Strain-mode-specific mechanical testing and the interpretation of bone adaptation in the deer calcaneus.

The artiodactyl (deer and sheep) calcaneus is a model that helps in understanding how many bones achieve anatomical optimization and functional adaptation. We consider how the dorsal and plantar cortices of these bones are optimized in quasi-isolation (the conventional view) versus in the context of load sharing along the calcaneal shaft by "tension members" (the plantar ligament and superficial digital flexor tendon). This load-sharing concept replaces the conventional view, as we have argued in a recent publication that employs an advanced analytical model of habitual loading and fracture risk factors of the deer calcaneus. Like deer and sheep calcanei, many mammalian limb bones also experience prevalent bending, which seems problematic because the bone is weaker and less fatigue-resistant in tension than compression. To understand how bones adapt to bending loads and counteract deleterious consequences of tension, it is important to examine both strain-mode-specific (S-M-S) testing (compression testing of bone habitually loaded in compression; tension testing of bone habitually loaded in tension) and non-S-M-S testing. Mechanical testing was performed on individually machined specimens from the dorsal "compression cortex" and plantar "tension cortex" of adult deer calcanei and were independently tested to failure in one of these two strain modes. We hypothesized that the mechanical properties of each cortex region would be optimized for its habitual strain mode when these regions are considered independently. Consistent with this hypothesis, energy absorption parameters were approximately three times greater in S-M-S compression testing in the dorsal/compression cortex when compared to non-S-M-S tension testing of the dorsal cortex. However, inconsistent with this hypothesis, S-M-S tension testing of the plantar/tension cortex did not show greater energy absorption compared to non-S-M-S compression testing of the plantar cortex. When compared to the dorsal cortex, the plantar cortex only had a higher elastic modulus (in S-M-S testing of both regions). Therefore, the greater strength and capacity for energy absorption of the dorsal cortex might "protect" the weaker plantar cortex during functional loading. However, this conventional interpretation (i.e., considering adaptation of each cortex in isolation) is rejected when critically considering the load-sharing influences of the ligament and tendon that course along the plantar cortex. This important finding/interpretation has general implications for a better understanding of how other similarly loaded bones achieve anatomical optimization and functional adaptation.

Ontogenic transformation of the ankle from the initial mediolateral arrangement of the calcaneus and talus: A histological study of human embryos and early fetuses.

The human calcaneus is robust and provides a prominent heel for effective bipedal locomotion, although the adjacent talus has no muscle attachments. However, there is incomplete information about the morphological changes in these prominent bones during embryo development. We examined serial histological sections of 23 human embryos and early-term fetuses (approximately 5-10 weeks' gestational age [GA]). At a GA of 5 weeks, the precartilage talus was parallel to and on the medial side of the calcaneus, which had a prolate spheroid shape and consisted of three masses. At a GA of 6 weeks, the cartilaginous talus extended along the proximodistal axis, and the tuber calcanei became long and bulky, with a small sustentaculum talus at the "distal" side. At a GA of 6 to 8 weeks, the sustentaculum had a medial extension below the talus so that the talus "rode over" the calcaneus. In contrast, the talus had a more complex shape, depending on the growth of adjacent bones. At a GA of 9 to 10 weeks, the talus was above the calcaneus, but the medial part still faced the plantar subcutaneous tissue because of the relatively small sustentaculum. Therefore, the final morphology appeared after an additional several weeks. Muscle activity seemed to facilitate growth of the tuber calcanei, but growth of the other parts of calcaneus, including the sustentaculum, seemed to depend on active proliferation at the different sites of cartilage. Multiple tendons and ligaments seemed to fix the talus so that it remained close to the calcaneus.

Outcomes of open reduction and internal fixation of calcaneus fractures: A database study comparing patients with and without diabetes.

