Managing the open calcaneal fracture: A systematic review.

INTRODUCTION: Open fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm. MATERIAL AND METHODS: A literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions. RESULTS: A total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points. CONCLUSION: The complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.

Reliability, validity and responsiveness of the Spanish Manchester-Oxford Foot Questionnaire (MOXFQ) in patients with foot or ankle surgery.

BACKGROUND: The Manchester-Oxford Foot Questionnaire (MOXFQ) has been validated in Spanish for use in patients undergoing foot and ankle surgery. METHODS: 120 patients completed the MOXFQ and the SF-36 before surgery and 6 and 12 months postoperative. Surgeons completed the American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating System. Psychometric properties were assessed for all three MOXFQ dimensions, and for the MOXFQ Index. RESULTS: The Spanish MOXFQ demonstrated consistency with Cronbach's alpha values between 0.65 and 0.90, and reliability ([ICCs] >0.95). It shows a moderate to strong correlation between the Walking/standing dimension and the related domains of the SF-36 (|r|>0.6), the AOFAS Ankle-Hindfoot Scale (|r|>0.47) and Hallux-MTP-IP Scale (|r|>0.64). Responsiveness was excellent, (effect sizes >2.1). The respective minimal detectable change (MDC90) was 14.18 for the MOXFQ Index. CONCLUSIONS: The Spanish version of the MOXFQ showed good psychometric properties in patients with foot and ankle disorders.

Calcaneal Fractures-Which Approach for Which Fracture?

Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.

Indications and Surgical Treatment of Acute and Chronic Tibiofibular Syndesmotic Injuries with and Without Associated Fractures.

Syndesmosis injury may occur in a wide variety of clinical scenarios. Accurate diagnosis and anatomic reconstruction are necessary for optimizing clinical outcomes. The management considerations of syndesmotic injuries with associated proximal fibula fractures are reviewed. Methods to improve the accuracy of syndesmotic reduction are outlined. The management of fractures of the posterior malleolus, Chaput tubercle, and Wagstaffe tubercle is discussed with an emphasis on their contributions to syndesmotic stability. The evolving role of flexible fixation for syndesmosis injuries is discussed. Causes and strategies for dealing with loss of reduction and malreduced syndesmotic injuries are presented.

High-Energy Pilon Fractures: Role of External Fixation in Acute and Definitive Treatment. What are the Indications and Technique for Primary Ankle Arthrodesis?

External fixation is an essential tool in the management of high-energy pilon fractures. Reduction techniques using the external fixator and fixation constructs for use with external fixation as a part of stage management are reviewed. The concepts of external fixation with limited articular fixation is discussed. The use of circular external fixation in both acute management of high-energy pilon fractures, as well as the indications and technique for acute ankle arthrodesis as part of primary treatment of pilon fractures are outlined.

Recombinant Human Platelet-Derived Growth Factor BB in Combination With a Beta-Tricalcium Phosphate (rhPDGF-BB/ß-TCP)-Collagen Matrix as an Alternative to Autograft.

BACKGROUND: Joint arthrodesis often employs autograft to promote union; graft harvesting can lead to perioperative morbidity. A Canadian randomized controlled trial (RCT) demonstrated that recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) combined with beta-tricalcium phosphate (ß-TCP)-collagen was a safe, effective alternative to autograft. This multicenter North American RCT compared the safety and efficacy of rhPDGF-BB/ß-TCP-collagen with autograft for ankle and hindfoot fusion. Subclassification using propensity scores (PS) incorporated patients from previous trials for enhanced statistical power for noninferiority testing and broader review of treatments. METHODS: Patients requiring ankle or hindfoot arthrodesis and supplemental bone graft were treated with rhPDGF-BB/ß-TCP-collagen (n = 69) or autograft (n = 35). Outcomes included joint fusion on computed tomography (24 weeks), clinical healing status, visual analog scale (VAS) pain, Short-Form 12 (SF-12), American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, and Foot Function Index (FFI) scores over 52 weeks. PS methodology addressed potential selection bias arising from pooling data among these patients and 2 previous RCTs with similar inclusion criteria, surgical techniques, graft harvest techniques, and outcomes. All 132 rhPDGF-BB/ß-TCP-collagen-treated patients and 167 of 189 candidate autograft-treated controls were selected for comparison by an independent statistician blinded to outcomes. RESULTS: In the PS subclassification, 68.1% treatment patients and 68.4% controls achieved >50% osseous bridging at fusion sites. Clinical healing status was achieved in 84.8% of treated patients and 90.7% of controls at 52 weeks. Clinical, functional, and quality of life results demonstrated noninferiority of rhPDGF-BB/ß-TCP-collagen to autograft. Safety-related outcomes were equivalent. CONCLUSION: PS subclassification analysis of 3 RCTs demonstrated that rhPDGF-BB/ß-TCP-collagen was as effective as autograft for ankle and hindfoot fusions, with less pain and morbidity than treatment with autograft. LEVEL OF EVIDENCE: Level I, prospective randomized study.

