Displaced intra-articular heel fractures (DIACF) have always been a technical challenge for trauma orthopaedic surgeons and foot and ankle surgeons. Although there is currently insufficient evidence from an evidence-based medical perspective that surgical treatment of DIACF is definitely superior to non-surgical treatment; in clinical work, the trans-lateral expanded access incisional reduction internal fixation (ORIF) remains the treatment of choice for most orthopedic surgeons and is the most effective means of anatomically reconstructing the anatomical morphology of the heel bone (Bohler angle, articular surface repositioning, height and heel width). And the anatomical reconstruction of the heel is associated with improved long-term clinical outcomes. However, the high rate of incisional complications associated with this treatment has always been a problem for orthopedic surgeons; the high rate of complications is also the main reason for the controversy over the choice of surgical or non-surgical treatment of heel fractures.
Non-surgical or surgical treatment
When considering non-operative versus operative treatment, it is important to understand that the best treatment is not determined by a single factor, but rather by a triad of factors that include the patient, the fracture, and the medical team.
Patient factors ① Age: Buckley found that patients under 30 years of age had a better prognosis after surgical treatment, and patients over 50 years of age had a deviated outcome (the difference was not statistically significant); however, some authors have concluded that there is no relationship between age and various outcome scores. (ii) Gender: male patients under 30 years of age and female patients had better results with surgical treatment than with non-surgical treatment. Patients with a light workload had better results with surgery than with non-surgical treatment; patients with a heavy workload had deviated results with either surgical or non-surgical treatment, but the percentage of patients who returned to work earlier and developed subacromial arthritis after surgical treatment was reduced. ④ Patients with insurance or workers’ compensation coverage had a deviated outcome for both surgical and non-surgical treatment and had a higher rate of advanced subtrochanteric arthritis.
Fracture factors ①Bohler’s angle: The outcome of surgery was unclear in patients with a post-injury Bohler’s angle <0< span="">°; patients with a Bohler’s angle >15° had better surgical outcomes, but non-surgical treatment was superior to those with a Bohler’s angle <0< span="">° who required a greater proportion of patients to undergo subtalar joint fusion. (ii) SANDERS staging: SANDERS type II had better surgical results than nonoperative treatment, and the SANDERS p summary, MCS) score was lower than in patients with type II fractures. ③Patients with bilateral fractures had a worse prognosis than patients with unilateral fractures, but there was no significant difference between the outcome of surgical and non-surgical treatment for patients with bilateral fractures. ④The Zwipp prognostic score for open fractures was worse than that for closed fractures. ⑤ The AOFAS score, Zwipp score, and FFI score become lower when the posterior articular surface step increases and when the postoperative Bohler angle is smaller. < component index, FFI) and SF-36 (mental function 5.5 times higher in patients with type 1I fractures. foot function scores in patients with Sanders type III and III fractures (no significant difference between operative and nonoperative outcomes for foot type IV fractures; the proportion of patients with Sanders type IV fractures requiring fusion of the subtalar joint was Sanders>
Medical Team There was a paracorrelation between late talofibular fusion and the number of fractures treated by the physician. The outcome of surgical treatment may be biased if the number of heel fractures treated is less than 1 per month.
Individualization of treatment options Some scholars have scored patients with DIACFs on each of six factors: age, blistering, comorbidities, poor habits, trauma energy, and number of intra-articular fracture fragments, and assigned a risk class based on the total score, which determines whether incisional reduction and internal fixation, minimally invasive screw fixation, external fixation, or conservative treatment should be used.
