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PubMed2004

[Operative results of treatment of intraarticular calcaneus fractures with the "low contact plate"].

Calcaneus fractures are a major cause of accident- related invalidity. Long-term results are unsatisfactory with various therapy concepts as reported in the literature. Objective of this study is the long-term clinical and radiological outcome of a patient group treated with a low contact plate. Subjective assessment of function by the patient was an important evaluation criterion. From 01/92 to 12/98 a total of 182 patients with 209 calcaneus fractures were treated. Out of them 95 patients with 109 calcaneus fractures had a follow-up over a period ranging from 6 to 88 months (average 37.9 months). Severe impairment of walking was reported by 34.7 % of the patients. Severe impairment for work was declared by 68.4 % of the patients. 74.7 % of the patients complained middle or severe burden-pain. 64.3 % of the patients felt their quality of life impaired. After the injury 75.8 % of the patients were still employed. Arthrosis of the inferior ankle joint was found in 91.5 % of the cases. Within this collective three patient groups were formed with different follow-up periods to evaluate the temporal course, showing no significant differences. Frequently good functional and subjective results cannot be expected even with standardized operative procedures.

Adolescent↗
PubMed2005

[The effect of sports activities in children and adolescents on the calcaneus--an investigation with quantitative ultrasound].

PURPOSE: To determine whether quantitative ultrasound (QUS) parameters speed of sound (SOS) and broadband ultrasound attenuation (BUA) on the calcaneus are different between athletic children and a reference population. PATIENTS AND METHODS: From a college of physical education, 177 children and adolescents (121 boys and 56 girls, age range from 11 to 18 years) were included in this study. QUS was performed on the calcaneus using the Saharatrade mark device (Hologic, USA). SOS and BUA were estimated. Regional reference values of 3299 children were used to determine significant differences between athletes and reference population. The influence of activitiy level, age, height, and weight was estimated using correlation analysis. RESULTS: Sportsmen showed significant (p < 0.05) higher values of the QUS parameters (SOS 1581.1 m/s; BUA 69.7 dB/MHz) compared to the reference data (SOS 1563.9 m/s; BUA 64.2 dB/MHz). Significant correlation was observed between BUA and the level of activity, age, weight, and height (p < 0.01) and between SOS and weight and height (p < 0.05). In the group of soccer players and athlets, significant correlation was found between BUA vs. age and BUA vs. weight (p < 0.05). Furthermore, significant corelation was observed between BUA vs. age and weight in judokas and wrestlers. For the level of activity, a significant correlation to BUA was only found in the group of judokas and wrestlers (p < 0.01). CONCLUSION: An increase in quantitative ultrasound parameters on the calcaneus occurs in children and adolescents with increased physical activity.

Adolescent↗
PubMed1993

[The CT classification of intra-articular calcaneus fractures].

93 patients with 102 intraarticular calcaneus fractures (ICF) were examined by CT from 1986 to 1992. The images were evaluated with the use of a modified classification based on the number of fractured heel bone facets (2 facets in 4.8%, 3 facets in 53.9%, 4 facets in 32.3%, comminution in 8.8% of the fractures), the involvement of the calcaneus-cuboid joint (60.8%) and the fracture mechanism (tongue-type in 28.4%, joint depression in 62.7%) with the weight-bearing calcaneal compartments taken into special consideration. In that way, each intraarticular calcaneus fracture could be scored, enabling a fast diagnosis comprising factors relevant for the therapy and prognosis.

Adolescent↗
PubMed2005

Thawing of frozen calcaneus bone specimens has no effect on the bone mineral density using dual energy x-ray absorptiometry: a study in rabbits and humans.

