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ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 121-126

Reduction and functional outcome of open reduction and internal fixation with plate versus minimally invasive screw fixation in displaced intra-articular calcaneum fractures


Department of Orthopaedic Surgery, Liaquat National Hospital and Medical College, Karachi, Pakistan

Date of Submission09-Jun-2020
Date of Decision18-Jul-2020
Date of Acceptance25-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Farhan Sozera
Department of Orthopaedics surgery, Block K, 1st Floor, Liaquat National Hospital and Medical College, National Stadium Road, Karachi 74800
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_18_20

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  Abstract 


Introduction: Calcaneum fracture accounts for 2% of all fractures and 60% of all tarsal bone fractures. The most favored treatment for intra-articular fractures is open reduction and internal fixation using an extended lateral approach. The use of minimally invasive reduction and fixation of calcaneal fractures may have a role in this group of patients where there is a concern regarding wound healing and infection. Materials and Methods: This was a prospective study conducted from April 1, 2016, to April 30, 2018. Eighteen patients were included in the study. Preoperative and postoperative plain radiographs were compared for reduction parameters (improvement of Bohler's angle or Gissane's angle, the width of the calcaneus), Functional outcome was assessed using American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score and visual analog scale. Results: The patients followed up for an average of 15.56 ± 4.85 months. No significant differences in reduction were observed between the open and closed groups (P > 0.05). The average AOFAS scores of the two groups were 76.45 ± 6.83 and 84.65 ± 7.65 (open versus closed) (P = 0.087). The mean visual analog scores of the open and closed groups were 1.38 ± 1.15 and 0.75 ± 0.45 (P = 0.034). The complication rates of the open and closed groups were 33% (3/9) and 10% (1/9) (P = 0.0053). Conclusion: Closed reduction and percutaneous screw fixation have shown better results in terms of outcome and complications. However, multicenter controlled randomized clinical trials are still required prior to widespread practical implementation.

Keywords: Calcaneum fracture, functional outcome, reduction outcome


How to cite this article:
Sozera F, Younus S, Memon N, Memon N, Najjad KR, Qazi AR. Reduction and functional outcome of open reduction and internal fixation with plate versus minimally invasive screw fixation in displaced intra-articular calcaneum fractures. J Orthop Dis Traumatol 2020;3:121-6

How to cite this URL:
Sozera F, Younus S, Memon N, Memon N, Najjad KR, Qazi AR. Reduction and functional outcome of open reduction and internal fixation with plate versus minimally invasive screw fixation in displaced intra-articular calcaneum fractures. J Orthop Dis Traumatol [serial online] 2020 [cited 2021 Apr 16];3:121-6. Available from: https://www.jodt.org/text.asp?2020/3/3/121/305737




  Introduction Top


Calcaneum fracture is common fracture accounts for 2% of all fractures including 60% of all tarsal bone fractures.[1] Approximately 75% of fractures are intra-articular. Recent studies reported that there is no statistically significant difference between conservative treatment and surgery in terms of functional outcomes.[2] The gold standard treatment for intra-articular fractures is open reduction internal fixation using an extended lateral approach. Open reduction and internal fixation (ORIF) of displaced calcaneal fractures has been shown to be superior to nonoperative treatment in a select group of healthy patients.[3] However, lots of retrospective or randomized controlled studies have demonstrated that ORIF has a high risk of wound healing complications, which is up to 13.8%–29%.[4],[5],[6] The complications of an extensile lateral approach with the calcaneus have been reported extensively in the literature with infection rates varying from 1.8% to 27%.[7] The use of minimally invasive reduction and fixation of calcaneal fractures may have a role in this group of patients where there is a concern regarding wound healing and infection.[8] Cannulated screw fixation always uses a minimally invasive or percutaneous approach. The previous study have reported that cannulated screw fixation may produce a less rigid fixation, such as secondary loss of reduction, compared with plate fixation.[9] Minimally invasive surgical techniques include limited exposure, which makes achieving a satisfactory closed reduction technically demanding and difficult to accomplish.

Many surgeons have questioned the quality of reductions achieved with minimally invasive techniques. In contrast many open reduction surgeons have started to question the value of precise open reduction techniques because of the high rates of posttraumatic arthritis, chronic pain, postoperative fibrosis, and loss of subtalar function.

To address this problem, we need a minimally invasive method to achieve a precise reduction. Therefore, we achieved a satisfactory reduction using a traction and open surgical technique. On the other hand, this reduction device is a closed reduction tool that will not affect the wound or increase the complication rate. After satisfactory reduction, percutaneous fixation can be accomplished according to standard procedures. In this study, we attempted to compare reductions via X-ray radiographs (improvement of Bohler's angle or Gissane's angle, the width of the calcaneus), and the American Orthopedic Foot and Ankle Society (AOFAS), visual analog scale (VAS), complications of the short-term outcome and function of open reduction plate fixation versus closed reduction percutaneous fixation.


