BACKGROUND:The aim of this study was to evaluate clinical outcomes after surgery for displaced intra-articular fractures using an external fixator and minimal internal fixation. METHODS:In this retrospective observational study, a total of 39 patients (32 [82%] men and 7 [18%] women) with 48 displaced intra-articular calcaneal fractures were included. An extended lateral approach was used to stabilize fractures using multiple sagittal plane screws, axial percutaneous threaded Kirschner wires for the frontal fracture plane, and an external fixator for reduction assistance and maintenance. The following variables were assessed: preoperative and postoperative Böhler's angle; calcaneal length, height, and width; postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores; and complications. Mean duration of follow-up was 74 ± 26 months. RESULTS:The mean time from surgery to external fixator removal was 12 ± 1 weeks. The mean preoperative Böhler's angle (-3 ± 21 degrees), calcaneal length (7.9 ± 0.6 cm), and calcaneal height (3.6 ± 0.5 cm) were significantly increased (P < .05) at final follow-up (28.3 ± 6.5, 8.3 ± 0.6, and 4.5 ± 0.5, respectively), whereas the mean preoperative calcaneal width (4.2 ± 0.5) was significantly decreased from the final follow-up mean (3.8 ± 0.5). There were no significant differences between any of the normal and postoperative measures. The mean AOFAS score was 82 ± 12. Complications included superficial pin tract infection (n = 7, 15%), superficial wound edge necrosis (n = 4, 8%), and deep infection (n = 2, 4%). CONCLUSION:Our findings suggest that use of an external fixator with minimal internal fixation is an effective option for treating displaced intra-articular calcaneal fractures. LEVEL OF EVIDENCE:Level IV, retrospective case series.

BACKGROUND:Displaced intra-articular calcaneal fractures are challenging injuries, and there is debate regarding the best method of treatment. PATIENTS AND METHODS:Between January 2018 and January 2021, a prospective study was conducted on 46 patients with 56 displaced intraarticular calcaneal fractures that were treated with minimally invasive fixation using Kirschner wires (KWs) through the sinus tarsi approach. RESULTS:The mean follow-up period was 22.36 months. The American Orthopaedic Foot and Ankle Society (AOFAS) score was adopted as a method of clinical evaluation; the mean AOFAS score was 78.4. All cases showed radiographic evidence of adequate healing, with no collapse till the final follow-up. Complications included persistent pain, subtalar arthritis, deep infection and superficial pin site infection. CONCLUSION:The use of the sinus tarsi approach and percutaneous KWs represents a minimally invasive approach which expands the indications of surgery for displaced intra-articular calcaneal fractures with fewer treatment-related complications. Level of evidence (4) case series. Trial registration This study has been approved by the ethical research committee of the Faculty of Medicine, Tanta University, under the code: 35901/10/22.

BACKGROUND::We compared the radiographic results and clinical outcomes of patients operated on via the extended sinus tarsi approach (ESTA) and the extended lateral approach (ELA) for treatment of displaced intraarticular calcaneal fractures. METHODS::We retrospectively studied the utility of the ELA (46 patients, 52 feet) and the ESTA (56 patients, 64 feet) in patients operated on between January 2009 and March 2015. We evaluated pre- and postoperative x-rays and computed tomography (CT) data. Pain, patient-reported functional outcomes, satisfaction, and postoperative complications were investigated at the 3-year follow-up. RESULTS::Neither the postoperative nor 3-year follow-up Böhler angles, nor the calcaneal width, differed significantly between the 2 groups (both P > .05). However, the maximum step-off of the posterior facet on the 3-month CT follow-up of the ESTA group was significantly less than that of the ELA group ( P < .05). We found no significant between-group differences in terms of postoperative translation ( P = .232) or angulation ( P = .132) of the sustentacular fragment on the 3-month CT follow-up. At the 3-year follow-up, we found no significant between-group difference in the mean visual analog scale pain score at rest ( P = .641) or during weightbearing ( P = .525). We found no significant between-group difference in the Foot Function Index (FFI) ( P = .712) or self-reported satisfaction ( P = .823). The ELA group experienced significantly more wound complications ( P = .041) and nonunions ( P = .041) than the ESTA group. Four instances of superficial peroneal nerve injury were reported in the ESTA group ( P = .127). CONCLUSION::Compared with the ELA, the ESTA afforded comparable, favorable radiological results and clinical outcomes, associated with fewer wound complications and nonunions. We suggest that the ESTA is an effective operative option when treating displaced, intraarticular calcaneal fractures. LEVEL OF EVIDENCE::Level III, comparative study.