The purpose of this paper is to study whether the deep freezing of bone and later thawing affects the bone mineral density (BMD) measurement. We used 56 calcanei from 28 adult female New Zealand white rabbits and 102 human calcanei from 51 donors post-mortem (27 men and 24 women, age 30-89). Dual energy x-ray absorptiometry evaluated BMD of the frozen specimen and of the thawed specimen. A main analysis compared BMD of each specimen in the frozen and thawed states. The mean BMD of 224 areas of frozen rabbits' calcanei was 0.31 +/- 0.08 g cm(-2) (95% confidence interval (CI) from 0.30 to 0.32 g cm(-2)) while the mean BMD of thawed rabbits' calcanei was 0.31 +/- 0.08 g cm(-2) (95% CI from 0.30 to 0.32 g cm(-2); paired t-test p > 0.01). The mean BMD of 306 areas of frozen human calcaneus was 0.73 +/- 0.22 g cm(-2) (95% CI from 0.70 to 0.76 g cm(-2)) while the mean BMD of thawed human calcaneus was 0.73 +/- 0.22 g cm(-2) (95% CI from 0.70 to 0.76 g cm(-2); p > 0.01). For both the rabbit and the human calcanei, a Bland-Altman analysis showed a mean difference between the BMD in the frozen and thawed states of 0.00 (limits of agreement, rabbit: -0.07 to 0.08 g cm(-2), human: -0.16 to 0.21 g cm(-2)). A high correlation was observed between calcaneus BMD in the frozen and thawed states (r = 0.94, 0.97, 0.92 and 0.99 respectively in all rabbit calcanei, all human calcanei, immobilized rabbit calcanei and osteopenic human calcanei, all p < 0.01). Bone mineral density is not affected by deep freezing and later thawing of the specimen. Therefore, the specimens need not be thawed to obtain valid and precise BMD measurement. These results are relevant to general musculoskeletal as well as osteoporosis research where the specimens undergo multiple tests in series.

Absorptiometry, Photon↗
PubMed1999

Facilitating edema resolution with a foot pump after calcaneus fracture.

OBJECTIVES: To determine whether the use of a foot pump (intermittent pneumatic pedal compression device) in patients with excessive edema precluding surgery after acute fracture of the calcaneus leads to more rapid resolution of the edema. DESIGN: Prospective randomized setting. Standard hospital in-patient ward at a Level I trauma center. PATIENTS: Those patients with excessive edema precluding operative intervention upon admission after an intraarticular calcaneus fracture who signed an informed consent participated in the study. Twenty-eight patients were enrolled and completed the study: thirteen patients in the foot pump group and fifteen patients in the control group. INTERVENTION: In the control group, patients had a bulky compression dressing, posterior splint, and elevation while awaiting surgery. In the study group, the patients had a foot pump applied to the foot with a posterior splint and elevation while awaiting surgery. MAIN OUTCOME MEASUREMENTS: The volumetric change of the foot at twenty-four-hour intervals for up to seventy-two hours in both the control and study groups. RESULTS: All thirteen patients tolerated the foot pump. The differences in the volume between Day I (baseline) and Day 2 for the foot pump and control groups were minus forty and plus seventy-six milliliters, respectively (p = 0.02). Between Days 1 and 3, the differences were minus ninety-six milliliters for the foot pump group and plus thirty-seven milliliters for the control group (p = 0.02). CONCLUSIONS: A significant progressive decrease in the foot volume was noted during the first forty-eight hours after application of the foot pump in patients with excessive edema precluding operative fixation of a calcaneus fracture upon presentation. The pump was well tolerated by all the patients in the study group. Thus, we believe the pump serves as a useful adjunct in the preoperative edema resolution following these complicated fractures.

Ankle Injuries↗
PubMed2002

Percutaneous pin placement in the medial calcaneus: is anywhere safe?

OBJECTIVE: To redefine the medial calcaneal anatomic safe zone for pin placement with respect to reproducible palpable landmarks. DESIGN: Anatomic study. SETTING: Medical school anatomy laboratory. INTERVENTIONS: Thirty-three fresh-frozen adult cadaveric feet were used. Three palpable anatomic landmarks were identified on each ankle and labeled as Point A (posteroinferior medial calcaneus), Point B (inferior medial malleolus), and Point C (navicular tuberosity). The medial neurovascular bundle was carefully dissected, and the medial calcaneal nerve, the most posterior branch of the lateral plantar nerve, the lateral plantar nerve, the medial plantar nerve, and the posterior tibial artery were identified. These structures were recorded at the point at which they transected a line from Point A to B and from Point A to C. Based on the findings of the first thirty-three feet, two pins were placed percutaneously into the medial calcaneus of ten additional feet. Pin 1 was placed one half the distance from Point A to B. Pin 2 was placed one third the distance from Point A to C. The neurovascular structures were then dissected and identified in relation to the pin position. RESULTS: The medial calcaneal, most posterior branch of the lateral plantar, and lateral plantar nerves are at significant risk for abutting the pins or being directly injured at the margins of these relative safe zones. CONCLUSION: The medial calcaneus provides a small window for safe percutaneous pin placement. Posterior to the halfway point from Point A to B and posterior to the one-third mark from Point A to C remain the relatively safest regions; a more posterior placement in the safe zone is safest. Careful blunt dissection and the use of cannulas may help to avoid neurovascular injury.

