Top PDF Original Article Assessment of the curative effects of open reduction and internal fixation with bone grafting on calcaneal displaced intra-articular fractures

neous necrosis, and infection of incision. Se- cond, calcaneus is a sort of cancellous bone with a rich blood supply. Thus, it may be subject to huge bleeding after undergoing an opera- tion. Infection probability will also increase if post-operative incision drainage is not smooth [22]. A recent study reported that the best sur- gical time is within 8 hours after injury when no swelling or blisters appear and more than seven days to 2 weeks after injury when swelling has disappeared [23]. Negative pressure closed dr- ainage is an active drainage mode applied in treating ankle trauma. Some research has indi- cated that negative pressure closed drainage can effectively clear effusion flowing from the wound surface to reduce infection incidence [24]. Differences in subtalar arthritis incidence obtained one year after the operation of the groups was of no statistical significance (P>0.05). Yet, at the time of last follow up, the non-surgical group’s subtalar arthritis inci- dence was obviously higher than the surgical group (45.24% vs. 21.62%), with statistically significant differences (X 2 =6.221, P<0.05).

that it may be because the poking reduction was difficult to achieve complete anatomical reduction for the fractures where the articular surface is seriously destroyed and displaced [17]. In addition, the minimally invasive poking reduction is difficult to completely remove the small pieces of broken bones in the articular cavity, resulting in the uneven surface of subta- lar joint and leading to traumatic arthritis [18]. It also seriously affects the long-term efficacy and prognosis. The clinical efficacy of poking reduction fixation for Sanders type II fractures was studied for the first time in this trial, and it was comprehensively analyzed and compared with the traditional ORIF method. X-ray was used to make sure that after the Kirschner wire had reached the bottom of posterior articular calcaneal, upward poking could be conducted to reset the posterior articular surface and cal- caneal at the same time, and 2 Kirschner wires can be drilled in when necessary. The incision was sutured after satisfactory with the reduc- tion results in imaging examination, ensuring the complete reduction of the articular surface, long-term efficacy and prognosis [19, 20]. This type of research has not been widely reported both at home and abroad.

Abstract: Objective: To evaluate the outcomes of the application of intraoperative percutaneous traction using an external fixator for the reduction of medial wall shortening and misalignment in calcaneal fractures. Methods: From December 2011 to December 2013, 23 Sanders type III or type IV calcaneal fractures with medial wall shortening and misalignment in 22 patients were reduced with open reduction and internal fixation combined with intraopera- tive percutaneous traction. Bohler’s angle, Gissane’s angle, calcaneal height and calcaneal width were measured before surgery, after reduction with common technique and after reduction with the external fixator, respectively. At every follow-up visit, clinical outcomes were evaluated by the Maryland Foot Score. Results: Bohler’s angle, Gis- sane’s angle, calcaneal height and calcaneal width were improved after reduction with common technique (P < 0.05). Whereas, reduction with the external fixator improved Bohler’s angle, Gissane’s angle and calcaneal width further compared with reduction with common technique (P < 0.05). During the follow-up period, associate soft tissue-related complications were observed in one case. At the final follow-up visit, clinical outcomes of eleven of thirteen Sanders type III fractures (84.62%) and eight of ten Sanders type IV fractures (80%) were considered excel- lent or good according to the Maryland Foot Score. Conclusion: Intraoperative percutaneous traction using an exter- nal fixator represents a safe and effective method for the reduction of medial wall shortening and misalignment that cannot be well reduced through the lateral approach. The combined use of intraoperative percutaneous traction and open reduction and internal fixation through the extended lateral approach for complex displaced intra-articular calcaneal fractures ensures desirable clinical outcomes.

Ever since Lenormant first described the use of bone grafting to fill the space created after open reduction of a calcaneal fracture in 1928, this technique has maintained its popularity. Choices of bone graft have included autog- enous and allogenous cancellous bone grafts, polymethyl- methacrylate (PMMA), and bone substitutes. However, the need for bone grafts in the treatment of intraarticular cal- caneal fracture is still controversial, and there is no strong evidence to support any functional benefits of using bone grafts [6]. Surgeons in favor of bone grafting believe that it could stimulate fracture healing, leading to early full weight-bearing; may prevent posttraumatic arthritis; and could increase mechanical strength, thus helping to prevent significant late collapse [7, 8]. Those not in favor of bone grafts have stated that the highly vascular calcaneus heals radiographically 4–8 weeks after surgery in the absence of bone grafting [9–11], that internal fixation can adequately support the articular surface, that bone grafting increases the infection rate, blood loss, and postoperative pain [12, 13], and that it is also important to consider donor site morbidity and complications involved with harvesting an autograft [14, 15].

