Search

Purpose . It is currently still common practice to obtain conventional radiographs in the follow-up of surgically treated displaced intra-articular calcaneal fractures at regular intervals. There is, however, insufficient evidence that these radiographs can be used to predict functional outcome. The aim of the current study was to evaluate the correlation between the most commonly used angles on lateral radiographs and disease-specific patient-reported outcome measures (PROMs). Methods . Two available databases, containing a total of 233 patients, were used in this study. Eleven angles on the lateral images of the preoperative and at 1-year follow-up radiographs were measured. The 6 most commonly used angles were also measured immediately postoperatively. These 6 most commonly used angles were correlated with PROMs (American Orthopaedic Foot and Ankle Society hindfoot score, Foot Function Index) by a Spearman's rho analysis. After a Bonferroni correction was applied, a P value of <.0042 was considered to be statistically significant. Results . After exclusion of bilateral fractures, primary arthrodesis, open fractures, wound infections, other wound complications, nonavailable radiographs, and nonresponders, 86 patients remained. No significant correlations were found between the measured angles on the preoperative and at 1-year follow-up radiographs and the PROMs. Conclusion . No apparent correlation between lateral radiograph morphology and outcome was detected. Therefore, long-term follow-up radiographs after confirmed healing may be restricted to patients with persistent complaints on indication. Levels of Evidence: Prognostic, Level IV: Retrospective.

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.

Background: Fractures of the posterior process of the talus are frequently overlooked, possibly leading to nonunion, arthritis, and chronic pain. Given the rare occurrence, previous case series have been small and without functional outcome scores. Therefore, we aimed to provide evidence on outcomes after nonoperative and operative management of posterior process fractures of the talus., Methods: All patients treated at a level 1 trauma center between 2012 and 2018 were retrospectively evaluated. Patient, fracture, and treatment characteristics were collected, and functional outcome as well as quality of life were assessed. Twenty-nine patients with posterior process fractures of the talus were identified in our database., Results: The most frequently seen mechanism of trauma was fall from height in 13 patients (44.8%). Twenty-two patients underwent primary arthrodesis or operative reduction and fixation of the fracture (75.9%). Eighty-two percent of the patients returned the questionnaires with a mean follow-up of 6 years. The 2 patients with primary arthrodesis were excluded from outcome analysis. The mean Foot Function Index score was 1.8 (range 0.0-10). The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 78.7 points (range 0-100). The mean quality of life EuroQol-5D (EQ-5D) index score was 0.78 (range -0.26 to 1). The mean visual analog scale (VAS) on overall patient satisfaction was 8.2 (range 1-10)., Conclusion: Operative management of extended posterior talar fractures was found to provide good functional outcome, quality of life, and patient satisfaction. Although the patients treated nonoperatively were found to have less severe injuries, they demonstrated worse overall outcome, which is supportive of surgical management. Nonoperative treatment is therefore only justified in selected patients., Level of Evidence: Level IV, retrospective case series.

Background: The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve., Methods: MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017)., Results: Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I 2 =0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes., Conclusions: The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: To date, there is no consensus regarding which postoperative imaging technique should be used after open reduction and internal fixation of an intra-articular calcaneal fracture. The aim of this study was to clarify whether Brodén's view is sufficient as postoperative radiologic examination to assess step-offs and gaps of the posterior facet., Methods: Six observers estimated the size of step-offs and gaps on Brodén's view in 42 surgically treated intra-articular calcaneal fractures. These findings were compared to postoperative CT scans (gold standard). Inter- and intraobserver reliability were calculated and compared using intraclass correlation coefficients (ICCs)., Results: An accuracy of approximately 75% for both step-offs and gaps was found in foot and ankle experts. Less experienced observers correctly identified step-offs and gaps in approximately 62% of cases on fluoroscopy and in 48% on radiographs. Interobserver reliability for intraoperative fluoroscopy as well as postoperative radiographs was fair for step-offs, whereas interobserver reliability for gaps was excellent. Intraobserver reliability showed a low level of agreement for intraoperative fluoroscopy, in contrast to postoperative radiographs with excellent agreement for step-offs and good agreement for gaps., Conclusion: Our results show that especially for more experienced foot and ankle surgeons, in the majority of fractures, Brodén's view accurately showed step-offs and gaps following open reduction and internal fixation. Interobserver reliability showed a fair level of agreement for step-offs and excellent agreement for gaps. Intraobserver reliability was only enough for radiographs, not for fluoroscopy., Level of Evidence: Level IV, case series.

