Paradigm Shift for the Surgical Management of Calcaneal Fractures?

Calcaneal fractures account for up to 75% of all foot fractures and 1% to 2% of all fractures. Approximately 75% of calcaneal fractures are intraarticular, resulting in a prolonged recovery, more pain, and disability. The most common mechanism of injury includes falls from a height and motor vehicle accidents. This article reviews studies that compare nonoperative with operative treatment. The literature continues to support surgical intervention; however, these injuries can still be managed nonoperatively in certain clinical scenarios. This article focuses on the surgical management of intraarticular calcaneal fractures and highlights the sinus tarsi approach.

Minimally Invasive Plate Osteosynthesis for Distal Tibia Fractures.

Surgical treatment of distal tibia fractures can present as a difficult task. Intramedullary nailing (IMN), external fixation, and open reduction internal fixation (ORIF) have displayed various complications ranging from a high rate of knee morbidity with IMN to wound complications and infection with ORIF. Minimally invasive plate osteosynthesis (MIPO) has been used to decrease development of these complications. MIPO respects the soft tissue envelope along with maintaining the biological environment needed for proper osseous healing. Favorable results have been shown with MIPO in regard to function, healing time, and decreased complications.

Primary Arthrodesis in Severely Comminuted Fractures.

At present there is controversy regarding the appropriate treatment of severely comminuted fractures of the lower extremity. Even with near-perfect anatomic reduction of severely comminuted fractures, development of posttraumatic arthritis is still present at an increased rate. Primary fusion of comminuted fractures of the foot and ankle creates successful and predictable outcomes, which dismisses the chance of developing posttraumatic arthritis and decreases complications and the need for revisional procedures.

Intramedullary Nailing of Fibular Fractures.

The reamed intramedullary (IM) technique has many benefits. However, open plating is the most commonly used technique. Previously, IM stabilization was reserved for fibular fractures, which were given lower priority, and generally associated with injuries to the distal tibia or instances in which the soft tissue envelope was unsuitable for an open approach. This article reviews the literature and the level of evidence, and presents case examples and operative technique.

Is Subtalar Joint Cartilage Resection Necessary for Tibiotalocalcaneal Arthrodesis via Intramedullary Nail? A Multicenter Evaluation.

Tibiotalocalcaneal arthrodesis with intramedullary nailing is traditionally performed with formal preparation of both the subtalar and ankle joints. However, we believe that subtalar joint preparation is not necessary to achieve satisfactory outcomes in patients undergoing tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail. The primary aim of the present retrospective study was to evaluate the outcomes of patients who had undergone tibiotalocalcaneal arthrodesis with an intramedullary nail without formal subtalar joint cartilage resection. A multicenter medical record review was performed to identify consecutive patients. Pain was assessed using a visual analog scale, and osseous union at the tibiotalar joint was defined as bony trabeculation across the arthrodesis site on all 3 radiographic views. Progression of joint deterioration was evaluated across time at the subtalar joint, using a modified grading system developed by Takakura et al. Forty consecutive patients (aged 61.9 ± 12.9 years; 17 men) met the inclusion and exclusion criteria. Compared with the pain reported preoperatively (6.4 ± 2.7), a statistically significant decline was seen in the pain experienced after surgery (1.2 ± 1.8; p < .001). The mean time to consolidated arthrodesis at the ankle joint was 3.8 ± 1.5 months. A statistically significant increase in deterioration at the subtalar joint was observed across time [t(36) = -6.200, p < .001]. Compared with previously published data of subtalar joint cartilage resection, the present study has demonstrated a similar decline in pain, with a high rate of union, and also a decrease in operative time when preparation of the subtalar joint was not performed.

Intraoperative evaluation of medial intercuneiform instability after Lapidus arthrodesis: intercuneiform hook test.

