risk factors for nonunion of posttraumatic SA. ConclusionPatients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.

Two and three-dimensional CT mapping of the sustentacular fragment in intra-articular calcaneal fractures

The sustentaculum tali are tightly bound to the talus by the interosseous and deltoid ligament complex and have been considered a ‘‘constant fragment”. Yet there is a dearth of study on the anatomical patterns of the sustentacular segment. Consequently, this study is designated with the purpose of defining the prevalence and displacement of sustentacular fractures in intra-articular calcaneal fractures (ICFs) applying computed tomography (CT) mapping in both two-dimensional (2D) and three-dimensional (3D) conditions. From January 2019 to December 2020, the CT images of sixty-seven patients with eighty-one ICFs were retrospectively evaluated, besides, basic patient demographics and mechanisms of injury were documented. And the prevalence of sustentacular fractures was characterized in the sagittal or coronal CT planes. The subluxation, angulation, and translation of the portion of the sustentacular bone were noted. By decreasing rebuilt fracture fragments to suit a model of the sustentaculum tali, a 3D map was generated. Overall, the sustentacular fracture in 21 (25.9%) of the 81 ICFs, 15 (71.4%) were nondisplaced, 6 (28.6%) were displaced, and mean coronal angulation was 21.9°, and no comminuted. The relationship between sustentaculum tali and the talus was anatomically aligned in 71 (87.7%), and subluxation in 10 (12.3%). According to the research, 3D mapping demonstrated that most fracture lines start from the anterior of the sustentaculum tali, extending obliquely to the sulcus of the flexor halluces longus tendon. Moreover, this study provides a detailed description (displacement or articular dislocation) of the frequency of sustentacular fragments in ICFs. The finding disproves the ‘‘constant’’ theory of the sustentacular fragments, due to the fact that comminuted fracture of sustentaculum tali was rare. And the expertise of these fracture patterns may affect the progress of fixation concepts and surgical approaches. Moreover, we further speculated that the displacement of the sustentacular fragment was considerably more probable to emerge in the higher-order Sanders classification. Nevertheless, bigger sample size is required to further validate this position.

Comparison of screw versus locking plate fixation via sinus tarsi approach for displaced intra-articular calcaneal fractures

BackgroundThe optimal treatment of displaced intra-articular calcaneal fractures (DIACF) is controversial. This study compared the fixation stability of screws and locking plates in DIACF treated via the sinus tarsi approach (STA). MethodsWe retrospectively evaluated 118 DIACF cases treated via STA and extracted data that could affect treatment outcomes. Loss of Böhler’s angle after surgery was measured to compare fixation stability. ResultsThe loss of Böhler’s angles was significantly smaller in the locking plate group than in the screw group (2.6 ± 2.7º vs. 5.6 ± 5.3º, P < 0.01). There was no difference in the clinical outcomes between the groups. On multivariate logistic regression analysis, screw fixation was significantly associated with loss of Böhler’s angle by> 10º (odds ratio, 8.63; 95% confidence interval, 1.16–64.4; P < 0.05). ConclusionsLocking plate fixation is more reliable than screw fixation for preventing correction loss in DIACF treated via STA. Level of evidenceIII

Fracture mapping of intra-articular calcaneal fractures.

Calcaneal fractures have complex morphology, which brings great challenges to clinical treatment. The primary fracture lines could help us simplify the fracture. Fracture mapping technology can help surgeons understand the fracture morphology more intuitively. This study aims to develop a further understanding of calcaneal fractures by delineating the primary fracture lines through the fracture mapping technology. Ninety cases of intra-articular calcaneal fractures were reviewed between March 2016 and January 2019 at a level 1 trauma centre. The CT data of these cases were reconstructed and reduced using software. We superimposed the primary fracture lines on a standard model and created the distribution and heat map of the intra-articular calcaneal fractures. SPSS 18.0 was used to count the differences between the different groups. The primary fracture lines concentrated at the Gissane angle and the posterior articular surface, which could be summarized in two ring structures. There were 43 cases of fracture involving calcaneocuboid joint, including 32 cases of joint-depression fracture and 11 cases of tongue-type fracture. The area ratio of lateral fragment of simple tongue-type fracture is larger than joint-depression fracture. The primary fracture lines of calcaneus were distributed in two rings on the surface of calcaneus. Based on the distribution of primary fracture rings, we integrated the classification of calcaneal fracture and proposed some treatment recommendations.

