Calcaneal fractures

NewsBot · Oct 3, 2022

Calcaneus Fracture Fixation in Prone Position: A Novel Technique and Case Series
Khalid Hasan et al
Cureus. 2022 Aug 27;14(8):e28480

Introduction: Calcaneus is one of the most commonly fractured tarsal bones. The use of computed tomography (CT) has enabled more accurate fracture configuration and classification of fractures. The outcomes of operative versus nonoperative treatment of these fractures have been extensively debated with variable results. Significant complications following intra-articular fractures have been reported in the literature despite management by experienced surgeons. This article will discuss the treatment of calcaneus fractures by open reduction and internal fixation in a prone position with a calcaneal traction pin, and assess the outcomes following this novel technique.

Methods: Fifty-three patients with 58 acute displaced intra-articular calcaneal closed fractures (Sanders type II and III), presented to one tertiary center, were treated by open reduction and internal fixation in a distracted prone position through an extensile lateral approach by a single surgeon and assessed for postoperative wound and soft tissue complications. The primary outcome measure was postoperative wound complications. Secondary outcome measures were postoperative ankle and subtalar range of motion and return to work. Radiological assessment of anatomical reduction by measuring preoperative and postoperative Bohler's angle, Gissane angle, and posterior facet joint depression was conducted. A comparison was made with paired sample t-test with a confidence interval of 95%.

Results: Fifty-three patients with 58 calcaneus fractures were treated surgically. Three cases (5.6%) developed postoperative wound infection, of which only one needed surgical intervention. The reoperation rate was 5.6% in our study. Half of the patients (50%) were able to be followed up long-term, and the radiographs showed significant restoration of Bohler's angle and posterior facet joint depression in 24 patients. Return to full duties was achieved in an average of 5.6 months for 16 of 22 patients, who were available for follow-up questions with regard to return-to-work status.

Conclusion: Operative treatment of calcaneus fracture by open reduction and internal fixation in the novel distracted prone position technique has shown a low rate of the wound and soft tissue complications and can be considered as an alternative approach in treating these fractures.
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NewsBot · Oct 18, 2022

The subtalar calcaneal angle: A novel angle for evaluation of displaced calcaneal fractures - A retrospective study
Abdelkader Shekhbihi et al
J Orthop. 2022 Sep 29

Objectives: The radiological measurement of the Böhler angle (BA) and the critical angle of Gissane (CAG) is used not only to diagnose and corroborate the suspicion of the presence of calcaneal fractures but also to assess the prognosis of different injury patterns and to evaluate the operative reduction of calcaneal fractures. Notwithstanding, many previous studies indicated the poor intra- and interobserver reproducibility of both angles. In this retrospective study, we present the subtalar calcaneal angle (SCA) as an additional diagnostic tool -to BA and CAG-which can be applied on pre- and postoperative radiographs to assess calcaneal fractures involving the posterior facet.

Design: Retrospective Study.

Methods: Two retrospective groups were established, a 'CF-group' including radiographs of patients diagnosed with a calcaneal fracture and underwent operative treatment in the authors' traumatology department, and a 'control group' with 50 lateral calcaneal radiographs clear of skeletal lesions. Initially, the SCA, BA, and CAG were measured in both groups by three examiners. Those measurements were repeated one month later. The intra- and intertester reliabilities of all three angles were tested by determining the intraclass correlation coefficient (ICC). A paired t-test was used to prove the statistically significant difference between the SCA values for the pre- and postoperative groups, while the significant difference between the SCA values for the control and preoperative groups was tested through an independent-samples t-test.

Results: The intra- and interobserver reliability of the SCA and the BA was in close proximity. The values of the SCA in both the control and postoperative groups were significantly different compared to the measurements of the preoperative group. The CAG showed poor intertester reliability.

Conclusion: The subtalar calcaneal angle is a new instrument with proven reliability in estimating the prognosis of displaced calcaneal fractures and the postoperative alignment of the posterior facet.
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NewsBot · Oct 30, 2022

Introduction of a modified Degan classification to specify treatment algorithms in fractures of the anterior process of the calcaneus
Charlotte Cibura et al
BMC Musculoskelet Disord. 2022 Oct 28;23(1):942

Background: Fractures of the anterior process of the calcaneus are often missed, and their treatments and results receive little attention in the current literature. The aim of this study was to specify treatment algorithms through a modification of the Degan classification.

Methods: Between 2009 and 2019, patients with APC fractures were retrospectively analyzed. The Degan classification was used and modified. Type III fractures were further divided into subgroups A (not displaced) and B (displaced). The type of treatment and complications were recorded. Return to work and posttraumatic osteoarthritis were determined as primary and secondary outcome parameters, respectively.

Results: Forty-one patients with 43 fractures were included. Follow-up averaged 35,5 months (range 1,5-152 months). Fractures were eight type I, six type II, 15 type IIIA and 14 type IIIB. The fracture was initially recognized in 29 (70,7%) patients, and missed in 12 (29,3%) patients, respectively. Overall, the delayed diagnosed fractures had a significantly higher complication rate (p < 0,000) than the initially diagnosed fractures and received surgical treatment significantly (p < 0,009) more often. After surgical treatment of 13 type IIIB, one nonunion occurred. Six missed type IIIA fractures were treated surgically after delayed diagnosis because of persistent symptoms. Two type I fractures required arthrodesis of the Chopart joint. Four patients did not return to work during the follow-up (3 missed type IIIA fractures, 1 type II fracture).

Conclusion: Missed APC type IIIA fractures are at risk to develop complications, which is why computed tomography diagnostics should be performed if there is any clinical suspicion.
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NewsBot · Nov 23, 2022

Comparison of screw versus locking plate fixation via sinus tarsi approach for displaced intra-articular calcaneal fractures
KoheiSato et al
Foot and Ankle Surgery 21 November 2022

Background
The optimal treatment of displaced intra-articular calcaneal fractures (DIACF) is controversial. This study compared the fixation stability of screws and locking plates in DIACF treated via the sinus tarsi approach (STA).

Methods
We retrospectively evaluated 118 DIACF cases treated via STA and extracted data that could affect treatment outcomes. Loss of Böhler’s angle after surgery was measured to compare fixation stability.

Results
The loss of Böhler’s angles was significantly smaller in the locking plate group than in the screw group (2.6±2.7º vs. 5.6±5.3º P<0.01). There was no difference in the clinical outcomes between the groups. On multivariate logistic regression analysis, screw fixation was significantly associated with loss of Böhler’s angle by >10º (odds ratio, 8.63; 95% confidence interval, 1.16-64.4; P<0.05).

Conclusions
Locking plate fixation is more reliable than screw fixation for preventing correction loss in DIACF treated via STA.
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NewsBot · Jan 24, 2023

Minimally invasive K-wire fixation of displaced intraarticular calcaneal fractures through a minimal sinus tarsi approach
Ayman Youssef Eltabbaa et al
J Orthop Traumatol. 2023 Jan 21;24(1):4

Background: Displaced intra-articular calcaneal fractures are challenging injuries, and there is debate regarding the best method of treatment.

Patients and methods: Between January 2018 and January 2021, a prospective study was conducted on 46 patients with 56 displaced intraarticular calcaneal fractures that were treated with minimally invasive fixation using Kirschner wires (KWs) through the sinus tarsi approach.

Results: The mean follow-up period was 22.36 months. The American Orthopaedic Foot and Ankle Society (AOFAS) score was adopted as a method of clinical evaluation; the mean AOFAS score was 78.4. All cases showed radiographic evidence of adequate healing, with no collapse till the final follow-up. Complications included persistent pain, subtalar arthritis, deep infection and superficial pin site infection.

