Application of Human Acellular Dermal Matrix with Skin Graft for Lacunar Soft-Tissue Defect of Lateral Heel after Calcaneal Fracture.

OBJECTIVE: To investigate the clinical effect of human acellular dermal matrix (HADM) combined with split-thickness skin graft in repairing lacunar soft tissue defects of the lateral heel after calcaneal fracture. METHODS: From June 2018 to October 2020, providers repaired 11 cases of lacunar soft tissue defects at the lateral part of the heel using HADM combined with split-thickness skin graft. After thorough debridement, the HADM was trimmed and filled into the lacunar defect area. Once the wound was covered, a split-thickness skin graft and negative-pressure wound therapy were applied. Providers evaluated the appearance, scar, ductility of the skin graft site, appearance of the donor site, healing time, and any reoperation at follow-up. RESULTS: Of the 11 cases, 8 patients achieved successful wound healing by primary intention. Three patients showed partial necrosis in the edge of the skin graft, but the wound healed after standard wound care. Evaluation at 6 and 12 months after surgery showed that all patients had wound healing and mild local scarring; there was no obvious pigmentation or scar formation in the donor skin area. The average healing time was 37.5 days (range, 24-43 days). CONCLUSIONS: The HADM combined with split-thickness skin graft is a simple and effective reconstruction method for lacunar soft tissue defect of the lateral heel after calcaneal fracture. In this small sample, the combination demonstrated few infections, minor scar formation, few donor site complications, and relatively short hospital stays.

Comparison between intramedullary nail and conventional plate for displaced intra-articular calcaneal fractures: A meta-analysis.

OBJECTIVES: This study aimed to compare the efficacy and safety of the intramedullary nail and conventional plate for the treatment of displaced intra-articular calcaneal fractures from clinical comparative trials. MATERIALS AND METHODS: A comprehensive search of English databases was carried out in the Springer, PubMed, ScienceDirect, Web of Science, and Cochrane Library databases until September 2023. Studies on calcaneal fractures treated by an intramedullary nail or a plate were considered for inclusion. Endpoints included duration of operation, length of hospital stay, the Visual Analog Scale (VAS) score, postoperative functional score, radiological parameters, and complications. The mean difference (MD) and risk difference (RD) as the combined variables, as well as the 95% confidence intervals, (CIs) were calculated. RESULTS: Five retrospective controlled studies covering 473 feet at the one-year follow-up met the inclusion criteria. The meta-analysis demonstrated that there were significant differences in the duration of operation (MD: -10.81; 95% CI: -16.32, -5.31; p=0.0001), length of hospital stay (MD: -3.65; 95% CI: -4.35, -2.95; p<0.00001). No significant differences were found regarding postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (MD: 0.36; 95% CI: -3.89, 4.61; p=0.87), VAS (MD: 1.95; 95% CI: -0.30, 4.21; p=0.09), or postoperative Böhler angle (MD: 0.94; 95% CI: -0.04, 1.92; p=0.06) between the two groups. The incidence of total complications (RD: -0.31; 95% CI: -0.46, -0.17; p<0.0001) and wound-healing complications (RD: -0.16; 95% CI: -0.30, -0.03; p=0.02) were lower in the intramedullary nail group. There were no significant differences in the incidences of revision surgery, implant removal, superficial wound infection, deep infection, and nonunion. CONCLUSION: Compared to conventional plates, the intramedullary nail showed a shorter duration of operation, reduced length of hospital stay, and fewer postoperative total complications and wound-healing complications in treating displaced intra-articular calcaneal fractures.

[Effectiveness of vertical compression of locking plate combined with hollow screws in treatment of Sanders type â ¡ and â ¢ calcaneal fractures].

