Maryland Foot Score Research Articles

Balloon-assisted reduction, pin fixation and tricalcium phosphate augmentation for calcaneal fracture: A retrospective analysis of 42 patients

IntroductionThe treatment of intra-articular calcaneal fractures is still complex and controversial. Although open reduction and internal fixation (ORIF) is favored by many authors, several percutaneous techniques have been introduced to reduce complications and to obtain satisfactory clinical and radiological results. Among these percutaneous treatments, balloon reduction and bone graft augmentation is gaining an increasing popularity. Materials and methodsWe retrospectively examined a series of 42 patients treated operatively with a minimally invasive reduction technique using an inflatable bone tamp filled with tricalcium phosphate (calcaneoplasty) for Sander’s type II, III and IV calcaneal fractures between 2010 and 2015. Conventional X-rays and CT scan were performed pre-operatively, at 3 and 12 months post-operatively and at the last-follow-up. The American Orthopaedic Foot and Ankle Society (AOFAS) score and the Maryland Foot Score (MFS) were used for clinical evaluation. Bohler’s angle and the Score Analysis of Verona (SAVE) were calculated to assess bone reduction. ResultsAll 42 patients were available for clinical and radiographic follow-up at an average of 665 months (range 38–92). At the last follow-up the mean AOFAS score was 82.1 (good) and the mean MFS was 80.8 (good). The mean Bohler’s angle improved from 1.29° pre-operatively to 27.8° at the last follow-up. The SAVE highlighted good and excellent results in 30 (72%) patients. There were only 3 (7.1%) cases of superficial skin infection with only 6 (14.2%) patients complaining of residual pain. No cases of adverse reaction or deep infection were observed. ConclusionsCalcaneoplasty appears to be a valid option of treatment for calcaneal fractures and a reliable alternative to ORIF. This technique allows stable fracture reduction and early weight-bearing combined with good clinical and radiological results and few complications.

Mini-plate fixation via sinus tarsi approach is superior to cannulated screw in intra-articular calcaneal fractures: A prospective randomized study

Intra-articular displaced calcaneal fractures are common fractures and are often treated with surgical interventions. Sinüs tarsi approach provides secure access to lateral wall and joint facets. The aim of the study is to compare cannulated screw (CS) fixation and mini-plate (MP) fixation via sinus tarsi approach with Sanders types 2 and 3 fracture of calcaneus. Sixty patients with Sanders types 2 and 3 calcaneal fracture underwent surgical intervention were randomly allocated into two groups as group MP fixation and group CS fixation regarding osteosynthesis method for 5-year period. Open reduction via sinüs tarsi approach was performed in both groups. Demographic variables, time to surgery (TS), operation duration (OD), length of hospital stay (LOS), surgical complications, and reoperations were recorded. Pre- and postoperative Gissane and Böhler angles; calcaneal length, height, and width; ankle anterior-posterior (AP) and lateral X-rays; and computed tomography were also recorded for radiological evaluation and fracture characteristics. Maryland Foot Score (MFS) was used to evaluate functional outcomes. Preoperative age, type of fracture, calcaneal length, height, and Gissane and Böhler angles, TS, LOS, and OD were not different between the groups. The postoperative calcaneal widening was significantly better restored in group MP compared with that of group CS. The incidence of reoperation and algoneurodystrophy was statistically higher in group CS than group MP. MFS in group MP was also higher than group CS at final visit. MP fixation via sinus tarsi approach is superior to CS fixation in Sanders types 2 and 3 calcaneal fractures.

3D CT scan assessment of the outcome of displaced intra-articular calcaneal fractures: operative versus non-operative treatment

