Tongue-type Calcaneal Fractures Research Articles

Functional Outcomes of Tongue-Type Calcaneal Fractures Treated with Percutaneous Screw Fixation

Functional Outcomes of Tongue-Type Calcaneal Fractures Treated with Percutaneous Screw Fixation

Intraoperative Foot Positioning During Percutaneous Calcaneal Fixation: A Technical Note.

Percutaneous screw fixation is a good modality for operative management of extra-articular and some intra-articular fractures of the calcaneum amenable to closed reduction. Tongue-type calcaneal fractures with a dislocated posterior facet are usually treated with percutaneous fixation. When treating calcaneal fractures with substantial soft tissue compromise, particularly open fractures, percutaneous reduction techniques are crucial. They also provide patients with local or systemic contraindications to open reduction with a therapeutic option. We describe the intraoperative positioning of the foot using a lithotomy stirrup during percutaneous fixation of the calcaneal fractures with minimum manipulation of the foot and C-arm and consistent imaging.

Percutaneous Cannulated Screw Fixation vs. Plating With Minimally Invasive Longitudinal Approach After Closed Reduction for Intra-Articular Tongue-Type Calcaneal Fractures: A Retrospective Cohort Study.

ObjectiveDisplaced intra-articular tongue-type fractures are often treated with surgical interventions, and there is a lack of consensus regarding the surgical approach. This retrospective cohort study aimed to compare percutaneous cannulated screw (PCS) fixation and plating with a minimally invasive longitudinal approach (MILA) after closed reduction for the treatment of tongue-type calcaneal fractures.Materials and MethodsA total of 77 patients with intra-articular tongue-type calcaneal fractures between September 2015 and July 2019 were included in this study. They were randomly allocated into two groups: PCS fixation (n = 32) and MILA (n = 45). The outcome measures included demographic variables, operation time (OT), preoperative time (POT), hospital stay time (HST), blood loss, visual analog scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, postoperative complications, and imaging parameters. The patients were clinically examined at 1, 3, 6, and 12 months, with a final follow-up period of 27 months.ResultsNo significant differences were observed during the follow-up in calcaneal length, height, Gissane's and Böhler's angles, VAS scores, AOFAS hindfoot scores, or complication rates between the two groups. However, the postoperative VAS scores in the PCS group were significantly lower than those in the MILA group (p < 0.05). Furthermore, the OT, POT, and HST in the PCS group were significantly shorter than those in the MILA group (p < 0.05). Blood loss was lower in the PCS group than those in the other group (p = 0.044). However, postoperative calcaneal widening was significantly smaller in the MILA group than that in the PCS group (p < 0.001).ConclusionsAfter closed reduction for the treatment of tongue-type calcaneal fractures, PCS fixation was superior to MILA in terms of OT, POT, HST, blood loss, pain, and degree of comfort. Meanwhile, MILA has the advantage of restoring the calcaneal width. Under the same rehabilitation program, the two approaches showed similar abilities in maintaining the closed reduction.

Treatment of tongue type calcaneal fractures operated using RS screw

Treatment of tongue type calcaneal fractures operated using RS screw

Three-dimensional computed tomography mapping of 136 tongue-type calcaneal fractures from a single centre.

BackgroundThis study aimed to evaluate tongue-type calcaneal fractures using three-dimensional (3D) computed tomography (CT) mapping method.MethodsA consecutive series of 136 tongue-type calcaneal fractures was used. CT data were used to reconstruct and reposition the 3D calcaneus body. E-3D Medical 18.01 software was used to superimpose the fractured calcaneal entity on the template, and the fracture line was drawn on the template. Finally, the heatmap was obtained using the fracture statistical analysis function. At the same time, the distribution of fracture lines in the anterior part of the calcaneus (APC) was recorded. Cases were divided into the following 3 subtypes according to the distribution of the tongue-type fracture lines of the calcaneal body: medial-lateral (Group A), upper-lateral (Group B), and upper-lateral-medial (Group C).ResultsThere were 68 cases in Group A, 48 cases in Group B, and 20 cases in Group C. Based on subtype, the characteristic fracture map of Groups A, B and C was constructed. The APC was evenly divided into zones A, B, and C from lateral to medial. In Group A, the most common types involve APC were Type AC (24, 35.3%) and Type A (11, 16.2%). In Group B, the most common types were Type AC (20, 41.7%), Type AB (8, 16.7%) and Type C (8, 16.7%). In Group C, the most common types were Type AC (8, 40.0%) and Type A (5, 25.0%).ConclusionsThis study investigates the distribution characteristics of fracture lines in subgroups of tongue-type calcaneal fractures for the first time. The results can help doctors improve their understanding of tongue-type calcaneal fractures, optimize internal fixation design, and provide a standard model for biomechanical experiments.

