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Eelsing R, Hemke R, van Oudenaarde K, Halm JA, Schepers T. Radiographic assessment of calcaneal fractures; A new approach to Böhler's angle using computed tomography. Foot (Edinb) 2024; 60:102119. [PMID: 39083853 DOI: 10.1016/j.foot.2024.102119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Böhler's angle (BA) is used for identifying calcaneal fractures and evaluating calcaneal collapse after reconstruction. This study investigates whether it is possible to determine BA with the help of Computed Tomography (CT). METHODS A retrospective study was performed to compare the BA on conventional radiograph (Gold Standard, GS) versus measurements on CT. Two groups were studied: one group consisted of 11 subjects with a diagnosed calcaneal fracture, the other group of 11 subjects with a fracture of the lower extremities but no calcaneal fracture. A lateral Böhler angle (LBA), central Böhler angle (CBA) and a medial Böhler angle (MBA) were defined on CT. Furthermore, BA was reconstructed out of a 3D reconstruction (3DBA). RESULTS CBA approached the GS with a mean difference of 3.78° (95 %CI: 2.82-4.75) with no significant difference in variance (p = 1.000). 3DBA approached the GS with a mean difference of 2.14° (95 %CI: 1.57-2.70) with a significant difference in variance (p = 0.014). No relevant correlations were found between LBA/MBA and the GS. ICC between raters was considered as good or excellent for both CBA and 3DBA. CONCLUSION Giving the high accuracy and better capability to visualize the anatomy in the case of severe injury, measuring BA on 3D reconstruction is a suggested alternative to the traditional technique. LEVEL OF EVIDENCE III, Retrospective.
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Affiliation(s)
- Robin Eelsing
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences, AMS - Musculoskeletal Health, Amsterdam, the Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences, AMS - Musculoskeletal Health, Amsterdam, the Netherlands
| | - Kim van Oudenaarde
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences, AMS - Musculoskeletal Health, Amsterdam, the Netherlands
| | - Jens A Halm
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences, AMS - Musculoskeletal Health, Amsterdam, the Netherlands
| | - Tim Schepers
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences, AMS - Musculoskeletal Health, Amsterdam, the Netherlands.
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2
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Yeomans D, Lewis TL, Pearkes T, Stone B, Hepple S, Riddick A, Harries W, Kelly M, Winson I, Robinson P. Radiological outcomes following open versus percutaneous fixation versus arthroscopically assisted percutaneous fixation of calcaneal fractures: a ten-year retrospective observational study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:823-832. [PMID: 37715837 DOI: 10.1007/s00590-023-03716-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/27/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Calcaneal fractures are often major injuries associated with considerable morbidity. The optimal surgical management of displaced calcaneal fractures remains contentious with open, percutaneous and arthroscopically assisted percutaneous approaches all offering potential benefits for patients. The aim of this study was to assess which of these three separate surgical approaches to the management of displaced calcaneal fractures provides the best radiographic deformity correction. METHODS This is a retrospective observational study of all calcaneal fractures undergoing operative fixation at a single major trauma centre in the UK. The primary outcome was pre- and post-operative assessment of the deformity correction using radiographic parameters (angle of Gissane and Bohler's angle). Secondary outcomes included fracture configuration, complications and re-operation rate. RESULTS Between 01/01/2009 and 31/12/2019, 152 calcaneal fractures in 134 patients underwent operative management via either an open or percutaneous approach. One-way ANOVA testing of the pre- and post-operative radiographic parameters demonstrated that an open approach offered superior post-operative correction of Bohler's angle when compared to percutaneous alone (p < 0.05); however, there was no difference in post-operative angle of Gissane (p > 0.05). The mean follow-up for complication and re-operation data was 3.5 years (range 0.1-12.4). Overall complication rate following all surgical fixation was 7.2% with a further 32.2% requiring further long-term surgical intervention for subtalar arthritis or removal of metalwork. CONCLUSION Arthroscopically assisted percutaneous fixation does not offer superior radiographic deformity correction compared to percutaneous technique alone. Open fixation yielded improved correction of Bohler's angle when compared to percutaneous alone; however, there was no difference in post-operative angle of Gissane. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Daniel Yeomans
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK.
