Treatment Of Intra-articular Calcaneal Fractures Research Articles

Treatment of Displaced Intra-articular Calcaneal Fractures by Intramedullary Nail. Preliminary Report.

Open reduction and plate stabilisation is a recognised method of treatment of intra-articular calcaneal fractures. The surgical approach to the calcaneal bone used in these procedures is associated with a high risk of complications. The aim of this paper is to present the author's experience with a new surgical method and analyse early outcomes of the treatment of calcaneal fractures by Calcanail intramedullary nailing. The study encompassed 17 patients (5 women and 12 men) with 18 calcaneal fractures (5 in the right foot and 13 in the left foot). The mean age of the patients was 47 years (range: 22-68 years). The mean time between the injury and surgery was 6 days (range: 3-14 days). The mean duration of follow-up was 12 months (range: 6-18 months). The fractures were classified according to the system presented by Guy Utheza. Bone union was achieved in all patients within 12 weeks of surgery. No infectious complications were observed. The mean AOFAS score was 82/100. Mean Bohler's angle was -3 degrees pre-operatively and +29 degrees post-operatively. 1. The use of Calcanail intramedullary nailing in the treatment of displaced intra-articular fractures is a minimally invasive procedure associated with a low risk of complications. 2. The innovative posterior approach allows for the intrafocal reduction of an articular surface fracture through the prepared intramedullary canal.

Biomechanical comparison of conventional and anatomical calcaneal plates for the treatment of intraarticular calcaneal fractures – a finite element study

Initial stability is essential for open reduction internal fixation of intraarticular calcaneal fractures. Geometrical feature of a calcaneal plate is influential to its endurance under physiological load. It is unclear if conventional and pre-contoured anatomical calcaneal plates may exhibit differently in biomechanical perspective. A Sanders’ Type II-B intraarticular calcaneal fracture model was reconstructed to evaluate the effectiveness of calcaneal plates using finite element methods. Incremental vertical joint loads up to 450 N were exerted on the subtalar joint to evaluate the stability and safety of the calcaneal plates and bony structure. Results revealed that the anatomical calcaneal plate model had greater average structural stiffness (585.7 N/mm) and lower von Mises stress on the plate (774.5 MPa) compared to those observed in the conventional calcaneal plate model (stiffness: 430.9 N/mm; stress on plate: 867.1 MPa). Although both maximal compressive and maximal tensile stress and strain were lower in the anatomical calcaneal plate group, greater loads on fixation screws were found (average 172.7 MPa compared to 82.18 MPa in the conventional calcaneal plate). It was noted that high magnitude stress concentrations would occur where the bone plate bridges the fracture line on the lateral side of the calcaneus bone. Sufficient fixation strength at the posterolateral calcaneus bone is important for maintaining subtalar joint load after reduction and fixation of a Sanders’ Type II-B calcaneal fracture. In addition, geometrical design of a calcaneal plate should worth considering for the mechanical safety in practical usage.

Fixation of intra-articular calcaneal fractures aided by self-designed director for sustentaculum tali screwing

Objective To evaluate our self-designed director for sustentaculum tali screwing used to fixate intra-articular calcaneal fractures in comparison with a conventional screwing director. Methods From May 2012 to October 2013, a total of 40 patients received surgical treatment of intra-articular calcaneal fracture at our department. Our self-designed director for sustentaculum tali screwing was used in 20 of them (24 feet, group A) while a conventional screwing director was used in the other 20 patients (22 feet, group B). The 2 groups were compatible in preoperative clinical data, showing no significant differences (P>0.05). The operation time, fluoroscopy frequency, rate of accurate screwing, and Maryland foot scores were compared between the 2 groups. Results The patients were followed up for an average of 15 months (range, 12 to 24 months). Group A had shorter operation time (77.8±9.5 min) than group B (84.4±9.4 min), lower fluoroscopy frequency (2.5±0.9 times) than group B (4.1±1.3 times), a higher rate of accurate screwing (91.7%) than group B (68.2%), and a higher excellent to good rate by Maryland foot scoring (91.7%) than group B (63.6%). The above differences were all statistically significant (P< 0.05). Conclusion In the treatment of intraarticular calcaneal fractures, our self-designed director for sustentaculum tali screwing can significantly enhance the accuracy in fixation of sustentaculum tali to ensure good clinical outcomes. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal; Director for sustentaculum tali screwing

