Posterior Tuberosity Research Articles

Técnica quirúrgica del manejo de las fracturas de calcáneo a través de un abordaje del seno del tarso

Calcaneal articular fractures are fractures classically associated with a high rate of complications and poor outcomes. Osteosynthesis of the calcaneus through a sinus tarsi approach has shown results equal to or superior to those of the extended approach, having become the new gold standard.The objective of this article is to detail step by step the surgical technique of osteosynthesis of intra-articular fractures of the calcaneus through a sinus tarsi approach, from the selection of the fracture, positioning of the patient, layout of the operating room and the fluoroscope, the entire surgical process until postoperative treatment.The surgical technique described below is described in 6 steps.1.Layout of the operating room. Patient and Fluoroscope Positioning2.Reduction of the posterior tuberosity (correct height and varus)3.Sinus tarsi approach.4.Reduction of the articular surface and correct visualization. Arthroscopy5.Fixation of the articular surface6.Fixation of the posterior tuberosityAnatomical reduction of complex calcaneal fractures through an Sinus Tarsi Approach requires an understanding of the fracture and its associated deformities. Following the described sequence step by step will help to achieve a better reduction in order to achieve better functional results.

Two-pin Posterior Tuberosity to Medial Wall Reduction Technique in Calcaneal Fracture Using Sinus Tarsi Approach

Introduction: The purpose of this study was to describe a novel technique in the surgical treatment of displaced intra-articular calcaneal fractures using 2 Schanz pins to reduce the posterior tuberosity to the medial wall (constant fragment) and correcting the varus malalignment while using the sinus tarsi approach. Materials and Methods: Twelve patients with calcaneal fractures Sanders type 2 and 3 underwent surgical fixation using this technique at our center from January 2021 to September 2021. One Schanz pin was inserted into the constant fragment and another one was inserted into the posterior tuberosity from lateral to medial. By holding the 2 pins the fracture fragments were first disengaged by applying a distraction force. The heel was then brought out of varus by a combination of maneuvres. The posterior calcaneal tuberosity pin was pushed medially and then the 2 pins were held together with one hand. The ankle was then dorsiflexed to lock the reduction. Harris heel views were taken to ensure reduction. Results: The mean Bohler angle improved from 7.5 degrees preoperatively to 29 degrees postoperatively. The mean Visual Analog Scale was 2.3 out of 10 at 6 months’ follow-up. None of the patients had wound complications, sural nerve neuropraxia, or revision surgery due to malreduction. Discussion: The 2-pin posterior tuberosity to medial wall reduction technique in calcaneal fractures using the sinus tarsi approach is a useful maneuver that can be used by orthopedic surgeons to correct the varus malalignment which is a frequent problem in calcaneal fracture fixation.

Sagittal Orientation and Variabilities of the Anatomical Insertional Footprint of the Achilles Tendon: A Cadaveric Study

Category: Hindfoot; Sports Introduction/Purpose: New surgical techniques for Achilles tendon insertional pathology are evolving rapidly. Whether via open surgery, minimally invasive, or endoscopic approaches, more information about the Achilles' insertional footprint is needed to help surgeons with decision making. This study investigated the footprints of the Achilles insertion in sagittal orientation to delineate the anatomical landmarks, safe zones for bone resection3-down surgeries in treating insertional Achilles tendinopathies. Methods: Twenty fresh frozen cadavers were selected excluding insertional Achilles tendon pathology on lateral view x-rays. The calcanei were dissected maintaining the Achilles tendon insertion intact. Dimensions of the posterior tuberosity were recorded and marked to plan for three sagittal cuts (medial, middle, and lateral) (Fig 1 A). Using an oscillating saw (Fig 1 B.), the posterior tuberosity was cut into four pieces (Fig 1 C,E). A trapezoid shape (Fig 1 D) was reconstructed demonstrating relative location of the footprints of the Achilles insertion compared to the boundaries of the tuberosity on each piece (A, most superior point in the posterior tuberosity; B, most superior point in the Achilles insertion; C, most inferior point in the Achilles insertion; D, most inferior point in the posterior tuberosity). Data regarding footprints of the Achilles tendon insertion in the sagittal orientation was analyzed and compared within each trapezoid region and among different regions. Results: AB (calcaneal tuberosity tip to the upper limit of the Achilles insertion) was shortest at the medial cut (9.35mm) and longest at the lateral cut (12.15mm). However, the tendon thickness at the insertion (the distance from the proximal to the distal limits) represented by BC was shortest at the lateral cut (13.19mm) and longest at the middle cut (14.04mm). AD, the distance from the highest to the lowest point of the calcaneal tuberosity, was the longest at the middle cut (41.20mm). AB:BC ratio was highest at the lateral cut and lowest at the medial cut, indicating the safe amount of bone to be resected at the Achilles insertion. Tendon thickness relative to the whole calcaneal tuberosity (BC:CD) was highest at the medial wall (Table1). Conclusion: The sagittal orientation and variability of the Achilles tendon insertion is an under-studied topic in the literature. It needs to be addressed given recent trends towards minimally invasive procedures in treating insertional Achilles pathology. This study precisely delineated the footprint in each region of the insertion by creating a trapezoid pattern to compare the coordinates across these areas. This could lead to future three-dimensional reconstruction of the Achilles insertional footprint and patient- specific instrumentation software directed towards optimizing the management of Insertional Achilles pathology.