IntroductionComputed tomography (CT) scan is helpful in identifying bone deformities resulting from intraarticular calcaneal fractures such as loss of calcaneal height, increased width of calcaneal wall, and disruption of the posterior articular facet. The aim of this study is to compare the result of spiral CT scan assisted analysis of calcaneum anatomy, articular congruity and onset of arthritic changes with intraarticular calcaneal fractures in patients treated either operatively or conservatively.Material and methodsTwenty patients were recruited, 9 in the operative group and 11 in the conservative group. CT scan of the injured foot and ankle were taken followed by detailed functional assessment based on the American Orthopaedic Foot & Ankle Society Score (AOFAS) and Maryland Foot Score (MFS). Calcaneal height, length and width were measured to assess the functional and radiological outcome in the patients. The presence and severity of arthritic changes were reviewed.ResultsThe calcaneal height, length and width were relatively restored in the operative group compared to the conservative group. A significantly larger posterior articular facet step was seen in the conservative group with accelerated onset and significantly higher (p = 0.001) grade of arthritis in the subtalar joints apart from having significantly higher (p = 0.038) incidences of calcaneocuboid arthritis. The operative group showed significant improvement (p = 0.009) in functional outcome based on MFS scoring system.ConclusionsOperative intervention with calcaneal locking plate provides good framework for near anatomical bone healing and redistributes the mechanical forces on the foot resulting in improved pain, function and alignment in patients.

Sinus tarsus mini incision approach with percutaneous reduction and fixation for Sanders II、III calcaneal fractures

Objective To explore the methods and clinical effect of the sinus tarsus mini incision approach with percutaneous fixation technique in the treatment of Sanders II, III calcaneus fractures. Methods From January 2015 to May 2016, the clinical data of 64 cases with Sanders II, III calcaneus fractures who were treated by sinus tarsus mini incision approach with percutaneous reduction and fixation were analyzed retrospectively. The average age was 46.64±10.51 years (range, 25-68) and 49 patients were males and 15 patients were females. According to Sander's classification, 39 patients were Sanders II and 25 were Sanders III fracture. Calcaneal varus was corrected and the length, width and height of bone were reduced by sinus tarsus mini incision approach with percutaneous fixation technique. Calcaneal fracture was treated by calcaneal bone plate combined with percutaneous screw fixation. Complications and operation procedure were recorded post-operation. Anteroposterior, lateral and axial views of preoperative and postoperative X-ray and CT scan were taken to assess the classification, restoration and intertion status of fracture. Radiological assessment was performed using Bohler's angle and Gissane's angle. Functional outcome was assessed using the Maryland foot score (MFS). Results All of the sixty-four patients were followed up for 12-18 months (average, 14.80±2.03). After surgery, only 4 cases of superficial necrosis of the incision were found, and the incisions were all healed and no infection occurred after surgery. No tendon tenosynovitis was seen after surgery. There were no fracture displacement, internal fixation failure, and fracture deformity healing cases. The mean time of bone union was 9.44±1.38 weeks (8-12 weeks) without fracture deformity healing case. The mean time of bone union was 9.17±1.16 weeks for the 23 cases with bone graft. For the 41 cases without bone graft, the bone healing average time was 9.91±1.62 weeks, and there is no statistically difference between cases with and without bone graft (t=1.936, P=0.061). Bohler's angle was 6.625°±4.904° (range, -5°-15°) preoperative, and improved to 31.031°±4.660° (range, 24°-40°), which had statistically significant difference (t=-28.863, P=0.000). Gissane's angle was from preoperative 76.094°±12.981° (range, 55°-105°) to 127.328°±6.486° (range, 115°-140°) at the time of the latest follow-up, and the difference had statistically significant (t=-28.246, P=0.000). Maryland Score: excellent 30 cases (22 cases of type II, 8 cases of type III), good 27 cases (15 of type II, 12 of type III), fair 7 cases (2 of type II, 5 of type III). The overall good rate was 89.06% (57/64). Conclusion The tarsal sinus minimally invasive small incision reduction and internal fixation combined with percutaneous reduction and fixation technique in the treatment of calcaneal fractures, exerts the advantages of small trauma, clear surgical exposure for reduction, reliable fixation, and low incision complications, which is applicable to treat the Sanders II, III calcaneal fractures. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal

Factors Influencing Functional Outcomes of Subtalar Fusion for Posttraumatic Arthritis After Calcaneal Fracture.

Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis. This study aimed to identify factors associated with functional outcomes and quality of life after subtalar fusion for posttraumatic subtalar arthritis after calcaneal fracture. This is a retrospective study with follow-up by questionnaire in two level 1 trauma centers. Patients who underwent subtalar arthrodesis for posttraumatic arthritis after a calcaneal fracture between 2001 and 2016 were identified and contacted for completion of a survey consisting of the Foot and Ankle Ability Measure (FAAM), Maryland Foot Score (MFS), Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire, EuroQol 5-dimensional (EQ-5D) questionnaire, and EuroQol visual analog scale (EQ-VAS). Exclusion criteria were initial subtalar arthrodesis at an outside facility, primary arthrodesis for fracture, initial arthrodesis earlier than 2001, amputation of the fused foot or leg, younger than 18 years at time of fusion, and inability to communicate in English. A total of 159 patients met our inclusion criteria. Eighty-four patients completed the questionnaires, resulting in a response rate of 59%. Median FAAM score was 79 (interquartile range [IQR], 48-90), median MFS was 74 (IQR, 56-86), and median PROMIS PF was 45 (IQR, 38-51). Quality of life was significantly lower when compared to a reference population ( P = .001). Smoking was independently associated with worse outcomes. Complications after fusion (such as nonunion, implant failure, and infectious complications), high-energy trauma, and ipsilateral injury were also predictors for poorer outcomes. Acceptable functional outcomes and quality of life were observed after subtalar fusion. Smoking, complications after subtalar fusion, high-energy trauma, and presence of ipsilateral injuries were independently associated with worse functionality and quality of life. Prognostic level III, comparative series.

Ultrasound Guidance Does Not Improve the Results of Shock Wave for Plantar Fasciitis or Calcific Achilles Tendinopathy: A Randomized Control Trial.

To establish whether the use of ultrasound to direct shock waves to the area of greater calcification in calcaneal enthesopathies was more effective than the common procedure of directing shock waves to the point where the patient has the most tenderness. Two-armed nonblinded randomized control trial with allocation concealment. The Sports Clinic at Sydney University. Participants 18 years or older with symptomatic plantar fasciitis (PF) (with heel spur) or calcific Achilles tendinopathy (CAT). Seventy-four of 82 cases completed treatment protocol and 6-month follow-up. Patients were randomized to receive either ultrasound-guided (UG) or patient-guided (PG) shock wave at weekly intervals over 3 to 5 weeks. Reduced pain on visual analog scale (VAS) and improved functional score on Maryland Foot Score (MFS) (for PF) or Victorian Institute of Sport Assessment-Achilles (VISA-A) (for CAT). Follow-up was at 6 weeks and 3 and 6 months. Comparative 6-month improvements in MFS for the 47 PF cases were PG +20/100 and UG +14/100 (P = 0.20). Comparative 6-month improvement in VISA-A score for the 27 CAT cases were PG +35/100 and UG +27/100 (P = 0.37). Comparative (combined PF and CAT) 6-month improvement in VAS pain scores for all 38 PG cases were +38/100 with +37/100 for all 36 UG shock wave cases. Although both treatment groups had good clinical outcomes in this study, results for the 2 study groups were almost identical. This study shows that there is no major advantage in the addition of ultrasound for guiding shock waves when treating calcaneal enthesopathies (PF and CAT).

Functional outcomes and quality of life in patients with subtalar arthrodesis for posttraumatic arthritis

IntroductionSubtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis, a condition frequently seen in patients who suffered major trauma. Functional outcomes in trauma patients may be influenced by concomitant injuries and the severity of the initial trauma. The aim of this study was to evaluate quality of life and functional outcomes of subtalar arthrodesis for posttraumatic arthritis in patients with severe or complex foot injuries. Materials and methodsThis is a retrospective single center study with prospective follow-up. Patients who underwent subtalar arthrodesis for posttraumatic arthritis between 2000 and 2016 were included and invited to complete a Maryland Foot Score (MFS), a EuroQol five-dimensional (EQ-5D™) and Visual Analog Scale (EQ-VAS™) questionnaire, and four additional questions. ResultsForty patients were included in the study, functional outcome scores were available for 30 patients (response rate 75%). Additional surgery of the fused foot was performed in 29 patients and 15 suffered multiple lower extremity injuries. Six patients were polytraumatized. Ninety percent of all patients would recommend the procedure to others, walking abilities improved in 69% and less pain was experienced in 76%. Median MFS score was 61 (IQR 53–72). Quality of life was significantly lower when compared to a reference population (p<0.001). ConclusionSatisfaction was high, as 90% of all patients would recommend subtalar fusion to others, even though the relatively poor outcome measures would suggest differently. Existing functional outcomes measures were influenced by concomitant injuries and additional procedures. This demands development of instruments suitable for severely injured patients with multiple or complex injuries.