Objective: To probe into the effectiveness of vertical compression of locking plate combined with hollow screws in the treatment of Sanders type Ⅱ and Ⅲ calcaneal fractures. Methods: The clinical data of 128 patients with Sanders type Ⅱ and Ⅲ calcaneal fractures who were admitted between March 2019 and April 2022 and met the selection criteria were retrospectively analyzed. Among them, 65 patients were treated with locking plate combined with hollow screw vertical compression (study group), and 63 patients were treated with simple locking plate (control group). There was no significant difference in baseline data between the two groups ( P>0.05), such as gender, age, fracture side and Sanders classification, cause of injury, time from injury to operation. The operation time, intraoperative blood loss, hospital stay, and fracture healing time were recorded and compared between the two groups. Before operation and at 12 months after operation, the American Orthopaedic Foot and Ankle Association (AOFAS) score (including total score, pain score, functional score, and alignment score) was used to evaluate the recovery of foot function, and imaging indicators such as calcaneal width, calcaneal height, calcaneal length, Böhler angle, and Gissane angle were measured on X-ray films. Results: All patients were followed up 12 months after operation. There was no significant difference in operation time, intraoperative blood loss, hospital stay, and fracture healing time between the two groups ( P>0.05). Poor wound healing occurred in 1 case in the study group and 2 cases in the control group. At 12 months after operation, there was no significant difference between the two groups in the pre- and post-operative difference of calcaneal length, calcaneal height, Gissane angle, and Böhler angle ( P>0.05). However, the pre- and post-operative difference in calcaneal width in the study group was significantly higher than that in the control group ( P<0.05). The pre- and post-operative difference of AOFAS total score in the study group was significantly higher than that in the control group ( P<0.05), and further analysis showed that the pre- and post-operative difference of pain and function scores in the study group were significantly higher than those in the control group ( P<0.05), while there was no significant difference in the pre- and post-operative difference of force score between the two groups ( P>0.05). Conclusion: Compared with simple locking plate treatment, the treatment of Sanders type Ⅱ and Ⅲ calcaneal fractures with vertical compression of locking plate combined with hollow screws can more effectively improve the width of the subtalar calcaneal articular surface, avoid peroneal longus and brevis impingement, reduce pain, and increase the range of motion of the subtalar joint, and the effectiveness is better.

[A prospective study on treatment of Sanders type â ¡ and â ¢ calcaneal fractures with interlocking intramedullary nail fixation system].

Objective: To explore the effectiveness of interlocking intramedullary nail fixation system for Sanders type Ⅱ and Ⅲ calcaneal fractures by comparing with open surgery. Methods: Forty patients (40 feet) with Sanders type Ⅱ and Ⅲ calcaneal fractures, who were admitted between May 2020 and December 2022 and met the selection criteria, were included in the study. They were randomly allocated into control group and minimally invasive group using a random number table method, with 20 cases in each group. The patients were treated with the interlocking intramedullary nail fixation system in the minimally invasive group and with steel plate internal fixation via a lateral L-shaped incision in the control group. There was no significant difference between the two groups ( P>0.05) in terms of gender, age, fracture classification and side, cause of injury, time from injury to admission, and preoperative width, length, height, Böhler angle, and Gissane angle of the calcaneus. The operation time, intraoperative blood loss, incision length, hospital stay, fracture healing time, incidence of complications, as well as pre- and post-operative imaging indicators (Böhler angle, Gissane angle, width, height, and length of the calcaneus) and American Orthopaedic Foot and Ankle Society (AOFAS) score of foot were recorded and compared between the two groups. Results: The incision length, operation time, and hospital stay of the minimally invasive group were significantly shorter than those of the control group, and the intraoperative blood loss significantly reduced ( P<0.05). All patients of the two groups were followed up, with the follow-up time of 8-12 months (mean, 10.2 months) in the minimally invasive group and 8-12 months (mean, 10.4 months) in the control group. No complication occurred in the minimally invasive group after operation. One case of incision epidermal necrosis and 1 case of traumatic arthritis occurred in the control group after operation. However, there was no significant difference in the incidence of complications between the two groups ( P>0.05). At last follow-up, the AOFAS score was significantly higher in the minimally invasive group than in the control group ( P<0.05). Imaging examination showed that the calcaneal fractures of the two groups healed, and there was no significant difference in healing time between the two groups ( P>0.05). Compared with preoperative conditions, the Böhler angle and Gissane angle of the calcaneus in the two groups significantly increased, the width narrowed, and the height and length increased at 3 days after operation and the last follow-up, with significant differences ( P<0.05). There was no significant difference between 3 days after operation and last follow-up ( P>0.05). There was no significant difference between the two groups at each time point ( P>0.05). Conclusion: The interlocking intramedullary nail fixation system in treatment of Sanders type Ⅱ and Ⅲ calcaneal fractures has the advantages of minimal trauma, shortened hospital stay, reliable fracture reduction and fixation, and satisfactory foot function recovery.

