Rev. bras. ortop. vol.51 número3

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Original

Article

Comparative

study

on

three

surgical

techniques

for

intra-articular

calcaneal

fractures:

open

reduction

with

internal

fixation

using

a

plate,

external

fixation

and

minimally

invasive

surgery

夽

Missa

Takasaka,

Cintia

Kelly

Bittar,

Fernando

Saddi

Mennucci

∗

_,

Carlos

Augusto

de

Mattos,

José

Luís

Amim

Zabeu

HospitaleMaternidadeCelsoPierro,PontifíciaUniversidadeCatólicadeCampinas(PUC-Campinas),Campinas,SP,Brazil

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Articlehistory: Received27April2015 Accepted10July2015 Availableonline9April2016

Keywords:

Calcaneus/injuries Calcaneus/surgery Comparativestudy

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Objective:Toevaluate,compareandidentifythesurgicaltechniquewithbestresultsfor treatingintra-articularcalcanealfractures, takingintoaccountpostoperativeoutcomes, complicationsandscoringintheAofasquestionnaire.

Methods:This wasa retrospectivestudy on54 patientswith fracturesofthecalcaneus whounderwentsurgerybetween2002and2012bymeansofthefollowingtechniques:(1) openreductionwithextendedL-shapedlateralincisionandfixationwithdouble-Hplateof 3.5mm;(2)openreductionwithminimalincisionlateralapproachandpercutaneous fixa-tionwithwiresandscrews;and(3)openreductionwithminimalincisionlateralapproach andfixationwithadjustablemonoplanarexternalfixator.

Results:Patientstreatedusingalateralapproach,withfixationusingaplatehadamean Aofasscoreof76points;thosetreatedthroughaminimalincisionlateralapproachwith screwandwirefixationhadameanscoreof71points;andthosetreatedthrougha mini-malincisionlateralapproachwithanexternalfixatorhadameanscoreof75points.The threesurgicaltechniqueswereshowntobeeffectivefortreatingintra-articularcalcaneal fractures,withoutanyevidencethatanyofthetechniquesbeingsuperior.

Conclusion:Intra-articularcalcanealfracturesarecomplexandtheirtreatmentshouldbe individualizedbasedonpatientcharacteristics,typeoffractureandthesurgeon’s experi-encewiththesurgicaltechniquechosen.

夽

StudyconductedattheServiceofOrthopedyandTraumatology,HospitaleMaternidadeCelsoPierro,PontifíciaUniversidadeCatólica deCampinas(PUC-Campinas),Campinas,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:fmenucci@msn.com(F.S.Mennucci). http://dx.doi.org/10.1016/j.rboe.2016.04.002

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rev bras ortop.2016;51(3):254–260

255 Estudo

comparativo

entre

três

técnicas

cirúrgicas

para

fraturas

intra-articulares

de

calcâneo:

reduc¸ão

aberta

e

fixac¸ão

interna

com

placa,

fixac¸ão

externa

e

minimamente

invasiva

Palavras-chave: Calcâneo/lesões Calcâneo/cirurgia Estudocomparativo

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Objetivo: Avaliar,comparareidentificaratécnicacirúrgicacommelhorresultadoparao tratamentodefraturasintra-articularesdocalcâneo,levandoemconsideraçãoevolução pós-operatória,complicaçõesepontuaçãonoquestionárioAofas.

Métodos: Estudoretrospectivode54pacientescomfraturasdecalcâneooperadosentree 2002e2012comastécnicas1)reduçãoabertacomincisãolateralalargadaem“L”efixação complacaduplo“H”de3,5mm,2)reduçãoabertaporincisãolateraleconômicaefixação percutâneacomfioseparafusose3)reduçãoabertaporincisãolateraleconômicaefixação comfixadorexternomonoplanarregulável.

