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Background: Melioidosis is an emerging infectious disease caused by the Gram-negative bacterium Burkholderia pseudomallei, which can lead to a range of clinical manifestations including acute septicaemia and chronic localized infections. Osteomyelitis is an uncommon but well-recognized complication of melioidosis, with the calcaneus being a relatively rare site of involvement. Case Description: The authors present a case series of three patients with calcaneal osteomyelitis caused by Burkholderia pseudomallei, infection. All three patients presented with non-specific symptoms like fever and weight loss, followed by localized ankle/foot pain and swelling. Diagnosis was made based on imaging findings (radiographs and MRI) and isolation of Burkholderia pseudomallei, from blood or pus cultures. Treatment involved a combination of initial intravenous antibiotic therapy (meropenem or ceftazidime) for 4-6 weeks, followed by oral trimethoprimsulfamethoxazole for 6 months. One patient required surgical drainage of a plantar abscess. All patients had a favorable clinical outcome with a resolution of osteomyelitis on follow-up imaging. Conclusion: Calcaneal osteomyelitis is a rare but potentially serious complication of melioidosis. Early recognition and prompt initiation of appropriate antibiotic therapy are crucial for favorable outcomes. Clinicians should maintain a high index of suspicion for osteomyelitis in patients with melioidosis, especially in patients from Endemic areas as well as in patients with risk factors like diabetes. Close follow-up and monitoring for potential relapse or reactivation are essential, particularly in immunocompromised individuals. [ABSTRACT FROM AUTHOR]

Background: Posterior tibial tendon (PTT) tendoscopy and medializing calcaneal osteotomy (MCO) are among the available techniques for patients presenting with symptomatic flexible hindfoot valgus (stage IA) progressive collapsing foot deformity (PCFD). The aim of this study was to determine clinical and radiographic outcomes of combined PTT tendoscopy and MCO for patients presenting with symptomatic stage IA PCFD. Methods: A retrospective cohort study was performed in order to determine clinical and radiographic outcomes of 30 combined PTT tendoscopies and MCO on 27 patients presenting with symptomatic stage IA PCFD, with a minimum follow-up of 24 months. Patient satisfaction was assessed at last available follow-up as very satisfied, satisfied, and unsatisfied. Clinical assessment was performed evaluating preoperative and last available follow-up visual analog scale for pain (VAS-P), Foot and Ankle Outcome Score (FAOS), and the 36-Item Short Form Health Survey (SF-36). Magnetic resonance imaging (MRI) was performed preoperatively on all patients. Standard weightbearing anteroposterior, lateral, and long axial view radiographs of the foot and ankle were taken preoperatively, immediate postoperatively, at 6 weeks, 3 months, 6 months, 1 year postoperatively, and last follow-up evaluation available for each patient. Results: The mean follow-up was 38.6 (range, 26-62) months. We registered 27 very satisfied, 1 satisfied, and 2 unsatisfied patients. There was statistically significant improvement on all clinical scores (VAS-P, FAOS and SF-36), as well as on lateral talo–first metatarsal and hindfoot alignment angles. We found low-grade PTT tears in 5 patients (16.67%) in whom preoperative MRI documented PTT tenosynovitis alone. Conclusion: We found that combined PTT tendoscopy and MCO provide significant clinical and radiographic improvement for patients presenting with symptomatic stage IAB PCFD. PTT tendoscopy should be considered in the treatment of all surgically addressed flexible valgus feet as it detects tendon tears which are frequently missed on an MRI. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Background: Calcaneal tuberosity avulsion fractures are challenging to treat because of the poor bone stock and high risk of fixation failure secondary to the strong Achilles tendon pull. The purpose of this study is to compare the tensile force to failure of 2 different types of screw fixation construct in a cadaveric model of calcaneal tuberosity avulsion fracture. Methods: An oblique osteotomy was created in the calcanei of 7 matched pairs of cadaveric specimens to simulate a tuberosity avulsion fracture and one specimen from each pair randomized into one of the 2 groups for comparison. Two cancellous screws were inserted perpendicular to the fracture line at the posteromedial and posterolateral corners of the avulsed fragment for the 2-screw construct. For the second group, an additional stab incision was made at the midline of the Achilles insertional region for a screw placed between the initial 2 screws with a trajectory toward the calcaneocuboid joint in the 3-screw construct. These specimens were then mounted and loaded to failure. Results: The mean force to a predefined failure at 3.0-mm gap for the 3-screw construct was 468.7 ± 267.9 N vs 278.9 ± 164.0 N for the 2-screw construct (P <.001). The addition of a central nonparallel screw in the 3-screw construct significantly increased the force required for fracture gap displacement at all cut-off points (1.0-8.0 mm) when compared to the 2-screw construct (P <.001). Notably, the mean peak tensile force for the 3-screw construct was 499.4 ± 255.4 N occurred at the gap displacement of 4.1 mm for the 3-screw construct whereas the mean peak tensile force for the 2-screw construct was 315.9 ± 162.4 N displacing the gap at 4.3 mm. Conclusion: This study showed that an additional central nonparallel screw in the 3-screw construct provided significant mechanical superiority compared to a 2-screw construct. Clinical Relevance: The present study supported the use of augmented fixation with an additional central off-axis screw to reduce risk of fixation failure in calcaneal tuberosity avulsion fractures. [ABSTRACT FROM AUTHOR]

