Maryland Foot Score Research Articles

Outcomes of Percutaneous Fixation in Intra-articular Calcaneal Fractures.

Displaced intra-articular calcaneal fractures have been proven to be challenging fororthopaedicsurgeons worldwidedue to the poor clinical outcomes. Historically, the decision whether for fixation or conservative management depended mostly on the literature of the time, initiallyfavouringconservative management but attitudes slowly shifted to operative intervention. Percutaneous fixation options have been increasingly popular for their ability for fracture reduction without skin and wound complications of the open method.A retrospective study of 17 patients with a total of 18 calcaneal fractures treated in our hospital by a single surgeon from January 2017 to December 2019 was conducted. Fixation was done percutaneously using cannulated screws, with the patients in a lateral position. Intraoperative imaging was done using a mini-image intensifier to visualise fracture reduction, and the O-arm was used in most cases.Using the Sanders classification, there were a total of 4 IIA, 3 IIB, 2 IIC, 2 IIIAB, and 7 IIIAC.Results showed that 16 calcaneal fractures (94%) had good to excellent outcomes with the American Orthopedic Foot and Ankle Society (AOFAS) score and Maryland Foot Score (MFS), while 14 calcaneal fractures (78%) showed good to excellent outcomeswith the Kerr calcaneal score. There were no wound complications encountered in our series. However, there was one patient with a k-wire broken intraoperative and left in situ and there were two patients with prominent screws.Despite this, our experience with percutaneous fixation of displaced intra-articular calcaneal fractures has been generallyfavourable, allowing for good outcomes and satisfactory reduction of the fracture fragments.

Which type of supra-syndesmal fractures Weber C or Equivalent Weber C have the best reduction of the distal tibio-fibular syndesmosis? A prospective CT-scan investigation on 60 ankles

IntroductionThe reduction of the distal tibiofibular syndesmosis (SyTFd) is a crucial factor in the functional prognosis following a suprasyndesmotic ankle fracture. Few studies have compared, using computed tomography (CT), the quality of SyTFd reduction in Weber C ankle fractures (WebC) and Equivalent Weber C (EqWebC) fractures, where there is a medial ligament injury instead of a bony malleolar lesion. This CT-based study aimed to answer the following questions: (1) Do Weber C fractures allow for better reduction of the distal tibiofibular syndesmosis compared to Equivalent Weber C fractures? (2) Are the functional outcomes one year postoperatively better for Weber C fractures compared to Equivalent Weber C fractures? HypothesisThe hypothesis was that WebC fractures would present better reduction of the SyTFd than EqWebC fractures due to the restoration of bone anatomy, considering the bony nature of the medial ligament involvement. Materials and methodsSince December 2021, all patients presenting with an ankle fracture were included in a database. Suprasyndesmotic fractures were extracted, and between December 2021 and February 2022, 60 patients underwent surgery for a suprasyndesmotic fracture (28 WebC – 32 EqWebC). All patients were operated on using the same technique and underwent a postoperative bilateral CT scan in axial slices with both ankles in a neutral position (foot at 90 ° to the leg). An analysis of 8 measurements was performed under the same conditions. Each fractured ankle was compared to the healthy contralateral ankle, and a delta was obtained for each measurement. The follow-up was standardized. At one year, an AOFAS Score and a Maryland Foot Score (MFS) were recorded. Statistical differences between the two groups were measured using the Student's t-test and Chi-square test. ResultsThere was a significant difference between the WebC and EqWebC groups for clinical scores at one year postoperatively: AOFAS: 92.0 ± 6.3 [78–100] vs. 80.1 ± 5.4 [62–100], p < 0.05; MFS: 90.9 ± 6.4 [78–100] vs. 81.6 ± 5.2 [64–100], p < 0.05. CT scan analysis of the SyTFd reduction found significantly better reduction in the WebC group. DiscussionWebC fractures showed better clinical scores associated with better SyTFd reduction on postoperative CT scans. The anatomical reduction related to the bone reduction criteria during surgery could explain our findings. Level of evidenceIII; Case-Control Comparative Study.

