Neue Techniken in der operativen Versorgung von Calcaneusfrakturen

The ideal treatment of displaced intra-articular calcaneal fractures is still controversially discussed. Because of the variable fracture patterns and the vulnerable soft tissue coverage an individual treatment concept is advisable. In order to minimize wound edge necrosis associated with extended lateral approaches, selected fractures may be treated percutaneously or in a less invasive manner while controlling joint reduction via a sinus tarsi approach. Fixation in these cases is achieved with screws, intramedullary locking nails or modified plates that are slid in subcutaneously. A thorough knowledge of the three dimensional calcaneal anatomy and open reduction maneuvers is a prerequisite for good results with less invasive techniques. Early functional follow-up treatment aims at early rehabilitation independent of the kind of fixation. Peripheral fractures of the talus and calcaneus frequently result from subluxation and dislocation at the subtalar and Chopart joints. They are still regularly overlooked and result in painful arthritis if left untreated. If an exact anatomical reduction of these intra-articular fractures is impossible, resection of small fragments is indicated.     

Talus- und Kalkaneusfrakturen

The treatment of displaced fractures of the talus and calcaneus is associated with a considerable learning curve. Malunion results in significant limitations of global foot function and painful posttraumatic arthritis. While early reduction of dislocations and fracture dislocations represent an emergency situation, the timing of definitive fixation has no measurable impact on the results and the incidence of avascular necrosis in central fractures of the talus. For internal fixation of displaced fractures with central comminution or medial joint impaction, anatomically shaped interlocking plates are available in addition to screws. The ideal treatment of displaced intra-articular calcaneal fractures is still controversial. Because of the variable fracture patterns and the vulnerable soft tissue cover, an individual treatment concept is advisable. In order to minimize the wound margin necrosis associated with extensile lateral approaches, selected fractures should be treated with less invasive fixation while controlling joint reduction via a sinus tarsi approach. Fixation in these cases is achieved with screws, intramedullary locking nails or modified plates that are inserted subcutaneously. Displaced extra-articular and simple intra-articular fractures can be reduced and fixed percutaneously. Functional aftertreatment aims at early rehabilitation independent of the kind of fixation. Peripheral fractures of the talus and calcaneus frequently result from subluxation and dislocation at the subtalar and Chopart's joints. They are still regularly overlooked and result in painful arthritis if left untreated. If an exact anatomical reduction of these intra-articular fractures is impossible, resection of small fragments is indicated.     

An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures

The approach to the treatment of intra-articular calcaneal fractures has often been the subject of discussion. The results achieved with both operative and non-operative management remain to some extent unpredictable. Minimally invasive osteosynthesis offers an alternative approach, especially in those cases in which open reduction would be hazardous and non-operative treatment inadequate. This technique requires minimal dissection and preserves subtalar motion almost completely. The authors believe that displaced intra-articular calcaneal fractures are best treated through operative intervention. Restoration of articular congruity is an integral, though not necessarily sufficient, component of a successful long-term outcome following calcaneal fracture. The extra-articular dimensions of the calcaneus must be restored in order to tolerate standard shoe-wear, maintain a functional range of talocalcaneal motion and avoid subsequent tibiotalar arthrosis. However, in certain circumstances open reduction may be associated with an unacceptably high complication rate. In these cases, the authors have found a "minimally invasive" osteosynthesis technique useful in dealing with competing goals. In our experience, this technique can, when used appropriately, result in a functional recovery of the patient suffering a calcaneal fracture.     

跟骨插入式钢板的研制及其在跟骨关节内移位性骨折手术中的应用

目的 研制一种适合于经跗骨窦切口经皮插入式的跟骨微创钢板,探讨其在移位性跟骨关节内骨折治疗中的疗效. 方法 自2006年9月至2008年9月经跗骨窦切口入路,采用跟骨经皮插入式钢板治疗跟骨关节内骨折38例(40足),其中SandersⅡ型22足(Ⅱa型6足,Ⅱb型14足,Ⅱc型2足),Ⅲ型18足(Ⅲab型7足,Ⅲac型10足,Ⅲbc型1足).根据X线片对手术前后跟骨高度、宽度、长度及跟骨Bohlers角和Gissanes角进行比较分析,并观察术后切口愈合情况.采用Maryland足部评分系统评价临床功能疗效. 结果 所有患者术后获得3～24个月(平均12个月)随访,X线片示术后跟骨高度、宽度、长度及跟骨Bohlers角和Gissanes角均获得满意矫正,与术前比较,差异均有统计学意义(P<0.01).Maryland足部评分系统显示:优32足,良6足,可2足,优良率95.0%.术后未发现明显并发症. 结论 采用经跗骨窦切口跟骨插入式钢板治疗跟骨关节内移位性骨折不仅可以获得满意的疗效,而且能够有效避免术后并发症的发生.     

