Management Of Intra-articular Calcaneal Fractures Research Articles

A functional outcome of intra articular calcaneum fracture managed surgically with plate fixation: A prospective study

Intraarticular fractures account for approximately 75% of calcaneal fractures and historically have been associated with poor functional outcomes. The management of intraarticular calcaneal fractures remains a controversy, with strong arguments supporting both conservative & operative managements. Significant controversy remains over the results of nonoperative versus operative treatment. The lack of standardization of results has made it difficult to compare studies that have evaluated outcomes [1]. Aims and Objective: To evaluate the functional and radiological outcome of intra-articular calcaneal fractures managed surgically with a plate in terms of bohler’s and gissane’s angle, rate of radiological union and AOFAS score. Methods: A prospective study including 25 patients with an intra-articular calcaneal fracture who met the inclusion criteria was conducted in SGITO, Bangalore, between November 2019 and November 2020. Patients were managed surgically with plate fixation and were followed up regularly at 6 weeks, 12 weeks, 24 weeks and 1 year. Radiological outcome and functional outcome evaluated using AOFAS score. Results: Mean age of the patients was 33.6 years. The mean time duration between injury and surgery was 7.8 days. The mean time for fracture union was 13.64 ±2.56 weeks. The difference between pre and post-operative mean bohler’s and gissane’s angle was statistically significant with a p value

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.

Minimal invasive surgery in the management of intra-articular calcaneal fractures: A retrospective comparison of screw fixation alone versus screw with small locking plate fixation techniques.

The aim of this study was to compare clinical and radiological outcomes of screw fixation alone versus screw with small locking plate fixation techniques in the management of intra-articular calcaneal fractures by minimal invasive surgery. A total of 42 patients treated with minimally invasive surgery because of an intra-articular calcaneal fracture were retrospectively reviewed and included in the study. The patient were then divided into two groups based on the implemented surgical technique: Group A, 20 patients (16 male, 4 female; mean age = 43.41 ± 15.50) receiving screw fixation alone and group B, 22 patients (17 male, 5 female; mean age = 43.38 ± 14.00) receiving screw with small locking plate fixation. The radiographic assessment included Bohler's, Gissane, joint line parallel, and calcaneal varus angles at immediate post-operative and 2-year follow up period through the calcaneal axial and lateral foot radiographs. There was a significant increase in joint line parallel angle from post-operative period to 2-year follow up in Group A compared to Group B, mean (SD) 3.27 (2.15) degrees versus (vs) 0.44 (3.00) degrees, P = 0.025. No statistical significant difference of the immediate, 2-year post-operative period and the change in Bohler's-Gissane angle, calcaneal varus, and FAAM of ADL between groups were observed, P > 0.05. For time-point comparisons in each group, there was a significant loss of calcaneal varus and increase in joint line parallel angle from post-operative period to 2-year follow up in Group A, from mean (SD) 1.82 (11.22) to 4.41 (9.73) degrees and 4.09 (5.32) to 7.36 (5.24) degrees, P = 0.047 and <0.0001, respectively. Group A had statistical significant less complications as zero vs 5, P = 0.049. The screw fixation alone seems to provide inferior stability of posterior facet fixation and calcaneal varus reduction with lower complication rates compared to screw with small-locking plate fixation. Level III, Therapeutic Study.

Minimally Invasive Reduction of Intraarticular Calcaneal Fractures With Percutaneous Fixation Using Cannulated Screws Versus Kirschner Wires: A Retrospective Comparative Study.

Several minimally invasive techniques were developed for management of intraarticular calcaneal fractures. This study aimed to compare the functional and radiological outcomes of 2 minimally invasive reduction and fixation techniques using cannulated screws or Kirschner wires (K-wires) for fixation. This study was a retrospective comparative review of patients with displaced intraarticular calcaneal fractures, who were treated with cannulated screws or K-wires techniques. Clinical and radiological data were collected and compared between both groups. Functional outcomes and patient satisfaction using the Maryland Foot Score (MFS) and the visual analogue scale (VAS) of pain, in addition to the complications, were compared between both groups. In total, 70 patients were included in the study: 34 in the cannulated screws group, with a mean age of 35.2 ± 4 years, and 36 in the K-wires groups, with a mean age of 33.4 ± 3 years. The operative time was shorter in the K-wires group (40.5 ± 5.6 minutes) compared to the cannulated screw group (49.5 ± 4.5 minutes), P < .001. There were no statistically significant differences between both groups regarding the radiological parameters, including Bohler's angle, angle of Gissane, calcaneal width, height, or length. The mean MFS, mean VAS, and complications were not different between the 2 groups. Treatment of displaced intraarticular calcaneal fractures with minimally invasive reduction and fixation using either cannulated screws or K-wires can achieve similar excellent functional and radiological outcomes, with high patient satisfaction. The use of K-wires has the advantage of reduced operative time than cannulated screws. Level III: Retrospective comparative study.

