Treatment of displaced intra-articular calcaneal fractures by ligamentotaxis: current concepts’ review

Introduction  

A large variety of therapeutic modalities for calcaneal fractures have been described in the literature. No single treatment modality for displaced intra-articular calcaneal fractures has proven superior over the other. This review describes and compares the different percutaneous distractional approaches for intra-articular calcaneal fractures. The history, technique, anatomical and fracture considerations, limitations and the results of different distractional approaches reported in the literature are reviewed.     

Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary?

Background

The aim of this retrospective study was to determine the need for bone grafting in the surgical treatment of displaced intra-articular calcaneal fractures. We reviewed 390 cases of displaced intra-articular calcaneal fractures treated with plate osteosynthesis with or without autologous iliac bone grafting, and compared outcomes and complications related to fracture stabilization.

Materials and methods

Three hundred ninety patients with displaced intra-articular calcaneal fractures that were treated with plate osteosynthesis from December 2002 to December 2010 were reviewed. Two hundred two patients (group A) were treated by osteosynthesis with autologous bone grafting, and 188 patients (group B) were treated by osteosynthesis without bone grafting. One hundred eighty-one patients with an AO type 73-C1 fracture (Sanders type II), 182 patients with an AO type 73-C2 fracture (Sanders type III), and 27 patients with an AO type 73-C3 fracture (Sanders type IV) were included in this study. Bohler’s angle, the crucial angle of Gissane, and calcaneal height in the immediate postoperative period and at the 2-year follow-up were compared. Any change in the subtalar joint status was documented and analyzed. The final outcomes of all patients were evaluated by the AOFAS Ankle–Hindfoot Scale and compared in both groups.

Results

The mean full weight-bearing time in group A (with bone grafting) was significantly lower (median 6.2 months, range 2.8–9.2 months) than that in group B (without bone grafting; median 9.8 months, range 6.8–12.2 months). The immediate-postoperative Bohler’s angle and that at the 2-year follow-up were significantly higher in group A. The loss of Bohler’s angle after 2 years was significantly lower in group A (mean 3.5°; 95 % CI 0.8°–6.2°) than in group B (mean 6.2°; 95 % CI 1.0°–11.2°). The average change in the crucial angle and the average change in calcaneal height were not statistically significant for either group. The infection rate in the bone grafting group was higher, though statistically insignificantly so, than in the nongrafting group (8.3 vs. 6.3 %). No significant difference was found between the groups in terms of the rates of good reduction, postoperative osteoarthritis, and subtalar fusion. Regarding the efficacy outcomes, the mean AOFAS score was lower (mean 76.4 points; 95 % CI 65.8–82.9 points) in group A than in group B (mean, 81.6 points; 95 % CI, 72.3–88.8 points), but this difference was not significant (p > 0.05).

Conclusions

Bohler’s angle showed improved restoration and the patients returned to full weight-bearing earlier when bone grafting was used in the treatment of intra-articular calcaneal fracture. However, the functional outcomes and complication rates of both groups were similar.     

Is there a reliable outcome measurement for displaced intra-articular calcaneal fractures?

BACKGROUND: The treatment of displaced intra-articular calcaneal fractures remains controversial, because of difficulties in assessing the outcome. The goal of this study, therefore, was to compare different outcome measurements with gait analysis, using dynamic pedography. METHODS: Twenty patients with operatively treated displaced intra-articular calcaneal fractures were followed up clinically and radiographically. In addition, foot pressure was measured using dynamic pedography. RESULTS: No significant difference was found between the two clinical outcome scores used (p = 0.08); both revealed good results. Dynamic pedography, however, showed a shift of the maximum impact and roll-off of the foot to the lateral side, as well as a widening of these zones in the heel and on the sole in 14 of 20 patients. CONCLUSION: These results indicate that traditional outcome measurements underestimate functional deficits in our patients. Monitoring plantar pressure distribution might therefore be a useful tool for assessing foot function in these patients.     

The physiological range of the Böhler’s angle in the adult Croatian population

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

Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful?

