The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Surgical Treatment of Calcaneal Fractures of Sanders Type II and III by a Minimally Invasive Technique Using a Locking Plate Liehu Cao, MD 1, Weizong Weng, MD 1, Shaojun Song, MD 1, Ningfang Mao, PhD, MD 1, Haihang Li, MD 1, Yuanqi Cai, MD 1, Qirong Zhou Jr., MM 1, Jiacan Su, MD, PhD 2 1 2
Surgeon, Department of Orthopaedic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China Clinical Professor, Department of Orthopaedic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
The aim of the present study was to investigate the outcomes of surgical treatment of calcaneal fractures of Sanders type II and III using a minimally invasive technique and a locking plate. We reviewed 33 feet in 33 consecutive patients with Sanders type II and III calcaneal fractures who had undergone a minimally invasive technique using percutaneous reduction and locking plates. All operations were performed by the same € hler’s angle surgeons. The postoperative evaluation included radiographs, determination of restoration of Bo and Gissane’s angle, and administration of the American Orthopaedic Foot and Ankle Society ankle-hind foot scale, Maryland Foot Score, and visual analog scale of pain. The mean visual analog scale score was 1.6 1.4 when radiographic fracture healing was observed. The median functional score of the 33 patients (33 feet) reached 82 (interquartile range 80 to 99) at the last follow-up evaluation according to the American Orthopaedic Foot and Ankle Society ankle-hind foot scale and 89 (interquartile range 80 to 99) according to € hler’s angle and Gissane’s angle. PostMaryland Foot Score. All cases achieved restoration of a normal Bo operative superficial infections occurred in 2 patients, subtalar arthritis developed in 2, and no soft tissue necrosis was observed. For Sanders type II and III fractures of the calcaneus bone, treatment with a minimally invasive technique combining percutaneous reduction and locking plate fixation provided satisfactory clinical results, with a lower incidence of complications. However, longer term studies with a larger sample size and more randomized controlled trials are required to define the superiority of our minimally invasive technique compared with conventional surgical treatment of calcaneal fractures. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus intra-articular fractures internal fixation locking plate minimally invasive surgery
The calcaneus is the most frequently fractured tarsal bone, representing 2% of all fractures and 60% of all tarsal fractures (1). These injuries can be extra-articular or intra-articular fractures, with intraarticular fractures constituting approximately 60% to 75% of all calcaneus fractures (2). These intra-articular fractures are usually caused by axial loading that occurs during a fall from height or a road traffic accident. The use of computed tomography (CT) scanning allows for better understanding of the fracture configuration and classification. The Sanders classification, based on CT scanning of these fractures, is one of the commonly used systems of classification. Sanders type II and III fractures are the most common types of calcaneus fractures, and these most often result from high-energy
Financial Disclosure: None reported. Conflict of Interest: None reported. Drs. Cao and Weng contributed to the work equally and should be regarded as co-first authors. Address correspondence to: Jiacan Su, MD, PhD, Department of Orthopaedic Surgery, Changhai Hospital, 168 Changhai Road, Shanghai 200433 China. E-mail address: [email protected] (J. Su).
trauma in the young adult population. Surgery is the treatment of choice for these displaced intra-articular fractures. The aims of the surgical treatment include anatomic reduction of the articular surface, rigid internal fixation, and reconstruction of the calcaneus bone morphology, allowing patients to begin functional exercises of the subtalar joint as soon as possible and potentially preventing the development of post-traumatic arthritis. Currently, the most widely accepted surgical technique for intraarticular calcaneal fractures is open reduction and plate fixation (ORPF) using an expanded incision on the lateral wall of the heel with or without additional bone grafting (3). Conventional ORPF surgery through a lateral approach allows wide exposure to the subtalar joint, permitting accurate reduction of the facet fragments, the ability to easily decompress the lateral wall, exposure of the calcaneocuboid joint, and the ability to provide a sufficient lateral area for plating and rigid fixation. However, ORPF also has distinct disadvantages, such as a greater incidence of wound complications and the inability to assess the medial wall directly (4,5). Moreover, in cases of wound complications or skin necrosis, additional open surgery for removal of the failed components is required (5).
