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.

Coverage of defects over Posterior aspect of Ankle Joint and Heel with Lateral Calcaneal Artery Flap- Experience in Mymensingh Medical College Hospital.

Lateral calcaneal artery flap is randomly used by many Plastic Surgeons for covering any defect on the posterior aspect of heel. A prospective observational study was conducted in the Department of Burn and Plastic Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2020 to June 2022, to see the outcome of the flap for coverage of defects over the posterior aspect of ankle joint and heel. A total number of 09 patients, selected by purposive sampling, were included in the study. The age of the patients ranged from 06 years to 70 years. The cause of the defects were post traumatic in 07 cases, electric burn in 01 case and pressure sore in 01 case. The defect sizes varied from 3×2 to 6×3cm. and flap size ranged from 4×2.5 to 7×4.5cm. The follow-up period ranged from 3 to 6 months. All the flaps survived completely without any complications; except in two cases. In one case, there was marginal epidermal necrolysis that healed secondarily without the need of any further surgical intervention. In the other case, there was gangrene of about 0.5 cm area at the flap tip, which was debrided and the resulting wound healed secondarily. The average operating time was 63 minutes. The results were satisfactory on the context of adequate coverage, and flap and donor site morbidity. So, the lateral calcaneal artery flap can be a good and safe option for the coverage of posterior ankle and heel defects.

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.

Alteration of the calf strength by heel cord lengthening, gastrocnemius recession through tenotomy or fasciotomy. A retrospective clinical force analysis before and after surgery.

BACKGROUND: Indications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called 'functional pes equinus' and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension. METHODS: This study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended. RESULTS: The operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant CONCLUSION: A correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established. LEVEL OF EVIDENCE: Level III: retrospective cohort study.

Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries.

BACKGROUND: Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes. METHODS: Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up. RESULTS: Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis. CONCLUSION: APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

[Analysis of the curative effect of triple surgery under endoscope in the treatment of intractable heel pain].

OBJECTIVE: To investigate the clinical effect the treatment of arthroscopy-assisted calcaneal spur resection combined with plantar fascia release and calcaneal decompression in the treatment of the patients with intractable calcaneal pain. METHODS: The clinical data of 50 patients with intractable heel pain from January 2016 to January 2019 were retrospectively analyzed, including 20 males and 30 females;aged from 40 to 68 years old with an average of (50.12±7.35)years old, the medical history ranged from 1 to 4 years. All patients underwent arthroscopy-assisted calcaneal spur resection combined with plantar fascia release and calcaneal decompression, and were followed up, the duration ranged from 24 to 60 months with an average of(42.00±3.28) months. All patients had obvious heel pain before surgery, and X-ray examinations often showed the presence of calcaneal spurs. In addition to the routine foot examination, the changes in the height and angle of the arch of the foot were also measured pre and post-operatively by X-ray, for the evaluation of clinical effect. The VAS system was used to evaluate the degree of foot pain;the AOFAS scoring system was used to comprehensively evaluate the foot pain, voluntary movement, gait and stability. RESULTS: The VAS decreased from (8.75±1.24) before surgery to (5.15±2.35) at 3 months after surgery, (4.07±2.53) at 6 months after surgery, and (3.95±2.44) at the last fllow-up(P<0.05). The AOFAS score increased from (53.46±4.17) before surgery to(92.46±2.53) at 3 months after surgery, (96.33±2.46) at 6 months after surgery, and (97.05±2.37) at the last follow-up(P<0.05). The arch height was (41.54±1.15) mm before operation and (41.49±1.09) mm after the operation, the difference was not statistically significant(P>0.05). The internal arch angle of the foot arch was (121±6)° before operation and (122±7)° after operation. The difference was not statistically significant(P>0.05). CONCLUSION: Arthroscopy-assisted calcaneal bone spurs resection combined with plantar fascia release and calcaneal decompression exhibited great clinical effect for treating intractable heel.

A modified perforator-based stepladder V-Y advancement flap in the Achilles tendon area for coverage of larger posterior heel defects.

