Plasma and tissue concentrations of 2 g prophylactic cefazolin prior to lower extremity surgery.

Surgical site infections (SSIs) are among the most clinically relevant complications and the use of prophylactic cefazolin is common practice. However, the knowledge about the pharmacological aspects of prophylactic cefazolin in the lower extremities remains limited. In this prospective cohort, a sub-study of the WIFI-2 randomized controlled trial, adults between 18 and 75 years of age who were scheduled for implant removal below the level of the knee and randomized for cefazolin, was included. A maximum of two venous plasma, target-site plasma, and target-site tissue samples were taken during surgery. The primary outcomes were the cefazolin concentrations in venous plasma, target-site plasma, and target-site tissue. A total of 27 patients [median (interquartile range) age, 42 (29-59) years; 17 (63%) male] with 138 samples were included in the study. A minimum of 6 weeks follow-up was available for all patients. The mean (SD) venous plasma, target-site plasma, and target-site tissue concentrations were 36 (13) µg/mL, 29 (13) µg/mL, and 28 (13) µg/g, respectively, and the cefazolin concentrations between the different locations of surgery did not differ significantly in both target-site plasma and target-site tissue (P = 0.822 and P = 0.840). In conclusion, 2 g of prophylactic cefazolin demonstrates adequacy in maintaining coverage for a duration of at least 80 minutes of surgery below the level of the knee, significantly surpassing the MIC90 required to combat the most prevalent microorganisms. This study represents the first of its kind to assess cefazolin concentrations in the lower extremities by examining both plasma and tissue samples in this magnitude.

Accuracy of ultrasound in diagnosing ankle injuries in emergency care.

BACKGROUND: Ankle injuries are one of the most common presentations in the ED. Although fractures can be ruled out using the Ottawa Ankle Rules, the specificity is low, which means many patients may still receive unnecessary radiographs. Even once fractures are ruled out, assessment of ankle stability is recommended to rule out ruptures, but the anterior drawer test has only moderate sensitivity and low specificity and should be performed only after swelling has receded. Ultrasound could be a reliable, cheap and radiation free alternative to diagnose fractures and ligamentous injuries. The purpose of this systematic review was to investigate the accuracy of ultrasound in diagnosing ankle injuries. METHODS: Medline, Embase and the Cochrane Library were searched up to 15 February 2022 to include studies of patients of 16 years or older presenting to the ED with acute ankle or foot injury, who underwent ultrasound and had diagnostic accuracy as outcome. No restrictions were applied for date and language. Risk of bias and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach were assessed. RESULTS: Thirteen studies evaluating 1455 patients with bony injuries were included. In 10 studies, the reported sensitivity for fracture was >90%, but varied among studies between 76% (95% CI 63% to 86%) and 100% (95% CI 29% to 100%). In nine studies, the reported specificity was at least 91%, but varied between 85% (95% CI 74% to 92%) and 100% (95% CI 88% to 100%).Six studies including 337 patients examined the use of ultrasound for ligamentous injuries and found a sensitivity and specificity >94% and 100%. Overall quality of evidence for both bony and ligamentous injuries was low and very low. CONCLUSION: Ultrasound has the potential to be a reliable method for diagnosing foot and ankle injuries, however, higher grade evidence is needed. PROSPERO REGISTRATION NUMBER: CRD42020215258.

The minimal clinically important difference (MCID) of the Olerud Molander Ankle Score (OMAS) in patients with unstable ankle fracture.

INTRODUCTION: The Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury. MATERIALS AND METHODS: Data for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC). RESULTS: This cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4-20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1-15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months. CONCLUSIONS: The calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3-6-month follow-up and from 7.5 to 11.4 at 6-12-month follow-up, depending on moment and method.

Open Ankle Arthrodesis: A Retrospective Analysis Comparing Different Fixation Methods.

A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.

Evaluation of Functional Outcome and Complications in Bridge Plating Compared to Transarticular Screws for Lisfranc Injuries: A Systematic Review and Meta-analysis.