Resultados: Pacientestratadospelaviadeacessolateralefixac¸ãocomplacativerammédia de76pontosnaescalaAofas,empacientestratadospelaviadeacessolateraleconômica efixac¸ãocomfioseparafusoamédiafoide71enospacientestratadoscomviadeacesso lateralefixadorexternofoide75pontos.Astrêstécnicascirúrgicasdemostraram-seefetivas notratamentodafraturaintra-articulardocalcâneo,semevidênciadesuperioridadedeuma técnicasobreasdemais.

Conclusão: :Afraturaintra-articulardocalcâneoéumafraturacomplexaeseutratamento deveserindividualizado,baseadonascaracterísticasdopaciente,notipodefraturaena experiênciadocirurgiãocomatécnicaoperatóriaescolhida.

Introduction

Calcanealfracturescorrespondtoapproximately1%to2%of allthefracturesofthehumanbodyandconstitutenearly60% oftarsalbonesfractures.Theygenerallyfollowhigh-energy axialtraumas,suchasfallfromheightormotoraccidents.

Accordingtothe currentliterature,60% to75% ofthese fracturesareconsideredtobedisplacedandintra-articular,1–3 which evidences the difficulty of the treatment. They can causegreatdisabilityduetopainandchronicstiffness,in addi-tiontohindfootdeformities.Thesefracturesarecharacterized clinicallybypoorfunctionalresultsduetotheircomplexity.

Approximately80%to90%ofthecalcanealfractures hap-peninmalesbetween21and40years,mostlyinindustrial workers.Severalauthors4–7_have_reported_that_the rehabilita-tionofthesefracturescantakefromninemonthstoseveral years,whichimplicatesgreateconomicburdenonsociety.

Sincetheearly1980s,thetreatmentofchoicefordisplaced and intra-articular calcaneal fractures was open reduction with internal fixation; however, soft tissue complications, suchassurgicaldehiscenceandinfection,canoccurinupto 30%ofthepatients.8–10

Inanattempttoreducecomplicationrates,newsurgical techniquesemerged,suchasminimallyinvasiveincisionand percutaneousfixation,whichcauselessinjurytothetissues andreducetheincidenceofsofttissuecomplications.10,11

Despite the modern surgical techniques and the con-siderablenumberofstudies intheliterature,11–13 _calcaneal fracturesandtheirbesttreatmentmethodremainanenigma fororthopedicsurgeons.

Thisstudyaimedtoassess,compare,andidentifythe sur-gicaltechniquewiththebestclinicalfunctionalresultinthe treatment ofdisplaced and intra-articular calcaneous frac-ture, including (1) open reduction withextended L-shaped lateralincisionandfixationwith3.5-mmdouble-Hplate;(2) open reductionwithminimalincisionlateral approachand percutaneous fixationwithwires and screws;and (3) open reductionwithminimalincisionlateralapproachandfixation withadjustablemonoplanarexternalfixator.

Material

and

methods

ThestudyprotocolwasapprovedbytheResearchEthics Com-mitteeunderNo.064/11.

Thiswasaretrospectivestudythatanalyzedthemedical chartsof54patientswith60calcanealfractures,operatedon between2002and2012,inanuniversityhospitalin Campi-nas,SP,Brazil,byasingleorthopedicsurgeon(foot-and-ankle specialist).Theinclusioncriteriacomprisedskeletallymature individuals withdeviatedintra-articularcalcaneal fractures classified asSanderstypeIIand III,who were operatedon withoneofthefollowingsurgicaltechniques:

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Fig.1–WidelateralapproachasdescribedbySeligson(A);reductionofthefracturebydirectvisualizationwithperiosteum elevator(B);temporaryfixationofthereductionwithKirschner1.6wire(C);internalfixationwith3.5-mmcalcaneusplate (D).

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rev bras ortop.2016;51(3):254–260

257

Fig.3–Exampleofcalcanealfracturetreatedwithminimalincisionlateralapproachandfixationwithpinsandscrews.(A) Minimalincisionlateralapproach;(BandC)post-operativeresult.

fibularistendons,itispushedoutanteriorlytoexhibitthe lateralaspectofthecalcaneusandthecalcaneocuboidand subtalarjoints.Thefractureisthenreducedandfixedwith a3.5-mmcalcaneusimplant(Figs.1and2).

