Improved Interobserver Reliability of the Sanders Classification in Calcaneal Fractures Using Segmented Three-Dimensional Prints

We examined the added value of 3-dimensional (3D) prints in improving the interobserver reliability of the Sanders classification of displaced intraarticular calcaneal fractures. Twenty-four observers (radiologists, trainees, and foot surgeons) were asked to rate 2-dimensional (2D) computed tomography images and 3D prints of a series of 11 fractures, selected from cases treatment at our level I trauma center between 2014 and 2016. The interobserver reliability for the Sanders classification was assessed using kappa coefficients. Three versions of the Sanders classification were considered: Sanders classification with subclasses, Sanders classification without subclasses, and the combination of Sanders types III and IV because of the high incidence of comminution in both types. The reference standard for classification was the perioperative findings by a single surgeon. The 3D print always yielded higher values for agreement and chance-corrected agreement. The Brennan-Prediger–weighted kappa equaled 0.35 for the 2D views and 0.63 for the 3D prints for the Sanders classification with subclasses (p?=?.004), 0.55 (2D) and 0.76 (3D) for the classification without subclasses (p?=?.003), and 0.58 (2D) and 0.78 (3D) for the fusion of Sanders types III and IV (p?=?.027). Greater agreement was also found between the perioperative evaluation and the 3D prints (88% versus 65% for the 2D views; p?<?.0001). However, a greater percentage of Sanders type III-IV were classified with 2D than with 3D (56% versus 32%; p?<?.0001). The interobserver agreement for the evaluation of calcaneal fractures was improved with the use of 3D prints after “digital disarticulation.”     

跟骨关节内移位骨折手术治疗效果的影响因素分析

目的探讨影响跟骨关节内移位骨折疗效的相关因素。方法对82例跟骨关节内移位骨折患者的临床资料进行回顾性分析。分析影响疗效的相关因素。结果单因素和多因素分析结果显示摔伤高度、体重、Sanders分型、摔伤距手术时间、术前Bhler角、术前Gissane角、术后中药熏洗是影响临床疗效评价的临床因素（P〈0.01或P〈0.05）。体重越重、摔伤高度、Sanders分型越高、摔伤距手术时间越长、术前Bhler角和术前Gissane角越小患者预后越差。结论摔伤高度、体重、Sanders分型、摔伤距手术时间、术前Bhler角、术前Gissane角、术后中药熏洗是影响临床疗效评价的临床因素。     

延长的外侧入路治疗跟骨关节内骨折

目的：评估延长的外侧入路治疗有移位的跟骨关节内骨折的临床疗效。方法：对34例跟骨关节内骨折,按Sanders分类法进行骨折分类。采用延长的外侧入路进行切开复位内固定。随访时间6－28个月,平均12．5个月。结果：按“跟骨关节内骨折评分标准”对患足功能进行评分。本组优17侧,良19侧,可2侧,差1侧。优良率为92．3％。结论：采用延长的外侧入路治疗有移位的跟骨关节内骨折能获得满意的临床疗效。     

Interobserver and intraobserver reliability of two classification systems for intra-articular calcaneal fractures