C-Nail® locking nail versus conventional plate for thalamic calcaneal fractures

BackgroundSurgery for displaced intra-articular calcaneal fractures (DIACFs) is often followed by skin complications that adversely impacts the functional outcomes. Minimally invasive techniques have been developed to decrease the risk of skin complications. The objective of this study was to compare C-Nail® locking-nail fixation to conventional plate fixation for DIACFs. HypothesisC-Nail® fixation restores calcaneal anatomy similarly to conventional plate fixation and decreases the frequency of skin complications compared to conventional plate fixation, while providing satisfactory functional outcomes. Material and methodsIn this case-control study of DIACFs, fixation was with a non-locking plate in 30 patients treated between January 2016 and June 2017 and with the C-Nail® in 25 patients treated between April 2017 and April 2018. Computed tomography was performed before surgery then bilaterally after surgery for measurements of the following calcaneal parameters: height, length, width, joint-surface step-off and inter-fragmentary distance. The values of these parameters were compared between the two groups. Postoperative skin complications were recorded. The functional outcome was assessed by determining the AOFAS score 1 year after the injury. ResultsThe two groups showed no significant differences for age, sex or fracture type. Wound healing was delayed in 3 patients in the plate group. The mean postoperative values of the calcaneal parameters were not significantly different between the two groups. The mean AOFAS score was 85.3±10.4 (range, 50–100) in the plate group and 87.0±12.0 (range, 64–100) in the C-Nail® group (p>0.05). DiscussionMinimally invasive C-Nail® fixation provides similar restoration of calcaneal anatomy as does conventional plate fixation. Level of evidenceIII, retrospective case-control study.

Effectiveness comparison of two surgical methods in treatment of intra-articular displaced calcaneal fractures in older children

To compare the effectiveness of open reduction and internal fixation with plate and closed reduction and internal fixation with Kirschner wire (K-wire) in the treatment of intra-articular displaced calcaneal fractures in older children. A clinical data of 35 older children (37 feet) with intra-articular displaced calcaneal fractures who were admitted between November 2014 and November 2020 and met the selection criteria were retrospectively analyzed. Among them, 19 cases (20 feet) underwent open reduction and internal fixation with plate (plate group), and 16 cases (17 feet) underwent closed reduction and internal fixation with K-wire (K-wire group). There was no significant difference in gender, age, cause of injury, side and type of fracture, and time from injury to admission, and preoperative calcaneal Gissane angle and Böhler angle ( P>0.05). The postoperative calcaneal Gissane angle, Böhler angle, complications, and fracture healing were compared between the two groups. The ankle function was evaluated based on the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system. Incision necrosis occurred in 1 foot in the plate group after operation, which healed after symptomatic treatment; the other incisions in the two groups healed by first intention. All children were followed up 12-39 months (mean, 19 months). X-ray films showed that the fractures in both groups healed; the healing time was (2.65±0.71) months in the plate group and (2.24±1.38) months in the K-wire group respectively, with no significant difference ( t=1.161, P=0.253). At last follow-up, the calcaneal Gissane angle and Böhler angle returned to normal; and the difference between pre- and post-operation in the two group was significant (P<0.05), but there was no significant difference between the two groups in the difference between before and after operation ( P>0.05). In the plate group, the plate was removed at 11-22 months after operation (mean, 16.8 months). At last follow-up, the AOFAS ankle-hindfoot score in the plate group was 91.2±5.1, which was significantly higher than that in the K-wire group (86.9±6.1) ( t=2.316, P=0.027). The ankle function was rated as excellent in 15 feet, good in 4 feet, and fair in 1 foot in the plate group, and excellent in 14 feet and good in 3 feet in the K-wire group, and the difference between the two groups was not significant ( Z=1.712, P=0.092). For intra-articular displaced calcaneal fracture in older children, the open reduction and internal fixation with plate and closed reduction and internal fixation with K-wire can achieve good effectiveness, but the former has better recovery of ankle function.