The presence of intercuneiform instability is not routinely inspected within the overall surgical management of hallux valgus and has therefore been underreported as a potential cause of recurrence. We sought to demonstrate the incidence of this unique type of proximal instability to state its potential importance in the correction and definitive management of hallux valgus in patients with moderate to severe intermetatarsal angles with superimposed hypermobility. A total of 34 patients underwent 38 tarsometatarsal arthrodeses for hallux valgus correction and were retrospectively reviewed for 36 months from May 2007 to May 2010. The incidence of intercuneiform instability was 73.68% and was determined by the findings of the intraoperative "hook" test. The high rate of proximal instability could warrant consideration for routine intermetatarsal arthrodesis as a component of this procedure. A technique for evaluating the presence of intercuneiform instability after Lapidus arthrodesis is also presented.

Radiographic assessment of posterior malleolar ankle fractures.

The anatomy of the posterior tibial malleolus plays an important role in the structure and function of the ankle mortise. With specific respect to ankle fractures, the presence, size, and displacement of posterior malleolar fractures (Volkmann's fracture) helps determine which will be amendable to operative fixation. The objective of the present study was to increase the body of knowledge with respect to the ability of foot and ankle reconstructive surgeons to assess posterior malleolar ankle fractures using plain film radiography. Three different variables were investigated on Sawbones(®) models: (1) differing size of posterior malleolar fractures (10%, 25%, and 50% of the tibial plafond), (2) differing displacement of posterior malleolar fractures (0 and 5 mm of proximal displacement), and (3) 2 different radiographic projections (standard lateral and externally rotated lateral projections). Accurate identification of the posterior malleolar fracture occurred on 86.67% (26 of 30) of standard lateral radiographs and 100% (30 of 30) of externally rotated lateral radiographs. Furthermore, the surgeons described the fracture with greater precision and had greater interclass correlation coefficient values with respect to measurement of sagittal plane displacement (0.977 versus 0.939) and percentage of involvement of the tibial plafond (0.972 versus 0.775) with an externally rotated lateral projection compared with a standard lateral projection. Our results provide evidence that an externally rotated lateral radiographic projection can provide surgeons with some additional information with respect to the presence, size, and displacement of posterior malleolar ankle fractures.

Reliability of a rating scale for assessing alignment of the posterior facet after surgical repair of joint depression fractures of the calcaneus.

Radiographs are frequently used to classify joint depression calcaneal fractures and assess the degree of repair of such injuries. To associate the degree of repair with clinical outcomes such as foot-related quality of life and subjective patient satisfaction, it would be useful to have a valid measuring instrument that has been shown to reliably categorize the alignment of the posterior facet of the calcaneus. To be considered valid, the measurement must have inter-rater and intrarater reliability. In an effort to demonstrate the validity of a coronal plane computed tomographic measurement for categorizing the alignment of the posterior facet after repair of joint depression fractures of the calcaneus, we measured the inter-rater and intrarater reliability of the classification system.

Considerations of a midline posterior approach to the ankle and subtalar joints.

The standard incisional approaches for ankle and subtalar joint surgery include the medial, lateral, or anterior. However, in patients with a history of traumatic injuries or previous surgery, in which the soft tissues of the foot and ankle have been compromised, a direct midline posterior approach might be preferable. The approach offers unparalleled exposure, provides excellent frontal plane visualization, and reduces the risk of vascular compromise by preserving the surrounding angiosomes. We report on 2 separate cases in which a midline posterior approach to the ankle and subtalar joints was used successfully for fusion procedures of the tibiocalcaneal and subtalar joints.

Use of a posterior antiglide plate in a pediatric ankle fracture: a case report.

The authors describe the case of a 13-year-old male with a Salter-Harris II fracture-subluxation of the fibula. Open reduction and internal fixation with a posterior antiglide plate achieved mortise stability and avoided penetration of the fibular physis by fixation devices. After searching the Medline, EMBASE, CINAHL, and the Cochrane Library databases, to our knowledge, there have been no published reports describing the advantages associated with the use of a posterior antiglide plate for fixation of the immature fibula.