Individualized reconstruction plate for treatment of calcaneal fractures via tarsal sinus incision

Objective To investigate the clinical efficacy of individualized reconstruction plate in the treatment of calcaneal fractures through the tarsal sinus incision. Methods From May 2010 to September 2012, we treated 46 cases of calcaneal fracture (51 feet) involving talocalcaneal joint. They were 35 males and 11 females, 17 to 65 years of age (average, 35 years). The injury affected the left foot in 24 cases, the right foot in 17, and both feet in 5. By the Sander's classification, 30 feet were type Ⅱ and 21 type Ⅲ. The fractures were reduced through the tarsal sinus incision before internal fixation with individualized reconstruction according to the morphology of fracture. When necessary, fixation with hollow screws was added. The Bohler and Gissane angles were compared between preoperation and postoperation. The clinical efficacy was evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) system. Results The patients were followed up for 8 to 14 months (average, 12 months). No such complications as incision infection, skin necrosis, plate loosening or exposure occurred in this group. There were significant differences in the Bohler and Gissane angles between preoperation and postoperation [(31.70°±5.50° and 122.10°±6.79° at 3 days postoperation) and (30.95°±3.47° and 122.49°±4.83° at 6 months postoper-ation) versus (6.14°±1.58° and 91.63°±4.76° at preoperation)] (P 0.05). All the patients obtained bony union at 6 months postoperation. According to the AOFAS scores, 38 feet were ex-cellent, 9 feet good and 4 feet fair, giving an excellent to good rate of 92.2% . Conclusion In the treatment of intra-articular calcaneal fractures through the tarsal sinus incision, application of individualized reconstruction plate can lead to fine fracture reduction, rigid internal fixation, early exercise, and decreased incision-related complications. Key words: Calcaneal fracture; Fracture fixation, internal; Bone plates

Effect of sustentaculum screw placement on outcomes of intra-articular calcaneal fracture osteosynthesis: A prospective cohort study using 3D CT

IntroductionCorrect placement of the sustentacular screw is an important component during the open reduction and internal fixation of calcaneal fractures. The hypothesis of this study is that certain 3D-CT images would help detect the real placement of the sustentaculum screw. The aims of the study are to investigate the postoperative status of the sustentacular screw and to evaluate the effect of the sustentaculum screw placement on the treatment of intra-articular calcaneal fractures. Patients and methods119 patients with intra-articular calcaneal fractures meeting the inclusion criteria were included in this prospective study. The postoperative sustentaculum screw was detected via radiographs and CT scans. According to the placement of the screw, the patients were divided into three groups: the sustentaculum screw with accurate fixation (group A), marginal fixation (group B), and non-fixation (group C). The perioperative parameters and the change of Böhler's angles on the postoperative and final follow-up radiographs were analyzed. The clinical outcomes were evaluated by the AOFAS ankle-hindfoot score and Short Form-36 questionnaire. ResultsEighty-five patients were followed up with an average time of 26 (range, 12–48) months. 3D-CT confirmed that 18 cases were in group A, 33 in group B, and 34 in group C. Except the length of stay, significant difference in the operating time and blood loss existed among three groups (P < 0.05). The mean decrease in Böhler's angle of group C was the greatest (P < 0.05). No significant difference could be detected in the AOFAS or SF-36 scores among the three groups either at the one-year follow-up or the final follow-up (P > 0.05). ConclusionThe sustentaculum screw with non-fixation may cause the decrease of Böhler's angle throughout the follow-up. The clinical outcomes were similar whether the screw was accurately placed within the sustentaculum or not.

Plating for intra-articular calcaneal fractures…. Is it an overkill?

