| Calcaneal fractures account for approximately 2% of all fractures, and are the most common of tarsal bone fractures. It is often stated that these fractures are mainly occupational injuries, which occur during falls from height in young males, and cause significant long-term disability. As a result, it may place a considerable economic burden on the individual and related community, which is disproportionate to their prevalence. Fractures, especially the displaced intra-articular fractures of the calcaneus remain among the most challenging of fractures for the orthopedic surgeon to effectively manage. Open reduction and internal fixation through an extended L-shaped lateral approach was once the most commonly used method in clinical practice, however, the high wound related complication rate has been reported to be an inevitable shortcoming for this approach. To avoid the feared soft tissue complications, several minimally-invasive and percutaneous approaches have been proposed throughout the history of calcaneal fracture treatment and gained popularity for selected injury patterns. But the inadequate exposure and poor fixation strength of the calcaneus is still a problem for most of the minimally invasive techniques. In an effort to increase the strength of fixation, shorten the operative time and decrease the wound complications at the same time, a minimally invasive approach that features a small longitudinal lateral incision on the hindfoot and the use of a plate and compression bolts was introduced by our group in 2004. Previous studies carried out by our team proved that the functional outcome after the minimally invasive longitudinal approach (MIL A) was as good as, if not better than, the traditional L-shaped extensile lateral approach with the benefit of a significantly lower complication rate. The current study, as an ongoing part of previous studies, was aimed to further evidence the outcomes of MILA and proof the clinical value of axial view of calcaneus.Lateral and axial views are the standard plain radiographs in assessing calcaneal fractures in each phase of the treatment. Lateral view has gained popularity in diagnosis of calcaneal injury. Bohler angle and Gissane angle can also be assessed with a lateral view, which are the two typical indexes used to diagnose and evaluate heel fracture. However, with the development of imaging technology, some believe axial view can be abandoned for its useless to diagnosis and treatment, since what can gain from axial view can also be offered by CT scans and even better. 156 unilateral calcaneal fracture patients were included in the study to analyse the value of axial view in diagnosis, pre- and postoperative stage of the therapeutic process, and figure out whether axial view is still a diagnostically useful method in dealing with calcaneal fracture.Minimally technique has been a tendency for treating calcaneal fractures in recent years, and various minimally invasive approaches have been introduced to minimize the wound complication rate. Some of these approaches have been proved effective in lowering the prevalence of wound-related complications. The sinus tarsi approach has become one of the most frequently applied minimally invasive approaches because of its ability to provide adequate exposure for the posterior facet, the anterolateral fragment, and the lateral wall. We designed a perspective trial in the current study to compare the clinical outcomes of the widely used sinus tarsi approach with those of the minimally invasive longitudinal approach. At the same time, four factors of the patients that may influence the functional outcome of displaced intra-articular calcaneal fractures were selected for evaluation:patient age, surgical technique (the minimally invasive longitudinal approach or the sinus tarsi approach), Sanders classification, and the time to the start of weight-bearing activity. Multinomial linear regression was used to analyze the relationship between functional recovery and these four factors.Part 1 The important role of the axial view of calcaneus in dealing with calcaneal fracturesBackground:The study aimed to analyze the value of axial view in different phases of treatment and demonstrate whether axial view is still useful in dealing with calcaneal fracture.Methods:One hundred and fifty six patients with suspected unilateral calcaneal fractures were enrolled in the study, and all of them signed the informed consent. Two separate assessments were held on two occasions respectively with a three weeks gap. Lateral views were assessed firstly and lateral combined with axial views were assessed three weeks later. Each of the 156 sets was evaluated by one of 6 surgeons randomly. Sensitivity and specificity value were compared between the two assessments. A new value angle Z was introduced into the study which may be related to long-term lateral pain after calcaneal fractures. Axial views of the 156 unaffected feet were obtained and Z values of them were measured and recorded at the same time. Data of 31 patients who confirmed their lateral hindfoot pain after calcaneal fractures were reviewed. Liner regression was employed to analyze the relationship between angle Z and severity of lateral pain.Results:Sixteen