Minimally Invasive Surgery vs Nonoperative Treatment for Displaced Intraarticular Calcaneal Fracture: A Prospective Propensity Score Matched Cohort Study With 2-Year Follow-up.

BACKGROUND: Optimal management of displaced intraarticular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiologic outcomes of minimally invasive surgery vs nonoperative treatment in displaced intraarticular calcaneal fracture up to 2 years. METHODS: All displaced intraarticular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma center were considered for inclusion. The decision to treat was made by a multidisciplinary team consisting of fellowship-trained orthopaedic surgeons. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction and internal fixation. Nonoperative protocol involved symptomatic management with no attempt at closed reduction. The Manchester-Oxford Foot Questionnaire (MOXFQ) and EuroQol-5 Dimensions-5 Level (EQ-5D-5L) patient-reported outcome measures were used to assess foot and ankle and general health related quality of life outcomes, respectively, at 2-year follow-up. Radiographic assessment was performed based on preinjury and 12-week postinjury radiographs. RESULTS: A total of 101 patients were included for analysis between August 2014 and January 2019. We propensity score matched 46 patients in the surgical cohort to 46 patients in the nonsurgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (P > .05); however, the surgical cohort had a significantly higher EQ-5D-5L Index score (P < .05) and return to work (91% vs 72%, P < .05) and physical activity rate (46 vs 35%, P < .05) despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. In addition, 14% of patients in the nonoperative cohort subsequently underwent arthrodesis compared with none of the patients in the surgical cohort. CONCLUSION: In this study, we found that operative treatments were associated with low rates of surgical complication at 2 years and long-term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared with nonoperative treatment for less severe fractures. LEVEL OF EVIDENCE: Level III, retrospective cohort.

The role of patient positioning in surgical fixation of the calcaneus fractures using the lateral extensile approach.

INTRODUCTION: Calcaneus is the most commonly fractured tarsal bone. Open reduction and internal fixation of the displaced intra-articular fractures is considered the gold standard treatment. The lateral extensile approach is the most commonly used approach, and usually, the patients are kept in lateral decubitus position. Recent study has descried calcaneus fracture fixation utilizing the lateral extensile approach with the patient in prone position. The aim of this study was to compare the postoperative radiological outcome, reoperation rate, operative and anesthesia time, infection and the wound complications rate between the two groups. METHODS: The data of 49 adult patients with unilateral closed calcaneus fracture underwent open reduction and internal fixation using lateral extensile approach were collected. Postoperative Bohler's, Gissane angles and complications rate were compared between the two groups. RESULTS: A total of 49 patients were included. Lateral position was utilized in 26 patients (53.1%), while 23 patients (46.9%) were operated in prone position. Majority of the patients were males 87.8% (43 patients), and the mean age of the patients was 31.12 ± 7.50. The most commonly mechanism of injury was fall from height in (91.8%) of the patients. The mean preoperative Bohler's angle was 9.33 ± 13.07 and increased to 22.69 ± 9.15 postoperatively. The mean preoperative angle of Gissane was 130.45 ± 26.98 whereas it was 124.76 ± 17.20 postoperatively. The mean postoperative Bohler's angle and angle of Gissane were significantly higher among patient who underwent fixation in lateral position (25.88 ± 6.62, 137.15 ± 11.17) when compared to the prone one (19.09 ± 10.35, 110.74 ± 10.81). There was no significant difference between the two groups regarding the reoperation rate (p 0.947), infection (p 0.659, operative time (p 0.688), anesthesia time (p 0.522) and wound complications (p 0.773). CONCLUSION: Surgical restoration of the Bohler's and Gissane's angles with the patient placed in the lateral decubitus position remains superior to the prone position with no difference in the complication rate between the two groups.

Classification of intraarticular calcaneal fractures: comparison of two classification systems.

