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The authors present the case of an adult female patient with an embedded needle in the calcaneus. The use of the Michele hand trephine under fluoroscopy for removal of an intracalcaneal metallic foreign body is described. Care must be taken not to violate the subtalar joint or leave osseous defects if multiple trephine attempts are required.
Fracture of the anterior process of the calcaneus is a common injury that is often misdiagnosed. The key to management of this injury is an accurate diagnosis and proper treatment. Two case studies are presented to demonstrate how improper diagnosis can lead to surgical treatment of the condition.
Computed tomography (CT) is of cardinal importance in the study of displaced intra-articular fractures of the calcaneus, as with this imaging technique the primary fracture line of Palmer can be followed and its various locations visualised. If the three-stage classification system of these fractures as vertical, horizontal or mixed fractures, based on their radiological appearance, is adopted, a correlation can be established between the location of Palmer's line and these three anatomical types. The fundamental fracture line is medial in the vertical types, lateral in the horizontal types and is located in the centre of the posterior facet in the mixed types. It can be seen that the fundamental fracture line separates a laterally detached fragment which is always tilted, giving a vertical slope to the surface of the posterior facet which it supports and thus giving a vertical image. This fragment is itself separated from a medially detached fragment which is tilted horizontally and produces a horizontal image on the lateral view. The CT sections must be examined for the presence of a secondary sagittal line completely isolating the horizontally tilted fragment. The importance of the location of the fundamental fracture line, which is on the borderline between tilting and horizontalisation, suggests that pronation-supination of the foot is a factor in the causal mechanism of these fractures. A clear understanding of the three-dimensional position of the fragments and of their displacement, essentially defined by the location of the fracture line, is a prequisite before attempting surgical reduction of calcaneal fractures.
The study aimed at determining precision and accuracy of the ultrasound technique measuring bone mineral density in the calcaneus bone in children. Bone densitometer of Achilles type was adapted for measurements in children. Ultrasound beam was narrowed and a system of special pads positioning the foot were used for this purpose. Precision (CV (%) SOS: phantom 0.42, patients -0.42; BUA: phantom 1.46, patients -3.03) and accuracy of this technique were determined in comparison with dual energy X-ray absorptiometry as well as its value in diagnosis of osteopenia in childhood. An increase in SOS and BUA with the age was found. A decrease in these parameters was noted in children with osteopenia, comparing with the values in healthy children. Significant correlations (r ranging from 0.50 to 0.91) between ultrasound and DEXA techniques were seen. The results suggest that ultrasound technique might be useful in pediatric densitometry.
Forty-one displaced intraarticular fractures of the calcaneus in 38 patients were treated with open reduction and screw fixation of the posterior facet, bone grafting, and percutaneous pinning of the body. A single extensile posterolateral approach was used in all but two cases in which an additional medial incision was needed. Using early functional aftercare, all fractures healed without secondary displacement in an average of eight weeks. Follow-up periods averaged 4.2 years. Results were graded as excellent in 14 patients, good in 16, fair in three, and poor in five. There was a strict correlation between the clinical results and the severity of the articular comminution. A satisfactory outcome depended on the restoration of articular congruency and extraarticular alignment of the os calcis.
Twenty-two patients with 22 displaced intraarticular fractures of the calcaneus were treated by open reduction and internal fixation using a lateral approach and, when needed, a medial approach, followed by early motion. These patients were evaluated from 16 to 72 months (average, 37 months) after surgery. At follow-up evaluation, the result was assessed on the basis of restoration of anatomy and function. Combining the anatomic and functional findings, the results in this series were good in 17 patients, fair in one, and poor in four.
The operative treatment of intraarticular calcaneal fractures has three principal aims: restoration of height, length, and width of the calcaneus, reconstruction of the subtalar and calcaneocuboid joint surfaces, and stable osteosynthesis using an H-plate or screws. In 68% of the cases, the sustentacular fragment was the key to open reduction, making the medial approach mandatory. In complex fractures, a lateral approach is added. In "blow-out" fractures or cases with comminution of the sustentacular fragment, an extended lateral approach only is used. For precise preoperative planning of roentgenograms in three planes, four Brodén's views and axial plus coroneal or three-dimensional computed tomography scans are required. From July 1983 to July 1990, 157 intraarticular calcaneal fractures were treated by open reduction. The results in 123 cases are 61% good or excellent, 32.5% satisfactory, and 6.5% poor. The following early complications occurred: superficial wound edge necrosis (8.3%), hematoma (2.5%), nonunion (1.3%), and infection (1.9%). Four patients (3.3%) in the follow-up group have developed degenerative changes severe enough to require subtalar fusion. To facilitate the comparison of results, new fracture classification and follow-up scoring systems have been devised.