Conclusion: The use of the sinus tarsi approach and percutaneous KWs represents a minimally invasive approach which expands the indications of surgery for displaced intra-articular calcaneal fractures with fewer treatment-related complications. Level of evidence (4) case series.
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NewsBot · Feb 6, 2023

Factors influencing functional outcome in fractures of the anterior process of the calcaneus
Weiyuan Xiao et al
Orthop Traumatol Surg Res. 2023 Feb 3;103572.

Introduction: Fractures of the anterior process of the calcaneus (APC) are easily overlooked in clinical practice. Most patients have good to excellent clinical outcome after conservative treatment, while some patients may have persisting symptoms and unfavorable functional outcomes. The aim of this study was to identify the risk factors associated with unfavorable functional outcome after conservative treatment in APC fractures.

Methods: All patients presenting with APC fractures and receiving conservative treatment from April 2019 to April 2020 were retrospectively assessed. The primary outcome measurement was the ankle joint function assessed using Karlsson Scoring System at 2 years post-injury. The risk factors associated with unfavorable functional outcomes (Karlsson score≤80) were evaluated by logistic regression analysis.

Results: 84 patients were included with a mean age of 40 years. 26 (31%) patients presented with unfavorable functional outcome at 2 years post-injury. In multivariate logistic regression, concomitant fractures of talonavicular (TN) joints and older age were significantly associated with unfavorable functional outcome (P<0.05). Patients with concomitant fractures of TN joints had an odds ratio of 3.623 for unfavorable functional outcome. The optimal cutoff age for an unfavorable outcome was ≥ 47.5 years, with an odds ratio of 5.010.

Conclusion: Most patients with APC fractures achieved good to excellent results when treated conservatively. Attention should be paid to those with concomitant fractures of TN joints and with age ≥ 47.5 years, which might lead to unfavorable functional recovery.
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NewsBot · Feb 6, 2023

Factors influencing functional outcome in fractures of the anterior process of the calcaneus
Weiyuan Xiao et al
Orthop Traumatol Surg Res. 2023 Feb 3;103572.

Introduction: Fractures of the anterior process of the calcaneus (APC) are easily overlooked in clinical practice. Most patients have good to excellent clinical outcome after conservative treatment, while some patients may have persisting symptoms and unfavorable functional outcomes. The aim of this study was to identify the risk factors associated with unfavorable functional outcome after conservative treatment in APC fractures.

Methods: All patients presenting with APC fractures and receiving conservative treatment from April 2019 to April 2020 were retrospectively assessed. The primary outcome measurement was the ankle joint function assessed using Karlsson Scoring System at 2 years post-injury. The risk factors associated with unfavorable functional outcomes (Karlsson score≤80) were evaluated by logistic regression analysis.

Results: 84 patients were included with a mean age of 40 years. 26 (31%) patients presented with unfavorable functional outcome at 2 years post-injury. In multivariate logistic regression, concomitant fractures of talonavicular (TN) joints and older age were significantly associated with unfavorable functional outcome (P<0.05). Patients with concomitant fractures of TN joints had an odds ratio of 3.623 for unfavorable functional outcome. The optimal cutoff age for an unfavorable outcome was ≥ 47.5 years, with an odds ratio of 5.010.

Conclusion: Most patients with APC fractures achieved good to excellent results when treated conservatively. Attention should be paid to those with concomitant fractures of TN joints and with age ≥ 47.5 years, which might lead to unfavorable functional recovery.
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NewsBot · Mar 23, 2023

Delayed Surgical Treatment of Displaced Intra-Articular Calcaneal Fractures in Major Trauma Is Safe and Effective
Attilio Basile et al
Clin. Med. 2023, 12(5), 2039; https://doi.org/10.3390/jcm12052039

Background: To assess whether delaying operative fixation through the sinus tarsi approach resulted in a decreased wound complications rate or could hinder the quality of reduction in subjects with Sanders type II and III displaced intra-articular calcaneus fractures. Methods: From January 2015 to December 2019, all polytrauma patients were screened for eligibility. We divided patients into two groups: Group A, treated within 21 days after injury; Group B, treated more than 21 days after injury. Wound infections were recorded. Radiographic assessment consisted of serial radiographs and CT scans: postoperatively (T0) and at 12 weeks (T1) and at 12 months after surgery (T2). The quality of reduction of the posterior subtalar joint facet and calcaneal cuboid joint (CCJ) was classified as anatomical and non-anatomical. A post hoc power calculation was performed. Results: A total of 54 subjects were enrolled. Four wound complications (three superficial, one deep) were identified in Group A; two wound complications (one superficial one deep) were identified in Group B. According to “mean interval between trauma and surgery” and “duration of intervention”, there was a significant difference between the groups (p < 0.001). There were no significant differences between Groups A and B in terms of wound complications or quality of reduction. Conclusions: The sinus tarsi approach is a valuable approach for the surgical treatment of closed displaced intra-articular calcaneus fractures in major trauma patients who need delayed surgery. The timing of surgery did not negatively influence the quality of the reduction and the wound complication rate. Level of evidence: level II, prospective comparative study.
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NewsBot · Apr 7, 2023

Sinus Tarsi Versus Extended Lateral Approach for Displaced Intra-Articular Calcaneal Fractures: A Single Surgeon's Experience
Philip K Lim et al
Foot Ankle Spec. 2023 Apr 3

Background: The aim of the study is to investigate the differences between the extensile lateral (EL) and sinus tarsi (ST) approaches for the treatment of displaced intra-articular calcaneus fractures as treated by a single surgeon.

Methods: A retrospective cohort study performed at a Level 1 trauma center. One hundred twenty-nine consecutive intra-articular calcaneus fractures from 2011 to 2018 that were surgically treated by a single surgeon. Primary outcomes were time to surgery, operative time, postoperative restoration of the critical angle of Gissane, postoperative wound complications, and need for unplanned re-operation.

Results: Patient characteristics, including demographics, mechanism of injury, and fracture patterns were similar between the EL and ST approach groups. There was a significant decrease in unplanned secondary procedures (P = .008), shorter time to definitive fixation (P = .00001), and shorter average operative time in the ST group (P = .00001). Postoperative measurement of the critical angle of Gissane between the two groups was significantly different, but minute with an average difference of approximately 3 degrees (P = .025). Measurements in both groups were within the expected range of normal.

Conclusions: For displaced intra-articular calcaneus fractures, a limited open ST approach is associated with a significant reduction in the time to definitive fixation and decreased operative time. The EL approach was associated with a small, but significant improvement in the restoration of the critical angle of Gissane compared with the ST approach. Therefore, an ST approach may allow for earlier surgical intervention and result in equivalent quality of reduction compared with an EL approach.
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NewsBot · Apr 18, 2023

Calcaneus Tuberosity Avulsion Fracture - A Surgical Emergency? Modified Corticocancellous Screw Fixation Technique: A Case Report
Sanket Tanpure et al
J Orthop Case Rep. 2022 Dec;12(12):114-117

Introduction: Avulsion tuberosity fracture of the calcaneus is relatively unusual and occurs more frequently in elderly osteoporotic patients. Direct trauma to the heel is a rare cause in young individuals. Failure to perform early open reduction and internal fixation (ORIF) potentially leads to soft-tissue complications due to pressure necrosis of the overlying skin.

Case report: A 29-year-old male patient experienced left heel pain with swelling after the assault as he was hit by an iron rod 8 days prior. Radiographs revealed a Beavis Type 2 calcaneal avulsion fracture. An open reduction with two corticocancellous (CC) screw fixation was intended for the fracture.

