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Aims Which is the best extensile lateral (ELA) or sinus tarsi (STA) approach for osteosynthesis displaced intraarticular calcaneal fracture (DIACF) is still debatable. The current RCT’s primary objective was to compare the complications incidence after open reduction and internal fixation of DIACFs through STA vs. ELA. The secondary objectives were the differences in intraoperative radiation exposure, time to fracture union, functional and radiological outcomes. Methods Between August 2020 and February 2023, 157 patients with Sanders type II and III fractures were randomly assigned to either ELA (81 patients with 95 fractures) or STA (76 patients with 91 fractures). The primary outcome was the incidence of complications. The secondary outcomes were Böhler’s and Gissane angles angle, fracture union, and American Orthopaedic Foot and Ankle Society (AOFAS) score. Results No statistical differences between both groups regarding basic demographic data, injury characteristics, and fracture classification; however, patients in the STA group were operated upon significantly earlier (4.43 ± 7.37 vs. 7 ± 6.42 days, p  = 0.001). STA’s operative time was significantly shorter (55.83 ± 7.35 vs. 89.66 ± 7.12 min, p  < 0.05), and no statistical difference regarding intraoperative radiation exposure. The time to fracture union was significantly shorter in STA (6.33 ± 0.8 vs. 7.13 ± 0.7 weeks, p  = 0.000). Skin complications (superficial or deep infection) and Subtalar osteoarthritis were significantly higher in ELA (18.9% vs. 3.3%, p  = 0.001) and (32.6% vs. 9.9%, p  = 0.001), respectively. The radiological parameters were significantly better in STA postoperatively and at the last follow up. The AOFAS scores were significantly better in STA (83.49 ± 7.71 vs. 68.62 ± 7.05, respectively, p  = 0.000). Conclusion During osteosynthesis of Sanders type II and III DIACFs, STA is superior to ELA in terms of operating earlier, shorter operative time, fewer complications, and better radiological and functional outcomes.

Purpose The aim of this study is to investigate the preoperative and postoperative psychological health status of patients with calcaneal fractures, and to explore the impact of preoperative psychological health status on the prognosis of surgical treatment for calcaneal fracture patients. Methods This study included 67 patients with calcaneal fractures who underwent surgical treatment in the Foot and Ankle Surgery Department of Honghui Hospital in Xi’an from November 2019 to September 2022. Patients were divided into two groups based on the presence of preoperative anxiety/depression symptoms, with patients exhibiting preoperative anxiety/depression symptoms assigned to Group A and those without such symptoms assigned to Group B. Preoperative and final follow-up assessments were conducted using the Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale (VAS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Score to evaluate patients. Results Among the 67 patients with complete follow-up for calcaneal fractures, 33 patients exhibited preoperative anxiety/depression symptoms (49.25%). Both Group A and Group B patients showed significant improvements in various evaluation indicators after calcaneal fracture surgery compared to preoperative assessments, but the overall prognosis of Group A was worse than that of Group B. Conclusions The preoperative psychological health status of patients is related to postoperative clinical outcomes, and patients with poorer psychological health have a worse prognosis.