Novel Technique for the Treatment of a Tongue-Type Calcaneal Fracture in the Setting of Chronic Osteomyelitis.

Osteomyelitis of the calcaneus combined with a pathologic fracture is a rare and difficult presentation for any practicing foot and ankle surgeon. Treatment for achieving an aseptic nonunion involves a variety of steps, including surgical debridement, antibiotic administration, and fracture stabilization. In this case series, we report a novel technique for the treatment of a tongue-type calcaneal fracture in the setting of chronic osteomyelitis using the Biomet JuggerLoc bone-to-bone system for fixation.

A Development of the Essex-Lopresti Maneuver: Minimally Invasive Reduction and Fixation of Tongue-Type Calcaneal Fractures via a Single Incision.

Tongue-type calcaneal fractures are a subset of displaced intraarticular calcaneal fractures. A reduction maneuver for this fracture pattern was described by Essex-Lopresti. The aim of this article is to describe a modification of this technique that allows reduction and fixation of tongue-type calcaneal fractures via a single, minimally invasive incision. We retrospectively reviewed all patients undergoing fixation utilizing this technique at our institution. We identified 13 fractures in 12 patients with a median follow-up of 12 months. Median Böhler angle was 3.5° preoperatively and 26.5° at final follow-up. The median AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score was 78. There were no complications or further surgeries in this series. We believe that reduction and fixation of tongue-type calcaneal fractures using this minimally invasive technique is safe and reliable and avoids the potential soft tissue problems of fixation with more extensive incisions.Levels of Clinical Evidence: Level IV.

Mid- to long-term outcome in patients treated with a mini-open sinus-tarsi approach for calcaneal fractures.

While the extended lateral approach was the gold standard for treatment of calcaneal fractures for decades, the mini-open approach through the sinus tarsi gained popularity in recent years. Although widely used, there are only a few reports available in the literature reporting on mid- to long-term results. Therefore, the purpose of the study was to report on mid- to long-term radiographic and clinical outcomes of calcaneal fractures treated surgically using a mini-open sinus tarsi approach. In this retrospective review, radiographic and clinical outcome measures of 30 consecutive patients (34 fractures) were analyzed. Conventional radiographs were used to measure the Boehler's angle before and after surgical fixation. Computed tomography (CT) scans were analyzed to distinguish between joint depression and tongue-type calcaneal fractures. Each calcaneal fracture was additionally categorized according to the Sanders classification. The clinical outcome was measured using a 5-point Likert scale ranging from 0 (very unsatisfied) to 4 (very satisfied), the Visual Analog Scale (VAS) for pain, and the Maryland Foot Score. The Boehler's angle improved from 12.6 degrees preoperatively to 26.3 degrees postoperatively (P < 0.001). Loss of sagittal reduction (i.e., a decline of the Boehler's angle of > 5 degrees) from postoperative to the last follow-up was evident in nine (26%) fractures. Out of 29 patients with an available satisfaction score, 20 (69%) were very satisfied, 8 (28%) were satisfied, and one (3%) was moderately satisfied. Satisfaction at the last follow-up declined with higher age at surgery. An overall low complication rate was evident, with painful hardware needing removal being the most common complication. Approaching calcaneus fractures through the sinus tarsi providessatisfactory mid- to long-term radiographic and clinical outcomes, independent of the severity of the fractures according to the Sanders classification. Level IV, Retrospective Case Series.

Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review

Because consensus on the optimal surgical treatment of tongue-type calcaneal fractures is lacking, this study aimed to compare outcomes and postoperative complications of open and closed surgical treatment of these fractures. For this cases series, all patients 18 years or older who underwent operative fixation of tongue-type calcaneal fractures at 2 level I trauma centers between 2004 and 2015 were considered eligible for participation. Data on explanatory and outcome variables were collected from medical records based on available follow-up. Additionally, a systematic literature review on surgical treatment of these fractures was conducted. Fifty-six patients (58 tongue-type fractures) were included. Open reduction internal fixation was performed in 33 fractures, and closed reduction internal (percutaneous) fixation was performed in 25. More wound problems and deep infections were observed with open treatment compared with the closed approach: 10 (30%) versus 3 (12%) and 4 (12%) versus 0 (0%) procedures, respectively. In contrast, revision and hardware removal predominated in patients with closed treatments: 4 (16%) versus 1 (3%) and 9 (36%) versus 8 (24%) procedures, respectively. The systematic literature review yielded 10 articles reporting on surgical treatment for tongue-type fractures, all showing relatively good outcomes and low complication rates with no definite advantage for either technique. Both open and closed techniques are suggested as accurate surgical treatment options for tongue-type calcaneal fractures. Surgical treatment should be individualized, considering both fracture and patient characteristics and the treating surgeon's expertise. We recommend attempting closed reduction internal fixation if deemed feasible, with conversion to an open procedure if satisfactory reduction or fixation is unobtainable.

Characteristics of anterior inferior calcaneal cortex

BackgroundMinimal invasive surgery of calcaneal fracture provided satisfactory outcomes. In tongue type calcaneal fracture, percutaneous screw usually purchases in anterior inferior calcaneal cortex. However, there was no detail about the cortex of anterior inferior calcaneus so the surface anatomy and cortical thickness of this area were studied. Methods88 calcaneus from embalmed cadavers were enrolled. Anterior part of the inferior cortex was identified. Surface anatomy was examined. Length, anterior and posterior widths were measured. Anterior inferior calcaneal cortex was divided into anterior, middle and posterior segments. The cortical thickness at middle, medial most and lateral most of 3 segments were measured. ResultsAnterior inferior calcaneal cortex was a long trapezoidal shape with well-defined borders as a dense and thick cortical bone, convex relief from medial and lateral walls. Mean(SD) length was 33.40(3.46) millimeters (mm). Median(min,max) of anterior and posterior width were 10.50(8.21,19.26) mm and 14.00(10.05,20.42) mm, respectively. Mean(SD) of middle cortical thickness of anterior and middle segment were 3.12(0.76) and 3.72(0.74). Median(min,max) middle cortical thickness of posterior segment was 3.13(1.62,6.51) mm. Whereas, of the medial most were 1.31(0.78,3.11), 1.31(0.90,2.57) and 1.26(0.85,2.61) mm and of the lateral most were 1.17(0.67,2.64), 1.38(0.80,2.55) and 1.31(0.84,2.61) mm, respectively. Inter-intraobserver reliabilities of the measurements were >0.79. The statistical analysis showed the middle cortex is significantly the thickest (P<0.001) and posterior width is significant wider than the anterior (P<0.001). ConclusionsAnterior inferior calcaneal cortex has special characteristics in term of surface anatomy, width and thickness. For the percutaneous screw insertion from posterosuperior to anterior inferior calcaneus in tongue type calcaneal fracture, we recommend that screw should purchase in middle cortex due to maximal cortical thickness as well as its cortical width could accept 6.5 or 7.0mm screw without screw extrusion.

Soft tissue complications and timing of surgery in patients with a tongue-type displaced intra-articular calcaneal fracture: An international retrospective cohort study