Fractures of the calcaneal tuberosity are relatively uncommon and are seen most frequently in elderly and diabetic patients. These injuries are typically avulsion fractures caused by concentric contraction of the gastrocnemius-soleus muscle complex. Displacement of these fractures can compromise the skin over the posterior aspect of the heel; therefore, early recognition and management are imperative. Surgical management of calcaneal tuberosity fractures requires reduction and stable fixation of the displaced fragment. When the patient has preexisting tightness of the gastrocnemius-soleus complex, successful management must also address this pathology to improve outcome.

BACKGROUND:Operative intervention is an accepted treatment for fractures of the calcaneus. However, the literature discourages surgery for these fractures in the elderly. The purpose of this paper was to review the outcomes of surgical treatment of displaced fractures of the calcaneus in elderly patients. METHODS:Between November 1987 and June 2000, forty-two patients (forty-four fractures) who were sixty-five years of age or older underwent surgery for a calcaneal fracture. The mechanism of injury, fracture pattern, and medical comorbidities were recorded. Thirty-five patients with a total of thirty-seven fractures were available for follow-up, which was conducted with physical and radiographic examinations and outcomes assessment with the Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and the Short Musculoskeletal Function Assessment survey. RESULTS:The minimum duration of follow-up was two years, and the average duration was forty-four months. All but one fracture (97% of the fractures) healed at an average of 110 days. The average active range of motion was 38 degrees of plantar flexion, 10 degrees of dorsiflexion, 16 degrees of inversion, and 11 degrees of eversion. The average American Orthopaedic Foot and Ankle Society score was 82.4 points, the average SF-36 score was 52.8 points, and the average Short Musculoskeletal Function Assessment score was 20.4 points. Posttraumatic subtalar arthritis developed in twelve patients. There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully. CONCLUSIONS:Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care.

BACKGROUND:Calcaneal fracture-dislocations are rare but potentially disabling injuries that are regularly overlooked at first presentation. To date, only about 50 cases have been reported in the literature. METHODS:Over a period of 8 years, 10 patients (average age 61.7 years) with acute fracture-dislocations of the calcaneus were treated at 2 level 1 trauma centers. The calcaneocuboid joint was involved in 9 patients. There was a concomitant fracture of the lateral talar process and of the tip of the distal fibula in 7 patients each. Open reduction and internal fixation was performed in 9 of 10 patients via an oblique lateral dislocation approach. One patient underwent primary subtalar fusion. All patients were seen for clinical and radiographic follow-up at an average of 3 years using patient-reported outcome scores. RESULTS:Anatomic fixation was achieved in all patients as judged by postoperative computed tomographic imaging. In the 9 patients treated with internal fixation, the Foot Function Index averaged 12.8, the EuroQol 5D score averaged 0.89 and the visual analog scale score for patient satisfaction averaged 79.3 at final follow-up. Signs of mild subtalar arthritis were seen in 6 patients. No secondary subtalar fusions were needed. CONCLUSION:When recognized and treated early, prognosis of calcaneal fracture-dislocation was favorable. A dislocation approach starting over the distal fibula, continuing over the sinus tarsi, and extending toward the calcaneocuboid joint allowed for adequate visualization of the subtalar joint and treatment of all components of the injury. LEVEL OF EVIDENCE:Level IV, retrospective case series.