BACKGROUND: For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Most studies have found reliability and reproducibility to be poor for fracture classification schemes. The purpose of this study was to evaluate the interobserver and intraobserver reliability of the Sanders and Crosby-Fitzgibbons classification systems, two commonly used methods for classifying intra-articular calcaneal fractures. METHODS: Twenty-five CT scans of intra-articular calcaneal fractures occurring at one trauma center were reviewed. The CT images were presented to eight observers (two orthopaedic surgery chief residents, two foot and ankle fellows, two fellowship-trained orthopaedic trauma surgeons, and two fellowship-trained foot and ankle surgeons) on two separate occasions 8 weeks apart. On each viewing, observers were asked to classify the fractures according to both the Sanders and Crosby-Fitzgibbons systems. Interobserver reliability and intraobserver reproducibility were assessed with computer-generated kappa statistics (SAS software; SAS Institute Inc., Cary, North Carolina). RESULTS: Total unanimity (eight of eight observers assigned the same fracture classification) was achieved only 24% (six of 25) of the time with the Sanders system and 36% (nine of 25) of the time with the Crosby-Fitzgibbons scheme. Interobserver reliability for the Sanders classification method reached a moderate (kappa = 0.48, 0.50) level of agreement, when the subclasses were included. The agreement level increased but remained in the moderate (kappa = 0.55, 0.55) range when the subclasses were excluded. Interobserver agreement reached a substantial (kappa = 0.63, 0.63) level with the Crosby-Fitzgibbons system. Intraobserver reproducibility was better for both schemes. The Sanders system with subclasses included reached moderate (kappa = 0.57) agreement, while ignoring the subclasses brought agreement into the substantial (kappa = 0.77) range. The overall intraobserver agreement was substantial (kappa = 0.74) for the Crosby-Fitzgibbons system. CONCLUSIONS: Although intraobserver kappa values reached substantial levels and the Crosby-Fitzgibbons system generally showed greater agreement, we were unable to demonstrate excellent interobserver or intraobserver reliability with either classification scheme. While a system with perfect agreement would be impossible, our results indicate that these classifications lack the reproducibility to be considered ideal.     

Sanders classification of calcaneal fractures in CT images with deep learning and differential data augmentation techniques

BackgroundClassification of the type of calcaneal fracture on CT images is essential in driving treatment. However, human-based classification can be challenging due to anatomical complexities and CT image constraints. The use of computer-aided classification system in standard practice is additionally hindered by the availability of training images. The aims of this study is to 1) propose a deep learning network combined with data augmentation technique to classify calcaneal fractures on CT images into the Sanders system, and 2) assess the efficiency of such approach with differential training methods.MethodsIn this study, the Principle component analysis (PCA) network was selected for the deep learning neural network architecture for its superior performance. CT calcaneal images were processed through PCA filters, binary hashing, and a block-wise histogram. The Augmentor pipeline including rotation, distortion, and flips was applied to generate artificial calcaneus fractured images. Two types of training approaches and five data sample sizes were investigated to evaluate the performance of the proposed system with and without data augmentation.ResultsCompared to the original performance, use of augmented images during training improved network performance accuracy by almost twofold in classifying Sanders fracture types for all dataset sizes. A fivefold increase in the number of augmented training images improved network classification accuracy by 35%. The proposed deep CNN model achieved 72% accuracy in classifying CT calcaneal images into the four Sanders categories when trained with sufficient augmented artificial images.ConclusionThe proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of computer-aided system in assisting physicians in evaluating calcaneal fracture types.     

Different types and epidemiological patterns of calcaneal fractures based on reviewing CT images of 957 fractures

IntroductionCalcaneal fractures may have lifelong debilitating sequences, if not treated properly. Identifying different types of calcaneal fractures based on the computed tomography (CT) scans can increase our conception about these fractures.MethodsIn a cross-sectional study, the available CT images of all consecutive patients with the diagnosis of calcaneal fracture, from January 2015 to December 2018, were reviewed to determine different patterns and types of these fractures.ResultsCT images of 886 patients (mean age, 41.29 ± 14.9; range, 3–89 years; male/female, 4.86; pediatric: 3.7%) with 957 calcaneal fractures were evaluated. The peak incidence of calcaneal fractures was seen in patients between 30 to 39 years of age (29%). The rate of open fractures and bilateral involvements were 2.4% and 8.0%, respectively. Among 680 (71.0%) intra-articular calcaneal fractures, subtalar calcaneal fractures were the most common type (94.3%). The majority of intra-articular subtalar calcaneal fractures were displaced (95.0%) with calcaneocuboid joint (CCJ) involvement (59.9%). Fracture lines were extended to the CCJ in about 86.9% of Sanders type IV, 66.3% of type III, and 60.2% of type II. Among 261 extra-articular fractures (27.3%), calcaneal body fracture (55.6%) was the most frequent type, followed by medial tubercle fracture (24.1%), calcaneal tuberosity fracture (10.4%), Degan type I anterior process fractures (5.4%), Degan type II anterior process fracture (3.4%), and isolated lateral tubercle fracture (1.1%). Most of bilateral calcaneal fractures were intra-articular subtalar fractures with involvement of CCJ. Although majority of intra-articular calcaneal fractures were displaced; less than half of the extra-articular fractures were displaced.ConclusionDisplaced intra-articular subtalar calcaneal fractures with CCJ involvement are the most frequent type of unilateral and bilateral calcaneal fractures. It appears that there is a correlation between Sanders type and the probability of CCJ involvement. Unlike intra-articular subtalar calcaneal fractures, the CCJ in the majority of extra-articular calcaneal body fractures was intact.Level of evidenceLevel IV.     

