Treatment Of Intra-articular Calcaneal Fractures Research Articles

Locking plate internal fixation for minimally invasive treatment of intra-articular calcaneal fractures

Objective To summarize and evaluate the technique and clinical outcome of limited tarsal sinus incision plus locking plate internal fixation for minimally invasive treatment of intra-articular calcaneal fractures. Methods Between February 2010 and February 2011,16 cases of intra-articular calcaneal fractures were treated in a minimally invasive manner in our department. All cases were evaluated carefully with routine X-rays and CT scans preoperatively to define the type of fracture and the involvement of articular surface.Open reduction and locking plate internal fixation with percutaneous screws were performed via a limited tarsal sinus approach 3 to 6 days after injury (average,4 days).Regular X-ray follow-ups were conducted to measure the Bohler's and Gissane angles.Overall functional evaluation was carried out according to Visual Analogue Scale (VAS),the Hind-foot Score by American Orthopaedic Foot and Ankle Society (AOFAS) and Short Form 36 Health Survey Questionnaire (SF-36).Complications were recorded as well.Results The 13 cases were followed up for a mean duration of 18 months (from 12 to 24 months).There were no wound infection,skin and flap necrosis or implant failure.Bone union was achieved at an average of 10 weeks (from 8 to 12 weeks) post-operatively.The average Bohler's angle was improved significantly from 13.4° ± 3.4° (from 8° to 19°) pre-operatively to 26.5° ± 4.5° ( from 21° to 38°) post-operatively ( t =9.781,P ＜ 0.001 ).The average Gissane angle was improved significantly from 88.1° ± 7.6° (from 77° to 100°)pre-operatively to 116.2°±7.5° (from 100°to 124°) post-operatively (t =12.934,P ＜0.001).On average,the VAS score was 1.5 ± 1.7,the AOFAS score was 84.2 ± 5.9 and the SF-36 score was 79.5 ± 8.1 at the final follow-up.The follow-ups revealed no post-traumatic arthritis. Conclusion Open reduction and locking plate fixation with percutaneous screws via a limited tarsal sinus incision is a safe and reliable treatment for intra-articular calcaneal fractures,because it has the advantages of direct reduction of the articular surface,solid fixation,and limited soft tissue complications. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal; Bone plates; Surgical procedures, minimally invasive

Treatment of displaced intraarticular calcaneal fractures with or without bone grafts: A systematic review of the literature

Background:The necessity of bone grafts in the treatment of intraarticular calcaneal fractures continues to be one of the most debated topics in foot and ankle surgery. The purpose of this study was to determine whether there are sufficient objective cumulative data in the literature to compare the two methods and if the bone graft was needed in surgical treatment of intraarticular calcaneal fractures.Materials and Methods:A comprehensive search of all relevant articles from 1990 to 2010 was conducted. Two reviewers evaluated each study to determine its suitability for inclusion and collected the data of interest. Meta-analytic pooling of group results across studies was performed for the two treatment methods.Results:The systematic review identified 32 primary studies with 1281 fractures, which contained 4 comparative studies, 13 with bone grafts, and 15 without bone grafts in treatment methods. The infection rate in bone graft group was higher through statistically insignificant than in non-graft group (8.3% vs. 6.3%) No significant difference was found between good reduction rate, postoperative osteoarthritis rate, and subtalar fusion rate. The average full weight-bearing time in bone graft group was significantly lower (5.4 months) than in non-graft group (10.5 months). The mean postoperative Böhler's angle was significantly higher in bone graft group (lose due to collapse was significancy less). For the efficacy outcomes, the bone graft group had a lower American Orthopaedic Foot and Ankle Society Score (AOFAS) (71.4 points vs. 80.5 points) but a higher Creighton score (89.9 points vs. 81.0 points) compared with non-graft group. Pooled mean results showed 35% of the patients in bone graft group had an excellent result, 40% had a good result, 21% had a fair result, and 4% had a poor result. In the non-graft group, the corresponding values were 34, 42, 14, and 10%, respectively.Conclusions:The operative treatment of intraarticular calcaneal fractures with bone grafts could restore the Böhler's angle better and the patients could return to full weight bearing earlier. However, the functional and efficacy outcomes appear to be similar between the two treatment groups. There were more joint depression and comminuted fractures in the bone graft group, and the mean followup time was shorter. Large sample comparative studies are still needed.