Hybrid Percutaneous Management of Acute Midsubstance Achilles Tendon Ruptures

Background: Operative management techniques of Achilles tendon ruptures can be categorized into open repair, mini-open repair, or percutaneous repair. Indications: Surgical repair of acute ruptures of the Achilles tendon is indicated in athletic populations, with percutaneous repair being an effective technique with more favorable outcomes. Technique: With the patient prone, the Achilles rupture is identified and the Percutaneous Achilles Repair System (PARS) jig is inserted under the proximal paratenon. A series of Keith needles and flat braided SutureTape sutures are passed transversely across the proximal stump of the tendon. The sutures are then shuttled through the distal stump using a SutureLasso through medial and lateral percutaneous incisions on the distal medial and distal lateral borders of Achilles, respectively. Sutures are passed, tensioned, and secured to the posterior tuberosity of the calcaneus with two SwiveLock anchors. Results: Percutaneous repair, compared with open repair, results in lower wound complication rates, improved cosmetic appearance and fewer adhesions. Following surgery, patients follow a 5-stage rehabilitation protocol with return to sport when patients demonstrate dynamic neuromuscular control during multiplane activities without pain or swelling. Outcome studies have compared percutaneous repairs to open repairs, with percutaneous repairs demonstrating a quicker return to work or baseline activities (2.8 months versus 5.6 months) and a shorter return to play for athletes (average 18 weeks). Also, a greater number of PARS patients were able to return to baseline activities within 5 months (98%), compared with open repair patients (82%; P = .0001). In a prospective randomized controlled trial of 33 patients, Lim et al reported no postoperative wound infections in the percutaneous group and a 21% infection rate in the open repair group ( P = .01). Finally, in a recent systematic review of only percutaneous repairs, reported rates of sural nerve injury and rerupture were only 3.3% and 2.1%, respectively. Discussion/Conclusion: Compared to open repair, percutaneous Achilles repair allows for decreased risk of soft-tissue complications with comparable functional outcomes and earlier return to activity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Minimally invasive Vs open medial displacement calcaneal osteotomy. A cadaveric study

Category: Hindfoot; Hindfoot Introduction/ Purpose: Medial displacement calcaneal osteotomy (MDCO) is routinely used to correct hindfoot valgus in flexible pes planovalgus deformities. Classically MDCO was described through a lateral heel oblique incision with soft tissue dissection and the use of sagittal saw. Recently, minimally invasive surgical (MIS) techniques have gained popularity among foot and ankle surgeons, with the aim to reduce wound complications and postoperative pain and swelling. MIS calcaneal osteotomy was reported to be safe and effective as compared to open techniques. The aim of this cadaveric study was to compare the degree of deformity correction (coronal calcaneal displacement) using MIS vs open MDCO. Methods: Eight matched pairs foot and ankle cadaveric specimen were used. All specimens were checked radiographically for any previous foot and ankle operations or deformities. For each pair, one foot (right or left) was randomly assigned to either open or MIS MDCO. After the completion of osteotomy, the calcaneal tuberosity was maximally displaced medially and fixed with 2 mm wire. The displacement was measured manually using a flexible metric ruler. All osteotomies and manual measurement was done by the same Orthopaedic surgeon. Displacement was measured on standardized axial calcaneal radiographs by three blinded foot and ankle Orthopaedic surgeons independently using an image processing software with standard scaling for magnification. The displacement was measured laterally on the anterior body fragment and medially on the posterior tuberosity fragment Figures 1. Data was compared using the Wilcoxon-Mann-Whitney U test with the P value of < 0.05 considered significant. Results: Five right and three left ankles underwent MIS osteotomy. On manual measurement the mean medial displacement was 7.87 mm and 8.66 mm for MIS and open technique respectively P=0.21). On radiographs, on medial measurements the average displacement of MIS osteotomy was 5.83 mm compared to 6.36 mm for the open group with a P value of 0.34. On lateral measurements the average displacement of MIS osteotomy was 5.94 mm compared to 6.17 mm for the open group with a P value of 0.67. Conclusion: This cadaveric study reported comparable coronal displacement using MIS vs open techniques for medical displacement calcaneal osteotomy. MIS calcaneal osteotomy offers a reliable alternative to open techniques with the potential advantages of lower wound related complications.