IntroductionTongue-type displaced intra-articular calcaneal fractures (DIACF) are associated with a specific pattern of fracture displacement in contrast to joint depression fractures. This may result in tension of soft tissue in the posterior part of the heel. Tension-induced ischemia can result in skin necrosis. The objectives of this study were to investigate whether patients with tongue-type calcaneal fractures exert a higher risk of complications, especially of the posterior soft tissues, than joint depression type fractures. Also, late interventions (e.g., antibiotics, debridements, and amputations) and the effect of timing of surgery on the complication rate was assessed. MethodsIn this international retrospective cohort study, data of adult patients with a DIACF in the period January 1, 2005–December 31, 2015 were extracted from patients’ medical files. Descriptive, univariate, and multivariable analyses were performed in SPSS. ResultsA total of 560 patients with 632 DIACF were included (295 tongue-type and 337 non-tongue-type fractures). At hospital presentation, 20.3% of the patients with a tongue-type fracture had compromised posterior soft tissue versus 12.8% with non-tongue-type fractures (p = 0.032). However, corrected for potential confounders the risk was no longer statistically significant (OR 1.497; 95% CI 0.831–2.696). Patients with a TT-DIACF had a 1.2–3.4-fold higher rate of any local wound complication (deep infections, and full thickness lesions, p < 0.03). In addition they had 2.0–8.0-fold more intravenous antibiotics, debridements, soft tissue coverage procedures and amputations (p < 0.03). Patients who underwent surgery within two days after trauma had a higher risk to develop any complication, in particular superficial infections, when compared to surgery between 3–7 days, but no significant difference between 3 and 7 and ≥8 days could be demonstrated. ConclusionDespite the fact that patients with a tongue-type fracture developed posterior skin and soft tissue compromise nearly twice as often, this difference disappeared after correction for confounders. The overall complication risk was increased in patients with tongue-type calcaneal fractures as compared to patients with a non-tongue-type fracture. Whether or not patients with tongue-type fractures require immediate surgery cannot be concluded from the data.

A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise

Displaced calcaneal fractures encompass a spectrum of fracture patterns, many of which are associated with soft tissue complications. Displaced tongue-type calcaneal fractures often cause pressure on the posterior heel skin, particularly when treatment is delayed. Resultant partial- or full-thickness skin necrosis presents significant challenges to the treating surgeon. In this article, the authors report on a case of full-thickness skin necrosis associated with a displaced tongue-type calcaneus fracture. The authors describe the use of a specialized heel window casting technique, which eliminates posterior heel pressure and greatly facilitates soft tissue surveillance and local wound care. The article also reviews the literature on soft tissue complications associated with displaced calcaneus fractures.

Finite Element Analysis of Tongue Type Calcaneal Fracture with Open Reduction and Internal Fixation with Locking Plate

Open reduction and internal fixation (ORIF) with plate is the standard treatment for displaced intra-articular calcaneal fractures. We constructed a three-dimensional complete foot finite element model, which was also modified to evaluate the biomechanical effect of Sanders IIB tongue-type calcaneal fracture treated by ORIF with locking plate. We compared plates with locking screws (LSs) and those with non-locking screws (NSs). Static standing was simulated by applying ground reaction force and the pulling force of the Achilles tendon. ORIF with plate using NS or LS provided good stability for Sanders IIB tongue-type calcaneal fracture and might allow light touch weight-bearing in the early postoperative period.

A Prospective Study on Radiological and Functional Outcome of Displaced Tongue Type Intra-Articular Calcaneal Fractures Treated by Percutaneous Screw Fixation.

Calcaneal fractures have posed a challenge to orthopaedic surgeon for many years. The major problem is to reconstruct the fracture and improve healing of the fracture and also the surrounding tissues. Anatomic restoration of the three-dimensional anatomy of the calcaneum is the goal of surgical management of calcaneal fractures. Over the years, various techniques have been developed to accomplish this goal. To determine the functional outcome in displaced tongue-type calcaneal fracture treated by percutaneous screw fixation. A prospective study was conducted from October 2012 and September 2014. A total of 23 patients with intra-articular 'tongue type' calcaneal fractures were included in the study. Complete clinical and radiological evaluation was done. The surgical procedure encompassed closed reduction and fixation with two criss-cross 6.5 mm cannulated cancellous across the fracture site under fluoroscopic guidance. Postoperatively, on day three ankle and toe mobilization was begun. Non-weight bearing crutch mobilization was begun on postoperative day three. Reviews were done at 6 weeks, 12 weeks and 24 weeks postoperatively. At 6 weeks partial weight bearing mobilization was started. Full weight bearing was begun at 12 weeks. The patient was finally reviewed at 24 weeks and assessment of ankle function was done as per the Maryland foot scoring system. Radiographs were compared and preoperative and postoperative Gissane's and Bohler's angles were also compared. The results were analysed as per descriptive statistics (frequency, percentage). The complications noted were documented. Of the 23 patients under the study, three had excellent results with mean score of 90, 17 had good results with mean score of 82.94 and three had fair results with mean score of 74. Only one patient had subtalar arthritis as a complication. No other complications were seen. Percutaneous screw fixation of tongue type calcaneal fractures is a very effective surgical technique.