Open Reduction and Internal Fixation with Plate and Screw versus Triplanar External Fixation in the Surgical Treatment of Calcaneal Fractures: A Retrospective Cohort Study.

Background: The treatment of displaced intra-articular calcaneal fractures (DIACF) is debated. This study compares open reduction and internal fixation (ORIF) with minimally invasive osteosynthesis (MIOS). Methods: We conducted a retrospective study on 70 patients with DIACF treated between January 2018 and September 2022, divided into ORIF (n = 50) and MIOS (n = 20) groups. Functional outcomes were assessed using the Maryland Foot Score (MFS) and the Creighton-Nebraska Health Foundation Assessment Scale (CNHFAS). Radiographic outcomes, complication rates, and reintervention rates were evaluated. A chi-square analysis examined the correlation between Sanders classification and treatment choice. Results: The chi-square analysis indicated no significant correlation between the complexity of the fracture and the type of treatment chosen (χ2 = 0.175, p = 0.916). Additionally, the Cochran-Armitage test for trend showed no significant trend in the choice of treatment based on fracture complexity (statistic = 0.048, p = 0.826). A Kaplan-Meier analysis showed a longer time to reintervention for MIOS (p = 0.029). Complication rates were similar, with specific complications varying between groups. Quality-of-life outcomes were comparable. Conclusions: ORIF is preferable for high-demand patients due to better anatomical outcomes, while MIOS suits high-risk patients by reducing reinterventions and complications. Further randomized trials are needed to confirm these findings.

Long-Term Outcome Analysis of Surgically Treated Talus Fractures in a Tertiary Care Hospital.

Aim The present study aims to look at the long-term clinical and radiological outcomes of surgically treated talus fractures. We have compared the outcomes and complications between simple and complex talar fracture patterns. Additionally, patients' ability to return to activity following surgical treatment of these fractures was also analysed. Materials and methods Retrospective analysis of surgically treated talus fractures at the PSG Institute of Medical Sciences and Research from 2012 to 2015. The fractures were classified as neck and body fractures. The fractures were classified anatomically (neck and body) based on their severity (simple and complex) fracture patterns. A radiological assessment was done at follow-up to assess for complications of malunion, avascular necrosis (AVN), and arthritis. The outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Maryland foot score (MFS). Results Twenty patients were included in the analysis. There were 12 talar neck and eight body fractures, subclassified into simple (10) and complex fracture patterns (10). The surgical approach involved either a medial malleolus osteotomy/via fractured medial malleolus (55%) or a non-osteotomy-based approach (anteromedial (AM)/anterolateral (AL)/combined AM and AL) (45%). The average AOFAS score was 71.34, while the MFS was 74.35. The outcomes were consistently unfavourable for patients with complex fractures with a higher propensity for complications, but no difference was observed when comparing neck and body fractures. There was a 10% incidence of malreduction in the non-osteotomy-based approach group. AVN was found in 35% of cases, and post-traumatic arthritis occurred in 75% of cases during the five-year follow-up period. Conclusion The findings of the present study consistently reiterate the propensity for complex talus fractures to develop complications like AVN and post-traumatic arthritis in the long term. This study serves to help predict talus fractures based on their severity, with poor outcomes noted with more complex fracture types. We also advocate a more extensile medial malleolus osteotomy-based approach to better visualise complex body fractures of the talus and obtain more anatomical reduction.

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.

Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up

IntroductionThis study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period. MethodsPatients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS). ResultsIn total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF–36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3–7) and 6 months (IQR, 3,25–6,75) for PSF and ORIF treated, respectively ConclusionThis long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.