Bone Defects After Surgery for Displaced Intraarticular Calcaneal Fractures Spontaneously Improve Without Bone Grafting

BackgroundMost intraarticular displaced calcaneal fractures are accompanied by bone defects after surgical treatment, but the concern about negative effects of bone defects has not been resolved yet owing to the few studies on this issue. Therefore, studies on volumetric changes in bone defects over time and the correlation between postoperative outcomes and residual bone defects will be helpful to address the controversy on the necessity of bone grafting in bone defects of calcaneal fractures.Questions/purposes(1) Do bone defects change in size in the first year after surgical treatment of displaced intraarticular calcaneal fractures? (2) Does the size of residual bone defects correlate with postoperative radiographic or clinical outcomes?MethodsBetween 2015 and 2019, 99 patients with displaced intraarticular calcaneal fractures visited the investigators’ institution, of whom 95 received surgical treatment. Of the patients treated with surgery, 25% (24 of 95) did not undergo open reduction and internal fixation via an extensile lateral approach, and 19% (18 of 95) had multiple fractures, bilateral fractures, open fractures, or a history of previous surgery on the calcaneus; all of these patients were excluded. During the study period, CT was routinely performed for calcaneal fractures immediately after and 12 months after the surgery, but 6% (6 of 95) of the patients had insufficient CT data due to loss to follow-up before 12 months or other reasons, leaving 47 patients for evaluation in this retrospective study. Fractures were fixed with plate and screws, and bone grafting was not performed in all patients. To answer our first question, which was on the changes in bone defects over time, volumetric measurements of the bone defect were performed using CT via the ITK-SNAP software. The percentage of volumetric change was calculated as a fraction of the volumetric change over 12 months from the initial volume. The percentage of the residual bone defect was calculated as a fraction of the volume of the residual bone defect relative to the volume of the entire calcaneus. To answer our second question, which was on the correlation between residual bone defects and postoperative outcomes, we assessed the Böhler angle, Gissane angle, calcaneal height, Olerud-Molander Ankle Score (OMAS), and VAS score for pain and compared these parameters with the size of the residual bone defect using the Pearson correlation coefficient. The OMAS and VAS scores for pain were evaluated and recorded during patient visits, and we obtained the scores through a chart review. All volumetric measurements and radiographic evaluations were performed by two orthopaedic surgeons, and the intraobserver and interobserver reliability were assessed using the intraclass correlation coefficient.ResultsThe mean volume of the bone defect measured using CT was 4 ± 3 cm³ immediately after surgery and 1 ± 1 cm³ 12 months after surgery. During the first 12 months after surgery, the mean volume of the bone defect was reduced by 77% (95% confidence interval 73% to 80%). The mean residual bone defect in the entire calcaneus was 2% (95% CI 1% to 2%), and none of the postoperative outcomes were correlated with the residual bone defect.ConclusionAs bone defects substantially resolve without treatment, surgeons do not need to use bone graft for the surgical treatment of displaced intraarticular calcaneal fractures. Future studies that include patients who underwent bone grafting for the treatment of calcaneal fractures are needed to confirm our findings and to further investigate whether bone grafting has additional benefits for the recovery of bone defects.Level of EvidenceLevel III, therapeutic study.     

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.     