Pediatric calcaneal fractures: outcomes of surgical fixation and its characteristics

Objective The purpose of this study was to analyze the outcomes of surgical treatment of displaced intra-articular calcaneal fractures (ICFs) in children and its characteristics.Methods Between January 2004 and October 2008,we review the results of 9 displaced,intra-articular fractures in 8 skeletally immature patients,who were treated with open reduction and internal fixation in our hospital.There were 7 males and 1 female,with the mean age of 13.1 years (range:10 to 15 years).Preoperative radiographs and computed tomographic scans were used to classify fractures.Clinical and radiographic evaluation were performed in postoperative follow-up visits.The functional outcomes were assessed with use of the modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score.The published literatures of child ICFs treated with ORIF were reviewed.Results In the series,there were 4 tongue-type and 5 joint depression-type fractures according to Essex-Lopresti classification,and according to Sanders classification,we found 5 type-Ⅱ fractures,3 type-Ⅲ and 1 type-Ⅳ fractures.The mean follow-up time was 47.4 months (range:21 to 72 months).All fractures healed within 2 to 4 months.The average preoperative and postoperative Bohler angles were 5.7 and 33.1 degrees respectively,and the mean Gissane angles were 106.5 and 128.0 degrees respectively.The mean modified-AOFAS score was 65.2 points (range:53 to 68 points).Skin necrosis was found in one foot.After the review of literatures,78.6％ (48/61) of displaced ICFs were male in children.Based on the Sanders classification,36 of 67 (53.7％) were type-Ⅱ fractures,25 of 67 (37.3％) were type-Ⅲ and 6 of 67 (9.0％) were type-Ⅳ; And 15 of 37 (40.5％) were tongue-type,22 of 37 (59.5％) were joint depression-type fractures according to Essex-Lopresti classification.Conclusion Most children with displaced ICFs treated with ORIF had a good clinical outcome with few complications.The children and adolescents that were exposed to high-energy trauma suffer calcaneal fractures that were similar to adult fracture patterns. Key words: Calcaneus; Fractures, closed; Child; Treatment outcome

Treatment of intraarticular calcaneal fractures using poking reduction combined with Ilizarov method

Objective To introduce the treatment of intraarticular calcaneal fractures with poor soft tissue using poking reduction combined with Ilizarov methods. Methods From September 2007 to September 2009,11 patients with the intraarticular calcaneal fractures were treated with poking reduction combined with Ilizarov methods,including 10 males and 1 female at average age of 33.6 years(range,21-50 years).Four patients had the left calcaneal fractures and seven with the right ones.According to Sander classification,there were seven patients with type II fractures,three with type III fractures and one with type IV fracture.The various extents of heel soft tissue injury were emerged in all the patients.Before operation,B(o)hler angle was 0°-12°(average 8°)and Gissane angle 70°-95°(average 80°).According to AO classification of close soft tissue injury,there were three patients with type IC2,six with type IC3,one with type IC5 and one with open soft tissue injury.The collapse of the articular surface was recovered by Steinmann pin which passed through the lateral calcaneal tubercle.The medial and lateral fracture fragments were corrected by using the tensed olive wires.The heighat and width were maintained by using the Ilizarov external fixation. Results The mean duration of follow-up was 13.3 months (range,6-20 months).All fractures were healed after mean duration for 8.1 weeks(range,7-10weeks).The postoperative B(o)hler angle was 20°-45°(average 33°)and Gissane angle 100°-118°(average 107°).According to Maryland Foot Score system,the result of postoperative function was excellent in seven patients,good in three and fair in one,with excellence rate of 91%. Conclusions For the intraarticular calcaneal fractures,the poking reduction combined with Ilizarov method is able to recover and maintain the normal calcaneal height and width and reduce postoperative wound infections and many other complications.specially for Sanders II or III with severe soft tissue injury in the open or closed calcaneal fractures.Master of surgical indications and operating poims can attain satisfactory clinical efficacy. Key words: Foot injures; Calcaneal; Poking reduction