the assessment of filling of the central cancellous bone defect with bone regenerate, the rate of complications (including prolonged wound healing, superficial and deep infection and the need for revision surgery) and clinical outcome. Resorption of the BGS and filling of the bony defect was accessed by comparing the immediate post‑operative radiographs with follow‑up radiographs at 1 year. The final clinical outcome of the patients was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle‑Hindfoot Scale. [26]

diabetes have been demonstrated as indepen- dent risk factors for wound complications [28, 29], but no significant difference in the number of patients with smoking and diabetes in three groups, thus excluding their influences on com- plications. In addition, it is reported that the operative time might be closely related with wound complication [30]. In this study, the L-shaped lateral approach indeed required more time to accomplish the operation than other approaches. However, the recent study performed by Ho et al. indicated the surgical timing may not affect postoperative infection rates in calcaneal fractures [31]. The possible cause may be that the surgery is performed by experienced hands because the association between wound complications and the experi- ence level of the surgical team has been proved in the study of Schepers et al. [32]. The more postoperative complications inevitably result in longer time to heal the wound, longer length of stay and more cost. As anticipated, the length of stay and the operation cost of the EL and MI groups were also significantly higher than those of the PR group.

In the reported cases, the cancellous screws were passed from the non-articular area. Their direction was oblique, from front to back and from medial to lateral, fixing the trochlea to the capitulum. Alterna- tively, Herbert screws were inserted into the articular surface buried beneath the cartilage; their direction was perpendicular to the fracture line, securing the frag- ment of the trochlea to the posterior wall with maximum compression. We opted for this type of osteosynthesis be- cause it is more stable from a biomechanical point of view.

Gentle handling of soft tissue during raising of the lateral skin flaps to ensure good circulation is the most important factor in our opinion [18] [19]. Blade size 15 was used to make a curvilinear incision straight down to bone. Retracting the flap with a suture anchor and using the “no touch” technique minimizes soft tissue trauma.

There is a controversy whether the comminuted calcaneal fractures should benefit more from conservative or from surgical treatment. Aiming to contribute to this unsolved clinical question we reviewed the long-term outcome (up to 96 months) of in 44 patients (mean age 35 years) with 47 calcaneal fractures who were treated surgically. In these patients open reduction and internal fixation were performed using a calcaneal reconstruction plate. The functional outcome was measured according to the Rowe Score and the level of pain by Visual Analog Scale. The objective outcome was estimated by the current radiographs. The clinical results were good to excellent in 69% of patients. Poor outcome observed in one patient who developed Complex Regional Pain Syndrome in his foot. The radiographic evaluation showed satisfactory reconstruction (according to the Boehler angle measurements) in 35 of operated calcanei. These results indicate on the sa- tisfactory outcome of surgical treatment in the majority of the patients who were diagnosed with comminuted fracture of calcaneus.

328 patients with 328 displaced intra-articular calcaneal fractures met the inclusion criteria. Among them, 274 pa- tients were available for follow up with a mean duration of 71 months (range, 48–99 months). There were 231 males and 43 females, with an average age of 38.5 years (range, 18–69 years). The injury mechanisms included a fall from a height in 145 patients, a traffic injury in 62, a crush injury in 51, and a sprain in 16. According to Sanders clas- sification, the fracture pattern included 105 type II, 121 type III and 48 type IV fractures. According to American Orthopaedic Foot & Ankle Society hindfoot score, the functional outcomes were excellent in 104 patients (37.96%), good in 132 (48.18%), fair in 27 (9.85%), and poor in 11 (4.01%) (Table 1). Soft tissue complications were reported in 32 patients, including 13 patients with superficial infection, 5 wound edge necrosis, 2 deep infec- tion, 3 sural nerve injury, 4 medial plantar nerve injury, and 7 with restricted movement of flexor hallucis longus tendons (2 with concurrent medial plantar nerve injury). Superficial infection and wound edge necrosis were re- solved by dressing changes. Deep infection extended to the level of hardware in both patients, which required hardware removal. Hardware removal and neurolysis was

Numerous conservative and operative meth- ods have been described for the treatment of distal radial fractures [1-7]. The primary goal in all methods of treatment is the restoration of the joint with maximum recovery of function [1, 4]. Although many studies have presented the results of surgical methods, limited studies have compared managed percutaneous pin- ning with locked plate fixation in the treatment of complex intra-articular fracture types, such asdistal radial fractures [1, 2, 7, 15]. In our study, there were significantly more volar tilt losses and arthritic changes at the end of fol- low-up in patients who underwent K-wire fixa- tion. In addition, there was no significant differ- ence in ROM between the groups; however, it was found that functional outcomes differed significantly between methods.