Conclusion: The avulsed bone fragment was small causing difficulty in reduction. The result of closed reduction in such a scenario is not promising and usually requires ORIF. We performed a modified surgical procedure of CC screw fixation in which one screw was passed perpendicular to the fracture plane for reduction of the fracture and another screw was passed obliquely to nullify Achilles forces. We believe that this technique of fracture management improves patient outcome and early mobilization.
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NewsBot · May 19, 2023

Biomechanics of calcaneus impacted by talus: a dynamic finite element analysis
Mengquan Huang et al
Comput Methods Biomech Biomed Engin. 2023 May 17

This paper aimed to investigate the biomechanical changes during the talus impact with the calcaneus at varying velocities. Various three-dimensional reconstruction software was utilized to construct a finite element model that consisted of the talus, calcaneus, and ligaments. The explicit dynamics method was used to explore the process of the talus impacting on the calcaneus. The velocity of impact was altered from 5 m/s to 10 m/s with a 1 m/s interval. Stress readings were collected from the posterior, intermediate, and anterior subtalar articular (PSA, ISA, ASA), calcaneocubic articular (CA), Gissane Angle (GA), calcaneal base (BC), medial wall (MW), and lateral wall (LW) of the calcaneus. The changes in the amount and distribution of stress in the different regions of the calcaneus that varied with velocity were analysed. The model was validated through comparison with findings from the existing literature. During the process of impact between the talus and calcaneus, the stress in the PSA reached its peak first. Notably, stress was concentrated mainly in the PSA, ASA, MW, and LW of the calcaneus. At varying impact velocities of the talus, the mean maximum stress of the PSA, LW, CA, BA, and MW exhibited statistically significant differences (P values were 0.024, 0.004, <0.001, <0.001, and 0.001, respectively). However, the mean maximum stress of the ISA, ASA, and GA was not statistically significant (P values were 0.289, 0.213, and 0.087, respectively). In comparison with the velocity at 5 m/s, the mean maximum stress increases in each region of the calcaneus at a velocity of 10 m/s were as follows: PSA 73.81%, ISA 7.11%, ASA 63.57%, GA 89.10%, LW 140.16%, CA 140.58%, BC 137.67%, MW 135.99%. The regions of stress concentration were altered, and the magnitude and sequence of peak stress in the calcaneus also varied according to the velocity of the talus during impact. In conclusion, the velocity of the talus during impact had a significant influence on the magnitude and distribution of stress within the calcaneus, which was a crucial factor in the development of calcaneal fractures. It was possible that the magnitude and sequence of stress peaks played a vital role in determining the emergence of fracture patterns.
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NewsBot · Jun 5, 2023

3D mapping of intra-articular calcaneal fractures
Guang Shi et al
Sci Rep. 2023 May 31;13(1):8827

To determine the pattern of intra-articular calcaneal fractures (ICFs) by a three-dimensional (3D) mapping and determine whether there were consistent fracture patterns and comminution zones. In this study, 67 patients with ICFS by CT scan were included. The calcaneal fractures fragments in CT were multiplanar reconstructed and virtual reduced. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a standard calcaneal template. The cohort included 26 (38.8%) left calcaneal fractures, 27 (40.30%) right calcaneal fractures, and 14 (20.9%) cases with bilateral fractures. Comminuted fractures accounted for 92.5%. Sagittal 3D mapping shows that the fracture line is mainly concentrated at the critical angle of Gissane and extending rear to the posterior of the tuberosity of the lateral wall and the anterior of the medial process of the calcaneus tuberosity but with more significant variation in the medial wall. The average angle of fracture lines concerning the long calcaneal axis (LCA) was 29.1° and 19.2° in the lateral and medial walls. Axial 3D mapping shows that fracture lines were primarily concentrated in the anterior area to the posterior joint facet and extending along the rear joint facet and calcaneus sulcus to the posteriorly of the tuberosity. The mean angle of fracture lines concerning the LAC was 11° in the axial wall. Our data provided elucidated that ICFs have consistent characteristic fracture patterns and comminution zones. This study provides visual guidelines for understanding fracture morphology, which may assist with fracture classification, preoperative planning, development of fixation concepts.
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NewsBot · Aug 3, 2023

Are the non-weight bearing guidelines for the after treatment of calcaneal fractures still decisive? A Dutch survey among orthopaedic and trauma surgeons
Coen Verstappen et al
Eur J Orthop Surg Traumatol. 2023 Jul 8

Purpose: The current rehabilitation for patients with surgically treated displaced intra-articular calcaneal fractures (DIACFs) consists of non-weightbearing for 8-12 weeks. The purpose of the present survey was to investigate the current pre-, peri- and post-operative practices among Dutch foot and ankle surgeons. Moreover, it aims to analyze whether surgeons comply to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) guidelines and which decision criteria were used in the determination of the start of weightbearing.

Methods: A survey was distributed among Dutch trauma and orthopaedic surgeons to determine the most common practices in postoperative weightbearing in patients with DIACFs.

Results: 75 surgeons responded to the survey. 33% of the respondents adhered to the AO guidelines. 4% of the respondents strictly followed non-weightbearing guidelines, while 96% interpret the AO guidelines or their local protocol freely, in any frequency. When respondents tended to deviate from the AO guidelines or local protocol, a good patients' compliance to therapy was expected. 83% of the respondents started weightbearing on the fracture, based on reported patient complaints. 87% of the respondents did not see any relation between early weightbearing and the occurrence of complications, including loosening of osteosynthesis materials.

Conclusion: This study demonstrates that there is limited consensus on the rehabilitation for DIACFs. Moreover, it shows that most surgeons are inclined to interpret the current (AO) guideline or their own local protocol freely. New guidelines, supported with well-founded literature, could help surgeons in a more appropriate daily practice in weightbearing for the rehabilitation of calcaneal fractures.
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NewsBot · Aug 10, 2023

Endoscopic Screw Removal, Debridement of the Peroneal Tendons and Subtalar Joint and Lateral Calcaneal Ostectomy for Management of Chronic Heel Pain after Calcaneal Fracture
Charles Churk Hang Li, Tun Hing Lui
Arthrosc Tech. 2023 Apr 16;12(5):e661-e665

Calcaneal fracture is one of the most common foot and ankle fractures, but the best treatment of this fracture is still under debate. No matter the treatment strategy of this intra-articular calcaneal fracture, early and late complications frequently occur. In order to treat these complications, combination of various ostectomy, osteotomy, and arthrodesis techniques have been proposed to re-establish the calcaneal height, restore the talocalcaneal relationship, and create a stable, plantigrade foot. In contrast to this approach of addressing all the deformities, another feasible approach is concentrating on those aspects that are the most clinically pressing.10, 11, 12, 13, 14, 15 Different arthroscopic and endoscopic approaches focused on the patient's symptoms and not the correction of the talocalcaneal relationship or restoration of the height or length of the calcaneus have been proposed to deal with late complications of calcaneal fractures. The purpose of this technical note is to describe the details of endoscopic screw removal, debridement of the peroneal tendons, and subtalar joint and lateral calcaneal ostectomy for management of chronic heel pain after calcaneal fracture. It has the advantage of dealing with various sources of lateral heel pain after calcaneal fracture, including the subtalar joint, peroneal tendons, lateral calcaneal cortical bulge and screws.
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NewsBot · Sep 7, 2023

The statistical fragility of outcomes in calcaneus fractures: A systematic review of randomized controlled trials
Michael Megafu et al
Foot (Edinb). 2023 Aug 24

Introduction: The purpose of this study was to utilize the fragility index to assess the robustness of randomized controlled trials (RCTs) evaluating the management of calcaneus fractures. We hypothesize that the dichotomous outcomes in calcaneus fracture literature will be statistically fragile and comparable to other orthopedic specialties.

