| Calcaneal fractures are the most frequent tarsal bone fracture and represent2%of all adult fractures. About75%of all calcaneal fractures in adults are displaced intra-articular fractures involving the subtalar joint. There have been dramatic changes in management protocols as our understanding of the fracture has evolved. The primary goal of fracture treatment has changed from the prevention of life-threatening infections which is frequently through partial or total calcanectomy during the18th and19th centuries into restoration of the functional outcomes as far as possible and reducing the long-term complications such as heel pain, lateral impingement syndrome and subtalar joint arthritis. Despite controversy related to optimal management of intraarticular fractures still persists, surgery treatment of the fractures has been accepted by most surgeons and has been improved greatly over the past20years because of the improvement of surgical techniques, the use of high-quality intraoperative imaging modalities to assess the quality of reduction, and effective preoperative management of soft tissue. Currently, numerous studies with large patient cohorts have demonstrated that surgery treatment predict higher functional outcomes and a lower incidence of posttraumatic subtalar arthritis.The goal of operative treatment of calcaneal fractures is to obtain the best possible reduction of the articular surfaces, to restoration of heel height and length, restoration of mechanical axis of the hindfoot, and to hold the reduction with stable internal fixation. These goals must be balanced with the need to minimize the operative risks, especially the risk of wound healing complications. Operative management can consist of reduction through an extended open incision, lateral and medial approaches, limited incision or percutaneous techniques. The extended lateral approach with L-shaped incision has been the most frequently used operative technique as better visualization and reduction of fracture fragments. Besides, laterally based plate is commonly accepted to give the most rigid fixation. However,the prolonged operating time and extensive surgical wound exposure will significantly increase the incidence of wound complications. Folk reported25%of wound complications in his study, of which21%required surgical intervention. Therefore, a number of authors have proposed closed reduction, minimally invasive fixation, and various internal fixation devices to minimize soft tissue problems in the treatment of calcaneal fractures.One controversial issue involving management decisions and outcome evaluation has been the inadequate classification systems available. For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Many classification systems have been advocated in the past, however, most studies have found reliability and reproducibility to be poor for fracture classification schemes. Many of these classifications are based on X ray-based evaluations of the fracture patterns, have given a poor exposure of the subtalar joints. With the introduction and development of the CT scan technique, classification methods based on the status of the intra-articular elements are now the most accepted. But, the CT scan cannot provide the overall condition of the calcaneal fracture. Thus, Professor Zhang Yingze proposed the concept of calcaneal bony destructive injuries according to the clinical features of the calcaneus which was so severely destroyed that it is impossible to reduce anatomically with surrounding soft tissue intact.Our minimally invasive technique was proposed including small lateral incision, percutanous leverage, fixation using anatomic plate and compression bolts. Small lateral incision and percutanous leverage can minimize the soft tissue associated complications, fixation using anatomic plate and compression bolts can avoid the inadequate reduction of the medical wall and the poor restoration of the hell width. The study were to compare the biomechanical stability obtained using our technique and the conventional with an anatomic plate and cancellous screws in the fixation of cadavers calcaneal fractures, to compare the clinical outcomes of our surgical technique with traditional open reduction and internal fixation with anatomical plate and screws for displaced intra-articular calcaneal fractures, and a new concept of calcaneal bony destructive injuries was proposed and the preliminary outcomes of such injuries treated by an anatomic plate and compression bolts was present.Part1A biomechanical comparison of conventional versus an anatomic plate and compression bolts for the fixation of intra-articular calcaneal fracturesObjective:The purpose of this study was to compare the biomechanical stability obtained using our technique featured an anatomical plate and compression bolts and the conventional with an anatomic plate and cancellous screws in the fixation of intraarticular calcaneal fractures.Methods:Eighteen fresh frozen lower limbs cadavers were used to created a reproductive Sanders type-Ⅲ calcaneal fracture pattern with osteotomy. The calcaneus fractures were randomly selected to be fixed either using our anatomical plate and compression bolts or conventional anatomic plate and cancellous screws. Reduction of fracture was evaluated through X radiographs. Each calcaneus was successively loaded at a frequency of1HZ for1000cycles through the talus using an increasing axial force20N to200N and20N to700N, representing the partial weightbearing and full weightbearing respectively, and then the specimens were loaded to failure. Data extracted from the mechanical testing machine were recorded and used to test for difference in the results with the Wilcoxon signed rank test.Results:No significant difference was detected between our fixation technique and conventional technique in displacement during20-200N cyclic loading (p=0.06), while the anatomical plate and compression bolts showed a great lower irreversible deformation during20-700N cyclic loading (p=0.008). The load achieved at loss of fixation of the constructs for the two groups were significant different:anatomic plate and compression bolts at3839.6±152.4N and anatomic plate and cancellous screws at3087.3±58.9N (p=0.008). The difference between the ultimate displacements was not significant (p=0.767).Conclusion:Our technique featured anatomical plate and compression bolts for calcaneus fracture fixation was demonstrated to provide biomechanical stability as good as or better than the conventional with anatomic plate and cancellous screws under the axial loading. The study supports the mechanical viability of using our plate and compression bolts for the fixation of calcaneal fracture.Part2A minimally invasive approach featured an anatomic plate and compression bolts to treat displaced intra-articular calcaneal