An evaluation of the efficacy of percutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III displaced intra-articular calcaneal fractures

BackgroundThe aim of this retrospective monocentric study was to investigate the clinical efficacy of percutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III displaced intra-articular calcaneal fractures (DIACFs).MethodsThe medical records of calcaneal fractures patients who were admitted to our department from January 2018 to January 2020 were retrospectively reviewed, and those meeting the inclusion criteria were fnally included for analysis. All patients were treated with percutaneous reduction and screw fixation, and no patients received bone grafting. The radiologic parameters evaluated included the BÖhler angle and the calcaneal height. In addition, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, Maryland Foot Score (MFS), and visual analog scale (VAS) score were determined.ResultsThirty-eight patients with Sanders Type-II and Type-III DIACFs were finally included, including 30 males and 8 females aged 21 to 61 years [(42.6 ± 9.6) years]. According to the Essex-Lopresti classification, 27 of the fractures were the tongue type, and 11 were the joint compression type. According to the Sanders classification, 27 of the fractures were type II, and 11 were type III. Immediately postoperatively, the calcaneal height had recovered to 39.8 ± 2.1 mm, the BÖhler angle had recovered from 4.2° ± 13.6° preoperatively to 27.2° ± 3.4° (P = 0.000). All patients were followed up for 18–42 months [(25.2 ± 9.5) months]. All fractures healed. No differences were found in the outcome measures six-months postoperatively (BÖhler angle, p = 0.24; calcaneal height, p = 0.82) or at final follow-up (BÖhler angle, p = 0.33; calcaneal height, p = 0.28) compared to the immediately postoperative values. At the final follow-up, the AOFAS score was 91.7 ± 7.4 points, with an excellent and good rate of 92.1%; the MFS was 90.3 ± 7.8 points, with an excellent and good rate of 92.1%; and the VAS score was 2.2 ± 1.5 points. None of the patients had incision complications, and one patient developed traumatic arthritis.ConclusionPercutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III DIACFs can achieve good recovery and maintenance of the BÖhler angle and calcaneal height. Moreover, it has the advantage of a low complication rate.

HyProCure for Pediatric Flexible Flatfoot: What Affects the Outcome.

BackgroundThe high success rate, minimal invasion, and safety of subtalar arthroereisis (SA) have made it a primary mode of surgical management for pediatric flexible flatfoot. The HyProCure procedure is a new surgery for SA, However, very few available studies reported the therapeutic effects of the HyProCure procedure, especially in pediatric flexible flatfoot. The main aim of the present study was to investigate the clinical and radiological outcomes of the HyProCure procedure for pediatric flexible flatfoot and analyze the risk factors for therapeutic outcomes and sinus tarsi pain.MethodsIn this retrospective cohort study, 69 pediatric flexible flatfoot patients (107 feet) who underwent the HyProCure procedure were included between July 2015 and September 2020. All patients underwent the HyProCure procedure with or without gastrocnemius recession. The Maryland foot score (MFS), visual analog scale (VAS), radiographic data, and complications were assessed at a minimum 1-year follow-up and statistically analyzed.ResultsThe mean follow-up was 35.9 months (range, 13–73 months). At the last follow-up, VAS (0.64 ± 1.16) was significantly lower than the preoperative VAS (4.06 ± 1.43) (p < 0.001); MFS (90.39 ± 12.10) was significantly higher than the preoperative MFS (71.36 ± 10.25) (p < 0.001). The AP talar-second metatarsal angle (T2MT angle) significantly decreased from 17.0 ± 5.4° preoperatively to 11.4 ± 5.2° at the last follow-up (p < 0.001). The lateral talar-first metatarsal angle (Meary's angle) significantly decreased from 13.8 ± 6.4° preoperatively to 6.3 ± 5.0° at the last follow-up (p < 0.001). The calcaneal declination angle (Pitch angle) significantly increased from 13.5 ± 4.9° preoperatively to 14.8 ± 4.4° at the last follow-up (p < 0.001). Logistic regression analysis indicated that patients with a longer distance from the tail end of the implant exceeding the longitudinal talar bisection line had 275.8% greater odds of MFS < 90. Yet, no risk factors were found in connection with sinus tarsi pain.ConclusionsThe HyProCure procedure for pediatric flexible flatfoot achieved satisfactory curative effects with a low complication rate; implant depth was associated with unsatisfactory postoperative outcome.