The influence of foot and ankle injury patterns and treatment delays on outcomes in a tertiary hospital; a one-year prospective observation

BackgroundAnkle and foot fractures are amongst the most common injuries, and patterns may vary from primary care set up to tertiary hospitals. Severe foot injuries are projected to have significantly worse outcomes and surgical delays are thought to alter prognosis. MethodsAll patients with foot and ankle trauma were prospectively evaluated at a Tertiary trauma centre over one year. The incidence, fracture patterns, risk factors, and outcomes were evaluated, and cases were divided into simple foot injuries (FASS≤3) and severe foot injuries (FASS>3). Injury mechanisms, associated injuries, and delays in treatment were evaluated, and outcomes were analyzed using Visual–Analogue Scale Foot and Ankle (VASFA), Maryland Foot Score (MFS) and Foot and ankle disability index (FADI). Results294 Foot and Ankle injuries (51 females, 243 males) were encountered in 2919 trauma cases (incidence of 10%). 80 patients (27.2%) had simple foot injuries and 214 (72.8%) had severe foot injuries. 29 patients (9.9%) were below 18years; most (65.3%) patients were between 18 and 45 years age. Road traffic accident was most commonest mode of injury, with ankle fractures (30.6%) the most common. Metatarsal fractures (27.9%) and calcaneal fractures (21.4%) were 2nd and 3rd most common injuries in the foot. Surgical delay averaged 1 day in both severe and simple injuries. Injury led to 32 (10.9%) below knee amputations. Outcome evaluation in 127 (91 severe, 36 simple injuries) patients showed mean Maryland foot score of 89.30 in simple injury group and 84.87 in severe injury group. Mean VASFA score was 82.87 (simple) and 81.87 in severe injury, and mean FADI score was 93.13 (simple) and 91.05 (severe injury). More detailed analysis revealed that more good scores (64.4%) were documented in severe injuries group, and more excellent scores (52.8%) in simple injuries group. ConclusionFoot injuries constitute 10% of all orthopaedic trauma at tertiary hospitals; Majority of them are severe foot injuries, with 68.7% being open injuries. Surgical delay was similar in simple and severe foot and ankle injuries. Outcomes of severe injuries were similar to simple foot and ankle injuries, reflecting on the quality of care that could be administered to them when they present to tertiary hospitals.

Outcome Determining Factors for displaced Intra-articular Calcaneal Fractures treated operatively.

Introduction: Calcaneal fractures are caused by high energy trauma and mostly are intra-articular fractures. Nondisplaced intra-articular calcaneal fracture (IACF) can be treated non-operatively. However, displaced intra-articular need to be reduced and fixed anatomically to facilitate early ankle rehabilitation and minimize functional impairment. This study was done to find out the outcome of the IACF patients who underwent operative treatment.Methods: 62 patients with IACF were selected in this study and had been followed up from June 2009 to May 2013. They were placed into two groups; the operative treated and non-operative treated groups. Bilateral ankle lateral view plain radiographs were taken for comparison of the Bohler and Gissane angles. Both groups of patients were assessed by the Maryland Foot Score (MFS) and the SF-36v2 general health survey questionnaire. The ability of the patients to perform activity of daily living (ADL) and /or return to work (RTW) was assessed as well.Results: The operative treatment group of displaced IACF patients achieved no significant better scores in the mean MFS and SF-36v2 mean scores as compared to non operated cases. There was no difference in RTW between the 2 groups, but earlier ADL was recorded in the operated group. However, this study had found 5 associated factors which causes major effect to the patients’ outcome to treatment.Conclusions: The patient’s compliance with post-operative rehabilitation regimen were found to be significantly related with the outcomes.