Treatment of displaced intra-articular calcaneal fractures has changed numerous times in the last decades. Currently, less invasive surgery has reemerged and is increasingly used. The sinus tarsi approach is most commonly used. It combines the open approach to the subtalar joint with percutaneous reduction of the overall shape of the calcaneus. The results in the literature show overall similar functional outcome compared with the extended lateral approach, however with a significant reduction in wound complications. This article deals with the sinus tarsi approach in which the reduction is fixated using screws only. Indications, surgical technique, and possible pitfalls are discussed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Epidermal inclusion cysts are common epithelial cysts of the skin. The latter classically originate from progressive cystic ectasia of the infundibular portion of hair follicle. Therefore, these cysts are usually found in hairy regions and rarely in glabrous skin such as the palms and soles. The etiology of glabrous epidermal inclusion cysts appear to be different from that of those located in hairy regions. It has been suggested that implantation of epithelial cells into subcutaneous tissue, such as during trauma, is most likely the pathophysiologic basis. Epidermal inclusion cysts on the palms and soles are often misdiagnosed, leading to improper treatment. Therefore, we report a rare case of an epidermal inclusion cyst of the heel after minimally invasive surgery of a displaced intra-articular calcaneal fracture., (Copyright © 2018 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Tongue-type displaced intra-articular calcaneal fractures (DIACF) are associated with a specific pattern of fracture displacement in contrast to joint depression fractures. This may result in tension of soft tissue in the posterior part of the heel. Tension-induced ischemia can result in skin necrosis. The objectives of this study were to investigate whether patients with tongue-type calcaneal fractures exert a higher risk of complications, especially of the posterior soft tissues, than joint depression type fractures. Also, late interventions (e.g., antibiotics, debridements, and amputations) and the effect of timing of surgery on the complication rate was assessed., Methods: In this international retrospective cohort study, data of adult patients with a DIACF in the period January 1, 2005-December 31, 2015 were extracted from patients' medical files. Descriptive, univariate, and multivariable analyses were performed in SPSS., Results: A total of 560 patients with 632 DIACF were included (295 tongue-type and 337 non-tongue-type fractures). At hospital presentation, 20.3% of the patients with a tongue-type fracture had compromised posterior soft tissue versus 12.8% with non-tongue-type fractures (p = 0.032). However, corrected for potential confounders the risk was no longer statistically significant (OR 1.497; 95% CI 0.831-2.696). Patients with a TT-DIACF had a 1.2-3.4-fold higher rate of any local wound complication (deep infections, and full thickness lesions, p < 0.03). In addition they had 2.0-8.0-fold more intravenous antibiotics, debridements, soft tissue coverage procedures and amputations (p < 0.03). Patients who underwent surgery within two days after trauma had a higher risk to develop any complication, in particular superficial infections, when compared to surgery between 3-7 days, but no significant difference between 3 and 7 and ≥8 days could be demonstrated., Conclusion: Despite the fact that patients with a tongue-type fracture developed posterior skin and soft tissue compromise nearly twice as often, this difference disappeared after correction for confounders. The overall complication risk was increased in patients with tongue-type calcaneal fractures as compared to patients with a non-tongue-type fracture. Whether or not patients with tongue-type fractures require immediate surgery cannot be concluded from the data., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