2. Mini-incisionandfixationwiththreadsandscrews:lateral 3-to5-cmincisiondirectlyabovethetarsalsinus.Divulsion ofthesofttissues,payingcarefulattentiontothefibularis tendons.Thejointfractureisreducedusingdelicate fine-tipchisels.Atemporaryfixationisperformedusing1.6-mm Kirschnerwiresinthefragments,formaintenanceofthe reduction,anddefinitefixationisachievedwithcannulated 3.5-or4.5-mmscrews(Fig.3).

3. Mini-incisionandmonoplanarexternalfixator:lateral 3–5-cm incision directly abovethe tarsalsinus. Divulsionof the soft tissues,payingcarefulattention tothe fibularis tendonsandthesuralnerve.Thejointfractureisreduced usingdelicatefine-tipchisels.Atemporaryfixationis per-formed using1.6-mm Kirschnerwiresin thefragments, for maintenanceof the reduction.Two Schanz pins are insertedinthecalcaneusbelowthejointsurfaceofthe sub-talarregion,twopinsareinsertedintheposteriorregionof thecalcaneusand,finally,twopinsareinsertedinthe ante-riorregion.Theexternalfixatorisblocked.Thenthemain and verticalrails aredistracteduntilproperreductionis visualizedunderfluoroscopy(Fig.4).

Post-operatively,earlymobilizationoftheankleand sub-talarjointsisstimulatedinthefirstpost-operativeweek.The suturesareremovedtwoweeksafterthesurgery.Forpatients operatedwiththeexternalfixationtechnique,partialloadis initiatedafterfour weeks; totalload starts ateightweeks,

Table1–Patientsoperatedwitheachsurgicaltechnique.

Surgicaltechnique Numberof patients

Numberof fractures

L-shapedincisionandplate fixation

20 23

Lateralmini-incisionandfixation withthreadsandscrews

27 27

Adjustablemonoplanarfixator 7 10

togetherwiththeremovalofthefixator.Inothertechniques, partialloadisinitiatedintheeighthpost-operativeweek.All patients undergopost-operativeoutpatientfollow-up forat leasttwoyears.

Skeletally immaturepatients, those withcalcaneal frac-turesclassifiedasSanderstypesI _andIV_,_and_those_who_had undergonepriorfootsurgerywerenotincluded.

Procedures

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Fig.4–Exampleoffracturetreatedwithminimalincisionlateralapproachandfixationwithmonoplanarexternalfixator.

BilateralX-raysinlateralandaxialviewsweretaken preop-eratively,aswellasintheimmediateandlatepost-operative. TheBöhlerandGissaneanglesweremeasured.Thepatients respondedtotheAmericanOrthopedicFootandAnkleSociety (AOFAS)14_and_Johnson15 _{questionnaires,}_and_early_and _late surgicalcomplicationswerealsorecorded.TheAOFAS ques-tionnairemeasuresthesubjectivescaleofpain,footfunction, andthealignmentofthefootandankle,withthefollowing variables:levelofactivity(basicorrecreational),walked dis-tance,abilitytowalkindifferentsurfaces,gaitabnormality, footand hindfootmotion(flexion-extensionand inversion-eversion),andanklehindfootstability.

Johnson’squestionnaireassessescomplicationsand sub-jective satisfaction of the patient: completely satisfied, satisfiedwithminimalrestrictions,satisfiedwithhigh restric-tions,anddissatisfied.

Thegoalwastoassesswhichofthefollowingsurgical tech-niquespresentedthebestresultinthetreatmentofdisplaced andintra-articularcalcaneousfracture:L-shapedlateral inci-sionandfixationwithplate;mini-lateralincisionandfixation withwiresand screws; and adjustablemonoplanarfixator. TheStudent’st-testforcomparisonofmeans,withunknown anddifferentvariances,wasusedforeachpairofmethods.

