Treatment of Displaced Intra-articular Calcaneal Fractures with Percutaneous Screw Fixation at Key Points of the Calcaneus

Abstract

Background: Plate or screw fixation are usually the preferred surgical procedures for the treatment of displaced intra-articular calcaneal fractures (DIACFs), but they are associated with many complications. We therefore attempted to treat DIACFs with percutaneous screw fixation at key points of the calcaneus and observed its efficacy.

Methods: In this retrospective study, 30 patients (35 feet, 5 patients were bilateral) with DIACFs were rigorously screened. Using a homemade calcaneal distractor, reduction of fracture by percutaneous or sinus tarsi approach and screw fixation of the key points of the calcaneus. The visual analogous scale (VAS) score was utilized to evaluate the degree of walking pain, while the American Orthopaedic Foot & Anle Society (AOFAS) ankle-hindfoot scale and Maryland foot score were used to evaluate ankle-foot function and surgical effects.

Results: All 30 patients were followed up for a minimum of 12 months and a maximum of 36 months. Postoperatively, one patient had a superficial infection of traction needle track, one patient had sural nerve injury, and all patients had no pain caused by screw irritation. Follow-up showed that all fractures healed without screw breakage and loss of fracture reduction. The height, length, width, Böhler angle and Gissane angle of the calcaneus were recovered well. All patients could walk normally; AOFAS score: 87.1±8.5 points, with an excellent and good rate of 88.6%; Maryland score: 85.2±9.4 points, with an excellent and good rate of 85.7%; and VAS score: 2.3±1.5 points.

Conclusions: Percutaneous screw fixation at key points of the calcaneus is clinically effective in the treatment of DIACFs.

Introduction

Calcaneal fractures, as the most common type of tarsal fractures, account for approximately 60% of tarsal fractures, with the majority (approximately 75%) falling into the category of intra-articular fractures. How to effectively treat displaced intra-articular calcaneal fractures (DIACFs) has always been one of the most problematic issues in the field of foot and ankle surgery. Standard conservative treatment is also desirable for patients with contraindications to surgery, but such patients have a high tendency to undergo subtalar arthrodesis in the later stages [1, 2]. The extended lateral approach with open reduction and plate fixation, which is extensively applied at present, provides favorable fracture reduction and fixation[3, 4, 5, 6]. However, such a procedure has been criticized due to the many complications associated with the incision [7, 8, 9, 10, 11, 12], and its postoperative function is even worse than that of conservative treatment in severe cases[13, 14]. The screw fixation technique, which has been highly sought after in recent years, has the advantages of less trauma and fewer incision complications [15, 16, 17, 18, 19]. However, problems such as loss of fracture reduction and screw pullout in the later stages have been frequently reported [20, 21]. Therefore, our goal is to probe the indications of screw fixation for DIACFs, explore the direction of screw fixation, clarify the correct place of screw fixation to compensate for the deficiency of conventional operations, and reduce the complications related to screw fixation. In clinical work, we have repeatedly summarized the shortcomings, made improvements, and formed a complete set of screw treatment techniques for DIACFs through strict control of indications and the use of screws to fix the key points of the calcaneus.

Patients And Methods

This retrospective study was conducted in the Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University from January 2017 to January 2019. The research protocol was approved by the hospital ethics committee, and all patients signed informed consent before surgery. Inclusion criteria: ① Patients with fresh calcaneal fractures aged > 16 years and ② patients with large calcaneal tuberosity and sustentaculum tali fracture fragment were selected according to imaging examination preoperatively. Exclusion criteria: Patients with old or pathological calcaneal fractures and severe osteoporosis. A total of 30 patients (35 feet, 5 patients were bilateral), including 26 males and 4 females with an average age of 46.8 years, were screened (Table 1). 

Improvement of preoperative imaging examination: X-ray examinations were performed to determine the Böhler angle, Gissane angle, calcaneal length, height and transverse width, and to investigate the varus and valgus as well as the subtalar joint. Moreover, all patients were classified according to the Essex-Lopresti classification (22 feet were tongue-type fracture, 11 feet were joint depression type, and 2 feet could not be classified). CT scans were conducted of the calcaneus on axial, 30° semicoronal and sagittal positions to determine the degree of fracture, displacement of the intra-articular bone block, displacement of the sustentaculum tali and involvement of the calcaneocuboid joint. Furthermore, all patients were classified according to Sanders classification (22 feet with Sanders II, 7 feet with Sanders III, and 6 feet with Sanders IV) (Table 2). Preoperatively, all the affected feet underwent treatments such as plaster fixation, ice compress and medication to reduce swelling. For patients with simple calcaneal fractures, surgery can be performed after preoperative examination without waiting for the appearance of a skin “wrinkle sign”. In general, the time from injury to surgery ranged from 3–10 d. 