BACKGROUND: Posterior heel defect coverage is challenging because of the paucity of suitable flaps. The traditional local stepladder V-Y advancement flap is recommended only for small defects because of the lack of an axial pedicle. This study reports our experience of using the perforator-based stepladder V-Y advancement flaps in a larger posterior heel defect repair. METHODS: Twenty-two patients with posterior heel defects were treated with modified perforator-based stepladder V-Y advancement flaps in the Achilles tendon area for 11 years. Sixteen males and six females aged 3-74 years underwent surgery. The defect size, perforator characteristics, flap size, flap movement, sural nerve, lesser saphenous vein, deep fascia, flap survival, and outcome quality were analyzed. RESULTS: The perforators were found to predominate within two 2-cm intervals: 0-2 cm and 4-6 cm proximal to the tip of the lateral malleolus. Twenty-one perforator-based flaps healed uneventfully, and only one developed tip necrosis on the lower edge, which healed by secondary intention. The maximum distance of distal movement was 5.0 cm for the modified flap in contrast to 2.5 cm for the traditional flap. All flaps allowed adequate and durable reconstruction to be achieved, with excellent contouring after 2-28 months of follow-up. CONCLUSIONS: The perforator-based stepladder V-Y advancement flap resulted in good outcomes for larger posterior heel defects compared with conventional transfer methods. The flap is a reliable, well-vascularized, sensate, and pliable local flap option that uses similar tissue from adjacent skin for defect repair and creates an internal gliding surface for the Achilles tendon.

[Our experience of the sural flap with distal pedicle in the repair of foot plantar and heel of foot lesions]. / Notre expérience du lambeau sural à pédicule distal dans la réparation des lésions du talon et de la plante du pied.

PURPOSE: The sural flap has often been used to cover the weight-bearing and non-weight-bearing areas of the foot and ankle. This study reports our experience in the coverage of these defects in the foot in weight-bearing areas. PATIENTS AND METHOD: This is a retrospective and descriptive study of 70 months. This study includes 16 patients presenting a loss of plantar substance and/or heel of the foot covered by a sural flap with a distal pedicle. The sampling technique described by Masquelet served as our reference. An increase in the length of the pedicle of at least two centimeters during the dissection made it possible to avoid any stretching or compression for the most distal lesions. RESULTS: The average age was 35 years with a sex ratio of three in favor of men. Traumatic lesions predominated (n=10) with an average area of lesions of 68.8cm2. The average partial and total support times were 1.8 and 3.6 months respectively. We noted one case of flap necrosis. The natural evolution of the flap took place in three progressive stages: regeneration, keratinization and squamous metaplasia. Normal bipodal support and stable gait without footwear anomaly were noted in 15 cases. CONCLUSION: The distal pedicle sural flap technique is accessible. Its reliability makes it an ideal choice for distal loss of substance to the leg and foot.

Complete avulsion of the heel pad with talar and calcaneal fracture: salvage with multiple K-wire anchorage, internal fixation and free ALT flap.

BACKGROUND: Degloving of the sole of the foot is a rare and serious injury because the heel pad cannot be replaced by similar tissue. The management is challenging and only a few cases have been reported with different treatment regimens. METHODS: Here, we report on a 46-year-old female patient with complex foot trauma consisting of complete avulsion of the heel pad at the hindfoot and a soft tissue defect at the posterior aspect of the heel accompanied by rupture of the anterior tibial tendon and fractures of the talus, calcaneus and midfoot. The sole of the foot was fixed to the calcaneus with multiple temporary Kirschner wires and moist wound dressings. The anterior tibial tendon was sutured. The soft tissue defect at the posterior heel was treated with a free anterolateral thigh flap. The fractures were fixed in staged procedures. RESULTS: At 2-year follow-up, the patient had a durable soft tissue cover over the heel with full sensation over the sole and a pliable flap over the posterior aspect of the heel. The patient was able to fully bear weight and was pain free during her daily activities in comfortable, custom shoes. All fractures had healed, the talar neck fracture after one revision and bone grafting. The foot was plantigrade and stable with preserved painless but limited range of motion at the ankle, subtalar and mid-tarsal joints. CONCLUSION: The unique tissue at the sole of the foot can be salvaged even in cases of full degloving at the hindfoot with the simple method of anchorage with multiple temporary K-wires. Traumatic defects of the vulnerable skin at the posterior aspect of the heel requires durable coverage with free flap coverage. With staged treatment of all bone and soft tissue injuries, a favorable result can be obtained even in case of a complex foot trauma.