Abstract 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

Background: We compared the effectiveness of the extensile lateral approach (ELA) and modified sinus tarsi approach (MSTA) with a variable-angle locking anterolateral plate in treating Sanders type II and III calcaneal fractures.Methods: We reviewed 45 DIACFs treated by a single surgeon from 2017 to 2020. Open reduction using ELA and MSTA was performed in 25 and 20 patients, respectively. Follow-up evaluations included radiological assessments and clinical evaluations.Results: Pre- and postoperative radiologic parameters for the calcaneus were significantly different. The average American Orthopaedic Foot and Ankle Society scores were 81.24 and 85.00, the mean visual analogue scale scores were 2.28 and 1.65, and the wound-related complication rates were 64.0% and 15.0% in the ELA and MSTA groups, respectively. Bony union was achieved in all cases.Conclusions: For Sanders type II and III fractures, MSTA seems to be a safer and more satisfactory method, with fewer postoperative complications. [ABSTRACT FROM AUTHOR]

Background: The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods: Twenty-eight patients (mean age 54.6 years, range 20-94) with Cierny-Mader stage IIIB chronic calcaneal osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results: All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion: Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities. [ABSTRACT FROM AUTHOR]

Background: Calcaneal fractures are not uncommon, accounting for 2% and 60.0% of all adult and tarsal fractures, respectively. Its treatment is still controversial. Aim of the work: To assess results and complications of calcaneal fractures treatment by fixation with calcaneal plate on clinical and radiological basis. Patients and Methods: A convenient sample of 20 patients, with calcaneal fractures and treated by calcaneal plate fixation were included. They were assessed in preoperative period in a systematic manner. Then, treated with a locking plate. Postoperatively, immediate X-rays, examination of the neurovascular status had been done. Anti-edematous, pain therapy, intravenous antibiotics and anticoagulation medication were administered. All patients had been followed up at 8, 16 weeks after operation and assessed for functional and anatomical state. RESULTS: According to the American Orthopedic Foot Ankle Society [AOFAS] Ankle-Hindfoot Score, the outcome was excellent [30.0%], good [40.0%], fair [20.0%] and poor [10.0%]. At the last follow‑up, Bohler’s angle was restored to normal [20°-40°] in 17 feet [85 %] while 3 feet [15 %] was less than normal. Wound infection was seen in [10%], each of varus heel deformity and flexion deformity of big toe was found in one patient [5.0%] and two case had reflex sympathetic dystrophy.Finally, there was no association between fracture type and subtalar arthritis. However, patients with subtalar arthritis had significantly lower AOFAS score when compared to patients with no subtalar arthritis [76.22±6.24 vs 87.0±6.05 respectively, p < 0.001]. Conclusion: Displaced calcaneal fractures treated surgically are associated with a relatively better functional outcome, provided that, Bohler's angle was restored to its normal or near normal values.

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 < 0.001], intraoperative blood loss [SMD = − 1.26, 95% CI (− 1.82, − 0.69), P < 0.001], the number of intraoperative X-ray exposures [SMD = − 0.66, 95% CI (− 1.20, − 0.12), P < 0.001], postoperative complications [OR = 0.49, 95% CI (0.31, 0.79), P < 0.001], excellent and good rate of calcaneal fracture outcome [OR = 4.09, 95% CI (2.03, 8.22), P < 0.001]. 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. [ABSTRACT FROM AUTHOR]

Despite the advances in operative management, displaced intra-articular calcaneal fractures (DIAFCs) are often associated with long term sequelae, permanent disability, a considerable reduction in quality of life, and a high socio-economic cost. Randomized controlled trials have shown that patient reported outcomes of surgery are no better than those of nonoperative management. Methodological flaws and selection bias may have influenced the results, however, and subgroup analysis showed that some patients could benefit from surgery, whilst patients' preference can be the decisive factor in choosing a management modality. Fractures with significant lateral wall displacement predisposing to impingements often require surgery, and management has to be individualized and tailored to the patient. Surgery does not usually achieve excellent results, though it exposes the patient to potential risks and complications. Wound healing problems and infections affect around 20% of patients when the extensile lateral approach has been used. Sinus tarsi approach and minimally invasive surgery may be viable alternatives, offering similar results with fewer wound complications, but most of the available studies are of low to moderate quality. Late subtalar joint arthrodesis is often required: however, such procedure would be less technically difficult and could result in better foot function should the shape of the calcaneus have been anatomically restored with surgery in the acute phase. [ABSTRACT FROM AUTHOR]

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.

