• View in gallery

    Endobutton-assisted minimally invasive surgical osteosynthesis procedure described by Kesemenli et al18 for a split, displaced calcaneal fracture (A). A 2.7-mm passing pin is passed from the lateral to the medial side of the calcaneus with a drill (B). The tunnel is enlarged with a 5.0-mm Endobutton drill over the passing pin (C). With the aid of the traction strings, the Endobutton arrangement, lying perpendicular to the long axis of the calcaneus, is passed through the 5-mm-diameter tunnel from the lateral to the medial side (D). When one Endobutton reaches the medial cortex, the traction strings on that side are taken out. The foot is put in the equinus position, and closed reduction is performed. At this point, the No. 5 FiberWire sutures (Arthrex Inc, Naples, Florida) passing through the outer holes of the Endobutton are pulled laterally, and compression is provided (E). After fracture reduction and compression, a No. 5 FiberWire suture is tied below the skin at the lateral side (F).

  • View in gallery

    Preoperative (A), early postoperative (B), and late postoperative (C) lateral radiographs of the foot of a patient with tarsal dislocation. Increased density on the talar articular surface of the calcaneal bone and narrowing in the subtalar joint space were found to be suspicious for early subtalar arthritis. D, Preoperative computed tomographic scan showing the split segmentation of the calcaneus. E, Computed tomographic scan showing early postoperative fracture reduction.

  • View in gallery

    Preoperative fluoroscopic views of fracture reduction and fixation. A, After the first Endobutton devices were implanted without tightening, a 2.7-mm passing pin was passed from the lateral to the medial side of the calcaneus with a drill. Second fixation devices will be implanted through the guide of this passing pin. B, After the fixation devices were implanted, they were tied and the fracture line was closed. In some cases, a Steinmann wire was used to correct calcaneal axial misalignment.

  • View in gallery

    A, Preoperative lateral radiograph of the foot. B, Early postoperative lateral radiograph of the foot showing the modification of the Kesemenli18 technique by using a Steinmann wire. C, Late postoperative lateral radiograph of the foot. The patient had a poor American Orthopaedic Foot and Ankle Society score due to subtalar arthrosis at the time of latest follow-up. D, Preoperative coronal section computed tomographic (CT) scan showing a Sanders type 4 calcaneal fracture. E, Preoperative axial section CT scan showing the displaced and varus position of the fracture line. F, A CT scan showing early postoperative fracture reduction.

  • View in gallery

    A, Preoperative lateral radiograph of the foot showing a depressed subtalar joint. B, Early postoperative lateral radiograph of the foot. C, Late postoperative lateral radiograph of the foot. The patient experienced painful subtalar joint movement and had a poor American Orthopaedic Foot and Ankle Society score at the time of latest follow-up. D, Preoperative coronal section computed tomographic (CT) scan showing a Sanders type 3AC calcaneal fracture. E, Preoperative axial section CT scan showing a displaced fracture line. F, A CT scan showing early postoperative fracture reduction.

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Treatment of Calcaneal Fractures with Closed Reduction and the Endobutton-Assisted Technique

Short-Term Analysis

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  • 1 Department of Orthopaedics and Traumatology, Akdeniz University, School of Medicine, Antalya, Turkey.
  • | 2 Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Kocaeli, Turkey.

Background

Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis.

Methods

Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments.

Results

The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent.

Conclusions

With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

Background

Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment of calcaneal fractures. This study presents short-term clinical and radiologic results of patients with calcaneal fractures treated by closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis.

Methods

Twenty-one feet of 18 patients (four women and 14 men) with calcaneal fractures were retrospectively analyzed. Böhler and Gissane angles were measured from the preoperative, postoperative, and latest follow-up lateral radiographs of the feet. American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the 6-month and latest follow-up clinical assessments.

Results

The mean preoperative Böhler angle of 17.1° was corrected to a mean of 20.4° postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3°. The mean preoperative and postoperative Gissane angles were 116° and 117.8°, respectively. The mean value of this angle measured at the time of latest follow-up was 117.4°. The mean 6-month postoperative AOFAS score was 59.8 points. The mean AOFAS score at the time of latest follow-up (79.1 points) was significantly higher than the mean score 6 months postoperatively (P < .001). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent.

Conclusions

With a low learning curve and satisfactory clinical outcomes, this technique can be used in acute, edematous cases with soft-tissue injuries to avoid calcaneal enlargement, infection, and soft-tissue problems.