Treatment of calcaneal fractures in patients with diabetes mellitus (DM) is challenging. The purpose of this study was to compare post-operative outcomes after open reduction and internal fixation (ORIF) for calcaneus fracture in patients with complicated DM, uncomplicated DM, and patients without DM. A commercially available de-identified database was queried for all calcaneus fracture diagnoses undergoing ORIF from 2010 to 2021. The patients were separated into three groups for analysis: patients without DM (10,951, 82.6%), uncomplicated DM (1,500, 11.3%) and complicated DM (802, 6.1%). At 1 year, post-operative adverse events were assessed among the three groups. The odds of adverse event(s) for each group were compared between the three groups with and without characteristic matching. In the unmatched cohorts, patients with complicated DM, when compared with patients without DM and patients with uncomplicated DM, had significantly higher rates of all adverse events with exception of DVT. Rates of CNA were significantly higher in patients with complicated DM compared with no DM (OR 107.7 (CI 24.83-467.6) p < 0.0001) and uncomplicated DM (OR 44.26 (CI 3.86-507.93) p = 0.0002). After matching, non-union, AKI, sepsis, surgical site infection, and wound disruption were higher in patients with complicated DM compared with patients without DM. There were no significant differences in the three groups with regard to reoperation, DVT, MI, pneumonia, or below the knee amputation. Patients with DM who underwent ORIF for calcaneus fracture experienced higher rates of post-operative adverse events compared with those patients without DM.

Pediatric calcaneal osteomyelitis: an analysis of literature-reported 128 cases.

BACKGROUND: Calcaneal osteomyelitis (CO) poses a formidable challenge in treatment due to the distinct anatomical structure and functional properties of the calcaneus. The present study endeavors to furnish a thorough and comprehensive understanding of the clinical manifestations, therapeutic strategies, and therapeutic outcomes pertaining to pediatric calcaneal osteomyelitis (PCO) by conducting a meticulous synthesis and analysis of cases reported in the literature. METHODS: A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted to identify English-language studies analyzing PCO between 2000 and 2021. The quality of the included studies was assessed using the National Institutes of Health (NIH) assessment scale. Effective data were extracted and analyzed. RESULTS: A total of 42 studies, encompassing 128 patients, fulfilled the established inclusion criteria. The gender distribution revealed a male-to-female ratio of 2:1 (81 boys and 40 girls). The median age at the time of diagnosis was 8 years, while the median duration of symptoms was 0.6 month. Trauma emerged as the primary etiology (41 cases, 54%), and limited activity was the most prevalent symptom (68 cases). The positive rate for pathogen culture was 75.4% (49/65), with Staphylococcus aureus being the most commonly isolated pathogen (28 cases, 57.1%). Surgical intervention was performed in 51% (64/126) of the patients, with debridement serving as the primary surgical strategy. The rate of infection recurrence was 6.8% (8/118), and the risk of below-knee amputation was 0.8% (1/124). CONCLUSIONS: PCO occurred more frequently in male patients, with trauma being the primary underlying cause and Staphylococcus aureus being the most prevalent bacterial pathogen isolated. Over half of the patients underwent surgical intervention. Nonetheless, it is imperative that treatment strategies undergo further refinement, as approximately 7% of patients experienced infection recurrence.

Correlation of Posterior Tibial Tendon Ultrasound with Calcaneal Inclination Angle in Indonesian Professional Athletes with Medial Ankle Pain.

Background: Adult-acquired flatfoot deformity (AAFD) is characterized by partial or complete flattening of the longitudinal medial arch, which develops after maturity. AAFD secondary to posterior tibialis tendon dysfunction (PTTD) is one of professional athletes' most common foot and ankle pathologies. Different modalities and procedures can be used to establish the diagnosis of AAFD and PTTD. However, imaging measurements such as the calcaneal inclination index and ultrasonography (US) of the posterior tibialis tendon (PTT) in professional athletes with medial ankle and focal pain along the PTT have yet to be widely studied. This study investigates the correlation of PTT ultrasound for evaluating PTTD with calcaneal inclination angle (CIA) for evaluating AAFD in professional athletes with medial ankle and focal pain along the PTT. Through this study, clinicians and radiologists may benefit from considering AAFD in athletes with PTTD. Methods: 112 Indonesian professional athletes with medial ankle or foot pain and focal pain along the direction of the PTT underwent foot radiography using the CIA and ankle ultrasound to observe PTT abnormalities. Results: A negative correlation between fluid thickness surrounding the PTT and the CIA (p<0.001; 95% CI - 0.945, - 0.885), as well as a negative correlation between PTT thickness and CIA (p<0.001, 95% CI - 0.926, - 0.845), with a correlation coefficient (r) of - 0.921 and - 0.892, respectively. No significant correlation was found between PTT tear and CIA (p = 0.728; 95% CI -0.223, - 0.159; r - 0.033). Conclusion: This study showed a negative correlation between PTTD and AAFD via ultrasound and CIA in professional athletes with medial ankle and focal pain along the PTT. A better understanding of PTTD and AAFD imaging will lead to more effective management and prompt treatment.