Background Following successful treatment, displaced intra-articular calcaneal fractures (DIACFs) necessitate an extensive rehabilitation regimen, significantly influencing functional and socio-economic outcomes. Apart from surgical intervention, the implementation of a comprehensive rehabilitation protocol is crucial to optimize foot stability and functional recovery. The objective of this study is to ascertain the optimal rehabilitation protocol for patients with surgically treated DIACFs, either permissive weight bearing (PWB) or Restricted Weight Bearing, focusing on functional outcomes, health-related quality of life (HRQoL), radiographic parameters, cost-effectiveness, and incidence of complications. Methods Study design: A prospective multicenter randomized controlled trial. Study population: Presence of surgically (extended lateral, sinus tarsi, or percutaneous approach) treated unilateral DIACFs (Sanders type II to IV), aged 18–67 years (labor force). Patients must be able to understand and follow weight bearing instructions. N = 115 patients with DIACFs will be included. Interventions: Patients with DIACFs will be randomly allocated to one of the rehabilitation protocols, either PWB or RWB. Primary outcome measure: Functional outcome, measured with the American Orthopaedic Foot & Ankle Society Score (AOFAS)). Secondary outcomes: Functional outcome (Maryland Foot Score, MFS), HRQoL (EuroQol-5D, EQ-5D), differences in radiographic parameters, cost-effectiveness, and complications. Nature and extent of burden: The PWB protocol is aimed to be non-inferior to the RWB protocol. Previous analysis of this protocol in other lower extremity fractures has shown a safe complication rate. Follow-up is standardized according to current trauma guidelines, namely at time points 2, 6, 12 weeks, and 6 months. The radiation exposure for both groups will differ from standard care (one extra CT scan of the foot will be made). Therefore, the burden for participants is considered minimal, with no significant health risks. Discussion This study will be the first study to define an optimal rehabilitation regime for surgically treated patients with DIACFs. The limitations of this study include the absence of patient blinding, as this is impossible in rehabilitation. Additionally, the primary outcome measure (AOFAS) has limited validity for DIACFs. However, it is the most commonly used questionnaire in the literature on DIACFs. There is an apparent need since current literature is lacking on this specific topic. Trial registration ClinicalTrials.gov NCT05721378, accepted on February 7, 2023.

Background Calcaneal fractures are the most common type of tarsal fractures. The sustentaculum tali (ST) offers anatomical stability in calcaneal fractures, and recently, ST screws have been widely used in their treatment. This study aimed to investigate the clinical efficacy and value of ST screw fixation via a modified sinus tarsi approach (MSTA) for treating displaced intraarticular calcaneal fractures (DIACFs). Methods This study enrolled 64 patients (64 feet): 32 patients in the calcaneal locking plate combined with the ST screw group (CLP-STS Group) and 32 patients in the simple calcaneal locking plate internal fixation group (CLP Group). The minimum follow-up duration was 18 months. Ankle function was evaluated using VAS, AOFAS, and Short Form-36 scores. Imaging evaluation included the Böhler angle, Gissane angle, length, height, and width of the calcaneus, and the Böhler angle in both groups 1 year after surgery. Results Functional evaluation revealed that postoperative AOFAS and VAS scores in the CLP-STS Group were significantly better than those in the CLP Group. After surgery, the Böhler angle, Gissane angle, and length, height, and width of the calcaneus were significantly corrected compared to the preoperative values; however, the difference in these indicators between the two groups was not significant. Nevertheless, at the 1-year postoperative follow-up, the calcaneal Böhler angle loss in the CLP-STS Group was significantly better than that in the CLP Group. Conclusion Compared to simple calcaneal locking plate internal fixation, combining the plate with the additionally free ST screw can resolve the limited intraoperative exposure of MSTA, reduce postoperative foot pain in patients, and improve clinical efficacy.

Purpose Several minimally invasive procedures were used to treat displaced intra-articular calcaneal fractures (DIACFs). No agreement among different authors about either the ideal fixation method or which technique is minimally invasive. The aim of this study was to compare functional and radiographic outcomes of two minimally invasive techniques in treatment of Sanders type II and III DIACFs by using K-wires or cannulated screws without bone grafts. Methods A prospective randomized controlled study was conducted on 28 patients (34 feet) with Sanders type II or III DIACFs, treated by closed reduction and fixation using cannulated screws or K-wires, at the Orthopedics Department of Sohag University Hospital, between April 2020 and February 2022. Functional assessment was done by American Orthopedic Foot and Ankle Society (AOFAS) score and VAS for pain. Radiographic assessment was done by measurement of three calcaneal angles (Gissane, Böhler’s, and posterior facet inclination angles) and three calcaneal distances (height, length, and width of the calcaneus). Results Mean ages of patients at the time of operation were 34.8 years for the cannulated screw group and 36.6 years for the K-wire group. A vast majority of patients were males (78.6%). Involvement of the right side in the cannulated screw group was 57.1% and that in the K-wire group was 47.9%. Mean operative time was significantly shorter among the K-wire group (42 min) compared to the cannulated screw group (57 min). Mean AOFAS score was higher among the cannulated screw group (85.9 points) compared to the K-wire group (75.8 points). Final VAS was significantly better among the cannulated screw group compared to the K-wire group. Mean time of radiographic union in the cannulated screw group was 8.9 weeks and that in the K-wire group was 10.1 weeks. Conclusion Both techniques avoided wound complications associated with ORIF with the advantage of a shorter hospital stay. Patients in the cannulated screw group had better functional and radiographic outcomes and a lower rate of subtalar arthritis than patients in the K-wire group. K-wires had advantages of reduced operative time, and easy removal as an outpatient procedure.