Minimally-invasive treatment of calcaneal fractures

Percutaneous reduction methods play an important role in the management of calcaneal fractures with severe soft tissue compromise, particularly open fractures, and they offer a treatment alternative in patients with local or systemic contraindication to open reduction. Percutaneous reduction by pin leverage (Westhues or Essex-Lopresti maneuver) followed by minimally invasive screw fixation is a treatment option that yields good to excellent results in tongue-type fractures with posterior facet displacement as a whole (Sanders-type IIC). This method can be applied to selected Sanders-type IIA or IIB fractures if the quality of joint reduction is controlled arthroscopically. Although some authors have expanded the use of percutaneous reduction by traction, leverage, and compression with subsequent K-wire or screw fixation with remarkable results, the uniform application of percutaneous methods to all intra-articular calcaneus fractures is critical. Inadequate joint reduction and redislocation of the fragments in highly unstable fractures may occur in a considerable percentage of cases. Prolonged transfixation of the subtalar and calcaneocuboid joints is strongly discouraged, because functional aftertreatment is an important part of the rehabilitation after calcaneal fractures.     

The use of subtalar arthroscopy in open reduction and internal fixation of intra-articular calcaneal fractures

Congruency of the subtalar joint is a major predictor of outcome after intra-articular calcaneal fractures. Because of the irregular shape of the posterior joint facet, minor steps may be overlooked with direct vision or intra-operative fluoroscopy during open reduction and internal fixation (ORIF). In a preliminary series of 15 subtalar arthroscopies during hardware removal after ORIF of intra-articular calcaneal fractures, patients with visible steps of 1 mm or more had significantly inferior functional results compared to those with an intact subtalar joint (117 vs. 158 points with the 200-point score, 71.3 vs. 91.2 points with the Maryland Foot Score, P<0.01). Congruency of the posterior facet was controlled arthroscopically in 47 intra-articular calcaneus fractures after open reduction and temporary K-wire-fixation. In 12 cases (25.5%), despite seemingly correct reduction as judged fluoroscopically, incongruencies in the posterior calcaneal facet were detected and reduction was repeated, temporarily removing the K-wires. After anatomical reduction a standard AO calcaneal plate was fixed to the lateral wall. Intra-operative arthroscopy appears to be useful in detecting minor incongruencies after ORIF of intra-articular calcaneus fractures. In the hands of an experienced surgeon it is less time demanding than intra-operative X-rays and more precise than fluoroscopy.     

Limb Reconstruction System Assisted Reduction and Internal Fixation for Intra‐Articular Calcaneal Fractures: A New Application

Background

Minimally invasive reduction and fixation of intra-articular calcaneal fractures poses great challenges for orthopaedic surgeons. The aim of the present study was to report the technical points, evaluate the efficacy of minimally invasive reduction and internal fixation assisted by the temporary limb reconstruction system (LRS) external fixator for intra-articular calcaneal fractures, and propose the indications of our protocol.

Methods

In this retrospective study, a series of 34 consecutive closed and displaced intra-articular calcaneal fractures involving the articular surface were treated by this technology between June 2016 and April 2018. X-ray and computed tomography (CT) scans were performed before and after surgery to measure Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot. Postoperative complications were recorded. Imaging and clinical outcomes were comprehensively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle scoring system. After testing the normality of the data, Bohler's angle and the length of calcaneus were compared using the Wilcoxon signed-rank test. The height, width of the calcaneus, and the mechanical axis of the hindfoot were compared using the Paired-Samples t-test.