Non-surgical treatment
Non-operative treatment can be considered for the vast majority of nondisplaced extra-articular heel fractures, patients with posterior articular surface fracture displacement less than 1 to 2 mm, patients with severe medical disease unable to tolerate anesthesia and surgery, patients who are unable to walk, bedridden and wheelchair bound for long periods of time, and patients with poor compliance. Traditional non-operative treatment methods using anterior and posterior braces or tubular fixation in short leg casts for 4 to 6 weeks have shown evidence of poor efficacy. The modern standard approach to nonoperative functional therapy includes post-injury elevation of the affected limb, soft splinting of the ankle in neutral position, ice and the use of nonsteroidal anti-inflammatory drugs; after the inflammation has resolved and pain has decreased, ankle flexion and extension, hindfoot internal and external rotation, active pedal exercises in neutral foot position, and isometric contraction of the intrinsic and extrinsic muscles of the foot are started; after the pain and edema have completely resolved, crutches and partial weight-bearing are started, followed by a gradual increase in weight-bearing according to the After complete resolution of pain and edema, crutches and partial weight-bearing were started, and then weight-bearing was gradually increased according to the progress of fracture end healing; physical therapy should be continued until 12 weeks after injury. However, before choosing non-operative treatment for DIACFs, patients should be informed that although there is no significant difference in function and quality of life between surgical and non-operative treatment 2 to 3 years after injury, surgical patients may return to work more quickly, and non-operative patients are more likely to require fusion surgery for subacromial arthritis later in life than surgical patients.
Surgical treatment
Swelling is more pronounced after heel fracture, and can be reduced by ice, elevation of the affected limb, medication, and hyperbaric oxygen in the early post-injury period. Surgery is usually performed after the swelling has decreased and skin folds have appeared in about 1 week. Recently, some authors conducted a retrospective study on the timing of surgery and divided the injury into early (within 3 d), medium (3-10 d), and late (more than 10 d) groups according to the time from surgery. there was no difference in the infection rate between the three groups, and only one case of 74-year-old diabetic patient developed deep infection requiring debridement and removal of the internal fixation. Therefore, the authors concluded that if patients can be strictly selected to exclude risk factors such as open fractures, severe neurovascular disease, insulin-dependent diabetes mellitus, poor compliance, immunodeficiency-type disease, and severe systemic disease, treatment of DIACFs by an experienced surgeon via a lateral expanded access ORIF early after injury will not increase the rate of surgical infection.
Surgical approach
The trans-lateral expanded approach ORIF is the most common approach used by surgeons in the treatment of Sanders II and III fractures. After complete exposure of the heel bone, the medial wall displacement of the heel bone, correction of the internal and external rotation axis, repositioning of the posterior articular surface, heel bone length and height, and heel dice joint displacement are restored by traction and cocking. The fixation of the fracture was completed with the use of a lateral plate screw system.
When resetting the posterior articular surface of the heel, it is usually believed that the medial talar bone is firmly held by the medial structures such as the triangular ligament and the talocalcaneal intertrochanteric ligament without displacement, and its correspondence with the talus does not change, which is the anatomical marker of resetting. A recent study by Berberian et al. on CT of 100 patients with heel fractures found that a total of 42 cases contained displaced, angulated, separated, and laterally displaced talar bones, which may affect the quality of fracture repositioning and patient prognosis. When the fracture line was medial and the posterior articular surface was three- or four-part fracture, the likelihood of displacement of the talonavicular process increased. Although the impact of displaced talipes and mid-articular surface asymmetry on fracture repositioning and clinical outcomes is unknown; it suggests that clinicians may need to choose a medial approach or a combined internal and external approach for these fractures.
Minimally invasive surgical approach Unlike pain and limited mobility after lower extremity hip and knee injuries, which are the main causes of functional limitation and disability, satisfactory outcomes in patients with DIACFs depend primarily on the presence of comorbidities, which are the main cause of poor prognosis. Although some authors have reported that short-term comorbidities of surgery do not affect the medium- and long-term clinical outcome, problems such as necrosis of the wound skin margin, rupture, and infection are still problems that plague orthopedic surgeons, which may be related to risk factors such as positioning of the surgical incision, vascular disease, and smoking. Minimally invasive surgical treatment of heel fractures adopted to reduce these short-term surgical comorbidities has been a hot topic of clinical research in recent years.
