Comparison of Surgical Techniques for the Treatment of Intraarticular Calcaneal Fractures

Abstract

INTRODUCTION: Optimal treatment for displaced intraarticular calcaneal fractures is controversial. We aimed to compare the clinical and radiological results of minimal invasive and open surgeries for calcaneal fractures.METHODS: Patients with calcaneal fractures treated with surgery in the authors’ institutions in 2010-2015 were retrospectively reviewed. Patients were divided into two groups, open reduction and percutaneous fixation and subdivided into groups according to Sanders classification. Inversion-eversion range-of-motions were measured with a goniometer on the last follow-up. Functional assessment was done with American Foot and Ankle Society AOFAS ankle-hindfoot scale and Maryland foot scores MFS . Pain is assessed with a 10-cm VAS scale. Calcaneal height and width were measured both preoperatively and on the last follow-up. Complications were also assessed. RESULTS: 52 calcanei of 42 patients were treated with open reduction and 40 calcanei of 32 patients were treated with minimal-invasive surgery. Mean age for both groups were 35 and mean follow-up was 25.5 months. There are no statistically significant differences between two groups, in terms of age. Mean time to surgery from admission was 8.2 2-14 days in open reduction group and 2.5 1-5 days in percutaneous reduction group. There are no statistically significant differences between two groups, in terms of ROM, VAS, AOFAS and Maryland scores. Functional scores were better in Sanders 2 group than Sanders 3 group, free from surgical technique. Calcaneal height restoration is independent from the surgical technique. Calcaneal width is more restored by open reduction p=0.001 . There are 3 deep infections and 5 other wound complications in the open-reduction group while there were wound complications with minimal-invasive surgery.DISCUSSION AND CONCLUSION: Both treatment methods for calcaneal fractures end with similar clinical results but percutaneous fixation has advantages of early surgery and less complications. Sanders classification is prognostic.

Keywords

• Calcaneal fracture,minimal-invasive,open

Eklem İçi Kalkaneus Kırıklarında Cerrahi Tekniklerin karşılaştırılması

Abstract

GİRİŞ ve AMAÇ: Ayrılmış eklem içi kalkaneus kırıklarının en uygun tedavisi tartışmalıdır. Bu çalışmada kalkaneus kırıklarında minimal girişimsel ve açık cerrahilerin klinik ve radyolojik sonuçlarının karşılaştırılması amaçlanmıştır.YÖNTEM ve GEREÇLER: Yazarların kurumlarında 2010-2015 yılları arasında kalkaneus kırığı nedeniyle ameliyat edilen hastalar geriye dönük incelenmiştir. Hastalar, açık yerine koyma ve perkütan tespit olarak ikiye ayrılmış, daha sonra bu gruplar da Sanders sınıflamasına göre kendi içlerinde alt gruplara ayrılmıştır. İnversiyon-eversiyon hareket açıklıkları son kontrolde gonyometre ile ölçülmüştür. Fonksiyonel değerlendirme Amerikan Ayak ve Ayak Bileği Cemiyeti AOFAS ayak bileği-ardayak skalası ve Maryland Ayak Skorlaması MFS ile yapılmıştır. Ağrı 10 cm görsel analog skala VAS ile değerlendirilmiştir. Kalkaneus yüksekliği ve genişliği hem ameliyat öncesinde hem de son control muayenesinde ölçülmüştür. Komplikasyonlar ayrıca değerlendirilmiştir.BULGULAR: 42 hastanın 52 kalkaneusu açık yerine koyma yöntemiyle, 32 hastanın 40 kalkaneusu minimal girişimsel teknikle ameliyat edilmiştir. Her iki grup için de ortalama yaş 35 olup ortalama takip süresi 25,5 aydır. Yaş yönünden iki grup arasında anlamlı bir fark yoktur. Başvurudan ameliyata kadar geçen süre, açık cerrahi için 8,2 2-14 gün, ve perkütan cerrahi için 2,5 1-5 gündür. ROM, VAS, AOFAS ve Maryland skorları açısından iki grup arasında anlamlı bir fark yoktur. Cerrahi teknikten bağımsız olarak, Sanders 2 grubunda Sanders 3 grubundan daha iyi fonksiyonel skorlar elde edilmiştir. Kalkaneus yüksekliği, cerrahi teknikten bağımsız olarak düzelmiştir. Kalkaneus genişliği açık cerrahi ile daha başarılı düzelmiştir p=0.001 . Açık redüksiyon grubunda 3 derin enfeksiyon ve 5 diğer yara komplikasyonu görülmüşken minimal girişimsel cerrahiyle bu komplikasyonlar görülmemiştir.TARTIŞMA ve SONUÇ: Kalkaneus kırıkları için her iki tedavi yöntemi de benzer klinik sonuçları sağlamıştır ama perkütan cerrahi ile daha erken ve daha az komplikasyonlu ameliyat avantajları mevcuttur. Sanders sınıflaması prognostik değer taşımaktadır.