Summary: Sepsis of the calcaneal bursae (CB) presents significant treatment challenges with limited clinical data available in the literature. The objective of this retrospective cohort study was to assess the clinical outcomes associated with CB lavage using either a through‐and‐through needle or bursoscopic technique. Clinical records of 29 horses treated for septic calcaneal bursitis using either technique between 2005 and 2019 were reviewed. Fisher's exact test was used to assess statistical significance between first surgical technique and success at first surgery (i.e. not requiring >1 lavage), survival to discharge and return to work (RTW). Bursoscopy was performed in 13/29 (44.8%) cases, and needle lavage in 16/29 (55.2%). In the needle group, 12 (75%) horses were discharged following the first surgery. Four had repeat interventions; two (12.5%) had needle lavage and two (12.5%) had bursoscopy. Of the two horses to have repeat needle lavage, one was subjected to euthanasia and one discharged, and of the two that underwent bursoscopy, one was discharged and one received a third bursoscopy prior to discharge. In the bursoscopy group, seven (53.8%) were discharged and three (23.1%) were subjected to euthanasia following the first surgery. Three (23.1%) received a second bursoscopic lavage with one discharged, one subjected to euthanasia and one having a third bursoscopic lavage prior to discharge. Overall, 18/24 (75%) followed up cases RTW, 10 (55.5%) from the needle group, eight (44.4%) the bursoscopy group. No statistically significant differences between first surgical technique used and success at first surgery (no subsequent lavage(s) required), survival to discharge or return to work were detected. The main limitations of this study are that it is a retrospective study, has a small population with limited statistical power and potential selection bias. No statistically significant differences existed between the outcomes of the two techniques, contrary to the belief that bursoscopic lavage is superior. Larger, multicentred studies, with greater statistical power are required to further assess this relationship. [ABSTRACT FROM AUTHOR]

Management of intra-articular calcaneal fractures remains a debated topic in orthopedics, 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 postoperative fracture geometry with computed tomography used for preoperative 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 (53 patients; 5 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; 2 superficial (3.7%), 3 deep (5.6%); 4 of whom were smokers. Smokers were statistically more likely to have wound infections than nonsmokers (p =.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 postoperative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management. [ABSTRACT FROM AUTHOR]

In calcaneal fractures, Böhler's and Gissane's angles are considered important parameters to guide treatment strategy and provide prognostic information during follow-up visits. Therefore, lateral radiographs have to be accurate. The aim of this study was to evaluate the effect of craniocaudal and posteroanterior angular variations (i.e., simulate lower leg malposition) from the true lateral radiograph on Böhler's and Gissane's angles. In this radioanatomical study, 15 embalmed, skeletally mature, human anatomic lower limb specimens were used. Using predefined criteria, a true lateral radiograph (i.e., 0° angular variation) was obtained. Angular variations from this true lateral radiograph were made from –30° to +30° deviation in the craniocaudal and posteroanterior direction at 5° intervals. Böhler's and Gissane angles were independently assessed by 2 experienced trauma surgeons. Böhler's angle decreased with increasing caudal angular variations (maximum –4.3° deviation at –30°). With increasing of the posterior angular variations, Böhler's angle increased (maximum 5.0° deviation at +30°) from the true lateral radiograph, but all deviations were within the measurement error. The deviation of the angle of Gissane was most pronounced in the cranial direction, with the mean angle decreasing by –8.8° at +30° angular variation. Varying angular obliquity in the caudal and posteroanterior direction hardly affected Gissane's angle. Foot malpositioning during the making of a lateral radiograph has little influence on Böhler's and Gissane's angles. If used for clinical decision-making in initial treatment and during follow-up of calcaneal fractures, these parameters can reliably be obtained from any lateral radiograph. [ABSTRACT FROM AUTHOR]