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.09.003
2
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
To prevent wound complications and associated problems, alternative techniques using Steinman pins for percutaneous reduction and fixation by Kirschner wire screws have been recommended by several investigators (6–8). These studies (6–8) have shown that reduction through leverage techniques combining Kirschner wire screw fixation provides a decreased incidence of wound complications and reliable improvement in patient recovery. This method has been shown to be associated with less early postoperative pain, better range of motion (ROM), higher functional scores of the injured ankle, and fewer complications compared with open surgery. The objective of the present study was to evaluate the long-term results of osteosynthesis achieved after minimally invasive percutaneous reduction and fixation with locking plates and a double Steinman technique. Patients and Methods Patients and Preoperative Assessment The present prospective study included 37 consecutive patients who had standard radiographic and CT evidence of Sanders type II and III fractures (Fig. 1). The exclusion criteria included multiple fractures, open fracture, lower limb fracture on the same side, previous chronic degenerative joint disease, previous foot and ankle surgical intervention, peripheral neural or vessel damage, serious osteoporosis, unmanaged diabetes in patients younger than 18 years, and refusal to participate or loss to follow-up. For all cases, plain radiographs and preoperative and postoperative CT scans were performed. Traumatic soft tissue damage was determined using the classification method of Tscherne and Oestern (9). In addition to radiographic evaluation using the calcaneus n views at 20 and 40 (10), all patients underwent a lateral, calcaneus axial, and Brode bilateral calcaneal preoperative CT scan for fracture classification and surgical planning. Fractures were evaluated by the classification scale of Sanders et al (11,12). All patients were surgically treated with a locking plate (Synthes USA, Paoli, PA) after a modified percutaneous reduction with double Steinman pins using a minimally invasive surgical technique (Fig. 2). All procedures were performed at the Department of Orthopaedics, Changhai Hospital, affiliated with the Second Military Medical University, from January 2007 to September 2010. The ethics review committee of the Second Military Medical University approved the study, and all patients provided written informed consent for the study (Table 1).
swelling was aided by elevation and cooling of the injured limb. A preoperative antibiotic was administered and a tourniquet applied. The patient was placed in a lateral position on a radiolucent operating table. The procedures were performed by the same surgeons (L.C. and J.S.), with the patient under spinal or general anesthesia with the foot elevated over a “closed gown pack.” The initial step in this procedure was a “punch technique,” which involves applying a hammer to punch onto the lateral and medial wall with gauze of appropriate thickness between the bone and hammer to restore the height and width of the calcaneus. With the guidance of the radiographic image intensifier, 2 parallel Steinmann pins were then inserted from the calcaneus tubercle toward the subtalar joint. Next, closed percutaneous reduction using a leverage technique with axis stress onto the pins down €hler’s angle. The anatomic restoration of to the distal side was attempted to restore Bo n radiographic views. The reduction of the the posterior facet was verified in Brode calcaneus was verified by examining the lateral radiographic view. Surgical exposure was gained in a minimally invasive manner, starting with an axially directed incision (2 to 3 cm) located on the posterolateral wall of heel, close to the calcaneus locking plate in axis length and parallel to the Achilles tendon (Fig. 3A). Careful subperiosteal dissection was then performed along the lateral calcaneus wall to develop a subfascial plane to fit the locking plate and surgical operation. A periosteum elevator was used to create a subfascial tunnel. Reduction was performed under image intensifier control, and an attempt was made to lift and relocate the articular process (Fig. 2). After the cavity was washed with normal saline solution, a calcaneus locking plate of appropriate size was selected and inserted into the subfascial tunnel (Fig. 3B), and an intraoperational C-arm fluoroscope (GE Co., Ltd., Chicago, IL) was used to ensure proper plate placement. Subsequently, an identical plate was placed on the implant area as a temporary “scope” for selective stab incisions through which appropriate screws were inserted into the calcaneus bone (Fig. 3B). The use of sleeves enabled adjustment of the plate location and ensured the optimal screw trajectory. The surgical procedure was completed by removing the Steinmann pins and insertion of the screws, and the incisions was sutured without drainage (Fig. 3C). Postoperative radiographs were performed directly after surgery (Fig. 4). Postoperative Treatment A compression dressing was applied on the operated site for 48 hours after surgery. The patients were allowed non-weightbearing mobilization with a crutch for the first 3 weeks after surgery. Subsequently, passive and active ankle ROM exercises, including the ankle and subtalar and midtarsal joints were started. Next, gradual transition to one sixth to one tenth partial weightbearing activity was started, followed by full weightbearing activity.