Surgical treatment of calcaneal fractures with bioabsorbable screws

There is no consensus for the best surgical treatment of intra-articular calcaneal fractures. Bioabsorbable implants have been recommended for the treatment of some fractures. The aim of this study was to estimate the outcome and complications of surgical treatment of calcaneal fractures using bioabsorbable screws. We retrospectively reviewed 58 patients who underwent surgical treatment using bioabsorbable screws. The minimum follow-up was 15 months (mean, 23 months; range, 15-32 months). Fifty-five of 58 patients healed without additional complications. The mean adjusted American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 73.6 ± 22.4, the mean foot function index score was 23.9 ± 7.1, and the mean calcaneal fracture scoring system score was 77.2 ± 8.5. One patient had a superficial wound infection which healed after irrigation and debridement without removal of the implant. Two patients had consistent effusion from the wound for two weeks which healed after drainage and elastic dressing. We identified no evidence of soft tissue irritation or other complications directly attributed to the bioabsorbable screws. Our observations indicate that bioabsorbable screws provide sufficient stabilisation to allow for calcaneal fracture union with the advantage of no implant removal needed.

Arthroscopic Subtalar Arthrodesis after a Calcaneus Fracture Covered with a Forearm Flap

Surgical treatment of intraarticular calcaneal fractures is often associated with postoperative wound problems. Soft tissue necrosis, bone loss and uncontrollable infection are a challenge for the surgeon and amputation may in some cases be the ultimate solution. A free flap can be very helpful to cover a significant soft tissue defect and help in fighting the infection. However, the free flap complicates the surgical approach if subtalar arthrodesis and bone reconstruction are needed. This study demonstrates the value of an arthroscopic technique to resect the remaining articular cartilage in preparation for subtalar arthrodesis and bone grafting. This approach avoids compromising the soft tissues and minimizes damage to the free flap.

Operative treatment of calcaneal fractures

Objective To investigate the injury mechanism, clinical classification, treatment methods and clinical results of calcaneal fractures. Methods From June 2005 to May 2009, 83 feet in 70 patients with calcaneal fractures were treated. According to Sanders and Essex-Lopresti classifications, 63 feet had intra-articular fractures (30 feet of type Ⅱ, 21 type Ⅲ, and 12 type Ⅳ ) and 20 feet had extra-articular fractures (3 feet of lateral condylar fracture, 5 anterior process fracture, 9 calcaneal body fracture and 3 nodules fracture) . Reduction with a conventional lateral L-incision, mini-incision, or leverage was conducted depending on the clinical classification of the fracture involved. Fixation with a conventional plate or locking plate, simple screws and Kirschner wire was applied in all patients. Bone grafting was performed in the 20 cases whose defects were larger than 2 cm3. Functions and complications of the feet were observed at the follow-up. Results The 70 patients were followed up from 12 to 30 months (average, 18 months). The total average American Orthopaedic Foot and Ankle Society(AOFAS) score was (90.3 ± 11.0) points (48 to 100 points). The average AOFAS score for the 20 feet of extra-articular calcaneal fracture was (98.1±2.6)points (90 to 100 points), with no complications; the average AOFAS score for the other 63 feet of intra-articular calcaneal fracture was (87.8 ± 11.4) points (48 to 100 points) with such complications as necrosis at the skin edge of incision in 2 feet, sural nerve injury in 4 and traumatic subtalar arthritis in 10.Conclusions Treatment of extra-articular calcaneal fractures may have better clinical results than treatment of intra-articular calcaneal fractures. The preoperative evaluation of the fracture type and severity of soft tissue injury is especially essential to the treatment. Key words: Calcaneus; Fractures; Fracture fixation, internal; Postoperative complications

Efficacy analysis of L-shaped incision and internal fixation for 21 cases with intra-articular fracture of calcaneus

Objective To observe the clinical efficacy of intra-articular calcaneal fractures treatment with L-shaped incision and internal fixation. Methods 21 cases with intra-articular calcaneal fracture were treated with lateral L-shaped incision,through the Steinmann pin traction reduction, Kirschner wire and screw plate fixation,and the restoration of function in our hospital from March 2004 to June 2008. Results 21 patients in this group by L-shaped incision and internal fixation, the excellent rate of Sanders( Ⅱ type, Ⅲ type, Ⅳ type)were 96%,91% and 63% respectively,Overall satisfactory rate was 81%. sural cutaneous nerve injury was in 1 patient,less than the width of the heel in 1 patientConclusion The procedure is simple, trauma and faster recovery time, functional recovery of good, high patient satisfaction. L-shaped incision intra-articular calcaneal fracture fixation can be used as treatment of intra-articular calcaneal fracture of the main method ,should be in clinic. Key words: L-shaped incision; Intra-articular calcaneal; Fracture fixation