Of the 84 fractures, 60 were secondary to low energy skiing injuries. 90% of the patients returned to their pre-injury occupations.17 A series of 26 patients were divided into 2 groups based on fracture pattern. Type A fractures with twisting injuries with little comminution, whereas Type B fractures were more severe injuries, with a crush component. On treatment with open reduction and internal fixation, 65% cases had good to excellent results. Better results were obtained in Type A fractures (84%) than B (53%). Crucial factors besides fracture type were the length of immobilization and quality of reduction. Prolonged immobilization resulted in poor outcome, showing the need for stable fixation to permit early mobilisation 1 .

There is a degree of interobserver and intraobserver variability in the measurement of angles on X-ray, which needs to be taken into consideration. If these radiological measurements can reflect the accuracy of the reduction, then we have found no correlation between the accuracy of reduction and functional outcome. We could not find a correlation between patients with good correction of Bo¨hler’s angle and high functional score either. These findings seem to go against the current philosophy of restoring radiological landmarks to obtain good function. We realize that, without values for outcome measures such as range of movement of the ankle and the subtalar joint, our results are incomplete. Furthermore, the small number of patients in this paper is a recognized weakness of our study. On the other hand, we feel that the most important outcome measures are the patient-derived measures of satisfaction and function; more so than clinician-derived subjective values.

A 1–2-mm-thick osteotomy was made in the lateral wall of the calcaneus with a sharp and wide osteotome. The bone flap that contained the integrated skin and sub- cutaneous tissue was retracted to expose subtalar joints and the fractured fragments. The bone flap should con- tain the integrated skin and subcutaneous tissue. After the desired fracture reduction was achieved, a well-molded biodegradable plate was implanted and Kirschner wires were used to fixate the fractured frag- ments provisionally. C-arm X-ray images of the lateral, axial, oblique, and Brodén’s positions of the calcaneus were obtained to determine if the anatomic geometry of calcaneus was restored. Then, the 3.1-mm flat and low-profile head screws were driven into the prefabri- cated hole (Fig. 1). The 1.2-mm thick free-form bio- degradable plate (Inion, Finland) was bathed in a 70 °C thermostat filled with normal saline for 1 min to make the plate malleable. This malleable state continued for 10–15 s. The free-form plate was cut at the midline along its longitudinal axis, and the cutout was opened to make a Y-shaped plate after bathing (Fig. 2). The plate was embedded in the calcaneus under the bone flap (Fig. 1), and hot normal saline was used to help make the plate more suitable. The periosteal margin of the lat- eral wall was sutured using Vicryl 2-0 (Ethicon, Division of Johnson & Johnson, Somerville, NJ) (Fig. 1). No wound drainage was required in all patients (Fig. 2).

Femoral neck fractures are serious injuries that are associated with high mortality and morbidity. Considerable controversy still exists for best treatment of non-displaced (Garden I and Garden II) fractures. Our case is a 34-year-old woman with Garden type II femoral neck fracture, who refused all surgical options and willingly ignored her problem. The patient received subcutaneous injections of 20 mcg Teriparatidefor 6 weeks. 3 months later she returned to our center with uneventful recovery of her fracture. Although rigid internal fixation of femoral neck fractures has long been the cornerstone of treatment, especially in non- impacted cases, non-operative management does not mean a poor result.

parts undergoing ORIF during late period. Despite it was extremely challenging to suc- cessfully perform ORIF for patients with delayed acetabular fracture and those waited for 65 d prior to surgery, excellent therapeutic effect of anatomic reduction was obtained due to simple fracture. Letournel and Letournel [14] catego- rized the surgical procedures into three stages according to the time interval between the inju- ry and surgery: the 1st stage was 1-20 d after injury, the 2nd stage was 21-120 d and the 3rd stage over 120 d after fracture. It is convenient and efficacious to perform ORIF for patients with early fracture (belonging to the 1st stage). For those left untreated for > 3 weeks after bone fractures (acetabular fracture and dislo- cation, pubic branch fracture and dislocation, sacroiliac fracture and dislocation, as well as ala of ilium fracture, etc.), both the number and length of incision should be increased to guar- antee the high quality of reduction. In addition, the delay of ORIF for acetabular fractures threatens the survival of femoral head, espe- cially for those accompanied by persistent dis- location and semi-dislocation, and leads to abrasion of articular cartilage, chondrolysis, osteonecrosis of femoral head and posterior wall necrosis, etc. Although it is still easy to identify the fracture line and obtain relatively high quality of reduction within 120 d after inju- ry, it becomes more challenging to identify the fracture line and achieve excellent anatomic reduction exceeding 120 days. Instead, alter- native surgical approaches rather than ORIF should be considered to treat hip joint cartilagi- nous injury and abrasion.