The optimal treatment strategy of Lisfranc injury is still in debate. This study aimed to compare the functional outcome and complications of dorsal bridge plating (BP) and transarticular screws (TAS). A systematic review and meta-analysis of the present literature was performed. PubMed, EMBASE, and Cochrane databases were searched using set search criteria and date range January 2000 to July 26, 2021. Randomized controlled trials (RCTs) and observational comparative studies concerning the outcome of dorsal BP and TAS for the fixation of Lisfranc injuries were eligible for inclusion. Random effect models were used to analyze pooled data. Forest plots using 95% confidence intervals (CI) were created to illustrate mean differences and odds ratios. Four observational studies were eligible for inclusion, including 111 patients in the BP group and 87 patients in the TAS group. American Orthopaedic Foot & Ankle Society (AOFAS) score was significantly higher in the BP group (mean difference 7.08, 95% CI 1.50-12.66, p = .01). Osteoarthritis was significantly less common in the BP group compared to the TAS group (odds ratio 0.45, 95% CI 0.22-0.94, p = .03). No significant difference was found between the groups in terms of postoperative infection, hardware removal, chronic pain, and secondary arthrodesis. Dorsal bridge plating of fractures in the Lisfranc joint may lead to better functional outcome and a lower incidence of post-traumatic arthritis when compared to transarticular screws. A larger body of high-quality evidence is required to independently analyze the severity of fractures in the different columns involved and subsequent outcomes of operative management.

Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial).

BACKGROUND: Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. METHODS: This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. DISCUSSION: If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284.

The added value of SPECT/CT in the painful foot and ankle: A review of the literature.

INTRODUCTION: Foot and ankle injuries are common. Radiographic assessment is difficult because of the complex anatomy. In the past decade SPECT/CT made its introduction in assessing bone pathology, it combines both morphologic and pathologic imaging in one image aiming to increase sensitivity and specificity when compared with MRI or CT alone. The purpose of this review was to provide a literature overview on the diagnostic value of SPECT/CT in foot and ankle pathology. METHODS: A literature search was conducted in the databases of PubMed and EMBASE between January 2004 and September 2019 for articles describing the diagnostic value of SPECT/CT in foot and ankle pathology. For assessment of methodological quality of each study included in the analysis, QUADAS-2 checklist was used. Main outcomes were change of management, improved diagnosis and symptomatic improvement. RESULTS: A total of eight studies were identified describing the diagnostic value of SPECT/CT in foot and ankle pathology based on patient data. The combined analysis shows that change of management and improved diagnosis occurred in 48-62% and 40-79% of the patients when compared with other imaging modalities and/or clinical assessment. Symptomatic improvement due to treatment based on SPECT/CT findings occurred in 92% of the patients. CONCLUSION: SPECT/CT is useful when diagnosis based on other imaging modalities is inconclusive or when treatment based on these modalities does not lead to the desired symptomatic improvement.

Open Ankle Arthrodesis: a Systematic Review of Approaches and Fixation Methods.

BACKGROUND: Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA. METHODS: A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation. RESULTS: We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance. CONCLUSION: This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA. LEVEL OF EVIDENCE: Level IIa.

Claims in orthopedic foot/ankle surgery, how can they help to improve quality of care? A retrospective claim analysis.

BACKGROUND: Orthopedic foot/ankle surgery is a high risk specialty when it comes to malpractice claims. This study aims to evaluate the incidence, characteristics and outcome of claims in this area. METHODS: This was a retrospective, 10-year claim analysis, with data from an anonymous database. Baseline claim/claimant characteristics were collected from all orthopedic foot/ankle-related cases. RESULTS: Of 460 claims in total, most were related to delay in/wrong diagnosis or to (complications of) elective surgical procedures. Whether a claim was settled was related to type of injury (fracture) and type of claim (diagnostic mistake). Median amount disbursed in settled claims was €12,549. Claim incidence did not increase over the years. CONCLUSION: Missed fracture diagnosis and "failed"/disappointing results of elective surgical procedures were the most common causes for claims. Sufficient knowledge of missed (foot) fractures and clear communication/expectation management before elective procedures could help to improve quality of healthcare and patient satisfaction.

Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections.

BACKGROUND: A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI. METHODS: We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire. RESULTS: Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score. CONCLUSIONS: This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed. LEVEL OF EVIDENCE: Level 3, prognostic and epidemiological.

Seasonal effect on the incidence of post-operative wound complications after trauma-related surgery of the foot, ankle and lower leg.

INTRODUCTION: Post-operative wound complications remain among the most common complications of orthopedic (trauma) surgery. Recently, studies have suggested environmental factors such as season to be of influence on wound complications. Patients operated in summer are reported to have more wound complications, compared to other seasons. The aim of this study was to identify if "seasonality" was a significant predictor for wound complications in this cohort of trauma-related foot/ankle procedures. MATERIALS AND METHODS: This retrospective cohort study included all patients undergoing trauma-related surgery (e.g. fracture fixation, arthrodesis, implant removal) of the foot, ankle or lower leg. Procedures were performed at a Level 1 Trauma Center between September 2015 until March 2019. Potential risk factors/confounders were identified using univariate analysis. Procedures were divided into two groups: (1) performed in summer (June, July or August), (2) other seasons (September-May). The number of surgical wound complications (FRIs, SSIs or wound dehiscence) was compared between the two groups, corrected for confounders, using multivariate regression. RESULTS: A total of 599 procedures were included, mostly performed in the hindfoot (47.6%). Patients were on average 46 years old, and mostly male (60.8%). The total number of wound complications was 43 (7.2%). Age, alcohol abuse, open fracture and no tourniquet use were independent predicting factors. No difference in wound complications was found between summer and other seasons, neither in univariate analysis [4 (3.2%) vs 39 (8.2%), p = 0.086] nor when corrected for predicting factors as confounders (p = 0.096). CONCLUSIONS: No seasonality could be identified in the rate of wound complications after trauma surgery of the lower leg, ankle and foot in this cohort. This lack of effect might result from the temperate climate of this cohort. Larger temperature and precipitation differences may influence wound complications to a larger extent. However, previous studies suggesting seasonality in wound complications might also be based on coincidence.

