From OT Europe

How should we treat calcaneal fractures?

EFORT

The Interactive Expert Exchange session entitled “Treatment For Calcaneus Fractures: Nonoperative, Open & MIS,” scheduled for our upcoming Lisbon meeting, will allow attendees with an expertise in Foot & Ankle Trauma to develop or reject their engagement toward minimally invasive surgical techniques, traditional surgery or non-surgical approaches when facing articular displaced fractures. Indeed, by extensively discussing all the medical characteristics, pros and cons and expected results of each procedure with experts who make a choice like this on a daily basis, participants will be able to overcome the most common doubts of treatment choice for this specific type of traumatic injury. The direct and closed exchange ensured by the high interactivity of this session format will lead practitioners from the audience to challenge each indication presented by the faculty panel and attempt to establish a common strategy for the decision-making.

Lisbon Banner

Calcaneal fractures involving the joints are disabling injuries that jeopardize a patient’s working capacity, as well as a majority of regular day-to-day activities. Such injuries represent more than 2% of all fractures and 65% to 70% of these fractures have displacement of the articular surfaces, particularly on the subtalar side. Treatment of articular displaced calcaneal fractures is still challenging, as evidenced by the significant number of reports in the literature in which the results were poor. Many authors have attempted to define algorithms for conservative and surgical treatment depending on the articular involvement and the degree of displacement. Despite several comparative studies between conservative and surgical methods, the management of these injuries remains controversial. There are several reasons for this.

First, it is practically impossible to obtain a satisfactory reduction using conservative methods because this often leads to pain and/or causes hindfoot deformity, impingement and disturbed gait. Second, reduction and fixation are difficult even with an extensive and accurate open surgical approach, which may not be within the reach of all surgical centers. Finally, the high risk of major complications related to open surgery, such as wound complications, infection and nerve injury, must be carefully considered.

Although open reduction and internal fixation (ORIF), particularly with last generation hardware, is currently considered the treatment of choice for fractures type II, III and IV according to Sanders’ classification, uncertainty remains about the comparative final results of surgical and conservative treatment as neither of them provides good results without the risk of considerable early or delayed complications. Minimally invasive surgical (MIS) techniques have been recently introduced for reduction and fixation of these fractures using different innovative tools as external “mini” fixators or percutaneous screws, with the aim of obtaining results that are comparable to those reported with traditional open procedures and of reducing the rate of complications related to the surgical approach. Most recent results with MIS are superior and can be considered comparable to those reported with ORIF.

The complete program of this Interactive Expert Exchange (IEE) session will attempt to draft a new treatment algorithm for articular displaced calcaneal fractures that is based on both the most recent advances in surgical techniques and a critical experience-based review of indications.

Faculty members from the panel will consider all the therapeutic options available today in order to define a novel, “patient-tailored” approach which will consider not only the injury pattern, but also any additional factors, such as a patient’s age, activity, risk factors and personal expectations, as well as the surgeon’s experience.

Treatment for Calcaneus Fractures: Nonoperative, Open & MIS
Friday 7 June 2019 | 10:00 – 12:15

Introduction & Conclusions
Bruno Magnan (Italy)

Questions & Presentations
Treatment of Calcaneus Fractures: Overview – Bruno Magnan (Italy)
Calcaneal Fractures: What Are We Aiming For? – Ian Winson (United Kingdom)
ORIF Today: Strengths and Limits – Walter Daghino (Italy)
Calcaneal Fractures – Should We or Should We Not Operate? – Stefan Rammelt (Germany)
MIS and Ex-Fix Could Be Options for Displaced Calcaneal Fractures – Elena Manuela Samaila (Italy)

Discussion on Clinical Cases
Provocateurs: Per-Henrik Agren (Sweden) & Tim Schepers (Netherlands)

As the most common fracture mechanism is a fall from a height of between 1 meter and 3 meters, the population at-risk are active, young and middle-aged people. Unfortunately, most of the cases observed are complex and cannot be treated with a standard procedure. Besides, during the last 50 years of clinical reports in the field, we have witnessed both enthusiasm and disappointment regarding surgical or conservative treatments due to the unsatisfactory results of both approaches and the severe post-surgical complications (treatment-dependent lack of reduction, skin necrosis, infection, etc.) that are regularly seen. Thus, today the debate is still open and the decision between conservative or surgical treatment for calcaneal fractures can be crucial in about 30% of the cases if only articular displaced calcaneal fractures are considered.

As innovation gains ground, the availability of new devices enhances and improves established treatments in foot and ankle trauma by shifting treatments toward new approaches. However, it is clear that conservative, open and MIS techniques will remain a part of the options available to treat articular displaced fractures and the decisions regarding which technique to use these will depend on the medical status of a specific patient, the surgeon’s experience and preferences and his or her capacity to balance the pros and cons of every approach.

To better guide the treatment choice, this session will address the different types of fractures, the possible treatment-related complications, the quality parameters of surgical reconstruction, as well as the current evidence associated with malalignment and post-treatment residual motion, among others. The multinational panel of experts will share the best tips and tricks to ensure the best outcome for the patient and highlight the importance of the surgical team’s expertise.

IEE banner

The format of this exchange, including lectures, open debates and case presentations, will lead to a deep evaluation of all possibilities for the practitioners facing a calcaneal fracture. The highly experienced surgeons in the specialty of foot trauma will discuss pros and cons of each approach to help the attendees’ decision-making.

As of this year, the IEE sessions can be attended by any participant fully-registered for the EFORT Congress without any extra fee to be paid. Sign-up for the Lisbon meeting on our registration platform as of 07 January 2019. Join the session and challenge the experts!