Chopart fractures and dislocations.

Fractures and dislocations of the midfoot and Chopart complex are among the most difficult foot injuries to manage. The treating surgeon is faced with a wide array of treatment challenges. Plain radiographs often grossly underestimate the extent of injury. The anatomy in this region of the foot is quite intricate with numerous articulations. Fractures can occur in isolation or as part of a more complex injury pattern. Misdiagnosis and under treatment can lead to severe alterations of both normal anatomy and function. This article discusses the rationales and techniques for treating these difficult injuries.

Calcaneal Fractures - Should We or Should We not Operate?

The best treatment for displaced, intraarticular fractures of the calcaneum remains controversial. Surgical treatment of these injuries is challenging and have a considerable learning curve. Studies comparing operative with nonoperative treatment including randomized trials and meta-analyses are fraught with a considerable number of confounders including highly variable fracture patterns, soft-tissue conditions, patient characteristics, surgeon experience, limited sensitivity of outcome measures, and rehabilitation protocols. It has become apparent that there is no single treatment that is suitable for all calcaneal fractures. Treatment should be tailored to the individual fracture pathoanatomy, accompanying soft-tissue damage, associated injuries, functional demand, and comorbidities of the patient. If operative treatment is chosen, reconstruction of the overall shape of the calcaneum and joint surfaces are of utmost importance to obtain a good functional result. Despite meticulous reconstruction, primary cartilage damage due to the impact at the time of injury may lead to posttraumatic subtalar arthritis. Even if subtalar fusion becomes necessary, patients benefit from primary anatomical reconstruction of the hindfoot geometry because in situ fusion is easier to perform and associated with better results than corrective fusion for hindfoot deformities in malunited calcaneal fractures. To minimize wound healing problems and stiffness due to scar formation after open reduction and internal fixation (ORIF) through extensile approaches several percutaneous and less invasive procedures through a direct approach over the sinus tarsi have successfully lowered the rates of infections and wound complications while ensuring exact anatomic reduction. There is evidence from multiple studies that malunited displaced calcaneal fractures result in painful arthritis and disabling, three-dimensional foot deformities for the affected patients. The poorest treatment results are reported after open surgical treatment that failed to achieve anatomic reconstruction of the calcaneum and its joints, thus combining the disadvantages of operative and nonoperative treatment. The crucial question, therefore, is not only whether to operate or not but also when and how to operate on calcaneal fractures if surgery is decided.

Axial and shear pullout forces of composite, porcine and human metatarsal and cuboid bones.

OBJECTIVES: The varying mechanical properties of human bone have influence on the study results. Pullout and shear forces of human bone were compared to different substitutes to evaluate their suitability for biomechanical studies. METHODS: After bone mineral density (BMD) determination, axial pullout tests were performed with cortical 3.5 mm nonlocking (NL) and 2.7 mm head locking (HL) screws on human, porcine and polyurethane composite bones. Porcine and human constructs were additionally loaded in shear direction. RESULTS: Apparent BMD was significantly lower in osteoporotic (159 mgHA/ccm ± 56) and nonosteoporotic (229 mgHA/ccm ± 25) human bone than that in porcine bone (325 mgHA/ccm ± 42; p < 0.01). Axial construct stiffness and ultimate pullout force of porcine bone (NL: 666N/mm ± 226, 910N ± 140; HL: 309N/mm ± 88, 744N ± 185) was significantly different from composite bone (NL: 1284N/mm ± 161; 1175N ± 116; HL: 1241N/mm ± 172, 1185N ± 225) and osteoporotic human bone (NL: 204N/mm ± 121, 185N ± 113; HL: 201N/mm ± 65; 189N ± 58) but not from nonosteoporotic human bone (NL: 620N/mm ± 205, 852N ± 281; HL: 399N/mm ± 224; 567N ± 242). Porcine bone exhibited an ultimate shear force (NL: 278N ± 99; HL: 431N ± 155) comparable to nonosteoporotic human bone (NL: 207 ± 68: HL: 374N ± 137). CONCLUSION: Screw pullout and shear forces of porcine bone are close to nonosteoporotic human bone. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Human bone specimens used in biomechanical studies are predominantly of osteoporotic bone quality. Conclusions on nonosteoporotic human bone behaviour are difficult. Alternatives such as porcine bone and composite bone were investigated, and it could be shown that screw pullout and screw shear forces of porcine bone are close to nonosteoporotic human bone.