The Pathologic Achilles Insertion Angle (PAIA): A Novel Angular Measurement to Guide Both Evaluation and Treatment of Insertional Achilles Tendinopathy

Category: Hindfoot; Sports Introduction/Purpose: Insertional Achilles tendinopathy (IAT) refers to calcified enlargement of the Achilles insertion. Recently, the Zadek osteotomy has been proven to be an effective and minimally invasive procedure for IAT with a dorsal-based closing wedge osteotomy on the posterior tuberosity of the calcaneus. However, determining the wedge size and location to determine the exact enlargement of the tuberosity remains clinically challenging. The goal of this study was to examine the morphology of the calcaneus in both normal control and IAT groups, and to propose a novel algorithm to determine the angular measurement to guide treatment with a Zadek osteotomy. Methods: Lateral weightbearing images of 40 control feet were used to determine the size of the calcaneus and contour of the tuberosity. The shape of the calcaneus was mapped onto part of a circle the Standard Circle (SC) whose center and radius were statistically fitted and scaled in relation to the height and width of the calcaneus. The diseased tuberosity of 40 patients with IAT was outlined and compared to their respective SC's. An angle was calculated by which the diseased calcaneus curve was rotated around the weightbearing point to fit the SC. We defined this angular measurement as the Pathologic Achilles Insertion Angle (PAIA). The size of the PAIA should be the exact size of the Zadek osteotomy if the apex of the osteotomy is chosen at the weightbearing point of the calcaneus. The effect of moving the apex of the osteotomy anteriorly on the calcaneal pitch angle was calculated. Results: From the morphology of the 40 normal calcanei, the equation of the Standard Curve, R^2=(x+a)^2+(y+b)^2 was created to calculate the SC. The offsets of the center of SC and the radius of SC (a, b, and R) were scaled in relation to the width and height of the calcaneus. From the morphology of the 40 enlarged tuberosities in the IAT group, an algorithm was created to automate the calculation of PAIA. This represented the extent of the enlarged Achilles insertion, which also determined the size and location of the wedge to normalize the contour of the enlarged posterior tuberosity. Using the weightbearing point of the calcaneus as the apex of the osteotomy did not change the pitch angle of the calcaneus, but moving the apex of the osteotomy anteriorly reduced the calcaneal pitch angle determined by both the original PAIA and the calcaneal pitch angle of each specific foot. Conclusion: Based on mechanism of mapping and curve fitting, the newly developed PAIA, will not only guide evaluation of the enlarged tuberosity in IAT, but also calculate the size of the Zadek osteotomy taking the patient's calcaneus size, IAT enlargement size, and pitch angle in consideration.

Use of Weight-Bearing Computed Tomography in the Evaluation of Abnormal Hindfoot Morphology in Charcot-Marie-Tooth Patients