Outcomes of Partial Calcanectomy in an Academic Limb Salvage Center: A Multicenter Review.

Chronic nonhealing heel ulcerations have been established as an independent risk factor for major amputation, with poor rates of limb salvage success. Partial calcanectomy is a controversial limb salvage procedure reserved for patients with these heel ulcerations. We conducted a retrospective cohort study reviewing 39 limbs that underwent a partial calcanectomy from 2012 to 2018 to evaluate the proportion of patients healed, time to healing, ulcer recurrence, and postoperative functional level compared to the preoperative state. In addition, age, gender, body mass index, smoking status, coronary artery disease, diabetes mellitus, renal insufficiency, dialysis, peripheral arterial disease, method of closure, and percent of calcaneus resected were evaluated. Mean follow-up for our cohort was 2.3 years. We had a 1 year mortality rate of 11%, and a major amputation rate of 18%. Our results demonstrated a 77% healing rate with a median time to healing of 162 days. We found that patients who were closed primarily had a faster time to healing compared to patients who underwent closure by secondary intention. Our data showed that ulcer recurrence developed in 57% of healed limbs. We found that 76% of our patients were ambulatory postoperatively. These results suggest that partial calcanectomy is a viable limb salvage procedure with a predictable level of ambulation and function in a high-risk patient population.

Recurrent heel ulcers with calcaneal osteomyelitis in myelomeningocele: Treatment by partial calcanectomy and posterior transfer of tibialis anterior tendon.

OVERVIEW: Calcaneus deformity of the foot is common in patients with myelodysplasia, mainly due to muscle imbalance. This deformity, especially in ambulatory patients, can result in gait problems and development of pressure sores, which can be complicated by calcaneal osteomyelitis. MATERIAL AND METHODS: This retrospective cross-sectional study included 12 patients (18 feet), with calcaneus deformity due to myelomeningocele, and presented with penetrating heel ulcers complicated by calcaneal osteomyelitis. The mean age of the included cases was 11 years. The ulcers were unilateral in six patients and bilateral in six. Sensation was absent on the plantar aspect of the foot in all cases. The treatment was done in two stages; The first stage was eradication of infection and obtaining good soft tissue coverage, and the second stage was obtaining motor balance to achieve a more plantigrade and braceable foot. RESULTS: The average follow-up period was 19.2 months. In the final follow-up, twelve feet were graded as good, five as fair and one as poor according to Legaspi grading system. CONCLUSION: The combination of partial calcanectomy and subsequent transfer of tibialis anterior tendon, to improve the foot position and gait, can efficiently prevent ulcer recurrence in myelomeningocele patients with calcaneal deformity. LEVEL OF CLINICAL EVIDENCE: 4: Retrospective case series study.

[Controversy of subtalar arthroereisis in symptomatic flatfoot].

Flatfoot could be divided into flexible flatfoot and rigid flatfoot. Flatfoot with symptoms is called symptomatic flatfoot, surgical treatment is required if conservative treatment is not effective. Subtalar arthroereisis is a minimally invasive procedure which has been used for many years with good results in flexible flatfoot, however, still has many controversial points. Controversial points focus on indications and contraindications, optimal age, subtalar arthroereisis alone or not, efficacy and safety of absorbable material implants, and implant removal. The paper reviewed and summarized the use and controversies of subtalar arthroereisis in symptomatic flatfoot as follows:the best indication for subtalar arthroereisis was pediatric flexible flatfoot syndrome and aged from 10 to 12 years old was optimal age for treatment;tarsal coalitions with flatfoot and adult flatfoot were relative indications. Stiff flatfoot, joint laxity, and subtalar arthritis were contraindications;obesity and neurogenic flexible flatfoot were relative contraindications. The correction ability of subtalar arthroereisis alone was limited, and it's combined with other procedures depending on patient's situation. The safety and efficacy of absorbable material implants had been reported. Routine removal of the implant was not necessary, the main reason of which was tarsal sinus pain.

Primary Cutaneous Cribriform Carcinoma of the Heel: A Rare Case Report.

