| PART 1 Minimally Invasive Sinus Tarsi Approach with Cannulated Screw Fixation Combined with Vacuum-assisted Closure for the Treatment of Severe Open Calcaneal Fractures with Medial WoundsIntroductionThe incidence of calcaneal fractures accounts for approximately 1-2%of body fractures and around 60%of tarsal fractures.Fractures of the calcaneus are usually due to high-energy longitudinal force,such as that in falling or a traffic accident.According to the current literature,60 to 75%of calcaneal fractures are displaced intra-articular fractures(1-3),which makes treatment of the calcaneus difficult.Calcaneal fractures may often result in significant disability due to pain and chronic stiffness and are typically associated with poor functional recovery due to their complexity.Moreover,approximately 80 to 90%of calcaneal fractures occur in men between 21 and 40 years of age.Previous studies(4-7)reported that the rehabilitation of calcaneal fractures may take 9 months to several years,which in turn brings great economic burden.Open reduction and internal fixation has been used for displaced intra-articular calcaneal fractures since the early 1980s.Currently,for calcaneal fracture of the articular surface,open reduction and internal fixation is generally considered as an effective treatment.However,such treatment have has higher rates of soft-tissue complications,such as dehiscence and infection,which could be as high as 30%(8-10).To reduce the incidence of complications and soft-tissue damage,new surgical techniques,such as minimally invasive incision and percutaneous fixation,are developed(10,11).Currently,treatment of open fractures of the calcaneus remains challenging.Open calcaneal fractures are mostly intra-articular fractures,which are mostly comminuted and with irregular shape,soft-tissue damage around the calcaneus,and intraductal structure damage.Treatment of open calcaneal fractures is particularly complicated in multiple trauma.The incidence of open calcaneal fractures is relatively high,and the treatment of fractures with complications is relatively difficult.Optimizing treatment options and preventing complications are an effective means of obtaining good treatment outcomes(12).Several controversies regarding the treatment of open calcaneal fractures exist.However,early continuous irrigation and debridement,intravenous antibiotics,and fracture fixation have been apparently standardized.Nevertheless,no consensus on the second stage of treatment has been established.Most scholars suggest a definitive fix,which deals with the treatment of tibia pilon fractures(13-18).Open calcaneal fractures account for 3 to 12%of all calcaneal fractures(15.19,20).For the second stage of treatment of open calcaneal fractures,especially in cases of severe soft-tissue injury,conventional lateral enlargement incision may lead to skin necrosis,infection,and even osteomyelitis.Moreover,early complex internal fixation procedures are not suitable for severe open ca.lcaneal fractures(15).Ample evidence shows that minimally invasive approaches for calcaneal fracture reduction and internal fixation provide good imaging performance with good therapeutic outcomes and less wound complications(21).Even for complex calcaneal fractures,minimally invasive tarsal sinus incisions could be employed for adequate exposure to achieve anatomic reduction and strong internal fixation,and excellent or good functional recovery and minimal soft-tissue complications were observed in most patients(22).No comparative study on the treatment using tarsal sinus incision versus lateral enlargement incision in open calcaneal fractures has been conducted.The majority of wounds associated with open calcaneal fractures are located on the medial side.The aim of this study was to investigate the clinical results and advantage of a minimally invasive sinus tarsi approach with cannulated screw fixation combined with vacuum-assisted closure for the treatment of severe open calcaneal fractures with medial wounds.We performed a prospective analysis to compare patients who underwent surgery with plate fixation to those who underwent surgery with minimally invasive cannulated screw fixation.Patients and MethodsPatient GroupsA total of 31 patients(32 feet)with open calcaneal fracture who were admitted to our hospital(the institution of WM)between January 2008 and May 2013 were selected for the study.Inclusion criteria were open calcaneal fractures with medial wounds and Sanders type ?and type ? fractures.The mean age of the patients was 36.3 years(range,22-55 years),and the mean time from injury to surgery was 3 h(range,30 min to 7 h).All patients were randomly divided into the following 2 groups:the cannulated screw group and the plate group.In the cannulated screw group,there were 12(75.00%)male(12 feet)and 4(25.00%)female patients(4 feet)with a mean age of 35.8 years(range,24-53 years).In this group,12(75.00%)feet had Gustilo type ? A fractures and 4(25.00%)feet had Gustilo type ? B fractures,and 10(66.67%)feet had Sanders type II fractures and 6(33.33%)feet had Sanders type ? fractures.The patients in the cannulated screw group were treated with early debridement,fracture reduction,and cannulated fixation.Soft tissue defects were temporarily covered with vacuum-assisted closure,and were enveloped by skin or flap grafts during a second-stage surgery.In the plate group,there were 10(66.67%)male(11 feet)and 5(33.33%)female patients(5 feet)with a mean age of 37.1 years(range,22-55 years).In this group,13(81.25%)feet had Gustilo type ? A fractures