Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature.

INTRODUCTION: Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences. METHODS: A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied. RESULTS: 3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or ≥10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01). CONCLUSION: Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.

Current management options for displaced intra-articular calcaneal fractures: Non-operative, ORIF, minimally invasive reduction and fixation or primary ORIF and subtalar arthrodesis. A contemporary review.

BACKGROUND: Management of Displaced Intra-articular Calcaneal Fractures (DIACFs) continues to be technically demanding. The literature has not been definitive in its guidance for surgeons dealing with these injuries. Recent publications have further added to the lack of clarity. This review is intended to summarise the present state of knowledge, and provide some genuine guidance for clinicians. OBJECTIVES: To review previous research, focussing on articles published within the last fifteen years, and summarise the findings to aid surgeons in managing DIACFs with choosing best management for patients. METHODS: We reviewed the best evidence and literature, focussing on articles published within the last fifteen years, and summarised findings into workable recommendations. Variables of (1) patient, (2) the associated soft tissue injury and (3) the fracture characteristics were used to aid surgeons in choosing the best of the available options for each patient that presents with a DIACF. AUTHORS SUMMARY: Management of DIACFs can best be divided into four broad categories: (i) non-operative management, (ii) open reduction and internal fixation, (iii) minimally invasive reduction and fixation, and (iv) primary subtalar arthrodesis. The evolution of the literature would suggest orthopaedic surgeons managing calcaneus fractures should have an expert's knowledge, surgical expertise and the latest techniques to cover these four options, to tailor the treatment of DIACFs to the individual patient.

Coronal plane partial articular fractures of the distal femoral condyle: current concepts in management.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Talus fractures: a current concepts review of diagnoses, treatments, and outcomes.

The talus is the key articular segment linking the leg and foot, and as such, is subject to complex loads and may occasionally fracture. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Appropriate, expedient treatment provides the patient the best chance of obtaining a good functional outcome. Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. This current concepts review discusses the pathomechanics, presentation, workup, treatment, and prognosis of fractures of the talar head, neck, body, lateral process, posterior process, and talar extrusions. Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review.

Tarsometatarsal joint complex and midtarsal injuries.

In this article the following areas will be reviewed; the anatomy of the midfoot; mechanisms of injury and current classification systems; diagnosis; treatment options and the evidence for current practice; areas of treatment uncertainty and recommended guidelines for management.

Current concepts review: ankle fractures.

Ankle fractures are common injuries that require meticulous technique in order to optimise outcome. The Lauge-Hansen and Danis-Weber classifications in addition to careful evaluation of the injury mechanism can help guide treatment but surgeons must be aware that there are injury patterns that will not always fit the afore mentioned patterns. The principles of atraumatic soft tissue handling, rigid internal fixation and early range of motion exercises are critical for successfully treating these injuries. There are still areas of treatment uncertainty and future directed research is needed in order to address some of these questions.

Evidence for the best treatment for displaced intra-articular calcaneal fractures.

In conclusion, this clinical scenario has proved to be a clinic conundrum. Unfortunately the surgical team may focus on the fracture and may overlook significant patient characteristics that could help in guiding optimal patient care. Operative management is the treatment of choice as long as complications can be minimized. Nonoperative care can lead to successful results in select patients in a high percentage of cases. Percutaneous fixation and arthroscopic reduction are new are- as for scientific study.

Benign calcaneal bone cyst and pathologic fracture--surgical treatment with injectable calcium-phosphate bone cement (Norian): a case report.

Solitary calcaneal bone cysts are uncommon. Usually they measure 1/3 to 1/2 of the calcaneal length. Symptomatic calcaneal bone cysts are generally treated with open debridement and autologous bone grafting. We report a case of a patient with a displaced intra-articular calcaneal fracture who presents with a large benign calcaneal bone cyst. This patient was treated with debridement and filling of defect with injectable calcium-phosphate bone cement (Norian) and open reduction and internal fixation of the calcaneal fracture.

Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful?

