To evaluate the early clinical efficacy of incisional repositioning implant locking plate internal fixation for intra-articular fractures of the heel. Methods In this group, 21 patients with 25 heel fractures, all Sanders type III and IV fractures, had preoperative lateral and axial radiographs and CT of the heel. all patients underwent internal fixation with an incisional reduction locking plate. Results Early postoperative radiographs showed that all 25 heel fractures were well repositioned, and at follow-up, according to the AOFAS ankle-hindfoot scoring system, of the 21 cases and 25 feet, 16 were excellent, 8 were good, and 1 was fair. Conclusion The treatment of intra-articular fractures of the heel with incisional reduction and locking plate internal fixation can achieve good results.
Heel fracture is one of the common clinical fractures, accounting for 1%-2% of the whole body fractures, and most of them involve the talocalcaneal joint, with the majority of young adults. The heel bone is difficult to handle because of its special shape and location, little peripheral soft tissue encapsulation and poor blood supply; Sanders III and IV fractures are severely comminuted and the talocalcaneal joint surface is mostly collapsed. In recent years, internal fixation with bone grafting and locking plate has been widely used in clinical practice. From 2008 to 2010, 23 patients with 28 heel fractures underwent internal fixation with an incisional repositioning implant and locking plate, and the results were satisfactory.
1. Clinical data
1.1 General information
There were 21 cases (25 feet) of heel fracture in this group, 15 cases (19 feet) in men and 6 cases (6 feet) in women; age 19-53 years, average 34.5 years, 19 cases of high fall injury and 2 cases of car accident injury. According to Sanders typing: 6 cases and 6 feet of type III and 15 cases and 19 feet of type IV, the admission time was 2h-1 week after the injury, and the lateral and axial x-ray and CT of the heel bone were taken routinely before the operation.
1.3 Post-admission treatment
After admission, the affected limb was immobilized in a plaster cast and treated symptomatically until the swelling subsided significantly and skin wrinkles appeared before surgery, which took about 7 days.
1.2 Surgical method
Lumbar anesthesia was used, and the patient was placed in the lateral position, and a tourniquet was applied intraoperatively. A lateral “L”-shaped incision was made from one finger behind the lateral ankle, extending distally to the level of the skin junction between the dorsalis pedis and the plantar skin, and then folding forward to the base of the 5th metatarsal. In the longitudinal part of the incision, the gastrocnemius nerve travels at the posterior edge of the peroneus longus tendon, and in its transverse part, the line between the tip of the outer ankle and the base of the 5th metatarsal and the intersection of the incision is the travel point of the gastrocnemius nerve.
The gastrocnemius nerve was exposed and protected, and all soft tissues on the lateral surface of the heel were lifted upward along with the periosteum to form a full-thickness flap, which included the long and short peroneal tendons and the gastrocnemius nerve. The fractured lateral cortical bone of the heel was first pried up and turned over, and the collapsed fracture of the inferior talocrural articular surface was pried up from below with a small periosteal striker, while a periosteal striker was used to press the Achilles tendon from above to below at the stopping point of the heel. The Bohler angle, Gissane angle, and heel height were restored simultaneously under C-arm guidance. For large bone defect gaps after repositioning, the joint surface was held up by using autologous iliac bone bitten into multiple small bone blocks.
The lateral wall of the heel was finally repositioned, and the lateral wall of the heel was squeezed from the outside to the inside with the thumb to correct the widened heel body and to check the normal heel-fibula gap to avoid pressure on the peroneal tendon. after the C-arm check for satisfactory repositioning, a suitable locking plate was selected and shaped, and the screws were screwed in as far as possible to fix the screws in the area without fracture or in the solid bone under the articular cartilage surface. After the operation, a rubber sheet was placed locally to drain the joint, the skin was tightly sutured, the incision was closed, and the postoperative incision was wrapped with pressure.
1.3 Postoperative treatment
The cast of the short leg was fixed for 2 weeks, and the rubber sheet was removed within 2-3 days according to the drainage flow, or longer if the drainage flow was higher. 2 weeks later, the cast was removed and functional exercise of the ankle joint was performed.
2. Results
2.1 Imaging measurement results
X-ray measurements were performed before and after surgery, and the results of Bohler’s angle and Gissane’s angle measurements before and after surgery in this group are shown in Table 1. The differences between Bohler’s angle and Gissane’s angle before and after surgery were statistically significant, and the postoperative improvement was obvious.
