Treatment Of Intra-articular Calcaneal Fractures Research Articles

Clinical and radiological assessment of the Polish modification of the Ilizarov external fixator for the treatment of intra-articular calcaneal fractures.

There is currently no established gold standard for the treatment of calcaneal fractures. To conduct a clinical and radiological evaluation of patients following intra-articular calcaneal fractures treated with the Polish modification of the Ilizarov method. This was a 2-center retrospective study. We evaluated 27 patients (2 women and 25 men) aged 28-73 years (mean age 50.5 years) after treatment of intra-articular calcaneal fractures with the Polish modification of the Ilizarov method. We assessed pain using a visual analogue scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) scores, patient satisfaction with treatment, use of analgesics, duration of Ilizarov treatment, length of hospital stay, duration of surgery, patient's declared willingness to choose the same treatment again, complications, degenerative changes, Böhler angle, inflection angle, and Gissane angle. The mean follow-up period was 3 years and 2 months. Following treatment, the mean VAS pain score was 2.3. Prior to surgery, all patients were taking analgesics in comparison with only 2 patients (7.4%) at long-term follow-up. The treatment was rated as satisfactory by 11 patients, with 16 patients rating it as highly satisfactory. The mean post-treatment AOFAS score was 76.6 points. The Ilizarov fixator was removed after a mean period of 88 days. The mean duration of hospital stay was 7.4 days. The mean duration of the procedure was 44 min. All patients would choose the same treatment again. Complications were observed in 5 patients. The long-term follow-up visit revealed degenerative changes in the talocalcaneal joint in 8 patients. The median Böhler angle was 5.5° preoperatively and 28.5° postoperatively, p < 0.001. The median preoperative inflection angle of 160° decreased to 145°, p < 0.001. The median preoperative Gissane's angle of 119° increased significantly to a median postoperative value of 143°, p < 0.001. The patients achieved good clinical and radiological outcomes.

EVALUATING SHORT-TERM OUTCOMES POST- INTRA-ARTICULAR CALCANEAL FRACTURE FIXATION VIA A SINUS TARSI APPROACH IN A NON-EXCLUSIVELY SELECTED COHORT

AimsManagement of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications.MethodsAll patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score.ResultsFifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%).ConclusionIntra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.

Comparison of different intraoperative reduction monitoring methods in a cadaveric intraarticular calcaneal fracture model: 3D scan vs arthroscopy vs nanoscopy.

Visualization of the subtalar joint surface in surgical management of calcaneal factures remains a big challenge and anatomic reduction of the articular surface is essential for a good clinical outcome. We hypothesize that video-assistance can provide superior fracture reduction compared to fluoroscopy and that nanoscopy (NSC) achieves more extensive visualization compared to fracturoscopy (FSC). Ten human cadaveric feet with artificially pre-fractured intraarticular calcaneal fractures with involvement of the posterior facet were treated via a minimal invasive subtalar approach. After initial control of reduction by 2D fluoroscopy, the reduction was further analyzed intraoperatively by FSC and NSC. 3D Scan served as gold standard control of reduction. Need of revision of reduction after the different visualization techniques was recorded and the extent of visualization of the subtalar joint surface in the medio-lateral dimension was compared for FSC and NSC. To quantify access and visualization of the medial and posterior facet, a depth gauge was used to measure from laterally at the clinically widest portion of the calcaneus targeted to the sustentaculum tali. The distance in millimetres was referred to the complete medio-lateral distance seen on paracoronal CT at the widest portion of the calcaneus. Fracture analysis in preoperative CT-scans according to Sanders classification revealed four type IC, two IIA, three IIC and one IIIAC fractures. Mean visualization of the medial and posterior facet was significantly improved with NSC (30.4 ± 3.78mm) compared to FSC (23.6 ± 6.17mm) (p = 0.008). An imperfect reduction requiring revision was more often required with NSC compared to FSC. Insufficient reduction using video-assistance was found in two cases. In order to optimize subtalar joint reduction and congruency, video-assisted techniques, especially NSC, provide superior visualization and thus can improve reduction in the surgical treatment of intraarticular calcaneal fractures.