| | | | - Tim Pearkes
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Bradley Stone
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Steve Hepple
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Andrew Riddick
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | | | - Michael Kelly
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Ian Winson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Peter Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Gao D, Wong TM, Fang C, Leung FK, Li X, Jia B, Wang Y, Yu B. Arthroscopic-assisted percutaneous fixation of intra-articular calcaneal fractures using an intraoperative distraction device. J Orthop Surg (Hong Kong) 2021; 29:2309499020979095. [PMID: 33410380 DOI: 10.1177/2309499020979095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the quality of reduction and clinical outcomes by using Percutaneous Distractor and Subtalar Arthroscopy Closed Reduction followed by Internal Fixation (PDSA-CRIF) in the intra-articular calcaneal fracture. METHODS A consecutive case series of 453 patients with 507 displaced intra-articular calcaneal fractures was recruited in this retrospective study. We performed PDSA-CRIF to treat intra-articular calcaneal fractures. The quality of reduction was assessed by early postoperative Computed Tomography (CT) scans and measurement of serial Bohler's angles during follow-ups. Clinical outcomes were evaluated by Visual Analogue Scale (VAS) and the American Foot & Ankle Society ankle-hind foot scale (AOFAS) scoring system. RESULTS Fifty-nine patients (68 fractures) who had complete clinical data and follow-up of at least 12-months (mean: 14 months, range: 12-59 months) were finally included. Anatomical and near-anatomical reduction in subtalar articular surface which had less than 2 mm gap or step-off was found in 93% fractures. Unsatisfactory reduction was found in 7%. CONCLUSION Arthroscopic-assisted percutaneous fixation using a distraction device is effective in achieving positive short-term results in the displaced intra-articular calcaneal fractures. A multicenter, large sample, randomized control trial is needed to fully evaluate the long-term effects of PDSA-CRIF in comparison to other methods.
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Affiliation(s)
- Di Gao
- Department of Orthopedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Orthopedics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak Man Wong
- Department of Orthopedics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Frankie Kl Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Xiang Li
- Department of Orthopedics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Bin Jia
- Department of Orthopedics, Shenzhen Pingle Orthopedics Hospital, Shenzhen, China
| | - Yu Wang
- Department of Orthopaedics, Chifeng Municipal Hospital, Inner Mongolia, China.,Chifeng Clinical Medical School of Inner Mongolia Medical University, Inner Mongolia, China
| | - Bin Yu
- Department of Orthopedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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De Boer AS, Van Lieshout EMM, Vellekoop L, Den Hartog D, Kleinrensink GJ, Verhofstad MHJ. The Influence of Radiograph Obliquity on Böhler's and Gissane's Angles in Calcanei. J Foot Ankle Surg 2020; 59:44-47. [PMID: 31882146 DOI: 10.1053/j.jfas.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 02/03/2023]
Abstract
In calcaneal fractures, Böhler's and Gissane's angles are considered important parameters to guide treatment strategy and provide prognostic information during follow-up visits. Therefore, lateral radiographs have to be accurate. The aim of this study was to evaluate the effect of craniocaudal and posteroanterior angular variations (i.e., simulate lower leg malposition) from the true lateral radiograph on Böhler's and Gissane's angles. In this radioanatomical study, 15 embalmed, skeletally mature, human anatomic lower limb specimens were used. Using predefined criteria, a true lateral radiograph (i.e., 0° angular variation) was obtained. Angular variations from this true lateral radiograph were made from -30° to +30° deviation in the craniocaudal and posteroanterior direction at 5° intervals. Böhler's and Gissane angles were independently assessed by 2 experienced trauma surgeons. Böhler's angle decreased with increasing caudal angular variations (maximum -4.3° deviation at -30°). With increasing of the posterior angular variations, Böhler's angle increased (maximum 5.0° deviation at +30°) from the true lateral radiograph, but all deviations were within the measurement error. The deviation of the angle of Gissane was most pronounced in the cranial direction, with the mean angle decreasing by -8.8° at +30° angular variation. Varying angular obliquity in the caudal and posteroanterior direction hardly affected Gissane's angle. Foot malpositioning during the making of a lateral radiograph has little influence on Böhler's and Gissane's angles. If used for clinical decision-making in initial treatment and during follow-up of calcaneal fractures, these parameters can reliably be obtained from any lateral radiograph.