Risk of osteoarthritis secondary to partial or total arthrodesis of the subtalar and midtarsal joints after a minimum follow-up of 10 years

IntroductionThe goal of this retrospective, multicentre study was to evaluate the long-term outcomes in patients who have undergone partial or total arthrodesis of the subtalar and midtarsal joints. HypothesisSecondary osteoarthritis of the adjacent joints can negatively affect the outcomes more than 10 years after these fusion procedures. Material and MethodsThe outcomes of 72 fusions (total: 22; partial: 50) performed between 1981 and 2002 were evaluated using the Maryland Foot Score (MFS), self-evaluation questionnaire and three weight-bearing X-ray views (Meary's with cerclage wire around heel, lateral and dorsoplantar). The average follow-up was 15±5 years (range 10–31). ResultsThere were two deep infections that resolved after lavage and antibiotics therapy. There were 21 early complications (10 complex regional pain syndrome, 7 delayed wound healing, 2 superficial infections, 2 venous thrombosis) that all resolved. There were five cases of non-union (6.9%) that healed after being re-operated. After five years, secondary osteoarthritis led to the fusion being extended to the tibotalar joint (1 case) and midtarsal joint (1 case). At the last follow-up, the average MFS was 71.5 (range 25–100). Patient deemed the result as either excellent (10%), very good (9%), good (55%), poor (19%) or bad (7%). Pain at the last follow-up was present in 84% of cases. The rear-foot was normally aligned in 45% of cases, varus aligned in 22% and valgus aligned in 33%. The MFS was significantly better in patients with normal alignment. Patients with neurological foot disorders had significantly more preoperative (80% cavovarus) and postoperative foot deformity (P<0.05). At the last follow-up, the rate of secondary osteoarthritis in the surrounding joints was elevated: 73% tibiotalar, 58.3% subtalar, 65.8% talonavicular, 53.5% calaneocuboid. The presence of osteoarthritis was not correlated with pain or lower MFS. However there was significantly more pain at last follow-up than at 12 months postoperative and two fusions were required in patients with secondary osteoarthritis. ConclusionAlthough partial or total arthrodesis of the subtalar and midtarsal joints is a reliable procedure, it induces secondary osteoarthritis. Even though it seems to be well tolerated more than 10 years after the initial procedure, this possibility must be discussed with young, active patients. Level of evidenceIV, retrospective study.

Central tendon splitting combined with SutureBridge double-row technique as a surgical treatment for insertional Achilles tendinopathy

Background Surgical treatment of insertional Achilles tendinopathy should be considered when a variety of conservative measures fail. To achieve a satisfactory outcome, thorough debridement of the Achilles tendon is critical, besides excision of the bursitis and the calcaneal exostosis. Central tendon-splitting provides straightforward access to the calcified or degenerative tissue within the Achilles tendon. For Achilles tendon reconstruction if detachment is present, several surgical techniques have been reported. Controversy surrounds the technique can provide maximum security for reattachment of the Achilles tendon. The SutureBridge double-row construct, initially used in rotator cuff repair, is probably a good choice. Methods Ten consecutive patients with insertional Achilles tendinopathy underwent tendon reattachment using the SutureBridge technique through a central tendon-splitting approach. We retrospectively evaluated the surgical outcomes, which included pre- and postoperative visual analog scale (VAS), postoperative Maryland Foot Score (MFS), postoperative range of motion of the affected ankle, and related complications. Follow-up was performed in the outpatient department. Results One patient was lost to follow-up. Nine patients (two male and seven female; 12 feet) were reviewed with a minimum follow-up of six months (range 6-30 months). The postoperative VAS pain scores were markedly lower than the preoperative scores. Postoperative MFS was 92.1±8.0 (range 74-100). No intra- or postoperative complications were found, except for one case of delayed healing incision. At last follow-up, all affected ankles achieved their normal range of motion, and patients were able to resume daily activities without any assistive device. Conclusions Although a randomized control trial with a larger sample may be necessary to compare the central tendonsplitting combined with the SutureBridge technique with other techniques, our results confirmed that it was a promising alternative for treatment of insertional Achilles tendinopathy.