Results

Thirty-two fractures were followed up for an average of 20.66 months (from 12 to 32 months). All fractures achieved stable reduction and bony union. The articular surface was reduced and fixed with direct vision through the sinus tarsi incision. No failure of internal fixation or loss of reduction was detected during follow-up. There were no soft tissue complications. Bohler's angle; the length, height, and width of the calcaneus; and the mechanical axis of the hindfoot improved significantly. The AOFAS scores averaged 84.12 points; seven cases were rated excellent, 20 good, four fair, and one poor.

Conclusions

For intra-articular calcaneal fractures, minimally invasive surgery assisted with temporary LRS external fixation can reconstruct the calcaneal shape and the sub-talar articular surface. This simple surgical modality with limited complications may be helpful in the surgical treatment of most type II and III calcaneal fractures except comminuted fractures of the calcaneal tuberosity.     

Displaced intra-articular calcaneal fractures

BACKGROUND: Calcaneal fractures comprise 1 to 2 percent of all fractures. Approximately 75% of calcaneal fractures are intra-articular. The management of intra-articular calcaneal fractures remains controversial. Nonoperative treatment options include elevation, ice, early mobilization, and cyclic compression of the plantar arch. Operative treatment options include closed reduction and percutaneous pin fixation, open reduction and internal fixation, and arthrodesis. The effect of operative versus nonoperative treatment has been the focus of several comparative studies. OBJECTIVE: This study was designed to determine the effect of operative treatment compared with nonoperative treatment on the rate of union, complications, and functional outcome after intra-articular calcaneal fracture in adults.     

Standardized treatment of intra-articular calcaneal fractures using an oblique lateral incision and no bone graft

BACKGROUND: The purpose of this study was to evaluate our protocol with the modified skin incision without bone graft in the treatment of intra-articular calcaneal fractures in a consecutive series. METHODS: Thirty-three displaced intra-articular calcaneal fractures operatively treated by a single surgeon were evaluated. Each fracture was managed according to a standardized protocol that included an oblique lateral incision and stable internal fixation, without supplemental bone graft. Fractures were classified according to two accepted criteria. Patients were evaluated with serial clinical and radiographic examinations. Final evaluation was made after at least a 2-year follow-up and was determined by the use of a functional outcome assessment questionnaire. RESULTS: Anatomic or near anatomic reductions were obtained in 97% of cases. All fractures healed without loss of initial reduction or collapse. Excellent or good results were achieved in 88% of non-worker's compensation patients and 27% of worker's compensation patients. Fractures with anatomic reductions were more likely to achieve a good or excellent result. Ninety-two percent of patients returned to the workforce. Complications included one superficial wound infection and five cases of peroneal tendinitis requiring hardware removal. One patient underwent subtalar fusion secondary to painful posttraumatic arthritis. CONCLUSIONS: The open reduction and internal fixation using our standardized protocol is an effective method of treatment for intra-articular calcaneal fractures.     

经“八”字切口微创固定治疗跟骨关节内骨折

目的探讨经跟骨外侧"八"字切口、Y型解剖板微创固定治疗跟骨关节内骨折的疗效。方法对46例闭合跟骨关节内骨折采用跟骨外侧"八"字切口、Y型解剖板微创固定治疗。结果 46例均获得随访,时间12~30个月。患者骨折均愈合,无一例发生切口深部感染、皮肤坏死及骨髓炎等严重并发症。按AOFAS评分标准评价:优30足,良14足,可3足,差2足,优良率为89.8%。结论经跟骨外侧"八"字切口、Y型解剖板微创固定治疗跟骨关节内骨折,术中直视下复位跟骨后关节面,固定可靠,可早期活动。     

跟骨关节内移位骨折微创手术治疗临床疗效分析

目的探讨微创手术治疗跟骨关节内移位骨折的临床疗效。方法自2009-03－2010-10,采用小切口置入跟骨解剖钢板加压螺栓内固定治疗106例（131足）跟骨关节内骨折,其中SandersⅡ型59足,Ⅲ型57足,Ⅳ型15足。术后根据X线片和CT评估骨折复位质量,应用AOFAS评分标准评估患足功能恢复。116足经后足外侧纵形入路治疗,14足行跗骨窦入路。1例SandersⅣ型骨折同时行外侧纵形人路和跗骨窦人路治疗。结果本组手术时间平均83（60～135）min。Bohler角术前平均-1．7°,术后平均29°。骨折复位质量良好者达96．2％。术后24个月84例（95足）获得随访,患足功能恢复优34足,良47足,可11足,差3足,优良率85．3％。结论应用解剖接骨板加压螺栓系统微创内固定治疗跟骨关节内骨折可获得满意疗效。     