Even after evolution of computerized tomography and improved surgical measures, treatment of intraarticular calcaneal fractures remains a controversy. Hence this study was carried out to compare functional outcomes of displaced intraarticular calcaneal fractures, treated with operative management with plating and conservative management with cast. This study was carried out as a prospective, comparative study. Twenty nine (30 fractures) patients with acute, displaced intraarticular fractures of calcaneum aged 18-50 years, were enrolled in the study. Open fractures and fractures older than two weeks were excluded. 30 fractures were divided into two groups (operative and conservative; n=15 in each). Evaluation in form of post treatment restoration of Bohler's angle, heel varus angle and with Creighton-Nebraska (C-N) score for functional outcome was done at the end of 12 months. When we consider the clinical evaluation under the C-N score, the results of operatively managed calcaneal fractures are slightly better than those of the conservative group. But this did not have any statistical significance. Also, there was significant difference in pre and post treatment Bohler's angle and heel varus angle in operative group. Three cases of plating suffered from post-operative wound dehiscence. A relatively better functional outcome was observed in displaced and comminuted fractures in plating, provided that the Bohler's angle was restored. In conservative group, functional outcome of minimally displaced fractures were better than displaced comminuted fractures. Post treatment Bohlers angle has prognostic importance in functional outcome.

Long-term Results of Operative Treatment of Calcaneal Fractures.

This paper presents the long-term results of surgical treatment of intra-articular calcaneal fractures, including subjective evaluation, orthopaedic examination and radiographic evaluation. A total of 126 patients with 135 calcaneal fractures were treated surgically at the Department of Traumatology of the Military Medical Institute in Warsaw between 2008 and 2012. The analysis involves 73 patients (53 persons were lost to follow-up), including 45 men (61.6%). The mean age of the patients was 46.2 years (18-77 years). Based on imaging studies, patients required specific surgical techniques: the minimally invasive Westhues method involving fixation with a bundle of K-wires or open reduction and internal fixation with a plate and screws. The outcomes of the surgical treatment of calcaneal fractures were assessed on the basis of a subjective evaluation and orthopaedic and radiographic examinations. Statistical analysis was performed using Microsoft Excel. Based on the Creighton-Nebraska scores, in the group of patients treated with a bundle of K-wires (minimally invasive Westhues method), there were 12 excellent results (42.8%), 5 good (17.9%), 6 satisfactory (21.4%) and 5 poor (17.9%). In the group of patients treated with a plate and screws, excellent and good results (58.1%) prevailed in Sanders type II fractures. Most of the poor results were recorded in patients with type IV fractures. In general, radiographic results were better than functional and subjective evaluation. A statistically significant relationship between the subjective outcome of treatment and patient age was found (p <0.001). The least satisfying results were found for patients younger than 39 years of age. 1. The key to success in the surgical treatment of calcaneal fractures is appropriate restoration of Bôhler's angle 2. A good or excellent radiographic outcome did not always coincide with good functional results and good subjective evaluation 3. The poorer subjective scores in younger patients resulted from their inability to return to pre-injury activity levels.

Clinical Analysis of Internal Fixation Treatment of Intra-articular Calcaneal Fractures with Titanium Plate.

To explore the clinical effect of internal fixation treatment of intra-articular calcaneal fractures with titanium plate, we used open reduction and internal fixation with titanium plate to 48 treated feet from 42 patients with intra-articular calcaneal fractures. The efficacy of surgical treatment was evaluated based on assessment of pain, function, and line of force aspects according to the American Orthopedic Foot and Ankle Society scoring system. Our data show that internal fixation with titanium plate is an effective treatment for calcaneal fractures. It provides satisfactory reduction, reliable fixation, and early rehabilitation.

Early Minimally Invasive Percutaneous Fixation of Displaced Intra-Articular Calcaneal Fractures With a Percutaneous Angle Stable Device

The Minimally Invasive Reduction and Osteosynthesis System® (MIROS) is a percutaneous angle stable device for the treatment of fractures. The aim of the present study was to evaluate the clinical and radiographic results of an early minimally invasive osteosynthesis with the MIROS device. A total of 40 consecutive patients were treated for an intra-articular fracture of the calcaneus. We evaluated the clinical and radiographic outcomes after treatment of intra-articular calcaneal fractures with the MIROS hardware. Soft tissue damage was noted. The patients completed the American Orthopaedic Foot and Ankle Society survey at 12 and 24 months and underwent radiologic evaluations. A statistically significant association between the American Orthopaedic Foot and Ankle Society score and type of soft tissue lesion. A Sanders type II, III, and IV fracture was found in 15, 20, and 15 of 50 fractures, respectively. Postoperatively, restoration of the posterior facet was reached in 13 of 15, 18 of 20, and 11 of 15 with a type II, III, and IV fracture, respectively. The American Orthopaedic Foot and Ankle Society scale mean score was 85 at the final follow-up visit. No significant association was found between the score and the preoperative variables (p > .09), although patients with bilateral fractures had a significantly lower score. The MIROS device for early treatment of intra-articular calcaneus fractures resulted in excellent clinic and radiologic results. The standardized technique we have reported, with the elastic wires acting as a girder for the fractured and displace subtalar joint and the collapsed lateral calcaneal wall, has permitted early weightbearing with positive stimuli for the bone healing. The drainage effect of the percutaneous wires likely prevented compartment syndrome when applied within the first hours after the trauma.