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Affiliation(s)
- A Siebe De Boer
- Resident Surgery, Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Assistant Professor and Research Coordinator, Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Leonie Vellekoop
- Resident Surgery, Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Surgeon, Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gert Jan Kleinrensink
- Professor, Department of Anatomy and Neurosciences, Erasmus MC, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Professor, Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Herlyn A, Brakelmann A, Herlyn PK, Gradl G, Mittlmeier T. Calcaneal fracture fixation using a new interlocking nail reduces complications compared to standard locking plates - Preliminary results after 1.6 years. Injury 2019; 50 Suppl 3:63-68. [PMID: 31378540 DOI: 10.1016/j.injury.2019.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical treatment of displaced intra-articular calcaneal fractures using a standard extended lateral approach for plate fixation is frequently associated with substantial wound healing complications and infections. This matched pairs analysis compares the new minimally-invasive calcaneal interlocking nailing technique to standard locking plate fixation in terms of reduction capacity, complication rates, and functional outcomes. METHODS Forty feet in 38 patients (mean patient age 52.5 years, range 27-78) were treated with calcaneal locking nail (LN)(n=20) or locking plate (LP)(n=20) and followed clinically and radiologically for 20 months. Follow-up included radiological assessments and functional evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Foot Function Index (R-FFI). RESULTS Times for surgery were similar for both techniques (LN 93min, range 34 to 175 vs. LP 101min, range 53 to 305). Length of hospital stay was significantly lower in the LN group (7.6 days, range 3 to 14 vs. LP 11 days, range 6 to 37). Time away from work was shorter by 3.5 days in LN group. LP group had superior range of motion in plantarflexion, eversion, and inversion at follow-up, while LP patients were superior in demonstrating a secure heelstrike (79% vs. LN 58%) and fewer needed permanent walking aids. AOFAS and FFI scores revealed no differences for both groups. Radiographs indicated an adequate reconstruction in both groups, followed by a slight loss of reduction at follow-up (LP 4.7° postoperative vs. follow-up; LN 5.1°). The overall complication rate between groups was significant with 5% complications in the LN group vs. 50% in the LP group (5% deep infection, 35% impaired wound healing, 5% hardware breakage, 5% superficial wound infection; LN: 5% superficial wound infection). CONCLUSIONS The new calcaneal interlocking nail shows promising results in terms of reduction capacity and safety. Use of the minimally invasive locking nail technique minimized the risk of postoperative wound complications and achieved superior functional outcomes compared with standard locking plate fixation via the extended lateral approach.
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Affiliation(s)
- Anica Herlyn
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany.
| | - Anna Brakelmann
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany
| | - Philipp Ke Herlyn
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany
| | - Georg Gradl
- Dept. of Trauma, Orthopedic and Reconstructive Surgery, Klinikum München Harlaching, Sanatoriumsplatz 2, D-81545 München, Germany
| | - Thomas Mittlmeier
- Dept. of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057 Rostock, Germany
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Looijen RC, Misselyn D, Backes M, Dingemans SA, Halm JA, Schepers T. Identification of Postoperative Step-Offs and Gaps With Brodén's View Following Open Reduction and Internal Fixation of Calcaneal Fractures. Foot Ankle Int 2019; 40:797-802. [PMID: 30957544 PMCID: PMC6610549 DOI: 10.1177/1071100719840812] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To date, there is no consensus regarding which postoperative imaging technique should be used after open reduction and internal fixation of an intra-articular calcaneal fracture. The aim of this study was to clarify whether Brodén's view is sufficient as postoperative radiologic examination to assess step-offs and gaps of the posterior facet. METHODS Six observers estimated the size of step-offs and gaps on Brodén's view in 42 surgically treated intra-articular calcaneal fractures. These findings were compared to postoperative CT scans (gold standard). Inter- and intraobserver reliability were calculated and compared using intraclass correlation coefficients (ICCs). RESULTS An accuracy of approximately 75% for both step-offs and gaps was found in foot and ankle experts. Less experienced observers correctly identified step-offs and gaps in approximately 62% of cases on fluoroscopy and in 48% on radiographs. Interobserver reliability for intraoperative fluoroscopy as well as postoperative radiographs was fair for step-offs, whereas interobserver reliability for gaps was excellent. Intraobserver reliability showed a low level of agreement for intraoperative fluoroscopy, in contrast to postoperative radiographs with excellent agreement for step-offs and good agreement for gaps. CONCLUSION Our results show that especially for more experienced foot and ankle surgeons, in the majority of fractures, Brodén's view accurately showed step-offs and gaps following open reduction and internal fixation. Interobserver reliability showed a fair level of agreement for step-offs and excellent agreement for gaps. Intraobserver reliability was only enough for radiographs, not for fluoroscopy. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Rosalie C. Looijen