  Materials and Methods Top


This was a prospective study conducted at the Department of orthopedic surgery, Liaquat National Hospital, 700 bedded tertiary care hospital from April 1, 2016, to April 30, 2018. A total number of patients included in the study were 18. Mean patient age was 35 years. Fifteen patients were male (83.3%) and 3 were female (16.6%). Mechanism of injury was fall from height in all patients. The inclusion criterion was patients who underwent surgical treatment of a unilateral calcaneal intra-articular closed fracture without other associated fractures, and the exclusion criteria were patients who were treated conservatively and the lack of surgical conditions. The patients were separated into a closed reduction percutaneous group and an open reduction internal fixation group. The open reduction group operation was performed at 7–10 days after injury, after the swelling had subsided, and the closed reduction group operation was performed at 1–3 days after injury. All the patients have been discharged 2–3 days after discharge. A single orthopedic surgeon has performed all surgeries. X-rays and computed tomography (CT) scans were obtained before the surgery. The VAS score was recorded on postoperative day 1 by the surgeon. The patients followed up for an average of 15.56 ± 4.85 months. The open reduction plate fixation group included calcaneus fractures of 9 patients 5 of these were Sanders type II, 3 of these were Sanders Type III, and 1 was Sanders Type IV. The closed reduction percutaneous fixation group included 9 calcaneus fractures 6 of these were Sanders type II, 2 of these were Sanders Type III, and 1 was Sanders Type IV. The patient characteristics are shown in [Table 1]. Lateral and axial X-ray views were obtained before the surgery, and the length, width, height, Bohler's angle, Gissane's angle, and varus or valgus angle of the calcaneus were recorded before and after the surgery according to these views. The measurement method used was in accordance with a previous study.[10] The varus angle was defined as a positive value, and the valgus angle as a negative value. The measurements obtained from the X-ray images were determined by a senior attending orthopedic surgeon [Table 2]. The AOFAS [Table 3] hindfoot score was utilized for clinical outcome assessment. The AOFAS hindfoot score was recorded at the final follow-up, whereas the visual analog scores for pain were recorded after surgery. The length of stay was recorded during the hospitalization, and the complication rate was recorded separately. The complications included early complications (i.e., superficial infections, deep infections, and wound necrosis) and late complications (i.e., posttraumatic arthritis, stiffness, chronic pain, fixation failure, lateral impingement, and joint penetration) [Table 4].
Table 1: Preoperative charecteristics

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Table 2: Reduction parameters

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Table 3: Ankle-Hind foot Scale (100points Total)

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Table 4: Clinical assessment

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Implant choice

The calcaneus locking plate system was selected for open reduction plate fixation. A 4.5-mm-diameter cannulated screw and a 6.5-mm-diameter cannulated screw were selected for closed reduction percutaneous fixation.

Surgical technique

The extensile lateral approach used was similar to the previously referenced technique.[11] For closed reduction percutaneous fixation, the patient was positioned in the prone position. After surgical draping, a localization K-wire on the skin was positioned perpendicular to the subtalar joint on the lateral view. Two K-wires were separately placed to penetrate perpendicularly to the calcaneus axis in the talus neck and into the calcaneus tuberosity. In some more comminuted cases (such as Sanders type IV), the front traction K-wire should be implanted in both the tibia and the navicular bone instead of the talus bone. We applied manual traction. The traction was monitored by lateral views to confirm the subtalar joint was distracted. The length of the calcaneus was reduced, and the presence of the subtalar joint gap to elevate the compressed articular surface and lateral wall was verified through the established tunnel, the lateral and central surfaces of the subtalar joint may be reduced and temporarily fixed using a 4.0-mm cannulated screw guide wire percutaneously. When subtalar joint reductions were completed and assessed by lateral and axial views, a 4.0-mm cannulated screw was implanted for subtalar articular fixation. Finally, the wound was closed with sutures, and a bandage was applied.