Ankle Injuries↗
PubMed2004

Sciatic nerve blockade improves early postoperative analgesia after open repair of calcaneus fractures.

OBJECTIVE: To determine the effectiveness of analgesia, with or without sciatic nerve blockade, after open repair of calcaneus fracture. DESIGN: Randomized, prospective trial involving 30 patients divided into 3 groups of 10, all having open repair of calcaneus fractures. Group 1 used morphine patient-controlled analgesia alone. Groups 2 and 3 had morphine patient-controlled analgesia and a "one-shot" bupivacaine sciatic nerve blockade, either presurgically (group 2) or postsurgically (group 3). SETTING: Harborview Medical Center operating rooms and orthopedic floors. OUTCOME MEASURES: Morphine use over 24 hours, visual analogue scale pain scores, and sciatic nerve blockade duration. RESULTS: In the absence of sciatic nerve blockade, initial postoperative pain was marked, even with a mean recovery room dose of intravenous morphine more than 30 mg. Sciatic nerve blockade with bupivacaine had a mean duration of 14 hours and substantially reduced pain for the first 24 postoperative hours. Presurgical blockade confers no advantage over postsurgical blockade. CONCLUSION: Sciatic nerve blockade confers significant benefit over morphine alone for analgesia after open repair of calcaneus fractures. Postsurgical sciatic nerve blockade provides the longest possible postoperative block duration.

Adult↗
PubMed2004

Percutaneous pin placement in the medial calcaneus: is anywhere safe?

OBJECTIVE: To redefine the medical calcaneal anatomic safe zone for pin placement with respect to reproducible palpable landmarks. DESIGN: Anatomic study. SETTING: Medical school anatomy laboratory. INTERVENTIONS: Thirty-three fresh-frozen adult cadaveric feet were used. Three palpable anatomic landmarks were identified on each ankle and labeled as Point A (posteroinferior medial calcaneus), Point B (inferior medial malleolus), and Point C (navicular tuberosity). The medial neurovascular bundle was carefully dissected, and the medial calcaneal nerve, the most posterior branch of the lateral plantar nerve, the lateral plantar nerve, the medial plantar nerve, and the posterior tibial artery were identified. These structures were recorded at the point at which they transected a line from Point A to B and from Point A to C. Based on the findings of the first thirty-three feet, two pins were placed percutaneously into the medial calcaneus of ten additional feet. Pin 1 was placed one half the distance from Point A to B. Pin 2 was placed one third the distance from Point A to C. The neurovascular structures were then dissected and identified in relation to the pin position. RESULTS: The medial calcaneal, most posterior branch of the lateral plantar, and lateral plantar nerves are at significant risk for abutting the pins or being directly injured at the margins of these relative safe zones. CONCLUSION: The medial calcaneus provides a small window for safe percutaneous pin placement. Posterior to the halfway point from Point A to B and posterior to the one-third mark from Point A to C remain the relatively safest regions; a more posterior placement in the safe zone is safest. Careful blunt dissection and the use of cannulas may help to avoid neurovascular injury.

Ankle Injuries↗
PubMed1988

Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region.