Calcaneal intra-articular fracture osteosynthesis: Clinical and radiological prospective study of 31 cases

Osteosynthesis for calcaneal fractures remains controversial. We osteosynthesize all displaced intraarticular fractures, the only contraindications regarding age, local and arterial status, or non-compliance. We here report a prospective study of 31 calcaneal articular fractures, with a mean 4.5 years follow-up.Following CT scan, patients were operated at a mean 6.1 days with the same surgical (single surgeon-extended lateral approach) and post-operative protocol. On Sanders' classification, there were 18 type II, 8 type III, and 5 type IV fractures. Twenty-six patients had clinical and comparative standard X-ray follow-up; 19 also had CT assessment.Two complications needed repeat surgery: one limited skin necrosis, one infected hematoma. Fifty-eight % were very satisfied, and 42% satisfied; 77% returned to work. Mean Kitaoka score was 86.2. Tibiotarsal motion was normal, and subtalar motion 45%. X-ray confirmed anatomical reconstruction: no joint reduction defect; medial arch angle, calcaneal pitch, calcaneal soft-pad thickness, and calcaneus height, length and width subnormal. Mean Boehler angles were: 6.6° preoperatively, 32.3° postoperatively, and 27.1° on follow-up for injured vs. 32° for non-injured foot. Thirty-six % had posterior subtalar remodeling on standard X-ray, and 79% on CT scan, without correlation with functional results or radiological type.Due to calcaneal posterior facet height loss, we recommend 10 weeks' non-weightbearing. These good results match the literature, generally indicating surgery for displaced calcaneal intraarticular fractures.     

Minimal-invasive Osteosynthese von Kalkaneusfrakturen

Objective

Anatomic reduction of displaced calcaneal fractures with minimal soft tissue alteration.

Indications

Extra-articular and selected intra-articular calcaneal fractures (simple fracture pattern: Sanders type?II, critical soft tissue conditions, contraindications to open reduction), temporary stabilization of complex injuries or polytraumatized patients.

Contraindications

Impossible percutaneous reduction and fixation.

Surgical technique

Gross reduction of the main fragments is achieved with a Schanz screw introduced percutaneously into the tuberosity fragment. Fine reduction is obtained through percutaneous manipulation of the fragments wit Kirschner wires, Steinmann pins, sharp and smooth elevators via stab incisions. Anatomic reduction of the subtalar joint is controlled arthroscopically in cases of displaced intra-articular fractures. Fixation is achieved with screws introduced percutaneously.

Postoperative management

Early range of motion exercises of the ankle and subtalar joints are initiated the first postoperative day. Beginning on postoperative day?2, patients are mobilized with partial weight bearing for 6–8?weeks. As soon as the edema has subsided, patients are encouraged to wear their own shoes.

Results

Between 1998 and 2008, 68?patients were treated with definite percutaneous fixation for displaced calcaneal fractures. In 37?patients with intraarticular fractures (Sanders types?IIA and IIB), anatomic joint reduction was verified with subtalar arthroscopy. No soft tissue-related complications were observed. Thirty-five patients were followed for a minimum of 2?years postoperatively, the average was 5?years postoperatively. Subjectively, 33 of 35?patients were satisfied with the clinical outcome. The AOFAS Hindfoot Score averaged 90.7 (range 64–100) at a mean of 5?years after surgery. Percutaneous screw fixation of calcaneal fractures is associated with minimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. With intra-articular fractures, proper reduction of the articular surface has to be confirmed intraoperatively.     

The Effect of Primary Fracture Line Location on the Pattern and Severity of Intraarticular Calcaneal Fractures: A Retrospective Radiographic Study

This retrospective radiographic study sought to evaluate how primary fracture line location relates to the pattern and severity of intraarticular calcaneal fractures. Preoperative lateral radiographs and semicoronal computed tomography scans of 100 displaced intraarticular calcaneal fractures (89 patients) were evaluated for Bohler's angle, Sanders classification, and calcaneocuboid, anterior, or middle subtalar articular involvement. Primary fracture line location was measured on semicoronal computed tomography views as a ratio of the width of the posterior facet. There were 60 Sanders type II (29 IIA, 29 IIB, 2 IIC), 35 type III (10 IIIAB, 9 IIIAC, 16 IIIBC) and 5 type IV fractures. The mean Bohler's angle was 10.1+/-15.6 degrees. The mean primary fracture line location was calculated to be found at 45.7+/-18.2% of the width of the posterior facet, as measured from lateral to medial. Statistical analysis found a significant association between primary fracture line location and Sanders class (r=.636; P<.001) and Bohler's angle (r=-.287; P=.005); as the fracture line moved medially, comminution increased and Bohler's angle decreased. Forty-eight percent of the fractures involved the calcaneocuboid joint; 39% involved the anterior (n=28) or middle (n=11) subtalar facets, or both. A medial primary fracture line correlated to greater involvement of the calcaneocuboid joint (r=.247; P=.015) and the anterior (r=.241; P<.001) and middle (r=.344; P=.003) facets. These results suggest that intraarticular calcaneal fractures exhibiting a medial primary fracture line are associated with a more severe fracture pattern and an increased incidence of anterior articular extension.     