Patient Reported Outcome Measures (PROMs) in Surgery: Evaluation after Minimally Invasive Reduction and Percutaneous K-Wires Fixation for Intra-Articular Calcaneal Fractures

The optimal surgical treatment of intra-articular calcaneal fractures (IACF) is still under debate. In the literature, results are based on clinical or radiographical findings. Few studies have evaluated the effect of patient expectations on patient-reported outcomes after surgery and little is known about outcomes directly reported by the patient who experienced it. Patient reported outcome measures (PROMs) may represent a viable and useful tool for evaluating the efficacy of the procedure and can be considered as an indicators of health-care quality. The aim of this study is to evaluate PROMs after minimally invasive reduction and percutaneous Kirschner-wires fixation for IACF, and to compare PROMs to pre-operative and last follow-up radiographic findings. 33 consecutive patients with IACF treated with minimally invasive reduction and percutaneous K-wires fixation were included. Data collection included demographics, pre-operative and last available Böhler and Gissane angle X-rays, foot function index (FFI), and foot and ankle outcome score (FAOS). At a mean follow up of 36.7 months, the mean FFI score was 24.3 ± 19.9 and the mean FAOS score was 68 ± 24.8. Patients with better Gissane angle showed better activity limitations FFI subscores. Moreover, worse pre-operative Gissane and Böhler angle were significantly associated with a worse total FAOS score and subscores. Minimally invasive reduction and percutaneous K-wires fixation provided satisfactory PROMs. Despite these results, prospective randomized studies are required to confirm the validity and reliability of PROMs in evaluating different treatments.

Calcaneus Fracture Fixation: Assessing the Adequacy of the Sinus Tarsi Surgical Fixation Technique

Category: Trauma; Hindfoot Introduction/Purpose: Intra-articular calcaneus fractures are devastating injuries, and life-changing for patients that develop post-traumatic arthritis, a common outcome. Debate exists as to whether non-operative symptomatic management, or operative treatment, best manages these injuries, partially due to the difficulty of achieving anatomic subtalar joint reduction. Traditionally, a large, lateral extensile incision has been used, plagued with soft tissue complications quoted at rates upwards of 22%. A less invasive incision, the limited sinus tarsi approach (ST-a), has become more common, proposed to lower complication rates without compromising radiographic nor clinical outcomes. The primary purpose of this study was to objectively assess the adequacy of joint reduction along with the associated soft tissue complications using the ST-a and compare it to the standards of the lateral extensile incision. Methods: All calcaneus fractures fixated through the ST-a at our institution were reviewed between March 2017 and Jan 2020. Inclusion criteria included the presence of preoperative and post-operative X-rays and CT scans. Primary outcomes were radiographic measures, including Bohler's angle on X-ray, and the maximum summative step deformity at the posterior facet of the subtalar joint in all three planes on CT scan. Secondary clinical outcomes included soft tissue complications (infection, delayed wound healing) and the need for reoperation. Results: Thirty patients were included with an average age of 48.9 +- 13.9 (n=24 males, n=6 females) and Sanders classification of 2.8. Pre-operatively, the mean Bohler's angle and summative posterior facet step deformity were 5.8 +- 16.6° and 17.2 +- 9.3mm, respectively. These radiographic outcomes were significantly improved postoperatively to 27.2 +- 7.7° and 5.3 +- 2.9mm. Soft tissue complication rates were half that of the comparative extensile approach. Conclusion: Using the ST-a, radiographic joint reduction was acceptable compared to literature standards. There was subsequently a lower incidence of soft tissue complications than previously quoted for the lateral extensile approach. Although technically more demanding, the ST-a is a valuable method for the treatment of intra-articular calcaneal fractures and should be considered when planning operative management of intra-articular calcaneus fractures.

Displaced intra-articular fractures of the calcaneus: Percutaneous reduction and screw fixation

Background: Extensile open technique to reduce and fix intra-articular calcaneal fractures have a high rate of wound complications. A technique of percutaneous reduction and fixation with screws alone was devised to avoid these problems. The clinical results, & radiographs were evaluated in this study after operational treatment using this approach. Methods: The study looked at 33 patients who had intra-articular calcaneal fractures in Sri Lakshmi Narayana Institute of Medical Science Puducherry from January 2020 to December 2021. At 3 months after the injury, all patients were evaluated for early postoperative sequelae. The clinical outcomes were evaluated for patients who were seen at least 6 months following surgery. The articular reduction was quantitatively analysed in patients who received both preoperative and postoperative radiographic images. Results: No complications were found at the 3-month follow-up. At least 6 months after the injury, screw irritation 9% (3 patients), subtalar osteoarthritis 3% (1 patient) requiring subtalar fusion percent, malunion 9%(3pt), and deep infection 0 percent were among the consequences. The Bohler angle, calcaneal facet height, and width all improved markedly after surgery. The Bohler angle increased by +24.1 degrees on average after surgery, with a loss of 4.9 degrees during the 3-month follow-up, 54.5 percent of patients reported a residual pain level of 3 or lower at the final follow-up.Conclusion: Based on articular reduction and amount of residual discomfort, this study suggests that percutaneous treatment of intra-articular calcaneal fractures with screws alone could offer acceptable early results.