Eight patients had reconstructive surgery for soft-tissue, associated Achilles tendon, and calcaneus defects on the posterior aspect of the ankle. In group A, those patients with skin, soft-tissue, and Achilles tendon loss were treated with free groin flaps that included sheets of the external oblique aponeurosis based on the superficial circumflex iliac vessel. The groin flap provided skin coverage, and the aponeurosis was rolled to form a tendon-like structure to replace the Achilles tendon. In group B, those patients with an additional calcaneus bone loss were treated with free iliac osteocutaneous flaps, together with the external oblique aponeurosis based on the deep circumflex iliac vessel. The iliac bone was then utilized to reconstruct the calcaneus defect. All composite free tissue transfers were successful, except in two group B patients who suffered partial skin loss. The advantages of this technique are (1) a single, one-stage procedure, (2) faster wound healing with fewer adhesions of the reconstructed Achilles tendon, and (3) good cosmesis and minimal morbidity at the donor site.

Achilles Tendon↗
PubMed2004

Insufficiency fracture of the body of the calcaneus in elderly patients with osteoporosis: a report of two cases.

Two cases of insufficiency fracture of the body of the calcaneus are presented to show its clinical presentation and diagnosis. It often is overlooked as a cause of pain in the ankle region. Both patients were elderly women with pain developing at the lateral aspect of the hindfoot in the absence of significant trauma. Physical examination was significant for marked tenderness at the superolateral aspect of the calcaneus. These clinical features suggested the diagnosis, which was confirmed by radionuclide bone scan and magnetic resonance imaging. Magnetic resonance imaging was the diagnostic tool in both cases, after abnormal bone scans and normal plain radiographs. Radiologic alterations were not seen for up to 2 months after the onset of pain. Treatment consisted of rest and protected weightbearing for 8 weeks, with complete resolution of symptoms in both patients. An insufficiency fracture of the body of the calcaneus should be considered in a differential diagnosis of elderly patients with osteoporosis with spontaneous pain in the ankle region.

Aged↗
PubMed1998

Bone mineral assessments in the calcaneus after anterior cruciate ligament injury. An investigation of 92 male patients before and two years after reconstruction or revision surgery.

The aim of this study was to assess the Bone Mineral Areal mass (BMA) in the calcaneus of male patients with unilateral anterior cruciate ligament (ACL) injury before and after reconstruction and to assess whether the BMA ratio or the BMA of the injured and uninjured side correlated with the level of activity, functional performance or the time period between the injury and the reconstruction. Ninety-two male patients with unilateral ACL injury were included in the study. The BMA was analysed immediately prior to surgery: a median of 11 (2-192) months after the injury in 30 patients aged 26 (15-41) years scheduled for primary ACL reconstruction (Group A). Forty-nine patients aged 29 (18-49) years had their BMA analysed a median of 24 (23-29) months after the primary ACL reconstruction (Group B). Thirteen patients aged 27 (21-39) years had their BMA analysed a median of 24 (20-45) months after ACL revision surgery (Group C). The median BMA ratio (injured side/uninjured side) was 96 (88-105)% in Group A, 96 (86-118)% in Group B and 95 (83-111)% in Group C. In all three groups, the median BMA value in the calcaneus was significantly lower on the injured side compared with the uninjured side (P=0.001, P=0.0003, P=0.01 in Groups A, B and C, respectively). The time period between the injury and the reconstruction neither correlated with the BMA ratio nor the BMA of the injured or the uninjured side in Group A. The level of activity as measured by the Tegner activity level and the functional performance as measured by the one-leg-hop quotient did not correlate with the BMA ratio in any of the groups. In the 49 patients with a primary ACL reconstruction (Group B), the post-operative Tegner activity level correlated with the BMA, on both the injured and uninjured side (P=0.0003, P=0.0005, respectively), when the BMA was assessed two years after the index operation. Male patients with unilateral ACL injury had a significantly lower BMA in the calcaneus on the injured side compared with the uninjured side before primary reconstruction, two years after primary reconstruction and two years after revision surgery. The time period between the injury and the index operation did not correlate with the BMA. A high level of activity correlated with the BMA on both the injured and the uninjured side two years after primary reconstruction.

Absorptiometry, Photon↗
PubMedDate not supplied

A study of the homogeneity of the trabecular bone mineral density in the calcaneus.