High rates of postoperative wound infection (POWI) have been reported after surgery for calcaneal fractures. This is a retrospective cohort study to determine the causative pathogens of these infections and subsequent treatment strategies. In addition, microbacterial growth from superficial wound swabs and deep fluid or tissue cultures were compared. Patients with a unilateral surgically treated calcaneal fracture during a 15-year period were included. Patient, fracture, and surgical characteristics were collected from the electronic medical records. An infection was categorized as deep or superficial using the Centers for Disease Control and Prevention criteria. Secondary outcomes were wound edge necrosis and wound dehiscence. The collection of culture swabs, their results, and treatment strategies were documented. Of 357 patients, 92 (26%) developed a POWI; 55 (60%) deep and 37 (40%) superficial. The most frequent causative pathogens were Enterobacteriaceae and Staphylococcus aureus. Of the 55 patients with deep infection, 31 (56%) were treated with intravenous antibiotics and surgical debridement, 2 (4%) with intravenous antibiotics, and 22 (40%) with implant removal. In 33 of 92 patients (36%) with a POWI, both superficial and deep cultures were obtained, with a microorganism not cultured from the superficial swab 13 (39%) times. In conclusion, we found that one quarter of patients with operative calcaneal fracture treatment developed a POWI, mainly caused by Enterobacteriaceae or S. aureus. Physicians should not rely on the results of superficially obtained cultures for adequate treatment of deep infection. Because the spectrum of sensitivity profiles varies greatly between hospitals and countries, we recommend empiric antibiotic treatment of both gram-positive and gram-negative microorganisms on suspicion of deep infection., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Calcaneal fractures are notoriously difficult to treat and wound complications occur often. However, owing to the rare nature of these fractures, clinical trials on this subject are lacking. Thus, biomechanical studies form a viable source of information on this subject. With our systematic review of biomechanical studies, we aimed to provide an overview of all the techniques available and guide clinicians in their choice of method of fracture fixation. A literature search was conducted using 3 online databases to find biomechanical studies investigating methods of fixation for calcaneal fractures. A total of 14 studies investigating 237 specimens were identified. Large diversity was found in the tested fixation methods and in the test setups used. None of the studies found a significant difference in favor of any of the fixation methods. All tested methods provided a biomechanically stable fixation. All the investigated methods of fixation for calcaneal fractures seem to be biomechanically sufficient. No clear benefit was found for locking plates in the fixation of calcaneal fractures; however, a subtle mechanical superiority might exist compared with nonlocking plates in the case of fractures in osteoporotic bone. Several of the techniques tested would be suitable for a minimal invasive approach. These should be investigated further in clinical trials., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: To investigate whether the sinus tarsi approach (STA) allows for a similar anatomical reduction of the posterior talocalcaneal facet as the extended lateral approach (ELA) and compare the rate of postoperative wound complications., Design: Retrospective., Setting: Level 1 trauma center., Patients: All consecutive patients from 2012 to 2015 with a closed displaced intra-articular calcaneal fracture Sanders type II and III surgically treated with the ELA (N = 60) and the STA (N = 65)., Main Outcome Measurements: Wound complications, timing of surgery, operative time, length of postoperative hospitalization, and reduction of the posterior facet and calcaneal body., Results: Incidence of wound complications, time to surgery, postoperative duration of hospital admission, and number of hospital admissions because of wound complications were significantly different between the ELA group and STA group. There was no significant difference in restoration of calcaneal anatomy with either approach. Importantly, the STA was performed in a median duration of 105 minutes and the ELA in a median of 134 minutes, accounting for nearly half an hour difference in operating time (P < 0.001)., Conclusions: The largest benefit of the STA was found in the significant reduction in wound complications and operative time, where time to closure may have accounted for the latter difference. This difference was without a compromise in reduction. Additional studies comparing functional outcome, especially rates of subtalar arthrosis, will be needed to determine the long-term benefits of STA., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The standard operative treatment of Lisfranc fracture dislocations currently consists of open reduction and transarticular fixation. Recently, bridge plating has been used more often. Using joint spanning, the reduced fracture dislocation is temporary stabilized to minimize articular damage. The present study describes the outcomes of patients treated with bridge plating after tarsometatarsal fracture dislocations compared with transarticular screw fixation. A retrospective cohort study was performed. Patients with an isolated tarsometatarsal injury who had been treated operatively from June 2000 to October 2013 were included. The primary functional outcome was measured using the American Orthopaedic Foot and Ankle Society midfoot score and the Foot Function Index. The secondary outcome was patient satisfaction, which was measured using the EuroQol 5 dimensions questionnaire and a visual analog scale. A total of 34 patients were included. Bridge plating was used in 21 patients. In 13 patients, Kirschner wires or transarticular screws or a combination were used. The median follow-up period was 49 (interquartile range 18 to 89) months. The implants were removed in 10 of 13 patients in the transarticular group and 17 of 21 patients in the bridge plating group. The incidence of wound complications was comparable in both groups. The median American Orthopaedic Foot and Ankle Society score was lower in the transarticular group (77 versus 66). The Foot Function Index score was 18 in both groups. Patient satisfaction was 90% in the bridge plating group and 80% in the transarticular group. Bridge plating for Lisfranc injuries led to at least similar results compared with transarticular fixation in terms of functional outcomes and patient satisfaction. Longer follow-up is necessary to determine whether the prevention of secondary damage to the articular surface leads to less post-traumatic arthritis and better functional outcomes., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The most important goal of surgical management of displaced intra-articular calcaneal fractures is anatomic correction. This reduction is usually stabilized using plate and screw osteosynthesis. In addition, Kirschner wires (K-wires) can be used to maintain the surgical reduction or stability of the construct. In the present study, we evaluated the frequency and type of use of additional K-wires and subsequent migration in the surgical management of displaced intra-articular calcaneal fractures. The data from 279 patients treated surgically from January 1, 2000 to December 31, 2014 in a level 1 trauma center using an extended lateral approach were analyzed after 1 year of follow-up. All postoperative radiographic images were reviewed to identify the cases in which K-wires were used. Data on the number and type of K-wires used, K-wire location, and K-wire migration found on follow-up imaging studies were collected. Of the 279 patients, 69 K-wires had been used in 49 (18%) patients. A total of 25 (36%) lost (buried), 38 (55%) bent, and 6 (9%) unmodified straight K-wires had been placed. Overall, in 4 (5.8%) of 69 K-wires, secondary dislocation was seen. One (4%) of the lost, 3 (50%) of the unmodified, and none of the bent K-wires showed secondary dislocation. K-wire migration was seen in 5.8% of the cases. None of the bent K-wires and only 1 of the lost K-wires had migrated in the present study. These 2 techniques are preferred when using K-wire fixation in the treatment of displaced intra-articular calcaneal fractures. The use of unmodified straight K-wires should be discouraged., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is an increasing incidence of fragility fractures of the ankle in the elderly population. The open reduction and internal fixation of these fractures is challenging, due to reduced bone stock quality as a result of osteoporosis. Biomechanical studies have shown contradicting results using reinforced constructions in the fixation of fibular fractures. We therefore performed a meta-analysis of biomechanical studies on reinforced fixation of distal fibular fractures., Methods: A literature search was conducted utilizing three online databases considering biomechanical testing of different fixation techniques of distal fibular fractures. A meta-analysis was performed on two biomechanical outcome measures; torsional stiffness and torque to failure., Findings: In a total number of 13 studies 8 different reinforcement techniques were identified. Of these studies, six compared locked lateral plating with conventional lateral plating. There were no statistically significant differences between the locking and non-locking lateral plate for torque to failure or torsional stiffness. Locked plating strength was independent from bone mineral density in four studies. An antiglide plate proved to be biomechanically superior compared to a lateral plate in one study and to a locked plate in another., Interpretation: Locked lateral plates are not biomechanically superior to conventional lateral plates. However the strength of locked plating may be independent of bone mineral density and could make this technique more suitable in the fixation of severe osteoporotic fractures., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: The goal of calcaneal fracture surgery is to restore its anatomy and good foot function. However, loss of height of the subtalar joint can occur post-operatively, as expressed by a decrease in Böhler's angle (BA). The aim of this study was to identify potential factors associated with a post-operative decrease in BA., Methods: All consecutive adult patients treated with open reduction and internal fixation (ORIF) by an extended lateral approach (ELA) between 2000 and 2013 were retrospectively included. Primary outcome was the occurrence of a calcaneal collapse, defined as a postoperative decrease of ≥10° in BA. The BA was measured pre-operatively, directly following surgery and at one year follow-up. Patient characteristics (body mass index, diabetes mellitus, smoking/alcohol/substance abuse, American Society of Anaesthesiologist classification), fracture classification and treatment characteristics: per-operative increase in BA and occurrence of post-operative wound infection (POWI) were collected., Results: A total of 262 patients with 276 calcaneal fractures were included. A calcaneal collapse occurred in 46 cases (17%). The median preoperative BA, per-operative increase in BA and post-operative decrease in BA were, respectively, 2°, 27° and 4°. A calcaneal collapse was seen more often following a per-operative increase of >25° in BA, but no significant association was found (p = 0.056). Uni- and multivariate analysis showed that patients with substance abuse and those with POWI had significantly more calcaneal collapse (p < 0.05). No association was found between substance abuse and the occurrence of POWI (p = 0.293)., Conclusions: In nearly one in six patients with an intra-articular calcaneal fracture treated with ORIF by an ELA, a post-operative collapse of ≥10° was found during follow-up. Calcaneal collapse was correlated with the occurrence of a POWI and substance abuse.