Evaluating Short-Term Outcomes Post–Intra-Articular Calcaneal Fracture Fixation via a Sinus Tarsi Approach in a Non-Exclusively Selected Cohort

Management of intra-articular calcaneal fractures remains a debated topic in orthopedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and postoperative fracture geometry with computed tomography used for preoperative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Fifty-eight intra-articular calcaneal fractures (53 patients; 5 bilateral, mean age = 46.91 years) with a mean follow-up of 35.4 months (6-57) were included. Five patients (9.4%) had wound complications; 2 superficial (3.7%), 3 deep (5.6%); 4 of whom were smokers. Smokers were statistically more likely to have wound infections than nonsmokers (p = .04). Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of postoperative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.

Intra-articular Calcaneus Fractures: Current Concepts Review.

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1% to 2% of all fractures. Roughly 75% of these fractures include intra-articular involvement of the posterior facet of the calcaneus. Intra-articular calcaneal fractures are challenging injuries to manage for both patients and surgeons given their association with both early and late complications. This article aims to review the management, classification systems, surgical approaches, and care regarding intra-articular calcaneal fractures. A review of the current literature yielded treatment strategies that aim to reduce complications such as soft tissue injury or loss of articular reduction while maintaining satisfactory clinical outcomes. The purpose of this article is to review these current concepts in the management of intra-articular calcaneal fractures. Level of Evidence: Level V, expert opinion.

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.

Functional outcome in non-operative management of displaced Intra-articular calcaneal fractures (Diacf’s)

Displaced intra-Articular calcaneus fractures (DIACFs) represent a source of potential disability to the patient, economic burden to the society and a treatment challenge to the average orthopedic surgeon. Despite lack of evidence whether operative management is superior to non-operative management, there is a trend favoring the former. This was a 2 year retrospective study & a 1 year prospective study of 37 patients with 44 displaced intra-articular calcaneal fractures managed non-operatively to observe the functional outcome of intra-articular fractures of calcaneus in adults in an Indian population. Each patient was followed up at 3, 6, 9 months and 1 year from injury. Appropriate lateral and axial view x-rays done at 3 months and 1 year follow-ups and radiological assessment done. Retrospective patients from previous two years were re-assessed with appropriate x-rays and functional outcome scoring done. The AOFAS score was assessed and recorded at each of these follow-ups. In our study of 37 patients with 44 displaced intra-articular calcaneal fractures, AOFAS clinical outcome at 1 year was excellent in 7 cases (15.91%), good in 29 cases (65.91%), fair in 7 cases (15.91%) and poor in one case (2.27%). Complications were seen in 11 patients at one year follow-up but none of the patients with complications required any surgical intervention and the average AOFAS functional outcome score at 1 year was 80.43 (Good). We hereby conclude that non-operative management of intra-articular calcaneal fractures continues to be an acceptable mode of treatment with low complications and comparable functional outcome with less complications.

Outcome Analysis of Operative and Non-operative Management of Intra-Articular Calcaneal Fractures

Outcome Analysis of Operative and Non-operative Management of Intra-Articular Calcaneal Fractures

Interobserver Reliability and Intraobserver Reproducibility of Three Radiological Classification Systems for Intra-articular Calcaneal Fractures