Calcaneal fractures are the most commonly seen tarsal bone fractures, constituting 2% of all fractures and 65% of all tarsal fractures.1 Seventy percent of these fractures are intra-articular fractures.2 Calcaneal fractures are caused by high-energy trauma. The configuration of the fracture is determined by the position of the foot when the fracture occurs, the bone quality, and the strength of the force that causes the fracture. Force components such as angular and shear force with compression play a role in the formation of these fractures. The state of the soft tissue significantly affects the results of calcaneal fractures.3-5

Conservative or surgical treatment methods are used to treat calcaneal fractures. However, there is no complete consensus on the ideal method of treatment. Closed reduction and percutaneous pinning, open reduction and internal fixation, and primary arthrodesis are procedures used in the surgical treatment.2,6-9 Although many studies reveal that there are no significant differences between conservative and surgical treatments in terms of functional outcomes and pain,10-12 Bajammal et al13 indicated the superiority of surgical treatment in terms of the return to work time and using footwear. The aim of surgical treatment is to restore the normal biomechanics of the Achilles tendon and the rear of the foot by anatomical reduction of the articular surface.14 However, although the rate of wound-healing problems after open reduction and internal fixation are reported in the literature as being 16% to 25%, there are also studies that report this rate to be as high as 43%.11,15,16 Its highly concerning soft-tissue–related complication has prompted many attempts to develop minimally invasive approaches for the treatment of calcaneal fractures. Many authors have described several techniques using arthroscopy-assisted osteosynthesis, minimally invasive plates, percutaneous leverage, percutaneous cannulated screws, the minimally invasive sinus tarsi approach, the “Brixian bridge” technique, external fixation, and mediolateral compression via bolts or Endobutton fixation devices (Smith & Nephew Inc, Andover, Massachusetts).8,17-28

In this study, we aimed to evaluate the clinical and radiologic results of a simple reduction technique described by Kesemenli et al18 for the treatment of calcaneal fractures by presenting 21 feet of 18 patients. The clinical and radiologic results were evaluated retrospectively to investigate the usability of the technique.

Materials and Methods

Twenty-one feet (11 left and ten right) of 18 patients (four women and 14 men) with calcaneal fractures between 2008 and 2010 were retrospectively analyzed. All of the patients were treated by the Kesemenli technique, which described the closed indirect reduction with Endobutton-assisted minimally invasive osteosynthesis (Fig. 1).18 The mean age of the patients was 32.3 years (range, 25–52 years). Mean follow-up was 33.5 months (range, 25–47 months). All of the patients had experienced high-energy trauma, and seven patients had concomitant injury. Of the 18 patients, four had vertebrae fractures, one had a tarsal dislocation (Fig. 2), one had ipsilateral femur and tibia fractures, and one had a radius fracture. Approval for this study was obtained from the Akdeniz University Ethical Board for Clinical Trials. The patients or their families were informed that data from the case would be submitted for publication, and they gave their informed consent, which was archived in the patients' folders.

Figure 1. Endobutton-assisted minimally invasive surgical osteosynthesis procedure described by Kesemenli et al18 for a split, displaced calcaneal fracture (A). A 2.7-mm passing pin is passed from the lateral to the medial side of the calcaneus with a drill (B). The tunnel is enlarged with a 5.0-mm Endobutton drill over the passing pin (C). With the aid of the traction strings, the Endobutton arrangement, lying perpendicular to the long axis of the calcaneus, is passed through the 5-mm-diameter tunnel from the lateral to the medial side (D). When one Endobutton reaches the medial cortex, the traction strings on that side are taken out. The foot is put in the equinus position, and closed reduction is performed. At this point, the No. 5 FiberWire sutures (Arthrex Inc, Naples, Florida) passing through the outer holes of the Endobutton are pulled laterally, and compression is provided (E). After fracture reduction and compression, a No. 5 FiberWire suture is tied below the skin at the lateral side (F).
Figure 1.

Endobutton-assisted minimally invasive surgical osteosynthesis procedure described by Kesemenli et al18 for a split, displaced calcaneal fracture (A). A 2.7-mm passing pin is passed from the lateral to the medial side of the calcaneus with a drill (B). The tunnel is enlarged with a 5.0-mm Endobutton drill over the passing pin (C). With the aid of the traction strings, the Endobutton arrangement, lying perpendicular to the long axis of the calcaneus, is passed through the 5-mm-diameter tunnel from the lateral to the medial side (D). When one Endobutton reaches the medial cortex, the traction strings on that side are taken out. The foot is put in the equinus position, and closed reduction is performed. At this point, the No. 5 FiberWire sutures (Arthrex Inc, Naples, Florida) passing through the outer holes of the Endobutton are pulled laterally, and compression is provided (E). After fracture reduction and compression, a No. 5 FiberWire suture is tied below the skin at the lateral side (F).