(1) Closed reduction internal fixation. As early as 1935, Westhues proposed the use of Schanz pins for the treatment of heel fractures by percutaneous cocking of the heel tuberosity in combination with plaster fixation, and in the 1940s and 1950s, Gissane and Essex-Lopresti widely used this repositioning technique for the surgical treatment of heel tongue fractures. treated 247 intra-articular fractures of the heel; 89% of the patients were operated within 48 h after injury, 73.9% achieved anatomic reduction (less than 2 mm displacement of the articular surface and satisfactory restoration of heel height and width), 7% developed superficial pin tract infection, 1.7% developed deep infection, 4.5% developed loss of reduction, and 1% were treated with myocutaneous flaps; 176 patients were followed up with Creighton- DeWall et al. compared the results of ORIF and percutaneous internal fixation for DIACFs and showed no difference in restoration of Bohler angle, loss of repositioning, fusion of the subtalar joint, or removal of the internal fixation; while the percutaneous repositioning group had no difference in incision The incidence of complications and the rate of deep infection were significantly lower in the percutaneous repositioning group than in the incisional repositioning group. In 88 cases of lingual heel fractures (mainly with diabetes mellitus, peripheral vascular disease, soft tissue blisters, multiple injuries, etc.) treated with percutaneous reduction screw internal fixation technique over a 10-year period, only 1 case developed superficial infection, and 14% of the patients were found to have loss of reduction, 20% required removal of internal fixation, and 9% developed subtalar arthritis at follow-up.
The advantages of closed reduction internal fixation are: (1) the procedure is minimally invasive, and the reduction and internal fixation are completed through small incisions, so it is suitable for patients with poor soft tissue conditions and associated risk factors; (2) no extensive dissection of soft tissue is required, the fixation is simple, and the risk of skin necrosis is low; (3) anesthesia and operating time are shortened, and the removal of the internal fixation is simple. However, because the intra-articular fracture is not exposed, it also has inevitable disadvantages: (1) higher incidence of mal-replacement and re-displacement compared with incisional repositioning; (2) inability to directly see the effect of repositioning, which can only be judged by X-ray fluoroscopy; (3) poor results for intra-articular collapsed fractures and fracture types with crushed heel anterior process.
(2) Small incision incisional repositioning or arthroscopic-assisted repositioning internal fixation. In order to improve the quality of posterior heel articular surface repositioning, some scholars have used small trans-lateral incisions to reveal and reposition the posterior heel articular surface under direct vision, and then various fixations were taken to complete the fixation of the heel fracture. kline et al. treated two groups of patients with DIACFs with similar fracture types using an expanded lateral approach and a minimally invasive approach, respectively. The incidence of wound comorbidity was found to be 29% (9% required surgery) and 6% (no surgery) for the expanded lateral approach and minimally invasive approach, respectively; the reoperation rate was 20% and 2%, respectively; and the patient satisfaction rate was 84% and 94%, respectively. The clinical outcomes of the two groups were similar according to FFI and VAS, but the incidence of wound comorbidity and the rate of secondary surgery were lower in the minimally invasive approach. The minimally invasive treatment of intra-articular fractures of the heel through a limited incision of the lateral tarsal sinus combined with external fixation of the anatomical locking plate reported by Zhang Guozhu et al. achieved good results with the advantages of less trauma, lower infection rate, satisfactory articular surface repositioning, and reliable fixation. Shi Zhongmin et al. compared the recent outcomes of limited incision through the tarsal sinus incision and expanded lateral approach ORIF for Sanders type II DIACFs, and found that there were no significant differences between the two groups in terms of fracture healing, improvement of Bohler’s angle, Gissane’s angle, AOFAS and VAS scores, but the SF-36 scores in the minimally invasive group were better than those in the incision group; the occurrence of late talofibular joint The occurrence of stiffness was also significantly less in the minimally invasive group than in the incision group. Some authors have treated patients with DIACFs with risk factors (open fracture, smoking, diabetes, alcohol abuse, and cocaine) using techniques such as temporary external fixation frames, arthroscopic-assisted repositioning, and percutaneous hollow nail fixation, resulting in no infection or wound comorbidity.