Intra-articular calcaneal fractures represent an ongoing challenge for the orthopedic community, with the benefits of the previous "gold standard" treatment of open reduction and internal fixation having been called into question in several large randomized controlled trials. Fine wire circular fixation may represent a useful alternative treatment for these injuries, combining minimally invasive application with rigid fixation, which allows the possibility of early weight bearing We performed a systematic review of published studies that used circular fixation for calcaneal fractures and recorded functional outcomes at follow-up. In a total of 11 studies with 255 calcaneal fractures for which there was follow-up, our inclusion criteria were met: 8.2% of fractures were bilateral, 11.9% of fractures were open fractures, and 12.6% of patients had multiple orthopedic injuries. Functional outcomes were assessed with the use of a variety of tools across the different studies, but outcomes compared favorably with those seen with open reduction and internal fixation. Although pin site infections were common (22.6%), serious complications, including deep infection (0.8%), wound infection (1.6%), and complex regional pain syndrome (0.8%), were exceedingly rare. The results suggest that this is a viable alternative treatment for calcaneal fractures, but higher-quality randomized controlled trials are required before the technique can enter mainstream use. [ABSTRACT FROM AUTHOR]

Purpose There are multiple skeletal maturity grading systems, but none of them utilizes the phalanges of the foot. To minimize radiation, it would be ideal if one could assess the skeletal maturity of a foot based on bones seen on routine foot radiographs, if guided growth is being considered as a treatment option. We developed a system that correlates changes of the appearance of the foot phalanges to peak height velocity (PHV) and the recently described calcaneal apophyseal ossification grading system. Methods We selected 94 children from the Bolton-Brush study, each with consecutive radiographs from age ten to 15 years old. Using the anteroposterior view, we analyzed the ossification patterns of the phalanges and developed a sixstage system. We then determined the PHV for each subject and defined its relationship with our system. Our system was then compared with the previously established calcaneal system. Results We calculated an Intraclass correlation coefficient (ICC) range of 0.957 to 0.985 with a mean of 0.975 and interclass reliability coefficient of 0.993 indicating that this method is reliable and consistent. Our system showed no significant difference between gender with respect to PHV, which makes it a reliable surrogate for determining bone age in paediatric and adolescent patients. Conclusions Our system has a strong association with the calcaneal system. It is a simple six-stage system that is reliable and correlated more strongly with PHV than chronological age. The system requires knowledge of the ossification markers used for each stage but is easily used in a clinical setting. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to compare the postoperative pain levels in patients undergoing osteosynthesis of the calcaneus with either a popliteal nerve block or an ankle block. Methods: A retrospective analysis of all consecutive patients undergoing operative fixation of a calcaneal fracture via a sinus tarsi approach between August 2012 and April 2017 in a single foot/ankle specialized center was performed. Single-shot popliteal blocks were placed using ultrasound guidance by an anesthesiologist while ankle blocks were placed by a foot/ankle specialized surgeon. Pain levels were measured through the numerical rating scale (NRS). In total, 83 patients were included in this study; 33 received a popliteal block, and 50 received an ankle block. No statistically significant differences were present in baseline characteristics between the 2 groups. Results: Comparable postoperative pain levels were observed in both groups. There was no statistically significant difference in amount of morphine used between the 2 groups. Conclusion: No differences were found in postoperative pain levels between patients receiving a single-shot popliteal block and patients who received a single-shot ankle block following calcaneal fracture surgery. Level of Evidence: III, comparative series. [ABSTRACT FROM AUTHOR]

Background: Calcaneal fractures are uncommon and have a substantial impact on hindfoot function and quality of life. Several surgical treatment options are available; both in surgical approach and type of operation. The aim of this study was to compare functional outcome and quality of life following ORIF and primary arthrodesis. Furthermore, predictors of worse functional outcome were explored.Methods: A retrospective cross-sectional cohort study was performed in patients with surgical fixation of a calcaneal fracture with a minimum follow-up of 18 months. Patients received ORIF through the 1) Extended Lateral Approach (ELA), 2) Sinus Tarsi Approach (STA) or 3) primary arthrodesis via STA. Participants were presented a questionnaire containing demographics, the AOFAS hindfoot scale, Foot Function Index, SF-36, EQ-5D and patient satisfaction.Results: In total 95 patients participated in this study. The three groups were comparable regarding patient characteristics. A median score of 74.5 points on the AOFAS hindfoot scale and 11.9 on the FFI was found for the entire group. There were no statistically significant differences between patients with ORIF of primary arthrodesis. Patients scored a median of 49.0 on the Physical Component Scale of the SF-36 and 55.4 on the Mental Component Scale. On the EQ-5D patients scored a median of 0.8 points. Again no statistically significant differences were observed between the three subgroups. Socio-economic status was the only statistically significant predictor of worse functional outcome (β: 4.06, 95% CI: 0.50-7.62) after multivariable analysis.Interpretation: Good midterm outcomes following in terms of functional outcome and in quality of life are observed. We observed no statistical significant difference in functional outcome between patients with ORIF and patients with primary arthrodesis. The only predictor of worse functional outcome is a lower socio-economic status. [ABSTRACT FROM AUTHOR]

