Treatment Of Intra-articular Calcaneus Fractures Research Articles

Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach

Surgical treatment of intra-articular calcaneus fractures via aminimally invasive approach. Intra-articular dislocated calcaneus fractures. Fracture older than 14days; poor soft tissue quality in the surgical area. Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsalIV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of aSchanz screw in the calcaneal tuberosity from lateral or posterior as areduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing acannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath. Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8weeks; subsequently increased load bearing. Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Minimally Invasive Osteosynthesis of Intraarticular Calcaneus Fracture Augmented by Femoral Head Allograft: A Retrospective Study.

Aim: The aim of this retrospective study is to report the results of minimally invasive osteosynthesis when used for the treatment of intraarticular calcaneus fracture. This old technique is regaining popularity recently with the multiple advances added by different institutes when it is used in the management of intraarticular calcaneus fracture.Methods: Twenty-four patients who suffered from intraarticular calcaneus fractures between 2014 and 2019 were included. Twelve of them had Sanders II fractures (group A) and 12 had Sanders III + IV fractures (group B). The mean follow-up duration was 37.5 months. The mean age at presentation was 54.23 ± 12.48 years. The skin condition at presentation was poor (blood-filled blisters) in 25% of patients equally distributed between the two groups. The mean time to surgery was 5.6 days where patients with poor skin conditions were treated lately. The technique involved percutaneous ascending proximal-to-distal pinning of the calcaneus after reduction using a 2 cm mini-incision below the lateral malleolus and augmenting the fixation with femoral head cancellous allograft. The primary outcomes variables analyzed in this study are post-operative Bohler angle, post-operative Gissane angle, American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at long-term follow-up (Excellent>95, Good 75-94, Fair 51-74, poor 0-50), and the delta angle benefit score. The secondary outcomes included post-operative complications such as infection and osteoarthritis.Results: The radiological results showed significant improvement of Bohler angle from 6.09° ± 21.6 pre-operatively, to 31.79° ± 14.1 postoperatively with a p-value <0.001. An adequate reduction was achieved in 54.16% to 70.8% of patients. There is a trend to normalization of overcorrected fracture especially Sanders II with a mean reduction of 12,71° ± 11,88 at one year post-operatively (p=0.05). AOFAS score at the last follow-up shows 20.83% poor results (AOFAS<50), 50% fair results (AOFAS between 51-74), 16.67% good results (AOFAS 75-94), and 12.5% excellent results (AOFAS>95. The satisfaction rate was 83.3% (45.8% partially satisfied, and 37.5% fully satisfied). The incidence of superficial infection (wound inflammation and pin tract infection) was more prevalent in higher group B (40%) compared to group A (0%) with p=0.014. Other complications including osteoarthritis and varus deformity were found in 95.8% and 58.3% of patients respectively at three-year follow-up.Conclusion: The combination of minimally invasive osteosynthesis and femoral head allograft for the treatment of intraarticular calcaneus fractures seems to give fair to good functional results. Radiological data demonstrated that when the Bohler angle is over-reduced >40°, there was a tendency to autocorrection over time. This may be due to progressive depression of the angle over time as weight bearing is authorized; however, this must be analyzed carefully due to the low number of patients who were overreduced (seven patients). Our study demonstrates that this technique has a low early complication rate (especially low infection and soft tissue problems) but carries high long-term complications such as osteoarthritis and hindfoot varus.

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.

The surgical treatment of intra-articular calcaneus fractures: our long-term experience

Objective. We report on the clinical and radiographic results obtained using surgical treatment with plates and screws in displaced intra-articular calcaneal fractures (DIACFs). Methods. 41 patients were included for a total of 43 DIACFs treated at our unit between 2008-2019. Fractures were classified by Sanders classification and radiographically we considered Böhler’s angle. The American Orthopedic Foot and Ankle Score (AOFAS) was used for clinical evaluation. Results. Of 43 fractures, 3 were classified type I, 13 type II, 20 type III and 7 type IV. The mean follow-up was 87.51 months (min. 9, max. 136). The average AOFAS score was 82.88 and the post-operative mean Bohler angle was 22.65°. We observed the following complications: one infection requiring hardware removal and hyperbaric oxygen therapy and 3 instances of delay in wound healing treated with antibiotic and medications. Hardware removal was needed in 10 cases. Conclusions: the good functional and clinical results seen in our study encourage us to propose surgery as the first choice of treatment of DICFs.

Treatment of intra-articular calcaneus fractures – a review of current treatment options

Treatment of calcaneal fractures remains a challenge for the orthopedic surgeon and is still controversial. There is no consensus on whether surgery is a better option that non-operative treatment. The indications for non-operative treatment are non-displaced extra-articular fractures and intra-articular fractures with fragment displacement of less than 2 mm on CT image (Sanders type 1) This type of treatment should be considered in patients with peripheral vascular disease, uncontrolled diabetes mellitus, uncooperative patients and in poor general health. Open repositioning and internal stabilization with LCP plateand screws is now considered the gold standard in the surgical treatment of DIACF. Despite the atraumatic surgical technique and modification of operational approach (limited-incision sinus tarsi approach [STA]) the risk of local complications is as high as 18 percent. Hence the observed constant development of minimally invasive methods. Their aim is to reduce the number of complications in relation to the ORIF method while ensuring anatomical reposition and equally stable osteosynthesis. The most popular minimally invasive techniques include closed reposition using the Westhus method and stabilisation with Kirschner wires, cannulated screws, treatment with external fixators or percutaneous balloon plasty. Each of the techniques listed above can be successfully used to treat transarticular fractures as early as the first few days after injury. The problem is the stability of the union, the quality of reduction and its maintenance until union is achieved and the long period of required weight relief of the operated limb.The methods using intramedullary nails offer new possibilities among minimally invasive techniques. The technique of surgery and implant designs differ significantly, but the possibility of correct reposition, the stability of osteosynthesis and the results of treatment obtained, according to the authors of the studies, are promising. Ultimately, the choice of the method of surgical treatment of calcaneal fractures should be selected taking into account the type of fracture, comorbidities, local condition of periarticular tissues as well as the experience and preferences of the operator. It seems that due to the development of imaging techniques and the lower number of complications after minimally invasive procedures, further development of these techniques should be expected.

