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Background: It was aimed to compare conventional surgery and three-dimensional (3D) model-assisted surgery used in the treatment of calcaneal fractures. Materials & Methods: A total of 37 patients with unilateral calcaneal fractures were randomly divided into two groups as a conventional surgery group (n: 19) and a 3D model-assisted surgery group (n: 18). The preoperative, postoperative and last follow up angles of the Bohler and Gissane, calcaneal width and facet height were measured. The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for both groups were recorded. Finally, the follow-up AOFAS scores were evaluated. A questionnaire was used to determine the perceptions of the resident doctors about the 3D model. Results: The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for 3D model-assisted surgery group were 83.3 +/- 4.6 minutes, 83.6 +/- 4.6 ml, 6.8 +/- 1.4 times and 13.0 +/- 0.8 weeks, and as for conventional group they were 130.0 +/- 5.8 minutes, 105.1 +/- 5.6 minutes, 11.7 +/- 1.5 ml, 22.2 +/- 2.4 times and 13.3 +/- 0.8 weeks, respectively (p < 0.0001). The both groups significantly restored Bohler angle, Gissane angle, calcaneal width and calcaneal facet height after operation (p < 0.0 001). The 3D model-assisted group was significantly more succesful in restoration and protection of achieved correction of calcanel facet height (p < 0.0001). The difference was determined among the groups at the final follow-up examination with respect to the amount of change according the values achieved postop. were significant in Bohler angle (p < 0.001), calcaneal facet height (p < 0.0001) and calcaneal widht (p = 0.017). There was no significant difference between AOFAS scores of the two groups at last follow-up. Resident doctors exhibited high scores of overall satisfaction with the use of a 3D printing model. Conclusions: Compared to the conventional group, the 3D model-assisted group provide successful intervention and reduce operation, instrumentation time and the fluoroscopy usage with less blood loss. Performing 3D-assisted surgery helps the quality of reduction during the surgery and stability of internal fixation to protect achieved reduction at follow-up more succesfully. (C) 2020 Elsevier Ltd. All rights reserved., European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT), This paper is part of a Supplement supported by the European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT).

Category: Hindfoot Introduction/Purpose: To date, minimally invasive surgery (MIS) involving calcaneal osteotomy for Haglund deformity associated with intractable insertional Achilles tendinopathy has not been reported. This study presents the radiographic and clinical outcomes of our novel MIS-dorsal closing wedge calcaneal osteotomy (DCWCO) technique compared to open Haglund resection. We hypothesized that earlier clinical improvement after MIS-DCWCO could be achieved by leaving the Achilles tendon insertion site untouched. Methods: We retrospectively reviewed and compared the clinical and radiographic parameters of patients who underwent MIS- DCWCO (11 cases) or open Haglund resection (14 cases) between January 2012 and June 2019. The minimum duration of follow-up for inclusion was 18 months. We measured the calcaneal pitch, Meary's, Fowler-Philip, and Böhler's angles. Clinical outcomes were evaluated using the visual analogue scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores measured preoperatively and at 3, 6, 9, 12, and >=18 months, postoperatively. Results: In both groups, the Meary's and calcaneal pitch angles did not change significantly, whereas the Fowler-Philip and Böhler's angles were significantly changed postoperatively. Significant improvements in VAS and VISA-A scores were observed in both groups (P < .001). The extent of correction of the four radiographic and two clinical parameters were not significantly different between the two groups. However, VAS and VISA-A scores at postoperative 6 months were significantly different, whereas these parameters were not significantly different at all other time points. Conclusion: Both techniques provided similar postoperative clinical and radiographic improvement. However, MIS-DCWCO achieved earlier clinical improvement than open Haglund resection.

Purpose Calcaneal fractures are one of the most challenging injuries to treat and one of the most divisive. The purpose of this historical review is to highlight the evidence of calcaneal fracture and its treatment through history. Methods Archaeological, religious, artistic, literary and historical accounts were searched for descriptions of calcaneal fracture to give a thorough overview of the subject. The scientific literature was searched to highlight the evolution of treatment techniques. Results For over 2500 years, the only available option was conservative treatment due to the high risk of infection and limb loss in a world without antibiotics, plastic surgery techniques and adequate osteosynthesis devices. At the beginning of the twentieth century, treatment was still rather crude, consisting of closed reduction by impaction by a Cotton’s mallet, immobilisation of the foot into presses and strict bed rest in a plaster cast for five weeks. Only in the case of untreatable pain, triple arthrodesis could be employed. Regardless, the results were dismal. The debate on the superiority of open reduction and primary subtalar arthrodesis over open and closed reduction spans the entire history of medicine. Conclusion The long path of history has brought great improvement in the treatment of calcaneus fracture, but the debate about the best treatment is far from being over. There is a lack of good quality randomised control trials conducted according to an agreed set of outcome scores despite some excellent efforts. Therefore, despite the attempts made over the years and new, more precise prognostic scores, the outcomes of each technique in use today are as unique as the individuals who suffer from a calcaneal fracture.

Introduction Calcaneal fractures may have lifelong debilitating sequences, if not treated properly. Identifying different types of calcaneal fractures based on the computed tomography (CT) scans can increase our conception about these fractures. Methods In a cross-sectional study, the available CT images of all consecutive patients with the diagnosis of calcaneal fracture, from January 2015 to December 2018, were reviewed to determine different patterns and types of these fractures. Results CT images of 886 patients (mean age, 41.29 ± 14.9; range, 3–89 years; male/female, 4.86; pediatric: 3.7%) with 957 calcaneal fractures were evaluated. The peak incidence of calcaneal fractures was seen in patients between 30 to 39 years of age (29%). The rate of open fractures and bilateral involvements were 2.4% and 8.0%, respectively. Among 680 (71.0%) intra-articular calcaneal fractures, subtalar calcaneal fractures were the most common type (94.3%). The majority of intra-articular subtalar calcaneal fractures were displaced (95.0%) with calcaneocuboid joint (CCJ) involvement (59.9%). Fracture lines were extended to the CCJ in about 86.9% of Sanders type IV, 66.3% of type III, and 60.2% of type II. Among 261 extra-articular fractures (27.3%), calcaneal body fracture (55.6%) was the most frequent type, followed by medial tubercle fracture (24.1%), calcaneal tuberosity fracture (10.4%), Degan type I anterior process fractures (5.4%), Degan type II anterior process fracture (3.4%), and isolated lateral tubercle fracture (1.1%). Most of bilateral calcaneal fractures were intra-articular subtalar fractures with involvement of CCJ. Although majority of intra-articular calcaneal fractures were displaced; less than half of the extra-articular fractures were displaced. Conclusion Displaced intra-articular subtalar calcaneal fractures with CCJ involvement are the most frequent type of unilateral and bilateral calcaneal fractures. It appears that there is a correlation between Sanders type and the probability of CCJ involvement. Unlike intra-articular subtalar calcaneal fractures, the CCJ in the majority of extra-articular calcaneal body fractures was intact. Level of evidence Level IV.