A Minimally Invasive Technique for the Reduction of Calcaneal Fractures Using the Endobutton®

Calcaneal fractures are very common injuries, and closed reduction-percutaneous pinning, open reduction-internal fixation, and primary arthrodesis are the procedures used in the surgical treatment of these injuries. The aim of surgical treatment is to restore the normal biomechanics of the Achilles tendon and rearfoot by anatomic reduction of the articular surfaces. Minimization of the soft tissue complications commonly associated with the open treatment of calcaneal fractures can be achieved using indirect closed reduction and Kirschner wire or screw-assisted minimally invasive percutaneous osteosynthesis methods. In the present report, we describe a technique for the treatment of calcaneal fractures associated with soft tissues that are at risk of complications and present the cases of 3 patients treated with indirect, minimally invasive reduction of comminuted calcaneal fractures with the Endobutton^® fixation device. From our experience with this method, we believe it will be useful in cases of acute calcaneal fracture with pronounced soft tissue injury localized to the hindfoot.     

Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective,randomized, controlled multicenter trial

BACKGROUND: Open reduction and internal fixation is the treatment of choice for displaced intra-articular calcaneal fractures at many orthopaedic trauma centers. The purpose of this study was to determine whether open reduction and internal fixation of displaced intra-articular calcaneal fractures results in better general and disease-specific health outcomes at two years after the injury compared with those after nonoperative management. METHODS: Patients at four trauma centers were randomized to operative or nonoperative care. A standard protocol, involving a lateral approach and rigid internal fixation, was used for operative care. Nonoperative treatment involved no attempt at closed reduction, and the patients were treated only with ice, elevation, and rest. All fractures were classified, and the quality of the reduction was measured. Validated outcome measures included the Short Form-36 (SF-36, a general health survey) and a visual analog scale (a disease-specific scale). RESULTS: Between April 1991 and December 1997, 512 patients with a calcaneal fracture were treated. Of those patients, 424 with 471 displaced intra-articular calcaneal fractures were enrolled in the study. Three hundred and nine patients (73%) were followed and assessed for a minimum of two years and a maximum of eight years of follow-up. The outcomes after nonoperative treatment were not found to be different from those after operative treatment; the score on the SF-36 was 64.7 and 68.7, respectively (p = 0.13), and the score on the visual analog scale was 64.3 and 68.6, respectively (p = 0.12). However, the patients who were not receiving Workers' Compensation and were managed operatively had significantly higher satisfaction scores (p = 0.001). Women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively (p = 0.015). Patients who were not receiving Workers' Compensation and were younger (less than twenty-nine years old), had a moderately lower B?hler angle (0 degrees to 14 degrees ), a comminuted fracture, a light workload, or an anatomic reduction or a step-off of < or =2 mm after surgical reduction (p = 0.04) scored significantly higher on the scoring scales after surgery compared with those who were treated nonoperatively. CONCLUSIONS: Without stratification of the groups, the functional results after nonoperative care of displaced intra-articular calcaneal fractures were equivalent to those after operative care. However, after unmasking the data by removal of the patients who were receiving Workers' Compensation, the outcomes were significantly better in some groups of surgically treated patients.     

影响跟骨关节内骨折疗效的因素

目的探讨影响跟骨关节内骨折疗效的因素。方法回顾总结自1999年1月1日—2004年1月31日收治的58例跟骨关节内骨折并加以分析。结果本组58例中有56例获得随访，根据改良的跟骨关节内骨折的评分标准评分，优20例，良24例，可8例，差4例，总的优良率达到78．6％。结论影响跟骨关节内骨折疗效的主要因素包括骨折的类型、治疗的方法、复位的质量、术后并发症的预防及功能锻炼。     