Preoperative Treatment and Surgical Technique
Postoperative Follow-Up and Assessment
Surgery was performed either in the first 12 to 24 hours or after the swelling had subsided and skin wrinkling had appeared. Preoperatively, resolution of soft tissue
The duration of surgery and radiographic image intensifier use was recorded. For postoperative evaluation of the reduction, radiographs of the calcaneus in the lateral,
Fig. 1. Right calcaneal fracture in a 42-year-old male patient caused by a fall from a height. (A) Radiograph of lateral view and (B) computed tomography scan indicated a Sanders type III fracture preoperatively.
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 2. Modified percutaneous reduction technique with 2 Steinmann pins inserted from the calcaneus tubercle to the subtalar joint (cautiously maintaining a safe distance between the €hler’s angle was detected. (B) After reduction, Bo € hler’s angle was restored. pin tips and the subtalar articular surface). (A) Before reduction, an obvious loss of Bo
n 20 and 40 views were obtained, and the postoperative Bo € hler’s axial, and Brode angle and Gissane’s angle were recorded. At the last follow-up evaluation, a CT scan of both calcanei was obtained to examine the morphology of the calcaneus and to evaluate arthritic changes in the lower ankle joint. Two of the treating surgeons (J.S. and L.C.) and 1 independent reviewer (W.W.) followed up all patients first immediately after the surgery to evaluate the condition of €hler and Gissane angles. The the surgical sites and, radiologically, specifically, the Bo patients were also evaluated at 6, 26, and 52 weeks with a clinical examination for signs of wound healing problems or infection and underwent hindfoot ROM and gait function tests such as toe and heel gait, squatting, jumping, and so forth. At the last follow-up visit, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale (13,14), Maryland Foot Score (MFS) (15), and visual analog scale (VAS) of pain (16) were used to quantify the functional outcomes and postoperative satisfaction rate. n 20 and 40 views At 52 weeks after surgery, we obtained lateral, axial, and Brode of both feet. Two examiners (L.C. and W.W.) assessed the following radiographic parameters at the last follow-up visit to judge the reduction of the calcaneal shape: € hler’s angle, Gissane’s angle, width and height of the heel, and axial alignment of the Bo hindfoot with respect to the tibia.
Table 1 Patient characteristics (n ¼ 33 feet; 33 consecutive patients) Characteristic Sex Male Female Age (y) Mean SD Range Fracture side Right Left Injury mechanism Fall from height Traffic accident Sports related Follow-up (mo) Mean SD Range Sanders classification Type II Type III Tscherne and Oestern classification 1 2 3 Abbreviation: SD, standard deviation. Data presented as n (%), unless otherwise noted.
Value 25 (75.76) 8 (24.24) 36 11.5 20 to 57 18 (54.55) 15 (45.46) 26 (78.79) 6 (18.18) 1 (3.03) 21 8.9 12 to 39 20 (60.61) 13 (39.39) 21 (63.64) 10 (30.3) 2 (6/06)
Statistical analyses was conducted by 1 of us (W.W.), and the Wilcoxon matchedpairs signed rank test was used for statistical analysis to compare the preoperative and postoperative AOFAS and MFS scores, because the distribution of the scores was not gaussian. For the VAS of pain, the paired t test was used for statistical analysis. A p value of < .05 was regarded as statistically significant.