patients were excluded due to satisfied axial view was hard to obtain. The remaining 140 patients 122 male and 18 female with a mean age of 39.2 years (range,19-61 years) were eventually included into the study. According to the comparative results of the two assessments, without axial view, specificity value will be significantly lower in diagnosing calcaneal fractures (p<0.05) and sensitivity value will be significantly lower in distinguishing intra-articular fractures (p< 0.05). The average angle Z value of the 140 unaffected calcaneuses is 99.35±7.73°(range,83.0-119.7°). The 95% confidence threshold of angle Z was estimated from 98.06° to 100.64° (p<0.05). Liner regression shows that the severity of lateral pain will obviously aggravate along with the increase of angle Z value (p<0.05).Conclusions:Axial view is useful in diagnosing a patient with suspected calcaneal fracture especially for distinguishing intra-articular fractures and selection for CT scan. With the introduction of angle Z, axial view can get excellent performance in intra-operative assessment as well as in post-operative follow up procedure. Axial view can still play an irreplaceable role in assessing and evaluating calcaneal fractures, and can combined with lateral view to effectively improve the quality of treatment.Part 2 Displaced Intra-Articular Calcaneal Fractures Treated in a Minimally Invasive Fashion:Longitudinal Approach Versus Sinus Tarsi ApproachBackground:The study aims to assess the clinical outcomes of minimally invasive longitudinal approach (MILA) for displaced intra-articular calcaneal fractures (DIACFs) compared with the sinus tarsi approach (STA).Methods:Patients with DIACFs, who were admitted to the trauma center of our hospital from September 2009, were randomly assigned to be treated via MILA or STA. All patients underwent the same standardized postoperative rehabilitation protocol. Functional outcome was assessed by using the American Orthopaedic Foot & Ankle Society (AOFAS) scores.Results:From September 2009 to April 2010,167 patients met the inclusion criteria and were included into the study. Among them,37 cases were lost to follow-up due to various reasons. The other 130 patients were followed up for an average of 27 months. Clinically,63 patients (69 feet) were treated via MILA (MILA group), and 67 patients (72 feet) via STA (STA group). The two groups were comparable in age, sex, fracture type, and time from injury to operation. The operation time in MILA group was significantly shorter than that in STA group (p<0.05). Wound healing complications were found in 2.9% cases in MILA group and 12.5% in STA group. The average time to start progressive weight-bearing exercise was 5.3 weeks in MILA group and 5.6 weeks in STA group (p>0.05). The good and excellent results in two groups were comparable in Sanders Ⅱ/Ⅲ calcaneal fractures (p>0.05), but the good to excellent rate in STA group is significantly higher for Sanders IV fractures (p<0.05).Conclusions:Outcomes are similar for MILA and STA in the treatment of Sanders Ⅱ/Ⅲ DIACFs, with the benefit of lower complication rate and shorter operation time for MILA. For Sanders IV injury, however, STA is the treatment of choice.Part 3 Analysis for factors affecting outcomes of displaced intra-articular calcaneal fractures after minimally invasive surgical treatmentBackground:The primary purpose of the current study was to investigate whether the suspected factors related to outcomes of displaced intra-articular calcaneal fractures (DIACFs) after minimally invasive surgical treatment.Methods:Patients with DIACFs, who were admitted to the trauma center of our hospital from September 2009, were randomly assigned to be treated via MILA or STA. All clacaneal fractures in both groups were fixed with the same implants-anatomic plates and multiple compression bolts. All patients underwent the same standardized postoperative rehabilitation protocol. The study was approved by the local ethics committee, and each patient signed the informed consent form. Functional outcome was assessed by using the American Orthopaedic Foot & Ankle Society (AOFAS) scores. Multinomial liner regression was performed to identify the 4 potential influencing factors (age, Sanders classification, surgical approach and the time to start weight-bearing exercise) for functional outcomes.Results:From September 2009 to April 2010,167 patients met theinclusion criteria and were included into the study, however,37 caseswere lost to follow-up due to various reasons eventually. The multinomial liner regression analysis was tested to be statistically significant (F=51.72,p<0.05). Three factors, including surgical approach, the Sandersclassification and the time to start weight-bearing exercise, were found tobe associated with the functional outcome (all p<0.05). Conclusions:Severely sanders classification can indicate a poorfunctional outcome of DIACFs. Since restoration of the articular surfaceis a fairly important factor that can improve the function outcomes, highquality restoration of articular surface should be achieved as long as wecan. Early weight-bearing exercise may be a critical factor to improve thefunctional outcomes. |
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