Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures

Background: The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach. Methods: A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker’s compensation claims. Plain radiographs were used to characterize injuries and review outcomes. Results: Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker’s compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union. Conclusion: In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion. Level of Evidence: Level IV, retrospective case series.

Assessment of Progressive Collapsing Foot Deformity Using Semiautomated 3D Measurements Derived From Weightbearing CT Scans

Background: In progressive collapsing foot deformity (PCFD), hind- and midfoot deformities can be hard to characterize based on weightbearing plain radiography. Semiautomated 3-dimensional (3D) measurements derived from weightbearing computed tomography (WBCT) scans may provide a more accurate deformity assessment. In the present study, automated 3D measurements based on WBCT were used to compare hindfoot alignment of healthy individuals to patients with PCFD. Methods: The WBCT scans of 20 patients treated at our institution with either a flexible (N = 10) or rigid (N = 10) PCFD were compared with the WBCT scans of a control group of 30 healthy individuals. Using semiautomated image analysis software, from each set of 3D voxel images, we measured the talar tilt (TT), hindfoot moment arm (HMA), talocalcaneal angle (TCA; axial/lateral), talonavicular coverage (TNC), and talocalcaneal overlap (TCO). The presence of medial facet subluxation as well as sinus tarsi/subfibular impingement was additionally assessed. Results: With the exception of the TCA (axial/lateral), the analyzed measurements differed between healthy individuals and patients with PCFD. The TCA axial correlated with the TNC in patients with PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. Conclusion: Using 3D measurements, in this relatively small cohort of patients, we identified relevant variables associated with a clinical presentation of flexible or rigid PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. Such WBCT-based markers possibly can help the surgeon in decision-making regarding the appropriate surgical strategy (eg, osteotomies vs realignment arthrodesis). However, prospective studies are necessary to confirm the utility of the proposed parameters in the treatment of PCFD. Level of Evidence: Level III, case-control study.

Surgical Treatment Using Sinus Tarsi Approach with Anterolateral Fragment Open-Door Technique in Sanders Type 3 and 4 Displaced Intraarticular Calcaneal Fracture

Although various outcomes of the sinus tarsi approach have been reported, these are limited to the Sanders type 2 displaced intraarticular calcaneal fractures (DIACF) because of the limited visibility of the posterior facet joint. In this study we aimed to (1) introduce a sinus tarsi approach combined with an anterolateral fragment open-door technique that enables adequate visibility of the innermost and middle portion of the posterior facet joint, and (2) evaluate the radiographic and clinical outcomes of the patients treated with that technique. This is a retrospective case-series study performed on medical records of 25 patients who presented with the Sanders type 3 or 4 DIACF and were treated with the sinus tarsi approach. The radiologic measurements showed significant corrections of the Bohler’s angle, calcaneal width, length, height, and articular step-off in both X-rays and CTs in the last follow-up period. The mean AOFAS score was 90.08 ± 6.44 at the last follow-up. Among all the follow-up patients, two cases (8%) had acute superficial infections, and no other wound complications occurred. Therefore, we suggest that the Sanders type 3 or 4 DIACF could be successfully treated with the proposed technique with low complications and bring out effective clinical and radiologic outcomes.

Anatomical Study of Sinus Tarsi–Based Lateral Lengthening Calcaneal Osteotomy

Background: Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO. Methods: Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures. Results: Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet. Conclusion: Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy. Clinical Relevance: Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible. Level of Evidence: Level II, prospective cohort study.

Less Invasive Treatment of 265 Intraarticular Calcaneal Fractures with An Interlocking Nail (C-nail)

Objectives: Less invasive restoration of joint congruity and calcaneal shape in displaced intra-articular calcaneal fractures via a sinus tarsi approach followed by minimally invasive internal fixation with an interlocking nail (C-nail) results in a low rate of soft-tissue complications and good outcomes. Design: Prospective case-control study. Setting: Regional Hospital Trauma Department Patients: A total of 265 calcaneal fractures were treated by using the C-nail between 2011 and 2018 at the Department of Traumatology at the Regional Hospital Pardubice. Intervention: The reduced joint surface was fixed with one or two screws with short thread. All other fragments were fixed after reduction with the C-Nail introduced through the tuberosity. The fragments were fixed with 7 interlocking screws passing through the nail. Main Outcome Measures: Patients were assessed for complications, restoration of Böhler angle, posterior facet reduction with postoperative computed tomography, and weight-bearing radiographs after 6 and 12 months. Results: Wound edge necrosis was seen in three cases (1.1%) and soft tissue infection was observed in one case (0.4%). Böhler’s angle was improved from 5.9° preoperatively to 32.1° postoperatively, measuring 27.6° after 12 months. Conclusions: Two hundred forty-nine patients (222 males and 27 females; mean age 47.3 years) with 265 calcaneal fractures were treated between 2011 and 2018 less-invasively. The sinus tarsi-approach with use of the C-nail shows low risk of infection due to high stability of the fixed fracture.