Factors Related to the Inconstancy of Sustentaculum Tali Fragments in Intra-Articular Calcaneus Fractures

Category: Trauma Introduction/Purpose: Since intra-articular fractures are common in calcaneus fractures, anatomical reduction is important. Several ligaments such as spring ligament and deltoid ligament are attached to the Sustentaculum tali (ST). It is known that ST fragment is constant in calcaneus fracture. However, few studies have been reported to prove this. Therefore, we studied to establish criteria for the inconstancy of ST fragments through the analysis of computed tomography (CT) of the unaffected calcaneus, to confirm the prevalence of ST fragment inconstancy by applying these criteria, and to analyze the factors related to the inconstancy of the ST fragment. Methods: From 2012 to 2020, CT scans of calcaneus fractures of 122 patients (101 men and 21 women) were taken, and angulation and diastasis of ST fragment were measured in the semi-coronal plane. As a control, angulation and diastasis were measured in 62 unaffected calcaneus. After establishing criteria for the inconstancy of ST fragments, we evaluated the prevalence of ST fragment inconstancy. After, we analyzed related factors. Patient factors included age, BMI, smoking, and diabetes. Radiographic factors included the degree of comminution of the posterior facet, location of the outermost fracture line of the posterior facet, presence of an intra-articular fracture of the ST, and width of the ST fragment. Results: The upper limit of the 95% CI of angulation and diastasis was 7.58° and 2.51 mm, respectively. Based on these criteria, the inconstancy of the ST fragment was observed in 34.5%. The width of the ST fragment was significantly smaller in the inconstant group. Severe comminution of the posterior facet, intra-articular fracture of the ST, and diabetes were significantly higher in the inconstant group. The inconstancy of the ST fragment was significantly associated with the width of the ST fragment (p &lt; 0.001) (Table 1). Cut-off values for the inconstancy of the ST fragment were 20.5 mm for the width of the ST fragment. Conclusion: In intra-articular calcaneal fractures, ST fragment inconstancy was observed in 34.5%. The width of the ST fragment was significantly associated with the inconstancy of the ST fragment.

Minimally Invasive Intra-Calcaneal Fractures vs Conservative Treatment: A Propensity Score Matched Cohort Series

Category: Trauma; Hindfoot Introduction/Purpose: We prospectively assessed the impact of minimally invasive internal fixation of displaced intra-articular calcaneal fractures (DIACF) results in better health outcomes up to 2 years post- injury than non-operative management. Methods: All isolated calcaneal fractures were reviewed and the decision to treat was made by a multidisciplinary meeting. Operative-treatment protocol involved sinus-tarsi approach or per-cutaneous reduction &amp; internal fixation under the care of a fellowship-trained-foot and ankle surgeon. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ5D-L scores were used to assess general and disease-specific outcomes respectively. Secondary outcome measures included return to work and return to leisure activity levels. Statistical analysis was performed to assess normality of data (Shapiro Wilk test/Q-Q plots). Propensity matching was conducted using nearest neighbour matching, followed by regression analysis and modelling to compare baseline covariates between the two different groups. Results: Between 2015-2019 total of 93 patients met the inclusion criteria. After propensity score matching 44 patients were found in the surgical/ treatment group. The mean age was 40 (vs. 43.3) in the surgical group, no significant difference in age, sex, peripheral vascular disease, smoking status, laterality, and baseline Bohlers and Guisane angle in the propensity score matched sample. The surgically treated group had a higher Sanders class(p&lt;0.05), higher MOXFQ at 12 months (p&lt;0.05) and EQ-5DL scores at 24 months(p&lt;0.05) and were more likely to return to work at 12m (95% vs 77%)(p&lt;0.05), and physical activity levels at 12m (57% vs 36%)(p=0.054). The wound complication rate was 14.8%, no patients required further surgery; whilst non-operative- treatment mandated surgery for arthritis (6), and or/an injection (7 vs.3). Conclusion: Both non-operative and operative treatments are valid in DIACF. MIS-surgery offers better functional outcomes for severer injury patterns, and a less-likely need for arthritis intervention at 2yrs.