PURPOSE: Accurately classifying displaced intraarticular calcaneal fractures (DIACFs) is essential for orthopedic surgeons to choose optimal treatment methods and provide results evaluation and communication. Many authors studying used Sanders classification reported moderate intra- and interobserver reliability. Taking the software opportunity of 3D virtual exarticulation, Goldzak updated French tri-dimensional Utheza classification, providing an alternative framework for classifying DIACFs. The aim of this study was to compare the intra- and interobserver reliability of Sanders versus Goldzak classification systems. METHODS: The CT scans of 30 patients with displaced intraarticular calcaneal fractures, treated in the same trauma center between 2014-2018, were analyzed by 16 medical doctors (specialists and residents in orthopedic surgery, specialists and residents in radiology), and classified according to Sanders and Goldzak classifications. The same images were sent on two separate sessions, in a randomized order. Interobserver reliability and intraobserver reproducibility were assessed using Kappa statistics and Gwet's AC1 coefficient. RESULTS: Interobserver reliability using Gwet reported a value of 0.36 for Goldzak classification and 0.30 for Sanders classification (corresponding to "fair assessment" in both cases). In absence of subclasses, "substantial assessment" was reported for Goldzak classification (Gwet of 0.61) and "moderate assessment" for Sanders classification (Gwet of 0.46). Goldzak system had a greater interobserver reliability in the group of radiology residents. Intraobserver reliability coefficient was 0.60 for Goldzak classification and 0.69 for Sanders classification, indicating a substantial agreement for both classifications. CONCLUSION: Despite the better view of the fracture lines provided by 3D reconstructions, this study failed to prove the superiority of Goldzak classification compared to Sanders classification for DIACFs.

Factors influencing functional outcome of fractures of the anterior process of the calcaneus.

INTRODUCTION: Fractures of the anterior process of the calcaneus (APC) are easily overlooked in clinical practice. Most patients have good to excellent clinical outcome after conservative treatment, while some patients may have persisting symptoms and unfavorable functional outcomes. The aim of this study was to identify the risk factors associated with unfavorable functional outcome after conservative treatment in APC fractures. METHODS: All patients presenting with APC fractures and receiving conservative treatment from April 2019 to April 2020 were retrospectively assessed. The primary outcome measurement was the ankle joint function assessed using Karlsson Scoring System at 2 years post-injury. The risk factors associated with unfavorable functional outcomes (Karlsson score ≤ 80) were evaluated by logistic regression analysis. RESULTS: In total, 84 patients were included with a mean age of 40 years. 26 (31%) patients presented with unfavorable functional outcome at 2 years post-injury. In multivariate logistic regression, concomitant fractures of talonavicular (TN) joints and older age were significantly associated with unfavorable functional outcome (p<0.05). Patients with concomitant fractures of TN joints had an odds ratio of 3.623 for unfavorable functional outcome. The optimal cutoff age for an unfavorable outcome was ≥ 47.5 years, with an odds ratio of 5.010. CONCLUSION: Most patients with APC fractures achieved good to excellent results when treated conservatively. Attention should be paid to those with concomitant fractures of TN joints and with age ≥ 47.5 years, which might lead to unfavorable functional recovery. LEVEL OF EVIDENCE: IV; case series.

The impact of sustentaculum tali fracture on clinical outcome in patients affected by isolated calcaneal fractures.

INTRODUCTION: The sustentaculum tali is displaced in almost half of calcaneal fractures and during surgical fixation represents one of the main reference points upon which the other bone has to be reduced. The purpose of this study was to investigate which subtalar joint fracture pattern is more frequently associated with sustentaculum tali involvement. Furthermore, correlation between postoperative clinical outcome and sustentaculum tali integrity was performed. MATERIAL AND METHODS: Patients with isolated calcaneal fractures were analyzed. Sanders-type fracture and involvement of both sustentaculum tali and calcaneocuboid joint were detected on computed tomography imaging; postoperative AOFAS scores were analyzed according to sustentacular involvement. RESULTS: Fifty calcaneus fractures in 47 patients were included in the final analysis. The sustentaculum tali was fractured in 18 cases (36.0%), thus contradicting its supposed constant position. Sanders type 3 and 4 fractures were more frequently associated with fractured sustentaculum than type 2 (p = 0.012). Sanders type 4 fractures were associated with displaced sustentacular fragment significantly more than type 2 and 3 (p = 0.043). Patients with intact sustentaculum tali reported significantly higher (p < 0.001) mean AOFAS scores than the uninjured group (84.4 ± 9.1 and 74.3 ± 9.5, respectively). CONCLUSION: Sanders type 3 and 4 fractures were more frequently associated with sustentaculum tali and/or calcaneocuboid joint involvement than simpler fractures. Injury of sustentaculum tali was related to significant worse postoperative clinical outcomes, underlying the relevance of this fragment on clinical course.