Heel pad puncture, a well-established procedure for obtaining hematologic samples from infants, may be complicated by acute osteomyelitis of the calcaneus. One such case is presented which involved a 3½-month-old female. Physicians are cautioned that calcaneal osteomyelitis should be suspected if soft tissue swelling and erythema are present around the heel area.
A densitometric study was performed on 50 dry calcanei to assess bone mineral density (BMD) in the constituent regions of the bone. In the lateral projection, the area with the highest BMD was the anterosuperior region, where the greatest concentration of trabeculae occurs. The areas with the least BMD were the intermediate or retrothalamic and the anteroinferior regions, where the neutral triangle is situated. In the dorsoplantar projection, a greater BMD was observed in the intermediate and middle regions, whereas the anterior region showed the lowest BMD. These results conform to the arrangement previously described for the trabecular system. It is concluded that bone densitometry, measured by dual x-ray absorptiometry, is useful for assessing trabecular architecture of the calcaneus.
The method of treatment for comminuted articular fracture of the calcaneus with the use of a "Deroo" fixator is presented. A "Deroo" eliminates the need for the cast, allows for an early active foot mobilization in the first post-operative day, prevents muscular atrophy. Crosby and Fitzgibbons classification served to assess clinical and radiological results; in 5 cases they were rated excellent, in 10 good, in 5 fair and in 7 cases results were poor.
We observed 39 feet with a "too-long" anteromedial process of the calcaneus (TLAP) in 25 children and adolescents. The abnormality was diagnosed from symptoms (ankle sprains or persistent ankle or foot pain) in 33 cases. Six cases of TLAP were noted on radiographs taken of the patient's opposite, asymptomatic foot. Initial treatment by 3 weeks of strapping failed in seven of seven cases, and 3-6 weeks of primary plaster immobilization failed in 10 of 25 feet. Primary immobilization treatment failed in 17 of 33 symptomatic feet. Resection of the TLAP provided good results in 14 of 15 feet when used as a secondary procedure after failure of immobilization treatment and in one foot in which it was used as primary treatment. We believe that this abnormality is an anatomic variant that becomes symptomatic because of inversion stress with impingement of the abnormally long process between talus and cuboid.
BACKGROUND: Internal fixation of displaced intraarticular calcaneal fractures in patients older than 50 years remains controversial. This is, in many cases, due to fear of loss of fixation and the risk of implant failure in osteoporotic bone. It is the objective of this study to compare the fixation strength obtained using calcaneal plates with and without locking screws, in the fixation of osteoporotic cadaveric intraarticular calcaneal fractures. METHODS: In seven pairs of fresh frozen lower limbs cadavers, intraarticular calcaneal fractures were created with a dynamic single impact loading device and stabilized using either the low profile locking plate, or the conventional calcaneus plate. Radiographs were obtained to assess reduction. The specimens were then subjected to cyclic loading followed by loading to failure, using matched pairs of cadaveric lower limbs. The Wilcoxon signed rank test was used to test for differences in the results. FINDINGS: The locking plate showed a significant lower irreversible deformation during cyclic loading and a significant higher load to failure. The difference between the ultimate displacement, and work to failure was not significant. A low bone mineral content in the area of the posterior facet correlated only in the conventional plate group with increased irreversible deformation. INTERPRETATION: This study supports the mechanical viability of using locking calcaneal plates for the fixation of intraarticular calcaneal fractures in elderly patients.
The purpose of this study was to evaluate the effects of therapeutic ultrasound (US) on the healing process in the Achilles tendon (Tendo calcaneus) of Wistar rats after tenotomy. Sonication was performed at a frequency of 1 MHz, an intensity of 0.5 W/cm(2) (SATA), for 5 min, over a period of 14 consecutive days in two modalities (n = 15); in both continuous and pulsed modes. The control group was divided into tenotomized, mock-sonicated and nontenotomized tendons (n = 15). On the 15th postoperative day, the tendons were removed and analyzed by using the polarized light microscopy, with the purpose of detecting and measuring the organization of collagen fibers through birefringence. The results showed a high birefringence for the tendons treated using the pulsed mode (p < 0.001), revealing the best organization and aggregation of collagen bundles. Sonication in the continuous mode induced a decrease (p = 0.047) in the ability to quicken the healing process. These findings suggest that US therapy is beneficial in the early healing process of tendons when the pulsed mode is used.
