Background. Surgical management of calcaneus fractures is demanding and has a high risk of wound complications. Traditionally these fractures are managed with splinting until swelling has subsided. We describe a novel protocol for the management of displaced intra-articular calcaneus fractures utilising a temporizing external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique is to allow for earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the extensile approach. Methods. The records of patients with displaced calcaneus fractures from 2010–2014 were retrospectively reviewed. A total of 10 patients with 12 calcaneus fractures were treated with this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours of injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. Results. The average Bohler's angle improved from 13.2 (range −2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. Conclusions. Early temporizing external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. In our series there were no complications related to the use of the external fixator. Level of Evidence. IV Retrospective case series

Purpose: To evaluate the objective outcomes in patients who had undergone hardware removal after ORIF of calcaneus fractures. Materials and Methods: Between 1994 and 2002, 31 cases of hardware removal was performed in 30 patients (25 male, 5 female) with an average age at operation of 47 years (31 to 65 years) were reviewed. Patients’ demographic details were recorded including smoking habit. Fracture patterns were graded according to the Sanders’ classification with preoperative CT scans. The clinical result was assessed using Bristol hind foot scoring system. Serial radiographs assessments were also recorded. Results: Average follow-up was 4.5 years. Average delay from time of injury to surgery was 12.4 days (range 5 to 24 days). 7 (23%)fractures were Sanders’ type 2A, 8 (26%)fractures were type 2B, 6 (19%)fractures were type 2C, 2 (6%) fractures were type 3AB and 8 (26%) fractures were type 3AC. Average time from surgery to hardware removal was 27 months (range 11 to 45 months). There were 16 smokers and 14 non-smokers. There were 5 deep infections and 3 superficial wound infections after ORIF of calcaneus fractures. 84% of the patients shown objective improvement following hardware removal at the latest follow-up. 2 patients had unsuccessful hardware removal due to dense scarring. No wound infections were recorded. Smoking habit had no significant bearing on the objective outcome improvement following hardware removal (p= 0.891), time from surgery to hardware removal (p=0.53) and wound morbidity (p= 0.4882). Objective improvement showed a statistically significant improvement in the Sanders’ type 2 compared with Sanders’ type 3 (p=0.015). Conclusion: Removal of hardware is justified in symptomatic patients following ORIF calcaneus fractures. It results in an improved objective outcome and has a low complication rate. Hardware removal may be considered in cases of Sanders’ type 2 calcaneus fractures which are refractory to improvement

Purpose: Fractures of the calcaneus remain a significant clinical challenge. Little study has been done to investigate the potential benefit of bone graft in the treatment of these fractures. The purpose of this study is to compare the clinical outcome of calcaneus fractures treated with and without ICBG. Method: In an ongoing study at a Level I Trauma Center 45 patients with calcaneus fractures requiring operative management were enrolled in a prospective, randomized study. 24 patients were randomized to ORIF without graft (control) and 24 patients were randomized to ORIF with ICBG (study group). Demographic, intra-operative and long term clinical outcome data was collected. Outcome measures included pain scores, Creighton-Nebraska Foot Scores, time to weight bearing, return to work and wound complications. Results: The groups showed no differences in gender, age, mechanism of injury, fracture classification or time to surgery (avg. 12 days). Tscherne scores at presentation differed, with higher average scores in the control group. There were 2 open fractures in each group. The groups showed no statistically significant differences in any of the clinical outcome measures. There was no difference in pain scores (control mean 2.6 vs. study mean 4.1, p = 0.1), Creighton-Nebraska Scores (control 71 vs. study 55, p = 0.1), time to weight bearing (control 2.6 months vs. study 2.7 months, p = 0.9). At 6 months 38% of controls had returned to work (with 87% of those returning to the some occupation) while 39% of the study group returned to work (71% to same occupation). An overall wound complication rate of 27% was seen with 30% of controls and 24% of study patients exhibiting wound issues. Conclusion: In this prospective randomized study, patients treated with ORIF for calcaneus fractures showed no difference in clinical outcomes with or without the addition of ICBG. No clear benefit is demonstrated to warrant the additional operative time, pain and possible complications that have been previously documented to be associated with ICBG