It is well established that the postoperative results were affected by the surgeon volume in a variety of elective and emergent orthopaedic surgeries; however, by far, no evidences have been available as for surgically treated displaced intra-articular calcaneal fractures (DIACFs). We aimed at investigating the relationship between surgeon volume and deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of DIACFs. This was a further analysis of prospectively collected data from a validated database. Patients with DIACFs stabilised by ORIF between 2016 and 2019 were identified. Surgeon volume was defined as the number of surgically treated calcaneal fractures within one calendar year and was dichotomised based on the optimal cut-off value. The outcome measure was DSSI within 1 year postoperatively. Multivariate logistics regression analyses were performed to examine the relationship, adjusting for confounders. Among 883 patients, 19 (2.2%) were found to have a DSSI. The DSSI incidence was 6.5% in surgeons with a low volume (

There are no studies on epidemiologic characteristics of deep vein thrombosis (DVT), when specified at in patients with bilateral calcaneal fractures. This study aimed to address the preoperative DVT in bilateral calcaneal fractures. Between October 2014 and December 2018, adult patients presenting with bilateral calcaneal fractures and having preoperative Duplex ultrasound (DUS) of bilateral lower extremities for detection of DVT were included. Their medical data were collected, with regards to demographics, comorbidities, injury-related data and biomarkers. Baseline characteristics between patients with and without DVT were compared using bivariate tests. The further multivariate logistics regression analysis was conducted to identify independent factors associated with DVT. In total, 258 patients with bilateral calcaneal fractures were included, with 21 (8.1%) having preoperative DVT, diagnosed at 7.7 ± 4.2 days after injury. The prevalence rate of proximal DVT was 1.9% and of distal DVT was 6.2%. Thirty five thrombi were found, with 6 (17.1%) in proximal veins and 29 (82.9%) in distal veins. Nine patients had DVTs in multiple veins, and 2 patients had bilateral DVTs. The multivariate analyses showed history of allergy (odds ratio [OR] = 2.17), concurrent other fractures (OR = 4.53), prolonged time since injury (for each day, OR = 1.16), elevated plasma D-dimer level (≥1.73 vs1.73 mg/L, OR = 3.74) and reduced albumin level (34.2 g/L vs ≥34.2 g/L, OR = 2.92) were independent factors associated with DVT. Multiple factors were identified to be associated with DVT and greater consideration should be given to the use of pharmacologic prophylaxis in patients involving these factors, to reduce DVT occurrence.

Background: Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO. Methods: Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures. Results: Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet. Conclusion: Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy. Clinical Relevance: Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible. Level of Evidence: Level II, prospective cohort study.

Introduction: The calcaneal spur is also known as an enthesophyte which is a bony outgrowth from the calcaneum at the plantar fascia insertion. Treatment aspect ranges from initial conservative methods, invasive techniques to surgical excision of the spur in cases which are not responding to any other alternative methods. This article aims in evaluating the functional outcome of calcaneal spur excision coupled with a dose of autologous platelet-rich plasma injection in recalcitrant cases of the calcaneal spur. Materials and Methods: A total of 42 cases of confirmed calcaneal spur cases were recruited for the study. All participants were offered with calcaneal excision with a dose of autologous platelet-rich plasma injection. All patients were evaluated preoperatively and post-operatively with VAS and FFI scores at the end of the 1st , 3rd; and 6th months. Results: The patients who received calcaneal spur excision along with a single dose of autologous plateletrich plasma injection reported statistically significant pain relief at the end of 6 months while comparing with the pre-operative VAS score (p = 0.003) and FFI score showed a statistically significant functional outcome between both groups at the end of 6 months (p Conclusion: Surgical removal of calcaneal spur along with a dose of an autologous platelet-rich plasma injection serve the better management for calcaneal spur and improves the functional quality of life. Keywords: Calcaneal spur, Plateletrich plasma, VAS score.

Deep surgical site infection (DSSI) is a serious complication affecting the surgical outcome of displaced intra-articular calcaneal fracture, and a risk prediction model based on the identifiable risk factors will provide great clinical value in prevention and prompt interventions. This study retrospectively identified patients operated for calcaneal fracture between January 2014 and December 2019, with a follow-up ≥1 year. The data were extracted from electronic medical records, with regard to demographics, comorbidities, injury, surgery and laboratory biomarkers at admission. Univariate and multivariate logistics regression analyses were used to identify the independent factors for DSSI, thereby the risk prediction model was developed. Among 900 patients included, 2.7% developed a DSSI. The multivariate analyses identified five factors independently associated with DSSI, including current smoking (OR, 2.8; 95% confidence interval [CI], 1.3-6.4; P = .021), BMI ≥ 26.4 kg/m2 (OR, 3.1; 95% CI, 1.6-8.4; P = .003), ASA ≥II (OR, 1.3; 95% CI, 1.0-5.1; P = .043), incision level of II (OR, 3.8; 95% CI, 1.3-12.6; P = .018) and NLR ≥6.4 (OR, 3.2; 95% CI, 1.3-7.5; P = .008). A score of 14 as the optimal cut-off value was corresponding to sensitivity of 0.542 and specificity of 0.872 (area, 0.766; P < .001); ≥14 was associated with 8.1-times increased risk of DSSI; a score of 7 was corresponding sensitivity of 100% and 10 corresponding to sensitivity of 0.875. The risk prediction model exhibited excellent performance in distinguishing the risk of DSSI and could be considered in practice for improvement of wound management, but its validity requires to be verified by better-design studies.

Introduction The minimally invasive approach for displaced intra-articular calcaneal fractures is significantly reducing postoperative wound complications. One minimally invasive method, the sinus tarsi approach (STA) has been increasingly widely used. STA is, however, challenging due to its technical demands and the risk of injury to the sural nerve (SN). The purpose of this study was to identify the SN and its branches including their anatomical relationship to the STA as well as to describe an anatomical windows technique for STA including determination of the safe angle for screw insertion into the sustentaculum tali fragment. Methods Thirty-two adult cadaveric legs were disarticulated at the knee and unpaired. STA was performed on each specimen. The anatomy and distribution of the sural nerve and its branches were identified in relation to the incision. Three surgical windows were identified and selected. Kirshner wires were inserted in pairs via each of the windows towards the center of the sustentaculum tali. The safe angle for wire insertion in relation to the SN or its branches was then measured as well as the appropriate intraoperative drilling angle. Results The plantar branch presented in the distal window in none of the samples, while the dorsal branches presented in 37.5% and the main SN presented in only 6.25%. In the middle window, the dorsal branch presented most often (43.75%) followed by the plantar branch (25.00%) and the SN (21.88%). In the proximal window, the SN presented in 100% of the samples, while the dorsal branch presented in none and the plantar branch presented in about 15.63% of the specimens. All three windows had their own acceptable average angle for screw insertion towards the sustentaculum tali. Conclusions The distal window is the safest for surgical approach and for calcaneal surgery screw fixation in terms of avoiding sural nerve injury. In addition, that window provides a wide working angle for screw fixation.

