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

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

OBJECTIVE The aim of this study was to introduce a novel method of simultaneous in situ decompression of lateral calcaneal bulge and subtalar arthrodesis via a single incision for malunion after calcaneal fractures and evaluate the feasibility of this method. METHODS From September 2010 to October 2011, six patients (five males and one female) with malunion and delayed heel pain after conservative treatment of displaced intra-articular calcaneal fractures were included in our study. The mean age of the six patients was 32.9 years (range, 25-71 years). Patients were treated with this novel technique at our department and the functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scores during follow-up. Information of the six patients including surgical data and pre/postoperative function scores were retrospectively analyzed using SPSS 19.0 statistical software. RESULTS The average operation time between wire insertion and incision suture was 42.2 ± 11.5 min (range, 25-56 min). The blood loss in all patients was all less than 50 ml each. The average fluoroscopy time was 25.7 ± 11.6 s (range, 11-43 s). No wound-related and other short-term complications were recorded. Six patients who were included in our study were followed for an average period of 66.2 ± 4.7 months (range, 60-73 months). There was no patient lost to follow up. Heel pain was observed to be greatly improved preoperatively in all of the six patients. All patients restored to normal activity of life after surgery. Radiological evidence of fusion was observed in five patients. The average fusion time of these five patients was 3.5 months (range, 2-4 months). The remaining one failed to achieve fusion and the hardware removal was performed due to screw tail irritation. This patient was satisfied with the final outcomes subjectively after removal of hardware. The mean AOFAS scores at 24 months postoperative were 82.0 ± 7.0, which was greatly improved compared to preoperative (44.8 ± 10.7) (P

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

Category: Trauma; Hindfoot Introduction/Purpose: High energy calcaneus fractures have significant soft tissue compromise and typically poor outcomes. The purpose of this study was to describe patient complications and outcomes, after undergoing staged treatment for high energy calcaneus fractures, including initial treatment with medial calcaneal external fixation followed by definitive reconstruction. Methods: A retrospective chart review with prospective data was performed from April 2013 to February 2019. Inclusion criteria for the study included: patients >18 years of age, closed Sanders III and IV fractures or open fractures of the calcaneus. Patients were initially treated with placement of a medial based external fixator with closed reduction. Once the soft tissue envelope had improved, definitive fixation was performed, either ORIF or ORIF with primary subtalar fusion. Results: There were a total of 15 patients that met inclusion criteria for the study. 9 of the fractures were open and 6 were closed. The medial calcaneal external fixation (ex-fix) was placed at a mean of 2.0 (0-12) days after initial injury. The definitive procedure occurred at a mean of 23.6 (12-42) days after ex-fix placement. 11 of the patients underwent calcaneus fracture ORIF with primary subtalar (ST) fusion and 4 patients were treated with calcaneus fracture ORIF alone. 14 (93%) of the patients showed radiographic union at an average of 6.7 months. Mean PROMIS scores showed improvement in physical function, mood, and a decrease in pain at an average of 19 (5-72) months after initial injury. The average VAS pain score was 3.5 (0-7). Conclusion: A staged protocol for high-energy and open calcaneal fractures is an effective tool in treating these difficult injuries. It allows the soft tissues to improve while maintaining length and alignment of the fracture for definitive fixation and minimizing complications. There were improvements in physical function, mood, and a decrease in pain at final follow-up of almost 2 years. [Table: see text]

Category: Trauma Introduction/Purpose: There is increasing interest on how to best manage displaced intraarticular calcaneal fractures (DIACF). Intramedullary locking devices (ILDs) have recently been advocated since the technique adopts a minimally invasive approach which may minimise complications and therefore improve outcomes. We reviewed the literature of commercially available devices to identify their characteristics, efficacy and safety. Methods: Medline, Scopus and EMBASE databases were searched to identify studies reporting use of ILDs for treating DIACF. A PRISMA checklist was used to sort eligible studies. Technical notes and biomechanical studies were first reviewed. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies. Results: Thirteen studies investigated two devices (Calcanail; C-Nail). Four technical notes described how to use these devices and three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Seven clinical studies (302 feet, 289 patients) demonstrated satisfactory clinical (AOFAS, VAS) and radiographic (Bohler’s angle, Gissane angle, Goldzak index, posterior facet step-off) outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications; soft tissue issues were reported in 3-5% of cases. Conversion to subtalar fusion was necessary in 4-6% of cases. Four (57%) studies were authored by implant designers and in 5 (71%) relevant conflict of interest were disclosed. Mean CMS was 61 (moderate quality). Conclusion: Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications including infection and wound breakdown are less frequent than after open lateral approaches. The quality of evidence provided so far is only moderate and biased by potential conflict of interest, raising concerns about the generalisability of results.

