Percutaneous reduction, cannulated screw fixation and calcium sulfate cement grafting assisted by 3D printing technology in the treatment of calcaneal fractures.

BACKGROUND: Percutaneous reduction, cannulated screw fixation and calcium sulfate cement grafting (PR + CSC) for treatment of displaced and intra-articular calcaneal fractures (DIACFs) is a difficult technique, because the minimally invasive treatment has limited exposure and cannot be used to reduce articular surface under direct vision. The goal of this study was to apply 3D printing technology to preoperative planning and surgery of DIACFs, and to evaluate its effectiveness, feasibility and safety in fracture repair. METHODS: We enrolled 81 patients with DIACFs in the study from August 2015 to August 2017. Patients with DIACFs in our hospital were randomly divided into the 3D printing group (40 cases) and the conventional group (41 cases). The operation duration, blood loss volume and the number of fluoroscopy were compared. Radiological results were evaluated using radiographs and functional results were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score. The complications were also assessed. In addition, we made a questionnaire to verify the usefulness of the 3D printed model for both doctors and patients. RESULTS: The operation duration, blood loss volume and the number of fluoroscopy in 3D printing group were significantly less than that in the conventional group. Besides, 3D printing group achieved significantly better radiological results than conventional group both postoperatively and at the final follow-up except the calcaneal width at the final follow-up. The AOFAS score in the 3D printing group was significantly higher than that in the conventional group. In addition, the questionnaire from doctors and patients exhibited high scores of overall satisfaction of the 3D printed models. As for complications, there was no significant difference among the two groups. CONCLUSION: This study suggested the clinical feasibility of PR + CSC assisted by 3D printing technology in the treatment of DIACFs. LEVEL OF EVIDENCE: II.

Comparison of percutaneous cannulated screw fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial.

BACKGROUND: The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs. METHODS: Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC (N = 42) or MISTA (N = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded. RESULTS: The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group (p < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group (p < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group (p < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures (p < 0.05). CONCLUSION: The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs. TRIAL REGISTRATION: ChiCTRIOR16008512 . 21 May 2016.

Percutaneous treatment of calcaneus fractures associated with underlying bone cysts.

BACKGROUND: Calcaneal bone cysts with pathological fractures are rare. There is no clear consensus on their management with a few reports of open curettage, bone grafting and internal fixation in the treatment of pathological calcaneal fractures. No minimally invasive management has been reported before. METHODS: We reviewed our experience in treating five patients with pathologic calcaneus fractures associated with pre-existing bone cysts who underwent percutaneous cyst curettage, fracture reduction, screw fixation and calcium sulfate cement injection between 2004 and 2009. RESULTS: All of the pathologic fractures healed with satisfactory radiological results. There were no soft tissue complications or cyst recurrences. Partial weightbearing with plaster cast immobilization was allowed at 4 weeks postoperatively and full weightbearing was allowed at 6 weeks postoperatively. CONCLUSION: This percutaneous technique provided a minimally invasive option for treatment of a calcaneal bone cyst with pathologic fracture.

Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intra-articular calcaneal fractures.

BACKGROUND: The conventional treatment for displaced intraarticular fractures of the calcaneus (DIACF), with open reduction and internal plate fixation (ORIF), carries the risk of wound infection and delayed recovery. Alternatively percutaneous fixation techniques offer the possibility of equivalent outcomes in with a reduction in soft tissue complications. The goal of the present study was to evaluate the outcome of percutaneous reduction (PR), screw fixation, and calcium sulphate cement (CSC) grafting in the treatment of DIACF. METHODS: Ninety patients were randomly assigned to PR and CSC grafting or ORIF between January 2006 and August 2008. The blood loss, Böhler's angle, calcaneal width, length, height and articular congruity of the posterior facet, wound complication, range of joint motion were compared, function scores such as American Orthopaedic Foot and Ankle Society score (AOFAS) and Maryland foot score (MFS) were measured. RESULTS: The quality of reduction was not significantly different between the two groups. There were significant differences favoring PR in blood loss (p < 0.01), range of joint motion (p < 0.01), AOFAS (p < 0.01) and MFS (p < 0.01) between the two groups. Postop infection was 12% ORIF and 3% PC (p = 0.23). Earlier weightbearing in the PR group did not result in a greater frequency of redisplacement than in the OR group. CONCLUSION: Our results indicate that compared with ORIF, the percutaneous reduction, fixation and CSC grafting for treatment of DIACF might allow accelerated weightbearing activity, reduce joint stiffness and improve the patients' satisfaction.