Results A total of 33 patients (33 feet) with closed, dislocated, and intraarticular fractures of the calcaneus and a mean age of 36 11.5 (range 20 to 57) years who had completed at least 1 year of follow-up formed the study group. Of the 33 patients, 25 were male (75.76%) and 8 were female. The excluded patients included 1 patient who refused to participate, 2 patients who were lost to follow-up because their address could not be retrieved, and 1 patient who experienced failed percutaneous reduction of the articular surface and underwent open reduction. Of the 33 patients, 26 fractures (78.79%) had resulted from a fall from height, 6 (18.18%) resulted from a traffic accident, and 1 (3.03%) resulted from sports-related trauma. In 31 of the 33 calcaneal fractures, the soft tissue injury was graded as 1 or 2 , and the other 2 were graded as 3 . Sanders type II and III fractures were diagnosed, because all the patients had a joint deviation of 2 mm. All surgeries were performed within 48 hours after the injury, and the mean operation time was 69 14.6 (range 59 to 82) minutes. The mean hospital stay was 5 1.7 (range 3 to 8) days, and the mean intraoperative fluoroscopic time was 3.6 0.5 (range 3 to 5) minutes. To obtain proper retention of the fracture and rigid fixation, 5 to 7 screws were used. The mean follow-up period after surgery was 21 8.9 (range 12 to 39) months. All patients progressed to radiographic evidence of solid union in a mean period of 8.2 1.1 (range 7 to 11) weeks. The median AOFAS score was 82 (interquartile range 80 to 99) at the last follow-up evaluation, corresponding to a good-to-excellent rate of 93.94% (31 of 33), with excellent results achieved in 30 patients, good results in 1, and fair results in 2 patients owing to the development of subtalar arthritic changes. Compared with a preoperative median AOFAS score of 74 (interquartile range 70 to 78), the functional outcomes were significantly improved (p < .0001). The postoperative median MFS score at the last follow-up evaluation was 89 (interquartile range 80 to 99), significantly improved compared with the preoperative median value of 72 (interquartile range 70 to 74; p < .0001; Table 2). The mean VAS score for pain was 3.3 1.5
4
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 3. (A) Posterolateral axis incision as an initial exposure entrance (gray arrow), parallel with the Achilles tendon. Attention should be given to the related anatomic structures, including the distal tibia (red arrow) and extensor digitorum longus. The plate should be placed underneath the extensor digitorum longus. (B) The calcaneus locking plate was placed through the subfascial tunnel and then properly adjusted under fluoroscopic guidance. The selective stab incisions were made with an identical overlying plate on the lateral wall of heel as a “scope,” making it possible for the surgeons to locate the screw holes accurately without the need for additional exposure. Screw implantation was ready when the sleeves were inserted. (C) Photograph taken immediately after the operation. The damage to the soft tissue was less invasive than that with open reduction and plate fixation.
(range 3 to 6) and 1.6 0.4 (range 1 to 3) at 4 weeks after surgery and when radiographic fracture healing was detected, respectively, which was significantly decreased (p < .001) from the score of 6.7 0.8 (range 5 to 8) preoperatively (Table 3). Full weightbearing was achieved at a mean period of 8.5 1.8 (range 7 to 13) weeks postoperatively. Radiographic evidence of solid bony union was achieved
in all patients at a mean period of 8.2 1.1 (range 7 to 11) weeks. The € hler angle was 31 3.6 (range 27 to 38 ) postoperatively mean Bo compared with 9 2.7 (range 0 to 19 ) preoperatively. The mean Gissane angle was 121 5.7 (range 110 to 135 ) postoperatively compared with 107 4.8 (range 100 to 111 ) preoperatively € hler’s angle of 25 to 40 to be normal (17) (Table 4). Considering a Bo
Fig. 4. (A and B) Postoperative radiographs showing satisfactory morphology restoration, including the width and height of the calcaneus bone. In addition, the articular surface was € hler’s and Gissane’s angles. restored with respect to Bo
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Table 2 Functional outcomes after treatment of intra-articular calcaneal fractures (n ¼ 33 feet; 33 patients)
AOFAS MFS
Median Score (IQR)
Range
Preoperatively
Last Follow-Up Visit
Preoperatively
Last Follow-Up Visit
74 (70 to 78) 72 (70 to 74)
82 (80 to 99) 89 (80 to 99)
64 to 80 62 to 78
78 to 100 79 to 100
Table 4 Preoperative and postoperative angles (n ¼ 33 feet; 33 patients) Value
p Value Mean SD Range