Citation: Journal of the American Podiatric Medical Association 105, 1; 10.7547/8750-7315-105.1.33

Figure 2. Preoperative (A), early postoperative (B), and late postoperative (C) lateral radiographs of the foot of a patient with tarsal dislocation. Increased density on the talar articular surface of the calcaneal bone and narrowing in the subtalar joint space were found to be suspicious for early subtalar arthritis. D, Preoperative computed tomographic scan showing the split segmentation of the calcaneus. E, Computed tomographic scan showing early postoperative fracture reduction.
Figure 2.

Preoperative (A), early postoperative (B), and late postoperative (C) lateral radiographs of the foot of a patient with tarsal dislocation. Increased density on the talar articular surface of the calcaneal bone and narrowing in the subtalar joint space were found to be suspicious for early subtalar arthritis. D, Preoperative computed tomographic scan showing the split segmentation of the calcaneus. E, Computed tomographic scan showing early postoperative fracture reduction.

Citation: Journal of the American Podiatric Medical Association 105, 1; 10.7547/8750-7315-105.1.33

After systemic and local examinations, preoperative radiographs were taken. Böhler and Gissane angles were measured from the preoperative, early postoperative, and latest follow-up lateral radiographs of the feet. To elucidate the configurations of the fractures and classify them, preoperative thin-section computed tomographic scans were obtained, and the fractures were classified according to the Sanders classification.29,30 In some patients, the Kesemenli18 technique was modified when the fracture line was perpendicular to the long axis of the calcaneus and to restore a varus-positioned calcaneus by using Steinmann or Kirschner wires, which had been removed 4 weeks after surgery (Figs. 3 and 4). A computed tomographic scan was taken 1 day after the operation to examine fracture reduction and the positions of the Endobuttons (Fig. 2E). American Orthopaedic Foot and Ankle Society (AOFAS) scores were used for the clinical assessment of patients. Patients were questioned using this scale twice in different periods (postoperative month 6 and latest follow-up) to evaluate the relief of pain and improvement of function during follow-up. According to this scale, 90 to 100 points was considered excellent; 80 to 89 points, good; 70 to 79 points, moderate; and less than 70 points, poor.

Figure 3. Preoperative fluoroscopic views of fracture reduction and fixation. A, After the first Endobutton devices were implanted without tightening, a 2.7-mm passing pin was passed from the lateral to the medial side of the calcaneus with a drill. Second fixation devices will be implanted through the guide of this passing pin. B, After the fixation devices were implanted, they were tied and the fracture line was closed. In some cases, a Steinmann wire was used to correct calcaneal axial misalignment.
Figure 3.

Preoperative fluoroscopic views of fracture reduction and fixation. A, After the first Endobutton devices were implanted without tightening, a 2.7-mm passing pin was passed from the lateral to the medial side of the calcaneus with a drill. Second fixation devices will be implanted through the guide of this passing pin. B, After the fixation devices were implanted, they were tied and the fracture line was closed. In some cases, a Steinmann wire was used to correct calcaneal axial misalignment.

Citation: Journal of the American Podiatric Medical Association 105, 1; 10.7547/8750-7315-105.1.33

Figure 4. A, Preoperative lateral radiograph of the foot. B, Early postoperative lateral radiograph of the foot showing the modification of the Kesemenli18 technique by using a Steinmann wire. C, Late postoperative lateral radiograph of the foot. The patient had a poor American Orthopaedic Foot and Ankle Society score due to subtalar arthrosis at the time of latest follow-up. D, Preoperative coronal section computed tomographic (CT) scan showing a Sanders type 4 calcaneal fracture. E, Preoperative axial section CT scan showing the displaced and varus position of the fracture line. F, A CT scan showing early postoperative fracture reduction.
Figure 4.

A, Preoperative lateral radiograph of the foot. B, Early postoperative lateral radiograph of the foot showing the modification of the Kesemenli18 technique by using a Steinmann wire. C, Late postoperative lateral radiograph of the foot. The patient had a poor American Orthopaedic Foot and Ankle Society score due to subtalar arthrosis at the time of latest follow-up. D, Preoperative coronal section computed tomographic (CT) scan showing a Sanders type 4 calcaneal fracture. E, Preoperative axial section CT scan showing the displaced and varus position of the fracture line. F, A CT scan showing early postoperative fracture reduction.