External fixation in intra-articular fractures of the calcaneus: Is it a valid option as definitive treatment?

INTRODUCTION: The therapeutic management of calcaneal fractures is currently a major source of controversy in the literature. There is no consensus on the need to treat these injuries conservatively or surgically, nor on the criteria for deciding one option or the other. Although the gold standard has classically been the open approach and osteosynthesis, there are currently minimally invasive techniques that also report good results. Our objective is to present our results and experience with the MBA® Orthofix external fixator in a series of cases of calcaneal fractures. METHODS: We performed a retrospective observational study in our center, between the years 2019 and 2021, of Sanders types II-IV calcaneal fractures operated with MBA® Orthofix external fixator. We recorded a total of 38 patients, 42 fractures. We registered demographic information, intraoperative, postoperative, radiological and functional parameters, using the American Orthopedic Foot and Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D and VAS scales. RESULTS: A total of 26 men and 12 women were included, and the median age was 38 years. Mean follow-up was 24,4 months (6, 8-40, 1). The average time to surgery was 7 days and partial loading was started at 2.5 weeks after external fixation, which was removed at 9.2 weeks. The average Böhler angle correction was 7, 4°, Gissane - 12,2°, length 2 mm and calcaneal width was reduced by 5 mm. We recorded two superficial infections, one peroneal entrapment and three subtalar arthrodesis due to post-traumatic osteoarthritis. The AOFAS obtained was 79.1 + / - 15.7 points, MOXFQ 20.1 + / - 16.1 points, EQ-5D 0.84 + / - 0.2 and VAS 3.3 + / - 1.9. CONCLUSION: The external fixator is an excellent surgical alternative for complex articular fractures of the calcaneus, obtaining clinical and radiological results comparable to other osteosynthesis techniques and significantly reducing soft tissue complications.

Comparison between screw fixation and plate fixation via sinus tarsi approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis.

BACKGROUND: Optimal surgical fixation for displaced intra-articular calcaneal fractures (DIACF) remains a subject of debate, particularly regarding the superiority between screw fixation and plate fixation via the sinus tarsi approach (STA). This review aims to determine the preferred treatment for DIACF and compare the outcomes of minimally invasive surgery options. METHODS: Our study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on distal intra-articular fractures of the calcaneus (DIACFs) that were fixed using cannulated screws or plates via STA. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, and complications. RESULT: A total of 728 patients from 7 studies met the inclusion criteria. Among them, 435 patients underwent screw fixation via STA, and 373 patients underwent plate fixation via STA. The study found no statistically significant differences between the screw fixation and the plate fixation via sinus tarsi approach (STA) in terms of AOFAS scores, Bohler's angle, Gissane's angle, sural nerve injury, secondary subtalar arthrodesis and reoperation. Compared with screw fixation, plate fixation via STA can reduce reduction loss of Bohler's angle (WMD = - 1.64, 95% CI = [- 2.96, - 0.31], P = 0.06, I2 = 59%), lower the incidence of fixation failure (OR = 0.32, 95% CI = [0.13, 0.81], P = 0.78, I2 = 0%), and decrease intra-articular step-off (WMD = - 0.52, 95% CI = [- 0.87, - 0.17], P = 0.66, I2 = 0%). CONCLUSIONS: Plate fixation demonstrates superior capability in restoring calcaneal width, maintaining Bohler's angle, and minimizing intra-articular step-off, thereby maintaining better reduction of the subtalar articular surface. In addition, plate fixation exhibits the modest complication rate and a low incidence of fixation failure. Therefore, we recommend the use of plate fixation through the STA, especially for complex and comminuted intra-articular calcaneal fractures.

Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study.

BACKGROUND: Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction. METHODS: This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate. RESULTS: Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork. CONCLUSION: Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane. LEVEL OF EVIDENCE: III.

Calcaneal tuberosity avulsion fractures - A review.

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

A Comparative Analysis of Between Percutaneous Cannulated Screw Fixation and Traditional Plate Internal Fixation in Treatment of Sanders II and III Calcaneal Fractures.

The objective of this study is to compare the clinical efficacy of percutaneous cannulated screw fixation and traditional plate internal fixation in the treatment of Sanders II and III calcaneal fractures. The records of 64 patients were retrospectively analyzed. Thirty-three cases were fixed by percutaneous cannulated screws. Thirty-one cases were fixed with traditional steel plates. The preoperative preparation time of the screw group and plate group was 3 ± 1.7 days and 4.6 ± 2.1 days. The surgery time was 118.9 ± 43.8 minutes and 146.9 ± 47.6 minutes. The length of hospitalization was 8.7 ± 3.9 days and 17.0 ± 7.9 days. Intraoperative blood loss was 38.2 ± 27.7 mL and 67.1 ± 58.8 mL. The postoperative drainage volume of the plate group was 85.1 ± 53.7 mL, and no wound drainage was needed in the screw group after surgery. Postoperative wound complications occurred in 2 cases of the screw group and 8 cases of the plate group. The recovery effects of Gissane angle and Bohler angle are similar in the 2 groups. The excellent and good rate of the American Orthopaedic Foot and Ankle Society ankle-hindfoot Scale in the screw group was 96.8% at 12 months after surgery, whereas the rate was 93.5% in the plate group. Compared with the traditional plate internal fixation, the percutaneous cannulated screw group achieved a similar excellent and good rate of clinical treatment. It has the advantages of less trauma, less bleeding, low incidence of complications, short preoperative preparation, and hospitalization time.

Fracturas por avulsión de la tuberosidad posterior del calcáneo "en pico de pato". Evaluación funcional y radiográfica / Avulsion fractures of the posterior calcaneal tuberosity (beak fracture). functional and radiographic evaluation

Objetivos: Comunicar los resultados funcionales y radiográficos en seis pacientes con fractura "en pico de pato" (beak fracture)y realizar una revisión de la bibliografía.materiales y métodos:Se evaluaron los resultados funcionales (escala de la AOFAS) y radiológicos en seis pacientes (3 hombres y 3 mujeres; edad promedio 35.6 años). El tiempo promedio transcurrido entre la lesión y el ingreso en el quirófano fue de 2.83 h. Se realizó la rama vertical del abordaje lateral extendido. Se fijó con tornillos canulados y macizos de 3,5; 4,0 o 4,5 mm solos o combinados con placas de 3,5 y 2,7 mm bloqueadas.Resultados:Después de un seguimiento de entre 8 y 24 meses, todos los pacientes tenían signos francos de consolidación. Al ingresar, todos presentaban signos de sufrimiento de partes blandas sin signos de necrosis. El puntaje de la escala de la AOFAS fue de 82,4 (5, buenos y 1, regular). Las complicaciones fueron: una infección profunda y pérdida de la reducción en el mismo paciente.Conclusiones:Las fracturas "en pico de pato" pueden generar complicaciones de partes blandas si no son tratadas de manera urgente, debido al compromiso inicial de partes blandas. La reducción abierta y la fijación con tornillos y placas es el sistema de fijación más estable. Nivel de Evidencia: IV