Three-step closed reduction and percutaneous screw fixation: A reliable and reproducible protocol in managing displaced intra-articular calcaneal fractures

BackgroundFor displaced intra-articular calcaneal fractures (DIACFs), the less invasive surgical techniques vary widely. Herein, the study is to introduce a novel, reliable and reproducible protocol of three-step closed reduction (distracting, elevating, and clamping) and percutaneous screw fixation for DIACFs. MethodsThis retrospective study included 32 patients with 33 DIACFs treated by the abovementioned surgical procedures with an average follow-up of 17.7 months. Postoperative outcomes were evaluated by complications, radiographs, and functional scores. ResultsThere were no incision complications. Postoperative Böhler's angle, height, and width were significantly recovered with p < 0.001. Especially, mean postoperative subtalar incongruity was 0.5 ± 0.5 mm. The average values of Maryland Foot Score (MFS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle hindfoot score were 93.6 ± 5.9, 91.7 ± 6.7, respectively. The average scores of short form-36 (SF-36) and visual analog scale (VAS) were 89.9 ± 10.4 and 3.1 ± 1.6, respectively. Further subgroup analysis showed that the functional scores were comparable among different fracture types according to either Sanders or Essex-Lopresti classification. ConclusionWe consider the three-step reduction (distracting, elevating and clamping) and percutaneous screw fixation to be a reliable and reproducible protocol for the treatment of DIACFs.

Initial surgical outcomes of two modified minimally invasive repair techniques for acute achilles tendon rupture

Despite numerous treatment modalities, there remains no clear consensus on the optimal surgical approach to mid-substance acute Achilles tendon ruptures (AATR). The purpose of this study is to present two novel minimally invasive surgery (MIS) approaches for AATR and compare their outcomes. Retrospective analysis of two surgeons's AATR patients (N=18) who underwent one of two modified minimally invasive repairs (MMIR). Group A received a modified Krackow suture repair via mini-open incision with percutaneous calcaneal anchors. Group B received a modified Kessler suture repair percutaneously. The mean follow-up period was 23.9 +/- 5.1 and 14.7 +/- 1.9 months respectively. Surgical outcomes were measured using Maryland Foot Score (MFS) and The Self-Reported Foot and Ankle Score (SEFAS). There was no statistically significant difference in patient outcomes between the two MMIR techniques. Overall, patient satisfaction with Maryland score was 95.7 +/- 9.0 in Group A and 89.6 +/- 19.0 in Group B (p=0.41). Overall SEFAS score was 43 +/- 4.73 in Group A and 39 +/- 11.6 in Group B (p=0.15). Sural nerve injury occurred in two of the eight patients in Group B (25%), with only one of the patients seeking further treatment for neuritic pain. There were no other complications in terms of wound dehiscence, infection, rerupture or functionality in either of the two surgical groups. These findings suggest that the reported MIS techniques may be an acceptable consideration for surgical treatment of acute Achilles tendon ruptures.

Short Term Clinico-Radiological Outcome of Extra Osseous Talo-Tarsal Stabilization (EOTTS) in Flat Foot: An Indian Perspective.

Flexible flat foot is one of the most common foot conditions found amongst any age group across the world. One very important reason for this condition is the incongruency or partial dislocation of one or more joints within the talo-tarsal mechanism. This flexible talo-tarsal malalignment is termed as recurrent talo-tarsal joint dislocation (RTTJD). Between 2016 and 2018, 32 patients were advised Extra osseous talo-tarsal stabilization (EOTTS) as a standalone procedure for RTTJD following detailed clinical examination including foot posture index (FPI) scoring and weight-bearing radiographic evaluation. Subjective assessment was done through Maryland Foot Score (MFS) questionnaire. Radiological parameters like talar declination angle, talar second metatarsal angle and tibio-calcaneal valgus angle were assessed for preoperative and postoperative comparison. 15 patients (20 feet) underwent surgery and rest 17 patients (25 feet) became our control group. A retrospective record analysis of longitudinal data was done over a period of 4years. The purpose of this study is to depict the short-term results of EOTTS procedure in terms of functional and radiological improvement and compare it with the non-surgical group. Significant improvement was seen in MFS from 67.31 ± 16.04 to 95.47 ± 4.36 over a mean follow-up period of 30.66 ± 7.09months. Total FPI improved by 96.83 ± 4.80% at final follow-up of EOTTS group. Radiologically, maximum correction achieved was in coronal plane (93.07 ± 30.05%). EOTTS, as a standalone procedure improved the foot radiological angles and restored the normal foot biomechanics significantly in presence of competent spring ligament and posterior tibial tendon. This procedure resulted in excellent patient satisfaction score as assessed by MFS questionnaire. III.