Osteopenia and Osteoporosis Screening Detection: Calcaneal Quantitative Ultrasound with and without Calibration Factor Comparison to Gold Standard Dual X-ray Absorptiometry.

BACKGROUND: osteoporosis is a worldwide major health problem that normally diagnosed in advanced stages. So, an early detection at preclinical stage is now an interesting issue. A key factor to early diagnosis the disease is the used of noninvasive bone densitometry. Dual energy x-ray absorptiometry (DXA) is the gold standard techniques for the proposed. However, the high cost, non-widely available and exposed to ionizing radiation are still a drawback of the machine. Therefore, a cheaper, smaller and non-ionizing device such quantitative ultrasound (QUS) is now a favor alternative method, but the possibility of used QUS measurement instead of DXA is still limited due to their uncertainties. So, the aim of our study was to calibrated the QUS with the DXA to allowing the possible to establish a calibration factor (CF) to improve the measured value closer to the standard method. METHODOLOGY: 135 healthy men and women aged 30-88 years were recruited for lumbar spine/femoral neck DXA and calcaneal QUS scanning. The Pearson's correlation between T- and Z-score from the two systems were studied. Moreover, the sensitivity, specificity and percentage of diagnosed accuracy for both with and without CF were calculated. RESULTS: The significant correlation between the two systems showed a positive trajectory in highly correlation (r = 0.784-0.899). Analyses showed a higher sensitivity, specificity and reduced the misdiagnosed rates when applied the CF in QUS values. CONCLUSIONS: QUS results showed a significantly correlated with DXA results for both lumbar spine and femoral neck sites with some percentage differences. These differences can be reduced by applied an individual specific machine CF to improve a QUS results. As identification of high risk of osteopenia and osteoporosis to reduce the demand of DXA propose, using a QUS alternative method can be a reliable that provide a cheaper and lack of ionizing radiation.

A case of early-onset congenital syphilitic osteomyelitis of the calcaneus and literature review.

BACKGROUND: Congenital syphilis (CS) is a sexually transmitted disease caused by Treponema pallidum (TP). When the skeletal system is involved, it often results in multiple, symmetrical bone destruction at the epiphyses of long tubular bones such as the humerus and radius, rarely involving the calcaneus. This article reports a case of calcaneal osteomyelitis caused by TP in a child with no other bone damage and subtle clinical manifestations, No similar cases have been reported. CASE PRESENTATION: A 4-month-old male infant presented with right foot swelling without any obvious cause and no history of trauma. X-ray and CT scans showed bone loss in the calcaneus and surrounding soft tissue swelling. Review of past medical records revealed that the infant had been diagnosed with CS infection during a hospital stay for "pneumonia" at one month old. The parents refused surgery, opting for conservative treatment at an external hospital for three weeks, during which the symptoms of the affected foot showed no significant improvement. Subsequently, the child was treated at our hospital with surgery, including lesion removal and cast fixation, followed by oral antibiotic treatment. The last follow-up showed no swelling or tenderness in the affected foot, with good mobility, and X-rays indicated that the bone had essentially returned to normal. CONCLUSIONS: Early CS rarely involves the calcaneus. When diagnosing unexplained calcaneal osteomyelitis in infants, this rare cause should be considered. A thorough medical history should be taken and a careful physical examination conducted. Once diagnosed, timely surgical debridement and appropriate antibiotic therapy targeting TP infection are required. Early identification and intervention can result in a good prognosis without related complications.

Youth Athletes With Sever's Disease Exhibit Altered Achilles Tendon Ultrasound Characteristics: A Retrospective Case-Control Study.

