Aims. Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications. Methods. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Results. Fifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%). Conclusion. Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management

Background: Closed reduction of intra-articular calcaneal fractures sometimes lack the accuracy desired for restoring the normal anatomy of the articular surface of the calcaneus. In this study, we evaluate the preliminary results of closed reduction of the intra-articular calcaneal fractures with an Ilizarov frame. Patients and Method: Forty patients (25 males and 15 females) with 50 intra-articular fracture calcaneal fractures were treated with closed reduction and an Ilizarov frame. The mean age was 25.4 years (range from 19 to 65). Union was achieved after two months. The results were evaluated on the basis of combined clinical and radiological examination at the latest follow-up. Results were classified according to the protocol and scoring system used by Paley and Hall 1993. Results: The mean follow up period was 1.9 years (range 6 months to 4 years). At final follow up there were 15 excellent feet, 26 were good, 6 fair and 3 poor. The mean Bohler angle postoperatively was 260 (range 17 to 35). Superficial infection occurred in seven feet and was controlled. Skin pressure necrosis of the posterior aspect of the heel occurred in three feet. One needed a skin graft. Conclusion: This method is a minimally invasive technique. The technique has the ability to restore the normal anatomy, shape and length of the calcaneal body, especially in Sander’s type III and type IV fractures. It is particularly useful for osteoprotic bone as it provides rigid fixation

This edition of the Cochrane Corner looks at the three reviews that were published in the second half of 2023: surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures; cryotherapy following total knee arthroplasty; and physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

Background. Optimal management of displaced intra-articular calcaneal fractures remains controversial. The aim of this prospective cohort study was to compare the clinical and radiological outcomes of minimally invasive surgery (MIS) versus non-operative treatment in displaced intra-articular calcaneal fracture up to 2-years. Methods. All displaced intra-articular calcaneal fractures between August 2014 and January 2019 that presented to a level 1 trauma centre were considered for inclusion. The decision to treat was made by a multidisciplinary meeting. Operative treatment protocol involved sinus tarsi approach or percutaneous reduction & internal fixation. Non-operative protocol involved symptomatic management with no attempt at closed reduction. All fractures were classified, and the MOXFQ/EQ-5D-5L scores were used to assess foot and ankle and general health-related quality of life outcomes respectively. Results. 101 patients were recruited at a level 1 major trauma centre, between August 2014 and January 2019. Our propensity score matched 44 patients in the surgical cohort to 44 patients in the non-surgical cohort. At 24 months, there was no significant difference in the MOXFQ Index score (p<0.05) however the patients in the surgical cohort had a significantly higher EQ-5D-5L Index score (p<0.05). There was also a higher return to work (91% vs 72%, p<0.05) and physical activity rate (46 vs. 35%, p<0.05) in the surgical cohort despite a higher proportion of more complex fractures in the surgical cohort. The wound complication rate following surgery was 16%. 14% of patients in the non-operative cohort subsequently underwent arthrodesis compared to none of the patients in the surgical cohort. Conclusion. In this study, we found operative treatments were associated with low rates of surgical complication at 2-years and long term pain improvement, facilitating earlier and better functional outcomes for complex injury patterns compared to nonoperative treatment

Aims. We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial. Methods. HeFT recruited 151 patients aged over 16 years with closed displaced, intra-articular fractures of the calcaneus. Patients with significant deformity causing fibular impingement, peripheral vascular disease, or other significant limb injuries were excluded. Participants were randomly allocated to open reduction and internal fixation (ORIF) or nonoperative treatment. We report Kerr-Atkins scores, self-reported difficulty walking and fitting shoes, and additional surgical procedures at 36, 48, and 60 months. Results. Overall, 60-month outcome data were available for 118 patients (78%; 52 ORIF, 66 nonoperative). After 60 months, mean Kerr-Atkins scores were 79.2 (SD 21.5) for ORIF and 76.4 (SD 22.5) for nonoperative. Mixed effects regression analysis gave an estimated effect size of -0.14 points (95% confidence interval -8.87 to 8.59; p = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p = 0.175), or on the type of shoes worn (p = 0.432) at 60 months. Additional surgical procedures were conducted on ten participants allocated ORIF, compared to four in the nonoperative group (p = 0.043). Conclusion. ORIF of displaced intra-articular calcaneal fractures, not causing fibular impingement, showed no difference in outcomes at 60 months compared to nonoperative treatment, but with an increased risk of additional surgery. Cite this article: Bone Joint J 2021;103-B(6):1040–1046

Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Introduction The results of open reduction and internal fixation of displaced intra-articular calcaneal fractures has been shown to be superior to closed management. We report our early experience with the AO locking calcaneal plate for these injuries in particular looking for wound complications. Methods Between December 2001 and March 2003 a total of 28 patients with 29 displaced intra-articular calcaneal fractures were treated by two surgeons. The average delay from injury to time of surgery was 11 days. A standard “L” shape lateral approach was used with the patient in a lateral decubitus position. Reduction was temporarily held with K wires before the locking plate was applied, with the bending tools used for in-situ plate moulding. Wounds were closed over a drain using Allgower-Donati sutures after haemostasis. Stitches were removed at two weeks when the wounds had healed. Results Of the 29 fractures treated there was only two minor wound problems. In one patient this occurred after using the larger plate and consisted of slight necrosis at the inferior corner of the wound, which healed non-operatively. There have been two patients requiring removal of their plates between 10 and 15 months after surgery. They both complained of lateral pain, which may have been due to the plate being bulkier than other currently used plates. After removal both patients had immediate relief from their symptoms. The AO locking plate offers advantages over the standard plate. These include the option for locking screws as well as 2.7 mm and 3.5 mm screws, increased strength, and the ability to mould the plate in-situ using the bending irons in the screw holes. This in-situ moulding allows better contouring of the plate. On one occasion even this plate was too large and required trimming to fit the bone. We have not experienced an increase in wound problems due to bulkier plate. Conclusions Our early experience with the AO Locking plate has been positive, with minimal complications. We would recommend the use of this plate for fixation of displaced intra-articular calcaneal fractures, and suggest the need for a smaller plate to be designed

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

Objectives. This study aimed to investigate the functional effects of microRNA (miR)-214-5p on osteoblastic cells, which might provide a potential role of miR-214-5p in bone fracture healing. Methods. Blood samples were obtained from patients with hand fracture or intra-articular calcaneal fracture and from healthy controls (HCs). Expression of miR-214-5p was monitored by qRT-PCR at day 7, 14 and 21 post-surgery. Mouse osteoblastic MC3T3-E1 cells were transfected with antisense oligonucleotides (ASO)-miR-214-5p, collagen type IV alpha 1 (COL4A1) vector or their controls; thereafter, cell viability, apoptotic rate, and the expression of collagen type I alpha 1 (COL1A1), type II collagen (COL-II), and type X collagen (COL-X) were determined. Luciferase reporter assay, qRT-PCR, and Western blot were performed to ascertain whether COL4A1 was a target of miR-214-5p. Results. Plasma miR-214-5p was highly expressed in patients with bone fracture compared with HCs after fracture (p < 0.05 or p < 0.01). Inhibition of miR-214-5p increased the viability of MC3T3-E1 cells and the expressions of COL1A1 and COL-X, but decreased the apoptotic rate and COL-II expression (p < 0.05 or p < 0.01). COL4A1 was a target of miR-214-5p, and was negatively regulated by miR-214-5p (p < 0.05 or p < 0.01). Overexpression of COL4A1 showed a similar impact on cell viability, apoptotic rate, and COL1A1, COL-II, and COL-X expressions inhibiting miR-214-5p (p < 0.01). Conclusion. Inhibition of miR-214-5p promotes cell survival and extracellular matrix (ECM) formation of osteoblastic MC3T3-E1 cells by targeting COL4A1. Cite this article: Q. S. Li, F. Y. Meng, Y. H. Zhao, C. L. Jin, J. Tian, X. J. Yi. Inhibition of microRNA-214-5p promotes cell survival and extracellular matrix formation by targeting collagen type IV alpha 1 in osteoblastic MC3T3-E1 cells. Bone Joint Res 2017;6:464–471. DOI: 10.1302/2046-3758.68.BJR-2016-0208.R2

We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review. The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group. The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up

In this paper, we critically appraise the recent publication of the United Kingdom Heel Fracture Trial, which concluded that when patients with an absolute indication for surgery were excluded, there was no advantage of surgical over non-surgical treatment in the management of calcaneal fractures. We believe that selection bias in that study did not permit the authors to reach a firm conclusion that surgery was not justified for most intra-articular calcaneal fractures. Cite this article: Bone Joint J 2015;97-B:880–2