Objectives: To present the functional and radiographic outcomes of six patients with beak fractures and to carry out a literature review. materials and methods: The functional (AOFAS Score) and radiological outcomes of six patients were evaluated. Three patients were male and three were female (mean age: 35.6 years). The mean time interval between injury and admission to the operating room was 2.83 hours. The extensile lateral approach was used. The fracture was fixed with 3.5, 4.0, or 4.5mm cannulated and solid screws alone or in combination with 3.5 and 2.7mm locking plates. Results: After a follow-up period of between 8 and 24 months, all the patients had clear signs of consolidation. On admission, all presented signs of soft tissue pain without signs of necrosis. The AOFAS score was 82.4 (5 good and 1 fair). The complications observed were a deep infection and loss of reduction in the same patient. Conclusions: Beak fractures can generate soft tissue complications if they are not treated urgently due to initial soft tissue involvement. Open reduction and fixation with screws and plates is the most stable fixation system. Level of Evidence: IV

[Minimally Invasive Osteosynthesis of Calcaneal Fractures Using the Anterolateral Locking Plate]. / Miniinvazivní osteosyntéza zlomenin patní kosti anterolaterální úhlove stabilní dlahou.

PURPOSE OF THE STUDY Extended lateral approach to calcaneus fractures is associated with a high risk of infection. Such risk can be reduced by using mini-invasive approaches. The sinus tarsi approach provides a good overview of the posterior joint facet of the calcaneus and can also be done as a mini-invasive procedure. The authors present their fi rst experience with osteosynthesis of joint depression calcaneal fractures using the anterolateral locking plate inserted through the sinus tarsi approach. MATERIAL AND METHODS During the period from 1 February 2020 to 31 January 2022, 18 patients were treated by the anterolateral locking plate in the authors' department (3 women, 15 men). Eleven fractures were classifi ed according to Sanders as IInd grade, fi ve as IIIrd grade and two fractures were classifi ed as tongue-type (as described by Essex-Lopresti). The fractures were treated by open reduction through the sinus tarsi approach and osteosynthesis by the anterolateral locking plate combined with headless screws. The following factors were examined: time from injury, duration of surgery, quality of reduction (post-op control with multiplanar CT scans), wound and technical complications, loss of reduction after treatment, substance abuse and comorbidities. The follow-up was 12-36 months (median 17). At one year after surgery, the functional outcomes were evaluated using the AOFAS Hindfoot score. RESULTS The most common negative predispositions for successful healing were smoking (9 cases), alcohol abuse, drug abuse, mild mental retardation, personality disorder, insulin-dependent diabetes and epilepsy (1 case each), hypothyreodism and bronchial asthma (2 cases each). The time from injury to surgery and duration of surgery surgery were measured. The quality of reduction was excellent in 12 patients (dislocation less than 1 mm), good in 6 patients (dislocation less than 2 mm), dislocation more than 2 mm was not present in the group. In one case, a revision surgery was performed because of screw malposition into the subtalar joint, delayed wound healing was observed in two cases. There was no case of deep surgical site infection or loss of reduction. The mean AOFAS score after one year was 85 points. The most common complaints were scar pain or discomfort. DISCUSSION The current studies on osteosynthesis of calcaneal fractures favor the sinus tarsi approach for its lower risk of wound-related complications compared to the extended lateral approach. The sinus tarsi approach requires the use of different osteosynthetic material than the conventional calcaneal plate. If a conventional locking plate is to be used, the surgical approach has to be modifi ed. In 2021, Wang et al. published an intermediate step leading to the reduction of early complications and the use of conventional locking calcaneal plate inserted through the sinus tarsi approach, with an additional incision. The sinus tarsi approach is used also when intramedullary nailing is performed, which is preferred by biomechanical studies evaluating the rigidity of osteosynthesis. However, when comparing nails and locking plates, the differences are insignifi cant. The use of anterolateral locking plates was presented by Xie et al., with results similar to those of our own group of patients. CONCLUSIONS The results of the followed-up group of patients confi rm low complication rate of the sinus tarsi approach as reported by current literature. At the same time, it provides good options for reduction even in complicated fractures. For successful osteosynthesis, the anterolateral locking plate with headless screws may be used. The incidence of post-operative complications is low even in high-risk patients. Adhesions of peroneal tendons can be treated with material removal and tissue release. They could be prevented by good physiotherapy. Key words: calcaneus, osteosynthesis, anterolateral plate, peroneal tendons, sinus tarsi approach.

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

AIMS: 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). METHODS: 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. RESULTS: 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 ± 3.78 mm) compared to FSC (23.6 ± 6.17 mm) (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. CONCLUSION: 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.

