Journal Reading

Oleh Barkah Pangastutiningtyas 2061210044 PEMBIMBING : Dr. Satriyo Aji Sp.OT

Laborarotium Ilmu Bedah RSUD Kanjuruhan Kepanjen Kepaniteraan Klinik Fakultas Kedokteran Universitas Islam Malang

Background
The calcaneus is the most frequently injured tarsal bone, with calcaneal fractures constituting 60% of fractures affecting the foot and about 1% to 2% of all fractures. Approximately 75%of calcaneal fractures have an intra-articular component, The recovery period is requently prolonged, and a return to the preinjury level of activity may not be reached due to pain, loss of motion, and/or the need for specialized footwear

Background
Surgical treatment of displaced intraarticular fractures of the calcaneus is a standard procedure To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques.

Material &Methode

This retrospective study was composed of all adult patients with displaced intraarticular calcaneal fractures treated according to the method of Forgon and Zadravecz between 1998 and 2006

Material &Methode
We excluded patients with extra-articular fractures, open fractures, and ipsilateral complex foot injuries as well as those who refused to participate and those whose addresses could not be retrieved. Only fracture patterns with fragments of the tuberosity and sustentaculum sufficiently large to provide support for the screws were determined to be good candidates for this technique of closed reduction and percutaneous screw fixation, independent of any specific fracture classification.

Material &Methode
1
Radiographic Assessment
Preoperative standard radiographs and computed tomography (CT) scans were acquired routinely for all patients, and postoperative standard radiographs were made routinely to assess the reduction

Material &Methode
1
Radiographic Assessment
With use of preoperative CT scans, the fractures were classified according to the systems of Sanders, EssexLopresti, and Crosby and Fitzgibbons. On the immediate postoperative radiographs, the height and length of the calcaneus were measured on the lateral radiographs and the width was measured on the axial radiograph. Preoperative and postoperative measurements of the Bohler angle were obtained and compared with the measurements on follow-up radiographs

Material &Methode
2
Surgical Procedure

The first modification concerned the placement of the distraction screws. These were positioned in the calcaneal tuberosity and the distal part of the tibia instead of the cuboid and the talus. The second modification involved inserting the transcalcaneal rod from a plantar direction to unlock and push up any remaining depressed parts of the subtalar joint surface of the calcaneus

Material &Methode
2
Surgical Procedure

The third modification was the insertion of a cannulated screw from the lateral side into the sustentaculum tali into the sustentaculum tali to maintain reduction of the subtalar joint surface and to reduce the bulging of the lateral wall.

Fig. 1-A Distraction after placement of the external fixator. Fig. 1-B A cannulated screw has been used to reduce and secure the tongue-type fracture (1), and a fluoroscopy-guided reduction of a displaced subtalar joint fragment, with use of one or two transcalcaneal punches (2 and 3), is being performed.

Fig. 1-C Clinical photograph showing reduction of the subtalar joint with use of a transcalcaneal punch. Fig. 1-D Percutaneous positioning of a guidewire for the insertion of a cannulated lag screw that will connect the lateral wall with the sustentaculum tali

Surgical Procedure

For most fracture types :

Compression was applied with a screw directed from the lateral side into the sustentaculum tali A second screw was usually placed in the sustentaculum tali from the posterolateral side to stabilize the tuberosity fragment. A third screw was positioned, extending from posteromedial to anterolateral, to form an x-shaped configuration relative to the second screw.

Removal of one or more screws was performed when patients complained of a palpable screw head, but only after the fracture had healed completely.

For patients who had clinical signs and symptoms of painful subtalar arthritis, subtalar arthrodesis was performed, but only after the fracture had healed completely and the hardware had been removed. The surgical procedure was completed by removing the external fixation device and suturing the stab incisions All patients were advised to exercise the foot and ankle immediately postoperatively.

Figs. 2-A and 2-B Preoperative lateral (Fig. 2-A) and axial (Fig. 2-B) radiographs demonstrating a displaced intra-articular calcaneal fracture.

Figs. 2-C and 2-D Two years postoperatively, lateral (Fig. 2-C) and axial (Fig. 2-D) radiographs demonstrate a healed fracture in good alignment.

Material &Methode
3
Physical Examination
Physical examination included a thorough assessment of alignment, stability, and the ability to walk on the heels as well as on the tips of the toes. The range of motion of the ankle and subtalar joints was measured with a goniometer. The ankle range of motion was measured with the patient sitting with the leg in the horizontal position, and the subtalar range of motion was measured with the patient kneeling.
For unilateral fractures, the measurements were compared with measurements from the contralateral foot and ankle. For bilateral fractures, the following normative values were used for comparison: inversion of 25, eversion of 5, and sagittal range of motion of the ankle joint of 60

Material &Methode
4
Functional Outcome Measurements
To quantify pain and functional disability, the American Orthopaedic Foot & Ankle Society (AOFAS) anklehindfoot scale and the Maryland Foot Score (MFS) were used The AOFAS ankle-hindfoot scale consists of subjective and objective variables classified into three major categories: pain, function, and alignment. The MFS has the same major categories. Total scores for both scales range from 0 to 100.