and 3(18.75)feet had Gustilo type ? B fractures,and 11(68.75%)feet had Sanders type II fractures and 5(31.25%)feet had Sanders type ? fractures.EvaluationAll patients were evaluated both clinically and radiologically.Clinically,patients were evaluated using the American Orthopedic Foot and Ankle Society(AOFAS)ankle-hindfoot scale(6),and the rates of wound healing complications and deep infections were evaluated.Radiologically,reduction was documented in all patients postoperatively using plain radiographic evaluations,including anteroposterior and lateral views,and a calcaneal tangential view.The Bohler and Gissane angles were determined and compared before and after surgery.The outcomes were assessed postoperatively at 1,3,6,and 12 months and annually thereafter.To avoid examiner bias,clinical scoring was performed by 2 independent observers who were not involved in the surgical treatment of the patients and who were blinded to the radiological findings.All of the patients were followed,and the duration of follow-up ranged from 10 to 36 months(mean,24 months).Statistical AnalysisData were analyzed using SPSS for Windows(version 8.0,SPSS Inc.,Chicago,IL).The Pearson chi-square test,independent sample t-test,and one-way ANOVA were used to define relations between clinical and radiological results.Statistical significance was set at p? 0.05.ResultsIn the cannulated screw group,the posterior facet joint was successfully reduced to<2 mm of displacement in 11(68.75%)patients.The Bohler angle increased from 10.07° ± 6.13° preoperatively to 30.09°± 7.660 postoperatively.The Gissane angle increased from 107.11° ± 10.06° preoperatively to 117.75° ± 8.86° postoperatively.The heel height,width,Bohler angle,and Gissane angle were better postoperatively than preoperatively.According to the AOFAS ankle-hindfoot scale,in the cannulated screw group,8(50.00%)feet achieved excellent results and 4(25.00%)achieved good results.In terms of complications in the cannulated screw group,2(12.50%)feet had local wound skin necrosis that was treated successfully with dressing,1(6.25%)foot had a large area of skin necrosis that was repaired with a gastrocnemius nerve skin flap after debridement,and 1(6.25%)foot had chronic osteomyelitis ultimately requiring ankle amputation.The mean duration of hospitalization in the cannulated screw group was 18.7 days.In the plate group,the posterior facet joint was successfully reduced to<2 mm of displacement in 14 patients(93.33%).The Bohler angle increased from 10.03° ±6.71° preoperatively to 35.140 ± 4.21° postoperatively.The Gissane angle increased from 104.32°± 9.940°preoperatively to 119.23°± 5.76° postoperatively.The heel height,width,Bohler angle,and Gissane angle were better postoperatively than preoperatively.According to the AOFAS ankle-hindfoot scale,in the plate group,9(56.25%)feet achieved excellent results and 4(25.00%)achieved good results.In terms of complications in the plate group,2(6.25%)patients had mild wound-related complications after early debridement and 5(31.25%)patients had wound complications after internal fixation,including 2(12.50%)patients with local skin local necrosis that was treated successfully with dressing and 3(18.75%)patients with superficial skin infection that was treated successfully with dressing.The mean duration of hospitalization in the plate group was 26.7 days.There were no statistically significant differences in radiological indicators,early postoperative complications,or AOFAS ankle-hindfoot scores between the 2 groups.However,the duration of hospitalization was statistically significantly shorter in the cannulated screw group than in the plate group(p = 0.021).ConclusionThe treatment of open calcaneal fractures is a difficult clinical problem.A detailed clinical evaluation,careful debridement,and adequate soft tissue treatment are important for treatment success.A minimally invasive sinus tarsi approach with cannulated screw fixation combined with vacuum-assisted closure is an effective method for the treatment of severe open calcaneal fractures with medial wounds.It can result in good reduction and stable fixation,and it requires few days of hospitalization.However,this study was limited by the small number of patients,the short duration of follow-up,the lack of analysis of long-term outcomes,and the lack of a randomized controlled design.PART2 Quantitative Digital Anatomy Study of Placement Technology of Sustentaculum Tali Screws Guided by 3D Navigation of Intelligent RobotIntroductionThe incidence of calcaneal fractures accounts for approximately 1-2%of body fractures and around 60%of tarsal fractures.Fractures of the calcaneus are usually due to high-energy longitudinal force,such as that in falling or a traffic accident.According to the current literature,60 to 75%of calcaneal fractures are displaced intra-articular fractures(1-3).Currently,for calcaneal fracture of the articular surface.open reduction and internal fixation is generally considered as an effective treatment.However,such treatment have has higher rates of soft-tissue complications,such as dehiscence and infection,which could be as high as 30%(4-6).To reduce the incidence of complications and soft-tissue damage,new surgical techniques,such as minimally invasive incision and percutaneous fixation,are developed(6,7).Ample evidence shows that minimally invasive approaches for calcaneal fracture reduction and internal fixation provide good imaging performance with good therapeutic outcomes and less wound complications(8).Even for complex calcaneal fractures,minimally