The research is aimed to introduce various corrective osteotomies utilized in treating calcaneal malunions in published papers, to further analyze the results, and to summarize recommended indications. The relevant research screening was conducted on the following search engines: the Cochrane Library, Web of Science, PubMed, Embase, Medline, and Academic Search Premier. Key words input included “calcaneal/calcaneus”, “malunion,” and “malunited fracture(s)” with Boolean operators “AND” and “OR.” The inclusion criteria were researches containing surgical procedures treating calcaneal malunion with corrective osteotomy and published in the English language. For included research article, such information was extracted and analyzed: the type of calcaneal malunion, the time from initial injury to corrective surgery, the method of osteotomy, outcomes of each osteotomy (score systems, Bohler angle, talocalcaneal height and width of calcaneus, etc.), the function of the affected limb, post-operative complications, and patients’ satisfaction. For included review, descriptive, commentary, or indicative sentences about corrective osteotomy were highlighted, analyzed, and summarized. Ten research articles (170 patients with 184 feet) and nine reviews were included in this review, presenting seven types of corrective osteotomies (lateral wall exostectomy, Dwyer osteotomy, lateral wedge opening osteotomy, Romash osteotomy, tongue osteotomy, sagittal resection osteotomy, and modified Dwyer osteotomy). A different corrective osteotomy with/without arthrodesis is recommended to be utilized based on the classification of the malunion and the condition of the cartilage in treating malunited calcaneal fractures. With adequate postoperative care and rehabilitation, the results of treatment could be associated with patients’ satisfaction and good function.

Introduction Only a few reports have described calcaneal insufficiency fractures (IFs) following total knee arthroplasty (TKA). Herein, we describe nine cases of calcaneal IFs following ipsilateral TKA. The purpose of this study was to investigate the incidence of calcaneal fractures following TKA and determine the characteristics of patients with IFs. Patients and methods We retrospectively investigated cases of calcaneal IF that occurred following TKA. We collected and analyzed radiographic and magnetic resonance imaging (MRI) findings as well as patient demographic data. We compared the demographic data, bone mineral density (BMD), and preoperative hip-knee-ankle angle (HKA) between cases with a calcaneal fracture following TKA and 100 cases without a fracture following TKA. Results We performed a total of 1548 knee arthroplasties at our clinic from 2011 to 2020. Nine calcaneal IFs in eight patients were diagnosed following ipsilateral TKA. All patients were women with varus knee osteoarthritis (mean age, 71.8 years). The average change in the alignment angle was 14.7° ± 5.4°. In eight cases, dysfunction was observed in the opposite lower limb. The postoperative onset of hindfoot pain started at an average of 5.6 months. In seven patients, calcaneal fractures occurred idiopathically, but in one patient, two fractures occurred after long-distance walking. No abnormal findings on a calcaneus radiograph were seen for six fractures. MRI demonstrated a definite fracture line and bone marrow edema in all patients. All patients, except one with type 2 diabetes mellitus (T2DM), had osteoporosis. Fractures healed without complications in eight patients; however, the calcaneal anterior facet fracture became displaced and caused a flat foot in one case. The calcaneal IF rate was 0.58% among all cases. Besides one case with T2DM, significant differences were observed in preoperative HKA and BMD between cases with a calcaneal fracture following TKA and those without a fracture. Conclusions A change in the load on the calcaneus due to changes in the alignment of the lower extremities after TKA may cause calcaneal IFs. Orthopedic surgeons should be aware of the possible occurrence of calcaneal IFs following TKA, especially in women with osteoporosis and severe varus knee.

Objective The purpose of this clinical communication is to report the management of common calcaneal tendon rupture in dogs using a transarticular calcaneo-tibial locking plate as a method of temporary immobilization of the tarsocrural joint to support primary repair of the common calcaneal tendon. Study Design Dogs presented with partial or complete common calcaneal tendon rupture treated with primary tendon repair supported by the transarticular calcaneo-tibial locking plate technique from July 2016 to December 2019 were included. The tarsus was placed at a standing angle of 150 degrees and the pre-contoured Fixin locking ‘L’ or ‘T’ plate was medially applied with two locking screws inserted in the calcaneus and two screws inserted in the distal tibia. Tendon healing judgement was mostly based on clinical palpation and ultrasound examination was not performed in all the cases. Plates were removed in all dogs 6 weeks postoperatively. Results All tendons healed and no complications at the level of the tenorrhaphy were noted in the postoperative period. All dogs returned to hunting activity with full function of the affected limb. No major complications requiring revision surgery were observed. Minor complications occurred in two cases; osteomyelitis and screw pull-out. Conclusion The use of a transarticular calcaneo-tibial locking plate for temporary immobilization of the tarsocrural joint after surgical repair of common calcaneal tendon rupture appears to be an effective technique with comparable results to other reported techniques.

