Johann Marian Gavlik

The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures.

A wealth of clinical and experimental data suggests, that anatomical restoration of the posterior calcaneal facet is a major predictor of outcome after intra-articular calcaneus fractures. The value of subtalar arthroscopy was examined in three clinical study groups (I–III). Materials and Methods: (I) The subtalar joint was inspected arthroscopically in 28 patients during hardware removal one year after open reduction and internal fixation (ORIF). This procedure was accompanied by subtalar arthrolysis in all cases. (II) Open subtalar arthroscopy was performed to evaluate the quality of reduction after ORIF of intra-articular calcaneus fractures in 59 cases. Arthroscopy was performed after seemingly exact reconstruction of the posterior facet as judged visually and fluoroscopically. (III) Arthroscopically assisted percutaneous reduction and screw fixation (PRSF) was performed in 18 patients with Sanders II fractures. Reduction was achieved with a Schanz screw introduced percutaneously into the tuberosity fragment and controlled fluoroscopically, while fine corrections were made under arthroscopic guidance. Results: (I) Clinical results after ORIF of intra-articular calcaneus fractures were highly correlated to the degree of residual incongruities and chondromalacia of the posterior facet as seen arthroscopically during hardware removal (P<0.01). (II) In 13 of 59 cases (22.0%) during ORIF despite seemingly accurate reduction, steps between 1–2 mm were detected arthroscopically in the posterior calcaneal facet and reduction was repeated subsequently in these cases. (III) Fifteen patients who underwent arthroscopically guided PRSF were re-evaluated after a minimum of one year with excellent clinical results (94.1 pts. with the AOFAS scales). No wound complications were seen. Conclusions: Subtalar arthroscopy provides a most precise and thorough view of the posterior facet of the calcaneus both in assessing the quality of initial reduction as well as evaluation during hardware removal after intra-articular calcaneus fractures. It is more precise than intra-operative fluoroscopy and less time consuming than standard Brodén views during surgery. The use of arthroscopy allows anatomical percutaneous reduction and screw fixation of Sanders II fractures. It therefore provides a useful additional tool in treating intra-articular calcaneus fractures.

The use of subtalar arthroscopy in open reduction and internal fixation of intra-articular calcaneal fractures

Congruency of the subtalar joint is a major predictor of outcome after intra-articular calcaneal fractures. Because of the irregular shape of the posterior joint facet, minor steps may be overlooked with direct vision or intra-operative fluoroscopy during open reduction and internal fixation (ORIF). In a preliminary series of 15 subtalar arthroscopies during hardware removal after ORIF of intra-articular calcaneal fractures, patients with visible steps of 1 mm or more had significantly inferior functional results compared to those with an intact subtalar joint (117 vs. 158 points with the 200-point score, 71.3 vs. 91.2 points with the Maryland Foot Score, P<0.01). Congruency of the posterior facet was controlled arthroscopically in 47 intra-articular calcaneus fractures after open reduction and temporary K-wire-fixation. In 12 cases (25.5%), despite seemingly correct reduction as judged fluoroscopically, incongruencies in the posterior calcaneal facet were detected and reduction was repeated, temporarily removing the K-wires. After anatomical reduction a standard AO calcaneal plate was fixed to the lateral wall. Intra-operative arthroscopy appears to be useful in detecting minor incongruencies after ORIF of intra-articular calcaneus fractures. In the hands of an experienced surgeon it is less time demanding than intra-operative X-rays and more precise than fluoroscopy.

Avascular necrosis after minimally displaced talus fracture in a child.

This is a case report of a delayed diagnosis in a 5 year old child who sustained a minimally displaced fracture of the proximal or posterior aspect of the talar neck of the left fot with no subluxation at the subtalar or ankle joint of his left talus. Avascular necrosis (AVN) appeared 6 months after the injury. The further course was protracted with another 12 months of non-weight bearing. The case was followed until 36 months after the injury with nearly full functional recovery. An extensive literature review revealed a calculated incidence of AVN after reportedly non-displaced talus fractures in children of 16 per cent which is considerably more than is reported in adults. Nearly half of all reported cases occurred after the fracture had been missed initially. 8 of 11 cases with reported age occurred between 1 and 5 years. No child was older than 9 years, which indicates that the immature talus may be more prone to AVN. Some possible causes for the higher incidence of AVN in children with non-displaced talus fractures are discussed. Prolonged non weightbearing cannot be recommended, since it reportedly does not alter the course of the disease.

Historical and current treatment of calcaneal fractures.

To The Editor: We congratulate Dr. Sanders on his excellent Current Concepts Review “Displaced Intra-Articular Fractures of the Calcaneus” (82-A: 225-50, Feb. 2000). Since this topic is of paramount interest and is still a matter of some debate, we would like to provide some information from the non-English-language literature. The historical review should mention the pioneering work of the French school in the 1920s, above all Leriche, who, dissatisfied with the results of closed treatment of calcaneal fractures, practiced open reduction and internal fixation with staples and screws1. The method of percutaneous leverage of the displaced tuberosity fragment and subsequent plaster immobilization of the pin was introduced as early as 1934 by the German surgeon Westhues2. We are well aware that the difficulties in the management of calcaneal fractures are reflected by a long historical record of different treatment options. However, the two above-mentioned procedures represent “milestones” that influenced and inspired surgeons like Palmer and Essex-Lopresti, who established the principles of modern treatment of calcaneal fractures. The computed-tomography-based classification by Zwipp and colleagues3, which was cited by Dr. Sanders, has proved to be of prognostic value when supplemented by an evaluation of soft-tissue damage and comminution on a 12-point scale. Bone fragments (maximum, five) and affected joint facets (maximum, three) are credited with 1 point each. Open or closed soft-tissue damage is scored on a 3-point scale. An additional point is assigned in case of extensive comminution of one major bone fragment or a fracture of another tarsal bone. With a predictive value of 86%, an excellent result can be expected with less than 7 points; a good result, with 7 or 8 points; a satisfactory result, with 9 to 10 points; and a poor result, with 11 or 12 points4. These …