Irreducible tongue-type calcaneal fracture due to interposition of flexor hallucis longus

We present a rare case of interposition of the flexor hallucis longus (FHL) tendon blocking percutaneous closed reduction of a displaced tongue-type calcaneal fracture, and necessitating open repositioning of the tendon and internal fixation through a single extensile lateral approach. Although not recognized until during surgery, with a high index of suspicion, preoperative diagnosis of this injury combination should be possible on high resolution CT, thus enabling better planning of the procedure. The presence of a small sustentacular fragment, especially if markedly displaced or rotated, should further alert the physician as to increased likelihood of such tendon entrapment within the fracture. In the literature, fracture fixation and extrication of the FHL tendon have been performed via either or both lateral and medial approaches. A medial approach may prove necessary when there is severe displacement or rotation of the sustentacular fragment. Arthroscopically assisted surgery may aid in disengaging the tendon from within the fracture site.

Turning Tongues Into Joint Depressions

The articular surface of the posterior facet may be extremely difficult to reduce anatomically in a tongue-type calcaneal fracture because the fragment tends to translate when attempting the rotational component of the reduction. A new osteotomy that converts the tongue into a joint depression fragment to permit an accurate articular surface reduction is described to assist in realignment. This technique has been used successfully by the author in more than 30 fractures, and the results are reported herein. Surgeons faced with this dilemma may use the maneuver to solve a difficult problem.

A Percutaneous Technique for Reduction and Internal Fixation of Displaced Intra-Articular Calcaneal Fractures.

A retrospective cohort study demonstrated that, in comparison with open reduction and internal fixation through an extensile lateral approach, our percutaneous technique for reduction and internal fixation of displaced intra-articular calcaneal fractures decreases the rate of complications and achieves and maintains extra-articular fracture reductions just as well. Position the patient correctly to obtain excellent fluoroscopic views, which are key to the procedure. The techniques for reducing and fixing joint depression and tongue-type calcaneal fractures differ and will be described separately. Identify screw entry points and paths using fluoroscopic images, and confirm the final positions with c-arm imaging. Apply a splint; then obtain postoperative images to confirm fracture reduction and screw placement. The results of percutaneous reduction of displaced intra-articular calcaneal fractures in seventy-nine patients with a total of eighty-three fractures were compared with those obtained by another surgeon using the extensile lateral approach. IndicationsContraindicationsPitfalls & Challenges.

Percutaneous Fixation of Displaced Calcaneal Fracture

Purpose To review the techniques and outcomes of percutaneous fixation, with the modified Essex-Lopresti technique, in isolated, displaced tongue-type calcaneal fractures. Methods This is a retrospective review of 24 patients who received percutaneous calcaneal screw fixation in our hospital, from April 2003 to June 2009. One patient had bilateral fixation performed. All patients had a serial of X-rays of the injured foot, which included anteroposterior, axial, lateral, and Broden’s views. Preoperative and post-operative Bohler’s and Gissane’s angles were measured. The patients’ conditions were continuously assessed in serial follow-ups, and the Maryland Foot Score was used to evaluate the clinical outcome. Results Bohler’s and Gissane’s angles were fully restored in 13 and 17 out of 25 fractures, respectively. The mean duration of post-operative hospital stay was 4 days. There were no major post-operative complications. Sixteen patients were able to resume their original jobs. The Maryland Foot Score rated 13 out of 25 injured limbs (52%) as excellent, 9 (36%) as good, and 3 (12%) as fair. There were no patients rated as poor. The three patients with fair results complained of pain and stiffness at the subtalar joint. Conclusion Percutaneous fixation of displaced tongue-type calcaneal fractures is an effective treatment with acceptable clinical outcome, short hospital stay, minimal skin complications, and quick recovery.