In the article “Treatment of intra-articular fractures of the heel with locking plate external fixation via tarsal sinus approach” by Hui Huang et al. in this issue, in order to reduce the occurrence of soft tissue comorbidities, an attempt was made to use the tarsal sinus approach to reduce the local soft tissue stripping and to use external placement of the bone plate to reduce the placement of subcutaneous internal fixation. There were no skin complications in the incision except for one patient who had oozing of the nail tract, and the anatomical morphology of the heel bone (Bohler’s and Gissane’s angles) was better improved; a good clinical outcome was obtained (84.6%). In the article “Unilateral external fixation brace combined with limited internal fixation for intra-articular fractures of the heel bone” by Chai Leizi et al, a small lateral transverse incision was used to expose and reposition the posterior articular surface of the heel bone, and an external fixation brace was used to restore the heel bone morphology and internal and external rotation; the anatomy of the heel bone was better restored, and the incision complication rate was only 5.3%, and a better clinical outcome was achieved. The incision complication rate was only 5.3%, and the clinical outcome was good (excellent rate 89.5%). Both authors have made useful attempts in minimally invasive treatment.
The advantages of small-incision ORIF: (1) less soft tissue stripping, less local flap blood supply; (2) good exposure of the posterior articular surface of the heel and the articular surface of the heel dice, which can be repositioned and fixed under direct vision, with reliable results; (3) enhanced stability after screw fixation of the joint plate; (4) less surgical trauma is more conducive to early functional exercise. However, small-incision ORIF also has its disadvantages: (1) the learning curve is long and requires a higher operator; (2) there is a possibility of inadequate fixation and fracture re-displacement if screw fixation is used alone; (3) it cannot well handle comminuted fractures of the anterior heel process. However, as surgeons have become more proficient in this technique, the indications for surgery have expanded from simple Sanders type II fractures to type III fractures. When using this technique, it is important to note that (1) surgery should be performed early after the injury to prevent local hematoma mechanization from making the repositioning difficult; (2) repositioning can be done by prying the heel bone medial wall, posterior articular surface of the heel bone, Bohler and Gissane angles, and heel bone length and width height in a sequential manner by using Kirschner pins and external fixation brace distraction.
(3) Development and application of new techniques Some authors have reported the combination of various percutaneous repositioning techniques, the use of balloon expansion to reset displaced posterior heel articular surface fractures, and the injection of injectable artificial bone to maintain fracture repositioning and assist in fixation, which has achieved good clinical efficacy. As various manufacturers have introduced their own intramedullary fixation systems for heel fracture treatment, some authors have also reported better clinical results. However, the summary and clinical application of these techniques have yet to be further accumulated by clinical data.
Most old heel fractures are associated with varying degrees of deformity, and the CT staging of Stephens and Sanders is commonly used in clinical practice as a basis for treatment. For type I lateral wall synostosis of the heel, lateral wall resection and decompression is used; for type II lateral wall synostosis of the heel with talocalcaneal arthritis, in situ fusion of the talocalcaneal joint or fusion with open implants is chosen; for type III lateral wall synostosis of the heel combined with talocalcaneal arthritis and hindfoot valgus deformity, osteotomy of the heel is also required along with fusion of the talocalcaneal joint. Various osteotomies and fusions are performed to correct the deformity and relieve pain. In the article “Heel mound reconstruction with subtalar joint fusion for old Sanders II intra-articular heel fracture” written by Qingpeng Sun in this issue, the deformity of old heel fracture is treated by bracing the subtalar joint, implanting a bone block and fusing the subtalar joint, which can improve the patient’s pain, function and strength. , function, and force lines.
However, in patients with DIACFs with a short post-injury period, osteotomy correction via the original fracture line and internal fixation can be considered when the articular cartilage degeneration is not yet severe.Rammelt et al. used this surgical approach to treat five patients with DIACFs who visited the clinic at an average of 2.9 months after injury over a 10-year period, and all patients were satisfied with the results at an average follow-up of 4.1 years, and AOFAS hindfoot scores and radiographic indices improved significantly, and no patient required stage II fusion of the subtalar joint. Preservation of the joint, restoration of force lines, and osteotomy orthopedics is a treatment for early healing of intra-articular deformities of the heel, before the development of subtalar arthritis.