Clinical and biomechanical comparison of suture-external button versus interference screw associated with V-Y advancement or turndown flaps for flexor hallucis longus transfer in chronic Achilles tendon rupture.

PURPOSE: Surgical treatment of chronic Achilles tendon rupture is a technically challenging procedure. We aimed to compare the clinical outcomes, range of motion, and strength of ankle plantar- and dorsiflexors between two techniques for fixation of flexor hallucis longus tendon to the calcaneus: interference screw and suture-external button. METHODS: Twenty-five patients participated in this retrospective comparative study. All patients underwent short harvest FHL tendon transfer for chronic AT rupture were asked for a follow-up visit, at least one year following surgery. The outcomes were evaluated by visual analog scale (VAS), AOFAS ankle-hindfoot score, and VISA-A questionnaire. Ankle ROM with possible restriction in addition to isokinetic strength of ankle plantar- and dorsiflexors was assessed. RESULTS: No statistically significant difference was observed between the groups for pain (P = 0.81), AOFAS ankle-hindfoot scale (P = 0.97), and VISA-A (P = 0.44). Notably, more decrease in ankle dorsiflexion was seen in interference screw group in comparison with suture-external button group (4.4 ± 6.6 vs. 9.5 ± 6.1 degrees, P = 0.06). The difference of active dorsiflexion between operated and non-operated side in interference screw group was statistically significant (P = 0.02). Biotenodesis screw imposed more limb asymmetry in comparison with suture-external button technique. CONCLUSIONS: Fixation of transcalcaneal FHL tendon transfer for chronic AT either by interference screw or suture-external button has encouraging postoperative clinical results. Although ROM of the ankle joint reduced in both techniques, interference screw may result in more reduction in dorsiflexion of the ankle.

Calcaneal Lengthening after Tarsal Bone Fusion for Massive Calcaneus Defect Reconstruction.

OBJECTIVES: Calcaneus defect remains challenging with limited strategies for reconstruction. Current methods, including graft transplantation, substitution, and distraction osteogenesis, showed limited advantages with certain shortcomings. Current calcaneus lengthening for partial calcaneus loss reconstruction requires bone loss of less than 35%. We introduced our combination of tarsal bone fusion and gradual lengthening method in treating massive calcaneus loss. METHODS: From January 2015 to December 2021, tarsal bone fusion and calcaneus gradual lengthening were performed in six patients with unilateral massive traumatic loss of the calcaneal tuberosity. A retrospective study was held to evaluate the outcomes of this novel technique. Clinical outcomes were assessed based on the American Orthopedic Foot and Ankle Score (AOFAS). Radiological data were assessed, which included tibio-calcaneal angle (TCA), calcaneal interface angle (CIA), metatarsal declination angle (MDA), angle of longitudinal arch (ALA), and the amount of calcaneus axial lengthening (CAL). RESULTS: The mean calcaneal axial lengthening was 43.8 ± 3.1 mm (range, 39-49.5 mm), and the mean proportion of the lengthened calcaneus was 47.8% ± 3.7% (range, 42.8-55.3%). The mean external fixation time was 104.8 ± 67.5 days (range, 69 to 242 days), and the mean external fixation index was 2.4 ± 1.6 days/cm. All patients stuck to the postoperative follow-up plan with an average follow-up time (FT) of 35.0 ± 6.7 months (range, 26-40 months). Deformities of the injured limbs were all corrected according to radiography. Based on the AOFAS, three excellent and three good results were achieved. CONCLUSION: The Ilizarov technique remains an option for calcaneus reconstruction with a great amount of loss once combined with tarsal bone fusion. The function of the injured foot and ankle can be satisfactorily restored using these techniques in our study. Apart from calcaneus elongation, tarsal bone fusion is somehow necessary to reinforce the proximal segment of the distracted calcaneus for creating a larger distraction callus, correcting concomitant foot deformities, and enhancing hindfoot stability. It is necessary to choose flexibly when tarsal bones should be fused.

The Impact of De-Roofing of Lateral Calcaneal wall in Open Reduction and Internal Fixation of Intra-Articular Fractures: Clinico-Radiological Outcomes of a Novel Technique and Review of Literature.