Primary cutaneous cribriform carcinoma (PCCC) is an extremely rare carcinoma of the sweat glands. In this case report, we present a 41-year-old man with PCCC in the heel. The patient had heel pain for 10 months, and his complaints had increased in the past 2 months. Physical examination revealed a firm nonmobile mass at his heel. The PCCC in the heel was excised by wide resection after biopsy, and the defect that occurred after resection was reconstructed with a vascularized free anterolateral thigh flap. There were no complications during or after the surgery. No recurrence or metastasis was encountered during 48 months of follow-up. The patient continues his daily life activities without any problems or pain. In the heel, PCCC can be effectively treated by extensive resection and reconstruction of the defect with a skin graft/vascularized flap. Cribriform carcinomas of visceral organs and primary cutaneous adenoid cystic carcinoma should be included in the differential diagnosis, which should be made carefully, histopathologically, and immunohistochemically.

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases.

BACKGROUND: The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot. PATIENTS AND METHODS: This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm2 . RESULTS: The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow-up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12-18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes. CONCLUSION: The SCIP flap can be an optimal durable skin flap for weight-bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.

Surgical outcomes of reconstruction of soft tissue defects of the heel using various free flaps.

BACKGROUND: The goals of heel reconstruction are functional and aesthetic. Primarily due to the particular function of the heel in supporting the entire weight of the body while standing, these goals can be achieved by providing the heel with a durable and weight-bearing surface with adequate contour. Various methods such as skin graft, fasciocutaneous, and musculocutaneous local flaps have been reported for reconstructing this area. This retrospective study introduces different kinds of free flaps for heel reconstruction. METHODS: Between July 2010 and September 2016, 13 patients underwent soft tissue reconstruction of the heel with anterolateral thigh flap, lateral arm flap, superficial circumflex iliac artery perforator flap, and temporalis muscle flap. Immediate and delayed postoperative results of the surgery were evaluated with satisfaction assessed subjectively among the patients. RESULTS: There were 8 cases of anterolateral thigh flap (61.5%), 2 cases of lateral arm flap (15.3%), 2 cases of superficial circumflex iliac artery perforator flap (15.3%), and 1 case of temporalis muscle flap (7.6%). The mean duration of surgery was 261.69 (range, 114-442) minutes and the average length of absolute immobilization was 8.38 (range, 6-11) days. All flaps survived with 3 cases of minor revision due to partial necrosis, wound dehiscence, and bulky flap. There were no morbidities among donors. Satisfactory aesthetic and functional results were observed among all the patients. CONCLUSION: This article suggests that various free flaps can be considered as reliable options in heel reconstruction, resulting in acceptable functional and aesthetic outcomes.

Virtual planning of the anterolateral thigh free flap for heel reconstruction.

PURPOSE: three dimensional (3-D) virtual planning is an example of computer assisted surgery that improved management of composite tissue defects. However, converting the 3-D construct into two dimensional format is challenging. The purpose of this study was to assess 3-D virtual planning of complex heel defects for better optimized reconstruction. PATIENTS AND METHODS: a prospective analysis of 10 patients [9 male and 1 female; mean age = 27.9 years] with post-traumatic heel defects was performed. Heel defects comprised types II (three patients) or III (seven patients) according to Hidalgo and Shaw and were managed using anterolateral thigh (ALT) free flap adopting 3-D virtual planning of the actual defect which was converted into a silicone two dimensional mold. The mean definitive size of the defects was 63.4 cm3 . Functional, aesthetic, and sensory evaluations of both donor and recipient sites were performed 1 year after surgery. RESULTS: Six patients received thinned ALT (mean size = 139 cm3 ) while four patients received musculofasciocutaneous ALT flap (mean size = 199 cm3 ). One flap exhibited partial skin flap necrosis. Another flap was salvaged after re-exploration secondary to venous congestion. The mean follow-up was 20.2 months. The Maryland foot score showed 4 excellent, 5 good, and 1 fair cases. The mean American Orthopedic Foot and Ankle hind foot scoring was 76.3 (range: 69-86). All patients regained their walking capability. CONCLUSIONS: 3-D virtual planning of complex heel defects facilitates covering non-elliptical defects while harvesting a conventional elliptical flap with providing satisfactory functional outcomes and near-normal contour, volume, and sensibility.