The coherent-to-Compton scattering ratio (CCSR) is a technique that has been proposed for measuring trabecular bone mineral density (TBMD). This paper investigates the effect of fat on the CCSR and its correlation to the error in TBMD measurements. It is a computational study to determine the relationship between the magnitude of fat error and the momentum-transfer variable chi, which represents the incident photon energy and the scattering angle. Variation in fat content contributes significantly to the error in CCSR measurements. When employing a typical 241Am source (E gamma = 59.45 keV), the resulting error decreases with increasing momentum-transfer variable or angle. For example, the error ranges from +14 mg/cc at an angle of 45 degrees (chi = 18.3) to +3 mg/cc at an angle of 135 degrees (chi = 44.3) for an osteoporotic trabecular region (100 mg/cc mineral) of a calcaneus that contains 6% less fat than a calibration standard. The error is about 0.3-1.2 mg/cc less for regions containing 2-3X more bone mineral and is reduced and opposite in sign for regions containing about 7% more fat than the calibration standards (e.g., -9 mg/cc at 45 degrees and -1.5 mg/cc at 135 degrees). Others have shown that the intrinsic sensitivity of the CCSR method for measuring TBMD at a given photon energy generally increases with increasing detector angle. Thus large angles are advantageous both for reduced sensitivity to fat variation and increased sensitivity to bone mineral variation. The primary disadvantage is reduced count rates that degrade precision unless long counting lines are employed.(ABSTRACT TRUNCATED AT 250 WORDS)
Trabecular bone mineral density (TBMD) was measured in vivo in the calcaneus by a new method that uses the ratio of coherent to Compton-scattered photons arising from irradiation of a small volume of trabecular bone by a gamma ray source with highly collimated geometry. TBMD values for healthy men (22-77 years) were in the range of 180-357 mg/ml, and values for healthy women (18-73 years) were in the range of 160-321 mg/ml. In contrast, values in a small group of paraplegics were in the range of 90-199 mg/ml.
We describe three patients who developed gross calcaneus deformity following surgery for talipes equinovarus. One also had an associated valgus deformity and another had supination of the forefoot; all had intractable problems with footwear. Operation for transfer of the tibialis anterior to the heel, with correction of the associated deformities, was successful and improved both their gait and the shoe problems.
OBJECTIVES: To analyze using quantitative ultrasound of calcaneus (QUS) the prevalence of osteoporosis in institutionalized elderly people, in order to contribute to state reliable criteria (T-score units) for the diagnosis of osteoporosis which allow advances in bone fracture prevention. MATERIAL AND METHODS: Elderly people (n=171) were divided into separate groups according to sex and age criteria (three decades, from 70 to 90 years) and analyzed using QUS. RESULTS: Both globally and in the younger groups, women showed significantly lower values than men in all densitometry variables (p < 0.001). In the oldest group only T-score and BUA showed statistical differences (p = 0.039 y p = 0.025, respectively). The prevalence of osteoporosis in women was higher than in men whichever criteria were applied in all age groups. Applying the WHO criteria with QUS, the prevalence of osteoporosis in global population is close to that stated by DEXA using the same criteria. CONCLUSIONS: QUS could be useful to assess the bone mass evolution with age and for the diagnosis and monitoring of osteoporosis. In our elderly population, the WHO criteria for DEXA, are also the most suitable ones for QUS utilization.
OBJECTIVE: To study the role of the synchronized springy lengthening apparatus for the tibia and calcaneal tendon designed by the author in preventing the clubfoot of secondary to the Ilizarov tibia lengthening. METHODS: Based on the Ilizarov tibia lengthening apparatus, a special synchronized springy lengthening apparatus for the tibia and calcaneal tendon was designed. The tibial was made of distal and proximal 2 rings respectively and 4 threaded rods, and the calcaneal was made of a half ring, 2 hinges and a threaded rod with spring. The half ring was fixed to the calcaneus by 2 crossed wires. The fracture tibia and fibula, ankle joint, talocalcaneal joint were attached to the apparatus. At the same time of tibia lengthening, the soft tissue was simultaneously stretched, the ankle joint could move, and the leg could bear weight. If the clubfoot angle was larger, the percutaneous fasciotomy of calcaneal tendon was performed; if the angle was less than 20 degrees, the pes deformities were corrected only by the stretch of calcaneal tendon. RESULTS: Seventy-seven patients' tibia were lengthened averagely 4.6 cm, with an average speed of 0.7 mm/d. The healing made tibia lengthened, and the index was 1.35 months/cm. There were not the secondary varus and valgus deformities and clubfoot in all the patients. The clubfoot with 100-400 angle of the 16 patients were corrected after tibia lengthening. CONCLUSIONS: The new apparatus coincides with the biomechanical principle and can effectively prevent the secondary deformities of foot such as clubfoot, talipes varus and valgus after tibia lengthening procedure.