- Trauma Unit, Amsterdam University
Medical Center, Amsterdam, the Netherlands
| | - Dominique Misselyn
- Department of Trauma Surgery, University
Hospitals Leuven (UZ), Louvain, Belgium
| | - Manouk Backes
- Trauma Unit, Amsterdam University
Medical Center, Amsterdam, the Netherlands
| | - Siem A. Dingemans
- Trauma Unit, Amsterdam University
Medical Center, Amsterdam, the Netherlands
| | - Jens A. Halm
- Trauma Unit, Amsterdam University
Medical Center, Amsterdam, the Netherlands
| | - Tim Schepers
- Trauma Unit, Amsterdam University
Medical Center, Amsterdam, the Netherlands,Tim Schepers, MD, PhD, Trauma Unit,
Amsterdam UMC, Meibergdreef 9, PO Box 22660, Amsterdam, 1100DD, the Netherlands.
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Galluzzo M, Greco F, Pietragalla M, De Renzis A, Carbone M, Zappia M, Maggialetti N, D'andrea A, Caracchini G, Miele V. Calcaneal fractures: radiological and CT evaluation and classification systems. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:138-150. [PMID: 29350643 PMCID: PMC6179077 DOI: 10.23750/abm.v89i1-s.7017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/31/2022]
Abstract
Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)
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Pan M, Chai L, Xue F, Ding L, Tang G, Lv B. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017; 6:433-438. [PMID: 28747337 PMCID: PMC5539306 DOI: 10.1302/2046-3758.67.2000640] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures. METHODS Two types of fixation systems were selected for finite element analysis and a dual cohort study. Two fixation systems were simulated to fix the fracture in a finite element model. The relative displacement and stress distribution were analysed and compared. A total of 71 consecutive patients with closed Sanders type 2 calcaneal fractures were enrolled and divided into two groups according to the treatment to which they chose: the EFLIF group and the ORIF group. The radiological and clinical outcomes were evaluated and compared. RESULTS The relative displacement of the EFLIF was less than that of the plate (0.1363 mm to 0.1808 mm). The highest von Mises stress value on the plate was 33% higher than that on the EFLIF. A normal restoration of the Böhler angle was achieved in both groups. No significant difference was found in the clinical outcome on the American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale, or on the Visual Analogue Scale between the two groups (p > 0.05). Wound complications were more common in those who were treated with ORIF (p = 0.028). CONCLUSIONS Both EFLIF and ORIF systems were tested to 160 N without failure, showing the new construct to be mechanically safe to use. Both EFLIF and ORIF could be effective in treating Sanders type 2 calcaneal fractures. The EFLIF may be superior to ORIF in achieving biomechanical stability and less blood loss, shorter surgical time and hospital stay, and fewer wound complications.Cite this article: M. Pan, L. Chai, F. Xue, L. Ding, G. Tang, B. Lv. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017;6:433-438. DOI: 10.1302/2046-3758.67.2000640.
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Affiliation(s)
- M Pan
- Orthopaedics Department, Southern Medical University Fengxian District Central Hospital, No. 6600, Nanfeng Road, Fengxian District, Shanghai, China
| | - L Chai
- Orthopaedics Department, The People's Hospital of Bozhou, Anhui Province, No. 3, Xuejia Alley, Qiaocheng District, Bozhou city, Anhui Province, China
| | - F Xue
- Orthopaedics Department, Southern Medical University Fengxian District Central Hospital, No. 6600, Nanfeng Road, Fengxian District, Shanghai, China
| | - L Ding
- Orthopaedics Department, Southern Medical University Fengxian District Central Hospital, No. 6600, Nanfeng Road, Fengxian District, Shanghai, China
| | - G Tang
- Orthopaedics Department, Southern Medical University Fengxian District Central Hospital, No. 6600, Nanfeng Road, Fengxian District, Shanghai, China
| | - B Lv
- Orthopaedics Department, Southern Medical University Fengxian District Central Hospital, No. 6600, Nanfeng Road, Fengxian District, Shanghai, China
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Gonzalez TA, Ehrlichman LK, Macaulay AA, Gitajn IL, Toussaint RJ, Zurakowski D, Kwon JY. Determining Measurement Error for Bohler's Angle and the Effect of X-Ray Obliquity on Accuracy. Foot Ankle Spec 2016; 9:409-16. [PMID: 27354399 DOI: 10.1177/1938640016656236] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA. METHODS A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement. RESULTS A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity. CONCLUSIONS Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph. LEVELS OF EVIDENCE Level V: Cadaver bench study.