Category: Hindfoot; Trauma Introduction/Purpose: Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objectives of this study were (1) to conduct a systematic review of clinical outcomes following SDA, (2) to assess the demographics, indications, and surgical technique used, (3) to assess the clinical and radiographic outcomes of this procedure and its role in improving function, (4) to provide treatment recommendations based on the best available literature, and (5) to identify knowledge deficits that require further investigation. Methods: MEDLINE and EMBASE were queried with an end date of January 1, 2018 using the keywords The keywords used for this search included ‘‘subtalar,’’ ‘‘talar,’’ ‘‘talus,’’ ‘‘bone,’’ ‘‘block,’’ ‘distraction,’ ‘arthrodesis,’ ‘fusion,’ ‘arthritis,’ ‘arthrosis,’ ‘calcaneus,’ ‘calcaneal,’ ‘fracture,’ ‘malunion,’ ‘deformity,’ and ‘‘clinical outcome,’’ alone and in various combinations using the Boolean operator ‘‘AND.’’ Data abstraction was performed by two independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least five patients, (4) reporting clinical and/or radiographic outcomes of SDA. Data collected included: demographics, operative techniques, radiographic measures, clinical and functional outcomes, and complications. The level of evidence for each study was assessed according to the method described by Wright et al. Methods followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle hindfoot scores with a weighted average of 33 points of improvement. Conclusion: Subtalar bone block arthrodesis provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. These consistent clinical outcomes throughout the literature, despite different lengths of followup periods, suggest that the functional results do not deteriorate with time. Higher confidence recommendations for SDA require longer follow-up, clear indications and treatment protocols, standardized clinical and radiographic outcome measures, and direct comparison or stratification of results based on graft type and other operative techniques. [Table: see text]

Category: Hindfoot; Trauma Introduction/Purpose: The fixation of displaced intraarticular fractures of the calcaneus have posed many challenges for the surgeon, including an anatomic reduction, fracture stabilization, and soft tissue concerns. The extensible lateral and sinus tarsi approaches must be delayed until soft tissues concerns resolve and despite this are susceptible to wound necrosis and skin infections. Intramedullary fixation allows immediate fixation without soft tissue compromise. Methods: The retrospective case series is comprised of 23 patients; 19 intramedullary fixation of the calcaneus and 4 primary arthrodesis with the FH Orthopedics CalcaNail. Fracture classification, timing to surgery, accuracy of reduction, complications, and outcome were recorded. Results: There were zero wound complications. Bohler’s angle was restored as well as articular surface. One patient required implant removal after healing seconding to prominent hardware. One patient required conversion to a subtalar arthrodesis. There were no implant mechanical failures. Conclusion: The intramedullary fixation of calcaneus fractures has been performed extensively outside the US with documented success. This series of early US experience exhibits similar utility. The ability to reduce the fracture intrafocally and stabilize with a minimally invasive approach have proven useful with no incidence of wound complications. Not to mention no delay from time of injury to surgery is needed.

Background Calcaneal fractures account for around 2% of all fractures and most of them are intra-articular fractures. Many implants have been used in the fixation of calcaneal fractures, but their biomechanical stability has not yet been well investigated. The aim of this study was to compare the primary stability of four fixations of calcaneal fracture. Methods Eight cadaveric calcaneus samples were used to simulate the Sanders’ types III fracture pattern and fixed through four different implants, namely, K-wires, cannulated screws (CS), absorbable screws (AS), and plate-screw system (PSS). Each specimen was then placed into a custom-made jig and was loaded through a material testing machine to simulate the physiological condition. The primary stability was measured in the vertical direction as the stiffness and anterior–posterior direction as the calcaneocuboid force. One-way analysis of variance was used for data analysis. Results The results showed the highest stiffness of 634 (383–891; SD 226) N/mm in the intact model. It was significantly higher than the models fixed with K-wires, CS or PSS. There was no significant difference in vertical stiffness between fractures fixed with AS and the intact model or other fixed models. The intact model showed the lowest calcaneocuboid force of 153 (120–218; SD 39) N, while the fractures fixed with AS showed the greatest force of 242 (146–398; SD 84) N. The significance was only detected between these two models. Conclusions The global stiffness was similar when the calcaneal fractures were fixed by K-wires, CS and PSS. The stability of the AS fixation differed along both the vertical and anterior–posterior directions, and was greatly influenced by the bone quality. AS for fracture fixation should be designed with greater strength and pull-out resistance.

Computed tomography (CT) is nowadays the cornerstone for fracture pattern delineation in calcaneal fracture, and for operative planning. It is often challenging for radiologists in generating clinically oriented and meaningful CT reports to the orthopedic surgeon. The article aims to review the commonly encountered calcaneal injuries and highlight the key points in the description of these injuries and implications of the underlying classification system with respect to the surgeon’s perspective. A thorough understanding of the pathoanatomy and potential complications of calcaneal fractures also helps radiologists in tailoring the radiology report in contribution to overall patient’s management and prognostication. By doing so, we suggest ways in which the radiologists can add value to the radiology report.