Background: Most displaced intra-articular calcaneus fractures need to be treated surgically but postoperative soft tissue complications limit to achieve of optimal functional outcomes. Certain mini-invasive techniques lead to better soft tissue healing but anatomical reduction gets compromised. Objectives: We aim to evaluate the results of lateral wall de-roofing of the calcaneum to achieve good anatomical reduction as well as to minimise soft tissue complications in the internal fixation of calcaneal fractures. Materials and Methods: Thirty-two patients (40 ft) with displaced intra-articular calcaneus fractures (10 were of Sanders type II, 16 were of type III, and 14 were of type IV) were treated between January 2018 and September 2021. All patients were managed surgically with open reduction and internal fixation using lateral extensile approach combined with de-roofing of the lateral wall. All patients were followed up for ≥1 year using functional parameters American Orthopaedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS) and radiological parameters (Bohler angle, Gissane angle, height of the calcaneus, width of the calcaneus and pitch of calcaneus). Results: Out of 32 patients, one patient lost to follow-up. At 1 year follow-up, mean AOFAS hindfoot score was 86.2 ± 5 (Sanders type II: 91.2, Sanders type III: 87.6, and Sanders type III: 81.4), mean VAS score was 91.3 ± 2.1, mean Bohler angle (°) was 27.2 ± 4.7, mean Gissane angle (°) was 136.4 ± 5.2, mean calcaneus height was 46.2 ± 2.1 mm and mean calcaneus width was 45.1 ± 3.2 mm. Patients with decreased Bohler angle between postoperative images and follow-up had lower AOFAS hindfoot scores. Complications included persistent swelling (64.10%), stiffness (33.33%), superficial infections (5.12%), and wound dehiscence (10.25%). Conclusion: Lateral wall de-roofing is a useful technique which allows the lateral wall to get flattened reducing soft tissue complications and providing bone graft as well. This approach also adequately exposes fracture fragments, subtalar and calcaneocuboid joints for good anatomical reduction. Hence, it can act as a useful adjunct in the internal fixation of intra-articular calcaneus fractures. Level of Evidence: III.

A simple modified technique for screw fixation of displaced intra-articular calcaneus fracture through a sinus tarsi approach: a comparison with plate fixation.

BACKGROUND: Plates and screws are frequently used for the fixation of displaced intra-articular calcaneus fracture (DIACF). In this study, we compared the outcomes of a modified screw fixation technique with plate fixation via a sinus tarsi approach (STA). METHODS: A series of 187 DIACF patients who were treated via an STA using a plate fixation (n = 81) or a screw fixation (n = 106) were included. Screw fixation was done with two 2.7 mm screws and two 6.5 mm cannulated screws. Outcomes were evaluated radiographically and clinically. Clinical evaluations included pain assessment by Visual Analogue Scale (VAS) and functional assessment by the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire and Foot Function Index (FFI). RESULTS: The mean final VAS was smaller in the screw group (P = 0.01). The mean AOFAS and FFI scores were not significantly different between the two groups (P = 0.17 and P = 0. 19, respectively). The mean improvement of Bohler's angle, but not the Gissane's angle, was significantly greater in the screw group (P = 0.014 and P = 0.09, respectively). The mean improvement of calcaneal length and height were not significantly different between the two groups (P = 0.78 and P = 0.22, respectively). The hardware removal rate was 14.8% in the plate group and 3.8% in the screw group (P = 0.007). CONCLUSION: The modified screw fixation method provides lower pain, better radiographic outcome, and lower rate of hardware removal compared to plate fixation in the treatment of DIACF.

The combined talus and sustentaculum fracture: A case series.