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Affiliation(s)
- Tyler A Gonzalez
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - Lauren K Ehrlichman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - Alec A Macaulay
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - I Leah Gitajn
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - R James Toussaint
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - David Zurakowski
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - John Y Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts (TAG, LKE, AAM, ILG)The Orthopaedic Institute, Gainesville, Florida (RJT)Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts (DZ)Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
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10
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Pastor T, Gradl G, Klos K, Ganse B, Horst K, Andruszkow H, Hildebrand F, Pape HC, Knobe M. Displaced intra-articular calcaneal fractures: is there a consensus on treatment in Germany? INTERNATIONAL ORTHOPAEDICS 2016; 40:2181-2190. [PMID: 26899483 DOI: 10.1007/s00264-016-3134-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 02/08/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Open reduction in displaced intra-articular calcaneal fractures entails a high rate of wound healing deficits and infections as well as an uncertain outcome, which leads to remaining ambiguity in treatment preferences. METHODS Between January and July 2011, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 31-question web-based survey regarding three broad domains: fracture classification, surgical treatment algorithms and risk factors for wound healing deficits. RESULTS The response rate was 47 %. With an incidence of 77 %, open reduction via an extended lateral approach and plate fixation was the main treatment option for displaced intra-articular fractures of the joint-depression-type (Sanders II or III). Percutaneous techniques were only preferred in individual cases, with mainly precarious wound situations (59 %) as well as in patients with a reduced general health condition (ASA 3 and 4; 41 %). The re-operation rate due to infections and wound healing deficits after an extended lateral approach was reported with a percentage of 0-5 % by 88 % of the respondents. Participants stated that especially a poor microcirculation of the foot, disregard of soft tissue conserving techniques, overall condition of the patient, smoking, long time-to-surgery and operation time are the main reasons for wound healing deficits. CONCLUSION Given the extended lateral approach as the preferred treatment option, we found minimally invasive techniques and primary arthrodesis of the lower ankle joint play a minor role in treating intra-articular calcaneal fractures in Germany. Ninety percent of our respondents stated less than 5 % of patients required re-operations due to infections and wound healing deficits. Level of Evidence Level V, expert opinion.
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Affiliation(s)
- Tatjana Pastor
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Gertraud Gradl
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Kajetan Klos
- Department of Orthopaedic Trauma, St. Vincenz and Elisabeth Hospital Mainz, Mainz, Germany
| | - Bergita Ganse
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Klemens Horst
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Hagen Andruszkow
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopaedic Trauma, University of Aachen Medical Center, RWTH Aachen University, 30 Pauwelsstreet, 52074, Aachen, Germany.