Early Stage Results in the Treatment of Intra-Articular Calcaneus Fractures and the Factors Affecting Complication Rates

Early Stage Results in the Treatment of Intra-Articular Calcaneus Fractures and the Factors Affecting Complication Rates

Sinus tarsi approach combined with medial distraction technique for treatment of intra-articular calcaneus fractures

?To discuss the effectiveness of limited open reduction via sinus tarsi approach using medial distraction technique in the treatment of intra-articular calcaneus fractures by comparing with open reduction and internal fixation via extensile L-shaped incision. ?A retrospective analysis was made on the clinical data of 21 patients with intra-articular calcaneus fractures treated by sinus tarsi approach combined with medial distraction technique between April 2013 and November 2014 (minimally invasive group), and 32 patients treated by extensile L-shaped incision approach between June 2012 and September 2014 (extensile incision group). No significant difference was found in gender, age, injury pattern, fracture classification, time from injury to operation, preoperative Böhler angle, Gissane angle, calcaneal varus angle, the ankle and hind-foot score of American Orthopaedic Foot and Ankle Society (AOFAS), and visual analogue scale (VAS) score between 2 groups (P>0.05), which was comparable. The operation time, wound complications, and bone healing time were recorded. The postoperative function was also evaluated by AOFAS score and VAS score. The pre-and post-operative Böhler angle, Gissane angle, and calcaneal varus angle were measured on the X-ray films, and the corrective angle was calculated. ?Sixteen patients were followed up 6-18 months (mean, 11.5 months) in the minimally invasive group, and 23 patients for 6-24 months (mean, 13.5 months) in the extensile incision group. Difference was not significant in operation time between 2 groups (t=0.929, P=0.796). No complication occurred in the minimally invasive group; partial skin flap necrosis occurred in 3 cases of the extensile incision group, was cured after dressing change. There was no loosening of implants or reduction loss in 2 groups at last follow-up. Subtalar joint stiffness occurred in 1 case of the minimally invasive group and 4 cases of the extensile incision group, and 1 patient had discomfort for the implants in the extensile incision group. The bone healing time was (9.9±0.8) weeks in the minimally invasive group, and was (10.1±0.7) weeks in the extensile incision group, showing no significant difference (t=0.613, P=0.845 ). Böhler angle, Gissane angle, calcaneal varus angle, AOFAS score, and VAS score were significantly improved at last follow-up when compared with preoperative values in 2 groups (P<0.05), but there was no significant difference between 2 groups (P>0.05), and the corrective value of angle showed no significant difference between 2 groups (P>0.05). ?Limited open reduction via sinus tarsi approach for intra-articular calcaneus fractures could reduce the incidence of wound complications effectively. Meanwhile, the medial distraction technique is helpful to correct the heel varus deformity.

Surgical complications of intra-articular calcaneal fracture treatment

Introduction: The authors present complications following surgical treatment of intra-articular calcaneus fractures, in regards to the surgical technique employed, based on their own clinical material. Materials and methods: The techniques analyzed included the Westhues’ technique and its modifi cation with additional bone stabilization by Kirschner wires and the percutaneous stabilization by Rapala. The research material covered the years from 1990 to 2012 and consists of 82 operated patients - 68 men (83%) and 14 women (17%). Analyzed calcaneus fractures were divided using the Essex-Lopresti classifi cation. Results: The authors of the article indicate that the most frequently registered complications of surgical treatment of intra-articular calcaneus fractures in early observation were thromboembolic complications and local infl ammatory reactions of the skin at the point of incision and placing the stabilizing material. During the long-term follow-up, the post-thrombotic syndrome and algodystrophic disorders were the most common. Conclusions: Factors contributing to the occurrence of the complications registered were fracture morphology, fixation of bone fragments by an excessive number of stabilizing materials and prolonged immobilization of the operated limb. Cite this article as: Golec P., Tomaszewski K.A., Nowak S., Dudkiewicz Z. Surgical complications of intra-articular calcaneal fracture treatment. Med Rehabil 2016; 20(2): 25-30.

Sinus Tarsi Approach for Calcaneus Fractures

For decades the optimal treatment of intra-articular calcaneus fractures has been debated in the literature with no definitive solution reached. Although improved implant design and surgical techniques have led some to advocate for operative treatment, high rates of wound complications, particularly with use of the extensile lateral approach, have been touted as reasons to avoid operative fixation of calcaneus fractures. Given the advent of newer lower profile implants, better fixation techniques and improved surgical approaches that preserve the lateral vascular supply to the calcaneus, fewer complications and improved functional outcomes are more commonly reported in patients with operatively treated calcaneus fractures. Minimally invasive approaches, including the sinus tarsi approach, are being frequently used to treat displaced intra-articular calcaneus fractures with promising results. The literature has shown that through the use of these approaches, there has been a decreased rate of wound complications, hematoma formation, surgical time, and equivalent functional outcomes to the extensile lateral approach. This article focuses on describing the sinus tarsi approach, surgical technique, and outcomes.

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.

The Treatment of Intra-articular Calcaneus Fractures with Severe Soft Tissue Damage with a Hinged External Fixator or Internal Stabilization: Long-term Results

We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhler's angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhler's angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.