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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Calcaneal fractures

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Calcaneal fractures

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Psychological dysfunction following calcaneal fractures

Calcaneal stress fractures in minimalist/barefoot runners

Calcaneal spur and its correlation with the talar articular facets

Calcaneal morphology and plantar fasciitis

Calcaneal spur and vitamin D, lipid profile and calcitonin

Painful Calcaneal Spur Often Misdiagnosed for Lumbar Radicular Pain

Calcaneal bone marrow lesions and plantar fasciitis

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