The management of intra-articular calcaneal fractures is difficult. One aspect for successful management is the use of a reliable and reproducible fracture classification system (FCS). The purpose of this study was to evaluate the interobserver reliability and intraobserver reproducibility of Letournel, Sanders, and Zwipp classification systems on CT scan and the Bohler's angle measurement on plain X-ray. Furthermore, we studied if the addition of a CT scan to the plain X-ray influenced the evaluation of fracture extension to the calcaneocuboid joint. The CT scan and plain X-ray images of 51 intra-articular calcaneal fractures were evaluated two times by three observers (two radiologists and one orthopedic surgeon) within a 5-month interval. The interobserver reliability was measured using the Fleiss kappa while the intraobserver reproducibility was measured using the Cohen's kappa. The mean kappa values for the interobserver reliability and intraobserver reproducibility of the Sanders classification were 0.25 and 0.39, respectively, of Zwipp classification were 0.24 and 0.16, respectively, while those of the Letournel classification were 0.50 and 0.42, respectively. For the Böhler's angle, the mean kappa values for the interobserver reliability and intraobserver reproducibility were 0.34 and 0.32, respectively. The addition of CT scan images to plain X-ray found a higher incidence of calcaneocuboid joint involvement. Clinicians should be aware of the limitation regarding the interobserver reliability and intraobserver reproducibility of the Letournel, Sanders and Zwipp classification systems for calcaneal fractures. Future studies should attempt to improve the present classification systems.

Minimally Invasive Arthroscopic-Assisted Reduction with Percutaneous Fixation in the Management of Intra-Articular Calcaneal Fractures: A Review of 24 Cases

A retrospective analysis of 24 cases of minimally invasive, open reduction, and internal fixation of intra-articular calcaneal fractures is presented. Collected data included articular step-off, medial wall displacement, and Boehler's angle, in addition to other descriptive characteristics of the fracture and case series. The operative technique is described in detail including the optimal screw constructs. Arthroscopic assistance was used in 10 of the cases. The articular step-off of the posterior facet, medial wall displacement, and Boehler's angle all displayed statistically significant change between the preoperative and postoperative periods (P < .0001). These results were consistent with the goal of restoration of articular congruity, calcaneal morphology, and calcaneal height. There were no soft tissue complications. The mean overall follow-up duration was 2.8 years (range 1 to 10 years). Of the 18 patients who were followed for more than 1 year (range 1.0 to 10 years), none went on to subtalar fusion. The results of this study suggest that a minimally invasive approach can improve radiographic parameters consistent with the ultimate goals of operative reduction of calcaneal fractures, and can be used to achieve satisfactory results with minimal risk of wound complication. 4.

(ii) The hindfoot: Calcaneal and talar fractures and dislocations—Part I: Fractures of the calcaneum

Summary While extra-articular calcaneal fractures are usually treated simply with good results, the management of intra-articular calcaneal fractures remains controversial. Despite advances in surgical techniques and a good understanding of possible complications making operative treatment relatively ‘safe', doubts remain about the efficacy of surgery in reducing the two main problems of persistent pain and subtalar osteoarthritis. Further randomised controlled trials may be required to confirm or refute the potential benefits of surgery.

A modified technique for the treatment of intra-articular calcaneal fractures with the use of the Ilizarov apparatus

The management of intra-articular calcaneal fractures during the past years has been ranged from the nihilistic approach of no active treatment to open reduction and internal fixation (ORIF) or even to early subtalar arthrodesis. The management of such fractures with the use of circular external fixators in a closed fashion or in combination with minimal approach is demonstrated in our study. The midterm results of 36 intra-articular calcaneal fractures treated between 1996 and 2003 with the use of the Ilizarov apparatus according to our modified operative strategy are presented. In treating calcaneal fractures, the classic Essex-Lopresti classification into depression and tongue type has been proved very useful in our hands. While the depression-type fractures can be reduced through skeletal traction and the above-mentioned minimal approach, tongue-type fractures can cause difficulties in reducing and especially maintaining the reduction of the tongue fragment. Especially for these fractures, a combined technique was applied by reducing the fracture with Steinmann pins according to the Essex-Lopresti method and incorporating them into the Ilizarov apparatus. This technique appears to be a lot easier and more accurate than the alternative “bent-wire technique” for reducing and holding down a tongue fragment. The original Essex-Lopresti manipulation alone with plaster immobilization does not allow weight bearing and is associated with regional osteoporosis. Apart from the Essex-Lopresti classification, the material was also categorized by the widely accepted Sanders CT classification for comparison of our results to those of the literature. The SF-36 patient-oriented general health status questionnaire was utilized before, during, and after the treatment period to assess patients’ satisfaction levels. We propose this operative strategy as an option for the treatment of all calcaneal fractures.

Displaced intraarticular calcaneal fractures

Calcaneal fractures comprise 1 to 2 percent of all fractures. Approximately 75% of calcaneal fractures are intra-articular. The management of intra-articular calcaneal fractures remains controversial. Nonoperative treatment options include elevation, ice, early mobilization, and cyclic compression of the plantar arch. Operative treatment options include closed reduction and percutaneous pin fixation, open reduction and internal fixation, and arthrodesis. The effect of operative versus nonoperative treatment has been the focus of several comparative studies.This study was designed to determine the effect of operative treatment compared with nonoperative treatment on the rate of union, complications, and functional outcome after intra-articular calcaneal fracture in adults.