Arthrodesis of both the ankle and the hindfoot has been discussed in the literature since the early part of the last century. Techniques have been modified substantially since these early discussions, though complications remain a frustrating element in patient management. Early procedures relied on molded plaster casts to hold fixation in corrected positions. Successful outcomes were hampered by loss of reduction in these casts and subsequent malunions. In addition, motion within these casts lead to a high rate of nonunion between the opposed bony surfaces. The era of internal fixation allowed compression across arthrodesis sites, enhancing union but creating a host of technical errors leading to unsatisfying results. Malunion is also seen in post-traumatic situations. In particular, non-operative management of calcaneus fracture (or other hindfoot fractures) leads to not only arthritis of the involved joint surfaces, but malunion complicating successful fusion. Fusion in-situ leads to a high level of patient dissatisfaction, leading surgeons to challenging deformity correction while trying to achieve successful arthrodesis in compromised joints. This lecture will focus on two types of malunion, one iatrogenic, one acquired. Revision triple arthrodesis (iatrogenic) can range from simple to challenging. A variety of studies document patient dissatisfaction following correction via this technique, ranging from Graves and Mann (1993) where the highest dissatisfaction rate was in highest in valgus malunion, to Sangeorzan and Hansen (1993), who found a 9% failure rate, most with varus malunion. The precarious balance required to create a plantigrade foot via triple arthrodesis with pre-existing deformity leaves even the most skilled surgeon challenged. As such, this component of the lecture will focus on recognition and correction of malunion based on a structured algorithmic approach we first presented in 1997. This algorithm is based on recognition of the apex of the deformity, and creating osteotomies to achieve balance. We reviewed 28 patients who returned for follow-up examination who received treatment through this algorithm and found a statistically significant improvement in pre- and postoperative AOFAS ankle/hindfoot score, from an average of 31 points preoperatively to 59 postoperatively (p<0.01). All patients united, and all stated they would undergo the revision procedure again. Comparisons of pre- and postoperative shoe wear modification demonstrated a statistically significant improvement (p=0.01). Preoperatively, 20 patients required restrictive devices such as ankle foot orthoses and orthopaedic shoes. Postoperatively, only 1 patient required such a restrictive device. In fact, 17 patients required no modifications to their shoe wear at all. The second component to this lecture will assess acquired hindfoot deformity, from malunion created by calcaneus fractures. A 2005 JBJS study by Brauer, et.al. found operative management resulted in a lower rate of subtalar arthrodesis with a shorter time off work compared to non-operative management. Removing the expense of time off work still netted a $2800 savings for operative management over non-operative management. Sanders echoed these thoughts in a JBJS 2006 paper, suggesting patients with displaced intra-articular calcaneal fractures may benefit from acute operative treatment given the difficulty encountered in restoring the calcaneal height and the talo-calcaneal relationship in symptomatic calcaneal fracture malunion. Thus, with these challenges in mind, the goal of this component of the lecture is to introduce methods to achieve balance and union with calcaneus fracture malunion. Vertically oriented multiplanar calcaneal osteotomy may assist the surgeon in avoiding the higher non-union rate associated with bone-block arthrodesis procedures. In this vein, the challenges associated with bone block subtalar arthrodesis will be explored

Introduction and Objectives: Our aim was to study the clinical and work-related results of minimally invasive athrodesis in the treatment of severe calcaneus fractures. Materials and Methods: A total of 50 fractures (42 patients) with intraarticular calcaneus fractures were treated by means of a minimally invasive primary arthrodesis using the VIRA. ®. (Biomet, Valencia, Spain) system with a minimum follow-up of 12 months and a mean follow-up of 21 months. Mean age was 41 years of age. Eight procedures were bilateral and 3 open. According to Sanders classification 74% were type IV. We performed a prospective study with clinical and radiographic assessment (AOFAS scale) 12 months after surgery. Results: The mean AOFAS score was 76.6 points (SD: 13.97): 26% were very good, 62% good and 12% fair to poor. There was no statistical variation of AOFAS in Sanders type of fracture, whether or not the lesion was bilateral and whether or not there was an associated lesion. We found an association (p=0.06) between the AOFAS score and the previous health status of the patient. Böhler’s angle improved slightly, although significantly (p=0.05), and there was seen to be correspondence with the postoperative AOFAS scale. Subtalar arthrodesis was achieved in 48 cases (96%) at 3 months. Discussion and Conclusions: Primary arthrodesis using minimally invasive systems is a valid option for the surgical treatment of severe fractures of the calcaneus. It provides good clinical and radiological outcomes with minimally aggressive surgery and a low complication rate