BACKGROUND: The sustentaculum tali is a biomechanically important stabilizer of the hindfoot and contributes to articular congruency of the subtalar joint. Sustentaculum injury associated with a talus fracture has been described infrequently and treatment of this combined injury varies. The purpose of this study was to describe and evaluate the outcomes of the combined talus and sustentaculum fracture. METHODS: Retrospective chart and radiographic review was performed on all talus fractures (n = 436) requiring operative fixation over a 21-year period at a single Level-1 trauma center. All talus fractures with sustentaculum fractures were included. Statistical analysis was performed using Chi-squared and Fishers exact tests where appropriate. RESULTS: Sustentaculum fractures occurred in 6.2 % (n = 27) of patients with talus fractures. Average follow-up was 14 months; 18.5 % were open fractures, 88.8 % were from high-energy mechanisms, and 44.4 % were polytraumas. Diagnosis of the sustentaculum fracture was missed on presenting radiographs in 69.2 % (n = 18). The most common associated talus fracture was a talar neck fracture (40.7 %) and the majority (73.7 %) were Hawkins II. Overall, 40.7 % (n = 11) of the sustentaculum fractures were treated with independent fixation and 7.4 % (n = 2) were treated with acute subtalar arthrodesis. Subtalar post-traumatic osteoarthritis (PTOA) at final follow-up was seen in 23.1 % of combined injuries. Independent sustentaculum fixation did not influence the rate of PTOA or re-operation (p = 0.92, p = 0.91, respectively). CONCLUSION: Talar fractures have an associated sustentaculum fracture in approximately 6 % of cases, especially with Hawkins II fracture-dislocations. Over two-thirds of the associated sustentaculum fractures were missed on presenting radiographs, reiterating the need for heightened awareness and consideration of advanced imaging for all talus fractures. The rate of PTOA following these combined injuries at mean follow-up of 24 months does not exceed established rates after isolated talus fractures. Further research is required to determine the optimal management of the sustentaculum in these combined injuries. LEVEL OF EVIDENCE: IV.

Anatomy of the Achilles tendon-A pictorial review.

The Achilles tendon (AT) is the strongest tendon of the human body. The knowledge of AT anatomy is a basic prerequisite for the successful treatment of acute and chronic lesions. The structure of the AT results from a complicated fusion of three parts: the tendons of the medial and lateral gastrocnemius and the soleus muscles. From proximal to distal, the tendon fibers twist in a long spiral into a roughly 90° internal rotation. The tendon is narrowest approximately 5-7 cm above its calcaneal insertion and from there it expands again. The topography of the footprints of the individual AT components reflects the tendon origins. The anterior (deep) AT fibers insert into the middle third of the posterior aspect of the calcaneal tuberosity, the posterior (superficial) fibers pass over the calcaneal tuberosity and fuse with the plantar aponeurosis. A deep calcaneal bursa is interposed between the calcaneal tuberosity and the AT anterior surface. The AT has no synovial sheath but is covered along its entire length with a sliding connective tissue, the paratenon which is, however, absent on its anterior surface. The AT is supplied by the posterior tibial artery (PTA) and the peroneal artery (PA). Motor innervation of the triceps surae muscle is provided by fibers of the tibial nerve which also gives off sensitive fibers for the AT. Sensitive innervation is also provided via the sural nerve. The sural nerve crosses the AT approximately 11 cm proximal to the calcaneal tuberosity. The forces acting on the AT during exercise may be up to 12 times the body weight. Physiological stretching of AT collagen fibers ranges between 2% and 4% of its length. Stretching of the tendon over 4% results in microscopic failure and stretching beyond 8% in macroscopic failure.

Modified Calcanization of Tibia for Hindfoot Defect Reconstruction: Method and Preliminary Results.

OBJECTIVES: To introduce our modified technique for calcanization of the tibia in managing massive bony loss of hindfoot and preliminary outcomes. METHODS: From January 2015 to December 2021, modified calcanization of the tibia were performed in 10 patients with unilateral loss of the calcaneus. Clinical outcomes were assessed based on the American Orthopaedic Foot & Ankle Society score and Symptom Checklist-90-Revised questionnaire. Paired two-group t-test was applied to compare the parameters. RESULTS: The mean lengthened length of the tibia was 77.3 ± 3.0 mm (range, 74-83 mm). The mean external fixation time was 123.7 ± 52.1 days (range, 117-134 days) and the mean external fixation index was 1.601 ± 0.046 days/mm. All patients stuck to the postoperative follow-up plan with an average follow-up time of 29.7 ± 3.4 months (range, 24-35 months). Deformities of the injured limbs were well corrected. Based on American Orthopaedic Foot & Ankle Society score, eight good and two fair results were achieved. The mental status of all patients was within the normal range, and several indices of the Symptom Checklist-90-Revised questionnaire of each patient were improved after the whole procedure. CONCLUSION: We demonstrate that the modified calcanization of the tibia is qualified for total loss of calcaneus with limited complications. Early rehabilitation is attainable since external fixation time is shortened due to a simplified procedure.

["Calcaneogenesis" with secondary Achilles tendon-bone allograft for repair of the loss of hindfoot function : A 12-year case report]. / "Kalkanogenese" mit sekundärer Achillessehnen-Knochenblock-Alloplastik zur Wiedergewinnung der Rückfußfunktion : Eine 12-Jahres-Kasuistik.