Ankle fractures with syndesmotic rupture require operative treatment. In most cases, this consists of fixation of the tibiofibular joint with 1 or more screws. Bioabsorbable screws are used for the same purpose but have the advantage that screw removal is unnecessary. The aim of the present study was to compare the results of bioabsorbable and metallic syndesmotic screws. A systematic search was performed in the Ovid MEDLINE electronic database and Google Scholar. Three randomized controlled trials and one comparison study, with 260 patients, were included. The experimental group consisted of patients with syndesmotic injuries treated with bioabsorbable screws versus the control group (patients treated with metallic screws). The primary outcomes were complications and wound infections. No statistically significant difference was demonstrable in the overall number of complications between the 2 groups. In the group of patients with a bioabsorbable screw, 32 of 137 (23.4%) experienced a complication versus 7 of 123 patients (5.7%) with a metallic screw. Data on wound-related complications showed no statistically significant difference, 19.7% versus 5.7%. The average maximum range of motion in both groups was comparable. Bioabsorbable syndesmotic screws and metallic syndesmotic screws were comparable with respect to the incidence of complications and range of motion. However, the absolute number of complications was greater with bioabsorbable screws., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In the Netherlands about 18,000 procedures with implant removal are performed annually following open or closed reduction and fixation of fractures, of which 30-80% concern the foot, ankle and lower leg region. For clean surgical procedures, the rate of postoperative wound infections (POWI) should be less than ~2%. However, rates of 10-12% following implant removal have been reported, specifically after foot, ankle and lower leg fractures. Currently, surgeons individually decide if antibiotics prophylaxis is given, since no guideline exists. This leads to undesirable practice variation. The aim of the study is to assess the (cost-)effectiveness of a single intravenous gift of Cefazolin prior to implant removal following surgical fixation of foot, ankle and/or lower leg fractures., Methods: This is a double-blind randomized controlled trial in patients scheduled for implant removal following a foot, ankle or lower leg fracture. Primary outcome is a POWI within 30 days after implant removal. Secondary outcomes are quality of life, functional outcome and costs at 30 days and 6 months after implant removal. With 2 x 250 patients a decrease in POWI rate from 10% to 3.3% (expected rate in clean-contaminated elective orthopaedic trauma procedures) can be detected (Power = 80%, 2-sided alpha = 5%, including 15% lost to follow up)., Discussion: If administration of prophylactic antibiotics prior to implant removal reduces the infectious complication rate, this will offer a strong argument to adopt this as standard practice of care. This will consequently lead to less physical and social disabilities and health care use. A preliminary, conservative estimation suggests yearly cost savings in the Netherlands of € 3.5 million per year., Trial Registration: This study is registered at Clinicaltrials.gov ( NCT02225821 ) and the Netherlands Trial Register ( NTR4393 ) and was granted permission by the Medical Ethical Review Committee of the Academic Medical Centre on October 7 2014.