Calcaneal fractures are potentially devastating injuries. To effectively manage calcaneal fractures, surgeons must understand the anatomy of the calcaneus as well as the surgical techniques necessary to restore normal biomechanics of the foot. Surgeons also must understand calcaneal fracture patterns and classifications; initial management techniques, surgical indications and rationale, temporizing management techniques, surgical approaches, definitive management techniques, and postoperative management for calcaneal fractures; as well as outcomes and common complications of calcaneal fractures.

Calcaneal fractures are infrequent but, more often, serious. We report a series of 29 cases of calcaneal fractures surgically treated in the Orthopaedics and Traumatology in the University Hospital (CHU) Hassan II of Fez. This retrospective study aims to present the principles and to evaluate the results of surgical treatment for articular fractures of the calcaneus, in comparison with conservative treatment. Our study included 21 men and 8 women, the average age was 21-61 years. Etiology was dominated by road traffic accidents as wel as by falls from a high place. The evaluation of the lesions was based on the classification of Duparc. The treatment was based on open reduction associated with Y-plate osteosynthesis or one-third tubular plate osteosynthesis using triangulation. Clinical results were evaluated on the basis of kitaoka score, with an average follow-up period of 24 months. 86% of patients have had good medium-term results.

PURPOSE:To compare the efficacy of percutaneous poking reduction and fixationwith open reduction and fixation in the treatment of displaced calcaneal fractures. METHODS:Reports of studies using case-controlled trials (CCT) to compare the percutaneous poking reduction and fixation with the open reduction and fixation in the management of calcaneal fractures were retrieved from the Cochrane Library, PubMed Database, CNKI, Chinese Biomedical Database, Wanfang Data (from January of 2005 to August of 2015). Methodological quality of the trials was critically assessed, and relevant data were extracted. Statistical software Revman 5.0 was used for data-analysis. RESULTS:Fifteen articles were included in the meta-analysis. Comparison of the efficacy of percutaneous poking reduction and fixation with open reduction and fixation in the treatment of calcaneal fractures revealed statistical significance in the incidence of complications after operation [RR = 0.32, 95% CI (0.20, 0.5), p < 0.05]. However, there were neither statistical significance in the degrees of recovery for calcaneal Bohler angle [WMD = -1.65, 95% CI (-3.43, 0.14), p > 0.05] and calcaneal Gissane angle [WMD = -3.21, 95% CI (-6.75, 0.33), p > 0.05], nor statistical significance in the rate of good foot function after operation [RR= 0.95, 95% CI (0.90, 1.00), p > 0.05]. CONCLUSION:For the treatment of calcaneal fractures, percutaneous poking reduction and fixation is su- perior to open reduction and fixation in terms of the incidence of postoperative complications. But both techniques can obtain satisfactory clinical function.