OBJECTIVE: To determine whether autologous bone graft supplementation with open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures (DIACFs) is beneficial in achieving and maintaining restoration of calcaneal height and anatomic reduction of the posterior facet. DESIGN: Prospective historical cohort. SETTING: Level I trauma center, university hospital. PATIENTS AND INTERVENTION: Twenty DIACFs in twenty patients who received ORIF with bone graft supplementation were individually prospectively matched to twenty DIACFs in twenty patients who received only ORIF. Matching criteria for these pairs of patients included age, sex, occupational workload, Essex-Lopresti and Sanders classification, preoperative Böhler's angle, and fixation in the joint. MAIN OUTCOME MEASUREMENTS: Postoperative computed tomography assessed quality of anatomic reduction. Postoperative and three-month follow-up radiographs assessed Böhler's angle. A validated visual analog scale and Short Form-36 assessed functional outcome at a minimum of two years after surgery. RESULTS: Twenty-one fractures were (Orthopaedic Trauma Association) 73-C2 (Sanders Type III); fifteen fractures were 73-C1 (Sanders Type II); and four fractures were 73-C3 (Sanders Type IV). In the individually matched pairs of patients, the mean preoperative Böhler's angle was 2 degrees (standard deviation [SD] 14 degrees) for the bone graft group and 1 degree (SD 12 degrees) for the non-bone graft group. Preoperative Böhler's angle differed between individually matched pairs an average of 4 degrees (range 0 to 10 degrees). Böhler's angle increased with surgery a mean of 26 degrees (SD14 degrees) in the bone graft group and 27 degrees (SD 10 degrees) in the non-bone graft group. In the first three months after surgery, a mean decrease in Böhler's angle of 7 degrees (SD 4 degrees) in the bone graft group and 6 degrees (SD 7 degrees) in the non-bone graft group occurred. Statistical analysis of the individually matched pairs found no significant difference between the bone graft and non-bone graft patients regarding the change in Böhler's angle obtained with surgery (p = 0.98) and the change in Böhler's angle in the three months after surgery (p = 0.94). Quality of reduction was similar between groups, with eight matched pairs obtaining an equal reduction, six achieving a better reduction with bone graft, and six achieving a poorer reduction with bone graft. No differences in functional outcome were detected. CONCLUSIONS: We found no objective radiographic or functional benefit to the use of bone graft supplementation in the operative treatment of DIACFs.

Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial.

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons' score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016). Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.

Subtalar joint movement: clinical and computed tomography scan correlation.

The purpose of this study was to compare subtalar motion measured externally (representing clinical assessment) with subtalar motion measured by computed tomography (CT), in normal individuals. Ten recreationally active subjects (20 lower extremities), aged 20 to 35 years with no lower extremity pathologic condition, were involved in the study. External subtalar inversion and eversion was assessed using a goniometer. By overlaying CT images of the subtalar joint in inversion and eversion on neutral images, angular subtalar motion was measured directly. Subtalar motion measured by CT ranged from 5 degrees to 16 degrees (mean, 11 degrees). External subtalar motion ranged from 39 degrees to 54 degrees (mean, 46 degrees), overestimating CT measurement of subtalar motion by approximately three-fold. This discrepancy is probably secondary to soft tissue motion and talocrural motion that is not isolated from subtalar motion at clinical examination. This solidifies our belief that clinical assessment of subtalar motion should no longer be used to determine or document the measurement of subtalar motion.

Reliability of clinical measurement of subtalar joint movement.

This study was designed to evaluate the intra- and interexaminer reliability during repeated clinical measurements of subtalar movement. The study was a blinded experimental model in which 11 Royal College certified orthopaedic surgeons measured the subtalar movement of the 10 lower extremities of five normal subjects. The measurements were performed in accordance with previously published recommendations. Measurements of both inversion and eversion were recorded in degrees. Employing a variance component analysis, a coefficient of agreement between examiner measures was established. The coefficient of agreements were 0.107 for right lower extremities and 0.0656 for left lower extremities. An evaluation of means and ranges of individual examiner measures demonstrated a potential average loss of range of motion of 20% simply because of variability in measurement. It was also determined that a learning curve did not exist within examiners in this study. The reliability of clinical estimates of subtalar movement by this method is extremely poor. Both inter- and intraexaminer reliability are so poor as to suggest that this method of examination no longer be used to determine or document the measurement of subtalar movement.