BACKGROUND: Calcanectomy and Achilles tendon resection are very hard to repair. OBJECTIVE: Ilizarov's "calcaneogenesis" is possible with ankle joint preservation. Even after 3.5 years of functio laesa of the triceps surae muscle it can be rebuilt. MATERIAL AND METHODS: A 25-year-old motorcyclist suffered a 3rd degree open calcaneal dislocation fracture (type 5). Osteitis and necrosis required calcanectomy, resection of the Achilles tendon and a latissimus dorsi muscle transfer. A talus corpus osteotomy with Ilizarov distraction created in the 1st step a "neo-calcaneus". In a delayed 2nd step a fresh-frozen Achilles tendon-bone block allograft was transplanted to regain active plantar flexion. RESULTS: The initial AOFAS score of 35 points was significantly improved to 70 points 12 years after step 1. After both operations the patient could walk without an orthosis and regained 88% of normal plantar flexion strength. Quantitative measure of health outcome according to EQ-5D-5L was marked by the patient with 80 out of 100 points. DISCUSSION: "Calcaneogenesis" with preservation of the ankle joint is possible and innovative. Despite 3.5 years of disconnection of the triceps surae muscle, an Achilles tendon-bone block allograft could restore 88% of the push-off force even attached to a neo-calcaneus that is 1/3 smaller than normal, which is also new.

The effect of screw insertion configuration of Sinus Tarsi plate on biomechanical performance using finite element analysis.

Sinus Tarsi plates are used as implants for minimally invasive surgery of calcaneus bone fractures. This study evaluated the screw fixation patterns of Sinus Tarsi plates for optimal biomechanical performance. Six three-dimensional (3D) finite element models with different positional screws were evaluated for calcaneus fracture stabilization using Sinus Tarsi plates with 5, 6, and 7 holes. Walking stance conditions as heel strike, midstance, and push-off phases were used to compare loading. Results indicated that the equivalent (EQV) stress exhibited in the implant was higher than in the surrounding bone, with the highest value during the push-off phase. The maximum EQV stress or risk of failure decreased when an insertion screw was placed in the anterior bone using a 7-hole plate, and the most stable strain result at the fracture bone site was recorded for a Sinus Tarsi plate with 7 holes (TT 7-1). The screw insertion pattern and configuration of the Sinus Tarsi plate impacted the biomechanical performance of the calcaneal fracture.

Morphologic evaluation of vascular foramina in dry calcaneus.

PURPOSE: The purpose of this study is to provide reference data regarding the morphology of vascular foramina (VF) of calcaneus among the Turkish population. METHODS: This study was performed using 49 dry calcanei (26 right, 23 left). The number as well as the location of VF in relation of each surface of calcaneus were evaluated. The total length (TL), the distance between the most posterior point of calcaneus and the largest foramina on the medial (LMS), lateral (LLS), superior (LSS) and inferior (LIS) surfaces were measured and foraminal indexes of the largest foramina on the medial (FI1), lateral (FI2), superior (FI3) and inferior (FI4) surfaces were calculated. RESULTS: The mean values of the TL, LMS, LLS, LSS, LIS were measured to be 74.83 ± 6.00 mm, 41.34 ± 4.78 mm, 31.18 ± 7.63 mm, 49.61 ± 13.40 mm, 39.25 ± 13.56 mm, respectively. The mean values of the FI1, FI2, FI3 and FI4 were calculated to be 55.40 ± 6.21%, 41.73 ± 10.06%, 66.01 ± 16.82%, 52.16 ± 16.80%, respectively. The maximum numbers of VF were detected most commonly on the lateral (28.29%) and medial (26.45%) surfaces, and least commonly on the anterior (0.98%) and posterior (8.29%) surfaces. CONCLUSIONS: VF were observed to be most commonly located on the lateral and medial surfaces, and least commonly on the anterior and posterior surfaces. Having adequate knowledge of the morphologic and morphometric properties of the VF is important in regarding the surgical approaches to the calcaneus towards the aim of reducing the vascular damage, especially in lateral approaches for orthopedists and of using differential sign from cystic lesions for radiologists.

Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform.

INTRODUCTION: The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures. METHODS: This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type. RESULTS: A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels. CONCLUSIONS: Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

Proposed complementary osteological indicators: Advancing the estimation of puberty stages in Bioarcheology.