Arthroscopic Versus Posterior Endoscopic Excision of a Symptomatic Os Trigonum

Background: Both subtalar arthroscopic and posterior endoscopic techniques are used to treat posterior ankle impingement syndrome (PAIS). However, there have been no studies comparing the 2 procedures. Hypothesis: Both arthroscopic and endoscopic excisions of the os trigonum are safe and effective in treating PAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-eight patients were treated with excision of the os trigonum either by an arthroscopic (16 patients) or endoscopic (12 patients) technique. The mean patient age was 29.8 years (range, 17-55 years), and the mean follow-up period was 30 months (range, 18-58 months). Preoperative and postoperative visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Maryland Foot Score (MFS) were used to analyze the functional results. Duration of surgery, time to return to sports (RTS), and patient satisfaction were evaluated as well. The size of the os trigonum was measured using T1-weighted sagittal magnetic resonance imaging (MRI). The clinical and MRI results were compared between the 2 groups. Results: The VAS score, AOFAS score, and MFS for both the arthroscopic group (preoperative: 6.3, 63.8, and 61.5, respectively; postoperative: 1.2, 89.9, and 89.6, respectively) and endoscopic group (preoperative: 6.7, 64.8, and 62.5, respectively; postoperative: 1.2, 89.9, and 88.4, respectively) improved significantly (P < .01). The mean surgery and RTS times were 39.4 minutes and 7.5 weeks in the arthroscopic group and 34.8 minutes and 8.0 weeks in the endoscopic group, respectively (P > .05). All patients were satisfied with the results. There were no significant differences between the 2 groups in the preoperative and postoperative VAS score, AOFAS score, or MFS (P > .05). The mean size of the os trigonum was 11.1 × 8.8 mm2 in the arthroscopic group and 12.6 × 10.4 mm2 in the endoscopic group, and the difference was significant (P < .05). Two patients underwent both arthroscopic and endoscopic procedures because of technical difficulty in removing the large os trigonum arthroscopically. Conclusion: Both arthroscopic and posterior endoscopic excisions of the os trigonum were safe and effective in treating PAIS. The arthroscopic procedure was more demanding, especially in cases of a large os trigonum. The posterior endoscopic approach had the advantage of addressing problems in the posterior ankle joint and allowed a more extensive release of the flexor hallucis longus.

The Salvage of Complex Hindfoot Problems with Use of a Custom Talar Total Ankle Prosthesis

There has been recent interest in the use of a custom long-stemmed talar component for salvage of failed total ankle replacement or for management of combined ankle and hindfoot pathology. The purpose of this study was to retrospectively review prospective data on patients who underwent total ankle arthroplasty with a custom long-stemmed talar prosthesis. From November 2004 to February 2006, thirty-three custom total ankle arthroplasties were performed in thirty-two patients. The indication for this prosthesis was stage-IV adult-acquired flatfoot deformity in six patients (19%), failure of a prior total ankle replacement because of severe subsidence and loosening of the talar component in thirteen (41%), and combined arthritis of the ankle and hindfoot joints in thirteen patients (41%; fourteen ankles). Patients were assessed for range of motion, radiographic results, and functional outcomes with use of the Short Form-36 (SF-36) subscale scores, American Orthopaedic Foot & Ankle (AOFAS) hindfoot score, and the Maryland Foot Score (MFS) at a minimum of four years. All patients were followed for an average of 58.6 months (minimum, fifty-two months) There was an overall increase in the total arc of motion following surgery from an average (and standard deviation) of 21.3° ± 14° preoperatively to 32.2° ± 11° postoperatively (p < 0.05). Subsidence (<3 mm) was noted in three patients. One patient had asymptomatic osteolysis around the talar stem. The mean Physical Component Summary score on the SF-36 was 28.2 ± 5.6 preoperatively and increased to 39.7 ± 6.5 postoperatively (p < 0.05). The mean SF-36 Mental Component Summary value increased from 42.2 ± 13.8 preoperatively to 50.8 ± 12.6 postoperatively (p < 0.05). The mean MFS was 47 ± 13 preoperatively and increased to 75 ± 10 postoperatively (p < 0.05). The average AOFAS hindfoot score increased from 41 ± 16 preoperatively to 68 ± 12 postoperatively (p < 0.05). There were three failures at greater than thirty-six months after surgery. Our data indicate that the use of a custom long-stemmed talar component, either placed primarily in patients with ankle and hindfoot arthritis or used as a revision prosthesis in patients with a failed total ankle replacement, is promising.