invasive tarsal sinus incisions could be employed for adequate exposure to achieve anatomic reduction and strong internal fixation,and excellent or good functional recovery and minimal soft-tissue complications were observed in most patients(9).Currently,the minimally invasive treatment of calcaneal fractures with displaced articular surfaces requires reduct the subtalar articular surface and fixed with a screw through the sustentaculum tali.The maintenance of calcaneal axis,height and length can be obtained by various fixing methods,such as mini plate,screws,needles,external fixator,etc.Therefore,for minimally invasive treatment of calcaneal fractures with displaced articular surfaces,sustentaculum tali screws are particularly important?However,the commonly used minimally invasive incision generally cannot expose the sustentaculum tali located inside the calcaneus,making it difficult to place the load-bearing protrusion screw and the screw position is not ideal.For this reason,this study plans to use 3D x-ray with the aid of surgical robot positioning system,to measure and simulate the insertion of calcaneal sustentaculum tali screws to design and guide the operation for minimally invasive treatment of calcaneal fracture with articular surface displacement.Materials and MethodsFrom July 2015 to June 2016,a total of 74 normal calcaneus CT images from the imaging data of The Jinan Third People's Hospital were selected for the study..There were 44 males and 30 females,aged from 19 to 62 years(average 37.6 years)?42 on the right and 32 on the left.CT equipment and image reconstruction software are Siemens definition as + 64 rows of 128-slice volume spiral CT,and data measurement software is Siemens definition as+ with measurement equipment.The CT images of calcaneus axis and coronal position are selected so that the two images just show the maximum diameter marking in the window.The marking can be regarded as the position of the load distance projection screw in coronal position and axial position so that it passes through the center of the load distance projection coronal position and axial position.A new marking intersection on the lateral side of the calcaneus can be regarded as the position where the Sustentaculum Tali screw is located on the lateral wall of the calcaneus,i.e.the nail entry point of the Sustentaculum Tali screw of the calcaneus.The length of the screw in the coronal and axial positions of the calcaneus distance process and its angle with the lateral wall and cross section of the calcaneus were measured respectively.The distance from the insertion point of the screw to the subtalar joint and the distance parallel to the subtalar joint to the posterior edge of the calcaneus were measured.Record data.Sixteen foot bone specimens were selected for this study,including 8 on the left and 8 on the right,with a total of 16 feet.Planning and simulating the insertion of distance projection screws by the TiRobot surgical robot positioning system.Post-measure and verify screw position and record the data.Data were analyzed using SPSS for Windows(version 8.0,SPSS Inc.,Chicago,IL).The Pearson chi-square test,independent sample t-test,and one-way ANOVA were used to define relations between clinical and radiological results.Statistical significance was set at p? 0.05.ResultsThe group of CT:When the screw is placed on the axis of the Sustentaculum Tali process,the length of the Sustentaculum Tali process screw is about 4.03±0.33 cm,the angle of placing the screw is 79.4±3.60 with the lateral wall of the calcaneus and 23.2±4.1° with the transverse section of the calcaneus,and the insertion point is located on the latera.l wall about 1.01±0.21 cm from the inferior articular surface and 1.49±0.2 cm parallel to the distance from the inferior articular surface to the posterior edge of the calcaneus.The group of the TiRobot surgical robot positioning system:When the screw is placed on the axis of the Sustentaculum Tali process,the length of the Sustentaculum Tali process screw is about 4.13±0.53 cm,the angle of placing the screw is 78.4±4.6°with the lateral wall of the calcaneus and 24.2±4.7° with the transverse section of the calcaneus,and the insertion point is located on the lateral wall about 1.00±0.42 cm from the inferior articular surface and 1.89±0.33 cm parallel to the distance from the inferior articular surface to the posterior edge of the calcaneus.According to statistical analysis,there is no statistical difference between the two groups.ConclusionQuantitative Digital Anatomy Study of Placement Technology of SustentaculumTali Screws Guided by 3D Navigation of Intelligent Robot have important guiding significance for minimally invasive nail placement of calcaneal fracture.The technology of placing Sustentaculum Tali Screws under the guidance of intelligent robot 3D navigation is accurate,and can achieve personalized operation planning for specific cases.However,for the clinical application of Tianji orthopaedic robot positioning system with distance protruding screws,there are still some problems such as expensive equipment and high operation cost.Moreover,the current planning mode of Tianji orthopaedic surgery robot positioning system for traumatic orthopaedics is 2D mode,and we can only choose the internal fixation mode based on spinal pedicle screws for 3D perspective navigation of the load-bearing process screws.Therefore,this study is limited to the experimental stage and has not yet been applied to clinical practice. |
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