距下关节融合与跟骨丘部矫形术治疗严重跟骨骨折畸形愈合

目的观察距下关节融合与跟骨丘部矫形术联合治疗严重跟骨骨折畸形愈合的临床疗效,探讨其手术适应证及优、缺点。方法1994年12月~2006年1月,对84例(96足)跟骨骨折畸形愈合的患者行距下关节融合与跟骨丘部矫形术,采取跟骨外侧手术入路,取自体松质骨植骨距下关节融合及内固定。其中男51例62足,女33例34足;年龄21~58岁,平均38.5岁。单侧72例,双侧12例。损伤原因:高处坠落伤57例,交通事故伤22例,其他5例。损伤至手术时间6~31个月,平均9.5个月。结果术后患者均获随访1~132个月。根据美国足踝外科协会足与踝关节评分标准,优31足,良53足,差12足,优良率87.5%。术后X线片示Bo。hler角、Gissane角、跟骨丘部高度及跟骨宽度与术前比较,差异均有统计学意义(P<0.01)。结论自体松质骨植骨距下关节融合与跟骨丘部矫形术是治疗跟骨骨折畸形愈合的一种有效方法,能恢复后足外形及功能,明显降低跟骨骨折步行疼痛后遗症的发生率。     

跟骨丘部植骨重建距下关节融合治疗跟骨关节内陈旧骨折

目的探讨跟骨丘部自体骨植骨重建距下关节融合术治疗陈旧性跟骨关节内骨折的手术方法及适应证. 方法 2000年7月～2003年10月,对11例跟骨陈旧性骨折患者行自体髂骨植骨丘部重建距下关节融合的方法进行治疗.其中男9例,女2例,年龄21～48岁;均为单侧足.跟骨外侧改良L形切口,全部取髂骨植骨重建跟骨丘部高度,髂骨块平均为3.0 cm×2.5 cm×1.8 cm,跟骨外膨的外侧壁均切除. 结果 11例获随访3～18个月,平均11.5个月.重建丘部骨10～12周愈合,术后8周部分负重,平均13.2周完全负重行走.根据张铁良跟骨关节内骨折评分标准:优4例,良5例,可2例.X线片示Bhler角、跟骨宽度以及跟骨丘部高度基本恢复正常. 结论自体髂骨植骨、跟骨丘部高度重建及距下关节融合术是治疗陈旧性跟骨骨折的一种有效方法,可矫正跟骨畸形,并恢复外形及功能.     

跟骨丘部重建距下关节融合治疗跟骨骨折严重畸形愈合

目的介绍自体植骨丘部重建距下关节融台术治疗严重跟骨骨折畸形愈台的方法，探讨手术适应证及优、缺点。方法1998年11月～2002年8月．对17例21足跟骨骨折严重畸形愈台患者采用自体植骨丘部重建距下关节融台的方法进行治疗．男13例17足．女4例4足；年龄25～45岁，平均35.4岁；单侧跟骨骨折13侧13足，双侧4例8足．选择跟骨外侧改良“L”形切口行自体植骨丘部重建距下关节融合术，其中15例17足取髂骨植骨，1例2足分别取髂骨植骨和跟骨外膨的外侧壁植骨．1例2足取跟骨外膨的外侧壁植骨。所有跟骨外嘭的外删壁均做切除．结果15例18足获得随访。随访时间9～22个月，平均14．5个月。按Maryland方法评价术后功能：优7足，良9足，可2足；优良率为88．9%，X线片示Bohler角、Gissane角、距骨倾斜角、跟骨宽度及丘部高度基本恢复正常，结论自体植骨丘部重建距下关节融台术是治疗严重跟骨骨折畸形愈合的一种有技方法。可明显矫正跟骨畸形．恢复后足外形及功能。     

évaluation des résultats du traitement fonctionnel et chirurgical des fractures thalamiques du calcanéus : à propos d’une série rétrospective de 304 cas

Introduction

The treatment of thalamic fractures of the calcaneus is often an institutional decision, with no systematic correlation to osteo-chondral lesions. The aim of this retrospective study was to evaluate the results of functional and surgical treatment and to clarify the therapeutic indications based on the thalamic comminution and the position of the thalamic fundamental fracture line.