Клінічні аспекти діагностики та лікування внутрішньосуглобових переломів п’яткових кісток

В аналітичному огляді літератури розглянуті питання діагностики та лікування внутрішньосуглобових переломів п’яткових кісток. Висвітлені основні тенденції і напрямки діагностики та лікування: механогенез, сучасні класифікації, стандарти обстеження, можливості оптимізації надання медичної допомоги постраждалим із внутрішньосуглобовими переломами п’яткових кісток. У результаті проведеного аналізу встановлено, що існує проблема діагностики й якісного лікування внутрішньосуглобових переломів п’яткових кісток, яка потребує вирішення шляхом розробки, впровадження комплексних методик діагностики та лікування на засадах доказової медицини.

Sinus Tarsi Approach With Percutaneous Screw Fixation for Intra-Articular Calcaneal Fractures

The aim of this study was to evaluate the outcomes of surgical treatment of intra-articular calcaneal fractures by using the sinus tarsi approach combined with percutaneous medial reduction by leverage technique and percutaneous screw fixation. We assessed the outcomes of 29 patients treated using sinus tarsi approach with percutaneous screw fixation. All patients were evaluated both clinically and radiologically. The Böhler and Gissane angle were evaluated postoperatively using radiographs. During the median follow-up period of 27.0 ± 10.3 months, no cases with failure to reduce or displace hardware were detected. All cases achieved the restoration of a normal Böhler and Gissane angle. The median preoperative Böhler angle was 12.3° ± 2.5° while postoperatively it was 30.5° ± 5.7° (p < .01). The median preoperative Gissane angle was 98.1° ± 7.5°, which was 125.9° ± 3.6° postoperatively (p < .01). At the last follow-up, the median American Orthopedic Foot and Ankle Society hindfoot score was 87.7 ± 5.9, and the median Maryland foot score was 88.6 ± 5.9. Our technique for intra-articular calcaneal fractures can effectively correct calcaneal tuberosity outward displacement, medial wall overlapping, and the hindfoot varus deformity with less soft tissue damage. This technique is a good alternative for the treatment of calcaneal fractures, resulting in minimal soft tissue damage, few wound complications, and excellent radiological and clinical outcomes.

Comparative study on curative effect of minimally invasive locking plate for the treatment of intra-articular calcaneal fractures via sinus tarsi approach

To compare clinical efficacy of minimally invasive locking plate and anatomic locking plate in treating intra-articular calcaneal fractures via sinus tarsi approach. A retrospective analysis was conducted of 48 patients with intra-articular calcaneal fractures treated with surgery via sinus tarsi approach from July 2016 to June 2017. According to differernt methods of internal fixation, the patients were divided into minimally invasive locking plate group and anatomic locking plate group. In minimally invasive locking plate group, there were 14 males and 10 females, aged from 27 to 46 years old with an average age of (38.70±5.58) years old, 18 patients were typeⅡand 6 patients were type Ⅲ according to Sanders classification. In anatomic locking plate group, there were 17 males and 7 females, aged from 26 to 46 years old with an average age of (37.10±6.44) years old, 16 patients were typeⅡ and 8 patients were type Ⅲ according to Sanders classification. Operative time, visual analogue scale (VAS), postoperative complications between two groups were compared, and Böhler angle, Gissane angal, calcaneal width and height were recorded and compared between two groups at 1 week after operation and final follow up. The functional effect was assessed according to Maryland foot function score at final follow up. All patients were followed up for (14.10±1.94) months (ranged 12 to 18 months). All patients were obtained bone union from 8 to 16 weeks with an average of (10.60±2.25) weeks. Operation time, VAS score and complication rate in minimally invasive locking plate group were (69.50±7.51) min, (2.80±1.07) and 2 cases respectively, and (77.50±7.15) min, (3.80±1.09) and 8 cases in anatomic locking plate group respectively, there were statistical difference between two groups (P<0.05). However, there were no statistically differences in Maryland foot function score, Böhler angle, Gissane angle, calcaneal width and height at 1 week after opertaion and final follow-up between two groups (P>0.05). Compare with anatomic locking plate, minimally invasive locking plate via sinus tarsi approach for Sanders typeⅡ and Ⅲ intra-articular calcaneal fractures could obtain similar reliable fixation and functional recovery with more simple operation, shorter operative time, lighter postoperative pain and less complications.