OBJECTIVES: Calcaneal apophysitis (Sever's disease) is an overuse condition caused by repetitive traction stress to the calcaneal apophysis. Whether Achilles tendon morphology is altered in this young patient population remains unknown. Therefore, we aimed to identify differences in Achilles tendon morphology between youth athletes diagnosed with calcaneal apophysitis and healthy controls. METHODS: This retrospective chart review included 46 patients (n = 23 Sever's disease, 15F/8M, 12.4 ± 2.3 years old) and (n = 23 healthy controls, 13F/10M, 15.9 ± 1.5 years old) who sought care in a Children's Hospital Sports Medicine/Orthopedics Department between 2012 and 2022. We measured ultrasound-derived degree of tendon thickening, Achilles tendon thickness (cm), and cross-sectional area (CSA [cm2]). Separate multivariate analyses of covariance (MANCOVAs) were used to compare degree of thickening, mass-normalized Achilles tendon thickness, and CSA between participant groups, covarying for age. Cohen's d effect sizes were used to assess the magnitude of mean differences and standard error (MDSE) between groups. RESULTS: Young athletes with Sever's disease had a significantly greater degree of tendon thickening with a large effect compared with healthy controls (MDSE: 0.07 [0.01] mm P < .001, d = 1.39). Achilles tendon thickness and CSA did not statistically differ between groups; however, the magnitude of between-group differences for these measures (MDSE: 0.18 [0.05] cm, MDSE: 0.27 [0.07] cm2, respectively) were moderate. CONCLUSIONS: Our findings demonstrate previously unrecognized differences in Achilles tendon morphology between young athletes with clinically diagnosed Sever's disease and healthy controls. Our study supports incorporating diagnostic ultrasound as part of a comprehensive examination to ensure appropriate diagnosis and clinical management for adolescents with heel pain.

A simple modified technique for screw fixation of displaced intra-articular calcaneus fracture through a sinus tarsi approach: a comparison with plate fixation.

BACKGROUND: Plates and screws are frequently used for the fixation of displaced intra-articular calcaneus fracture (DIACF). In this study, we compared the outcomes of a modified screw fixation technique with plate fixation via a sinus tarsi approach (STA). METHODS: A series of 187 DIACF patients who were treated via an STA using a plate fixation (n = 81) or a screw fixation (n = 106) were included. Screw fixation was done with two 2.7 mm screws and two 6.5 mm cannulated screws. Outcomes were evaluated radiographically and clinically. Clinical evaluations included pain assessment by Visual Analogue Scale (VAS) and functional assessment by the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire and Foot Function Index (FFI). RESULTS: The mean final VAS was smaller in the screw group (P = 0.01). The mean AOFAS and FFI scores were not significantly different between the two groups (P = 0.17 and P = 0. 19, respectively). The mean improvement of Bohler's angle, but not the Gissane's angle, was significantly greater in the screw group (P = 0.014 and P = 0.09, respectively). The mean improvement of calcaneal length and height were not significantly different between the two groups (P = 0.78 and P = 0.22, respectively). The hardware removal rate was 14.8% in the plate group and 3.8% in the screw group (P = 0.007). CONCLUSION: The modified screw fixation method provides lower pain, better radiographic outcome, and lower rate of hardware removal compared to plate fixation in the treatment of DIACF.

Robot-assisted versus traditional fixation for the treatment of calcaneal fractures: a meta-analysis.

OBJECTIVE: With the development of surgical technology, the level of digital medicine is constantly improving. The birth of new technologies has a certain impact on traditional methods. At present, robot-assisted technology has been applied to patients with calcaneal fractures, which poses a challenge to traditional surgery. We aimed to assess whether robot-assisted internal fixation confers certain surgical advantages through a literature review. DESIGN: The databases PubMed, EMBASE, the Cochrane Library, the China National Knowledge Infrastructure (CNKI), and the Wanfang Data Knowledge Service Platform were systematically searched for both randomized and nonrandomized studies involving patients with calcaneal fractures. MAIN RESULTS: Five studies were identified that compared clinical indexes. For the clinical indexes, robot-assisted surgery is generally feasible because of intraoperative fluoroscopy, complications, the Gissane angle, the calcaneal width, and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score 3 and 6 months after the operation (P < 0.05). However, on the operation time, Böhler's angle at 3 and 6 months, Gissane angle and calcaneal width at 6 months after the operation did not show good efficacy compared with those of the traditional group (P > 0.05). CONCLUSIONS: Based on the current evidence, the advantages of robot-assisted fixation over traditional fixation are clear. The long-term clinical effects of the two methods are also good, and the short-term effect of robot assistance is better. However, the quality of some studies is low, and more high-quality randomized controlled trials (RCTs) are needed for further verification.

