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.     

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.     

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 fate of B?hler’s angle in conservatively-treated displaced intra-articular calcaneal fractures

Purpose

Although the predictive value of Böhler’s angle on outcome remains subject of debate, the initial angle at the time of trauma still guides treatment. Changes in Böhler’s angle during follow-up are frequently reported following surgical treatment of displaced intra-articular calcaneal fractures (DIACF). The aim of the present study was to determine the changes in Böhler’s angle as a measure of secondary fracture displacement following conservative management of DIACF.

Methods

Thirty-eight patients with a total of 44 displaced intra-articular calcaneal fractures treated conservatively with a minimum of two lateral radiographs during follow-up were analysed. Böhler’s angle at different follow-up times was measured by three observers. The change in angle was compared with the angle at trauma, and influence of trauma mechanism and common calcaneal fracture classifications were determined.

Results

The results showed a significant decline over time of the Böhler’s angle in conservatively-treated patients of more than 11° on average at a mean follow-up of 29.2 weeks. This decrease was not related to gender, the initial angle, or the Essex-Lopresti or Sanders classification. A statistically significantly higher decrease was detected in high energetic trauma compared with low energetic trauma.

Conclusion

The conservative treatment of displaced intra-articular calcaneal fractures is still a viable option, yet a significant secondary displacement in time should be taken into account, as reflected in a decrease of Böhler’s angle of 11° up to one year following trauma.     

Surgical treatment of pulmonary hydatid cysts: is capitonnage necessary?

BACKGROUND: Hydatid disease of the lung caused by Echinococcus granulosus is frequently encountered in Mediterranean countries. The ideal surgical method for treating this disease is still unknown. METHODS: Between 1994 and 2001, 71 patients with pulmonary hydatid cysts were treated surgically. There were 41 male and 30 female patients with a mean age of 30.2 years (range, 5 to 70 years). Cystotomy and closure of bronchial openings were performed in all patients. Obliteration of the residual cavity by imbricating sutures from within (capitonnage) was achieved in 39 patients (group 1). There were 34 patients with intact cysts and 37 patients with at least one complicated cyst. The average diameter of the cysts was 6.4 cm, and the mean number of cysts per patient was 1.4. The surgical outcome was assessed in group 1 patients and in patients who had undergone closure of bronchial openings without capitonnage (group 2; n = 32). The groups were comparable in regard to clinical characteristics. RESULTS: There was no mortality. The total hospitalization time (mean +/- standard error of the mean) was 5.0 +/- 5.0 days for group 1 and 5.9 +/- 6.9 days for group 2 (p = 0.91). Stay in the intensive care unit was 1.64 +/- 1.22 days in group 1 and 1.60 +/- 1.52 days in group 2 (p = 0.90). The duration of air leak was 2.56 +/- 4.73 days in group 1 and 2.38 +/- 4.74 days in group 2 (p = 0.87). There was no significant difference between groups in the development of empyema (1 patient in group 2 only) and prolonged air leak (5 patients in group 1 and 4 in group 2). There was also no significant difference in the rate of recurrence (3 patients in group 1 only). CONCLUSIONS: We conclude that capitonnage provides no advantage in operations for pulmonary hydatid cysts.     

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.     

Triple arthrodesis: is bone grafting necessary? The results in 100 consecutive cases

Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site. The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion. Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site.     

Long-term results of dorsally displaced distal radius fractures treated with the pi-plate: is hardware removal necessary?

The purpose of this study was to evaluate the outcome of patients treated with open reduction and internal fixation (ORIF) using dorsal plates and screws (AO/ASIF pi-plate) for dorsally displaced fractures of the distal radius. Although extensor tendon rupture is a recognized complication of all distal radial fractures, there appears to be an increased risk of this using dorsal plating. In addition, there is the added complication of extensor tendon irritation and dorsal wrist pain, which may necessitate plate removal. The low-profile pi-plates intended to overcome this problem have not done so, with quoted rates ranged from 19% to 55%.We treated 32 completely evaluated patients (13 men and 19 women) in our department between 2000 and 2004, with an average age of 46 years. They underwent ORIF of dorsally displaced fractures of the distal radius using the specially designed pi-plate. Bone graft was used in 18 patients who had significant metaphyseal defect. Clinical examination, plain radiographs, and functional assessments using the modified Mayo Wrist Score were performed at an average follow-up of 86 months (range, 56-115 months). Satisfactory reduction was achieved in all 32 fractures at the time of operative fixation with no instances of loss of fracture reduction during the study period. According to the Mayo Wrist Score, 23 patients (72%) had excellent or very good results, 7 (22%) had fair results, and 2 (6%) had poor results. Two cases (6.25%) of extensor tendon rupture were noted during the first postoperative month, and 2 other patients showed progressive weakness of index finger extension 6 months postoperatively. The remaining 28 patients had no soft tissue problems.     