Percutaneous Reduction and Injection of Norian Bone Cement for the Treatment of Displaced Intra-articular Calcaneal Fractures

The treatment of intra-articular calcaneal fractures remains controversial. Although open reduction and fixation are favored by many authors, increased risk of soft tissue complications makes this method of treatment a challenge. Conversely, conservative treatment frequently leads to severe functional impairment and disability. Percutaneous surgical techniques have been employed to reduce the incidence of soft tissue complications but carry the risk of inadequate reduction and fracture stabilization. Norian SRS bone cement is an injectable calcium phosphate cement. Recent clinical studies have demonstrated the safe use of Norian SRS bone cement to augment standard plate fixation of calcaneal fractures. The authors describe their method of combining a percutaneous technique of fracture reduction with stabilization using Norian SRS bone cement. A total of 10 patients with 12 displaced intra-articular calcaneal fractures underwent this method of treatment. All 12 cases achieved adequate reduction on postoperative radiographs. Full weight bearing was started at 1 month postoperation, and none of the cases demonstrated loss of reduction on serial postoperative radiographs. No wound complications or cement-related soft tissue reactions were encountered. A 6-month assessment using the visual analog scale, the Maryland Foot Score, and the Short Form 36 general health survey showed encouraging results. Early results of treating displaced intra-articular calcaneal fractures using this method of a percutaneous technique of fracture reduction combined with Norian SRS bone cement stabilization are encouraging and promising.

Operative treatment of intra-articular calcaneal fractures with calcaneal plates and its complications.

Background:In a retrospective study we analysed intra-articular calcaneal fracture treatment by comparing results and complications related to fracture stabilization with nonlocking calcaneal plates and locking compression plates.Materials and Methods:We performed 76 osteosynthesis (67 patients) of intra-articular calcaneal fractures using the standard extended lateral approach from February 2004 to October 2007. Forty-two operations using nonlocking calcaneal plates (group A) were performed during the first three years, and 34 calcaneal fractures were stabilized using locking compression plates (group B) in 2007. In the Sanders type IV fractures, reconstruction of the calcaneal shape was attempted. Depending on the type of late complication, we performed subtalar arthroscopy in six cases, arthroscopically assisted subtalar distraction bone block arthrodesis in six cases, and plate removal with lateral-wall decompression in five cases. The patients were evaluated by the AOFAS Ankle-Hindfoot Scale.Results:Wound healing complications were 7/42 (17%) in group A and 1/34 (3%) in group B. No patient had deep osseous infection or foot rebound compartment syndrome. Preoperative size of Böhler's angle correlated with postoperative clinical results in both groups. There were no late complications necessitating corrective procedure or arthroscopy until December 2008 in Group B. All late complications ccurred in Group A. The overall results according to the AOFAS Ankle Hindfoot Scale were good or excellent in 23/42 (55%) in group A and in 30/34 (85%) in group B.Conclusion:Open reduction and internal fixation of intra-articular calcaneal fractures has become a standard surgical method. Fewer complications and better results related to treatment with locking compression plates confirmed in comparison to nonlocking ones were noted for all Sanders types of intra-articular calcaneal fractures. Age and Sanders type IV fractures are not considered to be the contraindications to surgery.

Results of open reduction and cortico-cancellous autograft of intra-articular calcaneal fractures according to Palmer

To assess the mid term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture using the modified Palmer technique. Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. The mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. Following Utheza, five fractures (28%) were classified as vertical, three as horizontal (17%) and 10 (55%) as combined. Mean preoperative Böhler angle was -4 degrees (range, -42 to 26 degrees ). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the subthalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screws inserted in a transverse position. Patients were evaluated at the last follow-up by physical examination and by the functional score described by Kitaoka. Böhler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side. Follow-up ranged from 12 to 38 months (mean, 23 months). One patient required a subtalar arthrodesis for advanced osteoarthritis. One patient experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, the mean Kitaoka score was 74 (range, 34-98). The functional score was considered good or excellent in 11 cases (64.7%), fair in three (17.6%), and poor in three (17.6%). The mean Böhler angle was 23.4 degrees (range, 5-40 degrees ) postoperatively and 22.7 degrees (range, 0-38 degrees ) at the last follow-up. A modest loss of correction was observed in four cases. The final Böhler angle was at least 85% compared to the healthy side in 10 cases out of 14 unilateral fractures. The functional score correlated well with restoration of Böhler's angle. Operative treatment of intra-articular calcaneal fractures following a modified Palmer technique provided encouraging results, since restoration of Böhler's angle was obtained. The main advantages include an absence of hardware prominence, resulting in an absence of skin complications, and a stable fixation.