In vivo attenuation profile of 660 nm and 830 nm wavelengths on human elbow skin and calcaneus tendon of different phototypes.

Physical factors and tissue characteristics determine the transmission of light through tissues. One of the significant clinical limitations of photobiomodulation is the quantification of fluence delivered at application sites and optical penetration depth in vivo. There is also the difficulty of determining the distances of the application points to cover a uniformly irradiated area. Thus, the aim was to evaluate in vivo the influence of melanin on light transmission of the 660 nm and 830 nm laser wavelengths on skin and tendon. Thirty young individuals of both sexes were recruited, divided into two groups based on melanin index, and submitted to photobiomodulation protocols in the posterior region of the elbow (skin-skin) and the calcaneus tendon (skin-tendon-skin). The irradiation area was evaluated using a homemade linear array of five sensors. We found significant transmission power values for different melanin indexes and wavelengths (p<0.0001). Also, different equipment can generate significant differences in the transmitted power at an 830-nm wavelength. Average scattering values are 14 mm and 21 mm for 660 nm, in higher and lower melanin index, respectively. For 830 nm, values of 20 mm and 26 mm are indicated. Laser light transmission in vivo tissues is related to wavelength, beam diameter, tissue thickness, and composition, as well as melanin index. The 830-nm laser presents higher light transmission on the skin than 660 nm. The distances between the application points can be different, with higher values for 830 nm than 660 nm.

Flatfoot Reconstruction for Painful Pediatric Idiopathic Flexible Flatfoot: Prospective Study Demonstrates Improved Alignment, Function, and Patient-reported Outcomes.

BACKGROUND: This prospective study was undertaken to report outcomes following reconstructive surgery for patients with painful pediatric idiopathic flexible flatfoot. METHODS: Twenty-five patients with pediatric idiopathic flexible flatfoot were evaluated pre- and post flatfoot reconstruction with lateral column lengthening (LCL). All patients had lengthening of the Achilles or gastrocnemius, while 13 patients had medial side soft tissue (MSST) procedures, 7 underwent medial cuneiform plantarflexion osteotomy (MCPO), and 5 had medializing calcaneal osteotomy. Measures of static foot alignment-both radiographic parameters and clinical arch height indices-were compared, as were measures of dynamic foot alignment and loading, including arch height flexibility and pedobarography. Preoperative and postoperative patient-reported outcome (PRO) scores were compared between those treated with or without MSST procedures. RESULTS: The median subject age was 13.8 years (range: 10.3 to 16.5) at the time of surgery. All radiographic parameters improved with surgery ( P <0.001). The mean sitting arch height index showed a modest increase after surgery ( P =0.023). Arch height flexibility was similar after surgery. The mean center-of-pressure excursion index increased from 14.1% to 24.0% ( P <0.001), and the mean first metatarsal head (MH) peak pressure dropped ( P <0.001), while the mean fifth MH peak pressure increased ( P =0.018). The ratio of peak pressure in the fifth MH to peak pressure in the second MH increased ( P =0.010). The ratio of peak pressure in the first MH to peak pressure in the second MH decreased when an MCPO was not used ( P <0.002), but it remained stable when an MCPO was included. Mean scores in all PRO domains improved ( P <0.001). Patients treated without MSST procedures showed no difference in PROMIS Pain Interference scores compared to those without MSST procedures. CONCLUSIONS: Flatfoot reconstruction surgery using an LCL with plantarflexor lengthening results in improved PROs. LCL changes but does not normalize the distribution of MH pressure loading. The addition of an MCPO can prevent a significant reduction in load-sharing by the first MH.

Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique.

OBJECTIVE: Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP. METHODS: Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated. RESULTS: The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P <0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters. CONCLUSION: Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform.

INTRODUCTION: The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures. METHODS: This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type. RESULTS: A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels. CONCLUSIONS: Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

Coxa pedis: can calcaneal pronation angle be considered a predictive sign of medial plantar arch overload?