Surgical procedures: ① Recovery of height and length of the calcaneus, as well as correction of the varus and valgus. Drilled a 3.0-mm Kirschner wire vertically on the coronal surface of the calcaneus tuberosity, talus neck and cuboid for traction, and sleeved homemade calcaneus distractor (Chinese Patent No.: 20192254154.4) (Fig. 1) on the inside and outside of the Kirschner wire. The distraction rod connected to the Kirschner wire at the talus neck and cuboid bone was adjusted to form two pulling forces along the calcaneal longitudinal axis and plantar plane to restore the height and length of the calcaneus. For cases with varus calcaneus, the medial distraction force should be greater than the lateral distraction force to correct the varus. In contrast, for cases with valgus calcaneus, the lateral distraction force should be greater than the medial distraction force. After the length and height of the calcaneus, as well as the varus and valgus, were restored, the medial column of the calcaneus was temporarily fixed with 1–2 Kirschner wires. ② Reduction of the articular facet fragment and restoration of the calcaneus width: According to the Sanders and Essex-Lopresti classification, the articular facet fragment was restored with different reduction techniques (the Essex-Lopresti technique or percutaneous reduction by levering-up or direct reduction via sinus tarsi approach). In this study, 22 cases were reduced using the Essex-Lopresti technique, 6 cases by lever up (Fig. 2), and 7 cases involved the sinus tarsi approach. After the facet fragment was reduced, the lateral wall of the calcaneus was squeezed by hand to restore the width of the calcaneus. In this step, the C-arm should be used repeatedly to perform lateral and axial fluoroscopy of the feet. ③ Fixation of the articular facet fragment: According to the size of the facet fragment, one or two 4.3-mm hollow screws were inserted (ITS Company, Australia) into the sustentaculum tali from different positions of the calcaneal thalamus, and the positions of the screws were confirmed using lateral and axial fluoroscopy to prevent the screws from entering the articular cavity and the flexor hallux longus tendon groove. For those with a large tongue fragment, a screw can be added from the tail end of the fragment to the plantar side of the calcaneus tuberosity to strengthen the fixation. ④ Fixation of the whole calcaneus: A hollow 5.5-mm or 6.5-mm screw was inserted into the medial part of the calcaneal tuberosity along the axis of the calcaneal bone to direct the sustentaculum tali and maintain the calcaneal height. Moreover, a hollow 5.5-mm or 6.5-mm screw was inserted into the anterior process of the calcaneus along the axis at the lateral part of the calcaneal tuberosity to maintain the calcaneal length. C-arm fluoroscopy showed that the fracture was well reduced, and the incision or nail hole was closed after flushing (Fig. 3, Fig. 4).

Functional training (including active and passive flexion and extension of toe and ankle joints) was started immediately postoperatively. Two weeks postoperatively, varus and valgus exercises were performed on the feet (including ankle and subtalar joints). One month postoperatively, the injured feet were trained to step on the ball and circle. The timing of weight-bearing was determined according to the fracture healing, which is generally 3 months postoperatively, to start full weight-bearing and start the squat exercise in the auxiliary state. Outpatient reexamination is generally carried out 1, 3, 6 and 12 months postoperatively, and follow-up is performed once a year after 1 year postoperatively.

Results

All 30 patients were followed up, with the shortest follow-up time of 12 months and the longest follow-up time of 36 months. Among all cases, one case developed a superficial infection of the traction needle track, which healed after intravenous infusion of antibiotics. One case showed symptoms of sural nerve injury postoperatively, which was considered to be caused by the suture in the screw incision, and recovered completely 2 months after suture removal. None of the patients suffered from pain caused by screw irritation. At the last follow-up, all fractures healed without screw fracture or reduction loss. The average height of the calcaneus was 39.7 ± 1.9 mm, which was 100.3% of the normal value; the average length was 70.6 ± 2.7 mm, which was 102.9% of the normal value; and the average width was 33.0 ± 1.7 mm, which was 108.9% of the normal value. Moreover, the Böhler angle recovered from 4.4°±13.8° preoperatively to 26.4°±6.3° at the last follow-up, with statistical significance (p < 0.05), while the Gissane angle recovered from 92.8°±11.6° preoperatively to 129.9°±4.9° at the last follow-up, with statistical significance (p < 0.05) (Table 3). All patients could walk normally; AOFAS score: 87.1 ± 8.5 points, with an excellent and good rate of 88.6%; Maryland score: 85.2 ± 9.4 points, with an excellent and good rate of 85.7%; and VAS score: 2.3 ± 1.5 points (Table 4). 