Unlabelled: Subtalar joint distraction arthrodesis has been well reported with use of structural iliac crest or local autologous bone graft for malunited calcaneal fractures. Early reports for structural allograft did not yield good, consistent results, leading to a subsequent lack of recommendation in previous literature. Newer studies have had promising results utilizing femoral allograft as an alternative to autogenous bone graft. We performed a retrospective chart review on 10 patients (12 feet) undergoing subtalar joint distraction arthrodesis with femoral neck allograft for malunited calcaneal fractures. The primary aim of this study was to report on successful union rates and, in addition, outline any consistent complications. Twelve of the 12 procedures (100%) yielded successful fusion with a mean final follow-up of 7.7 months (range = 2.2-35.1 months). The mean increase in talocalcaneal height was 4 mm (range = 2-6 mm). The overall complication rate was 16.6%, including one superficial wound complication that healed uneventfully and one hardware removal. In conclusion, the current study reports a 100% successful fusion rate with interpositional structural femoral neck allograft in treatment for malunited calcaneal fractures.Levels Of Evidence: Therapeutic, Level IV: Case series. [ABSTRACT FROM AUTHOR]

Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, smoking and co-morbidities such as diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Careful attention to neurovascular status and the soft tissue envelope of the foot and ankle is essential to the management of these injuries especially where crush injuries have occurred. Open fractures should be treated urgently with a combined approach with the plastic surgeons. A good understanding of surgical anatomy is key to managing these fractures. Good intra-articular involvement and ligamentous stability are crucial in predicting long-term prognosis. The core principles of management are: to maintain the soft tissue envelope (minimize disruption); to obtain appropriate alignment; restoration of joint surfaces; and rehabilitation to obtain optimum function. [ABSTRACT FROM AUTHOR]

Subtalar hyperpronation and ankle dorsiflexion restriction have been theoretically associated with Achilles tendinopathy (AT). However, evidence to support these associations is lacking. To compare foot alignment and ankle dorsiflexion range of motion (ROM) between the symptomatic and non-symptomatic limbs of individuals with unilateral AT. And to verify whether differences exist between individuals with symptomatic pronated feet and individuals with symptomatic neutral/supinated feet in terms of tendon pain, structure, and symptom severity. Sixty-three participants with unilateral AT underwent a bilateral evaluation of pain during tendon palpation, symptom severity, tendon thickening, tendon neovascularization, ankle dorsiflexion ROM, and foot posture alignment [foot posture index (FPI), navicular drop, navicular drift, and longitudinal arch angle (LAA)]. Side and group comparisons were made using t-tests and correlations were evaluated using the Pearson test. There were no differences between the symptomatic and non-symptomatic limbs regarding foot posture alignment. Specifically, non-significant negligible differences were observed between limbs regarding FPI [mean difference (MD)=-0.23; 95% confidence interval (CI)=-0.70, 0.25), navicular drop (MD=0.58 mm; 95%CI=-0.25, 1.43), navicular drift (MD=0.16 mm; 95%CI=-0.77, 1.09), and LAA (MD=0.30º; 95%CI=-1.74, 2.34). There was no difference between limbs regarding ankle dorsiflexion ROM. However, lower ankle dorsiflexion was associated with worse symptom severity (r = 0.223). Finally, no difference was observed between individuals with symptomatic pronated feet and individuals with symptomatic neutral/supinated feet in terms of tendon pain or structure. Static foot alignment measures do not seem to be clinically relevant in patients with AT. Smaller ankle dorsiflexion ROM, however, was associated with greater symptom severity in this population. • Individuals with Achilles tendinopathy (AT) and symptomatic pronated feet did not differ from individuals with AT and symptomatic neutral/supinated feet in terms of tendon pain, structure, or symptom severity. • The symptomatic and non-symptomatic limbs of individuals with unilateral AT had no differences in terms of foot alignment, evaluated by static measures. • Pronated foot posture was not more prevalent in individuals with AT when compared to neutral/supinated foot postures. • Smaller ankle dorsiflexion range of motion was associated with greater symptom severity and may be relevant for this population. • Static foot alignment measures do not seem to be clinically relevant in patients with AT. [ABSTRACT FROM AUTHOR]