Background. One of the main causes of pain in patients with consequences of calcaneal fractures is the lateral impingement syndrome. This term means lateral displacement of outer calcaneal wall at the moment of fracture, narrowing of anatomical space under the lateral malleolus and compression of soft tissues in this region, including tendons of short and long peroneal muscles. This leads to chronic traumatization of tendons, alteration of their normal tracking and development of tendinitis and tenosynovitis. At this moment there are no articles in foreign or Russian literature describing how prolonged traumatization influences the internal structure of the tendons. The purpose of this study was to evaluate the morphological changes in structure of peroneus brevis tendon after different duration of compression between outer wall of calcaneus and the tip of the lateral malleolus in patients with calcaneal malunion.Materials and methods. Fifteen patients with calcaneal malunion and lateral impingement syndrome were treated operatively between 2016 and 2017. To confirm the lateral impingement syndrome, the authors performed clinical examination and AP x-rays of ankle joint. Two peroneus brevis tendon specimens were obtained intraoperatively in each of 15 patients: one specimen from compressed and one from non-compressed area. Obtained specimens were histologically examined according to standard protocol.Results. Microscopically all specimens showed separation of collagen bundles with loose connective tissue degeneration, increase of vascularization and inflammation. The degree of these changes differed according to the compression duration. This allowed us to analyze the dynamics of these changes.Conclusion. The morphological changes in structure of peroneus brevis tendon during the compression between outer wall of calcaneus and the tip of the lateral malleolus correspond with dynamics of common pathologic reactions. Early stages showed signs of mechanical damage of bundles and inflammation. In prolonged impingement the intensity of inflammation decreases, but the connective tissue degeneration of the tendon continues with lipoid infiltration.

Background In the last decade, the sinus tarsi approach (STA) has gained interest over the extensile lateral approach (ELA) in the operative treatment of displaced intra-articular calcaneal fractures (DIACF's), mainly because of the lower rate of surgical site infections (SSIs). However, most studies are small and retrospective. The aim of this study was to evaluate the rate of SSIs of the STA in a large, prospective series of patients and to identify predictors for SSIs. Methods In this prospective cohort study, all consecutive patients who were operatively treated for a DIACF in our Level 1 trauma center between August 2012 and January 2019 were included and followed for at least one year. All operative procedures were performed by two specialized foot and ankle trauma surgeons using the STA. Using multinomial logistic regression, risk factors for SSIs were identified. Results A total of 237 calcaneal fractures in 214 patients were included, of which 179 underwent open reduction and internal fixation and 58 a primary arthrodesis. Most patients were male (73.6%) and the mean age was 45.9 years. There were 16 patients that developed a SSI (6.8%), of which 9 (3.8%) were deep and 7 (3%) were superficial infections. The multivariate analysis pointed out that surgery within one week after injury increased the chance of a SSI, as well as an ASA of 2 or higher and more than 150 cc of blood loss during the procedure. Conclusion This study confirms the low risk of SSI in DIACFs treated via STA. Significant predictors for SSIs were surgery within one week after injury, ASA of 2 or higher and blood loss > 150cc.

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 Levels of Evidence: Prognostic, Level IV: Retrospective

Category: Ankle, Hindfoot Introduction/Purpose: Operative management of displaced intra-articular calcaneus fractures frequently involves placement of P: A screws in order to maintain calcaneal length and axial alignment. While plate fixation may still be more commonly utilized, screw-only fixation for the treatment of these fractures has been demonstrated by several authors to be safe and effective. Directing fixation from the tuber into the anterior process can be challenging. Understanding the calcaneal long-axis as it relates to the long-axis of the foot, a measurement we call the Tuber-to-Anterior Process Angle (TAPA), can facilitate the ease and accuracy of guide-wire and cannulated screw placement. The goals of this study are to define the TAPA, and to report a surgical technique which uses this angle to facilitate axial screw placement. Methods: Eight cadaver feet were utilized. A longitudinal pin was placed from the center of the posterior calcaneal tuber to the 2nd metatarsal heads. Next, the calcaneocuboid joint was exposed, and a wedge of cuboid was removed. A calcaneal pin was then placed, exiting at the center of the anterior process. The tips of two small K-wires were impacted into the medial and lateral-most aspects of the articular surface. A true axial view of each specimen was obtained. On these images, a digital line was drawn from the posterior tuber starting point and the central calcaneal pin, representing the calcaneal long-axis. The angle subtended by this line and the long-axis of the foot represents the TAPA. Digital lines were drawn between the posterior tuber starting point and the medial and lateral K-wires, and the range between their subtending angles represents the axial plane tolerance for screw placement within the anterior process. Results: The average TAPA measured 10.9 ± 1.3 degrees (range: 8.4-13.0). The average angle, as measured to the medial extent of the anterior calcaneus, measured 2.8 ± 1.3 degrees (range: 0.4-4.3). The average angle, as measured to the lateral extent of the anterior calcaneus, measured 19.0 ± 2.7 degrees (range: 15.7-22.7). Conclusion: Knowledge of the Tuber-to-Anterior Process Angle (TAPA), found to be 10.9 degrees (± 1.8 degrees) laterally deviated from the long-axis of the foot, simplifies placement of posterior-to-anterior screws in the calcaneus. Understanding this relationship reduces reliance on intraoperative axial fluoroscopy and increases operative efficiency. Furthermore, this knowledge can be applied during other procedures in which axial screw placement is performed, such as with corrective calcaneal osteotomy.

