Experience of titanium plate internal fixation for intra-articular fractures of the heel bone.
Objective.
To determine the surgical efficacy of titanium plate internal fixation for intra-articular fractures of the heel. Methods From August 2002 to July 2006, a total of 35 cases were treated with titanium plate internal fixation for intra-articular fractures and complete data were obtained, according to sanders typing: 14 cases of type II, 18 cases of type III and 3 cases of type IV. Intraoperative routine x-ray fluoroscopy of the heel was performed in lateral position to observe the recovery of Böhler angle and Gissane angle, and broden position to understand the recovery of the posterior articular surface. None of them had bone graft. Results Thirty-five cases with complete follow-up data were retrospectively analyzed and followed for 7 to 24 months, with a mean of 9 months.
The efficacy was evaluated according to the Maryland foot score: excellent in 21 cases, good in 10 cases, acceptable in 3 cases, and poor in 1 case, with an excellent rate of 88.6%. Conclusion The treatment of intra-articular fracture of the heel with titanium plate can better restore the anatomical structure of the heel bone, restore the collapsed posterior talocalcaneal joint surface, and provide good conditions for functional recovery.
Materials and methods
1.Clinical data
The total number of cases in this group was 35 feet, 30 males and 4 females, including 1 male with bilateral heel fracture. Age 26-43 years old, average 34.5 years old. Causes: 25 cases of fall from height injury and 9 cases of car accident injury. There were 3 cases of combined pelvic fracture, 1 case of lumbar compression fracture with incomplete paralysis, 1 case of femoral stem fracture, and 2 cases of ankle fracture. All cases were closed fractures. Preoperatively, lateral radiographs of the heel on the patient’s side, orthopantomogram of the ankle joint, and CT scans of the heel in coronal and horizontal positions were routinely taken.
According to Sanders’ staging criteria: 14 cases of type II, 18 cases of type III, and 3 cases of type IV.
2.Treatment method
The heel fracture was not suitable for emergency surgery due to obvious swelling. A wide lateral incision was used in all cases. The whole flap was sharply peeled along the lateral surface of the heel bone, and the flap was retracted without contact by drilling into the medullary cavity of the fibula, the talus and the dice bone with three Kirschner pins in turn to reveal the lateral wall of the heel bone and the posterior articular surface of the talus. The heel tuberosity is repositioned with a Kirschner needle to facilitate the repositioning of the heel tuberosity. The collapsed lateral articular surface bone was pried up with reference to the inferior talocrural articular surface and temporarily fixed with a C-arm fluoroscopic view of the lateral heel bone to see whether the Böhler angle and Gissane angle were mixed, whether the posterior talocrural articular surface shift was restored in Broden’s position, and whether the width of the heel bone was restored in the axial view. The heel-fibular spacing was restored. If the repositioning was satisfactory, the lateral wall of the heel was repositioned and the appropriate heel titanium plate was placed on the lateral side and screwed in sequence, with at least one screw screw screwed into the solid talar bone. In all cases, no bone graft was removed.
Drainage strips were routinely placed in the incision. For Sanders type IV fracture, functional training was started in 3-4 weeks with post-operative braking in a short leg cast, and in the rest of the cases, the ankle joint was actively moved immediately after surgery without assisted external fixation, and the incision was removed at 3 weeks, and partial weight bearing was started after 3 months. The incision was dismantled at 3 weeks, and partial weight-bearing started after 3 months. Postoperatively, 1 month, 3 months, 6 months, and 1 year were taken to review and follow up the functional recovery.