Purpose Managing displaced intra-articular calcaneal fractures remains controversial. A prospective randomised trial was undertaken to compare open reduction and internal fixation (ORIF) with minimally invasive reduction and percutaneous fixation (MIRPF). Methods Forty-five displaced intra-articular calcaneal fractures were randomised to undergo either ORIF ( n  = 23) or MIRPF ( n  = 22). Patients were followed up clinically and radiologically for a minimum of one year postoperatively. The primary outcome measure was wound-healing complication. Functional outcome was assessed using Creighton Nebraska Health Foundation (CNF) scale, and radiological outcome was assessed using plain radiographs and computed tomography (CT) scans. Results Of the 23 heels in the ORIF group, seven (30%) had wound-healing problems, compared with none in the MIRPF group ( p  = 0.005). There was no statistically significant difference in radiological outcomes between groups, as measured by Böhler’s angle, Gissane’s angle and Score Analysis of Verona (SAVE). Median time to return to work was two weeks earlier ( p  = 0.004), and the functional outcome score (CNF scale) at one year of follow-up was better ( p  = 0.013) following MIRPF compared with ORIF. Conclusion MIRPF is associated with fewer wound-healing problems, better functional outcome and earlier return to work compared with ORIF.

Background The management of displaced intra-articular calcaneal fractures (DIACFs) remains challenging and controversial. A prospective randomized controlled trial was conducted to compare percutaneous reduction, cannulated screw fixation and calcium sulfate cement (PR+CSC) grafting with minimally invasive sinus tarsi approach and plate fixation (MISTA) for treatment of DIACFs. Methods Ultimately, 80 patients with a DIACFs were randomly allocated to receive either PR+CSC ( N  = 42) or MISTA ( N  = 38). Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores. Radiological results were assessed using plain radiographs and computed tomography (CT) scans, and postoperative wound-related complications were also recorded. Results The average time from initial injury to operation and the average operation time in the PR+CSC group were both significantly shorter than those in the MISTA group ( p  < 0.05). There were significantly fewer complications in the PR+CSC group than those in the MISTA group (7.1 % vs 28.9 %, p  < 0.001). The calcaneal width immediate postoperatively and at the final follow-up in the MISTA group were obviously improved compared to those in the PR+CSC group ( p  < 0.001). The variables of sagittal motion and hindfoot motion of the AOFAS scoring system in the PR+CSC group were significantly higher than those in the MISTA group ( p  < 0.05). The good and excellent results in the two groups were comparable for Sanders Type-II calcaneal fractures, but the good to excellent rate in the MISTA group was significantly higher for Sanders Type-III fractures ( p  < 0.05). Conclusion The clinical outcomes are comparable between the two minimally invasive techniques in the treatment of Sanders Type-II DIACFs. The PR+CSC grafting is superior to the MISTA in terms of the average time between initial injury and operation, operation time, wound-related complications and subtalar joint activity. However, the MISTA has its own advantages in improving the calcaneal width, providing a more clear visualization and accurate reduction of the articular surface, especially for Sanders Type-III DIACFs. Trial registration ChiCTRIOR16008512 . 21 May 2016.