改良外侧“L”形切口治疗跟骨关节内移位骨折

 目的 探讨改良外侧“L”形切口治疗跟骨关节内移位骨折的临床疗效。 方法 自2005年 1月至2011年10月收治跟骨关节内移位骨折患者 133例143足,男 125例,女8例;年龄 19~65岁,平均 43.2岁。左侧56例,右侧67例,双侧10例,均为闭合骨折。其中3例合并脊柱损伤。根据Sanders分型：Ⅱ型15足、Ⅲ型107足、Ⅳ型21足。均采用外侧改良“L”型切口,切开复位异型钢板内固定。术后均未给予石膏外固定,早期行踝关节功能练习,术后6周部分负重,12周完全负重。采用美国足与踝关节外科协会(American Orthopaedic Foot and Ankle Society, AOFAS)踝与后足功能评分系统评价术后足踝功能。结果 125例135足获得随访(8例8足术后12周后失访),随访时间12~28个月,平均 18.5 个月。骨折均愈合,愈合时间8~16周,平均13周。无神经损伤,骨髓炎。4足切口裂开,骨折愈合内固定钢板取出后皮肤愈合。17足发生距下关节创伤性关节炎,行走时疼痛。5足负重后关节面出现塌陷。根据AOFAS踝与后足功能评分系统,优94例、良29例、可14例、差6例,优良率为92.9%。 结论应用改良外侧切口切开复位异型钢板内固定治疗跟骨关节内移位骨折可以获得满意疗效,但在临床应用中需要掌握熟练手术技术。     

Calcaneal fractures: Where are we now?

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

Surgical treatment of intra-articular calcaneal fractures: description of a technique using an adjustable uniplanar external fixator

Several surgical techniques are available for the treatment of intra-articular calcaneal fractures. The use of a uniplanar external fixator is an option for the treatment of fractures classified as Sanders types 2 and 3. Satisfactory reduction and stabilisation of the fracture are achieved by means of mini-incisions and fixator adjustment. The advantages of this technique include less soft-tissue damage, avoidance of internal implants and early weight-bearing with the potential to improve postoperative recovery.     

Treatment of displaced intra-articular calcaneal fractures with triangular tube-to-bar external fixation: long-term clinical follow-up and radiographic analysis

Sixty-six feet (62 patients) with displaced intra-articular calcaneal fractures underwent manual reduction and distraction with the use of a triangular tube-to-bar external fixation device and were retrospectively reviewed at a minimum of 1-year post-operative. Final radiographic follow-up revealed complete consolidation in all fractures, maintenance of reduction, and limited degenerative osteoarthrosis about the subtalar joint. Our results indicate that with proper application and attention to detail, restoration of calcaneal morphology using triangular tube-to-bar external fixation should be considered a viable alternative in the treatment of displaced intra-articular fractures of the calcaneus.     

Y型钢板治疗跟骨关节内骨折

目的探讨切开复位Y型钢板内固定治疗跟骨关节内骨折的治疗方法和疗效。方法对64例累及关节面的跟骨骨折作切开复位Y形钢板内固定治疗。结果术后患足功能按Maryland足部评分系统优25例，良32例，优良率为89．06％。结论切开复位Y型钢板内固定是治疗跟骨关节内骨折较好的方法。     

Osteosynthesis for intra-articular calcaneal fractures

PURPOSE: To correlate treatment results of intra-articular calcaneal fractures with their computed tomographic (CT) classification. METHODS: 36 men and 4 women with 48 intra-articular calcaneal fractures (8 bilateral) underwent open reduction and internal fixation with bone grafting via an extensile lateral approach. Based on 2-dimensional CT scans, the fractures were categorised using the Sanders classification. There were 16 type-II, 20 type-III, and 12 type-IV fractures. Radiographs and Maryland foot scores were used for evaluation of the results at a mean of 38 (range, 26-66) months. RESULTS: Anatomic reduction of the posterior calcaneal facet was achieved in 38 of 48 fractures. The Bohler and Gissane angles were restored to between 92 and 99% of normal, respectively. Despite this, the mean functional scores were 84 in type-II, 83 in type-III and 67 in type-IV fractures. CONCLUSION: Surgical results were superior in type-II and -III fractures. Type-IV fractures fared poorly, despite excellent restoration of calcaneal anatomy; subtalar arthrodesis should have been considered.