Background: Calcaneal fractures are a prevalent form of injury caused by high-energy trauma. This study aimed at investigating whether bone graft and non-bone graft are essential for the internal fixation of calcaneal fractures. A meta-analysis of relevant clinical studies evaluated radiographic parameters, functional outcomes, and complications that offer practical recommendations on the suitability of bone grafts for the management of Calcaneal fractures. Methods and analysis: This study performed a comprehensive search on PubMed, EMBASE, and Cochrane electronic to retrieve related clinical studies. The studies incorporated in our meta-analysis were identified after doing a preliminarily screening, reading of the full-text articles, and eliminating repeated studies. After quality assessment and data extraction, the standardized mean difference and risk ratio were selected as effect sizes. The data on Böhler angle, Gissane angle, calcaneal height, American Orthopaedic Foot and Ankle Society hindfoot scores, Maryland Foot Evaluation, and rate of wound infection were analyzed using Revman 5.3 software (Cochrane Collaboration). Results and Conclusions: This study did not reveal any significant differences (P

Background: To examine the relationship of the Bohler's angle with age, sex, and laterality, and to analyze the interrater agreement. ----- Methods: After 248 digital lateral radiographs of the foot were submitted to exclusion criteria, three raters independently measured the Bohler's angle on the remaining 130 X-rays in PACS. The variables were analyzed with correlation coefficients, and one-way ANOVA. The repeated measures of ANOVA were computed across age groups (30-39, 40-49, 50-59, and 60-69 years). The interrater agreement was calculated using intraclass correlation coefficient (ICC). ----- Results: The mean value of the Bohler's angle was 34±5° (21-46°). It was not related to age (in general [p=0.057], and across groups [p from 0.107 to 0.122]), sex (p=0.344; p=0.342), and laterality (p=0.618; p=0.617). The interrater reliability was almost perfect (ICC=0.94). ----- Conclusions: The Bohler's angle was not related to age, sex, and laterality, whereas the interrater agreement was almost perfect.

Background The extensile lateral approach (ELA) has been widely used to treat displaced intra-articular calcaneal fractures (DIACFs) and remains the gold standard procedure. Orthopedic surgeons are extremely concerned of the high rate of wound complications. This study intended to report a new surgical technique of the lateral wall osteotomy combined with an embedded biodegradable implant for treating DIACFs and assess clinical and radiological results. Methods From May 2013 to December 2015, a total of 17 patients with 19 calcaneal fractures underwent surgical treatment using our new technique. Radiographic images, computed tomography (CT) scans, and magnetic resonance (MR) images of the operative limb were obtained to assess fracture healing and biodegradable implant degradation. American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at the last follow-up was obtained to assess functional result for all cases. Böhler’s and Gissane’s angles, width, and height of the injured calcaneus were analyzed using preoperative and last follow-up radiographic images. Results All radiological parameters were significantly improved at the last follow-up, with an increase of 15.58°, 8.38°, and 7.65 mm in Böhler’s angle, Gissane’s angle, and calcaneal height, respectively, and a decrease of 2.51 mm in calcaneal width (p

Purpose: To compare the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of displaced calcaneal fractures. Methods: Reports of studies using case-controlled trials (CCT) to compare the percutaneous poking reduction and fixation with the open reduction and fixation in the management of calcaneal fractures were retrieved from the Cochrane Library, PubMed Database, CNKI, Chinese Biomedical Database, Wanfang Data (from January of 2005 to August of 2015). Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.0 was used for data-analysis. Results: Fifteen articles were included in the meta-analysis. Comparison of the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of calcaneal fractures revealed statistical significance in the incidence of complications after operation [RR = 0.32, 95% CI (0.20, 0.5), p 0.05] and calcaneal Gissane angle [WMD = −3.21, 95% CI (−6.75, 0.33), p > 0.05], nor statistical significance in the rate of good foot function after operation [RR = 0.95, 95% CI (0.90, 1.00), p > 0.05]. Conclusion: For the treatment of calcaneal fractures, percutaneous poking reduction and fixation is superior to open reduction and fixation in terms of the incidence of postoperative complications. But both techniques can obtain satisfactory clinical function.

Category: Hindfoot; Trauma Introduction/Purpose: The lateral extensile approach (LEA) to the calcaneus has long been a popular surgical approach to treat calcaneal fractures. However, high rates of wound complications have led surgeons to investigate alternative approaches. As a result, the sinus tarsi approach has grown in popularity. The lateral extensile approach affords substantial visualization of the calcaneus. However, this visualization has never been compared in a quantitative manner to the sinus tarsi approach (STA). The objective of this cadaveric study is to compare calcaneal visualization afforded by a sinus tarsi approach and a lateral extensile approach. Methods: Seven pair-matched, fresh-frozen, below-knee cadaver specimens were obtained. For each pair, one side received an LEA and the other side received a STA. To identify areas of the calcaneus accessible by instrument, a curette was used to mark the visualized calcaneal surfaces. The calcaneus was then disarticulated and cleared of all soft tissue. The curette markings were then identified and marked with blue surgical marker. Photos were taken of each calcaneus, and visualized surface areas were calculated using Image J software. Results: There were no statistically significant differences in the articular surfaces accessible between the two approaches (831.99 mm2 for LEA vs. 903.41 mm2 for STA, p=0.53) including the anterior, middle, and posterior facets. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA (p=0.02). The LEA allowed better exposure to the lateral wall (pConclusion: In comparison to the LEA, the STA allows for equivalent exposure to articular surfaces. While the LEA allows for greater exposure of the lateral wall and posterior tuberosity, direct visualization of these structures may not warrant the higher risk of wound complications. Surgeons should be mindful of these differences when choosing a surgical approach in the treatment of calcaneal fractures.