Introduction: Much of the currently available data on the technical aspects of syndesmotic screw placement are based upon biomechanical studies, using cadaveric legs with different testing protocols, and on surgeon preference. The primary aim of this study was to investigate the effect of the level of syndesmotic screw insertion on functional outcome. Further, the effects of number of cortices engaged, the diameter of the screw, use of a second syndesmotic screw and the timing of removal on functional outcome were tested., Material and Method: All consecutive patients treated for an ankle fracture with concomitant acute distal tibiofibular syndesmotic injury that had a metallic syndesmotic screw placed, between 1 January 2004 and 31 December 2010, were included. Patient characteristics (i.e., age at injury and gender), fracture characteristics (i.e., affected side, trauma mechanism, Weber fracture type and number of fractured malleoli), and surgical characteristics (i.e., level of screw placement, screw diameter, tri- or quadricortical placement, number of syndesmotic screws used and the timing of screw removal) were recorded. Outcome was measured using validated questionnaires, which were sent by post, and consisted of the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Olerud-Molander Ankle Score (OMAS) and a single question Visual Analog Scale (VAS) for patient satisfaction with outcome., Results: During the 7-year study period, 122 patients were treated for syndesmotic injury. A total of 93 patients (76%) returned the questionnaire. The median follow-up was 51 months. The outcome scoring systems showed an overall score for the entire group of 92 points for the AOFAS, 77 for the OMAS and 8.2 for the VAS. Outcome was statistically significantly influenced by the number of fractured malleoli, age, trauma mechanism and the level of screw insertion., Conclusion: Overall, the functional outcome of acute syndesmotic injuries treated with a syndesmotic screw was good and mainly influenced by patient and fracture characteristics. Most different technical aspects of placement appeared not to influence these results. Only screw placement above 41 mm negatively influenced outcome., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: Post-operative wound infections (PWI) following calcaneal fracture surgery can lead to prolonged hospital stay and additional treatment with antibiotics, surgical debridement or implant removal. Our aim was to determine the incidence of superficial and deep PWI and to identify risk factors (RF)., Methods: This study is a retrospective case series. All consecutive patients from 2000 to 2010 with a closed unilateral calcaneal fracture treated with open reduction and internal fixation (ORIF) by an extended lateral approach were included. Patient, fracture, trauma and peri-operative characteristics were collected, including RF such as smoking, diabetes mellitus, time to operation, pre-operative in- or outpatient management and wound closure technique. The primary end point was a PWI as defined by the US Centers for Disease Control and Prevention., Results: A total of 191 patients were included of which 47 patients (24.6%) had a PWI; 21 (11.0%) and 26 (13.6%) patients had a superficial and deep wound infection, respectively. American Society of Anesthesiologists (ASA) classification higher than ASA 1 was associated with an increased risk. Placement of a closed suction drain at the end of surgery was associated with less PWI (35% vs 15%, p = 0.002). In this study, none of the previously reported RF were associated with an increased risk for PWI., Conclusions: ORIF of displaced calcaneal fractures is associated with a high rate of PWI of 25%. Factors that were associated with an increased risk were ASA classification other than 1 and absence of a closed suction drain placement. A closed suction drain may be a protective measure to avoid wound complications.