Résultats du traitement des fractures articulaires du calcaneus par relèvement à foyer ouvert et greffe systématique selon la méthode de Palmer. À propos de 18 cas

To assess the mid-term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture according to Palmer.Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. Mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. According to Rev Chir Orthop 79 (1993) 49-57, five fractures (28 percent) were classified as vertical, three as horizontal (17 percent), and 10 (55 percent) as combined. Mean preoperative Böhler angle was -4 degrees (range, -42-26 degrees ). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the sub thalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screw(s) inserted in a transverse position. Patients were evaluated at the last follow-up by physical examination and by the functional score described by Foot Ankle Int 15 (1994) 349-353. Böhler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side.Follow-up ranged from 12 to 38 months (average, 23 months). One patient (one calcaneus) required a subtalar arthrodesis for advanced osteoarthritis. One patient (one calcaneus) experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, mean Kitaoka score was 74 (range, 34-98). Functional score was considered good or excellent in 11 cases (64.7 percent), fair in three (17.6 percent) and poor in three (17.6 percent). Mean Böhler angle was 23.4 degrees (range, 5-40 degrees ) postoperatively and 22.7 degrees (range, 0-38 degrees ) at the last follow-up. A modest loss of correction was observed in four cases. Final Böhler angle was at least 85 percent comparatively to the healthy side in 10 cases among 14 unilateral fractures. Functional score correlated well with restoration of Böhler's angle.Operative treatment of intra-articular calcaneal fractures according to Palmer provided encouraging results, since restoration of Böhler's angle was obtained. Main advantages include an absence of hardware prominence, resulting in an absence of skin complication, and a stable fixation.

Treatment of Intra-articular Calcaneal Fractures Using Minimally Invasive Sinus Tarsi Approach in Diabetic Patients

목 적: 관절내 종골 골절 수술의 합병증으로 5∼30%에서 창상 치유의 문제가 발생된다고 한다. 특히 당뇨병을 가진 관절내 종골 골절 환자에 있어 광범위한 절개술 및 무리한 피부 피판의 박리는 추후 피부 이식이나 별도의 치료가 필요할 정도로 문제가 발생할 수 있다. 이에 최소 절개 족근동 접근법을 이용하여 관절내 종골 골절을 치료하고 그 치료결과 및 합병증에 대하여 알아보고자 하였다. 대상 및 방법: 2002년 1월부터 2005년 7월까지 12명의 당뇨병을 동반한 관절내 종골 골절 환자를 대상으로 하였다. 수술 시 접근은 족근동을 중심으로 약 3 cm 크기의 절개를 통해 이루어졌으며, 수술 후 평균 추시 기간은 19개월 (13∼32)이었고 평균 나이는 47세 (39∼67)였다. 수상 후부터 수술일까지의 기간은 평균 8일 (5∼14)이었다. 목발에 의한 부분적 체중 부하는 수술 후 평균 7.3주 (6∼9), 완전한 체중 부하는 평균 9.3주 (7∼11)에 시행하였다. 결 과: American Orthopedic Foot and Ankle Society scale for Ankle and Hindfoot에 의한 수술 후 기능 평가에서 우수 1예 (3%), 만족 9예 (75%), 보통 1예 (3%), 그리고 불만족 1예 (3%)의 결과를 얻었다. 전 예에서 골유합을 얻었으며 심부 감염이나 피부 괴사 등의 합병증은 관찰되지 않았다. 결 론: 최소 절개 족근동 접근법을 이용한 관절내 종골 골절의 치료는 당뇨병이 있는 환자군에서 조직 절개를 최소화하여 심부 감염이나 피부 괴사를 줄일 수 있는 유용한 방법으로 추천할 만하다.