Category: Trauma Introduction/Purpose: Displaced intraarticular calcaneus fractures comprise the majority of all calcaneus fractures. Many are indicated for open reduction and internal fixation (ORIF) through an extensile lateral approach (ELA). Unfortunately, this approach has reported complication rates of up to 32%. Improved edema management may reduce the incidence of complications. While compression wrapping has been shown to reduce wound complications in ankle arthroplasty, it has not been well studied in lower extremity trauma. This study aimed to evaluate the benefit of compression wrapping in calcaneus fractures treated surgically with an ELA. Methods: This study included 19 patients from 2015-2018 who underwent ORIF of closed intra-articular calcaneal fractures via an ELA by two surgeons. Demographics, comorbidities, fracture characteristics, and time to surgery were recorded. Following surgery, the extremity was initially immobilized in a short leg splint with transition to serial compression wrappings on postoperative day two. Wrappings involved application of multi-layered cotton cast padding and short stretch elastic bandages to the extremity in a distal to proximal fashion. Wraps were replaced every three days by trained physiotherapists until the two- week postoperative visit. The primary outcome was development of a wound complication. A minor complication was defined as wound appearance prompting initiation of oral or IV antibiotics or local wound care. A major complication was defined as development of flap necrosis or return to the OR for debridement. Results: Mean age was 47.7 years. 3 patients (15.7%) were diabetic, and 7 patients (36.8%) were smokers. Mean BMI was 26.9 kg/m2 (SD 4.4). Mean time to surgery was 11.4 days from injury (SD 6.93). The rate of minor soft tissue complication was 4/19 (26.3%); 2 patients required oral antibiotics only, 1 local wound care only, and 1 both antibiotics and local wound care. The rate of major complication was 2/19 (10.5%), with 1 patient requiring a return to OR and another requiring both a return to the OR and IV antibiotics. Of those patients, 1 was noncompliant with the protocol. All patients progressed to eventual soft tissue healing. Statistical analysis identified diabetes as a risk factor for any complication (p=0.02, relative risk 5.3). Conclusion: Compression wrapping resulted in a low incidence of major soft tissue complications in calcaneus fractures treated with an extensile lateral approach. Compression wrapping is an effective method of post-operative soft tissue management for calcaneal fractures, and may have further applications for similar high energy foot and ankle fractures. Further studies are warranted to determine whether this novel wound care technique is superior to standard post-operative wound care.

Category: Trauma; Hindfoot Introduction/Purpose: Fractures of the calcaneus are life-changing events with a major socioeconomic impact from lost productivity. Traditional operative treatment with the extensile lateral approach has shown relatively high rates of wound complications. Less invasive approaches can improve fracture alignment and decrease wound healing complications. The purpose of this study is to report our experience with the sinus tarsi approach in treating calcaneus fractures. Methods: We retrospectively identified patients at our institution treated with a limited sinus tarsi approach for calcaneus fractures from 2009-2018. Demographic and radiographic data were collected including: age, sex, mechanism of injury, occupation, presence of diabetes, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements. Results: Our analysis included 105 fractures in 100 patients: 86% males, 42% smokers, 4% diabetics, with an average body mass index of 26.5. The fractures were: Sanders type 2 (32%), type 3 (48%), type 4 (18%), and 2% were a tongue-type variant. Preoperatively 38% of fractures displayed a negative angle, 50% had an angle 0-20 degrees, and 12% over 20 degrees; postoperatively 13% had an angle 0-20 degrees, and 87% had an angle over 20 degrees. Of patients working prior to the injury, 72% had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 12% (12/100), with only 2% (2/100) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p=0.55). Conclusion: The limited sinus tarsi approach for depressed calcaneus fractures allows radiographic restoration of calcaneal height with a low rate of wound complications, even amongst active smokers. To the authors’ best knowledge, this is the largest published case series of calcaneus fractures treated with the sinus tarsi approach. Further follow up is needed to determine the success of this approach in mitigating long term complications.

The aim of this study was to analyze the management of displaced intra-articular calcaneal fractures in children at our pediatric orthopedic and to determine the results following open reduction via minimally invasive sinus tarsi approach and fixation with Kirschner wires (K-wires). Overall, 25 available cases of calcaneal fractures in children with mean age of 9.8 years were treated by open reduction from January 2010 to December 2015. All patients were followed up from 12 to 30 months (mean: 19 months). Clinical functional outcomes were graded using the American Orthopedic Foot and Ankle Society hindfoot scores. Radiographic evaluation included measurement of the Bohler's angle and Gissane's angle of the calcaneus on the lateral view. All fractures healed within 3 months. According to the American Orthopedic Foot and Ankle Society foot scoring system, the mean scores of type II fractures were 92.7±2.1, type III 90.2±1.8, and type IV 89.7±2.7 at the latest follow-up. The preoperative and postoperative Bohler's angles were 17.1°±10.7° and 35.9°±6.7° in Sanders type II fractures, 14.4°±11.5° and 34.7°±8.5° in type III, 9.3°±9.7° and 35.1°±4.9° in type IV, respectively. The preoperative and postoperative Gissane's angles were 102.6°±11.5° and 125.7°±7.8° in Sanders type II fractures, 101.7°±9.1° and 117.5°±10.8° (P