Materials and methods

It was a retrospective study conducted between 1990 and 2008. The fracture should involve the subtalar joint with an extension possible at the calcaneocuboid joint. Iinitial CT scans were carried out systematically to analyze the chondral lesions and the dysmorphia of the calcaneus bone. Cases were not included if the Kitaoka score was affected by neurological lesion or musculoskeletal sequela.

Results

Two thousand six hundred (and) twenty-four patients or 304 fractures were included. The average time of the revision of results was 39 months. The population was male (78%) with 38% of work-related accident. The treatment was functional in 172 cases, and surgical in 132 cases (89 subtalar arthrodesis with bone reconstruction and 43 osteosynthesis). The parameter ??work-related accident?? degraded the duration of sick leave and the Kitaoka score regardless of the treatment carried out. Subtalar joint osteoarthritis was present in 90% of cases reviewed. The Kitaoka score was correlated with the reconstruction of the calcaneus bone. It was higher in the group of vertical fractures treated by internal fixation or arthrodesis reconstruction versus functional treatment.

Discussion

Review of the literature confirms the importance of the patient parameters (sex, age, secondary benefit) on the final functional outcome. Surgical treatment has a high rate of complications, which requires a selection of the surgical indications in order to improve the Kitaoka score. The high rate of early secondary osteoarthritis of the subtalar joint, noted in a series of literature, is an important argument to advise a subtalar arthrodesis with calcaneus bone reconstruction immediately if the subtalar joint reconstruction seems impossible.

Conclusions

Functional treatment is the best choice for calcaneus fractures, with a global congruency of the subtalar joint. Osteosynthesis seems appropriate for simple fractures with an internal fundamental fracture line associated with a verticalization of a lateral thalamus fragment. Arthrodesis should be reserved for comminuted fractures.     

Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report.

Six patients with ankle joint destruction and delayed metaphyseal union after tibial plafond fracture were surgically treated with tibiotalar arthrodesis and metaphyseal reconstruction, using a fixed-angle cannulated blade-plate. The procedure was performed through a posterior approach in five cases and a lateral approach in one case. The subtalar joint was preserved in all cases. Metaphyseal union and a stable arthrodesis were obtained in all cases without loss of fixation and with no mechanical failure of the blade-plate. Union was obtained in an average of 26 weeks. No secondary procedures were required to obtain union. All six patients were ambulatory at last follow-up. Stable internal fixation for simultaneous tibiotalar fusion and metaphyseal reconstruction can be achieved with a cannulated blade-plate while preserving the subtalar joint in complex plafond fractures.     

Subtalar arthrodeses and arthrodeses of the ankle joint (author's transl)

We present a check-up study of five arthrodeses of the ankle joint and five subtalar arthrodeses. The arthrodeses of the ankle joint were indicated because of hard pains after bimalleolar fractures and fractures of the pilon tibial. Subtalar arthrodeses were indicated in posttraumatic arthritis of the calcaneus after intraarticular fractures of the calcaneus. Resection-compression-arthrodesis following Charnley was used for the ankle joint, subtalar arthrodesis was done by the technic of using a corticocancellous bone graft from the iliac crest. With an average postoperative follow-up period of four years four from five patients in every group had a good results. In cases clear indication the early arthrodesis should be preferred.     