Early Results of Surgical Treatment of Intra-Articular Calcaneal Fractures Using T-Shaped Plates

Background: Displaced intra-articular calcaneus fractures are still now a controversial topic among orthopedic surgeons. There is no single treatment option to manage all different fractures. Objective: The aim of this study was the assessment and evaluation of providing and maintaining stable fixation by the use of a T-shaped plate for displaced intra-articular calcaneal fractures. Patients and Methods: A randomized controlled study was conducted on18 patients were conducted between the ages of 18 to 50 years in the Orthopedic and Traumatology Department of Zagazig University Hospital from August 2020 to April 2021 including 6 months follow-up periods, all patients with closed D.I.A.C.F with no morbidity. T plates were the method of fixation for all patients. Results:Mean A.O.F.A.S. hindfoot scale result was 86.61, 88.8% of patients their results were satisfying (excellent and good), and 11.1% of patients their results were unsatisfying (fair). Complications were seen in 27.7% (wound complication, subtalar arthritis, symptomatic hardware, and delayed union). Conclusion: T-shaped plates can provide stable support and rigid fixation as they maintain proper reduction and alignment to displaced intra-articular calcaneus fractures.

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

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

Minimally invasive approach with external fixator for intra-articular calcaneal fractures in children.

Calcaneal fractures are rare in pediatric population, with more displaced intra-articular fractures encountered due to the increasing number of high-energy trauma. Operative interventions are gaining popularity because of the unsatisfactory outcomes of traditional conservative methods. This study investigated the clinical outcomes of a minimally invasive technique using the sinus tarsi approach and external fixator in the treatment of intra-articular calcaneal fractures in pediatric patients.Patients who underwent open reduction between January 2010 and January 2018 at our institute were included in this study and reviewed retrospectively. Radiological and clinical parameters were all recorded and analyzed.Overall, 29 patients were included in the study, including 23 boys and 6 girls (10.2 ± 2.2 years old). The average follow-up was 29.5 months postoperatively (range, 26–72 months). Bohler angle was 15.2 ± 3.3° preoperatively, and 34.0 ± 3.8° postoperatively (P < .001); Gissane angle was 101.8 ± 6.2 degrees preoperatively, and 129.7 ± 6.2° postoperatively (P < .001). The average length of incision was 3.4 ± 0.7 cm. At the last follow-up, all patients showed satisfactory clinical outcomes and the score was 90.0 ± 2.3 according to American Orthopedic Foot and Ankle Society Scale.Minimally invasive approach with external fixator is an effective method for treating displaced intra-articular calcaneal fractures in pediatric patients, with a lower incidence of wound-related complications and good cosmetic outcomes.

Evaluation of patient outcomes after operative treatment of intra-articular calcaneus fractures.

Background: Percutaneous reduction with fixation and open reduction internal fixation are often used to treat intra-articular calcaneus fractures with no consensus on the preferred method. Open techniques have been associated with an increased risk of wound complications, while percutaneous techniques may result in inferior reduction capabilities. These injuries pose a challenge to patients as they often result in poor patient outcomes. We retrospectively analyzed patient outcomes of a single surgeon’s experience in treating these injuries at a busy urban Level 1 trauma center. Methods: Patients with intra-articular calcaneus fractures managed operatively over 10 years with a minimum six-month follow-up were included. Patients were divided into two cohorts based on operative technique: closed reduction and percutaneous fixation (CRPF) or open reduction internal fixation (ORIF). Descriptive analysis of each cohort included postoperative infection, the need for repeat operations, development of post-traumatic subtalar arthritis, and reduction capabilities as assessed by Bohler’s angle. Results: Sixty-two patients were included in this study, with 33 patients in the CRPF group and 29 patients in the ORIF group. Infection requiring a return to the operating room occurred in 1 (3%) CRPF and 7 (24%) ORIF patients. Instrumentation was removed in 23 (70%) CRPF and 9 (31%) ORIF patients. Clinical subtalar arthritis developed in 10 (30%) CRPF and 7 (24%) ORIF patients, requiring arthrodesis in 2 (6%) and 5 (17%) patients, respectively. Both techniques had acceptable restoration of Bohler’s angle immediately postoperatively and at final follow-up. Conclusions: Percutaneous reduction with fixation and open reduction internal fixation may both be considered for the surgical treatment of intra-articular calcaneal fractures. Indications for each technique may vary between surgeons, and each has its own set of risk factors and complications, however, both have been shown to result in an acceptable reduction. Level of Evidence: Level IV.