Percutaneous fixation of displaced intraarticular fractures of the calcaneus. A retrospective case series study and a review of the literature.

PURPOSE: To evaluate the outcome of displaced intraarticular calcaneal fractures (DIACFs) of a case series of patients who were treated with a percutaneous fixation technique. MATERIALS AND METHODS: Eight patients were operated for DIACFs and they were evaluated for the outcome and complications in a mean follow up of 9 months (range: 6 - 12 months). At the last follow up the AOFAS score, the Boehlers' angle and the presence of any complication were noted. The time from injury to surgery was also reported. The correlation of the AOFAS score and the development of post traumatic subtalar arthritis to the type of fracture, to the post operative Boehler's angle and to the time from injury to surgery were investigated. RESULTS: The overall mean AOFAS (Americal Orthopaedic Foot and Ankle Society) score was 84,625 (Range: 73 - 96). The mean AOFAS score of type II and type III fractures was 87,667 and 75,500 respectively. The mean AOFAS score for fractures with a postoperative Boehler's angle of less than 10° and more or equal to 10° was 76,750 and 92,500 respectively. This difference was found to be statistically significant. The mean AOFAS score for fractures who were treated less or equal to six days and more than six days post injury was 91,250 and 78 respectively. Two out of four patients with a post operative Boehler's angle less than 10° developed post traumatic subtalar arthritis. No patient out of four for whom a Boehler's angle of more than 10° has been achieved, developed subtalar arthritis. No infection occurred in any of the patients. CONCLUSION: Percutaneous fixation is a safe and effective way of treating DIACFs. The outcome is directly related to the quality of reduction, which is significantly dependent to the timing of surgery. The earlier the fracture is operated the better the reduction by closed means is.

Study on Sustentaculum Tali Fragment Constancy in Intraarticular Calcaneus Fracture.

OBJECTIVES: To establish reproducible measurements of the sustentaculum tali (ST) fragment regarding fracture classification and patient-related factors. DESIGN: Retrospective. SETTING: Trauma center, University Hospital. PATIENTS: A retrospective analysis of the 142 fractured calcanei of 122 patients (101 men and 21 women) treated at our institution between 2012 and 2020 was performed. As control, 62 unaffected calcanei were used. INTERVENTION: Radiographic images were evaluated twice within 2 weeks by 2 orthopaedic surgeons and 1 postgraduate student. Angulation and diastasis were used to distinguish ST fragment constancy based on computed tomography. Using these parameters, the prevalence of inconstant ST fragments was assessed. We also analyzed factors related to ST fragment inconstancy. Patient factors included age, body mass index, smoking, and diabetes. Radiographic factors included the Sanders classification, location of the outermost fracture line of the posterior facet, presence of an intraarticular fracture of the ST, and ST fragment width. MAIN OUTCOME MEASUREMENTS: Angulation and diastasis were used to confirm the ST fragment constancy. Potential risks for inconstant ST fragment subsequently defined. RESULTS: According to the criteria, ST fragment inconstancy was observed in 34.5%. ST fragment width was significantly smaller in the inconstant group ( P < 0.001). Severe comminution of the posterior facet ( P < 0.05), intraarticular fracture of the ST ( P < 0.001), and diabetes ( P < 0.05) were significantly higher in the inconstant group. The cut-off value of the ST fragment width was 20.5 mm. CONCLUSIONS: In intraarticular calcaneus fractures, small ST fragment width, comminuted fracture, intraarticular fracture of the ST, and diabetes were associated with the inconstant group. The ST fragment was expected to be inconstant when the width was less than 20.5 mm.

[Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach]. / Operative Versorgung intraartikulärer Kalkaneusfrakturen mittels Plattenosteosynthese über den Sinus-tarsi-Zugang.

OBJECTIVE: Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach. INDICATIONS: Intra-articular dislocated calcaneus fractures. CONTRAINDICATIONS: Fracture older than 14 days; poor soft tissue quality in the surgical area. SURGICAL TECHNIQUE: Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction 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 a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X­rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath. POSTOPERATIVE MANAGEMENT: Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing. RESULTS: 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.