Inlayed plate via lateral bone flap approach for displaced intra-articular calcaneal fractures

Objective To evaluate the clinical efficacy of inlayed plate via the lateral bone flap approach for treatment of displaced intra-articular calcaneal fractures.Methods From January 2011 to January 2013,23 patients with displaced intra-articular calcaneal fracture were treated with inlayed plate via the lateral bone flap approach.They were 17 men and 6 women,18 to 65 years of age (mean,35.3 years).The fractures involved 26 feet,on the left in 15 feet and on the right in 11 feet.By Sanders' classification,5 feet were type ⅡA,8 feet type Ⅲ AB,6 feet type Ⅲ AC and 7 feet type Ⅳ.The clinical efficacy was assessed by the Maryland foot scoring system.The B(o)hler's and Gissane's angles,height and width of the calcaneus and the range of motion (ROM) of the ankle were also evaluated postoperatively.Results The patients were followed up for 21 to 45 months (average,26.3 months).The postoperative B(o)hler's angle (33.0° ± 7.4°),Gissane' s angle (121.3° ± 8.2°),height (39.4 ± 5.2 mm),width (26.2 ± 3.5 mm) and ROM (63.2° ± 4.3°) were obviously improved compared to the preoperative ones (-1.6° ± 7.6°,144.6° ±10.3°,28.7 ±4.3 mm,35.2 ±3.3 mm,34.1°±4.4°,respectively).The Maryland foot scoring showed excellent functional recovery in 14 feet,good in 10 feet,and fair in 2 feet,giving an excellent to good rate of 92.3％.Conclusion In the treatment of displaced intra-articular calcaneal fracture,the plate that is implanted via the lateral bone flap approach is a new fixation method with good clinical efficacy because it can lead to good exposure that facilitates fine reduction and fixation,a lower rate of soft tissue complications and good functional recovery. Key words: Calcaneus fracture; Fracture fixation ,internal; Bone plate

Surgical treatment of intra-articular calcaneal fractures: description of a technique using an adjustable uniplanar external fixator.

Several surgical techniques are available for the treatment of intra-articular calcaneal fractures. The use of a uniplanar external fixator is an option for the treatment of fractures classified as Sanders types 2 and 3. Satisfactory reduction and stabilisation of the fracture are achieved by means of mini-incisions and fixator adjustment. The advantages of this technique include less soft-tissue damage, avoidance of internal implants and early weight-bearing with the potential to improve postoperative recovery.

Minimally Invasive Sinus Tarsi Effective for Intra-Articular Calcaneal Fractures

The current standard treatment of displaced intra-articular calcaneal fractures is open reduction and internal fixation, which is achieved by 1 of 2 methods: the minimally invasive sinus tarsi approach or the extensile lateral approach. This article discusses a study that compared the outcomes of minimally invasive sinus tarsi compared with the extensile lateral approach for the treatment of intra-articular calcaneal fractures.

Factors affecting long-term treatment results of displaced intraarticular calcaneal fractures: a post hoc analysis of a prospective, randomized, controlled multicenter trial.