Functional outcome measures after displaced intra-articular calcaneal fractures.

We have devised a new scoring system using visual analogue scales (VAS) to determine the functional outcome in 15 patients with 20 displaced intra-articular calcaneal fractures, confirmed by CT. The average follow-up was 19 months. A VAS was completed separately by the patient, the surgeon and an independent assessor. It showed satisfactory agreement between observers and strong correlations with a General Health Survey (SF36), a pain scale (McGill Pain Questionnaire) and a disease-specific, historical scale for calcaneal fractures (the Rowe score).

Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip.

Our purpose was to determine the incidence of deep-vein thrombosis (DVT) in patients who have had early operative fixation of fractures of the lower extremity distal to the hip. There is a high incidence of distal thrombosis in patients who have undergone early operative fixation of lower-extremity fractures. The incidence of DVT is higher with proximal extremity fractures than with distal extremity fractures. Most clots are occult and do not progress clinically. Given the high incidence of DVT with femoral and tibial plateau fractures, older age, and longer operating times, anticoagulation prophylaxis may be indicated. Ours was a prospective incidence study. All patients who had had early operative fixation of lower-extremity fractures were eligible (n = 176). Seventy-four were excluded based on specific criteria. The remaining 102 patients underwent lower-extremity venography an average of 9 days after operative fixation of their fractures (range 3-22 days). Eight patients had bilateral lower-extremity fractures. The patients were followed clinically for 6 weeks to identify complications related to venous disease. The overall incidence of clinically occult DVT was 28%. Of the represented fractures, 40% were of the femoral shaft (eight of 20), 43% of the tibial plateau (12 of 28), 22% of the tibial shaft (12 of 54), and 12.5% of the tibial plafond (one of eight). Four of the thrombi were proximal to the popliteal fossa. Four of the patients had clinical evidence of pulmonary embolism while in the hospital. One of them had objective confirmation on further testing. No patient had clinical evidence of pulmonary emboli as an outpatient by follow-up criteria. The incidence of DVT has not been determined for patients with early stabilization of lower-extremity fractures. This study suggests a higher DVT incidence in more proximal fractures, but little risk of embolization. Thrombus formation proximal to the popliteal fossa is rare. Older age, longer operating times, and longer times before fracture fixation all correlate with an increased incidence of DVT.

Intraarticular fractures of the calcaneus: value of CT findings in determining prognosis.

The prognosis of intraarticular calcaneal fractures is variable, ranging from severe functional impairment and pain to complete return of normal function. Clinical assessment and CT scanning were performed 1-11 years after fracture in 45 patients (51 fractures) to determine the relationship between the CT findings and clinical status. Conservatively treated (n = 18) and surgically treated (n = 33) fractures were assessed. Clinical assessment included evaluation of subjective parameters (pain, activity, gait, and use of orthotics) and objective measurement of subtalar motion. CT evaluation included assessment of abnormalities in the posterior subtalar joint, loss of calcaneal height, tendon abnormalities, and calcaneocuboid joint abnormalities. A poor clinical outcome, caused by loss of subtalar motion, was more common when CT showed incongruity or degeneration of the posterior facet (p = .04) and when Bohler's angle was decreased (p = .0006). Other CT findings, such as loss of calcaneal height and tendon abnormalities, did not correlate with clinical outcome. An unexpected finding was that surgical screws were intraarticular in eight (24%) of 33 surgically treated patients; however, this finding was not significantly associated with poor clinical outcome. Our findings indicate that the CT findings of degenerative change and incongruity of the posterior subtalar joint correlate significantly with poor clinical outcome.

Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen.

Seventeen displaced intraarticular calcaneal fractures treated operatively were matched with 17 nonoperatively treated displaced intraarticular calcaneal fractures among Workers' Compensation Board patients. Matching criteria included type of fracture, age, year of injury, and occupation. After follow-up averaging 6.3 years and 5.4 years, respectively, no significant differences existed between the two groups in heel pain, subtalar motion, and return to work. However, in those fractures treated operatively, the overall clinical result was better when an anatomic reduction of the subtalar joint was achieved.