Category:Hindfoot; OtherIntroduction/Purpose:The hindfoot deformity seen in Charcot-Marie-Tooth disease (CMT) is poorly understood, and the contribution of abnormal bone morphology has never been conclusively demonstrated. The purpose of this study was to compare the three-dimensional (3D) bone morphology of the talus, calcaneus and navicular in a cohort of CMT patients versus a control population. We used the data obtained from weight-bearing computed tomography (WBCT) to reconstruct the geometric shape of each bone using 3D surface meshing techniques. Surface mesh analysis of this type is commonly used in engineering to evaluate and optimize 3D geometries and structures.Methods:A total of 17 WBCTs from 15 patients (average age 24) with CMT who underwent WBCT without previous surgeries, degenerative changes or open physes were included. These were compared to 20 healthy control WBCTs. Calcaneal measurements included the radius of curvature and the angle between the posterior tuberosity and posterior facet in the sagittal plane. Talar measurements include axial and sagittal declination between the body and neck as well as coronal rotation of the talar head relative to the body. Surface-mesh model analysis was performed comparing the average of the CMT cohort to the controls using CT analysis software (Disior Bonelogic). Means were compared with a t test (p<0.05).Results:CMT patients had significantly less sagittal declination (plantarflexion) versus controls (14.9 versus 25.1 degrees respectively) (p<0.01). Similarly, CMT patients had less talar head coronal rotation versus controls (30.2 versus 42.5 degrees respectively) (p<0.001). There was no difference in axial rotation of the talar neck versus body between the groups (p=0.88). The calcaneal radius of curvature in CMT patients was significantly smaller than the control population (716.6 versus 2143.5 mm respectively) (p<0.05). Angular differences were also significant between the posterior tuberosity and posterior facet of the subtalar joint in the sagittal plane (CMT 57.7 degrees, control 67.9 degrees) (p<0.001). Additionally, surface-mesh model analysis demonstrated the largest differences in morphology at the navicular tuberosity, medial talar head, sustentaculum tali and anterior process of the calcaneus (Figure 1).Conclusion:This is the first study to quantify the morphologic differences in osteology seen in CMT patients. The decreased sagittal declination of the talar neck is seen with a reciprocal decreased slope of the posterior facet of the calcaneus. The coronal rotation of the talar head and abnormal navicular tuberosity morphology shows changes seen in patients with CMT and may be attributed to unbalanced pull of the posterior tibial tendon during development. These findings will help refine, and potentially revolutionize the surgical reconstruction of cavovarus deformity in CMT patients.

Abnormal Bone Morphology in Charcot-Marie-Tooth Disease.

Although long suspected, it has yet to be shown whether the foot and ankle deformities of Charcot-Marie-Tooth disease (CMT) are generally associated with abnormalities in osseous shape. Computed tomography (CT) was used to quantify morphologic differences of the calcaneus, talus, and navicular in CMT compared with healthy controls. Weightbearing CT scans of 21 patients (27 feet) with CMT were compared to those of 20 healthy controls. Calcaneal measurements included radius of curvature, sagittal posterior tuberosity-posterior facet angle, and tuberosity coronal rotation. Talar measurements included axial and sagittal body-neck declination angle, and coronal talar head rotation. Surface-mesh model analysis of the hindfoot was performed comparing the average of the CMT cohort to the controls using a CT analysis software (Disior Bonelogic 2.0). Means were compared with a t test (P < .05). CMT patients had significantly less talar sagittal declination vs controls (17.8 vs 25.1 degrees; P < .05). Similarly, CMT patients had less talar head coronal rotation vs controls (30.8 vs 42.5 degrees; P < .001). The calcaneal radius of curvature in CMT patients was significantly smaller than controls (822.8 vs 2143.5 mm; P < .05). CMT sagittal posterior tuberosity-posterior facet angle was also significantly different from that of controls (60.3 vs 67.9 degrees respectively; P < .001).Surface-mesh model analysis demonstrated the largest differences in morphology at the navicular tuberosity, medial talar head, sustentaculum tali, and anterior process of the calcaneus. This is the first study to quantify the morphologic differences in hindfoot osteology seen in CMT patients. Patients identified with osseous changes of the calcaneus, especially a smaller axial radius of curvature, may benefit from a 3-dimensional osteotomy for correction.

Fracture mapping of complex intra-articular calcaneal fractures.

BackgroundIntra-articular calcaneal fracture remains challenging to manage. Computed tomography and fracture mapping are useful for the diagnosis and treatment of calcaneal fractures. The aim of the present study was to characterize calcaneal fracture patterns using fracture mapping.MethodsSixty-two calcaneal fractures were retrospectively included in the study. For each case, the fracture was simulated reduction manually. The fracture lines and zones of comminution were graphically superimposed onto an intact calcaneal template to identify fracture patterns. Major fracture lines and comminution were assessed by focusing on the posterior joint facet, medial wall, lateral wall, sustentaculum tali, and anterior process.ResultsThe fracture lines were mostly concentrated on the area anterior to the posterior joint facet and extended medially. The longitudinal lines ran posteriorly from the angle of Gissane, and separated the sustentaculum tali and medial wall from the calcaneal tuberosity. In the lateral wall, the fracture lines extended posteriorly with some branches to the bottom of the calcaneus. No fracture lines passed through the sustentaculum tali. Fracture lines of the posterior tuberosity and anterior process were rare.ConclusionsCalcaneal fracture lines follow characteristic patterns, which are closely related to the bone structure and fracture mechanism. These fracture patterns will aid clinicians choose surgical approach and fixations in the treatment of calcaneal fractures.