Citation: Journal of the American Podiatric Medical Association 105, 1; 10.7547/8750-7315-105.1.33

Figure 5. A, Preoperative lateral radiograph of the foot showing a depressed subtalar joint. B, Early postoperative lateral radiograph of the foot. C, Late postoperative lateral radiograph of the foot. The patient experienced painful subtalar joint movement and had a poor American Orthopaedic Foot and Ankle Society score at the time of latest follow-up. D, Preoperative coronal section computed tomographic (CT) scan showing a Sanders type 3AC calcaneal fracture. E, Preoperative axial section CT scan showing a displaced fracture line. F, A CT scan showing early postoperative fracture reduction.
Figure 5.

A, Preoperative lateral radiograph of the foot showing a depressed subtalar joint. B, Early postoperative lateral radiograph of the foot. C, Late postoperative lateral radiograph of the foot. The patient experienced painful subtalar joint movement and had a poor American Orthopaedic Foot and Ankle Society score at the time of latest follow-up. D, Preoperative coronal section computed tomographic (CT) scan showing a Sanders type 3AC calcaneal fracture. E, Preoperative axial section CT scan showing a displaced fracture line. F, A CT scan showing early postoperative fracture reduction.

Citation: Journal of the American Podiatric Medical Association 105, 1; 10.7547/8750-7315-105.1.33

Mean ± SD values were calculated for descriptive statistics of continuous variables and median values for discrete variables. The Shapiro-Wilk test was used to analyze the normality of the data. The Pearson correlation test was used to analyze the correlations between the data. The paired-sample test was used to compare the mean values of the same variable measured at different periods. A two-tailed hypothesis was considered in the analyses, and significant differences were accepted at P ≤ .05. A commercially available software program (SPSS 15.0 for Windows; SPSS Inc, Chicago, Illinois) was used in the evaluation of statistical analyses.

Results

All of the operations were performed by one of us (C.C.K.), and all of the radiologic and clinical evaluations were performed by same surgeon (H.A.). According to the Sanders classification, 12 feet were type 2 (three type A, six type B, and three type C), seven were type 3 (three type AB, two type AC [Fig. 5], and two type BC), and two were type 4. The mean preoperative Böhler angle of 17.1° (range, −6°to 36°) was corrected to a mean of 20.4° (range, 4°–40°) postoperatively. The mean value of this angle measured at the time of latest follow-up was 21.3° (range, 6°–44°). There were significant differences in Böhler angles between preoperative compared with postoperative and latest follow-up (P = .004 and P = .001, respectively), and there was no significant difference between postoperative and latest follow-up Böhler angles (P = .094).

The mean preoperative Gissane angle of 116° (range, 92°–159°) was corrected to a mean of 117.8° (range, 94°–150°) postoperatively. The mean value of this angle was measured at the time of latest follow-up as 117.4° (range, 97°–145°). There were no statistically significant differences among preoperative, postoperative, and latest follow-up Gissane angles.

The mean 6-month postoperative AOFAS score was 59.8 (range, 40–70). The mean AOFAS score at the time of latest follow-up was significantly higher than the mean score 6 months postoperatively (P < .001). It was evaluated to be 79.1 points (range, 61–92 points). Regarding the latest follow-up AOFAS scores, four were poor, four were moderate, ten were good, and three were excellent.

There was a significant negative correlation between the age of the patients and AOFAS scores that were noted for the clinical evaluation (r = −0.867 and −0.858, respectively; P < .001). Also, there was a significant positive correlation between preoperative Böhler angles and latest follow-up AOFAS scores (r = 0.465; P = .033).

No complications occurred during or after any of the operations, and no infection or wound problems were seen in any of the patients. All of the patients returned to work in less than 1 year after treatment, and none of the patients noted foot expansion or walking disorders. During short-term follow-up, subtalar joint arthritis was noted in four of 21 feet.

Discussion

The calcaneus is a tarsal bone that makes up the lateral column of the foot, providing vertical support for body weight, and forms the leverage arm to provide gastrosoleus function. Calcaneal fractures are the most commonly seen tarsal bone fractures, constituting 2% of all fractures and 65% of all tarsal fractures,1 and 70% of these fractures are intra-articular fractures.2 Inadequate treatment of intra-articular calcaneal fractures may result in pain and significant functional limitations.6 There remain controversies regarding treatment options for calcaneal fractures.13,31,32 Conservative treatment is the best option for nondisplaced fractures. Severe peripheral vascular disease, insulin-dependent diabetes, drug and substance abuse, tobacco use, open fractures, and life-threatening levels of polytrauma are relative contraindications for surgery. Buckley et al,11 in a randomized study of 424 patients, found no difference between surgical and conservative treatments. In their study, it was reported that conservative treatment was appropriate for patients older than 50 years, those claiming unemployment benefits (workers' compensation), and patients with a heavy workload but that late arthrosis, and ultimately more need for arthrodesis, was seen in patients treated conservatively.11