Ergebnisse nach operativer Versorgung intraartikulärer Calcaneusfrakturen

The operative management of displaced intra-articular calcaneus fractures is demanding for the surgeon. Precise preoperative diagnosis, classification and planning is indispensable for succesful treatment. Surgery aims at anatomical restoration of the calcaneal shape as well as exact reduction of the joint facets, especially at the subtalar joint. Even minor steps of 1 – 2 millimeters are associated with the development of painful posttraumatic arthritis.

Arthroskopisch gestützte, perkutane Schraubenosteosynthese intraartikulärer Calcaneusfrakturen / Arthroscopically-Assisted, Percutaneous Osteosynthesis of Intra-Articular Calcaneus Fractures

Im Rahmen der operativen Versorgung intraartikularer Calcaneusfrak-turen gilt der Vermeidung weichteilbedingter Komplikationen hochste Prioritat. Die Methode der arthroskopisch gestutzten perkutanen Schraubenosteosynthese wurde entwickelt, um die Vorteile des minimal-invasiven Vorgehens zu nutzen, ohne auf eine exakte Kontrolle der Gelenkreposition zu verzichten. Das Verfahren wurde von 3/98 bis 6/00 bei 15 Patienten mit geschlossenen Sanders-II-Frakturen angewendet. Die Reposition des tuberositaren Hauptfragmentes mittels einer perkutan eingebrachten Schanz-Schraube (Westhues-Manover) erfolgte unter arthroskopischer Sicht und Bildwandlerkontrolle. Falls erforderlich, wurden anschliesend mit einem von plantar eingebrachten Stosel Feinkorrekturen der Gelenkflache vorgenommen. Die Retention erfolgte mittels perkutan eingebrachter Kortikalis-Zugschrau-ben. Bei 10 Patienten lag 1 Jahr postoperativ ein sehr gutes funktionelles Resultat vor.

Calcaneusfrakturen — Klassifikation und Therapie

ZusammenfassungGrundlagen: Die operative Versorgung von intraartikulären Fersenbeinfrakturen stellt immer noch eine chirurgische Herausforderung dar. Das diagnostische Werkzeug Computertomographie erlaubt, über die Möglichkeit der vollständigeren Darstellung der Frakturpathologie eine, für die prognostische Einschätzung und exakte präoperative Planung, bedeutsame Klassifikation der Verletzung. Methodik: Alle intraartikulären Fersenbeinfrakturen, mit einer Verwerfung einer der drei Gelenkfacetten von mehr als einem Millimeter bzw. alle extraartikulären Frakturen, mit einer schweren Fehlstellung des Rückfußes sollten, falls keine Kontraindikation vorliegt, offen reponiert und übungsstabil retiniert werden. Ziele der operativen Therapie sind die anatomische Rekonstruktion der frakturierten Gelenkebenen, die Wiederherstellung von Höhe, Länge und Breite des Rückfußes sowie die Retention mittels übungsstabiler, nicht gelenkübergreifender Osteosynthese, welche eine frühfunktionelle Behandlung im patienteneigenen Schuh gestattet. Ergebnisse: Von den 348, im Zeitraum vom 1. 10. 1993 bis 1. 12. 1999, offen rekonstruierten Calcaneusfrakturen konnten bislang 169 Patienten im Mittel 18 Monate (10–47 Monate) postoperativ nachuntersucht werden. Unter Zugrundelegen des 200-Punkte-Score nachZwipp konnten 10% der Ergebnisse als sehr gut, 57% als gut, 30% als befriedigend sowie 3% als schlecht eingestuft werden. Schlußfolgerungen: Die offene Reposition und übungsstabile nicht gelenküberbrückende Retention von Fersenbeinfrakturen sollte, unter Würdigung und Beachtung der Komplikationraten sowie unter Kenntnis der genannten Indikationskriterien und Kontraindikationen erwogen werden. Das klinische Ergebnis korreliert gut mit der durch die 12-Punkte-Klassifikation evaluierten primären Verletzungsschwere, die somit eine prognostische Aussage erlaubt.SummaryBackground: Fractures of the calcaneus still represent a challenge to surgical therapy. New radiological techniques made visualisation of the three-dimensional fracture pattern possible and allow precise classification and exact pre-operative planning. Methods: Over the last years there has been a clear tendency towards open reduction and internal fixation of intra-articular calcaneal fractures. The use of the Y-shaped calcaneal plate developed by Sanders can be highly recommended as a standard fixation device. Results: From 348 open reducted calcaneus fractures (10.93–12.99) 169 could be reviewed and documented with a mean follow-up time of 18 (10–47) months. Anatomical reconstruction of the calcaneus and congruency of its joint surfaces lead to good and very good results in 67% and to poor results in 3% of cases. Conclusions: It can be concluded from the presented data, that in intra-articular calcaneal fractures precise anatomical reposition, stable osteosynthesis without joint transfixation and early functional treatment yield excellent and good results in a high percentage of cases. Respecting indications and contraindications and being aware of complications operative treatment should be performed.