Introduction. We present a consecutive series of 19 patients with 22 intra-articular calcaneal fractures treated by percutaneous arthroscopic fixation (percutaneous arthroscopic calcaneal osteosynthesis “PACO”). Traditional open reduction and fixation regularly has significant wound complications. PACO has the advantage of direct visualization of the joint surface reduction with the benefit of minimal soft tissue trauma and wound complications. Methods. Between July 2010 & April 2012, 39 isolated closed intra-articular calcaneal fractures were admitted to St Mary's Hospital. All Sanders type 2 and type 3 fractures were included. Undisplaced fractures (13) were treated non-operatively and comminuted type 4 fractures (4) were treated with primary arthroscopic fusion. Surgery was performed on the next list with no delay for swelling. All patients had pre and post op CT scans. Patients were discharged in a temporary cast with routine follow up at 2, 6 and 12 weeks. Technique. Arthroscopy was performed in the lateral position with a 4.0mm arthroscope, using two sinus tarsi portals and a posterolateral portal. The fracture fragments were reduced percutaneously, held with wires before definitive fixation. Results. There were 10 three-part fractures (Sanders 3AB) and 12 two part (Sanders 2A/2B). Bohler's angle improved from 9.9 (7–18) to 27.7 (23–32) P <0.001. The mean time to surgery was 4 days (1–7), mean post-op stay was 1.9 days. Mean articular step of 0.9mm (0.4–1.9mm) on post-op CT. There were no deep wound infections. Conclusions. PACO is an accurate and reliable technique for fixation of calcaneal fractures, with a low complication rate, and minimal pre and post-operative delay

Aim: Our purpose was to evaluate the use of indirect and closed reduction with Ilizarov external fixator in intra-articular calcaneal fractures. Materials and Methods: In a period of 5 years (2004–2008), 26 patients with 29 intra-articular fractures of calcaneus (eighteen type III and eleven type IV according to Sanders classification) were treated with the Ilizarov fixator. Twenty-one patients were male and five female. The average age was 45 years (range 22 – 67 years). Five fractures were open. Fractures were evaluated by preoperative radiographs and CT scans. Restoration of the calcaneal bone anatomy was obtained by closed means using minimally invasive reduction technique by Ilizarov fixator. Arthrodiatasis and ligamentotaxis, and closed reduction of the subtalar joint were performed in 24 cases. In 5 cases the depressed posterior calcaneal facet was elevated by small lateral incision and stabilized in frame by wires. Postoperatively, partial, early weight bearing was encouraged in all patients. Results: The mean follow-up period was 2,1 years (range 1 – 4 years). The AOFAS Ankle – Hindfoot Score, and physical examination were used in functional evaluation. The average score was 77,4 (range 70–90). Seven patients had limited degenerative radiological findings of osteoarthrosis about the subtalar joint and three of them had painful subtalar movement. Two of the patients complained of heel pad pain. Nine patients had grade II pin tract infections and were detected from a total of 258 wires. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. Conclusion: Indirect closed reduction of calcaneal bone anatomy and arthrodiatasis of subtalar joint with Ilizarov external fixator is a viable surgical alternative for intra-articular calcaneal fractures

Aim: The purpose of this study was to report the long-term follow-up (mean of 15 years) of patients with displaced intra-articular calcaneal fractures from a randomised controlled trial published in 1993. Patients and Methods: 46 patients (82% of patients in the initial study group) were alive at a mean of 15 years post injury. The patients had been randomly allocated to either conservative or operative (Soeur and Remy technique) treatment in the original study. Clinical (AOFAS, FFI and calcaneal fracture score) and radiological (Böhler’s angle and calcaneum height) outcome measures were used. The grade of osteoarthritis was also assessed at long-term follow-up. Results: 26 patients (57%) were reviewed and these patients served as the focus of the study (11 conservative and 15 operative). The clinical outcomes after conservative treatment were not found to be different from those after operative treatment, scores of the AOFAS were 78.5 and 70 respectively (p = 0.11); scores of the FFI were 24.4 and 26.9 respectively (p = 0.66) and calcaneal fracture scores were 70.1 and 63.5 respectively (p = 0.41). The radiological outcomes after conservative treatment were not found to be different from those after operative treatment, Böhler’s angles were 10° and 16° respectively (p = 0.07) and the height of the calcaneum were 37mm and 36mm respectively (p = 0.57). There was no difference in the grade of osteoarthritis between the groups. Conclusion: The functional and radiological long-term outcomes after conservative treatment of displaced intra-articular calcaneal fractures were equivalent to those after operative treatment. The operative technique showed no benefit compared to conservative treatment at long-term follow-up. There was a trend for higher scores on clinical outcomes with conservative treatment

Introduction. Considerable controversy exists with regard to the surgical management of displaced intra-articular calcaneal fractures. Protagonists for internal fixation would suggest there is sufficient evidence to expect better functional outcomes with surgery. However, this is not conclusive. Aim. To identify factors which improved outcome following surgery. Method. Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fixation at our hospital (mean age 45 years). We reviewed 20 patients within the Shropshire region using four recognised hindfoot scoring systems. Patients were classified according to Sanders’ classification with pre-operative CT scans. The mechanism of injury and post-operative management were recorded. Clinical and radiographic assessments were also made. Results. Average follow-up was 3.6 years. The overall surgical results were comparable with similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). Seventy-five percent of our patients returned to work within six months at an average of five months. Three patients developed a superficial wound infection. Age, energy of injury, time to surgery, time spent in plaster and time to commencing physiotherapy had no significant bearing on functional outcome. However, early weightbearing at six weeks positively influenced outcome with all four scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of subtalar joint mobility (r=−0.74, p=0.001). Conclusions. We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint

To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFS), a model was constructed based on a randomized clinical trial. Model outputs were costs and quality-adjusted life years (QALYs). When a societal perspective was taken (i.e. productivity losses were included), operative management was less costly and more effective than non-operative care. Sensitivity analysis revealed that cost-effectiveness was highly dependent on the estimates of productivity losses. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for an incremental gain of .06 QALYs, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFs). A decision tree was constructed to model the effect on costs and quality-adjusted life years (QALYs) of operative versus non-operative management for DIACFs. Complication rate, fusion rate, patient survival and utilities, and productivity losses were estimated from a recent prospective randomized control trial. Four-year costs were estimated from the center treating 73% of the patients in the trial. A societal perspective was used. Future costs and benefits were discounted at 5% and reported in 2002 Canadian Dollars. One-way and multi-way sensitivity analysis was performed on all variables using plausible ranges. When productivity losses were included, operative management was less costly ($13,000 saving) and had a gain of .06 QALYs (based on improvements in health related quality of life), making it the dominant strategy compared to non-operative treatment. The cost-effectiveness was most sensitive to the return to work estimates. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for a .06 QALY gain, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. The treatment of the DIACF has long a source of uncertainty in orthopedic surgery. A recent prospective, randomized, trial concluded that operative management provided no improvement over non-operative care. The cost-effectiveness of operative management indicates that it is a moderately economically attractive treatment (a CU ratio of < $50,000). Further exploration of the impact of productivity losses is required. Funding: Dr. Brauer is supported by a grant from Alberta Heritage Foundation

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders’ type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain. In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum

Aim. The optimal treatment of displaced intra-articular calcaneal fractures (DIACF) remains controversial. The operative treatment group has better anatomical recovery, functional outcome scores and less pain than non operative treatment patients, but it may lead to a higher incidence of complications, such as delayed wound healing and surgical site infections. The aim of this study was to analyze the prophylactic effect using a biphasic bone substitute (BS) eluting antibiotic on calcaneal implant-related infections. Methods. We conducted a retrospective non-randomized review of all patients with DIACF (type Sanders 2, 3, 4) from 2009 to 2017; 103 calcaneal fractures of 90 patients (13 bilaterally) were treated with plates. All cases received the same systemic antibiotic prophylaxis; BS was used on more complex cases with large bone defect and BS was added with antibiotic on higher risk patients. We collected data including complications: major (deep infections, osteomyelitis) and minor complications (wound dehiscence, superficial infection). We considered the absence of deep infections after 6 months. We compared statistically the outcomes of 3 operative groups: the first was treated with plates only (A), the second with plates and BS (B) and the third with plates added with BS eluting antibiotic (vancomicine or gentamicine) (C). Results. We examined 99 cases (group A: n33, B: n52, C: n14), 4 patients were lost; the mean age was 47,8 years (range 18–83 years). Minimal follow up was 6 months (range: 6 – 42 months). We have observed 8 (8,1%) implant-related infection (A:4, 12,1%; B:4, 7,7%), 2 (2%) superficial infection (B:2, 3,8%), 20 (20,2%) wound healing defects (A:11, 33,3%; B:7, 13,5%; C:2, 14,2%). We found a relevant reduction of the rates in the group C regarding the major complications without a statistic evidence. Conclusion. The three groups are uneven; particularly the group C has a high concentration of more severe risk patients. The low number of cases in the group C, which limited the statistic evidence, represents a second limit. The absence of major infection on group C found in this study, needs larger data to confirm this result. The open surgery has an intrinsic rate of skin complications but the use of BS eluting local antibiotic is an additional tool to manage difficult complex fractures and to prevent implanted-related infection, inhibiting bacterial colonization and biofilm protection, particularly in those patients that have suffered from a minor complication, which could lead to a deep infection

Since 2008 the improvised explosive device has been responsible for a significant proportion of injuries sustained whilst on operational duty in Afghanistan. Vehicles have been developed and adapted to offer maximal protection to service personnel. As a result of the decrease in mortality, there has been an increase in the severity of injuries to the lower limb. Hind-foot injuries are a difficult cohort of injuries to treat successfully. Those that are amenable to reconstruction carry a significant morbidity, which may result in either early or delayed amputation. There has been a new injury pattern to the lower limb, not previously described in the medical literature. This pattern consists of a displaced intra-articular calcaneal fracture, distal third tibial fracture and midfoot injury within the same limb. We believe the combination of the three injuries form the “unhappy triad of the ankle”. Each of the injuries is individually reconstructable, but the combination of all three primary amputation should be considered as part of the surgical options