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Surgical Treatment of Calcaneal Fractures of Sanders Type II and III by a Minimally Invasive Technique Using a Locking Plate Liehu Cao, MD 1, Weizong Weng, MD 1, Shaojun Song, MD 1, Ningfang Mao, PhD, MD 1, Haihang Li, MD 1, Yuanqi Cai, MD 1, Qirong Zhou Jr., MM 1, Jiacan Su, MD, PhD 2 1 2
Surgeon, Department of Orthopaedic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China Clinical Professor, Department of Orthopaedic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
The aim of the present study was to investigate the outcomes of surgical treatment of calcaneal fractures of Sanders type II and III using a minimally invasive technique and a locking plate. We reviewed 33 feet in 33 consecutive patients with Sanders type II and III calcaneal fractures who had undergone a minimally invasive technique using percutaneous reduction and locking plates. All operations were performed by the same € hler’s angle surgeons. The postoperative evaluation included radiographs, determination of restoration of Bo and Gissane’s angle, and administration of the American Orthopaedic Foot and Ankle Society ankle-hind foot scale, Maryland Foot Score, and visual analog scale of pain. The mean visual analog scale score was 1.6 1.4 when radiographic fracture healing was observed. The median functional score of the 33 patients (33 feet) reached 82 (interquartile range 80 to 99) at the last follow-up evaluation according to the American Orthopaedic Foot and Ankle Society ankle-hind foot scale and 89 (interquartile range 80 to 99) according to € hler’s angle and Gissane’s angle. PostMaryland Foot Score. All cases achieved restoration of a normal Bo operative superficial infections occurred in 2 patients, subtalar arthritis developed in 2, and no soft tissue necrosis was observed. For Sanders type II and III fractures of the calcaneus bone, treatment with a minimally invasive technique combining percutaneous reduction and locking plate fixation provided satisfactory clinical results, with a lower incidence of complications. However, longer term studies with a larger sample size and more randomized controlled trials are required to define the superiority of our minimally invasive technique compared with conventional surgical treatment of calcaneal fractures. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus intra-articular fractures internal fixation locking plate minimally invasive surgery
The calcaneus is the most frequently fractured tarsal bone, representing 2% of all fractures and 60% of all tarsal fractures (1). These injuries can be extra-articular or intra-articular fractures, with intraarticular fractures constituting approximately 60% to 75% of all calcaneus fractures (2). These intra-articular fractures are usually caused by axial loading that occurs during a fall from height or a road traffic accident. The use of computed tomography (CT) scanning allows for better understanding of the fracture configuration and classification. The Sanders classification, based on CT scanning of these fractures, is one of the commonly used systems of classification. Sanders type II and III fractures are the most common types of calcaneus fractures, and these most often result from high-energy
Financial Disclosure: None reported. Conflict of Interest: None reported. Drs. Cao and Weng contributed to the work equally and should be regarded as co-first authors. Address correspondence to: Jiacan Su, MD, PhD, Department of Orthopaedic Surgery, Changhai Hospital, 168 Changhai Road, Shanghai 200433 China. E-mail address: [email protected] (J. Su).
trauma in the young adult population. Surgery is the treatment of choice for these displaced intra-articular fractures. The aims of the surgical treatment include anatomic reduction of the articular surface, rigid internal fixation, and reconstruction of the calcaneus bone morphology, allowing patients to begin functional exercises of the subtalar joint as soon as possible and potentially preventing the development of post-traumatic arthritis. Currently, the most widely accepted surgical technique for intraarticular calcaneal fractures is open reduction and plate fixation (ORPF) using an expanded incision on the lateral wall of the heel with or without additional bone grafting (3). Conventional ORPF surgery through a lateral approach allows wide exposure to the subtalar joint, permitting accurate reduction of the facet fragments, the ability to easily decompress the lateral wall, exposure of the calcaneocuboid joint, and the ability to provide a sufficient lateral area for plating and rigid fixation. However, ORPF also has distinct disadvantages, such as a greater incidence of wound complications and the inability to assess the medial wall directly (4,5). Moreover, in cases of wound complications or skin necrosis, additional open surgery for removal of the failed components is required (5).