Methods: We performed a PubMed search for calcaneus fracture RCTs from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The fragility index (FI) of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient (FQ) was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

Results: Of the 3003 studies screened, 97 met the search criteria, with 19 RCTs evaluating calcaneus fractures included in the analysis. Seventy-nine dichotomous outcomes with 30 significant (P < 0.05) outcomes and 49 with nonsignificant (P> 0.05) outcomes were identified. The overall FI and FQ of all outcomes were 6 (IQR 3-8) and 0.067 (IQR 0.032-0.100), respectively.

Conclusions: The literature surrounding calcaneus fractures may not be as statistically stable as previously thought. The sole reliance on the P value may depict misleading results. We, therefore, recommend reporting the P value in conjunction with the FI and FQ to give a robust contextualization of clinical findings in the calcaneus fracture literature.
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NewsBot · Sep 12, 2023

Prevalence and Predictors of Peroneal Tendon Instability Accompanying Calcaneal Fractures
Amir Reza Vosoughi et al
Foot Ankle Int. 2023 Sep 2

Background: We aimed to find the prevalence of peroneal tendon instability (PTI) accompanying different types of calcaneal fractures and to determine predictors of PTI based on preoperative CT scanning.

Methods: In a retrospective cross-sectional study, preoperative CT scans of 400 consecutive calcaneal fractures undergoing surgery were reviewed for comminuted fragments in the lateral gutter of the ankle, fractures at the tip of the lateral malleolus, dislocated peroneal tendons, excessive displacement of the lateral calcaneal wall, calcaneal fracture-dislocation, superior peroneal retinaculum (SPR) avulsion fracture (fleck sign), and shape of the retromalleolar groove. The correlation of these variables with intraoperative SPR stress test, defined as the diagnostic criteria for PTI in calcaneal fractures, was evaluated.

Results: In total, 369 patients (mean age, 39 ± 13; range, 11-72 years), with 321 (87.0%) of them male, were included. Among all calcaneal fractures, 67 cases (16.7%) had associated PTI as confirmed intraoperatively by an SPR stress test. A statistically significant association was found between PTI in calcaneal fractures and comminuted fragments in the lateral gutter of the ankle (P = .03), dislocated peroneal tendons (P < .001), calcaneal fracture-dislocation (P < .001), SPR avulsion fracture (P < .001), and Sanders type IV of calcaneal fracture (P = .02). There was no statistically significant relationship between PTI and the mechanism of injury (P = .98), side of fracture (P = .30), uni- or bilateral calcaneal fractures (P = .27), a fracture at the tip of lateral malleolus (P = .69), shape of the retromalleolar groove (P = .78), or excessive displacement of the lateral calcaneal wall (P = .06). The most specific CT finding to predict PTI accompanying calcaneal fractures was calcaneal fracture-dislocation (99.1%).

Conclusion: Following calcaneal fracture fixation, PTI was confirmed with intraoperative SPR stress test in one-sixth of cases. With the exception of calcaneal fracture-dislocation, preoperative findings on CT scanning and calcaneal fracture pathoanatomy are insufficient to diagnose PTI accompanying calcaneal fractures.
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NewsBot · Oct 24, 2023

The impact of sustentaculum tali fracture on clinical outcome in patients affected by isolated calcaneal fractures
Giacomo Sani et al
Eur J Orthop Surg Traumatol. 2023 Oct 19

Introduction: The sustentaculum tali is displaced in almost half of calcaneal fractures and during surgical fixation represents one of the main reference points upon which the other bone has to be reduced. The purpose of this study was to investigate which subtalar joint fracture pattern is more frequently associated with sustentaculum tali involvement. Furthermore, correlation between postoperative clinical outcome and sustentaculum tali integrity was performed.

Material and methods: Patients with isolated calcaneal fractures were analyzed. Sanders-type fracture and involvement of both sustentaculum tali and calcaneocuboid joint were detected on computed tomography imaging; postoperative AOFAS scores were analyzed according to sustentacular involvement.

Results: Fifty calcaneus fractures in 47 patients were included in the final analysis. The sustentaculum tali was fractured in 18 cases (36.0%), thus contradicting its supposed constant position. Sanders type 3 and 4 fractures were more frequently associated with fractured sustentaculum than type 2 (p = 0.012). Sanders type 4 fractures were associated with displaced sustentacular fragment significantly more than type 2 and 3 (p = 0.043). Patients with intact sustentaculum tali reported significantly higher (p < 0.001) mean AOFAS scores than the uninjured group (84.4 ± 9.1 and 74.3 ± 9.5, respectively).

Conclusion: Sanders type 3 and 4 fractures were more frequently associated with sustentaculum tali and/or calcaneocuboid joint involvement than simpler fractures. Injury of sustentaculum tali was related to significant worse postoperative clinical outcomes, underlying the relevance of this fragment on clinical course.
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NewsBot · Oct 30, 2023

Minimally Invasive Osteosynthesis of Calcaneal Fractures Using the Anterolateral Locking Plate
V Bába et al
Acta Chir Orthop Traumatol Cech. 2023;90(5):329-334.

PURPOSE OF THE STUDY Extended lateral approach to calcaneus fractures is associated with a high risk of infection. Such risk can be reduced by using mini-invasive approaches. The sinus tarsi approach provides a good overview of the posterior joint facet of the calcaneus and can also be done as a mini-invasive procedure. The authors present their fi rst experience with osteosynthesis of joint depression calcaneal fractures using the anterolateral locking plate inserted through the sinus tarsi approach. MATERIAL AND METHODS During the period from 1 February 2020 to 31 January 2022, 18 patients were treated by the anterolateral locking plate in the authors' department (3 women, 15 men). Eleven fractures were classifi ed according to Sanders as IInd grade, fi ve as IIIrd grade and two fractures were classifi ed as tongue-type (as described by Essex-Lopresti). The fractures were treated by open reduction through the sinus tarsi approach and osteosynthesis by the anterolateral locking plate combined with headless screws. The following factors were examined: time from injury, duration of surgery, quality of reduction (post-op control with multiplanar CT scans), wound and technical complications, loss of reduction after treatment, substance abuse and comorbidities. The follow-up was 12-36 months (median 17). At one year after surgery, the functional outcomes were evaluated using the AOFAS Hindfoot score. RESULTS The most common negative predispositions for successful healing were smoking (9 cases), alcohol abuse, drug abuse, mild mental retardation, personality disorder, insulin-dependent diabetes and epilepsy (1 case each), hypothyreodism and bronchial asthma (2 cases each). The time from injury to surgery and duration of surgery surgery were measured. The quality of reduction was excellent in 12 patients (dislocation less than 1 mm), good in 6 patients (dislocation less than 2 mm), dislocation more than 2 mm was not present in the group. In one case, a revision surgery was performed because of screw malposition into the subtalar joint, delayed wound healing was observed in two cases. There was no case of deep surgical site infection or loss of reduction. The mean AOFAS score after one year was 85 points. The most common complaints were scar pain or discomfort. DISCUSSION The current studies on osteosynthesis of calcaneal fractures favor the sinus tarsi approach for its lower risk of wound-related complications compared to the extended lateral approach. The sinus tarsi approach requires the use of different osteosynthetic material than the conventional calcaneal plate. If a conventional locking plate is to be used, the surgical approach has to be modifi ed. In 2021, Wang et al. published an intermediate step leading to the reduction of early complications and the use of conventional locking calcaneal plate inserted through the sinus tarsi approach, with an additional incision. The sinus tarsi approach is used also when intramedullary nailing is performed, which is preferred by biomechanical studies evaluating the rigidity of osteosynthesis. However, when comparing nails and locking plates, the differences are insignifi cant. The use of anterolateral locking plates was presented by Xie et al., with results similar to those of our own group of patients. CONCLUSIONS The results of the followed-up group of patients confi rm low complication rate of the sinus tarsi approach as reported by current literature. At the same time, it provides good options for reduction even in complicated fractures. For successful osteosynthesis, the anterolateral locking plate with headless screws may be used. The incidence of post-operative complications is low even in high-risk patients. Adhesions of peroneal tendons can be treated with material removal and tissue release. They could be prevented by good physiotherapy. Key words: calcaneus, osteosynthesis, anterolateral plate, peroneal tendons, sinus tarsi approach.
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NewsBot · Nov 1, 2023