Calcaneus Fracture Fixation: Assessing the Adequacy of the Sinus Tarsi Surgical Fixation Technique

Category: Trauma; Hindfoot Introduction/Purpose: Intra-articular calcaneus fractures are devastating injuries, and life-changing for patients that develop post-traumatic arthritis, a common outcome. Debate exists as to whether non-operative symptomatic management, or operative treatment, best manages these injuries, partially due to the difficulty of achieving anatomic subtalar joint reduction. Traditionally, a large, lateral extensile incision has been used, plagued with soft tissue complications quoted at rates upwards of 22%. A less invasive incision, the limited sinus tarsi approach (ST-a), has become more common, proposed to lower complication rates without compromising radiographic nor clinical outcomes. The primary purpose of this study was to objectively assess the adequacy of joint reduction along with the associated soft tissue complications using the ST-a and compare it to the standards of the lateral extensile incision. Methods: All calcaneus fractures fixated through the ST-a at our institution were reviewed between March 2017 and Jan 2020. Inclusion criteria included the presence of preoperative and post-operative X-rays and CT scans. Primary outcomes were radiographic measures, including Bohler's angle on X-ray, and the maximum summative step deformity at the posterior facet of the subtalar joint in all three planes on CT scan. Secondary clinical outcomes included soft tissue complications (infection, delayed wound healing) and the need for reoperation. Results: Thirty patients were included with an average age of 48.9 +- 13.9 (n=24 males, n=6 females) and Sanders classification of 2.8. Pre-operatively, the mean Bohler's angle and summative posterior facet step deformity were 5.8 +- 16.6° and 17.2 +- 9.3mm, respectively. These radiographic outcomes were significantly improved postoperatively to 27.2 +- 7.7° and 5.3 +- 2.9mm. Soft tissue complication rates were half that of the comparative extensile approach. Conclusion: Using the ST-a, radiographic joint reduction was acceptable compared to literature standards. There was subsequently a lower incidence of soft tissue complications than previously quoted for the lateral extensile approach. Although technically more demanding, the ST-a is a valuable method for the treatment of intra-articular calcaneal fractures and should be considered when planning operative management of intra-articular calcaneus fractures.

Medial Structures at Risk During Sinus Tarsi Approach for Fixation of Sustentaculum Tali Fractures: A Cadaveric Study

Category: Hindfoot; Trauma; Other Introduction/Purpose: Calcaneal fractures are a common injury with potential for concomitant involvement of the sustentaculum tali. Common surgical repair involves a sinus tarsi approach with placement of a lag screw from lateral to medial. There is no current study that focuses on the potential damage to the medial structures after screw placement. The goal of this paper was to describe the incidence in which medial structures were damaged using a sinus tarsi approach for lateral to medial screw fixation of the sustentaculum tali. Methods: Seven fresh-frozen below-the-knee cadaver specimens were used for the present anatomic dissection study. Prior to investigations, specimens were inspected with fluoroscopic radiographs for any pathology or prior operational intervention Each specimen underwent screw placement using the sinus tarsi approach. Medial dissection of the calcaneus was performed after screw placement to determine the proximity of the anatomical structures of interest to the inserted hardware. The four anatomical structures of interest were the tibialis posterior tendon, flexor hallucis longus, flexor digitorum longus, and posterior neurovascular bundle. Distance from the 4.0 mm screw to the previously mentioned anatomic structures was measured with a scientific ruler and recorded to the nearest millimeter. The mean, standard deviation, and range for distances were calculated for all structures. Analysis of variance (ANOVA) was used to determine statistical significance. Results: The average patient age, height, and weight were 79.3 years, 5 feet 4 inches, and 127 lbs respectively. The primary outcome of interest was the longitudinal distance between the medial aspect of the screw to the anatomical structures of interest. On average, the posterior neurovascular bundle had the closest proximity to the medial aspect of the screw for all seven specimens with a mean distance of 6.4 mm. The second closest structure was the FHL with a mean distance of 7 mm, followed by the FDL and tibialis posterior tendon, with mean distances of 9.9 mm and 13.9 mm respectively. The posterior neurovascular bundle was hit by the screw on one occasion, whereas the hardware contacted the FDL on two separate occasions. The screw was placed through the FDL in one of the two occasions; however, the FDL was not transected or ruptured. Conclusion: This study sheds more light on the potential risks to medial structures when placing the sustentacular screw during open reduction and internal fixation of displaced intraarticular calcaneal fractures. We urge the orthopedic surgeon to exercise extreme caution when performing this critical step of the procedure to minimize avoidable injury to structures of importance that may increase the morbidity of the patient.