Comparison of Percutaneous Screw Fixation and Calcium Sulfate Cement Grafting Versus Open Treatment of Displaced Intra-Articular Calcaneal Fractures

The conventional treatment for displaced intraarticular fractures of the calcaneus (DIACF), with open reduction and internal plate fixation (ORIF), carries the risk of wound infection and delayed recovery. Alternatively percutaneous fixation techniques offer the possibility of equivalent outcomes in with a reduction in soft tissue complications. The goal of the present study was to evaluate the outcome of percutaneous reduction (PR), screw fixation, and calcium sulphate cement (CSC) grafting in the treatment of DIACF. Ninety patients were randomly assigned to PR and CSC grafting or ORIF between January 2006 and August 2008. The blood loss, Böhler's angle, calcaneal width, length, height and articular congruity of the posterior facet, wound complication, range of joint motion were compared, function scores such as American Orthopaedic Foot and Ankle Society score (AOFAS) and Maryland foot score (MFS) were measured. The quality of reduction was not significantly different between the two groups. There were significant differences favoring PR in blood loss (p < 0.01), range of joint motion (p < 0.01), AOFAS (p < 0.01) and MFS (p < 0.01) between the two groups. Postop infection was 12% ORIF and 3% PC (p = 0.23). Earlier weightbearing in the PR group did not result in a greater frequency of redisplacement than in the OR group. Our results indicate that compared with ORIF, the percutaneous reduction, fixation and CSC grafting for treatment of DIACF might allow accelerated weightbearing activity, reduce joint stiffness and improve the patients' satisfaction.

Treatment of Displaced Intra-Articular Calcaneal Fractures with Closed Reduction and Percutaneous Screw Fixation

Surgical treatment of displaced intra-articular fractures of the calcaneus is a standard procedure in many institutions. To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques. All patients who underwent percutaneous screw fixation according to the method of Forgon and Zadravecz between 1998 and 2006 were selected. Postoperative infections were recorded. During follow-up, pain, functional outcome, range of motion, and change in footwear were evaluated with the use of the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients also completed a general health status form (Short Form-36 [SF-36]) and a visual analog scale (VAS) for patient satisfaction. Subsequent subtalar arthrodesis and the removal of irritating screws were performed when indicated. We reviewed the cases of thirty-seven patients who had a combined total of thirty-nine displaced intra-articular calcaneal fractures and a follow-up period of at least twenty-four months. Five wound infections occurred, two of which were superficial and three of which were deep. At a mean follow-up time of sixty-six months, the mean AOFAS and MFS scores were 84 and 86 points, respectively, of 100 possible points. The mean score on the SF-36 was 76 points, and the mean score on the visual analog scale for patient satisfaction was 7.9 points of 10 possible points. Twenty-nine patients (78%) were able to wear normal shoes. At the time of follow-up, subtalar arthrodesis had been performed in two patients and seventeen patients (46%) had undergone an uncomplicated removal of painful screws. No substantial correlation was found between the severity of the fracture (Sanders classification) or the quality of the reduction when correlated with functional outcome parameters. We consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.

First Metatarsal Dorsal Close Wedge Osteotomy Combined with Medial Cuneiform Plantar Open Wedge Osteotomy for the Treatment of a Cavus Foot

Purpose: We wanted to analyze the results of the 1st metatarsal dorsal close wedge osteotomy (MTDW) combined with medical cuneiform plantar open wedge (MCPOW) for treating forefoot deformity of a cavus foot. Materials and Methods: We retrospectively analyzed 30 patients. Their mean age was 21.5 years (SD 10.6 years) and the average follow-up period was 2.3 years. Thirty-four cases of thirty patients were classified as group A, as classified by the 1st MTDW combined with the MCPOW, 16 feet (14 patients) were group B by the 1st MTDW or MCPOW, 12 feet (10 patients), and group C by triple arthrodesis, 6 feet (6 patients). We evaluated the ankle dorsiflexion, plantarflexion, heel alignment, and the Maryland foot score (MFS) preoperatively and the last follow-up, and we analyzed the radiologic Hibb, Meary, calcaneal pitch and tibiotalar angles. Results: The ankle dorsiflexion (p=0.01), plantar flexion (p=0.03) and heel alignment (p=0.02) of group A were significantly improved more than that of groups B and C. The MFS of group A revealed better than group B and C (p=0.01). The Meary (p=0.01), Hibb (p=0.02) and calcaneal pitch angle (p=0.02) of group A were significantly improved more than that of groups B and C. Conclusion: 1st MTDW combined with MCPOW osteotomy that focuses at the apex of the deformity for correction of a cavus foot can obtain better clinical and radiological results than other surgical procedures.