Eponyms for the Description and Classification of Calcaneus Fractures
Nina D. Fisher et al
Source

There are several eponyms used in the assessment and management of calcaneus fractures. However, the origin of these eponyms is no longer widely known. Named for orthopaedic surgeons who made substantial contributions to the management of calcaneus fractures as well as the field of orthopaedic surgery, understanding the context of how these descriptors were derived helps give context to their use in the present day. The purpose of this review is to provide a historical perspective and comprehensive collection of the most common eponyms related to calcaneus fractures.
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NewsBot · Nov 6, 2023

Functional outcomes of primary subtalar arthrodesis in sanders type IV calcaneal fractures, a case series
Bishoy Emil Naguib et al
Trauma Case Rep. 2023 Oct 18

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.
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NewsBot · Dec 28, 2023

Prospective Clinical and Computed Tomography Evaluation of Calcaneus Fractures Treated Through Sinus Tarsi Approach
Julia C Mastracci et al
Foot Ankle Orthop. 2023 Dec 21;8(4)

Background: The traditional lateral extensile approach to the calcaneus allows for excellent visualization but is associated with high wound complication rates. The sinus tarsi approach has been shown to produce similar radiographic outcomes with much lower rates of wound complications. The purpose of this study is to prospectively determine clinical and radiographic outcomes in calcaneus fractures treated with a sinus tarsi approach.

Methods: Twenty-nine patients with 30 calcaneus fractures underwent operative fixation through a sinus tarsi approach and were prospectively evaluated. Routine pre- and postoperative radiographs were obtained, in addition to computed tomography (CT) scans at 6 weeks and 12 months after surgery. Patient-reported outcomes including American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, Veterans Rand 12-Item Health Survey (VR-12), and Foot Functional Index (FFI) were recorded. Patients were followed for a minimum of 1 year postoperation.

Results: Twenty-one patients with 22 calcaneus fractures completed 1 year of follow-up. At 12 months postoperation, 20 of 22 patients (91%) had 0 to 2 mm of fracture displacement at the posterior facet on CT scans whereas 2 of 22 patients had 2 to 4 mm of fracture displacement. There was no significant change in posterior facet fracture displacement comparing 6-week and 12-month postoperative CT scans (P > .99). Mean postoperative Bohler angle was 26.1 degrees compared to 13.2 degrees preoperatively. All patients had complete union of fracture site. There were no major wound complications. Four of 22 patients (18.2%) had minor wound complications. AOFAS, FFI, and VAS pain scores improved postoperatively but were not found to correlate with Bohler angle or critical angle of Gissane.

Conclusion: We found that in select patients excellent anatomic alignment and good clinical outcomes with low wound complication rates can be achieved when fixing calcaneus fractures through the sinus tarsi approach
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NewsBot · Jan 5, 2024

The Nightmare of Calcaneus: Gustilo-Anderson Type IIIB Fractures
Sabri Batin, Yakup Ekinci, Kaan Gürbüz
J Am Podiatr Med Assoc. 2023 Nov-Dec;113(6):21-179.

Background: The aim of this study was to share the clinical results of open calcaneus fractures, which are extremely rare and have become the fearful nightmare of orthopedic surgeons.

Methods: Between June of 2014 and June of 2020, of 196 patients with the diagnosis of calcaneus fracture, Gustilo-Anderson type IIIB, 17 patients (11 men and six women; mean age, 36.2 ± 4.6 years; range, 22-56 years) under prospective follow-up were retrospectively screened and included in the study. Patients were recorded in terms of classification of fracture, mechanism of injury, comorbidities, surgical progress, complications, and associated orthopedic and nonorthopedic injuries. Functional clinical results and quality of life of the patients were evaluated at the 6-month follow-up with the American Orthopedic Foot and Ankle Society score and the 36-Item Short Form Health Survey questionnaire.

Results: The most common etiologic factor was work-related injuries, with 29.4%. Although triple arthrodesis surgery was performed in three cases because of pseudoarthrosis, amputation was performed in one case because of deep infection. The most common soft-tissue defect was located at the medial aspect of the foot, which was commonly reconstructed with the used of reverse flow island sural flap. The average total American Orthopedic Foot and Ankle Society hindfoot score was 51.6 (range, 48-74) and similarly, physical component, pain, and social parameters on the 36-Item Short Form Health Survey were statistically significant compared to Turkish population normal scores.

Conclusions: A long and laborious process is required for both the patient and the surgeon in the treatment of open calcaneal fractures. However, it is possible to obtain good results with soft-tissue reconstructions.
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NewsBot · Jan 16, 2024

Is Subclassification by Number of Fracture Fragments Necessary for Sanders Type IV Calcaneal Fractures?
Dong-Hee Kim et al
J Am Podiatr Med Assoc. 2023 Nov-Dec;113(6):21-135

Background: The Sanders classification is a widely used method for classifying calcaneal fractures. Type IV fractures (>4 fragments) are known to vary in the number of fracture fragments. However, all relevant cases are classified as type IV irrespective of the number of fragments. We investigated the need for evaluation of postoperative prognoses based on radiologic factors and subtypes of Sanders classification type IV fractures.

Methods: Fifty-six Sanders type IV calcaneal fractures were enrolled between 2010 and 2018. Patients were divided into two groups according to the number of fragments: four fragments (group 1) and more than four fragments (group 2). Radiologic evaluation was performed using a postoperative recovery percentage calculated from postoperative reduction of the Böhler angle, Gissane angle, and vertical height. Radiologic evaluation was divided into two groups according to postoperative recovery: good and bad recovery groups. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analog scale (VAS) score were used for clinical outcome evaluation.

Results: There was no significant difference in AOFAS ankle-hindfoot score (P = .909) or VAS score (P = .963) between groups 1 and 2. However, there was a significant (P = .001) difference in AOFAS ankle-hindfoot score or VAS score between good and bad recovery groups.

Conclusions: Clinical results of Sanders type IV fractures were not related to the number of bone fragments but to the degree of injury to the Böhler angle, Gissane angle, and vertical height. Therefore, subtype classification of type IV calcaneal fractures is superfluous, and it is important to try to restore these parameters during surgery.
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NewsBot · Jan 19, 2024

Efficacy and Postoperative Complication Rates of Different Surgical Approaches for Calcaneal Fractures: A Network Meta-analysis
Lieliang Luo, Jintang Chen, Zhennan An, Weipeng Sun, Minying Li, Chongzhi Ouyang, Wenzheng Wu, Peng Gu, Yuxuan Tao, Ziwei Jiang, Xiaohui Zheng
Altern Ther Health Med. 2023 Nov 17

Context: Calcaneal fractures (CFs) are the most common kind of tarsal fracture. The choice of surgical approach is a key element in the management of CFs, but the best method remains in dispute. Also, no single approach is appropriate for all kinds of CFs.

Objective: The study intended to evaluate the relationship between six surgical approaches for clinical treatment of CFs and prevention of postoperative complications, to provide an evidence-based approach for treatment.