OBJECTIVE: To determine whether autologous bone graft supplementation with open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures (DIACFs) is beneficial in achieving and maintaining restoration of calcaneal height and anatomic reduction of the posterior facet. DESIGN: Prospective historical cohort. SETTING: Level I trauma center, university hospital. PATIENTS AND INTERVENTION: Twenty DIACFs in twenty patients who received ORIF with bone graft supplementation were individually prospectively matched to twenty DIACFs in twenty patients who received only ORIF. Matching criteria for these pairs of patients included age, sex, occupational workload, Essex-Lopresti and Sanders classification, preoperative B?hler's angle, and fixation in the joint. MAIN OUTCOME MEASUREMENTS: Postoperative computed tomography assessed quality of anatomic reduction. Postoperative and three-month follow-up radiographs assessed B?hler's angle. A validated visual analog scale and Short Form-36 assessed functional outcome at a minimum of two years after surgery. RESULTS: Twenty-one fractures were (Orthopaedic Trauma Association) 73-C2 (Sanders Type III); fifteen fractures were 73-C1 (Sanders Type II); and four fractures were 73-C3 (Sanders Type IV). In the individually matched pairs of patients, the mean preoperative B?hler's angle was 2 degrees (standard deviation [SD] 14 degrees) for the bone graft group and 1 degree (SD 12 degrees) for the non-bone graft group. Preoperative B?hler's angle differed between individually matched pairs an average of 4 degrees (range 0 to 10 degrees). B?hler's angle increased with surgery a mean of 26 degrees (SD14 degrees) in the bone graft group and 27 degrees (SD 10 degrees) in the non-bone graft group. In the first three months after surgery, a mean decrease in B?hler's angle of 7 degrees (SD 4 degrees) in the bone graft group and 6 degrees (SD 7 degrees) in the non-bone graft group occurred. Statistical analysis of the individually matched pairs found no significant difference between the bone graft and non-bone graft patients regarding the change in B?hler's angle obtained with surgery (p = 0.98) and the change in B?hler's angle in the three months after surgery (p = 0.94). Quality of reduction was similar between groups, with eight matched pairs obtaining an equal reduction, six achieving a better reduction with bone graft, and six achieving a poorer reduction with bone graft. No differences in functional outcome were detected. CONCLUSIONS: We found no objective radiographic or functional benefit to the use of bone graft supplementation in the operative treatment of DIACFs.     

Plating for intra-articular calcaneal fractures…. Is it an overkill?

Objectives

Even after evolution of computerized tomography and improved surgical measures, treatment of intraarticular calcaneal fractures remains a controversy. Hence this study was carried out to compare functional outcomes of displaced intraarticular calcaneal fractures, treated with operative management with plating and conservative management with cast.

Material and methods

This study was carried out as a prospective, comparative study. Twenty nine (30 fractures) patients with acute, displaced intraarticular fractures of calcaneum aged 18–50 years, were enrolled in the study. Open fractures and fractures older than two weeks were excluded. 30 fractures were divided into two groups (operative and conservative; n = 15 in each). Evaluation in form of post treatment restoration of Bohler''s angle, heel varus angle and with Creighton–Nebraska (C–N) score for functional outcome was done at the end of 12 months.

Results

When we consider the clinical evaluation under the C–N score, the results of operatively managed calcaneal fractures are slightly better than those of the conservative group. But this did not have any statistical significance. Also, there was significant difference in pre and post treatment Bohler''s angle and heel varus angle in operative group. Three cases of plating suffered from post-operative wound dehiscence.

Conclusion

A relatively better functional outcome was observed in displaced and comminuted fractures in plating, provided that the Bohler''s angle was restored. In conservative group, functional outcome of minimally displaced fractures were better than displaced comminuted fractures. Post treatment Bohlers angle has prognostic importance in functional outcome.     

External fixation in comminuted,displaced intra-articular fractures of the distal radius: is it sufficient?