Introduction: The diagnosis of calcaneal osteomyelitis is a challenge, and diagnostic delays have been reported in the literature. The progression is often indolent, laboratory results commonly fail to reveal an underlying infectious process and radiographs changes are seen after 7 days. We discuss the literature on the diagnosis and treatment of calcaneal osteomyelitis which can result in long-term sequelae in the pediatric patient. Case presentation: A 9-year-old white boy presented to our institution with heel pain and an inability to weight bear. There was a 10-day delay in diagnosis of calcaneal osteomyelitis, with a total of three presentations to our emergency department. The condition was misdiagnosed as Sever's disease on two separate occasions with discharge home. On his third presentation the diagnosis was finally clinched when he developed more definitive signs and symptoms, with pyrexia and signs of lymphangitis. Magnetic resonance imaging revealed diffuse osteomyelitis of his calcaneum. He underwent surgery and 2 weeks of antibiotics administered intravenously, followed by 4 weeks of oral therapy. We are happy to report a good recovery without any complications at his 12-month follow up. Conclusions: Physicians should include calcaneal osteomyelitis as a differential in any child presenting with heel pain. Delays in the diagnosis can result in disastrous complications in the pediatric patient, such as growth arrest. [ABSTRACT FROM AUTHOR]

Lateral column lengthening osteotomy is very useful surgical technique in treating stage II of pes planovalgus deformity of the foot. Either autograft from the iliac crest or allograft can be used for this purpose. In our technique we describe a novel method of obtaining bone graft locally from the calcaneus and therefore avoiding complications and morbidity associated with iliac crest graft. [ABSTRACT FROM AUTHOR]

The article focuses on a study that compares the radiographic and clinical outcome of nonlocking and locking plates in the treatment of intraarticular calcaneal fractures. Topics discussed include the wide use of open reduction and internal fixation (ORIF) for the treatment of such fractures, the lateral position of the patients during the operation while under general or spinal anesthesia and the preoperative and postoperative radiographic assessments.

Background: Plantar fasciopathy is the most common cause of acquired sub-calcaneal heel pain in adults. To-date, research of this condition has mainly focused on management rather than causal mechanisms. The aetiology of plantar fasciopathy is likely to be multifactorial, as both intrinsic and extrinsic risk factors have been reported. The purpose of this review is to critically reevaluate risk factors for plantar fasciopathy. Methods: A detailed literature review was undertaken using English language medical databases. Results: No clear consensus exists as to the relative strength of the risk factors reported. Conclusions: To-date numerous studies have examined various intrinsic and extrinsic risk factors implicated in the aetiology of plantar fasciopathy. How these factors interact may provide useful data to establish an individuals' risk profile for plantar fasciopathy and their potential for response to treatment. Further research is indicated to rank the relative significance of these risk factors. [ABSTRACT FROM AUTHOR]

Background: Calcaneal osteomyelitis is difficult to manage and requires a multidisciplinary approach. The aim of this study was to describe the characteristics and outcomes of calcaneal osteomyelitis, and to determine prognostic factors. Methods: This was an observational and retrospective study including all patients presenting with calcaneal osteomyelitis referred to a tertiary referral centre between January 2005 and December 2010. Results: Forty-two patients (mean age 50.7 y, range 22-89 y) were included. Fifteen were female. The mean duration of follow-up was 20 months (range 12-48 months). Twenty-six (62%) were post-traumatic osteomyelitis and 16 (38%) were secondary to neurological damage (sensitivity or motor impairment). All patients underwent surgical management with bone curettage and appropriate antibiotic therapy. Staphylococcus aureus was the most commonly isolated bacterium and was found in 29 patients. Polymicrobial samples were observed in 29 patients. Pseudomonas aeruginosa was associated with calcaneal osteomyelitis secondary to neurological damage ( n = 7; 44% p = 0.045). Twenty-eight patients (66.7%) healed without the need to resort to amputation. The mean time to healing was 29 weeks with a range of 4-144 weeks. Relapse of bone infection occurred in 17 patients (40.5%). Seven patients (16.7%) required amputations. Favourable prognostic factors for healing without amputation were an American Society of Anesthesiologists (ASA) score < 2 ( p < 10−4), post-traumatic calcaneal osteomyelitis ( p = 0.001), age < 65 y ( p = 0.02), absence of neuropathy ( p = 0.005), and absence of diabetes mellitus ( p = 0.02). Conclusions: Calcaneal osteomyelitis is characterized by frequent relapse with delayed wound healing. Clinicians should take into account the impact of older age, as well as co-morbidities such as diabetes mellitus or the presence of neuropathy, during the routine management of patients with this difficult-to-treat bone infection. [ABSTRACT FROM AUTHOR]