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Gonzalez TA, Lucas RC, Miller TJ, Gitajn IL, Zurakowski D, Kwon JY. Posterior Facet Settling and Changes in Bohler's Angle in Operatively and Nonoperatively Treated Calcaneus Fractures. Foot Ankle Int 2015; 36:1297-309. [PMID: 26109606 DOI: 10.1177/1071100715592448] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with calcaneus fractures often exhibit settling of the posterior facet with a corresponding decrease in Bohler's angle (BA) following either operative or nonoperative treatment. Both injury BA and postoperative BA have been shown to be prognostic for outcomes; however, the demographic and surgeon-specific factors that may contribute to settling have not been critically examined in the literature. The purpose of this study was to identify these causative factors. METHODS 234 patients with intra-articular calcaneus fractures were analyzed. All patients had preoperative plain radiographs, at least 5 months of orthopedic follow-up, and computed tomography scanning performed. BA was measured on the injury radiographs for all patients. For operatively treated patients, BA was measured on the immediate postoperative radiographs and compared with the last available radiograph. For nonoperatively treated patients, BA was measured on the last available radiograph. All patients were fully weightbearing at the time of final follow-up but not on initial radiographs due to their recent injury. Demographic data including age, gender, energy of injury mechanism, tobacco use, diabetes, osteoporosis, rheumatoid arthritis, and substance/alcohol abuse were retrospectively collected. Fractures were classified using the Essex-Lopresti and Sanders classifications. Time to full weightbearing was documented, as were any reports of noncompliance with weightbearing restrictions. For patients treated operatively, type of fixation (calcaneal-specific perimeter plate, nonperimeter plate, screw fixation), use of locking screws, use of bone graft or graft substitutes, and the number of screws supporting the posterior facet were documented. RESULTS There was a statistically significant amount of settling within the operative and nonoperative groups, but there was no statistically significant difference in settling of BA between the groups. The average settling of BA for the operative and nonoperative group was 8 degrees. Age greater than 50 years, diabetes, and alcohol abuse were all statistically significant and independent predictors of BA settling irrespective of treatment. CONCLUSION The amount of BA settling between the operative and nonoperative group was not significant and showed an average decrease of 8 degrees in each group. However, the amount of settling that we found, irrespective of treatment, increased with patient age, alcohol abuse, and diabetes. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Tyler A Gonzalez
- Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Robert C Lucas
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Timothy J Miller
- KSF Orthopaedic Center, P.A., Orthopaedic Surgery, Houston, TX, USA
| | - I Leah Gitajn
- Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - John Y Kwon
- Orthopaedic Surgery, Harvard Medical School; Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Predicting loss of height in surgically treated displaced intra-articular fractures of the calcaneus. INTERNATIONAL ORTHOPAEDICS 2015; 40:513-8. [PMID: 26374115 DOI: 10.1007/s00264-015-2982-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/17/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The goal of calcaneal fracture surgery is to restore its anatomy and good foot function. However, loss of height of the subtalar joint can occur post-operatively, as expressed by a decrease in Böhler's angle (BA). The aim of this study was to identify potential factors associated with a post-operative decrease in BA. METHODS All consecutive adult patients treated with open reduction and internal fixation (ORIF) by an extended lateral approach (ELA) between 2000 and 2013 were retrospectively included. Primary outcome was the occurrence of a calcaneal collapse, defined as a postoperative decrease of ≥10° in BA. The BA was measured pre-operatively, directly following surgery and at one year follow-up. Patient characteristics (body mass index, diabetes mellitus, smoking/alcohol/substance abuse, American Society of Anaesthesiologist classification), fracture classification and treatment characteristics: per-operative increase in BA and occurrence of post-operative wound infection (POWI) were collected. RESULTS A total of 262 patients with 276 calcaneal fractures were included. A calcaneal collapse occurred in 46 cases (17%). The median preoperative BA, per-operative increase in BA and post-operative decrease in BA were, respectively, 2°, 27° and 4°. A calcaneal collapse was seen more often following a per-operative increase of >25° in BA, but no significant association was found (p = 0.056). Uni- and multivariate analysis showed that patients with substance abuse and those with POWI had significantly more calcaneal collapse (p < 0.05). No association was found between substance abuse and the occurrence of POWI (p = 0.293). CONCLUSIONS In nearly one in six patients with an intra-articular calcaneal fracture treated with ORIF by an ELA, a post-operative collapse of ≥10° was found during follow-up. Calcaneal collapse was correlated with the occurrence of a POWI and substance abuse.
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Effect of sustentaculum screw placement on outcomes of intra-articular calcaneal fracture osteosynthesis: A prospective cohort study using 3D CT. Int J Surg 2015; 19:72-7. [DOI: 10.1016/j.ijsu.2015.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 05/03/2015] [Accepted: 05/07/2015] [Indexed: 11/18/2022]
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Jiang N, Song HJ, Xie GP, Wang L, Liang CX, Qin CH, Yu B. Operative vs nonoperative treatment of displaced intra-articular calcaneal fracture: A meta-analysis of randomized controlled trials. World J Meta-Anal 2015; 3:61-71. [DOI: 10.13105/wjma.v3.i1.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/04/2014] [Accepted: 12/19/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate clinical efficacy of displaced intra-articular calcaneal fracture (DIACF) following operation and nonoperation.
