Introduction

Fractures of the calcaneus are the most commonly occurring fractures in the tarsal bones, accounting for 60% of all tarsal fractures. Among these fractures, 75% are displaced intra-articular fractures. The management of these fractures proves to be challenging and often controversial. Traditionally, open reduction and internal fixation with a conventional plate, using an extensible lateral L-shaped approach, has been considered the standard treatment for displaced intra-articular calcaneal fractures. This approach provides excellent exposure of the fracture and allows for direct reduction of the depressed posterior facet fragment. However, various studies have reported a high rate of postoperative wound complications associated with this technique, including wound edge necrosis, dehiscence, hematoma, or deep infection. To minimize these complications, several minimally invasive procedures have been introduced, such as percutaneous reduction internal fixation, arthroscopically assisted fixation, and minimal incision techniques via different approaches. These techniques aim to reduce soft tissue trauma, thereby lowering the risk of operative complications, while still achieving good fracture reduction.

Aims and Objectives

1.To assess the functional outcome of open reduction and internal fixation of calcaneal fractures using plates and an extensible lateral approach, using the Ankle Orthopedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Score

2.To analyze the advantages and disadvantages of open reduction and internal fixation of calcaneal fractures using locking plates and an extensible lateral approach.

Material & Methods

This study was conducted at the Department of Orthopaedics, Ravindra Nath Tagore Medical College and Maharana Bhupal Hospital in Udaipur, Rajasthan, between December 2021 and November 2022. A total of thirty patients with calcaneum fractures who visited the Orthopedics casualty and outpatient department were admitted and selected for the study based on specific criteria. These patients were followed up for a period of 9 months. Prior to the study, ethical clearance was obtained from the Ethical Committee.

The inclusion criteria for patient selection were as follows:

1.Patients who were willing to give consent and participate in the follow-up

2.Age range of 20 to 60 years

3.Patients with Sanders type II, III, and IV fractures

4.Fractures that occurred within the past 4 weeks

5.Closed fractures of the calcaneum.

On the other hand, the following criteria were used for exclusion:

1.Fractures that occurred more than 4 weeks prior

2.Sanders type I calcaneal fractures

3.Avulsion and compound fractures

4.Patients who were not willing to undergo surgery.

5.Patients who were lost to follow-up or deceased.

The surgical procedure was performed by the senior author, usually within 5 to 12 days (average of 7.4 days) after the injury. Upon admission, all patients had their affected extremities elevated and ice applied to reduce swelling and prevent blisters. Spinal subarachnoid block analgesia or epidural anesthesia was administered, and the patients were positioned either in a lateral decubitus position with the affected foot's lateral malleolus uppermost for unilateral fractures or in a supine position for bilateral fractures.(fig1)

In the routine treatment group, the standard extended lateral approach with an L-shaped incision was employed. The vertical part of the incision was placed between the fibula and Achilles tendon, while the horizontal part aligned with the base of the fifth metatarsal. A full-thickness flap was created by making an incision directly to the bone at the corner. Three 2.0-mm Kirschner wires were used to hold the flap in place once the lateral wall of the calcaneus and subtalar joints were exposed. Distraction with a 3.5 mm Steinmann pin was used for fracture reduction, and fixation was achieved using a Y-plate or H-plate specifically designed for the calcaneus. Rigid fixation was confirmed under C-arm fluoroscopy, and rubber drains were inserted into the anterior and posterior incisions. The incision was then closed in layers, followed by compression bandaging.