Avulsion fractures of the posterior tuberosity of the calcaneus (Case report and literature review)

Avulsion fracture of the calcaneal tuberosity is a rare lesion. We describe the observation of an elderly and diabetic patient who presented this lesion. Surgical treatment was performed by screwing, completed by an immobilization with good anatomical and functional results.

Exposure of the Calcaneus via the Sinus Tarsi Approach versus the Lateral Extensile Approach: A Cadaveric Study

Category:Hindfoot; TraumaIntroduction/Purpose:The lateral extensile approach (LEA) to the calcaneus has long been a popular surgical approach to treat calcaneal fractures. However, high rates of wound complications have led surgeons to investigate alternative approaches. As a result, the sinus tarsi approach has grown in popularity. The lateral extensile approach affords substantial visualization of the calcaneus. However, this visualization has never been compared in a quantitative manner to the sinus tarsi approach (STA). The objective of this cadaveric study is to compare calcaneal visualization afforded by a sinus tarsi approach and a lateral extensile approach.Methods:Seven pair-matched, fresh-frozen, below-knee cadaver specimens were obtained. For each pair, one side received an LEA and the other side received a STA. To identify areas of the calcaneus accessible by instrument, a curette was used to mark the visualized calcaneal surfaces. The calcaneus was then disarticulated and cleared of all soft tissue. The curette markings were then identified and marked with blue surgical marker. Photos were taken of each calcaneus, and visualized surface areas were calculated using Image J software.Results:There were no statistically significant differences in the articular surfaces accessible between the two approaches (831.99 mm2 for LEA vs. 903.41 mm2 for STA, p=0.53) including the anterior, middle, and posterior facets. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (p=0.02). The LEA allowed better exposure to the lateral wall (p<0.01) and superior greater tuberosity of the calcaneus (p=0.05).Conclusion:In comparison to the LEA, the STA allows for equivalent exposure to articular surfaces. While the LEA allows for greater exposure of the lateral wall and posterior tuberosity, direct visualization of these structures may not warrant the higher risk of wound complications. Surgeons should be mindful of these differences when choosing a surgical approach in the treatment of calcaneal fractures.

The effect of build angle on the tissue surface adaptation of maxillary and mandibular complete denture bases manufactured by digital light processing

Statement of problemThe effect of different build angles on the tissue surface adaptation of complete denture bases manufactured by digital light processing (DLP) is unclear. PurposeThe purpose of this in vitro study was to evaluate the effect of build angle on the tissue surface adaptation of DLP-printed complete denture bases. Material and methodsBoth maxillary and mandibular denture bases were virtually designed based on reference casts and fabricated by the DLP technique. For each arch, a total of 40 denture bases were fabricated with 4 different build angle conditions (90, 100, 135, and 150 degrees) and divided into 4 groups (90D, 100D, 135D, and 150D; 10 denture bases per group). The scanned intaglio surface of each DLP denture base was superimposed on the scanned edentulous area of the reference cast to compare the degree of tissue surface adaptation. Root-mean-square estimate, positive average deviation, and negative average deviation values were measured and displayed with a color deviation map. The Mann-Whitney test and Kruskal-Wallis analysis of variance were used for statistical analyses (α=.05). ResultsNo statistically significant differences were found for root-mean-square estimate values among any build angle groups in either the maxillary or mandibular arch. With the increase of build angles, the area of positive deviation in the maxillary arch moved from the palatal region to the posterior palatal seal area, and negative deviation became pronounced at the posterior tuberosity. In the maxillary arch, the 135D group showed favorable color distribution of surface deviation. In the mandibular arch, a positive deviation was detected at the labial slope to the crest of the ridge, whereas a negative deviation was observed at the buccal shelf and the retromolar pad. The 100D group showed favorable distribution of surface deviation in the mandible. ConclusionsIn both arches, the difference of overall tissue surface adaptation was not statistically significant in the 4 different build angles. However, the color deviation map revealed that the 135-degree build angle may be appropriate in the maxillary DLP-printed denture base and the 100-degree angle, in the mandibular denture base.