Functional and radiological outcome of depressed intra-articular fractures of calcaneus managed with operative methods

Calcaneal fractures are the most common fracture of the tarsal bones, controversy still exists on the best treatment option for these fractures. However as a better understanding of fracture patterns with computed tomography scans and modern surgical techniques and hardware has improved outcome and lowered morbidity. Hence we aim at evaluating the radiological and functional outcomes of displaced intra-articular calcaneal fractures treated with operative methods with calcaneal plate or by percutaneous/mini-open Ilizarov fixation. In our study we included 30 patients, 23 were male and rest 7 were female. The mechanism of injury involved fall from height in 20 cases and road traffic accident in the remaining cases. These patients were followed average 14.6 months and the functional outcome was assessed in all the patients using Creighton-Nebraska health foundation assessment scale (CNHFAS). According to this scale, 8(26.66%) patients had excellent results, 14 (46.66%) patients had good results, 4(13.33%) patients had fair results and 4(13.33%) patients had poor results. The results were promising, revealing that the operative treatment of intra-articular calcaneal fractures should be done as anatomical reduction and rigid internal fixation to allow early movement and weight bearing. The technique of contoured plate fixation with a lateral approach and ilizarov external fixator are good with regards to fracture union and functional outcome.

Surgically treated calcaneal joint fractures: What does postoperative computed tomography give us?

IntroductionThere is currently great controversy about the ideal treatment of intraarticular calcaneal fractures. The objective of this study is to determine the usefulness of postoperative computed tomography (CT). Material and MethodsWe conducted a retrospective descriptive study of patients operated on in the period 2007–2015 in our center. Epidemiological variables, specific fracture data, surgical intervention as well as results and complications were collected. The radiological evaluation was performed using simple radiology (Böhler angle) and coronal CT (congruence of posterior subtalar joint). For the functional results we use the AOFAS hindfoot scale and the EVA scale for the level of pain. ResultsWe included 46 fractures in 43 patients (3 bilateral). 35 were male and 8 female, with an average age of 42 years (18−79) and an average follow-up of 57.39 months (33–129). Preoperative CT was performed in all cases, of which 11 were Sanders II, 23 type III and 12 type IV. Postoperative CT was only performed in 17 cases. The subsequent subtalar reduction measured by CT was satisfactory (articular step <2 mm) in 12 cases. The average presurgical Böhler angle was 6.45 ± 10.21 (-22−25) and the post-surgical angle of 20.46 ± 7.09 (4−38). Subtalar osteoarthritis developed in 19 cases (symptomatic in 12) and calcaneo-cuboid osteoarthritis in 6 cases (only 1 symptomatic). The AOFAS was 74.28 ± 18.98 (27−100) and the EVA was 4.14 ± 2.98 (2–9). A CT scan with a step of less than 2 mm was statistically significant, with a higher result on the AOFAS scale (77.17 average points) as well as lower EVA on average (2.83) (p = 0.002). Regarding the Böhler, it was statistically significant the relationship of an angle> 20° post-surgical with higher AOFAS (80.82) and lower VAS (3.18) (p = 0.001). The literature search obtained a total of 117 articles that met the search criteria, of which only 29 requested postoperative CT. ConclusionsThe indication of postoperative CT in patients operated by intraarticular calcaneal fracture is the best technique to corroborate the correct reduction of the subtalar joint surface, although it is not universally accepted, according to the literature.

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

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

Application of medial column classification in treatment of intra-articular calcaneal fractures.