To study the factors affecting long-term treatment results of displaced intraarticular calcaneal fractures (DIACFs). A post hoc analysis. Tertiary care teaching hospitals. Eight to twelve years of results from a randomized controlled multicenter trial of operative versus nonoperative treatment (n = 56) were divided into 2 groups: the superior 50% results (n = 28) and the inferior 50% results (n = 28), regardless of the treatment given. The determinant of this division was a visual analog score for pain and function. The operative treatment consists of open reduction and internal fixation, whereas the nonoperative treatment consists of nonweight bearing and early range of motion exercise. A visual analog score for pain and function, the short-form 36 (SF-36) general health outcome questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Olerud-Molander score. We compared age, sex, fracture type (Sanders classification), treatment given, Böhler angle, residual articular surface step-off at healing, type of occupation, and injury insurance between the 2 groups. Patients of the superior group had higher physical SF-36, AOFAS, and Olerud-Molander score than in the inferior group. Operative treatment, better Böhler angle and articular surface restoration, light labor/retirement, and absence of injury insurance were more common in the superior group. Age, sex, pretreatment Böhler angle, and fracture type were comparable in the superior and inferior groups. The decision making for definitive treatment of intraarticular calcaneal fractures is multifactorial with a spectrum of results and trends such as patient demographic features that should be considered in choosing the best treatment option. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Observation of the effect of improved bone plate fixation and bone grafting in the treatment of intra-articular calcaneal fracture

Objective To investigate the effect of improved bone plate fixation and bone grafting in the treat ment of intra-articular calcaneal fracture.Methods 80 patients with intra-articular calcaneal fractures were randomly divided into the two groups.The non-bone graft group(47 feet in 40 patients)was given improved bone plate fixation.The bone graft group(50 feet in 40 patients)was given improved bone plate fixation and bone grafting.Results The incidence rate of complication in the non-bone graft group was 25.0％ and that in the bone graft group was 19.1％.The difference between the two groups was not significant(x2 =0.21,P ＞ 0.05).Postoperative Bhler's angle and calcaneal height between the two groups had significant differences (t =14.5,16.99,all P ＜ 0.05).The excellent rate of Maryland functionality in non-bone graft group was 66.0％,which was significantly lower than 86.0％ in the bone graft group(x2 =5.38,P ＜ 0.05).The average full weight bearing time between the two groups had significant difference (t =11.17,P ＜ 0.05).Bhler's angle after 1 year and forwa rd Bhler's angle loss of the non-bone graft group had significant differences compared with the bone graft group (t =29.76,9.81,all P ＜ 0.05).Conclusion Improved bone plate fixation and bone grafting in the treatment of intra-articular calcaneal fracture can obtain better results and avoid the long-term loss of reduction. Key words: Fracture fixation; Calcaneal

Up‐regulation of the chemo‐attractive receptor ChemR23 and occurrence of apoptosis in human chondrocytes isolated from fractured calcaneal osteochondral fragments

To study the expression level of a panel of pro/anti-apoptotic factors and inflammation-related receptors in chondral fragments from patients undergoing surgical treatment for intra-articular calcaneal fractures, cartilage fragments were retrieved from calcaneal fractures of 20 patients subjected to surgical treatment. Primary cultures were performed using chondral fragments from fractured and control patients. Chondrocyte cultures from each patient of the fractured and control groups were subjected to immunofluorescence staining and quantitatively analyzed under confocal microscopy. Proteins extracted from the cultured chondrocytes taken from the fractured and control groups were processed for Western blot experiments and densitometric analysis. The percentage of apoptotic cells was determined using the cleaved PARP-1 antibody. The proportion of labelled cells was 35% for fractured specimens, compared with 7% for control samples. Quantification of caspase-3 active and Bcl-2 proteins in chondrocyte cultures showed a significant increase of the apoptotic process in fractured specimens compared with control ones. Fractured chondrocytes were positively stained for ChemR23 with statistically significant differences with respect to control samples. Densitometric evaluation of the immunoreactive bands confirmed these observations. Human articular chondrocytes obtained from patients with intra-articular calcaneal fractures express higher levels of pivotal pro-apoptotic factors, and of the chemo-attractive receptor ChemR23, compared with control cultures. On the basis of these observations, the authors hypothesize that consistent prolonged chondrocyte death, associated with the persistence of high levels of pro-inflammatory factors, could enhance the deterioration of cartilage tissue with consequent development of post-traumatic arthritis following intra-articular bone fracture.

