The subtalar distraction bone block arthrodesis following the late complications of calcaneal fractures: A systematic review

Introduction: The late complications following a displaced intra-articular calcaneal fractures includes painful arthrosis for which a subtalar fusion might be considered. In case of malalignment due to loss of height and varus deformity a reconstructive arthrodesis is necessary. The primary aim of the current review study was to assess the functional outcome of the subtalar distraction bone block arthrodesis in the management of late complications of displaced intra-articular calcaneal fractures. Methods: The literature was searched for studies in which a subtalar distraction bone block arthrodesis was used in the management of persistent complaints following a displaced intra-articular calcaneal fractures, after its first description in 1988 up to November 1st 2011. The methodological quality of the included studies was assessed using the Coleman Methodology Score. Results: Twenty-one studies reporting on 456 patients were identified. In 93 percent the procedure was a salvage procedures following the late complications of a calcaneal fracture (372 cases). Duration of follow-up ranged from 21 to 108 months (average 40 months). Union rates were reported with an overall average of 96% (range 83-100%). The average modified AOFAS score (maximum 94 points) was 73 points at final follow-up (range 64-83 points). Six studies reported pre- and post-reconstruction AOFAS outcome scores with an average increase of 44.2 points. Wound complications occurred in approximately 6%. With the exception of one study all were level 4 retrospective case series, with an average Coleman Methodology Score of 55 (range 41-79) points. Conclusions: The subtalar distraction bone block arthrodesis is a technically demanding procedure which, in the right hands, provides an overall good result. This is reflected in a significant increase in outcome scores post-operatively. Although most complications are considered minor, there are several pitfalls which should be recognized and avoided

The primary arthrodesis for severely comminuted intra-articular fractures of the calcaneus: A systematic review

Background: Although open reduction and internal fixation via the extended lateral approach is currently considered gold-standard, severely comminuted calcaneal fractures might not be amendable for reconstruction. The primary aim of the current review study was to assess the functional outcome of the primary arthrodesis in the management of comminuted displaced intra-articular calcaneal fractures. Methods: The literature was searched for studies published between January 1st 1990 and December 1st 2010, to identify studies in which a primary arthrodesis was utilized for the treatment of displaced intra-articular calcaneal fractures between. The methodological quality of the included studies was assessed using the Coleman Methodology Score. Results: Seven case series and one abstract were identified, reporting on 120 patients with 128 severely comminuted calcaneal fractures. Average follow-up time was 28 months and union rate 97%. Functional outcome was assessed using the modified AOFAS score in seven studies; with a weighted average of 77.4 (range 72.4-88). One study reported a 75% good to excellent outcome on the Paley score. Three studies reported on return to work, ranging from 75 to 100%. Overall reported wound complications occurred in 19.4%. The average Coleman Methodology Score was 56 (range 38-68) points. Conclusions: The primary arthrodesis for the treatment of Sanders type-IV comminuted displaced intra-articular calcaneal fractures provides overall good results considering the severe nature of the injury. Therefore, in the process of choosing the best treatment modality for a severely comminuted calcaneal fracture, the primary arthrodesis should receive full consideration

Displaced Intra-articular Fractures of the Calcaneus: with an emphasis on minimally invasive surgery

Displaced intra-articular calcaneal fractures are complex injuries. Classically these fractures are treated with open reduction and internal fixation (ORIF) or conservatively. When comparing these two treatment modalities, ORIF has a significantly higher rate of wound complications and conservative management has a significantly higher rate of secondary fusions. Therefore a minimally invasive surgical procedure was introduced at the Erasmus MC in 1998, combining the benefits of both techniques. The aim of this thesis was threefold: 1. To set a basis for improved translatability of outcome in future trials. 2. To determine the outcome of percutaneous reduction and internal fixation using the modified method of Forgon and Zadravecz. 3. To determine the best practice for delayed complications after displaced-intra-articular calcaneal fractures. Important conclusions were: 1. Uniformity in treatment of intra-articular calcaneal fractures More uniformity can been obtained in the evaluation of displaced intra-articular calcaneal fractures. The classification systems by Crosby and by Sanders are the most frequently applied out of the 64 available fracture classifications, and show the best interobserver agreement. The standard radiographs show little correlation with outcome. Out of 34 different outcome scoring systems the AOFAS and the MFS are the most useful. 2. Percutaneous treatment of intra-articular calcaneal fractures Minimal invasive surgery, according to Forgon and Zadravecz, for displaced intra-articular calcaneal fractures, provides overall good to excellent result in 71 to 90% of patients. 3. Management of late complications In case of persistent complaints a subtalar arthrodesis provides equal results compared to a triple arthrodesis. Smoking was a definite risk factor for a failing arthrodesis