Although comparative studies in the literature report that surgical treatment gives better results for shoe wearing and time to return to work, there is also substantial reporting of the complications resulting from surgery.11,13,15,16 Although the rate of necrosis of the wound edge after open reduction and internal fixation is 0.4% to 14% with the extended lateral plate-and-screw approach, this rate is 27% with the combined medial and lateral approach in the treatment of displaced fractures of the calcaneus.5,14,33-36 Infection rates are reported to be 1.3% to 7% with the lateral approach.14,34,35 Ebraheim et al37 reported infection rates of 8.5% in surgical approaches involving minimal internal fixation performed directly over the sinus tarsi, where the peroneal tendon and the sural nerve are placed aside for protection, and they reported rates of 9.2% for soft-tissue complications, such as peroneal tendinitis, sinus tarsi syndrome, and compartment syndrome. Neither soft-tissue complication nor infection was seen in any of the present patients operated on with the closed indirect reduction Endobutton-assisted minimally invasive technique. This technique can also be used in acute, edematous cases with soft-tissue injuries. Also, modification of the technique may be necessary if the fracture line is perpendicular to the long axis of the calcaneus or in the case of calcaneovarus or valgus deformity. In the present study, Steinmann or Kirschner wires were used in four of 18 patients to maintain the calcaneal long axis.

A low learning curve, less morbidity, early recovery, a decreased rehabilitation period, and smaller scars will be the superiority of this technique compared with other techniques using open reduction. Furthermore, this technique was found to be more successful compared with conservative treatments in terms of time to return to work and latest follow-up AOFAS scores. Indeed, in surgically treated patients with Sanders type 2 and 3 fractures, Thordarson and Krieger10 found the mean AOFAS score to be 86.7, whereas in patients with similar fractures treated conservatively this score was 55. In the present study, the mean AOFAS score at latest follow-up was found to be 79.1 points, and 13 of 21 feet (61.9%) were evaluated as good or excellent.

The Böhler angle at the time of initial evaluation is one of the important factors for the prognosis of fractures of the calcaneus.38-40 When this angle decreases or is found to be negative, a depression of the posterior facet is indicated.41 Although Böhler in his original article defines the normal value of the angle to be 30° to 35°, very different values have been reported in the literature.39-41 In their study of 268 patients, Seyahi et al42 found the normal value of the Böhler angle to be 20° to 46° and of the Gissane angle to be 100° to 133° for the Turkish population. Measured from their postoperative and latest follow-up lateral foot radiographs, the mean Böhler and Gissane angle results of the present patients, with Endobutton-assisted minimally invasive fixation surgery, were at normal values. Regarding clinical prognoses evaluated by AOFAS scores, there was a statistically significant positive correlation between preoperative Böhler angle and latest follow-up AOFAS scores. Nevertheless, there was no statistically significant correlation of either preoperative or postoperative radiologic measurements with AOFAS scores. The present study revealed that preoperative Böhler angle had a significant role in clinical prognosis, which was mentioned in previous studies.38-40 Nevertheless, the age of the patients may also have a prognostic role in the treatment of calcaneal fractures. The present study clearly showed that the clinical results were statistically significantly negatively affected by the age of the patients.

Patients with calcaneal fractures commonly experienced large foot and shoe problems due to lack of mediolateral compression when they were treated by conservative, mini-open, primer arthrodesis or only lateral approaches.10,43-45 In previous studies, López-Oliva et al45 reported that 81% of patients could wear normal shoes after reconstruction arthrodesis for the treatment of severe calcaneal fractures. Tomesen et al46 reported that 78% were able to wear normal shoes by using closed reduction and percutaneous screw fixation. The result of the present study with respect to normal shoe wear (83.3%; 15 of 18 patients) was comparable with that of López-Oliva et al45 and Tomesen et al.46 And this result was also higher than that of other studies, which reported the results of closed techniques to be 64.2%47 and 68.7%.19

Conclusions

We believe that Endobutton-assisted minimally invasive fixation surgery, which has a short learning curve and a low risk of complications or infection, may be an alternative method for calcaneal fracture fixation, especially with primary fracture lines parallel to the long axis of the bone or with soft-tissue pathologic abnormalities or a high risk of soft-tissue complications.

Financial Disclosure: None reported.

Conflict of Interest: None reported.

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Corresponding author: Halil Atmaca, MD, Department of Orthopaedics and Traumatology, Akdeniz University, School of Medicine, Dumlupinar Ave, 07058, Konyaaltı-Antalya, Turkey. (E-mail: drhalilatmaca@hotmail.com)