Case shown in [Figure 1] is of 40 year old male with left calcaneum fracture operated with ORIF using LCP
Figure 1: (a) Case of 40-year-old male presented with history of fall having left calcaneum fracture Figure shows peroperative lateral approach. (b) Peroperative picture showing skin flap and fracture. (c) Postoperative X-ray left calcaneum anteroposterior and lateral view showing fracture fixed with calcaneum 3.5 mm LCP. (d) Postoperative X-ray of left calcaneum lateral view showing fracture fixed with 3.5 mm LCP. (e) Follow up image showing wound healed

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  • Case 1: 45-year-old male with left calcaneum fracture operated with ORIF.
  • Case 2: 45 year old male with Right Calcaneum fracture operated with CRIF using cannulated screw [Figure 2].
Figure 2: (a) Case of 45-year-old male present with history of fall with right calcanuem fracture. (b) Preopertaive image showing swelling of right foot. (c) Postoperative X-ray of Calcaneum lateral view showing fracture fixed with percutaneous screw. (d) Postoperatve X-ray of Calcaneum anteroposterior view showing fracture fixed with anteroposterior view

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American Orthopaedic Foot and Ankle Society From: http://www.aofas.org/i4a/pages/index.cfm?pageid = 3494.

Postoperative management

Non-weight-bearing ambulation was begun from the 2nd day until 6 weeks. After 6 weeks, lateral and axial view X-rays were obtained. Weight-bearing from a tolerated to full weight-bearing was permitted at 6–8 weeks after surgery. After 8 weeks, the patients were allowed to return to light work (after 10 weeks for medium work and 12 weeks for heavy work).


  Results Top


This study includes 18 patients. Mean patient age was 35 years. Fifteen patients were male (83.3%) and 3 were female (16.6%). Mechanism of injury was fall from height in all patients.

Radiological assessment

Postoperatively, lateral and AP views were obtained to assess the reduction. We analyzed length, width, height, varus, and valgus angles for the calcaneus reduction, and Bohler's and Gissane's angles for articular surface reduction.

The ORIF group length was restored from 7.24 ± 0.50 (cm) (range, 6.38–9.05) preoperatively to 7.58 ± 0.48 (cm) (range, 6.48–8.43) postoperatively. The CRIF group length was restored from 8.65 ± 0.80 (cm) (range 7.20–9.79) to 7.52 ± 0.45 (cm) (range 6.79–8.3) postoperatively with P = 0.387.

ORIF group height was restored from 4.51 ± 0.46 (cm) (range, 3.40–4.79) preoperatively to 4.10 ± 0.53(cm) (range, 3.19–4.72) postoperatively whereas in CRIF group height was restored from 4.50 ± 0.59(cm) (range, 3.40–4.55) to 4.50 ± 0.59(cm) (range, 3.35–4.83) postoperatively with P = 0.436.

ORIF group width was restored from 4.78 ± 0.56 (cm) (range, 3.20–6.40) preoperatively to 3.92 ± 0.46(cm) (range, 3.11–4.92) postoperatively. CRIF group width was restored from 4.14 ± 0.14 (cm) (3.24–4.99) preoperatively to 3.85 ± 0.51(cm) (range, 3.11–4.57) postoperative with P = 0.615.

ORIF group Bohler's angle was restored from 1.65 ± 26.94° (range, −44.00–35.50°) preoperative to 20.24 ± 10.87° (range, 5.90–41.00°) postoperative. CRIF group Bohler's angle was restored from 1.65 ± 14.55° (range, −13.11–38.70°) preoperative to 21.84 ± 10.45° (range, 11.7–47.3°) postoperative with P = 0.573.

ORIF group Gissane's angle was restored from 117.54 ± 12.3° (range, 100.20–144.20°) preoperative to 114.65 ± 12.76° (range, 101.7–140.00°) postoperative. CRIF group Gissane's group was restored from 121.34 ± 14.76° (range, 84.40–135.50°) preoperative to 120.81 ± 16.72° range, 84.40–135.50°) postoperative with P = 0.365.

Varus or Valgus angulation was restored in ORIF group from 1.97 ± 4.75° (range, −8.00to 11.00°) preoperative to 1.52 ± 2.35° (range, −2.00–8.00°) postoperative. CRIF group varus or valgus angulation was restored from 3.30 ± 5.17° (range, −8.00–13.00°) preoperative to 1.43 ± 4.86° (range, −1.00-4.00°) postoperative with P = 0.814.


  Clinical Assessment Top


According to AOFAS ankle hind foot score, ORIF group score was 76.45 ± 6.83 (range 67–91) as compared to CRIF group score was 84.65 ± 7.65 (range 74–100) with P = 0.0087.

VAS score in ORIF group was 1.38 ± 1.15 (range 0–4) as that of CRIF group was 0.75 ± 0.45 (range 0–3) with P = 0.0034.

Complications happened in ORIF group were 33%, 3 out of 9 (1 with wound infection, 1 skin necrosis, 1 chronic pain) and that of CRIF group was 10% (1 with Chronic pain) with P = 0.0053.

Length of hospital stay in ORIF group was 7.86 ± 3.12 days and that of CRIF group was 6.71 ± 1.65 days with P = 0.0034.