BACKGROUNDThere are many types of treatments for calcaneal fractures, including conservative treatment, conventional surgical treatment, and minimally invasive surgery. The choice of specific treatment options is still controversial. Open reduction and internal fixation are currently the most commonly used surgical procedures in the clinic. A good fracture reduction effect can be achieved by using the lateral extension incision of the calcaneus; however, many studies have reported a high incidence of postoperative incision complications. Although there are many methods for the classification of intra-articular calcaneal fractures, it is generally believed that the computed tomography (CT) classification proposed by Sanders has high application value in the selection of treatment methods and evaluation of prognosis of calcaneal fractures. However, this method has no clear guiding significance for the choice of surgical incision and surgical plan.AIMTo explore the application and clinical efficacy of medial column classification in the treatment of intra-articular calcaneal fractures.METHODSFrom July 2017 to July 2018, 91 patients, including 60 males and 31 females aged 27 to 60 years, were enrolled. All participants had closed intra-articular calcaneal fracture, and their surgical options were selected under the guidance of medial column classification. The patients’ fractures were classified according to the Sanders classification: Type II, 35 cases; Type III, 33 cases; and Type IV, 23 cases. Among them, 53 patients had medial column displacement (shortened varus) and underwent open reduction and internal fixation with L-lateral incision of the calcaneus; 38 patients had no displacement of the medial column and underwent open reduction and internal fixation with tarsal sinus incision. The calcaneus Böhler angle, Gissane angle, length, width, height, and step thickness of the articular surface were evaluated by X-ray and three-dimensional CT before and after surgery and at the last follow-up. Foot function recovery was assessed by the Maryland foot scoring criteria.RESULTSAll patients were followed for 5 to 14 mo, with an average of 10.5 ± 2.9 mo. The fractures of all patients healed, and the healing time was 10 to 19 wk, with an average of 10.8 ± 1.5 wk. One patient developed wound infection 1 wk after surgery and was actively debrided and implanted with antibiotic calcium sulfate to control the infection. The patient's fracture healed 5 mo after surgery. One patient developed a sural nerve injury, and the symptoms disappeared 3 mo after surgery. The patients were assessed according to the Maryland foot scoring system: Excellent in 77 cases, good in 10, and fair in 4. The excellent and good rate was 95.6%.CONCLUSIONMedial column classification can effectively guide the surgical selection for intra-articular fractures of the calcaneus.

Fracturas intraarticulares de calcáneo tratadas quirúrgicamente: ¿qué nos aporta la tomografía computarizada postoperatoria?

IntroductionThere is currently great controversy about the ideal treatment of intraarticular calcaneal fractures. The objective of this study is to determine the usefulness of postoperative computed tomography (CT). Patients and methodsWe conducted a retrospective descriptive study of patients operated on in the period 2007 to 2015 in our center. Epidemiological variables, specific fracture data, surgical intervention as well as results and complications were collected. The radiological evaluation was performed using simple radiology (Böhler angle) and coronal CT (congruence of posterior subtalar joint). For the functional results we use the AOFAS hindfoot scale and the EVA scale for the level of pain. ResultsWe included 46 fractures in 43 patients (three bilateral). Thirty-five were male and eight female, with an average age of 42 years (18-79) and an average follow-up of 57.39 months (33-129). Preoperative CT was performed in all cases, of which 11 were Sanders ii, 23 type iii and 12 type iv. Postoperative CT was only performed in 17 cases. The subsequent subtalar reduction measured by CT was satisfactory (articular step < 2 mm) in 12 cases. The average presurgical Böhler angle was 6.45 ± 10.21 ([-22]-25) and the post-surgical angle of 20.46 ± 7.09 (4-38). Subtalar osteoarthritis developed in 19 cases (symptomatic in 12) and calcaneo-cuboid osteoarthritis in six cases (only one symptomatic). The AOFAS was 74.28 ± 18.98 (27-100) and the EVA was 4.14 ± 2.98 (2-9). A CT scan with a step of less than 2 mm was statistically significant, with a higher result on the AOFAS scale (77.17 average points) as well as lower EVA on average (2.83) (p = 0.002). Regarding the Böhler, it was statistically significant the relationship of an angle > 20° post-surgical with higher AOFAS (80.82) and lower VAS (3.18) (p = 0.001). The literature search obtained a total of 117 articles that met the search criteria, of which only 29 requested postoperative CT. ConclusionsThe indication of postoperative CT in patients operated by intraarticular calcaneal fracture is the best technique to corroborate the correct reduction of the subtalar joint surface, although it is not universally accepted, according to the literature.