Introduction: External fixation has been extensively used to treat the intra-articular fractures of the distal radius and it has several distinct advantages over conventional POP cast and plate fixation. However, the limitation of external fixation to achieve articular congruity in the comminuted intra-articular fractures of the distal radius has been documented in the literature. This could be because external fixation alone does not expand crushed cancellous bone and cannot work without soft tissue hinges. This prospective study was conducted to look at the results of comminuted, displaced intra-articular fractures of the distal radius treated exclusively by external fixation. Materials and methods: A 2-year follow-up of 27 patients with comminuted, displaced intra-articular fractures of distal radius that were treated exclusively by external fixation is presented. The radiological results, functional results and complications were analyzed according to the scoring system given by Jakim et al. Results: Anatomical reduction could not be achieved in 12 patients (44%) and reduction was lost in two patients (7%). Excellent and good results were seen in 59.3%, fair results were seen in 22.2% and poor results were seen in 18.5% of the cases. Outcome scores of patients without articular step were significantly better as compared to the patients with articular step at healing. There was a positive correlation between the restoration of normal anatomy (radiological results) and the functional outcome (r=0.775). Overall nine patients (33%) had complications. Conclusion: We conclude that although the external fixation is reliable in maintaining the reduction in displaced comminuted intra-articular fractures, it is inadequate in restoring articular congruity in many cases. The complications of external fixation are frequent and may be potentially serious in nature.     

Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures – A systematic review of the literature

IntroductionCalcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences.MethodsA literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied.Results3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0–3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p = 0.970, p = 0.748) or studies with <10 or ≥10 operations per year (respectively p = 0.326, p = 0.378). However, lower rates of POWI were found in studies with a follow up of >3 months (p = 0.01).ConclusionLarge differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3 months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.     

Double measurement of the Böhler angle: prognostic value of radiological angles in posterior facet fractures of the calcaneus

In 1931, B?hler proposed that measuring the radiological angle of the tuberosity could be useful in posterior facet fractures of the calcaneus to evaluate initial damage as well as reduction quality. In opposition to the 1998 SOFCOT symposium, certain authors considered that the B?hler angle has no prognostic value. Progress in pathological anatomy has helped to better understand posterior facet fractures, justifying the use of a "double measurement". The fundamental fracture line separates the posterior facet into a lowered medial fragment and a pivoted lateral fragment. The double contour of the posterior facet visualized radiographically allows measurement of a medial B?hler angle and a lateral B?hler angle. It is demonstrated that is the smaller the medial B?hler angle, the greater the subtalar degeneration. Surgical restoration of a satisfactory B?hler angle is a necessary prerequisite for a good outcome. "Double measurement" of the B?hler angle on the lateral view contributes to the prognostic value of this historical angle.     

Does Kapandji wiring help in older patients? A retrospective comparative review of displaced intra-articular distal radial fractures in patients over 55 years

Forty-six patients aged 55–90 with intra-articular displaced fractures of the distal radius were reviewed retrospectively. All patients were treated with either manipulation and plaster of Paris or Kapandji wiring. Radiographic and functional review was performed by an independent observer a mean of 17 months after the fracture.

The results showed superior anatomical and functional results in the group treated with Kapandji wiring. The mean dorsal angle was significantly better in the wired group, and the improvement in dorsal angle, radial angle and radial length from presentation to final result was also significantly better. Functional results were excellent or good in 19/23 of the wired group, compared with 12/23 of the plaster group. There was a strong correlation between functional outcome and both dorsal angle and radial length at union.

These results support the use of this method of wire fixation in older patients, as the technique is simple and complications were few.     

Do Kirschner wires maintain reduction of displaced Colles' fractures?

Fifty-three patients underwent closed reduction and longitudinal k-wiring of displaced Colles’ fractures and were reviewed after a mean of 26 months. Radiographs taken at the time of injury, after reduction and k-wiring, and at fracture union were compared for radial shortening and dorsal angulation. Manipulation significantly improved fracture position (P < 0.001). Dorsal angulation was successfully corrected by manipulation in 98%, and this position was maintained to fracture union in all cases. Seventy-three percentage of fractures manipulated for radial shortening >2 mm were adequately reduced, but 41% of these fractures subsequently lost position to malunite. In this group of patients, the mean radial shortening between reduction and fracture union was 1.6 mm. This did not correlate with Frykman Class or radial shortening at injury.

Closed reduction and k-wire stabilisation is an attractive technique because it is relatively non-invasive compared with plating or external fixation. However, a degree of radial shortening between reduction and fracture union must be anticipated. Fractures reduced inadequately to allow for this loss of radial length, are more likely to malunite. This may compromise functional outcome.     