Most of the clinical calcaneal fractures have complexities, mechanical parameters of bone block change obviously, and biomechanical changes change seriously. For posterior calcaneal articular surface fracture combined with die-punch bone block, it is often overlooked clinically, and it is not easy to find by routine X-ray examination. But it can be found by coronal and axial CT scan. In the past, for surgical treatment of calcaneal comminuted fractures, the restoration of overall calcaneal shape and length, width, height and other geometric parameters are emphasized, and the restoration of the Gissane angle, Bohler angle and the weight-bearing axis of hind feet are emphasized. Open reduction and internal fixation for involved subtalar articulatio calcaneocuboidea injury and calcaneal fracture were performed by Zongjun Li et al, and the restoration of Gissane angle and Bohler angle were emphasized, for which the total good rate was 95.2% after surgery[6]. During regular follow-up after surgery, the above anatomical parameters basically returned to normal, and the patients were very satisfied with this; however, in the long-term, these patients often still have joint pain and even dysfunction. However, through further CT scans, it was found that some of partial subchondral bone for the patients with dysfunction were collapsed in the posterior articular surface of calcaneal subtalar joint and the cancellous bone of the corpus calcanei; this change was not found in the patients with normal function through CT scans. In the patients with anatomical reduction for the die-punch bone block, if the recovery of Bohler angle is not very good, their mid-term and long-term pain is not obvious, and their joint function is also barrier-free. We also found that the calcaneal width was significantly reduced on the die-punch bone after anatomical reduction, which might be related to the expanding of the collapsed bone block and fracture separation. This phenomenon is particularly evident in comminuted fractures.

(2) the size and displacement of sustentacular tali relative to superior medial fragments, (3) the presence of a step or diastasis of the posterior facet, and (4) impingement of the fibular malleolus on the tuberosity of the Calcaneum. Such scans also provide information regarding fractures involving the sinus tarsi, calcaneocuboid joint, and anterior calcaneal process, all of which could be relevant while planning the lateral surgical approach. Thus a better surgical planning became possible. CT evaluation of calcaneal fractures has allowed classification systems to offer prognostic significance.

Methods: From July 2010 to July 2014, 20 consecutive patients who underwent open reduction and internal fixation for a closed Mason type II radial head fracture were retrospectively reviewed. Patients with Mason type I, III, simple type II, and comminuted type II fractures treated without bone grafting were excluded. A clinical examination and radiographic evaluation were performed. The overall functional result was evaluated using the Mayo Elbow Performance Score (MEPS). The Broberg and Morrey classification was used to evaluate traumatic arthritis. Results: The average follow-up duration was 31 months (range, 24 – 50 months). Bone union of the radial head fracture was achieved in all patients at an average of 13.5 weeks (range, 12 – 17 weeks). Postoperative radiographs showed no cases of postsurgical ligamentous instability, necrosis of the radial head, or internal fixation failure. The mean range of motion of the affected elbow was 128° ± 8.4° in flexion, 14.5° ± 11.1° in extension, 68.7° ± 14.1° in pronation, and 65.2° ± 18.2° in supination. The mean MEPS was 92 ± 7.9 points (range, 80 – 100); the outcome was excellent (90 – 100 points) in 13 patients and good (75 – 89 points) in 7 patients. The MEPS tended to be higher in patients with an isolated fracture ( p = 0.016). Based on the Broberg and Morrey classification for radiographic assessment of post-traumatic arthritis, 15 elbows had no evidence of degenerative changes (grade 0), and 5 elbows had grade 1 changes.

These complications include deep and superficial infections and wound sloughs, which reportedly occur in 1.8% to 27% of patients. This high frequency of infection is likely attributed to thin soft- tissue envelope around the calcaneus especially the lateral wall, which is exposed for surgery . Recently, less invasive surgical techniques for treating displaced intra-articular calcaneus fractures have been undertaken in an attempt to reduce complication rates and promising clinical and radiographic outcomes.These recent techniques include limited-incision sinus tarsi ORIF,percutaneous stabilization with pins and /or screws, and minimally invasive plate osteosynthesis (MIPO(