Open reduction internal fixation versus minimally invasive percutaneous fixation for calcaneus fractures: Mid-term outcomes and social consequences.

Objectives This study aims to evaluate the mid-term clinical, functional, radiological, and socioeconomic outcomes of calcaneus fractures treated with open reduction-internal fixation (ORIF) versus minimally invasive percutaneous fixation (MIPF).Patients and methods A total of 48 patients (34 males, 14 females; mean age: 44.05 years; range, 19 to 64 years) who underwent either ORIF or MIPF for calcaneus fractures between January 2010 and January 2016 were retrospectively analyzed. The patients were divided into two groups as the ORIF group (n=36) and MIPF group (n=12). The American Orthopaedic Foot & Ankle Society (AOFAS) score, Maryland Foot Score (MFS), and the Short Form-36 (SF-36) scores were assessed for the clinical assessment. The mean duration of operation, mean length of hospitalization, pedobarographic gait analysis, the incidence of contralateral knee pain, increased shoe size, and change of profession due to significant heel pain were also evaluated. The Böhler’s angle, Gissane angle, and calcaneal varus were measured for radiological assessment.Results There was a significant difference in the mean operation time (p=0.001) and length of hospitalization (p=0.001) between the two groups. There was no significant difference between the pre- and postoperative third-year Böhler’s and Gissane angles (p=0.05, p=0.07, p=0.09, respectively). There were no significant differences between the postoperative first-, second-, and third-year AOFAS, MFS, and SF-36 scores (p=0.57, p=0.55 p=0.85, p=0.64, p=0.21, p=0.51, p=0.20, p=0.15, p=0.22, respectively). Thirteen patients in the ORIF group and five patients in the MIPF group changed their job due to significant heel pain. The increased shoe size was correlated with the residual calcaneal varus (p=0.001).Conclusion Both methods have pros and cons in the treatment of calcaneal fractures. Although MIPF is more advantageous in terms of operation duration and length of hospitalization, more favorable radiological results can be obtained with ORIF. Calcaneal varus should be corrected to prevent the increased shoe size and contralateral knee pain.

Efficacy of calcium phosphate cementing in the surgical treatment of Sanders Type II and III calcaneal fractures using screw fixation with sinus tarsi approach.

This study aimed to determine the effectiveness of calcium phosphate cementing in the surgical treatment of Sanders type II and III calcaneal fractures using screw fixation with sinus tarsi approach. In this retrospective study, 85 feet of 84 patients (74 males, 10 females; mean age 43 [17-61] years) in whom screw fixation was performed using the sinus tarsi approach for Sanders type II or III calcaneal fractures were included. The mean follow-up was 28 (14-39) months. Patients were categorized into 2 groups on the basis of whether calcium phosphate cement (CPC) was used. Group 1 had 37 patients with CPC (38 calcaneal fractures) and group 2 had 47 patients without CPC (47 calcaneal fractures). In the clinical assessment, the American Orthopedic Foot Ankle Society (AOFAS) hind foot score and the Maryland Foot Score (MFS) were used at the final follow-up. In the radiological assessment, Bohler's angle on plain radiograph and posterior facet step-off on computed tomography were measured pre-and postoperatively. At the final follow-up, the mean Bohler's angle was 26.2° (20°-33°) in group 1 and 26° (17°-30°) in group 2 (P = 0.85). The mean posterior facet step-off was 1.6 (0-5) mm in group 1 and 1.5 (0-5) mm in group 2 (P = 0.85). The mean AOFAS score was 83.8 (59-100) in group 1 and 85.8 (60-100) in group 2 (P = 0.5). The mean MFS was 86.3 (66-100) in group 1 and 87.7 (66-100) in group 2 (P = 0.62). Evidence from this study have shown that CPC may have no significant effect on clinical and radiological outcomes in the surgical treatment of Sanders type II and III calcaneal fractures using screw fixation with sinus tarsi approach.