Discussion

Currently, the commonly used minimally invasive percutaneous reduction and fixation technique is derived from the method described by Essex-Lopresti [22], and DIACFs that undergo percutaneous reduction are often fixed with Kirschner wires or screws. At the early stage, screws combined with the percutaneous reduction technique were used for simple Essex-Lopresti tongue-type fractures [16, 17, 19, 23] and Sanders type II fractures [21, 24, 25]. However, with the progress of percutaneous reduction techniques, more complex types of DIACFs can also be reduced using this technique [15, 18]. As a result, percutaneous reduction combined with screw fixation has become more widely indicated, with some researchers even applying this technique to almost all types of calcaneal fractures [18, 26, 27, 28]. Subsequently, the disadvantages of screw fixation have gradually emerged [20, 21], which are mainly manifested as screw pullout associated with osteoporosis and the loss of reduction caused by the unstable fixation of fractures. From this point of view, screw fixation is not suitable for patients with severe osteoporosis. As for the loss of fracture reduction is often closely related to the improper position and orientation of the screw in addition to severely fractures.

Studies have shown that the sustentaculum tali and thalamus, the tuberosity and the anterior part of the calcaneus are the three key points of calcaneal fracture fixation. Any type of fixation method can achieve firm fixation of calcaneal fractures only on the premise of fixing these key points. In view of the anatomical characteristics of the calcaneus itself, most calcaneal fractures in the clinic have completely retained these key points with large fragment, which provide a favorable supporting point and anatomical basis for screw fixation.Therefore, the presence or absence of a large critical fragment is the key to the suitability of the technique for the treatment of DIACFs, rather than the degree of articular facet comminuted as an absolute indication of the choice of screw fixation.

Few clinical studies have been conducted on the direction of screws to ensure maximum fixation strength. According to the author’s experience, the first screw should be placed from the thalamus toward the sustentaculum tali, which is more tightly fixed because of the high density of the trabeculae radiating from the body. The second screw should be placed from the medial part of the tuberosity along the longitudinal axis of the calcaneus to the sustentaculum tali. The sustentaculum tali has a hard cortex and forms a strong inner bearing column with the medial wall of the calcaneus so that the screw can well maintain the height of the calcaneus. The third screw should be placed from the lateral part of the tuberosity along the transverse axis to the anterior part of the calcaneus. However, according to the specific situation,the author will try to make the screw toward the anterior part, where the trabeculae are more abundant and the bone is more rigid (Fig. 5).

In terms of complications, the incidence of complications (1 case of superficial infection of the needle track and 1 case of sural nerve injury) in this study was 6.7%, which was basically consistent with the 0%-15% [17, 18, 19, 29] reported in the literature. For the purpose of preventing the pain caused by skin irritation of the screw tail cap, the screw head was specially buried, and no patient experienced such a complication. A study by Tomesen [18] using percutaneous screws to treat DIACFs showed that the width of the calcaneus was widened by approximately 23.6% compared to the normal, resulting in approximately 22% of patients being unable to walk normally with shoes on. This can be attributed to the large number of Sanders IV cases in the study and the fact that all of them were reduced using a minimally invasive percutaneous approach. In this study, Sanders type IV and some Sanders type III fractures were reduced through the sinus tarsi approach under direct vision, and the satisfactory reduction of the collapsed articular facet was beneficial for the recovery of calcaneus width, which was also better than that achieved by the method used in Tomesen’s study. Therefore, effective reduction is a prerequisite for screw fixation. For cases with obvious fracture displacement, closed reduction should not be pursued excessively, and satisfactory reduction can be obtained by combining limited incision, which provides a preferable foundation for screw fixation and reduction of complications.

In summary, in this study, percutaneous screw fixation at key points of the calcaneus was applied to treat nonsevere osteoporotic DIACFs with large calcaneus tuberosity ,anterior part and sustentaculum tali fragment, which was characterized by the advantages of being minimally invasive and having few complications and reliable fixation, and achieved favorable clinical outcomes. This technique is still an effective supplement to classic surgery, especially with more prominent advantages for patients with contraindications of open reduction and internal fixation. Furthermore, percutaneous screw fixation at key points of the calcaneus in the treatment of patients with DIACFs significantly shortens the preoperative waiting time and total hospital stay, significantly reduces the medical burden, and achieves favorable social benefits.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by the First Affiliated Hospital of Chongqing Medical University, approval number: 2020-414.

Consent for publication

Not applicable

Availability of data and materials

The materials and data in this study are original and can be obtained from the corresponding author

Competing interests

The authors declare that they have no competing interests

Funding

This study was not supported by any funds

Authors' contributions

Xiang Zhang, Orthopaedic Surgeon, Writing the manuscript ,Collecting the data,Statistical analysis,Assisted in the surgeries.