PURPOSE: To assess whether a correlation between the calcaneal pronation angle and the presence of internal plantar arch overload signs (such as upper-medial spring ligament lesion, posterior tibial tendon tenosynovitis, etc.) could lead to a better understanding of coxa pedis pathology. MATERIAL AND METHODS: One hundred ankle MRIs of consecutive patients were retrospectively reviewed measuring the calcaneal pronation angle and either the presence or absence of internal plantar arch overload signs. Next, the association of overload signs with increasing pronation angle was evaluated to establish a cut-off point beyond which coxa pedis pathology could be defined. RESULTS: The tibial-calcaneal angle values in patients with and without effusion proved to be significantly different (p < 0.0001). The tibial-calcaneal angle values in patients with and without oedema also demonstrated a significant difference (p < 0.0056). Regarding posterior tibial tendon, a significant difference was found between the two groups (p < 0.0001). For plantar fascia enthesopathy, the result was borderline significant (p < 0.054). A linear correlation was found between the value of pronation angle and the extent of spring ligament injury (p < 0.0001). In contrast, no correlation with age was found. CONCLUSION: In conclusion, the literature associates medial longitudinal plantar arch overload with posterior tibial tendinopathy and spring ligament complex injuries. Our data show that both injuries are highly correlated with increased calcaneal pronation angle, which could be considered a predictive sign of internal plantar arch overload, prior to the development of the associated signs.

Is the occurrence of extra-articular calcaneal fractures of the joint depression type related to osteoporosis and aging?

PURPOSE: The authors experienced several cases of extra-articular calcaneal fracture accompanied by joint depression involving the entire posterior facet without joint involvement. This type of fracture and its characteristics and treatment outcomes have not been previously reported. The study was performed to analyze the characteristics of extra-articular calcaneal fractures of the joint depression type and their postoperative clinical and radiographic results and complications. METHODS: Between February 2013 and March 2021, 23 extra-articular calcaneal fractures of the joint depression type were consecutively treated by a single surgeon. Relationships between fracture characteristics and patient demographics were assessed. Clinical results were quantified using visual analog scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and Foot Function Index, radiographic results were evaluated using Böhler's angles, and calcaneal widths were determined using calcaneal axial and lateral radiographs obtained preoperatively and at last follow-up. RESULTS: Twenty (87%) of the 23 cases occurred in women, and the mean age of all patients was 65.8 years (43-90). The three men were older than 65. Five (21.7%) patients had osteopenia, and 12 (52.2%) had osteoporosis. Bone mineral density testing could not be performed in the other six patients. Clinical and radiographic results were significantly improved after surgery. CONCLUSION: Extra-articular calcaneal fractures of the joint depression type are much more common in women and occur at an older age than calcaneal fractures commonly occur. These fractures are also more common in patients with a low bone mineral density. LEVEL OF EVIDENCE: Level IV.

Are there associations between hip geometry and bone quality? An analysis on 3074 adults from a general population.

INTRODUCTION: Patients with reduced bone mineral density and altered hip geometry are susceptible for hip pathologies. Knowledge on associations between bone properties and hip geometric parameters might facilitate identification of patients at risk for hip pathologies. The aim of the present study was to identify associations of bone properties assessed by quantitative ultrasound (QUS) at the heel and hip geometric parameters like center-edge angle (CE), neck-shaft angle (NSA) and alpha angle. MATERIALS AND METHODS: Hip geometric parameters (CE, NSA and alpha angle) of 3074 participants from the population-based Study of Health in Pomerania were assessed on magnetic resonance imaging. QUS was performed on both calcanei providing broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness-index. Based on the stiffness-index the individual osteoporotic fracture risk (low, moderate or high) was determined. Associations between QUS-based and hip geometric parameters were calculated in linear regression models adjusted for age, sex, body height and weight. Interactions of QUS markers with age and sex on hip geometric parameters were tested. RESULTS: Significant inverse associations between BUA (ß = - 0.068), SOS (ß = - 0.024) as well as stiffness-index (ß = - 0.056) and CE were present, while fracture risk was positively associated with CE (ß for high = 1.28 and moderate = 2.54 vs. low fracture risk). Interactions between BUA and sex as well as between SOS and age were detected in the models for CE. Furthermore, there was an inverse relation between fracture risk and NSA that was restricted to the moderate risk (ß for moderate vs. low fracture risk = - 0.60). There were no significant associations between QUS parameters and alpha angle. CONCLUSIONS: In the general population, several associations between QUS-based bone properties or fracture risk and hip geometry are present. Less dysplastic hips had a lower stiffness-index and a higher fracture risk, whereas more valgus hips had a lower fracture risk.