All patients also completed the Short Form-36 (SF-36) general health status form and rated their satisfaction with the outcome on a modified visual analog scale (VAS) on a range from 0 to 10,

Material &Methode
5
Statistical Methods
To investigate whether different variables could have a predictive value for the postoperative outcomes, relationships between radiographic, clinical, and functional outcomes were studied.

Radiographic outcomes included the Sanders classification, the quality of the reduction, and restoration of the Bohler angle. Clinical outcomes included the ability to wear normal shoes and the ability to return to work. The functional outcomes included the AOFAS score, the MFS, the SF-36 score, and the VAS score.

Material &Methode
5
Statistical Methods

The Fisher exact test to identify the proportion of patients who required a change in footwear and the proportion of patients who returned to work on the basis of fracture type.

independent Student t test To determine the relationship between Bohler angle and functional outcome measures,

one-way analysis of variance test to study relationships between fracture type and functional outcome measures and restoration of Bohler angle.

Result
Excluded patients : multiple fractures open fractures extra-articular fractures Younger than fifteen years

The most frequent mechanism of injury was a fall from a height: 32 fell down stairs or fell from a ladder, 1 one patient attempted to commit suicide by jumping from a height. Other causes included sports injuries (n = 3) and one traffic accident.

Complications

Postoperative infection of the wound Screw-track infections Osteomyelitis of the calcaneus Removal of hardware due to pain around the screw sites Subtalar arthritis type-I complex regional pain syndrome Transient neurologic disorders Hammer-toe deformities.

Radiographic Examination

Radiographic Examination

Physical Examination

The average sagittal range of motion (plantar flexion plus dorsiflexion) was 43 (range, 15 to 75). The average range of motion of the subtalar joint was 21 (range, 0 to 60)

Functional Outcome Assessments

The mean AOFAS score was 84.1 points The mean MFS was 86.4 points The mean SF-36 score was 76.4 points

Functional Outcome Assessments

Functional Outcome Assessments

No pain was reported by twenty-two patients (59%), twelve patients (32%) reported only mild pain. The remaining three patients (8%) had severe pain with substantial limitations in their daily activities.

Twenty-one patients (57%) were able to perform physical activities at the same level as before their injuries. Twenty-nine patients (78%) were able to wearnormal shoes, while six (16%) used shoes with orthotic devices. Two patients had obtained custom-made orthopaedic shoes.

Statistical Analysis

There was no difference between fracture type and return-to-work status. The proportion of patients who returned to work was similar for each fracture type. No difference in functional outcomes was de tected on the basis of the postoperative Bohler angle

Discussion
Historically, calcaneal fractureswere treated nonoperatively with unsatisfactory results. As operative fracture care and imaging techniques have improved during the last decade, surgical procedures have become more popular A major concern for most surgeons is the complication rate associated with this procedure. Zwipp et al. superficial wound edge necrosis in 8.3% of their cases. Buckley et al. a superficial wound complication rate of 17% and a deep infection rate of 5% in the operative group treated with open reduction and plate fixation. Kundel et al superficial wound complications in 7% of their patients, deep infections in 7%, and a total complication rate of 30% In with an effort minimize infectious complications, Forgon and in the group opento reduction and plate fixation Zadravecz developed a technique employing closed reduction and percutaneous fixation for the treatment of displaced intraarticular calcaneal fractures

Discussion
Tornetta reported excellent results in 55%, good results in 32%, and fair results in 13% of patients who underwent the percutaneous EssexLopresti reduction and fixation technique, according to the scores achieved on the MFS. However, they included only patients who had Essex-Lopresti tongue-type, Sanders type-IIC calcaneal fractures.

Gavlik et al. treated fifteen patients with percutaneous, arthroscopically assisted osteosynthesis to ensure anatomical reduction, with minimally invasive manipulation of the fragments. Thismethod was applied in Sanders type-II fractures only. The authors reported an average AOFAS score of 93.7 and an average MFS of 95.8. Postoperatively and at the time of the one-year followup, no wound complications were observed.

Discussion
Our current study can best be compared with that of Schepers et al., who used a comparable surgical technique on sixty-one calcaneal fractures, some of which were open fractures. Schepers s study AOFS value MFS value VAS Complication 83 79 7.2 15% Our current study 84 86 7.9 13% Hampir sama 2

Able to wear normal 79 % shoes Subtalar artrodosis 5

In our present study, the overall quality of fracture reduction, as judged by restoration of calcaneal length, height, and width, was very good.

Conclusion
We consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.