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.09.003
2
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
To prevent wound complications and associated problems, alternative techniques using Steinman pins for percutaneous reduction and fixation by Kirschner wire screws have been recommended by several investigators (6–8). These studies (6–8) have shown that reduction through leverage techniques combining Kirschner wire screw fixation provides a decreased incidence of wound complications and reliable improvement in patient recovery. This method has been shown to be associated with less early postoperative pain, better range of motion (ROM), higher functional scores of the injured ankle, and fewer complications compared with open surgery. The objective of the present study was to evaluate the long-term results of osteosynthesis achieved after minimally invasive percutaneous reduction and fixation with locking plates and a double Steinman technique. Patients and Methods Patients and Preoperative Assessment The present prospective study included 37 consecutive patients who had standard radiographic and CT evidence of Sanders type II and III fractures (Fig. 1). The exclusion criteria included multiple fractures, open fracture, lower limb fracture on the same side, previous chronic degenerative joint disease, previous foot and ankle surgical intervention, peripheral neural or vessel damage, serious osteoporosis, unmanaged diabetes in patients younger than 18 years, and refusal to participate or loss to follow-up. For all cases, plain radiographs and preoperative and postoperative CT scans were performed. Traumatic soft tissue damage was determined using the classification method of Tscherne and Oestern (9). In addition to radiographic evaluation using the calcaneus n views at 20 and 40 (10), all patients underwent a lateral, calcaneus axial, and Brode bilateral calcaneal preoperative CT scan for fracture classification and surgical planning. Fractures were evaluated by the classification scale of Sanders et al (11,12). All patients were surgically treated with a locking plate (Synthes USA, Paoli, PA) after a modified percutaneous reduction with double Steinman pins using a minimally invasive surgical technique (Fig. 2). All procedures were performed at the Department of Orthopaedics, Changhai Hospital, affiliated with the Second Military Medical University, from January 2007 to September 2010. The ethics review committee of the Second Military Medical University approved the study, and all patients provided written informed consent for the study (Table 1).
swelling was aided by elevation and cooling of the injured limb. A preoperative antibiotic was administered and a tourniquet applied. The patient was placed in a lateral position on a radiolucent operating table. The procedures were performed by the same surgeons (L.C. and J.S.), with the patient under spinal or general anesthesia with the foot elevated over a “closed gown pack.” The initial step in this procedure was a “punch technique,” which involves applying a hammer to punch onto the lateral and medial wall with gauze of appropriate thickness between the bone and hammer to restore the height and width of the calcaneus. With the guidance of the radiographic image intensifier, 2 parallel Steinmann pins were then inserted from the calcaneus tubercle toward the subtalar joint. Next, closed percutaneous reduction using a leverage technique with axis stress onto the pins down €hler’s angle. The anatomic restoration of to the distal side was attempted to restore Bo n radiographic views. The reduction of the the posterior facet was verified in Brode calcaneus was verified by examining the lateral radiographic view. Surgical exposure was gained in a minimally invasive manner, starting with an axially directed incision (2 to 3 cm) located on the posterolateral wall of heel, close to the calcaneus locking plate in axis length and parallel to the Achilles tendon (Fig. 3A). Careful subperiosteal dissection was then performed along the lateral calcaneus wall to develop a subfascial plane to fit the locking plate and surgical operation. A periosteum elevator was used to create a subfascial tunnel. Reduction was performed under image intensifier control, and an attempt was made to lift and relocate the articular process (Fig. 2). After the cavity was washed with normal saline solution, a calcaneus locking plate of appropriate size was selected and inserted into the subfascial tunnel (Fig. 3B), and an intraoperational C-arm fluoroscope (GE Co., Ltd., Chicago, IL) was used to ensure proper plate placement. Subsequently, an identical plate was placed on the implant area as a temporary “scope” for selective stab incisions through which appropriate screws were inserted into the calcaneus bone (Fig. 3B). The use of sleeves enabled adjustment of the plate location and ensured the optimal screw trajectory. The surgical procedure was completed by removing the Steinmann pins and insertion of the screws, and the incisions was sutured without drainage (Fig. 3C). Postoperative radiographs were performed directly after surgery (Fig. 4). Postoperative Treatment A compression dressing was applied on the operated site for 48 hours after surgery. The patients were allowed non-weightbearing mobilization with a crutch for the first 3 weeks after surgery. Subsequently, passive and active ankle ROM exercises, including the ankle and subtalar and midtarsal joints were started. Next, gradual transition to one sixth to one tenth partial weightbearing activity was started, followed by full weightbearing activity.