Design: The research team performed a meta-analysis using the data from a previously published review and updating that data through a new narrative review. The team performed a systematic search in PubMed, Embase, the Cochrane Library, and the Chinese National Knowledge Internet (CNKI) from inception until January 2022, with no language restrictions. The search used the following keywords for the search: calcaneus, heel bone, surgical wounds, surgical incisions, prospective trials, prospective trials, and randomized controlled trials.

Outcome measures: The research team compared the complication rates, American Orthopedic Foot and Ankle Society (AOFAS) scores, and Bohler's angles for the six surgical approaches, which were: (1) the extensive lateral approach (ELA), (2) the sinus tarsi approach (STA), (3) the horizontal arc approach (HAA), (4) the longitudinal approach (LA), (5) the oblique lateral incision (OLI), and (6) the modified incision (MI)). The team summarized the results using a random effects model.

Results: The research team analyzed the data from 19 RCTs with 1521 participants. They all were randomized controlled trials (RCTs). The complication rates were available for 18 studies, which included 1474 participants. The rates were significantly lower: (1) for HAA compared to ELA, [OR=-2.03; 95% CrI: [-3.63, -0.43)]; (2) for LA compared to ELA (OR=-1.83; 95% CrI: [-2.83, -0.84]); and (3) for STA compared to ELA (OR=- 1.22; 95% CrI: [-1.67, -0.78]). Of the 19 studies, 11 RCTs, with 942 participants, used the AOFAS scale. The probabilities for the surface under the cumulative ranking curve (SUCRA) indicated that OLI (0.694 ) >LA (0.596) >HAA (0.51) >STA (0.477) >ELA (0.224). In addition, ELA had the worst SUCRA (0.224). Of the 19 studies, 15 RCTs, with 1376 participants, used the Bohler angle as an outcome measure. The probability of SUCRA for the surgical approaches indicated that LA (0.723) >ELA (0.667) >STA (0.468) >HAA (0.373) >MI (0.27).

Conclusions: The meta-analysis provides an evidence-based approach to the clinical treatment of CFs for six surgical approaches. HAA had the best outcomes, and ELA had the worst.
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NewsBot · Feb 21, 2024

Geographical Differences in Wound Complication Rates Following the Sinus Tarsi Approach in Displaced Intra-articular Calcaneal Fractures: A Systematic Review of the Literature
Robin Eelsing et al
Clin Orthop Surg. 2024 Feb;16(1):134-140

Background: The sinus tarsi approach (STA) has gained popularity for the treatment of displaced intra-articular calcaneal fractures. No large studies comparing wound complications worldwide after STA surgery are available. The aim of this systematic review was to compare postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following STA surgery between continents and countries and their differences in climate.

Methods: A literature search was performed using the databases of PubMed, Embase, and the Cochrane Library. Studies published before January 1, 2000, including < 10 patients and written in a language other than English were excluded.

Results: In total, 86 studies containing 4,392 surgeries via STA from 20 different countries were included. The mean POWC was 5.9% and the mean POWI was 4.4%. The highest median POWC rate was in North America (8.5%) and the lowest in South America (2.0%). No significant differences were found in the POWC and POWI rates between countries (p = 0.178 and p = 0.570, respectively), but significant differences were found between the POWC and POWI rates between continents (p = 0.011 and p = 0.036, respectively). The number of surgeries per year and climate differences, as represented by mean local temperature, were not correlated with both the POWC/POWI rates and functional outcome scores.

Conclusions: Significant differences between the POWC and POWI rates were found between continents but not between individual countries. With a mean POWC of 5.9% and a mean POWI rate of 4.4%, STA has an intrinsic low risk for complications given the minimally invasive nature of the approach and is inevitably becoming the gold standard for calcaneal surgery.
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NewsBot · Feb 22, 2024

Impact of sustentaculum tali screw positioning on radiographic and functional outcomes in calcaneal fractures
Zihua Li et al
J Orthop Surg Res. 2024 Feb 12;19(1):136

Background: To investigate whether accurate placement of sustentaculum tali screws have the impacts on the clinical efficacy of calcaneal fractures.

Methods: A retrospective analysis of 72 cases (73 feet) of calcaneal fractures from September 2015 to September 2019 treated with open reduction and internal fixation with sustentaculum tali screws was conducted. Patients were divided into the sustentaculum tali fixation group (ST group) and the sustentaculum fragment fixation group (STF group) according to the location of the sustentaculum tali screw placement. The functional outcomes at preoperative, 7 days and 1 year postoperative were collected and analyzed.

Results: In the ST group (40 feet), the Gissane's angle altered from (109.89 ± 12.13)° to (121.23 ± 9.34)° and (119.08 ± 8.31)° at 7 days and 1 year postoperative, respectively. For Böhler's angles altered from (11.44 ± 5.94)°, to (31.39 ± 7.54)°, and (30.61 ± 7.94)° at 7 days and 1 year postoperative, respectively. In the STF group (33 feet), Gissane's angle altered from (110.47 ± 14.45)°, to (122.08 ± 8.84)°, and (120.67 ± 9.07)° and Böhler's angle altered from (11.32 ± 6.77)°, to (28.82 ± 8.52)°, and (28.25 ± 9.13)° (P < 0.001). However, there was no statistically significant difference in functional outcomes at 1 week after surgery and 1 year after surgery (P > 0.05). The AOFAS scores at the final follow-up of the two groups: ST group (88.95 ± 6.16) and STF group (89.78 ± 8.76); VAS scores, ST group (0.83 ± 0.98) and STF group (1.03 ± 1.59), all differences were not statistically significant (P > 0.05).

Conclusion: The position of sustentaculum tali screws has no significant difference on the short-term clinical outcome in patients with calcaneal fractures, while reliable fixation of screws to sustentaculum tali fragment can achieve similar clinical outcome.
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NewsBot · Mar 5, 2024

Calcaneal tuberosity avulsion fractures – A review
Zhiyi Liu et al
Injury Volume 55, Issue 2, February 2024, 111207

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years
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NewsBot · Mar 9, 2024

Beak-type fractures of the calcaneus
Ahmad Zeidan et al
Ugeskr Laeger. 2024 Feb 19;186(8)

Beak fractures represent a rare subtype of calcaneal fractures with potential risk of soft tissue complications due to compromised local perfusion. Early diagnosis and timely intervention are crucial to prevent necrosis, infection, and soft tissue defects. This case report describes a 71-year-old male with a beak fracture and delayed intervention with reoccurring soft tissue defects. Given the rarity of the condition, atypical presentation and need for urgent intervention, this emphasizes the importance of awareness of beak fractures of the calcaneus.
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NewsBot · Mar 26, 2024

An investigation into the frequency and risk factors of low back pain following surgical treatment of isolated calcaneal fractures
Dilek Bayraktar et al
Acta Orthop Traumatol Turc. 2024 Jan;58(1):45-56

Objective: This study aimed to determine the frequency of low back pain after calcaneal fractures treated with open reduction internal fixation (ORIF) and the risk factors that cause this condition.

Methods: Thirty-one patients (27 males and 4 females) who underwent surgery for a unilateral calcaneal fracture between 2016 and 2020 and had no complaints of low back pain before fracture surgery were included in the study. The patients were divided into 2 groups: those who developed low back pain after the operation and those who did not. Patients were evaluated with the Life Quality Short Form SF-36, the Oswestry Disability Index (ODI), and American Orthopedic Foot-Ankle Association Score (AOFAS). Sanders' fracture type, joint range of motion (ROM) measurements of injured and uninjured limbs, maximal isometric muscle strength measurements, balance on 1 leg with pedobarographic measurements, and walking time were evaluated. The obtained data were compared among the 2 groups.