Greater Tuberosity Decortication Decreases Load to Failure of All-Suture Anchor Constructs in Rotator Cuff Repair

To evaluate the effect of greater tuberosity decortication on ultimate load to failure and displacement after cyclic loading with an all-suture anchor. A 2.9-mm all-suture anchor was evaluated in decorticated and nondecorticated greater tuberosities of 10 matched pairs of human cadaveric shoulders. Greater tuberosity decortication was performed to a mean depth of 1.7mm. Anchors were placed in the anterior, middle, and posterior tuberosity. Anchors were tested under cyclic loads followed by load-to-failure testing. Displacement after 20, 100, and 200 cycles and ultimate failure strength were determined. Clinical failure was defined as displacement greater than 5mm during cyclic loading. After 20 and 100 cycles, there was no difference in mean displacement between the decorticated and nondecorticated cohorts (P= .139 and P= .127, respectively). The mean displacement after 200 cycles was greater in the decorticated cohort, although not significantly (3.4 vs 2.7mm; P= .05). The mean ultimate load to failure was significantly lower in the decorticated cohort (314 vs 386N, P= .049). There were 2 clinical failures in the decorticated specimens and 1 in the nondecorticated specimens. A minimal greater tuberosity decortication significantly decreases the ultimate load to failure of an all-suture anchor. However, decreased biomechanical strength may not necessitate actual clinical failure. A decrease in ultimate load to failure could increase the risk of catastrophic postoperative anchor failure. However, while this decrease in strength is statistically significant, the overall decrease in strength may not be sufficient in magnitude to translate to clinical failure.

Fractura por avulsión de tipo II de la tuberosidad posterior del calcáneo (en pico de pato). Serie de casos

BackgroundThe objective of the study is to know the incidence, the results of the surgery and the need for rehabilitation of type II avulsion fractures of the posterior tuberosity of the calcaneus. Materials and methodsAn observational study of a series of cases was carried out. We retrospectively reviewed all the calcaneal fractures diagnosed in our hospital in the last 12 years and selected the ones classified as avulsion fractures of the tuberosity of the calcaneus (duck beak). ResultsWe found 10 fractures with an avulsion fracture pattern of the calcaneal tuberosity (duck beak), which correspond to 4% of all the calcaneal fractures reviewed. All were treated by an open reduction and internal fixation. One case was treated urgently due to signs of suffering of soft tissue. Four cases presented post-surgical complications. Three cases required specific rehabilitation treatment. Usually, there is no a unique formula to establish a rehabilitation program after surgery. DiscussionIt is likely to expect an increase rate of this particular fracture according to that elderly population increase with associated osteoporosis and diabetes. The displaced fragment produced by the Achilles’ tendon may compromise scaring after surgery. Often a specific rehabilitative protocol is not needed.Evidence level. IV.

Use of 3D Prints to Compare the Efficacy of Three Different Calcaneal Osteotomies for the Correction of Heel Varus.

Cavovarus deformity of the hindfoot is typically caused by neurologic disorders. Multiple osteotomies have been described for the correction of varus deformity but without clinical comparison. In this study, we used 18 identical 3-dimensional (3D) prints of a patient with heel varus to compare the operative correction obtained with Dwyer, oblique, and Z osteotomies. A computed tomography (CT) scan of a patient with heel varus was used to create 18 identical 3D prints of the talus, calcaneus, and cuboid. Coordinate frames were added to the talus and calcaneus to evaluate rotation. The prints were then divided into 3 groups of 6 models each. A custom jig precisely and accurately replicated each osteotomy. Following the simulated operations, cut models were CT scanned and compared with 6 uncut models. Measurements were calculated using multiplanar reconstruction image processing. An analysis of variance (ANOVA) was performed on the initial data to determine significant differences among the measured variables. A Tukey Studentized range test was run to compare variables that showed statistically significant differences using the ANOVA. The coronal angle of the Dwyer and oblique osteotomies was significantly less than that of the Z osteotomy ( P < .05). The axial angle, lateral displacement, and calcaneal shortening of the uncut model and Z osteotomy were significantly less than the Dwyer and oblique osteotomies. Dwyer, oblique, and Z osteotomies did not create either lateral translation or coronal rotation without the addition of a lateralizing slide or rotation of the posterior tuberosity. Dwyer and oblique osteotomies would be best suited for mild deformity, yet the amount of calcaneal shortening must be acknowledged. A Z osteotomy is a complex procedure that has the capability of correcting moderate-severe coronal plane rotation but fails to provide lateralization of the pull of the Achilles insertion.