A minimally invasive sinus tarsi approach with percutaneous plate and screw fixation for intra-articular calcaneal fractures

According to characteristic of anatomical structure of calcaneus and sinus tarsi approach, the minimally invasive plate for treatment of displaced intra-articular calcaneal fractures had been designed. Here we aimed to review the effect of this treatment. Forty intra-articular calcaneal fractures in 38 patients from September 2006 to September 2008 were treated with percutaneous plate via sinus tarsi approach under the monitoring of C-shaped arms. All calcaneal anatomical parameters, including height, width, length, Böhlers angle and Gissane angle were measured by X-ray before and after surgery. Postoperative lateral wound healing was also evaluated and clinical functional outcomes were graded using the Maryland foot score. All patients had been followed up for an average of 12 months ranged from 3 months to 24 months. X-ray indicated satisfactory restoration of the calcaneal height, width, length, Böhlers angle and Gissanes angle. Maryland foot score demonstrated that excellent result was achieved in 32 cases, good in 6 cases, fair in 2 cases, and the excellent and good rate was 95%. Postoperative complications were not found in all fractured feet. Our results suggest that this minimally invasive sinus tarsi approach with new designed plate and screw fixation technique for the treatment of intra-articular calcaneal fractures can not only obtain the satisfactory outcomes, but also can effectively prevent surgical complications.

Comparative Study of Peroneal Tenosynovitis as the Complication of Intraarticular Calcaneal Fracture in Surgically and Non-Surgically Treated Patients

BackgroundCalcaneus has the most fracture prevalence among tarsal bones. About 3/4 of calcaneal fractures are intra-articular fractures with displacement. The majority of calcaneal fractures occur in 21 - 35 year old young men, and that are mostly active people, these fractures cause complete disability for 15 months. Moreover, inappropriate treatment leads to lots of social and economical damages.ObjectivesIn this study we compared the incidence and the severity of peroneal tenosynovitis as a complication of non-operative and operative treatment of intra-articular calcaneal fractures. In this study, some other complications of this fracture were also analyzed and the prevalence of the complication was higher in non-operated patients.Patients and MethodsA total of 140 patients with intra-articular calcaneal fracture were analyzed prospectively. These patients were divided into 2 groups: operated group and non-operated group.ResultsIn non-operated group (56 patients), 22 patients were complicated by peroneal tenosynovitis. In operated group (84 patients), 8 patients had the same complication. Statistical analysis revealed that the prevalence, and the severity of this complication in the mentioned groups had a meaningful difference. The results in operated group were much better than the non-operated one.ConclusionsAlthough some of the orthopedic surgeons are not interested to manage these fractures surgically and most of them treat these cases conservatively (casting, etc.), in most displaced intra-articular calcaneal fractures, surgical treatment is the method of choice. Moreover, in non-surgical treatment the prevalence of these complications among the patients is more and as a result, inevitable social, occupational and familial damages occur.

Pediatric and adolescent intra-articular fractures of the calcaneus

Calcaneal fractures in childhood are very rare, whereas particularly intra-articular displaced fractures are not typical in skeletally immature children. Various techniques of osteosynthesis have been described. This study aimed to determine clinical and radiological outcome after surgical treatment of intraarticular calcaneal fractures. Fourteen intraarticular fractures of the calcaneus were included in this retrospective study. Eleven children (2 girls and 9 boys) aged 6-16 years (average age 11.5 years) underwent surgical treatment. One child sustained a Type II open fracture of both calcanei. All injuries occurred after a high-energy trauma; 3 patients had multiple additional fractures. The clinical and radiological postoperative follow up was an average 44 months. In 4 cases, a reduction through a minimally invasive approach and fixation with K-wires or screws could be achieved. Eleven fractures were treated with open reduction and internal fixation with plate osteosynthesis, K-wires or screws. In one case with open fractures of both heel bones, an additional external fixator was applied. The surgical treatment approach adopted enabled the pre-operative Böhler’s angle (average 16°) to be improved to an average 30°. In all cases, except for the patient with open fractures, a good functional result and outcome could be achieved. In calcaneal fractures in childhood, anatomical reduction is the determining factor, as in fractures in adults, whereas the surgical technique seems to have no influence on clinical outcome in children. The wound healing problems that have often been described were not observed in this age group.

Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary?