In the past our laboratory has reported a method of measuring trabecular bone mineral density (TBMD) in the calcaneus in vivo by using the coherent-to-Compton scattering ratio. In the present work the distribution of TBMD in the calcaneus has been studied, and the reproducibility of this technique in vivo has been determined. It is found that although the TBMD may vary within the calcaneus, a region exists over which the variation in density is not large. This region coincides with the midportion of the heel and is the site chosen for the measurement of TBMD by the coherent-to-Compton scattering ratio technique. The reproducibility of this technique in vivo has been determined to be 3.4%.

Bone and Bones↗
PubMed2000

Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus.

The charts and radiographs of 99 patients with 106 intraarticular fractures of the calcaneus were retrospectively reviewed. There were 75 men and 24 women. The average age was forty-two (range, 17 to 81). Fifty-seven of the fractures were left and 49 were right. The mechanism of injury was a fall from a height in 69 patients and motor vehicle accident in 30 patients. According to Sanders classification, seventy-one cases (67%) had type II fractures, 25 cases (23.6%) had type III, and ten cases (9.4%) had type IV. All the patients had operative management through a limited sinus tarsi approach with minimal fixation of the fracture with one or several pins. One of the pins was usually applied from the talus to the calcaneus through the fracture after reduction of the posterior facet. Nine cases (8.5%) developed postoperative infection, four cases (3.8%) had superficial wound infection, four cases (3.8%) had pin tract infection and one case (0.9%) had osteomylitis. Our follow-up at an average of 29 months (range, 12 to 84 months) showed that the American Orthopedic Foot and Ankle Society, Ankle-Hindfoot Score for the all group was 77.6 (range, 31-91). Forty-one fractures (38.8%) were graded excellent, 39 fractures (36.7%) good, 14 fractures (13.2%) fair, and 12 fractures (11.3%) were failures. Although radiological degenerative changes in the subtalar joint were seen in 41 cases (38.7%), only six cases (5.6%) required subsequent subtalar fusion. The authors conclude that the operative method used in the current study which followed the principle of minimal soft tissue damage and minimal internal fixation may be a good option for management of calcaneus fractures.

Adolescent↗
PubMed2004

Simple bone cysts of the calcaneus: a report of five cases and a review of the literature.

BACKGROUND: Simple bone cysts of the calcaneus are relatively uncommon. There is no clear consensus on either their etiology or management. Pathological fractures of such cysts are exceptionally rare. MATERIALS AND METHODS: Five simple bone cysts of the calcaneus were present in three males and two females with an average age of 44 years. One patient presented with pain, three cysts were incidental findings on ankle radiographs, and one patient presented with a fracture after a significant fall. RESULTS: All five were managed nonoperatively and had satisfactory outcomes. CONCLUSIONS: A review the literature on the etiology and management of simple bone cysts of the calcaneus and the outcomes of these patients indicate that complications of these cysts are rare and nonoperative management is appropriate.

Adolescent↗
PubMed2005

Local bone graft harvested from the distal tibia or calcaneus for surgery of the foot and ankle.

BACKGROUND: Numerous operative procedures around the foot and ankle use bone graft to augment healing. Autologous bone graft remains the preferred type for these procedures. This can be harvested from the iliac crest, but complications are frequent. The purpose of our study was to investigate the option of harvesting the bone graft from the ipsilateral distal tibia or calcaneus. METHOD: Bone graft was harvested in 114 patients from the distal tibia (70 patients) or calcaneus (44 patients). The patients were followed postoperatively for an average of 16 (range 5 to 28) months and were evaluated for complications (minor and major), satisfaction, and healing rates. RESULTS: There were no major complications. Ten patients (8.7%) had minor complications including initial incisional sensitivity or local numbness, none of which affected function or required additional treatment. Satisfaction rate for the procedure was 100%. CONCLUSION: Use of autologous bone graft harvested from the ipsilateral distal tibia or calcaneus is a safe and reliable alternative to iliac crest bone graft harvest for operative procedures of the foot and ankle.

Adolescent↗
PubMed2006

Vascularized bone graft from the medial calcaneus for treatment of large osteochondral lesions of the medial talus.