Sinus tarsi approach in high-risk patients with displaced intra-articular calcaneus fractures: A case series

PurposeThough research exists regarding calcaneal fractures, the treatment approach for displaced intra-articular calcaneal fractures (DIACF) remains controversial. The most common approach, the extensile lateral approach (ELA), for the treatment of DIACFs has high rates of wound complications reported. In contrast, the sinus tarsi approach (STA) is becoming more popular due to its minimally invasive technique. The objective of this retrospective study is to investigate the incidence of wound complications in high-risk patients with DIACF following operative fixation via the STA. MethodsFollowing IRB approval, a retrospective chart review was performed between 2007 and 2013 to assess high-risk patients for the presence of wound complications, including deep infections and delayed wound healing, following the use of STA for the management of DIACF's (n = 36). Demographics, risk factors, and secondary outcomes such as time to surgery were recorded. ResultsOf the 36 high-risk patients included in our study, seven had post-operative complications following operative fixation via the STA. Specifically, four patients had delayed wound healing, and three developed deep infections. Time to surgery had the greatest negative effect on postoperative complications and was influenced by age, sex, and the presence of a concomitant injury. ConclusionIn conclusion, this study demonstrates that the STA is a viable option for high-risk patients with displaced intra-articular fractures. Additionally, time to surgery should be minimized, when possible, to reduce risks of post-operative complications, including infections and delayed wound healing.

Primary subtalar arthrodesis in the treatment of comminuted calcaneal fractures: a functional and quality of life analysis

Objective: To survey literature findings on primary arthrodesis in Sanders type III and IV fractures and analyze functional and quality of life outcomes in patients submitted to this initial surgical procedure. Methods: This study described the profile of 12 patients diagnosed with severe comminuted intra-articular calcaneal fractures of Sanders type III and IV operated by a foot and ankle team. Patients attended from January 2016 to August 2021 with pre-/postoperative follow-up and application of the Orthopedic Foot and Ankle Score (AOFAS) questionnaire and Short Form Health Survey 36 (SF-36) quality of life questionnaire, along with clinical evaluation, were included. Data search was performed using the following online databases: PUBMED, MEDLINE, LILACS, and SCIENCE. Results: Most patients had a good range of motion, a mean AOFAS score of 81.71 points, and high mean scores in the domains physical functioning (84.44 points), role-physical (5.55 points), bodily pain (23 points), and general health (96.11 points) according to the SF-36 questionnaire. In general, there was bone consolidation after primary arthrodesis of the subtalar joint, and the functional status of patients was satisfactory. Conclusion: Primary arthrodesis is a relevant choice in fractures with more than three fragments, with a better postoperative outcome, including pain and maintenance of the hindfoot axis. Larger studies should be performed to assess more results of primary arthrodesis as a first treatment option for Sanders type III and IV fractures. Level of Evidence IV; Therapeutic Study; Case Series.