METHODS: Literature search was performed of PubMed and Cochrane Library by two independent authors to identify randomized controlled trials (RCTs) comparing operative vs nonoperative treatment of DIACF from inception to December 31st, 2013. RCT quality was evaluated by the modified Jadad scale. Dichotomous variables were pooled using risk ratios by review manager 5.3 software. Fixed-effects or random-effects models were adopted with P > 0.05 or P≤ 0.05 for heterogeneity tests, respectively.
RESULTS: Eight RCTs comprising 767 cases met inclusion criteria. Results revealed that more surgically treated patients could resume pre-injury job (P = 0.006). No statistical differences were found between the two groups in residual pain (P = 0.33), shoe fitting problems (P = 0.07), limited walking distance (P = 0.56) or secondary late arthrodesis (P = 0.38). However, operative treatment was associated with a higher complication rate (P = 0.003). Subgroup analyses of specific complications revealed that except for a higher risk of superficial wound problems (P < 0.0001) in operative group, the two groups had similar complication rate in deep wound infection (P = 0.34), compartment syndrome (P = 0.46), thromboembolism (P = 0.32), reflex sympathetic dystrophy (P = 0.51) or traumatic arthritis secondary to DIACF (P = 0.43).
CONCLUSION: Current evidence demonstrates that compared with operative treatment, conservative treatment of DIACF lead to similar clinical outcomes regarding residual pain, shoe fitting, walking distance and secondary subtalar arthrodesis but a significantly lower complication rate.
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Arastu M, Sheehan B, Buckley R. Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis. INTERNATIONAL ORTHOPAEDICS 2013; 38:539-45. [PMID: 24337927 DOI: 10.1007/s00264-013-2235-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 11/26/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE The optimal treatment of calcaneal fractures is controversial. A specific subgroup of healthy patients has good outcomes with open reduction and internal fixation using an extensile lateral approach. However, there are many patients who do not fit into this category. Consequently, they are either denied surgical intervention or put at significant risk of developing complications as a result of open surgical intervention. Minimally invasive reduction and fixation (MIRF) of calcaneal fractures can restore the height, width, length and shape of the hindfoot in addition to restoring the orientation of the posterior facet of the calcaneus (Böhler's angle). METHODS We present a series of 31 patients treated with minimally invasive reduction and fixation technique using threaded K wires and Steinmann pins as an alternative treatment method in patients who are not suitable for open reduction and internal fixation. RESULTS The mean time to surgery from injury was six days (range one to ten days). The mean duration of surgery was 35 minutes (range 11-52 minutes). The mean followup was 14.9 months (range of seven to 30 months). The mean change in Böhler's angle and length of the calcaneus from intra-operative fixation to final followup were 18.7° and 4.7 mm, respectively. The complication rate was low and there was one case of a superficial wound infection and no cases of deep infection or peroneal impingement in this series. CONCLUSION The MIRF technique with the use of threaded K wires has not been previously described in the literature. In our experience, the operative time is short and can be safely performed even in the presence of extensive soft tissue swelling in the immediate period following injury. The infection risk is low and calcaneal morphology was improved and maintained in terms of Böhler's angle. This technique is suitable to be considered in patients who have significant medical co-morbidities (smokers, diabetics, peripheral vascular disease) and in those patients who are not suitable for an extensile lateral approach and internal fixation.
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Affiliation(s)
- Mateen Arastu
- Department of Orthopaedic Trauma, Queens Medical Centre, Nottingham, England,
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Reply to comment on Bakker et al.: Change of Böhler's angle during conservatively-treated displaced intra-articular calcaneal fractures. INTERNATIONAL ORTHOPAEDICS 2013; 37:551-2. [PMID: 23275082 DOI: 10.1007/s00264-012-1755-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/09/2012] [Indexed: 10/27/2022]
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Jiang N, Yu B. Comment on Bakker et al.: change of Böhler's angle during conservatively-treated displaced intra-articular calcaneal fractures. INTERNATIONAL ORTHOPAEDICS 2012; 37:549-50. [PMID: 23271692 DOI: 10.1007/s00264-012-1752-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 12/08/2012] [Indexed: 10/27/2022]
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