Background: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high-energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatment, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study was to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After institutional review board approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and fractures with less than 6 weeks of postoperative weightbearing, which were excluded for radiographic outcomes. A total of 51 fractures underwent ORIF using cannulated screws alone (group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (group 2). Sixty-one fractures (41 vs 20, respectively) met criteria for radiographic comparison. The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, unplanned return to the operating room (OR), and cost comparison. Results: There was no statistically significant difference between preoperative Bohler angles for group 1 (14.4 degrees) versus group 2 (12.2 degrees) ( P = .44), nor was there a significant difference between postoperative Bohler angles for group 1 (30.1 degrees) versus group 2 (27.1 degrees) ( P = .14). Similarly, preoperative Gissane angles for group 1 (130.5 degrees) and group 2 (133.4 degrees) ( P = .54) and postoperative Gissane angles for group 1 (118.2 degrees) and group 2 (119.8 degrees) ( P = .44) showed no statistically significant difference. There were a total of 3 wound complications in group 1 versus 2 wound complications in group 2 ( P = .66). There was no statistically significant difference in operative duration ( P = .97) or the number of unplanned returns to the OR between the 2 groups ( P = .68). Based on the implants used at this institution, and depending on the number of screws used, the estimated cost range of a plate construct was $1070 to $1235, while the estimated cost range of a cannulated screw construct was $717 to $1264. Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Furthermore, the amount of angular correction achieved by initial reduction showed no statistically significant difference between groups, and the amount of reduction lost between initial and final postoperative radiographs showed no statistically significant difference between groups. With regard to the 2 techniques, there was no statistically significant difference in rates of postoperative complications and return to the OR. Our data suggest that fixation using cannulated screws alone versus sinus tarsi plate provides similar radiographic outcomes and risk of complications. The 2 techniques were also similar in terms of implant costs. Our results indicate that either technique effectively improved radiographic parameters. Level of Evidence: Level III, retrospective comparative study.

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Aims Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351.

Surgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position. MethodsPatients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated. ResultsA total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced rerupture of the Achilles tendon within the first year of primary repair. ConclusionThe mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.

Background: This study sought to identify variables associated with socioeconomic disparities in the treatment of distal forearm fractures in children. Methods:A single-institution retrospective cohort study of patients less than 18 years of age with isolated fractures of the distal radius and ulna. Patient included underwent a closed reduction and casting under sedation by an orthopedic resident with outpatient, clinical follow up within two weeks of injury. Demographic data were collected.Primary outcomes evaluated were the final fracture alignment and rate of surgical treatment.Results: 177 children included in this study, including 105 with private insurance and 72 with Medicaid or no insurance, 129 were white and 48 were minorities, and 51 were female while 126 were male. There were no statistically significant differences between patient groups when assessed for treatment outcome, mean fracture displacement, time to first clinic appointment, and duration of follow-up. Rates of surgical treatment between all groups tested were non-significant. Of patients that met institutional operative criteria, a lower percentage of nonwhite (p=0.03), male (p=0.07), and non-private insurance patients (p=0.08) received surgery when surgery was indicated compared to white female patients with insurance.Conclusions: At a single institution, no clear disparities in the overall care and outcomes of children with distal radius and ulna fractures were identified. When surgery was indicated by institutional standards, a significantly