Preoperative Treatment and Surgical Technique
Postoperative Follow-Up and Assessment
Surgery was performed either in the first 12 to 24 hours or after the swelling had subsided and skin wrinkling had appeared. Preoperatively, resolution of soft tissue
The duration of surgery and radiographic image intensifier use was recorded. For postoperative evaluation of the reduction, radiographs of the calcaneus in the lateral,
Fig. 1. Right calcaneal fracture in a 42-year-old male patient caused by a fall from a height. (A) Radiograph of lateral view and (B) computed tomography scan indicated a Sanders type III fracture preoperatively.
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 2. Modified percutaneous reduction technique with 2 Steinmann pins inserted from the calcaneus tubercle to the subtalar joint (cautiously maintaining a safe distance between the €hler’s angle was detected. (B) After reduction, Bo € hler’s angle was restored. pin tips and the subtalar articular surface). (A) Before reduction, an obvious loss of Bo
n 20 and 40 views were obtained, and the postoperative Bo € hler’s axial, and Brode angle and Gissane’s angle were recorded. At the last follow-up evaluation, a CT scan of both calcanei was obtained to examine the morphology of the calcaneus and to evaluate arthritic changes in the lower ankle joint. Two of the treating surgeons (J.S. and L.C.) and 1 independent reviewer (W.W.) followed up all patients first immediately after the surgery to evaluate the condition of €hler and Gissane angles. The the surgical sites and, radiologically, specifically, the Bo patients were also evaluated at 6, 26, and 52 weeks with a clinical examination for signs of wound healing problems or infection and underwent hindfoot ROM and gait function tests such as toe and heel gait, squatting, jumping, and so forth. At the last follow-up visit, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale (13,14), Maryland Foot Score (MFS) (15), and visual analog scale (VAS) of pain (16) were used to quantify the functional outcomes and postoperative satisfaction rate. n 20 and 40 views At 52 weeks after surgery, we obtained lateral, axial, and Brode of both feet. Two examiners (L.C. and W.W.) assessed the following radiographic parameters at the last follow-up visit to judge the reduction of the calcaneal shape: € hler’s angle, Gissane’s angle, width and height of the heel, and axial alignment of the Bo hindfoot with respect to the tibia.
Table 1 Patient characteristics (n ¼ 33 feet; 33 consecutive patients) Characteristic Sex Male Female Age (y) Mean SD Range Fracture side Right Left Injury mechanism Fall from height Traffic accident Sports related Follow-up (mo) Mean SD Range Sanders classification Type II Type III Tscherne and Oestern classification 1 2 3 Abbreviation: SD, standard deviation. Data presented as n (%), unless otherwise noted.
Value 25 (75.76) 8 (24.24) 36 11.5 20 to 57 18 (54.55) 15 (45.46) 26 (78.79) 6 (18.18) 1 (3.03) 21 8.9 12 to 39 20 (60.61) 13 (39.39) 21 (63.64) 10 (30.3) 2 (6/06)
Statistical analyses was conducted by 1 of us (W.W.), and the Wilcoxon matchedpairs signed rank test was used for statistical analysis to compare the preoperative and postoperative AOFAS and MFS scores, because the distribution of the scores was not gaussian. For the VAS of pain, the paired t test was used for statistical analysis. A p value of < .05 was regarded as statistically significant.