Intra-articulaire calcaneusfracturen

ABSTRACT About 0.6% of all fractures is an intra-articular calcaneal fracture. Patients often have additional injuries, and returning to work can take up to one year. The diagnostics consist of plain, lateral and axial, radiographs of the calcaneus. In addition a CT-scan is performed in three planes. Because of the lack of a standardised classification and disease specific outcome-scores there is no agreement on the best treatment modality. More randomised controlled trials are mandatory in the future to determine the best treatment modality for the different types of intra-articular calcaneal fractures

Influence of approach and implant on reduction accuracy and stability in Lisfranc fracture-dislocation at the tarsometatarsal joint

Background: Besides early diagnosis, an anatomical and stable reduction is paramount for obtaining a favorable outcome. The current study looked at the influence that the type of approach for tarsometatarsal injuries has on the accuracy of the reduction and the effect that the type of fixation has on stabili

Final results from the EU project AVATAR: aerodynamic modelling of 10 MW wind turbines

This paper presents final results from the EU project AVATAR in which aerodynamic models are improved and validated for wind turbines on a scale of 10 MW and more. Special attention is paid to the improvement of low fidelity engineering (BEM based) models with higher fidelity (CFD) models but also with intermediate fidelity free vortex wake (FVW) models. The latter methods were found to be a good basis for improvement of induction modelling in engineering methods amongst others for the prediction of yawed cases, which in AVATAR was found to be one of the most challenging subjects to model. FVW methods also helped to improve the prediction of tip losses. Aero-elastic calculations with BEM based and FVW based models showed that fatigue loads for normal production cases were over predicted with approximately 15% or even more. It should then be realised that the outcome of BEM based models does not only depend on the choice of engineering add-ons (as is often assumed) but it is also heavily dependent on the way the induced velocities are solved. To this end an annulus and element approach are discussed which are assessed with the aid of FVW methods. For the prediction of fatigue loads the so-called element approach is recommended but the derived yaw models rely on an annulus approach which pleads for a generalised solution method for the induced velocities

Increased rates of wound complications with locking plates in distal fibular fractures

Introduction: There is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures. Patients and methods: During a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula. Results: A total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p = 0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p = 0.008). Conclusion: There is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures

Extended Lateral Approach for Intra-articular Calcaneal Fractures: An Inverse Relationship between Surgeon Experience and Wound Complications

The current reference standard for the treatment of displaced intra-articular calcaneal fractures is open reduction and internal fixation using an extended lateral approach. In the present retrospective study, we evaluated the results of a consecutive series of patients treated in the same fashion from June 2005 to September 2011 using a subcuticular single-layer closure technique. We also determined the risk factors for the development of wound complications and the rate of wound complications. Also, we assessed which patient, fracture, and surgical characteristics affected these complications. During the 75-month study period, we operated on 53 displaced intra-articular calcaneal fractures in 50 patients using the extended lateral approach. The incision was closed using the subcuticular technique in 49 cases (92.45%). In the subcuticular closure group 2 (4.1%) deep infections and 2 (4.1%) superficial wound complications (1 dehiscence and 1 infection) occurred. Wound edge or flap necrosis was not encountered. The use of bone-void filler and the experience of the surgical team were significantly (p < .001 and p = .026, respectively) associated with the occurrence of wound complications. The subcuticular single-layer suture technique is a suitable closure technique in the treatment of displaced intra-articular calcaneal fractures. It was associated with a low complication rate combined with the extended lateral approach. The effect of bone void fillers on the incidence of complications should receive more attention in future research. The association between wound complications and the experience level of the surgical team supports the need for centralization of this complex injury