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

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

A prospective comparative study between percutaneous cannulated screws and Kirschner wires in treatment of displaced intra-articular calcaneal fractures

PurposeSeveral minimally invasive procedures were used to treat displaced intra-articular calcaneal fractures (DIACFs). No agreement among different authors about either the ideal fixation method or which technique is minimally invasive. The aim of this study was to compare functional and radiographic outcomes of two minimally invasive techniques in treatment of Sanders type II and III DIACFs by using K-wires or cannulated screws without bone grafts.MethodsA prospective randomized controlled study was conducted on 28 patients (34 feet) with Sanders type II or III DIACFs, treated by closed reduction and fixation using cannulated screws or K-wires, at the Orthopedics Department of Sohag University Hospital, between April 2020 and February 2022. Functional assessment was done by American Orthopedic Foot and Ankle Society (AOFAS) score and VAS for pain. Radiographic assessment was done by measurement of three calcaneal angles (Gissane, Böhler’s, and posterior facet inclination angles) and three calcaneal distances (height, length, and width of the calcaneus).ResultsMean ages of patients at the time of operation were 34.8 years for the cannulated screw group and 36.6 years for the K-wire group. A vast majority of patients were males (78.6%). Involvement of the right side in the cannulated screw group was 57.1% and that in the K-wire group was 47.9%. Mean operative time was significantly shorter among the K-wire group (42 min) compared to the cannulated screw group (57 min). Mean AOFAS score was higher among the cannulated screw group (85.9 points) compared to the K-wire group (75.8 points). Final VAS was significantly better among the cannulated screw group compared to the K-wire group. Mean time of radiographic union in the cannulated screw group was 8.9 weeks and that in the K-wire group was 10.1 weeks.ConclusionBoth techniques avoided wound complications associated with ORIF with the advantage of a shorter hospital stay. Patients in the cannulated screw group had better functional and radiographic outcomes and a lower rate of subtalar arthritis than patients in the K-wire group. K-wires had advantages of reduced operative time, and easy removal as an outpatient procedure.

Autologous Micro Fragmented Adipose Cells Therapy for Subtalar Joint Osteoarthritis – Case Report and Review of Literature

Introduction: Post-traumatic subtalar joint arthritis is uncommon and the majority results as a consequence of either an intra-articular calcaneal or talar fracture. A unique case of management of subtalar joint arthritis is described using autologous microfragmented adipose cells therapy. Case Report: We presented a 48-year-old male with symptomatic left subtalar joint arthritis, which was managed conservatively with analgesia and multiple steroid injections. During surgery, fat cells were aspirated from the abdomen and transferred to the Lipogems kit for mechanical breakdown of adipose tissue for around 20 minutes. Final 10ml of the product was injected into the subtalar joint. Patient was followed up at regular intervals and Visual analogue score (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ) and Foot and Ankle Ability Measure scores (FAM-ADL) were collected. Results: No perioperative complications were noted relating to abdominal liposuction and intra-articular injection of lipoaspirate and during the follow-up period. Improvement in VAS, MOX FQ and FAM-ADL scores was noted up to 6 months of follow-up. Discussion: The subtalar joint plays a central role in load transmission and movement at the hindfoot and its malalignment and arthritis lead to impaired function and pain. Intra articular injections of fat cells and their regenerative potential in degenerative joint diseases have been well documented in literature. Lipogem technique has been used in knee, hip and ankle arthritis, but it is not documented to use in the subtalar joint. Conclusion: This unique case report demonstrated the successful use of a single-dose autologous micro fragmented fat cells therapy leading to functional improvement in subtalar joint arthritis with no complications.