A measuremental approach to calcaneal fractures

Objective

The calcaneus is the most frequently broken tarsal bone in the setting of trauma. The diagnosis, treatment and prognosis of calcaneal fractures depend on the location and type determined by the Sanders classification. With the help of measurements on lateral view radiographs like the Böhler’s angle, the angle of Gissane, the calcaneal inclination angle and the calcaneal facet height, we can predict the severity of the trauma and prognosis by assessing the collapse of the calcaneus. On computed tomography (CT), calcaneal fractures which reach into the joint space can be classified by the Sanders classification system according to the number of fragments. In this study, we tried to determine whether calcaneal fracture severity determined by angle and facet height measurements on lateral X-ray radiographs correlate with the Sanders classification.

Materials and methods

Among 69 patients diagnosed with calcaneal fractures, we performed a retrospective study by analysing the Böhler’s angle, the angle of Gissane, the calcaneal inclination angle and the calcaneal facet height on digital lateral X-rays and by classifying the fractures according to the Sanders classification by CT. We compared the results of the two different imaging modalities.

Results

We found that, as the Sanders classification type became more severe from type 1 to type 4, a general decrease was observed in the Böhler’s angle, the inclination angle and the facet length, whereas a general increase was observed for the mean values of the angle of Gissane.

Conclusion

These findings suggest that measurements obtained from lateral X-rays coincide with the Sanders classification and, therefore, might indicate the prognosis.     

Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data

BACKGROUND: The purpose of this study was to demonstrate the general health status after treatment of displaced intraarticular calcaneal fractures compared to normative data, other orthopaedic procedures, and other medical conditions. METHODS: Three hundred and twelve patients between 25 and 64 years of age were treated for displaced intraarticular calcaneal fractures at a Level I trauma center. Followup ranged from 2 to 8 years. The Short Form 36 Health Status Survey (SF-36) was used for outcome measurement. RESULTS: The scores in eight SF-36 categories in patients with displaced intraarticular calcaneal fractures differed by more than five points from the population norms. This suggests that there is clinical and social relevance to this injury. Outcomes in patients with displaced intraarticular calcaneal fractures were not as good across most SF-36 categories as were outcomes of patients with other orthopaedic conditions. Outcomes in patients with intraarticular calcaneal fractures also were worse across most categories than outcomes in patients who had organ transplants or myocardial infarctions. CONCLUSION: By comparing treatment for displaced intraarticular calcaneal fractures with treatment for orthopaedic problems or other disease processes, we concluded that intraarticular calcaneal fractures are serious life-changing events.     

Revisit of Broden's View for Intraarticular Calcaneal Fracture

Background

This study was performed to investigate the relationship between coronal computed tomography (CT) and Broden''s view in terms of location of the fracture line and fracture pattern.

Methods

Forty-five feet of 45 patients with intraarticular calcaneal fractures were evaluated. The mean age of the patients was 46.3 years (standard deviation, 18.1; range, 15 to 80 years), and there were 34 men and 11 women. The Broden''s views were acquired using the ray sum projection, reviewed, and correlated with the coronal CT image to determine the location of the fracture on the posterior facet and fracture pattern described by the Sanders classification. The quantified location of the fracture line was defined as the distance between the medial margin of posterior facet and the fracture line divided by the whole length of the posterior facet, which was expressed as a percentage.