Results
The follow-up period was 8-28 months, with a mean of 10 months. Early incisional skin margin necrosis occurred in 3 feet, which healed under the scab after dressing change. Peroneal sound was injured in 2 feet, which gradually reduced after symptomatic treatment. No incisional infection or peroneal tendon injury occurred. According to the Maryland foot score standard evaluation of treatment effect: excellent 21 cases, good 10 cases, can 3 cases, poor 1 case, excellent rate 88.6%
Discussion
Due to the special anatomical form and complex function of the heel bone, there has been a debate on whether to adopt conservative treatment or incision and internal fixation for intra-articular fractures of the heel bone. since the 1990s, a large amount of literature has reported good results with incision and internal fixation treatment. The goal of heel fracture surgery is to restore the anatomical shape of the heel and reposition the posterior talar articular surface, allow early postoperative activity, minimize the impact of the fracture on the patient, and restore the function of the affected foot so that it can return to life pain-free. We used incisional repositioning titanium plate internal fixation treatment for type II type III and type IV of Sanders’ staging.
Attention must be paid to the restoration of heel width and the restoration of the posterior articular surface under the talus during surgery. Pain is the most common complication of late intra-articular fractures of the heel and is an important factor affecting the recovery of the patient’s walking function. In cases of late residual heel pain from intra-articular heel fractures, most of the pain is located in the foot and below the outer ankle. This is due to uncorrected heel width, narrowing of the heel-fibular gap, and pain caused by the heel-fibular impingement syndrome caused by bone blocks or plate screws in the lateral wall of the heel that trap the fibular tendon. We prevented this by observing the recovery of the heel-fibular gap in the heel width intraoperatively through axial films, and the talofibular joint is another common cause of pain. The recovery of the posterior talofibular joint surface is an effective measure to prevent late pain, which was effectively prevented in all of our cases by intraoperative observation of the recovery of the heel width and heel-fibular gap by axial films. Subtrochanteric arthritis is another common cause of pain. Poor repositioning and fixation of the posterior talofibular articular surface can lead to changes in the axis of the heel bone and the line of negative gravity, which can lead to subtrochanteric arthritis. Restoration of the subtrochanteric articular surface is an effective measure to prevent late onset pain. In all of our cases, the recovery of Böhler angle and Gissane angle was observed intraoperatively by lateral radiographs, and the recovery of posterior talar articular surface displacement was observed in Broden’s position, which restored the length and height of the heel bone, reconstructed the arch of the foot from the appearance, and fixed it after satisfactory repositioning, which effectively prevented the occurrence of painful subtrochanteric arthritis.
The cancellous bone collapsed after the heel fracture, and the bone defect appeared after the prying up of the posterior articular surface of the subtalar, but whether bone grafting is necessary is still debated. We agree with Letournel that the site of the bone defect is the central triangle, which is normally cancellous bone. Therefore, no bone grafting was done in any of our cases and no recurrence of posterior joint surface collapse was observed during the follow-up period. However, the Sanders IV fracture with severe heel comminution was only 3 feet in our cases. We have no experience with bone grafting, and to prevent secondary articular surface collapse, we used a plaster brace for 4 weeks after surgery.
Postoperative skin necrosis infection or non-healing of the incision is a frequent complication of heel fractures and directly affects the outcome of treatment.
Our preventive measures are.
(1) Choose the appropriate timing for surgery. It is usually about 7-10 days after the injury.
(2) Try to use full-thickness skin face, sharp peeling, and not over-stretching of the flap. We peeled sharply along the surface of the heel bone intraoperatively and used a kerfing needle for contactless flap traction. The suture is divided into two layers to reduce skin tension, and drainage strips are routinely placed under the incision to drain the subcutaneous blood accumulation.
(3) Reduce factors affecting incision healing, such as obesity, smoking, diabetes, etc. In this group of cases, skin necrosis occurred in 3 foot incisions, which healed smoothly after drug exchange without serious complications such as infection.
In conclusion, titanium plate internal fixation for intra-articular fractures of the heel, with early activity, can better restore the anatomical structure of the heel bone to reconstruct the collapsed posterior talocalcaneal joint surface, providing good conditions for functional recovery and satisfactory clinical results. Now it has become the main technique for the treatment of intra-articular fractures of the heel.