EFORT

The Interactive Expert Exchange session entitled “Treatment For Calcaneus Fractures: Nonoperative, Open & MIS,” scheduled for our upcoming Lisbon meeting, will allow attendees with an expertise in Foot & Ankle Trauma to develop or reject their engagement toward minimally invasive surgical techniques, traditional surgery or non-surgical approaches when facing articular displaced fractures. Indeed, by extensively discussing all the medical characteristics, pros and cons and expected results of each procedure with experts who make a choice like this on a daily basis, participants will be able to overcome the most common doubts of treatment choice for this specific type of traumatic injury. The direct and closed exchange ensured by the high interactivity of this session format will lead practitioners from the audience to challenge each indication presented by the faculty panel and attempt to establish a common strategy for the decision-making.

Lisbon Banner

Calcaneal fractures involving the joints are disabling injuries that jeopardize a patient’s working capacity, as well as a majority of regular day-to-day activities. Such injuries represent more than 2% of all fractures and 65% to 70% of these fractures have displacement of the articular surfaces, particularly on the subtalar side. Treatment of articular displaced calcaneal fractures is still challenging, as evidenced by the significant number of reports in the literature in which the results were poor. Many authors have attempted to define algorithms for conservative and surgical treatment depending on the articular involvement and the degree of displacement. Despite several comparative studies between conservative and surgical methods, the management of these injuries remains controversial. There are several reasons for this.

First, it is practically impossible to obtain a satisfactory reduction using conservative methods because this often leads to pain and/or causes hindfoot deformity, impingement and disturbed gait. Second, reduction and fixation are difficult even with an extensive and accurate open surgical approach, which may not be within the reach of all surgical centers. Finally, the high risk of major complications related to open surgery, such as wound complications, infection and nerve injury, must be carefully considered.

Although open reduction and internal fixation (ORIF), particularly with last generation hardware, is currently considered the treatment of choice for fractures type II, III and IV according to Sanders’ classification, uncertainty remains about the comparative final results of surgical and conservative treatment as neither of them provides good results without the risk of considerable early or delayed complications. Minimally invasive surgical (MIS) techniques have been recently introduced for reduction and fixation of these fractures using different innovative tools as external “mini” fixators or percutaneous screws, with the aim of obtaining results that are comparable to those reported with traditional open procedures and of reducing the rate of complications related to the surgical approach. Most recent results with MIS are superior and can be considered comparable to those reported with ORIF.

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The complete program of this Interactive Expert Exchange (IEE) session will attempt to draft a new treatment algorithm for articular displaced calcaneal fractures that is based on both the most recent advances in surgical techniques and a critical experience-based review of indications.

Faculty members from the panel will consider all the therapeutic options available today in order to define a novel, “patient-tailored” approach which will consider not only the injury pattern, but also any additional factors, such as a patient’s age, activity, risk factors and personal expectations, as well as the surgeon’s experience.

Treatment for Calcaneus Fractures: Nonoperative, Open & MIS
Friday 7 June 2019 | 10:00 – 12:15

Introduction & Conclusions
Bruno Magnan (Italy)

Questions & Presentations
Treatment of Calcaneus Fractures: Overview – Bruno Magnan (Italy)
Calcaneal Fractures: What Are We Aiming For? – Ian Winson (United Kingdom)
ORIF Today: Strengths and Limits – Walter Daghino (Italy)
Calcaneal Fractures – Should We or Should We Not Operate? – Stefan Rammelt (Germany)
MIS and Ex-Fix Could Be Options for Displaced Calcaneal Fractures – Elena Manuela Samaila (Italy)

Discussion on Clinical Cases
Provocateurs: Per-Henrik Agren (Sweden) & Tim Schepers (Netherlands)

As the most common fracture mechanism is a fall from a height of between 1 meter and 3 meters, the population at-risk are active, young and middle-aged people. Unfortunately, most of the cases observed are complex and cannot be treated with a standard procedure. Besides, during the last 50 years of clinical reports in the field, we have witnessed both enthusiasm and disappointment regarding surgical or conservative treatments due to the unsatisfactory results of both approaches and the severe post-surgical complications (treatment-dependent lack of reduction, skin necrosis, infection, etc.) that are regularly seen. Thus, today the debate is still open and the decision between conservative or surgical treatment for calcaneal fractures can be crucial in about 30% of the cases if only articular displaced calcaneal fractures are considered.

As innovation gains ground, the availability of new devices enhances and improves established treatments in foot and ankle trauma by shifting treatments toward new approaches. However, it is clear that conservative, open and MIS techniques will remain a part of the options available to treat articular displaced fractures and the decisions regarding which technique to use these will depend on the medical status of a specific patient, the surgeon’s experience and preferences and his or her capacity to balance the pros and cons of every approach.

To better guide the treatment choice, this session will address the different types of fractures, the possible treatment-related complications, the quality parameters of surgical reconstruction, as well as the current evidence associated with malalignment and post-treatment residual motion, among others. The multinational panel of experts will share the best tips and tricks to ensure the best outcome for the patient and highlight the importance of the surgical team’s expertise.

IEE banner

The format of this exchange, including lectures, open debates and case presentations, will lead to a deep evaluation of all possibilities for the practitioners facing a calcaneal fracture. The highly experienced surgeons in the specialty of foot trauma will discuss pros and cons of each approach to help the attendees’ decision-making.

As of this year, the IEE sessions can be attended by any participant fully-registered for the EFORT Congress without any extra fee to be paid. Sign-up for the Lisbon meeting on our registration platform as of 07 January 2019. Join the session and challenge the experts!