Results

The fracture line on the Broden''s view was positioned at 22.3% (standard deviation, 29.6) laterally compared to that on coronal CT (p < 0.01). Although all cases showed posterior facet involvement on the CT scan, the fracture line was positioned lateral to the posterior facet in 6 cases (13.3%) in the Broden''s view. The coronal CT and Broden''s view showed a low level of agreement in the fracture pattern according to the Sanders classification, with kappa values of 0.23.

Conclusions

Surgeons should consider that the fracture line on the Broden''s view shows positioning laterally compared to coronal CT and they should consider that the fracture line at the lateral to posterior facet on the Broden''s view might be an intraarticular fracture line. There are some limitations when applying the Sanders classification with the Broden''s view.     

跟骨关节内骨折的诊断与治疗

跟骨骨折是跗骨中最常见的骨折,约75%的跟骨骨折为关节内骨折。虽然跟骨骨折的治疗经验日益增多,但对其诊断和处理仍存在争论,包括最合适的分类方法、治疗方法的选择、手术治疗的指征、手术入路及术后处理等。本文对跟骨关节内骨折的诊断和治疗进行综述。对于有移位的跟骨关节内骨折,手术疗效优于保守治疗。     

The primary arthrodesis for severely comminuted intra-articular fractures of the calcaneus: A systematic review

BackgroundAlthough open reduction and internal fixation via the extended lateral approach is currently considered gold-standard, severely comminuted calcaneal fractures might not be amendable for reconstruction. The primary aim of the current review study was to assess the functional outcome of the primary arthrodesis in the management of comminuted displaced intra-articular calcaneal fractures.MethodsThe literature was searched for studies published between January 1st 1990 and December 1st 2010, to identify studies in which a primary arthrodesis was utilized for the treatment of displaced intra-articular calcaneal fractures between. The methodological quality of the included studies was assessed using the Coleman Methodology Score.ResultsSeven case series and one abstract were identified, reporting on 120 patients with 128 severely comminuted calcaneal fractures. Average follow-up time was 28 months and union rate 97%. Functional outcome was assessed using the modified AOFAS score in seven studies; with a weighted average of 77.4 (range 72.4–88). One study reported a 75% good to excellent outcome on the Paley score. Three studies reported on return to work, ranging from 75 to 100%. Overall reported wound complications occurred in 19.4%. The average Coleman Methodology Score was 56 (range 38–68) points.ConclusionsThe primary arthrodesis for the treatment of Sanders type-IV comminuted displaced intra-articular calcaneal fractures provides overall good results considering the severe nature of the injury. Therefore, in the process of choosing the best treatment modality for a severely comminuted calcaneal fracture, the primary arthrodesis should receive full consideration.     

Patient satisfaction after open reduction and internal fixation through lateral extensile approach in displaced intraarticular calcaneal fractures (Sander's type II and III)

AimTo determine patient satisfaction in the patients of displaced intraarticular calcaneal fractures treated with standard lateral approach.MethodThe patients of displaced calcaneal fractures (Sander's type II and III) treated between March 2009 and March 2012 were included in the retrospective review and functional outcome was evaluated using American Orthopaedic Foot and Ankle Society (AOFAS) hind foot score, Creighton Nebraska Health Foundation Assessment (CNHFA) scale and foot function index (FFI).ResultThe cohort included 26 patients (19 males: seven were females) with a mean age of 38.16 ± 13.53 years (range 18–64 years). The mean period of follow-up was 24.42 ± 6.68 months. The patients achieved good functional scores after anatomical reduction of the fracture. The complication rate was low following strict inclusion criteria.ConclusionCareful patient selection in displaced intraarticular calcaneal fractures treated through lateral extensile approach achieves good patient satisfaction.     

Grouping of intraarticular calcaneal fractures relative to treatment options

None of the classifications of intraarticular calcaneal fractures are comprehensive enough to accommodate all types of fractures. Of the 150 intraarticular calcaneal fractures, 37 could not be placed in the commonly used Sanders classification. These then were grouped according to where their primary fracture line was located in relation to the posterior calcaneal facet. Twenty-three fractures were anteromedial to the facet; 75% of these were of the tongue type and were amenable to being treated with the Essex-Lopresti method of reduction and placement of two screws. The joint depression type in this group required open reduction and internal fixation through the lateral approach. Eight fractures were located posterolateral to the facet. They were treated from the lateral or the medial approach. Six fractures crossed the facet transversely; these were treated percutaneously with placement of two lag screws. Clinically this grouping was helpful because it provided a guideline to appropriate treatment strategies for fractures that could not be accommodated in the Sanders classification.     