Objective To evaluate the rate of subtalar arthrodesis based on a computed tomography (CT) scan after open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneal fractures. Design Retrospective chart review. Setting Single tertiary care practice. Patients A retrospective chart review was performed to identify patients who sustained an acute, displaced, intra-articular calcaneal fracture and underwent open reduction and primary subtalar arthrodesis. Thirty-five patients participated in the study. Intervention Each patient included in the study was treated with open reduction and primary subtalar arthrodesis. Main outcome measures All patients were evaluated with CT for arthrodesis of the posterior facet of the subtalar joint, which was quantitated. Other outcome measures included radiographic parameters, the Veterans RAND Item Health Survey, and the Foot and Ankle Ability Measure. Results The median patient age was 47.8 years (range 21.5-79.5 years). The median patient follow-up was 34.4 months (range 4.6-104.1 months). The Sanders classification was as follows: 3% (1/35) type II, 40% (14/35) type III, and 57% (20/35) type IV. Based on a CT scan, primary subtalar union occurred in 94.3% (33/35) of patients. Conclusions Open reduction and primary subtalar arthrodesis for acute, displaced, intra-articular calcaneus fractures has a high rate of union and good pain and function outcomes. It should be strongly considered for patients with significant cartilage injury and comminution of the posterior facet. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE The aim of this study was to compare clinical and radiological outcomes of screw fixation alone versus screw with small locking plate fixation techniques in the management of intra-articular calcaneal fractures by minimal invasive surgery. METHODS A total of 42 patients treated with minimally invasive surgery because of an intra-articular calcaneal fracture were retrospectively reviewed and included in the study. The patient were then divided into two groups based on the implemented surgical technique: Group A, 20 patients (16 male, 4 female; mean age = 43.41 ± 15.50) receiving screw fixation alone and group B, 22 patients (17 male, 5 female; mean age = 43.38 ± 14.00) receiving screw with small locking plate fixation. The radiographic assessment included Bohler's, Gissane, joint line parallel, and calcaneal varus angles at immediate post-operative and 2-year follow up period through the calcaneal axial and lateral foot radiographs. RESULTS There was a significant increase in joint line parallel angle from post-operative period to 2-year follow up in Group A compared to Group B, mean (SD) 3.27 (2.15) degrees versus (vs) 0.44 (3.00) degrees, P = 0.025. No statistical significant difference of the immediate, 2-year post-operative period and the change in Bohler's-Gissane angle, calcaneal varus, and FAAM of ADL between groups were observed, P > 0.05. For time-point comparisons in each group, there was a significant loss of calcaneal varus and increase in joint line parallel angle from post-operative period to 2-year follow up in Group A, from mean (SD) 1.82 (11.22) to 4.41 (9.73) degrees and 4.09 (5.32) to 7.36 (5.24) degrees, P = 0.047 and

Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Fifty-eight intra-articular calcaneal fractures (fifty-three patients; five bilateral, mean age = 46.91 years) with a mean follow up of 35.4 months (6 – 57) were included. Five patients (9.4%) had wound complications; two superficial (3.7%), three deep (5.6%); four of whom were smokers. Smokers were statistically more likely to have wound infections than non-smokers (p=0.04). Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.

We aimed to assess the effects of medial displacement calcaneal osteotomy (MDCO) through a minimal skin inci-sion in terms of pain, function, and alignment in patients with unilateral adult acquired flatfoot. American Ortho-pedic Foot and Ankle Society (AOFAS) hindfoot scale and Numeric Pain Rating Scale (NPRS) were assessed as outcomes at the baseline (T0), at 6 months (T1), and at 1 year (T2) from surgery. We analyzed data of 20 patients (7 male and 13 female), mean aged 46.6 ? 5.34 years, showed significant differences after 6 months in terms of AOFAS total score (44.30 ? 7.39 vs 96.50 ? 4.89; p = .0001), AOFAS subitems (p < .001), and pain (NPRS: 7.95 ? 1.36 vs 1.05 ? 1.05; p = .0001). At 1 year after surgery (T2), all outcome measures still significantly differ from baseline (p < 01). Therefore, percutaneous MDCO through a minimal skin incision seemed to be safe and effective in the middle and long term in reducing pain and improving function and alignment in patients with unilateral adult acquired flatfoot. ? 2020 by the American College of Foot and Ankle Surgeons. All rights reserved.

Highlight • The largest and first study to compare EIN with CST for displaced tibial shaft fracture in a Chinese population. • The CST procedure had faster surgical time, cast duration, and longer hospitalization. Patients in EIN group began exercising and endured weight-bearing earlier. • The CST provided better results of coronal correction than EIN. Moreover, CST patients had less malalignment (> 5°) in complications. • The characteristics of the patient and fracture, the individual's situation and expectation should be considered when choosing the best approach., Background The objective of this study was to compare the outcomes and complications of patients who underwent either the calcaneal skeletal traction (CST) or the elastic intramedullary nails (EIN) procedure. Methods We retrospectively reviewed data of patients who underwent EIN or CST surgery for tibia shaft fracture at our center from 2013 to 2018. The patient demographics, fracture characteristics, radiographic information, length of hospital stay, and medical expenses were recorded. All patients were clinically followed-up until they started to walk or for at least 6 months. The treatment outcomes and postoperative complications of the two procedures were compared. Results Overall, 186 patients who underwent EIN and CST were included in the study. The EIN patients had more low-energy mechanism of injury. In radiographic evaluation, significant differences were observed in distributions of fracture classification and location. Moreover, associated fibula fractures were higher in the EIN group than in the CST group. The CST procedure had faster surgical time, cast duration and lower expenses, and longer hospitalization time. Although they required more clinical visits, patients in the EIN group began exercising and endured weight-bearing earlier than those in the CST group. The average time for bone healing was 68.5 days in the EIN group, and 69.6 days in the CST group. However, the CST provided slight better results of coronal correction than EIN. Moreover, CST patients had less malalignment (> 5°) in complications. None had delay union, nonunion, and shortening over 10 mm at final assessment. Conclusions Both EIN and CST patients showed similar treatment outcomes. Hence, not only the characteristics of the patient and fracture, but also the individual's situation and expectation should be considered when choosing the best approach.

To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus. Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors. Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64–1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision. A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146

AimsNo randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.MethodsBetween August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction.ResultsAlthough four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001).ConclusionThe ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293.

Background: Calcaneal fracture-dislocations are rare but potentially disabling injuries that are regularly overlooked at first presentation. To date, only about 50 cases have been reported in the literature. Methods: Over a period of 8 years, 10 patients (average age 61.7 years) with acute fracture-dislocations of the calcaneus were treated at 2 level 1 trauma centers. The calcaneocuboid joint was involved in 9 patients. There was a concomitant fracture of the lateral talar process and of the tip of the distal fibula in 7 patients each. Open reduction and internal fixation was performed in 9 of 10 patients via an oblique lateral dislocation approach. One patient underwent primary subtalar fusion. All patients were seen for clinical and radiographic follow-up at an average of 3 years using patient-reported outcome scores. Results: Anatomic fixation was achieved in all patients as judged by postoperative computed tomographic imaging. In the 9 patients treated with internal fixation, the Foot Function Index averaged 12.8, the EuroQol 5D score averaged 0.89 and the visual analog scale score for patient satisfaction averaged 79.3 at final follow-up. Signs of mild subtalar arthritis were seen in 6 patients. No secondary subtalar fusions were needed. Conclusion: When recognized and treated early, prognosis of calcaneal fracture-dislocation was favorable. A dislocation approach starting over the distal fibula, continuing over the sinus tarsi, and extending toward the calcaneocuboid joint allowed for adequate visualization of the subtalar joint and treatment of all components of the injury. Level of Evidence: Level IV, retrospective case series.