Treatment of complex calcaneal fractures under computer navigation: report of 130 feet

To investigate the effects of computer navigation in the treatment of intra-articular calcaneal fractures. 130 feet in 110 patients with intra-articular calcaneal fractures, 57 calcanei with fracture of Sander's type II, 45 of type III, and 28 cases of type IV, were treated with internal fixation under computer navigation, and were followed up for 16.3 months (6 - 24 months). According to the Maryland Foot Score system, excellent result was noted in 63 feet, good result in 57 feet, and fair result in 10 feet, with the excellent and good rates being 92.31% together. Using computer navigation to treat intra-articular calcaneal fractures is one of the best ways for treatment of calcaneal fractures.

Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey

The treatment of intra-articular calcaneal fractures is controversial and randomised clinical trials are scarce. Moreover, the socio-economic cost remains unclear. The aim of this study was to estimate the incidence, treatment preferences and socio-economic cost of this complex fracture in the Netherlands. This data may aid in planning future clinical trials and support education. The method of study was of a cross-sectional survey design. A written survey was sent to one representative of both the traumatology and the orthopaedic staff in each hospital in the Netherlands. Data on incidence, treatment modalities, complications and follow-up strategies were recorded. The socio-economic cost was calculated. The average response rate was 70%. Fracture classifications, mostly by Sanders and Essex-Lopresti, were applied by 29%. Annually, 920 intra-articular calcaneal fractures (0.4% incidence rate) were treated, mainly with ORIF (46%), conservative (39%) and percutaneous (10%) treatment. The average non-weight-bearing mobilisation was 9 weeks (SD 2 weeks). An outcome score, mainly AOFAS, was documented by 7%. A secondary arthrodesis was performed in 21% of patients. The socio-economic cost was estimated to be €21.5–30.7 million. Dutch intra-articular calcaneal fracture incidence is at least 0.4% of all fractures presenting to hospitals. Better insight into treatment modalities currently employed and costs in the Netherlands was obtained.

Chondrocyte Viability After Intra-articular Calcaneal Fractures in Humans

Chondral damage from the impact of injury may contribute to the high incidence of post-traumatic arthritis after calcaneal fractures, but this has yet to be proven. We sought to study the effect of intra-articular calcaneal fractures on chondrocyte viability and to correlate these effects with injury severity, time from injury to surgery, and patient age and co-morbidities. Irreducible osteochondral fragments from 12 patients undergoing operative treatment for intra-articular calcaneal fractures were analyzed. Control cartilage was obtained from four tissue donors who died of unrelated causes. The cartilage was assessed for chondrocyte viability through the full thickness of tissue using a Live/Dead assay followed by laser scanning confocal microscopy. Patient demographics including injury classification and severity, time from injury to surgery, and patient age were recorded. Chondrocyte viability from fracture patients averaged 72.8% +/- 12.9% (range 53% to 95%), which was significantly lower than the 94.8% +/- 1.5% viability observed in the control specimens (p = 0.005). Chondrocyte viability declined with higher energy injuries (p = 0.13), time from injury to surgery (p = 0.07), and increasing patient age (p = 0.07). However, none of these factors reached a level of statistical significance. A significant decline in chondrocyte viability occurs after intra-articular fractures of the calcaneus. This may contribute to the development of post-traumatic arthritis.

The Comparison of Radiographic Parameters and Clinical Results after Operative Treatment of Displaced Intraarticular Calcaneal Fractures

목 적: 전위된 관절내 종골 골절에 대한 수술적 치료 후 임상 결과와 방사선학적 계측치와의 상관관계를 알아보고자 하였다. 대상 및 방법: 전위된 관절내 종골 골절로 수술적 치료를 받은 환자 중 1년 이상 추시가 가능하였던 35예를 대상으로 하였다. 최종 추시에서 방사선학적 계측은 정상측과 환측의 Bohler 각, Gissane 각, Heel height, 종골 폭, Talocalcaneal 각, Talar declination 각, 거골하 관절면의 부조화를 측정하였으며 임상 결과는 Creighton-Nebraska Health Foundation Assessment Score (CNH)를 이용하였고 방사선 측정치와 CNH 점수와의 상관관계를 Pearson correlation 방법을 이용하여 상관분석을 하였다. 결 과: 여러 가지 방사선 계측치 중 거골하 관절면의 부조화만이 강한 음적 선형관계를 보였다. 거골하 관절면의 부조화의 건측과 환측의 방사선 측정치 차이의 평균은 0.54 mm (0~2.5)이었으며 CNH 점수와의 상관계수는 -0.784 (p=0.002)이었다. 결 론: 전위된 종골 골절의 수술적 치료 후 임상 결과와 상관관계가 있는 방사선학적 계측치는 거골하 관절면의 부조화였다.