Background This randomized controlled trial compared the clinical outcomes and complications of a novel minimally invasive percutaneous osteosynthesis (MIPO) with those of conventional treatment via an extended L-shaped lateral approach for calcaneal fractures. Methods Sixty-four patients with displaced intraarticular calcaneal fractures were enrolled. The patients were randomly allocated to receive either MIPO (29 patients) or open reduction and internal fixation via an extended L-shaped lateral approach (35 patients). The same calcaneal plate (AO Synthes, Oberdorf, Switzerland) was used in both groups. The primary clinical outcomes included operative time, VAS postoperatively, and wound healing complications. Secondary clinical outcomes included time to operation, length of incision, postoperative drainage, length of hospital stay, medical expense, AOFAS score, and SF-36 score. Preoperative and postoperative calcaneal height, width, and length, Bohler’s angle, and Gissane’s angle were compared. Results The operative time in the MIPO group was 52.5 ± 11.1 min, which was significantly shorter than 82.8 ± 16.2 min in the conventional treatment group ( P  < 0.001). One week postoperatively, the VAS value was 3.2 ± 1.4 in the MIPO group, which was lower than that in the conventional treatment group, 3.9 ± 1.3 ( P  = 0.038). In the conventional treatment group, 13 of 35 fractures (37.1%) had wound healing problems, whereas this issue occurred in only 2 of 29 fractures (6.7%) in the MIPO group ( P  = 0.004). In the MIPO group, deep and superficial infections occurred in none of the cases and 1 of 29 (3.4%) patients, respectively. Length of incision in the MIPO group was shorter than that in the conventional treatment group (4.2 ± 0.6 vs. 10.9 ± 1.5 cm; P  < 0.001). Hospital stay was 9.7 ± 2.8 days in the MIPO group and 11.7 ± 2.6 days in the conventional treatment group ( P  = 0.004). At the last follow-up, the SF-36 scores and AOFAS scores in the two groups were comparable ( P  > 0.05). The postoperative radiographic data, the Bohler’s angle, Gissane’s angle, and calcaneal height, width, and length in the two groups were comparable ( P  > 0.05). Conclusions Compared with conventional ORIF, the advantages of MIPO are a considerably shortened operating time and hospital stay, decreased postoperative pain, and reduced risk of wound healing complications.

Purpose To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus. Methods Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors. Results Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions ( p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64–1.00, p  = 0.028), indicating a good accuracy as a test to predict wound revision. Conclusion A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146

Background Chronic lateral ankle instability (CLAI), frequently resulting from ankle sprains, is often associated with undiagnosed hindfoot varus deformities, specifically subtle cavus foot (SCF). While ligament reconstruction remains the standard treatment for CLAI with SCF, there is ongoing debate regarding the need for adjunctive calcaneal osteotomy to correct the underlying malalignment. Our study aims to evaluate the clinical efficacy and necessity of minimally invasive calcaneal osteotomy combined with arthroscopic modified Broström procedure in patients with CLAI with SCF. Materials and methods A retrospective analysis of 102 patients with CLAI and SCF was conducted from November 2016 to November 2022. Patients undergoing arthroscopic modified Broström procedure were assigned to the control group, while those receiving arthroscopic modified Broström procedure with minimally invasive calcaneal osteotomy were placed in the experimental group. General data and complications were documented. Preoperative and postoperative imaging included calcaneal pitch angle, Meary’s angle, arch height, and calcaneus valgus angle. Clinical outcomes were measured using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and visual analogue scale (VAS). Results A total of 81 patients with 2-year follow-up were included, with 46 in the experimental group and 35 in the control group. Significant differences in imaging indicators were observed in the experimental group at all follow-up points ( P < 0.001), while no significant changes were noted in the control group ( P > 0.05). Both groups demonstrated improvements in AOFAS and VAS scores ( P < 0.001), with differences between 3- and 24-month follow-up ( P < 0.001). Significant differences in imaging indicators and AOFAS scores were found between groups at both follow-up intervals ( P < 0.01). The complication rate was 6.52% in the experimental group and 11.43% in the control group. Conclusions For patients with CLAI with SCF, arthroscopic modified Broström procedure with minimally invasive calcaneal osteotomy is an effective treatment that minimizes bone and soft tissue damage. Our study suggests that it is necessary to correct hindfoot alignment while stabilizing the ankle joint to enhance function and reduce recurrence of chronic ankle instability. Level of evidence: Level III, retrospective comparative study