Surgical management of intraarticular fractures of the calcaneus.

In this study we evaluated the interim results of surgical management of intraarticular calcaneal fractures in 26 feet in 19 patients. The mean age of the 15 male and 4 female patients in our series was 28.3 (range 17-54) years. There were 7 bilateral and 12 unilateral fractures. We obtained anteroposterior (AP), lateral, and skyline views and computed tomography (CT) scans of all patients preoperatively. According to Sanders CT classification, we detected type II, III, and IV fractures in 12, 10, and 4 cases, respectively. We performed extended lateral incisions in all patients but one and used Sherman plate, screw, and staples to achieve anatomic reduction. The mean follow-up period was 38.2 (range 18-50) months. Patients were evaluated by X-ray, CT, and Maryland foot score. We found that anatomic reduction had been achieved in 20 cases as confirmed by X-ray and CT postoperatively. With regard to the Maryland foot score, excellent, good, fair, and poor results were obtained in 9, 11, 4, and 2 cases, respectively. None of our patients required secondary intervention. We conclude that in order to obtain satisfactory results in the management of intraarticular calcaneal fractures, anatomic reduction must be achieved and maintained using strength hardware.

The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol

The management of intra-articular calcaneal fractures remains controversial with strong arguments supporting both conservative and operative management. This study assesses the results of open reduction and internal fixation (ORIF) of displaced intra-articular fractures of the calcaneum in two independent centres where the indications for operative management had been strictly defined. Forty-seven patients (51 fractures) who had sustained such injuries underwent an ORIF performed by one of the senior surgeons using the technique described by Eastwood et al. [JBJS 75-B(1993)189] All of the fractures were assessed by plain X-ray and CT scan and graded according to the Sanders classification [Clin. Orthop . 290(1993)97]. Patients were assessed at a minimum of 2 years post-surgery both clinically and with a standardised questionnaire based on that described by Kerr et al. [Injury 27(1996)35]. The mean age at operation was 42 and 50 years for the two centres, and the mean follow-up was 44 months. Seventy-six per cent of the patients were male. Eighty-eight per cent of the injuries were due to a fall from a height. Fifteen patients had contralateral foot/ankle injuries. Thirty-four of 46 patients were in employment at the time of the injury, 24 of these were in physical jobs and 20 sustained their injury whilst at work. Overall, the satisfaction rate was 90%. Ninety-four per cent of patients in work returned to work at a median of 6 months. Bilateral injuries were associated with a significantly poorer outcome as were those with heel pad pain. Delay to operation greater than 14 days was associated with a higher infection rate. Smoking was not related to infection rate.

Rapid prototyping (stereolithography) in the management of intra-articular calcaneal fractures.

The purpose of this study was to evaluate and compare the diagnostic performance of stereolithography vs workstation-based three-dimensional (3D) reformations in intra-articular calcaneal fractures. A total of 30 intra-articular calcaneal fractures were examined using standard radiographs, coronal CT scans, and 2D and 3D reformations. The CT data were transferred to an outside institution, and stereolithograms were produced from photopolymer resin employing a laser beam system. 3D reformations and stereolithograms were analyzed in a blinded fashion by two staff radiologists. Receiver-operating-characteristic (ROC) curves were obtained for six clinically significant fracture components. Standard radiographs, coronal CT scans, and 2D reformations served as the standard of reference. The area under the ROC curves for 3D reformations and stereolithograms were 1.0 and 0.98 for abnormal tuber angles, 0.91 and 0.91 for anterior and middle talo-calcaneal joint involvement, 0. 90 and 0.95 for involvement of the posterior talo-calcaneal joint, 0. 65 and 0.78 for the presence of a lateral bulge, 0.80 and 0.81 for the involvement of the calcaneocuboidal joint, and 0.62 and 0.67 for the presence of a "tongue-type" fracture. No statistically significant difference was demonstrated for the two methods (Wilcoxon signed-rank test, p = 0.138). Based on our results stereolithograms did not prove to be statistically superior to workstation-based 3D reformations. Stereolithograms may still be useful for teaching purposes and for surgical planning at a thinking-efficacy level.