Keywords

• Kalkaneus kırığı,minimal invazif,açık

References

1. Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Foot (Edinb). 2009;19(4):197-200
2. Nork SE, Barei DP. Ankle and hindfoot trauma. In: Fischgrund JS, editor. Orthopaedic Knowledge Update, Rosemont; American Academy of the Orthopaedic Surgeons; 2008. p. 493-509.
3. Clare MP SR. Calcaneal fractures. Fuss Sprung 2007; 5:58- 73.
4. Bruce J, Sutherland A. Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev. 2013;1:CD008628
5. Buckley RE, Tough S. Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg. 2004;12(3):172-178
6. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. Foot Ankle Int. 2013;34(6):773-780.
7. Rammelt S, Zwipp H, Schneiders W, Dürr C. Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 2013;471(9):2885-2898.
8. Folk JW, Starr AJ, Early JS. Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma. 1999;13(5):369-372.

9. Forgon M, Zadravecz G. Zu den Repositions—und Retentionsproblemen der Kalkaneusfraktur. Aktuelle Traumatol. 1983;13(6):239-246.
10. Fernandez DL, Koella C. Combined percutaneous and “minimal” internal fixation for displaced articular fractures of the calcaneus. Clin Orthop Relat Res. 1993; 290:108-116.
11. Tornetta P 3rd. Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res. 2000; 375:91-96.
12. Gavlik JM, Rammelt S, Zwipp H. Percutaneous, arthroscopically-assisted osteosynthesis of calcaneus fractures. Arch Orthop Trauma Surg. 2002;122(8):424- 428.
13. Gould N. Lateral approach to the os calcis. Foot Ankle. 1984 Jan-Feb;4(4):218-20.
14. Heffernan G, Khan F, Awan N, Riordain CO, Corırigan J. A comparison of outcome scores in os calcis fractures. Ir J Med Sci. 2000; 169:127-128.
15. Kitaoka H, Alexander I, Adelaar R, Nunley J, Myerson M, Sanders M. Clinical rating systems for the ankle, hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int. 1994; 15:349–353.
16. Broden B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol. 1949; 31:85–88.
17. Morrey BF, Wiedeman GP. Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg [Am] 1980;62-A:777–784.
18. Makki D, Alnajjar HM, Walkay S, Ramkumar U, Watson AJ, Allen PW. Osteosynthesis of displaced intra-articular fractures of the calcaneum: a long-term review of 47 cases. J Bone Joint Surg Br. 2010;92(5):693-700.
19. Ene R, Popescu D, Panaitescu C, Circota G, Cirstoiu M. Low complications after minimally invasive fixation of calcaneus fracture. Journal of medicine and life 2013, 6.1: 80.
20. Pelliccioni AAA, Bittar CK, Zabeu JLA. Surgical treatment of intraarticular calcaneous fractures of sanders' types ii and iii. Systematic review. Acta Ortop Bras. 2012;20(1):39-42
21. Fan B, Zhou X, Wei Z, Ren Y, Lin W, Hao Y, Shi G, Feng S. Cannulated screw fixation and plate fixation for displaced intra-articular calcaneus fracture: A meta-analysis of randomized controlled trials. Int J Surg. 2016 Oct;34:64- 72
22. Khurana Ankit, Dhillon Mandeep S, Prabhakar Sharad, John Rakesh. Outcome evaluation of Minimally invasive surgery versus Extensile lateral approach in management of displaced intra-articular calcaneal fractures: A Randomised control trial. The Foot 2017; 31: 23-30
23. Wu J, Zhou F, Yang L, Tan J. Percutaneous Reduction and Fixation with Kirschner Wires versus Open Reduction Internal Fixation for the Management of Calcaneal Fractures: A Meta-Analysis. Sci Rep. 2016;6:30480