OBJECTIVES: The study of puberty is a well-established area of bioarcheological research, which greatly enhances our understanding of adolescence and growth in the past. Since the publications of Shapland and Lewis' works, which have become "standards" for estimating puberty in skeletal material, no additional osteological indicators of puberty have been proposed. Nevertheless, clinical practice constantly develops skeletal maturation markers that could be useful in bioarcheology. This study aims to assess the applicability and reliability of novel puberty indicators as a complementary tool to estimate puberty in skeletal remains. MATERIALS AND METHODS: Four new maturation markers including spheno-occipital synchondrosis, humeral head ossification, calcaneal apophysis ossification, and mandibular premolar mineralization were selected and applied to a sample of 85 adolescents from pre-Roman southern Italy (Pontecagnano, 7th-4th BCE). RESULTS: Despite some limits in adapting the original clinical methods to osteoarcheological material, the use of these novel skeletal indicators had moderate to excellent scoring repeatability and an overall high agreement with the puberty and menarche status previously estimated with standard methods. These results encourage us to apply these markers in bioarcheology. In some cases, minor adaptations of the original scoring systems are suggested to enhance reliability. DISCUSSION: Including the proposed indicators in routine puberty data collection allows us to refine puberty estimation and improve the ability to identify key growth milestones in poorly preserved skeletons. Further application to osteological collections with diverse chronology and geographical differences is needed to assess how and to what extent the newly proposed maturation markers perform.

Is the occurrence of extra-articular calcaneal fractures of the joint depression type related to osteoporosis and aging?

PURPOSE: The authors experienced several cases of extra-articular calcaneal fracture accompanied by joint depression involving the entire posterior facet without joint involvement. This type of fracture and its characteristics and treatment outcomes have not been previously reported. The study was performed to analyze the characteristics of extra-articular calcaneal fractures of the joint depression type and their postoperative clinical and radiographic results and complications. METHODS: Between February 2013 and March 2021, 23 extra-articular calcaneal fractures of the joint depression type were consecutively treated by a single surgeon. Relationships between fracture characteristics and patient demographics were assessed. Clinical results were quantified using visual analog scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and Foot Function Index, radiographic results were evaluated using Böhler's angles, and calcaneal widths were determined using calcaneal axial and lateral radiographs obtained preoperatively and at last follow-up. RESULTS: Twenty (87%) of the 23 cases occurred in women, and the mean age of all patients was 65.8 years (43-90). The three men were older than 65. Five (21.7%) patients had osteopenia, and 12 (52.2%) had osteoporosis. Bone mineral density testing could not be performed in the other six patients. Clinical and radiographic results were significantly improved after surgery. CONCLUSION: Extra-articular calcaneal fractures of the joint depression type are much more common in women and occur at an older age than calcaneal fractures commonly occur. These fractures are also more common in patients with a low bone mineral density. LEVEL OF EVIDENCE: Level IV.

Prediction of carcass weight using the morphometry of ankle bones in hair goats.

BACGROUND: Morphologic measurements such as body lenght, wither height, heart girth, chest width, body leght, cannon-bone circumference is used to predict carcass weight. For this purpose, estimating carcass weight with measurements of key bones such as ankle bones, which play a significant role in the balance distribution of body weight, seems possible. OBJECTIVES: The aim of this study is to create new regression models for effective carcass weight estimation by using the morphometric data of the talus and calcaneus bones of hair goats. METHODS: Study materials consisted of talus and calcaneus bones obtained from abattoir products of hair goat kids (12-18 months old, 20 female and 20 male) and adult hair goats (36-48 months old, 20 female and 20 male). Morphometric measurements of the talus and calcaneus of each animal were taken by a digital caliper. Using the morphometric measurements, an index and a factor were calculated for each bone. Regression analysis and correlations were examined in IBM SPSS 21 programme. RESULTS: As a result, statistical analysis of GLc, GLt, Bd, Calfactor and Talfactor were statistically significant on predicting carcass weight. CONCLUSION: Specific anatomical structures, such as certain bone measurements, such as talus and calnaneus could serve as indicators of growth performance and also carcass weight performance. In addition new anatomical factors and indices may be produced and new regression methods may be applied with these new parameters to predict carcass weight.

Influence of serum uric acid on bone and fracture risk in postmenopausal women.