OBJECTIVE:To investigate clinical effect of percutaneous reduction combined with internal fixation of calcaneal nail in treating Sanders typeⅡto Ⅲ calcaneal fractures. METHODS:From July 2017 to August 2019, clinical data of 98 patients with Sanders typeⅡto Ⅲ calcaneal fractures treated were retrospectively analyzed, and divided into observation group and control group according to different surgical methods. In observation group, there were 35 males and 21 females, aged from 23 to 58 years old with an average of (34.50±7.81) years old;29 patients with Sanders typeⅡand 27 patients with Sanders type Ⅲ;30 patients on the left side and 26 patients on the right side;the time from fracture to operation ranged from 1 to 4 days with an average of (3.45±0.54) days;and treated with percutaneous reduction combined with internal fixation of calcaneal nail system. In control group, there were 25 males and 17 females, aged from 25 to 60 years old with an average of (35.27±7.64) years old;23 patients with Sanders type Ⅱ and 19 patients with Sanders type Ⅲ;24 patients on the left side and 18 patients on the right side;the time from fracture to operation ranged from 2 to 5 days with an average of (3.42±0.62) days;and treated with open reduction and internal fixation. Operation time, blood loss, hospital stay, fracture healing time, and postoperative visual analogue scale (VAS) at 1 day, preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Böhler angle, Gissane angle and calcaneus width, and postoperative complications were compared between two groups. RESULTS:All patients were followed up from 13 to 18 months with an average of (15.6±2.2) months. There were significant differences in operation time, blood loss, hospital stay, fracture healing time and postoperative VAS at 1 day between two groups (<0.05). There was statistical difference in postoperative AOFAS score at 12 months between two groups (<0.05), and AOFAS score at 12 months after operation was higher than that before operation (<0.05). According to AOFAS score, 21 patients got excellent result, 30 good and 5 moderate in observation group, and 10 excellent, 22 good, 7 moderate and 3 poor in control group, which had statistical difference between two groups (<0.05). Postoperative Böhler angle, Gissane angle and calcaneus width at 6 months were better than that before operation between two groups(<0.05). One patient in observation and 20 patients in control group occurred skin numbness after operation, and 14 patients occurred skin necrosis in control group, there were obvious difference between two groups(<0.01). CONCLUSION:Compared with open reduction and internal fixation, percutaneous reduction combined with internal fixation system in treating Sanders typeⅡto Ⅲ calcaneal fractures is feasible for fracture repair without waiting for foot deswelling, which could accurately restore normal shape and position of the fractured heel bone, completely eliminate fracture malunion, and reduce postoperative complications. Therefore, it could shorten operation time, hospital stay, fracture healing time, reduce amount of blood loss, promote postoperative recovery, and less complications, high safety, which could be used as a choice of orthopedic surgery for foot and ankle trauma.

This review article covers the use of small incision open reduction and internal fixation for the treatment of the intra-articular calcaneal fracture. The central concept is to match the fracture anatomy with the appropriate surgical approach. Covered first is the mechanism and pathoanatomy, which produces a stereotypical pattern. The major components to address include the posterior facet, superomedial fragment, anterolateral fragment, and tuberosity. The choices of approaches discussed are percutaneous, lateral, medial, and combined. A reduction strategy follows that of the extensile approach, and the goal is total anatomic restoration. Fixation consists of small fragment implants, minifragment implants, and K wires. Specific fracture patterns amenable to selective small incision approaches are described. Detailed surgical strategies are provided. These techniques will be placed in the context of pertinent literature on this subject.

Significant progress had been made in the management of calcaneal fractures. This is reflected in the marked decrease in complication rates associated with the current intervention of these potentially devastating injuries. The treatment priorities that are key to achieve best results in a displaced calcaneal fracture are an anatomic reconstruction of the entire calcaneus including articular surfaces, height, alignment, and length, with a function directed postoperative management. The value of these priorities is confirmed by long term followup results. Conservative treatment should be considered only in cases of extraarticular fractures, in cases of minor displaced intraarticular fractures in patients who are nonambulatory, and in cases where there is a clear contraindication for surgery. An anatomic reconstruction of an os calcis fracture is difficult to obtain. In two-part fractures, according to the classification described by Sanders et al, an anatomic reduction is obtainable in more than 80% of cases. However, if the articular cartilage damage that is typically present is considered, a 70% rate of good to excellent clinical results is more realistic. In three-part fractures, anatomic reduction is attainable in approximately 60% of cases with a 70% rate of good results. These two subgroups comprise approximately 90% of all calcaneal fractures. It has been put into practice recently to optimize the extended lateral approach using posteromedial and anterolateral windows, so that an anatomic reduction can be achieved in more than 60% of os calcis fractures considered as Type III according to the classification described by Sanders et al. Additional scientific work in this area of trauma orthopaedics would benefit most from a general consensus on a fracture classification system and on a clinical scoring system, with 5-year followup studies using these treatment methods and evaluation systems.

INTRODUCTION:This study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period. METHODS:Patients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS). RESULTS:In total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF-36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3-7) and 6 months (IQR, 3,25-6,75) for PSF and ORIF treated, respectively CONCLUSION: This long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.