BACKGROUND: Operative treatment of large osteochondral lesions of the talus is difficult because the blood supply is poor in the talar dome. The purpose of this study was to evaluate the results of a vascularized bone graft transfer from the medial calcaneus to the large osteochondral lesion. METHODS: Four ankles in four patients with medial osteochondral lesions were treated through a medial transmalleolar approach. Vascularized bone graft was harvested from the medial calcaneus using the calcaneal branch of the posterior tibial artery and was placed through a fenestration of the medial aspect of the talar dome. The mean duration of postoperative followup was 34 (range 24 to 48) months. Clinical and radiographic evaluations were made before surgery and at final followup. RESULTS: According to the AOFAS ankle-hindfoot scale, mean pain and function scores improved from 20 to 33 points and 30 to 43 points, respectively. The mean total score improved from 60 to 83 points. Plain radiography at followup showed slight osteosclerosis in all patients, but joint space narrowing was not seen in any patient. Cysts seen preoperatively on MRI or CT resolved after 12 months postoperatively, and MRI or CT did not reveal any findings indicative of osteonecrosis. CONCLUSIONS: Clinical and radiographic results were satisfactory. Vascularized bone grafts harvested from the calcaneus were successful for the treatment of large osteochondral lesions of the medial talus.

Adult↗
PubMed1997

Quantitative ultrasound of the calcaneus reflects the mechanical properties of calcaneal trabecular bone.

To provide new information about the potential role of quantitative ultrasound (QUS) in fracture risk prediction, we assessed whether QUS and densitometric variables derived from measurements of intact cadaveric feet were associated with the mechanical properties of calcaneal trabecular bone. We obtained 31 intact cadaveric feet from the local anatomic gifts program, including 13 men and 18 women, with a mean age of 77 years (range 50-91 years). Broadband ultrasound attenuation (BUA) and ultrasound transit velocity (SOS) were assessed in the intact cadaveric feet using a water-based ultrasound system. In addition, we measured the bone mineral density (BMD) of the posterior calcaneus using dual-energy X-ray absorptiometry. Cubes of trabecular bone were then removed from the calcaneus at approximately the same location as the QUS measurements were obtained, and the elastic modulus and ultimate strength of the trabecular bone specimens were measured by compressing them in the mediolateral direction. We found that QUS variables were moderately to strongly correlated with the mechanical properties of calcaneal trabecular bone (r2 = 0.48-0.63, p < 0.001 for all). However, the strongest associations with the mechanical properties trabecular bone were provided by calcaneus BMD and trabecular bone apparent density (r2 = 0.66-0.88). BUA and densitometric measurements were independently associated with elastic modulus, but not with ultimate strength. Our results indicate that QUS measurements of the intact heel are associated with the mechanical properties of calcaneal trabecular bone and, in some cases, provide information in addition to that provided by BMD or density measurements.

Absorptiometry, Photon↗
PubMed1998

In vivo high resolution MRI of the calcaneus: differences in trabecular structure in osteoporosis patients.

The purpose of this study was to use high resolution (HR) magnetic resonance (MR) images of the calcaneus to investigate the trabecular structure of patients with and without osteoporotic hip fractures and to compare these techniques with bone mineral density (BMD) in differentiating fracture and nonfracture patients. Axial and sagittal HR MR images of the calcaneus were obtained in 50 female (23 postmenopausal patients with osteoporotic hip fractures and 27 postmenopausal controls). A three-dimensional gradient-echo sequence was used with a slice thickness of 500 micron and in plane resolution of 195 x 195 micron. Texture analysis was performed using morphological features, analogous to standard histomorphometry and fractal dimension. Additionally, BMd measurements of the hip (dual-energy X-ray absorptiometry) were obtained in all patients. Significant differences between both patient groups were obtained using morphological parameters and fractal dimension as well as hip BMD (p < 0.05). Odds ratios for the texture parameters apparent (app.) bone volume/total volume and app. trabecular separation were higher than for hip BMD. Receiver operator characteristic values of texture measures and hip BMD were comparable. In conclusion, trabecular structure measures derived from HR MR images of the calcaneus can differentiate between postmenopausal women with and without osteoporotic hip fractures.

Absorptiometry, Photon↗