A Prospective Cohort Study of Closed Foot Injuries in a Tertiary Hospital in Ghana

Objective: Our objectives were to determine the proportion of closed foot injuries and their treatment outcomes at a large trauma hospital in Accra, Ghana.Methods: A structured questionnaire was used to record, for each patient, the type of closed foot injury, the mechanism of injury, any concomitant injuries, the time interval between injury and arrival at the KBTH for treatment as well as the type of treatment instituted.Enrolled patients were followed up for six months, complications resulting from the foot injury or its treatment were recorded for each patient. The function of the foot after healing of the injury was measured using the American Foot and Ankle Society Score.Results: A total of 46 patients presented with closed foot injuries, males accounted for 58.7% and females 41.3%. Road traffic trauma was by far the most predominant cause of injury accounting for 63% of cases. Soft tissue contusions involving the foot had excellent outcomes after treatment; displaced metatarsal shaft fractures treated with open reduction and internal fixation with Kwires had a good outcome; displaced metatarsal shaft fractures treated with cast immobilization had unfavorable outcomes. Non-operative treatment of Lanfranc fracture-dislocation with cast immobilization resulted in severe limitation of climbing stairs, shoe wear, walking on uneven surfaces and inability to return to previous occupation.Conclusions: Displaced intra-articular calcaneal fractures cause significant persistent foot pain after treatment and Lisfranc fracture- islocations have unfavorable outcomes if treated conservatively with cast immobilization alone. Fractures of the foot cause a longterm morbidity with residual foot pain, limitation of foot wear, climbing stairs, walking on uneven surfaces and difficulty integrating into previous occupation. The resulting foot dysfunction is worse if the fracture is not appropriately stabilized.

Calcaneus Fracture and Posterior Arthroscopic Primary Subtalar Arthrodesis (C-PASTA).

The procedure begins with the patient in the prone position. The subtalar joint is visualized with a 1.9-mm flexible camera through a standard posterior arthroscopic approach. With the help of the C-arm, position in the subtalar joint space is confirmed. The joint space is debrided with use of a 4-0 shaver and then prepared for arthrodesis arthroscopically with use of an osteotome and a burr. Next, we inject allograft demineralized matrix-based bone putty under direct arthroscopic visualization to fill residual gaps or defects. The arthrodesis is performed under fluoroscopic guidance with use of 2 guidewires followed by 2 to 3 titanium compression screws. The first screw is inserted along the posteromedial calcaneus and into the talar dome medially. The second is placed laterally into the head-neck junction of the talus. The third screw is placed distal to proximal from the plantar anterior process to the talar head. Finally, images are obtained in multiple views to ensure proper screw placement, and the screws are tightened sequentially to ensure equal compression across the joint. Nonoperative treatment of calcaneal fractures includes cast immobilization with non-weight-bearing, although this treatment is typically reserved for nondisplaced, small extra-articular fractures6. Operative treatment of calcaneal fractures includes open reduction and internal fixation, which is traditionally performed via a sinus tarsi approach or extensile lateral approach. Primary subtalar arthrodesis has been utilized primarily for Sanders type-IV fractures6. Displaced intra-articular calcaneal fractures are associated with alarmingly high rates of posttraumatic arthritis (30% to 70% within 1 year of injury), and surgical outcomes are inversely proportional to the severity of the fracture pattern, with Sanders III and IV having the worst outcomes1. Treating these most severe fracture patterns with primary open subtalar arthrodesis has shown favorable results in terms of union rates, pain scores, and functional outcomes throughout the literature2,3. However, some authors have reported rates of revision as high as 60%4. Thus, the PASTA procedure has been established, resulting in significantly better time to union, return to work, activities of daily living, and sports activities compared with open techniques5. Thus, given the favorable results of primary open subtalar arthrodesis and the proven results with use of an arthroscopic technique in the non-acute setting, we propose that C-PASTA can serve as an alternative treatment option in the acute setting for patients with Sanders type-III and IV calcaneal fractures. We expect the outcomes of this procedure to mirror those found throughout the literature, which shows favorable results for open primary subtalar arthrodesis1-3. With use of an arthroscopic approach, we expect better time to union, return to work, activities of daily living, and sports activities than if the procedure were performed in an open fashion5. In addition, minimizing soft-tissue damage through an arthroscopic approach may decrease the risk of infection and stimulate postoperative healing, perhaps accounting for the more favorable postoperative recovery period compared with an open procedure. In the arthroscopic approach to the subtalar joint, identify the flexor hallucis longus, making sure to stay lateral to that tendon to remain in the "safe zone."Utilizing the TRIMANO device (Arthrex) to distract the ankle longitudinally in addition to a solid bump placed on the anterior aspect of the ankle allows for optimal subtalar joint visualization.Fish-scaling with an osteotome followed by bone grafting allows for a good fill between cancellous fragments to stimulate an optimal environment for fusion.Divergent screws should be placed and tightened sequentially to ensure equal compression across the joint. ADL's = activities of daily livingCT = computed tomographySCD = sequential compression deviceAP = anteroposteriorDVT = deep vein thrombosisBID = twice dailyVit = vitamin.