Normative size of the osseous part of calcaneal bursa and its comparison with other calcaneal articular areas

The retro-calcaneal bursa presents a synovial and a non-synovial osseous part of variable dimensions. Studies objectively measuring the variability of the size of this osseous bursal surface cannot be found in literature. The objective of this study was to investigate (i) the dimension variability of the bony part of the bursa and (ii) the relationship of this surface to other articulating areas of the calcaneus. A digital planimeter was used to measure the bursae (n=86) and other articular surface areas of the calcaneus and statistically compared with ANOVA and correlation estimations. The osseous area measured 1.12 (±0.55) cm2, with only the superior articulating area demonstrating a weak correlation to this osseous surface.The osseous area presents a weak correlation with the axial articulating area of the calcaneus. Information on the size of the bony bursa may help safe excision of retrocalcaneal exostoses and in Achille’s tendon repair around the posterior tuberosity.

Biomechanical evaluation of reconstruction plates with locking, nonlocking, and hybrid screws configurations in calcaneal fracture: a finite element model study.

Calcaneal fractures are the most common fractures of the tarsal bones. The stability of fixation is an important factor for successful reconstruction of calcaneal fractures. The purpose of this study was to analyze the biomechanical influence of plate fixation with different combinations of locking and nonlocking screws during early weight-bearing phase. A three-dimensional FE foot model was established using ANSYS software, which comprised bones, cartilages, plantar fascia, and soft tissue. Calcaneal plate was fixed with whole locking (WLS), whole nonlocking (WNS), and hybrid screw configurations for FE analysis. The WNS generated a 6.1° and 2.2° Bohler angle decrease compared with the intact model and WLS (WNS: 18.9; WLS: 21.1; intact: 25.0°). Some hybrid screw configurations (Bohler angle: 21.5° and 21.2°) generated stability similar to WLS. The FE results showed that the fragments at the posterior facet and the posterior tuberosity sustained more stress. This study recommends that the hybrid screw configuration with at least four locking screws, two at the posterior facet fragment and two at the posterior tuberosity fragment, is the optimal choice for the fixation of Sanders type IIB calcaneal fractures.

Avulsion fracture of the posterosuperior tuberosity of the calcaneus managed with lag screw fixation

BackgroundTo review the efficacy of lag screw fixation in management of avulsion fracture of the posterosuperior tuberosity of the calcaneus. MethodsSince 2002, thirteen patients with displaced fracture of the posterior tuberosity of the calcaneus were treated with emergency reduction of the fracture and lag screw fixation. The medical records and radiographs of the patients were reviewed and the patients were assessed according to the Kerr calcaneal fracture scoring system during the latest follow up. ResultsThere was no skin necrosis, but one wound dehisced in a patient with unstable diabetes and hypothyroidism. All fractures healed, but two had separation of the fracture fragments after the plaster was removed, both of them were elderly osteoporotic patients. The overall average calcaneal score was 93 (range, 77–100). The average calcaneal score of the patients with closed reduction was 91 (range, 77–100). The average calcaneal score of the patients with open reduction was 94 (range, 79–100). Complications occurred in seven patients (54%). ConclusionsPercutaneous or open reduction of the avulsion fracture of the posterosuperior tuberosity of the calcaneus together with lag screw fixation and equinus short leg cast immobilization can provide good results without skin necrosis. The surgeon should pay attention of the details of the operation and the rehabilitation program in order to minimize the complications.

Determining Measurement Error for Bohler's Angle and the Effect of X-Ray Obliquity on Accuracy.

Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA. A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement. A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity. Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph. Level V: Cadaver bench study.

The Significance of Calcaneal Posterior Tuberosity Fragment Reduction When Treated with Open Reduction in Displaced Intra-Articular Calcaneal Fractures

The Significance of Calcaneal Posterior Tuberosity Fragment Reduction When Treated with Open Reduction in Displaced Intra-Articular Calcaneal Fractures