For ankle fractures, in general, several studies have been published on immobilization (e.g., cast or boot) versus early motion after surgical treatment. However, no studies have been performed to determine the best aftercare strategy for surgically treated patients with ankle fractures with concomitant acute distal tibiofibular syndesmotic injuries. The aim of the present review was to compare the functional outcomes of ankle fractures with syndesmotic injury treated with a cast or boot versus early motion. We performed a systematic review using the electronic databases from January 1, 2000 to September 1, 2012 of the Cochrane Library, PubMed MEDLINE(®), EMbase, and Google Scholar. The included studies were those in which ankle fractures with acute distal tibiofibular syndesmotic injuries had been treated with 1 or more syndesmotic screws, with a mean follow-up period of at least 12 months and at least 25 patients included. The functional outcomes, measured using the American Orthopaedic Foot Ankle Society Hindfoot scale, Olerud-Molander Ankle Scale, and Short Musculoskeletal Function Assessment, were compared. A total of 9 studies were identified with a total of 531 patients. The number of included patients ranged from 28 to 93. The mean follow-up period was 12 to 101 months. Of the 9 studies, 3 used an early motion protocol (195 patients) and 6 (336 patients) a protocol of immobilization for at least 6 weeks. For the American Orthopaedic Foot Ankle Society Hindfoot scale, the mean scores for immobilization were 86 to 91 points and for early motion, 84 to 89. For the Olerud-Molander Ankle Scale, the scores for immobilization were 47 to 90 and for early motion, 46 to 82 points. The Short Musculoskeletal Function Assessment score for immobilization was 11 and for early motion ranged from 12 to 27 points. No apparent differences could be detected in the published data considering the functional outcomes between immobilization versus an early motion protocol in ankle fractures with acute distal tibiofibular syndesmotic injuries treated with a syndesmotic screw. However, level 1 and 2 studies on this subject are lacking., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Besides early diagnosis, an anatomical and stable reduction is paramount for obtaining a favorable outcome. The current study looked at the influence that the type of approach for tarsometatarsal injuries has on the accuracy of the reduction and the effect that the type of fixation has on stability., Methods: Consecutive patients treated surgically for an acute Lisfranc injury were included. All radiographs were reassessed for accuracy and secondary displacement following either a closed or an open approach and in terms of the type of fixation (Kirschner wires alone or a combination of screws and plates and Kirschner wires). A total of 28 patients were included. Six patients were treated with closed reduction and percutaneous fixation and 22 with open reduction internal fixation. Sixteen patients were treated with Kirschner wires only (6 closed, 10 open), 7 with screws with or without Kirschner wires, and 5 with medial plating with or without Kirschner wires., Results: In the closed reduction group, 2 of 6 (33%) reductions were considered acceptable versus 19 of 22 (86%) in the open group (P = .021). All 6 secondary displacements occurred in the Kirschner wire fixation group (37.5%) versus none in the rigid fixation group (P = .024)., Conclusion: The results demonstrate that open reduction and internal fixation with screws or plate resulted in better reduction and better maintenance of reduction in both low- and high-energy Lisfranc injuries. These results should be further evaluated in light of functional outcome., Level of Evidence: Level III, retrospective comparative case series.