How Does Mechanism of Injury Relate to Similar Fracture Patterns in Bilateral Displaced Intra-articular Calcaneal Fractures?

Several biomechanical/cadaver studies have established a correlation between mechanism of injury and fracture classification in calcaneal fractures. However, this has never been backed up by clinical studies. In this study, the hypothesis is tested whether the alleged similar mechanism of injury for both feet in bilateral calcaneal fractures leads to similar fracture types. In this retrospective cross-sectional cohort study, patients with unilateral and bilateral calcaneal fractures treated between 2000 and 2017 were classified according to Essex-Lopresti and Sanders. Positive predictive values were computed, signifying the chance that the fracture type in the left foot corresponded to that in the right foot. These were compared to the a priori chance of a fracture type (percentage of fracture type in unilateral fractures) by constructing 95% confidence intervals of the positive predictive value of each fracture type. Of the 451 patients, 413 (91.6%) had unilateral and 38 (8.4%) bilateral calcaneal fractures. Mechanisms of injury were similar for uni- and bilateral fractures. Using the Essex-Lopresti fracture classification, 34 cases (90%) had the same classification in both feet, compared with 24 (63%) in the Sanders classification. The chance of a fracture type in the left, with the right foot as reference, was significantly larger than expected from a priori chance in the unilateral population. This leads to a new hypothesis, that, more than mechanism of injury, the magnitude of the impact and the position of the foot are important in predicting fracture classification in the calcaneus.

Lateral Process Fracture of the Talus: A Case Series and Review of the Literature.

Fracture of the lateral process of the talus (LPFT) is a frequently overlooked injury that can lead to severe complaints if not treated adequately. The aim of this study was to evaluate treatment and long-term outcomes of LPFT through a review of the literature. Furthermore, we propose a modified classification based on severity and intra- or extra-articular location of LPFT. Patients diagnosed with LPFT and treated at a Level 1 trauma center between 2001 and 2018 were included. Fracture and treatment characteristics were recorded in combination with functional outcome and quality of life after a mean follow-up of 5.5 (range 0.8 to 17.2) years. A comprehensive literature search was performed to identify all case series regarding patients with LPFT; 36 patients were included. According to our modified classification, 1 patient had type 1A (2.8%), 6 patients had type 1B (16.7%), 10 patients had type 2 (27.8%), 11 patients had type 3 (30.6%), 6 patients had type 4A (16.7%), and 2 patients had type 4B (5.6%). Twenty-eight patients underwent operative fixation (78%). The median American Orthopaedic Foot and Ankle Society Hindfoot Score was 75 (range 12 to 100). The median Foot Function Index was 2 (range 0 to 9). The median score for the EuroQol-5D was 0.8 (range -0.5 to 1), and the median score for health status component was 75 (range 30 to 98). There is some room for conservative treatment of LPFT; however, we strongly believe that this should be considered only for nondisplaced, small-fragment, and extra-articular fractures. Surgical treatment leads to an overall good (long-term) outcome.

Anterior inferior tibiofibular ligament avulsion fractures in operatively treated ankle fractures: a retrospective analysis.