Calcaneus traction compression with orthopaedic reduction forceps combined with percutaneous minimally invasive treatment of intra-articular calcaneal fractures: An analysis of efficacy

BackgroundThe treatment of displaced calcaneal fractures is controversial.Open reduction and internal fixation are widely described as the gold standard in the literature,but these technique shave many complications,including skin necrosis,internal fixation leakage and deep infection and wound healing problems.Percutaneous reduction and unilateral external fixation have received increasing attention because they can provide a good, stable reduction and reduce the soft tissue complications caused by open surgery(such as deep infection and delayed wound healing).The purpose of this retrospective study was to evaluate the reduction imaging and clinical results of calcaneus traction compressionwith orthopaedic compression reduction forceps combined with percutaneous minimally invasive external fixation for intra-articular calcaneal fractures. MethodsThis was a retrospective analysis. A total of 35 patients with unilateral calcaneal fractures were divided into two groups: 1) the open reduction, internal fixation group (19 feet)and 2) the percutaneous minimally invasive, closed reduction external fixation group (16 feet).Evaluation of the reduction include dimaging measurements of the calcaneus length,width,and height,and the Bohler angle and Gissane angle before and after surgery.Clinical outcomes included the time of surgery,length of hospital stay,operation time,wound-related complications,the American Orthopaedic Foot and Ankle Society hindfoot score,the visual analogue score for pain, and the SF-36 score. ResultsThe average follow-up time was 25.52 ± 1.68 months.There was no significant difference in reduction between the open group and the closed group (P > 0.05).The operation time of the open group was significantly longer than that of the closed group(P = 0.0001).The length of hospitalization and waiting time for surgery in the open reduction group were significantly longer than those in the closed reduction group (P < 0.05).Incidence-related complications in the open group and closed group were 21.1 %(4/19) and 6.3 %(1/16),respectively (P = 0.0001).The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores in the open and closed groups were 81.35 ± 5.25 and 82.52 ± 4.78, respectively (P = 0.0875). The visual analogues cale (VAS) scores of the open group and the closed group were 1.81 ± 1.32 and 0.78 ± 0.91, respectively (P = 0.0412).The SF-36 scores were 80 ± 4.5 and 79 ± 4.2, respectively. ConclusionOur research shows that for various types of intra-articular calcaneal fractures compared with open reduction,internal plate fixation,calcaneus traction compression with orthopaedic reduction forceps combined with percutaneous minimally invasive external fixation is a simple and effective method for treating calcaneal fractures; not only can the calcaneus be corrected, but it can also provide notable imaging and clinical results.

Outcomes of Minimally-Invasive Sinus Tarsi Approach for the Treatment of Intra-articular Calcaneal Fracture

Background: Open reduction and internal fixation is the standard surgical treatment of calcaneal fractures. However, it is associated with a high rate of wound problems. Objectives: In this study, we evaluated the clinical and radiologic outcomes, as well as the wound complication rates of sinus tarsi minimally-invasive approach in the treatment of intra-articular calcaneus fracture. Methods: In a retrospective study, 62 patients who were referred with an intra-articular calcaneus fracture and treated with a minimally-invasive sinus tarsi approach were included. The radiographic evaluations included the assessment of Bohler and Gissane angles before and after the surgery, as well as the height and length of the calcaneus. The clinical outcome was assessed with the American Orthopedic Foot and Ankle Society (AOFAS) questionnaire. Results: The Mean±SD age of the patients was 41.8±12.7 years. The Mean±SD follow-up of the patients was 21.3±10 ‎months. After 6 months, in 43 patients (69.3%) both Bohler’s and Gissane’s angles were significantly improved after the surgery (P=0.003 and P&lt;0.001, respectively). The calcaneus height was significantly improved after the surgery (P=0.009), as well. The Mean±SD AOFAS score of the patients was found 79.6±7. Wound infection was seen in only 1 case (1.6%). Delayed wound healing occurred in 4 cases (6.4%). No other wound complication such as dehiscence and skin necrosis was recorded. Conclusion: Minimally-invasive sinus tarsi approach is an efficacious procedure for the treatment of intra-articular calcaneus fracture with a minimized rate of wound complications.