Could percutaneous fixation with crossed Schanz pins be an alternative to open reduction in the treatment of intra-articular calcaneal fractures?

Despite modern operative techniques and a considerable number of studies in the literature, the best treatment for calcaneal fractures remains an enigma for orthopaedic surgeons. The purpose of the study was to compare clinical and radiographic outcomes between anatomic calcaneal plate (ACP) fixation and crossed Schanz pin (CSP) fixation in the treatment of Sanders type II and III displaced intra-articular calcaneus fractures (DICFs). Consecutive 65 patients (49 males, 16 females) who underwent surgery for DCIFs between January 2009 and February 2013 were retrospectively evaluated. The patients were divided into two groups as ACP and CSP according to the operative technique. The groups were compared in terms of demographic features, injury mechanism, operation time, fluoroscopy exposure, complications, full weight-bearing time, functional, and radiological outcomes. VAS-rest score did not differ significantly between the groups while the VAS-activity score was significantly higher in the CSP group (p = 0.001 and p = 0.645, respectively). Foot Function Index (FFI) was significantly lower, Maryland Foot Score (MFS) and the American Orthopaedic Foot and Ankle Society-hindfoot score (AOFAS) were significantly higher in the ACP group (p = 0.047, p = 0.016, and p < 0.001, respectively). While no difference was observed between the preoperative and the early post-operative (1st day) Böhler angle and Gissane angle, both were significantly higher in the ACP group at the post-operative last control (p < 0.001 and p < 0.001, respectively). Although crossed Schanz pin fixation shortens the operation time in displaced intra-articular calcaneus fractures compared to anatomic calcaneal plate, increased fluoroscopy exposure rates and low functional and radiological outcomes are disadvantageous of crossed Schanz pin. Anatomic calcaneal plate is still a better technique for preserving the alignment and elevating the displaced intra-articular segment for good to excellent mid-term results.

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.

Long-term results of displaced intra-articular calcaneal fractures treated with minimal invasive surgery using percutaneous screw fixation

Over the last 20 years, minimally invasive surgery using Percutaneous Screw Fixation (PSF) has been performed increasingly frequently in the treatment of Displaced Intra-Articular Calcaneal Fractures (DIACFs). The purposes of this study were to assess the long-term postoperative outcomes of mobility, foot function, stability, pain and patient satisfaction. All patients had DIACFs and underwent PSF between 1998 and 2006 according to the method reported by Forgon and Zadravecz. Functional outcomes, range of motion and change in footwear were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients completed a general health status form (Short Form-36 [SF-36]) and visual analogue scale (VAS) for patient satisfaction. Anatomical restoration was assessed based on the pre- and postoperative radiographic images. Sixty-six patients with an DIACF were observed in the period 1998-2006. Patients who had open fractures, died or were <18 years of age at trauma were excluded. A total of 46 patients were asked to complete the questionnaires, during the last quarter of 2018. Of these patients, 27 with 29 DIACFs responded (58%). Nineteen were males, and the mean age at trauma was 45 years. Seven cases were classified as Sanders type II, 14 as Sanders type III, and 8 as Sanders type IV. The mean pre- and postoperative Böhler angles were 10 ͦ and 26 ͦ, respectively. The average follow-up period was 16 years, and at the follow-up, the mean AOFAS, MFS, SF-36 and VAS scores were 76, 74, 63 and 7.7 points, respectively. In comparison to the results at 5-10 years postoperatively in a previous study, we observed a decline in the average AOFAS and MFS scores by 8 and 11 points, respectively. Patient satisfaction decreased by 0.1 points and general health by 14 points. The long-term results of this study show relatively good functional outcomes is two-thirds of the treated patients. According to the reported scores, patients described their level of function as essentially normal. PSF should therefore be considered as a good option in patients with DIAC fractures, especially in patients with Sanders II and III fractures. Therapeutic Level III.

Minimally invasive sinus tarsi approach in Sanders II-III calcaneal fractures in high-demand patients.