Objective To assess the clinical outcomes of open calcaneal fractures with medial wounds treated with one‐stage management, including early modern wound care, sequential reduction, and frame structure fixation using percutaneous Kirschner wires. Methods A total of 19 patients with open calcaneal fractures admitted to our hospital from May 2016 to March 2019 were selected in this study. Twelve type‐II and seven type‐IIIA medial open injuries were identified according to the classification of Gustilo and Anderson. Fractures were stratified by Sanders classification, including nine type‐II fractures, seven type‐III fractures, and three type‐IV fractures. All patients accepted one‐stage irrigation and debridement, sequential reduction of calcaneal fractures through the open medial wound, percutaneous Kirschner wire fixation, and primary closure of wounds covered with vacuum‐assisted closure (VAC) device. The Bohler angle, the Gissane angle, and the width of the calcaneus were compared before and after surgery. The functional results were evaluated according to the Paley and Hall score system, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Maryland Foot Score, and related complications. Results The follow‐up duration for all patients ranged from 14 to 28 months (mean, 22.7 months). The angle of Bohler and Giasane was increased from (−7.6° ± 15.0°) and (96.6° ± 7.6°) before surgery to (23.7° ± 6.1°) and (124.1° ± 7.1°) postoperatively (P, Open calcaneus fractures with medial wound is treated by one‐stage sequential reduction and frame structure fixation using percutaneous Kirschner wires. This technique allows direct restoration of calcaneal morphology with a minimal invasion of soft tissues at an early stage.

Many people with heel pain in the general population are often diagnosed with plantar calcaneal spurs (PCS). The aim of this study was to evaluate the radiological and demographic characteristics of PCS patients and to compare the differences with the control group. In 2018, 420 patients with weightbearing lateral ankle X-ray images were included in the study. The patients were divided into 2 groups as PCS group and control group. Groups were compared age and age group (20-29, 30-39, 40-49, 50-59, 60-69, 70 and over) weight, height, body mass index ( 30), chronic diseases as demographically and were also compared radiologically as calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), Bohler angle and Gissane angle. A statistically significant relationship was found between gender and PCS. Plantar calcaneal spur is more common in females than in males (X2:8.101, p 30 (X2:7.698, p < .021). Although the CIA angle was within normal limits in both groups, it was significantly lower in patients with PCS than in the control group(p < .05). There was no statistically significant difference between the 2 groups in terms of age, chronic disease, LTCA, Bohler angle, Gissane angle. Female gender and obesity are among the risk factors for PCS formation. CIA may have an important role in PCS formation. In order to clarify the etiology and pathophysiology of PCS, further studies with radiological features are needed.

Background: Untreated or inappropriately treated, calcaneal fractures can result in arthritis, chronic ankle pain, and ankle deformity which can significantly impact the lifestyle of affected patients. Even though calcaneal fractures are common among those with multiple injuries, they can easily be missed, and not treating them would significantly impact on the patient negatively. Case Presentation: This article is a retrospective recall of the six patients seen with calcaneal fractures that were treated in our hospital between 2010 and 2018, they were mainly multiply injured and the advanced trauma life support (ATLS) protocol helped to delineate these fractures, the use of modern-day operative and non-operative methods of management and rehabilitation were employed. Discussion and conclusion: Calcaneal fractures are mostly associated with high-energy trauma which includes falls from heights or vehicle accidents with almost 50% soft tissue involvement. This is similar to cases presented in this paper as all the patients were either involved in road traffic accidents or had fallen from a height, however, soft tissue destruction manifesting as open fractures were absent in our series. Calcaneal fractures are rare and can easily be missed as patients may present as multiply injured. Prompt and adequate Rehabilitation is important to improve function.

Introduction There is currently great controversy about the ideal treatment of intraarticular calcaneal fractures. The objective of this study is to determine the usefulness of postoperative computed tomography (CT). Patients and methods We conducted a retrospective descriptive study of patients operated on in the period 2007 to 2015 in our center. Epidemiological variables, specific fracture data, surgical intervention as well as results and complications were collected. The radiological evaluation was performed using simple radiology (Bohler angle) and coronal CT (congruence of posterior subtalar joint). For the functional results we use the AOFAS hindfoot scale and the EVA scale for the level of pain. Results We included 46 fractures in 43 patients (three bilateral). Thirty-five were male and eight female, with an average age of 42 years (18-79) and an average follow-up of 57.39 months (33-129). Preoperative CT was performed in all cases, of which 11 were Sanders ii, 23 type iii and 12 type iv. Postoperative CT was only performed in 17 cases. The subsequent subtalar reduction measured by CT was satisfactory (articular step 20° post-surgical with higher AOFAS (80.82) and lower VAS (3.18) (p = 0.001). The literature search obtained a total of 117 articles that met the search criteria, of which only 29 requested postoperative CT. Conclusions The indication of postoperative CT in patients operated by intraarticular calcaneal fracture is the best technique to corroborate the correct reduction of the subtalar joint surface, although it is not universally accepted, according to the literature.

Calcaneal fractures account for 60–75% of all tarsal fractures and represent surgical challenges because of their frequency and complexity. Despite standardized procedures and new implants, literature reports high revision rates and unsatisfactory results. The study aims to describe the role of the surgeon with respect to the clinical outcome. Between 2014 and 2017, 94 calcaneal fractures (all type AO C1-3) were re-examined in 86 patients (67 male and 19 female; mean age: 51 years). The treatment was always carried out by means of locking compression plate via the extensile lateral approach. A comparison was made between treatment by an experienced (ES) and less experienced surgeon (LES). Annually, the ES performed at least 30 procedures for calcaneus fracture treatment as compared to

Background: Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy. Methods: Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images. Results: The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches. Conclusions: Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA. Levels of Evidence:: Level IV, Cadaveric study

Objective To describe the clinical presentation and outcome of two greyhounds with calcaneal malunions that were treated with corrective osteotomy and partial tarsal arthrodesis. Study design Short case series. Animals Two adult racing greyhounds. Methods Varus and recurvatum deformity of the calcaneus was ascribed to malunion of prior calcaneal fracture with concomitant central bone fracture that had been sustained during racing in both dogs. Both dogs exhibited severe, weight-bearing lameness and had radiographic evidence of moderate to severe osteoarthritis of the proximal intertarsal joint. A closing wedge corrective osteotomy and partial tarsal arthrodesis were performed with a 2.7-mm locking compression plate and cancellous autograft. Results Calcaneal morphology and alignment of the common calcaneal tendon seemed restored postoperatively. The implant was removed in one dog, while the other dog experienced no postoperative complications. Lameness improved in both dogs, although residual intermittent lameness after heavy exercise was reported by owners of both dogs 1 year after surgery. Overall, owner satisfaction and outcome were considered good-to-excellent in both dogs. Conclusion Corrective osteotomy and partial tarsal arthrodesis for treatment of malunited calcaneal fractures may be considered in dogs with clinical signs related to calcaneal malunion.