2.2 Results of efficacy evaluation
According to the American Foot and Ankle Society AOFAS ankle-hindfoot scoring system [1], patients were scored for pain (40 points), function (50 points), and force line (10 points), with 90-100 points being excellent, 75-89 points being good, and <75 points being fair and poor. 21 cases of 25 feet were obtained with follow-up for 3-20 months, with an average of 12 months. of the 21 cases of 25 feet, 16 feet were excellent, 8 feet were good, and 1 foot. < span="">
2.3 Postoperative complications
The incision healing was delayed in 2 cases and healed after 2 to 6 weeks with hyperbaric oxygen therapy and drug changes. No postoperative complications such as deep soft tissue infection and fracture redisplacement occurred in all patients. The foot appearance was good, and they could wear shoes normally without assistance and walking distance was not significantly limited.
Table 1 Bohler’s angle and Gissane’s angle measurements (X(-)±S)
Item Preoperative Postoperative t P
Bohler’s angle
Gissane angle
-13.5°±6.2°
82.5°±17.3°
23.6°±7.8°
114°±6.3°
19.418
9.053
<0.01
<0.01
3. Discussion
3.1 The aim of heel fracture treatment is to restore the normal biomechanical characteristics and function of the hindfoot, and its repositioning technique is considered to be the key to the whole surgical treatment, while the recovery of heel width, Boher’s angle and Gissane’s angle are important criteria for evaluating heel fracture surgery. We believe that at the time of repositioning one should consider
(1) Restoring the flatness of the subtalar articular surface (especially the posterior talar articular surface);
(2) restoration of the heel height and Bohler angle;
(3) Restoration of the width of the heel bone;
(4) Restoration of the length of the heel bone (Gissane’s angle);
(5) Resetting the heel-fibula gap to restore the function of the peroneal tendon;
(6) restoring the valgus position of the heel tuberosity. In order to avoid postoperative loss of heel height, change of Bohler’s angle and Gissane’s angle, the subtalar joint surface should be fully exposed, the fracture block should be dissected and reset, the heel bone should be sufficiently traction and squeezed to restore the heel width, and the cavity should be filled with artificial bone or autologous iliac bone graft.
If good repositioning and fixation are not obtained, it will lead to fibrous adhesions and osteoarthritis under the talus, heel valgus deformity and even spastic flatfoot, which will eventually cause metatarsal fasciitis, peroneal tendinitis, heel-fibular collision syndrome, long-term swelling and pain, and seriously affect daily work life. Therefore, anatomical repositioning and restoration of the foot arch as much as possible is the key to clinical treatment.
3.2 Bone defect area is usually left after fracture repositioning, we believe that if the defect is small, no bone grafting can be done, and if the defect is more than 50px×50px, bone grafting is needed, which can not only increase the mechanical support of the joint surface and promote fracture healing, but also eliminate the cavity to prevent hematoma, liquefaction and exudation, reduce the chance of affecting flap healing and even infection, and at the same time prevent the joint surface from collapsing again after weight-bearing and avoid loss of repositioning. Maintain the heel height.
3.3 Compared with the reconstructive plate, the locking plate adopts the principle of biomechanical fixation of external fixator, which can completely rely on the interlocking structure of the plate itself to achieve effective fixation of Sanders III and IV comminuted bone block; the plate can leave a certain gap with the bone surface, which eliminates the undesirable effect of the plate and bone heavy pressure contact, which can greatly improve the growth and recovery of blood flow and periosteum and promote fracture healing.
3.4 The surface of the heel bone is dense connective tissue and skin, with poor blood flow resulting in poor resistance to infection, and the outer soft tissue of the heel bone is thin and prone to postoperative infection, skin necrosis, and incision cracking. Therefore, soft tissue healing and infection are particularly problematic in heel fractures compared to fractures in other areas. In order to reduce the incision complications, firstly, the timing of surgery should be correctly grasped, before the swelling decreases and the scar tissue is not formed, which is the ideal time for surgery, 3-7 days after the injury; if the blister is formed, it is delayed to l0-12 days after the injury.
Second, pay attention to intraoperative soft tissue protection, sharp incision, subperiosteal peeling, and avoid strong traction on the flap. Third, drainage of the incision, avoid accumulation of blood, tension-free sutures, pressure dressing, elevation of the affected limb to reduce edema, and avoid premature suture removal. It has been suggested that the duration of intraoperative tourniquet use and prolonged surgery are also factors that lead to poor incision healing, dehiscence, and infection. If skin margin necrosis occurs, healing can be promoted by intensifying local dressing changes and hyperbaric oxygen chamber treatment for 1 to 2 weeks.
Most heel fractures involve the joint, and the treatment of intra-articular fractures of the heel has long been controversial and tricky to manage. For more complex fractures, it is difficult to achieve satisfactory results by simply using plaster braking or heel prying, and late complications of traumatic arthritis can occur, often leaving sequelae such as pain, flat feet, and heel widening. The application of internal fixation with an incisional locking plate is an effective treatment for Sanders III and IV heel fractures, as it can effectively restore the subtalar joint and provide effective bone grafting for severe compression fractures.