BackgroundThe aim of this retrospective study was to determine the need for bone grafting in the surgical treatment of displaced intra-articular calcaneal fractures. We reviewed 390 cases of displaced intra-articular calcaneal fractures treated with plate osteosynthesis with or without autologous iliac bone grafting, and compared outcomes and complications related to fracture stabilization.Materials and methodsThree hundred ninety patients with displaced intra-articular calcaneal fractures that were treated with plate osteosynthesis from December 2002 to December 2010 were reviewed. Two hundred two patients (group A) were treated by osteosynthesis with autologous bone grafting, and 188 patients (group B) were treated by osteosynthesis without bone grafting. One hundred eighty-one patients with an AO type 73-C1 fracture (Sanders type II), 182 patients with an AO type 73-C2 fracture (Sanders type III), and 27 patients with an AO type 73-C3 fracture (Sanders type IV) were included in this study. Bohler’s angle, the crucial angle of Gissane, and calcaneal height in the immediate postoperative period and at the 2-year follow-up were compared. Any change in the subtalar joint status was documented and analyzed. The final outcomes of all patients were evaluated by the AOFAS Ankle–Hindfoot Scale and compared in both groups.ResultsThe mean full weight-bearing time in group A (with bone grafting) was significantly lower (median 6.2 months, range 2.8–9.2 months) than that in group B (without bone grafting; median 9.8 months, range 6.8–12.2 months). The immediate-postoperative Bohler’s angle and that at the 2-year follow-up were significantly higher in group A. The loss of Bohler’s angle after 2 years was significantly lower in group A (mean 3.5°; 95 % CI 0.8°–6.2°) than in group B (mean 6.2°; 95 % CI 1.0°–11.2°). The average change in the crucial angle and the average change in calcaneal height were not statistically significant for either group. The infection rate in the bone grafting group was higher, though statistically insignificantly so, than in the nongrafting group (8.3 vs. 6.3 %). No significant difference was found between the groups in terms of the rates of good reduction, postoperative osteoarthritis, and subtalar fusion. Regarding the efficacy outcomes, the mean AOFAS score was lower (mean 76.4 points; 95 % CI 65.8–82.9 points) in group A than in group B (mean, 81.6 points; 95 % CI, 72.3–88.8 points), but this difference was not significant (p > 0.05).ConclusionsBohler’s angle showed improved restoration and the patients returned to full weight-bearing earlier when bone grafting was used in the treatment of intra-articular calcaneal fracture. However, the functional outcomes and complication rates of both groups were similar.

Minimally Invasive Technique Versus an Extensile Lateral Approach for Intra-Articular Calcaneal Fractures

The optimal method for treating intra-articular fractures of the calcaneus remains controversial. Extensile approaches allow excellent fracture exposure, but high rates of wound complications are seen. Newer minimally invasive techniques for calcaneus fracture fixation offer a potentially lower wound complication rate, but long-term clinical results are not available. The aim of this study was to compare the outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation via an extensile approach versus those with a minimally invasive sinus tarsi approach. We performed a retrospective review of all intra-articular calcaneal fractures treated operatively between October 2005 and December 2008. A total of 112 fractures were found that met our inclusion criteria; 79 were treated with an extensile lateral approach and 33 via a minimally invasive approach based on surgeon preference. Chart and radiographic results were thoroughly reviewed on all 112 fractures, specifically for wound healing complications and the need for further surgeries within the study period. Additionally, all patients were contacted and asked to return for a research visit that included radiography, clinical examination, and quality of life questionnaires (Short Form 36 [SF-36], foot function index [FFI], visual analog scale [VAS] pain). A total of 47 of 112 (42%) patients returned for a research visit (31 extensile, 16 minimally invasive). The 2 groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, workers' compensation status). In the extensile group, 53% of fractures were Sanders II and 47% were Sanders III, whereas in the minimally invasive group 61% were Sanders II and 39% were Sanders III. The overall wound complication rate was 29% in the extensile group (9% required operative intervention) versus 6% in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20% of the extensile group required a secondary surgery within the study period versus 2% in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84% of patients in the extensile group were satisfied with their result versus 94% in the minimally invasive group (P = .32). Both groups had 100% union rates, and no differences were noted in the final postoperative Bohler's angle and angle of Gissane. Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach. Level III, retrospective comparative case series.