The current reference standard for the treatment of displaced intra-articular calcaneal fractures is open reduction and internal fixation using an extended lateral approach. In the present retrospective study, we evaluated the results of a consecutive series of patients treated in the same fashion from June 2005 to September 2011 using a subcuticular single-layer closure technique. We also determined the risk factors for the development of wound complications and the rate of wound complications. Also, we assessed which patient, fracture, and surgical characteristics affected these complications. During the 75-month study period, we operated on 53 displaced intra-articular calcaneal fractures in 50 patients using the extended lateral approach. The incision was closed using the subcuticular technique in 49 cases (92.45%). In the subcuticular closure group 2 (4.1%) deep infections and 2 (4.1%) superficial wound complications (1 dehiscence and 1 infection) occurred. Wound edge or flap necrosis was not encountered. The use of bone-void filler and the experience of the surgical team were significantly (p < .001 and p = .026, respectively) associated with the occurrence of wound complications. The subcuticular single-layer suture technique is a suitable closure technique in the treatment of displaced intra-articular calcaneal fractures. It was associated with a low complication rate combined with the extended lateral approach. The effect of bone void fillers on the incidence of complications should receive more attention in future research. The association between wound complications and the experience level of the surgical team supports the need for centralization of this complex injury., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Information about the influence of delayed surgery on infectious wound complications is ambiguous. A clinical audit was performed to test the hypothesis that early surgery lowers the rate of infectious wound complications. Secondly we looked at the influence of surgical delay and complications on patient reported functional outcome., Methods: All consecutive, closed distal fibular fractures treated surgically with a plate were included and retrospectively analysed for the delay in operation and wound complications. In a second cohort of patients with a AO-Weber B-type ankle fracture outcome was measured using the Olerud-Molander ankle score (OMAS), the American Orthopaedic Foot and Ankle Society score (AOFAS) and a visual analog score (VAS) for overall satisfaction., Results: Patients treated within one day experienced no wound complications (zero out of 60), whereas in the delayed group 11% (16/145) did (p = 0.004). A similar significant difference was found for the patients treated within one week (2/98) versus after one week (14/107). A systematic review of the literature showed a difference in wound complications of 3.6% (early) versus 12.9% (late) (p < 0.0001). After 43 months, the median AOFAS was 11.5 points lower in the complication group, the OMAS 10 points, and the VAS 0.5 points, with all differences being statistically significant., Conclusions: Every effort should be made to operate on closed ankle fractures as soon as reasonably possible. A delay in surgery is associated with a significant rise in infectious wound complications, which significantly lowers outcome and patient satisfaction. These fractures should preferably be treated within the first day.

Introduction: Ankle fractures are one of the most frequently encountered musculoskeletal injuries, and 10% of patients have a concomitant distal tibiofibular syndesmotic disruption necessitating surgical repair. A national survey was conducted to gain more insight into the current approaches in the management of syndesmotic injuries in the Netherlands., Materials and Methods: A postal survey was sent to one or two staff members of the trauma and orthopaedic surgery departments in each of the 86 hospitals in the Netherlands. Questions concerned the pre-, per- and postoperative strategies and the different ideas on the type, number and placement of the syndesmotic screw., Results: A total of 85.2% of the trauma surgeons and 61.9% of the orthopaedic surgeons responded (representing 87% of all hospitals). Syndesmotic injury was judged mainly using the 'Hook test'. Syndesmotic injuries in a Weber-B ankle fracture were treated with one screw in 81.2% of cases and in Maisonneuve injuries mainly with two screws. The 3.5-mm screw was used most frequently over three cortices at 2.1-4.0cm above the tibial plafond. Removal of the syndesmotic screw was routinely done by 87.0% of surgeons, mostly between 6 and 8 weeks. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication., Conclusion: Compared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Currently, the metallic syndesmotic screw is the gold standard in the treatment of syndesmotic disruption. Whether or not this screw needs to be removed remains debatable. The aim of the current study was to determine the complications which occur following routine removal of the syndesmotic screw following operative treatment of unstable ankle fractures., Methods: This was a retrospective study with consecutive cases in a Level-2 Trauma center. All patients with routine removal of a syndesmotic screw, following the treatment of an unstable ankle fracture, between January 1, 2004 and November 30, 2010 were included. Complications recorded were: 1) minor or major wound infection following removal of the syndesmotic screw, 2) recurrent syndesmotic diastasis, and 3) unnecessary removal of a broken screw, not recognized during preoperative planning prior to surgery., Results: A total of 76 patients were included. A wound infection occurred in 9.2% (N = 7) of which 2.6% (N = 2) were deep infections requiring reoperation. Recurrent syndesmotic diastasis was found in 6.6% (N = 5) of patients, and in 6.6% (N = 5) screws were broken at the time of implant removal. In the group with recurrent diastasis the screws were removed significantly earlier compared with the group without recurrent diastasis (Mann-Whitney U-test; p = 0.011) and the group with screw breakage had their screws significantly longer in place compared with the group without breakage (p = 0.038)., Conclusion: A total of 22.4% complications occurred upon routine removal of the syndesmotic screw. Removal might therefore be considered only in selected cases with complaints, after a minimum of eight to twelve weeks and using antibiotic prophylaxis during removal.