Aim To evaluate if the sinus tarsi approach treated with open reduction and internal fixation (ORIF), without using plate fixation, provided good functional results in active adult population. The hypothesis was that the sinus tarsi approach with limited incision provided good results comparable to other approaches. Methods A total of 78 patients (81 feet) surgically treated for articular calcaneus fracture were reviewed according to inclusion criteria: Sanders fracture type II-III, minimum follow-up of 2 years, patients aged 18-65 years. Exclusion criteria were smokers, diabetics, non-collaborative patients and patients with Sanders fracture type I and IV. A mean follow-up was 52.6 months. Radiographic changes of the Bohler's angle were reported. For the clinical evaluation, Visual Analogue Scale (VAS) for calcaneal fractures, American Orthopaedic Foot and Ankle Society (AOFAS) score and Maryland Foot Score (MFS) were used. Results A statistically significant restitution of Böhler's angle from preoperative to postoperative (13.5°-27°; p<.001) was found. The AOFAS and MFS showed pain relief and good/excellent functional activities at the final follow-up in 65 of 78 (83.3%) patients. In eight (out of 81; 10%) feet a superficial wound infection was observed. In three (3.8%) patients a subtalar arthrodesis was performed. Conclusion The mini-invasive sinus tarsi approach for active adult population is a valid and reproducible technique with a low rate of major complications, but it is mandatory advice to patients regarding the expectation of the results.

Patterns and Implications of Early Syndesmotic Screw Failure in Rotational Ankle Fractures.

The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome. A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS). A total of 113 patients (67%) had intact screws and 56 patients (33%) demonstrated either screw breakage or backout. Patients with SS failure were younger (P = .002) and predominantly male (P = .045). Fracture classification and energy level of injury were not associated with screw failure. Nine screws (11%) demonstrated backout (2 also broke) and 56 other screws broke. There was no association between the number of screws or cortices of purchase and screw failure. There was a trend toward a higher proportion of screw removal (20%) in this failed SS group compared with the intact SS group (12%) (P = .25), but with similar ankle ROM and MFS (P > .07). Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal. Level III, retrospective case-control study.

Does the minimally invasive complete plantar fasciotomy result in deformity of the Plantar arch? A prospective study

BackgroundComplete plantar fasciotomy has been associated with changes in foot loading, leading to medial longitudinal arch collapse. The purpose of this study is to analyse our clinical experience with percutaneous complete plantar fasciotomy and quantify the possible changes in foot loading measured by the calcaneal pitch angle. MethodsA prospective case series study with patients operated between 2005–2012 was conducted, where AOFAS, Maryland Foot Score (MFS), VAS and radiological calcaneal pitch (CP) were recorded. Postoperative data were collected, where the surgeon evaluated the presence of complications, and an independent investigator performed radiological and scale evaluations follow-up: AOFAS, MFS, VAS and Benton-Weil questionnaire. ResultsA total of 60 patients, 62 feet, with a mean follow-up of 57 months (range 13–107) were studied. The MFS increased a mean of 21 points (p=.001), the AOFAS score a mean of 25 points (p=.001), and the VAS decreased a mean of 8.89 points (p=.001). A total of fifty-seven feet (91.9%) were pain-free at the end of follow-up. The mean CP dropped from 20.2° (range 11–34) preoperatively to 19.3° (range 11–34) at the end of follow-up (p=.05). In 25 feet (40.3%) there were no changes in the calcaneus pitch angle, in 21 feet dropped 1° (33.9%), in 11 dropped 2° (17.8%), 3 feet 3° (4.8%) and 2 feet (3.2%) 4°. Postoperative complications were noted in 4 feet (6.4%), with lateral column pain. The surgery meets the expectations of all patients. ConclusionsPercutaneous total fascia release is safe and does not produce a significant drop in arch height based on the radiological finding. Lack of success after surgery may be explained by other pathologies that might appear like plantar fasciitis. Further studies with gait analysis after total plantar fascia release in patients are needed.

Single- vs 2-Screw Lag Fixation of the Medial Malleolus in Unstable Ankle Fractures.

The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws. Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23. Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws (P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation (P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores (P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups (P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups. The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points. Level III, retrospective case-control study.