The February 2023 Foot & Ankle Roundup³⁶⁰ looks at: Joint inflammatory response in ankle and pilon fractures; Tibiotalocalcaneal fusion with a custom cage; Topical application of tranexamic acid can reduce blood loss in calcaneal fractures; Risk factors for failure of total ankle arthroplasty; Pain catastrophizing: the same as pain forecasting?.

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Aims

Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected.

Aims

We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial.

Aims

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

Aims

The aim of this study was to investigate whether including the stages of ulnar physeal closure in Sanders stage 7 aids in a more accurate assessment for brace weaning in patients with adolescent idiopathic scoliosis (AIS).

Three dimensional printing is an emerging new technology in medicine and the current educational value of 3D printed fracture models is unknown. The delayed surgery and need for CT imaging make calcaneal fractures an ideal scenario for preoperative 3D printed (3Dp) fracture models. The goal of this study is to assess if improvements in fracture understanding and surgical planning can be realized by trainees when they are given standard CT imaging and a 3Dp model compared to standard CT imaging and a virtual 3D rendering (3D CT). Ethics approval was granted for a selection of calcaneal fracture imaging studies to be collected through a practice audit of a senior orthopaedic trauma surgeon. 3Dp models were created in house. Digital Imaging and Communications in Medicine (DICOM) files of patient CT scans were obtained from local servers in an anonymized fashion. DICOM files were then converted to .STL models using the Mimics inPrint 2.0 (Materialise NV, Leuven, Belgium) software. Models were converted into a .gcode file through a slicer program (Simplify3D, Blue Ash, OH USA). The .gcode files were printed on a TEVO Little Monster Delta FDM printer (TEVO USA, CO USA) using 1.75mm polylactic acid (PLA) filament. Study participants rotated through 10 workstations viewing CT images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. A questionnaire at each workstation assessed fracture classification, proposed method of treatment, confidence with fracture understanding and satisfaction with the accuracy of the 3Dp model or 3D volume rendering. Participants included current orthopaedic surgery trainees and staff surgeons. A total of 16 residents and five staff completed the study. Ten fracture cases were included in the analysis for time, confidence of fracture understanding, perceived model accuracy and treatment method. Eight fracture cases were included for assessment of diagnosis. There were no cases that obtained universal agreement on either Sanders classification or treatment method from staff participants. Residents in their final year of studies had the quickest mean time of assessment (60 +/− 24 sec.) and highest percentage of correct diagnoses (83%) although these did not reach significance compared to the other residency years. There was a significant increase in confidence of fracture understanding with increasing residency year. Also, confidence was improved in cases where a 3Dp model was available compared to conventional CT alone although this improvement diminished with increasing residency year. Perceived accuracy of the cases with 3Dp models was significantly higher than cases without models (7 vs 5.5 p < 0.0001). This is the first study to our knowledge to assess trainee confidence as a primary outcome in the assessment of the educational value of 3Dp models. This study was able to show that a 3Dp model aides in the perceived accuracy of fracture assessment and showed an improvement in trainee confidence, although the effect on confidence seems to diminish with increasing residency year. We propose that 3D printed calcaneal fracture models are a beneficial educational tool for junior level trainees and the role of 3Dp models for other complex orthopaedic presentations should be explored

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Aims

Identifying predictors of compartment syndrome in the foot after a fracture of the calcaneus may lead to earlier diagnosis and treatment. The aim of our study was to identify any such predictors.

Aims

The purposes of this study were to clarify first, the incidence of peroneal tendon dislocation in patients with a fracture of the talus and second the factors associated with peroneal tendon dislocation.

Aims

We report the use of the distal radius and ulna (DRU) classification for the prediction of peak growth (PG) and growth cessation (GC) in 777 patients with idiopathic scoliosis. We compare this classification with other commonly used parameters of maturity.

The December 2014 Trauma Roundup³⁶⁰ looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and calcaneal fractures: a 20-year experience; bleeding and pelvic fractures; optimising timing for acetabular fractures; and tibial plateau fractures.