Objectives. The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function. Methods. Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery. Results. In 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months). The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351). Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001). Conclusions. At five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes. Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Purpose: We assess the results of the surgical treatment of intra-articular fractures of the calcaneus using the Ilizarov external fixator. Materials and Methods: During the period of January 2004 to June 2009 we treated 72 intra-articular calcaneus fractures in 68 patients, 51 male and 17 female with a mean age of 34 (range 18–56). The mean follow –up period was 2 years and 10 months (range 3 months to 4 years). All patients received preoperative CT-scan to facilitate classification and pre-operative planning. Of the 72 fractures, 37 (51.4%) were Sanders type II, 30 (41.6%) were type III and 5 (7%) were type IV. The Ilizarov fixator used consisted of 2 rings positioned above the ankle joint and a foot plate. 1.5 and 1.8 mm wires were used, as well as 1.8 mm wires with an olive for the reduction of displaced fragments. Under image intensification and distraction the fracture was reduced and the articular surface was restored as close as possible. Results: The clinical outcome was excellent in 29 patients (40.4%), good in 32 (44.4%), moderate in 7 (9.7%) and poor in 4 (5.5%). As far as the complications are concerned, we had 17 cases of pin track infection treated with the removal of the pins, ankle joint stiffness in 12 patients treated with physiotherapy, 2 patients developed reflex sympathetic algodystrophy, 2 malunion, 8 developed post-traumatic osteoarthritis and 1 of them underwent subtalar arthrodesis. Conclusion: The use of the Ilizarov external fixator for the treatment of intra-articular calcanear fractures has proved itself to be an alternative method to O.R.I.F with similarly good results. Given the fact that the learning curve is relatively steep, it has proven, from our experience, to be a safe and valuable tool for the treatment of these challenging fractures

As the population ages, we can expect to see more elderly patients with calcaneal fractures. Age alone does not reflect a person’s health or functional status, and should not, therefore, be used as a contraindication to surgical fixation. We report on the management of all patients over 65 years with calcaneal fractures receiving treatment at our institution over a 14-year period. Seventy-three patients > 65 years old with 76 calcaneal fractures treated from 1990 to 2004 were identified from a trauma database. A review of clinical notes was performed; demographics, co-morbidities, mechanism of injury, associated injuries, and management data were collected. For patients receiving operative treatment the fracture classification, operative indications, treatment and outcomes were reviewed. Twenty-seven patients with 29 fractures were treated without fixation, and 46 patients with 47 fractures were treated with fracture fixation. When compared with non-operatively treated patients, those treated operatively had lower mean injury severity scores (8.9 vs. 17.2) and fewer mean co-morbidities (1.0 vs. 2.2). Fractures were treated operatively either with an extensile lateral approach, small incision fixation, or a push screw. Follow-up (two weeks to 50 months) was available on all patients treated operatively, and radiographic follow-up was available on 32 patients. Wound infection and persistent drainage was seen in three and two patients, respectively. There was one non-union. One subtalar fusion was required. Eleven patients subsequently required plate removal. This retrospective review demonstrates that operative treatment of calcaneal fractures in carefully selected, elderly patients can result in good outcomes with acceptable complication rates. The complication profile for patients over 65 with calcaneus fractures appears to be similar to younger patients

This is a retrospective study examining the injury pattern, management and short-term outcomes of British Military casualties sustaining hindfoot fractures from the conflicts in Iraq and Afghanistan. In the 12-years of war, 114 patients sustained 134 hindfoot injuries. The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, with 30 (26%) undergoing internal fixation. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%). Nineteen patients (17%) required trans-tibial amputation in this time, with a further 17 (15%) requiring other revision surgery. Deep infection requiring surgical treatment occurred in 13 cases (11%) with S. aureus the commonest infective organism (46%). Deep infection was strongly associated with operative fracture management (p=0.0022). When controlling for multiple variables, the presence of deep infection was significantly associated with a requirement for amputation at 18 months (p=0.001). There was no association between open fractures and requirement for amputation at 18 months (p=0.926), nor was conservative management associated with amputation requirement (p=0.749)

Aims: The goal of this study to compare the clinical outcome of patients with calcaneus fractures differential strategy and non-differential conservative strategy treated. Methods: The study based on the results of treatment of 122 patients with 140 heel bone fractures. Results of only conservative treated 52 patients (54 fractures) in period 1992–1999 were retrospectively evaluated. Results of 70 patients (86 fractures) differential strategy treated in period 1999–2001 were prospectively evaluated. The plain radiographs – that is lateral, antero-posterior, oblique radiographs of the foot, axial and Broden view – and computerized tomography were used for examine patients. In period 1999–2001 the patients were differential strategy treated. All patients were divided in 5 groups: non-displacement fractures (early range of motion), beak type fractures (close reduction internal fixation by cannulated screw), tongue-type fractures (axial reposition axial fixation by Schantz screw), jointdepression and comminuted fractures (ORIF calcaneus bone plate AO). The results were evaluated by own score system in first group in 4 – 8 years period and 1 – 2,5 years period in second group. Results: The results of differential strategy treated patients with heel bone fractures (excellent – 60,9%± 5,9, good – 29,0%± 4,8, fair – 5,8%± 2,4, bad – 4,3%± 2,1) were reliably (p≥95%) better than results in only conservative treated group (excellent – 26,8%±4,7, good – 23,9%±4,5, fair – 23,9%±4,5, bad 25,4%±4,6). Conclusions: This study demonstrates that the differential strategy of treatment allows to reach good results and minimize soft tissue trauma