Osteotomy for salvage of the arthritic ankle.

Ankle arthrodesis continues to be the procedure of choice for ankle arthritis. Coester and colleagues showed that arthrodesis is a significant risk factor for development of arthritis in the ipsilateral hindfoot and forefoot, however. Total ankle arthroplasty has gained significant interest but is not yet ideally suited for younger active patients because of unacceptable failure rates and complications. Osteotomies can play an important role in re-establishing normal alignment and potentially decreasing the rate of progression of wear on the articular surfaces and decreasing pain, which may allow more time before arthrodesis or arthroplasty are needed. The success of total ankle arthroplasty depends largely on the alignment of the foot and ankle and osteotomies can be used in a staged manner as part of a reconstructive effort including total ankle arthroplasty. Supramalleolar osteotomies can be used to align the tibia; alternatively, osteotomies in the midfoot and hindfoot can be used to balance the foot and ankle making them suitable for arthroplasty in an individual who perhaps would not otherwise have that treatment option. Further studies will continue to clarify the role and indications for osteotomies for treatment of ankle arthritis.

Early Fixation of Calcaneus Fractures.

The treatment of calcaneus fractures is controversial. Historically, most operatively treated fractures have been approached with a lateral extensile incision requiring delay in operative treatment until swelling has improved. There is a current trend and interest in small incision approaches allowing, and in some cases requiring, earlier operative fixation. Clinical scenarios amenable to consideration for early fixation are reviewed. The sinus tarsi surgical approach and reduction techniques are outlined in detail.

Treatment of Peripheral Talus Fractures.

Peripheral talus fractures include injuries to the lateral process, posteromedial talar body, and talar head. These injuries are rare and are often missed. Nonunion with conservative treatment is high and excision can lead to joint instability, rapid arthrosis, and earlier need for arthrodesis. Open reduction internal fixation of most peripheral talus fractures is critical to achieving a good outcome. Open reduction leads to more rapid union and ability to mobilize the ankle and subtalar joints, quicker revascularization of the talus, and lower rates of arthrosis. Surgical treatment can lead to substantial functional improvement and a slowing of the degenerative process.

Late Treatment of Syndesmotic Injuries.

Normal syndesmosis anatomy and alignment are essential to ankle function. Although injuries to the syndesmosis are common with ankle injuries, accurate diagnosis and reduction continue to be a challenge. Late reconstruction for syndesmosis is reviewed. A surgical technique for late reconstruction is outlined in detail.

Prognostic value of computed tomography classification systems for intra-articular calcaneus fractures.

BACKGROUND: There are several published computed tomography (CT) classification systems for calcaneus fractures, each validated by a different standard. The goal of this study was to measure which system would best predict clinical outcomes as measured by a widely used and validated musculoskeletal health status questionnaire. METHODS: Forty-nine patients with isolated intra-articular joint depression calcaneus fractures more than 2 years after treatment were identified. All had preoperative CT studies and were treated with open reduction and plate fixation using a lateral extensile approach. Four different blinded reviewers classified injuries according to the CT classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders. Functional outcomes evaluated with a Musculoskeletal Functional Assessment (MFA). The mean follow-up was 4.3 years. RESULTS: The mean MFA score was 15.7 (SD = 11.6), which is not significantly different from published values for midfoot injuries, hindfoot injuries, or both, 1 year after injury (mean = 22.1, SD = 18.4). The classification systems of Crosby and Fitzgibbons, Eastwood, and Sanders, the number of fragments of the posterior facet, and payer status were not significantly associated with outcome as determined by the MFA. The Sanders classification trended toward significance. Anterior process comminution and surgeon's overall impression of severity were significantly associated with functional outcome. CONCLUSIONS: The amount of anterior process comminution was an important determinant of functional outcome with increasing anterior process comminution significantly associated with worsened functional outcome (P = .04). In addition, the surgeon's overall impression of severity of injury was predictive of functional outcome (P = .02), as determined by MFA. LEVEL OF EVIDENCE: Level III, comparative series.