An Innovative Approach to Calcaneal Decubitus Ulcerations Through Calcaneal Decorticalization with Use of Localized Bone Marrow and Negative-Pressure Wound Therapy: A Case Study.

Heel decubitus ulcerations are relatively common occurrences that can be limb threatening. There are many options to treat these ulcerations, ranging from conservative wound care to serial debridement with flap reconstruction. However, not all patients are good candidates for major reconstructive surgery. In this case, we present a 46-year-old man who failed 3 months of conservative wound care after sustaining a heel decubitus ulcer because of immobilization from a motor vehicle accident. The ulceration was treated with sharp excision of the wound with calcaneal decorticalization and use of negative-pressure wound therapy to use the localized bone marrow within the wound bed. The patient went on to heal within 3 months of operative intervention and remains healed greater than 1 year postoperatively. This technique provided the ability to use localized bone marrow to assist in wound healing without the operative morbidity of a reconstructive procedure.

Low Risk of Wound Complications With Sinus Tarsi Approach for Treatment of Calcaneus Fractures.

BACKGROUND: Operative management displaced intra-articular calcaneus fractures is commonly associated with wound complications. Open reduction internal fixation is traditionally performed through the extensile lateral approach has relatively high rates of wound complications. The sinus tarsi approach to displaced intra-articular calcaneus fractures is a less invasive approach to achieve fracture reduction and fixation as well as reduce wound healing complications. The purpose of this study is to report the rates of wound complications associated with the sinus tarsi approach in the treatment of displaced intra-articular calcaneus fractures. METHODS: We retrospectively identified patients treated with a limited sinus tarsi approach for displaced intra-articular calcaneus fractures from January 2009 to December 2018. Demographic and radiographic data were collected including age, gender, mechanism of injury, occupation, presence of diabetes mellitus, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements. RESULTS: One hundred and five fractures were identified in 100 patients who underwent open reduction internal fixation for displaced intra-articular calcaneus fractures. Using the Sanders computed tomographic classification, we identified 32% Type 2, 48% Type 3, 18% Type 4, and 2% tongue-type variants. For the preoperative Bohler's angle, 38% of fractures displayed a negative angle, 50% had an angle 0° to 20°, and 12% over 20°. Postoperatively, all patients demonstrated an improvement in Bohler's angle with 13% with 0° to 20° and 87% over 20°. Approximately, 72% of patients working prior to the injury had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 11.9% (12/105), with 1.9% (2/105) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p = .55). CONCLUSION: Operative management of displaced intra-articular calcaneus fractures through the sinus tarsi approach allows restoration of calcaneal height with a low rate of wound complications, even among active smokers.

Sinus Tarsi Approach With Percutaneous Screw Fixation for Intra-Articular Calcaneal Fractures.

The aim of this study was to evaluate the outcomes of surgical treatment of intra-articular calcaneal fractures by using the sinus tarsi approach combined with percutaneous medial reduction by leverage technique and percutaneous screw fixation. We assessed the outcomes of 29 patients treated using sinus tarsi approach with percutaneous screw fixation. All patients were evaluated both clinically and radiologically. The Böhler and Gissane angle were evaluated postoperatively using radiographs. During the median follow-up period of 27.0 ± 10.3 months, no cases with failure to reduce or displace hardware were detected. All cases achieved the restoration of a normal Böhler and Gissane angle. The median preoperative Böhler angle was 12.3° ± 2.5° while postoperatively it was 30.5° ± 5.7° (p < .01). The median preoperative Gissane angle was 98.1° ± 7.5°, which was 125.9° ± 3.6° postoperatively (p < .01). At the last follow-up, the median American Orthopedic Foot and Ankle Society hindfoot score was 87.7 ± 5.9, and the median Maryland foot score was 88.6 ± 5.9. Our technique for intra-articular calcaneal fractures can effectively correct calcaneal tuberosity outward displacement, medial wall overlapping, and the hindfoot varus deformity with less soft tissue damage. This technique is a good alternative for the treatment of calcaneal fractures, resulting in minimal soft tissue damage, few wound complications, and excellent radiological and clinical outcomes.

Early Clinical, Functional, and Mortality Outcomes for Heel Ulcers Treated With a Vertical Contour Calcanectomy.

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state.