跟骨丘部重建加距下关节融合术治疗Sanders Ⅲ型跟骨关节内陈旧性骨折

目的：观察跟骨丘部重建与距下关节融合术联合治疗严重的跟骨关节内陈旧性骨折的临床疗效,总结其手术适应证及注意要点。方法：2006年3月至2011年7月,采用跟骨丘部重建与距下关节融合术联合治疗SandersⅢ型跟骨关节内陈旧性骨折患者26例,男15例,女11例;年龄27—45岁,平均34岁;病程7～24个月,平均18个月。术前X线片及CT示Gissane角增大,Bohler角减小,跟骨增宽向两侧膨出。术后复查时行影像学检查并对跟骨宽度、丘部高度、Bohler角及Gissane角进行测量,并与术前比较。根据AOFAS踝后足评分标准对手术前后患足功能进行评分,比较改善程度。结果：24例患者获完整随访,随访时间5-26个月,平均19个月。X线片证实所有患者融合成功,未发生严重感染,其中1例患者术后出现皮缘坏死,行带腓肠神经营养血管岛状皮瓣转位修复术后皮瓣存活,伤口愈合良好。患者AOFAS踝后足评分由术前的（41．00±8．22）分提高到术后的（79．04±7．46）分;结果优3例,良15例,中6例。术后跟骨宽度、丘部高度、Btihler角及Gissane角较术前有明显改善（P〈0．01）。结论：重建跟骨丘部的距下关节融合术是治疗陈旧性跟骨骨折的一种有效方法,可矫正跟骨畸形、恢复足部外形并改善后足功能。     

Block distraction arthrodesis for the treatment of failed calcaneal fractures

We had excellent results with our procedure and had only one unsatisfied patient. This patient's fusion site had an undersized graft; therefore, he had continued pain. Because he had no further intra-articular pain, he did not feel the need for further surgery. Block distraction arthrodesis is far more difficult to perform than subtalar arthrodesis without the use of bone graft. It is critical to allow more intraoperative time during the first two or three cases than required for regular arthrodesis of the subtalar joint. It also is essential to place the heel in a rectus position at the time of arthrodesis. With proper preoperative examination and planning, meticulous intraoperative treatment, and guarded postoperative care, block distraction arthrodesis is an excellent procedure for the treatment of poorly-treated or neglected calcaneal fractures.     

Occult osteochondral fractures of the subtalar joint: a review of 10 patients.

Ten patients were treated who had occult osteochondral fractures of the subtalar joint that were not associated with dislocation. Nine osteochondral fractures involved the posterior facet. Seven patients had a stiff and painful subtalar joint, and an arthrodesis was performed. Three patients presented with adequate subtalar joint motion and were treated with physiotherapy. Detection of osteochondral fractures of the subtalar joint is difficult. The "early warning" signs are massive swelling without definitive bone injury on radiographic examination, and a failure to regain subtalar motion after a period of immobilization. Confirmatory evidence is obtained from CT scans or MRI. Initially, aggressive physiotherapy should be considered. Arthrodesis should be used for patients who remain symptomatic.     

Offene Reposition und Osteosynthese mit primärer subtalarer Arthrodese bei intraartikulärer Kalkaneusfraktur

OBJECTIVE: To prevent the development of painful posttraumatic degenerative joint disease by a primary one-stage procedure to treat calcaneal fractures involving obvious comminution or severe and extensive cartilage damage to the subtalar facet. INDICATIONS: Sanders type IV calcaneal fractures with severe and extensive cartilage destruction. The definitive indication for arthrodesis can only be established intraoperatively. CONTRAINDICATIONS: Severe closed IIIrd or IV nd degree soft-tissue injury according to Tscherne & Oestern. Open fractures. Vascular impairment. Diabetes mellitus. Generalized or local inactivity osteoporosis > grade I according to Kanis. Age > approximately 50 years. SURGICAL TECHNIQUE: Extended lateral approach. Osteosynthesis of the calcaneal fracture, reconstruction of axes, subtalar facet denuded of cartilage, bone graft from the anterior iliac crest, arthrodesis by screw fixation of the subtalar joint. POSTOPERATIVE MANAGEMENT: After edema has subsided, mobilization without a cast and partial loading up to 15 kg for 12 weeks. Clinical and radiologic review after 6 and 12 weeks. RESULTS: This operation is performed very rarely. Within a retrospective study including patients over a period of 14 years (1990-2004), a total of 434 patients with a calcaneal fracture were treated surgically. Primary subtalar arthrodesis was performed in only six of these patients. Healing within 4 months was achieved in all six patients. The clinical and radiologic follow-ups took place on average after 4.9 years (2.5-7.5 years). Radiologically, almost anatomic reconstruction of the axes could be achieved (Gissane and B?hler angles, talometatarsal and talocalcaneal angles, calcaneal length and width). The functional outcomes were also good to very good with an average AOFAS (American Orthopaedic Foot and Ankle Society) Score of 88 points (63-94 points) and a Hanover Score of 84 points (62-90 points).     