Comminuted intraarticular calcaneal fractures: Multiplanar VA locked plating and interlocked nailing incorporate longitudinal strut and provide superior stability – a biomechanical cadaveric study

Treatment of comminuted intraarticular calcaneal fractures remains controversial and challenging. The aim of this study was to investigate the biomechanical performance of three different methods for fixation of such fractures. Comminuted calcaneal fractures, including Sanders III AB fracture of the posterior facet and Kinner II B fracture of the calcaneocuboid joint (CCJ) articular calcaneal surface, were created in 18 human cadaveric lower legs by osteotomizing. The ankle joint, medial soft tissues and midtarsal bones along with their ligaments were preserved. The specimens were randomized to three groups for fixation with either (1) 2.7 mm variable-angle locking lateral calcaneal plate (Group 1), (2) 2.7 mm variable-angle locking anterolateral calcaneal plate in combination with one 4.5 mm and one 6.5 mm cannulated screws (Group 2), or (3) interlocking calcaneal nail with 3.5 mm screws in combination with three separate 4.0 mm cannulated screws (Group 3). All specimens were biomechanically tested to failure under axial loading in midstance foot position. Each test commenced with a quasi-static compression ramp from 50 to 200 N, followed by progressively increasing cyclic loading at 2 Hz. Starting from 200 N, the peak load of each cycle increased at a rate of 0.2 N/cycle. Interfragmentary movements were captured by motion tracking. In addition, mediolateral X-rays were taken every 250 cycles with a triggered C-arm. Böhler angle after 5000 cycles (1200 N peak load) increased significantly more in Group 1 compared to both other groups (P ≤ 0.020). Varus deformation of 10° between the calcaneal tuberosity and the lateral calcaneal fragments was reached at significantly lower number of cycles in Group 1 compared the other groups (P ≤ 0.017). Both cycles to 10° plantar gapping between the anterior process and the calcaneal tuberosity fragments, and 2 mm displacement at the CCJ articular calcaneal surface revealed no significant differences among the groups (P ≥ 0.773). From a biomechanical perspective, treatment of comminuted intraarticular calcaneal fractures using anterolateral variable-angle locking plate with additional longitudinal screws or interlocked nail in combination with separate transversal screws provides superior stability as opposed to lateral variable-angle locked plating only.     

Treatment of intraarticular calcaneal fractures in adults. A treatment algorithm

Summary Significant progress has been made in terms of the management of calcaneal fractures. This is reflected in the marked decrease in complication rates associated with the current intervention of these potentially devastating injuries. The treatment priorities that, in the authors opinion, are key to achieve best results in a displaced calcaneal fracture are anatomic reconstruction of the entire calcaneus: articular surfaces, height, alignment, and length, with a function directed postoperative management. The value of these priorities are confirmed by the authors longterm follow-up results as presented here. To reemphasize, conservative treatment should be considered only in cases of extraarticular fractures, minor displaced intraarticular fractures in nonambulatory patients, and in cases where there is a clear contraindication for surgery. Regarding the technical requirements for an anatomic reconstruction, the os calcis fracture should be categorized as a procedure for experts. In two-part fractures, according to the Sanders classification, an anatomical reduction is obtainable in more than 80 %–90 % of cases. However, in consideration of the articular cartilage damage, a 70 % rate of good to excellent clinical results seems realistic. In three-part fractures, anatomic reduction is attainable in about 60 % of cases with a 70 % rate of good results. These two subgroups comprise about 90 % of all calcaneus fractures. It is the authors recent experience to optimize the extended lateral approach using posteromedial and anterolateral windows, so that an anatomic reduction in more than 60 % of Sanders Type III os calcis fractures can be achieved. Further scientific work in this area of trauma orthopedics would benefit most from a general consensus on a fracture classification system and on a clinical scoring system, with 5 year follow-up studies using these treatment methods and evaluation systems.