Clinical Outcome Scoring of Intra-articular Calcaneal Fractures

Outcome reporting of intra-articular calcaneal fractures is inconsistent. This study aimed to identify the most cited outcome scores in the literature and to analyze their reliability and validity. A systematic literature search identified 34 different outcome scores. The most cited outcome score was the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, followed by the Maryland Foot Score (MFS) and the Creighton-Nebraska score (CN). Reliability (internal consistency) and validity (content, construct, and criterion) were determined for the 3 outcome scoring systems. Internal consistency (Cronbach's alpha, reliability) was similar for the Maryland Foot Score (alpha=0.82) and American Orthopedic Foot and Ankle Society hindfoot score (alpha=0.78), but lower for the Creighton-Nebraska (alpha = 0.61). Floor and ceiling effects were good for all 3 scores. The individual items within these outcome scores showing best content validity were pain, return to work, subtalar range of motion, walking distance, ankle range of motion, and gait abnormalities or limping. Construct validity was good for all individual items except sagittal motion, stability at physical exam, and shoe size. The 3 outcome scores showed high correlation with patient satisfaction as measured with a visual analog scale (VAS, criterion validity) and indication for an arthrodesis. In conclusion, pending consensus, we would recommend choosing between the widely accepted, reliable and valid AOFAS hindfoot and the Maryland Foot Score as the scoring systems of choice. 2.

FRACTURES OF THE FIFTH METATARSAL RESULTS OF THE EARLY OPERATIVE TREATMENT OF ACUTE DISPLACED FRACTURES

Background. Fracture of the proximal 5th metatarsal bone (MTB) reach almost 2% of all fractures of the foot. Conservative treatment is method of choice in almost all cases. Selected cases can benefit from acute surgery especially if the proximal fragment is severe displaced or the excessive articular step off is present. Materials and methods. In a 4 year period 14 patients were operated due to the acute fracture of proximal 5th MTB. All patients were treated in less than 2 weeks after the injury. 10 patients had base avulsion fracture in zone I and 4 had Jones fracture in zone II with dislocation of fragments? 5 mm, articular step off of 2 mm and 30% of articulation surface. We used tension bend wire in 9 cases (64%), partially threaded cancellous screw in 4 cases (28%) and bone sutures in 1 case (7%). Postoperatively all patients used crutches with nonweight bearing for 4 weeks and afterwards partial weight bearing till the end of the treatment. All patients were practicing active exercises for ankle, foot and toes. The results were evaluated according to the Maryland Foot Score (MFS) at least 20 months after injury. Results. 13 patients (93%) were included in follow up. 12 patients were evaluated as excellent and only one as a good. All 13 patients have no or slight pain with no change in ADL or work ability. 9 patients (69%) reached full functional result and 4 (31%) patients had slight limitation during distance walk. Patients reached full weight bearing in average 7 weeks (5–13). Conclusions. Early operative treatment of selected cases allows fast return to preoperative activity without long term functional sequel. Both operative procedures, screw fixation and tension wire, yielded comparable and excellent end result.

A new technique for treatment of calcaneal fractures with a multihole plate: indications and results

Surgical treatment with open reduction and internal fixation is advocated for Sanders' type II and III intra-articular fractures of the calcaneus. Some clinical and technical problems in this type of operation are due to the thickness and the stiffness of the plates. The authors report their experience in the open reduction and internal fixation (ORIF) of type II and type III fracture using the multihole GECO® plate with 22 fractures treated in 19 patients during the period November 1994–May 1996. Fourteen patients (17 fractures) were followed-up at a mean of 18 months for both clinical and radiographic tests. According to the American Orthopaedic Foot and Ankle Society (AOFAS) score and to the Maryland Foot Score (MFS) the clinical results were ‘excellent’ and ‘good’ in 12 cases and 13 cases, respectively. There were more necroses of the surgical wound margins than in the literature; this was due to the learning curve and the initial prolonged surgical times. Peroneal tendonitis occurred less frequently (12%) than in the literature (20–30%).