Subtalare Distraktionsarthrodese mit allogenem Knochenspan

Isolated subtalar disorders often require subtalar arthrodesis in combination with bone transplantation for the hindfoot reconstruction. Arthrodesis using an iliac crest bone graft is the standard procedure. We present results after subtalar arthrodesis using an allogenic bone graft. Clinical and radiological examinations were performed on 19 feet preoperatively, 6, 12 weeks and 12 months postoperatively. The AOFAS score of 35 (31-42) points preoperatively improved to 86 (78-90) points 12 months postoperatively. The VAS points of 6 (4-8) preoperatively decreased to 2 (1-2) points 12 months postoperatively. Osseous fusion could be acchieved in all cases. Using allogenic bone graft for subtalar arthrodesis leads to secure integration and avoids iliac crest bone graft morbidity.     

Triple arthrodesis of the foot after calcaneal fractures. Twelve patients treated using K wires stabilization

The most frequent problem following intra-articular calcaneal fracture is pain from the subtalar joint. Subtalar arthrodesis is not considered to be an optimal solution because it can lead to degenerative changes in the ankle joint. The aim of this study was to evaluate patients with such fractures treated by triple arthrodesis. The treated group consisted of 12 patients (5 female, 7 male) with no bilateral fractures. The mean age at injury was 36 years (22–54). The patients had surgery 2 years on average after injury. In all cases the arthrodesis was stabilized with Kirschner wires.The follow-up ranged from 1 to 5 years (average 2.9 ± 1.4). In 2 feet the calcaneal fracture was associated with a fracture of the talus. At clinical evaluation the Ankle–Hindfoot Scale (AOFAS) was applied. From the 100 point scale the question concerning movement in the subtalar joint was removed which made the scale range from 0 to 94 points. Postoperative scoring ranged from 19 to 92 points (mean 57.3 ± 25.1). The patients also evaluated the result of treatment on a visual analogue scale from 0 to 10 points which gave a mean score of 7.7 ± 2.2. Early results of the treatment of calcaneal fractures by triple arthrodesis show that this is valuable method for the prevention of significant foot pain.     

Primary subtalar arthrodesis for the treatment of comminuted intra-articular calcaneal fractures

We report the short- and mid-term results in six patients (seven feet) affected by markedly comminuted intra-articular calcaneal fractures (Sanders type IV), treated by primary subtalar arthrodesis. The average age at surgery was 40 years. In all patients, arthrodesis of the subtalar joint was performed using a limited lateral approach to the calcaneus; it was stabilised with two or three cannulated screws. No patient had a preliminary reduction and internal fixation of the fracture. The time from injury to surgery averaged 20 days because all of the patients had associated visceral and/or other skeletal injuries. All of the patients were followed up clinically and radiographically 2 times, at an average of 12 months and 53 months after surgery. At the short-term follow-up, the mean AOFAS score was 70 points; the X-rays showed a complete fusion of the subtalar joint in all seven feet, without any sign of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints. In all cases, an altered shape of the calcaneus was present. At the mid-term follow-up, the mean AOFAS score increased to 85 points; in one patient, radiographic signs of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints were present and, in another patient, only talo-navicular joint was present, although both patients were free from pain. The difference between the two AOFAS scores was statistically significant. We believe that primary subtalar arthrodesis performed for markedly comminuted Sanders type IV calcaneal fractures yielded good mid-term results, and it is especially indicated when surgical treatment is delayed for whatever reason. A preliminary open reduction and internal fixation to restore the normal height of the calcaneus before performing the subtalar arthrodesis, as suggested by several authors, does not seem indispensable to obtain good clinical results.     