Thus, the following were compared: (1) if the L-shaped lateralincisionandfixationwithplatewasequaltothe mini-lateralincisionandfixationwithwiresandscrews;(2)ifthe L-shapedlateralincisionandfixationwithplatewasequalto theadjustablemonoplanarfixator;and(3)ifthemini-lateral incisionandfixationwithwiresandscrewswasequaltothe adjustable monoplanar fixator. The answes for the AOFAS questionnairefromeachpatientcomprisedthecollecteddata.

Results

Of20patientstreatedbylateralaccessroutewithplate fixa-tion,16walkedwithoutrestrictions(80%),twolimped(10%), andtwoneededcrutches(10%).Themeanscoreof76(range: 62 to94)wasobtainedintheAOFASscale,inwhich excel-lentresultsrangefrom90to100points.Goodresultsrange from80to89;regular,from70to79;andbad,below69.The meanpost-operativeBöhleranglewas22◦ _(range:₁₂_to₃₂◦₎ andthemeanGissaneanglewas129◦_(range:₁₀₀_to₁₃₂◦_); nor-malvaluesrangefrom20◦_and₄₀◦_for_the_first_angle,_and_are approximately100◦_for_the_second.16

Ofthe 27 patientstreated withminimal incision lateral approach and minimal fixation, 24 walked without limita-tions, two limped, and one needed crutches. All patients presented difficulty to walk in uneven terrain. The mean AOFASscorewas71points(range:60to90).Themean post-operativeBöhlerangleinthesepatientswas18◦_(range:₆_to 40◦₎_and_the_mean_Gissane_angle_was₈₈◦_(range:₇₆_to₁₀₂◦_).

Ofthesevenpatientswhoweretreatedwithminimal inci-sionlateralapproachandexternalfixation,sixwalkedwithout limitationsandonepresentedlimping.ThemeanAOFASscore was75points(range:63to87).Themeanpost-operative Böh-leranglewas17.8◦_(range:₀_to₃₂◦₎_and_the_mean_Gissane_angle was103◦_(range:₁₀₀_to₁₂₆◦_).

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rev bras ortop.2016;51(3):254–260

259

Table2–Resultsfromthestatisticalanalysis.

tobs t-tab p-value v

Comparing

L-shapedincisionandplatefixation 0.77 −2.02 0.44 39.54 Lateralmini-incisionandfixationwithpinsandscrews

Comparing

Lateralmini-incisionandfixationwithpinsandscrews −0.53 −2.19 0.61 11.41 Adjustablemonoplanarfixator

Comparing

L-shapedincisionandplatefixation 0.12 −2.14 0.90 14.07 Adjustablemonoplanarfixator

Discussion

Thecomplexcalcaneus anatomy,itsspongybonestructure with thin cortical, articular and displaced fractures, high-energytrauma,andlittlesofttissuecoveragecontributetothe difficultyinhandlingitsfractures.17–19

In developed countries, most of the displaced intra-articular calcaneal fractures are treated bymeans ofopen reductionvialateralapproachandfixationwithplateand 3.5-mmscrew. This techniqueoffers good visualization ofthe fracture, atthe cost ofgreater damagetothe soft tissues, whichincreasestheriskofnecrosis,surgicaldehiscence,and infection.Thus,severalsurgeonshavebeensearchingfor min-imallyinvasivesurgicaltechniqueswithlessdamagetothe softtissues.20,21

Inthegroupassessed,mostpatientsweremalesatworking age(meanof40years)andallcaseshadaxialtraumadueto fallfromheightasthetraumamechanism.

Inthe analysisoftheradiographic resultsoftheBohler andGissaneanglemeasurements,itwasobservedthatinthe openreductionwithplateandfixationwithplateandscrews andintheopenreduction(minimalincision)with percuta-neousfixationgroups,itwaspossibletorestoretheanglesin 100%ofthecases,whereas intheopenreduction(minimal incision)withadjustablemonoplanarexternalfixatorgroup itwasonlypossibletorestoretheBohleranglein40%ofthe cases.Meanwhile,allvaluesfortheGissaneanglewerearound thereferencevalue.Therecanbeasmallvariancein measur-ingtheseangles,assmallrotationsduringtheradiographic examinationmayinfluencetheobtainedvalues,andalsodue totheprecisionofthegoniometerused.Nevertheless,these measurementswerestandardizedandperformedbyan expe-riencedprofessional.

AccordingtotheJohnsonscore,nopatientwasshownto becompletelysatisfiednorcompletelydissatisfiedwithany oftheusedtechniques.Thiscanbeconsideredapositivefact, duetothetypicalclinicalevolutionofcalcanealfractures.

As for the AOFAS questionnaire, it was observed that regarding the minimally invasive technique with percuta-neous fixation, 7.4% of the patients presented excellent results;51.8%,good;29.6%,fair;andonly11.1%oftheresults wereconsideredpoor.Regardingtheminimallyinvasive tech-niquewithexternalfixation(monoplanaradjustablefixator), thequestionnaireresultsappointed20% goodresults; 60%, fair; and 20%, poor. In the literature, good and excellent resultscanvarybetween42%and62%withtheconventional

Table3–ResultsfromtheAOFASscale.

Surgicaltechnique/AOFAS Mean Variation

L-shapedincisionandplate fixation

76 62–94

Minimalincisionlateral approachwithpinsand screws

71 60–90

Adjustablemonoplanar fixator

75 63–87

technique of open reduction and fixation using plate and screws. This demonstrates anadvantage ofthe mini-open reductionwithpercutaneousfixationcomparingtotheother techniques,asitpresented65.2%goodandexcellentresults, whichwasabovetheobservedmean(Table3).

Regardingthecomplications,atopicofhighrelevancefor thechoiceofthedefinitetreatment,thepresentstudy demon-stratedthatinthegrouptreatedwithmini-openreductionand percutaneousfixation,therewerenosofttissuecomplications suchasnecrosis,dehiscence,tendinitis,ornervousinjuries, whichcanreachfrom27%to33%ofthecasesintheliterature. Inthe externalfixationwithadjustablemonoplanar fixator group,onepatient(14.2%)presentedsofttissueinfection.In the grouptreatedwiththeconventional techniqueofopen reductionandfixationwithplate andscrews,four patients (20%)presentedthefollowingcomplications:infection(25%), skinnecrosis(50%),andsuralnerveneuroma(25%).

The literature indicates that approximately 80% of the patients who undergo the conventional surgical technique returntowork.22,23_The_present_study_demonstrated_that,_with theminimallyinvasivetechniqueandpercutaneousfixation, allpatientsreturnedtotheirworkactivities.Ofthepatients treated withthe conventional technique, 100%returned to theirworkactivities;however,50%ofthemresumeddifferent activities.

Thediscrepancyfoundintheliteraturebetweentheresults obtainedwiththeconventionaltechniqueofL-shapedaccess andtheminimallyinvasivetechniquesmaybeexplainedby thefactthatthelattercauseslessmorbidity,sincetheyare lessaggressivecausinglesssofttissuesdamage.

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thephysicalandmentalstateofthepatient, andthe pres-enceofcomorbidities,suchassmokinganddiabetesmellitus, whichdirectlyinfluencethehealingprocessandcanincrease theriskofsurgicalcomplications.Theliteratureshowsthat the learning curve for the treatment with open reduction andfixationfordisplacedintra-articularcalcaneusfractures isaround35–50surgeries.24_Therefore,_the_surgeon’s experi-encemustalsobeconsideredwhendecidingthebestsurgical technique.

Conclusions

In the face ofaninternational discussion about the effec-tivenessofminimallyinvasivetechnique,thisstudyproved theefficiencyofsuchtechniquesanddemonstratedthat,in addition to that, they are correlated with lower morbidity andbetterqualityoflifeofthepatients,findings thathave alreadybeenobservedintheliterature.However,thepresent studydidnotdemonstrateastatisticalsuperiorityofthe min-imallyinvasivetechniquewithpercutaneousfixationoverthe othertechniques.Studieswithahighernumberofpatientsare needed,consideringthesmallnumberofrandomizedstudies comparingthesetechniques.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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