While the extended lateral approach was the gold standard for treatment of calcaneal fractures for decades, the mini-open approach through the sinus tarsi gained popularity in recent years. Although widely used, there are only a few reports available in the literature reporting on mid- to long-term results. Therefore, the purpose of the study was to report on mid- to long-term radiographic and clinical outcomes of calcaneal fractures treated surgically using a mini-open sinus tarsi approach.In this retrospective review, radiographic and clinical outcome measures of 30 consecutive patients (34 fractures) were analyzed. Conventional radiographs were used to measure the Boehler's angle before and after surgical fixation. Computed tomography (CT) scans were analyzed to distinguish between joint depression and tongue-type calcaneal fractures. Each calcaneal fracture was additionally categorized according to the Sanders classification. The clinical outcome was measured using a 5-point Likert scale ranging from 0 (very unsatisfied) to 4 (very satisfied), the Visual Analog Scale (VAS) for pain, and the Maryland Foot Score.The Boehler's angle improved from 12.6 degrees preoperatively to 26.3 degrees postoperatively (P 0.001). Loss of sagittal reduction (i.e., a decline of the Boehler's angle of 5 degrees) from postoperative to the last follow-up was evident in nine (26%) fractures. Out of 29 patients with an available satisfaction score, 20 (69%) were very satisfied, 8 (28%) were satisfied, and one (3%) was moderately satisfied. Satisfaction at the last follow-up declined with higher age at surgery. An overall low complication rate was evident, with painful hardware needing removal being the most common complication.Approaching calcaneus fractures through the sinus tarsi provides satisfactory mid- to long-term radiographic and clinical outcomes, independent of the severity of the fractures according to the Sanders classification.Level IV, Retrospective Case Series.

Intra-articular calcaneal fracture is one of the most challenging fractures in orthopedic surgery. The main complications of intra-articular calcaneal fractures are postoperative wound complications, subtalar arthritis, malalignment and subtalar stiffness.Conversion of the operative technique from the classic L shaped incision to the mini-invasive sinus tarsi approach renders the wound complications as less as possible. Subtalar arthritis can be minimized by anatomical reduction of the posterior facet. Malalignment can be simply prevented by calcaneal tuberosity reduction and fixation by percutanouscannulated screws. Early subtalar range of motion without weight bearing can overcome the subtalar stiffness.In this study, we included 20 patients with unilateral intra-articular calcaneal fracture without ipsilateral lesions. The patients were treated by open reduction and internal fixation through sinus tarsi approach. The patients were divided in two groups. The first group A were treated by the mentioned above technique without operative supplementation of iliac bone graft. The second group B were treated by the same technique with supplementation of iliac bone graft.Significant improvement was observed in the two groups regarding pain, AOFAS score. No significant difference between the two groups apart from that the group B treated with supplementation of iliac bone graft had earlier bone consolidation and consequently earlier weight bearing which allow for rapid return to daily activities.

Background: Three-dimensional (3D) fluoroscopy is thought to be advantageous in the open reduction and internal fixation (ORIF) of calcaneal fractures. The goal of this multicenter randomized controlled trial was to investigate the clinical effect of additional intraoperative 3D fluoroscopy on postoperative quality of reduction and fixation and patient-reported outcome as compared to conventional 2-dimensional (2D) fluoroscopy in patients with intra-articular fractures of the calcaneus. Methods: Patients were randomized to 3D or conventional 2D fluoroscopy during operative treatment of calcaneal fractures. Primary outcome was the difference in quality of fracture reduction and implant position on postoperative computed tomography (CT). Secondary endpoints included intraoperative corrections (prior to wound closure), complications, and revision surgery (after wound closure). Function and patient-reported outcome were evaluated after surgery and included range of motion, Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short-Form 36 (SF-36) questionnaires, and Kellgren-Lawrence posttraumatic osteoarthritis classification. A total of 102 calcaneal fractures were included in the study in 100 patients. Fifty fractures were randomized to the 3D group and 52 to the 2D group. Results: There was a statistically significant difference in duration of surgery between the groups (2D 125 min vs 3D 147 min; P < .001). After 3D fluoroscopy, a total of 57 intraoperative corrections were performed in 28 patients (56%). The postoperative CT scan revealed an indication for additional revision of reduction or implant position in 69% of the 3D group vs 60% in the 2D fluoroscopy group. At 2 years, there was no difference in number of revision surgery, complications, FAOS, AOFAS score, SF-36 score, or posttraumatic osteoarthritis. Conclusion: The use of intraoperative 3D fluoroscopy in the treatment of intra-articular calcaneal fractures prolongs the operative procedures without improving the quality of reduction and fixation. There was no benefit of intraoperative 3D fluoroscopy with regard to postoperative complications, quality of life, functional outcome, or posttraumatic osteoarthritis. Level of Evidence: Level I, prospective randomized controlled study.

Varicose veins are permanently dilated tortuous and elongated path causing abnormal circulation. The varicose vein is the most common condition among females. The prevalence of varicose veins shows that females are more affected by it. In India, it is most common in females due to long-standing household work. Varicose veins are classified according to the long great saphenous vein varicosity, short/small saphenous vein varicosity, and varicose veins due to perforator incompetence. The calcaneal spur is also known as a heel spur and it occurs due to a bony outgrowth that is present in the heel bone. The heel spur is located at the back of the heel or under the sole. The spur occurring in the back of the heel is often associated with Achilles tendinopathy and the spur under the sole is associated with plantar fasciitis. A 55-year-old female with right-hand dominance came with complaints of pain in both the lower limb, pain in the neck region, and heel pain with these complaints patient was referred for physiotherapy after Ayurveda treatment. The patient presented with a history of osteoarthritis 5 years back, following which she started having pain in both the lower limb and heel. Patient were diagnosed with varicose vein and calcaneal spur with cervical radiculopathy. Therapeutic intervention for the patient comprised of patient education, thermotherapy, ultrasound, TENS, strengthening exercises, and range of motion exercises. The outcome of all this intervention showed improvement in function. Early physiotherapy intervention after diagnosis should be started to improve quality of life, activities of daily living, and prevent chronic disability.

Recommendation: There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. Level of Evidence: Level V, consensus, expert opinion.