fracturesObjective:Because of improvements in preoperative evaluation, the use of intraoperative imaging to verify the quality of reduction, and advancements in surgical techniques that include specialized hardware and soft tissue management, operative intervention has been shown to be effective at treating fractures of the calcaneus. The purpose of this paper was to compare the outcomes of our surgical technique featured an anatomic plate and compression bolts with traditional open reduction and internal fixation with AO plate and screws for displaced intra-articular calcaneal fracturesMethods:We retrospectively analyzed106patients (118feet,23female and83male) in our hospital for displaced intra-articular calcaneal fractures from January2007to April2010. Of them,64patients(71feet) were treated with an anatomic plate and multiple compression bolts through a small lateral incision (the compression group);42patients(47feet) were treated with traditional open reduction and internal fixation, which involved using AO anatomic plate and screws through standard L-shaped extended lateral approach (the tradition AO group). The operations were performed usually at5.4days (range, from1to16days) after the injury. The age, gender, mechanism of injury, pre-existing comorbidities, associated injuries, the Sanders type of fracture, and the length of stay were collected and analyzed. The average time of surgery, the Bohler angel, the quality of operation, and any postoperative complications were also analyzed and compared between the two groups. During following-up, radiographs of the calcaneus were made to assess whether the fixation had failed and whether the fracture had healed. The condition of the subtalar joint, pain and functional result were evaluated by using the American Orthopaedic Foot&Ankle Society (AOFAS) scores. Subsequent subtalar arthrodesis and early implant removal were performed if indicated. Routine hardware removal was scheduled for all patients at1year follow-up.Results:all the patients were followed for an average of26months (range, twelve to fifty months). No significant differences between the two groups were detected with regard to the age at the time of the injury, gender, mechanism of injury, pre-existing comorbidities, associated injuries, the Sanders type of fracture, and the length of stay (p>0.05for all). There was no difference in the mean interval from the initial injury to definitive intervention between the two groups, but the operative time in the compression group was much shorter than the tradition AO groups (84±21.09mins versus104.26+25.33mins, p<0.05). Although the Bohler angels were improved greatly in both groups, no significant differences were detected between the compression group and the tradition AO group (26.6±5.6°versus28.1±+7.8°, p>0.05). Wound associated complications were7/71(9.86%) in the compression group, without deep infections, while12patients in the tradition AO group had wound associated complications and3cases had the hardware removed earlier due to deep infection. The average time after surgery to start weight-bearing exercise is4.66weeks in compression group and9.60weeks in tradition group (p<0.05). Posttraumatic arthritis was indentified in9patients of the compression group and7patients of the tradition AO group(p>0.05). The mean AOFAS score is higher in the compression group than in the tradition AO group, but the difference is not statistically significant (85.75±9.36versus84.29±9.51, p>0.05).Conclusion:The study results suggest that the minimally invasive approach featured an anatomic plate and compression bolts to treat displaced intra-articular calcaneal fracture can equivalent functional outcome with, if not better than the open reduction and internal fixation with trational L-shaped lateral approach. It can reduce the soft tissue associated complications and specifically the rigid internal fixtion allows early weight-bearing exercise, which will improve the therapeutic effect. It is a good alternative to treat displaced intra-articular calcaneal fractures.Part3Introduction of the concept of calcaneal bony destructive injuries and its treatment algorism with an anatomic plate and compression boltsObjective:The purpose of this study is to introduce the concept of calcaneal bony destructive injuries, and present the preliminary results of such injuries treated by an anatomic plate and compression bolts, following by early exercise.Methods:From April2004to October2006,12patients with calcaneal bony destructive injuries were identified and treated in our department. When the soft tissue swelling subsided, the patients were treated by internal fixation with an anatomic plate and three or four compression bolts. The reduction was achieved by percutaneous distraction and leverage. Postoperative radiographs were taken to assess the reduction. Supervised functional exercise began48hours after the operation. Progressively earlier weight-bearing commenced4weeks after surgery to mould the subtalar joint. Postoperative complications were collected. During following-up, the functional recovery was evaluated by using the American Orthopaedic Foot and Ankle Society (AOFAS) scores.Results:Ten male and two female with an average of39years (range, from24to56years) were included in the study. According to Sander’s classification, all patients were categorized as Type Ⅳ. There was an average of7.6days (range, from6to11days) before the operations were performed. The average operating time was78mins (range,56to93mins). The restoration of the height, length, width, normal outline of the calcaneus and the mechanical axis of the hindfoot were demonstrated on the radiographs. The postoperative Bohler angle of the affected calcaneus was24.5±3.7degrees. The reduction of the posterior facet was regarded as anatomical(less than3 mm displacement) in seven patients and more than3mm displacement was noted in the other five patients. Postoperative superficial infections occurred in one patient. All patients were followed up for an average of76months (range,66to87months). At the latest follow up, there was mild pain in two cases and moderate pain in one case after two-kilometer walking. However, no subtalar arthrodesis was required until the last follow up. The mean AOFAS score was82(range,65to94), and there were four of feet with excellent results, five with good results, two with fair results and one with poor result.Conclusion:The concept of calcaneal bony destructive injuries was first proposed. The calcaneal bony destructive injuries are not an absolute indication of primary arthrodesis. Anatomic plate and compression bolts for the treatment of calcaneal bony destructive injuries in combination with early exercise to mould the subtalar joint is a reasonable treatment alternative. |
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