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.

Primary arthrodesis versus open reduction and internal fixation following intra-articular calcaneal fractures: a weight-bearing CT analysis.

PURPOSE: To compare primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) in displaced intra-articular calcaneal fractures (DIACFs), based on clinical outcome and 2D and 3D geometrical analyses obtained from weight-bearing (WB) cone-beam CT images. MATERIALS AND METHODS: In this prospective study, 40 patients with surgically treated calcaneal fractures were included, consisting of 20 PA and 20 ORIF patients. Weight-bearing cone-beam CT-images of the left and right hindfoot and forefoot were acquired on a Planmed Verity cone-beam CT-scanner after a minimum of 1-year follow-up. Automated 2D and 3D geometric analyses, i.e., (minimal and average) talo-navicular joint space, calcaneal pitch (CP), and Meary's angle (MA), were obtained for injured and healthy feet. Clinical outcomes were measured using the EQ5D and FFI questionnaires. RESULTS: Overall, there were no differences in baseline patient characteristics apart from age (p < 0.005). The calcaneal pitch in 2D after treatment by ORIF (13.8° ± 5.6) was closer to the uninjured side (18.1° ± 5.5) compared to PA (10.9° ± 4.5) (p < 0.001). Meary's angle in 2D was closer to the uninjured side (8.7° ± 6.3) after surgery in the PA cohort (7.0° ± 5.8) compared to the ORIF cohort (15.5° ± 5.9) (p = 0.046). In 3D measurements, CP was significantly decreased for both cohorts after surgery (- 4.09° ± 6.2) (p = 0.001). MA was not significantly affected overall or between cohorts in 3D. Clinical outcomes were not significantly different between the ORIF and PA cohorts. None of the radiographic measurements in 2D or 3D correlated with any of the clinical outcomes studied. CONCLUSION: Three-dimensional WB CT imaging enables functional 2D and 3D analyses under natural load in patients with complex calcaneal fractures. Based on clinical outcome, both PA and ORIF appear viable treatment options. Clinical correlation with geometrical outcomes remains to be established.

Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature.

BACKGROUND: Minimally invasive surgery (MIS) in medial displacement calcaneus osteotomy (MDCO) has been proposed for surgical correction of adult-acquired flat foot deformity (AAFD) to reduce complications of open approaches. The aim of our study is to systematically analyze complications and the clinical and radiological results of MIS- MDCO. METHODS: A systematic review of the English literature was performed on 30th October 2023. Randomized controlled trials and non-randomized trials, cohort studies, case-control studies and case series concerning surgical correction of AAFD with MIS-MDCO and with at least 15 patients were included. Case reports, technical notes, animal or cadaveric studies were excluded. The quality and risk of bias of the studies included were evaluated using GRADE and MINORS systems. Complications rate, clinical and radiological results were inferred from the studies included. RESULTS: Nine articles were included. A total of 501 cases treated with MIS-MDCO were analysed with a mean follow-up of 11.9 ± 5.1 months. The reported wound infection rate was about 3% and sural neuropathy was rated about 1%. Only 4% of the cases required removal of the screw for pain. In the comparative studies (MIS versus Open MDCO), comparable clinical results but with significant differences (P < 0.001) in infection rates (1% versus 14%) and sural neuropathy (2% versus 1%) were observed. CONCLUSION: AAFD correction performed with MIS-MDCO, with the limitation of a poor quality and high risk of bias of the included studies, seems to provide good clinical results and high subjective satisfaction with a lower complication rate compared to open approach. Further high-quality long-term comparative studies could better clarify complications and clinical and radiological outcomes of the MIS technique in the treatment of AAFD. LEVEL OF EVIDENCE: Level IV.