Results A total of 33 patients (33 feet) with closed, dislocated, and intraarticular fractures of the calcaneus and a mean age of 36 11.5 (range 20 to 57) years who had completed at least 1 year of follow-up formed the study group. Of the 33 patients, 25 were male (75.76%) and 8 were female. The excluded patients included 1 patient who refused to participate, 2 patients who were lost to follow-up because their address could not be retrieved, and 1 patient who experienced failed percutaneous reduction of the articular surface and underwent open reduction. Of the 33 patients, 26 fractures (78.79%) had resulted from a fall from height, 6 (18.18%) resulted from a traffic accident, and 1 (3.03%) resulted from sports-related trauma. In 31 of the 33 calcaneal fractures, the soft tissue injury was graded as 1 or 2 , and the other 2 were graded as 3 . Sanders type II and III fractures were diagnosed, because all the patients had a joint deviation of 2 mm. All surgeries were performed within 48 hours after the injury, and the mean operation time was 69 14.6 (range 59 to 82) minutes. The mean hospital stay was 5 1.7 (range 3 to 8) days, and the mean intraoperative fluoroscopic time was 3.6 0.5 (range 3 to 5) minutes. To obtain proper retention of the fracture and rigid fixation, 5 to 7 screws were used. The mean follow-up period after surgery was 21 8.9 (range 12 to 39) months. All patients progressed to radiographic evidence of solid union in a mean period of 8.2 1.1 (range 7 to 11) weeks. The median AOFAS score was 82 (interquartile range 80 to 99) at the last follow-up evaluation, corresponding to a good-to-excellent rate of 93.94% (31 of 33), with excellent results achieved in 30 patients, good results in 1, and fair results in 2 patients owing to the development of subtalar arthritic changes. Compared with a preoperative median AOFAS score of 74 (interquartile range 70 to 78), the functional outcomes were significantly improved (p < .0001). The postoperative median MFS score at the last follow-up evaluation was 89 (interquartile range 80 to 99), significantly improved compared with the preoperative median value of 72 (interquartile range 70 to 74; p < .0001; Table 2). The mean VAS score for pain was 3.3 1.5
4
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 3. (A) Posterolateral axis incision as an initial exposure entrance (gray arrow), parallel with the Achilles tendon. Attention should be given to the related anatomic structures, including the distal tibia (red arrow) and extensor digitorum longus. The plate should be placed underneath the extensor digitorum longus. (B) The calcaneus locking plate was placed through the subfascial tunnel and then properly adjusted under fluoroscopic guidance. The selective stab incisions were made with an identical overlying plate on the lateral wall of heel as a “scope,” making it possible for the surgeons to locate the screw holes accurately without the need for additional exposure. Screw implantation was ready when the sleeves were inserted. (C) Photograph taken immediately after the operation. The damage to the soft tissue was less invasive than that with open reduction and plate fixation.
(range 3 to 6) and 1.6 0.4 (range 1 to 3) at 4 weeks after surgery and when radiographic fracture healing was detected, respectively, which was significantly decreased (p < .001) from the score of 6.7 0.8 (range 5 to 8) preoperatively (Table 3). Full weightbearing was achieved at a mean period of 8.5 1.8 (range 7 to 13) weeks postoperatively. Radiographic evidence of solid bony union was achieved
in all patients at a mean period of 8.2 1.1 (range 7 to 11) weeks. The € hler angle was 31 3.6 (range 27 to 38 ) postoperatively mean Bo compared with 9 2.7 (range 0 to 19 ) preoperatively. The mean Gissane angle was 121 5.7 (range 110 to 135 ) postoperatively compared with 107 4.8 (range 100 to 111 ) preoperatively € hler’s angle of 25 to 40 to be normal (17) (Table 4). Considering a Bo
Fig. 4. (A and B) Postoperative radiographs showing satisfactory morphology restoration, including the width and height of the calcaneus bone. In addition, the articular surface was € hler’s and Gissane’s angles. restored with respect to Bo
L. Cao et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Table 2 Functional outcomes after treatment of intra-articular calcaneal fractures (n ¼ 33 feet; 33 patients)
AOFAS MFS
Median Score (IQR)
Range
Preoperatively
Last Follow-Up Visit
Preoperatively
Last Follow-Up Visit
74 (70 to 78) 72 (70 to 74)
82 (80 to 99) 89 (80 to 99)
64 to 80 62 to 78
78 to 100 79 to 100
Table 4 Preoperative and postoperative angles (n ¼ 33 feet; 33 patients) Value
p Value Mean SD Range