Treatment of calcaneus and mid-foot fractures using closed reposition and fixation with the Ilisarov fixator]

Sixteen fractures of the calcaneus involving the subtalar joint were treated by closed reduction and external fixation using the Ilisarov apparatus. Except for four cases in which temporary arthrodesis of the subtalar or ankle joint was used, fixation was usually only used for the calcaneus. The operative technique is described precisely. Initial follow-up examinations (on average after 1 year) show advantages over conservative treatment, e.g. better anatomical reduction. In addition, early mobilization of the joint and early weight-bearing result in less pain from disuse osteoporosis. Furthermore, several case reports demonstrate the efficiency of this method in tarsal and metatarsal fracture-dislocations.     

Calcaneus fractures: facts, controversies and recent developments

The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.     

Operative und konservative Behandlungsmaßnahmen nach Fehlheilungen und Pseudarthrosen am Fuß

Malunion is the main problem following calcaneus fractures.Depression of the subtalar joint results in flattening and lateral bulging. Besides subtalar arthrodesis, it is also often necessary to achieve narrowing of the calcaneus. The talonavicular joint is a site where nonunion is particularly common.In symptomatic patients revision arthrodesis with screws and bone interposition may be necessary. Further distally, malunion often affects joint congruity and can also make arthrodesis necessary, for example of the tarsometatarsal joints. In the midfoot, even a slight deformity can result in overloading of the metatarsal heads, and corrective osteotomy may be needed in such cases.     

Comparison of open isolated subtalar arthrodesis with autogenous bone graft versus outpatient arthroscopic subtalar arthrodesis using injectable bone morphogenic protein-enhanced graft

Isolated subtalar joint arthrodesis is an established salvage procedure that can be performed in various ways for varying diagnoses. The purpose of this article is to report a new arthroscopic subtalar arthrodesis technique that has been developed. The results of this method versus an open technique were compared. Length of hospital stay, tourniquet time, morbidity, and fusion rate were studied in 17 fusion patients between 1990 and 1997. Twelve patients had open arthrodesis with bone graft and 5 patients had arthroscopic arthrodesis with supplemental, injectable, osteoinductive enhanced-graft gel. The length of stay decreased 1.7 days with the arthroscopic procedure. Tourniquet time was not significantly different. One open procedure required refusion, whereas none did in the arthroscopic group. One patient in each group required AO screw removal. In selected patients with subtalar arthrosis without significant hindfoot deformity, arthroscopic arthrodesis can be an effective. It is too early to determine if there are specific advantages in this procedure compared with a conventional open arthrodesis.     

Results of arthrodesis of the ankle joint (author's transl)

We present a check-up study of 47 arthrodeses of the ankle joint, partly in combination with an arthrodesis of the subtalar joint. By resection-compression-arthrodesis following Charnley-Horwitz-Adams we reached a bony fusion of the ankle joint in all cases. 83% of our cases showed a good or at least fair result. The remaining patients complained of painful walking in spite of orthopaedic shoes. In these cases a further fusion of subtalar joints especially of the talo-navicular joint should be considered.     

Primary subtalar arthrodesis of calcaneal fractures

We evaluated retrospectively the long-term results of isolated calcaneal fractures treated with open reduction and internal fixation and a primary subtalar arthrodesis. From 1990 to 1997 258 patients were treated with a calcaneal fracture, for the current study six patients were included. Six different surgeons operated on the patients. The indication for the fusion was based on the comminution of the posterior facet according to the preoperative CT as well as the intraoperative evaluation of destruction of the cartilage. The restoration of length, axes and angles of the calcaneus was almost anatomical in all cases. Follow-up was done at a mean of 4.9 (2.5 - 7.5 years). Using the AOFAS score, the results were good or excellent in five patients. In one patient with a painful arthritis in the talonavicular joint and hyperesthesia of the sural nerve, the results were fair. All returned to their profession within 9 months and had no or only minor daily restrictions. The results are comparable with single surgeon series. We found open reconstruction of the calcaneus with primary fusion of the subtalar joint may be indicated in selected patients and, in these 6 patients led to good results.