Background: Open reduction and internal fixation is the standard surgical treatment of calcaneal fractures. However, it is associated with a high rate of wound problems. Objectives: In this study, we evaluated the clinical and radiologic outcomes, as well as the wound complication rates of sinus tarsi minimally-invasive approach in the treatment of intra-articular calcaneus fracture. Methods: In a retrospective study, 62 patients who were referred with an intra-articular calcaneus fracture and treated with a minimally-invasive sinus tarsi approach were included. The radiographic evaluations included the assessment of Bohler and Gissane angles before and after the surgery, as well as the height and length of the calcaneus. The clinical outcome was assessed with the American Orthopedic Foot and Ankle Society (AOFAS) questionnaire. Results: The Mean±SD age of the patients was 41.8±12.7 years. The Mean±SD follow-up of the patients was 21.3±10 ‎months. After 6 months, in 43 patients (69.3%) both Bohler’s and Gissane’s angles were significantly improved after the surgery (P=0.003 and P

Background: The calcaneal slide osteotomy is a common procedure used for the surgical correction of heel varus and valgus deformities. A variety of fixation methods exist including screws and plates. The literature shows a high rate of hardware prominence with screws leading to subsequent removal of hardware. Few studies have examined the use of plates for fixation of a calcaneal osteotomy. The purpose of this study was to assess outcomes following fixation of a calcaneal osteotomy with a calcaneal slide plate. Methods: This is a retrospective consecutive case series of all patients who underwent either a medial or lateral calcaneal slide osteotomy using the specialized calcaneal slide plate between September 2013 and December 2018 by a single surgeon. The primary outcome measures were the rate of hardware removal, healing of the calcaneal osteotomy, and any associated complications such as infection or incision healing delays. Patient baseline demographics and procedure-related data were recorded. The minimum follow-up was 4 months. A total of 81 procedures were performed using this calcaneal slide plate. Results: All of the patients had one or more additional procedures at the same time as the calcaneal osteotomy. All of the calcaneal osteotomies healed without displacement. Only 1 patient (1.2%) returned to the operating room and had removal of the calcaneal slide plate, which was after osteotomy union for an infected wound. There were no cases of hardware failure or removal due to it being symptomatic. Conclusion: A specialized calcaneal slide plate was an effective fixation device for both medial and lateral calcaneal slide osteotomies for a variety of foot and ankle conditions. The union rate was 100% and none of the patients had hardware symptoms, which is an improvement on published reports of symptomatic hardware after calcaneal slide osteotomy. Level of Evidence: Level IV, retrospective case series.

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multi-database literature search was performed on 14th December 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36 – 104 weeks). Surgical site infection occurred in 11.2% (95% CI 6.3% - 19%) of patients, implant failure occurred in 8.1% (95% CI 5% - 12.8%) of patients, and unplanned return to theatre occurred in 10.1% (95% CI 6.1% - 16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7% - 34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (81.5%) (95%CI: 67.4% - 90.4%) of patients were able to return to similar pre-operative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for non-operative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. 81.5% (95%CI: 67.4% - 90.4%) of patients were able to return to a similar pre-injury mobility status after tibio-talar-calcaneal nailing.

CASE A 25-year-old man presented with a closed calcaneal fracture after a 6-storey fall, complicated by osteomyelitis from fixation attempts necessitating near-complete debridement of his calcaneal tuberosity. He underwent a successful single-stage calcaneal and soft-tissue reconstruction using a femoral head structural allograft vascularized with an osteocutaneous medial femoral condyle flap. At the 18-month follow-up, his limb is largely pain-free and functional, allowing ambulation and his combined allograft-vascularized bone reconstruction shows radiographic evidence of incorporation. CONCLUSION Calcaneal tuberosity reconstruction with a femoral head structural allograft and vascularized bone flap is a viable option for calcaneal tuberosity bone loss because of injury/infection.

Calcaneal spur and plantar fasciitis are the most common causes of plantar heel pain. There are many effective physical modalities for treating this musculoskeletal disorder. So far, the are no clear recommendations confirming the clinical utility of high-intensity laser therapy (HILT) in the management of painful calcaneal spur with plantar fasciitis. This study aimed to evaluate the effectiveness of HILT in pain management in patients with calcaneal spur and plantar fasciitis. A group of 65 patients was assessed for eligibility based on the CONSORT guidelines. This study was prospectively registered in the Australian New Zealand Clinical Trial Registry platform (registration number ACTRN12618000744257, 3 May 2018). The main eligibility criteria were: cancer, pregnancy, electronic and metal implants, acute infections, impaired blood coagulation, cardiac arrhythmias, taking analgesic or anti-inflammatory medications, non-experience of heel pain, or presence of other painful foot conditions. Finally, 60 patients were randomly assigned into two groups: study group (n = 30, mean age 59.9 ± 10.1), treated with HILT (7 W, 149.9 J/cm2, 1064 nm, 4496 J, 12 min), and placebo-controlled group (n = 30, mean age 60.4 ± 11.9), treated with sham HILT therapy. Both groups received ultrasound treatments (0.8 W/cm2, 1 MHz frequency, 100% load factor, 5 min). Treatment procedures were performed once a day, five times per week for three weeks (total of 15 treatment sessions). Study outcomes focused on pain intensity and were assessed before (M1) and after (M2) the treatment as well as after 4 (M3) and 12 (M4) weeks using the Visual Analogue Scale (VAS) and the Laitinen Pain Scale (LPS). According to VAS, a statistically significant decrease in the study group was observed between M1 and M2 by 3.5 pts, M1 and M3 by 3.7 pts, and M1 and M4 by 3.2 pts (p &lt, 0.001). On the other hand, the control group showed a statistically significant decrease (p &lt, 0.001) between M1 and M2 by 3.0 pts, M1 and M3 by 3.4 pts, and M1 and M4 by 3.2 pts. According to LPS, a statistically significant decrease in the study group was observed between M1 and M2 by 3.9 pts, M1 and M3 by 4.2 pts, and M1 and M4 by 4.0 pts (p &lt, 0.001). On the other hand, the control group showed a statistically significant decrease between M1 and M2 by 3.2 pts (p = 0.002), M1 and M3 by 4.0 pts (p &lt, 0.001), and M1 and M4 by 3.9 pts (p &lt, 0.001). However, there were no statistically significant differences between the groups in VAS and LPS (p &gt, 0.05). In conclusion, the HILT does not appear to be more effective in pain management of patients with calcaneal spurs and plantar fasciitis than the conservative standard physiotherapeutic procedures.

The Achilles tendon acts by transmitting the force created by the contraction of the sural triceps to the calcaneus. This allows the elevation during the gait cycle. A sudden contraction in elderly patients may generate avulsion fracture of the posterior tubercle of the calcaneus due to poor bone quality or rupture of the tendon, with one of these two structures yielding in most cases. We report the case of a 72-year-old woman who suffered a low energy right heel trauma while stepping off the bus. She was diagnosed an avulsion fracture of the posterior tubercle of the calcaneus. When performing ORIF procedure of the fracture, an associated rupture of the Achilles tendon is diagnosed. Both pathologies are treated in the same surgical act. We recommend using a second imaging study along with the x-ray in order to anticipate associated injuries and adequate surgical planning in elderly patients.