This is a case series report on the outcomes of patients that have received ORIF of their calcaneal fractures at Craigavon Hospital, Northern Ireland, for the first 2 years since it opened. It is a one surgeon series. Methods. Patients were identified from the theatre logbook. The patient recalled to clinic for interview and examination. Outcome was assessed using The Ankle-Hindfoot Scale devised by the American Orthopaedic Foot and Ankle Society. This was recorded with data for the patient's notes and CT scans. These data included age, date of surgery, mechanism of injury, associated injuries and previous function. The calcaneal fractures were classified according to the Sanders Classification. Results. Sixteen patients identified from the theatre register. Of these patients, 10 patients were contactable and attended for evaluation. The data from these 10 patients was then analysed. There 9 male patients and one female. Time from operation from 9.5 months to 33 months. All patients had fractures classified as Sanders Type IV. All implants were Variax calcaneal plates. One patient had metalwork removed at 15 months. All patients had commenced weightbearing at 3 months. Outcome scores ranged from 52–97 (mean 78.3, median 79). Six of the ten had returned to work at this review. Subtalar motion was universally affected. Discussion. This one surgeon case series reflects the current literature on calcaneal fractures, in that there is a variation in outcome which is multifactorial. There is also a difficulty in defining a classification system which can reflect outcome. The results of this series suggest that there is a trend of improving outcome scores as time from injury progresses, and that outcome score tends to decrease as age at injury increases

A high rate of complications is associated with open reduction and internal fixation of Sanders type 4 fractures of the calcaneum. We assessed the long-term outcome of 83 Sanders type 4 comminuted intra-articular fractures of the calcaneum in 64 patients who underwent non-operative treatment between 1999 and 2005. Each fracture was treated by closed reduction and immobilisation in a long leg cast. Patients were reviewed every three months in the first year, and every six months thereafter. At each visit, the involved ankles were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) criteria. The degree of fracture healing and the presence of osteoarthritis were assessed.

At a mean follow-up of 51 months (24 to 70) the mean AOFAS score was 72 (52 to 92). Osteoarthritis was scored radiologically using Graves’ classification and was evident in the subtalar joints of 75 ankles (90%) on x-ray and in all ankles on CT scans, of which 20 were grade 0 or 1, 39 grade 2, and 24 grade 3.

A non-operative approach to treating these fractures may be simpler, less expensive, easier to administer with fewer complications, and may be better tolerated than surgery, by many patients.

Objective: to study the surgical applicability and clinical results of the Vira. ®. system in treatment for severe fractures of the calcaneus. Material and Method: 50 acute intraarticular fractures of the calcaneus treated with the Vira. ®. system over a two-year period were analyzed in 42 patients. The mean age was 41 years. Eight were bilateral fractures and 47 were closed fractures. According to the Sanders classification, most of the fractures were type IV, followed by type III AB, and the inferior cortical was broken in 42 cases. All the patients were evaluated, in a prospective manner, using the AOFAS scale, plain radiographs and CT scan studies. Results: the average AOFAS score 12 months after surgery was 76.6 points (SD: 13.9). In 26% cases the results were very good, in 62% good, and in 12% mild and poor. The Böhler angle improvement after surgery was significant (p=0.05) though clinically irrelevant. Subtalar arthrodesis was achieved in all but two cases. The post-surgical complications were: 4 disorders of the plantar support, 4 cases of osteolysis at the tip of the screws, and 3 soft tissue problems. Conclusions: The Vira system is a validated option for the surgical treatment of severe fractures of the calcaneus, yielding good clinical and radiological results with a surgical procedure that is only minimally aggressive and has a low rate of complications

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle

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

Introduction and purpose: The VIRA system allows reconstruction of the fractured bone and its arthrodesis with the talar bone eliminating all movement of the subtalar joint by means of a minimally invasive approach. The aim is to restore the shape of the foot and prevent joint degenerative changes in the long term without the complications and sequelae of open surgery. Material and methods: Between November 2004 and June 2006, 30 intraarticular calcaneal fractures in 25 patients were treated surgically by means of the Vira System. Using Sanders’ classification 6 cases were classified as type II, 13 as type III and 11 as type IV. Five patients had open fractures. There was a mean period of 8.7 days between the accident and surgery. Seven cases had associated lesions and fractures in other locations. Only 2 cases required iliac crest grafts in the operated area. Results: All patients except 10 have returned to their usual occupations. Eight cases evolved favorably but have had a short follow-up. Two cases experienced a delayed healing of the subtalar arthrodesis and had to be reoperated; they required an autologous graft. The mean period of temporary disability in patients discharged from hospital was 163.7 days. Clinical assessment using the AOFAS scale reached a mean value of 76.6 points. No surgical or post-surgical complications were seen in the group studied. Conclusions: The VIRA System seems capable of achieving its purpose in the first series of patients operated. It allows a quick recovery both postoperatively and in the subsequent evolution without any associated complications. It accelerates the patients’ return to work by decreasing convalescence and minimizing sequelae