Displaced intraarticular calcaneal fractures Prognostic factors for poor outcome

The controversial nature of treatment for displaced intraarticular calcaneal fractures has led to numerous publications. Amidst the debate, a few studies have reported the association between patient and injury characteristics and outcome. Factors reported to be associated with a poor outcome included worker's compensation status, BOhler's angle ＜ 0°at fracture presentation, male sex, heavy-labor employment, bilateral calcaneal fracture, and Sander's classification type Ⅳ fracture. Key words: Calcaneal; Fractures; Prognostic factors

SRS Cancellous Bone Cement Augmentation of Calcaneal Fracture Fixation

The proper treatment of intraarticular calcaneal fractures remains controversial. The goal of operative treatment is to achieve anatomic reduction with stable internal fixation. One method for stabilizing fracture constructs is the use of calcium phosphate bone cement. The goal of this study was to evaluate a series of patients who had open reduction and internal fixation of intra-articular calcaneal fractures with calcium phosphate bone cement augmentation. Fifteen patients had open reduction and internal fixation through an extensile lateral approach with standard low-profile hardware. The walls of the bone defect beneath the posterior facet were impacted with a curette and the void filled with SRS bone cement. Preoperative and postoperative plain radiographs and computed tomography (CT) were obtained on each patient. The most recent radiographs were assessed for maintenance of reduction. Nine patients were followed for an average of 13 (6 to 60) months. Six patients had less than 6 months followup. There were five type IIA, five type IIB, four type IIC, and one type IIIB-C fractures. All 15 fractures were noted on postoperative CT to have less than 2-mm of step-off with complete cement fill of the bony void. None of the patients developed a soft-tissue reaction to the cement. The first six patients were allowed to bear weight 6 weeks after injury, and the following nine patients were allowed to bear weight at 3 weeks after injury. No patient had any visible loss of reduction on most recent radiographs. Followup CT at 7 months in one patient and 12 and 51 months in another patient revealed no change in the bone-cement interface or amount of cement remaining. One patient's CT at 12 months revealed apparent fragmentation of the cement mass without loss of reduction. There was one major wound complication necessitating cement and hardware removal and free flap coverage. In this small series, patients had no evidence of soft-tissue reaction or loss of reduction with early weightbearing after open reduction and internal fixation augmented with calcium phosphate bone cement.

A modified technique for the treatment of intra-articular calcaneal fractures with the use of the Ilizarov apparatus

The management of intra-articular calcaneal fractures during the past years has been ranged from the nihilistic approach of no active treatment to open reduction and internal fixation (ORIF) or even to early subtalar arthrodesis. The management of such fractures with the use of circular external fixators in a closed fashion or in combination with minimal approach is demonstrated in our study. The midterm results of 36 intra-articular calcaneal fractures treated between 1996 and 2003 with the use of the Ilizarov apparatus according to our modified operative strategy are presented. In treating calcaneal fractures, the classic Essex-Lopresti classification into depression and tongue type has been proved very useful in our hands. While the depression-type fractures can be reduced through skeletal traction and the above-mentioned minimal approach, tongue-type fractures can cause difficulties in reducing and especially maintaining the reduction of the tongue fragment. Especially for these fractures, a combined technique was applied by reducing the fracture with Steinmann pins according to the Essex-Lopresti method and incorporating them into the Ilizarov apparatus. This technique appears to be a lot easier and more accurate than the alternative “bent-wire technique” for reducing and holding down a tongue fragment. The original Essex-Lopresti manipulation alone with plaster immobilization does not allow weight bearing and is associated with regional osteoporosis. Apart from the Essex-Lopresti classification, the material was also categorized by the widely accepted Sanders CT classification for comparison of our results to those of the literature. The SF-36 patient-oriented general health status questionnaire was utilized before, during, and after the treatment period to assess patients’ satisfaction levels. We propose this operative strategy as an option for the treatment of all calcaneal fractures.