Stabilisation of acute femoral fractures in Paget’s disease

Eleven cases of acute femoral fractures in patients with Paget’s disease are presented following stabilisation with the solid AO femoral nail. In three cases with severe deformity of the femur, reaming was required to enable implant insertion. No corticotomies were required. The median operation time was 55 (35–65) min. There was no operative mortality and no patient developed signs of acute respiratory distress syndrome/fat embolism. Skeletal stability was achieved in all cases. The reconstruction proximal locking option (spiral blade) was utilised in ten of the eleven cases. In all cases a 9 mm nail was inserted. One patient (pagetic sarcoma) died 23 months after surgery. Ten of the eleven fractures healed uneventfully. The mean time to union was 32 (26–42) weeks.

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Résumé  Nous présentons onze cas de fracture du fémur associée à la maladie de Paget que nous avons traité avec un enclouage solide verrouillé (SFN) de AO (Synthes). Dans trois cas la déformation du fémur était si sévère qu’il fallu faire un alésage du canal médullaire pour permettre l’introduction du clou. En aucun cas il a était nécessaire de faire une ostéotomie. Le temps médian opératoire était 55 minutes (35–65). La mortalité opératoire était nulle avec pas un seul cas de syndrome d’insuffisance réspiratoire ou d’embolie graisseuse pendant ou aprés l’opération. La stabilité de l’ostéosynthèse a été obtenue dans tous les cas. Dans 10 cas sur 11, l’option de verrouillage avec la lame spirale a été utilisé. Dans chaque cas un clou de 9 mm de diametre a été utilisé. Un malade (avec sarcome associéà la maladie de Paget) est mort 23 mois aprés la chirurgie. La consolidation de la fracture a étéétablie dans 10 cas sur 11 sans aucun problème. Le temps moyen d’union était 32 (26–42) semaines.

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Accepted: 5 September 1999     

Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures: does correction of Bohler's angle alter outcomes?

The study reviewed in this article evaluated a group of patients who underwent surgical therapy for calcaneal fractures at a Level I trauma center. One group of patients was treated after outpatient referral to the center, whereas the other group was admitted to, and underwent surgery at, the center. This study attempted to determine which patient risk factors or injury characteristics might lead to an increased rate of wound-healing complications. Bohler's angle is a classic radiographic method of determining the severity of calcaneal injury in this group of patients. The question posed by the authors of this study was: Does a drastic correction in Bohler's angle lead to an increased incidence of wound-healing complications? The authors do not recommend undercorrection of Bohler's angle but urge avoidance of overcorrection and stress the importance of early surgical fixation after lateral skin wrinkling is found.     

How reliable are CT scans for the evaluation of calcaneal fractures?

Introduction  

CT scans are deemed to be the gold standard for the evaluation of calcaneal fractures. However, the reliability of the interpretation has not been studied systematically.     

Does operative fixation affect outcomes of displaced medial epicondyle fractures?

Purpose

Long-term functional results remain equivocal between operative fixation and closed management of displaced humeral medial epicondyle fractures. The purpose of this study was to determine whether a functional difference exists between treatment types.

Methods

One hundred and forty patients with a displaced medial epicondyle fracture between 2007 and 2014 met the inclusion criteria. Of this large cohort, only 12 patients agreed to return to clinic at a mean follow-up of 3 years for prospective evaluation. Data collection included radiographs, physical examination, validated outcome tools, and grip strength testing with a Jamar dynamometer.

Results

Both groups were comparable with regard to age, dominant side injured, length of follow-up, preinjury sports involvement, and initial displacement (10 mm operative vs. 9 mm nonoperative); however, half of the surgical group presented with an associated unreduced elbow dislocation versus 0 % in the nonoperative group. Both treatment methods resulted in high patient satisfaction and elbow function scores. There were four osseous nonunions (67 %) and one malunion (17 %) in the nonoperative group versus none in the operative group (p = 0.015). Patients treated nonoperatively had a nonsignificant decrease in grip strength (9 ± 6 lbs) as compared to operative patients (6 ± 5 lbs, medium effect size eta = 0.25, p = 0.25).

Conclusions

In this small cohort, operative management of displaced medial epicondyle fractures resulted in a higher rate of fracture union and return to sports. Other objective and subjective measures were similar between the two treatment groups.