  Discussion Top


The standard treatment of displaced intra-articular calcaneus fracture is open reduction plate fixation. Open reduction plate fixation can provide better fracture visualization and facilitate direct restoration of the subtalar joint and the anatomic parameters, including length, width, height, and alignment.[12] Although open reduction plate fixation may offer superior reduction and rigid fixation, it has some disadvantages, such as skin necrosis and infection complications, which occur in approximately 20%–37% of such cases with higher rates among smokers and diabetics.

In recent years, many studies have reported minimally invasive plate fixation with sinus tarsi incision or small lateral wall incisions and external fixation for calcaneus fracture.[13],[14] The minimally invasive treatments have become prevalent as a way to reduce tissue damage and the complication rate and to accelerate healing.[15],[16] Compared with open reduction internal fixation, the timing of surgery is more liberal because surgery may be performed soon after the injury. However, minimally invasive percutaneous fixation relies on indirect K-wire reduction techniques that require substantial use of fluoroscopy to ensure exact anatomic reduction, which remains an important issue.

Peng et al. conducted study on 40 patients and concluded that the closed reduction percutaneous fixation with traction device method may provide equivalent reduction results and superior outcomes for the length of stay, VAS score, and complication rate for displaced intra-articular calcaneum fractures.[17]

Baoyou et al. conducted RCT on 707 patients and concluded that Cannulated screw fixation and plate fixation have similar fixation effectiveness and functional outcomes in the treatment of displaced intra-articular calcaneus fractures. Due to the shorter duration of surgery and low rate of complications, cannulated screw fixation is superior to plate fixation.[18]

Limitations of the current study were first, it was conducted in single institution, second total number of cases were limited. Third outcome were only evaluated by simple X-rays CT scan would be expected to determine quality of reduction in further studies.


  Conclusion Top


This study was focused on the comparison of reduction and functional outcomes of minimally invasive surgery versus open reduction plate fixation. There were no significant differences in the reduction regarding length, width, height, and Bohler's, Gissane's, and varus and valgus angles between the open reduction plate fixation group and closed reduction percutaneous fixation group. The functional outcome assessments showed that the closed reduction percutaneous fixation group had lower VAS scores after surgery, a lower complication rate, and a shorter hospital stay; however, no significant differences in the AOFAS hind foot scores were observed. However, multicenter controlled randomized clinical trials are still required prior to widespread practical implementation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-44.  Back to cited text no. 3
    
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Al-Mudhaffar M, Prasad CV, Mofidi A. Wound complications following operative fixation of calcaneal fractures. Injury 2000;31:461-4.  Back to cited text no. 4
    
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Xia S, Lu Y, Wang H, Wu Z, Wang Z. Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures-a randomized controlled trial. Int J Surg 2014;12:475-80.  Back to cited text no. 5
    
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Chen ZW, Yang LZ, Wu WT, Liu CL. Treatment of sanders type III and IV calcaneal fractures with open reduction and internal fixation. Zhongguo Gu Shang 2011;24:641-4.  Back to cited text no. 6
    
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Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18:1-6.  Back to cited text no. 7
    
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Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clinical orthopaedics and related research. 1993:128-34.  Back to cited text no. 11
    
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Schepers T, van Lieshout EM, van Ginhoven TM, Heetveld MJ, Patka P. Current concepts in the treatment of intra-articular calcaneal fractures: Results of a nationwide survey. Int Orthop 2008;32:711-5.  Back to cited text no. 12
    
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Cao L, Weng W, Song S, Mao N, Li H, Cai Y, et al. Surgical treatment of calcaneal fractures of Sanders type II and III by a minimally invasive technique using a locking plate. J Foot Ankle Surg 2015;54:76-81.  Back to cited text no. 13
    
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Dayton P, Feilmeier M, Hensley NL. Technique for minimally invasive reduction of calcaneal fractures using small bilateral external fixation. J Foot Ankle Surg 2014;53:376-82.  Back to cited text no. 14
    
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Zhang T, Su Y, Chen W, Zhang Q, Wu Z, Zhang Y. Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: Longitudinal approach versus sinus tarsi approach. J Bone Joint Surg Am 2014;96:302-9.  Back to cited text no. 15
    
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Peng Y, Liu J, Zhang G, Ji X, Zhang W, Zhang L, et al. Reduction and functional outcome of open reduction plate fixation versus minimally invasive reduction with percutaneous screw fixation for displaced calcaneus fracture: A retrospective study. J Orthop Surg Res 2019;14:124.  Back to cited text no. 17
    
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Fan B, Zhou X, Wei Z, Ren Y, Lin W, Hao Y, et al. Cannulated screw fixation and plate fixation for displaced intra-articular calcaneus fracture: A meta-analysis of randomized controlled trials. Int J Surg 2016;34:64-72.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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