AIMS: Uric acid has been associated with several metabolic conditions, including bone diseases. Our objective here was to consider the relationship between serum uric acid levels and various bone parameters (bone mineral density, ultrasonographic parameters, vitamin D, PTH and serum calcium), as well as the prevalence and risk of fragility fracture. METHODS: An observational and cross-sectional study carried out on 679 postmenopausal women, classified into 3 groups according to their serum uric acid levels, in whom bone densitometry, calcaneus ultrasounds, PTH, vitamin D and serum calcium analysis were done. Bone fractures were collected through the clinical history and lateral spinal X-ray. RESULTS: Higher uric acid levels were found in women with older age, high BMI, diabetes, and high blood pressure. Higher levels of PTH and serum calcium were also observed, but did not effect on vitamin D. Serum uric acid was positively related to densitometric and ultrasonic parameters and negatively associated with vertebral fractures. CONCLUSIONS: In the population of postmenopausal women studied, sUA levels were correlated with BMD, BUA, and QUI-Stiffness, and this correlation was independent of age and BMI. In addition, sUA was associated with a decrease in vertebral fractures. These results imply a beneficial influence of sUA on bone metabolism, with both a quantitative and qualitative positive effect, reflected in the lower prevalence of vertebral fractures.

Ontogenic transformation of the ankle from the initial mediolateral arrangement of the calcaneus and talus: A histological study of human embryos and early fetuses.

The human calcaneus is robust and provides a prominent heel for effective bipedal locomotion, although the adjacent talus has no muscle attachments. However, there is incomplete information about the morphological changes in these prominent bones during embryo development. We examined serial histological sections of 23 human embryos and early-term fetuses (approximately 5-10 weeks' gestational age [GA]). At a GA of 5 weeks, the precartilage talus was parallel to and on the medial side of the calcaneus, which had a prolate spheroid shape and consisted of three masses. At a GA of 6 weeks, the cartilaginous talus extended along the proximodistal axis, and the tuber calcanei became long and bulky, with a small sustentaculum talus at the "distal" side. At a GA of 6 to 8 weeks, the sustentaculum had a medial extension below the talus so that the talus "rode over" the calcaneus. In contrast, the talus had a more complex shape, depending on the growth of adjacent bones. At a GA of 9 to 10 weeks, the talus was above the calcaneus, but the medial part still faced the plantar subcutaneous tissue because of the relatively small sustentaculum. Therefore, the final morphology appeared after an additional several weeks. Muscle activity seemed to facilitate growth of the tuber calcanei, but growth of the other parts of calcaneus, including the sustentaculum, seemed to depend on active proliferation at the different sites of cartilage. Multiple tendons and ligaments seemed to fix the talus so that it remained close to the calcaneus.

Minimally invasive technique for acute fixation and subtalar fusion of displaced intra-articular calcaneus fractures.

Displaced intra-articular calcaneus fractures (DIACFs) are difficult injuries to treat and are often encountered by orthopedic surgeons. For DIACFs treated nonoperatively or with open reduction internal fixation (ORIF), a common complication is painful subtalar arthritis and the need for a secondary subtalar fusion, which prolongs the overall recovery time. One treatment option to address this sequela involves ORIF with subtalar fusion as the primary treatment. We describe a reproducible, minimally invasive surgical technique for primary ORIF with subtalar fusion when the calcaneal tuberosity is amendable to cannulated screw fixation to treat these complex calcaneal fractures. Our technique offers advantages compared to other techniques in that it avoids screw traffic, allows easy bony compression of the subtalar joint, and minimizes soft tissue damage via percutaneous screw fixation. Fourteen fractured calcanei in 12 patients underwent our technique and all achieved bony union with a median time to fusion of 107.5 days (range, 54-530 days). Eight patients returned to work with the remaining 4 patients having an unknown work status at last follow-up, although 2 of these 4 patients resumed normal activities. Only 1 patient experienced a complication, which was an infection after achieving bony union, and was treated with successful hardware removal and our infection protocol. Overall, we conclude our surgical technique offers a successful option in the treatment of DIACFs when the calcaneal tuberosity is amendable to cannulated screw fixation.

Postoperative 3D computed tomographic evaluation of 92 calcaneal fracture reduction using the sinus tarsi technique and fixation with 3.5 mm cortical screws.