BACKGROUND: There is no consensus about the optimal treatment of anterior inferior ligament avulsion fractures of the ankle. The aim of this study is to provide insights regarding the incidence of anterior inferior ligament avulsion fractures, the association with fracture type, and correlation with treatment. METHODS: This study is a retrospective analysis in a level-1 trauma center of adult patients with an ankle fracture operated between the dates 01-01-2009 and 01-09-2017 who had a pre- and postoperative CT-scan. Within the study population, the incidence of AITFL avulsion fracture was defined. Primary outcome was the type of avulsion fracture and related treatment. Secondary outcome was additional surgery in relation to the initial treatment. RESULTS: In total, 65 of 252 (25.8%) patients were diagnosed with an anterior inferior ligament avulsion fracture. Zero patients had a Wagstaffe type 1 fracture, 28 (43.1%) had a type 2, 32 (49.2%) had a type 3, and 5 (7.7%) had a type 4. There was a correlation between Wagstaffe type 2 and Weber B fractures, p < 0.0001, and Wagstaffe type 3 avulsions were correlated with a Weber C fracture, p < 0.0001. Thirty-five of the avulsed fragments (53.8%) were smaller than 5 mm. In 13 (20%) of patients with anterior inferior ligament avulsion fracture, the avulsed fragments were directly fixated during initial surgery. Size and direct fixation of the fragment were significantly correlated (p < 0.0001). Within the anterior inferior ligament avulsion fracture group, only a total of four patients (6.2%) underwent a revision. CONCLUSION: In the current study, an incidence of 25.8% of anterior inferior ligament avulsion fracture in surgically treated ankle fractures is reported. A correlation between the type of Wagstaffe injury and Weber classification was showed. Most fragments smaller than 5 mm were not fixated; however, not all injuries needed syndesmotic screws due to syndesmotic instability. LEVEL OF EVIDENCE: Level IV.

Target site antibiotic concentrations in orthopedic/trauma extremity surgery: is prophylactic cefazolin adequately dosed? A systematic review and meta-analysis.

Background and purpose - The incidence of surgical site infections (SSIs) in trauma/orthopedic surgery varies between different body parts. Antibiotic prophylaxis (e.g., with cefazolin) lowers infection rates in closed fracture surgery and in primary arthroplasty. For prophylactic antibiotics to prevent infections, sufficient concentrations at the target site (location of surgery) are required. However, dosage recommendations and the corresponding efficacy are unclear. This review assesses target site cefazolin concentrations and the effect of variation in dose and location of target site during orthopedic extremity surgery. Methods - For this meta-analysis and systematic review, the literature was searched using the following keywords: "cephalosporins," "orthopedic," "extremity," "surgical procedures," and "pharmacokinetics". Trials measuring target site antibiotic concentrations (bone, soft tissue, synovia) during orthopedic surgery after a single dose of cefazolin were included. Results - The search identified 14 studies reporting on concentrations in the shoulder (n = 1), hip (n = 8), knee (n = 8), or foot (n = 1). A large variation was seen between studies, but the pooled results of 4 studies showed higher concentrations in hip than in knee (mean difference: 4 ug/g, 95% CI 0.8-7). Articles comparing different doses of cefazolin reported higher bone concentrations after 2 g than before, but pooling results did not lead to a statistically significant difference. Interpretation - Although not all results could be pooled, this study shows that cefazolin concentrations are higher in the hip than in the knee. These findings suggest that the dose of prophylactic cefazolin might not be sufficient in distal parts of the extremity. Further research should investigate whether a higher dose of cefazolin can lead to higher concentrations and fewer SSIs.

Assessing Quality of Syndesmotic Reduction in Surgically Treated Acute Syndesmotic Injuries: A Systematic Review.

There is no universal method with cutoff values for the assessment of distal tibiofibular joint reduction in acute syndesmotic injuries. It is important to detect malreductions because they may lead to impaired functional outcome and may demand reoperations. The aim of this study was to systematically review the literature to evaluate the appropriateness of different image techniques in determining syndesmotic malalignment. A literature search was conducted in Medline, Embase, and the Cochrane Library to search for articles assessing syndesmotic reduction. Excluded were articles where no criteria and/or measurements for syndesmotic reduction were provided, only normative values were provided and reviews. In total, 2157 articles were found, of which 1421 studies were screened for title and abstract after exclusion of duplicates. One hundred ten studies were eligible for full-text analysis. Of these, 61 were excluded. Three studies where added after screening the included references. Fifty-two studies were included, of which 32 were original publications and 20 were publications referring to the original publications. From the original publications, 14 used plains radiographs, 19 computed tomographic (CT) scans, and 5 used 3-dimensional CT scans (some authors used >1 modality in their study). For each modality, a large number of parameters and different cutoff values were reported. CT scanning is superior to plain radiography in the assessment of the quality of joint reduction. Parameters used the most were fibular position in the incisura and fibular rotation. The criteria for adequate reduction should at least include the position of the fibula in the incisura and rotation of the fibula, while ensuring adequate fibular length, all equaling or at least approaching the values of the uninjured contralateral side.

Managing the open calcaneal fracture: A systematic review.

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

A systematic review and meta-analysis of the sinus tarsi and extended lateral approach in the operative treatment of displaced intra-articular calcaneal fractures.

BACKGROUND: The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve. METHODS: MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017). RESULTS: Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I2=0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes. CONCLUSIONS: The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF.