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The treatment of calcaneal osteomyelitis is challenging, and no effective treatment has been confirmed. In particular, Pseudomonas aeruginosa is resistant to many treatments and is associated with a high risk of amputation. The induced membrane technique has recently shown efficacy in treating osteomyelitis. In this paper, we present two cases of calcaneal osteomyelitis with Pseudomonas aeruginosa infection treated by the Masquelet technique combined with a fibular free flap. Case 1 involved a 25-year-old woman who developed calcaneal osteomyelitis following a calcaneal open fracture. Case 2 involved a 46-year-old man with paraplegia who developed calcaneal osteomyelitis secondary to a chronic skin ulcer. In the first stage of surgery, the necrotic bone and soft tissue were debrided, and a polymethylmethacrylate cement spacer was implanted into the bone defect. In the second stage of surgery, a free fibula flap was transplanted to the bone defect, and the peroneal artery and vein were anastomosed to the dorsal artery and saphenous vein. In Cases 1 and 2, the C-reactive protein concentration had decreased to normal by 21 and 36 days after surgery, respectively. Both patients showed no recurrence of osteomyelitis for >3 years of follow-up. The Masquelet technique involves the use of an induced membrane with neovascularization around the cement spacer. Drug delivery to the calcaneal region is considered to increase through this membrane, contributing to the suppression of Pseudomonas aeruginosa. The blood circulation in the free fibular flap is stable, contributing to wound healing.

Talar neck fractures, though rare, pose significant challenges in treatment due to their complex nature and potential for severe complications. Despite the fact that most of talar fractures are treated operatively, there is scarcity of clear recommendations concerning appropriate surgical technique and care. Historically, conservative management was favored, but open reduction and internal fixation (ORIF) have become the standard of care. However, merely restoring rotation, axis, and length is insufficient; restoring the articulating surface in an anatomical manner is essential for long-term joint health. Surgical access to the fracture site via anteromedial and anterolateral approaches provides visualization, but risks compromising the sensitive, partly retrograde blood supply to the talar body. While being biomechanically superior, screws inserted from a posterior to anterior direction pose challenges in soft tissue preservation and accurate placement. Despite widespread usage of this technique, postoperative outcomes remain suboptimal with considerable rates of malunion, osteonecrosis and osteoarthritis. An overlooked technique in the literature is the use of a distractor, commonly employed in minimally-invasive surgical calcaneal fracture treatment in order to maintain length, alignment and joint reposition during fixation. With the potential to reduce soft tissue damage and preserve the blood supply minimally invasive techniques present a promising advancement in fracture management of talar neck fractures.

IntroductionAnkle fractures require temporary fixation to allow swelling to subside prior to surgery; this is typically achieved using calcaneal distraction or cast immobilization. We compared the results of these methods in the treatment of Danis–Weber type C ankle fractures.MethodsThis retrospective study analyzed the data of 86 patients with Danis–Weber type C ankle fractures, of whom 40 underwent calcaneal distraction and 46 underwent cast immobilization. Clinical measures including preoperative detumescence time, daily swelling value, skin condition, and pain, SF-36 Health Survey (SF-36) score and ankle scores were compared between the two groups.ResultsBaseline characteristics did not differ significantly between the groups. Calcaneal distraction resulted in a lower preoperative detumescence time (6.22 ± 0.64 vs. 8.94 ± 0.82 days) and lower daily swelling values compared with cast immobilization, leading to a lower skin necrosis rate. Resting pain scores were significantly lower in the calcaneal distraction group than in the cast immobilization group at various postoperative time points (P

Background: The sinus tarsi incision open approach for plate and/or screw fixation of displaced intra-articular calcaneal fractures is a well-accepted method. A more recently introduced method employing a minimal incision approach and a locking intra-medullary nail construct exists. This matched pairs analysis compares the fracture reduction capacity of the minimally-invasively placed calcaneal locking nail with the sinus tarsi incision open method. Methods: Twenty-two displaced intra-articular calcaneal fractures were matched for age, gender, laterality, Essex-Lopresti classification, and soft-tissue injury and managed with either sinus tarsi incision open method (group 1, N=11) or minimally-invasively placed calcaneal locking nail (group 2, N=11). Intra-operative tourniquet time and total operative duration were collected. Follow-up included Gissane and Böhler radiological assessments. Results: Significant differences between groups were identified for tourniquet time (p=0.000002) where group 1 had greater use of and duration of tourniquet control, lower pre-operative Böhler angle (p=0.02973), lower post-operative final follow-up Böhler angle (p=0.000992), lower change between pre- and post-operative final follow-up Böhler angle (p=0.02823), and lower change between pre- and post-operative final follow-up Gissane angle (p=0.01432) than group 2. Conclusion: We identified superior Gissane and Böhler angle restoration with the use of the minimally-invasively placed calcaneal locking nail compared to the sinus tarsi incision open method. Ultimately, a larger patient population is necessary to determine whether the minimally-invasively placed calcaneal locking nail warrants replacing the sinus tarsi incision open approach for operative management of displaced intra-articular calcaneal fractures. Level of evidence: III-Therapeutic study: Retrospective comparative analysis at a single institution Category: Trauma, Surgical Management

PurposeTo compare the effect of two internal fixation methods of calcaneal plate fixation and Philos plate fixation in treating split fractures of humeral greater tuberosity.Patients and methodsA total of 37 patients with split fractures of humeral greater tuberosity were retrospectively analyzed from September 2016 to April 2021. Enrolled patients were divided into Group A (calcaneal anatomical locking plates), and Group B [Proximal Humeral Internal Locking System (PHILOS)]. The demographics, injury-related variables, surgery-related variables, Constant-Murley score, and postoperative complication between the two groups were compared.ResultsThere were 16 in Group A and 21 in Group B. Fracture union was achieved in all patients, with an average of 11.9 months. The mean length of incision was significantly different between groups (Group A, 6.16 cm ± 1.07 cm; Group B, 9.09 cm ± 1.30 cm, p

Background: Primary subtalar arthrodesis (PSTA) is a valid option in treating Sanders IV calcaneal fractures with few studies to assess its outcomes. Methods: Seventeen patients with Sanders IV calcaneal fractures were managed by open reduction and primary subtalar arthrodesis. Functional outcomes were measured by AOFAS-AHS and FAAM-ADL. We also documented time to return to work, union rate, wound complications and the need for second surgeries. Results: Fourteen patients were followed for two years. At final follow-up, the mean AOFAS-AHS score was 74.42 ± 1.95, while the mean FAAM- ADL score was 59.21 ± 1.6. Conclusion: PSTA is a valid option in treating these severe fractures. It may reduce the overall disability time.

Background: Acquired adult flatfoot deformity (AAFD) results in a loss of the medial longitudinal arch of the foot and dysfunction of the posteromedial soft tissues. Hintermann osteotomy (H-O) is often used to treat stage II AAFD. The procedure is challenging because of variations in the subtalar facets and limited intraoperative visibility. We aimed to assess the impact of augmented reality (AR) guidance on surgical accuracy and the facet violation rate. Methods: Sixty AR-guided and 60 conventional osteotomies were performed on foot bone models. For AR osteotomies, the ideal osteotomy plane was uploaded to a Microsoft HoloLens 1 headset and carried out in strict accordance with the superimposed holographic plane. The conventional osteotomies were performed relying solely on the anatomy of the calcaneal lateral column. The rate and severity of facet joint violation was measured, as well as accuracy of entry and exit points. The results were compared across AR-guided and conventional osteotomies, and between experienced and inexperienced surgeons. Results: Experienced surgeons showed significantly greater accuracy for the osteotomy entry point using AR, with the mean deviation of 1.6 ± 0.9 mm (95% CI 1.26, 1.93) compared to 2.3 ± 1.3 mm (95% CI 1.87, 2.79) in the conventional method (P =.035). The inexperienced had improved accuracy, although not statistically significant (P =.064), with the mean deviation of 2.0 ± 1.5 mm (95% CI 1.47, 2.55) using AR compared with 2.7 ± 1.6 mm (95% CI 2.18, 3.32) in the conventional method. AR helped the experienced surgeons avoid full violation of the posterior facet (P =.011). Inexperienced surgeons had a higher rate of middle and posterior facet injury with both methods (P =.005 and.021). Conclusion: Application of AR guidance during H-O was associated with improved accuracy for experienced surgeons, demonstrated by a better accuracy of the osteotomy entry point. More crucially, AR guidance prevented full violation of the posterior facet in the experienced group. Further research is needed to address limitations and test this technology on cadaver feet. Ultimately, the use of AR in surgery has the potential to improve patient and surgeon safety while minimizing radiation exposure. Clinical Relevance: Subtalar facet injury during lateral column lengthening osteotomy represents a real problem in clinical orthopaedic practice. Because of limited intraoperative visibility and variable anatomy, it is hard to resolve this issue with conventional means. This study suggests the potential of augmented reality to improve the osteotomy accuracy. [ABSTRACT FROM AUTHOR]

The treatment of displaced intra-articular calcaneal fractures is not standardized, as many surgeons prefer not to perform surgery, considering a high rate of cutaneous complications associated with the usual extensile lateral approach. The Calcanail® represents a percutaneous osteosynthesis device that is biomechanically more stable than multiple screws or locking plates. While it effectively restores the height and axis of the hindfoot, it appears to be less reliable in achieving articular reduction of the thalamic surface in cases of mixed fractures. Therefore, we developed a new technique suitable for comminuted mixed fractures, using the Calcanail® device with an arthroscopically guided closed reduction internal fixation of the thalamic surface.

Background: Calcaneal fractures are the most common type of tarsal fractures. The sustentaculum tali (ST) offers anatomical stability in calcaneal fractures, and recently, ST screws have been widely used in their treatment. This study aimed to investigate the clinical efficacy and value of ST screw fixation via a modified sinus tarsi approach (MSTA) for treating displaced intraarticular calcaneal fractures (DIACFs). Methods: This study enrolled 64 patients (64 feet): 32 patients in the calcaneal locking plate combined with the ST screw group (CLP-STS Group) and 32 patients in the simple calcaneal locking plate internal fixation group (CLP Group). The minimum follow-up duration was 18 months. Ankle function was evaluated using VAS, AOFAS, and Short Form-36 scores. Imaging evaluation included the Böhler angle, Gissane angle, length, height, and width of the calcaneus, and the Böhler angle in both groups 1 year after surgery. Results: Functional evaluation revealed that postoperative AOFAS and VAS scores in the CLP-STS Group were significantly better than those in the CLP Group. After surgery, the Böhler angle, Gissane angle, and length, height, and width of the calcaneus were significantly corrected compared to the preoperative values; however, the difference in these indicators between the two groups was not significant. Nevertheless, at the 1-year postoperative follow-up, the calcaneal Böhler angle loss in the CLP-STS Group was significantly better than that in the CLP Group. Conclusion: Compared to simple calcaneal locking plate internal fixation, combining the plate with the additionally free ST screw can resolve the limited intraoperative exposure of MSTA, reduce postoperative foot pain in patients, and improve clinical efficacy. [ABSTRACT FROM AUTHOR]