BACKGROUND: Fixation of calcaneus through the sinus tarsi approach is increasingly popular due to the lower rate of wound complications. The use of postoperative CT provided a better evaluation tool than using plain radiography. Our objective of the present study is to evaluate the quality of fracture reductions by postoperative 3D CT scans after surgical intervention using the sinus tarsi approach and fixation with 3.5 cortical screws. METHODS: Between January 2018 and April 2020, 86 consecutive patients with 92 closed displaced intra-articular calcaneal fractures underwent ORIF with 3.5 mm screws constructed via a minimally invasive sinus tarsi approach by a single foot and ankle surgeon. RESULTS: The preoperative radiographic assessment found 36 joint depression type and 56 tongue type fractures according to the Essex-Lopresti classification. Preoperative CT assessment found 82 type II and 10 type III according to the Sander classification. Analysis of pre- and postoperative CT parameters showed that the height of the posterior facet, the length of the posterior facet, Gissane, and Bohler's angle were significantly improved. In addition, the means of posterior facet step-off in postoperative CT was 1.07, and 72% of posterior facet reductions were < 2 mm step-offs. CONCLUSION: With postoperative CT scan assessment, the treatment of displaced intra-articular calcaneal fracture with 3.5 mm screws via sinus tarsi approach has achieved good quality of reduction. Therefore, the screws-only technique is an option for treating calcaneal fracture with less soft tissue damage and implant cost.

A novel method to perform morphological measurements on three-dimensional (3D) models of the calcaneus based on computed tomography (CT)-imaging.

Background: While current preoperative and postoperative assessment of the fractured and surgically reconstructed calcaneus relies on computed tomography (CT)-imaging, there are no established methods to quantify calcaneus morphology on CT-images. This study aims to develop a semi-automated method for morphological measurements of the calcaneus on three-dimensional (3D) models derived from CT-imaging. Methods: Using CT data, 3D models were created from healthy, fractured, and surgically reconstructed calcanei. Böhler's angle (BA) and Critical angle of Gissane (CAG) were measured on conventional lateral radiographs and corresponding 3D CT reconstructions using a novel point-based method with semi-automatic landmark placement by three observers. Intraobserver and interobserver reliability scores were calculated using intra-class correlation coefficient (ICC). In addition, consensus among observers was calculated for a maximal allowable discrepancy of 5 and 10 degrees for both methods. Results: Imaging data from 119 feet were obtained (40 healthy, 39 fractured, 40 reconstructed). Semi-automated measurements on 3D models of BA and CAG showed excellent reliability (ICC: 0.87-1.00). The manual measurements on conventional radiographs had a poor-to-excellent reliability (ICC: 0.22-0.96). In addition, the percentage of consensus among observers was much higher for the 3D method when compared to conventional two-dimensional (2D) measurements. Conclusions: The proposed method enables reliable and reproducible quantification of calcaneus morphology in 3D models of healthy, fractured and reconstructed calcanei.

Stable Clinical and Radiological Outcomes at Medium and over 5 Year Follow Up of Calcaneus Fracture Open Reduction Internal Fixation Using a Sinus Tarsi Approach.

The sinus tarsi approach is increasingly growing in popularity for open reduction internal fixation of calcaneus fractures. Multiple studies have demonstrated favorable short-term results compared to the traditional extensile L incision, however long-term data over 5 years is currently limited to a single retrospective case series. Following local ethical approval, all patients who had completed a minimum 5 years from time of operation were contacted with a Standardized Telephone Questionnaire completed. This followed a previous retrospective chart review, with follow up telephone or clinic consultation performed by Davey et al. of this cohort at mean 35 months. Thirty-four fractures (31 patients) completed minimum 5 year follow up from the eligible group of 54 fractures (49 patients). Regarding functional outcomes, a significant improvement in mean Maryland Foot Score was observed between short- (mean 35.8 months) and medium-term (mean 81.9 months) of 77.6 (SD 15.0) to 86 (SD 7.9) (p = .0082). There was no significant difference in postoperative and long term radiographic Bohler's angle (p = .9683). Eleven feet (32%) proceeded to require reoperation, with removal of metal performed in 10 (29%), fusion in 2 (6%), and skin grafting following wound breakdown for 1 (3%). Four feet (12.9%) experienced post operative wound complications, including 3 (9.68%) cases of infection and 2 (6.45%) of delayed wound healing. This study demonstrated stable clinical and radiographic outcomes over 5 years following Calcaneus Fracture Open Reduction Internal Fixation using a sinus tarsi approach, supporting its continued usage when treating intraarticular calcaneus fractures for which operative intervention is indicated.