Functional outcome assessment of intra-articular calcaneal fractures, operative vs conservative

The man who has actually ‘fallen on feet’ is perhaps less fortunate than the idiom would suggest as he may have sustained fractures of spine, pelvis, and most importantly, Calcaneum. Despite the surgeon’s extensive experience with this injury, it’s a major socio-economic impact with regard to the time lost from work and recreation, and despite the attention given to it for many years throughout the world, whether to operate or conserve the intra articular fracture remains a dilemma. To compare the functional outcomes of intra-articular calcaneal fractures, treated with operative management by open reduction and internal fixation with plating and conservative management with cast application. The objectives were determined by the following parameters a) functional scoring system which includes: pain on activity, pain at rest, Range of Inversion/Eversion, Activity Return to Work Change in shoe size, Swelling. b) Radiographic assessment in form of X-rays and CT scan Bohler’s Angle, Heel varus deformity. Aims & Objectives: To evaluate the functional outcomes of intra-articular calcaneal fractures, treated with operative management by open reduction and internal fixation with plating and conservative management with cast application. Materials and Methods: It was a prospective, randomized, evaluative study. Patients in age group of 20-60 years were randomly divided into two groups of 20 each Group A – Operative group, Group B – Conservative group. Open fractures & Patients presenting after 2 weeks of injury were excluded from the study. Results: The functional outcome of operative group (mean 83.9) was slightly better than the conservative group (mean 78.22). But this was not statistically significant. A large previous trial showed similar results. Approximately 73% (22) patients from both groups had good to excellent results. Conclusion: Displaced and comminuted fractures managed surgically have a relatively better functional outcome as compared to conservative. Functional outcomes of operative group weren’t significantly better than those of conservative group.

Management of calcaneus fractures by a new "Below-the-ankle" ilizarov frame: A series of 10 cases.

The optimal management of intra-articular calcaneal fractures is still controversial. Open reduction and internal fixation are always associated with serious complications. Various alternative methods have been used with variable effects. This retrospective study aimed to analyze the clinical efficacy and safety of a new "below-the-ankle" Ilizarov frame in patients with calcaneal fractures caused by high-energy trauma. We retrospectively explored ten patients with calcaneal fractures, of which four, five, and one were Sanders type II, III, and IV, respectively. All fractures were caused by high-energy trauma and were followed up for an average period of 21 months (range: 9-29 months). Clinical outcomes were primarily assessed by radiological criteria, functional scores of the foot and ankle, rate of complications, and ankle range of movement. The Ilizarov frame was removed after an average period of 12 weeks (range: 11-15 weeks). Only two patients developed pin-tract infections, and none developed osteomyelitis, deep infections, neurovascular injury, malunion, and ankle arthrodesis. Based on the radiological assessment of the reduction of the subtalar joint and fracture fragments, all patients had excellent restored joint structure, with eight and two patients having good-to-excellent and fair ankle scores, respectively. The ranges of plantarflexion and dorsiflexion were 25°-43° and 8°-22°, respectively. The Ilizarov frame could be safe and effective for calcaneal fractures caused by high-energy trauma. This treatment protocol provides an effective approach to treat severe calcaneal fractures caused by high-energy events; however, long-term outcomes are still unknown.