Post Operative Care

In the immediate period following the operation, a compression bandage and limb elevation were utilized to effectively reduce swelling. On the 14th day after the operation, the sutures were removed. Two weeks thereafter, mobilization of the ankle joint and subtalar joint was initiated.Few examples showed different cases & followup .(fig 1,2,3)

Post Operative Protocol

Following the operation, intravenous antibiotics were administered for a duration of 5 days, while oral antibiotics were continued for 7 days. A below knee slab was applied to all patients postoperatively. Regular follow-ups were scheduled on a monthly basis for the first three months, followed by visits every three months. These follow-up appointments consisted of subjective evaluations (assessing patient satisfaction) and clinical assessments. The clinical assessments included evaluating pain levels, gait, activity limitations, maximum continuous walking distance, ankle hindfoot stability, plantar flexion and dorsiflexion at the ankle, as well as inversion and eversion at the subtalar joint. These assessments were based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Score. The purpose of using this score during the follow-up period was to gauge the patient's functional improvement. Additionally, radiographs were taken of all patients to assess radiological union, using anteroposterior, lateral view, and Harris axial view.(fig 2).

Table 1: American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score

Figure 1 a,b,c,d ,e,f shows the wrinkle sign, preop sanders type 3 , CT scan showing Sanders type III lateral calcaneal approach with application of lateral anatomical plate, fracture reduction process with the use of K-wires, Functional outcome at 9 months follow up.

Case 3

Fig 3 a, b, c, d: Before the surgery, a clinical photograph was taken, which showed fractures in the right and left calcaneum. CT scans were also performed, revealing Sanders type III fractures in both the left and right calcaneum, respectively. Postoperative radiographs showed the condition of the left and right calcaneum after the surgery. A follow-up examination conducted 9 months after the surgery showed inversion and the preservation of the longitudinal arch of the foot.

CASE 4 Before the surgery, an X-ray was taken. Postoperative X-rays, including both lateral and axial views, were taken at the 9-month mark. The functional outcome at the 9-month follow-up showed positive results for plantar flexion and dorsiflexion, respectively.

Result & Observations

Table 2: Age and Gender wise distribution of patients

Table 4: Number of cases with complications and associated comorbidities and risk factor

Table 5: Duration of fracture union

Table 6: Radiological analysis

Table 7: Functional outcome at 9 months-pain

Table 8: Sanders classification and AOFAS scoring at 3 months follow up

Table 9: Sanders classification and AOFAS scoring at 9 months follow up

Discussion

Although there is ongoing debate about the best way to manage displaced intra-articular calcaneal fractures, the most commonly used approach has been an L-shaped, extensile lateral approach.

This method allows for a good view of the fractured lateral wall of the calcaneus and subtalar joints, as well as the reduction of the subtalar and calcaneocuboid articulations using Steinmann pins. (fig3) Additionally, the fracture is stabilized using internal fixation plates, which have been shown to result in positive functional outcomes. In our study, we observed significant improvements in calcaneal height, width, length, Böhler's angle, and Gissane's angle using this extensile lateral L-shaped approach, with a success rate of 86.8%. Recently, there has been increased focus on the delicate management of soft tissues using the extensile lateral L-shaped approach, including the creation of full-thickness flaps and a "no touch" technique.

However, postoperative wound complications still occur. Previous research has identified risk factors for such complications, including diabetes, smoking, and open fractures. In our own research, we excluded patients with these risk factors and employed full-thickness flaps and a "no touch" technique.

The treatment of displaced calcaneal fractures has also been successfully achieved using percutaneous screws fixation. However, this approach may not fully expose the lateral wall of the calcaneus and limit the use of common calcaneal plates. In our team's approach, we utilized a calcaneus plate with a protruding screw hole for support of fractured fragments below the posterior articular surface.

This creates a solid triangle support through front, central, and rear screw fixation. Our plate has a simple structure, small size, and perfect fit with the lateral calcaneus, providing adequate strength to support the fractured calcaneus while reducing tension on the skin and soft tissues. Additionally, the plate allows for easy insertion and extraction through the channel between the peroneal tendon and the lateral wall of the calcaneus due to its minimal space occupation.

Conclusion

In summary, when it comes to treating displaced fractures in the calcaneum joint, employing an extended lateral approach with calcaneum locking plates and screws for open reduction and internal fixation can yield a considerable number of favorable outcomes, with only a minimal occurrence of unsatisfactory results. Therefore, this treatment approach stands as a superior choice for managing displaced fractures in the calcaneum joint.

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