Abstract: Background and aim: Open reduction and internal fixation (ORIF) of intra-articular calcaneal fractures through an extended lateral approach is frequently accompanied by a high complication rate. However, ORIF currently provides the best long-term clinical results. The aim of this study was twofold: (1) to evaluate both mid- to long-term clinical and radiological results of a consecutive series treated by ORIF and (2) to determine the influence of short-term complications on long-term clinical outcome. Methods: Patients with a displaced intra-articular calcaneal fracture, treated with ORIF, through an extended lateral approach, in a level-2 trauma centre between 1995 and 2008 were evaluated for the study. The long-term functional outcome (American Orthopaedic Foot & Ankle Society (AOFAS), 36-Item Short-Form Health Survey (SF-36) and Visual Analogue Scale (VAS)) and radiographic results (e.g., Böhler and Gissane angle, height, width and joint reduction) were determined. Short- and long-term complications were documented. Results: A total of 57 patients matched the inclusion criteria, from which 39 patients agreed to participate in this study (68%). The median follow-up was 6.5 years (range 2–16 years). Based on the AOFAS hindfoot score, 74% of the patients had a good-to-excellent long-term clinical result. Radiological results were satisfying with a median postoperative Böhler angle of 26° and 25° at follow-up. Complications occurred in 32% of all patients; mainly wound-healing problems were noted. Short-term complications did not influence mid- to long-term clinical results (p >0.05). Anatomic reconstruction of the calcaneus was associated with improved long-term clinical results (p <0.05). Conclusion: Despite the high complication rate following ORIF of a calcaneal fracture, complications do not affect mid- to long-term clinical outcome. Surgical treatment should focus on restoring the anatomy. Level of evidence: Therapeutic level IV. [Copyright &y& Elsevier]

Abstract: Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, smoking and co-morbidities such as diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Careful attention to neurovascular status and the soft tissue envelope of the foot and ankle is essential to the management of these injuries especially where crush injuries have occurred. Open fractures should be treated urgently with a combined approach with the plastic surgeons. A good understanding of surgical anatomy is key to managing these fractures. Good intra-articular involvement and ligamentous stability are crucial in predicting long-term prognosis. The core principles of management are: to maintain the soft tissue envelope (minimize disruption); to obtain appropriate alignment; restoration of joint surfaces; and rehabilitation to obtain optimum function. [Copyright &y& Elsevier]

B-mode ultrasound is an established imaging modality for evaluating canine tendon injury. However, full extent of tendon injury often remains difficult to estimate, as small changes in sonographic appearance are associated with large changes in biomechanical strength. The acoustoelastic strain gauge ( ASG) is an ultrasound-based tissue evaluation technique that relates the change in echo intensity observed during relaxation or stretching of tendons to the tissue's mechanical properties. This technique deduces stiffness gradient (the rate of change of normalized stiffness as a function of tissue strain) by analyzing the ultrasound dynamic images captured from gradually deforming tissue. ASG has been proven to accurately model strain and stiffness within tendons in vitro. To determine the feasibility and repeatability for in vivo ASG measurements of canine tendon function, stiffness gradients for the gastrocnemius tendons of 10 clinically normal dogs were recorded by two nonindependent observers at three sites (musculotendinous junction, mid tendon, and insertion). Average stiffness gradient indices (0.0132, 0.0141, 0.0136) and dispersion values (0.0053, 0.0054, 0.0057) for each site, respectively, were consistent with published mechanical properties for normal canine tendon. Mean differences of the average stiffness gradient index and dispersion value between observers and between limbs for each site were less than 16%. Using interclass coefficients ( ICC), intra-observer ( ICC 0.79-0.98) and interobserver ( ICC 0.77-0.95) reproducibility was good to excellent. Right and left limb values were symmetric ( ICC 0.74-0.92). Findings from this study indicated that ASG is a feasible and repeatable technique for measuring stiffness gradients in canine tendons. [ABSTRACT FROM AUTHOR]

Chronic osteomyelitis associated with soft-tissue defect following surgical management is a severe complication for orthopaedic surgeons. Traditionally, the treatment protocol for the notorious complication involved thorough debridement, bone grafting, long-term antibiotic use and flap surgery. Alternatively, platelet-rich plasma (PRP), a high concentration of platelets collected via centrifugation, has been successfully used as an adjuvant treatment for bone and soft-tissue infection in medical practices. PRP has numerous significant advantages, including stypsis, inflammation remission and reducing the amount of infected fluid. It increases bone and soft-tissue healing and allows fewer opportunities for transplant rejection. Through many years of studies showing the advantages of PRP, it has become preferred organic product for the clinical treatment of infections, especially for chronic osteomyelitis associated with soft-tissue defect. To promote the clinical use of this simple and efficacious technique in trauma, we report the case of a patient with chronic calcaneal osteomyelitis associated with soft-tissue defect that healed uneventfully with PRP. [ABSTRACT FROM AUTHOR]

The article reports on the results of research which was conducted to evaluate the short term results of total ankle arthroplasty (TAA) with combined bony reconstructions for treatment of end-stage ankle osteoarthritis with accompanying cavovarus/hindfoot varus deformities. Researchers evaluated eight patients. They found that it was occasionally necessary to perform combined calcaneal and metatarsal osteotomies with TAA to successfully treat osteoarthritis with deformity.