Osteochondral lesions of the talus (OLTs) occur infrequently and are missed at the initial presentation in up to 67% of cases. Probably more than 1500 OLTs have been reported in published studies, of which, thus far, only 5 cases have been an inverted anterolateral OLT. An anterolateral OLT results from a hypersupination trauma, in which the talar dome is caught behind the fibula. Apparently, if the forces are large enough a "flip of the coin" phenomenon occurs, causing the fragment to invert 180° upside down. We present the case of a young female patient with an inverted OLT that was treated with open reduction and internal fixation using bioabsorbable pins. Follow-up radiographs and computed tomography showed a congruent joint and complete healing of the osteochondral fragment. At the short-term follow-up visit, the functional outcome was promising., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Although open reduction and internal fixation is currently considered the gold standard in surgical treatment of displaced intra-articular calcaneal fractures, various different approaches exist including the limited lateral approach. The aim of this systematic review was to combine the results of studies using the sinus tarsi approach, which is the most frequently applied limited lateral approach., Method: A literature search in the electronic databases of the Cochrane Library and Pubmed Medline, between January 1st 2000 to December 1st 2010, was conducted to identify studies in which the sinus tarsi approach or a modified sinus tarsi approach was utilized for the treatment of displaced intra-articular calcaneal fractures. The methodological quality of the included studies was assessed using the Coleman methodology score., Results: A total of eight case series reporting on 256 patients with 271 calcaneal fractures was identified. Overall good to excellent outcome was reached in three-quarters of all patients. An average complication rate of minor wound complications of 4.1% was reported and major wound complications in 0.7%. The need for a secondary subtalar arthrodesis occurred at an average rate of 4.3%. The average Coleman methodology score was 56.8 (range 39-72) points., Conclusion: The results, i.e. functional outcome and complication rates, of the sinus tarsi approach compare similarly or favourably to the extended lateral approach. Therefore, in the process of tailoring the best treatment modality to the right patient and the right fracture type, the sinus tarsi approach might be a valuable asset.

The long-term follow-up of intra-articular calcaneal fractures is often accompanied by complications. Frequently occurring are arthrosis, arthrofibrosis of the subtalar joint, and malunion. Uncommon is the calcaneal nonunion. A total of three cases is presented in this report, including a review of the literature. The occurrence of a nonunion appears to be more common after conservative treatment, but the pathophysiology remains unclear, however smoking may play a role.

Objective: Percutaneous reduction by distraction and subsequent percutaneous screw fixation to restore calcaneal and posterior talocalcaneal facet anatomy. The aim of this technique is to improve functional outcome and to diminish the rate of secondary posttraumatic arthrosis compared to conservative treatment and, secondly, to reduce infectious complications compared to open reduction and internal fixation (ORIF)., Indications: Sanders type II-IV displaced intraarticular calcaneal fractures., Contraindications: Isolated centrally depressed fragment. Patients who are expected to be noncompliant., Surgical Technique: Four distractors (Synthes) are positioned, two on each side of the foot, between the tuberosity of the calcaneus and talus and between the tuberosity and cuboid. A distracting force is given over all four distractors. A blunt drifter is then introduced from the plantar side to unlock and push up any remaining depressed parts of the subtalar joint surface of the calcaneus. The reduction is fixated with two or three screws inserted percutaneously., Postoperative Management: Directly postoperatively, full active range of motion exercises of the ankle joint can start, with the foot elevated in the 1st postoperative week. Stitches are removed after 14 days. Implant removal is necessary in 50-60% of patients., Results: Between 1999 and 2004, 59 patients with 71 fractures were treated by percutaneous skeletal triangular distraction and percutaneous fixation. A total of 50 patients with 61 fractures and a minimum follow-up of 1 year were available for follow-up. According to the American Orthopaedic Foot and Ankle Society Hindfoot Score, 72% had a good to excellent result. A secondary subtalar arthrodesis was performed in five patients and planned in four (total 15%). Böhler's angle increased by about 20 degrees postoperatively. Sagittal motion was 90% and subtalar motion 70% compared to the healthy foot.

Background: The outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures., Methods: A cohort of patients with displaced intra-articular calcaneal fractures treated with percutaneous surgery was retrospectively defined. Clinical outcome was evaluated by standardized physical examination, radiographs, three published outcome scores, and a visual analogue scale of patient satisfaction., Results: Fifty patients with 61 calcaneal fractures were included. After a mean follow-up period of 35 months, the mean values of the Maryland foot score, the Creighton-Nebraska score, and the American Orthopaedic Foot and Ankle Society score were 79, 76, and 83 points out of 100, respectively. The average visual analogue scale was 7.2 points out of 10. The average range of motion of the ankle joint was 90% of normal and subtalar joint movements were almost 70% compared with the healthy side or normal values. Superficial wound complications occurred in seven cases (11%) and deep infections in two (3%). A secondary arthrodesis of the subtalar joint was performed in five patients and was scheduled in four patients (15%)., Conclusions: Compared with the outcome of historic controls from randomized trials and meta-analyses, this study indicates favorable results for the percutaneous technique compared with the open technique. Despite similar rates of postoperative infection and secondary arthrodesis, the total outcome scores and preserved subtalar motion are overall good to excellent.