OBJECTIVES:To assess the outcome of the sinus tarsi approach and C-Nail fixation of displaced intra-articular calcaneal fractures (DIACFs). DESIGN:Prospective study. SETTING:University Trauma Department. PATIENTS:Sixty-four patients (mean age 44.3 years, 48 men and 16 women) with 75 DIACFs were treated between October 1, 2016 and December 31, 2018. INTERVENTION:In all cases, the posterior facet was reduced through the sinus tarsi approach and fixed with one or 2 screws. After reducing all fragments to the articular block, the final fixation was performed percutaneously with C-Nail, locked with 6 screws. MAIN OUTCOME MEASUREMENTS:Patients were assessed for restoration of the Böhler angle, complications, and overall fracture reduction. To assess the functional outcome, we used the Mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score and Maryland Foot Score after 12 months. RESULTS:The Böhler angle improved from -0.5 degrees preoperatively to 28.6 degrees postoperatively. The articular step-off was reduced from 5.4 mm preoperatively to 0.6 mm postoperatively. The postoperative radiologic calcaneal score was 2.9, on average. Superficial wound edge necrosis was seen in 3 patients (4%) and superficial infection was observed in one (1.3%). After a 1-year follow-up, we recorded a mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score of 90.2 and a mean Maryland Foot Score of 91.2. CONCLUSIONS:After obtaining an anatomic reduction of the articular surface of the posterior facet with lag screws, the C-Nail represented a viable alternative to plate stabilization in the treatment of DIACFs, combining primary stability with low soft tissue complications. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The optimal treatment of calcaneal fractures (CF) is currently controversial and is still under debate. It is well established that conservative treatment of these fractures is associated with poor results. Several surgical techniques are described in the literature; however, there is no consensus on which of these is more effective. The main goals of surgery are to restore the subtalar joint congruence, and calcaneal width, height, shape and alignment, thus avoiding medial and lateral impingement and enabling the patient to resume a normal lifestyle. ORIF is the most popular technique for these fractures, but it is associated with high rates of wound complications, hardware failure and infections. Several minimally-invasive techniques have been developed recently for the treatment of CF, with the common aim to be as simple, effective and inexpensive as possible and to reduce surgical times, complications and length of hospital stay.

The choice of the best treatment method for displaced intra-articular calcaneal fractures (DIACFs) remains controversial. Using a network meta-analysis, this study aims to evaluate the radiographic characteristics, clinical effectiveness, and incision complications of nonoperative treatment, open reduction and internal fixation, minimally invasive reduction, and fixation. The studies were abstracted from Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software. Seventeen RCTs involving 1297 participants with 1354 fractures were included. A total of 5 treatments-extensile lateral approach (ELA), minimally invasive longitudinal approach (MILA), sinus tarsi approach (STA), percutaneous reduction and fixation (PRF), and nonoperative treatment-were analyzed. The treatments were ranked based on Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of recovery of Böhler's angle, the treatments were ranked as follows: MILA (75.3%), PRF (68.3%), ELA (54.7%), STA (51.6%), and nonoperative (0%). In terms of Böhler's angle after treatment, the treatments were ranked as follows: PRF (65.3%), ELA (64.0%), STA (63.5%), MILA (56.9%), and nonoperative (0.2%). In terms of American Orthopaedic Foot & Ankle Society score, the treatments were ranked as follows: PRF (87.0%), MILA (52.9%), STA (46.6%), ELA (40.4%), and nonoperative (23.1%). In terms of excellent and good satisfaction ratings, the treatments were ranked as follows: STA (96.2%), ELA (66.8%), PRF (34.9%), and nonoperative (2%). In terms of incision complications, the treatments were ranked as follows: PRF (84.1%), MILA (80.0%), STA (35.8%), and ELA (0.1%). Given the good results of the minimally invasive approach in terms of radiographic characteristics, clinical effectiveness and incision complications, the minimally invasive approach is a good alternative for DIACFs. More randomized controlled trials focused on DIACFs are needed to further examine this conclusion.