Weidong Ni, Orthopaedic Surgeon, Supervising the study,Editing the manuscript. 

Wei Huang,Orthopaedic Surgeon, Editing the manuscript.

Gang Luo, Orthopaedic Surgeon, Chief surgeon, Designing the study,Editing the manuscript.

Statement

All the authors confirmed that all the methods described in the text were carried out in accordance with the relevant guidelines and regulations under the Declaration section, and the study protocol was approved by the hospital ethics committee and obtained the informed consent of the patient.

References

1. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84(10):1733-44.
2. Csizy M, Buckley R, Tough S, Leighton R, Galpin R. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003;17(2):106-12.
3. Eastwood DM, Langkamer VG, Atkins RM. Intra-articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. J Bone Joint Surg Br. 1993;75(2):189-95.
4. Schepers T, van Lieshout EM, van Ginhoven TM, Heetveld MJ, Patka P. Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey. Int Orthop. 2008;32(5):711-5.
5. Sharr PJ, Mangupli MM, Winson IG, Buckley RE. 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. Foot Ankle Surg. 2016;22(1):1-8.
6. Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int. 1996;17(1):2-9.
7. Al-Mudhaffar M, Prasad CVR, Mofidi A. Wound complications following operative fixation of calcaneal fractures. Injury. 2000;31(6):461-4.
8. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18(1):1-6.
9. Griffin D, Parsons N, Shaw E, Kulikov Y, Lamb SE. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ. 2014;349:g4483.
10. Hsu AR, Anderson RB, Cohen BE. Advances in surgical management of intra-articular calcaneus fractures. J Am Acad Orthop Surg. 2015;23(7):399-407.
11. Koski A, Kuokkanen H, Tukiainen E. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scand J Surg. 2005;94(3):243-5.
12. Veltman ES, Doornberg JN, Stufkens SAS, Luitse JSK, Bekerom MPJVD. Long-term outcomes of 1,730 calcaneal fractures: systematic review of the literature. J Foot Ankle Surg. 2013;52(4):486-90.
13. Coughlin MJ. Calcaneal fractures in the industrial patient. Foot Ankle Int. 2000;21(11):896-905.
14. Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, et al. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma. 2003;17(4):241-9.
15. Abdelgaid SM. Closed reduction and percutaneous cannulated screws fixation of displaced intra-articular calcaneus fractures. Foot Ankle Surg. 2012;18(3):164-79.
16. Gavlik J, Rammelt S, Zwipp H. Percutaneous, arthroscopically-assisted osteosynthesis of calcaneus fractures. Arch Orthop Trauma Surg. 2002;122(8):424-8.
17. Schepers T, Schipper IB, Vogels LM, Ginai AZ, Mulder PG, Heetveld MJ, et al. Percutaneous treatment of displaced intra-articular calcaneal fractures. J Orthop Sci. 2007;12(1):22-7.
18. Tomesen T, Biert J, Frölke JPM. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am. 2011;93(10):920-8.
19. Tornetta IP. Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res. 2000(375):91-6.
20. Li YN, Wu Y. Treatment of calcaneal fracture with minimally invasive surgery. Int J Orthop. 2012;33(5):318-9.
21. Wei N, Zhou Y, Chang W, Zhang Y, Chen W. Displaced intra-articular calcaneal fractures: classification and treatment. Orthopedics. 2017;40(6):e921-9.
22. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the Os calcis. Br J Surg. 1952;39(157):395-419.
23. Park IH, Song KW, Shin SI, Lee JY, Kim TG, Park RS. Displaced intra-articular calcaneal fracture treated surgically with limited posterior incision. Foot Ankle Int. 2000;21(3):195-205.
24. Woon CY, Chong KW, Yeo W, Eng-Meng Yeo N, Wong MK. Subtalar arthroscopy and flurosocopy in percutaneous fixation of intra-articular calcaneal fractures: the best of both worlds. J Trauma. 2011;71(4):917-25.
25. Xu XY, Hu M. Current status of treatment and minimally invasive trend of calcaneal fracture. Zhongguo Gu Shang. 2019;32(11):979-81.
26. DeWall M, Henderson CE, McKinley TO, Phelps T, Marsh JL. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma. 2010;24(8):466-72.
27. Stulik J, Stehlik J, Rysavy M, Wozniak A. Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006;88(12):1634-41.
28. Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years. Arch Orthop Trauma Surg. 2008;128(6):585-91.
29. Smerek JP, Kadakia A, Belkoff SM, Knight TA, Myerson MS, Jeng CL. Percutaneous screw configuration versus perimeter plating of calcaneus fractures: a cadaver study. Foot Ankle Int. 2008;29(9):931-5.