24. Biz C, Barison E, Ruggieri P, Iacobellis C. Radiographic and functional outcomes after displaced intra-articular calcaneal fractures: a comparative cohort study among the traditional open technique (ORIF) and percutaneous surgical procedures (PS). J Orthop Surg Res. 2016;11(1):92
25. V. Popelka, P. Simko, Surgical treatment of intra-articular calcaneal fractures, Acta Chir. Orthop. Traumatol. Cech. 2011;78: 106e113
26. Zeng Z, Yuan L, Zheng S, Sun Y, Huang F, Minimally invasive versus extensile lateral approach for Sanders type II and III calcaneal fractures: A meta-analysis of randomized controlled trials, Inter J Surg,2018;50:146-53
27. Jin C, Weng D, Yang W, He W, Liang W, Qian Y. Minimally invasive percutaneous osteosynthesis versus ORIF for Sanders type II and III calcaneal fractures: a prospective, randomized intervention trial. J Orthop Surg Res. 2017;12(1):10
28. Rubino R, Valderrabano V, Sutter PM, Regazzoni P. Prognostic Value of Four Classifications of Calcaneal Fractures. Foot Ankle Inter 2009;30:3
29. Sanders R, Vaupel Z, Erdogan M, Downes K. Operative Treatment of Displaced Intraarticular Calcaneal Fractures: Long-term (10–20 Years) Results in 108 Fractures Using a Prognostic CT Classification. J Orthop Trauma. 2014 Oct;28(10):551-63
30. Alexandridis, G., Gunning, A.C., van Olden, G.D.J. et al. International Orthopaedics (SICOT) (2018) 42: 2231
31. Swords MP, Alton TB, Holt S, Sangeorzan BJ, Shank JR, Benirschke SK. Prognostic Value of Computed Tomography Classification Systems for Intra-articular Calcaneus Fractures. Foot Ankle Interl 2014; 35(10): 975– 80
32. de Vroome, Stefan W., and Frits M. van der. “Cohort Study on the Percutaneous Treatment of Displaced Intra- Articular Fractures of the Calcaneus.” Foot Ankle Inter, 2014; 35: 156–62
33. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally invasive technique versus an extensile lateral approach for intraarticular calcaneal fractures. Foot Ankle Int. 2013; 34(6):773-780
34. Weber M, Lehmann O, Sägesser D, Krause F. Limited open reduction and internal fixation of displaced intra- articular fractures of the calcaneum. J Bone Joint Surg Br. 2008; 90(12):1608-1616
35. Zwipp H, Paša L, Žilka L, Amlang M, Rammelt S, Pompach M. Introduction of a new locking nail for treatment of intraarticular calcaneal fractures. J Orthop Trauma. 2016; 30(3):e88-e92.
36. Reinhardt S, Martin H, Ulmar B, et al. Interlocking nailing versus interlocking plating in intra-articular calcaneal fractures: a biomechanical study. Foot Ankle Int. 2016; 37(8):891-897.
37. Elgamal TA, Tanagho AE, Ferdinand RD. Temporary external fixation facilitates open reduction and internal fixation of intra-articular calcaneal fractures. Acta Orthop Belg. 2013; 79(6):738-741.
38. Jacquot F, Letellier T, Atchabahian A, Doursounian L, Feron JM. Balloon reduction and cement fixation in calcaneal articular fractures: a five-year experience. Int Orthop. 2013; 37(5):905-910.
39. Chen L, Zhang G, Hong J, Lu X, Yuan W. Comparison of percutaneous screw fixation and calcium sulfate cement grafting versus open treatment of displaced intra- articular calcaneal fractures. Foot Ankle Int. 2011;32(10):979-85.
40. Wei N, Zhou Y, Chang W, Zhang Y, Chen W. Displaced Intra-articular Calcaneal Fractures: Classification and Treatment. Orthopedics. 2017;40(6):e921-e929