The present study is assigned to throw the light on the benefit of using Kessler suture compared with polypropylene mesh implantation in healing of induced tenotomy of common calcaneal tendon in a rabbit model based on clinico-histopathological evaluation. Twenty adults New Zealand white male rabbits were used for this clinical prospective study divided equally and randomly into two groups. The first group, (suture group n=10) and the second group (mesh group n=10). Under the effect of general anesthesia, longitudinal skin incision over the common calcaneal tendon was made, and the skin flap was reflected. The tendon was isolated by blunt dissection from the surrounding tissue, with small curved forceps. Simulation of a rabbit’s common calcaneal tendon rupture was made by sharp transvers incision with scalpel. The first group repair with (Kessler Suture) using polypropylene suture size 4.0. In contrast, the second group repair with (polypropylene mesh implantation) after initial suturing of the cut ends of tendon by two simple interrupted stitches using polyglyconate suture size 4.0. The surgical skin wounds were re-stitched by simple interrupted pattern with 3-0 silk. After clinical follow-up of the treatment rabbits, certain secondary health problems were encountered represented by swelling of operative site and lameness. Grossly, adhesions were noticed between the tendon and subcutaneous tissue in rabbits of both groups. Microscopical examination reflected presence of inflammatory cells perivascular edema and few capillaries at two months. At the end of experiment there were perfect orientation and organization of collagen fibers in mesh group in comparing with suture group. Based on the results obtain from this study, it seemed that both groups reflected best outcome in healing of operated tendons with superiority of mesh group in comparing with suture group.

Management of unicondylar femoral fractures is mainly done by open reduction and internal fixation. Anatomic reduction in the articular surface is paramount in this type of lesion. Medial condyle fractures lack specific osteosynthesis material for fixation.We report a case resolved with the sparsely documented technique using calcaneal plate fixation.

Background Calcaneal apophysitis, or Sever's disease, is the most common cause of heel pain in childhood and adolescence. It is regarded as an overuse syndrome. Studies on the incidence of calcaneal apophysitis in young athletes and their associated return-to-play time are lacking in the current literature. The aim of our current study was to identify the incidence of calcaneal apophysitis in professional youth soccer, the associated time to return-to-play, predisposing factors and their impact on time to return-to-play. Methods Retrospective evaluation of injury data gathered from a German youth soccer academy in the years 2009–2018. In total, 4326 injury cases in 612 players were included in the study. The diagnosis and the follow-up visits were carried out in a weekly consultation hour at the youth academy. Results During the observation period of 10 years, 22 cases of calcaneal apophysitis were detected. The incidence of calcaneal apophysitis per 100 athletes per year was found to be 0.36. The mean age of the affected athletes at the time of diagnosis was 11.8 ± 2.1 years (MW ± SD). The complaints were unilateral in 20 and bilateral in two cases. Three of the 22 detected cases of calcaneal apophysitis (13.6%) were recurrent injuries. The mean time to return-to-play of the affected athletes was 60.7 ± 64.9 days (MW ± SD). Athletes with recurrent complaints showed longer recovery time and time to return-to-play when compared to players with primary diagnosed disease. Our results could show that neither age nor body mass index at the time of diagnosis had an impact on time to return-to-play. Conclusions This is the first study investigating the incidence of calcaneal apophysitis and the associated time to return-to-play in youth elite soccer. Calcaneal apophysitis results in substantial time loss for the athletes. Further prospective clinical studies are required to fully understand the etiology and risk factors for calcaneal apophysitis and therefore develop preventive strategies.

Background Three-dimensional (3D) printing technology has developed rapidly in orthopaedic surgery and effectively achieves precise and personalized surgery. The purpose of this meta-analysis was to assess the efficacy of 3D printing technology in the management of displaced intra-articular calcaneal fractures (DICFs) by extended lateral approach (ELA). Methods We searched PubMed, Web of Science, Embase, Cochrane Library, CNKI, VIP, and VANFUN databases were searched up to October 2020. All clinical studies comparing traditional surgery and 3D printing-assisted surgery in the management of DICFs were obtained, evaluating the quality of the included studies and extracting data. For each study, we assessed odds ratios (ORs), standard mean difference (SMD), and 95% confidence interval (95% CI) to assess and synthesize the outcomes. Results Three RCTs and nine retrospective studies involving 732 patients were included met our inclusion criteria with 366 patients in the 3D group and 366 patients in the conventional group. The meta-analysis showed that there were significant differences of the operative time in the 3D group [SMD = − 1.86, 95% CI (− 2.23, − 1.40), P P P P P Conclusion The current study indicates that 3D printing-assisted ELA surgery showed a better rate of excellent and good outcome, shorter operation time, less intraoperative blood loss, fewer intraoperative fluoroscopies, fewer complications. Besides, there is still a need for large-sample, high-quality, long-term randomized controlled trials to confirm the conclusion.

Background Plantar fasciitis due to calcaneal spur is a common cause of heel pain and functional disability, and its management presents a huge challenge for clinicians which results sometimes in unpleasant clinical outcomes. The efficacy of extracorporeal shock wave therapy (ESWT) as an alternative therapeutic option to surgical management after failure of conservative treatment has been addressed. Our aim was to evaluate the efficacy of ESWT in the treatment of plantar fasciitis in calcaneal spur patients using ultrasonography. Results The mean plantar fascia (PF) thickness was statistically significantly higher in the calcaneal spur patient group (5.66 ± 1.14 mm) than in the healthy control group (2.40 ± 0.35 mm), (P = 0.001). Significant PF thickness reduction, visual analog scale (VAS), and Roles and Maudsley score (RMS) improvement were observed (P < 0.001) after 4 sessions of ESWT. Conclusion PF thickness increases significantly in calcaneal spur patients and responds to treatment. ESWT decreases the thickness of the PF and improves pain and function significantly.

Avulsion fractures of the calcaneal tuberosity, although relatively uncommon, occur more frequently in patients with osteoporosis and in the elderly. The results of closed manipulation are poor in these fractures, usually requiring open reduction and internal fixation. However, it is difficult to fix the bone fragment rigidly, because the avulsed bone fragment is small and thin, and the bone quality of the calcaneal body in the elderly is poor. Hence, it is necessary to limit prolonged weight-bearing after the operation. We performed an innovative surgical procedure of suture fixation to the anchor screw in four cases, following which earlier postoperative rehabilitation with full weight-bearing walking and range of motion exercises was possible, and bony union was achieved without repeated displacement of the fragment in all patients. We believe this technique would prove useful in surgical management of calcaneal tuberosity avulsion fractures.