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.     

Computed tomography scanning of intra-articular distal radius fractures: does it influence treatment?

The purpose of this study is to determine whether the addition of computed tomography (CT) results in changes in the evaluation and treatment of intra-articular distal radius fractures. Fifteen intra-articular distal radius fractures were evaluated independently by 4 hand surgeons. Plain x-rays were reviewed initially followed by the corresponding CT scans for comparison of articular step-off and gapping, comminution, and treatment. Kappa coefficients (kappa) of intraobserver and interobserver reliability for treatment plans were generated. Computed tomography scans improved the sensitivity of measurement of articular surface gapping, improved the accuracy of detection of comminution and distal radioulnar joint involvement, and altered proposed treatment plans within observers (intraobserver agreement: kappa =.54, moderate) and improved agreement of proposed treatment plans between observers (kappa =.34 to kappa =.44, fair to moderate). Computed tomography scanning influenced observers to change treatment plans and resulted in increased interobserver reliability in the proposed management of these injuries.     

Check radiography after fixation of hip fractures: is it necessary?

Technological advances in radiography in the form of image intensification has not only made internal fixation of femoral neck fracture much easier but these high resolution films can be saved as hard copies and can also be reversed into 'positives' at a later date. However, requesting routine post-operative check radiographs for these fractures are still a common practice. A retrospective study was carried out to compare the quality of image intensifier films with conventional post-operative radiographs. 79 sets of films were reviewed with particular reference to adequacy of fixation and possible joint penetration by the screws. No significant difference was noted between the two sets of films. We suggest that routine post-operative radiographs after femoral neck fracture fixation are unnecessary unless there is some clinical indication. This has significant implications in relation to patient discomfort, radiation exposure and cost-effectiveness.     

Surgical resection of unilateral lung metastases: is bilateral thoracotomy necessary?

urgical resection of lung mestastases is routine procedure for selected patients with pulmonary nodules and solid tumors. In some cases, patients present with unilateral pulmonary metastases amenable to surgical resection. Surgeons are still divided between unilateral approach directed to the radiologically detected nodules, or bilateral exploratory thoracotomy. This study evaluates the need for bilateral thoracotomy in patients diagnosed with unilateral lung metastases. A retrospective evaluation was made of a prospective database from a single institution (1990–1997) of all consecutive patients (n = 267) diagnosed on admission with unilateral (n = 179) or bilateral (n= 88) lung nodules. Ipsilateral thoracotomy was performed on all patients with unilateral disease. Bilateral thoracotomy was performed on all patients with bilateral lung metastases. Histology: adenocarcinoma (25%), osteosarcoma (23%), squamous cell carcinoma (18%), soft-tissue sarcoma (18%), and other (16%). Median follow-up was 17 months. Contralateral disease-free survival and overall survival were determined. Univariate and multivariate analyses were performed to determine prognostic factors for overall and contralateral disease-free survival. The two groups of patients with confirmed bilateral metastases (synchronous or metachronous) were compared. Actuarial overall 5-year survival was 34.9%. Contralateral recurrence-free 6-month, 12-month, and 5-year survival were 95%, 89%, and 78%, respectively. Patients who experienced recurrence in the contralateral lung within 3, 6, or 12 months had an overall 5-year survival rate of 24%, 30%, and 37%, respectively. When patients with recurrence in the contralateral lung were compared to patients with bilateral metastases on admission, there was no significant difference in overall survival. Only histology and the number of pathologically proven metastases significantly (p <0.05) predicted recurrence in the contralateral lung. Bilateral exploration of unilateral lung metastases is not warranted in all cases. Most patients will have only unilateral disease, and delaying contralateral thoracotomy until disease is detected radiologically does not appear to affect outcome.