Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management.

OBJECTIVES: To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures. PATIENTS AND METHODS: We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates. RESULTS: Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups. CONCLUSIONS: Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.

Parallel versus Angulated Screw Configuration in Subtalar Arthrodesis for Posttraumatic Arthritis.

Background: To compare radiographic union and clinical outcomes between parallel and angulated screw configurations (SCs) for patients undergoing subtalar arthrodesis due to posttraumatic subtalar arthritis (PSA) after displaced intra-articular calcaneal fractures. Methods: This study retrospectively reviewed 140 consecutive PSA cases from March 2011 to November 2021 (parallel SC: group 1, n = 80; angulated SC: group 2, n = 60). Radiographic union, Foot and Ankle Outcome Score (FAOS), and visual analog scale (VAS) scores were among the outcome assessments. Six months after surgery, nonunion was confirmed based on plain radiographs, clinical evaluation, and computed tomography. Results: Groups 1 and 2 included 14 (17.5%) and 3 (5.0%) nonunion cases, respectively (p = 0.035). There was no significant difference in preoperative FAOS and VAS scores between the groups. However, group 2 had significantly better clinical outcomes in 2 of the 5 FAOS domains (sports and quality of life), as well as VAS scores at 3 and 6 months postoperatively and at the final follow-up (p < 0.05). Conclusions: Using the angulated SC for PSA had a lower nonunion rate and superior clinical outcomes than the parallel SC. Obtaining better radiological and clinical outcomes when using the angulated SC, rather than the parallel SC, would be advantageous.

Fixation with multiple K-wires and PRP injection as an effective way to manage heel pad avulsion.

The treatment of acute heel pad avulsion differs significantly from managing other soft tissue injuries due to its unique soft tissue structure. This case report outlines a scenario involving a male in his 20s who suffered heel pad avulsion without a calcaneal fracture but with an ipsilateral medial malleolus fracture after a twisting injury to the ankle caused by a road traffic accident. Immediate action was taken within 24 hours of the injury, involving thorough debridement of the wound, fixation to the calcaneum using multiple K-wires, primary suturing and internal fixation of the medial malleolus with two cannulated cancellous screws. Postoperative care included PRP (platelet-rich plasma) injections into the wound twice, removal of K-wires after 6 weeks and allowing walking with full weight bearing after 8 weeks. A year later, the wound had completely healed, and the patient was comfortably walking pain-free with full weight-bearing capabilities.

Current Management of Intra-Articular Calcaneal Fractures.

Intra-articular calcaneal fractures are debilitating injuries that can result in a dramatic effect on quality of life post-injury. Surgical intervention is generally advised when significant displacement or comminution is present but can present a host of complications secondary to the limited blood supply and fragility to the soft tissues following injury. Surgical approaches to calcaneal fractures generally include the lateral extensile approach, minimal incision (sinus tarsi approach), or percutaneous approach. Each approach presents risks and benefits; therefore, determining the optimal incisional approach should be based on patient comorbidities, fracture pathoanatomy, soft tissue envelope concerns, and patient pre-injury functional status.

Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature.

INTRODUCTION: To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications. MATERIALS AND METHODS: A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width). RESULTS: A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I2=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups. CONCLUSION: Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes. LEVEL OF EVIDENCE: Therapeutic Level III.

Is it necessary to graft the void defect during open reduction and internal fixation of calcaneal fractures?

PURPOSE: There are still controversies on the effect of grafting during open reduction and internal fixation of calcaneal fractures. The aim of this study was to compare the radiological and functional outcomes in patients with or without intraoperative grafting. METHODS: In a comparative retrospective study, among 442 operatively-treated calcaneal fractures, 60 patients with unilateral closed sanders type II intraarticular calcaneal fracture who underwent ORIF via lateral extensile approach using locking anatomical plates with at least 1 year follow-up without any postoperative wound complication were enrolled. The patients were separated into 2 groups: with bone allograft and without bone allograft. The functional outcome of the patients was assessed using visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, foot function index (FFI), and short-form (SF-36) health survey. Radiographic variables included Böhler angle, Gissane angle, calcaneal width, calcaneal height, and talar declination angle. Also, the differences (delta) of these values in comparison to the uninjured foot were calculated. RESULTS: The mean age was 39.1 ± 12.7 (range, 13-67) years with 54 males, 90.0%. No statistically significant differences were detected in age, gender, affected side, and subtypes of calcaneal fractures between the two groups (p > 0.05). The average follow-up was 25.1 (range, 12-48) months. The differences for all radiographic measurements and also, the delta values between the groups were not statistically significant, except talar declination angle which was more in cases without grafting (p = 0.007). Although the differences between the two groups regarding AOFAS ankle-hindfoot scale (p = 0.257), VAS for pain (p = 0.645), and FFI (p = 0.261) were not statistically significant; the group with bone graft experienced less pain (19.7 ± 22.0) than the other group (26.7 ± 22.8). The difference between the groups was not statistically significant (p = 0.87) according to the SF-36 questionnaire. CONCLUSIONS: Incorporating allografts into the void defects during ORIF of displaced intraarticular calcaneal fractures may not improve functional outcomes and recover postoperative radiological parameters. Therefore, routine use of allograft to fill the defects during ORIF of calcaneus may not be recommended. Of note, that these findings solely relate to the treatment of Sanders type II fractures. LEVEL OF EVIDENCE III: Comparative retrospective study.

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.

Postoperative complications after displaced intra-articular calcaneal fracture operations.

BACKGROUND: The objective was to compare postoperative complications in the management of displaced intra articular calcaneal fractures (DIACF) between two groups; the open reduction and internal fixation (ORIF) group versus the percutaneous fixation (PF) group. METHODS: A total of 243 DIACFs were diagnosed and 127 of them received operations either with ORIF 75 (59.1 %) or PF 52 (40.9 %) between 2004 and 2018. Postoperative complications, radiological Sanders's classification and improvement of Böhler's angle were analyzed. RESULTS: Early complication rate (<6 weeks), rate of deep wound infections and wound edge necrosis were significantly better in PF than in ORIF patient group. There were no significant differences in late complications (>6 weeks from operation) nor in improvement of Böhler's angle. CONCLUSION: Complication rate is lower when using PF technique while fracture reduction remains the same compared to the ORIF. LEVEL OF EVIDENCE: IV retrospective cohort study at a single institution.

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.

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.

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.

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.

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.