Results: Low back pain was observed in 71% of the patients and was detected after an average of 6 months from the operation. In ODI, 59.1% of the patients reported that low back pain limited their lives slightly. Patients with low back pain have lower AOFAS scores and worse SF-36 physical functionality than those without low back pain (P < .001, P=.016). Balance time on 1 foot in pedobarographic measurements, foot in ROM, ankle in ankle active, passive plantar flexion, inversion, active hip, passive internal, external rotation, muscle is the foot eversion force. In these measurements, the values of the injured side are intact. It was statistically significantly lower than the other side (interaction P < .1).

Conclusion: Low back pain may occur after unilateral calcaneal fractures treated by ORIF. This may be caused by decreased angles of ankle dorsi and plantar flexion, foot inversion, hip abduction, and internal and external rotation. In the rehabilitation program, not only the ankle region but also the hip joint of the affected side should be included, and the kinetic chain that describes the interaction mechanism of the human body should not be forgotten.
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NewsBot · May 27, 2024

Stable Clinical and Radiological Outcomes at Medium and over 5 Year follow up of Calcaneus Fracture Open Reduction Internal Fixation using a Sinus Tarsi Approach
Conor S. O'Driscoll,et al
May 13, 2024DOI:https://doi.org/10.1053/j.jfas.2024.05.001

The Sinus Tarsi Approach is increasingly growing in popularity for open reduction internal fixation of calcaneus fractures. Multiple studies have demonstrated favorable short-term results compared to the traditional extensile L incision, however long-term data over 5 years is currently limited to a single retrospective case series. Following local ethical approval, all patients who had completed a minimum 5 years from time of operation were contacted with a standardised telephone questionnaire completed. This followed a previous retrospective chart review, with follow up telephone or clinic consultation performed by Davey et al of this cohort at mean 35 months. Thirty-four fractures (31 patients) completed minimum 5 year follow up from the eligible group of 54 fractures (49 patients). Regarding functional outcomes, a significant improvement in mean Maryland Foot Score was observed between short- (mean 35.8 months) and medium-term (mean 81.9 months) of 77.6 (SD 15.0) to 86 (SD 7.9). (p=0.0082.) There was no significant difference in postoperative and long term radiographic Bohler's angle. (p=0.9683.) Eleven feet (32%) proceeded to require reoperation, with removal of metal performed in 10 (29%), fusion in 2 (6%) and skin grafting following wound breakdown for 1 (3%). Four feet (12.9%) experienced post operative wound complications, including 3 (9.68%) cases of infection and 2 (6.45%) of delayed wound healing. This study demonstrated stable clinical and radiographic outcomes over 5 years following Calcaneus Fracture Open Reduction Internal Fixation using a Sinus Tarsi Approach, supporting its continued usage when treating intraarticular calcaneus fractures for which operative intervention is indicated.
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NewsBot · Jun 4, 2024

An investigation into the frequency and risk factors of low back pain following surgical treatment of isolated calcaneal fractures
Dilek Bayraktar Nadir Özkayın et al
Acta Orthop Traumatol Turc., 2024; 10.5152/j.aott.2024.23031

Objective: This study aimed to determine the frequency of low back pain after calcaneal fractures treated with open reduction internal f ixation (ORIF) and the risk factors that cause this condition. Methods: Thirty-one patients (27 males and 4 females) who underwent surgery for a unilateral calcaneal fracture between 2016 and 2020 and had no complaints of low back pain before fracture surgery were included in the study. The patients were divided into 2 groups: those who developed low back pain after the operation and those who did not. Patients were evaluated with the Life Quality Short Form SF-36, the Oswestry Disability Index (ODI), and American Orthopedic Foot-Ankle Association Score (AOFAS). Sanders' fracture type, joint range of motion (ROM) measurements of injured and uninjured limbs, maximal isometric muscle strength measurements, balance on 1 leg with pedobarographic measurements, and walking time were evaluated. The obtained data were compared among the 2 groups. Results: Low back pain was observed in 71% of the patients and was detected after an average of 6 months from the operation. In ODI, 59.1% of the patients reported that low back pain limited their lives slightly. Patients with low back pain have lower AOFAS scores and worse SF-36 physical functionality than those without low back pain (P < .001, P = .016). Balance time on 1 foot in pedobarographic measurements, foot in ROM, ankle in ankle active, passive plantar flexion, inversion, active hip, passive internal, external rotation, muscle is the foot eversion force. In these measurements, the values of the injured side are intact. It was statistically significantly lower than the other side (interaction P < .1). Conclusion: Low back pain may occur after unilateral calcaneal fractures treated by ORIF. This may be caused by decreased angles of ankle dorsi and plantar flexion, foot inversion, hip abduction, and internal and external rotation. In the rehabilitation program, not only the ankle region but also the hip joint of the affected side should be included, and the kinetic chain that describes the interaction mechanism of the human body should not be forgotten
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NewsBot · Jun 4, 2024

Postoperative 3D computed tomographic evaluation of 92 calcaneal fracture reduction using the sinus tarsi technique and fixation with 3.5 mm cortical screws
Adisorn Chongmuenwai et al
Eur J Orthop Surg Traumatol. 2024 Jun 4

Background: Fixation of calcaneus through the sinus tarsi approach is increasingly popular due to the lower rate of wound complications. The use of postoperative CT provided a better evaluation tool than using plain radiography. Our objective of the present study is to evaluate the quality of fracture reductions by postoperative 3D CT scans after surgical intervention using the sinus tarsi approach and fixation with 3.5 cortical screws.

Methods: Between January 2018 and April 2020, 86 consecutive patients with 92 closed displaced intra-articular calcaneal fractures underwent ORIF with 3.5 mm screws constructed via a minimally invasive sinus tarsi approach by a single foot and ankle surgeon.

Results: The preoperative radiographic assessment found 36 joint depression type and 56 tongue type fractures according to the Essex-Lopresti classification. Preoperative CT assessment found 82 type II and 10 type III according to the Sander classification. Analysis of pre- and postoperative CT parameters showed that the height of the posterior facet, the length of the posterior facet, Gissane, and Bohler's angle were significantly improved. In addition, the means of posterior facet step-off in postoperative CT was 1.07, and 72% of posterior facet reductions were < 2 mm step-offs.

Conclusion: With postoperative CT scan assessment, the treatment of displaced intra-articular calcaneal fracture with 3.5 mm screws via sinus tarsi approach has achieved good quality of reduction. Therefore, the screws-only technique is an option for treating calcaneal fracture with less soft tissue damage and implant cost.
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NewsBot · Jun 9, 2024

Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management
E Acar et al
Niger J Clin Pract. 2024 May 1;27(5):583-591

Objectives: To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures.

Patients and methods: We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates.

Results: Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups.

Conclusions: Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.
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NewsBot · Jul 2, 2024

Comparison of the Radiographic and Clinical Outcomes between the Sinus Tarsi and Extended Lateral Approaches for Intra-Articular Calcaneal Fractures: A Retrospective Study
Jui-Ting Mao et al
J. Pers. Med. 2024, 14(3), 259; https://doi.org/10.3390/jpm14030259

The aim of this study was to compare the radiological and functional outcomes of the extended lateral and sinus tarsi approaches for managing displaced intraarticular calcaneal fractures. This retrospective study involved 44 patients with displaced intra-articular calcaneal fractures. The patients were treated with either the extended lateral or sinus tarsi approach and followed up for at least a year. The radiological and clinical outcomes were compared between the approaches. The waiting time for surgery was shorter and the complication rate was lower in the sinus tarsi approach group than in the other group. There were no significant differences in the American Orthopedic Foot and Ankle Society ankle–hindfoot score, Foot Function Index, or visual analog scale score between the groups. In both groups, the radiological outcomes (Böhler angle, calcaneal width, and calcaneal height) were better postoperatively than preoperatively. The sinus tarsi approach is a safe and effective alternative to the extended lateral approach for managing displaced intraarticular calcaneal fractures. It is associated with a lower complication rate and a shorter waiting time for surgery than the extended lateral approach, with similar functional and radiological outcomes.
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NewsBot · Jul 8, 2024

Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform
Dahyun Kang et al
Emerg Radiol. 2024 Jul 6

Introduction: The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures.