Abstract: Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Open fractures should be treated urgently with a combined approach with the plastic surgeons. Temporary external fixation may be required to stabilize the fracture before definitive fixation and subsequent soft tissue cover. Foot elevation is essential to reduce swelling after major fractures or crush injuries. Compartment syndrome should be considered in anyone with disproportionate pain. Mild forms of compartment syndrome are easily missed and can result in clawing of the toes. Patients suffering fractures to the foot and ankle also require deep vein thrombosis prophylaxis whilst in plaster or until mobile. [ABSTRACT FROM AUTHOR]

Introduction: The optimal management of calcaneal fractures is controversial, as correlation between anatomical restoration and outcome has not been proven, and complications after surgery are frequent. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Ipsilateral talar and calcaneal fractures represent a rare combination injury that has only recently been reported in the literature with small case series. Objective: To identify the commonly observed fracture patterns, complications, and outcomes of a consecutive series of patients with ipsilateral talar and calcaneal fractures. Methods: Forty-five cases of ipsilateral talus and calcanal fractures were identified from an orthopaedic trauma registry at a University-based, level I trauma center for retrospective review. Main outcome measurements: Post-operative complications, the need for secondary surgery, and the visual analogus pain score. Results: Five patients were treated with an early below knee amputation (BKA). Five patients were treated with a primary subtalar arthrodesis. Twenty-eight of the 35 patients who did not undergo early BKA or primary subtalar arthrodesis developed subtalar arthritis. Five patients had deep wound complications. Four patients had talar body collapse from avascular necrosis. There were 13 open fractures of which 8 resulted in an eventual BKA. The mean visual analogus pain score for the patient population was 4.0. Conclusion: The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. Subtalar arthritis was a common finding regardless of treatment. Open fractures frequently resulted in a below knee amputation. [Copyright &y& Elsevier]

Abstract: Background: The purpose of the report was to present a 45-year-old lady who had a chronic osteomyelitis right calcaneum with a large non-healing ulcer and discharging sinus, treated by split-heel incision of Gaenslen. Objectives: Patients who have a recurrent ulcer of the heel often have a below-the-knee amputation because durable soft tissue coverage cannot be obtained over the calcaneus. Often, even if the ulcer heals satisfactorily or the area appears to be revascularized as a result of a peripheral vascular procedure, the resulting surface is not durable and the ulcer recurs. Gaenslen''s technique is recommended for refractory cases or patients with a draining sinus centrally located on the plantar aspect of the heel. An excellent functional result can be obtained. Method: Calcaneum was divided from posterior to anterior with a broad osteotome and split into two halves to expose the interior of the bone. Sequestra, infected material, necrotic slough damaged cortex were removed. The wound was closed loosely with a drain in situ. Result: The pressure sore and the surgical wound healing were remarkable at the end of 6 weeks. The heel had a deeply situated surgical scar and over which the surrounding tissues were laid, thus forming thick cushions. Conclusions: Split-heel incision of Gaenslen removed all sequestra, obviously infected matter and did little damage to the cortex. The resultant scar was painless and was so deeply situated that the tissues on either side curl inward to form ‘cushions’. [Copyright &y& Elsevier]

Abstract: Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Open fractures should be treated urgently. Temporary external fixation may be required to stabilize the fracture before definitive fixation and subsequent soft tissue cover. Foot elevation is essential because compartment syndrome of the foot occurs after major fractures or crush injuries. Mild forms of compartment syndrome are easily missed and result in clawing of the toes so, as part of the routine examination, the foot pulses and peripheral nerves must be assessed and documented. [Copyright &y& Elsevier]

This report describes an endoscopic approach for visualization and repair of heel structures potentially involved in patients presenting chronic calcaneal tendon insertion pain. Tendon–bone junction separation allows enthesis debridement. Tenodesis with a knotless absorbable anchor completes this minimally invasive surgical procedure for chronic insertional Achilles tendinopathy. [ABSTRACT FROM AUTHOR]