Background: The artificial bone grafts are performed on the defect after reduction of the calcaneal fracture. Generally, it is an artificial bone graft with an implant, and there are a few reports of an artificial bone graft without an implant. Cases: We report three cases (42-year-old male, 67-year-old male, 21-year-old female) of a tongue-shaped calcaneal fracture treated using a cylindrical unidirectional porous β-tricalcium phosphate artificial bone (Affinos®, Kurare co Ltd., Hyougo, Japan) to surgically repair bone defects after reduction. The bone defect is often observed when fracture is reduced in calcaneal fracture. There were significant bone defects, which were then fixed using Affinos® (forming a cylindrical shape block; diameter 10 mm x height 20 mm) to support the bone fragment, an artificial β-tricalcium phosphate bone with a porosity of 57 % (pore size 25–300 μm), characterized by a novel unidirectional porous structure. Postoperative early rehabilitation started with partial load from 5 weeks after surgery and was full weight bearing at 9 weeks after surgery. There was no correction loss and good bone fusion was obtained. By 12 months postoperatively, patients were able to be walking without pain and absorption and bone fusion around the artificial bone were observed maintaining the morphology immediately after reduction. The result was a good clinical result of one excellent (92 points) and two good (81 and 84 points) 1 year after surgery in the postoperative AOFAS Ankle-Hindfoot Scale. Conclusion: Affinos® has a frost-like structure, which endows it with good tissue invasive properties because of the capillary effect. Moreover, it has excellent osteoconduction capability. In these 3 cases, Affinos® showed good strength, affinity, absorption, and bone substitution in a tongue-shaped calcaneal fracture. Further prospective studies are required to confirm our findings.

Introduction: Subtalar dislocation is defined by a simultaneous total separation of the talocalcaneal and talonavicular joints. Lateral variety is the rarest. It is the result of a high energy trauma. It occurs following forced eversion, with the foot locked in a rut with pressure on the lateral aspect of the leg. Articular fractures of the calcaneus occur as a result of axial impact on the greater tuberosity.We report the case of a lateral subtalar dislocation associated with a calcaneal fracture. Case presentation: A 62-year-old man who presented to the emergency room following a 9 m fall. Initial examination revealed a swelling of the right foot and ankle with a deformity giving the appearance of a “flat foot” without skin opening. The neuro-vascular examination was normal.A radiological assessment including an antero-posterior and lateral X-ray of the right ankle and a axial view if the calcaneus, showed a calcaneal articular fracture and a lateral dislocation of the subtalar joint. CT scan confirmed the diagnosis. Closed reduction by external maneuvers failed. Through a lateral mini-approach centered on the subtalar joint, open reduction of the dislocation was achieved and controlled fluoroscopically. Osteosynthesis of the calcaneal fracture was performed using a percutaneous pinning. Consolidation was obtained at 3 months post-operatively.At the last follow-up, the patient reported occasional pain. The radiological assessment showed early arthritic changes of the subtalar joint. Conclusion: In rare cases of subtalar dislocation, the direction of displacement, associated bone injuries, and open reduction would be responsible for a poor functional outcome. At present, there is no certain way to avoid subtalar osteoarthritis.

Abstract Background Compared with open comminuted calcaneal fractures, less emphasis is placed on postoperative surgical site infection (SSI) of closed comminuted calcaneal fractures. This study aimed to identify the risk factors associated with SSI and build a nomogram model to visualize the risk factors for postoperative SSI. Methods We retrospectively collected patients with closed comminuted calcaneal fractures from the Second Affiliated Hospital of Wenzhou Medical University database from 2017 to 2020. Risk factors were identified by logistics regression analysis, and the predictive value of risk factors was evaluated by ROC (receiver operating characteristic curve). Besides, the final risk factors were incorporated into R4.1.2 software to establish a visual nomogram prediction model. Results The high-fall injury, operative time, prealbumin, aspartate aminotransferase (AST), and cystatin-C were independent predictors of SSI in calcaneal fracture patients, with OR values of 5.565 (95%CI 2.220–13.951), 1.044 (95%CI 1.023–1.064), 0.988 (95%CI 0.980–0.995), 1.035 (95%CI 1.004–1.067) and 0.010 (95%CI 0.001–0.185) (Ps

Autografts, allografts, bone graft substitutes, and bone replacement materials have been utilized in isolation or in combination to fill bony defects and enhance fracture healing or arthrodesis in all subspecialties of orthopedics. Although there is a robust literature on the effect of bone grafts on managing large bone defects in long bones and arthrodesis, little has been published on the management of calcaneal bony defects. In this review, we aim to discuss the various options for calcaneal bony defects and the current clinical evidence behind each graft option.

A total of 35 patients with 36 Sanders type 2 and 3 calcaneal fractures were treated with open reduction and internal fixation using the sinus tarsi approach. Wires, screws, plates, and combinations of these were used for the fixation of fractures. The patients were followed for 10-44 months and evaluated for radiological and clinical outcomes. Bohler angle was corrected from a preoperative mean of 0.68 degrees (range: 34.7-23.4 degrees) to postoperative mean of 23.5 degrees (range: 16-40 degrees). Gissane angle was corrected from a preoperative mean of 94.7 degrees (range: 41.8-123.8 degrees) to 110 degrees postoperatively (range: 87.7-135.8 degrees). Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) scoring. The score, at last follow-up was 62-90 with an average of 82. We conclude that the sinus tarsi approach can be used for earlier intervention and permits adequate access for satisfactory reduction of Sanders type 2 and 3 calcaneal fractures and optimum implant placement. The approach is associated with a low incidence of soft tissue complications.

Compound Gustilo-type III intra-articular calcaneus fractures are challenging to treat. Anatomical reduction of the subtalar joint increases the chances of a better functional outcome and is traditionally achieved by an open reduction and plating. Conversely, ORIF is associated with a high risk of infection and even amputation. In our case study, we present the treatment of a Gustilo-type III intra-articular calcaneus fracture with a circular external fixator and a temporary antibiotic cement spacer for fracture reduction and stabilization. Active bio-glass was implanted to fill bone loss and to prevent infection. A closing-wedge calcaneal tuberosity osteotomy was used to facilitate wound closure. We paid special attention to reducing the posterior facet. The patient returned to work and full ambulation five months post-injury.

Abstract:: Objective: To introduce the application of “Hand as Foot” teaching method in calcaneal skeletal traction nursing.

Calcaneal osteomyelitis with pseudarthrosis after calcaneal fracture is rare, and its treatment is challenging. We describe the use of a free fibular osteocutaneous flap to treat a 52-year-old man who presented with calcaneal osteomyelitis and pseudarthrosis after an operation for a closed comminuted fracture. The patient was previously treated with multiple surgeries and antibiotics for 8 months, but he was not cured. We performed radical osteomyelitis bone debridement and reconstruction with a free fibular osteocutaneous flap and autotrabecular bone grafting from the iliac crest. The skin flap survived, and rehabilitation was initiated early. At 2 years postoperatively, his pain and ambulatory function had markedly improved, and he could walk without problems in daily life. Free fibular osteocutaneous flap and autogenous cancellous bone grafting are considered practical options for the treatment of calcaneal osteomyelitis with pseudarthrosis.

The best treatment for displaced, intra-articular fractures of the calcaneus remains controversial and it is generally agreed, that there is no single method that is suitable for all patients.

BackgroundCalcaneal fracture is common and carries high morbidity and disability. Its treatment is therefore of vital concern. Many topics concerning calcaneal fracture remain controversial, and the subject has not yet been well-researched. We aim to analyze and illustrate the trends in development, overall knowledge structure, “hotspots,” and research frontiers on the topic of calcaneal fracture.MethodsLiterature relating to calcaneal fracture published between 2000 and 2021 was retrieved from Science Citation Index Expanded (SCIE) database of the Web of Science. Three bibliometric tools (Bibliometrix, CiteSpace, and VOSviewer software) were used for analysis and the generation of knowledge maps. Annual trends in publication counts and the relative contributions of different countries, regions, institutions, authors, and journals, as well as keyword clusters, “hot topics,” and research frontiers, were analyzed.ResultsA total of 1,687 publications were included in the analysis. The number of calcaneal fracture articles published worldwide each year was highest in 2019, with a total of 128 articles. The United States has made the greatest contribution to the field, with the largest number of publications and the highest H-index. Foot & Ankle International was the most productive journal, publishing a total of 167 articles on calcaneal fracture during the study period. Hebei Medical University of China and the University of California, San Francisco were the most prolific institutions. Professors T. Schepers, S. Rammelt, H. Zwipp, and Y. Z. Zhang have made remarkable contributions to the field. However, the degree of collaboration between researchers and among institutions was relatively low, and took place mainly in Europe and the Americas. All relevant keywords could be categorized into three clusters: studies of internal fixation, studies of fractures, and studies of osteoporosis. A trend of balanced and diversified development could be seen within these clusters. Keywords with ongoing “citation bursts,” such as sinus tarsi approach, wound complications, minimally invasive technique, extensile lateral approach, surgical treatment, and plate, may continue to be research “hotspots” in the near future.ConclusionBased on current global trends, the number of publications on calcaneal fracture will continue to increase. Topics such as minimally invasive techniques and complications have become important hotspots of research. We recommend enhancing international communication and collaboration for future research in this field.

Charcot neuroarthropathy is a progressive condition characterized by joint dislocations, pathological fractures and debilitating deformities. This pathology occurs most commonly in the joints of the foot and ankle. A 36-year-old male with peripheral neuropathy presented with progressively worsening right ankle pain. He rated his pain at 9/10 on the VAS (visual analog scale). Physical examination of the right lower extremity revealed a significant rearfoot valgus, zero degrees of ankle and subtalar joint range of motion, and a three-centimeter shortening of the right lower extremity. Radiographs additionally demonstrated talar collapse with obliteration of the talar body. The patient's symptoms failed to improve with conservative care given the progressively worsening nature of the patient's pathology, and surgical intervention was planned. Due to the advanced Charcot arthropathic degeneration, fragmentation, talar body collapse, limb shortening, and contracture of the gastrocnemius, TTC (tibio-talo-calcaneal) arthrodesis with the use of allogenic femoral head and retrograde intramedullary nailing with a gastrocnemius recession, all followed by application of an external ring fixator was employed. Following surgical intervention, a stable, plantigrade foot was noted with optimal positioning at the ankle joint. At ten-year follow-up the patient reported complete resolution of pain with no complications or recurrence of deformity. This highlights that TTC arthrodesis with FHA (femoral head allograft), when performed in the appropriate patient and setting, can correct deformity, restore limb length, prevent or delay limb amputation, and improve patient functionality and quality of life.

Soft tissue defects of the posterior heel of the foot is very challenging for reconstruction due to the bony prominence and limited local tissue availability. The study was conducted in the department of general surgery, Muzaffarnagar Medical College & Hospital, Muzaffarnagar between June 2022 to December 2023. Ten patients with soft tissue defects over the posterior heel underwent reconstruction using a lateral calcaneal flap. The etiology is trauma in 03 patients (30%), chronic ulcer in 01 and surgical wound dehiscence for repair of Tendo-Achilles in 06 patients (60%). All flaps had good perfusion and survived completely. In 3 cases there was partial loss of skin graft managed conservatively. The lateral calcaneal flap can be used safely to provide sensory skin coverage of posterior heel in single stage. [ABSTRACT FROM AUTHOR]

Summary:. Traditionally, full-thickness wounds with exposed structures are treated with flap coverage or dermal regenerative templates. Most dermal regenerative templates are biologic in origin, but recently synthetic options have become available. One such product is a synthetic hybrid-scale fiber matrix (SHSFM). In this case, SHSFM was used to treat a recalcitrant calcaneal wound. After the wound granulated, it was biopsied, and histopathologic analysis was conducted. A 16-year-old woman involved in a motor vehicle collision sustained multiple traumatic injuries which were stabilized. Postoperatively, she developed a calcaneal infection and associated wound, which developed into a chronic, nonhealing wound. Failed treatments included removal of hardware, multiple debridements, and advanced wound therapies. An SHSFM was then trialed, which led to granulation of the wound without infection. Despite wound healing, the patient subsequently elected to undergo a below-the-knee amputation due to pain and functional disability from posttraumatic ankle arthritis. The heel was biopsied at the time of amputation for analysis. Pathologists noted excellent granulation tissue formation and complete coverage of the wound surface area and 75% of the wound depth, which included epithelialization and decreasing inflammation at wound edges. Collagen deposition and numerous interspersed blood vessels were present. Foreign material and bacteria were absent. No osteomyelitis was observed. This analysis provided the opportunity to investigate the in vivo regenerate from a novel synthetic SHSFM. Given the uniqueness and challenges presented in this case, the usage of this relatively new product warrants further investigation with larger populations and assorted wound etiologies.

Gold standard treatment for a malunited collapsed calcaneal fracture is distraction subtalar joint arthrodesis with structural graft. Various grafts are have been reported in the literature with femoral head or iliac crest allograft being most common. The present case report demonstrates a case of a 64-year-old female who presented two years after attempted subtalar joint fusion. The patient had pain recalcitrant to conservative care with clear bony collapse on weight bearing radiography and complete non-union on computed tomography. A novel technique is presented wherein a dorsally based posterior calcaneal osteotomy is performed and the removed bone wedge placed into the subtalar fusion to serve as structural autograft. The patient remained non-weight-bearing for 8 weeks post-operatively. Computed tomography was obtained at 6 months after surgery noting greater than 40% osseous bridging. The patient had improvement in all symptomatology and had complete return to activity from her baseline before the index surgery. Technique is illustrated along with description of details.

Tongue-type calcaneal fractures cause significant pressure on the soft tissue coverage of the posterior calcaneus, resulting in skin ischemia and necrosis. Literature shows most are fixated with ORIF weeks after the initial trauma, allowing for soft tissue stabilization. No previous case study has reported an open tongue-type calcaneal fracture that was immediately surgically corrected. This case study documents an open tongue-type calcaneal fracture that was surgically corrected immediately following a high energy trauma. A 48-year-old male had a zip lining accident where his brakes failed and he crashed into a tree feet first. The patient presented with a laceration and exposed calcaneal bone to the left lower extremity. Imaging confirmed a tongue-type calcaneal fracture with protrusion of the calcaneus. Procedures performed were incision and drainage of left heel wound, left Achilles tendon lengthening, and open reduction and temporary external fixation of left calcaneus. Surgical intervention resulted in a reduction of the left calcaneus with return to function. This case illustrates a rare occurrence with a novel fix: using an Achilles lengthening and temporary external pinning to reduce an open tongue-type calcaneal fracture immediately following the traumatic incident.

Hoffa fracture is a general term for single condylar or double condylar coronal fractures of the distal femur. It is a rare intra-articular fracture. At present, there is no specific fixation method for such fractures. The traditional method to fix Hoffa fracture mainly includes cannulated screws, however, failures of this type of internal fixation have been reported from time to time. Therefore, many scholars have proposed a more solid internal fixation that used cannulated screws combined with a buttress plate or lateral plate to treat this type of fracture, which has been widely recognized. Currently, there is no specially designed anatomical plate for lateral fixation of comminuted Hoffa fractures. In this report, we demonstrate a comminuted Hoffa fracture fixed by cannulated screws combined with a calcaneal reticular plate. The patient was followed up for 14 months. The knee joint ROM was 0– 120°, and the KSS score was 90 at the last follow-up. The efficacy was excellent according to the evaluation of Letenneur function. There was no pain after the activity and recovered to the pre-injury movement and exercise ability.

This case study presents a treatment algorithm including revision surgery for recurrent displacement of tongue type calcaneal fractures complicated by osteomyelitis and local soft tissue deficit. Most literature focuses on pathologic fractures through infected bone, with prior research citing suture anchors, one versus two stage curettage with use of antibiotic containing calcium phosphate cement. A 36 year old male sustained a displaced tongue type calcaneal fracture who initially underwent cannulated screw fixation. He was lost to early follow up due to social issues and was seen 30 days later with hardware failure, a large posterior soft tissue deficit, soft tissue and bone infection, and fracture recurrence. Patient underwent multiple staged surgeries involving incision and drainage, removal of failed hardware, bone biopsy, antibiotic bead placement, and long term IV antibiotics. Final reconstruction 9 days later included fracture reduction aided by Achilles z-lengthening, internal fixation, and a medial forearm fasciocutaneous free flap to address the posterior soft tissue deficit. Limb loss was a possible outcome without a multidisciplinary approach including a free flap from our plastic surgery partners. The treatment protocol outlined in this report emphasizes the importance of early removal of failed hardware, repeat irrigation and curettage, antibiotic impregnated beads for local antibiotic delivery, targeted IV antibiotic therapy, serial bone biopsy, and interdisciplinary consultation for management of a large skin defect compromised by infection.

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.

Summary:. The thoracodorsal artery perforator (TDAP) flap has a long vascular pedicle that is ideal for lower extremity reconstruction, but it generally relies on the presence of a dominant septocutaneous perforator vessel. Surgical delay optimizes flap survival by creating relative ischemia to augment perforator vessels. In this report, we describe the use of a delayed free TDAP flap in the setting of an absent dominant perforator vessel for the reconstruction of a calcaneal degloving injury. A 22-year-old actively smoking patient with a body mass index of 33.5 presented with a nonhealing left heel wound with overlying necrotic changes after traumatic degloving injury. The entire weight-bearing portion of the calcaneal fat pad and the flanking regions were debrided. The TDAP flap was elevated, revealing three small thoracodorsal artery perforators. Given that a dominant perforator was absent, the flap was surgically delayed. Free-tissue transfer occurred 8 days later. This operation was conducted entirely in left lateral decubitus with simultaneous wound preparation and flap harvest. The flap was elevated on two perforators to elongate the pedicle’s length and inset to cover exposed calcaneus and pad the heel. Six months postoperatively, the patient is doing well without flap compromise or ulceration. The TDAP flap is a versatile microsurgical tool, and surgical delay extends the utility of this flap when a dominant septocutaneous perforator is unavailable. Recipient site debridement may occur simultaneously with the TDAP delay procedure. Importantly, only one position is required for flap elevation, microsurgical anastomosis, and insetting, thus obviating intraoperative repositioning.

The aim of this report is to aid the trauma surgeon with some technique tips to aid with maintaining and obtaining reduction of these complex tongue-type calcaneal fractures. This will be conveyed via two case examples (high- and low-energy fracture patterns), each requiring different principles of fixation.

This case report demonstrates a paediatric calcaneal stress fracture not seen on traditional radiograph but diagnosed by MRI. A young athlete presented at age 15 with heel pain and no trauma. Calcaneal stress fractures in children are rare and could be underdiagnosed since radiographs are often false negative especially in the early stages. Therefore, calcaneal stress fractures with a normal radiograph could be misclassified as Server's injury. The treatment strategy for a calcaneal stress fracture is more aggressive than for Server's injury and therefore distinction towards a stress fracture is important to choose the optimal treatment. Consequently, when a child presents with acute limp, refusal to walk and/or heel pain, with no evident trauma and negative radiographs further investigation is needed. We propose performing a bone scintigraphy or MRI to avoid overlooking stress fractures of the calcaneus and misclassify these fractures as Sever's injury.

Background: This study aims to compare the efficacy of the sinus tarsal approach (STA) with that of the conventional L-shaped lateral approach (CLSLA) in the treatment of calcaneal fractures by meta-analysis.Methods: PubMed, Embase, Web of Science, the Chinese National Knowledge Infrastructure, and China Wanfang database were searched to collect clinical randomized or non-randomized controlled trials of STA and CLSLA in the treatment of calcaneal fractures from January 2010 to May 2020. The data were analyzed by Stata 15.0 software.Results: A total of 12 clinical trials were included, all of which were retrospective studies, including 961 patients. The results showed that when STA was compared with CLSLA, there was no difference in operation time with mean difference (MD) = −5.51 [95% confidence interval (CI): −12.57 to 1.55, P > 0.05], less bleeding during operation with MD = −18.49 (95% CI:−23.79 to −13.18), no difference in Böhler angle after an operation with MD = 0.78 (95% CI: −0.09 to 1.65) and in Gissane angle with MD = −0.07 (95% CI: −1.90 to 1.77), no difference in American Orthopedic Foot and Ankle Society score with MD = 2.16 (95% CI: −1.07 to 5.38), higher-excellent and better rate of Maryland food function with relative ratio = 1.12 (95% CI: 1.04 to 1.20), and lower of incidence of postoperative complications with relative ratio = 0.23 (95% CI: 0.14–0.37).Conclusion: STA was more effective than CLSLA in the treatment of calcaneal fractures. Moreover, STA had advantages in less intraoperative bleeding, higher-excellent and better rate of Maryland foot function, lower incidence of postoperative complications, and higher safety.

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

Background: Due to pressures of lifestyle and survival, both the urban and rural sections of society cannot give enough time for follow-up, thereby compelling many individuals to discontinue physiotherapy treatment. Treatment of plantar fasciitis (PF) requires multiple sessions and therefore falls into the scope of this problem. Taping has the advantage that it remains on the patient for multiple days and therefore negates the need for the patient's follow-up. If a single session of taping can deliver outcomes comparable to conventional LASER therapy, it would become a viable alternative solution for this problem. The aim was to compare and analyze the change in ankle muscle strength, flexibility, dorsiflexion, range of motion, and foot function in individuals with PF between the taping and LASER group. Materials and methods: Sixty-one participants diagnosed with PF were randomly allocated into a study and control group. The study group received a single session of low-dye calcaneal taping while the control group received five sessions of LASER therapy. Both the groups received a home exercise program. A pre- and post-intervention assessment of all the variables was done for both groups. Results: A within-group analysis using the Wilcoxon signed-rank test showed a significant difference in all the variables in both the laser and taping group (p < 0.05). A between-group analysis using the Mann–Whitney U test showed no difference in outcomes between the taping and laser groups (p > 0.05). Conclusion: A single session of taping can provide comparable outcomes as a conventional LASER therapy for short-term benefits in individuals with PF. CTRI registration number: CTRI/2018/02/011850

Introduction: Joint preserving surgery for flatfoot reconstruction utilizes correction of bony malalignment and medial soft tissue reconstruction. A medial displacement calcaneal osteotomy (MDCO) can be an essential adjunct to deformity correction and good patient outcomes. Our cadaveric study compares three different surgical techniques utilizing two cannulated screws to best maintain medial translation of the calcaneal osteotomies. Materials and methods: Fifteen above knee fresh-frozen, matched pair cadaveric specimens (30 limbs) were randomized equally to three groups. MDCO were performed on all specimens, followed by manual 10 mm translation. The groups consisted of a “simultaneous drilling,” “staggered drilling,” and a control group, which involved simultaneous drilling of only the near cortex. Following screw fixation, the calcaneal tuberosity was manually translated in a lateral direction. The loss of correction was measured in millimeters. Results: The “simultaneous” drilling group experienced the greatest mean loss of correction at 2.6 mm (range 1.37–3.48 mm). The “staggered” group showed an average loss of 1.16 mm (range 0.36–2.67 mm). The control group demonstrated the greatest maintenance of correction with a mean loss of 0.036 mm (range 0.01–0.06 mm). Conclusions: MDCO realigns the hindfoot adding support to the medial soft tissue reconstruction during flatfoot correction. Loss of initial correction may result in residual deformity and poor long-term outcomes. Our study demonstrates that simultaneous drilling of only the tuberosity near cortex prior to screw fixation was the best at maintaining osteotomy correction. Level of evidence: : Level V, Cadaveric study

Introduction: Pathologic calcaneal fractures, often arising from osteomyelitis, present intricate challenges in orthopedic surgery. This paper explores the historical context, etiological factors, and evolving treatment approaches for these fractures, with a focus on the interplay between infection and compromised bone integrity. Methods: A retrospective analysis of four cases of pathologic calcaneal fractures complicating osteomyelitis, treated at the University of Pittsburgh Medical Center from 2017 to 2021, was conducted. The patients underwent debridement, external fixation, and long-term antibiotic therapy. A comprehensive literature review was conducted, encompassing all relevant papers discussing surgical treatment strategies for pathologic calcaneal fractures. Results: The case series reveals the complexities of managing these fractures. While external fixation stabilized the fractures and facilitated infection control, the outcomes varied. Some patients achieved fracture union and improved ulceration, while others experienced complications and, tragically, mortality due to underlying comorbidities. Discussion: Treatment modalities for osteomyelitis-related calcaneal fractures encompass debridement, external fixation, and tailored antibiotic therapy. Debridement is essential for infection control and wound preparation. External fixation provides stability, facilitates wound care, and allows for antibiotic delivery. Antibiotic therapy complements surgical interventions and targets the infection. However, challenges persist, including compromised overall health, persistent infection, and limited long-term outcomes. Conclusion: Pathologic calcaneal fractures complicated by osteomyelitis pose a formidable clinical challenge. Despite innovative approaches like the use of suture anchors and external fixation, achieving successful outcomes remains elusive. These cases often result in substantial morbidity and, at times, mortality due to the intricate interplay of infection, compromised bone quality, and comorbidities. Clinicians must balance aggressive intervention with a realistic assessment of the patient's overall health and prognosis. Further research and standardized treatment approaches are imperative to address the unique complexities of these cases and improve patient outcomes.

Background: Reduction of calcaneal fractures using the sinus tarsi approach can be challenging due to limited visualization of the fragment fragments and lack of direct access for reduction instrumentation. The present study introduces a modified reduction technique using a percutaneously placed two pin joint distractor along the medial wall of the calcaneus to assist with reduction. Case Study: We present the treatment of a 44-year-old male with Sanders IV calcaneus fracture. Multiple reduction techniques were attempted through a sinus tarsi approach including use of a traction pin through the calcaneal tuberosity. Adequate reduction was then attained using a two-pin joint distractor inserted percutaneously along the medial aspect of the calcaneus at the sustentaculum tali and tubor. Adequate reduction with this method provided adequate reduction for definitive fixation. This technique has been reproducible at our institution. Conclusions: The technique described in the present study may assist surgeons in the reduction of difficult calcaneus fractures with minimal invasiveness. The technique can be used to realign the calcaneus with minimal soft tissue dissection and can be performed immediately following injury in instances of extensive soft tissue swelling. Percutaneous reduction avoids the risk of wound complications and infection that is common with the lateral extensile approach. Minimally invasive reduction and fixation of the calcaneus as described is technically demanding, and hindfoot osteology and surface anatomy should be understood.

Purpose: This study was aimed to compare conventional surgery and surgery assisted by 3D printing technology in the treatment of calcaneal fractures. In addition, we also investigated the effect of 3D printing technology on the communication between doctors and patients. Methods: we enrolled 75 patients with calcaneal fracture from April 2014 to August 2016. They were divided randomly into two groups: 35 cases of 3D printing group, 40 cases of conventional group. The individual models were used to simulate the surgical procedures and carry out the surgery according to plan in 3D printing group. Operation duration, blood loss volume during the surgery, number of intraoperative fluoroscopy and fracture union time were recorded. The radiographic outcomes Böhler angle, Gissane angle, calcaneal width and calcaneal height and final functional outcomes including VAS and AOFAS score as well as the complications were also evaluated. Besides, we made a simple questionnaire to verify the effectiveness of the 3D-printed model for both doctors and patients. Results: The operation duration, blood loss volume and number of intraoperative fluoroscopy for 3D printing group was 71.4 ± 6.8 minutes, 226.1 ± 22.6 ml and 5.6 ± 1.9 times, and for conventional group was 91.3 ± 11.2 minutes, 288.7 ± 34.8 ml and 8.6 ± 2.7 times respectively. There was statistically significant difference between the conventional group and 3D printing group (p < 0.05). Additionally, 3D printing group achieved significantly better radiographic results than conventional group both postoperatively and at the final follow-up (p < 0.05). However, No significant difference was noted in the final functional outcomes between the two groups. As for complications, there was no significant difference between the two groups. Furthermore, the questionnaire showed that both doctors and patients exhibited high scores of overall satisfaction with the use of a 3D printing model. Conclusion: This study suggested the clinical feasibility of 3D printing technology in treatment of calcaneal fractures.

In this case report, two horses with chronic refractory infections in the tuber calcanei were successfully managed via intravenous antibiotic regional limb perfusion through the lateral saphenous vein after failure of conventional treatment approaches, including surgery and intravenous regional limb perfusion using the cranial branch of the medial saphenous vein. Surgical delay in these cases may have allowed the development of chronic infection, which prevented the conventional regional perfusion from working effectively. The spatial difference of the vessels relative to the tuber calcanei possibly contributed to the treatment outcome in these horses. This report describes a novel approach for regional antimicrobial perfusion to the equine plantar hock region using the lateral saphenous vein. [ABSTRACT FROM AUTHOR]

Background: There is an ongoing debate if bone graft substitutes (BGSs) are beneficial in the treatment of displaced intra-articular calcaneal fractures (DIACFs). The purpose of this study was to evaluate the effect of an injectable calcium sulfate/hydroxyapatite BGS (CERAMENTTM iBONE VOID FILLER, BONESUPPORT AB, Lund, Sweden) in internal fixation of calcaneal fractures. Methods: The records of patients presenting with calcaneal fractures type Sanders III and IV and treated with internal fixation plus BGS were reviewed. Radiographs were analyzed using different measurements (including Böhler's angle and calcaneal facet height). The clinical outcome was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Results: A total of 20 fractures were available for radiographic and clinical examination at a minimum follow-up of 12 months. No decrease in Böhler's angle was recorded in six fractures, a reduction of

Fracture-dislocations of the midfoot are relatively rare injuries. We present a case of a 20-year-old man presenting with navicular-cuneiform and calcaneal-cuboid fracture-dislocation of his right foot due to a crush injury during work. The patient's injury was treated by open reduction internal fixation.

Introduction: Calcaneal articular facet of talus plays an important role in joint stability as well as in mobility. In many diseases of foot viz., talocalcaneal arthritis, coalition, intra-articular fracture, congenital flatfoot, valgus deformity; as well as in different surgical procedures viz., triple arthrodesis, internal and external fixation, osteotomy, and anatomic reduction; the size and shape of bones, the inter-relationship of talus and calcaneum with other bones of foot is an important clinical consideration. Aim: To explore the variability of the types of the calcaneal facets of talus in population of West Bengal, India. Materials and Methods: An observational descriptive study was conducted with dry specimens of tali preserved in Department of Anatomy of medical teaching institutions of Kolkata for six months; with 144 tali of unknown age and sex (69 right and 75 left-sided), collected from bone libraries of seven different medical colleges of West Bengal by non probability sampling. The borders of the calcaneal articular facets were traced with colour sketch pen, following which authors unanimously agreed upon the ‘type’ of the calcaneal facets on visual impression as was guided in the mostly used classification standard method as described by Arora AK et al., and Kaur M et al. Data was extrapolated and analysed in Microsoft excel software 2010. Results: Out of 144 tali (right=69, left=75) maximum number of type II (47.92%) was observed. For right-side, type I, II and V facets in 47.83%, 43.48% and 8.70% were observed respectively. On left-side, type I- 36%, type II- 52%, type III, IV, V 4% was observed each. Authors did not find any type III or type IV on right-side. Conclusion: Maximum prevalence of the type II articular facet was found and absence of type III/IV facets in the right-side in the current study population provides us a reflection of the anthropometric data for the population of West Bengal, but there remains scope of further study with larger sample size supported by imaging facilities.

ObjectiveDisplaced intra-articular tongue-type fractures are often treated with surgical interventions, and there is a lack of consensus regarding the surgical approach. This retrospective cohort study aimed to compare percutaneous cannulated screw (PCS) fixation and plating with a minimally invasive longitudinal approach (MILA) after closed reduction for the treatment of tongue-type calcaneal fractures.Materials and MethodsA total of 77 patients with intra-articular tongue-type calcaneal fractures between September 2015 and July 2019 were included in this study. They were randomly allocated into two groups: PCS fixation (n = 32) and MILA (n = 45). The outcome measures included demographic variables, operation time (OT), preoperative time (POT), hospital stay time (HST), blood loss, visual analog scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, postoperative complications, and imaging parameters. The patients were clinically examined at 1, 3, 6, and 12 months, with a final follow-up period of 27 months.ResultsNo significant differences were observed during the follow-up in calcaneal length, height, Gissane's and Böhler's angles, VAS scores, AOFAS hindfoot scores, or complication rates between the two groups. However, the postoperative VAS scores in the PCS group were significantly lower than those in the MILA group (p < 0.05). Furthermore, the OT, POT, and HST in the PCS group were significantly shorter than those in the MILA group (p < 0.05). Blood loss was lower in the PCS group than those in the other group (p = 0.044). However, postoperative calcaneal widening was significantly smaller in the MILA group than that in the PCS group (p < 0.001).ConclusionsAfter closed reduction for the treatment of tongue-type calcaneal fractures, PCS fixation was superior to MILA in terms of OT, POT, HST, blood loss, pain, and degree of comfort. Meanwhile, MILA has the advantage of restoring the calcaneal width. Under the same rehabilitation program, the two approaches showed similar abilities in maintaining the closed reduction.

Purpose: Dorsal closing wedge calcaneal osteotomy (DCWCO) is indicated in patients with insertional tendinopathy of the calcaneal (Achilles) tendon. The Chauveaus-Liet's (CL) angle is represented by the difference between the angle of verticalization (α) and morphological angle (β) of the calcaneus (CL angle = α − β). The purpose of the study was to assess whether the DCWCO affects the Chauveaus-Liet's angle. Methods: The study included 12 patients indicated to DCWCO. Three directions of close wedge osteotomy were designed for each patient—horizontal, vertical and in the middle type of osteotomy and a virtual osteotomy was created in each of them in the ABAQUS system in cooperation with Czech Technical University. The most used directions of osteotomy according to the available literature were used. We evaluated α and β angles before and after osteotomy, changes of the length plantar aponeurosis and the elevation of distal insertional point of the calcaneal tendon. The changes of grades, median and standard deviation were observed. Results: The change of the alfa angle was dependent on the direction of the osteotomy and the change of the beta angle was affected by the size of the osteotomy. The greatest elevation of the distal insertional point of the calcaneal tendon occurred in the horizontal type of the osteotomy. Conclusion: Our study shows that the more we want to reduce the tension in the calcaneal tendon, the more we have to perform an osteotomy horizontally. This study could serve as a preoperative guide for osteotomy planning. [ABSTRACT FROM AUTHOR]