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

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