The aim of this study was to investigate the risk factors of wound infection after open reduction and internal fixation of calcaneal fractures. In all, 299 patients with 318 calcaneal fractures who underwent open reduction and internal fixation by a single surgeon were grouped according to different outcomes. We gathered the data on each patient including sex, age, injury mechanism, body mass index (BMI), time to operation, fracture type, associated injuries, treatment course, tourniquet time, blood loss, bone graft (yes or no), diabetes (yes or no), smoking history, and complications. Univariate analysis and multivariable analysis were used to determine the association between risk factors and wound infection. Patients who met the entry criteria included 267 males and 32 females with a mean age of 38.6 years. Among them, 5.3% (n = 17) suffered wound infection, and all of the wounds healed after different treatments. According to the univariate analysis, the patients who developed wound infections were active smokers, more obese (higher BMI), had a longer time from injury to operation, and longer tourniquet time. Multivariate analysis indicated that a higher BMI, delayed operation, and active smoking were independent risk factors for wound infection after open reduction and internal fixation of calcaneal fractures. Patients with calcaneal fractures who were smokers and had a higher BMI had a high risk of wound infections. We suggested that surgeons wait to operate until swellings of the injured foot improved, and we also suggested the operation should be within 14 days after the injury.

Background The ideal treatment for comminuted intraarticular calcaneal fractures is still debated. Open reduction and internal fixation (ORIF) is the most popular surgical procedure; however, wound complications, implant choice, and infection remain major concerns. This study aimed to demonstrate the results of an innovative, minimally invasive surgical procedure, namely, a closed reduction technique using large-diameter Steinmann pins and percutaneous calcaneoplasty using injectable calcium sulfate cement (MIIG X3, Wright Medical Technology, Inc., Arlington, TN), in patients with comminuted calcaneal fractures. Methods From January 2012 to January 2014, 20 patients (three women, 17 men) with comminuted calcaneus fractures (Sanders classification type III and Essex-Lopresti classification joint-depression type fracture) were included. Plain films and CT scans were obtained preoperatively in all patients. The operation was performed within three days post-injury, and patients were not allowed to bear weight until three months postoperatively. During this period, the patients were educated on how to perform bed exercises for joints above the surgical site, including muscle strengthening and body conditioning. Early active range of motion exercises for the ankle and forefoot began 3 to 6 weeks postoperatively. All patients were followed up regularly. The results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and Böhler’s angle of the calcaneus. Results After an average follow-up of two years, none of the patients required further surgery or experienced soft tissue complications. The clinical results were rated good to excellent on the AOFAS scale in 80% of the cases (16 of 20 patients), and most patients had pain relief and returned to their former daily activities at the same level as before the injury. Conclusions A modified Essex-Lopresti procedure with percutaneous calcaneoplasty appears to be a safe and effective procedure to treat comminuted calcaneal fractures with acceptable functional results. Long-term outcomes and additional cases using this technique are required to support our conclusion.

Introduction: Patients with lower extremity fractures have a high incidence of peri- and postoperative complications, such as extensive swelling, blisters, surgical wound infection, slow wound healing, persistent wound drainage and suture dehiscence. In calcaneal and tibial plafond fractures and ankle fractures/dislocations, especially in patients older than 50 years and those with diabetes, these complications are associated with a longer hospital stay and increased treatment costs and morbidity and mortality rates. The objective of this study is to perform a literature review of the management of blisters in lower extremity fractures and, based on the findings, to develop a management protocol for these lesions. Methods: Literature review of the state of the art in international databases. Articles published in indexed journals from 1995 to 2014 addressing soft-tissue management in ankle, calcaneal and tibial plafond fractures were selected. Results: Various treatment methods have been described in the literature: observation without intervention, application of sterile dressing, content aspiration, removal of the blister roof and application of an antibiotic ointment or topical treatment alone; all have similar outcomes regarding the delay in definitive surgery and the incidence of mild and severe soft-tissue complications. No large studies comparing these treatment alternatives are available. Conclusion: There is no consensus in the literature on the proper management of blisters. Further studies should be performed to define a protocol for the management of these lesions.

Background This randomized controlled trial compared the clinical outcomes and complications of a novel minimally invasive percutaneous osteosynthesis (MIPO) with those of conventional treatment via an extended L-shaped lateral approach for calcaneal fractures. Methods Sixty-four patients with displaced intraarticular calcaneal fractures were enrolled. The patients were randomly allocated to receive either MIPO (29 patients) or open reduction and internal fixation via an extended L-shaped lateral approach (35 patients). The same calcaneal plate (AO Synthes, Oberdorf, Switzerland) was used in both groups. The primary clinical outcomes included operative time, VAS postoperatively, and wound healing complications. Secondary clinical outcomes included time to operation, length of incision, postoperative drainage, length of hospital stay, medical expense, AOFAS score, and SF-36 score. Preoperative and postoperative calcaneal height, width, and length, Bohler’s angle, and Gissane’s angle were compared. Results The operative time in the MIPO group was 52.5 ± 11.1 min, which was significantly shorter than 82.8 ± 16.2 min in the conventional treatment group (P 0.05). The postoperative radiographic data, the Bohler’s angle, Gissane’s angle, and calcaneal height, width, and length in the two groups were comparable (P > 0.05). Conclusions Compared with conventional ORIF, the advantages of MIPO are a considerably shortened operating time and hospital stay, decreased postoperative pain, and reduced risk of wound healing complications.

Background According to the anatomic characteristics of the calcaneus and the sinus tarsi approach, we designed a combined plate. The goal of this study was to retrospectively assess the functional outcomes and complications of treatment with our self-designed plate. Methods From March 2014 to October 2015, 18 patients with closed calcaneal fractures (14 Sanders type II and 4 type III) were treated with our combined locking plate through a minimally invasive sinus tarsi approach. All patients underwent both clinical and radiological evaluations. Results The follow-up duration for all patients ranged from 6 to 13.5 months. The radiographs demonstrated significant corrections of the calcaneal width, length, height, Böhler angle, and Gissane angle from preoperatively to 3 months postoperatively and the last follow-up. However, there were no significant differences in the variables between 3 months postoperatively and the last follow-up. The mean Maryland foot score was 88.1 ± 8.8, in which excellent outcomes were achieved in 11 patients, good in 4, and fair in 3 (excellent and good rate, 83.3% (15 of 18)). No statistical significances in the mean Maryland foot score (88.1 ± 8.8 vs 87.8 ± 10.1, p = 0.9), and the excellent and good rate (85.7 vs 75.0%, p = 1.0) was found between type II and type III fractures. No complications were observed in all fractured feet. Conclusion Treatment with our self-designed combined plate through a sinus tarsi approach may be safe and effective for type II and type III calcaneal fractures. Electronic supplementary material The online version of this article (doi:10.1186/s13018-016-0497-4) contains supplementary material, which is available to authorized users.

Introduction Calcaneal fractures constitute the most common fractures in hindfoot. Lots of controversies exist in the management of calcaneal fractures but now-a-days, it is preferable to perform open reduction and internal fixation and early mobilizatation. Aim To evaluate the functional outcome after open reduction and internal fixation of displaced intra-articular fractures of the calcaneum by locking calcaneal plate. Materials and methods The study was conducted in the Department of Orthopaedic Surgery from September 2013 to April 2016. Thirty intra-articular fractures of the calcaneum were treated by locking calcaneal plate. Patients were followed up for a period of 24 months. Bohler's angle was measured in preoperative, immediate Post-operative period and after 2 years, follow-up was compared. Results were evaluated according to American Orthopaedic Foot and Ankle Society (AOFAS) Score. Results After 24 months of follow-up, all 24 patients were available for evaluation. Radiological union was achieved in a mean time of 12.5 weeks. Mean duration of hospital stay was 21 days. Bohler's angle was significantly higher after 2 years of follow-up when compared with preoperative x-ray. According to the AOFAS, Ankle-Hind foot Scale outcome score results were excellent in 43.3% of the patients, good in 33.3%, fair in 10%, and poor in 13.3% of patients. The mean AOFAS score was 79.9 (Range 49-96). Conclusion Open reduction and internal fixation of intra-articular fractures of the calcaneum with locking calcaneal plate gives good results. Maintenance of calcaneal height and Bohler's angle helps to decrease the incidence of subtalar arthritis.

Wstęp: Autorzy pracy prezentują obserwacje własne z zakresu operacyjnego leczenia złamań stawowych kości piętowej z zastosowaniem przezskórnych zespoleń małoinwazyjnych w skojarzeniu ze zunifikowanym autorskim programem fizjoterapii. Materiały i metody: Są nimi zespolenie Westhuesa oraz jego modyfikacja z dodatkową stabilizacją odłamów kostnych drutami Kirschnera, a także przezskórna stabilizacja sposobem Rąpały. Materiał badań obejmuje lata 1990- 2012, a stanowi go 82 operowanych, w tym 68 mężczyzn (83%) i 14 kobiet (17%). Analizowane złamania kości piętowej klasyfikowano stosując podział Essex-Lopresti, a do oceny wyników czynnościowych w obserwacji odległej posłużono się kryteriami Creighton-Nebraska. Wyniki: Wśród mężczyzn z rozpoznanym złamaniem typu "języka", u których zastosowano zespolenie odłamów kostnych sposobem Westhuesa, wyniki dobre odnotowano u 12 operowanych, czyli u 17,6%, oraz wyniki zadowalające u pozostałych 7, czyli u 10,3%. W grupie kobiet leczonych z powodu złamań stawowych kości piętowej typu „języka” sposobem Westhuesa odnotowano wyniki dobre u 2 operowanych, czyli u 14,3%, oraz wynik zły u jednej z nich, co stanowi 7,1%. Wnioski: Na podstawie analizy zebranego materiału autorzy pracy skłaniają się do stwierdzenia, że wymienione zespolenia odłamów kostnych są jedynie z pozoru małoinwazyjne, a powikłane zwłaszcza powikłaniami skojarzonymi u większości operowanych prowadzą w obserwacji odległej do niekorzystnych wyników czynnościowych. Introduction: The authors present their own observations of the surgical treatment of articular calcaneal fractures using a minimally invasive percutaneous fixation in combination with the unifi ed self-developed physiotherapy program. Material and methods: The analyzed techniques include the Westhues’ technique and its modifi cation with additional stabilization of the bone fragments with Kirschner wires, as well as transdermal stabilization by Rąpała. The research material comprises 82 patients with intraarticular fractures - 68 men (83%) and 14 women (17%) treated surgically between 1990 and 2012. The analyzed calcaneus fractures were divided by Essex-Lopresti scale and evaluation of functional outcome at follow-up was based on the Creighton-Nebraska criteria. Results: Men with the "tongue type" fracture treated using the Westhues’ technique had good functional outcomes in 12 cases (17.6%) and acceptable in 7 cases (10.3%). Women with the “tongue type” fracture treated using the Westhues’ technique had good functional outcomes in 2 cases (14.3%) and in one case, poor (7.1%). Conclusions: After analysis of the material, the authors claim that minimally invasive techniques are not really minimally invasive, taking the observed complications into consideration in most of the patients, which lead to the poor functional outcome at long term follow-ups.

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?

Background The study aimed to analyze the role of axial view in different phases of treatment and demonstrate whether axial view is still useful in evaluating the calcaneal fractures. Methods 156 patients with suspected unilateral calcaneal fractures were enrolled in the study, axial and lateral view of the affected foot and single axial view of the unaffected foot were gained. 16 were excluded due to unsatisfying axial radiograph. The remain 140 patients were eventually included into the study. Two separate assessments were conducted on two occasions with a three weeks interval to diagnose fractures. Lateral views were assessed firstly, and lateral combined with axial views were assessed three weeks later. Each of the 140 sets was evaluated by one of 6 surgeons randomly. Sensitivity and specificity value were compared between the two assessments. A new value Z which can directly reflect the degree of bulge on the calcaneal lateral wall on the axial view were introduced into the study. Z value of the 140 unaffected feet were measured. Data of another group of 31 patients who confirmed their lateral hindfoot pain caused by widening of calcaneus was reviewed. Liner regression was employed to analyze the relationship between angle Z and the severity of lateral pain. Results According to the two assessments, without axial view, specificity value will be significantly lower in diagnosing calcaneal fractures (p = 0.024) and sensitivity value will be significantly lower in distinguishing intra-articular fractures (p < 0.001). The normal threshold of angle Z was estimated from 98.06° to 100.64° (p

The aim of this study was to compare the clinical effect of operative treatment and nonoperative treatment for elderly patients with Sanders II–III calcaneal fractures. The study consisted of 60 patients with Sanders II–III calcaneal fractures who were treated in our institution from January 2007 to April 2012. The clinical effect between the operative treatment group of 32 patients and the nonoperative treatment group of 28 patients was studied. Böhler angle, Gissane angle, subtalar joint motion, calcaneal width, and calcaneal height were measured before and after treatment, and these indexes were also measured on the uninjured foot. All patients were followed-up for at least 2 years, and at the last follow-up, we evaluated foot function that was assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score system. A 10-cm visual analog scale (VAS) was used to measure the degree of pain. Böhler angle, Gissane angle, calcaneal width, and calcaneal height, which were preoperatively and postoperatively measured, had a significant difference in the operative group (P

Background Open reduction with internal fixation (ORIF) and percutaneous surgery (PS) are the most common surgical procedures for the treatment of displaced intra-articular calcaneal fractures. The purpose of this retrospective study was to compare the clinical and radiological results of these techniques and to verify the prognostic value of the radiographic measurement tools proposed in the literature. Methods A consecutive series of 104 calcaneal fractures was included in this analysis. Essex-Lopresti and Sanders classifications were used to evaluate the injuries, and their prognostic correlation was tested. Böhler’s angle was measured pre- and postoperatively and evaluated as radiological outcome. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society hindfoot scale (AOFAS), Maryland Foot Scale (MFS), 17-Foot Function Index (FFI), Short Form-36 (PCS), and a 10-point visual analogue scale (VAS). Results A total of 87 fractures (5 bilateral), 54 in males and 28 in females, were evaluated with a mean follow-up of 77.0 months. Overall mean age was 51.6 years old. The most frequent cause of trauma was a fall from a height. According to Essex-Lopresti, there were 58 joint depression fractures, 26 tongue, and 3 comminute. According to Sanders: 37 type II, 31 type III, and 19 type IV. Patients were divided into three groups according to surgical treatment: 19 in the ORIF group, 35 in the PS Screw group, and 33 in PS K-wire group. The ORIF group obtained significantly better results (82 AOFAS, 86 MFS, 19.6 FFI, 46.2 PCS, 8 VAS) with respect to the PS K-wire group (74 AOFAS, 76 MSF, 26.4 FFI, 40.8 PCS, 6 VAS). The PS Screw group obtained intermediate results (79 AOFAS, 82 MFS, 22.4 FFI, 41.6 PCS, 7 VAS). The restoration of the Böhler’s angle was achieved most frequently (p = 0.02) in the ORIF group, without better clinical results. Conclusion The results were best in the ORIF group, despite its risk of complications, inferior in the PS Screw group, however without statistical significance (p > 0.05), and worse in the PS K-wire group. Finally, our data confirmed the prognostic correlation between the two radiographic classifications used and the clinical outcomes.