Methods: This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type.

Results: A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels.

Conclusions: Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.
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NewsBot · Jul 31, 2024

Is the occurrence of extra-articular calcaneal fractures of the joint depression type related to osteoporosis and aging?
Chul Hyun Park et al
Int Orthop. 2024 Jul 26

Purpose: The authors experienced several cases of extra-articular calcaneal fracture accompanied by joint depression involving the entire posterior facet without joint involvement. This type of fracture and its characteristics and treatment outcomes have not been previously reported. The study was performed to analyze the characteristics of extra-articular calcaneal fractures of the joint depression type and their postoperative clinical and radiographic results and complications.

Methods: Between February 2013 and March 2021, 23 extra-articular calcaneal fractures of the joint depression type were consecutively treated by a single surgeon. Relationships between fracture characteristics and patient demographics were assessed. Clinical results were quantified using visual analog scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and Foot Function Index, radiographic results were evaluated using Böhler's angles, and calcaneal widths were determined using calcaneal axial and lateral radiographs obtained preoperatively and at last follow-up.

Results: Twenty (87%) of the 23 cases occurred in women, and the mean age of all patients was 65.8 years (43-90). The three men were older than 65. Five (21.7%) patients had osteopenia, and 12 (52.2%) had osteoporosis. Bone mineral density testing could not be performed in the other six patients. Clinical and radiographic results were significantly improved after surgery.

Conclusion: Extra-articular calcaneal fractures of the joint depression type are much more common in women and occur at an older age than calcaneal fractures commonly occur. These fractures are also more common in patients with a low bone mineral density.
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NewsBot · Aug 15, 2024

Radiographic assessment of calcaneal fractures; A new approach to Böhler's angle using computed tomography
Robin Eelsing et al
Foot (Edinb). 2024 Jul 20

Background: Böhler's angle (BA) is used for identifying calcaneal fractures and evaluating calcaneal collapse after reconstruction. This study investigates whether it is possible to determine BA with the help of Computed Tomography (CT).

Methods: A retrospective study was performed to compare the BA on conventional radiograph (Gold Standard, GS) versus measurements on CT. Two groups were studied: one group consisted of 11 subjects with a diagnosed calcaneal fracture, the other group of 11 subjects with a fracture of the lower extremities but no calcaneal fracture. A lateral Böhler angle (LBA), central Böhler angle (CBA) and a medial Böhler angle (MBA) were defined on CT. Furthermore, BA was reconstructed out of a 3D reconstruction (3DBA).

Results: CBA approached the GS with a mean difference of 3.78° (95 %CI: 2.82-4.75) with no significant difference in variance (p = 1.000). 3DBA approached the GS with a mean difference of 2.14° (95 %CI: 1.57-2.70) with a significant difference in variance (p = 0.014). No relevant correlations were found between LBA/MBA and the GS. ICC between raters was considered as good or excellent for both CBA and 3DBA.

Conclusion: Giving the high accuracy and better capability to visualize the anatomy in the case of severe injury, measuring BA on 3D reconstruction is a suggested alternative to the traditional technique.
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NewsBot · Aug 20, 2024

Three dimensional analysis of factors affecting the prognosis of calcaneal fractures
Meng Lu et al
J Orthop Surg Res. 2024 Aug 10;19(1):473

Purpose: Analyzing the correlation between patients' basic information, three-dimensional parameters after calcaneal fractures, and the prognosis of calcaneal fractures.

Methods: A retrospective analysis was conducted on 43 patients with calcaneal fractures who underwent surgical treatment in the Foot and Ankle Surgery, Xi'an Honghui Hospital, from September 2019 to August 2022. Patient demographics including gender and age were collected, as well as the preoperative posterior articular surface collapse area, number of fracture fragments, length, width, height, and volume of the calcaneus obtained from preoperative three-dimensional imaging. Patients were followed up for VAS, AOFAS, and SF-36 scores. Correlation analysis was performed on the obtained data.

Results: All 43 included patients received complete follow-up, including 40 males and 3 females, with an average follow-up time of 35.37 ± 10.73 months, and an average age of 43.98 ± 12.08 years. All patients' VAS, AOFAS, and SF-36 scores at the last follow-up showed no correlation with patient age, gender, or the area of posterior articular collapse, number of fracture fragments, length, width, height, or volume of the calcaneus.

Conclusions: The prognosis of calcaneal fractures is unrelated to three-dimensional factors such as patient age, gender, length, width, height, volume of the calcaneus, area of the posterior joint, and number of fracture fragments.
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NewsBot · Aug 21, 2024

Functional and Radiological Outcome after Internal Fixation of Intra-articular Calcaneal Fractures
J Daniel Jey Janeson et al
J Orthop Case Rep. 2024 Aug;14(8):205-211

Introduction: Calcaneal fractures are rare injuries constituting 2% of all fractures. Fractures of calcaneum correspond to nearly 60-75% of the tarsal bone fractures. The calcaneum is the most commonly fractured tarsal bone 90% occur in males between 21 and 45 years of age. The calcaneal fracture may be extra-articular (sparing the subtalar joint) and intra-articular involving the subtalar joint. Intra-articular fractures account for approximately 75% of calcaneal fractures and have been associated with poor functional outcomes. In this study, we aim to assess the functional outcome of internal fixation in displaced intra-articular calcaneal fractures.

Materials and methods: A prospective interventional study was conducted on patients with only intra-articular calcaneal fractures admitted to Chettinad Hospital and Research Institute, Kelambakkam during the period from May 1, 2022, to February 29, 2024, and a total of 32 patients were considered. The functional outcome was assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scoring System.

Results: The average age of the patients in our study was 39 years of which all were male. Fall from height is the most common mode of injury. The right calcaneum is more commonly involved than the left. The mean duration of hospital stay was around 10 days. The fracture classification was based on the sanders and Essex-Lopresti classification of which 17 patients were sanders type 3 and 13 patients were sanders type 2 and 1 patient was sanders type 4. The mean time for radiological union is 12 weeks. The Bohler's angle and Gissane's angle preoperatively 16.16 ± 8.87 and 121.48 ± 7.47 restored to near normal values after fixation 27.77 ± 6.02 and 113.485 ± 44, respectively. Heel height and heel width restored to near normal values of (pre-operative heel height - 24.74 ± 3.71 and heel width - 39.97 ± 4.11 and post-operative heel height - 31.55 ± 3.38 and heel width - 34.0 ± 3.1), respectively. The most common complications were wound-related complications (superficial wound infection - 9.7%, deep wound infection - 3.2%, and wound margin necrosis and wound dehiscence 6.4%) and the most common late complications were complex regional pain syndrome - 9.7% and subfibular lateral impingement with peroneal tendinitis - 6.5%. AOFAS grading of functional outcome had shown good to excellent results in 83.8% (26 patients) of the cases. The mean AOFAS score was 83.39 in our study.

Conclusion: The present study shows that open reduction and internal fixation give superior radiographic results as shown by the restoration of Bohler's and Gissane's angle and height and width of the calcaneus to near normal values, indicating anatomical restoration of calcaneal shape. The functional outcome by AOFAS score showed good to excellent results in most of the patients with minimal wound complications.
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Calcaneal fractures

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